Human papillomavirus prevalence, persistence and cervical dysplasia in females with cystic fibrosis.

BACKGROUND: A higher risk of human papillomavirus (HPV)-related cervical intra-epithelial neoplasia (CIN) is suspected among females with cystic fibrosis (CF). METHODS: We conducted a single center prospective cohort study among females attending the Lyon adult CF center. We performed a cervical cytology (Hologic Thinprep®) and HPV testing with genotyping (Clinical Arrays Papillomavirus; Genomica, enabling 35 genotype detection, 20 of which are high-risk (HR-HPV)) at inclusion. We followed all females with positive HPV tests at 6, 12 and 24 months to evaluate HPV persistence, and performed a colposcopy in cases of abnormal cytology. RESULTS: We included eighty-five participants, 18 (21%) of whom were lung-transplanted. The mean age at inclusion was 31.9 (range 18-59) years. The prevalence of HPV (all types) was 31.8%. HR-HPV was found in 25.9% of the whole cohort, 44.4% of transplanted patients, and 20.1% of nontransplanted patients. Genotype-specific HR-HPV persistence at 12 months was 43.5% among transplanted and 34.6% among nontransplanted patients. Overall, 17.6% (15/85) of females had an abnormal cytology: 44.4% (8/18) among transplanted and 10.4% (7/67) among nontransplanted patients. CIN was identified in 12 (14.1%) patients (6 low-grade, 6 high-grade). High-grade CIN developed in 4 nontransplanted patients. CONCLUSION: Transplanted females had high HR-HPV, abnormal cervical cytology and CIN prevalence rates compared to large published cohorts in the general non-CF population. Although HR-HPV prevalence and persistence were globally not significantly different in nontransplanted females compared to the general population, we reported high frequencies of abnormal cytology and CIN. Cervical cancer screening and prevention should be promoted among females with CF.

[Patient safety culture for health professionals in primary care : French adaptation of the MOSPSC questionnaire (Medical Office Survey on Patient Safety Culture)]. / Culture de sécurité des professionnels de santé en soins primaires : adaptation en langue française du questionnaire MOSPSC (« Medical Office Survey on Patient Safety Culture ¼).

BACKGROUND: Patient safety culture (PSC) takes into account a number of individual and organizational factors. Evaluation of PSC with the participation of primary health care professionals can be carried out through self-administered surveys such as the AHRQ's Medical Office Survey on Patient Safety Culture (MOSPSC) questionnaire. AIM: To translate the MOSPSC questionnaire into French, while analyzing its psychometric properties. METHODS: The MOSPSC questionnaire was first translated into French, with linguistic analysis included, and then back-translated into English, in accordance with the ISPOR recommendations. Lastly, the French version of the MOSPSC questionnaire was completed by health professionals from 36 outpatient structures. Study of the psychometric properties (test-retest, Cronbach's α, and factor analysis) was conducted based on the professionals' responses. RESULTS: After linguistic analysis, the notion of "team" was translated in the final questionnaire as "structure". This term was used in the pilot survey of 415 professionals. The participation rate was 64.1% (266/415); 51.9% (138/415) were paramedics (mainly nurses and physiotherapists). The Cronbach coefficient α inclusive of all dimensions was 0.94. A "reporting of safety incidents" dimension was added, and the "staff training" dimension was merged with "development and standardization of office processes", bringing to 13 the number of dimensions identified after factor analysis. CONCLUSIONS: Having been adapted and validated, the French version of the questionnaire can be used as a tool for assessment of PSC in France. It should not only facilitate the monitoring of PSC in primary care facilities, but also prove conducive to comparison of PSC evolution in different establishments. Lastly, it Could contribute to national and international research on risk management in primary care.

Upper limb and hand patterns in cerebral palsy: Reliability of two new classifications.

AIM: To evaluate the inter- and intra-rater reliability of two previously developed classifications of upper limb and hand patterns. METHOD: Two hundred and twelve films of patients with CP (118 of UL postures and 94 of hand tasks; median age 14, 3-46 years) were viewed by 18 examiners from 2 different rehabilitation centers, and one expert who had participated in the design of the classifications. They classed upper limb (3 patterns with sub-types) and hand patterns (2 patterns with subtypes) twice, at 2 months' interval. Inter- and intra-rater reliability were analysed. RESULTS: Intra-rater and inter-rater reliability were very high for upper limb and hand patterns (0.87 < k < 0.92), and high for the subtypes (0.58 < k < 0.68). Examiners stated that both classifications were useful and feasible in clinical practice. INTERPRETATION: Despite the single, short training session on use of the classifications, agreement between the examiners and the expert examiner was good to high, confirming that these classifications are easy to use and reliable. The classifications proposed here provide homogenous terminology for use in both clinical practice and research, to describe, evaluate and follow-up changes in upper limb and hand patterns in patients with cerebral palsy, particularly those with dyskinesia.

Assessment of patient safety culture: what tools for medical students?

BACKGROUND: The assessment of patient safety culture refers mainly to surveys exploring the perceptions of health professionals in hospitals. These surveys have less relevance when considering the assessment of the patient safety culture of medical students, especially at university or medical school. They are indeed not fully integrated in care units and constitute a heterogeneous population. This work aimed to find appropriate assessment tools of the patient safety culture of medical students. METHODS: Systematic review of the literature. Surveys related to a care unit were excluded. A typology of the patient safety culture of medical students was built from the included surveys. RESULTS: Eighteen surveys were included. In our typology of patient safety culture of medical students (15 dimensions), the number of dimensions explored by survey (n) ranged from 1 to 12, with 6 "specialized" tools (n ≤ 4) and 12 "global" tools (N ≥ 5). These surveys have explored: knowledge about patient safety, acknowledgment of the inevitability of human error, the lack of skills as the main source of errors, the errors reporting systems, disclosure of medical errors to others health professionals or patients, teamwork and patient involvement to improve safety in care. CONCLUSIONS: We recommend using Wetzel's survey for making an overall assessment of the patient safety culture of medical students at university. In a specific purpose-e.g. to assess an educational program on medical error disclosure-the authors recommend to determine which dimensions of patient safety will be taught, to select the best assessment tool. Learning on patient safety should however be considered beyond the university. International translations of tools are required to create databases allowing comparative studies.

Management of drooling in children with cerebral palsy: A French survey.

AIM: To characterise children with cerebral palsy (CP) and pathological drooling in France, and to describe care pathways, assessment and treatment. METHOD: A transversal, observational, descriptive survey of the practices and opinions of 400 health professionals potentially involved in the care of children with CP, was carried out nationally across France in 2013. RESULTS: The response rate was 36%. Seventy-five questionnaires were returned and analysed (52%). A small proportion of children were specifically treated for drooling (<25%). Assessments were carried out in 75% of cases and 91% of professionals prescribed treatments. Use of assessment tools varied widely. The most common treatment was oro-facial rehabilitation (95% of professionals), followed by anticholinergic drugs (Scopolamine(®)) (94%) botulinum toxin injections (BT) (66%) and surgery (34%). Scopolamine was considered to be less effective than BT and to have more side effects. CONCLUSION: The rate of pathological drooling in children with CP is likely underestimated and under treated in France. There is a lack of knowledge regarding assessment tools. Aside from rehabilitation, current practice is to prescribe medication as the first-line treatment, however professionals consider that BT is more effective and has less side effects.

Implementation of a computerized system in pediatric wards to improve nutritional care: a cluster randomized trial.

BACKGROUND/OBJECTIVES: Malnutrition occurs frequently in hospitalized children. We aimed to assess whether a computerized system could lead to improved clinical practices in malnourished children. SUBJECTS/METHODS: Healthcare workers (242) from six departments in a pediatric university hospital participated in a cluster randomized trial, studying 1457 malnourished children hospitalized from September 2009 to August 2011. Following a baseline observational pre-intervention period, all departments were randomized into either intervention or control arms. A computerized malnutrition-screening system was implemented in the intervention group to automatically trigger a dietetic referral in real time. Furthermore, the nutrition support team conducted an awareness campaign with healthcare workers and a leadership-based strategy to reinforce the message during the entire study period. Adherence to practice guidelines (daily weights, investigation of etiology for malnutrition, management by a dietitian and application of refeeding protocols) was compared between pre- and post-intervention periods in both the intervention and trial arms. RESULTS: When compared with the pre-intervention period, the clinical practices were significantly improved within the intervention arm for every outcome (P<0.01), whereas remained unchanged in the control arm. In addition, during the post-intervention period, malnutrition etiology investigation by physicians (adjusted odds ratio (OR) of 4.4, 95% confidence interval (CI) 1.7-11.8, P=0.003) and management by a dietitian (OR 2.7, 95% CI 1.0-6.9, P=0.046) occurred more frequently in the intervention clusters. CONCLUSIONS: Implementation of an electronic system to detect malnutrition in real time was associated with a rapid improvement in clinical practices for better care of hospitalized children.

Is it possible to limit the risks of thyroid surgery?

OBJECTIVE: Inferior laryngeal nerve (ILN) palsy and hypocalcemia remain the two most frequent major complications after thyroid surgery. Their occurrences may be explained by the influence of factors related to the patient, the surgical procedure, thyroid pathology, or the surgeon's technique. This study aims To assess whether systematically following a rigorous surgical technique during thyroidectomy affects postoperative complications and long-term patient recovery. METHODS: We conducted a multicenter, cross-sectional study of prospectively collected data in five high-volume referral centers enrolling all patients who underwent thyroid surgery between April 2008 and December 2009. Inferior laryngeal nerve (ILN) palsy and hypocalcemia were systematically assessed during hospitalization based on objective criteria. A six-month follow-up was conducted in cases of early complications. Multivariate regression models were computed to quantify their relationship with potential risk factors. RESULTS: A total of 3574 thyroid procedures were completed. Non-visualization of the ILN during dissection and a large thyroid mass were major risk factors for permanent ILN palsy (OR, 4.17 and 2.61, p<0.01) and persistent complications after initial injury (OR, 4.17 and 2.42, p<0.05). The presence of thyroiditis on the surgical specimen was an independent risk factor for permanent hypoparathyroidism and poor recovery after initial dysfunction (OR, 1.76 and 1.88, p<0.05). CONCLUSIONS: Thorough meticulous technique in thyroid surgery is a determinant of ILN function but fails to prevent persistent hypoparathyroidism.

[Primary eccrine porocarcinoma: a clinicopathological study of 50 cases]. / Étude clinique et histopronostique de 50 cas de porocarcinome eccrine.

BACKGROUND: Eccrine porocarcinoma is a rare cutaneous tumor arising from the intra-epidermal portion of eccrine sweat glands, the acrosyringium. Histoprognostic studies in large series are rare. Herein, we report a retrospective study of 50 cases. PATIENTS AND METHODS: Fifty cases of porocarcinoma were retrieved from a histopathological register. Each histopathological sample was evaluated for the following criteria: presence or absence of dermal invasion, pattern of the infiltrative component (pushing or infiltrative), tumor thickness, lymphovascular emboli, perineural invasion and mitotic index. Clinical data and outcome were also retrieved for each patient. RESULTS: Mean patient age was 77 years (range: 43-99 years). The mean duration of progression prior to diagnosis was 4 years and 5 months. The 2 most common skin locations were the head (38%) and lower limbs (20%). The lesions showed no specific distinctive clinical features. Six cases were in situ, and 44 were invasive (23 with limited infiltration and 20 with scattered infiltration). Mean tumor thickness was 4.37 mm (range: 0.5 to 20 mm). Neighboring or remote epidermal involvement was noted in 7 cases. Lymphovascular emboli were observed in 3 cases. No cases of neurotropism were observed. The average mitotic index was 6.5 mitoses/high power (×400) field. A mean follow-up of 24.3 months was available for 48 patients. Local recurrence was noted in 5 patients, 4 of whom died from visceral metastases. These 5 cases showed no distinctive clinical features, a scattered pattern of the invasive component, cuticular cells, significant tumor thickness (mean 12.8 mm, range 9-20 mm), and an elevated mitotic index. Two histopathological criteria were significantly associated with a metastatic outcome: scattered pattern of the dermal invasive component (P=0.04) and significant tumor thickness, above 10mm (P<0.01). CONCLUSION: Porocarcinoma is a tumor without any particular clinical criteria to distinguish it from squamous cell carcinoma. The architecture of the invasive component and tumor thickness constitute 2 important histoprognostic criteria.

[Frequency, causes and risk factors of postpartum haemorrhage: a population-based study in 106 French maternity units]. / Incidence, étiologies et facteurs de risque de l'hémorragie du post-partum : étude en population dans 106 maternités françaises.

OBJECTIVE: To estimate the incidence, to describe the aetiology and to identify the risk factors of postpartum haemorrhage (PPH). MATERIAL AND METHOD: Prospective study conducted in 106 French maternity units of six perinatal networks between December 2004 and November 2006. PPH was defined by a blood loss superior to 500 mL or necessitating an examination of the uterus, or a peripartum haemoglobin drop superior to 2 g/dL. Severe PPH was defined by at least one of these criteria : peripartum haemoglobin drop superior or equal to 4 g/dL, embolization, conservative surgical procedure, hysterectomy, transfusion, transfer to intensive care or death. RESULTS: The incidence of PPH was 6.4% [CI 95% 6.3-6.5] with variations between maternity units from 1.5% to 22.0%; incidence of severe PPH was 1.7% [CI 95% 1.6-1.8] with variations between units from 0% to 4%. Atony was the main aetiology of PPH, whatever the mode of delivery and severity. The risk factors identified were those classically described in the literature. CONCLUSION: In these six French perinatal networks, in 2005-2006, the PPH profile was characterized by an incidence of severe forms higher than previous population-based estimates from other countries. This suggests a more frequent aggravation of PPH and the implication of inadequate PPH management.

[Practices for management of grave postpartum haemorrhage after vaginal delivery: a population-based study in 106 French maternity units]. / Prise en charge des hémorragies graves du post-partum après un accouchement par voie basse : étude en population dans 106 maternités françaises.

OBJECTIVES: Describe management of severe postpartum haemorrhages (PPH) and its compliance with national guidelines and identify determinants of non-optimal care. PATIENTS AND METHOD: Population-based cohort study of 1379 women with severe PPH due to uterine atony after vaginal delivery, conducted in 106 French maternity units between December 2004 and November 2006. Severe PPH was defined by a peripartum haemoglobin drop of 4g/dL or more, blood loss of 1000 mL or more, hysterectomy, or transfer to intensive care for PPH. The frequency of each recommended procedure for the management of PPH was described. Associations between quality of care and both individual and institutional characteristics were assessed by univariate analysis and multivariate logistic regression. RESULTS: Management of severe PPH was not optimal in 65.9% of cases. The recommended components that were applied least often were administration of second line uterotonics, and transfusion of patients with a low haemoglobin. After adjustment for individual characteristics, the risk of either non- or suboptimal care was significantly higher in non-university public maternity units (aOR 2.62 [95% CI: 1.49-4.54]) compared with university hospital units, in units with fewer than 2000 annual deliveries (aOR 2.32 [95% CI: 1.49-3.57]), and in units without an obstetrician always present (aOR 1.96 [95% CI: 1.26-3.03]). CONCLUSIONS: Management practices for severe PPH can be improved, to an extent that varies by component of care and type of hospital. A qualitative approach should help to identify the individual and organizational factors explaining why guidelines are not fully applied.

[ICD-10 adaptation of 15 Agency for Healthcare Research and Quality patient safety indicators]. / Adaptation au codage CIM-10 de 15 indicateurs de la sécurité des patients proposés par l'Agence étasunienne pour la recherche et la qualité des soins de santé (AHRQ).

BACKGROUND: In the United States, the Agency for Healthcare Research and Quality (AHRQ) has developed 20 Patient Safety Indicators (PSIs) to measure the occurrence of hospital adverse events from medico-administrative data coded according to the ninth revision of the international classification of disease (ICD-9-CM). The adaptation of these PSIs to the WHO version of ICD-10 was carried out by an international consortium. METHODS: Two independent teams transcoded ICD-9-CM diagnosis codes proposed by the AHRQ into ICD-10-WHO. Using a Delphi process, experts from six countries evaluated each code independently, stating whether it was "included", "excluded" or "uncertain". During a two-day meeting, the experts then discussed the codes that had not obtained a consensus, and the additional codes proposed. RESULTS: Fifteen PSIs were adapted. Among the 2569 proposed diagnosis codes, 1775 were unanimously adopted straightaway. The 794 remaining codes and 2541 additional codes were discussed. Three documents were prepared: (1) a list of ICD-10-WHO codes for the 15 adapted PSIs; (2) recommendations to the AHRQ for the improvement of the nosological frame and the coding of PSI with ICD-9-CM; (3) recommendations to the WHO to improve ICD-10. CONCLUSIONS: This work allows international comparisons of PSIs among the countries using ICD-10. Nevertheless, these PSIs must still be evaluated further before being broadly used.

[Improvement of maxillofacial bone distraction osteogenesis: future prospects]. / Potentialisation de la distraction ostéogénique maxillofaciale, voies d'avenir.

Distraction osteogenesis is a tissue engineering technique based on Ilizarov's study on long bones. McCarthy transposed it rapidly to facial bones. His results in cranial and maxillofacial surgery are good and reproducible. However, the current protocols are long and the devices used are bulky. Finding new devices and association with other tissue engineering techniques should improve distraction osteogenesis and the patient's comfort.

Prevalence of liver complications in children receiving long-term parenteral nutrition.

BACKGROUND/OBJECTIVES: The hepatic prognosis of long-term home total parenteral nutrition (TPN)-dependent children is poorly documented. The objective was to study outcome data in home TPN-dependent children and to describe precisely their liver biopsies in the attempt to analyze risk factors for biochemical and histological hepatic abnormalities. SUBJECTS/METHODS: Medical records of 42 children receiving home TPN for more than 2 years between January 1998 and December 2007 in a single approved home total parenteral center were reviewed. Hepatic biochemical abnormalities were analyzed. Hepatic biopsies were classified by two independent pathologists. RESULTS: Duration of TPN was 7.9±0.8 years (mean±s.e.m.), with an average age at onset of 1.5±0.5 years. A total of 24 patients (57%) developed biochemical liver abnormalities in an average of 2.9±0.4 years after starting TPN. Risk factors for biochemical abnormalities were younger age at TPN commencement, longer duration of TPN, higher rate of catheter-related infections and higher volume and energy content of TPN. Liver biopsies were carried out in 43% of patients (mean age 3.2±0.9 years). Almost all patients had fibrosis (94%). Risk factors were dependent on each histological abnormality: fibrosis was significantly associated with a shorter length of bowel and a longer duration of TPN; cholestasis correlated with a lower percentage of total parenteral energy intake due to lipids; and steatosis had no risk factor identified. CONCLUSION: Our study reports a high rate of histological liver abnormalities and analyzes risk factors in children who underwent very long-term home TPN.

Multifaceted intervention to decrease the rate of severe postpartum haemorrhage: the PITHAGORE6 cluster-randomised controlled trial.

OBJECTIVE: Decreasing the prevalence of severe postpartum haemorrhages (PPH) is a major obstetrical challenge. These are often considered to be associated with substandard initial care. Strategies to increase the appropriateness of early management of PPH must be assessed. We tested the hypothesis that a multifaceted intervention aimed at increasing the translation into practice of a protocol for early management of PPH, would reduce the incidence of severe PPH. DESIGN: Cluster-randomised trial. POPULATION: 106 maternity units in six French regions. METHODS: Maternity units were randomly assigned to receive the intervention, or to have the protocol passively disseminated. The intervention combined outreach visits to discuss the protocol in each local context, reminders, and peer reviews of severe incidents, and was implemented in each maternity hospital by a team pairing an obstetrician and a midwife. MAIN OUTCOME MEASURES: The primary outcome was the incidence of severe PPH, defined as a composite of one or more of: transfusion, embolisation, surgical procedure, transfer to intensive care, peripartum haemoglobin decrease of 4 g/dl or more, death. The main secondary outcomes were PPH management practices. RESULTS: The mean rate of severe PPH was 1.64% (SD 0.80) in the intervention units and 1.65% (SD 0.96) in control units; difference not significant. Some elements of PPH management were applied more frequently in intervention units-help from senior staff (P = 0.005), or tended to - second-line pharmacological treatment (P = 0.06), timely blood test (P = 0.09). CONCLUSION: This educational intervention did not affect the rate of severe PPH as compared with control units, although it improved some practices.

Dermoscopic features of acral lentiginous melanoma in a large series of 110 cases in a white population.

BACKGROUND: Acral lentiginous melanoma (ALM) is a rare but distinctive subtype of melanoma. The diagnosis is often delayed and misdiagnosis is common, due to frequently unusual clinical presentation and a higher rate of amelanosis than in other melanoma subtypes. OBJECTIVES: We aimed to investigate the dermoscopic features of a large series of ALM in a white-skinned population, in order to emphasize their diagnostic value. METHODS: All recorded dermoscopic photographs of ALM, including nail unit variants, were collected from the files of the University Hospital Department of Dermatology (Lyons, France) and reviewed. RESULTS: In total 110 lesions, including 66 (60%) palmoplantar ALM and 44 (40%) ALM of the nail apparatus, were analysed for dermoscopic characteristics. The mean Breslow thickness was 2.6 mm. In volar skin melanomas, the two most prevalent patterns were irregular diffuse pigmentation (60%) and the parallel-ridge pattern (53%). Minor dermoscopic patterns, commonly noted in benign lesions, were also detected but only focally within the lesions. Among the 44 nail unit lesions, 31 (70%) presented irregular lines with variegations in colours, spacing, width and disruption of parallelism. Two cases of melanonychia striata had a triangular shape. Both corresponded to early ungual ALM. Association with subungual haemorrhage was not uncommon. The study included 37 (34%) amelanotic melanomas. However, dermoscopy enabled detection of microscopic remnants of pigmentation in most cases. The vascular pattern found in almost half of these lesions was polymorphous, with combinations of milky-red areas (95%), linear irregular vessels (49%), dotted vessels (43%) and hairpin vessels (41%). CONCLUSIONS: The presence of a parallel-ridge pattern and/or irregular diffuse pigmentation within the lesion is highly indicative of melanoma on volar skin. An irregular lines pattern is the most prominent dermoscopic feature of pigmented ALM of the nail apparatus. Amelanotic ALM either in volar skin or in nail apparatus is characterized by remnants of pigmentation and a polymorphic vascular pattern.

[Screening and management of glucose metabolism disorders in cystic fibrosis patients. Practices survey in 4 French reference centers]. / Dépistage et prise en charge des troubles du métabolisme glucidique chez les patients atteints de mucoviscidose. Etude de pratiques au sein du réseau EMERA.

OBJECTIVE: Glucose metabolism disorders are a new point of interest in cystic fibrosis (CF) management. Cystic fibrosis-related diabetes mellitus (CFRD) increases alteration of pulmonary function as well as patients' morbidity and mortality. In France, CF patients are exclusively followed up in reference centers. We conducted a practices survey on screening and diagnosis of glucose metabolism disorders at 4 French CF centers. The objective of this study was to assess adherence to practice guidelines developed in 2002 at these centers. METHODS: This study was conducted in 2 sessions: 60 medical records were randomly selected in 2005 and in 2007 for patients aged over 10 years followed up at 4 CF centers. A questionnaire survey was completed for each patient with questions on CFRD screening, diagnosis, monitoring and treatment. Our guidelines recommend random blood glucose (RBG) at each standard biological test, annual glycosylated haemoglobin and an oral glucose tolerance test (OGTT) at 10, 15 and 18 years of age, then every 2 or 3 years. RESULTS: An annual RBG was performed in 82% of patients in 2005 and 91.5% in 2007. HbA1c screening was performed annually for 77% of patients in the 1st session and for 90% of patients for the 2nd session (p<0.10). Adherence to OGTT guidelines was better for adults than children: 96% had an OGTT during the 3 years of the first session and 79% during the second session, while fewer than 50% of children had their OGTT at 15 and 18 years of age. Taking the OGTT at 10 years of age could not be assessed because no patients were 10 years old during the study period. Screening for neurological complications of CFRD was assessed in the majority of diabetic patients, while half or less than half had annual fundus oculi or microalbuminuria dosage. DISCUSSION: There was an improvement in screening for CFRD and glucose metabolism disorders between 2005 and 2007, even though practices could still be improved. This shows that clinical guidelines can be implemented and followed. However, screening and management criteria for glucose metabolism disorders must be consensus-based with higher evidence in order to limit the variability of practices and prevent CFRD-related complications.

Incidence and management of postpartum haemorrhage following the dissemination of guidelines in a network of 16 maternity units in France.

BACKGROUND: In France obstetric haemorrhage is the leading cause of maternal death. The aim of this study was to evaluate if the management of postpartum haemorrhage at individual maternity units followed guidelines established by the Aurore Network. METHODS: A descriptive study was carried out in 16 maternity units of the Aurore network between October 2004 and September 2005. Cases and data were prospectively identified and collected. RESULTS: Postpartum haemorrhage occurred in 1144 of 21 350 deliveries, an overall incidence of 5.4+/-0.3%. Of these, 316 cases were rated as severe. Diagnosis was clinical in 82.5% of severe cases and 77.5% of non-severe cases; the remainder were detected by postpartum laboratory tests. Uterotonic agents were given prophylactically to 46.7% of the 896 patients following vaginal delivery. In cases in which postpartum haemorrhage was due to uterine atony, 83.1% of women underwent examination of the uterine cavity and 96.3% received oxytocin, which proved therapeutic. Sulprostone was administered to 39.5% cases of persistent postpartum haemorrhage. A uterotonic was given prophylactically to 85.4% of the 247 patients at caesarean delivery. Oxytocin was therapeutic in 94.8% of cases of uterine atony. Sulprostone was administered in 84.4% of cases of persistent postpartum haemorrhage. CONCLUSION: The regional guidelines issued by the Aurore network were only partially followed. More effective guideline dissemination and implementation is required to improve the prevention and management of confirmed haemorrhage.

Impact of guidelines for endoscopy in patients with Barrett's esophagus: a multifaceted interventional study.

OBJECTIVE: To evaluate the impact of a multifaceted interventional program on the compliance of hepatogastroenterologists with guidelines for Barrett's esophagus. DESIGN: In both 2002 and 2005, anonymous postal surveys were sent out, involving eight criteria pertaining to three main areas to assess compliance, to 245 hepatogastroenterologists based in private and public hospitals, and in the community, in a specific region of France. The multifaceted intervention was based on reminders, conferences, postal campaigns and esophageal mapping. Main outcome measures were based on biopsies for diagnosis, surveillance intervals and management of patients with high-grade dysplasia. RESULTS: In 2002 and 2005, survey response rates were 81.6 and 73.9%, respectively. In terms of diagnosis, compliance with the systematic performance of biopsies increased from 26.5 to 59.9% (p<0.01) and, with follow-up, from 41.0 to 52.0%, respectively (p<0.02). Management of high-grade dysplasia increased from 16.0 to 24.3% (p<0.01). Total compliance (with all criteria) was achieved by 5.0% of hepatogastroenterologists in 2002 and by 10.7% in 2005 (p<0.01). CONCLUSION: The present study suggests that a multifaceted interventional program can dramatically improve physician compliance with the guidelines for Barrett's esophagus. For this reason, we recommend that national scientific societies disseminate their guidelines through targeted activity to ensure that they are followed by hepatogastroenterologists.

Quality monitoring in thyroid surgery using the Shewhart control chart.

BACKGROUND: A control chart can help to interpret and reduce sources of variability in patient safety by continuously monitoring indicators. The aim of this study was to monitor the outcome of thyroid surgery using control charts. METHODS: Patients who had thyroid surgery during 2006-2007 were included in the study. Safety was monitored based on postoperative complications of recurrent laryngeal nerve palsy and hypocalcaemia. Indicators were extracted prospectively from the hospital information system and plotted each month on a P-control chart. Performance of the surgical team was also measured retrospectively for 2004-2005 (baseline period) to compare surgical outcomes before and after control chart implementation. Electromyographic monitoring of recurrent laryngeal nerves was not used, nor was calcium or vitamin D given routinely. RESULTS: The outcomes of 1114 thyroid procedures were monitored. Although the proportion of patients with recurrent laryngeal nerve palsy was similar for baseline and monitored periods (6.4 and 7.2 per cent respectively), there was a 35.3 per cent decrease in hypocalcaemia after implementation of control charts (P < 0.001). Complications almost doubled during a period when one surgeon was away and operating room renovations took place. CONCLUSION: Outcome monitoring in thyroid surgery using control charts is useful for identifying potential issues in patient safety.

[Early prenatal interview: implementation of a sheet link "carried" by patient. The Aurore perinatal network experience]. / Entretien prénatal précoce : mise en place d'une fiche de liaison << portée >> par la patiente. A propos de l'expérience du réseau périnatal Aurore.

INTRODUCTION: Early prenatal interview has needed the implementation of a new communication tool between follow-up pregnancy professionals: a link sheet filled and carried by patients. OBJECTIVE: To assess the utilization of link sheet by trained professionals, the contribution of the interview and the patient acceptation of the link sheet. MATERIALS AND METHOD: Descriptive survey from the database of link sheets returned by professionals to Aurore perinatal network and semi-guided interviews with 100 randomized patients. RESULT: One thousand one hundred and nineteen link sheets were sent to Aurore perinatal network by 55 professionals out of 78 trained. For primipare, precocious prenatal interview contribution has concerned health care security (60%) and emotional security (56%). For multipare, this contribution has concerned mainly emotional security (80%). No interviewed patient has refused link sheet principle. CONCLUSION: Link sheet principle, like implemented by Aurore perinatal network, seems pertinent to professionals and patients but it constitutes only one of the elements of network elaboration of personalized care.