Association between burnout and stigma in physicians

BACKGROUND

Physicians suffering from burnout are more likely to develop depression, substance dependence, and cardiovascular diseases, which can affect their practices. Stigmatization is a barrier to seeking treatment. This study aimed to understand the complex links between burnout among medical doctors and the perceived stigma.

METHODS AND FINDINGS

Online questionnaires were sent to medical doctors working in five different departments of the Geneva University Hospital. The Maslach Burnout Inventory (MBI) was used to assess burnout. The Stigma of Occupational Stress Scale in Doctors (SOSS-D) was used to measure the three stigma dimensions. Three hundred and eight physicians participated in the survey (response rate: 34%). Physicians with burnout (47%) were more likely to hold stigmatized views. Emotional exhaustion was moderately correlated with perceived structural stigma (r = 0.37, P < .001) and weakly correlated with perceived stigma (r = 0.25, P = 0.011). Depersonalization was weakly correlated with personal stigma (r = 0.23, P = 0.04) and perceived other stigma (r = 0.25, P = 0.018).

CONCLUSION

These results suggest the need to adjust for existing burnout and stigma management. Further research needs to be conducted on how high burnout and stigmatization impact collective burnout, stigmatization, and treatment delay.

A new clinical severity score for the management of acute small bowel obstruction

Objective

Small bowel obstruction (SBO) is a common hospital admission diagnosis. Identification of patients who will require a surgical resection because of a non-viable small bowel remains a challenge. We aimed to identify risk factors for intestinal resection in patients with SBO and to develop a practical clinical score designed to guide surgical vs. conservative management.

Methods

We performed a prospective cohort study and included all patients admitted for an acute SBO between 2007 and 2016 in our center. Patients were divided in three categories: conservative management, surgical treatment with or without bowel resection. Clinical variables were assessed and compared between groups. Logistic regression models were used to identify the best predictors.

Results

604 patients were included in this study. 438 (73%) had surgery of which 127 (21%) had small bowel resection. 166 (27%) patients were treated conservatively. Among 13 clinical variables, univariate and multivariate logistic regression models identified 8 variables with a strong association with small bowel resection: age ≥70 years, a first episode of SBO, absence of bowel movement for ≥3 days, abdominal guarding, C-reactive protein ≥50, and 3 signs on abdominal CT-scan, namely, small bowel transition point, lack of small bowel contrast enhancement, and the presence of &gt; 500 mL of intra-abdominal fluid. Each variable was given one point. We observed that 71-100% of patients with ≥4 points required a surgical resection. Sensitivity and specificity of this score were 65% and 88%, respectively and the area under the curve (AUC) was 0.84 (95% CI 0.80-0.89). Additionally, we propose two variants of the 8-tem score: a 7-item score excluding the lack of contrast enhancement, specifically designed for patient with contrast allergies or renal insufficiency, and a simplified 4-item score leaving age, guarding, transition zone on CT-scan, and the presence of 500 mL of fluid on CT scan. Both scores showed similar performances compared to the 8-item score with an AUC of 0.83 and 0.80 for the 7- and 4-item scores, respectively.

Conclusion

We developed a practical clinical severity score designed to tailor management of patients presenting with a SBO. A score of ≥ 4 points indicates the need for surgical exploration given the high likelihood of small bowel ischemia in these patients.

Recipients with blood group A associated with longer survival rates in cardiac valvular bioprostheses

Background

Pigs/bovines share with humans some of the antigens present on cardiac valves. Two such antigens are: the major xenogenic Ag, “Gal” present in all pig/bovine very close to human B-antigen of ABO-blood-group system; the minor Ag, pig histo-blood-group AH-antigen identical to human AH-antigen and present by some animals. We hypothesize that these antigens may modify the immunogenicity of the bioprosthesis and also its longevity. ABO distribution may vary between patients with low (<6 years) and high (≥15 years) bioprostheses longevity.

Methods

Single-centre registry study (Paris, France) including all degenerative porcine bioprostheses (mostly Carpentier-Edwards 2nd/3rd generation heart valves) explanted between 1985 and 1998 and some bovine bioprostheses. For period 1998–2014, all porcine bioprostheses with longevity ≥13 years (follow-up ≥29 years). Important predictive factors for bioprosthesis longevity: number, site of implantation, age were collected. Blood group and other variables were entered into an ordinal logistic regression analysis model predicting valve longevity, categorized as low (<6 years), medium (6–14.9 years), and high (≥15 years).

Findings

Longevity and ABO-blood group were obtained for 483 explanted porcine bioprostheses. Mean longevity was 10.2 ± 3.9 years [0–28] and significantly higher for A-patients than others (P = 0.009). Using multivariate analysis, group A was a strong predictive factor of longevity (OR 2.09; P < 0.001). For the 64 explanted bovine bioprosthesis with low/medium longevity, the association, with A-group was even more significant.

Interpretation

Patients of A-group but not B have a higher longevity of their bioprostheses. Future graft-host phenotyping and matching may give rise to a new generation of long-lasting bioprosthesis for implantation in humans, especially for the younger population.

Fund

None.

Effect of an organised screening program on socioeconomic inequalities in mammography practice, knowledge and attitudes

BACKGROUND

Breast cancer stands as the leading cause of cancer related mortality in women worldwide. Mammography screening has the potential to improve prognosis by reducing stage at diagnosis. Socioeconomic inequalities in mammography cancer screening have been widely reported. The influence of organised programs on socioeconomic disparities regarding mammography screening is to date unclear. We aimed to investigate the impact of an organised regional screening program on socioeconomic inequalities in terms of the uptake, knowledge and attitudes towards mammography screening.

METHODS

Data were obtained from two cross-sectional surveys of women 50 to 69 years old conducted in 1998 and 2012, before and after the implementation of an organised breast cancer screening program in Geneva, Switzerland. Socioeconomic status was measured by monthly household income and education level. Logistic and linear regression multivariable models were used to investigate the evolution of socioeconomic gradients between 1998 and 2012 in terms of uptake, knowledge and attitudes towards mammography screening.

RESULTS

In 1998, before the implementation of an organised screening program, 44% of women from the lowest education category reported mammography practice conforming to recommendations versus 63% of the more educated participants. This socioeconomic gradient was no longer present in 2012 where reported mammography practice at guideline-recommended frequency were 83 and 82% in the lowest and highest education level categories respectively (change in education gradient over time, p = 0.018). The difference in mammography practice in agreement with recommendations between the lowest and the highest income category went from 27 percentage points in 1998 to 14 percentage points in 2012 (change in income gradient over time, p = 0.10). The socioeconomic gradient in negative attitudes towards mammography screening persisted in 2012 but was reduced compared to 1998. We did not observe a reduction in the socioeconomic disparities in knowledge regarding mammography screening over this period.

CONCLUSIONS

This study suggests that mammography screening programs may lessen socioeconomic inequities in mammography practice. Such programs should feature adapted communication tools to reach women of lower socioeconomic status to attempt to further reduce socioeconomic gradients in mammography screening.

CT scan-based modelling of anastomotic leak risk after colorectal surgery

AIM

Prolonged ileus, low-grade fever and abdominal discomfort are common during the first week after colonic resection. Undiagnosed anastomotic leak carries a poor outcome and computed tomography (CT) scan is the best imaging tool for assessing postoperative abdominal complications. We used a CT scan-based model to quantify the risk of anastomotic leak after colorectal surgery.

METHOD

A case-control analysis of 74 patients who underwent clinico-radiological evaluation after colorectal surgery for suspicion of anastomotic leak was undertaken and a multivariable analysis of risk factors for leak was performed. A logistic regression model was used to identify determinant variables and construct a predictive score.

RESULTS

Out of 74 patients with a clinical suspicion of anastomotic leak, 17 (23%) had this complication confirmed following repeat laparotomy. In multivariate analysis, three variables were associated with anastomotic leak: (1) white blood cells count > 9 × 10(9) /l (OR = 14.8); (2) presence of ≥ 500 cm(3) of intra- abdominal fluid (OR = 13.4); and (3) pneumoperitoneum at the site of anastomosis (OR = 9.9). Each of these three parameters contributed one point to the risk score. The observed risk of leak was 0, 6, 31 and 100%, respectively, for patients with scores of 0, 1, 2 and 3. The area under the receiver operating characteristic curve for the score was 0.83 (0.72-0.94).

CONCLUSION

This CT scan-based model seems clinically promising for objective quantification of the risk of a leak after colorectal surgery.

Perceived usefulness of nine quality improvement tools among Swiss physicians

BACKGROUND

Doctors' opinions about quality improvement tools likely influence their uptake and eventual impact on patient care. Little is known about physicians' perception of the comparative utility of various quality improvement tools.

METHODS

We conducted a mail survey of doctors in Geneva, Switzerland (2745 physicians, of whom 56% participated), to measure the perceived usefulness of 9 quality improvement tools.

RESULTS

In decreasing order of perceived utility these tools were regular continuous education (rated as very or extremely useful by 75% of respondents), mortality and morbidity conferences (65%), quality circles (60%), patient satisfaction measurement (42%), assessment of the fulfillment of therapeutic objectives (41%), assessment of compliance with guidelines (36%), periodic evaluation of doctors' skills (14%), onsite visits with peer-review of medical records (11%), and certification of office practices (8%).

CONCLUSION

Quality improvement tools seen as most useful by physicians are traditional methods such as continuous education and mortality and morbidity conferences. Methods that rely on the measurement of indicators or that have a judgmental component received less support.

[Development and assessment of a sensory-motor scale for the neonate: a clinical tool at the bedside]

INTRODUCTION

Improved perinatal care has increased the survival of newborns. However, neonatal intensive care is a source of nociceptive stimuli that may have a negative long-term impact on the child's neurobehavioral development. During the period of maximal brain plasticity, supportive developmental care can therefore be beneficial. The purpose of this study was to develop an assessment tool of neonatal behavior for daily use by healthcare providers and validate its content.

METHOD

A behavioral assessment tool starting off with 45 clinical variables in 6 areas of sensory-motor behavior was validated in two stages using footage of babies between 25 and 37 weeks gestational age. The intraclass correlation coefficient of 65 evaluations allowed simplification of the tool down to 23 variables, prior to a final analysis of validity and reliability.

RESULTS

For the 23 variables, the reliability between observers was low for 7 (intraclass correlation coefficient [ICC]<0.4), fair for 4 (ICC 0.4-0.5) and good for 12 (ICC>0.5). The agreement between novice and expert observers ranged from 46.7% to 98.7%. Twenty variables had a level of agreement above 60%.

CONCLUSIONS

This validation study of a newborn sensory-motor behavior assessment scale has identified pertinent variables for a structured assessment by healthcare providers.

Is atrial fibrillation associated with pulmonary embolism?

BACKGROUND

A pulmonary embolism (PE) is thought to be associated with atrial fibrillation (AF). Nevertheless, this association is based on weak data.

OBJECTIVES

To assess whether the presence of AF influences the clinical probability of PE in a cohort of patients with suspected PE and to confirm the association between PE and AF.

PATIENTS/METHODS

We retrospectively analyzed the data from two trials that included 2449 consecutive patients admitted for a clinically suspected PE. An electrocardiography (ECG) was systematically performed and a PE was diagnosed by computer tomography (CT). The prevalence of AF among patients with or without a PE was compared in a multivariate logistic regression model.

RESULTS

The prevalence of PE was 22.8% (519/2272) in patients without AF and 18.8% (25/133) in patients with AF (P = 0.28). After adjustment for confounding factors, AF did not significantly modify the probability of PE (odds ratio [OR] 0.68, 95% confidence interval [CI] 0.42-1.11). However, when PE suspicion was based on new-onset dyspnea, AF significantly decreased the probability of PE (OR 0.47, 95% CI 0.26-0.84). If isolated chest pain without dyspnea was the presenting complaint, AF tended to increase the probability of PE (OR 2.42, 95% CI 0.97-6.07).

CONCLUSIONS

Overall, the presence of AF does not increase the probability of PE when this diagnosis is suspected. Nevertheless, when PE suspicion is based on new-onset dyspnea, AF significantly decreases the probability of PE, as AF may mimic its clinical presentation. However, in patients with chest pain alone, AF tends to increase PE probability.

Scoring system to predict the risk of surgical-site infection after colorectal resection

BACKGROUND

There is no dedicated scoring system for predicting the risk of surgical-site infection (SSI) after resection of the colon or rectum. Generic scores, such as the National Nosocomial Infections Surveillance index, are not used by colorectal surgeons.

METHODS

Multivariable analysis of risk factors for SSI was performed in patients who underwent resection of the colon or rectum, and were followed during the first month after operation. A logistic regression model was used to identify determinant variables and construct a predictive score.

RESULTS

There were 534 patients of whom 114 (21·3 per cent) developed SSI. In multivariable analysis, four parameters correlated with an increased risk of SSI: obesity (odds ratio (OR) 2·93, 95 per cent confidence interval 1·71 to 5·03), contamination class 3-4 (OR 3·33, 2·08 to 5·32), American Society of Anesthesiologists grade III-IV (OR 1·82, 1·14 to 2·90) and open surgery (OR 2·22, 1·01 to 4·88). Each of these contributed 1 point to the risk score. The observed risk of SSI was 5 per cent for a score of 0, 12·0 per cent for a score of 1 point, 18·7 per cent for 2 points, 44 per cent for 3 points and 68 per cent for 4 points. The area under the receiver operating characteristic curve for the score was 0·729.

CONCLUSION

A simple clinical score based on four preoperative variables was clinically useful in predicting the risk of SSI in patients undergoing colorectal surgery.

Accuracy of measurement of puborectal contraction by perineal ultrasound in patients with faecal incontinence

AIM

The study aimed to determine the accuracy of measurement of puborectal contraction, measured by perineal ultrasound during anal voluntary contraction in patients with incontinence.

METHOD

Puborectalis sling contraction in 32 consecutive patients investigated for faecal incontinence was determined by two examiners on two occasions (four measurements per patient). The examiners were blinded to each other's results.

RESULTS

The mean anterior movement of the puborectalis sling was between 11 and 12 mm for both examiners on both occasions. The global intraclass correlation coefficient for examiners and occasions together was 0.92. The absolute agreement on the movement exceeding or not 8 mm was 87.5% (28 of 32), and the corresponding κ statistic was 0.84. The differences between the two experts were minimal.

CONCLUSION

The study confirms the reliability of puborectalis sling contraction measurement and its value as a preoperative predictive tool to assess the prognosis of sphincter repair for postdelivery faecal incontinence.

Clinicoradiological score for predicting the risk of strangulated small bowel obstruction

BACKGROUND

Intestinal ischaemia as a result of small bowel obstruction (SBO) requires prompt recognition and early intervention. A clinicoradiological score was sought to predict the risk of ischaemia in patients with SBO.

METHODS

A clinico-radiological protocol for the assessment of patients presenting with SBO was used. A logistic regression model was applied to identify determinant variables and construct a clinical score that would predict ischaemia requiring resection.

RESULTS

Of 233 consecutive patients with SBO, 138 required laparotomy of whom 45 underwent intestinal resection. In multivariable analysis, six variables correlated with small bowel resection and were given one point each towards the clinical score: history of pain lasting 4 days or more, guarding, C-reactive protein level at least 75 mg/l, leucocyte count 10 x 10(9)/l or greater, free intraperitoneal fluid volume at least 500 ml on computed tomography (CT) and reduction of CT small bowel wall contrast enhancement. The risk of intestinal ischaemia was 6 per cent in patients with a score of 1 or less, whereas 21 of 29 patients with a score of 3 or more underwent small bowel resection. A positive score of 3 or more had a sensitivity of 67.7 per cent and specificity 90.8 per cent; the area under the receiver operating characteristic curve was 0.87 (95 per cent confidence interval 0.79 to 0.95).

CONCLUSION

By combining clinical, laboratory and radiological parameters, the clinical score allowed early identification of strangulated SBO.

Clinical prediction rules for pulmonary embolism: a systematic review and meta-analysis

SUMMARY BACKGROUND

Pretest probability assessment is necessary to identify patients in whom pulmonary embolism (PE) can be safely ruled out by a negative D-dimer without further investigations.

OBJECTIVE

Review and compare the performance of available clinical prediction rules (CPRs) for PE probability assessment.

PATIENTS/METHODS

We identified studies that evaluated a CPR in patients with suspected PE from Embase, Medline and the Cochrane database. We determined the 95% confidence intervals (CIs) of prevalence of PE in the various clinical probability categories of each CPR. Statistical heterogeneity was tested.

RESULTS

We identified 9 CPR and included 29 studies representing 31215 patients. Pooled prevalence of PE for three-level scores (low, intermediate or high clinical probability) was: low, 6% (95% CI, 4-8), intermediate, 23% (95% CI, 18-28) and high, 49% (95% CI, 43-56) for the Wells score; low, 13% (95% CI, 8-19), intermediate, 35% (95% CI, 31-38) and high, 71% (95% CI, 50-89) for the Geneva score; low, 9% (95% CI, 8-11), intermediate, 26% (95% CI, 24-28) and high, 76% (95% CI, 69-82) for the revised Geneva score. Pooled prevalence for two-level scores (PE likely or PE unlikely) was 8% (95% CI,6-11) and 34% (95% CI,29-40) for the Wells score, and 6% (95% CI, 3-9) and 23% (95% CI, 11-36) for the Charlotte rule.

CONCLUSION

Available CPR for assessing clinical probability of PE show similar accuracy. Existing scores are, however, not equivalent and the choice among various prediction rules and classification schemes (three- versus two-level) must be guided by local prevalence of PE, type of patients considered (outpatients or inpatients) and type of D-dimer assay applied.

Myeloid-related protein (MRP8/14) expression in gingival crevice fluid in periodontal health and disease and after treatment

BACKGROUND AND OBJECTIVE

Myeloid-related protein (MRP8/14) and its subunits are biomarkers of inflammation. The present study evaluated whether gingival crevice fluid levels of these markers discriminate periodontitis from healthy sites in patients with chronic periodontitis or diseased from healthy subjects, and whether these biomarkers detect longitudinal changes after therapy.

MATERIAL AND METHODS

Levels of MRP8/14, MRP14 and total protein were quantified in 19 periodontitis patients before non-surgical periodontal therapy, after 3 and 6 mo of treatment, and were measured once in 11 periodontally healthy subjects. In total, diseased subjects contributed 59 sites with probing depths >4 mm (PP) and 21 sites <4 mm (PH); healthy subjects contributed 91 sites (HH).

RESULTS

Overall, in diseased subjects, MRP8/14, MRP14 and total protein were not significantly different between PP and PH sites. However, at baseline, MRP8/14 and total protein had significantly higher values at sites in periodontally diseased than in healthy subjects. Clinical improvement was associated with a significant decrease of MRP8/14 and MRP14 from baseline to month 6 in PP sites. Interestingly, a similar decrease was observed in PH sites for all three markers. At 6 mo, however, levels of MRP8/14 and protein in PP and PH sites of patients were still significantly higher than in healthy subjects.

CONCLUSION

Gingival crevice fluid levels of MRP8/14 did not differentiate between clinically diseased and healthy sites in patients with chronic periodontitis. However, this marker was elevated in periodontally diseased compared with healthy subjects, and its values decreased following therapy. MRP8/14 may be used to monitor the response to treatment.

Survival predictors in second-line chemotherapy for metastatic gastric cancer

e15575

Background: Many patients (pts) with metastatic gastric cancer (MGC) are in good condition after first line chemotherapy (chemo) and are offered further treatment. However there is no established predictor to select pts who will most likely benefit from second line chemotherapy (SLC). Methods: We conducted a retrospective review of all patients with metastatic gastric or gastro-oesophageal junction adenocarcinoma who were treated until death at our institution and died between 01.1994 and 06.2008. Prognostic values of the tumour characteristics, pts characteristics at SLC, previous curative surgery (PCS) and sensitivity to previous chemo were analysed by Cox univariate and multivariate regression for overall survival (OS). Results: 65 pts with MGC were treated at our institution up to their death. Of these, 43 pts (65%) received SLC. 24 pts (55.8%) received CPT-11 based SLC. 4 pts (9.3%) docetaxel-platin, anthracyclines and fluoropyrimidine based SLC. 3 pts (7%) oxaliplatin and 3 pts (9.3 %) other chemo. Median OS from the start of SLC was 30.1 weeks. 25 pts (58.1%) had disease control (response and stable disease) lasting at least 12 weeks under SLC. Potential prognostic variables with their frequencies and prognostic values are listed in the Table . Multivariate analysis showed that PCS was significant predictor for OS (HR=0.46, p<.05). PFS1 of more than 26 weeks was a strong significant OS predictor (HR=0.41, p<.05). Interaction test between PFS1 and PCS was not significant (p=0.48). Conclusions: Benefit from a SLC in MGC is highly related to former sensitivity to first line chemo. This is of major importance in the design of trials in MGC in a second line setting. [Table: see text]

No significant financial relationships to disclose.

Cardiac biomarkers for risk stratification in non-massive pulmonary embolism: a multicenter prospective study

BACKGROUND

Troponins (cTnI and cTnT), N-terminal pro-Brain Natriuretic Peptide (NT-proBNP), myoglobin, heart-type fatty acid-binding protein (H-FABP) and fibrin D-Dimer are emergent candidates for risk stratification in pulmonary embolism (PE).

OBJECTIVE

To compare the respective prognostic values of biomarker with non-massive PE to predict an adverse outcome at 3 months.

PATIENTS/METHODS

One hundred and forty-six consecutive patients with non-massive PE were included in this multicenter prospective study. The combined outcome consisted of intensive care monitoring on admission, death or hospitalization attributable to either a PE-related complication [defined by PE/deep vein thrombosis (DVT) relapse or major bleeding under anticoagulation] or to dyspnoea with or without chest pain during follow-up.

RESULTS

The outcome was met in 12% of patients. In univariate analysis, a NT-proBNP level above 300 pg/ml was the strongest predictor of unfavorable outcome with an odds ratio (OR) of 15.8 [95% confidence interval (CI): 2.05-122). ORs for the other variables were: 8.0 for D-dimer >2000 ng/ml (95% CI: 1.1-64), 4.7 for H-FABP >6 ng/ml (95% CI:1.5-14.8), 3.5 for cTnI >0.09 ng/ml (95% CI:1.2-9.7), 3.4 for myoglobin >70 ng/ml (95% CI:0.9-12.2). Receiver operating curve (ROC) analysis indicated that NT-proBNP was the best predictor [area under the curve (AUC) 0.84; 95%CI: 0.76-0.92; P < 0.0001] with a negative predictive value of 100% (95% CI: 91-100) at 300 pg/ml. At that cut-off, the true negative rate for NT-proBNP was 40%. In multivariate analysis, NT-proBNP was the only significant independent predictors.

CONCLUSIONS

NT-proBNP appears to be a good risk stratification marker in identifying low-risk patients with non-massive PE who could be treated in an outpatient setting.

Lipodystrophy and weight changes: data from the Swiss HIV Cohort Study, 2000-2006

BACKGROUND AND OBJECTIVES

Combination antiretroviral therapy (cART) is changing, and this may affect the type and occurrence of side effects. We examined the frequency of lipodystrophy (LD) and weight changes in relation to the use of specific drugs in the Swiss HIV Cohort Study (SHCS).

METHODS

In the SHCS, patients are followed twice a year and scored by the treating physician as having 'fat accumulation', 'fat loss', or neither. Treatments, and reasons for change thereof, are recorded. Our study sample included all patients treated with cART between 2003 and 2006 and, in addition, all patients who started cART between 2000 and 2003.

RESULTS

From 2003 to 2006, the percentage of patients taking stavudine, didanosine and nelfinavir decreased, the percentage taking lopinavir, nevirapine and efavirenz remained stable, and the percentage taking atazanavir and tenofovir increased by 18.7 and 22.2%, respectively. In life-table Kaplan-Meier analysis, patients starting cART in 2003-2006 were less likely to develop LD than those starting cART from 2000 to 2002 (P<0.02). LD was quoted as the reason for treatment change or discontinuation for 4% of patients on cART in 2003, and for 1% of patients treated in 2006 (P for trend <0.001). In univariate and multivariate regression analysis, patients with a weight gain of >or=5 kg were more likely to take lopinavir or atazanavir than patients without such a weight gain [odds ratio (OR) 2, 95% confidence interval (CI) 1.3-2.9, and OR 1.7, 95% CI 1.3-2.1, respectively].

CONCLUSIONS

LD has become less frequent in the SHCS from 2000 to 2006. A weight gain of more than 5 kg was associated with the use of atazanavir and lopinavir.

Drug selection errors in relation to medication labels: a simulation study

The aim of this study was to assess the impact of differences in drug label information on injectable drug selection errors. Differences in the display of drug strength information were assessed in a randomised controlled trial involving ward nurses, intensive care nurses, nurse anaesthetists, ward physicians, and anaesthetists. A set of 24 on-screen tasks were constructed. For each task, a label corresponding to an instruction consisting of two from three possible pieces of information (concentration, quantity, volume) had to be selected from a list of 10 items. The set was presented three times to participants using three different label formats. Format A provided two pieces of strength information different from those in the instruction. Format B and C provided all three pieces in a random and a fixed sequence, respectively. The frequency of errors was statistically higher with formats A and B than with format C, and greater in nurses than in anaesthetists. Regulatory bodies should therefore implement a standard requiring that the concentration (expressed in 'mg x ml(-1)'), the amount and the volume of drug be displayed on medication labels in fixed locations.

Celecoxib versus ibuprofen in the prevention of heterotopic ossification following total hip replacement: a prospective randomised trial

We examined whether a selective cyclooxygenase-2 (COX-2) inhibitor (celecoxib) was as effective as a non-selective inhibitor (ibuprofen) for the prevention of heterotopic ossification following total hip replacement. A total of 250 patients were randomised to receive celecoxib (200 mg b/d) or ibuprofen (400 mg t.d.s) for ten days after surgery. Anteroposterior radiographs of the pelvis were examined for heterotopic ossification three months after surgery. Of the 250 patients, 240 were available for assessment. Heterotopic ossification was more common in the ibuprofen group (none 40.7% (50), Brooker class I 46.3% (57), classes II and III 13.0% (16)) than in the celecoxib group (none 59.0% (69), Brooker class I 35.9% (42), classes II and III 5.1% (6), p=0.002). Celecoxib was more effective than ibuprofen in preventing heterotopic bone formation after total hip replacement.

Measuring human-error probabilities in drug preparation: a pilot simulation study

OBJECTIVES

Designing a safe medication process requires the ability to model its reliability using methods such as probabilistic risk assessment (PRA). However, lack of data, especially on human-error probabilities (HEPs), limits its use. To assess whether small-scale simulations could help generate HEP data, a pilot study was conducted among nurses and anaesthetists. It focused on two core activities, namely, the manual preparation of medications and the arithmetic necessary to prepare drugs. Its specific objectives were to evaluate whether HEPs could be high enough to be measurable and to determine whether these HEPs could be sensitive to individuals and task details. These would give some insight into the level of detail required by PRA analysis.

METHODS

Thirty nurse and 28 anaesthetist volunteers were involved in the experiment. Nurses and anaesthetists had to prepare medications for 20 patients and 22 syringes of various drugs, respectively. Both groups had to perform 22 calculations relating to the preparation of drugs. HEPs, distribution of HEPs and dependency of HEPs on individuals and task details were assessed.

RESULTS

In the preparation tasks, overall HEP was 3.0% for nurses and 6.5% for anaesthetists. In the arithmetic tasks, overall HEP was 23.8% for nurses and 8.9% for anaesthetists. A statistically significant difference was noted between the two groups. In both preparation and arithmetic tasks, HEPs were dependent on individual nurses but not on individual anaesthetists. In every instance, HEPs were dependent on task details.

CONCLUSION

Our study illustrates that small-scale simulations represent an interesting way of generating HEPs. HEPs are, indeed, in the range of 10(-2) and 10(-1). But in most cases, HEPs depend heavily on operators and task details. This dependency means that the influence of these parameters must be determined before advanced PRA analysis. There is therefore an urgent need to develop experimental research into assessing this influence by means of randomised controlled trials.

Quantitative scoring of an interferon-gamma assay for differentiating active from latent tuberculosis

The aim of this study was to assess the contribution of an interferon-gamma release assay (T-SPOT.TB) to the differentiation of active tuberculosis (TB) from latent TB infection by quantifying spot-forming units (sfu). The investigation was a prospective study of contacts exposed to a case of contagious TB and cases of HIV-negative culture-proven TB referred over a 16-month period. Tuberculin skin tests (TSTs) and T-SPOT.TB were performed in 310 contacts 8-12 weeks after exposure. In subjects with culture-proven TB, T-SPOT.TB was performed within 2 weeks of initiation of treatment. The analysis included all contacts with a positive T-SPOT.TB result and all subjects with TB. TB contacts (n = 127) and cases (n = 58) were included. Mean+/-sd T-SPOT.TB results were 107+/-56 (range 1-207) sfu for TB, 54+/-60 (7-239) sfu for contacts with positive T-SPOT.TB results and a TST induration diameter of >5 mm, and 19+/-27 (7-143) sfu for contacts with positive T-SPOT.TB results and a TST induration diameter of < or =5 mm. By receiver operating characteristic curve analysis, a threshold value of 49.5 sfu showed a sensitivity of 83% and specificity of 74% for distinguishing latent TB infection from TB. Although T-SPOT.TB results were significantly related to disease activity, the test cannot be recommended for the diagnosis of tuberculosis.

Adding a dialysis dose to continuous hemofiltration increases survival in patients with acute renal failure

Acute renal failure (ARF) in critically ill patients is associated with high mortality. Optimal method and dose of continuous renal replacement therapy could improve survival in these patients. We studied the hypothesis that an increase in dialysis dose obtained by continuous veno-venous hemodiafiltration (CVVHDF) is associated with a better survival than continuous veno-venous hemofiltration (CVVH) among critically ill patients with ARF. In a prospective randomized trial, these two methods were compared in patients undergoing renal replacement therapy in two intensive care units (ICUs). The patients had either CVVH (1-2.5 l/h replacement fluid) or continuous CVVHDF (1-2.5 l/h replacement fluid+1-1.5 l/h dialysate) according to their body weight. 28- and 90-day mortalities, renal recovery, and duration of ICU stay were the main outcome measures. Two hundred and six patients were randomized from October 2000 to December 2003. Twenty-eight-day survivals (%) were, respectively, 39 and 59 (P=0.03) in the CVVH and CVVHDF groups. Three months survivals (%) were, respectively, 34 and 59 (P=0.0005) in the CVVH and CVVHDF groups. Apache II score, age, baseline blood urea nitrogen, and hemodiafiltration (hazard ratio 0.59, 95% confidence interval 0.40-0.87; P=0.008) were independent predictors of survival at 90 days. Renal recovery rate among survivors (71 versus 78% in the CVVH and CVVHDF groups respectively, P=0.62) was not affected by the type of renal replacement therapy. These results suggest that increasing the dialysis dose especially for low molecular weight solutes confers a better survival in severely ill patients with ARF.

Factor V Leiden and prothrombin G20210A polymorphisms as risk factors for miscarriage during a first intended pregnancy: the matched case-control 'NOHA first' study

Factor V Leiden (FVL) and prothrombin G20210A (FIIG20210A) mutations are associated with a higher risk of miscarriage: we sought to understand whether this association differs by clinical time of unexplained miscarriage, and by ethnic origin, among women with no previous thrombotic episode, during the first intended pregnancy. We performed a case-control study nested in a cohort of 32 683 women. We analyzed 3496 pairs of women matched for classical confounding factors. The FVL and FIIG20210A mutations were associated with an increased risk of miscarriage in Caucasian women [odds ratio (OR) 3.19, 95% confidence interval (CI) 2.37-4.30, P < 0.001 and OR 2.36, 95% CI, 1.72-3.24, P < 0.001, respectively]. Among non-Caucasian women, the mutations were rare and the associations with risk of miscarriage less clear. FVL and FIIG20210A mutations were independent risk factors for miscarriages only for women with related clinical signs occurring from the 10th week of gestation on (OR 3.46, 95% CI 2.53-4.72, P < 0.001 and OR 2.60, 95% CI 1.86-3.64, P < 0.001, respectively). These results indicate that FVL and FIIG20210A mutations are associated with a significant risk of spontaneous abortion which clinical signs occur from the 10th week on of the first intended pregnancy.

Étude BPCO-EP : prévalence et prédiction de l’embolie pulmonaire dans l’exacerbation de la broncho-pneumopathie obstructive chronique

INTRODUCTION

Patients suffering from chronic obstructive pulmonary disease (COPD) are often admitted to hospital with an exacerbation of their disease that manifests itself with an increase in cough and/or sputum, increased dyspnoea and sometimes chest pain. These episodes are most often attributed to an acute exacerbation of bronchial infection but the real cause is often unknown. COPD is considered a risk factor for pulmonary embolism (PE) and PE is part of the differential diagnosis of an acute exacerbation of COPD. However, the symptoms of these two conditions overlap to a considerable extent and the investigation of PE is often ignored in these patients. Therefore the true prevalence of PE in this situation is unknown. Nevertheless several small series suggest that up to 30% of patients seen as emergencies with exacerbations of COPD may have a deep vein thrombosis or PE. The aims of this study are therefore: 1. To evaluate the prevalence of PE in patients admitted as emergencies with exacerbations of COPD; and 2. To attempt to develop a prediction guide for PE in this population in order to identify the patients in whom PE should be investigated.

MATERIALS AND METHODS

600 consecutive patients admitted as emergencies with exacerbations of COPD will be included in a cross sectional study in three university hospitals (Geneva and Lausanne in Switzerland, and Amiens in France). Patients fulfilling the inclusion criteria will be investigated by a diagnostic algorithm appropriate for the study of PE, including D-dimer levels and, in those with abnormal results, ultrasonic scan of the deep veins of the legs and spiral CT scan. The patient characteristics on admission will be incorporated in a multivariate regression analysis in an attempt to identify the predictive factors for PE in these patients. The expected duration of the study is 24 months.

EXPECTED RESULTS

This study should determine the prevalence of PE in patients admitted as emergencies with exacerbations of COPD and therefore help decide when, and in which patients, a systematic search for PE should be undertaken.

Suspicion of pulmonary embolism in outpatients: nonspecific chest pain is the most frequent alternative diagnosis

OBJECTIVES

Several recent studies have focused on identifying clinical predictors of embolism. However, although pulmonary embolism is ruled out in 70-85% of the patients in whom it is suspected, data on the clinical characteristics and discharge diagnosis of such patients are scarce. Our aim was to evaluate whether clinical characteristics would allow predicting alternative diagnoses other than pulmonary embolism thereby ruling out venous thromboembolism.

DESIGN

Retrospective analysis.

SETTING

Emergency centres of two teaching and general hospitals.

SUBJECTS

A total of 1090 consecutive outpatients admitted for clinically suspected pulmonary embolism and a diagnosis established by a validated algorithm and a 3-month follow-up.

OUTCOMES

Discharge diagnoses of patients in whom pulmonary embolism was ruled out were identified and regrouped into two categories: (i) nonspecific chest pain and (ii) diagnosis other than pulmonary embolism. Predictive accuracy of clinical and laboratory variables for diagnosing nonspecific chest pain was assessed by univariate and multivariate analysis.

RESULTS

In patients without pulmonary embolism, nonspecific chest pain (parietal chest pain, chest pain of unknown origin and pleuritis) was the most frequent discharge diagnosis (n = 334, 31% of the entire cohort, 43% of the patients without pulmonary embolism). Other patients without pulmonary embolism had a wide variety of diagnoses, of which the most frequent were bronchopneumonia (6.0% of the entire cohort) and heart failure (5.2%). In the multivariate analysis, seven variables were strongly associated with nonspecific chest pain: younger age (below 40 years), female gender, respiratory rate below 20 min(-1), heart rate below 100 min(-1), and absence of recent immobilization, dyspnoea and haemoptysis. Two of the 24 patients in whom all those characteristics were present had pulmonary embolism (8%, 95% CI 3-22%).

CONCLUSIONS

The most frequent discharge diagnosis in emergency ward patients in whom pulmonary embolism is ruled out is nonspecific chest pain. A clinical model did not allow to predict nonspecific chest pain with enough accuracy to rule out pulmonary embolism without further testing. Whether a more precise characterization of chest pain might allow an accurate identification of such patients deserves further study.

[Clinical prediction rules: a reader's guide]

INTRODUCTION

Clinical prediction rules or scores are instruments that allow to quantify the respective contributions of medical history, clinical examination and laboratory tests to a diagnosis or a prognosis in a given patient.

STATE OF THE ART

The development of clinical prediction rules requires three steps: 1) derivation of the rule from a population with known clinical characteristics and diagnosis or prognosis; 2) validation of the rule in a population distinct from the derivation sample; and 3) evaluation of the impact of the rule on clinician behavior and patient outcomes.

PERSPECTIVES

This paper provides a guide for the critical appraisal of a prediction rule illustrated by two clinical scores for the assessment of the clinical probability of pulmonary embolism.

CONCLUSIONS

Clinical prediction rules or scores have become indispensable components of the clinician's toolbox.

Prevalence of factor V Leiden and prothrombin G20210A mutations in unselected patients with venous thromboembolism

We determined the prevalence of factor V Leiden and of prothrombin G20210A mutations in a cohort of unselected outpatients (n = 748) referred for suspected deep vein thrombosis (DVT) and/or pulmonary embolism (PE) and a pooled analysis of similar studies was also performed. Based on the clinical presentation, the prevalence of factor V Leiden was 15.7% in the 83 patients with DVT and 14.1% in the 99 patients with PE compared with 5.3% in patients without DVT and/or PE (control group). The prevalence of the prothrombin G20210A mutation did not differ among the three groups (3.9% for controls, 4. 8% for DVT and 3.9% for PE patients). We then divided the 99 patients with PE by separately analysing those with PE but without DVT (n = 57) and those with PE and DVT (n = 42). Compared with the control group, the prevalence of factor V Leiden was 10.5%, odds ratio (OR) 2.10 [95% confidence interval (95% CI) 0.68-5.45] in patients with primary PE and 19.1%, OR 4.20 (95% CI 1.54-10.30) in patients with DVT and PE. For the prothrombin G20210A mutation, no statistically significant differences were found between the control group and the three other groups. In conclusion, our data and the pooled analysis indicate that patients with primary PE are less often affected by the factor V Leiden mutation. No statistically significant differences were observed between patients and controls for the prothrombin G20210A mutation.

Risk of major bleeding in unselected patients with venous thromboembolism

PURPOSE

To evaluate the risk of major bleeding in unselected patients given anticoagulant treatment (heparin overlapped and followed by oral anticoagulants) because of deep vein thrombosis (DVT) or pulmonary embolism (PE).

SUBJECTS AND METHODS

We screened the database of 1590 outpatients suspected of DVT and PE in prospective diagnostic studies conducted in Geneva between 1992 and 1998.

RESULTS

Four hundred and eleven of 1590 patients (26%) were anticoagulated for confirmed venous thromboembolism (PE, 300; DVT, 111). One patient was excluded because of concomitant thrombolytic therapy. Five (1.2%; 95% confidence interval, 0.4-2.8) of the remaining 410 patients experienced a major hemorrhagic event during the 3-month follow-up, including two fatal events. All bleedings occurred during the first month of therapy (heparin, two; oral anticoagulants, two; combined treatment, one) and the median age of the patients who bled was 80 years. At least one serious comorbid condition associated with higher bleeding risk was present in four patients and, in one case, the bleeding was clearly related to an excessive intensity of anticoagulation.

CONCLUSION

The rate of bleeding events in this population of unselected outpatients is similar to that reported in controlled therapeutic trials. The hemorrhagic events occurred early in the course of anticoagulant therapy and concerned old patients mostly affected by at least one comorbid condition. Particular care should be used to avoid the risk of overtreatment.

Short-term impact of a university based smoke free campaign

STUDY OBJECTIVE

The aim of this study was to evaluate the impact of a smoke free programme implemented at the University of Geneva, Switzerland, in 1996. This programme included a prohibition to smoke in university buildings everywhere except in limited areas, and a smoking cessation counselling service.

METHODS

Surveys were conducted before and four months after the programme was implemented, in representative samples of programme participants (n = 833) and university members not exposed to the programme (n = 1023).

RESULTS

In retrospective assessments, participants reported being less bothered by environmental tobacco smoke after programme implementation, but no between group difference was detected in prospective assessments. Relationships between smokers and non-smokers improved moderately in the intervention group and remained unchanged in the comparison group (between group p = 0.001). Proportions of smokers who attempted to quit smoking in the past four months increased from 2.0% to 3.8% in the intervention group and remained unchanged at 3.5% in the comparison group (between group difference: p = 0.048). No impact on smoking prevalence (25%) was detected. The programme was appreciated by university members, although some of its modalities were criticised.

CONCLUSION

A regulation prohibiting smoking everywhere but in limited areas of university buildings was acceptable and reduced the perception of bother by environmental tobacco smoke. It did not, however, influence smoking habits or attitudes toward smoking.

Metformin treatment leads to an increase in basal, but not insulin-stimulated, glucose disposal in obese patients with impaired glucose tolerance

AIMS

This study was initiated to test the hypothesis that metformin treatment leads to enhanced glucose disposal at ambient insulin concentrations.

METHODS

Nineteen obese patients with impaired glucose tolerance (IGT) were treated with either metformin or placebo in a randomized, double-blind, placebo-controlled, cross-over study. Insulin secretion and insulin resistance were quantified using the homeostasis model assessment (HOMA) and insulin-stimulated glucose disposal were measured by determining the steady-state plasma glucose (SSPG).

RESULTS

The average benefit of metformin was 0.6 mmol/l for glucose (95% confidence interval (CI) 0.2-0.9 P = 0.002), 2.8 pmol/l for insulin (95% CI 0.2-5.4, P = 0.019). Insulin resistance, as quantified by HOMA, was improved by 1.1 (95% CI 0.2-2.0, P = 0.004), without any change in insulin secretion. Basal and insulin-stimulated glucose oxidation were comparable in the placebo and metformin-treated groups at the end of each treatment period, as was the SSPG concentration. However, both systolic and diastolic blood pressures fell significantly following metformin administration as compared to treatment with placebo.

CONCLUSIONS

These results indicate that metformin administration to patients with IGT is associated with enhanced glucose disposal at baseline insulin concentrations and a fall in blood pressure. In contrast, neither glucose oxidation nor glucose disposal were increased in association with metformin treatment under conditions of physiological hyperinsulinaemia.

Superficial vein thrombosis of lower limbs: influence of factor V Leiden, factor II G20210A and overweight

Superficial vein thrombosis (SVT) has been reported in patients with thrombophilia. In the present unmatched case-control study, the two most common thrombophilic abnormalities (factor V Leiden and factor II G20210A) were searched for in 112 consecutive patients with SVT of lower limbs and in 180 healthy donors. FV Leiden was present in 16/112 (14.3%) SVT patients and 11/180 (6.1%) controls (odds ratio 2.51, 95% CI 1.04-6.24) and FII G20210A in 4/112 (3.6%) patients and 2/180 (1.1%) controls (OR 3.28, 95% CI 0.46-36.84). In addition, body mass index (BMI) > or =28 kg/m2 was also associated with SVT (OR 2.81, 95% CI 1.60-5.00). After adjustment for BMI > or =28 kg/m2, the association between FV Leiden and SVT remained strong though no longer statistically significant. Among patients with SVT, the presence of FV Leiden was independently associated with the absence of varicose veins (OR 4.62, 95% CI 1.25-18.0) and with a BMI > or =28 kg/m2 (OR 3.74, 95% CI 1.05-15.1). In conclusion, both FV Leiden and overweight seem to predispose to SVT, a finding that should be confirmed in larger studies.

[Availability and quality of necessary data for establishing health assessment in the canton of Geneva: implications for the monitoring of the development of problems and impact of health policies]

The global health assessment of the population of the canton of Geneva, based on the WHO's 38 "Health-for-ALL" targets, shown several gaps in the health information system. The quality of the available data is discussed in regard of various criteria (type of statistics, representativeness, frequency of data collection, diffusion, comparability, concern for validation). Two examples are presented: 1.) The incidence of low birthweight shows how a hospital-based statistics indicator can accurately reflect a trend over time, but provide a biased estimation of a risk level. 2.) The evolution of several indicators concerning drug consumption shows how important it is to validate these indicators in order to allow an adequate interpretation. Such a validation is seldom made. The present situation could be improved by a more efficient structure of the canton's health statistics.

The driver's role in fatal two-car crashes: a paired "case-control" study

This population-based study examines drivers' characteristics associated with driving errors that resulted in fatal motor vehicle crashes. Routinely collected data from the Fatal Accident Reporting System were used to assess whether a driver initiated the crash (case) or was passively involved (control) in 6,506 two-car collisions (81% of 7,993 eligible events). A paired comparison of cases and controls avoided confounding by environmental factors, exposure to traffic, and differences in case fatality. The strongest predictor of crash initiation is alcohol (odds ratio (OR) = 11.5; 95% confidence interval (CI) 9.57-13.9). Odds ratios are elevated even at the lowest blood alcohol concentration levels and increase dramatically as alcohol levels rise. Drivers aged 40-49 years are least likely to initiate crashes; odds ratios rise in a U-shaped manner to 3.35 in teenagers (95% CI 2.72-4.13) and to 22.1 in drivers over 80 years (95% CI 14.2-34.5). Other risk factors for initiating a fatal crash are the following: not wearing a seat belt (OR = 1.54; 95% CI 1.35-1.75), driving without a valid driver's license (OR = 2.16; 95% CI 1.72-2.73), and having had a crash within the last year (OR = 1.21; 95% CI 1.07-1.38). Driving errors leading to fatal crashes do not occur at random, but are associated with specific driver characteristics. The risk factors for crash initiation among crash-involved drivers are similar to risk factors for crash involvement found in other studies. These findings suggest that driving errors often explain high rates of crash involvement, invite further use of crash initiation in traffic injury research, and underscore the value of population-based registries for analytic epidemiology.