Stéphane Gennai

Factors and outcomes associated with physicians' adherence to recommendations of infectious disease consultations for inpatients

OBJECTIVES Solicited consultations constitute a substantial workload for infectious disease specialists (IDSs). The impact of physician adherence to recommendations on clinical outcomes following solicited IDS consultations has not been previously studied. The objectives of the study were to identify the factors associated with adherence and to determine whether adherence to recommendations was associated with better clinical outcomes. METHODS A prospective study was conducted on 621 patients, aged > or = 18 years, hospitalized in a university-affiliated hospital in France, who received an IDS consultation between December 2007 and June 2008. The main outcome was early clinical improvement, and the secondary outcomes were length of stay and in-hospital mortality. RESULTS Adherence to the IDSs recommendations was 88.2% (548/621) for antimicrobial treatment and 72.2% (317/439) for diagnostic or monitoring tests. In a multivariable analysis, independent factors of adherence to therapeutic recommendations were a community-acquired infection [adjusted odds ratio (OR), 1.8; 95% confidence interval (CI), 1.1-3.0] and discontinuation or non-use of antibiotic treatment (adjusted OR, 9.7; 95% CI, 1.2-80.3). Adherence to recommendations for antibiotic treatment was associated with a higher rate of early clinical improvement (60.7% versus 43.9%, P = 0.01), shorter median length of stay (20 days versus 23 days, P = 0.03) and comparable in-hospital mortality (7.7% versus 5.5%, P = 0.50). CONCLUSIONS Factors associated with non-adherence must be anticipated by IDSs during consultations, because non-adherence leads to worse clinical outcomes. Further studies are needed to identify the interventions that could improve physician adherence to recommendations made during solicited consultations.

Infectious disease specialist telephone consultations requested by general practitioners

Abstract Background: Infectious diseases (ID) make up a substantial part of a general practitioners (GPs) workload. GPs frequently solicit ID specialists requesting advice on managing their patients with ID. The objectives of this study were to examine GP reasons for soliciting ID consultations and to assess the GPs’ and specialists’ opinions of the ID consultation service. Methods: This was a prospective study of consecutive solicited ID consultations requested by GPs from the ID specialists of a 2200-bed university-affiliated hospital, conducted between October 2008 and March 2009. Data related to GP characteristics, their reasons for requesting the consultation, the recommendations given by the specialists, and the specialists’ perceptions of the exchange were collected. GPs were asked to report their adherence to recommendations and their perceptions of the consultations. Results: A mean of 57 telephone consultations per month were requested by GPs during the study period. ID specialist recommendations were related to antibiotic treatment (66.2%), diagnostic or monitoring tests (46.5%), and a subsequent formal consultation or hospitalization (29.6%). The reasons reported for GPs requesting an ID consultation were related to patient management (96.5%), rapidity of access (86.3%), and quality of care improvement (84.2%). GPs were satisfied with the telephone consultations in 97.9% of cases and ID specialists in 94.7%. Conclusions: Telephone consultations with ID specialists were widely appreciated by GPs, probably due to the accessibility of these specialists. Further study is needed to assess the effects of these telephone consultations on quality of care.

Effects of cyclosporine a in ex vivo reperfused pig lungs.

Several works highlight the role of CsA in the prevention of IRI, but none focus on isolated lungs. Our objective was to evaluate the effects of CsA on IRI on ex vivo reperfused pig lungs.

Real-time measurements of endogenous carbon monoxide production in isolated pig lungs.

Abstract. Ischemia-reperfusion injuries are a critical determinant of lung transplantation success. The endogenous production of carbon monoxide (CO) is triggered by ischemia-reperfusion injuries. Our aim was, therefore, to assess the feasibility of exhaled CO measurements during the ex vivo evaluation of lungs submitted to ischemia-reperfusion injuries. Five pigs were euthanized and their lungs removed after pneumoplegia. After cold storage (30 min, 4°C), the lungs were connected to an extracorporeal membrane oxygenation circuit, slowly warmed-up, and ventilated. At the end of a 45-min steady state, CO measurements were performed by optical-feedback cavity-enhanced absorption spectroscopy, a specific laser-based technique for noninvasive and real-time low gas concentration measurements. Exhaled CO concentration from isolated lungs reached 0.45±0.19  ppmv and was above CO concentration in ambient air and in medical gas. CO variations peaked during the expiratory phase. Changes in CO concentration in ambient air did not alter CO concentrations in isolated lungs. Exhaled CO level was also found to be uncorrelated to heme oxygenase (HO-1) gene expression. These results confirm the feasibility of accurate and real-time CO measurement in isolated lungs. The presented technology could help establishing the exhaled CO concentration as a biomarker of ischemia-reperfusion injury in ex vivo lung perfusion.

Exhaled carbon monoxide is correlated with ischemia reperfusion injuries during ex vivo lung perfusion in pigs

Measurement of exhaled carbon monoxide (eCO) might help in the selection of lung grafts during ex vivo lung perfusion (EVLP) since its endogenous production is increased under ischemia reperfusion. The objective of this study was to measure eCO variations depending on the extent of lung ischemia reperfusion injuries. Using a porcine model and a laser spectrometer instrument, eCO was measured during EVLP. eCO was compared after 30 min (D0) or 24 h (D1) of cold ischemia. The ability of eCO to distinguish lungs deemed suitable for transplantation was evaluated. Six lungs were studied at D0 and compared to six lungs studied at D1. eCO was systematically higher on D1 (1.35 ± 0.26 ppmv versus 0.95 ± 0.31 ppmv, p = 0.01). The best threshold concentration for eCO to select lungs was 0.86 ppmv (area under the receiver operating characteristic curve: 0.65 [95% confidence interval: 0.34-0.97], p = 0.40). These results show that eCO varies during EVLP. The interpretation of this variation and the role of eCO as a biomarker of ischemia reperfusion injuries during EVLP should be tested in further clinical studies.

Post-conditioning with Cyclosporine A after a 24-hour cold ischemia in ex vivo reperfused pig lungs

ABSTRACT Objective: To evaluate the effects of 1 and 5 μM of Cyclosporine A (CsA), administered 24 hours after a cold ischemic period, in an ex vivo reperfused pig lung model. Methods: The experiments were performed in 15 pigs. Each pair of lungs was surgically separated. Extracorporeal perfusion and mechanical ventilation were started after a cold ischemia of 2 hours for one lung and 24 hours for the contralateral. We constituted three groups (n = 5 each): two groups for which the lung underwent a 24-hour ischemia received either 1 or 5 μM of CsA at the time of reperfusion, and a control group without CsA. For each group, lungs undergoing a 2-hour ischemia did not receive CsA. Results: Reperfusion with either CsA increased the PO2 levels in a dose dependent manner, and reduced concentrations of the receptor for advanced glycation endproducts, compared to the control. The pulmonary arterial pressure, the capillary pressure, and the pulmonary vascular resistances were not increased, even with 5 μM of CsA. No significant change was shown on cytokines levels. Discussion: Postconditioning with CsA improves lung function, after a 24-hour cold ischemic period. Either 1 or 5 μM seemed to be safe regarding the pulmonary vascular pressures and resistances.

J-06 Consultation mobile d’infectiologie : description de l’activité et impact clinique

Contexte La consultation mobile d’infectiologie (CMI) est un des outils utilises par notre centre hospitalier dans le cadre du bon usage de l’antibiotherapie. Depuis decembre 2007 et pour une duree de 1 an, nous evaluons l’impact de cette CMI dont nous presentons ici les resultats intermediaires. Methode L’ensemble des conseils dispenses par la CMI a ete recense. Tous les avis concernant des patients hospitalises etaient suivis d’une evaluation entre la 48e et la 96e heure par un medecin independant de la CMI. Il analysait l’evolution des patients et l’observance aux avis therapeutiques et aux conduites diagnostiques proposees. Resultats 732 avis ont ete donnes par la CMI entre le 6 decembre 2007 et le 5 janvier 2008. 39 % des conseils concernaient des patients hospitalises et 61 % des patients externes au CHU. Les avis externes etaient demandes par des medecins liberaux dans 49 % des cas, des particuliers dans 35 % des cas, des medecins exercant dans des hopitaux peripheriques et cliniques dans 13 % des cas. Les motifs de consultation concernaient une question therapeutique ou une aide au diagnostic dans plus de la moitie des cas (54 %). Les autres demandes concernaient des conseils pour le voyage, des accidents d’exposition aux liquides biologiques et des questions diverses (vaccinations, informations generale). En ce qui concerne les patients hospitalises, la CMI etait aussi souvent interpellee en medecine qu’en chirurgie (respectivement 48 % et 52 %). Parmi les 221 patients beneficiant d’une evaluation, l’observance aux propositions therapeutiques etait de 82 %, celle aux conduites diagnostiques proposees de 87 %. Conclusion La CMI est largement sollicitee tant a l’exterieur du CHU que par les medecins du CHU. L’observance aux conseils est particulierement elevee tant pour les propositions diagnostiques que therapeutiques.