CRP under 130 mg/L rules out the diagnosis of Legionella pneumophila serogroup 1 (URINELLA Study).

INTRODUCTION: In case of pneumonia, some biological findings are suggestive for Legionnaire's disease (LD) including C-reactive protein (CRP). A low level of CRP is predictive for negative Legionella Urinary-Antigen-Test (L-UAT). METHOD: Observational retrospective study in Nord-Franche-Comté Hospital with external validation in Besançon University Hospital, France which included all adults with L-UAT performed during January 2018 to December 2022. The objective was to determine CRP optimal threshold to predict a L-UAT negative result. RESULTS: URINELLA included 5051 patients (83 with positive L-UAT). CRP optimal threshold was 131.9 mg/L, with a negative predictive value (NPV) at 100%, sensitivity at 100% and specificity at 58.0%. The AUC of the ROC-Curve was at 88.7% (95% CI, 86.3-91.1). External validation in Besançon Hospital patients showed an AUC at 89.8% (95% CI, 85.5-94.1) and NPV, sensitivity and specificity was respectively 99.9%, 97.6% and 59.1% for a CRP threshold at 131.9 mg/L; after exclusion of immunosuppressed patients, index sensitivity and NPV reached also 100%. CONCLUSION: In case of pneumonia suspicion with a CRP level under 130 mg/L (independently of the severity) L-UAT is useless in immunocompetent patients with a NPV at 100%. We must remain cautious in patients with symptoms onset less than 48 h before CRP dosage.

Effect of storage time and donor sex of transfused red blood cells on 1-year survival in patients undergoing cardiac surgery: an observational study.

BACKGROUND: Red blood cell (RBC) storage lesions and RBCs from females transfused into male recipients may have adverse effects on transfusion recipients' survival. We hypothesized that the effect of donor sex and the effect of age of blood on mortality would be most apparent in cardiac surgery patients. STUDY DESIGN AND METHODS: Using data from French Blood Services and two university hospitals, we conducted a retrospective cohort study on cardiac surgery patients whose first transfusion occurred between 2007 and 2011. The age of blood and donor sex effects on 1-year survival were studied using Cox regression modeling, with time-dependent stratification on the number of RBCs and adjustments for the type of surgery and other products transfused. RESULTS: Among the 2715 cardiac surgery patients, 85.1% were alive after 1 year. Age of blood and donor sex were associated with survival before adjustments (p < 0.0001). However, the adjusted hazard ratios (HRs) for patients transfused with blood stored for 29 days or more versus 14 days or less were 0.97 (95% confidence interval [95% CI], 0.69-1.35; p = 0.98) and 1.22 (95% CI, 0.81-1.82) for patients who received only sex-mismatched RBCs versus all matched units (p = 0.27). For males transfused solely with female RBCs, the HR was 0.96 (95% CI, 0.57-1.61; p = 0.69); in females transfused only with male RBCs, it was 2.03 (95% CI, 0.87-4.73; p = 0.17). CONCLUSIONS: In this first study of survival after transfusion in France, there was no significant effect for age of blood or donor sex. Contrary to previously reported data, female RBCs appear to be safe for male recipients.

Automatic detection of cirrhosis in hospitalized patients: a pragmatic experience.

BACKGROUND/AIM: We evaluated the relevance of a systematic automatic detection of cirrhosis using biochemical markers in hospitalized patients. METHODS: We automatically calculated three free biochemical tests (APRI, Fib-4, and Forns) in patients consecutively hospitalized in our university hospital between July and September, 2010. Patients >18 years not known to suffer from chronic liver disease, were contacted to undergo liver stiffness measurement (LSM) as a reference diagnostic tool. To limit false positives, we required at least one APRI≥2 (indicating cirrhosis) and Fib-4>3.25 and/or Forns>6.9, without obvious overestimation. RESULTS: A total of 10,035 APRI, 9903 Fib-4, and 1250 Forns were available in 4074 patients. The fibrosis tests were independently influenced by the location of the patient, especially Cardiology (Lower Forns) and Hematology/Oncology Departments (higher APRI, Fib-4, and Forns). Overall, 101 patients (2.48%) were suspected to have cirrhosis. LSM identified two cases of cirrhosis (LSM>13 kPa). In intent-to-diagnose analyses, the highest positive predictive values of the APRI, Fib-4, and Forns for the diagnosis of cirrhosis were 1.98, 1.98, and 11.76%, respectively. The positive predictive value never exceeded 50% in per-protocol analyses when considering patients with numerous positive results of the fibrosis tests. CONCLUSION: In hospitalized patients, automatic detection of cirrhosis on the basis of APRI, Fib-4, and Forns was inefficient because of too many false-positive results.

Improved survival of cirrhotic patients with variceal bleeding over the decade 2000-2010.

BACKGROUND AND OBJECTIVE: Advances in the management of variceal bleeding (VB) have been highlighted recently. We aimed at assessing whether changing the management of VB has improved the outcome (mortality and rebleeding rates). METHODS: The files of two cohorts (n=57, 2000-2001 and n=64, 2008-2009) of patients referred to our university center were reviewed after a cross-searching using two coding systems. Data were recorded during the six months after VB. RESULTS: As compared to 2000-2001, more use of general anesthesia (25.4% vs. 11.1%; P=0.049), band ligations (96.1% vs. 71.4%; P=0.001), octreotide (95.3% vs. 80.7%; P=0.012) and antibiotic prophylaxis (93.8% vs. 82.5%; P=0.09) were performed in 2008-2009, whereas the number of red-cell units transfused during the hospital stay (4.3 ± 3.2 vs. 7.1 ± 5.7; P=0.005) decreased. Surprisingly, more than 60% of patients reached the emergency department from home without medical assistance in both periods. In 2008-2009, patients had more comorbidities and no patients underwent early-TIPS but the 6-week mortality rate (24.6% vs.10.9%; P=0.048) was lower. The 6-week mortality was associated with high MELD score (HR=1.13; 95%CI: 1.08-1.18) and hypovolemic shock (HR=5.36; 95%CI: 1.96-14.67) at admission. In multivariate analysis adjusted on MELD and comorbidities, the 2008-2009 period (HR: 0.42; 95%CI: 0.20-0.87; P=0.02) was associated with a lower 6-month mortality rate. CONCLUSIONS: Although cirrhotic patients with VB had more comorbidities in 2008-2009 and received no early-TIPS, their prognosis has improved during this last decade concomitantly to a more intensive care and a lower transfusion strategy.

Outcomes associated with routine systemic antifungal therapy in critically ill patients with Candida colonization.

PURPOSE: To assess the evolution of patient deep colonization by Candida spp. in a surgical ICU over an 8-year period. METHODS: This retrospective, observational study included all patients hospitalized for more than 2 days in a surgical and trauma ICU of a university hospital, from 2005 to 2012. Mycological samples were monitored weekly from five sites (oropharyngeal, rectal, gastric, tracheal and urinary). Preemptive fluconazole therapy was started in patients highly colonized with Candida albicans. The evolution in Candida spp. involved in the deep colonization sites distribution over the study period (main outcome measure, trend chi-square and time-series analysis), antifungal consumption, ICU-acquired candidemia and mortality were determined. RESULTS: Among the 3029 patients with ICU stay >48 h, 2651 had at least one set of mycological sampling. Thirty percent of the 31,171 samples were positive to Candida spp. Caspofungin consumption increased over the years, whereas fluconazole consumption decreased. No trend in C. albicans colonization was observed, after adjusting on colonization risk-factors. A significant increase of acquired C. glabrata colonization was observed, whereas the clearing of C. parapsilosis colonization significantly decreased. No significant shift of colonization to other Candida spp. and mortality was observed. CONCLUSIONS: Preemptive strategy of antifungal drug prescriptions in highly colonized ICU patients induced an increase in C. glabrata colonization without significant shift of colonization to other Candida spp. in surgical ICU patients. However, the potential detrimental impact of fluconazole on Candida ecology in ICU and/or on Candida susceptibility to antifungal drugs should be considered, and deserves further studies.

[Cost of hospital-based management of acute myeloid leukemia: from analytical to procedure-based tarification]. / Coûts hospitaliers de prise en charge des leucémies aiguës myéloïdes: de la comptabilité analytique à la T2A.

The confrontation of the macro- and micro-economic approaches of hospital costs is a recurrent question, in particular for pathologies where length of stay is highly variable, like acute myeloid leukemias (AML). This monocentric and retrospective study compares direct hospital medical costs of induction and relapse treatment sequences for AML, valued according to four different approaches: the analytic accounting system of our hospital, the French Diagnosis Related Group (DRG) cost databases of hospital discharges (readjusted, or not, to actual hospital stay duration), and official tariffs from the new French DRG prospective payment system. The average cost of hospital AML care valued by the analytic accounting system of our hospital is 61,248 euros for the induction phase and 91,702 euros for the relapse phase. All other national valuation methods result in a two- to four-fold underestimation of these costs. Even though AMLs are now individualized in the 10th version of the French diagnosis related group (DRG) classification, the impact of this issue in other pathologies is going to increase with the gradual implementation of the French DRG prospective payment system. That is why it must be assessed before the progressive extension of this financing system.