Risk factors for severe morbidity and definitive stoma after elective surgery for sigmoid diverticulitis: a multicenter national cohort study.

BACKGROUND: In the decision to perform elective surgery, it is of great interest to have data about the outcomes of surgery to individualize patients who could safely undergo sigmoid resection. The aim of this study was to provide information on the outcomes of elective sigmoid resection for sigmoid diverticular disease (SDD) at a national level. METHODS: All consecutive patients who had elective surgery for SDD (2010-2021) were included in this retrospective, multicenter, cohort study. Patients were identified from institutional review board-approved databases in French member centers of the French Surgical Association. The endpoints of the study were the early and the long-term postoperative outcomes and an evaluation of the risk factors for 90-day severe postoperative morbidity and a definitive stoma after an elective sigmoidectomy for SDD. RESULTS: In total, 4617 patients were included. The median [IQR] age was 61 [18.0;100] years, the mean ± SD body mass index (BMI) was 26.8 ± 4 kg/m2, and 2310 (50%) were men. The indications for surgery were complicated diverticulitis in 50% and smoldering diverticulitis in 47.4%. The procedures were performed laparoscopically for 88% and with an anastomosis for 83.8%. The severe complication rate on postoperative day 90 was 11.7%, with a risk of anastomotic leakage of 4.7%. The independent risk factors in multivariate analysis were an American Society of Anesthesiologists (ASA) score ≥ 3, an open approach, and perioperative blood transfusion. Age, perioperative blood transfusion, and Hartmann's procedure were the three independent risk factors for a permanent stoma. CONCLUSIONS: This series provides a real-life picture of elective sigmoidectomy for SDD at a national level. TRIAL REGISTRATION: Comité National Information et Liberté (CNIL) (n°920361).

Nebulised liposomal amphotericin-B as maintenance therapy in allergic bronchopulmonary aspergillosis: a randomised, multicentre trial.

BACKGROUND: In allergic bronchopulmonary aspergillosis (ABPA), prolonged nebulised antifungal treatment may be a strategy for maintaining remission. METHODS: We performed a randomised, single-blind, clinical trial in 30 centres. Patients with controlled ABPA after 4-month attack treatment (corticosteroids and itraconazole) were randomly assigned to nebulised liposomal amphotericin-B or placebo for 6 months. The primary outcome was occurrence of a first severe clinical exacerbation within 24 months following randomisation. Secondary outcomes included the median time to first severe clinical exacerbation, number of severe clinical exacerbations per patient, ABPA-related biological parameters. RESULTS: Among 174 enrolled patients with ABPA from March 2015 through July 2017, 139 were controlled after 4-month attack treatment and were randomised. The primary outcome occurred in 33 (50.8%) out of 65 patients in the nebulised liposomal amphotericin-B group and 38 (51.3%) out of 74 in the placebo group (absolute difference -0.6%, 95% CI -16.8- +15.6%; OR 0.98, 95% CI 0.50-1.90; p=0.95). The median (interquartile range) time to first severe clinical exacerbation was longer in the liposomal amphotericin-B group: 337 days (168-476 days) versus 177 days (64-288 days). At the end of maintenance therapy, total immunoglobulin-E and Aspergillus precipitins were significantly decreased in the nebulised liposomal amphotericin-B group. CONCLUSIONS: In ABPA, maintenance therapy using nebulised liposomal amphotericin-B did not reduce the risk of severe clinical exacerbation. The presence of some positive secondary outcomes creates clinical equipoise for further research.

[Cushing's syndrome with inhaled corticosteroid: Drug interactions to avoid]. / Syndrome de Cushing sous fluticasone inhalée : interactions médicamenteuses à éviter.

Cushing's syndrome is an iatrogenic event occurring during co-administration of inhaled corticosteroids and potent inhibitors of P450 cytochromes. We report the clinical case of a 29-year-old woman with a past history of asthma treated with inhaled fluticasone propionate (FP), chronic pulmonary aspergillosis and allergic bronchopulmonary aspergillosis (ABPA) treated with itraconazole (ITZ), and Mycobacterium xenopi infection treated with moxifloxacin (MXF), ethambutol (EMB) and clarithromycin (CLR). Four months after initiation of antibiotic and antifungal medication, the patient contracted Cushing's syndrome. Its etiology consisted in interaction between FP, ITZ and CLR, which led to pronouncedly increased corticosteroid concentrations in circulating plasma cells. Following on the one hand cessation of FP and ITZ and on the other hand hydrocortisone supplementation, evolution was favorable. Several cases of iatrogenic Cushing's syndrome induced by co-administration of FP and potent CYP3A4 inhibitors have been reported in the literature. If possible, FP should be avoided in patients being treated with CYP3A4 inhibitors. Due to its differing physicochemical properties, beclometasone may be considered as the safest therapeutic alternative.

A survey on the use of gentamicin in infective endocarditis.

US and European guidelines recommend a daily divided gentamicin dose (3 mg/kg in two or three equally divided doses) for the treatment of infective endocarditis caused by staphylococci or enterococci, but once-daily dosing (3 mg/kg/day) is recommended for streptococcal endocarditis. However, studies have recommended the use of higher doses of gentamicin (4 or ≥5 mg/kg/day) administered once-daily. A survey was conducted in France by mailing a questionnaire to the 595 members of the French Infectious Disease Society regarding their gentamicin prescription patterns in infective endocarditis, focusing on the dosing regimen. The survey was answered by 137 physicians (23%). The proportions of physicians following guideline-based regimens were similar for each organism (30.9%, 38.8%, and 39.4% for staphylococci, enterococci, and streptococci, respectively [p=0.26]). In contrast, the proportions of physicians following literature-based regimens were significantly different for each organism (59.6%, 42.5%, and 27.7% for staphylococci, enterococci, and streptococci, respectively [p<0.001]). The number of years practicing and the type of practice (university vs. non-university hospital) did not influence the gentamicin dose or regimen. Although adherence to published guidelines for gentamicin administration in patients with infective endocarditis was poor, a large proportion of physicians who did not follow those guidelines used literature-based regimens.

Voriconazole for chronic pulmonary aspergillosis: a prospective multicenter trial.

Early evidence suggests the efficacy of voriconazole for chronic pulmonary aspergillosis (CPA). We conducted a prospective, open, multicenter trial to evaluate the efficacy and safety of voriconazole for proven CPA in minimally or non-immunocompromised patients. Patients had CPA confirmed by chest computed tomography (CT) and/or endoscopy, positive Aspergillus culture from a respiratory sample, and positive serologic test for Aspergillus precipitins. Patients received voriconazole (200 mg twice daily) for a period of 6-12 months and were followed for 6 months after the end of therapy (EOT). The primary endpoint was global success at 6 months, defined as complete or partial (≥50 % improvement) radiological response and mycological eradication. Forty-one patients with confirmed CPA were enrolled. All patients had A. fumigatus as the etiologic agent. By EOT, five patients had died from comorbidities and seven had discontinued voriconazole due to toxicity. The global success rate at 6 months was 13/41 (32 %): 10/19 (53 %) for chronic necrotizing aspergillosis and 3/22 (14 %) for chronic cavitary aspergillosis (p = 0.01). The respective success rates at EOT were 58 and 32 %. Clinical symptoms and quality of life also improved during treatment. Voriconazole is effective for CPA, with acceptable toxicity. The response rate is higher and obtained more rapidly in necrotizing than cavitary forms.

[Spontaneous pneumomediastinum]. / Pneumomédiastin spontané.

INTRODUCTION: Pneumomediastinum, which can be spontaneous or secondary, is defined by the presence of free air in the mediastinum as shown on a chest X-ray and/or chest CT, with or without subcutaneous emphysema. Secondary pneumomediastinum develops in various contexts (thoracic traumatism, perforation of central airway or digestive tract, pneumothorax, barotraumatism complicating mechanical ventilation…). Spontaneous pneumomediastinum , which will be the focus of this review, develops without any of the above-mentioned conditions. STATE OF ART: Spontaneous pneumomediastinum is a rare entity which usually occurs in young people either without medical history or with an history of asthma. A trigger event is detected in 40% to 60% of cases. Positive diagnosis is made on chest radiographt but thoracic CT is more sensitive. Distinction between spontaneous pneumomediastinum and secondary pneumomediastinum is in general easy but may sometimes be more difficult, particularly in case of oesophageal perforation. The evolution of spontaneous pneumomediastinum is most often benign but, rare complications may occur. Management is most often conservative. PERSPECTIVES: There is no consensual management of spontaneous pneumediastinum because of the lack of randomized prospective studies. This may be explained by the rarity of the disease. The actual trend is to offer to the patients a conservative treatment, which could be ambulatory in some cases. CONCLUSIONS: Spontaneous pneumomediastinum is a rare entity developing mainly in young subjects. The evolution is in general benign, justifying a conservative approach.

[Early outcomes following lung transplantation in patients aged 65 years and older]. / Résultats précoces de la transplantation pulmonaire chez les patients âgés de 65 ans et plus.

INTRODUCTION: The number of lung transplantations performed is increasing worldwide. With an improved experience and outcomes, the age of the recipient on its own has ceased to be an absolute contra-indication. We report our first experience with lung transplantation in patients aged 65 years or older. METHODS: From January 2014 to March 2019, the files of patients aged 65 years or older undergoing lung transplantation were retrospectively reviewed. RESULTS: During the study period, 241 patients underwent lung transplantation in Bichat hospital (Paris, France), including 25 recipients aged 65 years or older. Underlying diagnoses were interstitial (72%) and obstructive (28%) disease. The rate of single lung transplantation was 80%. Sixteen patients required ECMO assistance during the procedure. Early complications were mostly grade III primary graft dysfunction (12%) and cellular rejection (20%). Overall one-year survival rate was 76%. CONCLUSION: After a careful selection of the recipients, the early results of our retrospective single center series are encouraging. We continue to consider lung transplantation in rigorously selected recipients of aged 65 years and more.

Optimal duration of antibiotic therapy in vertebral osteomyelitis.

OBJECTIVES: To compare the risk of relapse of vertebral osteomyelitis (VO), according to the duration of antibiotic therapy (< or =6 weeks versus >6 weeks). METHODS: We performed a 10-year retrospective study to assess the risk of VO relapse and to verify that this risk was not enhanced in patients who received 6 weeks of antibiotic therapy (Group 1) as compared with those who received a longer treatment (Group 2). VO was diagnosed based on clinical manifestations, magnetic resonance imaging and/or computed tomography findings, and isolation of a pyogenic organism in blood cultures and/or a discovertebral biopsy. Relapse was diagnosed based on isolation of the same organism in blood cultures and/or a discovertebral biopsy. Outcome was evaluated 6 months post-treatment and in December 2004. RESULTS: Group 1 included 36 patients (mean age, 58 +/- 15 years) and Group 2 included 84 patients (mean age, 67 +/- 15 years) (P = 0.003). Clinical data and microorganisms were comparable in the 2 groups. In the first 6 months, 6 (5%) patients died (Group 1, n = 2; Group 2, n = 4), and 5 (4%) in Group 2 relapsed, 2 with recurrent VO and 3 with recurrent bacteremia. In 2004, 91 patients were evaluated (mean follow-up, 40.6 +/- 31 months): 77 (85%) were cured, 13 (14%) died (Group 1, n = 3; Group 2, n = 10), 1 had VO due to a different microorganism (Group 2), and no long-term relapses occurred. CONCLUSION: Our results suggest that antibiotic therapy of VO could be safely shortened to 6 weeks without enhancing the risk of relapse.

Legionnaire's pneumonia: is there really an interstitial disease?

OBJECTIVE: Legionella pneumonia is usually classified as "atypical pneumonia", which suggests a predominance of interstitial patterns in chest X-rays. Based on a selection of recent clinical cases and a brief review of the literature, the aim of the study is to clarify, how far the actual radiological findings would be consistent with these expectations. PATIENTS AND METHODS: A retrospective analysis of 18 epidemic personal cases and a review of the literature data were performed to describe the chest X-ray findings of Legionella pneumophila (LP) community acquired pneumonia. X-ray review was performed simultaneously and in consensus by two radiologists (J.P.T., E.C.) and a physician (C.G.). RESULTS: From our series, 17 patients had an abnormal chest X-ray on admission. Among these pathological X-ray cases, infiltrates were more often confluent (n=16), or patchy (n=7), rather than interstitial (n=1). Fifteen patients had infiltrates involving the lower lung fields. Bilateral distribution of abnormalities and pleural effusion were each observed in three cases. Radiological findings deteriorated between the second and seventh days following admission, particularly in the form of patchy infiltrates with pleural effusion. The review of the literature is consistent with these findings, by reporting prevalent confluent or patchy infiltrates. CONCLUSIONS: These findings are consistent with the physiopathological particularity of this affection and incite us to avoid the classification "atypical pneumonia" in radiologic terminology. This term is more appropriate for clinical and microbiological use.

[Diagnosis and epidemiological surveillance of influenza and respiratory syncytial virus infections: interest of multiplex PCR]. / Diagnostic et surveillance épidémiologique des infections grippales et à virus respiratoire syncytial: intérêt de la PCR multiplex.

OBJECTIVE: Respiratory infections require a rapid etiological diagnosis for efficient management of cases. We evaluated multiplex PCR used for the diagnosis and the epidemiological surveillance of influenza and respiratory syncytial virus (RSV) infections. PATIENTS AND METHODS: Our study included 278 patients (mean age: 37.2+/-22.9 years) with flu or flu-like syndromes, consulting physicians affiliated with the GROG Poitou-Charentes or hospitalized in the Poitiers teaching hospital. A multiplex PCR detecting A(H3), A(H1) and B influenza viruses, and RSV A and B, was performed with both a direct examination by immunofluorescence and cell-culture. RESULTS: We diagnosed a viral infection in 139 (50.0%) patients: 99 cases of influenza A(H3), 2 cases of influenza A(H1), 28 cases of influenza B and 11 cases of RSV infections. The diagnosis yield in GROG patients (52.3%) was significantly higher than that observed in hospitalized patients (34.5%) (P=0.04). All techniques were correlated in 61% of cases. The multiplex PCR yielded 22.3% more positive samples compared to the conventional techniques. All positive samples by conventional techniques were also positive by multiplex PCR. We observed a perfect correlation between viral types and subtypes determined by PCR and cell-culture. CONCLUSION: Multiplex PCR is a sensitive technique allowing an efficient and rapid diagnosis of respiratory infections due to influenza and RSV.

[Allergic bronchopulmonary aspergillosis: Evaluation of a maintenance therapy with nebulized Ambisome®]. / Aspergillose bronchopulmonaire allergique : évaluation d'un traitement d'entretien par Ambisome® nébulisé.

BACKGROUND: Allergic bronchopulmonary aspergillosis (ABPA) affects 3-13% of patients with asthma. Its natural history includes possibly life-threatening exacerbations and evolution towards fixed obstructive ventilatory disorders or even irreversible lung fibrosis lesions. ABPA prognosis is directly associated with exacerbation control and the main objective of the treatment is to decrease their frequency and duration. Recommendations regarding dosage and duration of treatment are not very precise. The currently used combination of itraconazole and corticosteroid therapy has many limitations. The interests of a therapeutic strategy using nebulized liposomal amphotericin B (LAmB) are to heighten antifungal lung tissue concentration, to circumvent drug interactions and decrease the potential toxicity of systemic antifungal treatments. Finally, this association leads to improved eradication of Aspergillus, thereby limiting the risk of side effects and the emergence of treatment-resistant Aspergillus strains. METHODS: This is a phase II, multicentre, randomized, single blind, controlled therapeutic study, with the objective of comparing the potential benefit on exacerbation control of a maintenance therapy by LAmB nebulization. The main objective of the study is to compare the incidence of severe clinical exacerbations in ABPA treatment, between a maintenance treatment strategy with nebulized LAmB and a conventional strategy without antifungal maintenance therapy. EXPECTED RESULTS: The results will guide practitioners in the management of ABPA treatments and help to define the place of aerosols of LAmB on "evidence base medicine" criteria.

Botulism in patients who inhale cocaine: the first cases in France.

We describe 2 cases of mild botulism in patients who inhaled cocaine. Botulism, though rare, is increasing in incidence among illicit drug users. To our knowledge, these are the first cases of botulism in illicit drug users in France. Clinicians should be aware of this phenomenon; botulism should be considered in illicit drug users with neurological symptoms.

[Co-infection with Mycobacterium tuberculosis and Pneumocystis jiroveci in a patient without HIV infection]. / Co-infection à Mycobacterium tuberculosis et Pneumocystis jiroveci chez une patiente non infectée par le VIH.

INTRODUCTION: Co-infection with Pneumocystis jiroveci and Mycobacterium tuberculosis is rarely reported in patients without HIV infection. CASE REPORT: We report the case of a 30 year old woman admitted to hospital for respiratory distress associated with a diffuse infiltrative pneumopathy. Corticosteroid therapy had been started two months earlier for suspected pulmonary sarcoidosis. Fibreoptic bronchoscopy and broncho-alveolar lavage produced evidence of Mycobacterium tuberculosis and cysts of Pneumocystis jiroveci. HIV serology was negative. Clinical progress was satisfactory following anti-tuberculous and anti-fungal therapy. CONCLUSION: Pneumocystis pneumonia is rare in subjects without HIV infection and is most often associated with a pathology or treatment leading to depression of cellular immunity. Corticosteroid treatment, even of short duration, presents the greatest risk. Systematic antibiotic prophylaxis should be considered in relation to the immune status of the patient. Co-infection with the tubercle bacillus as reported here is exceptionally rare.

Dielectric relaxation properties of carboxylic acid-terminated n-alkyl monolayers tethered to Si(1 1 1): dynamics of dipoles and gauche defects.

Molecular-level insights into the organization and dynamics of n-alkyl monolayers covalently bonded to Si(1 1 1) were gained from admittance measurements of dipolar relaxation in rectifying Hg|| HOOC-C10H(25-n) Si junctions performed as a function of applied voltage and temperature. A collective behavior of dipole dynamics is inferred from the non-Debye asymmetric relaxation peak shape and strong coupling of the dipole relaxation path with some bending vibrations of the n-alkyl OML (multi-excitation entropy model). A variety of relaxation mechanisms is observed in the frequency range (0.1 Hz-10 MHz) with different dependence of relaxation frequency and dipolar strength on measurement temperature and applied voltage. Their microscopic origin is discussed by comparing the activation energy of relaxation frequency with previous molecular mechanics calculations of saddle point energy barriers for structural defects such as gauche conformations or chain kinks in n-alkanes assemblies. Gauche conformations organized in pairs (kinks) have vanishing relaxation strength below an order-disorder transition temperature T(D) = 175 K and their probability strongly increases with applied reverse voltage, above T(D). The presence of hydrogen bonds between terminal carboxylic acid functionalities is inferred from a comparison with a similar junction bearing a low density of carboxylic acid end groups. This temperature-dependent hydrogen-bond network provides some additional stiffness against external electrostatic stress, as deduced from the rather weak sensitivity of relaxation frequencies to applied bias voltage.

An estimation of burden of serious fungal infections in France.

OBJECTIVE OF THE STUDY: An estimation of burden of serious fungal diseases in France is essential data to inform public health priorities on the importance of resources and research needed on these infections. In France, precise data are available for invasive fungal diseases but estimates for several other diseases such as chronic and immunoallergic diseases are by contrast less known. MATERIALS AND METHODS: A systematic literature search was conducted using the Web of Science Platform. Published epidemiology papers reporting fungal infection rates from France were identified. Where no data existed, we used specific populations at risk and fungal infection frequencies in those populations to estimate national incidence or prevalence, depending on the condition. RESULTS: The model predicts high prevalences of severe asthma with fungal sensitization episodes (189 cases/100,000 adults per year), of allergic bronchopulmonary aspergillosis (145/100,000) and of chronic pulmonary aspergillosis (5.24/100,000). Besides, estimated incidence for invasive aspergillosis is 1.8/100,000 annually based on classical high risk factors. Estimates for invasive mucormycosis, pneumocystosis and cryptococcosis are 0.12/100,000, 1/100,000 and 0.2/100,000, respectively. Regarding invasive candidiasis, more than 10,000 cases per year are estimated, and a much higher number of recurrent vaginal candidiasis is probable but must be confirmed. Finally, this survey was an opportunity to report a first picture of the frequency of tinea capitis in France. CONCLUSION: Using local and literature data of the incidence or prevalence of fungal infections, approximately 1,000,000 (1.47%) people in France are estimated to suffer from serious fungal infections each year.

Analysis of nutritional parameters in idiopathic scoliosis patients after major spinal surgery.

OBJECTIVE: The aim of the study is to investigate the evolution of nutritional parameters after major spinal surgery in patients with idiopathic scoliosis. METHODS: This retrospective study included 31 patients with a mean age of 18 y, diagnosed with idiopathic scoliosis. The following variables were analyzed: demographic, surgical (type, number of fused segments, duration, and blood loss), nutritional assessment (proteins, albumin, prealbumin, transferrin, lymphocytes, and body mass index), and duration of hospitalization at different time points. Statistical analyses were performed with the SPSS 6.1 software. RESULTS: Before surgery, nutritional status was normal in all patients. At 24-48 h after surgery, statistically significant decrease with respect to preoperative values was recorded for all the parameters studied: proteins (P < 0.001), albumin (P < 0.001), prealbumin (P < 0.01), transferrin (P < 0.001), and lymphocytes (P < 0.001). CONCLUSION: Our results showed a significant postoperative decrease in the nutritional parameters analyzed in a previously well-nourished population considered to be at low risk for nutritional depletion.

[Anesthesia for scoliosis surgery: preoperative assessment and risk screening of patients undergoing surgery to correct spinal deformity]. / Anestesia para la cirugía de la escoliosis. Estudio preoperatorio y selección de pacientes de riesgo en la cirugía de las deformidades raquídeas.

Spinal column deformity is associated with potentially serious alterations of respiratory and cardiac function. Such alterations, in association with the underlying disease that caused the deformity--such as neuromuscular disease--are risk factors that affect the prognosis for scoliosis patients undergoing anesthesia and surgery. It is important for the anesthesiologist to carry out a detailed preoperative assessment to identify patients at risk with the aim of decreasing morbidity and mortality related to surgical correction of deformities. Of paramount importance is awareness of the risk of injury to the spinal cord that will affect function. Other issues are how to manage the patient in anomalous positions, the risk associated with hypothermia secondary to exposure of a large surgical field for a long period, and bleeding, which can sometimes exceed the patient's total volume. In the case of scoliosis surgery, all those situations may converge, obliging us to provide careful intraoperative monitoring, particularly of spinal function; to choose the appropriate anesthetic technique; and to maintain vigilance during the early postoperative period to foresee possible complications. Because scoliosis surgery is multidisciplinary, several teams must work together to assure success.

Rapid diagnosis of alcoholic ketoacidosis by proton NMR.

In alcoholic patients, metabolic acidosis can be related to lactate acidosis associated with sepsis or thiamine deficiency, ketoacidosis, methanol or ethylene glycol poisoning. High resolution proton nuclear magnetic resonance (NMR) can be used to detect abnormal organic acid metabolites in urine or serum from patients with various metabolic disorders. In the present case, a 26-year-old patient was admitted for a coma associated with severe metabolic acidosis. Alcoholic ketoacidosis (AKA) was identified by urine proton NMR. Her metabolic disorders rapidly improved. Persisting associated neurological alteration was related to extrapontine myelinolysis as shown by imaging cerebral NMR.

Maternal Herpes simplex virus type 2 encephalitis following Cesarean section.

Herpes simplex virus type 2 (HSV-2) encephalitis is rare especially during pregnancy. In immunocompetent patients, HSV-2 meningitis (contrary to HSV-1 meningitis) is usually mild, without encephalitis. We report a rare case of maternal HSV-2 encephalitis following Cesarean section. The woman had no symptomatic genital lesion, and the infant was not infected. The route of meningeal infection (neuronal or hematogenous) is discussed.