Care pathways of sepsis survivors: sequelae, mortality and use of healthcare services in France, 2015-2018.

BACKGROUND: Individuals who survive sepsis are at high risk of chronic sequelae, resulting in significant health-economic costs. Several studies have focused on aspects of healthcare pathways of sepsis survivors but comprehensive, longitudinal overview of their pathways of care are scarce. The aim of this retrospective, longitudinal cohort study is to identify sepsis survivor profiles based on their healthcare pathways and describe their healthcare consumption and costs over the 3 years following their index hospitalization. METHODS: The data were extracted from the French National Hospital Discharge Database. The study population included all patients above 15 years old, with bacterial sepsis, who survived an incident hospitalization in an acute care facility in 2015. To identify survivor profiles, state sequence and clustering analyses were conducted over the year following the index hospitalization. For each profile, patient characteristics and their index hospital stay and sequelae were described, as well as use of care and its associated monetary costs, both pre- and post-sepsis. RESULTS: New medical (79.2%), psychological (26.9%) and cognitive (18.5%) impairments were identified post-sepsis, and 65.3% of survivors were rehospitalized in acute care. Cumulative mortality reached 36.6% by 3 years post-sepsis. The total medical cost increased by 856 million € in the year post-sepsis. Five patient clusters were identified: home (65.6% of patients), early death (12.9%), late death (6.8%), short-term rehabilitation (11.3%) and long-term rehabilitation (3.3%). Survivors with early and late death clusters had high rates of cancer and primary bacteremia and experienced more hospital-at-home care post-sepsis. Survivors in short- or long-term rehabilitation clusters were older, with higher percentage of septic shock than those coming back home, and had high rates of multiple site infections and higher rates of new psychological and cognitive impairment. CONCLUSIONS: Over three years post-sepsis, different profiles of sepsis survivors were identified with different mortality rates, sequels and healthcare services usage and cost. This study confirmed the importance of sepsis burden and suggests that strategies of post-discharge care, in accordance with patient profile, should be further tested in order to reduce sepsis burden.

One-year hospital readmission for recurrent sepsis: associated risk factors and impact on 1-year mortality-a French nationwide study.

BACKGROUND: Sepsis is a complex health condition, leading to long-term morbidity and mortality. Understanding the risk factors for recurrent sepsis, as well as its impact on mid- and long-term mortality among other risk factors, is essential to improve patient survival. METHODS: A risk factor analysis, based on French nationwide medico-administrative data, was conducted on a cohort of patients above 15 years old, hospitalized with an incident sepsis in metropolitan France between 1st January 2018 and 31st December 2018 and who survived their index hospitalization. Two main analyses, focusing on outcomes occurring 1-year post-discharge, were conducted: a first one to assess risk factors for recurrent sepsis and a second to assess risk factors for mortality. RESULTS: Of the 178017 patients surviving an incident sepsis episode in 2018 and included in this study, 22.3% died during the 1-year period from discharge and 73.8% had at least one hospital readmission in acute care, among which 18.1% were associated with recurrent sepsis. Patients aged between 56 and 75, patients with cancer and renal disease, with a long index hospital stay or with mediastinal or cardiac infection had the highest odds of recurrent sepsis. One-year mortality was higher for patients with hospital readmission for recurrent sepsis (aOR 2.93; 99% CI 2.78-3.09). Among all comorbidities, patients with cancer (aOR 4.35; 99% CI 4.19-4.52) and dementia (aOR 2.02; 99% CI 1.90-2.15) had the highest odds of 1-year mortality. CONCLUSION: Hospital readmission for recurrent sepsis is one of the most important risk factors for 1-year mortality of septic patients, along with age and comorbidities. Our study suggests that recurrent sepsis, as well as modifiable or non-modifiable other risk factors identified, should be considered in order to improve patient care pathway and survival.

Trends in bacterial sepsis incidence and mortality in France between 2015 and 2019 based on National Health Data System (Système National des données de Santé (SNDS)): a retrospective observational study.

OBJECTIVE: This study aims to provide a case definition of sepsis of presumed bacterial aetiology based on 10th revision of the International Classification of Diseases (ICD-10) codes, to assess trends in sepsis incidence and mortality between 2015 and 2019 in France, and to describe the characteristics of affected patients and hospital stays. DESIGN: Nationwide, population-based, retrospective observational study. SETTING: Metropolitan France between 2015 and 2019. PARTICIPANTS: Between 2015 and 2019, 1 224 433 patients with sepsis of presumed bacterial aetiology were selected from the French National Hospital Discharge Database (Programme de Médicalisation des Systèmes d'Information) and were identified from corresponding ICD-10 codes for explicit sepsis or implicit sepsis. MAIN OUTCOMES MEASURES: Annual overall and age-specific and gender-specific incidence and 95% CI, as well as trends in sepsis incidence and mortality, were estimated. Comorbidities, length of hospital stay and outcomes were described. RESULTS: The sex-standardised and age-standardised incidence per 100 000 (95% CI) increased from 357 (356.0 to 359.0) in 2015 to 403 (401.9 to 405.0) in 2019 and remained higher for males compared with females. Children under 1 year and patients over 75 years consistently had the highest incidence. The most common comorbidities were cancer and chronic heart failure. The median hospital length of stay was 12 days. Most patients came from home, but only half returned home after their hospital stay and approximately 15% were discharged to long-term care. In-hospital mortality was about 25% and declined along the study period. CONCLUSIONS: Medico-administrative databases can be used to provide nationwide estimates of the in-hospital burden of bacterial sepsis. The results confirm the high burden of sepsis in France. These data should be complemented by estimating the additional burden associated with fungal and viral infections during the COVID-19 pandemic.

Individual decontamination measures reduce by two the incidence of surgical site infections in spinal surgery.

BACKGROUND: In spinal surgery, incidence of surgical site infections (SSI) is estimated between 1 and 10%. It results in increased morbidity, mortality and cost of management. Individual Staphylococcus aureus (SA) decolonization has already proved efficiency to prevent those events in various surgical domains. The aim of this study was to evaluate a strategy of prevention of SSI and in particular the decolonization of the nasal carriage of SA by a protocol with Mupirocin application. METHODS: We conducted a bicentric observational study on 5314 spinal surgery patients over a seven-year period. In both center, we compared periods before and after implementation of two measures: modification of antibioprophylaxis and staphylococcus decolonization. Homogeneity of the different samples of patients was assessed through measure of individual and surgical variables. We measured monthly incidence of SSI and evaluated its evolution in order to assess efficiency of these interventions. RESULTS: The incidence of SSI decreased by half, from 7.3% to 3% at the Beaujon Hospital and from 8.3% to 3.9% at the Georges-Pompidou European Hospital (GPEH). We do not observe any significant decrease of SA rate in these SSI. CONCLUSION: We believe that Staphylococcus aureus decolonization should be recommended in spinal surgery, and should be combined with an overall improvement of the quality of care.

Are suicide rates higher in the cancer population? An investigation using forensic autopsy data.

Previous population-based studies have identified increased suicide rates among cancer patients. Available post mortem data on the contribution of cancer to completed suicide are limited, however. This study examines forensic autopsy data in order to assess whether cancer is significantly more frequent in a suicide population compared with a control population. In total, 232 cases were included in both the suicide and the control groups. Based on a complete standard histological examination, cancer was significantly more often found in the suicide group than in the control one (8.6% vs. 3.9%, p=0.03). The multivariate analysis also showed that the presence of cancer increased the risk of suicide. Moreover, cancer was not known to the deceased in 70% of cases, while the most frequent mental disease found in cancer-related suicide cases was depression (75%). In the 20 cancer-related suicide cases analysed herein, it was difficult to ascertain whether malignancy was the only motive for committing suicide, as cancer could be considered to be either a major causative factor for suicide or an incidental finding. Therefore, further research is warranted with the help of the psychological autopsy method to investigate the link between suicide and cancer further.

Is post-mortem ultrasonography a useful tool for forensic purposes?

PURPOSE: To investigate the interest of post-mortem ultrasonography in the diagnosis of pathological background, and manner and cause of death. METHODS: Post-mortem ultrasonography exams were carried out on 38 fresh human adult cadavers referred to the Department of Forensic Medicine and Pathology (Garches, France). Data obtained from ultrasonography were independently compared with further forensic autopsy findings. RESULTS: Two important limitations relative to ultrasound utilization appeared: hyper-echoic abdominal and thoracic walls, with gas distension of the whole digestive tube and subcutaneous tissues (due to precocious putrefactive gas releasing); and difficulty in accessing lateral and posterior structures (i.e. liver, spleen, kidneys, lung bases, aorta) due to rigor mortis and evident non-compliance of the subject. Post-mortem diagnoses (moderate ascites, gallbladder stones, bladder globe, chronic kidney disease, cirrhosis, thyroid gland cysts and hypertrophy, intrauterine device), were strongly limited. False negative diagnoses comprised fatty liver, pleural effusion, thoracic aortic dissection, and focal organ and/or soft tissues lesions (for example, wounds or infarcts). CONCLUSION: According to the results, post-mortem ultrasonography seems to have a very limited role for forensic purposes. Other post-mortem utilizations are cited, proposed, and discussed.

Memory functions following surgery for temporal lobe epilepsy in children.

Surgical treatment appears to improve the cognitive prognosis in children undergoing surgery for temporal lobe epilepsy (TLE). The beneficial effects of surgery on memory functions, particularly on material-specific memory, are more difficult to assess because of potentially interacting factors such as age range, intellectual level, left-handedness, type of surgery and seizure outcome. This study investigated memory functions in 20 right-handed children who had left or right-temporal lobe surgery - including hippocampectomy - and became seizure-free. The neuropsychological evaluation included tests measuring verbally and visually mediated episodic memory, everyday memory as well as attention/working memory and language/semantic memory. We also assessed the relationships between age of seizure onset, general cognitive ability and memory functions. Children with TLE showed poor memory efficiency before surgery that tended to improve about 1 year after surgery. We found a material-specific memory effect, especially after surgery-9 (out of 12) children with left TLE had worse verbal memory results while 5 (out of 8) with right TLE had worse visual memory results. Post-operatively, most children had poor everyday memory performance on the Rivermead Behavioural Memory Test. No significant relationship was observed between episodic memory scores and age of epilepsy onset but children with early onset remained with lower Performance IQ values, Rey's figure copy scores and naming performances after surgery. Surgery significantly improved all the attention/working memory scores, some verbal episodic memory tasks and naming test performances. A different pattern of episodic and semantic memory limitations related to left or right TLE was observed.