Philippe AEGERTER | CHU Ambroise Paré (AP-HP, Boulogne-Billancourt (original) (raw)

Papers by Philippe AEGERTER

European Journal of Human Genetics, 2009

Mutations identified in the fibrillin-1 (FBN1) gene have been associated with Marfan syndrome (MF... more Mutations identified in the fibrillin-1 (FBN1) gene have been associated with Marfan syndrome (MFS). Molecular analysis of the gene is classically performed in probands with MFS to offer diagnosis for at-risk relatives and in children highly suspected of MFS. However, FBN1 gene mutations are found in an ill-defined group of diseases termed 'type I fibrillinopathies', which are associated with an increased risk of aortic dilatation and dissection. Thus, there is growing awareness of the need to identify these non-MFS probands, for which FBN1 gene screening should be performed. To answer this need we compiled the molecular data obtained from the screening of the FBN1 gene in 586 probands, which had been addressed to our laboratory for molecular diagnosis. In this group, the efficacy of FBN1 gene screening was high in classical MFS probands (72.5%,), low (58%) in those referred for incomplete MFS and only slight (14.3%) for patients referred as possible MFS. Using recursive partitioning, we found that the best predictor of the identification of a mutation in the FBN1 gene was the presence of features in at least three organ systems, combining one major, and various minor criteria. We also show that our original recommendation of two systems involved with at least one with major criterion represents the minimal criteria because in probands not meeting these criteria, the yield of mutation identification drastically falls. This recommendation should help clinicians and biologists in identifying probands with a high probability of carrying a FBN1 gene mutation, and thus optimize biological resources.

Arthritis and Rheumatism, 2008

ObjectiveTo evaluate and improve the reliability of power Doppler ultrasonography (PDUS) for dete... more ObjectiveTo evaluate and improve the reliability of power Doppler ultrasonography (PDUS) for detecting and scoring enthesitis in patients with spondylarthitis, using a 3-step procedure.To evaluate and improve the reliability of power Doppler ultrasonography (PDUS) for detecting and scoring enthesitis in patients with spondylarthitis, using a 3-step procedure.MethodsIn the first step, we evaluated the reliability of 5 sonographers by bilaterally scanning 5 entheses twice in 5 patients. In the second step, starting from disagreements observed during the first step, we established consensus guidelines. The sonographers' implementation was further evaluated in 2 reliability exercises: one on 60 PDUS enthesitis images and the other by scanning 5 new patients. In the third step, we performed a final reliability evaluation of 5 additional patients after 1 year. Kappa coefficients (κ) as well as variance component analysis (VCA) and generalizability theory (GT) were used to assess reliability.In the first step, we evaluated the reliability of 5 sonographers by bilaterally scanning 5 entheses twice in 5 patients. In the second step, starting from disagreements observed during the first step, we established consensus guidelines. The sonographers' implementation was further evaluated in 2 reliability exercises: one on 60 PDUS enthesitis images and the other by scanning 5 new patients. In the third step, we performed a final reliability evaluation of 5 additional patients after 1 year. Kappa coefficients (κ) as well as variance component analysis (VCA) and generalizability theory (GT) were used to assess reliability.ResultsThe initial intra- and interobserver reliability were poor, especially for detecting and scoring Doppler signal. VCA and GT showed that most variability was accounted for by interaction between sonographer and enthesis. Implementation of consensus guidelines was associated with a significant improvement in Doppler reliability between the first and second steps (mean interobserver κ increased from 0.13 to 0.51 for binary Doppler scoring in patients; P < 0.005), which persisted in the third step (mean interobserver κ = 0.57). The high GT coefficients reached in the last steps supported such improvement.The initial intra- and interobserver reliability were poor, especially for detecting and scoring Doppler signal. VCA and GT showed that most variability was accounted for by interaction between sonographer and enthesis. Implementation of consensus guidelines was associated with a significant improvement in Doppler reliability between the first and second steps (mean interobserver κ increased from 0.13 to 0.51 for binary Doppler scoring in patients; P < 0.005), which persisted in the third step (mean interobserver κ = 0.57). The high GT coefficients reached in the last steps supported such improvement.ConclusionThe 3-step procedure used in this study to standardize PDUS technique was associated with a significant improvement in interobserver reliability for detecting enthesitis in spondylarthritis patients. Such an approach can be useful to standardize PDUS assessment of musculoskeletal disorders.The 3-step procedure used in this study to standardize PDUS technique was associated with a significant improvement in interobserver reliability for detecting enthesitis in spondylarthritis patients. Such an approach can be useful to standardize PDUS assessment of musculoskeletal disorders.

Journal of Critical Care, 2002

Objective: To determine the impact of systemic candidiasis on the mortality and length of hospita... more Objective: To determine the impact of systemic candidiasis on the mortality and length of hospital stay of intensive care unit (ICU) patients and the associated workload. Design: Multicenter, retrospective, matched-cohort study. Setting: Data were retrieved from a computerized database that prospectively collected clinical data submitted by 32 ICUs in the Paris, France area. Patients: A total of 149 stays with systemic candidiasis, including 104 candidemia, on ICU admission were identified in a 3-year period (1995-1997) among 49,063 admissions (3 per 1,000 admission). A total of 121 cases were matched with patients with no evidence of systemic Candida infection during the hospitaliza-tion period under study (same ICU, date of ICU admission, age, sex, simplified acute physiology score (SAPS II), location of the patient before admission, type of admission). Results: Patients with systemic candidiasis had longer ICU length of stays than controls (25 vs 10 d; P ϭ .001) with a relative risk for death of 2.27 (95% confidence interval, 1.64-3.11; P ϭ .001). There was no difference between patients with systemic candidiasis with or without positive blood culture. Conclusions: Systemic Candida infections increased mortality and morbidity in severely ill patients. Optimizing management of such infections is imperative.

Journal of The American Geriatrics Society, 2005

Objectives: To determine whether patients aged 80 and older have similar treatment intensity to t... more Objectives: To determine whether patients aged 80 and older have similar treatment intensity to that of younger patients in the intensive care unit (ICU).Design: Multicenter, matched-cohort study.Setting: Data were extracted from a multicenter database with 36 ICUs in the Paris area (France) during a 4-year period (1997–2000).Participants: Three thousand one hundred seventy-five patients aged 80 and older (oldest-old) were retrospectively matched to 3,175 patients aged 65 to 79 (young-old).Measurements: The matching criteria were severity status on admission (±2) (assessed using a corrected Simplified Acute Physiology Score II leaving out age points), Charlson Comorbidity Index, type of admission (surgical vs medical), sex, admission to same ICU, and year of ICU admission. The underlying condition was classified using the McCabe classification. The functional status was assessed using the Knaus classification. The ICU workload was assessed using the OMEGA scoring system.Results: Total and daily workload were lower in the oldest-old than in matched young-old patients. Estimated mean direct medical cost per stay was approximately $1,280 lower for oldest-old patients. Older patients received less mechanical ventilation (adjusted odds ratio (AOR)=0.69, 95% confidence interval (CI)=0.61–0.78), less tracheostomy (AOR=0.37, 95% CI=0.28–0.50), and less renal support (AOR=0.52, 95% CI=0.41–0.66) than matched young-old patients. Oldest-old patients had a shorter length of ICU stay than matched young-old patients and the same length of post-ICU stay.Conclusion: Oldest-old patients receive less treatment in the ICU than young-old patients even after adjustment for severity of illness.

International Journal of Technology Assessment in Health Care, 2006

Objectives: To estimate the expected cost and clinical benefits associated with the use of drotre... more Objectives: To estimate the expected cost and clinical benefits associated with the use of drotrecogin alfa (activated) [Xigris; Eli Lilly and Company; Indianapolis, IN] in the French hospital setting. Methods: The PROWESS study results (1,271 patients with multiple organ failure) were adjusted to 9,948 hospital stays from a database of Parisian area intensive care units (ICUs)the CubRea database. The analysis features a decision tree with a probabilistic sensitivity analysis.

Intensive Care Medicine, 2001

Objective: To evaluate patient outcome and the efficiency of stays in intensive care units (ICUs)... more Objective: To evaluate patient outcome and the efficiency of stays in intensive care units (ICUs). Design: Prospective study. Setting: Seven ICUs of teaching hospitals in the Paris area. Patients: Two hundred eleven stays including one in three consecutive patients admitted from September to November 1996. Measurements and main results: For each patient, the following information was collected during the ICU stay: diagnosis, severity scores, organ failures, workload, cost and mortality. A cost-effectiveness ratio was computed for 176 stays with at least one organ failure, at hospital discharge and 6 months later. Quality of life was measured with EuroQol questionnaires 6 months after discharge in 64 patients representing 62% of the patients contacted. The mean total ICU cost per stay was US$ 14,130 (±6,550) (higher for non-survivors – US$ 19,060, median 10,590 – than for survivors – US$ 12,370, median 5,780). The incremental cost-effectiveness ratio was US$ 1,150 per life-year saved and the incremental cost-utility ratio was US$ 4,100 per quality-adjusted life-year (QALY) saved, without discounting. These results compare favourably with other health-care options. However substantial variations were observed according to age, severity, diagnosis, number of organ failures and discount rate. Intoxication had the lowest ratio (US$ 620/QALY) and acute renal insufficiency the highest (US$ 30,625/QALY). Conclusions: This work provides medical and economic information on ICU stays in teaching hospitals and enables comparisons with other health-care options.

Intensive Care Medicine, 2005

Objective To construct and validate an update of the Simplified Acute Physiology Score II (SAPS I... more Objective To construct and validate an update of the Simplified Acute Physiology Score II (SAPS II) for the evaluation of clinical performance of Intensive Care Units (ICU). Design and setting Retrospective analysis of prospectively collected multicenter data in 32 ICUs located in the Paris area belonging to the Cub-Rea database and participating in a performance evaluation project. Patients 33,471 patients treated between 1999 and 2000. Measurements and results Two logistic regression models based on SAPS II were developed to estimate in-hospital mortality among ICU patients. The second model comprised reevaluation of original items of SAPS II and integration of the preadmission location and chronic comorbidity. Internal and external validation were performed. In the two validation samples the most complex model had better calibration than the original SAPS II for in-hospital mortality but its discrimination was not significantly higher (area under ROC curve 0.89 vs. 0.87 for SAPS II). Second-level customization and integration of new items improved uniformity of fit for various categories of patients except for diagnosis-related groups. The rank order of ICUs was modified according to the model used. Conclusions The overall performance of SAPS II derived models was good, even in the context of a community cohort and routinely gathered data. However, one-half the variation of outcome remains unexplained after controlling for admission characteristics, and uniformity of prediction across diagnostic subgroups was not achieved. Differences in case-mix still limit comparisons of quality of care.

To update the epidemiology of septic shock we analyzed clinical, microbiologic, and outcome varia... more To update the epidemiology of septic shock we analyzed clinical, microbiologic, and outcome variables from 100,554 intensive care unit admissions on the Collège des Utilisateurs de Bases de données en Réanimation (CUB-Réa) database, collected from 22 hospitals over a 8-year period, 1993 to 2000. The overall frequency of septic shock was 8.2 per 100 admissions (i.e., 8,251 stays). It increased from 7.0 (in 1993) to 9.7 per 100 admissions (in 2000). The distribution analysis of the sites of infection and of the types of pathogens showed an increase in the rate of pulmonary infection (p ϭ 0.001) and of multiresistant bacteria-related septic shock (p ϭ 0.001). The crude mortality was 60.1% and declined from 62.1% (in 1993) to 55.9 (in 2000) (p ϭ 0.001). As compared with matched intensive care unit admissions without sepsis, the excess risk of death due to septic shock was 25.7 (95% confidence interval, 24.0-27.3) and the matched odds ratio of death was 3.9 (95% confidence interval, 3.5-4.3). The frequency of septic shock is increasing with more multiresistant strains. Its crude mortality rate is decreasing, but patients with septic shock still have a high excess risk of death than critically ill patients who are nonseptic.

Critical Care Medicine, 2007

To determine whether mortality rates among intensive care unit (ICU) patients differ according to... more To determine whether mortality rates among intensive care unit (ICU) patients differ according to the time of ICU admission, we compared the death rates for patients admitted during weekday day shifts and off hours (from 6:30 pm to 8:29 am the next day for night shifts, from Saturday 1:00 pm to Monday 8:29 am for weekends, and from 8:30 am to 8:29 am the following morning for public holidays). Retrospective cohort study of data collected prospectively from 23 ICUs located in the Paris metropolitan region, France. Between January 2000 and December 2003, 51,643 patients were admitted to these ICUs. Patients were grouped according to their day and time of admission and compared using univariable and multivariable analyses. None. Of the 51,643 patients admitted to ICUs, 33,857 (65.6%) were admitted during off hours. These latter patients were less critically ill than those admitted during day shifts, had fewer failed organs, required fewer support procedures, and their crude in-hospital mortality was lower (20.7 vs. 24.5%, p &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; .0001). After adjustment for initial disease severity, in-hospital mortality was not higher for off-hours admissions than weekday day admissions and even remained slightly lower (adjusted odds ratio, 0.93; 95% confidence interval, 0.87-0.98). Admission during off hours is common. In our ICUs, off-hours admissions were not associated with higher mortality and might even be associated with a lower death rate.

Intensive Care Medicine, 2008

Objective To determine the concomitant incidence, molecular diversity, management and outcome of ... more Objective To determine the concomitant incidence, molecular diversity, management and outcome of nosocomial candidemia and candiduria in intensive care unit (ICU) patients in France. Design A 1-year prospective observational study in 24 adult ICUs. Patients Two hundred and sixty-two patients with nosocomial candidemia and/or candiduria. Measurements and results Blood and urine samples were collected when signs of sepsis were present. Antifungal susceptibility of Candida strains was determined; in addition, all blood and 72% of urine C. albicans isolates were analyzed by using multi-locus sequence type (MLST). The mean incidences of candidemia and candiduria were 6.7 and 27.4/1000 admissions, respectively. Eight percent of candiduric patients developed candidemia with the same species. The mean interval between ICU admission and candidemia was 19.0 ± 2.9 days, and 17.2 ± 1.1 days for candiduria. C. albicans and C. glabrata were isolated in 54.2% and 17% of blood and 66.5% and 21.6% of urine Candida-positive cultures, respectively. Fluconazole was the most frequently prescribed agent. In all candidemic patients, the prescribed curative antifungal agent was active in vitro against the responsible identified strain. Crude ICU mortality was 61.8% for candidemic and 31.3% for candiduric patients. Seventy-five percent of the patients were infected with a unique C. albicans strain; cross-transmission between seven patients was suggested in one hospital. Conclusions Candidemia is late-onset ICU-acquired infection associated with high mortality. No difference in susceptibility and genetic background were found between blood and urine strains of Candida species.

Aids, 2000

To assess the efficacy of highly active antiretroviral treatment (HAART) on AIDS-Kaposi's... more To assess the efficacy of highly active antiretroviral treatment (HAART) on AIDS-Kaposi's sarcoma (KS). Prospective cohort of patients followed for 24 months. Four referral hospitals of the West Paris metropolitan area. Thirty-nine AIDS-KS patients, 42 +/- 9 years old, who began HAART (HIV-protease inhibitor and two nucleoside analogues) between March and December 1996, were enrolled. One was lost to follow-up at month 12. KS response, using criteria of the AIDS clinical trials group (ACTG), CD4 cell counts, and plasma HIV-RNA, assessed every 6 months. ACTG TIS staging of KS. Eighteen patients had T1 KS and 21 T0 KS. One patient died from KS at month 6. KS improved progressively, with complete and partial response rates of 46% and 28% at month 24, respectively. Only six patients were still receiving systemic KS therapy at month 24. Complete response was observed in 10 of the 19 patients without systemic KS therapy at inclusion. Patients with complete response at month 24 had higher CD4 cell counts than others (465 +/- 343 versus 185 +/- 167 x 10(6)/l; P < 0.01), but the proportion of patients with HIV-1 RNA < 500 copies/ml was not significantly different. An increase in CD4 cell counts from inclusion to month 12 of > 150 x 10(6)/l [odds ratio (OR), 13.4; 95% confidence interval (CI), 2-82] and T0 KS at inclusion: [OR, 7; 95% CI, 1.1-42] were predictive of complete response at month 24. HAART appears to have prolonged efficacy on AIDS-KS, even without specific KS therapy, and this effect appears to be linked to the restoration of immune function.

Journal of Critical Care, 2005

The objective of this study is to develop and validate a questionnaire designed to assess the cul... more The objective of this study is to develop and validate a questionnaire designed to assess the culture, organization, and management of intensive care units. This is a prospective multicenter study. The study was conducted in 26 intensive care units located in Paris. All personnel were asked to complete the questionnaire. The questionnaire was developed in 2 steps: (1) development of a theoretical framework based on organizational theory and (2) testing of the reliability and validity of a comprehensive set of measures. The internal consistency of the items composing each scale was tested by using the Cronbach alpha. Convergent, and discriminant validity was assessed by factor analysis with varimax rotation. The overall completion rate was 74% with 1000 respondents (750 nurses, 26 head nurses, 168 physicians, and 56 medical secretaries). Starting with a 220-item questionnaire, we constructed a short version-conserving metrological characteristics with good reliability and validity. The short questionnaire, entitled Culture, Organization, and Management in Intensive Care, consists of 106 items distributed in 9 dimensions and 22 scales: culture (n = 3), coordination and adaptation to uncertainty (n = 3), communication (n = 3), problem solving and conflict management (n = 2), organizational learning and organizational change (n = 2), skills developed in a patient-caregiver relationship (n = 1), subjective unit performance (n = 3), burnout (n = 3), and job satisfaction and intention to quit (n = 2). All the scales showed good-to-high reliability, with Cronbach alpha scores higher than .7 (with the exception of coordination [.6]). Team satisfaction-oriented culture is positively correlated with good managerial practices and individual well-being. The Culture, Organization, and Management in Intensive Care questionnaire enables staff and managers to assess the organizational performance of their intensive care unit.

Intensive Care Medicine, 1998

Objective: An instrument able to estimate the direct costs of stays in Intensive Care Units (ICUs... more Objective: An instrument able to estimate the direct costs of stays in Intensive Care Units (ICUs) simply would be very useful for resource allocation inside a hospital, through a global budget system. The aim of this study was to propose such a tool. Design: Since 1991, a region-wide common data base has collected standard data of intensive care such as the Omega Score, Simplified Acute Physiologic Score, length of stay, length of ventilation, main diagnosis and procedures. The Omega Score, developed in France in 1986 and proved to be related to the workload, was recorded on each patient of the study. Setting: Eighteen ICUs of Assistance Publique-Hopitaux de Paris (AP-HP) and suburbs. Patients: 1) Hundred twenty-one randomly selected ICU patients; 2) 12,000 consecutive ICU stays collected in the common data base in 1993. Measurements: 1) On the sample of 121 patients, medical expenditure and nursing time associated with interventions were measured through a prospective study. The correlation between Omega points and direct costs was calculated, and regression equations were applied to the 12,000 stays of the data base, leading to estimated costs. 2) From the analytic accounting of AP-HP, the mean direct cost per stay and per unit was calculated, and compared with the mean associated Omega score from the data base. In both methods a comparison of actual and estimated costs was made. Results: The Omega Score is strongly correlated to total direct costs, medical direct costs and nursing requirements. This correlation is observed both in the random sample of 121 stays and on the data base’ stays. The discrepancy of estimated costs through Omega Score and actual costs may result from drugs, blood product underestimation and therapeutic procedures not involved in the Omega Score. Conclusions: The Omega system appears to be a simple and relevant indicator with which to estimate the direct costs of each stay, and then to organise nursing requirements and resource allocation.

Critical Care Medicine, 2003

In recent years, protective ventilation with airway pressure limitation has constituted a major a... more In recent years, protective ventilation with airway pressure limitation has constituted a major advance in acute respiratory distress syndrome treatment and has led to a substantial improvement in prognosis. With this therapeutic rationale, one may even question nowadays whether the severity of respiratory failure still influences mortality. To determine whether the severity of respiratory failure, scored according to the usual criteria, still influences mortality in acute respiratory distress syndrome patients when a low stretch ventilation was used and to assess the impact on mortality of other nonpulmonary organ dysfunction, particularly circulatory failure. A retrospective study conducted in the medical intensive care unit of a French university hospital from October 1993 to December 2001. PATIENTS A total of 150 acute respiratory distress syndrome patients who were administered uniform protective ventilation with a limited plateau pressure (&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;30 cm H2O), a low positive end-expiratory pressure (&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;10 cm H2O), and the same strategy concerning hemodynamic support and dialysis when required. Mean age, general severity index (Simplified Acute Physiologic Score II), number of associated organ failures (Logistic Organ Dysfunction Score), respiratory severity indices (Pao2/Fio2, Lung Injury Severity Score), and severity of initial circulatory failure (circulatory failure present at admission or that developed during the first 48 hrs) were compared, according to recovery or death, and evaluated by a logistic regression model, which allows simultaneous control of multiple factors. The average mortality rate for the whole group was 38%, with 93 patients recovering after an average duration of mechanical ventilation of 18 +/- 13 days. The major factor significantly and independently associated with probability of dying was the severity of circulatory failure (p =.0001, odds ratio = 10.17). Patients free from initial circulatory failure (39 patients) had a 95% recovery rate. With our low stretch strategy, the severity of circulatory failure was the main determinant of acute respiratory distress syndrome prognosis. Patients with isolated respiratory failure during the first 48 hrs of respiratory support have an excellent chance of recovery when treated with protective ventilation associated with a low positive end-expiratory pressure.

Intensive Care Medicine, 2007

Objective Transesophageal echocardiography (TEE) is increasingly used in hemodynamic monitoring i... more Objective Transesophageal echocardiography (TEE) is increasingly used in hemodynamic monitoring in the intensive care unit. This paper describes and validates a scoring system for assessing competence in TEE performed by intensivists for this indication. Design Prospective study over an 18-month period. Settings Two medical intensive care units. Methods The scoring system is used to assess four aspects of TEE: quality of the views (score out of 14); semiquantitative evaluation of respiratory variations in the superior vena cava, valve regurgitation, size of the right ventricle (score out of 10); accuracy of measurement of velocity-time integrals for pulmonary and aortic flow, peak velocity of the E and A waves of mitral flow, left ventricular fractional area change (score out of 8); summary and proposed treatment (score out of 8). The scoring system was validated by using it to assess intensivists after 1 month (M1), 3 months (M3) and 6 months (M6) of training. TEE was done on a mechanically ventilated, hypotensive patient and scored by comparing the intensivist's examination with that of the expert examiner. The intensivists were divided into two groups of theoretical expertise at the start of training. Results Nineteen intensivists were evaluated. The scores at M1 for level 0 (no experience in echocardiography) and level 1 (previous experience) were, respectively, 18.5 ± 4 and 24.7 ± 5. The scores at M1, M3, and M6 were, respectively, 20.4 ± 5, 30.4 ± 5 and 35.7 ± 3. At M6, the intensivists had performed TEE 29 ± 10 times. Conclusion The scoring system was discriminatory and sensitive to change, and could be used as a tool to assess an intensivist's mastery of TEE.

International Journal of Epidemiology, 1990

A detailed stochastic model of HIV infection and AIDS for large cities in central Africa is descr... more A detailed stochastic model of HIV infection and AIDS for large cities in central Africa is described, which reproduces past events in Kinshasa, Zaire and projects rapid future spread of the disease, consistent with recent findings for Nairobi, Kenya. Most of the parameters used describe the behaviour of individuals, and it is therefore possible to look at the effects of changes in such behaviour, and thus to test various strategies aimed at providing effective public health policies. The model demonstrates that, if the spread of infection is to be controlled, changes in the behaviour of the major risk groups are essential. With appropriate modifications, this model could be adapted for use elsewhere in Africa.

To assess, by means of meta-analysis techniques for diagnostic tests, the accuracy of dermoscopic... more To assess, by means of meta-analysis techniques for diagnostic tests, the accuracy of dermoscopic (also known as dermatoscopy and epiluminescence microscopy) diagnosis of melanoma performed by experienced observers vs. naked-eye clinical examination. MEDLINE, EMBASE, PASCAL-BIOMED, and BIUM databases were screened through May 31, 2000, without any language restrictions. Original studies were selected when the following criteria were met: spectrum of lesions well described, histologic findings as standard criterion, and calculated or calculable sensitivity and specificity. Eight of 672 retrieved references were retained. Three investigators extracted data. In case of disagreement, consensus was obtained. Summary receiver operating characteristic curve analysis was used to describe the central tendency of the studies, and to compare dermoscopy and clinical examination. Selected studies represented 328 melanomas, mostly less than 0.76 mm thick, and 1865 mostly melanocytic benign pigmented skin lesions. For dermoscopic diagnosis of melanoma, the sensitivity and specificity ranges were 0.75 to 0.96 and 0.79 to 0.98, respectively. Dermoscopy had significantly higher discriminating power than clinical examination, with respective estimated odds ratios of 76 (95% confidence interval, 25-223) and 16 (95% confidence interval, 9-31) (P =.008), and respective estimated positive likelihood ratios of 9 (95% confidence interval, 5.6-19.0) and 3.7 (95% confidence interval, 2.8-5.3). The roles of the number of lesions analyzed, the percentage of melanoma lesions, the instrument used, and dermoscopic criteria used in each study could not be proved. For experienced users, dermoscopy is more accurate than clinical examination for the diagnosis of melanoma in a pigmented skin lesion.

Critical Care, 2005

We conducted a prospective observational study from January 1995 to December 2004 to evaluate the... more We conducted a prospective observational study from January 1995 to December 2004 to evaluate the impact on recovery of a major advance in renal replacement therapy, namely continuous veno-venous haemodiafiltration (CVVHDF), in patients with refractory septic shock.