Toward improvement of knowledge of financial conflicts of interest in a large medical school in France.

INTRODUCTION: Conflict of interests (COIs) adversely affect the integrity of science and public health. The role of medical schools in the teaching and management of COIs has been highlighted by the publication of an annual evaluation of American medical schools based on their COIs policies by the American Medical Student Association (AMSA). A deontological charter was adopted by French medical schools in 2018 but its impact on COI comprehension by students and its effects on COI prevention were not evaluated. METHODS: A 10-item direct survey was conducted among about 1000 students in Paris-Cité University in order to investigate the respect of the charter regarding COIs both in the medical school and in affiliated teaching hospitals. RESULTS: Cumulative results show a satisfying respect of prevention policies regarding COIs in the medical school and hospitals despite the fact that the existence of the charter and its major aspects were insufficiently known. Disclosure of COIs by teachers was insufficient. CONCLUSION: This first direct study among students shows better results than expected according to current non-academic surveys. Moreover, this study demonstrates the feasibility of this kind of survey whose repetition should be an appropriate tool to improve the implementation of the charter within medical schools and teaching hospitals, in particular mandatory disclosure of COIs by teachers.

Continuous versus intermittent infusion of vancomycin in severe Staphylococcal infections: prospective multicenter randomized study.

A continuous infusion of vancomycin (CIV) may provide an alternative mode of infusion in severe hospital-acquired methicillin-resistant staphylococcal (MRS) infections. A multicenter, prospective, randomized study was designed to compare CIV (targeted plateau drug serum concentrations of 20 to 25 mg/liter) and intermittent infusions of vancomycin (IIV; targeted trough drug serum concentrations of 10 to 15 mg/liter) in 119 critically ill patients with MRS infections (bacteremic infections, 35%; pneumonia, 45%). Microbiological and clinical outcomes, safety, pharmacokinetics, ease of treatment adjustment, and cost were compared. Microbiological and clinical outcomes and safety were similar. CIV patients reached the targeted concentrations faster (36 +/- 31 versus 51 +/- 39 h, P = 0.029) and fewer samples were required for treatment monitoring than with IIV patients (7.7 +/- 2.2 versus 11.8 +/- 3.9 per treatment, P < 0.0001). The variability between patients in both the area under the serum concentration-time curve (AUC(24h)) and the daily dose given over 10 days of treatment was lower with CIV than with IIV (variances, 14,621 versus 53,975 mg(2)/liter(2)/h(2) [P = 0.026] and 414 versus 818 g(2) [P = 0.057], respectively). The 10-day treatment cost per patient was $454 +/- 137 in the IIV group and was 23% lower in the CIV group ($321 +/- 81: P < 0.0001). In summary, for comparable efficacy and tolerance, CIV may be a cost-effective alternative to IIV.

[Prevention of nosocomial pneumonia in patients treated with invasive ventilation]. / Prévention des pneumonies nosocomiales chez les patients traités par ventilation invasive.

Nosocomial pneumonia is one of the primary causes of nosocomial infection in intensive care patients, leading to high mortality and prolonged hospitalization. Mechanical ventilation and its duration are major risk factors. When invasive ventilation is indispensable, preventive measures should aim at optimizing patient care by carefully applying basic rules of hygiene and recommended procedures for use of ventilation equipment. Different preventive measures have been proposed and should be considered in light of several criteria: the cost/benefit ratio, the level of proof (size of the study population, quality and pertinence of judgement criteria), feasibility, routine cost, and absence of secondary collateral adverse effects.

Efficiency and safety of mechanical ventilation with a heat and moisture exchanger changed only once a week.

The cost of mechanical ventilation (MV) is high. Efforts to reduce this cost, as long as they are not detrimental for the patients, are needed. MV with heat and moisture exchangers (HME) changed every 48 h is safe, efficient, and cost-effective. Preliminary reports suggest that the life span of these filters may be prolonged. We determined prospectively whether a hygroscopic and hydrophobic HME (Hygrobac-Dar; Mallinckrodt) provided safe and efficient heating and humidification of the inspired gases when changed only once a week. Patients who were considered to require mechanical ventilation for more than 48 h were included in the study. HMEs were initially set for 7 d. Efficient airway heating and humidification were assessed by clinical parameters (number of tracheal suctionings and instillations required, peak airway pressures) and hygrometric measurements performed by psychrometry. Resistance was measured from Day 0 to Day 7. Bacterial colonization of circuits and HMEs was studied. A total of 377 days of mechanical ventilation with 60 HMEs was studied. Clinical parameters and hygrometric measurements did not change between Day 0 and Day 7. Mean absolute humidity was 30.3 +/- 1.3 mg H(2)O/L on Day 0 and 30.8 +/- 1.5 mg H(2)O/L on Day 7 (p = 0.7). Endotracheal tube occlusion never occurred. Three HMEs were replaced prematurely because of insufficient absolute humidity. This rare event occurred only in patients with COPD and after the third day of use. In addition, the absolute humidity delivered by the HMEs was significantly lower in patients with COPD than in the rest of the population. Resistance did not change from Day 0 to Day 7 (2.4 +/- 0.3 versus 2.7 +/- 0.3 cm H(2)O/L/s; p = 0.4). Bacterial samples of both circuits and ventilator sides of HMEs were sterile in most cases. We conclude that mechanical ventilation can be safely conducted in non-COPD patients using an HME changed only once a week, leading to substantial cost savings (about $110,000 per year if these findings were applied to the university-affiliated hospitals in Paris).

Safety, efficacy, and cost-effectiveness of mechanical ventilation with humidifying filters changed every 48 hours: a prospective, randomized study.

OBJECTIVE: To determine whether three hydrophobic and hygroscopic heat and moisture exchangers (HMEs) retain their heating and humidifying properties (assessed by psychrometric measurements of absolute humidity, relative humidity, and tracheal temperature) for 48 hrs without any drop in their bacteriologic efficiency. DESIGN: Prospective randomized clinical trial. PATIENTS: Sixty-one consecutive unselected mechanically ventilated intensive care unit patients. INTERVENTIONS: Patients were randomly allocated to one of the three HMEs studied (Hygrobac-Dar from Mallinckrodt, n = 21; Humid-Vent from Gibeck, n = 20; and Clear-Thermal from Intersurgical, n = 20). MEASUREMENTS AND MAIN RESULTS: Hygrometric parameters were measured by psychrometry after 3, 24, and 48 hrs of use. Peak airway pressure was recorded every 6 hrs and averaged over 24 hrs. Bacterial colonization of both patients and circuits was studied. Patients in all three groups were similar in terms of age, indications for, and overall duration of mechanical ventilation. Tracheal tube occlusion never occurred. Hygrometric data included 371 measurements whereas bacteriologic data included >700 samples and cultures. The Hygrobac-Dar HMEs gave a significantly higher absolute humidity whatever the time of measurement (3, 24, or 48 hrs) than the other two HMEs (p < .001). The Clear-Thermal HMEs gave the poorest hygrometric parameters (p < .01); five of them were replaced prematurely (24 hrs) because the absolute humidity was <25 mg H2O/L. This did not occur for the other HMEs. Mean peak airway pressures were identical in the three groups. The bacterial colonizations of both patient and circuit were similar (and negligible for circuits) for all three groups. CONCLUSION: Some HMEs may be used safely for 48 hrs without change. However, this does not pertain to every brand of HME. Objective in vivo evaluation of their humidifying performances is decisive before extending their duration of use.

Use of a pulse oximeter in an adult emergency department: impact on the number of arterial blood gas analyses ordered.

STUDY OBJECTIVES: To assess the impact of pulse oximetry (SpO2) on the indications and the number of arterial blood gas (ABG) levels ordered in an adult emergency department (ED). DESIGN: A prospective study during a 2-month period in 1993 with a pulse oximeter available and a comparison with the same period in 1992 without the oximeter. SETTING: An adult medical ED of a university hospital in France. PATIENTS: All patients who underwent ABG or SpO2 measurements. INTERVENTIONS: During the prospective study, residents ordered ABG or SpO2 measurements at their discretion. The reasons for their ordering were reviewed by two independent experts who determined whether their choice was justified. The data were compared with those for 184 consecutive patients who had ABG measurements in 1992. MEASUREMENTS AND RESULTS: The study included 152 patients. SpO2 alone was used in 33 patients; ABG levels were measured in 119 patients. The use of SpO2 did not result in the ordering of fewer useful ABG determinations. One hundred and five (88%) ABG measurements were justified. There were fewer unjustified ABG determinations in 1993 when the pulse oximeter was available than in 1992 when it was not (14 of 119 vs 54 of 184; p<0.001) mainly because fewer ABG determinations were ordered for miscellaneous nonrespiratory indications (13 of 119 vs 43 of 184; p<0.01). CONCLUSION: The availability of a pulse oximeter did not affect the ordering of useful ABG measurements but allowed a significant reduction of unjustified ABG measurements. Substantial cost savings could be achieved by using SpO2 in an ED.

Changing heat and moisture exchangers every 48 hours rather than 24 hours does not affect their efficacy and the incidence of nosocomial pneumonia.

Heat and moisture exchangers (HME) (Dar-Hygrobac II, Peters) can safely be used every 24 h for long-term mechanical ventilation and provide a cost-saving alternative to heated humidifiers. We have prospectively determined whether changing HMEs every 48 h only affects their clinical and bacteriological efficiency in a series of consecutive nonselected ICU patients requiring long-term mechanical ventilation. Two consecutive periods were compared. During period 1, HMEs were replaced every day; during period 2, they were changed every 48 h. Patients from the two periods were similar in terms of age and indication for and overall duration of MV (10 +/- 8.6 versus 10 +/- 9 d, p = 0.9). Minute ventilation and maximum values for peak airway pressure were identical during the two periods. These values were also identical after 1 and 2 d of HME use during period 2, indicating that HME resistance was not increased by prolonged use. Obstruction of the tracheal tube occurred only once in a period 1 patient. The results of quantitative cultures indicate that the maximum and mean levels of bacterial colonization during the two periods were similar for the pharynx, trachea, Y-connector, patient, and ventilator side of the HME. More importantly, the incidence of nosocomial pneumonia was similar during the two periods (6/61 versus 8/68, p = 0.7). Thus, prolonged HME use is safe and provides a substantial reduction in the cost of mechanical ventilation.