Patterns of mortality and their changes in France (1968-99): insights into the structure of diseases leading to death and epidemiological transition in an industrialised country

BACKGROUND

Epidemiological transition theory is based on a succession of specific "patterns" of causes of death in human societies. However, the reality and consistency of patterns of causes of death in a population at a given moment has never been formally and statistically evaluated.

METHODS

Correlation analyses and principal component analysis were used to explore the correlation between age and sex cause-specific death rates and to identify consistent patterns of mortality in France for two periods: 1968-79 and 1988-99.

RESULTS

Cause-specific death rates in France from 1988 to 1999 were found to be strongly and consistently correlated across space and time. The analysis outlines four specific patterns: mortality of 45 - 84-year olds, mostly by neoplasms, cardiovascular and digestive diseases; mortality of the oldest old (>84 years); mortality of 25 - 64-year-old men, notably by HIV infection; and mortality by injury and poisoning of 15 - 44-year olds. These patterns, which cover 96% of the total mortality during the period, differ from those for the period 1968-79 when respiratory diseases and conditions affecting children aged <1 year shaped mortality. They also differ substantially from those predicted by classical epidemiological transition theory.

CONCLUSION

This study provides evidence for an evolutionary structure of patterns of mortality in contemporary France and therefore suggests using the concept of epidemiological transition in a less simplistic way than is commonly the case. It also shows much stronger interrelationships between diseases leading to death than is usually believed and suggests that current categorisations of cause-specific mortality in populations need reconsideration.

Temporal artery biopsy for diagnosing giant cell arteritis: the longer, the better?

OBJECTIVE

To investigate the relation between temporal artery biopsy (TAB) length and diagnostic sensitivity for giant cell arteritis.

METHODS

Histological TAB reports generated from four hospital pathology departments were reviewed for demographics, histological findings, and formalin fixed TAB lengths. A biopsy was considered positive for giant cell arteritis if there was a mononuclear cell infiltrate predominating at the media-intima junction or in the media.

RESULTS

Among 1821 TAB reports reviewed, 287 (15.8%) were excluded because of missing data, sampling errors, or age < 50 years. Mean TAB length of the 1520 datasets finally analysed (67.2% women; mean (SD) age, 73.1 (10.0) years) was 1.33 (0.73) cm. Histological evidence of giant cell arteritis was found in 223 specimens (14.7%), among which 164 (73.5%) contained giant cells. Statistical analyses, including piecewise logistic regression, identified 0.5 cm as the TAB length change point for diagnostic sensitivity. Compared with TAB length of < 0.5 cm, the respective odds ratios for positive TAB without and with multinucleated giant cells in samples > or = 0.5 cm long were 5.7 (95% confidence interval, 1.4 to 23.6) and 4.0 (0.97 to 16.5).

CONCLUSIONS

A fixed TAB length of at least 0.5 cm could be sufficient to make a histological diagnosis of giant cell arteritis.

Lack of validity of a French adaptation of a scale measuring attitudes towards clinical practice guidelines

BACKGROUND

Valid instruments to measure practitioners' attitudes towards clinical practice guidelines need to be developed. However, few of the available instruments have been thoroughly validated.

OBJECTIVE

To adapt into French and to test the reliability and validity of a scale for measurement of attitudes towards guidelines developed by Elovainio et al.

METHODS

A 27-item scale (divided into six dimensions) measuring attitudes towards guidelines was translated into French by two English native translators, reviewed and finalized by expert committee and administered to 314 practitioners who agreed to participate. Main practitioners' characteristics were collected. Item and dimension reproducibility were assessed for 62 practitioners by calculation of intraclass correlation coefficients. Internal construct validity was assessed by principal components analyses. Convergent and discriminant validity were analysed.

RESULTS

Item response rates ranged from 82 to 100%. In the test-retest procedure, intraclass correlation coefficients for separate items ranged from 0.1 to 0.7 and those for dimensions were 0.7 [95% confidence interval (CI): 0.5-0.8] for usefulness, 0.5 (0.3-0.6) for reliability, 0.4 (0.2-0.5) for individual competence, 0.5 (0.3-0.6) for organizational competence, 0.7 (0.5-0.8) for impracticality and 0.4 (0.3-0.6) for availability. The factorial structure after Varimax rotation showed that none of the different solutions obtained had a strictly comparable structure to that of the original scale. External construct validity was satisfactory.

CONCLUSION

This scale does not have satisfactory psychometric properties and therefore cannot confidently be used in future research assessing whether attitudes towards guidelines are a determining factor in physicians' compliance with guidelines. More research is needed to develop valid scales in a more rigorous procedure, involving qualitative and quantitative steps.

Stimulation sous-thalamique dans la maladie de Parkinson sévère

The subthalamic nucleus (STN) is the main target of deep brain stimulation (DBS) treatment for severe idiopathic Parkinson's disease. But there is still no clear information on the location of the effective contacts (used during the chronic phase of stimulation). Our aim was to assess the anatomical structures of the subthalamic area (STA) involved during chronic DBS. Ten patients successfully treated were included. The surgical procedure was based on direct STN targeting (stereotactic MRI based) pondered by the acute effects of intraoperative stimulation. We used a formaldehyde-fixed human specimen to compare by matching MRI images obtained at 1.5 Tesla (performed in clinical stereotactic conditions) and at very high field at 4.7 Tesla. This allowed accurate analysis of the anatomy of the STA and retrospective precision of the location of the center of effective contacts which were located within the STN in 4 patients, at the interface between the STN and the ZI and/or FF in 13, at the interface between ZI and FF in 2 and between the STN and the substantia nigra in one. These results were consistent with the literature, revealing the implication of neighboring structures, especially the zona incerta and Forel's Field, in the clinical benefit.

Reduced exhaled NO is related to impaired nasal potential difference in patients with cystic fibrosis

Nitric oxide (NO) plays a central role in many airway physiological functions, and its production appears to be related with progression of lung disease in patients with cystic fibrosis (CF). However, underlying mechanisms which specifically link NO and CF-related lung disease remain unclear. Following in vitro and animal studies suggesting a role for NO in ion transport in various epithelia, this work investigates the relationship between transepithelial baseline potential difference (BPD), an index of airway ion transport, and exhaled NO in the airways of adult patients with CF. Association with other phenotypic traits, lung function tests and CFTR genotype was also assessed. Using simple linear regression, F(E)NO and transepithelial BPD values were significantly inversely correlated (p<0.001, r=-0.53). Polynomial analysis evidenced an asymptotic relationship between F(E)NO and BPD values, yielding a plateau for absolute BPD values above 50 mV. This relation was not altered by adjustment for clinical and genetic characteristics of the patients. The relationship between exhaled NO and transepithelial BPD suggests that low NO concentrations likely worsens airway ion transport impairment resulting from CFTR defect. These results fit with experimental studies that suggest the inhibitory effect of NO on sodium absorption, which is the main determinant of airway basal transepithelial conductance.

[Residual leukocyte counting in plasma by a real-time genomic amplification assay]

BACKGROUND

Systematic plasma leukoreduction, which was introduced in France in April 1st 2001, has given rise to more sensitive methods for residual leukocytes counting. The technologies in application at this moment (Nageotte hemocytometers and flow cytometry methods) have been modified by a thirty fold sample concentration prior to analysis, inducing frequent downgrading of the plasma unit. So, in order to improve the detection threshold, we developed a more sensitive assay using "Real-Time Polymerase Chain Reaction" technology.

MATERIALS AND METHODS

Real-time polymerase chain reaction was performed on a highly conserved HLADQalpha1 gene sequence. In order to determine the analytical performances of the method (accuracy, sensitivity, linearity and specificity) serial dilutions series ranging from 10(4) to 1 cells/ml were performed. A total of 18 series were prepared from three leukocyte stock solutions, by 1 in 10 serial dilutions in three plasmas completely devoided of white cells (called negative plasmas). To examine the specificity of the assay two negative controls were analyzed in each run.

RESULTS

a sensitivity of 10 cells/ml (10(4) leukocytes/l) was achieved and the assay was linear between 10 and 10(4) cells/ml. The slope (-3.72) of the average standard curve calculated from all series, showed an amplification yield of 92.85%.

CONCLUSION

we developed a quantitative assay for residual leukocytes in leukodepleted plasma, that agreed with the quality control requirement specifications.

Prevalence of spondyloarthropathies in France: 2001

OBJECTIVE

To estimate the prevalence of spondyloarthropathies (SpAs) in France in a multiregional representative sample in the year 2001.

METHODS

A two stage random sample was constituted in seven areas from the national telephone directory and the next birthday method in each household. Interviewers were patient-members of self help groups trained to administer telephone surveys using a validated questionnaire for detecting inflammatory joint disease. Quality of data collection was controlled periodically. SpA was confirmed by the patient's rheumatologist or by clinical examination. Prevalence estimates after probability sampling correction were standardised for age and sex (1999 national census).

RESULTS

Among the 15 219 anonymous telephone numbers selected, 3.6% were places of work or secondary residences and were excluded. The phone interview participation rate ranged across regions from 55.1 to 69.9%. 3554 men and 5841 women were included in the study. Twenty nine cases of SpA were confirmed. All but one fulfilled ESSG criteria. Mean age was 47 years (range 21-78). The overall prevalence standardised for age and sex was 0.30% (95% confidence interval (CI) 0.17 to 0.46). Prevalence was similar in women (0.29% (95% CI 0.14 to 0.49)) and men (0.31 % (95% CI 0.12 to 0.60)). Geographical analysis by department clustering found no significant differences. The prevalence of SpA was as high as that of rheumatoid arthritis.

CONCLUSION

Prevalence of SpA in France was 0.30% in 2001, with no difference between women and men. Ankylosing spondylitis and psoriatic arthritis were the most common SpA subsets.

Prevalence of rheumatoid arthritis in France: 2001

BACKGROUND

Prevalence estimates of rheumatoid arthritis (RA) vary across Europe. Recent estimates in southern European countries showed a lower prevalence than in northern countries.

OBJECTIVES

To estimate the prevalence of RA in France in a multiregional representative sample in the year 2001.

METHODS

A two stage random sample was constituted in seven areas (20 counties) from the national telephone directory of households and by the next birthday method in each household. Patient-interviewers, member of self help groups, were trained to administer telephone surveys using a validated questionnaire for case detection of inflammatory rheumatism, and conducted the survey under quality control. All suspected cases of RA were confirmed by their rheumatologist or by clinical examination. Prevalence estimates after probability sampling correction were standardised for age and sex (national census 1999).

RESULTS

An average response rate of 64.7% (two stages combined) led to a total of 9395 respondents. Standardised prevalence was 0.31% (95% confidence interval 0.18 to 0.48) for RA, 0.51% in women and 0.09% in men, with a higher age-specific prevalence in the 65-74 year age band. A geographical analysis of county clustering showed significant variation across the country.

CONCLUSION

This national multiregional cooperative study demonstrates the usefulness of working in association with patients of self help groups. It showed a similar prevalence of RA to that of the spondyloarthropathies estimated concomitantly during the survey. It provides a reliable basis for definition of population targets for healthcare delivery and drug treatments.

Improving model robustness with bootstrapping -- application to optimal discriminant analysis for ordinal responses (ODAO)

OBJECTIVE

Recent results published by Coste et al. in discriminant analysis with ordinal responses showed the superiority of optimal discriminating analysis for ordinal responses (ODAO) both in terms of classification and simplicity of implementation compared to classic methods (Fisher's discrimination, logistic regression) applied to medical data (prognostics of burns) and to simulated data. Nevertheless, the solutions obtained by ODAO may be sensitive to re-sampling (i.e the estimated coefficients by ODAO may show excessive sensitivity to the training sample). This study proposes some solutions to control the fluctuations of sampling and to ensure model stability.

METHODS

We used intensive computational methods and bootstrapping, at the outset of model building in order to reduce the sampling variability of estimated coefficients. Thus, the estimation of the coefficients was not based on the minimization of a classification criterion of the training sample, but on the minimization of an aggregate criterion of bootstrapped replications of a classification criterion. Five aggregate criteria were studied.

RESULTS

The improvement in terms of robustness appeared in 30% of the test cases with moderate training sample size and 55% of those with small training sample size.

CONCLUSION

Simulated test cases showed that bootstrapping can help construct more robust models in difficult classification situations and small training samples which are particularly frequent.

Characterization of human FCGR3B*02 (HNA-1b, NA2) cDNAs and IMGT standardized description of FCGR3B alleles

The low-affinity Fc gamma receptor IIIb (Fc gamma RIIIb and CD16b) is constituted by a unique FCGR3B polypeptide chain that comprises two extracellular immunoglobulin-like domains, and is expressed as a glycosylphosphatidyl inositol-anchored receptor on the neutrophils. The FCGR3B chain bears allotypes that define the human neutrophil antigen-1 (HNA-1 and NA) system involved in major post-transfusional reactions. FCGR3B is highly homologous to FCGR3A, which is expressed as a transmembrane receptor on natural killer cells and monocytes/macrophages. Its transcription products were not yet fully characterized. In the present work, we sequenced FCGR3B cDNAs with complete 3' untranslated region from purified granulocytes of HNA-1b/HNA-1b (NA2/NA2) genotyped donors. We characterized two FCGR3B cDNAs of different lengths corresponding to two polyadenylation sites. This result was corroborated by data raised by serial analysis of gene expression (SAGE). FCGR3B allele polymorphisms, from this article [FCGR3B*02 (HNA-1b, NA2)] and from the literature, are described for the first time according to the IMGT standardized nomenclature and to the IMGT unique numbering for C-LIKE-DOMAIN (http://imgt.cines.fr). These rules, described in the IMGT Scientific chart, are based on the IMGT-ONTOLOGY concepts. IMGT allele alignments and IMGT Collier de Perles graphical two-dimensional representations are provided for the two Ig-like domains (or C-LIKE-DOMAINs) [D1] and [D2] of FCGR3B*02. The standardized description of FCGR3B allele polymorphisms was approved by the IMGT Nomenclature Committee (IMGT-NC) and is freely available in IMGT repertoire at IMGT, http://imgt.cines.fr.

Comparison of health care professionals' self-assessments of standards of care and patients' opinions on the care they received in hospital: observational study

OBJECTIVES

To compare the views of healthcare professionals and patients regarding compliance with standards of care concerning patient information.

DESIGN

Self-rated questionnaire survey.

SETTING

Nine wards in short stay French hospitals.

PARTICIPANTS

939 patients and 359 healthcare professionals (physicians, nurses, assistants and other professionals).

MAIN OUTCOME MEASURE

Patients' and healthcare professionals' views of compliance with 20 standards of patient care described in the French accreditation manual. Comparison of the rank order of the standards within the two samples.

RESULTS

The response rate was 61.5% in the patient group and 85.8% in the healthcare professionals. The rank orders for the 20 items were similar in both groups (Spearman rank order correlation 0.6, p = 0.004). The two items ranked highest by healthcare professionals ("consent request for a surgical procedure" and "the doctors ask the visitors to leave the room before examining a patient") were also the two ranked highest by the patients. Three items were ranked low by both groups: "consent request for students to be present", "health education given to patients", and "possibility to express satisfaction during discharge". Patients were more satisfied with their pain management than were healthcare providers. Professionals were more satisfied with the social services than the patients.

CONCLUSION

There are both similarities and differences between patients' and healthcare professionals' views of care. Accurate assessments of quality performed during the accreditation procedure require that both patients' and professionals' views be taken into account.

Comparison of health care professionals' self-assessments of standards of care and patients' opinions on the care they received in hospital: observational study

OBJECTIVES

To compare the views of healthcare professionals and patients regarding compliance with standards of care concerning patient information.

DESIGN

Self-rated questionnaire survey.

SETTING

Nine wards in short stay French hospitals.

PARTICIPANTS

939 patients and 359 healthcare professionals (physicians, nurses, assistants and other professionals).

MAIN OUTCOME MEASURE

Patients' and healthcare professionals' views of compliance with 20 standards of patient care described in the French accreditation manual. Comparison of the rank order of the standards within the two samples.

RESULTS

The response rate was 61.5% in the patient group and 85.8% in the healthcare professionals. The rank orders for the 20 items were similar in both groups (Spearman rank order correlation 0.6, p = 0.004). The two items ranked highest by healthcare professionals ("consent request for a surgical procedure" and "the doctors ask the visitors to leave the room before examining a patient") were also the two ranked highest by the patients. Three items were ranked low by both groups: "consent request for students to be present", "health education given to patients", and "possibility to express satisfaction during discharge". Patients were more satisfied with their pain management than were healthcare providers. Professionals were more satisfied with the social services than the patients.

CONCLUSION

There are both similarities and differences between patients' and healthcare professionals' views of care. Accurate assessments of quality performed during the accreditation procedure require that both patients' and professionals' views be taken into account.

Nitric oxide synthase 1 as a potential modifier gene of decline in lung function in patients with cystic fibrosis

BACKGROUND

The severity of lung disease varies widely in patients with cystic fibrosis (CF) who have the same type of mutations of the cystic fibrosis transmembrane regulator (CFTR) gene, suggesting involvement of "modifier" genes. The nitric oxide synthase 1 (NOS1) gene is a candidate for this role because exhaled nitric oxide (NO) is reduced in patients with CF and NOS1 activity contributes to transepithelial ionic transport, immune defence, and non-specific inflammation of the airways.

METHODS

Dinucleotide GT repeat polymorphism was studied in the 5' untranslated region of the NOS1 gene, immediately upstream from the transcription initiation site, in 59 patients with CF and 59 healthy controls.

RESULTS

Nineteen alleles of the NOS1 gene were identified according to the number of GT repeats (from 18 to 36) in the 5 untranslated region. Exhaled NO levels were significantly correlated with the number of GT repeats. Patients with CF who had the NOS1 genotype associated with high NO production had a slower decline in lung function during the 5 year follow up period. There was no confounding effect of age, chronic bacterial colonisation of the airway, or CFTR genotype.

CONCLUSIONS

These data suggest a possible link between the NOS1 gene locus and the rate of decline in lung function in patients with CF.

Detection of cases of inflammatory rheumatic disorders: performance of a telephone questionnaire designed for use by patient interviewers

OBJECTIVE

To assess the performance in the detection of cases of rheumatoid arthritis (RA) and the spondyloarthropathies (SpA) of a questionnaire suitable for use in telephone surveys conducted by patient interviewers.

METHODS

A questionnaire was designed with reference to the signs, symptoms, and epidemiological criteria for RA (ACR 1987) and SpA (ESSG 1991). Three groups of respondents were recruited from the rheumatology outpatient clinics of 10 university hospitals: 235 with RA, 175 with SpA, and 195 controls with other rheumatological disorders. All diagnoses were confirmed by a rheumatologist. Patient from self help groups and social organisations were trained by a polling company professional to conduct a standard telephone interview using the new questionnaire.

RESULTS

In an RA-control comparison, logistic regression showed that a set of five items, predominantly ACR criteria, were the most informative. Self reported diagnosis performed best (sensitivity 0.99, specificity 0.87). In an SpA-control comparison, a set of three items from the ESSG criteria were the most informative, with self reported diagnosis again performing best (sensitivity 0.85, specificity 0.96). Overall agreements with clinical diagnoses were 97.7% for RA and 94.4% SpA, dropping to 90.4% and 79.1%, respectively, when self reported diagnosis was excluded. Without self reported diagnosis, questions about peripheral joint and spinal pain made significant contributions to diagnostic performance.

CONCLUSION

A questionnaire in plain language was developed for use in detecting cases of RA and SpA. It performed satisfactorily when administered by patient interviewers and is now available for epidemiological surveys of the general population.

[Cost-effectiveness analysis of laparoscopic surgery versus methotrexate: comparison of data recorded in an ectopic pregnancy registry]

OBJECTIVES

To compare the cost efficacy ratios of medical therapy (methotrexate - MTX) and laparoscopic surgery for ectopic pregnancy, based on an observational study of effectiveness.

MATERIAL AND METHODS

Data were collected by a population register of the Auvergne area. We computed the costs before, during and after hospitalization of women who could be treated either by MTX or laparoscopic surgery. We detailed costs related to the various existing facilities. We considered the entire treatment.

RESULTS

One hundred nine cases of ectopic pregnancy were treated by laparoscopic surgery and 46 by MTX. Second-line therapy was required in 3% of women who underwent laparoscopic surgery, and 35% of those given MTX. MTX was found to be less costly (1,342 euros) than laparoscopic surgery (2,113 euros). The efficacy threshold for MTX was 11% (giving a failure rate of 89%).

CONCLUSION

MTX is much more cost effective than laparoscopic surgery but the frequent need for second-line treatment must also be assessed.

[Fertility after ectopic pregnancy: 10-year results in the Auvergne Registry]

OBJECTIVES

The purpose of this work was to study the fertility after ectopic pregnancy (EP) according to the type of contraception at the time of EP (none, IUD, other) and treatment (medical, conservative surgical, radical).

MATERIAL AND METHODS

Ten-year Auvergne EP registry data were analyzed (1626 women, among whom 741 tried to become pregnant again). Fertility was characterized by the time to a new pregnancy and its outcome (EP recurrence, intrauterine pregnancy (IUP)). The censored data methodology was used.

RESULTS

The rate of recurrence was much higher in women who had a IUD at the time of EP than in women without contraception. The opposite trend was observed for IUP (the rate of IUP was 1.7-fold higher in women who had a IUD at the time of EP). The rate of recurrence doubled in women treated medically. The rate of IUP was significantly lower in women given conservative treatment than in women given radical treatment.

CONCLUSION

Contraception at the time of EP must be considered when studying subsequent fertility. The increase in rate of recurrence following medical treatment observed in the present study should be confirmed by others in search for an explanation. Our results point out the need for control trials on EP treatment, and provide data for planning such trials.

Reducing the number of T3 orders in the Paris hospital network: towards better appropriatness of thyroid function test prescription

In vitro thyroid function tests are among the most frequently prescribed laboratory procedures. Serum triiodothyronine (T3) tests are seldom necessary as a first-level measurement. Our objectives were to measure the proportion of T3 measurements relative to all in vitro thyroid function tests in a large hospital network and to investigate the contributions of various interventions to change prescribers'behavior. We performed two cross-sectional surveys in 1995 and 1998 in the 50 Paris University hospitals. Questionnaires were mailed to the heads of the 30 laboratories performing thyroid function tests. One-month orders of free and total thyroxine, free and total T3 and thyrotropin were recorded; changes in T3 measurement orders between the two periods were estimated and association with interventions were expressed as odds ratios and 95% confidence intervals. Twenty-five heads of laboratory responded to both surveys. In 1995, T3 measurements constituted 21% of in vitro thyroid function test ordering, which seems to us exceedingly high. The decrease in T3 measurement ordering observed in 1998 (15% of thyroid function test ordering) was independently associated with multiple behavioral changes: educational interventions, structured test form use and year of prescription.