Pierre Czernichow

L-alanyl-L-glutamine dipeptide-supplemented total parenteral nutrition reduces infectious complications and glucose intolerance in critically ill patients: The French controlled, randomized, double-blind, multicenter study*

Objective:Glutamine (Gln)–supplemented total parenteral nutrition (TPN) improves clinical outcome after planned surgery, but the benefits of Gln-TPN for critically ill (intensive care unit; ICU) patients are still debated. Design:Prospective, double-blind, controlled, randomized trial. Setting:ICUs in 16 hospitals in France. Patients:One-hundred fourteen ICU patients admitted for multiple trauma (38), complicated surgery (65), or pancreatitis (11). Interventions:Patients were randomized to receive isocaloric isonitrogenous TPN via a central venous catheter providing 37.5 kcal and 1.5 g amino acids·kg−1·day−1 supplemented with either L-alanyl-L-glutamine dipeptide (0.5 g·kg−1·day−1; Ala-Gln group, n = 58) or L-alanine + L-proline (control group, n = 56) over at least 5 days. Measurements and Main Results:Complicated clinical outcome was defined a priori by the occurrence of infectious complications (according to the criteria of the Centers for Disease Control and Prevention), wound complication, or death. The two groups were compared by chi-square test on an intention-to-treat basis. The two groups did not differ at inclusion for type and severity of injury (mean simplified acute physiology score II, 30 vs. 30.5; mean injury severity score, 44.9 vs. 42.3). Similar volumes of TPN were administered in both groups. Ala-Gln-supplemented TPN was associated with a lower incidence of complicated outcome (41% vs. 61%; p < .05), which was mainly due to a reduced infection rate per patient (mean, 0.45 vs. 0.71; p < .05) and incidence of pneumonia (10 vs. 19; p < .05). Early death rate during treatment and 6-month survival were not different. Hyperglycemia was less frequent (20 vs. 30 patients; p < .05) and there were fewer insulin-requiring patients (14 vs. 22; p < .05) in the Ala-Gln group. Conclusions:TPN supplemented with Ala-Gln dipeptide in ICU patients is associated with a reduced rate of infectious complications and better metabolic tolerance.

Epidemiology and course of acute upper gastro-intestinal haemorrhage in four French geographical areas

Objective To compare incidence rates and epidemiological characteristics of acute upper gastrointestinal haemorrhage (AUGIH) in France with those of other European studies. Design Population‐based multi‐centre prospective survey. Setting 29 public hospitals and 96 private specialists in gastroenterology in four administrative areas in France during 1996. Subjects A total of 2133 AUGIH patients 18 years and over were included in the six‐month study. Outcome measures Incidence and mortality. Results The overall incidence in France was 143 cases per 100 000 persons per year, classified as out‐patients (16%), emergency admissions (59%) and in‐patients (25%). The incidence rates increased with age except for in‐patients, and were higher in males. Peptic ulcer (36.6%), varices (13.7%) and erosive disease (12.3%) were the most frequent diagnoses. In 677 patients (31.7%), aspirin, antiinflammatory drugs or corticosteroids were taken on the 7 days before bleeding. The overall mortality (out‐patients excluded) was 14.3% (10.7% for emergency patients and 23% for in‐patients). Mortality was associated with comorbidities (especially malignancies, cirrhosis, asthma or respiratory deficiency), was lower in emergency patients using non‐steroid anti‐inflammatory drugs, and higher in in‐patients using corticosteroids. Conclusions In France, patients with AUGIH are frequently managed as out‐patients. Gastrotoxic drug use is frequently associated with AUGIH and constitutes a strategic opportunity for preventive treatment. Discrepancies between countries are not clearly explained either by demographic factors or by drug use, but this may be related to the emphasis on AUGIH in in‐patients. Eur J Gastroenterol Hepatol 12:175‐181

Nosocomial Urinary Tract Infections in Urologic Patients: Assessment of a Prospective Surveillance Program Including 10,000 Patients

OBJECTIVE Hospital-acquired urinary tract infections (HUTI) represent a significant impairment in the quality of health care. Incidence in catheterized patients has been estimated at approximately 20%, however few data are available in urologic patients. We report a prospective surveillance program over 6 years in our urologic department and evaluate its evolution. METHODS Population consists of all patients admitted to the urology ward for 48 hours or more over a 6-year period from 1994. Data recorded: age, gender, duration of stay, insertion and removal of catheters, diagnosis of HUTI. ANALYSIS calculation of incidence, and incidence density for HUTI and for catheter-related HUTI, analysis of trends by chi(2) trend test. RESULTS A total of 10,054 consecutive patients were included, 52% were catheterized. The median incidence of catheter-related HUTI in catheterized patients was 13.0%, the incidence density was 25.1 HUTI/1000 patient-days of catheterization. The proportion of HUTI and specific catheter-related HUTI patients decreased, respectively from 8.4% and 14.2% to 6.5% and 12.3% during the study period (p<0.05). CONCLUSION The rate of HUTI was not as high as previously reported, perhaps due to a controlled catheter policy. Surveillance was associated with a significant decrease in infection rates, suggesting a beneficial feedback effect. Evaluation of diagnoses and surgical procedures would ensure an optimal quality control program.

Postoperative management of stage II/III colon cancer: A decision analysis

BACKGROUND & AIMS Two separate decisions must be made for the management of patients with resected stage II/III colon cancer: whether to begin adjuvant chemotherapy and whether patients should be included in a follow-up protocol consisting of regular monitoring of carcinoembryonic antigen level and of colonoscopy and imaging. The standard management for these patients is adjuvant chemotherapy for stage III patients and follow-up for stage II/III patients with resected colon cancer. METHODS Decision analysis was used to compare the effectiveness (5-year survival rate) and cost-effectiveness ratio of 7 strategies of treatment and follow-up. RESULTS The most cost-effective strategies were adjuvant chemotherapy for all patients with stage II/III resected colon cancer, with either no follow-up or follow-up only for patients aged less than 75 years with a seric preoperative carcinoembryonic antigen level of >5 ng/mL (5-year survival, 62.3% or 62.7%; cost per surviving patient,

Short-term effects of air pollution on mortality in the cities of Rouen and Le Havre, France, 1990-1995.

8254 or

Non-steroidal anti-inflammatory drugs and segmental non-gangrenous colitis: a case-control study

8657, respectively). The order of efficacy of the strategies was insensitive to changes in the values of the studied variables. The method of follow-up does little to improve 5-year survival but adds substantial cost. CONCLUSIONS The current standard strategy may not be the most cost-effective strategy for the management of patients with resected colon cancer.

Surveillance of unplanned return to the operating theatre in neurosurgery combined with a mortality–morbidity conference: results of a pilot survey

Abstract In this study, the authors examined the short-term effects of ambient air pollution on mortality across 2 French cities: Rouen and Le Havre. In Poisson regression models, which controlled for day-of-week effects, the authors used nonparametric smoothing to control for temporal trend, weather, and influenza epidemics. In Rouen, an interquartile range increase of 60.5–94.1 μg/m3 of ozone was associated with an increase of 4.1 % (95% confidence interval = 0.6, 7.8) of total mortality. Daily variations in sulfur dioxide (interquartile range increase = 17.6–36.4 μg/m3) were also associated with an 8.2% increase (95% confidence interval = 0.4, 16.6) in respiratory mortality. An increase of 6.1% (95% confidence interval = 1.5, 10.9) of cardiovascular mortality was also observed with an interquartile range increase of nitrogen dioxide (i.e., 25.3–42.2 μg/m3). With respect to Le Havre, an interquartile range increase in daily levels of sulfur dioxide (11.3–35.6 μg/m3) was associated with an increase of approximately 3% (95% confidence interval = 0.8, 5) of cardiovascular mortality. For particulate matter less than or equal to 13 urn in diameter (interquartile increase = 21.5, 45.4 μg/m3), an increase of 6.2% (95% confidence interval = 0.1,12.8) was observed. The estimates of pollutant effects and their standard deviations were slightly affected by the degree of smoothing temporal variations in this study. When low collinearity was present, the 2-pollutant models provided acceptable estimates of pollutant effects. They suggested that the ozone effect was independent of the Black Smoke effect, and that the effects of sulfur dioxide and nitrogen dioxide were unlikely to be confounded by ozone concentrations. However, high collinearity leads to large estimates of the pollutant coefficient variances and, therefore, leads to inaccurate estimates of pollutant effects. The analysis of the contributory effects of different pollutant mixtures requires further investigation in those instances in which high collinearity between pollutants is present.

Is Continuous Subglottic Suctioning Cost-Effective for the Prevention of Ventilator-Associated Pneumonia?

Objective To determine, in a case-control study, whether exposure to non-steroidal anti-inflammatory drugs (NSAIDs) was associated with segmental non-gangrenous colitis. Methods One hundred and sixteen consecutive patients with segmental non-gangrenous colitis were compared with 232 age- and gender-matched hospital controls (two controls for each patient). Data on past medical history and use of drugs within 30 days before admission were collected using a standardized questionnaire administered to each patient. Results Twenty patients (17.2%) and eight controls (3.4%) were taking NSAIDs on admission (P < 0.0001). Nineteen out of 20 patients and only two out of eight controls had used NSAIDs within the last 30 days before admission (P < 0.005). The association between NSAIDs and segmental non-gangrenous colitis was significant in patients over 60 years of age (P < 0.0001) but not in those under 60 years (P = 0.4) even if in the latter group, the percentage of NSAIDs users among patients with segmental non-gangrenous colitis was twice as high as in controls. For all considered criteria except NSAIDs, comparison between both groups showed that only the use of digitalis was significantly greater in patients than in controls (P < 0.05). Conclusions The association between use of NSAIDs and segmental non-gangrenous colitis may be causal. The mechanism by which NSAIDs may cause this condition remains unclear and may not be univocal.

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

Background Unplanned return to the operating theatre (UROT) is a useful trigger tool that could be used to identify surgical adverse events (SAEs). The present study describes the feasibility of SAE surveillance in neurosurgical patients, based on UROT identification, completed with SAE analysis at a morbidity–mortality conference (MMC) meeting. Method For consecutive patients who underwent a neurosurgical procedure between 1 November 2008 and 30 April 2009, return to the operating theatre (ROT) was identified based on the hospital information system associated to prospective payment (HISPP). ROT was classified as planned or unplanned and UROT was further classified as related to the natural history of the disease or related to an adverse event (AE-UROT). MMC meetings were organised to discuss results of UROT surveillance and to analyse AE-UROT. Results 1006 neurosurgical procedures were included in the surveillance. HISSP identified 152 ROTs, with 73 UROTs related to an SAE (7.3% (5.7% to 9.0%)): infectious SAE (n=24, 2.4% (1.5% to 3.5%)), haemorrhagic SAE (n=23, 2.3% (1.5% to 3.4%)), other cause SAE (n=26, 2.8% (1.9% to 4.0%)), and infectious and other cause SAE (n=2, 0.2% (0.0% to 0.7%)). Identification of AE-UROT through HISSP required a 4 h/month time frame. Eight UROTs related to SAE cases were discussed during MMC meetings, leading to the identification of non-conforming care processes and practical improvement actions. Conclusion UROT related to SAE surveillance in neurosurgical patients was considered feasible. The association of surveillance and MMCs allowed staff to concentrate on the analysis of most frequent or most severe AEs and was a practical and useful tool to stimulate improvement. The impact on healthcare quality of SAE surveillance associated with MMC warrants further research.

Épidémiologie des complications gastro-duodénales associées aux anti-inflammatoires non stéroïdiens

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.