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Identification of delay barriers to care is essential for an effective and efficient healthcare service delivery. In this study, we described the delay in care among parents of the patients seeking treatment for dengue. We also examined the factors affecting the severity of dengue (dengue with warning signs, severe dengue). A convergent parallel design mixed-method approach using Key Informant Interviews (KII) and a survey guided by the Three-Delay Model were conducted among 24 respondents at the National Children’s Hospital (NCH). Coding and thematic analysis using NVIVO and bivariable generalized linear models with a Poisson distribution and robust variance were utilized to analyze the KII transcripts and survey data, respectively. Results showed that financial constraints and previous dengue infection (first delay), mode of transportation, traffic density, and location (second delay), and hospital capacity (third delay) influenced the overall delay uncertainty in seeking care treatment for dengue infection. Furthermore, our bivariable analysis showed that travel time to NCH and place of residency, service given from previous health facilities, and parents’ educational background were associated and played a role in the severity of dengue infection. Interventions focused on the identified factors contributing to delayed care should be made to avoid unwanted clinical outcomes.

International audience; Patients with oropharyngeal squamous cell carcinoma (OPSCC) display a significant risk of synchronous primary neoplasia (SPN) which could impact their management. The aims of this study were to evaluate the risk and distribution of SPN in OPSCC patients according to their HPV (p16) status, the predictive factors of SPN and the impact of SPN on therapeutic strategy and oncologic outcomes.Material and methods: All OPSCC patients treated from 2009 to 2014 were included in this multicentric retrospective study. Univariate analyses were conducted using Chi-2 and Fisher exact tests. For multivariate analyses, all variables associated with a p ≤ 0.10 in univariate analysis were included in logistic regression models.Results: Among the 1291 patients included in this study, 75 (5.8%) displayed a SPN which was preferentially located in the upper aerodigestive tract, lung and esophagus. Comorbidity level (p = 0.03), alcohol (p = 0.005) and tobacco (p = 0.01) consumptions, and p16 tumor status (p < 0.0001) were significant predictors of SPN. In multivariate analysis, p16+ status was significantly associated with a lower risk of SPN (OR = 0.251, IC95% [0.133;0.474]). Patients with a SPN were more frequently referred for non-curative treatment (p = 0.02). In patients treated with curative intent, there was no impact of SPN on the therapeutic strategy (surgical vs. non-surgical treatment). We observed no overall survival differences between patients with or without SPN.Conclusion: P16 tumor status is the main predictive factor of SPN in OPSCC patients. This study provides crucial results which should help adapt the initial work-up and the global management of OPSCC patients.

International audience; Objectives: Patient-and procedure-related changes in modern medicine have turned CoNS into one of the major nosocomial pathogens. Treatments of CoNS infections are challenging owing to the large proportion of MDR strains and oxazolidinones often remain the last active antimicrobial molecules. Here, we have investigated a long-lasting outbreak (2010-13) due to methicillin-and linezolid-resistant (LR) CoNS (n " 168), involving 72 carriers and 49 infected patients. Methods: Antimicrobial susceptibilities were tested by the disc diffusion method and MICs were determined by broth microdilution or Etest. The clonal relationship of LR Staphylococcus epidermidis (LRSE) was first determined using a semi-automated repetitive element palindromic PCR (rep-PCR) method. Then, WGS was performed on all cfr-positive LRSE (n " 30) and LRSE isolates representative of each rep-PCR-defined clone (n " 17). Self-transferability of cfr-carrying plasmids was analysed by filter-mating experiments. Results: This outbreak was caused by the dissemination of three clones (ST2, ST5 and ST22) of LRSE. In these clones, linezolid resistance was caused by (i) mutations in the chromosome-located genes encoding the 23S RNA and L3 and L4 ribosomal proteins, but also by (ii) the dissemination of two different self-conjugative plasmids carrying the cfr gene encoding a 23S RNA methylase. By monitoring linezolid prescriptions in two neighbouring hospitals, we highlighted that the spread of LR-CoNS was strongly associated with linezolid use. Conclusions: Physicians should be aware that plasmid-encoded linezolid resistance has started to disseminate among CoNS and that rational use of oxazolidinones is critical to preserve these molecules as efficient treatment options for MDR Gram-positive pathogens.

International audience; BACKGROUND: Surgery is generally proposed for Boerhaave's syndrome, spontaneous rupture of the esophagus. But diagnosis can be difficult, delaying appropriate management. The purpose of the present study was to evaluate outcome of conservative surgery for primary or T-tube repair performed in two tertiary referral centers. METHODS: From June 1985 to November 2010, among 53 patients presenting with Boerhaave's syndrome treated surgically, 39 underwent a conservative procedure. These patients were retrospectively divided into two groups by type of repair: primary suture (group 1, n = 25) or suture on a T-tube (group 2, n = 14). Patients in group 1 were further stratified into two subgroups depending on whether the primary suture was made with reinforcement (subgroup rS) or not (subgroup S). RESULTS: Length of stays in hospital and intensive care were shorter in patients in group 1 (p = 0.037), but after a shorter delay before therapeutic management (p = 0.003) compared with group 2. For the other variables studied, outcome was more favorable in group 1, but the differences were not significant. Comparing subgroups rS and S showed that the rate of persistent leakage was significantly lower after reinforced suture (p = 0.021). CONCLUSIONS: These findings from the largest reported cohort of Boerhaave's syndrome patients undergoing conservative surgery showed that primary and T-tube repair provide at least equivalent results. Reinforced sutures appear to provide better outcomes by reducing postoperative leakage.

OBJECTIVE:To better understand the role of hope among terminally ill cancer patients.DESIGN:Qualitative analysis.SETTING:A tertiary specialized cancer centre in Canada.PARTICIPANTS:Cancer patients in palliative care with an estimated remaining life expectancy of 12 months or less (N = 12) and their loved ones (N = 12) and treating physicians (N = 12).METHODS:Each patient underwent up to 3 interviews and identified a loved one who participated in 1 interview. Treating physicians were also interviewed. All interviews were fully transcribed and analyzed by at least 2 investigators. Interviews were collected until saturation occurred.MAIN FINDINGS:Seven attributes describe the experiences of palliative cancer patients and their caregivers: hope as an irrational phenomenon that is a deeply rooted, affect-based response to adversity; initial hope for miraculous healing; hope as a phenomenon that changes over time, evolving in different ways depending on circumstances; hope for prolonged life when there is no further hope for cure; hope for a good quality of life when the possibility of prolonging life becomes limited; a lack of hope for some when treatments are no longer effective in curbing illness progression; and for others hope as enjoying the present moment and preparing for the end of life.CONCLUSION:Approaches aimed at sustaining hope need to reflect that patients' reactions might fluctuate between despair and a form of acceptance that leads to a certain serenity. Clinicians need to maintain some degree of hope while remaining as realistic as possible. The findings also raise questions about how hope influences patients' perceptions and acceptance of their treatments., ObjectifMieux comprendre le rôle de l’espoir chez un patient cancéreux en phase terminale.Go to:Type d’étudeAnalyse qualitative.Go to:ContexteUn établissement tertiaire spécialisé en oncologie situé au Canada.Go to:ParticipantsDes patients cancéreux en phase palliative avec une espérance de vie estimée à moins d’un an (N = 12), leurs proches (N = 12) et leurs médecins traitants (N = 12).Go to:MéthodesLes patients ont été interviewés jusqu’à 3 reprises; chacun a désigné un proche qui a été interviewé une fois. Toutes les entrevues ont été transcrites intégralement et analysées par au moins 2 chercheurs. On a effectué des entrevues jusqu’à l’atteinte de la saturation.Go to:Principales observationsDes patients en phase terminale et leurs soignants ont décrit leur expérience à l’aide de 7 caractéristiques : l’espoir comme un phénomène irrationnel profondément ancré, correspondant à une réaction affective à l’adversité; l’espoir initial d’une guérison miraculeuse; l’espoir comme un phénomène qui change avec le temps et qui évolue différemment selon les circonstances; l’espoir de vivre plus longtemps même s’il n’y a plus d’espoir de guérison; l’espoir d’une bonne qualité de vie lorsque la possibilité de vivre plus longtemps est de plus en plus limitée; pour certains, une diminution de l’espoir quand les traitements n’arrivent plus à ralentir la progression de la maladie; et pour d’autres, une forme d’espoir qui consiste à apprécier le moment présent et à se préparer à mourir.Go to:ConclusionLes façons de soutenir l’espoir chez un patient doivent tenir compte du fait que ses réactions peuvent fluctuer entre le désespoir et une forme d’acceptation menant à une certaine sérénité. Le clinicien se doit de maintenir un certain degré d’espoir tout en demeurant le plus réaliste possible. Les présentes observations nous amènent également à nous demander comment l’espoir modifie la façon dont le patient perçoit son traitement et comment il l’accepte.

To compare peripartum management of anticoagulated patients concerning locoregional analgesia, post-partum hemorrhage and thrombotic events according to planified interruption or not of antithrombotic therapy.We conducted a single tertiary care center retrospective study of all deliveries associated with antithrombotic therapy from January 2005 to September 2011.We identified 120 cases with prophylactic (71%) or curative (29%) anticoagulation. Two thrombotic events occurred. In case of curative therapy, the use of locoregional analgesia was lower (P0.0001) and post-partum hemorrhage occurred more frequently (P=0.07) compared to prophylactic therapy. According to planified interruption or not of antithrombotic therapy, we observed a more prolonged duration of therapeutic interruption before delivery (55.6h±63.3 vs 26.4 h±11.6, P0.0001), higher use of locoregional analgesia (83% vs 71%, P=0.02) but no difference concerning cesarean rate (35% vs 39%, P=0.8) or post-partum hemorrhage (13% vs 14%, P=0.9).In case of curative anticoagulation, plannified interruption favours the use of perimedullar analgesia after 24hour delay. In case of preventive anticoagulation, plannified interruption appears unnecessary as the 12hour delay is easier to reach.

International audience; OBJECTIVE: To evaluate the incidence, the impact on survival and the predictive factors of bile leakage (BL) in a recent large monocentric series of liver resections performed in a referral tertiary care centre. BACKGROUND: Previous reports dealing with bile leakage (BL) after liver resection are rare and have displayed conflicting results regarding incidence, impact on follow-up and predictive factors. METHODS: A retrospective review of the records of 912 patients who underwent a total of 1001 consecutive liver resections without biliary reconstruction, performed between January 2005 and May 2011. BL was defined by the presence of bile in the abdominal drains, a radiologically or surgically drained bilioma or biliary peritonitis. BL severity was established according to the Clavien-Dindo classification. Fifty-eight pre-, per- and post-resection variables were analysed and the independent BL predictive factors were identified using logistic regression. RESULTS: The incidence of BL was 8%. Clavien-Dindo I-II, IIIa, IIIb or IV rates were 29%, 35%, 32.5% and 2.5%, respectively. BL did not increase in-hospital mortality (2.5% versus 2.9%, P = 1.0), but doubled the median duration of hospital stay (16 versus 9 days, P < 0.001) and increased 1-year mortality (11% versus 5%, P = 0.03). Multivariate analysis identified that pre-operative bevacizumab [odds ratio (OR) = 2.9, confidence interval (CI) 95% = 1.58-5.41] P = 0.001], a major hepatectomy [OR = 2.6 (CI 95% = 1.48-4.76) P = 0.001], a two-stage hepatectomy [OR = 2.5 (CI 95% = 1.17-5.52) P = 0.018], the selective clamping technique [OR = 2.6 (CI 95% = 1.03-6.78) P = 0.042], R1 or R2 resection [OR = 2.6 (CI 95% = 1.52-4.64) P = 0.001] and the absence of a methylene blue test [OR = 2.6 (IC 95% = 1.43-4.65) P = 0.002] were independent risk factors of BL. CONCLUSION: BL remains frequent after liver resection. It has a dramatic impact on patient survival and care costs. Its incidence could be reduced by avoiding the pre-operative use of bevacizumab, avoiding selective clamping and performing a blue dye test in all resections.

International audience; BACKGROUND: Whether proadrenomedullin (ProADM) improves the performance of the Risk of Early Admission to ICU (REA-ICU) score in predicting early, severe community-acquired pneumonia (ESCAP) has not been demonstrated. METHODS: Secondary analysis was completed of the original data from 877 consecutive patients with community-acquired pneumonia (CAP) enrolled in the Procalcitonin-Guided Antibiotic Therapy and Hospitalization in Patients With Lower Respiratory Tract Infections (ProHOSP) study, a multicenter trial in EDs of six tertiary-care hospitals in Switzerland. ESCAP was defined by either the requirement for mechanical ventilation or vasopressive drugs or occurrence of death within 3 days of ED presentation. RESULTS: Eighty patients (9.1%) developed ESCAP (47 required mechanical ventilation, 19 vasopressive drugs, and 16 died) within 3 days of ED presentation. They had a higher median ProADM value (2.18 nmol/L vs 1.15 nmol/L, P < .001). Combining ProADM testing with the REA-ICU score improved the area under the curve (0.81) compared with either parameter (ProADM [0.73] or REA-ICU score [0.76], P < .001) and resulted in a net reclassification improvement of 0.20 (P < .001). A ProADM value ≥ 1.8 nmol/L or assignment to REA-ICU risk classes III-IV predicted ESCAP with a sensitivity of 76.3% and a negative predictive value of 96.7%. Excluding 21 patients with major criteria of severe CAP on presentation showed similar results. CONCLUSION: These study findings demonstrate that the addition of ProADM to the REA-ICU score improves the classification of a substantial proportion of patients in the ED at intermediate or high risk for ESCAP, which may translate into better triage decisions.