Antibiotic prescription in nursing homes for dependent elderly people: a cross-sectional study in Franche-Comté.

OBJECTIVES: We had for objective to determine the rate of patients treated with antibiotics and the determinants of antibiotic stewardship in nursing homes for dependent elderly people (French acronym EHPAD), of a French region (Franche-Comté). PATIENTS AND METHODS: A representative sample of EHPAD, in Franche-Comté, was included in a cross-sectional study made between April and June 2012. An external auditor and the EHPAD head physician collected data on the facility and on residents receiving antibiotics on the study day. An infectious diseases specialist and an infection control practitioner analyzed each prescription, a posteriori, to assess criteria of antimicrobial stewardship including re-assessment of the prescription between 48 and 72h after initiation of antibiotic treatment. RESULTS: Sixty-one (2.76%) of the 2210 residents in 18 nursing homes were under antibiotic treatment. This rate ranged from 0% to 7.5% among nursing homes. Sixty-two percent of prescriptions complied with recommendations regarding the choice of the drug, and 41.5% could not be improved by choosing an agent with a weaker ecological impact. Globally, 17.8% of prescriptions met all stewardship criteria including re-assessment of the prescription between 48 and 72h after initiation of antibiotic treatment. CONCLUSIONS: The study results differed. The rate of antibiotic prescription was low in Franche-Comté EHPAD compared to available European data, but antibiotic therapy could be greatly improved. This stresses the need to better train EHPAD physicians for antibiotic stewardship.

Atypical squamous cells of undetermined significance (ASCUS): clinical-cytological significance.

The objective of this paper is to compare histologic results of microbiopsies and/or endocervical curettage obtained following the older cytological "atypical" diagnosis and the newer Bethesda ASCUS terminology. We reviewed a series of atypical smears (n = 245) from December 1991 to February 1995 and ASCUS cases (n = 120) from March 1995 to May 1996, when some atypias were renamed ASCUS according to the Bethesda classification. These patients were examined by colposcopy for cervical lesion and clinical evaluation. Menopausal women were underrepresented in atypical smears (n = 21/245, 8.6%) in comparison with ASCUS (n = 29/120, 24.2%, P = 0.001). Since, no low or high grade squamous intraepithelial lesion (L/HSIL) was ever found in the >/= 50 years group, we reviewed only patients under 50 years. Atypical smears resulted in 61/224 (27.2%) positive biopsies of which 47 (21%) were LSIL and 14 (6.2%) were HSIL; ASCUS smears yielded 17/91 (18.7%) positive pathology diagnoses with 13 (14.3%) LSIL and 4 (4.4%) HSIL. Endocervical curettage positivity (ECC) was at 6/109 (5.5%) for atypias, and 1/53 (1.9%) for ASCUS. Cervical biopsies in ASCUS smears show a tendency to a lower histologic positivity rate, in comparison with atypical cytology. Persistent ASCUS smears should be evaluated by colposcopy, and thereafter at 6-month intervals. The exact meaning of ASCUS, in spite of a 17.5% CIN rate, remains unknown, but constitutes a high-risk group.

Complex hyperplasia of the endometrium. Predictive value of curettage vs. hysterectomy specimens.

We reviewed 94 cases of complex endometrial hyperplasia (CH) with and without atypia to assess some of the clinical and pathologic changes observed on curettage and in hysterectomy specimens. Age, parity, height, weight and nomograms did not differ between CH with or without atypia, and CH associated with endometrial carcinoma. CH without atypia, however, predicted lesser degrees of malignancy as compared to CH with atypia. Progesterone or progestinlike treatment is indicated for CH without atypia along with endometrial monitoring, but CH with atypia necessitates diagnostic and therapeutic hysterectomy whenever fertility is not a priority.

All histological types of primary human rhabdomyosarcoma express alpha-cardiac and not alpha-skeletal actin messenger RNA.

Eleven human primary rhabdomyosarcomas (RMSs), including all histological variants, were analyzed morphologically, immunohistochemically for intermediate filament proteins and actin isoforms, and by means of Northern blots with probes specific for total actin, alpha-skeletal (SK), alpha-cardiac (CARD), and alpha-smooth muscle actin messenger (m)RNAs. All tumors disclosed ultrastructural evidence of skeletal muscle features with terminal differentiation in three cases. The RMSs contained immunohistochemically the intermediate filament proteins vimentin and desmin and reacted positively with the alpha-sarcomeric actin antibody, which recognizes alpha-SK and alpha-CARD actin isoforms. All RMSs reacted with the total actin probe, recognizing at 2.1 kb cytoplasmic actin mRNAs and at 1.7 kb alpha-actin mRNAs. With the specific probes, all RMSs expressed alpha-CARD actin mRNA, four neoplasms expressed also alpha-smooth muscle actin mRNA, whereas the probe for alpha-SK actin mRNA never produced a signal except in one case, in which the tumor masses were intermingled with non-neoplastic preexistent striated muscle fibers. Because alpha-CARD and alpha-smooth muscle actins are transiently expressed during normal skeletal muscle development, RMSs seem to follow normal skeletal myogenesis without completing the final step, consisting of alpha-SK actin mRNA expression. The use of Northern blots for alpha-CARD actin as an adjunct to conventional techniques may be helpful for the precise identification of primary RMSs compared to other soft tissue neoplasms.

Allocating human resources among the services of a health care organization.

The problem of optimizing the allocation of human resources among the services of a health organization is explored. The suggested approach borrows from normative budgeting models (ADVISOR) and product portfolio matrices to derive an allocation rule that seems to offer a reasonable rationale for eliminating certain services and reallocating the available resources to other services. The authors describe the approach and its implementation.

An assessment of the risk of neoplasia in long-term ileal reservoirs using the DMH rodent model.

This study was undertaken to determine if the construction of an ileal reservoir induces mucosal changes that can potentiate the effect of a chemical carcinogen (1,2-dimethylhydrazine) on ileal mucosa. Animals were divided into three groups: 1) sham operation (n = 19), 2) total colectomy with ileorectal anastomosis (n = 20), 3) total colectomy with an ileal reservoir made of terminal ileum sutured to the rectum (n = 20). An adaptation period of 12 weeks was allowed to promote fecal stasis and the histologic changes before exposure to weekly subcutaneous injections of DMH (25 mg/kg) for 16 weeks. Sodium butyrate was added to the diet as a tumor promotor. All animals were sacrificed one month later. Fecal stasis, along with enlargement, occurred in all the reservoirs (mean dimensions, 74 X 58 X 43 mm). Their mean volume was 88 +/- 14 ml. The histologic changes in the ileal reservoirs were: chronic inflammation (14/20), villous atrophy (14/20), and atrophy of the glands (8/20). In group 3, five carcinomas were seen. There were three in the duodenum and two in the reservoirs. In contrast, 21 carcinomas were detected in the control groups. There were 17 in the colon, 3 in the jejunum, and 1 in the ileum. No significant difference in the number of carcinomas was seen in the ileum with and without reservoir. Although it is possible to induce carcinomas in ileal reservoirs, the incidence remained significantly less than in the colon. In conclusion, the histologic changes induced by the construction of an ileal reservoir do not increase the risk of malignant transformation in the DMH model for intestinal carcinogenesis.

Assessment of validity of DNA measurement in tissue sections by model simulation.

Computer modelling is used to simulate nuclear segments obtained by random sectioning through tissue. A few more computations lead to DNA measurement simulation. Two methods of DNA measurement (a direct one and a variant of the "plug" method) are tested on simulated diploid, tetraploid and octaploid cell populations. The two methods result in negatively skewed DNA frequency distributions. Both the right skewness and the coefficient of variation of measurements are increasing with the ploidy level because nuclear DNA content is assumed to be related to nuclear size in the chosen model. Observed mean values are biased underestimates of expected values but are strongly correlated to the degree of ploidy. The variant of the "plug" method gives rise to smaller coefficients of variation. Finally, the bias introduced by measuring nuclear segments instead of whole nuclei increases the variance of measurements but contributes to less than half the experimentally observed variance. Our conclusion is that microspectrophotometry on tissue sections is a valuable method for DNA content evaluation of small clusters of pathological cells as one may find in endoscopic biopsies.

Discrimination between precancerous and cancerous lesions of the uterine cervix by DNA measurements on tissue sections.

Morphologically typical uterine cervical biopsies were separated into normal cervices, condylomas and cervical intraepithelial neoplasias (CIN) grades I, II and III. At least 100 nuclei per lesion were measured on 4 micron Feulgen-stained sections using a Zeiss microspectrophotometer, with a variant of the plug method used to compute the nuclear DNA content. DNA distribution histograms were then decomposed into subsets of diploid, tetraploid, octoploid and aneuploid cells. The decomposition, which assumed a log-normal model of polydiploidy distribution, led to the identification of six indices: (1) the percentage of diploid cells, (2) the percentage of tetraploid cells, (3) the percentage of octoploid cells, (4) the percentage of aneuploid cells with DNA contents less than tetraploidy, (5) the percentage of aneuploid cells with DNA contents between tetraploidy and octaploidy and (6) the percentage of aneuploid cells with DNA contents greater than octoploidy. These indices, along with the mean nuclear radius, the 5c exceeding rate and the 2c deviation index, generated a nine-dimensional space. Two methods of discriminant analysis on this space showed discriminating powers of 78.22% and 87.13%, respectively, as compared to the original diagnoses. The most discriminating variable in both analyses appeared to be the percentage of octoploid cells.

Computerized axial tomography and fine-needle biopsy in surgery of the pancreas.

Notable advances have been made in the investigation of pancreatic disorders. However, many of the diagnostic tests required are still of an invasive nature and are attended by difficulty and risk. The authors have found that the noninvasive method of axial tomography is highly reliable for the evaluation of pancreatic lesions, especially in cases in which a pancreatic mass is present or the duct of Wirsung is dilated. This procedure can also be helpful in the follow-up of patients who have suffered from acute or chronic pancreatitis. The same diagnostic problem is present at operation. To obtain a quick and reliable diagnosis of pancreatic lesions, the authors performed fineneedle aspiration biopsies followed by immediate staining and examination of the specimen. Among 43 patients an accurate diagnosis was obtained in 41 instances and no complication was ascribed to this diagnostic procedure.