Prevalence and Risk Factors of Sleep Disturbance in a Large HIV-Infected Adult Population.

This cross-sectional study evaluates the prevalence and factors associated with sleep disturbances in French adult HIV-infected outpatients. Patients fullfilled a self-administered questionnaire on their health behavior, sleep attitudes (Pittsburgh sleep quality index, PSQI), quality of life and depression; 1354 patients were enrolled. Median sleeping time was 7 h. Poor sleep quality was observed in 47 % of the patients, and moderate to serious depressive symptoms in 19.7 %. Factors significantly associated with sleep disturbances were depression, male gender, active employment, living single, tobacco-smoking, duration of HIV infection, nevirapine or efavirenz-including regimen. Prevalence of poor sleepers is high in this HIV adult outpatient population. Associated factors seem poorly specific to HIV infection and more related to social and psychological status. Taking care of these disturbances may prove to be an effective health management strategy.

HIV-infected patients aged above 75years.

BACKGROUND: Little data is available on HIV-infected patients aged over 75years. METHODS: A descriptive study of HIV-infected patients aged over 75years was conducted in six hospitals of the Pays de la Loire region, France. Socio-demographic, immuno-virological, and therapeutic characteristics were collected via an electronic medical record software (Nadis®). To assess frailty, a simplified geriatric assessment was conducted during an HIV routine visit. RESULTS: Among the 3965 patients followed in the six centers, 65 (1.6%) were aged over 75years. From January to May 2016, 51 patients were included in the study: median age 78.7years, male patients 74.5%, homosexual transmission 41.2%, living at home 98% and single in 54.5% of cases, median duration of HIV infection 18.8years, median CD4 nadir 181 cells/mm3; CDC stage C 36.4%. All patients were on antiretroviral therapy and 98% of them had an HIV RNA<50c/mL; 82% of patients had at least one comorbidity and 58% at least two comorbidities. Eleven of 51 patients (21.6%) were diagnosed as at risk of frailty and 2/51 (3.9%) were considered frail. Cognitive disorders were diagnosed in 60.8%, depression in 35.3%, malnutrition in 25.5%, and vitamin D deficiency in 45.9%. CONCLUSIONS: HIV-infected patients aged above 75years are well-managed, but the prevalence of geriatric comorbidities is high.

Clinical qualitative evaluation of the diagnosis of acute otitis media in general practice.

OBJECTIVES: Assess the quality of the diagnosis of acute otitis media (AOM) given by general practitioners (GPs) on a daily basis and compare it with the diagnosis of ear, nose and throat specialist (ENTS) which is considered as the gold standard. METHODOLOGY: Every GP had to include six children aged 1-4 years for whom he suspected or diagnosed that they were suffering from AOM. Parents had to accept to see the ENTS participating in the survey within 48 h. RESULTS: Twenty-four GPs took part in the survey and included at least one child, which amounts to a final 57% acceptability rate. Two hundred and eight eardrums were included in the survey. 21.9% of assumptions or diagnosis's of AOM (30/137) were declared null by the ENTS. GPs diagnose AOM without any doubt only in 54% of all cases. The diagnosis and the assumption of AOM were respectively confirmed in 83.8% of all cases and 71.4% by the ENTS. The combination of redness and bulge, and isolated redness accounted for respectively 44.3% and 26.2% of the main otoscopical factors reminiscent of the AOM according to GPs. In the case of redness and bulge, the diagnosis was confirmed in 83% of all cases by the ENTS as opposed to 75% regarding the isolated redness. An AOM was suspected in 57.1% of the eardrums barely or not visible or without any sign of infection and not confirmed in 25% of all cases. CONCLUSION: The global over diagnosis is 21.9% and 25% when the otoscopy is hindered by the presence of cerumen or when the eardrums are only inflammatory. Even though the over diagnosis is inferior to the one mentioned in published writings, post-graduate teaching on the various cerumen removal techniques and the use of pneumatic otoscopy could contribute to improving the quality of diagnosing AOM.

[Reliability of the diagnosis of acute otitis media by general practitioners]. / Evaluation de la pertinence du diagnostic d'otite moyenne aiguë porté par le médecin généraliste.

OBJECTIVES: To assess reliability of the diagnosis of Acute Otitis Media (AOM) given by General Practitioners (GPs) compared with the diagnosis of Otorhinolaryngologists (ORLs) considered as the reference diagnosis. METHODOLOGY: Every GP had to include 6 children aged 1 to 4 years for whom he suspected or diagnosed AOM. Parents had to accept to consult the ORL participating in the survey within 48 h. RESULTS: 24 GPs took part in the survey and included at least 1 child, which amounts to a final 57% acceptability rate. Two hundred and eight eardrums were included in the survey. 21.9% of assumptions or diagnosis of AOM (30/137) were declared null by the ORL. GPs diagnose AOM with certainty only in 54% of all cases. The diagnosis and the assumption of AOM were respectively confirmed in 83.8% of all cases and 71.4% by the ORL. The combination of redness and bulge and isolated redness accounted for respectively 44.3% and 26.2% of the main otoscopical factors reminiscent of the AOM according to GPs. In the case of redness plus bulge, the diagnosis was confirmed in 83% of all cases by the ORL as opposed to 75% regarding the isolated redness. AOM was suspected in 57.1% of the eardrums little or not visible with no sign of infection and was not confirmed in 25% of all cases. CONCLUSION: The global overdiagnosis was 21.9% and 25% when the otoscopy is hindered by the presence of cerumen or when the eardrums show inflammation alone. Even though the overdiagnosis was lower than the reported one in literature, post-graduate teaching on the various cerumen removal techniques and the use of pneumatic otoscopy should contribute to improve the quality of diagnosing AOM.

[Postpartum contraception: medical guidelines, women's point of view]. / La contraception du post-partum: les recommandations médicales, le point de vue des femmes.

PURPOSE: Postpartum contraception is subjected to specific medical guidelines related to the suckling mode. The practitioner must conciliate prescription rules with women's expectations. The purpose of this work was to estimate the medical practice in the maternity centre at a local hospital and the actual practice of women at home, in immediate postpartum and during the year that followed the childbirth. METHOD: One hundred and four new mothers from the maternity centre, in September 2004, took the survey. During their stay after birth, they filled a questionnaire on contraception. Various data have been collected from their obstetrical file. The analysis allowed the synthesis of medical guidelines on postpartum contraception. One year later, patients answered a telephone survey about their contraceptive practice. RESULTS: In our survey, two-third of the new mothers (61.5%) chose breast-feeding. Seventy percent of them received progestins as contraceptives. Three out of four women (78%) followed this prescription after they left the hospital. Two-third (62.5%) of the women who had chosen artificial suckling received a prescription of estroprogestin. The majority of them (96%) used it after their return home. A high number of women (87.5%) estimated that these contraceptions were efficient, but more than a third of them thought they were uneasy to use (38.9%). Half of the women (52.8%) forgot their contraception during postpartum and the majority of them (86%) changed it within a year. A quarter (23.1%) of the contraception follow-up during this time was made by a general practitioner. CONCLUSION: The practice in the maternity centre generally follows medical guidelines. However, it seems important to adapt postpartum contraception to the real practice of women. The general practitioner plays a major role in this management, especially during well-baby visits.

[Assessing the usefulness of a permanently opened clinical microbiology laboratory]. / Evaluation des services rendus par le système de fonctionnement en continu d'un laboratoire de bactériologie.

UNLABELLED: Since 2005, the clinical microbiology laboratory of the Angers teaching hospital has implemented after hours service requiring the overnight presence of a technician specialized in bacteriology. During that time, bacterial identifications and antibiotic susceptibility testing to antimicrobial agents can be performed for critical samples. OBJECTIVES: The authors wanted to evaluate the impact of the after-hours service on the decrease of delay from sampling to results, and from sampling to the implementation of an appropriate antimicrobial therapy. A therapy could be initiated, changed for more efficient agents, or changed to narrower-spectrum agents (major benefits). METHODS: A 4-month prospective study was made. All samples for which identification and/or susceptibility testing were performed during after-hours service (continued analyses) were included in the study. Delays observed were compared with theoretical delays estimated in the absence of the after-hours service. RESULTS: A minimum 24 hour-decrease of the delay for results was observed for 97 % of the 430 samples included. Overall, a major benefit was obtained for more than 25 % of the analyses, representing a cumulated 111-day benefit in days of efficient treatments and a cumulated 27-day benefit in days of prescription of narrower-spectrum agents. DISCUSSION: This organization, unique in French hospitals, is directly related to the improvement of antimicrobial treatments, like antibiotic practice guidelines or infection disease specialists. It was evaluated as a relevant strategy, potentially cost saving, with a significant impact on both the efficiency of treatments and microbial ecology.

Assessment of the usefulness of performing bacterial identification and antimicrobial susceptibility testing 24 h a day in a clinical microbiology laboratory.

The impact of inoculating agar media with positive blood cultures and of performing bacterial identification and antimicrobial susceptibility testing (AST) for positive urine cultures, blood cultures and certain fluid cultures after day hours (night service (NS)) was evaluated in a clinical microbiology laboratory. The impact of the NS was assessed in terms of decreases in the delays from the time of sampling to the time at which results became available and of the consequences for patient management and antimicrobial treatment. Two major benefits were obtained: initiation of earlier appropriate treatment, and change to a reduced-spectrum but still efficient regimen. The hours of laboratory testing and the availability and transmission of results to the clinical staff were recorded. Concurrently, these hours were estimated as though laboratory tests had been performed in the absence of NS. Reductions in delay were defined as the differences between the hours actually spent and the estimated hours. Economic concerns were also considered. Overall, 430 samples for which an identification and/or AST were performed during the NS were included in the study. The NS led to the implementation of earlier appropriate therapy in 97 cases (22.6%), and to the change to reduced-spectrum but still efficient regimens in 23 additional cases (5.3%). In conclusion, there appeared to be benefits from a system providing bacterial identification and AST overnight, but a study of the cost-effectiveness of the NS would be useful to back up this observation.

Measurement and interpretation of hand hygiene compliance rates: importance of monitoring entire care episodes.

Our objective was to assess the importance of monitoring hand hygiene compliance (HHC) during series of successive contacts with patients or surroundings for measurement and interpretation of the compliance rates. A direct observational study of HHC was performed in four intensive care units (ICUs) and four healthcare settings with non-intensive care wards (NICWs). Hand hygiene (HH) opportunities were differentiated into two categories: extra-series opportunities (ESOs) (before or after a single contact, and before the first contact or after the last contact of a series of successive contacts) or as intra-series opportunities (ISOs) (from the opportunity following the first contact to the opportunity preceding the last in the same series). In all, 903 opportunities of HH were performed in ICUs and 760 in NICWs. The proportion of ISOs was 46.0% in ICUs and 22.9% in NICWs. The overall HHC was significantly higher in NICWs than in ICUs (61.2% vs 47.5%, P<0.00001). The HHC was significantly higher for ESOs than for ISOs (67.7% vs 28.5%, P<0.00001). The HHC for ISOs was significantly higher in ICUs (32.2% vs 19.0%, P<0.005). If the distribution of categories of HH opportunities observed in NICWs had been the same as in ICUs, the overall HHC would have been similar in NICWs (46.4%) and in ICUs (47.5%). Monitoring HHC during entire care episodes in series of successive contacts is necessary to avoid a strong overestimation of the overall compliance rates. Concurrently, comparison of compliance data should take into account the proportion of ISOs included in the evaluation study.