Complications after partial nephrectomy: robotics overcomes open surgery and laparoscopy: the PMSI French national database.

PURPOSE: To evaluate three partial nephrectomies (PN) procedures: open (OPN), standard laparoscopy (LPN), and robot-assisted laparoscopy (RAPN), for the risk of initial complications and rehospitalization for two years after the surgery. MATERIALS AND METHODS: From the French national hospital database (PMSI-MCO), every hospitalization in French hospitals for renal tumor PN in 2016-2017 were extracted. Complications were documented from the initial hospitalization and any rehospitalization over two years. Chi-square and ANOVA tests compared the frequency of complications and length of initial hospitalization between the three surgical procedures. Relative risks (RR) and 95% confidence intervals were computed. RESULTS: The 9119 initial hospitalizations included 4035 OPN, 1709 LPN, and 1900 RAPN; 1475 were excluded as the laparoscopic procedure performed was not determined. The average length of hospitalization was 8.1, 6.2, and 4.5 days for OPN, LPN, and RAPN, respectively. Compared to OPN, there were fewer complications at the time of initial hospitalization for the mini-invasive procedures: 29% for OPN vs. 20% for LPN (0.70 [0.63;0.78]) and 12% for RAPN (RR=0.43, 95%CI [0.38;0.49]). For RAPN compared to LPN, there were fewer haemorrhages (RR=0.55 [0.43;0.72]), anemia (0.69 {0.48;0.98]), and sepsis (0.51 [0.36;0.71]); during follow up, there were fewer urinary tract infections (0.64 [0.45;0.91]) but more infectious lung diseases (1.69 [1.03;2.76]). Over the two-year postoperative period, RAPN was associated with fewer acute renal failures (RR=0.73 [0.55;0.98]), renal abscesses (0.41 [0.23;0.74]), parietal complications (0.69 [0.52;0.92]) and urinary tract infections (0.54 [0.40;0.73]) than for OPN. CONCLUSIONS: Conservative renal surgery is associated with postoperative morbidity related to the surgical procedure fashion. Mini-invasive procedures, especially robot-assisted surgery, had fewer complications and shorter hospital lengths of stay.

COVID-19 crisis and the incidence of hospital admissions for psychosis in France.

OBJECTIVES: We aimed to assess the impact of the COVID-19 crisis on the occurrence of new hospital admissions for cases of psychosis in France. METHOD: We conducted a retrospective observational study from the French national PMSI database. We included patients hospitalized between 2018 and 2020 with a principal diagnosis of schizophrenia or delusional disorder with no history of psychosis in the previous 10 years. In total, we included 77,172 inpatients at crisis centers and/or in full-time hospitalization at 465 French hospitals. We assessed the number of inpatients during the year of the Covid crisis (2020) and the two years prior (2018, 2019). RESULTS: The number of inpatients in full-time hospitalization decreased gradually from 2018 to 2020 by 10.6%. This downward trend was observed in all age groups. In contrast, in crisis centers the number of inpatients increased by 13.4% between 2019 and 2020, while a 7.6% decrease was seen between 2018 and 2019. The greatest increase was observed in the 31-60-year age category, and particularly amongst 46-60-year-olds, i.e. 38.0%. CONCLUSION: The COVID-19 crisis was associated with an increase in the number of inpatients with a new episode of psychosis in crisis centers but not in full-time hospitalization. The profile of patients in crisis centers was different from that seen in preceding years and included more middle-to-late age adults. Particular attention should be given to this category of patients in the crisis environment to prevent the occurrence of new cases of psychosis in France.

Outcomes after acute coronary syndrome in patients with inflammatory bowel disease.

BACKGROUND: Patients with chronic inflammatory conditions are at an increased risk of developing atherothrombotic events. We aimed to assess the 1-year prognosis after myocardial infarction (MI) in patients with inflammatory bowel disease (IBD). METHODS: From the PMSI (Program de Medicalisation des Systèmes d'informatique) database, 246 out of 39,835 consecutive MI patients, hospitalized between 2012 and 2017, were diagnosed with IBD and followed up for 1 year after discharge. A matched cohort was built matching each MI patient with IBD to patient without IBD using age and sex (n = 1,470, matching ratio 1:5). RESULTS: Compared with MI patients without IBD, MI patients with IBD were younger (aged 69 vs. 70.8 years, p = 0.04) with a higher rate of increased body mass index (BMI) (21.5% vs 15%, p = 0.004), previously diagnosed ischemic cardiopathy (18.3% vs 12.6%, p < 0.0008) and chronic renal disease (8.9% vs 5.6%, p = 0.02). In our age- and sex-matched cohort, we found that all-cause mortality (9% vs 8.3, p = 0.729), stroke (0.8% vs 0.6%, p = 0.656) and hospitalization resulting from heart failure (3ool, .3% vs 3.5%, p = 0.846) did not significantly differ between the IBD and non-IBD groups within the first year after initial admission whereas the risk of recurrent MI was increased by 50% (2.9% vs 1.9%, p = 0.33) in the IBD group without reaching statistical significance. Moreover, a significant increase in the blood transfusion rate at the 1-year follow-up was observed in MI patients with IBD compared with MI patients without IBD (15.1% vs 9.4%, p < 0.001). CONCLUSION: Our findings suggest that both residual MI risk and bleeding events should be carefully monitored in MI patients diagnosed with chronic inflammation such as that observed in IBD.

Obesity and mortality in critically ill COVID-19 patients with respiratory failure.

BACKGROUND: Patients with obesity are at increased risk of severe COVID-19, requiring mechanical ventilation due to acute respiratory failure. However, conflicting data are obtained for intensive care unit (ICU) mortality. OBJECTIVE: To analyze the relationship between obesity and in-hospital mortality of ICU patients with COVID-19. SUBJECTS/METHODS: Patients admitted to the ICU for COVID-19 acute respiratory distress syndrome (ARDS) were included retrospectively. The following data were collected: comorbidities, body mass index (BMI), the severity of ARDS assessed with PaO2/FiO2 (P/F) ratios, disease severity measured by the Simplified Acute Physiology Score II (SAPS II), management and outcomes. RESULTS: For a total of 222 patients, there were 34 patients (15.3%) with normal BMI, 92 patients (41.4%) who were overweight, 80 patients (36%) with moderate obesity (BMI:30-39.9 kg/m2), and 16 patients (7.2%) with severe obesity (BMI ≥ 40 kg/m2). Overall in-hospital mortality was 20.3%. Patients with moderate obesity had a lower mortality rate (13.8%) than patients with normal weight, overweight or severe obesity (17.6%, 21.7%, and 50%, respectively; P = 0.011. Logistic regression showed that patients with a BMI ≤ 29 kg/m2 (odds ratio [OR] 3.64, 95% CI 1.38-9.60) and those with a BMI > 39 kg/m2 (OR 10.04, 95% CI 2.45-41.09) had a higher risk of mortality than those with a BMI from 29 to 39 kg/m2. The number of comorbidities (≥2), SAPS II score, and P/F < 100 mmHg were also independent predictors for in-hospital mortality. CONCLUSIONS: COVID-19 patients admitted to the ICU with moderate obesity had a lower risk of death than the other patients, suggesting a possible obesity paradox.

Cost-Effectiveness of Thrombectomy in Patients With Acute Ischemic Stroke: The THRACE Randomized Controlled Trial.

BACKGROUND AND PURPOSE: The benefit of mechanical thrombectomy added to intravenous thrombolysis (IVT) in patients with acute ischemic stroke has been largely demonstrated. However, evidence of the economic incentive of this strategy is still limited, especially in the context of a randomized controlled trial. We aimed to analyze whether mechanical thrombectomy combined with IVT (IVMT) is cost-effective when compared with IVT alone. METHODS: Individual-level cost and outcome data were collected in the THRACE randomized controlled trial (Thrombectomie des Artères Cerébrales) including patients with acute ischemic stroke. Patients were assigned to receive IVT or IVMT. The primary outcomes were modified Rankin Scale score of functional independence at 90 days (score 0-2) and the EuroQol-5D quality-of-life score at 1 year. RESULTS: Treating acute ischemic stroke with IVMT (n=200) versus IVT (n=202) increased the rate of functional independence by 10.9% (53.0% versus 42.1%; P=0.028), at an increased cost of $2116 (€1909), with no significant difference in mortality (12% versus 13%; P=0.70) or symptomatic intracranial hemorrhage (2% versus 2%; P=0.71). The cost per one averted case of disability was estimated at $19 379 (€17 480). The incremental cost per one quality-adjusted life year gained was $14 881 (€13 423). On sensitivity analysis, the probability of cost-effectiveness with IVMT was 84.1% in terms of cases of averted disability and 92.2% in terms of quality-adjusted life years. CONCLUSIONS: Based on randomized trial data, this study demonstrates that IVMT used to treat acute ischemic stroke is cost-effective when compared with IVT alone. CLINICAL TRIAL REGISTRATION: URL: http://www.clinicaltrials.gov. Unique identifier: NCT01062698.

The Best Use of the Charlson Comorbidity Index With Electronic Health Care Database to Predict Mortality.

BACKGROUND: The most used score to measure comorbidity is the Charlson index. Its application to a health care administrative database including International Classification of Diseases, 10th edition (ICD-10) codes, medical procedures, and medication required studying its properties on survival. Our objectives were to adapt the Charlson comorbidity index to the French National Health Insurance database to predict 1-year mortality of discharged patients and to compare discrimination and calibration of different versions of the Charlson index. METHODS: Our cohort included all adults discharged from a hospital stay in France in 2010 registered in the French National Health Insurance general scheme. The pathologies of the Charlson index were identified through ICD-10 codes of discharge diagnoses and long-term disease, specific medical procedures, and reimbursement of specific medications in the past 12 months before inclusion. RESULTS: We included 6,602,641 subjects at the date of their first discharge from medical, surgical, or obstetrical department in 2010. One-year survival was 94.88%, decreasing from 98.41% for Charlson index of 0-71.64% for Charlson index of ≥5. With a discrimination of 0.91 and an appropriate calibration curve, we retained the crude Cox model including the age-adjusted Charlson index as a 4-level score. CONCLUSIONS: Our study is the first to adapt the Charlson index to a large health care database including >6 million of inpatients. When mortality is the outcome, we recommended using the age-adjusted Charlson index as 4-level score to take into account comorbidities.

The impact of valve surgery on short- and long-term mortality in left-sided infective endocarditis: do differences in methodological approaches explain previous conflicting results?

AIMS: The aim of this study was to evaluate the effect of valve surgery (VS) in infective endocarditis (IE) on 5-year mortality and to evaluate whether conflicting results reported by previous studies could be due to differences in their methodological approaches. METHODS AND RESULTS: Four hundred and forty-nine patients with a definite left-sided IE were selected from a prospective, population-based study. Association between VS and 5-year mortality was examined with a Cox model. To determine the impact of different methodological approaches, we also analysed the relationship between VS and mortality in our database, according to each method used in the five previous studies. Valve surgery was performed in 240 patients (53%). It was associated with an increase in short-term mortality [within the first 14 post-operative days; adjusted hazard ratio (HR), 3.69; 95% confidence interval (CI), 2.17-6.25; P<0.0001] and a decrease in long-term mortality (adjusted HR, 0.55; 95% CI, 0.35-0.87; P=0.01). At least 188 days of follow-up were required for VS to provide an overall survival advantage. When applying each study's method to our database, we obtained results similar to those reported. CONCLUSION: Previous conflicting results appear to be related to differences in statistical methods. When using appropriate models, we found that VS was significantly associated with reduced long-term mortality.

Head-to-head comparison of diagnostic scores for acute heart failure in the emergency department: results from the PARADISE cohort.

BREST and PREDICA scores have recently emerged for the diagnosis of acute heart failure (AHF) in the emergency department (ED). This study aimed to perform a head-to-head comparison in a large contemporary cohort. BREST and PREDICA scores were calculated from, respectively, 11 and 8 routine clinical variables recorded in the ED in 1386 patients from the PArADIsE cohort. The diagnostic performance of the scores for adjudicated AHF diagnosis was assessed by the area under the ROC curve (AUC). Acute HF diagnosis was adjudicated according to the European Society of Cardiology criteria and BNP levels. A BREST score ≤ 3 or PREDICA score ≤ 1 was associated with low probabilities of AHF (5.7% and 2.6%, respectively). Conversely, a BREST score ≥ 9 or PREDICA score ≥ 5 was associated with a high risk of AHF diagnosis (77.3% and 66.9%, respectively) although more than half of the population was within the "gray zone" (4-8 and 2-4 for the BREST and PREDICA scores, respectively). Diagnostic performances of both scores were good (AUC 79.1%, [66.1-82.1] for the BREST score and 82.4%, [79.8-85.0] for the PREDICA score). PREDICA score had significantly higher diagnostic performance than BREST score (increase in AUC 3.3 [0.8-5.8], p = 0.009). Our study emphasizes the good diagnostic performance of both BREST and PREDICA scores, albeit with a significantly higher diagnostic performance of the PREDICA score. Yet, more than half of the population was classified within the "gray zone" by these scores; additional diagnostic tools are needed to ascertain AHF diagnosis in the ED in a majority of patients. Clinical trial registration: NCT02800122.

Leveraging National Claims and Hospital Big Data: Cohort Study on a Statin-Drug Interaction Use Case.

BACKGROUND: Linking different sources of medical data is a promising approach to analyze care trajectories. The aim of the INSHARE (Integrating and Sharing Health Big Data for Research) project was to provide the blueprint for a technological platform that facilitates integration, sharing, and reuse of data from 2 sources: the clinical data warehouse (CDW) of the Rennes academic hospital, called eHOP (entrepôt Hôpital), and a data set extracted from the French national claim data warehouse (Système National des Données de Santé [SNDS]). OBJECTIVE: This study aims to demonstrate how the INSHARE platform can support big data analytic tasks in the health field using a pharmacovigilance use case based on statin consumption and statin-drug interactions. METHODS: A Spark distributed cluster-computing framework was used for the record linkage procedure and all analyses. A semideterministic record linkage method based on the common variables between the chosen data sources was developed to identify all patients discharged after at least one hospital stay at the Rennes academic hospital between 2015 and 2017. The use-case study focused on a cohort of patients treated with statins prescribed by their general practitioner or during their hospital stay. RESULTS: The whole process (record linkage procedure and use-case analyses) required 88 minutes. Of the 161,532 and 164,316 patients from the SNDS and eHOP CDW data sets, respectively, 159,495 patients were successfully linked (98.74% and 97.07% of patients from SNDS and eHOP CDW, respectively). Of the 16,806 patients with at least one statin delivery, 8293 patients started the consumption before and continued during the hospital stay, 6382 patients stopped statin consumption at hospital admission, and 2131 patients initiated statins in hospital. Statin-drug interactions occurred more frequently during hospitalization than in the community (3800/10,424, 36.45% and 3253/14,675, 22.17%, respectively; P<.001). Only 121 patients had the most severe level of statin-drug interaction. Hospital stay burden (length of stay and in-hospital mortality) was more severe in patients with statin-drug interactions during hospitalization. CONCLUSIONS: This study demonstrates the added value of combining and reusing clinical and claim data to provide large-scale measures of drug-drug interaction prevalence and care pathways outside hospitals. It builds a path to move the current health care system toward a Learning Health System using knowledge generated from research on real-world health data.

Comparison of Unplanned 30-Day Readmission Prediction Models, Based on Hospital Warehouse and Demographic Data.

Anticipating unplanned hospital readmission episodes is a safety and medico-economic issue. We compared statistics (Logistic Regression) and machine learning algorithms (Gradient Boosting, Random Forest, and Neural Network) for predicting the risk of all-cause, 30-day hospital readmission using data from the clinical data warehouse of Rennes and from other sources. The dataset included hospital stays based on the criteria of the French national methodology for the 30-day readmission rate (i.e., patients older than 18 years, geolocation, no iterative stays, and no hospitalization for palliative care), with a similar pre-processing for all algorithms. We calculated the area under the ROC curve (AUC) for 30-day readmission prediction by each model. In total, we included 259114 hospital stays, with a readmission rate of 8.8%. The AUC was 0.61 for the Logistic Regression, 0.69 for the Gradient Boosting, 0.69 for the Random Forest, and 0.62 for the Neural Network model. We obtained the best performance and reproducibility to predict readmissions with Random Forest, and found that the algorithms performed better when data came from different sources.

Impact of a Healing Garden on Self-Consciousness in Patients with Advanced Alzheimer's Disease: An Exploratory Study1.

BACKGROUND: The environment of patients with Alzheimer's disease and related disorders (ADRD) intensifies the consequences of cognitive impairment and exacerbates behavioral problems if inappropriate or, conversely, mitigate these problems if its design is tailored to the needs of these persons. OBJECTIVE: We evaluate the impacts of hospitalization and of a specific healing garden on self-consciousness which represent a central impairment in ADRD. The self-consciousness questionnaire (SCQ), validated for its assessment at mild to moderate phases of the disease, explores the dimensions of personal identity, awareness of cognitive deficiencies, self-assessment of affective state, awareness of body representation, prospective memory, capacity for introspection, and moral judgments. METHODS: After having verified, by means of a preliminary study, its feasibility to the more advanced stages of the disease, this questionnaire allowed assessment of the impact of the environment by comparing, in routine care, patients hospitalized in a cognitive-behavioral unit who solely remain indoors with others who use the Art, Memory and Life healing garden. RESULTS: A significant decrease in SCQ due to an increase in anosognosia during hospitalization was observed in the group that remained indoors. For the group using the garden, a positive effect on overall SCQ score was observed, as a result of a significant improvement in body representation as the driving parameter. CONCLUSION: Factors that are grounded in the hypotheses that spearheaded its conception, such as sensory enrichment, familiarity, contact with nature, scaffolding role for cognitive functions, supportive effect for social interactions, and the "Nancy hypotheses of beauty", thus contribute to their validation.

Vaccine Education of Medical Students: A Nationwide Cross-sectional Survey.

Physicians play a primary role in vaccination of the population. Strong initial training of medical students is therefore essential to enable them to fulfill this role. This cross-sectional nationwide online survey conducted between September 2015 and January 2016 obtained 2,118 completed surveys from 6,690 eligible respondents (response rate, 32%) at 27 of 32 medical schools in France regarding their education about vaccination. The data were analyzed in April-June 2016. The survey covered their knowledge, attitudes, practices, and perceptions, and assessed their level of perceived preparedness for their future practice as interns. Around a third of the students (n=708, 34%) felt insufficiently prepared for questions about vaccination, especially for communicating with patients on side effects (n=1,381, 66%) and strategies to respond to vaccine hesitancy (n=1,217, 58%). The mean knowledge score was 26/45 (SD=7.9). Lecture courses, which are the main education method used in French medical schools (1,891/5,660 responses, 33%), were considered effective by only 11% of students (693/6,155 responses), whereas practical training was significantly associated with better perceived preparedness (p<0.001). In conclusion, education about vaccination during medical school in France is not optimal. Methods based on practical learning methods (case-based learning, clinical placements, and other hands-on methods) appear to produce the best results and must be favored for improving students' preparedness.