Contamination of healthcare workers' mobile phones by epidemic viruses.

Mobile phones (MPs) are potential reservoirs of nosocomial bacteria, but few data are available concerning viruses. We aimed to evaluate the presence of virus RNA from epidemic viruses including metapneumovirus, respiratory syncytial virus, influenza viruses, rotavirus (RV) and norovirus on the MPs used by healthcare workers (HCWs) and to relate it to hygiene measures. An anonymous behavioural questionnaire about MP use at hospital was administered to the HCWs of four adult and paediatric departments of a university hospital. After sampling personal (PMP) and/or professional MPs (digital enhanced cordless telephone, DECT), virus RNAs were extracted and amplified by one-step real-time reverse transcription-quantitative PCR. The molecular results were analysed in a masked manner in relation to the behavioural survey. Questionnaires from 114 HCWs (25 [corrected] senior physicians, 30 residents, 32 nurses, 27 nurses' assistants) working either in adult (n = 58) or paediatric (n = 56) departments were analysed. Medical personnel used their PMP more frequently than paramedical HCWs (33/65 vs. 10/59, p <0.001). MPs were used during care more frequently in adult wards than in paediatric ones (46/58 vs. 27/56, p <0.001). Virus RNA was detected on 42/109 (38.5%) collected MPs, with RV found on 39, respiratory syncytial virus on three and metapneumovirus on one. The presence of virus RNA was significantly associated with MPs from the paediatric HCWs (p <0.001). MPs routinely used in hospital, even during care, can host virus RNA, especially RV. Promotion of frequent hand hygiene before and after MP use, along with frequent cleaning of MPs, should be encouraged.

Risk factors for quinolone-resistance in women presenting with Escherichia coli acute pyelonephritis.

UNLABELLED: In France, according to the National Epidemiology Observatory of Bacterial Resistance to Antibiotics, 15.3% of outpatient urinary Escherichia coli isolates were fluoroquinolone-resistant in 2010. This puts to question the relevance of empirical fluoroquinolone therapy for community-acquired acute pyelonephritis (APN), potentially severe infections. OBJECTIVES: We had for aim to identify individual risk factors for quinolone-resistant E. coli in community-acquired APN. PATIENTS AND METHODS: A retrospective cohort study of 344 adult female patients presenting with E. coli APN was conducted at the Roanne and Saint-Etienne hospital emergency departments, from January 2011 to February 2012. We studied the demographic, administrative, and clinical factors. E. coli strains with intermediate susceptibility on the antibiogram were considered as resistant. RESULTS: There was 23% of isolates that were resistant to nalidixic acid and 17.4% to ofloxacin. Complicated APN was not a significant risk factor (univariate analysis). Three risk factors of resistance to nalidixic acid and ofloxacin were independent (multivariate analysis): fluoroquinolone use in the previous 3 months, hospitalization in the previous 6 months, and stay in a long-term care facility. The resistance to ofloxacin reached 30.6% if at least 1 of these risk factors was present; it was 9% when none of the factors were present. CONCLUSIONS: These results suggest that local recommendations for the empirical therapy of APN should be reviewed. The limitations of our study require backing up our results with prospective multicentric studies that could lead to drafting new national recommendations.

Long-term results of tension-free vaginal tape (TVT) for the treatment of female urinary stress incontinence.

OBJECTIVES: Prospective evaluation of outcome and complications over a 5-year period post-treatment of urinary stress incontinence by TVT, and comparison of our results with the reference studies. MATERIALS AND METHODS: About 94 patients were treated for urinary stress incontinence only by one TVT procedure (single surgical procedure), between April 1997 and December 1998; 68% of patients presented pure urinary stress incontinence and 32% mixed incontinence. We found also a 25.5% rate of sphincter deficiency (UCP < 20 cm H(2)O) in this cohort. Patients were evaluated after 5 years: 52 complete evaluations (clinical, flow measurement with measurement of post-mictional residue, 24h PAD-test, quality of life questionnaire), 30 complete telephone interviews, 12 lost to follow-up (2 patients deceased). RESULTS: About 87% of the patients had a 5-year follow-up. The success rate was 79.2% overall (84.5% for the pure urinary stress incontinence and 67% for the mixed incontinence cases), and 72.2% for the cases of associated sphincter deficiency. We had only a 13% rate of patients lost to follow-up. More than half of the urinary urgency cases were treated successfully, however with a less satisfactory outcome in cases of bladder instability. The urodynamic exploration appeared to reveal that TVT caused dysuria: 52% of patients had a maximum flowrate below 15 ml/s, but the quality of life was improved, with a 95% rate of satisfaction without functional problems. We observed no late complications such as vaginal erosion or rejection of the prolene; the de novo syndrome was rare, with 8.5% of urinary frequency, 6% of urinary urgency and only 5.7% of invalidating dysuria. We saw no cases of pelvic floor disease after TVT treatment. DISCUSSION: Our casuistry results are comparable with the reference studies by Scandinavian authors, Rezapour and Ulmsten, confirming the long-term success of the TVT procedure. Concerning the apparently elevated rates of post-TVT dysuria found by urodynamic exploration, a distinction has to be drawn between post-TVT urinary problems (frequent but oligosymptomatic), and true, severe dysuria (rare). However, "dysuria" in the broad sense did not affect the patients' quality of life, and is a reminder of the absolute necessity of meticulous compliance with the correct surgical techniques. CONCLUSION: Treatment of urinary incontinence by TVT is a reliable, mini-invasive, reproducible technique, almost suitable for outpatients, with no serious complications; it is inexpensive and very successful, including in complicated cases such as sphincter deficiency. All the recent data confirms, with this 5-year follow-up, that the TVT procedure is comparable to the previously gold standard, the Burch colposuspension.

Older people included in a venous thrombo-embolism clinical trial: a patients' viewpoint.

BACKGROUND AND OBJECTIVES: despite the numerous publications debating ethical rules of clinical research, older patients' opinions are rarely taken into account. We report on the feelings and memories related by older patients included in a randomised controlled trial. DESIGN AND SETTINGS: a closed-questionnaire was submitted to patients, aged >65 years, who had been included in the randomised trial "PREPIC". PREPIC was a multicentre open trial performed in France, that included 400 patients over 42 months. The aim of PREPIC was to evaluate the benefits and risks of prophylactic filter placement in patients with proximal deep-vein thrombosis who were considered to be at risk for pulmonary embolism. RESULTS: 104 patients (mean age: 74 years) were interviewed. At the time the trial was proposed to them, 45% of patients felt surprised or shocked and 30% feared incurring additional risks. While 85% of patients did not remember the trial methods (including the randomisation), most older patients (77%) not only judged that they received clear medical information but also well remembered (95%) the aim of the study and the treatment they received (67%). Finally, most older patients not only did not regret their participation (91%), but would also recommend their close relations to participate in a clinical trial (62%). CONCLUSIONS: this study demonstrates that medical scientific information can be understood and remembered by older people.

Death of terminally ill patients on a stretcher in the emergency department: a French speciality?

OBJECTIVES: To determine the frequency, modalities of admission and management of terminally ill patients who died on a stretcher in an emergency department (ED). DESIGN AND SETTING: Retrospective study in an ED of a university hospital. METHODS: Current place of residence, modalities of admission in ED, mortality probability scores and type of management were extracted for each patient in the terminal stage of chronic disease who died on a stretcher in our ED during a 3year period. RESULTS: Of 159 deaths observed in the ED, 56 (35%) concerned terminally ill patients. The illness was a malignancy in 22 cases, a neurological disease in 22 cases and a cardiopulmonary disease in 12 cases. Most of the patients were referred by their regular doctor. Seventy-two percent of the malignancy patients were living at home, 55% of the neurological patients came from nursing facilities and 58% of the cardio-respiratory patients came from the hospital. In 73%, 83% and 23% of the patients with malignancy, cardiopulmonary and neurological diseases, respectively, admission was related to the evolution of the chronic disease. Severity of illness on admission was similar whatever the disease. Request for compassionate end-of-life care was expressed in only 12.5%. At the ED, 91% of patients with neurological diseases received palliative support care. Supportive therapy was undertaken in one third of patients with malignancy or cardiopulmonary disease. CONCLUSION: An ED may be used as a place for dying for some terminally ill patients. This could be related to the legal opposition to withdrawal or withholding of life-support therapies as well as the absence of guidelines from scientific bodies.

[First epileptic seizure in the elderly: electroclinical and etiological data in 341 patients]. / Première crise d'épilepsie chez le sujet de plus de 60 ans: données électrocliniques et étiologiques.

This study included 341 subjects aged over 60 years, 174 females and 167 males, (mean age 72-years), who experienced their first epileptic seizure and fulfilled all inclusion criteria over an 8-year period. Data were available from the physical examination, EEG, laboratory tests and CT scan or MRI for all patients. The international classification of epileptic seizures was applied, 41 p.cent of the seizures were generalized and 59 p.cent were partial. Status epilepticus occurred in 8 p.cent of the patients. The EEG recording was contributive to diagnosis or helpful for localizing the epileptic focus in 55 p.cent of the patients. Normal brain imaging was observed in 40 p.cent of the patients. The main etiology was cerebrovascular disease (33 p.cent), acute stroke (27 patients), or more often postvascular epilepsy (87 patients). Other etiologies were degenerative cortical dementia in 7 p.cent of the patients, metabolic and toxic disorders in 11 p.cent, and benign or malignant brain tumors in 6.5 p.cent. Thirty-two percent of the seizures were of unknown origin (cryptogenic seizures). No correlation was found between sex, age, and etiology. An antiepileptic drug treatment was initiated in 77 p.cent of the patients who were given either valproate (43 p.cent), carbamazepine (26 p.cent) or barbiturates (7 p.cent). These findings are in agreement with those reported in the reviewed literature.

[Two new cases of cardiac papillary fibroelastoma with ischemic stroke]. / Deux nouveaux cas de fibroélastome papillaire cardiaque responsable d'accident vasculaire ischémique.

A 22 and 25 year-old man were admitted to our emergency care unit for a stroke of the left superficial middle cerebral artery territory and vertebrobasilar infarction. Complete assessment of ischemic attack retained, in both cases, the presence of a valvular cardiac tumor. After heparin treatment, surgery confirmed the data provided by echocardiography. Histology confirmed the diagnosis of a papillary fibroelastoma. The diagnosis of cardiac tumors is based on transthoracic echocardiography and transesophageal echocardiography (TEE). High definition TEE allows localizing the tumor and determining its relationship with the contiguous anatomical structures. TEE is also a better guide for surgical procedure. Echocardiography is essential in the management of cerebral ischemic attacks in young patients.

Serum and ascitic procalcitonin levels in cirrhotic patients with spontaneous bacterial peritonitis: diagnostic value and relationship to pro-inflammatory cytokines.

OBJECTIVE: To assess the potential role of procalcitonin and pro-inflammatory cytokines, TNF-alpha, and IL-6, in the diagnosis of spontaneous bacterial peritonitis (SBP). DESIGN: Prospective study. SETTING: The emergency unit of a teaching hospital. PATIENTS: We included 21 patients with SBP and 40 patients with sterile ascitic fluid. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: For the diagnosis of SBP, the best markers were serum levels of procalcitonin with a cut-off value of 0.75 ng/ml, a sensitivity of 95%, a specificity of 98%, and ascitic fluid levels of IL-6 with a cut-off value of 5,000 ng/ml, a sensitivity of 100%, and a specificity of 88%. C-reactive protein and serum polymorphonuclear count have low sensitivity/specificity at 62/92% and 57/90%, respectively. From 21 patients with SBP, ascitic fluid to serum ratio of TNF-alpha and IL-6 was greater than to 2 in all cases with a mean at 6.2 +/- 6.5 and 34 +/- 31, respectively. By contrast, this ratio for procalcitonin was less than 1 in all cases with a mean at 0.31 +/- 0.25. We found no correlation between procalcitonin levels and cytokine levels in either ascitic fluid or serum. CONCLUSIONS: Serum procalcitonin level may become a useful marker for the diagnosis of SBP in cirrhotic patients. The low ratio of ascitic fluid to serum procalcitonin supports the hypothesis that procalcitonin is not produced intraperitoneally.

Endotoxaemia in patients with severe sepsis or septic shock.

OBJECTIVE: To examine the incidence and the bacteriological and clinical significance of endotoxaemia in ICU patients with severe sepsis or septic shock. DESIGN: Prospective review. SETTING: A 15-bed general ICU in a university hospital. PATIENTS: One hundred sixteen patients hospitalised in our ICU fulfilling Bone's criteria for severe sepsis or septic shock and with an available early endotoxin assay (chromogenic limulus assay). INTERVENTIONS: None. MEASUREMENTS AND RESULTS: The clinical characteristics of the population were: age 63.6 +/- 11.4 years; SAPS II: 45.4 +/- 15.6; mechanical ventilation: 72.4%; septic shock: 51.7% (n = 60); bacteraemia: 28.4% (n = 33); gram-negative bacteria (GNB) infection 47.4% (n = 55); ICU mortality: 39.6% (n = 46). Detectable endotoxin occurred in 61 patients (51.2%; mean level: 310 +/- 810 pg/ml). There was no relationship between detectable endotoxin and severity of infection at the moment of the assay. Endotoxaemia was associated with a higher incidence of bacteraemia (39.3% vs 16.3%; p = 0.01). There was a trend (p = 0.09) towards an association between positive endotoxin and gram-negative bacteraemia or GNB infection but this was non-significant. This relationship became significant only in the case of bacteraemia associated with GNB infection irrespective of the site of infection. CONCLUSION: Early detection of endotoxaemia appeared to be associated with GNB infection only in cases of bacteraemic GNB infection. Early endotoxaemia correlated neither to occurrence of organ dysfunction nor mortality in patients with severe sepsis or septic shock. This study suggests that the use of endotoxaemia as a diagnostic or a prognostic marker in daily practice remains difficult.

[Bepridil: importance of serum level in treatment surveillance]. / Bépridil: intérêt du dosage sérique dans la surveillance du traitement.

OBJECTIVE: Despite precise recommendations for prescription and monitoring, tosades de pointes is still observed with bepridil. The purpose of this study was to demonstrate the contribution of bepridil serum assay in therapeutic supervision. PATIENTS AND METHODS: Seventy-five patients over 70 years of age were included. Prolongation of the QT interval was observed in 23 patients. RESULTS: The potential prognostic factors for increased QT interval as demonstrated by univariate logistic regression were hypokaliemia, bradycardia, renal failure and bepridil serum level. After multivariate logistic regression, the persisting causal factors for increased QT interval were hypokaliemia, bradycardia and bepridil serum level. CONCLUSION: Prolongation of the QT interval remains dependent on several variables. Bepridil determination during treatment is insufficient alone.

[Rapid diagnosis of the type of meningitis (bacterial or viral) by the assay of serum procalcitonin]. / Diagnostic rapide du type de méningite (bactérienne ou virale) par le dosage de la procalcitonine sérique.

OBJECTIVE: It has been shown that serum procalcitonin (PCT) can be used to differentiate bacterial from viral meningitis in children in all cases. The aim of this study was to demonstrate the interest of PCT in the management of suspected meningitis in adults. PATIENTS AND METHODS: We conducted a prospective study including 179 consecutive patients admitted to the emergency department for suspected meningitis. All samples were taken at patient admission. The discriminant potential between bacterial and viral meningitis was studied for cerebrospinal fluid parameters (cytology, protein, glucose, lactate) and serum parameters (C reactive protein, PCT). RESULTS: Thirty-two patients had bacterial meningitis, 90 had viral meningitis and meningitis was ruled out in 57. Among all studied parameters, the most discriminant for distinguishing between bacterial and viral meningitis in 100% of the cases proved to be serum procalcitonin with a threshold value of 0.93 ng/ml. CONCLUSION: Serum procalcitonin is an interesting parameter in the emergency department for management of meningitis suspicion in adults.

[Prevention of venous thromboembolism in polytraumatized patients. Epidemiology and importance]. / Prophylaxie de la maladie veineuse thromboembolique chez le patient polytraumatisé. Epidémiologie et intérêt.

OBJECTIVE: Unfractionated heparin, low-molecular-weight heparin (LMWH), mechanical compression, and vena cava filters are part of a large panel of chemical or physical methods proposed to trauma patients as prophylaxis against venous thromboembolism. This prophylactic strategy is based on a 1961 autopsy survey showing a 16.6% rate of pulmonary embolism in this population. The objective of this study was to assess the incidence of deep venous thrombosis (DVT) and pulmonary embolism (PE) in multiple trauma patients. METHODS: A Medline and Current Contents search was conducted for prospective studies including trauma patients with ISS > 9 whose incidence of DVT and PE was evaluated by contrast venography and/or duplex scan and by ventilation/perfusion lung scan and/or pulmonary angiography and/or autopsy, respectively. RESULTS: Twelve studies met the selection criteria for DVT. Among the global population of 2,374 trauma patients (14% of all admissions) 47% suffered lower limb injury and 17% had severe head injury. Overall incidence of DVT was about 20%. It was about 38% in patients without prophylaxis (range 2 to 61.5%) and about 13% in patients with prophylaxis (range 0.8 to 37%). Similar variations were observed for proximal DVT. In comparative studies (unfractionated heparin versus LMWH or versus mechanical compression devices), the incidence of thromboembolic events varied from 3.2 to 44% in patients given unfractionated heparin, 0.8 to 31% in those given LMWH, and 3.1% to 12% with mechanical compression. Thirteen studies met the selection criteria for PE and included an overall population of 4,245 trauma patients where the diagnosis of PE was suspected only if the patient had clinical signs. The incidence of PE and fatal PE was about 1.4% and 0.3% respectively. Only one study systematically studied the presence of PE and showed an incidence of 18.7% for PE in a population of 32 patients. DISCUSSION: The current literature reports wide variability in methodology, characteristics of the study population and prophylaxis. These differences explain the wide variability from one study to another in the risk factors for venous thrombosis identified by univariate and multivariate analysis. CONCLUSION: Current methodological imperfections make it impossible to correctly assess the incidence of DVT and PE in the multiple trauma population. Studies with a rigorous methodology using a precise stratification of the trauma injuries are required to determine the real risk for DVT/PE in trauma patients and to assess the impact of early systematic prophylaxis.

High sensitivity and specificity of serum procalcitonin levels in adults with bacterial meningitis.

It was shown in children that serum procalcitonin was the best marker to use to differentiate bacterial from viral meningitis. To evaluate procalcitonin in the diagnosis of acute bacterial and viral meningitis, we conducted a prospective study including adult patients who were suspected of having meningitis and who were admitted to an emergency department. Cerebrospinal fluid (CSF) and serum levels of procalcitonin were measured in 105 consecutive patients. The diagnosis of meningitis was based on clinical findings, gram staining, culture, and chemical analysis of CSF. Twenty-three patients had bacterial meningitis, 57 had viral meningitis, and 25 did not have meningitis. Bacteriologic and chemical analysis of CSF did not allow correct differentiation of viral from bacterial meningitis. On the other hand, a serum procalcitonin level >0.2 ng/mL had a sensitivity and specificity of up to 100% in the diagnosis of bacterial meningitis. Serum procalcitonin levels seem to be the best marker in differentiating between bacterial and viral meningitis in adults.

[Diagnosis and development of heparin-induced thrombocytopenia. Biological and clinical aspects]. / Diagnostic et gestion des thrombopénies induites par l'héparine. Aspects biologiques et cliniques.

Two types of thrombocytopenia occur during treatment with heparin: type I and type II heparin-induced thrombocytopenia (HIT). Type I HIT is due to a direct interaction between heparin and platelets. They are asymptomatic, occur early, mild and transitory. Type II HIT which is immunoallergic in nature is the most important complication of this treatment. The thrombocytopenia has a different presentation, acute with a fall in platelets over 30 per cent and is often associated with the occurrence or worsening of a venous or arterial thrombotic episode. The major problems of this secondary type are threefold: its recognition, its confirmation and its management should be as early as possible to avoid the development of often dramatic complications which compromise the prognosis. Laboratory investigations are required by highly reliable specialist laboratories following a careful clinical history. The natural history of the platelet count should enable the difficult diagnosis of HIT to be made more accurately. The treatment of confirmed HIT and/or symptomatic HIT often requires a multidisciplinary approach from a specialized team involving clinicians and hematologists. Two therapies with the benefit of large experience have just been obtained in France with marketing approval (AMM) for the management of HIT: danaparoid (Orgaran) and recombinant hidurin, lepirudin (Refludan). A declaration to the regional drugs monitoring center should not be omitted. In addition, each patient should be given a certificate confirming the immunallergy thus avoiding any further exposure with potentially dramatic consequences.

Does bicarbonate therapy improve the management of severe diabetic ketoacidosis?

OBJECTIVE: The use of bicarbonates in the treatment of severe diabetic ketoacidosis remains controversial, especially regarding the benefit/risk ratio. The aim of this study was to assess the efficacy of bicarbonate therapy during severe diabetic ketoacidosis (pH <7.10). DESIGN: Retrospective study. SETTING: The emergency unit of a teaching hospital. PATIENTS: The records of 39 patients consecutively admitted for severe diabetic ketoacidosis were analyzed (pH <7.10). The patients were divided into two groups: group 1 (n = 24; patients with bicarbonate treatment) and group 2 (n = 15; patients without bicarbonate treatment). INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: We compared two groups of patients presenting with severe diabetic ketoacidosis (pH values between 6.83 and 7.08) treated with or without bicarbonate. A group of 24 patients received 120+/-40 mmol sodium bicarbonate. The two groups were similar at admission with regard to clinical and biological parameters. No difference could be demonstrated between the two groups concerning the clinical parameters or the normalization time of biochemical parameters. If the number of patients with hypokalemia was comparable between the two groups, the potassium supply was significantly more important in group 1 compared with group 2 (366+/-74 mmol/L vs. 188+/-109 mmol/L, respectively; p < .001). CONCLUSIONS: Data from the literature and this study are not in favor of the use of bicarbonate in the treatment of diabetic ketoacidosis with pH values between 6.90 and 7.10.

[Fatal voluntary poisoning with cibenzoline. Failure of conventional therapies]. / Intoxication volontaire mortelle à la cibenzoline. Echec des thérapeutiques conventionnelles.

BACKGROUND: Massive voluntary ingestion of cibenzoline causes major cardiotoxicity. We report on two cases where conventional treatments were ineffective. CASE REPORTS: Two patients were admitted to the intensive care unit of a University Hospital after massive voluntary intoxication with cibenzoline. Delay to admission after ingestion of cibenzoline was 1.5 and 4 hours. Circulatory impairment developed rapidly in both patients due to major atrioventricular and ventricular conduction disorders. Conventional intensive care procedures (sodium lactate and adrenaline) were performed but only provided temporary and incomplete efficacy. Outcome was fatal in both cases. DISCUSSION: The lethal potential of cibenzoline is very high. Extra-corporeal cardiocirculatory assistance might be an advisable measure if conventional therapy is unsuccessful. No clearly defined prognosis factors in cibenzoline intoxications have been reported.