[Evidence-based practice and nursing: intramuscular injection in psychiatry]. / Pratique factuelle et soins infirmiers : l'injection intramusculaire en psychiatrie.

Intramuscular injection is a frequent technical procedure in psychiatry. In France, nurses who perform this care do not have official guidelines for good practice. The advanced practice nurse is a field actor who can promote evidence-based practice to improve the quality of care for the benefit of the patient.

Alcohol-related hepatocellular carcinoma is a heterogenous condition: Lessons from a latent class analysis.

BACKGROUND: Alcohol-associated hepatocellular carcinoma (AL-HCC) poor prognosis has been attributed to diagnosis at a later stage. However, host factors and specific health trajectories have been associated with severe outcomes in alcohol-related liver disease. We hypothesize AL-HCC is not a homogeneous condition but encompasses subgroups yielding different outcomes. AIMS: Our aim was to provide a first attempt at a clinical phenotyping of AL-HCC. METHODS: We analysed data for the calendar years 2007-2013 from the French nationwide administrative hospital database. We selected patients with AL-HCC only. Clustering of AL-HCC phenotypes was performed by latent class analysis (LCA). RESULTS: The study included 11 363 patients with AL-HCC, mainly male (89.6%), median age 67 years [IQR: 61; 74] of which 71.2% had at least one metabolic comorbidity. Five phenotypes were identified. Phenotype 1 (41.4%) displayed high rates of unrecognized cirrhosis prior to HCC diagnosis (81%), low rates of metabolic comorbidities (diabetes 13%), and mostly compensated liver disease at HCC diagnosis while the four other phenotypes displayed high rates of metabolic comorbidities (diabetes up to 100%), various patterns of liver disease trajectories and overall 42% unrecognized cirrhosis. In adjusted survival analysis, compared to phenotype 1, risk of death after HCC diagnosis was significantly different for all phenotypes. CONCLUSION: LCA uncovers AL-HCC is a heterogeneous condition with distinct phenotypes yielding specific survival outcomes. Frequent unrecognized cirrhosis prior to HCC underlines the urgent need for implementing strategies to identify the underlying liver disease prior to HCC onset in patients with documented alcohol use disorders and metabolic comorbidities.

[Therapeutic alliance between sectorial psychiatry inpatients and nurses and aides: A prospective, observational and cross-sectional study]. / Alliance Thérapeutique Entre Les Patients Hospitalisés En Psychiatrie De Secteur Et Les Infirmier(e)s Et Aide-Soignant(e)s: Une Etude Prospective, Observationnelle Et Transversale.

BACKGROUND: Therapeutic alliance represents a rarely studied object when it relates to nurses and care provided by a nursing team in acute care hospitalization. OBJECTIVE: The objective was to study how factors might influence the therapeutic alliance built between nurses and aides and adult inpatients in an acute care unit of sectorial general psychiatry. METHOD: This is a prospective, observational and cross-sectional study using a therapeutic alliance measurement scale. Therapeutic alliance (TA) score was measured with a STAR-P scale in a sample of 240 patients. RESULTS: The median score found is 33.4 (±7.8) out of a maximum theoretical score of 48. The global score of TA in patients aged 60 years old or more is significantly higher than the score of patients between 18 and 29 years old (p=0.021). The lack of external follow-up in the three months after hospital release is not associated with TA global score (p=0.73). If inpatients, no matter what their diseases or types of care are, under legal obligation or not, consider their TA is rather good after their hospital stay. Only sociodemographic factors like age, housing conditions (insecure or sustainable), having a job or not, living alone or with a partner affect TA and follow-up. CONCLUSION: Results evoke concepts of anomie and attachment, that seem to play an important role in the lack of follow-up after hospital stay, and indicate the mandatory global approach to care and an involvement of health professionals as well as social beings, where empathy must find its place.

CONTEXTE: L'alliance thérapeutique représente un objet très peu étudié quand il concerne les infirmiers et les soins prodigués par une équipe infirmière et dans le cadre de l'hospitalisation en soins aigus. OBJECTIF: L'objectif était d'étudier l'influence de facteurs sur l'alliance thérapeutique construite entre les infirmier(e)s et les aides-soignant(e)s et les patients adultes hospitalisés dans un service de soins aigus en psychiatrie générale de secteur. MÉTHODE: Il s'agit d'une étude prospective, observationnelle et transversale utilisant une échelle de mesure de l'alliance thérapeutique. Le score d'alliance thérapeutique (AT) a été mesuré à l'aide de l'échelle STAR-P sur un échantillon de 240 patients. RÉSULTATS: Le score moyen obtenu est de 33,4 (±7,8) sur un score maximum théorique de 48. Le score global d'AT des patients âgés de 60 ans ou plus, est significativement plus élevé que celui des patients ayant entre 18 et 29 ans (p = 0,021). L'absence de suivi ambulatoire au cours des trois mois suivant la sortie d'hospitalisation n'est pas associée au score global d'AT (p = 0,73). Si les patients hospitalisés, quelques soit leurs troubles et les différentes formes de soins, sous obligation légale ou non, jugent plutôt bonne l'AT à l'issue de leur hospitalisation. Seuls des facteurs sociaux-démographiques comme, l'âge, les conditions d'hébergement (précaire ou durable), avoir ou non un emploi, vivre seul ou avec un partenaire influent sur l'AT et le suivi. CONCLUSION: Les résultats convoquent les concepts d'anomie et d'attachement, qui semblent jouer un rôle important dans l'absence de suivi post-hospitalisation, ce qui indiquent la nécessaire approche globale des soins et une implication des professionnels de santé mais aussi du social où l'empathie doit trouver sa place.

Geographical Disparities of Outcomes of Hepatocellular Carcinoma in France: The Heavier Burden of Alcohol Compared to Hepatitis C.

BACKGROUND: Data on alcohol-related HCC are limited. AIMS: Our aim was to describe the incidence, management, and prognosis of alcohol compared to Hepatitis C (HCV)-related HCC at a national level. METHODS: Incident cases of HCC were identified in French healthcare databases between 2009 and 2012 and analyzed retrospectively. Demographic data, type, location, and annual HCC-caseload of the hospitals where patients were first managed were retrieved. Survival of incident cases was computed from the time of diagnosis and adjusted for potential confounding variables. RESULTS: The study population included 14,060 incident cases of alcohol and 2581 HCV-related HCC. Alcohol-related HCC was more frequent than HCV-related HCC (29.37 and 5.39/100,000 adults/year, respectively) with an heterogeneous distribution on the French territory. The optimal treatment was less frequently curative (20.5% vs 35.9%; p < 0.001), and survival was significantly shorter (9.5 [9.0-10.0] versus 16.8 [15.5-18.7] months p < 0.001) in alcohol compared to HCV-related HCC, with marked variations between regions for a given risk factor. In multivariable analysis in the whole study population, curative treatment was a strong predictor of survival (adjusted HR 0.28 [0.27-0.30] months p < 0.001). Being managed at least once in a teaching hospital during follow-up was independently associated with receiving a curative treatment and survival. CONCLUSION: In France, incidence of alcohol-related HCC is high and prognosis is poor compared to HCV-related HCC, with marked variations between regions. These results should guide future health policy initiatives pertaining to HCC care. Importantly, increasing patient' referral in expert centers could increase chances to receive curative treatment and improve outcomes.

Geographical variations in incidence, management and survival of hepatocellular carcinoma in a Western country.

BACKGROUND & AIMS: Information on the incidence, management, and prognosis of hepatocellular carcinoma (HCC) is derived from population samples, regional data, or registries. Comprehensive national evaluations within a given country are lacking. This study aimed to investigate regional variations in HCC care within France. METHODS: This observational study analysed data from French administrative databases for more than 30,000 patients with HCC diagnosed between 2009 and 2012, and followed-up until 2013. The incidence of HCC, access to surgery, and survival, at both the national level and two geographical levels (the 21 French regions and 95 French departments into which France is divided administratively), were determined. The influence on outcome of the structure of the hospital where HCC was first managed was assessed. RESULTS: At the national level, the median survival was 9.4months and only 22.8% of patients had curative treatment. There were marked variations between regions and departments in incidence, access to curative treatment (range 1.3-28.8% and 8.1-32.3% respectively), and in median survival (range 5.7-12.1 and 4.3-16.5months respectively). The administrative type and annual HCC-caseload of the hospital where patients were first admitted also had an independent influence on treatment and survival. CONCLUSION: Despite full insurance coverage for all citizens, national measures to reduce inequities in the management of cancer patients, standardised recommendations for HCC surveillance and management, the percentage of patients undergoing curative treatment and their survival may vary four-fold depending on their postcode. The hospital in which patients are first managed has a clear influence on accessibility to both good care and survival. LAY SUMMARY: Population-based studies have highlighted large and sometimes unexpected differences between countries in the survival of patients with malignancy. As these differences are considered to indicate the overall effectiveness of health systems, in addition to the incidence of the cancer or quality of registration, variations within a given country should be minimal. However, similar to between countries differences, this study shows differences within the same country in the incidence, curative treatment rate, and survival of patients with HCC. Evidence that access to care and survival varies within a country can strengthen the impetus for government and clinicians to address these disparities.

Laparoscopic left lateral sectionectomy: a population-based study.

BACKGROUND: Laparoscopic left lateral sectionectomy (LLS) has now become standard practice. However, published series are small and retrospective. The aim was to compare at a national level the use and short-term outcome of laparoscopic and open LLS. METHODS: National hospital discharge databases were screened to identify all adult patients who had undergone elective LLS in France between 2007 and 2012. Outcome measurements included blood transfusion, severe morbidity, mortality and length of hospital stay. The independent influence of the laparoscopic approach on these outcomes was tested overall and after stratifying for the indication (benign condition, primary malignancy, liver metastasis). RESULTS: Over the 6-year study period, 2198 patients underwent LLS, accounting for 6.9% of all elective liver resections. Some 28.5% of LLS procedures were performed laparoscopically. Among hospitals in which LLS was carried out, 33.2% of procedures were done laparoscopically (median 2 laparoscopic LLS resections per year). The laparoscopic approach was independently associated with a shorter length of hospital stay irrespective of the indication, and a lower transfusion rate in patients with benign condition or primary malignancy. CONCLUSION: LLS is seldom performed and the laparoscopic approach has not been adopted widely. The potential benefit of laparoscopic LLS varies according to the indication.

Laparoscopic Distal Pancreatectomy for Pancreatic Ductal Adenocarcinoma: Time for a Randomized Controlled Trial? Results of an All-inclusive National Observational Study.

OBJECTIVES: The aim of this study is to compare at a national level, the early and long-term outcome of distal pancreatectomy (DP) performed by laparoscopy (LapDP) or open surgery (OpenDP) for pancreatic ductal adenocarcinoma (PDAC). BACKGROUND DATA: LapDP is feasible and safe for benign conditions but its use for PDAC is controversial. METHODS: French healthcare databases were screened to identify all patients who had undergone LapDP or OpenDP for PDAC between 2007 and 2012. Endpoints were (i) 90-day mortality, (ii) morbidity, (iii) transfusion rate, (iv) length of hospital stay (LOS), and (v) long-term survival. Logistic regression and adjusted Cox models were used to compare LapDP and OpenDP with regard to these outcomes. Confounders included (i) patients' characteristics; (ii) associated surgical procedures; and (iii) characteristics of the hospital. Performance of the resulting models was determined by the area under the receiver operating characteristic (ROC) curve. RESULTS: Over the 6-year period, there were 2753 operations for PDAC: 2406 OpenDP and 347 LapDP (12.6%). The overall 90-day mortality rate was 5.2%; median LOS was 15 days, and median survival was 38 months. LapDP was not correlated with 90-day mortality but was associated with reduced pleuropulmonary morbidity (odds ratio (OR) 0.73, P = 0.028), blood transfusion (OR 0.44, P = 0.001), and LOS (P = 0.042), and was associated with increased survival (P = 0.0007). CONCLUSIONS: LapDP has not been adopted widely for PDAC. The early and long-term results of LapDP as currently practiced are as good as those of OpenDP. The next step in the evaluation of LapDP should be a randomized controlled trial (RCT), but such a trial is likely to suffer from insufficient recruitment.

How surgical technology translates into practice: the model of laparoscopic liver resections performed in France.

OBJECTIVES: Analyze, at a national level, the adoption and practice of laparoscopic liver resections (LAP), compared to open resections (OPEN). BACKGROUND: LAP initiated 20 years ago, has been described for all hepatectomies, and is considered as the reference technique for some resections. There are, however, no data on its adoption outside selected specialty centers. METHODS: French Healthcare databases were screened to identify all patients who underwent an elective LAP or OPEN between 2007 and 2012. Patients' demographics, associated conditions, indication for surgery, hepatectomy performed, and hospital type and hepatectomy caseload were retrieved. Patients who had possible overcoding of biopsies as wedge resections were identified to select REAL resections. Time trend analyses were performed using a piecewise linear regression and the average annual percent change (AAPC) calculated. RESULTS: There were 7881 (17.8%) LAP and 36,359 (82.2%) OPEN performed in an average of 483 hospitals. Of these, biopsies accounted for 29.9% of the LAP (7.3% of the OPEN, P<0.0001) and the incidence of LAP biopsies increased after 2009. The AAPC of the incidence of real LAP increased more than that of real OPEN (7.0% vs 1.3%) but most were minor resections (61.1% vs 28.9% for OPEN, P<0.0001), only 15% of patients were operated by LAP and intermediate (or major) resections were performed in 19.5% (or 4.8%) of hospitals performing liver resections. The proportion of resections performed by LAP was inversely related to annual caseload. The overall incidence of resections performed for benign conditions did not increase. CONCLUSIONS: LAP is not developing, has not been adopted for intermediate/major resections, does not result in overuse for benign indications and some of the 2009 -consensus statements are not applied.

Incidence and risks of liver resection: an all-inclusive French nationwide study.

OBJECTIVE: To evaluate at a national level the incidence of liver resection, postoperative mortality, and variables that predict this outcome. BACKGROUND: Data on indications of and results of liver resection are mainly derived from high-volume centers. Nationwide data are lacking. METHODS: French health care databases were screened to identify all patients who had undergone elective hepatectomy between 2007 and 2010. The patients' age, address, associated conditions, indication and extent of hepatic (or extrahepatic) surgery and the hospital type, location, and hepatectomy caseload were retrieved. Logistic regression was used to measure the influence of these parameters on in-hospital and 90-day mortality rates. The model, created using patients operated on in 2007 and 2009, was tested in those operated on in 2008 and 2010. RESULTS: Overall, 28,708 hepatectomies were performed. The annual incidence (13.2 per 10 adult inhabitants) varied between regions, but the extremal quotient was limited to 2.2 because 15% of the operations took place outside the patients' home region. Hospitals performed a median of 4 resections per year but 53% of all resections were performed in institutions with a volume of more than 50 per year. Treatment for primary tumors and major resections correlated with hepatectomy caseload. In-hospital and 90-day mortality were 3.4% and 5.8%, respectively. The area under the receiver operating characteristic curve of the prognostic model was 0.78/0.77 in the training and validation sample. CONCLUSIONS: There were significant disparities in practice. In-hospital mortality underestimated true, postoperative mortality by more than 50%. The model created may be useful for more efficient regionalization of care and patient counseling.

Observance to antiretroviral treatment in the rural region of the Democratic Republic of Congo: a cognitive dissonance.

INTRODUCTION: This study aimed to understand the influence of local media, religion and cultural beliefs on the therapeutic compliance of patients living with HIV. METHODS: This study was conducted in two rural hospitals in the Central Kongo province of the Democratic Republic of Congo. Semi-directional interviews were conducted with patients on antiretroviral therapy using a phenomenological qualitative method. RESULTS: Our results indicated that patients living with HIV in the rural region of the Democratic Republic of Congo are in a constant state of tension between the messages for compliance to antiretroviral treatment advocated by caregivers, and those broadcasted by audiovisual media, religious leaders and local beliefs. This dissonance constitutes a real barrier to therapeutic compliance. CONCLUSION: Collaborative strategies between healthcare providers, patients, as well as religious, media and traditional organizations are urgently needed.

The epidemiology of Budd-Chiari syndrome in France.

INTRODUCTION: Epidemiological data is lacking on primary Budd-Chiari syndrome (BCS) in France. METHODS: Two approaches were used: (1) A nationwide survey in specialized liver units for French adults. (2) A query of the French database of discharge diagnoses screening to identify incident cases in adults. BCS associated with cancer, alcoholic/viral cirrhosis, or occurring after liver transplantation were classified as secondary. RESULTS: Approach (1) 178 primary BCS were identified (prevalence 4.04 per million inhabitants (pmi)), of which 30 were incident (incidence 0.68 pmi). Mean age was 40 ±â€¯14 yrs. Risk factors included myeloproliferative neoplasms (MPN) (48%), oral contraceptives (35%) and factor V Leiden (16%). None were identified in 21% of patients, ≥2 risk factors in 25%. BMI was higher in the group without any risk factor (25.7 kg/m2 vs 23.7 kg/m2, p < 0.001). Approach (2) 110 incident primary BCS were admitted to French hospitals (incidence 2.17 pmi). MPN was less common (30%) and inflammatory local factors predominated (39%). CONCLUSION: The entity of primary BCS as recorded in French liver units is 3 times less common than the entity recorded as nonmalignant hepatic vein obstruction in the hospital discharge database. The former entity is mostly related to MPN whereas the latter with abdominal inflammatory diseases.

Standardized care management ensures similar survival rates in HIV-positive and HIV-negative patients with hepatocellular carcinoma.

OBJECTIVE: It has been suggested that HIV infection has a detrimental impact on patients with hepatocellular carcinoma (HCC). The present study sought to test this hypothesis, while controlling for tumor extension and liver disease. DESIGN AND SETTING: A case control and a cohort approach were performed in patients with HCC managed prospectively via dedicated multidisciplinary team meeting in a single tertiary institution between 2004 and 2009. SUBJECTS: Of 473 consecutive treatment-naive patients with HCC, 23 were HIV-positive (HIV) and 450 were HIV-negative (HIV). HIV patients were matched 1:2 with a control group of HIV patients in terms of the etiology of HCC, the severity of liver disease, tumor extension, and year of diagnosis. INTERVENTION: Curative or palliative treatment of HCC. MAIN OUTCOME MEASURES: Eligibility for HCC treatment, the treatment actually administered, and the survival rate. RESULTS: The HIV population was younger than the HIV population (mean age: 49 vs. 61 years, respectively; P < 0.0001). Curative treatment was recommended by the multidisciplinary team meeting and then actually performed to a similar extent in HIV patients (74% and 43%, respectively) and their matched HIV controls (74% and 56%, respectively). The HIV and their matched HIV patients did not differ significantly in terms of the 3-year survival rate [44% vs. 48%, respectively; mean (95% confidence interval) hazard ratio = 0.64 (0.3-1.3); P = 0.2]. In a cohort analysis, HIV status was not an independent predictor of survival among curatively treated patients. CONCLUSION: In an equal-access unbiased environment, HIV status does not significantly influence treatment access, delivery, and outcome.

Prospective evaluation of the management of hepatocellular carcinoma in the elderly.

BACKGROUND: An increasing proportion of patients with hepatocellular carcinoma are older than 75 years. Previous studies suggested that ageing does not adversely impact survival but they have the drawback of being retrospective and spanning a prolonged period of time. GOALS: Evaluate management and prognosis of hepatocellular carcinoma in elderly. PATIENTS AND METHODS: A multidisciplinary oncology meeting prospectively evaluated all patients with hepatocellular carcinoma. Management were standardised according to European and American guidelines. Forty patients older than 75 years were matched with younger patients for tumour extension and liver function. Both groups were compared for the type of treatment and survival. RESULTS: Male/female ratio was 1.2 as compared to 7 in controls. Cirrhosis was related mostly to hepatitis C virus in elderly, and equally to hepatitis C or B virus and alcohol in controls. Curative treatments were recommended in 55% of elderly and 75% of controls. Treatment actually performed was curative in 25% in elderly as compared to 63% in controls. Median survival (30 months) was identical in both groups. CONCLUSION: Despite more restricted access to curative treatments, survival of elderly patients with hepatocellular carcinoma is comparable to that of younger patients.