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Renaud B.,Groupe Hospitalier Henri Mondor Albert Chenevier | Renaud B.,University Paris Est Creteil | Schuetz P.,Harvard University | Claessens Y.-E.,Center Hospitalier Princesse Grace | And 3 more authors.
Chest | Year: 2012

Background: Whether proadrenomedullin (ProADM) improves the performance of the Risk of Early Admission to ICU (REA-ICU) score in predicting early, severe community-acquired pneumonia (ESCAP) has not been demonstrated. Methods: Secondary analysis was completed of the original data from 877 consecutive patients with community-acquired pneumonia (CAP) enrolled in the Procalcitonin-Guided Antibiotic Therapy and Hospitalization in Patients With Lower Respiratory Tract Infections (ProHOSP) study, a multicenter trial in EDs of six tertiary-care hospitals in Switzerland. ESCAP was defined by either the requirement for mechanical ventilation or vasopressive drugs or occurrence of death within 3 days of ED presentation. Results: Eighty patients (9.1%) developed ESCAP (47 required mechanical ventilation, 19 vasopressive drugs, and 16 died) within 3 days of ED presentation. They had a higher median ProADM value (2.18 nmol/L vs 1.15 nmol/L, P<.001). Combining ProADM testing with the REA-ICU score improved the area under the curve (0.81) compared with either parameter (ProADM [0.73] or REA-ICU score [0.76], P<.001) and resulted in a net reclassification improvement of 0.20 (P<.001). A ProADM value ≥ 1.8 nmol/L or assignment to REA-ICU risk classes III-IV predicted ESCAP with a sensitivity of 76.3% and a negative predictive value of 96.7%. Excluding 21 patients with major criteria of severe CAP on presentation showed similar results. Conclusion: These study findings demonstrate that the addition of ProADM to the REA-ICU score improves the classification of a substantial proportion of patients in the ED at intermediate or high risk for ESCAP, which may translate into better triage decisions. ©2012 American College of Chest Physicians.


Barry B.,Service ORL | Ortholan C.,Center hospitalier Princesse Grace
Cancer/Radiotherapie | Year: 2014

Head and neck cancer is frequently associated with alcohol and tobacco consumption but there is an increasing incidence of oropharyngeal carcinoma associated with oncogenic type-16 human papillomavirus (HPV). The clinical profile of these patients is distinct from that of other patients, with an earlier onset, 1/1 male to female sex ratio, cystic cervical nodes. Detection of intratumoral viral DNA is essential to confirm the role of HPV. According to several reports, the prognosis in terms of survival and locoregional control is better in HPV-positive oropharyngeal carcinoma than in HPV-negative oropharyngeal carcinoma or associated with tobacco consumption. The future lies in vaccination of women against cervical cancer but vaccination of boys will be certainly necessary. © 2014 Société française de radiothérapie oncologique (SFRO).


Charachon A.,Center Hospitalier Princesse Grace
Acta Endoscopica | Year: 2013

Zenker's diverticulum is an outpouching of the mucosa through the Killian's triangle due to a default of the cricopharyngeal muscle. The reference surgical treatment including diverticulectomy and section of the cricopharyngeal muscle tends to be replaced by rigid or flexible endoscopic treatment. Endoscopic treatment consists in the section of the wall between the diverticulum and the esophagus, and of the cricopharyngeal muscle in it. For flexible endoscopy, exposure of this wall is best obtained with the help of a flexible diverticuloscope. The section is done with the help of endoscopic knives and must be limited to the section of the cricopharyngeal muscle or by the diverticulum's bottom. Symptoms resolution is usually obtained in one treatment session with a very low morbidity. Food intakes can usually restart within 12-24 hours. Infection, and particularly its extent to the mediastinum, is the most feared complication. Using CO2 insufflation and endoscopic clips could help avoiding part of the complications. © Springer-Verlag 2013.


Latcu G.D.,Center Hospitalier Princesse Grace
Journal of interventional cardiac electrophysiology : an international journal of arrhythmias and pacing | Year: 2011

Analysing ventricular fibrillation (VF) rate and regularity at different sites and at different times may help understanding some of the mechanisms underlying VF in humans. Twelve episodes of VF (19.4±5.6 s) were induced during electrophysiological study in eight men (63±14 years old). Calculation of dominant frequency (DF) by fast Fourier transform, short-time Fourier transform, and analysis of the pitch frequency [VF cycle length duration (CL)] were performed. For each episode, we analysed the 12 lead-surface ECG, three unipolar, 10 near-field, and three far-field bipolar recordings by means of three quadripolar catheters positioned at the right ventricular apex (RV apex), right ventricular outflow tract, and at the coronary sinus (exploring the lateral left ventricular epicardium) (LV). Fast and regular discrete activation covered the whole duration of every intracardiac recording, whereas surface ECG consistently displayed chaotic and fibrillatory pattern. DF (5.25±0.64 Hz) was very similar on surface ECG recordings and in various intracardiac recordings. Intracardiac activation was rather regular during VF despite the fibrillatory process with very low SD of the CL. There were some significant inverse correlations between VF rate and VF regularity. Intracardiac sites displaying the fastest and most regular activations were those including the RV apex. VF rate and stability slightly increased over time. Finally, the parameters exploring the VF rate were found to be well correlated together, as well as parameters of VF regularity Human VF induced during electrophysiological study has a clear DF of activation and appears quite regular in intracardiac recordings. There is some spatial heterogeneity, which needs to be more detailed in order to localize possible driving sources. Fastest VF are the most regular. Rate and stability tend to increase during the initial phases of VF.


Squara F.,Center Hospitalier Princesse Grace | Squara F.,Pasteur University Hospital | Latcu D.G.,Center Hospitalier Princesse Grace | Massaad Y.,Center Hospitalier Princesse Grace | And 3 more authors.
Europace | Year: 2014

Aims During radiofrequency (RF) delivery, lesion volume is highly dependent on contact force (CF). It has recently been shown that changes of bipolar electrogram (EGM) predict transmurality. We hypothesized that there is a correlation between CF and EGM criteria of transmural lesion (TL) during RF. Methods and results We prospectively studied consecutive 512 RF applications from atrial fibrillation ablation procedures. A force-sensing ablation catheter (Tacticath®, Endosense) was used to continuously measure CF and force-time integral (FTI) during each RF application. Distal bipolar EGM was analysed before, during, and after each RF application. Depending on initial EGM morphology, transmurality of lesions was defined by: (i) disappearance of the positivity after RF when there was QR morphology, (ii) diminution >75% of the positivity when there was QRS morphology, or (iii) disappearance of the R′ positivity when there was RSR′ morphology. Electrogram criteria were validated by electrophysiologists blinded to force measurements. Force-time integral was higher in TL than in non-transmural lesions (NTLs): 652 ± 248 vs. 212 ± 140 gs (P < 0.001). Mean CF per RF pulse was higher in TL than in NTL: 26.3 ± 12.5 vs. 11.3 ± 10.3 g (P < 0.001). The best cut-off to predict TL was an FTI ≥ 392 gs [sensitivity 0.89, specificity (Sp) 0.93, positive predictive value (PPV) 0.98, and negative predictive value 0.67] and a higher FTI (>700 gs) warrants transmurality of RF atrial lesions (100% Sp and PPV). Conclusion Contact force and FTI during RF are correlated with TL. During RF delivery, a target FTI > 392 gs can be used as an endpoint. © 2014 Published on behalf of the European Society of Cardiology. All rights reserved.


Chenevier-Gobeaux C.,Groupe Hospitalier Cochin Broca HOtel Dieu | Trabattoni E.,Groupe Hospitalier Cochin Broca HOtel Dieu | Trabattoni E.,University of Paris Descartes | Roelens M.,Groupe Hospitalier Cochin Broca HOtel Dieu | And 3 more authors.
Clinica Chimica Acta | Year: 2014

Presepsin is elevated in patients developing infections and increases in a severity-dependent manner. We aimed to evaluate circulating values of this new biomarker in a population free of any acute infectious disorder. We recruited 144 consecutive patients presenting at the emergency department (ED) without acute infection or acute/unstable disorder, and 54 healthy participants. Presepsin plasmatic concentrations were measured on the PATHFAST point-of-care analyzer. The 95th percentile of presepsin values in the ED population is 750. ng/L. Presepsin was significantly increased in patients aged ≥. 70. years vs. younger patients (470 [380-601] ng/L vs. 300 [201-457] ng/L, p. <. 0.001). Prevalence of elevated presepsin values was increased in patients in comparison to controls (80% vs.13%, p. <. 0.001), and in patients aged ≥. 70. years in comparison to younger patients (87% vs. 47%, p. <. 0.001). Presepsin concentrations were significantly increased in patients with kidney dysfunction. Aging was an independent predictor of an elevated presepsin value. In conclusion, presepsin concentrations increase with age and kidney dysfunction. Therefore interpretation of presepsin concentrations might be altered in the elderly or in patients with impaired renal function. Adapted thresholds are needed for specific populations. © 2013 Elsevier B.V.


Gomes B.,King's College London | Calanzani N.,University of Edinburgh | Curiale V.,Center Hospitalier Princesse Grace | Mccrone P.,King's College London | Higginson I.J.,King's College London
Cochrane Database of Systematic Reviews | Year: 2013

Background: Extensive evidence shows that well over 50% of people prefer to be cared for and to die at home provided circumstances allow choice. Despite best efforts and policies, one-third or less of all deaths take place at home in many countries of the world. Objectives: 1. To quantify the effect of home palliative care services for adult patients with advanced illness and their family caregivers on patients' odds of dying at home; 2. to examine the clinical effectiveness of home palliative care services on other outcomes for patients and their caregivers such as symptom control, quality of life, caregiver distress and satisfaction with care; 3. to compare the resource use and costs associated with these services; 4. to critically appraise and summarise the current evidence on cost-effectiveness. Search methods: We searched 12 electronic databases up to November 2012. We checked the reference lists of all included studies, 49 relevant systematic reviews, four key textbooks and recent conference abstracts. We contacted 17 experts and researchers for unpublished data. Selection criteria: We included randomised controlled trials (RCTs), controlled clinical trials (CCTs), controlled before and after studies (CBAs) and interrupted time series (ITSs) evaluating the impact of home palliative care services on outcomes for adults with advanced illness or their family caregivers, or both. Data collection and analysis: One review author assessed the identified titles and abstracts. Two independent reviewers performed assessment of all potentially relevant studies, data extraction and assessment of methodological quality. We carried out meta-analysis where appropriate and calculated numbers needed to treat to benefit (NNTBs) for the primary outcome (death at home). Main results: We identified 23 studies (16 RCTs, 6 of high quality), including 37,561 participants and 4042 family caregivers, largely with advanced cancer but also congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), HIV/AIDS and multiple sclerosis (MS), among other conditions. Meta-analysis showed increased odds of dying at home (odds ratio (OR) 2.21, 95% CI 1.31 to 3.71; Z = 2.98, P value = 0.003; Chi2 = 20.57, degrees of freedom (df) = 6, P value = 0.002; I2 = 71%; NNTB 5, 95% CI 3 to 14 (seven trials with 1222 participants, three of high quality)). In addition, narrative synthesis showed evidence of small but statistically significant beneficial effects of home palliative care services compared to usual care on reducing symptom burden for patients (three trials, two of high quality, and one CBA with 2107 participants) and of no effect on caregiver grief (three RCTs, two of high quality, and one CBA with 2113 caregivers). Evidence on cost-effectiveness (six studies) is inconclusive. Authors' conclusions: The results provide clear and reliable evidence that home palliative care increases the chance of dying at home and reduces symptom burden in particular for patients with cancer, without impacting on caregiver grief. This justifies providing home palliative care for patients who wish to die at home. More work is needed to study cost-effectiveness especially for people with non-malignant conditions, assessing place of death and appropriate outcomes that are sensitive to change and valid in these populations, and to compare different models of home palliative care, in powered studies. © 2016 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.


Missana M.C.,Center hospitalier Princesse Grace
Journal of visceral surgery | Year: 2013

Skin-sparing mastectomies (SSM) have gained acceptance among teams performing immediate breast reconstruction because this technique provides the best cosmetic outcome. Nevertheless, in France, concerns have been raised that limited skin excision during mastectomy could result in an increased risk of local recurrence especially in invasive breast cancer; many surgeons continue to have reservations regarding the oncologic safety of this operation. This is a retrospective, long-term follow-up study of 400 patients operated and followed by two oncoplastic surgeons. A total of 400 patients with breast cancer underwent SSM with immediate breast reconstruction from January 1, 1992 to December 31, 2002. The American Joint Committee on Cancer pathological staging was Stage 0 (41.5%), Stage I (33.25%), Stage II (16%), Stage III (7.5%), while 1.75% were non-stageable. With a mean follow-up period of 88 months (range: 13-215 months), the locoregional recurrence rate was 3.5%, the rate of distant metastases was 13.5%, and 83% of patients have remained free of recurrent disease. This study provides encouraging results suggesting that skin-sparing mastectomy is a safe and reliable option for the management of selected cases of women with invasive or in situ breast cancer. Copyright © 2013. Published by Elsevier Masson SAS.


Meo M.,CNRS Informatics, Signals & Systems Lab in Sophia Antipolis | Zarzoso V.,CNRS Informatics, Signals & Systems Lab in Sophia Antipolis | Meste O.,CNRS Informatics, Signals & Systems Lab in Sophia Antipolis | Latcu D.G.,Center Hospitalier Princesse Grace | Saoudi N.,Center Hospitalier Princesse Grace
IEEE Transactions on Biomedical Engineering | Year: 2013

Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia encountered in clinical practice. Radiofrequency catheter ablation (CA) is increasingly employed to treat this disease, yet the selection of persistent AF patients who will benefit from this treatment remains a challenging task. Several parameters of the surface electrocardiogram (ECG) have been analyzed in previous works to predict AF termination by CA, such as fibrillatory wave (f-wave) amplitude. However, they are usually manually computed and only a subset of electrodes is inspected. In this study, a novel perspective of the role of f-wave amplitude as a potential noninvasive predictor of CA outcome is adopted by exploring ECG interlead spatial variability. An automatic procedure for atrial amplitude computation based on cubic Hermite interpolation is first proposed. To describe the global f-wave peak-to-peak amplitude distribution, signal contributions from multiple leads are then combined by condensing the most representative features of the atrial signal in a reduced-rank approximation based on principal component analysis (PCA). We show that exploiting ECG spatial diversity by means of this PCA-based multilead approach does not only increase the robustness to electrode selection, but also substantially improves the predictive power of the amplitude parameter. © 1964-2012 IEEE.


Carbonne B.,Center Hospitalier Princesse Grace | Pons K.,Hopital Trousseau | Maisonneuve E.,Hopital Trousseau
Best Practice and Research: Clinical Obstetrics and Gynaecology | Year: 2016

Second-line methods of foetal monitoring have been developed in an attempt to reduce unnecessary interventions due to continuous cardiotocography (CTG), and to better identify foetuses that are at risk of intrapartum asphyxia. Very few studies directly compared CTG with foetal scalp blood (FBS) and CTG only. Only one randomised controlled trial (RCT) was published in the 1970s and had limited power to assess neonatal outcome. Direct and indirect comparisons conclude that FBS could reduce the number of caesarean deliveries associated with the use of continuous CTG. The main drawbacks of FBS are its invasive and discontinuous nature and the need for a sufficient volume of foetal blood for analysis, especially for pH measurement, resulting in failure rates reaching 10%. FBS for lactate measurement became popular with the design of test-strip devices, requiring <0.5 mL of foetal blood. RCTs showed similar outcomes with the use of FBS for lactates compared with pH in terms of obstetrical interventions and neonatal outcomes. In conclusion, there is some evidence that FBS reduces the need for operative deliveries. However, the evidence is limited with regard to actual standards, and large RCTs, directly comparing CTG only with CTG with FBS, are still needed. © 2015 Elsevier Ltd. All rights reserved.

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