Search

Position du probleme Les facteurs incitant les medecins a utiliser des recommandations de pratique clinique (RPC) dans le contexte hospitalier public francais sont mal connus. L’objectif de ce travail est de preciser quels elements seraient, du point de vue des medecins et des internes exercant en service de medecine adulte, les plus a meme de favoriser leur utilisation. Methodes Enquete transversale par questionnaire anonyme auto administre a questions fermees, plus un commentaire libre, aupres des deux centres hospitaliers universitaires et des 20 centres hospitaliers bretons, concernant les caracteristiques individuelles et professionnelles des medecins et des internes, leur point de vue sur les recommandations, leur recours a des RPC, leur opinion sur l’utilite et l’impact previsible d’efforts d’amelioration de leur elaboration et de leur mise en place. L’analyse descriptive dissocie les medecins et les internes ; les opinions et attentes sont croisees avec les caracteristiques des repondants, en utilisant le test du Chi 2. Resultats Sur 783 internes et medecins, 390 ont repondu (50 %). Neuf internes et huit medecins sur dix ayant repondu estiment les avantages des recommandations (harmonisation des pratiques, aide a la decision) superieurs a leurs inconvenients (rigidite, manque de liberte). Un sur trois declare les utiliser regulierement. Des recommandations concernant des pathologies courantes, incluant diagnostic et traitement, elaborees au niveau national et adaptees localement, presentees de facon synthetique dans un guide de poche et transmises directement aux internes par les medecins du service, auraient le plus de chance d’etre utilisees. Un medecin sur deux utiliserait plus des recommandations diffusees par des societes savantes ou mises en place en lien avec une evaluation des pratiques. Conclusion Les efforts de developpement de l’utilisation de recommandations de pratique clinque dans les services hospitaliers devraient prendre en compte la grande receptivite des internes mais aussi la necessaire implication des medecins seniors dans l’accompagnement specifique de leur diffusion.

AIMS--To assess the value of histology in diagnosing inflammatory bowel disease (IBD) in colorectal biopsy specimens. METHODS--Retrospective, double blind evaluation of colorectal biopsy specimens from 41 patients with colitis (28 with ischaemic colitis and 13 with acute self-limited colitis) and 84 patients with IBD (42 with Crohn's disease and 42 with ulcerative colitis). RESULTS--The features distinguishing IBD from other forms of colitis included distorted architecture, lymphocyte and plasma cell infiltrate, excess of polymorphonuclear leucocytes, polymorphonuclear cryptitis, crypt abscesses, and basal lymphoid aggregates. The features discriminating between Crohn's disease and ulcerative colitis included an irregular or villous surface, distorted architecture, decrease in mucus content, and polymorphonuclear cryptitis. Using multivariate analysis, 90% of patients with Crohn's disease and 71% of those with ulcerative colitis were correctly classified, the former being strongly defined by epithelioid granulomas, microgranulomas and isolated giant cells, and the latter best defined by an irregular or villous surface, decrease in mucus content and crypt atrophy. CONCLUSIONS--Examination of colorectal biopsy specimens is a reliable method for diagnosing IBD. In the absence of epithelioid granulomas, microgranulomas and isolated giant cells a diagnosis of Crohn's disease is based on the absence of histological criteria favouring ulcerative colitis. The histological spectrum of indeterminate colitis remains to be clarified.

Objective.To describe the French program for the prevention of healthcare-associated infections and antibiotic resistance and provide results for some of the indicators available to evaluate the program. In addition to structures and process indicators, the 2 outcome indicators selected were the rate of surgical site infection and the proportion of methicillin-resistant Staphylococcus aureus (MRSA) isolates among the S. aureus isolates recovered.Design.Descriptive study of the evolution of the national structures for control of healthcare-associated infections since 1992. Through national surveillance networks, process indicators were available from 1993 to 2006, surgical site infection rates were available from 1999 to 2005, and prevalence rates for MRSA infection were available from 2001 to 2007.Results.A comprehensive national program has gradually been set up in France during the period from 1993 to 2004, which included strengthening of organized infection control activities at the local, regional, and national levels and developing large networks for surveillance of specific infections and antibiotic resistance. These achievements were complemented by instituting mandatory notification for unusual nosocomial events, especially outbreaks. The second phase of the program involved the implementation of 5 national quality indicators with public reporting. Surgical site infection rates decreased by 25% over a 6-year period. In France, the median proportion of MRSA among S. aureus isolates recovered from patients with bacteremia decreased from 33.4% to 25.7% during the period from 2001 to 2007, whereas this proportion increased in many other European countries.Conclusions.Very few national programs have been evaluated since the Study on the Efficacy of Nosocomial Infection Control. Although continuing efforts are required, the French program appears to have been effective at reducing infection rates.

Continuing medical education came into being in the United States in the late twenties when the mediocrity of the initial medical training of practicing physicians was recognized. Medical schools created a classical system of continuing education; the first mandatory program was initiated in urology in 1934. By 1957, the first set of guidelines for good medical practice were published by the American Medical Association (AMA). The mandatory nature of continuing education was widespread by the end of the sixties with variable regulations from state to state. At the same time, the AMA created an honorary diploma for physicians who complete 150 h post-graduate training within 3 years. Starting in 1970, the political predominance of the AMA in continuing education was questioned by other professional associations (hospitals, medical schools). After much discussion and opposing debate, a common association for continuing education was created in 1981. The AMA remained a leader in the early nineties and now has started programs targeted to patients.

The aim of this study was to evaluate the prognosis and the determinants of survival in cirrhotics presenting with variceal bleeding. One hundred and ninety one consecutive patients with cirrhosis (alcoholic 93 percent) were enrolled between 1983 and 1988. Treatment was principally but not exclusively based on early endoscopic sclerotherapy. At admission all patients were classified according to Child-Pugh's classification (class A = 16 percent; class B = 53 percent; class C = 31 percent). The rebleeding rates at 48 hours and for the entire hospitalisation were 11 and 30 percent respectively. Actuarial survival rates were 45, 40, and 37 percent at 12, 18, and 36 months, respectively. Prognostic factors, as determined by uni- and multivariate analysis (Cox model), corresponded to Child-Pugh's score, to the five components, and the occurrence of early bleeding recurrence. This study also showed that: i) the role of Child-Pugh's classification on long-term prognosis is determined during the 3 months following index bleeding; ii) early rebleeding is a significant prognostic factor, particularly in Child-Pugh's class B patients; iii) there are few indicators of early rebleeding (serum albumin level, presence of gastric varices at initial endoscopy). Prognosis of variceal bleeding is still severe in cirrhosis but efforts made to prevent early bleeding recurrence seem to be fully justified.