Publications by authors named "Fiona Ecarnot"

90 Publications

Impact on antimicrobial consumption of procalcitonin-guided antibiotic therapy for pneumonia/pneumonitis associated with aspiration in comatose mechanically ventilated patients: a multicenter, randomized controlled study.

Ann Intensive Care 2021 Oct 12;11(1):145. Epub 2021 Oct 12.

Medical Intensive Care Unit, University Hospital, Besançon, France.

Background: In comatose patients receiving oro-tracheal intubation for mechanical ventilation (MV), the risk of aspiration is increased. Aspiration can lead to chemical pneumonitis (inflammatory reaction to the gastric contents), or aspiration pneumonia (infection caused by inhalation of microorganisms). Distinguishing between the two types is challenging. We tested the interest of using a decisional algorithm based on procalcitonin (PCT) values to guide initiation and discontinuation of antibiotic therapies in intubated patients.

Methods: The PROPASPI (PROcalcitonin Pneumonia/pneumonitis Associated with ASPIration) trial is a multicenter, prospective, randomized, controlled, single-blind, superiority study comparing two strategies: (1) an intervention group where threshold PCT values were used to guide initiation and discontinuation of antibiotics (PCT group); and (2) a control group, where antibiotic therapy was managed at the physician's discretion. Patients aged 18 years or over, intubated for coma (Glasgow score ≤ 8), with MV initiated within 48 h after admission, were eligible. The primary endpoint was the duration of antibiotic treatment during the first 15 days after admission to the ICU.

Results: From 24/2/2015 to 28/8/2019, 1712 patients were intubated for coma in the 5 participating centers, of whom 166 were included in the study. Data from 159 were available for intention-to-treat analysis: 81 in the PCT group, and 78 in the control group. Overall, 67 patients (43%) received antibiotics in the intensive care unit (ICU); there was no significant difference between groups (37 (46%) vs 30 (40%) for PCT vs control, p = 0.432). The mean duration of antibiotic treatment during the first 15 days in the ICU was 2.7 ± 3.8 days; there was no significant difference between groups (3.0 ± 4.1 days vs 2.3 ± 3.4 days for PCT vs control, p = 0.311). The mean number of days under MV was significantly higher in the PCT group (3.7 ± 3.6 days) than in controls (2.7 ± 2.5 days, p = 0.033). The duration of ICU stay was also significantly longer in the PCT group: 6.4 ± 6.5 days vs 4.6 ± 3.5 days in the control group (p = 0.043). After adjustment for SAPS II score, the difference in length of stay and duration of mechanical ventilation between groups was no longer significant.

Conclusion: The use of PCT values to guide therapy, in comparison to the use of clinical, biological (apart from PCT) and radiological criteria, does not modify exposure to antibiotics in patients intubated for coma. Trial registration Clinicaltrials.gov Identifier NCT02862314.
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http://dx.doi.org/10.1186/s13613-021-00931-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8505789PMC
October 2021

A qualitative study of the perception of nursing home practitioners about the implementation of quality indicators for drug consumption in nursing homes.

Aging Clin Exp Res 2021 Oct 6. Epub 2021 Oct 6.

Service de Gériatrie, CHU de Reims, Reims, France.

Introduction: Nursing homes (NHs) are an ideal environment in which to implement interventions aimed at reducing inappropriate prescriptions. Quality indicators (QIs) may be useful to standardize practices, but it is unclear how they mediate change. In the framework of a quantitative study aimed at reducing the prescription of anticholinergic drugs among NH residents using QIs, we performed a qualitative study to describe the investigators' perception of the utility of QIs.

Methods: Qualitative study using focus group methodology. Focus groups were recorded and transcribed, and analyzed by thematic analysis. Participants were purposefully recruited from among the medical directors of the NHs in the quantitative study.

Results: Five medical directors participated in two focus group meetings. The main themes to emerge were: (1) communication is key to introducing new practices and achieving lasting uptake; (2) improved coordination and communication provided useful information to help interpret the quantitative results observed: e.g., participants reported that they were able to obtain contextual and patient-specific information that explained why some prescribers had consistently, but justifiably "poor" performance on the quantitative indicators; (3) negative aspects reported included reluctance to change among prescribers and the tendency to shirk responsibility.

Conclusion: From the point of view of medical directors of NHs participating in an interventional program to reduce inappropriate prescriptions of anticholinergic drugs, the main factor driving the success of the program was communication, which is key to achieving adherence. Improved communication provides useful insights into the reasons why no quantitative reduction is observed in objective quality indicators.
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http://dx.doi.org/10.1007/s40520-021-01989-7DOI Listing
October 2021

Available Bleeding Scoring Systems Poorly Predict Major Bleeding in the Acute Phase of Pulmonary Embolism.

J Clin Med 2021 Aug 16;10(16). Epub 2021 Aug 16.

Department of Cardiology, University Hospital Jean Minjoz, 25000 Besançon, France.

We aimed to compare six available bleeding scores, in a real-life cohort, for prediction of major bleeding in the early phase of pulmonary embolism (PE). We recorded in-hospital characteristics of 2754 PE patients in a prospective observational multicenter cohort contributing 18,028 person-days follow-up. The VTE-BLEED (Venous Thrombo-Embolism Bleed), RIETE (Registro informatizado de la enfermedad tromboembólica en España; Computerized Registry of Patients with Venous Thromboembolism), ORBIT (Outcomes Registry for Better Informed Treatment), HEMORRHAGES (Hepatic or Renal Disease, Ethanol Abuse, Malignancy, Older Age, Reduced Platelet Count or Function, Re-Bleeding, Hypertension, Anemia, Genetic Factors, Excessive Fall Risk and Stroke), ATRIA (Anticoagulation and Risk Factors in Atrial Fibrillation), and HAS-BLED (Hypertension, Abnormal Renal/Liver Function, Stroke, Bleeding History or Predisposition, Labile International Normalized Ratio, Elderly, Drugs/Alcohol) scores were assessed at baseline. International Society on Thrombosis and Haemostasis (ISTH)-defined bleeding events were independently adjudicated. Accuracy of the overall original 3-level and newly defined optimal 2-level outcome of the scores were evaluated and compared. We observed 82 first early major bleedings (3.0% (95% CI, 2.4-3.7)). The predictive power of bleeding scores was poor (Harrel's C-index from 0.57 to 0.69). The RIETE score had numerically higher model fit and discrimination capacity but without reaching statistical significance versus the ORBIT, HEMORRHAGES, and ATRIA scores. The VTE-BLEED and HAS-BLED scores had significantly lower C-index, integrated discrimination improvement, and net reclassification improvement compared to the others. The rate of observed early major bleeding in score-defined low-risk patients was high, between 15% and 34%. Current available scoring systems have insufficient accuracy to predict early major bleeding in patients with acute PE. The development of acute-PE-specific risk scores is needed to optimally target bleeding prevention strategies.
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http://dx.doi.org/10.3390/jcm10163615DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8396851PMC
August 2021

Healthy Ageing and Vaccines: Application of the P4 Medicine Concept to Immunizations.

Gerontology 2021 Jul 9:1-7. Epub 2021 Jul 9.

Department of Cardiology, University Hospital Besancon, Besancon, France.

In today's tormented world, it appears useful to take advantage of communication channels to promote life-course immunization and affirm its major role in healthy ageing. Instead of developing the argument of chronological age, we demonstrate the life-course principle here based on the P4 medicine concept. Are vaccines "preventive, personalized, predictive, and participatory?" Based on detailed analysis of research findings, we successively demonstrate the seminal role of vaccines on preventable infectious diseases, post-sepsis functional decline, non-communicable diseases (cardio-neuro-vascular, respiratory, and renal diseases), community protection, antimicrobial resistance, and perhaps even old-age dementia. Healthy ageing and the promotion of immunization are closely dependent on health literacy and provision of information by skilled health-care professionals. However, personal autonomy and individual freedom are influenced by psycho-cognitive hurdles (cultural approaches, beliefs, emotions, and behaviours), the opinions of the public/family/friends, and the increasing role of social media, which challenges scientific evidence. A similar phenomenon exists when dealing with the issue of healthy ageing, whose success depends greatly on life-course immunization.
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http://dx.doi.org/10.1159/000517211DOI Listing
July 2021

An Original Risk Score to Predict Early Major Bleeding in Acute Pulmonary Embolism: The Syncope, Anemia, Renal Dysfunction (PE-SARD) Bleeding Score.

Chest 2021 Jul 2. Epub 2021 Jul 2.

Department of Cardiology, University Hospital Jean Minjoz, Besançon, France; EA3920, University of Burgundy Franche-Comté, Besançon, France; F-CRIN, INNOVTE network, France.

Background: Improved prediction of the risk of early major bleeding in pulmonary embolism (PE) is needed to optimize acute management.

Research Question: Does a simple scoring system predict early major bleeding in acute PE patients, identifying patients with either high or low probability of early major bleeding?

Study Design And Methods: From a multicenter prospective registry including 2,754 patients, we performed post hoc multivariable logistic regression analysis to build a risk score to predict early (up to hospital discharge) major bleeding events. We validated the endpoint model internally, using bootstrapping in the derivation dataset by sampling with replacement for 500 iterations. Performances of this novel score were compared with that of the VTE-BLEED, RIETE, and BACS models.

Results: Multivariable regression identified three predictors for the occurrence of 82 major bleeds (3.0%; 95% CI, 2.39%-3.72%): Syncope (+1.5); Anemia, defined as hemoglobin <12 g/dL (+2.5); and Renal Dysfunction, defined as glomerular filtration rate <60 mL/min (+1 point) (SARD). The PE-SARD bleeding score was calculated by summing all the components. Overall, 52.2% (95% CI; 50.29%-54.11%) of patients were classified as low bleeding-risk (score, 0 point), 35.2% (95% CI, 33.39%-37.04%) intermediate-risk (score, 1-2.5 points), and 12.6% (95% CI, 9.30%-16.56%) high-risk (score >2.5 points). Observed bleeding rates increased with increasing risk group, from 0.97% (95% CI, 0.53%-1.62%) in the low-risk to 8.93% (95% CI, 6.15%-12.44%) in the high-risk group. C-index was 0.74 (95% CI, 0.73-0.76) and Brier score 0.028 in the derivation cohort. Similar values were calculated from internal bootstrapping. Performance of the PE-SARD score was better than that observed with the VTE-BLEED, RIETE, and BACS scores, leading to a high proportion of bleeding-risk reclassification in patients who bled and those who did not.

Interpretation: The PE-SARD bleeding risk score is an original, user-friendly score to estimate risk of early major bleeding in patients with acute PE.
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http://dx.doi.org/10.1016/j.chest.2021.06.048DOI Listing
July 2021

Impact of Midregional N-Terminal Pro-Atrial Natriuretic Peptide and Soluble Suppression of Tumorigenicity 2 Levels on Heart Rhythm in Patients Treated With Catheter Ablation for Atrial Fibrillation: The Biorhythm Study.

J Am Heart Assoc 2021 07 30;10(13):e020917. Epub 2021 Jun 30.

Department of CardiologyUniversity Hospital Besançon Besançon France.

Background We assessed the impact of preprocedural plasma levels of MRproANP (midregional N-terminal pro-atrial natriuretic peptide) and sST2 (soluble suppression of tumorigenicity 2) on recurrence of atrial fibrillation (AF) at 1 year after catheter ablation of AF. Methods and Results This was a prospective, multicenter, observational study including patients undergoing catheter ablation of AF. MRproANP and sST2 were measured in a peripheral venous blood preprocedure, and MRproANP was assessed in the right and left atrial blood during ablation. The primary end point was recurrent AF between 3 and 12 months postablation, defined as a documented (>30 seconds) episode of AF, flutter, or atrial tachycardia. We included 106 patients from December 2017 to March 2019; 105 had complete follow-up, and the mean age was 63 years with 74.2% males. Overall, 34 patients (32.1%) had recurrent AF. In peripheral venous blood, MRproANP was significantly higher in patients with recurrent AF (median, 192.2; [quartile 1-quartile 3, 155.9-263.9] versus 97.1 [60.9-150.7] pmol/L; <0.0001), as was sST2 (median, 30.3 [quartile 1-quartile 3, 23.3-39.3] versus 23.4 [95% CI, 17.4-33.0] ng/mL; =0.0033). In the atria, MRproANP was significantly higher than in peripheral blood and was higher during AF than during sinus rhythm. Receiver operating characteristic curve analysis identified a threshold of MRproANP>107.9 pmol/L to predict AF recurrence at 1 year and a threshold of >26.7 ng/mL for sST2. By multivariate analysis, MRproANP>107.9 pmol/L was the only independent predictor of recurrent AF (OR, 24.27; 95% CI, 4.23-139.18). MRproANP<107.9 pmol/L identified subjects at very low risk of recurrence (negative predictive value >95%). Conclusions Elevated MRproANP level independently predicts recurrent AF, whereas sST2 levels do not appear to have any prognostic value in assessing the risk of recurrence of AF up to 1 year after catheter ablation. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT03351816.
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http://dx.doi.org/10.1161/JAHA.121.020917DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8403329PMC
July 2021

Mental health and stress among ICU healthcare professionals in France according to intensity of the COVID-19 epidemic.

Ann Intensive Care 2021 Jun 4;11(1):90. Epub 2021 Jun 4.

Service de Médecine Intensive Réanimation-Unité de Sevrage Ventilatoire et Réhabilitation, CH de Bethune, Bethune, France.

Background: We investigated the impact of the COVID-19 crisis on mental health of professionals working in the intensive care unit (ICU) according to the intensity of the epidemic in France.

Methods: This cross-sectional survey was conducted in 77 French hospitals from April 22 to May 13 2020. All ICU frontline healthcare workers were eligible. The primary endpoint was the mental health, assessed using the 12-item General Health Questionnaire. Sources of stress during the crisis were assessed using the Perceived Stressors in Intensive Care Units (PS-ICU) scale. Epidemic intensity was defined as high or low for each region based on publicly available data from Santé Publique France. Effects were assessed using linear mixed models, moderation and mediation analyses.

Results: In total, 2643 health professionals participated; 64.36% in high-intensity zones. Professionals in areas with greater epidemic intensity were at higher risk of mental health issues (p < 0.001), and higher levels of overall perceived stress (p < 0.001), compared to low-intensity zones. Factors associated with higher overall perceived stress were female sex (B = 0.13; 95% confidence interval [CI] = 0.08-0.17), having a relative at risk of COVID-19 (B = 0.14; 95%-CI = 0.09-0.18) and working in high-intensity zones (B = 0.11; 95%-CI = 0.02-0.20). Perceived stress mediated the impact of the crisis context on mental health (B = 0.23, 95%-CI = 0.05, 0.41) and the impact of stress on mental health was moderated by positive thinking, b = - 0.32, 95% CI = - 0.54, - 0.11.

Conclusion: COVID-19 negatively impacted the mental health of ICU professionals. Professionals working in zones where the epidemic was of high intensity were significantly more affected, with higher levels of perceived stress. This study is supported by a grant from the French Ministry of Health (PHRC-COVID 2020).
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http://dx.doi.org/10.1186/s13613-021-00880-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8177250PMC
June 2021

Impact of early (<7 days) pacemaker implantation after cardiac surgery on long-term pacemaker dependency.

Pacing Clin Electrophysiol 2021 Jun 24;44(6):1018-1026. Epub 2021 May 24.

Department of Cardiology, University Hospital Besançon, Boulevard Fleming, Besançon, France.

Objective: We aimed to investigate pacemaker dependency after at least 1 year in patients with early (<7 days) implantation, compared to those who received a pacemaker ≥7 days after cardiac surgery. Secondary endpoints were length of hospital stay and in-hospital complications.

Methods: Retrospective analysis of 108 consecutive patients who received a pacemaker after cardiac surgery between 06/2012 and 06/2018. Characteristics and outcomes were compared between patients with early (<7 days) and late (≥7 days) implantation. Patients were followed up with evaluation of pacemaker dependency between April and June 2019. We identified predictors of dependency by logistic regression.

Results: In total, 63.9% were men, average age 71.9 ± 11.8 years; 32 (29.6%) had early implantation, and 76 (70.4%) late implantation. After a median 3.2 years [IQR 1.9, 4.5] of follow-up, 30 patients (27.8%) had died, and there was no difference in pacemaker dependency among survivors (66.7% vs. 46.5%, early vs. late respectively, p = .15). Patients in the early group had a shorter length of stay (11.5 [9.0, 14.0] vs. 15.0 [11.5, 20] days, p = .002) and less often had new-onset atrial fibrillation (AF) post-surgery (22.7% vs. 47.8%, p = .05). The only significant predictor of dependency was aortic valve replacement surgery (OR = 4.70, 95% CI [1.36 to 16.24]).

Conclusion: Early implantation of a permanent pacemaker (<7 days after cardiac surgery) does not impact on the proportion of patients with long-term (>12 months) pacemaker dependency, but is associated with shorter length of stay and less frequent new-onset AF. These findings warrant prospective confirmation in randomized trials.
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http://dx.doi.org/10.1111/pace.14260DOI Listing
June 2021

The 2020 ESC-ACVC quality indicators for the management of acute myocardial infarction applied to the FAST-MI registries.

Eur Heart J Acute Cardiovasc Care 2021 Apr;10(2):207-215

Department of Cardiology, University Hospital Besancon, Boulevard Fleming, Besancon 25000, France.

Aims: We estimated the 2020 European Society of Cardiology-Acute Cardio Vascular Care (ESC-ACVC) quality indicators (QI) for the management of acute myocardial infarction, from three existing registries to determine the feasibility of assessment, room for improvement, association with outcomes, and suitability for centre benchmarking.

Methods And Results: Data were extracted from three French nationwide registries, namely FAST-MI 2005, 2010, and 2015. Feasibility of assessment and room for improvement were estimated by the denominator (patients in whom QI could be measured) and numerator (patients who satisfied the QI, among those eligible). Associations between composite QIs (CQIs) and mortality were assessed by multivariate analysis. Centre benchmarking was based on the centres mean CQI, vs. the national mean. The 2020 QIs were measured in 12 660/13 130 patients from FAST-MI. Measurement feasibility ranged from 15% to 100% with greater potential for implementation with the 2020 QI set. The mean (±SD) value of the opportunity-based CQI was 0.72 ± 0.01 and attainment of the all-or-none CQI 8.5%. Both CQIs were associated with adjusted 1-year mortality. Centre categorization into low, intermediate, and high quality was feasible, and distinguished centres with differing mortality.

Conclusion: Most of the 2020 QI can be measured from existing registries in all domains but not in the patient's satisfaction domain. This assessment shows potential for implementation. Both CQIs were inversely associated with one-year mortality and centre benchmarking was feasible.
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http://dx.doi.org/10.1093/ehjacc/zuab010DOI Listing
April 2021

Renal dysfunction improves risk stratification and may call for a change in the management of intermediate- and high-risk acute pulmonary embolism: results from a multicenter cohort study with external validation.

Crit Care 2021 02 9;25(1):57. Epub 2021 Feb 9.

Department of Cardiology, University Hospital Jean Minjoz, 3 Boulevard Fleming, 25000, Besançon, France.

Background: Renal dysfunction influences outcomes after pulmonary embolism (PE). We aimed to determine the incremental value of adding renal dysfunction, defined by estimated glomerular filtration rate (eGFR), on top of the European Society of Cardiology (ESC) prognostic model, for the prediction of 30-day mortality in acute PE patients, which in turn could lead to the optimization of acute PE management.

Methods: We performed a multicenter, non-interventional retrospective post hoc analysis based on a prospectively collected cohort including consecutive confirmed acute PE stratified per ESC guidelines. We first identified which of three eGFR formulae most accurately predicted death. Changes in global model fit, discrimination, calibration and reclassification parameters were evaluated with the addition of eGFR to the prognostic model.

Results: Among 1943 patients (mean age 67.3 (17.1), 50.4% women), 107 (5.5%) had died at 30 days. The 4-variable Modification of Diet in Renal Disease (eGFR) formula predicted death most accurately. In total, 477 patients (24.5%) had eGFR < 60 ml/min. Observed mortality was higher for intermediate-low-risk and high-risk PE in patients with versus without renal dysfunction. The addition of eGFR information improved model fit, discriminatory capacity, and calibration of the ESC model. Reclassification parameters were significantly increased, yielding 18% reclassification of predicted mortality (p < 0.001). Predicted mortality reclassifications across risk categories were as follows: 63.1% from intermediate-low risk to eGFR-defined intermediate-high risk, 15.8% from intermediate-high risk to eGFR-defined intermediate-low risk, and 21.0% from intermediate-high risk to eGFR-defined high risk. External validation in a cohort of 14,234 eligible patients from the RIETE registry confirmed our findings with a significant improvement of Harrell's C index and reclassification parameters.

Conclusion: The addition of eGFR-derived renal dysfunction on top of the prognostic algorithm led to risk reclassification within the intermediate- and high-risk PE categories. The impact of risk stratification integrating renal dysfunction on therapeutic management for acute PE requires further studies.
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http://dx.doi.org/10.1186/s13054-021-03458-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7874488PMC
February 2021

Non-readmission decisions in the intensive care unit: A qualitative study of physicians' experience in a multicentre French study.

PLoS One 2021 14;16(1):e0244919. Epub 2021 Jan 14.

Department of Intensive Care, François Mitterrand University Hospital, Dijon, France.

Purpose: Deciding not to re-admit a patient to the intensive care unit (ICU) poses an ethical dilemma for ICU physicians. We aimed to describe and understand the attitudes and perceptions of ICU physicians regarding non-readmission of patients to the ICU.

Materials And Methods: Multicenter, qualitative study using semi-directed interviews between January and May 2019. All medical staff working full-time in the ICU of five participating centres (two academic and three general, non-academic hospitals) were invited to participate. Participants were asked to describe how they experienced non-readmission decisions in the ICU, and to expand on the manner in which the decision was made, but also on the traceability and timing of the decision. Interviews were recorded, transcribed and analyzed using textual content analysis.

Results: In total, 22 physicians participated. Interviews lasted on average 26±7 minutes. There were 14 men and 8 women, average age was 35±9 years, and average length of ICU experience was 7±5 years. The majority of respondents said that they regretted that the question of non-readmission was not addressed before the initial ICU admission. They acknowledged that the ICU stay did lead to more thorough contemplation of the overall goals of care. Multidisciplinary team meetings could help to anticipate the question of readmission within the patient's care pathway. Participants reported that there is a culture of collegial decision-making in the ICU, although the involvement of patients, families and other healthcare professionals in this process is not systematic. The timing and traceability of non-readmission decisions are heterogeneous.

Conclusions: Non-readmission decisions are a major issue that raises ethical questions surrounding the fact that there is no discussion of the patient's goals of care in advance. Better anticipation, and better communication with the patients, families and other healthcare providers are suggested as areas that could be targeted for improvement.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0244919PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7808577PMC
May 2021

Being useful among persons aged over 65: social representations from a cross-sectional European study.

Aging Clin Exp Res 2021 Sep 3;33(9):2565-2572. Epub 2021 Jan 3.

Korian, (The Korian Foundation for Ageing Well), Paris, France.

Background: There is a compelling need to prepare our societies and healthcare systems to deal with the oncoming wave of population ageing. The majority of older persons maintain a desire to be valued and useful members of society and of their social networks.

Aims: We sought to investigate the perception of usefulness among persons aged 65 years and over in four European countries.

Methods: We performed a cross-sectional survey with a representative sample of individuals aged 65 years or older from the population of retired persons (including recently retired persons and oldest-old individuals) from 4 European countries selected using quota sampling. In February 2016, an internet questionnaire was sent to all selected individuals. The characteristics used for the quota sampling method were sex, age, socio-professional category, region, city size, number of persons in household, autonomy, marital status, place of residence, income and educational status. The questionnaire contained 57 questions. Sociodemographic characteristics were recorded. Responses were analysed with principal components analysis (PCA).

Results: A total of 4025 persons participated; 51% were males, and 70% were aged 65-75 years. PCA identified six classes of individuals, of which two classes (Classes 2 and 3) were characterized by more socially isolated individuals with little or no sense of usefulness, low self-esteem and a poor sense of well-being. These two classes accounted for almost 20% of the population. Younger and more autonomous classes reported a more salient sense of usefulness.

Conclusions: The loss of the sense of usefulness is associated with dissatisfaction with life and a loss of pleasure, and persons with profiles corresponding to Classes 2 and 3 should, therefore, be targeted for interventions aimed at restoring social links.
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http://dx.doi.org/10.1007/s40520-020-01767-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8429162PMC
September 2021

Duration of palliative care involvement and cancer care aggressiveness near the end of life.

BMJ Support Palliat Care 2020 Dec 21. Epub 2020 Dec 21.

Department of Supportive and Palliative Care, Centre Hospitalo-Universitaire de Grenoble, Grenoble, France

Objectives: Previous studies have found an association between aggressive cancer care and lower quality end of life. Despite international recommendations, late or very late referral to palliative care seems frequent. This study aimed to evaluate the association between the duration of involvement of a palliative care team (PCT), and aggressive cancer care, and to identify factors associated with aggressive cancer care.

Methods: We performed an observational retrospective study in a single academic teaching hospital. In total, 561 inpatients with solid tumours or haematological malignancies were included. Patients followed by a PCT for at least 1 month before death were classified in the palliative care group. Aggressive cancer care was defined as: hospitalisations and/or a new line of chemotherapy within the last month of life, location of death, the use of chemotherapy in the last 2 weeks and hospice admissions within the last 3 days of life.

Results: Among the 561 patients, 241 (43%) were referred to the PCT; 89 (16%) were followed by the PCT for a month or more before death. In the last 2 weeks of life, 124 (22%) patients received chemotherapy, 110 (20%) died in an acute care unit. At least one criterion of aggressive cancer care was found in 395 patients overall (71%). Aggressive cancer care was significantly less frequent when the PCT referral occurred >1 month before death (p<0.0001).

Conclusion: More studies are needed to understand reasons for late referrals despite international recommendations encouraging integrative palliative care.

Ethics Approval: The study was approved by the Grenoble Teaching Hospital ethics committee, and by the CNIL (French national commission for data privacy; Commission Nationale de l'Informatique et des Libertés) under the number 1987785 v 0. Due to ethical and legal restrictions, data are only available on request.
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http://dx.doi.org/10.1136/bmjspcare-2020-002641DOI Listing
December 2020

How can optical coherence tomography be used to optimize percutaneous coronary intervention?

Cardiovasc Diagn Ther 2020 Oct;10(5):1415-1428

Department of Cardiology, University Hospital Besançon, Besançon, France.

Optical coherence tomography (OCT) imaging provides high resolution assessment of coronary parietal and endoluminal abnormalities. Clinical evidence and intuitive utilization make this tool relevant for use in daily practice in the catheterization laboratory. In the present review, we summarize the benefits of OCT for the optimization of percutaneous coronary intervention (PCI) in daily practice. First, we focus on the characterization of lesion type with a view to anticipating challenges during PCI. Then, we describe the utility of OCT to identify culprit lesions and ambiguous angiographic findings. Finally, we outline targets for optimization after PCI and the mechanisms underlying stent failure.
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http://dx.doi.org/10.21037/cdt.2020.04.02DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7666932PMC
October 2020

Early prescription of direct oral anticoagulant for the treatment of intermediate-high risk pulmonary embolism: a multi-center, observational cohort study.

Thromb Res 2020 12 8;196:476-482. Epub 2020 Oct 8.

Department of Cardiology, EA3920, University Hospital Besançon, Boulevard Fleming, 25030 Besançon, France.

Objectives: The safety and efficacy of direct oral anticoagulants (DOACs) in intermediate-high risk pulmonary embolism (PE) are unknown. The aims of the present study were to describe outcomes of patients receiving early apixaban or rivaroxaban prescription rather than the recommended delayed prescription strategy.

Methods: Retrospective post-hoc analysis based on prospectively collected data from a multicenter cohort including all consecutive PE patients stratified as intermediate-high risk. Group definitions were: early group with DOAC prescription <72 h after admission; delayed group with DOAC prescription between 72 h and discharge. The 30-day primary efficacy outcome was a clinical composite of all-cause death and hemodynamic decompensation. The 30-day primary safety outcome was major bleeding.

Results: Among 2411 patients admitted with PE, 302 were treated with a DOAC for an intermediate-high risk PE: 34.2% in the early group and 65.9% in the delayed group. The primary outcome occurred in 4.8% (including 1 death and 4 hemodynamic decompensations) in the early DOAC group and in 9.0% in the delayed DOAC group (OR, 0.44, 95% CI 0.15-1.30). The rate of major bleeding did not differ between groups (OR, 0.99; 95% CI 0.45-2.18). The length of stay was numerically shorter in the early group whereas the other outcomes did not differ significantly.

Conclusion: The rate of 30-day outcomes was low in patients receiving a DOAC earlier after admission. Patients in the early DOAC group had a numerically shorter length of stay, with similarly low rates of death and bleeding, and similar RV function recovery compared to the delayed strategy.
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http://dx.doi.org/10.1016/j.thromres.2020.10.003DOI Listing
December 2020

Family perceptions of clinical research and the informed consent process in the ICU.

J Crit Care 2020 Sep 28. Epub 2020 Sep 28.

Department of Intensive Care, François Mitterrand, University Hospital, Dijon, France; Clinical Epidemiology, University of Burgundy, INSERM CIC 1432, Dijon, France; Lipness Team, INSERM Research Centre LNC-UMR1231 and LabEx LipSTIC, University of Burgundy, Dijon, France. Electronic address:

Purpose: We investigated experiences of families who provide consent for research on behalf of a loved-one hospitalized in intensive care (ICU).

Methods: Multicentre, qualitative, descriptive study using semi-directive interviews in 3 ICUs. Eligible relatives were aged >18 years, and had provided informed consent for a clinical trial on behalf of a patient hospitalized in ICU. Interviews were conducted from 06/2018 to 06/2019 by a qualified sociologist, recorded and transcribed.

Results: Fifteen relatives were interviewed; average age 50.3 ± 15 years. All emphasized their interest in clinical research, seeing it as a duty. Involving their loved-one in research allowed them to find meaning in the events. Participants underlined that trust in caregivers and communication are determinant. The strict regulation of research was perceived as a guarantee of safety. Participants felt they lacked the intellectual capacity and knowledge to question explanations. The greatest fear was not that they might incur a risk for the patient, but rather, that they might deprive the patient of a chance at a cure.

Conclusion: Acceptance of research opportunities by relatives on behalf of decisionally-incapacitated patients is underpinned by trust in the physicians and the legislative framework. Communication and the quality of information provided by the caregivers are key.
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http://dx.doi.org/10.1016/j.jcrc.2020.09.032DOI Listing
September 2020

Elevated D-dimers and lack of anticoagulation predict PE in severe COVID-19 patients.

Eur Respir J 2020 10 22;56(4). Epub 2020 Oct 22.

Dept of Cardiology, University Hospital, Besançon, France.

Background: Coronavirus disease 2019 (COVID-19) may predispose to venous thromboembolism. We determined factors independently associated with computed tomography pulmonary angiography (CTPA)-confirmed pulmonary embolism (PE) in hospitalised severe COVID-19 patients.

Methods: Among all (n=349) patients hospitalised for COVID-19 in a university hospital in a French region with a high rate of COVID-19, we analysed patients who underwent CTPA for clinical signs of severe disease (oxygen saturation measured by pulse oximetry ≤93% or breathing rate ≥30 breaths·min) or rapid clinical worsening. Multivariable analysis was performed using Firth penalised maximum likelihood estimates.

Results: 162 (46.4%) patients underwent CTPA (mean±sd age 65.6±13.0 years; 67.3% male (95% CI 59.5-75.5%). PE was diagnosed in 44 (27.2%) patients. Most PEs were segmental and the rate of PE-related right ventricular dysfunction was 15.9%. By multivariable analysis, the only two significant predictors of CTPA-confirmed PE were D-dimer level and the lack of any anticoagulant therapy (OR 4.0 (95% CI 2.4-6.7) per additional quartile and OR 4.5 (95% CI 1.1-7.4), respectively). Receiver operating characteristic curve analysis identified a D-dimer cut-off value of 2590 ng·mL to best predict occurrence of PE (area under the curve 0.88, p<0.001, sensitivity 83.3%, specificity 83.8%). D-dimer level >2590 ng·mL was associated with a 17-fold increase in the adjusted risk of PE.

Conclusion: Elevated D-dimers (>2590 ng·mL) and absence of anticoagulant therapy predict PE in hospitalised COVID-19 patients with clinical signs of severity. These data strengthen the evidence base in favour of systematic anticoagulation, and suggest wider use of D-dimer guided CTPA to screen for PE in acutely ill hospitalised patients with COVID-19.
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http://dx.doi.org/10.1183/13993003.01811-2020DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7487272PMC
October 2020

Risk stratification tool for all surgical site infections after coronary artery bypass grafting.

Infect Control Hosp Epidemiol 2021 02 3;42(2):182-193. Epub 2020 Sep 3.

Department of Thoracic and Cardiovascular Surgery, Jean Minjoz University Hospital, Besançon, France.

Objective: To develop a risk score for surgical site infections (SSIs) after coronary artery bypass grafting (CABG).

Design: Retrospective study.

Setting: University hospital.

Patients: A derivation sample of 7,090 consecutive isolated or combined CABG patients and 2 validation samples (2,660 total patients).

Methods: Predictors of SSIs were identified by multivariable analyses from the derivation sample, and a risk stratification tool (additive and logistic) for all SSIs after CABG (acronym, ASSIST) was created. Accuracy of prediction was evaluated with C-statistic and compared 1:1 (using the Hanley-McNeil method) with most relevant risk scores for SSIs after CABG. Both internal (1,000 bootstrap replications) and external validation were performed.

Results: SSIs occurred in 724 (10.2%) cases and 2 models of ASSIST were created, including either baseline patient characteristics alone or combined with other perioperative factors. Female gender, body mass index >29.3 kg/m2, diabetes, chronic obstructive pulmonary disease, extracardiac arteriopathy, angina at rest, and nonelective surgical priority were predictors of SSIs common to both models, which outperformed (P < .0001) 6 specific risk scores (10 models) for SSIs after CABG. Although ASSIST performed differently in the 2 validation samples, in both, as well as in the derivation data set, the combined model outweighed (albeit not always significantly) the preoperative-only model, both for additive and logistic ASSIST.

Conclusions: In the derivation data set, ASSIST outperformed specific risk scores in predicting SSIs after CABG. The combined model had a higher accuracy of prediction than the preoperative-only model both in the derivation and validation samples. Additive and logistic ASSIST showed equivalent performance.
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http://dx.doi.org/10.1017/ice.2020.412DOI Listing
February 2021

No impact of a prescription booklet on medication consumption in nursing home residents from 2011 to 2014: a controlled before-after study.

Aging Clin Exp Res 2021 Jun 3;33(6):1599-1607. Epub 2020 Aug 3.

Department of Geriatrics and Internal Medicine, Maison Blanche Hospital, Reims University Hospitals, 45 Rue Cognacq-Jay, 51000, Reims, France.

Background: Older persons are particularly exposed to adverse events from medication. Among the various strategies to reduce polypharmacy, educational approaches have shown promising results. We aimed to evaluate the impact on medication consumption, of a booklet designed to aid physicians with prescriptions for elderly nursing home residents.

Methods: Among 519 nursing homes using an electronic pill dispenser, we recorded the daily number of times that a drug was administered for each resident, over a period of 4 years. The intervention group comprised 113 nursing homes belonging to a for-profit geriatric care provider that implemented a booklet delivered to prescribers and pharmacists and specifically designed to aid with prescriptions for elderly nursing home residents. The remaining 406 nursing homes where no such booklet was introduced comprised the control group. Data were derived from electronic pill dispensers. The effect of the intervention on medication consumption was assessed with multilevel regression models, adjusted for nursing home status. The main outcomes were the average daily number of times that a medication was administered and the number of drugs with different presentation identifier codes per resident per month.

Results: 96,216 residents from 519 nursing homes were included between 1 January 2011 and 31 December 2014. The intervention group and the control group both decreased their average daily use of medication (- 0.05 and - 0.06). The booklet did not have a statistically significant effect (exponentiated difference-in-differences coefficient 1.00, 95% confidence interval 0.99-1.02, P = .45).

Conclusion: We observed an overall decrease in medication consumption in both the control and intervention groups. Our analysis did not provide any evidence that this reduction was related to the use of the booklet. Other factors, such as national policy or increased physician awareness, may have contributed to our findings.
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http://dx.doi.org/10.1007/s40520-020-01670-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8203501PMC
June 2021

Vaccines in older age: moving from current practice to optimal coverage-a multidisciplinary consensus conference.

Aging Clin Exp Res 2020 Aug 22;32(8):1405-1415. Epub 2020 Jun 22.

Dipartimento di Scienze Mediche, Università degli Studi di Ferrara, Ferrara, Italy.

Vaccines are a key strategy to promote healthy aging, but vaccine coverage remains below target levels in at-risk adults and older individuals. We present here the results of a multidisciplinary consensus conference convened to perform a multidimensional assessment of vaccination in geriatric medicine, with a view to developing a well-defined strategy for the promotion of vaccines in older people. We discuss recommended vaccines in older individuals, and describe the wide regional heterogeneity between regions in the Italian context. The main obstacles to implementation of vaccines in practice are reviewed, as well as potential strategies to remove these barriers. Finally, the importance of including vaccines and vaccination in undergraduate and postgraduate medical education is underlined. The information summarized in this document is expected to help develop educational and promotional initiatives to achieve greater uptake of vaccines among older individuals, as a key means to promote healthy aging.
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http://dx.doi.org/10.1007/s40520-020-01622-zDOI Listing
August 2020

Metaphor use in the ICU: rigor with words!

Intensive Care Med 2020 11 18;46(11):2126-2127. Epub 2020 Jun 18.

Intensive Care Unit, Besançon University Hospital, Besançon, France.

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http://dx.doi.org/10.1007/s00134-020-06156-6DOI Listing
November 2020

Raising awareness of the needs of older COVID patients after hospital discharge.

Aging Clin Exp Res 2020 08 12;32(8):1595-1598. Epub 2020 Jun 12.

Department of Cardiology, University Hospital Besancon, Boulevard Fleming, 25000, Besancon, France.

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http://dx.doi.org/10.1007/s40520-020-01620-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7291942PMC
August 2020

The shortage of skilled workers in Europe: its impact on geriatric medicine.

Eur Geriatr Med 2020 06;11(3):345-347

Department of Cardiology, University Hospital Besancon, Besançon, France.

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http://dx.doi.org/10.1007/s41999-020-00323-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7176573PMC
June 2020

Coping with the COVID-19 crisis in Sub-Saharan Africa: let us not leave older people behind!

Eur Geriatr Med 2020 08 22;11(4):709-710. Epub 2020 Apr 22.

Department of Geriatrics, University Hospitals of Guadeloupe, Pointe-à-Pitre, Guadeloupe.

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http://dx.doi.org/10.1007/s41999-020-00324-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7175814PMC
August 2020

Strategies to Improve Vaccine Uptake throughout Adulthood.

Interdiscip Top Gerontol Geriatr 2020 9;43:234-248. Epub 2020 Apr 9.

University of Geneva, Geneva, Switzerland.

Vaccine-preventable diseases represent a considerable burden on world health, and can have long-lasting consequences in those infected, especially in older adults, who can suffer functional decline, disability, and death. Vaccine uptake across the life course is desirable, but often suboptimal. A number of factors have been identified as contributors to low vaccine coverage, including sociodemographic characteristics, logistic factors such as ease of access and convenience, cultural attitudes including health literacy, and vaccine hesitancy. Strategies to improve vaccine uptake can target all the components underpinning low coverage, and include technology and communication-based strategies, physician-centered approaches, targeting healthcare workers for influenza vaccination, system-based factors, improved vaccine efficacy, and above all, political will and leadership.
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http://dx.doi.org/10.1159/000504486DOI Listing
September 2020

Integrating functional ageing into daily clinical practice.

J Frailty Sarcopenia Falls 2019 Jun 1;4(2):30-35. Epub 2019 Jun 1.

University of Franche-Comté, Besançon, France.

The analysis of the ageing trajectory clearly demonstrates the constant involvement of functional ability in daily life, from its development in youth, to its preservation through midlife into very old age. While maintaining function appears to be largely related to persistent regular exercise, the risk factors for functional decline are extremely diverse, ranging from a decrease or discontinuation of physical activity, to nutritional/metabolic disturbances, chronic diseases and unfavourable socio-demographic and socio-economic contexts. Prevention of functional decline is a major public health challenge, both for individuals and for society as a whole, and needs to be urgently addressed. Engaging citizens to be conscious of their responsibility for, and role in their own ageing process is equally as important as reinforcing the involvement of society in promoting healthy ageing through enhanced basic and health education, promotion of a healthy diet, long term practice of moderate physical activity, and the continual battle against deleterious life habits and behaviours. The success of these combined actions would be quite simply demonstrated by a change from the current pandemics of morbidity, to the compression of disability, which is expected by all.
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http://dx.doi.org/10.22540/JFSF-04-030DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7155303PMC
June 2019

Criteria deemed important by the relatives for designating a reference person for patients hospitalized in ICU.

J Crit Care 2020 06 26;57:191-196. Epub 2020 Feb 26.

Department of Intensive Care, Centre Hospitalier de Dieppe, France; Espace de Réflexion Ethique de Normandie, University Hospital Caen, France. Electronic address:

Purpose: We investigated the criteria that patients' relatives deem important for choosing, among themselves, the person best qualified to interact with the caregiving staff.

Methods: Exploratory, observational, prospective, multicentre study between 1st March and 31st October 2018 in 2 intensive care units (ICUs). A 12-item questionnaire was completed anonymously by family members of patients hospitalized in the ICU 3 and 5 days after the patient's admission. Relatives were eligible if they understood French and if no surrogate had been appointed by the patient prior to ICU admission. More than one relative per patient could participate.

Results: In total, 87 relatives of 73 patients completed the questionnaire, average age of relatives was 58 ± 15 years, 46% were the spouse, 30% were children/grandchildren. Items classed as being the most important attributes for a reference person were: good knowledge of the patient's wishes and values; an emotional attachment to the patient; being a family member; and having an adequate understanding of the clinical status and clinical history.

Conclusion: This study identifies the attributes considered by relatives to be most important for designating, among themselves, a reference person for a patient hospitalized in the ICU.
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http://dx.doi.org/10.1016/j.jcrc.2020.02.017DOI Listing
June 2020

Comprehensive Geriatric Assessment in Cardiovascular Disease.

Adv Exp Med Biol 2020 ;1216:87-97

Intermediate Care Unit (Department of Geriatric Care, OrthoGeriatrics and Rehabilitation), E.O. Galliera Hospital, Genoa, Italy.

Frailty and cardiovascular disease (CVD) are both highly prevalent in older adults. Cardiovascular disease has been identified as the most frequent cause of death, while frailty has been identified as one of geriatric giants characterized by decreased physiological reserves and increased vulnerability. However, the exact pathobiological links between the two conditions have not been fully elucidated. Consequently, we observe a relevant difficulty not only in accurately defining cardiovascular risk in vulnerable elderly patients (and the other way around), but also a lack of consensus regarding CVD management in the very old. Nowadays, considering the enormous technical innovation, many elderly patients, if appropriately selected, could be eligible even for the most complex treatments, including invasive cardiological procedures. Identification of frail patients at risk of negative outcomes can allow the customization of therapeutic interventions in elderly patients with CVD, allowing the elderly who can benefit from them to undergo even invasive procedures and avoiding futile or dangerous treatments for the most vulnerable patients. A large number of tools and definitions for assessing frailty have been proposed; different scales and assessment tools can be useful for different purposes, but at present there is no clear indication for their use in CVD. In this chapter, we will describe the main geriatric approach to ascertain frailty, the assessment tools used in patients with cardiovascular diseases, and propose an operational strategy to evaluate frailty and identify patients eligible for pharmacologic or surgical interventions.
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http://dx.doi.org/10.1007/978-3-030-33330-0_10DOI Listing
February 2020

Validation and Performance Comparison of Two Scoring Systems Created Specifically to Predict the Risk of Deep Sternal Wound Infection after Bilateral Internal Thoracic Artery Grafting.

Surg Infect (Larchmt) 2020 Jun 27;21(5):433-439. Epub 2019 Dec 27.

Department of Thoracic and Cardio-Vascular Surgery, University Hospital Jean Minjoz, Besançon, France.

The Gatti and the bilateral internal mammary artery (BIMA) scores were created to predict the risk of deep sternal wound infection (DSWI) after bilateral internal thoracic artery (BITA) grafting. Both scores were evaluated retrospectively in two consecutive series of patients undergoing isolated multi-vessel coronary surgical procedures-i.e., the Trieste (n = 1,122; BITA use, 52.1%; rate of DSWI, 5.7%) and the Besançon cohort (n = 721; BITA use, 100%; rate of DSWI, 2.5%). Baseline patient characteristics were compared between the two validation samples. For each score, the accuracy of prediction and predictive power were assessed by the area under the receiver-operating characteristic curve (AUC) and the Goodman-Kruskal gamma coefficient, respectively. There were significant differences between the two series in terms of age, gender, New York Heart Association functional class, chronic lung disease, left ventricular function, surgical priority, and the surgical techniques used. In the Trieste series, accuracy of prediction of the Gatti score for DSWI was higher than that of the BIMA score (AUC, 0.729 vs. 0.620, p = 0.0033). The difference was not significant, however, in the Besançon series (AUC, 0.845 vs. 0.853, p = 0.880) and when only BITA patients of the Trieste series were considered for analysis (AUC, 0.738 vs. 0.665, p = 0.157). In both series, predictive power was at least moderate for the Gatti score and low for the BIMA score. The Gatti and the BIMA scores seem to be useful for pre-operative evaluation of the risk of DSWI after BITA grafting. Further validation studies should be performed.
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http://dx.doi.org/10.1089/sur.2019.252DOI Listing
June 2020

Pharmacy-based interventions to increase vaccine uptake: report of a multidisciplinary stakeholders meeting.

BMC Public Health 2019 Dec 18;19(1):1698. Epub 2019 Dec 18.

University of Geneva, Geneva, Switzerland.

Background: Despite the existence of efficacious vaccines, the burden of vaccine-preventable diseases remains high and the potential health benefits of paediatric, adolescent and adult vaccination are not being achieved due to suboptimal vaccine coverage rates. Based on emerging evidence that pharmacy-based vaccine interventions are feasible and effective, the European Interdisciplinary Council for Ageing (EICA) brought together stakeholders from the medical and pharmacy professions, the pharmaceutical industry, patient/ageing organisations and health authorities to consider the potential for pharmacy-based interventions to increase vaccine uptake. We report here the proceedings of this 3-day meeting held in March 2018 in San Servolo island, Venice, Italy, focussing firstly on examples from countries that have introduced pharmacy-based vaccination programmes, and secondly, listing the barriers and solutions proposed by the discussion groups.

Conclusions: A range of barriers to vaccine uptake have been identified, affecting all target groups, and in various countries and healthcare settings. Ease of accessibility is a potentially modifiable determinant in vaccine uptake, and thus, improving the diversity of settings where vaccines can be provided to adults, for example by enabling community pharmacists to vaccinate, may increase the number of available opportunities for vaccination.
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http://dx.doi.org/10.1186/s12889-019-8044-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6921486PMC
December 2019
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