Evaluation of the impact of a therapeutic drug monitoring program in a Swiss University Hospital

Background and objective: Therapeutic Drug Monitoring (TDM) has been introduced early 1970 in our hospital (CHUV). It represents nowadays an important routine activity of the Division of Clinical Pharmacology and Toxicology (PCL), and its impact and utility for clinicians required assessment. This study thus evaluated the impact of TDM recommendations in terms of dosage regimen adaptation. Design: A prospective observational study was conducted over 5 weeks. The primary objective was to evaluate the application of our TDM recommendations and to identify potential factors associated to variations in their implementation. The secondary objective was to identify pre-analytical problems linked to the collection and processing of blood samples. Setting: Four representative clinical units at CHUV. Main outcome measure: Clinical data, drug related data (intake, collection and processing) and all information regarding the implementation of clinical recommendations were collected and analyzed by descriptive statistics. Results: A total of 241 blood measurement requests were collected, among which 105 triggered a recommendation. 37% of the recommendations delivered were applied, 25 % partially applied and 34% not applied. In 4% it was not applicable. The factors determinant for implementation were the clinical unit and the mode of transmission of the recommendation (written vs oral). No clear difference between types of drugs could be detected. Pre-analytical problems were not uncommon, mostly related to completion of request forms and delays in blood sampling (equilibration or steady-state not reached). We have identified 6% of inappropriate and unusable drug level measurements that could cause a substantial cost for the hospital. Conclusion: This survey highlighted a better implementation of TDM recommendations in clinical units where this routine is well integrated and understood by the medical staff. Our results emphasize the importance of communication with the nurse or the physician in charge, either to transmit clinical recommendations or to establish consensual therapeutic targets in specific conditions. Development of strong partnerships between clinical pharmacists or pharmacologists and clinical units would be beneficial to improve the impact of this clinical activity.

Estudi d'utilització d'antifúngics sistèmics a l'Hospital Universitari Vall d'Hebron

Objectius: Descriure les principals característiques de la utilització dels antifúngics sistèmics a l’Hospital Universitari Vall d’Hebron (HUVH) i avaluar la seva adequació. Metodologia: Estudi de prescripció-indicació en pacients majors de 16 anys amb seguiment prospectiu de 40 casos incidents consecutius. Limitats a 10 els casos de fluconazole, es realitza una anàlisi descriptiva ponderada. S’avalua l’adequació segons les recomanacions de la Infectious Diseases Society of America (IDSA). Resultats: El fluconazole va ser el fàrmac més emprat (74,8%; IC del 95%: 60,7-88,9), seguit del voriconazole. L’ús més habitual va ser l’empíric-anticipat (53,4%; IC del 95%: 28,6-78,1) i la indicació més freqüent la profilaxi d’infecció fúngica invasiva (25,0%; IC del 95%: 2,4-47,5). Es van considerar adequades el 71,7% (IC del 95%: 49,1-94,3) de les indicacions, el 100% (IC del 95%: 100-100) dels fàrmacs seleccionats, el 51,2% (IC del 95%: 21,8-80,6) de les dosis i el 61,7% (IC del 95%: 32,6-90,7) de les durades. Conclusions: Els resultats suggereixen que a l’HUVH es fa una prescripció raonada dels antifúngics sistèmics però caldria millorar el seu ús empíricanticipat i específic. Cal interpretar-los amb cautela per la manca de precisió i la dificultat per valorar la situació clínica

Proportion of out of hospital adult non traumatic cardiac arrest presenting as a convulsion

Introduction: The majority of convulsions are due to an epilepticseizure or a convulsive syncope. In some cases, this is the firstsymptom of an out of hospital cardiac arrest (OH-CA).Objective: This study was aimed to measure the proportion of adultnon traumatic OH-CA presenting as a convulsion.Methodology: We prospectively collected all incoming calls with anout-of-hospital non traumatic seizure as the chief complaint in patients>18 years during a 24-months period. Among these calls, we collectedcases identified as OH-CA by paramedics.Results: During the 24-months period, the EMS dispatch centerreceived 561 calls for an out-of-hospital non traumatic convulsion in anadult. Twelve cases were ultimately classified as CA. In this group, onebystander spontaneously reported that the patient was known forepilepsy. The incidence of OH-CA presenting as convulsions wastherefore 2.1% of all calls for convulsion. Over the same period, theEMS dispatch center received 1035 calls related to an adult nontraumatic OH-CA. Therefore the rate of OH-CA presenting as aconvulsion represented 1.2% of all adult non traumatic OH-CA.Conclusion: Only 12 cases out of the 531 calls for non traumatic adultconvulsions were confirmed OH-CA (2.1%). Nevertheless, this unusualpresentation of OH-CA must be recognized by dispatchers, even whena patient is reported by bystander as a known epileptic. Dispatchersshould keep bystanders on line or call them back before paramedics'arrival, and have them confirm the progressive return of a normalpattern of breathing and state of consciousness; if not, they shouldencourage when necessary bystander to initiate CPR. For dispatchers,a past medical history of epilepsy should not be regarded as sufficientinformation to rule-out OH-CA. It is mandatory that known epilepticpatients should be monitored in the same way as non-epileptic patients.

Thrombolyse de l'accident vasculaire cérébral ischémique aigu: rôles du praticien et de l'hôpital périphérique [Thrombolysis of acute ischemic cerebral vascular accident: roles of the physician and the peripheral hospital]

Thrombolysis administered intravenously within 3 hours (or within 6 hours intra-arterially) after symptoms onset improves the functional outcome of acute ischemic stroke patients. In Switzerland this treatment is only performed by specialized centers. At the level of a community hospital or a general practitioner, the management is based on the appropriate selection of patients in whom thrombolysis could be indicated, followed by their immediate transfer to a reference medical center. Because of the very short therapeutic window, specific criteria have to be used. We present the guidelines of Les Cadolles Hospital in Neuchâtel established in collaboration with the Department of Neurology of the University Hospital of Lausanne and a retrospective analysis of emergency admissions for suspected stroke at Les Cadolles between January 1st 2001 and December 31st 2002.

Short term evolution of a highly transmissible methicillin-resistant Staphylococcus aureus clone (ST228) in a tertiary care hospital.

Staphylococcus aureus is recognized as one of the major human pathogens and is by far one of the most common nosocomial organisms. The genetic basis for the emergence of highly epidemic strains remains mysterious. Studying the microevolution of the different clones of S. aureus is essential for identifying the forces driving pathogen emergence and spread. The aim of the present study was to determine the genetic changes characterizing a lineage belonging to the South German clone (ST228) that spread over ten years in a tertiary care hospital in Switzerland. For this reason, we compared the whole genome of eight isolates recovered between 2001 and 2008 at the Lausanne hospital. The genetic comparison of these isolates revealed that their genomes are extremely closely related. Yet, a few more important genetic changes, such as the replacement of a plasmid, the loss of large fragments of DNA, or the insertion of transposases, were observed. These transfers of mobile genetic elements shaped the evolution of the ST228 lineage that spread within the Lausanne hospital. Nevertheless, although the strains analyzed differed in their dynamics, we have not been able to link a particular genetic element with spreading success. Finally, the present study showed that new sequencing technologies improve considerably the quality and quantity of information obtained for a single strain; but this information is still difficult to interpret and important investments are required for the technology to become accessible for routine investigations.

A Many-to-many 'rural hospital theorem'

We show that the full version of the so-called 'rural hospital theorem' (Roth, 1986) generalizes to many-to-many matching where agents on both sides of the market have separable and substitutable preferences.

Vancomycin-resistant Enterococci in Intensive Care Hospital Settings

Vancomycin-resistant enterococci (VRE) have recently emerged as a nosocomial pathogen and present an increasing threat to the treatment of severely ill patients in intensive-care hospital settings. We outline results of a study of the epidemiology of VRE transmission in ICUs and define a reproductive number R0; the number of secondary colonization cases induced by a single VRE-colonized patient in a VRE-free ICU, for VRE transmission. For VRE to become endemic requires R0 >1. We estimate that in the absence of infection control measures R0 lies in the range 3-4 in defined ICU settings. Once infection control measures are included R0=0.6, suggesting that admission of VRE-colonized patients can stabilize endemic VRE.

Major depressive disorders in the general hospital: how to implement guidelines.

OBJECTIVE: An implementation study that evaluated the impact of previously adopted guidelines on the clinical practice of medical residents was conducted to improve the recognition and treatment of major depressive disorders (MDDs) in hospitalized patients with somatic diseases. METHODS: Guidelines were implemented in two wards (ENT and oncology) using intranet diffusion, interactive sessions with medical residents, and support material. Discharge letters of 337 and 325 patients, before and after the intervention, respectively, were checked for statement of diagnosis or treatment of MDDs and, in a post hoc analysis, for any mention about psychiatric management. RESULTS: No difference was found in the number of diagnosed or treated MDDs before and after the intervention. However, significantly more statements about psychological status (29/309 vs. 13/327) and its management (36/309 vs. 19/327) were observed after the intervention (P<.01). CONCLUSION: The intervention was not successful in improving the management of MDDs. However, a possible effect on general psychological aspects of medical diseases was observed.

Length of hospital stay and postdischarge mortality in patients with pulmonary embolism: a statewide perspective

BACKGROUND: The optimal length of stay (LOS) for patients with pulmonary embolism (PE) is unknown. Although reducing LOS is likely to save costs, the effects on patient safety are unclear. We sought to identify patient and hospital factors associated with LOS and assess whether LOS was associated with postdischarge mortality. METHODS: We evaluated patients discharged with a primary diagnosis of PE from 186 acute care hospitals in Pennsylvania (January 2000 through November 2002). We used discrete survival models to examine the association between (1) patient and hospital factors and the time to discharge and (2) LOS and postdischarge mortality within 30 days of presentation, adjusting for patient and hospital factors. RESULTS: Among 15 531 patient discharges with PE, the median LOS was 6 days, and postdischarge mortality rate was 3.3%. In multivariate analysis, patients from Philadelphia were less likely to be discharged on a given day (odds ratio [OR], 0.82; 95% confidence interval [CI], 0.73-0.93), as were black patients (OR, 0.88; 95% CI, 0.82-0.94).The odds of discharge decreased notably with greater patient severity of illness and in patients without private health insurance. Adjusted postdischarge mortality was significantly higher for patients with an LOS of 4 days or less (OR, 1.55; 95% CI, 1.21-2.00) relative to those with an LOS of 5 to 6 days. CONCLUSIONS: Several hospital and patient factors were independently associated with LOS. Patients with a very short LOS had greater postdischarge mortality relative to patients with a typical LOS, suggesting that physicians may inappropriately select patients with PE for early discharge who are at increased risk of complications

Validación del delta base déficit como modelo predictor de resultados en pacientes politraumáticos. Hospital Parc Taulí Sabadell. Estudio preliminar

Les escales de valoració al pacient politraumàtic són essencials per al seu maneig i pronòstic. Podem definir índexs de gravetat o probabilitat de supervivència. Segons quins paràmetres analitzi, podem parlar d’escales fisiològiques, anatòmiques, bioquímiques i els índexs de probabilitat de supervivència. El BISS és un model de probabilitat provat a Holanda que ha demostrat ser objectiu. El nostre treball consisteix en la validació del BISS als nostres pacients. Durant dos anys vàrem recollir 354 pacients podent incloure només 167 al nostre estudi. Els resultats van ser significatius amb l’estudi posterior, però degut a la gran pèrdua de pacients no podem afirmar la nostra hipòtesi.

Estudio epidemiológico de la presencia de cuerpos extraños en pacientes asistidos entre 1983 y 2009 en el servicio de Otorrinolaringologia del Hospital Central de Maputo (Moçambique)

Antecedents: els cossos estranys en l'especialitat d'ORL en països en desenvolupament representen un important problema de salut pública. Objectius: caracteritzar el perfil dels pacients, identificar els cossos estranys i establir relacions entre ells. Metodologia: estudi descriptiu, retrospectiu, de 4.826 pacients amb cossos estranys durant un període ampli (1983-2009). Resultats: el 52.8% dels pacients van ser de sexe masculí i el 64.9% d'edat pediàtrica. Els objectes metàl•lics (24.5%) la localització a l'oïda (40.3%) van ser els més freqüents. Conclusions: es demostren evidències d'interès en salut pública i es proposen estratègies de prevenció i de control.

Características epidemiológicas y evolución de los pacientes con bacteriemia por Staphylococcus aureus ingresados en un Hospital de tercer nivel.

El objetivo del estudio fue describir las características epidemiológicas y los factores de riesgo de la bacteriemia por Staphylococcus aureus (BSA) en pacientes adultos atendidos en un hospital de tercer nivel. Se incluyeron 188 pacientes con BSA, 62 % hombres y con una edad media de 64±15,3 años. El 24% eran SARM. La mayoría provenían de servicios médicos (63,8%). El origen más frecuente de la BSA fue nosocomial (56,4%) seguido del relacionado con el ámbito sanitario (RAS) (28,7%) y comunitario (14,9 %). Presentaban enfermedad de base subyacente un 96%, siendo la más frecuente la neoplasia con un total de 65 pacientes (35 %). La enfermedad de base se consideró fatal en 38,3% pacientes, últimamente fatal en 22,3 % y no fatal en 39,4 %. El foco de infección resultó aparente en 151 pacientes (80,3%), siendo el más frecuente el catéter vascular (45,7 %). Presentaron fiebre el 73,9 %, leucocitosis un 44% y bandas en la analítica un 25%. Presentaron complicaciones el 36,2 % de los pacientes con BSA: shock (26,1%) y metástasis sépticas (14,4%). La evolución fue favorable en 126 pacientes (67%), mientras que 52 (27,7%) fallecieron, 43 de ellos (22,9%) en relación con al BSA y en 7 (3,7%) recidivó.

Donner la parole aux médecins traitants [Letting the treating physicians speak].

OBJECTIVE: Quality assessment in consultation and liaison psychiatry (CLP) is extremely difficult and must take into account numerous factors. The general practitioner (GP) of the patients seen by CL psychiatrists seems an essential factor to be considered in evaluating CL work. However, as far as we know, no study is doing so. Therefore, we have implied the GP to assess our CL work at the hospital St-Loup-Orbe. METHOD: We put up a qualitative study consisting of semi-structured interviews with 18 GPs caring for 45 patients having been submitted to a psychiatric CL intervention. Furthermore, we invited the GPs to assesses CLP as a specialization as well as CLP practiced at St-Loup-Orbe hospital. RESULTS: Impact is judged by the GPs with regard to the total number as: highly favorable> favorable> indifferent> negative. The GPs' critiques, whether positive or negative, are highly informative. CONCLUSIONS: GPs accept favorably CLP interventions and consider them on the whole as constructive. On the other hand, they are not sufficiently considered as partners during their patients' hospital stay. Furthermore, CLP must evaluate its impact at distance from the consultation and take into account the GPs' assessments to improve CL quality.