Effect of age and exposure group on the onset of AIDS in heterosexual and homosexual HIV-infected patients. SEROCO Study Group.

OBJECTIVE: To analyse the influence of age at seroconversion and sexual exposure group on the progression of HIV disease. DESIGN: This multicentre prospective cohort study involved 443 subjects whose date of HIV infection was known to within +/- 1 year. Individuals whose sexual behaviour was exclusively heterosexual after HIV infection constituted the heterosexual group (n = 131). AIDS-free survival was compared with that of men (n = 312) infected through homosexual sex and who continued homosexual activity after HIV infection. They constituted the homosexual group. METHODS: The end-point was the onset of an AIDS-defining illness listed in the 1987 revised Centers for Disease Control and Prevention (CDC) criteria. Using the Kaplan-Meier method, AIDS-free survival curves were plotted for three age categories (< 20, 20-39, > or = 40 years). A Cox model was used to quantify the effect of age and to assess the influence of exposure group on AIDS onset after adjustment for age. Because of the high incidence of Kaposi's sarcoma (KS) among homosexual men, a disease that can be an early AIDS-defining illness, multivariate analysis was performed with and without consideration of the occurrence of KS. RESULTS: Patients aged > or = 40 years at seroconversion progressed more rapidly to AIDS than younger patients (P < 0.006). When age was fitted as a continuous variable and adjusted for exposure group, the relative risk of developing AIDS by any time after seroconversion was 1.34 for a 10-year increase difference [P = 0.03; 95% confidence interval (CI), 1.03-1.77]. After adjustment for age, the relative risk of developing AIDS (CDC criteria) was 2.42 (P = 0.008; 95% CI, 1.18-4.97) among the homosexual men (AIDS cases, n = 56). All cases of KS (n = 19) involved the homosexual group. Excluding KS as a first manifestation of AIDS, homosexual or bisexual subjects had a risk of AIDS of 1.92 (P = 0.07; 95% CI, 0.92-4.03) compared with heterosexual subjects. CONCLUSIONS: The risk of AIDS increases with age at seroconversion. The more rapid progression towards AIDS in the homosexual group than in the heterosexual group persisted after adjustment for age. Further studies are required to determine the possible role of repeated exposure to HIV or other pathogens acquired sexually.

Socio-demographic variation in perceived illness and the use of primary care: the value of community survey data for primary care service planning.

This paper addresses the question of the prevalence of self reported morbidity in the community and reports on results obtained using the Nottingham Health Profile in a population survey of morbidity. The variation between demographic and social groups and the relationship with GP are considered. The results show that certain aspects of morbidity vary according to social group more markedly than other aspects, and that some dimensions of self reported morbidity are predictive of recent consultation reported by the respondents. The interpretation of data of this sort for health planning purposes is considered. For example, the manual groups were particularly susceptible to tiredness and sleep disturbance, but these were not conditions associated with more frequent consultation. The manual groups also reported higher levels of pain and emotional distress, which were associated with propensity to consult. Other types of morbidity associated with consultation with the general practitioner were physical symptoms of pain and feelings of social isolation, but these did not show a strong class difference.

The French version of the Nottingham Health Profile. A comparison of items weights with those of the source version.

The efficient and reliable assessment of general community health requires the development of comprehensive and parsimonious measures of proven validity. The Nottingham Health Profile (NHP) has been demonstrated to be a reliable indicator of common expressions of discomfort and stress in the general population. The present paper describes its linguistic adaptation into French, the derivation of item weights by Thurstone's method of paired comparisons and the comparison of item weights across various sociodemographic groups. There is more similarity than variation on the valuation of the state of health explored by the NHP between the French and the British population as little inter-cultural or inter-linguistic variations were found. The differences in judgement of severity elicited across sociodemographic groups in the French sample cast some doubts on the relevance of general weights for use in population surveys.

Cross-cultural adaptation of health measures. European Group for Health Management and Quality of Life Assessment.

There is increasing interest throughout Europe in measuring health needs in the general population and in the 'quality of life' of patients. This has led to a demand for questionnaires capable of measuring health status in a reliable and valid manner. Most existing measures have, however, been standardised only in the U.S.A. and, to a lesser extent, in the U.K. The issue of translation and retesting of questionnaires prepared in the English language for use in other countries has received surprisingly little attention. This paper describes some of the technical, linguistic and conceptual issues raised by translation and the processes involved in producing acceptable country-specific versions of the Nottingham Health Profile according to a systematic method.

Characteristics of elderly people receiving home-help in three regions of France.

This study examined the allocation of home-help to the elderly using survey data collected on 3153 elderly respondents living at home in Haute-Normandie, Lille, and Ile-de-France. The samples of respondents were stratified by age, sex and area of residence, and were randomly selected from the electoral registers. The analysis identified 399 elderly people "in need": of home-help - living alone with disability. Of these, only 21% received home help. Of 174 home help recipients, 49% were "in need", and they received 52% of the volume (hours) of help allocated. The pattern of allocation varied regionally.

[Sciatica and other low-back disorders in private practice: extent of the problem and therapeutic approaches]. / Les sciatiques et autres affections vertébrales basses en médecine libérale: ampleur du phénomène et attitudes thérapeutiques.

Using data collected by INSERM in a 1975 survey among French general practitioners and specialists in private practice, the reporting of sciatica and low back pain (LBP) was studied, as well as doctors' diagnoses and therapeutic approaches. Only 0.7% of patients were reported as having sciatica, while 2.8% were reported with LBP. These percentages suggest, respectively, 1.5 and 6.5 million consultations with private practitioners. The prevalence of sciatica was estimated at 8%. There was no urban-rural difference in the consultation rate; three-quarters of the patients were seen by GPs. The frequency of LBP was higher among the employed, particularly among manual workers. Referrals for additional examinations were nearly twice as high for sciatica as for LBP. GPs prescribed more medicines, and more sick leave, than specialists, but made fewer referrals for additional examination, probably because the patients seen were different, or were at a different stage of disease. It is concluded that the formulation of standards of care specific to each level of care might be useful.

[Development of a conversion table of dependence of the aged on home aide needs]. / Etablissement d'une table de passage de la dépendance des personnes âgées au besoin d'aide à domicile.

Planning home help for geographical areas requires information on disabilities and required needs. This paper proposes a methodology to estimate the amount of help required. The analysis is based on survey data from three French regions: Ile-de-France, Languedoc-Roussillon and Basse-Normandie and from a team of experts. The total need, whether covered by professionals or by the patient's social network is considered for three aspects: Activities of Daily Living (ADL), Instrumental Activities of Daily Living (IADL) and additional help resulting from home conditions. The required average number of hours per week varies from 49.9 for people confined to bed or chair, to 3.8 for people able to get out of their house without help (group 4). The need for IADL represents 44% of the total need for group 1 and 60% for group 4. Housing conditions generated an additional time representing 3 to 5% of total need, according to the group considered. The methodology allows to identified discrepancies between requirements and help provided by region and by disability group within each region. It appears to be a useful tool in planning home-help.

[Study of the factors associated with the inability to perform household tasks among aged persons on the Ile-de-France. Application to the sub-regional planning of home-help services]. / Etude des facteurs liés à l'incapacité pour les tâches domestiques chez les personnes âgées en Ile-de-France. Application à la planification infra-régionale des services d'aide ménagère.

The aim of this paper is to present the preliminary results of a planning project in the area of health and social services for the elderly, which makes it possible to estimate the number of persons likely to seek help from such services at the administrative area levels with decisional powers. This involves identifying predictors of disability from raw data routinely available in the census and at various administrative area levels, the municipality being the preferred level. From the epidemiological data collected at the regional level, an indicator of disability has been constructed. Initially, those factors possibly associated with disabilities were identified by regrouping the variables in four dimensions (discriminant analysis): socio-economic, physical environment, human environment, local administrative area environment (district data from census, medical-social services offered in the area, ect.). Subsequently, a logistic regression made it feasible to calculate the coefficients attached to these predictors of disability. In our sample, sex, age and level of housing amenities in the dwelling place appear to be predictors of disability. The application of the coefficients obtained at the region level--by means of an epidemiological approach to distributions by sex, age and dwelling amenities characterizing a municipality or group of municipalities (territorial approach)--enabled us to estimate the number of persons 65 and over likely to seek help from home-assistance services at whatever administrative area level chosen. In certain of its quantitative aspects, this mixed approach (individual and area) helps in determining need, the first step in the planning process.

[The decision to hospitalize. Apropos of a survey of 539 hospitalizations requested by general practitioners]. / La décision d'hospitaliser. A propos d'une enquête sur 539 hospitalisations demandées par des généralistes.

Reasons for hospitalization. A study about 539 hospitalizations decided by general practitioners. In this paper hospitalization is studied from the point of view of the general practitioner (GP) who is the most frequent supplier of in-patients. Five GP's practising in the southern suburbs of Paris have analysed their decision to hospitalize a total of 539 patients over one year. Owing to the number of hospital units available in that area and to the variety of diseases treated, it is understandable that these patients were referred to not less than 62 different units. Nevertheless, two-thirds of the patients were referred to 3 units: the Regional Hospital Centre (CHR) and 2 private hospitals. The majority of surgical patients were referred to the private sector, the choice of the unit in such cases being determined by the surgeon's skills as experienced or heard of by the GP. The CHR attracts GP's by its departments of internal medicine and specialties. The notoriety of a department as a whole or that of particular physicians working in the department explains the GP's choice. The degree of uncertainty surrounding the diagnosis, which varies with the nature of the disease requiring hospitalization, divides the departments into two categories: over one-half of the patients with a known diagnosis were referred to surgical departments, whereas 41 percent of those with unknown or uncertain diagnoses were sent to the internal medicine department.

[Descriptive and prognostic value of health status perception by a group of patients with chronic respiratory insufficiency using respirators]. / Valeur descriptive et pronostique de la santé perçue dans une population d'insuffisants respiratoires chroniques appareillés.

Using a self questionnaire we have done a domiciliary study of the perception of health and respiratory function in a population of 537 patients suffering from chronic respiratory disease. We arranged elsewhere the objective biological data of the severity of the disease represented in the computerised dossier on each patient and were able to compare this objective data to the subjective data gathered by the questionnaire. The objective data, in particular the blood gas analysis, appeared to be very weakly linked to the perception that the subjects had of their health and of their physical mobility. A study of the survival at one year showed that functional capacity and psychological approach of subjects were better predictive factors of mortality than the severity of the disease defined according to medical criteria. This study recalls the limits of standard methods of follow up for chronic respiratory failure, and stresses the importance of physical independence in these subjects: this functional indicator seems to have a value which is both descriptive as it is connected, as a whole, to the indicators of the quality of life and also prognostic as it is a better predictive factor for mortality at one year.

[Multicenter French cohort of adults with HIV infection. Description and course after 4 years of follow-up. SEROCO]. / Cohorte francaise multicentrique d'adultes infectés par le VIH. Description et évolution après 4 ans de suivi. SEROCO.

OBJECTIVES: A prospective multicentric epidemiological study (SEROCO) of subjects with a diagnosis of human immunodeficiency virus (HIV) infection was started on January 1, 1988 in order to better understand the natural history of HIV infection and factors related to outcome. Observations after 4 years of follow-up are reported here. METHODS: After authorization by the French national ethics committee and the national commission for personal freedom, 18 French centres included non-haemophiliac volunteers who were asymptomatic, had had non anti-HIV treatment and whose HIV positivity had been known less than 1 year at inclusion. These last three criteria were not required for patients whose precise date of contamination was known within a range of +/- 3 months. RESULTS: On July 15, 1992, there were 1453 infected subjects in the cohort (1063 males, 417 females; age range at inclusion 18-75 years; mean age 31.3 +/- 9.4). Globally, 2.7% of the subjects were symptomatic at inclusion. Mean CD4 lymphocyte count at inclusion was 508/mm3. Clinically, 51.5% of the patients had a history of sexually transmitted disease at inclusion. After 4 years (on July 15, 1992) mean follow-up was 28 +/- 12.9 months for a total of 3428 patient-years. Disease progression to stage IV was observed in 439 patients including 202 who developed the acquired immuno-deficiency syndrome (AIDS). Among these 202 patients, 113 had died at the end-point of this report. The first manifestation of AIDS was Kaposi sarcoma in 44, pulmonary pneumocystosis in 38 and cerebral toxoplasmosis in 27. The probability of developing AIDS was calculated at 13.9% at 5 years, 27.7% at 7 years and 33.7% at 10 years. The probability of a CD4 count below 200/mm3 was 32.7, 55.6 and 67% at 5, 7 and 10 years respectively. For patients with a CD4 count below 200, the probability of developing AIDS was 18% at 1 year, 39% at 2 years and 51% at 3 years. CONCLUSIONS: SEROCO has been a most useful prospective epidemiological tool due to the diversity of the subjects included. The observed natural history of HIV infection will lead to specific research projects aimed at better understanding the disease process.

Factors associated with home visiting in an inner London general practice.

We decided to examine the services provided by doctors in an inner London practice for domiciliary care. It was expected that the study would highlight the most relevant questions and variables related to access and uptake of this service; it would thus contribute to the design of an accurate procedure for auditing the pattern of delivery of home care to be conducted in the practice in the future. During the study period, 1976-81, there were 90 500 doctor-patient contacts. For patients up to the age of 10 years the proportion of home visits was 9.2%, falling to 2.2% in the age group 20 to 29; then there is a quasi plateau till the age of 60. After 60 the proportion of home visits doubles in each of the following 10 year age groups, reaching 54% in the over 80s. The proportion of home visits (standardised by age) rises from social class II (8.0%) to social class V (10.0%), but is higher in social class I (11.7%). The proportion of home visits according to distance from the practice rises from 8.2% near the health centre to 9.6% at a distance of 0.25 to 0.50 mile, and drops to 8.8% beyond 0.75 mile. The distance effect is not consistent when the social class dimension is added: social classes I and II have higher proportions of home visits in certain age and distance groups. Single people have the lowest proportion of home visits (6.8%); there are large differences between men and women among widowed (14.1% and 8.6% respectively) and divorced or separated (7.0% and 10.7% respectively) patients. There are important variations in the proportions of home visits made by the doctors in the practice, the trainees carrying out proportionally many more home visits. Data collected in the practice can be used to define specific issues for future audit exercises. Furthermore, sociodemographic characteristics of patients have been shown to be associated with use and access to medical services.

Factors correlated with homosexually acquired human immunodeficiency virus infection in the era of "safer sex". Was the prevention message clear and well understood? Alain Brugeat Physician Group.

A cross-sectional survey was conducted between November 1986 and January 1988 among 246 homosexual/bisexual patients by consulting physicians promoting human immunodeficiency virus (HIV) infection prevention, to determine factors correlated with HIV infection a few years after the launch of safer sex recommendations. After adjustment for numbers of sexual partners and frequency of unprotected receptive anal intercourse, seropositive subjects, compared to seronegative ones, had significantly higher frequencies of: (1) receptive anal intercourse using condoms and extraneous lubricants, (2) anorectal douching before or after intercourse, (3) past history of syphilis, and (4) nitrite inhalations. The first three factors remained significant after multivariate analysis. Eighty-three percent of the subjects practicing receptive anal intercourse with condoms plus lubricants used inappropriate lubricants. Some factors identified in our study are well established risk factors for homosexually acquired HIV infection, suggesting that safer sex recommendations still are not followed by all. Our results also elicit additional factors that independently increase the risk. Two of them, extraneous lubrication of the condom for anal receptive intercourse and anorectal douching, may result from a misunderstood notion of "safer sex," or from practices thought by mistake to protect against HIV.

Influence of neurologic manifestations of primary human immunodeficiency virus infection on disease progression. SEROCO Study Group.

To determine the influence of neurologic manifestations of primary human immunodeficiency virus (HIV) infection on disease progression, 277 nonhemophiliac adults enrolled < 1 year after HIV infection were studied. Patients with neurologic manifestations during symptomatic primary HIV infection (PSI) (group N+; n = 23), with nonneurologic manifestations (group N-; n = 112) during PSI, and without any clinical manifestation during primary infection (group NPI; n = 142) were compared for disease progression. Age at infection, sex, mode of infection and CD4+ cell count at first visit did not differ between groups. In a Cox model, the relative risk (RR) of developing AIDS was 6.11 (95% confidence interval [CI], 1.94-19.28) in group N+ and 2.32 (95% CI, 0.93-5.83) in group N- compared with group NPI. The RR of AIDS onset after adjustment for treatment and age at infection was, respectively, 4.65 (95% CI, 1.43-15.03) and 2.03 (95% CI, 0.80-5.19) in groups N+ and N-. Neurologic manifestations of primary HIV infection are associated with an accelerated progression of disease.

International Quality of Life Assessment (IQOLA) Project.

The International Quality of Life Assessment (IQOLA) Project is a 4-year project to translate and adapt the widely used MOS SF-36 Health Survey Questionnaire in up to 15 countries and validate, norm, and document the new translations as required for their use in international studies of health outcomes. In addition to the eight-scale SF-36 health profile, the project will also validate psychometrically based physical and mental health summary scores, as well as health utility indexes incorporating SF-36 scales for use in cost-utility studies.