Evaluation of socio-economic insecurity in peripheral artery disease patients.

The social and economic environment has become a major determinant of cardiovascular health. The objective of our study was to assess socio-economic insecurity in patients with symptomatic PAD. The PRECAR study was a non-interventional prospective cohort study. Patients were recruited from the Vascular Medicine and Surgery Departments of Grenoble-Alpes University Hospital or during a consultation as part of the therapeutic education program "On the move! Better understanding and better living with arterial disease". The analysis of socio-economic and environmental data was based on the EPICES score (a reliable index used to measure individual deprivation) and INSEE parameters (level of education and socio-professional category). Cardiovascular risk factors were also recorded. 150 patients with symptomatic PAD were included between November 2017 and June 2018. 84% were men. In our population 54% (CI95% 45.7 - 62.1) were in a precarious situation compared to 40% (CI95% 39.8 - 40.2) in the general population, according to the EPICES score (P<0.001). Levels of education were low and patients with a baccalaureate or higher education degree were under-represented. Executives, intellectuals and intermediate professions were also under-represented in the PAD population. This data opens new perspectives on the social characterisation of patients that may contribute to improving the outcomes of patients with peripheral vascular disease.

Bleeding complications following peripheral regional anaesthesia in patients treated with anticoagulants or antiplatelet agents: A systematic review.

BACKGROUND: Patients on either antiplatelet or anticoagulant therapy may need procedures performed under peripheral nerve blocks in preference to general anaesthesia techniques. The risk of bleeding associated with peripheral nerve blocks under these circumstances remains unknown. This systematic review evaluates the incidence of bleeding complications following peripheral nerve blocks in patients receiving antiplatelet and/or anticoagulant medication. METHOD: All English, French and Spanish publications on peripheral nerve blocks in patients receiving antiplatelet and/or anticoagulant medication, from 1978 to 2018 from various sources including Pubmed, were reviewed. Publications on neuraxial anaesthesia (spinal or epidural) and eye blocks were excluded. RESULTS: Twenty-four articles were selected, including six observational studies and 18 case reports. Patients received antiplatelet agents only, in 4 studies, anticoagulants only in 14 studies, and both in 6 studies. In the observational studies, 80 bleeding complications (haematoma or minor bleeding at the puncture site) were identified following 9738 peripheral nerve blocks. Amongst case reports, 15 bleeding complications were noted following 50 peripheral nerve blocks. Bleeding complications were reported mostly with lumbar plexus blocks (1 requirement for blood transfusion, 1 catheter embolization, 1 surgical exploration and 1 death). The overall estimate of the incidence of bleeding complications was 0.82% (0.64%-1.0%). CONCLUSION: This systematic review found that bleeding complications following peripheral nerve blocks were rare in patients receiving antiplatelet and/or anticoagulant medication.

Obstetric outcomes associated with induction of labour after caesarean section.

PURPOSE: To evaluate the efficiency and safety of inducing labour with oxytocin in women with a single prior Caesarean section, with particular focus on the Bishop score. METHODS: Between January 1, 2013 and March 31, 2017, we included all women with a singleton full-term pregnancy and single prior Caesarean section in this monocentric retrospective observational study. Women for whom vaginal delivery was not recommended and those who went into spontaneous labour were excluded. The choice between induction of labour and caesarean section was made by the obstetrician and the patient, taking into account both the patient's personal medical history and the clinical observations on admission to hospital. The primary outcome was the rate of vaginal delivery. RESULTS: Out of 966 women with no contraindication to trial of labour after previous caesarean delivery (TOLAC), 248 were induced, with a vaginal delivery rate of 58.5% (95% CI [52.06; 64.67]). This rate was 81.7% (67/82) among women with Bishop ≥6 and 47% (78/166) if Bishop was <6. Eight cases of uterine rupture were reported in the induction of labour group. Regarding maternal morbidity, this was the main difference between the caesarean section and the induction of labour groups (p=0.049). Neonatal morbidity was low in both groups. CONCLUSIONS: The rate of vaginal delivery after induction of labour with oxytocin infusion was satisfactory. Nevertheless, maternal morbidity and especially the risk of uterine rupture were not minor. It is thus essential before inducing labour to inform the woman about the rate of success of TOLAC and the risks of uterine rupture.

Oral information in orthopaedics: how should the patient's understanding be assessed?

INTRODUCTION: Patient information is governed by recommendations of best practices required from any healthcare professional. The aim of this study was to design a tool to measure patient comprehension of the information provided during a surgical consultation before a scheduled surgery. MATERIAL AND METHODS: This was a single-center prospective study of 21 patients using a rating scale-type visual analog scale. Each patient was interviewed and asked to score his or her understanding of the information provided. The investigator checked the external validity of the tool using questions to assess patient's understanding level. RESULTS: The results show that there is a tendency to overvalue some information (reasons for the intervention and alternatives to surgery) and that certain information is not understood (risks and complications) or not provided (postoperative follow-up). CONCLUSION: This study confirms that a rating scale can measure the understanding of information and there is a variation between perceived and actual understanding.

[Trusted person and living will: information and implementation defect]. / Personne de confiance et directives anticipées: défaut d'information et de mise en œuvre.

PURPOSE: The French law allows the persons of age to appoint a trusted person and to draft advance directives in case they are one day in a condition that prevents them from expressing their will regarding their health care. Our study objective was to assess patients' and relatives' knowledge and collecting their opinion regarding these means of expression of their will. METHODS: An anonymous survey by self-administered questionnaire was conducted in the admission offices of the University Hospital of Nancy in April 2011. The questions focused on trusted person and anticipated directives. RESULTS: We collected 367 answers, 61.8% of which were females. Average age of respondents was 48.7 years old (standard deviation: 15.6). Three fourths of respondents were informed of their possibility to appoint a trusted person and were able to establish the difference between a trusted person and a contact person. Respondents mainly chose their spouse (52%). They thought that the trusted person's opinion takes precedence over the family's or relatives' one (64.7%), given that this opinion is based on indications previously provided by the patient (74.8%). The majority of people surveyed were ignorant of the possibility to draft advance directives but were glad of it (57.5%). They would include herein their refusal of unreasonable obstinacy (75.8%), their wishes to withhold/withdraw of some treatments, to stop active treatments in case of high odds of chronic coma or vegetative state (52.8%) or their will to donate organ after death (50.6%). More than three fourths of the patients wished to include these informations on their health care card chip. CONCLUSION: Legal means of expression of the patient's wishes and are not systematically known by the population. The possibility to appoint a trusted person is much more known than that to draft advance directives. After the release in December 2012 of the Sicard report regarding the end of life in France, an important information campaign of the general public remains to be undertaken.

[Requests for access to medical files at the Nancy University Hospital Center]. / Evaluation des demandes d'accès au dossier medical au CHU de Nancy.

OBJECTIVE: Law 2002-303 of March 04, 2002, authorizes patients to have direct access to their medical record, without requiring a physician to serve as interme-diary. The aim of this study was to characterize these requests for a 23-month period. METHOD: A database was created to record information about these requests. The descriptive and quantitative analysis here covers 23 months. RESULTS: There were 942 requests in all, 64.5% by patients themselves and 18.5% by their heirs or assignees. The mean age of the patients seeking access to their medical file was 53 years, with a slight majority of men. Heirs and assignees av-eraged 49 years of age and were generally women. Thirty percent of them reported wanting some additional information, while 51% requested a copy of the entire file. Only 5.8% asked for a physician to help them understand the file, although that was systematically offered. CONCLUSION: Patients' new legal rights to direct access to their medical files imply that physicians will modify the way they maintain these files.

From paper-based to electronic guidelines: application to French guidelines.

In order to develop an internet-based decision support system, making available for French general practitioners several prevention guidelines is was necessary to implement paper based guideline. We propose a framework allowing to transform paper based practice guideline into their electronic form. Three different problems were identified: computability (e.g. determinism of the eCPG), logic (e.g. ambiguities when combining Booleans operators) and external validity (i.e. stability of decision for variations around thresholds and proportion of subjects classified in the various terminal nodes). The last problem concerned documentation of evidence: the level of evidence was associated only with the terminal decision node and not with the pathway through the decision tree. We concluded that computerisation of guidelines is not possible without expertise or authors advice. To improve computability it is necessary to provide authors with a framework that checks ambiguities, and logical errors.

Guideline development: focus on breast cancer screening in the EsPeR project.

We describe in this paper, the implementation of a clinical practice guideline focused on breast cancer screening. Our aim in conceiving such a computerized guideline was first to help general practitioners in appreciating the risks their female patients might develop breast cancer and secondly to suggest them the screening measures adapted to each particular case. This implementation enables us to present our general methodology to elaborated and promulgate guidelines within the EsPeR project. This methodology aims at providing guidelines based on knowledge validated according to the EBM principles, that can be used in real time and updated according to current knowledge.

Method to determine the bed capacity, different approaches used for the establishment planning project in the University Hospital of Nancy.

In France hospital bed capacity is determined according to a national and regional authorization which has been established by the regional hospital agency. The bed capacity evolution in a hospital is fixed by considering the different proposals of the hospital in negotiation with the regional hospital agency. Types of beds are differentiated according to the patients' needs : medicine, surgery and obstetrics. The first approach is taken at the national level and then at the regional level using a specific ratio of beds for 100,000 inhabitants in each category. For a given hospital, the authorized number of beds takes into consideration their occupation. Target bed occupation ratios were fixed in 1992 and are still in use. In the establishment project of the University Hospital of Nancy (developed over a five year period) four approaches have been formulated and their results have been compared. In this study, the two traditional methods of bed ratio per 100,000 inhabitants and target bed occupation have been updated according to the present conditions of hospitalisation; the third method is based on the reapportionment of the present patients and the possible risk to the hospital for refusing patients. The last method consists of determining the expected pathologies five years in advance in Lorraine and the beds needed to treat them. These four methods have given consistent results under the accepted revised target occupation bed ratios in accordance with the reduction of the length of stay between 1992 and 1999.

Modeling uncertainty in computerized guidelines using fuzzy logic.

Computerized Clinical Practice Guidelines (CPGs) improve quality of care by assisting physicians in their decision making. A number of problems emerges since patients with close characteristics are given contradictory recommendations. In this article, we propose to use fuzzy logic to model uncertainty due to the use of thresholds in CPGs. A fuzzy classification procedure has been developed that provides for each message of the CPG, a strength of recommendation that rates the appropriateness of the recommendation for the patient under consideration. This work is done in the context of a CPG for the diagnosis and the management of hypertension, published in 1997 by the French agency ANAES. A population of 82 patients with mild to moderate hypertension was selected and the results of the classification system were compared to whose given by a classical decision tree. Observed agreement is 86.6% and the variability of recommendations for patients with close characteristics is reduced.

[Description of long-term stays, based on PMSI data, in hospital specializing in short-term stays]. / Description des séjours longs, au moyen des données du PMSI, dans un hôpital spécialisé de court séjour.

OBJECTIVE: In a context of organization of care where the budget of hospitals is a function of the number and of the severity of the in-patients and not of the duration of stay, stays of long duration (SLD) in short-stay hospitals represent a problem of both medical and administrative management. To identify the characteristics of long-duration stays. METHODS: The data used in this retrospective study were drawn from the Standardized Discharge Summaries of the year 1997 of a University Hospital of the Paris area (France). A stay of long duration (SLD) was defined in an arbitrary way as a stay exceeding 30 days. The stays of long duration (> 30 days) were subdivided in "long stays" (from 31 to 60 days) and "very long stays" (more than 60 days). RESULTS: The SLDs represent 3.7% of the discharge summaries of our hospital, among them, 40% are medical DRGs and 60% surgical DRGs. The patients in SLD more often come from other structures of care than the patients having a short duration stay of (SDS) coming mainly from their residence and were also hospitalised in several different units during their stay. Patients having a long stay were more often classified in DRGs outside the principal activity of this hospital (i.e. cardiovascular diseases). CONCLUSION: This first approach suggests that a set of simple descriptive variables (pre-existing and acquired co-morbidity, admission in surgical ward, multi-unit stay...) makes it possible to identify the patients likely to have a long duration stay. Simple variables added to the current hospital minimum medical record would make it possible to consider a predictive approach.

The French Virtual Medical University.

This paper is the description of a French Virtual Medical University based on the federation of existing or currently being developed resources in several Medical Schools in France. The objectives of the project is not only to share experiences across the country but also to integrate several resources using the New Information and Communication Technologies to support new pedagogical approaches for medical students and also for continuing medical education. The project includes: A virtual Medical Campus using secure access from several sites, The Integration of new interactive resources based on pedagogical methods, Implementation of new indexing and search engines based on medical vocabularies and ontologies, The definition of general and specific portals, the evaluation of the system for ergonomics and contents.

A critical appraisal of the use of Internet for calculating cardiovascular risk.

This paper aims to retrieve and evaluate the quality of the Internet sites providing information on cardiovascular risk. We searched web pages related to risk prediction using six search engines. Sites proposing a cardiovascular risk prediction were selected for evaluation. The quality of each site was checked against criteria testing the validity, type and potential usefulness of information for physicians or patients. Search engines retrieved about 50 10(6) web pages. Eight sites were included. Only 2 of them provided calculation of cardiovascular risk based on Framingham equation. The others proposed algorithms, guidelines, or general information on cardiovascular health. Most sites lacked details to ensure quality of information. Present search engines are inefficient to retrieve precise and valid information. Facing the inflation of medical information, a systematic approach to validate the quality of a site is mandatory. Application of Evidence Based Medicine concepts gives a solution for evaluation of internet-based medical information.

Paediatric case-mix of the Lorraine regional database in 1994 and 1995.

In the region, there is a need to predict the necessary number of paediatric beds. Paediatric discharge data from the 1994-95 Lorraine regional database of Anonymous Discharge Summaries (ADS) are used for this study. We analyse the concentration and specialisation of the hospital activity types and we estimate the numbers of paediatric beds needed for the year 2,000. For the same percentage of the case-mix by hospital group, concentration of the activity is more important in the small District General Hospital (DGH) than in the Teaching Hospital (TH). In the most important Medical Diagnosis Categories (MDC), the case-mix variation by age class can't be characterised inside of the MDC group. The different methods we use to estimate the need of paediatric beds, give similar estimations for the year 2,000.

Case mix of elderly in-patients in the 29 hospitals in Lorraine in 1994 and 1995.

The creation of regional standardized medical information databases in relation with the French anonymous discharge dataset allows the study of the geriatric case mix processed in the Lorraine region for patients over 69. The age histogram (69 to 107 years) presents a two mode distribution with an important dip centered on 79 years probably in connection with the demography of Lorraine and the consequences of the First World War. These geriatric patients represent 17% of hospitalisations in public and private hospitals participating in the public sector. The case mix is related to the size of the hospital and to its juridical status. The bigger the size of an hospital, the less its activity is concentrated on a small number of disorders. Lung and heart diseases represent the first cause of hospitalisation in all hospitals. It is necessary to underline the limitation of an approach which uses the patients' individual hospitalisations, and which does not allow different stays of a given patient on the same hospital or between different hospitals to be linked. This approach prevents from appreciating the care network for this elderly population suffering from chronic diseases.