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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.

Factors associated with the choice of oral versus intravenous CT are not clearly established. Our purpose was to evaluate the influence of social status and home distance to hospital on the use of oral CT in patients with metastatic colorectal cancer (mCRC). This retrospective single‐center study included mCRC patients between 2011 and 2017. Patient social status was assessed by European Deprivation Index (EDI) and home distance to the hospital was calculated. Univariable and multivariable logistic regression analyses were performed. One hundred and seventy‐five mCRC patients were included, with 71 receiving oral CT. Most deprived patients received less oral CT (OR 0.5 [0.26, 0.96], p = .039). No association was found for road distance. Previous use of adjuvant oral CT was associated with oral CT in mCRC (OR 2.65 [1.06, 6.66], p = .038). Our results suggest that deprived social status is a factor associated with decreased use of oral CT in patients with mCRC. Clinical trial registration: no registration.

Background: The common areas of general practitioners’ practices (eg, reception, secretariat, waiting room, toilets) are places at risk of cross-transmission of viral diseases such as COVID-19, however risk is poorly documented. Aim: To evaluate the risks of viral cross-transmission in general practitioners’ practices based on the organization of the common areas of the premises. Design and setting: Cross-sectional multicenter observational study in randomly selected general practitioners’ practices in a French department (Seine-Maritime). The practices were included in 4 strata (1, 2, 3–5, or ≥6 general practitioners). Method: Each practice was visited and a questionnaire describing practice organization, cleaning of the premises, screening of high-risk patients was completed on site and observation of the premises). Results: Data collection started in December 2019 and was discontinued due to the national lockdown related to the global SARS-CoV-2 pandemic. Eighty-two practices were analyzed. A hydroalcoholic solution was available in 7.3% of practices and surgical masks in 1.2%. In a majority of waiting rooms, the minimum distance between chairs facing each other was >2 m (78.0%), but was more frequently 1 m for chairs at 90° (53.7%). Overall, 79.3% of waiting rooms could be properly ventilated and waste bins were present in 23.9% of cases. A cleaning protocol was reported in 39.2% of practices. Conclusion: The COVID-19 epidemic allowed the national dissemination of standard precautions. It will be interesting to monitor over the next few years whether the renewed consideration of standard precautions to prevent viral cross-contamination will be maintained over time.

To increase the knowledge about S. capitis in the neonatal setting, we conducted a nationwide 3-month survey in 38 neonatal intensive care units (NICUs) covering 56.6% of French NICU beds. We demonstrated 14.2% of S. capitis BSI (S.capBSI) among nosocomial BSIs. S.capBSI incidence rate was 0.59 per 1000 patient-days. A total of 55.0% of the S.capBSIs were late onset catheter-related BSIs. The S. capitis strains infected preterm babies (median gestational age 26 weeks, median birth weight 855 g). They were resistant to methicillin and aminoglycosides and belonged to the NRCS-A clone. Evolution was favorable in all but one case, following vancomycin treatment.

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.

La préparation cutanée par une douche préopératoire est un facteur contributif bien établi de la sécurité de la prise en charge chirurgicale. Ceci a conduit à des recommandations formelles concernant ses modalités techniques (produits à utiliser, traitement des pilosités…) sans que soient abordées les conditions concrètes de leur mise en œuvre. En partant d’une situation clinique concrète et fréquente, les auteurs examinent ce qui se joue autour de la réalisation de ce soin, souvent réalisé au domicile par le patient lui-même ou ses proches, en fait un véritable « travail du malade ». Cette analyse prend en compte successivement les informations données au patient (contenu et modalités), la prévision de difficultés potentielles de réalisation, le contrôle de la réalité et de l’efficacité de la douche à l’entrée dans le service, puis au bloc opératoire, les décisions à prendre en cas de défaillance… Des dimensions contextuelles sont mises en évidence : nécessaire respect de l’intimité du patient, mais aussi ambiguïté de la parole sur la propreté perçue comme un jugement de qualité de vie et de respectabilité, « évitement » d’une procédure ancillaire sous-évaluée, partage des tâches imprécise dans l’équipe soignante, faiblesse du partenariat soignants-soignés, effet de la charge de travail et du rythme rapide imposé par le « virage ambulatoire ». On conçoit que la réalisation optimale de ce soin utile, peu technique (sinon simple), peu coûteux et sans risque particulier se heurte à de nombreux obstacles pratiques. Les auteurs formulent des propositions pour que les recommandations soient améliorées en précisant les tâches propres aux différents acteurs dans un esprit de partenariat efficace avec le patient.

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.

International audience; BACKGROUND:There are no studies reporting the rate of surgical site infection (SSI) after surgery for endometriosis, although this information is valuable when discussing the most appropriate treatment strategy with the patient.METHODS:We conducted a prospective cohort study in a university hospital and regional reference center for endometriosis. We sought to measure the rate of SSI after endometriosis surgery using prospective SSI post-discharge surveillance data and the hospital information system via an ad hoc algorithm using both diagnosis and procedure code classifications.RESULTS:Among 896 consecutive endometriosis surgical procedures, we identified 365 procedures with involvement of the gastrointestinal tract, defined as the deep invasive procedure (DIP) group, 107 procedures with involvement of an ovary, and 424 other procedures. Twelve SSI (all organ/space infections) were observed, all in the DIP group, corresponding to an overall SSI incidence of 1.3% 95% confidence interval (CI) 0.7-2.3, and an SSI incidence in the DIP group of 2.8%, 95% CI 1.5-4.9. The median delay between the procedure and the SSI was 6.5 days (range, 3-23). At least one micro-organism was found in 10 patients (four Escherichia coli, four Enterobacter cloacae, three Enteroccus faecalis, two Bacteroides fragilis, one Pseudomonas aeruginosa, one Candida albicans).CONCLUSION:A low overall rate of SSI after surgery for endometriosis was observed. Nevertheless, procedures with involvement of the intestinal tract were at risk of SSI.

International audience; no abstract

International audience

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.

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.

International audience

Aliment Pharmacol Ther 2011; 33: 1133–1142 Summary Background Crohn’s disease incidence rates have stabilised in industrialised countries since the 1980s. Conversely, a continuing increase in childhood-onset Crohn’s disease incidence has been reported. Aim To confirm trends in inflammatory bowel disease (IBD) incidence in northern France over an extended time period (1988–2007) with a focus on childhood-onset Crohn’s disease. Methods The IBD patients recorded in the EPIMAD registry between 1988 and 2007 were included. Standardised incidence rates were calculated for Crohn’s disease and ulcerative colitis in the entire population, and separately according to age. Evolution of phenotypes at diagnosis was also studied. Results A total of 12 084 incident IBD cases (7428 Crohn’s disease and 4656 ulcerative colitis) were recorded. Crohn’s disease incidence rates increased from 5.2 cases/100 000 persons in 1988–1990 to 6.7 in 2006–2007 (+29%), stabilising after a peak at 7.1 in 1997–1999. Crohn’s disease incidence rates in the 10–19-year age category increased by 71%, from 6.5 (1988–1990) to 11.1 (2006–2007). The frequency of initial ileo-colonic localisation increased from 52.9% in 1988–1990 to 68.6% in 2006–2007 (P

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 & Aims: The natural history of pediatric Crohn's disease and risk factors necessitating surgery have not been thoroughly described. Methods: In a geographically derived incidence cohort diagnosed from 1988 to 2002, we identified 404 Crohn's disease patients (ages, 0–17 years at diagnosis) with a follow-up time ≥2 years. Results: Median follow-up time was 84 months (range, 52–124 months). The most frequent disease location at diagnosis was the terminal ileum/colon (63%). Follow-up was characterized by disease extension in 31% of children. Complicated behavior was observed in 29% of children at diagnosis and 59% at follow-up. Kaplan–Meier survival estimates of the cumulative incidence of surgery were 20% at 3 years and 34% at 5 years from diagnosis. Multivariate Cox models showed that both structuring behavior at diagnosis (hazard ratio [HR], 2.54; 95% confidence interval [CI]: 1.58–4.01) and treatment with corticosteroids (HR, 2.98; 95% CI: 1.64–5.41) were associated with increased risk for surgery, whereas treatment with azathioprine (HR, 0.51; 95% CI: 0.33–0.78) was associated with decreased risk. Azathioprine was introduced earlier in the course of disease in patients not undergoing surgery than in patients requiring surgery. Conclusions: Pediatric Crohn's disease was characterized by frequent occurrence, with time, of a severe phenotype with extensive, complicated disease. Immunosuppressive therapy may improve the natural history of this disease and decrease the need for performing surgery.

Le risque infectieux hospitalier est une preoccupation ancestrale que l’on a cru voir disparaitre avec l’apparition des antibiotiques. Devenues un enjeu majeur de sante publique, les Infections Nosocomiales (IN) sont censees designer a la fois les infections qui touchent les malades et les professionnels de sante. Force est de constater que les IN touchant les malades ont davantage de visibilite sociale que celles susceptibles de concerner les soignants. Grâce a une enquete qualitative fondee sur des entretiens semi-directifs aupres de 117 soignants, exercant a l’hopital, nous avons voulu cerner ce risque professionnel, tel qu’il est percu par les soignants. Les resultats sont presentes et discutes en deux parties : la segmentation des representations du risque infectieux et les pratiques comme construction de compromis entre des exigences contradictoires.

International audience; Background Inconsistent compliance of health care workers with standard precautions has already been documented. The objective of this study was to develop a questionnaire to investigate the sociocognitive determinants of compliance with standard precautions based on the theory of planned behavior. Methods To construct the Standard Precautions Questionnaire (SPQ), items were selected using a systematic review of literature and semistructured interviews with 54 health care workers. Thirty-five items were selected for a draft questionnaire. These questionnaires were sent to 649 health care workers in 3 medical specialties (pediatrics, geriatrics, and intensive care) in a French University hospital. A total of 331 valid questionnaires were analyzed. Results Factor analysis yielded a final 7-factor solution with an explained variance of 66.51%, with 24 items. The 7 dimensions were the following: attitude toward standard precautions, social influence facilitating organization, exemplary behavior of colleagues, organizational constraints, individual constraints, and intention to perform standard precautions. Some differences were observed between medical specialties on attitude toward standard precautions, social influence, and individual constraints. Conclusion The SPQ met the conditions of reliability and validity in accordance with psychometric demands and could be used to evaluate attitudes and intention to perform standard precautions among medical and nursing staff.

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.

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

Background: Environmental exposures in early life have been implicated in the aetiology of inflammatory bowel disease. Objective: To examine environmental risk factors prior to the development of inflammatory bowel disease in a paediatric population based case control study. Methods: A total of 222 incident cases of Crohn’s disease and 60 incident cases of ulcerative colitis occurring before 17 years of age between January 1988 and December 1997 were matched with one control subject by sex, age, and geographical location. We recorded 140 study variables in a questionnaire that covered familial history of inflammatory bowel disease, events during the perinatal period, infant and child diet, vaccinations and childhood diseases, household amenities, and the family’s socioeconomic status. Results: In a multivariate model, familial history of inflammatory bowel disease (odds ratio (OR) 4.3 (95% confidence interval 2.3–8)), breast feeding (OR 2.1 (1.3–3.4)), bacille Calmette-Guerin vaccination (OR 3.6 (1.1–11.9)), and history of eczema (OR 2.1 (1–4.5)) were significant risk factors for Crohn’s disease whereas regular drinking of tap water was a protective factor (OR 0.56 (0.3–1)). Familial history of inflammatory bowel disease (OR 12.5 (2.2–71.4)), disease during pregnancy (OR 8.9 (1.5–52)), and bedroom sharing (OR 7.1 (1.9–27.4)) were risk factors for ulcerative colitis whereas appendicectomy was a protective factor (OR 0.06 (0.01–0.36)). Conclusions: While family history and appendicectomy are known risk factors, changes in risk based on domestic promiscuity, certain vaccinations, and dietary factors may provide new aetiological clues.

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 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.

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.

International audience; Data on the natural history of elderly-onset inflammatory bowel disease (IBD) are scarce.METHODS:In a French population-based cohort we identified 841 IBD patients >60 years of age at diagnosis from 1988 to 2006, including 367 Crohn's disease (CD) and 472 ulcerative colitis (UC).RESULTS:Median age at diagnosis was similar for CD (70 years (IQR: 65-76)) and UC (69 years (64-74)). Median follow-up was 6 years (2-11) for both diseases. At diagnosis, in CD, pure colonic disease (65%) and inflammatory behaviour (78%) were the most frequent phenotype. At maximal follow-up digestive extension and complicated behaviour occurred in 8% and 9%, respectively. In UC, 29% of patients had proctitis, 45% left-sided and 26% extensive colitis without extension during follow-up in 84%. In CD cumulative probabilities of receiving corticosteroids (CSs), immunosuppressants (ISs) and anti tumor necrosis factor therapy were respectively 47%, 27% and 9% at 10 years. In UC cumulative probabilities of receiving CS and IS were 40% and 15%, respectively at 10 years. Cumulative probabilities of surgery at 1 year and 10 years were 18% and 32%, respectively in CD and 4% and 8%, respectively in UC. In CD complicated behaviour at diagnosis (HR: 2.6; 95% CI 1.5 to 4.6) was associated with an increased risk for surgery while CS was associated with a decreased risk (HR: 0.5; 0.3 to 0.8). In UC CS was associated with an increased risk (HR: 2.2; 1.1 to 4.6) for colectomy.CONCLUSIONS:Clinical course is mild in elderly-onset IBD patients. This information would need to be taken into account by physicians when therapeutic strategies are established.

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.

BACKGROUNDSubjects without known colorectal adenomas or cancer constitute a large majority of the population where 85% of all cases of colorectal cancer are thought to occur. Consequently these people should be considered for screening to decrease mortality from colorectal cancer in the general population.AIMSTo estimate the incidence rate of rectosigmoid adenomas in these subjects.METHODSSubjects without adenomas or cancer at a previous examination which had visualised the rectosigmoid underwent a fibre endoscopy every three years. Endoscopic data and population characteristics were collected prospectively.RESULTSA total of 450 subjects fulfilled the selection criteria; 287 (64%) underwent at least two examinations, and 163 had three or more. At the second examination, with a mean delay of 39 months, the incidence rate of rectosigmoïd adenomas was 1.50% per patient year. The rate was 1.75% per patient year (95% CI 0.80–3.33) at the third endoscopy with an additional mean delay of 38 months. The cumulative incidence rate at six years was 7.3% (95% CI 4.3–10.3), representing a mean of 1.2% per patient year. This rate increased with age and was higher for men than for women after age adjustment (p< 0.03).CONCLUSIONSThe incidence rates are very low compared with those of patients with prior adenomas. These results should be considered in establishing rectosigmoid adenoma screening strategies.

Background: To describe long-term postoperative evolution of pediatric-onset Crohn's disease (CD) and identify predictors of outcome we studied a population-based cohort (1988–2004) of 404 patients (0–17 years), of which 130 underwent surgery. Methods: Risks for a second resection and first need for immunosuppressors (IS) and/or biologics were estimated by survival analysis and Cox models used to determine predictors of outcome. Impact of time of first surgery on nutritional catch-up was studied using regression. Results: In all, 130 patients (70 females) with a median age at diagnosis of 14.2 years (interquartile range: 12–16) were followed for 13 years (9.4–16.6). Probability of a second resection was 8%, 17%, and 29% at 2, 5, and 10 years, respectively. In multivariate analysis, age

Resume La reponse secretoire et hormonale digestive a la nutrition artificielle peut etre influencee par differents parametres : la voie d'administration des nutriments (enterale ou parenterale), le site d'administration (gastrique ou duodeno-jejunal) de la nutrition enterale, le rythme d'administration continu ou discontinu, et la composition de l'apport nutritionnel. Ces differents facteurs doivent etre pris en compte pour determiner les modalites optimales de la nutrition artificielle, les modifications physiologiques entrainees par la nutrition artificielle pouvant avoir, selon la pathologie consideree, soit un effet benefique, soit un effet nefaste.

Background: Identification of children with Crohn's disease (CD) at high risk of disabling disease would be invaluable in guiding initial therapy. Our study aimed to identify predictors at diagnosis of a subsequent disabling course in a population-based cohort of patients with pediatric-onset CD. Methods: Among 537 patients with pediatric CD diagnosed at

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.

Background: We examined short- and long-term benefits and safety of infliximab (IFX) in a population-based cohort of Crohn's disease (CD) patients

Growth retardation and malnutrition are major features of pediatric Crohn's disease (CD). We examined nutritional and growth parameters from diagnosis to maximal follow-up in a population-based pediatric cohort, and we determined predictive factors.A total of 261 patients (156 boys, 105 girls) with onset of CD before the age of 17 were identified from 1988 to 2004 through the EPIMAD registry (Registre des Maladies Inflammatoires Chroniques de l'Intestin) in northern France. Median age at diagnosis was 13 years (11.2-15.4) and median follow-up was 73 months (46-114). Z-scores of height/age, weight/age, and body mass index (BMI)/age were determined. Multivariate stepwise regression analysis identified predictive factors for malnutrition and growth retardation at maximal follow-up.At diagnosis, 25 children (9.5%) showed height less than -2 s.d., 70 (27%) weight less than -2 s.d., and 84 (32%) BMI less than -2 s.d. At maximal follow-up, growth retardation was present in 18 children (6.9%), whereas 40 (15%) had malnutrition. Nutritional status was more severely impaired in children with stricturing disease. Growth and nutritional retardation at diagnosis, young age, male gender, and extraintestinal manifestations at diagnosis were indicators of poor prognosis. A significant compensation was observed for weight and BMI in both genders and for height in girls. No treatment was associated with height, weight, or BMI at maximal follow-up.In our pediatric population-based study, growth retardation and severe malnutrition were still present at maximal follow-up in 6.9 and 15% of CD children, respectively. Young boys with substantial inflammatory manifestations of CD have a higher risk of subsequent growth failure, especially when growth retardation is present at diagnosis.

Background: Geographic variations in the incidence of inflammatory bowel disease (IBD) may reflect variations in the distribution of environmental etiologic factors. We assessed spatial variation in the incidence of IBD in northern France and analyzed its association with a deprivation index. Methods: All cases of IBD included in the EPIMAD registry between 1990 and 2003 were extracted. The standardized incidence ratio (SIR) was calculated for each canton in the region. The association between incidence and deprivation was assessed using the Townsend deprivation index. Results: The mean annual incidence rates of Crohn's disease (CD) and ulcerative colitis (UC) were 6.2 × 10−5 and 3.8 × 10−5, respectively. The mean cumulative numbers of cases by canton were 18.4 (1–183) for CD and 11.3 (0–148) for UC. For both CD and UC, mapping depicted spatial heterogeneity in the SIR with spatial autocorrelation. A high relative risk (RR) of CD was observed in mainly rural and periurban cantons of the region. For UC, a high RR was found in cantons of the south and the center of Pas-de-Calais. No significant correlation was observed between spatial variations in IBD and deprivation. Conclusions: The incidence of IBD is associated with spatial heterogeneity in northern France. The noteworthy predominance of CD in agricultural areas warrants further investigations. (Inflamm Bowel Dis 2009;)

OBJECTIVES: The natural history of ulcerative colitis (UC) has been poorly described in children. METHODS: In a geographically derived incidence cohort diagnosed from 1988 to 2002, we identified 113 UC patients (age 0-17 years at diagnosis) with a follow-up of at least 2 years. The cumulative risk of colectomy was estimated by the Kaplan-Meier method. Risk factors for disease extension were assessed with logistic regression models, and risk factors for colectomy with Cox hazards proportional models. RESULTS: Median follow-up time was 77 months (46-125). At diagnosis, 28% of patients had proctitis, 35% left-sided colitis, and 37% extensive colitis. Disease course was characterized by disease extension in 49% of patients. A delay in diagnosis of more than 6 months and a family history of inflammatory bowel disease were associated with an increased risk of disease extension, with odds ratios of 5.0 (1.2-21.5) and 11.8 (1.3-111.3), respectively. The cumulative rate of colectomy was 8% at 1 year, 15% at 3 years, and 20% at 5 years. The presence of extra-intestinal manifestations (EIMS) at diagnosis was associated with an increased risk of colectomy (hazard ratio (HR)=3.5 (1.2-10.5)). Among the patients with limited disease at diagnosis, the risk of colectomy was higher in those who experienced disease extension than in those who did not (HR= 13.3 1.7-101.7). CONCLUSIONS: Pediatric UC was characterized by widespread localization at diagnosis and a high rate of disease extension. Twenty percent of children had their colon removed after 5 years. The colectomy rate was influenced by disease extension and was associated with the presence of EIMS at diagnosis.

The impact on patients' attitudes of quality report cards on infection control in hospitals has never previously been studied. In 2006, the French government implemented a mandatory report card on infection control activity (ICALIN) in all hospitals. This approach was aimed at encouraging professionals to change their routine practices in case they should lose patients due to a low ICALIN score. Our objective was to assess what impact ICALIN could have on patients' attitude as regards hospital choice. We performed a survey of patients and visitors in 14 randomly selected hospitals of various ICALIN scores. A convenience sample of 381 patients and visitors completed an anonymous questionnaire on ICALIN, their reasons for choosing a hospital and attitude in the event of a low ICALIN score. Factors associated with interest in ICALIN and impact of ICALIN on hospital choice were assessed by logistic regression. Our results showed that 77% of participants were interested in ICALIN. ICALIN was ranked sixth as a reason for choosing a hospital. In the case of a low ICALIN, 24.1% of participants would refuse admission and 54.9% would seek advice from their general practitioner. Sociodemographic factors had no influence on patients' attitude. In conclusion, our survey suggests that patients take note of poor performance on infection control report cards. As most patients rely on their general practitioner to interpret these report cards, there is a definite need for further communication with general practitioners on this issue.