What ultimately matters in root canal treatment success and tooth preservation: A 25-year cohort study.

AIM: There are currently no prospective studies evaluating the long-term outcomes of non-surgical root canal treatments beyond 5 years, both in terms of treatment success and tooth preservation, and identifying factors predictive of treatment outcome. The aim of the present work was therefore to fill this gap by assessing these outcomes over time and identifying predictive variables based on systematic data collection over a 25-year period. METHODOLOGY: Data concerning the treatments (N = 2500) were systematically collected since 1990. Information was recorded among clinical, technical, radiographic and patient-related characteristics, i.e., approximately 150 variables for each treatment. The data were analysed regarding both treatment success and tooth preservation by multivariable Cox proportional hazards model, and survival curves were generated. The statistical significance level was set at 0.0125. RESULTS: In total, 56.4% of the treatments could be followed over time (0-25 years, mean = 6.5 years, median = 5 years). Survival probability decreased almost linearly for treatment success, with about 85% after 5 years and 60% after 20 years, and for tooth preservation, with about 90% at 5 years and 50% at 20 years. The variables significantly associated with treatment failure were: pre-operative pain (Hazard Ratio-HR = 1.56 [95% CI 1.23-1.97]), persistent pain (HR = 2.63 [95% CI 1.44-4.80]), good operator rating of treatment prognosis (HR = 0.46 [95% CI 0.36-0.58]), size of periapical bone radiolucency (HR = 1.88 [95% CI 1.67-2.11]), and tooth type (p = .0006). For tooth extraction, they were: combined endodontic-periodontal lesion (HR = 3.37 [95% CI 1.88-6.05]), pre-existing complication before treatment (HR = 1.67 [95% CI 1.26-2.21]), good operator rating of treatment prognosis (HR = 0.45 [95% CI 0.33-0.60]), clinical failure of root canal treatment (HR = 2.78 [95% CI 1.98-3.89]) and tooth type (p = .0012). CONCLUSION: Root canal treatment success and tooth preservation on the arch are not static outcomes, but evolve with time. Among a substantial set of potential predictors, only a small proportion was significantly predictive of treatment success and tooth preservation, most of them being disease and patient characteristics, and not technical aspects, except pre-existing complications. These observations challenge the importance frequently given to byzantine considerations related to the numerous technical details of endodontic procedures, as opposed to general concepts of good clinical practice.

Impact of rural versus urban setting on kidney markers: a cross-sectional study in South-Kivu, DRCongo.

BACKGROUND: Most studies of chronic kidney disease (CKD) in Sub-Saharan Africa (SSA) have been conducted in urban settings. They relied on GFR estimated from serum creatinine alone and on the inexpensive, convenient urinary dipstick to assess proteinuria. The dipstick for proteinuria has not been directly compared with the gold standard albumin-to-creatinine ratio (ACR) in a large-sized study in SSA. We hereby assessed the influence of rural versus urban location on the level, interpretation, and diagnostic performance of proteinuria dipstick versus ACR. METHODS: In a cross-sectional population-based study of CKD in both urban (n = 587) and rural (n = 730) settings in South-Kivu, Democratic Republic of Congo (DRC), we assessed the prevalence, performance (sensitivity, specificity, positive predictive value and negative predictive value) and determinants of a positive dipstick proteinuria as compared with albuminuria (ACR). Albuminuria was subdivided into: A1 (< 30 mg/g creatinine), A2 (30 to 299 mg/g creatinine) and A3 (≥ 300 mg/g creatinine). RESULTS: The overall prevalence of positive dipstick proteinuria (≥ 1+) was 9.6 % (95 % CI, 7.9-11.3) and was higher in rural than in urban residents (13.1 % vs. 4.8 %, p < 0.001), whereas the prevalence of albuminuria (A2 or A3) was similar in both sites (6 % rural vs. 7.6 % urban, p = 0.31). In both sites, dipstick proteinuria ≥ 1 + had a poor sensitivity (< 50 %) and positive predictive value (< 11 %) for the detection of A2 or A3. The negative predictive value was 95 %. Diabetes [aOR 6.12 (1.52-24.53)] was a significant predictor of A3 whereas alkaline [aOR 7.45 (3.28-16.93)] and diluted urine [aOR 2.19 (1.35-3.57)] were the main predictors of positive dipstick proteinuria. CONCLUSIONS: ACR and dipstick proteinuria have similar positivity rates in the urban site whereas, in the rural site, dipstick was 2-fold more often positive than ACR. The poor sensitivity and positive predictive value of the dipstick as compared with ACR makes it unattractive as a screening tool in community studies of CKD in SSA.

Factors to improve quality for older patients in the emergency department: a qualitative study of patient trajectory.

BACKGROUND: Managing older people in the emergency department remains a challenge. We aimed to identify the factors influencing the care quality of older patients in the emergency department, to fine-tune future interventions for older people, considering the naturalistic context of the ED. METHODS: This is a qualitative study of some 450 h of observations performed in three emergency departments selected for their diverse contexts. We performed seventy observations of older patient trajectories admitted to the emergency department. Themes were extracted from the material using an inductive reasoning approach, to highlight factors positively or negatively influencing management of patient's trajectories, in particular those presenting with typically geriatric syndromes. RESULTS: Four themes were developed: no geriatric flow routine; risk of discontinuity of care; unmet basic needs and patient-centered care; complex older patients are unwelcome in EDs. CONCLUSIONS: The overall process of care was based on an organ- and flow-centered paradigm, which ignored older people's specific needs and exposed them to discontinuity of care. Their basic needs were neglected and, when their management slowed the emergency department flow, older people were perceived as unwelcome. Findings of our study can inform the development of interventions about the influence of context and organizational factors.

Healthcare professionals' perspective can guide post-marketing surveillance of artemisinin-based combination therapy in Uganda.

BACKGROUND: Efficient testing to identify poor quality artemisinin-based combination therapy (ACT) is important to optimize efforts to control and eliminate malaria. Healthcare professionals interact with both ACT and malaria patients they treat and hence could observe, first-hand, suspect poor quality artemisinin-based combinations linked to poor malaria treatment outcomes and the factors associated with inappropriate use or treatment failure. METHODS: A cross-sectional study of 685 HCP perspectives about the efficacy of ACT between June and July 2018 at selected health facilities in Uganda. Medicine samples were obtained from the seven regions of Uganda and tested for quality using the Germany Pharma Health Fund™ minilabs. RESULTS: The average age of the 685 respondents was 30 (SD = 7.4) years. There was an almost equal distribution between male and female respondents (51:49), respectively. Seventy percent (n = 480) were diploma holders and the nurses contributed to half (49%, n = 334) of the study population. Sixty-one percent of the HCPs reported having ever encountered ACT failures while treating uncomplicated malaria. Nineteen percent of HCPs thought that dihydroartemisinin/piperaquine gave the most satisfactory patient treatment outcomes, while 80% HCPs thought that artemether/lumefantrine gave the least satisfactory patient treatment outcomes, possibly due to dosing schedule and pill burden. Healthcare professionals from the Central region (OR = 3.0, CI 0.3-1.0; P = 0.0001), Eastern region (OR = 5.4, CI 2.9-9.8; P = 0.0001) and Northern region (OR = 5.3, CI 2.9-9.9; P = 0.0001) had a higher chance of encountering ACT failure in 4 weeks prior to the survey as compared to those from the western region. Healthcare professionals from private health facilities also had higher chances of encountering ACT failures in past 4 weeks as compared to those from public health facilities (OR = 2.7, CI 1.7-3.9; P = 0.0001). All 192 samples passed the quality screening tests. The random sample of 10% of all samples randomly obtained by the laboratory staff also passed the chemical content analysis and dissolution tests. CONCLUSION: ACT medicines are widely available over-the-counter to the public and it is very difficult to report and monitor a decrease in efficacy or treatment failure. The perspectives of HCPs on treatment failure or lack of efficacy may potentially guide optimization efforts of sampling methodologies for the quality survey of ACT medicines.

Can we predict functional decline in hospitalized older people admitted through the emergency department? Reanalysis of a predictive tool ten years after its conception.

BACKGROUND: In the Emergency Department (ED), early and rapid identification of older people at risk of adverse outcomes, who could best benefit from complex geriatric intervention, would avoid wasting time, especially in terms of prevention of adverse outcomes, and ensure optimal orientation of vulnerable patients. We wanted to test the predictive ability of a screening tool assessing risk of functional decline (FD), named SHERPA, 10 years after its conception, and to assess the added value of other clinical or biological factors associated with FD. METHODS: A prospective cohort study of older patients (n = 305, ≥ 75 years) admitted through the emergency department, for at least 48 h in non-geriatric wards (mean age 82.5 ± 4.9, 55% women). SHERPA variables (i.e. age, pre-admission instrumental Activity of Daily Living (ADL) status, falls within a year, self-rated health and 21-point MMSE) were collected within 48 h of admission, along with socio-demographic, medical and biological data. Functional status was followed at 3 months by phone. FD was defined as a decrease at 3 months of at least one point in the pre-admission basic ADL score. Predictive ability of SHERPA was assessed using c-statistic, predictive values and likelihood ratios. Measures of discrimination improvement were Net Reclassification Improvement and Integrated Discrimination Improvement. RESULTS: One hundred and five patients (34%) developed 3-month FD. Predictive ability of SHERPA decreased dramatically over 10 years (c = 0.73 vs. 0.64). Only two of its constitutive variables, i.e. falls and instrumental ADL, were significant in logistic regression analysis for functional decline, while 21-point MMSE was kept in the model for clinical relevance. Demographic, comorbidity or laboratory data available upon admission did not improve the SHERPA predictive yield. CONCLUSIONS: Prediction of FD with SHERPA is difficult, but predictive factors, i.e. falls, pre-existing functional limitation and cognitive impairment, stay consistent across time and with literature. As accuracy of SHERPA and others existing screening tools for FD is moderate, using these predictors as flags instead of using composite scales can be a way to screen for high-risk patients.

Johan Mackenbach, awarded an honorary doctorate for his work on health inequalities, in a discussion of burning issues in tackling health inequalities.

On 20 March 2015, Professor Johan Mackenbach of the Erasmus University Medical Centre was awarded a doctorate honoris causa by the Catholic University (Université Catholique) of Louvain, Belgium, for his outstanding contribution to the analysis of health inequalities in Europe and to the development of policies intended to address them. In this context, a debate took place between Professor Mackenbach, Professor Maniquet, a well-being economist, and a representative of the Federal Health Ministry (Mr. Brieuc Vandamme). They were asked to debate on three topics. (1) socio-economic inequalities in health are not smaller in countries with universal welfare policies; (2) Policies needs to target either absolute inequalities or relative inequalities; (3) The focus of policies should either address the social determinants of health or concentrate on access to health care. The results of the debate by the three speakers highlighted the fact that welfare systems have not been able to tackle diseases of affluence. Targets for health policies should be set according to opportunity cost: health care is increasingly costly and a focus on health inequalities above all other inequalities runs the risk of taking a dogmatic approach to well-being. Health is only one dimension of well-being and policies to address inequality need to balance preferences between several dimensions of well-being. Finally, policymakers may not have that much choice when it comes to reducing inequality: all effective policies should be implemented. For example, Belgium and other European countries should not leave aside health protection policies that are evidence-based, in particular taxes on tobacco and alcohol. In his final contribution, Professor Mackenbach reminded the audience that politics is medicine on a larger scale and stated that policymakers should make more use of research into public health.

Capnography as a diagnostic tool for pulmonary embolism: a meta-analysis.

STUDY OBJECTIVE: Multiple studies have evaluated capnography for the diagnosis of pulmonary embolism; accordingly, we conduct a meta-analysis of these trials. METHODS: We performed a systematic search from 1990 to 2011, using MEDLINE, EMBASE, and the Cochrane Library, including studies evaluating capnography as a diagnostic tool alone or in conjunction with other tests. After study quality evaluation, we calculated the pooled sensitivity, specificity, likelihood ratios, and diagnostic odds ratios. RESULTS: We included 14 trials with 2,291 total subjects, with a 20% overall prevalence of pulmonary embolism. The pooled diagnostic accuracy for capnography was sensitivity 0.80 (95% confidence interval [CI] 0.76 to 0.83), specificity 0.49 (95% CI 0.47 to 0.51), negative likelihood ratio 0.32 (95% CI 0.23 to 0.45), positive likelihood ratio 2.43 (95% CI 1.70 to 3.46), and diagnostic odds ratio 10.4 (95% CI 6.33 to 17.1). The area under the summary receiver operating characteristic curve was 0.84. To reach pulmonary embolism posttest probabilities less than 1%, 2%, or 5%, pulmonary embolism prevalence or pretest probability had to be less than 3%, 5%, or 10% respectively. Because of interstudy differences in dead space measurements methodologies, the best cutoff in alveolar dead space or end tidal CO2 conferring the best negative likelihood ratio could not be evaluated. CONCLUSION: Pooled data suggest a potential diagnostic role for capnography when the pulmonary embolism pretest probability is 10% or less, perhaps after a positive D-dimer test result.

Cerebral embolization during percutaneous valve implantation does not occur during balloon inflation valvuloplasty: prospective diffusion-weighted brain MRI study.

BACKGROUND AND AIM OF THE STUDY: The study aim was to define the timing of cerebral embolization events during transcatheter aortic valve implantation (TAVI), and to determine if events were more closely associated with valve implantation or with balloon inflation. METHODS: Between January 2008 and November 2011, a total of 114 patients underwent TAVI at the author's institution. Of these patients, 44 had previously undergone imaging before and after TAVI, and were included in the study (26 transfemoral (TF); 18 transapical (TA)). Eleven patients who had only balloon valvuloplasty (BV) during the same period were included, as were 22 patients who had open aortic valve replacement (AVR), as controls. All 77 patients underwent neurological examination, and all had cerebral MRIs before and after their procedures. RESULTS: Fifty of the 77 patients who underwent postprocedural MRI had new cerebral lesions, as follows: 24/26 (92%) in TF patients; 17/18 (94%) in TA patients; 3/11 (27%) in BV patients; and 6/22 (27%) in AVR patients (TF and TA versus BV and AVR, p < 0.0001). The mean number and volume of embolic lesions per patient were respectively 5.4/438 mm3 for TF, 11.6/3414 mm3 for TA, 0.7/46 mm3 for BV, and 0.4/48 mm3 for AVR (TF versus TA and BV versus AVR, p = NS; TF and TA versus BV and AVR, p < 0.0001). No association was found between either the EuroSCORE or patient age and the number of events. CONCLUSION: In the present study, an incidence of silent cerebral embolic lesions after TAVI was identified which was significantly higher than that for BV or AVR. This indicated an association of embolism with valve implantation rather than with balloon inflation.

Alcohol drinking among college students: college responsibility for personal troubles.

BACKGROUND: One young adult in two has entered university education in Western countries. Many of these young students will be exposed, during this transitional period, to substantial changes in living arrangements, socialisation groups, and social activities. This kind of transition is often associated with risky behaviour such as excessive alcohol consumption. So far, however, there is little evidence about the social determinants of alcohol consumption among college students. We set out to explore how college environmental factors shape college students' drinking behaviour. METHODS: In May 2010 a web questionnaire was sent to all bachelor and master students registered with an important Belgian university; 7,015 students participated (participation = 39%). The survey looked at drinking behaviour, social involvement, college environmental factors, drinking norms, and positive drinking consequences. RESULTS: On average each student had 1.7 drinks a day and 2.8 episodes of abusive drinking a month. We found that the more a student was exposed to college environmental factors, the greater the risk of heavy, frequent, and abusive drinking. Alcohol consumption increased for students living on campus, living in a dormitory with a higher number of room-mates, and having been in the University for a long spell. Most such environmental factors were explained by social involvement, such as participation to the student folklore, pre-partying, and normative expectations. CONCLUSIONS: Educational and college authorities need to acknowledge universities' responsibility in relation to their students' drinking behaviour and to commit themselves to support an environment of responsible drinking.

Experiences of Cultural Differences, Discrimination, and Healthcare Access of Displaced Syrians (DS) in Lebanon: A Qualitative Study.

The study aims to examine cultural differences and discrimination as difficulties encountered by DS when using the Lebanese healthcare system, and to evaluate the equity of DS access to health services in Lebanon. This is a qualitative study using in-depth semi-structured interviews with DS and Lebanese healthcare professionals. The participants were selected by visiting two hospitals, one public Primary Healthcare Center, and three PHCs managed by Non-Governmental Organizations. The recruitment of participants was based on reasoned and targeted sampling. Thematic analysis was performed to identify common themes in participants' experiences of DS in accessing Lebanese healthcare. Twenty interviews took place with directors of health facilities (n = 5), health professionals (n = 9), and DS (n = 6) in six different Lebanese healthcare institutions. The results showed barriers of access to care related to transportation and financial issues. Healthcare services provided to the DS appear to be of poor quality due to inequitable access to the health system, attributable to the discriminatory behavior of healthcare providers. Among the several factors contributing to the presence of discrimination in the Lebanese healthcare system, the persisting fragility of the healthcare system-facing a humanitarian crisis-emerged as the major driver of such unequal treatment. The number of DS in Lebanon is roughly equal to a quarter of its citizens; there is an urging need to restore the Lebanese health system to ensure the equitable provision of health services for DS and appropriate working conditions for health professionals.

Healthcare bias and health inequalities towards displaced Syrians in Lebanon: a qualitative study.

Introduction: According to Lebanese official data, Lebanon hosts over 1.5 million displaced Syrians (DS). Research shows that migrants encounter barriers when accessing healthcare. The social determinants of health (SDOH) related to migration are an additional challenge for DS in Lebanon, though bias plays a significant factor in exacerbating health inequalities. This study aims to identify DS perception of healthcare biases in the Lebanese healthcare system, and its consequences on DS' accessing and receiving quality healthcare in Lebanon. Methods: A qualitative analysis using in-depth, semi-structured interviews was utilized. 28 semi-structured interviews were conducted with doctors (n = 12) and nurses (n = 16) in 2021. Six group interviews were conducted with DS (n = 22) in Lebanese healthcare facilities. The recruitment of participants relied on reasoned and targeted sampling. Thematic analysis was performed to identify common themes in participants' experiences with DS accessing Lebanese healthcare. Results: The findings indicated that there were barriers to accessing healthcare related to the SDOH, such as transportation and financial resources. The results also suggested that DS perceived health biases, including discriminatory behavior from Lebanese healthcare providers, stereotypes and racism leading to health inequalities. Conclusion: Based on the perceptions and experiences reported by participants, the underlying causes of biases are due to the fragility of the Lebanese healthcare system when facing a humanitarian crisis as well as a collapsing infrastructure torn by past wars and the current socio-political and financial crises in the country. Global initiatives are required to provide the necessary resources needed for offering equitable health services. Such initiatives involve addressing biases, health inequities, discrimination, and the lack of a Lebanese infrastructure system for the provision of healthcare. Addressing health inequalities remains a major health objective in achieving health equity on the micro level (cultural awareness and competencies) and macro level (equitable distribution of resources, implementation of a universal health coverage) in order to guarantee quality healthcare services to DS.

Perceived work ability and turnover intentions: a prospective study among Belgian healthcare workers.

AIM: To report a study exploring prospective relations between nurses' perceived work ability and three forms of turnover intentions, respectively, intent to leave the ward, organization and profession. BACKGROUND: Turnover of nursing staff is a major challenge for healthcare settings and for healthcare in general, urging the need to improve retention. DESIGN: Survey. METHODS: Based on the longitudinal data of the Belgian sample from the European Nurses' Early Exit study, a total of 1531 healthcare workers who remained in their job, completed in 2003 and 1 year later a self-administered questionnaire including the Work Ability Index to assess work ability. Multiple logistic regression analysis was performed adjusting for possible confounding variables. RESULTS: In a population with low intent to leave at baseline prospective analyses showed that a poor work ability at baseline increased the risk of high intent to leave the ward and high intent to leave the organization, 1 year later. A substantial deterioration in work ability was a risk factor for developing high turnover intentions 1 year later. Social support had no effect on the relation between work ability and all three types of intent to leave but the relation between work ability and intent to leave the ward was borderline significantly moderated by good interpersonal relations. CONCLUSIONS: Poor work ability was a risk factor for developing turnover intentions. Maintaining good work ability and improving poor work ability becomes increasingly important to retain nurses.

Beta-5 score to evaluate pig islet graft function in a primate pre-clinical model.

BACKGROUND: We developed a composite scoring system to accurately assess pig islet function in pre-clinical primate studies. METHODS: Two scoring methods that have been clinically validated in human islet allotransplantation were tested in six non-diabetic and nine streptozotocin (STZ)-induced diabetic primates: (i) SUITO index=[1500 × fasting C-peptide (ng/ml)]/[fasting blood glucose (FBG, mg/dl) - 63] and (ii) CP/G ratio =[fasting C-peptide (ng/ml) × 100]/FBG (mg/dl). Both scores were analysed as a function of the ß-cell mass of the native primate pancreas. Next, a proposed ß5 score based on FBG values, daily glycosuria, post-prandial glycosuria, polydipsia, and polyuria was validated on the same primates. Ranges of normal and pathologic values for each parameter were assessed during 5 months in non-diabetic and diabetic primates, respectively. Finally, scores were tested on the nine STZ-induced diabetic primates, four of which were transplanted with microencapsulated pig islets and five with macroencapsulated pig islets. All parameters required for each score were measured prior to transplantation and up to 12 weeks post-transplantation. For the CP/G ratio after transplantation, primate C-peptide was replaced by porcine C-peptide. RESULTS: The Suito index was not correlated with the pancreatic ß-cell mass in contrast to the CP/G ratio (R(2) = 0.17, P = 0.645 vs. R(2) = 0.76, P = 0.003; respectively). The internal consistency of the parameters implied by the ß5 score was confirmed by a Cronbach's alpha test of 0.97. Diabetes was confirmed by a significant decrease in the CP/G ratio and the ß5 score before and after diabetes induction, respectively. After transplantation, a significant correlation was found between the CP/G ratio and the ß5 score, which reflected the functionality of pig islet xenografts and diabetes control. In addition, the CP/G ratio and ß5 score were correlated with the glycosylated hemoglobin course after transplantation and diabetes correction with macroencapsulated pig islets. CONCLUSION: The proposed ß5 score provides a valid tool to accurately assess islet transplantation in a primate pre-clinical model.

Prevalence and Risk Factors of CKD in South Kivu, Democratic Republic of Congo: A Large-Scale Population Study.

BACKGROUND: The prevalence of chronic kidney disease (CKD) in African American individuals is high but whether this applies to native populations in sub-Saharan Africa is unclear. METHODS: In a cross-sectional study, we assessed the prevalence and risk factors of CKD in rural and urban adults in South Kivu, Democratic Republic of Congo. Glomerular filtration rate (GFR) was estimated using the CKD-Epidemiology Collaboration (CKD-EPI) equations based on serum creatinine (eGFRcr), cystatin C (eGFRcys), or both markers (eGFRcr-cys), without ethnic correction factor. CKD was defined as an eGFR <60 ml/min per 1.73 m2 and/or albuminuria (albumin-to-creatinine ratio ≥30 mg/g). RESULTS: A total of 1317 participants aged 41.1 ± 17.1 years (730 rural, 587 urban) were enrolled. The prevalence of hypertension (20.2%; 95% confidence interval [CI], 18-22.3), diabetes mellitus (4.3%; 95% CI, 3.2-5.4) and obesity (8.9%; 95% CI, 7.4-10.5) was higher in urban than rural participants (all P < 0.05). HIV infection prevalence was 0.41% (95% CI, 0.05-0.78). The prevalence of eGFRcr <60 ml/min per 1.73 m2 was 5.4% (95% CI, 4.2-6.7). The prevalence of albuminuria was 6.6% (95 % CI, 5.1-8.1). The overall prevalence of CKD was 12.2% (95% CI, 10.2-14.2) according to CKD-EPIcr. Factors independently associated with CKD-EPIcr were older age (adjusted odds ratio [aOR], 1.05 [1.04-1.07]), urban residence (aOR 1.86 [1.18-2.95]), female sex (aOR 1.66 [1.04-2.66]), hypertension (aOR 1.90 [1.15-3.12]), diabetes (aOR 2.03 [1.02-4.06]), and HIV infection (10.21 [2.75-37.85]). The results based on eGFRcys or eGFRcr-cys were largely consistent with the preceding. CONCLUSION: Overall, the burden of CKD is substantial (>11%), predominantly in the urban area, and largely driven by classic risk factors (gender, aging, HIV, hypertension, and diabetes).

Comparison of bilateral internal thoracic artery revascularization using in situ or Y graft configurations: a prospective randomized clinical, functional, and angiographic midterm evaluation.

BACKGROUND: Bilateral internal thoracic arteries (BITA) demonstrated superiority over other grafts to the left coronary system in terms of patency and survival benefit. Several BITA configurations are proposed for left-sided myocardial revascularization, but the ideal BITA assemblage is still unidentified. METHODS AND RESULTS: From 03/2003 to 08/2006, 1297 consecutive patients underwent isolated bypass surgery in our institution. 481 patients met the inclusion criteria for randomization, and 304 (64%) were randomized. Patients were allocated to BITA in situ grafting (n=147) or Y configuration (n=152) then evaluated for clinical, functional, and angiographic outcome after 6 months and 3 years. Patient telephone interviews were conducted every 3 months and a stress test performed twice yearly under the referring cardiologist's supervision. Angiographic follow-up was performed 6 months after surgery. The primary and secondary end points were, respectively, major adverse cerebrocardiovascular events (MACCE) and the proportion of ITA grafts that were completely occluded at follow-up angiography. More arterial anastomoses were performed in patients randomized to the Y than the in situ configuration (3.2 versus 2.4; P<0.001). No significant difference between the 2 groups in terms of hospital mortality or morbidity was found. At follow-up, there was no significant difference in any MACCE rate between the 2 groups. 450 out of 464 anastomosis (97%) in the BITA Y group and 287 of 295 (97%) in the BITA in situ group were controlled patent (P=0.99). CONCLUSIONS: Excellent patency rates were achieved using both BITA configurations with no significant differences in terms of MACCE up to 19 months postoperatively, but longer-term results remain to be established.

[Fever and malaria in children under 5 years of age in Benin: do we have accurate statistics?]. / Fièvres et paludisme chez les enfants de 0 à 5 ans au Bénin: avons-nous de vraies statistiques?

INTRODUCTION: In Benin, mothers generally seek health care for their children with fever and malaria only when complications appear, including severe anemia, convulsions, and coma. Statistics from the national health system are based on consultations at national health care centers and do not take into account existing cases in the community. OBJECTIVES: To determine the prevalence of malaria from the analysis of subjects with fever and their management in two participating villages. This evaluation--and a better approach to fighting childhood malaria--rely on habits of management and care-seeking and the extent of parental participation. METHODS: Parents in two villages were interviewed about their practices in managing fever in children and about active malaria screening. RESULTS: The prevalence of (thick smear-positive) malaria was the same in both villages (p>0.05). Parents brought children to health centers for consultation in only 6% of the cases of fever. Treatment was administered immediately within 48 hours for most children (75%) but only 15% received adequate anti-malarial treatment. DISCUSSION: Care-seeking is highly associated with perceptions and representations of childhood fever: for every case treated at the health centre, 16 remain in the community. CONCLUSION: Adequate management of fever and the malaria often associated with it requires understanding the perceptions and representations of parents, which will make it possible to learn the true proportion of malaria in fevers in the two villages and thus to apply appropriate strategies.

[Perceptions of parental participation by health professionals in childhood malaria control in Benin]. / Perceptions de la participation des parents par les professionnels de santé a la lutte contre le paludisme de l'enfant au Bénin.

The aim of this study was to explore and document the perceptions of health professionals regarding parental participation in the fight against child malaria, specifically with regard to fever management, in Benin (West Africa). The findings indicate that community participation in Malaria control in general, and in the case of children in particular, is essential due to the contributing factors surrounding the disease. This form of participation is different from the one recommended and practiced within the structure of the National Health system. Deep-seated, thorough reform of health care program planning is necessary in order to contribute to the improvement of the population's participation in this process. The concept of health promotion was used to frame and shed light on the analysis of the proposed recommendations. Parents' participation, one that integrates their perceptions and depictions of child fever, is not currently a reality in Benin; the study revealed that the participants seek out and request the development of skills necessary that could enable them to better contribute to the fight against malaria.

A federal audit of the Belgian radiotherapy departments in breast cancer treatment.

BACKGROUND: The Belgian Federal College of Radiotherapy carried out an external audit of breast cancer patient documentation in the 26 Belgian radiotherapy centres. The objective was to assess compliance with the recommendations regarding minimal requirements for documentation of radiotherapy prescription and administration. All centres volunteered to take part in this audit. METHODS: Two experienced radiation oncologists site-visited the departments over a 6 month period (Sept. 2003-Feb. 2004), with a list of items to be verified, including details on the surgery, the pathological report, details on systemic treatments, details on the radiotherapy prescription (and consistency with therapeutic guidelines) and delay surgery/radiotherapy. FINDINGS: Three hundred and eighty-nine patients files were reviewed, for a total of 399 breast cancers (10 patients with bilateral cancer). Mean age was 57.8 y (range 29-96). Breast conservative surgery (BCS) was used in 71%; radical mastectomy in 29%. A complete pathological report was present in all files but 2 (99.5% conformity). 5.2% were treated for DCIS, 61.6% for pT1, 28.2% for pT2 and 5% for pT3-4. Data regarding resection margins were specified to be free in 76.2%, tangential in 12% (within 2 mm) and positive for DCIS in 3.8% or invasive cancer in 1.5% (no information, on margins in 6.5%). The pT stage was always specified, and consistent with the macroscopic and microscopic findings. Hormonal receptors were routinely assessed (94.7%), as well as Her2neu (87.4%). Axillary surgery was carried out in 92%, either by sentinel node biopsy or by complete clearance, in which case the median number of nodes analysed was 12 for all centres together (7-17). All radiotherapy prescriptions were in line with evidence-based standards of therapy (i.e., irradiation of breast after BCS or after mamectomy (in case of pN+), but one. The mean delay between surgery and radiotherapy was 5.5 weeks (SD 11 days). CONCLUSION: There was a high degree of conformity of the various centres with the minimal requirements for documentation of radiotherapy prescription and administration of the Federal College of Radiotherapy. In addition, the quality of surgery (assessed by margin clearance) and of pathological reports was excellent, whatever the institution of origin (teaching vs. non-teaching, private vs. public). Belgian patients referred for radiotherapy are treated with great care. Prescriptions are based on pathological evidence, gathered through appropriate surgery. All indications were evidence-based; there was no overuse of radiotherapy in early breast cancer treatment.

Fractional flow reserve of pedicled internal thoracic artery and saphenous vein grafts 6 months after bypass surgery.

BACKGROUND: Although the internal thoracic artery was proven superior to saphenous vein graft in long-term patency, it is thought to be a more resistive conduit than the vein graft. Moreover, patency studies comparing both left and right internal thoracic arteries have provided results favoring the former. Fractional flow reserve is an established functional index of coronary blood flow. METHODS: To compare the fractional flow reserve between both internal thoracic arteries and saphenous vein grafts, 43 bypass grafts were studied 6 months after revascularization. Intra-graft pressures were measured during cardiac catheterization using a pressure-wire advanced to the first distal anastomosis of 12 left internal thoracic arteries (ITAs), 10 right ITAs and of 21 vein grafts. Pressure gradients between the aorta and the graft were measured at baseline and during a maximal hyperemia. RESULTS: At baseline, pressure gradient was recorded in the left ITA (2.9+/-2.2 mmHg), in the right ITA (1.2+/-1.2 mmHg) and in the vein graft (0.4+/-0.7 mmHg). During maximal hyperemia, pressure gradient increased to 9.6+/-3.2 mmHg in left ITA, to 4.5+/-2.0 mmHg in the right ITA (p<0.001 vs left ITA) and to 3.3+/-2.7 mmHg in vein (p<0.001 vs left ITA; NS vs right ITA). Fractional flow reserve was 0.90+/-0.04 in left ITA, 0.95+/-0.03 in right ITA (p<0.01 vs left ITA) and 0.96+/-0.03 in vein (p<0.001 vs left ITA). CONCLUSION: Internal thoracic arteries and saphenous vein grafts allow myocardial revascularization with minimal resistance to maximal blood flow. The resistance appears significantly higher in left ITA compared to both the right ITA and venous grafts.

Patient empowerment in theory and practice: polysemy or cacophony?

OBJECTIVE: This paper examines how the term "empowerment" has been used in relation to the care and education of patients with chronic conditions over the past decade. METHODS: Fifty-five articles were analysed, using a qualitative method of thematic analysis. RESULTS: Empowerment is more often defined according to some of its anticipated outcomes rather than to its very nature. However, because they do not respect the principle of self-determination, most anticipated outcomes and most evaluation criteria are not specific to empowerment. Concerning the process of empowerment, our analysis shows that (i) the educational objectives of an empowerment-based approach are not disease-specific, but concern the reinforcement or development of general psychosocial skills instead; (ii) empowering methods of education are necessarily patient-centred and based on experiential learning; and (iii) the provider-patient relationship needs to be continuous and self-involving on both sides. CONCLUSION: Our analysis did not allow for the unfolding of a well-articulated theory on patient empowerment but revealed a number of guiding principles and values. PRACTICE IMPLICATIONS: The goals and outcomes of patient empowerment should neither be predefined by the health-care professionals, nor restricted to some disease and treatment-related outcomes, but should be discussed and negotiated with every patient, according to his/her own particular situation and life priorities.