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Duhem H, Moore JC, Rojas-Salvador C, Salverda B, Lick M, Pepe P, Labarere J, Debaty G, Lurie KG. Reply to: Elevation of head and thorax after return of spontaneous circulation - A few caveats to consider. Resuscitation 2021; 163:205-206. [PMID: 33895235 DOI: 10.1016/j.resuscitation.2021.04.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Accepted: 04/08/2021] [Indexed: 11/16/2022]
Affiliation(s)
- Helene Duhem
- University Grenoble Alps/CNRS/CHU de Grenoble Alpes/TIMC-IMAG UMR, 5525 Grenoble, France
| | - Johanna C Moore
- Hennepin Healthcare Research Institute, Minneapolis, MN, USA
| | | | - Bayert Salverda
- Hennepin Healthcare Research Institute, Minneapolis, MN, USA
| | - Michael Lick
- Hennepin Healthcare Research Institute, Minneapolis, MN, USA
| | - Paul Pepe
- Dallas County Fire Rescue, Dallas, TX, USA; Palm Beach County Fire Rescue, West Palm Beach, FL, USA; Broward Sheriff's Office, Fire/Rescue Department, Fort Lauderdale, FL, USA
| | - Jose Labarere
- University Grenoble Alps/CNRS/CHU de Grenoble Alpes/TIMC-IMAG UMR, 5525 Grenoble, France
| | - Guillaume Debaty
- University Grenoble Alps/CNRS/CHU de Grenoble Alpes/TIMC-IMAG UMR, 5525 Grenoble, France.
| | - Keith G Lurie
- Hennepin Healthcare Research Institute, Minneapolis, MN, USA
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Boussat B, Quan H, Labarere J, Southern D, Couris CM, Ghali WA. Mitigating imperfect data validity in administrative data PSIs: a method for estimating true adverse event rates. Int J Qual Health Care 2021; 33:6129200. [PMID: 33544120 DOI: 10.1093/intqhc/mzab025] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Revised: 11/22/2020] [Accepted: 02/04/2021] [Indexed: 11/12/2022] Open
Abstract
QUESTION Are there ways to mitigate the challenges associated with imperfect data validity in Patient Safety Indicator (PSI) report cards? FINDINGS Applying a methodological framework on simulated PSI report card data, we compare the adjusted PSI rates of three hospitals with variable quality of data and coding. This framework combines (i) a measure of PSI rates using existing algorithms; (ii) a medical record review on a small random sample of charts to produce a measure of hospital-specific data validity and (iii) a simple Bayesian calculation to derive estimated true PSI rates. For example, the estimated true PSI rate, for a theoretical hospital with a moderately good quality of coding, could be three times as high as the measured rate (for example, 1.4% rather than 0.5%). For a theoretical hospital with relatively poor quality of coding, the difference could be 50-fold (for example, 5.0% rather than 0.1%). MEANING Combining a medical chart review on a limited number of medical charts at the hospital level creates an approach to producing health system report cards with estimates of true hospital-level adverse event rates.
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Affiliation(s)
- Bastien Boussat
- Department of Community Health Sciences, Cumming School of Medicine, O'Brien Institute for Public Health, University of Calgary, TRW Building, 3280 Hospital Drive NW, Calgary, AB T2N 1N4, Canada.,Quality of Care Unit, Grenoble University Hospital, Boulevard de la Chantourne, 38043 cedex 09, Grenoble, France.,TIMC UMR 5525 CNRS, Computational and Mathematical Biology Team, Grenoble Alpes University, Boulevard de la Chantourne, Pavillon Taillefer, 38043 cedex 09, Grenoble, France
| | - Hude Quan
- Department of Community Health Sciences, Cumming School of Medicine, O'Brien Institute for Public Health, University of Calgary, TRW Building, 3280 Hospital Drive NW, Calgary, AB T2N 1N4, Canada
| | - Jose Labarere
- Quality of Care Unit, Grenoble University Hospital, Boulevard de la Chantourne, 38043 cedex 09, Grenoble, France.,TIMC UMR 5525 CNRS, Computational and Mathematical Biology Team, Grenoble Alpes University, Boulevard de la Chantourne, Pavillon Taillefer, 38043 cedex 09, Grenoble, France
| | - Danielle Southern
- Department of Community Health Sciences, Cumming School of Medicine, O'Brien Institute for Public Health, University of Calgary, TRW Building, 3280 Hospital Drive NW, Calgary, AB T2N 1N4, Canada
| | - Chantal M Couris
- Canadian Institute for Health Information, Indicator Research and Development Team, Research and Analysis Division, 4110 Yonge Street, Suite 300, Toronto, ON M2P 2B7, Canada
| | - William A Ghali
- Department of Community Health Sciences, Cumming School of Medicine, O'Brien Institute for Public Health, University of Calgary, TRW Building, 3280 Hospital Drive NW, Calgary, AB T2N 1N4, Canada
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Duhem H, Moore JC, Rojas-Salvador C, Salverda B, Lick M, Pepe P, Labarere J, Debaty G, Lurie KG. Improving post-cardiac arrest cerebral perfusion pressure by elevating the head and thorax. Resuscitation 2021; 159:45-53. [PMID: 33385469 DOI: 10.1016/j.resuscitation.2020.12.016] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Revised: 12/04/2020] [Accepted: 12/15/2020] [Indexed: 01/17/2023]
Abstract
AIM The optimal head and thorax position after return of spontaneous circulation (ROSC) following cardiac arrest (CA) is unknown. This study examined whether head and thorax elevation post-ROSC is beneficial, in a porcine model. METHODS Protocol A: 40 kg anesthetized pigs were positioned flat, after 7.75 min of untreated CA the heart and head were elevated 8 and 12 cm, respectively, above the horizontal plane, automated active compression decompression (ACD) plus impedance threshold device (ITD) CPR was started, and 2 min later the heart and head were elevated 10 and 22 cm, respectively, over 2 min to the highest head up position (HUP). After 30 min of CPR pigs were defibrillated and randomized 10 min later to four 5-min epochs of HUP or flat position. Multiple physiological parameters were measured. In Protocol B, after 6 min of untreated VF, pigs received 6 min of conventional CPR flat, and after ROSC were randomized HUP versus Flat as in Protocol A. The primary endpoint was cerebral perfusion pressure (CerPP). Multivariate analysis-of-variance (MANOVA) for repeated measures was used. Data were reported as mean ± SD. RESULTS In Protocol A, intracranial pressure (ICP) (mmHg) was significantly lower post-ROSC with HUP (9.1 ± 5.5) versus Flat (18.5 ± 5.1) (p < 0.001). Conversely, CerPP was higher with HUP (62.5 ± 19.9) versus Flat (53.2 ± 19.1) (p = 0.004), respectively. Protocol A and B results comparing HUP versus Flat were similar. CONCLUSION Post-ROSC head and thorax elevation in a porcine model of cardiac arrest resulted in higher CerPP and lower ICP values, regardless of VF duration or CPR method. IACUC PROTOCOL NUMBER 19-09.
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Affiliation(s)
- Helene Duhem
- University Grenoble Alps/CNRS/CHU Grenoble Alpes/TIMC-IMAG UMR 5525, Grenoble, France
| | - Johanna C Moore
- Department of Emergency Medicine, Hennepin Healthcare, Minneapolis, MN, USA; Hennepin Healthcare Research Institute, Minneapolis, MN, USA
| | | | - Bayert Salverda
- Hennepin Healthcare Research Institute, Minneapolis, MN, USA
| | - Michael Lick
- Hennepin Healthcare Research Institute, Minneapolis, MN, USA
| | - Paul Pepe
- Dallas County Fire Rescue, Dallas, TX, USA; Palm Beach County Fire Rescue, West Palm Beach, FL and Broward Sheriff's Office, Fire Rescue Department Fort Lauderdale, FL, USA
| | - Jose Labarere
- University Grenoble Alps/CNRS/CHU Grenoble Alpes/TIMC-IMAG UMR 5525, Grenoble, France
| | - Guillaume Debaty
- University Grenoble Alps/CNRS/CHU Grenoble Alpes/TIMC-IMAG UMR 5525, Grenoble, France.
| | - Keith G Lurie
- Hennepin Healthcare Research Institute, Minneapolis, MN, USA; Department of Emergency Medicine, University of Minnesota, Minneapolis, MN, USA
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Duhem H, Moore J, Rojas-Salvador C, Pepe P, Salverda B, Lick M, Labarere J, Debaty G, Lurie K. Elevation of head and thorax increases cerebral perfusion pressure and lowers intracranial pressure after restoration of spontaneous circulation in a porcine model of cardiac arrest. Resuscitation 2020. [DOI: 10.1016/j.resuscitation.2020.08.092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Debaty G, Labarere J, Frascone RJ, Wayne MA, Swor RA, Mahoney BD, Domeier RM, Olinger ML, O'Neil BJ, Yannopoulos D, Aufderheide TP, Lurie KG. Long-Term Prognostic Value of Gasping During Out-of-Hospital Cardiac Arrest. J Am Coll Cardiol 2017; 70:1467-1476. [PMID: 28911510 DOI: 10.1016/j.jacc.2017.07.782] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2017] [Accepted: 07/18/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND Gasping is a natural reflex that enhances oxygenation and circulation during cardiopulmonary resuscitation (CPR). OBJECTIVES This study sought to assess the relationship between gasping during out-of-hospital cardiac arrest and 1-year survival with favorable neurological outcomes. METHODS The authors prospectively collected incidence of gasping on all evaluable subjects in a multicenter, randomized, controlled, National Institutes of Health-funded out-of-hospital cardiac arrest clinical trial from August 2007 to July 2009. The association between gasping and 1-year survival with favorable neurological function, defined as a Cerebral Performance Category (CPC) score ≤2 was estimated using multivariable logistic regression. RESULTS The rates of 1-year survival with a CPC score of ≤2 were 5.4% (98 of 1,827) overall, and 20% (36 of 177) and 3.7% (61 of 1,643) for individuals with and without spontaneous gasping or agonal respiration during CPR, respectively. In multivariable analysis, 1-year survival with CPC ≤2 was independently associated with younger age (odds ratio [OR] for 1 SD increment 0.57; 95% confidence interval [CI]: 0.43 to 0.76), gasping during CPR (OR: 3.94; 95% CI: 2.09 to 7.44), shockable initial recorded rhythm (OR: 16.50; 95% CI: 7.40 to 36.81), shorter CPR duration (OR: 0.31; 95% CI: 0.19 to 0.51), lower epinephrine dosage (OR: 0.47; 95% CI: 0.25 to 0.87), and pulmonary edema (OR: 3.41; 95% CI: 1.53 to 7.60). Gasping combined with a shockable initial recorded rhythm had a 57-fold higher OR (95% CI: 23.49 to 136.92) of 1-year survival with CPC ≤2 versus no gasping and no shockable rhythm. CONCLUSIONS Gasping during CPR was independently associated with increased 1-year survival with CPC ≤2, regardless of the first recorded rhythm. These findings underscore the importance of not terminating resuscitation prematurely in gasping patients and the need to routinely recognize, monitor, and record data on gasping in all future cardiac arrest trials and registries.
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Affiliation(s)
- Guillaume Debaty
- University Grenoble Alps/CNRS/TIMC-IMAG UMR 5525, Grenoble, France; Department of Emergency Medicine, University Hospital of Grenoble Alps, Grenoble, France.
| | - Jose Labarere
- University Grenoble Alps/CNRS/TIMC-IMAG UMR 5525, Grenoble, France; Quality of Care Unit, CIC 1406, INSERM, University Hospital of Grenoble Alps, Grenoble, France
| | - Ralph J Frascone
- Department of Emergency Medicine, Regions Hospital, St. Paul, Minnesota
| | - Marvin A Wayne
- Whatcom County Emergency Medical Services, Department of Emergency Medicine, PeaceHealth St. Joseph Medical Center, Bellingham, Washington
| | - Robert A Swor
- Department of Emergency Medicine, William Beaumont Hospital, Royal Oak, Michigan
| | - Brian D Mahoney
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, Minnesota
| | - Robert M Domeier
- Department of Emergency Medicine, St. Joseph Hospital, Ann Arbor, Michigan
| | - Michael L Olinger
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis, Indiana
| | - Brian J O'Neil
- Department of Emergency Medicine, Wayne State University, Detroit, Michigan
| | - Demetris Yannopoulos
- Department of Medicine, Cardiovascular Division, University of Minnesota Medical Center, Minneapolis, Minnesota
| | - Tom P Aufderheide
- Department of Emergency Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Keith G Lurie
- Department of Emergency Medicine, William Beaumont Hospital, Royal Oak, Michigan
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Bosson JL, Labarere J. Determining Indications for Care Common to Competing Guidelines by Using Classification Tree Analysis: Application to the Prevention of Venous Thromboembolism in Medical Inpatients. Med Decis Making 2016; 26:63-75. [PMID: 16495202 DOI: 10.1177/0272989x05284105] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background. Substantial variations have been reported in the advice given by competing guidelines addressing the same clinical problem. Objective. This study aimed to assess the usefulness of classification tree analysis in comparing competing guidelines. Method. The authors implemented a classification tree–growing algorithm on cross-sectional data from 818 patients to determine indications for prophylactic heparin treatment common to 4 competing guidelines disseminated between 1998 and 2000 and addressing the prophylaxis of venous thromboembolism in medical inpatients. Results. The resulting classification tree involved 10 terminal nodes. Its mean accuracy estimated by performing 10-fold cross-validation was 82% (s = 3). The guidelines consistently supported prophylactic heparin treatment for 5 indications: a previous episode of deep vein thrombosis or pulmonary embolism, recent paralysis of lower limb(s), congestive heart failure with one or more risk factors, recent myocardial infarction, and malignancy with one or more risk factors. These indications involved 257 patients (31.4%) and were supported by robust scientific evidence. Deep vein thrombosis was detected in 27 of these patients (10.5%). Two consistent negative indications involved 347 patients (42.4%). Deep vein thrombosis was detected in 9 of these patients (2.6%). Three indications involving 214 patients (26.2%) were discordant over the 4 guidelines. Conclusion. Classification tree analysis of real patient data is a useful strategy to identify indications common to competing guidelines. These indications should be considered for inclusion when updating guidelines. The findings of recently completed randomized trials have partly resolved the disagreement among the 4 guidelines. This approach may be helpful when developing new guidelines or for identifying topics warranting further complementary clinical trials.
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Duraffourg A, Yayehd K, Fourny M, Turk J, Massoutier M, Ageron FX, Debaty G, Ricard C, Vanzetto G, Belle L, Labarere J. [Reperfusion in ST elevation myocardial infarction. From the guidelines to practice]. Ann Cardiol Angeiol (Paris) 2014; 63:312-320. [PMID: 25283574 DOI: 10.1016/j.ancard.2014.09.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
BACKGROUND International guidelines have recommendations for selecting the type of reperfusion (fibrinolysis or angioplasty) in the setting of ST-segment elevation myocardial infarction (STEMI), and suggest that emergency-care networks adapt these recommendations according to the local environment. AIM To assess the proportions of STEMI patients treated with fibrinolysis or angioplasty in accordance with regional guidelines. METHOD Observational study based on a permanent registry of patients with STEMI of <12h duration in an emergency network in the French North Alps (Isère, Savoie, Haute-Savoie) from January 2009 to December 2012. RESULTS The registry included 2620 patients. Reperfusion was given in 2425/2620 (93%) of patients. Reperfusion type was in accordance with recommendations in 1567/2620 (60%) patients. Guideline-recommended fibrinolysis and angioplasty were performed in 47% (656/1385) and 79% (911/1149) respectively, of patients. In multivariable analysis, variables independently associated with guideline-recommended reperfusion were: an age < 65 years (OR 1.60; 95%CI 1.33-1.90), being managed in Haute-Savoie versus Isère or Savoie (OR 1.38; 95%CI 1.12-1.71), an arterial tension < 100mmHg (OR 1.73; 95%CI 1.27-2.35), a cardiogenic shock (OR 0.50; 95%CI 0.30-0.84), a pacemaker or left bundle branch block (OR 0.49; 95%CI 0.28-0.88), and an initial management outside the network (followed by treatment in an interventional centre in the network) (OR 0.62; 95%CI 0.40-0.94). Patients initially treated by mobile intensive care units were more often reperfused in accordance with recommendations when admitted < 3 (versus ≥ 3) h following symptom onset (adjusted OR 2.05; 95% CI 1.61-2.59), while those initially treated by in-hospital emergency units were less often reperfused in accordance with recommendation when treated < 3h following symptom onset (adjusted OR 0.67; 95% CI 0.46-0.97). In-hospital major adverse cardiac events (9.1% vs. 8.5%) and in-hospital mortality (6.4% vs. 5.1%) were not significantly different between patients reperfused in accordance with (versus not) recommendations. CONCLUSIONS Forty percent of patients with STEMI were not reperfused with fibrinolysis or angioplasty in accordance with regional guidelines. Characterization of this population should allow us to improve guideline adherence.
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Affiliation(s)
- A Duraffourg
- Médecins de Montagne Rhône-Alpes, 256, rue de la République, 73000 Chambery, France
| | - K Yayehd
- Service de cardiologie, CHU Campus, 03 BP 30284, Lomé, Togo
| | - M Fourny
- Unité d'évaluation médicale, CHU, 38000 Grenoble, France
| | - J Turk
- Service d'aide médicale urgente, centre hospitalier, 73000 Chambery, France
| | - M Massoutier
- Unité d'évaluation médicale, CHU, 38000 Grenoble, France
| | - F X Ageron
- Service d'aide médicale urgente, centre hospitalier, 74000 Annecy, France
| | - G Debaty
- Service d'aide médicale urgente, CHU, 38000 Grenoble, France
| | - C Ricard
- Réseau nord Alpin des urgences, centre hospitalier, 74000 Annecy, France
| | - G Vanzetto
- Service de cardiologie, CHU, 38000 Grenoble, France
| | - L Belle
- Service de cardiologie, centre hospitalier, 74000 Annecy, France.
| | - J Labarere
- Unité d'évaluation médicale, CHU, 38000 Grenoble, France
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Batailler P, François P, Mô Dang V, Sellier E, Vittoz JP, Seigneurin A, Labarere J. Trends in patient perception of hospital care quality. Int J Health Care Qual Assur 2014; 27:414-26. [DOI: 10.1108/ijhcqa-02-2013-0014] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Purpose
– The purpose of this paper is to investigate trends in patient hospital quality perceptions between 1999 and 2010.
Design/methodology/approach
– Original data from 11 cross-sectional surveys carried out in a French single university hospital were analyzed. Based on responses to a 29-item survey instrument, overall and subscale perception scores (range 0-10) were computed covering six key hospital care quality dimensions.
Findings
– Of 16,516 surveyed patients, 10,704 (64.8 percent) participated in the study. The median overall patient perception score decreased from 7.86 (25th-75th percentiles, 6.67-8.85) in 1999 to 7.82 (25th-75th percentiles, 6.67-8.74) in 2010 (p for trend <0.001). A decreasing trend was observed for the living arrangement subscale score (from 7.78 in 1999 to 7.50 in 2010, p for trend <0.001). Food service and room comfort perceptions deteriorated over the study period while patients increasingly reported better explanations before being examined.
Practical implications
– Patient perception scores may disguise divergent judgments on different care aspect while individual items highlight specific areas with room for improvement.
Originality/value
– Despite growing pressure on healthcare expenditure, this single-center study showed only modest reduction in patients’ hospital-care perceptions in the 2000s.
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Cracowski JL, Chabot F, Labarere J, Faure P, Degano B, Schwebel C, Chaouat A, Reynaud-Gaubert M, Cracowski C, Sitbon O, Yaici A, Simonneau G, Humbert M. Proinflammatory cytokine levels are linked to death in pulmonary arterial hypertension. Eur Respir J 2013; 43:915-7. [DOI: 10.1183/09031936.00151313] [Citation(s) in RCA: 83] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Labarere J, Bernet J. Protoplasmic Incompatibility and Cell Lysis in PODOSPORA ANSERINA. I. Genetic Investigations on Mutations of a Novel Modifier Gene That Suppresses Cell Destruction. Genetics 2010; 87:249-57. [PMID: 17248762 PMCID: PMC1213738 DOI: 10.1093/genetics/87.2.249] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
In Podospora anserina, protoplasmic incompatibility (a phenomenon that prevents heterokaryon formation because of the destruction of the fused cells) can be studied in homokaryotic strains that combine nonallelic incompatibility genes or carry mutations at the lys loci. In these strains cell destruction occurs early in development and is associated with an arrest of growth.-From the self-lysing strains lysA(1) and RV (R and V are nonallelic incompatibility genes) mutations have been selected that suppress the self-lysing trait, i.e., that prevent cell destruction and remove growth inhibition. Some of them were derived from a novel modifier locus, modC, located near the mating-type locus.-In C/D and C/E incompatibility systems, modC mutations, which per se have no obvious effect, were considered in addition to mutations in the previously identified modifier loci, modA and modB. The demonstration of a functional interdependence among the three mod genes suggested that modC is not the structural gene for the protease associated with cell lysis, but is involved, like modA and modB, in its control.-All three modC mutant strains investigated exhibit defects in the formation of protoperithecia, suggesting that the modC gene function is essential to the occurrence or development of the female organs. This is the third argument that supports the hypothesis ( Boucherie, Bégueret and Bernet 1976) that protoplasmic incompatibility and female organ formation might be related phenomena.
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Affiliation(s)
- J Labarere
- Laboratoire de Génétique, Université de Bordeaux II, Allée des Facultés, 33405 Talence, France
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Abstract
A mutation (modD) was selected in a gene involved in the control of protoplasmic incompatibility. Previous results (Labarere and Bernet 1979) showed that modD decreased the density of protoperithecia and caused a defect in ascospore germination. In addition, modD has a third defect: when modD stationary cells were isolated in order to obtain further development, renewal of growth rarely ensued. Instead, the modD cells lysed or produced microthalli from which normal growth never occurred. These defects were suppressed by beta-phenyl pyruvic acid, a protease inhibitor, and by the presence of a mutation (modC) that suppresses the proteases associated with protoplasmic incompatibility. The stationary wild-type cells' regeneration was inhibited by beta-phenyl pyruvic acid at levels that maintained modD cells' regeneration. These results suggest a biological role for the proteases associated with protoplasmic incompatibility.
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Affiliation(s)
- J Labarere
- Laboratoire de Génétique, Allée des Facultés, 33405 Talence, France
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Belle L, Chacornac M, Ageron FX, Hugon V, Usseglio P, Debatty G, Labarere J, Fourny M, Rubio C, Vanzetto G. 242 Regional emergency care network for the management of acute myocardial infarction. Experience of RESURCOR in the French northern Alps. BMJ Qual Saf 2010. [DOI: 10.1136/qshc.2010.041616.16] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Sellier E, Pavese P, Gennai S, Stahl JP, Labarere J, Francois P. Factors and outcomes associated with physicians' adherence to recommendations of infectious disease consultations for inpatients. J Antimicrob Chemother 2009; 65:156-62. [DOI: 10.1093/jac/dkp406] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Constans J, Salmi LR, Sevestre-Pietri MA, Perusat S, Nguon M, Degeilh M, Labarere J, Gattolliat O, Boulon C, Laroche JP, Le Roux P, Pichot O, Quéré I, Conri C, Bosson JL. A clinical prediction score for upper extremity deep venous thrombosis. Thromb Haemost 2008; 99:202-7. [PMID: 18217155 DOI: 10.1160/th07-08-0485] [Citation(s) in RCA: 70] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
It was the objective of this study to design a clinical prediction score for the diagnosis of upper extremity deep venous thrombosis (UEDVT). A score was built by multivariate logistic regression in a sample of patients hospitalized for suspicion of UEDVT (derivation sample). It was validated in a second sample in the same university hospital, then in a sample from the multicenter OPTIMEV study that included both outpatients and inpatients. In these three samples, UEDVT diagnosis was objectively confirmed by ultrasound. The derivation sample included 140 patients among whom 50 had confirmed UEDVT, the validation sample included 103 patients among whom 46 had UEDVT, and the OPTIMEV sample included 214 patients among whom 65 had UEDVT. The clinical score identified a combination of four items (venous material, localized pain, unilateral pitting edema and other diagnosis as plausible). One point was attributed to each item (positive for the first 3 and negative for the other diagnosis). A score of -1 or 0 characterized low probability patients, a score of 1 identified intermediate probability patients, and a score of 2 or 3 identified patients with high probability. Low probability score identified a prevalence of UEDVT of 12, 9 and 13%, respectively, in the derivation, validation and OPTIMEV samples. High probability score identified a prevalence of UEDVT of 70, 64 and 69% respectively. In conclusion we propose a simple score to calculate clinical probability of UEDVT. This score might be a useful test in clinical trials as well as in clinical practice.
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Affiliation(s)
- Joel Constans
- CHU Bordeaux and Bordeaux II University, Vascular and Internal Medicine Unit, Bordeaux, France.
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Sellier E, Labarere J, Sevestre MA, Belmin J, Thiel H, Couturier P, Bosson JL. Risk factors for deep vein thrombosis in older patients: a multicenter study with systematic compression ultrasonography in postacute care facilities in France. J Am Geriatr Soc 2007; 56:224-30. [PMID: 18070003 DOI: 10.1111/j.1532-5415.2007.01545.x] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To identify risk factors for deep vein thrombosis (DVT) in older patients with restricted mobility or functional disability. DESIGN Cross-sectional. SETTING Forty-two postacute care departments in France. PARTICIPANTS Eight hundred twelve patients aged 65 and older. MEASUREMENTS Twenty-two predefined characteristics were investigated, including medical and surgical risk factors, dependence in six basic activities of daily living (ADLs) rated using the Katz index, mobility, the reported value of the Timed Up and Go Test, and pressure ulcers. All patients underwent lower limb ultrasonography on the day of the cross-sectional study. RESULTS DVT was found in 113 patients (14%, 33 proximal DVTs (4%) and 80 isolated distal DVTs (10%)). A positive trend was found in the odds of DVT for higher values on the Timed Up and Go Test for patients who were not bedridden or confined to a chair (P=.007). In two-level multivariable analysis adjusting for prophylaxis against venous thromboembolism, independent risk factors for DVT were aged 80 and older (adjusted odds ratio (aOR)=1.71, 95% confidence interval (CI)=1.05-2.79), previous history of venous thromboembolism (aOR=2.03, 95% CI=1.06-3.87), regional or metastatic-stage cancer (aOR=2.71, 95% CI=1.27-5.78), dependence in more than three ADLs (aOR=2.18, 95% CI=1.38-3.45), and pressure ulcers (aOR=1.85, 95% CI=1.05-3.24). CONCLUSION Severe dependence in basic ADLs and higher Timed Up and Go Test score are associated with greater odds of DVT in older patients in postacute care facilities in France.
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Affiliation(s)
- Elodie Sellier
- Quality of Care Unit, University Hospital, Grenoble, France
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Laborde L, Fulcheri J, Gelbert-Baudino N, Schelstraete C, Mathieu M, Durand M, Baudino F, Vié Le Sage F, Gothie I, Roche F, Devoldere C, Salinier C, Gout JP, Plasse M, Caron FM, François P, Labarere J. Intérêt du Breastfeeding Assessment Score pour la prédiction du sevrage précoce de l'allaitement maternel en France. Arch Pediatr 2007; 14:978-84. [PMID: 17512178 DOI: 10.1016/j.arcped.2007.03.031] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2006] [Revised: 02/09/2007] [Accepted: 03/19/2007] [Indexed: 10/23/2022]
Abstract
BACKGROUND The Breastfeeding Assessment Score (BAS) was derived to help identify mothers at increased risk of early weaning in United States. Data are currently lacking on the accuracy of the BAS for French mother-infant pairs. OBJECTIVE To assess the accuracy of the BAS in a French validation cohort. METHODS We used the original data from a prospective cohort study of 488 mothers who were breastfeeding at discharge in 9 maternity wards in 2005. The outcome measures were assessed using structured follow-up telephone interviews at 4 and 26 weeks. RESULTS The weaning rate was 3% at 14 days of infant age. The corresponding area under ROC curve was 0.73 [0.60-0.85] and was comparable to that observed in the derivation cohort (0.75). For a cut point of 8 recommended by the authors of the BAS, 43% of mother-infant pairs were categorized at high risk and the weaning rate in this subgroup was 5%. The mother-infant pairs with a score lower than 8 had a shorter median breastfeeding duration (18 versus 20 weeks, P=0.02), were more likely to report breastfeeding difficulties after discharge (63% versus 53%, P=0.03), and were less likely to be "very satisfied" with breastfeeding experience (66% versus 77%, P=0.007). CONCLUSION The intrinsic properties of the BAS are robust. However, its use would be of limited interest in France because of the relatively low rate of early weaning. Randomized trials are needed before recommending routine use of BAS-based breastfeeding support intervention.
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Affiliation(s)
- L Laborde
- Unité d'évaluation médicale, centre hospitalier universitaire, 38043 Grenoble cedex 09, France
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Labarere J, Bosson JL, Sevestre MA, Sellier E, Richaud C, Legagneux A. Intervention targeted at nurses to improve venous thromboprophylaxis. Int J Qual Health Care 2007; 19:301-8. [PMID: 17726037 DOI: 10.1093/intqhc/mzm034] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVE To assess the effectiveness of an intervention targeting both physicians and nurses vs. physicians only in improving venous thromboprophylaxis for older patients. DESIGN Cluster randomized trial. SETTING Fifty hospital-based post-acute care departments in France. PARTICIPANTS Patients aged 65 years or older. INTERVENTION A multifaceted intervention to implement a clinical practice guideline addressing venous thromboprophylaxis. MAIN OUTCOME MEASURES The effectiveness outcomes were elastic stocking use, ambulation or mobilization under the supervision of a physical therapist and anticoagulant-based prophylaxis. Patient outcomes included deep vein thrombosis and anticoagulant-related adverse events. RESULTS One department allocated to the intervention targeted at physicians only and seven departments allocated to the intervention targeted at both physicians and nurses dropped out of the study. Compared with the intervention targeted at physicians only (n = 497 patients), the intervention targeted at both physicians and nurses (n = 315 patients) was associated with a higher rate of mobilization (62 vs. 37%, P < 0.001) and comparable levels of elastic stocking (32 vs. 39%, P = 0.74) and anticoagulant (55 vs. 48%, P = 0.36) use. The rates of deep vein thrombosis (15 vs. 13%, P = 0.50), bleeding (1 vs. 1%, P = 0.99) and thrombocytopaenia (0 vs. 0.2%, P = 0.99) did not differ between the two groups. CONCLUSIONS A multifaceted intervention targeting nurses in addition to physicians can increase the frequency of mobilization of older patients to prevent venous thromboembolism but does not alter the use of elastic stockings and anticoagulant. A differential drop-out of departments might have contributed to creating imbalances in baseline characteristics and outcomes in this study.
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Affiliation(s)
- Jose Labarere
- Unité d'Evaluation Médicale, Pavillon Taillefer, Centre Hospitalier Universitaire, BP 217, 38043 Grenoble Cedex 9, France.
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Abstract
AIM To estimate the percentage of breastfeeding mothers with home access to e-technologies and to compare breastfeeding outcomes for mothers with and without access to e-technologies. METHODS We conducted a prospective observational study of 550 breastfeeding mothers discharged from nine maternity units in France. RESULTS Overall, 435 mothers (79%; 95% confidence interval [95% CI], 75-82) had home access to e-technologies. Mothers with access to e-technologies were less likely to be unemployed (6% vs. 15%, p = 0.004), to smoke during pregnancy (8% vs. 16%, p = 0.03), to have a breastfeeding assessment score <8 (39% vs. 59%, p < 0.001) and to use a pacifier (23% vs. 41%, p < 0.001). Although mothers with access to e-technologies had a longer median breastfeeding duration than those without home access to e-technologies (19 vs. 16 weeks, p = 0.02), adjusted hazard ratios for breastfeeding discontinuation (0.85; 95% CI, 0.60-1.21), overall satisfaction rates (73% vs. 67%, p = 0.19) and breastfeeding difficulties after discharge (58% vs. 61%, p = 0.60) were not different for the two groups. CONCLUSION A vast majority of breastfeeding mothers have home access to e-technologies in France. However, access to e-technologies was not independently associated with better breastfeeding outcomes in this study.
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Labarere J, Belle L, Fourny M, Genès N, Lablanche JM, Blanchard D, Cambou JP, Danchin N. Outcomes of Myocardial Infarction in Hospitals With Percutaneous Coronary Intervention Facilities. ACTA ACUST UNITED AC 2007; 167:913-20. [PMID: 17502532 DOI: 10.1001/archinte.167.9.913] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
BACKGROUND Despite evidence on the efficacy and safety of percutaneous coronary intervention (PCI) for patients with acute myocardial infarction, it is unclear whether patients admitted to hospitals with on-site PCI facilities (herein after, PCI hospitals) have improved outcomes in routine practice. METHODS We compared processes of care, hospital outcomes, and 1-year mortality rate for 1176 consecutive patients admitted to 126 PCI hospitals and 738 patients admitted to 190 non-PCI hospitals in France from November 1 to November 30, 2000. RESULTS Patients admitted to PCI hospitals were more likely to receive evidence-based acute (within 48 hours of admission) and discharge medications and to undergo PCI within 48 hours of admission than those admitted to non-PCI hospitals (54% vs 6.2%; P<.001). Despite comparable rates of in-hospital stroke (0.9% vs 1.1%; P=.75) and reinfarction (1.7% vs 2.5%; P=.25), patients admitted to PCI vs non-PCI hospitals had lower in-hospital (7.5% vs 12%; P=.001) and 1-year (13% vs 20%; P<.001) mortality rates. Admission to PCI hospitals was associated with decreased hazard ratios of mortality after adjusting for baseline characteristics (0.75; 95% confidence interval, 0.57-0.98) or propensity score (0.76; 95% confidence interval, 0.59-0.97). Most of the survival benefit of admission to a PCI hospital was explained by the use of PCI and evidence-based discharge medications. CONCLUSIONS In this prospective observational study, admission of patients with acute myocardial infarction to PCI hospitals was associated with greater use of PCI and evidence-based medications and with improved 1-year survival. Although we cannot exclude the possibility that some unmeasured confounding factors might explain the survival benefit of admission to PCI hospitals, our findings support routine use of PCI and evidence-based medications for these patients.
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Affiliation(s)
- Jose Labarere
- Techniques pour l'Evaluation et la Modélisation des Actions de Santé, Centre Hospitalier Universitaire, Grenoble, France.
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Labarere J, Stone RA, Obrosky DS, Yealy DM, Meehan TP, Fine JM, Graff LG, Fine MJ. Comparison of outcomes for low-risk outpatients and inpatients with pneumonia: A propensity-adjusted analysis. Chest 2007; 131:480-8. [PMID: 17296651 DOI: 10.1378/chest.06-1393] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Low-risk patients with community-acquired pneumonia are often hospitalized despite guideline recommendations for outpatient treatment. METHODS Using data from a randomized trial conducted in 32 emergency departments, we performed a propensity-adjusted analysis to compare 30-day mortality rates, time to the return to work and to usual activities, and patient satisfaction with care between 944 outpatients and 549 inpatients in pneumonia severity index risk classes I to III who did not have evidence of arterial oxygen desaturation, or medical or psychosocial contraindications to outpatient treatment. RESULTS After adjusting for quintile of propensity score for outpatient treatment, which eliminated all significant differences for baseline characteristics, outpatients were more likely to return to work (odds ratio [OR], 2.0; 95% confidence interval [CI], 1.5 to 2.6) or, for nonworkers, to usual activities (OR, 1.4; 95% CI, 1.1 to 1.8) than were inpatients. Satisfaction with the site-of-treatment decision (OR, 1.1; 95% CI, 0.7 to 1.8), with emergency department care (OR, 1.4; 95% CI, 0.9 to 1.9), and with overall medical care (OR, 1.1; 95% CI, 0.8 to 1.6) was not different between outpatients and inpatients. The overall mortality rate was higher for inpatients than outpatients (2.6% vs 0.1%, respectively; p < 0.01); the mortality rate was not different among the 242 outpatients and 242 inpatients matched by their propensity score (0.4% vs 0.8%, respectively; p = 0.99). CONCLUSIONS After adjusting for the propensity of site of treatment, outpatient treatment was associated with a more rapid return to usual activities and to work, and with no increased risk of mortality. The higher observed mortality rate among all low-risk inpatients suggests that physician judgment is an important complement to objective risk stratification in the site-of-treatment decision for patients with pneumonia.
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Affiliation(s)
- Jose Labarere
- Veterans Affairs Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, University Dr C, Building 28, 1A102, Pittsburgh, PA 15240, USA
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Debaty G, Belle L, Labarere J, Fourny M, Torres JP, Savary D, Usseglio P, Menthonnex E, Guenot O, Vanzetto G. [Evolution of strategies of revascularisation in acute coronary syndromes with ST elevation. Analysis of the data of RESURCOR]. Arch Mal Coeur Vaiss 2007; 100:105-11. [PMID: 17474495] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/15/2023]
Abstract
The aim of this study was to describe the changes in strategy of revascularisation in acute coronary syndromes with ST elevation (ACS ST+) since setting up a health care network. The authors analysed the incidence of coronary angioplasty and of intravenous thrombolysis from a prospective permanent hospital register of patients with ACS ST+ in the three Northern Alps departments from october 1st 2002 to december 31st 2004. Respectively, 171 patients were enrolled in 2002 and 675 in 2003, and 588 in 2004. The use of percutaneous coronary intervention increased (57, 69, and 78% in 2002, 2003, 2004, p< 0.01) in relation to the increased use of immediate secondary percutaneous coronary intervention (27, 36, 43%, p< 0.01) although the use of primary percutaneous coronary intervention did not changed (30, 33, 35%, p= 0.17). These results were observed in hospitals with and without Percutaneous Coronary Intervention facilities. An increase in prehospital (49, 67, 68%, p= 0.02) and hospital thrombolysis (48, 68, 73%, p= 0.03) was only observed in patients managed in institutions without Percutaneous Coronary Intervention facilities. The average delay to arterial punction (120. 124, 100 minutes, p< 0.01) and to intravenous thrombolysis (40, 30, 25 minutes, p< 0.01) decreased during the same period. Patients with ACS ST+ more commonly benefit from coronary revascularisation at increasingly shorter intervals to treatment. This would seem to be related to the better coordination of practitioners after the implantation of a health care network.
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Affiliation(s)
- G Debaty
- Service d'aide médicale urgente 38, centre hospitalier universitaire, Grenoble
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23
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Ferrier C, Belle L, Labarere J, Fourny M, Vanzetto G, Guenot O, Debaty G, Savary D, Machecourt J, François P. [Comparison of mortality according to the revascularisation strategies and the symptom-to-management delay in ST-segment elevation myocardial infarction]. Arch Mal Coeur Vaiss 2007; 100:13-9. [PMID: 17405549] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/14/2023]
Abstract
The aim of this study was to compare the mortality associated to primary angioplasty and thrombolysis in patients managed for an elevated ST-segment acute coronary syndrome in less than or more than 3 hours after the onset of symptoms. We analyzed the in-hospital mortality of 846 patients (including 276 [33%] treated by primary angioplasty, 511 [60%] by thrombolysis, and 59 [7%] without revascularisation) included from October 2002 to December 2003 in a registry of patients with an elevated ST-segment acute coronary syndrome managed in less than 12 hours in Northern Alps districts. The overall in-hospital mortality was at 6.0% (51/846). For the 631 managed in <3 hours, the mortality rates were respectively at 5.0%, 4.6% and 11.1% respectively in case of primary angioplasty, thrombolysis and without revascularisation (p=0.21). For the 215 patients with pain lasting more than 3 hours, the mortality rates were at 2.7%, 10.3% and 21.7% in case of primary angioplasty, thrombolysis and no revascularisation, respectively (p=0.01). In the multivariable analysis, the OR of death in case of thrombolysis compared to primary angioplasty was at 1.65 (95% IC: 0.73 - 3.75) for patients with pain " 3 hours, and 4.98 (95% IC: 1.32-18.37) for those with pain > 3 hours. These results are in line with randomized trials conclusions and confirm the international guidelines suggesting primary angioplasty for patients with a chest pain >3 hours and either angioplasty or thrombolysis in case of chest pain < 3 hours.
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Affiliation(s)
- C Ferrier
- Réseau des urgences corornariennes (RESURCOR), réseau nord-alpin des urgences
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Labarere J, Bosson JL, Pernod G. More on: incorrect use of thromboprophylaxis for venous thromboembolism in medical and surgical patients: results of a multicentric, observational, and cross-sectional study in Brazil. J Thromb Haemost 2006; 4:2737-8. [PMID: 16981888 DOI: 10.1111/j.1538-7836.2006.02215.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Labarere J, Bosson JL, Sevestre MA, Delmas AS, Dupas S, Thenault MH, Legagneux A, Boge G, Terriat B, Pernod G. Brief report: graduated compression stocking thromboprophylaxis for elderly inpatients: a propensity analysis. J Gen Intern Med 2006; 21:1282-7. [PMID: 16995891 PMCID: PMC1924758 DOI: 10.1111/j.1525-1497.2006.00623.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Graduated compression stockings (GCS) are often used for deep vein thrombosis prophylaxis in nonsurgical patients, although evidence on their effectiveness is lacking in this setting. OBJECTIVE To determine whether prophylaxis with GCS is associated with a decrease in the rate of deep vein thrombosis in nonsurgical elderly patients. METHODS Using original data from 2 multicenter nonrandomized studies, we performed multivariable and propensity score analyses to determine whether prophylaxis with GCS reduced the rate of deep vein thrombosis among 1,310 postacute care patients 65 years or older. The primary outcome was proximal deep vein thrombosis detected by routine compression ultrasonography performed by registered vascular physicians. RESULTS Proximal deep vein thrombosis was found in 5.7% (21/371) of the GCS users and in 5.2% (49/939) of the GCS nonusers (odds ratio [OR], 1.09; 95% confidence interval [CI], 0.64-1.84). Although adjusting for propensity score eliminated all differences in baseline characteristics between users and nonusers, the OR for proximal deep vein thrombosis associated with GCS remained nonsignificant in propensity-stratified (adjusted OR, 1.11; 95% CI, 0.59-2.10) and propensity-matched (conditional OR, 0.92; 95% CI, 0.42-2.02) analysis. Similar figures were observed for distal and any deep vein thrombosis. The rates of deep vein thrombosis did not differ according to the length of stockings. CONCLUSIONS Prophylaxis with GCS is not associated with a lower rate of deep vein thrombosis in nonsurgical elderly patients in routine practice. Randomized studies are needed to assess the efficacy of GCS when properly used in this setting.
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Affiliation(s)
- Jose Labarere
- ThEMAS TIMC-IMAG UMR CNRS 5525 UJF, Grenoble, France.
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Renaud B, Coma E, Labarere J, Hayon J, Roy PM, Boureaux H, Moritz F, Cibien JF, Guérin T, Carré E, Lafontaine A, Bertrand MP, Santin A, Brun-Buisson C, Fine MJ, Roupie E. Routine use of the Pneumonia Severity Index for guiding the site-of-treatment decision of patients with pneumonia in the emergency department: a multicenter, prospective, observational, controlled cohort study. Clin Infect Dis 2006; 44:41-9. [PMID: 17143813 DOI: 10.1086/509331] [Citation(s) in RCA: 77] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2006] [Accepted: 08/07/2006] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND Although the Pneumonia Severity Index (PSI) has been extensively validated, little is known of the impact of its routine use as an aid to site-of-treatment decisions for patients with pneumonia who present to emergency departments (EDs). METHODS A prospective, observational, controlled cohort study of patients with pneumonia was conducted in 8 EDs that used the PSI (PSI-user EDs) and 8 EDs that did not use the PSI (PSI-nonuser EDs) in France. The outcomes examined included the proportion of "low-risk" patients (PSI risk classes I-III) treated as outpatients, all-cause 28-day mortality, admission of inpatients to the intensive care unit, and subsequent hospitalization of outpatients. RESULTS Of the 925 patients enrolled in the study, 472 (51.0%) were treated at PSI-user EDs, and 453 (49.0%) were treated at PSI-nonuser EDs; 449 (48.5%) of all patients were considered to be at low risk. In PSI-user EDs, 92 (42.8%) of 215 patients at low risk were treated as outpatients, compared with 56 (23.9%) of 234 patients at low risk in PSI-nonuser EDs. The adjusted odds ratios for outpatient treatment were higher for patients in PSI risk classes I and II who were treated in PSI-user EDs, compared with PSI-nonuser EDs (adjusted odds ratio, 7.0 [95% confidence interval, 2.0-25.0] and 4.6 [95% confidence interval, 1.3-16.2], respectively), whereas the adjusted odds ratio did not differ by PSI-user status among patients in risk class III or among patients at high risk. After adjusting for pneumonia severity, mortality was lower in patients who were treated in PSI-user EDs; other safety outcomes did not differ between patients treated in PSI-user and PSI-nonuser EDs. CONCLUSIONS The routine use of the PSI was associated with a larger proportion of patients in PSI risk classes I and II who had pneumonia and who were treated in the outpatient environment without compromising their safety.
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Affiliation(s)
- Bertrand Renaud
- Department of Emergency Medicine, Centre Hospitalier Universtaire Henri Mondor, Créteil, France
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Sellier E, Labarere J, Bosson JL, Auvray M, Barrellier MT, Le Hello C, Belmin J, Le Roux P, Sevestre MA. Effectiveness of a Guideline for Venous Thromboembolism Prophylaxis in Elderly Post–Acute Care Patients. ACTA ACUST UNITED AC 2006; 166:2065-71. [PMID: 17060535 DOI: 10.1001/archinte.166.19.2065] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
BACKGROUND Thromboprophylaxis in elderly patients, including post-acute care patients, is at variance with scientific evidence. The purpose of this study was to determine whether a multifaceted intervention was followed by a decrease in deep venous thrombosis (DVT). METHODS A prospective preintervention-postintervention study was conducted in 1373 patients (preintervention phase, n = 709; postintervention phase, n = 664), aged 65 years or older, enrolled in 33 hospital-based post-acute care facilities in France. An evidence-based guideline addressing pharmacologic and mechanical prophylaxis was implemented through a multifaceted intervention. The main outcome measure was any DVT diagnosed at routine comprehensive ultrasonography performed by registered angiologists. RESULTS A DVT was found in 91 patients (12.8%) in the preintervention phase and in 52 patients (7.8%) in the postintervention phase (P = .002). The decrease in DVT involved the calf (7.1% vs 3.6%; P = .005) and the proximal venous segments (5.8% vs 4.2%; P = .18) and remained significant after adjusting for risk factors (adjusted odds ratio of any DVT, 0.58; 95% confidence interval, 0.39-0.86). Pharmacologic prophylaxis with either low-molecular-weight heparin at the high-risk dose, unfractionated heparin, and vitamin K antagonist was similar in the 2 study groups, whereas patients in the postintervention group were more likely to use graduated compression stockings (27.4% vs 34.6%; P = .004) and less likely to receive low-molecular-weight heparin at the low-risk dose (24.7% vs 18.5%; P = .006), which was not recommended by our guideline. CONCLUSIONS A multifaceted intervention addressing venous thromboembolism prophylaxis in post-acute care patients can be followed by a significant decrease in the rate of any DVT in elderly patients. More active interventions are needed to enforce compliance with evidence-based guidelines.
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Affiliation(s)
- Elodie Sellier
- Quality of Care Unit, University Hospital, and ThEMAS, TIMC-IMAG, National Center for Scientific Research (CNRS 5525
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Boyer L, Francois P, Doutre E, Weil G, Labarere J. Perception and use of the results of patient satisfaction surveys by care providers in a French teaching hospital. Int J Qual Health Care 2006; 18:359-64. [PMID: 16931825 DOI: 10.1093/intqhc/mzl029] [Citation(s) in RCA: 75] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE . The aim of this study was to assess clinical staff's opinions on the results of in-patient satisfaction surveys and their use within the quality improvement process. SETTING The institution is a 2200-bed teaching hospital of tertiary health care employing 8000 professionals. Patient satisfaction surveys are carried out each year using a validated questionnaire mailed to a random sample of patients. The specific results of each department are sent to the medical and paramedical managers. METHODS We conducted a questionnaire survey on 500 care providers randomly selected in every medical and surgical department. RESULTS A total of 261 questionnaires were returned and analysed. Overall, 94% of responders had a favourable opinion of the patient satisfaction surveys. They considered that the patient was able to judge hospital service quality, especially in its relational, organizational, and environmental dimensions. The specific results for the department were less well known than the overall hospital results (60 versus 76%). These results were formally discussed in the department according to 40% of responders; 40% declared that these data resulted in improvement actions and considered that they led to modifications in their behaviour with patients. CONCLUSIONS Despite a declared interest in satisfaction surveys, the results remain underused by hospital staff and insufficiently discussed within teams.
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Affiliation(s)
- Laurent Boyer
- Centre Hospitalier Grenoble, Unite d'Evaluation Medicale, Grenoble, France.
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Labarere J, Bosson JL, Sevestre MA, Boge G, Terriat B. Thromboprophylaxis with graduated compression stockings for elderly inpatients: more evidence is needed. J Thromb Haemost 2006; 4:1838-40. [PMID: 16879231 DOI: 10.1111/j.1538-7836.2006.02040.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Sellier E, Labarere J, Sevestre MA, Auvray M, Le Hello C, Barrellier MT, Belmin J, le Roux P, Bosson JL. P11-11 - Réduction des thromboses veineuses profondes chez les patients hospitalisés en services de soins de suite après implantation multifacette de recommandations pour la pratique clinique. Rev Epidemiol Sante Publique 2006. [DOI: 10.1016/s0398-7620(06)76951-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
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Labarere J, Stone RA, Scott Obrosky D, Yealy DM, Meehan TP, Auble TE, Fine JM, Graff LG, Fine MJ. Factors associated with the hospitalization of low-risk patients with community-acquired pneumonia in a cluster-randomized trial. J Gen Intern Med 2006; 21:745-52. [PMID: 16808776 PMCID: PMC1924717 DOI: 10.1111/j.1525-1497.2006.00510.x] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2005] [Revised: 01/24/2006] [Accepted: 03/10/2006] [Indexed: 11/28/2022]
Abstract
BACKGROUND Many low-risk patients with pneumonia are hospitalized despite recommendations to treat such patients in the outpatient setting. OBJECTIVE To identify the factors associated with the hospitalization of low-risk patients with pneumonia. METHODS We analyzed data collected by retrospective chart review for 1,889 low-risk patients (Pneumonia Severity Index [PSI] risk classes I to III without evidence of arterial oxygen desaturation) enrolled in a cluster-randomized trial conducted in 32 emergency departments. RESULTS Overall, 845 (44.7%) of all low-risk patients were treated as inpatients. Factors independently associated with an increased odds of hospitalization included PSI risk classes II and III, the presence of medical or psychosocial contraindications to outpatient treatment, comorbid conditions that were not contained in the PSI (cognitive impairment, history of coronary artery disease, diabetes mellitus, or pulmonary disease), multilobar radiographic infiltrates, and home therapy with oxygen, corticosteroids, or antibiotics before presentation. While 32.8% of low-risk inpatients had a contraindication to outpatient treatment and 47.1% had one or more preexisting treatments, comorbid conditions, or radiographic abnormalities not contained in the PSI, 20.1% had no identifiable risk factors for hospitalization other than PSI risk class II or III. CONCLUSIONS Hospital admission appears justified for one-third of low-risk inpatients based upon the presence of one or more contraindications to outpatient treatment. At least one-fifth of low-risk inpatients did not have a contraindication to outpatient treatment or an identifiable risk factor for hospitalization, suggesting that treatment of a larger proportion of such low-risk patients in the outpatient setting could be achieved without adversely affecting patient outcomes.
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Affiliation(s)
- Jose Labarere
- VA Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA 15240, USA.
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Belle L, Labarere J, Meunier O, Amon V, Fourny M, Bouvaist H, Guenot O, Hugon V, Broin P, Fromage P, Haddad C, François P. [Factors associated with early invasive strategy in patients with acute coronary syndrome. A multicenter study]. Ann Cardiol Angeiol (Paris) 2006; 55:39-48. [PMID: 16457035 DOI: 10.1016/j.ancard.2005.09.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/06/2023]
Abstract
OBJECTIVES To identify the factors associated with early cardiac catheterization in patients with a non ST-segment elevation acute coronary syndrome. METHODS We analyzed data collected by retrospective chart review for 208 patients presenting at seven French hospitals with an acute coronary syndrome (chest pain at rest within 24 h prior to presentation with positive cardiac markers and/or electrocardiographic changes) between January and March 2005. RESULTS Eighty-seven patients (42%) were first admitted to hospitals with cardiac catheterization facilities. One hundred ten patients (53%, 95% confidence interval [95% CI], 46-60) underwent early cardiac catheterization less than 48 h following presentation. In addition to presentation at hospitals with catheterization facilities, factors independently associated with early catheterization included positive cardiac markers in patients first admitted to hospitals without catheterization facilities (adjusted odds ratio [aOR] 34.5, 95% CI, 4.4-268.0) and diabetes mellitus (aOR, 0.4, 95%CI, 0.2-0.9). With the exception of positive cardiac markers, no risk factors comprising the TIMI risk score were associated with increased odds of early cardiac catheterization. During the index hospital stay, six patients (3%) died, seven patients (3%) had pulmonary edema, three patients (1%) had major or minor bleeding, and none had ST segment elevation myocardial infarction. CONCLUSION Despite the dissemination of international guidelines, the use of early cardiac catheterization remains related to initial presentation at hospitals with catheterization facilities rather than risk assessment in patients with a non ST-segment elevation acute coronary syndrome.
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Affiliation(s)
- L Belle
- Réseau des urgences coronariennes (RESURCOR), réseau nord-alpin des urgences, centre hospitalier de la région d'Annecy, BP 2333, 74011 Annecy, France.
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Belle L, Labarere J, Fourny M, Cambou JP, Danchin N. [Variations in the management of patients with acute myocardial infarction in alpine hospitals compared to other French hospitals. Secondary analysis of the USIC 2000 study data]. Ann Cardiol Angeiol (Paris) 2005; 54:310-6. [PMID: 17183825 DOI: 10.1016/j.ancard.2005.05.020] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/13/2023]
Abstract
OBJECTIVE To compare processes of care for acute myocardial infarction among patients admitted to alpine vs other French hospitals. METHODS Prospective observational study of patients with ST-elevation and non ST-elevation myocardial infarction of less than 48 hours hospitalized in 369 intensive care units in November 2000. RESULTS Fifty-five patients were enrolled in nine alpine hospitals and 2265 patients in 360 other French hospitals. Patients baseline characteristics did not differ between the two groups with the exception of ST-elevation myocardial infarction which was less frequent in patients admitted to alpine hospitals (71 vs. 83%, P = 0.02). Patients living in the alpine area were less likely to be admitted to hospitals with on-site cardiac catheterization facilities (42 vs. 60%, P < 0.01) although the use of primary (20%) and rescue (24%) percutaneous coronary intervention did not differ significantly between the two groups. There were no differences in the use of medical treatments between the two groups with the exception of low-molecular-weight heparin. The risk of in-hospital death and complications did not differ significantly between the two groups while the risk of death at one year was lower in patients admitted to alpine hospitals (5 vs. 16%, P = 0.04). CONCLUSION In 2000, a lower proportion of patients living in the alpine area had access to hospitals with cardiac catheterization facilities compared to other French patients. This finding supports the creation of an additional cardiac catheterization laboratory with experienced operators performing percutaneous coronary interventions 24 hours/7 days and the implementation of an emergency medical care network for acute coronary syndromes in the alpine area.
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Affiliation(s)
- L Belle
- Réseau des urgences coronariennes (Resurcor), réseau nord-alpin des urgences, centre hospitalier de la région d'Annecy, Annecy, France.
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Sevestre MA, Labarere J, Brin S, Carpentier P, Constans J, Degeilh M, Deslandes B, Elgrishi I, Lanoye P, Laroche JP, Le Roux P, Pichot O, Quéré I, Bosson JL. Optimisation de l’interrogatoire dans l’évaluation du risque de maladie thromboembolique veineuse : l’étude OPTIMEV. ACTA ACUST UNITED AC 2005; 30:217-27. [PMID: 16292199 DOI: 10.1016/s0398-0499(05)88206-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
UNLABELLED Venous thromboembolism (VTE) is a frequent disease and remains a major cause of mortality and morbidity among our patients. During the 20 past years, clinical description, diagnostic tools, and treatment have changed dramatically. Most published data describing risk factors for VTE no longer apply to the patients seen in daily practice. We present here the rationale, aims, and methodology of the OPTIMEV Study (OPTimisation de l'Interrogatoire pour la Maladie thromboEmbolique Veineuse). RATIONALE Risk factors for VTE are numerous, complex and interactions between them and their clinical importance is difficult to measure (table I). For example, odds ratios for VTE recurrence vary greatly across longitudinal studies. We searched the National Library of Medecine (PubMed) and the Amedeo website using the following keywords: "venous thromboembolism", "pulmonary embolism", "deep vein thrombosis", "risk factors". We selected 84 relevant articles published between 1972 and 2005. Based on this literature analysis, we identified the following major risk factors: VTE recurrence, surgery, cancer, immobilization, age, biological factors. For these factors, data are lacking and some questions are proposed. OBJECTIVES The broad objective of the study is to better evaluate clinical risk factors that fit today's practice against VTE. Specific aims are: 1) to determine whether risk factors are different between proximal and distal deep vein thrombosis (DVT); 2) to develop and prospectively validate a new prediction rule for outpatients. The primary hypothesis is that careful assessment of VTE recurrence, adequate surgical thromboprophylaxis, cancer staging, and varicose vein stratification according to the CEAP classification, is mandatory for accurate evaluation of thromboembolic disease risk. METHODS We conducted a multicenter, prospective, cohort study of 10000 patients. Enrollees are inpatients and outpatients presenting with a clinical suspicion of VTE in Emergency Departments and outpatient clinics in France. 4173 patients have been enrolled at this time (Figure 2). All eligible patients are enrolled during a selected period of time through different seasons. Data are collected by physicians in charge of the patients using an electronic case recording form. Collected data include baseline characteristics, risk factors, results of diagnostic investigations. Outcome measures obtained through telephone interview at 3 and 12 months include cancer diagnosis, VTE recurrence, haemorrhagic events, treatments, death. Univariate and multivariate analysis will be performed using multilevel logistic regression. The study organization is performed by the Centre d'Investigation Clinique de Grenoble and is sponsored by the French Society of Vascular Medicine. First results, to be published in 2006, will allow development of new prediction rules for VTE diagnosis.
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Affiliation(s)
- M A Sevestre
- Conseil Scientifique D'OPTIMEV, CHU Grenoble, 38043 Grenoble.
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Labarere J, Gelbert-Baudino N, Ayral AS, Duc C, Berchotteau M, Bouchon N, Schelstraete C, Vittoz JP, Francois P, Pons JC. Efficacy of breastfeeding support provided by trained clinicians during an early, routine, preventive visit: a prospective, randomized, open trial of 226 mother-infant pairs. Pediatrics 2005; 115:e139-46. [PMID: 15687421 DOI: 10.1542/peds.2004-1362] [Citation(s) in RCA: 139] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Despite growing evidence of the benefits of prolonged breastfeeding for mother and infant health, the rate of breastfeeding at infant age of 6 months remains below the Healthy People 2010 goal. The greatest decrease in the breastfeeding rate occurs during the first 4 postpartum weeks. Mothers who discontinue breastfeeding early are more likely to report lack of confidence in their ability to breastfeed, problems with the infant latching or suckling, and lack of individualized encouragement from their clinicians in the early postdischarge period. Observational studies suggest that primary care physicians can increase breastfeeding rates through specific advice and practices during routine preventive visits. However, robust scientific evidence based on randomized, controlled trials is currently lacking. OBJECTIVE The purpose of this study was to determine whether attending an early, routine, preventive, outpatient visit delivered in a primary care physician's office would improve breastfeeding outcomes. DESIGN The study was a prospective, randomized, parallel-group, open trial. SETTING Participants were recruited at a level 3 maternity facility, with an average of 2000 births per year, in France. PARTICIPANTS A total of 231 mothers who had delivered a healthy singleton infant (gestational age: > or =37 completed weeks) and were breastfeeding on the day of discharge were recruited and randomized (116 were assigned to the intervention group and 115 to the control group) between October 1, 2001, and May 31, 2002; 226 mother-infant pairs (112 in the intervention group and 114 in the control group) contributed data on outcomes. INTERVENTION Support for breastfeeding in the control group included the usual verbal encouragement provided by the maternity ward staff members, a general health assessment and an evaluation for evidence of successful breastfeeding behavior by the pediatrician working in the obstetrics department on the day of discharge, provision of the telephone number of a peer support group, mandatory routine, preventive, outpatient visits at 1, 2, 3, 4, 5, and 6 months of infant age, and 10 weeks of paid maternity leave (extended to 18 weeks after the birth of the third child). In addition to the usual predischarge and postdischarge support, the mothers in the intervention group were invited to attend an individual, routine, preventive, outpatient visit in the office of 1 of the 17 participating primary care physicians (pediatricians or family physicians) within 2 weeks after the birth. The participating physicians received a 5-hour training program on breastfeeding, delivered in 2 parts in 1 month, before the beginning of the study. OUTCOME MEASURES The primary outcome was the prevalence of exclusive breastfeeding reported at 4 weeks (defined as giving maternal milk as the only food source, with no other foods or liquids, other than vitamins or medications, being given). The secondary outcomes included any breastfeeding reported at 4 weeks, breastfeeding duration, breastfeeding difficulties, and satisfaction with breastfeeding experiences. Classification into breastfeeding categories reported at 4 weeks was based on 24-hour dietary recall. RESULTS Ninety-two mothers (79.3%) assigned to the intervention group and 8 mothers (7.0%) assigned to the control group reported that they had attended the routine, preventive, outpatient visit in the office of 1 of the 17 primary care physicians participating in the study. Mothers in the intervention group were more likely to report exclusive breastfeeding at 4 weeks (83.9% vs 71.9%; hazard ratio: 1.17; 95% confidence interval [CI]: 1.01-1.34) and longer breastfeeding duration (median: 18 weeks vs 13 weeks; hazard ratio: 1.40; 95% CI: 1.03-1.92). They were less likely to report any breastfeeding difficulties (55.3% vs 72.8%; hazard ratio: 0.76; 95% CI: 0.62-0.93). There was no significant difference between the 2 groups with respect to the rate of any breastfeeding at 4 weeks (89.3% vs 81.6%; hazard ratio: 1.09; 95% CI: 0.98-1.22) and the rate of mothers fairly or very satisfied with their breastfeeding experiences (91.1% vs 87.7%; hazard ratio: 1.04; 95% CI: 0.95-1.14). CONCLUSIONS Although we cannot exclude the possibility that findings might differ in other health care systems, this study provides preliminary evidence of the efficacy of breastfeeding support through an early, routine, preventive visit in the offices of trained primary care physicians. Our findings also suggest that a short training program for practicing physicians might contribute to improving breastfeeding outcomes. Multifaceted interventions aiming to support breastfeeding should involve primary care physicians.
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Affiliation(s)
- Jose Labarere
- Quality of Care Unit, Grenoble University Hospital, Grenoble, France.
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Abstract
BACKGROUND Training programs are commonly viewed as an effective way to improve breastfeeding-related practices of health professionals. The objective of this study was to determine whether a 3-day training program for maternity ward professionals was followed by an increase in duration of any breastfeeding. METHODS A before-and-after study was conducted involving two retrospective random samples of 308 mothers who had delivered a healthy singleton infant of 37 weeks' or more gestation and 2,500 g or more birthweight in a level 3 maternity ward in a university hospital in France. Data were gathered from medical records and postal questionnaire. RESULTS Study participants included 169 mothers (54.9%) in the pre-intervention sample and 178 (57.8%) in the post-intervention sample. The prevalence of any breastfeeding at birth was 77.5 percent (70.5%-83.6%) in the pre-intervention sample and 82.6 percent (76.2%-87.8%) in the post-intervention sample(p=0.24); the median duration of any breastfeeding was 13 weeks and 16 weeks, respectively(chi2 log-rank test=5.8, p=0.02). The decreased risk of weaning in the post-intervention sample persisted after adjustment for baseline characteristics (adjusted hazard ratio=0.70 [0.54-0.91]). It was paralleled by significant improvement in maternity ward practices that are known to affect the duration of breastfeeding. CONCLUSION An intensive 3-day training program for maternity ward professionals can be followed by a significant but moderate increase in the duration of any breastfeeding. Multifaceted interventions involving prenatal components and community support should be planned in Western countries with low to intermediate prevalence of breastfeeding.
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Labarere J, Bosson JL, Brion JP, Fabre M, Imbert B, Carpentier P, Pernod G. Validation of a clinical guideline on prevention of venous thromboembolism in medical inpatients: a before-and-after study with systematic ultrasound examination. J Intern Med 2004; 256:338-48. [PMID: 15367177 DOI: 10.1111/j.1365-2796.2004.01365.x] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Clinical practice guidelines on prevention of venous thromboembolism in medical inpatients have been implemented in various settings, although few studies have assessed their impact on venous thromboembolism events. OBJECTIVE To determine whether the implementation of a locally developed guideline is followed by changes in the rate of deep vein thrombosis. DESIGN A before-and-after study consisting in two "1-day" cross-sectional studies. SETTING Thirteen adult medical wards in a teaching hospital in France. SUBJECTS All the patients hospitalized on the day of the cross-sectional study. INTERVENTION A clinical guideline integrating scientific evidence and data on target medical providers' practices was developed by a local expert panel and implemented through a multifaceted intervention. MEASUREMENTS Prevalence of deep vein thrombosis detected by systematic ultrasound examination. RESULTS The study included 338 patients in the preintervention sample and 340 in the postintervention sample. The prevalence of deep vein thrombosis decreased from 9.5% (95% CI, 6.6-13.1) in the preintervention sample to 3.2% (95% CI, 1.6-5.7) in the postintervention sample (P < 0.01). The decrease in the rate of thrombosis involved all deep veins of the lower limbs and remained significant after adjustment for risk factors (adjusted odds ratio = 0.47, 95% CI, 0.32-0.70). No additional cases of pulmonary embolism or deep vein thrombosis were reported either on the day of the study or in the following 2 days. CONCLUSIONS Active implementation of a clinical practice guideline directed at medical providers (doctors, nurses and physical therapists) can be followed by a significant decrease in prevalence of deep vein thrombosis.
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Affiliation(s)
- J Labarere
- Unite d'Evaluation Medicale, Pavillon D, Centre Hospitalier Universitaire de Grenoble, 38-043 Grenoble Cedex 9, France.
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Bosson JL, Labarere J, Sevestre MA, Belmin J, Beyssier L, Elias A, Franco A, Le Roux P. Deep Vein Thrombosis in Elderly Patients Hospitalized in Subacute Care Facilities. ACTA ACUST UNITED AC 2003; 163:2613-8. [PMID: 14638561 DOI: 10.1001/archinte.163.21.2613] [Citation(s) in RCA: 67] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
BACKGROUND The efficacy of venous thromboembolism prophylaxis has not been established, to our knowledge, in elderly patients hospitalized in subacute care facilities. OBJECTIVES To describe risk factors and physician practices in the prevention of venous thromboembolism and to estimate the prevalence of deep vein thrombosis. METHODS A multicenter cross-sectional study was conducted in the subacute care departments of 36 French hospitals. The study population included 852 inpatients older than 64 years. Systematic ultrasound examination was performed by angiologists. RESULTS Of the 852 inpatients, 178 (20.9%; 95% confidence interval [CI], 18.2%-23.8%) had 3 or more risk factors other than age, while 144 patients (16.9%; 95% CI, 14.4%-19.6%) had none. The rate of prophylactic anticoagulant treatment was 56.1%, ranging from 20.0% to 86.9%, depending on the department. In multivariate analysis, prophylaxis use was associated with acute immobilization (odds ratio [OR], 4.17; 95% CI, 2.48-7.01), chronic immobilization (OR, 3.19; 95% CI, 2.22-4.60), major surgical procedure (OR, 6.81; 95% CI, 4.26-10.88), and congestive heart failure (OR, 1.65; 95% CI, 1.02-2.67). Prophylaxis use was low in patients who had cancer (OR, 0.49; 95% CI, 0.29-0.84) or myocardial infarction (OR, 0.39; 95% CI, 0.14-1.00). It was not significantly associated with paralytic stroke or history of venous thromboembolism. Deep vein thrombosis was detected in 135 patients (15.8%; 95% CI, 13.4%-18.5%): 50 (5.9%; 95% CI, 4.4%-7.7%) had proximal vein thrombosis and 85 (10.0%; 95% CI, 8.0%-12.2%) had calf vein thrombosis. CONCLUSIONS The prevalence of deep venous thrombosis is high in these patients, despite wide use of prophylaxis. Further prospective studies assessing the clinical benefit of extended duration prophylaxis are needed in elderly patients hospitalized in subacute care settings.
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Affiliation(s)
- Jean-Luc Bosson
- Centre d'Investigation Clinique, Centre Hospitalier Universitaire-BP 217, 38043 Grenoble CEDEX 9, France.
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Labarere J, Bellin V, Fourny M, Gagnaire JC, Francois P, Pons JC. Assessment of a structured in-hospital educational intervention addressing breastfeeding: a prospective randomised open trial. BJOG 2003; 110:847-52. [PMID: 14511968] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/27/2023]
Abstract
OBJECTIVE To determine whether a single one-to-one in-hospital education session could increase the rate of breastfeeding at 17 weeks. DESIGN A prospective, randomised, parallel group, open trial. SETTING A level two maternity hospital in France. SAMPLE Breastfeeding mothers who were employed outside the home prenatally and were delivered of a healthy singleton. INTERVENTION A structured one-to-one in-hospital education session. METHODS One hundred and six mother-infant pairs were allocated to the intervention group and 104 to the control group (receiving usual verbal encouragement). A total of 93 mother-infant pairs in the intervention group and 97 in the control group provided complete data for final evaluation of efficacy. MAIN OUTCOME MEASURE Rate of breastfeeding at infant age of 17 weeks. RESULTS There was no significant difference between the two groups in the rate of any breastfeeding (34.4% in the intervention group vs 40.2% in the control group, relative risk = 0.86 [0.52-1.40]), and in the rate of exclusive breastfeeding (14.0% in the intervention group vs 14.4% in the control group, relative risk = 0.97 [0.42-2.22]). CONCLUSION Our findings suggest that a single in-hospital educational intervention has no effect on the breastfeeding rate at four months. Guidance provided by maternity staff should be reinforced by a long term multifaceted support programme in countries with a low to intermediate rate of breastfeeding.
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Affiliation(s)
- Jose Labarere
- Quality of Care Unit, Grenoble University Hospital, Pavillon D Villars, CHU-BP 217, 38 043 Grenoble cedex 9, France
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Labarere J, Bellin V, Fourny M, Gagnaire JC, Francois P, Pons JC. Assessment of a structured in-hospital educational intervention addressing breastfeeding: a prospective randomised open trial. BJOG 2003. [DOI: 10.1111/j.1471-0528.2003.02539.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Abstract
OBJECTIVES To estimate whether a 3-day training program for health professionals was followed by changes in maternity ward practices and in the rate of exclusive breastfeeding. METHODS A retrospective study in the maternity ward of a French university hospital involved two cross-sectional samples of 323 mother-infant pairs in 1997 and 324 in 2000. RESULTS The rate of exclusive breastfeeding at discharge increased from 15.8% (12.0-20.2) in the before sample to 35.2% (30.0-40.6) in the after sample (P<0.01). This result persisted in the multivariable analysis [adjusted odds ratio, 2.74 (1.72-4.37)]. Infants in the before sample were less likely to be breastfed within 1 h of birth (9.2% vs. 16.9%, P=0.01), to room-in 24 h/day (56.6% vs. 72.6%, P<0.01), and were more likely to receive formula supplementation (77.6% vs. 54.0%, P<0.01). CONCLUSIONS A training program for health professionals can be effective in improving maternity ward practices and increasing exclusive breastfeeding rate at discharge.
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Affiliation(s)
- J Labarere
- Unité d'évaluation médicale, Hôpital Nord, Centre Hospitalier Universitaire de Grenoble, Grenoble, France.
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François P, Bertrand D, Labarere J, Fourny M, Calop J. Evaluation of a program to improve the prescription-writing quality in hospital. Int J Health Care Qual Assur Inc Leadersh Health Serv 2002; 14:268-74. [PMID: 11729624 DOI: 10.1108/09526860110404248] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
This paper aims to evaluate the effectiveness of a program designed to improve the quality of drug prescription-writing at a university hospital in France. Improvement actions included feed-back from yearly audits and the dissemination of recommendations on how best to write the prescriptions. A random sample of 30 stays was selected from among the hospitalizations for the year 1996. From each patient, medical records were searched for the first prescription order of the stay and its quality was assessed according to standards. A total of 872 records were relevant and included 3,289 medications. The results were compared to those obtained for the two previous years. Actions to sensitize prescribers resulted in an insufficient improvement of most indicators of prescription-writing quality with results remaining well below ideal standards. The hospital staff concerned had a positive opinion of the program which led to an awareness of prescription problems. This assessment showed that the program had a moderate impact on prescribers' practice and efforts must be continued.
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Affiliation(s)
- P François
- Laboratoire GPSP, Université Joseph Fourier, Grenoble, France
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Abstract
OBJECTIVE To develop a brief French-language, generic, self-administered questionnaire to measure inpatient satisfaction. DESIGN Issues relevant to patients were identified using three open-ended questions designed in accordance with the disconfirmation paradigm. The content of patients' responses was analysed and then supplemented by items taken from published instruments in order to generate a pool of 93 items. Twenty-nine items were selected following a strict procedure. Content validity was judged by comparing the questionnaire to existing instruments. Construct validity was supported by testing specific hypotheses derived from the literature and by performing principal component analysis. Reliability was estimated by calculating Cronbach's alpha. SETTING A 2200-bed French teaching hospital. SUBJECTS A mail survey was carried out on a random sample of 1000 inpatients within 2-4 weeks of discharge. Eligible subjects were medical, surgical and obstetrics inpatients who had stayed in the hospital for more than 24 hours. RESULTS The participation rate (71%) and the completion rate (95%) were indicators of acceptability. There were modest differences between the questionnaire and published instruments (financial aspects, amenities). Construct representation by principal component analysis consisted of six scales which accounted for 58% of the variance in total satisfaction scores. The reliability estimates of internal consistency ranged from 0.67 to 0.86. CONCLUSION We propose that the self-administered multidimensional inpatient satisfaction questionnaire provided encouraging preliminary psychometric information. This instrument is intended to involve patient feedback in a continuous quality health care improvement strategy.
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Affiliation(s)
- J Labarere
- Unité d'évaluation, Centre Hospitalier Universitaire, Grenoble, France.
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Bertrand D, Labarere J, François P. [Effectiveness of a program for improving drug prescriptions and hospitalization reporting at a university hospital]. Sante Publique 1999; 11:343-55. [PMID: 10667060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/15/2023]
Abstract
OBJECTIVES To evaluate the effectiveness of a method for improving the quality of care applied to the formulation of medical prescriptions and to the release of hospitalisation reports. The actions comprised the diffusion of results of audits and recommendations of good practice. METHODS For each of the 41 services, 30 visits from 1996 were selected at random. 3289 prescriptions and 1067 correspondence files were analyzed. The results were compared to those obtained from the previous two years. RESULTS Patient identification was complete in 44% of prescriptions, the identification of the prescribing doctor and his signature were present in 62% and 19% of cases respectively. 37% of medicines included all information. 7 indicators out of 12 for the quality of prescriptions improved (p < 0.0001). Files were found for 83% of hospital visits and 56% were sent (released) within a week. The practitioner was identified in 79% of cases, the main diagnosis in 96% and the treatment in 65% of cases. Five out of nine indicators of the quality of correspondence improved (p < 0.01). For each theme, the number of indicators improving was similar (p > 0.05). The services that improved for one theme didn't necessarily improve for the second (p > 0.05). DISCUSSION The evaluation of the programme, based on a strategy of quality assurance, shows modest progress. Given that the improvement of two themes for a given service are not correlated, the programme appears to sensitise professionals at an individual level rather than collectively. However, this programme is an important step for introducing a mode of continued improvement of quality.
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Affiliation(s)
- D Bertrand
- Service d'Information et Informatique Médicales, CHU de Grenoble
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Barroso G, Blesa S, Labarere J. Wide Distribution of Mitochondrial Genome Rearrangements in Wild Strains of the Cultivated Basidiomycete Agrocybe aegerita. Appl Environ Microbiol 1995; 61:1187-93. [PMID: 16534984 PMCID: PMC1388402 DOI: 10.1128/aem.61.4.1187-1193.1995] [Citation(s) in RCA: 24] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
We used restriction fragment length polymorphisms to examine mitochondrial genome rearrangements in 36 wild strains of the cultivated basidiomycete Agrocybe aegerita, collected from widely distributed locations in Europe. We identified two polymorphic regions within the mitochondrial DNA which varied independently: one carrying the Cox II coding sequence and the other carrying the Cox I, ATP6, and ATP8 coding sequences. Two types of mutations were responsible for the restriction fragment length polymorphisms that we observed and, accordingly, were involved in the A. aegerita mitochondrial genome evolution: (i) point mutations, which resulted in strain-specific mitochondrial markers, and (ii) length mutations due to genome rearrangements, such as deletions, insertions, or duplications. Within each polymorphic region, the length differences defined only two mitochondrial types, suggesting that these length mutations were not randomly generated but resulted from a precise rearrangement mechanism. For each of the two polymorphic regions, the two molecular types were distributed among the 36 strains without obvious correlation with their geographic origin. On the basis of these two polymorphisms, it is possible to define four mitochondrial haplotypes. The four mitochondrial haplotypes could be the result of intermolecular recombination between allelic forms present in the population long enough to reach linkage equilibrium. All of the 36 dikaryotic strains contained only a single mitochondrial type, confirming the previously described mitochondrial sorting out after cytoplasmic mixing in basidiomycetes.
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Labarere J, Barroso G. Ultraviolet irradiation mutagenesis and recombination in Spiroplasma citri. Isr J Med Sci 1984; 20:826-9. [PMID: 6511358] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
A method for obtaining and screening uv-induced mutants from Spiroplasma citri is described. Lethality response curves showed that S. citri is more sensitive to uv irradiation than are other microorganisms. The presence of a shoulder in the lethality response curve showed the existence of systems able to repair uv-induced DNA damages. Toxic-resistant mutants have been obtained. A uv fluence equal to 10 J/m2 multiplied by 2.5 X 10(3) gave the spontaneous mutation frequency. Arsenic acid- and xylitol-resistant mutants were used to investigate transfer of genetic information in S. citri. After 90 min of incubation, the recombination frequency was 5 X 10(-5).
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Labarere J, Bernet J. A Pleiotropic Mutation Affecting Protoperithecium Formation and Ascospore Outgrowth in Podospora anserina. ACTA ACUST UNITED AC 1979. [DOI: 10.1099/00221287-113-1-19] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Labarere J, Bernet J. A Mutation Inhibiting Protoplasmic Incompatibility in Podospora anserina that Suppresses an Extracellular Laccase and Protoperithecium Formation. ACTA ACUST UNITED AC 1978. [DOI: 10.1099/00221287-109-1-187] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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