Fair comparison of mortality data following cardiac surgery.
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Cardiology Service, Hospital↗
Biomedical subjects
R Ecochard
Publications and source records attributed to R Ecochard.
Characteristics, management, and in-hospital mortality of acute myocardial infarction in the "real world" in France--data from a large unselected cohort of 2,519 consecutive patients in a French region.
OBJECTIVE: The prospective PRIMA study (Prise en charge de l'Infarctus du Myocarde Aigu; management of acute MI) sought to determine characteristics, management, and in-hospital mortality of myocardial infarction (MI), regardless of age and hospital facilities, in the "real world" in a region in France. METHODS AND RESULTS: Data were prospectively collected in all patients with MI admitted in all hospitals in three departments in the Rh ne-Alpes region between September 1, 1993 and January 31, 1995. 2,519 patients (68% men; mean +/- SD: 68 +/- 14 years) were included. Time from onset of symptoms to admission was < 6 h in 56% of the patients (median: 4 h 30 min). MI was non-Q wave in 12%. Among Q wave MI, location was anterior in 44%. At admission, Killip class was > 1 in 33%. The overall rate of thrombolysis was 36%. It was significantly higher in men than in women, in younger patients than in older patients, in lower Killip classes, in Q wave MI, and when the delay before initial medical intervention was < 6 hours. After age-adjustment, there was no difference between men and women for thrombolysis rate (odds ratio women/men: 0.92; p = 0.10). During the first 5 days, Killip class worsened in 17%. In-hospital mortality rate was 14%. Multivariate analysis identified age, anterior location, presence of Q waves, and higher Killip classes as significant predictors of in-hospital mortality. CONCLUSIONS: This large unselected cohort revealed that among patients with MI in a French region, there was a high proportion of elderly patients, a low rate of thrombolysis, and a high in-hospital mortality.
Age of Onset↗
Accuracy of three-dimensional gadolinium-enhanced MR angiography in the assessment of extracranial carotid artery disease.
OBJECTIVE: The purpose of this study was to assess three-dimensional (3D) gadolinium-enhanced MR angiography, used alone or in association with duplex Doppler sonography, with a fast acquisition time (8 sec) for evaluating the extracranial carotid arteries. SUBJECTS AND METHODS: In this prospective study, 48 successive patients with carotid artery stenoses were examined with 3D gadolinium-enhanced MR angiography and 3D time-of-flight MR angiography. Of the 44 eligible patients, conventional angiography was available in 33 and duplex sonography in 27. We used the North American Symptomatic Carotid Endarterectomy Trial technique to quantify stenosis on all angiograms, and a 250 cm/sec threshold at duplex sonography to diagnose stenoses greater than 70%. Image quality of 3D gadolinium-enhanced MR angiography and 3D time-of-flight MR angiography was assessed, as well as sensitivity and specificity for each technique alone and in combination with duplex sonography. Conventional angiography was the gold standard. RESULTS: Three-dimensional gadolinium-enhanced MR angiography yielded good image quality in 90% of cases. When used alone, it yielded a sensitivity and a specificity of 94% and 85%, respectively, in screening stenoses greater than 70% (70-99%). When combined with duplex Doppler sonography, it provided a 100% sensitivity and specificity for detection of stenoses between 70% and 99% and would have obviated 61% of conventional angiography. In comparison, 3D time-of-flight MR angiography used alone yielded a sensitivity of 88% and a specificity of 94%. In combination with duplex Doppler sonography, its use would have obviated conventional angiography in 74% of cases. Three-dimensional gadolinium-enhanced MR angiography provided accurate results in the diagnosis of occlusions and ulcers and can visualize distant stenoses. CONCLUSION: Used alone, 3D gadolinium-enhanced MR angiography is not accurate enough to replace conventional angiography in the evaluation of extracranial carotid arteries. In association with duplex Doppler sonography, however, it is accurate and may obviate a significant number of conventional angiographic examinations.
Adult↗
[Program for medicalization of the information systems in France: tool for management and quality assessment?].
OBJECTIVE: We analyzed data reported in the scientific literature to assess how the program for medicalizing information systems employed in France for budget management and allocation could be used to evaluate health care quality. A MANAGEMENT TOOL: In France the PMSI (Programme de Médicalisation des Systèmes d'Information) is used outside health care facilities to plan an allocate health care budgets. Within each facility, it can be used to coordinate external and internal resource allocations. The goal is to medicalize management decisions. Certain methods are based on calculations of total costs per hospital stay and others on the construction of budgets for individual units. A QUALITY ASSESSMENT TOOL: Medical criteria of final outcome of health care, for example mortality, are widely used for inter-hospital comparisons. The PMSI can be a useful tool for monitoring inter-hospital comparisons if three prerequisites are met: comparable data, identification of convenient tracers of care episodes or clinical situations, and multifactorial adjustment to account for variations in rates. The most widely used adjustment factors concern patient characteristics: age, sex, case severity, comorbidity, socio-economic level and hospital characteristics: size and status, number of stays and interventions, emergency and intensive care activity, referral practices.
Delivery of Health Care↗
A critical appraisal of the quality of the management of infective endocarditis.
OBJECTIVES: The purpose of this study was to assess the quality of the management of infective endocarditis. BACKGROUND: Although many guidelines on the management of infective endocarditis exist, the quality of this management has not been evaluated. METHODS: We collected data on all patients (116) hospitalized with infective endocarditis over 1 year in all hospitals in the Rhône-Alpes region (France). RESULTS: Prophylactic antibiotics were not given before infective endocarditis to 8/11 cardiac patients at risk and who underwent an at risk procedure. Among the 55 cardiac patients at risk and with fever and who consulted a physician, blood cultures were not performed before antibiotic therapy was initiated for 32 patients. In-hospital antibiotic therapy was incorrect for 23 patients. The portal of entry was not treated for 16/61 patients with an accessible portal of entry. Among the 19 patients who had severe heart failure or fever persisting more than 2 weeks in spite of antibiotic therapy and who could have undergone early surgery, surgery was delayed for five, and not performed for three. Overall, the average score was 15/20. CONCLUSIONS: More information on the management of infective endocarditis should be widely disseminated to the physicians' and the dentists' communities and to the patients at risk.
Aged↗
The mean of sperm parameters in semen donations from the same donor. An important prognostic factor in insemination.
We analysed 12,100 consecutive cycles of artificial insemination by donor spermatozoa in 1901 infertile couples. In our analysis, particular attention was given to finding an appropriate way of taking into account the respective effects of female and male factors on the pregnancy success rate and the level at which these factors act (cycle vs. woman and donation vs. donor). A total of 1213 pregnancies occurred. The pregnancy rate per cycle was lower as the age of the woman increased (p < 0.0001) and varied with the type of infertility: fecundity was higher (p = 0.03) in the case of azoospermia than of severe oligozoospermia. After taking into account these factors, significant unexplained variation in likelihood to conceive remained. A part of this heterogeneity was shown to be due to variation in fecundability between semen donors. In order to explain this heterogeneity between donors, compositional covariates were used, particularly the mean of results of the semen analysis performed for donations from the same donor. For each semen characteristic, the overall mean of the different donations of a donor was an important predictive factor of successful insemination: after taking into account all of the other factors, the odds ratios for an increase of 50 x 10(6)/mL spermatozoa, of a 20% increase in sperm motility and of a 2 point increase in the post-thaw quality index, were, respectively, 1.13, 1.37 and 1.56. After adjustment for these factors, the specific characteristics of each semen donation were no longer significantly predictive of successful insemination. This observation has a biological interpretation: sperm with low parameters but produced by a normally fertile man can have a satisfactory success rate.
Adult↗
[From the prescription of contraceptives to their application. A study of the on-going use of contraceptive methods in immigrant circles during the post-partum period].
PURPOSE: The research presented here aimed at establishing a possible link between the level of integration of an immigrant population and the rate of continuity following a prescription for contraception given to women on leaving the maternity clinic. MATERIALS AND METHODS: From June 1995 to November 1996, a study was conducted in Valence among 71 women who came from Turkey, sub-Saharan Africa and the Maghreb. Out of 87 women interviewed at the maternity, 71 were seen a second time. As well as taking into consideration socio-demographical factors, the study compared the degree of integration with the use of the prescribed contraceptive method six months after leaving the maternity clinic. RESULTS: The study shows that there is no significant link between the level of integration and the continued use of a contraceptive method six months after birth. The only salient fact is that women who had lived less than 10 years in France systematically used a contraceptive method (P = 0.004, relative risk: 1.44, 95% confidence interval: 1.12-1.84). DISCUSSION: Our study would tend towards the following observation: the more recently the immigrant arrived, the more receptive they were towards proposals made by the medical personnel. We consider that rather than it being the case of either total confidence in, or distrust of, medical contraception, the cultural factor remains important and must be taken into account in any approach among this kind of population. It is more a question of community health education than of medical prescription.
Adult↗
Multi-level modelling of conception in artificial insemination by donor.
Data on insemination with donor's sperm have a crossed hierarchical structure due to the coexistence of female factors (ovulatory cycles within pregnancy attempt within women) and male factors (inseminations within donations within donors). A crossed random multi-level logistic model, taking account of this structure, permits an improved estimation of the fixed effects and provides insights into their influence at each level in the hierarchy. We present an efficient algorithm for fitting such models using alternating EM steps. We further discuss the inclusion of compositional covariates to determine what information the quality of a donation conveys regarding the donor basal fecundability and on the specific sperm donation.
Adult↗
Use of logistic function to analyse delayed graft function in renal transplantation.
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Adult↗
Study of the variations of the cesarean sections rate in the Rhône-Alpes region (France): effect of women and maternity service characteristics.
OBJECTIVE: To analyze the variations of the rate of prophylactic cesarean sections and cesarean sections during labor according to the women's and maternity services' characteristics. STUDY DESIGN: The study population was a sample of 8470 women having delivered in one of the 86 maternity services of the Rhône-Alpes region (France) in 1990. The women's characteristics were risk factors for pregnancy or delivery. The maternity services' characteristics included those describing the service structure and the mode of recruitment. For the statistical analysis we used a two-level logistic model. RESULTS: After taking into account the women's characteristics, there remained a variation between the maternity services. This variation was in part explained by the type of recruitment of the maternity service. When the proportion of women with a previous cesarean section or a dystocia increased in the maternity service the cesarean sections rate decreased in women presenting similar characteristics. CONCLUSION: Thus, the maternity services which receive many "at risk" women tend to have higher cesarean section rates than the others. However, in comparison with women presenting similar characteristics, these same maternity services tend to perform fewer cesarean sections.
Cesarean Section↗
Relation between locomotion impairment, functional independence in retirement, and occupational strain resulting from work carried out during working life. Study of a sample population of 350 miners in the Loire valley in France.
STUDY OBJECTIVES: To analyse long term effects of working conditions experienced at an advanced age, and after retirement by quantifying occupational strain, impairment, and disability to establish their interrelation. DESIGN: Retrospective study. PARTICIPANTS: Retired miners from The French Coal Board who had worked in the coal fields of the Loire valley. From a potential population of 507 retired miners, 350 were completely evaluated. MEASUREMENT: The study examines the occupational strain experienced by each subject, measured using both auto-evaluation and evaluation by experts and the locomotion impairment and the functional independence. MAIN RESULTS: A significant relation between the evaluation of occupational strain and functional independence and locomotion impairment of the low back was found and also a significant relation between locomotion impairment of the low back and the length of time spent working at the coal face. CONCLUSIONS: This study confirms other studies as regards the effects of occupation on health status and on the aging process, but it goes further to show the consequences of this relation on functional independence.
Activities of Daily Living↗
[Analysis of natural family planning failures. In 7007 cycles of use].
MATERIALS AND METHODS: The analysis concerned 626 users using NFP in order to avoid a conception during a total of 6740 cycles. Participation in the study did not interfere with their plan of conception, and they were invited to behave, as far as possible, as though they ignored the study. Of these 626 couples, 530 were french, 61 belgian and 35 swiss. On the whole, 39.3% used birth control to limit births and 60.7% to space them. RESULTS: The observed pregnancy rates are 1.13, 6.47 and 17.58 for one year in actuarial method respectively for method, method + user and total pregnancy rate. The pregnancy rate was higher for women before 35 years (RR: 3.8; 95 p100 confidence interval: 1.4-10.3), during the six months after delivery (RR: 2.5; 1.0-4.6) and, of course, for couples with inprotected sexual intercourse in fertile phase (RR: 4.8; 2.1-11.2). DISCUSSION: NFP can be placed among methods of great theorical effectiveness. But pregnancies as a result of intercourses during the fertile phase despite its identification are frequent: couples have to be informed.
Actuarial Analysis↗
[Non metastatic breast cancer surgery in the Rhône department between 1988 and 1994].
BACKGROUND: From the results obtained in the breast cancer register, this report describes the usual surgical practice of breast cancer in the Rhône department (France). METHODS: This study concerned 4,028 cases of non-metastatic breast cancer diagnosed during the period 1988-1994. Three periods were determined (1988-89, 1990-92, 1993-94). Univariate analysis described the relation between the type of surgical practice and the explanatory factors. Logistic regression analysis was used to search for changes in surgical practice during the three periods. RESULTS: The proportion of conservative breast surgery rose from 53% in 1988 to 64.5% in 1994. Taking the period 1988-89 as the reference period, the adjusted odds ratio of conservative surgery during the period 1990-92 was 1.4 [1.1-1.7]. During the period 1993-94, this adjusted odds ratio was 1.9 [1.6-2.3]. Finally we observed that conservative surgery was less frequent in patients 70 years of age or older. CONCLUSION: Conservative breast surgery increased significantly during the defined period. This observation can be explain by two events. First there was a significant increase of small breast cancer (< 20 mm) among women aged 50 to 69 who benefited from the systematic screening breast cancer since 1988. Secondly a significant "period effect" was observed. This "period effect" proves a modification of surgical practice after adjustment for cancer characteristics.
Adult↗
[The impact of the data collection method on the medico-economic classification of admissions for myocardial infarction at the public hospitals in Lyon].
The aim of the PMSI (Programme de Médicalisation du Système d'Information) is to describe the activity of hospitals for budget allocation. To control the quality of this information, the authors carried out a study comparing the classification in homogenous disease groups (HDG) obtained from the PMSI with that obtained from the epidemiological data base of the PRIMA trial for patients admitted to the Civil Hospitals of Lyon for myocardial infarction between September 1st 1993 and January 31st 1995. Six hundred and fifty standardised hospital summaries were reconstituted form PRIMA data and grouped using the GENRSA 3 software. Five hundred and forty-one of these hospital stays were found in the PMSI data base and grouped. The concordance not due to chance between the two classifications was then assessed by the global kappa coefficient. It was less than the 40% threshold under which concordance not due to chance is considered to be unlikely. The discordances were essentially due to the presence of an associated diagnosis classifying the hospital stay in the HDG corresponding to complicated myocardial infarction. The presence of a classifying associated diagnosis was observed significantly more often in the PRIMA than in the PMSI data base. This results in an underestimation of the hospital activity and could have important repercussions in terms of budget allocation.
Budgets↗
[Survival after 60 years of age among elderly retired miners].
This study analyses long term effects of working conditions at an advanced age and post retirement. A longitudinal study was done among 63,000 retired miners between 60 to 65 years old. The standardised mortality ratio (SMR) in the cohort was above that expected on the basis of concurrent mortality in the reference population (SMR = 111; 95% confidence interval (CI): 108-114). The excess mortality was observed in occupational groups with exposure to underground tasks (10 years of underground tasks: RR = 2; 95% CI: .1.7-2.5), but there was sign of a healthy worker effect after 25 underground years. The effects of modern technologies and of medical progress have changed working conditions and care has reduced mortality for retired manual workers: exposure to underground tasks before 1950: RR = 1.7; CI 95%: 1.4-2.0; after 1950: RR = 1.2; CI 95%: 1.1-1.2.
Aged↗
[Use of a logistic regression model at two levels in the analysis of medical practice variations: the prophylactic cesarean].
We show the use of a hierarchical logistic model to study the variations of the prophylactic cesarean section rate between the maternity hospitals of the Rhône-Alpes region. These variations are analyzed according to the women characteristics at first level, and the maternity hospital characteristics at second level. We present the two-level hierarchical logistic model and the method of estimation of the fixed and random parameters. Then, we compare and discuss the results obtained with those of the usual logistic model. The usual logistic model underestimates the standard error of the regression parameters. In our example however, the results obtained with the hierarchical model do not modify the conclusions concerning the effect of the women characteristics. All the women characteristics increase significantly the probability for a woman to have a prophylactic cesarean section. Nevertheless, the hierarchical model reveals the effect of the maternity hospital characteristics and shows that the maternity hospitals which receive many "at risk" women tend to perform fewer prophylactic cesarean sections than the others, in women with the same characteristics. It permits to estimate the residual variance of second level linked to the unobserved characteristics of the maternity hospitals. It permits to show that the effect of the main characteristics of the women (previous cesarean section, dystocia, chronic fetal distress) vary between maternity hospitals.
Bias↗
[Decision analysis of congenital toxoplasmosis in the absence of exact knowledge of the treatment benefits and secondary effects].
Decision analysis seemed the appropriate method to bring out the interest of toxoplasmosis serology in children born from mothers who seroconverted during pregnancy. In particular it provides the possibility to choose between IgA serology, recently introduced in hospital practice, and IgM serology that is the reference test. We study a series of 96 children suspected of having congenital toxoplasmosis who were followed up until the age of one. A decision analysis is thereafter conducted by synthesizing data about clinical efficacy with the RBNCN ratio that is the net benefit of treating an affected person divided by the net cost of treating an unaffected person; these costs and benefits are clinical. The effectiveness of the treatment (sulphonamides in most cases) was not quantified. Therefore, we used the fact that the RBNCN ratio is equal to the number of healthy children likely to be treated unnecessarily in order not to leave untreated a contaminated child. Although data available in the literature and data from our study still remain insufficient to draw a final conclusion, IgA antibodies are significantly more sensitive than IgM antibodies (p < 0.01). Conversely, IgA antibodies are significantly less specific than IgM antibodies (p < 0.001). The sensitivity analysis shows that the IgA test is preferred to the IgM test if the mother is contaminated during the third trimester. On the other hand, for low prevalences, as observed in the first trimester, the IgM serology is more useful.
Anti-Infective Agents↗
Comparison of the effects of different menstrual tampons on the vaginal epithelium: a randomised clinical trial.
The effects on the vaginal epithelium of three different menstrual tampons in normal conditions of use were studied in 41 women during the menstrual period. The vaginal epithelium was studied in a total of 123 cycles at a structural and ultra-structural level with colposcopy, vaginal smear and biopsy on TEM and SEM. One of the three tampons studied showed a lower level of abnormalities on colposcopy (36.6% vs. 56.1% vs. 68.3%), with an inverse correlation between the severity of the dryness and the quantity of blood absorbed by the tampon (4.2 g when the colposcopy was normal vs. 1.8 g in case of severe dryness). Cytology is not a good test for assessing the effects of tampons because of the high rate of acellular and uninterpretable samplings. The biopsy effects were defined according to their depth in the epithelium. The same tampon showed the lowest level in biopsy abnormalities. No correlation was found between severity of the colposcopy and biopsy results. Colposcopy can demonstrate the degree of severity of dryness or any other effect, but biopsy only confirms the effect and does not correlate the degree of severity. Materials and designs of tampons can play a role in reducing the drying effects to the vaginal epithelium.
Adolescent↗