Associations of coping and health-related behaviors with medical students' well-being and performance during objective structured clinical examination.

Objective structured clinical examination (OSCE) is a valid method to evaluate medical students' competencies. The present cross-sectional study aimed at determining how students' coping and health-related behaviors are associated with their psychological well-being and performance on the day of the OSCE. Fourth-year medical students answered a set of standardized questionnaires assessing their coping (BCI) and health-related behaviors before the examination (sleep PSQI, physical activity GPAQ). Immediately before the OSCE, they reported their level of instant psychological well-being on multi-dimensional visual analogue scales. OSCE performance was assessed by examiners blinded to the study. Associations were explored using multivariable linear regression models. A total of 482 students were included. Instant psychological well-being was positively associated with the level of positive thinking and of physical activity. It was negatively associated with the level of avoidance and of sleep disturbance. Furthermore, performance was negatively associated with the level of avoidance. Positive thinking, good sleep quality, and higher level of physical activity were all associated with improved well-being before the OSCE. Conversely, avoidance coping behaviors seem to be detrimental to both well-being and OSCE performance. The recommendation is to pay special attention to students who engage in avoidance and to consider implementing stress management programs.Clinical trial: The study protocol was registered on clinicaltrial.gov NCT05393206, date of registration: 11 June 2022.

A time-adjusted control chart for monitoring surgical outcome variations.

BACKGROUND: Statistical Process Control (SPC) tools providing feedback to surgical teams can improve patient outcomes over time. However, the quality of routinely available hospital data used to build these tools does not permit full capture of the influence of patient case-mix. We aimed to demonstrate the value of considering time-related variables in addition to patient case-mix for detection of special cause variations when monitoring surgical outcomes with control charts. METHODS: A retrospective analysis from the French nationwide hospital database of 151,588 patients aged 18 and older admitted for colorectal surgery between January 1st, 2014, and December 31st, 2018. GEE multilevel logistic regression models were fitted from the training dataset to predict surgical outcomes (in-patient mortality, intensive care stay and reoperation within 30-day of procedure) and applied on the testing dataset to build control charts. Surgical outcomes were adjusted on patient case-mix only for the classical chart, and additionally on secular (yearly) and seasonal (quarterly) trends for the enhanced control chart. The detection of special cause variations was compared between those charts using the Cohen's Kappa agreement statistic, as well as sensitivity and positive predictive value with the enhanced chart as the reference. RESULTS: Within the 5-years monitoring period, 18.9% (28/148) of hospitals detected at least one special cause variation using the classical chart and 19.6% (29/148) using the enhanced chart. 59 special cause variations were detected overall, among which 19 (32.2%) discordances were observed between classical and enhanced charts. The observed Kappa agreement between those charts was 0.89 (95% Confidence Interval [95% CI], 0.78 to 1.00) for detecting mortality variations, 0.83 (95% CI, 0.70 to 0.96) for intensive care stay and 0.67 (95% CI, 0.46 to 0.87) for reoperation. Depending on surgical outcomes, the sensitivity of classical versus enhanced charts in detecting special causes variations ranged from 0.75 to 0.89 and the positive predictive value from 0.60 to 0.89. CONCLUSION: Seasonal and secular trends can be controlled as potential confounders to improve signal detection in surgical outcomes monitoring over time.

Association of Personality Traits With the Efficacy of Stress Management Interventions for Medical Students Taking Objective Structured Clinical Examinations.

PURPOSE: Personality traits are associated with psychophysiological stress, but few studies focus on medical students. This study aimed to better understand the association of personality traits with the efficacy of stress management interventions for medical students. METHOD: A randomized controlled trial was conducted with fourth-year students who took the objective structured clinical examination at Bernard University Lyon 1 in December 2021. Students were randomized in cardiac biofeedback, mindfulness, and control groups. Each intervention was implemented for 6 minutes before the examination. Physiological stress levels were collected during the intervention. Psychological stress levels were rated by students at baseline and after the intervention. Personality traits were assessed via the Big-Five Inventory. Interactions between personality traits and the efficacy of the interventions were analyzed using multivariable linear regression models. RESULTS: Four hundred eighty-one students participated. Higher baseline psychological stress levels were associated with higher neuroticism and agreeableness (ß = 10.27, 95% confidence interval (CI) [7.40, 13.13], P < .001 and ß = 3.42, 95% CI [0.98, 5.85], P = .006, respectively) and lower openness (ß = -4.95, 95% CI [-7.40, -2.49], P < .001). As compared to the control intervention, both stress management interventions led to lower levels of psychological (P < .001 for both) and physiological stress levels (biofeedback: P < .001 and mindfulness: P = .009). Biofeedback efficacy varied by extraversion score for psychological (ß = -5.66, 95% CI [-10.83, -0.50], P = .03) and physiological stress reduction (ß = -0.002, 95% CI [-0.003, -0.00004], P = .045). Mindfulness efficacy varied by agreeableness score for psychological stress reduction (ß = -7.87, 95% CI [-13.05, -2.68], P = .003). CONCLUSIONS: Students with a high score in extraversion may benefit more from biofeedback interventions, while students with high scores in agreeableness may benefit more from mindfulness interventions.

Length of Stay Prediction With Standardized Hospital Data From Acute and Emergency Care Using a Deep Neural Network.

OBJECTIVE: Length of stay (LOS) is an important metric for the organization and scheduling of care activities. This study sought to propose a LOS prediction method based on deep learning using widely available administrative data from acute and emergency care and compare it with other methods. PATIENTS AND METHODS: All admissions between January 1, 2011 and December 31, 2019, at 6 university hospitals of the Hospices Civils de Lyon metropolis were included, leading to a cohort of 1,140,100 stays of 515,199 patients. Data included demographics, primary and associated diagnoses, medical procedures, the medical unit, the admission type, socio-economic factors, and temporal information. A model based on embeddings and a Feed-Forward Neural Network (FFNN) was developed to provide fine-grained LOS predictions per hospitalization step. Performances were compared with random forest and logistic regression, with the accuracy, Cohen kappa, and a Bland-Altman plot, through a 5-fold cross-validation. RESULTS: The FFNN achieved an accuracy of 0.944 (CI: 0.937, 0.950) and a kappa of 0.943 (CI: 0.935, 0.950). For the same metrics, random forest yielded 0.574 (CI: 0.573, 0.575) and 0.602 (CI: 0.601, 0.603), respectively, and 0.352 (CI: 0.346, 0.358) and 0.414 (CI: 0.408, 0.422) for the logistic regression. The FFNN had a limit of agreement ranging from -2.73 to 2.67, which was better than random forest (-6.72 to 6.83) or logistic regression (-7.60 to 9.20). CONCLUSION: The FFNN was better at predicting LOS than random forest or logistic regression. Implementing the FFNN model for routine acute care could be useful for improving the quality of patients' care.

Virulent systemic feline calicivirus infection: a case report and first description in Ireland.

BACKGROUND: Virulent systemic feline calicivirus (VS-FCV) infection is an emerging disease. It is distinct from classic oronasal calicivirus infection as it manifests with unique systemic signs including severe cutaneous ulcerations, limb oedema, and high mortality, even in adequately vaccinated cats. Devastating epizootic outbreaks with hospital-acquired infections have been described in the United States, the United Kingdom, continental Europe and Australia with up to 54 cats affected in one outbreak and a mortality rate of up to 86%. This highly contagious and potentially fatal disease has not yet been reported in Ireland. CASE PRESENTATION: An 11-month-old male neutered vaccinated domestic shorthair cat was presented with a 10-day history of lethargy, decreased appetite and progressively worsening pitting oedema in all four limbs. The signs were first noted after another kitten from a high-density cat shelter was introduced in to the household. Additional physical examination findings included marked pyrexia, and lingual and cutaneous ulcers. Virulent systemic feline calicivirus was diagnosed based on compatible history and clinical signs, exclusion of other causes, and calicivirus isolation by RT-PCR both in blood and oropharyngeal samples. Negative calicivirus RT-PCR in blood following resolution of the clinical signs further supported the diagnosis. CONCLUSION: This case represents the first known case of VS-FCV infection in Ireland. Given the severity of the clinical signs, and the high risk for epizootic outbreaks, Irish veterinarians should be aware of the disease to ensure prompt diagnosis and implementation of adequate preventive measures, in order to limit the threat that this disease represents for the wider cat population and particularly given the risk of hospital-acquired VS-FCV infection. Virulent systemic calicivirus should be suspected in cats with pyrexia of unknown origin, oedema or ulceration affecting the limbs or the face, and exposure to rescue cats from high-density households.

Operating room organization and surgical performance: a systematic review.

BACKGROUND: Organizational factors may influence surgical outcomes, regardless of extensively studied factors such as patient preoperative risk and surgical complexity. This study was designed to explore how operating room organization determines surgical performance and to identify gaps in the literature that necessitate further investigation. METHODS: We conducted a systematic review according to PRISMA guidelines to identify original studies in Pubmed and Scopus from January 1, 2000 to December 31, 2019. Studies evaluating the association between five determinants (team composition, stability, teamwork, work scheduling, disturbing elements) and three outcomes (operative time, patient safety, costs) were included. Methodology was assessed based on criteria such as multicentric investigation, accurate population description, and study design. RESULTS: Out of 2625 studies, 76 met inclusion criteria. Of these, 34 (44.7%) investigated surgical team composition, 15 (19.7%) team stability, 11 (14.5%) teamwork, 9 (11.8%) scheduling, and 7 (9.2%) examined the occurrence of disturbing elements in the operating room. The participation of surgical residents appeared to impact patient outcomes. Employing specialized and stable teams in dedicated operating rooms showed improvements in outcomes. Optimization of teamwork reduced operative time, while poor teamwork increased morbidity and costs. Disturbances and communication failures in the operating room negatively affected operative time and surgical safety. CONCLUSION: While limited, existing scientific evidence suggests that operating room staffing and environment significantly influences patient outcomes. Prioritizing further research on these organizational drivers is key to enhancing surgical performance.

Combining the Hospital Frailty Risk Score With the Charlson and Elixhauser Multimorbidity Indices to Identify Older Patients at Risk of Poor Outcomes in Acute Care.

OBJECTIVE: The Hospital Frailty Risk Score (HFRS) can be applied to medico-administrative datasets to determine the risks of 30-day mortality and long length of stay (LOS) in hospitalized older patients. The objective of this study was to compare the HFRS with Charlson and Elixhauser comorbidity indices, used separately or combined. DESIGN: A retrospective analysis of the French medical information database. The HFRS, Charlson index, and Elixhauser index were calculated for each patient based on the index stay and hospitalizations over the preceding 2 years. Different constructions of the HFRS were considered based on overlapping diagnostic codes with either Charlson or Elixhauser indices. We used mixed logistic regression models to investigate the association between outcomes, different constructions of HFRS, and associations with comorbidity indices. SETTING: 743 hospitals in France. PARTICIPANTS: All patients aged 75 years or older hospitalized as an emergency in 2017 (n=1,042,234).Main outcome measures: 30-day inpatient mortality and LOS >10 days. RESULTS: The HFRS, Charlson, and Elixhauser indices were comparably associated with an increased risk of 30-day inpatient mortality and long LOS. The combined model with the highest c-statistic was obtained when associating the HFRS with standard adjustment and Charlson for 30-day inpatient mortality (adjusted c-statistics: HFRS=0.654; HFRS + Charlson = 0.676) and with Elixhauser for long LOS (adjusted c-statistics: HFRS= 0.672; HFRS + Elixhauser =0.698). CONCLUSIONS: Combining comorbidity indices and HFRS may improve discrimination for predicting long LOS in hospitalized older people, but adds little to Charlson's 30-day inpatient mortality risk.

Comparison of healthcare costs before and after a STEMI: A French national health data system-based cohort study.

BACKGROUND: Few studies have investigated real-world healthcare costs following a myocardial infarction (MI) and, to our knowledge, none after an ST-elevation MI (STEMI) specifically. Producing such data is important in order to help evaluate the economic burden of STEMI, but also to feed economic evaluation models and eventually show the economic interest of reducing STEMI incidence. The aim of this study was to estimate the healthcare cost in the year preceding and the year following a STEMI in France, in order to estimate the surplus in healthcare resource consumption after a STEMI. METHODS: This study was conducted from the healthcare system perspective. The individual data from the HIBISCUS-STEMI cohort, which included patients with acute STEMI undergoing primary percutaneous coronary intervention, were matched with the French national health data system (Système National des Données de Santé, SNDS) using a probabilistic method. All expenses (in- and out-hospital) presented for reimbursement were taken into account to estimate a mean annual healthcare cost. RESULTS: A total 258 patients from the HIBISCUS-STEMI cohort were included in this economic study. The total mean healthcare cost was estimated at €3516 before the STEMI, and at €9980 after the STEMI. Hospitalizations constituted the largest cost item, 27 % of the total cost before the STEMI and 41.8 % after the STEMI (Δ + 338.8 %). Follow-up and rehabilitative care represented the second largest cost item (25.9 % before and 18 % after the STEMI, Δ + 96.7 %). Treatments represented 19.4 % of the total cost before the STEMI and 17.2 % after (Δ + 150.8 %). CONCLUSIONS: This study shows a significant surplus (threefold) of healthcare resource consumption in the year following a STEMI compared to the year preceding the STEMI.

Intrathoracic eosinophilic sclerosing fibroplasia with intralesional bacteria in a cat.

Case summary: A 9-year-old neutered female domestic shorthair cat was presented for investigation of a cranial mediastinal mass. Moderate peripheral eosinophilia and mild-to-moderate polyclonal gammopathy were identified. A thoracoabdominal CT scan documented a cranial mediastinal mass encircling the trachea. Ultrasound-guided fine-needle aspiration and core-needle biopsy were performed, but cytology and histopathology were inconclusive. Surgical debulking was performed. Further histological samples identified severe pyogranulomatous and eosinophilic fibrosing mediastinitis, consistent with feline eosinophilic sclerosing fibroplasia. Gram staining and fluorescence in situ hybridisation (FISH) identified numerous Gram-positive coccoid bacteria. Eosinophilia and hyperglobulinaemia resolved after surgery and combined antimicrobial and immunosuppressive therapy. The cat died 3 months later after developing acute haemorrhagic diarrhoea and dyspnoea. Relevance and novel information: Eosinophilic sclerosing fibroplasia is reportedly mainly confined to the gastrointestinal tract in cats. Less commonly, extragastrointestinal cases have been described. Lesions in the mediastinal or sternal lymph nodes have been reported, all in association with evident gastrointestinal involvement. The presence of pleural effusion was variable in these cases. To the authors' knowledge, this is the first report of eosinophilic sclerosing fibroplasia presenting due to lower respiratory signs in a cat. Intralesional bacteria were identified using Gram staining and FISH examination. The presence of intralesional bacteria in the normally sterile mediastinal tissue may support the involvement of penetrating injuries in the pathogenesis of the disease. Eosinophilic sclerosing fibroplasia should be suspected in any cat with abdominal and/or thoracic masses, particularly if associated with peripheral eosinophilia and polyclonal gammopathy.

Two-stage multi-objective optimization for ICU bed allocation under multiple sources of uncertainty.

Due to the impact of COVID-19, a significant influx of emergency patients inundated the intensive care unit (ICU), and as a result, the treatment of elective patients was postponed or even cancelled. This paper studies ICU bed allocation for three categories of patients (emergency, elective, and current ICU patients). A two-stage model and an improved Non-dominated Sorting Genetic Algorithm II (NSGA-II) are used to obtain ICU bed allocation. In the first stage, bed allocation is examined under uncertainties regarding the number of emergency patients and their length of stay (LOS). In the second stage, in addition to including the emergency patients with uncertainties in the first stage, it also considers uncertainty in the LOS of elective and current ICU patients. The two-stage model aims to minimize the number of required ICU beds and maximize resource utilization while ensuring the admission of the maximum number of patients. To evaluate the effectiveness of the model and algorithm, the improved NSGA-II was compared with two other methods: multi-objective simulated annealing (MOSA) and multi-objective Tabu search (MOTS). Drawing on data from real cases at a hospital in Lyon, France, the NSGA-II, while catering to patient requirements, saves 9.8% and 5.1% of ICU beds compared to MOSA and MOTS. In five different scenarios, comparing these two algorithms, NSGA-II achieved average improvements of 0%, 49%, 11.4%, 9.5%, and 17.1% across the five objectives.

Effect of the Implementation of the French Hospital Regionalization Policy on Patient Mobility.

A new law was voted in France in 2016 to increase cooperation between public sector hospitals. Hospitals were encouraged to work under the leadership of local referral centers and to share their support functions (e.g., information systems) with newly created hospital groups, called "Regional Hospital Groups." The law made it compulsory for each public sector hospital to become affiliated with one of 136 newly created hospital groups. The policy's aim was to ensure that all patients were sent to the hospital best qualified to treat their unique condition, among the hospitals available at the regional level. Therefore, we aimed to assess whether this regionalization policy was associated with changes in observed patterns of patient mobility between hospitals. This nationwide observational study followed an interrupted time series design. For each stay occurring from 2014 to 2019, we ascertained whether or not the stay was followed by mobility toward another hospital within 90 days, and whether or not the receiving hospital was part of the same Regional Hospital Group as the sender hospital. The proportion of mobility directed toward the same regional hospital group increased from 22.9% in 2014 (95% CI 22.7-23.1) to 24.6% in 2019 (95% CI 24.4-24.8). However, the absence of discontinuity during the policy change year was consistent with the hypothesis of a preexisting trend toward regionalization. Therefore, the policy did not achieve major changes in patterns of mobility between hospitals. Other objectives of the reform, including long-term consequences on the healthcare offer, remain to be assessed.

Economic analysis of surgical outcome monitoring using control charts: the SHEWHART cluster randomised trial.

IMPORTANCE: Surgical complications represent a considerable proportion of hospital expenses. Therefore, interventions that improve surgical outcomes could reduce healthcare costs. OBJECTIVE: Evaluate the effects of implementing surgical outcome monitoring using control charts to reduce hospital bed-days within 30 days following surgery, and hospital costs reimbursed for this care by the insurer. DESIGN: National, parallel, cluster-randomised SHEWHART trial using a difference-in-difference approach. SETTING: 40 surgical departments from distinct hospitals across France. PARTICIPANTS: 155 362 patients over the age of 18 years, who underwent hernia repair, cholecystectomy, appendectomy, bariatric, colorectal, hepatopancreatic or oesophageal and gastric surgery were included in analyses. INTERVENTION: After the baseline assessment period (2014-2015), hospitals were randomly allocated to the intervention or control groups. In 2017-2018, the 20 hospitals assigned to the intervention were provided quarterly with control charts for monitoring their surgical outcomes (inpatient death, intensive care stay, reoperation and severe complications). At each site, pairs, consisting of one surgeon and a collaborator (surgeon, anaesthesiologist or nurse), were trained to conduct control chart team meetings, display posters in operating rooms, maintain logbooks and design improvement plans. MAIN OUTCOMES: Number of hospital bed-days per patient within 30 days following surgery, including the index stay and any acute care readmissions related to the occurrence of major adverse events, and hospital costs reimbursed for this care per patient by the insurer. RESULTS: Postintervention, hospital bed-days per patient within 30 days following surgery decreased at an adjusted ratio of rate ratio (RRR) of 0.97 (95% CI 0.95 to 0.98; p<0.001), corresponding to a 3.3% reduction (95% CI 2.1% to 4.6%) for intervention hospitals versus control hospitals. Hospital costs reimbursed for this care per patient by the insurer significantly decreased at an adjusted ratio of cost ratio (RCR) of 0.99 (95% CI 0.98 to 1.00; p=0.01), corresponding to a 1.3% decrease (95% CI 0.0% to 2.6%). The consumption of a total of 8910 hospital bed-days (95% CI 5611 to 12 634 bed-days) and €2 615 524 (95% CI €32 366 to €5 405 528) was avoided in the intervention hospitals postintervention. CONCLUSIONS: Using control charts paired with indicator feedback to surgical teams was associated with significant reductions in hospital bed-days within 30 days following surgery, and hospital costs reimbursed for this care by the insurer. TRIAL REGISTRATION NUMBER: NCT02569450.

A new standardized tool for quantification of closed-loop communication in trauma care: CAST Grid reliability study.

BACKROUND: The CAST Grid has been developed to evaluate the use of closed-loop communication (CLC) in the trauma bay. METHODS: The CAST Grid and two validated non-technical team performance assessment tools (the TEAM and T-NOTECHS grids) were completed by 2 independent reviewers based on trauma care simulation videos from a French Level 1 trauma center. Intra- and inter-rater agreements were evaluated for CLC parameters and non-technical performance, and correlations between these parameters were analyzed. RESULTS: The study analyzed 11 videos. The intra- and inter-rater agreement for the number of CLC per minute (CLC/min) was moderate and good, respectively, based on Lin's concordance correlation coefficient [95%CI] (0.57 [-0.40;0.94] and 0.77 [0.33;0.94]). However, the agreement was poor for the percentage of CLC (0.37 [-0.58;0.89] and -0.36 [-0.71;0.14], respectively). The study found that a lower number of CLC/min was correlated with an increased duration of the simulation (r = -0.75 [-0.93; -0.25]). CONCLUSION: The CAST Grid showed a relatively good inter-rater agreement to quantify the number of CLC/min which was inversely correlated with the duration of care. This tool opens up the possibility of quantifying CLC and allows for new analyses of team functioning and interactions.

Diagnosis, Classification, and Assessment of the Underlying Etiology of Uveitis by Artificial Intelligence: A Systematic Review.

Recent years have seen the emergence and application of artificial intelligence (AI) in diagnostic decision support systems. There are approximately 80 etiologies that can underly uveitis, some very rare, and AI may lend itself to their detection. This synthesis of the literature selected articles that focused on the use of AI in determining the diagnosis, classification, and underlying etiology of uveitis. The AI-based systems demonstrated relatively good performance, with a classification accuracy of 93-99% and a sensitivity of at least 80% for identifying the two most probable etiologies underlying uveitis. However, there were limitations to the evidence. Firstly, most data were collected retrospectively with missing data. Secondly, ophthalmic, demographic, clinical, and ancillary tests were not reliably integrated into the algorithms' dataset. Thirdly, patient numbers were small, which is problematic when aiming to discriminate rare and complex diagnoses. In conclusion, the data indicate that AI has potential as a diagnostic decision support system, but clinical applicability is not yet established. Future studies and technologies need to incorporate more comprehensive clinical data and larger patient populations. In time, these should improve AI-based diagnostic tools and help clinicians diagnose, classify, and manage patients with uveitis.

The increasing age of respiratory syncytial virus-related hospitalisation during COVID-19 pandemic in Lyon was associated with reduced hospitalisation costs.

BACKGROUND: Preventive measures applied during the COVID-19 pandemic have modified the age distribution, the clinical severity and the incidence of Respiratory Syncytial Virus (RSV) hospitalisations during the 2020/21 RSV season. The aim of the present study was to estimate the impact of these aspects on RSV-associated hospitalisations (RSVH) costs stratified by age group between pre-COVID-19 seasons and 2020/21 RSV season. METHODS: We compared the incidence, the median costs, and total RSVH costs from the national health insurance perspective in children < 24 months of age during the COVID-19 period (2020/21 RSV season) with a pre-COVID-19 period (2014/17 RSV seasons). Children were born and hospitalised in the Lyon metropolitan area. RSVH costs were extracted from the French medical information system (Programme de Médicalisation des Systémes d'Information). RESULTS: The RSVH-incidence rate per 1000 infants aged < 3 months decreased significantly from 4.6 (95 % CI [4.1; 5.2]) to 3.1 (95 % CI [2.4; 4.0]), and increased in older infants and children up to 24 months of age during the 2020/21 RSV season. Overall, RSVH costs for RSVH cases aged below 2 years old decreased by €201,770 (31 %) during 2020/21 RSV season compared to the mean pre-COVID-19 costs. CONCLUSIONS: The sharp reduction in costs of RSVH in infants aged < 3 months outweighed the modest increase in costs observed in the 3-24 months age group. Therefore, conferring a temporal protection through passive immunisation to infants aged < 3 months should have a major impact on RSVH costs even if it results in an increase of RSVH in older children infected later in life. Nevertheless, stakeholders should be aware of this potential increase of RSVH in older age groups presenting with a wider range of disease to avoid any bias in estimating the cost-effectiveness of passive immunisation strategies.

Continued Performance Improvement-What Practicing Surgeons Can Learn From Athletes.

This Viewpoint describes how surgeons can optimize performance with methods for continuous performance improvement used by athletes.

Veno-arterial extracorporeal membrane oxygenation for cardiogenic shock after acute myocardial infarction: Insights from a French nationwide database.

BACKGROUND: We aimed to analyze the impact of timing of implantation (strategy-outcome relationship) and volume of procedures (volume-outcome relationship) on survival of veno-arterial extracorporeal membrane oxygenation (VA ECMO) for cardiogenic shock complicating acute myocardial infarction (AMI). METHODS: We conducted an observational retrospective study through two propensity score-based analyses using a nationwide database between January 2013 and December 2019. We classified patients into early implantation (VA ECMO on the day of primary percutaneous coronary intervention [PCI]) and delayed implantation (VA ECMO beyond the day of PCI) groups. We classified patients into low- or high-volume groups based on the median hospital volume. RESULTS: During the study period 649 VA ECMO were implanted across 20 French hospitals. Mean age was 57.1 ± 10.4 years, 80% were male. Overall, 90-day mortality was 64.3%. Patients in the early implantation group (n = 479, 73.8%) did not show a statistical difference in 90-day mortality than in the delayed group (n = 170, 26.2%) (HR: 1.18; 95% CI 0.94-1.48; p = 0.153). The mean number of VA ECMO implanted during the study period by low-volume centers was 21.3 ± 5.4 as compared to 43.6 ± 11.8 in high-volume centers. There was no significant difference in 90-day mortality between high-volume and low-volume centers (HR: 1.00; 95% CI: 0.82-1.23; p = 0.995). CONCLUSIONS: In this real-world nationwide study, we did not find a significant association between early VA ECMO implantation as well as high-volume centers and lower mortality in AMI-related refractory cardiogenic shock.

The Economic Cost of Thyroid Cancer in France and the Corresponding Share Associated With Treatment of Overdiagnosed Cases.

OBJECTIVES: Thyroid cancer incidence in France has increased rapidly in recent decades. Most of this increase has been attributed to overdiagnosis, the major consequence of which is overtreatment. We aimed to estimate the cost of thyroid cancer management in France and the corresponding cost proportion attributable to the treatment of overdiagnosed cases. METHODS: Multiple data sources were integrated: the mean cost per patient with thyroid cancer was estimated by using the Echantillon Généraliste des Bénéficiaires data set; thyroid cancer cases attributable to overdiagnosis were estimated for 21 departments using data from the French network of cancer registries and extrapolated to the whole country; medical records from 6 departments were used to refine the diagnosis and care pathway. RESULTS: Between 2011 and 2015, 33 911 women and 10 846 men in France were estimated to be diagnosed of thyroid cancer, with mean cost per capita of €6248. Among those treated, 8114 to 14 925 women and 1465 to 3626 men were due to overdiagnosis. The total cost of thyroid cancer patient management was €203.5 million (€154.3 million for women and €49.3 million for men), of which between €59.9 million (or 29.4% of the total cost, lower bound) and €115.9 million (or 56.9% of the total cost, upper bound) attributable to treatment of overdiagnosed cases. CONCLUSIONS: The management of thyroid cancer represents not only a relevant clinical and public health problem in France but also a potentially important economic burden. Overdiagnosis and corresponding associated treatments play an important role on the total costs of thyroid cancer management.

Excess mortality among non-COVID-19 surgical patients attributable to the exposure of French intensive and intermediate care units to the pandemic.

PURPOSE: The mobilization of most available hospital resources to manage coronavirus disease 2019 (COVID-19) may have affected the safety of care for non-COVID-19 surgical patients due to restricted access to intensive or intermediate care units (ICU/IMCUs). We estimated excess surgical mortality potentially attributable to ICU/IMCUs overwhelmed by COVID-19, and any hospital learning effects between two successive pandemic waves. METHODS: This nationwide observational study included all patients without COVID-19 who underwent surgery in France from 01/01/2019 to 31/12/2020. We determined pandemic exposure of each operated patient based on the daily proportion of COVID-19 patients among all patients treated within the ICU/IMCU beds of the same hospital during his/her stay. Multilevel models, with an embedded triple-difference analysis, estimated standardized in-hospital mortality and compared mortality between years, pandemic exposure groups, and semesters, distinguishing deaths inside or outside the ICU/IMCUs. RESULTS: Of 1,870,515 non-COVID-19 patients admitted for surgery in 655 hospitals, 2% died. Compared to 2019, standardized mortality increased by 1% (95% CI 0.6-1.4%) and 0.4% (0-1%) during the first and second semesters of 2020, among patients operated in hospitals highly exposed to pandemic. Compared to the low-or-no exposure group, this corresponded to a higher risk of death during the first semester (adjusted ratio of odds-ratios 1.56, 95% CI 1.34-1.81) both inside (1.27, 1.02-1.58) and outside the ICU/IMCU (1.98, 1.57-2.5), with a significant learning effect during the second semester compared to the first (0.76, 0.58-0.99). CONCLUSION: Significant excess mortality essentially occurred outside of the ICU/IMCU, suggesting that access of surgical patients to critical care was limited.