[Patient education: state of the art of the programs in the region of Provence-Alpes-Côte d'Azur in 2008 before the publication of official documents relative to the authorizations of the Regional Health Agency (ARS)]. / Éducation thérapeutique du patient : état des lieux des programmes en région Provence-Alpes-Côte d'Azur en 2008 avant la parution des textes officiels sur les autorisations de l'Agence Régionale de Santé.

BACKGROUND: At the request of the Hospitalization Regional Agency (ARH)--in the context of the 2007-2011 plan aimed at improving the quality of life for patients affected by chronic diseases--the purpose of this work was to draw up a clear assessment of the 2008 Therapeutic Education programmes in the Provence-Alpes-Côte d'Azur (PACA) region. The study was carried out before the publication of the therapeutic education statutory orders and ARS (regional health agency) authorizations. METHODS: Cross-sectional study, carried out in the three sectors of medical management in the region--namely health-care institutions, ambulatory structures and health networks--made it possible to identify, first, which structures had actually launched therapeutic education programmes and then, how the procedures had been designed and set up. RESULTS: Among all the medical structures investigated, the study has listed 491 programmes, heterogeneously located throughout the PACA region. These programmes primarily target diabetes, respiratory and cardiovascular diseases. Their main objectives are the patients' quality of life, adherence to treatment and protective health behaviour (health improvement). The hospitalization sector programmes preferentially target the 30 to 60 years old, whereas the ambulatory and health networks programmes are more inclined to target the over 60 years old part of the population. More than 50% of the professionals involved in the programmes have never benefited from a specific training concerning the patients' therapeutic education. CONCLUSION: This study has pointed out a great number of important aspects which need drastic improvement in terms of therapeutic education organization - the involvement and training of health professionals, for instance.

Evaluating counseling outcome on adherence to prophylaxis and follow-up after sexual HIV-risk exposure: a randomized controlled trial.

OBJECTIVE: Post-exposure prophylaxis (PEP) is recommended for the management of sexual HIV-risk exposure. However, a high percentage of exposed patients discontinue both their 28-day prophylaxis course before 15 days and HIV testing follow-up before M3. The objective of this study is to assess the efficacy of a counseling intervention in enhancing both adherence to PEP and HIV testing follow-up. METHODS: Between 1 June 2004 and 31 December 2005, 54 patients exposed to sexual HIV-risk exposure were included in a multicenter, prospective, controlled, randomized trial, comparing a group receiving a counseling intervention in addition to traditional medical management (intervention group (IG), n=28) vs. a control group (CG, n=26). Patients in the IG received interactive counseling interventions focused on adherence to PEP and to HIV testing follow-up, led by specially trained nurses. The main outcome measures were proportion of patients achieving 100% adherence to PEP as evaluated on D15 by a self-completed patient questionnaire and on HIV testing on D45 and M3. RESULTS: Groups were well balanced at baseline for age, sex, and circumstances of exposure. The proportion of 100% adherent patients to PEP was significantly higher in the IG compared to the CG (54% vs. 23%, p=0.036). Patients in the IG were more likely to complete the HIV testing follow-up at D45 (86% vs. 54%, p=0.023) and M3 (68% vs. 38%, p=0.056). CONCLUSIONS: This study suggests the effectiveness of a counseling program to enhance adherence to both PEP and HIV testing follow-up after sexual exposure.

[An epidemic of unidentified illness experienced by a hospital's staff: a qualitative study]. / Epidémie de malaises survenus dans un hôpital: une enquête qualitative.

An outbreak of non-specific complaints of illness and poor health occurred among 40% of the staff at the Archet 2 Hospital in Nice, France, between October 26 and November 26, 2000. This study utilises a psychosocial approach to describe how health-care workers experienced this unusually extensive phenomenon, and aims to contribute useful findings to the management of this type of emergency situation. A qualitative survey was conducted through face to face personal interviews with the first twelve staff members concerned; moreover, articles published in the press during that period were analysed in order to asses the impact of the media on this event. The study demonstrates that, although the source of the problem originated from an issue possibly related to questionable air quality, there were actually an array of factors which contributed to generate a mass psychogenic phenomenon: substantial collective societal complaints and staff members' perceived non-acknowledgement of the reality of their symptoms, lack of an obvious cause to account for those symptoms and collective representation regarding toxic gases, which were all claims promulgated by articles in the press. In addition to the need for technical improvements on the building and premises, the study underlines the relevance of simultaneously addressing related issues with the social structure, represented by the community of concerned hospital personnel, in order to facilitate a solution to the problem and avoid its potential recurrence in the future.

Behavioral state organization in normal human term fetuses: the relationship between periods of undefined state and other characteristics of state control.

Repeated alteration in episodes of quiet sleep and active sleep is a basic feature of behavioral state organization in human fetuses. When compared to normal fetuses, at-risk fetuses generally exhibit extended periods of no coincidence (PsNC), that is, associations between state variables that cannot be classified as a sleep state. The purpose of this study was to determine if fetuses with extended PsNC differ in other state measures from fetuses with short PsNC. Fetal heart rate and fetal eye and gross body movements were collected simultaneously on 85 normal human fetuses between 37 and 41 weeks gestation for a total of 9,135 minutes (mean 108.8 +/- 12.7 minutes, range 85-130 minutes). We found that as percent PsNC increased, the frequency (r = 0.464, p < 0.0001) of state changes increased and the time spent in active sleep (r = -0.456, p < 0.0001) and the number of fetuses entering an awake state (chi 2 = 4.26, p < 0.039) decreased. In contrast, percent PsNC was independent of the length of time spent in quiet sleep (r = 0.070, p > 0.05). We interpret these findings as an indication that extended PsNC may be the result of disruption of homeostatic control mechanisms during active sleep.

Association between funisitis and elevated interleukin-6 in cord blood.

OBJECTIVE: [corrected] To determine whether elevated plasma interleukin-6 (IL-6) in umbilical venous cord blood at delivery is associated with funisitis and whether IL-6 can be used to screen for funisitis in preterm neonates. METHODS: At the time of delivery, umbilical venous cord blood samples were collected from 92 infants for whom placental pathology results were also available. Interleukin-6 concentrations in the umbilical venous cord blood plasma were measured by immunoassay. Histologic examinations of the placenta and umbilical cord were done to determine the presence or absence of funisitis and chorioamnionitis. For a power of 90% with an alpha of.05, 12 subjects were required in each group. RESULTS: We found a significant association between the presence of histologic funisitis and elevated umbilical venous cord blood plasma IL-6 concentrations (defined as 10 pg/mL or greater). Of 15 infants whose umbilical cords showed funisitis, 93% (14 of 15) had elevated umbilical venous cord blood plasma IL-6 concentrations. Of 77 infants without funisitis, 32% (25 of 77) had elevated IL-6 concentrations in their cords (P <.001, two-sided Fisher exact test). The negative predictive value of IL-6 as a screening test for funisitis was 98%. CONCLUSION: In preterm neonates, screening for funisitis by using the immunoassay for IL-6 appears to be valid. In the near future, elevated umbilical venous cord blood IL-6 concentrations at delivery could be clinically useful to identify children who might benefit from early treatment for systemic fetal inflammatory syndrome.

Behavioural state change in normal human fetuses following a single vibroacoustic stimulus: effect of duration of quiet sleep prior to stimulation.

We examined 96 normal human fetuses between 37 and 41 weeks of gestation to determine the relationship between the duration of the active state following a single vibroacoustic stimulus (VAS) and the time spent in prestimulus state 1F, i.e. quiet sleep (QS). All fetuses were observed to enter state 1F prior to testing. After remaining in this state for 3 min, each fetus was randomized into one of three groups: no stimulation (Group I, N = 32); a single 1-s VAS delivered after 3-5 min of QS (Group II, N = 33); and a single 1-s VAS delivered after 18-20 min of QS (Group III, N = 31). Fetuses in Groups I, II, and III were otherwise behaviourally indistinguishable. Heart rate and eye and body movements were monitored until the fetus either returned to state 1F and remained in that state for 3 min or did not return to state 1F within 60 min. Of the 64 fetuses who were stimulated, 62 responded, indicating that there was no effect of prestimulus state duration on the sensitivity to VAS. Fetuses stimulated after 18-20 min of QS behaved similarly to fetuses who entered an active period spontaneously.(ABSTRACT TRUNCATED AT 250 WORDS)

Spectral analysis of heart rate variability during quiet sleep in normal human fetuses between 36 and 40 weeks of gestation.

Respiratory sinus arrhythmia (RSA) is a clinical manifestation of the parasympathetic nervous system which can be identified in the high-frequency region of the heart rate variability (HRV) power spectrum. The purpose of this study was to determine the relative contribution of RSA to overall HRV for human fetuses in quiet sleep. The study population consisted of 13 normal human fetuses between 36 and 40 weeks of gestation for whom data were collected during spontaneous breathing and normally occurring apneic periods. Fetal breathing was monitored continuously using real-time sonography. The fetal electrocardiogram was captured transabdominally in 3-min blocks at a rate of 833 Hz and fetal R-waves were extracted from the raw signal using adaptive signal processing techniques. Fetal behavioral state was determined at the beginning and end of each 3-min data collection period. The fetal R-wave interbeat intervals (IBIs) were converted to equally-spaced, time-based data, and linear detrending of the time series was accomplished by subtracting the mean heart period from each weighted IBI. Total power (TP, 0.0-2.5 Hz) was divided into RSA (0.4-1.0 Hz), high-frequency (HF, 0.2-2.5 Hz), low-frequency (LF, 0.04-0.2 Hz), and very-low-frequency (VLF, 0.0-0.04 Hz) regions, and the power densities were summed to determine the absolute power for each frequency component. A total of 81 3-min blocks (mean per subject 6.3, range 2-14) were available for analysis. Eleven (85%) of 13 fetuses demonstrated a HF peak during fetal breathing, and RSA accounted for approximately 20% of the TP.(ABSTRACT TRUNCATED AT 250 WORDS)

Temporal stability in the distribution of behavioral states for individual human fetuses.

Although behavioral state analyses have been useful in differentiating between groups of normal and at-risk fetuses, the large between-subject differences in the percent time spent in the various behavioral states poses a major obstacle in identifying abnormal neurological functioning in individual fetuses. Does this variability represent a true difference in state organization between fetuses, or does it simply reflect individual fluctuations in state control at the time of observation? To answer this question, we examined each of 33 human fetuses for 4 h on three separate days between 38 and 40 weeks gestation. The percent time spent in each behavioral state and in transition and insertion periods was determined for each of the three 4-h study sessions, and within-subject analysis of variance was performed to obtain an objective measure of state profile consistency for each fetus. We found that, on the average, fetuses exhibited remarkable within-subject consistency in their state profiles. However, even among this group of low-risk fetuses, there were significant differences in the degree of state organization achieved by individual fetuses. These findings, which indicate the existence of a well-developed central nervous system before birth, suggest that individual differences in the consistency of behavioral state profiles may be indexing important between-subject differences in neurological development.

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.

Impact of short-term adherence on virological and immunological success of HAART: a case study among French HIV-infected IDUs.

To evaluate the impact of injection drug users (IDUs) adherence on effectiveness of highly active antiretroviral therapy (HAART), repeated measures of plasma viral load and CD4+ counts before HAART initiation and at last visit in the cohort were studied. Data were collected by means of patient's face-to-face and self-administered questionnaires about adherence to HAART during the week prior to the last visit. Of a total of 119 patients treated with HAART, undetectable viral load was obtained for 55 patients (46.2%) (G3); 34 patients (28.6%) (G2) had a viral load decline > 0.5 log copies/ml but still detectable viral load at last visit in the cohort, while 30 patients (25.2%) (G1) had no decline or decline

Maternal anxiety during pregnancy: effect on fetal behavior at 38 to 40 weeks of gestation.

The purpose of this study was to determine if there is a relationship between fetal behavior and maternal anxiety during pregnancy. The study population consisted of 18 uncomplicated human pregnancies at 38 to 40 weeks gestation. Maternal anxiety was assessed one time using Spielberger's State-Trait Anxiety Inventory. After an overnight fast, each mother was given a standard meal on arrival to the fetal testing unit. Each fetus was examined for 4 hours using heart rate monitoring and real-time sonography. Fetal behavioral states were assigned based on heart rate pattern and the presence or absence of eye and gross body movements. We found that, compared with fetuses of mothers with low trait anxiety scores, fetuses of mothers with relatively high trait anxiety scores spent significantly more time in quiet sleep and exhibited less gross body movement when in active sleep. The results of this pilot study raise the possibility that maternal anxiety during pregnancy may have a significant effect on fetal behavior.

[Epidemiological surveillance of HIV-seropositive subjects identified in Provence-Alpes-Cote d'Azur in 1996-1997]. / Surveillance épidémiologique des nouvelles séropositivités VIH dépistées dans la région Provence-Alpes-Côte d'Azur en 1996 et 1997. Le groupe EVALVIH.

OBJECTIVE: The aim of this study was to assess trends in new HIV-positivities identified in the Provence-Alpes-Cote d'Azur area in southern France in 1996 and 1997 and to identify any weaknesses in the screening policy. METHODS: Data were collected from the EVALVIH epidemiological surveillance system initiated in 1995. The data were obtained from both anonymous reports of medical biology laboratories and of prescribing physicians in the area. RESULTS: From January 1996 to December 1997, 825 persons (67% men, 33% women) were found to be HIV-positive. Although the percentage of intravenous drug users (18%) and homo-bisexual individuals (23%) remained high, the proportion of heterosexuals was higher (45%). The number of identified cases of HIV seropositivity fell from 271 in the first semester 1996 to 137 in the second semester 1997, i.e. a 49% decline (p < 0.001). There was no significant difference in this trend for age, gender, transmission mode, or geographical origin of the subjects. CONCLUSION: These results confirm the positive impact of the HIV prevention program in the Provence-Alpes-Cote d'Azur region and the insufficiencies of the screening policy requiring urgent reconsideration.

Trends and differentials in dietary patterns and nutrient intake among migrant Puerto Rican families.

Preoccupation to define the nutritional status of Puerto Rican families migrating to the United States, motivated the present research. A total of 526 families residing in the South Bronx, New York, and four communities in Puerto Rico, were therefore studied. Results in regard to nutrient intake suggest that the mothers' diets appear to be adequate in the South Bronx as well as in Puerto Rico, except in iron consumption, in the latter. Furthermore, the data show an apparent tendency to overconsumption of certain foods in both the South Bronx and Puerto Rico, particularly of the protein group, as well as a high consumption of sugar and carbonated beverages in Puerto Rico. Dietary data were corroborated through nutritional anthropometry, conforming a tendency for overweight and obesity among the women studied. Detailed information on the dietary changes occurred during the last five years, is provided. Educational programs such as EFNEP, availability of new foods, and the food preferences of children in their homes, seem to be influencing factors in the dynamics of food modifications within societal groups in transition.

Vagal tone during quiet sleep in normal human term fetuses.

The purpose of this paper was to calculate vagal tone (V) for 17 normal human fetuses in quiet sleep (QS) between 36 and 40 weeks gestation. The fetal cardiac electrical signal was captured transabdominally in 3-min blocks at a rate of 833 times per second and fetal R-waves were extracted using adaptive signal processing techniques. Fetal R-wave interbeat intervals were converted to equally spaced, time-based data, and the low-frequency component was removed using a 21-point third-order moving polynomial. The parameter V was calculated by taking the natural logarithm of the sum of the power densities between 0.3 Hz and 1.3 Hz. We found that fetal breathing was associated with an approximately 25% increase in V as compared to nonbreathing, 3.33 +/- 0.48 versus 2.57 +/- 0.47, p < 0.0001. Furthermore, there was a significant linear relationship between the mean single-fetus V during spontaneous respiration and the mean single-fetus V during normally occurring apneic periods, r = 0.772, p < 0.002. We conclude that respiratory activity is associated with a significant increase in vagal tone for normal human fetuses in QS.

Morphology of active sleep--quiet sleep transitions in normal human term fetuses.

Periods of no coincidence (PsNC) among state variables appear to be more predictive of neurobehavioral outcome than the amount of time spent in any particular behavioral state. It has recently been suggested that analysis of the ordering of state variables during a state transition may provide results equivalent to full state analysis. If this were the case, then there ought to be a relationship between the duration of PsNC and fetal heart rate (FHR)-fetal eye movement (FEM) sequencing at the time of a state change. To test this hypothesis, we compared full state analysis with analysis of individual state transitions for 52 normal human fetuses between 38 and 42 weeks of gestation. For the study population as a whole, FHR was the first variable to change in 62 (77%) of 81 1F-->2F transitions and FEM was the first variable to change in 50 (63%) of 79 2F-->1F transitions (chi 2 = 67.9, p < 0.001). Ordering of FHR and FEM at the time of a state change was reversed in 8 (67%) of 12 fetuses with PsNC > or = 15% and is only 6 (15%) of 40 fetuses with PsNC < 15% (chi 2 = 12.5, p < 0.001). We conclude that fetuses who exhibit poor state organization more often display a FHR-FEM sequence at the time of a state transition which is opposite that of fetuses with considerably better state control. However, since only one-third of fetuses with reversed FHR-FEM sequencing actually exhibited more than one such episode, it is unlikely that isolated analysis of state transitions will provide a reliable measure of behavioral state organization in the individual fetus.

Influence of early mobilisation of pulmonary function in surgical patients.

This work confirms the generally known decrease in arterial oxygen following surgery. On the basis of a more rapid restitution of pulmonary function the superiority of mobilization to the usual respiratory exercises is clearly shown.

Early heart rate response of normal human term fetuses to vibroacoustic stimulation.

We examined cardiac reactivity in the first 45 seconds following a single 1 second vibroacoustic stimulus (VAS) to determine if the prestimulus fetal heart rate (FHR) pattern was predictive of the immediate post-VAS heart rate response. Forty-nine normal human fetuses between 37 and 41 weeks of gestation were observed to enter quiet sleep and remain in that state for 3 to 5 minutes before testing. In general, VAS elicited an initial acceleratory response of approximately 20 beats/min above the mean prestimulus heart rate followed by a deceleratory response to an average of approximately 4 beats/min below baseline values. Fetuses with different average prestimulus heart rate patterns generally differed in their early cardiac response to VAS: when compared to a high baseline FHR, a low resting heart rate was associated with a greater increase in heart rate above baseline (r = -0.401; P = 0.03), a greater decrease below prestimulus values (r = -0.312; P = 0.03), and a greater difference between maximum and minimum heart rates (r = -0.465; P = 0.001). Higher baseline heart rates were associated with lower FHR variability in the prestimulus period (r = -0.422; P = 0.009). When we examined the time course of the early response, we found that fetuses that achieved a maximum heart rate quickly exhibited less of an increase above prestimulus values (r = 0.894; P = 0.005), displayed a greater decrease below baseline (r = 0.507; P = 0.0002), and reached the minimum heart rate faster (r = 0.575; P = 0.0001) than fetuses that required longer to achieve a maximum cardiac response.(ABSTRACT TRUNCATED AT 250 WORDS)