Impact of direct ICU admission of pneumococcal meningitis in France: a retrospective analysis of a French medico-administrative (PMSI) database.

BACKGROUND: Current guidelines for adult patients with pneumococcal meningitis (PM) recommend initial management in intermediate or intensive care units (ICU), but evidence to support these recommendations is limited. We aimed to describe ICU admission practices of patients with PM. METHODS: We conducted a retrospective analysis of the French medico administrative database of consecutive adult patients with PM and sepsis criteria hospitalized between 2011 and 2020. We defined two groups, "Direct ICU" corresponding to a direct ICU admission and "Delayed ICU" corresponding to a secondary ICU admission. RESULTS: We identified 4052 patients hospitalized for a first episode of PM, including 2006 "Direct ICU" patients (50%) and 2046 "delayed ICU" patients (50%). The patients were mainly males [n = 2260 (56%)] with median age of 61 years [IQR 50-71] and a median Charlson index of 1 [0-3]. Among them, median SAPS II on admission was 46 [33-62], 2173 (54%) had a neurological failure on admission with 2133 (53%) in coma, 654 (16%) with brainstem failure, 488 (12%) with seizures and 779 (19%) with focal signs without coma. PM was frequently associated with pneumonia [n = 1411 (35%)], and less frequently with endocarditis [n = 317 (8%)]. The median ICU length of stay and hospital length of stay were 6 days [2-14] and 21 days [13-38], respectively. In-hospital mortality was 27% (n = 1100) and 640 (16%) patients were secondarily transferred to rehabilitation care unit. Direct ICU group was significantly more severe but after adjustment for age, sex, comorbidities, organ failures on admission and admission from home, direct ICU admission was significantly associated with a lower mortality (Odds ratio 0.67 [0.56-0.80], p < 0.01). This corresponded to one death avoided for 11 PM directly admitted in ICU. CONCLUSIONS: Among patients with PM and sepsis, direct ICU admission was associated with lower mortality rates when compared to delayed admission.

Return on investment of workplace-based prevention interventions: a systematic review.

BACKGROUND: Occupational Safety and Health is an important public health topic. Many employers may regard health promotion or prevention initiatives as an additional cost with few benefits. The aim of this systematic review is to identify the studies conducted on the return on investment (ROI) of preventive health interventions conducted within workplaces, and to describe their designs, topics and calculation methods. METHODS: We searched PubMed, Web of Science, Science Direct, National Institute for Occupational Safety and Health, International Labour Organization and Occupational Safety and Health Administration from 2013 to 2021. We included studies that evaluated prevention interventions in the workplace setting and reported an economic outcome or company-related benefits. We report the findings according to PRISMA reporting guidelines. RESULTS: We included 141 articles reporting 138 interventions. Of them, 62 (44.9%) had an experimental design, 29 (21.0%) had a quasi-experimental design, 37 (26.8%) were observational studies and 10 (7.2%) were modelling studies. The interventions' objectives were mostly related to psychosocial risks (N = 42; 30.4%), absenteeism (N = 40; 29.0%), general health (N = 35; 25.4%), specific diseases (N = 31; 22.5%), nutrition (N = 24; 17.4%), sedentarism (N = 21; 15.2%) musculoskeletal disorders (N = 17; 12.3%) and accidents (N = 14; 10.1%). The ROI calculation was positive for 78 interventions (56.5%), negative for 12 (8.7%), neutral for 13 (9.4%) and undetermined for 35 (25.4%). CONCLUSION: There were many different ROI calculations. Most studies have a positive result but randomized controlled trials have fewer positive results than other designs. It is important to conduct more high-quality studies so that results can inform employers and policy-makers.

Sick leave due to COVID-19 during the first pandemic wave in France, 2020.

OBJECTIVES: To quantify the burden of COVID-19-related sick leave during the first pandemic wave in France, accounting for sick leaves due to symptomatic COVID-19 ('symptomatic sick leaves') and those due to close contact with COVID-19 cases ('contact sick leaves'). METHODS: We combined data from a national demographic database, an occupational health survey, a social behaviour survey and a dynamic SARS-CoV-2 transmission model. Sick leave incidence from 1 March 2020 to 31 May 2020 was estimated by summing daily probabilities of symptomatic and contact sick leaves, stratified by age and administrative region. RESULTS: There were an estimated 1.70M COVID-19-related sick leaves among France's 40M working-age adults during the first pandemic wave, including 0.42M due to COVID-19 symptoms and 1.28M due to COVID-19 contacts. There was great geographical variation, with peak daily sick leave incidence ranging from 230 in Corse (Corsica) to 33 000 in Île-de-France (the greater Paris region), and greatest overall burden in regions of north-eastern France. Regional sick leave burden was generally proportional to local COVID-19 prevalence, but age-adjusted employment rates and contact behaviours also contributed. For instance, 37% of symptomatic infections occurred in Île-de-France, but 45% of sick leaves. Middle-aged workers bore disproportionately high sick leave burden, owing predominantly to greater incidence of contact sick leaves. CONCLUSIONS: France was heavily impacted by sick leave during the first pandemic wave, with COVID-19 contacts accounting for approximately three-quarters of COVID-19-related sick leaves. In the absence of representative sick leave registry data, local demography, employment patterns, epidemiological trends and contact behaviours can be synthesised to quantify sick leave burden and, in turn, predict economic consequences of infectious disease epidemics.

Use of mental health services in the aftermath of COVID-19 waves: a retrospective study conducted in a French Psychiatric and Neurosciences University Hospital.

OBJECTIVE: The COVID-19 pandemic and the restrictive measures taken to prevent its propagation had profound effects on mental health and well-being, especially in children and young adults (<25 years old). This study aimed to analyse the medium and long-term impact of the COVID-19 pandemic on the use of the mental health services, by age groups and gender. DESIGN: We conducted a retrospective study using the medical and administrative information system databases of patients, between 2019 and 2021. SETTING: This study was conducted in the Groupe Hospitalier Universitaire Paris Psychiatry and Neurosciences. OUTCOME MEASURES: We reported three indicators: the number of new patients attending outpatient clinics, the number of emergency department (ED) visits and the number of hospital admissions. METHODS: We considered the weekly number of each indicator, by age groups and by gender. We also collected the reasons of ED visits and hospital admissions. The 2020 and 2021 data were compared with the same period in 2019. The evolution of the indicators over the 3 years was analysed with interrupted time-series analysis. RESULTS: All three indicators showed a dramatic decrease during the first lockdown period (March 2020) especially for the youngest. In 2021, the activity resumed but without reaching its prepandemic level. Moreover, mental healthcare seeking was significantly lower since the beginning of the pandemic compared with the prepandemic period for all age groups, except for young women (<25 years old). Among them, there was a higher level of mental health services use in 2021, compared with 2019: +20% of new patients at the outpatient clinics, +39% of ED visits and+17% of hospital admissions. CONCLUSIONS: The COVID-19 pandemic has had severe consequences on populations' mental health, especially among young women, which seem to persist months after the end of restrictive measures.

A cross-sectional study: Nitrous oxide abuse in Parisian medical students.

BACKGROUND AND OBJECTIVES: Nitrous oxide (N2 O) has euphoric properties, which are associated with an alarming increasing misuse. A lack of data exists regarding medical students. The objectives are: (i) evaluate the prevalence of N2 O use and N2 O use disorder (NUD) among French medical students, (ii) assess whether education about addictions has an impact on consumption, (iii) draw up clinical profiles of N2 O users with or without NUD, (iv) identify factors associated with use and NUD. METHODS: A cross-sectional study among medical students at Université de Paris, using an online questionnaire. RESULTS: Out of the 981 medical students (29% of the total medical students) who completed the questionnaire, 80% had used N2 O. 19% had a mild use disorder, 4% moderate, and 1% severe. N2 O use was significantly associated with the use of poppers (p < .0005), alcohol (p < .0005), and cocaine (p = .004). Factors significantly associated with NUD were alcohol use disorder (p = .017), male gender (p = .006), and being part of a student association (p = .0130). DISCUSSION AND CONCLUSION: This survey shows a high prevalence of N2 O use and NUD among medical students. It could be explained by the N2 O pharmacokinetic profile or by a perception of "harmlessness." We also identified associated risk factors that may be useful to better identify and treat students seeking help. SCIENTIFIC SIGNIFICANCE: This is the first study to evaluate the use of this product among medical students. The evaluation of factors impacting use and dependence is also new in this population, which is at risk of misuse of substances.

From psychiatric hospitals to residential facilities: Characteristics of patients who benefited from an institutional partnership.

OBJECTIVES: The population of older adults is growing fast, especially in Europe and Northern America. Old age is often associated with mental health comorbidities. Moreover, life expectancy of people suffering from psychiatric disorders has increased, but with age-related difficulties, such as loss of independence. This represents a challenge for public health policies, as this population requires specific care and living conditions. As a response, a convention was signed between living facilities for dependent elderly (EHPAD) and the GHU Paris Psychiatry and Neurosciences. The agreement included dedicated places in EHPAD for older patients with psychiatric disorders. The aim of the study was to describe the sociodemographic and clinical characteristics of those patients. METHODS: We conducted a cross-sectional study among patients who applied for an EHPAD admission. RESULTS: Between 2016 and 2019, 163 patients applied for placement in an EHPAD, and 117 were admitted (72%). Applicants were 71 years old on average. Admitted patients were older than non-admitted and lived in different Parisian sectors. Among admitted patients, nine in 10 were single, divorced or widowed, and 64.3% were childless. Almost half of them were schizophrenic or had delusional disorders (46.9%), and 65.3% were considered as moderately dependent. At the time of the study, 89 patients still lived in EHPAD. Almost half of them had anxiety and depressive disorders (48.3%), 19.1% had cognitive disorders, and 42.7% manifested agitation. CONCLUSIONS: Our study highlighted older psychiatric patients' specificities regarding their admission status into long-term living facilities.

Are there reasons behind high Handrub consumption? A French National in-depth qualitative assessment.

BACKGROUND: Hand hygiene (HH) is the most important measure for preventing healthcare-associated infections. A significant correlation between alcohol-based handrub consumption (AHRC) and observed HH compliance rates has been established. In France, publicly reported AHRC displayed a large heterogeneity across healthcare facilities (HCFs). We aimed to describe programmes for promoting HH in the top and medium AHRC scorers and to assess factors and drivers leading to a high AHRC score in a panel of French HCFs. METHODS: We performed a nationwide qualitative comparative case study based on in-depth semi-structured interviews in 16 HCFs with high, 4-year AHRC scores, and a sample of seven university hospitals (UHs) with medium AHRC scores. Infection Prevention and Control Team (IPC) members (n = 62), quality managers/chief executive officers (n = 23) and frontline workers (n = 6) were interviewed, using a grounded theory approach and an iterative thematic approach. RESULTS: Ninety-one interviews were performed. There was a large heterogeneity in IPC structures and objectives, with specific patterns associated with high AHRC that were more organisational than technical. Four areas emerged: (1) strong cohesive team structure with supportive and outcome-oriented work attitude, (2) IPC structure within the organization, (3) active support from the institution, (4) leadership and role model. Among high AHRC scorers, a good core IPC organisation, a proactive and flexible management, a frequent presence in the clinical wards, and working in a constructive safety climate were prominent. CONCLUSION: We highlighted that IPC structure and activity is heterogeneous, with organisational and behavioural characteristics associated with high AHRC score. Beyond technical challenge, our work underlines the importance of strong structure of the IPC and behavioural approaches in implementing key IPC programmes.

Older medical outliers on surgical wards: impact on 6-month outcomes.

BACKGROUND: Medical patients are on occasion admitted transiently to surgical wards when more appropriate wards are at capacity, potentially leading to suboptimal care. The aim of this study was to compare 6-month outcomes in older adults diagnosed with medical conditions in the ED then admitted inappropriately to surgical wards (defined as outliers), with outcomes in comparable patients admitted to medical wards (controls). METHODS: In a matched cohort study, 100 consecutive medical outliers from the ED aged 75 years and over were matched according to age, sex and diagnosis to 200 controls. Collected data included number of diagnoses reported in acute care, level of patient illness severity, length of stay, mortality and destination of patients discharged from acute care units (home, rehabilitation facility, nursing home or palliative care facility). An assessment was made of patient vital status and living environment (home, nursing home or hospital) at 6 months post-ED admission. RESULTS: Mean age was 85.6 years. The most common ED diagnoses were gait disorders/falls (18%), neurological disorders (17%) and exhaustion (16%). Outliers displayed lower illness severity levels (0.001) and shorter lengths of stay from ED admission to acute care discharge (p=0.040). Subsequent to acute care, outliers were less commonly discharged home (45% vs 59%) and more commonly discharged to rehabilitation facilities (42% vs 28%). At 6 months post-ED admission, multivariable regression analysis showed that outlier status (OR=0.44 (0.25-0.83); p=0.011) and numbers of diagnoses reported in acute care (OR=0.87 (0.76-0.98); p=0.028) were independently associated with lower probability of living at home. CONCLUSION: Outlying of older patients to surgical wards negatively affects their prospects of living at home at 6 months after hospital admission. Older patients hospitalised via the ED are entitled to appropriate medical care.

Sepsis and septic shock in France: incidences, outcomes and costs of care.

BACKGROUND: Sepsis is one of the leading causes of death worldwide. The associated incidence, mortality and trends do not differ greatly between documented reports. The purpose of this study was to provide an in-depth description of patients with sepsis and septic shock hospitalized in France from 2010 to 2015 and to explore the temporal trends of their clinical characteristics, costs and outcomes. METHODS: Retrospective cohort study of the French hospital administrative database in which organ failure therapies and severity scores are systematically registered. All patients admitted between 2010 and 2015 for sepsis and septic shock as defined by an ICD-10 code for infection, and for organ failure or the use of organ failure supplementation were included. Incidence, outcomes and trends were analyzed. Subgroup analyses based on several coding strategies and adjusted for severity scores were performed. RESULTS: A total of 737,147 patients with sepsis and 492,902 patients with septic shock were included. From 2010 to 2015, the incidence of sepsis and septic shock increased, respectively, from 206 to 243 and from 135 to 171 cases per 100,000 population. Case fatality remained at 34% for sepsis, but decreased from 46 to 44% for septic shock. Median hospital stay costs amounted to €11,400 (IQR: 5036; 24,364) for patients with sepsis and €16,439 (IQR: 7339; 29,360) for patients with septic shock. After adjustment for case-mix and illness severity, the risk of death was stable for sepsis (0.08% [- 0.04; 0.20] per year), but decreased for sepsis patients admitted to the intensive care unit and for cases of septic shock (- 0.33%[ - 0.40; - 0.27] per year). CONCLUSIONS: Sepsis is common, frequently fatal and expensive to treat. Its incidence has increased. Case fatality has decreased in most severely affected patients, owing partly to general improvements in care.

Factors associated with single-room assignment among patients admitted through the emergency department during influenza epidemics.

INTRODUCTION: Every winter, emergency departments (EDs) face overcrowding with patients presenting influenza-like symptoms, and organisational issues such as single room assignment and droplet precautions to avoid hospital-acquired influenza. Our main objective was to assess the impact of PCR results and patient's severity on single room assignment. METHODS: All patients admitted to Bichat-Claude Bernard Hospital through the ED and tested for influenza by PCR (GenXpert, Cepheid) or (FilmArray, BioMérieux) on a nasopharyngeal swab were retrospectively included during three influenza seasons (2015-2018. RESULTS: Of 1,330 included patients, 278 (20.9%) had a positive PCR for influenza. The median time to obtain a PCR result was 19 hours, and 238 (18.3%) patients were assigned a single room. Among patients with positive and negative influenza PCR, 22.3% and 16.7% were assigned a single room (p = 0.03). The multivariable analysis was performed on the two first epidemic periods, excluding the third epidemic because of the concomitant use of influenza immune-chromatic test. Only level 1 of the Emergency severity index (ESI) (aOR, 1.9; 95% CI, 1.3-2.8; p < 0.01) was associated with single-room assignment. PCR result was not statistically associated with the decision of single room assignment (aOR, 1.4; 95%CI, 1.0-1.4; p = 0.07). CONCLUSION: A PCR positive for influenza was not significantly associated with single-room assignment. Less than one quarter of influenza patients were adequately assigned a single room, likely due to the long turnaround time of PCR result and other conflicting indications for single room-assignment. Accelerating biological diagnosis could improve single-room assignment.

Hand hygiene improvement or antibiotic restriction to control the household transmission of extended-spectrum ß-lactamase-producing Escherichia coli: a mathematical modelling study.

BACKGROUND: The best strategy to control ESBL-producing Escherichia coli (ESBL-EC) spread in the community is lacking. METHODS: We developed an individual-based transmission model to evaluate the impact of hand hygiene (HH) improvement and reduction in antibiotic use on the within-household transmission of ESBL-EC. We used data from the literature and incorporated key elements of ESBL-EC transmission such as the frequency and nature of contacts among household members, antibiotic use in the community and hand hygiene behaviour. We introduced in a household a single ESBL-EC colonised person and simulated the transmission dynamics of ESBL-EC over a one-year time horizon. RESULTS: The probability of ESBL-EC transmission depended on the household composition and the profile of the initial carrier. In the two-person household, the probability of ESBL-EC transmission was 5.3% (95% CI 5.0-5.6) or 6.6% (6.3-6.9) when the index person was a woman or a man, respectively. In a four-person household, the probability of transmission varied from 61.4% (60.9-62.0) to 68.8% (68.3-69.3) and was the highest when the index patient was the baby. Improving HH by 50% reduced the probability of transmission by 33-62%. Antibiotic restriction by 50% reduced the transmission by 2-6%. CONCLUSIONS: The transmission of ESBL-EC is frequent in households and especially those with a baby. Antibiotic reduction had little impact on ESBL-EC. Improvement of hygiene in the community could help prevent transmission of ESBL-EC.

The Insertion Site Should Be Considered for the Empirical Therapy of Short-Term Central Venous and Arterial Catheter-Related Infections.

OBJECTIVES: Little is known on causative pathogens of intravascular catheters infection according to the catheter insertion site. The present study aimed to describe the epidemiology of causative microorganisms of catheter-related infection and colonization according to the insertion site. DESIGN: Multicenter observational study using data from four large randomized controlled trials investigating different prevention strategies in which extensive prospective high-quality data collection at catheter insertion and catheter removal was performed. SETTING: Twenty-five ICUs in France. PATIENTS: Patients were recruited from 2006 to 2014 as soon as they required a catheterization with a short-term central venous catheter or peripheral arterial catheter with an expected duration of use of more than 48 hours. We described the distribution of microorganisms in central venous catheter and arterial catheter-related bloodstream infections and colonization according to the insertion type (femoral vs nonfemoral) included in the four studies. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: A total of 7,235 patients and 15,259 catheters were included. Among central venous catheter, the distribution of microorganisms associated with catheter-related bloodstream infection and colonization was significantly different between femoral and nonfemoral sites. Among central venous catheter catheter-related bloodstream infection, nonfermenting Gram-negative bacilli were more frequently detected at the femoral site (31% vs 4% for nonfemoral site; p < 0.01). After adjustment for confounding factors, the femoral site was still associated with an increased risk for catheter-related bloodstream infection due to nonfermenting Gram-negative bacilli (odds ratio, 6.33; 95% CI, 1.59-25.28; p < 0.01). Among colonized arterial catheters, the distribution of microorganisms was significantly different between femoral and radial site (p < 0.01). Colonized arterial catheters due to nonfermenting Gram-negative bacilli were more frequently observed at the femoral site (20% vs nonfemoral site 12%; p = 0.01). CONCLUSIONS: The proportion of intravascular catheter infections due to nonfermenting Gram-negative bacilli was high for the femoral insertion site. Empirical antipseudomonal therapy should be considered if a femoral catheter-related bloodstream infection is suspected.

Septic shock among patients with systemic lupus erythematosus: Short and long-term outcome. Analysis of a French nationwide database.

OBJECTIVES: We aimed to assess the characteristics, outcomes and costs of septic shock complicating Systemic Lupus Erythematosus (SLE). METHODS: Characteristics of SLE patients experiencing a septic shock in France from 2010 to 2015 were analyzed through the French medico-administrative database. Factors associated with the 1-year post-admission mortality were analyzed, the crude 1-year survival of SLE patients experiencing septic shock was compared to those admitted for another reason, and we compared the 1-year outcome associated with SLE septic shock survival to a matched SLE ICU control population. RESULTS: Among 28,522 SLE patients, 1068 experienced septic shock. The 1-year mortality rate was 43.4%. Independently of the severity, an associated Sjögren syndrome was the only specific SLE phenotype associated with mortality (HR 1.392[1.021-1.899]). Within one year, post-septic shock survivors (n = 738) were re-admitted 6.42[17.3] times with total cost of € 14,431[20,444]. Unmatched analysis showed that the outcome of patients admitted in ICU for septic shock was poorer than that of patients admitted in ICU or hospital for another disease. However, 1-year healthcare use of septic shock survivors was not different from the other ICU survivors when matched on severity. CONCLUSIONS: Septic shock is a frequent and severe complication among SLE patients even if it is not associated with more healthcare use than another episode of same severity.

Investigating the cultural and contextual determinants of antimicrobial stewardship programmes across low-, middle- and high-income countries-A qualitative study.

BACKGROUND: Most of the evidence on antimicrobial stewardship programmes (ASP) to help sustain the effectiveness of antimicrobials is generated in high income countries. We report a study investigating implementation of ASP in secondary care across low-, middle- and high-income countries. The objective of this study was to map the key contextual, including cultural, drivers of the development and implementation of ASP across different resource settings. MATERIALS AND METHODS: Healthcare professionals responsible for implementing ASP in hospitals in England, France, Norway, India, and Burkina Faso were invited to participate in face-to face interviews. Field notes from observations, documentary evidence, and interview transcripts were analysed using grounded theory approach. The key emerging categories were analysed iteratively using constant comparison, initial coding, going back the field for further data collection, and focused coding. Theoretical sampling was applied until the categories were saturated. Cross-validation and triangulation of the findings were achieved through the multiple data sources. RESULTS: 54 participants from 24 hospitals (England 9 participants/4 hospitals; Norway 13 participants/4 hospitals; France 9 participants/7 hospitals; India 13 participants/ 7 hospitals; Burkina Faso 8 participants/2 hospitals) were interviewed. Across Norway, France and England there was consistency in ASP structures. In India and Burkina Faso there were country level heterogeneity in ASP. State support for ASP was perceived as essential in countries where it is lacking (India, Burkina Faso), and where it was present, it was perceived as a barrier (England, France). Professional boundaries are one of the key cultural determinants dictating involvement in initiatives with doctors recognised as leaders in ASP. Nurse and pharmacist involvement was limited to England. The surgical specialty was identified as most difficult to engage with in each country. Despite challenges, one hospital in India provided the best example of interdisciplinary ASP, championed through organisational leadership. CONCLUSIONS: ASP initiatives in this study were restricted by professional boundaries and hierarchies, with lack of engagement with the wider healthcare workforce. There needs to be promotion of interdisciplinary team work including pharmacists and nurses, depending on the available healthcare workforce in different countries, in ASP. The surgical pathway remains a hard to reach, but critical target for ASP globally. There is a need to develop contextually driven ASP targeting the surgical pathway in different resource settings.

Evaluation of hospital length of stay and revenues as a function of admission mode, clinical pathways including observation unit stay and hospitalization characteristics.

OBJECTIVES: Hospital length of stay (days) and revenues per day (euros) could be different depending on admission mode. To determine the impact of admission mode as a function of clinical pathway, we conducted the present study. Data sources: We included 159,206 admissions to three academic hospitals during a four-year period. Data were obtained from the electronic system of the hospital trust. STUDY DESIGN: A case (through-emergency department)-control (elective (EA)) study was conducted (77,052), matched by age, stay severity and type, disease-related group, and discharge mode. Principal findings: Through-emergency department were significantly elderly, more severe, had more intensive care stays, a higher mortality rate, longer length of stay (days) (9.5 ± 12 vs. 6.8 ± 9.5; p < 0.0001), and lower revenues per day (647 ± 451 vs. 721 ± 422; p = 0.01). In case-control study, mean differences between cases and controls were: longer length of stay -0.64 and revenues per day -75.6; for ≥75 years -1.2 and -102.1; medical -0.9 and -90.4; and discharge to facilities care centers -1.5 and -81.8. Among cases, 40% had a stay in observation unit before being admitted in hospital ward. Differences were strongly reduced for patients who did not go to observation unit before being admitted. Differences were reduced from 0.64 to 0.2 days for length of stay and from 79 to 41 euros for revenues per day when patients did not stay in observation unit before being admitted. CONCLUSIONS: We conclude that admission mode is associated with length of stay and revenues. However, as differences are weak, elective admissions should not be prioritized on economic arguments. Otherwise, our study indicates that among through-emergency department admissions, observation unit stay is associated with longer length of stay and lower revenues.

Experiences and perspectives of implementing antimicrobial stewardship in five French hospitals: a qualitative study.

The aim of this study was to describe current antimicrobial stewardship programmes (ASPs) in France, both at policy level and at local implementation level, and to assess how ASP leaders (ASPL) worked and prioritised their activities. A qualitative study based on face-to-face semi-structured interviews with healthcare professionals responsible for ASPs across five French hospitals was conducted. Five infectious diseases specialists and one microbiologist were interviewed between April-June 2016. Stewards had dedicated time to perform ASP activities in two university-affiliated hospitals, whilst in the other hospitals (one university, one general and one semi-private), ASPLs had to balance these activities with clinical practice. Consequently, they had to adapt interventions according to their resources (IT or human). Responding to colleagues' consultation requests formed baseline work. Systematic and pro-active measures allowed for provision of unsolicited counselling, whilst direct counselling on wards required appropriate staffing. ASPLs aimed at increasing clinicians' ability to prescribe adequately and awareness of the unintended consequences of inappropriate use of antibiotics. Thus, persuasive, e.g. education, measures were preferred to coercive ones. ASPLs faced several challenges in implementing the ASP: overcoming physicians' or units' reluctance; and balancing the influence of medical hierarchy and professional boundaries. Beyond resources constraints, ASPLs' conceptions of their work, as well as contextual and cultural aspects, led them to adopt a persuasive and collaborative approach of counselling. This is the first qualitative study regarding ASPs in France exploring stewards' experiences and points of view.

Efficacy of subcutaneous injection of platelet-rich plasma in alopecia: A clinical and histological pilot study on a rat model with a six-month long-term follow-up experience.

PURPOSE: To assess the potential of platelet-rich plasma (PRP) subcutaneous injection of to treat alopecia and to evaluate local toxicity. MATERIALS-METHODS: Twelve Hairless rats were used. At D0, we performed systematic clinical examination and divided the rat back into four quadrants (Q). We initiated subcutaneous injection using either PRP in PRPQ+, platelet-poor plasma (PPP) in PPPQ+, physiological serum (PS) in PSQ+, or no treatment (Q4). At D7, D14, D21, and D28 but also second month (M2), M3, M4, M5, rats had exactly the same injection procedure. Follow-up with PRP efficacy and toxicity at D28 and M6 using clinical and histological evaluation was performed. RESULTS: Hair density was significantly improved at D28 and at M6 for PRPQ+ vs PSQ+ (respectively, P = .0156 and P = .0313), PPPQ+ (respectively, P = .042 and P = .046). Significant histological improvement was observed between D28 and M6, for PRPQ+ vs PPPQ+ and PSQ+ for vessels (respectively, P = .0160 and P = .021), collagen (respectively, P = .0036 and P = .032), and epithelium (respectively, P = .0138 and P = .022) with no local toxicity. CONCLUSION: Our study suggests that subcutaneous PRP injections using controlled concentration of platelets and leukocytes improve hair growth.

Universal or targeted approach to prevent the transmission of extended-spectrum beta-lactamase-producing Enterobacteriaceae in intensive care units: a cost-effectiveness analysis.

OBJECTIVE: Several control strategies have been used to limit the transmission of multidrug-resistant organisms in hospitals. However, their implementation is expensive and effectiveness of interventions for the control of extended-spectrum beta-lactamase-producing Enterobacteriaceae (ESBL-PE) spread is controversial. Here, we aim to assess the cost-effectiveness of hospital-based strategies to prevent ESBL-PE transmission and infections. DESIGN: Cost-effectiveness analysis based on dynamic, stochastic transmission model over a 1-year time horizon. PATIENTS AND SETTING: Patients hospitalised in a hypothetical 10-bed intensive care unit (ICU) in a high-income country. INTERVENTIONS: Base case scenario compared with (1) universal strategies (eg, improvement of hand hygiene (HH) among healthcare workers, antibiotic stewardship), (2) targeted strategies (eg, screening of patient for ESBL-PE at ICU admission and contact precautions or cohorting of carriers) and (3) mixed strategies (eg, targeted approaches combined with antibiotic stewardship). MAIN OUTCOMES AND MEASURES: Cases of ESBL-PE transmission, infections, cost of intervention, cost of infections, incremental cost per infection avoided. RESULTS: In the base case scenario, 15 transmissions and five infections due to ESBL-PE occurred per 100 ICU admissions, representing a mean cost of €94 792. All control strategies improved health outcomes and reduced costs associated with ESBL-PE infections. The overall costs (cost of intervention and infections) were the lowest for HH compliance improvement from 55%/60% before/after contact with a patient to 80%/80%. CONCLUSIONS: Improved compliance with HH was the most cost-saving strategy to prevent the transmission of ESBL-PE. Antibiotic stewardship was not cost-effective. However, adding antibiotic restriction strategy to HH or screening and cohorting strategies slightly improved their effectiveness and may be worthy of consideration by decision-makers.

Intra-articular Injection of Mesenchymal Stem Cells and Platelet-Rich Plasma to Treat Patellofemoral Osteoarthritis: Preliminary Results of a Long-Term Pilot Study.

PURPOSE: To assess the feasibility and safety of concomitant intra-articular (IA) knee injection of mesenchymal stem cells (MSCs) and platelet-rich plasma (PRP) under fluoroscopic guidance to treat patellofemoral osteoarthritis (OA). MATERIALS AND METHODS: This prospective study included 19 consecutive patients referred for fluoroscopically guided IA MSC and PRP injection for symptomatic patellofemoral chondropathy in which conservative treatment had failed. Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score and magnetic resonance (MR) data, including T2 mapping sequence, were prospectively collected before and 6 months after treatment. Clinical data without MR imaging were collected until 12 months after the procedure. RESULTS: WOMAC scores were significantly lower after IA injection of MSCs and PRP at 6 months and during 12-months follow-up compared with baseline (mean score decreased from 34.3 to 14.2; P < .0018). Patients reported no complications. Concerning MR imaging follow-up, there were no significant differences in grade, surface, or T2 value of the chondral lesions (P > .375). CONCLUSIONS: IA injection of MSCs and PRP in early patellofemoral OA appears to allow functional improvement.