Dental Emergencies Management in COVID-19 Pandemic Peak: A Cohort Study.

Due to the global coronavirus disease 2019 pandemic, the high risk of cross-contamination and the overload of hospital facilities have resulted in a real urgency for restricting dental emergency patient flow. In this context, the objectives of the current work were to 1) measure the ability of a triage-based management strategy to limit patient admission and 2) evaluate the success rate of both on-site and remote emergency management regarding symptom relief and pain control over a 1-mo period. We included all patients contacting the dental medicine department for an emergency consultation during the lockdown, between April 1 and April 30, 2020 (N = 570). Following a telephone consultation and based on preestablished admission guidelines, a decision was made at baseline (T0) to either admit the patient for treatment or perform remote management by providing advice and/or drug prescription. Patients were then followed up systematically at 1 wk and 1 mo. Management failure was defined as the need for emergency admission for patients managed remotely since T0 and for new emergency admission for those admitted at T0. The global follow-up rate of patients with a complete data set was 91.4% (N = 521). Of included patients, 49.3% could be managed without admission for emergency reasons for 1 mo. The proportion of successful management was 71.8% and 90.2% at 1 mo for remote and on-site management, respectively. To conclude, the proposed triage-based emergency management strategy with systematic follow-up was a good compromise between limiting patient admission and ensuring effective symptom relief and pain control. The strategy can be useful in situations where regulation of the emergency patient flow is required.

Orthostatic blood pressure drop and cardiovascular and psychotropic medication dosages in acutely ill geriatric inpatients.

OBJECTIVES: . To investigate the dose-response relationship between cardiovascular or psychotropic medication dosages and falling orthostatic blood pressure in geriatric inpatients. METHODS: . This cross-sectional study included 100 consecutive geriatric inpatients of a Belgian hospital. The end points were the maximum changes of systolic (sBP) and diastolic (dBP) blood pressure in a standing up position at one or three minutes. The dosages of six classes of vascular and five classes of psychotropic medications were expressed in terms of a proportion of defined daily doses (DDD). Bivariate and multivariate linear regression models were used. RESULTS: . The 100 geriatric patients (85 ± 5 years, 58 % women) received 7.7 ± 4 medications (mean DDD: vascular = 1.0, psychotropic = 0.74) on the day of an orthostatic test (lying sBP: 136 ± 21; dBP: 72 ± 14 mm Hg). In a standing position, sBP and dBP fell by 12 ± 17 and 11 ± 5 mmHg, respectively. At the individual level, BP change was not correlated with vascular DDD (sBP: p = 0.07, r2 = 0.04; dBP: p = 0.59; r2 = 0.004) nor with psychotropic DDD (sBP: p = 0.14, r2 = 0.02; dBP: p = 0.82; r2 = 0.0). In multivariate analysis, sBP drop was positively associated with age, diabetes, falls history, and number of medications, but not with the DDD of any of the medication classes, while dBP drop was positively associated with age, diabetes, stroke and anaemia, but again with the DDD of any of the medication classes. CONCLUSION: . No correlation was found between vascular and psychotropic medication dosages and the orthostatic blood pressure drop expressed as a continuous variable.

[HIV-associated haematological complications]. / Pathologies hématologiques liées à l'infection par le VIH.

Despite recent advances in combined anti- retroviral therapy that have profoundly changed the prognosis of HIV infection, HIV-associated haematological complications remains frequent whatever the stage of the disease. Some types of lymphoma observed a dramatic reduction in their incidences but others such as diffuse B-cell lymphoma and Hodkin lymphoma remain as frequent as before the CART era. Treatments for lymphoma are nowadays not different for people living with HIV than for others. Other non- neoplastic diseases such as immune thrombo- penic purpura, thrombotic microangiopathies and hemophagocytic lymphohistiocytosis are still associated with HIV infection and will be discussed.

Bien que les traitements antirétroviraux combinés aient profondément modifié le pronostic de l'infection par le VIH, les complications hématolo- giques associées au VIH restent fréquentes à tous les stades de la maladie. Certains types de lymphomes ont vu leur incidence fortement diminuer alors que d'autres (lymphome B diffus et lymphome de Hodgkin) ont gardé une incidence stable. Le traitement de ces lymphomes n'est plus censé différer entre les personnes vivant avec le VIH et les autres. Les pathologies non malignes telles que les purpuras thrombo- péniques immuns, les microangiopathies thrombotiques et les syndromes d'activation macrophagiques, également associées au VIH, seront également abordées.

Spousal Caregiving Is Associated with an Increased Risk of Frailty: A Case-Control Study.

BACKGROUND: Evidence suggests that providing care for a disabled elderly person may have implications for the caregiver's own health (decreased immunity, hypertension, and depression). OBJECTIVE: Explore if older spousal caregivers are at greater risks of frailty compared to older people without a load of care. DESIGN: Case-control study. SETTING: Participants were assessed at home in Wallonia, Belgium. PARTICIPANTS: Cases: community-dwelling spousal caregivers of older patients, recruited mainly by the geriatric outpatient clinic. CONTROLS: people living at home with an independent spouse at the functional and cognitive level matched for age, gender and comorbidities. MEASUREMENTS: Mini nutritional assessment-short form (MNA-SF), short physical performance battery (SPPB), frailty phenotype (Fried), geriatric depression scale (GDS-15), clock drawing test, sleep quality, and medications. The multivariable analysis used a conditional logistic regression. RESULTS: Among 79 caregivers, 42 were women; mean age and Charlson comorbidity index were 79.4±5.3 and 4.0±1.2, respectively. Among care-receivers (mean age 81.4±5.2), 82% had cognitive impairment. Caregiving was associated with a risk of frailty (Odd Ratio (OR) 6.66; 95% confidence interval (CI) 2.20-20.16), the consumption of antidepressants (OR 4.74; 95% CI 1.32 -17.01), shorter nights of sleep (OR 3.53; 95% CI 1.37-9.13) and more difficulties maintaining a social network (OR 5.25; 95% CI 1.68-16.40). CONCLUSIONS: Spousal caregivers were at an increased risk of being frail, having shorter nights of sleep, taking antidepressants and having difficulties maintaining their social network, compared to non-caregiver controls. Older spousal caregivers deserve the full attention of professionals to prevent functional decline and anticipate a care breakdown.

Very long-term Voice Handicap Index Voice Outcomes after Montgomery Thyroplasty: A cross-sectional study.

OBJECTIVE: The aim of this multicentric cross-sectional study was to examine the permanency of Montgomery thyroplasty (MTIS) results from a patient's perspective. DESIGN: The study consisted of collecting Voice Handicap Index (VHI-30) questionnaires from patients who had previously been operated with MTIS between 2 and 12 years before. Very long-term (>2 years) postoperative data were compared with the previously acquired preoperative and early postoperative VHI results. Influence of factors such as age, gender, size/side of the prosthesis and length of the follow-up were also analysed. SETTING: Multicentric study involving three tertiary European voice centres. PARTICIPANTS: Forty-nine unilateral vocal fold paralysis (UVFP) patients, treated by MTIS, were included in the study. MAIN OUTCOME MEASURES: The Voice Handicap Index-30 score. RESULTS & CONCLUSIONS: The median VHI was significantly different over time-points (Friedman's test P < .001), with a significant difference between preoperative and early postoperative time-points (median VHI: 70 vs 21, respectively; P < .001) and between preoperative and very long-term postoperative time-points (median VHI: 70 vs 16, respectively; P < .001). The median VHI did not differ for the early and very long-term postoperative time-points (median VHI: 21 vs 16; P = .470). Age differences, gender differences and size/side differences of the prostheses, centres where surgery took place and length of the follow-up showed no significant influence. Medialisation thyroplasty (MT) overall and MTIS, in particular, should be considered as a possible standard of care for UVFP when permanency of voice results is sought.

Health problems associated with irritable bowel syndrome: analysis of a primary care registry.

BACKGROUND: Associations between irritable bowel syndrome and other health problems have been described, but comprehensive reports are missing, especially in primary care. AIMS: To investigate which health problems are associated with irritable bowel syndrome, how they cluster together and when they are typically diagnosed relative to irritable bowel syndrome. METHODS: We used Intego, a general practice registry in Flanders, Belgium. Patients with an irritable bowel syndrome diagnosis (n = 13 701) were matched with controls without gastrointestinal diagnosis and controls with organic gastrointestinal disease. Long-term prevalences of 680 symptoms and diagnoses were compared between patients and controls. Results were summarised using functional enrichment analysis and visualised in a network and we calculated incidence rate ratios in the 10 years before and after the irritable bowel syndrome diagnosis for the network's key components. RESULTS: Various symptoms and infections, but not neoplasms, were enriched in irritable bowel syndrome patients compared to both control groups. We characterised the comorbidities of irritable bowel syndrome as psychosocial health problems, urogenital symptoms and infections, musculoskeletal symptoms and other somatic symptoms. These had a uniform incidence in the years around the irritable bowel syndrome diagnosis, and did not structurally precede or follow irritable bowel syndrome. CONCLUSIONS: Irritable bowel syndrome shares long-term associations with psychosocial health problems, urogenital symptoms and infections, musculoskeletal symptoms and other somatic symptoms in primary care. Clinicians are encouraged to take comorbidities into account when diagnosing and managing irritable bowel syndrome, as this may have important treatment implications.

Assessment of passive musculoarticular ankle stiffness in children, adolescents and young adults with haemophilic ankle arthropathy.

OBJECTIVES: To measure passive musculoarticular ankle stiffness (PMAAS) and its intra- and interday reliability in adult control subjects without ankle disorders. We also sought to quantify PMAAS in children, adolescents and young adults with haemophilia (CAAwH) taking into account the accurate tibiotalar and subtalar joints structural status obtained by magnetic resonance imaging (MRI). METHODS: We included 23 CAAwH and 23 typically developing boys (TDB) matched by age, weight and height, along with 25 healthy volunteers for reliability assessment. All CAAwH underwent bilateral ankle MRI, with anatomical status assessed using the International Prophylaxis Study Group MRI scale. All CAAwH underwent PMAAS testing for both sides randomly vs the dominant side (DS) in TDBs. For assessing viscous stiffness (VS) and elastic stiffness (ES), eight different oscillation frequencies were randomly repeated three times for each subject. RESULTS: Good-to-excellent intra- and interday reliability was observed for ES and VS variables. No relevant differences were observed between the ankle viscoelastic properties in CAAwH without joint damage and matched TDBs, whereas the study revealed significantly increased ES in the affected ankles of CAAwH with severe unilateral joint involvement compared to the non-affected joint. CONCLUSION: This study confirmed increased ES in the severely affected ankles of CAAwH compared to non-affected sides. No differences in the ankle viscoelastic properties of CAAwH with or without joint damage were observed, however, compared to matched TDB.

Predictors of clinicians' underuse of daily sedation interruption and sedation scales.

PURPOSE: The purpose of the study is to identify predictors of underuse of sedation scales and daily sedation interruption (DSI). METHODS: We surveyed all physicians and seven nurses in every Belgian intensive care unit (ICU), addressing practices and perceptions on guideline recommendations. Underuse was defined for sedation scales as use less than 3× per day and for DSI as never using it. Classification trees and logistic regressions identified predictors of underuse. RESULTS: Underuse of sedation scales and DSI was found for 16.6% and 32.5% of clinicians, respectively. Strongest predictors of underuse of sedation scales were agreeing that using them daily takes much time and being a physician (rather than a nurse). Further predictors were confidence in their ability to measure sedation levels without using scales, for physicians, and nurse/ICU bed ratios less than 1.98, for nurses. The strongest predictor of underuse of DSI among physicians was the perception that DSI impairs patients' comfort. Among nurses, lack of familiarity with DSI, region, and agreeing DSI should only be performed upon medical orders best predicted underuse. CONCLUSIONS: Workload considerations hamper utilization of sedation scales. Poor familiarity, for nurses, and negative perception of impact on patients' comfort, for physicians, both reduce DSI utilization. Targeting these obstacles is essential while designing quality improvement strategies to minimize sedative use.

Impact of being overweight on factor VIII dosing in children with haemophilia A.

INTRODUCTION: Treatment of haemophilia A (HA) requires infusions of factor VIII (FVIII) concentrates. The number of FVIII units infused to obtain a specific circulating FVIII level is calculated with the formula: [body weight (BW) (kg) × desired FVIII increase (%)]/2, with the assumption that each unit of FVIII infused per kg of BW increases the circulating FVIII level by 2%. AIM: The aim of this study was to evaluate the impact of several morphometric parameters (BW, body mass index (BMI)-for-age, height), age and type of FVIII concentrate on FVIII recovery in children with HA. METHODS: A total of 66 children aged between 10 and 18 with severe HA selected from six pharmacokinetic (PK) clinical trials using two recombinant FVIII concentrates were included in the analysis. Regression tree (RT) was used to identify predictors of FVIII recovery. RESULTS: The median age was 14.5 years with a median FVIII recovery of 2.09 for all children. The median FVIII recovery was not significantly different between age groups. Two groups were created by RT: children with a BMI-for-age percentile

[HIV infection : Reaching a zero risk of transmission]. / Transmission du VIH : Est-ce une fatalité ?

Despite a global reduction in the prevalence of HIV-infection, the HIV-epidemic is far from over. The prevention of HIV-transmission in all its forms (sexual, mother-to-child etc) must therefore remain a pillar in the fight against AIDS, and both potent and accessible prevention strategies are required. In addition to the classical and wellknown methods such as the condom, ant iretroviral therapy represents a potent prevention tool and the residual risk of transmission of correctly treated HIV-positive persons is virtually nihil. Antiretroviral therapy may and should be used in the prevention of HIV-transmission as Treatment as Prevention (TasP), Pre-Exposure Prophylaxis (PrEP), and Post- Exposure Prophylaxis (PEP). However, because of their exorbitant costs, the accessibility of these prevention strategies is limited, particularly for the most vulnerable populations.

Si l'infection par le VIH est globalement en diminution dans le monde, nous n'apercevons pas encore la fin de l'épidémie. Dès lors, nous avons besoin de moyens performants et accessibles pour tous pour diminuer la transmission du virus, essentiellement sexuelle mais aussi via la transmission de la mère à son enfant. En plus des moyens utilisés de façon répandue tel que le préservatif, le traitement antirétroviral représente à ce jour un outil très performant en termes de prévention, à travers la prophylaxie pré-exposition, la prophylaxie postexposition et le traitement de la personne infectée qui voit son risque de transmission virtuellement annulé. Néanmoins, l'accès à ces molécules coûteuses reste difficile pour les populations les plus défavorisées.

Classification and regression tree analysis vs. multivariable linear and logistic regression methods as statistical tools for studying haemophilia.

INTRODUCTION: Haemophilia is a rare genetic haemorrhagic disease characterized by partial or complete deficiency of coagulation factor VIII, for haemophilia A, or IX, for haemophilia B. As in any other medical research domain, the field of haemophilia research is increasingly concerned with finding factors associated with binary or continuous outcomes through multivariable models. Traditional models include multiple logistic regressions, for binary outcomes, and multiple linear regressions for continuous outcomes. Yet these regression models are at times difficult to implement, especially for non-statisticians, and can be difficult to interpret. AIMS: The present paper sought to didactically explain how, why, and when to use classification and regression tree (CART) analysis for haemophilia research. MATERIALS & METHODS: The CART method is non-parametric and non-linear, based on the repeated partitioning of a sample into subgroups based on a certain criterion. Breiman developed this method in 1984. Classification trees (CTs) are used to analyse categorical outcomes and regression trees (RTs) to analyse continuous ones. RESULTS: The CART methodology has become increasingly popular in the medical field, yet only a few examples of studies using this methodology specifically in haemophilia have to date been published. Two examples using CART analysis and previously published in this field are didactically explained in details. CONCLUSION: There is increasing interest in using CART analysis in the health domain, primarily due to its ease of implementation, use, and interpretation, thus facilitating medical decision-making. This method should be promoted for analysing continuous or categorical outcomes in haemophilia, when applicable.

Learning curve of medialization thyroplasty using a Montgomery™ implant.

UNLABELLED: Type I thyroplasty--also called medialization thyroplasty (MT)--is considered as an effective treatment for glottic incompetence in general and for abductor vocal fold palsy in particular. In the past there have been some concerns about the experience a laryngeal framework surgeon should have in order achieve an acceptable voice outcome. To assess the learning curve of MT performed using the Montgomery(®) hard silicone implant. A retrospective study involving 36 patients divided into three consecutive groups (1, 2, 3) of 12 MT patients or six consecutive groups (1a, 1b, 2a, 2b, 3a, 3b) of six MT patients. OUTCOME MEASURES: acoustic and aerodynamic outcome improvements (δ) compared to the duration of intervention [operative times (OT)]. Data were analysed by Anova, Kuskal Wallis and χ (2) statistical tests, according to data distributions. OT decreased significantly between groups 1, 2 and 3 with a mean OT of 90.5', 71.5' and 56' (p < 0.001), respectively. Objective δ such as maximum phonation time (MPT) (p 0.376), Estimated Sub-Glottic Pressure (ESPG) (p: 0.675) Shimmer (p: 0.543) and Jitter (p: 0.709) did not show significant improvement. Only the voice handicap index (VHI) δ of group 2 showed significant improvement (p 0.005) compared with the two other groups 1 and 3. Surgeon experience decreases the OT significantly. On the other hand, our study did not show a correlation between surgeon experience and voice outcome measures improvemnts (MPT, ESGP, Shimmer, Jitter).

Reduction of potentially inappropriate medications using the STOPP criteria in frail older inpatients: a randomised controlled study.

BACKGROUND: Hospital admissions may provide an opportunity to discontinue potentially inappropriate medications (PIMs) in older patients. Little is known about the effect of using the Screening Tool of Older People's potentially inappropriate Prescriptions (STOPP) in this context. This study aimed to test the hypothesis that specific STOPP recommendations from an inpatient geriatric consultation team (IGCT) to the hospital physician leads to reductions in PIMs for patients at discharge. METHODS: This was a randomised controlled study in 146 frail inpatients (in 2011). The intervention consisted of STOPP recommendations made by the IGCT to ward physicians to discontinue PIMs, in addition to the standard geriatric advice. RESULTS: Intervention (n = 74) and control (n = 72) groups were similar in terms of patient characteristics (median age 85 years; median number of daily drugs, seven) and PIM distribution (68 and 57 PIMs in 53 and 51 % of patients, respectively). At discharge, the reduction in PIMs was twice as high for the intervention group as for the control group (39.7 and 19.3 %, respectively; p = 0.013). The proportion of patients who still had one or more PIM at discharge did not differ between groups. In the 50 patients followed-up a year later, the majority of PIMs that had been stopped during hospitalisation had not been restarted after discharge (17/28; 61 %). The clinical relevance of PIMs identified at baseline in those patients was considered major (29 %), moderate (37 %), minor (5 %), deleterious (8 %), or not assessed (11 %). Discontinuation rate was not associated with clinical importance. CONCLUSION: Specific STOPP recommendations provided to hospital physicians doubled the reduction of PIMs at discharge in frail older inpatients. To further improve the appropriateness of prescribing in older patients, clinicians should focus on the STOPP criteria that are of major clinical importance, and general practitioners should be actively involved.

Physical and mental quality of life in adult patients with haemophilia in Belgium: the impact of financial issues.

In Belgium, where haemophilia affects approximately 1:7000 people (2011), data on patients' quality of life (QoL) is scarce. This project aims to assess physical and mental QoL (P-QoL and M-QoL) simultaneously, and to analyse the influence of different variables on these two aspects of QoL. After Ethics Committee approval, we contacted 84 adult haemophilia A (HA) and haemophilia B (HB) patients, without current inhibitors, on replacement therapy (on-demand or secondary prophylaxis), regularly followed up at our comprehensive treatment centre. Seventy-one (n = 59 HA, n = 12 HB) replied to our questionnaire, which included the SF36v2 QoL assessment forms. We analysed two groups of variables: one including variables previously associated with decreased QoL, and another including variables with unclear impact on QoL (e.g., patients' understanding of haemophilia-related issues, economical concerns). In our population (mean ± SD age: 45.2 ± 14.7 years old), P-QoL appeared more reduced than M-QoL. P-QoL was strongly influenced by the number of arthropathies while M-QoL was primarily affected by patients' concern of personal costs due to haemophilia. Among this latter group, having knowledge of insurance coverage had a positive impact on M-QoL. Scores did not depend on haemophilia type. QoL was impaired in our haemophilia patients. A simultaneous assessment of P-QoL and M-QoL confirmed the benefit of primary prophylaxis in P-QoL, while originally pointing out the major burden of patients' concerns and poor understanding of haemophilia-related economical issues on their M-QoL. This might become a particularly challenging issue in times of financial crisis.

Body weight and fat mass index as strong predictors of factor VIII in vivo recovery in adults with hemophilia A.

BACKGROUND: The treatment of hemophilia A requires infusions of factor VIII (FVIII) concentrates. The number of units to be given in order to obtain the target level is calculated using the formula: [body weight (BW) × desired FVIII increase]/2, which assumes that each unit infused per kg of BW increases the FVIII level by 2%. OBJECTIVES: The present observational study evaluated the dependence of FVIII recovery on different morphometrical variables: BW, fat mass index (FMI), body mass index, and the difference between actual and ideal BW. PATIENTS AND METHODS: FVIII recovery was measured in 46 non-actively bleeding hemophilia A patients, being treated with a recombinant FVIII concentrate. Regression trees were used to identify morphometrical predictors of recovery. RESULTS: The median recovery was 2.08 for all patients, 2.63 for those with a BW ≥ 81.0 kg and 1.87 for others (P < 0.001). The recovery was significantly higher when FMI was ≥ 20% compared with FMI < 15% (median recovery: 2.35 vs. 1.74; P = 0.007). Using regression trees, three groups were created: BW < 80.5 kg and FMI < 22.3%, BW < 80.5 kg and FMI ≥ 22.3% and BW ≥ 80.5 kg. Median recovery in these groups was 1.80, 2.16 and 2.63, respectively (P < 0.001). CONCLUSIONS: The dose calculation of FVIII should take into account both BW and FMI, and be adapted to underweight or overweight patients. Comparison of the average recovery after different FVIII concentrates should keep in mind morphometrical patient characteristics.

[Tachycardia-related cardiomyopathy: a case report]. / Cardiomyopathie rythmique.

Tachycardia-mediated cardiomyopathy is a form of dilated cardiomyopathy and heart failure induced by a persistent/chronic supraventricular or ventricular tachyarythmia. The incidence and the patho-physiology remain unspecified. Sometimes related to a previous cardiomyopathy, the diagnosis is always retrospective, but important because of the clinical and the significant haemodynamic improvement following the control of heart rate.

A prognostic index for progression-free survival in malignant mesothelioma with application to the design of phase II trials: a combined analysis of 10 EORTC trials.

PURPOSE: For cytostatic agents or when the response assessment is difficult, adaptations to phase II designs may allow a better assessment of therapeutic activity: first by using the progression-free survival rate (PFSR) as primary end-point instead of the response rate, and second by considering progression-free survival (PFS) risk groups based on a prognostic index (PI). In mesothelioma, current treatments yield disappointingly poor results and there is a need to investigate new regimens. The purpose of this report is to provide a PI for PFS in mesothelioma and reference values for the PFSR. MATERIALS AND METHODS: Data on 523 patients included in 10 European Organisation for Research and Treatment of Cancer (EORTC) mesothelioma studies were analysed to identify prognostic factors using a multivariate Cox regression model. Subsequently, a PI and a nomogram for PFS were developed. The PFSRs at 3, 4, 5 and 6 months were estimated. RESULTS: A performance status>0, stage IV disease and mixed or sarcomatous histological type were indicators of a poor prognosis for PFS. From the PI, based on these three variables, four risk groups were defined. The median progression-free survival ranged from 5.3 to 2.1 months in these risk categories. The PFSRs at 3 months were 70.6%, 62.4%, 54.2% and 42.1% in the four categories, respectively. CONCLUSION: The PI allows dividing patients into homogeneous risk categories in which PFSRs can be calculated and used to design future phase II mesothelioma trials. Defining homogeneous categories of patients avoids dilution of results between groups and improves the assessment of therapeutic activity.