Predicting Coronavirus Disease 2019 Infection Risk and Related Risk Drivers in Nursing Homes: A Machine Learning Approach.

OBJECTIVE: Inform coronavirus disease 2019 (COVID-19) infection prevention measures by identifying and assessing risk and possible vectors of infection in nursing homes (NHs) using a machine-learning approach. DESIGN: This retrospective cohort study used a gradient boosting algorithm to evaluate risk of COVID-19 infection (ie, presence of at least 1 confirmed COVID-19 resident) in NHs. SETTING AND PARTICIPANTS: The model was trained on outcomes from 1146 NHs in Massachusetts, Georgia, and New Jersey, reporting COVID-19 case data on April 20, 2020. Risk indices generated from the model using data from May 4 were prospectively validated against outcomes reported on May 11 from 1021 NHs in California. METHODS: Model features, pertaining to facility and community characteristics, were obtained from a self-constructed dataset based on multiple public and private sources. The model was assessed via out-of-sample area under the receiver operating characteristic curve (AUC), sensitivity, and specificity in the training (via 10-fold cross-validation) and validation datasets. RESULTS: The mean AUC, sensitivity, and specificity of the model over 10-fold cross-validation were 0.729 [95% confidence interval (CI) 0.690‒0.767], 0.670 (95% CI 0.477‒0.862), and 0.611 (95% CI 0.412‒0.809), respectively. Prospective out-of-sample validation yielded similar performance measures (AUC 0.721; sensitivity 0.622; specificity 0.713). The strongest predictors of COVID-19 infection were identified as the NH's county's infection rate and the number of separate units in the NH; other predictors included the county's population density, historical Centers of Medicare and Medicaid Services cited health deficiencies, and the NH's resident density (in persons per 1000 square feet). In addition, the NH's historical percentage of non-Hispanic white residents was identified as a protective factor. CONCLUSIONS AND IMPLICATIONS: A machine-learning model can help quantify and predict NH infection risk. The identified risk factors support the early identification and management of presymptomatic and asymptomatic individuals (eg, staff) entering the NH from the surrounding community and the development of financially sustainable staff testing initiatives in preventing COVID-19 infection.

The effect of environmental factors on the incidence of perforated appendicitis.

BACKGROUND: Acute appendicitis is the most common abdominal emergency. Its etiopathogenesis appears to be multifactorial. Several studies suggested a relationship between the development of acute appendicitis and some environmental factors. Air pollution predisposes some people to develop perforated appendicitis. However, data are relatively scarce and the results still controversial. AIM: Determine the seasonal variation of acute appendicitis and study the association between perforated appendicitis and short-term exposure to climatic factors and to air pollutants. METHODS: A cross-sectional study was conducted including patients hospitalized in the general surgery department of Farhat Hached University Hospital in Sousse for acute appendicitis between January 1st and December 31st, 2014. Climatic conditions were collected from the National Institute of Meteorology. Data on air pollution were given by the National Agency for the Protection of the Environment and obtained by the modeling of the atmospheric pollution. For statistical analysis, we used mean concentrations of each environmental factor corresponding to the day of hospital admission and lagged by the 7 previous days. These factors were compared between the group of patients with perforated appendicitis and patients with nonperforated appendicitis. RESULTS: We collected 246 cases of acute appendicitis. Perforated appendicitis was reported in 15.2% of the cases. The incidence of acute appendicitis was higher during summer. Compared to nonperforated appendicitis, perforated appendicitis was significantly associated with the mean relative humidity of the 5 day lag (p = 0.046), rainfall of the 7 day lag (p = 0.043), and consultation delay (p <10-3). Furthermore, perforated appendicitis was significantly associated with the daily mean concentration of carbon dioxide (p = 0.042), the 2- day lag mean concentration of particulate matter less than 10 µ (PM10 ) (p = 0.016), and the 2-day lag mean concentration of ozone (p = 0.048). After multivariate statistical analysis, predictive factors for perforated appendicitis were the consultation delay (OR: 1.621, 95% CI [1.288 - 2.039]; p<10-3) and the 2 day lag mean concentration of PM10 (OR: 1.066, 95% CI [1.007- 1.130]; p = 0.029). CONCLUSION: Short-term exposure to particulate matter was associated with perforated appendicitis. Further large-scale studies are needed to support this conclusion. KEY WORDS: Air pollution, Appendicitis, perforated appendicitis, Climateparticulate matter.

[Chronic fatigue syndrome: A new disorder?] / Le syndrome de fatigue chronique : une nouvelle maladie ?

More than 30 years after its individualization, chronic fatigue syndrome (CFS) remains a debilitating condition for the patient and a confusing one to the physicians, both because of diagnostic difficulties and poorly codified management. Despite the numerous work carried out, its pathophysiology remains unclear, but a multifactorial origin is suggested with triggering (infections) and maintenance (psychological) factors as well as the persistence of inflammatory (low grade inflammation, microglial activation…), immunologic (decrease of NK cells, abnormal cytokine production, reactivity to a variety of allergens, role of estrogens…) and muscular (mitochondrial dysfunction and failure of bioenergetic performance) abnormalities at the origin of multiple dysfunctions (endocrine, neuromuscular, cardiovascular, digestive…). The complexity of the problem and the sometimes contradictory results of available studies performed so far are at the origin of different pathophysiological and diagnostic concepts. Based on a rigorous analysis of scientific data, the new American concept of Systemic Disease Exertion Intolerance proposed in 2015 simplifies the diagnostic approach and breaks with the past and terminologies (CFS and myalgic encephalomyelitis). It is still too early to distinguish a new disease, but this initiative is a strong signal to intensify the recognition and management of patients with CFS and stimulate research.

[Prevention of infections in adults and adolescents with systemic lupus erythematosus: Guidelines for the clinical practice based on the literature and expert opinion]. / Prévention des infections au cours du lupus systémique chez l'adulte et l'adolescent : élaboration de recommandations pour la pratique clinique, à partir d'une analyse de la littérature et de l'avis d'experts.

PURPOSE: To develop French recommendations about the management of vaccinations, the screening of cervical cancer and the prevention of pneumocystis pneumonia in systemic lupus erythematosus (SLE). METHODS: Thirty-seven experts qualified in internal medicine, rheumatology, dermatology, nephrology and pediatrics have selected recommendations from a list of proposition based on available data from the literature. For each recommendation, the level of evidence and the level of agreement among the experts were specified. RESULTS: Inactivated vaccines do not cause significant harm in SLE patients. Experts recommend that lupus patient should receive vaccinations accordingly to the recommendations and the schedules for the general public. Pneumococcal vaccination is recommended for all SLE patients. Influenza vaccination is recommended for immunosuppressed SLE patients. Live attenuated vaccines should be avoided in immunosuppressed patients. Yet, recent works suggest that they can be considered in mildly immunosuppressed patients. Experts have recommended a cervical cytology every year for immunosuppressed patients. No consensus was obtained for the prevention of pneumocystis pneumonia. CONCLUSION: These recommendations can be expected to improve clinical practice uniformity and, in the longer term, to optimize the management of SLE patients.

Postdepletion Lymphocyte Reconstitution During Belatacept and Rapamycin Treatment in Kidney Transplant Recipients.

Belatacept is used to prevent allograft rejection but fails to do so in a sizable minority of patients due to inadequate control of costimulation-resistant T cells. In this study, we report control of costimulation-resistant rejection when belatacept was combined with perioperative alemtuzumab-mediated lymphocyte depletion and rapamycin. To assess the means by which the alemtuzumab, belatacept and rapamycin (ABR) regimen controls belatacept-resistant rejection, we studied 20 ABR-treated patients and characterized peripheral lymphocyte phenotype and functional responses to donor, third-party and viral antigens using flow cytometry, intracellular cytokine staining and carboxyfluorescein succinimidyl ester-based lymphocyte proliferation. Compared with conventional immunosuppression in 10 patients, lymphocyte depletion evoked substantial homeostatic lymphocyte activation balanced by regulatory T and B cell phenotypes. The reconstituted T cell repertoire was enriched for CD28(+) naïve cells, notably diminished in belatacept-resistant CD28(-) memory subsets and depleted of polyfunctional donor-specific T cells but able to respond to third-party and latent herpes viruses. B cell responses were similarly favorable, without alloantibody development and a reduction in memory subsets-changes not seen in conventionally treated patients. The ABR regimen uniquely altered the immune profile, producing a repertoire enriched for CD28(+) T cells, hyporesponsive to donor alloantigen and competent in its protective immune capabilities. The resulting repertoire was permissive for control of rejection with belatacept monotherapy.

[Screening and management of cardiovascular risk factors in systemic lupus erythematosus: Recommendations for clinical practice based on the literature and expert opinion]. / Dépistage et prise en charge du risque cardiovasculaire au cours du lupus systémique : élaboration de recommandations pour la pratique clinique, à partir d'une analyse de la littérature et de l'avis d'experts.

PURPOSE: To develop French recommendations about screening and management of cardiovascular risk factors in systemic lupus erythematosus (SLE). METHODS: Thirty-nine experts qualified in internal medicine, rheumatology and nephrology have selected recommendations from a list developed based on evidence from the literature. For each recommendation, the level of evidence and the level of agreement among the experts were specified. RESULTS: Experts recommended an annual screening of cardiovascular risk factors in SLE. Statins should be prescribed for primary prevention in SLE patients based on the level of LDL-cholesterol and the number of cardiovascular risk factors, considering SLE as an additional risk factor. For secondary prevention, experts have agreed on an LDL-cholesterol target of <0.7 g/L. Hypertension should be managed according to the 2013 European guidelines, using renin-angiotensin system blockers as first line agents in case of renal involvement. Aspirin can be prescribed in patients with high cardiovascular risk or with antiphospholipid antibodies. CONCLUSION: These recommendations about the screening and management of cardiovascular risk factors in SLE can be expected to improve clinical practice uniformity and, in the longer term, to optimize the management of SLE patients.

Renal transplantation using belatacept without maintenance steroids or calcineurin inhibitors.

Kidney transplantation remains limited by toxicities of calcineurin inhibitors (CNIs) and steroids. Belatacept is a less toxic CNI alternative, but existing regimens rely on steroids and have higher rejection rates. Experimentally, donor bone marrow and sirolimus promote belatacept's efficacy. To investigate a belatacept-based regimen without CNIs or steroids, we transplanted recipients of live donor kidneys using alemtuzumab induction, monthly belatacept and daily sirolimus. Patients were randomized 1:1 to receive unfractionated donor bone marrow. After 1 year, patients were allowed to wean from sirolimus. Patients were followed clinically and with surveillance biopsies. Twenty patients were transplanted, all successfully. Mean creatinine (estimated GFR) was 1.10 ± 0.07 mg/dL (89 ± 3.56 mL/min) and 1.13 ± 0.07 mg/dL (and 88 ± 3.48 mL/min) at 12 and 36 months, respectively. Excellent results were achieved irrespective of bone marrow infusion. Ten patients elected oral immunosuppressant weaning, seven of whom were maintained rejection-free on monotherapy belatacept. Those failing to wean were successfully maintained on belatacept-based regimens supplemented by oral immunosuppression. Seven patients declined immunosuppressant weaning and three patients were denied weaning for associated medical conditions; all remained rejection-free. Belatacept and sirolimus effectively prevent kidney allograft rejection without CNIs or steroids when used following alemtuzumab induction. Selected, immunologically low-risk patients can be maintained solely on once monthly intravenous belatacept.

Prognosis of vasculitis associated myelodysplasia.

Systemic and immune manifestations have been reported in patients with MDS. The correlation between immunological abnormalities and prognosis in myelodysplastic syndrome patients remains controversial. Most of the authors agree that the median survival in myelodysplastic syndrome is not related to the presence of systemic and immune manifestations, but only with the existence of a systemic vasculitis.

Long-term results of 360A° scleral buckling and vitrectomy with silicone oil tamponade for management of gunshot-perforating ocular injury.

PURPOSE: This is a retrospective consecutive study to assess the long-term results of combined scleral buckling and pars plana vitrectomy (PPV) with silicone oil for the management of perforating ocular injury caused by gunshots. METHODS: Data were gathered from medical records of patients who underwent scleral buckling and PPV with silicone oil 2 weeks after primary repair elsewhere, in Magrabi eye center (Tanta, Egypt), from June 2005 to May 2010. RESULTS: The evaluated group consisted of 49 cases, out of which 26 cases presented with gunshot injury. Twenty-two were male (84.62%) and four were female (15.38%), with a mean age of 27.19+12.7 years. The follow-up ranged from 12 to 72 months, with a mean period of 32.04+8.9 months. The t-test was used to determine the visual outcome and main prognostic factors. Visual acuity improved in 22 of 26 eyes (76.92%), was unchanged in 4 eyes (15.38%), and worsened in 2 eyes (6.69%). Ten eyes (38.46%) achieved visual acuity between (20/40) and (20/100), and eight eyes (30.76%) had visual acuity between (20/200) and (20/400). The 18 eyes (69.23%) with visual acuity better than counting fingers (CF) had an attached retina with no signs of active proliferation after removal of the silicone oil. CONCLUSION: POI due to gunshot is usually a terminal event for the eye. Eyes with perforating injury can be saved and may attain useful vision after performance of combined scleral buckling and PPV with silicone oil tamponade. The final visual outcome depends on the macular or the optic nerve involvement and the final retinal stability, and phthisis bulbi can also be prevented.

Rapid Rhino versus Merocel nasal packs in septal surgery.

OBJECTIVE: To compare Rapid Rhino and Merocel packs for nasal packing after septoplasty, in terms of patient tolerance (both with the pack in place and during removal) and post-operative complications. MATERIALS AND METHODS: Thirty patients (aged 18-40 years) scheduled for septoplasty were included. Following surgery, one nasal cavity was packed with Rapid Rhino and the other one with Merocel. Patients were asked to record pain levels on a visual analogue score, on both sides, with the packs in situ and during their removal the next day. After pack removal, bleeding was compared on both sides. RESULTS: The mean ± standard deviation pain score for the Rapid Rhino pack in situ (4.17 ± 1.78) was less than that for the Merocel pack (4.73 ± 2.05), but not significantly so (p = 0.314). The mean pain score for Rapid Rhino pack removal (4.13 ± 1.76) was significantly less that that for Merocel (6.90 ± 1.67; p = 0.001). Bleeding after pack removal was significantly less for the Rapid Rhino sides compared with the Merocel sides (p <0.05). CONCLUSION: Rapid Rhino nasal packs are less painful and cause less bleeding, compared with Merocel packs, with no side effects. Thus, their use for nasal packing after septal surgery is recommended.

A 5-year prospective follow-up study in essential cryofibrinogenemia patients.

INTRODUCTION: Cryofibrinogenemia may be essential, or secondary to diseases such as neoplasia, infection, thrombosis, and collagen vascular diseases. In a previous study, we reported the occurrence of neoplasia in some essential cryofibrinogenemia patients after a short period of follow-up. PURPOSE: We performed a prospective multi-center 5-year follow-up study in essential cryofibrinogenemia patients (2005-2009). RESULTS: 23 patients with essential cryofibrinogenemia were included, mean age 59 years (range: 33-79), 14 males. After a mean follow-up period of 24 months, 11/23 (47%) of cases that were initially diagnosed as essential cryofibrinogenemia were found to have an underlying lymphoma (6 T lymphoma and 5 B lymphoma). CONCLUSION: This prospective study suggests that some cases of cryofibrinogenemia that are initially considered as essential, may have underlying lymphoma. Thus, we further suggest that regular follow-up should be performed in patients with essential cryofibrinogenemia.

Systemic and immune manifestations in myelodysplasia: a multicenter retrospective study.

OBJECTIVE: The presence of systemic and/or immune manifestations in myelodysplasia has been currently reported. The influence of these manifestations on the natural outcome of myelodysplastic syndrome has to be considered. We present a multicenter retrospective study (2002-2009) of patients with myelodysplastic syndrome disclosing systemic and/or immune manifestations. METHODS: Forty-six patients with myelodysplasia presenting with systemic and/or immune manifestations were compared in terms of survival with 189 patients with myelodysplasia lacking these features. RESULTS: The clinical picture in these cases consisted of fever (13%), arthralgia or arthritis (13%), and cutaneous manifestations (67%). Four cases of systemic vasculitis have been reported in our series, and they have a worse prognosis. Immune anomalies were recorded in 29% of the cases, and the presence of cryoglobulins was also associated with a worse prognosis. CONCLUSION: A difference in survival between patients with myelodysplastic syndrome with systemic manifestations and patients lacking these manifestations has been observed in the presence of systemic vasculitis and/or cryoglobulins.

The effect on outcome of peribulbar anaesthesia in conjunction with general anesthesia for vitreoretinal surgery.

The purpose of this study was to evaluate peri-operative outcome after vitreoretinal surgery when peribulbar anaesthesia is combined with general anaesthesia. Sixty adult patients undergoing elective primary retinal detachment surgery with scleral buckling or an encircling procedure received either peribulbar anaesthesia in conjunction with general anaesthesia or general anaesthesia alone. For peribulbar anaesthesia a single percutaneous injection of 5-7 ml of local anaesthetic solution (0.75% ropivacaine with hyaluronidase 15 iu.ml(-1)) was used. The incidence of intra-operative oculocardiac reflex and surgical bleeding interfering with the surgical field, postoperative pain and analgesia requirements, and postoperative nausea and vomiting were recorded. In the block group there was a lower incidence of oculocardiac reflex and surgical bleeding intra-operatively. Patients in the block group also had better postoperative analgesia and a lower incidence of postoperative nausea and vomiting compared with the group without a block. The use of peribulbar anaesthesia in conjunction with general anesthesia was superior to general anaesthesia alone for vitreoretinal surgery with scleral buckling.

Outcome of living donor liver transplantation for Egyptian patients with hepatitis C (genotype 4)-related cirrhosis.

BACKGROUND: Hepatitis C virus (HCV) recurrence after living donor liver transplantation (LDLT) represents a challenging issue due to universal viral recurrence and invasion into the graft, although the incidence of histological recurrence, risk factors, and survival rates are still controversial. PATIENTS AND METHODS: Recurrence of HCV was studied in 38 of 53 adult patients who underwent LDLT. RESULTS: Recipient and graft survivals were 86.6% at the end of the follow-up which was comparable to literature reports for deceased donor liver transplantation (DDLT). Clinical HCV recurrence was observed in 10/38 patients (26.3%). Four patients developed mild fibrosis with a mean fibrosis score of 0.6 and mean grade of histological activity index (HAI) of 7.1. None of the recipients developed allograft cirrhosis during the mean follow-up period of 16 +/- 8.18 months (range, 4-35 months). Estimated and actual graft volumes were negatively correlated with the incidence and early clinical HCV recurrence. None of the other risk factors were significantly correlated with clinical HCV recurrence: gender, donor and recipient ages, pretransplantation Child-Pugh or model for end-stage liver disease (MELD) scores, pre- and postoperative viremia, immunosuppressive drugs, pulse steroid therapy, and preoperative anti-HBc status. CONCLUSIONS: Postoperative patient and graft survival rates for HCV (genotype 4)-related cirrhosis were more or less comparable to DDLT reported in the literature. Clinical HCV recurrence after LDLT in our study was low. Small graft volume was a significant risk factor for HCV recurrence. A longer follow-up and a larger number of patients are required to clarify these issues.

An intraventricular clear cell meningioma revealed by an inflammatory syndrome in a male adult: a case report.

Intraventricular meningiomas are infrequent intracranial tumors. Clinical symptoms are mainly due to an increased intracranial pressure or a direct pressure on the surrounding brain structures. Inflammatory syndrome was described in some patients with chordoid meningiomas. Here we report a case of right intraventricular clear cell meningioma in a 50-year-old man who presented with fever, headache, and inflammatory syndrome. Clinical and biological normalization was rapidly obtained after tumor removal. Immunohistochemical examination showed tumor cells and lymphocytes positivity for the pyrogenic cytokine interleukin-6, with a same intensity. To our knowledge, this is the first case described in the literature concerning an adult man with an intraventricular clear cell meningioma associated with a systemic inflammatory syndrome.

Plasma met-enkephalin, beta-endorphin and leu-enkephalin levels in human hepatic encephalopathy.

To address the role of the opioid system in the pathogenesis of hepatic encephalopathy (HE) we measured plasma met-enkephalin, beta-endorphin and leu-enkephalin in patients with different grades of HE compared to control subjects and patients with cirrhosis. Plasma met-enkephalin levels were significantly higher in patients with cirrhosis and all grades of HE than controls. Plasma beta-endorphin levels were similar in the 3 groups. Plasma leu-enkephalin levels were significantly higher in HE grades II, III and IV than in controls, patients with cirrhosis and HE grade I patients. Our results support data on the involvement of met-enkephalin and leu-enkephalin in the pathogenesis of HE and provide a rationale for the use of opioid receptor antagonists in the treatment of HE.

Serum levels of astroglial S100-beta and neuron-specific enolase in hepatic encephalopathy patients.

To find a reliable, noninvasive method for the diagnosis of cognitive impairment in patients with hepatic cirrhosis we measured serum levels of astroglial S100beta and neuron-specific enolase in cirrhotic patients with and without hepatic encephalopathy (HE). S100beta levels showed a significant increase in groups with HE stage 1 and 2 compared to both control and cirrhosis patients. However serum neuron-specific enolase levels were not significantly different between the studied groups. S100beta levels had a specificity of 91.3% and sensitivity of 51.7% for detection of HE from cirrhosis. Serum S100beta may be a useful surrogate marker for the diagnosis of mild cognitive impairment in cirrhotic patients before they progress to more advanced stages of HE.

Serum levels of astroglial S100-beta and neuron-specific enolase in hepatic encephalopathy patients

To find a reliable, noninvasive method for the diagnosis of cognitive impairment in patients with hepatic cirrhosis we measured serum levels of astroglial S100beta and neuron-specific enolase in cirrhotic patients with and without hepatic encephalopathy [HE]. S100beta levels showed a significant increase in groups with HE stage 1 and 2 compared to both control and cirrhosis patients. However serum neuron-specific enolase levels were not significantly different between the studied groups. S100beta levels had a specificity of 91.3% and sensitivity of 51.7% for detection of HE from cirrhosis. Serum S100beta may be a useful surrogate marker for the diagnosis of mild cognitive impairment in cirrhotic patients before they progress to more advanced stages of HE