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To increase the donor pool, the strategy of transplantation from "marginal" donors was developed though patients' preferences about these donors were insufficiently known. The preferences of patients registered on the waiting list or already transplanted in eight transplant teams covering four main organs (i.e., kidney, liver, heart, and lung) were evaluated using the discrete choice experiment method. In each left during 2 days, patients were interviewed on four scenarios. Of 178 eligible patients, 167 were interviewed; 40% accepted marginal graft in their own situation and 89% at least in one of the scenarios. Imagining urgent situations or rare profiles with difficult access to transplantation, respectively, 86% and 71% accepted these grafts. Most (76%) preferred to be informed about these grafts and 43% preferred to be involved in decision. The emergency [OR = 1.24; 95% CI: (1.06-1.45)] and the hazardousness [OR = 0.88; 95% CI: (0.78-0.99)] of the transplantation were factors independently associated with marginal graft acceptance. Most patients preferred to be informed and to be involved in the decision. Marginal grafts could be more accepted by patients in critical medical situations or perceiving their situation as critical. Physicians' practices in transplantation should be reconsidered taking into account individual preferences. This study was performed in a single country and thus reflects the cultural bias and practice thereof.

Pain management and patient satisfaction were targeted in the emergency department of a Paris university hospital. In 1999, 77.0% of patients complained of pain on arrival and more than half of patients did not experience pain relief at discharge. The purpose of the study was to evaluate the outcomes of the implementation of a team piloting pain management on pain reduction and pain care satisfaction.Two cross-sectional surveys (04/10/1999 to 19/10/1999 and 03/04/2007 to 18/04/2007) were conducted before and after a team piloting pain management was deployed in the emergency department. Consecutive patients age 18 years and older who visited the department suffering from pain were given structured questionnaires that validated scales scoring pain upon arrival and at discharge. Patients' files were analyzed using structured forms. The parameters associated with pain reduction and patient satisfaction were sought.In 2007, 65.0% of patients had their pain relieved vs. 35.1% in 1999 (P0.001); 60.2% were satisfied with the pain care received vs. 39.8%. Pain management (e.g. waiting time ≤ 20 min: 47.6% vs. 20.8%; interventions on pain before the physician's examination: 63.0% vs. 13.8%; and pain reassessment after intervention: 13.8% vs. 4.5%) improved. Both pain reduction and patient satisfaction were significantly associated with intervention before the physician's examination. Pain reduction was independently and positively associated with time of survey, triage level (depending on the severity of their condition), pain intensity on arrival, and negatively associated with discharge without hospitalization. Satisfaction was independently and positively associated with waiting time before examination (0-20 min) and the absence of procedural pain.The implementation of a team piloting pain management seemed to have had positive effects on pain management in the emergency department. However, respectively, 56.2% and 39.8% of patients remained without pain relief and dissatisfied with pain management at the end of their visit.

BACKGROUND & AIMS Equality of access to organ transplantation is a mandatory public health requirement. Referral from a local to a university hospital and then registration on the national waiting list are the two key steps enabling access to liver transplantation (LT). Although the latter procedure is well defined using the Model for End-stage Liver Disease score that improves equality of access, the former is mostly reliant on the practices of referring physicians. The aim of this study was to clarify the factors determining this initial step. METHODS This observational study included consecutive inpatients with cirrhosis of whatever origin in a cohort constituted between 2003 and 2008, using medical records and structured questionnaires concerning patient characteristics and the opinions of hospital clinicians. Candidates for LT were defined in line with these opinions. RESULTS Four hundred and thirty-three patients, mostly affected by alcoholic cirrhosis, were included, 21.0% of whom were considered to be candidates for LT. Factors independently associated with their candidature were: physician empathy [odds ratio (OR) = 10.8; 95% CI: 4.0-29.5], adherence to treatment (OR = 16.6; 95% CI: 3.7-75.2), geographical area (OR = 6.8; 95% CI: 2.2-21.3) and the patient's physiological age (OR = 2.3; 95% CI: 1.1-4.7). CONCLUSIONS Several subjective markers restrict the referral of patients from local hospitals to liver transplant centres. Their advancement to this second step is thus markedly weakened by initial subjectivity. The development of objective guidelines for local hospital physicians to assist them with their initial decision-making on LT is now necessary.

Background Evidence for the effectiveness of the morbidity and mortality conferences in improving patient safety is lacking. The aim of this survey was to assess the opinion of participants concerning the benefits and the functioning of morbidity and mortality conferences, according to their organizational characteristics. Methods We conducted a survey of professionals involved in a morbidity and mortality conference using a self-administered questionnaire in three French teaching hospitals in 2012. The questionnaire focused on the functioning of morbidity and mortality conferences, the perceived benefits, the motivations of participants, and how morbidity and mortality conferences could be improved. The perception of participants was analysed according to the characteristics of morbidity and mortality conferences. Results A total of 698 participants in 54 morbidity and mortality conferences completed the questionnaire. Most of them (91 %) were satisfied with how the morbidity and mortality conference they attended was conducted. The improvements in healthcare quality and patient safety were the main benefits perceived by participants. Effectiveness in improving safety was mainly perceived when cases were thoroughly analysed (adjusted odds ratio [a0R] =2.31 [1.14–4.66]). The existence of a written charter (p = 0.05), the use of a standardized case presentation (p = 0.049), and prior dissemination of the meeting agenda (p = 0.02) were also associated with the perception of morbidity and mortality conference effectiveness. The development and achievement of improvement initiatives were associated with morbidity and mortality conferences perceived as being more effective (p

Background The aim of this study was to identify the characteristics of morbidity and mortality conferences (MMCs) associated with the implementation of patient health-care quality and safety improvement initiatives. Methods We conducted an observational study of MMCs and followed up improvement initiatives for 1 year. Data on MMC baseline characteristics were abstracted using document analysis and observation of a meeting in three university hospitals in France (Grenoble, Nice, and Cochin [Paris] hospitals). Fifty-nine MMCs were included in medical (n = 24), surgical (n = 21), and anesthesiology and/or intensive care (n = 14) departments. An effectiveness index was computed by summing a composite score for each initiative pertaining to the MMC. Results Overall, 282 initiatives were identified in 42 MMCs. During the follow-up period, 215 initiatives (76 %) were totally or partially implemented and the impact was evaluated for 73 (26 %). An effectiveness index higher than the median (i.e., ≥10) was associated with a standardized presentation of cases (81 % versus 29 %, p

Two anti-cancer drugs are currently approved for the treatment of HER2-positive metastatic breast cancer (MBC): trastuzumab-based therapy (TBT) administered intravenously as first line therapy until disease progression and lapatinib, an oral self-administered dual therapy with capecitabine (L+C) as second intention for patients who continue to progress despite TBT. In current practice, TBT is still prescribed beyond disease progression. In addition to medical reasons, the difficulty to switch eligible patients to oral drugs may also be explained by economic reasons. Thus, we aimed at comparing the budgetary impact of TBT and L+C for progressing HER2+MBC after TBT from the French Health Insurance perspective.A budget impact analysis was performed on a 3-year time horizon (2012-2014) to simulate a dynamic cohort of 4182 HER2-positive patients with a progressing MBC treated with TBT (73%) and L + C (27%). The model was adjusted on progression-free survival (PFS). Office visits, clinical evaluations, drug acquisition, administration costs, and transportation costs obtained from the literature and published databases were considered.In the base case analysis (2012), the annual treatment cost per patient for TBT (€36,077) was 2-times higher than that of L + C (€17,165). Using L + C for all patients (n = 4182) would avoid €34.8 million of drug administration and transportation costs. Hospital costs represented 1% vs 88%, while community costs represented 99% vs 12% of L + C and TBT treatment costs, respectively. The lack of direct comparison PFS and treatment dosage modification data were the main limitations. However, no major changes from baseline results were observed from sensitivity analyses.Despite a slightly higher acquisition cost, the treatment cost of L + C remains lower than that of TBT, and it is the only approved anti-HER2 treatment for HER2-positive patients with progressing MBC. Based on this, it seems important to consider the potential savings for Health Insurance with the use of oral drug due to the reduction of outpatient hospitalizations. Such reductions may result in a subsequent budget reduction for hospitals, but may also provide those facing acute medical activity with opportunities to better manage other diseases whose treatment cannot be externalized.

Incidence of breast cancer with brain metastases (BCBM) is increasing, especially among patients over-expressing HER2. Epidemiology on this sub-type of cancer is scarce, since cancer registries carry no information on the HER2 status. A retrospective database analysis was conducted to estimate the burden of BCBM, especially among HER2-positive patients in a secondary objective.Patients with a new diagnosis of BCBM carried out between January and December 2008 were identified from the national hospital database using the International Disease Classification. Patients receiving a targeted anti-HER2 therapy were identified from the national pharmacy database. Hospital and pharmacy claims were linked to estimate the burden of HER2-positive patients. Data on hospitalizations were extracted to describe treatment patterns and healthcare costs during a 1-year follow-up. Predictors of treatment cost were analyzed through multi-linear regression analysis.Two thousand and ninety-nine BCBM patients were identified (mean age (SD) = 57.8 (13.6)), of whom 12.2% received a targeted anti-HER2 therapy; 79% of patients had brain metastases associated with extracranial metastases, and the attrition rate reached 82%. Patients received mostly palliative care (47.4%), general medical care (40.6%), and chemotherapy (35.0%). The total annual hospital cost of treatment was 8,426,392€, representing a mean cost of 22,591€ (±14,726) per patient, mainly influenced by extracranial metastases, surgical acts, and HER2-overexpression (p 0.0001).The database linkage of hospital and pharmacy claims is a relevant approach to identify sub-type of cancer. Chemotherapy was widely used as a systemic treatment for breast cancer rather than for local treatment of brain metastases whose morbi-mortality remains high. The variability of treatment costs suggests clinical heterogeneity and, thus, extensive individualization of protocols.

Background/Aims In France, the most common cause of cirrhosis is excessive alcohol consumption. Post-transplant survival rates in patients with alcoholic liver disease (ALD) are at least as good as those seen with other indications. However, fewer of these patients are found on the waiting list. To understand the reasons for this discrepancy, it was decided to examine physicians' attitudes concerning the allocation of deceased donor liver allografts. Methods Using a standardized postal questionnaire, 1739 physicians were asked to allocate 100 liver transplants to two competing groups of patients who were equivalent except for the cause of their cirrhosis (i.e. alcohol-related or primary biliary cirrhosis). A composite score was then used to assess their attitude regarding the behavior of alcoholics and their responsibility for their illness. Results Among the 475 respondents (response rate: 27.3%), 55.2% allocated fewer than 50 transplants to ALD patients. This lower rate was independently associated with factors such as being a general practitioner (odds ratio [OR]=3.2, 95% confidence interval [95%CI]=1.8–5.9), a misinterpretation of ALD patients being equivalent to others (OR=1.8, 95%CI=1.1–3.0) or unfavorable attitudes regarding alcoholics (OR=4.0, 95%CI=1.7–9.5, to OR=126.8, 95%CI=34.0–472.1). Conclusions Greater information and education of physicians may improve access to liver transplantation for ALD patients.

Rationale Changes in the demography of doctors require changes in care practices. Objectives The aim of this study was to identify factors associated with doctors’ workload in the ophthalmology consultation department of a university hospital, with a view to developing methods to improve the organization of hospital outpatient clinics. Methods A 10-day cross-sectional survey was carried out in an ophthalmology outpatient clinic (in- and outpatient consultations, including emergencies) specializing in the uveitis care. Demographic and management data for each patient were collected on a structured form. The doctor’s workload was assessed, using a scale taking into account the duration of the consultation and the number of diagnostic tests performed, as a function of management complexity. Results Of the 861 consultations studied, 39.7% were highly complex. The level of complexity of consultations was correlated with the type of referral (phi = 0.602), consultation duration (phi = 0.545), the number of consultations in the previous year (phi = 0.499), and the number of diagnostic tests performed (phi = 0.445). Consultations were longer and diagnostic tests were more frequently performed if patients had been referred by an ophthalmologist, consulted a faculty doctor or a fellow, or presented with uveitis. Consultations were also more complex for patients with at least four previous consultations in the past year. Conclusions Type of referral, status of the attending doctor and number of consultations within the course of 1 year were associated with doctors’ workload and could be taken into account to predict the duration of complexity of consultations when scheduling appointments.

Summary Background Mortality-morbidity conferences (M&MC) are a recognized technique for evaluating and improving medical practices as well as improving patient safety. Objectives To describe the current practices for identification and management of care-related adverse events and to evaluate the effectiveness of an intervention to promote M&MC in a university hospital. Methods The study was designed as a before-and-after survey. In the first part of the survey (September-December 2004), we interviewed the heads of the clinical departments and units in a Parisian university hospital (n=37), using a semi-structured questionnaire. Questions concerned the management of adverse events or errors in their departments or units. The intervention took place during these interviews and consisted of providing information on methods currently available to improve inpatient safety, including broad-based M&MC. The second part involved a structured questionnaire sent by e-mail in December 2005. Results In 2004, 24 of the 37 departments discussed adverse events, 11 kept a register of them, and 9 used M&MC, mostly covering a specific limited segment of their specialty field. Only 2 used structured M&MC that covered the entire specialty field. In 2005, 3 departments had expanded the field covered by their M&MC, and 9 had established M&MC for their entire field (n=12). Six departments had not changed the field of their M&MC and 14 had not introduced it. Conclusion Our survey of department heads allowed us both to collect information about the methods they used for managing and evaluating adverse events and to provide information to them. This intervention may have contributed to increasing and improving the use of M&MC.

Key points Awareness of the importance of what were previously called iatrogenic accidents is not new, but recent publications have demonstrated the frequency and severity of the accidents and incidents associated with care, which are now known simply as “adverse events”. Research has helped us to understand the principal mechanisms underlying them and the circumstances that promote them. It shows that root causes, often linked to the organization of care, should be sought beneath the initial appearance of mistakes. Institutions providing health care must ascertain how to develop a new culture that makes it possible to improve patient safety by implementing new policies, that is, a group of several coordinated measures intended to decrease patient risk. These policies should use accepted techniques, such as reports and appropriate information management for events for which reporting is mandatory, but extended to medical accidents; critical activity analyses must also be used, for comparison with a standard, following the model used for evaluations of professional practices. New techniques are also necessary, such as operational feedback in the form of morbidity-mortality reviews and in-depth analyses of the most serious events. Institutions must establish indicators to prove the effectiveness of this new policy.

This community-based cross-sectional study in 533 participants from 135 households with multiple generations living in the same household aimed at investigating the relationship between Helicobacter pylori infection in children and the other household members. H. pylori infection in children was found significantly associated with the infection in mothers [OR (95% CI): 2.50 (1.19-5.26)], even after being adjusted for sex, age group and sibling number [adjusted OR (95% CI): 2.47 (1.12-5.47)]. It was also significantly associated with the infection in both parents [adjusted OR (95% CI): 4.14 (1.29-13.23)]. No significant association between H. pylori infection in the father, grandparent(s), uncle or aunt with that in their children was found. Results from the present study showed intra-familial transmission in a multi-generation population and supported the hypothesis of person-to-person transmission of H. pylori infection.

The study aimed at evaluating the seroprevalence of and sociodemographic, health, lifestyle, and environmental hygiene conditions associated with Helicobacter pylori infection in Vietnamese children. Data from 824 children, aged from 6 months to 15 years and gastrointestinal symptom free when consulted, admitted to a university hospital, were collected using a structured questionnaire and ELISA test for H. pylori infection. The data were examined using univariate and multivariate analyses. H. pylori seroprevalence was 34.0%. Age groups from 3 to 6 years and older than 6, and number of offspring were positively and independently associated with H. pylori seropositivity [adjusted OR (95% CI): 2.9 (1.5-5.5); 1.9 (1.1-3.1) and 1.8 (1.1-2.6), respectively]. Breastfeeding more than 6 months was negatively and independently associated with H. pylori seropositivity [adjusted OR (95% CI): 0.5 (0.3-0.9)]. Mother's age, history of allergy, gastro-duodenal disease history in the past, initiating collective life before 6 years, sharing bed with parents and time of bed sharing with parents > 24 months were positively but not independently associated with H. pylori seropositivity. None of the other environmental or lifestyle conditions examined was associated with H. pylori infection. Our results support person-to-person transmission and the role of sociodemographic factors in H. pylori infection.

Objectives: To examine the cost-effectiveness of strategies for management of primary asymptomatic hyperparathyroidism: surgical strategies and medical follow-up versus surgery. Design: We used a Markov state-transition decision-analytic model for an hypothetical cohort of 55-year-old women to compare with a lifetime horizon costs and effectiveness of bilateral neck exploration (BNE), unilateral neck exploration (UNE), video-assisted parathyroidectomy (VAP) and lifelong medical follow-up shifting for either BNE or UNE in case of disease progression. Methods: Data on localization tests, complications and treatment efficacies were derived from a systematic review of the literature. Outcomes were expressed as quality-adjusted life years (QALY). Costs (€2002) discounted at 3% yearly were estimated from the health care system perspective. Results: In the base-case analysis, VAP strategy (VAPS) was the most effective and BNE strategy (BNES) was the least costly. UNE strategy (UNES) had an incremental cost-effectiveness ratio of €2688/QALY versus BNES and VAPS of €17 250/QALY in comparison with UNES. Surgical management was more effective than medical follow-up with acceptable incremental cost-effectiveness ratios. VAPS became less effective than UNES over 71 years. Differences between UNES and VAPS were sensitive to success and complication rates, quality-of-life weights and procedural costs. Medical follow-up strategies became the most effective if quality-of-life weight for this condition was higher than 0.99. Conclusions: Surgery is more effective than medical follow-up at a reasonable cost and can be preferred except in patients choosing medical follow-up. Minimally invasive surgery is cost-effective compared to the traditional surgical approach.

Reporting of incidents or near incidents because of medical devices in French hospitals relies on procedures following European and national guidelines. The authors intend to evaluate hospital staff knowledge on these surveillance procedures as a marker of appropriate application. A telephone survey is conducted on a sample of Paris University hospital staff (n = 327) using a structured questionnaire. Two-hundred sixteen persons completed the questionnaire. The response rate was lower among physicians, especially surgeons paid on an hourly basis. Rates of correct answers were different according to age, seniority, job, and department categories. Physicians and nurses correctly answered questions on theoretical knowledge more often than the other job categories. However, on questions dealing with actual practice conditions, correct answers depended more on age and seniority with a U-shaped distribution (minimum rates in intermediate categories of age and seniority).

This study confirmed several independent risk and protective factors for RCC identified in the authors' previous study. Protective factors such as oral contraceptive use and moderate alcohol consumption were identified only in women. Tobacco consumption and severe obesity were the main independent risk factors. There were other modifiable risk markers, however, such as occupational exposure, thiazidic drug intake, and urinary tract infections. The associations between risk factors and RCC were weak, even for tobacco, for which the association was weaker than that for lung cancer. The identified risks involve a large proportion of the population, however, and the risk attributable to these types of exposure is high. The authors' recommendations for the prevention of RCC are therefore similar to those for the prevention of cardiovascular disease and cancer, and should be disseminated to the general population. The high-risk groups identified are too large for a specific early-screening program for RCC, but such screening might be appropriate if restricted to selected age groups.

To determine whether intravenous drug users (IDUs) are more likely to misuse high dosage buprenorphine (HDB) if they are homeless.We carried out a cross-sectional study using data collected from HDB users between 1998 and 1999. Data were collected by use of a structured questionnaire with questions about demographic characteristics, and use of HDB and other substances. IDUs were considered to be homeless if they did not live on their own or with their parents or friends.IDUs were recruited from three centers for the treatment of drug users, three health care networks, one prison, one sleep-in, and two centers that provide psychosocial support for IDUs.Of the 788 eligible patients, 779 answered the questionnaire (response rate: 98.9%).Homeless IDUs were more likely to have injected HDB than those who were not homeless (67% vs. 47%; p0.001), and their injection behaviors were more likely to be unsafe. The first HDB injection was more likely to result in medical complications in the homeless group than in the nonhomeless group (58% vs. 38%; p=0.001). Homeless IDUs were less likely to receive medical followed-up and were less well informed about the correct way of using HDB than nonhomeless IDUs.Homeless IDUs are more likely to misuse HDB. Thus, HDB maintenance therapy may not be the most appropriate maintenance therapy for this group.

Aims: To study the sociodemographic characteristics and sexual behaviours in contraception choices of injecting drug users (IDUs) and to compare the contraceptive practices of non-HIV-positive IDUs to those of the general population. Design: Two surveys were used: a sample of IDUs attending 10 drug abuse treatment centres in the Paris region (IDU) and the Parisian subsample of the National French Survey of Sexual Behaviour (ACSF). Measurements: Percentages of contraception practices were estimated separately for 81 IDU and 130 ACSF women, and for 175 IDU and 168 ACSF men, aged 25–34, not reporting prostitution or HIV seropositivity. Findings: Most IDU (77%) and ACSF (84%) women, and IDU (73%) and ACSF (75%) men currently used a contraceptive method. Male condoms were more widely used by IDUs than by the general population (64 vs. 10% in women, 75 vs. 14% in men), for all subgroups of educational level, marital status, recent multipartnership status and sexual activity. Conclusions: Contraceptives are used as often by IDUs as by the general population aged 25–34. However, the methods employed differ, with higher condom use by IDUs, which suggest that IDUs take into account the risk of HIV contamination in their contraceptive practices.

OBJECTIVE: To examine the cost-effectiveness of therapeutic strategies for patients with toxic thyroid adenoma. DESIGN: A decision analytic model was used to examine strategies, including thyroid lobectomy after a 3-month course of antithyroid drugs (ATDs), radioactive iodine (RAI), and lifelong ATDs followed by either RAI (ATD-RAI) or surgery (ATD-surgery) in patients suffering severe drug reactions. METHODS: Outcomes were measured in quality-adjusted life years. Data on the prevalence of co-incident thyroid cancer, complications and treatment efficacies were derived from a systematic review of the literature (1966-2000). Costs were examined from the health care system perspective. Costs and effectiveness were examined at their present values. Discounting (3% per year), variations of major cost components, and every variable for which disagreements exist among studies or expert opinion were examined by sensitivity analyses. RESULTS: For a 40-year-old woman, surgery was both the most effective and the least costly strategy (Euro 1391),while ATD-RAI cost the most (Euro 5760). RAI was more effective than surgery if surgical mortality exceeded 0.6% (base-case 0.001%). RAI become less costly for women of more than 72 years (more than 66 in discounted analyses). For women of 85, ATD-RAI may be more effective than RAI and have an inexpensive marginal cost-effectiveness ratio (Euro 4975) if lifelong follow-up results in no decrement in quality of life. CONCLUSIONS: Age, surgical mortality, therapeutic costs and patient preference must all be considered in choosing an appropriate therapy.

The aim of this study was to identify relationships between injecting and sexual risk behaviours and hepatitis C virus (HCV) status knowledge in intravenous drug users (IDUs). It was a cross-sectional survey (March 1994-June 1995) in 10 drug abuse treatment or psychosocial centres in Paris, France. We used a structured questionnaire about sexual, injecting, HIV and HCV antibody testing practices and results during the previous 6 months. Six hundred and twelve sexually active IDUs aged 18 or older who were current injecting drug users were interviewed. Of 592 respondent IDUs, 37% did not report consistent HCV testing and 34% reported being HCV-positive. HCV-positive IDUs were older than HCV-negatives and HCV-unknowns. HCV-unknowns and HCV-positives had a lower educational level than HCV-negatives. After adjusting for demographic characteristics and HIV status, the factors associated with being HCV-unknown were not using condoms (OR: 2.9; 95% CI: 1.9-4.6) as well as clean equipment (OR: 1.8; 95% CI: 1.2-3.0). Not using new equipment was negatively associated with being HCV-unknown (OR: 0.4; 95% CI: 0.2-0.6) and with being HCV-positive (OR: 0.5; 95% CI: 0.3-0.8). Our study suggests that particular sexual and injecting risk-behaviours are associated with not knowing HCV status. As HCV-unknown IDUs are likely to be at the risk of transmitting HCV or acquiring other infections. HCV testing should be encouraged and associated with sexual counselling. Special attention should be paid to disinfecting practices for HCV-positives and use of new injecting equipment should be recommended for HCV-negatives.

The objective of this study was to assess adaptation and feasibility of practice guidelines for thyroid nodule management. For one month physicians completed a self-administered semi-structured questionnaire concerning a draft version of the guidelines for each consecutive patient. A sample group of 20 endocrinologists, 20 surgeons and 120 general practitioners from all parts of France took part in this study. The main outcome measures were whether the case description was found by the physicians, and whether recommendations were found and agreement with these recommendations were assessed. We found that two hundred and fifty-three patients (of whom 85% were women) were included in the study: 52% were seen for a surgical decision; 20% for diagnosis or screening and 28% for follow-up. Four percent of the women were pregnant; 2% of the patients had a large nodule; and 2%, a retrosternal nodule. These last three situations had not been well identified in the draft guidelines. The patient’s case description was appropriately identified in 75% of the responses. Most cases reported as being not found were, however, covered by the guidelines. Physicians in private practice were less likely than the others to identify their patient’s cases. Physicians agreed with the recommendation in 77% of cases. General practitioners were more likely and endocrinologists less likely than surgeons to disagree. Most disagreements and alternative proposals were not evidence-based. Our conclusion is that this study shows that the draft guidelines were applicable, and allowed minor improvements of the final version. Adapting guidelines to practice could improve their use and, consequently, the quality of health care.

Aims. To characterize and identify determinants of risk behaviour patterns of intravenous drug users (IDUs) independently of changes due to knowledge of HIV or hepatitis C Virus (HCV) seropositivity. Design. A cross-sectional survey using a structured questionnaire concerning sexual, injecting and HIV and HCV antibody testing practices. Setting. IDUs were interviewed in the Paris region at 10 treatment or psychosocial centres. Participants. Six hundred and twelve consecutive sexually active IDUs over 18 years able to answer the questionnaire. Measurements. Five hundred and ninety-five IDUs completed the questionnaire. The risk-behaviour patterns of the 328 IDUs not reporting HIV or HCV seropositivity were analysed by phi correlation. Risk factors for each risk behaviour were determined by regression logistic models yielding odds ratios (OR) and their 95% confidence intervals (95%CI). Findings. Several risk behaviour patterns were suggested: (1) lending, borrowing; (2) not or inconsistently testing HIV and HCV serology and not or inconsistently using condoms; (3) having multiple partners and prostitution; and (4) not using clean equipment. Alcohol abuse was independently and specifically associated with lending (OR = 3.8; 95% CI: 2.1-7.0) and borrowing (OR = 3.3; 95% CI: 1.8-6.1); homelessness with injecting risk behaviours and with prostitution (OR = 2.7; 95% CI: 1.2-6.1); low educational level and having children with not or inconsistently using condom and serology testing; and cocaine use with not or inconsistently using condoms (OR = 0.4; 95% CI: 0.3-0.7) and serology testing and not using clean equipment (OR = 0.4; 95% CI: 0.2-0.8). Having multiple partners and prostitution had no common risk factors. Conclusions. Identifying specific risk factors could help to target drug harm reduction programmes for each risk behaviour pattern among IDUs not reporting HIV and HCV seropositivity.

Risk behaviors at the first intravenous substance injection are unknown. A structured questionnaire was used to investigate the circumstances of the first injection and the changes in risk behaviors between the first and the most recent injections in a group of 143 intravenous drug users (IDUs). When they first injected most subjects were not alone, the initiator was an IDU (94%) who prepared the injection (76%) and did it (79%). The proportions of IDUs sharing preparation equipment (58 vs. 14%), borrowing (23 vs. 2%) and lending injecting equipment (26 vs. 4%) decreased between the first and the most recent injection.

Although efficacy and tolerability are classical criteria for treatment choice, patient adherence and tariff issues related to novel oral anticancer drugs may also influence therapeutic decisions. We estimated the relative influence of efficacy, tolerability, expected adherence and route of administration of a chemotherapy treatment on 203 French physicians' preferences who participated in a Discrete Choice Experiment (DCE), a quantitative method used to elicit preferences. From a questionnaire with six scenarii, respondents had to choose between two treatments which differed with respect to these four attributes. Scenarii were first presented in a curative setting then in a palliative setting. Efficacy, tolerability and expected adherence had two modalities (good versus moderate) and route of administration had three modalities (intravenous (€286-379/session), oral with the current tariff (€28/consultation), oral with a hypothetical tariff (€114)). Efficacy was the reference criterion in choosing a treatment whatever the therapeutic goal (β: 2.114, p

Isolation practices in a university hospital were analyzed for 137 patients with multidrug-resistant bacteria. Isolation was ordered in writing by physicians for 40% and instituted by nurses for 60%; 74% were isolated. Compliance depended on physician ordering in writing (odds ratio, 36.3; 95% confidence interval, 4.8-274.9). Nurses complied best with hand washing.

Objective Neuropathic pain (NP) in acute conditions has been poorly investigated. A diagnostic score, the DN4 scale (DN4), has been developed to help physicians to detect and treat NP appropriately. DN4 is a 10-item questionnaire. If you have 4 or more positive responses out of 10 items, the answer to the questionnaire is positive and you have a neuropathic pain. We aimed to determine the prevalence of NP in emergency department (ED) patients and to describe this population. Methods We used the DN4 in the patients with NP visiting the adult ED of a university hospital. Patients were asked about the characteristics of their pain using a face-to-face questionnaire. Results Among 533 patients with a DN4 score, 114 (21.4%) had NP. Neuropathic pain was independently negatively associated with age of 65 years of older (odds ratio [OR], 0.2, 95% confidence interval [CI], 0.05-0.8) and positively associated with intense pain (OR, 5.2; 95% CI, 1.5-18.2), located to the limbs (OR, 2.3; 95% CI, 1.2-4.0). Conclusion Neuropathic pain was common in ED patients and associated to a higher level of pain.

Immunization of healthcare workers (HCWs) is a major issue for infection control in healthcare facilities. The aim of this study was to evaluate knowledge regarding occupational vaccinations, HBV, varicella and influenza vaccination rates and attitudes towards influenza vaccine among HCWs.A cross-sectional survey was conducted in two wards (Medicine and Paediatrics) of a 1182-bed teaching hospital in Paris, France.A standardized, anonymous, self-administered questionnaire was used.Of 580 HCWs, 395 (68%) completed the questionnaire. Knowledge about the occupational vaccinations of HCWs was low. HBV (69%), tuberculosis (54%) and influenza (52%) were the most cited vaccinations. Paediatric staff was more aware of influenza and pertussis immunizations (p.05). HBV vaccination rate was 93%, among whom 65% were aware of their immune status. Influenza vaccination rate for 2006-2007 was 30% overall, ranging from 50% among physicians to 20% among paramedical staff (p.05). Physicians based their refusal on doubts about vaccine efficacy, although paramedics feared side effects. Influenza vaccination was associated with knowledge of vaccine recommendations [OR=1.75, 95% CI: 1.13-2.57] and contact with patients [OR=3.05, 95% CI: 1.50-5.91].Knowledge of recommended occupational vaccinations is insufficient in HCWs, except for HBV and influenza. Although the HBV vaccine coverage of HCWs is satisfactory, a large proportion of them is unaware of immune status. Influenza vaccine coverage remains low, especially among paramedical staff because of fear of side effects. As vaccine coverage is associated with knowledge, educational campaigns should be strengthened to increase the adhesion of HCWs to vaccinations.

Background Legislative measures have been identified as one effective way of changing attitude or behaviour towards health care. The aim of this study was to describe trends in patients' complaints for medical issues; to evaluate the contribution of a law regarding patients' rights, and to identify factors associated to patients' perception of a medical error. Methods Patients with a complaint letter for medical issues in a French university hospital were included. Trends in complaint rates were analysed. Comparisons were made between a first (1998–2000) and a second (2001–2004) time period, before and after the diffusion of the law, and according to the perception of a medical error. Results Complaints for medical issues increased from 1998 to 2004. Of 164 complaints analysed, 66% were motivated by the perception of a medical error (47% during the first time period vs. 73% during the second time period; p = 0.001). Error or delay in diagnosis/treatment and surgical/medical complication were the main reasons for complaints. Surgical departments had the higher number of complaints. Second time period, substandard care, disability, and adverse effect of a health product were independently associated with the perception of a medical error, positively for the formers, and negatively for the latter. Conclusion This study revealed an increase with time in the number of complaints for medical issues in a university hospital, as well as an increase in the perception of a medical error after the passing of a law regarding patients' rights in France.

Background We aimed to examine access to care of opioid-dependent patients with chronic hepatitis C. Methods A standardized form was used to conduct a retrospective survey from 1999 to 2003 in a French university hospital. All HCV RNA positive in- or outpatients who had not had a liver biopsy or anti-HCV treatment were included. Opioid-dependence was defined as active opioid drug use or being on opioid substitution treatment. Results The survey included 580 patients; 137 (23.6%) were opioid-dependent. Fewer patients with than without current opioid dependence had had genotyping (40.1% versus 67.7%, p p = 0.022), and anti-HCV treatment (8.8% versus 18.3%, p = 0.008). Genotyping was independently, negatively, associated with: (1) current opioid-dependence (OR = 0.3, 95%CI = 0.2–0.5), (2) former opioid-dependence (OR = 0.5, 95%CI = 0.3–0.9), (3) unemployment (OR = 0.5, 95%CI = 0.3–0.7), and (4) HCV infection discovered by screening (OR = 0.5, 95%CI = 0.3–0.7). Access to liver biopsy was independently, negatively associated with current opioid-dependence (OR = 0.6, 95%CI = 0.4–0.9), but positively associated with alcohol consumption (OR = 2.0, 95%CI = 1.2–3.4) and abnormal ALT level (OR = 2.2, 95%CI = 1.5–3.2). Access to anti-HCV treatment was independently, negatively associated with HCV infection discovered by screening (OR = 0.5, 95%CI = 0.3–0.9), but positively associated with moderate hepatitis (OR = 6.8, 95%CI = 2.8–16.8), extensive fibrosis or cirrhosis (OR = 12.3, 95%CI = 5.5–27.5), abnormal ALT level (OR = 2.1, 95%CI = 1.3–3.6) and age (40–64 years) (OR = 1.9, 95%CI = 1.0–3.4). Conclusions Genotyping and liver biopsies were performed less frequently on current opioid dependent patients. Absence of genotyping was also independently associated with unemployment and former opioid-dependence. Alcohol consumption or abnormal ALT levels favored access to biopsy. Histological grade strongly conditioned access to anti-HCV treatment.

BackgroundThe current organ shortage has necessitated expanding the criteria for potential donations to marginal donors (older or sick donors whose organs would have been considered unsuitable before). In France, physicians are not required to provide information to recipients about marginal donors except for hepatitis C or hepatitis B infection and non-heart-beating donations. We hypothesized that patients can be informed about these risks by other information sources than health care professionals, such as websites and patient associations. ObjectiveThe objectives of the study were to identify the main health information sources of transplant patients other than health professionals and to evaluate the information provided by websites and associations to patients about the risks of transplantation from marginal donors. MethodsIn this study, the information sources for kidney, liver, heart, and lung patients that had already received transplants or registered on waiting lists were identified by a survey in four transplant centers. Further, the information proposed by French and English language websites and patient associations were evaluated, respectively, by a systematic review of websites and a survey among the presidents of kidney, liver, heart, and lung patient associations. ResultsFor the first survey, (367/402) 91.3% responses were registered. Apart from health professionals identified as the principal information source (363/367) 98.9%, 19 liver and 28 heart patients searched for information on the websites, while 37 kidney and 42 lung patients were more informed by patients’ associations. Our two last surveys showed that information about marginal donors is accessible by websites and (10/34) 30% of associations. All of the 60 Internet documents evaluated on French language and English language websites proposed information about marginal donors. Otherwise, (52/65) 80% of these documents were dedicated to health professionals and contained specialized information, difficult to understand by patients. Certain associations, (20/34) 59%, provided information about the risks of transplantation. There were 45/115 patients considering associations as their main information source that were informed by an association’s website. However, only (5/22) 23% of associations communicated the risks of transplantation with patients through their websites. ConclusionsCurrently, patients want to be more informed by other information sources than health professionals, particularly by the websites. Nevertheless, they cannot always trust information proposed by these sources. They need to have their physicians inform them about specialized keywords and present them with reliable information sources. So reliable centers such as universities, transplant centers, and associations should develop the quality and quantity of information proposed to patients on their websites.

To assess the concentration and kinetics of antibody response after hepatitis B vaccination among women healthcare workers. Design. Longitudinal retrospective seroepidemiological survey among women vaccinated against hepatitis B working in a university hospital and followed-up in an occupational health department. A structured form was used to collect socio-demographic characteristics, clinical data, age at vaccination, vaccination schedule, measurement of antibodies to hepatitis B surface antigen (anti-HBs antibody). Subjects were considered seronegative against hepatitis B when anti-HBs antibody concentration was less than 10 mIU/ml. Setting. A 1260-bed general hospital in Paris, France. Participants. All women healthcare workers visiting the occupational health department between January 1997 1st and December 2000 31st and who had a measurement of anti-HBs antibody. Irrespective of the age at the primary vaccination, 810 (92%) women were seropositive (anti-HBs antibody ≥10 mIU/ml). Only 22 women (4.5%) vaccinated before 26 years of age were seronegative, against 46 (13.2%) vaccinated after 25 years of age (p < 0.001). Seven years after vaccination, 78% of women were still seropositive. An inadequate vaccination schedule (adjusted hazard ratio (HR), 3.0; 95% confidence interval [CI], 1.6–5.5) and an age greater than 25 years at primary vaccination (HR, 2.6; 95% CI, 1.5–4.4) were associated with being seronegative against hepatitis B. Conclusions. Despite vaccination, some women healthcare workers were seronegative against hepatitis B virus. Vaccinating early in the career of a health-care worker using an adequate schedule seems key-elements to guarantee an anti-HBs measurement ≥10 mIU/ml.

Background Previously, patients with end-stage renal disease (ESRD) with uncontrolled hyperparathyroidism had few options other than parathyroidectomy, which was reserved for patients refractory to medical therapy. Newer calcimimetic agents, such as cinacalcet, may be an alternative, but raise the possibility of indefinite medical treatment that also would increase costs. Study Design Cost utility analysis. Setting & Population Base case consisted of prevalent adult US patients with ESRD refractory to management with standard medical therapy. Characteristics were obtained from patients who underwent parathyroidectomy in 2001, and, for purposes of comparison, patients in whom cinacalcet was used were assigned similar characteristics. All data came from preexisting literature and trials or from US Renal Data System analysis files. Intervention Use of cinacalcet hydrochloride versus parathyroidectomy. Perspective & Time Frame Medicare and societal costs and quality-adjusted life-years from the date of parathyroidectomy or use of cinacalcet followed up for 2 years, respectively. Model & Outcomes Primary outcomes were cost (measured in US dollars) and cost utility measured using cost per quality-adjusted life-years. Results At base-case surgical and drug costs, surgical and drug success rates, complication rates/costs, and benefit from correction of hyperparathyroidism, parathyroidectomy was found to be both less expensive and more cost-effective at 7.25 ± 0.25 months. Parathyroidectomy became more cost-effective at 15.28 to 16.32 months at the upper limit of sensitivity analysis, when drug/surgical costs and success/complication rates/costs were maximally weighted to favor cinacalcet-based medical therapy. Limitations We assumed current costs of both cinacalcet and parathyroidectomy and assumed cinacalcet use would be indefinite. Conclusions For patients with ESRD with uncontrolled hyperparathyroidism who are good candidates for either drug therapy or surgery, cinacalcet hydrochloride is the most cost-effective modality if the patient is to remain on dialysis therapy for 7.25 ± 0.25 months. Cinacalcet may be more optimal if used in patients who have high risk of mortality or who would expect to receive a kidney transplant quickly. For other subgroups, parathyroidectomy dominated.

To evaluate the quality of care in patients with pain who visit the emergency department of a university hospital and the evolution of their pain during their emergency department stay.A cross-sectional survey was performed using two valid scales (a numerical descriptor scale or a verbal pain intensity scale), and a structured questionnaire to patients and use of patient charts to collect information on pain intensity on arrival and before discharge, characteristics of pain and of its management.In the 726 participating patients, median age was 37 years (range: 18-97), and 54% of the patients were men. Upon arrival, 563 patients presented with pain (78%), ratedor =7 in 35% of the 390 patients evaluated using numerical descriptor scale. Forty-four percent had taken analgesics before arrival. Their median waiting time before initial medical examination was 30 min. Pain was identified by triage nurses (70%) or by physicians (77%) and was rated by nurses (23%) and physicians (11%). Forty-seven percent also experienced pain during care and 27% received analgesics during their stay. Pain intensity remained unchanged in 70% of patients, increased in 7% and decreased in 23%. Of the 480 patients with pain on arrival evaluated before discharge, 395 (82%) patients were unrelieved before going home, ratedor =7 in 32% of the 390 patients evaluated using numerical descriptor scale. Analgesics were ordered before leaving the emergency department in 81%.Even if pain has been identified, its assessment and management remains inadequate. The quality of care may be improved by educating the personnel in developing protocols and in evaluating pain management.

The study aimed at evaluating the seroprevalence of and sociodemographic, health, lifestyle, and environmental hygiene conditions associated with Helicobacter pylori infection in Vietnamese children. Data from 824 children, aged from 6 months to 15 years and gastrointestinal symptom free when consulted, admitted to a university hospital, were collected using a structured questionnaire and ELISA test for H. pylori infection. The data were examined using univariate and multivariate analyses. H. pylori seroprevalence was 34.0%. Age groups from 3 to 6 years and older than 6, and number of offspring were positively and independently associated with H. pylori seropositivity [adjusted OR (95% CI): 2.9 (1.5-5.5); 1.9 (1.1-3.1) and 1.8 (1.1-2.6), respectively]. Breastfeeding more than 6 months was negatively and independently associated with H. pylori seropositivity [adjusted OR (95% CI): 0.5 (0.3-0.9)]. Mother's age, history of allergy, gastro-duodenal disease history in the past, initiating collective life before 6 years, sharing bed with parents and time of bed sharing with parents24 months were positively but not independently associated with H. pylori seropositivity. None of the other environmental or lifestyle conditions examined was associated with H. pylori infection. Our results support person-to-person transmission and the role of sociodemographic factors in H. pylori infection.

The objective of the present study was to evaluate the feasibility of azithromycin prophylaxis with respect to tolerability and compliance during a pertussis outbreak among healthcare workers in a university hospital ward. Compliance with the prophylaxis regimen was 89%; compliance was 75% from intent-to-treat perspective. The rate of adverse events was 33%. Female sex was associated with reporting of adverse events. Nonstudents and healthcare workers who reported adverse events were less compliant with the prophylaxis regimen.

To examine the cost effectiveness of therapeutic strategies for toxic thyroid adenoma.Markov state transition decision analytic model.Ambulatory and inpatient.Hypothetical cohort of 40- year-old women with toxic thyroid adenomas. Patient age was varied in sensitivity analyses. Data on the prevalence of coincident thyroid cancer, complications, and treatment efficacies were derived from a systematic review of the literature.Thyroid lobectomy after a 3 month-course of antithyroid drugs (ATDs), high-dose (555 MBq) radioactive iodine (RAI), low-dose (555 MBq) RAI, and lifelong ATDs.Outcomes were measured in quality-adjusted life years (QALYs). Costs were estimated from the health care system perspective. Future costs and effectiveness were discounted at 3% per year. For a 40- year-old woman, surgery was the most effective, while low-dose RAI was the least costly. The marginal cost-effectiveness of surgery versus low-dose RAI was $13,183 per QALY. Surgery was less costly and more effective than lifelong ATDs. RAI was more effective than surgery if surgical mortality exceeded 0.90% (base-case 0.001%). Surgery provided relatively inexpensive gains ($50,000 per QALY) in quality-adjusted life expectancy in patients less than 74 years of age.For most patients less than 60 years of age, surgery is an effective strategy with a reasonable cost. However, for any given patient, surgical mortality, therapeutic costs and preference must be considered in choosing an appropriate therapy.

To estimate the prevalence of pain in adult patients attending an emergency department (ED) and to identify risk markers for insufficient pain relief, a cross-sectional survey was conducted for 16 days, 24 hours each day, in the ED of a Paris university hospital. A structured questionnaire was used to collect characteristics of pain and its management from patients. Pain intensity was evaluated both on arrival and before discharge using two scales (a numerical descriptor scale or a verbal pain intensity scale). On arrival, 78% of the patients complained of pain; among them, 54% complained of intense pain and 47% suffered procedural pain. Insufficient pain relief was assessed in 289 (77%) patients. We identified the following risk markers for insufficient pain relief: moderate or low pain intensity, no intervention in the ED before the medical examination, and no use of medication before arrival.

Background: In 1996, sublingual buprenorphine was authorized for prescription in France for maintenance therapy (MT). MT should facilitate the rehabilitation of opioid-dependent drug users and reduce the risks associated with injection. However, misuse and side effects have been reported. Objectives: To assess the frequency of buprenorphine injection in 404 subjects on buprenorphine MT and to determine the factors associated with the injection of buprenorphine. Methods: A cross-sectional survey was used to collect data from subjects on buprenorphine MT seeking treatment from health care networks, specialized structures, a prison and a hostel in three different regions of France (1998–1999). Information was collected by trained interviewers using a structured questionnaire. Results: About half (46.5%) of the subjects on MT (188/404) had ever injected buprenorphine; 67.2% of this subgroup had since used both injected and sublingual buprenorphine. Variables associated with buprenorphine injection were having injected a substance other than buprenorphine (odds ratio (OR): 13.18; 95% CI: 5.36–32.42), cannabis use (OR: 2.34; 95% CI: 1.51–3.63) and having a source of income other than a salary (OR: 1.58; 95% CI: 1.02–2.45) and heroin use (OR: 0.23; 95% CI: 0.09–0.61). Conclusions: To decrease buprenorphine injection, prescribers of buprenorphine should participate in networks with specialized centers, and social and professional rehabilitation programs should be implemented for subjects on buprenorphine MT.

Background Oral anticancer drugs (OADs) allow treating a growing range of cancers. Despite their convenience, their acceptance by healthcare professionals and patients may be affected by medical, economical and organizational factors. The way the healthcare payment system (HPS) reimburses OADs or finances hospital activities may impact patients’ access to such drugs. We discuss how the HPS in France and USA may generate disincentives to the use of OADs in certain circumstances. Discussion French public and private hospitals are financed by National Health Insurance (NHI) according to the nature and volume of medical services provided annually. Patients receiving intravenous anticancer drugs (IADs) in a hospital setting generate services, while those receiving OADs shift a part of service provision from the hospital to the community. In 2013, two million outpatient IADs sessions were performed, representing a cost of €815 million to the NHI, but positive contribution margin of €86 million to hospitals. Substitution of IADs by OADs mechanically induces a shortfall in hospital income related to hospitalizations. Such economic constraints may partially contribute to making physicians reluctant to prescribe OADs. In the US healthcare system, coverage for OADs is less favorable than coverage for injectable anticancer drugs. In 2006, a Cancer Drug Coverage Parity Act was adopted by several states in order to provide patients with better coverage for OADs. Nonetheless, the complexity of reimbursement systems and multiple reimbursement channels from private insurance represent real economic barriers which may prevent patients with low income being treated with OADs. From an organizational perspective, in both countries the use of OADs generates additional activities related to physician consultations, therapeutic education and healthcare coordination between hospitals and community settings, which are not considered in the funding of hospitals activities so far. Summary Funding of healthcare services is a critical factor influencing in part the choice of cancer treatments and this is expected to become increasingly important as economic constraints grow. Drug reimbursement systems and hospital financing changes, coupled with other accompanying measures, should contribute to improve equal and safe patient access to appropriate anticancer drugs and improve the management and care pathway of cancer patients.

The aim of this study was to determine the prevalence of venous thromboembolism (VT) in current prophylactic practice with low-molecular-weight heparin (LMWH) among medical inpatients and to analyze associated risk factors for VT. A cross-sectional survey on five given days was conducted in the medical departments of a university hospital. The prevalence of prophylaxis and confirmed VT was measured. Risk markers for receiving high doses of LMWH and for VT under prophylaxis were assessed by logistic regression models. Of 1194 inpatients, 1.4% suffered VT. The mean proportion of patients with LMWH prophylaxis was 24% (range: 4-64°k). The prevalence of VT was higher among inpatients receiving prophylaxis than among those patients not receiving prophylaxis (3.5% vs. 0.7%, p = 0.002). Under prophylaxis, independent risk markers for thrombosis were history of vein thrombosis (odds ratio [OR]: 4.03; confidence interval [95%CI]: 1.04-15.62) and age (OR: 1.08 ; 95%CI: 1.01-1.15). Two factors were independently associated with the prescription of high doses of LMWH: obesity was positively associated (OR: 7.50; 95%CI: 2.97-18.92; p < 0.0001) and respiratory insufficiency was negatively associated. In medical departments, current prophylaxis practice leads to many patients being given LMWH. LMWH doses and other preventive measures should be adapted in high-risk inpatients.

Background and objectives 70% to 80% of patients visiting an emergency department (ED) complain from pain. In 1999 a survey to the ED of a university hospital found that only a quarter of patients were relieved on discharge. We implemented and evaluated a program aiming at improving the management of pain in the ED. Programme A physician of the ED was appointed to lead the drafting of protocols by a multidisciplinary group of professionals and provide staff training. It was decided that the nurses on arrival using a validated scale would assess the pain. In case of pain, the priority sorting would be increased by a level. Moderate pain would be immediately treated using an analgesic stage 1 acting quickly and other measures (immobilisation) would be implemented if appropriate. Two cross-sectional surveys were conducted (04 October 1999–19 October 1999 and 03 April 2007–18 April 2007). The information was collected using a structured questionnaire in all patients over 17 years able to answer questions. Pain and its intensity were assessed on arrival and on discharge by a validated scale. A structured form enabled file analysis. Intervention was defined as every measure intended at pain relieving and pain relief as the disappearance of pain on discharge or a decrease in its intensity. The effectiveness of the program was assessed by the change in the proportion of patients relieved on discharge. Results 810 and 745 patients were eligible in 1999 and 2007, respectively. On 726 (90%) and 673 (90%) participants, 563 (77%) and 536 (80%) were painful on arrival, among them, 384 (68%) and 401 (75%) had their pain assessed on discharge. The proportions of patients relieved were 44% in 2007 vs 25% in 1999 (p Discussion and Conclusion Further progress is necessary since 56% of patients are still not relieved on discharge, including support for those whose symptoms seem less severe. A specific emphasis should be placed on the reassessment of pain after treatment and adjustment of therapy. The type of survey used comparing before to after does not allow determining whether the program implemented determined the improvement or whether other changes may explain it. The facts that the interventions on pain at the reception, sorting level are related to relief and that the program is mainly applied are in favour of the impact of this program. Monitoring indicators will track the impact of changes. The program established under the direction of a dedicated physician has had a positive impact on the management of pain in an ED. Such program should be continued. Contexte et objectifs La douleur touche 70 % a 80% des patients des Services d9accueil des urgences (SAU). En 1999, une enquete au SAU d9un hopital universitaire a montre qu9un quart seulement des patients etaient soulages a la sortie. Un programme ayant pour objectif l9amelioration de la prise en charge de la douleur dans ce SAU a ete mis en place et evalue. Programme Un medecin du SAU a ete designe pour mener la redaction de protocoles par un groupe pluriprofessionnel et assurer la formation du personnel. Il a ete decide que la douleur serait evaluee par les infirmiers d9accueil et d9orientation par une echelle validee, qu9en cas de douleur intense, la priorite de tri serait augmentee d9un niveau, que pour les douleurs moderees, un antalgique de palier 1 d9action rapide serait immediatement administre et d9autres mesures (immobilisation…) seraient prises si indiquees. Deux enquetes transversales ont ete effectuees (04/10/1999 - 19/10/1999 et 03/04/2007 – 18/04/2007). Les informations ont ete recueillies a l9aide d9un questionnaire structure chez tous les patients de plus 17 ans capables de repondre aux questions. L9existence d9une douleur et son intensite ont ete evaluees a l9arrivee et a la sortie par une echelle validee. Une grille structuree a permis l9analyse des dossiers. Sont appeles « intervention » les mesures antalgiques et « soulagement », une absence de douleur a la sortie ou une diminution de son intensite. Le critere principal de jugement de l9efficacite du programme est l9evolution de la proportion de patients soulages a la sortie. Resultats Respectivement, en 1999 et 2007, 810 et 745 patients etaient eligibles ; sur les 726 (90%) et 673 (90%) participants, 563 (77%) et 536 (80%) etaient douloureux a l9entree ; parmi eux, 384 (68%) et 401 (75%) avaient eu leur douleur evaluee a la sortie. La proportion de patients soulages etait de 44% en 2007 vs. 25% en 1999 (p L9execution du programme semble independamment lie au soulagement des patients : les patients de 2007 avaient 2,3 fois (IC 95% : 1,2 – 4,3) plus de chance d9etre soulages que ceux de 1999. L9urgence vitale, l9intensite de la douleur, la prise d9antalgique avant l9arrivee et l9intervention des l9accueil sont aussi independamment liees au soulagement. Discussion et conclusion Des progres restent a faire puisque 56% des patients ne sont toujours pas soulages a la sortie, notamment une prise en charge accentuee de ceux dont les symptomes semblent moins graves. L9accent doit aussi etre mis sur la reevaluation de la douleur apres traitement et l9ajustement du traitement. Le type d9enquete utilise comparant l9avant et l9apres ne permet pas d9identifier si seule l9application du programme a determine l9amelioration ou si d9autres evolutions peuvent l9expliquer. Le fait que l9intervention sur la douleur des l9accueil, le niveau de tri soient lies au soulagement et que le programme soit majoritairement applique sont en faveur de l9impact de ce programme. Le suivi d9indicateurs permettra de suivre l9impact des modifications apportees. Le programme mis en place sous la direction d9un medecin dedie, a eu un impact favorable sur la prise en charge de la douleur dans un SAU. Il sera poursuivi.

This study aimed to identify typical features of burns in rural areas and to improve their prevention by comparing the characteristics of burnt patients and their burns in rural and urban areas. A cross-sectional survey was conducted in 19 of the 23 French burns units over one year, using a structured questionnaire. We analysed the resulting database. Of the 1422 patients, excluding 188 burnt in unclassified areas, 420 (34%) were burnt in rural areas. Burns were more frequent in rural than in urban areas. Occupational burns were more frequent in rural than in urban areas. The characteristics of patients and burns did not differ between the areas. Patients burnt during everyday activities were older and more frequently had predisposing factors in rural than in urban areas. Burns occurred outdoors more often in rural than in urban areas and were frequently due to flames or explosions or to the use of barbecues or open fires. The hands and perineum were burnt more frequently in rural than in urban areas. Rural burns were more severe than urban burns: they were deeper, involved a larger body surface area and caused more deaths. Preventive measures in rural areas should take into account occupation and everyday activities. They should be specifically adapted to the profiles of burnt patients.

Enquete « un jour donne » repetee 5 fois (en 2005-2006) par des enqueteurs formes avec un questionnaire standardise utilisant des echelles validees (EN et EVA). 177 personnes auditees (âge moyen 63,7 ans, sexe ratio 1,38). 54,8 % des patients etaient hospitalises depuis moins de 7 jours. La douleur etait le motif principal de l’hospitalisation pour 79,2 % des patients et 52,7 % des patients etaient douloureux a l’admission ; 24,4 % de post-operatoires immediats. 33,3 % ont eu des douleurs induites par les soins. Quelle que soit l’origine de la douleur, 94,8 % ont beneficie d’une action antalgique, soulageant 75,3 % des patients. Dans les 24 heures precedant l’audit, 67,6 % des patients ont ressenti une douleur meme faible (dont 26,7 % liees aux soins) et 16,1 % des patients ont ressenti une douleur insupportable. Tous ont beneficie d’au moins une action a but antalgique, soulageant 73,3 % des patients. Les patients ayant declare une douleur insupportable etaient significativement plus souvent en post operatoire (44 % vs 5,5 %) ou douloureux avant l’hospitalisation (88,5 % vs 63,5 %). Ils ont plus souvent que les autres, reclame un traitement (70 % vs 25 %) et etaient plus souvent douloureux au moment de l’audit (89,5 % vs 59,2 %). Les personnes moins bien soulagees etaient plus souvent douloureuses avant l’hospitalisation au contraire des patients douloureux pendant les soins, souvent mieux soulages par ailleurs. Si le post-operatoire apparait independamment associe a des douleurs insupportables (OR : 32,37 ; IC : 2,9 - 358,8), un diagnostic principal oncologique n’etait pas associe a une majoration de la douleur. Les resultats observes durant cet audit sont encourageants puisque trois quarts des patients douloureux se sont dits soulages. En post-operatoire, les patients sont plus souvent douloureux (douleur intense et moins souvent soulagee). Les douleurs liees aux soins se retrouvent plus frequemment chez les patients non douloureux a l’admission ou avant l’hospitalisation mais sont tres bien soulagees.

INTRODUCTION: Type 2 diabetes is associated with severe micro- and macro-vascular complications. Physicians' and patients' adherence to follow-up guidelines permits postponing or reducing these complications. The objectives were to assess the level of adherence to fundamental follow-up guidelines and determine patients' characteristics associated with this level of adherence in the context of Luxembourg, where no guidelines were implemented. STUDY POPULATION: The exhaustive residing population treated for type 2 diabetes in Luxembourg during the 2000-2006 period (N = 21,068). METHODS: Seven fundamental criteria were extracted from international guidelines (consultation with the treating physician, HbA1c tests, electrocardiogram, retinal, dental, lipid and renal check-ups). The factors associated with the level of adherence to those criteria were identified using a partial proportional odds model. RESULTS: In 2006, despite 90% of the patients consulted at least 4 times their treating physician, only 0.6% completed all criteria; 55.0% had no HbA1c test (-8.6 points since 2000) and 31.1% had a renal check-up (+21.6 points). The sex (OR(male): 0.87 [95%CI, 0.83-0.92]), the nationality (OR(NonEU): 0.64 [0.52-0.78]), the type of antidiabetic treatment (ORoral: 1.48 [1.35-1.63], OR(mixed): 1.35 [1.20-1.52]) and the type of treating physician (ORG-ID: 0.47 [0.42-0.53]) were the main factors associated with the level of adherence in 2006 (3 or more criteria). CONCLUSION: A large percentage of patients were not provided with a systematic annual follow-up between 2000 and 2006. This study highlighted the necessity to promote guidelines in Luxembourg, education for physicians and to launch a national discussion on a disease management program for diabetic patients.

Background National authorities have to follow the evolution of diabetes to implement public health policies. An algorithm was developed to identify patients with treated type 2 diabetes and estimate its annual prevalence in Luxembourg using health insurance claims when no diagnosis code is available. Methods The DIABECOLUX algorithm was based on patients' age as well as type and number of hypoglycemic agents reimbursed between 1995 and 2006. Algorithm validation was performed using the results of a national study based on medical data. Sensitivity, specificity and predictive values were estimated. Results The sensitivity of the DIABECOLUX algorithm was found superior to 98.2%. Between 2000 and 2006, 22,178 patients were treated for diabetes in Luxembourg, among whom 21,068 for type 2 diabetes (95%). The prevalence was estimated at 3.79% in 2006 and followed an increasing linear trend during the period. In 2005, the prevalence was low for young age classes and increased rapidly from 40 to 70 for male and 80 for female, reaching a peak of, respectively 17.0% and 14.3% before decreasing. Conclusions The DIABECOLUX algorithm is relevant to identify treated type 2 diabetes patients. It is reproducible and should be transferable to every country using medico-administrative databases not including diagnosis codes. Although undiagnosed patients and others with lifestyle recommendations only were not considered in this study, this algorithm is a cheap and easy-to-use tool to inform health authorities. Further studies will use this tool with the aim of improving the quality of health care dedicated to diabetic patients in Luxembourg.