Drug re-challenges in cutaneous adverse drug reactions: information and effectiveness in the long-term management of patients.

BACKGROUND: In patients with cutaneous adverse drug reactions (CADR), drug skin tests and re-challenge under hospital surveillance (RCH) are helpful. The aim of this study was to determine if patients with negative drug RCH can tolerate subsequent treatments with the same drugs. PATIENTS AND METHODS: Patients with a negative RCH in the last 10 years answered a telephone questionnaire which was delivered by the same investigator in order to determine if subsequently the patients were able to tolerate the drug with which they had a negative RCH and also to study the reasons why the drugs were not taken again. RESULTS: Six hundred and thirty-seven RCH were analyzed (349 patients, mean age 47 years), 134 drugs were taken again (group A) and 359 were not (group B). In group A, 12 reactions occurred in 10 patients (9%). In group B, drugs were not taken again because 76% of the patients evaluated for an intolerance to antibiotics or radiocontrast media did not require a new course of these products or because their general practitioner (GP) did not want to prescribe these drugs. DISCUSSION: Ninety percent of the RCH (88.5% of the patients) with a CADR followed by investigations and a RCH have a good tolerance to subsequent treatment with the RC drug. The mechanisms involved in this intolerance despite negative RCH are discussed. CONCLUSION: The provocation test procedure, considered as useful by 88% of the patients, has a good negative predictive value. Furthermore, these investigations need to be accompanied by clear information on the patient and his GP.

[Incidence of chronic kidney disease in general population, EPIRAN study]. / Incidence de l'insuffisance rénale chronique en population générale, étude EPIRAN.

AIMS: To assess incidence of chronic kidney disease in general population and to describe baseline characteristics of incident patients. METHODS: Between 1st/01/04 and 30/06/06 all incident cases of chronic kidney disease in the Nancy district were prospectively identified. New cases were identified from all medical laboratories in this area and determined by a persistently increased serum creatinine level (> or = 150micromol/l, or paediatric levels) for 3 months after the 1st/01/04, and by living in Nancy area. RESULTS: The annual incidence rate of detected chronic kidney disease was 1 per thousand inhabitants (1,3 per thousand for men and 0,7 per thousand for women). Incidents patients were old (mean age: 77 years) and with numerous comorbidities (diabetes: 34 %, cardiac failure: 23 %). More than 30% of incident patients were diagnosed at sever stage of chronic kidney disease (<30ml/min/1,73m(2)). CONCLUSIONS: The annual incidence of diagnosed chronic kidney disease is common: 10 times more than end-stage renal disease in France. Most of these patients are diagnosed in a severe stage of chronic kidney disease whereas they could be detected earlier and benefit from adequate, appropriate and multidisciplinary take care.

[Interventions implemented to control an outbreak of vancomycin-resistant enterococci in a university hospital]. / Conduite adoptée face à une épidémie à ERG (ERV) dans un établissement de santé

At the end of 2004, a Vancomycin-resistant enterococci (VRE) outbreak occurred in the university hospital of Nancy. Interventions were simultaneous implemented in this hospital (promotion of hand washing, gathering of VRE carriers in the same part of units) and the outbreak seemed to be controlled before the end of 2005. But one year later, the number of discovered new colonisations increased again. Then, promotion of exclusive hand disinfection with alcohol-based hand-rub solutions and cohorting of VRE carriers in a dedicate ward were the only two effective interventions to control the outbreak. At the beginning of the year 2007, before being controlled, this outbreak expanded to several other healthcare centres in Lorraine. A specific regional team was set up in July 2007. A programme to eradicate VRE was elaborated based on national guidelines modified and adapted regarding particularities of each situation. These new guidelines were published on an internet site. A list of all healthcare centres accommodating patients colonized with VRE is established weekly and diffused to all hospitals in Lorraine which then could optimise readmission conditions of potential VRE carriers or contact patients. Between 2004 and 2008, more than 900 patients were found colonized with VRE in Lorraine. Finally, the application of all the measures previously described, seemed to be efficient to control the ERV outbreak in Lorraine.

Functional disability in France and its relationship with health-related quality of life - a population-based prevalence study.

OBJECTIVE: To estimate the prevalence of functional disability in France and assess its association with the health-related quality of life (HRQoL). METHODS: Each member in 8,000 households randomly selected in the Lorraine population were mailed a questionnaire asking about their sociodemographic characteristics; the presence of chronic locomotor or non-rheumatic diseases; functional disability on the Health Assessment Questionnaire (HAQ); and HRQoL on the Duke Health Profile. The prevalence of functional disability was described, and its relationship with HRQoL was assessed by logistic regression analysis. RESULTS: Among the 6,148 subjects who responded (mean age 46 years +/- 18.3, 48% men), the prevalence of moderate (HAQ >or= 1) and severe (HAQ >or= 2) functional disability, adjusted for age and sex, was 6.5% and 1.6% respectively. HRQoL was significantly low in all dimensions for subjects with severe functional disability. Functional disability of locomotor origin significantly affected the physical (OR = 10.6 [5.1-22.1]), mental (OR = 4.4 [2.5-7.8]), and social (OR = 2.4 [1.4-4.3]) dimensions, with a threshold effect according to the disability level and perceived health (OR= 10.6 [5.8-19.4]), with a cause-effect relationship. CONCLUSION: The prevalence of reported (i.e., not observed) functional disability in terms of its impact on HRQoL helps physicians to better understand its differential consequences, which should ease patient dependence, facilitate the analysis of health care needs and the development of prevention measures, and improve the HRQoL of patients and their families.

Relationship between procalcitonin values and infection in brain-dead organ donors.

BACKGROUND AND AIMS: An association between the inflammatory reactions estimated by several biomarkers and organ dysfunction has been reported in brain-dead organ donors (BDOD). Procalcitonin (PCT), a biomarker of inflammation due to bacterial infection, is increased among BDOD. However, is not known whether infection changes PCT values in BDOD. MATERIALS AND METHODS: We retrospectively analyzed 82 BDOD including several demographic and clinical parameters, bacterial culture results, antibiotics prescription, and plasma values of PCT measured before organ harvesting. Infection was diagnosed to be either a positive bacterial culture (restricted definition) and/or prescription of antibiotics (extended definition). RESULTS: The median PCT value was 1.5 (interquartile range [IQR], 0.4 to 6.9; range, 0 to 526 ng/mL; n=82). Thirty-eight (46%) and 24 (29%) patients had PCT values>2 ng/mL and >5 ng/mL, respectively. Median PCT values among infected (1.18; IQR, 0.27 to 6.55 ng/mL) versus noninfected (1.57; IQR, 0.53 to 7.15 ng/mL) BDOD (restricted definition) were not different (P=.36). The area under the receiver operating characteristic curve using PCT to predict infection (restricted definition) was 0.52. Specificity of PCT to predict infection was above 80% at PCT values>9 ng/mL. CONCLUSION: Our results confirmed PCT values are increased in BDOD, suggesting that this was not related to an infectious cause (whatever definition was used) unless PCT values are high.

Factors associated with anemia among incident pre-dialysis patients managed within a French care network.

BACKGROUND AND AIMS: Despite guidelines concerning the management of renal anemia, the international literature reports that a large proportion of pre-dialysis patients have hemoglobin values lower than the recommended level. The present study analyzed the evolution of pre-dialysis Hb levels and erythropoietin use over a 4-year period and investigated factors associated with anemia. METHODS: A total of 1315 patients initiating dialysis in Lorraine, France, were enrolled since 2001-2004. For each year, anemia, defined by Hb <11 g/dl, and erythropoietin use were investigated in three groups: all patients, patients whose dialysis was planned and patients whose dialysis was unplanned. RESULTS: At initiation of dialysis, all groups showed increases over time in mean hemoglobin levels, proportion of patients without anemia and with erythropoietin therapy. Among patients whose first dialysis was planned in 2004, 43.8% had anemia and 67.9% had received erythropoietin, compared with 75.4% and 29.4%, respectively, when dialysis was unplanned. Patients receiving unplanned dialysis were more likely to have anemia (odds ratio (OR) = 2.6), as were those with a serum albumin level < 3.5 g/dl (OR = 2.1), body mass index < 30 kg/m2 (OR = 1.9) (all p < 0.001) or glomerular filtration rate < 10 ml/min/1.73 m2 (OR = 1.4, p = 0.04). The year of dialysis initiation was also associated with anemia (p = 0.024). CONCLUSION: The proportion ofpatients starting dialysis with anemia might be reduced by earlier nephrology referral leading to erythropoietin administration, planned first dialysis while residual renal function remains, and greater attention to nutritional status.

Respiratory infections associated with nontuberculous mycobacteria in non-HIV patients.

The incidence of nontuberculous mycobacteria (NTM) pulmonary diseases in HIV-negative patients was studied prospectively from January 1, 2001 to December 31, 2003 by 32 sentinel sites distributed throughout France. In total, 262 patients who yielded NTM isolates from respiratory clinical specimens, met the bacteriological, radiological and clinical criteria established by the American Thoracic Society for NTM respiratory disease. Among the 262 NTM isolates, 234 were slow-growing mycobacteria (125 Mycobacterium avium-intracellulare complex (MAC), 66 M. xenopi, 34 M. kansasii) and 28 were rapidly growing mycobacteria (25 M. abscessus complex). In the Paris area, M. xenopi was the most frequently isolated species, followed by MAC. Most patients (>50%), except those with M. kansasii, had underlying predisposing factors such as pre-existing pulmonary disease or immune deficiency. Asthenia, weight loss, chronic cough and dyspnoea were the most common clinical symptoms. The classical radiological appearance of NTM infections was indistinguishable from that observed in patients with pulmonary tuberculosis. In summary, the incidence of nontuberculous mycobacteria pulmonary infections in HIV-negative patients was estimated at 0.74, 0.73 and 0.72 cases per 100,000 inhabitants in 2001, 2002 and 2003, respectively.

[Validation of a screening test of language and learning disorders for 6-year old children (ERTLA6)--a prospective study]. / Validité des epreuves du repérage des troubles du langage et des apprentissages de l'enfant de 6 ans (ERTLA6)--etude prospective.

Medical practitioners are, like the other health, education and childhood professionals, important actors of the language and learning disorders' screening. Six years old--the age at which children start the elementary school--is a key age for this screening. At the request of practitioners, a multidisciplinary staff had developed a screening tool: ERTLA6 (Epreuves de repérage des troubles du langage et des apprentissages de l'enfant de 6 ans). The objective was to validate the capacity of ERTLA6 to predict the school performance. A sample of 187 children was randomly constituted among the whole population of last year nursery school children in an area of France (the Académie de Nancy-Metz). Those children, aged from 5 to 6, were screened with ERTLA6 by the school practitioner during a medical visit (score from 0 [the best] to 18 [the worse]). The School outcomes (considered as judgment criteria) were assessed 2 or 3 years later, after two years of elementary school. 148 children had completed their follow-up (the others: 27 moving house, 6 absents the day of evaluation, 2 missing data). Mean age was 5; 10 years. With a threshold > or = 7, ERTLA6 sensibility and specificity were respectively 79% [63-94] and 87% [81-93]; the positive predictive value was 58% [42-74], the negative predictive value was 95% [90-99]. The percentage of well classified children was 84% [69-99]. To our knowledge, ERTLA6 is the first validated tool in France for screening language and learning disorders which can be used by practitioners for the prediction of school outcomes.

Early referral to a nephrologist is associated with better outcomes in type 2 diabetes patients with end-stage renal disease.

OBJECTIVE: End-stage renal disease (ESRD) requiring renal replacement therapy (RRT) is a late complication of type 2 diabetes. The correlation between pre-ESRD medical care and outcome has been rarely studied in France. METHODS: Community-based study of case-incIdent ESRD patients. Medical care practices were described retrospectively when starting RRT. Medical status, mortality, morbIdity, and quality-of-life were recorded prospectively. RESULTS: One hundred and fourty-eight ESRD patients with type 2 diabetes were included. Factors independently correlated with mortality within 3 Months of RRT onset were presence of physical impairment of ambulation at onset of RRT [odd ratio (OR): 5, (95%CI: 1.9-13.3)], and starting RRT in life-threatening circumstances [OR: 3.6, (95%CI: 1.2-10.7)]. Factors independently correlated with "poor outcome" 1 Year after the onset of RRT were BMI less than 20 kg/m2 [OR: 13.4, (95%CI: 1.5-120.2)] and presence of 2 [OR: 2.7, (95%CI: 0.9-8.4)], or 3 or more comorbId conditions [OR: 4, (95% CI: 1.4-11)]. Three Months after the first RRT session, survival was 16.4% better for patients who had had regular nephrological care versus none, and 9.1% better for those who had had late nephrological care versus none. Type 2 diabetes patients starting RRT in an emergency setting had had significant less regular nephrological care. Length of their first hospital stay was significantly longer. They were more likely to have lower resIdual renal function, gastrointestinal symptoms, lower serum albumin, lower hematocrit, lower serum calcium, and higher serum phosphorus. CONCLUSIONS: During the course of chronic renal failure in type 2 diabetes patients, early implementation of nephrological well-established guIdelines is associated with better outcome after starting RRT.