MACVIA-LR (Fighting Chronic Diseases for Active and Healthy Ageing in Languedoc-Roussillon): A Success Story of the European Innovation Partnership on Active and Healthy Ageing.

The Région Languedoc Roussillon is the umbrella organisation for an interconnected and integrated project on active and healthy ageing (AHA). It covers the 3 pillars of the European Innovation Partnership on Active and Healthy Ageing (EIP on AHA): (A) Prevention and health promotion, (B) Care and cure, (C) and (D) Active and independent living of elderly people. All sub-activities (poly-pharmacy, falls prevention initiative, prevention of frailty, chronic respiratory diseases, chronic diseases with multimorbidities, chronic infectious diseases, active and independent living and disability) have been included in MACVIA-LR which has a strong political commitment and involves all stakeholders (public, private, patients, policy makers) including CARSAT-LR and the Eurobiomed cluster. It is a Reference Site of the EIP on AHA. The framework of MACVIA-LR has the vision that the prevention and management of chronic diseases is essential for the promotion of AHA and for the reduction of handicap. The main objectives of MACVIA-LR are: (i) to develop innovative solutions for a network of Living labs in order to reduce avoidable hospitalisations and loss of autonomy while improving quality of life, (ii) to disseminate the innovation. The three years of MACVIA-LR activities are reported in this paper.

A reappraisal of ICU and long-term outcome of allogeneic hematopoietic stem cell transplantation patients and reassessment of prognosis factors: results of a 5-year cohort study (2009-2013).

Epidemiology and prognosis of complications related to allogeneic hematopoietic stem cell transplant (HSCT) recipients requiring admission to intensive care unit (ICU) have not been reassessed precisely in the past few years. We performed a retrospective single-center study on 318 consecutive HSCT patients (2009-2013), analyzing outcome and factors prognostic of ICU admission. Among these patients, 73 were admitted to the ICU. In all, 32 patients (40.3%) died in ICU, 46 at hospital discharge (63%) and 61 (83.6%) 1 year later. Survivors had a significantly lower sequential organ failure assessment (SOFA) score, serum lactate and bilirubin upon ICU admission. Catecholamine support, mechanical ventilation (MV) and/or renal replacement therapy during ICU stay, a delayed organ support and an active graft versus host disease (GvHD) significantly worsen the outcome. By multivariate analysis, the worsening of SOFA score from days 1 to 3, the need for MV and the occurrence of an active GvHD were predictive of mortality. In conclusion, the incidence of HSCT-related complications requiring an admission to an ICU was at 22%, with an ICU mortality rate of 44%, and 84% 1 year later. A degradation of SOFA score at day 3 of ICU, need of MV and occurrence of an active GvHD are main predictive factors of mortality.

[Ecthyma gangrenosum and Pseudomonas aeruginosa septicemia in intensive care unit]. / Ecthyma gangrenosum et septicémie àPseudomonas aeruginosa en réanimation.

We report a case of a Pseudomonas aeruginosa septicemia complicated by a septic shock after chemotherapy for pulmonary cancer. Bilateral legs necrotic purpura corresponding to echtyma gangrenosum lesions (erythematous inflammatory halo, positive bacteriologic cutaneous biopsy) was noted 48 h previous to the shock. Echtyma gangrenosum manifestation should alert physician to P. aeruginosa septicemia risk and can be useful to guide probabilist antibiotherapy.

Quality assessment in surgical care departments: proposal for a scoring system in terms of structure and process.

OBJECTIVE: To build a score able to reflect and rank surgical departments according to a definition of "quality" in terms of structure and process. METHODS: Collaborative design of a quality score in the framework of the French clinical research project NosoQual. Feasibility and observational study in 46 surgical departments visited between November 2002 and March 2003 according to standardised procedures. A bibliographic review followed by expert consultations, a field test, analysis and a final reconsideration leading to the definition of a consensual score. RESULTS: 138 variables comprised the score. They were classified into seven dimensions, each representing a different aspect of quality of care in surgery. According to the threshold and weight attributed to every variable, scores were calculated for each department. The average level of achievement of the scores varied from 42% to 71% of theoretical maxima. The variability of the scores related to the seven dimensions was larger and more significant than the one expressed by the overall score (coefficient of variation=0.1). CONCLUSION: This analytical work contributed to the design of a quality score for surgery. However, the progress of the score should continue to take into account all the obstacles that were observed and to meet the high requirements of the actual patient safety issue.

[Adult onset nemaline myopathy revealed by respiratory insufficiency]. / Révélation d'une myopathie à bâtonnets par une insuffisance respiratoire de l'adulte.

INTRODUCTION: We report a case of nemaline myopathy revealed in adulthood by a respiratory insufficiency. CASE REPORT: A 26-year-old patient, without past history, was admitted with respiratory and right cardiac insufficiency which appeared in a few days. There was a severe restrictive lung impairment with nocturnal hypoventilation. Minor skeletal abnormalities and areflexia suggested a congenital myopathy. Muscle biopsy revealed a nemaline myopathy. CONCLUSION: Respiratory insufficiency is common in nemaline myopathy with infancy or childhood onset, but very rare in adults. It may be explained by multiple mechanisms.

Unusual implication of biopsy forceps in outbreaks of Pseudomonas aeruginosa infections and pseudo-infections related to bronchoscopy.

Between January and April 2003, a sudden increase in positive respiratory tract specimens for Pseudomonas aeruginosa was observed in an intensive care unit of the University Teaching Hospital of Montpellier, France. Most of the strains were cultured from bronchoalveolar lavage fluid samples, suggesting that bronchoscopic procedures could be implicated. The relationships between isolates were investigated by antibiotyping and pulsed-field gel electrophoresis. Both phenotypic and molecular markers allowed identification of two consecutive nosocomial outbreaks of respiratory infections related to two different bronchoscopes. These two outbreaks implicated nine and seven patients, respectively. Four of these 16 patients had true infections and recovered with antibiotic therapy. Inspection of both bronchoscopes revealed a damaged internal channel caused by defective biopsy forceps. These defects led to improper cleaning and disinfection of the bronchoscopes despite adherence to all current reprocessing procedures. The two outbreaks were controlled after replacing the inner channels of the bronchoscopes and switching from use of re-usable to disposable biopsy forceps. These outbreaks emphasize the need to establish surveillance procedures for detecting contamination of bronchoscopes, and the importance of recording each endoscopic procedure to facilitate further investigations if needed.

[Descending necrotizing mediastinitis. A diagnosis not to be ignored]. / La médiastinite descendante nécrosante. Un diagnostic à ne pas méconnaître.

BACKGROUND: Acute descending posterior mediastinitis is a very serious condition which can develop after common ear-nose-throat infections. Clinical manifestations are typical and must be recognized rapidly for early diagnosis. CASE REPORTS: We report two cases. In the first case, a 28-year-old man had a retropharyngeal abscess which fistulized into the left pleural cavity. Three operations were necessary to achieve cure and favorable outcome. In the second case, mediastinitis was diagnosed in a 39-year-old patient following a throat infection. Despite early surgery, outcome was fatal due to development of pericarditis and tamponnade. DISCUSSION: These two cases illustrate the variable course of descending mediastinitis and emphasize the importance of early medicosurgical cure. Treatment is based on intravenous antibiotics using a combination of 2 or 3 drugs at high doses in association with emergency surgery and extensive mediastinal washings. Despite well-conducted treatment, descending necrotizing mediastinitis may lead to a fatal outcome.

Membranous tracheal rupture after endotracheal intubation.

BACKGROUND: Tracheobronchial rupture after tracheal intubation has been infrequently reported. We report 6 cases of membranous tracheal rupture after endotracheal intubation treated at our institution over 7 years. METHODS: Overinflation of the tracheal cuff was speculated to be a frequent cause of the tracheal damage because the lesion was always a linear laceration of the posterior membranous wall. The diagnosis was suspected on the basis of common signs such as subcutaneous emphysema, respiratory distress, pneumomediastinum, and pneumothorax. Fiberoptic bronchoscopy was the best means of confirming the diagnosis and determining the location and extent of the lesion. In 5 patients, extensive laceration with severe respiratory disorders required emergent repair through a right posterolateral thoracotomy. RESULTS: There were two postoperative deaths unrelated to the tracheal lesion. A patient with a small tracheal defect and favorable clinical presentation showed a rapid positive outcome after conservative treatment. CONCLUSIONS: Tracheal intubation-related airway ruptures are rare but probably underestimated. Early recognition and emergent repair are essential, because failure to do so could result in potentially lethal events.

[Parvovirus B19 infection revealed by acute renal insufficiency]. / Infection à parvovirus B19 révélée par une insuffisance rénale aiguë.

Human adult Parvovirus B19 infection is a well known disease most frequently seen in haematology and cancerology. To our knowledge, however, renal involvement in this context has never been reported. A case of severe infection caused by this virus is reported, where multiple organ involvement is associated with acute renal failure. The outcome was favourable with temporary dialysis and symptomatic treatment. Mechanisms of renal failure, presumably multifactorial, are discussed in the light of this case.

Ambulatory home total parenteral nutrition.

Ambulatory total parenteral nutrition (TPN) at home was used in 85 patients within a 6-yr period. Indications include severe malabsorption, fistulas, anorexia nervosa, and malignancies. The median duration of home TPN (HPN) was 67 days (range: 30-4,155 days). HPN duration for patients with benign diseases was longer [357.12 days (range: 30-4,155 days)] than for cancer patients [93.54 days (range: 30-421 days)]. Under HPN, patients gained a good nutritional status with an increase of total protein (p less than 0.001) and serum albumin levels (p less than 0.001). Weight gain was also significant (p less than 0.001). The rehospitalization rate was low (7.8%), but it was higher when HPN lasted for more than 3 months (10.87% +/- 1.58%) compared with short-term HPN (5.69% +/- 1.25%). Metabolic complications were unusual, and rehospitalization was related to the oncological treatment and/or infectious complications. Therefore, ambulatory HPN is a nutritional support that can significantly improve the life of patients with alimentary failure. Moreover, HPN allows significant cost savings compared to the alternative of prolonged hospitalization.