Effectiveness of a 'do not interrupt' vest intervention to reduce medication errors during medication administration: a multicenter cluster randomized controlled trial.

BACKGROUND: The use of a 'do not interrupt' vest during medication administration rounds is recommended but there have been no controlled randomized studies to evaluate its impact on reducing administration errors. We aimed to evaluate the impact of wearing such a vest on reducing such errors. The secondary objectives were to evaluate the types and potential clinical impact of errors, the association between errors and several risk factors (such as interruptions), and nurses' experiences. METHODS: This was a multicenter, cluster, controlled, randomized study (March-July 2017) in 29 adult units (4 hospitals). Data were collected by direct observation by trained observers. All nurses from selected units were informed. A 'Do not interrupt' vest was implemented in all units of the experimental group. A poster was placed at the entrance of these units to inform patients and relatives. The main outcome was the administration error rate (number of Opportunities for Error (OE), calculated as one or more errors divided by the Total Opportunities for Error (TOE) and multiplied by 100). RESULTS: We enrolled 178 nurses and 1346 patients during 383 medication rounds in 14 units in the experimental group and 15 units in the control group. During the intervention period, the administration error rates were 7.09% (188 OE with at least one error/2653 TOE) for the experimental group and 6.23% (210 OE with at least one error/3373 TOE) for the control group (p = 0.192). Identified risk factors (patient age, nurses' experience, nurses' workload, unit exposition, and interruption) were not associated with the error rate. The main error type observed for both groups was wrong dosage-form. Most errors had no clinical impact for the patient and the interruption rates were 15.04% for the experimental group and 20.75% for the control group. CONCLUSIONS: The intervention vest had no impact on medication administration error or interruption rates. Further studies need to be performed taking into consideration the limitations of our study and other risk factors associated with other interventions, such as nurse's training and/or a barcode system. TRIAL REGISTRATION: The PERMIS study protocol (V2-1, 11/04/2017) was approved by institutional review boards and ethics committees (CPP Ile de France number 2016-A00211-50, CNIL 21/03/2017, CCTIRS 11/04/2016). It is registered at ClinicalTrials.gov (registration number: NCT03062852 , date of first registration: 23/02/2017).

Individual decontamination measures reduce by two the incidence of surgical site infections in spinal surgery.

BACKGROUND: In spinal surgery, incidence of surgical site infections (SSI) is estimated between 1 and 10%. It results in increased morbidity, mortality and cost of management. Individual Staphylococcus aureus (SA) decolonization has already proved efficiency to prevent those events in various surgical domains. The aim of this study was to evaluate a strategy of prevention of SSI and in particular the decolonization of the nasal carriage of SA by a protocol with Mupirocin application. METHODS: We conducted a bicentric observational study on 5314 spinal surgery patients over a seven-year period. In both center, we compared periods before and after implementation of two measures: modification of antibioprophylaxis and staphylococcus decolonization. Homogeneity of the different samples of patients was assessed through measure of individual and surgical variables. We measured monthly incidence of SSI and evaluated its evolution in order to assess efficiency of these interventions. RESULTS: The incidence of SSI decreased by half, from 7.3% to 3% at the Beaujon Hospital and from 8.3% to 3.9% at the Georges-Pompidou European Hospital (GPEH). We do not observe any significant decrease of SA rate in these SSI. CONCLUSION: We believe that Staphylococcus aureus decolonization should be recommended in spinal surgery, and should be combined with an overall improvement of the quality of care.

Integration of a Commercial Barcode-Assisted Medication Dispensing System in a Teaching Hospital.

OBJECTIVES: A commercial barcode-assisted medication administration (BCMA) system was integrated to secure the medication process and particularly the dispensing stage by technicians and the administration stage with nurses. We aimed to assess the impact of this system on medication dispensing errors and barriers encountered during integration process. METHODS: We conducted a controlled randomized study in a teaching hospital, during dispensing process at the pharmacy department. Four wards were randomized in the experimental group and control group, with two wards using the system during 3 days with dedicated pharmacy technicians. The system was a closed loop system without information return to the computerized physician order entry system. The two dedicated technicians had a 1-week training session. Observations were performed by one observer among the four potential observers previously trained. The main outcomes assessed were dispensing error rates and the identification of barriers encountered to expose lessons learned from this study. RESULTS: There was no difference between the dispensing error rate of the control and experimental groups (7.9% for both, p = 0.927). We identified 10 barriers to pharmacy barcode-assisted system technology deployment. They concerned technical (problems with semantic interoperability interfaces, bad user interface, false errors generated, lack of barcodes), structural (poor integration with local information technology), work force (short staff training period, insufficient workforce), and strategic issues (system performance problems, insufficient budget). CONCLUSION: This study highlights the difficulties encountered in integrating a commercial system in current hospital information systems. Several issues need to be taken into consideration before the integration of a commercial barcode-assisted system in a teaching hospital. In our experience, interoperability of this system with the electronic health record is the key for the success of this process with an entire closed loop system from prescription to administration. BCMA system at the dispensing process remains essential to purchase securing medication administration process.

The impact of interventions by pharmacists collected in a computerised physician order entry context: a prospective observational study with a 10-year reassessment.

AIMS OF THE STUDY: This study assesses clinical interventions by pharmacists prospectively collected from medical and surgical wards, notably the acceptance of interventions, computerised physician order entry (CPOE)related problems, the potential impact of interventions on patient safety evaluated by a multidisciplinary committee, and their evolution over the 10 years since a first assessment. METHODS: A prospective observational study covering 13 months was conducted in a French teaching hospital with a patient information system that integrates an electronic health record (EHR) with a CPOE. Interventions by pharmacists were prospectively recorded using CPOE. All interventions were reviewed by two pharmacists. We assessed the interventions, the possible implications of the CPOE in prescribing errors, and the acceptance of interventions by physicians. A committee reviewed the potential clinical impact for patients. The results were compared with the same outcomes collected 10 years ago in the same hospital. RESULTS: A total of 2141 interventions by pharmacists were reviewed. Among them, 1589 (74.1%) were accepted by physicians. Regarding the potential clinical impact, a total of 1136 (53%) interventions concerned prescriptions that were potentially significant or serious for patients and 42 (2%) of them were potentially life-threatening. Ten years earlier, the acceptance rate was 23%. Moreover, 14.7% of errors were attributed to the use of the software, whereas 10 years earlier the rate of errors was 49%. CONCLUSIONS: The acceptance rate and frequency of CPOE-related errors were better than 10 years before, which is encouraging and shows the importance of regular training and collaboration with healthcare givers to reduce errors. The routine analysis of interventions by pharmacists with medical staff feedback should continue to improve their relevance and effectiveness.

Evaluation of exposure to effervescent drugs in a large health check-up population in France: a cross-sectional study.

OBJECTIVES: The relationship between high dietary sodium intake and hypertension is well established. Some drugs are associated with high-sodium content, particularly effervescent tablets (ETs). Despite a possible cardiovascular risk associated with the use of such drugs, observational data describing exposure to ETs in ambulatory subjects are lacking.This study aims to estimate the prevalence of exposure to ETs and to highlight factors associated with this exposure in a large French health check-up population. DESIGN: This was a cross-sectional study. SETTING AND PARTICIPANTS: Participants were French individuals who underwent medical check-ups at the Investigations Préventives et Cliniques centre between April and June 2017. RESULTS: In total, 1043 subjects were included in the study. The prevalence of exposure to ETs in the last 30 days was 26.9% (95% CI 24.2% to 29.6%). Exposure was frequent (ie, two ETs per week or more in the last 30 days) for 7.3% of subjects. Self-medication was the major source of exposure (93.8%). Paracetamol, aspirin, vitamins and betaine accounted for 95.3% of the ETs used. The factors associated with this exposure by multivariate analysis were: male gender, Overseas French origin, depression and body mass index ≥25 kg/m2. A diagnosis of hypertension or treatment with diuretics were not protective factors against exposure to ETs. CONCLUSION: Exposure to ETs is frequent in the general population, particularly through self-medication. Clinical conditions associated with low-salt requirements were not associated with lower exposure to ETs, suggesting a lack of awareness by practitioners and patients about this iatrogenic issue.

Pulp treatment for extensive decay in primary teeth.

BACKGROUND: In children, dental caries (tooth decay) is among the most prevalent chronic diseases worldwide. Pulp interventions are indicated for extensive tooth decay. Depending on the severity of the disease, three pulp treatment techniques are available: direct pulp capping, pulpotomy and pulpectomy. After treatment, the cavity is filled with a medicament. Materials commonly used include mineral trioxide aggregate (MTA), calcium hydroxide, formocresol or ferric sulphate.This is an update of a Cochrane Review published in 2014 when insufficient evidence was found to clearly identify one superior pulpotomy medicament and technique. OBJECTIVES: To assess the effects of different pulp treatment techniques and associated medicaments for the treatment of extensive decay in primary teeth. SEARCH METHODS: Cochrane Oral Health's Information Specialist searched the Cochrane Oral Health Group's Trials Register (to 10 August 2017), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2017, Issue 7), MEDLINE Ovid (1946 to 10 August 2017), Embase Ovid (1980 to 10 August 2017) and the Web of Science (1945 to 10 August 2017). OpenGrey was searched for grey literature. The US National Institutes of Health Trials Registry (ClinicalTrials.gov) and the World Health Organization International Clinical Trials Registry Platform were searched for ongoing trials. No restrictions were placed on the language or date of publication when searching the electronic databases. SELECTION CRITERIA: We included randomised controlled trials (RCTs) comparing interventions that combined a pulp treatment technique with a medicament or device in children with extensive decay in the dental pulp of their primary teeth. DATA COLLECTION AND ANALYSIS: Two review authors independently extracted data and assessed 'Risk of bias'. We contacted authors of RCTs for additional information when necessary. The primary outcomes were clinical failure and radiological failure, as defined in trials, at six, 12 and 24 months. We performed data synthesis with pair-wise meta-analyses using fixed-effect models. We assessed statistical heterogeneity by using I² coefficients. MAIN RESULTS: We included 40 new trials bringing the total to 87 included trials (7140 randomised teeth) for this update. All were small, single-centre trials (median number of randomised teeth = 68). All trials were assessed at unclear or high risk of bias.The 87 trials examined 125 different comparisons: 75 comparisons of different medicaments or techniques for pulpotomy; 25 comparisons of different medicaments for pulpectomy; four comparisons of pulpotomy and pulpectomy; and 21 comparisons of different medicaments for direct pulp capping.The proportion of clinical failures and radiological failures was low in all trials. In many trials, there were either no clinical failures or no radiographic failures in either study arm.For pulpotomy, we assessed three comparisons as providing moderate-quality evidence. Compared with formocresol, MTA reduced both clinical and radiological failures, with a statistically significant difference at 12 months for clinical failure and at six, 12 and 24 months for radiological failure (12 trials, 740 participants). Compared with calcium hydroxide, MTA reduced both clinical and radiological failures, with statistically significant differences for clinical failure at 12 and 24 months. MTA also appeared to reduce radiological failure at six, 12 and 24 months (four trials, 150 participants) (low-quality evidence). When comparing calcium hydroxide with formocresol, there was a statistically significant difference in favour of formocresol for clinical failure at six and 12 months and radiological failure at six, 12 and 24 months (six trials (one with no failures), 332 participants).Regarding pulpectomy, we found moderate-quality evidence for two comparisons. The comparison between Metapex and zinc oxide and eugenol (ZOE) paste was inconclusive, with no clear evidence of a difference between the interventions for failure at 6 or 12 months (two trials, 62 participants). Similarly inconclusive, there was no clear evidence of a difference in failure between Endoflas and ZOE (outcomes measured at 6 months; two trials, 80 participants). There was low-quality evidence of a difference in failure at 12 months that suggested ZOE paste may be better than Vitapex (calcium hydroxide/iodoform) paste (two trials, 161 participants).Regarding direct pulp capping, the small number of studies undertaking the same comparison limits any interpretation. We assessed the quality of the evidence as low or very low for all comparisons. One trial appeared to favour formocresol over calcium hydroxide; however, there are safety concerns about formocresol. AUTHORS' CONCLUSIONS: Pulp treatment for extensive decay in primary teeth is generally successful. Many included trials had no clinical or radiological failures in either trial arm, and the overall proportion of failures was low. Any future trials in this area would require a very large sample size and follow up of a minimum of one year.The evidence suggests MTA may be the most efficacious medicament to heal the root pulp after pulpotomy of a deciduous tooth. As MTA is relatively expensive, future research could be undertaken to confirm if Biodentine, enamel matrix derivative, laser treatment or Ankaferd Blood Stopper are acceptable second choices, and whether, where none of these treatments can be used, application of sodium hypochlorite is the safest option. Formocresol, though effective, has known concerns about toxicity.Regarding pulpectomy, there is no conclusive evidence that one medicament or technique is superior to another, and so the choice of medicament remains at the clinician's discretion. Research could be undertaken to confirm if ZOE paste is more effective than Vitapex and to evaluate other alternatives.Regarding direct pulp capping, the small number of studies and low quality of the evidence limited interpretation. Formocresol may be more successful than calcium hydroxide; however, given its toxicity, any future research should focus on alternatives.

External validation of the 80+ score and comparison with three clinical scores identifying patients at least 75 years old at risk of unplanned readmission within 30 days after discharge.

AIM OF THE STUDY: A potentially avoidable readmission is an unplanned readmission occurring within 30 days of discharge. As 20% of hospitalised elderly patients are rehospitalised as an unplanned readmission, it is necessary to identify with a clinical score those patients who are at risk of readmission and need discharge interventions as a priority. The main objective of this study was to externally validate and compare the 80+ score with the three other scores predicting the risk of unplanned readmission. METHODS: We conducted a retrospective case-control study using a clinical data warehouse. The study included patients hospitalised between 1 September 2014 and 31 October 2015 in an 800-bed university hospital. We included patients aged 75 and over. Cases were readmitted at the emergency department within 30 days after the index discharge. Controls were not readmitted as an emergency within 30 days. Four clinical scores (80+ score, LACE index, HOSPITAL score, TRST) were externally validated. Discrimination of the scores was assessed by calculating the area under the receiver operating characteristic curves (AUC). Calibration was assessed with a Hosmer-Lemeshow χ2 test. RESULTS: We included 438 patients. For discrimination, the 80+ score, the LACE index, the HOSPITAL score and the TRST had AUCs of 0.506 (95% confidence interval [CI] 0.413-0.546), 0.534 (95% CI 0.459-0.591, 0.517 (95% CI 0.466-0.598) and 0.589 (95% CI 0.524-0.654), respectively. The Hosmer-Lemeshow χ2 tests had p-values of 0.44, 0.43, 0.11 and 0.49, respectively. CONCLUSION: In our study, the 80+ score was externally validated and showed less favourable discrimination than the three other scores in this population.

Correction: Excess mortality and hospitalizations in transitional-age youths with a long-term disease: A national population-based cohort study.

[This corrects the article DOI: 10.1371/journal.pone.0193729.].

Excess mortality and hospitalizations in transitional-age youths with a long-term disease: A national population-based cohort study.

INTRODUCTION: The number of adolescents with a severe chronic disease has increased in high-income countries due to improvements in the prognosis of childhood-onset chronic conditions. The transition from childhood to adulthood is a critical period that may be associated with increased mortality and morbidity. We aimed to estimate the prevalence of adolescents with a long-term disease (LTD) in France and assess their mortality and hospitalization risks relative to the general population. MATERIALS AND METHODS: We extracted a population-based cohort from the French national health insurance database that included 61,119 subjects who reached 14 years of age between 2005 and 2014. LTDs are diagnosed by patients' physicians and then confirmed and registered by a physician of the national health insurance system. We assessed mortality and hospitalizations using data of patients who were between 14 and 21 years-old. RESULTS: Among 14-year-old adolescents, 3.30% (95% confidence interval: 3.16-3.44) had a LTD. Their mortality rate between the ages of 14 and 21 years was 20.9/10,000 person-years (13.7-32.1) versus 1.9 (1.5-2.5) for adolescents without a LTD. Mortality was higher in males than females in youths without a LTD, but not in those with a LTD. We found a similar pattern for the risk of hospitalization for an external cause. The five-year probability of hospitalization was 61.8% among youths with a LTD versus 42.7% for those without. The rate of planned hospitalizations sharply fell at 19 years-of-age among youths with a LTD, whereas the rate of unplanned hospitalizations remained stable. CONCLUSION: The 3% of youths with a LTD have ten-fold higher mortality than those without and a high risk of hospitalization. The decrease in the rate of planned hospitalizations at age 19 among youths with a LTD may indicate differences in medical practice after transfer to adult care or a break in medical care.

Abdominal Attenuation Values on Virtual and True Unenhanced Images Obtained With Third-Generation Dual-Source Dual-Energy CT.

OBJECTIVE: The purpose of this study is to investigate the magnitude of differences between attenuation values measured on virtual unenhanced images and true unenhanced images obtained using third-generation dual-source dual-energy CT (DECT). SUBJECTS AND METHODS: A total of 83 patients requiring thoracoabdominal CT for cancer workup were included in this prospective study. CT examinations included true unenhanced acquisitions (tube potential, 120 kVp) and arterial and portal phase dual-energy CT (DECT) acquisitions (tube potential, 100 kVp and Sn 150 kVp [where Sn denotes the interposition of a tin filter in the high-energy beam]; tube current-exposure time product, 190 and 95 mAs). Virtual unenhanced images were created using two commercially available DECT postprocessing algorithms, one of which was designed to create liver images (hereafter referred to as VNC1 images) and the other of which was designed to create images of organs containing minor amounts of fat (hereafter referred to as VNC2 images). Attenuation values on the liver, spleen, paraspinal muscles, retroperitoneal fat, renal cortex and medulla, and gallbladder and bladder lumens were measured. RESULTS: The attenuation values of all tissues were significantly different between virtual unenhanced and true unenhanced images (p = < 0.001-0.042), except for the liver and spleen in the portal phase and muscles in both phases. When statistically significant, correlations between these differences and body mass index (weight in kilograms divided by the square of height in meters) depended on the tissue imaged and algorithm used. The percentage of cases in which these differences were 10 HU or greater was 1% for the liver and approximately 5% for the spleen and muscles, regardless of the algorithm and phase, but on VNC1 images it reached approximately 30% for the kidney, 70% for the gallbladder and bladder, and depending on the phase, 40-70% for fat. On VNC2 images, the percentage of cases in which these differences were 20 HU or greater was approximately 90% for fat. CONCLUSION: Abdominal virtual unenhanced images obtained with third-generation dual-source DECT still should not replace true unenhanced images because of substantial differences in attenuation measurements for fluid, fat, and renal tissues.

Prevalence of computerized physician order entry systems-related medication prescription errors: A systematic review.

OBJECTIVE: The positive impact of computerized physician order entry (CPOE) systems on prescription safety must be considered in light of the persistence of certain types of medication-prescription errors. We performed a systematic review, based on the PRISMA statement, to analyze the prevalence of prescription errors related to the use of CPOE systems. MATERIALS AND METHODS: We searched MEDLINE, EMBASE, CENTRAL, DBLP, the International Clinical Trials Registry, the ISI Web of Science, and reference lists of relevant articles from March 1982 to August 2017. We included original peer-reviewed studies which quantitatively reported medication-prescription errors related to CPOE. We analyzed the prevalence of medication-prescription errors according to an adapted version of the National Coordinating Council for Medication Error Reporting and Prevention (NCCMERP) taxonomy and assessed the mechanisms responsible for each type of prescription error due to CPOE. RESULTS: Fourteen studies were included. The prevalence of CPOE systems-related medication errors relative to all prescription medication errors ranged from 6.1 to 77.7% (median = 26.1% [IQR:17.6-42,1]) and was less than 6.3% relative to the number of prescriptions reviewed. All studies reported "wrong dose" and "wrong drug" errors. The "wrong dose" error was the most frequently reported (from 7 to 67.4%, median = 31.5% [IQR:20.5-44.5]). We report the associated mechanism for each type of medication described (those due to CPOE or those occurring despite CPOE). DISCUSSION: We observed very heterogeneous results, probably due to the definition of error, the type of health information system used for the study, and the data collection method used. Each data collection method provides valuable and useful information concerning the prevalence and specific types of errors related to CPOE systems. CONCLUSIONS: The reporting of prescription errors should be continued because the weaknesses of CPOE systems are potential sources of error. Analysis of the mechanisms behind CPOE errors can reveal areas for improvement.

Providing physicians with feedback on medication adherence for people with chronic diseases taking long-term medication.

BACKGROUND: Poor medication adherence decreases treatment efficacy and worsens clinical outcomes, but average rates of adherence to long-term pharmacological treatments for chronic illnesses are only about 50%. Interventions for improving medication adherence largely focus on patients rather than on physicians; however, the strategies shown to be effective are complex and difficult to implement in clinical practice. There is a need for new care models addressing the problem of medication adherence, integrating this problem into the patient care process. Physicians tend to overestimate how well patients take their medication as prescribed. This can lead to missed opportunities to change medications, solve adverse effects, or propose the use of reminders in order to improve patients' adherence. Thus, providing physicians with feedback on medication adherence has the potential to prompt changes that improve their patients' adherence to prescribed medications. OBJECTIVES: To assess the effects of providing physicians with feedback about their patients' medication adherence for improving adherence. We also assessed the effects of the intervention on patient outcomes, health resource use, and processes of care. SEARCH METHODS: We conducted a systematic search of the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, and Embase, all from database inception to December 2016 and without any language restriction. We also searched ISI Web of Science, two trials registers, and grey literature. SELECTION CRITERIA: We included randomised trials, controlled before-after studies, and interrupted time series studies that compared the effects of providing feedback to physicians about their patients' adherence to prescribed long-term medications for chronic diseases versus usual care. We included published or unpublished studies in any language. Participants included any physician and any patient prescribed with long-term medication for chronic disease. We included interventions providing the prescribing physician with information about patient adherence to medication. Only studies in which feedback to the physician was the sole intervention or the essential component of a multifaceted intervention were eligible. In the comparison groups, the physicians should not have had access to information about their patients' adherence to medication. We considered the following outcomes: medication adherence, patient outcomes, health resource use, processes of care, and adverse events. DATA COLLECTION AND ANALYSIS: Two independent review authors extracted and analysed all data using standard methodological procedures expected by Cochrane and the Effective Practice and Organisation of Care group. Due to heterogeneity in study methodology, comparison groups, intervention settings, and measurements of outcomes, we did not carry out meta-analysis. We describe the impact of interventions on outcomes in tabular form and make a qualitative assessment of the effects of studies. MAIN RESULTS: We included nine studies (23,255 patient participants): eight randomised trials and one interrupted time series analysis. The studies took place in primary care and other outpatient settings in the USA and Canada. Seven interventions involved the systematic provision of feedback to physicians concerning all their patients' adherence to medication, and two interventions involved issuing an alert for non-adherent patients only. Seven studies used pharmacy refill data to assess medication adherence, and two used an electronic device or self-reporting. The definition of adherence differed across studies, making comparisons difficult. Eight studies were at high risk of bias, and one study was at unclear risk of bias. The most frequent source of bias was lack of protection against contamination.Providing physicians with feedback may lead to little or no difference in medication adherence (seven studies, 22,924 patients), patient outcomes (two studies, 1292 patients), or health resource use (two studies, 4181 patients). Providing physicians with feedback on medication adherence may improve processes of care (e.g. more medication changes, dialogue with patient, management of uncontrolled hypertension) compared to usual care (four studies, 2780 patients). None of the studies reported an adverse event due to the intervention. The certainty of evidence was low for all outcomes, mainly due to high risk of bias, high heterogeneity across studies, and indirectness of evidence. AUTHORS' CONCLUSIONS: Across nine studies, we observed little or no evidence that provision of feedback to physicians regarding their patients adherence to prescribed medication improved medication adherence, patient outcomes, or health resource use. Feedback about medication adherence may improve processes of care, but due to the small number of studies assessing this outcome and high risk of bias, we cannot draw firm conclusions on the effect of feedback on this outcome. Future research should use a clear, standardised definition of medication adherence and cluster-randomisation to avoid the risk of contamination.

Case 247: Jersey Finger of the Fifth Finger.

History A 34-year-old man without underlying medical conditions came to the emergency department for evaluation of persistent pain over the volar portion of his right fifth finger after a fall during a football match 3 days before. At physical examination, the injured finger was swollen and purple. Passive and active flexion of the proximal and distal interphalangeal joints were compromised, without interphalangeal instability. Radiography was performed in the emergency department, and the patient was released with a diagnosis of a fifth digit sprain. After the senior radiologist (V.M.C.) reviewed the radiographs, the patient was called back for assessment with ultrasonography (US) on the same day. US was performed with an Aplio 500 unit (Toshiba Medical Systems, Tokyo, Japan) using a multifrequency linear array 7.2-18.0-MHz PLT-1204BX transducer focused at the level of the flexor tendon. The patient was sitting in front of the examiner, with the hand lying palm up on the examination bed. No abnormality was observed during color Doppler US.

Computer-generated reminders delivered on paper to healthcare professionals: effects on professional practice and healthcare outcomes.

BACKGROUND: Clinical practice does not always reflect best practice and evidence, partly because of unconscious acts of omission, information overload, or inaccessible information. Reminders may help clinicians overcome these problems by prompting them to recall information that they already know or would be expected to know and by providing information or guidance in a more accessible and relevant format, at a particularly appropriate time. This is an update of a previously published review. OBJECTIVES: To evaluate the effects of reminders automatically generated through a computerized system (computer-generated) and delivered on paper to healthcare professionals on quality of care (outcomes related to healthcare professionals' practice) and patient outcomes (outcomes related to patients' health condition). SEARCH METHODS: We searched CENTRAL, MEDLINE, Embase, six other databases and two trials registers up to 21 September 2016 together with reference checking, citation searching and contact with study authors to identify additional studies. SELECTION CRITERIA: We included individual- or cluster-randomized and non-randomized trials that evaluated the impact of computer-generated reminders delivered on paper to healthcare professionals, alone (single-component intervention) or in addition to one or more co-interventions (multi-component intervention), compared with usual care or the co-intervention(s) without the reminder component. DATA COLLECTION AND ANALYSIS: Review authors working in pairs independently screened studies for eligibility and abstracted data. For each study, we extracted the primary outcome when it was defined or calculated the median effect size across all reported outcomes. We then calculated the median improvement and interquartile range (IQR) across included studies using the primary outcome or median outcome as representative outcome. We assessed the certainty of the evidence according to the GRADE approach. MAIN RESULTS: We identified 35 studies (30 randomized trials and five non-randomized trials) and analyzed 34 studies (40 comparisons). Twenty-nine studies took place in the USA and six studies took place in Canada, France, Israel, and Kenya. All studies except two took place in outpatient care. Reminders were aimed at enhancing compliance with preventive guidelines (e.g. cancer screening tests, vaccination) in half the studies and at enhancing compliance with disease management guidelines for acute or chronic conditions (e.g. annual follow-ups, laboratory tests, medication adjustment, counseling) in the other half.Computer-generated reminders delivered on paper to healthcare professionals, alone or in addition to co-intervention(s), probably improves quality of care slightly compared with usual care or the co-intervention(s) without the reminder component (median improvement 6.8% (IQR: 3.8% to 17.5%); 34 studies (40 comparisons); moderate-certainty evidence).Computer-generated reminders delivered on paper to healthcare professionals alone (single-component intervention) probably improves quality of care compared with usual care (median improvement 11.0% (IQR 5.4% to 20.0%); 27 studies (27 comparisons); moderate-certainty evidence). Adding computer-generated reminders delivered on paper to healthcare professionals to one or more co-interventions (multi-component intervention) probably improves quality of care slightly compared with the co-intervention(s) without the reminder component (median improvement 4.0% (IQR 3.0% to 6.0%); 11 studies (13 comparisons); moderate-certainty evidence).We are uncertain whether reminders, alone or in addition to co-intervention(s), improve patient outcomes as the certainty of the evidence is very low (n = 6 studies (seven comparisons)). None of the included studies reported outcomes related to harms or adverse effects of the intervention. AUTHORS' CONCLUSIONS: There is moderate-certainty evidence that computer-generated reminders delivered on paper to healthcare professionals probably slightly improves quality of care, in terms of compliance with preventive guidelines and compliance with disease management guidelines. It is uncertain whether reminders improve patient outcomes because the certainty of the evidence is very low. The heterogeneity of the reminder interventions included in this review also suggests that reminders can probably improve quality of care in various settings under various conditions.

Cardiovascular risk associated with high sodium-containing drugs: A systematic review.

BACKGROUND: Excess dietary sodium is associated with increased blood pressure (BP). Some drugs are associated with high sodium intake (in particular effervescent tablets), but the cardiovascular risk associated with such high sodium-containing drugs (HSCD) is largely underevaluated. OBJECTIVES: To summarize the evidence for a potential cardiovascular risk associated with exposure to HSCD, and to highlight possible risk factors associated with this iatrogenic issue; in general and/or specific populations. METHODS: We conducted a systematic review, by searching electronic databases including MEDLINE, EMBASE, Web of Science, CENTRAL and grey literature between 1960 and 2015. We included studies that reported modification of cardiovascular parameters or incidence/prevalence of cardiovascular outcomes, between a group of subjects exposed to HSCD relative to a non-exposed group. The threshold used to identify HSCD was 391 mg/day. We did not consider studies evaluating exposure to sodium as an active ingredient or those focusing on dialysis solutions or enteral/parenteral nutrition. Study quality was assessed using the EPHPP tool. RESULTS: A total of eight studies met our inclusion criteria. Four reported results for short-term exposure to HSCD (≤ 7 days) on BP fluctuations. One study reported an elevation of BP (associated sodium intake: 1,656 mg/day). Four studies evaluated a long-term exposure (≥ 2 years or discontinuation of a chronic treatment). Two studies reported iatrogenic risk. For these studies, drug associated sodium intake was high (> 1,500 mg/day) in patients with comorbidities (in particular, diabetes mellitus and hypertension). CONCLUSION: Despite numerous study limitations, this systematic review suggests three potential synergistic risk factors for cardiovascular complications after exposure to HSCD: a high sodium intake (≥ 1,500 mg/day), a long duration of exposure, and the presence of comorbidities. Further studies are required to characterize this iatrogenic risk. TRIAL REGISTRATION: PROSPERO CRD42016047086.

Birth of evidence-based medicine / Naissance de l'evidence-based medicine

Birth of evidence-based medicine. A new way of thinking came out from North American medicine in the 90's, well summarized by Gordon Guyatt in the JAMA paper "Evidence-based medicine: a new way of teaching medicine". European and French medicines, in the past, were the most influential through the discussion around vaccines of Bernoulli and d'Alembert, the introduction of statistics by Laplace, the objective analysis of therapeutic results by Pierre-Alexandre Louis, and the "experimental " method of Claude Bernard. Koch's postulates and causality criteria of Bradford Hill were also major contributions to make medicine more rational. The critical assessment of the scientific literature (and why not of literature and art?) was promoted at the right time, when exploded the number of articles of unequal quality, and the promotion of practices based on tradition, authoritarianism, and patho physiological hypothesis. This paper provides an analysis of this major change in medical reasoning, and its necessary integration within a new world of accelerated and disputable communication.

Naissance de l'evidence-based medicine. Un mode de raisonnement venu d'Amérique du Nord a réveillé la médecine européenne et française. Elles avaient pourtant produit autrefois les analyses des effets de la vaccination par Bernouilli et d'Alembert, les contributions statistiques de Laplace, les études thérapeutiques de Charles-Alexandre Louis et « la ¼ méthode expérimentale de Claude Bernard. Le postulat de Koch et les preuves de la causalité de Bradford Hill ont également contribué à pousser le développement d'une médecine scientifique née en Europe. L'apprentissage pendant les études de médecine de la lecture critique de la littérature scientifique (mais pourquoi ne pas l'étendre à la littérature et à la critique d'art ?) a été le bienvenu au moment de l'explosion du nombre d'articles de qualité variable, et de la diffusion de pratiques basées sur des opinions, des rumeurs ou des traditions. Cet article retrace le vécu des auteurs sur cette transformation des modes de raisonnement et de travail en médecine, en essayant de l'intégrer dans l'environnement nouveau que constituera le marché de l'information.

Nurse workload and inexperienced medical staff members are associated with seasonal peaks in severe adverse events in the adult medical intensive care unit: A seven-year prospective study.

OBJECTIVE: Our purpose was to identify potential organizational factors that contributed to life-threatening adverse events in adult intensive care unit. METHODS: A prospective, observational, dynamic cohort study was carried out from January 2006 to December 2013 in a 20-bed adult medical intensive care unit. All patients admitted to the intensive care unit and who experienced one or more selected life-threatening adverse events (mainly unexpected cardiac arrest, unplanned extubation, reintubation after planned extubation, and readmission within 48h of intensive care unit discharge) were included in the analysis. Negative binomial regression was used to model how human resources, work organization, and intensive care activity influenced the monthly rate of selected severe adverse events. Data were collected from local and national databases. RESULTS: Overall, 638 severe adverse events involving 498 patients were recorded. Adverse events increased seasonally in May, November and December (p<.001 vs other months). The proportion of inexperienced nurses and doctors' working hours could not explain these seasonal peaks of adverse events. Multivariate analysis identified bed-to-nurse ratio and the arrival of inexperienced residents or senior registrars as being independently associated with the rate of adverse events (incidence risk ratio=1.36 (95% confidence interval, 1.05-1.75), and 1.07 (95% confidence interval, 1.01-1.13), respectively; p=.01 in both cases). According to this model, a one-unit increase in the day-night shifts carried out by each nurse per month tended to reduce the rate of adverse events (incidence risk ratio=0.60 (95% confidence interval, 0.36-1.01), p=.05). Severity at intensive care unit admission did not influence the rate of adverse events (incidence risk ratio=1.02 (95% confidence interval, 1.00-1.04), p=.12). CONCLUSIONS: Results identify nurse workload and the arrival of inexperienced residents or senior registrars as risk factors for the occurrence of life-threatening adverse events in the adult medical intensive care unit. Limiting fluctuations in bed-to-nurse ratio and providing inexperienced medical staff members with sufficient supervision may decrease severe adverse events in critically ill patients.

Evaluating Continuity During Transfer to Adult Care: A Systematic Review.

CONTEXT: Appropriate outcomes are required to evaluate transition programs' ability to maintain care continuity during the transfer to adult care of youths with a chronic condition. OBJECTIVE: To identify the outcomes used to measure care continuity during transfer, and to analyze current evidence regarding the efficacy of transition programs. DATA SOURCES: PubMed (1948-2014), Web of Science (1945-2014), Embase (1947-2014), and the reference lists of the studies identified. STUDY SELECTION: Screening on titles and abstracts; full-text assessment by 2 reviewers independently. DATA EXTRACTION: By 2 reviewers independently, by using a Cochrane form adapted to observational studies, including bias assessment. RESULTS: Among the 23 studies retrieved, all but 5 were monocentric, 16 were cohorts (15 retrospective), 6 cross-sectional studies, and 1 randomized trial. The principal disease studied was diabetes (n = 11). We identified 24 indicators relating to 2 main aspects of continuity of care: engagement and retention in adult care. As designed, most studies probably overestimated engagement. A lack of adjustment for confounding factors was the main limitation of the few studies evaluating the efficacy of transition programs. LIMITATIONS: The assessment of bias was challenging, due to the heterogeneity and observational nature of the studies. CONCLUSIONS: This review highlights the paucity of knowledge about the efficacy of transition programs for ensuring care continuity during the transfer from pediatric to adult care. The outcomes identified are relevant and not specific to a disease. However, the prospective follow-up of patients initially recruited in pediatric care should be encouraged to limit an overestimation of care continuity.

SFE/SFHTA/AFCE primary aldosteronism consensus: Introduction and handbook.

The French Endocrinology Society (SFE) French Hypertension Society (SFHTA) and Francophone Endocrine Surgery Association (AFCE) have drawn up recommendations for the management of primary aldosteronism (PA), based on an analysis of the literature by 27 experts in 7 work-groups. PA is suspected in case of hypertension associated with one of the following characteristics: severity, resistance, associated hypokalemia, disproportionate target organ lesions, or adrenal incidentaloma with hypertension or hypokalemia. Diagnosis is founded on aldosterone/renin ratio (ARR) measured under standardized conditions. Diagnostic thresholds are expressed according to the measurement units employed. Diagnosis is established for suprathreshold ARR associated with aldosterone concentrations >550pmol/L (200pg/mL) on 2 measurements, and rejected for aldosterone concentration<240pmol/L (90pg/mL) and/or subthreshold ARR. The diagnostic threshold applied is different if certain medication cannot be interrupted. In intermediate situations, dynamic testing is performed. Genetic forms of PA are screened for in young subjects and/or in case of familial history. The patient should be informed of the results expected from medical and surgical treatment of PA before exploration for lateralization is proposed. Lateralization is explored by adrenal vein sampling (AVS), except in patients under 35 years of age with unilateral adenoma on imaging. If PA proves to be lateralized, unilateral adrenalectomy may be performed, with adaptation of medical treatment pre- and postoperatively. If PA is non-lateralized or the patient refuses surgery, spironolactone is administered as first-line treatment, replaced by amiloride, eplerenone or calcium-channel blockers if insufficiently effective or poorly tolerated.