Legriel S.,Center Hospitalier Of Versailles Andre Mignot Hospital |
Azoulay E.,CHU Saint Louis |
Resche-Rigon M.,CHU Saint Louis |
Lemiale V.,CHU Saint Louis |
And 14 more authors.
Critical Care Medicine | Year: 2010
Objectives: Few outcome data are available about convulsive status epilepticus managed in the intensive care unit. We studied 90-day functional outcomes and their determinants in patients with convulsive status epilepticus. Design: Two hundred forty-eight convulsive status epilepticus patients admitted to 18 intensive care units in 2005-2007 were included in a prospective observational cohort study. The main outcome measure was a Glasgow Outcome Scale score of 5 (good recovery) on day 90. Main results: Convulsive status epilepticus occurred out of hospital in 177 (67%) patients, and all but 15 patients were still seizing at medical team arrival. The median time from convulsive status epilepticus onset to anticonvulsant drug initiation was 40 mins (interquartile range, 5-80). Total seizure duration was 85 mins (interquartile range, 46.5-180). Convulsive status epilepticus was refractory in 49 (20%) patients. The most common causes of convulsive status epilepticus were anticonvulsive agent withdrawal (36.4%) in patients with previous epilepsy and stroke (27.7%) in inaugural convulsive status epilepticus. Mechanical ventilation was needed in 210 (85%) patients. On day 90, 42 (18.8%) patients were dead, 87 (38.8%) had marked functional impairments (Glasgow Outcome Scale score, 2-4), and 95 (42.4%) had a good recovery (Glasgow Outcome Scale score, 5). Factors showing independent positive associations with poor outcome (Glasgow Outcome Scale score, <5) were older age (odds ratio, 1.04/year; 95% confidence interval, 1.02-1.05; p = .0005), cerebral insult (odds ratio, 2.70; 95% confidence interval, 1.37-5.26; p = .007), longer seizure duration (odds ratio, 1.72/120 min; 95% confidence interval, 1.05-2.86; p = .03), on-scene focal neurologic signs (odds ratio, 2.08; 95% confidence interval, 1.03-4.16; p = .04), and refractory convulsive status epilepticus (odds ratio, 2.70; 95% confidence interval, 1.02-7.14; p = .045). Conclusions: Ninety days after intensive care unit admission for convulsive status epilepticus, half the survivors had severe functional impairments. Longer seizure duration, cerebral insult, and refractory convulsive status epilepticus were strongly associated with poor outcomes, suggesting a role for early neuroprotective strategies. © 2010 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins.
PubMed | CHU Pitie Salpetriere, CHU Hopital Raymond Poincare, Center Hospitalier Louis Pasteur, CHU Dijon Bourgogne and 7 more.
Type: | Journal: Trials | Year: 2016
It is now well documented that critically ill patients are exposed to stressful conditions and experience discomforts from multiple sources. Improved identification of the discomforts of patients in intensive care units (ICUs) may have implications for managing their care, including consideration of ethical issues, and may assist clinicians in choosing the most appropriate interventions. The primary objective of this study was to assess the effectiveness of a multicomponent program of discomfort reduction in critically ill patients. The secondary objectives were to assess the sustainability of the impact of the program and the potential seasonality effect.We conducted a multicenter, cluster-randomized, controlled, single (patient)-blind study involving 34 French adult ICUs. The experimental intervention was a 6-month period during which the multicomponent program was implemented in the ICU and included the following steps: identification of discomforts, immediate feedback to the healthcare team, and implementation of targeted interventions. The control intervention was a 6-month period during which any program was implemented. The primary endpoint was the monthly overall score of self-reported discomfort from the French questionnaire on discomforts in ICU patients (IPREA). The secondary endpoints were the scores of the discomfort items of IPREA. The sample size was 660 individuals to obtain 80% power to detect a 25% difference in the overall discomfort score of IPREA between the two groups (design effect: 2.9).The results of this cluster-randomized controlled study are expected to confirm that a multicomponent program of discomfort reduction may be a new strategy in the management of care for critically ill patients.ClinicalTrials.gov NCT02442934, registered 11 May 2015.
PubMed | Besancon University Hospital Center, CHU Saint Louis, University of Franche Comte, Oncologie medicale polyclinique and 4 more.
Type: Journal Article | Journal: Bulletin du cancer | Year: 2014
Sunitinib was the first targeted therapy improving progression-free survival (PFS) and overall survival (OS) in patients with metastatic renal cell carcinoma (mRCC) in the first line of treatment. Classically, sunitinib is administered at a dose of 50mg/day during four weeks followed by two weeks off (schedule 4/6). This schedule has two pitfalls: intermittent exposure with two weeks off and the increase in toxicity during the fourth week. Several alternative prescription schedules were studied with the aim of limiting the intensity of toxicity while maintaining efficacy. This review summarizes the published data on alternative schedules of sunitinib in terms of safety and efficacy. All articles and abstracts on alternative schedule of sunitinib in the mRCC were reviewed. Clinical trials were also searched. Studies evaluating the continuous schedule have not provided evidence of its superiority compared to the 4/6 schedules in terms of activity, tolerance or dose-intensity. Retrospective data of patients treated in a schedule two weeks of treatment on one week off (schedule 2/3) with sunitinib 50mg/day show PFS that seem superior to those obtained with a schedule 4/ 6, while having a better safety profile. The alternating schedule of sunitinib 2/3 (50mg/day) may be a better alternative to schedule 4/6 in terms of tolerance. If toxicity occurs with 50mg/day on a schedule 4/6, it would probably offer a better alternative in terms of efficiency than dose reduction. The results of ongoing and future studies are expected to prospectively validate the concept.
Khellaf M.,University Paris Est Creteil |
Michel M.,University Paris Est Creteil |
Quittet P.,Montpellier University Hospital Center |
Viallard J.-F.,CHU Haut Leveque |
And 21 more authors.
Blood | Year: 2011
Romiplostim, a thrombopoietic agent with demonstrated efficacy against immune thrombocytopenia (ITP) in prospective controlled studies, was recently licensed for adults with chronic ITP. Only France has allowed romiplostim compassionate use since January 2008. ITP patients could receive romiplostim when they failed to respond to successive corticosteroids, intravenous immunoglobulins, rituximab, and splenectomy, or when splenectomy was not indicated. We included the first 80 patients enrolled in this program with at least 2 years of follow-up. Primary platelet response (platelet count ≥ 50 × 10 9/L and double baseline) was observed in 74% of all patients. Long-term responses (2 years) were observed in 47 (65%) patients, 37 (79%) had sustained platelet responses with a median platelet count of 106 × 10 9/L (interquartile range, 75-167 × 10 9/L), and 10 (21%) were still taking romiplostim, despite a median platelet count of 38 × 10 9/L (interquartile range, 35-44 × 10 9/L), but with clinical benefit (lower dose and/or fewer concomitant treatment(s) and/or diminished bleeding signs). A high bleeding score and use of concomitant ITP therapy were baseline factors predicting romiplostim failure. The most frequently reported adverse events were: arthralgias (26%), fatigue (13%), and nausea (7%). Our results confirmed that romiplostim use in clinical practice is effective and safe for severe chronic ITP. This trial was registered at www.clinicaltrials.gov as #NCT01013181. © 2011 by The American Society of Hematology.
Aparicio T.,Hopitaux Universitaires Of Seine Saint Denis |
Svrcek M.,University Paris Est Creteil |
Zaanan A.,University of Paris Descartes |
Zaanan A.,University of Paris Pantheon Sorbonne |
And 14 more authors.
British Journal of Cancer | Year: 2013
Background:Small bowel adenocarcinoma (SBA) is a rare tumour with a poor prognosis. Molecular biology data on SBA carcinogenesis are lacking.Methods: Expression of HER2, β-catenin, p53 and mismatch repair (MMR) protein was assessed by immunohistochemistry. KRAS, V600E BRAF mutations and microsatellite instability were investigated.Results:We obtained samples from 63 SBA patients (tumour stages: I-II: 30%; III: 35%; IV: 32%; locally advanced: 3%). HER2 overexpression (3+) was observed in 2 out of 62 patients, overexpression of p53 in 26 out of 62, abnormal expression of β-catenin in 12 out of 61, KRAS mutation in 21 out of 49, BRAF V600E mutation in 1 out of 40 patients, MMR deficiency (dMMR) in 14 out of 61 and was consistent with Lynch syndrome in 9 out of 14 patients. All of the dMMR tumours were in the duodenum or jejunum and only one was stage IV. Median overall survival (OS) was 36.6 months (95% CI, 26.9-72.2). For all patients, in univariate analysis, stages I-II (P<0.001), WHO PS 0-1 (P=0.01) and dMMR phenotype (P=0.02) were significantly associated with longer OS. In multivariate analysis, disease stage (P=0.01) and WHO PS 0-1 (P=0.001) independently predicted longer OS. For stage IV patients, median OS was 20.5 months (95% CI: 14.6; 36.6 months). In multivariate analysis, WHO PS 0-1 (P=0.0001) and mutated KRAS status (P=0.02) independently predicted longer OS.Conclusion:This large study suggests that molecular alterations in SBA are closer to those in colorectal cancer (CRC) than those in gastric cancer, with low levels of HER 2 overexpression and high frequencies of KRAS mutations. The seemingly higher frequency of dMMR than in CRC may be explained by the higher frequency of Lynch syndrome in SBA patients. A dMMR phenotype was significantly associated with a non-metastatic tumour (P=0.02). A trend for a good prognosis and a duodenum or jejunum primary site was associated with dMMR. © 2013 Cancer Research UK.
PubMed | Institute Paoli Calmettes, Institute Regional Du Cancer Of Montpellier, Center Hospitalier University, Institute Bergonie and 11 more.
Type: Journal Article | Journal: Clinical oncology (Royal College of Radiologists (Great Britain)) | Year: 2014
Recent data suggest that patients with pulmonary metastases from sarcomas might benefit from ablation of their metastases. Some data are available regarding osteosarcomas/angiosarcomas and lung metastases. The purpose of this study was to assess the efficacy of local ablative treatment on the survival of patients with oligometastases (one to five lesions, any metastatic site, any grade/histology) from sarcomas.A multicentric retrospective study of the French Sarcoma Group was conducted in sarcoma patients with oligometastases who were treated between 2000 and 2012. Survival was analysed using multivariate sensitivity analyses with propensity scores to limit bias.Of the 281 patients evaluated, 164 patients received local treatment for oligometastases between 2000 and 2012. The groups characteristics were similar in terms of tumour size and remission of the primary tumours. The median follow-up was 25.7 months; 129 (45.9%) patients had died at this point. The median overall survivals were 45.3 (95% confidence interval = 34-73) months for the local treatment group and 12.6 for the other group (95% confidence interval = 9.33-22.9). Survival was better among patients who received local treatment (hazard ratio = 0.47; 95% confidence interval = 0.29-0.78; P < 0.001). Subgroup analyses revealed similar findings in the patients with single oligometastases (hazard ratio = 0.48; 95% confidence interval = 0.28-0.82; P = 0.007); a significant benefit was observed for grade 3, and a trend was observed for grade 2.Local ablative treatment seemed to improve the overall survival of the patients who presented with oligometastatic sarcomas, including soft tissue and bone sarcomas. The survival benefit remained after repeated local treatments for several oligometastatic events. Surgery yielded the most relevant results, but alternative approaches (i.e. radiofrequency ablation and radiotherapy) seemed to be promising. The relevance of these results is strengthened by our analysis, which avoided biases by restricting the population to patients with oligometastatic disease and used propensity scores.
PubMed | CHU Avicenne, French Institute of Health and Medical Research, CHU Henri Mondor and CHU Saint Louis
Type: Journal Article | Journal: Digestive and liver disease : official journal of the Italian Society of Gastroenterology and the Italian Association for the Study of the Liver | Year: 2016
Colorectal cancers are common in elderly patients. However, cancer screening is poorly used after 75. Elderly patients form a heterogeneous population with specific characteristics. Standards of care cannot therefore be transposed from young to elderly patients. Tumour resection is frequently performed but adjuvant chemotherapy is rarely prescribed as there are no clearly established standards of care. In a metastatic setting, recent phase III studies have demonstrated that doublet front-line chemotherapy provided no survival benefit. Moreover, several studies have established the benefit of bevacizumab in association with chemotherapy. There is a lack of evidence for the efficacy of anti-epidermal growth factor antibodies in elderly patients. Geriatric assessments could help to select the adequate treatment strategy for individual patients. Geriatric oncology is now the challenge we have to face, and more specific trials are needed.
Legriel S.,CH Versailles Site Andre Mignot |
Hilly-Ginoux J.,CH Versailles Site Andre Mignot |
Resche-Rigon M.,CHU Saint Louis |
Merceron S.,CH Versailles Site Andre Mignot |
And 9 more authors.
Resuscitation | Year: 2013
Background: The independent prognostic significance of postanoxic status epilepticus (PSE) has not been evaluated prospectively since the introduction of therapeutic hypothermia. We studied 1-year functional outcomes and their determinants in comatose survivors of cardiac arrest (CA), with special attention to PSE. Methods: 106 comatose CA survivors admitted to the intensive care unit in 2005-2010 were included in a prospective observational study. The main outcome measure was a Cerebral Performance Category scale (CPC) of 1 or 2 (favorable outcome) 1 year after CA. Results: CA occurred out-of-hospital in 89 (84%) patients and was witnessed from onset in 94 (89%). Median times were 6. min (IQR, 0-11) from CA to first-responder arrival and 23. min (14-40) from collapse to return of spontaneous circulation. PSE was diagnosed in 33 (31%) patients at a median of 39 h (4-49) after CA. PSE was refractory in 24 (22%) cases and malignant in 19 (20%). After 1 year, 31 (29.3%) patients had favorable outcomes including 2 (6.44%) with PSE. Factors independently associated with poor outcome (CPC. ≥ 3) were PSE (odds ratio [OR], 14.28; 95% confidence interval [95% CI], 2.77-50.0; P= 0.001), time to restoration of spontaneous circulation (OR, 1.04/min; 95% CI, 1-1.07; P=0.035), and LOD score on day 1 (OR, 1.28/point; 95% CI, 1.08-1.54; P= 0.003). Conclusion: PSE strongly and independently predicts a poor outcome in comatose CA survivors receiving therapeutic hypothermia, but some patients with PSE survive with good functional outcomes. PSE alone is not sufficient to predict failure to awaken after CA in the era of therapeutic hypothermia. © 2012 Elsevier Ireland Ltd.
Spadone C.,CHU Saint Louis
Annales Medico-Psychologiques | Year: 2010
The term of " liaison psychiatry" is used for a wide range of medical practices. The liaison psychiatry is the exercise of psychiatry in general hospitals, with patients hospitalised in somatic care departments: full time hospitalisation, day-limited stays, emergency units, and outpatient's consultations. It also aims to help caregivers and medical institutions. Liaison psychiatry works in collaboration with psychologists. Liaison psychiatry is supposed to answer two requests: one from the patient and the other from the caregivers or their institution. The psychiatrist is supposed to have polyvalent abilities concerning the entire psychiatric spectrum, as well as an in depth knowledge of links between somatic and psychological symptoms. He is also required to have an expertise in some specific medical fields essentially in specialised medical or surgical department recruitments in the hospital he works in. The liaison psychiatrist is confronted to numerous difficulties, essentially due to his external position concerning the medical departments. Generally psychiatry is conceived as part of the institution's services. A good example of these difficulties has been provided by the psychiatric care given to suicidal patients who have ingested caustic products. Psychiatry liaison will expand in the future. Today the limited number of doctors allowed to practise in French hospitals essentially limits it. © 2010 Elsevier Masson SAS.
Spadone C.,CHU Saint Louis
Annales Medico-Psychologiques | Year: 2016
Examination of the effects of drugs to contribute to diagnosis realizes an inversion of usual process of thinking, in psychiatry like in other medical specialties. Unlike the usual process, which starts from semiologic analysis to establish a diagnosis and then to choose the adequate therapeutic strategy, we use here an astonishing strategy, which starts from the analysis of therapeutic and adverse effects of the psychotropic drugs to lead to the diagnosis. The very rich works of Daniel Ginestet, eminent French psychiatrist, as well for semeiologic analysis as for psychopharmacology, suggest this author is one of the first one you have to read to have a better understanding of the question of psychotropic drugs as diagnosis contributor, question which involves very few articles in the international psychiatric literature. © 2015.