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Objective: Estimating overdiagnosis associated with breast cancer screening may use annual incidence rates of cancer. We simulated populations invited to screening programmes to assess two lead-time adjustment methods.Methods: Overdiagnosis estimates were computed using the compensatory drop method, which considered the decrease in incidence of cancers among older age groups no longer offered screening, and the method based on the decrease in incidence of late-stage cancers.Results: The true value of overdiagnosis was 0% in all the data sets simulated. The compensatory drop method yielded an overdiagnosis estimate of -0.1% (95% credibility interval -0.5% to 0.5%) when participation rates among the population and risk of cancers were constant. However, if participation rates increased with calendar year as well as risk of cancer with birth cohorts, the overdiagnosis estimated was 11.0% (10.5-11.6%). Using the method based on the incidence of early- and late-stage cancers, overdiagnosis estimates were 8.9% (8.5-9.3%) and 17.6% (17.4-17.9%) when participation rates and risks of cancer were constant or increased with time, respectively.Conclusion: Adjustment for lead time based on the compensatory drop method is accurate only when participation rates and risks of cancer remain constant, whereas the adjustment method based on the incidence of early- and late-stage cancers results in overestimating overdiagnosis regardless of stability of participation rates and breast cancer risk. [ABSTRACT FROM AUTHOR]

The purpose of this study was to compare compliance with recommendations and clinical outcomes between formal and informal infectious disease specialist consultations. Six hundred twenty-seven consecutive adult inpatients who received an infectious disease consultation in a university-affiliated hospital were included. After adjusting for quintile of propensity score, we compared compliance with the consultant's recommendations and clinical outcomes for 443 (70.7%) and 184 (29.3%) formal and informal consultations. Informal and formal consultations were associated with comparable levels of compliance with recommendations for antimicrobial treatment (86.5% vs 88.9%; adjusted odds ratio [aOR], 0.63; 95% confidence interval, 0.34-1.14; P = 0.13) and diagnostic or monitoring tests (72.6% vs 72.0%; aOR, 0.91 [0.53-1.57]; P = 0.73). The rates of early clinical improvement (58.2% vs 58.6%; aOR, 1.11 [0.70-1.74]; P = 0.66), subsequent consultation (34.2% vs 36.3%; aOR, 0.80 [0.53-1.21]; P = 0.29), in-hospital mortality (4.9% vs 8.4%; aOR, 0.55 [0.24-1.24]; P = 0.15), and the median length of stay (23 vs 20 days; aOR of discharge, 0.90 [0.74-1.10]; P = 0.30) did not differ depending on the type of consultation. This study provides observational evidence that informal consultations result in levels of compliance with recommendations comparable to formal consultations, without compromising patient safety. Further study is needed to refine the criteria for requesting or providing informal rather than formal consultations. [ABSTRACT FROM AUTHOR]

BACKGROUND: Although older patients with restricted mobility are at increased risk for venous thromboembolism, they are under-represented in clinical trials evaluating prophylactic treatments against deep vein thrombosis (DVT). OBJECTIVE: To determine whether prolonged prophylaxis with low-molecular-weight heparin (LMWH) is associated with a lower rate of DVT in older patients with restricted mobility. METHODS: Two cross-sectional studies were conducted in 50 hospital-based, post-acute care facilities in France in 2001 and 2003. The studies included 1603 evaluable patients aged >or=65 years, including 866 LMWH users (median treatment duration 23 days; interquartile range 13-42) and 737 LMWH non-users. All patients underwent complete compression ultrasonography performed by board-certified vascular medicine physicians. The primary study outcome was proximal DVT. Propensity analyses were used to control for bias in LMWH treatment assignment. RESULTS: The rate of proximal DVT was 4% (35/866) and 5.7% (42/737) for LMWH users and non-users, respectively (p = 0.16). Prophylaxis with LMWH was associated with decreased odds of proximal DVT after adjusting for baseline characteristics (odds ratio [OR] 0.56; 95% CI 0.33, 0.95; p = 0.03) or quintile of propensity score (OR 0.58; 95% CI 0.35, 0.99; p = 0.04). In propensity matched analysis, 342 LMWH users were at decreased odds of proximal DVT compared with 342 non-users (OR 0.50; 95% CI 0.24, 1.00; p = 0.04). The decrease in proximal DVT was paralleled by a similar decrease in distal DVT. Compared with non-users, only high-risk dose users had decreased odds of DVT. CONCLUSIONs: In this observational study, prophylaxis with a high-risk dose of LMWH was associated with decreased odds of proximal DVT in older patients with restricted mobility. Further study is needed before recommending routine prophylaxis with LMWH in these patients. [ABSTRACT FROM AUTHOR]

Abstract: Introduction: In observational studies, a significant difference in the outcomes between treated and untreated patients may be observed in absence of treatment effect and caused by differences in baseline characteristics. Exegesis: Propensity score analysis is a post hoc adjustment method which consists in deriving the conditional probability of receiving the treatment for a patient given his measured baseline characteristics (i.e., the propensity score). Matching each treated patient to an untreated one who has the nearest propensity score tends to balance baseline characteristics between the two groups and reduce the risk for overt bias. Then, the outcomes can be compared between matched treated and untreated patients. Conclusion: Propensity score analysis is relevant for clinical conditions and treatments for which randomized controlled trials are unlikely to be conducted. However, propensity analysis cannot adjust for unmeasured characteristics and sensitivity analysis should be performed to assess how sensitive the conclusions are to potential confounding factors. [Copyright &y& Elsevier]

We aimed to assess the appropriateness of routine blood culture testing parameters and antimicrobial therapy for patients with suspected bloodstream infection. We conducted a cross-sectional study of blood cultures registered in the microbiological laboratory at a university-affiliated hospital from 4 to 15 June 2007. Using a structured implicit chart review, two infectious disease specialists assessed the appropriateness of the testing parameters and antimicrobial therapy. Overall, 2,696 blood culture bottles were collected from 260 patients during their stay, including 955 bottles that were evaluated during the study period. The indication of fungal and bacterial blood cultures was rated as appropriate for 75% (95% confidence interval [CI], 65-83) and 91% (95% CI, 87-95) of patients. Only 45% (95% CI, 39-52) of patients had an adequate number of blood cultures (i.e., two to four). An optimal volume of blood (i.e., ≥10 mL) was inoculated in 13% (95% CI, 11-15) of adult bottles. Empirical antimicrobial therapy was appropriate for 60% (95% CI, 43-76) of patients with positive blood cultures. There is room for improvement regarding routine blood culture testing parameters and antimicrobial therapy. The effectiveness of multifaceted interventions in altering the appropriateness of blood culture parameters deserves further research. [ABSTRACT FROM AUTHOR]

Summary: Background: Tuberculosis prevention has been based on generalized BCG vaccination in France since 1949. The aim of this cross-sectional survey was to assess the impact of the change in BCG administration (in January 2006) and the end of compulsory vaccination (in July 2007). Method: A self-administered postal questionnaire was sent to a random sample of 2248 physicians practicing in 6 departments in the Rhône-Alpes region in 2008. Results: Overall, 923 questionnaires were analyzed. The median age of the respondents was 52 years, 67 % were male, 93 % were general practitioners, and 91 % practiced in private practice offices. The median number of BCG vaccines administered on a quarterly basis was 5 (interquartile range [IQR], 3–10) before January 2006, one (IQR, 0–3) between January 2006 and July 2007, and zero (IQR, 0–1) after July 2007 (P <0.001). The rate of BCG vaccination was significantly lower for male physicians, physicians older than 50 years, general practitioners, practitioners working in private offices, and for some departments. Thirty-nine percent of the physicians were informed of the national program against tuberculosis 2007–2009, and 41 % wished to be trained in the practice of intradermal vaccination. Conclusion: This survey suggests that the withdrawal of Monovax® and the lifting of generalized vaccination requirements were followed by a substantial decrease in the number of BCG vaccinations. The intradermal route constitutes an obstacle for BCG vaccination that might be overcome by specific training. [Copyright &y& Elsevier]

The study of nutritional, physiological and physical factors affecting basidiospore development in Rhizoctonia solani evidenced the critical influence of the physiological state of the mycelium subjected to a nutritional stress for fruiting induction. Comparison of four preculture media allowed identification of the optimal nutrient status provided by glucose, yeast extract and bacto-peptone, for subsequent basidial differentiation on a starved water agar medium. While variations of glucose and yeast extract concentrations are not determinant for basidial differentiation, the breakdown observed with a low bacto-peptone concentration underscores a major role for the nitrogen content which, however, should be considered in a balance with the carbon source. The basidial differentiation was shown: (i) to increase as the age of the preculture used to inoculate water agar increases; (ii) to be stimulated by a dark/light regime, and (iii) to be induced and increased by a cold temperature shock (8°C) when the mycelium was derived from young precultures. The effect of the cold temperature shock indicates that the preculture conditions can induce long-term physiological modifications in the mycelia. While the fruiting response to nutritional factors is similar whatever the strain used, the response to environmental factors depends mainly on the genotype of the strains. [ABSTRACT FROM AUTHOR]

Objectives: Within the past decade, biochemical markers have emerged as attractive tools to assess pulmonary arterial hypertension (PAH) prognosis, being noninvasive and easily repeatable.The objective of this study was to determine whether biomarkers measured at initial diagnostic right-sided heart catheterization predict 3-year all-cause mortality for incident cases of PAH independently of clinical and hemodynamic parameters.Methods: Patients with incident PAH were enrolled between December 2003 and April 2006 in six centers from the French Network on Pulmonary Hypertension and followed for 3 years.Venous blood samples were taken during right-sided heart catheterization, and analyses were centralized.Results: Among 110 enrolled patients, 11 underwent lung or heart/lung transplantation, and 27 died during follow-up. The Kaplan-Meier estimates of survival were 91%, 78%, and 75% at 1, 2, and 3 years, respectively. Plasma big endothelin-1 (hazard ratio [HR] per 1-SD increase, 1.48; 95% CI,1.14-1.92), serum troponin T . 0.01 mg/L (HR, 2.35; 95% CI, 1.05-5.29), and urinary F 2 -isoprostanes(15-F2t -isoprostane) (HR per 1-SD increase, 1.76; 95% CI, 1.31-2.36) were associated with increased unadjusted hazard of death. In multivariate analysis adjusting for patient characteristics, the level of urinary F 2 -isoprostanes was the only biomarker that remained independently associated with increased hazard of death (HR per 1-SD increase, 1.82; 95% CI, 1.28-2.60).Conclusions: This study shows that levels of urinary F 2 -isoprostane, a biomarker of lipid peroxidation,quantified at initial diagnostic right-sided heart catheterization are independently associated with mortality in a cohort of patients with incident PAH. [ABSTRACT FROM AUTHOR]

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

Context: In patients with suspected lower extremity deep vein thrombosis (DVT), compression ultrasound (CUS) is typically the initial test to confirm or exclude DVT. Patients with an initial negative CUS result often require repeat CUS after 5 to 7 days. Whole-leg CUS may exclude proximal and distal DVT in a single evaluation.Objective: To determine the risk of venous thromboembolism after withholding anticoagulation in patients with suspected lower extremity DVT following a single negative whole-leg CUS result.Data Sources: MEDLINE, EMBASE, CINAHL, LILACS, Cochrane, and Health Technology Assessments databases were searched for articles published from January 1970 through November 2009. Supplemental searches were performed of Internet resources, reference lists, and by contacting content experts.Study Selection: Included studies were randomized controlled trials and prospective cohort studies of patients with suspected DVT and a negative whole-leg CUS result who did not receive anticoagulant therapy, and were followed up at least 90 days for venous thromboembolism events.Data Extraction: Two authors independently reviewed and extracted data regarding a single positive or negative whole-leg CUS result, occurrence of venous thromboembolism during follow-up, and study quality.Results: Seven studies were included totaling 4731 patients with negative whole-leg CUS examinations who did not receive anticoagulation. Of these, up to 647 patients (13.7%) had active cancer and up to 725 patients (15.3%) recently underwent a major surgery. Most participants were identified from an ambulatory setting. Venous thromboembolism or suspected venous thromboembolism-related death occurred in 34 patients (0.7%), including 11 patients with distal DVT (32.4%); 7 patients with proximal DVT (20.6%); 7 patients with nonfatal pulmonary emboli (20.6%); and 9 patients (26.5%) who died, possibly related to venous thromboembolism. Using a random-effects model with inverse variance weighting, the combined venous thromboembolism event rate at 3 months was 0.57% (95% confidence interval, 0.25%-0.89%).Conclusion: Withholding anticoagulation following a single negative whole-leg CUS result was associated with a low risk of venous thromboembolism during 3-month follow-up. [ABSTRACT FROM AUTHOR]

Objective: To develop a generic French self-administered instrument for measuring hospitalized patients' satisfaction based on the patient's point of view: the questionnaire for satisfaction of hospitalized (QSH) patients.Design: The development was supervised by a steering committee and undertaken through three standard steps. Item generation was derived from 95 face-to-face interviews, performed in hospitalized patients and in patients scheduled to be admitted. The item reduction led to a 69-item questionnaire. The validation process was based on validity, reliability and some aspects of external validity.Setting: Medical, surgical and obstetrical departments (n = 187) of public hospitals (n = 11) from different French regions (n = 3).Participants: Eligible patients were adult subjects hospitalized for at least 24 h.Main Outcome Measures: QSH, sociodemographic data, hospitalization department, visual analogue scales of satisfaction.Results: The final version of QSH contained 45 items describing 9 dimensions, leading to 2 composite scores (staff and structure index). The factor structure accounted for 71% of the total variance. Internal consistency was satisfactory (item-internal consistency over 0.40; Cronbach's alpha coefficients ranged from 0.76 to 0.96). The scalability was satisfactory with inlier-sensitive fit (INFIT) statistics inside an acceptable range. Scores of dimensions were strongly positively correlated with visual analogue scale scores (all P < 0.001). External validity showed statistical associations between QSH scores and age or department. Participation rate was 91%.Conclusions: The availability of a reliable and valid French questionnaire concerning hospitalized patients' satisfaction, exclusively generated from patients' interviews, enables patient feedback to be incorporated in a continuous quality health-care improvement strategy. [ABSTRACT FROM AUTHOR]

Objective: Identification and estimation, by clinical pharmacists participating in routine medical rounds, of drug-related problems (DRPs), arising despite the use of a computerized physician order entry (CPOE) system. Methods: An 18-month prospective study of DRPs through a CPOE was conducted by seven clinical pharmacists participating in ward activity. DRPs were identified by two independent pharmacists using a structured order review (French Society of Clinical Pharmacy instrument). Results: A total of 29 016 medication orders relating to 8152 patients were analysed, and 2669 DRPs, involving 1564 patients (56% female; mean age 72·6 years), were identified representing 33 DRPs per 100 admissions. The most commonly identified DRPs were non-conformity to guidelines or contra-indication (29·5%), improper administration (19·6%), drug interaction (16·7%) and overdosage (12·8%). There were 429 different drugs associated with these DRPs. Cardiovascular drugs were the most frequently implicated (22·2%), followed by antibiotics/anti-infectives (13·3%) and analgesics/antiinflammatory drugs (11·3%). Different types of DRPs were closely associated with specific classes of drugs. Conclusions: Drug-related problems are common even after implementation of CPOE. In this context, routine participation of clinical pharmacists in clinical medical rounds may facilitate identification of DRPs. Pharmacists should be able to enhance patient safety through such involvement. [ABSTRACT FROM AUTHOR]

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