[PSA testing, biopsy and cancer and benign prostate hyperplasia in France]. / Dosage du PSA, biopsie, cancer et hypertrophie bénigne de la prostate en France.

INTRODUCTION: Prostate-specific antigen (PSA) testing is high in France. The aim of this study was to estimate their frequency and those of biopsy and newly diagnosed cancer (PCa) according to the presence or absence of treated benign prostatic hyperplasia (BPH). PATIENTS AND METHODS: This study concerned men 40 years and older covered by the main French national health insurance scheme (73 % of all men of this age). Data were collected from the national health insurance information system (SNIIRAM). This database comprehensively records all of the outpatient prescriptions and healthcare services reimbursed. This information are linked to data collected during hospitalisations. RESULTS: The frequency of men without diagnosed PCa (10.9 millions) with at least one PSA test was very high in 2011 (men aged 40 years and older: 30 %, 70-74 years: 56 %, 85 years and older: 33 % and without HBP: 25 %, 41 % and 19 %). Men with treated BPH totalized 9 % of the study population, but 18 % of the men with at least one PSA test, 44 % of those with at least one prostate biopsy and 40 % of those with newly managed PCa. Over a 3-year period, excluding men with PCa, 88 % of men with BPH had at least one PSA test and 52 % had three or more PSA tests versus 52 % and 15 % for men without BPH. One year after PSA testing, men of 55-69 years with BPH more frequently underwent prostate biopsy than those without BPH (5.4 % vs 1.8 %) and presented PCa (1.9 % vs 0.9 %). CONCLUSIONS: PSA testing frequencies in France are very high even after exclusion of men with BPH, who can be a group with more frequent managed PCa. LEVEL OF EVIDENCE: 4.

Pioglitazone and risk of bladder cancer among diabetic patients in France: a population-based cohort study.

AIMS/HYPOTHESIS: Previous studies have suggested an increased risk of bladder cancer with pioglitazone exposure. We aimed to investigate the association between pioglitazone exposure and bladder cancer in France. METHODS: This cohort study involved use of data from the French national health insurance information system (Système National d'Information Inter-régimes de l'Assurance Maladie; SNIIRAM) linked with the French hospital discharge database (Programme de Médicalisation des Systèmes d'Information; PMSI). The cohort included patients aged 40 to 79 years who filled a prescription for a glucose-lowering drug in 2006. The cohort was followed for up to 42 months. Pioglitazone exposure was modelled as a time-dependent variable and defined by having filled at least two prescriptions over a 6-month period. Incident cases of bladder cancer were identified by a discharge diagnosis of bladder cancer combined with specific aggressive treatment. Statistical analyses involved a multivariate Cox model adjusted for age, sex and exposure to other glucose-lowering drugs. RESULTS: The cohort included 1,491,060 diabetic patients, 155,535 of whom were exposed to pioglitazone. We found 175 cases of bladder cancer among exposed patients and 1,841 among non-exposed patients. Incidence rates were 49.4 and 42.8 per 100,000 person-years, respectively. Pioglitazone exposure was significantly associated with bladder cancer incidence (adjusted HR 1.22 [95% CI 1.05, 1.43]). We observed a dose-effect relationship, with a significantly increased risk for high cumulative doses (≥ 28,000 mg, adjusted HR 1.75 [95% CI 1.22, 2.50]) and long duration of exposure (≥ 24 months, adjusted HR 1.36 [1.04, 1.79]). CONCLUSIONS/INTERPRETATION: In this cohort of diabetic patients from France, pioglitazone exposure was significantly associated with increased risk of bladder cancer.

[Alzheimer disease and other dementia in France: Identification, management and neuroleptic use (2007-2009)]. / Maladie d'Alzheimer et autres démences : identification, prise en charge et consommation de neuroleptiques chez les bénéficiaires du régime général (2007-2009).

Numbers of patients with Alzheimer's disease or other dementia (ADD) are necessary for care organisation and indicators development as rates of neuroleptics prescription will have a negative risk-benefit balance. Among people of 60 years old and more covered by the general regime (11 millions, 80% of French people), patients with ADD were identified by at least one of the following criteria: long-term affection status for ADD (67.1% of the identified), refunds for Alzheimer medication (67.5%) or hospitalization for ADD (13.6%). In 2009, 353,482 patients were identified using the presence of one criterion in 2009 and 409,021 were identified the same year when criteria were selected over a period of 3 years (2007 to 2009) (prevalence 3.58%, 2.35 to 5.31% between French regions). By extrapolation, their number for whole France was 551,000. Among patients with ADD, 16% had at least three refunds for neuroleptic in 2009 (9.3 to 22.8% according to regions). Increased use of neuroleptic was associated with hospitalisation in a community hospital, the number of general practitioner consultation and an age between 60 and 75 years. At least one liberal psychiatrist consultation decreased the use. This study gives information among ADD patients management and supports prevention program for neuroleptics use.

[Carpal tunnel syndrome surgery in France in 2008: patients' characteristics and management]. / Syndrome du canal carpien opéré en France en 2008 : caractéristiques des malades et de leur prise en charge.

INTRODUCTION: Carpal tunnel syndrome (CTS) is the most common upper limb neuropathy. There has been a dramatic increase in CTS surgery since the 1990s. This study focuses on changing incidence of CTS surgery in France and associated factors. PATIENTS AND METHOD: Cases of CTS surgery were identified using the national hospital discharge database for persons living in metropolitan France. Patient characteristics, comorbidities and care management were studied using the reimbursement database of the beneficiaries covered by the general health insurance scheme (76% of the 64-million French population) comparing those with or without CTS surgery in 2008. RESULTS: In 2008, hospital admissions for CTS surgery were identified in 127,269 patients aged 20 years and older, giving an overall incidence of 2.7/1000 (females 3.6/1000, males 1.7/1000) in metropolitan France. Between 1999 and 2008, the number of patients with CTS surgery increased 25%. Half of this increase was directly related to increasing demographics. For people in the 20 to 59-year age range, incidences were respectively 2.5/1000, 3.6/1000 and 1.3/1000 with high regional variations (1.1/1000-5.5/1000). Individuals aged 60 years and older accounted for 36% of the patients. Using a negative binomial regression, regional incidence variation was significantly and positively associated with the regional density of surgeons practising CTS surgery, proportion of manual workers in the population and proportion of employment in the industrial sector and negatively associated with densities of primary care physicians, rheumatologists and physiotherapists. Certain comorbidities were found to be significantly associated with CTS surgery: diabetes mellitus (Relative Risk [RR]=1.6), hypothyroidism (RR=1.3), end-stage renal disease treated with dialysis (RR=3.3), depression (RR=1.5), hereditary metabolic disease (RR=1.3), ankylosing spondylosis (RR=1.5). Interestingly, a significant negative association was found for full healthcare coverage linked with very low income (RR=0.7) and certain chronic diseases: Alzheimer's disease (RR=0.3), Parkinson's disease (RR=0.7), neuroleptic medications (RR=0.4), multiple sclerosis (RR=0.7). This could be associated with lower frequency of occupational risk factors and a lack of complaint or investigation. After surgery, 55.0% of the patients in the 18 to 59 years age range had a period of sick leave and 36.8% returned to work later than the upper limit of the recommended recovery period of 56 days. The annual cost of sick leaves was estimated at 81 million euros for the general health insurance scheme. CONCLUSION: The number of CTS surgical procedures is increasing in France. Prevention of CTS in the workplace must be sustained and encouraged. Recommendations for sick leave periods should be followed.

Prevalence and treatment of diabetes in France: trends between 2000 and 2005.

AIMS: To estimate the prevalence of diabetes mellitus in France from 2000 to 2005, to monitor changes in its medical management and to determine the resultant costs to the French national healthcare system. METHODS: Using patients' data from the permanent sample of healthcare affiliates, we defined a treated diabetic patient as anyone who had been reimbursed for insulin or oral hypoglycaemic drugs at least twice within one calendar year. RESULTS: The prevalence of treated diabetic patients in 2005 in the French population covered by the general healthcare scheme was 3.6% (+/-0.1). The average annual increase between 2000 and 2005 was 5.7%, of which 0.7% can be attributed to population ageing. In 2005, the maximum prevalence of treated diabetic patients among those aged 70-79 years was 17.7% for men and 11.5% for women. Cardiovascular risk factors associated with diabetes were treated more often with drug therapy in 2005 than in 2000. In 2005, 73.8% of diabetic patients were given antihypertensive drugs and 54.9% received cholesterol-lowering agents. In 2005, the annual cost of treatment with antidiabetic drugs and treatment of cardiovascular risk factors was 760 euros per diabetic patient. CONCLUSION: The number of treated diabetic patients greatly increased between 2000 and 2005. At the same time, their associated cardiovascular risk factors were more frequently managed by drug therapy. As a result, the total expenditures for the healthcare system for treating diabetes and its associated cardiovascular risk factors doubled in five years, amounting to 1.8 billion euros in 2005.

[Bariatric surgery in France: results of a nationwide prospective survey]. / La chirurgie de l'obésité en France: résultats d'une enquête prospective nationale.

AIM: To compare the actual practice of bariatric surgery in France with the guidelines of scientific societies regarding surgical indications and followup. METHODS: This a prospective descriptive transversal study performed within a two month period (December 2002 - January 2003) in all patients for which a consent demand has been sent to the Medical Insurance Services (examined by an administrative consultant) and/or patients operated on for morbid obesity (with or without administrative consent). RESULTS: One thousand and three patients have been examined by an administrative consultant before obesity surgery and 1238 patients have been operated in 263 centres including 79 public (non-profit) centres and 184 private centres. In 16.7 % of the cases, there were wrong indications according to recognized criteria (BMI<35 kg/m(2) or lack of comorbidities for BMI between 35 and 39) or even contraindications because of other diseases. Patient informed consent was retrieved in only 54 % of medical files and follow up protocol was done in only 47 % of the cases. Because of several missing data, the practice of bariatric surgery followed the guidelines in only 34 % of cases. In hospital morbidity rate was 5 %. Two patients died postoperatively (mortality rate 0.2 %). CONCLUSIONS: This study demonstrates that the practice of bariatric surgery needs to be improved in France.

Cancer prone persons. A randomized screening trial based on colonoscopy: background, design and recruitment.

OBJECTIVE: Evidence-based counseling and prevention are not available so far for hereditary cancer prone persons, since we lack data based on clinical trials. There are very few high-risk persons in the population as a whole. Based on a familial history analysis, only 1.2% of all healthy volunteers attending screening centers reached the arbitrary high-risk level defined as a Relative Risk of more than 4. We describe a randomized trial based on colonoscopic screening for colorectal cancer on a sub-group of high-risk group persons. MATERIALS AND METHODS: Among the 77 members of the French Institutional Preventive Center Network, 37 took part in this protocol. During the first 3 years, 850,000 persons were interviewed at these 37 Health centers. The enrollment process was particularly time-consuming, since a large amount of information had to be delivered to the participants. RESULTS: The mean rate of recruitment of eligible candidates was far lower than predicted, averaging only 1.4 per 1,000 persons interviewed instead of the 9/1,000 expected. This mean figure was based, however, on inclusion rates ranging from 0.06/1,000 to 7/1,000 among the different centers. The low rates of recruitment were mainly due to the inter-center heterogeneity (differences in commitment and in the resources), and to the fact that the acceptability of undergoing a colonoscopy turned out to be lower than predicted. CONCLUSION: Population trials on cancer prone persons are feasible, but vast numbers have to be pre- screened to identify the few people with a high hereditary risk and willing to accept screening within a controlled trial.

Etiologic factors of chronic bronchitis in dairy farmers. Case control study in the Doubs region of France.

Relationships were investigated between chronic bronchitis and plant dust exposure assessed by quantification of barn threshing and cattle foddering and chronic bronchitis and acute respiratory syndromes after plant mold dust exposure. Two groups of male dairy farmers were studied in the Doubs region, France: 197 with chronic bronchitis and 163 control subjects without chronic bronchitis. There was no relationship between chronic bronchitis and exposure. Thirty-three chronic bronchitis patients had semidelayed respiratory syndromes (SDRS) vs two control subjects. Twenty-seven times out of 33 (16 of 17 in the nonsmokers), the SDRS preceded chronic bronchitis. Past history of acute respiratory syndromes during barn threshing (RSBT) was more frequent in chronic bronchitis; RSBT always preceded chronic bronchitis. It is concluded that host factors are important in chronic bronchitis and that acute effects after exposure may be predisposing factors to chronic bronchitis.

The prevalence and cost of diabetes in metropolitan France: what trends between 1998 and 2000?*.

OBJECTIVES: Our aim was to update available data concerning the prevalence and cost of diabetes in metropolitan France. METHODS: We performed a retrospective study using patient reimbursement data from all the 128 local health offices (CPAM) in metropolitan France. We selected patients who received reimbursements for an oral hypoglycemic agent or insulin. Thus, 704,423 patients were studied by using 1998 data and 1,145,603 patients were studied by using data from 2000. The expenditures studied represented the total amount reimbursed by national health insurance to diabetic patients. The cost differential which could be attributed to diabetes was calculated by determining the difference between costs generated by diabetic patients to those generated by the rest of the population of the same age. RESULTS: Between 1998 and 2000, the prevalence of diabetes treated in the population of affiliates covered by the general scheme increased from 2.78% to 2.96%. The total amount paid by the general scheme for care to diabetic patients (related to diabetes or not) was 5.710 billion euros in 2000 compared to 4.862 billion euros in 1998. The amount which can be attributed to diabetes alone can be estimated to be 2.414 billion euros in 2000 compared to 2.021 billion euros in 1998. After considering the impact of the increase in the number of treated diabetics, a modification in the modalities of medical care probably accounts for 183 million euros of the cost increase. Medical equipment (self blood glucose monitoring devices, reagent strips, finger lancets...) accounts for 39.3% (72 million euros) of this cost differential, medications account for 34.4% (63 million euros) and nursing care 16.9% (31 million euros). There was no change in the cost of diabetes with relation to expenses for medical consultations.

[Epidemiology of diabetes in metropolitan France]. / L'épidémiologie du diabète en France métropolitaine.

The statistical analysis of French HealthCare's database, containing total reimbursements to affiliates and a listing of delivered drug prescriptions in the form of specific drug codes, allowed us to update data on the epidemiology of diabetes. This study, performed during the first trimester of 1999 on the entire population of metropolitan France, found an overall prevalence of 2.78 % for diabetes in all affiliates of the regimen (Régime général) stricto sensu (3.06 % in the general population), 0.41 % corresponding to diabetic treated exclusively with insulin (0.44 % in the overall population) and to 0.12 % receiving both insulin and oral hypoglycemic agents concomitantly (0.13 % in the general population). The average age of diabetics, irrespective of the treatment they were receiving, was 63.1 years with a sex ratio M/F of 1.04. These findings confirm epidemiological forecasts which had predicted a significant increase in the prevalence of diabetes over the past few years. The study also confirmed data from the medical literature concerning geographic disparities in the epidemiology of this disease except for the results obtained in the north of France, a region generally thought to have a lower prevalence of diabetes, and which was found to have a prevalence equal to even greater than the national average.

[The cost of diabetes in metropolitan France]. / Le coût du diabète en France métropolitaine.

The statistical analysis of French HealthCare's database, containing total reimbursements to affiliates and a listing of delivered drug prescriptions in the form of specific drug codes, allowed us to update data of the cost of diabetes. This study, realized during the first trimester of 1999, used the combined databases of 110 local healthcare offices (CPAM) among the 128 existing in metropolitan France. French Social Security spent a total of 31.9 billion francs (4.9 billion euros) in care given to diabetics (or 24,137 francs per patient) comprised by 14.2 francs (2.2 billion euros) for in-hospital care and 17.7 billion francs (2.7 billion euros) for outpatient services. The total expenses for diabetic patients represented 4.7% of French Social Security's overall expenses for all its affiliates. The differential cost of diabetes (the difference, at equivalent ages, between cost generated by diabetic patients and those attributable to the remainder of the affiliated population) was estimated, for the generalized health-care regimen (régime général) in 1998, to be 13.3 billion francs (2.0 billion euros). These figures underscore the need to reinforce prevention and screening for end-organ complications since it is generally admitted that the disease's high cost is essentially related to its complications.

[Modalities of follow-up on non-insulin treated diabetics treated in metropolitan France in 1998]. / Les modalités de suivi des diabétiques non insulino traités en France métropolitaine durant l'année 1998.

The statistical analysis of French HealthCare's database allows a retrospective evaluation of the overall clinical care given to diabetics in the light of the guidelines (RBPC) promulgated by the National Agency of Health Accreditation and Evaluation (ANAES). This database contains no information on the stage of the disease process, the completeness of the clinical evaluation (neurological or foot examination) or the results of significant blood tests. We studied the follow-up care given to diabetics whom we were able to identify by isolating reimbursements for hypoglycemic agents using their corresponding drug codes. Considering the time needed for this new drug-coding system to become fully operational, the results can be extrapolated to the entire population of non-insulin treated diabetics. In 1998, almost all follow-up care was provided by general practitioners since only 5.5 % of the patients consulted an endocrinologist during the year studied. Blood sugar was generally monitored with fasting blood sugars rather than HbA1c which was only prescribed in 41.3 % of the patients during the final six months of the period under consideration. Screening and follow-up for degenerative complications were insufficient. Fewer than 40 % of the patients had received reimbursement for an ophtalmological consultation during the preceeding year and fewer than 30 % had an ambulatory resting EKG over the same time period. A certain number of factors were studied in order to determine if they were correlated to better clinical follow-up. The best follow-up was encountered in patients who had a consultation with an endocrinologist at least once during the year, those who were exonerated from co-payments (ALD 30) and finally, those aged between 40 and 59 years (at least with respect to appropriate laboratory tests).

[Analysis of health insurance benefits: material and methods]. / L'analyse des prestations remboursées par l'assurance maladie : matériel et méthodes.

The statistical analysis of national health insurance's database, containing a record of the care reimbursed to affiliated members and delivered drugs in the form of special pharmacy codes, enable us to evaluate the follow-up care given to diabetics, to update epidemiological information and to determine the actual cost of diabetes. The method used consisted in the identification of diabetics by isolating patients who received hypoglycemic agents during the 3-month inclusion period followed by a retrospective determination of total reimbursements made through the 128 local health offices (CPAM) located in metropolitan France in order to study the reimbursed care (medical consultations, procedures and drug prescriptions) given to diabetics over the preceding 12 month period. Considering that the pharmacy coding system was still incomplete at the time the study was undertaken, we had to verify that the population selected by the coding system was only partially operational, requiring a calculation involving weighted coefficients. Finally, we needed to take into account the fact that the resulting data contained virtually no information on facilities receiving a once a year total budget allocation (all public hospital).

Sexual abuse is more frequently reported by IBS patients than by patients with organic digestive diseases or controls. Results of a multicentre inquiry. French Club of Digestive Motility.

OBJECTIVES: The aim of this multicentre inquiry was to evaluate the prevalence of sexual abuse among IBS patients consulting a gastroenterologist, in comparison to healthy controls and patients with organic digestive diseases. PATIENTS AND METHODS: Patients with irritable bowel syndrome (IBS; Rome Criteria) were included by eight university hospitals (n = 196; 41.2 +/- 20.6 years; sex ratio (M/F) = 0.23). Control groups were: (i) patients consulting for the follow-up of non-neoplastic organic digestive diseases (n = 135; 41.5 +/- 17.0 years; 1.21); (ii) patients attending ophthalmology units (n = 200; 43.8 +/- 20.7 years; 0.81); (iii) healthy subjects seen in centres of the National Health System (n = 172; 40.3 +/- 16.3 years; 0.83). Each patient filled in an anonymous questionnaire, without help. Prevalence of sexual abuse in the various groups was compared by the chi 2 test. RESULTS: Sixty-two instance of sexual abuse (55 females, 7 males) were recorded among the 196 IBS patients (31.6%); 8 cases of verbal aggression, 4 of exhibitionism, 11 of sexual harassment, 22 sexual touches, 17 rapes. The prevalence of sexual abuse was 14.0% for the patients with organic digestive diseases (P = 0.0005 vs. IBS), 12.5% among ophthalmology patients (P < 0.0001) and 7.6% in healthy controls (P < 0.0001). Sexual abuse was accompanied by physical abuse in 23 IBS patients and 19 patients from control groups (not significant). Twenty-six IBS patients reported isolated physical abuse (14.7%) versus 40 from control groups (8.8%; P = 0.041). There was a significant trend towards more severe attacks of abuse among IBS patients than in others. CONCLUSION: This study confirms the high prevalence of sexual abuse among IBS patients consulting in Gastroenterology. Some of these patients would benefit from appropriate therapy. (In the majority of cases, this will be psychotherapy.)

Pulmonary embolism from a parasitic cardiac clot secondary to hepatic alveolar echinococcosis.

An exceptional form of hepatic alveolar echinococcosis with metastasis of the right atrium is reported. This cardiac location of the parasitosis was revealed by attacks of pulmonary embolism which produced secondary pulmonary lesions. This case suggests that pulmonary metastases of alveolar echinococcosis of the liver might be due to the migration of parasitic clots from the hepatic veins.

[Criteria of mass screening for cancer]. / Critères de dépistage de masse des cancers.

Evidence of the positive outcome of cancer screening (favorable effects higher than harmful effects) should be obtained before being acquired by the whole populations. The purpose of this article is to report the criterions necessary to the development of mass screening: knowledge of cancer, qualities of screening test, evidence of efficacy and efficiency, organizational aspects.

[Public health problems related to chemoprevention of cancers]. / Problèmes de Santé publique posés par la chimioprévention des cancers.

The chemoprevention sets down numbers of problems and requires certain number of conditions. First of all, one has to demonstrate the action's effectiveness by a randomised trial using the appropriate effectiveness indicators and to confirm the results of the trial by a pilot prevention's project. The action shouldn't have neither inconvenient nor major risks. In numerous prevention's action, the inconvenient are superior to the benefits. The action should be aware of respecting the major ethical aspects: respect the person's autonomy, don't to be harmful, respect the equity and be beneficial; it also has to avoid important psychological consequences. At last, the prevention's action has to appeal to cost effectiveness strategy.