National Trends in Patients Hospitalized for Stroke and Stroke Mortality in France, 2008 to 2014.

BACKGROUND AND PURPOSE: Stroke is the leading cause of death in women and the third leading cause in men in France. In young adults (ie, <65 years old), an increase in the incidence of ischemic stroke was observed at a local scale between 1985 and 2011. After the implementation of the 2010 to 2014 National Stroke Action Plan, this study investigates national trends in patients hospitalized by stroke subtypes, in-hospital mortality, and stroke mortality between 2008 and 2014. METHODS: Hospitalization data were extracted from the French national hospital discharge databases and mortality data from the French national medical causes of death database. Time trends were tested using a Poisson regression model. RESULTS: From 2008 to 2014, the age-standardized rates of patients hospitalized for ischemic stroke increased by 14.3% in patients <65 years old and decreased by 1.5% in those aged ≥65 years. The rate of patients hospitalized for hemorrhagic stroke was stable (+2.0%), irrespective of age and sex. The proportion of patients hospitalized in stroke units substantially increased. In-hospital mortality decreased by 17.1% in patients with ischemic stroke. From 2008 to 2013, stroke mortality decreased, except for women between 45 and 64 years old and for people aged ≥85 years. CONCLUSIONS: An increase in cardiovascular risk factors and improved stroke management may explain the increase in the rates of patients hospitalized for ischemic stroke. The decrease observed for in-hospital stroke mortality may be because of recent improvements in acute-phase management.

What is the evolution of stroke unit's accessibility in metropolitan France from 2009 to 2014? A trend analysis of over 600 000 patients using national hospital databases.

OBJECTIVES: We aimed to study trends in stroke unit (SU) admission during a period of their deployment in France and to assess whether this led to better and more equitable access to this specialised care. DESIGN: Analysis of records from the national hospital database. SETTING: All acute care hospitals in metropolitan France for the period 2009-2014. PARTICIPANTS: Over 600 000 patients admitted in acute care with a main diagnosis of stroke. MAIN OUTCOME MEASURES: Admission to a SU. RESULTS: Between 2009 and 2014, the number of stroke admissions rose from 93 728 to 109 456, and the proportion of SU admission from 23% to 44%. Overall, characteristics associated with higher probability of SU admission were: male gender, younger age, ischaemic stroke type, medium level of comorbidity and larger size of town of residence. Although likelihood of SU admission increased in all patients' categories during the study period, we identified steeper positive temporal trends among older patients, those with more comorbidities and those residing in medium or small towns (all p values <0.001), suggesting a 'catching up' phenomena. Temporal trends of men and women did not differ however. CONCLUSIONS: Admission to SU nearly doubled in France between 2009 and 2014. Faster trends observed for patients with lower admission to SU suggest that equity in access has improved over the period.

[The practitioner's role in surveillance and information on environmental risks]. / Surveillance et information sur les risques environnementaux: le rôle du praticien.

Health scares have entailed an increasing concern about environmental risks for populations. Authorities' response was to set up a system for the analysis, surveillance and management of environmental risks. Practitioners have an important role to play in this system, as primary actors of surveillance and as a close source of information about the environmental risks for the population. Three examples are developed. Children's lead poisoning still exists and entails irreversible neuropsychic deficits. Its diagnosis rests upon the recognition of risk factors and the prescription of a test of blood lead level. Carbon monoxide poisoning is the first cause of mortality by acute poisoning in France and it causes several thousand hospitalizations every year. Notification of the cases of lead and carbon monoxide poisonings is indispensable to remove their causes. Links between cancer and environment are an important social concern and a public health issue. Practitioners have a key role to play not only in the communication on this subject, but also to notify disturbing sanitary events and participate in the local investigations.

Screening for Elevated Blood Lead Levels in Children: Assessment of Criteria and a Proposal for New Ones in France.

The decline in children's Blood Lead Levels (BLL) raises questions about the ability of current lead poisoning screening criteria to identify those children most exposed. The objectives of the study were to evaluate the performance of current screening criteria in identifying children with blood lead levels higher than 50 µg/L in France, and to propose new criteria. Data from a national French survey, conducted among 3831 children aged 6 months to 6 years in 2008-2009 were used. The sensitivity and specificity of the current criteria in predicting blood lead levels higher than or equal to 50 µg/L were evaluated. Two predictive models of BLL above 44 µg/L (for lack of sufficient sample size at 50 µg/L) were built: the first using current criteria, and the second using newly identified risk factors. For each model, performance was studied by calculating the area under the ROC (Receiver Operating Characteristic) curve. The sensitivity of current criteria for detecting BLL higher than or equal to 50 µg/L was 0.51 (0.26; 0.75) and specificity was 0.66 (0.62; 0.70). The new model included the following criteria: foreign child newly arrived in France, mother born abroad, consumption of tap water in the presence of lead pipes, pre-1949 housing, period of construction of housing unknown, presence of peeling paint, parental smoking at home, occupancy rates for housing and child's address in a cadastral municipality or census block comprising more than 6% of housing that is potentially unfit and built pre-1949. The area under the ROC curve was 0.86 for the new model, versus 0.76 for the current one. The lead poisoning screening criteria should be updated. The risk of industrial, occupational and hobby-related exposure could not be assessed in this study, but should be kept as screening criteria.

Blood lead levels and risk factors in young children in France, 2008-2009.

BACKGROUND: The exposure of children to lead has decreased in recent years, thanks notably to the banning of leaded gasoline. However, lead exposure remains a matter of public health concern, because no toxicity threshold has been observed, cognitive effects having been demonstrated even at low levels. It is therefore important to update exposure assessments. A national study was conducted, in 2008-2009, to determine the blood lead level (BLL) distribution in children between the ages of six months and six years in France. We also assessed the contribution of environmental factors. METHODS: This cross-sectional survey included 3831 children recruited at hospitals. Two-stage probability sampling was carried out, with stratification by hospital and French region. Sociodemographic characteristics were recorded, and blood samples and environmental data were collected by questionnaire. Generalized linear model and quantile regression were used to quantify the association between BLL and environmental risk factors. RESULTS: The geometric mean BLL was 14.9µg/l (95% confidence interval (CI)=[14.5-15.4]) and 0.09% of the children (95% CI=[0.03-0.15]) had BLLs exceeding 100µg/l, 1.5% (95% CI=[0.9-2.1] exceeding 50µg/l. Only slight differences were observed between French regions. Environmental factors significantly associated with BLL were the consumption of tap water in homes with lead service connections, peeling paint or recent renovations in old housing, hand-mouth behavior, passive smoking and having a mother born in a country where lead is often used. CONCLUSIONS: In children between the ages of one and six years in France, lead exposure has decreased over the last 15 years as in the US and other European countries. Nevertheless still 76,000 children have BLL over 50µg/l and prevention policies must be pursued, especially keeping in mind there is no known toxicity threshold.