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Biomedical subjects

A Flahault

Publications and source records attributed to A Flahault.

At least 19 recordsLinked to original sources
PubMed2000

A survey of physicians' vaccine risk perception and immunization practices for subjects with immunological diseases.

Various publications have caused concern by implying that immunization may be linked to new cases or flare-ups of immunological diseases (IDs). In view of the resulting uncertainty, we studied physicians' vaccine risk perception and immunization practices for adults with IDs. A questionnaire was mailed to three groups of physicians in France: internal medicine specialists, general practitioners, and travel clinic physicians. Thirteen vaccines currently used for adults in France were studied. Risk perception was rated on a 10 cm visual analog scale (VAS). The distribution of the answers was compared between and within groups of physicians. Potential associations between risk perception and reported practices were investigated by multivariate analysis. In the three groups of physicians (n=762), the tetanus and Salk poliomyelitis vaccines had the lowest risk perception. The yellow fever, BCG and Sabin poliomyelitis vaccines were the least well perceived. The distribution of risk perception for these three live vaccines and the hepatitis B vaccine was uniform according to VAS grading. For the other vaccines studied, the distribution was skewed to the low-risk perception side of the VAS. Risk perception was greater for physicians who stated: (1) that certain IDs carried a high risk of adverse events following immunization; (2) that they sought the advice of the referent physician before immunization; (3) warned their patients of the risk of an ID flare-up after vaccination; (4) sought information about recent immunization in patients with a flare-up; and (5) had experience of the side effects of immunization in adults with ID. Risk perception was lower for physicians who said they updated immunizations, and for the internists. The worse the vaccine risk perception by physicians, the more uniform the distribution of perception, thus reflecting the disagreement of the scientific community about the risk of using such vaccines for adults with an ID. Risk perception and immunization practices were related in adults with ID. Understanding of decisions concerning immunization may help to improve immunization updating and prevent risk amplification when evidence is lacking.

Adult↗
PubMed2000

[Prevention of venous thromboembolism in a non-surgical medical ward. Proposed indications for low molecular weight heparin].

OBJECTIVE: The efficiency of venous thromboembolism prophylaxis with low molecular weight heparins (LMWH) has not been established in non surgical patients, so their official preventive use has been limited in France since 1995 to surgery. However, a survey conducted in 5 university hospitals in non surgical patients showed that 21-29% of patients still received a LMWH prescription. It seemed necessary to define the medical conditions for which the practical use of these heparins would be justified. We contacted external experts to obtain a consensus by using the Delphi method. METHODS: The Delphi method, created by the "Rand Corporation" in the USA and used in medicine since the nineteen seventies, is based on a light logistic, with questionnaires been sent by mail with a feed-back report A total of 48 experts were chosen by local staff teams in the 5 hospitals. For the 3 rounds, from March to October 1998, questions were devised by a multicentred staff team. RESULTS: Among the 48 experts contacted, 32 completed the 3 questionnaires, 7 of them did for 2, and 43 did for at least one questionnaire. The experts first defined a list of 12 risk or high risk situations and 11 aggravating factors. For any high risk situation, prescription is justified. For other cases, 2 risk situations are required, or one risk situation with at least 2 aggravating factors, to justify a prescription. If no risk situation is present, prescription is, according to experts, usually not justified. CONCLUSION: The maximal agreement defines the situations in which one use of low molecular weight heparins is proposed to prevent deep venous thrombosis in non surgical inpatients, in most current hospital situations and for more than 24 hours of hospitalization. Clinical trials are needed, to validate their effectiveness and define the optimal dose in these indications. To date, epidemiological studies should be conducted to evaluate the experts proposals by estimating risk factors for deep venous thrombosis.

Double-Blind Method↗
PubMed2000

[Prognostic factors in advanced pancreatic cancer. Multivariate analysis of predictive survival score. University Surgery Association].

STUDY AIM: To identify prognostic factors in advanced pancreatic cancer and to define a predictive score. PATIENTS AND METHOD: One hundred and sixty six patients were included in this multicentre study. Seventeen covariables were prospectively collected for each patient. Covariables associated with survival (p < 0.10) were analysed by a stepwise Cox model. RESULTS: Four prognostic factors were selected on multivariate analysis: pain (RR 1.5; CI: 1.1-2.0), ascites (RR 1.7; CI: 1.0-2.9), weight loss > 10 kg (RR 1.4; CI: 1.0-2.0), and metastases (RR 2.3: CI: 1.6-3.2). A score was defined by attributing a value of one for pain, ascites and weight loss, and two for metastases. Patients with a score > 2 had a median survival of 2 months (SE: 0.5), and patients with a score < or = 2 had a median survival of 6 months (SE: 0.6) (Logrank p < 0.0001). CONCLUSION: The proposed score may be helpful in therapeutic decisions concerning surgery, palliative chemotherapy and/or radiotherapy. However, this score must be validated on an independent series of patients.

Adult↗
PubMed2000

Forecasting disease risk for increased epidemic preparedness in public health.

Emerging infectious diseases pose a growing threat to human populations. Many of the world's epidemic diseases (particularly those transmitted by intermediate hosts) are known to be highly sensitive to long-term changes in climate and short-term fluctuations in the weather. The application of environmental data to the study of disease offers the capability to demonstrate vector-environment relationships and potentially forecast the risk of disease outbreaks or epidemics. Accurate disease forecasting models would markedly improve epidemic prevention and control capabilities. This chapter examines the potential for epidemic forecasting and discusses the issues associated with the development of global networks for surveillance and prediction. Existing global systems for epidemic preparedness focus on disease surveillance using either expert knowledge or statistical modelling of disease activity and thresholds to identify times and areas of risk. Predictive health information systems would use monitored environmental variables, linked to a disease system, to be observed and provide prior information of outbreaks. The components and varieties of forecasting systems are discussed with selected examples, along with issues relating to further development.

Communicable Diseases↗
PubMed2000

[Systemic lupus erythematosus and risk of hepatitis B vaccination: from level of evidence to prescription].

INTRODUCTION: Case reports focusing on immunological diseases occurring subsequently to vaccination are often described in the literature. Reporting of such cases may influence physicians' perception of risks related to immunization, and thereby immunization practices. The decision to vaccinate a patient with an immunological disease should not rely on such case reports, but on the level of evidence of a causal relationship between vaccination and the occurrence of an adverse event. This article describes the search for available data supporting such causality before taking the decision to introduce vaccination against hepatitis B in a female patient with systemic lupus erythematosus (SLE). CURRENT KNOWLEDGE AND KEY POINTS: Data extracted from Medline and surveillance system showed that: 1) biologic plausibility of a relationship between the HBs antigen and SLE was unlikely; 2) case reports or case series were seldom and not convincing regarding potential causality; and 3) there were neither controlled observational studies nor controlled clinical trials. The only available clinical study was of poor quality and did not show any adverse event. The level of evidence of a causal relationship between vaccination against hepatitis B and the occurrence of an adverse event in patients with SLE was low, in-between levels 4 and 5 as defined by the Center for evidence-based medicine. The risk-benefit ratio may therefore rely on these results and guide the decision whether or not vaccination should be introduced. FUTURE PROSPECTS AND PROJECTS: The type of reasoning reported in this paper can be used for other vaccines or other immunological diseases, and have wider applicability in terms of therapeutic risk management when data and evaluation are lacking that could guide decisions.

Adverse Drug Reaction Reporting Systems↗
PubMed2000

Risk factors of acute diarrhoea in summer--a nation-wide French case-control study.

The aim of this study was to identify risk factors for acute diarrhoea (AD) during the summer in France. A matched case-control study was conducted at a national level among patients of 500 general practitioners (GPs). From July to September 1996, 468 case-control pairs were included. Cases were more likely than controls (i) to live away from their main residence (OR 3.0; 95% CI 1.6-5.7), (ii) to have returned from a country at high risk of AD (OR 4.6; CI 0.9-23.1), and (iii) to have been in contact with a case of AD (OR 2.0; CI 1.3-3.1). A significantly decreased risk of AD was found for consumption of well-cooked chicken (OR 0.5; CI 0.3-0.8) and raw or undercooked home-made egg-containing products (OR 0.6; CI 0.4-0.8). These findings suggest that travel to high-risk areas, or travel within France, and being in contact with a case of AD, are risk factors for the occurrence of AD in summer in France.

Adolescent↗
PubMed2000

Reliability of report coding of hospital referrals in primary care versus practice-based coding.

Coding of medical data according to a suitable classification is useful to epidemiological research in primary care but its implementation at practice-based level may be considered as extra work by participating practitioners. Secondary coding from reported data can be considered as a possible alternative to practice-based coding. The purpose of this study was to assess the inter-rater reliability of report coding versus practice-based coding of morbidity data. Via teleinformatics, 300 French general practitioners from the French Sentinel epidemiological network transmitted in free text, on a continuous real-time basis, the health problems generating each hospital referral they made since August 1997. All these reports were centrally coded according to the International Classification of Primary Care (ICPC). A subsample of 120 reports were coded in local practices for comparison. Codes resulting from blind centralized free-text coding were compared with practice-based codes. For the 120 referrals reported, the K measure of agreement for the number of codes was 0.65 (95% confidence interval [CI], CI: 0.52-0.77), and for the chapters selected, 0.84 (95% CI: 0.78-0.91). Discrepancies attributable to the centralized coding only occurred for 7.5% of the referrals, and were due to the lack of specificity of the information transmitted as free text. A thesaurus of correspondences between problem(s) generating referrals and ICPC codes was built from 5000 referrals, and has been used routinely for the automated report coding of an additional sample of 1691 referrals. We conclude that centralized coding is a reliable alternative to practice-based coding in primary care, provided that physicians give sufficiently specific information.

Classification↗
PubMed2000

p53 gene status as a predictor of tumor response to induction chemotherapy of patients with locoregionally advanced squamous cell carcinomas of the head and neck.

PURPOSE: To determine whether p53 gene status predicts tumor responses to platinum- and fluorouracil-based induction chemotherapy in locoregionally advanced squamous cell carcinomas of the head and neck. PATIENTS AND METHODS: Tumor responses of 105 patients were measured at the primary tumor site. Objective response and major response were defined by a 50% and 80% reduction in tumor size, respectively. All coding parts of p53 gene were directly sequenced. p53 expression in tumor cells was determined by immunohistochemistry. Human papillomavirus infection was detected by polymerase chain reaction. Odd ratios were adjusted by stepwise logistic regression analysis. RESULTS: p53 mutations, p53 expression, and tumor stage were sufficient to explain the variation in tumor responses to chemotherapy in multivariate models. p53 mutation was the only variable to significantly predict objective response (odds ratio, 0. 23; 95% confidence interval, 0.10 to 0.57; P =.002) and was the strongest predictor of major response (odds ratio, 0.29; 95% confidence interval, 0.11 to 0.74; P =.006). p53 expression (odds ratio, 0.39; 95% confidence interval, 0.16 to 0.98) and tumor stage (odds ratio, 0.31; 95% confidence interval, 0.10 to 0.96) also predicted major response. Specific mutations (contact mutations) accounted for much of the reduction in the risk of major response associated with overall mutations. In complementary analyses, p53 expression was weakly predictive of major response in the subgroup with wild-type p53, and p53 mutations also predicted histologic response. CONCLUSION: p53 gene mutations are strongly associated with a poor risk of both objective and major responses to chemotherapy. Contact mutations are associated with the lowest risk of major response to chemotherapy.

Adult↗
PubMed2000

Pulmonary complications following lung resection: a comprehensive analysis of incidence and possible risk factors.

STUDY OBJECTIVES: To assess the incidence and clinical implications of postoperative pulmonary complications (PPCs) after lung resection, and to identify possible associated risk factors. DESIGN: Retrospective study. SETTING: An 885-bed teaching hospital. PATIENTS AND METHODS: We reviewed all patients undergoing lung resection during a 3-year period. The following information was recorded: preoperative assessment (including pulmonary function tests), clinical parameters, and intraoperative and postoperative events. Pulmonary complications were noted according to a precise definition. The risk of PPCs associated with selected factors was evaluated using multiple logistic regression analysis to estimate odds ratios (ORs) and 95% confidence intervals (CIs). RESULTS: Two hundred sixty-six patients were studied (87 after pneumonectomy, 142 after lobectomy, and 37 after wedge resection). Sixty-eight patients (25%) experienced PPCs, and 20 patients (7.5%) died during the 30 days following the surgical procedure. An American Society of Anesthesiology (ASA) score > or= 3 (OR, 2.11; 95% CI, 1.07 to 4.16; p < 0.02), an operating time > 80 min (OR, 2.08; 95% CI, 1.09 to 3.97; p < 0.02), and the need for postoperative mechanical ventilation > 48 min (OR, 1.96; 95% CI, 1.02 to 3.75; p < 0.04) were independent factors associated with the development of PPCs, which was, in turn, associated with an increased mortality rate and the length of ICU or surgical ward stay. CONCLUSIONS: Our results confirm the relevance of the ASA score in a selected population and stress the importance of the length of the surgical procedure and the need for postoperative mechanical ventilation in the development of PPCs. In addition, preoperative pulmonary function tests do not appear to contribute to the identification of high-risk patients.

Bronchial Fistula↗
PubMed2000

Nonnephrotoxic, dynamic, contrast enhanced magnetic resonance urography: use in nephrology and urology.

PURPOSE: We assessed the value of breath-hold, gadolinium (Gd) enhanced magnetic resonance urography for diagnosing urinary tract disease. MATERIALS AND METHODS: Dynamic magnetic resonance urography was performed in 38 consecutive patients presenting with urological disease in whom excretory urography was contraindicated. Renal function was impaired in 18 cases with a serum creatinine of 140 to 400 micromol./l. Fast spoiled, gradient echo sequences were acquired during breath-holding 5, 10 and 15 minutes after intravenous injection of 10 ml. of a Gd chelate. Opacification of the collecting system was evaluated using a scale of 0 to 3. Diagnostic value of the examinations was also analyzed. RESULTS: Dynamic magnetic resonance urography was sufficient for making the diagnosis in 95% of cases. We identified 71 pathological findings and the surgical anastomosis was always well visualized. Mean image quality score was 2.34 points for renal calices, 2.86 for renal pelves and 2.48 for ureters. Image quality significantly improved after injecting a diuretic. CONCLUSIONS: Gd enhanced magnetic resonance urography provides quality dynamic imaging of the urinary tract. It is a new approach for diagnosing urinary tract disorders in patients in whom excretory urography should be avoided.

Adult↗
PubMed2000

Automatic coding of reasons for hospital referral from general medicine free-text reports.

Although the coding of medical data is expected to benefit both patients and the health care system, its implementation as a manual process often represents a poorly attractive workload for the physician. For epidemiological purpose, we developed a simple automatic coding system based on string matching, which was designed to process free-text sentences stating reasons for hospital referral, as collected from general practitioners (GPs). This system relied on a look-up table, built up from 2590 reports giving a single reason for referral, which were coded manually according to the International Classification of Primary Care (ICPC). We tested the system by entering 797 new reasons for referral. The match rate was estimated at 77%, and the accuracy rate, at 80% at code level and 92% at chapter level. This simple system is now routinely used by a national epidemiological network of sentinel physicians.

Confidence Intervals↗
PubMed1999

Effect of adding clofazimine to combined clarithromycin-ethambutol therapy for Mycobacterium avium complex septicemia in AIDS patients.

This study compared the efficacies of clarithromycin-ethambutol and clarithromycin-ethambutol-clofazimine for the treatment of Mycobacterium avium complex (MAC) in AIDS patients. Thirty-four patients were randomized into two groups to receive clarithromycin 2 g/day and ethambutol 20 mg/kg/day, with or without clofazimine 200 mg/day. The evaluation was based primarily on blood cultures becoming negative after 2 months of therapy, but survival at 12 months and clinical evolution were also assessed. Inclusions were prematurely stopped because of a communication reporting increased mortality associated with clofazimine. At 2 months, the blood cultures of 55% of the clarithromycin-ethambutol group patients versus 81% of the clarithromycin-ethambutol-clofazimine group were negative; this difference is not significant (P=0.42). Only one relapse was observed during the study. No clarithromycin-resistant strain was isolated. No apparent difference in either survival or clinical evolution was observed in this small number of patients (median survival, 144 days in the clarithromycin-ethambutol group and 236 days in the clarithromycin-ethambutol-clofazimine group, P=0.44). The clarithromycin-ethambutol combination appears to be an effective and well-tolerated first-line therapy against MAC infections in AIDS patients.

AIDS-Related Opportunistic Infections↗
PubMed1999

Effect of aspirin in pregnant women is dependent on increase in bleeding time.

OBJECTIVES: Randomized trials with low-dose aspirin to prevent preeclampsia and intrauterine growth restriction have yielded conflicting results. In particular, 3 recent large trials were not conclusive. Study designs, however, varied greatly regarding selection of patients, dose of aspirin, and timing of treatment, all of which can be determinants of the results. Retrospectively analyzing the conditions associated with failure or success of aspirin may therefore help to draw up new hypotheses and prepare for more specific randomized trials. STUDY DESIGN: We studied a historical cohort of 187 pregnant women who were considered at high risk for preeclampsia, intrauterine growth restriction, or both and were therefore treated with low-dose aspirin between 1989 and 1994. Various epidemiologic, clinical, and laboratory data were extracted from the files. Univariate and multivariate analyses were performed to search for independent parameters associated with the outcome of pregnancy. RESULTS: Age, parity, weight, height, and race had no influence on the outcome. The success rate was higher when treatment was given because of previous poor pregnancy outcomes than when it was given for other indications, and the patients with successful therapy had started aspirin earlier than had those with therapy failure (17.7 vs 20.0 weeks' gestation, P =.04). After multivariate analysis an increase in Ivy bleeding time after 10 days of treatment by >2 minutes was an independent predictor of a better outcome (odds ratio 0.22, 95% confidence interval 0.09-0.51). Borderline statistical significance was observed for aspirin initiation before 17 weeks' gestation (odds ratio 0.44, 95% confidence interval 0.18-1. 08). Abnormal uterine artery Doppler velocimetric scan at 20-24 weeks' gestation (odds ratio 3.31, 95% confidence interval 1.41-7.7), abnormal umbilical artery Doppler velocimetric scan after 26 weeks' gestation (odds ratio 37.6, 95% confidence interval 3.96-357), and use of antihypertensive therapy (odds ratio 6.06, 95% confidence interval 2.45-15) were independent predictors of poor outcome. CONCLUSIONS: Efficacy of aspirin seems optimal when bleeding time increases >/=2 minutes with treatment, indicating a more powerful antiplatelet effect. This suggests that the dose of aspirin should be adjusted according to a biologic marker of the antiplatelet effect. A prospective trial is warranted to test this hypothesis.

Adult↗
PubMed1999

How do general practitioners approach hepatitis C virus screening in France?

To estimate the prevalence of infection by hepatitis C virus (HCV) in general practice, and to investigate attitudes to screening for HCV, a specific questionnaire was sent to the sentinel general practitioners (SGPs) of the French Sentinel Network. From the figures reported by SGPs, the number of anti-HCV tests performed in general practice during the six months before the survey (July December 1994) was extrapolated to about 350,000 tests for the whole of France during all of 1994 (95% CI: 314,000 382.000). Of the 312 participating SGPs, 224 (72%) had prescribed at least one anti-HCV test during these six months. and 217 (70%) knew of at least one anti-HCV-positive patient in their practice. With regard to their screening attitudes. 244 SGPs (78%) said they had prescribed anti-HCV tests for patients with no signs of previous or recent hepatitis infection; SGPs who had at least two HCV-positive patients in their practice were more likely to screen for anti-HCV than SGPs who did not (94% vs. 72%, p < 0.001). The main reason for prescription were that patients had an anti-HIV-positive status, were intravenous drug users and/or were blood transfusion recipients. For the 88 SGPs who had not prescribed any anti-HCV test during the six months before the study, the main reasons given were that few patients were at risk in their practice (81 SGPs) and that the risk factors for HCV infection were not well known (12 SGPs). Only 6 SGPs gave the absence of effective treatment as a reason for non-prescription. From the figures reported by SGPs, we extrapolated to 100,000 (95% CI: 90,000-110.000) the number of anti-HCV-positive patients known by the 52,000 French general practitioners in 1994. These results indicate that the Sentinel network may be a useful tool for assessing the evolution of attitudes to HCV screening in general practice.

Adolescent↗
PubMed1999

Impact of guidelines implemented in a paris university hospital: application to the use of antiemetics by cancer patients.

AIMS: To assess the impact with time of guidelines on antiemetic use in an 850-bed Paris university hospital with a high proportion of cancer patients. METHODS: Guidelines on the use of antiemetics available in cancer chemotherapy were drafted according to the Delphi technique. Their implementation was based upon a patient-specific antiemetic prescription form. To assess the impact of guideline implementation over time, discrepancies between current practice and the guidelines were compared before guideline implementation (between March and August 1995) and after implementation (between March and August 1997, and March and August 1998). RESULTS: Before the Delphi panel's guidelines were implemented, 5-HT3 antagonists were inappropriately administered in 70% of cases. After guideline implementation, this proportion dropped significantly (P<0.0001, Fisher's exact test) to 22% between March and August 1997 and 28% between March and August 1998. CONCLUSIONS: Implementation of guidelines seems to have resulted in significant changes with time, although a causal relationship has not been demonstrated. The development of guidelines by our hospital's multidisciplinary working group helped the various consultants to adjust medical practices to take account of these changes.

Academic Medical Centers↗
PubMed1999

Diarrhoea-related morbidity and rotavirus infection in France.

To assess the importance of diarrhoea in France and, specifically, rotavirus-related diarrhoea among children, we reviewed data obtained from three complementary sources: (1) general practitioner (GP) sentinel surveillance; (2) hospital discharge data from paediatric hospitals; and (3) laboratory based surveillance. The GP sentinel network is based on 500 physicians who electronically notify new cases of eight illnesses, including diarrhoea, each week. It was estimated that about 3.3 million patients seek medical attention for diarrhoea from their GP each year, with a winter outbreak associated with an increased rate of isolation of rotavirus. A national system of hospital discharge diagnosis was used to estimate the burden of diarrhoeal morbidity in two paediatric wards in Tours, France. Between 1994 and 1996, 1164 patients under 15 y of age (9.7% of all admissions) were admitted for diarrhoea, of whom 83% were reported as having viral gastroenteritis; 14.3% were dehydrated and 52% were under 1y old. Hospital admissions had a seasonal pattern similar to notifications from sentinel GP for children under 5 y old. A centralized laboratory surveillance network representing 17 of the 22 French regions describes a rotavirus outbreak each winter that is concomitant of outbreaks detected by the GP sentinel network and seen in hospitals. Most of the isolates (98%) identified through this surveillance system are among children under 5y of age. All the data reviewed in this study indicate that the epidemiology of rotavirus diarrhoea in France fits well with what has been reported in other developed countries.

Adolescent↗