Rapid response system for critically ill patients with haematological malignancies: A pre- and post-intervention study.

BACKGROUND: This study aimed to determine whether implementing a rapid response system (RRS) is associated with improved short-term outcomes in critically ill patients with haematological malignancies. METHODS: Our monocentric pre- versus post-intervention study was conducted between January 2012 and April 2020. RRS was activated at early signs of haemodynamic or respiratory failure. The primary outcome was the reduction in Sequential Organ Failure Assessment (SOFA) score on Day 3 after intensive care unit (ICU) admission. Secondary outcomes included time to ICU admission and mortality. RESULTS: A total of 209 patients with a median age of 59 years were enrolled (108 in the pre-intervention period and 101 in the post-intervention period). 22% of them had received an allogeneic transplant. The post-intervention period was associated with a shorter time to ICU admission (195 vs. 390 min, p < .001), a more frequent favourable trend in SOFA score (57% vs. 42%, adjusted odds ratio, 2.02, 95% confidence interval, 1.09 to 3.76), no significant changes in ICU (22% vs. 26%, p = .48) and 1-year (62% vs. 58%, p = .62) mortality rates. CONCLUSION: Detection of early organ failure and activation of an RRS was associated with faster ICU admission and lower SOFA scores on Day 3 of admission in critically ill patients with haematological malignancies.

Association of diagnostic work-up with subsequent attendance in a breast cancer screening program for false-positive cases.

The objective of this study is to determine whether the likelihood of returning for routine breast cancer screening differed for false-positive cases depending on the diagnostic work-up. Using the original data from a French population-based breast cancer screening program, we compared the attendance rates at the subsequent round of screening for 16,946 and 1,127 participants who received negative (i.e., American College of Radiology, ACR, categories 1-2) and false-positive mammograms, respectively. False-positive mammograms were categorized ACR 0 (i.e., warranting additional imaging evaluation), 3 (i.e., warranting clinical and imaging follow-up), and 4-5 (i.e., warranting biopsy). We estimated the odds ratios of attendance at subsequent screening round using logistic regression, adjusting for age and history of previous mammography. The attendance rates at the subsequent screening round were 80.6% for women who received negative mammograms versus 69.6, 74.3, and 70.1% for women who received false-positive mammograms warranting additional imaging evaluation, clinical and imaging follow-up, or biopsy, respectively. In comparison to women who received negative mammograms, the corresponding adjusted odds ratios of returning for routine screening were 0.6 [95% confidence interval (CI) 0.4-0.8], 0.8 (95% CI 0.6-0.9), and 0.6 (95% CI 0.4-0.8). No significant differences were found in odds ratios of attendance across ACR categories among women who received false-positive mammograms. Similar figures were observed for attending at least one of the two subsequent screening rounds. In conclusion, in comparison to women with normal or benign findings on index mammograms, false-positive cases warranting additional imaging evaluation, clinical and imaging follow-up, or biopsy had uniformly decreased odds of attending subsequent routine screening rounds.

Compliance with recommendations and clinical outcomes for formal and informal infectious disease specialist consultations.

The purpose of this study was to compare compliance with recommendations and clinical outcomes between formal and informal infectious disease specialist consultations. Six hundred twenty-seven consecutive adult inpatients who received an infectious disease consultation in a university-affiliated hospital were included. After adjusting for quintile of propensity score, we compared compliance with the consultant's recommendations and clinical outcomes for 443 (70.7%) and 184 (29.3%) formal and informal consultations. Informal and formal consultations were associated with comparable levels of compliance with recommendations for antimicrobial treatment (86.5% vs 88.9%; adjusted odds ratio [aOR], 0.63; 95% confidence interval, 0.34-1.14; P = 0.13) and diagnostic or monitoring tests (72.6% vs 72.0%; aOR, 0.91 [0.53-1.57]; P = 0.73). The rates of early clinical improvement (58.2% vs 58.6%; aOR, 1.11 [0.70-1.74]; P = 0.66), subsequent consultation (34.2% vs 36.3%; aOR, 0.80 [0.53-1.21]; P = 0.29), in-hospital mortality (4.9% vs 8.4%; aOR, 0.55 [0.24-1.24]; P = 0.15), and the median length of stay (23 vs 20 days; aOR of discharge, 0.90 [0.74-1.10]; P = 0.30) did not differ depending on the type of consultation. This study provides observational evidence that informal consultations result in levels of compliance with recommendations comparable to formal consultations, without compromising patient safety. Further study is needed to refine the criteria for requesting or providing informal rather than formal consultations.

Appropriateness of blood culture testing parameters in routine practice. Results from a cross-sectional study.

We aimed to assess the appropriateness of routine blood culture testing parameters and antimicrobial therapy for patients with suspected bloodstream infection. We conducted a cross-sectional study of blood cultures registered in the microbiological laboratory at a university-affiliated hospital from 4 to 15 June 2007. Using a structured implicit chart review, two infectious disease specialists assessed the appropriateness of the testing parameters and antimicrobial therapy. Overall, 2,696 blood culture bottles were collected from 260 patients during their stay, including 955 bottles that were evaluated during the study period. The indication of fungal and bacterial blood cultures was rated as appropriate for 75% (95% confidence interval [CI], 65-83) and 91% (95% CI, 87-95) of patients. Only 45% (95% CI, 39-52) of patients had an adequate number of blood cultures (i.e., two to four). An optimal volume of blood (i.e., ≥10 mL) was inoculated in 13% (95% CI, 11-15) of adult bottles. Empirical antimicrobial therapy was appropriate for 60% (95% CI, 43-76) of patients with positive blood cultures. There is room for improvement regarding routine blood culture testing parameters and antimicrobial therapy. The effectiveness of multifaceted interventions in altering the appropriateness of blood culture parameters deserves further research.

Chromosomal gene transfer in Spiroplasma citri.

The study of resistance marker rearrangement in Spiroplasma citri mutants provides evidence of transfer of chromosomal information followed by recombination. This is the first report of such a transfer in vivo in the mollicutes--that is, in the smallest self-replicating organisms. The double-resistant phenotypes obtained are stable even without selection pressure. The mechanism of gene transfer is insensitive to deoxyribonuclease, requires contact, and possibly, areas of fusion of the cell membranes; it shares properties with the transfer by protoplast fusion in Gram-positive bacteria. The extensive degenerative evolution of mollicutes has retained, in S. citri, bacterial functions of chromosomal transfer and recombination.

Drug-related problems in medical wards with a computerized physician order entry system.

OBJECTIVE: Identification and estimation, by clinical pharmacists participating in routine medical rounds, of drug-related problems (DRPs), arising despite the use of a computerized physician order entry (CPOE) system. METHODS: An 18-month prospective study of DRPs through a CPOE was conducted by seven clinical pharmacists participating in ward activity. DRPs were identified by two independent pharmacists using a structured order review (French Society of Clinical Pharmacy instrument). RESULTS: A total of 29 016 medication orders relating to 8152 patients were analysed, and 2669 DRPs, involving 1564 patients (56% female; mean age 72.6 years), were identified representing 33 DRPs per 100 admissions. The most commonly identified DRPs were non-conformity to guidelines or contra-indication (29.5%), improper administration (19.6%), drug interaction (16.7%) and overdosage (12.8%). There were 429 different drugs associated with these DRPs. Cardiovascular drugs were the most frequently implicated (22.2%), followed by antibiotics/anti-infectives (13.3%) and analgesics/antiinflammatory drugs (11.3%). Different types of DRPs were closely associated with specific classes of drugs. CONCLUSIONS: Drug-related problems are common even after implementation of CPOE. In this context, routine participation of clinical pharmacists in clinical medical rounds may facilitate identification of DRPs. Pharmacists should be able to enhance patient safety through such involvement.

[Propensity score analysis in observational research: application to a study of prophylaxis against venous thromboembolism]. / L'analyse par score de propension Exemple d'application à une étude observationnelle sur la prophylaxie de la maladie thromboembolique veineuse.

INTRODUCTION: In observational studies, a significant difference in the outcomes between treated and untreated patients may be observed in absence of treatment effect and caused by differences in baseline characteristics. EXEGESIS: Propensity score analysis is a post hoc adjustment method which consists in deriving the conditional probability of receiving the treatment for a patient given his measured baseline characteristics (i.e., the propensity score). Matching each treated patient to an untreated one who has the nearest propensity score tends to balance baseline characteristics between the two groups and reduce the risk for overt bias. Then, the outcomes can be compared between matched treated and untreated patients. CONCLUSION: Propensity score analysis is relevant for clinical conditions and treatments for which randomized controlled trials are unlikely to be conducted. However, propensity analysis cannot adjust for unmeasured characteristics and sensitivity analysis should be performed to assess how sensitive the conclusions are to potential confounding factors.

[Evolution of strategies of revascularisation in acute coronary syndromes with ST elevation. Analysis of the data of RESURCOR]. / Evolution des stratégies de revascularisation des syndromes coronaires aigus avec sus-décalage du segment ST. analyse des données du RESURCOR.

The aim of this study was to describe the changes in strategy of revascularisation in acute coronary syndromes with ST elevation (ACS ST+) since setting up a health care network. The authors analysed the incidence of coronary angioplasty and of intravenous thrombolysis from a prospective permanent hospital register of patients with ACS ST+ in the three Northern Alps departments from october 1st 2002 to december 31st 2004. Respectively, 171 patients were enrolled in 2002 and 675 in 2003, and 588 in 2004. The use of percutaneous coronary intervention increased (57, 69, and 78% in 2002, 2003, 2004, p< 0.01) in relation to the increased use of immediate secondary percutaneous coronary intervention (27, 36, 43%, p< 0.01) although the use of primary percutaneous coronary intervention did not changed (30, 33, 35%, p= 0.17). These results were observed in hospitals with and without Percutaneous Coronary Intervention facilities. An increase in prehospital (49, 67, 68%, p= 0.02) and hospital thrombolysis (48, 68, 73%, p= 0.03) was only observed in patients managed in institutions without Percutaneous Coronary Intervention facilities. The average delay to arterial punction (120. 124, 100 minutes, p< 0.01) and to intravenous thrombolysis (40, 30, 25 minutes, p< 0.01) decreased during the same period. Patients with ACS ST+ more commonly benefit from coronary revascularisation at increasingly shorter intervals to treatment. This would seem to be related to the better coordination of practitioners after the implantation of a health care network.

[Comparison of mortality according to the revascularisation strategies and the symptom-to-management delay in ST-segment elevation myocardial infarction]. / Comparaison de la mortalité en fonction de la stratégie de revascularisation et du délai douleur-prise en charge des syndromes coronaires aigus avec sus-décalage du segment ST.

The aim of this study was to compare the mortality associated to primary angioplasty and thrombolysis in patients managed for an elevated ST-segment acute coronary syndrome in less than or more than 3 hours after the onset of symptoms. We analyzed the in-hospital mortality of 846 patients (including 276 [33%] treated by primary angioplasty, 511 [60%] by thrombolysis, and 59 [7%] without revascularisation) included from October 2002 to December 2003 in a registry of patients with an elevated ST-segment acute coronary syndrome managed in less than 12 hours in Northern Alps districts. The overall in-hospital mortality was at 6.0% (51/846). For the 631 managed in <3 hours, the mortality rates were respectively at 5.0%, 4.6% and 11.1% respectively in case of primary angioplasty, thrombolysis and without revascularisation (p=0.21). For the 215 patients with pain lasting more than 3 hours, the mortality rates were at 2.7%, 10.3% and 21.7% in case of primary angioplasty, thrombolysis and no revascularisation, respectively (p=0.01). In the multivariable analysis, the OR of death in case of thrombolysis compared to primary angioplasty was at 1.65 (95% IC: 0.73 - 3.75) for patients with pain " 3 hours, and 4.98 (95% IC: 1.32-18.37) for those with pain > 3 hours. These results are in line with randomized trials conclusions and confirm the international guidelines suggesting primary angioplasty for patients with a chest pain >3 hours and either angioplasty or thrombolysis in case of chest pain < 3 hours.

Guideline development from an observational study.

PURPOSE: It is unknown whether data from observational studies can assist guideline developers in areas where scientific evidence is lacking. The purpose of this study is to develop a local clinical guideline for prophylaxis against venous thromboembolism based on observational study results. DESIGN/METHODOLOGY/APPROACH: The authors performed a classification tree analysis on original data from a cross-sectional study of risk factors, prophylaxis, and prevalence of deep vein thrombosis in 818 medical in-patients hospitalised in French teaching and community hospitals. The dependent variable was the use of pharmacological prophylaxis. The rate of any deep vein thrombosis detected by routine compression ultrasonography was used as an illustrative variable. Using group consensus of expert panelists, a practice guideline was developed based on the results of this study and a systematic review of the literature. FINDINGS: The resulting classification tree involved eight terminal subsets. The mean misclassification rate was 31 per cent in tenfold cross-validation and the area under the ROC curve was 0.75. The classification tree was converted into graded recommendations. According to these recommendations, 455 patients (56 per cent) required prophylaxis. The corresponding rate of deep vein thrombosis was 11 per cent (28/245, [CI = 8-16]) in 245 prophylaxis users and 11 per cent (23/210, [7-16]) in 210 prophylaxis non-users. Conversely, 363 patients (44 per cent) did not require prophylaxis: 63 actually received prophylaxis and six had deep vein thrombosis (2 per cent, [0.6-4]). RESEARCH LIMITATIONS/IMPLICATIONS: Further prospective validation of the guideline is important prior to its implementation. ORIGINALITY/VALUE: Integrating data from observational studies may be an effective way to develop guidelines when robust scientific evidence is lacking.

[Performance of the Breastfeeding Assessment Score for the prediction of early weaning in France]. / Intérêt du Breastfeeding Assessment Score pour la prédiction du sevrage précoce de l'allaitement maternel en France.

BACKGROUND: The Breastfeeding Assessment Score (BAS) was derived to help identify mothers at increased risk of early weaning in United States. Data are currently lacking on the accuracy of the BAS for French mother-infant pairs. OBJECTIVE: To assess the accuracy of the BAS in a French validation cohort. METHODS: We used the original data from a prospective cohort study of 488 mothers who were breastfeeding at discharge in 9 maternity wards in 2005. The outcome measures were assessed using structured follow-up telephone interviews at 4 and 26 weeks. RESULTS: The weaning rate was 3% at 14 days of infant age. The corresponding area under ROC curve was 0.73 [0.60-0.85] and was comparable to that observed in the derivation cohort (0.75). For a cut point of 8 recommended by the authors of the BAS, 43% of mother-infant pairs were categorized at high risk and the weaning rate in this subgroup was 5%. The mother-infant pairs with a score lower than 8 had a shorter median breastfeeding duration (18 versus 20 weeks, P=0.02), were more likely to report breastfeeding difficulties after discharge (63% versus 53%, P=0.03), and were less likely to be "very satisfied" with breastfeeding experience (66% versus 77%, P=0.007). CONCLUSION: The intrinsic properties of the BAS are robust. However, its use would be of limited interest in France because of the relatively low rate of early weaning. Randomized trials are needed before recommending routine use of BAS-based breastfeeding support intervention.

[Analysis of the accuracy of a coronary syndrome register]. / Analyse de l'exhaustivité d'un registre des syndromes coronaires.

Registers of the management of infarction can complement information obtained from randomised trials evaluating the methods and practice of treatment. In order to do this, the quality of the registers must be assured, and in particular the accuracy of the recorded cases. The objective of this study was to evaluate the accuracy of a register for the in-hospital and pre-hospital management of acute coronary syndromes with ST segment elevation of less than 12 hours' duration. Using a capture-recapture method, the study compared cases in the register with eligible cases present in the hospital and emergency ambulance service databases at two establishments, giving a recruitment rate of 61%. The rate of accuracy was estimated at 84% (95% CI [82 ; 86]). The independent factors associated with failure of notification were female sex (ORa=6.65 [2.04-21.69]), presentation at nights, weekends or bank holidays (ORa=4.13 [1.33-12.85]), direct admission to hospital without passing by the emergency ambulance service (ORa=2.85 [1.03-7.69]), primary angioplasty (ORa=6.18 [1.60-23.79]) and the absence of reperfusion (ORa=40.38 [6.21-262.40]). With more than 80% accuracy, the results produced by the register are robust. The selection bias linked to the under-representation of certain subgroups, while real, has only a marginal impact on estimates derived from the register. Factors associated with failure of notification should be taken into account when operating such a register.

[Factors associated with early invasive strategy in patients with acute coronary syndrome. A multicenter study]. / Facteurs associés a la réalisation d'une coronarographie précoce en présence d'un syndrome coronarien aigu sans sus-décalage du segment ST. Résultats d'une etude multicentrique.

OBJECTIVES: To identify the factors associated with early cardiac catheterization in patients with a non ST-segment elevation acute coronary syndrome. METHODS: We analyzed data collected by retrospective chart review for 208 patients presenting at seven French hospitals with an acute coronary syndrome (chest pain at rest within 24 h prior to presentation with positive cardiac markers and/or electrocardiographic changes) between January and March 2005. RESULTS: Eighty-seven patients (42%) were first admitted to hospitals with cardiac catheterization facilities. One hundred ten patients (53%, 95% confidence interval [95% CI], 46-60) underwent early cardiac catheterization less than 48 h following presentation. In addition to presentation at hospitals with catheterization facilities, factors independently associated with early catheterization included positive cardiac markers in patients first admitted to hospitals without catheterization facilities (adjusted odds ratio [aOR] 34.5, 95% CI, 4.4-268.0) and diabetes mellitus (aOR, 0.4, 95%CI, 0.2-0.9). With the exception of positive cardiac markers, no risk factors comprising the TIMI risk score were associated with increased odds of early cardiac catheterization. During the index hospital stay, six patients (3%) died, seven patients (3%) had pulmonary edema, three patients (1%) had major or minor bleeding, and none had ST segment elevation myocardial infarction. CONCLUSION: Despite the dissemination of international guidelines, the use of early cardiac catheterization remains related to initial presentation at hospitals with catheterization facilities rather than risk assessment in patients with a non ST-segment elevation acute coronary syndrome.

Mating type switching in the tetrapolar basidiomycete Agrocybe aegerita.

The study of fruiting in the basidiomycete Agrocybe aegerita has shown that some haploid homokaryotic strains can spontaneously switch their mating specificities at the two unlinked A and B mating type factors. This event causes the dikaryotisation of primary homokaryons without plasmogamy and leads to the differentiation of sporulating fruit-bodies (pseudo-homokaryotic fruiting). For each mating type factor, the genetic analyses have revealed that: (1) parental and switched mating types segregate meiotically as Mendelian markers, (2) a total of six switched mating type factors (two parental and four nonparental) were obtained from a wild strain, (3) most of the nonparental factors have specificities differing from those of a large series of wild factors, (4) strains with the same expressed mating type can generate different specificities, (5) switching is always restricted to the same mating type in a homokaryon, (6) nonparental types can switch again, and (7) meiosis fixes the specificities to which switching can occur. This suggests, for the first time in filamentous fungi, the existence of a mechanism analogous to the mating type switching in yeasts. We hypothese that both A and B mating type regions in A. aegerita are constituted of three loci, one specialized in expression and two other carrying silent information. Mating type switching in homokaryotic strains would occur by copy transposition of silent A and B information into the expression loci. Moreover, we propose that during meiosis the silent loci are substituted by copies of the expressed loci.

Protoplasmic Incompatibility in PODOSPORA ANSERINA: A Possible Role for Its Associated Proteolytic Activity.

A mutation (modD) was selected in a gene involved in the control of protoplasmic incompatibility. Previous results (Labarere and Bernet 1979) showed that modD decreased the density of protoperithecia and caused a defect in ascospore germination. In addition, modD has a third defect: when modD stationary cells were isolated in order to obtain further development, renewal of growth rarely ensued. Instead, the modD cells lysed or produced microthalli from which normal growth never occurred. These defects were suppressed by beta-phenyl pyruvic acid, a protease inhibitor, and by the presence of a mutation (modC) that suppresses the proteases associated with protoplasmic incompatibility. The stationary wild-type cells' regeneration was inhibited by beta-phenyl pyruvic acid at levels that maintained modD cells' regeneration. These results suggest a biological role for the proteases associated with protoplasmic incompatibility.

Protoplasmic Incompatibility and Cell Lysis in PODOSPORA ANSERINA. I. Genetic Investigations on Mutations of a Novel Modifier Gene That Suppresses Cell Destruction.

In Podospora anserina, protoplasmic incompatibility (a phenomenon that prevents heterokaryon formation because of the destruction of the fused cells) can be studied in homokaryotic strains that combine nonallelic incompatibility genes or carry mutations at the lys loci. In these strains cell destruction occurs early in development and is associated with an arrest of growth.-From the self-lysing strains lysA(1) and RV (R and V are nonallelic incompatibility genes) mutations have been selected that suppress the self-lysing trait, i.e., that prevent cell destruction and remove growth inhibition. Some of them were derived from a novel modifier locus, modC, located near the mating-type locus.-In C/D and C/E incompatibility systems, modC mutations, which per se have no obvious effect, were considered in addition to mutations in the previously identified modifier loci, modA and modB. The demonstration of a functional interdependence among the three mod genes suggested that modC is not the structural gene for the protease associated with cell lysis, but is involved, like modA and modB, in its control.-All three modC mutant strains investigated exhibit defects in the formation of protoperithecia, suggesting that the modC gene function is essential to the occurrence or development of the female organs. This is the third argument that supports the hypothesis ( Boucherie, Bégueret and Bernet 1976) that protoplasmic incompatibility and female organ formation might be related phenomena.

A New Method for the Screening of Mutations Related to Protoplasmic Incompatibility, Differentiation and Plasma Membrane in the Fungus PODOSPORA ANSERINA.

In Podospora anserina previous investigations showed that mutations in genes involved in the control of protoplasmic incompatibility cause defects at various stages of differentiation during the life cycle and also modify properties of the plasma membrane. To establish these relationships in another way, a new method for screening mutations has been developed as a first step. Eighty-five new mutants were selected for resistance to toxic products (sorbose or thiourea); in a second step these mutants were tested for modifications of protoplasmic incompatibility and cellular differentiation. Seven of the sorbose or thiourea resistant-mutants (i.e., 8%) exhibited new patterns of protoplasmic incompatibility. Genetic analyses were carried out with three mutants. Mutation X25 suppresses protoplasmic incompatibility resulting from all allelic interactions and restores the fertility of the crosses female symbol Vx male symbol V1 and female symbol Z1 x male symbol Z2. Mutation V41 is an allele of the v locus with new properties. Mutation X61 totally suppresses the V/V'1 interaction and weakens all of the other allelic incompatibility systems; X61 strains are defective in protoperithecia differentiation. Electrophoresis of plasma membrane proteins showed that X61 strains lack two polypeptides whose apparent molecular weights are 41,000 and 44,000. This new screening method is especially efficient for obtaining new mutants and identifying additional genes involved in incompatibility. These results provide further support demonstrating the relationships between protoplasmic incompatibility, cellular differentiation and plasma membrane.

[Optimizing history taking for evaluating the risk of venous thromboembolism: the OPTIMEV study]. / Optimisation de l'interrogatoire dans l'évaluation du risque de maladie thromboembolique veineuse: l'étude OPTIMEV.

UNLABELLED: Venous thromboembolism (VTE) is a frequent disease and remains a major cause of mortality and morbidity among our patients. During the 20 past years, clinical description, diagnostic tools, and treatment have changed dramatically. Most published data describing risk factors for VTE no longer apply to the patients seen in daily practice. We present here the rationale, aims, and methodology of the OPTIMEV Study (OPTimisation de l'Interrogatoire pour la Maladie thromboEmbolique Veineuse). RATIONALE: Risk factors for VTE are numerous, complex and interactions between them and their clinical importance is difficult to measure (table I). For example, odds ratios for VTE recurrence vary greatly across longitudinal studies. We searched the National Library of Medecine (PubMed) and the Amedeo website using the following keywords: "venous thromboembolism", "pulmonary embolism", "deep vein thrombosis", "risk factors". We selected 84 relevant articles published between 1972 and 2005. Based on this literature analysis, we identified the following major risk factors: VTE recurrence, surgery, cancer, immobilization, age, biological factors. For these factors, data are lacking and some questions are proposed. OBJECTIVES: The broad objective of the study is to better evaluate clinical risk factors that fit today's practice against VTE. Specific aims are: 1) to determine whether risk factors are different between proximal and distal deep vein thrombosis (DVT); 2) to develop and prospectively validate a new prediction rule for outpatients. The primary hypothesis is that careful assessment of VTE recurrence, adequate surgical thromboprophylaxis, cancer staging, and varicose vein stratification according to the CEAP classification, is mandatory for accurate evaluation of thromboembolic disease risk. METHODS: We conducted a multicenter, prospective, cohort study of 10000 patients. Enrollees are inpatients and outpatients presenting with a clinical suspicion of VTE in Emergency Departments and outpatient clinics in France. 4173 patients have been enrolled at this time (Figure 2). All eligible patients are enrolled during a selected period of time through different seasons. Data are collected by physicians in charge of the patients using an electronic case recording form. Collected data include baseline characteristics, risk factors, results of diagnostic investigations. Outcome measures obtained through telephone interview at 3 and 12 months include cancer diagnosis, VTE recurrence, haemorrhagic events, treatments, death. Univariate and multivariate analysis will be performed using multilevel logistic regression. The study organization is performed by the Centre d'Investigation Clinique de Grenoble and is sponsored by the French Society of Vascular Medicine. First results, to be published in 2006, will allow development of new prediction rules for VTE diagnosis.

[Variations in the management of patients with acute myocardial infarction in alpine hospitals compared to other French hospitals. Secondary analysis of the USIC 2000 study data]. / Comparaison de la prise en charge de l'infarctus aigu du myocarde dans les établissements de l'arc alpin et les autres établissements français. Résultats de l'étude USIC 2000.

OBJECTIVE: To compare processes of care for acute myocardial infarction among patients admitted to alpine vs other French hospitals. METHODS: Prospective observational study of patients with ST-elevation and non ST-elevation myocardial infarction of less than 48 hours hospitalized in 369 intensive care units in November 2000. RESULTS: Fifty-five patients were enrolled in nine alpine hospitals and 2265 patients in 360 other French hospitals. Patients baseline characteristics did not differ between the two groups with the exception of ST-elevation myocardial infarction which was less frequent in patients admitted to alpine hospitals (71 vs. 83%, P = 0.02). Patients living in the alpine area were less likely to be admitted to hospitals with on-site cardiac catheterization facilities (42 vs. 60%, P < 0.01) although the use of primary (20%) and rescue (24%) percutaneous coronary intervention did not differ significantly between the two groups. There were no differences in the use of medical treatments between the two groups with the exception of low-molecular-weight heparin. The risk of in-hospital death and complications did not differ significantly between the two groups while the risk of death at one year was lower in patients admitted to alpine hospitals (5 vs. 16%, P = 0.04). CONCLUSION: In 2000, a lower proportion of patients living in the alpine area had access to hospitals with cardiac catheterization facilities compared to other French patients. This finding supports the creation of an additional cardiac catheterization laboratory with experienced operators performing percutaneous coronary interventions 24 hours/7 days and the implementation of an emergency medical care network for acute coronary syndromes in the alpine area.

Overdiagnosis associated with breast cancer screening: A simulation study to compare lead-time adjustment methods.

OBJECTIVE: Estimating overdiagnosis associated with breast cancer screening may use annual incidence rates of cancer. We simulated populations invited to screening programmes to assess two lead-time adjustment methods. METHODS: Overdiagnosis estimates were computed using the compensatory drop method, which considered the decrease in incidence of cancers among older age groups no longer offered screening, and the method based on the decrease in incidence of late-stage cancers. RESULTS: The true value of overdiagnosis was 0% in all the data sets simulated. The compensatory drop method yielded an overdiagnosis estimate of -0.1% (95% credibility interval -0.5% to 0.5%) when participation rates among the population and risk of cancers were constant. However, if participation rates increased with calendar year as well as risk of cancer with birth cohorts, the overdiagnosis estimated was 11.0% (10.5-11.6%). Using the method based on the incidence of early- and late-stage cancers, overdiagnosis estimates were 8.9% (8.5-9.3%) and 17.6% (17.4-17.9%) when participation rates and risks of cancer were constant or increased with time, respectively. CONCLUSION: Adjustment for lead time based on the compensatory drop method is accurate only when participation rates and risks of cancer remain constant, whereas the adjustment method based on the incidence of early- and late-stage cancers results in overestimating overdiagnosis regardless of stability of participation rates and breast cancer risk.