[The relationship between the rigorous practice of sports and addictions: results from a survey in south-eastern France]. / Pratique sportive intensive et addictions: une enquête en région PACA.

This study aimed to assess the prevalence of cigarette, alcohol and cannabis consumption among top-ranked French student athletes aged between 16-24 years old, and to identify correlating factors. Overall, 837 athletes participated in the study (82% response rate). Among females, the amount and duration of sporting activity in which they were engaged on a weekly basis had a negative correlation to cigarette smoking and the occasional use of cannabis. Among males, however, a positive correlation of these factors was observed for cigarette smoking. Other determinants of alcohol, tobacco and cannabis use were the level of athletic competition and whether the athlete practiced a team sport (as opposed to an individual one), with some gender variations. Two major risk factors for young adult athletes were the existence of high psychological distress (for both sexes) and a lack of family support (particularly in the case of males). Further research is needed to investigate the specific motives to use so-called "recreational" drugs among young athletes engaging in high-level competition.

Disclosure of prognosis to terminally ill patients: attitudes and practices among French physicians.

BACKGROUND: Disclosure of the prognosis to terminally ill patients is a strong prerequisite for integrating the physical, psychological, spiritual, and social aspects of end-of-life care. OBJECTIVE: This study aimed to assess French physicians' general attitudes and effective practices (with patients followed up to death recently) toward such disclosure. DESIGN/SUBJECTS: We used data from a cross-sectional survey conducted among a national sample of 917 French general practitioners, oncologists, and neurologists. RESULTS: A majority of respondents opted for prognosis disclosure only at patients' request, very few opted for systematic disclosure without patient's request, and a significant minority opted for systematic concealment. Concerning deceased patients described by respondents, 44.5% of competent patients were informed of prognosis by their physician, 27.3% were informed by someone else, 9.0% refused to be informed, and 19.2% were simply not informed. Concealment was more frequent for older patients, and physicians involved in a nongovernmental organization (NGO) for patients' support were more likely to disclose the prognosis, even without patient's request. CONCLUSIONS: Disclosure of the prognosis to terminally ill patients is still far from systematic in France. Further research is needed to better understand the motivations of French physicians' disclosure practices, which are probably culturally shaped.

[Doctors' opinions on palliative care: results from a French survey on physicians attitudes and practices]. / Deux points de vue des médecins sur les soins palliatifs.

OBJECTIVE: To examine practitioners' opinions on palliative care. METHOD: Statistical analyses were carried out on data collected from 1000 physicians recruited to participate in a study on knowledge, attitudes and practices with respect to palliative care ("Palliative Care 2002"). A cluster analysis (CAH) was conducted based on responses to nine questions in order to identify homogeneous and contrasting profiles of opinions on palliative care. RESULTS: Two distinctly different categories of profiles emerged. The first one had a restrictive approach to palliative care (n = 387; 38.7%), while the second one supported its expansion (n = 613; 61.3%). CONCLUSION: A newly revised communication campaign which favoured and recognised palliative care could assist in the dissemination of related practices among physicians.

Opinions toward pain management and palliative care: comparison between HIV specialists and oncologists.

Despite the introduction of HAART, pain is still a common symptom in people living with HIV/AIDS. For these persons, pain management supplied by palliative care teams may support standard HIV care. This study compares opinions toward palliative care of 83 HIV specialists and 217 oncologists (French national survey: Palliative Care 2002). Data were collected by phone questionnaire. A cluster analysis was carried out in order to identify contrasted profiles of opinions toward palliative care. A logistic regression was performed to test the relationships between identified clusters and physicians' characteristics. With a two-cluster partition, we observed a profile corresponding to a restrictive conception of palliative care. Within this profile, physicians were more prone to consider that palliative care should be used only for terminally-ill patients, and only after all curative treatments have failed, with a restrained prescriptive power for physicians providing palliative care. This conception was associated with reluctance toward morphine analgesia. Once controlled for other physicians' characteristics, HIV specialists were more likely than oncologists to endorse this restrictive conception (OR=1.9, CI 95% [1.1; 3.3]). Thus French HIV specialists should be more informed about the utility of providing palliative care, even for patients who are not in terminal stage.

Evaluation of buprenorphine maintenance treatment in a French cohort of HIV-infected injecting drug users.

BACKGROUND: Buprenorphine was approved in France for treating opiate dependence in July 1995 and can be prescribed by general practitioners (GPs). Most studies assessing buprenorphine maintenance treatment (BMT) outcomes have taken place in GP settings. An evaluation of BMT outcomes in patients already followed for their HIV-infection could supply additional information about the changes in addictive practices in a non-GP setting. METHODS: We assessed BMT discontinuations and the course of self-reported addictive behaviours and characteristics associated with buprenorphine-injection misuse in 114 HIV-infected patients on BMT who were followed in a hospital-based outpatient department. RESULTS: The continuous series of follow-up visits at which these 114 patients reported regular buprenorphine prescriptions accounted for 237.5 person-years of observation, i.e. 475 follow-up visits. Of the 114 patients on BMT, 43% continued BMT throughout the follow-up, 40% stopped it, and results for 17% were not available either because they did not answer the self-administered questionnaire (5%) or because they were lost to follow-up (12%). Addictive behaviours declined but buprenorphine injection misuse remained stable. Depression measured by the CESD score (RR=1.04 95%CI [1.01-1.06]), cocaine use (RR=2.48 95%CI [1.31-4.68]) and alcohol consumption exceeding 4 alcohol units (AU) per day (RR=2.29, 95%CI [1.17-4.46]) were independently associated with buprenorphine injection misuse among stabilised BMT patients. CONCLUSIONS: Despite the reduction in drug injection after starting BMT, buprenorphine injection misuse mainly involves patients with characteristics of severe addiction. Better monitoring of the illicit drug use patterns of patients on BMT may suggest new medical strategies for GPs to improve BMT outcomes.

[Terminal care of patients by the general practitioner and the specialist. Results of a French survey "Attitudes and practices in palliative treatment--2002"]. / Prise en charge des malades en fin de vie en médecine générale et spécialisée. Résultats de l'enquête française "Attitudes et pratiques face aux soins palliatifs-2002".

OBJECTIVE: Assess the attitude of the practitioners with regard to the management of patients at the end of their lives, depending on the physician/patient communication and treatment of pain. Method Statistical analysis of the data collected among 1,000 practitioners recruited for a survey on knowledge, attitudes and practices regarding palliative care in 2002. RESULTS: The practitioners who felt "ill at ease" in the management of patients at the end of their life often had a poor opinion regarding morphine and did not systematically their patients of the therapeutic aims. CONCLUSION: Greater awareness by the practitioners of palliative care would help to improve the quality of care supplied to terminally ill patients.

The prescription of opioid analgesics to terminal cancer patients: impact of physicians' general attitudes and contextual factors.

OBJECTIVE: This study aimed to examine factors associated with the prescription of opioid analgesics to terminal cancer patients, including physicians' general attitudes toward morphine and contextual factors. METHODS: A survey was conducted among a sample of French general practitioners (GPs) and oncologists. Respondents were asked to describe the last three terminally ill patients they had followed up to death. RESULTS: Overall, 526 GPs and oncologists (global response rate: 57%) described 1,082 cancer patients, among whom 85.4% received opioid analgesics. Among other significant predictors (patient age, cancer type, family assistance), this prescription was less frequent for female patients followed by male physicians (OR = 0.53), and more frequent for patients followed by physicians trained in palliative care (OR = 2.70). On the other hand, physicians' attitudes toward morphine were not associated with prescription of morphine and other opioid analgesics. SIGNIFICANCE OF RESULTS: Although nonprescription of opioid analgesics is only a crude proxy measure for undertreatment of cancer pain, our findings suggest the need to develop training in palliative care in order to standardize practices among GPs and specialists. Our results also highlight the necessity to study pain assessment as an interaction between the physician and the patient, and to consider patients' and physicians' respective genders as a key variable within this interaction.

Factors related to delayed diagnosis of HIV infection in southeastern France. EVALVIH group.

We aimed to identify risk factors associated with delayed diagnosis of HIV infection in a French region highly affected by AIDS. Data were collected in southeastern France through the HIV-surveillance system based upon anonymous declarations by laboratories and physicians prescribing HIV testing. From January 1996 to December 1997, 825 persons were diagnosed for the first time as HIV infected (female: 32%; >40 years: 28%); 46% had been infected through heterosexual intercourse, 26% through homosexual intercourse, and 19% through intravenous drug use. The semestrial (6 monthly) incidence rate decreased from 122.7 to 69.7 per million inhabitants (P<0.001). County of residence, age, sex, country of birth, and transmission category did not change significantly during the observation period. Twenty-seven per cent had a delayed diagnosis of HIV infection. This proportion did not differ significantly according to sex or country of birth, or during the observation period. However, after controlling for the other factors, delay was more frequent among injecting drug users (IDUs) (35%, P<10(-2)) than other transmission categories; it was also positively associated with age (47% above 50 years vs 13% under 30 years, P<10(-2)). This study highlights that, in spite of the current AIDS prevention policy and wide access to HIV screening, the proportion of delayed diagnosis of HIV infection remains high. Physicians should concern themselves with this public health issue, and campaigns should target people insufficiently aware, especially IDUs and older people. Further research is needed to understand better the causes of delayed diagnoses and of inequalities in access to HIV screening.

Highly active antiretroviral therapy (HAART) and circulating markers of immune activation: specific effect of HAART on neopterin.

The circulating levels of immune activation markers, including neopterin, tumor necrosis factor receptor type II, and interleukin-2 receptors, are increased in human immunodeficiency virus-infected patients. We show here that highly active antiretroviral therapy significantly decreased neopterin levels. This effect is reversible, since neopterin levels increased after the arrest of treatment. Their determination may be useful in the evaluation of the efficacy of antiretroviral therapy.

Impact of highly active anti-retroviral therapy (HAART) on cytokine production and monocyte subsets in HIV-infected patients.

HIV infection is associated with cytokine production by monocytes and expansion of a monocyte subset that expresses high levels of CD16. Our study was designed to investigate the effects of anti-retroviral therapies on these immune parameters. Four groups of HIV+ patients were included in the study. The first group comprised drug-naive patients (n = 20); the second included patients who received two inhibitors of HIV reverse transcriptase (n = 45); the third group received a therapy combining these two inhibitors and one inhibitor of HIV protease (HAART) (n = 35); the fourth consisted of patients who had stopped their treatment (n = 20). The release of inflammatory cytokines (tumour necrosis factor, IL-1beta, IL-6) and immunoregulatory cytokines such as IL-10 by monocytes was determined by ELISA. The monocyte subsets expressing low or high levels of CD16 were studied by flow cytometry. Monocytes from patients naive of treatment released higher amounts of inflammatory cytokines and IL-10 than HIV- individuals. Each anti-retroviral therapy restored a normal pattern of cytokine secretion. Nevertheless, the release of cytokines increased again after the arrest of the treatment. The expansion of the monocyte subset that expresses high levels of CD16 was significantly decreased by HAART but not by the treatment including two inhibitors of reverse transcriptase. These results suggest that only HAART controls monocyte activation in the treatment of HIV infection.

[Chief health risks associated with intravenous heroin and cocaine abuse]. / Les principaux risques sanitaires associés à l'usage d'héroïne ou de cocaïne par voie intraveineuse.

THREE CATEGORIES OF COMPLICATIONS: Heroine and cocaine are the main drugs used by injecting drug-users (IDU) in France. There are three categories of complications associated with intravenous drug abuse: effects related to drug toxicity, effects associated with the administration route, and effects associated with social implications of drug-dependence. OTHER HEALTH PROBLEMS: The impact of HIV infection among IDU, particularly in southern Europe, has led to renewed interest in the other health problems raised by this population. A review of recent literature shows that cocaine toxicity is better understood than heroine toxicity. In addition, intravenous drug abuse can lead to a whole series of disease states related to trauma or infection.

[Trends in HIV prenatal screening from 1992 to 1994 in South Eastern France]. / Evolution entre 1992 et 1994 du dépistage prénatal du virus de l'immunodéficience humaine (VIH) en provence-alpes-côte d'azur, France.

BACKGROUND: To study trends in HIV testing among pregnant women before and after the introduction of mandatory screening in January 1993. METHODS: The study was based on data from the Prevagest surveys which were carried out in the Provence-Alpes-Côte d'Azur region in samples of pregnant women who just delivered in 1992 (n = 2,775) and 1994 (n = 2,701). RESULTS: The proportion of women declaring that they had been tested during pregnancy increased from 63% in 1992 to 73% in 1994 (p < 0.001). The percentage of women who believe they were tested without consent decreased from 14% in 1992 to 6% in 1994 (p < 0.001). In 1994, 86% nevertheless declared that they received no information on AIDS and its prevention during their pregnancy. After adjustment by a logistic model, type of prenatal care and educational level longer appeared in 1994 to be associated with a lower probability of declaring having been tested. On the contrary, women originating from North Africa, those younger than 25 years and married women had a lower probability of declaring that they have been tested in 1994 as well as 1992. CONCLUSIONS: This study stresses the need for improved communication between public health professionals and practitioners and the establishment of effective training programs in HIV preventive counselling for health professionals in charge of prenatal care.

Mandatory prenatal screening for the human immunodeficiency virus: the experience in south-eastern France of a national policy, 1992-1994.

OBJECTIVE: To evaluate the impact of the 1993 French National Policy which made it mandatory to offer screening for the presence of human immunodeficiency virus (HIV) to all pregnant women who planned to give birth, although women remained free to refuse the test. DESIGN: Successive surveys in April 1992 and May 1994 in south-eastern France. Logistic regressions were performed to identify factors which affected access to HIV testing for women who gave birth and those who terminated their pregnancy, and for each year of study. MAIN OUTCOME MEASURES: Attitudes and access to HIV testing among pregnant women, irrespective of pregnancy outcome. SETTING: All obstetrics and gynaecology departments and abortion clinics in the region. POPULATION: 3497 women in 1992 (2775 who were delivered and 722 who chose termination) and 3407 in 1994 (2701 who were delivered and 766 who chose termination). The response rates were 82% and 88%, respectively. RESULTS: In 1994 of women who were delivered, 73% had an HIV test, compared with 63% in 1992 (P < 0.001); however of women who terminated their pregnancy, only 28% had an HIV test, compared with 24.5% in 1992 (P not significant), although they were more at risk for HIV infection. Socioeconomic differences affecting access to testing were reduced between 1992 and 1994, but only among women who gave birth. CONCLUSION: Introduction of a policy which makes it mandatory to offer HIV screening to all women who intended to have their baby improved access to screening but did not improve the rate of preventative counselling. A mandatory requirement to offer HIV screening should be extended to women who request termination of pregnancy.

HIV screening for pregnant women in south eastern France: evolution 1992-1994-1996.

OBJECTIVES: To assess the evolution of the HIV screening practices towards pregnant women between 1992 and 1996, in relation with the 1993 French mandatory obligation to offer prenatal HIV testing and recent therapeutic possibilities to reduce HIV vertical transmission. STUDY DESIGN: Three successive surveys (January 1992, May 1994 and May 1996) about HIV screening policies among medical chiefs of all prenatal care and abortion departments of South Eastern France. Sixty-seven of the 74 departments concerned agreed to participate in the three surveys. RESULTS: The proportion of departments practising routine prenatal HIV screening had not increased since 1992 (89%) but systematic women's consent is more often requested (65.5 vs. 38.2%, P < 0.01). In the context of abortion, HIV testing is more often routinely offered (38.1 vs. 16.4%, P < 0.05) but selective screening remains a frequent practice (29.1%). CONCLUSION: Mandatory proposal of HIV testing to women who terminate could improve access to test but is not sufficient to guarantee adequate preventive counselling.

French general practitioners' attitudes toward maintenance drug abuse treatment with buprenorphine.

AIMS: To assess attitudes of general practitioners (GPs) toward buprenorphine maintenance drug abuse treatment just after its introduction in French ambulatory care (February, 1996). DESIGN: Cross-sectional survey by telephone interviews in a national random sample of French GPs (n = 1,186; response rate = 70.3%) carried out in April 1996. MEASUREMENTS: GPs' experience with care for IDU patients and HIV infection during the last 12 months. Logistic regression model to identify GPs' characteristics associated with readiness to prescribe buprenorphine for maintenance treatment. FINDINGS: A minority (24.0%) of GPs took care of IDU patients and 30.8% of these were prepared to prescribe buprenorphine (vs. only 7.5% in the rest of the sample). A positive attitude toward buprenorphine was related to GPs' experience with care for IDUs and with prescription of opiates for pain management and palliative care, tolerance toward drug use and personal characteristics such as tobacco use and interest in psychoanalysis. CONCLUSIONS: Giving general freedom of prescription of buprenorphine (rather than methadone) to all GPs did not lead to widespread acceptance of the drug's use in treating IDUs. The development of organized networks between specialist services for drug abuse treatment and motivated GPs may be necessary to maximize appropriate prescribing practices.

[Knowledge and behavior of pregnant women towards HIV infection and its screening]. / Connaissances et comportements des femmes enceintes face à l'infection par le virus de l'immunodéficience humaine et à son dépistage. Enquête Prevagest PACA.

OBJECTIVES: To assess knowledge and attitudes of pregnant women towards HIV infection and testing, and to compare them according to the outcome of the pregnancy (elective abortion vs delivery). METHODS: Between March 30 and April 26, 1992, all women ending their pregnancy in a medical center located in South Eastern France, were asked to complete an anonymous questionnaire: 3,589 (89.6%) responded: 2,825 women who delivered and 764 who chose abortion. RESULTS: 61.7% of the women who delivered and 24.1% of the women who chose abortion declared having been tested for HIV during pregnancy (p < 0.001). Among women who reported not having been tested, very few did so because they refused the test (2% among women who deliver and 1.5% among women who terminated pregnancy). A total of 2.6% of women tested during prenatal care and 19.6% in the context of abortion did not know the result of their test (p < 0.001). Knowledge about HIV transmission among women who delivered dit not differ significantly from that of women who terminated pregnancy. However risky behaviors were more frequent among the latter group (38.8% vs 17.7%, p < 0.001). CONCLUSION: This research confirms that systematic HIV screening during prenatal care was already diffused in France but remained mainly motive by foetal concerns and was not always associated with adequate preventive counselling, specially for migrant women and women with a low level of education. HIV screening and counselling is not guaranteed for women coming for elective abortion although they are more at risk for HIV infection. In spite of psychological difficulties, systematic proposal of HIV screening should be extended to the context of elective abortion.

[Mass screening programs for breast cancer in France. Comparative evaluation]. / Les programmes de dépistage de masse du cancer du sein en France. Evaluation comparative.

OBJECTIVE: The purpose of this work was to comparatively assess the results of mass screening programs for breast cancer implemented in six French departments in 1986, within the scope of the National Fund for Health Prevention, Education and Information of the National Health Insurance Office of Salaried Workers. MATERIAL AND METHODS: The data collected by the screening centres were analyzed by ten assessment teams that were independent from the program promotion staff, all using the same evaluation form. A complementary population study performed in eight French districts then, allowed assessing the frequency of self-referred screening (mammography performed out of program). RESULTS: The rate of participation in screening programs, in relation to the invited population, ranged from 21 to 48%, according to the district (36% in average). This low participation was probably related to the extent of self-referred screening. In fact, 19 to 40% of women, according to the district, had previously had a screening mammographic coverage: rate was around 68% in women aged 50 to 69 years. Positive findings with mammography ranged from 4.5 to 15.8% (10.1% in average), while intervention rates ranged from 0.7 to 1.6% and detection rates from 3.8 to 6.2%. The ratio between benign tumors and cancers ranged from 0.7 to 2.1 according to the district. In order to enlighten the judgement on French results, we propose a comparison with the international standards in force. CONCLUSION: The various experiences with breast cancer screening in France show that this screening is technically feasible on the basis of existing medical structures. However, some criteria are still below the expected values, especially if compared with international standards. This result is probably accounted for by the high rate self-referred screening before age 40 in France. In these conditions, the question is whether extending breast cancer screening programs in France is an appropriate course of action.

Mass screening programs for breast cancer in France--average values of assessment criteria.

Breast cancer is the most common cancer in women worldwide. Many studies have been performed worldwide to assess the effectiveness of screening in terms of reduced mortality due to breast cancer. Since the end of 1989, 10 breast cancer mass screening programs using mammography have been carried out in France under the sponsorship of the National Fund for Health Prevention, Education, and Information (FNPEIS) from the National Health Insurance of Salaried Workers (CNAMTS). These 10 campaigns, which are on a district scale, are organized according to variable methods and are assessed using a common procedure. Four groups of criteria are measured in this procedure, which investigates the impact, quality, effectiveness, and costs of screening programs. The average and extreme values of each criterion as calculated from the campaigns are presented in this paper. In order to enlighten the judgment on the French results, a comparison with the international standards in force and with the results of foreign screening programs is proposed.

HBV and HIV screening, and hepatitis B immunization programme in the prison of Marseille, France.

This study estimated the prevalence of hepatitis B virus (HBV) and human immunodeficiency virus (HIV) serological markers among inmates and evaluated inmates' compliance with an HBV immunization programme. During the mandatory consultation at the sexually transmitted disease (STD) clinic of the Marseille Prison (HIV counselling, and syphilis/HIV screening), physicians offered serological testing (anti-HBs, anti-HBc, HbsAg, anti-HIV) and Engerix B vaccination to each entrant. The number participating in the survey is 391/411 (89%); 75% were aged 18 to 35 years and 79% were men; 42% reported having had multiple sexual partners during the last 12 months. Report of an intravenous drug user (IDU) sexual partner was more frequent among women than men (22% vs 8%). Injecting drug use over lifetime was reported by 23%; 27% declared having shared their injection equipment during the last 12 months. 124/267 (32%) had an HBV marker: anti-HBs + only (immunized): 2.3%; anti-HBs + and anti-HBc +: 21.7%; anti-HBc + only: 6.4%; HBsAg +: 1.3%. The HIV seroprevalence was 6% (21% among IDUs). This survey underlines the high HBV and HIV seroprevalence among prisoners and the high proportion of inmates at risk for these infections. There is an urgent need for immunization and education programmes in this population. It demonstrates an HBV immunization programme is feasible and accepted by inmates and staff members.