Methodology used in comparative studies assessing programmes of transition from paediatrics to adult care programmes: a systematic review.

OBJECTIVE: To explore the methodologies employed in studies assessing transition of care interventions, with the aim of defining goals for the improvement of future studies. DESIGN: Systematic review of comparative studies assessing transition to adult care interventions for young people with chronic conditions. DATA SOURCES: MEDLINE, EMBASE, ClinicalTrial.gov. ELIGIBILITY CRITERIA FOR SELECTING STUDIES: 2 reviewers screened comparative studies with experimental and quasi-experimental designs, published or registered before July 2015. Eligible studies evaluate transition interventions at least in part after transfer to adult care of young people with chronic conditions with at least one outcome assessed quantitatively. RESULTS: 39 studies were reviewed, 26/39 (67%) published their final results and 13/39 (33%) were in progress. In 9 studies (9/39, 23%) comparisons were made between preintervention and postintervention in a single group. Randomised control groups were used in 9/39 (23%) studies. 2 (2/39, 5%) reported blinding strategies. Use of validated questionnaires was reported in 28% (11/39) of studies. In terms of reporting in published studies 15/26 (58%) did not report age at transfer, and 6/26 (23%) did not report the time of collection of each outcome. CONCLUSIONS: Few evaluative studies exist and their level of methodological quality is variable. The complexity of interventions, multiplicity of outcomes, difficulty of blinding and the small groups of patients have consequences on concluding on the effectiveness of interventions. The evaluation of the transition interventions requires an appropriate and common methodology which will provide access to a better level of evidence. We identified areas for improvement in terms of randomisation, recruitment and external validity, blinding, measurement validity, standardised assessment and reporting. Improvements will increase our capacity to determine effective interventions for transition care.

[Assessment of the management of cases of fever and malaria by general practitioners in the central Highlands of Madagascar, 2009-2010]. / Évaluation de la prise en charge des cas de fièvre et du paludisme par des médecins communautaires dans les Hautes Terres centrales de Madagascar, 2009-2010.

The aim of this study was to determine the frequency of confirmed malaria among patients with fever in the central Highlands of Madagascar, the clinical utility of treating this fever, and the involvement of community general practitioners in improving malaria management. This descriptive, prospective study took place from July 1, 2009, through June 30, 2010. Patients consulting for fever were classified into 2 groups: the first (G1) included all children younger than 5 years and the second group (G2) children 5 years or older and adults. In G1, 1383 cases of fever included 145 (10.5%) confirmed cases of malaria. The corresponding numbers in G2 were 1172 and 276 (23.5%). The prevalence of malaria was highest between December and May. In G1, the main clinical signs associated with a positive rapid diagnostic test (RDT) were pallor, jaundice, seizures, and failure to eat. In G2, a positive RDT was associated with pallor, coma, and jaundice. Treatment of patients with positive RDTs was based on quinine (51%) or artemisinin-based combination therapy (49%). Malaria remains endemic in the central Highlands of Madagascar. Efforts should be undertaken to improve prescription of antimalarial drugs.

Informed consent in clinical research in France: assessment and factors associated with therapeutic misconception.

BACKGROUND: Informed consent in clinical research is mandated throughout the world. Both patient subjects and investigators are required to understand and accept the distinction between research and treatment. AIM: To document the extent and to identify factors associated with therapeutic misconception in a population of patient subjects or parent proxies recruited from a variety of multicentre trials (parent studies). PATIENTS AND METHODS: The study comprised two phases: the development of a questionnaire to assess the quality of informed consent and a survey of patient subjects based on this questionnaire. RESULTS: A total of 303 patient subjects or parent proxies were contacted and 279 questionnaires were analysed. The median age was 49.5 years, sex ratio was 1 and 61% of respondents were professionally active. Overall memorisation of the oral or written communication of informed consent was good (69-97%), and satisfaction with the process was around 70%. Therapeutic misconception was present in 70% of respondents, who expected to receive better care and ignored the consequence of randomisation and treatment comparisons. This was positively associated with the acuteness and severity of the disease. CONCLUSION: The authors suggest that the risk of therapeutic misconception be specifically addressed in consent forms as an educational tool for both patients and investigators.

[Are sanitation services complaints an indicator of quality of care?]. / Les plaintes sanitaires sont-elles un indicateur de qualité des soins?

A retrospective analysis of 211 consecutive complaints treated at the Direction of Health and Social Assistance of Paris was undertaken in order to specify the nature of the complaints and to evaluate their pertinence as an indicator of quality of care. The majority of complaints concern public and private health establishments, in particular surgery and psychiatric services. Although the study confirms the dysfunctioning of the organisation of services and also of therapeutic methods and medical treatments, the evaluation of iatrogenic risks and their avoidable nature is difficult and requires precise instruction. Complaints seem to be a neglected indicator of quality, yet they concern information that is accessible and could, if used with other information, be a first milestone in the vigilance of medical treatments.

[The epidemiological surveillance network for nosocomial invasive aspergillosis of the Assistance Publique-Hôpitaux de Paris]. / Le réseau de surveillance épidémiologique de l'aspergillose invasive nosocomiale de l'Assistance Publique-Hôpitaux de Paris.

Since January 1990, a epidemiology surveillance network has been set up by the Paris hospitals for nosocomial invasive aspergillosis. The network includes 39 high risk clinics (haematology, bone marrow graft, organ transplantation) in 19 hospitals. Over the first 3 years of surveillance (1990-1992), 132 cases of aspergillosis have been registered as probably invasive and nosocomial. The incidence of nosocomial invasive aspergillosis invasive aspergillosis has been estimated at 1.16 per 1,000 patient-days in haematology wards, at 4.56% in bone marrow graft and at 1.57 in liver transplantation. Mortality was 57% for all cases registered and 75% for bone marrow transplant patients; 97% of these patients were immunodepressed. Room air filtration with an absolute filter system had been installed for only 32% of the patients at diagnosis of invasive nosocomial aspergillosis. Work areas were in the environment of 68% of the cases reported. Surveillance led to the establishment of incidence and mortality data and emphasized the importance of the problem in terms of public health. In addition, three main elements were recognized concerning the disease: the number of immunodepressed patients in increasing in the hospitals, room air filtration equipment is inadequate, unavoidable work areas in hospitals have a significant effect. A practical guide for the prevention of invasive nosocomial aspergillosis in case of work areas in the hospital was published in 1993. Nevertheless, the proposed measures must be integrated into a global prevention strategy to eliminate sources of contamination and improve food facilities, architecture, air conditioning, internal organization and personnel training in high risk clinics.

[Prospective Payment Information Systems and epidemiology: a difficult link to establish]. / Programme de Médicalisation des Systèmes d'Information et épidémiologie: une liaison qui ne va pas de soi.

This paper reviews the epidemiologic limitations to take into account when using data produced within the frame of the French Prospective Payment System for planning or medical evaluation purposes. Problems in describing medical data include completeness, reliability, granularity (precision) and sequencing. Referral bias hamper morbidity data collected at the institutional level. Differences in the case-mix may be due to the characteristics of the reference population but also to available equipment and variations in medical practice.

A nosocomial outbreak of multidrug-resistant Mycobacterium bovis among HIV-infected patients. A case-control study.

OBJECTIVE: To identify risk factors in a nosocomial outbreak of multidrug-resistant Mycobacterium bovis (MDRMB) tuberculosis (TB) among HIV-infected patients. DESIGN: We evaluated the study period (from the first to the last MDRMB smear-positive patients hospitalized in the unit) using a case-control study with three control groups. Since MDRMB is extremely rare, we assumed that a single strain was responsible for all six cases. SETTING: A 19-bed infectious diseases unit in Paris, France. PATIENTS: The index case was an AIDS patient who was hospitalized in September 1989 because of MDRMB TB. The cases were five HIV-infected patients who developed MDRMB TB between January 1990 and October 1991. Controls were randomly selected from HIV-infected patients in our unit during the study period (case-control study 1, 15 patients), during the contact period (at least one MDRMB smear-positive patient hospitalized in the unit; case-control study 2,20 patients), and patients matched according to the length of contact (case-control study 3, 24 patients). INTERVENTIONS: After detecting the nosocomial outbreak, we took respiratory isolation precautions for all patients suspected of having active TB. MAIN OUTCOME MEASURES: Risk factors for MDRMB nosocomial transmission, and the occurrence of new cases of MDRMB infection in HIV-infected patients and health-care workers after the introduction of isolation precautions. RESULTS: The most important predictor of nosocomial transmission of MDRMB to HIV-infected patients was the (mean +/- s.d.) length of contact in days [cases, 22 +/- 15.8; study 1 controls, 11.2 +/- 18.9 (P = 0.07); study 2 controls, 14.6 +/- 8.5 (P = 0.043)]. Only one case of MDRMB TB resulted from exposure to MDRMB-smear-positive patient after the introduction of respiratory isolation measures. The incubation period in the single health-care worker who developed MDRMB TB was longer than in the cases. CONCLUSION: In a nosocomial outbreak of MDRMB TB, the contact time was the main risk factor of transmission to HIV-infected patients. Respiratory isolation measures appear to be effective.

[Evaluation of the screening strategy for lead poisoning in 1-to-3-year-old children monitored in maternal-child welfare centers in Paris]. / Evaluation de la stratégie de dépistage du saturnisme chez les enfants âgés de 1 à 3 ans, suivis dans les centres de protection maternelle et infantile à Paris.

A procedure for screening for lead poisoning was implemented since 1987 in the maternal and child health centers of 6 Paris "arrondissements". It relies on a screening of the children through environmental and clinical information. Our study aimed at evaluating this procedure and at estimating the prevalence of lead poisoning in the children aged 1 to 3 years old attending free maternal and child health centers in Paris. We did a cross-sectional survey of a sample of 512 children. A questionnaire concerning each child's risk factors was answered by the paediatric nurses of the clinics. Potential lead poisoning cases were detected by capillary determining of free erythrocyte protoporphyrins (FEP). Blood lead level (PbB) was measured in children with FEP > or = 350 micrograms/l. The prevalence rate of lead poisoning was estimated at 1.9% +/- 1.7% for a PbB threshold > or = 250 micrograms/l and at 9.6% +/- 3.5% for a PbB threshold > or = 150 micrograms/l. The detection procedure identified 4 children out of 5 with a PbB > or = 250 micrograms/l and 2 children out of 3 with a PbB > or = 150 micrograms/l.

[Causes and modalities of pediatric ambulatory care in ten hospitals in the Ile-de-France region]. / Motifs et modalités de recours ambulatoire pédiatrique dans dix hôpitaux de la région Ile-de-France.

BACKGROUND: The increasing shortage of financial resources requires optimal use of hospital care by patients. However, the studies carried out to date in France have been limited to patients who are hospitalized, and have not included those seen as out-patients. POPULATION AND METHODS: All patients seen as out-patients in 10 hospitals in the Paris district (3 pediatric hospitals and 7 pediatric departments located in hospitals for adults and children), during the week of 19-26 April 1989, were given a questionnaire on the age, sex, nationality, socio-cultural and economic features of the family, history of earlier medical visits or admissions, the existence of pediatrician or practitioner, and the means and time taken to get to the hospital. Medical diagnosis was established for each patient following the WHO International Classification of Diseases (9th edition). RESULTS: 2,365 out of 2,675 questionnaires were usable. The main features were: 50% of patients were less than 3 years old, 55% were of French origin; 78% belonged to families with relatively low socio-economic status. Both parents had professional activities in 49% of families, 7% of mothers did not speak or write French. The ratio of patients aged less than 3 years admitted to the emergency ward was higher than the average. The most frequent diseases presented by these patients were respiratory (23%), infectious (14%), gastro-intestinal (10%) and neurological (7%); 14% of the patients were seen for symptoms that could not be assigned to a specific disease. 39% of patients were seen in out-patient clinics and 61% in emergency wards. 40% were sent by a health professional to out-patient clinics and only 25% to emergency wards. CONCLUSIONS: Despite the fact that this study is subject to particular conditions, i.e., relative frequency of infectious diseases due to seasonal causes, it suggests that the hospital is becoming the primary source of health care with an increasing percentage of patients seen in "emergency", even though this emergency is often more apparent than real. Health care networks should be established.

[Monitoring of infections in intensive care units. Strategy of data collection]. / La surveillance des infections en réanimation. Stratégie de recueil.

The aim of this article defines the principles of the infections surveillance. Its pertinence: its efficiency as a means for prevention of diseases. Its objectives: to spot aggregate cases and the variations of endemic. These specific methods according to the clearing defined priorities on criterions cost effectiveness.

Epidemiological survey of a major outbreak of nosocomial legionellosis.

Forty-seven nosocomial cases of legionellosis due to Legionella pneumophila serogroup 1 were diagnosed in one major outbreak from November 1982 to March 1983 in a 960-bed teaching hospital. Contaminated water was considered to be a possible source of infection because, during that period, monthly samples were found to be positive with averages of 10(4) CFU/l. After chlorination of hot water associated with flushing of outlets, nearly all samples taken in the next two years were found to be negative. A case-control study was performed to examine potential risk factors. Three groups of controls were randomly selected among eligible patients. In a multivariate analysis, only three clinical factors were found to be associated with legionellosis patients: malignant illness (relative risk, RR = 3.5), presence of an ultimately fatal disease (RR = 2.6), and exposure to corticosteroids prior to admission (RR = 7.9). Investigations of in-hospital exposures suggest that during this nosocomial outbreak diagnostic or therapeutic respiratory procedures had not increased the risk of illness. Although the epidemiological association between water contamination and disease remains unclear, the eradication of L. pneumophila from the identified supply seems to have been effective in preventing disease in this hospital.

[A certificate of proficiency in community health methods adapted to a tropical milieu]. / Un certificat de méthodes en santé communautaire pour l'exercice en milieu tropical.

The authors report on their 4 years of experience and research in education and training of medical doctors, nurses and male nurses, in the field of community health methodology in developing countries. They start from the fact, widely recognized by national and international organizations (W.H.O.), that improvement of health status of a population demands some other activities than curative ones, i.e. comprehensive knowledge of its social and cultural environment, evaluation of its health status, organization and management of the health services, clearly defined and fully observed collaboration between various partners, population, professionals, politicians. Neither medical doctors nor nurses and male nurses have been taught and trained in these fields. The authors suggest a part-time course of three months, built round the learning of methods and techniques of socioethnology, economics, epidemiology, management of services, and communication. Taking into account the pecularities of the audiences (foreigners, or nationals), the authors propose a pedagogical pattern based on the experience of the participants, both in simulated situation (case studies) or in actual situation (survey and setting-up of a program in a community).