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Late adjuvant chemotherapy (aCT) administration after colectomy (56 d) is known to be associated with impaired prognosis. We aim to identify risk factors associated with late aCT, especially the travel time between patients' home and hospital.We performed a retrospective monocentre cohort study. Patients included had a colectomy for a stage III or high risk stage II colon cancer between 2009 and 2015 performed at a French university hospital. Risk factors for late aCT were identified using a fractional polynomial logistic regression.Ninety-four patients were included. The risk of late aCT was associated with travel time length, emergent colectomy, the need for scheduled care before aCT, and length of time between colectomy and postoperative multidisciplinary meeting advising aCT.Our study suggests that, in patients with colon cancer, factors unrelated to disease severity and complexity could be associated with a higher risk of late aCT.

Summary Introduction During the last decade, most studies on totally implanted venous access-associated adverse events (TIVA-AE) were conducted retrospectively and/or were based on a limited sample size. The aim of our survey was two-fold: to estimate the incidence of TIVA-AE and to identify risk factors in patients with cancer. Methods Data from our routine surveillance of TIVA-AE were collected prospectively between October 2009 and January 2011 in two oncology referral centers in Northern France. The open cohort under surveillance during the same time period was reconstituted retrospectively using data from the hospital information systems. Incidences of first TIVA-AE per 1000 TIVA-days were calculated. Risk factors were identified using multivariate logistic regressions. Results We included 2286 cancer patients, corresponding to 582,347 TIVA-days. Among the 133 first TIVA-AE observed (incidence 0.23 per 1000 TIVA-days [0.19–0.27]), there were 50 infectious AE (incidence 0.09 [0.06–0.11]) and 83 non-infectious AE (incidence 0.14 [0.11–0.17]). Compared to non-metastatic solid cancers, metastatic cancers (aOR = 2.3 [0.9–6.0]), and hematologic malignancies (aOR = 3.2 [1.1–8.8]) tended to be associated with a higher risk of infectious TIVA-AE (P = 0.087). Solid cancer type was associated with non-infectious TIVA-AE (P = 0.030), especially digestive cancers. Discussion We report accurate estimations of TIVA-AE incidences in one of the largest populations among previously published studies. As in previous studies, metastatic cancers and hematologic malignancies tended to be associated with a higher risk of infectious TIVA-AE. Further studies are warranted to confirm the effect of digestive cancers.

Objectif : Notre objectif etait de construire, a partir du Programme de medicalisation des systemes d’information (PMSI), un indicateur de suivi des delais d’initiation de la chimiotherapie (CT) adjuvante pour cancer du colon et de l’evaluer. Materiel et methodes : A partir du PMSI au CHU de Rouen, nous avons calcule le delai entre la colectomie pour cancer du colon et la CT, chez des patients hospitalises entre 2009 et 2015. Par comparaison au dossier medical, nous avons identifie les vrais et les faux positifs, et nous avons calcule la valeur predictive positive (VPP) de notre methode. Resultats : Parmi les 102 patients selectionnes, la VPP etait de 91 % (IC 95 % : [86–97]). Conclusion : La qualite de l’indicateur meriterait d’etre confirmee dans d’autres etablissements. Applique aux bases PMSI nationales, il pourrait servir d’outil de pilotage au sein des agences regionales de sante et de l’Institut national du cancer.

Summary Introduction Totally implanted venous access (TIVA) improves the safety and welfare of patients treated with cancer chemotherapy (CCT). We aimed to evaluate patients’ perception of TIVA placement, TIVA use, and information on TIVA, and to assess the association between patients’ perception and their attitude regarding a potential TIVA re-implantation. Methods We conducted a single center cross-sectional survey in a university hospital in Northern France. Patients included were consecutive urologic or digestive cancer inpatients admitted for a CCT cycle via TIVA between April 9th and May 9th 2014. We analyzed patients’ satisfaction, experience, and attitude, especially when requiring potential TIVA re-implantation under local anesthesia (LA), using a standardized questionnaire and medical records. We analyzed risk factors for refusing potential TIVA re-implantation under LA using multivariate logistic regression. Results Eighty-one patients were interviewed (no refusals), including 57 with a TIVA device placed under LA in our university hospital. Among them, 52/57 (91%) reported satisfactory TIVA placement, but respectively 21/57 (37%) and 18/57 (32%) complained of painful or uncomfortable TIVA placement; 51/57 (89%) were satisfied with care provided during CCT cycles. Risk factors for refusing potential re-implantation under LA were: TIVA placement considered painful (P = 0.012) or uncomfortable (P = 0.038) and dissatisfaction with care provided during CCT cycles (P = 0.028). Discussion We show that despite good overall satisfaction regarding TIVA, some aspects were less positive and warrant improvement actions. It suggests that these actions could not only improve patients’ experience of TIVA use but could also facilitate continuation of treatment in the long term.

Introduction We aimed to assess the association between a patient’s social status and the cost of stay for a single uncomplicated vaginal delivery. Currently, few data have been reported. Material and methods We conducted an observational study with data retrieved from the medical and administrative databases of a university hospital in North-West France. We included all patients admitted in 2014 and classified in either Diagnosis-Related Group (DRG) « Single uncomplicated vaginal deliveries in a primiparous patient » or DRG « Single uncomplicated vaginal deliveries in a multiparous patient ». Criteria defining poor social status were: a specific healthcare benefit in relation to low income or for foreign undocumented patients, and/or a consultation with a social worker during the hospital stay except if no social problem was diagnosed. We compared the cost of stay between patients with poor social status and patients with good social status using a multivariate median regression stratified on parity, and adjusted for age, gestational age and neonatal hospitalization. Results Among 686 primiparous patients, 21% had poor social status, which was associated with an increase in the median cost of stay (+€475; 95% CI [+334 to +616]), mostly explained by a 1-day increase in the median length of stay.Among 899 multiparous patients, 29% had poor social status, which was not associated with the cost of stay. Discussion Social status had an impact on the cost of vaginal deliveries in primiparous patients. Our findings suggest a need to redefine the DRG classification according to patients' social status.

National audience; Le Haut Conseil de la santé publique (HCSP) présente son rapport d’évaluation de 10 ans de politique de lutte contre le cancer (2004-2014).À partir de l’analyse des six axes clés de la politique de lutte contre le cancer (Recherche, Observation, Prévention, Dépistage, Soins, Qualité de vie), le HCSP s’est, plus particulièrement attaché à répondre aux quatre questions principales suivantes :• Quel a été l’impact des deux premiers Plans cancer en termes de réduction des inégalités de santé ?• Dans quelle mesure un plan thématique et un opérateur dédié (Institut national du Cancer – INCa) ont-ils constitué un progrès ?• L’expérience acquise dans ce champ est-elle extrapolable à d’autres maladies chroniques ?• Quels enseignements peut-on tirer d’une comparaison avec les expériences étrangères, notamment sur l’organisation des dépistages ?Cette évaluation a conduit à formuler soixante recommandations visant à améliorer la prévention, le dépistage et la prise en charge des cancers, à garantir des soins personnalisés et efficaces, à améliorer la qualité de vie des patients pendant et après le cancer, et à réduire les inégalités sociales et territoriales de santé face au cancer. Il s’agit aussi de renforcer larecherche et le recueil des données en cancérologie et d’optimiser le pilotage et la gouvernance concernant cette maladie.Globalement, ces recommandations sont cohérentes avec les orientations du Plan cancer 2014-2019 actuellement en cours.Cette évaluation menée par dix professionnels, membres ou non du HCSP a fait appel à environ soixante auditions d’acteurs clés de la lutte contre le cancer, à une étude détaillée des principaux documents en lien avec cette thématique et à une étude qualitative de parcours individuels auprès de trente patients et de leur entourage professionnel et personnel.

International audience; PURPOSE:Although considered safer than central venous catheters for administration of cancer chemotherapy, totally implanted venous access (TIVA) is associated with adverse events that may impair prognosis and quality of life of patients receiving chemotherapy. Our aim was to assess the feasibility and interest of surveillance of cancer chemotherapy TIVA-adverse events (AE), associated with morbidity-mortality conferences (MMCs) on TIVA-AE.METHODS:We performed a prospective interventional study in two hospitals (a university hospital and a comprehensive care center). For each cancer chemotherapy care pathway within each hospital, we set up surveillance of TIVA-AE and MMC on these events. Patients included in surveillance were those with a TIVA either placed or used for chemotherapy cycles in one of the participating wards. Feasibility of MMC was assessed by the number of MMC meetings that actually took place and the number of participants at each meeting. The interest of MMC was assessed by the number of TIVA-AE identified and analyzed, and the number and type of improvement actions selected and actually implemented.RESULTS:We recorded 0.41 adverse events per 1000 TIVA-day. MMCs were implemented in all care pathways, with sustained pluriprofessional attendance throughout the survey; 39 improvement actions were identified during meetings, and 18 were actually implemented.CONCLUSIONS:Surveillance of TIVA-AE associated with MMC is feasible and helps change practices. It could be useful for improving care of patients undergoing cancer chemotherapy.

The assessment of a health technology is frequently accompanied by uncertainty about its impact, at short or long terms, on the health of the population. The Health Authorities may request additional « post-registration » data that will allow a relevant reassessment of these technologies. The responsibility to collect this information lies with the industry and the HAS evaluates the methodology. This guideline provides practical benchmarks on methodological aspects of these studies. It describes the different types of studies to consider depending on the objectives, including the use of databases and cohorts and European studies. It emphasizes the importance of establishing a scientific committee, clearly defining the objectives of the study, justifying the methodological choices, documenting the representativeness or completeness of centers, investigators and patients, limiting the number of lost of follow-up patients and missing data, describing the statistical analysis methods, the bias and their possible impact on results. The publication of the results of these studies is strongly encouraged.

Background Unplanned return to the operating theatre (UROT) is a useful trigger tool that could be used to identify surgical adverse events (SAEs). The present study describes the feasibility of SAE surveillance in neurosurgical patients, based on UROT identification, completed with SAE analysis at a morbidity–mortality conference (MMC) meeting. Method For consecutive patients who underwent a neurosurgical procedure between 1 November 2008 and 30 April 2009, return to the operating theatre (ROT) was identified based on the hospital information system associated to prospective payment (HISPP). ROT was classified as planned or unplanned and UROT was further classified as related to the natural history of the disease or related to an adverse event (AE-UROT). MMC meetings were organised to discuss results of UROT surveillance and to analyse AE-UROT. Results 1006 neurosurgical procedures were included in the surveillance. HISSP identified 152 ROTs, with 73 UROTs related to an SAE (7.3% (5.7% to 9.0%)): infectious SAE (n=24, 2.4% (1.5% to 3.5%)), haemorrhagic SAE (n=23, 2.3% (1.5% to 3.4%)), other cause SAE (n=26, 2.8% (1.9% to 4.0%)), and infectious and other cause SAE (n=2, 0.2% (0.0% to 0.7%)). Identification of AE-UROT through HISSP required a 4 h/month time frame. Eight UROTs related to SAE cases were discussed during MMC meetings, leading to the identification of non-conforming care processes and practical improvement actions. Conclusion UROT related to SAE surveillance in neurosurgical patients was considered feasible. The association of surveillance and MMCs allowed staff to concentrate on the analysis of most frequent or most severe AEs and was a practical and useful tool to stimulate improvement. The impact on healthcare quality of SAE surveillance associated with MMC warrants further research.

Objective.To establish whether continuous subglottic suctioning (CSS) could be cost-effective.Design.Cost-benefit analysis, based on a hypothetical replacement of conventional ventilation (CV) with CSS.Setting.A surgical intensive care unit (SICU) of a tertiary care university hospital in France.Patients.All consecutive patients receiving ventilation in the SICU in 2006.Methods.Efficacy data for CSS were obtained from the literature and applied to the SICU of our hospital. Costs for CV and CSS were provided by the hospital pharmacy; costs for ventilator-associated pneumonia (VAP) were obtained from the literature. The cost per averted VAP episode was calculated, and a sensitivity analysis was performed on VAP incidence and on the number of tubes required for each patient.Results.At our SICU in 2006, 416 patients received mechanical ventilation for 3,487 ventilation-days, and 32 VAP episodes were observed (7.9 episodes per 100 ventilated patients; incidence density, 9.2 episodes per 10,000 ventilation-days). Based on the hypothesis of a 29% reduction in the risk of VAP with CSS than CV, 9 VAP episodes could have been averted. The additional cost of CSS for 2006 was estimated to be €10,585.34. The cost per averted VAP episode was €1,176.15. Assuming a VAP cost of €4,387, a total of 3 averted VAP episodes would neutralize the additional cost. For a low VAP incidence of 6.6%, the cost per averted VAP would be €1,323. If each patient required 2 tubes during ventilation, the cost would be €1,383.69 per averted VAP episode.Conclusion.Replacement of CV with CSS was cost-effective even when assuming the most pessimistic scenario of VAP incidence and costs.

To assess whether comparison of quality of hip fracture care among three teams located in different hospitals is associated with improvement in process and outcomes.A baseline assessment was performed using quality indicators selected by professionals.were discussed among the three teams followed by a post-comparison assessment of the same indicators.Three hospitals in North Western France.Professionals caring for patients operated on for a low-impact hip fracture.Review and discussion of comparative performance results by three teams followed by implementation of quality improvement as deemed necessary by each team.Fifteen quality indicators of health care during orthopedic and rehabilitation stay, mobility, dependence and place of residence before hip fracture and 3 months after discharge, 3 month post-surgery mortality and readmission rates.Major differences were observed among hospitals throughout the care process during baseline period. Comparison of performance and discussion among the three teams were followed by corrective action in 11 areas. After comparison, a significant improvement was observed in 10 areas, seven of which corresponded to quality improvement areas chosen for improvement action by professionals. A significant decrease in readmission rate (6.7% vs. 15.7%, P0.001) was observed but there was no change in mortality, functional outcome or length of stay.Comparison of performance among voluntary teams, on fields selected by health-care professionals, was associated with improvement in the care process and with improvement of some related outcomes.

Background Older age and the use of bilateral internal thoracic artery (ITA) grafting are both considered risk factors for surgical wound infection (SWI) after coronary artery bypass grafting (CABG). The 2014 European Guidelines recommend that bilateral ITA grafting should be considered in patients aged younger than 70 years. Our aim was to investigate interaction between age and the number of ITA grafts. Methods All patients aged 18 years and older who had undergone CABG with at least 1 ITA at Rouen University Hospital between 2001 and 2012 were selected. Data regarding surgical procedure (single/bilateral ITA grafting) were extracted from the medical information system. SWI was identified from prospective surveillance of patients according to Centers for Disease Control and Prevention criteria. Independent factors associated with SWI were assessed by logistic regression, and an interaction test between age (≤69 or ≥70 years) and the number of ITA grafts was performed. Results SWI occurred in 71 of 2,726 patients (2.6%). Bilateral ITA grafting was associated with SWI (adjusted odds ratio [aOR], 2.55; 95% confidence interval, 1.51 to 4.30). After fitting an interaction term between age and number of ITA grafts, the aORs for SWI after bilateral ITA grafting substantially differed between patients aged 69 years and younger (aOR, 1.88; 95% confidence interval, 0.94 to 3.75) and 70 years and older (aOR, 3.52; 95% confidence interval, 1.69 to 7.33). However, this interaction failed to reach statistical significance ( p = 0.2213), possibly because of insufficient statistical power (23.5%) despite the large sample size. Conclusions Age 70 years and older compared with age 69 years and younger was associated with higher occurrence of SWI after bilateral ITA grafting, but this interaction was not statistically significant. Larger studies are needed to test this interaction.

Contexte : Une epreuve de lecture critique d'article (LCA) sera introduite en 2008 dans l'examen classant national (ECN). Les rares travaux consacres a cette epreuve suggerent une concordance mediocre des corrections. But : Identifier certains facteurs lies a la concordance des corrections d’une epreuve de LCA. Sujets et methodes : 59 etudiants volontaires de DCEM 2 et DCEM 3 ont ete soumis a une epreuve de LCA dans les conditions prevues pour l'ECN. Trois correcteurs ayant prepare l’epreuve (choix d’article, questions et reponses attendues selon 16 questions, grilles de correction (s), ponderations), ont corrige chaque copie de facon independante, sans grille puis avec une grille. L'accord entre les 3 couples de correcteurs, avec ou sans grille, pour les 16 questions, soit 96 couples, a ete mesure par les coefficients de correlation intraclasse (CCI). La valeur mediane du CCI pour chaque facteur (questions, grille ou non, questions ou resume, couples de correcteurs) a ete comparee aux autres CCI par le test de Mann-Whitney ; les facteurs independants de variations du CCI ont ete determines par une analyse de regression multiple. Resultats : 6 questions sur 16, l’usage de la grille, et l’un des couples de correcteurs etaient lies de facon independante aux CCI. Conclusion : La concordance des corrections d'une epreuve de LCA semble dependre fortement de la qualite de l’epreuve et des correcteurs ; le recours a une grille de correction pourrait representer un facteur d’amelioration d’impact modeste de cette concordance.

Resume Introduction Les personnes âgees sont les plus exposees au risque de denutrition, notamment au cours de sejours en institution ou en secteur hospitalier. La denutrition est faiblement identifiee et peu traitee chez cette population. Objectif Identifier les actions mises en œuvre par les etablissements hospitaliers et institutions en Haute-Normandie pour la prise en charge et la prevention de la denutrition. Methodes En janvier 2003, une etude transversale a ete conduite dans tous les etablissements de sante en Haute-Normandie : 36 etablissements publics de sante (EPS), 28 etablissements prives de sante (EPrS), 161 etablissements d’hebergement pour les personnes âgees et dependantes (EHPAD). Resultats Vingt-deux pour cent des etablissements avaient mis en place un protocole specifique pour la prise en charge de la denutrition : 30,3% pour les EPS, 13,6% pour les EHPAD non medicalisees (p = 0,22). Soixante-sept pour cent de l’ensemble des etablissements declaraient faire un releve de consommation de repas : 81,8% pour les EPS, 45,5% pour les EHPAD non medicalisees (p = 0,10). Cinquante-quatre pour cent des institutions permettaient le choix du repas : 85,0% pour EPrS, 45,4% pour les EPS (p = 0,01). Cinquante et un pour cent realisaient un recensement des habitudes alimentaires. L’aide au cours du repas etait apportee par les aides-soignantes dans 46,9% des institutions. Quarante-neuf pour cent estimaient disposer de moyens humains suffisants pour l’aide du patient au cours du repas : 95,5% pour les EHPAD non medicalisees, 20,7% pour les ESP (p Discussion Ces resultats montrent une sensibilisation importante des etablissements au probleme de la denutrition, mais une mise en œuvre encore insuffisante de procedures systematisees. Le role central des aides-soignantes est demontre, leur proximite aupres du patient pourrait etre benefique dans la prevention et la prise en charge de la denutrition. Conclusion Un consensus existe dans les institutions de Haute-Normandie sur la necessite de depister et prendre en charge la denutrition, mais ceci n’est cependant pas toujours applique. Une meilleure organisation des soins et la possibilite pour les soignants de partager leurs experiences et savoir-faire dans la prise en charge de la denutrition pourrait ameliorer la qualite des soins dans ce domaine.

Resume Introduction. – Des regles de bonnes pratiques de distribution et d'utilisation des produits sanguins labiles ont ete etablies pour les etablissements de transfusion sanguine et les etablissements de sante, en particulier pour l'utilisation des concentres de plaquettes Rhesus (D) incompatible. Le but de ce travail est d'estimer le taux d'attribution des plaquettes Rhesus (D) incompatible, de determiner le degre de mise en œuvre de la prophylaxie et d'evaluer les consequences immunologiques a court et moyen termes des patients transfuses. Methodes. – Les transfusions de plaquettes Rhesus (D) incompatible au cours de l'annee 2003 au CHU de Rouen ont ete identifiees retrospectivement afin de caracteriser les patients et les actes transfusionnels. Le role de certains facteurs dans l'injection preventive d'Ig anti-D d'une part et dans l'apparition d'allo-immunisation d'autre part a ete etudie. Resultats. – En un an, 280 concentres de plaquettes Rhesus (D) incompatible ont ete administres a 67 patients. La prophylaxie par injection d'Ig anti-D n'etait pas systematique. Quatre immunisations dans le systeme Rhesus ont ete identifiees : deux contre l'antigene (Ag) D, une contre l'Ag E, et une contre l'Ag C. Les deux immunisations contre l'Ag D sont survenues chez deux patientes jeunes ayant un statut non immunocompetent. La prophylaxie etait plus frequente chez les patients polytransfuses, il n'a pas ete observe de lien avec les autres parametres etudies. Conclusion. – Le respect de la compatibilite du Rhesus (D) des concentres de plaquettes n'est pas toujours possible. L'immunisation antierythrocytaire persiste, en particulier, vis-a-vis des antigenes du systeme Rhesus, meme chez le patient non immunocompetent. Les recommandations de la prophylaxie par injection d'immunoglobuline (Ig) specifique anti-D pourraient etre reconsiderees.

Objective To evaluate the main changes in characteristics, practices and outcome between 1996 and 2000 in patients admitted for an acute upper gastrointestinal haemorrhage (AUGIH). Patients and methods All consecutive patients (n=1165) admitted for an AUGIH in four French administrative areas were entered into two separate 6-month studies conducted in 1996 (n=712) and 2000 (n=453). Epidemiological and biological characteristics, endoscopic haemostatic procedures and outcomes were compared. Results Patient characteristics remained unchanged between the two studies; the two main bleeding lesions were peptic ulcer and oesophagogastric varices (30.2 versus 31.1% and 22.5 versus 20.3%). The use of non-steroidal anti-inflammatory drugs or aspirin was more frequent in 2000 (26.5 versus 32.6%; P

Contexte : L'introduction d'une epreuve de lecture critique d'articles dans l'examen classant national en 2008 implique de former les etudiants et de mettre au point une procedure reproductible de correction. Actuellement la formation est tres variable entre les differentes facultes et la reproductibilite de ce type d'epreuve est inconnue. But : Evaluer la reproductibilite de la correction d'une epreuve de lecture critique d'articles dans des conditions proches de celles de l'examen national classant. Sujets et methodes : 59 etudiants volontaires de 2e et 3e annees du deuxieme cycle des etudes medicales ont passe une epreuve surveillee de trois heures, sur un article original en francais, comportant 10 questions validees et un resume de 250 mots au plus. Trois enseignants ayant prepare le dossier de l'epreuve ont corrige en aveugle les questions et le resume selon 16 items, sans grille de correction. L'accord entre les trois paires de correcteurs a ete apprecie par les coefficients de correlation intra classe (CCI). Resultats : En moyenne, l'accord entre les correcteurs etait modere ou mediocre : CCI = 0,68 (intervalle de confiance a 95 % : 0,52 - 0,80), CCI = 0,71 (0,55 - 0,81) et CCI = 0,48 ( 0,26 - 0,65) selon la paire. Cette concordance etait variable suivant les items (tres mauvaise pour deux questions). Elle etait meilleure pour les questions que pour le resume pour 2 des 3 paires de correcteurs. Conclusion : Cette methode de correction de l'epreuve de lecture critique d'articles est peu reproductible. L'impreparation actuelle des etudiants et des enseignants est probablement un facteur aggravant.

Contexte : Un dispositif de formation en sante publique, dissociant l'apprentissage de connaissances theoriques (auto-apprentissage) et mise en oeuvre (sur des situations pratiques), a ete mis en place dans le cursus medical a l'Universite de Rouen. Buts : Decrire les modalites de cet enseignement et son impact preliminaire. Sujets et methodes : L'enseignement de la 2 e annee du 2 e cycle (determinants et grands problemes de sante) est reparti sur huit seances thematiques (90 mn) par petits groupes. Chacune est preparee par l'etudiant sur la base d'objectifs avec un polycopie ; elle est consacree a analyser une action ou une etude sur le meme theme, fondee sur un article publie. La participation des etudiants a ete recueillie. Leur satisfaction a ete evaluee par questionnaire anonyme a chaque seance. L'examen associe des QCM et une epreuve pratique. La correlation entre les scores obtenus a l'examen et le nombre de seances suivies a ete testee. Resultats : En 2002, sur une promotion de 88 etudiants, la participation moyenne etait de 36 %, stable sur les 8 seances. La qualite de l'enseignement a ete jugee excellente ou satisfaisante par 85 % des etudiants. Le nombre de seances suivies etait correle avec les scores a l'epreuve pratique (r = 0,31, p = 0,02) et aux QCM (r = 0,42, p = 0,0005). Conclusion : L'enseignement de la sante publique associant auto-apprentissage et etude de cas pratiques par petits groupes est apprecie des etudiants. Il est associe a de meilleurs resultats a l'examen, mais le role explicatif de cette forme d'enseignement dans les resultats demande confirmation.

Resume Objectif Identifier une strategie de depistage du SARM ( Staphylococcus aureus resistant a la meticilline) a l’admission en service de soins de suite geriatrique ayant une efficacite et un cout acceptables par comparaison avec ceux d’une strategie maximaliste combinant le depistage de 6 sites de prelevement. Methode Le depistage du SARM a ete effectue de facon prospective pendant 3 mois pour tous les patients admis dans un service de soins de suite et de readaptation geriatrique, au moyen de prelevements des narines, des aisselles, des urines, des cicatrices, des ulceres cutanes et des escarres. Six strategies ont ete definies combinant differents sites de prelevement. Leur cout et leur efficacite ont ete compares a ceux d’une strategie maximaliste associant le prelevement des 6 sites. Resultats Le depistage par le prelevement combine des 6 sites etait la strategie la plus efficace mais aussi la plus couteuse. La strategie la moins couteuse ne comportait que le prelevement des ulceres et des escarres mais son efficacite etait de 45 %. La strategie pour laquelle la perte d’efficacite etait la plus faible par rapport a la strategie de reference maximaliste etait le prelevement des ulceres et des escarres associe a un prelevement des narines : son efficacite etait de 91 % et son cout 2,5 fois moins important que celui de la strategie de reference. Discussion Une etude preliminaire realisee sur une courte duree a etabli une strategie de depistage du SARM adaptee aux specificites d’un service de soins de suite et a son recrutement. La capacite d’identifier la meilleure strategie de depistage de SARM dans un service de soins de suite et de readaptation peut etre un point important pour controler la diffusion du SARM.

Resume Le but de ce travail etait d'estimer le pronostic vital a court terme chez les patients transfuses et d’identifier les facteurs qui l'influencent. Patients et methodes. – Les patients admis et transfuses au CHU de Rouen au premier semestre 1996 ont ete recherches de facon retrospective, ainsi que leur etat a six mois (vivant ou decede). Les caracteristiques des patients transfuses ont ete comparees a celles de l'ensemble des patients admis. Les facteurs independants associes au deces a six mois ont ete recherches par le modele de Cox. Resultats. – En six mois, 1887 patients ont ete transfuses. Ils etaient plus âges, avaient ete admis plus souvent en chirurgie et en reanimation, et avaient eu des sejours plus longs que l’ensemble des patients admis. La survie actuarielle etait de 76,1 % a six mois chez les patients transfuses. La mortalite a six mois etait plus forte, de facon independante, chez les patients de 75 ans et plus, chez les hommes, en cas de passage en reanimation, en cas de transfusion de plasma frais ou de concentres de plaquettes homologues. Elle etait moins elevee en cas d'intervention chirurgicale, chez les enfants de moins de 16 ans, et chez les patients dont les sejours etaient classes en « Affections de l'appareil circulatoire », « Affections et traumatismes de l'appareil musculosquelettique et du tissu conjonctif » ou « Traumatismes, allergies et empoisonnements ». Conclusion. – Dans cette etude realisee dans un etablissement hospitalo-universitaire, la survie des patients transfuses est principalement associee aux caracteristiques et a la gravite des pathologies ayant justifie les transfusions.

Summary Hepatitis C viral infection (HCV) is a frequent and severe disease; screening strategies to-date remain insufficient. Objective To assess the efficiency of HCV screening of high-risk groups among patients consulting general practitioners. Methods A cost-effectiveness analysis was performed involving general medicine screening practices recorded during a survey of 127 practitioners (10 041 patients) conducted in 1997. A reference strategy, defined as HCV screening for illicit drug users and transfused patients, and five extended strategies, where the screening population was broadened to include other risk groups as well, were considered. Average cost and marginal cost-effectiveness ratios were determined for each extended strategy and compared with those observed for the reference strategy. The sensitivity of HCV screening to funding modalities, HCV seroprevalence and proportion of HCV high-risk groups among patients attending general practitioners was studied. Results The reference strategy was the most cost-effective method irrespective of the funding modality considered. Fixed practitioner payment was the least efficient funding modality. The average cost of one positive test was sensitive to variations of HCV seroprevalence in the high-risk group as well as the proportion of high-risk patients among the general practitioners’ patients. Conclusion Extension of hepatitis C screening to risk groups other than transfused patients and illicit drug users implies a substantial increase in healthcare costs as well as social consensus for such expenditures.

Low-dose aspirin (< 330 mg/d) is recommended for the prevention of myocardial infarction or ischemic stroke. Six to 12% of the general population is exposed to low-dose aspirin. The most frequently studied digestive complications are bleeding peptic ulcers, whose risk is increased twofold by low-dose aspirin treatment, and non-complicated peptic ulcers. History of bleeding or non-complicated peptic ulcer, alcohol intake, concomitant treatment with NSAID or calcic inhibitors are demonstrated risk factors of bleeding ulcer associated with low-dose aspirin. The role of enteric coating, of low-dose aspirin dose, of delay since low-dose aspirin treatment onset, and of Helicobacter pylori infection, remains controversial. Antisecretory drugs (H2 inhibitors, proton pump inhibitors), and nitroglycerin are associated with a decreased risk of bleeding ulcer. The protective effect of COX-2 inhibitors on the risk of bleeding ulcer is suppressed by concomitant treatment with low-dose aspirin. The risk of no- complicated peptic ulcer was increased by low-dose aspirin intake by a factor 2.9 in one study. Low-dose aspirin dose, infection by Helicobacter pylori, NSAID intake, and absence of enteric coating, are possible risk factors for non-complicated peptic ulcer. No association was retrieved with alcohol intake and peptic ulcer history.

Resume Les anti-inflammatoires non-steroidiens non salicyles (AINS) sont parmi les medicaments les plus prescrits et utilises, du fait de leur efficacite therapeutique dans de multiples indications. En France, le pourcentage de sujets de 40 ans et plus traites dans l’annee par AINS a ete estime a 25 %. Le benefice attendu du traitement AINS est contrebalance par la frequence des effets secondaires gastro-duodenaux. Des symptomes dyspeptiques sont associes au traitement AINS chez 30 a 40 % des patients, soit environ deux fois plus que chez des sujets controles. Les lesions endoscopiques asymptomatiques sont egalement tres repandues, avec une frequence variant de 20 a 80 % des sujets, en fonction des populations etudiees, des modalites du traitement et de la definition des lesions endoscopiques. Le risque d’ulcere symptomatique ou d’ulcere complique par une hemorragie, une perforation ou une stenose est multiplie par 4 environ par le traitement AINS, de meme que le risque de deces associe a une complication ulcereuse. Parmi les facteurs de risque de complications gastro-duodenales sous AINS, certains sont bien demontres tels que l’âge, les antecedents ulcereux compliques ou non, la consommation excessive d’alcool, la specialite AINS utilisee, la posologie, l’association avec les corticoides ou l’aspirine, ou les anticoagulants (pour les hemorragies ulcereuses). En revanche, l’effet de la duree du traitement (institution recente ou non) et de l’infection associee par Helicobacter pylori reste controverse.

Longitudinal binary data are often used in panel studies where short-term associations between air pollutants and respiratory health outcomes are investigated. A Markov regression model in which the transition probabilities depend on the covariates, as well as the past responses, was used to study the short-term association between daily ozone (O3) concentrations and respiratory health outcomes in a panel of schoolchildren in Armentieres, Northern France. The results suggest that there was a small but statistically significant association between O3 and children's cough episodes. A 10 μg/m3 increase in O3 concentrations was associated with a 13.9 % increase in cough symptoms (CI 95% = 1.2–28.1%). The use of a Markov regression model can be useful as it permits one to address easily both the regression objective and the stochastic dependence between successive observations. However, it is important to verify the sensitivity of the Markov regression parameters to the time-dependence structure. In this study, it was found that, although what happened on the previous day was a strong predictor of what happened on the current day, this did not contradict the O3-respiratory symptom associations. Compared to the Markov regression model, the signs of the parameter estimates of marginal and random-intercept models remain the same. The magnitudes of the O3 effects were also essentially the same in the three models, whose confidence intervals overlapped. Copyright © 2003 John Wiley & Sons, Ltd.

Resume Introduction Depuis octobre 1996, les etablissements de sante doivent depister le virus de l'hepatite C (VHC) et le virus de l'immunodeficience humaine (VIH) chez les patients avant et trois mois apres chaque transfusion sanguine. Le but de ce travail etait d'evaluer la mise en œuvre de cette mesure reglementaire dans un etablissement par une comparaison avant/apres. Methodes Une etude retrospective concernant la pratique ou non des tests de depistage pour le VHC et le VIH a ete realisee sur deux echantillons aleatoires de 150 patients transfuses en 1996 et en 1998. Resultats La couverture des transfusions par les tests de depistage pre-transfusionnels pour le VHC et le VIH etait de 23 % en 1996 et 20 % en 1998 (non significatif). Les tests post-transfusionnels etaient realises par l'etablissement chez 6 % des malades transfuses en 1996 et 3 % en 1998. Conclusion Cette etude suggere que le depistage surtout post-transfusionnel du VHC et du VIH ne semble pas assure pour la majorite des patients transfuses et que cette pratique n'a pas evolue en deux ans.

The aim of this study was to compare home polysomnography (HoPSG) with laboratory polysomnography (LabPSG) in the diagnosis of sleep apnea syndrome (SAS). A total of 103 patients referred for investigation of SAS underwent two full polysomnographies, using the portable Minisomno device at home and the Respisomnographe in the laboratory (both devices manufactured by the same company). Twenty percent of home-studied device polysomnography (HoSD-PSG) recordings and 5% of LabPSG recordings were excluded from analysis either because of lost data or poor quality data. Sleep stage distribution and subjective quality of sleep were similar by both methods. Using LabPSG, the mean (+/- SD) RDI was 25.7 (+/- 30.6) versus 22.8 (+/- 31.5) using HoSD-PSG (p > 0.05). Absolute differences between the home and laboratory respiratory disturbance index (RDI) were less than 10 for 65% of patients. Discordant RDIs (i.e., differences greater than 10) were observed for 63% of individuals with severe SAS (RDI > 30) versus 22% of those with normal or moderate SAS (RDI

Objective To compare incidence rates and epidemiological characteristics of acute upper gastro-intestinal haemorrhage (AUGIH) in France with those of other European studies. Design Population-based multi-centre prospective survey. Setting 29 public hospitals and 96 private specialists in gastroenterology in four administrative areas in France during 1996. Subjects A total of 2133 AUGIH patients 18 years and over were included in the six-month study. Outcome measures Incidence and mortality. Results The overall incidence in France was 143 cases per 100 000 persons per year, classified as out-patients (16%), emergency admissions (59%) and in-patients (25%). The incidence rates increased with age except for in-patients, and were higher in males. Peptic ulcer (36.6%), varices (13.7%) and erosive disease (12.3%) were the most frequent diagnoses. In 677 patients (31.7%), aspirin, anti-inflammatory drugs or corticosteroids were taken on the 7 days before bleeding. The overall mortality (out-patients excluded) was 14.3% (10.7% for emergency patients and 23% for in-patients). Mortality was associated with co-morbidities (especially malignancies, cirrhosis, asthma or respiratory deficiency), was lower in emergency patients using non-steroid anti-inflammatory drugs, and higher in in-patients using corticosteroids. Conclusions In France, patients with AUGIH are frequently managed as out-patients. Gastrotoxic drug use is frequently associated with AUGIH and constitutes a strategic opportunity for preventive treatment. Discrepancies between countries are not clearly explained either by demographic factors or by drug use, but this may be related to the emphasis on AUGIH in in-patients.

Hepatitis C : emerging Disease or better Knowledge ? Hepatitis C virus (HCV) identified in 1989 is mainly transmitted through transfusion of blood products, intravenous drug abuse, or medical procedures with blood contact. Detection of HCV contaminated blood products, education of intravenous drug users (decrease of needle sharing), and improvement in disinfection of medical devices allowed to obtain an important decrease in these transmissions. Sexual transmission and mother-to-child transmission are uncommon. In one patient out of four, the origin of transmission remains unknown. Infection by HCV causes acute hepatitis C, that becomes chronic in more than 50% of infected patients. Most of the time, the infection remains asymptomatic. About 20% of patients with chronic hepatitis C develop cirrhosis, with the risk of evolution toward liver cancer. The optimal treatment is presently the combination of interferon and ribavirin. In France, the overall prevalence of HCV infection is about 1%. It reaches 5.5% in patients with a history of blood products transfusion and 60% in intravenous drug users. It is generally admitted that only 10% of infected subjects are identified. The prevalence of HCV infection varies between French areas from 0.7 to 1.8%, and hospital care varies in the same proportion. These discrepancies could be explained by intravenous drug users prevalences, or by differences in screening or management of patients. In the world, the prevalence of HCV infection is estimated to average 2%. The highest prevalences are observed in Africa probably due to higher proportions of intravenous drug users, or to more frequent contaminations by blood products or medical procedures. In the future, HCV infection will represent an important problem for health care systems, as well for industrial countries as for developing countries., La transmission du virus de l'hépatite C (VHC) identifié en 1989 se fait essentiellement par les produits sanguins lors de transfusions, d'injections de drogues ou encore de soins médicaux invasifs. Le dépistage des produits sanguins contaminés, l'information des toxicomanes et le progrès des méthodes d'asepsie des soins ont permis de réduire fortement le risque de ces transmissions. La transmission sexuelle et de la mère à l'enfant sont rares. Chez un malade sur quatre la cause de la contamination est inconnue. La contamination par le VHC donne lieu à une hépatite aiguë qui évolue dans plus d'un cas sur deux vers une hépatite chronique de façon le plus souvent asymptomatique. Une fois sur cinq l'hépatite chronique se complique par une cirrhose, avec un risque ultérieur de cancer du foie. Actuellement le meilleur traitement est l'association interfé- ron-ribavirine. La prévalence de l'infection par le VHC varie en France de 1 % dans la population générale, 5,5% chez les personnes ayant des antécédents de transfusion et 60% chez les toxicomanes. On estime que 10% seulement des personnes contaminées sont connus. En France, la fréquence de l'infection par le VHC et du recours aux soins pour les sujets infectés varie du simple au double d'une région à l'autre, du fait de fréquences différentes des groupes à risque (toxicomanes), pas d'un meilleur diagnostic de l'infection ou d'une prise en charge différente des malades. Dans le monde, la prévalence de l'infection par le VHC est en moyenne de 2%, mais elle est supérieure à 10% en Afrique. Une proportion plus importante de toxicomanes ou des contaminations plus fréquentes par les produits sanguins ou le matériel médico-chirurgical pourraient intervenir. L'infection par le VHC devrait poser dans l'avenir des problèmes importants aux systèmes de santé des pays industrialisés et sous-développés., Josset Valérie, Merle Véronique, Czernichow Pierre. Hépatite C : émergence d'une maladie ou progrès scientifiques?. In: Espace, populations, sociétés, 2000-2. Maladies émergeantes et reviviscentes. pp. 273-280.

PURPOSE: This study was conducted to evaluate the incidence, identify the risk factors, and assess the prognosis of elderly institutionalized patients who develop fecal incontinence. PATIENTS AND METHODS: We enrolled 1,186 patients 60 years of age and older living in long-term care facilities who did not have fecal incontinence. We assessed their medical history, treatment, mobility, and cognitive function. Patients were followed up for 10 months to determine the incidence of fecal incontinence, defined as at least one involuntary loss of feces. Independent risk factors associated with fecal incontinence were identified using Cox proportional hazards models. The prognosis of incontinent patients was assessed by comparing their survival rate with that in the continent patients. RESULTS: Fecal incontinence occurred in 234 patients (20%), and was usually associated with acute diarrhea or fecal impaction. We identified five risk factors for the development of fecal incontinence: a history of urinary incontinence (rate ratio [RR]: 2.0, 95% confidence interval [CI] 1.5 to 2.6); neurological disease (RR: 1.9, 95% CI 1.0 to 3.4); poor mobility (RR: 1.7, 95% CI 1.2 to 2.4); severe cognitive decline (RR: 1.4, 95% CI 1.1 to 1.9); and age older than 70 years (RR: 1.7, 95% CI 1.0 to 2.8). Ten-month mortality in the 89 patients with long-term (≥8 days) incontinence was 26%, significantly greater than that observed in the continent group (6.7%) or in the 145 patients with transient incontinence (10%). CONCLUSIONS: Long-lasting or permanent fecal incontinence was associated with increased mortality, suggesting that this symptom is a marker of poor health in older patients. Actions that improve mobility might help prevent fecal incontinence in elderly patients.

A previous study suggested that most surgical patients do not remember having received information about surgical site infection (SSI). In other fields, written information has been suggested to improve patient satisfaction and recollection of information. Our objective was to assess if providing patients with written information about SSI, in addition to oral information, could influence patient satisfaction, recall of information, and opinion regarding SSI. A total of 207 patients scheduled for digestive surgery at a university hospital were randomized between usual oral information about SSI, plus an information leaflet about SSI (group O/L), or usual oral information alone (group O). Patients were interviewed 5 weeks after surgery to assess their recall and satisfaction regarding information, opinion regarding SSI, and declared intention of seeking legal action in case of SSI. Surgeons and interviewer were blinded to patients’ group allocation. Recruitment occurred between October 2005 and August 2006. Of the original 207 patients, 161 patients (O/L = 87, O = 74) underwent operation and were interviewed as scheduled. Satisfaction was higher in group O/L (67% vs. O: 43%; P = 0.003). The recall of having received information (O/L: 39% vs. O: 31%; P = 0.29), was similar between the two groups. Judging SSI as always preventable was more frequent in group O/L (28% vs. O: 9%; P = 0.004) with a trend toward a more frequent intention of seeking legal action (O/L: 10% vs. O: 3%; P = 0.055). The leaflet did not improve patient recall of information about SSI, but it was associated with an increased level of satisfaction. The association between the leaflet and judging SSI as always preventable was unexpected.

Objective: To determine, in a case-control study, whether exposure to non-steroidal anti-inflammatory drugs (NSAIDs) was associated with segmental non-gangrenous colitis. Methods: One hundred and sixteen consecutive patients with segmental non-gangrenous colitis were compared with 232 age- and gender-matched hospital controls (two controls for each patient). Data on past medical history and use of drugs within 30 days before admission were collected using a standardized questionnaire administered to each patient. Results: Twenty patients (17.2%) and eight controls (3.4%) were taking NSAIDs on admission (P

Objective.To evaluate the knowledge of healthcare students after four curricula on infection control and to identify sources of information.Design.Cross-sectional study.Setting.Four healthcare schools at Rouen University (Rouen, France).Participants.Medical students, nursing students, assistant radiologist students, and physiotherapist students taking public health courses.Methods.To measure students' knowledge of infection control and their sources of information, 6 multiple-choice questions were asked about 3 specific areas: standard precautions, hand hygiene, and nosocomial infection. Each questionnaire section had 10 possible points, for an overall perfect score of 30. The sources of information for these 3 areas were also recorded: self-learning, practice training in wards, formal training in wards, and teaching during the curriculum. A logistic regression analysis was performed to identify factors associated with acceptable level of knowledge.Results.Three hundred fifty students (107 medical students, 78 nursing students, 71 physiotherapist students, and 94 assistant radiologist students) were included in the study. The mean overall score (±SD) was 21.5 ± 2.84. Nursing students had a better mean overall score (23.2 ± 2.35) than did physiotherapist students (21.9 ± 2.36), medical students (21.1 ± 2.35), and assistant radiologist students (20.5 ± 3.04; P < .001). The mean scores (±SD) for the component sections of the questionnaire were 8.5 ±1.4 for standard precautions, 7.4 ± 1.26 for hand hygiene, and 5.7 ± 1.55 for nosocomial infections (P < .001). The main source of information was material taught during the curriculum. Results of multivariate analysis indicate that the probability of attaining acceptable knowledge in each area was smaller for medical students and assistant radiologist students than for nursing students.Conclusion.The overall score for infection control indicated that instruction was effective; however, knowledge levels were different by area (the best scores were results of tests of standard precautions) and curriculum (nursing students achieved the best overall score). Ward training for daily infection control practice (ie, bedside instructions training and course work) could be improved for healthcare students.

Premature mortality: Comparative Methods. The analysis of premature mortality by the Potential Years Lost of Live (PYLL) is made difficult when important variations exist in the into-regional mortality. In this case, overmortality implies some years of life that are lost. The PYLL rates are then highly linked to the Comparative Index Rates of Mortality. We propose, in this paper, to calculate a Premature Mortality Comparative Index, corrected as for mortality; this index is no longer linked to the mortality rates. The cartography of the French pattern let appear significant differences., L'analyse de la mortalité prématurée par les Années Potentielles de Vie Perdues (A.P.V.P.) est rendu difficile lorsqu'il existe des variations importantes de la mortalité inter-régionale. La surmortalité implique alors des années supplémentaires de vie perdue. Les taux d'A.P.V.P. sont donc fortement liés aux taux de l'Indice Comparatif de Mortalité. Ce travail propose le calcul d'un Indice Comparatif de Mortalité Prématurée corrigé du niveau de la mortalité ; cet indice n'est plus lié aux taux de mortalité. La cartographie de l'exemple français fait apparaître des nuances significatives., Czernichow P., Vaguet A., Frenkiel J., Froment L., Maret Y., Guermond Yves. La prématurité des décès : méthodes comparées. In: Espace, populations, sociétés, 1990-3. Les inégalités géographiques de la mortalité (I) - The Geographical Inequalities of Mortality (I) pp. 417-426.