Facteurs pronostiques de patients atteints de démence suivis en centre mémoire de ressource et de recherche : exemple d'utilisation de bases de données médicales à des fins de recherche clinique

Dementia is a major public health problem. Prognostic factors of dementia will condition progression of cognitive and executive functions, institutionalisation and survival. When these factors are modifiable, improvement of their knowledge can help implementing actions to reduce the cognitive decline or improve survival. Studies allowing their analysis must be conducted on patients and are part of clinical research. While not always designed for research purpose, medical databases are increasingly being used for research. The objective of this work is to discuss advantages and limitations in the use of medical databases for research purposes in the clinical study of prognostic factors of dementia. For this, we used the medical database of patients with dementia, followed in the memory centre of Lille – Bailleul. We confirmed that patients with Alzheimer's disease with a high level of education had a higher cognitive decline, but a similar mortality, compared to the low levels of education. We have described a cognitive decline significantly different, but a similar mortality between Alzheimer's disease, mixed dementia ('MA with CVD') and vascular dementia, patients with 'MA with CVD' having an intermediate decline compared to others. We showed that the risk of developing vascular or mixed dementia increased significantly with the number of subcortical hyperintensities in patients with mild cognitive impairment. This work highlights in particular the difficulty to establish the diagnosis of mixed dementia, the complexity of the analysis of the decline in cognitive functions (taking into account the progression of dementia, lack of monitoring instrument of the cognitive functions both simple to use and sensitive to small changes over time or non-linear decline in cognitive functions), the advantages in terms of cost and time of the use of medical databases, and the selection problems of the population referred to a tertiary care centre.This work shows the interest for clinical research to use medical data on dementia patients cared in a tertiary care centre. Thus, despite problems of population representativity, populations studied from medical databases do represent the one clinicians are interested in.Les démences constituent une préoccupation majeure de santé publique. Les facteurs pronostiques des démences vont conditionner la rapidité du déclin des fonctions cognitives et exécutives et la survie des patients. Quand ces facteurs sont modifiables, l'amélioration de leur connaissance peut permettre de mettre en place des actions visant à limiter le déclin cognitif et à prolonger l'autonomie. Les études permettant leur analyse sont réalisées sur des populations de sujets malades et s'inscrivent dans le cadre de la recherche clinique. Les bases de données médicales, qui ne sont pas toujours constituées à des fins de recherche, sont néanmoins de plus en plus utilisées à ces fins.L'objectif de mon travail est l'étude des facteurs pronostiques de patients, pris en charge au centre de mémoire de ressource et de recherche (CMRR) du Centre Hospitalier Régional et Universitaire (CHRU) de Lille et du centre médical des monts de Flandres de Bailleul. Pour cela, nous avons utilisé la base de données médicales informatisées des patients consultant au CMRR de Lille-Bailleul. Ce travail s'est en particulier intéressé aux avantages et aux limites de l'utilisation de bases de données médicales à des fins de recherche clinique dans l'étude des facteurs pronostiques des démences.Dans une population de 670 patients ayant une maladie d'Alzheimer, nous avons confirmé que le déclin des fonctions cognitives (évaluées par le MMSE) était significativement plus élevé chez les sujets ayant un niveau d'éducation intermédiaire ou élevé par rapport aux sujets ayant un bas niveau d'éducation. Cependant, la mortalité ne différaient pas de façon significative entre ces trois groupes. Nous avons décrit une mortalité similaire entre patients ayant une maladie d'Alzheimer, une démence mixte ou une démence vasculaire. Les patients ayant une démence mixte avaient un déclin du MMSE plus important que les patients ayant une démence vasculaire mais moins important que les patients ayant une maladie d'Alzheimer. Enfin, nous avons montré que le risque de développer une démence vasculaire ou mixte augmentait de manière significative avec le nombre d'hypersignaux sous corticaux chez des patients ayant un mild cognitive impairment.Ces travaux soulignent la difficulté de l'établissement du diagnostic des démences mixtes, la complexité de l'analyse du déclin des fonctions cognitives (prise en compte du stade de progression des démences, absence d'instrument de suivi des fonctions cognitives à la fois simple d'utilisation et sensible aux faibles variations au cours du temps ou non linéarité du déclin des fonctions cognitives), les avantages en terme de coût et de temps de l'utilisation de bases de données médicales, et les problème de sélection de la population issue d'une structure de soins.Malgré les problèmes de représentativité des populations, ce travail montre l'intérêt de l'utilisation à des fins de recherche clinique de données médicales concernant des patients pris en charge en structure de soins

Outcomes Associated With Esophageal Perforation Management

International audienceObjective: To evaluate outcomes associated with esophageal perforation (EP) management at a national level and determine predictive factors of 90-day mortality (90dM), failure-to-rescue (FTR), and major morbidity (MM, Clavien-Dindo 3-4). Background: EP remains a challenging clinical emergency. Previous population-based studies showed rates of 90dM up to 38.8% but were outdated or small-sized. Methods: Data from patients admitted to hospitals with EP were extracted from the French medico-administrative database (2012–2021). Etiology, management strategies, and short and long-term outcomes were analyzed. A cutoff value of the annual EP management caseload affecting FTR was determined using the “Chi-squared Automatic Interaction Detector” method. Random effects logistic regression model was performed to assess independent predictors of 90dM, FTR, and MM. Results: Among 4765 patients with EP, 90dM and FTR rates were 28.0% and 19.4%, respectively. Both remained stable during the study period. EP was spontaneous in 68.2%, due to esophageal cancer in 19.7%, iatrogenic postendoscopy in 7.3%, and due to foreign body ingestion in 4.7%. Primary management consisted of surgery (n = 1447,30.4%), endoscopy (n = 590,12.4%), isolated drainage (n = 336,7.0%), and conservative management (n = 2392,50.2%). After multivariate analysis, besides age and comorbidity, esophageal cancer was predictive of both 90dM and FTR. An annual threshold of ≥8 EP managed annually was associated with a reduced 90dM and FTR rate. In France, only some university hospitals fulfilled this condition. Furthermore, primary surgery was associated with a lower 90dDM and FTR rate despite an increase in MM. Conclusions: We provide evidence for the referral of EP to high-volume centers with multidisciplinary expertise. Surgery remains an effective treatment for EP

Centralization and Oncologic Training Reduce Postoperative Morbidity and Failure-to-rescue Rates After Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy for Peritoneal Surface Malignancies: Study on a 10-year National French Practice.

International audienceObjective: Evaluate at a national level the postoperative mortality (POM), major morbidity (MM) and failure-to-rescue (FTR) after cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) across time and according to hospital-volume.Background: CRS/HIPEC is an effective therapeutic strategy commonly used to treat peritoneal surface malignancies. However, this aggressive approach has the reputation to be associated with a high POM and MM.Methods: All patients treated with CRS/HIPEC between 2009 and 2018 in France were identified through a national medical database. Patients and perioperative outcomes were analyzed. A cut-off value of the annual CRS/HIPEC caseload affecting the 90-day POM was calculated using the Chi-squared Automatic Interaction Detector method. A multivariable logistic model was used to identify factors mediating 90-day POM.Results: A total of 7476 CRS/HIPEC were analyzed. Median age was 59 years with a mean Elixhauser comorbidity index of 3.1, both increasing over time (P 70 years (P = 0.002), Elixhauser comorbidity index ≥8 (P = 0.006), lower gastro-intestinal origin, (P < 0.010), MM (P < 0.001), and <45 procedures/yr (P = 0.002).Conclusion: In France, CRS/HIPEC is a safe procedure with an acceptable 90-day POM that could even be improved through centralization in high-volume centers

Specificity of Procedure volume and its Association With Postoperative Mortality in Digestive Cancer Surgery

International audienceObjectives: We aimed to examine whether the improved outcome of a digestive cancer procedure in high-volume hospitals is specific or correlates with that of other digestive cancer procedures, and determine if the discriminant cut-off of hospital volume may influence postoperative mortality (POM) regardless of the procedure. Background: Performing complex surgeries in tertiary centers is associated with improved outcome. However, the association between POM and hospital volume of nonspecific procedures is unknown. Methods: Patients who underwent colectomy, proctectomy, esophagectomy, gastrectomy, pancreatectomy, and hepatectomy for cancer between 2012 and 2017 were identified in the French nationwide database. Chi-square automatic interaction detector was used to identify the cut-off values of the annual caseload affecting the 90-day POM. A common threshold was estimated by minimization of chi-square distance taking into account the specific mortality of each procedure. Results: Overall, 225,752 patients were identified. Hospitals were categorized according to the procedure volume (colectomy: ≥80 cases/yr, proctectomy: ≥35/yr, esophagectomy: ≥41/yr, gastrectomy: ≥16/yr, pancreatectomy: ≥26/yr, and hepatectomy: ≥76/yr). The overall 90-day POM was 5.1% and varied significantly with volume. The benefits of high volume were transferable across procedures. High-volume hospitals for colorectal cancer surgery significantly influenced the risk of death after hepatectomy ( P < 0.001) and pancreatectomy ( P < 0.001). The common threshold for all procedures that influenced POM was 199 cases/yr (odds ratio 1.29, P < 0.001). Conclusion: In digestive cancer surgery, the volume–POM relationship of one procedure was associated with the volume of other procedures. Thus, tertiary hospitals should be defined according to the common threshold of different procedures

Rev Epidemiol Sante Publique

Introduction : La France a été fortement touchée par la pandémie de COVID-19, et aucune étude n'a décrit de manière exhaustive son impact sur les hospitalisations. Notre objectif était de décrire la distribution géographique et l’évolution temporelle des hospitalisations liées à la COVID-19 et la mortalité intrahospitalière en France durant la première vague, de janvier à juin 2020. Méthodes : Cette étude de cohorte rétrospective est basée sur les données de la base nationale du PMSI. Les hospitalisations contiguës ont été rassemblées en « séquences de soins » afin de limiter les biais lors des calculs d'incidence et de mortalité. Les taux d'incidence et leur évolution, la mortalité et le taux de létalité ont été comparés selon différents niveaux géographiques. Les corrélations entre incidence, mortalité et taux de létalité ont été analysées. Résultats : Durant la première vague épidémique, nous avons dénombré 98 366 patients hospitalisés en France (taux d'incidence 146,7/100 000 habitants), parmi lesquels 18,8 % sont décédés. L’âge médian était de 71 ans, le ratio homme/femme de 1,16 et 26,2 % des patients ont nécessité des soins intensifs. L’Île-de-France et le Grand Est ont été les régions touchées les plus précocement et les plus sévèrement. Une rapide augmentation de l'incidence et de la mortalité sur 4 semaines a été suivie par une lente diminution durant 10 semaines. Le taux de létalité a progressivement diminué durant cette période et était corrélé positivement avec l'incidence et la mortalité. Discussions : La description géographique et temporelle de cette première vague épidémique de COVID-19 en France montre d'importantes variations régionales et départementales, qu'une analyse globale n'aurait pas pu mettre en évidence. La précision apportée par ces analyses peut aider à mieux comprendre la dynamique de futures vagues épidémiques.INTRODUCTION: Even though France was severely hit by the COVID-19 pandemic, few studies have addressed the dynamics of the first wave on an exhaustive, nationwide basis. We aimed to describe the geographic and temporal distribution of COVID-19 hospitalisations and in-hospital mortality in France during the first epidemic wave, from January to June 2020. METHODS: This retrospective cohort study used the French national database for all acute care hospital admissions (PMSI). Contiguous stays were assembled into "care sequences" for analysis so as to limit bias when estimating incidence and mortality. The incidence rate and its evolution, mortality and hospitalized case fatality rates (HCFR) were compared between geographic areas. Correlations between incidence, mortality, and HCFR were analyzed. RESULTS: During the first epidemic wave, 98,366 COVID-19 patients were hospitalized (incidence rate of 146.7/100,000 inhabitants), of whom 18.8% died. The median age was 71 years, the male/female ratio was 1.16, and 26.2% of patients required critical care. The Paris area and the North-East region were the first and most severely hit areas. A rapid increase of incidence and mortality within 4 weeks was followed by a slow decrease over 10 weeks. HCFRs decreased during the study period, and correlated positively with incidence and mortality rates. DISCUSSION: By detailing the geographical and temporal evolution of the COVID-19 epidemic in France, this study revealed major interregional differences, which were otherwise undetectable in global analyses. The precision afforded should help to understand the dynamics of future epidemic waves

Risk factors of mortality among patients hospitalised with COVID-19 in a critical care or hospital care unit: analysis of the French national medicoadministrative database

International audienceObjective To explore mortality risk factors for patients hospitalised with COVID-19 in a critical care unit (CCU) or a hospital care unit (HCU). Design Retrospective cohort analysis using the French national (Programme de médicalisation des systèmes d'information) database. Setting Any public or private hospital in France. Participants 98 366 patients admitted with COVID-19 for more than 1 day during the first semester of 2020 were included. The underlying conditions were retrieved for all contiguous stays. Main outcome measures In-hospital mortality and associated risk factors were assessed using frailty Cox models. Results Among the 98 366 patients included, 25 765 (26%) were admitted to a CCU. The median age was 66 (IQR: 55-76) years in CCUs and 74 (IQR: 57-85) years in HCUs. Age was the main risk factor of death in both CCUs and HCUs, with adjusted HRs (aHRs) in CCUs increasing from 1.60 (95% CI 1.35 to 1.88) for 46 to 65 years to 8.17 (95% CI 6.86 to 9.72) for ≥85 years. In HCUs, the aHR associated with age was more than two times higher. The gender was not significantly associated with death, aHR 1.03 (95% CI 0.98 to 1.09, p=0.2693) in CCUs. Most of the underlying chronic conditions were risk factors for death, including malignant neoplasm (CCU: 1.34 (95% CI 1.25 to 1.43); HCU: 1.41 (95% CI 1.35 to 1.47)), cirrhosis without transplant (1.41 (95% CI 1.22 to 1.64); 1.27 (95% CI 1.12 to 1.45)) and dementia (1.30 (95% CI 1.16 to 1.46); 1.07 (95% CI 1.03 to 1.12)). Conclusion This analysis confirms the role of age as the major risk factor of death in patients with COVID-19 irrespective to admission to critical care and therefore supports the current vaccination policies targeting older individuals. copyright