Role of safety-engineered devices in preventing needlestick injuries in 32 French hospitals.

OBJECTIVES: To evaluate safety-engineered devices (SEDs) with respect to their effectiveness in preventing needlestick injuries (NSIs) in healthcare settings and their importance among other preventive measures. DESIGN: Multicenter prospective survey with a 1-year follow-up period during which all incident NSIs and their circumstances were reported. Data were prospectively collected during a 12-month period from April 1999 through March 2000. The procedures for which the risk of NSI was high were also reported 1 week per quarter to estimate procedure-specific NSI rates. Device types were documented. Because SEDs were not in use when a similar survey was conducted in 1990, their impact was also evaluated by comparing findings from the recent and previous surveys. SETTING: A total of 102 medical units from 32 hospitals in France. PARTICIPANTS: A total of 1,506 nurses in medical or intensive care units. RESULTS: A total of 110 NSIs occurring during at-risk procedures performed by nurses were documented. According to data from the 2000 survey, use of SEDs during phlebotomy procedures was associated with a 74% lower risk (P<.01). The mean NSI rate for all relevant nursing procedures was estimated to be 4.72 cases per 100,000 procedures, for a 75% decrease since 1990 (P<.01); however, the decrease in NSI rates varied considerably according to procedure type. Between 1990 and 2000, decreases in the NSI rates for each procedure were strongly correlated with increases in the frequency of SED use (r=0.88; P<.02). CONCLUSION: In this French hospital network, the use of SEDs was associated with a significantly lower NSI rate and was probably the most important preventive factor.

[Outcome of patients with systemic rheumatic diseases admitted to intensive care units: a retrospective study of 39 cases]. / Pronostic des maladies systémiques admises en réanimation: étude rétrospective de 39 séjours.

PURPOSE: Patients with systemic rheumatic diseases are rarely admitted in intensive care units and very few studies focusing on the prognosis of those patients have been published. METHODS: Retrospective study over seven years in two intensive care units. RESULTS: Among 33 patients with systemic disease diagnosed 90 +/- 133 months before admission in the intensive care unit, who were aged 50 +/- 21 years and represented a total of 39 stays in the intensive care unit, the main cause of admission was acute respiratory failure (33%). Mean simplified acute physiology score (SAPS II) was 47 +/- 22. Two-thirds of the patients were under mechanical ventilation. Infection was diagnosed in 33% of the cases and exacerbation of the systemic rheumatic disease in 26%. Nosocomial infection was found in 19 patients (49%). Ten patients died during their stay in the intensive care unit, six from infection, three from an exacerbation of the systemic rheumatic disease, one from an unidentified cause. CONCLUSION: Even if severity scores of patients suffering from systemic diseases are higher at admission in intensive care units than those of other patients, there is no relevant reason to refuse critical care to these patients.

[Occupational risk of exposure to blood in nurses. Results of a one-year monitoring of the risk for nurses in 17 hospitals]. / Exposition accidentelle au sang du personnel soignant. Résultats d'un an de surveillance du risque pour les infirmières dans 17 hôpitaux.

To evaluate the incidence of risk factors for exposure of health care providers to patients' blood, a prospective multicenter study was carried out in 1990 in 17 hospitals in continental France. 521 nurses from 20 departments of medicine and 9 intensive care nurses participated in the study. Trained investigators documented exposures to blood using a standardized questionnaire and carried out monthly 24 hours cross-sectional surveys to determine the number of high risk procedures performed on a given day. One hundred and eighty-three exposures to blood were documented, for an incidence of 0.35/nurse/year. Needle-stick injuries were the most common events (75%). Exposure to blood occurred during a sampling procedure in 48% of cases, an infusion-related procedure in 20% of cases, and an injection in 17% of cases. Comparisons of rates of procedures associated with needle-stick injuries and of procedures performed during a typical day demonstrated differences in the magnitude of the risk associated with each procedure: infusion-related procedures carried the greatest risk, followed by venous blood sampling procedures. Sixty-four percent of exposures to blood occurred after completion of the procedure. Forty-nine percent of documented exposures to blood would probably not have occurred if universal infection control recommendations (CDC, DGS) had been implemented. Twenty-seven percent of exposures to blood involved HIV-positive patients, who accounted for only 7% of patients managed in the participating centers during the study period.(ABSTRACT TRUNCATED AT 250 WORDS)

Stimulation of peripheral blood lymphocytes of HIV-infected patients by jacalin, a lectin mitogenic for human CD4+ lymphocytes.

The proliferative response of peripheral blood mononuclear cells stimulated by jacalin was investigated in 157 samples from 104 HIV-infected patients at various clinical stages of disease. Jacalin proliferative response correlated with the absolute numbers and percentages of CD4+ lymphocytes and with the percentages of Leu 8 lymphocytes. It correlated negatively with the percentages of CD8+ and CD38+ lymphocytes. It was depressed during acute HIV infection and at advanced stages. The response in Centers for Disease Control groups II and III was heterogeneous and similar; in both, some patients showed a very low response. Further follow-up of the present patients should indicate whether jacalin responsiveness has a prognostic value.

Nonsteroid antiinflammatory agents as a substitute treatment for steroids in ATGAM-treated cadaver kidney recipients.

A nonsteroid antiinflammatory agent (Ibuprofen) was used in a controlled randomized study to determine its ability to replace steroids in the prophylaxis of cadaveric kidney rejection. Thirty-three cadaver kidney recipients were randomly assigned either to a control group (16 patients) receiving azathioprine, high doses of prednisolone, and antithymocyte globulin (ATGAM) for three months, or to an experimental group (17 patients) receiving azathioprine and ATGAM according to the same protocol, ibuprofen instead of steroids. The frequency of rejection was higher in the experimental group (2.18 episodes per patient) than in the control group (1.44 episodes per patient). Nevertheless, in the experimental group 5 patients had no early rejection episode, 60% of early rejections were totally reversible without steroids, and 3 patients never received steroids at all during the first year and had normal renal function and biopsies. Steroids had to be introduced in the treatment of 14 patients, but after an average period of 32.5 days after surgery OKT3+ cell level was higher in the experimental group than in the control group, but similar to the OKT3+ cell level of patients receiving conventional therapy without ATGAM. Whatever the type of treatment, an increase in the OKT4+/OKT8+ ratio was associated in most cases with increased serum creatinine values. Conversely, a decreased OKT4+/OKT8+ ratio associated with renal failure was found in cases showing biological evidence of cytomegalovirus infection.

Antithymocyte globulin in cadaver kidney transplantation: a randomized trial based on T-cell monitoring.

The influence of horse antihuman thymocyte globulin (ATG) on renal allograft survival was assayed between March 1977 and August 1978. Fifty consecutive patients were randomly assigned to the treatment or the control group. Patients in both groups received azathioprine and prednisolone. ATG was added in the experimental group. The daily dosage was such as to maintain the rosette-forming cell (RFC) level at 10% of baseline values. The number of renal failure episodes (RFE's)was significantly lower in the experimental group during the period (1 month) ATG was given than it was in the control group during that same period of time. Two years after transplantation, kidney survival was 79% in the ATG group and 52% in the control group. The amount of steroids necessary to control RFE's was significantly lower in the ATG group. The dosages of ATG used in the experimental group were relatively small (average daily dose, 3.08 +/- 0.26 mg/kg of body wt), and adverse reactions were mild. Blood tolerance was excellent. T-cell monitoring thus appears to be an effective method in evaluating the daily dosage of ATG.

Are there non-steroid-dependent rejection episodes?

We undertook two randomised studies in an effort to decrease the dosage of steroids in transplanted patients and to replace harmful steroid therapy by nonsteroid anti-inflammatory (NSAI) drugs. In the first study, 50 consecutive transplant recipients were randomly assigned to the treatment or the control group. In both groups, patients received azathioprine and prednisolone. ATG was added to this protocol in the experimental group. The number of renal failure episodes and consequently the amount of steroid necessary to control these episodes were significantly lower in the ATG group than in the other group. Two year post-transplantation kidney survival was 79% in the ATG group and 52% in the control group. In the second study, 15 consecutive transplant recipients were randomly assigned to two control groups and to one experimental group, where steroids were replaced by NSAI drugs. This preliminary, and very limited, pilot trial demonstrates the existence of early acute renal failure episodes, probably of immunological origin, which can improve spontaneously in the absence of steroid therapy.

Plasma 1,25(OH)2D3 and iPTH in transplanted adults with persisting hypophosphataemia.

Hypophosphataemia is a common finding among kidney transplanted patients [1,2]. In a previous study in kidney transplanted children with plasma creatinine below 1.1mg/dl, we demonstrated [3] a negative correlation between plasma phosphorus and 1 alpha, 25-dihydroxyvitamin D3 (1,25(OH)2D3), the renal hormonal form of vitamin D. No such correlation was apparent in children with minimal increase in plasma creatinine. The aim of the present investigation carried out in hypophosphataemic transplanted adults was two-fold: 1) to determine whether hypophosphataemia results from persisting hyperparathyroidism or from a renal phosphorus leak, or both, and 2) to study the relation between plasma phosphorus, iPTH and 1,25(OH)2D3 in these patients.

Idiopathic portal hypertension (perisinusoidal fibrosis) after renal transplantation.

We report the cases of two renal transplant recipients suffering from idopathic portal hypertension, a condition characterised by increased portal venous pressure in the absence of both histological lesion of the liver and obstruction of the portal vein. In these two patients, perisnusoidal fibrosis, invisible by light microscopy, was demonstrated by electron microscopy; it is suggested that partial obstruction of hepatic sinusoids by perisinusoidal fibrosis could be the mechanism for increased portal venous pressure in all the patients with idiopathic portal hypertension. In these two patients, who received 6-mercaptopurine and azathioprine, perisinusoidal fibrosis might be the consequence of prolonged administration of these drugs.

[Bacterial infections in renal homotransplant recipients. Results of regular bacteriological controls (author's transl)]. / Accidents infectieux bactériens après transplantation rénale. Résultats et intérèt d'une surveillance bactériologique systématique.

Bacterial infections were studied in 51 immunosuppression kidney transplant recipients. Eighty infectious episodes occured in the first six post-transplantation months. Forty percent of these episodes were nonfebrile, detected during the routine bacteriological follow-up examination. Out of these 80 bacterial infections, 59 were localized (47 in the urinary tract, nine in the surgical wound and three in the lungs) and 21 had spread. Neutopenia occured in 13 patients, in association with septicaemia in eight of them. Usually septicaemia appeared before neutropenia. In 12 cases, infectious episodes (10 septicaemias and two localized infections) and transplant failure were closely related. The bacterial strains responsible for these infections were essentially: Staphylococcus spp (39), Streptococcus spp (14), Klebsiella pneumoniae (9), Escherichia coli (9). Most of the localized infections cleared up when treated with a specific antibiotic. Seven failures of antibiotic treatment were observed in 21 cases of generalized infections. The importance of regular post-transplantation bacteriological check-up in detecting and treating infectious complications in graft recipients must be emphasized.

Kidney-graft rejection: has the need for steroids to be re-evaluated?

In a group of azathioprine-treated patients whose renal allografts functioned immediately, 53 received prophylactic steroid treatment while 54 were given steroids only at the onset of the first renal failure. Three types of renal failure were identified, and their distribution in the patient groups was different, but the incidence of both reversible and irreversible renal failure episodes was identical in the two groups, suggesting that steroid treatment of early rejection episodes may not be necessary.