Hospitalization of HIV positive patients: Significant demand affecting all hospital sectors.

BACKGROUND: In a context of the evolution of severe morbidities in patients living with HIV (PLWH), the aim of this study was to describe reasons for hospitalization and the mode of care for the patients requiring hospitalization. METHODS: All admissions (≥24h) of PLWH to 10 hospitals in the south of Paris (COREVIH Ile-de-France Sud) between 1/1/2011 and 12/31/2011 were identified. The hospital database and the file of patients followed in the HIV referral department of each hospital were matched. Detailed clinical and biological data were collected, by returning to the individual medical records, for a random sample (65% of hospitalized patients). RESULTS: A total of 3013 hospitalizations (1489 patients) were recorded in 2011. The estimated rate of hospitalized patients was about 8% among the 10105 PLWH routinely managed in COREVIH Ile-de-France Sud in 2011. The majority (58.5%) of these hospitalizations occurred in a unit other than the HIV referral unit. Non-AIDS-defining infections were the main reason for admission (16.4%), followed by HIV-related diseases (15.6%), hepatic/gastrointestinal diseases (12.0%), and cardiovascular diseases (10.3%). The median length of stay was 5 days overall (IQR: 2-11), it was longer among patients admitted to a referral HIV care unit than to another ward. HIV infection had been diagnosed >10 years previously in 61.4% of these hospitalized patients. They often had associated comorbidities (coinfection HCV/HVB 40.5%, smoking 45.8%; hypertension 33.4%, dyslipidemia 28.8%, diabetes 14.8%). Subjects over 60 years old accounted for 15% of hospitalized patients, most of them were virologically controlled under HIV treatment, and cardiovascular diseases were their leading reason for admission. CONCLUSION: Needs for hospitalization among PLWH remain important, with a wide variety in causes of admission, involving all hospital departments. It is essential to prevent comorbidities to reduce these hospitalizations, and to maintain a link between the management of PLWH, that becomes rightly, increasing ambulatory, and recourse to specialized inpatient services.

Stability of HIV RNA in plasma specimens stored at different temperatures.

OBJECTIVES: In resource-limited countries, HIV-1 RNA quantification is usually performed in reference laboratories. Samples from remote areas are transported under suboptimal conditions. Here we evaluated HIV-1 RNA stability in plasma stored at different temperatures for 1 week. METHODS: Blood samples collected in ethylenediaminetetraacetic acid (EDTA) and processed within 6 h of collection were tested by HIV-1 RNA quantification using Roche Cobas Ampliprep-Cobas TaqMan (Roche Diagnostics). The results were compared with matched HIV-1 RNA concentrations determined from plasma stored for 1 week at 4, 22, 30 or 37 degrees C. RESULTS: A total of 51 samples were evaluated: 10 stored at 4 degrees C, 15 at 22 degrees C, 16 at 30 degrees C and 10 at 37 degrees C. Keeping plasma at 4, 22 or 30 degrees C for 1 week did not affect HIV RNA measurement. Compared with HIV-1 RNA concentrations determined from fresh plasma, the correlation was significant for each of the three temperatures with no RNA decay. In contrast, HIV-1 RNA levels decreased significantly when plasma was stored at 37 degrees C. The 10 samples submitted at this temperature showed a weaker correlation (rho=0.84; P=0.012) and a significantly reduced median HIV-1 RNA concentration (-0.92 log(10) HIV-1 RNA copies/mL; P=0.005). CONCLUSION: Plasma can be saved for up to 1 week at 30 degrees C before shipping to a reference laboratory for HIV-1 RNA quantification.

Syndromic surveillance based on emergency department activity and crude mortality: two examples.

Recent public health crises have shown the need for readily available information allowing proper management by decision-makers. One way of obtaining early information is to involve data providers who already record routine data for their own use. We describe here the results of a pilot network carried out by the InVS (Institut national de veille sanitaire) which gathered data available in real time from hospital emergency departments and register offices. Emergency departments data were registered from patients' computerised medical files. Mortality data were received from the national institute of statistics (Insee). Data were transmitted automatically on a daily basis. Influenza data from outbreaks in 2004/05 and 2005/06 were compared with data from the sentinel network for the same periods. Environmental health data were compared with meteorological temperatures recorded in Paris between June and August 2006. A mortality analysis was conducted on a weekly basis. Correlation between influenza data from emergency departments and data from Sentiweb (sentinel network) was significant (p<0.001) for both outbreaks. In 2005 and 2006, the outbreaks were described similarly by both sources with identification of the start of the outbreaks by both systems during the same weeks. As for data related to heat, a significant correlation was observed between some diagnoses and temperature increases. For both types of phenomena, mortality increased significantly with one to two weeks lag. To our knowledge, this is the first time that a study using real time morbidity and mortality data is conducted. These initial results show how these data complement each other and how their simultaneous analysis in real time makes it possible to quickly measure the impact of a phenomenon.

Syndromic surveillance based on emergency department activity and crude mortality: two examples.

Recent public health crises have shown the need for readily available information allowing proper management by decision-makers. One way of obtaining early information is to involve data providers who already record routine data for their own use. We describe here the results of a pilot network carried out by the InVS (Institut national de veille sanitaire) which gathered data available in real time from hospital emergency departments and register offices. Emergency departments data were registered from patients' computerized medical files. Mortality data were received from the national institute of statistics (Insee). Data were transmitted automatically on a daily basis. Influenza data from outbreaks in 2004/05 and 2005/06 were compared with data from the sentinel network for the same periods. Environmental health data were compared with meteorological temperatures recorded in Paris between June and August 2006. A mortality analysis was conducted on a weekly basis. Correlation between influenza data from emergency departments and data from Sentiweb (sentinel network) was significant (p<0.001) for both outbreaks. In 2005 and 2006, the outbreaks were described similarly by both sources with identification of the start of the outbreaks by both systems during the same weeks. As for data related to heat, a significant correlation was observed between some diagnoses and temperature increases. For both types of phenomena, mortality increased significantly with one to two weeks lag. To our knowledge, this is the first time that a study using real time morbidity and mortality data is conducted. These initial results show how these data complement each other and how their simultaneous analysis in real time makes it possible to quickly measure the impact of a phenomenon.

A descriptive, retrospective study of 567 accidental blood exposures in healthcare workers in three West African countries.

We conducted a multi-centre study in West African hospital wards to document accidental blood exposure (ABE) risks in these settings, and assessed the incidence of ABE in participating healthcare workers (HCWs) retrospectively. In total, 1241 HCWs participated in the survey from 43 hospital wards. Among them, 567 (45.7%) had sustained at least one ABE with an estimated incidence of 0.33 percutaneous injuries (PCIs) and 0.04 mucocutaneous contacts (MCCs)/HCW/year in medical or intensive care personnel and 1.8 PCIs/HCW/year in surgeons. The ABE was a needlestick in 454 (80.1%) of 567 cases, a cut in 19 cases (3.4%), a splash or contact with non-intact skin in 87 cases (15.3%), and was undocumented in seven cases (1.2%). The source patient's human immunodeficiency virus (HIV) serostatus was positive in 74 cases (13.1%), negative in 65 cases (11.5%), and unknown in 416 cases (73.4%). The ABE was not notified in the ward in 392 cases (69.1%). Healthcare structures can improve HCWs' safety and reduce the stigma against HIV-infected patients by improving access to training, information, primary prevention (ABE prevention equipment) and secondary prevention (postexposure prophylaxis) of occupational infection risks.

Nosocomial infections and hospital mortality: a multicentre epidemiology study.

The aim of this study was to evaluate the number of deaths associated with nosocomial infections (NI) and the contribution of these NI to death. A multicentre descriptive study was conducted in 16 tertiary-care hospitals (14 222 beds) in Northern France. Medical records of consecutive patients who died at least 48 h after admission were reviewed for cause of death, NI and disease severity, before admission and before NI onset. The contribution of NI to death was assessed by agreement between two physicians according to a three-category scale of probability. Among the 1945 patients who died during the study, 26.6% had an NI. According to the agreed diagnosis, NI contributed to the deaths of 284 (14.6%) patients(certainly for 6.6% and possibly for 8%), thereby ranking NI as the fourth most frequent cause of death. Considering the deaths that had not been anticipated independently of NI two weeks before they occurred, NI definitely contributed to 2.8% of them. Lower respiratory tract, bloodstream and surgical wound infections were responsible for 39, 20 and 14%, respectively,of all NI in these patients. The impact of NI on in-hospital mortality seems to be lower than had previously been estimated in France based on US data from the 1970s and 1980s. To improve healthcare quality, further studies are needed to elucidate the processes that may contribute to fatal severe NI.

Positive and negative tropic curvature induced by microbeam irradiation of protonemal tip cells of the moss Ceratodon purpureus.

The photoreceptor phytochrome mediates tropic responses in protonemata of the moss Ceratodon purpureus. Under standard conditions the tip cells grow towards unilateral red light, or perpendicular to the electrical vector of polarized light. In this study the response of tip cells to partial irradiation of the apical region was analysed using a microbeam apparatus. The fluence response curve gave an unexpected pattern: whereas a 15-min microbeam with light intensities around 3 micro mol m (-2) s (-1) induced a growth curvature towards the irradiated side, higher light intensities around 100 micro mol m (-2) s (-1) caused a negative response, the cells grew away from the irradiated side. This avoidance response is explained by two effects: the light intensity is high enough to induce photoconversion into the active Pfr form of phytochrome, not only on the irradiated but also on the non-irradiated side by stray light. At the same time, the strong light on the irradiated side acts antagonistically to Pfr. As a result of this inhibition, the growth direction is moved to the light-avoiding side. Such a Pfr-independent mechanism might be important for the phototropic response to distinguish between the light-directed and light-avoiding side under unilateral light.

[Nosocomial risk factors of hepatitis C infection. A multicenter study in a hospital-based population]. / Facteurs de risque nosocomiaux de l'infection par le virus de l'hépatite C. Une étude multicentrique en population hospitalière.

PURPOSE: Drug abuse and blood transfusion are well known risk factors for hepatitis C virus (HCV) infection. However, the route of transmission remains undetermined for 30% of HCV infections. The potential for nosocomial transmission of HCV in health care settings has been suggested but remains poorly estimated. The aim of the study was to assess the prevalence and to identify risk factors for hepatitis C virus (HCV) infection in hospitalized patients frequently exposed to invasive procedures. METHOD: A multi-center sero-prevalence study was conducted in hospitalized patients who underwent invasive procedures in interventional radiology wards in 6 University hospitals in Paris between 1998 and 1999. Each patient presenting in the ward was consecutively interviewed by a medical investigator. Data were collected on a standardized questionnaire including items on socio-demographic characteristics, past exposure to intravenous drug use, blood transfusions, underlying diseases and type and number of previous invasive procedures. Before procedure, HCV antibody testing (ELISA) was performed in all patients after informed consent. In all HCV-positive patients, HCV viremia was detected using polymerase chain reaction. RESULTS: Overall, 91 of 944 (9.7%) patients were HCV-positive, of whom 90% had positive viremia and 10 were identified HCV positive by the screening. HCV prevalence decreased with age and ranged from 4.5% to 22% according to center. Logistic regression analysis showed that intravenous drug use, history of blood transfusions and endoscopy were found as independent risk factors for HCV infection (odds ratio [CI95%]: 77.3 [23.3-256.3], 4.7 [2.7-8.2] et 1.20 [1.01-1.44]). No other risk factor for nosocomial or iatrogenic transmission was identified. CONCLUSION: The results suggest that, except for blood transfusions, other healthcare-related procedures may partly explain HCV transmission. This emphasizes the need to reinforce compliance with standard precautions of hygiene.

Medication misuse in hospitalized patients with renal impairment.

OBJECTIVES: The potential consequences of medication misuse in renal impairment have not been assessed in a population of in-patients. The purpose of this study was to determine the frequency and potential consequences of a lack of dosage adjustment in hospitalized patients with renal impairment. DESIGN: Order sheets for in-patients having a creatinine above 0.7 mg/dl were analysed. We considered the appropriateness of prescriptions for medications having potential nephrotoxicity and/or eliminated through renal excretion or metabolism (TEM medications) and having manufacturer's guidelines for dosage adjustment in renal impairment. MAIN MEASURES: On the basis of these guidelines, each line of prescription was rated as 'appropriate order', 'inappropriate dosage', or 'contra-indicated order'. Experts also rated prescriptions as potentially fatal or severe, serious, significant, or without potential for increased adverse effects. RESULTS: Two hundred and two order sheets were completed for 164 patients. They totalled 1469 lines of prescription, 85% of which were TEM medications, with guidelines for dosage adjustment for 71% of them (n = 886). Of these 886 prescriptions, 34% were inappropriate, 14% being contra-indicated and 20% with inappropriate dosage given the patient's renal function. Among the 202 order sheets, 75% included at least one inappropriate prescription. Sixty-three per cent included at least one prescription with potentially adverse consequences, 3% of these having potentially fatal or severe consequences. CONCLUSION: This study confirms that physicians do not take into account sufficiently patient renal function when prescribing. In light of these results, improving the quality of drug prescription in patients with renal impairment could be of importance for improving the quality of care.

[Cataract surgery in Togo]. / La chirurgie de la cataracte au Togo.

Cataract remains a major cause of blindness in sub-Sahara and a major public health problem. Blindness prevalence in Togo is equal to 1%, more than half of it is due to cataract, while the number of cataract surgeries is low because of the lack of resources. We assessed the eye healthcare in Togo by cataract surgery. The aim was to estimate the number of cataract surgeries and the Cataract Surgery Rate (CSR) in the administrative regions. The demographic data (denominator) was collected from the Demography and Health Survey (1998) while the number of cataract surgeries (numerator) was obtained from medical registers. The Cataract Surgery Rate (CSR, operated cataracts per million) was assessed from 1995 to 2001. From 1995 to 2001, 3,885 cataract surgeries were performed. Public services predominated with 53.03% (n=2061) of the cataracts operated followed by confessional hospitals with 37.1% (n=1443) and private clinics 3.4% (n=143). Decentralised eye healthcares provided 241 cataract extractions. The University hospital centre of Lome Tokoin was the leader, with 32.5% (n=1,262) of operated cataracts followed by the confessional hospital of Glei, 27.2% (n=1,058). The average per centre per year was 43 cataract surgeries. The mean CSR was 126 and varied from 52 to 163 cataract surgeries per million people per year. There was an important concentration of cataract services in Lome where 41% (n=1,586) of cataracts were operated and the CSR was 334. The unequal distribution of cataract services (41% in Lome) leaves many regions without any resources. Since 1999, the CSR increased by 37% in 2000 and 14% in 2001. The Togolese eye healthcare system is poor and substantial further efforts are necessary to make it accessible and affordable to all those in need. This may be the way to reduce cataract surgery barriers and the unacceptable high prevalence of operable cataract blindness.

Assessing residents' prescribing behavior in renal impairment.

OBJECTIVE: Although fitting orders to renal function avoids overdosage and therefore iatrogenic risk, dosage adjustment is rarely made. The objective of this study was to assess residents' prescribing behavior in renal impairment, through a standardized simulated clinical setting. METHOD: This criterion-referenced study was carried out in a French teaching hospital. The hospital had 118 residents; 71 of them were asked to complete a questionnaire including four vignettes, simulating drug prescription in four 'patients' with various degrees of renal impairment (16 orders). The patients had an order of gentamicin sulfate, diclofenac sodium, and amlodipine bensylate. For each drug, the resident could maintain the order, discontinue the order, or change the dosage. A fourth drug, enalapril maleate, was to be started, with three possible dosages and the possibility of not prescribing it. The reference chosen for assessment was the Vidal dictionary, which corresponds to the Physician's Desk Reference and is the French reference for prescription. RESULTS: All the residents approached for the survey accepted the offer to complete the questionnaire. Among the 16 simulated orders, the median number of appropriate orders per resident was nine. Considering the renal function of their patients, 62% of residents wrote an inappropriate order for gentamicin, 42% wrote an inappropriate order for didofenac, and 52% wrote an inappropriate order for enalapril. Although no adjustment to renal function was required, 28% of the residents decreased the dosage of amlodipine and ordered an underdose. CONCLUSION: Considering the iatrogenic risk related to the lack of dosage adjustment, attention should be drawn to increasing residents' awareness of dosage adjustment in renal impairment and to providing them with better information on patients' renal function.

[Knowledge, opinions and tobacco consumption in a French faculty of medicine]. / Connaissances, opinions et consommation de tabac au sein d'une faculté de médecine française.

OBJECTIVE: Tobacco consumption among French physicians is regularly followed-up and well-known; however, there is little information concerning the smoking habits of medical students even though they are the physicians of the future. How do they behave? Do they smoke? More or less than the other populations of the same age? METHOD: All the students of a Parisian medical school were surveyed with a self-questionnaire completed and collected just before the exams at the end of the year. The questionnaire incorporated both past and present smoking habits and also the students' knowledge and opinions on tobacco consumption. RESULTS: A total of 681 students replied. More than one-third were smokers (34.6%) among which 21.0% smoked every day and 13.6% smoked occasionally. Gender had no influence on prevalence rate and both men and women smoked a comparable number of cigarettes per day (males 12.0 cig/day, females 10.4 cig/day). Eleven percent were former smokers and 68.4% would like to quit. Nearly 100% believed that cigarette smoke can bother others and 75% felt they were exemplary figures for others on the subject of tobacco use. Finally, two-thirds of the students smoked light cigarettes. CONCLUSION: The smoking habits of medical students are similar to those of the general population of the same age. It is necessary to develop specific prevention programs for medical students because they will play an important public health role in the future in reducing the prevalence of tobacco consumption in France.

Epidemiology of invasive aspergillosis in France: a six-year multicentric survey in the Greater Paris area.

Invasive aspergillosis is the most prevalent mould infection. An epidemiological surveillance network was set up in 18 teaching hospitals in Paris and the Greater Paris area. Prospective surveillance was conducted between 1994 and 1999. Between 1994 and 1997 cases were categorized as proven or probable aspergillosis and then the European Organization for Research and Treatment of Cancer/Mycoses Study Group criteria were used. The authors analysed 621 cases (115 proven, 506 probable). No seasonal variation was found. Haematological disorders (73%) including stem-cell transplantation (36%), solid-organ transplantations (10%) and AIDS (9%) were the main underlying conditions. The crude mortality was 63%. Incidence of IA was 8% (CI(95): 6.5-9.5) in acute myelocytic leukaemia and 6.3% (CI(95): 4.3-8.3) in acute lymphocytic leukaemia. Incidence was 12.8% (CI(95): 10.8-14.8) following allogeneic stem-cell transplantation and 1.1% (CI(95): 0.7-1.5) following autologous stem-cell transplantation. In solid-organ recipients incidence ranged from 11% following heart-lung transplantation and small bowel to 0.4% following kidney transplantation. Incidence in HIV infected patients ranged from 0.02 to 0.13% per annum. This large series confirmed that patients with haematologic disorders and transplantations are the most at risk for IA.

Mycobacterium xenopi spinal infections after discovertebral surgery: investigation and screening of a large outbreak.

BACKGROUND: Mycobacterium xenopi spinal infections were diagnosed in 1993 in patients who had undergone surgical microdiscectomy for disc hernia, by nucleotomy or microsurgery, in a private hospital. Contaminated tap water, used for rinsing surgical devices after disinfection, was identified as the source of the outbreak. Several cases were recorded in the 4 years after implementation of effective control measures because of the long time between discectomy and case detection. The national health authorities decided to launch a retrospective investigation in patients who were exposed to M xenopi contamination in that hospital. METHODS: Mailing and media campaigns were undertaken concurrently to trace exposed patients for spinal infections. Patients were screened by magnetic resonance imaging (MRI), and the scans were reviewed by a radiologist who was unaware of the diagnosis. Suspected cases had discovertebral biopsy for histopathological and bacteriological examination. FINDINGS: Of 3244 exposed patients, 2971 (92%) were informed about the risk of infection and 2454 (76%) had MRI. Overall, 58 cases of M xenopi spinal infection were identified (overall cumulative frequency 1.8%), including 26 by the campaign (mean delay in detection 5.2 years, SD 2.4, range 1-10 years). Multivariate analysis showed that the risk of M xenopi spinal infection was related to nucleotomy and high number of patients per operating session. INTERPRETATION: Failures in hygiene practices could result in an uncontrolled outbreak of nosocomial infection. Patients who have been exposed to an iatrogenic infectious hazard should be screened promptly and receive effective information.

Morbidity and mortality associated with surgical site infections: results from the 1997-1999 INCISO surveillance.

Since 1997, a surgical-site infections (SSI) surveillance network (INCISO) has been implemented in volunteer general surgical units in Northern France. For three months each year, all patients who undergo a surgical procedure are consecutively reviewed for their peri-operative condition and traced for outcome with a 30-day follow-up. Of the 38973 surgical patients included over a three-year period, 1344 (3.4%) developed SSI and 568 died (1.5%) including 78 with an SSI. Organ-space and deep incisional SSI were associated with a higher mortality and required re-operation more frequently than did superficial incisional SSI. SSI incidence and mortality varied according to the surgical procedure. SSI was a significant predictor of mortality, independently of NNIS risk index and other survival predictors. Thirty-eight percent of deaths in SSI patients were attributable to infection. Hence, the significant impact of SSI on mortality and morbidity in surgical patients is now an additional reason to reinforce compliance of surgical staff with preventive measures and hygiene practices.

Nosocomial infections in geriatric long-term-care and rehabilitation facilities: exploration in the development of a risk index for epidemiological surveillance.

OBJECTIVE: To compute a risk index for nosocomial infection (NI) surveillance in geriatric long-term-care facilities (LTCFs) and rehabilitation facilities. DESIGN: Analysis of data collected during the French national prevalence survey on NIs conducted in 1996. Risk indices were constructed based on the patient case-mix defined according to risk factors for NIs identified in the elderly. SETTING: 248 geriatric units in 77 hospitals located in northern France. PARTICIPANTS: All hospital inpatients on the day of the survey were included. RESULTS: Data from 11,254 patients were recorded. The overall rate of infected patients was 9.9%. Urinary tract, respiratory tract, and skin were the most common infection sites in both rehabilitation facilities and LTCFs. Eleven risk indices, categorizing patients in 3 to 7 levels of increasing NI risk, ranging from 2.7% to 36.2%, were obtained. Indices offered risk adjustment according to NI rate stratification and clinical relevance of risk factors such as indwelling devices, open bedsores, swallowing disorders, sphincter incontinence, lack of mobility, immunodeficiency, or rehabilitation activity. CONCLUSION: The optimal index should be tailored to the strategy selected for NI surveillance in geriatric facilities in view of available financial and human resources.

Microinjection of heme oxygenase genes rescues phytochrome-chromophore-deficient mutants of the moss Ceratodon purpureus.

In protonemal tip cells of the moss Ceratodon purpureus (Hedw.) Brid., phototropism and chlorophyll accumulation are regulated by the photoreceptor phytochrome. The mutant ptr116 lacks both responses as a result of a defect in the biosynthesis of phytochromobilin, the chromophore of phytochrome, at the point of biliverdin formation. The rescue of the phototropic response and of chlorophyll synthesis were tested by injecting different substances into tip cells of ptr116. Microinjection was first optimised with the use of fluorescent dyes and an expression plasmid containing a green fluorescent protein (GFP) gene. Injected phycocyanobilin, which substitutes for phytochromobilin, rescued both the phototropic response and light-induced chlorophyll accumulation in ptr116. The same results were obtained when expression plasmids with heme oxygenase genes of rat (HO-1) and Arabidopsis thaliana (L.) Heynh. (HY1) were injected. Heme oxygenase catalyses the conversion of heme into biliverdin. Whereas HY1 has a plastid target sequence and is presumably transferred to plastids, HO-1 is proposed to be cytosolic. The data show that ptr116 lacks heme oxygenase enzyme activity and indicate that heme oxygenases of various origin are active in Ceratodon bilin synthesis. In addition, it can be inferred from the data that the intracellular localisation of the expressed heme oxygenase is not important since the plastid enzyme can be replaced by a cytosolic one.