Incidence,prévalence et facteurs de risque de survenue d’une première complication infectieuse sur chambres à cathéter implantables

Background

Totally implantable venous-access ports (TIVAP) should present less risk of complications than central venous catheters over a long time period.

Aims

Firstly, the study's objective was to assess the prevalence and incidence of a first infectious complication on a TIVAP and secondly, to assess the risk factors associated with this first infection.

Methods

The authors made a longitudinal historical cohort study of patients with a TIVAP in 2003, in the Dijon University Hospital.

Results

Two hundred and nineteen patients (sex-ratio 1.9) were included, with a total follow-up of 92,773 patients-days. Ninety percent of the TIVAP were used for chemotherapy, 5% for antibiotic drug administration, 2% for parenteral nutrition and 3% for other reasons (recurrent blood transfusions, etc.). Overall, 34 (16.3%) out of 209 patients presented with at least one infectious complication, with an incidence rate of 0.37 infection/1,000 patients-days. The 5-year cumulative probability to be free of infectious complication was only 62.8%. In multivariate analysis, only underlying hematological neoplasia (by contrast with solid tumors) was significantly associated to a higher risk of infectious complication.

Conclusions

The infectious risk linked to the use of TIVAP is significant, higher in case of underlying hematological neoplasia and during the first months of use.     

A randomised controlled trial of delayed cord clamping in very low birth weight preterm infants

This study was carried out to assess the feasibility of late cord clamping of 45 s in preterm infants delivered mainly by caesarean section and the effects on post-partal adaptation and anaemia of prematurity. Prior to delivery, 40 infants of <33 gestational weeks were randomised to either 20 s or 45 s of late cord clamping. After the first shoulder was delivered, oxytocin was given intravenously to the mother in order to enhance placento-fetal transfusion while the infant was held below the level of the placenta. The 20 infants in group 1 (20 s) had a mean birth weight of 1070 g and a mean gestational age of 29 + 4/7 weeks versus 1190 g and 30 weeks in group 2 (45 s). On day 42 of life there were ten infants without transfusions in group 2 versus three in group 1 (P < 0.05). Out of the 20 infants in group 1, 19 and 15/19 in group 2 were delivered by caesarean section. There were no significant differences in Apgar scores, temperature on admission, heart rate, blood pressure and requirements for artificial ventilation. Conclusion Delayed cord clamping of 45 s is feasible and safe in preterm infants below 33 weeks of gestation. It is possible to perform the procedure at caesarean section deliveries and it should be performed whenever possible. It reduces the need for packed red cell transfusions during the first 6 weeks of life. Received: 10 February 2000 / Accepted: 12 April 2000     

Embracing bioethics in neonatal intensive care, part I: evolving toward neonatal evidence-based ethics

Ethical treatment dilemmas are not new to the NICU. With technologic advances over the past 20 years, NICU care has developed rapidly, and survival rates have improved for some of the tiniest and most critically ill infants. In guiding clinical practice, however, standards in evidenced-based medicine have often superseded standards in evidence-based ethics. Part I of this article presents a historical review of neonatal care and an overview of cases that have set precedents in neonatal ethical debate. It also includes recommendations for enhancing the skills of neonatal nurses as patient advocates in NICU ethical issues, an area that is, at times, controversial and baffling to clinicians.     

Individual differences in moral judgment competence influence neural correlates of socio-normative judgments

To investigate how individual differences in moral judgmentcompetence are reflected in the human brain, we used event-relatedfunctional magnetic resonance imaging, while 23 participantsmade either socio-normative or grammatical judgments. Participantswith lower moral judgment competence recruited the left ventromedialprefrontal cortex and the left posterior superior temporal sulcusmore than participants with greater competence in this domainwhen identifying social norm violations. Moreover, moral judgmentcompetence scores were inversely correlated with activity inthe right dorsolateral prefrontal cortex (DLPFC) during socio-normativerelative to grammatical judgments. Greater activity in rightDLPFC in participants with lower moral judgment competence indicatesincreased recruitment of rule-based knowledge and its controlledapplication during socio-normative judgments. These data supportcurrent models of the neurocognition of morality according towhich both emotional and cognitive components play an importantrole.     

End-of-life care in intensive care units: family routines and environmental factors

The purpose of this study was to describe family care routines and to explore environmental factors when patients die in Swedish intensive care units (ICUs). The main research questions were: what are the physical environmental circumstances and facilities when caring for patients in end‐of‐life and are there any routines or guidelines when caring for dying patients and their families? A questionnaire was sent to 79 eligible Swedish ICUs in December 2003, addressed to the unit managers. The response rate was 94% (n = 74 units). The findings show that, despite recommendations highlighting the importance of privacy for dying ICU patients and their families, only 11% of the respondents stated that patients never died in shared rooms in their ICU. If a patient dies in a shared room, nurses strive to ensure a dignified good‐bye by moving the body to an empty room or to one specially designated for this purpose. The majority (76%) of the units had waiting rooms within the ICU. The study also revealed that there is a need for improvements in the follow‐up routines for bereaved families. Many units reported (51%) that they often or almost always offer a follow‐up visit, although in most cases the bereaved family had to initiate the follow‐up by contacting the ICU. Guidelines in the area of end‐of‐life care were used by 25% of the ICUs. Further research is necessary to acquire a deeper knowledge of the circumstances under which patients die in ICUs and what impact the ICU environment has on bereaved families.     

CORMs protect endothelial cells during cold preservation,resulting in inhibition of intimal hyperplasia after aorta transplantation in rats

Allograft vasculopathy is the leading cause for chronic transplant loss. We investigated if the addition of carbon monoxide releasing molecules (CORMs) to the preservation solution would protect the endothelium from cold preservation injury in an aortic transplantation model. In particular, we tested if CORM preserve vascular functioning and limit neo‐intima formation following cold preservation (Cp). Abdominal aortas from Lewis or Fisher rats were subjected to Cp in University of Wisconsin (UW) solution to which 50 μm of CORM‐3 was added or not. Hereafter, whole mount staining, acetylcholine mediated vasorelaxation (AMV) and aortic transplantation was performed. In vitro CORM‐3 protected human umbilical vein endothelial cells from Cp injury and prevented denudation and intercellular gap formation in aortic grafts. Cp resulted in loss of AMV of aorta segments. By contrast, AMV was preserved after the addition of CORM‐3 during Cp. Two months after transplantation Cp of aorta grafts resulted in an increased adventitial remodelling and neo‐intima formation. This was significantly blunted by CORM‐3 in syngeneic recipients. Our study demonstrates that addition of CORM‐3 to UW solution prevents endothelial damage, thereby maintaining vascular function directly after cold preservation. Hence, our findings might offer a novel strategy to prevent vascular damage during CP.