A Simple Molecular Tool for the Assessment of Kidney Transplant Biopsies.

BACKGROUND: The Banff Classification for Allograft Pathology recommendations for the diagnosis of kidney transplant rejection includes molecular assessment of the transplant biopsy. However, implementation of molecular tools in clinical practice is still limited, partly due to the required expertise and financial investment. The reverse transcriptase multiplex ligation-dependent probe amplification (RT-MLPA) assay is a simple, rapid, and inexpensive assay that permits simultaneous evaluation of a restricted gene panel using paraffin-embedded tissue blocks. The aim of this study was to develop and validate a RT-MLPA assay for diagnosis and classification of rejection. METHODS: A retrospective cohort of 220 kidney transplant biopsies from two centers, which included 52 antibody-mediated rejection, 51 T-cell-mediated rejection, and 117 no-rejection controls, was assessed. A 17-gene panel was identified on the basis of relevant pathophysiological pathways. A support vector machine classifier was developed. A subset of 109 biopsies was also assessed using the Nanostring Banff Human Organ Transplant panel to compare the two assays. RESULTS: The support vector machine classifier train and test accuracy scores were 0.84 and 0.83, respectively. In the test cohort, the F1 score for antibody-mediated rejection, T-cell-mediated rejection, and control were 0.88, 0.86, and 0.69, respectively. Using receiver-operating characteristic curves, the area under the curve for class predictions was 0.96, 0.89, and 0.91, respectively, with a weighted average at 0.94. Classifiers' performances were highest for antibody-mediated rejection diagnosis with 94% correct predictions, compared with 88% correct predictions for control biopsies and 60% for T-cell-mediated rejection biopsies. Gene expression levels assessed by RT-MLPA and Nanostring were correlated: r = 0.68, P < 0.001. Equivalent gene expression profiles were obtained with both assays in 81% of the samples. CONCLUSIONS: The 17-gene panel RT-MLPA assay, developed here for formalin-fixed paraffin-embedded kidney transplant biopsies, classified kidney transplant rejection with an overall accurate prediction ratio of 0.83. PODCAST: This article contains a podcast at https://dts.podtrac.com/redirect.mp3/www.asn-online.org/media/podcast/CJASN/2023_04_10_CJN10100822.mp3.

Quality of care in cystic fibrosis: assessment protocol of the French QIP PHARE-M.

BACKGROUND: The PHARE-M care quality improvement program, modeled on the US Cystic Fibrosis Quality Improvement Program, was introduced at 14 cystic fibrosis centers (CFCs) in the French Cystic Fibrosis Network between 2011 and 2013. The pilot phase assessments attested the progressive adherence of the teams and improvements in care management. The PHARE-M Performance research project aims at assessing in 2015 the impact of the PHARE-M program on patient health indicators at trained versus untrained centers. It also sought to identify contextual factors that could account for variability in the performance of the PHARE-M among the trained centers. METHODS: A mixed methodology combining: a quantitative experimental study: a comparison, using a mixed model for repeated data (from 2011 to 2015), of the average changes over time in forced expiratory volume in 1 s (FEV1) and body mass index (BMI) between two groups of patients included in a closed cohort (non-transplant patients, continuous follow-up at one participating CFC, and a CF-causing mutation), one having benefitted from the PHARE-M program and the other not having done so, and a realistic study: a characterization of the impact on care management and an identification of mechanisms through which the PHARE-M intervention improved the team's effectiveness in different CFC contexts; this required modeling the intervention, context, and impact on care management with respect to the criteria of the chronic care model (CCM); this was done using a self-administered questionnaire given to professionals and patients/parents supplemented with focus groups. CONCLUSION: Although the study population was controlled, it may be difficult to establish a causal relationship between the differences in the changes over time in patient health indicators in the two groups of patients and the PHARE-M intervention as it is often the case in complex interventions rolled out in adaptive environments. The analysis of factors associated with variations in the impact of the PHARE-M at the different trained CFCs required the adoption of instruments validated in other contexts; these could be useful for assessing the performance of other interventions in healthcare practices at CFCs in France.

Cost-effectiveness and clinical outcomes of double versus single cord blood transplantation in adults with acute leukemia in France.

Double cord blood transplantation extends the use of cord blood to adults for whom a single unit is not available, but the procedure is limited by its cost. To evaluate outcomes and cost-effectiveness of double compared to single cord blood transplantation, we analyzed 134 transplants in adults with acute leukemia in first remission. Transplants were performed in France with reduced intensity or myeloablative conditioning regimens. Costs were estimated from donor search to 1 year after transplantation. A Markov decision analysis model was used to calculate quality-adjusted life-years and cost-effectiveness ratio within 4 years. The overall survival at 2 years after single and double cord blood transplants was 42% versus 62%, respectively (P=0.03), while the leukemia-free-survival was 33% versus 53%, respectively (P=0.03). The relapse rate was 21% after double transplants and 42% after a single transplant (P=0.006). No difference was observed for non-relapse mortality or chronic graft-versus-host-disease. The estimated costs up to 1 year after reduced intensity conditioning for single and double cord blood transplantation were € 165,253 and €191,827, respectively. The corresponding costs after myeloablative conditioning were € 192,566 and € 213,050, respectively. Compared to single transplants, double cord blood transplantation was associated with supplementary costs of € 21,302 and € 32,420 up to 4 years, but with increases in quality-adjusted life-years of 0.616 and 0.484, respectively, and incremental cost-effectiveness ratios of € 34,581 and €66,983 in the myeloablative and reduced intensity conditioning settings, respectively. Our results showed that for adults with acute leukemia in first complete remission in France, double cord transplantation is more cost-effective than single cord blood transplantation, with better outcomes, including quality-adjusted life-years.

[Public free anonymous HIV testing centers: cost analysis and financing options]. / Centre de dépistage anonyme et gratuit : étude de coût et des modes de financement.

The services of general interest provided by hospitals, such as free HIV clinics, have been funded since 2005 by a lump sum covering all costs. The allocation of the budget was initially determined based on historical and declarative data. However, the French Ministry of Health (MoH) recently outlined new rules for determining the allocation of financial resources and contracting hospitals for each type of services of general interest provided. The aim of this study was to estimate the annual cost of a public free anonymous HIV-testing center and to assess the budgetary implications of new financing systems. Three financing options were compared: the historic block grant; a mixed system recommended by the MoH associating a lump sum covering the recurring costs of an average center and a variable part based on the type and volume of services provided; and a fee-for-services system. For the purposes of this retrospective study, the costs and activity data of the HIV testing clinic of a public hospital located in the North of Paris were obtained for 2007. The costs were analyzed from the perspective of the hospital. The total cost was estimated at 555,698 euros. Personnel costs accounted for 31% of the total costs, while laboratory expenses accounted for 36% of the total costs. While the estimated deficit was 292,553 euros under the historic system, the financial balance of the clinic was found to be positive under a fee-for-services system. The budget allocated to the HIV clinic under the system recommended by the MoH covers most of the current expenses of the HIV clinic while meeting the requirements of free confidential care.

Health problems among detainees in Switzerland: a study using the ICPC-2 classification.

BACKGROUND: Little is known about the health status of prisoners in Switzerland. The aim of this study was to provide a detailed description of the health problems presented by detainees in Switzerland's largest remand prison. METHODS: In this retrospective cross-sectional study we reviewed the health records of all detainees leaving Switzerland's largest remand prison in 2007. The health problems were coded using the International Classification for Primary Care (ICPC-2). Analyses were descriptive, stratified by gender. RESULTS: A total of 2195 health records were reviewed. Mean age was 29.5 years (SD 9.5); 95% were male; 87.8% were migrants. Mean length of stay was 80 days (SD 160). Illicit drug use (40.2%) and mental health problems (32.6%) were frequent, but most of these detainees (57.6%) had more generic primary care problems, such as skin (27.0%), infectious diseases (23.5%), musculoskeletal (19.2%), injury related (18.3%), digestive (15.0%) or respiratory problems (14.0%). Furthermore, 7.9% reported exposure to violence during arrest by the police. CONCLUSION: Morbidity is high in this young, predominantly male population of detainees, in particular in relation to substance abuse. Other health problems more commonly seen in general practice are also frequent. These findings support the further development of coordinated primary care and mental health services within detention centers.

Participation of French hospital physicians to continuing medical education events: a survey with 300 physicians to assess duration, methods, financing, and needs.

INTRODUCTION: Little data on the educational needs and practices of French hospital physicians have been obtained through surveys. Given that continuing medical education (CME) information is now available on http://www.cnfmc.fr and providers are accredited, we investigated CME practices and knowledge of the CME system with the use of a representative sample of hospital physicians. METHODS: A questionnaire was prepared during 2 work sessions organized by TNS Healthcare Sofres in July 2007. A sample of 300 physicians was selected to represent hospital physicians throughout 5 main regions and hospital types. Telephone numbers were dialed automatically in order to meet quota objectives. Questionnaires were administered by telephone between August 30 and September 7, 2007 by trained operators. RESULTS: Among the 300 interviewed physicians, 218 (73%) were from general or specialized hospitals and 82 (27%) were from university hospitals. They were located equally all over France. Their specialties were: medicine, 130 (43%); laboratory, 51 (17%); pharmacy, 45 (15%); surgery, 15 (5%); psychiatry, 9 (3%); and others, 49 (17%), including emergency and radiology. One hundred twenty-five of the physicians (42%) stated that they took part in continuing education programs for more than 10 days per year, 122 (41%) between 6 and 10 days per year, and 51 (17%) less than 5 days; 2 (<1%) did not answer. Two hundred fourteen of the physicians subscribed to either specialized or general medical journals; 86 (29%) did not subscribe to any journal. For live in-class events, approximately 65% of the educational, travel, and lodging expenses were paid for by physicians and hospitals. The pharmaceutical industry paid for 25% of these expenses. In response to the question "Did you participate in a performance improvement program in your hospital?", 75 (25%) said that they had (16% for the 82 physicians in university hospitals, and 29% for the 211 physicians in general hospitals), 210 (70%) said that they had not, including the 134 (45% of the 300) who said that it was scheduled, and 15 (5%) did not answer. Seminars were preferred for continuing education programs, and interactive workshops and e-learning methods were requested for the future. Among the 300 physicians, 246 (82%) expressed difficulties following up on CME events, and 54 (18%) had no difficulty with their education. DISCUSSION: This telephone survey of 300 hospital physicians showed that although they took part in many educational programs, they had organizational, personal, and financial issues. E-learning could make it easier for physicians to continue their education.

[French hospital doctors attend many educational programmes but have organisational and financial difficulties for their continuing medical education]. / La formation continue des praticiens hospitaliers: importante mais avec des difficultés organisationnelles et financières.

INTRODUCTION: Few data on the educational needs and practices of the French hospital doctors have been obtained through surveys. Considering that the CME information is now available on www.cnfmc.fr and that providers were accredited, we investigated, on a representative sample of hospital doctors, the CME practices and the knowledge of the CME system. METHODS: A questionnaire was prepared during 2 working sessions organised by TNS Healtcare Sofres in July 2007. A sample of 300 doctors was set to be representative of hospital doctors through the 5 main regions, and hospital types. Telephone numbers were dialled by an automat in respect of the objectives of quotas. Questionnaires were administered by telephone between August 30 and September 7, 2007, and done by trained operators. RESULTS: Among the 300 interviewed doctors, 218 (73%) were from general or specialised hospitals and 82 (27%) were from Universitary hospitals. They were equally installed all over France. Their specialties were: medicine 130 (43%); biology 51 (17%); pharmacy 45 (15%); surgery 15 (5%); psychiatry 9 (3%); others 49 (16%) including emergency and radiology. Among the 300 doctors, 125 (42%) declared having continuing education for more than 10 days per year, 122 (41%) between 6 and 10 days per year, and 51 (17%) less than 5 days, 2 (<1%) did not answer. 214 (71%) doctors were subscribing medical specialised or general journals, and 86 (29%) did not subscribe to any journal. For the sessions called " présentielles ", about 65% of the funding of the pedagogic expenses, the travel and housing were supported by the doctors and hospitals. The pharmaceutical industry supported 25% of these expenses. To the question " did you performed a clinical audit in your hospital? ", 75 (25%) answered yes (16% for the 82 doctors in Universitary hospitals, and 29% for the 211 doctors in general hospitals), 210 (70%) answered no, including the 134 (45% of the 300) who said that it was programmed. 15 (5%) did not answer. The educational methods that were preferred were congresses, and interactive workshops were demanded for the future, as well as the e-learning methods. Among the 300 doctors, 165 (55%) had organisational difficulties for their education, 143 (48%) had personal difficulties such as availability, and 135 (45%) had financial difficulties. 54 (18%) had no difficulty at all for their education. DISCUSSION: This survey through telephone interviews of 300 hospital doctors showed that they followed many educational programmes, and they had difficulties to organize their education, with personal and financial difficulties. The e-learning development could be a solution that gives facilities to doctors.

[Equity and planning: a critical analysis of a third generation regional healthcare management program]. / Equité et planification: analyse critique d'un schéma régional d'organisation sanitaire de troisième génération "perinatalité".

The third generation of the regional healthcare organization plan (Sros III) proposes to develop the organisation of healthcare and its management according to evolution of its activities and the populations concerned. At the time of a strategic analysis of SROS III (what we refer to as its perinatal period), the question is whether promoters can move from an approach based on accessibility (egalitarian equity) to a needs-based approach (differential equity), which although more complicated in to apply and implement, was found be much better adapted to healthcare users. The research is derived from an analysis of documents from November 2004 to November 2006. A university public hospital developed the data which supported a proposal to shift from level I to level II. This proposition was retained in the territory's medical plan authorized by the regional health authorities. Health professionals and the architects of the healthcare plan have the capacity to new organizations responsible for taking into account the activities and healthcare needs of the population in order to initiate and establish differential equity.

[Medical management of patients with stable coronary artery disease in France in 2004. Data from the Mutualité Sociale Agricole]. / La prise en charge des patients souffrant d'une maladie coronaire en France en 2004. Données de la Mutualité sociale agricole.

AIM: To describe the treatment of ambulatory patients with coronary artery disease, using information from the French farmers' insurance fund (Mutualité Sociale Agricole, MSA) database. POPULATION AND METHODS: Analysis of cardiovascular medications bought and reimbursed during the second quarter of 2004 for 16,694 patients affiliated with the MSA who were first diagnosed with coronary artery disease in 1998, 2001 or 2003. RESULTS: On average, 71% of patients received antiplatelet agents, 56% beta-blockers, 59% statins, and 36% ACE inhibitors. Only 32% received the combination of antiplatelet agents, statins, and beta-blockers, and only 14% all four classes. Practice guidelines were followed more closely in patients diagnosed most recently. Patients receiving all four classes of secondary prevention medication more often has a history of myocardial infarction or were younger. Average doses were consistent with recommendations for beta-blockers, but appeared too low for ACE inhibitors and statins (except for atorvastatin). PERSPECTIVES: Medical management of patients with chronic coronary artery disease in France, while still suboptimal, is improving. Our findings, which are concordant with previous registry data, emphasize the underuse of recognized secondary prevention medications in very elderly patients and the importance of the initial prescription at diagnosis.