De-escalation and discontinuation strategies in high-risk neutropenic patients: an interrupted time series analyses of antimicrobial consumption and impact on outcome.

Febrile neutropenia (FN) is the main reason for antibiotic prescription in hematology wards where, on the other hand, antibiotic stewardship (AS) is poorly explored. The objectives of the present study were to evaluate (1) the impact of an AS intervention on antibiotic consumption and (2) the applicability and acceptance rate of the intervention and its clinical impact. A persuasive AS intervention based on European Conference on Infection in Leukaemia (ECIL) guidelines for FN was implemented in a high-risk hematology ward in a tertiary referral public university hospital. This included the creation and diffusion of flow charts on de-escalation and discontinuation of antibiotics for FN, and the introduction in the team of a doctor dedicated to the implementation of flow charts and to antibiotic prescription revision. All consecutive patients receiving antibiotics during hospitalization were included. A segmented linear regression model was performed for the evaluation of antibiotic consumption, taking into account 1-year pre-intervention period and 6-month intervention period. Overall, 137 consecutive antibiotic prescriptions were re-evaluated, 100 prescriptions were for FN. A significant reduction of the level of carbapenem consumption was observed during the intervention period (level change (estimate coefficient ± standard error) = - 135.28 ± 59.49; p = 0.04). Applicability and acceptability of flow charts were high. No differences in terms of intensive care unit transfers, bacteremia incidence, and mortality were found. A persuasive AS intervention in hematology significantly reduced carbapenem consumption without affecting outcome and was well accepted. This should encourage further applications of ECIL guidelines for FN.

[External validation of the short emergency geriatric assessment (SEGA) instrument on the SAFES cohort]. / Validation externe de la grille de fragilité SEGA sur la cohorte SAFES.

The aim of the study was to achieve the external validation of the SAGA instrument on the SAFES cohort. This was a prospective longitudinal multicentre cohort study, including patients aged 75 years or over, hospitalized in a short stay medical ward via emergency department. A comprehensive geriatric assessment was implemented. The psychometric validation enabled the study of feasibility, internal consistency, convergent, discriminant, and predictive validity of the instrument. The 1 306 patients of the cohort was 85±6 years, with a majority of women (65%). The completion rate of the SEGA instrument was 94%. Internal consistency was good (Cronbach alpha coefficient=0.7). Convergent validity was poor: Donini instrument (kappa=0.18; IC 95%=0.13-0.23), Rockwood instrument (kappa=0.04; IC 95%=0.02-0.06), and Winograd instrument (kappa=0.04; IC 95%=0.01-0.07). The ability of the instrument to discriminate clinically different groups was good. The SEGA instrument predicted well one-year mortality as well as one-year institution admission. Despite poor convergent validity (which is classic with frailty tools, SEGA instrument has satisfactory metrological properties, allowing its use in emergency departments and immediate post-emergency circumstances.

MDCT Linear and Volumetric Analysis of Adrenal Glands: Normative Data and Multiparametric Assessment.

OBJECTIVES: To study linear and volumetric adrenal measurements, their reproducibility, and correlations between total adrenal volume (TAV) and adrenal micronodularity, age, gender, body mass index (BMI), visceral (VAAT) and subcutaneous adipose tissue volume (SAAT), presence of diabetes, chronic alcoholic abuse and chronic inflammatory disease (CID). METHODS: We included 154 patients (M/F, 65/89; mean age, 57 years) undergoing abdominal multidetector row computed tomography (MDCT). Two radiologists prospectively independently performed adrenal linear and volumetric measurements with semi-automatic software. Inter-observer reliability was studied using inter-observer correlation coefficient (ICC). Relationships between TAV and associated factors were studied using bivariate and multivariable analysis. RESULTS: Mean TAV was 8.4 ± 2.7 cm(3) (3.3-18.7 cm(3)). ICC was excellent for TAV (0.97; 95 % CI: 0.96-0.98) and moderate to good for linear measurements. TAV was significantly greater in men (p < 0.0001), alcoholics (p = 0.04), diabetics (p = 0.0003) and those with micronodular glands (p = 0.001). TAV was lower in CID patients (p = 0.0001). TAV correlated positively with VAAT (r = 0.53, p < 0.0001), BMI (r = 0.42, p < 0.0001), SAAT (r = 0.29, p = 0.0003) and age (r = 0.23, p = 0.005). Multivariable analysis revealed gender, micronodularity, diabetes, age and BMI as independent factors influencing TAV. CONCLUSIONS: Adrenal gland MDCT-based volumetric measurements are more reproducible than linear measurements. Gender, micronodularity, age, BMI and diabetes independently influence TAV. KEY POINTS: • Volumetric measurements are more reproducible than linear measurements for adrenal glands. • Inter-observer reproducibility of adrenal gland volume is excellent using semiautomatic software. • Gender, age, BMI, and diabetes independently influence total adrenal gland volume. • Adrenal micronodularity is associated with increased total adrenal gland volume.