[French practical guidelines for the diagnosis and management of IPF - 2021 update, full version]. / Recommandations pratiques pour le diagnostic et la prise en charge de la fibrose pulmonaire idiopathique ­ Actualisation 2021. Version intégrale.

BACKGROUND: Since the previous French guidelines were published in 2017, substantial additional knowledge about idiopathic pulmonary fibrosis has accumulated. METHODS: Under the auspices of the French-speaking Learned Society of Pulmonology and at the initiative of the coordinating reference center, practical guidelines for treatment of rare pulmonary diseases have been established. They were elaborated by groups of writers, reviewers and coordinators with the help of the OrphaLung network, as well as pulmonologists with varying practice modalities, radiologists, pathologists, a general practitioner, a head nurse, and a patients' association. The method was developed according to rules entitled "Good clinical practice" in the overall framework of the "Guidelines for clinical practice" of the official French health authority (HAS), taking into account the results of an online vote using a Likert scale. RESULTS: After analysis of the literature, 54 recommendations were formulated, improved, and validated by the working groups. The recommendations covered a wide-ranging aspects of the disease and its treatment: epidemiology, diagnostic modalities, quality criteria and interpretation of chest CT, indication and modalities of lung biopsy, etiologic workup, approach to familial disease entailing indications and modalities of genetic testing, evaluation of possible functional impairments and prognosis, indications for and use of antifibrotic therapy, lung transplantation, symptom management, comorbidities and complications, treatment of chronic respiratory failure, diagnosis and management of acute exacerbations of fibrosis. CONCLUSION: These evidence-based guidelines are aimed at guiding the diagnosis and the management in clinical practice of idiopathic pulmonary fibrosis.

[French practical guidelines for the diagnosis and management of IPF - 2021 update, short version]. / Recommandations pratiques pour le diagnostic et la prise en charge de la fibrose pulmonaire idiopathique ­ Actualisation 2021. Version courte.

BACKGROUND: Since the previous French guidelines were published in 2017, substantial additional knowledge about idiopathic pulmonary fibrosis has accumulated. METHODS: Under the auspices of the French-speaking Learned Society of Pulmonology and at the initiative of the coordinating reference center, practical guidelines for treatment of rare pulmonary diseases have been established. They were elaborated by groups of writers, reviewers and coordinators with the help of the OrphaLung network, as well as pulmonologists with varying practice modalities, radiologists, pathologists, a general practitioner, a head nurse, and a patients' association. The method was developed according to rules entitled "Good clinical practice" in the overall framework of the "Guidelines for clinical practice" of the official French health authority (HAS), taking into account the results of an online vote using a Likert scale. RESULTS: After analysis of the literature, 54 recommendations were formulated, improved, and validated by the working groups. The recommendations covered a wide-ranging aspects of the disease and its treatment: epidemiology, diagnostic modalities, quality criteria and interpretation of chest CT, indication and modalities of lung biopsy, etiologic workup, approach to familial disease entailing indications and modalities of genetic testing, evaluation of possible functional impairments and prognosis, indications for and use of antifibrotic therapy, lung transplantation, symptom management, comorbidities and complications, treatment of chronic respiratory failure, diagnosis and management of acute exacerbations of fibrosis. CONCLUSION: These evidence-based guidelines are aimed at guiding the diagnosis and the management in clinical practice of idiopathic pulmonary fibrosis.

The impact of the COVID-19 epidemic on primary care in South-eastern France: implementation of a real-time monitoring system based on regional health insurance system data.

BACKGROUND: The spring 2020 COVID-19 epidemic severely impacted France's healthcare system. The associated lockdown (17 March- 11 May 2020) and the risk of exposure to SARS-CoV-2 led patients to change their use of healthcare. This article presents the development and implementation of a real-time system to monitor i) private doctors' activity in South-eastern France, and ii) changes in prescription of drugs for people with diabetes, mental health disorders and for certain vaccines from Mars 2020 to October 2020. METHODS: Data extracted from the regional healthcare insurance databases for 2019 and 2020 were used to construct indicators of healthcare use. They were calculated on a weekly basis, starting from week 2 2020 and compared for the same period between 2019 and 2020. RESULTS: Private doctors' activity decreased during the spring 2020 lockdown (by 23 % for general practitioners and 46 % for specialists), followed by an almost complete return to normal after it ended until week 41. Over the same period, a huge increase in teleconsultations was observed, accounting for 30 % of private doctors' consultations at the height of the crisis. The start of the lockdown was marked by a peak in drug prescriptions, while vaccinations declined sharply (by 39 % for the measles, mumps and rubella (MMR) vaccine in children under 5 years old, and by 54 % for human papillomavirus vaccine in girls aged 10-14 years old). CONCLUSION: The ongoing COVID-19 epidemic may lead to health consequences other than those directly attributable to the disease itself. Specifically, lockdowns and foregoing healthcare could be very harmful at the individual and population levels. The latter issue is a concern for French public authorities, which have implemented actions aimed at encouraging patients to immediately seek treatment. However, the COVID-19 crisis has also created opportunities, such as the roll-out of teleconsultation and tele-expertise. The indicators described here as part of the monitoring system can help public decision-makers to become more responsive and to implement tailored actions to better meet the general population's healthcare needs.

[The impact of the COVID-19 pandemic on first-line primary care in southeastern France: Feedback on the implementation of a real-time monitoring system based on regional health insurance data]. / L'impact de l'épidémie de COVID-19 sur les soins de premier recours en région Provence-Alpes-Côte d'Azur : retour d'expérience sur la mise en place d'un dispositif de surveillance en temps réel à partir des données régionales de l'Assurance maladie.

BACKGROUND: Starting in spring 2020, the COVID-19 pandemic markedly impacted the French healthcare system. Lockdown and risks of exposure to the coronavirus induced patients to modify their ways of use. The objective of this article was to share feedback on the implementation of a real-time monitoring system concerning (a) the activity of private practitioners in southeastern France, and (b) the evolution of reimbursements for drugs prescribed to persons with diabetes, for treatment of mental health disorders, and for performance of some vaccines. METHODS: Data regarding 2019 and 2020 were extracted from regional health insurance databases. They were used to elaborate several indicators relative to the general health insurance scheme, which were calculated and updated each week, starting with week 2. RESULTS: We observed a drop in private physician activity during the lockdown (-23% for general practitioners; -46% for specialist doctors), followed by a return to a semblance of normalcy. Concomitantly, a boom in teleconsultations occurred: at the height of the crisis they represented 30% of medical acts. The initial stage of the lockdown was characterized by peak provisioning for drugs, whereas vaccination strongly declined (-39% regarding measles, mumps and rubella vaccine among children aged less than 5 years; -54% regarding human papillomavirus vaccine among girls aged 10 to 14 years). CONCLUSION: The COVID-19 pandemic could lead to health effects other than those directly attributable to the coronavirus itself. Renouncing care may result in healthcare delays highly deleterious for people and society. Public authorities are preoccupied with these questions; they have set up action plans aimed at encouraging patients to seek treatment without delay. That said, the COVID-19 pandemic crisis has also created opportunities, such as the expansion of telemedicine. Although partial, these indicators can provide useful information enabling public decision makers to be reactive and to implement specific actions to meet the health needs of the population.

[Relevance of the health insurance databases to study spatial disparities in asthma prevalence: A study in southeastern France]. / Intérêt des données de remboursement de l'assurance-maladie pour l'étude des disparités territoriales de la prévalence de l'asthme : une étude en Provence-Alpes-Côte d'Azur.

BACKGROUND: Data on asthma prevalence at a small-area level would be useful to set up and monitor French local public health policies. This study, based on drug reimbursement databases in southeastern France, aimed to (1) compare asthma-like disorders prevalence estimated by using three different indicators; (2) study sociodemographic characteristics associated with these indicators; (3) verify whether these indicators are equivalent to study geographical disparities of the asthma-like disorders prevalence at a small-area level. METHODS: The study was conducted among the beneficiaries of the National Health Insurance Fund aged 18-44 years residing in southeastern France in 2010 (n=1,371,816). Using data on asthma drugs reimbursements (therapeutic class R03), we built three indicators to assess asthma-like disorders prevalence: at least 1, 2 or 3 purchase(s) in 2010. We analyzed sociodemographic characteristics associated with these indicators, and their geographical disparities at a small-area level using multilevel logistic regression models. RESULTS: The crude asthma-like disorders prevalence varied between 2.6 % and 8.4 % depending on the indicator. It increased with age, was higher for women than for men, and among low-income people for all three indicators. We measured significant geographical disparities. Areas with high prevalence rates were the same regardless of the indicator. CONCLUSION: The indicators built in this study can be useful to identify high prevalence areas. They could contribute to launch discussion on environmental health issues at the local level.

Benefits of Completion 3D Angiography Associated with Contrast Enhanced Ultrasound to Assess Technical Success after EVAR.

OBJECTIVES: This study evaluated a new strategy to assess technical success after standard and complex endovascular aortic repair (EVAR), combining completion contrast enhanced cone beam computed tomography (ceCBCT) and post-operative contrast enhanced ultrasound (CEUS). METHODS: Patients treated with bifurcated or fenestrated and branched endografts in the hybrid room during the study period were included. From December 2012 to July 2013, a completion angiogram (CA) was performed at the end of the procedure, and computed tomography angiography (CTA) before discharge (group 1). From October 2013 to April 2014, a completion ceCBCT was performed, followed by CEUS during the 30 day post-operative period (group 2). The rate of peri-operative events (type I or III endoleaks, kinks, occlusion of target vessels), need for additional procedures or early secondary procedures, total radiation exposure (mSv), and total volume of contrast medium injected were compared. RESULTS: Seventy-nine patients were included in group 1 and 54 in group 2. Peri-operative event rates were respectively 8.9% (n = 7) and 33.3% (n = 18) (p = .001). Additional procedures were performed in seven patients (8.9%) in group 1 versus 17 (31.5%) in group 2 (p = .001). Two early secondary procedures were performed in group 2 (3.7%), and three (3.8%) in group 1 (p = .978). Median radiation exposure due to CBCT was 7 Gy cm(2) (5.25-8) (36%, 27%, and 9% of the total procedure exposure, respectively for bifurcated, fenestrated, and branched endografts). CEUS did not diagnose endoleaks or any adverse events not diagnosed by ceCBCT. Overall radiation and volume of contrast injected during the patient hospital stay in groups 1 and 2 were 34 (25.8-47.3) and 11 (5-20.5) mSv, and 184 (150-240) and 91 (70-132.8) mL respectively (reduction of 68% and 50%, p < .001). CONCLUSIONS: Completion ceCBCT is achievable in routine practice to assess technical success after EVAR. Strategies to evaluate technical success combining ceCBCT and CEUS can reduce total in hospital radiation exposure and contrast medium volume injection.

CT pulmonary angiogram with 60% dose reduction: Influence of iterative reconstructions on image quality.

GOALS: To compare the quality of low-dose CT images with sinogram affirmed iterative reconstruction (SAFIRE), and full-dose CT with filtered back projection reconstructions (FBP). MATERIALS AND METHODS: Fifty pulmonary CT performed by a dual-source technique (120kVp; 110mAs) with (a) the same energy in both tubes, and (b) the distribution of reference mAs with 40% in tube A (44mAs) and 60% in tube B (66mAs). Each acquisition allowed reconstruction of: (a) full-dose images (with both tubes) with FBP reconstructions (group 1); and (b) low-dose images (from tube A) reconstructed with SAFIRE (group 2). RESULTS: Group 2 images presented: (a) a significant objective reduction in noise measured in the trachea on mediastinal (16.04±5.66 vs 17.66±5.84) (P=0.0284) and pulmonary (29.77±6.79 vs 37.96±9.03) (P<0.0001) images; (b) a similar subjective perception of noise and overall image quality (P=1), which was considered to be excellent in 66% (33/50) of the cases, with no influence on the detection of elementary pulmonary lesions of infiltration (98.4%; 95% CI=[96.9%-99.9%]). CONCLUSION: Despite a 60% reduction in radiation dose, the image quality with iterative reconstruction is objectively better and subjectively similar to full-dose FBP images.

Computed tomography for pulmonary embolism: assessment of a 1-year cohort and estimated cancer risk associated with diagnostic irradiation.

BACKGROUND: The principal concern of any radiation exposure in computed tomography (CT) is the induction of stochastic risks of developing a radiation-induced cancer. The results given in this manuscript will allow to (re-)calculate yield of chest CT. PURPOSE: To demonstrate a method to evaluate the lifetime attributable risk (LAR) of cancer incidence/mortality due to a single diagnostic investigation in a 1-year cohort of consecutive chest CT for suspected pulmonary embolism (PE). MATERIAL AND METHODS: A 1-year cohort of consecutive chest CT for suspected PE using a standard scan protocol was analyzed retrospectively (691 patients, 352 men, 339 women). Normalized patient-specific estimations of the radiation doses received by individual organs were correlated with age- and sex-specific mean predicted cancer incidence and age- and sex-specific predicted cancer mortality based on the BEIR VII results. Additional correlation was provided for natural occurring risks. RESULTS: LAR of cancer incidence/mortality following one chest CT was calculated for cancer of the stomach, colon, liver, lung, breast, uterus, ovaries, bladder, thyroid, and for leukemia. LAR remains very low for all age and sex categories, being highest for cancer of the lungs and breasts in 20-year-old women (0.61% and 0.4%, respectively). Summation of all cancer sites analyzed raised the cumulative relative LAR up to 2.76% in 20-year-old women. CONCLUSION: Using the method presented in this work, LAR of cancer incidence and cancer mortality for a single chest CT for PE seems very low for all age groups and both sexes, but being highest for young patients. Hence the risk for radiation-induced organ cancers must be outweighed with the potential benefit or a treatment and the potential risks of a missed and therefore untreated PE.

Emphysema in asymptomatic smokers: quantitative CT evaluation in correlation with pulmonary function tests.

PURPOSE: To provide quantitative information on emphysema in asymptomatic smokers in correlation with pulmonary function tests (PFT). PATIENTS AND METHODS: The study population included 75 smokers (current smokers: n=39; ex-smokers: n=36) and 25 nonsmokers who underwent volumetric high-resolution CT of the chest with automated quantification of emphysema and PFTs. RESULTS: Current smokers had a higher percentage of emphysema in the right lung (P=0.041) and right upper lobe (P=0.037). The overall percentage of emphysema did not differ according to the Gold stage (P=0.77). Smokers with emphysema had significantly higher mean values of FRC (P=0.012), RV (<0.0001) and TLC (P=0.0157) than smokers without emphysema but no significant differences were found in neither the mean values of TLCO nor in expiratory flows (P>0.05). Correlations were found between the percentage of emphysema and (a) cigarette consumption of current (r=0.34215; P=0.0330) and ex-smokers (r=0.44104; P=0.0071); and (b) alterations of TLC, FRC, RV and DLCO of smokers. CONCLUSION: Quantitative CT allows recognition of regional specificities and subclinical functional alterations in smokers with emphysema.

[Castleman's disease: unusual presentation of Castleman's disease and review of literature]. / La maladie de Castleman : observations inhabituelles et revue de la littérature.

Castleman disease is a rare disorder of the lymphoid system which can be classified into two clinical groups, monocentric disease versus multicentric disease, and two histological types, the hyaline vascular form versus the plasma cell form. We report three cases of monocentric Castleman disease. The first one is a classical form of Castleman's disease. The second one is characterized by an uncommon radiological presentation, with a calcification within the tumor. The third one is a plasma cell form with monoclonal proliferation associated with a monoclonal gammapathy. These three cases highlight the polymorphic clinical and radiological features of Castleman disease. They underlie the difficulty of surgical resection due to the tumor vascularization. Other diagnosis hypothesis and associated diseases will also be discussed (HIV, Kaposi's sarcoma, POEMS syndrome).

Single- and dual-source chest CT protocols: Levels of radiation dose in routine clinical practice.

PURPOSE: To establish the radiation dose level for single- and dual-source thoracic CT scans in daily practice. MATERIALS AND METHODS: The dose levels delivered during 634 consecutive examinations over a period of 2 months were recorded. The CT scans were performed using: (a) a standard protocol (single source, single energy [group 1]: n=266; dual source, single energy [group 2]: n=276; (b) with prospective ECG synchronisation [group 3]: n=13; or (c) with dual energy [group 4]: n=79. All the acquisitions included kilovoltage selection depending on the weight and automatic milliamperage modulation. RESULTS: The mean DLP of the standard protocols was 97.12 mGycm (group 2; BMI=23.1kg/m(2)) and 211.1 mGycm (group 1; BMI=27.3kg/m(2)), the choice of protocol depending on the diameter of the thorax relative to the diameter of the field of the second source, and therefore on the patient's morphotype. When imaging included examination of the proximal and middle coronary arteries (group 3), the mean DLP was 105.5 mGycm. Morphological and functional imaging (group 4) was obtained with a mean DLP of 404.3 mGycm. CONCLUSION: Depending on the objective of the protocol, the mean DLP varied from 97.12 to 404.3 mGycm.

[Potentially inappropriate prescriptions for the elderly: a study of health insurance reimbursements in Southeastern France]. / Prescriptions médicamenteuses potentiellement inadaptées chez les personnes âgées : une étude en Provence-Alpes-Côte d'Azur à partir des données de remboursements de l'Assurance maladie.

BACKGROUND: This study conducted in the region of Provence-Alpes-Côte d'Azur (PACA) sought to assess the feasibility of constructing and using indicators of potentially inappropriate prescriptions for the elderly from health insurance reimbursement data. We present and discuss different indicators of inappropriate prescriptions for people aged 70 years or older (at-risk prescriptions, dangerous or at-risk coprescriptions, absence of necessary coprescriptions) and reports their prevalence in PACA. METHODS: The indicators were constructed from the French list of inappropriate prescriptions, national agency guidelines, and the advice of experts in the field. The indicators selected were applied to the databases of the PACA Salaried Workers' Health Insurance Fund for 2008 for all recipients aged 70 years or older and compared according to age, sex, chronic disease status, and, after standardization for age and sex, according to district of residence. RESULTS: In January 2009, 500,904 recipients aged 70 years or older were identified in the data base of the Salaried Workers' Health Insurance Fund, 60.8% of whom were women and 52.1% of whom had approved coverage for a chronic disease. The potentially inappropriate prescriptions most frequently observed here, in decreasing order, were: prescription of an NSAID without the coprescription of gastric protection (28.1%); long-term benzodiazepine treatment (21.5%); prescription of long half-life benzodiazepine (14.9%), and long-term treatment with NSAIDs (11.6%). Overall, the prevalence of each increased significantly with age and was higher among women and people with chronic diseases. Significant variations were also observed between the different districts of PACA. CONCLUSION: Our results confirm that a substantial proportion of elderly people receive potentially inappropriate prescriptions. They also suggest that health insurance reimbursement data could be used in some prescription domains for monitoring trends in the potentially inappropriate prescriptions in the populations of various territories, provided that specific limitations are considered.

[Evaluation of hospital stays linkage quality to study health spatial variation. a feasibility study in three French regions]. / Évaluation de la qualité du chaînage des séjours hospitaliers pour l'étude des variations spatiales de santé à partir des données du PMSI. Étude de faisabilité dans trois régions françaises.

BACKGROUND: Since 2001, the French hospital stay databases (Programme de médicalisation des systèmes d'information, PMSI) have included a unique and anonymous identifier in order to cross-link discharge abstracts from a given patient, within and across hospitals. These data could be used to estimate prevalence for some diseases at a territorial level provided that linkage quality is good enough. Few morbidity data are available at this scale. This study analyzes the link between linkage quality and hospitalization rates in three French regions (Picardy, Brittany and Provence-Alpes-Côte d'Azur-Paca). METHODS: We studied short stays in medicine-chirurgical-obstetrical units for the 2004-2005 period (all stays, and stays with mention of cancer or asthma). To study linkage quality, the percentage of linkable stays (no error during the production of the anonymous identifier) was calculated at regional and territorial levels (areas used by regional health authorities). The interquartile range (IQR=third quartile-first quartile) of the percentage of linkable stays was calculated and the link between this percentage and standardized rates of people hospitalized at least once in 2004 or 2005 tested by Spearman correlation coefficients. RESULTS: For all stays, percentages of linkable stays were 94.4%, 96.6% and 97.0% in Picardy, Paca and Brittany respectively in 2004-2005. Geographical variation at the territorial level was higher in Picardy (IQR between 4 and 6) than in the two other regions (IQR between 1 and 2). The percentage of linkable stays was positively and significantly associated with the hospitalization rate for all stays and those with mention of cancer in Picardy only. CONCLUSION: According to these results, PMSI data earlier than 2006 should be used with precaution; linkage quality should be analyzed before making geographical or time comparisons of hospitalization rates. Comparisons cannot always be made. Other studies should be carried out in other regions, and to analyze recent trends in linkage quality.

Feedback and lessons from the prescription of rimonabant, a drug to be used under strict guidelines, in southeastern France, March 2007 through June 2008.

BACKGROUND: To provide feedback on the initial market authorization of rimonabant, a drug to be used under strict guidelines, we conducted a study with information from the National health insurance reimbursements database for southeastern France. The aims of this study were to: (1) describe the characteristics of subjects who have had one rimonabant prescription reimbursed; (2) study the frequency of prescriptions that did not comply with reimbursement criteria; (3) study the frequency of prescriptions for patients simultaneously treated with antidepressants; and (4) analyse the factors associated with both types of prescription (patient and prescriber characteristics). METHODS: Using the database of drug reimbursements maintained by the southeastern France general health insurance fund, we studied the characteristics of outpatients with at least one reimbursement for rimonabant, compared them to the rest of the population, and analysed compliance with the indications, contraindications, and regulations for rimonabant prescription with multivariate logistic regressions. RESULTS: A total of 10,510 beneficiaries (0.28%) had at least one rimonabant reimbursement. Among them, 55.7% were treated for diabetes. For at least 62.4% of rimonabant beneficiaries, the reimbursement regulations were not respected: this was significantly more frequent among women less than 57 years old, subjects with no chronic diseases, and when the prescriber was not an endocrinologist; 11.4% of rimonabant beneficiaries also received an antidepressant treatment. CONCLUSION: Despite the specific status of rimonabant regarding its reimbursement modalities, these results suggest that some prescribers get around reimbursement instructions and that a significant percentage of prescriptions did not respect an important contraindication. Tools to follow up the prescriptions of new drugs with strict guidelines for use should be developed and physicians should be better informed and trained regarding specific prescription regulations.