Publications by authors named "Béatrice Trombert Paviot"

49 Publications

Assessment of the impact of an expectant management in case of abnormally progressing first-stage labor.

Eur J Obstet Gynecol Reprod Biol 2021 Mar 26;258:362-365. Epub 2021 Jan 26.

Department of Obstetrics, Centre Hospitalier Universitaire de Saint-Étienne, Saint-Étienne, France; INSERM U1059 Sainbiose, Université Jean Monnet, Saint-Étienne, France. Electronic address:

Objective: To compare the cesarean section rate before and after the introduction of an expectant management protocol in patients with abnormally progressing first-stage labor.

Methods: A prospective monocentric cohort study performed between January 2012 and July 2016.

Results: 267 patients were included, 97 in the control group and 170 in the study group. The number of cesarean sections decreased from 86 % to 45 % (p < 0.001). The number of instrumental extractions increased from 8.3% to 29.4% (p < 0.001). The number of postpartum hemorrhages increased from 5.2% to 18% (p < 0.01). No differences in the rates of perineal lesions, neonatal pHa below 7.10, and shoulder dystocia were observed.

Conclusion: The expectant management in patients with labor arrest in the first stage was associated with a decrease in the number of cesarean sections, at the cost of an increase in instrumental extractions and postpartum hemorrhages.
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http://dx.doi.org/10.1016/j.ejogrb.2021.01.041DOI Listing
March 2021

Stroke Care in Brazil and France: National Policies and Healthcare Indicators Comparison.

J Multidiscip Healthc 2020 2;13:1403-1414. Epub 2020 Nov 2.

Health Services and Performance Research - HESPER, Université Claude Bernard Lyon 1. Faculté de Médecine, Lyon, Rhône-Alpes, France.

Objective: To identify the commonalities and discrepancies between national health policies to combat stroke in France and Brazil.

Justification: Both healthcare systems were structured as universal access and comprehensive care attention, hierarchized by the level of care, politically and administratively decentralized. France is an industrialized, high-income country, with health care involving copayment and reimbursement of expenses, and spontaneous demand for services. Brazil is a member of the BRICs, of upper middle income with totally free health care, with an active search for hypertension and diabetes in the general population.

Methods: Data regarding policies, risk factors, and health indicators about stroke care, from 2010 to 2017, were obtained from both countries (publicly accessible information or on request) from the respective Ministries of Health or international agencies.

Results: About acute stroke hospitalizations, on average, Brazil has 0.75 per 1000 annual population hospitalizations versus 1.54 per 1000 in France. Brazil has 0.21 per 1000 population deaths per year versus 0.40 per 1000 in France. The in-hospital mortality rate in Brazil has 139 per 1000 hospitalized people versus 263 in France. The average length of stay of acute hospitalizations was 7.6 days in Brazil versus 12.6 in France. The prevalence of strokes by age group shows from 0 to 39 years old (this rate is stable); 40-59 years (it is increasing in both countries); and 60-79 and 80+ years (this rate has been increasing in France and decreasing in Brazil).

Conclusion: No major differences were found about the health policies and the National Health Plans related to stroke. However, the data directly linked to the period of hospitalization differed substantially between countries. Subsequent studies can be implemented to identify the explanatory factors, notably among the risk factors and actions in primary care, and the moments after hospital care, such as secondary prevention and palliative care.
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http://dx.doi.org/10.2147/JMDH.S262900DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7646412PMC
November 2020

Hypokalemia is frequent and has prognostic implications in stable patients attending the emergency department.

PLoS One 2020 4;15(8):e0236934. Epub 2020 Aug 4.

Université de Lorraine, Inserm, Centre d'Investigations Cliniques- Plurithématique 1433, and Inserm U1116, CHRU, Nancy, France.

Background: Potassium disturbances are associated with adverse prognosis in patients with chronic conditions. Its prognostic implications in stable patients attending the emergency department (ED) is poorly described.

Aims: This study aimed to assess the prevalence of dyskalemia, describe its predisposing factors and prognostic associations in a population presenting the ED without unstable medical illness.

Methods: Post-hoc analysis of a prospective, cross-sectional, multicenter study in the ED of 11 French academic hospitals over a period of 8 weeks. All adults presenting to the ED during this period were included, except instances of self-drug poisoning, inability to complete self-medication questionnaire, presence of an unstable medical illness and decline to participate in the study. All-cause hospitalization or deaths were assessed.

Results: A total of 1242 patients were included. The mean age was 57.2±22.3 years, 51% were female. The distribution according to potassium concentrations was: hypokalemia<4mmol/L(n = 620, 49.9%), normokalemia 4-5mmol/L(n = 549, 44.2%) and hyperkalemia >5mmol/L(n = 73, 0,6%). The proportion of patients with a kalemia<3.5mmol/L was 8% (n = 101). Renal insufficiency (OR [95% CI] = 3.56[1.94-6.52], p-value <0.001) and hemoglobin <12g/dl (OR [95% CI] = 2.62[1.50-4.60], p-value = 0.001) were associated with hyperkalemia. Female sex (OR [95% CI] = 1.31[1.03-1.66], p-value = 0.029), age <45years (OR [95% CI] = 1.69 [1.20-2.37], p-value = 0.002) and the use of thiazide diuretics (OR [95% CI] = 2.04 [1.28-3.32], p-value = 0.003), were associated with hypokalemia<4mmol/l. Two patients died in the ED and 629 (52.7%) were hospitalized. Hypokalemia <3.5mmol/L was independently associated with increased odds of hospitalization or death (OR [95% CI] = 1.47 [1.00-2.15], p-value = 0.048).

Conclusions: Hypokalemia is frequently found in the ED and was associated with worse outcomes in a low-risk ED population.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0236934PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7402484PMC
October 2020

Association between executive function and the evolution of behavioral disorders in Alzheimer's disease.

Int J Geriatr Psychiatry 2020 09 7;35(9):1043-1050. Epub 2020 Jul 7.

Aging Psychiatry Unit, University Hospital Le Vinatier, Bron, France.

Objective: This study was aimed at evaluating the association between cognitive functioning and the occurrence of behavioral and psychological symptoms of dementia (BPSD) in patients with Alzheimer's disease (AD).

Methods/design: The population is derived from the PACO cohort, including 237 patients with prodromal or mild AD. A neuropsychological tests battery exploring verbal and visual memory, language, attention, and executive functions was performed at baseline. BPSD were assessed at 6-, 12-, and 18-month follow-up with neuropsychiatric inventory (NPI).

Results: Lower baseline performance on Stroop test interference score was associated with higher subsequent overall NPI scores (P = .006), subscores of anxiety/depression (P = .03), and apathy inventory (P = .01). Conversely, other executive functions, verbal or visual memory, and language performances were not associated with a higher risk of BPSD.

Conclusion: Our results suggest that poorer inhibition performance would be associated with a higher risk of 18-month BPSD occurrence, including anxiety, depression, and apathy. A better knowledge of the predictive factors of the BPSDs would make it possible to better identify the patients at risk, to propose preventive strategies and an earlier adapted care. J Am Geriatr Soc 68:-, 2020.
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http://dx.doi.org/10.1002/gps.5327DOI Listing
September 2020

Prevalence of Psychiatric Complications in Young Adults After Childhood Cancer Treatment: Results of the Long-Term Follow-Up Studies in Oncology.

J Adolesc Young Adult Oncol 2020 04 29;9(2):247-255. Epub 2019 Oct 29.

Department of Pediatric Hematology and Oncology Unit, University Hospital of Saint-Etienne, Saint-Etienne, France.

This study evaluated the long-term psychological impact of childhood cancer and also sought to identify the risk factors in the development of psychological issues. Young adult (18-38 years) survivors of a childhood cancer (except leukemia), diagnosed younger than 15 years between 1987 and 1999 in the Rhône-Alpes region of France, were invited to a semistandardized psychological interview after a medical follow-up consultation during two successive long-term follow-up studies in Oncology (SALTO-1 and -2). Psychiatric issues from the DSM-IV were diagnosed and compared with the general French population (GFP) through interviews based on the Mini-International Neuropsychiatric Interview (MINI). Of the 288 childhood cancer survivors (CCSs) who attended the consultations, 247 completed the MINI interview. Fifty-five percent indicated they had suffered from psychiatric issues after their cancer compared to 31.9% of the GFP ( < 0.0001). These issues were generally anxiety problems (40.5%), mood disorders (28.7%), and substance dependency (10.5%;  < 0.0001). The risk of suicide was, however, less for the CCS group (8.9% vs. 13.6%,  = 0.03). Unemployment was a significant risk factor for mood disorders ( = 0.009). Men were 4.1 times more likely than women to be addicted during their lifetime ( = 0.0004), while adults cured of bone tumors were 14.3 times more likely to be at risk of drug dependence than adults cured of central nervous system tumors ( = 0.01). CCSs are particularly vulnerable to psychiatric disorders throughout their life. Systematic and long-term psychological monitoring of these patients will enable their psychiatric issues to be detected sooner.
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http://dx.doi.org/10.1089/jayao.2019.0056DOI Listing
April 2020

Automated Control of Codes Accuracy in Case-Mix Databases by Evaluating Coherence with Available Information in the Electronic Health Record.

Stud Health Technol Inform 2019 Aug;264:551-555

Public Health and Medical Information Department, University Hospital Center of Saint Etienne, France.

Coding accuracy in case-mix databases enables efficient funding of health facilities and accurate epidemiological statistics based on patients' stays information. We assume that the data collected in the electronic health record, especially drug prescriptions and medical reports are relevant for checking the consistency of the coding of diagnoses. We evaluated a new coding control tool, "TOLBIAC control", embedded in the Web100T coding assistant. This tool interacts with the Vidal Application Programming Interface and the electronic health record of the University Hospital of Saint-Etienne. The micro-average F-measure was 0.76 for drug prescriptions and 0.55 for free text medical reports. This initial evaluation has revealed that drug prescriptions in EHRs can successfully be used to develop an automated ICD-10 code-control tool. Nevertheless the "TOLBIAC control" tool is not yet fully effective for widespread use because of its limited performance in text analysis, a feature that is currently undergoing improvements.
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http://dx.doi.org/10.3233/SHTI190283DOI Listing
August 2019

[Are advice section illustrations in children's health record books understandable for parents?]

Sante Publique 2019 Marc Apr;31(2):195-202

Background: French child health record books contain preventive care illustrations, which may not always be fully understood. The aim of this study was to describe the degree to which illustrations may be understood in the parent advice section of the French child health record, and to determine the factors associated with poor understanding by young parents.

Method: A cross sectional survey was conducted on a sample of 80 parents of children aged 6 or younger from two French areas. Each parent was interviewed following a semi-structured questionnaire that incorporated social and demographic factors and questions about each of the eleven illustrations. The main outcome was the number of correct answers compared to number of expected answers. The data univariate analysis was followed by a multivariate analysis.

Results: The illustrations of "crying baby", "shaken baby syndrome", "baby car safety", "vision deficiency screening" or "hearing deficiency screening" are misunderstood by more than 60% of the parents. Being a father or being unable to read French significantly increased the risk of not finding 6 of the expected prevention items.

Conclusions: The meaning of illustrations from the French child health record is not accessible to every parent despite the fact that they convey important reminders on preventive care. Family physicians and specialist pediatricians should seize opportunities to enhance preventive care education within medical consultations.
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http://dx.doi.org/10.3917/spub.192.0195DOI Listing
January 2021

Does Personality Predict Behavioral and Psychological Symptoms of Dementia? Results from PACO Prospective Study.

J Alzheimers Dis 2019 ;69(4):1099-1108

Memory Clinical and Research Center of Lyon (CMRR), Aging Institute I-Vie, University Hospital of Lyon, Villeurbanne, France.

Background: Premorbid personality could play a role in the onset of behavioral and psychological symptoms (BPS) in Alzheimer's disease (AD) but prospective studies are lacking.

Objective: The present study aimed at prospectively assessing the influence of premorbid personality traits on BPS evolution in a population of patients with prodromal or mild AD.

Methods: We used a multicenter prospective cohort study of 237 patients followed-up for 18 months. The influence of personality traits on BPS evolution, measured with Neuropsychiatric Inventory (NPI), was assessed using linear mixed-effect models.

Results: A principal components analysis of the 12 NPI behavioral domains yielded five factors labelled as psychotic symptoms, affective symptoms, behavioral dyscontrol, apathy/appetite symptoms, and sleep disorders. During the follow-up, higher neuroticism was significantly associated with a higher progression of affective symptoms (p < 0.0001), apathy/appetite symptoms (p = 0.002), sleep disorders (p = 0.001) as well as global NPI scores (p < 0.0001). Greater conscientiousness was related to a lower evolution of psychotic (p = 0.002), affective (p = 0.02) and apathy/appetite symptoms (p = 0.02), and global NPI score (p < 0.0001). Higher openness was associated with lower affective symptoms evolution (p = 0.01). A significant relationship was found between higher extraversion, lower affective symptoms (p = 0.02), and higher behavioral dyscontrol (p = 0.04).

Conclusion: The present analysis suggests that premorbid personality may influence the evolution of BPS in prodromal or mild AD. Given these results, it seems important to give more importance to personality assessment in early AD, in order to better identify and manage patients at risk of adverse behavioral changes.
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http://dx.doi.org/10.3233/JAD-190183DOI Listing
September 2020

The impact of severe late-effects after 12 Gy fractionated total body irradiation and allogeneic stem cell transplantation for childhood leukemia (1988-2010).

Pediatr Hematol Oncol 2019 Mar 12;36(2):86-102. Epub 2019 Apr 12.

c Host Research Team EA4607 SNA-EPIS, PRES Lyon, Jean Monnet University, University Hospital , Saint-Etienne , France.

This study consists of a retrospective study including 71 childhood leukemia survivors (36 females) treated with allo-HSCT 12 Gy fractionated total body irradiation (fTBI) conditioning, with a median age of 25.0 y at time of follow-up and a median delay of 14.8 y since the graft. The recovery ratio was 90%. The number of severe late-effects was specified for each patient: 21 with growth deficiency (final height <162.5 cm for 12/35 men and <152.0 cm for 9/36 women - Growth deficiency was correlated to young age at the time of the allograft); 5 with sclerodermic chronic graft vs. host disease; 9 with osteonecrosis; risk of impaired fertility for 25 women and 28 men (only 2 women had a child); 8 with diabetes; 5 with pulmonary late-effects including 1 death; 5 with chronic renal insufficiency including 1 death; 2 with cardiac late-effects; 2 with arterial high blood pressure; 11 (8 women) declared 14 subsequent cancers (7 with thyroid carcinomas, 3 with multiple squamous cell carcinomas, 2 with epidermoïdis carcinomas of the tongue or the lip, 1 with bone sarcoma, and 1 with carcinoma of the breast); 6 with chelating treatments of hemochromatosis; 14 with important educational underachievement; 11 with depression at adult age; 1 with hepatitis B virus infection; 4 with other severe late-effects, including 2 with blindness. The average number of severe late-effects was 2.3 with a positive correlation according to delay from fTBI ( < 0.0002). Two-thirds had at least 2 late-effects. These results emphasize the urgent abandonment of conditioning by TBI in children.
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http://dx.doi.org/10.1080/08880018.2019.1591549DOI Listing
March 2019

Clinical and Radiological Predictors of Functional Outcome After Isolated Medial Patellofemoral Ligament Reconstruction at Midterm Follow-up.

Am J Sports Med 2019 05 3;47(6):1338-1345. Epub 2019 Apr 3.

Department of Orthopaedic Surgery, University Hospital of Saint Étienne, Saint Étienne, France.

Background: Isolated medial patellofemoral ligament reconstruction (iMPFLR) is increasingly used for the surgical treatment of recurrent patellofemoral instability.

Purpose: The purpose of this study was to identify the clinical and radiological predictors that can significantly influence the functional outcomes after an iMPFLR.

Study Design: Case series; Level of evidence, 4.

Methods: A total of 107 patients (112 ligament reconstructions) who underwent iMPFLR were evaluated with a mean ± SD follow-up of 59 ± 33 months (range, 12-123 months). Functional International Knee Documentation Committee (IKDC) and Kujala scores were assessed preoperatively and every 12 months. Radiological assessment of patellar height and tilt (Laurin angle, Merchant angle, Maldague classification) and computed tomography (CT) scan measurement of patellar tilt (contracted and relaxed quadriceps) and tibial tubercle-trochlear groove distance were performed preoperatively and at 6 months. Femoral tunnel position was assessed following the criteria formulated by Schöttle. The amount of femoral tunnel widening was measured by means of 3-dimensional CT scan at 6 months. Predictors were determined from univariate and multivariate regression analyses integrating clinical and radiological criteria pre- and postoperatively. The dependent variable was defined as the difference between pre- and postoperative scores.

Results: Between pre- and postoperative measurement at last follow-up, a significant improvement for IKDC and Kujala functional scores was observed (Kujala: 57 ± 11.3 to 87 ± 12.9, P < .001; IKDC: 47.8 ± 13.1 to 79 ± 15.8, P < .001). Demographics (age, body mass index, sex), dislocation characteristics (number of dislocations, time between first dislocation and surgery, age at first dislocation, mechanism of first dislocation, knee side), clinical data (frontal limb alignment, hyperlaxity, recurvatum, pre- and postoperative range of motion), and complications (quadriceps atrophy, complex regional pain syndrome) did not influence functional scores. The predictors of lower improvement in functional scores included small correction of the patellar tilt reported on the CT scan measurement, malpositioning of the femoral tunnel, and a widening of this tunnel near the medial cortex. Malpositioning of the femoral tunnel was correlated with tunnel widening, and patients with anterior and proximal malpositioning experienced stiffness in flexion.

Conclusion: Overall, iMPFLR demonstrated good outcomes. Predictors influencing the functional results were identified. Less improvement in clinical outcome was reported for patients with a high preoperative patellar tilt and only a small correction in tilt and for those who had femoral tunnel malpositioning, which was correlated with tunnel widening.
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http://dx.doi.org/10.1177/0363546519831294DOI Listing
May 2019

Semantic Queries Expedite MedDRA Terms Selection Thanks to a Dedicated User Interface: A Pilot Study on Five Medical Conditions.

Front Pharmacol 2019 6;10:50. Epub 2019 Feb 6.

Laboratoire d'Informatique Médicale et d'Ingénierie des Connaissances en e-Santé, INSERM, Sorbonne Université, Université Paris 13, Paris, France.

Searching into the MedDRA terminology is usually limited to a hierarchical search, and/or a string search. Our objective was to compare user performances when using a new kind of user interface enabling semantic queries versus classical methods, and evaluating term selection improvement in MedDRA. We implemented a forms-based web interface: OntoADR Query Tools (OQT). It relies on OntoADR, a formal resource describing MedDRA terms using SNOMED CT concepts and corresponding semantic relations, enabling terminological reasoning. We then compared time spent on five examples of medical conditions using OQT or the MedDRA web-based browser (MWB), and precision and recall of the term selection. OntoADR Query Tools allows the user to search in MedDRA: One may enter search criteria by selecting one semantic property from a dropdown list and one or more SNOMED CT concepts related to the range of the chosen property. The user is assisted in building his query: he can add criteria and combine them. Then, the interface displays the set of MedDRA terms matching the query. Meanwhile, on average, the time spent on OQT (about 4 min 30 s) is significantly lower (-35%; < 0.001) than time spent on MWB (about 7 min). The results of the System Usability Scale (SUS) gave a score of 62.19 for OQT (rated as good). We also demonstrated increased precision (+27%; = 0.01) and recall (+34%; = 0.02). Computed "performance" (correct terms found per minute) is more than three times better with OQT than with MWB. This pilot study establishes the feasibility of our approach based on our initial assumption: performing MedDRA queries on the five selected medical conditions, using terminological reasoning, expedites term selection, and improves search capabilities for pharmacovigilance end users. Evaluation with a larger number of users and medical conditions are required in order to establish if OQT is appropriate for the needs of different user profiles, and to check if conclusions can be extended to other kinds of medical conditions. The application is currently limited by the non-exhaustive coverage of MedDRA by OntoADR, but nevertheless shows good performance which encourages continuing in the same direction.
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http://dx.doi.org/10.3389/fphar.2019.00050DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6374626PMC
February 2019

Do Home-Based Psychiatric Services for Patients in Medico-Social Institutions Reduce Hospitalizations? Pre-Post Evaluation of a French Psychiatric Mobile Team.

Psychiatr Q 2019 03;90(1):89-100

Psychiatry Department, University Hospital of Saint Etienne, Saint Etienne, France.

World Health Organization recommends the implementation of alternatives to full-time hospitalizations. Psychiatric home-care has known a worldwide development in the last 20 years. The psychiatric mobile team for social and medico-social institutions in Saint-Etienne, France, (Equipe mobile d'intervention en établissements Sociaux et Médico-sociaux, ESMS) aims to support professionals from medico-social housing institutions (MSHI) in order to maintain people in housing. The objective of the study was to evaluate the efficiency of home-based interventions to reduce hospitalizations and improve collaboration between psychiatric hospital facilities and MSHI. We used a pre-post study design. A same cohort of patients living in a MSHI one year before intervention and one year after implementation of the ESMS was studied. Hospitalizations were compared between the two periods. A survey was conducted for qualitative evaluation among professionals in MHSI. Sixty-three patients were included. Most patients suffered from psychotic disorders (71%). We found a significant decrease in the mean number of admissions per year from 2,06 to 1,48 (Wilcoxon signed rank test; df64; p = 0,01). Mobile-team interventions included answering phone calls, home visits, coordination meetings, or clinical interviews with patients in inpatient and outpatient services, with an average of 9,3 interventions per patient (SD = 11,4). ESMS was evaluated as "essential" for 73% of 11 professionals from MSHI who answered the questionnaire in May 2017. Assertive Community Treatment and Crisis Resolution Teams are the most studied home-care models in psychiatry. Our results tend to show the efficiency of mobile-team interventions in MSHI, to enhance partnerships.
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http://dx.doi.org/10.1007/s11126-018-9603-6DOI Listing
March 2019

Dysautonomia in Childhood Cancer Survivors: A Widely Underestimated Risk.

J Adolesc Young Adult Oncol 2019 02 23;8(1):9-17. Epub 2018 Aug 23.

4 Host Research Team EA4607 SNA-EPIS (Autonomic Nervous System, Epidemiology, Physiology, Exercise, and Health), Jean Monnet University of Saint-Etienne, PRES (Education and Research Cluster) Lyon, Saint-Etienne, France.

Purpose: Survival rate of childhood cancers is now reaching 80% overall. However, early or late complications related to surgery, chemotherapy, and radiotherapy remain at a high rate and greatly increase the risk of late mortality. The objective of this study is to assess the autonomic nervous system (ANS) activity, measured through heart rate variability indices in childhood cancer survivors compared with healthy controls.

Methods: This prospective study included 51 long-term childhood cancer survivors diagnosed before 15 years of age between 1987 and 1992 and controlled for age and sex with healthy volunteers.

Results: We observed a significant increase in spontaneous heart rate (beats per minute) (67 ± 10 vs. 60 ± 10, p = 0.001), and all the studied parameters showed a significantly altered ANS activity in cases compared with healthy controls. In both groups, the main cofactors of dysautonomia (tobacco, drugs, cannabis, estro-progestative pills, alcohol, limited physical activity) were analyzed without any significant difference. The effect of cancer treatments received was not analyzed due to the small number of participants.

Conclusion: The results showed a significant ANS dysfunction in childhood cancer survivors compared with healthy controls and suggested the value of autonomic screening to underscore and possibly quantify the effect of the cancer treatments in a larger cohort. This evaluation could lead to the recommendation to increase physical activity, the most efficient way known to improve ANS activity, as already shown in other pathologies (breast cancer).
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http://dx.doi.org/10.1089/jayao.2018.0021DOI Listing
February 2019

Fecundity and Quality of Life of Women Treated for Solid Childhood Tumors Between 1948 and 1992 in France.

J Adolesc Young Adult Oncol 2018 08 31;7(4):415-423. Epub 2018 May 31.

5 Department of Paediatric Oncology, Institut Gustave Roussy , Villejuif, France .

Purpose: To describe fecundity in female survivors of childhood cancer and consider the correlation with quality of life (QOL).

Materials And Methods: Of 1744 women treated for childhood cancer before the age of 15 years at one of eight French cancer treatment centers between 1948 and 1992, 1187 who were alive in 2005 were sent a self-administered questionnaire, including questions about health status, QOL (MOS SF-36), and fecundity. A standardized fecundity ratio (SFR) was calculated (SFR: observed/expected number of children) for each individual based on a national reference.

Results: Of the 972 individuals (82%) who responded, 53% had at least 1 child. The overall SFR, 0.65, was dependent upon the initial diagnosis, more decreased in Central Nervous System tumors (0.24; p < 10) than in Germ cell (0.46; p = 0.03) or Sympathetic Nervous System tumors (0.79; p = 0.02). The average QOL motor score was 72.5 ± 19.5, and the average mental score was 61.4 ± 16.7. After adjusting for age, pathology, and self-reported sequelae in the questionnaires, it was determined that SF-36 mental (p = 0.002) and motor (p < 0.0002) scores correlated positively with fecundity, and SF-36 scores correlated negatively with locomotor late effects (p < 0.0001), growth insufficiency (p = 0.002), and psychological disorders (p < 0.001). Gonadal insufficiency was correlated with neither motor nor mental scores.

Conclusion: Women treated for childhood cancer demonstrated impaired fecundity that correlated with poor QOL, as registered by the SF-36. Patients should be warned of the risk of impaired fecundity early during the follow-up. If possible, preservation of fertility should be prioritized at initiation of therapy.
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http://dx.doi.org/10.1089/jayao.2017.0126DOI Listing
August 2018

Predictors of Discharge Destinations and Three-Month Evolution of Patients Initially Hospitalized in a Cognitive Behavioral Unit.

J Alzheimers Dis 2017 ;60(4):1259-1266

Neurology Unit, CM2R, CHU de Saint Etienne, Hôpital Nord, Saint Etienne, France.

Background: Previous studies showed that a third of patients living at home entered an institution after hospitalization in Cognitive and Behavioral Units (CBUs).

Objective: The main objective of this study was to identify predictors of discharge destination for these patients. The secondary objective was to estimate whether institutionalization can have an impact on a patient's long-term prognosis.

Methods: The study population was selected from the EVITAL study and included 140 participants living at home before hospitalization in CBUs. Factors favoring nursing-home admission were investigated and the impact of discharge destinations (i.e., home or nursing home) on patients' prognosis was examined.

Results: Institutionalized patients were more likely to be women (F = 4.7; p = 0.03), with a higher dementia severity (F = 9.82; p = 0.007), often living alone (F = 19.69; p = 0.001), with a caregiver other than spouse (F = 8.93; p = 0.003), and with a higher patient quality of life (QoL) according to the caregiver (F = 11.73; p = 0.001). When using multivariate logistic linear regressions, we showed a relationship between marital status (OR = 0.19, 95% CI: 0.08-0.43, p < 0.001), dementia severity (OR = 0.15, 95% CI: 0.03-0.79, p = 0.03), QoL (OR = 0.88, 95% CI: 0.79-0.98, p = 0.017), and institutionalization. At three months, a higher overall rate of rehospitalization (F = 12.21; p < 0.001) and rehospitalization for behavioral and psychological symptoms of dementia (F = 6.76; p = 0.006) were observed for patients staying at home after CBU discharge.

Conclusion: Our study allows for a better understanding of the institutionalization risk factors of the patients hospitalized in CBUs. Identification of these factors could help clinicians to better support patients and to help the transition to be smoother. Moreover, our results suggest that prognosis of institutionalized patients is not unfavorable when compared with patients staying at home.
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http://dx.doi.org/10.3233/JAD-170419DOI Listing
July 2018

Long-Term Follow-up Consultation After Childhood Cancer in the Rhône-Alpes Region of France: Feedback From Adult Survivors and Their General Practitioners.

J Adolesc Young Adult Oncol 2017 Dec 25;6(4):524-534. Epub 2017 May 25.

9 Department of Internal Medicine Unit, University Hospital of Saint-Etienne , Saint-Etienne Cedex 02, France .

Purpose: We evaluated the satisfaction of adult survivors of childhood cancers and their general practitioners (GP) after a long-term consultation.

Methods: The first Long-term Follow-up Study in Oncology (SALTO1) is a prospective cohort study of survivors of childhood cancers (except leukemia) diagnosed between 1987 and 1992 in the Rhône-Alpes and Auvergne regions of France. Of the 481 patients eligible for the study, 150 participated in a long-term consultation with a pediatric oncologist and an internist, after which survivors and their GPs received long-term plans and recommendations based on consultation findings. A year after the consultation, survivors and their GPs assessed their satisfaction with the process.

Results: Of the 150 survivor participants in the long-term follow-up, 120 (80%) completed the satisfaction form, with 107 (89%) reporting satisfaction. Forty-eight (32%) expressed strengthening their follow-up as a consequence of the consultation. Of the 79 survivors sent recommendations, 76 (96%) reported reading them, most (n = 68; 86%) found them useful, and 56 (71%) followed recommendations. Of the 107 GPs of the survivors, 82 (77%) conceded having been poorly informed about long-term complications for their patients after chemotherapy, and 93 (88%) appreciated having a hospital contact available for these patients.

Conclusion: The long-term consultations ultimately enhanced medical follow-up of survivor participants, improving knowledge of both patients and family physicians regarding the patients' early disease, its treatments, and possible concerns, and offering consultative resources of medical specialists. The levels of participation of survivors and their physicians and reported satisfaction encourage the adoption of such consultations throughout France.
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http://dx.doi.org/10.1089/jayao.2017.0019DOI Listing
December 2017

How to Link SNOMED CT Procedure and WHO International Classification of Health Interventions (ICHI).

Stud Health Technol Inform 2017 ;236:40-47

Department of Health Policy and Management Kuwait University, Kuwait.

Among different used healthcare terminology resources there is a need to link them to ease their interoperability. SNOMED CT is the most detailed clinical reference terminology for procedure used in the Electronic Health Record (EHR). WHO developed since 2006 an aggregated classification named ICHI required for statistics and resource allocation. It is based on an ontology framework defined in ISO 1828 named Categorial Structure (CAST) for surgical procedures. We present ICHI coding structure, ISO 1828 CAST standard for surgical procedures and SNOMED CT procedures hierarchy concept model and their relations. We demonstrate the obstacles to align ICHI coding structure with ISO 1828 CAST which can be linked with SNOMED CT procedures hierarchy concept model. We recommend to update ICHI coding structure to decrease the gap with ISO 1828 CAST and SNOMED CT concept model for procedures hierarchy to allow users to share the different terminology resources.
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April 2018

Histopathologic features predict survival in diffuse pleural malignant mesothelioma on pleural biopsies.

Virchows Arch 2017 Jun 27;470(6):639-646. Epub 2017 Mar 27.

Department of Pathology, North Hospital, University Hospital of Saint Etienne, Avenue Albert Raimond, Cedex 2, 42055, Saint Etienne, France.

Malignant pleural mesothelioma is a rare tumor with a poor prognosis. The only universally recognized pathological prognostic factor is histopathological subtype with a shorter survival in non-epithelioid subtypes. Recently, a grading of epithelioid mesothelioma on surgical resection has been proposed. The aim of our work is to assess the prognostic role of several histopathological factors on a retrospective cohort of 116 patients diagnosed as a pleural mesothelioma for more than 95% of patients on pleural biopsy. Our work shows that mitotic count <3/10 HPF (p < 0.0001), the lack of necrosis (p = 0.0379), mild nuclear atypia (p = 0.0054), the lack of atypical mitoses (p = 0.0265), a nucleoli size <3 μm (p = 0.0139), and a nucleoli absent or visible at 200× or higher magnification (p = 0.0170) are significantly associated with a better median overall survival in epithelioid mesothelioma. The presence of atypical mitoses was found to be related to a worse median survival in non-epithelioid mesothelioma. Mitotic count, necrosis, nuclear atypia, and nucleoli size are not associated with overall survival in non-epithelioid mesothelioma. Our work highlights that histopathological prognostic factors can be assessed on pleural biopsies and can predict reliably median overall survival. This is of interest in order to define subgroups of patients who could benefit of different therapies and select patients who could benefit of surgical excision.
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http://dx.doi.org/10.1007/s00428-017-2109-zDOI Listing
June 2017

Histopathologic features predict survival in diffuse pleural malignant mesothelioma on pleural biopsies.

Virchows Arch 2017 Jun 27;470(6):639-646. Epub 2017 Mar 27.

Department of Pathology, North Hospital, University Hospital of Saint Etienne, Avenue Albert Raimond, Cedex 2, 42055, Saint Etienne, France.

Malignant pleural mesothelioma is a rare tumor with a poor prognosis. The only universally recognized pathological prognostic factor is histopathological subtype with a shorter survival in non-epithelioid subtypes. Recently, a grading of epithelioid mesothelioma on surgical resection has been proposed. The aim of our work is to assess the prognostic role of several histopathological factors on a retrospective cohort of 116 patients diagnosed as a pleural mesothelioma for more than 95% of patients on pleural biopsy. Our work shows that mitotic count <3/10 HPF (p < 0.0001), the lack of necrosis (p = 0.0379), mild nuclear atypia (p = 0.0054), the lack of atypical mitoses (p = 0.0265), a nucleoli size <3 μm (p = 0.0139), and a nucleoli absent or visible at 200× or higher magnification (p = 0.0170) are significantly associated with a better median overall survival in epithelioid mesothelioma. The presence of atypical mitoses was found to be related to a worse median survival in non-epithelioid mesothelioma. Mitotic count, necrosis, nuclear atypia, and nucleoli size are not associated with overall survival in non-epithelioid mesothelioma. Our work highlights that histopathological prognostic factors can be assessed on pleural biopsies and can predict reliably median overall survival. This is of interest in order to define subgroups of patients who could benefit of different therapies and select patients who could benefit of surgical excision.
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http://dx.doi.org/10.1007/s00428-017-2109-zDOI Listing
June 2017

Inconsistencies Between Antiparkinsonian Drugs and ICD-10 Codes in Inpatients: A TOLBIAC Project Case Study.

Stud Health Technol Inform 2016 ;228:364-8

INSERM, U1142, LIMICS, F-75006, Paris, France; Sorbonne Universités, UPMC Université. Paris 06, UMR_S 1142, LIMICS, F-75006, Paris, France; Paris University13, Sorbonne Paris City, LIMICS, (UMR_S 1142), F-93430, Villetaneuse, France.

In France, data derived from hospital information systems are adequate to feed the prospective payment system. The consistency between drugs prescribed to patients and their indications could solve difficulties related to the identification of ICD-10 undercoded chronic diseases as the Parkinson Disease. Our goal was to highlight patients' stays mentioning administration of antiparkinsonian drugs and not coded for Parkinson's disease. Our approach was to parameterize tables of associations between ICD-10 codes and drug identifiers in the Web100T® application that collects medical information in our hospital and displays related inconsistencies for patients' stays. Based on acute care patients' stays of the second semester of 2015, we identified 246 patients corresponding to 253 stays, for which 33% of stays were not coded with the ICD-10 G20 code of the Parkinson's disease. The precision of our approach was 29%. Based on these data we predict roughly 84 patient stays without mention of Parkinson Disease. We plan to extend this study to other drugs and other kinds of data available in the health information system, such as biology or medical devices in order to improve the coding of chronic diseases in our hospital.
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April 2017

Fetching Connected Pedometer Data to Analyze Patients Walking.

Stud Health Technol Inform 2016 ;221:130

Service de Médecine Vasculaire et Thérapeutique - CHU Hôpital Nord, Saint-Etienne, France.

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January 2017

Improvement of Diagnosis Coding by Analysing EHR and Using Rule Engine: Application to the Chronic Kidney Disease.

Stud Health Technol Inform 2015 ;210:120-4

INSERM, U1142, LIMICS, F-75006, Paris, France; Sorbonne Universités, UPMC Univ. Paris 06, UMR_S 1142, LIMICS, F-75006, Paris, France; Université Paris 13, Sorbonne Paris Cité, LIMICS, (UMR_S 1142), F-93430, Villetaneuse, France.

Coding medical diagnosis in case mix databases is a time-consuming task as every information available in patient records has to be taken into account. We developed rules based on EHR data with the Drools rules engine in order to support diagnosis coding of chronic kidney disease (CKD) in our hospital. 520 patients had a GFR < 60 ml/min as estimated by the Cockroft-Gault formula and corresponded to 429 case mix database entries. We compared stays in which the patient was older than 12 and younger than 65 or 80 at the time of the stay. We concluded that our rules engine implementation may improve coding of CKD for 45.6% of patients with a GFR < 60 ml/min and younger than 65. When patients are older than 65 our rule engine may be less useful for suggesting missing codes of CKD because the estimation of GFR by the Cockroft-Gault formula becomes less reliable as patients get older.
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October 2016

Age at Birth of First Child and Fecundity of Women Survivors of Childhood Acute Lymphoblastic Leukemia (1987-2007): A Study of the Childhood Cancer Registry of the Rhône-Alpes Region in France (ARCERRA).

Pediatr Hematol Oncol 2015 May;32(4):273-83

Childhood Cancer Registry of the Rhône-Alpes Region (ARCERRA) and University of Saint-Etienne , Saint-Etienne , France.

We studied the fecundity of 174 successive ALL (1987-2007) in females of the Childhood Cancer Registry of the Rhône-Alpes Region (ARCERRA) with a median age at follow-up of 25.6 years (18.0-37.4). We distinguished five treatment groups: Group Ia, chemotherapy only (n = 130); Ib, chemotherapy with cranial radiotherapy (n = 10); II, TBI conditioning allograft (n = 27); III, chemotherapy conditioning allograft (n = 4); IV, TBI conditioning autograft (n = 3). Twenty-three women had their first child at the mean age of 25.8 ±3.0 years, i.e., 2.0 ±2.9 years earlier than the general population of the Rhône-Alpes region (P = 0.003). The standardized fertility ratio (SFR), expressed as the number of actual births observed (O) to the number that would be expected in women of the same age in the general population (E) (SFR = O/E) was decreased for Group Ia (0.62; 95%CI, 0.52-0.74) and collapsed in Group II (0.17; 0.11-0.25). In univariate analysis, TBI (P = 0.013) and alkylating agents (P = 0.01) were negatively correlated with fecundity, but not with the age at diagnosis or the anthracyclines doses. In multivariate analysis including TBI and alkylating agents, we still found a negative correlation between TBI (P = 0.035), as well as alkylating agents (P = 0.028), and fecundity. More precisely, fecundity was negatively correlated with cumulative cyclophosphamide equivalent dose (P = 0.001), with a fecundity decreased for ≥1g/m(2), but without any dose effect; results not found in the Group Ia. Age at first child seems younger but the young median age of the cohort not allows concluding; fecundity is collapsed after fractionated total body irradiation and decreased after chemotherapy without any demonstrable cause. A delay of fertility is not excluded.
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http://dx.doi.org/10.3109/08880018.2015.1020178DOI Listing
May 2015

Initial and long-term evaluation of patients with Alzheimer's after hospitalization in cognitive and behavioural units: the EVITAL study design.

BMC Psychiatry 2014 Nov 15;14:308. Epub 2014 Nov 15.

Background: Alzheimer's disease and related disorders are characterized by cognitive impairment associated with behavioral and psychological symptoms of dementia. These symptoms have significant consequences for both the patient and his family environment. While risk factors for behavioral disorders have been identified in several studies, few studies have focused on the evolution of these disorders. Moreover, it is important to identify factors linked to the long-term evolution of behavioral disorders, as well as patients' and caregivers' quality of life. Our purpose is to present the methodology of the EVITAL study, which primary objective is to determine the factors associated with the evolution of behavioral disorders among patients with Alzheimer's disease and related disorders during the year following their hospitalization in cognitive and behavioral units. Secondary objectives were 1) to assess the factors related to the evolution of behavioral disorders during hospitalization in cognitive and behavioral units; 2) to identify the factors linked to patients' and caregivers' quality of life, as well as caregivers' burden; 3) to assess the factors associated with rehospitalization of the patients for behavioral disorders in the year following their hospitalization in cognitive and behavioral units.

Method/design: A multicenter, prospective cohort of patients with Alzheimer's disease and related disorders as well as behavioral disorders who are hospitalized in cognitive and behavioral units. The patients will be included in the study for a period of 24 months and followed-up for 12 months. Socio-demographic and environmental data, behavioral disorders, medications, patients and caregivers quality of life as well as caregivers burden will be assessed throughout hospitalization in cognitive and behavioral units. Follow-up will be performed at months 3, 6 and 12 after hospitalization. Socio-demographic and environmental data, behavioral disorders, medications, patients and caregivers quality of life, unplanned rehospitalization as well as caregivers burden will also be assessed at each follow-up interview.

Discussion: The present study should help better identify the factors associated with reduction or stabilization of the behavioral and psychological symptoms of dementia in patients with Alzheimer's disease. It could therefore help clinicians to better manage these symptoms.

Trial Registration: Clinical Trials NCT01901263. Registered July 9, 2013.
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http://dx.doi.org/10.1186/s12888-014-0308-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4239389PMC
November 2014

[Not Available].

Therapie 2014 Nov-Dec;69(6):483-90

Centre de pharmacovigilance, Centre hospitalier universitaire de Saint-Étienne, Saint-Étienne - Hôpital Nord, France.

Aim: To evaluate the value of research in the case-mix database to identify cases of drug-related anaphylactic or anaphylactoid shock.

Methods: Hospital stays of patients discharged from the University Hospital of Saint-Étienne between July 1st 2009 and June 30th 2012. Five codes from the international classification of diseases were selected: T88.6, T88.2, J39.3, T80.5 and T78.2.

Results: Among 89 cases identified by the programme for medicalization of information system (programme de médicalisation des systèmes d'information, PMSI), 40 were selected (45%). Of these, 16 cases were spontaneously reported by physicians. The unspecific code "anaphylactic shock unspecified (T78.2)" was coded for 57.5% of cases.

Conclusion: The study confirms the interest of the PMSI as a tool for health monitoring, in addition to spontaneous reporting. Nevertheless, coding with insufficient precision about the causal role of the drug, requires a return to the medical record and so an important time consuming process.
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http://dx.doi.org/10.2515/therapie/2014057DOI Listing
July 2016

[Drug-related anaphylactic shocks: under-reporting and PMSI].

Therapie 2014 Nov-Dec;69(6):483-90. Epub 2014 Oct 1.

Centre de pharmacovigilance, Centre hospitalier universitaire de Saint-Étienne, Saint-Étienne - Hôpital Nord, France.

Aim: To evaluate the value of research in the case-mix database to identify cases of drug-related anaphylactic or anaphylactoid shock.

Methods: Hospital stays of patients discharged from the University Hospital of Saint-Étienne between July 1st 2009 and June 30th 2012. Five codes from the international classification of diseases were selected: T88.6, T88.2, J39.3, T80.5 and T78.2.

Results: Among 89 cases identified by the programme for medicalization of information system (programme de médicalisation des systèmes d'information, PMSI), 40 were selected (45%). Of these, 16 cases were spontaneously reported by physicians. The unspecific code "anaphylactic shock unspecified (T78.2)" was coded for 57.5% of cases.

Conclusion: The study confirms the interest of the PMSI as a tool for health monitoring, in addition to spontaneous reporting. Nevertheless, coding with insufficient precision about the causal role of the drug, requires a return to the medical record and so an important time consuming process.
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http://dx.doi.org/10.2515/therapie/2014057DOI Listing
February 2015

Ci4SeR--curation interface for semantic resources--evaluation with adverse drug reactions.

Stud Health Technol Inform 2014 ;205:116-20

INSERM, U1142, LIMICS, F-75006, Paris, France; Sorbonne Universités, UPMC Univ Paris 06, UMR_S 1142, LIMICS, F-75006, Paris, France; Université Paris 13, Sorbonne Paris Cité, LIMICS, (UMR_S 1142), F-93430, Villetaneuse, France.

Evaluation and validation have become a crucial problem for the development of semantic resources. We developed Ci4SeR, a Graphical User Interface to optimize the curation work (not taking into account structural aspects), suitable for any type of resource with lightweight description logic. We tested it on OntoADR, an ontology of adverse drug reactions. A single curator has reviewed 326 terms (1020 axioms) in an estimated time of 120 hours (2.71 concepts and 8.5 axioms reviewed per hour) and added 1874 new axioms (15.6 axioms per hour). Compared with previous manual endeavours, the interface allows increasing the speed-rate of reviewed concepts by 68% and axiom addition by 486%. A wider use of Ci4SeR would help semantic resources curation and improve completeness of knowledge modelling.
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May 2015

Frequency and severity of adverse drug reactions due to self-medication: a cross-sectional multicentre survey in emergency departments.

Drug Saf 2013 Dec;36(12):1159-68

EA 3826, Faculté de Médecine, 1 rue Gaston Veil, 44035, Nantes, France,

Background: Little is known about the relation of adverse drug reactions (ADRs) to self-use of medications.

Objective: The aim of this study was to determine the frequency and severity of ADRs related to self-medication (ADR-SM) among emergency department (ED) patients and to describe their main characteristics.

Methods: A prospective, cross-sectional, observational study was conducted over a period of 8 weeks (1 March to 20 April 2010), in the ED of 11 French academic hospitals. Adult patients presenting to the ED during randomization periods were included, with the exception of cases of self-drug poisoning, inability to complete self-medication questionnaire, or refusal. Clinical outcomes were assessed as well as history of self-medication behaviours and all drugs taken. All doubtful files and those related to ADR-SM were systematically reviewed by an expert committee.

Results: A total of 3,027 of 4,661 patients presenting to the ED met the inclusion criteria. Of these, 84.4 % declared a self-medication behaviour, 63.7 % took at least one non-prescribed drug during the previous 2 weeks and 59.9 % took a prescribed medication. A total of 296 patients experienced an ADR (9.78 %), of which 52 (1.72 %) were related to self-medication. Those ADRs related to self-medication included prescribed drugs (n = 19), non-prescribed drugs (n = 17), treatment discontinuation (n = 14), and interactions between non-prescribed and prescribed drugs (n = 2). The ADRs attributed to non-prescribed drugs represented 1 % of all patients taking non-prescribed drugs (n = 1,927). ADR severity was significantly lower for those related to self-medication (p = .032).

Conclusion: Self-medication is frequent; its potential toxicity should not be neglected, taking into account the rate of adverse drug reactions in about 1 % of ED patient.
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http://dx.doi.org/10.1007/s40264-013-0114-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3834162PMC
December 2013

Academic difficulties and occupational outcomes of adult survivors of childhood leukemia who have undergone allogeneic hematopoietic stem cell transplantation and fractionated total body irradiation conditioning.

Pediatr Hematol Oncol 2014 Apr 2;31(3):225-36. Epub 2013 Oct 2.

Childhood Cancer Registry of the Rhône-Alpes Region , Saint-Etienne , France.

We studied academic and employment outcomes in 59 subjects who underwent allogeneic hematopoietic stem cell transplantation (a-HSCT) with fractionated total body irradiation (fTBI) for childhood leukemia, comparing them with, first, the general French population and, second, findings in 19 who underwent a-HSCT with chemotherapy conditioning. We observed an average academic delay of 0.98 years among the 59 subjects by Year 10 of secondary school (French class Troisième), which was higher than the 0.34-year delay in the normal population (P < .001) but not significantly higher than the delay of 0.68 years in our cohort of 19 subjects who underwent a-HSCT with chemotherapy. The delay was dependent on age at leukemia diagnosis, but not at fTBI. This delay increased to 1.32 years by the final year of secondary school (Year 13, Terminale) for our 59 subjects versus 0.51 years in the normal population (P = .0002), but did not differ significantly from the 1.08-year delay observed in our cohort of 19 subjects. The number of students who received their secondary school diploma (Baccalaureate) was similar to the expected rate in the general French population for girls (observed/expected = 1.02) but significantly decreased for boys (O/E = 0.48; CI: 95%[0.3-0.7]). Compared with 13.8% of the general population, 15.3% of the cancer survivors received no diploma (P = NS). Reported job distribution did not differ significantly between our cohort of childhood cancer survivors and the general population except that more female survivors were employed in intermediate-level professional positions. Academic difficulties after fTBI are common and their early identification will facilitate educational and professional achievement.
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http://dx.doi.org/10.3109/08880018.2013.829541DOI Listing
April 2014

[Refusal of application to care in Alzheimer's disease and related diseases: establishment of a mobile unit hospital extra].

Geriatr Psychol Neuropsychiatr Vieil 2013 Mar;11(1):49-55

CM2R, CHU de Saint-Étienne, France.

Unlabelled: Refusal of care and support in these patients with Alzheimer's disease and related illnesses at home is a cause of accelerated loss of autonomy and increases the risk of a crisis with early institutionalization. Factors contributing to the denial of care are poorly understood and very few epidemiological data exist.

Materials And Methods: we compared age, diagnosis, level of severity of the disease, the type of behavioral, family status of 101 patients living in denial of care and support as seen by a mobile home (group UPEPc) to 136 control patients seen at the memory clinic (group CM). Patients living in denial of care appear to significantly low age [82/80.5, p<0.0001], with more advanced disease [average MMSE 18/22, p<0.0001], the presence family conflicts and behavioral disorders [delirious--hallucination, agitation--aggression, depression, apathy, p<0.05].

Conclusion: the profile of patients refusing home care is specific and it is important to educate GPs conditions that favor an obstacle to medicalization. The advantage of a mobile extramural to analyze risk factors for refusal of care and propose alternatives should be further investigated.
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http://dx.doi.org/10.1684/pnv.2013.0390DOI Listing
March 2013