Opposite evolution in incidence of Crohn's disease and ulcerative colitis in Northern France (1988-1999)

BACKGROUND

Northern France was characterised by a high incidence of Crohn's disease (CD) and a low incidence of ulcerative colitis (UC) according to the first inquiry undertaken in the late 1980s.

AIMS

To assess the trends in the incidence of inflammatory bowel disease (IBD) over a 12 year period (1988-1999) in the same area of Northern France.

PATIENTS

Patients living in Northern France (Nord, Pas-de-Calais, Somme, and Seine Maritime--total of 5,790,526 inhabitants) between 1988 and 1999 were included in the study. Case ascertainment was established according to methodology previously described.

METHODS

Trends in incidence were studied using a Poisson regression model in four three year periods (1988-90, 1991-93, 1994-96, and 1997-99) adjusted for age at diagnosis and sex. Incidence rates were standardised for age with the European standard population.

RESULTS

During 1988-99, 7066 cases of IBD were recorded (56.8% CD, 37.7% UC, and 5.5% indeterminate colitis). Mean annual incidence rate of CD increased from 5.2/100,000 inhabitants in 1988-90 to 6.4 in 1997-99 (adjusted p for trend <0.001). In contrast, the incidence of UC decreased from 4.2 to 3.5 (adjusted p for trend <0.001). The ileocolonic subtype of CD increased by 25% even though median age at diagnosis and frequency of digestive investigations were not different.

CONCLUSIONS

Contrary to what has been reported in other countries in Northern Europe, the incidence of CD increased by 23% in 12 years in Northern France while that of UC decreased by 17% during the same period. This indicates that some factors which influence IBD frequency (in both directions) are still at work in this area of Europe, and that further studies aimed at identifying these should be performed. The rising incidence of CD could enhance the burden of this disease on the public health system in France.

Mediastinitis after coronary artery bypass graft surgery: influence of the mammary grafting for diabetic patients

Mediastinitis is a severe complication of coronary artery bypass graft surgery (CABG) particularly when harvesting internal mammary arteries (IMA). CABG in diabetic patients often uses two IMA because the saphenous graft is damaged. To our knowledge this risk of mediastinitis has not previously been reported in diabetic patients. All consecutive diabetic patients undergoing CABG over a three-year period from 1998 to 2000 were included in the study. Data recorded were: age, sex, duration of stay, whether one or two IMA were used, diagnosis of mediastinitis. Calculation of relative risk and analysis of trends by chi2 trend tests was also performed. In total 256 diabetic patients were included in the cohort. The incidence of mediastinitis was 4.3% (11/256). The risk of mediastinitis was higher in patients with two IMA than in patients with one IMA (relative risk 5.97, 95 CI 1.63-21.93, P=0.004). Age and sex were not confounding factors. No patients with mediastinitis died. Bilateral IMA grafting is associated with higher risk of mediastinitis in diabetic patients. The authors suggest that the risk of mediastinitis in diabetic patients should be taken into consideration when cardiac surgeons choose unilateral or bilateral IMA harvesting for surgery.

Nosocomial urinary tract infections in urologic patients: assessment of a prospective surveillance program including 10,000 patients

OBJECTIVE

Hospital-acquired urinary tract infections (HUTI) represent a significant impairment in the quality of health care. Incidence in catheterized patients has been estimated at approximately 20%, however few data are available in urologic patients. We report a prospective surveillance program over 6 years in our urologic department and evaluate its evolution.

METHODS

Population consists of all patients admitted to the urology ward for 48 hours or more over a 6-year period from 1994. Data recorded: age, gender, duration of stay, insertion and removal of catheters, diagnosis of HUTI.

ANALYSIS

calculation of incidence, and incidence density for HUTI and for catheter-related HUTI, analysis of trends by chi(2) trend test.

RESULTS

A total of 10,054 consecutive patients were included, 52% were catheterized. The median incidence of catheter-related HUTI in catheterized patients was 13.0%, the incidence density was 25.1 HUTI/1000 patient-days of catheterization. The proportion of HUTI and specific catheter-related HUTI patients decreased, respectively from 8.4% and 14.2% to 6.5% and 12.3% during the study period (p<0.05).

CONCLUSION

The rate of HUTI was not as high as previously reported, perhaps due to a controlled catheter policy. Surveillance was associated with a significant decrease in infection rates, suggesting a beneficial feedback effect. Evaluation of diagnoses and surgical procedures would ensure an optimal quality control program.

Difficulties in the management of an incomplete form of refractory thrombotic thrombocytopenic purpura, the usefulness of vincristine

BACKGROUND

Although several etiologies can be identified in thrombotic thrombocytopenic purpura (TTP), idiopathic cases are still frequent. Incomplete forms are more rare. Currently, the diagnosis may be made in cases of thrombocytopenia and microangiopathic hemolytic anemia. According to the literature, mortality and morbidity are significantly improved with plasma exchange. However, treatment in refractory forms remains problematic.

CASE REPORT

A 33-year old woman presented with an incomplete form of TTP, refractory to a combination of therapeutics. The patient underwent plasma infusion, plasma exchange, and then was started on corticosteroids. She also received intravenous immunoglobulins and antiplatelet agents in close proximity to vincristine (Oncovin) infusion. The main biological indicators used were the platelet count, hematocrit, LDH, and the presence of schistocytes. Following vincristine treatment, the patient's condition rapidly improved.

CONCLUSION

Vincristine administered after the failure of standard therapeutics was effective in this refractory form of TTP.

Assessment of prolonged hospital stay attributable to surgical site infections using appropriateness evaluation protocol

BACKGROUND

The accepted standard in estimating the stay prolongation attributable to surgical site infections is the matched-cohort study method (MCS), which is associated with selection bias. The Appropriateness Evaluation Protocol (AEP) has been used to estimate stay prolongation attributable to nosocomial infections but has not been validated specifically for surgical site infections.

AIM OF THE STUDY

To compare estimates of stay prolongation attributable to surgical site infections after digestive surgery, obtained by AEP and by MCS.

METHODS

Sixty-five surgical site infections after digestive tract surgery were analyzed by AEP and MCS. AEP stay prolongation was the number of days judged specifically appropriate for the care of surgical site infections. MCS stay prolongation was the difference of stay duration in surgical site infection cases and two controls matched by age, sex, and diagnosis-related groups. Sensitivity and specificity of AEP, and agreement between both methods, were calculated.

RESULTS

The mean AEP stay prolongation was 3.5 days vs 7.2 days for MCS. The sensitivity of AEP was 58% and the specificity was 75%. The agreement between the two methods was poor.

CONCLUSION

Surgical site infections after digestive tract surgery increased the hospital stay. Accurate estimations of a prolongation of stay will vary according to the method selected.

Nonlinear short-wave propagation in ferrites

In this paper we discuss the propagation of nonlinear electromagnetic short waves in ferromagnetic insulators. We show that such propagation is perpendicular to an externally applied field. In the nonlinear regime we determine various possible propagation patterns: an isolated pulse, a modulated sinusoidal wave, and an asymptotic two-peak wave. The mathematical structure underlying the existence of these solutions is that of the integrable sine-Gordon equation.

Postoperative management of stage II/III colon cancer: a decision analysis

BACKGROUND & AIMS

Two separate decisions must be made for the management of patients with resected stage II/III colon cancer: whether to begin adjuvant chemotherapy and whether patients should be included in a follow-up protocol consisting of regular monitoring of carcinoembryonic antigen level and of colonoscopy and imaging. The standard management for these patients is adjuvant chemotherapy for stage III patients and follow-up for stage II/III patients with resected colon cancer.

METHODS

Decision analysis was used to compare the effectiveness (5-year survival rate) and cost-effectiveness ratio of 7 strategies of treatment and follow-up.

RESULTS

The most cost-effective strategies were adjuvant chemotherapy for all patients with stage II/III resected colon cancer, with either no follow-up or follow-up only for patients aged less than 75 years with a seric preoperative carcinoembryonic antigen level of >5 ng/mL (5-year survival, 62.3% or 62.7%; cost per surviving patient, $8254 or $8657, respectively). The order of efficacy of the strategies was insensitive to changes in the values of the studied variables. The method of follow-up does little to improve 5-year survival but adds substantial cost.

CONCLUSIONS

The current standard strategy may not be the most cost-effective strategy for the management of patients with resected colon cancer.

Long-wave and short-wave asymptotics in nonlinear dispersive systems

In this paper we study the interplay between short- and long-space scales in the context of conservative dispersive systems. We consider model systems in (1+1) dimensions that admit both long- and short-wavelength solutions in the linear regime. A nonlinear analysis of these systems is constructed, making use of multiscale expansions. We show that the equations governing the lowest order involve only short-wave properties and that the long-wave effects to leading order are determined by a secularity elimination procedure.

[Cost of early management of chronic inflammatory intestinal disease]

OBJECTIVES

The aim of this study was to assess the cost of the first management of inflammatory bowel disease (IBD) from the onset of first symptoms until 6 weeks after the diagnosis. This cost was calculated in French francs (FF) for all IBD and namely for Crohn's disease (CD), ulcerative colitis (UC), and ulcerative proctitis (UP).

MATERIAL AND METHODS

Data concerning 258 patients were collected by the mean of a standardized questionnaire from 3 different sources: the patient, his general practitioner, and his gastroenterologist.

RESULTS

Two hundred and fifty eight patients were included: 144 CD (55.8%), 76 UC (29.5%), 30 UP (11.6%), and 8 chronic unclassifiable colitis (CUC) (3.1%). The mean direct costs of the diagnosis (m +/- SD) were 23,116 +/- 40,820 FF for CD, 10,628 +/- 17,316 FF for UC and 3,451 +/- 2,743 FF for UP. Although unplanned hospitalizations occurred in only 38% of the patients (98/258), they represented the 3/4 of the mean costs: 78.2% for CD and 64% for UC. Indirect costs generated by days off work were 4,719 +/- 6,610 FF for CD, 2,996 +/- 6,897 FF for UC and 1,230 +/- 3,622 FF for UP.

CONCLUSION

The first management of a patient with CD was twice more expensive than the one with UC and 6.5 times than the one with UP.

[Risk factors of contamination by hepatitis C virus. Case-control study in the general population]

In 30% of patients with hepatitis C virus, the source of infection is unknown.

OBJECTIVE

To identify the risk factors of infection by hepatitis C virus in a case-control study.

METHODS

Cases had positive hepatitis C virus serology, and were living in Fecamp (Normandy, France). Controls (2 for each case) were age and sex-matched subjects with negative hepatitis C virus serology, living in Fecamp. Demographic, medical, professional, and environmental data were collected. Statistical analysis included chi 2 or Fisher's exact test and multiple logistic regression.

RESULTS

The risk factors of hepatitis C virus by univariate analysis were: history of transfusion, high number of sexual partners, hepatitis C virus infection in a relative, history of digestive or genitourinary surgery, an invasive medical procedure, digestive endoscopy, biopsy, lumbar or pleural puncture, medical care after an accident, injections, multiple deliveries or abortion. Risk factors of hepatitis C virus infection by multivariate analysis: hepatitis C virus infection in a relative (Odds ratio: 4.58), history of transfusion (Odds ratio: 2.32), of a surgical procedure (Odds ratio: 2.50), of medical care after an accident (Odds ratio: 1.51), of injections (Odds ratio: 2.24).

CONCLUSION

Our results suggest the possible nosocomial transmission of hepatitis C virus. Intrafamilial transmission is also possible.

Incidence of rectosigmoid adenomatous polyps in subjects without prior colorectal adenoma or cancer: a prospective cohort study

BACKGROUND

Subjects without known colorectal adenomas or cancer constitute a large majority of the population where 85% of all cases of colorectal cancer are thought to occur. Consequently these people should be considered for screening to decrease mortality from colorectal cancer in the general population.

AIMS

To estimate the incidence rate of rectosigmoid adenomas in these subjects.

METHODS

Subjects without adenomas or cancer at a previous examination which had visualised the rectosigmoid underwent a fibre endoscopy every three years. Endoscopic data and population characteristics were collected prospectively.

RESULTS

A total of 450 subjects fulfilled the selection criteria; 287 (64%) underwent at least two examinations, and 163 had three or more. At the second examination, with a mean delay of 39 months, the incidence rate of rectosigmoïd adenomas was 1.50% per patient year. The rate was 1.75% per patient year (95% CI 0.80-3.33) at the third endoscopy with an additional mean delay of 38 months. The cumulative incidence rate at six years was 7.3% (95% CI 4.3-10.3), representing a mean of 1.2% per patient year. This rate increased with age and was higher for men than for women after age adjustment (p< 0.03).

CONCLUSIONS

The incidence rates are very low compared with those of patients with prior adenomas. These results should be considered in establishing rectosigmoid adenoma screening strategies.

[Diagnostic and therapeutic management of patients with chronic inflammatory bowel disease]

BACKGROUND

The period of time required for the diagnosis of a chronic illness depends on initial clinical symptoms and their perception by the patient and the physicians. The aim of this study was to describe the procedures of diagnosis of incident cases of Inflammatory Bowel Disease (IBD).

METHODS

Patients reported by the Registry of inflammatory bowel disease of northern France (EPIMAD) in 1994 were included. Standardized questionnaires describing clinical history, patient behavior, medical consultations and examinations were collected by an interviewer practitioner from three sources: patients, general practitioners (GP) and gastroenterologists (GE). Patients were divided in 2 groups according to the time between symptom onset and diagnosis: more than 9 months or less than 9 months (D > 9 and D < or = 9).

RESULTS

258 patients were included: 144 Crohn's disease (CD) (56%), 106 ulcerative colitis (UC) (41%) and 8 chronic unclassifiable colitis (CUC). Median time between symptom onset and diagnosis was 3 months, 196 (76%) patients belonged to the group D < or = 9 and 62 (24%) to the group D > 9. There was no difference between the 2 groups for initial clinical symptoms. The delay between symptom onset and the consultation to the GP and the GE was longer in the group D > 9: respectively 1 month vs 0 and 7.6 vs 2. Thirty-five percent of patients in the group D > 9 had consulted more than one GP vs 14% (p < 0.05). Diagnosis management by the GE was the same in both groups. Patients of group D < or = 9 had more often perceived their symptoms as serious (p < 0.05).

CONCLUSIONS

Delay to diagnosis in a quarter of patients with IBD was more than 9 months. This later diagnosis was not due to patient management by the GE but rather to a longer delay to consulting the GP and between GP and GE referral. Patient interpretation of the symptoms could also explain the variability of this delay.

Enteral nutrition modifies gut-associated lymphoid tissue in rat regardless of the molecular form of nitrogen supply

BACKGROUND

It has been suggested that beneficial effect of elemental enteral diets in the treatment of inflammatory bowel diseases could be mediated by the suppression of protein dietary antigens. The objective of the present work was to study the effect of enteral diet on gut associated lymphoid tissue and on gastric Lactobacillus flora, in rat.

METHODS

The effects of three molecular forms of nitrogen supply: amino acids, oligopeptides or whole casein, were compared in rats on continuous enteral diet. Frozen sections of small bowel were studied with monoclonal antibodies anti-CD5, -CD4, -CD8, -CD25, -macrophages, -MHC II. The Lactobacillus flora was also enumerated in the stomach, in order to assess the effect of ED on rat flora.

RESULTS

Growth and mucosa morphology were identical in control and enteral groups. Rats on enteral diet showed, whatever was the molecular form of nitrogen supply, a decrease in CD5+, CD4+ and CD8+ intraepithelial cell numbers, but not in lamina propria cell number, and a decreased MHC II epithelial expression, when compared to control rats. The enterally fed rats also showed a decrease in Lactobacillus gastric contents.

CONCLUSIONS

The current study demonstrates that continuous enteral nutrition modifies MHC II epithelial expression and gut associated lymphoid tissue cell number in rat, whatever is the molecular form of nitrogen supply. Intestinal flora could be responsible, at least for part, for these results.

[Compared efficiency of three strategies of management of chronic hepatitis C. Effect on the risk of cirrhosis 8 years after diagnosis]

OBJECTIVES AND METHODS

The goal of treating chronic hepatitis C with alfa interferon is to eradicate HCV infection. The actual influence of this treatment on the development of cirrhosis is unknown. Moreover, the poor results and the high cost of this treatment have caused a public health problem. Three strategies were evaluated by decision analysis: no treatment (S1), treatment of chronic active hepatitis only (S2), treatment of all chronic hepatitis (S3). For each strategy, we estimated the probability of the occurrence of the following events based on data in the literature: presence of chronic active hepatitis, chronic persistent hepatitis or cirrhosis at the time of diagnosis; discontinuation of interferon because of adverse events; biological response to treatment; incidence of cirrhosis 8 years after diagnosis without treatment or in case of response to treatment.

RESULTS

The risk of cirrhosis was 28.5% with S1, 25.4% with S2, and 25.2% with S3, 8 years after diagnosis. If HCV infection was detected early before cirrhosis, the number of cases of cirrhosis occurring in an 8 year-followup period would be 45,600 with S1, 40,640 with S2, and 40,320 with S3 and the cost of S2 and S3 would be 1.23 10(9) French Francs (FF), and 2.57 10(9) FF, respectively. The mean cost to prevent one case of cirrhosis would vary from 248,000 FF with S2 to 487,000 FF with S3.

CONCLUSION

This decision analysis study suggests that the S3 strategy is not suitable for a population of HCV infected patients, because of its low efficiency and high cost.