Les aléas de la transmission

La question de la transmission sous des formes variées, et selon des problématiques renouvelées, constitue aujourd’hui encore l’une des interrogations majeures de l’ethnologie. Indissociable de l’idée de « continuité culturelle » sur laquelle s’est fondée la discipline, elle n’en reste pas moins essentielle dans les sociétés modernes. La transmission se conjugue donc le plus souvent avec « la tradition » et « l’identité », et celles-ci sont également soumises à des questionnements multiples et surtout à de fréquentes réévaluations critiques de la part des anthropologues. Les contributions réunies dans ce recueil ne reflètent pas tous les aspects du problème mais permettent de mieux saisir la perspective qui fût la nôtre et sa portée heuristique. En effet, elles sont d’une très grande diversité et permettent d’appréhender quelques-unes des formes inédites, actuelles, que peut prendre la transmission avec ses impasses, ses transformations, ses renversements même. Enfin, elles font la preuve qu’à défaut d’être « organisée » elle reste de toute façon « bonne à penser » en dépit de tous les aléas auxquels, aujourd’hui, elle est le plus souvent soumise. Le Congrès national des sociétés historiques et scientifiques rassemble chaque année universitaires, membres de sociétés savantes et jeunes chercheurs. Ce recueil est issu de travaux présentés lors du 143e Congrès sur le thème « La transmission des savoirs »

Comparison and combination of a hemodynamics/biomarkers-based model with simplified PESI score for prognostic stratification of acute pulmonary embolism: findings from a real world study

Background: Prognostic stratification is of utmost importance for management of acute Pulmonary Embolism (PE) in clinical practice. Many prognostic models have been proposed, but which is the best prognosticator in real life remains unclear. The aim of our study was to compare and combine the predictive values of the hemodynamics/biomarkers based prognostic model proposed by European Society of Cardiology (ESC) in 2008 and simplified PESI score (sPESI).Methods: Data records of 452 patients discharged for acute PE from Internal Medicine wards of Tuscany (Italy) were analysed. The ESC model and sPESI were retrospectively calculated and compared by using Areas under Receiver Operating Characteristics (ROC) Curves (AUCs) and finally the combination of the two models was tested in hemodinamically stable patients. All cause and PE-related in-hospital mortality and fatal or major bleedings were the analyzed endpointsResults: All cause in-hospital mortality was 25% (16.6% PE related) in high risk, 8.7% (4.7%) in intermediate risk and 3.8% (1.2%) in low risk patients according to ESC model. All cause in-hospital mortality was 10.95% (5.75% PE related) in patients with sPESI score ≥1 and 0% (0%) in sPESI score 0. Predictive performance of sPESI was not significantly different compared with 2008 ESC model both for all cause (AUC sPESI 0.711, 95% CI: 0.661-0.758 versus ESC 0.619, 95% CI: 0.567-0.670, difference between AUCs 0.0916, p=0.084) and for PE-related mortality (AUC sPESI 0.764, 95% CI: 0.717-0.808 versus ESC 0.650, 95% CI: 0.598-0.700, difference between AUCs 0.114, p=0.11). Fatal or major bleedings occurred in 4.30% of high risk, 1.60% of intermediate risk and 2.50% of low risk patients according to 2008 ESC model, whereas these occurred in 1.80% of high risk and 1.45% of low risk patients according to sPESI, respectively. Predictive performance for fatal or major bleeding between two models was not significantly different (AUC sPESI 0.658, 95% CI: 0.606-0.707 versus ESC 0.512, 95% CI: 0.459-0.565, difference between AUCs 0.145, p=0.34). In hemodynamically stable patients, the combined endpoint in-hospital PE-related mortality and/or fatal or major bleeding (adverse events) occurred in 0% of patients with low risk ESC model and sPESI score 0, whilst it occurred in 5.5% of patients with low-risk ESC model but sPESI ≥1. In intermediate risk patients according to ESC model, adverse events occurred in 3.6% of patients with sPESI score 0 and 6.65% of patients with sPESI score ≥1.Conclusions: In real world, predictive performance of sPESI and the hemodynamic/biomarkers-based ESC model as prognosticator of in-hospital mortality and bleedings is similar. Combination of sPESI 0 with low risk ESC model may identify patients with very low risk of adverse events and candidate for early hospital discharge or home treatment.

Evidence-based Guidelines for the Management of Exocrine Pancreatic Insufficiency After Pancreatic Surgery

To provide evidence-based recommendations for the management of exocrine pancreatic insufficiency (EPI) after pancreatic surgery

Breakthrough Lactobacillus rhamnosus GG bacteremia associated with probiotic use in an adult patient with severe active ulcerative colitis: case report and review of the literature

Probiotics are widely investigated in the treatment of various bowel diseases. However, they may also have a pathogenic potential, and the role of Lactobacillus spp. as opportunistic pathogens, mostly following disruption of the intestinal mucosa, is emerging. We report on a case of bacteremia caused by L. rhamnosus GG in an adult patient affected by severe active ulcerative colitis under treatment with corticosteroids and mesalazine. Lactobacillus bacteremia was associated with candidemia and occurred while the patient was receiving a probiotic formulation containing the same strain (as determined by PFGE typing), and was being concomitantly treated with i.v. vancomycin, to which the Lactobacillus strain was resistant. L. rhamnosus GG bacteremia, therefore, was apparently related with translocation of bacteria from the intestinal lumen to the blood. Pending conclusive evidence, use of probiotics should be considered with caution in case of active severe inflammatory bowel diseases with mucosal disruption

Stroke prevention in atrial fibrillation: findings from Tuscan FADOI Stroke Registry

Despite vitamin K antagonists (VKAs) are considered the first choice treatment for stroke prevention in atrial fibrillation (AF), literature shows their underuse in this context. Since data about VKAs use prior and after acute stroke lack, the aim of this study was to focus on management of anticoagulation with VKAs in this context. Data were retrieved from Tuscan FADOI Stroke Registry, an online data bank aimed to report on characteristics of stroke patients consecutively admitted in Internal Medicine wards in 2010 and 2011. In this period 819 patients with mean age 76.5±12.3 years were enrolled. Data on etiology were available for 715 of them (88.1%), 87% being ischemic and 13% hemorrhagic strokes. AF was present in 238 patients (33%), 165 (69.3%) having a known AF before hospitalization, whereas 73 patients (31.7%) received a new diagnosis of AF. A percentage of 89% of strokes in patients with known AF were ischemic and 11% hemorrhagic. A percentage of 86.7% of patients with known AF had a CHADS2 ≥2, but only 28.3% were on VKAs before hospitalization. A percentage of 78.8% of patients treated with VKAs before stroke had an international normalized ratio (INR) ≤2.0; 68.7% of patients with VKAs-related hemorrhagic strokes had INR ≤3.0. Combined endpoint mortality or severe disability in patients with ischemic stroke associated with AF was present in 47%, while it was present in 19.30% and 19.20% of atherothrombotic and lacunar strokes, respectively. At hospital discharge, VKAs were prescribed in 25.9% of AF related ischemic stroke patients. AF related strokes are burdened by severe outcome but VKAs are dramatically underused in patients with AF, even in higher risk patients. Efforts to improve anticoagulation in this stroke subtype are warranted

Clinical outcomes of elderly patients with bloodstream infections due to extended-spectrum β-lactamase-producing Enterobacteriaceae in an Italian Internal Medicine ward

Purpose: Infections caused by ESBL-producing Enterobacteriaceae (ESBL-EB) are a major health problem, but data regarding elderly patients is lacking. Methods: We performed a retrospective observational study quantifying the effects of antimicrobial treatment and primary infection site on clinical outcomes in an historical case series of 42 patients aged 80.7 ± 10 years admitted to an Internal Medicine ward in Italy for ESBL-EB bloodstream infections (BSI). Results: At multivariate risk analysis, we found that urinary tract as primary infection site (RR=0.181 [0.037–0.886], p=0.035) and definitive antibiotic therapy (RR=0.517 [0.147–0.799], p= 0.038) decreased the relative risk of a negative clinical response, while the respiratory tract origin increased the relative risk (RR =2.788 [1.407–9.228], p=0.025). Also regarding 30 days mortality, multivariate risk analysis identified that urinary tract as primary infection site (RR=0.098 [0.011–0.743], p=0.025) and definitive antibiotic therapy (RR=0.236 [0.058–0.961], p =0.044) decreased the relative risk, while the respiratory origin increased the relative risk (RR=4.241 [1.040–17.295], p= 0.014). We observed similar outcomes in patients definitively treated with carbapenems or with carbapenem-free treatments. Additionally, an initially inappropriate therapy did not correlate with worse outcomes if a switch to an effective definitive treatment was performed promptly. Conclusions: Carbapenem-sparing regimens (e.g. piperacillin-tazobactam alone or with an aminoglycoside) could be empirically safely used in elderly patients at high risk of ESBL-EB BSI and for definitive treatment of ascertained cases if the primary site is the urinary tract, leaving early carbapenem use for cases at higher risk of death, such as those with pneumonia

Clinical outcomes of elderly patients with bloodstream infections due to extended-spectrum β-lactamase-producing Enterobacteriaceae in an Italian Internal Medicine ward

Purpose: Infections caused by ESBL-producing Enterobacteriaceae (ESBL-EB) are a major health problem, but data regarding elderly patients is lacking. Methods: We performed a retrospective observational study quantifying the effects of antimicrobial treatment and primary infection site on clinical outcomes in an historical case series of 42 patients aged 80.7 ± 10 years admitted to an Internal Medicine ward in Italy for ESBL-EB bloodstream infections (BSI). Results: At multivariate risk analysis, we found that urinary tract as primary infection site (RR=0.181 [0.037–0.886], p=0.035) and definitive antibiotic therapy (RR=0.517 [0.147–0.799], p= 0.038) decreased the relative risk of a negative clinical response, while the respiratory tract origin increased the relative risk (RR =2.788 [1.407–9.228], p=0.025). Also regarding 30 days mortality, multivariate risk analysis identified that urinary tract as primary infection site (RR=0.098 [0.011–0.743], p=0.025) and definitive antibiotic therapy (RR=0.236 [0.058–0.961], p =0.044) decreased the relative risk, while the respiratory origin increased the relative risk (RR=4.241 [1.040–17.295], p= 0.014). We observed similar outcomes in patients definitively treated with carbapenems or with carbapenem-free treatments. Additionally, an initially inappropriate therapy did not correlate with worse outcomes if a switch to an effective definitive treatment was performed promptly. Conclusions: Carbapenem-sparing regimens (e.g. piperacillin-tazobactam alone or with an aminoglycoside) could be empirically safely used in elderly patients at high risk of ESBL-EB BSI and for definitive treatment of ascertained cases if the primary site is the urinary tract, leaving early carbapenem use for cases at higher risk of death, such as those with pneumonia

Minimally Invasive versus Open Distal Pancreatectomy for Ductal Adenocarcinoma (DIPLOMA): A Pan-European Propensity Score Matched Study

OBJECTIVE: The aim of this study was to compare oncological outcomes after minimally invasive distal pancreatectomy (MIDP) with open distal pancreatectomy (ODP) in patients with pancreatic ductal adenocarcinoma (PDAC). BACKGROUND: Cohort studies have suggested superior short-term outcomes of MIDP vs. ODP. Recent international surveys, however, revealed that surgeons have concerns about the oncological outcomes of MIDP for PDAC. METHODS: This is a pan-European propensity score matched study including patients who underwent MIDP (laparoscopic or robot-assisted) or ODP for PDAC between January 1, 2007 and July 1, 2015. MIDP patients were matched to ODP patients in a 1:1 ratio. Main outcomes were radical (R0) resection, lymph node retrieval, and survival. RESULTS: In total, 1212 patients were included from 34 centers in 11 countries. Of 356 (29%) MIDP patients, 340 could be matched. After matching, the MIDP conversion rate was 19% (n = 62). Median blood loss [200 mL (60-400) vs 300 mL (150-500), P = 0.001] and hospital stay [8 (6-12) vs 9 (7-14) days, P 0.99) were comparable for MIDP and ODP, respectively. R0 resection rate was higher (67% vs 58%, P = 0.019), whereas Gerota's fascia resection (31% vs 60%, P < 0.001) and lymph node retrieval [14 (8-22) vs 22 (14-31), P < 0.001] were lower after MIDP. Median overall survival was 28 [95% confidence interval (CI), 22-34] versus 31 (95% CI, 26-36) months (P = 0.929). CONCLUSIONS: Comparable survival was seen after MIDP and ODP for PDAC, but the opposing differences in R0 resection rate, resection of Gerota's fascia, and lymph node retrieval strengthen the need for a randomized trial to confirm the oncological safety of MIDP