An epidemiological assessment of coagulase-negative staphylococci from an intensive care unit.
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Detection of an unusual combination of four resistance markers among coagulase-negative staphylococci (CNS) isolated in the same intensive care unit led to the undertaking of an epidemiological assessment. Seventeen CNS isolates from the same unit and 38 epidemiologically unrelated Staphylococcus epidermidis isolates were typed by eight methods, including analysis of immunoblot patterns and hybridisation patterns (HP) obtained with three probes. The probes comprised plasmids carrying the genes encoding 16S rRNA (pBA2), aacA-aphD (pSF815A), and aacA-aphD with part of IS256 (pIP1307). Immunoblot patterns and HP with pIP1307 indicated that 14 of the 17 CNS isolates from the same unit resulted from the spread of an epidemic strain. (+info)
Drug administration errors and their determinants in pediatric in-patients.
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OBJECTIVE: . To quantify the type and frequency of drug administration errors to pediatric in-patients and to identify associated factors. DESIGN: Prospective direct-observation study of drug administration errors from April 2002 to March 2003. SETTING: Four clinical units in a pediatric teaching hospital. STUDY PARTICIPANTS: Twelve observers accompanied nurses giving medications and witnessed the preparation and administration of all drugs to all patients on all weekday mornings. INTERVENTION: None. MAIN OUTCOME MEASURE: Discrepancies between physicians' orders and actual drug administration. RESULTS: During the 1719 observed administrations to 336 patients by 485 nurses, 538 administration errors were detected, involving timing (36%), route (19%), dosage (15%), unordered drug (10%), or form (8% form). These errors occurred for 467 (27%) of the 1719 administrations. Intravenous drugs (OR = 0.28; CI = 0.16-0.49; versus miscellaneous) were associated with fewer errors. Error rates were higher for cardiovascular (OR = 3.38; CI = 1.24-9.27; versus miscellaneous) and central nervous system drugs (OR = 2.65; CI = 1.06-6.59; versus miscellaneous); unspecified dispensing system (OR = 2.06; CI = 1.29-3.29; versus store in the unit); non-intravenous non-oral administration (OR = 4.44; CI = 1.81-10.88; versus oral administration); preparation by the pharmacy (OR = 1.66; CI = 1.10-2.51); and administration by a hospital pool nurse, temporary staffing agency nurse, or nurse intern (OR = 1.67; CI = 1.04-2.68; versus registered full-time nurse). Each additional management procedure in the patient increased the risk of error (OR = 1.22; CI = 1.01-1.48). CONCLUSIONS: The risk factors identified in our study should prove useful for designing preventive strategies, thereby improving the quality of care. (+info)
Were less disabled patients the most affected by 2003 heat wave in nursing homes in Paris, France?
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OBJECTIVE: To analyse the change of mortality rates (MRs) and their contributing medical factors among nursing home patients during the 2003 heat wave in France. METHODS: A retrospective observational study was conduced in all nursing homes of the Assistance-Publique-Hopitaux de Paris (AP-HP), the French largest public hospital group. All AP-HP nursing home patients (4,403) who were institutionalized in May, 2003, were concerned. The MRs of patients between three periods (before, during and after the August 2003 heat wave period) were compared according to their demographic characteristics, level of dependence and medical condition. RESULTS: The MR increased from 2.2 per cent persons month (ppm) (1.9-2.4) before heat wave up to 9.2 ppm (8.0-10.4) during heat wave and back to 2.4 ppm (2.2-2.7) after heat wave. MRs before heat wave were higher among highly dependent patients compared to those less dependent [mortality rate ratio (MRR) = 2.66 (1.69-4.21)]. This difference disappeared during the heat wave [MRR = 1.28 (0.91-1.81)] and appeared again after heat wave [MRR = 2.21 (1.52-3.23)]. The same pattern was observed for several medical conditions, such as severe malnutrition or swallowing disorders. CONCLUSION: These results suggest that medical care during heat wave has been directed towards more fragile patients, helping to limit deaths in this group. Less frail patients made the largest contribution to excess mortality during the heat wave. During extreme weather conditions, specific attention should be paid not only to frail persons, but to all the elderly community. (+info)
Fetal dextrocardia: diagnosis and outcome in two tertiary centres.
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OBJECTIVE: To evaluate the incidence of fetal dextrocardia, associated cardiac and extracardiac malformations, and outcome. DESIGN: Retrospective echocardiographic study. SETTING: Two tertiary centres for fetal cardiology. PATIENTS: 81 consecutive fetuses with a fetal dextrocardia presenting at Guy's Hospital, London, between 1983 and 2003 and at Hopital Robert Debre, Paris, between 1988 and 2003. Fetal dextrocardia was defined as a condition in which the major axis of the heart points to the right. RESULTS: The incidence was 0.22%. There were 38 fetuses (47%) with situs solitus (SS), 24 (30%) with situs ambiguus (SA), and 19 (23%) with situs inversus (SI). Structural cardiac malformations were found in 25 cases (66%) of SS, 23 cases (96%) of SA, and 12 cases (63%) of SI. Extracardiac malformations were identified in 12 cases (31%) of SS, in five cases (21%) of SA, and in two cases (10%) of SI. Of the 81 cases of fetal dextrocardia, there were 27 interrupted pregnancies (15 of 24 SA, 10 of 38 SS, and 2 of 19 SI), six intrauterine deaths (3 of 38 SS, 2 of 24 SA, and 1 of 19 SI), and five neonatal deaths (3 of 24 SA, 1 of 19 SI, and 1 of 38 SS). There were 43 survivors (24 of 38 SS, 15 of 19 SI, and 4 of 24 SA). CONCLUSION: The majority of fetuses with dextrocardia referred for fetal echocardiography have associated congenital heart disease. There is a broad spectrum of cardiac malformation and the incidence varies according to the atrial situs. Fetal echocardiography enables detection of complex congenital heart disease so that parents can be appropriately counselled. (+info)
Evaluating mortality in intensive care units: contribution of competing risks analyses.
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INTRODUCTION: Kaplan-Meier curves and logistic models are widely used to describe and explain the variability of survival in intensive care unit (ICU) patients. The Kaplan-Meier approach considers that patients discharged alive from hospital are 'non-informatively' censored (for instance, representative of all other individuals who have survived to that time but are still in hospital); this is probably wrong. Logistic models are adapted to this so-called 'competing risks' setting but fail to take into account censoring and differences in exposure time. To address these issues, we exemplified the usefulness of standard competing risks methods; namely, cumulative incidence function (CIF) curves and the Fine and Gray model. METHODS: We studied 203 mechanically ventilated cancer patients with acute respiratory failure consecutively admitted over a five-year period to a teaching hospital medical ICU. Among these patients, 97 died before hospital discharge. After estimating the CIF of hospital death, we used Fine and Gray models and logistic models to explain variability hospital mortality. RESULTS: The CIF of hospital death was 35.5% on day 14 and was 47.8% on day 60 (97/203); there were no further deaths. Univariate models, either the Fine and Gray model or the logistic model, selected the same eight variables as carrying independent information on hospital mortality at the 5% level. Results of multivariate were close, with four variables selected by both models: autologous stem cell transplantation, absence of congestive heart failure, neurological impairment, and acute respiratory distress syndrome. Two additional variables, clinically documented pneumonia and the logistic organ dysfunction, were selected by the Fine and Gray model. CONCLUSION: The Fine and Gray model appears of interest when predicting mortality in ICU patients. It is closely related to the logistic model, through direct modeling of times to death, and can be easily extended to model non-fatal outcomes. (+info)
Epilepsy among the homeless: prevalence and characteristics.
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Homelessness is associated with several risk factors for epileptic seizures. Epilepsy is a stigmatizing condition, which can lead to problematic social adjustment and competence. We found a markedly higher prevalence of seizures among the homeless than that estimated in the general population, with a large majority of non-alcoholic etiology. Unexpected proportion of subject taking treatment and compliance rate call for reflection on the optimal management of epilepsy in this population. (+info)
Mortality among Paris sewage workers.
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OBJECTIVES: To describe the mortality of Paris sewage workers. METHODS: A cohort of all Paris sewage workers since 1970 was established and followed up in mortality until 1999. The causes of death were determined by matching with a national database. The mortality rates were compared to the rates of a local reference population. RESULTS: A large excess in mortality (standardised mortality ratio (SMR) = 1.25; 530 cases, 95% CI 1.15 to 1.36) and in particular mortality from cancer (SMR = 1.37, 235 cases) was detected which was particularly important in the subgroup of subjects who had left employment because they resigned or were laid off (SMR = 1.77; 50 cases). The excess mortality is to a large extent due to alcohol related diseases (SMR = 1.65, 122 cases) especially malignant (SMR = 1.85, 16 cases) and non-malignant (SMR = 1.68, 38 cases) liver diseases, lung cancer (SMR = 1.47, 68 cases), and infectious diseases (SMR = 1.86, 25 cases). The SMRs for some diseases (all cancers, cancers of the oesophagus and lung, all alcohol related diseases) seem to increase with duration of employment as a sewage worker. Other than lung cancer, smoking related diseases were not in excess. CONCLUSION: The increased mortality by both malignant and non-malignant liver diseases is probably due to excessive alcohol consumption, but could be partially the result of occupational exposure to chemical and infectious agents and interactions of these factors. The excess lung cancer is unlikely to be due to an increased smoking prevalence. (+info)
A new way to compare health systems: avoidable hospital conditions in Manhattan and Paris.
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Based on a comparison of discharges for avoidable hospital conditions (AHCs), we find that Paris provides greater access to primary care than Manhattan. Age-adjusted AHC rates are more than 2.5 times as high in Manhattan as in Paris. In contrast, the difference in rates of hospital discharge for "marker conditions" are only about 20 percent higher in Manhattan. Rates of discharges for AHCs are higher among residents of low-income neighborhoods in both cities, but the disparity among high- and low-income neighborhoods is more than twice as great in Manhattan. Our analysis highlights the consequences of access barriers to care in Manhattan, particularly among vulnerable residents. (+info)