Pessac, France
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Corcuff J.-B.,Haut Leveque Hospital | Young J.,Bicetre Hospital | Masquefa-Giraud P.,Bordeaux University Hospital Center | Chanson P.,Bicetre Hospital | And 2 more authors.
European Journal of Endocrinology | Year: 2015

Context: Severe Cushing's syndrome elicited by ectopic ACTH syndrome (EAS) or adrenal carcinoma (ACC) can threaten life in the short term. The effectiveness of oral administration of the inhibitors of steroidogenesis ketoconazole and metyrapone in this situation is poorly described. Objective: To report the short-term effectiveness and tolerability of metyrapone and ketoconazole elicited either by EAS or by ACC in patients exhibiting severe hypercortisolism. Design: Retrospective analysis of data obtained for patients with urinary free cortisol (UFC) level estimated to be fivefold the upper limit of the normal range (ULN). Patients and settings: A total of 14 patients with EAS and eight with ACC treated in two tertiary-care university hospitals. Intervention: Metyrapone and ketoconazole treatment in combination (along with symptomatic treatments for co-morbidities). Main outcome: Evolution of clinically relevant endpoints (blood pressure, kalaemia and glycaemia) and biological intensity of hypercortisolism 1 week and 1 month after starting steroidogenesis inhibition. Results: After 1 week of treatment, median UFC fell from 40.0 to 3.2 ULN and from 16.0 to 1.0 ULN in patients with EAS and ACC respectively. Median UFC after 1 month of treatment was 0.5 and 1.0 ULN in patients with EAS and ACC respectively and UFC values were normal in 73 and 86% of patients respectively. Clinical status improved dramatically along with kalaemia, glycaemia and blood pressure, allowing a decrease in the relevant treatments. Side effects were minimal and only two patients (one EAS and one ACC) experienced plasma transaminase elevations necessitating ketoconazole withdrawal. Conclusion: Metyrapone-ketoconazole combination therapy is well tolerated and provides rapid control of endocrine cancer-related life-threatening hypercortisolism. © 2015 European Society of Endocrinology.


Thomas P.A.,Aix - Marseille University | Berbis J.,Aix - Marseille University | Falcoz P.,NHC | Le pimpec-barthes F.,HEGP | And 5 more authors.
European Journal of Cardio-thoracic Surgery | Year: 2014

OBJECTIVES: Nutritional assessment is not included yet as a major recommendation in lung cancer guidelines. The purpose of this study was thus to assess the influence on surgical outcome of the nutritional status of patients with primary lung cancer undergoing lobectomy. METHODS: We queried Epithor, the national clinical database of the French Society of Thoracic and Cardiovascular Surgery, and identified a retrospective cohort of 19 635 patients having undergone lobectomy for a primary lung cancer in the years 2005-11. Their nutritional status was categorized according to the WHO definition: underweight (BMI < 18.5): 857 patients (4.4%), normal (18.5 ≤ BMI < 25): 9391 patients (47.8%), overweight (25 ≤ BMI < 30): 6721 patients (34.2%), obese (BMI ≥ 30): 2666 patients (13.6%). Operative mortality, pulmonary, cardiovascular, infectious and surgical complications rates were collected and analysed for these various BMI groups. RESULTS: In the normal-weight category, operative mortality, pulmonary, surgical, cardiovascular and infectious complications rates were 2.7, 14.6, 13.8, 5.5 and 4.1%, respectively. When compared with that of normal BMI patients, adjusted operative mortality was significantly lower in overweight (2.3%; odd ratio (OR): 0.72 [95% confidence interval (CI): 0.59-0.89]; P = 0.002) and obese patients (1.9%, OR: 0.54 [95% CI: 0.40-0.74]; P < 0.001), and significantly higher in underweight patients (4.1%, OR: 1.89 [95% CI: 1.30-2.75]; P = 0.001). Underweight patients experienced significantly more pulmonary (21.1%; P < 0.001), surgical (23.2%; P < 0.001) and infectious (5.1%; P = 0.05) complications (P < 0.0001). Among surgical complications, prolonged air leaks (17.6%; P < 0.001) and bronchial stump dehiscence (1.5%; P = 0.001) were significantly more frequent in underweight patients than in normal BMI patients. Obesity was not associated with increased incidence of postoperative complications, except for arrhythmia (5.6%; P < 0.05), deep venous thrombosis and pulmonary embolism (1.5%; P = 0.005). Moreover, a statistical protective effect of obesity was observed regarding surgical complications (7.1%; P < 0.001). CONCLUSIONS: Despite having an increased risk of some postoperative cardiovascular complications, obese patients should undergo surgical standard of care therapy for appropriately stage-specific lung cancer. In underweight patients, in addition to preoperative rehabilitation including a nutritional program, attention should be given to aggressive prophylactic respiratory therapy in the perioperative period, and specific intraoperative actions to prevent prolonged air leaks and bronchial stump dehiscence. © The Author 2013. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.


Henaine R.,Cardiologic Hospital Louis Pradel | Henaine R.,University of Lyon | Roubertie F.,Haut Leveque Hospital | Vergnat M.,Cardiologic Hospital Louis Pradel | Ninet J.,Cardiologic Hospital Louis Pradel
Archives of Cardiovascular Diseases | Year: 2012

Valvular pathology in infants and children poses numerous challenges to the paediatric cardiac surgeon. Without question, valvular repair is the goal of intervention because restoration of valvular anatomy and physiology using native tissue allows for growth and a potentially better long-term outcome. When reconstruction fails or is not feasible, valve replacement becomes inevitable. Which valve for which position is controversial. Homograft and bioprosthetic valves achieve superior haemodynamic results initially but at the cost of accelerated degeneration. Small patient size and the risk of thromboembolism limit the usefulness of mechanical valves, and somatic outgrowth is an universal problem with all available prostheses. The goal of this article is to address valve replacement options for all four valve positions within the paediatric population. We review current literature and our practice to support our preferences. To summarize, a multitude of opinions and surgical experiences exist. Today, the valve choices that seem without controversy are bioprosthetic replacement of the tricuspid valve and Ross or Ross-Konno procedures when necessary for the aortic valve. On the other hand, bioprostheses may be implanted when annular pulmonary diameter is adequate; if not or in case of right ventricular outflow tract discontinuity, it is better to use a pulmonary homograft with the Ross procedure. Otherwise, a valved conduit. Mitral valve replacement remains the most problematic; the mechanical prosthesis must be placed in the annular position, avoiding oversizing. Future advances with tissue-engineered heart valves for all positions and new anticoagulants may change the landscape for valve replacement in the paediatric population. © 2012 Elsevier Masson SAS.


John R.M.,Brigham and Women's Hospital | Morgan K.,St. Jude Medical | Brennecke L.H.,Charles River Laboratories | Benser M.E.,St. Jude Medical | Jais P.,Haut Leveque Hospital
Circulation: Arrhythmia and Electrophysiology | Year: 2015

Background - Endovascularly implanted leads risk vascular injury and endocarditis, and can be difficult to locate in desired positions for LV pacing. We evaluated the acute and long-term stability, electric performance and histopathology of a percutaneously placed intrapericardial lead (IPL). Methods and Results - Twelve adult mongrel dogs underwent defibrillator implants incorporating IPLs. Successful uncomplicated percutaneous implantation of an IPL was achieved in all. Early fluoroscopic shift noted with 3 of 6 of the initial version IPL-1 was not seen with the modified IPL-2. Mean±95% confidence interval bipolar capture threshold at 0.5-ms pulse width for the IPL increased from 0.69±0.14 V at implant to 1.50±0.34 V (P=0.003) at 12 weeks. The 12-week thresholds were higher for IPL compared with right ventricular endocardial leads (0.75±0.33 V; P=0.001) but not different compared with coronary sinus leads (1.33±0.58 V; P=0.994). IPL impedance increased from 742±46 Ω at implant to 1066±207 Ω at 12 weeks (P=0.007). R-wave amplitude at 12 weeks was 8.37±1.52 mV. There was no important phrenic nerve stimulation from IPL pacing. Histopathology in 8 animals showed adequate adhesion of the electrodes or mesh to the epicardium without damage to underlying vasculature. There was no evidence for late pericardial inflammation or effusion. Conclusions - The IPL demonstrated adequate stability of position and acceptable electric parameters without chronic pericardial inflammation in this canine model and offers a potential alternative to endocardial pacing leads. © 2015 American Heart Association, Inc.


Billioud V.,University of Lorraine | Laharie D.,Haut Leveque Hospital | Filippi J.,University Hospital of Nice | Roblin X.,Jean Monnet University | And 5 more authors.
Inflammatory Bowel Diseases | Year: 2011

Background: We evaluated adherence to adalimumab therapy in Crohn's disease (CD). Methods: This was an observational multicenter study conducted in four French university hospitals between April 4, 2008 and January 1, 2010. Patients were systematically asked, at each clinical visit, whether or not they delayed or missed an injection of adalimumab over the past 3 months. Patients were also asked about the reasons for their nonadherence. Results: Of the 108 patients analyzed, 33 (30.6%) delayed the administration of at least one injection and 16 (14.8%) missed at least one injection over the past 3 months. The main reasons for overall nonadherence were: forgetfulness (24.6%), infection (24.6%), and travel (20%). Other reasons for nonadherence were intentional nonadherence (10.8%), pharmaceutical supply issues (9.2%), side effects (7.7%), pregnancy (1.5%), and CD-related hospitalization (1.5%). Adalimumab regimen of 40 mg every other week was a positive predictor for injection delays (P = 0.02, odds ratio [OR] = 3.76, 95% confidence interval [CI], 1.28-11.05), whereas having at least one relapse in the past 12 months was associated with fewer delays (P = 0.02, OR = 0.37, 95% CI, 0.15-0.87). [correction made here after initial online publication]. Disease duration over 90 months negatively predicted failure to inject adalimumab (P = 0.009, OR = 0.17, 95% CI, 0.05-0.64). Conclusions: The overall nonadherence rate for adalimumab use was 45.4%. Most of the reasons for nonadherent behaviors could be avoided. An adalimumab regimen of 40 mg every other week was negatively related to adalimumab adherence; both the occurrence of at least one relapse in the past 12 months and disease duration over 90 months were positively related to adherence. © 2010 Crohn's & Colitis Foundation of America, Inc.


Koneru J.N.,Virginia Commonwealth University | Kaszala K.,Virginia Commonwealth University | Bordachar P.,Haut Leveque Hospital | Shehata M.,University of California at Los Angeles | And 2 more authors.
Heart Rhythm | Year: 2015

Background Implantable cardioverter-defibrillator (ICD) lead failure is one of the major causes of inappropriate shocks. Algorithms have been developed by manufacturers to identify ICD lead failure and avoid inappropriate shocks. The SecureSense RV Lead Noise Discrimination (St Jude Medical, St Paul, MN) algorithm is designed to differentiate oversensing due to lead failure from ventricular arrhythmias and withhold inappropriate therapies. Several non-lead failure-related issues can trigger the SecureSense automated algorithm. Objective Our objective was to explain the SecureSense algorithm in a detailed fashion, highlighting examples of SecureSense alerts triggered by non-lead failure-related issues. Methods This is a nonrandomized observational case series. SecureSense-triggered alerts from 3 ICD device clinics were analyzed, and representative examples of SecureSense triggers due to non-lead failure-related issues were chosen to explain the function and malfunction of this algorithm. Results The series includes 8 cases of SecureSense alerts triggered by non-lead failure-related issues - -myopotential oversensing (1), P-wave oversensing (1), T-wave oversensing (1), loss of capture (1), R-wave undersensing (1), timing cycle issues (2), and cross talk (1) - -and 1 case of failure of the algorithm to appropriately identify lead failure and prevent ICD shocks. Conclusion Lead failure detection algorithms such as the one assessed in this study have an inherent risk of false-positive and false-negative detections. The latter might have fatal consequences. The true accuracy of these algorithms needs to be evaluated in large-scale real-life prospective clinical studies. © 2015 Heart Rhythm Society. All rights reserved.


Oussalah A.,University of Lorraine | Evesque L.,University Hospital of Nice | Laharie D.,Haut Leveque Hospital | Roblin X.,Jean Monnet University | And 7 more authors.
American Journal of Gastroenterology | Year: 2010

OBJECTIVES:The objective of this study was to evaluate short- and long-term outcomes of infliximab in ulcerative colitis (UC), including infliximab optimization, colectomy, and hospitalization.METHODS:This was a retrospective multicenter study. All adult patients who received at least one infliximab infusion for UC were included. Cumulative probabilities of event-free survival were estimated by the Kaplan-Meier method. Independent predictors were identified using binary logistic regression or Cox proportional-hazards regression, and results were expressed as odds ratios or hazard ratios (HRs), respectively.RESULTS:Between January 2000 and August 2009, 191 UC patients received infliximab therapy. Median follow-up per patient was 18 months (interquartile range25-75th, 8-32 months). Primary non-response was noted in 42 patients (22.0%). Hemoglobin at infliximab initiation 9.4 g/dl (odds ratio4.35; 95% confidence interval (CI)1.81-10.42) was a positive predictor of non-response to infliximab. Infliximab optimization was required in 36 (45.0%) of 80 patients on scheduled infliximab therapy. The only predictor of infliximab optimization was infliximab indication for acute severe colitis (HR2.75; 95% CI1.23-6.12). Thirty-six patients (18.8%) underwent colectomy. Predictors of colectomy were: no clinical response after infliximab induction (HR7.06; 95% CI3.36-14.83), C-reactive protein at infliximab initiation 10 mg/l (HR5.11; 95% CI1.77-14.76), infliximab indication for acute severe colitis (HR3.40; 95% CI1.48-7.81), and previous treatment with cyclosporine (HR2.53; 95% CI1.22-5.28). Sixty-nine patients (36.1%) were hospitalized at least one time and UC-related hospitalizations rate was 29 per 100 patient-years (95% CI24-35 per 100 patient-years). Predictors of first hospitalization were: no clinical response after infliximab induction (HR3.87; 95% CI2.29-6.53), infliximab indication for acute severe colitis (HR3.13, 95% CI1.65-5.94), disease duration at infliximab initiation 50 months (HR2.14, 95% CI1.25-3.66), hemoglobin at infliximab initiation 11.8 g/dl (HR1.77; 95% CI1.03-3.04), and previous treatment with methotrexate (HR0.30; 95% CI0.09-0.97).CONCLUSIONS:Primary non-response to infliximab was noted in one fifth of patients and increased by seven and four the risks of colectomy and hospitalization, respectively. Infliximab optimization, colectomy, and hospitalization were required in half, one fifth, and one third of patients, respectively. Infliximab indication for acute severe colitis increased by three the risks of infliximab optimization, colectomy, and UC-related hospitalization. © 2010 by the American College of Gastroenterology.


Zghal F.,Rabta Hospital of Tunis | Bougteb H.,Haut Leveque Hospital | Reant P.,Haut Leveque Hospital | Lafitte S.,Haut Leveque Hospital | Roudaut R.,Haut Leveque Hospital
Echocardiography | Year: 2011

Biological and anatomical alterations in the elderly result in modifications of the myocardial deformation detected previously by magnetic resonance imaging (MRI) technology and could have consequences on speckle tracking's parameters in this patient population. Aim: To compare left ventricular (LV) 2D strain between elderly patients and young individuals without heart disease. Population and Methods: Patients without history of cardiac disease were enrolled from the geriatric department. After echocardiographic examination, exclusion criteria were LV myocardial abnormality, valve disease, and atrial fibrillation. The control group consisted of healthy subjects from the medical staff. 2D strain values were obtained from 16 segments in four-, three-, and two-chamber apical views for longitudinal and transversal strains, and from six basal segments in short-axis view for circumferential strain. Results: Forty-five elderly patients (35 females) with mean age of 83.4 ± 5.0 years (75-95 years) and 45 young subjects (28 females) with mean age of 33.6 ± 7.5 years (17-45 years) were assessed. There was no difference between the two groups considering LV ejection fraction (66 ± 6% vs. 65 ± 4%, P = ns). Feasibility of segmental 2D strain was 55.6% for circumferential strain, 63% for transversal strain, and 82% for longitudinal strain. Global longitudinal strain was significantly lower in elderly patients (-20.9 ± 1.9% vs. -22.2 ± 2.2%, P < 0.01). There was no significant difference in global transversal and circumferential strain. Conclusion: Aging results in a decrease in global longitudinal strain. This should be taken into account in the assessment of pathological myocardial dysfunction. © 2011, Wiley Periodicals, Inc.


Adam J.-P.,Haut Leveque Hospital | Jacquin A.,Haut Leveque Hospital | Laurent C.,Service de Chirurgie Digestive | Collet D.,Haut Leveque Hospital | And 4 more authors.
JAMA Surgery | Year: 2013

Objective: To compare preservation with the division of the splenic vessels in the surgical management of laparoscopic spleen-preserving distal pancreatectomy. Design: Bicentric retrospective study. Setting: Prospectively maintained databases. Patients: Between January 1997 and January 2011, 140 patients who underwent laparoscopic spleenpreserving distal pancreatectomy for benign or lowgrade malignant tumors in the body/tail of the pancreas were included. Patients treated with the attempted splenic vessel preservation were compared with patients treated with the attempted division of the splenic vessels (Warshaw technique). Main Outcome Measures: Operative outcomes and postoperative morbidity were evaluated. Results: The outcomes of 55 patients in the splenic vessel preservation group were compared with those of 85 patients in the Warshaw technique group. The clinical characteristics were similar in both groups, except for tumor size, which was significantly greater in the Warshaw technique group (33.6 vs 42.5 mm; P<.001). The mean operative time, mean blood loss, and rate of conversion to the open procedure did not differ between the 2 groups. The rate of successful spleen preservation was significantly improved following the splenic vessel preservation technique (96.4% vs 84.7%; P=.03). Complications related to the spleen only occurred in the Warshaw technique group (0% vs 10.5%; P=.03), requiring a splenectomy in 4 patients (4.7%). The mean length of stay was shorter in the splenic vessel preservation group (8.2 vs 10.5 days; P=.01). Conclusions: The short-term benefits associated with the preservation of the splenic vessels should lead to an increased preference for this technique in selected patients undergoing laparoscopic spleen-preserving distal pancreatectomy for benign or low-grade malignant tumors in the body/tail of the pancreas. © 2013 American Medical Association. All rights reserved.


Bojan M.,Necker Enfants Malades Hospital | Gioanni S.,Necker Enfants Malades Hospital | Mauriat P.,Haut Leveque Hospital | Pouard P.,Necker Enfants Malades Hospital
Critical Care | Year: 2011

Introduction: Experience with high-frequency oscillatory ventilation (HFOV) after congenital cardiac surgery is limited despite evidence about reduction in pulmonary vascular resistance after the Fontan procedure. HFOV is recommended in adults and children with acute respiratory distress syndrome. The aim of the present study was to assess associations between commencement of HFOV on the day of surgery and length of mechanical ventilation, length of Intensive Care Unit (ICU) stay and mortality in neonates and infants with respiratory distress following cardiac surgery.Methods: A logistic regression model was used to develop a propensity score, which accounted for the probability of being switched from conventional mechanical ventilation (CMV) to HFOV on the day of surgery. It included baseline characteristics, type of procedure and postoperative variables, and was used to match each patient with HFOV with a control patient, in whom CMV was used exclusively. Length of mechanical ventilation, ICU stay and mortality rates were compared in the matched set.Results: Overall, 3,549 neonates and infants underwent cardiac surgery from January 2001 through June 2010, 120 patients were switched to HFOV and matched with 120 controls. After adjustment for the delay to sternal closure, duration of renal replacement therapy, occurrence of pulmonary hypertension and year of surgery, the probability of successful weaning over time and the probability of ICU delivery over time were significantly higher in patients with HFOV, adjusted hazard ratios and 95% confidence intervals: 1.63, 1.17 to 2.26 (P = 0.004). and 1.65, 95% confidence intervals: 1.20 to 2.28 (P = 0.002) respectively. No association was found with mortality.Conclusions: When commenced on the day of surgery in neonates and infants with respiratory distress following cardiac surgery, HFOV was associated with shorter lengths of mechanical ventilation and ICU stay than CMV. © 2011 Bojan et al.; licensee BioMed Central Ltd.

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