Prolonged delay for controlling KPC-2-producing Klebsiella pneumoniae outbreak: the role of clinical management.

BACKGROUND: Carbapenemase-producing Enterobacteriaceae (CPE) are becoming of immediate concern for infection control policies. Prompt detection of CPE on health care setting admission is crucial to halt the spread of an outbreak. We report a cluster of 13 Klebsiella pneumoniae carbapenemase (KPC)-2-producing K pneumoniae cases in a tertiary care hospital.The objective of this study was to identify contributing factors originating the outbreak. METHODS: An outbreak investigation was conducted using descriptive epidemiology, observation of health care practices, and interviews of management staff. A root cause analysis was performed to identify patent and latent failures of infection control measures using the association of litigation and risk management method. RESULTS: The main patent failure was the delay in identifying KPC-2-producing K pneumoniae carriers. Contributing factors were work and environmental factors: understaffing, lack of predefined protocols, staff members' characteristics, and underlying patients' characteristics. Latent failures were as follows: no promotion of the national guidelines for prevention of CPE transmission, no clear procedure for the management of patients hospitalized abroad, no clear initiative for promoting a culture of quality in the hospital, biologic activity recently outsourced to a private laboratory, and poor communication among hospital members. CONCLUSION: Clinical management should be better promoted to control hospital outbreaks and should include team work and safety culture.

The response of medical virology laboratories to the influenza A(H1N1)pdm09 outbreak in Paris Île-de-France region.

The outbreak of influenza A(H1N1)pdm09 was a challenge for the laboratories of Paris Île-de-France region in charge of virological diagnosis. In order to evaluate the quality of their response to this challenge, a retrospective survey based on a self-administered standardized questionnaire was undertaken among the 18 hospital laboratories involved in A(H1N1)pdm09 virus detection over a period of 10 months from April 2009 to January 2010. All concerned laboratories responded to the survey. Due to imposed initial biosafety constraints and indications, virological diagnosis was performed in only two laboratories at the start of the studied period. Step by step, it was further settled in the other laboratories starting from June to November 2009. From the beginning, A(H1N1)pdm09-specific RT-PCR was considered the reference method while the use of rapid influenza detection tests remained temporary and concerned a minority of these laboratories. Among the overall 21,656 specimens received, a positive diagnosis of influenza A(H1N1)pdm09 was obtained in 5,390 cases (25%), the positivity range being significantly higher among women as compared to men (P<0.0001) and subjects below 45 years of age as compared to those over 65 years (P<0.0001). Two peaks in positivity frequency were observed at weeks 24 (30%, 8-12 June 2009) and 44 (50%, 26-30 October 2009) respectively, the latter one occurring 2 weeks earlier than the peak of epidemic at the national level. In contrast, a low positivity rate was detected at weeks 38-40 in relationship with other respiratory virus infections which were clinically misinterpreted as a peak of influenza epidemic. These data demonstrate the ability of medical virology laboratories of Paris Île-de-France region to provide in real time a valuable diagnosis of A(H1N1)pdm09 virus infection and a relevant view of outbreak evolution, suggesting they will be a crucial component in the management of future influenza epidemics.

The reliability and validity of the French version of the Cocaine Craving Questionnaire-Brief.

INTRODUCTION: Cocaine has become a noticeable part of the European drug scene and is the second most commonly used illicit drug among the general population. Craving is a core issue in cocaine dependence and is strongly associated with lapse and/or relapse. However, no craving scale exists in French. The objective of our study was to assess the reliability and validity of a French language version of the 10-item Cocaine Craving Questionnaire-Brief (CCQ-Brief). METHODS: A total of 131 individuals ranging in age from 18 to 65 years were enrolled in a 12-month outpatient treatment program in 2009. The participants were seeking treatment for cocaine dependence. They completed the Mini-International Neuropsychiatric Interview (MINI) and the French version of the CCQ-Brief. At the end of the interview, a Clinical Global Impression Scale (CGIS) was completed by a clinician blind to the subject's treatment group. We evaluated the internal consistency of the French CCQ-Brief using Cronbach's α coefficient and the correlation of each item with the total scale using the Pearson's coefficient. We conducted an exploratory factorial analysis followed by a scree test. Only items with factor loading >0.3 were retained. The convergent validity of the French CCQ-Brief was assessed using Pearson's correlation between the CCQ-Brief and the CGIS. RESULTS: The mean (SD) score of the 10-item CCQ-Brief was 3.4 (1.5). Cronbach's α coefficient 0.88 and remained high even when an item was deleted (ranging from 0.86 to 0.88), indicating that this tool possesses a high internal consistency. Each item exhibited a strong correlation with the total score ranging from 0.62 to 0.83. All items presented factor loadings ranged from 0.47 to 0.83. The correlation between the CCQ-Brief and the CGIS was high (r=0.49, p<0.0001), indicating a sufficient convergent validity. DISCUSSION: The French version of the CCQ-Brief is a reliable and valid instrument that can provide a comprehensive assessment of cocaine craving in treatment-seeking cocaine-dependent patients.

[Which are the predictive factors to be ranked within the 500 first medical students at the national ranking exam? A cross-sectional study of the 2009 class]. / Quels sont les facteurs prédictifs d'être reçu dans les 500 premiers à l'examen classant national (ECN) ? Une étude transversale au sein des étudiants en médecine de la promotion 2009.

PURPOSE: The objective of this study was to analyze, during a transversal study, the predictive sociodemographic and individual factors to be ranked within the first 500 medical students in the 2009 French national ranking exam (NRE). METHODS: In September 2009, 5570 medical students have chosen their subspecialty. They were invited to fill-up a questionnaire that included sociodemographics and educational items. Logistic regression was used to identify factors that were associated with being ranked within the first 500 medical students. RESULTS: A total of 4712 students (two third of women) responded to the questionnaire (92.3% response rate). The mean age of respondents was 24.7 years (±1.79). In the multivariate analysis, independent factors associated with being ranked within the first 500 medical students at the NRE were: being less than 25-year-old (odds ratio [OR]: 1.8; 95%CI: 1.3-2.5; P<0.001), region of origin (Île de France) (OR: 3.7; 95%CI: 2.3-5.8; P<0.0001), to succeed at the first medical year examination for the first time (OR: 1.7; 95%CI: 1.2-2.4; P<0.001), being in the first 20% of the medical students during externship (P<0.0001), critical reading test (CRT) teaching by graduate doctors (OR: 1.5; 95%CI: 1.05-2.1; P<0.001), and to participate in a national practicing ranking exam with a CRT (OR: 1.96; 95%CI: 1.3-3.03; P=0.002). CONCLUSION: Our study identified six factors independently associated with being ranked within the first 500 medical students in the French NRE. Education and training of the CRT, newly introduced test in 2009, seem to play an important role.

[Long-term results of laparoscopic sacral colpopexy for high-grade cystoceles]. / Résultats à long terme de la promontofixation laparoscopique dans les cystocèles de haut grade.

PURPOSE: To evaluate long-term functional and anatomical results of laparoscopic-sacral colpopexy (LSC) for the treatment of high-grade cystoceles. MATERIAL: Between 1997 and 2005, 43 women with symptomatic cystoceles of high grade (grade 3 or 4), isolated or not, were treated by LSC. All patients were seen at three months, six months and then yearly during follow-up. Each visit included an interrogatory searching for functional urinary symptoms or sexual and digestive symptoms. A clinical examination, always performed by the same operator, searched for an anatomical recurrence, which was defined by an anterior prolapse of stage greater or equals to 2. In addition, a uroflowmetry was performed systematically. Prognostic factors for cystocele recurrence were established by univariate analysis. RESULTS: With a mean follow-up of 4.1 years (2-10.1), the rate of correction of cystocele was 84%. Seven women had an anterior recurrence and were as follows: stage 2 (n=5), stage 3 (n=1) and stage 4 (n=1) associated with urinary-functional symptoms in three cases, with sexual problems in three cases or with rectal symptoms in two cases. In case of isolated cure of cystocele, we found no recurrence during follow-up. Mean uroflowmetry was 24+/-9ml/s. Nine women (21%) had dysuria associated with cystocele recurrence in four cases. Four patients had a pollakiuria (n=1), an urgenturia (n=1) or a stress-urinary incontinence (n=2) without anatomical recurrence. In a case, chronic-pelvic pain was revealing erosion of the tape into the bladder wall. No significant factor was associated with cystocele recurrence. CONCLUSION: LSC offered a viable and long-lasting correction of high-grade cystoceles, mostly when they are isolated. Anatomical recurrence was mainly revealed by the occurrence of functional symptoms. In case of atypical urinary symptoms, a cystoscopy has to be done to look for an erosion into the bladder wall.