Pharmaceutical care in an inpatient pediatric intensive care unit: an international multicentric study

Introduction Pediatric intensive care patient represent a population athigh risk for drug-related problems. Our objective is to describe drugrelated problems and intervention of four decentralized pharmacists inpediatric and cardiac intensive care unit.Materials & Methods Multicentric, descriptive and prospectivestudy over a six-month period (August 1st 2009-January 31st 2010).Drug-related problems and clinical interventions were compiled infour pediatric centers using a tool developed by the Socie´te´ Franc¸aisede Pharmacie Clinique. Data concerning patients, drugs, intervention,documentation, approval (if needed), and estimated impact werecompiled. The four pharmacists participating were from Belgium (B),France (F), Quebec (Q) and Switzerland (S).Results A total of 996 interventions were collected: 129 (13%) in B,238 (24%) in F, 278 (28%) in Q and 351 (35%) in S. These interventionstargeted 269 patients (median 22 month-old, 52% male): 69(26%) in B, 88 (33%) in F, 56 (21%) in Q and in S. These data werecollected during 28 non consecutive days in the clinical unit in B, 59days in F, 42 days in Q and 63 days in S. The main drug-relatedproblems were inappropriate administration technique (293, 29%),untreated indication (254, 25%) and supra therapeutic dosage (106,11%). The pharmacist's interventions concerned mainly administrationmode optimization (223, 22%), dose adjustment (200, 20%) andtherapeutic monitoring (164, 16%). The three major drug classesleading to interventions were anti-infectives for systemic use (233,23%) and alimentary tract and metabolism drugs (218, 22%). Interventionsconcerned mainly residents and all clinical staff (209, 21%).Among the 879 (88%) interventions requiring a physician's approval,731 (83%) were accepted. Interventions were considered as having amoderate (51%) or major (17%) clinical impact. Among the interventionsprovided, 10% were considered to have an economicalpositive impact. Differences and similarities between countries willbe presented at the poster session.Discussion & Conclusion Decentralized pharmacist at patient bedsideis a pre-requisite for pharmaceutical care. There are limitedstudies comparing the activity of clinical pharmacists betweencountries. This descriptive study illustrates the ability of clinicalpharmacist to identify and solve drug-related problems in pediatricintensive care unit in four different francophone countries.

Detrital zircon and micropalaeontological ages as new constraints for the lowermost tectonic unit (Talea Ori unit) of Crete, Greece

The Talea Ori unit is the lowermost known tectonic unit of Crete and the most external part of the Hellenides. Its stratigraphy ranges from Late Carboniferous to Oligocene and outcrops of the lower part are only known in the Talea Ori mountains (central Crete). In this area, a black sandstone at the base of the Galinos Beds, thought to be the oldest formation, contains zircons which were dated using the single grain evaporation method. The majority of these grains yielded Late Carboniferous ages (Variscan), while a small group yielded Early Proterozoic ages. The age distribution of these zircons suggests that, at the Carboniferous-Permian boundary, not much of the older North Gondwanan basement was exposed and that a river system carried detrital material from the Variscan belt towards the forming Neotethyan rift. Additionally, higher up in the stratigraphy benthic foraminifers (miliolids) were found in clasts from a conglomerate which was so far thought to be of Early Triassic age [Epting, M., Kudrass, H.-R., Leppig, U., Schaffer, A., 1972. Geologie der Talea Ori/Kreta. N. Jb. Geol. Palaont. Abh. 141, 259-285.]. These miliolids belong to the species Hoyenella inconstans [Michalik, J., Jendrejakova, O., Borza, K., 1979. Some new foraminifera species of the Fatra-Formation (Uppermost Triassic) in the West Carpathians. Geol. Carpath. 30 (1), 61-91.], thus attributing a Late Triassic (Carnian-Norian?) maximal age to this conglomerate. The carbonate platform from which the miliolids-bearing clasts come is not known. The presence to the north of a continuous hemipelagic record from the Carboniferous to the Triassic (Phyllite-Quartzite and Tripali units), attributed to the Palaeotethys realm, allows the Talea Ori unit and its lateral equivalents (the Ionian zone) to be assigned to the westward continuation of the Cimmerian block and therefore to the northern margin of the East Mediterranean Neotethys ocean. (c) 2006 Elsevier B.V. All rights reserved.

Putting the Special Case in Its Place: Switzerland and Small-N Comparison in Policy Research

This research note presents a set of strategies to conduct small-N comparisons in policy research including the Swiss case. Even though every country can be considered "special" to some extent, the Swiss political system is often viewed as a particularly difficult case for comparison because of the impact of its idiosyncratic institutional features (most notably direct democracy). In order to deal with this problem, our note sets out two possible strategies - the use of functional equivalents and of counterfactual reasoning - and explains how to implement them empirically through process tracing and the establishment of causal chains. As an illustration, these strategies are used for a comparison of the process of electricity market liberalisation in Switzerland and Belgium.

Relationships between anthropometric measures and athletic performance, with special reference to repeated-sprint ability, in the Qatar national soccer team.

The aim of this study was to determine potential relationships between anthropometric parameters and athletic performance with special consideration to repeated-sprint ability (RSA). Sixteen players of the senior male Qatar national soccer team performed a series of anthropometric and physical tests including countermovement jumps without (CMJ) and with free arms (CMJwA), straight-line 20 m sprint, RSA (6 × 35 m with 10 s recovery) and incremental field test. Significant (P < 0.05) relationships occurred between muscle-to-bone ratio and both CMJs height (r ranging from 0.56 to 0.69) as well as with all RSA-related variables (r < -0.53 for sprinting times and r = 0.54 for maximal sprinting speed) with the exception of the sprint decrement score (Sdec). The sum of six skinfolds and adipose mass index were largely correlated with Sdec (r = 0.68, P < 0.01 and r = 0.55, P < 0.05, respectively) but not with total time (TT, r = 0.44 and 0.33, P > 0.05, respectively) or any standard athletic tests. Multiple regression analyses indicated that muscular cross-sectional area for mid-thigh, adipose index, straight-line 20 m time, maximal sprinting speed and CMJwA are the strongest predictors of Sdec (r(2) = 0.89) and TT (r(2) = 0.95) during our RSA test. In the Qatar national soccer team, players' power-related qualities and RSA are associated with a high muscular profile and a low adiposity. This supports the relevance of explosive power for the soccer players and the larger importance of neuromuscular qualities determining the RSA.

Impact of a program to prevent incivility towards and assault of healthcare staff in an ophtalmological emergency unit: study protocol for the PREVURGO On/Off trial.

BACKGROUND: The emergency department has been identified as an area within the health care sector with the highest reports of violence. The best way to control violence is to prevent it before it becomes an issue. Ideally, to prevent violent episodes we should eliminate all triggers of frustration and violence. Our study aims to assess the impact of a quality improvement multi-faceted program aiming at preventing incivility and violence against healthcare professionals working at the ophthalmological emergency department of a teaching hospital. METHODS/DESIGN: This study is a single-center prospective, controlled time-series study with an alternate-month design. The prevention program is based on the successive implementation of five complementary interventions: a) an organizational approach with a standardized triage algorithm and patient waiting number screen, b) an environmental approach with clear signage of the premises, c) an educational approach with informational videos for patients and accompanying persons in waiting rooms, d) a human approach with a mediator in waiting rooms and e) a security approach with surveillance cameras linked to the hospital security. The primary outcome is the rate of incivility or violence by patients, or those accompanying them against healthcare staff. All patients admitted to the ophthalmological emergency department, and those accompanying them, will be enrolled. In all, 45,260 patients will be included in over a 24-month period. The unit analysis will be the patient admitted to the emergency department. Data analysis will be blinded to allocation, but due to the nature of the intervention, physicians and patients will not be blinded. DISCUSSION: The strengths of this study include the active solicitation of event reporting, that this is a prospective study and that the study enables assessment of each of the interventions that make up the program. The challenge lies in identifying effective interventions, adapting them to the context of care in an emergency department, and thoroughly assessing their efficacy with a high level of proof.The study has been registered as a cRCT at clinicaltrials.gov (identifier: NCT02015884).

Prevalence and factors of intensive care unit conflicts: the conflicus study.

RATIONALE: Many sources of conflict exist in intensive care units (ICUs). Few studies recorded the prevalence, characteristics, and risk factors for conflicts in ICUs. OBJECTIVES: To record the prevalence, characteristics, and risk factors for conflicts in ICUs. METHODS: One-day cross-sectional survey of ICU clinicians. Data on perceived conflicts in the week before the survey day were obtained from 7,498 ICU staff members (323 ICUs in 24 countries). MEASUREMENTS AND MAIN RESULTS: Conflicts were perceived by 5,268 (71.6%) respondents. Nurse-physician conflicts were the most common (32.6%), followed by conflicts among nurses (27.3%) and staff-relative conflicts (26.6%). The most common conflict-causing behaviors were personal animosity, mistrust, and communication gaps. During end-of-life care, the main sources of perceived conflict were lack of psychological support, absence of staff meetings, and problems with the decision-making process. Conflicts perceived as severe were reported by 3,974 (53%) respondents. Job strain was significantly associated with perceiving conflicts and with greater severity of perceived conflicts. Multivariate analysis identified 15 factors associated with perceived conflicts, of which 6 were potential targets for future intervention: staff working more than 40 h/wk, more than 15 ICU beds, caring for dying patients or providing pre- and postmortem care within the last week, symptom control not ensured jointly by physicians and nurses, and no routine unit-level meetings. CONCLUSIONS: Over 70% of ICU workers reported perceived conflicts, which were often considered severe and were significantly associated with job strain. Workload, inadequate communication, and end-of-life care emerged as important potential targets for improvement.

Parental attitude towards alternative medicine in the paediatric intensive care unit.

The interest in alternative medicine (AM) is growing. In the USA and Canada, studies showed that 34% of adults and 11% of children use AM. In a prospective cohort study, we investigated the interest in AM among parents of critically ill children in the paediatric Intensive Care Unit (ICU) of a university hospital. From January 1996 to April 1997, we distributed questionnaires to the parents of critically ill children. These strictly anonymous questionnaires were completed at home and returned by mail. Exclusion criteria were short ( < 1 day) or repeated hospitalizations, and insufficient proficiency of the German language. The inclusion criteria were fulfilled by 591 patients; 561 received the questionnaire (95%) and 289 (52%) were returned. Of the respondents, 70% would appreciate AM as a complementary therapy on the ICU, 23% found AM equally or more important than conventional medicine whereas only 7% regarded AM as unimportant. On the ICU, 18% used AM; surprisingly 41% of them did not discuss it with physicians or nurses. An additional 21% would have liked to use AM, but did not do so. Typically, AM-users administered AM also at home to their children and themselves. Their children were however, older.CONCLUSIONS: A substantial proportion of parents used measures of alternative medicine in the intensive care unit, or would have like to do so. However, few had the confidence to discuss this wish with the medical personal. This suggests that alternative medicine is of great interest, even on an intensive care unit. Nevertheless, discussion about alternative medicine seems to be taboo in doctor-patient relations.

10 ans de lutte contre la violence domestique dans le canton de Vaud: résumé de la recherche menée par l'Unité de Médecine des Violences (UMV) sur mandat de la Commission cantonale de lutte contre la violence domestique (CCLVD)

[Sommaire] Introduction. - 1. Quelques données de base: le contexte juridique, la violence domestique: une réalité chiffrée, principales institutions du réseau d'aide dans le canton de Vaud. - 2. Résumé de la recherche "10 ans de lutte contre la violence domestique dans le canton de Vaud": contexte, méthode, résultats, recommandations à l'intention de la CCLVD. - 3. Axes stratégiques de la politique cantonale de prévention de lutte contre la violence domestique 2011-2015. - Bibliographie [Introduction (extrait)] La violence entre membres d'une même famille ou entre proches, à savoir la violence domestique, a longtemps été considérée comme une affaire privée et un tabou. Un important changement de mentalité s'est toutefois opéré ces 20 dernières années. La lutte contre la violence envers les femmes d'une manière générale et contre la violence domestique en particulier préoccupe de plus en plus les organes internationaux, nationaux et locaux et est reconnue comme une tâche d'intérêt public. [...] Dans le canton de Vaud, en 1999, le Bureau de l'égalité entre les femmes et les hommes (BEFH) a mandaté l'Unité de Prévention de l'Institut de médecine sociale et préventive du CHUV, afin de mener une étude sur la violence conjugale, auprès des institutions concernées2. Cette recherche visait à établir un état des lieux et à identifier les besoins prioritaires. En 2001, des recommandations ont émergé de cette étude sous la forme de 40 mesures. Six d'entre elles ont été retenues comme prioritaires par la Conseillère d'Etat Madame Jacqueline Maurer Mayor. Presque 10 ans après, en automne 2008, la Commission cantonale de lutte contre la violence domestique (CCLVD), instituée par le Conseil d'Etat afin de coordonner les efforts en vue de la prévention et de la lutte contre la violence domestique, a décidé de faire un bilan sur la réalisation de ces mesures, d'identifier les besoins actuels des professionnel-le-s de terrain et les problématiques émergeantes. Les résultats de cette étude, menée par L'Unité d médecine des violences (UMV) ont servi de fondement à la CCLVD dans l'établissement d'un plan stratégique 2011-2015, en matière de lutte contre la violence conjugale dans le canton de Vaud. Le présent document présente à la fois un éclairage contextuel sur la situation dans le canton de Vaud aujourd'hui et une synthèse de la recherche précitée.

Prospective monitoring of cefepime in intensive care unit adult patients.

INTRODUCTION: Cefepime has been associated with a greater risk of mortality than other beta-lactams in patients treated for severe sepsis. Hypotheses for this failure include possible hidden side-effects (for example, neurological) or inappropriate pharmacokinetic/pharmacodynamic (PK/PD) parameters for bacteria with cefepime minimal inhibitory concentrations (MIC) at the highest limits of susceptibility (8 mg/l) or intermediate-resistance (16 mg/l) for pathogens such as Enterobacteriaceae, Pseudomonas aeruginosa and Staphylococcus aureus. We examined these issues in a prospective non-interventional study of 21 consecutive intensive care unit (ICU) adult patients treated with cefepime for nosocomial pneumonia. METHODS: Patients (median age 55.1 years, range 21.8 to 81.2) received intravenous cefepime at 2 g every 12 hours for creatinine clearance (CLCr) >or= 50 ml/min, and 2 g every 24 hours or 36 hours for CLCr < 50 ml/minute. Cefepime plasma concentrations were determined at several time-points before and after drug administration by high-pressure liquid chromatography. PK/PD parameters were computed by standard non-compartmental analysis. RESULTS: Seventeen first-doses and 11 steady states (that is, four to six days after the first dose) were measured. Plasma levels varied greatly between individuals, from two- to three-fold at peak-concentrations to up to 40-fold at trough-concentrations. Nineteen out of 21 (90%) patients had PK/PD parameters comparable to literature values. Twenty-one of 21 (100%) patients had appropriate duration of cefepime concentrations above the MIC (T>MIC >or= 50%) for the pathogens recovered in this study (MIC <or= 4 mg/l), but only 45 to 65% of them had appropriate coverage for potential pathogens with cefepime MIC >or= 8 mg/l. Moreover, 2/21 (10%) patients with renal impairment (CLCr < 30 ml/minute) demonstrated accumulation of cefepime in the plasma (trough concentrations of 20 to 30 mg/l) in spite of dosage adjustment. Both had symptoms compatible with non-convulsive epilepsy (confusion and muscle jerks) that were not attributed to cefepime-toxicity until plasma levels were disclosed to the caretakers and symptoms resolved promptly after drug arrest. CONCLUSIONS: These empirical results confirm the suspected risks of hidden side-effects and inappropriate PK/PD parameters (for pathogens with upper-limit MICs) in a population of ICU adult patients. Moreover, it identifies a safety and efficacy window for cefepime doses of 2 g every 12 hours in patients with a CLCr >or= 50 ml/minute infected by pathogens with cefepime MICs <or= 4 mg/l. On the other hand, prompt monitoring of cefepime plasma levels should be considered in case of lower CLCr or greater MICs.