The Influence of Sex and/or Gender on the Occurrence of Colorectal Cancer in the General Population in Developed Countries: A Scoping Review.

Objective: Gender as the "sociocultural role of sex" is underrepresented in colorectal cancer incidence studies, potentially resulting in underestimated risk factors' consequences and inequalities men/women. We aim to explore how literature focusing on differences between men and women in the incidence of colorectal cancer interprets these differences: through sex- or gender-related mechanisms, or both? Methods: We conducted a scoping review using PubMed and Google Scholar. We categorized studies based on their definitions of sex and/or gender variables. Results: We reviewed 99 studies, with 7 articles included in the analysis. All observed differences between men and women. Six articles examined colorectal cancer incidence by gender, but only 2 used the term "gender" to define exposure. One article defined its "sex" exposure variable as gender-related mechanisms, and two articles used "sex" and "gender" interchangeably to explain these inequalities. Gender mechanisms frequently manifest through health behaviors. Conclusion: Our results underscore the need for an explicit conceptual framework to disentangle sex and/or gender mechanisms in colorectal cancer incidence. Such understanding would contribute to the reduction and prevention of social health inequalities.

Risk factors and effect of dyspnea inappropriate treatment in adults' emergency department: a retrospective cohort study.

Dyspnea is a frequent symptom in adults' emergency departments (EDs). Misdiagnosis at initial clinical examination is common, leading to early inappropriate treatment and increased in-hospital mortality. Risk factors of inappropriate treatment assessable at early examination remain undescribed herein. The objective of this study was to identify clinical risk factors of dyspnea and inappropriate treatment in patients admitted to ED. This is an observational retrospective cohort study. Patients over the age of 15 who were admitted to adult EDs of the University Hospital of Toulouse (France) with dyspnea were included from 1 July to 31 December 2019. The primary end-point was dyspnea and inappropriate treatment was initiated at ED. Inappropriate treatment was defined by looking at the final diagnosis of dyspnea at hospital discharge and early treatment provided. Afterward, this early treatment at ED was compared to the recommended treatment defined by the International Guidelines for Acute Heart Failure, bacterial pneumonia, chronic obstructive pulmonary disease, asthma or pulmonary embolism. A total of 2123 patients were analyzed. Of these, 809 (38%) had inappropriate treatment in ED. Independent risk factors of inappropriate treatment were: age over 75 years (OR, 1.46; 95% CI, 1.18-1.81), history of heart disease (OR, 1.32; 95% CI, 1.07-1.62) and lung disease (OR, 1.47; 95% CI, 1.21-1.78), SpO2 <90% (OR, 1.64; 95% CI, 1.37-2.02), bilateral rale (OR, 1.25; 95% CI, 1.01-1.66), focal cracklings (OR, 1.32; 95% CI, 1.05-1.66) and wheezing (OR, 1.62; 95% CI, 1.31-2.03). In multivariate analysis, under-treatment significantly increased in-hospital mortality (OR, 2.13; 95% CI, 1.29-3.52) compared to appropriate treatment. Over-treatment nonsignificantly increased in-hospital mortality (OR, 1.43; 95% CI, 0.99-2.06). Inappropriate treatment is frequent in patients admitted to ED for dyspnea. Patients older than 75 years, with comorbidities (heart or lung disease), hypoxemia (SpO2 <90%) or abnormal pulmonary auscultation (especially wheezing) are at risk of inappropriate treatment.

Increasing access to fertility preservation for women with breast cancer: protocol for a stepped-wedge cluster randomized trial in France.

BACKGROUND: With the increase in the number of long-term survivors, interest is shifting from cancer survival to life and quality of life after cancer. These include consequences of long-term side effects of treatment, such as gonadotoxicity. Fertility preservation is becoming increasingly important in cancer management. International recommendations agree on the need to inform patients prior to treatments about the risk of fertility impairment and refer them to specialized centers to discuss fertility preservation. However, the literature reveals suboptimal access to fertility preservation on an international scale, and particularly in France, making information for patients and oncologists a potential lever for action. Our overall goal is to improve access to fertility preservation consultations for women with breast cancer through the development and evaluation of a combined intervention targeting the access and diffusion of information for these patients and brief training for oncologists. METHODS: Firstly, we will improve existing information tools and create brief training content for oncologists using a qualitative, iterative, user-centred and participatory approach (objective 1). We will then use these tools in a combined intervention to conduct a stepped-wedge cluster randomized trial (objective 2) including 750 women aged 18 to 40 newly treated with chemotherapy for breast cancer at one of the 6 participating centers. As the primary outcome of the trial will be the access to fertility preservation counselling before and after using the combined intervention (brochures and brief training for oncologists), we will compare the rate of fertility preservation consultations between the usual care and intervention phases using linear regression models. Finally, we will analyse our approach using a context-sensitive implementation analysis and provide key elements for transferability to other contexts in France (objective 3). DISCUSSION: We expect to observe an increase in access to fertility preservation consultations as a result of the combined intervention. Particular attention will be paid to the effect of this intervention on socially disadvantaged women, who are known to be at greater risk of inappropriate treatment. The user-centred design principles and participatory approaches used to optimize the acceptability, usability and feasibility of the combined intervention will likely enhance its impact, diffusion and sustainability. TRIAL REGISTRATION: Registry: ClinicalTrials.gov. TRIAL REGISTRATION NUMBER: NCT05989776. Date of registration: 7th September 2023. URL: https://classic. CLINICALTRIALS: gov/ct2/show/NCT05989776 . PROTOCOL VERSION: Manuscript based on study protocol version 2.0, 21st may 2023.

The Efficacy of CB-103, a First-in-Class Transcriptional Notch Inhibitor, in Preclinical Models of Breast Cancer.

BACKGROUND: The efficacy of CB-103 was evaluated in preclinical models of both ER+ and TNBC. Furthermore, the therapeutic efficacy of combining CB-103 with fulvestrant in ER+ BC and paclitaxel in TNBC was determined. METHODS: CB-103 was screened in combination with a panel of anti-neoplastic drugs. We evaluated the anti-tumor activity of CB-103 with fulvestrant in ESR1-mutant (Y537S), endocrine-resistant BC xenografts. In the same model, we examined anti-CSC activity in mammosphere formation assays for CB-103 alone or in combination with fulvestrant or palbociclib. We also evaluated the effect of CB-103 plus paclitaxel on primary tumors and CSC in a GSI-resistant TNBC model HCC1187. Comparisons between groups were performed with a two-sided unpaired Students' t-test. A one-way or two-way ANOVA followed by Tukey's post-analysis was performed to analyze the in vivo efficacy study results. THE RESULTS: CB-103 showed synergism with fulvestrant in ER+ cells and paclitaxel in TNBC cells. CB-103 combined with fulvestrant or paclitaxel potently inhibited mammosphere formation in both models. Combination of CB-103 and fulvestrant significantly reduced tumor volume in an ESR1-mutant, the endocrine-resistant BC model. In a GSI-resistant TNBC model, CB-103 plus paclitaxel significantly delayed tumor growth compared to paclitaxel alone. CONCLUSION: our data indicate that CB-103 is an attractive candidate for clinical investigation in endocrine-resistant, recurrent breast cancers with biomarker-confirmed Notch activity in combination with SERDs and/or CDKis and in TNBCs with biomarker-confirmed Notch activity in combination with taxane-containing chemotherapy regimens.

Predictive factors for early requirement of respiratory support through phone call to Emergency Medical Call Centre for dyspnoea: a retrospective cohort study.

BACKGROUND: Acute dyspnoea is a common symptom in Emergency Medicine, and severity assessment is difficult during the first time the patient calls the Emergency Medical Call Centre. OBJECTIVE: To identify predictive factors regarding the need for early respiratory support in patients who call the Emergency Medical Call Centre for dyspnoea. DESIGN, SETTINGS AND PARTICIPANTS: This retrospective cohort study carried out in the Emergency Medical Call Centre of the University Hospital of Toulouse from 1 July to 31 December 2019. Patients over the age of 15 who call the Emergency Medical Call Centre regarding dyspnoea and who were registered at the University Hospital or died before admission were included in our study. OUTCOME MEASURE AND ANALYSIS: The primary end-point was early requirement of respiratory support [including high-flow oxygen, non-invasive ventilation (NIV) or mechanical ventilation after intubation] that was initiated by the physicians staffed ambulance before admission to the hospital or within 3 h after being admitted. Associations with patients' characteristics identified during Emergency Medical Call Centre calls were assessed with a backward stepwise logistic regression after multiple imputations for missing values. MAIN RESULTS: During the 6-month inclusion period, 1425 patients called the Emergency Medical Call Centre for respiratory issues. After excluding 38 calls, 1387 were analyzed, including 208 (15%) patients requiring respiratory support. The most frequent respiratory support used was NIV (75%). Six independent predictive factors of requirement of respiratory support were identified: chronic ß2-mimetics medication [odds ratio (OR) = 2.35, 95% confidence interval (CI) 1.61-3.44], polypnea (OR = 5.78, 95% CI 2.74-12.22), altered ability to speak (OR = 2.35, 95% CI 1.55-3.55), cyanosis (OR = 2.79, 95% CI 1.81-4.32), sweats (OR = 1.93, 95% CI 1.25-3) and altered consciousness (OR = 1.8, 95% CI 1.1-3.08). CONCLUSION: During first calls for dyspnoea, six predictive factors are independently associated with the risk of early requirement of respiratory support.

Estimating complete cancer prevalence in Europe: validity of alternative vs standard completeness indexes.

Introduction: Comparable indicators on complete cancer prevalence are increasingly needed in Europe to support survivorship care planning. Direct measures can be biased by limited registration time and estimates are needed to recover long term survivors. The completeness index method, based on incidence and survival modelling, is the standard most validated approach. Methods: Within this framework, we consider two alternative approaches that do not require any direct modelling activity: i) empirical indices derived from long established European registries; ii) pre-calculated indices derived from US-SEER cancer registries. Relying on the EUROCARE-6 study dataset we compare standard vs alternative complete prevalence estimates using data from 62 registries in 27 countries by sex, cancer type and registration time. Results: For tumours mostly diagnosed in the elderly the empirical estimates differ little from standard estimates (on average less than 5% after 10-15 years of registration), especially for low prognosis cancers. For early-onset cancers (bone, brain, cervix uteri, testis, Hodgkin disease, soft tissues) the empirical method may produce substantial underestimations of complete prevalence (up to 20%) even when based on 35-year observations. SEER estimates are comparable to the standard ones for most cancers, including many early-onset tumours, even when derived from short time series (10-15 years). Longer observations are however needed when cancer-specific incidence and prognosis differ remarkably between US and European populations (endometrium, thyroid or stomach). Discussion: These results may facilitate the dissemination of complete prevalence estimates across Europe and help bridge the current information gaps.

The stake of informing patients of the risk of hypofertility after chemotherapy for breast cancer.

Introduction: Too few women with invasive breast cancer are informed of the risk of hypofertility after chemotherapy. However, this risk can be prevented by offering gamete preservation by a specialized team. We believe that if more women were informed about gamete preservation, more of them would accept it. Objectives: The primary objective is to describe each step of the oncofertility care pathway from provision of information to gamete preservation. The secondary objective is to estimate the impact of not receiving information by determining the proportion of women who would have undergone gamete preservation if they had been informed. Method: 575 women aged 18-40 years treated with chemotherapy for breast cancer between 2012 and 2017 in the Ouest-Occitanie region (~3 million inhabitants) were included. We first constructed a multivariate predictive model to determine the parameters influencing the uptake of the offer of gamete preservation among women who were informed and then applied it to the population of uninformed women. Results: Only 39% of women were informed of the risks of hypofertility related to chemotherapy and 11% ultimately received gamete preservation. If all had been informed of the risk, our model predicted an increase in gamete preservation of 15.35% in the youngest women (<30 years), 22.88% in women aged between 30 and 35 years and zero in those aged ≥36 years. We did not find any association with the European Deprivation Index (EDI). Conclusion: Oncologists should be aware of the need to inform patients aged ≤ 35 years about gamete preservation. If all received such information, the impact in terms of gamete preservation would likely be major.

Access to information and oncofertility consultation for young women with breast cancer: a population-based study.

Non-menopausal women with breast cancer treated with chemotherapy are at intermediate risk of post-treatment amenorrhea and decreased fertility. Although they should receive appropriate information, studies until now show that this is inadequate. We investigated the proportion of women who received information about this risk during the pre-treatment consultation, and those who received an oncofertility consultation to preserve their gametes. We also analysed the medical and non-medical factors influencing the transmission of information to patients and their uptake of oncofertility consultations. We included women aged 18-40 years treated with chemotherapy for breast cancer between 2012 and 2017 in the Midi-Pyrénées region (ca. 3 million inhabitants), France. Studied variables were included in a multilevel model. Among the 575 women, 41% of the women received information and 28% received an oncofertility consultation. These two steps on the care pathway were significantly influenced by the type of care structure, the woman's age, her parity at the time of diagnosis, and the metastatic status of the cancer. Female oncologist gender was significantly associated with higher transmission rate. We found no association between neoadjuvant chemotherapy status, level of deprivation (EDI), triple-negative status, marital status, and first-degree family history of cancer and information transmission or uptake of oncofertility consultation. Our study shows that not enough women are informed and have recourse to an oncofertility consultation. Despite a legal obligation, the health care system does not offer the necessary conditions for access to oncofertility care.

Treatment time interval in breast cancer: A population-based study on the impact of type and number of cancer centres attended.

OBJECTIVES: We studied both the independent and combined effects of the places of biopsy and treatment on the treatment time interval based on a population-based study. METHODS: We analysed the proportion of patients having a treatment time interval higher than the EUSOMA recommendation of 6 weeks, as a function of the number and the type of care centres the patients attended, from a French population-based regional cohort of women treated in 2015 for an incident invasive non-metastatic cancer (n = 505). RESULTS: About 33% [95% CI: 27; 38] of patients had a treatment time interval higher than 6 weeks. About 48% of the patients underwent their biopsy and their initial treatment in the different centres. Results from multivariable analyses supported the impact of the type and number of centres attended on the proportion of time intervals over 6 weeks. This proportion was higher among patients with biopsy and treatment in different centres and among patients treated in a university hospital. CONCLUSION: We pointed out the independent impact of the type and the number of care centres the patients attended, from biopsy to first treatment, on the treatment time interval, which is a well-known prognosis factor.

The impact of physician's characteristics on decision-making inhead and neck oncology: Results of a national survey.

OBJECTIVES: The aim of this study was to identify the socio-professional and behavioral factors influencing decision-making between surgical and non-surgical treatment in Upper AeroDigestive Tract (UADT) oncology among surgeons and oncologists. MATERIALS AND METHODS: We conducted a nationwide online survey among surgeons and medical or radiation oncologists treating head and neck cancer patients in France. The questionnaire collected physicians' demographics, type of practice, individual behavioral characteristics (attitudes toward risk and uncertainty) and data on decision-making via clinical case scenarios. RESULTS: In total, 197 questionnaires were usable. Clinical case scenarios were grouped into three categories according to the prognostic and functional impact of the choice between surgical or non-surgical treatment. For clinical case scenarios where evidence-based medicine considered surgery as the best option, surgeons were significantly more likely to offer surgery in multivariable analysis. When surgery and non-surgical treatment were equivalent, multivariable analysis showed that the tendency to offer surgery increased with the physician's age, and decreased as the number of patients treated per year increased. When non-surgical treatment was the best option because of very high surgical morbidity, multivariable analysis showed a higher propensity to opt for surgery for the age group 40 - 59 versus 25 - 39, and a lower likelihood of choosing surgery among oncologists. CONCLUSION: This study sheds light on the physicians' socio-professional and behavioral factors influencing decision-making in UADT oncology. These mechanisms, poorly studied and probably underestimated, partly explain the variability of the decisions taken when confronted with clinical situations that are subject to debate. CLINICALTRIALS: gov ID: NCT03663985.

Social and territorial inequalities in breast and cervical cancers screening uptake: a cross-sectional study in France.

OBJECTIVE: The objective of this cross-sectional study was to investigate the impact of socio-territorial characteristics on mammography and pap smear uptake according to the place of residence in the recommended age groups, and second outside the recommended age groups. SETTING AND PARTICIPANTS: We used an existing dataset of 1 027 039 women which combines data from the Health Insurance information systems, with census data from Midi-Pyrénées, France. PRIMARY AND SECONDARY OUTCOME MEASURES: Our outcome was, for each woman, the uptake of the pap smear and the uptake of the mammography during the year. RESULTS: A social gradient of screening uptake was found in the recommended age groups. This gradient was stronger in large urban areas:(1) For mammography: decile 10 (the most deprived) vs 1 (the least deprived), adjusted OR 0.777, 95% CI (0.748 to 0.808) in large urban area; adjusted OR= 0.808 for decile 1 to 0.726 for decile 10 in other areas vs decile 1 in urban areas;(2) For pap smear: decile 10 vs 1 adjusted OR 0.66, 95%CI (0.642 to 0.679) in large urban areas; adjusted OR= 0.747 for decile 1 to 0.562 for decile 10 in other areas vs decile 1 in urban areas).Screening rates were globally higher in large urban areas.For mammography, the social and territorial disparities were higher outside the recommended age group. CONCLUSIONS: Offering a universal approach to every woman, as it is often the case in nationally organised screening programmes, is likely to be insufficient to ensure real equity in access. Developing global dataset combining health data and diverse socioeconomic data, at individual and contextual levels, could enable a better understanding of the mechanisms involved in this social gradient, and therefore, the development of targeted territorial actions to improve equity of access to healthcare.

A national population-based study of patients, bystanders and contextual factors associated with resuscitation in witnessed cardiac arrest: insight from the french RéAC registry.

BACKGROUND: In out-of-hospital cardiac arrest (OHCA), bystander initiated cardiopulmonary resuscitation (CPR) increases the chance of return of spontaneous circulation and survival with a favourable neurological status. Socioeconomic disparities have been highlighted in OHCA field. In areas with the lowest average socioeconomic status, OHCA incidence increased, and bystander CPR decreased. Evaluations were performed on restricted geographical area, and European evaluation is lacking. We aimed to analyse, at a national level, the impact of area-level social deprivation on the initiation of CPR in case of a witnessed OHCA. METHODS: We included all witnessed OHCA cases with age over 18 years from July 2011 to July 2018 form the OHCA French national registry. We excluded OHCA occurred in front of rescue teams or in nursing home, and patients with incomplete address or partial geocoding. We collected data from context, bystander and patient. The area-level social deprivation was estimated by the French version of the European Deprivation Index (in quintile) associated with the place where OHCA occurred. We assessed the associations between Utstein variables and social deprivation level using a mixed-effect logit model with bystander-initiated CPR. RESULTS: We included 23,979 witnessed OHCA of which 12,299 (51%) had a bystander-initiated CPR. More than one third of the OHCA (8,326 (35%)) occurred in an area from the highest quintile of social deprivation. The higher the area-level deprivation, the less the proportion of bystander-initiated CPR (56% in Quintile 1 versus 48% in Quintile 5). The In the multivariable analysis, bystander less often began CPR in areas with the highest deprivation level, compared to those with the lowest deprivation level (OR=0.69, IC95%: 0.63-0.75). CONCLUSIONS: The level of social deprivation of the area where OHCA occurred was associated with bystander-initiated CPR. It decreased in the more deprived areas although these areas also concentrate more younger patients.

Physician practice variation in head and neck cancer therapy: Results of a national survey.

OBJECTIVES: Choice between surgical or medical treatments in head and neck cancer depends of many patient-related and disease-related factors. We investigated how patients' socioeconomic status and practitioners' specialty could affect medical decision-making. MATERIALS AND METHODS: We conducted a cross-sectional online, nationwide survey, send to surgeons, oncologists and radiotherapists specialized in head and neck oncology. We collected data on medical decision-making for seven clinical scientific scenarios involving head and neck carcinoma and physicians' demographic data. Patients' gender and socioeconomic position were distributed across scientific scenarios using a Latin square design. The scientific scenarios were grouped into several categories according to the prognostic and functional impact of the therapeutic choice. RESULTS: We obtained 206 assessable answers. Surgeons seemed to propose surgery in 49% of cases, whereas oncologists and radiotherapists opted for it in 34% of cases only. This was particularly relevant when the oncological result of surgery and the medical approach were equivalent, and when the surgery appeared to be superior in terms of curative potential but was burdened by a large functional impact. Patient's socioeconomic position also influence therapeutic decision. Among surgeons, the "single male manager" had significantly more chance of being offered surgery than the "married male blue-collar worker". Among oncologists and radiotherapists, the "single male blue-collar worker" had the lowest probability of being proposed surgery. Regarding gender, surgeons tended to offer surgical management more to women regardless of their clinical profile. CONCLUSIONS: Patients' sex, marital status, socioeconomic status, practitioners' specialty affect therapeutic management decisions in head and neck oncology.

How does comorbidity affect colon cancer patients' care trajectory? Results from the French EvaCCoR cohort study.

OBJECTIVE: Due to their advanced age in average, colon cancer patients are likely to be exposed to comorbidity. However, the influence of comorbidity on patients' care trajectory and survival is largely under-explored. Hence, we investigate the effect of comorbidity on patients care trajectory and survival based on an observational study in "real-life" setting. METHODS: This prospective observational study in two French regions includes patients aged over 18 and firstly treated for a colon cancer, stage II and III, diagnosed between 1st January and 31st December 2010. We assessed the influence of comorbidity (severe vs moderate or none), using the Charlson Comorbidity Index, on overall survival and patients' management steps. RESULTS: We analyzed 762 patients. We found comorbidity to be associated with adjuvant treatment delivery with a longer delay between surgery and chemotherapy initiation among patients with severe comorbidity. Severe comorbidity had an independent detrimental effect on overall survival that is slightly downsized after adjustment for adjuvant treatment delivery. CONCLUSION: Using observational "real-life" data, we showed that comorbidity impacts the colon cancer patients' care trajectory directly but also through indirect pathways involving adjuvant chemotherapy delivery. However, further studies are needed to better understand this mechanism.

Are social inequalities in acute myeloid leukemia survival explained by differences in treatment utilization? Results from a French longitudinal observational study among older patients.

BACKGROUND: Evidences support social inequalities in cancer survival. Studies on hematological malignancies, and more specifically Acute Myeloid Leukemia (AML), are sparser. Our study assessed: 1/ the influence of patients' socioeconomic position on survival, 2/ the role of treatment in this relationship, and 3/ the influence of patients' socioeconomic position on treatment utilization. METHODS: This prospective multicenter study includes all patients aged 60 and older, newly diagnosed with AML, excluding promyelocytic subtypes, between 1st January 2009 to 31st December 2014 in the South-West of France. Data came from medical files. Patients' socioeconomic position was measured by an ecological deprivation index, the European Deprivation Index. We studied first, patients' socioeconomic position influence on overall survival (n = 592), second, on the use of intensive chemotherapy (n = 592), and third, on the use of low intensive treatment versus best supportive care among patients judged unfit for intensive chemotherapy (n = 405). RESULTS: We found an influence of patients' socioeconomic position on survival (highest versus lowest position HRQ5: 1.39 [1.05;1.87] that was downsized to become no more significant after adjustment for AML ontogeny (HRQ5: 1.31[0.97;1.76] and cytogenetic prognosis HRQ5: 1.30[0.97;1.75]). The treatment was strongly associated with survival. A lower proportion of intensive chemotherapy was observed among patients with lowest socioeconomic position (ORQ5: 0.41[0.19;0.90]) which did not persist after adjustment for AML ontogeny (ORQ5: 0.59[0.25;1.40]). No such influence of patients' socioeconomic position was found on the treatment allocation among patients judged unfit for intensive chemotherapy. CONCLUSIONS: Finally, these results suggest an indirect influence of patients' socioeconomic position on survival through AML initial presentation.

Why are people increasingly attending the emergency department? A study of the French healthcare system.

OBJECTIVE: It is often asserted that the crowding phenomenon in emergency departments (ED) can be explained by an increase in visits considered as non-urgent. The aim of our study was to quantify the increase in ED visit rates and to determine whether this increase was explained by non-severe visit types. METHODS: This observational study covers all ED visits between 2002 and 2015 by adult inhabitants of the Midi-Pyrénées region in France. Their characteristics were collected from the emergency visit summaries. We modelled the visit rates per year using linear regression models, and an increase was considered significant when the 95% CIs did not include zero. The severity of the patients' condition during ED visit was determined through the 'Clinical Classification of Emergency' score. Non-severe visits were those where the patient was stable, and the physician deemed no intervention necessary. Intermediate-severity visits concerned patients who were stable but requiring diagnostic or therapeutic procedures. RESULTS: The 37 studied EDs managed >7 million visits between 2002 and 2015. There was an average increase of +4.83 (95% CI 4.33 to 5.32) visits per 1000 inhabitants each year. The increase in non-severe visit types was +0.88 (95% CI 0.42 to 1.34) per 1000 inhabitants, while the increase in intermediate-severity visit types was +3.26 (95% CI 2.62 to 3.91) per 1000 inhabitants. This increase affected all age groups and all sexes. DISCUSSION: It appears that the increase in ED use is not based on an increase in non-severe visit types, with a greater impact of intermediate-severity visit types requiring diagnostic or therapeutic procedures in ED.

Using ecological socioeconomic position (SEP) measures to deal with sample bias introduced by incomplete individual-level measures: inequalities in breast cancer stage at diagnosis as an example.

BACKGROUND: When studying the influence of socioeconomic position (SEP) on health from data where individual-level SEP measures may be missing, ecological measures of SEP may prove helpful. In this paper, we illustrate the best use of ecological-level measures of SEP to deal with incomplete individual level data. To do this we have taken the example of a study examining the relationship between SEP and breast cancer (BC) stage at diagnosis. METHODS: Using population based-registry data, all women over 18 years newly diagnosed with a primary BC in 2007 were included. We compared the association between advanced stage at diagnosis and individual SEP containing missing data with an ecological level SEP measure without missing data. We used three modelling strategies, 1/ based on patients with complete data for individual-SEP (n = 1218), or 2/ on all patients (n = 1644) using an ecological-level SEP as proxy for individual SEP and 3/ individual-SEP after imputation of missing data using an ecological-level SEP. RESULTS: The results obtained from these models demonstrate that selection bias was introduced in the sample where only patients with complete individual SEP were included. This bias is redressed by using ecological-level SEP to impute missing data for individual SEP on all patients. Such a strategy helps to avoid an ecological bias due to the use of aggregated data to infer to individual level. CONCLUSION: When individual data are incomplete, we demonstrate the usefulness of an ecological index to assess and redress potential selection bias by using it to impute missing individual SEP.

Identifying key factors leading to the optimal care pathway for patients with ST-segment elevation myocardial infarction: Results from the RESCAMIP registry.

BACKGROUND: In France, when someone presents with chest pain, it is recommended to call a health emergency number. The patient talks with an emergency doctor at a medical dispatch centre, who decides whether (or not) to send a Mobile Intensive Care Unit (MICU). Patients with an ST-segment elevation myocardial infarction (STEMI) should have an MICU as their first medical contact, to speed up confirmation of diagnosis and enable them to benefit from reperfusion therapy as quickly as possible. AIM: To evaluate the proportion of patients with STEMI benefiting from an optimal care pathway, and to identify the key factors leading to this pathway. METHODS: RESCAMIP was a multicentre registry conducted between May 2015 and May 2017 in Midi-Pyrénées. All patients treated for STEMI within 12hours of symptoms onset, without initially going into cardiac arrest, were included. RESULTS: Data from 1371 patients with STEMI were analysed; 60% had an MICU as their first medical contact. In-hospital mortality was 4%. Factors associated with calling the medical dispatch centre when presenting chest pain were: age>65 years (odds ratio [OR] 1.37, 95% confidence interval [CI] 1.02-1.83), personal history of cardiovascular disease (OR 1.9, 95% CI 1.22-2.96) and having cardiovascular risk factors (OR 1.84, 95% CI 1.35-2.5). Factors associated with sending an MICU as first medical contact were: male sex (OR 2.11, 955 CI 1.49-2.99) and personal history of cardiovascular disease (OR 1.69, 95% CI 1.07-2.65). CONCLUSIONS: The proportion of patients with STEMI going through non-optimal pathways was 40% in our area. We note that there are sex-based inequalities in accessing MICUs.