Diagnostic accuracy validation study of the M6 model without initial serum progesterone (M6NP) in triage of pregnancy of unknown location.

OBJECTIVES: The M6 prediction model stratifies the risk of development of ectopic pregnancy (EP) for women with pregnancy of unknown location (PUL) into low risk or high risk, using human chorionic gonadotrophin (hCG) and progesterone levels at the initial visit to a gynaecological emergency room and hCG level at 48 h. This study evaluated a second model, the M6NP model, which does not include the progesterone level at the initial visit. The main aim of this study was to validate the diagnostic accuracy of the M6NP model in a population of French women. STUDY DESIGN: Between January and December 2021, all women with an hCG measurement from the gynaecological emergency department of a teaching hospital were screened for inclusion in this study. Women with a pregnancy location determined before or at the second visit were excluded. The diagnostic test was based on logistic regression of the M6NP model, with classification into two groups: high risk of EP (≥5%) and low risk of EP (<5%). The reference test was the final outcome based on clinical, biological and sonographic results: failed PUL (FPUL), intrauterine pregnancy (IUP) or EP. Diagnostic performance for risk prediction of EP, and also IUP and FPUL, was calculated. RESULTS: In total, 759 women with possible PUL were identified. After screening, 341 women with PUL were included in the main analysis. Of these, 186 (54.5%) were classified as low risk, including three (1.6%) with a final outcome of EP. The remaining 155 women with PUL were classified as high risk, of whom 60 (38.7%), 66 (42.8%) and 29 (18.7%) had a final outcome of FPUL, IUP and EP, respectively. Of the 32 women with PUL with a final outcome of EP, 29 (90.6%) were classified as high risk and three (9.4%) were classified as low risk. Therefore, the performance of the M6NP model to predict EP had a negative predictive value of 98.4%, a positive predictive value of 18.7%, sensitivity of 90.6% and specificity of 59.2%. If the prediction model had been used, it is estimated that 4.5 visits per patient could have been prevented. CONCLUSION: The M6NP model could be used safely in the French population for risk stratification of PUL. Its use in clinical practice should result in a substantial reduction in the number of visits to a gynaecological emergency room.

Gender awareness among general practitioners in France: a cross sectional study using the Nijmegen Gender Awareness in Medicine Scale (N-GAMS).

Gender is a key determinant of health and healthcare use. The question of whether physicians are aware of gender issues is important to avoid gender bias in medical practice. This study aimed to validate the Nijmegen Gender Awareness in Medicine Scale (N-GAMS) in a representative population of French general practitioners (GPs) and to analyze their gender sensitivity and the presence of gender stereotypes among them. The N-GAMS, already validated in medical students, measures gender awareness through 3 subscores: gender sensitivity (GS) and gender-role ideology towards patients (GRIP) and doctors (GRID) (gender stereotypes). After translation into French, it was distributed to 900 GPs. The scale was validated through exploratory factor analysis (EFA). Psychometric properties were tested. Multivariate linear regressions were conducted to explore the associations between GPs' characteristics and N-GAMS subscores. EFA identified 3 meaningful factors consistent with prior theory. Subscores exhibited good internal consistency. The main findings were that GRIP was significantly higher in older physicians, in male physicians, among those who less involved their patients in decisions, and those who were not training supervisors. For GRID, results were quite similar to those of GRIP. GS was significantly higher for physicians working in health centres or medical homes and for those with gynecological practices but lower when they less involved patients in medical decisions. This study suggests that it is necessary to teach gender issues not only in medical schools but also as part of continuing medical education.

Geriatric assessment and quality of life for 2 years in older patients with head and neck cancer.

Due to the location and toxicity of treatments, head and neck cancer (HNC) has a major impact on quality of life (QoL). Objectiveto assess the effects of geriatric-assessment (GA)-driven interventions on QoL over 2 years in older adults with HNC.EGeSOR was a randomized study of HNC patients aged ≥65, receiving a pretreatment GA, a geriatric intervention and follow-up (intervention) or standard of care (control). The primary endpoint was QoL score (EORTC QLQ-C30, QLQ-HN35) over 24 months.475 patients were included (median age: 75.3; women: 31%; oral cancer: 44%). QoL scores improved over 24 months with various trajectories, without significant differences between the groups. 74% of patients (interventional group) did not receive the complete intervention. Cancer characteristics, functional status, and risk of frailty were associated with change in the Global Health Status QoL score.There is a need to develop alternative model of implementation such as patient-centered healthcare pathways. TRIAL REGISTRATION: NCT02025062.

Women's preferences for less active ectopic pregnancy treatment: A discrete choice experiment.

RESEARCH QUESTION: Shared decision-making has become a hallmark of quality care and is increasingly spotlighted in practice guidelines. Little is known about women's views for treatment of less active ectopic pregnancy. What are the preferences of women for less active ectopic pregnancy treatment-related attributes? DESIGN: A discrete choice model with 8 attributes depicting ectopic pregnancy treatment including varying levels of first-line treatment effectiveness, length of hospitalization, cost, length of sick leave, of convalescence, need for surgical management, for emergency care during convalescence and for tube removal was used. Childbearing aged women, i.e. those who might experience an ectopic pregnancy in the future, were recruited. They were asked to choose between hypothetical treatments in 18 choice tasks with different levels of all treatment attributes. A conditional logit McFadden's choice model was performed. The main outcome measure was preference weights for less active ectopic pregnancy treatment-related attributes. RESULTS: A total of 5770 observations from 178 women were analysed. The attributes displaying the highest marginal impacts on women's decisions included: higher rate of first-line treatment effectiveness, lower rate of tube removal, lower rate of surgical management, shorter length of hospitalization and, to a lesser extent, but still significant, shorter length of convalescence, absence of risk of emergency care during convalescence and lower cost. CONCLUSIONS: Trade-offs made by women between the attributes of less active ectopic pregnancy treatment suggest that no treatment option, either medical or surgical, is an obvious preferred option. These results encourage the promotion of shared decision-making.

Are breast cancer patients with suboptimal adherence to cardiovascular treatment more likely to discontinue adjuvant endocrine therapy? Competing risk survival analysis in a nationwide cohort of postmenopausal women.

BACKGROUND: High rates of discontinuation undermine the effectiveness of adjuvant endocrine therapy (AET) among hormone-receptive breast cancer patients. Patient prognosis also relies on the successful management of cardiovascular risk, which affects a high proportion of postmenopausal women. As with AET, adherence with cardiovascular drugs is suboptimal. We examined whether patient adherence with cardiovascular drugs was associated with the rate of AET discontinuation in a French nationwide claims database linked with hospitalisation data. METHODS: We identified postmenopausal women starting AET between 01/01/2016 and 31/12/2020 and taking at least two drugs for the primary prevention of cardiovascular disease (antihypertensive drugs, lipid-lowering drugs and platelet aggregation inhibitors) before AET initiation. Adherence was assessed for each drug class by computing the proportion of days covered. Women were categorised as fully adherent, partially adherent or fully non-adherent with their cardiovascular drug regimen based on whether they adhered with all, part or none of their drugs. AET discontinuation was defined as a 90-day gap in AET availability. Time to AET discontinuation according to levels of cardiovascular drug adherence was estimated using cumulative incidence curves, accounting for the competing risks of death and cancer recurrence. Multivariate cause-specific Cox regressions and Fine-and-Gray regressions were used to assess the relative hazards of AET discontinuation. RESULTS: In total, 32,075 women fit the inclusion criteria. Women who were fully adherent with their cardiovascular drugs had the lowest cumulative incidence of AET discontinuation at any point over the 5-year follow-up period. At 5 years, 40.2% of fully non-adherent women had discontinued AET compared with 33.5% of partially adherent women and 28.8% of fully adherent women. Both partial adherence and full non-adherence with cardiovascular drugs were predictors of AET discontinuation in the two models (cause-specific hazard ratios 1.16 [95% CI 1.10-1.22] and 1.49 [95% CI 1.39-1.58]; subdistribution hazard ratios 1.15 [95% CI 1.10-1.21] and 1.47 [95% CI 1.38-1.57]). CONCLUSION: Clinicians should be aware that patients who do not adhere with their entire cardiovascular drug regimen are also more likely to discontinue AET. This stresses the importance of integrated care, as suboptimal adherence with both treatment components poses a threat to achieving ideal patient outcomes.

Combined influence of immigration status and income on cervical cancer screening uptake.

The regular performance of Pap tests for cervical cancer screening reduces this disease's incidence and mortality. Income inequalities have been reported for this screening, partly because in some countries women must advance or even pay out-of-pocket costs. Because immigrant status is also associated with low Pap test uptake, we aimed to analyze the combined impact of immigrant status and low income on cervical cancer underscreening. This study, based on the French CONSTANCES cohort, uses data from the cohort questionnaires and linked health insurance fund data about Pap test reimbursement. To measure income inequalities in screening, we calculated a Slope Index of Inequality (SII) by linear regression, taking into account the migration status of participants. The majority of the 70,614 women included in the analysis were not immigrants (80.2%), while 12.9% were second-generation immigrants, and 6.9% first-generation immigrants. The proportion of underscreening increased with immigrant status, from 19.5% among nonimmigrants to 23.6% among the second generation, and 26.5% among the first (P < 0.01). The proportion of underscreening also increased as income level decreased. The income gradient rose significantly from 14% among nonimmigrants to 21% in second-generation immigrants and 19% in the first generation (P < 0.01). Among first-generation migrants, the shorter the duration of residence, the higher the SII. Women who are first- or second-generation immigrants are simultaneously underscreened and subject to a more unfavorable economic gradient than native French women born to native French parents. The accumulation of several negative factors could be particularly unfavorable to screening uptake.

Impact of a patient reminder letter from their general practitioners on influenza vaccination: A quasi-experimental study in Paris, France.

BACKGROUND: Seasonal influenza vaccination coverage levels remain too low in many countries. OBJECTIVES: This study aimed to evaluate the impact of a reminder letter from their general practitioner (GP) on patients' influenza vaccination. METHODS: Eligible patients for this controlled non-randomised study were the vulnerable categories targeted by the 2019-2020 national health insurance fund (NHIF) vaccination campaign, on the lists of 14 GPs from three practices in Paris (France) and unvaccinated on January 2, 2020 (mid-campaign). The choice of practices and assigning five GPs to the intervention arm were made for convenience. At mid-campaign, GPs in the intervention arm sent a standardised letter reminding each eligible patient to be vaccinated. In the control arm, GPs worked as usual. The intervention effect, calculated from the NHIF databases, was estimated by the difference between the groups in their vaccination coverage at the end of the campaign, with a linear mixed model adjusted for age, sex, chronic disease (at the patient level) and medical practice (at the GP level). RESULTS: The vaccination coverage at the end of the campaign was 14.7% in the intervention group (n = 317) and 1.7% in the control group (n = 493): a difference of 13.1% points (95% confidence interval [9.0-17.2], number needed to send 7.7). At the campaign's end, vaccination coverage among patients from the lists of GPs in the intervention arm was 62.7%, and 46.2% among patients from the control-arm GP lists. CONCLUSION: Reminder letters could help increase influenza vaccination coverage.

Presence of Primary Care Physicians and Patients' Ability to Register: A Simulated-Patient Survey in the Paris Region.

Using the health care system fully in some countries requires patients to register with a primary care physician (PCP). Public health policies measure PCP density to maintain satisfactory local PCP supplies and limit geographic inequalities. In an exhaustive simulated-patient survey in the Paris, France region, we analyzed how well presence of PCPs was associated with patients' ability to register for care. Of 5,188 census blocks, 55.4% had at least 1 PCP; however, only 38.6% had at least 1 PCP accepting registration for office visits, and only 19.4% had at least 1 PCP accepting registration for home visits (P <.001 across the 3 indicators). Cross-block inequalities in accepting registration were steeper than those related to PCP density, indicating that this density metric offers false reassurance and is inadequate to support policy decisions.

Excess healthcare expenditure in adults treated for solid cancer in childhood: a cohort study in France.

BACKGROUND: Due to late effects, childhood cancer survivors (CCS) are more likely to have multiple chronic conditions than the general population. However, little is known about the economic burden of care of CCS in the long term. OBJECTIVES: To estimate excess healthcare expenditure for long-term CCS in France compared to the general population and to investigate the associated factors. METHODS: We included 5353 5-year solid CCS diagnosed before the age of 21 years before 2000 from the French CCS cohort and obtained a random reference sample from the general population for each CCS, matched on age, gender and region of residence. We used the French national health data system to estimate annual healthcare expenditure between 2011 and 2018 for CCS and the reference sample, and computed the excess as the net difference between CCS expenditure and the median expenditure of the reference sample. We used repeated-measures linear models to estimate associations between excess healthcare expenditure and CCS characteristics. RESULTS: Annual mean (95% CI) excess healthcare expenditure was €3920 (3539; 4301), mainly for hospitalization (39.6%) and pharmacy expenses (17%). Higher excess was significantly associated with having been treated before the 1990s and having survived a central nervous system tumor, whereas lower excess was associated with CCS who had not received treatment with radiotherapy. CONCLUSIONS: Of the variables that influence excess healthcare expenditure, a lever for action is the type of treatment administered. Future research should focus on addressing the long-term cost-effectiveness of new approaches, especially those related to radiotherapy.

The Association Between Age and Admission to an Inappropriate Ward: A Cross-Sectional Survey in France.

Half of elderly patient hospitalizations are preceded by an emergency department (ED) visit. Hospitalization in inappropriate wards (IWs), which is more frequent in case of ED overcrowding and high hospital occupancy, leads to increased morbidity. Elderly individuals are the most exposed to these negative health care outcomes. Based on a nationwide cross-sectional survey involving all EDs in France, the aim of this study was to explore whether age was associated with admission to an IW after visiting an ED. Among the 4384 patients admitted in a medical ward, 4065 were admitted in the same hospital where the ED was located, among which 17.7% were admitted to an IW. Older age was associated with an increased likelihood of being admitted to an IW (OR = 1.39; 95% CI = 1.02-1.90 for patients aged 85 years and older and OR = 1.40; 95% CI = 1.02-1.91 for patients aged 75-84 years, compared with those under 45 years). ED visits during peak periods and cardio-pulmonary presenting complaint were also associated with an increased likelihood of admission to an IW. Despite their higher vulnerability, elderly patients are more likely to be admitted to an IW than younger patients. This result reinforces the need for special attention to be given to the hospitalization of this fragile population.

Frequency and determinants of technical procedures in French general practice: a cross-sectional study.

INTRODUCTION: Technical skills have many areas of application in general practice and are a dimension of medical competence. Several studies have attempted to describe the technical procedures performed in general practice but most had limitations in the data collection process, the scope of the procedures addressed, or the healthcare actors involved. No French comparable data have been published. The aim of the present study was therefore to describe the frequency and type of technical procedures in French general practice, and to assess their determinants, in particular rurality. METHODS: The present study was ancillary to the ECOGEN (Eléments de la COnsultation en médecine GENérale) study, which was an observational cross-sectional, multicentre, nationwide study conducted in 128 French general practices. Data were collected on 20 613 patient-GP encounters, including the characteristics of GPs and encounters, as well as the health problems managed during the encounter and their associated processes of care; the latter two variables were coded according to the International Classification of Primary Care classification. The GPs' practice location was first classified as rural area, urban cluster, or urban area; the former two categories were combined for analysis. The various technical procedures were classified according to the framework of the International Classification of Process in Primary Care. The frequency of each technical procedure was compared according to GP practice location. The dependent variable analysed was the performance of at least one technical procedure per each health problem managed. Bivariate analysis was performed for all independent variables followed by multivariate analysis for key variables, using a hierarchical model including three levels: the physician, the encounter, the health problem managed. RESULTS: The data included 2202 technical procedures performed. At least one technical procedure was performed in 9.9% of encounters and for 4.6% of health problems managed. The two most frequent groups of technical procedures performed were injections (44.2% of all procedures) and clinical laboratory procedures (17.0%). The following procedures were more often performed by GPs practicing in a rural area or an urban cluster than those practicing in an urban area: injection of joints, bursae, tendons and tendon sheaths (4.1% v 1.2% of all procedures), manipulation and osteopathy (10.3% v 0.4%), excision/biopsy of superficial lesions (1.7% v 0.5%), and cryotherapy (1.7% v 0.3%). Conversely, the following procedures were more often performed by GPs practicing in urban areas: vaccine injection (46.6% v 32.1%), point-of-care testing for group A streptococci (11.8% v 7.6%), and ECG (7.6% v 4.3%). GPs practicing in a rural area or an urban cluster performed more often technical procedures than those practising in an urban area (odds ratio=1.31, 95% confidence interval 1.04-1.65), according to the multivariate model. CONCLUSION: Technical procedures were more frequently performed and more complex when they were performed in French rural and urban cluster areas. More studies are required to assess patients' needs regarding technical procedures.

Disagreement between patients' and general practitioners' estimates of patient health literacy increases from the top to the bottom of the social ladder: a cross-sectional study in the Paris area.

BACKGROUND: Associated with both socioeconomic position and health outcomes, health literacy (HL) may be a mechanism contributing to social disparities. However, it is often difficult for general practitioners (GPs) to assess their patients' HL level. OBJECTIVE: To analyse disagreements about patient HL between GPs and their patients according to the patient's socioeconomic position. METHODS: For each of the 15 participating GPs (from the Paris-Saclay University network), every adult consulting at the practice on a single day was recruited. Patients completed the European HL Survey questionnaire and provided socio-demographic information. For each patient, doctors answered 4 questions from the HL questionnaire with their opinion of the patient's HL. The doctor-patient disagreement about each patient's HL was analysed with mixed logistic models to study its associations with patients' occupational, educational, and financial characteristics. RESULTS: The analysis covered the 292 patients (88.2% of the 331 included patients) for whom both patients and GPs responded. The overall disagreement was 23.9%. In all, 71.8% of patients estimated their own HL as higher than their doctors did, and the gap between doctors' answers and those of their patients widened from the top to the bottom of the social ladder. The odd ratio for the 'synthetic disagreement' variable for workers versus managers was 3.48 (95% CI: 1.46-8.26). CONCLUSIONS: The lower the patient's place on the social ladder, the greater the gap between the patient's and doctor's opinion of the patient's HL. This greater gap may contribute to the reproduction or maintenance of social disparities in care and health.

Trends in clomiphene citrate and gonadotropins use in women with infertility between 2010 and 2017: A population-based study in France.

PURPOSE: To describe temporal trends and assess factors associated with changes in the prescription of clomiphene citrate and gonadotropins between 2010 and 2017 in women with infertility aged 18-50 from metropolitan France. METHODS: 6321 prevalent women from a representative sample of the national medico-administrative database were identified. We performed a Cochran-Armitage trend test and calculated the rate ratios. A Poisson regression was used to derive the incidence rate ratios, for each treatment class. RESULTS: The prevalence rate and incidence rate of clomiphene citrate use significantly decreased by 20% (RR 0.80: 95% CI 0.71-0.90) and 23% (RR 0.77: 95% CI 0.66-0.89), respectively. Its initiation was higher in all age groups compared to the reference (18-24 years), with a downward gradient. It was also higher when the density of gynaecologists was higher and in disadvantaged areas. The prevalence rate and incidence rate of gonadotropin use increased by 11% (RR 1.11: 95% CI 1.01-1.22) and 33% (RR 1.33: 95% CI 1.14-1.55) respectively. Gonadotropin initiation was highest in the 31-35 age group, but it was also higher in the 25-30 and 36-40 age groups at a similar level (reference 18-24 years). Its initiation was higher when the density of gynaecologists was higher, but not associated with social deprivation. CONCLUSION: Our results showed an increase in gonadotropin use for infertility treatment in France during the 2010-2017 period and a decrease in clomiphene citrate use. Further work should be undertaken to analyse the use of these drugs in relation to women's care pathways.

Determinants of Inclusion in Mainstream School for Children with Autism Spectrum Disorders from the EpiTED Study: A 10-Year Follow-up Cohort.

Inclusion of students with Autism Spectrum Disorder (ASD) in mainstream schools has a positive impact on their social and daily living behaviors. Our objective was to identify clinical and socio-demographic variables promoting or limiting inclusion in mainstream school through childhood and adolescence. The EpiTED study is a long-term, prospective, multicenter cohort of 281 ASD children included before the age of 7, with a 10-year follow-up in France. Variables significantly linked to inclusion in mainstream school were identified using a mixed-effect logistic regression model: greater autonomy [OR = 1.45 (1.29-1.63)], lesser symptom severity [OR = 0.96 (0.92-0.99)] and fewer siblings [OR = 0.86 (0.75-0.99)]. In the multivariate model, the probability for a child of being included in mainstream school decreased over time [OR = 0.91 (0.85-0.97)], i.e. with age.

General practitioner gender and use of diagnostic procedures: a French cross-sectional study in training practices.

OBJECTIVES: The acceleration in the number of female doctors has led to questions about differences in how men and women practice medicine. The aim of this study was to assess the influence of general practitioner (GP) gender on the use of the three main categories of diagnostic procedures-clinical examinations, laboratory tests and imaging investigations. DESIGN: Cross-sectional nationwide multicentre study. SETTING: French training general practices. PARTICIPANTS: The patient sample included all the voluntary patients over a cumulative period of 5 days per office between November 2011 and April 2012. The GP sample included 85 males and 43 females. METHODS: 54 interns in general practice, observing their GP supervisors, collected data about the characteristics of GPs and consultations, as well as the health problems managed during the visit and the processes of care associated with them. Using hierarchical multilevel mixed-effect logistic regression models, we performed multivariable analyses to assess differences in each of the three main categories of diagnostic procedures, and two specific multivariable analyses for each category, distinguishing screening from diagnostic or follow-up procedures. We searched for interactions between GP gender and patient gender or type of health problem managed. RESULTS: This analysis of 45 582 health problems managed in 20 613 consultations showed that female GPs performed more clinical examinations than male GPs, both for screening (OR 1.75; 95% CI 1.19 to 2.58) and for diagnostic or follow-up purposes (OR 1.41; 95% CI 1.08 to 1.84). Female GPs also ordered laboratory tests for diagnostic or follow-up purposes more frequently (OR 1.21; 95% CI 1.03 to 1.43). Female GPs performed even more clinical examinations than male GPs to diagnose or follow-up injuries (OR 1.69; 95% CI 1.19 to 2.40). CONCLUSION: Further research on the appropriateness of diagnostic procedures is required to determine to what extent these differences are related to underuse or overuse.

Mental health consequences of military sexual trauma: results from a national survey in the French military.

BACKGROUND: Military sexual trauma (MST) is a major public health concern, given its prevalence and mental health sequelae. This phenomenon is particularly prevalent among women in the US military, although more cases involve men given their overrepresentation. Little is known about MST and its consequences in other military settings, including in Europe. METHODS: This study draws from a national survey in the French military, including 1268 servicemen and 232 servicewomen. We conducted bivariate and multivariate analysis, using simple and multinomial logistic regressions to evaluate the associations between different forms of MST (repeated sexual comments alone/one form of sexual oppression (coercion, repeated verbal unwanted attention or assault)/ several sexual stressors) and symptoms of depression and of positive post-traumatic stress disorder (PTSD) screening scores. RESULTS: Women were both more likely to experience MST and to experience more severe forms of MST than men. Women were also more likely than men to report mental health symptoms (31% versus 18% for symptoms of depression and 4.0% versus 1.8% for positive PTSD screening scores). Different forms of MST were associated with different levels of psychological distress. Women reporting repeated sexual comments alone had higher odds of depressive symptoms (OR=3.1 [1.7, 5.5]) relative to women with no MST. Likewise, the odds of depressive symptoms were 6.5 times higher among women and 8.0 times higher among men who experienced several sexual stressors relative to those who reported no MST. We also found higher relative risk of subthreshold PTSD screening scores among women reporting any form of sexual stressor, including sexual comments alone (RRR = 4.5 [2.8, 7.4]) and an elevenfold increase in the relative risk of positive PTSD screen scores (RRR = 11.3 [2.3, 55.6]) among women who experienced several sexual stressors relative to women with no MST. CONCLUSION: MST is associated with mental health distress among service members in the French military, especially for women. The heightened risk of MST coupled with psychological sequelae call for preventive programs to reduce MST and for screening programs to provide adequate psychological support.

Gestational weight gain in a migration context: are migrant women more at risk of inadequate or excessive weight gain during pregnancy?

BACKGROUND: Inadequate or excessive gestational weight gain (GWG) is associated with adverse maternal and neonatal outcomes. Little is known on adequacy of GWG in migrant women. This study investigates whether migrant women in France are at higher risk of inadequate or excessive GWG, and what characteristics are associated with GWG in migrant and non-migrant groups. METHODS: We used data from the PreCARE multicentric prospective cohort (N=10 419). The study includes 5403 women with singleton deliveries, with non-migrant (n=2656) and migrant (n=2747) status. We used multinomial logistic regression, adjusting for maternal age and parity, to investigate the association of migrant status, socioeconomic status-related variables and GWG. In stratified analyses, we identified factors associated with GWG in both groups. RESULTS: Compared with non-migrant women, migrant women had increased risk of inadequate GWG (adjusted odds ratio (aOR) 1.18; 95% CI 1.03 to 1.34). Non-migrant women with foreign origins had increased risk of excessive GWG (aOR 1.58; 95% CI 1.30 to 1.92). Women born in Sub-Saharan Africa had increased risk of both inadequate and excessive GWG. Regardless of migration status, women with lower education and women who did not start pregnancy with a normal weight were less likely to gain adequately. Inadequate prenatal care was associated with inadequate GWG only among non-migrant women. CONCLUSION: Migrant women are at higher risk of inadequate GWG.

The role of organization of care in GPs' prevention practice.

BACKGROUND: General practitioners (GPs) do not systematically include preventive recommendations in their practice, and some characteristics of health care organization are associated with more systematic prevention. But the characteristics of health care organization may act in a nonuniform manner depending on the type of preventive care. Thus, one characteristic can be positively associated with one type of preventive care and negatively associated with another. Our aim was to investigate the association between health care organization in general practice and different areas of preventive care (immunization and addiction prevention), in search of nonuniform associations. METHODS: We used a representative survey of 1,813 French GPs conducted in 2009. Four preventive care practices were studied: immunization through flu and HPV vaccination, and prevention of addictive behaviors concerning tobacco and alcohol use.Characteristics of GPs' health care organization and the social context of their practice were collected (spatial accessibility to GPs and socioeconomic level of the area of practice). We constructed mixed models to study associations and interactions between the organization variables and preventive care. RESULTS: Four out of five characteristics of GPs' organization have uneven impacts on different types of preventive care (p-interaction < 10-4). For example, number of daily consultations is associated with better immunization prevention but with poorer prevention counseling in addictive behaviors. In contrast, working with digital medical files is uniformly associated with both types of preventive care (OR = 1.29 [1.15-1.45]; P < 10-4). CONCLUSION: An approach centered on specific types of preventive care should help deepen our understanding of prevention and possibly help to identify a new typology for preventive care.

From sexual harassment to sexual assault: Prevalence and correlates of sexual trauma in the French military.

BACKGROUND: Sexual harassment (SH) is prevalent in military settings and dependent on the workplace environment. Few studies have investigated this issue in non-US military settings nor have examined how contextual and individual factors related to Military Sexual Trauma (MST) vary by gender. METHODS: This study draws on a national sexual survey in the French military including 1268 servicemen and 232 servicewomen. We examined four sexual stressors (repeated sexual comments, sexual coercion, repeated unwanted verbal sexual attention and sexual assault (SA)) and two combined measures of verbal SH (comments, unwanted attention) and MST (all forms). We conducted multivariate logistic regressions to identify contextual and individual factors related to these outcomes. RESULTS: 36.7% of women and 17.5% of men experienced MST in the last year and 12.6% and 3.5% reported SA. Factors associated with verbal SH differed from those related to SA. The odds of verbal SH were elevated among men who had sex with men (OR = 3.5) and among women officers (OR = 4.6) while the odds of SA were elevated among men less than 25 years (OR = 3.5) and women with less than a high school diploma (OR = 10.9). The odds of SH increased by 20% to 80% when men worked in units with higher female representation, higher prevalence of MST (sexual comments, or sexual assault, coercion, repeated unwanted attention) and lower acceptance of women in the miliatry. The odds of SA also increased by 70% among men working in units with higher female representation and higher prevalence of sexual oppression. The odds of SA against women were particular high (OR = 5.7) in units with a high prevalence of sexual assault, coercion, or repeated unwanted attention. CONCLUSION: MST is common in the French military, with women experiencing more severe forms than men. Our resuls call for programmatic action to reduce workplace factors related to verbal SH and SA in the French military.

Clinical course and cost assessment of infants with a first episode of acute bronchiolitis presenting to the emergency department: Data from the GUERANDE clinical trial.

INTRODUCTION: Bronchiolitis is the leading cause of hospitalization for infants but its economic burden is not well documented. Our objective was to describe the clinical evolution and to assess the 1-month cost of a first episode of acute bronchiolitis presenting to the emergency department (ED). METHODS: Our study was an epidemiologic analysis and a cost study of the cohort drawn from the clinical trial GUERANDE, conducted in 24 French pediatric EDs. Infants of 6 weeks to 12 months of age presenting at pediatric EDs with a first episode of bronchiolitis were eligible. The costs considered were collected from a societal viewpoint, according to the recommendations of the French National Health Authority. RESULTS: A total of 777 infants were included with a median age of 4 months. A total of 57% were hospitalized during the month following the first consultation in the ED, including 28 (3.6%) in an intensive care unit. The mean length of stay was 4.2 days (SD = 3.7). The average time to relief of all symptoms was 13 days (SD = 7). Average total cost per patient was €1919 (95% confidence interval: 1756-2138) from a societal perspective, mostly due to hospitalization cost. The estimated annual cost of bronchiolitis in infants was evaluated to be between €160 and €273 million in France. DISCUSSION: Bronchiolitis represent a high cost for the health care system and broadly for society, with hospitalizations costs being the main cost driver. Thus significant investments should be made to develop innovative therapies, to reduce the number of hospitalizations and length of stay.