Patient referral is influenced by dialysis centre structure in the Diamant Alpin Dialysis cohort study

Background. Late referral (LR) to the nephrologist of patients with progressing chronic kidney disease (CKD) has numerous deleterious effects and is observed in many countries. The contributing factors associated with LR are controversial and poorly defined. We hypothesized that these factors might be better identified by analysing patients starting dialysis in three distinct European countries within the same area. Method. The referral and progression of kidney failure patterns were analysed with demographic, clinical and biological data in 279 non-selected consecutive patients starting dialysis in eight centres of three adjacent regions in France, Italy and Switzerland. Results. Early referral (>6 months before the start of dialysis) was seen in 200 patients (71.6%), intermediate referral (1-6 months) in 42 (15.1%) and LR (<1 month) in 37 (13.3%). However inter-centre variations were between 2 and 19% for LR and 6-50% for combined late and intermediate referral. There were no differences at the national levels, but LR was more frequent in the large city centres than in the private or regional structures, with 31 out of 169 (18.3%), two out of 55 (5.4%) and four out of 55 (7.3%), respectively, of their patients (P<0.01). By multivariate analysis, it appears that, besides the presence of an active cancer and the CKD progression rate, the centre structure and the referring physician (primary care physicians and nephrologists are less responsible for LR than other medical specialists) play a significant role in the practice of LR. Conclusions. Within a dialysis cohort spread over adjacent regions of three countries, LR has the same global distribution pattern, indicating that different health and social security systems do not play a major role in inducing or preventing this practice. The contributing factors for LR that were identified are the type of the referring physician and the structure of the dialysis unit. Both factors are potential targets for an educational and collaborative approac

Incidence des sténoses des artères rénales au cours de la coronarographie (étude de 93 patients)

La prévalence des sténoses des artères rénales est très variable selon le type de population étudiée et les méthodes utilisées pour la détecter. Elle est estimée faible dans la population générale aux environs de 0.7 à 1% et est estimée entre 2 et 5 % dans la population hypertendue. L'équipe de cardiologie du centre hospitalier régional d'Annecy a réalisé une étude prospective consistant à pratiquer une artériographie rénale auprès de 93 patients coronarographiés, préalablement sélectionnés. Son objectif est de déterminer la prévalence des sténoses des artères rénales dans un groupe de patients inclus selon des critères d'hypertension artérielle ou d'augmentation de la créatininémie. Il s'agissait de 63 hommes et 30 femmes d'âge moyen 64 ans. Les facteurs de risque cardiovasculaire étaient constitués par un tabagisme, une hypertension artérielle, un diabète ou une dyslipidémie dans respectivement 53,97,19 et 52% des cas Sur les données de la coronarographie, 40 patients n'avaient pas de lésions coronaires significatives, tandis que 24, 11 et 18 des patients étaient respectivement mono, bi et tritronculaires. La prévalence des sténoses rénales significatives était dans cette population de 7.53 %. Nous avons pu identifier plusieurs facteurs pouvant orienter la recherche de sténoses des artères rénales : une atteinte coronarienne, un tabagisme actif et une maladie athéromateuse plurifocale. On ne connaît pas le rôle possible de la revascularisation précoce pour les sténoses de l'artère rénale dépistées par rapport au risque de l'évolution progressive vers l'occlusion de l'artère. Qu'il existe ou non une indication de revascularisation de l'artère, les patients ayant une sténose de l'artère rénale présentent un risque cardiovasculaire majeur et nécessitent une prise en charge globale. A notre sens, le vieillissement de la population, le lien entre l'âge et l'athérosclérose peuvent inciter à proposer une opacification des artères rénales systématique lors d'une coronarographie chez des patients hypertendus présentant une atteinte athéroscléreuse coronarienne.GRENOBLE1-BU Médecine pharm. (385162101) / SudocPARIS-BIUM (751062103) / SudocSudocFranceF

38. On the Seismicity in the Kwanto District after the Great Kwanto Earthquake, September 1, 1923(Part 2)

関東地方の地震活動を気象要覧(1924～1950),地震月報(1951～1956)を用いて局発地震のAnnual numberの変動によつて調べた.これらの資料に地震があつたとよく報告される地名を代表地名とし,それを中心とする50km位の半径の地域を1つの地域と考えた.このような分け方で,関東全域を関東地震の震央地域を含めて,約18の地域に分けて調べた結果,関東全体,利根川北部陸地等とまとめた広い地域は一様に減少の傾向を示すが,細分された地域では,各々特有の変化を示すことがわかつた.また,これらの地域の長期傾向を調べるために,5～10年の移動平均法が応用されたが,上記の傾向を一そう明瞭に示し,6個のgroupに分類することができた.In the first paper, it was shown by using materials published by Japan Meteorological Agency that the annual number of earthquakes, especially felt earthquakes in the epicentral region of the Great Kwanto earthquake, kept decreasing for about fifteen years after the main shock. Since it is necessary to compare the above results in the first paper with seismicity in the other regions of the Kwanto District, the annual number of local shocks in these regions was investigated in this paper by using the same materials(Geophysical Review for 1924-1950 and Seismological Bulletin for 1951- 1956)

Does the interference phenomenon affect strength development during same‐session combined rehabilitation program in hemodialysis patients?

International audienceIntroduction: This study aimed to assess if an interference effect could blunt the neuromuscular gains induced by a same-session combined rehabilitation in hemodialysis (HD) patients.Methods: Patients exercised twice a week, for 16 weeks, over their HD sessions. They were either always trained with resistance and endurance exercises (continuous training, “CONT”) or alternatively with 1 week of resistance alternated with 1 week of endurance (discontinuous training, “DISC”). Adherence and workload were continuously recorded. Short Physical Performance Battery (SPPB) score, one-leg balance test, and handgrip and quadriceps strength were evaluated before and after training intervention.Results: Adherence to both programs was high (>90%). SPPB score had significantly improved (CONT: +1.5 point, DISC: +1.2 pt, p < 0.001), like one-leg balance test (CONT: +3.7 s, DISC: +5.5 s, p < 0.05), handgrip strength of exercised (CONT: +5.5 kg, DISC: +5.6 kg, p < 0.001) and of nonexercised arm (CONT: +4.4 kg, DISC: +2.8 kg, p < 0.01) as well as maximal quadriceps strength (+22 N·m for dominant and +29 N·m for nondominant leg in both groups, p < 0.001) bearing no difference between the trainings.Conclusion: Same-session combined training does not induce an interference effect in HD patients and temporal separation of exercises does not optimize strength gains. These practical data may be relevant for clinicians and practitioners to alternate endurance and resistance exercises

Cardioprotective Effect of Acute Intradialytic Exercise: A Comprehensive Speckle-Tracking Echocardiography Analysis

Significance Statement Hemodialysis (HD) can lead to acute left ventricular (LV) myocardial wall motion abnormalities (myocardial stunning) due to segmental hypoperfusion. Exercise during dialysis is associated with favorable effects on central hemodynamics and BP stability, factors considered in the etiology of HD-induced myocardial stunning. In a speckle-tracking echocardiography analysis, the authors explored effects of acute intradialytic exercise (IDE) on LV regional myocardial function in 60 patients undergoing HD. They found beneficial effects of IDE on LV longitudinal and circumferential function and on torsional mechanics, not accounted for by cardiac loading conditions or central hemodynamics. These findings support the implementation of IDE in people with ESKD, given that LV transient dysfunction imposed by repetitive HD may contribute to heart failure and increased risk of cardiac events in such patients. Background Hemodialysis (HD) induces left ventricular (LV) transient myocardial dysfunction. A complex interplay between linear deformations and torsional mechanics underlies LV myocardial performance. Although intradialytic exercise (IDE) induces favorable effects on central hemodynamics, its effect on myocardial mechanics has never been comprehensively documented. Methods To evaluate the effects of IDE on LV myocardial mechanics, assessed by speckle-tracking echocardiography, we conducted a prospective, open-label, two-center randomized crossover trial. We enrolled 60 individuals with ESKD receiving HD, who were assigned to participate in two sessions performed in a randomized order: standard HD and HD incorporating 30 minutes of aerobic exercise (HDEX). We measured global longitudinal strain (GLS) at baseline (T0), 90 minutes after HD onset (T1), and 30 minutes before ending HD (T2). At T0 and T2, we also measured circumferential strain and twist, calculated as the net difference between apical and basal rotations. Central hemodynamic data (BP, cardiac output) also were collected. Results The decline in GLS observed during the HD procedure was attenuated in the HDEX sessions (estimated difference, −1.16%; 95% confidence interval [95% CI], −0.31 to −2.02; P = 0.008). Compared with HD, HDEX also demonstrated greater improvements from T0 to T2 in twist, an important component of LV myocardial function (estimated difference, 2.48°; 95% CI, 0.30 to 4.65; P = 0.02). Differences in changes from T0 to T2 for cardiac loading and intradialytic hemodynamics did not account for the beneficial effects of IDE on LV myocardial mechanics kinetics. Conclusions IDE applied acutely during HD improves regional myocardial mechanics and might warrant consideration in the therapeutic approach for patients on HD

Cardioprotective effect of intradialytic exercise on left atrial mechanics

International audienceLeft atrial (LA) function plays a pivotal role in cardiac performance by modulating left ventricular (LV) function. Impairments in LV function are commonly reported during hemodialysis (HD), but available data describing changes in LA function are limited. There is growing evidence of the cardioprotective effect of intradialytic exercise (IDE) on LV function, but studies analyzing its effect on LA function are scarce. Our aim was to evaluate whether IDE can limit the severity of HD-induced impairment in LA myocardial function. In this prospective, open-label, two-center randomized crossover trial, 56 stable individuals receiving HD participated in 2 HD sessions in random order: standard HD and a session incorporating 30 min of aerobic exercise. LA and LV global longitudinal strains (GLSs) were obtained before and at peak stress of HD (i.e., 30 min before the HD ending). IDE totally eradicated the decline in LA reservoir strain observed during HD (estimated difference: 3.1%, 95% confidence interval: 0.4/5.8, P = 0.02), whereas it did not affect the other components of LA mechanics. A similar result favoring IDE intervention was also demonstrated on GLS changes over the HD procedure (P 34 mL/m2). In conclusion, even a short duration of IDE at moderate intensity is effective in preventing HD-associated decline in LA reservoir function. Further research is needed to explore the long-term benefits of IDE on LA function.NEW & NOTEWORTHY A single bout of intradialytic exercise (IDE) at moderate intensity can prevent the hemodialysis-associated decline in left atrial (LA) function. This was partially explained by the relative preservation of left ventricular systolic function with IDE. Benefits of IDE on LA function were lost in patients with LA dilation. Further studies are needed to explore the mechanisms behind IDE-induced cardioprotection and evaluate the clinical impacts of the repetitive cardioprotective effects of IDE on LA function

Cardioprotective Effect of Acute Intradialytic Exercise: A Comprehensive Speckle-Tracking Echocardiography Analysis

International audienc

Bridging therapy or IV thrombolysis in minor stroke with large vessel occlusion

International audienceOBJECTIVE:Whether bridging therapy (intravenous thrombolysis [IVT] followed by endovascular treatment) is superior to IVT alone in minor stroke with large vessel occlusion (LVO) is unknown.METHODS:Multicentric retrospective observational study including, in intention-to-treat, consecutive IVT-treated minor strokes (NIHSS≤5) with LVO, with or without additional mechanical thrombectomy. Propensity-score (inverse probability of treatment weighting) was used to reduce baseline between-groups differences. The primary outcome was excellent outcome, i.e., modified Rankin score 0-1 at 3 months follow-up.RESULTS:Overall, 598 patients were included (214 and 384 in the bridging therapy and IVT groups, respectively). Following propensity-score weighting, the distribution of baseline clinical and radiological variables was similar across the two patient groups. Compared with IVT alone, bridging therapy was not associated with excellent outcome (OR=0.96; 95%CI=0.75-1.24; P=0.76), but was associated with symptomatic intracranial haemorrhage (OR=3.01; 95%CI=1.77-5.11; P<0.0001). Occlusion site was a strong modifier of the effect of bridging therapy on outcome (Pinteraction <0.0001), with bridging therapy associated with higher odds of excellent outcome in proximal M1 (OR=3.26; 95%CI=1.67-6.35; P=0.0006) and distal M1 (OR=1.69; 95%CI=1.01-2.82; P=0.04) occlusions, but with lower odds of excellent outcome for M2 (OR=0.53; 95%CI=0.38-0.75; P=0.0003) occlusions. Bridging therapy was associated with higher rates of symptomatic intracranial hemorrhage in M2 occlusions only (OR=4.40; 95%CI=2.20-8.83; P<0.0001).INTERPRETATION:Although overall outcomes were similar in intended bridging therapy as compared to intended IVT alone in minor strokes with LVO, our results suggest that intended bridging therapy may be beneficial in M1 occlusions, while the benefit-risk profile may favor IVT alone in M2 occlusions. This article is protected by copyright. All rights reserved

Impact of integrating objective structured clinical examination into academic student assessment: Large-scale experience in a French medical school

International audiencePurpose: Objective structured clinical examinations (OSCE) evaluate clinical reasoning, communication skills, and interpersonal behavior during medical education. In France, clinical training has long relied on bedside clinical practice in academic hospitals. The need for a simulated teaching environment has recently emerged, due to the increasing number of students admitted to medical schools, and the necessity of objectively evaluating practical skills. This study aimed at investigating the relationships between OSCE grades and current evaluation modalities.Methods: Three-hundred seventy-nine 4th-year students of University-of-Paris Medical School participated to the first large-scale OSCE at this institution, consisting in three OSCE stations (OSCE#1–3). OSCE#1 and #2 focused on cardiovascular clinical skills and competence, whereas OSCE#3 focused on relational skills while providing explanations before planned cholecystectomy. We investigated correlations of OSCE grades with multiple choice (MCQ)-based written examinations and evaluations of clinical skills and behavior (during hospital traineeships); OSCE grade distribution; and the impact of integrating OSCE grades into the current evaluation in terms of student ranking.Results: The competence-oriented OSCE#1 and OSCE#2 grades correlated only with MCQ grades (r = 0.19, P0.75). Conversely, the behavior-oriented OSCE#3 grades correlated with traineeship skill and behavior grades (r = 0.19, P<0.001, and r = 0.12, P = 0.032), but not with MCQ grades (P = 0.09). The dispersion of OSCE grades was wider than for MCQ examinations (P<0.001). When OSCE grades were integrated to the final fourth-year grade with an incremental 10%, 20% or 40% coefficient, an increasing proportion of the 379 students had a ranking variation by ±50 ranks (P<0.001). This ranking change mainly affected students among the mid-50% of ranking.Conclusion: This large-scale French experience showed that OSCE designed to assess a combination of clinical competence and behavioral skills, increases the discriminatory capacity of current evaluations modalities in French medical schools