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Background: Inappropriate visits to emergency departments (EDs) could represent from 20% to 40% of all visits. Inappropriate use is a burden on healthcare costs and increases the risk of ED overcrowding. The aim of this study was to explore socioeconomic and geographical determinants of inappropriate ED use in France., Method: The French Emergency Survey was a nationwide cross-sectional survey conducted on June 11 2013, simultaneously in all EDs in France and covered characteristics of patients, EDs and counties. The survey included 48 711 patient questionnaires and 734 ED questionnaires. We focused on adult patients (≥15 years old). The appropriateness of the ED visit was assessed by three measures: caring physician appreciation of appropriateness (numeric scale), caring physician appreciation of whether or not the patient could have been managed by a general practitioner and ED resource utilisation. Descriptive statistics and multilevel logistic regression were used to examine determinants of inappropriate ED use, estimating adjusted ORs and 95% CIs., Results: Among the 29 407 patients in our sample, depending on the measuring method, 13.5% to 27.4% ED visits were considered inappropriate. Regardless of the measure method used, likelihood of inappropriate use decreased with older age and distance from home to the ED >10 km. Not having a private supplementary health insurance, having universal supplementary health coverage and symptoms being several days old increased the likelihood of inappropriate use. Likelihood of inappropriate use was not associated with county medical density., Conclusion: Inappropriate ED use appeared associated with socioeconomic vulnerability (such as not having supplementary health coverage or having universal coverage) but not with geographical characteristics. It makes us question the appropriateness of the concept of inappropriate ED use as it does not consider the distress experienced by the patient, and segments of society seem to have few other choices to access healthcare than the ED., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Suicidal behaviors in France: still a public health issue. In 2015, 9,109 deaths by suicide were counted in France, representing 13.7 suicides per 100,000 inhabitants. This rate has been declining for 30 years as in many countries. A significant underestimation is however suggested for various reasons. The risk of suicide is three times higher for men than for women. Suicide rates increase among those over 75 years of age, mostly for men, while the highest suicide frequencies are found among those aged 35-65, and suicide is the second leading cause of death among adolescents and young adults. More than half of suicides are by hanging. Suicide attempts are 10 to 20 times more frequent than suicide, about 100 to 200,000 acts each year, and are also decreasing over the last years. In 2017, 88,712 hospitalizations for suicide attempts were recorded in France. Suicide attempts are associated with an increased risk of death, by suicide in particular, but also by somatic disease. The prevalence of suicidal ideation, appreciated through surveys in the general population, is high, estimated at about 5%. Many suicidal risk factors have been identified with a recognized lack of individual predictive ability. These data are crucial for guiding prevention actions and measuring their effects., Competing Interests: A. Vuagnat déclare n’avoir aucun lien d’intérêts.

Aims: A large number of people present each day at hospitals for non-fatal deliberate self-harm (DSH). Examination of the short-term risk of non-fatal recurrence and mortality at the national level is of major importance for both individual medical decision-making and global organisation of care., Methods: Following the almost exhaustive linkage (96%) of two national registries in France covering 45 million inhabitants (i.e. 70% of the whole population), information about hospitalisation for DSH in 2008-2009 and vital status at 1 year was obtained. Individuals who died during the index hospital stay were excluded from analyses., Results: Over 2 years, 136,451 individuals were hospitalised in medicine or surgery for DSH. The sample comprised 62.8% women, median age 38 in both genders, with two peaks at 16 and 44 years in women, and one peak at 37 years in men. The method used for DSH was drug overdose in 82.1% of cases. Admission to an intensive care unit occurred in 12.9%. Following index hospitalisation, 71.3% returned home and 23.7% were transferred to a psychiatric inpatient care unit. DSH recurrence during the following year occurred in 12.4% of the sample, within the first 6 months in 75.2%, and only once in 74.6%. At 1 year, 2.6% of the sample had died. The overall standardised mortality ratio was 7.5 but reached more than 20 in young adults. The causes were natural causes (35.7%), suicide (34.4%), unspecified cause (17.5%) and accident (12.4%). Most (62.9%) deaths by suicide occurred within the first 6 months following index DSH. Violent means (i.e. not drug overdose) were used in 70% of suicide cases. Concordance between means used for index DSH and for suicide was low (30% overall), except for drug overdose. Main suicide risk factors were older age, being male, use of a violent means at index DSH, index admission to an intensive care unit, a transfer to another medical department or to a psychiatric inpatient unit, and recurrence of DSH. However, these factors had low positive predictive values individually (below 2%)., Conclusions: Non-fatal DSH represent frequent events with a significant risk of short-term recurrence and death from various causes. The first 6 months following hospital discharge appear to be a critical period. Specific short-term aftercare programs targeting all people with a DSH episode have to be developed, along other suicide prevention strategies.

A national survey carried out in France in June 2013 studied for the first time all emergency department attendances over a 24-hour period. It enables patients' pathways through the emergency department to be described in detail, from their conditions of arrival through to the follow-up care downstream of their attendance., (Copyright © 2018 Elsevier Masson SAS. All rights reserved.)

Objectives: To determine whether implementation of a case-based payment system changed all-cause readmission rates in the 30 days following discharge after surgery, we analysed all surgical procedures performed in all hospitals in France before (2002-2004), during (2005-2008) and after (2009-2012) its implementation., Setting: Our study is based on claims data for all surgical procedures performed in all acute care hospitals with >300 surgical admissions per year (740 hospitals) in France over 11 years (2002-2012; n=51.6 million admissions)., Interventions: We analysed all-cause 30-day readmission rates after surgery using a logistic regression model and an interrupted time series analysis., Results: The overall 30-day all-cause readmission rate following discharge after surgery increased from 8.8% to 10.0% (P<0.001) for the public sector and from 5.9% to 8.6% (P<0.001) for the private sector. Interrupted time series models revealed a significant linear increase in readmission rates over the study period in all types of hospitals. However, the implementation of case-based payment was only associated with a significant increase in rehospitalisation rates for private hospitals (P<0.001)., Conclusion: In France, the increase in the readmission rate appears to be relatively steady in both the private and public sector but appears not to have been affected by the introduction of a case-based payment system after accounting for changes in care practices in the public sector., Competing Interests: Competing interests: None declared., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Background: In order to assess public health policies for the perinatal period, routinely produced indicators are needed for the whole population. In France, these indicators are used to compare the national public health policy with those of other European countries. French administrative and medical data (PMSI) are straightforward and reliable and may be a valuable source of information for research. This study aimed to measure the quality of PMSI data from three university health centers for core indicators in perinatal health., Method: PMSI data were compared with medical files in 2012 from 300 live births after 22 weeks of amenorrhea, drawn at random from University Hospitals in Dijon, Paris and Nancy. The variables were chosen based on the Europeristat Project's core and recommended indicators, as well as those of the French National Perinatal survey conducted in 2010. The information gathered blindly from the medical files was compared with the PMSI data positive predictive value (PPV) and the sensitivity was used to assess data quality., Results: Data on maternal age, parity and mode of delivery as well as the rates of premature births were superimposable for the two sources. The PPV for epidural injection was 96.2% and 94.3% for perineal tears. Overall, maternal morbidity was underdocumented in the PMSI, so the PPV was 100.0% for pre-existing diabetes, 88.9% for gestational diabetes and 100.0% for high blood pressure with a rate of 9.0% in PMSI and 6.3% in the medical files. The PPV for bleeding during labor was 89.5%., Conclusion: To conclude, PMSI data are apparently becoming more and more reliable for two reasons: on one hand, the importance of these data for budgetary promotion in hospitals; on the other, the increasing use of this information for statistical and epidemiological purposes., (Copyright © 2015 Elsevier Masson SAS. All rights reserved.)

Objective: To compare hospital discharge data (PMSI) with data in the reference databases: vital statistics and National Perinatal Surveys (NPS) for the principal perinatal indicators., Methods: Data concerning hospitalizations for delivery and childbirth were extracted from the PMSI 2010 database. The exhaustiveness was assessed by comparing discharge data with data from birth certificates. Indicators were compared with those in the 2010 NPS, which was based on a representative sample of births (n=15,000), using 95% confidence intervals., Results: About 823,360 hospital abstracts with delivery and 829,351 hospital abstracts with live births were considered. The exhaustiveness of the PMSI was 99.6% for live births in Metropolitan France. The distribution of maternal age, mode of delivery, birth weight and gestational age in the PMSI and NPS were very similar. In Metropolitan France, the prematurity rate was 6.9% (PMSI) vs. 6.6% [6.2-7.0] (NPS) and the rate of caesarean was 20.6% vs. 20.4% [19.8-21.1]. There were marked differences for the percentage of birth weights<2500g and for maternal diseases., Conclusion: The routine use of the PMSI for some indicators for follow-up purposes is foreseeable. Validation studies are still necessary for maternal diseases, for which recording is less standardized., (Copyright © 2013 Elsevier Masson SAS. All rights reserved.)

Settings: The HIV-positive population is still increasing because the incidence of the disease remains high while the effectiveness of highly active antiretroviral therapy (HAART) has dramatically reduced mortality. HIV infected patients have an increased life expectancy and are more readily admitted to intensive care units., Method: We conducted a nation-wide comparative study in France of how these patients are managed by ICU specialists, on one hand, and HIV specialists, on the other, to better understand the use of antiretroviral therapy in critically ill patients., Results: The results show heterogeneous responses of ICU specialists with an important proportion of non decisive answers. The answers of HIV specialists are more homogeneous. There appears to be little or no cooperation between the two specialties. The CISIH (French centers for the information and care of human immunodeficiency) are rarely consulted., Conclusions: ICU specialists must be better informed on this rapidly evolving disease. Access to updated information or to an HIV specialists must be made easier. Studies should also be made on how HAART is employed in ICUs (pharmacology, pharmacodynamics...).

Objective: The purpose of the study is to describe an intensive care unit's experience in the treatment of poststernotomy mediastinitis and to identify factors associated with intensive care unit death., Methods: Over a 10-year period, 316 consecutive patients with mediastinitis occurring less than 30 days after sternotomy were treated in a single unit. First-line therapy was closed-drainage aspiration with Redon catheters. Variables recorded, including patient demographics, underlying disease classification, clinical and biologic data available at intensive care unit admission and day 3, and their association with intensive care unit mortality, were subjected to multivariate analyses., Results: Intensive care unit mortality (20.3%) was significantly associated with 5 variables available at admission: age greater than 70 years (odds ratio, 2.70), operation other than coronary artery bypass grafting alone (odds ratio, 2.59), McCabe class 2/3 (odds ratio, 2.47), APACHE II score (odds ratio, 1.12 per point), and organ failure (odds ratio, 2.07). After introducing day 3 variables into the logistic regression model, independent risk factors for intensive care unit death were as follows: age greater than 70 years, operations other than coronary artery bypass grafting alone, McCabe class 2/3, APACHE II score, mechanical ventilation still required on day 3, and persistently positive bacteremia. For patients receiving mechanical ventilation for less than 3 days, mortality was very low (2.4%). In contrast, for patients receiving mechanical ventilation for 3 days or longer, mortality reached 52.8% and was associated with non-coronary artery bypass grafting cardiac surgery, persistently positive bacteremia, and underlying disease., Conclusions: In patients requiring intensive care for acute poststernotomy mediastinitis, age, type of cardiac surgery, underlying disease, and severity of illness at the time of intensive care unit admission were associated with intensive care unit death. Two additional factors (mechanical ventilation dependence and persistently positive bacteremia) were identified when the analyses were repeated with inclusion of day 3 patient characteristics.

Objectives: To compare the efficacy, ease of use and safety of intermittent vancomycin infusion (IVI) and continuous vancomycin infusion (CVI) in high-dose therapy of osteomyelitis., Methods: Forty-four patients with an osteomyelitis requiring vancomycin for more than 4 weeks were prospectively included, 21 receiving IVI and 23, CVI. The target serum concentration of vancomycin was 20-25 mg/L. Pharmacokinetics, adverse effects, and clinical efficacy were recorded., Results: The mean daily vancomycin dosing was the same in the two groups, but the serum vancomycin concentrations (trough or plateau) were lower in the IVI group than the CVI group (21.7 +/- 9.3 and 26.0 +/- 6.1 mg/L, respectively; P < 0.0001). The target concentrations were achieved quicker with CVI, and daily dosing was changed more frequently in the IVI group. After reaching the target, variability of vancomycin serum concentration (trough or plateau concentrations) was higher in the IVI group than in CVI group (standard deviation 7.9 mg/L vs. 5.6 mg/L, respectively; P = 0.001). CVI did not show clinical superiority, but adverse drug effects were more frequent in the IVI group as compared with the CVI group, 9 (42.9%) and 2 (8.7%), respectively (P = 0.03). Survival multiple regression using Cox's proportional hazard model showed that IVI (RR = 5.9, P = 0.03) and osteomyelitis of the foot (RR = 5.2, P = 0.01) were the only factors associated with adverse drug reactions leading to treatment termination., Conclusions: CVI is practical and effective, and may be a good alternative for patients requiring prolonged treatment with high vancomycin serum levels.

It is important to identify the optimal dosage and best method of infusion of parenteral vancomycin to be used over a several week period for the treatment of osteomyelitis. A retrospective study was undertaken to compare a high dose vancomycin treatment (HD: 40 mg/kg/d) with a standard dose treatment (SD: 20 mg/kg/d), and also to compare the modality of infusion using either intermittent vancomycin infusion (IVI) or continuous vancomycin infusion (CVI). 89 patients with Gram-positive cocci osteomyelitis requiring vancomycin treatment were followed, and the outcome and therapeutic safety were compared. There were significantly more adverse drug reactions (acute renal failure) in the IVI subgroup (HD-IVI vs SD-IVI, p-value 0.007). No cases of renal failure were found in the HD-CVI subgroup. The best outcome was found in the subgroup of patients who received HD-CVI (HD-CVI vs SD-IVI, overall log rank p-value 0.02). HD-CVI treatment appears to provide an improved outcome with fewer adverse drug reactions.

Background: Suboptimal levels of antiretroviral drugs result in virologic failure in HIV-infected patients treated with highly active antiretroviral therapy (HAART)., Objective: To assess the relationship between levels of indinavir in hair and virologic outcome., Design: Cross-sectional study., Setting: 7 AIDS clinics in France., Patients: 89 HIV-infected patients who received HAART that included indinavir., Measurements: Patients were classified as responders or nonresponders on the basis of viremia at the time of hair collection. In nonresponders, levels of indinavir in hair and resistance mutations in the protease gene were assessed at baseline and at the time of indinavir measurement., Results: Mean indinavir levels (+/-SD) were significantly higher in the 65 responders than in the 24 nonresponders (24.4 +/- 16 microg/g vs. 12.9 +/- 8.6 microg/g) (P < 0.001). Nonresponders with intermediate levels of indinavir in hair had more mutations in the protease gene than did nonresponders with low levels of indinavir in hair., Conclusion: Indinavir levels in hair are associated with virologic outcome in patients receiving HAART.

Kallikrein is synthesized in the distal tubules and produces kinins, which are involved in the regulation of vascular tone in the kidney. Urinary kallikrein activity has been reported to be partly inherited and to be reduced in essential hypertension. In a systematic search for molecular variants of the human kallikrein gene, nine single-nucleotide polymorphisms were identified. Five of those polymorphisms, including two nonsynonymous substitutions in exon 3, i.e., Arg53His (allelic frequency in Caucasian subjects, 0.03) and Gln121Glu (allelic frequency, 0.33), were studied in a normotensive group and two independent hypertensive groups for which 24-h urinary kallikrein activity had been measured. A significant decrease in urinary kallikrein activity was observed for the subjects who were heterozygous for the Arg53His polymorphism, compared with the other subjects. This finding was consistent in the two hypertensive groups and was observed with several kallikrein enzymatic assays. The Gln121Glu polymorphism and the other polymorphisms were not associated with changes in urinary kallikrein activity. None of the polymorphisms was associated with hypertension. Recombinant kallikrein variants were synthesized and enzymatically characterized, using native kininogen and kininogen-derived synthetic peptide substrates. No important effect was observed after Gln121 mutation, but there was a major decrease in enzyme activity when Arg53 was replaced by histidine. A model of kallikrein derived from crystallographic data suggested that Arg53 can affect substrate binding. The identification of a subset of subjects with genetically reduced kallikrein activity as a result of an amino acid mutation could facilitate analysis of the role of the kallikrein-kinin system in renal and vascular diseases.

Aims: Testing for hepatitis C virus (HCV) is recommended. The purpose of this study was to evaluate the efficacy of HCV testing in a medical consultation without an appointment and in an HIV testing center based on three testing strategies: 1997 French Consensus Conference, "Lettre de la Direction Générale de la Santé" (January 1996), and extension to other risk factors., Patients and Methods: For 6 months a free blood test was offered to any patient with a risk factor according to the literature., Results: There were 1 736 new patients at the medical consultation and 1 616 at the testing center. The patients were younger at the testing center than at the medical consultation (31.1 vs 43.3 years; P<0.001). Acceptance of screening was better at the testing center (97.8% vs 75.2%; P<0.001). There were more patients exposed to one of the risk factors at the testing center (31.2% vs 13.9%; P<0.001). Tests were more efficient at the testing center: 30 HCV positive patients/1 616 (1.86%) vs 11/1 736 (0.63%, P<0.01). Tests based on the 1997 French Consensus Conference provided detection in 27/30 (90%) of HCV positive patients at the testing center but only 4/11 (36.3%) at the medical consultation (P<0.01)., Conclusion: Testing was effective in both places but was more efficient at the testing center. Efficacy of the testing strategies differs significantly according to the place of screening. At the testing center, screening can be restricted to patients with a history of intravenous drug use and blood transfusion. At the medical consultation, screening should be extended to other risk factors.

Purpose: Anal incontinence affects approximately 10 percent of adult females. Damage to the anal sphincters has been considered as the cause of anal incontinence after childbirth in the sole prospective study so far available. The aims of the present study were to determine prospectively the incidence of anal incontinence and anal sphincter damage after childbirth and their relationship with obstetric parameters., Methods: We studied 259 consecutive females six weeks before and eight weeks after delivery. They were asked to fill in a questionnaire assessing fecal incontinence. Anal endosonography (7-10 MHz) was then performed. Two independent observers analyzed internal and external anal sphincters., Results: A total of 233 patients (90 percent) were assessed, of whom 31 had cesarean section. De novo sphincter defects were observed in 16.7 percent (14 percent external, 1.7 percent internal, and 1 percent both) in the postpartum period only after vaginal delivery. These disruptions occurred with the same incidence after the first and the second childbirth. Independent risk factors (odds ratio; 95 percent confidence interval) for sphincter defect were forceps (12; 4-20), perineal tears (16; 9-25), episiotomy (6.6; 5-17), and parity (8.8; 4-19) as revealed by multivariate analyses. The overall rate of anal incontinence was 9 percent and independent risk factors (odds ratio; 95 percent confidence interval) involved forceps (4.5; 1.5-13), perineal tears (3.9; 1.4-10.9), sphincter defect (5.5; 5-15), and prolonged labor (3.4; 1-11). Among these patients only 45 percent had sphincter defects., Conclusion: Anal incontinence after delivery is multifactorial, and anal sphincter defects account for only 45 percent of them. Primiparous and secundiparous patients have the same risk factors for sphincter disruption and anal incontinence. Because external anal sphincter disruptions are more frequent than internal anal sphincter damage, surgical repair should be discussed in symptomatic patients.

Fibromuscular dysplasia is a non-atherosclerotic, non-inflammatory vascular disease that primary involves medium-sized and small arteries, most commonly the renal and carotid arteries. Dysplasic stenoses can be classified by angiography into three main subtypes, multifocal (multiple contiguous stenoses with the "string of beads" appearance), unifocal (single stenosis in a given renal artery), or tubular. The multifocal subtype is the most frequent and is usually associated with medial dysplasia, whereas unifocal and tubular stenoses are associated with intimal and perimedial dysplasia, respectively. Renovascular hypertension, mainly in women aged 30 to 50 years, is the most common manifestation of renal artery fibromuscular dysplasia. Its prevalence in hypertensive patients is estimated to less than 1 percent. The true prevalence of the disease is probably higher, however, because many cases can go undetected in normotensive or asymptomatic hypertensive patients. The first line treatment is percutaneous transluminal angioplasty that usually allows blood pressure improvement or normalization. Stenosis progression is slow and rarely leads to ischemic renal failure. Recognition of renal artery fibromuscular dysplasia should lead to screening for associated carotid artery lesions. Fibromuscular dysplasia can be a familial disease.

The aim of this study was to conduct a formal pedigree analysis of the involvement of the elastin gene in families. From 140 subjects with renal FMD documented on angiography, family cases with documented renal artery fibromuscular dysplasia (FMD) and to test pedigrees were constructed and familial cases defined by angiographic evidence of FMD in at least one sibling. Familial screening was made either by echodoppler for asymptomatic subjects or by digital intravenous angiography for hypertensive subjects. Linkage analysis at the elastin gene locus was performed in these families with two polymorphic markers: one diallelic RFLP located in exon 16 and one multiallelic CA repeat located in intron 17 of the elastin gene. Fourteen pedigrees (10%) were obtained including nine sibling pairs, four trios and one vertical transmission from a father to his daughter. Most affected subjects were females (84%) but familial cases were more frequently bilateral than sporadic cases (80% vs 49%, p = 0.07). Pedigrees analysis was compatible with an autosomal dominant mode of inheritance and suggested in these families an age and sex-dependent incomplete penetrance model. Linkage analysis resulted in a maximum two-point lod score of 0.06 at theta = 0.20 using the dinucleotide CA repeat. Analysis of the diallelic marker revealed similar frequencies in affected and non affected subjects. This study highlights the role of genetics factors in approximately 10% of FMD cases. The elastin gene does not seem to be involved in the pathogenesis of FMD.

To describe the epidemiologic and microbial aspects of ventilator-associated pneumonia (VAP) in patients with acute respiratory distress syndrome (ARDS), we prospectively evaluated 243 consecutive patients who required mechanical ventilation (MV) for > or = 48 h, 56 of whom developed ARDS as defined by a Murray lung injury score > 2.5. We did this with bronchoscopic techniques when VAP was clinically suspected, before any modification of existing antimicrobial therapy. For all patients, the diagnosis of pneumonia was established on the basis of culture results of protected-specimen brush (PSB) (> or = 10(3) cfu/ml) and bronchoalvelolar lavage fluid (BALF) (> or = 10(4) cfu/ml) specimens, and direct examination of cells recovered by bronchoalveolar lavage (BAL) (< or = 5% of infected cells). Thirty-one (55%) of the 56 patients with ARDS developed VAP for a total of 41 episodes, as compared with only 53 (28%) of the 187 patients without ARDS for a total of 65 episodes (p = 0.0005). Only 10% of first episodes of VAP in patients with ARDS occurred before Day 7 of MV, as compared with 40% of the episodes in patients without ARDS (p = 0.005). All but two patients with ARDS who developed VAP had received antimicrobial treatment (mostly with broad-spectrum antibiotics) before the onset of infection, as compared with only 35 patients without ARDS (p = 0.004). The organisms most frequently isolated from patients with ARDS and VAP were methicillin-resistant Staphylococcus aureus (23%), nonfermenting gram-negative bacilli (21%), and Enterobacteriaceae (21%). These findings confirm that microbiologically provable VAP occurs far more often in patients with ARDS than in other ventilated patients. Because these patients are often treated with antibiotics early in the course of the syndrome, the onset of VAP is frequently delayed after the first week of MV, and is then caused mainly by methicillin-resistant S. aureus and other multiresistant microorganisms.

To determine risk factors for ventilator-associated pneumonia (VAP) caused by potentially drug-resistant bacteria such as methicillin-resistant Staphylococcus aureus, Pseudomonas aeruginosa, Acinetobacter baumannii, and/or Stenotrophomonas maltophilia, 135 consecutive episodes of VAP observed in a single ICU over a 25-mo period were prospectively studied. For all patients, VAP was diagnosed based on results of bronchoscopic protected specimen brush (> or = 10(3) cfu/ml) and bronchoalveolar lavage (> or = 10(4) cfu/ml) specimens. Seventy-seven episodes were caused by "potentially resistant" bacteria and 58 episodes were caused by "other" organisms. According to logistic regression analysis, three variables among potential factors remained significant: duration of mechanical ventilation (MV) > or = 7 d (odds ratio [OR] = 6.0), prior antibiotic use (OR = 13.5), and prior use of broad-spectrum drugs (third-generation cephalosporin, fluoroquinolone, and/or imipenem) (OR = 4.1). Distribution of the 245 causative bacteria was analyzed according to four groups defined by prior duration of MV (< 7 or > or = 7 d) and prior use or lack of use (within 15 d) of antibiotics. Although 22 episodes of early-onset VAP in patients receiving no prior antibiotics were caused by antibiotic-susceptible bacteria, 84 episodes of late-onset VAP in patients receiving prior antibiotics were mainly caused by potentially resistant bacteria. Differences in the potential efficacies (ranging from 100% to 11%) against microorganisms of 15 antimicrobial regimens were studied according to classification into these four groups. These findings may provide a more rational basis for selecting the initial therapy of patients suspected of having VAP.

Background: Reflux oesophagitis is considered a multifactorial disease, but the respective roles of the main factors involved in its pathophysiology have not been clearly established., Aims: To attempt to assign these roles by means of a multivariate logistic regression analysis of the main parameters associated with reflux oesophagitis., Patients: Eighty seven patients with gastro-oesophageal reflux disease were studied: 41 without oesophagitis and 46 with reflux oesophagitis grade 1 to 3., Methods: (1) Monovariate comparison of patients' characteristics and of parameters derived from in hospital 24 hour oesophageal pH monitoring, oesophageal manometry, double isotope gastric emptying studies, and basal and pentagastrin stimulated gastric acid and pepsin output determinations, between patients with and without oesophagitis. (2) Multivariate logistic regression analysis including the parameters significant in the monovariate analysis., Results: Among the 16 significant parameters from monovariate analysis, three significant independent parameters were identified by multivariate logistic regression analysis: number of refluxes lasting more than five minutes, reflecting oesophageal acid clearance (p = 0.002); basal lower oesophageal sphincter pressure (p = 0.008); and peak acid output (p = 0.012). These three parameters were not correlated with each other. The multivariate model was highly discriminant (correct classification of 81.3% of the cases (95% confidence intervals 0.723, 0.903). Risk for oesophagitis increased as a function of the tercile threshold values of the three parameters. Odds ratios of the three parameters for oesophagitis risk were similar, regardless of whether they were calculated when the patients were compared as a function of oesophagitis grade or the presence or absence of oesophagitis., Conclusions: This multivariate approach adds evidence that impaired oesophageal acid clearance and hypotonic lower oesophageal sphincter are the two major independent pathophysiological factors of oesophagitis, but also showed that the acid secretion level is an independent pathophysiological factor.

The present study was intended to examine the stability of amiodarone (Cordarex, CAS 1951-25-3) and its metabolite desethylamiodarone. For this purpose 20 ml of blood were taken from each of 12 patients treated with amiodarone and were stored, after centrifuging, at room temperature, +5 degrees C, -18 degrees C and -38 degrees C. The amiodarone and desethylamiodarone concentrations were determined by the HPLC method 30 min, 24 h, 48 h, 72 h, one and two weeks after blood-taking. It turned out that the serum levels decreased continuously as of the first day regardless of the storage temperature. Correction factors were therefore calculated for the amiodarone concentration: if the blood level determination takes place after 24 h one should add 8% to the obtained value, after 48 h 16%, after 72 h 19%, after one week 23% and after two weeks 32%.