La coagulopathie post-traumatique est fréquente et complexe, elle aggrave le pronostic des traumatisés. Son diagnostic repose sur la biologie standard mais récemment des techniques de biologie ...déportée permettant l’obtention rapide d’un INR ou d’une étude de la formation du caillot par thromboélastométrie, ont permis d’obtenir des informations plus précoces. Le traitement de la coagulopathie doit être entrepris le plus précocement possible. Deux stratégies sont possibles avec soit l’utilisation d’une association de CGR/plaquette/PFC selon un ratio défini, soit l’utilisation de concentrés de facteurs guidés par la thromboélastométrie. À la correction de la coagulopathie doit impérativement s’associer le traitement des facteurs favorisants tels que l’hypothermie, l’acidose et l’hypocalcémie.
Trauma-induced coagulopathy is frequent and complex, and is responsible for an impairment of trauma outcome. Diagnosis of trauma coagulopathy is usually done with standard biology but recently new technics arose and gave us the opportunity to have faster information on coagulopathy with quick INR measure or clot formation study with thrombelastometry. Treatment of the coagulopathy should be done earlier in the course of trauma. Two strategies are possible that include either the association of RBC, platelet and FFP in a predefined ratio, or the use of factor concentrates guided with thrombelastometry. Treatment of favouring factors such as hypothermia, acidosis and hypocalcemia is also mandatory.
BACKGROUND: The highest risk for suicide occurs immediately after psychiatric discharge. The U.S. Department of Veteran’s Affairs’ (VA) suicide prevention program emphasizes suicide surveillance and ...frequent contact after suicide attempt. OBJECTIVES: To describe the 6-month reattempt rate and appointment characteristics for veterans after VA hospitalization for suicide attempt. DESIGN: This retrospective observational study identified veterans hospitalized for suicide attempt (N = 504). Comparisons of patient characteristics and treatment delivery were conducted between veteran groups. RESULTS: The sample (N = 504) was predominantly White (82%) and male (91%), with a median age of 50 years. The 6-month reattempt rate was 6%. Timing of first appointment was earlier in the reattempt group (n = 20) versus the no-reattempt group (n = 467). Appointment intensity, especially telephone appointments, was greater in the reattempt group. CONCLUSION: The effect of postdischarge treatment on preventing suicide cannot be determined by evaluating only treatment timing and intensity. Future studies should measure the treatment quality and clinical severity.
Summary Surgical-site infections (SSIs) are a key target for nosocomial infection control programmes. We evaluated the impact of an eight-year national SSI surveillance system named ISO-RAISIN ...(infection du site opératoire – Réseau Alerte Investigation Surveillance des Infections). Consecutive patients undergoing surgery were enrolled during a three-month period each year and surveyed for 30 days following surgery. A standardised form was completed for each patient including SSI diagnosis according to standard criteria, and several risk factors such as wound class, American Society of Anesthesiologists (ASA) score, operation duration, elective/emergency surgery, and type of surgery. From 1999 to 2006, 14 845 SSIs were identified in 964 128 patients (overall crude incidence: 1.54%) operated on in 838 participating hospitals. The crude overall SSI incidence decreased from 2.04% to 1.26% ( P < 0.001; relative reduction: −38%) and the National Nosocomial Infections Surveillance system (NNIS)-0 adjusted SSI incidence from 1.10% to 0.74% ( P < 0.001; relative reduction: −33%). The most significant SSI incidence reduction was observed for hernia repair and caesarean section, and to a lesser extent, cholecystectomy, hip prosthesis arthroplasty, and mastectomy. Active surveillance striving for a benchmark throughout a network is an effective strategy to reduce SSI incidence.
Summary Background Multisite information regarding surgical site infection (SSI) rates for cardiac surgery programmes is not widely available. Ward characteristics that may affect outcomes have not ...been analysed previously. Aim To determine individual- and ward-level factors associated with SSI occurrence after coronary artery bypass grafting (CABG) and valvular surgery. Methods A dataset from the French national SSI database ISO-RAISIN 2008–2011 was used. Only adult patients were included. A standardized questionnaire was completed for each patient who underwent surgery, and patients with and without SSI were characterized. Patients and ward risk factors for SSI were analysed using a multilevel logistic regression model with SSI as binary outcome (two levels: patient and ward). Results Out of 8569 patients from 39 wards, the SSI rate was 2.2%. Micro-organisms were isolated in 144 patients (74%): 35% coagulase-negative staphylococci ( N = 51), 23% Staphylococcus aureus ( N = 33), 6% Escherichia coli ( N = 8). Higher probability of SSI was associated with the duration of preoperative hospitalization, the duration of follow-up, the duration of surgery >75th percentile and the SSI rate in the surgery ward. The residual heterogeneity between wards (median odds ratio: 1.53) was as relevant as duration of preoperative hospitalization (odds ratio: 1.57). Conclusion Although patient risk factors were more strongly associated with SSI occurrence, this study provided evidence for the existence of a ward-level effect. This should be taken into account when considering possible corrective interventions.
Abstract Background Cytoreductive surgery (CRS) and Hyperthermic intraperitoneal chemotherapy (HIPEC) are promising new approaches of peritoneal metastases. However these surgical procedures are ...associated with a high morbidity rate thus intensive care (IC) management following serious complications may be warranted for these patients. The impact of the prolonged IC stay or re-admission on long-term survival remains unknown. Methods We retrospectively analysed 122 consecutive HIPEC procedures over a one year period (2010–2011) in a single academic hospital. We analysed complications that would lead to prolonged stay or re-admission into ICU and analysed long term follow-up in patients whether they required intensive care (ICU group) or not (Control group). Results ICU group represented 26.2% of the cohort mainly due to septic or haemorrhagic shock. Among them acute kidney injury and respiratory failure were present in 50% and 47% respectively. Cohort overall mortality rate was of 5.7%. Patients were followed for 4 years and survival analysis was performed adjusting for main confounding factors in a Cox survival model. Survival was not different between groups, with a median survival of 38 months 32; 44 vs. 33 months 26; 39 in the ICU group and Control group respectively. Conclusion Prolonged stay or re-admission into ICU does not seem to statistically impact long term prognosis of patients undergoing CRS with HIPEC.
L’antibioprophylaxie chirurgicale (ABP) fait partie des mesures de prévention des infections du site opératoire (ISO). Depuis 2014, un module optionnel sur l’ABP est associé à la surveillance ...nationale des ISO, afin d’évaluer si l’incidence des ISO varie selon que l’ABP est administrée ou non en conformité avec les recommandations de la société française d’anesthésie et de réanimation (SFAR).
L’étude utilisait les données 2014 et 2015 de la surveillance nationale des ISO (interventions jugées prioritaires). L’incidence des ISO a été comparée, en analyse univariée et par discipline chirurgicale, d’une part selon que l’ABP recommandée était réalisée ou non, et d’autre part suivant que l’administration ABP était conforme au référentiel 2010 de la SFAR ou non.
En 2014 et 2015, 353 services (23,5 % des services participant à la surveillance) ont participé au module ABP. Parmi les 12 109 interventions de gynécologie-obstétrique, l’incidence des ISO était plus élevée pour les interventions avec ABP recommandée et non réalisée que pour les interventions avec ABP recommandée et réalisée : OR=2,14, IC95 % 1,31–3,48, p=0,002. Sur les ABP recommandées et réalisées, 55,9 % étaient conformes au référentiel. Parmi les 1928 interventions de neurochirurgie, l’incidence des ISO était plus élevée pour les interventions avec ABP recommandée et non réalisée que pour les interventions avec ABP recommandée et réalisée : OR=4,70, IC95 % 1,56–14,20, p=0,006. Sur les ABP recommandées et réalisées, 35,7 % étaient conformes au référentiel. Les ABP non-conformes l’étaient en raison du délai d’administration majoritairement trop tôt ; 90,5 % des administrations en chirurgie gynécologie-obstétrique et 93,3 % des administrations en neurochirurgie.
L’introduction, dans la surveillance ISO, d’un module ABP a permis de montrer que la non-conformité de l’ABP, facteur de risque d’ISO connu, est associé à une incidence plus élevée des ISO dans certaines spécialités. Ces résultats, qui soulignent l’intérêt de coupler évaluation de pratiques et surveillance épidémiologique, ont amené le comité de pilotage de la surveillance a intégré un représentant de la SFAR parmi ses membres.
Staphylococcus aureus (SA) est le 2e pathogène le plus fréquemment isolé lors d’infections nosocomiales (IN) en France. Les données de surveillance nationale (réseau BMR-Raisin) montrent la ...diminution des SA résistants à la méticilline (SARM) dans les établissements de santé (ES). Le nombre de signalements externes d’IN (SIN) à SA émis pour 2016 semble lui en augmentation, notamment en réanimation néonatale (RNN). Un bilan 2012–2016 des SIN à SA a été réalisé afin de documenter l’épidémiologie des infections à SA dans les ES français pour cette période.
Une analyse rétrospective des SIN rapportant SA comme micro-organisme, émis entre le 1er janvier 2012 et le 7 juillet 2016, a été réalisée. Un cas groupé a été défini comme au moins 2 cas d’infection à SA dans un même signalement. Les variables nombre de cas, service d’hospitalisation, site infectieux, nombre de décès ont été analysées.
Sur les 8452 SIN émis pour la période 2012–2016, 421 (5 %) impliquaient des SA, rapportant 904 cas. Parmi ces 421 SIN, 159 (37,7 %) concernaient un SARM. Depuis 2012, la proportion de SIN à SA parmi l’ensemble des SIN et celle des SIN à SARM parmi les SIN à SA restent stables. Les infections les plus fréquemment rapportées étaient les bactériémies (33 % des SIN à SA), et les infections du site opératoire (30 %). Au total 143 décès ont été rapportés dans les 421 SIN à SA, dont 91 liés à l’infection à SA. Pour 376 SIN (89,3 %) impliquant SA, un seul service était concerné, en majorité des services de chirurgie (n=187 ; 49,7 %). Les services de RNN représentaient 11,2 % des SIN à SA (n=42). Le nombre de SIN rapportant des SA en RNN est plus élevé en 2014 et 2016 par rapport aux autres années : 10 pour 2014 et 8 pour les 6 premiers mois 2016 contre 4 pour 2012, 4 pour 2013 et 5 pour 2015. Sur l’ensemble des SIN à SA, 90 SIN (21,4 %) concernaient des situations épidémiques. Parmi les 42 SIN à SA en RNN, 23 (55 %) rapportaient des cas groupés, dont 19 pour lesquels une transmission croisée entre les cas était privilégiée. Pour les cas groupés en RNN, les souches ont été adressées aux CNR des staphylocoques. Différents clones ont été décrits comme responsables d’épidémies (clone Géraldine, SARM producteur de PVL…) avec une diffusion très localisée contrairement à ce qui est observé lors d’épidémies chez l’adulte.
Il n’a pas été objectivé d’augmentation du nombre de SIN à SA, basé sur le volontariat des ES, entre 2012 et 2016 globalement. Cependant pour le 1er semestre 2016, le nombre de SIN à SA en RNN est élevé par rapport aux années précédentes. Ces épisodes font l’objet d’investigations poussées et de mise en place de mesures de contrôle.
Gearboxes and generators are fundamental components of all electrical machines and the backbone of all electricity generation. Since the wind energy represents one of the key energy sources of the ...future, the number of wind turbines installed worldwide is rapidly increasing. Unlike in the past wind turbines are more often positioned in arctic as well as in desert like regions, and thereby exposed to harsh environmental conditions. Especially the temperature in those regions is a key factor that defines the design and choice of components and materials of the drive train. To optimize the design and health monitoring under varying temperatures it is important to understand the thermal behaviour dependent on environmental and machine parameters. This paper investigates the behaviour of the stator temperature of the double fed induction generator of a wind turbine. Therefore, different scenarios such as start of the turbine after a long period of no load, stop of the turbine after a long period of full load and others are isolated and analysed. For each scenario the dependences of the temperature on multiple wind turbine parameters such as power, speed and torque are studied. With the help of the regression analysis for multiple variables, it is pointed out which parameters have high impact on the thermal behaviour. Furthermore, an analysis was done to study the dependences in the time domain. The research conducted is based on 10 months of data of a 2 MW wind turbine using an adapted data acquisition system for high sampled data. The results appear promising, and lead to a better understanding of the thermal behaviour of a wind turbine drive train. Furthermore, the results represent the base of future research of drive trains under harsh environmental conditions, and it can be used to improve the fault diagnosis and design of electrical machines.
Abstract
Background
Antibiotic use (ABU) surveillance in healthcare facilities (HCFs) is essential to guide stewardship. Two methods are recommended: antibiotic consumption (ABC), expressed as the ...number of DDD/1000 patient-days; and prevalence of antibiotic prescription (ABP) measured through point prevalence surveys. However, no evidence is provided about whether they lead to similar conclusions.
Objectives
To compare ABC and ABP regarding HCF ranking and their ability to identify outliers.
Methods
The comparison was made using 2012 national databases from the antibiotic surveillance network and prevalence study. HCF rankings according to each method were compared with Spearman’s correlation coefficient. Analyses included the ABU from entire HCFs as well as according to type, clinical ward and by antibiotic class and specific molecule.
Results
A total of 1076 HCFs were included. HCF rankings were strongly correlated in the whole cohort. The correlation was stronger for HCFs with a higher number of beds or with a low or moderate proportion of acute care beds. ABU correlation between ABC or ABP was globally moderate or weak in specific wards. Furthermore, the two methods did not identify the same outliers, whichever HCF characteristics were analysed. Correlation between HCF ranking varied according to the antibiotic class.
Conclusions
Both methods ranked HCFs similarly overall according to ABC or ABP; however, major differences were observed in ranking of clinical wards, antibiotic classes and detection of outliers. ABC and ABP are two markers of ABU that could be used as two complementary approaches to identify targets for improvement.
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