Clinical impact and cost-consequence analysis of ePlex® blood culture identification panels for the rapid diagnosis of bloodstream infections: a single-center randomized controlled trial.

To assess clinical impact and perform cost-consequence analysis of the broadest multiplex PCR panels available for the rapid diagnosis of bloodstream infections (BSI). Single-center, randomized controlled trial conducted from June 2019 to February 2021 at a French University hospital with an institutional antimicrobial stewardship program. Primary endpoint was the percentage of patients with optimized antimicrobial treatment 12 h after transmission of positivity and Gram stain results from the first positive BC. This percentage was significantly higher in the multiplex PCR (mPCR) group (90/105 = 85.7% %, CI95% [77.5 ; 91.8] vs. 68/107 = 63.6%, CI95% [53.7 ; 72.6]; p < 10- 3) at interim analysis, resulting in the early termination of the study after the inclusion of 309 patients. For patients not optimized at baseline, the median time to obtain an optimized therapy was much shorter in the mPCR group than in the control group (6.9 h, IQR [2.9; 17.8] vs. 26.4 h, IQR [3.4; 47.5]; p = 0.001). Early optimization of antibiotic therapy resulted in a non-statistically significant decrease in mortality from 12.4 to 8.8% (p = 0.306), with a trend towards a shorter median length of stay (18 vs. 20 days; p = 0.064) and a non-significant reduction in the average cost per patient of €3,065 (p = 0.15). mPCR identified all the bacteria present in 88% of the samples. Despite its higher laboratory cost, the use of multiplex PCR for BSI diagnosis leads to early-optimised therapy, seems cost-effective and could reduce mortality and length of stay. Their impact could probably be improved if implemented 24/7.

Validation of a tool for reporting pharmacists' interventions in everyday community pharmacy.

WHAT IS KNOWN AND OBJECTIVE: The French Society of Clinical Pharmacy (SFPC) asked a group of experts to adapt the SFPC hospital pharmacists' interventions reporting tool for use in community pharmacy practice. This study aimed to develop and validate a tool for the routine reporting of pharmacists' interventions in French community settings. METHODS: Two groups of community pharmacists coded reports of 60 typical pharmacists' interventions. One group was "experts" (n = 4) who had participated in the development of the tool (internal validation) and the other were "external" community pharmacists (n = 6), naïve to the tool (external validation). The Kappa coefficient was used to assess the inter-reliability of classification between participants. A 4-level Likert scale was used to evaluate ease of use and acceptability. RESULTS AND DISCUSSION: The tool we developed for recording and classifying PIs has 19 items; 11 non-ordered categories describing drug-related problems; and 7 items describing interventions. Two tables of definitions were provided to help community pharmacists in the classification. The mean κ statistic was (i) 0.63 for experts and 0.73 for external community pharmacists in categorizing drug-related problems and (ii) 0.69 for experts and 0.75 for external community pharmacists in categorizing interventions. WHAT IS NEW AND CONCLUSION: A specific tool for the documentation of pharmacists' interventions in community pharmacies is now available in French. Besides being useful to describe pharmacists' interventions in studies in community settings, it can be used to document the pharmaceutical patient record and to support the traceability process.

Illness representation and treatment beliefs in liver transplantation: an exploratory qualitative study.

BACKGROUND: The objective of this study was to gain detailed insight concerning liver transplanted patients' representations about transplantation, graft rejection and immunosuppressive drugs to adapt the educational follow-up. PATIENTS AND METHODS: Semi-structured interviews were conducted with 8 patients. Each interview was recorded and fully transcribed. The verbatim was first coded according to the themes of the Common Sense Model and an inductive approach for the remaining text. RESULTS: Transplantation is perceived both as a recovery and a new chronic condition. Participants feel powerless in the face of the risk of graft rejection. This risk is perceived as out of control as it is not associated with specific symptoms and external causes. The individual knowledge gained about transplantation relies on real-life experience shared between patients. Many participants feel anxiety. It responds to stress caused by immunosuppressant medication intake, routine check-ups, potential side effects and chronicity of immunodepression. Messages stressing the importance of the tacrolimus in the medication therapy are strengthened by a pre-discharge pharmaceutical consultation. DISCUSSION AND CONCLUSIONS: This study suggests that healthcare providers should systematically seek to determine illness representations to optimize the educational follow-up. The patient education program for liver transplanted patients should include three types of intervention: individualized education, behavioral intervention and psychological support. It should provide a support for stress management and acceptance of the new chronic condition. The involvement of a clinical pharmacist is relevant.

2017 French health authority guidelines for neonates at risk of early-onset sepsis: Adherence and barriers in a tertiary hospital.

The objective of this study was to evaluate the adherence to the French Health Authority's 2017 guidelines concerning early-onset sepsis (EOS) in neonates. This 6-month prospective observational study was conducted in 2020 in a tertiary hospital maternity unit. Neonates were classified according to their risk of EOS and the level of appropriate surveillance was analyzed. The risk of EOS was determined for 69.9% of the 1024 included neonates. Of the 123 neonates with a moderate or high risk of EOS, the optimal clinical surveillance was 88%. Even in a tertiary hospital, with training of caregivers, adherence to guidelines was incomplete. Some corrective measures are suggested and should be applied to enhance the adherence.

Caudal cervical arthrodesis using a distractable fusion cage in a dog.

This case report describes a cervical fusion cage, surgical technique and the long-term outcome of caudal cervical arthrodesis used to stabilise dynamic spinal cord compression at the sixth and seventh cervical intervertebral disc space (C6, C7) in a dog. A seven-year-old, 41 kg, entire male Dobermann Pinscher was admitted for progressive ataxia of two weeks duration. Neurological examination revealed ambulatory tetraparesis. Computed tomographic myelogram scans in neutral and traction positions of the neck were performed and were used to determine presence of a dynamic component. A C6-C7 surgical distraction and stabilisation using a distractable intervertebral fusion cage was performed. There was not any deterioration of neurological status was observed on postoperative neurological evaluation. Within eight weeks after surgery, gait and postural abilities had returned to normal. Computed tomography evaluation indicated a complete bridging callus within and outside the cage at 15 weeks after surgery. There were not any complications or recurrences of initial neurological deficits observed during the 40 month follow-up period. Based on the follow-up period data, a C6-C7 dynamic spinal cord compression with disc protrusion was successfully treated by a distractable cervical fusion cage.

Fibrotic myopathy of the iliopsoas muscle in a dog.

Fibrosis of the iliopsoas muscle can result in pelvic limb lameness in dogs. In this case report we describe fibrosis after an initial injury of the iliopsoas muscle in a dog. A seven-year-old hunting dog developed an acute onset of lameness and pain of the left pelvic limb after an intense period of exercise. Two months later, the dog was referred for evaluation of a non-weight-bearing left pelvic limb lameness. Orthopaedic examination revealed pain on hyperextension and internal rotation of the left coxofemoral joint. Neurological examination revealed a decreased patellar reflex in the left pelvic limb. Computed tomographic images showed non-uniform, contrast enhancement of the left iliopsoas muscle. The animal was treated with an iliopsoas tenomyectomy. Histopathological examination of the affected iliopsoas muscle revealed endomysial and perimysial mature fibrous replacement tissue. Sixteen weeks after surgery, the dog had returned to pre-injury levels of exercise.

Treatment with rhBMP-2 of extreme radial bone atrophy secondary to fracture management in an Italian Greyhound.

rhBMP-2 solution on a collagen sponge was placed along the diaphysis of an atrophicradius, which had a history of recurring fractures. Two months after rhBMP-2 treatment, new mineralized bone was present, which significantly increased the diameter of the radius and allowed the removal of the external skeletal fixator (ESF). Due to carpo-metacarpal joint compromise, a pancarpal arthrodesis was performed seven months later. At follow-up evaluation two years later the dog was only very mildly lame.

[Is ultrasound guidance contributive to vascular access in endovascular therapy?] / Intérêt de l'écho-guidage pour accès vasculaire dans la pratique de thérapies interventionnelles endoluminales.

OBJECTIVES: The aim of this study was to evaluate the contribution of ultrasound guidance (UG) to vascular puncture in endovascular therapy. Ultrasound guidance was evaluated by comparison with the rates of failures and complications of the traditional techniques of percutaneous vascular access. MATERIALS AND METHODS: We reviewed all the consecutive percutaneous revascularizations (percutaneous transluminal angioplasty and/or stenting, treatment of aneurysms and vascular traumatisms) since the standardization of the systems of closing (extra- and endovascular). The UG began in November 2011. The main objectives of the evaluation were the rate of failure of the punctures and the rate of complications (hematoma requiring transfusion or surgery for hemostasis, false aneurysm, dissection, thrombosis, infection). The failures and the complications were compared between two groups UG- and UG+. RESULTS: Between January 2008 and December 2014, 841 punctures were carried out by femoral route (85%), brachial route (12%), popliteal route (1%), axillary route (0.5%), and posterior tibial route (0.5%) with introducers between 4F and 12F. There were 20 complications (2.3%): six hematomas, four pseudo-aneurysms, three thromboses, one nervous paralysis, one stent infection, and seven percutaneous failures. The complications and the failures were significantly lower with ultrasound guidance (0.9% vs. 3.6%; P=0.02, and 0.2% vs. 1.4%; P=0.01, respectively). CONCLUSION: Ultrasound guidance makes it possible to significantly decrease the rate of complications and failures of the percutaneous accesses. This tool allowed a clear increase in the realization of the percutaneous angioplasties in outpatient hospitalization.

[Outpatient thoracoscopic resection of lung nodules within a fast-track recovery program]. / Résection thoracoscopique ambulatoire de nodules pulmonaires dans le cadre de la réhabilitation précoce.

INTRODUCTION: The objectives of outpatient surgery are to reduce the risks related to the hospitalization, to improve the postoperative recovery and to optimize contact with family physicians. The objective of this work is to present the first unit of outpatient pulmonary surgery and to report the results of the resections of pulmonary nodules in outpatient surgery in the setting of early discharge. METHODS: The indications for the resection of nodules were discussed in a multidisciplinary thoracic oncology meeting. The patients underwent resection of one or more lung nodules by thoracoscopy after verification that they met the anaesthetic and surgical criteria for ambulatory surgery. We analyzed the characteristics of the population, the duration of surgery, the type of resection, the time of the chest drain removal and the postoperative follow-up. RESULTS: Between November 2013 and December 2014, 51 patients underwent sub-lobar pulmonary resections. Among them 7 patients (4 men and 3 women), with an average age of 57.6 years (39-64) and histories of malignant tumor, underwent 7 atypical resections and two segmentectomies in outpatient surgery (3 patients had two resections). The average operating time was 53.75min (30-90). The chest drain was removed before the third hour in 8 cases and on the third day in one case. The average tumor diameter was 10.375mm (6-23). The histology revealed a metastasis of colorectal carcinoma in 4 cases, a metastasis of a renal carcinoma in 1 case, an in situ adenocarcinoma in 1 case and a benign tumor in 3 cases. Neither recurrence nor complication was observed during an average follow-up of 6 months. CONCLUSION: Thanks to a protocol of early mobilisation and discharge included in a well established clinical care pathway, thoracoscopic resection of lung nodules is feasible, with safety in properly selected and prepared patients in outpatient surgery.

Contrast echocardiographic visualization of cough-induced right to left shunt through a patent foramen ovale.

In a series of 24 consecutive patients referred to the echocardiography laboratory because of suspected patent foramen ovale, contrast two-dimensional and M-mode echocardiographic studies were performed during normal breathing and during two provocative tests: the Valsalva maneuver and cough. A right to left shunt was visualized in 8 patients during normal breathing, in 11 patients during the Valsalva maneuver and in 17 patients during the cough test. Cardiac catheterization performed in all 24 patients and postmortem examination available in 3 patients confirmed the patency of the foramen ovale in only 15 patients. In these 15 patients, echo contrast appeared in the left heart cavities in early systole and almost simultaneously with complete right heart opacification. In contrast, for the two false positive results during the cough test, ultrasound contrast appeared at any time of the cardiac cycle when the right heart cavities had been partially cleared of contrast material. Right and left atrial pressures were simultaneously measured in four patients, and the normal interatrial pressure gradient was reversed during the Valsalva maneuver and the cough test. Echocardiography during both provocative tests showed that the interatrial septum flattened or became convex toward the left atrium. The cough test appears to be more reliable and easier to perform in critically ill patients than the Valsalva maneuver for the detection of right to left shunting through a patent foramen ovale.

Left ventricular compliance in acute myocardial infarction in man.

Left ventricular end-diastolic pressure (P) and volume (V) were measured in 12 patients with acute myocardial infarction. It was assumed that the diastolic P-V relationship was exponential and corresponded to the formula P=be KV. In 7 patients submitted to volume loading, several data points of this relationship were obtained and at zero volume, the mean intercept with the ordinates was 0.037+/-0.015 kPa (SEM) (0.28+/-0.12 mmHg). In the other 5 patients, the P-V curve was plotted through this intercept and the pressure and volume co-ordinates obtained by control. The K coefficient (passive elastic modulus) was greater, and the normalised left ventricular compliance index (dV/VdP) was smaller in the infarct group than in the control group. This suggests decreased left ventricular compliance during the acute phase of myocardial infarction. By comparing left ventricular function curves plotted using either end-diastolic pressure or end-diastolic volume as the stretch index it is possible to evaluate the relative participation of decreased compliance and depressed contractility in global left ventricular function.

Two dimensional echocardiographic visualization of ventricular septal rupture after acute anterior myocardial infarction.

In three consecutive cases of ventricular septal rupture after acute anterior myocardial infarction, wide angle two dimensional echocardiography readily visualized the septal defect, permitting the defect to be localized and its size estimated. In addition, negative contrast echoventriculography identified a left to right shunt at the ventricular level. The echocardiographic findings were corroborated by cardiac catheterization data in all patients, by perioperative examination in two and by postmortem findings in one patient. Postoperative echocardiographic studies afforded demonstration of the patch closing the defect. In patients with acute myocardial infarction associated with the sudden appearance of a systolic murmur, two dimensional echocardiography should be performed promptly in order to guide the diagnosis and management of these critically ill patients. In some patients with severe cardiogenic shock, in whom a favorable prognosis depends on rapid treatment, two dimensional echocardiography may allow the patient to be taken to surgery immediately without further study.

Treatment of early postinfarction ventricular aneurysm by intra-aortic balloon pumping and surgery.

In nine patients with medically refractory left ventricular failure and/or ventricular arrhythmias, secondary to acute formation of a ventricular aneurysm, intra-aortic balloon pumping (IABP) was instituted 24 to 36 hours before diagnostic angiographic studies. Ventricular irritability was reduced and heart failure was controlled in all patients. Eight patients underwent operation, four within 3 weeks of an acute myocardial infarction and four within 3 months. All had resection of the recent infarction and two had myocardial revascularization as well. Two of the eight patients died in the early postoperative period from intractable ventricular fibrillation. All six patients who survived the operation (mean follow-up 12 months) had excellent clinical results. Ventricular irritability was suppressed and only one patient had residual heart failure. However, there was one late death 7 months after operation. The results suggest that surgical therapy may be effective in the management of medically unresponsive arrhythmias and/or congestive heart failure in the acute or intermediate postinfarction phase. IABP assistance was helpful in supporting the circulation and reducing ventricular irritability during the preoperative and postoperative periods.

Treatment of post-myocardial infarction angina by intra-aortic ballon pumping and emergency revascularization.

Twenty-one patients with postinfarction angina (2 to 15 days after acute myocardial infarction) unresponsive to medical therapy were treated by intra-aortic balloon pumping (IABP). Anginal pain and electrocardiographic (ECG) ST-segment changes were prevented in all patients. Coronary angiograms were obtained during IABP without complication and confirmed severe coronary artery disease. Of the four nonoperated patients, three had reinfarction and two died of cardiogenic shock. Seventeen patients underwent aorta-coronary bypass grafting, associated with aneurysmectomy in two patients and closure of a ventricular septal defect in one. Sixteen patients survived the operation. All survivors are in clinically improved condition and 14 are pain free from 9 to 28 months postoperatively, but three have mild heart failure.

Hemodynamic evaluation of heterotopic heart transplantation.

To assess the relative contribution of native and donor hearts to total circulatory performance after heterotopic transplantation, we used cardiac catheterization to examine 10 patients. Left and right ventricular filling pressures significantly decreased by 41% and 36%, respectively, cardiac index increased by 25%, and pulmonary arteriolar resistance was reduced by 61%. Patients were subdivided into two groups according to the presence of one (group I) or two (group II) peaks on the aortic pressure curve. In group I, the donor left ventricle assumed total left ventricular work and 80% of right ventricular work. Because the native left ventricle could not generate enough pressure to open the aortic valve, its entire stroke volume was ejected into the common left atrium. In addition, in all four patients a native aortic regurgitation occurred in diastole and systole. In contrast, in group II, native left ventricular systolic pressure always exceeded aortic diastolic pressure. The donor left ventricle contributed 68% to systemic blood flow and the donor right ventricle 51% to pulmonary blood flow. Mild native aortic regurgitation was demonstrated in two patients only. Native left ventricular function deteriorated postoperatively in all patients (ejection fraction decreased from 0.22 +/- 0.09 to 0.14 +/- 0.08), but this deterioration was more marked in group I. Postoperative depression of native left ventricular function could not be ascribed to progression of coronary artery disease but was mainly due to reduced preload (competitive filling) and increased afterload. Thus in group I patients with more severe preoperative left ventricular dysfunction, the donor heart behaved like a total biventricular assist device. In contrast, in group II patients the donor heart acted like a partial biventricular assist device.

Delayed semielective coronary bypass surgery for unstable angina pectoris: clinical follow-up and results of postoperative treadmill exercise.

Eighty patients with continued or repeated episodes of chest pain at rest and transitory ischemic electrocardiographic (ECG) changes were classified as having unstable angina pectoris. Following 10 days of intensive medical therapy, including beta blockade, all unerwent coronary arteriography. Medical treatment completely relieved the chest pain in 43 patients (Group I, 54 percent). In 37 patients (Group II, 46 percent) angina recurred within a week of admission (12 patients) or later (25 patients). Seventeen patients were not operated upon (nine were inoperable, four refused operation, and in four operation was not recommended). Sixty-three underwent saphenous vein bypass grafting either following a month of medical therapy (Group I) or within 24 to 48 hours of recurrent angina (Group II). The over-all operative mortality rate was 1.6 percent (1 patient) and the incidence of peroperative infarction was 11 percent. Of the 62 operative survivors, 71 percent were asymptomatic (mean follow-up period 22 months). The incidence of late operative myocardial infarction was 5 percent. Of 44 operative survivors tested by treadmill ECG, 66 percent had a negative response. Thirteen patients underwent postoperative angiographic evaluation (mean, 19.5 months). The over-all patency rate was 84 percent, and in 92 percent of patients at least one graft was patent. Thus, after stabilization by medical treatment, bypass operation could be performed with a low operative mortality rate and the long-term results compare favorably with those achieved with chronic stable angina.

Mechanical circulatory assistance by intra-aortic balloon pumping for the treatment of cardiogenic shock.

Although the shock state due to acute myocardial infarction may be reversed by IABP in 80 per cent of patients, 55 to 65 per cent remain balloon-dependent. Therefore some attempt to correct the underlying anatomic abnormalities (reversible ischaemic areas and/or mechanical defects) appears necessary if these patients are to survive. With IABP catheterization studies performed in these critically-ill patients are well tolerated. Myocardial depression after cardiopulmonary by-pass is often related to subendocardial ischaemia. The combination of IABP and surgery has resulted in survival of approximately 50 per cent of patients in cardiogenic shock secondary either to a mechanical defect complicating myocardial infarction or to open-heart surgery.

Comparative haemodynamic effects of dobutamine and isoproterenol in man.

Dobutamine was infused at a rate of 8 mcg/kg/min in 17 patients with or without congestive heart failure. Cardiac output increased from an average 2.92 to 4.45 1/min/m2(p less than 0.001) with no change in mean aortic pressure (93.4 to 97.8 mmHg) and only a slight increase in heart rate (78 to 87 beats/min). Left ventricular end-diastolic pressure decreased from an average 19 to 13.7 mmHg (p less than 0.01). Peak left ventricular dp/dt was doubled (1147 to 2370 mmHg/sec, p less than 0.001) and Vmax increased from 1.08 to 2.18 circ/sec (p less than 0.001). In 10 patients given equi-inotropic doses (100 per cent increase in peak dp/dt) Isoproterenol produced a greater increase in cardiac output (71 percent) than Dobutamine /51 percent). Isoproterenol caused mean aortic pressure to fall significantly (8 percent) while no change was noted with Dobutamine. Accordingly, peripheral vascular resistances were reduced to a greater extent with Isoproterenol than with Dobutamine (p less than 0.05). Mean pulmonary arterial pressure decreased significantly (25 +/- 5.9 to 22 +/- 5.7 mmHg, p less than 0.05) with Isoproterenol infusion and remained unchanged with Dobutamine infusion. Dobutamine increased both stroke work (57 percent) and minute work (83 percent). With Isoproterenol however, only minute work was significantly increased (90 percent). Dobutamine therefore is a potent inotropic drug, with mild chronotropic and peripheral vascular effect and may be valuable in the management of severe heart failure not associated with hypotension.

Massive pulmonary embolism without arterial hypoxaemia: pathophysiology in two cases.

Two cases of massive pulmonary embolism, confirmed by angiographic or necropsy findings, were remarkable by the absence of arterial hypoxaemia. The various mechanisms responsible for arterial hypoxaemia in pulmonary embolism are discussed. It is suggested that in patients with massive pulmonary embolism a markedly decreased cardiac output might account for the absence of arterial hypoxaemia. In the light of these two cases the finding of a normal PaO2 does not rule out the diagnosis of pulmonary embolism.