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The main purpose of this study was to explore the potential influences of pickleweed vegetation on the abundance, diversity and metabolic activities of microbial communities in four distinct areas of a petroleum-contaminated solid waste management unit (SWMU) located in Contra Costa County, northern California. The four areas sampled include two central areas, one of which is central vegetated (CV) and one unvegetated (UV), and two peripheral vegetated areas, one of which is located to the west side of the SWMU (V-West) and one located to the east side (V-East). Measurements were made of total petroleum hydrocarbons (TPH), polyaromatic hydrocarbons (PAH), soil physicochemical properties, and various aspects of microbial communities including metabolic activities, microbial abundances (PLFAs), diversity and composition based on amplicon sequencing. The peripheral V-East and V-West sites had 10-times lower electrical conductivity (EC) than that of the CV and UV sites. The high salinity levels of the CV and UV sites were associated with significant reductions in bacterial and fungal abundances (PLFA) when compared to V-East but not when compared to V-West. TPH levels of CV and UV were not significantly different from those of V-West but were substantially lower than V-East TPH (19,311 mg/kg of dry soil), the high value of which may have been associated with a pipeline that ran through the area. Microbial activities (in terms of soil respiration and the activities of three soil enzymes, i.e., urease, lipase, and phosphatase) were greatest in the vegetated sites compared to the UV site. The prokaryotic community was not diverse as revealed by the Shannon index with no significant variation among the four groups of samples. However, the fungal community of the peripheral sites, V-East and V-West had significantly higher OTU richness and Shannon index. Structure of prokaryotic communities inhabiting the rhizosphere of pickleweed plants at the three sites differed significantly and were also different from those found in the UV region of the central site according to pairwise, global PERMANOVA and ANOSIM analyses. The differences in OTU-based rhizosphere-associated bacterial and fungal communities' composition were explained mainly by the changes in soil EC and pH. The results suggest that saline TPH-contaminated areas that are vegetated with pickleweed are likely to have increased abundances, diversity and metabolic activities in the rhizosphere compared to unvegetated areas, even in the presence of high salinity. more...

Resume Introduction La physiopathologie classique de l’osteomyelite aigue chez l’enfant a ete decrite par Trueta, pour qui le point de depart de l’infection est metaphysaire. Cette hypothese a recemment ete remise en cause par une etude de Labbe, qui evoque une origine periostee. Nous avons donc voulu, par la realisation d’IRM precoces, etudier cette physiopathologie et voir s’il existait, en fonction des anomalies decrites, des facteurs pronostiques. Materiel et methode Il s’agit d’une etude prospective multicentrique incluant les osteomyelites des os longs d’enfants ayant eu une IRM alors que la duree des symptomes etait inferieure a 7 jours et qu’une antibiotherapie avait ete debutee depuis moins de 24 heures. Nous avons egalement collecte les donnees cliniques, biologiques et liees au traitement. Resultats Nous avons inclus 20 patients, l’un presentant une atteinte bifocale. L’atteinte predominait aux membres inferieurs (19/21). Le germe le plus souvent retrouve etait le Staphylococcus aureus. Une atteinte metaphysaire a ete retrouvee dans tous les cas. Aucune atteinte periostee isolee n’a ete decrite. Il n’a pas ete etabli de facteur pronostique en fonction des differents types d’anomalies IRM decrites. Conclusion Notre etude va dans le sens d’une origine metaphysaire de l’osteomyelite aigue de l’enfant. Niveau de preuve Deux. more...

Aim Combined infliximab and sphincter-sparing surgery can be effective in perianal fistula associated with Crohn's disease (CD). This study aimed to assess the efficacy of local surgery combined with infliximab on sustained fistula closure and to identify predictive factors for response after this combined treatment. Method Between 2000 and 2010, 81 patients with fistulising perianal CD were included in this observational study. Drainage with a loose seton was followed by infliximab therapy. The primary end-points were the rate of complete fistula closure and time required for this to occur. Results The fistula was complex in 71 (88%) of the 81 patients. Local proctological surgery was carried out in 77 (95%), including seton drainage in 62 (80.5%) of these. This was continued for a median duration of 3.8 months and the patient then received infliximab therapy. The median follow-up after treatment was 64 months (2–263). Initial complete closure of the fistula occurred in 71 (88%) cases at a median interval of 12.4 months (1–147) from the start of treatment. Recurrence was observed in 29 (41%) patients at a median interval of 38.5 months (2–48) from the start of treatment. They were treated again with combined treatment with successful closure in 19 (65.5%) patients. The total rate of closure of the fistula was 75.3%. Female gender, anal stenosis, rectovaginal and complex fistula formation were factors independently associated with failure of combined treatment. Conclusion Seton drainage for several months combined with infliximab therapy is effective in closing the fistula in 75% of patients with complex perianal fistula formation associated with CD. more...

RésuméIntroductionLe cancer broncho-pulmonaire est la première cause de décès par cancer en France. Son diagnostic est le plus souvent tardif, alors que le délai entre le début des symptômes et la prise en charge est considéré comme un facteur aggravant.Matériel et méthodesNotre étude prospective a recueilli les différentes dates de prise en charge de 139 patients consécutifs bénéficiant d’un traitement primaire pour un cancer thoracique dans notre hôpital entre novembre 2008 et mai 2009. L’objectif de cette étude était d’évaluer différents délais de prise en charge des patients porteurs d’un cancer thoracique quelle que soit sa prise en charge thérapeutique (médicale ou chirurgicale) et de déterminer la cause de ces délais.RésultatsLe délai médian entre la première imagerie pathologique et le traitement est de 9,6 semaines. Les délais étaient significativement plus courts dans les stades tardifs et les carcinomes à petites cellules (p=0,001). Il existait une tendance à des délais plus courts pour les femmes et des délais plus longs pour les classes d’âge les plus élevées.ConclusionL’évaluation des délais de prise en charge, en particulier pour les stades précoces, s’intègre dans le contrôle de la qualité de prise en charge de ces pathologies.SummaryIntroductionLung cancer is the main cause of cancer death in France. The diagnosis is often late and the delay between the onset of symptoms and management is considered an aggravating factor.Material and methodsOur prospective study collected the dates of the start of management of 139 consecutive patients receiving first line treatment for thoracic cancer in our hospital between November 2008 and May 2009. The aim of this study was to evaluate the delays in medical or surgical treatments in patients with thoracic cancer and to determine the cause of these delays.ResultsThe median delay between the first abnormal chest X-ray and treatment was 9.6 weeks. The delays were significantly shorter in the late stages and in small cell cancer (P=0.001). There was a tendency for shorter delays in women and for longer delays in older patients.ConclusionEvaluation of the delays in treatment, particularly in the early stages, is part of the quality control of management of these diseases. more...

Resume Introduction Il est admis que l’epiphysiolyse femorale superieure est une des causes de coxarthrose precoce et de conflit femoro-acetabulaire anterieur. On ne trouve pas dans la litterature de moyen diagnostic fiable pour mesurer la deformation sequellaire d’une epiphysiolyse. Nous proposons la mesure de l’index cervico-cephalique de profil (ICCP) sur une incidence de profil de hanche specifique. Hypothese L’ICCP permet de detecter et quantifier la translation posterieure de la tete femorale et la mesure de cet index est reproductible. Patients et methode Une etude radiographique prospective a ete menee par trois observateurs analysant les radiographies de hanche des patients ayant beneficie d’une arthroplastie pour coxarthrose (prothese totale de hanche ou resurfacage) entre janvier 2010 et decembre 2011. L’ICCP, qui quantifie la translation posterieure de la tete femorale, etait mesure sur un profil de hanche a 45° de flexion/45° d’abduction/30° de rotation laterale. Il etait egalement recherche la presence d’une deformation en crosse de pistolet sur la radiographie de face. Resultats L’analyse a porte sur 131 hanches chez 120 patients âges en moyenne de 61 ans (37–91 ans). La valeur seuil fixee a 9 % entrainait une sensibilite a determiner la presence d’une deformation en pistol grip de 89,1 % (IC95 % : 78,8–95,5 %) et une specificite de 82,4 % (IC95 % : 71,2–89,7 %). Vingt pour cent des hanches sans anomalie sur la face avaient un index pathologique. La reproductibilite interobservateur etait bonne pour l’index (coefficient de correlation intraclasse (CCI) = 0,61 ; IC95 % = 0,51–0,71) et la recherche du pistol grip (CCI = 0,74 ; IC95 % = 0,62–0,85). La reproductibilite intra-observateur etait excellente pour l’ICCP (CCI = 0,78 ; IC95 % = 0,57–0,88) et le pistol grip (CCI = 0,85 ; IC95 % = 0,74–0,92). Conclusion L’ICCP est un outil fiable et reproductible permettant d’identifier les deformations secondaires a une epiphysiolyse sur une radiographie de profil specifique du col. Il fait suspecter la presence d’une sequelle d’epiphysiolyse s’il est superieur a 9 %. Par ailleurs, cette etude demontre que 20 % des hanches avec une radiographie de face normale avaient un index pathologique. Niveau de preuve Niveau IV, etude prospective diagnostique sans groupe temoin. more...

Resume Au terme d’un cycle de vie technologique d’une machine d’imagerie de tomographie par emission de positons couplee a la tomodensitometrie (TEP/TDM), le service de medecine nucleaire du centre hospitalier universitaire Vaudois (CHUV) a renouvele son unique equipement. Il a realise a cette occasion un certain nombre de reorganisations pour l’arrivee de la nouvelle « TEP/TDM ». Ce projet crucial pour le service de medecine nucleaire a du s’integrer dans une demarche rigoureuse tant sur le plan de l’organisation du remplacement de l’equipement que sur l’adaptation de la structure d’accueil. Le CHUV a fait le choix d’une machine de derniere generation diminuant le temps d’examen, la quantite de radio-traceur et donc la dose delivree au patient, tout en augmentant les performances de detection des lesions. Afin de profiter au mieux de cette technologie, il fut necessaire d’etablir tous les besoins des acteurs du service de medecine nucleaire et de les associer au deroulement de la procedure d’acquisition. Ce processus fut organise par le service d’ingenierie biomedicale afin de proposer la nouvelle technologie TEP/TDM repondant a moindre cout aux attentes des medecins et patients. more...

Summary Background & aims More than half of individuals with eating disorders (ED) remain undetected in primary care, making a validated screening tool necessary. The aim of the study was to analyze the screening value of the SCOFF questionnaire for women in family practices. Methods 150 consecutive women attending their general practitioner (GP) in the south west of France were recruited. The written SCOFF questionnaire was completed, and then concealed in an envelope. The women were then assessed by a clinical interview for the diagnosis with ED DSM-IV criteria. Sensitivity and specificity were evaluated with a ROC curve. Results 143 women completed all the questionnaires and interviews. Sixteen % presented with some criteria of the DSM-IV TR ED, while 21 % of the group has a SCOFF score >1. A score > 2 had a sensitivity of 30%, and a specificity of 97%. A score > 1 had a sensitivity of 65%, and a specificity of 87%. Conclusion The prevalence of ED in a GP practice is relatively high and the SCOFF score is an easy and helpful screening tool increasing the identification of patients. A score equal to 2 or more has a sensitivity of 65,2% and a specificity of 87,5%. A few questions reflecting pragmatic clinical situations would improve the specificity of the screening. more...

Introduction The classic pathophysiology of acute osteomyelitis in children described by Trueta has a metaphyseal infection as the starting point. This hypothesis was recently brought into question by Labbe’s study, which suggested a periosteal origin. Thus, we wanted to study this disease's pathophysiology through early MRI examinations and to look for prognostic factors based on abnormal findings. Material and methods This was a prospective, multicentre study that included cases of long bone osteomyelitis in children who underwent an MRI examination within 7 days of the start of symptoms and within 24 hours of the initiation of antibiotic therapy. We also collected clinical, laboratory and treatment-related data. Results Twenty patients were included, including one with a bifocal condition. The lower limb was involved in most cases (19/21). Staphylococcus aureus was found most frequently. Metaphyseal involvement was present in all cases. No isolated periosteal involvement was found in any of the cases. No prognostic factors were identified based on the various abnormal findings on MRI. Conclusion Our study supports the metaphyseal origin of acute osteomyelitis in children. Level of evidence II. more...

La telesurveillance, integrant des objets connectes, devient un outil dans la prise en charge des patients diabetiques au quotidien en favorisant les echanges patients/soignants. Cette etude multicentrique, randomisee (n = 282), evalue l’efficacite du suivi par telesurveillance 1 an versus suivi habituel sur l’equilibre glycemique (HbA1c). Objectifs cliniques (IMC, tour de taille), biologiques (fractionnement lipidique), evolution des connaissances et habitudes, qualite de vie, satisfaction, impact medico-economique sont analyses. Le groupe telesurveille (n = 141) beneficie 1 an d’un dispositif connecte (lecteur de glycemie, balance et actimetre) et d’une tele-education avec logiciels interactifs sur tablette pour ameliorer equilibre alimentaire (enregistrement-correction de repas–quiz) et activite physique. Forme a leur utilisation, les patients transmettent les donnees 1 fois/semaine. Une plateforme securisee, presentant la synthese des donnees des 30 derniers jours (glycemies-poids-nombre de pas-repas saisis…) permet a chaque diabetologue-dieteticien la telesurveillance de ses patients via la messagerie. Les resultats retrouvent une amelioration de l’HbA1c chez les telesurveilles, 7,77 %–7,40 % vs controle 7,76 %–7,60 % (p = 0,05) avec une meilleure significativite (p = 0,04) chez les patients regulierement telesurveilles (≥ 6 fois/an), une diminution de l’IMC (−0,3) vs (+0,1) p = 0,09 et du tour de taille (−0,2 cm) vs (+0,7 cm) p = 0,06, une diminution de la consommation de lipides 37 %–35 % vs 39 %–40 % (p = 0,01) et une augmentation des glucides 43 %–46 % vs 41 %–41 % (p = 0,01). Ces premiers resultats montrent que la telesurveillance semble un outil efficace pour le suivi des patients diabetiques de type 2, visant le renforcement de la prise en charge a domicile en rationalisant le recours aux consultations et hospitalisations. more...

Resume Objectif L’association de plusieurs antalgiques de classe 1 (P : paracetamol, K : ketoprofene et N : nefopam) est frequemment employee dans une strategie multimodale pour le traitement de la douleur postoperatoire. Cependant, dans la pratique quotidienne, ces antalgiques sont frequemment reconstitues dans une meme poche de solute. L’objet de cette etude etait de statuer sur la stabilite physicochimique et bacteriologique de trois melanges d’antalgiques (P + K, P + N et K + N). Methodes Pour chacune des associations, les concentrations de chaque principe actif ont ete mesurees par HPLC sur une duree de 24 heures. Les trois melanges ont ete mis en culture pendant sept jours. Resultats Notre etude a permis de confirmer la stabilite chimique et bacteriologique de ces trois melanges sur une periode de 24 heures. Ces resultats autorisent donc la reconstitution de ces trois associations antalgiques pretes a l’emploi dans une meme poche de solute. more...

Resume Le plateau technique constitue aujourd’hui le cœur de tout hopital, en particulier tertiaire. Centre de competence, de technologies, d’innovations mais aussi de pouvoir et d’attrait, il est le lieu d’une activite heteroclite et pointue necessitant un personnel et une organisation adaptes. La cardioradiologie interventionnelle, l’electrophysiologie et l’endoscopie en sont les principaux moteurs et se sont developpes rapidement, parfois au coup par coup, chacune dans leur discipline, conduisant a des organisations disparates et peu optimales. Dans cet article, nous donnons l’exemple du centre hospitalier universitaire Vaudois a Lausanne (37 000 patients, 7000 collaborateurs, un budget de 600 millions d’euros, 17 000 equipements biomedicaux d’une valeur de 130 millions d’euros) qui demarre une reorganisation profonde de son plateau technique interventionnel. A l’aide de differents outils (interviews des chefs des services, realisation de fiches techniques des locaux, etc.) et d’une analyse de l’activite, des propositions qualitatives (nombre de salles endoscopiques et de lits a l’hopital de jour) et architecturales (estimation des besoins en surface et organisation des locaux) ont ete emises. Le projet va donc pouvoir se poursuivre par la redaction d’un dossier de credit d’etude avec comme objectif, la fin des travaux pour l’horizon 2016. more...

In the field of health, evidence-based medicine and associated methods like randomised controlled trials (RCTs) have become widely used. RCT has become the gold standard for evaluating causal links between interventions and health results. Originating in pharmacology, this method has been progressively expanded to medical devices, non-pharmacological individual interventions, as well as collective public health interventions. Its use in these domains has led to the formulation of several limits, and it has been called into question as an undisputed gold standard. Some of those limits (e.g. confounding biases and external validity) are common to these four different domains, while others are more specific. This paper describes the different limits, as well as several research avenues. Some are methodological reflections aiming at adapting RCT to the complexity of the tested interventions, and at overcoming some of its limits. Others are alternative methods. The objective is not to remove RCT from the range of evaluation methodologies, but to resituate it within this range. The aim is to encourage choosing between different methods according to the features and the level of the intervention to evaluate, thereby calling for methodological pluralism. more...

L'application du Guide de bonne execution des analyses de biologie medicale (GBEA.), dans les laboratoires d'etablissements publics, se repercute sur un bon nombre d'autres services comme les services de soins, les services administratifs ou les services biomedicaux. Ce texte vient modifier quelque peu les mentalites et les modes de travail. Il touche aussi bien a l'analyse, au prelevement, au calibrage des instruments qu'a l'archivage des donnees ou au compte rendu d'analyses. Pour les services biomedicaux, l'evolution se fait vers un meilleur suivi documentaire, une systematisation des maintenances preventives et l'emergence de nouveaux criteres de choix de materiel. Ceci necessite de trouver des moyens pour absorber les nouvelles charges de travail et les surcouts engendres. La certification des services, par rapport a un referentiel normatif relatif a la qualite, peut etre un moyen d'y parvenir, sachant que l'objectif ultime est d'ameliorer les prestations fournies au patient. more...

Lung cancer is the main cause of cancer death in France. The diagnosis is often late and the delay between the onset of symptoms and management is considered an aggravating factor.Our prospective study collected the dates of the start of management of 139 consecutive patients receiving first line treatment for thoracic cancer in our hospital between November 2008 and May 2009. The aim of this study was to evaluate the delays in medical or surgical treatments in patients with thoracic cancer and to determine the cause of these delays.The median delay between the first abnormal chest X-ray and treatment was 9.6 weeks. The delays were significantly shorter in the late stages and in small cell cancer (P=0.001). There was a tendency for shorter delays in women and for longer delays in older patients.Evaluation of the delays in treatment, particularly in the early stages, is part of the quality control of management of these diseases. more...

Summary Introduction It is a well-known fact that slipped capital femoral epiphysis (SCFE) is one of the causes of premature hip osteoarthritis and anterior femoroacetabular impingement. But there are no reliable, published diagnostic methods to measure the residual deformity of slipped capital femoral epiphysis. We propose using the lateral view head-neck index (LVHNI) measurement on a specific lateral X-ray view of the hip for this purpose. Hypothesis The LVHNI can detect and quantify the posterior translation of the femoral head and this index can be measured reliably. Materials and methods A prospective radiography study was performed by three observers. The hip X-rays of patients who were being treated by arthroplasty for hip osteoarthritis (total hip replacement or hip resurfacing) between January 2010 and December 2011 were analyzed. The LVHNI, which quantifies the posterior translation of the femoral head, was measured on a lateral view of the hip in 45° flexion/45° abduction/30° external rotation. The presence of a pistol grip deformity on A/P X-rays was also assessed. Results The analysis was performed on 131 hips in 120 patients having an average age of 61 years (range 37–91). The chosen LVHNI threshold of 9% resulted in a sensitivity of 89.1% (95% CI: 78.8%–95.5%) and a specificity of 82.4% (95% CI: 71.2%–89.7%) for detecting the presence of a pistol grip deformity. Twenty percent of the hips with no visible deformity on A/P X-rays had a pathological index value. The inter-observer reproducibility was good for the LHNI [intraclass correlation coefficient (ICC): 0.61; 95% CI: 0.51–0.71] and for detecting a pistol grip deformity (ICC: 0.74; 95% CI: 0.62–0.85). The intra-observer reproducibility was excellent for the LHNI (ICC: 0.78; 95% CI: 0.57–0.88) and the pistol grip deformity (ICC: 0.85; 95% CI: 0.74–0.92). Conclusion The LVHNI is a reliable and reproducible tool to identify deformities secondary to SCFE on specific lateral femoral neck X-rays. If the index value is greater than 9%, SCFE sequelae may be present. In addition, this study showed that 20% of hips with normal A/P X-rays had a pathological index. Level of evidence Level IV, prospective diagnostic study without control group. more...

Aims The purpose of this study was to investigate the clinical feasibility and utility of low-density array analysis on samples obtained from endoscopic ultrasound-guided fine needle aspiration biopsy in locally advanced and/or metastatic pancreatic ductal adenocarcinoma and chronic pancreatitis. Patients and methods In this prospective multicenter study, we quantified candidate gene expression in biopsies sampled from 44 locally advanced and/or metastatic pancreatic carcinoma and from 17 pseudotumoural chronic pancreatitis using dedicated low-density array microfluidic plates. Results We first demonstrated that 18S gene expression is stable and comparable in normal pancreas and pancreatic cancer tissues. Next, we found that eight genes ( S100P , PLAT , PLAU , MSLN , MMP-11 , MMP-7 , KRT7 , KRT17 ) were significantly over expressed in pancreatic cancer samples when compared to pseudotumoural chronic pancreatitis ( p value ranging from 0.0007 to 0.0215): Linear discriminative analysis identified S100P , PLAT , MSLN , MMP-7 , KRT7 as highly explicative variables. The area under receiver operating curve establishes the clinical validity of the potential diagnostic markers identified in this study (values ranging from 0.69 to 0.76). In addition, combination of S100P and KRT7 gave better diagnosis performances (Area Under Receiver Operating Curve 0.81, sensitivity 81%, specificity 77%). Conclusion We demonstrate that molecular studies on EUS-guided FNA material are feasible for the identification and quantification of markers in PDAC patients diagnosed with non-resectable tumours. Using low-density array, we isolated a molecular signature of advanced pancreatic carcinoma including mostly cancer invasion-related genes. This work stems for the use of novel biomarkers for the molecular diagnosis of patient with solid pancreatic masses. more...

Fossil ectomycorrhizae were found recently among permineralized plant remains in the middle Eocene Princeton chert of British Columbia. The ectomycorrhizae are associated with roots of Pinus and have a Hartig net that extends to the endodermis, a pseudoparenchymatous mantle, and contiguous extramatrical hyphae that are simple-septate. The mycorrhizal rootlets lack root hairs and dichotomize repeatedly to form large, coralloid clusters. Reproductive structures are absent. Based on the morphological characteristics, and the identity of the host, the closely related basidiomycete genera Rhizopogon and Suillus are suggested as comparable extant mycorrhizal fungi. These exquisitely preserved specimens represent the first unequivocal occurrence of fossil ectomycorrhizae and demonstrate that such associations were well-established at least 50 million years ago. more...

The aim of this study is to contribute to the psychometric validation of the self-administrated dysphagia-specific quality of life questionnaire, the Deglutition Handicap Index. Created on the model of the "Voice Handicap Index". this questionnaire consists of 30 statements on deglutition related aspects in daily life (5 point-rating scale). It is subdivided in three domains of 10 items: physical (symptoms), functional (nutritional and respiratory consequences) and emotional (psychosocial consequences).57 patients were included suffering of any kind of swallowing disorders. 17 questionnaires were eliminated because 1 to 3 items were not anchored. A test retest performed in an interval of 2 weeks, allowed the measure of the intraclasse correlation coefficient and the limits of agreement with Bland and Altman graphics.The intraclasse correlation coefficient was respectively 0.77 (0.64-0.90), 0.87 (0.79-0.94), 0.90 (0.84-0.96), 0.91 (0.85-0.96) for the Physical, Functional, Emotional and Total Scores. The limits of agreement are 9 points for the subscales and 20 points for the total score.The DHI has been validated in term of content, concurrent and construct validity. The reliability was satisfied in term of internal consistency. It is now validated for the temporal reliability. The DHI is the solely specific quality of life questionnaire related to deglutition available for all kind of oropharyngeal swallowing disorders in adults available in clinical practice. more...

Objective: To improve the quality of care provided for inpatients outlying in inappropriate wards of a teaching hospital because of lack of vacant beds in appropriate specialty wards. Methods: A multidisciplinary team consisting of hospital doctors, nurses and managers performed a prospective risk analysis of the process of care provided for outlying patients during their hospitalisation. The design of the study was Failure Modes, Effects and Criticality Analysis (FMECA). Failure modes were defined and classified according to their criticality, in order to identify priority actions for improvement. Criticality indices were calculated by multiplying occurrence, severity and detection scores. Results: Measures for improvement indicated by the most critical failure modes were the identification of specialist doctors in appropriate specialty wards to be responsible for the care of outlying patients falling within their sphere of competence; the identification of a nurse coordinator in each department to improve communication between the emergency department, appropriate specialty wards and outlying wards; the standardisation of medical records throughout the whole hospital to ensure better traceability and access to information. Conclusions: Using FMECA, we were able to identify the most critical failure modes of the complex process of care provided for outlying patients and to suggest subsequent improvement measures. Follow-up indicators were defined to assess implementation. more...

Researchers often use the Poisson regression model to analyze count data. Overdispersion can occur when a Poisson regression model is used, resulting in an underestimation of variance of the regression model parameters. Our objective was to take overdispersion into account and assess its impact with an illustration based on the data of a study investigating the relationship between use of the Internet to seek health information and number of primary care consultations.Three methods, overdispersed Poisson, a robust estimator, and negative binomial regression, were performed to take overdispersion into account in explaining variation in the number (Y) of primary care consultations. We tested overdispersion in the Poisson regression model using the ratio of the sum of Pearson residuals over the number of degrees of freedom (chi(2)/df). We then fitted the three models and compared parameter estimation to the estimations given by Poisson regression model.Variance of the number of primary care consultations (Var[Y]=21.03) was greater than the mean (E[Y]=5.93) and the chi(2)/df ratio was 3.26, which confirmed overdispersion. Standard errors of the parameters varied greatly between the Poisson regression model and the three other regression models. Interpretation of estimates from two variables (using the Internet to seek health information and single parent family) would have changed according to the model retained, with significant levels of 0.06 and 0.002 (Poisson), 0.29 and 0.09 (overdispersed Poisson), 0.29 and 0.13 (use of a robust estimator) and 0.45 and 0.13 (negative binomial) respectively.Different methods exist to solve the problem of underestimating variance in the Poisson regression model when overdispersion is present. The negative binomial regression model seems to be particularly accurate because of its theorical distribution ; in addition this regression is easy to perform with ordinary statistical software packages. more...

The combination of non-opioid analgesic drugs (P: paracetamol, K: ketoprofen and N: nefopam) is currently recommended for postoperative pain control. In practice, these analgesics are often administered in the same solution. We investigated the chemical stability and sterility of three mixtures of analgesics (P+K, P+N and K+N).For each mixture, concentrations of active principles were measured using high-performance liquid chromatography over 24 hours. These mixtures were cultured for microbiological colonization.Our study demonstrated chemical and bacteriologic stability of these three mixtures over a 24-hour period. The results allow the use of P+K, P+N and K+N in the same ready to use solution. more...

SUMMARYVertebral osteomyelitis (VO) is a rare event. To estimate the incidence of VO in France for 2002–2003, national hospital-discharge data were used. Hospital stays were categorized as definite, probable or possible VO. Unique patient identification numbers allowed the investigators to link patients with multiple hospital stays and to analyse data for individual patients. A sample of medical records was reviewed to assess the specificity of the VO case definition. In 2002–2003, 1977 and 2036 hospital stays corresponding to 1422 and 1425 patients (median age 59 years, male:female ratio 1·5) were classified as definite (64%), probable (24%) and possible (12%) VO. The overall incidence of VO was 2·4/100 000. Incidence increased with age: 0·3/100 000 (70 years). The main infectious agents reported wereStaphylococcusspp. (38%) andMycobacterium tuberculosis(31%). The most frequent comorbidities were septicaemia (27%) and endocarditis (9%). Three percent of patients died. A review of 90 medical records confirmed the diagnosis of VO in 94% of cases. Using a hospital database and a specific case definition, nationwide surveillance of VO is possible. more...

Introduction Le cancer bronchique chez les patients de 40 ans ou moins est rare et peu etudie. Le but de cette etude etait de decrire cette population et leur pathologie. Methode Etude prospective observationnelle menee dans 37 centres en France. Tous les patients de 40 ans ou moins ayant un diagnostic de cancer bronchique pose entre novembre 2010 et decembre 2013 ont ete inclus. Resultats Cent quarante-six patients ont ete inclus. L’âge median au diagnostic etait de 38 ans (20–40), 58 % etaient des hommes. La duree mediane entre les premiers symptomes et le diagnostic etait de 2 mois. La proportion des stades I-II, IIIA et IIIB-IV etait de 8 %, 10 % et 82 % ; le premier site metastatique etait le cerveau (46 %). L’histologie la plus frequente etait l’adenocarcinome (77 %). La mutation EGFR a ete cherchee chez 107 patients et 12 (11 %) etaient mutes. Cent-vingt-quatre patients (86 %) etaient ou avaient ete fumeurs de tabac (mediane de 20 paquets-annee), 86 patients (59 %) exposes au tabagisme passif dont 51 % dans l’enfance. Soixante-neuf patients (50 %) consommaient ou avaient consomme du cannabis. Le traitement de premiere ligne etait une chimiotherapie (91 %), une radiotherapie (40 %), une chirurgie (19 %) et des soins de confort (6 %). La survie mediane etait de 14,4 mois. Conclusion Cette etude est la premiere etude nationale prospective portant sur des patients de 40 ans ou moins ayant un cancer bronchique. Comparativement a l’epidemiologie rapportee du cancer bronchique, on note une plus forte proportion de femmes, de stades IIIB-IV au diagnostic, de consommateurs de tabac et de cannabis. more...

Aim: Lung cancer in patients under 40 years is infrequent and few data are available about the presentation and outcomes of lung cancer in this population. This study aimed to describe the clinical characteristics, the treatments and the outcome of lung cancer occurring in the population of young adults in France. Methods: A prospective observational clinical study was conducted in 37 centers in France. All patients under 40 years diagnosed with lung cancer between November 2010 and December 2013 were enrolled. Results: One hundred and fifty nine patients with lung cancer were included. Intermediate results are currently available for 117 patients. Median age at diagnosis was 38 (20-40). The proportion of men was 58%. Median time between symptoms and diagnosis was 2 months. The distribution of stages I- II, IIIA and IIIB-IV was 9%, 9% and 82% respectively; 66% were diagnosed with metastasis at presentation and the first metastasis site was brain in 47% of patients. Adenocarcinoma was the most common histologic subtype (78%). EGFR screening was performed for 83 patients and 10% of the patients had an activating mutation. Analysis of other driver biomarkers is ongoing. Eighty-four patients (86%) were current or former tobacco smoker with a median of 20 packs -year. Sixty-nine patients (59%) have been exposed to passive smoking essentially in childhood. About half of them (46%) were current or former cannabis smoker (among which 50% regularly). Socioeconomic status was lower comparing to general population, 24% of the patients had no diploma. The first line treatments were 88% chemotherapy, 43% radiotherapy, 21% surgery and 5% best supportive care. Median overall survival was 14.7 months. Conclusions: This study is the first national prospective study dedicated to patients under 40 years diagnosed with lung cancer. Compared to the general population of lung cancer, our preliminary results show a high proportion of women, adenocarcinoma histology, advanced disease at diagnosis and tobacco and cannabis use. Final analysis will be presented at the congress. Disclosure: All authors have declared no conflicts of interest. more...

Introduction Integrer les nouveaux outils de telemedecine pour optimiser la prise en charge des maladies chroniques represente un veritable enjeu sur un plan medical, organisationnel et economique. Nous avons initie une etude evaluant l’interet d’un programme de telesurveillance au domicile (suivi de l’equilibre glycemique et de l’hygiene de vie) chez des patients DT2, par comparaison a une prise en charge usuelle. Materiels et methodes Le dispositif comprend des logiciels d’education therapeutique sur tablette tactile et des capteurs connectes : lecteur de glycemie, balance et actimetre. Les donnees issues des capteurs sont envoyees vers un centre serveur securise et sont synthetisees dans un rapport de telesurveillance disponible en ligne pour les medecins qui decident de la conduite a tenir. Il s’agit d’un essai d’intervention comparatif, randomise, ouvert, multicentrique en deux bras (telesurveillance versus temoin). 282 patients seront recrutes a partir du reseau de soins en Diabetologie Midi-Pyrenees DIAMIP et suivis pendant 24 mois. L’objectif principal est de comparer l’evolution de l’HbA1c a 1 an dans les 2 bras de randomisation. Les objectifs secondaires sont le maintien de l’efficacite a 2 ans, l’evolution des connaissances, du comportement hygienodietetique, de la qualite de vie, des parametres cliniques et biologiques. Une evaluation medico-economique sera egalement realisee (ratio cout-efficacite, modelisation markovienne). Observations Nous montrons ici les premiers resultats qualitatifs sur des patients-tests demontrant la faisabilite du dispositif. Son utilisation pendant 3 mois s’accompagne d’une amelioration de l’equilibre alimentaire (logiciel de conseils nutritionnels), et d’une majoration de l’activite physique (actimetre) avec diminution des doses d’insuline. Discussion Notre hypothese est que ce dispositif permettra d’ameliorer l’hygiene de vie et la qualite du controle glycemique tout en rationalisant le recours aux consultations, permettant ainsi de reduire a long terme l’incidence des complications et les couts. Cette etude financee par la DGOS pourrait apporter un argument scientifique supplementaire pour la valorisation de l’activite de telemedecine. more...

Background The Lungscape project aims at building a virtual biobank to facilitate an international high-quality analysis of large numbers of tumors for molecular alterations linked to clinical and biological characteristics captured in the iBiobank. Methods Retrospective radically resected stage I-III non-small cell lung cancer cases from 15 ETOP centers, with mandatory comprehensive clinical annotations including at least 2 years of FU have been reviewed and captured. Results This first set of 1614 cases was enriched in adenocarcinoma (61.8%), with 28.8% of squamous and 4.9% of large cell histologies. Median age is 65 yrs, 37.6% are women, and respectively 13.9%, 33.5% and 49.6% are never, current and former smokers. Stage distribution is: IA 23.7%, IB 25.8%, IIA 16.4%, IIB 11.6%, IIIA 20.8%, IIIB 1.7%. At last FU, 52.8% of patients were still alive, with a median FU of 5.3 yrs. PFS No. of patients 5 years (95% C.I.) Median (mos) (95% C.I.) TOTAL 1614 46 (43.3, 48.6) 49.0 ( 43.9, 55.2) Stage Ia 382 64.5 (59.1, 60.5) NR Ib 417 55.4 (50.3, 60.5) 78.0 IIa 264 44.8 (38.4, 51.3) 46.9 IIb 187 39.2 (31.6, 46.8) 33.7 IIIa 335 20.0 (15.2, 24.8) 17.5 IIIb 28 11.9 (0.0, 25.3) 10.1 OS 1614 52.0 (49.3, 54.7) 64.2 (57.3, 76.9) Stage Ia 382 70.0 (64.9, 75.2) NR Ib 417 60.6 (55.5, 65.7) NR IIa 264 50.5 (43.8, 57.1) 62.2 IIb 187 43.7 (36.0, 51.4) 43.3 IIIa 335 29.3 (23.9, 34.7) 29.0 IIIb 28 10.3 (0.0, 27.1) 20.2 Conclusion This is the first large-scale series based on 7th TNM classification reporting on OS and PFS in the context of European standards of care. These data confirm the discriminative capacity of the 7th TNM with a potentially somewhat superior outcome. Histologies other than adenocarcinoma are currently actively being captured. Complete data including PFS and TTP - never reported before - as well as OS based on the expected 2400 patients correlated to stage, gender, smoking status, histology and age will be provided. This complete clinical dataset will be invaluable to investigate the impact of molecular characteristics on outcome. It will allow building future hypothesis for prospective evaluation of new treatment strategies and help in the development of a molecularly refined TNM. Disclosure All authors have declared no conflicts of interest. more...

Aided localization ability of 87 hearing-impaired listeners was tested for horizontal and vertical sound sources, at two signal levels, and for two orientations to the loudspeaker array (facing, sideways). Some listeners wore behind-the-ear (BTE) aids, others in-the-ear (ITE) aids. Some were bilaterally fitted, others unilaterally fitted. Listeners were tested only with types of aids and fittings that they were accustomed to wearing. The results strongly supported bilateral fitting for moderately and severely hearing-impaired listeners. However, for mildly impaired listeners, those fitted unilaterally performed as well, on average, as those fitted bilaterally. This suggests a need to consider individual listening requirements and also to provide such listeners with experience in unilaterally-aided listening before assessing the possible advantages of bilateral fitting. When hearing level was controlled, there was no overall difference in the performance of ITE and BTE aid wearers. This discrepancy with other research may be explained by measures (removal of intensity cues, permitting of head movement) designed to make the test situation more representative of real-life listening. more...

In a study including 392 patients we compared two groups of patients according to the indication for laparoscopic cholecystectomy: group I: 293 patients treated for simple cholelithiasis (n = 291) or gallbladder polyps (n = 2). Group II: 99 patients operated for complicated cholelithiasis. For each patient, 14 pre, intra and postoperative parameters were analysed and compared. Mean operative time was 80 minutes. Primary and secondary laparotomies were necessary in 5.8% and 1.3% of cases respectively. Biliary injury was the most frequent complication (1.3%). Mean hospital stay was 4.5 days. In terms of mean age, operative time, intraoperative incidents and complications, and primary laparotomy. There was a significant difference between the two groups (p less than 0.001). There were 4 secondary laparotomies in group II and one in group I. These results suggests that laparoscopic cholecystectomy is a safe technique with a low mortality rate (0.25%). The comparative study proves that this technique, first indicated for simple cholelithiasis, is also applicable to the majority of complicated cholelithiasis. more...

A prospective, comparative study is made of 262 patients (195 males, 67 females) subjected to laparoscopic cholecystectomy. Two groups were considered: simple cholelithiasis (SC) (187 cases), and complicated cholelithiasis (CC) (75 cases: 63 acute cholecystitis, 8 hydrocholecystitis, 4 pancreatitis). Mean age was 51 among the SC cases, and 57 in the CC patients. Mean operating time was 67 and 96 minutes for the SC and groups, respectively. Preoperative complications were more frequent in the CC group (51.4%) than in the SC patients (24%)--immediate laparotomies being performed in 2 and 25% of the SC and CC patients, respectively. Mortality was zero, with similar morbidity in both groups. Mean hospitalization time was 4.9 and 3.4 days for the CC and SC groups, respectively. more...

Background Researchers often use the Poisson regression model to analyze count data. Overdispersion can occur when a Poisson regression model is used, resulting in an underestimation of variance of the regression model parameters. Our objective was to take overdispersion into account and assess its impact with an illustration based on the data of a study investigating the relationship between use of the Internet to seek health information and number of primary care consultations. Methods Three methods, overdispersed Poisson, a robust estimator, and negative binomial regression, were performed to take overdispersion into account in explaining variation in the number (Y) of primary care consultations. We tested overdispersion in the Poisson regression model using the ratio of the sum of Pearson residuals over the number of degrees of freedom (χ 2 /df). We then fitted the three models and compared parameter estimation to the estimations given by Poisson regression model. Results Variance of the number of primary care consultations (Var[Y] = 21.03) was greater than the mean (E[Y] = 5.93) and the χ 2 /df ratio was 3.26, which confirmed overdispersion. Standard errors of the parameters varied greatly between the Poisson regression model and the three other regression models. Interpretation of estimates from two variables (using the Internet to seek health information and single parent family) would have changed according to the model retained, with significant levels of 0.06 and 0.002 (Poisson), 0.29 and 0.09 (overdispersed Poisson), 0.29 and 0.13 (use of a robust estimator) and 0.45 and 0.13 (negative binomial) respectively. Conclusion Different methods exist to solve the problem of underestimating variance in the Poisson regression model when overdispersion is present. The negative binomial regression model seems to be particularly accurate because of its theorical distribution ; in addition this regression is easy to perform with ordinary statistical software packages. more...