Long-Term Thoracic Endovascular Repair Follow-Up from 1999 to 2019: A Single-Center Experience.

BACKGROUND: Thoracic endovascular aortic repair (TEVAR) was introduced in the early 1990s and long-term follow-up studies are warranted in current guidelines. METHODS: Patients undergoing TEVAR were consecutively included from 1999 to 2019. Thoracic aortic disease includes thoracic aortic aneurysms, aortic dissection, traumatic rupture, penetrating aortic ulcer (PAU), and intramural hematoma (IMH). Our prospective database recorded baseline characteristics, endoleak or aneurysm growth, and death. Patients were included at the time of treatment and censored at death or first reintervention depending on the analysis. Primary end point was all-cause death; secondary end point was reintervention. Survival and failure analyses were done using STATA IC 16.0 and truncated at 15 years of follow-up. RESULTS: Two hundred and fifty six patients were included and 63% were men. Their mean age at intervention was 66.2 ± 14.5 years and they were followed for a mean of 5.2 ± 4.5 years. Indications for TEVAR were acute aortic syndrome in 40.6%, chronic aortic disease in 44.5%, and traumatic rupture in 14.8%. Technical success was seen in 94.1% of the operations, and the left subclavian artery was covered in 27.7%. A 30-day mortality rate was 21.2% (22/104) and 1.75% (2/114) (P < 0.001) for urgent and elective patients, respectively. Twelve patients (4.7%) died within 24 hr of treatment. Overall, long-term mortality recorded 112 (43.8%) deaths, 29 patients had reinterventions (11.3 %, 95% confidence interval: 7.7-15.9), and aneurysms accounted for 62.1% of all reinterventions. Twenty four (82.8%) reinterventions occurred within the first 5 years. CONCLUSIONS: This long-term follow-up study shows excess mortality in patients treated for acute aortic syndrome compared to chronic aortic disease, within the first 30 days; this difference diminishes at the end of follow-up. Most endoleaks occur within the first 5 years, although new endoleaks continue to develop decades after in previous endoleak-free patients calling for lifelong surveillance.

[Crisis at the hospital and the hospice, same combat: Break down the walls!] / Crise à l'hôpital et dans les EHPAD, même combat : abattons les murs !

The crisis in public hospitals and accommodation facilities for the elderly (EHPAD) focuses on issues of governance and internal resources (including financial ones), while the responses should be found in an organized and consolidated fluidity between the world of hospital or medico-social institutions and the usual living spaces of the population. At the hospital level, the main difficulties are due to a regularly announced, but incomplete, transfer between the activities of these institutions and outpatient medicine. The solution is certainly in a single governance of health policy, currently shared between the state and health insurance. For the EHPAD, the institutionalization of frail elderly people and/or those in the process of dependence, as well as the unsuccessful proliferation of multiple experiments in their care at home, lead, on one hand, to an increasingly complex offer, not understandable for everyone, and secondly, to rely mainly on the general practitioner for the coordination of this care. The solution is certainly in a universal offer, under common law, which would allow the elderly population to stay as long as possible at home, which is what they wish the most.

Long-term experience of steroid-free pediatric renal transplantation: effects on graft function, body mass index, and longitudinal growth.

Increased focus on the potential negative side effects of steroid usage in pediatric transplantation has led to steroid minimization or steroid-free transplantation. In this study, we report results after complete steroid avoidance in renal transplantation in the period 1994-2009. We evaluate the effects of complete steroid avoidance on allograft function, BMI, and linear growth. The majority of transplanted children were induced with antithymocyte globulin and immunosuppressed with a calcineurin inhibitor and mycophenolate mofetil. Steroids were given only when rejection occurred or due to comorbidities. Anthropometric data were collected from 65 transplantations in 60 children. Patient survival was 93%; graft survival was 81% after five yr (N = 42) and 63% after 10 yr (N = 16). Acute rejection within the first year of transplantation was 9%. The distribution of the children's BMI before transplantation was normal; the mean BMI-SDS was 0.21 before transplantation, and this value remained stable during the next five yr. Post-transplantation the children demonstrated significant improved growth as the mean height-SDS increased significantly from -1.7 to -1.1. Catch-up growth was most pronounced in the youngest (< six yr). Steroid-free immunosuppression in pediatric renal transplantation is safe and protects against steroid-induced obesity and short stature.

[Demography of psychiatrists and attractiveness factors: the example of Franche-Comté]. / Démographie des psychiatres et facteurs d'attractivité?: l'exemple de la Franche-Comté

INTRODUCTION: In France, the challenges of replacing departing psychiatrists with a new generation are compounded by an increased demand for psychiatric care, which threatens the accessibility of health care, particularly in rural and semi-rural areas. The objective of this study was to describe the location of psychiatrists trained in the Franche-Comté region, and to analyze the factors associated with establishing their practice in the region, particularly in the most understaffed areas. METHODS: We conducted a retrospective observational study, completed by a qualitative investigation with semi-directive interviews with psychiatrists and psychiatry residents. RESULTS: Between 1994 and 2013, 160 students entered psychiatry residencies in Franche-Comté. As of October 2013, 87 of them were full-time psychiatry practitioners and, 57% of them worked in Franche-Comté. The region of practice was associated with their birthplace (p=0.03). The qualitative investigation showed that, apart from family- and quality of life-related factors (work opportunities for the spouse, family closeness, desire to live in urban areas), opportunities to work in a team, implementation of dynamic and innovative projects and values of the establishment were also considered when choosing a site of practice. CONCLUSION: While the current increase in the number of psychiatry residents may respond, in the long run, to health care demographic problems in Franche-Comté, more specific interventions also seem necessary. Creation of time-shared jobs, facilitating the establishment of psychiatric practices within multidisciplinary clinics, task shifting and telemedicine may allow improvement of the psychiatric care offered in Franche-Comté.

[Creation of a consumer representatives committee in a multidisciplinary primary health care center. Findings, limitations and prospects]. / Mise en place d'un comité de représentants des usagers dans une maison de santé pluridisciplinaire. Constats, limites et perspectives.

INTRODUCTION: The St Claude multidisciplinary health centre in Besançon encouraged the creation of a consumer representatives committee to promote health democracy in primary health care. This project was developed with the help of a local consumers association. This study evaluated the perception and expectations of these fifteen health users/citizens. METHODS: A qualitative study based on individual semistructured interviews was carried out before initiation of the project. RESULTS: The results highlight the motivation and sense of initiative of the participants in this innovative project, who wish to discuss a wide range of topics. These topics were compared to the health centre's health project. Four common themes emerged: maintenance at home for the elderly, management of urgent consultations in the health centfre, prevention and information. These themes were used to guide the formation of this consumer group. The limitations defined by the consumers were also taken into account to ensure durability of the project. This study identified several markers: the original modality of identification of representatives, the themes shared with professionals, the proposed method of structuring activities. DISCUSSION: These preliminary observations and orientations could be used by other organizations to facilitate the creation of a group of consumer representatives.

[Logic model of the Franche-Comté Regional Health Project: advantages and limitations for the evaluation process]. / Cadre logique du Projet régional de santé de Franche-Comté : intérêts et limites pour la démarche d'évaluation.

The French "Hospitals, patients, health and territories" law of July 2009 created the Regional Health Project (PRS) to support regional health policy, and requires evaluation of these projects. The construction of these projects, which includes prevention planning, care planning, and medical and social welfare planning, presents an unprecedented complexity in France, where evaluation programmes are still in their infancy. To support future evaluations, the Franche-Comté Regional Health Agency (ARS FC), assisted by the expertise of EFECT Consultants, decided to reconstruct the PRS logic model. This article analyzes the advantages and limitations of this approach. The resulting logic model allows visualization of the strategy adopted to achieve the Franche-Comté PRS ambitions and expected results. The model highlights four main aspects of structural change to the health system, often poorly visible in PRS presentation documents. This model also establishes links with the usual public policy evaluation issues and facilitates their prioritization. This approach also provides a better understanding of the importance of analysis of the programme construction in order to be effective rather than direct analysis of the effects, which constitutes the natural tendency of current practice. The main controversial limit concerns the retrospective design of the PRS framework, both in terms of the reliability of interpretation and adoption by actors not directly involved in this initiative.

[Health education in the French Regional Health Agencies in 2012: observations and analysis]. / L'education pour la santé dans les Agences Régionales de santé en 2012 : constats et analyses.

This paper examines the role of health education in the French Agences régionales de santé (ARS, Regional Health Agencies) in 2012. A survey was conducted among public health managers working in the ARS. Most of the participants reported that health education plays an important role in their agency, notably through their regional health plan and the activities of the organizations responsible for promoting democracy in health care. This is also true of the links with the Institut national de prévention et d'education pour la santé (INPES, the National Institute for Health Prevention and Education) and the network of Instances régionales d'éducation et de promotion de la santé (IREPS, the Regional Authorities for Health Education and Promotion). However, the answers to the open-ended questions and the results of the interviews suggest that these results must be interpreted with caution. The study focuses on a number of factors that must be taken into account when considering the results of the quantitative analysis. These factors include: the subjective (or interpretive) dimension of the term "health education" emphasized by many of the participants (a term involving an emphasis on either health promotion or preventive medicine); the limited emphasis on health education in the ARS (beyond therapeutic patient education) compared to other issues such as health monitoring and security, health care and medico-social problems; the limited resources allocated to health education and the bleak budget outlook; the relationships with the main operators; and the need to develop, promote and apply knowledge of good practice. Finally, the study shows that the role of health education is dependent on individuals' willingness to promote it and, in particular, on the commitment of ARS managers.

ABO-incompatible kidney transplantation.

INTRODUCTION: Kidney transplantation is the optimal treatment for many patients with end-stage renal disease (ESRD). Due to shortage of donor kidneys in Denmark, there is a need to expand the possibilities for donation. At the Odense University Hospital (OUH), we have introduced ABO-incompatible kidney transplantation. We used antigenspecific immunoadsorptions to remove blood group antibodies and anti-CD20 antibody (rituximab) to inhibit the antibody production. The aim of introducing the ABO-incompatible kidney transplantation at the OUH was to increase the rate of living donor kidney transplantation without increasing rejection or mortality rates. MATERIAL AND METHODS: Retrospective evaluation. Eleven patients received ABO-incompatible kidney transplantation. The patients were followed for 3-26 months. RESULTS: One patient had an antibody-mediated rejection, one patient suffered T-cell-mediated rejection, and one patient died of myocardial infarction with a functioning graft on the third post-operative day. Both rejections were treated effectively. Among the patients, the average serum creatinine level was 128 micromol/l. CONCLUSION: The rejection and mortality rates for ABO-incompatible kidney transplantation at the OUH are similar to the results from ABO-compatible kidney transplantations performed at the OUH and at other hospitals.

[Limits of self regulation of the private food sector: the case of removing of vending machines from schools]. / Limites de l'autodiscipline des acteurs économiques dans le champ de l'alimentation: l'exemple du retrait des distributeurs automatiques.

Conflicts of interest between the food industry and public decision makers have increasingly multiplied over the last few years, especially within the context of implementing the French National Nutrition Programme. This paper describes the rhetoric and the strategies developed by the private sector in order to counter the law's implementation and enforcement based on a concrete example, namely, the removal of vending machines from schools. After having evoked possibilities of developing new partnerships as suggested by national and international health authorities, it reaffirms the right and the duty of the State to regulate within the framework of a health promotion policy, an approach which integrates the necessary open democratic public debate between the different sectors.

[The development of therapeutic patient education within the regions of France]. / Le développement de l'éducation thérapeutique du patient au sein des régions françaises.

Therapeutic patient education (TPE) constitutes a new type of prevention and care being offered in France. This article presents a review of its current organisation and status within the country. The work was carried out based upon a questionnaire targeted towards all of the Regional Social Insurance Registry Unions (URCAM). Nearly all of the regions are supported and served by a regional advisory group which most often times facilitated by a representative from the social health insurance office. The development of TPE is situated and structured, for the most part, within the regional public health policy. Training which is specifically targeted for health professionals remains quite erratic. The hospital continues to play an important role and is a driving force, along with the health care networks, in the development of TPE. The close involvement and participation of the general family practitioner and the organisation of high quality, comprehensive care options (through the dissemination of defined criteria and specifications) are the priority areas for action.