Effectiveness of an education health programme about Middle East respiratory syndrome coronavirus tested during travel consultations.

OBJECTIVE: We aimed to evaluate the level of knowledge of Middle East respiratory syndrome coronavirus (MERS-CoV) among Hajj pilgrims before and after an education health programme during international vaccine consultations in France. STUDY DESIGN: A cross-sectional study was performed in the consultation for travel medicine and international vaccination in Reims University Hospital between July 2014 and October 2015. METHODS: Consecutive adults (>18 years old) who attended for pre-Hajj meningococcal vaccination were eligible to complete an anonymous questionnaire with closed answers to evaluate their level of knowledge about MERS-CoV. To evaluate the effectiveness of the information given during the consultation, the same questionnaire was completed by the Hajj pilgrim before and after the consultation, where the information about MERS-CoV was provided. RESULTS: Among 82 Hajj pilgrim adults enrolled in the study, less than 25% were aware of the routes of transmission, symptoms and preventive behaviours to adopt abroad or in case of fever. Pilgrims had a higher rate of correct responses on each question at the time they completed the second questionnaire, as compared with the first, with 11 of 13 questions answered significantly better after delivery of educational information about MERS-CoV. However, although the rate of correct answers to the questions about routes of transmission, symptoms, preventive behaviours to adopt in case of fever and time delay between return and potential MERS-CoV occurrence increased significantly after receiving the information, the rates remained below 50%. CONCLUSION: Information given during travel consultations significantly increases the general level of knowledge, but not enough to achieve epidemic control.

[Misdiagnosis of hidradenitis suppurativa continues to be a major issue. The R-ENS Verneuil study]. / Errance médicale des patients atteints d'hidradénite suppurée : un problème majeur et persistant. Étude « R-ENS Verneuil ¼.

OBJECTIVE: To provide physicians with an understanding of the factors behind significant delays in the diagnosis of hidradenitis suppurativa (HS) in France. PATIENTS AND METHODS: This prospective multicentre national study conducted from October 2015 to March 2016 included all patients consulting for HS. Patient data were collected by means of a standardized questionnaire. Univariate and multivariate analyses were conducted to collect factors associated with a significant time to diagnosis of at least 5.5years, defined as the period between the onset of initial clinical signs and the time of formal diagnosis. RESULTS: The 16 participating centres enrolled 312 patients (62% women), of average age 35years. The average age at onset of HS was 22years. Before formal diagnosis by a dermatologist (64% of cases), 170 (54%), 114 (37%) and 45 (15%) patients had previously consulted at least 3, 5 and 10 general physicians, respectively. The average time between the initial clinical signs of HS, the first dermatology visit and the definitive diagnosis was 6.2 and 8.4 years, respectively. Active smoking (OR adjusted 1.85; P=0.027) and disease onset at a younger age (adjusted OR 0.92; P<0.001) were both associated with significant delays in diagnosis. CONCLUSION: These results emphasized misdiagnosis among HS patients but did not evidence any association between either sociodemographic or economic characteristics and the existence of significant times to diagnosis.

Measurement variability of liver metastases from neuroendocrine tumors on different magnetic resonance imaging sequences.

PURPOSE: To assess dimension measurement variability of liver metastases from neuroendocrine tumors (LMNET) on different magnetic resonance imaging (MRI) sequences. MATERIAL AND METHODS: In this institutional review board-approved retrospective study from January 2011 to December 2012, all liver MRI examinations performed at our department in patients with at least one measurable LMNET according to response evaluation criteria in solid tumors (RECIST1.1) were included. Up to two lesions were selected on T2-weighted MR images. Three reviewers independently measured long axes of 135 hepatic metastases in 30 patients (16 men, 14 women, mean age 61±11.4 (SD) years; range 28-78 years), during two separate reading sessions, on T2-weighted, diffusion-weighted MRI (DWI) (b; 50, 400, 800 s/mm2) and arterial, portal and late phases after intravenous administration of a gadolinium chelate. Intraclass-correlation coefficients and Bland-Altman plots were used to assess intra-and interobserver variability. RESULTS: Intra- and interobserver agreements ranged between 0.87-0.98, and 0.88-0.97, respectively. Intersequence agreements ranged between 0.92 [95%CI: 0.82-0.98] and 0.98 [95%CI: 0.93-0.99]. 95% limits of agreement for measurements were -10.2%,+8.9% for DWI (b=50s/mm2) versus -21.9%,+24.2% and -15.8,+17.2% for arterial and portal phases, respectively. CONCLUSION: An increase<9% in measurement and a decrease of -10% on DWI should not be considered as true changes, with 95% confidence, versus 24% and -22% on arterial and 17%, -16% on portal phases, respectively. DWI might thus be the most reliable MR sequence for monitoring size variations of LMNETs.

Long-term assessment of meniscal extrusion after meniscal repair.

BACKGROUND: Arthroscopic meniscal repair limits the medium-term risk of radiological osteoarthritis. Magnetic resonance imaging (MRI) cannot provide an accurate assessment of meniscal healing but may show harbingers of osteoarthritis such as meniscal extrusion. The objective of this study was to assess long-term meniscal extrusion after meniscal repair. HYPOTHESIS: Arthroscopic meniscal suture is not followed by meniscal extrusion and can, therefore, provide good knee function in the long-term. METHODS: Consecutive patients who underwent arthroscopic meniscal suture on a stable or stabilised knee were included retrospectively. MRI was performed to measure absolute meniscal extrusion (AME), relative meniscal extrusion (RME), anterior sagittal extrusion (ASE), posterior sagittal extrusion (PSE), coronal cartilage coverage index (cCCI), and sagittal cartilage coverage index (sCCI). RESULTS: After a mean follow-up of 8.8±0.87 years, there was no evidence of meniscal extrusion in these patients with stable or stabilised knees: AME, 1.7±1.03 and 2.3±0.93mm, RME, 17±0.10% and 28±0.12%, ASE, 2.52±1.43 and 1.71±2.42mm, PSE, 0.29±3.49 and 0.22±2.35mm, cCCI, 23±0.08% and 20±0.09%, and sCCI, 49±0,10% and 53±0.09%. CONCLUSION: In the long-term after meniscal repair, osteoarthritis is limited and meniscal function seems preserved. LEVEL OF EVIDENCE: IV, retrospective study.

Adjudication of osteonecrosis of the jaw in phase III randomized controlled trials of denosumab: a systematic review.

PURPOSE: Denosumab (an anti RANKL antibody) is known to be associated with an increased risk for osteonecrosis of the jaw (ONJ). Due to the variety of clinical presentation, many ONJ definitions are used. Evaluation of ONJ's frequency during phase III randomized controlled trials (RCTs) is crucial to assess benefit-risk ratio. We verified that phase III RCTs involving denosumab reported the definition of ONJ used. METHODS: We systematically searched in Central, Medline, Cochrane, and Scopus, until 31 August 2015. We included original phase III RCTs, involving denosumab. Post hoc analysis and trial extension were excluded. Articles that did not mention ONJ in their methods or results were excluded. The primary outcome was the prevalence of a complete definition of ONJ. When no definition was provided, ONJ adjudication process was analyzed. RESULTS: Of 313 articles found, 13 RCTs were included. A definition of ONJ was detailed in two RCTs (15%). For the remaining 11 RCTs, adjudication process was mentioned for nine. In those processes, "blinded," "expert," and "independent" were the most used words. CONCLUSION: Most of the published phase III RCTs involving denosumab did not specify the definition of ONJ used to adjudicate events in the study. Instead of definition, non-scientific and non-reproducible expressions were used. Because the chosen definition could impact the ONJ estimated frequency, it should be mandatory to give the precise definition used in each RCT publication involving denosumab.

[Use of high-flow nasal cannula in infants with bronchiolitis in a pediatric emergency department]. / Utilisation des lunettes nasales à haut débit chez les nourrissons hospitalisés en service d'accueil des urgences pédiatriques pour bronchiolite : étude observationnelle.

High-flow nasal cannula oxygen therapy (HFNC) is a technique for noninvasive ventilation commonly used in pediatric intensive care units for respiratory distress, particularly in acute bronchiolitis. HFNC was introduced in the pediatric emergency department of the Reims university hospital for the treatment of infants with moderate to severe acute viral bronchiolitis. This retrospective observational study aimed to investigate the use of HFNC in a pediatric emergency ward, describing the groups of infants with acute viral bronchiolitis to be treated either with conventional oxygen therapy or with HFNC therapy. A total of 89 infants aged less than 6 months were included between December 2013 and April 2014. The choice of the type of oxygen used belonged to the pediatrician, according to his or her assessment of the clinical severity of the patient's condition, guided by a protocol of HFNC use for the treatment of moderate to severe bronchiolitis and limited by the availability of a single device in the department. Eighty-nine infants were included; 64% were boys. Fifty-seven infants (64%) had no medical history. At admission, 39 infants (46.4%) had tachypnea and 75 (84.3%) intercostal indrawing. RSV was found in 75 infants (97.4% of infants had a positive respiratory virology test). Seventy-six infants (85.4%) were treated with conventional oxygen therapy and 13 (14.6%) with HFNC. At admission, the mean weight for infants treated with HFNC was lower (P=0.03), the oxygen saturation level was 86.7% versus 93.5% (P=0.03) for conventional oxygen therapy. Moreover, modified Wood's score was higher and the mean PCO2 was 61.1 versus 49.9mmHg (P<0.01). Six infants treated with conventional oxygen therapy (7.9%) and six with HFNC (46.1%) were then transferred to an intensive care unit. HFNC therapy in the pediatric emergency ward seems to be an advantageous therapeutic option in the early treatment of infants with moderate to severe bronchiolitis, but further studies are needed to specify its indications and effectiveness.

Ventricular tachycardias arising from the aortic sinus of valsalva: an under-recognized variant of left outflow tract ventricular tachycardia.

OBJECTIVES: To describe a normal heart left bundle branch block, inferior axis ventricular tachycardia (VT), that could not be ablated from the right or left ventricular outflow tracts. BACKGROUND: Whether these VTs are epicardial and can be identified by a specific electrocardiographic pattern is unclear. METHODS: Twelve patients with normal heart left bundle branch block, inferior axis VT and previously failed ablation were included in this study. Together with mapping in the right and left ventricular outflow tracts, we obtained percutaneous epicardial mapping in the first five patients and performed aortic sinus of Valsalva mapping in all patients. RESULTS: No adequate pace mapping was observed in the right and left ventricular outflow tracts. Earliest ventricular activation was noted in the epicardium and the aortic cusps. All patients were successfully ablated from the aortic sinuses of Valsalva (95% CI 0% to 18%). The electrocardiographic pattern associated with this VT was left bundle branch block, inferior axis and early precordial transition with Rs or R in V2 or V3. Ventricular tachycardia from the left sinus had rS pattern in lead I, and VT from the noncoronary sinus had a notched R wave in lead I. None of the patients had complications and all remained arrhythmia-free at a mean follow-up of 8 +/- 2.6 months. CONCLUSIONS: Normal heart VT with left bundle branch block, inferior axis and early precordial transition can be ablated in the majority of patients from either the left or the noncoronary aortic sinus of Valsalva.

A simple method of mapping atrial premature depolarizations triggering atrial fibrillation.

Atrial premature depolarizations (APDs) originating from focal sites, particularly the pulmonary veins (PV), may become triggers of atrial fibrillation (AF). Accurate mapping of APDs with conventional methods may be time consuming and expose the patient to unnecessary instrumentation of the left atrium. We hypothesized that the atrial activation sequence recorded using a simple system that includes an esophageal catheter and a custom-made 16-electrode catheter with two sets of floating electrodes eight in the coronary sinus and eight in the high right atrium) could be sufficient to localize the APDs. The study included 29 patients with frequent APDs and AF refractory to antiarrhythmic medications. The APD site of origin was confirmed with single-point sequential mapping techniques using the CARTO system ten patients) or by placement of multielectrode catheters in the right and left PV (19 patients). Of the 29 patients, 20 patients had a single APD focus; 8 patients had two different APD morphologies; and 1 patient had three APD foci. Mapping for ablation of the APD foci showed earliest activation in the left superior PV in 12 patients, right superior PV in 15 patients, right middle PV in 4 patients, right inferior PV in 1 patient, the lingular branch of the left superior PV in 2 patients, left inferior PV in 2 patients, and right atrium along the crista terminalis in 3 patients. The activation sequence and relative timing of the recordings obtained with our catheter configuration was highly predictive of right and left atrial origin and, more importantly, of right and left PV foci.

Empirical pulmonary vein isolation in patients with chronic atrial fibrillation using a three-dimensional nonfluoroscopic mapping system: long-term follow-up.

The purpose of this study was to assess the feasibility and long-term results of empirical isolation of both superior pulmonary veins in patients with chronic AF. Although localizing and ablating the focal triggers of AF has been proven an effective approach, this strategy is time consuming, often requires multiple procedures, and carries the risk of pulmonary vein stenosis. Whether ostial electrical isolation of the superior pulmonary veins, without initial detailed mapping, is a more efficient approach is not known. The study included 71 consecutive patients who had chronic AF. Using a nonfluoroscopic electroanatomic mapping system, the left and right superior pulmonary veins were ablated circumferentially at the venoatrial junction, with the aim of achieving electrical isolation of the veins. Following ablation, if frequent atrial ectopies were present, mapping and ablation were considered. The patients were periodically followed with 48-hour Holter and loop recorder monitoring. After the ablation of the right and left superior pulmonary veins 59 (83%) of 71 patients maintained sinus rhythm without premature atrial beats. The remaining 12 patients underwent further mapping and ablation including 5 patients who required isolation of the left inferior pulmonary veins. True electrical isolation could be achieved only in 45 (31%) of the 147 targeted veins. At the latest follow-up (mean 29 +/- 8 months), 80% of the patients with upper vein isolation remained in sinus rhythm off medications, 62% of the patients maintained sinus rhythm on previously ineffective medications, and 17% continued to be in AF. Fourteen (20%) patients developed intermittent episodes of left atrial flutter, and mapping in these patients revealed large electrically silent areas in the left atrium. Empirical isolation of pulmonary veins appeared to be an effective approach to help maintain sinus rhythm in patients with chronic AF. True electrical isolation of the pulmonary veins was associated with a higher likelihood of long-term success. Left atrial flutter was seen in a significant number of patients at long-term follow-up.

Radiofrequency ablation of a right atrial appendage-ventricular accessory pathway by transcutaneous epicardial instrumentation.

Epicardial location of accessory AV pathways may be responsible for the failure of conventional endocardial radiofrequency catheter ablation. Transcutaneous epicardial instrumentation provides access to the normal pericardium with no need for invasive thoracotomy or thoracoscopy. We report the case of successful epicardial mapping and ablation of a right atrial appendage-ventricular connection using a percutaneous epicardial approach, after repeated failure of endocardial ablation attempts.

First human experience with pulmonary vein isolation using a through-the-balloon circumferential ultrasound ablation system for recurrent atrial fibrillation.

BACKGROUND: Standard mapping and ablation of focal sources of atrial fibrillation are associated with very long procedure times and low efficacy. An anatomic approach to complete pulmonary vein isolation could overcome these limitations. METHODS AND RESULTS: Fifteen patients with atrial fibrillation refractory to medication underwent circumferential isolation of the pulmonary veins by using a novel catheter, with an ultrasound transducer (8-MHz) mounted near the tip, in a saline-filled balloon. Twelve atrial foci and/or atrial fibrillation triggers were identified in 9 patients (pulmonary vein locations: left upper, 3; right upper, 6; right middle, 1; right lower, 1; and left inferior, 1). In 5 patients, lesions were placed in the absence of any mapped triggers. Irrespective of trigger mapping, circumferential isolation of both upper pulmonary veins was attempted in all patients. The lower pulmonary veins were ablated when sinus rhythm activation mapping revealed evidence of a sleeve of atrial muscle in the vein. The median number of lesions per patient required to isolate 1 pulmonary vein was 4 (range, 1 to 29). After ablation, no evidence of narrowing was seen with repeat venography or follow-up computed tomography scan. After a mean follow-up of 35+/-6 weeks, 5 patients had recurrence of atrial fibrillation. Three responded to drugs that were previously ineffective, and 2 remained in atrial fibrillation. CONCLUSIONS: This novel ultrasound ablation system can successfully isolate multiple pulmonary veins. At early follow-up, this approach seems to be effective in preventing recurrent atrial fibrillation in a significant number of patients.