[Satisfaction of patients hospitalized in Ho Chi Minh City, Vietnam]

This study aims to describe the level of satisfaction of patients and their families, according to the type of hospital and the sociodemographic characteristics of patients hospitalised within Ho Chi Minh City (HCMC), Vietnam. The study is supported by a sample of 538 patients and their families from all of the hospitals in HCMC to whom an evaluation questionnaire was given to be filled out on the day of their release. The average age is 39, and 64.4% are women. The scores measuring the level of satisfaction vary from 57.7 to 90.7 points (on a scale of 0 to 100). The section under the heading "treatment provided by the doctors" received the highest scores (90.7/100). Dissatisfaction was primarily associated with factors such as the amount of time spent waiting, the behaviour of the hospital staff, cleanliness, the cafeteria and parking for motorbikes. Almost 100% of the patients spoke about their experiences during their stay in the hospital, and 50.2% had some negative opinions (1.042 complaints registered). The older patients, having a lower level of education and living either in other cities or in the rural region of HCMC, tented to be more satisfied than the younger patients, possessing higher levels of education and generally residing in the sub-urban or urban regions of HCMC. The patients who judged their condition to be very serious and their problems bad enough to justify hospitalisation, and who also felt that their health and condition had improved at the time of release compared to the time of admission were more satisfied than the other patients. Patients hospitalised who had an individual private room in a specialised hospital tended to be more satisfied that those who had a room sharing many beds for several patients in either a general hospital or in the emergency area of a specialised hospital. The authors observed no correlation between the level of satisfaction and the patient's gender. The results of this study have highlighed that certain domains, notably hat of the hospital's environment, should be reviewed and examined by health care administrators and managers in order to ensure the quality of the patient's care and coverage.

Antithrombotic therapy is associated with better survival in patients with severe heart failure and left ventricular systolic dysfunction (EPICAL study)

BACKGROUND

In patients with congestive heart failure (CHF), clinical trials have demonstrated the benefit of a number of drugs on morbidity and mortality. Nevertheless so far, there is no published controlled study of long-term antithrombotic therapy in patients with CHF. The aim of this work was to identify the relationship between cardiovascular drug use, especially antithrombotic therapy, and survival of CHF patients in current clinical practice, using an observational, population-based database.

METHODS

The EPICAL study (Epidémiologie de l'Insuffisance Cardiaque Avancée en Lorraine) has identified prospectively all patients with severe CHF in the community of Lorraine. Inclusion criteria were age 20-80 years in 1994, at least one hospitalisation for cardiac decompensation, NYHA III/IV HF, ventricular ejection fraction < or =30% or cardiothoracic index > or =60% and arterial hypotension or peripheral and/or pulmonary oedema. A total of 417 consecutive patients surviving at hospital discharge were included in the database. The average follow-up period was 5 years. Univariate Cox models were used to test the relationship of baseline biological and clinical factors to survival. Cardiovascular drug prescriptions were tested in a multivariate Cox model adjusted by other known predictive factors.

RESULTS

Duration of disease >1 year, renal failure, serum sodium > or =138 mmol/l, old age, serious comorbidity, previous decompensation, high doses of furosemide and vasodilators use were independently associated with poor prognosis at 1 and 5 years. Oral anticoagulants, aspirin, lipid lowering drugs and beta-blockers use were associated with better survival. There was no interaction between aspirin and angiotensin converting enzyme inhibitor use on survival.

CONCLUSION

Antithrombotic therapy was associated with a better long-term survival in our study population of severe CHF. These results together with other previously published circumstantial evidence urge for a prospective, controlled and randomised trial specifically designed to evaluate optimal oral anticoagulants and aspirin in patients with congestive heart failure.

Factors determining inpatient satisfaction with care

The objective of the study was to identify factors associated with satisfaction among inpatients receiving medical and surgical care for cardiovascular, respiratory, urinary and locomotor system diseases. Two weeks after discharge, 533 patients completed a Patient Judgments Hospital Quality questionnaire covering seven dimensions of satisfaction (admission, nursing and daily care, medical care, information, hospital environment and ancillary staff, overall quality of care and services, recommendations/intentions). Patient satisfaction and complaints were treated as dependent variables in multivariate ordinal polychotomous and dichotomous logistic stepwise regressions, respectively. Patient sociodemographic, health and stay characteristics as well as organization/ activity of service were used as independent variables. The two strongest predictors of satisfaction for all dimensions were older age and better self-perceived health status at admission. Men tended to be more satisfied than women. Other predictors specific for certain dimensions of satisfaction were: married, Karnofsky index more than 70, critical/serious self-reported condition at admission, emergency admission, choice of hospital by her/himself, stay in a medical service, stay in a private room, length of stay less than one week, stay in a service with a mean length of stay longer than one week. The factors associated with inpatient satisfaction elucidated in this study may be helpful in interpreting patient satisfaction scores when comparing hospitals, services or time periods, in targeting patient groups at risk of worse experiences and in focusing care quality programs.

Project, design, and use of a pilot plant for nanocapsule production

The aim of this study was to find the scale-up parameters necessary for the preparation of nanocapsules (NCs) for pharmaceutical purposes. Starting from the laboratory scale (0.06 L), we designed and assembled a pilot plant (2 L) to produce NCs with the so-called emulsification-diffusion technique. We wanted to check if classical tools adequate for the pharmaceutical industry and for industrial scale-up purposes according to well-known chemical engineering technique could be used to perform the NC preparation. Experiments were carried out by varying some operative parameters, such as the impeller speed, the agitation duration for the emulsion preparation, and the reagent concentrations. As expected, good accordance between the NC produced at the laboratory scale and at the pilot plant scale was obtained. We conclude that the pilot plant can be used to perform a scale-up study of the industrial production of NC.

Quality of life profiles in the first years of rheumatoid arthritis: results from the EURIDISS longitudinal study

OBJECTIVE

The aim of this study was to examine the quality of life (QoL) profiles of patients with early rheumatoid arthritis (RA) and to relate these to disease and impairment variables as indicated, respectively, by erythrocyte sedimentation rate (ESR) and by tender joint count (Ritchie Articular Index), fatigue, and pain.

METHODS

The present study uses part of the European Research on Incapacitating Disease and Social Support data of 573 patients with recently diagnosed RA (268 from the Netherlands, 216 from Norway, and 89 from France). A series of clinical and psychosocial data were collected on 4 (the Netherlands, France) and 3 (Norway) occasions, with 1-year intervals separating the waves of data collection.

RESULTS

Of the disease activity (ESR) and impairment variables (tender joint count, fatigue, pain), fatigue was identified as the consequence of disease that differentiated best on a series of QoL aspects such as disability, psychological well-being, social support, and "overall evaluation of health." Next came pain and tender joint count, and ESR showed by far the least differentiating ability. A principal-component analysis on the QoL measures used in this study yielded one general factor measuring "overall QoL." After rotation, two separate factors were encountered, one referring to the physical domain and the other to the psychological and social domains of QoL. Again, the QoL of RA patients experiencing much fatigue appeared to decline the most.

CONCLUSIONS

Because of the highly variable nature of RA, impairments, activities of daily living (ADL) and instrumental ADL restrictions, and psychosocial distress can vary erratically. In particular, "fatigue" as measured over a period of 2 to 3 years distinguished best among RA patients as shown by their QoL profiles. Although the physical domain was most affected, the significant effect of RA on the psychosocial domain should not be underestimated.

Compliance with drug therapy in rheumatoid arthritis. A longitudinal European study

OBJECTIVE

To delineate compliance with drug therapy in rheumatoid arthritis patients, determine specific characteristics of compliant and noncompliant patients, and look for changes in compliance over time.

PATIENTS AND METHODS

A prospective European cohort study (EURIDISS) recruited 556 patients in four countries over three years. Compliance with drug dosages and dosing times was evaluated yearly using a questionnaire.

RESULTS

Of the 556 patients, 429 (77.2%) were on drug therapy at all three evaluation time points. Use of steroids, nonsteroidal anti-inflammatory drugs, and second-line drugs varied significantly across countries. The compliance behavior was stable over time in 59.5% of them (35.7% of patients were consistently compliant and 23.8% consistently noncompliant); it was independent of disease duration and from the clinical features of the disease. Older patients and women were more likely to be compliant (odds ratios, 2.5 and 2, respectively).

CONCLUSION

Compliance with drug therapy can be measured using two simple questions. Compliance is more closely dependent on individual behavior than on responses to specific features of rheumatoid arthritis.

Effect of two years' supplementation with natural antioxidants on vitamin and trace element status biomarkers: preliminary data of the SU.VI.MAX study

The "SUpplementation en VItamines et Minéraux AntioXidants" (SU.VI.MAX) study is a randomized double-blind, placebo controlled, primary-prevention trial designed to test the efficacy of a daily supplementation with antioxidant vitamins (vitamin C, 120 mg; vitamin E, 30 mg; and beta-carotene, 6 mg) and minerals (selenium, 100 microg; and zinc, 20 mg) at nutritional doses (one to three times the daily recommended dietary allowances), in reducing the frequency of cancers and cardiovascular diseases. The study involves 12,735 eligible subjects (women aged 35-60 years, men aged 45-60 years) included in 1994 in France. They will be followed up for 8 years. The targeted population is the general population. The aim of this specific analysis is to assess the effect of 2 years of supplementation on biochemical indicators of vitamin and trace element on a subsample of 1000 subjects. The mean (+/- standard deviation) concentrations of plasma beta-carotene, alpha-tocopherol, vitamin C, selenium and zinc among participants who were randomly assigned to receive a daily supplementation with beta-carotene, vitamin E, vitamin C, selenium and zinc for 2 years were significantly higher than those who were assigned to receive placebo. Specifically, the mean concentrations among men in the intervention group were 0.86 +/- 0.70 micromol/L for beta-carotene, 35.3 +/- 9.3 micromol/L for alpha-tocopherol, 11.5 +/- 4.7 microg/ mL for vitamin C, 1.65 +/- 0.33 micromol/L for selenium, and 16.2 +/- 3.9 micromol/L for zinc. The mean concentrations among women in the intervention were 1.25 +/- 0.90 micromol/L for beta-carotene, 34.9 +/- 8.4 micromol/L for alpha-tocopherol, 12.6 +/- 4.0 microg/mL for vitamin C, 1.68 +/- 0.37 micromol/L for selenium, and 15.3 +/- 3.9 micromol/L for zinc. The values observed for beta-carotene and vitamin E in the supplementation group after 2 years of intervention are those that have been associated with the lowest risk of cancer in observational studies. They are definitely lower than concentrations reported in intervention studies showing an apparent negative effect of high levels of beta-carotene supplementation on the lung cancer incidence rate in high-risk subjects (initial level multiplied by 12-18). Data from the follow-up will ascertain if any plausible reduction in the incidence rate of cancers may be associated with such amounts of antioxidant agents.

Power Doppler US: evaluation of the morphology of stenoses with a flow phantom

PURPOSE

To determine the importance of technical settings at power Doppler ultrasonography (US) for the evaluation of stenoses.

MATERIALS AND METHODS

A computer-controlled phantom was used to induce a reproducible flow across a calibrated 71% stenosis in an 8.4-mm-diameter tube. Two transducers, 2-4 and 5-10 MHz, working at depths of 3.0 and 11.5 cm, respectively, with different beam angles (40 degrees, 60 degrees, and 90 degrees ), were used to simulate evaluation of pulsatile flow across normal and stenotic vessels in various conditions. For each condition, gain, pulse repetition frequency, and wall filter were progressively turned from low to high values. Two observers measured in a blinded fashion the apparent lumen of the stenotic and normal vessels on longitudinal and transverse images with the use of power Doppler US.

RESULTS

When the high-frequency transducer was used, gain significantly affected both stenotic and feeding vessel measurement, whereas pulse repetition frequency and filter only affected feeding vessel evaluation. When the low-frequency transducer was used, all factors, including flow velocity and beam angle, played a significant role (P <.001). In most conditions, overestimation of the lumen and underestimation of the lumen of the feeding vessel led to severe underestimation of the degree of stenosis.

CONCLUSION

Power Doppler US cannot be used to measure stenoses accurately. Underestimation of the degree of the stenosis was significantly higher with the low-frequency probe than with the high-frequency probe.

[Management, cost and mortality of a cohort of patients with advanced heart failure (the EPICAL study)]

The objectives of this study are to describe the management, outcomes and costs of patients with severe chronic heart failure (CHF) and to identify the associated socio-demographic and clinical determinants. In 1994, the EPICAL study enrolled in a French region a representative cohort of 358 patients presenting for the first time with severe CHF (NYHA class III or IV) requiring hospitalization. The mean annual cost per patient was 125 652 FF, 92.6 per cent of which was associated with in-patient care including the index hospitalization. Ten per cent of patients contributed 33 per cent of the total cumulative costs. The rate of readmission was very high (20 per cent per month of follow-up) and appeared as a major cost driver. Three variables were identified in a multivariate logistic regression as the main contributors to cost: the presence of co-morbidity, renal insufficiency and marital status (living alone versus with spouse). These findings confirmed the major clinical and economic interest of any intervention that could lower the rate of readmissions in this group of patients.

[Evaluation of professional practices]

Concepts and methods in professional practices evaluation are often confused. After a description of the classical conceptual framework, we present these methods in an approach in which practice is the principal result to be measured. Thus it makes it possible to apply the traditional epidemiological concepts to the evaluation of the professional practices with their three traditional fields: 1) In the descriptive approach, cross-sectional practice studies allow an observation and description of the usual behaviors, possibly compared to references. The methodological constraints are the same as which of descriptive epidemiological studies; 2) In the analytical approach, factors associated with practice - simple or conformed to criteria - are evidenced on a representative sample; 3) In the evaluative approach of practices improvement, the objectives are the assessment of formative, organizational or structural interventions, aiming at modifying practices. Three types of studies are to be used: quasi experimental in which clinical audit is the reference method in the field of medical care. The six main steps of clinical audit are described; experimental, based on the community randomized trial scheme, which have the advantage to provide results that can be immediately generalized; observational in which no control on the implementation of intervention is done. "Here and else" and "before and after" studies are used. To be effective for evaluation of professional practice, theses methods must come within the scope of a favorable institutional context.

[Methods of obtaining and formation mechanisms of polymer nanoparticles]

Severals processes exist today for manufacturing colloidal systems of nanospheres or nanocapsules. These nanoparticles have applications in various industrial fields such as cosmetic, pharmacy, food industry, agrochemicals.... The formation of nanoparticles allows the protection of an active molecule by a polymeric coating and the release of this product following a perfectly defined profile, which depends on the nature of the polymer, the type of particle and the field of use. The purpose of this article is to expose the different methods of preparation of nanoparticular systems. These methods are classified in two mains categories. The first gathers most of the methods which are based on polymerization reactions, the second presents the use of preformed polymers (of natural or synthetic origin). A thorough study is devoted to the mechanisms of formation, in order to find the advantages and the disadvantages of each technique to support the development of manufactoring processes.

Differential clinical prognostic classifications in dilated and ischemic advanced heart failure: the EPICAL study

BACKGROUND

The clinical management of severe congestive heart failure (CHF) should be graded according to the prognosis of each individual patient. Our objective was to elaborate a prognostic rating system for severe CHF.

METHODS

The EPICAL program (Epidémiologie de l'Insuffisance Cardiaque Avancée en Lorraine) identified patients with severe CHF defined by hospitalization accompanied by class III/IV dyspnea, edema, or hypertension; an ejection fraction </=30% or a cardiothoracic index >/=60%. Baseline variables were tested in Cox multivariate models.

RESULTS

Patients with ischemic heart disease (n = 219) had a lower 1-year survival rate (57.6%) than patients with dilated cardiomyopathy (n = 182) (69. 1%). Multivariate analysis identified 5 prognostic factors for ischemic CHF and 7 for CHF caused by dilated cardiomyopathy. These variables were used to classify patients within prognostic subgroups of good (>75%), intermediate, or poor (</=25%) 1-year survival.

CONCLUSION

A score for prognostic prediction was further derived from readily available data to help physicians improve decision making and to assist in clinical trials as a stratification tool.

Factors determining the use of hormone replacement therapy in recent naturally postmenopausal women participating in the French SU.VI.MAX cohort

The determinants of hormone replacement therapy (HRT) were studied in a cohort of recently postmenopausal women participating, in France, in a nutritional study (SU.VI.MAX Study). Analysis was performed-analysis on 592 women aged 45 years or more, who had undergone natural menopause which appeared in the 2 previous years. No differences were observed in education level, socio-professional categories, marital status, geographic residence, smoking habits, physical activity, or past contraceptive practice. Past regular gynecologic follow-up appeared to be the strongest determinant of HRT use (odds ratio [OR]: 3.18). Women who reported having had at least one of the studied pathologies (past history of breast cancer, phlebitis, anger, uterine fibroma, hypertension, diabetes or hypercholesterolemia), past abundant menstrual blood losses, and with body mass index (BMI) > or = 25 were less likely to be taking HRT than women free of pathology, with no history of past abundant menstrual blood losses and with low BMI (OR respectively of 0.40, 0.64, 0.62). Women over 51.3 years of age were less likely to use HRT than younger women (OR: 0.92). Finally, in our population, while socio-economic level was not a major determinant of HRT use, the regularity of gynecological follow-up before menopause, overweight, and the existence of a definite or possible contra-indication were strong determinants of HRT use.

Determinants of angiotensin-converting enzyme inhibitor prescription in severe heart failure with left ventricular systolic dysfunction: the EPICAL study

BACKGROUND

Angiotensin-converting enzyme (ACE) inhibitors have been demonstrated to reduce morbidity and mortality rates in patients with heart failure with left ventricular systolic dysfunction. Nevertheless, these drugs are underutilized in current practice and prescribed at doses below those usually recommended. The aim of this work was to identify the social, demographic, laboratory, clinical, and therapeutic factors associated with nonprescription of ACE inhibitors and/or their prescription at doses below those recommended in the treatment of severe long-term congestive heart failure (CHF).

METHODS AND RESULTS

An epidemiologic observational study, EPICAL (EPidémiologie de l'Insuffisance Cardiaque Avancée en Lorraine), studied 417 patients with severe CHF surviving after the index hospitalization. Multivariate logistic regression determined the factors associated with ACE inhibitor nonprescription and with their prescription at lower-than-recommended doses. ACE inhibitors were taken by 75% of the patients but 38% took lower-than-recommended doses. Factors shown to be associated with nonprescription included patients >65 years of age with renal impairment (odds ratio 19.5, confidence interval [CI] 7.9-48.0), nonsinus cardiac rhythm (odds ratio 2.0, CI 1.2-3.2), and prescription of potassium-sparing diuretics (odds ratio 2.4, CI 1. 2-4.7). Renal impairment was the single most important factor associated with prescription of lower-than-recommended doses, particularly in elderly patients.

CONCLUSIONS

Our results underline the need for optimal and better use of ACE inhibitor therapy. CHF treatment guidelines must be more uniformly applied by all physicians caring for patients with heart failure.

Selection of quality-of-life measures for a prevention trial: a psychometric analysis

Quality-of-life (QoL) outcomes have become increasingly important in the evaluation of health interventions. The objective of the present study was to determine which of three generic QoL instruments was most suitable for use in an 8-year nutritional primary prevention trial. We compared the Duke Health Profile, the Nottingham Health Profile, and the Short Form Health Survey Questionnaire (SF36). We conducted the comparison in two stages: (1) a statistical analysis of data from a pilot study (n = 963) comparing the psychometric properties of the three instruments; and (2) an assessment of the practicality of the tools. With regard to psychometric properties, convergent validity was comparable for the three scales, and the correlation with Global Health Assessment ranged from 0.24 to 0.72. Discriminant validity was best for the SF36, with a difference between scores in healthy subjects and those with chronic disease in the range of 4.4 to 15.8 (scores could range from 0 to 100, where 100 indicates perfect health). Reproducibility was good for all three instruments, with a test-retest intraclass correlation coefficient of over 0.60 for most dimensions. DHP and SF36 performed best in terms of responsiveness. We judged the practicality of the three tools as satisfactory. We chose the SF36 for its high responsiveness. We also selected the Duke Health Profile for its practicality and favorable psychometric properties.

Bias and precision in visual analogue scales: a randomized controlled trial

Various types of visual analogue scales (VAS) are used in epidemiologic and clinical research. This paper reports on a randomized controlled trial to investigate the effects of variations in the orientation and type of scale on bias and precision in cross-sectional and longitudinal analyses. This trial was included in the pilot study of the SU.VI.MAX (supplementation by antioxidant vitamins and minerals) prevention trial in France in 1994. Six types of VAS (simple, middle-marked, graphic rating, graduated, graduated-numbered, and numerical rating) and two orientations (horizontal and vertical) were used to measure three symptoms of ear, nose, and throat infection at 2-month intervals in 870 subjects. Differences between scales were analyzed by comparing variances (Levene's test) and means (variance-covariance analysis for repeated measures). Scale characteristics were shown to influence the proportion of zero and low values (i.e., there was a floor effect), but not mean scores. The precision of measurements varied cross-sectionally according to the type of scale, but no differences were observed in the precision of measurement of change over time. In conclusion, the characteristics of VAS seem to be important in cross-sectional studies, particularly when symptoms of low or high intensity are being measured. Researchers should try to reach a consensus on what type of VAS to use if studies are to be compared.

Compliance to drug treatment of patients with rheumatoid arthritis: a 3 year longitudinal study

OBJECTIVE

Patient compliance is considered necessary for the success of drug treatment in chronic diseases. We document compliance with drug treatment and the factors affecting it in a cohort of patients with rheumatoid arthritis (RA).

METHODS

A prospective cohort study of 556 patients with RA followed for 3 years in 4 counties: Oslo, Norway; Groningen, The Netherlands; and Nancy and Reims, France. Compliance to treatment was assessed annually by interview in terms of adherence to the dose and timing of the prescribed drug regimen.

RESULTS

Of the 556 subjects, 429 (77.2%) were taking medication for RA throughout the observation period. Consistent behavior was recorded in 59.5% of cases: 35.7% were consistently compliant, and 23.8% consistently noncompliant. Factors significantly associated with good compliance were older age (p = 0.00), female sex (p = 0.03), decreased disability (p = 0.04), very satisfactory contacts with health care professionals (p = 0.03), and more personal knowledge about the disease and its treatment (p = 0.03).

CONCLUSION

This longitudinal study identified compliance behavior as consistent over time in 60% of patients, determined by quality of contact with professionals and the amount of patient information available.

[Improvement in prevention of venous thromboembolism in medical environment. Mission impossible?]

PURPOSE

In France, low molecular weight heparins are widely used for prophylaxis of venous thromboembolism. This practice is not based on strong evidence supporting the use of this technique, thus leading to important difficulties in defining accurate guidelines. Improvement in the prophylaxis must focus on the process leading to prescription or non-prescription. Our primary objective was to identify and describe this process. We also analyzed the causes for dysfunction and implemented corrective actions.

METHODS

Basic tools and methods specific to improvement of quality were used including: flow charting for process description, causes-effect diagram for updating and analysis of dysfunction, weighted vote for decisions regarding corrective actions, and agenda and designation of leaders for the implementation of corrective actions.

RESULTS

The theoretical process beginning with the recognition of a risk and ending with the adequate treatment or prevention of this risk was demonstrated. The most important dysfunction was the lack of epidemiological and clinical trials. Key corrective actions were the following: standardization of practices where evidence was available; if not, collaborative efforts to collect valid epidemiological data through multicenter surveys and clinical trials; systematic appraisal of the quality of published data; assessment of the risk for venous thromboembolism during hospitalization. To achieve real improvement in practice, priority was given to repeated measures of the risk for thromboembolism. The use of low molecular weight heparins has been so wide however, that it has led to some difficulties. We must draw lessons from this experience.

CONCLUSION

Improvement of quality in terms of healthcare is not only based on auditing the practices or modifying the defective processes, but also on our ability not to use new drugs before fully assessing their validity.

"The SU.VI.MAX Study": a primary prevention trial using nutritional doses of antioxidant vitamins and minerals in cardiovascular diseases and cancers. SUpplementation on VItamines et Minéraux AntioXydants

The "SUpplementation en VItamines et Minéraux AntioXydants" (SU.VI.MAX) Study is a randomized double-blind, placebo-controlled, primary-prevention trial which started in 1994 in France. This epidemiologic study is designed to test the efficacy of a daily supplementation with antioxidant vitamins (vitamin C, 120 mg, vitamin E, 30 mg, and beta-carotene, 6 mg) and minerals (selenium, 100 microg, and zinc, 20 mg) at nutritional doses, in reducing the main causes of premature death (cancers and cardiovascular diseases); 12,735 eligible subjects (women aged 35 to 60 years, and men aged 45 to 60 years) were included in 1994 and and will be followed up for 8 years. Participants undergo a yearly visit consisting, every other year, of either biological sampling or clinical examination. They also regularly provide information on health events and dietary intake by filling out computerized questionnaires using the Minitel Telematic Network. After 2 years of supplementation, biochemical indicators of vitamin and trace element status reach reasonable level without reaching concentrations as high as those observed in intervention studies, which tested relatively high doses of antioxidants, and ended up with higher risk of pathology.

Shear stress abnormalities contribute to endothelial dysfunction in hypertension but not in type II diabetes

BACKGROUND

The relative contribution of the various hemodynamic and metabolic mechanisms leading to endothelial dysfunction may be different in specific vascular diseases. Since shear stress is one of the main mechanical stimuli of endothelial cells, the aim of this study was to investigate its contribution to endothelial dysfunction in two distinct vascular diseases, hypertension and type II diabetes.

SUBJECTS AND METHODS

We measured the radial artery diameter at baseline, after ischemic vasodilation and after nitroglycerin vasodilation in 16 untreated patients with high blood pressure, in 15 type II normotensive diabetic patients and in 17 healthy controls. Wall shear stress was evaluated by simultaneous measurements of whole blood viscosity and blood flow velocity.

RESULTS

In diabetic patients, whole blood viscosity was significantly higher whereas wall shear stress was similar compared to controls. In hypertensive patients, whole blood viscosity was higher and wall shear stress was lower than in controls. Endothelium-dependent vasodilation was impaired in both hypertensive and diabetic patients (P < 0.01) after adjustment for age, sex, body mass index and postnitroglycerin vasodilation. When adjustments were made for maximal systolic shear stress, endothelium-dependent vasodilation remained lower in the diabetic patients (P < 0.01), but not in those with high blood pressure compared to controls.

CONCLUSIONS

In hypertension, endothelium-dependent vasodilation is mainly due to a chronic decrease in shear stress (the most important physiological stimulus of the endothelial cells) with no major intrinsic endothelial cell dysfunction. In contrast, in diabetics, the lower endothelium-dependent vasodilation was not the result of an altered shear stress.

Assessment of deep vein thrombosis prophylaxis in surgical patients: a study conducted at Nancy University Hospital, France

OBJECTIVE

This retrospective evaluation aimed to assess the adequacy of prophylaxis against thromboembolism prescribed to surgical patients at the authors' institution, and to compare it with generally accepted published guidelines. Aspects considered were indications for prophylaxis, regimens used and monitoring.

METHODS

Eleven units (nine surgical and two surgical intensive care) took part in the survey on a voluntary basis. The clinical audit system used involved developing a set of criteria based on existing guidelines, comparing observed practice with those recommendations, analysing the factors underlying any deviation and developing corrective measures.

RESULTS

When the medical records of 117 patients hospitalized in October 1995 were examined, prophylaxis against deep vein thrombosis was documented in 86 (low molecular weight heparin in 85, dextran in one). No associated physical preventative measures were recorded. Indications and dosage were appropriately handled in 90.7% and 75.2% of patients, respectively. Ninety-five cases were outside the reference criteria: 74 for excluded surgical indications, 13 which involved laparoscopy, and eight in which spinal or epidural anaesthesia was administered. Platelet count was performed in 73.8% of cases before prophylactic treatment, and in 23.10% during its course. Anti-Xa activity was measured in 0.4% of cases. Analysis of causes showed that guidelines were not complied with either because of lack of organization, or because of disagreement with them.

DISCUSSION

In this study, indications for prophylaxis were well established and heparin dosages used were not fundamentally flawed. The weak point in practice was a failure to carry out platelet counts, particularly during the course of treatment. Appropriate corrective action consists of disseminating guidelines and relevant information, and using a preoperative checklist to assess thromboembolic risk.

CONCLUSION

Physicians agree that opportunities to improve preventative practices exist, and that the quality improvement programme should be pursued.

[Clinical research, evaluation of care and quality assurance]

This paper aims to clarify the concepts and terminology of clinical research, evaluation, and quality. Clinical research or clinical epidemiology aims to demonstrate the efficacy of medical care. The optimal methodology is a randomized, double-blind trial that allows a causal inference in respect of efficacy. This should be the first stage before generalization of all medical practice. Evaluation of quality of care aims to verify the effectiveness of medical care by comparing practice with references. The optimal methodology is clinical audit that allows fine-tuned diagnosis of the existence of deviant practices. The analysis of causes and correction of the care process are an integral part of the evaluation work. Thus quality assurance and quality management concepts and methods have been developed which tend to ensure solutions for better care and to maintain the level of quality of care to achieve patient satisfaction. Evaluation, clinical research and management quality could in fact be seen as the complementary facets of a comprehensive approach to quality of care.

A primary prevention trial using nutritional doses of antioxidant vitamins and minerals in cardiovascular diseases and cancers in a general population: the SU.VI.MAX study--design, methods, and participant characteristics. SUpplementation en VItamines et Minéraux AntioXydants

The SUpplementation en VItamines et Minéraux AntioXydants (SU.VI.MAX) Study is a randomized, double-blind, placebo-controlled, primary-prevention trial designed to test the efficacy of daily supplementation with antioxidant vitamins (vitamin C, 120 mg; vitamin E, 30 mg; and beta-carotene, 6 mg) and minerals (selenium, 100 microg; and zinc, 20 mg) at nutrition-level doses (one to three times the daily recommended dietary allowances) in reducing several major health problems in industrialized countries, especially the main causes of premature death, cancers and cardiovascular diseases. The present report describes the design, implementation, and baseline characteristics of participants in this 8-year cohort study, which started in 1994 in France; 12,735 eligible subjects (women aged 35-60, and men aged 45-60) were included in 1994 and will be followed for 8 years. Participants undergo a yearly visit consisting, every other year, of either biological sampling or clinical examination. They also regularly provide information on health events and dietary intake by filling out computerized questionnaires using the Minitel Telematic Network. Data on baseline characteristics of the participants suggest that the present sample is close to the national population in terms of geographic density, socioeconomic status, and the distribution of various major risk factors for the diseases under study. The choice of the study population should allow the results of this trial to apply to adult populations of both sexes in France and other industrialized countries.

Determining factors in the iron status of adult women in the SU.VI.MAX study. SUpplementation en VItamines et Minéraux AntioXydants

The iron status of a national sample of adults living in France and participating in the SU.VI.MAX cohort, was assessed using serum ferritin and hemoglobin concentrations. Complete data were obtained for 6648 women 35-60 y old and for 3283 men 45-60 y old. Assessment of iron dietary intakes was realized on a subsample of 3111 women and 2337 men who reported six 24 h dietary records during a one-year period; 22.7% of menstruating women and 5.3% of post-menopausal women presented a total depletion of iron stores (serum ferritin < 15 microg/l). Iron-deficient anemias were found in, respectively, 4.4% and less than 1% of these women. Three-quarters of the anemias were related to iron deficiency in menstruating women. In men, iron depletion and iron deficiency anemia were very rare. Post-menopausal women had much higher serum ferritin levels than menstruating women. In menstruating women, those using intrauterine devices had significantly lower serum ferritin levels than those without contraception, and much lower than those using oral contraception. The frequency of iron depletion reached 28.1% in women using intrauterine devices, but only 13.6% in those using oral contraceptives. The mean iron intake was 16.7 +/- 5.7 mg/d in men and 12.3 +/- 3.4 mg/d in women. Heme iron represented respectively, 11.1 and 10.4% of iron intake. Ninety-three percent of menstruating women had dietary iron intakes lower than recommended dietary allowances (RDA); 52.6% consumed less than two thirds of these RDA. In post-menopausal women and men, respectively 27.7% and 3.6% had dietary intakes lower than RDA. Serum ferritin was positively correlated with meat, fish and total iron intake, and negatively correlated with dietary products consumption, calcium and fiber intake.

[Therapeutic approach of French practitioners to rectal cancer]

OBJECTIVES

Improvements in treatment of rectal cancer have enabled a better control of locoregional disease. Our objective was to describe the therapeutic decisions of different specialists implied through clinical cases and the influence of their professional characteristics.

METHODS

In spring 1996, a questionnaire was mailed to a random sample of 621 French physicians, presenting 3 clinical cases of rectal cancer at different stages. The present analysis deals with a clinical case concerning a 46 year-old man bearing a T3N0 tumor, at 7 cm from the anal verge. Statistical analysis (uni and multivariate, by logistic regression) was performed with SPSS software.

RESULTS

Three hundred fifty two exploitable responses were returned (response rate: 57%). Half of the physicians chose a pluridisciplinary decision modality. There were differences according to the speciality (P < 0.003), to the type of practice (public/private) (P < 10(-4)) and to the proximity of specialized units (P = 0.03). Therapeutic attitudes consisted in a combination of radiotherapy and surgery (RT-SU) for 95% of the physicians. The therapeutic choice was in agreement with the French consensus conference for 71% of physicians. Two main attitudes emerged for this clinical case: exclusive RT-SU combination (43.5%) and RT-SU with optional or systematic chemotherapy (CT) (52%). The latter choice appeared to be closely dependent on medical speciality (P = 0.0004) and background (P = 0.002).

CONCLUSION

Decision making is mainly related to the place of work, whereas the therapeutic attitude depends on physicians' own characteristics. Until 1990, multiple therapeutic options for rectal cancer were performed in France. Nowadays, for a T3N0 tumor, the argumentation is rather focused on the indication of CT combined with the standard RT-SU treatment. Results from ongoing controlled studies will help update consensual recommendations.

Background and rationale behind the SU.VI.MAX Study, a prevention trial using nutritional doses of a combination of antioxidant vitamins and minerals to reduce cardiovascular diseases and cancers. SUpplementation en VItamines et Minéraux AntioXydants Study

The "SUpplementation en VItamines et MinérauxAntioXydants" (SU.VI.MAX) study is a randomized double-blind, placebo-controlled, primary prevention trial designed to test the efficacy of daily supplementation with antioxidant vitamins (vitamin C, 120 mg; vitamin E, 30 mg; and beta-carotene, 6 mg) and minerals (selenium, 100 micrograms; and zinc, 20 mg), at nutritional doses (one to three times the daily recommended dietary allowances), in reducing the frequency of major health problems in industrialized countries, and especially the main causes of premature death (cancers and cardiovascular diseases). The study involves 12,735 eligible subjects (women aged 35 to 60 years; men aged 45 to 60 years) included in 1994 in France. They will be followed up for 8 years. The objectives and the specific design of this intervention study are linked to its public health aim. The targeted population is the general population (not simply high-risk subjects) and the antioxidant agents tested are being administered at a level which is not pharmacologic and which may be attained by dietary intake of natural sources of these micronutrients and/or enriched foods. The amounts we are testing in the SU.VI.MAX study are those which, in observational studies have been associated with the lowest risk of diseases. This report presents the rationale and discusses the justification of the design, doses and combination of antioxidant micronutrients chosen in the SU.VI.MAX study.

[Prevention of venous thromboembolism. Survey of in-hospital medical practice]

OBJECTIVES

In an effort to improve the prevention of venous thromboembolism, the Nancy University Hospitals conducted a survey of medical practice concerning indications for preventive therapy and surveillance of platelet counts and anti Xa activity.

METHODS

The survey involved 163 medical files. Questionnaires were filled out in 6 units (3 medical wards and 3 intensive care units).

RESULTS

Indications for preventive therapy were found to be quite variable with the exception of very low risk of thromboembolism where the treat/do not treat ratio was 0.1/1, indicating a clear tendency for abstention. This ratio was 0.77/1 and 0.38/1 respectively for low and moderate risk and 2/1 for high risk. There was undoubtedly a ward effect. The attitudes in practice tended toward non-prevention in patients without limited mobility. For platelet counts, an initial count was performed in 95% of the cases and during treatment in 38% although the specific rates were not the same for different types of units. Anti-Xa activity, which according to prevention recommendations need not to be determined, was not monitored in 88% of the cases. In accordance with prevention recommendations, anti-Xa activity was not determined in 88% of the cases.

CONCLUSION

Further progress is needed in the prevention of venous thromboembolism and should be based on wider use of existing methods.

[Measurement of functional inability and quality of life in cardiac failure. Transcultural adaptation and validation of the Goldman, Minnesota and Duke questionnaires]

Cardiac failure has a big impact on the daily life of patients and this can be evaluated using quality of life questionnaires. The aim of this study was to translate and adapt for the French population and test the validity of two quality of life self-administered-questionnaires: the Duke health Profile, the Minnesota Quality of Life Questionnaire in Cardiac Failure and one function capacity questionnaire, the Goldman Specific Activity Scale. The questionnaires were translated and retranslated then submitted to a committee of experts: the final version was presented to 30 patients. The study of the quantitative properties of the three instruments was performed on a sample of 74 patients with cardiac failure to assess their validity and 26 stable patients after cardiac transplantation to test reproducibility. The results of this study show that these three instruments are valid and reproducible and are comparable to the original documents: Cronbach's Alpha ranging from 0.54 to 0.78 for the Duke, except for the social dimension, and from 0.73 to 0.93 for the Minnesota, except for its incapacity dimension, intraclass correlation coefficient > 0.6 in all dimensions. The validity of convergence with LVEF and the NYHA measured during hospitalisation for decompensation was poor, except for the Goldman. The three instruments provided coherent information. The authors conclude that a structured method allows transcultural adaptation of instruments of evaluation of quality of life, the French version having comparable properties to the original documents: they may be used for clinical research.

IgA nephropathy: prognostic classification of end-stage renal failure. L'Association des Néphrologues de l'Est

BACKGROUND

As yet, no clinical or morphological prognostic classification of IgA nephropathy (IgAN) has been generally accepted. The objective of our study was to quantify the risk of developing end-stage renal failure (ESRF) in IgAN.

METHODS

We report a prospective longitudinal study of 210 patients with IgAN confirmed by biopsy between 1987 and 1991. Thirty-two (15.2%) patients were lost to follow-up. Mean follow-up after renal biopsy was 5.6 (SD = 2.6) years. The variables included age, gender, illnesses prior to discovery of IgAN, clinical features at IgAN discovery, 24-h proteinuria, serum creatinine, IgA level, and antihypertensive drugs taken at the time of renal biopsy. Sixty-six renal biopsies were classified by light-microscopy according to Lee's morphological classification. The end-point was ESRF. Survival was analysed by a backward and forward stepwise procedure using the Cox model. The most accurate determination of relative risk was obtained by assessing collinearity of the variables.

RESULTS

Thirty-three patients (15.7%) (31 men) developed ESRF. The five univariately significant variables: gender, gross haematuria, 24-h proteinuria (24-P), serum creatinine (SC), and antihypertensive treatment, were candidates for multivariate analysis. The final model used SC (< or = 100, 100-150, > 150 mumol/l), 24-P (< 1, > or = 1 g/day) and gender (female vs male) as independent variables (relative risk and 95% confidence interval were 3.5 (2.1, 5.9) for SC; 5.1 (1.9, 13.6) for 24-P; and 3.5 (0.9, 15) for gender). These estimates were used to construct a prognostic classification of ERSF for men with IgAN: stage 1 (SC < or = 150 mumol/l and 24-P < 1 g/day), stage 2 ((SC > 150 mumol/l and 24-P < 1 g/day) or (SC < or = 150 mumol/l and 24-P > or = 1 g/day)); stage 3 (SC > 150 mumol/l and 24-P > or = 1 g/day). The ESRF-free survival was estimated with Kaplan-Meier analysis. It was 98.5% for stage 1, 86.6% for stage 2, 21.3% for stage 3 (P < 0.001), 7 years after histological diagnosis. The validity of Lee's prognostic classification was confirmed using an independent sample.

CONCLUSIONS

These classifications identify groups at high risk of ESRF. Therapeutic studies should focus on these groups.

[A survey on the practice of drug prescription in hospitals. Concepts and methodology]

A clinical practice survey, if patient focused, identifies and analyses complexity of drug use. It is not a clinical audit whose aim is to compare observed practice with predetermined criteria. A clinical practice survey is useful when a problem exists in a low evidence based clinical area or to elaborate clinical guidelines. Implementation is based on epidemiological methodology and project management and needs a framework determined by a facilitator (trained in quality improvement methods and expert in the clinical area concerned), planning (the more higher the number of wards, the higher the complexity) and the project guidelines must be respected. Since lack of physician involvement is a drawback, support provided by the quality centre (if it exists) must be limited to technical aspects. It is important to appreciate the level of quality culture of the organization and the project must be approved by the hospital manager.

Life events and disability in rheumatoid arthritis: a European cohort

The objective was to study the relationship between life events (LE) and the clinical status of patients suffering from recently diagnosed rheumatoid arthritis (RA) in a 2 yr follow-up. As part of a multicentre European cohort study, 370 French and Dutch patients were questioned three times at 1 yr intervals about LE which had occurred in the previous year. Three criteria were used to quantify the degree of disease activity (Ritchie's index), the level of functional disability [Health Assessment Questionnaire (HAQ)] and perceived health [Overall Evaluation of Health (OEH)]. Total LE and desirable LE showed a weak negative correlation with the HAQ scores. On the other hand, death-related LE did not seem to modify patient status. The higher the number of health-associated LE, the greater the deterioration in HAQ and OEH scores. The results indicate that LE do not affect the course of early RA in a spectacular manner.

[The DUKE health profile: a generic instrument to measure the quality of life tied to health]

To adapt the DUKE Health Profile, a 17-item self-report generic health related quality of life measure cross-culturally in french. A multidisciplinary expert committee was provided with three translations independent of each other, each backtranslated to the original language, and produced a synthesis version equivalent to the original. A cohort of 963 persons from the general population filled in the questionnaire twice in three months. The internal consistency was acceptable (Cronbach's alpha = 0.63-0.81) except in social dimension. Convergent validity was evidenced by a significant correlation with overall health. The test-retest reproducibility in stable subjects (601) was satisfactory (intraclass coefficient correlation r = 0.63-0.78) except in pain and disability dimensions. There was a significant modification of scores in the same direction as overall health change in subjects improved (n = 128) or worsened (n = 187). Age-adjusted scores were lower in females, in subjects with lower education, urban residency, unemployed and living alone and in subjects reporting a chronic disease. This short form questionnaire similar to the original version proved simple to use in the general population.

Health-related quality of life in long-term oxygen-treated chronic obstructive pulmonary disease patients

Chronic obstructive pulmonary disease (COPD) induces changes in daily activities and mood. Health-related quality of life (HRQL) measures are of particular relevance in the management of such patients, but predictors of HRQL have rarely been investigated. The aim of this study was to seek factors predicting HRQL in severe COPD patients under long term oxygen therapy (LTOT). The pulmonary function parameters at the start of LTOT were studied as potential predictors of future HRQL. HRQL was assessed after an average of 40 months follow-up by the Duke Health Profile (Duke) and by the St. George Respiratory Questionnaire (SGRQ). Sixty-one patients (47 males and 14 females) with a mean age of 66 years were included in the study. Stepwise multiple regression analyses conducted in each HRQL dimension identified few significantly predictive factors. By the Duke, higher Self-esteem scores were associated with higher Pao2 (p < 0.01) and with older age (p < 0.05); higher Social Health scores were associated with older age (p < 0.005), and higher Pain scores were associated with a higher FEV1/FVC ratio (p < 0.05). By the SGRQ, the Activity score correlated with FEV1/FVC (p < 0.05). The proportion of the variance in each score accounted for by covariates in the model did not exceed 10%. No other significant regression models could be identified using the other HRQL dimensions. Our findings demonstrated weak relations between lung function at the start of LTOT and some dimensions of HRQL measured by the Duke and the SGRQ at the end of follow-up.

Frequencies of five genetic polymorphisms in coronarographed patients and effects on lipid levels in a supposedly healthy population

Allele frequencies of genetic polymorphisms were compared between supposedly healthy subjects and angiographically proven coronary artery disease patients. The polymorphic candidate loci investigated were the apolipoprotein (apo) B signal peptide and XbaI polymorphism, the apo E polymorphism and two polymorphism of lipoprotein lipase (LPL) gene: Hind/III and PvuII. Apo B signal peptide and HindIII/LPL polymorphisms showed significant differences in allele partition between cases and controls; the rare alleles of both polymorphisms were less frequent (p < 0.05) in cases. We looked for associations between the polymorphisms and lipid concentration variability in a supposedly healthy population (145 men and 144 women). Apo B signal peptide, apo E and PvuII/LPL polymorphisms seem to influence some lipid metabolism parameters significantly. Apo AI and LpCIII levels were significantly different among apo B signal peptide genotypes: Del homozygotes had the highest concentrations of both variables. The epsilon 4 allele of apo E polymorphism was associated with increased concentrations of total cholesterol, LDL cholesterol and apo B. Increased LpAI:AII levels observed in E3 homozygotes (p < 0.01) have not previously been reported. LpAI:AII concentration was also influenced by PvuII/LPL polymorphisms.

An international study on measuring social support: interactions and satisfaction

Recently, a new instrument was developed to measure social support. It consists of two parts; the Social Support Questionnaire for Transactions (SSQT) and the Social Support Questionnaire for Satisfaction with the supportive transactions (SSQS). The SSQT measures the number of supportive interactions and has proved to have good psychometric properties. From the taxonomy that was used for the present study, it results that social support in general consists of two aspects. There are, on the one hand, actual supportive transactions and, on the other hand, the perception of being supported or the satisfaction with the social support provided. In the present study, two research questions were addressed. The first concerned the psychometric properties of the SSQS, measuring the individual's satisfaction with the supportive interactions provided. Secondly, the relative contribution of both supportive interactions (the SSQT) and the satisfaction with the support provided (the SSQS) were assessed, in explaining the level of health related quality of life outcome. The data of 744 rheumatoid arthritis (RA) patients from four different countries (116 French, 238 Norwegian, 98 Swedish and 292 Dutch patients) were used in the present study. At the entry of the study, all patients fulfilled four out of seven American Rheumatism Association (ARA) criteria and had a disease duration of 4 years or less. The results of the study indicate that the SSQS has good psychometric properties across countries. Cronbach's alpha for the emotional support scales was 0.80 or more, and for the instrumental support subscales around 0.60. The standardized regression coefficients demonstrated that, compared to supportive interactions, support satisfaction was more relevant in explaining health related quality of life measures, although it is recommended that the SSQT and SSQS be used to complement each other.

[Value of unipolar and bipolar recordings in radiofrequency ablation of accessory atrioventricular pathways]

The aim of the study was to compare the value of different modes of endocavitary recordings: unipolar alone, bipolar alone and the association of unipolar and bipolar recordings in radiofrequency ablation of accessory atrioventricular pathways. A retrospective analysis by three independent observers of 135 endocavitary recordings obtained immediately before radiofrequency application in 82 subjects who underwent radiofrequency ablation for symptomatic accessory atrioventricular pathways. In each case, the authors selected the "successful" record which corresponded to the final radiofrequency application and 0.1 or 2 records of "failures". Each initial recording being of 3 types (unipolar, bipolar and association of uni- and bipolar), a total of 390 anonymous and randomised recordings were analysed by the observers who determined whether the appearances indicated successful ablation. Univariate analysis of variants showed a correlation between success with the mode of recording (p = 0.03) and a left lateral position of the accessory pathways. In multivariate analysis, three variables remained correlated with successful ablation: the observer variable (p = 0.001), and two interactions observer - mode (p = 0.005) and observer-stability (p = 0.02). The benefits of the association of unipolar and bipolar recordings with respect to bipolar recording alone, seemed to be important in predicting failure. The results of tests of concordance in the group of failures were confirmatory: concordance between observers was only found between the unipolar mode alone and the association of unipolar and bipolar recordings. The results of this study suggest that the association of unipolar and bipolar endocavitary recordings may reduce the number of unnecessary application of radiofrequency energy by improved identification of recording showing failure.

Comparison of infective endocarditis in patients with and without previously recognized heart disease

In a consecutive series of patients with infective endocarditis, we compared the charts of 123 nonaddicted patients without previously known heart disease with those of 174 patients with native valve disease. The 2 groups were similar in age, sex, clinical findings, and mortality rates, but infective endocarditis was more often located on the aortic valve, more often due to Streptococcus bovis and enterococci in patients without previously known heart disease.

Nonspecific effects in longitudinal studies: impact on quality of life measures

A variety of factors may influence outcome measures in longitudinal studies, including placebo, Hawthorne, or natural history effects. Quality of life (QoL) measures are particularly subject to these phenomena. This 2-month postal survey was set up to examine the extent of nonspecific effects in a treatment (vitamin supplementation) group (n = 180), a placebo group (n = 180), as part of a stratified, randomized controlled trial, and two control groups (n = 768 each). Quality of life was measured using the SF36. The placebo effect had a significant impact on improving physical, mental, and pain dimensions (p = 0.02 to 0.04), and the Hawthorne effect was significant (p = 0.03 to 0.009) for psychological dimensions. Although the impact of natural history was not significant, it tended to worsen all QoL dimensions. Vitamin supplementation had no effect on QoL. These results demonstrate the importance of placebo and Hawthorne effects and suggest that they may be responsible for misleading results or reductions in the power of controlled trials.

Procedures associated with infective endocarditis in adults. A case control study

OBJECT

To assess the relative risk of infective endocarditis associated with various procedures and the protective efficacy of antibiotic prophylaxis by a case-control study.

BACKGROUND

Recommendations for the prevention of infective endocarditis are based on the hypothesis of a relationship between procedures and infective endocarditis which is supported by anecdotal reports and data from experimental models.

METHODS

Cases met the Von Reyn's diagnostic criteria modified with echocardiographic and macroscopic findings Controls were recruited from cardiology or medicinal wards. Cases (n = 171) and controls were matched as regards sex, age and underlying cardiac condition. They were requested to indicate all the medical, surgical or dental procedures within the previous 3 months. Among potential confounding factors, infectious episodes and skin wounds in the previous 3 months were reported. Antibiotic prophylaxis administration was documented for type, dosage, duration and administration schedule.

RESULTS

Cases significantly more frequently than controls had undergone at least one procedure (matched odds ratio, 1.6; 95% confidence interval, 1.01 to 2.53). Dental procedures considered as a whole were not associated with an increased risk, although scaling and root canal treatment showed a trend towards a higher risk of infective endocarditis (P = 0.065). Among non-dental procedures, only surgery appeared to be at risk (matched odds ratio, 4.7; 95% confidence interval, 1.02 to 22). Considering all procedures, the risk of infective endocarditis increased significantly with the number of procedures. While general co-morbid conditions did not differ between the two groups, cases significantly more frequently than controls had experienced an infectious episode or a skin wound. In multivariate analysis, only infectious episodes and skin wounds significantly increased the risk of infective endocarditis. Scaling was the only independent risk factor for viridans streptococcal infective endocarditis. The 46% protective efficacy of antibiotic prophylaxis was not significant.

CONCLUSIONS

Procedures do increase the risk of infective endocarditis. The interpretation of the apparent low risk associated with dental procedures may be as a result of the current practice of antibiotic prophylaxis. Our data suggest that surgery should be more clearly mentioned in future guidelines, and reemphasize that a rigorous treatment of any focal infection in cardiac patients is mandatory. From the efficacy rate of antibiotic prophylaxis,it can be estimated that the overall incidence of infective endocarditis might be reduced by 5 to 10% in France by appropriate use of antibiotic prophylaxis in cardiac patients.

The assessment of functional status in rheumatoid arthritis: a cross cultural, longitudinal comparison of the Health Assessment Questionnaire and the Groningen Activity Restriction Scale

OBJECTIVE

To compare a disease specific measure of functional status, the Health Assessment Questionnaire (HAQ) with a generic measure of functional status, the Groningen Activity Restriction Scale (GARS) in a cross cultural and longitudinal setting. Besides the comparison of psychometric properties, sex differences were also studied.

METHODS

In a sample of 634 patients with rheumatoid arthritis (RA) (290 from The Netherlands, 116 from France, 228 from Norway), the psychometric properties (Cronbach's alpha and rho) of the GARS and the HAQ were compared among countries. The sensitivity for change between T1 and T2 was tested by means of the standardized response mean for a one year followup; furthermore, the relative efficiency of both instruments was computed. A t test was used to trace sex differences.

RESULTS

The psychometric properties of both the HAQ and the GARS were very good. Both form unidimensional scales of hierarchically ordered items; alpha and rho are > 0.91 for both instruments. For patients who improved between T1 and T2, measured by the Ritchie Articular Index, the standardized response mean of the HAQ and the GARS were moderate, whereas for patients who worsened, the standardized response means were small. The results based on the relative efficiency were ambiguous. Furthermore, the mean score for women on the HAQ was 0.25 higher in contrast to scores for men. The GARS did not yield different scores for women and men.

CONCLUSION

The internal consistency of the GARS and the HAQ are comparable. The HAQ has yielded different results for women and men. Therefore, when the HAQ is used, sex differences should be taken into account. With respect to sensitivity to change, the GARS and the HAQ obtained much better results for patients who improved in contrast to patients who worsened. The GARS was found to be more sensitive to change for patients who improved.

[Value of calculation of the kappa coefficient in the evaluation of an imaging method]

Radiologists are often confronted to the choice of the most appropriate statistic tool for evaluating diagnostic imaging methods. Using a radiological literature example, the Kappa agreement test is herein described and its applications are determined. Although widely performed to determine the inter-rater agreement, this test is also suited for the confrontation of two or more diagnostic imaging methods applied on the same subjects and providing categorical data. It procures the degree of agreement between the different methods.

The measurement of social support in the 'European Research on Incapacitating Diseases and Social Support': the development of the Social Support Questionnaire for Transactions (SSQT)

Social support is supposed to have a beneficial effect on the health and wellbeing of people. It is a central concept in the 'EUropean Research on Incapacitating DIseases and Social Support' (EURIDISS). In general, two main distinctions concerning social support are made in the literature, providing four basic dimensions or types of social support: a social-emotional vs an instrumental type of social support, and a 'crisis' or 'problem-oriented' vs 'everyday' or 'daily' type of social support. Based on these types of social support, a series of items were formulated to measure actual supportive interactions or exchanges of resources. The items were spread over five scales. The social-emotional type of social support comprised three scales: daily emotional support; problem-oriented emotional support; and social companionship, while the instrumental type of social support consisted of two scales: the daily instrumental support and the problem-oriented instrumental support. Together, these items and scales constitute the so-called 'Social Support Questionnaire for Transactions' (SSQT). The main objective of this paper is to investigate whether one and the same instrument, i.e. the SSQT, allows for meaningful comparisons between patients with rheumatoid arthritis from different countries. More specifically, the dimensionality and invariance of the dimensions across countries of the SSQT are explored. To this end, patients from four different European countries (France, Norway, The Netherlands and Sweden) were asked to fill in the SSQT. The analysis of the data using principal component analysis (PCA) and simultaneous component analysis (SCA), did yield the intended scales, although the internal consistency of one of them, the daily instrumental support scale, is questionable.(ABSTRACT TRUNCATED AT 250 WORDS)

Programmed ventricular stimulation in survivors of acute myocardial infarction: long-term follow-up

The prognostic significance of ventricular tachyarrhythmias induced by programmed ventricular stimulation was evaluated in 492 consecutive survivors of acute myocardial infarction (AMI). Holter monitoring, signal-averaged electrocardiogram (ECG) and measurement of left ventricular ejection fraction (EF) were also performed. The protocol used up to 3 extrastimuli. Sustained monomorphic ventricular tachycardia (VT) < 270 beats/min, > 270 beats/min (ventricular flutter) (VFI), and ventricular fibrillation (VF) were induced in 99, 66 and 52 patients, respectively. Long term follow-up (mean 3.7 +/- 2.2 years) showed that most episodes of VT occurred during the first months following AMI (n = 14), but some patients (n = 6) could develop VT as late as 4 years after AMI. Sudden death (SD) (n = 22) always occurred during the first year following AMI. Multivariate analysis demonstrated that EF < 30% and induction of a VT < 270 beats/min were the only predictors for total cardiac death (P < 0.001). EF < 30%, induction of a VT < 270 beats/min and also of VFI (P < 0.05) were predictors for VT and SD: the risk was 4% in patients without inducible VT, 12% in those with inducible VF1, and 21% in those with inducible VT < 270 beats/min. In conclusion, induction of a sustained monomorphic VT < 270 beats/min or > 270 beats/min is a predictor of arrhythmic events during the first year as well as 4 years after myocardial infarction. However the risk of arrhythmic sudden death decreases after the first year, while the risk of VT persists. Because of the low positive predictive value of programmed stimulation (respectively 21% and 12% for the induction of a sustained VT and VFI), we recommended the indication of programmed stimulation in only the patients with one abnormal non-invasive investigation.