Evaluation of use and identification of predictive factors for nonuse of peripheral venous catheters in the emergency department.

The placement of peripheral venous catheters (PVC) is a frequent procedure in the emergency department (ED), which exposes patients to complications (hematoma, fluid leakage, phlebitis, edema, infection), increases hemolysis of blood samples, is time-consuming and costly. The main aim of this study is to analyze the rate of PVC nonuse in the ED and to identify predictive factors of their nonuse. This prospective single-center observational study was conducted in the ED of the Saint-Antoine Hospital in Paris, France between February and March 2022. Adult patients receiving a PVC were included. In addition to demographic and medical data, the reason for PVC prescription and the prescribing physician's expectation of PVC use were collected. A total of 304 patients were included, with a median age of 61.5 years (IQR: 43-79 years), of whom 152 (50%) were men. PVC were primarily prescribed for intravenous medication administration. Seventy-two (23.7%) PVC were not used. In multivariable analysis, the predictive factors of nonuse were the prescribing physician's expectation of nonuse [OR 6.35, CI 95% (2.64-15.29), for "no" and "not sure" vs. "yes" responses] and the reason for prescribing "just in case" [OR 3.54, CI 95% (1.37-9.17)]. PVC were not used in 23.7% of cases. Predictors of nonuse were the prescribing physician's expectation of nonuse and the reason for prescribing "just in case". A PVC should probably not be prescribed if the prescribing physician thinks it will not be used or prescribes it "just in case".

External validation of Glasgow-Blatchford, modified Glasgow-Blatchford and CANUKA scores to identify low-risk patients with upper gastrointestinal bleeding in emergency departments: a retrospective cohort study.

BACKGROUND: Upper gastrointestinal bleeding (UGIB) is a medical emergency with an approximate mortality of 10%, which results in a high hospitalisation rate. The Glasgow-Blatchford score (GBS) is recommended to identify low-risk patients who can be discharged from the emergency department (ED). A modified GBS (mGBS) and CANUKA score have recently been proposed but have not been well studied. The aim of this study was to assess whether the use of GBS, mGBS or CANUKA score could identify patients at low risk of death or need for intervention. METHODS: A single-centre retrospective study was performed including patients with suspected UGIB visiting the ED of Saint-Antoine hospital (Paris, France) from January 2016 to December 2018. Demographic and medical data needed to calculate GBS and CANUKA were collected, as well as outcomes data. Need for intervention was defined as the need for blood transfusion, endoscopic haemostasis or rebleeding within 7 days. In-hospital mortality was also collected. Sensitivity, specificity and predictive values were measured for the score thresholds of interest. RESULTS: A total of 386 patients were included. Median age was 60 years (38-78), 65.3% (n=252) were male and 60% (n=233) were hospitalised. A GBS≤1, mGBS=0 and CANUKA≤2 categorised 24.9%, 18.2% and 18.9% of patients as low risk, respectively. There was a need for intervention in 2.2%, 4.6% and 0% of those patients categorised as low risk by GBS, mGBS and CANUKA, respectively. No deaths occurred in the patients identified as low risk, regardless of the score used. All scores had a high sensitivity and negative predictive value. CONCLUSIONS: In patients with UGIB, the use of a GBS≤1 or CANUKA score ≤2 appears to be safe for identifying patients at low risk of death or need for intervention.

Left atrial compression by a large hiatal hernia: A rare cause of cardiac dysfunction.

Symptomatic hiatal hernia (HH) is most often revealed by gastroesophageal reflux disease, but there are atypical presentations some of which are life-threatening. We report the case of a 57-year-old woman brought to the emergency department with isolated shortness of breath for 24 h. Initial explorations revealed unexplained hyperlactatemia (6.4 mmol/L) without clinical or biological evidence of hypovolemia, distributive, obstructive or cardiogenic shock. Two hours after admission, we observed a decreased of blood pressure and an increase of lactate level to 7.9 mmol/L. A bedside echocardiography revealed an extra-cardiac left atrial compression and thoracoabdominal computed tomography showed a large sliding HH compressing the left atrium. After an upper gastrointestinal endoscopy permitting the aspiration of gastric contents, a repair surgery was performed without complications and patient was discharge three days later. Emergency physicians should be aware that HH can be a rare cause of cardiac symptoms by heart compression and certainly use echocardiography for unexplained hemodynamic failure.

Acute icteric hepatitis as the first isolated symptom of COVID-19.

Patients with COVID-19 may be asymptomatic or present with extrarespiratory symptoms, such as liver injury. It has been reported that 22.5%-46.2% of patients have moderate elevation of liver enzymes. To our knowledge, acute hepatitis has never been described as an isolated symptom of COVID-19 in a previously healthy patient. We report the case of a 53-year-old patient with COVID-19 whose first clinical presentation was acute icteric hepatitis, several days before the development of others symptoms. During the pandemic, we suggest that patients with acute hepatitis be considered as COVID-19 suspects, tested and isolated.

Outpatient Management of Patients With COVID-19: Multicenter Prospective Validation of the Hospitalization or Outpatient Management of Patients With SARS-CoV-2 Infection Rule to Discharge Patients Safely.

BACKGROUND: The Hospitalization or Outpatient Management of Patients With SARS-CoV-2 Infection (HOME-CoV) rule is a checklist of eligibility criteria for home treatment of patients with COVID-19, defined using a Delphi method. RESEARCH QUESTION: Is the HOME-CoV rule reliable for identifying a subgroup of COVID-19 patients with a low risk of adverse outcomes who can be treated at home safely? STUDY DESIGN AND METHODS: We aimed to validate the HOME-CoV rule in a prospective, multicenter study before and after trial of patients with probable or confirmed COVID-19 who sought treatment at the ED of 34 hospitals. The main outcome was an adverse evolution, that is, invasive ventilation or death, occurring within the 7 days after patient admission. The performance of the rule was assessed by the false-negative rate. The impact of the rule implementation was assessed by the absolute differences in the rate of patients who required invasive ventilation or who died and in the rate of patients treated at home, between an observational and an interventional period after implementation of the HOME-CoV rule, with propensity score adjustment. RESULTS: Among 3,000 prospectively enrolled patients, 1,239 (41.3%) demonstrated a negative HOME-CoV rule finding. The false-negative rate of the HOME-CoV rule was 4 in 1,239 (0.32%; 95% CI, 0.13%-0.84%), and its area under the receiver operating characteristic curve was 80.9 (95% CI, 76.5-85.2). On the adjusted populations, 25 of 1,274 patients (1.95%) experienced an adverse evolution during the observational period vs 12 of 1,274 patients (0.95%) during the interventional period: -1.00 (95% CI, -1.86 to -0.15). During the observational period, 858 patients (67.35%) were treated at home vs 871 patients (68.37%) during the interventional period: -1.02 (95% CI, -4.46 to 2.26). INTERPRETATION: A large proportion of patients treated in the ED with probable or confirmed COVID-19 have a negative HOME-CoV rule finding and can be treated safely at home with a very low risk of complications. TRIAL REGISTRY: ClinicalTrials.gov; No.: NCT04338841; URL: www.clinicaltrials.gov.

[Single use versus reusable flexible ureteroscopy for the treatment of urolithiasis: a comparative study of perioperative complications].

OBJECTIVE: To compare the perioperative complications of patients who underwent flexible ureteroscopy (fURS) for the treatment of urolithiasis according to the type of ureteroscope used, single-use (suURS) or reusable (rURS) flexible ureteroscope. PATIENTS AND METHODS: A retrospective and single-center study was conducted between January 2017 and May 2019, including all fURS performed for nephrolithiasis management. During the study period, 5rURS and 1suURS (UscopePU3022) were available. The primary endpoint was the occurrence of 30-days postoperative complications, especially infectious complications, classified according to Clavien-Dindo grading system. RESULTS: Overall, 322 consecutive fURS were included corresponding to 186 rURS (57.8%) and 136 suURS (42.2%). Respectively in rURS and suURS groups, the median (IQR) age was 57 (45-65) vs 57 (44-66) years (p=0.75), 83 (44.6%) vs 63 (46.3%) female were included (p=0.82), and median (IQR) Charlson score was 2 (1-3) vs 2 (0-3) (p=0.15). Fifty-one patients (15.8%) developed postoperative complications, 28 patients (15%) in rURS group and 23 patients (17.6%) in suURS group (p=0.64). Most of them (n=47, 92.1% of overall complications) were minor (Clavien I-II). Occurrence of urinary tract infection in suURS group (n=13; 9.5%) was equally comparable with rURS group (n=10; 5.4%), p=0.15. CONCLUSIONS: Our data suggests that suURS represents a safe alternative to rURS. Compared to reusable devices, UscopePU3022 use was associated with a similar complication rates, however, did not decrease the occurrence of infectious events.

Miami Pouch: A Simple Technique for Efficient Continent Cutaneous Urinary Diversion.

OBJECTIVE: To report a contemporary series of Miami pouch (MP) enriched with a full technical description and step-by-step video to contribute to wider use. PATIENTS AND METHODS: A retrospective charts review of all patients who had a MP at our center between January 2016 and December 2017 was performed. The MP technique uses the terminal 15cm of ileum and the right colon to build an intestinal heterotopic pouch located in the right iliac fossa and connected to the skin by an efferent catheterizable tube. Primary outcome was continence defined as the absence of leakage between clean intermittent self-catheterization (CISC) with a maximal interval of 4 hours between each CISC. RESULTS: Fifteen patients had MP during the study period. Thirty-day postoperative Clavien III complications were observed in 2 (13.3%) patients. At 39 months of median follow-up, continence was obtained for all patients except for 2 patients whom reported intermittent night-time leakages due to long intervals (5 to 7 hours) between 2 CISC. No significant alteration of renal function was reported and no stenosis of the efferent tube neither difficulty to perform CISC was observed. CONCLUSIONS: For patients who are candidates for radical cystectomy and not eligible for orthotopic neobladder, intestinal heterotopic pouch with a cutaneous continent urinary diversions as MP may be a reliable alternative. Patients should be informed of the existence of a valid alternative to ileal conduit since it may fit their expectations of a preserved body image without urine collecting appliances.

Efficacy and Safety of Surgery for Benign Prostatic Obstruction in Patients with Preoperative Urinary Catheter.

Purpose: To evaluate the efficacy and safety of benign prostatic obstruction (BPO) surgery in patients with preoperative urinary catheterization. Patients and Methods: We conducted a multi-institutional retrospective study including all patients who failed a trial without catheter (TWOC) after acute urinary retention (AUR) between January 2017 and January 2019. Patients with neurogenic bladder, prostate cancer, or urethral stricture were excluded from the analysis. Patients underwent either monopolar/bipolar transurethral resection of the prostate (TURP), photoselective vaporization of the prostate (PVP), prostate artery embolization (PAE), open prostatectomy (OP), or endoscopic enucleation. The primary endpoint was 12-month urinary catheter-free survival without using benign prostatic hyperplasia medications. Results: One hundred seventy-one consecutive men (median age: 71 years; median prostate volume: 75 cm3) underwent BPO surgery, including 48 (28%) TURP, 62 (36.3%) PVP, 21 (12.3%) endoscopic enucleation, 15 (8.8%) PAE, and 25 (14.6%) OP. The median duration of preoperative urinary catheterization was 69 days (interquartile range 46-125). The 12-month urinary catheter-free survival rate was 84.8% (145/171). Satisfactory voiding returned to 121 patients (70.8%). On backward stepwise multivariable analysis, PVP (odds ratio [OR] 0.27 [0.10-0.69]; p = 0.008), PAE (OR 5.27 [1.28-27.75]; p = 0.03), endoscopic enucleation (OR 0.08 [0-0.49]; p = 0.023), OP (OR 0.10 [0.01-0.57]; p = 0.034), Charlson score (OR 1.36 [1.14-1.66]; p = 0.001), and number of preoperative TWOC failure (OR 2.53 [1.23-5.51]; p = 0.014) were significantly associated with catheter-free survival. Conclusions: In this multi-institutional retrospective study, including patients with preoperative catheterization, the overall success rate of BPO surgery was 70.8% after 1-year follow-up. Compared with TURP, enucleation methods and PVP were associated with better catheter-free survival, whereas PAE was associated with higher risk of AUR recurrence.

The prognostic value of serum procalcitonin in acute obstructive pyelonephritis.

PURPOSE: To evaluate the prognostic value of procalcitonin (PCT) in the occurrence of infectious complications in the management of acute obstructive pyelonephritis (AOP) compared with other biological parameters (leucocyte count, C-reactive protein [CRP]). METHODS: We conducted a retrospective study including patients who were treated for AOP and performed serum PCT tests in our center between January 1, 2017 and December 31, 2017. Upper urinary tract obstruction was confirmed by either ultrasound or CT urography. Clinical examinations and laboratory tests including leukocyte count, CRP, urine and blood cultures, and serum PCT measurements were performed in the emergency unit. Treatment included early renal decompression using indwelling ureteral stents or nephrostomy and empiric antibiotic therapy. The primary endpoint was occurrence of severe sepsis (SS), a composite criterion including urosepsis and/or septic shock and/or admission to the intensive care unit (ICU) and/or death. RESULTS: A total of 110 patients (median age: 61 years) were included, of whom 56.3% were female. SS occurred in 39 cases (35.4%). Multivariate regression analysis showed that serum PCT (OR 1.08; 95% CI 1.03-1.17; p = 0.01), CRP (OR 1.007; 95% CI 1.001-1.015; p = 0.03), and diabetes mellitus (OR 5.1; 95% CI 1.27-27.24; p = 0.04) were independent predictors for SS. Serum PCT was the biological marker associated with the highest accuracy to predict SS (ROC 0.912 (95% CI 0.861-0.962) and was superior to CRP (p < 0.001): the sensitivity and specificity of PCT to predict SS were 95% and 77%, respectively, with a serum PCT cutoff value of 1.12 µg/L. CONCLUSIONS: PCT levels > 1.12 µg/L could help physicians to identify high-risk patients who could benefit from early and aggressive management in collaboration with intensive care specialists.

Micro-percutaneous nephrolithotomy (Microperc) for renal stones, outcomes and learning curve.

OBJECTIVE: To report the effectiveness, reliability and learning curve of Microperc, a minimal invasive percutaneous technique using a 4.85-Ch (16-gauge) sheath, in the treatment of nephrolithiasis. MATERIAL AND METHODS: 31 consecutive Micropercs for nephrolithiasis<2.5cm were performed by 2 operators in 2 different institutions from the 1st of May 2015 to 31st of December 2017. RESULTS: The mean size of stones was 19mm±11mm, and mean density was 1048±249UH. Stones were located in lower calyx in 21/31(68%), medium calyx in 3/31(10%), pelvis in 4/31(12%) and were multi-caliceal in 3/31(10%). Five patients (16%) had urinary diversion (4 ileal conduits, 1 enterocystoplasty with Mitrofanoff+bladder neck closure) all of those having neurological disease (2 multiple sclerosis, 3 spinal cord injury). Mean operating time was 83±35min and decreased after short period for both operators. 9/31(29%) patients had complication: 8 (26%) had fever (Clavien II) and 1 (3%) had renal colic pain (Clavien III) (required JJ stent). Stone-free was obtained in 13/31(42%) and 11/31(36%) had residual microfragments<3mm which did not require further treatment, corresponding to a technical success of 78% (24/31). Success rate was similar in patients with urinary diversion and patients with normal anatomy. CONCLUSIONS: This study showed that Microperc was an effective technic for kidney stone treatment with low complication rate, acceptable operating time and short learning curve. Microperc was useful for stones in the lower calyx and/or urinary diversion where retrograde ureteroscopy could reach its limits. LEVEL OF EVIDENCE: 3.

Alcohol consumption among French physicians: A cross-sectional study.

BACKGROUND: Data regarding French physicians' alcohol behaviours are scarce and most studies address this issue within the population of either medical students or residents. We aim to describe and assess the prevalence of hazardous alcohol consumption among French physicians. METHODS: A regional, cross-sectional, survey was conducted in 2018 using an online questionnaire among Parisian general practitioners and hospital doctors. Hazardous alcohol consumption was defined by an Alcohol Use Disorders Identification Test (AUDIT) score ≥ 8. Data were analysed in 2020. RESULTS: Five hundred fifteen physicians completed the survey: 108 general practitioners and 407 hospital physicians. The median age was 40 years [32-55] and 59 % were women. They considered their physical and mental health as average or bad in 10 % and 8% of cases, respectively. The prevalence of hazardous alcohol consumption was 12.6 %. Among the 65 physicians with hazardous alcohol consumption, 27 (41.5 %) did not considered it as risky and four (6.2 %) mentioned a potentially negative impact on patients' care. Factors independently associated with hazardous alcohol consumption were illegal drugs consumption (OR 4.62 [2.05-10.37]) and fixed term contract for hospital doctors (OR 2.69 [1.14-6.36]). CONCLUSIONS: The prevalence of hazardous alcohol consumption among French physicians was 12.6 %. Illegal substance users and fix-termed contract hospital doctors were more likely to have risky alcohol consumption. A large-scale national study would confirm the factors associated with hazardous alcohol consumption and could explore the efficacy of preventive measures to insure the safety and health of physicians and their patients.

Glial Endozepines Reverse High-Fat Diet-Induced Obesity by Enhancing Hypothalamic Response to Peripheral Leptin.

Research on energy homeostasis has focused on neuronal signaling; however, the role of glial cells has remained little explored. Glial endozepines exert anorexigenic actions by mechanisms which remain poorly understood. In this context, the present study was designed to decipher the mechanisms underlying the anorexigenic action of endozepines and to investigate their potential curative effect on high-fat diet-induced obesity. We carried out a combination of physiological, pharmacological, and molecular analyses together to dissect the underlying mechanisms of endozepine-induced hypophagia. To evaluate the potential anti-obesity effect of endozepines, different model of obesity were used, i.e., ob/ob and diet-induced obese mice. We show that the intracerebral administration of endozepines enhances satiety by targeting anorexigenic brain circuitry and induces STAT3 phosphorylation, a hallmark of leptin signaling. Strikingly, endozepines are entirely ineffective at reducing food intake in the presence of a circulating leptin antagonist and in leptin-deficient mice (ob/ob) but potentiate the reduced food intake and weight loss induced by exogenous leptin administration in these animals. Endozepines reversed high fat diet-induced obesity by reducing food intake and restored leptin-induced STAT3 phosphorylation in the hypothalamus. Interestingly, we observed that glucose and insulin synergistically enhance tanycytic endozepine expression and release. Finally, endozepines, which induce ERK activation necessary for leptin transport into the brain in cultured tanycytes, require tanycytic leptin receptor expression to promote STAT3 phosphorylation in the hypothalamus. Our data identify endozepines as potential anti-obesity compounds in part through the modulation of the LepR-ERK-dependent tanycytic leptin shuttle.

Selective Trans-arterial Embolization of Iatrogenic Vascular Lesions Did Not Influence the Global Renal Function After Partial Nephrectomy.

OBJECTIVE: To evaluate the renal function outcomes after selective trans-arterial embolization (SAE) of iatrogenic vascular lesions (IVL), including pseudoaneurysm and arteriovenous fistula, following partial nephrectomy (PN). MATERIALS AND METHODS: A multi-institutional study was conducted including consecutive patients who underwent PN between January 2009 and March 2019. Two surgical approaches were used: open and robot-assisted PN. Patients with SAE were identified and matched (1:2) with patients without IVL. The matching criteria were age, gender, Charlson score, creatinine clearance, RENAL score, and tumor size. The primary outcome was the evolution of global renal function at 6-months postoperatively. RESULTS: A total of 493 consecutive PN (360 open PN and 133 robot-assisted PN) were included. IVL occurred in 17 cases (3.4%) without statistical difference according to the surgical approach (P = .78). Patients from embolization group were matched to 34 cases without postoperative IVL. Groups were comparable concerning clinical, tumor and surgical characteristics. The clinical success of SAE, defined as the absence of recourse to a second embolization or a total nephrectomy, was obtained in 16 (94.1%) cases. No minor or major complications were reported after SAE. The preoperative estimated glomerular filtration rate (eGFR) was similar between control group (93 [85-102] ml/min) and embolization group (95 [83-102] ml/min) (P = .99). Median (IQR) eGFR between control group (87 [72-95] ml/min) and embolization group (83 [76-93] ml/min) at a follow-up of 6 months showed no significant difference (P = .73). CONCLUSION: IVL are rare complications of PN. SAE is an effective and minimally invasive management tool, with no deleterious effect on global renal function.

Predictive risk factors of urinary tract infection following flexible ureteroscopy despite preoperative precautions to avoid infectious complications.

PURPOSE: Urinary tract infection (UTI) is a common complication after flexible ureteroscopy (fURS) despite technical precautions to avoid infectious complications. The aim was to investigate incidence and predictive risk factors of UTI following fURS procedure. PATIENTS AND METHODS: We conducted a retrospective study including consecutive fURS performed in our center from January 2015 to March 2019. The indications were: nephrolithiasis management and diagnosis and conservative treatment of upper urinary tract urothelial carcinomas (UTUC). Since 2015, we had technical precautions to avoid postoperative infectious complications: centralized collection of preoperative urine cultures which are examined daily by an urologist and a service provider, systematic use of ureteral access sheath and application of standardized antibiotic prophylaxis measures. The primary endpoint was occurrence of UTI within 15 days following fURS. RESULTS: Six hundred and four fURS were included for nephrolithiasis (n = 462) and UTUC management (n = 142). The median (IQR) age in the study cohort was 61(48-68) years, 268 female patients were included (44.4%), the median (IQR) Charlson score was 2(1-4) and single-use fURS were used in 186 cases (30.8%). Postoperative UTI occurred in 41 cases (6.7%). In multivariate analysis, female gender (OR 2.20 [1.02-5.02], p = 0.04), UTI within the last 6 months (OR 2.34 [1.12-5.11], p = 0.02), preoperative polymicrobial urine culture (OR 4.53 [1.99-10.56], p < 0.001) and increased operative time (OR 1.02 [1.002-1.031], p = 0.02) remain associated with postoperative UTI. CONCLUSIONS: In a large cohort study, female gender, prior UTI, increased operative time and preoperative polymicrobial urine culture were associated with the occurrence of postoperative UTI. Limiting operative time and improving our knowledge of polymicrobial urine cultures could reduce the infectious risk.

MRI-targeted biopsy for detecting prostate cancer: have the guidelines changed our practices and our prostate cancer detection rate?

PURPOSE: In our center, until 2018, MRI-targeted biopsy was underused. Since January 2018, we systematically performed MRI-targeted biopsy for suspicious PI-RADS ≥ 3 lesions in accordance to the recent guidelines. We hypothesized that the implementation of systematic prebiopsy MRI would increase the detection rate (DR) of prostate cancer (PCa) without increasing DR of clinically insignificant PCa (insignPCa). PATIENTS AND METHODS: A retrospective study including consecutive men who underwent prostate biopsy for suspicion of PCa in our center between January 2017 and December 2018 was conducted. Combined biopsies were performed for suspicious MRI and systematic biopsies for nonsuspicious MRI. The primary outcome was to compare the DR of PCa per year. Secondary outcomes included DRs of clinically significant PCa (csPCa) and insignPCa between both years and outcomes of targeted vs systematic biopsies. RESULTS: A total of 306 men (152 in 2017 and 154 in 2018) were included. Respectively, median (IQR) age was 69 (63-75) vs 70 (65-76) years (p = 0.29) and median (IQR) PSA density was 0.17 (0.13-0.28) vs 0.17 (0.11-0.26) (p = 0.24). There was a significant increase in prebiopsy MRI performed (120 [78.9%] vs 143 [92.8%]; p < 0.001) in 2018. DRs of PCa (94 [61.8%] vs 112 [72.7%]; p = 0.04) and csPCa (76 [50%] vs 95 [61.6%]; p = 0.04) increased in 2018, while the insignPCa DR was stable (p = 0.13). The DR of PCa was 58.3%, 65% and 71.2%, respectively, in targeted, systematic and combined biopsies (p = 0.02). In case of nonsuspicious MRI, the prevalence of csPCA was 12.5%. CONCLUSIONS: Introducing systematical MRI-targeted biopsy in our clinical setting increased the PCa DR without overdiagnosing insignPCa. Implementation of prebiopsy MRI does not seem to avoid the need for systematic biopsy, and nonsuspicious MRI should not obviate the need for prostate biopsy when otherwise clinically indicated.