[ISO 9001: 2015 certification of all research activities of a university hospital center]

INTRODUCTION

In France, the number of hospitals involved in clinical research and committed to a quality approach is increasing. The objective of such approaches is to ensure the safety of patients involved in research projects by improving quality.

OBJECTIVE

The University Hospital of Amiens has chosen to certify all its clinical research activities in the same scope according to the ISO 9001: 2015 standard.

METHODS

Action planning has been established and a head of quality management has been appointed to oversee this process.

RESULTS

The activities in the five departments of our university hospital jointly certified in December 2019, are: activities related to internal and external sponsors, as well as methodology and monitoring of clinical research projects conducted in the Clinical Research and Innovation Department (CRID); help with clinical research investigations in the Clinical Research Center (CRC); management of the pathway of therapeutic units used in clinical research (excluding the manufacture of drugs) in the Clinical Trials Unit (CTU) of the Hospital Pharmacy; the conservation and provision of biological resources (tissues and fluids) for cancer research in the Tumor bank of Picardy; the collection, reception, preparation, quality control, conservation and provision of biological resources for research purposes. These activities fall within the framework of legal and regulatory activities and the provision of secure storage in the Biological Resources Center already ISO 9001 certified since 2004 and NF S96-900: 2011 certified since 2009.

CONCLUSIONS

The choice of a common quality approach has brought together more than 70 persons from 5 departments involved in clinical research projects within a single certificate with the aim of continuous improvement.

Unresectable hepatocellular carcinoma at dawn of immunotherapy era: real-world data from the French prospective CHIEF cohort

BACKGROUND AND OBJECTIVES

Hepatocellular carcinoma epidemiological data are limited in France. The Epidemio Liver Immunotherapy Tecentriq outcome research (ELITor) retrospective study, based on real-world data from the Carcinome HépatocellulaIrE en France (CHIEF) French cohort of hepatocellular carcinoma patients, aimed to get insight into the treatment patterns, the sociodemographic, clinical, biological, and etiological characteristics, and the quality of life of patients with unresectable hepatocellular carcinoma.

METHODS AND RESULTS

Between 1 September 2019 and 4 December 2020, 367 patients from the CHIEF cohort received at least one locoregional (52.8%) chemoembolization or radioembolization or systemic treatment (88.3%) and were selected for ELITor. Most patients had a Barcelona Clinic Liver Cancer (BCLC) C (93.2%) hepatocellular carcinoma stage and were affected by cirrhosis (67.7%). Alcohol was confirmed as the main etiology both as a single etiology (29.1%) and in association with other risk factors (26.9%), mainly metabolic disorders (16.2%).Tyrosine-kinase inhibitors, mainly sorafenib, were the most administered systemic treatments in first line. Patients who received at least one combination of atezolizumab and bevacizumab during the study period ( N  = 53) had a better performance status and less portal hypertension frequency than the overall population and more hepatitis B virus infection and fewer metabolic disorders as single etiology. Overall, the global health score before treatment (62.3 ± 21.9) was in line with that of reference cancer patients and worsened in 51.9% of the cases after first-line palliative-intent treatment.

CONCLUSION

This study provided real-life data on advanced hepatocellular carcinoma characteristics and treatment patterns and described the first patients to receive the atezolizumab-bevacizumab combination before it became the new standard of care for advanced hepatocellular carcinoma.

Occupational exposures in the rubber tire industry and risk of cancer: a systematic review

OBJECTIVE

This study aimed at investigate the association between cancer and the rubber tire industry using indicators used to estimate exposure, such as duration or historical time period of exposure.

METHODS

A systematic review using MEDLINE was carried out. The Preferred Reporting Items for Systematic Reviews (PRISMA) statement guided the systematic review. The Risk of Bias in Non-Randomized Studies of Exposures (ROBINS-E) was used to analyze biases in the selected studies.

RESULTS

A total of 240 articles were initially selected. Of these, 17 were included in this systematic review of 15 different cohorts and one case-control study. Five cohorts were composed of rubber industry employees including some who worked in the rubber tire industry, whereas the other 10 cohorts were composed exclusively of rubber tire industry employees. An increased risk of lung/respiratory cancer is possible in the oldest time periods without duration of exposure showing any association according to the analysis. The work areas of mixing and milling as well as compounding seem to be more specifically associated with this risk, which could be expected because of the exposure to fumes containing carcinogenic agents.

CONCLUSIONS

Having worked in the rubber tire industry in the past, especially in milling, mixing as well as compounding may be associated with an increased risk of lung/respiratory cancer.

Global survival trends for brain tumors, by histology: analysis of individual records for 556,237 adults diagnosed in 59 countries during 2000-2014 (CONCORD-3)

BACKGROUND

Survival is a key metric of the effectiveness of a health system in managing cancer. We set out to provide a comprehensive examination of worldwide variation and trends in survival from brain tumors in adults, by histology.

METHODS

We analyzed individual data for adults (15-99 years) diagnosed with a brain tumor (ICD-O-3 topography code C71) during 2000-2014, regardless of tumor behavior. Data underwent a 3-phase quality control as part of CONCORD-3. We estimated net survival for 11 histology groups, using the unbiased nonparametric Pohar Perme estimator.

RESULTS

The study included 556,237 adults. In 2010-2014, the global range in age-standardized 5-year net survival for the most common sub-types was broad: in the range 20%-38% for diffuse and anaplastic astrocytoma, from 4% to 17% for glioblastoma, and between 32% and 69% for oligodendroglioma. For patients with glioblastoma, the largest gains in survival occurred between 2000-2004 and 2005-2009. These improvements were more noticeable among adults diagnosed aged 40-70 years than among younger adults.

CONCLUSIONS

To the best of our knowledge, this study provides the largest account to date of global trends in population-based survival for brain tumors by histology in adults. We have highlighted remarkable gains in 5-year survival from glioblastoma since 2005, providing large-scale empirical evidence on the uptake of chemoradiation at population level. Worldwide, survival improvements have been extensive, but some countries still lag behind. Our findings may help clinicians involved in national and international tumor pathway boards to promote initiatives aimed at more extensive implementation of clinical guidelines.

Hospital-wide SARS-CoV-2 antibody screening of 4840 staff members in a University Medical Center in France: a cross-sectional study

OBJECTIVES

Healthcare workers are more likely to be infected by SARS-CoV-2. In order to assess the infectious risk associated with working in a hospital, we sought to estimate the proportion of healthcare professionals infected with SARS-CoV-2 by screening staff in a University Medical Center in France.

SETTING

A hospital-wide screening campaign (comprising a serological test and a questionnaire) ran from 18 May to 26 July 2020.

PRIMARY AND SECONDARY OUTCOME MEASURES

The seroprevalence rate was analysed in a multivariate analysis according to sociodemographic variables (age, sex and profession), exposure to SARS-CoV-2 and symptoms.

RESULTS

A total of 4840 professionals were included, corresponding to 74.5% of the centre's staff. The seroprevalence rate (95% CI) was 9.7% (7.0% to 12.4%). Contact with a confirmed case of COVID-19 was significantly associated with seropositivity (OR (95% CI: 1.43, (1.15 to 1.78)). The seroprevalence rate was significantly higher among nursing assistants (17.6%) than among other healthcare professionals. The following symptoms were predictive of COVID-19: anosmia (OR (95% CI): 1.55, (1.49 to 1.62)), ageusia (1.21, (1.16 to 1.27)), fever (1.15, (1.12 to 1.18)), myalgia (1.03, (1.01 to 1.06)) and headache (1.03, (1.01 to 1.04)).

Relationship between socioeconomic status and prostate cancer (incidence, aggressiveness, treatment with curative intent, and mortality): a spatial analysis using population-based cancer registry data

BACKGROUND

Morbidity and mortality associated with prostate cancer in a given geographic area might be related to the level of socioeconomic deprivation. The Somme area (a region of northern France) is considered economically disadvantaged, with major territorial disparities. The aim of this study was to assess the impact of the socioeconomic level on prostate cancer, using data from a population-based cancer registry.

METHODS

The source of data on cases of prostate cancer between 2006 and 2010 was the Somme cancer registry (Amiens, France). Socioeconomic status was measured according to the European Deprivation Index (EDI), which was used to classify each geographical "IRIS" unit (the smallest sub-municipal geographical entity for which French census data are available) according to its level of social deprivation. For spatial analysis, we considered a hierarchical generalized linear model.

RESULTS

In the spatial analysis, prostate cancer incidence was higher in the less disadvantaged areas and treatment frequency with curative intent was lower in the most disadvantaged areas. Cancer aggressiveness and mortality were higher in the most disadvantaged areas: relative risk (RR) = 1.36; 95% CI: [1.09; 1.73] and RR=3.09 [1.70; 5.59], respectively.

CONCLUSION

Our results evidenced a significant association between socioeconomic deprivation and prostate cancer, with worse outcomes among men with the lowest socioeconomic status.

Characteristics and outcomes of COVID-19 in hospitalized patients with and without diabetes

BACKGROUND

Coronavirus disease 2019 (COVID-19) is a rapidly progressing pandemic, with four million confirmed cases and 280 000 deaths at the time of writing. Some studies have suggested that diabetes is associated with a greater risk of developing severe forms of COVID-19. The primary objective of the present study was to compare the clinical features and outcomes in hospitalized COVID-19 patients with vs without diabetes.

METHODS

All consecutive adult patients admitted to Amiens University Hospital (Amiens, France) with confirmed COVID-19 up until April 21st, 2020, were included. The composite primary endpoint comprised admission to the intensive care unit (ICU) and death. Both components were also analysed separately in a logistic regression analysis and a Cox proportional hazards model.

RESULTS

A total of 433 patients (median age: 72; 238 (55%) men; diabetes: 115 (26.6%)) were included. Most of the deaths occurred in non-ICU units and among older adults. Multivariate analyses showed that diabetes was associated neither with the primary endpoint (odds ratio (OR): 1.12; 95% confidence interval (CI): 0.66-1.90) nor with mortality (hazard ratio: 0.73; 95%CI: 0.40-1.34) but was associated with ICU admission (OR: 2.06; 95%CI 1.09-3.92, P = .027) and a longer length of hospital stay. Age was negatively associated with ICU admission and positively associated with death.

CONCLUSIONS

Diabetes was prevalent in a quarter of the patients hospitalized with COVID-19; it was associated with a greater risk of ICU admission but not with a significant elevation in mortality. Further investigation of the relationship between COVID-19 severity and diabetes is warranted.

The association between body mass index class and coronavirus disease 2019 outcomes

BACKGROUND/OBJECTIVES

A growing body of data suggests that obesity influences coronavirus disease 2019 (COVID-19). Our study's primary objective was to assess the association between body mass index (BMI) categories and critical forms of COVID-19.

SUBJECTS/METHODS

Data on consecutive adult patients hospitalized with laboratory-confirmed COVID-19 at Amiens University Hospital (Amiens, France) were extracted retrospectively. The association between BMI categories and the composite primary endpoint (admission to the intensive care unit or death) was probed in a logistic regression analysis.

RESULTS

In total, 433 patients were included, and BMI data were available for 329: 20 were underweight (6.1%), 95 have a normal weight (28.9%), 90 were overweight (27.4%), and 124 were obese (37.7%). The BMI category was associated with the primary endpoint in the fully adjusted model; the odds ratio (OR) [95% confidence interval (CI)] for overweight and obesity were respectively 1.58 [0.77-3.24] and 2.58 [1.28-5.31]. The ORs [95% CI] for ICU admission were similar for overweight (3.16 [1.29-8.06]) and obesity (3.05 [1.25-7.82]) in the fully adjusted model. The unadjusted ORs for death were similar in all BMI categories while obesity only was associated with higher risk after adjustment.

CONCLUSIONS

Our results suggest that overweight (and not only obesity) is associated with ICU admission, but overweight is not associated with death.

Association between renin-angiotensin system inhibitors and COVID-19 complications

Aims

To describe the characteristics of patients hospitalized with COVID-19 (including their long-term at-home medication use), and compare them with regard to the course of the disease. To assess the association between renin–angiotensin system inhibitors (RASIs) and disease progression and critical outcomes.

Methods and results

All consecutive hospitalized patients with laboratory-confirmed COVID-19 in a university hospital in Amiens (France) were included in this study. The primary composite endpoint was admission to an intensive care unit (ICU) or death before ICU admission. Univariable and multivariable logistic regression models were used to identify factors associated with the composite endpoint. Between 28 February 2020 and 30 March 2020, a total of 499 local patients tested positive for SARS-CoV-2. Of these, 231 were not hospitalized {males 33%; median [interquartile range (IQR)] age: 44 (32–54)}, and 268 were hospitalized [males 58%; median (IQR) age: 73 (61–84)]. A total of 116 patients met the primary endpoint: 47 died before ICU admission, and 69 were admitted to the ICU. Patients meeting the primary endpoint were more likely than patients not meeting the primary endpoint to have coronary heart disease and to have been taking RASIs; however, the two subsets of patients did not differ with regard to median age. After adjustment for other associated variables, the risk of meeting the composite endpoint was 1.73 times higher (odds ratio 1.73, 95% confidence interval 1.02–2.93) in patients treated at baseline with a RASI than in patients not treated with this drug class. This association was confirmed when the analysis was restricted to patients treated with antihypertensive agents.

Conclusions

We highlighted a potential safety signal for RASIs, the long-term use of which was independently associated with a higher risk of severe COVID-19 and a poor outcome. Due to the widespread use of this important drug class, formal proof based on clinical trials is needed to better understand the association between RASIs and complications of COVID-19.

Predictive factors for the participation of general practitioners in lung cancer screening by low-dose CT scan in the Somme department in northern France

INTRODUCTION

A study on lung cancer screening using low-dose computed tomography (DEP KP80) was conducted in the Somme department in northern France between May 2016 and December 2018. We conducted a cross-sectional survey of family physicians in that department to identify potential predictive factors for their participation in this pilot study.

METHODS

A survey questionnaire was sent to the 545 general practitioners (GPs) of the Somme department. This survey rendered it possible to identify the investigators who were active in the DEP KP80 study. The questionnaire's content was focused on the socio-demographic conditions of GPs, their professional practices, and their medical practice situations.

RESULTS

The response rate was 38% (206 completed questionnaires). Active investigators in DEP KP80 accounted for 55% (n=113) of the GPs surveyed, and non-investigators for 45% (n=93). Age, gender, or medical practice situation were not related to the active GPs' participation in DEP KP80. A multivariate analysis revealed that two factors were correlated with active participation in organized screening: (1) prescription of nicotine replacement therapy; (2) smoking history of the GP.

CONCLUSIONS

Securing the active involvement of family physicians and of the French regional cancer screening coordination centers seems essential for the future organization of lung cancer screening on a regional or national level. Our results demonstrate that incorporating smoking cessation support structures into the program would maximize the mechanism's potential.

Cancer Among Adolescents and Young Adults Between 2000 and 2016 in France: Incidence and Improved Survival

Purpose: This study was undertaken to determine cancer survival and describe the spectrum of cancers diagnosed among French adolescent and young adult (AYA) population. Methods: All cases of cancer diagnosed in 15-24 years, recorded by all French population-based registries (18% of the French population), over the 2000-2016 period, were included. Age-standardized incidence rates, conventional annual percentage change (cAPC) of incidence over time, and 5-year overall survival (5yOS) were calculated. Results: We analyzed 2734 cancer diagnoses in adolescents and 4199 in young adults. Overall incidence rates were 231.9/10⁶ in 15-19 year olds and 354.0/10⁶ in 20-24 year olds. The most frequently diagnosed cancers in male AYA were malignant gonadal germ-cell tumors (GCT), Hodgkin lymphoma (HL), and malignant melanoma and were HL, thyroid carcinoma, and malignant melanoma in females. Cancer incidence was stable over time with a cAPC of 0.8% (p = 0.72). For all cancers combined, 5yOS was 86.6% (95% CI: 85.8-87.4), >85% for HL, non-Hodgkin lymphomas (NHL), GCT, thyroid carcinomas, and malignant melanomas, and around 60% and lower for osteosarcomas, Ewing tumors, hepatic carcinomas, and rhabdomyosarcomas. The 5yOS has significantly improved from 2000-2007 to 2008-2015 for all cancers pooled, with a substantial gain of 4% for 15-19 year olds and 3% for 20-24 year olds. Conclusion: Notwithstanding the encouraging results for some cancers, and overall, persistent poorer survivals in AYA were shown compared to children for acute lymphoblastic leukemia, osteosarcoma, Ewing tumor, rhabdomyosarcoma, and malignant hepatic tumors. These disparities require further investigation to identify and address the causes of these inferior outcomes.

Social Deprivation, Waiting Time for Diagnosis and Therapeutic Management of Patients With Prostatic Cancer in the Somme Area, France

Background: In France, prostate cancer is at the top of the list of the most common cancers in men. The morbidity and mortality of this cancer were found to be related to the geographic level of socioeconomic deprivation with a higher rate of mortality and more frequent aggressive cases among men with low socioeconomic level, this was associated with health disparities in the management of this cancer. Our study region is considered as an economically deprived area with a poverty rate significantly higher than the national average. Aim: The aim of our study was to assess the impact of the socioeconomic level on the incidence, mortality, aggressiveness and management of prostate cancer, using data from a population-based cancer registry. Methods: For this research, prostate cancer data, between 2006 and 2010, were obtained from the Somme area cancer registry. Social economic status was assessed using the European Deprivation Index (EDI). This index has been used to classify each geographical unit (IRIS) according to social deprivation. IRIS is the smallest submunicipal geographical entity for which census data are available. Each prostate cancer case was allocated to the corresponding IRIS by geolocalizing the addresses using geographic information system (GIS). For spatial analysis, hierarchical generalized linear modeling was fitted. To assess for spatial autocorrelation, Moran's I test was conducted and then spatial autocorrelation was modeled by a set of random effects that are assigned a conditional autoregressive (CAR) prior distribution. Results: A total of 2405 incident cases of prostate cancer were registered in the Somme area. The age-standardized rate was 98.2 cases per 100,000 person-years (PY). The standardized mortality rate was 28.1 deaths per 105 PY. The coefficient associated with the EDI obtained from the spatial analysis of prostate cancer incidence was negative (-0.348; 95% CI: −0.0831) which indicates that prostate cancer incidence was more important in the less deprived areas. The relative risk of prostate cancer mortality associated with the quintile 5 of the EDI relatively to quintile 1 was 3.09; 95% CI: [1.70-5.59]. For the aggressiveness, the coefficient associated with the EDI was 0.0493 with a 95% CI: [0.0162-0.0810], and the Q5/Q1 RR was equal to 1.36 95% CI: [1.09-1.73]. EDI estimated coefficient for proportion of cases who received curative treatment versus patients who received palliative treatment was −0.1089, 95 CI%: [−0.1505 to −0.0693]. EDI coefficient for waiting time was not significant. Conclusion: Our study showed a significant association between socioeconomic deprivation and prostate cancer with worse outcomes among men with the lowest socioeconomic status. Geographical differences in screening rate could explain this pattern. More in-depth research with a source data review is required to know precisely the determinism of this association and therefore adjust the eventual disparities.

Adolescent and young adult oncology patients in France: Heterogeneity in pathways of care

BACKGROUND

In order to evaluate at the population level the impact of the actions developed in France since 2004 to organize the care of adolescents and young adults (AYAs) with cancer, we conducted the present study to provide an unbiased view of the pathway of care of these patients.

METHODS

Using a population-based registry, we conducted a review of all cases of cancer diagnosed during 2012 and 2013 in 15- to 24-year-old patients living in nineteen French administrative areas.

RESULTS

The median times for diagnosis and treatment of the 993 included AYAs were 9 weeks (3-22) and 1 day (0-20), respectively. Delays in diagnosis were significantly longer in young adults than in adolescents, especially for soft-tissue sarcomas (48.7 weeks vs. 15.4 weeks, P = 0.04) and bone tumors (21.4 weeks vs. 10.1 weeks, P = 0.04). The first physicians seen by patients were mostly general practitioners (67.4%). Most patients (77.5%) were treated in adult units. Management decisions were taken within the context of a multidisciplinary team (MDT) in 85.3% of cases. MDT meetings that involved both pediatric and adult oncologists were uncommon (15.7% of patients). Twenty-six percent of patients were included in randomized or nonrandomized clinical studies. The proportion of inclusion was significantly higher in adolescents (39.5%) than in young adults (16.8%).

CONCLUSION

In France, pathways of care for AYAs are heterogeneous. It is necessary to organize a national network of expert centers with adequate medical skills and specific psychosocial support and facilities to provide the best possible care for these patients.

Factors associated with delayed screening of contacts of tuberculosis cases in the Somme, France

AIM

To analyze the factors associated with the time to initiating tuberculosis contact investigations in the Somme department, France.

METHODS

All reported tuberculosis cases and all their contacts screened between 2007 and 2011 were retrospectively included. Univariate and multivariate analyses were conducted to determine the factors associated with a "system delay"≤1 month and a "contact delay"≤0 days.

RESULTS

The mean time between the mandatory notification of a case of tuberculosis and the date set for the contact's screening (system delay) was 35.3 days and the average time between that date and when the contact was actually screened (contact delay) was 12.5 days. In multivariate analysis, a smear-positive sputum sample (OR: 3.68; 95% CI: 1.63-8.30) and a diagnosis at the university hospital (OR: 2.61; 95% CI: 1.14-5.96) were significantly associated with a system delay≤1 month. A smear-positive sputum sample (OR: 1.35; 95% CI: 1.08-1.69), male gender (OR: 1.21; 95% CI: 1.01-1.49), being born in a foreign country (OR: 1.31; 95% CI: 1.02-1.69), being a family member (OR: 1.37; 95% CI: 1.05-1.77), or being another type of close contact of the case (OR: 2.47; 95% CI: 1.81-3.36) were significantly associated with a contact delay≤0 days.

CONCLUSION

System and contact delays were longer than recommended, and the factors associated with the lengthening of these delays need to be taken into account.

Community-Acquired Infection With Healthcare-Associated Methicillin-Resistant Staphylococcus aureus: The Role of Home Nursing Care

Objective.

To better understand the role of indirect transmission in community-acquired infection with methicillin-resistant Staphylococcus aureus (MRSA).

Design.

Prospective case-control study.

Setting.

A French teaching hospital.

Patients.

A total of 198 case patients and 198 control patients with MRSA or methicillin-susceptible S. aureus infection diagnosed between April 2002 and July 2003.

Results.

Multivariate analysis showed a highly significant independent link between MRSA infection at admission and prior receipt of home nursing care (odds ratio [OR], 3.7; P<.001). Other independent risk factors were prior hospitalization (OR, 3.8; P<.001), transfer from another institution (OR, 2.3; P = .008), and age older than 65 years (OR, 1.6; P = .04). Prior home nursing care showed a frequency dose-response relationship. Eleven MRSA-infected patients had had home nursing procedures but no hospital stay in the previous 3 years. These patients' MRSA strains were related to the prevalent MRSA clone currently spreading in French hospitals.

Conclusion.

Home nursing care appears to be an independent risk factor for MRSA acquisition in the community. The reservoir probably consists of MRSA carriers discharged from the hospital. Community nurses seem to be a potential vector.

Alcohol, cigarette, and illegal substance consumption among medical students: a cross-sectional survey

This study investigated addictive substance use by French medical students. A cross-sectional survey was distributed to 255 participants randomly selected from 1,021 second- to sixth-year medical students. Questionnaires were self-administered and included questions on sociodemographic characteristics, mental health, and alcohol (The Alcohol Use Disorders Identification Test [AUDIT test]), tobacco (Fagerstrom test), and illegal substance consumption (Cannabis Abuse Screening Test [CAST test]). The AUDIT scores indicated that 11% of the study participants were at risk for addiction and 21% were high-risk users. Tobacco dependence was strong or very strong for 12% of the participants. The CAST score showed that 5% of cannabis users needed health care services. Cannabis users were also more likely than non-users to fail their medical school examinations (89% vs. 39%, p<.01). One quarter of medical student participants (n=41) had used other illegal drugs, and 10% of study participants had considered committing suicide during the previous 12 months. Psychoactive substance consumption by French medical students requires preventive measures, screening, and health care services.

Building spatial composite indicators to analyze environmental health inequalities on a regional scale

BACKGROUND

Reducing health inequalities involves the identification and characterization of social and exposure factors and the way they accumulate in a given area. The areas of accumulation then allow for prioritization of interventions. The present study aims to build spatial composite indicators based on the aggregation of environmental, social and health indicators and their inter-relationships.

METHOD

Preliminary work was carried out firstly to homogenize spatial coverage, and secondly to study spatial variation of environmental (EI), socioeconomic (SI) and health (HI) indicators. The aggregation of the different indicators was performed using several methodologies for which results and decision-makers' usability were compared.

RESULTS

Four methodologies were tested: 1) A simple summation of normalized HI, EI and SI indicators (IC), 2) the sum of the normalized HI, EI and SI indicators weighted by the first principal component of a Principal Component Analysis (IC PCA), 3) the sum of normalized and weighted indicators of the first principal component of Local Principal Component Analysis (IC LPCA), and 4) the sum of normalized and weighted indicators of the first principal component of a Geographically Weighted Principal Component Analysis (IC GWPCA).

CONCLUSION

The GWPCA is particularly adapted to taking into account the spatial heterogeneity and the spatial autocorrelation between SI, EI and HI. This approach invalidates the basic assumptions of many standard statistical analyses. Where socioeconomic indicators present high deprivation and where they are associated with potential modifiable health determinants, decision-makers can prioritize these areas for reducing inequalities by controlling the socioeconomic and health determinants.

Fighting violence against health workers: a way to improve quality of care?

Violence against health care workers impairs the quality of care. In one university medical center in France, 46% of the health care workers were physically assaulted at some point in the previous 12 months and 79% were verbally insulted. This article describes a participatory approach that was used to ensure health care workers take an active role in designing and implementing anti-violence measures. In each unit, a working group of health care professionals and managers developed an action plan for reducing violence-generating practices. This proactive approach is a powerful tool for motivating health care professionals to improve quality of care.

[Alcohol, tobacco, cannabis, anxiety and depression among second-year medical students. Identify in order to act]

INTRODUCTION

Excessive alcohol consumption and illicit drug use among students have negative repercussions on their health, education and society in general. Medical students are no exception.

METHODS

The objective of this study was to evaluate the consumption of alcohol, tobacco and cannabis as well as levels of anxiety and depression of students admitted to the second year of medical studies based on anonymous self-administered questionnaires containing the following tests: AUDIT, Fagerstrom, CAST and HAD.

RESULTS

198 of the 207 students involved agreed to participate. Excessive alcohol consumption was higher among women than among men (35% versus 22%), but fewer women were alcohol-dependent (2% versus 8%) (p < 0.05). 16% of students were tobacco smokers, with no signs of dependence in 80% of cases. 15% of students smoked cannabis and 52% of them presented problem use. 21% of women had a suspected anxiety disorder and 23% had a proven anxiety disorder, versus 17% and 6% of men, respectively (p = 0.002). 3% had a suspected depressive disorder and 0.5% had a proven depressive disorder. High-risk alcohol consumption was significantly correlated with high-risk cannabis use. No correlation was demonstrated between anxiety or depression and these consumptions.

DISCUSSION

Doctors appear to be particularly affected by psychological disorders or addictions and medical students are paradoxically less likely than the general population to receive appropriate care. Universities must provide monitoring and support for students in order to improve their health, but also to enable them to provide care and appropriate educational messages to their patients.

Prognostic factors associated with healing of venous leg ulcers: a multicentre, prospective, cohort study

BACKGROUND

Some prognostic markers of venous leg ulcer (VLU) healing have been evaluated, mostly in retrospective studies.

OBJECTIVES

To identify which clinical characteristics, among those known as possible prognostic factors of VLU healing, and which VLU-associated sociodemographic and psychological factors, are associated with complete healing at week 24 (W24).

METHODS

A prospective, multicentre, cohort study was conducted in 22 French dermatology departments between September 2003 and December 2007. The end point was comparison between healed and nonhealed VLUs at W24, for patient clinical and biological characteristics; psychological, cognitive and social assessments; affected leg inclusion characteristics; venous insufficiency treatment and percentage of initial wound area reduction during follow-up.

RESULTS

In total, 104 VLUs in 104 patients were included; 94 were analysed. The mean VLU area and duration were 36.8 ± 55.5 cm2 and 24.8 ± 45.7 months, respectively. At W24, 41/94 VLUs were healed. Univariate analysis significantly associated complete healing with superficial venous surgery (P = 0.001), adherence to compression therapy at W4 (P = 0.03) and W24 (P = 0.01), ankle-joint ankylosis (P = 0.01) and mean percentage of VLU area reduction at W4 (P = 0.04). Multivariate analysis retained superficial venous surgery during follow-up [odds ratio (OR) 8.4, 95% confidence interval (CI) 1.9-48.2] and percentage reduction of the VLU area at W4 (OR 1.6, 95% CI 1.0-2.14) as being independently associated with healing.

CONCLUSIONS

These results indicate that complete healing of long-standing, large VLUs is independently associated with ablation of the incompetent superficial vein and percentage of wound area reduction after the first 4 weeks of treatment.

The effect of patient characteristics on second primary cancer risk in France

Background

Although cancer survivors are known to be at greater risk of developing second primary cancer (SPC), SPC incidence estimates in France are thus far lacking. We used a multivariate approach to compute these estimates and analyzed the effect of patient characteristics (gender, age at diagnosis, first cancer site, year of diagnosis and follow-up) on SPC risk.

Methods

Data from ten French population-based cancer registries were used to establish a cohort of all patients diagnosed with a first cancer between 1989 and 2004 and followed up until December 31, 2007. The person-year approach was used to estimate standardized incidence ratios (SIRs) and excess absolute risks (EARs) of metachronous SPC. Multivariate Poisson regression models were then used to model SIRs and EARs separately by gender, adjusting for age, year of diagnosis, follow-up and first cancer site.

Results

Among the 289,967 followed-up patients with a first primary cancer, 21,226 developed a SPC. The SIR was of 1.36 (95% CI, 1.35-1.38) and the EAR was of 39.4 excess cancers per 10,000 person-years (95% CI, 37.4-41.3). Among male and female patients, multivariate analyses showed that age, year of diagnosis, follow-up and first cancer site were often independently associated with SIRs and EARs. Moreover, the EAR of SPC remained elevated during patient follow-up.

Conclusions

French cancer survivors face a dramatically increased risk of SPC which is probably related to the high rate of tobacco and alcohol consumption in France. Multivariate modeling of SPC risk will facilitate the construction of a tailored prediction tool to optimize SPC prevention and early detection strategies.

Finding a balance between patients' rights, responsibilities and obligations

Patients' rights have developed over recent decades in many countries, resulting in improved access to high quality medical care. The alliance between patients and physicians is a moral obligation, backed up by patient rights. Poor patient compliance with medical recommendations constitutes a public health issue, illustrating the difficulty of obliging patients to comply with treatment. The legal recognition of patients' responsibilities is defined in a few legislative and regulatory texts, but is primarily based on jurisprudence. Patients, who despite being fully aware and informed about the risks adopt a behaviour that is harmful to their health, tend to be considered as being irresponsible. This judicial approach raises a number of questions, as it fails to take into account the complexity of the human factors involved in a behaviour with either positive or negative health effects.

The precautionary principle: is it safe

The precautionary principle is generally acknowledged to be a powerful tool for protecting health but it was originally invoked by policy makers for dealing with environmental issues. In the 1990s, the principle was incorporated into many legislative and regulatory texts in international law. One can consider that the precautionary principle has turned into "precautionism" necessary to prove to the people, taking account of risk in decisions. There is now a risk that these abuses will deprive the principle of its meaning and value. When pushed to its limits, the precautionary principle can even be dangerous when applied to the healthcare field. This is why a critical analysis of the principle is necessary. Through the literature, it sometimes seems to deviate somehow from the essence of the precautionary principle as it is commonly used in relation to health. We believe that educational work is necessary to familiarize professionals, policy makers and public opinion of the precautionary principle and avoid confusion. We propose a critical analysis of the use and misuse of the precautionary principle.

Cancer incidence and survival in adolescents and young adults in France, 2000-2008

This study aimed to describe cancer incidence (2000-2008) and survival (2000-2004) in France in adolescents and young adults (AYA). All cases of cancer diagnosed in 15-24 years, recorded by all French population-based registries (14% of the French population), over the 2000-2008 period, were included. Incidence change over time was described with the conventional annual percentage change (cAPC). The survival of cases diagnosed (2000-2004) was estimated using Kaplan-Meier method. A total of 1022 in adolescents and 1396 in young adults were diagnosed. Overall incidence rates were 219.4/10(6) in 15-19 year olds and 293.1/10(6) in 20-24 year olds. The most frequently diagnosed cancers in male AYA were malignant gonadal germ-cell tumors and Hodgkin's disease, and were melanoma, thyroid carcinoma, and Hodgkin's disease in females. The age-standardized rates appeared stable over time in AYA, with a cAPC of +2.0% (P = 0.68). The 5-year overall survival for all cancers was different between genders and age groups, with 78.8% (95%CI: 75.6-82.0) for males and 85.2% (95%CI: 82.2-88.1) for females (P = 0.01), and 78.5% (95%CI: 75.0-82.1) in 15-19 year olds and 84.3% (95% CI: 81.6-87.0) in 20-24 year olds (P = 0.02). Noteworthy, the frequency and the distribution of tumor types in AYA are unique and different from the observed at any other age group. Survival in French AYA has improved over time. Epidemiological data might reflect major trends in the risk factors and preventive interventions. Thus, further research into etiology of cancers affecting AYA should become key priorities for cancer control among AYA.

Waiting time disparities in breast cancer diagnosis and treatment: a population-based study in France

Waiting times are key indicators of a health's system performance, but are not routinely available in France. We studied waiting times for diagnosis and treatment according to patients' characteristics, tumours' characteristics and medical management options in a sample of 1494 breast cancers recorded in population-based registries. The median waiting time from the first imaging detection to the treatment initiation was 34 days. Older age, co-morbidity, smaller size of tumour, detection by organised screening, biopsy, increasing number of specimens removed, multidisciplinary consulting meetings and surgery as initial treatment were related to increased waiting times in multivariate models. Many of these factors were related to good practices guidelines. However, the strong influence of organised screening programme and the disparity of waiting times according to geographical areas were of concern. Better scheduling of diagnostic tests and treatment propositions should improve waiting times in the management of breast cancer in France.

Healthy by law: heading towards a brave new world?

The law is a tool used by Government to protect public health. Health is an omnipresent preoccupation, inviting each one of us to protect ourselves against potential risks at all times and in all places. The right to health protection is a source of benefit entitlements and rights-obligations that render it effective. However, believing that the law can and should regulate all sectors of human life, still a utopian belief. International law suffers from intrinsic weaknesses that limit its effectiveness. The current economic context has lead to stricter controls over healthcare expenditure faced with the ever-growing demand for treatment, limiting the right to healthcare protection. Through health law, the State has developed controls over individuals. Individual liberties tend to be limited to the cause of the public health policy. Healthy by law, raises a question: are we heading towards a brave new world as described by Aldous Huxley?

Prevention of healthcare-associated infections in general practice: current practice and drivers for change in a French study

PURPOSE

The fight against Healthcare-associated infections is a public health priority and a major challenge for the safety and quality of care. The objective was to assess hygiene in general practitioners' (GPs') office and identify barriers to and drivers for better practice.

MATERIALS AND METHODS

We performed a cross-sectional study in which a questionnaire was sent to a randomly selected, representative sample of 800 GPs. We used a self-administered questionnaire. The first part assessed current practice and the second part focused on barriers and motivating factors for better practice. We performed a descriptive statistical analysis of the responses to closed questions and a qualitative analysis of the responses to open-ended questions.

RESULTS

Only a third of the GPs were aware of the current guidelines. Disposable equipment was used by 31% of the GPs. For the remainder, only 38% complied with the recommended procedures for sterilisation or disinfection. Seventy-two percent of the GPs washed their hands between consultations in the office. A significant minority of physicians disregarded the guidelines by never wearing gloves to perform sutures (11%), treat wounds (10%), fit intrauterine devices (18%) or perform injections (18%). The main barriers to good practice were the high cost of modifications and lack of time/space. Two third of the GPs did not intend to change their practices. The drivers for change were pressure from patients (4.8 on a scale of 1 to 7), inspection by the health authorities (4.8) and the fear of legal action (4.4).

CONCLUSIONS

Our results show that there are significant differences between current practice and laid-down professional guidelines. Policies for improvement of hygiene must take into account barriers and motivating factors.

Assessing urine human papillomavirus polymerase chain reaction testing as a tool for screening anal HPV infection in HIV-positive MSM

Multiple types of human papillomavirus (HPV) are responsible for most cervical cancers but also cause anal cancers-especially in HIV-positive patients. Furthermore, men who have sex with men (MSM) are twice as likely to develop anal cancers as non-MSM. A simple screening test for HPV infection would be useful in these patients. The aim of our study was to evaluate the detection of HPV by real-time polymerase chain reaction (PCR) in urine as a marker of anal infection in MSM. The study included 52 HIV-positive MSM treated at Amiens University Hospital (Amiens, France). After obtaining informed consent, we performed an anal swab and gathered 10 mL of first-void urine. Samples were extracted and amplified in a real-time PCR. Genotypes were determined with a PapilloCheck(®) system (Greiner Bio-One, Frickenhausen, Germany). The anal test was the gold standard for calculating the characteristics of the urine test. The sensitivity of the urine test for diagnosing anal HPV infection was 15%, the specificity was 66%, the positive predictive value was 87.5%, and negative predictive value was 4.5%. The prevalence of anal HPV infection in the study population was 94%. Genotype 42 was the most common. The anal HPV viral load was significantly lower in men in a stable relationship than in single men. However, there was no statistically significant relationship between anal viral load and anal intraepithelial lesions. We conclude that urine-based HPV is a poor predictor of anal HPV infection in HIV-positive MSM.

Occupational exposure to pesticides and bile tract carcinoma in men: results from a European multicenter case-control study

OBJECTIVES

To estimate the associations between occupational exposure to pesticides and extrahepatic biliary tract carcinoma in men, a population-based case-control study was carried out.

METHODS

Cases (n = 104), aged 35-70, diagnosed in 1995-1997, were sampled by active reporting systems from hospitals. Controls (n = 1,401) were a random sample of the general male population. Information on occupation and confounding factors was obtained by questionnaires. Exposures were quantified with respect to time, application methods, and use of personal protective equipment. Intensity was evaluated by using a published algorithm which weighted the exposure assigned according to the use of personal protective equipment and mode of application. Logistic regression analyses were conducted adjusted for gallstones, age, and country.

RESULTS

Being ever exposed to pesticides resulted in an odds ratio (OR) of 1.0 [95%-confidence interval (CI) 0.6-1.6]. A modestly elevated risk was found for backpack mounted sprayers OR = 1.4 [95% CI 0.7-2.6] and vine farmers OR = 2.5 [95% CI 0.9-7.2]. Using time periods and exposure frequency as intensity measure, no elevated risks were found. The only exception was year of maximum exposure which yielded an OR of 1.6 [95% CI 0.7-3.5]. However, no clear trend was observed in this analysis.

CONCLUSIONS

This study does not rule out that pesticide exposure represents an occupational risk factor for extrahepatic biliary tract carcinoma, but no indication of a strong association was observed. Some modes of exposure were weakly, albeit not significantly associated with carcinoma risk. The observed estimates of effects may be influenced by a lack of precise exposure assessment. Different chemical compositions of pesticides were utilized during a long time span of pesticide exposure, and it should be considered that the exposure is assessed with substantial uncertainty that could non-differential and bias results toward the null.

[Time trends in the geographic variation of thyroid cancer incidence by tumor size from 1983 to 2000 in France]

BACKGROUND

The aim of this investigation was to study geographic time trends of thyroid cancer incidence according to tumor size in France, 1983 to 2000.

METHODS

Incidence data were provided from six French registries over the period 1983-2000 covering seven administrative districts. Five tumor size groups were distinguished: < 10mm, 10-20mm, 20-40mm, > 40mm and unknown size. Papillary cancers diagnosed in women were analyzed according to tumor size in each geographic area. World age standardized rates were calculated and annual percent change rates were estimated for each tumor size group in each geographic area. Loglinear Poisson regression models were used to study geographic discrepancies in time trends incidences.

RESULTS

The six French registries included 2222 papillary thyroid cancers in women between 1983 et 2000. Thyroid cancer incidence was increasing in the six geographic areas. Geographical variations in time trends incidence between registries reflected geographical variations in time trends incidence of small sized tumors (less than 10mm).

CONCLUSION

Wide geographic variations in thyroid cancer incidence were noticed for small size tumors, which may be correlated with geographic variations in medical practices.

[Stenotrophomonas maltophilia and Pseudomonas aeruginosa water-associated microbiologic risk assessment in Amiens' University Hospital Centre]

BACKGROUND

Pseudomonas aeruginosa (Psa) and Stenotrophomonas maltophilia (Smalto) are major opportunistic waterborne pathogens causing hospital-acquired infections. This study aimed to assess the biocontamination level of cold water used in Amiens' university hospital wards, from March to June 2008.

METHODS

We cultivated 122 pairs of cold water first jet and taps cotton-swabs on Cetrimide agar for Psa, on Stenotrophomonas maltophilia selective medium with coloured indicator (SM2i) for Smalto, on Mueller Hinton agar used as isolation medium reference for both, 48h at 30 degrees C. Data analysed with Epi-Info 6.04dFr were compared with chi(2) test, significant at p<.05.

RESULTS

Psa and Smalto were isolated in 26.2 and 14.8% of water samples and in 21.3 and 10.7% of swab samples respectively. They were associated in 11.5% of water samples and 5% of swab samples. Psa was alone in 13.1% of water samples and 7.4% of swab samples whereas Smalto was found in 6.6% of water and 2.5% of swabs. Psa and Smalto were isolated from 14.8% of water samples and 8.2% of swab samples of the same tap. Finally, respectively 35.2 and 17.2% of the cold water taps were biocontaminated by Psa and Smalto. In fact, microbiologic water taps contamination risk was two-fold higher for Psa than for Smalto, p<.001, without variation between wards.

CONCLUSION

Sm2i and Cetrimide are suited and efficient medium respectively for Smalto and Psa isolation. Cold-water samples are sufficient for waterborne pathogens biocontamination risk appraisal. Our results urged healthcare workers on efficient water fittings microbiologic risk control to prevent healthcare associated waterborne infections, notably due to Psa and Smalto.

[Prostate cancer management and factors associated with radical prostatectomy in France in 2001]

INTRODUCTION

Prostate cancer was the most common cancer in men in France in 2005, and the second cause of male death from cancer. In this study, we analyzed clinical characteristics of patients with prostate cancer diagnosed in France in 2001 with a focus on therapeutic management of localized prostate cancers.

PATIENTS AND METHODS

A total of 2181 cases of prostate cancer diagnosed in 2001 from 11 French counties covered by a cancer registry were analyzed. A descriptive study of the clinical characteristics of patients was performed. Parameters studied included age, county, TNM stage, PSA value, Gleason score, D'Amico prognostic group, Charlson's comorbidity index and initial treatment modalities. For localized cancers, multivariate logistic regression analysis identified factors associated with radical prostatectomy.

RESULTS

The proportion of localized prostate cancer (T1 or T2) was 86.6 %. The use of invasive curative treatment (radical prostatectomy and radiotherapy) was 58.4 % for localized cancers. Significant differences in therapeutic management were found between counties. Radical prostatectomy was associated with age at diagnosis, D'Amico prognostic group and the presence of comorbidities.

CONCLUSIONS

Most of prostate cancers diagnosed in France in 2001 were clinically localized and were treated by invasive therapy. The consequences of these practices remain to be determined given the limited evolution of many prostate cancers and the frequency of adverse events related to invasive treatments.