Righini M.,University of Geneva |
Van Es J.,Amsterdam Medical Center |
Den Exter P.L.,Leiden University |
Roy P.-M.,University of Angers |
And 25 more authors.
JAMA - Journal of the American Medical Association | Year: 2014
IMPORTANCE: D-dimer measurement is an important step in the diagnostic strategy of clinically suspected acute pulmonary embolism (PE), but its clinical usefulness is limited in elderly patients. OBJECTIVE: To prospectively validate whether an age-adjusted D-dimer cutoff, defined as age x 10 in patients 50 years or older, is associated with an increased diagnostic yield of D-dimer in elderly patients with suspected PE. DESIGN, SETTINGS, AND PATIENTS: A multicenter, multinational, prospective management outcome study in 19 centers in Belgium, France, the Netherlands, and Switzerland between January 1, 2010, and February 28, 2013. INTERVENTIONS: All consecutive outpatients who presented to the emergency department with clinically suspected PE were assessed by a sequential diagnostic strategy based on the clinical probability assessed using either the simplified, revised Geneva score or the 2-level Wells score for PE; highly sensitive D-dimer measurement; and computed tomography pulmonary angiography (CTPA). Patients with a D-dimer value between the conventional cutoff of 500 μg/L and their age-adjusted cutoff did not undergo CTPA and were left untreated and formally followed-up for a 3-month period. MAIN OUTCOMES AND MEASURES: The primary outcomewas the failure rate of the diagnostic strategy, defined as adjudicated thromboembolic events during the 3-month follow-up period among patients not treated with anticoagulants on the basis of a negative age-adjusted D-dimer cutoff result. RESULTS: Of the 3346 patients with suspected PE included, the prevalence of PE was 19%. Among the 2898 patients with a nonhigh or an unlikely clinical probability, 817 patients (28.2%) had a D-dimer level lower than 500 μg/L (95% CI, 26.6%-29.9%) and 337 patients (11.6%) had a D-dimer between 500 μg/L and their age-adjusted cutoff (95% CI, 10.5%-12.9%). The 3-month failure rate in patients with a D-dimer level higher than 500 μg/L but below the age-adjusted cutoff was 1 of 331 patients (0.3% [95% CI, 0.1%-1.7%]). Among the 766 patients 75 years or older, of whom 673 had a nonhigh clinical probability, using the age-adjusted cutoff instead of the 500 μg/L cutoff increased the proportion of patients in whom PE could be excluded on the basis of D-dimer from 43 of 673 patients (6.4% [95% CI, 4.8%-8.5%) to 200 of 673 patients (29.7% [95% CI, 26.4%-33.3%), without any additional false-negative findings. CONCLUSIONS AND RELEVANCE: Compared with a fixed D-dimer cutoff of 500 μg/L, the combination of pretest clinical probability assessment with age-adjusted D-dimer cutoff was associated with a larger number of patients in whom PE could be considered ruled out with a low likelihood of subsequent clinical venous thromboembolism. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT01134068. Copyright 2014 American Medical Association. All rights reserved.
Hleyhel M.,French Institute of Health and Medical Research |
Hleyhel M.,University Pierre and Marie Curie |
Belot A.,Hospices Civils de Lyon |
Belot A.,Institute of Veille Sanitaire |
And 19 more authors.
Clinical Infectious Diseases | Year: 2013
Background. We examined trends in the incidence of the 3 AIDS-defining cancers (ADCs; Kaposi sarcoma [KS], non-Hodgkin lymphoma [NHL], and cervical cancer) among human immunodeficiency virus (HIV)-infected patients relative to the general population between 1992 and 2009 in France, focusing on age at ADC diagnosis and on patients with controlled viral load and restored immunity on combination antiretroviral therapy (cART). Methods. Age- and sex-standardized incidence rates were estimated in patients enrolled in the French hospital database on HIV, and in the general population in France during 4 calendar periods (1992-1996, 1997-2000, 2001-2004, and 2005-2009). Standardized incidence ratios (SIRs) were calculated for all periods and separately for patients on cART, with CD4 counts ≥500 cells/μL for at least 2 years and viral load ≤500 copies/mL. Results. Although the incidence of ADCs fell significantly across the calendar periods, the risk remained constantly higher in HIV-infected patients than in the general population. In patients with restored immunity, the relative risk remained significantly elevated for KS (SIR = 35.4; 95% confidence interval [CI], 18.3-61.9), and was similar to that of the general population for NHL (SIR= 1.0; 95% CI, .4-1.8). ADCs were diagnosed at a younger age in HIV-infected patients, with a particularly marked difference for NHL (-11.3 years, P< .0001). Conclusions. The incidence of all ADCs continued to fall, including cervical cancer, in the cART period, but the risk remained higher than in the general population in 2005-2009. In patients with stably restored immunity, KS remained significantly more frequent than in the general population. © The Author 2013.
Combination of rituximab, bortezomib, doxorubicin, dexamethasone and chlorambucil (RIPAD+C) as first-line therapy for elderly mantle cell lymphoma patients: Results of a phase II trial from the GOELAMS
Houot R.,University of Rennes 1 |
Le Gouill S.,University of Nantes |
Le Gouill S.,French Institute of Health and Medical Research |
Uribe M.O.,Center Hospitalier Of Mulhouse |
And 17 more authors.
Annals of Oncology | Year: 2012
Background: There is no consensual first-line chemotherapy for elderly patients with mantle cell lymphoma (MCL). The GOELAMS (Groupe Ouest-Est des Leucémies Aiguë s et Maladies du Sang) group previously developed the (R)VAD+C regimen (rituximab, vincristine, doxorubicin, dexamethasone and chlorambucil), which appeared as efficient as R-CHOP (rituximab, cyclophosphamide, doxorubicine, vincristine, prednisone) while less toxic. Based on this protocol, we now added bortezomib (RiPAD+C: rituximab, bortezomib, doxorubicin, dexamethasone and chlorambucil) given its efficacy in relapsed/refractory MCL patients. The goal of the current phase II trial was to evaluate the feasibility and efficacy of the RiPAD+C regimen as frontline therapy for elderly patients with MCL. Patients and methods: Patients between 65 and 80 years of age with newly diagnosed MCL received up to six cycles of RiPAD+C. Results: Thirty-nine patients were enrolled. Median age was 72 years (65-80). After four cycles of RiPAD+C, the overall response rate was 79%, including 51% complete responses (CRs). After six cycles, CR rate increased up to 59%. After a 27-month follow-up, median progression-free survival (PFS) is 26 months and median overall survival has not been reached. Four patients (10%) discontinued the treatment because of a severe toxicity and seven patients (18%) experienced grade 3 neurotoxicity. Conclusion: The bortezomib-containing RiPAD+C regimen results in high CR rates and prolonged PFS with predictable and manageable toxic effects in elderly patients with MCL. © The Author 2011. Published by Oxford University Press on behalf of the European Society for Medical Oncology. All rights reserved.
Bokobza B.,Pierre Mendes-France University |
Valverde A.,Center Hospitalier dArgenteuil |
Magne E.,Clinique Tivoli |
Delaby J.,Clinique de lAnjou |
And 7 more authors.
Journal de Chirurgie Viscerale | Year: 2010
To assess the results of the first single umbilical incision laparoscopic cholecystectomies (SILC) performed by the members of the Club Coelio Patients and methods.-That multicenter study concerned 65 consecutive patients submitted to SILC between September 2008 and December 2009. The operation was performed with a 0. scope in 35 and with a 30. scope in 30 patients. There were 56 women and nine men with a mean age of 49±14 years and a mean body mass index of 25±4. The main perioperative parameters analysed were operative time, conversion, morbidity and length of hospitalisation. One month after surgery, the aesthetic result was assessed by each patient on a visual analogue scale (VAS). A VAS score between 9 and 10 was considered as an excellent result. Results.-During laparoscopy, some degree of cholecystitis was evidenced in ten patients. Intraoperative cholangiography was performed in 57 patients and the mean operative time was 68±22 min. Conversion to conventional laparoscopic cholecystectomy (CLC) was required in eight patients (12%). We noted three complications (4%): two wound abscesses and 1 hemoperitoneum. The mean hospital stay was 2±1 days. The aesthetic result was considered as excellent by 45 patients (69%). Multivariate analysis revealed the following information: operative time was lower after five procedures (61±25 min vs. 72±18 min, regression coef-ficient:-7, P < 0.032) and when a 30. scope was used (56±18 min vs. 76±20 min, regression coefficient:-14, P < 0.011), conversion rate was higher in case of cholecystitis (60% [6/10] vs. 4% [2/55], OR: 33, P < 0.002) and the percentage of excellent aesthetic result was greater in patients that did not required a conversion to CLC (77% [44/57] vs. 12% [1/8], OR: 18, P < 0.012). Conclusions.-That study shows that SILC is feasible with a low morbidity but is associated with a quite long operative time and a high rate of conversion to CLC in case of cholecystitis. However, the operative time decreases with the growing experience of the surgeon and when a 30. scope is used. The major interest of the technique is cosmetic. © 2010 Elsevier Masson SAS.
Martin-Loeches I.,St Jamess Hospital |
Povoa P.,Centro Hospitalar Lisbon Ocidental |
Rodriguez A.,Hospital Joan XXIII |
Rodriguez A.,Institute Salud Carlos III |
And 22 more authors.
The Lancet Respiratory Medicine | Year: 2015
Background: Ventilator-associated tracheobronchitis has been suggested as an intermediate process between tracheobronchial colonisation and ventilator-associated pneumonia in patients receiving mechanical ventilation. We aimed to establish the incidence and effect of ventilator-associated tracheobronchitis in a large, international patient cohort. Methods: We did a multicentre, prospective, observational study in 114 intensive care units (ICU) in Spain, France, Portugal, Brazil, Argentina, Ecuador, Bolivia, and Colombia over a preplanned time of 10 months. All patients older than 18 years admitted to an ICU who received invasive mechanical ventilation for more than 48 h were eligible. We prospectively obtained data for incidence of ventilator-associated lower respiratory tract infections, defined as ventilator-associated tracheobronchitis or ventilator-associated pneumonia. We grouped patients according to the presence or absence of such infections, and obtained data for the effect of appropriate antibiotics on progression of tracheobronchitis to pneumonia. Patients were followed up until death or discharge from hospital. To account for centre effects with a binary outcome, we fitted a generalised estimating equation model with a logit link, exchangeable correlation structure, and non-robust standard errors. This trial is registered with ClinicalTrials.gov, number NCT01791530. Findings: Between Sept 1, 2013, and July 31, 2014, we obtained data for 2960 eligible patients, of whom 689 (23%) developed ventilator-associated lower respiratory tract infections. The incidence of ventilator-associated tracheobronchitis and that of ventilator-associated pneumonia at baseline were similar (320 [11%; 10·2 of 1000 mechanically ventilated days] vs 369 [12%; 8·8 of 1000 mechanically ventilated days], p=0·48). Of the 320 patients with tracheobronchitis, 250 received appropriate antibiotic treatment and 70 received inappropriate antibiotics. 39 patients with tracheobronchitis progressed to pneumonia; however, the use of appropriate antibiotic therapy for tracheobronchitis was associated with significantly lower progression to pneumonia than was inappropriate treatment (19 [8%] of 250 vs 20 [29%] of 70, p<0·0001; crude odds ratio 0·21 [95% CI 0·11-0·41]). Significantly more patients with ventilator-associated pneumonia died (146 [40%] of 369) than those with tracheobronchitis (93 [29%] of 320) or absence of ventilator-associated lower respiratory tract infections (673 [30%] of 2271, p<0·0001). Median time to discharge from the ICU for survivors was significantly longer in the tracheobronchitis (21 days [IQR 15-34]) and pneumonia (22 [13-36]) groups than in the group with no ventilator-associated lower respiratory tract infections (12 [8-20]; hazard ratio 1·65 [95% CI 1·38-1·97], p<0·0001). Interpretation: This large database study emphasises that ventilator-associated tracheobronchitis is a major health problem worldwide, associated with high resources consumption in all countries. Our findings also show improved outcomes with use of appropriate antibiotic treatment for both ventilator-associated tracheobronchitis and ventilator-associated pneumonia, underlining the importance of treating both infections, since inappropriate treatment of tracheobronchitis was associated with a higher risk of progression to pneumonia. Funding: None. © 2015 Elsevier Ltd.