Incidence, characteristics, and mortality of infective endocarditis in France in 2011.

OBJECTIVES: We assessed the determinants of mortality in infective endocarditis (IE), using the national hospital discharge databases (HDD) in 2011. METHODS: IE stays were extracted from the national HDD, with a definition based on IE-related diagnosis codes. This definition has been assessed according to Duke criteria by checking a sample of medical charts of IE giving a predictive positive value of 86.1% (95% confidence interval (CI): 82.7% - 89.5%). The impact of heart valve surgery on survival has been studied if performed during the initial stay, and over the year of follow-up. Risk factors of in-hospital mortality were identified using logistic regression model for the initial stay and Cox Time-dependent model for the 1-year mortality. RESULTS: The analysis included 6,235 patients. The annual incidence of definite IEs was 63 cases/million residents. Staphylococci and Streptococci were the most common bacteria (44% and 45%, respectively). A valvular surgery was performed in 20% of cases, but substantial variations existed between hospitals. The in-hospital mortality was 21% (ranging 12% to 27% according to the region of patients), associated with age>70, chronic liver disease, renal failure, S. aureus, P. aeruginosa or candida infection and strokes whereas valvular surgery, a native valve IE or intraveinous drug use (right heart IE) were significantly protective for an initial death. The same factors were associated with the one-year mortality, except for valvular surgery which was associated with a 1.4-fold higher risk of death during the year post IE. CONCLUSION: We reported a high IE incidence rate. Valvular surgery was considerably less frequent in this study than in the previous published data (near 50%) whereas mortality was similar. Surgery was associated with higher survival if undergone within the initial stay. There were significant regional differences in frequency of surgery but it did not impact mortality.

Overall care cost comparison between robotic and laparoscopic surgery for endometrial and cervical cancer.

OBJECTIVE: The aim of our medico-economic study was to compare robotic surgery cost with conventional laparoscopic cost in endometrial and cervical cancer. STUDY DESIGN: Our study included laparoscopic and robot-assisted procedures (radical hysterectomies and lymphadenectomies) for endometrial or cervical cancer ever since first using the Da Vinci® in 2008 within a hospital setting. In the hospital perspective, direct costs were determined by examining the overall medical pathway for each type of intervention. Actual costs were calculated for 27 conventional laparoscopic procedures and for 30 robot-assisted procedures including initial cost of the robot and its maintenance. We estimated the complete medical "overall care" costs by adding the costs of consultations, surgery and post-operative hospital stay to the costs of any eventual emergency consultation and/or hospitalisation within the two months that followed surgery. A sensitivity analysis was performed to evaluate the effects of variable modulations. RESULTS: For endometrial cancer, surgical procedure cost for robotic-assisted surgery was €7402 compared to €2733 for conventional laparoscopic surgery. When considering overall medical care, the patient treatment average cost was €6666 for the laparoscopic group (with an average length of stay of 5.27 days) as compared to €10,816 for robotic group (with an average hospital stay of 4.60 days), p=0.39. For cervical cancer, average surgical cost with robotic-assisted surgery was €8501 compared to conventional laparoscopic surgery at €3239. For cervical cancer, overall care average cost was €7803 for the laparoscopic group (with an average length of stay of 5.83 days) as compared to €12,211 for the robotic group (with an average hospital stay of 4.70 days) p=0.07. Sensitivity analysis results confirmed the cost overrun with the use of robotic assisted surgery. CONCLUSIONS: Conventional laparoscopy was less expensive in our institution than robotic-assisted surgery for the surgery of endometrial (1:2.7) and cervical (1:2.6) cancers. When considering overall medical care, the use of robotic-assisted surgery was found to be 1.6 times more expensive than conventional surgery.

[Approach and management of tobacco quitting process of the smoker patient by 149 residents in a university hospital in Tours]. / Abord et prise en charge du fumeur par 149 internes au CHRU de Tours.

INTRODUCTION: How do residents, specialists or general practitioners advise patients who are smokers when they are admitted to hospital? Do they assess their smoking status? How much do they know about smoking cessation? Do they know the tests essential to allow an effective approach to smokers? METHODS: One hundred and forty-nine residents were approached over a nine-month period by three pharmacy students. The questionnaire addressed the assessment of smokers and the possible management of their quitting process: the average time devoted to tobacco cessation, knowledge of "brief smoking cessation advice", assessment of nicotine addiction and motivation to quit as well as detection of withdrawal symptoms, knowledge of the list of nicotine substitutes prescribed by the Tours CHRU, and referral of smokers to a smoking cessation specialist. RESULTS: One hundred and thirty-four (90%) residents out of the 149 who were questioned reported that they tried to assess the smoking status of their patients. The average time devoted to tobacco in a consultation was 4 minutes. Seventy-seven percent of those concerned knew what constituted "brief smoking cessation" and 59% reported delivering it regularly. The Fagerström test was known by 96% of them but only 13% of residents used it. With the exception of two residents in pneumonology, the Q. MAT, an assessment test of motivation to quit smoking, was unknown to them. Nicotine withdrawal symptoms were well recognised. Sixty-nine percent of them knew about the prescription list and 75% of them prescribed nicotine substitutes. CONCLUSIONS: The approach to the smoking patient varied according to the resident's speciality. Smoking assessment was done systematically by most but did not always lead to an assessment of patients' motivation to stop smoking or to an offer of assistance with quitting. This observation led to the development of a tool to improve the approach to smokers, available within the CHRU intranet covering the principles of the management of the tobacco quitting process; informing, helping to stop feeling guilty, assessing the motivation to quit (Q.MAT), assessing the smoker's addiction (Fagerström test), offering assistance and a list of nicotine substitutes.

Bone and joint infections in hospitalized patients in France, 2008: clinical and economic outcomes.

BACKGROUND: Adult bone and joint infections (BJIs) often require repeated and prolonged hospitalizations and are considered as a serious public health issue. AIM: To describe the epidemiology and economical outcomes of BJI in France. METHODS: BJI hospitalizations with selected demographic, medical, and economic parameters from the French national hospital database for the year 2008 were identified. Overall patient characteristics and hospital stays for BJI underwent univariate analysis. Risk factors for device-associated infections were identified using multiple logistic regression modelling. FINDINGS: Of all hospitalizations in France, 0.2% were BJI-related, representing 54.6 cases per 100,000 population, with a higher prevalence in males (sex ratio: 1.54). BJIs were more often native (68%) than device-associated (32%). The mean age was 63.1 years. Only 39% of hospital discharges had microbiological information coded; Staphylococcus spp. were isolated in 66% of those cases. Obesity, Staphylococcus spp., male sex and age >64 years were important risk factors for device-associated infections, whereas diabetes and ulcer sores were significantly associated with native infections. The case fatality was 4.6%. Intensive care unit stays were needed in 6% of cases. Readmissions to hospital occurred in 19% of cases, with significantly longer stays for device-associated infections than for native BJIs (18.9 vs 16.8 days). The cost of BJIs was €259 million, or about €7,000 per hospitalization in 2008. CONCLUSIONS: This is the largest BJI study to date. The high economic burden of BJIs was mostly associated with more frequent and prolonged hospitalizations, high morbidity, and complexity of care.