Clinique du Millénaire

Diabetic foot osteomyelitis (DFOM) is a serious medical condition that necessitates robust diagnostic tools for effective clinical management. Conventional diagnostic methods for DFOM rely heavily on bacterial culture, which is time-consuming and may fail to capture the full microbial diversity present in infections. This pilot study explored the utility of metagenomics next-generation sequencing (mNGS) as a complementary diagnostic tool for DFOM. We retrospectively analysed ten bone biopsies from nine diabetic persons using both routine microbiological culture and mNGS. Routine culture identified 11 bacterial species across seven biopsies, while mNGS detected 84 species, including all those found by culture. High microbial diversity (Shannon index = 1.10) was associated with severe osteomyelitis, leading to amputation in three of seven DFOM cases. Interestingly, one culture-negative biopsy revealed high bacterial diversity by mNGS and progressed to a severe infection within 7 days. mNGS also identified resistance genes, providing additional insights for targeted therapy. Integrating mNGS into routine clinical microbiology may serve as a complementary method to conventional diagnostics, particularly for distinguishing infection from colonization and predicting clinical outcomes. However, challenges such as human DNA contamination and limited sequencing depth must be addressed to optimize its clinical application. These findings support the integration of mNGS into diagnostic workflows for bone biopsies for improved management of DFOM.

Understanding and predicting the effects of climate change on populations requires linking the environmental conditions to demographic rates and the demographic rates to population‐level consequences, but often this complete demographic pathway is not studied. Integrated population models (IPMs) incorporate demographic data into a single analytical framework, allowing for the inclusion of environmental covariates to test hypotheses considering how the environment influences demographic rates, and consequently, to which demographic rates population growth rate is most sensitive. In birds, there is strong evidence that environmental conditions impact population growth, and that long‐distance migrant avian species with short phenological windows are at greatest risk of population decline due to changing environmental conditions. We built a Bayesian IPM with over 40 years of mark‐recapture, fecundity, and nest box occupancy data and incorporated environmental covariates hypothesized to be driving the observed changes in two populations of a fast‐lived long‐distance migrant, the European pied flycatcher. Using variance decomposition methods, we identified the demographic pathways through which environmental covariates were acting. While several environmental covariates impacted fecundity and survival, only precipitation acted via apparent juvenile and adult survival contributed significantly to variation in population growth rate. Increased precipitation during the nest initiation, incubation, and hatchling stages had negative carry‐over effects on juvenile survival during the post‐fledging and overwintering period, and increased precipitation negatively impacted adult apparent survival, likely due to the increased energetic demands of caring for eggs and hatchlings in challenging conditions and reduced availability of aerial prey. We show that linking environmental covariates to demographic rates does not sufficiently explain or predict population‐level consequences, and that decomposing variation along the complete demographic pathway is a necessary step to appropriately identify how covariates influence population dynamics.

Abstract Background Tricuspid transcatheter edge-to-edge repair (T-TEER) is an emerging therapeutic intervention for patients with significant tricuspid regurgitation (TR). However, patient selection for T-TEER remains challenging. Prior studies have identified several hemodynamic markers, including the TAPSE/systolic PAP ratio (TAPSE/sPAP), cardiac output (CO), and pulmonary artery pulsatility index (PAPi), as potentially predictive of relevant outcome. The prognostic utility of these parameters in guiding patient selection for T-TEER remains to be fully elucidated. Objective To generate hypothesis as regards the prognostic value of these three invasive hemodynamic markers obtained from right heart catheterization (RHC) in patients eligible to T-TEER in terms of clinical response at one year ("improvement" versus "worse or no change" – the main outcome of TRI-FR trial, based on clinical events (unscheduled hospitalization for heart failure, death, tricuspid surgery) as well as PGA, NYHA and KCCQ). Methods All randomized patients in TRI-FR (N = 300) were eligible and analyzed, except those who withdrew their consent (N = 5), those allocated to T-TEER who experience a technical failure (TR grade 4+ or more in post-intervention) (N = 25), and those who had missing values for at least one of three RHC markers (N = 66). In each treatment arm, a linear relationship between RHC markers and outcome was first assessed using a generalized additive model, transformations were then applied accordingly. We fitted univariate and multivariable logistic regression models. The performances of the final model were investigated through discrimination, expressed as the area under the receiver-operating curve (AUC) and calibration (graphically). Results Out of 148 patients allocated to guideline directed medical therapy (GDMT) alone, and 152 patients allocated to T-TEER on top of GDMT, 109 and 100 were analyzed, and an improvement was observed in 39 out of 106 (36.8%) and 77 (77.8%) out of 99 patients assessed, respectively. In the GDMT alone arm, PAPi (log-transformed) and CO (3-degree polynomial) moderately predicted improvement (AUC = 0.696 and calibration far from good). In the T-TEER on top of GDMT, CO (3-degree polynomial) and TAPSE/sPAP (2-degree polynomial) moderately predicted improvement (AUC = 0.730 and moderate calibration). There were no significant relationship between hemodynamic measures and change in KCCQ or in 6-minute walk distance. Conclusion Key hemodynamic measures might be taken in account for patient selection for tricuspid valve interventions. This hypothesis has to be confirmed and probably added to other key clinical, biological and echocardiographic parameters.

Comprehensive knowledge of the clinical presentation, contemporary management, and outcomes on "all-comer" patients referred for mitral valve surgery (MVS) are critical to evaluate current practice and adherence to guidelines, understand selection biases, and inform key stakeholders on quality improvement. MITRACURE is a large international retrospective registry of consecutive adult patients who underwent isolated or combined MVS for mitral regurgitation (MR) in France or Canada in 2019 with in-depth clinical and echocardiographic characterization. Patients operated on for isolated mitral stenosis or who had a prior mitral valve intervention were excluded. Data were obtained from detailed chart abstraction and were site reported. In 2019, 3522 patients underwent MVS (48% combined) across 40 centers (88±46 MVSs/center, median 80, interquartile [51-131]). Mean age was 65±12 years, and 35% were women. The most common MR etiology was myxomatous (61%), followed by functional (9%), infective endocarditis (9%), and rheumatic disease (7%). MR quantification was performed in only 43%. Advanced clinical presentation was common: 43% were in New York Heart Association class III/IV, 30% exhibited congestive heart failure, 47% were on diuretics, 22% had atrial fibrillation/flutter, 35% presented with reduced ejection fraction, and 22% had pulmonary hypertension (≥50 mm Hg). Most patients were symptomatic or presented with class I/IIa indication for intervention, and an early intervention was performed only in 3% of patients. The repair rate was 62% overall and 80% in myxomatous disease. In-hospital mortality was 4.5% overall but 2.3% in patients with myxomatous MR (1.8% isolated, 3.1% combined). MITRACURE provides a contemporary, multicenter, "real-world" picture of the clinical presentation, management, and in-hospital outcomes of MVS for MR in two Western countries. Patients were often referred late in the disease process, with few patients undergoing early intervention. The higher mortality and lower repair rates reported may be more reflective of an unselected MR patient population but have room for improvement. Our results underline the need to develop strategies to improve management and outcomes of patients with MR.

To evaluate the impact of the AirSeal® insufflation system on postoperative pain, analgesic consumption, and patient satisfaction following robot-assisted radical prostatectomy (RARP), using real-world patient-reported outcomes (PROMs) collected via a digital health platform. This retrospective multicenter study included 312 patients undergoing RARP for localized prostate cancer across 19 French centers (September 2024-June 2025). Forty-seven patients (15.1%) underwent RARP with AirSeal® (low or standard pressure) and 265 (84.9%) with conventional insufflation (standard pressure). Pain scores, measured using the Visual Analogue Scale and analgesic use were recorded daily from postoperative day (POD) 1-14 via the CE-certified Betty Coaching smartphone application. Secondary outcomes included length of stay, sick leave duration, patient satisfaction at 6 weeks, and postoperative complications. Baseline characteristics were comparable between groups. Median pain scores were consistently lower with AirSeal®, with complete pain resolution by POD8 versus POD14 for conventional insufflation. By POD8, all AirSeal® patients were analgesic-free, compared to 83% at POD14 in the control group. All patients were opioid-free within 2 weeks. Hospital stay (median 1day) and satisfaction (median score 10/10) were similar. Complication rates (10.6% vs. 6.8%, p = 0.352) and readmissions did not differ significantly. Use of the AirSeal® system in RARP was associated with faster pain resolution and earlier cessation of analgesics without compromising perioperative safety. Digital PROMs collection via the Betty Coaching platform offers precise recovery monitoring, reinforcing its role in enhanced recovery pathways and supporting the integration of valveless insufflation technology into minimally invasive urologic surgery.

The sustainability of tax systems has emerged as a pressing challenge in the era of economic globalization and digitalization, where gaps in traditional tax rules facilitated Base Erosion and Profit Shifting (BEPS). This article examines the relevance and impact of the OECD’s BEPS Action 6, with a focus on Switzerland’s implementation and practice. The research objective is to assess how Action 6 strengthens legal coherence, enhances economic substance requirements, and curbs treaty abuse, including treaty shopping. Using a doctrinal legal analysis of OECD instruments, Swiss legislative measures, and relevant case law, this study identifies practical trends in beneficial ownership tests, anti-abuse rules, and substance-based treaty entitlement. The findings indicate that Switzerland has integrated Action 6 standards through targeted treaty amendments and administrative practice, improving the alignment between taxation and genuine economic activity.