[Results of a survey system for neurosurgical site infections, October 1998-January 2003]. / Résultats d'une surveillance des infections du site opératoire en neurochirurgie, octobre 1998-janvier 2003.

BACKGROUND AND PURPOSE: In the neurosurgery setting, incidence of surgical site infections (SSI) are considered as low to moderately low (1 to 10%). These infections are nevertheless a major problem because of the associated morbidity and mortality. A SSI survey system has been initiated in our neurosurgical unit. We report the incidence of SSI and identified SSI risk factors. METHODS: Data collected included demographic and medical information recorded with the operating room computer system. Any SSI occurring during the patient's postsurgical hospital stay or observed at postoperative visits was notified using a standardized questionnaire. SSIs were registered using Centers for Disease Control criteria. A multiple logistic regression model was used to determine SSI incidence and evaluate risk factors for SSI. Results were reported to the neurosurgical team every three months. RESULTS: From October 1998 to January 2003, 7399 operative procedures were collected. One hundred and twenty-two SSIs were notified with a mean incidence per patient of 1.65% (95% CI [1.37-1.95]). Among the SSIs 42% were superficial, 58% were deep or organ-space. Risk factors significantly associated with SSI were operation site (higher risk with CSF shunt), operation modality (higher risk with postponed operation) and operation duration greater than 75th percentile. CONCLUSION: SSI are an important problem in neurosurgery. This SSI survey gave us fundamental information about SSI and risk factors. Complementary studies are now necessary about postponed operative procedures. Propositions are made to improve the system.

Atrazine in municipal drinking water and risk of low birth weight, preterm delivery, and small-for-gestational-age status.

BACKGROUND: Atrazine is a herbicide used extensively worldwide. Bioassays have shown that it is embryotoxic and embryolethal. Evidence of adverse reproductive outcomes from exposure in the general population is sparse. AIMS: To evaluate the association between atrazine levels in municipal drinking water and the following adverse reproductive outcomes: increased risk of preterm delivery, low birth weight (LBW), and small-for-gestational-age (SGA) status. METHODS: A total of 3510 births that took place from 1 October 1997, to 30 September 1998 were analysed. Atrazine measurements were available for 2661 samples from water treatment plants over the past decade. A seasonal pattern was identified, with atrazine peaking from May to September. The geometric mean of the atrazine level for this period was calculated for each water distribution unit and merged with the individual data by municipality of residence. RESULTS: Atrazine levels in water were not associated with an increased risk of LBW or SGA status and were slightly associated with prematurity. There was an increased risk of SGA status in cases in which the third trimester overlapped in whole or in part with the May-September period, compared with those in which the third trimester occurred totally from October to April (OR = 1.37, 95% CI 1.04 to 1.81). If the entire third trimester took place from May to September, the OR was 1.54 (95% CI 1.11 to 2.13). CONCLUSIONS: Low levels of atrazine, a narrow exposure range, and limitations in the exposure assessment partly explain the lack of associations with atrazine. Findings point to the third trimester of pregnancy as the potential vulnerable period for an increased risk of SGA birth. Exposures other than atrazine and also seasonal factors may explain the increased risk.

[Clinical guidelines: what are the viewpoints of physicians and housestaff working in hospital medical departments?]. / Recommandations de pratique clinique: le point de vue des médecins et des internes des services hospitaliers de médecine adulte.

BACKGROUND: Factors facilitating use of clinical guidelines by physicians working in French public hospitals are unknown. We wanted to ascertain the desires of physicians and housestaff working in medical departments. METHODS: A cross-sectional survey using a self-administered questionnaire with closed-ended questions and free comment was conducted in the two academic regional hospitals and the 20 district hospitals of Brittany. The following items were noted: individual and professional characteristics, use of and opinion about clinical guidelines, perceived usefulness of specific attributes of guidelines or implementation efforts. The results are shown separately for physicians and housestaff. The statistical significance of associations between physician characteristics and their opinions was tested by using the chi-square test. RESULTS: 390 out of 783 responded (50%). Nine housestaff and eight physicians out of ten responders found more positive than negative points to guidelines (decision making tool, standardization of practices, versus rigidity, lack of freedom in practice). One out of three reported using them regularly. Guidelines focusing on general medicine, covering both diagnosis and treatment, developed at the national level with local adaptation, synthetic and pocket-sized guide-book given directly to the housestaff by the department's physicians, were more likely to be used. One physician out of two would use more guidelines from specialty organizations, or would use them as a self-training tool in practices evaluation. CONCLUSION: Implementation of guidelines in hospital medical departments should take into account the housestaff demands as well as the need for the physicians' implication.

Aortic Carpentier-Edwards supraannular porcine bioprosthesis: a 12-year experience.

BACKGROUND: After 35 years of cardiac valve replacement, the ideal substitute remains to be found. Homografts are considered best but, due to their scarcity, cannot meet the need of valve replacement. Artificial valves (mechanical or biological) remain the most commonly used but controversy is still present as to the better choice. We tested the Carpentier-Edwards bioprosthesis for its efficacy in valve replacement operations. METHODS: From 1983 to 1995, 1,108 consecutive patients had an isolated aortic valve replacement with a porcine Carpentier-Edwards bioprosthesis, model 2650 supraannular valve. Mean age was 73.8+/-8.3 years. Aortic stenosis was the most common lesion (1,049 patients, 94.7%). The follow-up of 980 operative survivors was 96% complete and represented a total of 4,735 patient-years (maximum, 13.8 years; mean, 4 years and 10 months). RESULTS: Actuarial survival including operative mortality (128 patients, 11.6%) was 43.6%+/-2.3% at 10 years and 27.3%+/-3.3% at 12 years and, at that time, was not statistically different from those of the normal French population matched for age and sex. Structural deterioration of the valve was observed in 27 patients, an actuarial freedom of 94.2%+/-1.5% at 10 years and 83.8%+/-4.5% at 12 years. Hazard function revealed a stable and low risk of structural deterioration until 10 years and significantly increased risk after that. Young age was found to be an increasing risk factor of deterioration. Reoperation for valve-related complications was necessary in 30 patients, an actuarial freedom of 94.5%+/-1.4% at 10 years. CONCLUSIONS: The Carpentier-Edwards porcine supraannular valve affords a good durability up to 10 years, with a low rate of reoperation. The risk of structural deterioration decreases with older age. It is our valve of choice in elderly patients.

[Clinical practice guidelines, what do the internists think?]. / Recommandations de pratiques cliniques, qu'en pensent les internes?

OBJECTIVE: Study the opinion and expectations of the internists in the public hospitals in the Brittany area regarding Clinical Practice Guidelines (CPG). METHODS: Cross-sectional survey using an anonymous, self-administered questionnaire, with closed questions concerning age, gender and status (internist in general medicine (IGM) or internist specialization student [ISS]), years and context of practice, the personal opinion of the residents regarding the CPG, the nature of those that they apply, their opinion on the interest and foreseeable impact of efforts in improvements and elaboration and prompting to use the guidelines. Descriptive analysis and statistics (chi 2) were made of the associations between the replies concerning the CPG and the characteristics of the internists. RESULTS: Among the 106 questionnaires analysed (reply rate: 50%), 96 internists (90%) felt that the advantages of the CPG were greater than their inconveniences and 66 (62%) claimed they applied the CPG in routine practice. Eighty-five (80%) considered efforts to improve the elaboration of CPG were of interest and 97 (91%) replied likewise regarding their accompanied diffusion. Guidelines concerning both diagnosis and treatment of common diseases, developed on national level and adapted locally, presented in summarized pocket-sized form and transmitted directly by the physicians of the department would have the best chance of being used. CONCLUSION: Any program aimed at developing the use of CPG in hospital departments should take into account the enthusiasm of the internists, but also the implication of senior physicians required in their specific accompanied diffusion.