[Experience feedback committee: a method for patient safety improvement]. / Le comité de retour d'expérience (CREX): une méthode pour l'amélioration de la sécurité des soins.

BACKGROUND: An experience feedback committee (CREX, Comité de Retour d'EXpérience) is a method which contributes to the management of safety of care in a medical unit. Originally used for security systems of civil aviation, the method has been adapted to health care facilities and successfully implemented in radiotherapy units and in other specialties. METHODS: We performed a brief review of the literature for studies reporting data on CREX established in hospitals. The review was performed using the main bibliographic databases and Google search results. RESULTS: The CREX is designed to analyse incidents reported by professionals. The method includes monthly meetings of a multi-professional committee that reviews the reported incidents, chooses a priority incident and designates a "pilot" responsible for investigating the incident. The investigation of the incident involves a systemic analysis method and a written synthesis presented at the next meeting of the committee. The committee agrees on actions for improvement that are suggested by the analysis and follows their implementation. Systems for the management of health care, including reporting systems, are organized into three levels: the medical unit, the hospital and the country as a triple loop learning process. The CREX is located in the base level, short loop of risk management and allows direct involvement of care professionals in patient safety. CONCLUSION: Safety of care has become a priority of health systems. In this context, the CREX can be a useful vehicle for the implementation of a safety culture in medical units.

Impact of the unfolded protein response on the pathogenicity of the necrotrophic fungus Alternaria brassicicola.

The unfolded protein response (UPR) is an important stress signalling pathway involved in the cellular development and environmental adaptation of fungi. We investigated the importance of the UPR pathway in the pathogenicity of the plant necrotrophic fungus Alternaria brassicicola, which causes black spot disease on a wide range of Brassicaceae. We identified the AbHacA gene encoding the major UPR transcription regulator in A. brassicicola. Deletion of AbHacA prevented induction of the UPR in response to endoplasmic reticulum stress. Loss of UPR in mutants resulted in a complete loss of virulence and was also associated with a cell wall defect and a reduced capacity for secretion. In addition, our results showed that the UPR was triggered by treatment of mycelia with camalexin, i.e. the major Arabidopsis thaliana phytoalexin, and that strains lacking functional AbHacA exhibited increased in vitro susceptibility to antimicrobial plant metabolites. We hypothesize that the UPR plays a major role in fungal virulence by altering cell protection against host metabolites and by reducing the ability of the fungus to assimilate nutrients required for growth in the host environment. This study suggests that targeting the UPR pathway would be an effective plant disease control strategy.

Prospective study of telephone calls to a hotline for infectious disease consultation: analysis of 7,863 solicited consultations over a 1-year period.

To respond to the increasing requests of non-infectious disease physicians for access to infectious diseases expertise, a hotline was created in the infectious diseases consultation (IDC) unit of the Grenoble university-affiliated hospital (GUH). This study describes the patterns of solicited consultations provided by the hotline during a 1-year period. We conducted a prospective study of consecutive solicited IDCs requested by physicians in 2008. A total of 7,863 consultations were requested by physicians over 1 year; 4,407 (56.0%) by ambulatory physicians, 2,933 (37.3%) by GUH physicians, and 523 (6.7%) by physicians in public or private hospitals. The majority of consultations were requested via cell phone (58.7%). The main reasons for requesting a consultation were related to antimicrobial treatment for hospital-based physicians and prophylaxis for ambulatory physicians (p < 0.001). Recommendations to perform diagnostic or monitoring tests were less frequent in ambulatory medicine (16%) than in the GUH (59%) or other hospitals (63%, p < 0.001). The route of consultation for patients with nosocomial infections was more likely to be formal (p < 0.001). The activity of the IDC hotline attests to an important need for such expertise consultation, both in hospitals and in ambulatory medicine.

Compliance with recommendations and clinical outcomes for formal and informal infectious disease specialist consultations.

The purpose of this study was to compare compliance with recommendations and clinical outcomes between formal and informal infectious disease specialist consultations. Six hundred twenty-seven consecutive adult inpatients who received an infectious disease consultation in a university-affiliated hospital were included. After adjusting for quintile of propensity score, we compared compliance with the consultant's recommendations and clinical outcomes for 443 (70.7%) and 184 (29.3%) formal and informal consultations. Informal and formal consultations were associated with comparable levels of compliance with recommendations for antimicrobial treatment (86.5% vs 88.9%; adjusted odds ratio [aOR], 0.63; 95% confidence interval, 0.34-1.14; P = 0.13) and diagnostic or monitoring tests (72.6% vs 72.0%; aOR, 0.91 [0.53-1.57]; P = 0.73). The rates of early clinical improvement (58.2% vs 58.6%; aOR, 1.11 [0.70-1.74]; P = 0.66), subsequent consultation (34.2% vs 36.3%; aOR, 0.80 [0.53-1.21]; P = 0.29), in-hospital mortality (4.9% vs 8.4%; aOR, 0.55 [0.24-1.24]; P = 0.15), and the median length of stay (23 vs 20 days; aOR of discharge, 0.90 [0.74-1.10]; P = 0.30) did not differ depending on the type of consultation. This study provides observational evidence that informal consultations result in levels of compliance with recommendations comparable to formal consultations, without compromising patient safety. Further study is needed to refine the criteria for requesting or providing informal rather than formal consultations.

Analysis of the effect of age on the prognosis of breast cancer.

To explore the effect of age at diagnosis on relative survival from breast cancer at different cancer stages and grades, using appropriate statistical modeling of time-varying and non-linear effects of that prognostic covariate. Data on 4,791 female invasive breast cancers diagnosed between 1990 and 1997 were obtained from a French cancer registry. The effect of age on relative survival was studied using an approach based on excess rate modeling. Different models testing non-linear and non-proportional effects of age were explored for each grade and each stage. In the whole population, the effect of age was not linear and varied with the time elapsed since diagnosis. When analyzing the different sub-groups according to grade and stage, age did not have a significant effect on relative survival in grade 1 or stage 3 tumors. In grade 2 and stage 4 tumors, the excess mortality rate increased with age, in a linear way. In grade 3 tumors, age was a time-dependent factor: older women had higher excess rates than younger ones during the first year after diagnosis whereas the inverse phenomenon was observed 5 years after diagnosis. Our findings suggest that when taking into account grade and stage, the time-varying impact of young age at diagnosis is limited to grade 3 tumors, without evidence of worst prognosis at 5 years for the youngest women.

[Can caesarean delivery prevent cerebral palsy? Medico-legal implications of a French ecological study]. / La césarienne peut-elle prévenir la paralysie cérébrale ? Implications médico-légales d'une étude écologique française.

OBJECTIVE: For a long time, the benefit of a caesarean delivery in the prevention of cerebral palsy (CP) has been put forward, which was based on the assumption that CP is due to asphyxia in more than 50 % of the cases. However, from register-based data, this rate has been estimated less than 4 %. The aim of this study was to evaluate whether the rate of caesarean sections for fetal indication was correlated with the prevalence rate of CP in a French county. PATIENTS AND METHODS: This was an ecological study of register-based prevalence estimates of children with CP (postnatal cases excluded) born between 1997 and 2003 in a French county compared with the rates of caesarean section for fetal distress obtained from the maternal and infant protection service of the county. RESULTS: Whilst the rate of caesarean section for fetal indication increased by 44% during the period studied, the prevalence of CP remained nearly stable around 1.5 per 1000 live births. There was no correlation between caesarean section and CP prevalence (r'=-0.36, P=0.43). DISCUSSION AND CONCLUSION: The present study was in accordance with the results of a recent meta-analysis which concluded that emergency and prophylactic caesarean deliveries were not efficient in the prevention of CP. Indication of caesarean delivery for foetal heart rhythm anomaly, which is the most relevant cause for the growing rate of caesarean sections, should be justified by additional examinations in ambivalent cases, in order not to consider it as defensive medicine, which is ethically and therefore juridically blameworthy.

[Blood salvage: decisive progress in vascular surgery]. / Récupérateurs de sang: un progrès décisif en chirurgie vasculaire.

There are two different methods of autotransfusion during an operation; one without blood washing and the other with wash red cells obtained after the filtering and concentration of the recovered blood. The first method has the advantage of being simple and cheap while recovering 1500-2000 ml of blood. Nevertheless it is insufficient in the case of an important or rapid bleeding. The weight of haemoglobin in the recovered blood is relatively low and the hemolysis is without clinical consequences. The rate of the coagulation factors is reduced. The autotransfusion with wash red cells requires a more important investment at the beginning. But the washing process eliminates the cell micro-aggregates and nearly all of the substances in the recovered blood. Therefore concentrated units of red cells may be obtained with hematocrits between 45 and 65%. Autotransfusion with washing offers a greater security when the bleeding is important or violent. The autotransfusion is useful for a bleeding between 1 and 3 litres. The average volume recovered corresponds to 2.5 pockets of blood extract, thus covering the costs for the kits. If the bleeding exceeds 1.5 times the blood volume, blood extract and plasma will be required in addition. The risk of homologue blood transfusion can only increase the development of autotransfusion techniques and particularly the recovery of blood during the operation process.

[An unusual cause of pericardial effusion during pleural drainage]. / Une cause inhabituelle d'épanchement péricardique au cours d'un drainage pleural.

A 66-year-old man was admitted for mitral valve replacement required by a mitral regurgitation resulting in a severe heart failure. He also suffered from chronic respiratory failure, related to a left concavity cyphoscoliosis. Postoperatively, hypoxemia occurred. His chest X-ray showed a left pleural effusion indicating a percutaneous pleural drainage. A local anaesthesia with a 21 G needle was performed prior to drain insertion, which was easily introduced into the pleural cavity. A few minutes later, the patient experienced an acute haemorrhagic shock. He was immediately transferred into the operating room, where the cardiac surgeon discovered and treated a coronary artery effraction. The vascular lesion was attributed to the needle used for local anaesthesia. The patient was discharged twelve days later without sequelae. Two factors were responsible for this accident: the patient's cyphoscoliosis and his left ventricle enlargement. This complication is uncommon. However, in case of a particular patient's anatomy, it is suggested to use a score devised to anticipate the risk of a difficult pleural drainage. This score should include general, thoracic, spinal, cardiac, hepatic and splenic morphology.

[Peroperative pneumothorax in thoracotomy: the value of pulse oximetry]. / Pneumothorax peropératoire au cours de thoracotomies: intérêt de l'oxymétrie de pouls.

Two cases of pneumothorax occurring during thoracotomy under one-lung ventilation are reported. One case occurred before pneumonectomy was carried out. The decrease in Spo2 shown by pulse oximetry, together with the increase in airway pressures, rapidly led to the diagnosis of pneumothorax. In the other case, the accident occurred after pneumonectomy, with a suddenly impossible ventilation, and a drastic decrease in Spo2 leading to hypoxic circulatory arrest. Hypoxaemia occurring during one-lung ventilation may be due to different causes. Shunting in the upper part of the lung is the main cause, but other diagnoses must be discussed, such as airway obstruction by blood or sputum, displacement of the selective endotracheal tube, bronchospasm, and pneumothorax. Monitoring of Spo2 by pulse oximetry would therefore seem to be mandatory during thoracic surgery, in order to allow an early diagnosis of hypoxaemia and speed up the treatment of its cause.

[Development of a screening scale for children at risk of baby bottle tooth decay]. / Élaboration d'un score de dépistage des enfants à risque du syndrome du biberon.

OBJECTIVE: Baby bottle tooth decay is a severe form of early childhood caries. This study aims to elaborate a screening tool for at risk children in order to facilitate primary prevention. METHODS: A case-control study was conducted among children suffering from baby bottle tooth decay and children with no dental caries. Cases were children aged 5 years or less at diagnosis who experienced at least four caries with one or more affecting maxillary incisors. Controls were children matched for age and sex. Parents were interviewed by phone about their child's exposure to potential risk factors. RESULTS: We included 88 children suffering from baby bottle tooth decay and 88 children with no dental caries. In multivariate analysis, low social class (OR 6.39 [95% CI, 1.45-28.11]), prolonged bottle feeding or bedtime feeding (OR 153.2 [95% CI, 11.77-1994.96]), and snacking (OR 5.94 [95% CI, 1.35-26.2]) were significantly associated with baby bottle tooth decay. Regular dental visits were a significant protecting factor (OR 0.13 [95% CI, 0.02-0.77]). A score was developed using these significant risk factors and tested on the survey population. The mean score was 13/20 for cases and 4/20 for controls. DISCUSSION: These results are in accordance with the literature, except for brushing teeth, which was not significantly associated with baby bottle tooth decay in our study. CONCLUSION: A screening scale with a score of 20 points was proposed. Future validation is required. Pediatricians and general practitioners should encourage parents to change their habits.

CD-ROM continuous medical education model for the management of urinary tract infections in family practice.

OBJECTIVES: This study had for aim to assess the acceptability of a model for continuing medical education, to improve the implementation of best practice recommendations for family practice. The training focused on the management of community acquired urinary tract infections in adults. The secondary objective was to identify barriers in the implementation of these best practice recommendations. METHODS: We conducted a prospective qualitative study. The intervention included an initial knowledge test, an audio-visual CD-ROM presentation, and a second knowledge test. After the session, family practitioners (FP) were asked to answer a face-to-face questionnaire in order to give their opinion on the training session. Ten FP, working in the Savoie and Isère sub-divisions in France, were included. RESULTS: All FP were satisfied with the e-learning training session. The element of the session, they best appreciated, was the audio-visual presentation. The comparison between initial and second test results showed a non-significant improvement of knowledge (P=0.07). The barriers, most frequently mentioned for knowledge and use of best practice recommendations, were: lack of time, content unfit for family practice, habits, and the very broad field of expertise required. CONCLUSION: FP accepted this model of continuing medical education. E-learning seems relevant to improve the implementation of best practice recommendations in family practice.

[Mortality and morbidity conference: A tool for quality and safety of care continuous improvement]. / La Revue de mortalité et morbidité : une méthode d'amélioration continue de la qualité et la sécurité des soins.

OBJECTIVE: The mortality and morbidity conference (MMC) is one of the keystones in the evaluation of quality of care. The objective of this work was to describe a MMC by presenting a case report. CASE REPORT: A 16-year old man suffering from chronic anaemia had to be transfused with two units of red blood cells in an outpatient unit. Although the transfusion went well for the first unit, the patient presented haemolysis during the transfusion of the second unit because the nurse administered the wrong unit. The incident was analysed during a mortality and morbidity conference with the attendance of the hemovigilance local correspondent. Immediate causes of the event were the failure to respect the transfusion procedure: in advance compatibility testing, failure to check the patient and blood component identification just before the transfusion. Factors contributing to the event were the deviation of transfusion practices, poor working conditions of nurses, linked to inadequate staff in relation to the activity. The discussion of the incident led to develop an action plan. DISCUSSION: This case shows the interest for staff members to discuss an adverse event. However, a well-defined methodology for conducting mortality and morbidity conferences is lacking and leads to a wide heterogeneity between teams. Major differences refer to criteria for case selection and quality of participants. This heterogeneity is likely to have an impact of the efficacy of mortality and morbidity conferences regarding the quality and safety of care.

Smart control of monodisperse Stöber silica particles: effect of reactant addition rate on growth process.

Control over the synthesis of monodisperse silica particles up to mesoscopic scale is generally made difficult due to intrinsic limitation to submicrometric dimensions and secondary nucleation in seeded experiments. To investigate this issue and overcome these difficulties, we have implemented single step processing by quantifying the effects of the progressive addition of a diluted tetraethyl orthosilicate solution in ethanol on the size and monodispersity of silica particles. Contrary to particles grown in seeded polymerization, monodisperse particles with size up to 2 microm were synthesized. Moreover, the particles exhibit a final diameter (d(f)), which varies with V(-1/3) over more than 2 orders of magnitude in rate of addition (V). On the basis of a kinetic study in the presence of addition showing that particle growth is limited by the diffusion of monomer species, we developed a diffusion-limited growth model to theoretically explain the observed d(f)(V) behavior and quantitatively retrieve the measured amplitude and exponent. Using a single parameter procedure, we can therefore predict and generate in the room temperature range, monodisperse particles of a targeted size by simply adjusting the rate of addition.

Arterial pressure and neurologic morbidity during carotid surgery under peridural anesthesia.

In 163 carotid reconstructions under peridural anesthesia performed from 1988 to 1991, we routinely measured residual systemic and carotid artery pressure during clamping. Seventy-nine patients (48.5%) were asymptomatic and 84 (51.5%) had a history of neurologic manifestations in the form of transient ischemic attacks (28%) or stroke (13.5%). None of the patients died perioperatvely. Eight patients (4.9%) had strokes, with complete recovery in five. A shunt was placed in 22 patients (13.5%) because of neurologic evidence that carotid clamping was poorly tolerated. This study showed a distinct association between residual pressure in the internal carotid artery and systemic arterial pressure and intraoperative neurologic morbidity. Using a cutoff value of 35 mm Hg for residual pressure, the sensitivity was 77% and specificity 81%. Using a cutoff of 80 mm Hg, the sensitivity was 60% and specificity 86%. There was no correlation between mean systemic arterial pressure and residual carotid artery pressure. The use of a shunt was the only factor with predictive value for postoperative neurologic complications. These findings suggest that measurement of systemic arterial pressure and residual carotid artery pressure is useful during carotid surgery, but further study is needed before this information can be extrapolated to carotid surgery under general anesthesia.

Postoperative analgesia by epidural methylprednisolone after posterolateral thoracotomy.

The aim of this study was to evaluate the potential analgesic effect of epidural methylprednisolone (MP) after posterolateral thoracotomy (PLT). Adult male patients undergoing PLT for lung surgery were included in a prospective, randomized, double blind study. Peroperative analgesia (bupivacaine plus sufentanil) was given by a thoracic epidural catheter associated with general anaesthesia. After surgery, patients received either MP 1 mg kg(-1) followed by a continuous epidural infusion of MP 1.5 mg kg(-1) during 48 h (MP group) or 0.9% saline as a bolus injection and continuous epidural infusion (P group). Additional morphine analgesia was administered by i.v. patient-controlled analgesia. Pain was assessed at rest and with mobilization every 4 h after operation during 48 h with a visual analogue scale (VAS). The primary end-point was the total morphine requirements during the 48 first postoperative hour. Twenty-four patients were allocated to MP (n=12) and P (n=12) groups. Characteristics of the two groups were similar. There were no differences between groups for morphine requirements (median and interquartile range) during the 48 h: 59 mg (40-78) in MP group vs 65 mg (59-93) in P group. There were no differences between groups for morphine requirements every 4 h during the 48 h and VAS for pain at rest and evoked pain. No side effects were reported. It was concluded in this small study that these results did not support the use of epidural steroids for postoperative analgesia after PLT.

Influence of respiratory disease on perioperative cardiac risk in patients undergoing elective surgery for abdominal aortic aneurysm.

We retrospectively reviewed perioperative cardiac complications in a series of 214 patients who underwent surgical treatment for infrarenal aortic aneurysm between 1992 and 1996. There were 192 men and 22 women, with a mean age of 68.3 years. Cardiac risk factors included angina in 28% of patients and previous myocardial infarction in 25%. Resting electrocardiography was normal in 80 patients (37.5%). Depending on clinical findings, thallium-201 scintigraphy was undertaken in 76 patients (35.5%) and led to elective coronary arteriography in 22 patients (10%). Results of coronary arteriography revealed lesions in 14 patients. Aortic reconstruction was performed by the transperitoneal route in all patients. Procedures consisted of aortoaortic bypass (63%), aortobiiliac bypass (27.5%), or aortobifemoral bypass (9.5%). Nine patients (4.2%) died within the first 30 postoperative days. The cause of death was myocardial infarction (MI) in two patients (1%), colonic necrosis in two (1%), acute pancreatitis in one (0.5%), acute renal insufficiency in three (1.4%), and multiple organ failure in one patient (0.5%). Nonfatal cardiac complications were observed in 15 patients (7%). Statistical analysis of risk factors revealed two predictors of perioperative cardiac complications, i.e., history of chronic bronchitis and reoperation. On review of the literature, we cannot propose a routine preoperative work-up. Prospective multicentric studies are needed to determine the predictive value of current preoperative screening methods.