Screening problematic use of substances among young subjects attending an emergency department, and subsequent treatment seeking.

INTRODUCTION: Young individuals constitute a key population for the screening of problematic use of substances (PUS), but they are not likely to seek support and are hard to reach. Targeted screening programs should thus be developed in the places of care they may attend for other reasons, including emergency departments (EDs). We aimed to explore the factors associated with PUS in young people attending an ED; we measured the subsequent access to addiction care after ED screening. METHODS: This was a prospective interventional single-arm study which included any individual aged between 16 and 25 years who attended the main ED of Lyon, France. Baseline data were sociodemographic characteristics, PUS status using self-report questionnaires and biological measures, level of psychological health, and history of physical/sexual abuse. Quick medical feedback was provided to the individuals presenting a PUS; they were advised to consult an addiction unit, and contacted by phone at three months to ask whether they had sought treatment. Baseline data were used to compare PUS and non-PUS groups using multivariable logistic regressions, to provide adjusted odds ratios (aORs) and 95% confidence intervals (95% CI), with age, sex, employment status, and family environment as the adjustment variables. The characteristics of PUS subjects who subsequently sought treatment were also assessed using bivariable analyses. RESULTS: In total, 460 participants were included; 320 of whom (69.6%) were presenting current substance use, and 221 (48.0%) with PUS. Compared to non-PUS individuals, PUS ones were more likely to be males (aOR=2.06; 95% CI [1.39-3.07], P<0.001), to be older (per one-year increase: aOR=1.09; 95% CI [1.01-1.17], P<0.05), to have an impaired mental health status (aOR=0.87; 95% CI [0.81-0.94], P<0.001), and to have a history of sexual abuse (aOR=3.33; 95% CI [2.03-5.47], P<0.0001). Only 132 (59.7%) subjects with PUS could be reached by phone at 3 months, among whom only 15 (11.4%) reported having sought treatment. Factors associated with treatment seeking were social isolation (46.7% vs. 19.7%; P=0.019), previous consultation for psychological disorders (93.3% vs. 68.4%; P=0.044), lower mental health score (2.8±1.6 vs. 5.1±2.6; P<0.001), and post-ED hospitalization in a psychiatric unit (73.3% vs. 19.7%; P<0.0001). DISCUSSION/CONCLUSION: EDs are relevant places to screen PUS in youth, but the level of seeking further treatment needs to be substantially improved. Offering systematic screening during an emergency room visit could allow for more appropriate identification and management of youth with PUS.

Using patient comments from a standardised experience survey to investigate their perceptions and prioritise improvement actions: a thematic and syntactic analysis.

BACKGROUND: Although patient experience surveys flourish in many countries with the aim to improve quality of care, questions remain concerning their ability to become effective drivers of change within institutions. The patient comments from the French national patient experience hospital survey were analysed using an innovative structured approach to characterise patient experience and identify field actions for the institutions. METHODS: The comments were taken from the two open-ended questions comprised in the patient experience survey of the Hospices Civils de Lyon between 2018 and 2019. The comments analysis methodology consisted in three steps: thematic analysis; syntactic analysis; generation of statistics for the creation of a patient journey and prioritisation of sub-themes. The STROBE statement checklist was followed. RESULTS: Over a year, 79.7% of the 7 362 respondents left at least one comment at the end of the survey and were included in the study, for a total of 5 868 surveys and 10 061 comments. These led to the identification of 28 general themes and 184 specific sub-themes. From the patient journey created, 23 sub-themes were prioritised and gathered into four key categories: relationship between patient and staff; environment; surgery and pain management; information and care coordination. For each of them, the actions and expectations formulated by the respondents were described. CONCLUSIONS: The analysis of patient comments obtained from a standardised survey allowed to characterise the patient journey using data that describes patient experience, enabling a prioritisation of actions aiming to improve practice and quality of care at the institution, department, and staff level.

One-month alcohol abstinence national campaigns: a scoping review of the harm reduction benefits.

Over the last decade, one-month alcohol abstinence campaigns (OMACs) have been implemented within the general population in an increasing number of countries. We identified the published studies reporting data on OMACs to explore the following aspects: profile of participants, rates and factors associated with the completion of the abstinence challenge, and outcomes and harm reduction benefits in participating in the challenges. We screened 322 records, including those found in the grey literature, and reviewed 6 studies and 7 Dry July Annual Reports. Compared to non-participating alcohol users, participants were more likely to be female, have a higher income, and a higher level of education. They were heavier drinkers and were more concerned by the consequences of alcohol on health and by their health in general. Participants who achieved the one-month abstinence challenge were lower drinkers and more likely to have registered on the campaign-related Internet communities. Both successful and unsuccessful participants frequently reported health benefits, including sleep improvement and weight loss. Successful participants were more likely to durably change their alcohol drinking habits. Overall, OMACs provide short- or mid-term harm reduction benefits for both successful and unsuccessful participants. Findings were limited by the paucity of studies, their observational nature, and heterogeneity in the features of the different national campaigns, which would probably gain in enhanced internationalization.

Effect of trickling filter on carbon and nitrogen removal in vertical flow treatment wetlands: A full-scale investigation.

Vertical Flow Treatment Wetland (VF-TW) systems achieve high efficiencies in terms of carbon related parameters removals from domestic wastewaters. Nitrogen removal is also efficient but optimisations are still needed. This article reports and discusses experimental data collected from 24-h monitoring campaigns of 29 full-scale VF-TWs, having different configurations and operation time up to 13 years. All monitored systems gathered 1 or 2 stage(s) of unsaturated or partially saturated VF-TW. Additionally, some of those included an aerobic biological Tricking Filter (TF) prior to TW stage(s). Results firstly showed that the implementation of a TF improved TSS, COD and BOD5 removal rates in the monitored systems. Regarding nitrogen removal, the association of TF with one stage of partially saturated vertical TW was found to achieve around 79% of nitrification in average and up to 92% in some cases. In the configurations where TF was associated to 2 successive stages of TW, almost all total nitrogen removal by nitrification/denitrification was achieved at the outlet of the first-stage TW. The contribution of the second-stage TW in denitrification was found very low due to limited availability of organic carbon to support heterotrophic denitrification. Specific solutions to enhance the contribution of the second stage in the denitrification process are discussed.

Adverse Events in Intensive Care and Continuing Care Units During Bed-Bath Procedures: The Prospective Observational NURSIng during critical carE (NURSIE) Study.

OBJECTIVES: Standard nursing interventions, especially bed-baths, in ICUs can lead to complications or adverse events defined as a physiologic change that can be life-threatening or that prolongs hospitalization. However, the frequency and type of these adverse events are rarely reported in the literature. The primary objective of our study was to describe the proportion of patients experiencing at least one serious adverse event during bed-bath. The secondary objectives were to determine the incidence of each type of serious adverse event and identify risk factors for these serious adverse events. DESIGN: Prospective multicenter observational study. SETTING: Twenty-four ICUs in France, Belgium, and Luxembourg. PATIENTS: The patients included in this study had been admitted to an ICU for less than 72 hours and required at least one of the following treatments: invasive ventilation, vasopressors, noninvasive ventilation, high-flow oxygen therapy. Serious adverse events were defined as cardiac arrest, accidental extubation, desaturation and/or mucus plugging/inhalation, hypotension and/or arrhythmia and/or agitation requiring therapeutic intervention, acute pain, accidental disconnection or dysfunction of equipment, and patient fall requiring additional assistance. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The study included 253 patients from May 1, 2018, to July 31, 2018 in 24 ICUs, representing 1,529 nursing procedures. The mean Simplified Acute Physiology Score II was 54 ± 19. Nursing care was administered by an average of 2 ± 1 caregivers and lasted between 11 and 20 minutes. Of the 253 patients included, 142 (56%) experienced at least one serious adverse event. Of the 1,529 nursing procedures, 295 (19%) were complicated by at least one serious adverse event. In multivariate analysis, the factors associated with serious adverse event were as follows: presence of a specific protocol (p = 0.011); tracheostomy (p = 0.032); administration of opioids (p = 0.007); presence of a physician (p = 0.0004); duration of nursing care between 6 and 10 minutes (p = 0.003), duration of nursing care between 11 and 20 minutes (p = 0.005), duration of nursing care greater than 40 minutes (p = 0.04) with a reference duration of nursing care between 20 and 40 minutes. CONCLUSIONS: Serious adverse events were observed in one-half of patients and concerned one-fifth of nurses, confirming the need for caution. Further studies are needed to test systematic serious adverse event prevention strategies.

Model of neo-Malthusian population anticipating future changes in resources.

In this paper we develop a class of models to study a population and resource dynamical system in which the decision to give birth is based on a rational far-sighted cost-benefit analysis on what the future of the resource level will be. This leads to consider a system in which a time forward population/resource dynamical system is coupled with a time backward Bellman's equation (which models the choice of having a child). We construct, from a population model with food consumption, an example, to study the change in time of the fertility rate when a catastrophic change in resource is announced at a given moment, when a birth control policy is announced and we compare these two announcements in case nothing happens. Moreover, we provide, mathematical tools to theoretically and numerically study this complex coupling of time forward and time backward equations.

Assessing the hospital volume-outcome relationship in surgery: a scoping review.

INTRODUCTION: Many recent studies have investigated the hospital volume-outcome relationship in surgery. In some cases, the results have prompted the centralization of surgical activity. However, the methodologies and interpretations differ markedly from one study to another. The objective of the present scoping review was to describe the various features used to assess the volume-outcome relationship: the analyzed datasets, study population, outcome, covariates, confounders, volume modalities, and statistical methods. METHODS AND ANALYSIS: The review was conducted according to a study protocol published in BMJ Open in 2020. Two authors (both of whom had helped to design the study protocol) screened publications independently according to the title, the abstract and then the full text. To ensure exhaustivity, all the papers included by each reviewer went through to the next step. INTERPRETATION: The 403 included studies covered 90 types of surgery, 61 types of outcome, and 72 covariates or potential confounders. 191 (47.5%) studies focussed on oncological surgery and 37.8% focussed visceral or digestive tract surgery. Overall, 86.6% of the studies found a statistically significant volume-outcome relationship, although the findings differed from one type of surgery to another. Furthermore, the types of outcome and the covariates were highly diverse. The majority of studies were performed in Western countries, and oncological and visceral surgical procedures were over-represented; this might limit the generalizability and comparability of the studies' results.

Use of multilayer silicone foam dressings as adjuvant therapy to prevent pressure injuries.

Despite progress in the prevention of pressure injuries (PIs), they remain a challenging public health problem because of their frequency and morbidity. Protection of the skin by multilayer silicone foam dressings may be an adjuvant measure to prevent PIs in high-risk patients. Despite the available clinical data and published recommendations on this measure, caregivers face difficulties in identifying patients who would benefit from this adjuvant measure. The objective of this work was to define the profiles of high-risk patients who would benefit optimally from this measure in combination with basic preventive procedures. This consensual expert opinion was drawn up using two methods: the Nominal Group Technique with eight medical and paramedical experts, and the Delphi process with 16 experts. The bases for this expert consensual opinion were a formal search and analysis of the published literature regarding evidence on the prevention of PIs using multilayer silicone foam dressings. The consensual expert opinion reported here addresses five proposals mostly intended to define patients who would benefit from the use of a multilayer silicone foam dressing (≥4 layers) to prevent PIs (sacrum and heels).

Prevalence of pressure injuries among critically ill patients and factors associated with their occurrence in the intensive care unit: The PRESSURE study.

BACKGROUND: The prevalence of pressure injuries (PIs) in critically ill patients has been extensively studied, but there is uncertainty regarding the risk factors. The main objective of this study was to describe the prevalence of PIs in critically ill patients. Secondary objectives were to describe PI, use of preventive measures for PI, and factors associated with occurrence of PI in the intensive care unit (ICU). MATERIAL AND METHODS: This was a 1-day point-prevalence study performed on a weekday in June 2017 in ICUs in France. On the same day, we noted the presence or absence of PI in all hospitalised patients of the participating ICUs, data on the ICUs, and the characteristics of patients and of PI. RESULTS: Eighty-six participating ICUs allowed the inclusion of 1228 patients. The prevalence of PI on the study day was 18.7% (95% confidence interval: 16.6-21.0). PIs acquired in the ICU were observed in 12.5% (95% confidence interval: 10.6-14.3) of critically ill patients on the study day. The most frequent locations of PI were the sacrum (57.4%), heel (35.2%), and face (8.7%). Severe forms of PI accounted for 40.8% of all PIs. Antiulcer mattresses were used in 91.5% of the patients, and active and/or passive mobilisation was performed for all the patients. Multiple logistic regression analysis identified longer length of stay in the ICU, a higher Simplified Acute Physiology Score, higher body weight, motor neurological disorder, high-dose steroids, and absence of oral nutrition on the study day as factors independently associated with occurrence of PI in the ICU. CONCLUSION: This large point-prevalence study shows that PIs are found in about one of five critically ill patients despite extensive use of devices for preventing PI. Acquisition of PI in the ICU is strongly related to the patient's severity of illness on admission to the ICU and length of stay in the ICU.

Cost effectiveness and policy announcement: The case of measles mandatory vaccination.

In a vaccination game, individuals respond to an epidemic by engaging in preventive behaviors that, in turn, influence the course of the epidemic. Such feedback loops need to be considered in the cost effectiveness evaluations of public health policies. We elaborate on the example of mandatory measles vaccination and the role of its anticipation. Our framework is a SIR compartmental model with fully rational forward looking agents who can therefore anticipate on the effects of the mandatory vaccination policy. Before vaccination becomes mandatory, parents decide altruistically and freely whether to vaccinate their children. We model eager and reluctant vaccinationist parents. We provide numerical evidence suggesting that individual anticipatory behavior may lead to a transient increase in measles prevalence before steady state eradication. This would cause non negligible welfare transfers between generations. Ironically, in our scenario, reluctant vaccinationists are among those who benefit the most from mandatory vaccination.

Assessing the performance of indicators during their life cycle: the mixed QUID method.

BACKGROUND: Quality indicators (QI) are mandatory in French hospitals. After a decade of use, the Ministry of Health set up an expert workgroup to enhance informed decision-making regarding currently used national QI, i.e. to propose a decision of withdrawing, revising or continuing their use. We report the development of an integrated method for a comprehensive appraisal of quality/safety indicators (QI) during their life cycle, for three purposes, quality improvement, public disclosure and regulation purposes. The method was tested on 10 national QI on use for up to 10 years to identify operational issues. METHODS: A modified Delphi technique to select relevant criteria and a development of a mixed evaluation method by the workgroup. A 'real-life' test on 10 national QI. RESULTS: Twelve criteria were selected for the appraisal of QI used for regulation goals, 11 were selected for hospital improvement and seven for public disclosure. The perceived feasibility and relevance were studied including hospital workers, patients and health authorities professionals; the scientific soundness of the indicator development phase was reviewed by analyzing reference documents; the metrological performance (limited to the discriminatory power and dynamics of change during the life cycle dimensions) was analyzed on the national datasets.Applied to the 10 QI, the workgroup proposed to withdraw four of them and to modify or suspend the six others. CONCLUSIONS: The value of the method was supported by the clear-cut conclusions and endorsement of the proposed decisions by the health authorities.

Improving the safety climate in hospitals by a vignette-based analysis of adverse events: a cluster randomised study.

OBJECTIVE: To assess the impact of a vignette-based analysis of adverse events (AEs) on the safety climate (SC) of care units. DESIGN: Prospective, open, cluster (a unit) randomised controlled trial. SETTING: Eighteen acute care units of seven hospitals in France. PARTICIPANTS: Healthcare providers who worked in the units. INTERVENTION: Vignette-based analyses of AEs were conducted with unit's providers once per month for six consecutive months. The AEs were real cases that occurred in other hospitals. The hospital risk manager conducted each analysis as follows: analysis of the immediate and root causes of the AE; assessment of the care unit's vulnerabilities and existing barriers in the occurrence of an identical AE and search for solutions. MAIN OUTCOME MEASURE: SC was measured using the French version of the Hospital Survey on Patient Safety Culture questionnaire. The primary outcome was the difference in the 'Organisational learning and continuous improvement' dimension score, from before to after the analyses. RESULTS: Median participation rate in the analyses was 20% (range: 7-45%). Before intervention, the response rate to the SC survey was 80% (n = 210) in the intervention group and 73% (n = 191) in the control group. After intervention, it was 59% (n = 141) and 63% (n = 148), respectively. The dimension score evolved differently for the groups from before to after intervention (intervention: +10.2 points ±8.8; control: -3.0 points ±8.5, P = 0.04). Side effects were not measured. CONCLUSIONS: Vignette-based analysis was associated with the improvement of the perception of participants regarding their institution's capacity for organisational learning and continuous improvement.

Canonical modeling of anticipatory vaccination behavior and long term epidemic recurrence.

Vaccination is one of humanity's main tools to fight epidemics. In most countries and for most diseases, vaccination is offered on a voluntary basis. Hence, the spread of a disease can be described as two interacting opposite dynamic systems: contagion is determined by past vaccination, while individuals decide whether to vaccinate based on beliefs regarding future disease prevalence. In this study, we show how the interplay between such anticipating behavior and the otherwise biological dynamics of a disease may lead to the emergence of recurrent patterns. We provide simulation results for (i) a Measles-like outbreak, (ii) canonical fully rational and far-sighted individuals, (iii) waning vaccine efficacy and vital dynamics, and (iv) long periods of time, i.e. long enough to observe several vaccination peaks. For comparison, we conducted a similar analysis for individuals with adaptive behavior. As an extension, we investigated the case where part of the population has an anti-vaccination stance.

[Emergence of the patient-actor in patient safety in France. A narrative review in social sciences and public health]. / L'émergence du patient-acteur dans la sécurité des soins en France : une revue narrative de la littérature entre sciences sociales et santé publique.

INTRODUCTION: For the last forty years, patients have been encouraged to take part in their care and to participate in improving the quality and safety of care. This phenomenon requires reflection on the conditions of emergence of this new role and its public health implications, particularly in the field of patient safety. METHODS: A narrative review of the international literature was conducted by searching Medline, Cairn and Persée databases. RESULTS: The database query identified 2,206 documents, 106 of which were included in the analysis. The emergence of the patient-actor is linked to sanitary crises and promoted by patient associations in the field of patient safety such as le Lien. This movement induces a transformation of the patient's role beyond the theme of patient safety: it revolutionizes the patient's contribution to the health system. CONCLUSION: This narrative review of the literature highlights the way in which health crises have encouraged the emergence of a new actor: the patient-actor, accompanied by new semantics concerning the power of the patient. The patient occupies a specific place in the field of safety of care. In collaboration with healthcare professionals, the patient must constitute a resource to improve patient safety. The various contributions of patients are described and an analysis of the acceptability of patient participation is proposed.

Multi-scale modelling of ovarian follicular development: From follicular morphogenesis to selection for ovulation.

In this review, we present multi-scale mathematical models of ovarian follicular development that are based on the embedding of physiological mechanisms into the cell scale. During basal follicular development, follicular growth operates through an increase in the oocyte size concomitant with the proliferation of its surrounding granulosa cells. We have developed a spatio-temporal model of follicular morphogenesis explaining how the interactions between the oocyte and granulosa cells need to be properly balanced to shape the follicle. During terminal follicular development, the ovulatory follicle is selected amongst a cohort of simultaneously growing follicles. To address this process of follicle selection, we have developed a model giving a continuous and deterministic description of follicle development, adapted to high numbers of cells and based on the dynamical and hormonally regulated repartition of granulosa cells into different cell states, namely proliferation, differentiation and apoptosis. This model takes into account the hormonal feedback loop involving the growing ovarian follicles and the pituitary gland, and enables the exploration of mechanisms regulating the number of ovulations at each ovarian cycle. Both models are useful for addressing ovarian physio-pathological situations. Moreover, they can be proposed as generic modelling environments to study various developmental processes and cell interaction mechanisms.

Hospital survey on patient safety culture (HSOPS): variability of scoring strategies.

OBJECTIVE: To assess the variability of safety culture dimension scores and their associated rankings depending on three different scoring strategies using the Hospital Survey On Patient Safety Culture (HSOPS). DESIGN: Cross-sectional study using a self-administered questionnaire. SETTING: The study was conducted in an 1836-bed acute-care French university hospital with an annual volume of 135 999 stays, between April 2013 and November 2014. PARTICIPANTS: All caregivers and technical-administrative staff with at least 6 months of employment, spending at least half of their working time in the hospital, were asked to participate. INTERVENTION: None. MAIN OUTCOME MEASURE: The variability of the HSOPS results using three different scoring methods: the percentage of positive responses recommended by the Agency for Healthcare Research and Quality, the averaged individual means and the averaged individual sums. RESULTS: The response rate was 78.6% (n = 3978). The percentage of positive responses resulted in lower scores compared to averaged individual means and averaged individual sums in the six least developed dimensions, and gave more widely spread scores and greater 95CIs in the six most developed dimensions. Department rankings also varied greatly depending on the scoring methods. CONCLUSION: The values of the HSOPS scores and their corresponding rankings greatly depended on the computation method. This finding shows how important it is to agree on the use of the same scoring strategies, before broadly comparing results within and across organizations.

Organizational and managerial factors associated with clinical practice guideline adherence: a simulation-based study in 36 French hospital wards.

OBJECTIVES: To identify managerial and organizational characteristics of multi-specialty medicine wards and individual characteristics of health professionals that are most strongly associated with clinical practice guidelines (CPG) adherence. DESIGN: Cross-sectional stratified cluster sample design. SETTING: Data were gathered from 36 randomly selected multi-specialty medicine wards. PARTICIPANTS: The study population included all health professionals involved in patient care working in the participating wards. MAIN OUTCOME MEASURES: The degree of CPG adherence was measured using clinical vignettes on three topics: pain management, managing heart failure and managing diabetes. Responses from each professional to each clinical case were quantified using a 10-point scale. Managerial and organizational characteristics of medical department and individual characteristics of health professionals were obtained using three questionnaires. RESULTS: The study sample consisted of 859 professionals (362 orderlies, 361 nurses and 136 physicians). Factors independently and positively associated with CPG adherence were (i) individual factors: low age of professionals, expertise in diabetology and activity in cardiology; (ii) organizational and managerial factors: good understanding between physicians and other personnel; and (iii) structural factors: computer-based test results and prescriptions, presence of medical specialists, inter-department mobility of orderlies, medium-length stay (between 7 and 10 days) and large bed capacity. CONCLUSIONS: Good CPG adherence in general medicine needs institutional dynamism, availability of clinical competence and team culture based on cooperation.

[The emergence of patient safety issues in France]. / L'émergence de la question de la sécurité des patients en France.

INTRODUCTION: The objective of this study was to elucidate the conditions of emergence of patient safety issues in the public debate and the limits to implementation of patient safety in the current health system. METHOD: A narrative review of the international literature was conducted by searching PubMed, Cairn and Persée databases. RESULTS: The database search retrieved 2,206 documents, 48 of which were included in the study. The theme of patient safety has spread worldwide, but emerged late in France. The delayed emergence of patient safety in France is essentially related to the euphemistic approach to the problem of patient safety, the difficulty of adopting systematic reasoning, the lack of human resources management levers and the ambiguous position of patients in relation to patient safety.