[Impact of care pathway on the delay for initiation of antituberculosis treatment in Conakry, Guinea]. / Influence des parcours de soins sur le début du traitement antituberculeux à Conakry (Guinée).

Complex care pathways can result in detrimental treatment delay particularly in tuberculosis patients. The purpose of this retrospective study was to assess the care pathways followed by tuberculosis patients prior to diagnosis and to assess impact on the delay for initiation of treatment in Conakry, Guinea. A total of 112 patients were interviewed at the time of first admission for pulmonary tuberculosis with positive bacilloscopy. Based on interview data, pathways were classified as conventional (use of health care facilities only) and mixed (use of health care facilities, self-medication, and traditional medicine). The correlation between patient characteristics and type of pathway was assessed by univariate and multivariate analysis and the two groups, i.e., conventional vs. mixed, were compared with regard to delay for initiation of treatment. The care pathway was classified as mixed in two out of three patients. Multivariate analysis showed that this type of pathway was only correlated with schooling (p=0.02). The mean delay for treatment was similar, i.e., 13.4 and 12.8 weeks for conventional and mixed pathways respectively (p<0.68). The percentage of pathways including three consultations at health care facilities was significantly higher in the conventional than mixed group (72% vs. 30%, p<0.001). The main reasons given for delayed use of health care facilities were poor knowledge of tuberculosis symptoms (26%) and high cost of care (12%). The findings of this study indicate that tuberculosis patients follow a variety of care pathways that can lead to delayed treatment. An information campaign is needed to increase awareness among the population and care providers.

Influence des parcours de soins sur le debut du traitement antituberculeux a Conakry (Guinee)

Les parcours de soins sont souvent complexes et peuvent induire des retards de traitement; avec des effets particulierement deleteres en cas de tuberculose. Nous avons cherche a identifier de facon retrospective; les parcours de soins des patients avant le diagnostic de tuberculose et l'influence de ces parcours sur les delais de traitement a Conakry-Guinee.Nous avons interroge 112 nouveaux patients a leur enregistrement pour tuberculose pulmonaire a bacilloscopie positive. Ont ete distingues les parcours conventionnels (recours aux seules structures sanitaires) et mixtes (associant structures sanitaires; automedication et medecine traditionnelle). L'influence des caracteristiques des patients sur le type de parcours a ete testee en analyses uni et multivariees et les delais de mise sous traitement ont ete compares pour les deux types de parcours. Deux patients sur trois ont suivi un parcours mixte. Ce type de parcours n'etait lie; en analyse multivariee; qu'au niveau de scolarisation (p=0;02). Les delais moyens de traitement etaient similaires (respectivement 13;4 et 12;8 semaines pour les parcours conventionnels etmixtes; p=0;68). La proportion de parcours comportant plus de trois recours aux structures sanitaires etait significativement plus elevee pour les parcours conventionnels que pour les parcours mixtes (72vs 30; p0;001). Les principales raisons invoquees pour l'utilisation tardive des structures sanitaires etaient l'ignorance des signes de la tuberculose (26) et le cout eleve des soins (12). Les parcours des patients sont multiples et peuvent induire des retards a la mise sous traitement antituberculeux. Une sensibilisation de la population et des soignants est necessaire

Long-term survival of patients with multiple sclerosis in West France.

In France no data have been published about comparing survival in multiple sclerosis (MS) patients with the general French population. We estimated survival probabilities in MS patients from a major centre for MS in West France. We also compared MS survival with the general population and assessed prognostic parameters. All patients with MS onset after January 1976 and classified as dead or alive on 1 January 2004 were included. One thousand eight-hundred and seventy-nine patients (sex ratio W: M 2.3; relapsing/progressive onset 77.4%/22.6%) fulfilled these criteria, disease duration ranged from one to 28 years. By 2004, 68 patients died (51 due to MS) and the 15 and 25-year survival probabilities were 96% and 88%. Male gender, progressive course (either primary or secondary), polysymptomatic onset, and increased annual relapse rate during the first two years of MS were related to a worse prognosis. After a mean follow-up duration of 12.7 years since clinical onset, MS increased the number of deaths compared with the general population. However taking into account disability status, we found that less disabled MS patients had a better survival and highly disabled patients a worse survival (eight-fold increase of mortality) compared with the French population.

[Factors linked to delayed diagnosis of tuberculosis in Conakry (Guinea)]. / Facteurs liés au retard du diagnostic de la tuberculose à Conakry (Guinée).

Untreated smear-positive pulmonary tuberculosis constitutes a reservoir of infection which is highly contagious. The present study was conducted in Conakry, Guinea, to determine the different options which are available when seeking treatment or care, and to ascertain the average delay in diagnosis of pulmonary tuberculosis and the main factors linked to the delay in diagnosis after the initial onset of symptoms. Through a cross-sectional study, 113 consecutive patients with smear-positive pulmonary tuberculosis were interviewed through the use of a questionnaire. The median total delay from the onset of symptoms of pulmonary tuberculosis until the diagnosis was 11 weeks. This delay period exceeded 4 weeks for 90 of the patients (80%). The average delay linked to the conventional health care system was double that of the one at the fault of the patient (6 weeks versus 3 weeks, respectively). 54% of the patients had initially resorted to non-conventional care. To shorten this mean delay period, it is necessary to both strengthen the professional abilities and skills which train for one to better to detect tuberculosis and to sensitize the population to the subject matter and information on the illness and its symptoms.

[From psychometry to neuropsychological disability in multiple sclerosis: a new brief French cognitive screening battery and cognitive risk factors]. / De la psychométrie au handicap neuropsychologique dans la sclérose en plaques. Proposition d'une batterie de dépistage en langue française et facteurs de risque cognitifs.

INTRODUCTION: Cognitive deficit in multiple sclerosis (MS) is a frequent early feature in the disease course, which conditions patients' overall disability. The goals of this study were to validate a reproducible brief screening battery written in French and to examine cognitive risk profiles in patients with a mild physical disability. METHODS: Cognitive performances of 40 patients with EDSS <4.5 were compared with those of a control group. The study was completed with an analysis of socio-demographic, clinical and psychological variables (questionnaires). RESULTS: Three tests were discriminative with satisfactory predictive values (positive: 88 percent; negative: 96 percent) and a time duration <30 minutes: PASAT (hard condition), backward digit span, learning stage of California Verbal Learning Test. Four variables were associated with cognitive deficit: educational level <11 years, age >40 years, pathological laughing-crying, unemployment. CONCLUSIONS: Our brief battery is an easy and reproducible tool. Completed with warning signs indicating the need for neuropsychological screening, this tool provides the practitioner with a global means of assessing disease activity and potentially therapeutic efficacy.

[Mitoxantrone as induction therapy in aggressive relapsing remitting multiple sclerosis: a descriptive analysis of 100 consecutive patients]. / Etude observationnelle de la mitoxantrone dans les formes rémittentes actives de sclérose en plaques: suivi à long terme d'une cohorte de 100 patients consécutifs.

INTRODUCTION: On the basis of the French and British (FB) MS Trial, Mitoxantrone (MITOX) was approved by the AFSAPPS in October 2003 in patients with aggressive multiple sclerosis (MS), given as induction therapy monthly for 6 months (ELSEP). We report an observational study of 100 aggressive relapsing remitting (RR) MS patients treated by induction therapy with MITOX and followed up to 5 years. METHODS: One hundred patients with aggressive RR MS received an induction therapy with MITOX 20 mg monthly combined with methylprednisolone 1 g for 6 months. MRI data within 12 months before and 6 months after MITOX induction were collected (mean cumulative dose 65 mg/m2). Clinical evaluation was performed every 6 months and data (relapses and EDSS scores) were prospectively recorded in the EDMUS Database. After MITOX, a maintenance therapy was given to 57 patients (MITOX every 3 months: 21; Interferon beta: 13; Azathioprine: 14; Methotrexate: 7; Glatiramer acetate: 2). The mean follow-up period was of 3.8 years. RESULTS: Patients were treated at a mean age of 27 +/- 9 years after 5 +/- 3 years of MS duration. Within the 12 months preceding MITOX onset, the annual relapse rate (ARR) was 3.2, the mean EDSS increased by 2.2 +/- 1 points (to a score of 4 at M0), 87 patients worsened by 1 point EDSS or more and 85 percent of patients had Gd enhancing lesions on MRI. During the 12 months following MITOX onset, the inflammatory activity of the disease dropped dramatically with a reduction of the ARR by 91 percent whereas 76 percent of patients were free of new relapse and MRI activity was reduced by 89 percent. In addition, the mean EDSS decreased by 1.2 points (p<10-6) and 60 percent of patients improved by 1 point EDSS or more. At a longer term, the reduction of the ARR was confirmed (0.28-0.37 up to 5 years) and the median time to the first relapse was 2.8 years. A significant improvement of disability was maintained until 4 years and got back to the initial level at year 5. The ARR was significantly lower (0.09) for patients treated with MITOX every 3 months as maintenance therapy than for patients treated by other disease modifying therapies (0.33-0.39) or not (0.43) after the induction. Three patients presented an asymptomatic decrease of the left ventricular ejection fraction under 50 percent, reversible in one case. CONCLUSION: MITOX as induction therapy monthly for 6 months was safe and had a rapid and strong impact on the inflammatory process and on the evolution of disability. The drug might be a good candidate as induction therapy followed by a maintenance therapy in patients with aggressive MS.

[Clinical guidelines: what are the viewpoints of physicians and housestaff working in hospital medical departments?]. / Recommandations de pratique clinique: le point de vue des médecins et des internes des services hospitaliers de médecine adulte.

BACKGROUND: Factors facilitating use of clinical guidelines by physicians working in French public hospitals are unknown. We wanted to ascertain the desires of physicians and housestaff working in medical departments. METHODS: A cross-sectional survey using a self-administered questionnaire with closed-ended questions and free comment was conducted in the two academic regional hospitals and the 20 district hospitals of Brittany. The following items were noted: individual and professional characteristics, use of and opinion about clinical guidelines, perceived usefulness of specific attributes of guidelines or implementation efforts. The results are shown separately for physicians and housestaff. The statistical significance of associations between physician characteristics and their opinions was tested by using the chi-square test. RESULTS: 390 out of 783 responded (50%). Nine housestaff and eight physicians out of ten responders found more positive than negative points to guidelines (decision making tool, standardization of practices, versus rigidity, lack of freedom in practice). One out of three reported using them regularly. Guidelines focusing on general medicine, covering both diagnosis and treatment, developed at the national level with local adaptation, synthetic and pocket-sized guide-book given directly to the housestaff by the department's physicians, were more likely to be used. One physician out of two would use more guidelines from specialty organizations, or would use them as a self-training tool in practices evaluation. CONCLUSION: Implementation of guidelines in hospital medical departments should take into account the housestaff demands as well as the need for the physicians' implication.

[Treatment of heterotopic ossification by extracorporeal shock wave: 26 patients]. / Traitement des paraostéoarthropathies par ondes de choc. Etude sur 26 patients.

OBJECTIVES: To evaluate the effects of extracorporeal shockwave therapy (ESWT) on heterotopic ossification leading to functional limitations in the short and medium term. METHODS: Twenty-six patients with heterotopic ossification received sessions of ESTW (4000 shocks, 3/s), with an energy ranging from 0.54 to 1.06 mJ/mm2, once a week for 4 consecutive weeks. Intermediary assessments performed 1 month after the last session related to pain (on a visual analog scale [VAS]), range of motion, functional independence (FIM), walking distance (whenever possible), radiology, and blood calcium and alkaline phosphatase levels. Eighteen patients with total hip arthroplasty (THA) were followed up by quiz, at 11 months, on average. RESULTS: Heterotopic ossification was neurogenic in 5 patients and nonneurogenic in 21. The length of evolution of ossification was 32+/-21 months. The measurements showing significant improvement in the short term were pain, with a mean decrease of 4.32 to 1.14 on a VAS; joint flexion, with an mean increase of 8.18+/-11.9 degrees; and walking distance, with a mean increase from 1126 to 2776 m. The treatment was tolerated for the most part. THA cases showed a decline in factors initially shown to be improved. However, the long-term results were superior to clinical status before treatment. CONCLUSION: ESWT might be an interesting treatment for heterotopic ossification and can be a complement to usual medical treatment, physiotherapy, and before surgery.

[Consumption of hand-hygiene products in health establishments in the west of France]. / La consommation de produits d'hygiène des mains dans les établissements de soins dans l'interrégion Ouest.

OBJECTIVES: The study had for aim to investigate hand hygiene product use in French hospitals between 2000 and 2003. DESIGN: A questionnaire was sent in 2002 and 2 more in 2003 and 2004 (for 2000 to 2003) requiring data on type of hospital, number of beds, staff members, admissions and patient-day, litres of mild soap, antiseptic soap and alcohol-based rub used and price per litre. Indices were calculated accordingly. RESULTS: 574 hospitals answered over the 4 year period (average 143 per year) representing an average of 50 000 beds/year, 80 000 full-time staff positions, 1.2 million admissions and 16 millions patient-days. The median consumption of mild soap was 3.8 l per bed, 2.7 l per staff member, 2.4 l per 100 admissions, and 10.6 ml per patient-day. The median consumption of antiseptic soap was 1 l per bed, 0.8 l per staff member, 4.8 l per 100 admissions, and 3.2 ml per patient-day. The median consumption of alcohol-based rub (HAS) was 0.3 l per bed, 0.3 l per staff-member, 1.5 l per admission, and 0.9 l per patient-day. Between 2000 and 2003, HAS use significantly increased from 69 to 88% (a relative increase of 31%) and the median consumption increased from 0.5 ml to 1.5 ml per patient-day. 370 fully completed grids gave a number of 7 opportunities per patient-day with less than 1 for HAS. CONCLUSION: The best indicator for an infection control practitioners is the quantity of alcohol-based solution in ml/patient-day and HAS per patient-day is the reference.

[Mortality rates in rural and urban areas of Brittany]. / Mortalité urbaine et rurale en Bretagne.

Relative differences in environment, behaviour, social composition as well as access to health care tend to suggest that levels of health may vary between urban and rural areas. The aim of this study was to identify rural-urban variations in mortality risks in the region of Brittany for the period from 1988 to 1992. The definition of urban and rural areas used adhered to that of the zoning of urban areas established by the INSEE (the National Statistical Office). The amalgamation of all causes of standardised mortality ratios (SMR) show only a moderately increased risk in the rural areas compared with the overall regional level (+4% in men, +5-7% in women). The analysis of cause specific SMRs display higher rural mortality for cardiovascular diseases and external causes of death, road traffic accidents in particular (+24% in men). Among all specific causes investigated, only lung cancer mortality risk appears to be higher in urban areas.

[Return to work after cardiac valvular surgery. Retrospective study of a series of 105 patients]. / La reprise du travail après chirurgie valvulaire cardiaque. Etude rétrospective d'une série de 105 patients.

This was a retrospective study realised by a mailed questionnaire of the medical and socio-professional conditions of return to work in patients with valvular heart disease aged 20 to 59 and operated in the cardiac surgery department of Rennes University Hospital in 1998. The results concern 105 patients of whom 78 were working before surgery and 27 were unemployed, and 53 were professionally active after surgery. The average age was 48 +/- 9 years and the male/female ratio was 2.38. After surgery, 78.4% of patients were NYHA Stages I or II, compared with 38.1% before surgery. Three main surgical procedures were carried out, sometimes in association: aortic valve replacement (71.4%), mitral valve replacement (21%) and mitral valvuloplasty (11.4%). Valve replacement was with a mechanical prosthesis in 83% of cases, a bioprosthesis in 11% of cases and a homograft in 6% of cases. Return to work (67.9%) after an average of 5.3 +/- 3.9 months was correlated with the following factors: age: 50 years old patients or more, were less likely to return to work (p < 0.02); postoperative NYHA stage: patients in stages III and IV were less likely to return to work (p < 0.03); the time off work before surgery: the longer the time (threshold > 6 months) the less likely the patients are to return to work (p < 0.03). Return to work was preferred to non-return (p < 0.03). This study shows the difficulties of professional rehabilitation of patients despite a satisfactory general condition. This is partially explained by the difficult economic context which favorises invalidity but also by the lack of information concerning the role of works doctors in the return to work. The realisation of a liaison file with permission of the person concerned between the general practitioner, the cardiologist and a medico-social security doctor and works doctor should remedy the difficulties in communication and sustain a policy of return to work.

[The French and English health systems: compared evolution after the mid-1990s]. / Les systèmes de santé français et anglais: évolution comparée depuis le milieu des années 90.

In the recent past, the British and French health care systems have both undergone significant reforms, enveloped in a state of Urgency, resulting primarily in France from the increasing rate of growth in health expenditure and in England from malfunctioning procedures such as waiting lists. After describing current features of the National Health Service (NHS), this study extracts and considers the points of convergence and divergence in the respective policies of the two countries: similarities in the choice of priorities, decentralisation of decision-making, negotiation between actors at the local level, development of the quality concept, and the differences in formulating objectives and involving the system's users. The considerations provided here should allow for a better understanding of the developments of these respective health policies and their future evolution.

[Evaluation of the immediate transfusion reaction incident reporting system at the Brest University Hospital Center]. / Evaluation du système de notification des incidents transfusionnels immédiats au CHU de Brest.

The Haemovigilance Unit of Brest University Hospital has had a reporting system of transfusion reactions since october 1994. Reporting "any unexpected or undesirable effect due or likely to be due to the administering of blood cell components" must be done on an answering machine immediately or in the next eight hours. The main goal of the evaluation of this epidemiological surveillance system was to assess its sensitivity, its positive predictive value, its acceptability, its timeliness and its simplicity, according to the Centers for Disease Control criteria. An exhaustive monitoring of the immediate transfusion reactions (ITR) occurring within the 24 hours following the procedure was conducted from April 1, to June 30, 1998. Two sources of information were used, the spontaneous notification to the Haemovigilance Unit using the answering machine, and a telephone survey of the nurse responsible for the transfusion or post-transfusion follow-up. During the survey, 19 ITR, among which 12 were reported to the Haemovigilance Unit on the answering machine, were recorded. The incidence rate of the I.T.R. was estimated at 5@1000 transfused blood cell components. The sensitivity of the notification system was estimated at 63% (95% confidence interval: 41-85) and the positive predictive value at 70% (95% confidence interval: 48-92). This notification system is operational. The function of sanitary alert is ensured at the primary level of the system surveillance. The undernotification of the ITR (37% of false negative) must be corrected by specific recommendations.

Long-term follow-up of percutaneous vena cava filters: a prospective study in 100 consecutive patients.

OBJECTIVES: the long-term outcome in following insertion of inferior vena cava (IVC) filters remains unclear. DESIGN: prospective study. MATERIAL AND METHODS: one hundred consecutive patients received percutaneous vena cava filters between 1988 and 1993. The patients underwent clinical examination, abdominal X-rays and duplex ultrasound of the IVC, right internal jugular vein and legs after a mean follow-up duration of 38+/-11 months. RESULTS: forty patients died after implantation (median 11.3 months; IQR: 1.8--20.4 months). The cause of death was known in 33 cases, and pulmonary embolism (PE) was suggested in three. Multivariate analysis revealed the mortality rate to be significantly higher in cancer patients (relative risk of 2.13). The 3-year survival was 20% for cancer patients and 71% for patients without cancer. Among the 60 living patients, thrombi were trapped in the filter in 10 cases, the filter tilted in four, was malpositioned in five and migrated in 29. These incidents were recorded as asymptomatic complications, as opposed to seven IVC thromboses and 23 recurrent lower limb thromboses, which were considered as symptomatic complications. CONCLUSION: long-term major complications are not frequent. As expected, cancer was the only factor predicting mortality. IVC filters seem effective in preventing PE.

[History of continuing medical education in the United States]. / Histoire de la formation médicale continue aux Etats-Unis.

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.

[Psychiatry and clinical research. A dialogue with hospital directors]. / Psychiatrie et recherche clinique. Dialogue avec les directeurs d'hôpitaux.

Clinical research must be considered as a main and compulsory medical activity which has to be promoted on a European level. Some difficulties appear to be specific to mental diseases and may represent obstacles or a reason not to participate in clinical research. In fact, financing, grants, organizations and research centers do exist and should push forward clinical research in psychiatry. Human and cultural factors may explain why so few breakthroughs have occurred in France in the considered field. Incentive politics as well as avoidance of technical and frequently definitive errors must be proned and issue from a deep analysis of how leading teams are organized and operate.

[Difficulties with the implementation and institutional stakes in the continuing education of private physicians]. / Difficultés de mise en place et enjeux institutionnels de la formation continue des médecins libéraux.

The Formation Medical Continue (FMC) is a continuing education programme for private practice doctors (generalists and specialists), and was established in the legislation of April 1996. In analysing the stages of the policy's introduction, an attempt was made to understand the difficulties encountered in its implementation. Using a semi-directive questionnaire, the opinions concerning the policy were collected from the different actors in the process: professionals, social welfare organisations, government agencies and health organisations. The analysis of their perceptions was complemented by an analysis of historical data and a review of the literature. The greatest difficulties with implementation related to the interactions among the stakeholders: the "game" of the medical unions, among themselves and with social security and government agencies; the under-representation of the medical profession, exacerbated by its divisions and the split between generalists and specialists; the indecision of government agencies, leaving the stakeholders waiting; the "game" of the social security funds, which act as if the principle of "mutualisation" of FMC funds can be by-passed. Conflicts of interest regarding the FMC have "crystallised" among the different stakeholders, as well as within the medical corpus. These conflicts relate in particular to the creation of the memorandum agreement and to the definition of the relationship with the pharmaceutical industry.

[Rating scales and questionnaires in Parkinson's disease]. / Echelles et questionnaires dans la maladie de Parkinson.

Rating scales and questionnaires used as measurement tools in Parkinson's disease are carefully constructed with well-defined items. The validity of a scale is its capacity to provide the intended measurement. One can distinguish perceived, content, and criteria-based validity as well as construction and sensitivity to change validity. The reliability of a scale is the capacity of a scale to produce statistically equivalent data in comparable situations. Reliability is composed of the following qualities: interobserver reliability, test-retest reliability, and internal coherence. UPDRES, mood scales (Hamilton, MADRS, CES-D, BDI), scales assessing cognitive disorders (MATTIS, MMSE), and quality of life questionnaires designed specifically for Parkinson's disease (PDQL, PDA-39, PDq-8) or for the general population (SF-36, SIP, NHP) are used in routine practice, and are particularly useful for clinical research. The metrological properties of these scales are analyzed here.

[Prescriptions for antidepressants in a population of psychiatrists and non-psychiatrists]. / Prescription d'antidépresseurs par une population hospitalière rennaise de psychiatres et de non psychiatres.

OBJECTIVE: Much proof has been accumulated over the last decade demonstrating that depression is a major public health issue. Use of psychotropics and more precisely antidepressants is considered to be excessive. It is however paradoxical that prescribing antidepressants has become commonplace. The aim of this study was to better assess the process of prescribing antidepressants in the hospital setting. METHODS: An epidemiological study was carried out to examine prescribing practices used by psychiatrists and non psychiatrists working in the Rennes University Hospital. The psychiatrist population was used as the reference population for univariate and multivariate analysis designed to ascertain differences concerning prescription practices. RESULTS: Duration of the clinical examination (shortest for non-psychiatric physicians, p = 0.0001), use of a diagnostic scale (more frequently for psychiatrists, p = 0.0008), reasons for choosing an antidepressant (pharmacological considerations more frequent among psychiatrists, p = 0.0009), and co-therapies (neuroleptic association more frequent among psychiatrists, p = 0.0001) were found to be different between the two prescribing populations. CONCLUSION: All patients with signs of depression are not necessarily given optimal care. Errors in assessing antidepressants is probably a common problem.