Conservative management or cesarean hysterectomy for placenta accreta spectrum: the PACCRETA prospective study

BackgroundPlacenta accreta spectrum is a life-threatening condition that has increased dramatically in recent decades along with cesarean rates worldwide. Cesarean hysterectomy is widely practiced in women with placenta accreta spectrum; however, the maternal outcomes after cesarean hysterectomy have not been thoroughly compared with the maternal outcomes after alternative approaches, such as conservative management.ObjectiveThis study aimed to compare the severe maternal outcomes between women with placenta accreta spectrum treated with cesarean hysterectomy and those treated with conservative management (leaving the placenta in situ).Study DesignFrom a source population of 520,114 deliveries in 176 hospitals (PACCRETA study), we designed an observational cohort of women with placenta accreta spectrum who had either a cesarean hysterectomy or a conservative management (the placenta left in situ) during cesarean delivery. Clinicians prospectively identified women meeting the inclusion criteria and included them at delivery. Data collection started only after the women had received information and agreed to participate in the study in the immediate postpartum period. The primary outcome was the transfusion of >4 units of packed red blood cells within 6 months after delivery. Secondary outcomes were other maternal complications within 6 months. We used propensity score weighting to account for potential indication bias.ResultsHere, 86 women had conservative management and 62 women had cesarean hysterectomy for placenta accreta spectrum during cesarean delivery. The primary outcome occurred in 14 of 86 women in the conservative management group (16.3%) and 36 of 61 (59.0%) in the cesarean hysterectomy group (risk ratio in propensity score weighted model, 0.29; 95% confidence interval, 0.19–0.45). The rates of hysterectomy, total estimated blood loss exceeding 3000 mL, any blood product transfusion, adjacent organ injury, and nonpostpartum hemorrhage-related severe maternal morbidity were lower with conservative management than with cesarean hysterectomy (all adjusted, P≤.02); but, the rates of arterial embolization, endometritis, and readmission within 6 months of discharge were higher with conservative management than with cesarean hysterectomy.ConclusionAmong women with placenta accreta spectrum who underwent cesarean delivery, conservative management was associated with a lower risk of transfusion of >4 units of packed red blood cells within 6 months than cesarean hysterectomy

Accompagner

Voici l'histoire de trente années de développement des soins palliatifs en France : de quoi mesurer le chemin parcouru et saisir les enjeux, référence faite au vécu réel des patients, soignants, accompagnants. Et de quoi prendre date, face au « désir » d'euthanasie active et de suicide assisté : ancré dans les années 1970, il joue du martelage médiatique de quelques cas atypiques et de l'injonction à suivre les pays « avancés ». Mais la France a su rester fidèle à sa tradition humaniste et laïque, par son choix de l'accompagnement médical, psychologique, social jusqu'à la mort. Une bonne base législative, la loi Leonetti d'avril 2005, mal connue et pas toujours bien appliquée, doit faire l'objet d'une révision. La vie d'abord donc, sans pression à la sortie, mais sans « obstination déraisonnable », en prenant en compte les directives anticipées du patient et en permettant au médecin, qui n'a pas pour intention première de tuer, de prendre toutes les dispositions qui mènent à une mort « apaisée ».Au docteur Thérèse Vanier (1923-2014), capitaine, croix de guerre. En reconnaissance des liens qu'elle a créés dès les années 1970 entre les hospices anglais et les soignants francophones, pour sa contribution à la diffusion de la culture palliative à travers l'Europe continentale. Accompagner les grands malades et les personnes handicapées mentales a été son quotidien

Stratification of amyotrophic lateral sclerosis patients: a crowdsourcing approach

Amyotrophic lateral sclerosis (ALS) is a fatal neurodegenerative disease where substantial heterogeneity in clinical presentation urgently requires a better stratification of patients for the development of drug trials and clinical care. In this study we explored stratification through a crowdsourcing approach, the DREAM Prize4Life ALS Stratification Challenge. Using data from >10,000 patients from ALS clinical trials and 1479 patients from community-based patient registers, more than 30 teams developed new approaches for machine learning and clustering, outperforming the best current predictions of disease outcome. We propose a new method to integrate and analyze patient clusters across methods, showing a clear pattern of consistent and clinically relevant sub-groups of patients that also enabled the reliable classification of new patients. Our analyses reveal novel insights in ALS and describe for the first time the potential of a crowdsourcing to uncover hidden patient sub-populations, and to accelerate disease understanding and therapeutic development