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Introduction et objectifs: Le CHU de Grenoble a mis en place en 2000 une consultation mobile en infectiologie (CMI), accessible 24h/24 et 7j/7 grâce à une ligne téléphonique portable directe. L’objectif de cette étude était d’évaluer l’observance des avis délivrés par la CMI et de mettre en évidence les facteurs associés à une meilleure observance. Matériels et méthodes: Étude prospective d’évaluation des avis infectieux délivérs pour les patients hospitalisés au CHU de Grenoble sur une période de 6 mois, de décembre 2007 à juin 2008. L’observance aux avis était évaluée au troisième jour par un médecin indépendant. Résultats: 890 avis étaient réalisés, 607 pouvaient être évalués à J3. L’observance était de 89,2 % pour les conseils thérapeutiques et de 75 % pour la prescription examens complémentaires. Les avis donnés par un médecin sénior étaient mieux suivis que ceux donnés par un interne (p = 0,02). L’observance était meilleure lorsqu’on proposait de ne pas débuter de traitement, elle était moins bonne pour les infections nosocomiales et lors des fins de semaines. Les examens complémentaires demandés pour le suivi thérapeutique étaient mieux suivis que ceux demandés à titre diagnostic (p< 0,001). Une meilleure observance était associée à une meilleure évolution clinique et à une durée de séjour plus basse (p= 0,01). Conclusion: La CMI est un service très sollicité en milieu hospitalier. L’observance des conseils qu’elle fournit est élevée. Elle améliore l’état clinique des patients et raccourcit la durée d’hospitalisation. [Copyright &y& Elsevier]

Objective: For a long time, the benefit of a caesarean delivery in the prevention of cerebral palsy (CP) has been put forward, which was based on the assumption that CP is due to asphyxia in more than 50 % of the cases. However, from register-based data, this rate has been estimated less than 4 %. The aim of this study was to evaluate whether the rate of caesarean sections for fetal indication was correlated with the prevalence rate of CP in a French county., Patients and Methods: This was an ecological study of register-based prevalence estimates of children with CP (postnatal cases excluded) born between 1997 and 2003 in a French county compared with the rates of caesarean section for fetal distress obtained from the maternal and infant protection service of the county., Results: Whilst the rate of caesarean section for fetal indication increased by 44% during the period studied, the prevalence of CP remained nearly stable around 1.5 per 1000 live births. There was no correlation between caesarean section and CP prevalence (r'=-0.36, P=0.43)., Discussion and Conclusion: The present study was in accordance with the results of a recent meta-analysis which concluded that emergency and prophylactic caesarean deliveries were not efficient in the prevention of CP. Indication of caesarean delivery for foetal heart rhythm anomaly, which is the most relevant cause for the growing rate of caesarean sections, should be justified by additional examinations in ambivalent cases, in order not to consider it as defensive medicine, which is ethically and therefore juridically blameworthy., (Copyright © 2014 Elsevier Masson SAS. All rights reserved.)

To evaluate the prevalence and the characteristics of use of midazolam among hospitalized patients and to analyze physicians' representation of this medicine. We conducted a retrospective study between 1st May and 22nd May 2011 in Grenoble University Hospital in France. All patients receiving midazolam during the study period were included, excepted if the prescription was performed in intensive care units, operating rooms or in pediatric units. Physicians from the different units were asked about the characteristics of patients receiving midazolam and about their practice concerning the use of midazolam. Forty-four patients were included, 82 % of whom having a cancer. The prevalence of prescription of midazolam was 3.3 % (44/1,323), 2.8 % (37/1,323) for anxiety relieving and 0.8 % (11/1,323) for sedation. The main refractory symptoms that justified the prescription were dyspnea (36.4 %), confusion (29.5 %), pain (27.3 %) and psychological suffering (27.3 %). Twenty-eight physicians were asked about their practice. The main representations of midazolam were the stop of active treatment (46.5 %) and premature cause of death (46.5 %). Practice of sedation is under-estimated by physicians as they have difficulties to differentiate anxiety relieving and sedation and they have difficulties to initiate a sedation. A guideline to help physicians using midazolam could improve practice.

Background: An experience feedback committee (CREX, Comité de Retour d'EXpérience) is a method which contributes to the management of safety of care in a medical unit. Originally used for security systems of civil aviation, the method has been adapted to health care facilities and successfully implemented in radiotherapy units and in other specialties., Methods: We performed a brief review of the literature for studies reporting data on CREX established in hospitals. The review was performed using the main bibliographic databases and Google search results., Results: The CREX is designed to analyse incidents reported by professionals. The method includes monthly meetings of a multi-professional committee that reviews the reported incidents, chooses a priority incident and designates a "pilot" responsible for investigating the incident. The investigation of the incident involves a systemic analysis method and a written synthesis presented at the next meeting of the committee. The committee agrees on actions for improvement that are suggested by the analysis and follows their implementation. Systems for the management of health care, including reporting systems, are organized into three levels: the medical unit, the hospital and the country as a triple loop learning process. The CREX is located in the base level, short loop of risk management and allows direct involvement of care professionals in patient safety., Conclusion: Safety of care has become a priority of health systems. In this context, the CREX can be a useful vehicle for the implementation of a safety culture in medical units., (Copyright © 2013 Elsevier Masson SAS. All rights reserved.)

Introduction: Bacterial meningitis is a diagnosis and therapeutic emergency. It is associated with high morbidity and mortality. The objective was to evaluate the management of suspicion of meningitis in an emergency unit, following the update of recommendations., Methods: A retrospective observational study was conducted between 1st January and 30th June 2009 in the emergency unit of Grenoble University Hospital. Inclusion criteria were: patient aged 15 years and 3 months or older with suspicion of meningitis (fever in the last 24 hours with the presence of at least one meningeal or neurological clinical sign), for whom a lombar puncture was realized in the 48 hours following the admission. Two infectious disease specialists independently evaluated the management of these patients in the emergency unit., Results: Sixty-eight patients were included. Median time of the lombar puncture was 5.5 hours after admission [25-75 percentiles, 3.7-8,9]. Median time for antibiotic administration was 6 hours after admission [25-75 percentiles, 3.3-8.75]. Lactate prescription was stable during the study period (P=0.58) whereas procalcitonin prescription increased significantly (P=0.02). The realization of a brain scanner before the lumbar puncture was associated with a significant delay in the realization of the lumbar puncture (P<0.001), and was not associated with a delay in the prescription and administration of antimicrobial treatment. According to the infectious disease specialists, an antimicrobial treatment was recommended for 37 patients (54.4%); and 35 of them (94.6%) received an antibiotic in the emergency department. Dosage of ceftriaxone complied with recommendations in 17.8% of cases. A brain scanner was recommended for 33 patients and realized for 25 among them (75.8%). Ten patients (28.6%) had a brain scanner whereas it was not recommended., Conclusion: Time management was in accordance with those found in previous studies, although higher than those recommended. Consequently it should be reduced. All professionals should be concerned. Staff training and writing of protocols are necessary (especially for the treatment and the brain scanner indications)., (Copyright © 2012 Elsevier Masson SAS. All rights reserved.)

Aim: The purposes of this study were to analyse the peer groups' activity and functioning in General Practice in Isere department, the participants' characteristics, and their opinion on this activity., Methods: A census of existing groups was realized by asking professional organisations to provide us a complete list of the groups in the department. For each group, a member was asked to answer a questionnaire about the institution. Each general practitioner (GP) participating to a group was sent a questionnaire about his profile and was asked to give his personal opinion on the group., Results: The group inventory was difficult to realize, as no organisation was able to give us a complete list. Sixteen groups were included in the study, involving a total of 131 GPs. Groups were 1 to 10 years old, most of them were independent. The mean number of meetings was eight times a year. Participants were more often females, new graduates or young doctors, and internship supervisors. They were highly satisfied about this activity which allowed them to increase the quality of patient care (98%), and to change their practice (75%)., Conclusion: This study showed that peer group activity was growing in Isere. It was widely welcomed by GPs, who wondered in which way those groups could satisfy the obligations of professional development mentioned in the 2009 French law: Hospital, Patient, Health, Territory (HPST)., (Copyright © 2012 Elsevier Masson SAS. All rights reserved.)

Objective: Baby bottle tooth decay is a severe form of early childhood caries. This study aims to elaborate a screening tool for at risk children in order to facilitate primary prevention., Methods: A case-control study was conducted among children suffering from baby bottle tooth decay and children with no dental caries. Cases were children aged 5 years or less at diagnosis who experienced at least four caries with one or more affecting maxillary incisors. Controls were children matched for age and sex. Parents were interviewed by phone about their child's exposure to potential risk factors., Results: We included 88 children suffering from baby bottle tooth decay and 88 children with no dental caries. In multivariate analysis, low social class (OR 6.39 [95% CI, 1.45-28.11]), prolonged bottle feeding or bedtime feeding (OR 153.2 [95% CI, 11.77-1994.96]), and snacking (OR 5.94 [95% CI, 1.35-26.2]) were significantly associated with baby bottle tooth decay. Regular dental visits were a significant protecting factor (OR 0.13 [95% CI, 0.02-0.77]). A score was developed using these significant risk factors and tested on the survey population. The mean score was 13/20 for cases and 4/20 for controls., Discussion: These results are in accordance with the literature, except for brushing teeth, which was not significantly associated with baby bottle tooth decay in our study., Conclusion: A screening scale with a score of 20 points was proposed. Future validation is required. Pediatricians and general practitioners should encourage parents to change their habits., (Copyright © 2012 Elsevier Masson SAS. All rights reserved.)

Objective: The mortality and morbidity conference (MMC) is one of the keystones in the evaluation of quality of care. The objective of this work was to describe a MMC by presenting a case report., Case Report: A 16-year old man suffering from chronic anaemia had to be transfused with two units of red blood cells in an outpatient unit. Although the transfusion went well for the first unit, the patient presented haemolysis during the transfusion of the second unit because the nurse administered the wrong unit. The incident was analysed during a mortality and morbidity conference with the attendance of the hemovigilance local correspondent. Immediate causes of the event were the failure to respect the transfusion procedure: in advance compatibility testing, failure to check the patient and blood component identification just before the transfusion. Factors contributing to the event were the deviation of transfusion practices, poor working conditions of nurses, linked to inadequate staff in relation to the activity. The discussion of the incident led to develop an action plan., Discussion: This case shows the interest for staff members to discuss an adverse event. However, a well-defined methodology for conducting mortality and morbidity conferences is lacking and leads to a wide heterogeneity between teams. Major differences refer to criteria for case selection and quality of participants. This heterogeneity is likely to have an impact of the efficacy of mortality and morbidity conferences regarding the quality and safety of care., (Copyright © 2010 Elsevier Masson SAS. All rights reserved.)

Background: In France, national incentives promote the development of morbidity and mortality conferences (M&MC) in hospitals., Objective: A systematic literature review was performed to investigate the effectiveness of M&MC as well as how they were conducted and how participants experienced them., Databases: The review was carried out by searching the MEDLINE and PASCAL databases and included articles in English and French. The following keywords were used: mortality, morbidity, conference, rounds, review, meetings, committee., Study Selection: Two independent reviewers selected all original studies describing or evaluating M&MC and published from 1st January 2002 through 31st December 2008., Results: We analyzed 17 articles, of which 11 reported structured interviews, 3 analyzed M&MC minutes, 2 monitored indicators, and 1 described observations of M&MC. They showed good physician participation and a wide variety of types of meeting organization. Attendance by paramedical staff, the number of cases covered per meeting, and case selection criteria affected their content. Studies of the efficacy of M&MC were rare and concerned specific topics (digestive endoscopy and childbirth)., Study Limitations: Both the methods and the objectives of studies analyzing M&MC are heterogeneous., Conclusion: The published studies viewed M&MC as a valuable tool for physician education and quality assurance, but the factors associated with their effectiveness require further study., (Copyright 2009 Elsevier Masson SAS. All rights reserved.)

There are two different methods of autotransfusion during an operation; one without blood washing and the other with wash red cells obtained after the filtering and concentration of the recovered blood. The first method has the advantage of being simple and cheap while recovering 1500-2000 ml of blood. Nevertheless it is insufficient in the case of an important or rapid bleeding. The weight of haemoglobin in the recovered blood is relatively low and the hemolysis is without clinical consequences. The rate of the coagulation factors is reduced. The autotransfusion with wash red cells requires a more important investment at the beginning. But the washing process eliminates the cell micro-aggregates and nearly all of the substances in the recovered blood. Therefore concentrated units of red cells may be obtained with hematocrits between 45 and 65%. Autotransfusion with washing offers a greater security when the bleeding is important or violent. The autotransfusion is useful for a bleeding between 1 and 3 litres. The average volume recovered corresponds to 2.5 pockets of blood extract, thus covering the costs for the kits. If the bleeding exceeds 1.5 times the blood volume, blood extract and plasma will be required in addition. The risk of homologue blood transfusion can only increase the development of autotransfusion techniques and particularly the recovery of blood during the operation process.

A 66-year-old man was admitted for mitral valve replacement required by a mitral regurgitation resulting in a severe heart failure. He also suffered from chronic respiratory failure, related to a left concavity cyphoscoliosis. Postoperatively, hypoxemia occurred. His chest X-ray showed a left pleural effusion indicating a percutaneous pleural drainage. A local anaesthesia with a 21 G needle was performed prior to drain insertion, which was easily introduced into the pleural cavity. A few minutes later, the patient experienced an acute haemorrhagic shock. He was immediately transferred into the operating room, where the cardiac surgeon discovered and treated a coronary artery effraction. The vascular lesion was attributed to the needle used for local anaesthesia. The patient was discharged twelve days later without sequelae. Two factors were responsible for this accident: the patient's cyphoscoliosis and his left ventricle enlargement. This complication is uncommon. However, in case of a particular patient's anatomy, it is suggested to use a score devised to anticipate the risk of a difficult pleural drainage. This score should include general, thoracic, spinal, cardiac, hepatic and splenic morphology.