Patients' Experience and Satisfaction Regarding the Pre-Operative Shower: The PRODOUCH Multicenter Descriptive Survey

Background: Patients' experience of the pre-operative shower remains poorly assessed in the literature although it is an essential step in the prevention of surgical site infection. For obese patients, a pre-operative shower could be challenging. The goal was to assess patient satisfaction and experience with the process of pre-operative shower, and the effect of obesity status. Patients and Methods: This study was a multicenter prospective survey of consecutive surgical patients from nine hospitals. Data on the pre-operative shower were collected via telephone interview two to four weeks after surgery, and included the place (hospital, home), time, information received, difficulties experienced, the presence or absence of a visual assessment of skin cleanliness by a healthcare professional after the pre-operative shower, and overall patient satisfaction with the pre-operative shower technique. Data on the surgical procedure and patients' characteristics were collected from patients' records, and included age, gender, and body mass index. Factors associated with patient satisfaction were assessed. Results: Among 430 patients, 91.6% declared having received information on the pre-operative shower and 94.8% were very or rather satisfied with the pre-operative shower. Two factors were independently associated with satisfaction: showering at home and having received information on the pre-operative shower, but not obesity status. Only 17% of patients reported a visual assessment of skin cleanliness by a healthcare professional after the pre-operative shower. Discussion: Overall, regardless of obesity status, patients were satisfied with the pre-operative shower and reported no difficulties. However, this survey highlights the fact that skin cleanliness was seldom assessed by healthcare professionals, which may represent an unidentified weakness in skin preparation before surgery.

Incorporation of skin preparation guidelines in local surgical facility protocols: what kind of barriers does it face? A multi-centre study in France

BACKGROUND

Surgical site infection (SSI) is the most frequent and severe adverse event after surgery. Among preventive measures, the preoperative skin preparation (PSP) is known to be heterogeneously implemented in routine practice. A prerequisite would be the actual incorporation of guidelines in French surgical local protocols.

AIM

To assess whether PSP recommendations have been incorporated in local protocols and to identify the reasons for the non-incorporation.

METHODS

An online survey was proposed to all infection control teams (ICTs) in facilities participating in the French national surveillance and prevention of SSI network Spicmi. The reference recommendations were based on the French Society for Hospital Hygiene guidelines.

FINDINGS

In all, 485 healthcare facilities completed the questionnaire. The incorporation of recommendations in the facility protocol varied between 30% and 98% according to the recommendation. The measures most frequently incorporated were antisepsis with an alcoholic product and cessation of systematic hair removal. The least frequently incorporated were the use of plain soap for preoperative shower and the non-compulsory skin cleaning in the operating room. Barriers reported were either specific to PSP (e.g. 'Concern about an increase of SSI', 'Scepticism about recommendations', 'Force of habit') or non-specific (e.g. 'The protocol not yet due to be updated').

CONCLUSION

We suggest that although some major prevention measures have been incorporated in the local protocol of most facilities, local protocols still frequently include some non-evidence based former recommendations. Communication about evolution of SSI rates, diffusion of guidelines by learned societies, and exchange with judiciary experts could make clear the conditions for applying recommendations.

Compliance with good practice guidelines for the prevention of vascular access infections: the multi-centre PHYDEL survey in French haemodialysis units

BACKGROUND

French guidelines for the prevention of vascular access infections in a haemodialysis setting were released in 2005. Compliance with these guidelines is currently unknown. The aim of this study was to assess compliance with the guidelines for vascular access infection prevention in French haemodialysis units, and to describe the difficulties reported.

METHODS

A cross-sectional survey was conducted between March and December 2019 in 200 haemodialysis units in France, selected at random. Data were collected via questionnaire, completed by telephone interview with an infection control practitioner. A practice was deemed compliant when >85% of units declared that they always complied with the guidelines.

RESULTS

In total, 103 units (51.5%) agreed to participate. Most practices complied with the guidelines; however, some practices did not reach the 85% compliance threshold for working in pairs when connecting central venous catheter (CVC) lines, performing hand hygiene before disconnecting lines, rinsing antiseptic soap before painting CVC exit site or arteriovenous fistula (AVF) puncture site, allowing antiseptic paint to dry, handling CVC branches with antiseptic impregnated gauze, performing hand hygiene after AVF compression with gloves, wearing protective eyewear when connecting/disconnecting CVC or when puncturing AVF, and wearing a gown when puncturing AVF. The most frequently reported difficulties were understaffing, difficulties with skin preparation because of exit site skin damage, and lack of buttonhole technical expertise.

CONCLUSIONS

Despite good overall compliance, this survey highlights some shortcomings in compliance with infection prevention guidelines, which could be associated with either higher risk of vascular access infection or increased blood-borne virus transmission.

Knowledge, attitudes and practices of French university students towards COVID-19 prevention-are health students better?

During the COVID-19 outbreak in 2020, public health measures (PHM) were implemented to prevent the spread of SARS-CoV-2. At university, we wondered whether health students would be more likely to comply with these safety measures against infectious disease transmission compared to other students. Thus, we collected 1 426 university students' responses to an online anonymous survey to describe their knowledge, attitudes and practices (KAP) of COVID-19 prevention measures and to compare the opinions and practices of health students and science students at the same university of Rouen Normandy (France). A higher proportion of science students (84.6%) compared to health students (73.9%) reported knowledge of the university's COVID-19 protocol, p<0.001. However, the health students compared to science students reported a higher compliance with PHM at home (91.4% vs 88.0%) and at university (94.1% vs 91.1%). In a multiple regression analysis, after adjustment for age, sex and university department, factors associated with higher compliance with PHM were knowledge of the university's COVID-19 protocol and a high perceived efficacy of PHM. A SARS-CoV-2 PCR result was not predictive of compliance with PHM. The results of this online survey in French students show a high level of knowledge and practices of COVID-19 prevention Although their performances could still be improved by training, the good results of health students regarding knowledge, attitudes and practices are encouraging as these students could be an added backup force to fight against viral pandemics.

[REIN: a tool to highlight inequalities in health]

On the occasion of the 20th anniversary of the REIN (French Renal Epidemiology and Information Network), a summary work on the contributions of the national French ESKD register was carried out. On the issue of Social Inequalities in Health, the following key messages were retained. Social inequalities in health exist throughout the journey of a patient with chronic kidney disease and manifest as territorial inequalities in access to home-based or independent dialysis treatment and to transplant, whether preemptive or otherwise. SIH are observed in adults as well as in the paediatric population. The female gender appears to be associated with a disparity in access to kidney transplant.

[Prevalence of End Stage Kidney Disease and distribution of treatment modalities]

On the occasion of the 20th anniversary of the REIN (French Renal Epidemiology and Information Network), a summary work on the contributions of the national French ESKD register was carried out. On the issue of ESKD prevalence, the following key messages were retained. While chronic kidney disease affects all age groups, there always are more patients to treat in the older age groups, with a median age of 71.1 years (IIQ 60.3-80.0) under dialysis and 58.7 years (IIQ 47.4-68.3) under renal transplant. Despite an increase in transplant activity and improved survival of grafts, the gap between the number of dialysis patients and transplant patients at the end of each year is only moderately reduced. There has been a moderate decrease in the proportion of in-centre haemodialysis that is explained by a significant increase in medicalised dialysis units (out-centre haemodialysis) and a decrease in self-care haemodialysis. Finally, a stable home-based care has been observed despite the ministerial incentives and the recommendations of the French-speaking scientific society (SFNDT-white paper).

Are patients living far from hospital at higher risk of late adjuvant chemotherapy for colon cancer?

INTRODUCTION

Late adjuvant chemotherapy (aCT) administration after colectomy (> 56 days) is known to be associated with impaired prognosis. We aim to identify risk factors associated with late aCT, especially the travel time between patients' home and hospital.

METHOD

We performed a retrospective monocentre cohort study. Patients included had a colectomy for a stage III or "high risk" stage II colon cancer between 2009 and 2015 performed at a French university hospital. Risk factors for late aCT were identified using a fractional polynomial logistic regression.

RESULTS

Ninety-four patients were included. The risk of late aCT was associated with travel time length, emergent colectomy, the need for scheduled care before aCT, and length of time between colectomy and postoperative multidisciplinary meeting advising aCT.

CONCLUSION

Our study suggests that, in patients with colon cancer, factors unrelated to disease severity and complexity could be associated with a higher risk of late aCT.

Staphylococcus capitis isolated from bloodstream infections: a nationwide 3-month survey in 38 neonatal intensive care units

To increase the knowledge about S. capitis in the neonatal setting, we conducted a nationwide 3-month survey in 38 neonatal intensive care units (NICUs) covering 56.6% of French NICU beds. We demonstrated 14.2% of S. capitis BSI (S.capBSI) among nosocomial BSIs. S.capBSI incidence rate was 0.59 per 1000 patient-days. A total of 55.0% of the S.capBSIs were late onset catheter-related BSIs. The S. capitis strains infected preterm babies (median gestational age 26 weeks, median birth weight 855 g). They were resistant to methicillin and aminoglycosides and belonged to the NRCS-A clone. Evolution was favorable in all but one case, following vancomycin treatment.

Lack of effect of a poster-based intervention to reduce the number of blood culture samples collected

OBJECTIVE

To reduce the number of blood culture samples collected.

PATIENTS AND METHOD

We performed a cluster randomized controlled trial in adult acute care, and subacute care and rehabilitation wards in a university hospital in France. A poster associating an image of eyes looking at the reader with a summary of blood culture sampling guidelines was displayed in hospital wards in the intervention group. The incidence rate of blood cultures per 1000 days during pre- and post-intervention periods was calculated.

RESULTS

Thirty-one wards participated in the study. The median difference in blood cultures/1000 days between periods was -1.863 [-11.941; 1.007] in the intervention group and -5.824 [-14.763; -2.217] in the control group (P=0.27).

CONCLUSION

The intervention did not show the expected effect, possibly due to the choice of blood cultures as a target of good practice, but also to confounding factors such as the stringent policy of decreasing unnecessary costly testing.

Patients' perception and attitude to totally implantable venous access for urologic or digestive cancer: A cross-sectional study

INTRODUCTION

Totally implanted venous access (TIVA) improves the safety and welfare of patients treated with cancer chemotherapy (CCT). We aimed to evaluate patients' perception of TIVA placement, TIVA use, and information on TIVA, and to assess the association between patients' perception and their attitude regarding a potential TIVA re-implantation.

METHODS

We conducted a single center cross-sectional survey in a university hospital in Northern France. Patients included were consecutive urologic or digestive cancer inpatients admitted for a CCT cycle via TIVA between April 9th and May 9th 2014. We analyzed patients' satisfaction, experience, and attitude, especially when requiring potential TIVA re-implantation under local anesthesia (LA), using a standardized questionnaire and medical records. We analyzed risk factors for refusing potential TIVA re-implantation under LA using multivariate logistic regression.

RESULTS

Eighty-one patients were interviewed (no refusals), including 57 with a TIVA device placed under LA in our university hospital. Among them, 52/57 (91%) reported satisfactory TIVA placement, but respectively 21/57 (37%) and 18/57 (32%) complained of painful or uncomfortable TIVA placement; 51/57 (89%) were satisfied with care provided during CCT cycles. Risk factors for refusing potential re-implantation under LA were: TIVA placement considered painful (P=0.012) or uncomfortable (P=0.038) and dissatisfaction with care provided during CCT cycles (P=0.028).

DISCUSSION

We show that despite good overall satisfaction regarding TIVA, some aspects were less positive and warrant improvement actions. It suggests that these actions could not only improve patients' experience of TIVA use but could also facilitate continuation of treatment in the long term.

Surgical Site Infection in Endometriosis Surgery Is a Rare Complication: Results of a Single Center's Prospective Surveillance of Eight Hundred Ninety-Six Procedures

Background: There are no studies reporting the rate of surgical site infection (SSI) after surgery for endometriosis, although this information is valuable when discussing the most appropriate treatment strategy with the patient. Methods: We conducted a prospective cohort study in a university hospital and regional reference center for endometriosis. We sought to measure the rate of SSI after endometriosis surgery using prospective SSI post-discharge surveillance data and the hospital information system via an ad hoc algorithm using both diagnosis and procedure code classifications. Results: Among 896 consecutive endometriosis surgical procedures, we identified 365 procedures with involvement of the gastrointestinal tract, defined as the deep invasive procedure (DIP) group, 107 procedures with involvement of an ovary, and 424 other procedures. Twelve SSI (all organ/space infections) were observed, all in the DIP group, corresponding to an overall SSI incidence of 1.3% 95% confidence interval (CI) 0.7-2.3, and an SSI incidence in the DIP group of 2.8%, 95% CI 1.5-4.9. The median delay between the procedure and the SSI was 6.5 days (range, 3-23). At least one micro-organism was found in 10 patients (four Escherichia coli, four Enterobacter cloacae, three Enteroccus faecalis, two Bacteroides fragilis, one Pseudomonas aeruginosa, one Candida albicans). Conclusion: A low overall rate of SSI after surgery for endometriosis was observed. Nevertheless, procedures with involvement of the intestinal tract were at risk of SSI.

Totally implanted venous access-associated adverse events in oncology: Results from a prospective 1-year surveillance programme

INTRODUCTION

During the last decade, most studies on totally implanted venous access-associated adverse events (TIVA-AE) were conducted retrospectively and/or were based on a limited sample size. The aim of our survey was two-fold: to estimate the incidence of TIVA-AE and to identify risk factors in patients with cancer.

METHODS

Data from our routine surveillance of TIVA-AE were collected prospectively between October 2009 and January 2011 in two oncology referral centers in Northern France. The open cohort under surveillance during the same time period was reconstituted retrospectively using data from the hospital information systems. Incidences of first TIVA-AE per 1000 TIVA-days were calculated. Risk factors were identified using multivariate logistic regressions.

RESULTS

We included 2286 cancer patients, corresponding to 582,347 TIVA-days. Among the 133 first TIVA-AE observed (incidence 0.23 per 1000 TIVA-days [0.19-0.27]), there were 50 infectious AE (incidence 0.09 [0.06-0.11]) and 83 non-infectious AE (incidence 0.14 [0.11-0.17]). Compared to non-metastatic solid cancers, metastatic cancers (aOR=2.3 [0.9-6.0]), and hematologic malignancies (aOR=3.2 [1.1-8.8]) tended to be associated with a higher risk of infectious TIVA-AE (P=0.087). Solid cancer type was associated with non-infectious TIVA-AE (P=0.030), especially digestive cancers.

DISCUSSION

We report accurate estimations of TIVA-AE incidences in one of the largest populations among previously published studies. As in previous studies, metastatic cancers and hematologic malignancies tended to be associated with a higher risk of infectious TIVA-AE. Further studies are warranted to confirm the effect of digestive cancers.

Impact of MaxZero™ needle-free connector on the incidence of central venous catheter-related infections in surgical intensive care unit

BACKGROUND

Central venous catheter-related infections (CRIs) are a complication of central venous catheters in intensive care unit (ICU). Some needle-free connectors have been designed to decrease CRI, but there is a lack of data concerning their impact on infection.

OBJECTIVES

The objective was to explore the impact of MaxZero™ connectors (BD; Franklin Lakes, US) on CRI in ICU.

METHODS

Observational, pre-post design study (2011-2013 and 2014-2016) conducted in the surgical ICU of a tertiary care hospital (18 beds). Patients with a central venous catheter and a length of stay ≥48 h were included. The connectors replaced all disposable caps used on infusion stopcocks and ramps. The primary parameter was to compare the incidence of CRI between the "before" period and the "after" period.

RESULTS

A total of 1633 patients were included (789 "before" and 844 "after"). There was no difference between groups concerning the global duration of catheterisation (12.5 ± 11.5 days vs. 12.1 ± 10.9 days). There were 61 CRIs before and 28 CRIs after the introduction of connectors; the incidence of CRI in the "before" group was 20.33 CRI/year (6.18 CRI per 1000 catheter-days) vs. 9.33 CRI/year (2.73 CRI per 1000 catheter-days) in the "after" group (incidence rate ratio = 0.44; 95% confidence interval = 0.28-0.68, p < 0.001). However, after a global analysis of the 6-year period, when adjusting for seasonal effect and pre-existing linear trend, the effect was no longer significant (adjusted incidence rate ratio = 0.57; 95% confidence interval = 0.24-1.35, p = 0.20).

CONCLUSIONS

Our results do not allow us to conclude to a potential beneficial effect of MaxZero™ on CRI but are compatible with its prolonged and safe use in ICU. Only future prospective works will be able to confirm the value of these connectors for CRI prevention.

Reassessment of antibiotic therapy in hospitals

INTRODUCTION

French national guidelines state that antibiotic therapies should be reassessed between 48 and 72hours after treatment initiation and that reassessment of antibiotic therapy (RA) must be recorded in patients' files.

OBJECTIVE

To determine whether RA is performed and recorded in patients' files in hospitals in a region of France.

METHODS

Setting: hospitals participating in the National nosocomial infection point- prevalence survey (NPS) in Upper-Normandy, France. Patients included those receiving antibiotic therapy (excluding antibiotic prophylaxis) on NPS day, started in the hospital in which the survey was conducted and ongoing for more than 72hours. Data collected included characteristics of participating hospitals and, for each included patient, characteristics of ward, infection and antibiotic therapy, and mention in the patients' files of explicit or implicit RA. The rate of explicit and implicit RA was calculated and factors associated with explicit or implicit RA were evaluated using a univariate analysis.

RESULTS

Thirty-three hospitals representing 87% of hospital beds region-wide were included in the study. In addition, 933 prescriptions were assessed for 724 infections in 676 patients. The overall rate of RA was 67.6% (49.3% of explicit RA and 18.3% of implicit RA). The rate of RA differed significantly according to infection and antibiotic class but not according to hospital or ward characteristics.

CONCLUSION

Our study provides new and reassuring results regarding reassessment of antibiotic therapy.

Case Fatality and Health Care Costs in HIV-Infected Patients: Evolution from 1992 to 2000 at Rouen University Hospital, France

Vital prognosis in HIV-infected patients has been improved by new therapies, leading to an increase in treatment and outpatient costs but lower inpatient care costs. The aim of the study was to compare the health care costs between 1992–1996 (first half) and 1996–2000 (second half) in HIV-infected patients at Rouen University Hospital. Hospitalization costs (including inpatient and outpatient care), infectious complication treatment and antiretroviral therapy costs were evaluated from a National Health Insurance viewpoint. Between 1992 and 2000, 1212 patients were admitted at least once. Total expenditure increased between the two periods from €13,660 to €27,567, i.e., a two-fold increase. During the same period, 125 deaths were avoided, and 3602 years of life were gained. The cost of one avoided death was €108,320 and the cost per life-year gained was €3776.

Is the Risk of Wound Infection Related to Bilateral Internal Thoracic Artery Graft Potentiated by Age?

BACKGROUND

Older age and the use of bilateral internal thoracic artery (ITA) grafting are both considered risk factors for surgical wound infection (SWI) after coronary artery bypass grafting (CABG). The 2014 European Guidelines recommend that bilateral ITA grafting should be considered in patients aged younger than 70 years. Our aim was to investigate interaction between age and the number of ITA grafts.

METHODS

All patients aged 18 years and older who had undergone CABG with at least 1 ITA at Rouen University Hospital between 2001 and 2012 were selected. Data regarding surgical procedure (single/bilateral ITA grafting) were extracted from the medical information system. SWI was identified from prospective surveillance of patients according to Centers for Disease Control and Prevention criteria. Independent factors associated with SWI were assessed by logistic regression, and an interaction test between age (≤69 or ≥70 years) and the number of ITA grafts was performed.

RESULTS

SWI occurred in 71 of 2,726 patients (2.6%). Bilateral ITA grafting was associated with SWI (adjusted odds ratio [aOR], 2.55; 95% confidence interval, 1.51 to 4.30). After fitting an interaction term between age and number of ITA grafts, the aORs for SWI after bilateral ITA grafting substantially differed between patients aged 69 years and younger (aOR, 1.88; 95% confidence interval, 0.94 to 3.75) and 70 years and older (aOR, 3.52; 95% confidence interval, 1.69 to 7.33). However, this interaction failed to reach statistical significance (p = 0.2213), possibly because of insufficient statistical power (23.5%) despite the large sample size.

CONCLUSIONS

Age 70 years and older compared with age 69 years and younger was associated with higher occurrence of SWI after bilateral ITA grafting, but this interaction was not statistically significant. Larger studies are needed to test this interaction.

Sociocognitive determinants of self-reported compliance with standard precautions: Development and preliminary testing of a questionnaire with French health care workers

BACKGROUND

Inconsistent compliance of health care workers with standard precautions has already been documented. The objective of this study was to develop a questionnaire to investigate the sociocognitive determinants of compliance with standard precautions based on the theory of planned behavior.

METHODS

To construct the Standard Precautions Questionnaire (SPQ), items were selected using a systematic review of literature and semistructured interviews with 54 health care workers. Thirty-five items were selected for a draft questionnaire. These questionnaires were sent to 649 health care workers in 3 medical specialties (pediatrics, geriatrics, and intensive care) in a French University hospital. A total of 331 valid questionnaires were analyzed.

RESULTS

Factor analysis yielded a final 7-factor solution with an explained variance of 66.51%, with 24 items. The 7 dimensions were the following: attitude toward standard precautions, social influence facilitating organization, exemplary behavior of colleagues, organizational constraints, individual constraints, and intention to perform standard precautions. Some differences were observed between medical specialties on attitude toward standard precautions, social influence, and individual constraints.

CONCLUSION

The SPQ met the conditions of reliability and validity in accordance with psychometric demands and could be used to evaluate attitudes and intention to perform standard precautions among medical and nursing staff.

Prevention of Nosocomial Infection and Standard Precautions: Knowledge and Source of Information Among Healthcare Students

Objective.

To evaluate the knowledge of healthcare students after four curricula on infection control and to identify sources of information.

Design.

Cross-sectional study.

Setting.

Four healthcare schools at Rouen University (Rouen, France).

Participants.

Medical students, nursing students, assistant radiologist students, and physiotherapist students taking public health courses.

Methods.

To measure students' knowledge of infection control and their sources of information, 6 multiple-choice questions were asked about 3 specific areas: standard precautions, hand hygiene, and nosocomial infection. Each questionnaire section had 10 possible points, for an overall perfect score of 30. The sources of information for these 3 areas were also recorded: self-learning, practice training in wards, formal training in wards, and teaching during the curriculum. A logistic regression analysis was performed to identify factors associated with acceptable level of knowledge.

Results.

Three hundred fifty students (107 medical students, 78 nursing students, 71 physiotherapist students, and 94 assistant radiologist students) were included in the study. The mean overall score (±SD) was 21.5 ± 2.84. Nursing students had a better mean overall score (23.2 ± 2.35) than did physiotherapist students (21.9 ± 2.36), medical students (21.1 ± 2.35), and assistant radiologist students (20.5 ± 3.04; P < .001). The mean scores (±SD) for the component sections of the questionnaire were 8.5 ±1.4 for standard precautions, 7.4 ± 1.26 for hand hygiene, and 5.7 ± 1.55 for nosocomial infections (P < .001). The main source of information was material taught during the curriculum. Results of multivariate analysis indicate that the probability of attaining acceptable knowledge in each area was smaller for medical students and assistant radiologist students than for nursing students.

Conclusion.

The overall score for infection control indicated that instruction was effective; however, knowledge levels were different by area (the best scores were results of tests of standard precautions) and curriculum (nursing students achieved the best overall score). Ward training for daily infection control practice (ie, bedside instructions training and course work) could be improved for healthcare students.

Natural history of elderly-onset inflammatory bowel disease: a population-based cohort study

Data on the natural history of elderly-onset inflammatory bowel disease (IBD) are scarce.

METHODS

In a French population-based cohort we identified 841 IBD patients >60 years of age at diagnosis from 1988 to 2006, including 367 Crohn's disease (CD) and 472 ulcerative colitis (UC).

RESULTS

Median age at diagnosis was similar for CD (70 years (IQR: 65-76)) and UC (69 years (64-74)). Median follow-up was 6 years (2-11) for both diseases. At diagnosis, in CD, pure colonic disease (65%) and inflammatory behaviour (78%) were the most frequent phenotype. At maximal follow-up digestive extension and complicated behaviour occurred in 8% and 9%, respectively. In UC, 29% of patients had proctitis, 45% left-sided and 26% extensive colitis without extension during follow-up in 84%. In CD cumulative probabilities of receiving corticosteroids (CSs), immunosuppressants (ISs) and anti tumor necrosis factor therapy were respectively 47%, 27% and 9% at 10 years. In UC cumulative probabilities of receiving CS and IS were 40% and 15%, respectively at 10 years. Cumulative probabilities of surgery at 1 year and 10 years were 18% and 32%, respectively in CD and 4% and 8%, respectively in UC. In CD complicated behaviour at diagnosis (HR: 2.6; 95% CI 1.5 to 4.6) was associated with an increased risk for surgery while CS was associated with a decreased risk (HR: 0.5; 0.3 to 0.8). In UC CS was associated with an increased risk (HR: 2.2; 1.1 to 4.6) for colectomy.

CONCLUSIONS

Clinical course is mild in elderly-onset IBD patients. This information would need to be taken into account by physicians when therapeutic strategies are established.

Long-term outcome after first intestinal resection in pediatric-onset Crohn's disease: a population-based study

BACKGROUND

To describe long-term postoperative evolution of pediatric-onset Crohn's disease (CD) and identify predictors of outcome we studied a population-based cohort (1988-2004) of 404 patients (0-17 years), of which 130 underwent surgery.

METHODS

Risks for a second resection and first need for immunosuppressors (IS) and/or biologics were estimated by survival analysis and Cox models used to determine predictors of outcome. Impact of time of first surgery on nutritional catch-up was studied using regression.

RESULTS

In all, 130 patients (70 females) with a median age at diagnosis of 14.2 years (interquartile range: 12-16) were followed for 13 years (9.4-16.6). Probability of a second resection was 8%, 17%, and 29% at 2, 5, and 10 years, respectively. In multivariate analysis, age <14, stenosing (B2) and penetrating (B3) behaviors and upper gastrointestinal location (L4) at diagnosis were associated with an increased risk of second resection. Probability of receiving IS or biologics was 18%, 34%, and 47% at 2, 5, and 10 years, respectively. In multivariate analysis, L4 was a risk factor for requiring IS or biologics, while surgery within 3 years after CD diagnosis was protective. Catch-up in height and weight was better in patients who underwent surgery within 3 years after CD diagnosis than those operated on later.

CONCLUSIONS

In this pediatric-onset CD study, mostly performed in a prebiologic era, a first surgery performed within 3 years after CD diagnosis was associated with a reduced need for IS and biologics and a better catch-up in height and weight compared to later surgery.

Clinical predictors at diagnosis of disabling pediatric Crohn's disease

BACKGROUND

Identification of children with Crohn's disease (CD) at high risk of disabling disease would be invaluable in guiding initial therapy. Our study aimed to identify predictors at diagnosis of a subsequent disabling course in a population-based cohort of patients with pediatric-onset CD.

METHODS

Among 537 patients with pediatric CD diagnosed at <17 years of age, 309 (57%) with 5-year follow-up were included. Clinical and demographic factors associated with subsequent disabling CD were studied. Three definitions of disabling CD were used: Saint-Antoine and Liège Hospitals' definitions and a new pediatric definition based on the presence at maximal follow-up of: 1) growth delay defined by body mass index (BMI), weight or height lower than -2 SD Z score; and 2) at least one intestinal resection or two anal interventions. Predictors were determined using multivariate analyses and their accuracy using the kappa method considering a relevant value ≥ 0.6.

RESULTS

According to the Saint-Antoine definition, the rate of disabling CD was 77% and predictors were complicated behavior and L1 location. According to the Liège definition, the rate was 37% and predictors included behavior, upper gastrointestinal disease, and extraintestinal manifestations. According to the pediatric definition, the rate of disabling CD was 15%, and predictors included complicated behavior, age <14, and growth delay at diagnosis. Kappa values for each combination of predictors were, respectively, 0.2, 0.3, and 0.2 and were nonrelevant.

CONCLUSIONS

Clinical parameters at diagnosis are insufficient to predict a disabling course of pediatric CD. More complex models including serological and genetic biomarkers should be tested.

Long-term outcome of treatment with infliximab in pediatric-onset Crohn's disease: a population-based study

BACKGROUND

We examined short- and long-term benefits and safety of infliximab (IFX) in a population-based cohort of Crohn's disease (CD) patients <17 years old at diagnosis.

METHODS

The following parameters were assessed: short- and long-term efficacy of IFX, impact of drug efficacy, and mode of administration on rate of resection surgery, growth and nutritional catch-up, and adverse events (AEs).

RESULTS

In all, 120 patients (69 female) required IFX with a median duration of 32 months (Q1 = 8-Q3 = 60). Median age at diagnosis was 14.5 years (12-16) and median interval between diagnosis and IFX initiation was 41 months (22-78). Median follow-up since CD diagnosis was 111 months (75-161). Fifty patients (42%) received episodic and 70 (58%) maintenance therapy. Sixty-five (54%) patients were in the "IFX efficacy" group: 38 (32%) still receiving IFX at the last visit and 27 (22%) stopping IFX while in remission. The "IFX failure" group included 55 (46%) patients: 17 (14%) who stopped IFX due to AEs and 38 (32%) nonresponders. The risk of surgery was reduced (P = 0.009) in the "IFX efficacy" group and lower (P = 0.03) in patients with scheduled versus episodic therapy. Patients in the "IFX efficacy" group had significant catch-up growth (P = 0.04), while those in the "IFX failure" group did not. Twenty-four patients presented AEs leading to cessation of IFX in 17 of them.

CONCLUSIONS

In this population-based cohort of pediatric-onset CD, IFX treatment was effective in more than half of patients during a median follow-up of 32 months. Long-term IFX responders had a lower rate of surgery and improved catch-up in growth, especially when receiving scheduled IFX therapy.

Is continuous subglottic suctioning cost-effective for the prevention of ventilator-associated pneumonia?

OBJECTIVE

To establish whether continuous subglottic suctioning (CSS) could be cost-effective.

DESIGN

Cost-benefit analysis, based on a hypothetical replacement of conventional ventilation (CV) with CSS.

SETTING

A surgical intensive care unit (SICU) of a tertiary care university hospital in France.

PATIENTS

All consecutive patients receiving ventilation in the SICU in 2006.

METHODS

Efficacy data for CSS were obtained from the literature and applied to the SICU of our hospital. Costs for CV and CSS were provided by the hospital pharmacy; costs for ventilator-associated pneumonia (VAP) were obtained from the literature. The cost per averted VAP episode was calculated, and a sensitivity analysis was performed on VAP incidence and on the number of tubes required for each patient.

RESULTS

At our SICU in 2006, 416 patients received mechanical ventilation for 3,487 ventilation-days, and 32 VAP episodes were observed (7.9 episodes per 100 ventilated patients; incidence density, 9.2 episodes per 10,000 ventilation-days). Based on the hypothesis of a 29% reduction in the risk of VAP with CSS than CV, 9 VAP episodes could have been averted. The additional cost of CSS for 2006 was estimated to be €10,585.34. The cost per averted VAP episode was €1,176.15. Assuming a VAP cost of €4,387, a total of 3 averted VAP episodes would neutralize the additional cost. For a low VAP incidence of 6.6%, the cost per averted VAP would be €1,323. If each patient required 2 tubes during ventilation, the cost would be €1,383.69 per averted VAP episode.

CONCLUSION

Replacement of CV with CSS was cost-effective even when assuming the most pessimistic scenario of VAP incidence and costs.

The changing pattern of Crohn's disease incidence in northern France: a continuing increase in the 10- to 19-year-old age bracket (1988-2007)

BACKGROUND

Crohn's disease incidence rates have stabilised in industrialised countries since the 1980s. Conversely, a continuing increase in childhood-onset Crohn's disease incidence has been reported.

AIM

To confirm trends in inflammatory bowel disease (IBD) incidence in northern France over an extended time period (1988-2007) with a focus on childhood-onset Crohn's disease.

METHODS

The IBD patients recorded in the EPIMAD registry between 1988 and 2007 were included. Standardised incidence rates were calculated for Crohn's disease and ulcerative colitis in the entire population, and separately according to age. Evolution of phenotypes at diagnosis was also studied.

RESULTS

A total of 12 084 incident IBD cases (7428 Crohn's disease and 4656 ulcerative colitis) were recorded. Crohn's disease incidence rates increased from 5.2 cases/100 000 persons in 1988-1990 to 6.7 in 2006-2007 (+29%), stabilising after a peak at 7.1 in 1997-1999. Crohn's disease incidence rates in the 10-19-year age category increased by 71%, from 6.5 (1988-1990) to 11.1 (2006-2007). The frequency of initial ileo-colonic localisation increased from 52.9% in 1988-1990 to 68.6% in 2006-2007 (P<0.0001). Ulcerative colitis incidence rates decreased during the same period.

CONCLUSIONS

From 1988 to 2007, Crohn's disease incidence increased by 29% in northern France and by 71% in the 10-19-year-old age group. Consequently, studies on Crohn's disease risk factors should focus on the population under 20 years of age.

Mapping of inflammatory bowel disease in northern France: spatial variations and relation to affluence

BACKGROUND

Geographic variations in the incidence of inflammatory bowel disease (IBD) may reflect variations in the distribution of environmental etiologic factors. We assessed spatial variation in the incidence of IBD in northern France and analyzed its association with a deprivation index.

METHODS

All cases of IBD included in the EPIMAD registry between 1990 and 2003 were extracted. The standardized incidence ratio (SIR) was calculated for each canton in the region. The association between incidence and deprivation was assessed using the Townsend deprivation index.

RESULTS

The mean annual incidence rates of Crohn's disease (CD) and ulcerative colitis (UC) were 6.2 x 10(-5) and 3.8 x 10(-5), respectively. The mean cumulative numbers of cases by canton were 18.4 (1-183) for CD and 11.3 (0-148) for UC. For both CD and UC, mapping depicted spatial heterogeneity in the SIR with spatial autocorrelation. A high relative risk (RR) of CD was observed in mainly rural and periurban cantons of the region. For UC, a high RR was found in cantons of the south and the center of Pas-de-Calais. No significant correlation was observed between spatial variations in IBD and deprivation.

CONCLUSIONS

The incidence of IBD is associated with spatial heterogeneity in northern France. The noteworthy predominance of CD in agricultural areas warrants further investigations.

[Information for patients about hospital infections in psychiatry: An assessment of healthcare professionals' knowledge, opinion and attitude]

INTRODUCTION

French legislation makes mandatory for healthcare providers the disclosure of hospital infection (HI) risk and actual occurrence to the patient. Given the specific diseases encountered in psychiatry, some difficulties may be expected in practical application of this regulation.

OBJECTIVES

The aim of our study was to describe the knowledge, declared practices and opinions of healthcare workers (HCW) in psychiatry concerning information for patients about HI.

METHODS

We randomly selected doctors, nurses and head nurses from four hospitals with psychiatric activity in Normandy. The HCW were asked to self-complete an anonymous questionnaire, including data describing the responding HCW and questions aiming at describing his/her knowledge, attitude in routine daily practice and opinion about information to patients about HI.

RESULTS

One hundred and forty-one HCW were initially selected, of which 114 (80.9%) eventually agreed to complete the questionnaire. Only eight HCW (7.0%) were considered to have a correct overall knowledge of legal obligations. Main errors concerned the obligation to inform the patient of the HI risk according to the medical procedures that are to be performed (43.9% of correct answers) and the obligation to inform the patient of the HI risk according to his/her medical condition (46.5%). The obligation to inform the patient of the occurrence of a HI was largely known (84.2%). HCW usually giving information about the risk of HI to patients without HI accounted for 5.3%. Main reasons advocated for not informing patients were a low level risk of HI in psychiatry (80.4%) and the lack of patients' demand (59.8%). In the case of HI occurrence, the percentage of HCW routinely informing patients was 13.2%. HCW systematically informing the patient's family about the occurrence of HI accounted for 9.6%. A large proportion of HCW supported delivering information to patients about HI (86.0%). HCW expected from information better approval of prevention programs by the patients (87.7%) but feared an increased anxiety in patients (75.4%) and a higher rate of care refusal (48.2%).

CONCLUSION

Whereas a very large proportion of HCW in psychiatry support delivering information to patients about HI, our study shows HCW's lack of awareness of regulations and lack of declared practices. Among factors explaining this contrast, a lower perceived HI risk and severity level are to be mentioned. Training programs focusing on risk and mechanisms of HI could be offered to professionals in psychiatry. The issue of specific communication difficulties with psychiatric patients should be addressed as well. In order to develop information on HI, specific methods suited to those patients should be developed.

Does comparison of performance lead to better care? A pilot observational study in patients admitted for hip fracture in three French public hospitals

OBJECTIVE

To assess whether comparison of quality of hip fracture care among three teams located in different hospitals is associated with improvement in process and outcomes.

DESIGN

A baseline assessment was performed using quality indicators selected by professionals.

RESULTS

were discussed among the three teams followed by a post-comparison assessment of the same indicators.

SETTING

Three hospitals in North Western France.

PARTICIPANTS

Professionals caring for patients operated on for a low-impact hip fracture.

INTERVENTION

Review and discussion of comparative performance results by three teams followed by implementation of quality improvement as deemed necessary by each team.

MAIN OUTCOME MEASURES

Fifteen quality indicators of health care during orthopedic and rehabilitation stay, mobility, dependence and place of residence before hip fracture and 3 months after discharge, 3 month post-surgery mortality and readmission rates.

RESULTS

Major differences were observed among hospitals throughout the care process during baseline period. Comparison of performance and discussion among the three teams were followed by corrective action in 11 areas. After comparison, a significant improvement was observed in 10 areas, seven of which corresponded to quality improvement areas chosen for improvement action by professionals. A significant decrease in readmission rate (6.7% vs. 15.7%, P < 0.001) was observed but there was no change in mortality, functional outcome or length of stay.

CONCLUSIONS

Comparison of performance among voluntary teams, on fields selected by health-care professionals, was associated with improvement in the care process and with improvement of some related outcomes.

Influence of infection control report cards on patients' choice of hospital: pilot survey

The impact on patients' attitudes of quality report cards on infection control in hospitals has never previously been studied. In 2006, the French government implemented a mandatory report card on infection control activity (ICALIN) in all hospitals. This approach was aimed at encouraging professionals to change their routine practices in case they should lose patients due to a low ICALIN score. Our objective was to assess what impact ICALIN could have on patients' attitude as regards hospital choice. We performed a survey of patients and visitors in 14 randomly selected hospitals of various ICALIN scores. A convenience sample of 381 patients and visitors completed an anonymous questionnaire on ICALIN, their reasons for choosing a hospital and attitude in the event of a low ICALIN score. Factors associated with interest in ICALIN and impact of ICALIN on hospital choice were assessed by logistic regression. Our results showed that 77% of participants were interested in ICALIN. ICALIN was ranked sixth as a reason for choosing a hospital. In the case of a low ICALIN, 24.1% of participants would refuse admission and 54.9% would seek advice from their general practitioner. Sociodemographic factors had no influence on patients' attitude. In conclusion, our survey suggests that patients take note of poor performance on infection control report cards. As most patients rely on their general practitioner to interpret these report cards, there is a definite need for further communication with general practitioners on this issue.

[When a cure leads to illness: health professionals in hospitals and the risk of infections]

The risk of infection in a hospital is an age-old concern that one would have thought vanished with the arrival of antibiotics. Nosocomial infections (NI), which have now become a major public health issue, refer to infections that affect both patients and professionals. However, NI affecting patients have more social visibility than those that are likely to affect health professionals. The aim of this qualitative research study based on 117 semi-guided interviews with hospital care providers is to establish the professional risk and the way it is perceived by health professionals. Results are presented and discussed in two parts: the segmentation of the infectious risk representations and practices such as negotiating compromises between conflicting requirements.

Natural history of pediatric Crohn's disease: a population-based cohort study

BACKGROUND & AIMS

The natural history of pediatric Crohn's disease and risk factors necessitating surgery have not been thoroughly described.

METHODS

In a geographically derived incidence cohort diagnosed from 1988 to 2002, we identified 404 Crohn's disease patients (ages, 0-17 years at diagnosis) with a follow-up time >or=2 years.

RESULTS

Median follow-up time was 84 months (range, 52-124 months). The most frequent disease location at diagnosis was the terminal ileum/colon (63%). Follow-up was characterized by disease extension in 31% of children. Complicated behavior was observed in 29% of children at diagnosis and 59% at follow-up. Kaplan-Meier survival estimates of the cumulative incidence of surgery were 20% at 3 years and 34% at 5 years from diagnosis. Multivariate Cox models showed that both structuring behavior at diagnosis (hazard ratio [HR], 2.54; 95% confidence interval [CI]: 1.58-4.01) and treatment with corticosteroids (HR, 2.98; 95% CI: 1.64-5.41) were associated with increased risk for surgery, whereas treatment with azathioprine (HR, 0.51; 95% CI: 0.33-0.78) was associated with decreased risk. Azathioprine was introduced earlier in the course of disease in patients not undergoing surgery than in patients requiring surgery.

CONCLUSIONS

Pediatric Crohn's disease was characterized by frequent occurrence, with time, of a severe phenotype with extensive, complicated disease. Immunosuppressive therapy may improve the natural history of this disease and decrease the need for performing surgery.