Showing papers in "Revue D Epidemiologie Et De Sante Publique in 2008"

Cancer incidence and mortality in France over the period 1980–2005

Abstract: BACKGROUND: The objective of this study was to provide updated estimates of national trends in cancer incidence and mortality for France for 1980-2005. METHODS: Twenty-five cancer sites were analysed. Incidence data over the 1975-2003 period were collected from 17 registries working at the department level, covering 16% of the French population. Mortality data for 1975-2004 were provided by the Inserm. National incidence estimates were based on the use of mortality as a correlate of incidence, mortality being available at both department and national levels. Observed incidence and mortality data were modelled using an age-cohort approach, including an interaction term. Short-term predictions from that model gave estimates of new cancer cases and cancer deaths in 2005 for France. RESULTS: The number of new cancer cases in 2005 was approximately 320,000. This corresponds to an 89% increase since 1980. Demographic changes were responsible for almost half of that increase. The remainder was largely explained by increases in prostate cancer incidence in men and breast cancer incidence in women. The relative increase in the world age-standardised incidence rate was 39%. The number of deaths from cancer increased from 130,000 to 146,000. This 13% increase was much lower than anticipated on the basis of demographic changes (37%). The relative decrease in the age-standardised mortality rate was 22%. This decrease was steeper over the 2000-2005 period in both men and women. Alcohol-related cancer incidence and mortality continued to decrease in men. The increasing trend of lung cancer incidence and mortality among women continued; this cancer was the second cause of cancer death among women. Breast cancer incidence increased regularly, whereas mortality has decreased slowly since the end of the 1990s. CONCLUSION: This study confirmed the divergence of cancer incidence and mortality trends in France over the 1980-2005 period. This divergence can be explained by the combined effects of a decrease in the incidence of the most aggressive cancers and an increase in the incidence of less aggressive cancers, partly due to changes in medical practices leading to earlier diagnoses.

[Consensus methods: review of original methods and their main alternatives used in public health].

Abstract: Background Consensus-based studies are increasingly used as decision-making methods, for they have a lower production cost than other methods (observation, experimentation, modeling) and provide results more rapidly. The objective of this paper is to describe the principles and methods of the four main methods – Delphi, nominal group, consensus development conference and RAND/UCLA – their use as reported in peer-reviewed publications and validation studies published in the healthcare literature. Methods A bibliographic search was performed in PubMed/MEDLINE, banque de donnees sante publique (BDSP), The Cochrane Library, Pascal and Francis. Keywords, headings and qualifiers corresponding to a list of terms and expressions related to the consensus methods were searched for in the thesauri and used in the literature search. A search with the same terms and expressions was performed on Internet using the website Google Scholar. Results All methods, precisely described in the literature, are based on common basic principles such as definition of the subject, selection of experts and direct or remote interaction processes. They sometimes use quantitative assessment for ranking items. Numerous variants of these methods have been described. Few validation studies have been implemented. Not implementing these basic principles and failing to describe the methods used to reach the consensus were both frequent reasons raising suspicion regarding the validity of consensus methods. Conclusion When it is applied to a new domain with important consequences in terms of decision-making, a consensus method should first be validated.

Quels facteurs influencent la pratique du dépistage des cancers féminins en France

Abstract: Background The two aims of the study were, first to estimate the declared two-year coverage of breast cancer and cervical cancer screenings, and second to determine the main factors influencing female cancer screening behaviors. Methods Three groups of women from the 2003 French decennial health interview survey were analyzed: 3378 women aged 50–74 years who answered the question on mammography use, 7912 women aged 25–65 years who answered the question on Pap-smear use, and 2528 women aged 50-65 years who answered both questions. Results The declared coverage of breast cancer screening was 71.2%, the declared coverage of cervical cancer screening was 76.3%. Almost 18% of women declared having undergone neither a mammography nor a Pap-smear in the last two years. The main factor linked to a more frequent practice of one or both cancer screenings (breast or cervix) was to have undergone recently the other screening. The other factors linked to mammography use were mainly healthcare and practitioner access variables. Those linked to Pap-smear use were mainly socioeconomic and socio-demographic variables, healthcare and practitioner access variables being also linked. The main factors linked to having undergone none of these two screenings were of financial nature, particularly household income and home ownership. Conclusion The study showed that it is appropriate to communicate on both screenings at the same time since they have a positive effect each other. Finally, practitioners continue to play a central role in collecting information on cancer screenings and encouraging screening in women not regularly screened.

La double peine des ouvriers : plus d’années d’incapacité au sein d’une vie plus courte

Abstract: En 2003, en France, un homme âge de 35 ans peut esperer vivre encore 43 ans, dont 28 indemne de toute incapacite, une femme, 49 ans, dont 29 indemne d'incapacite. Les incapacites les plus severes, impliquant eventuellement une situation de dependance, n'occupent en moyenne que 3 annees d'une vie pour les hommes et 5 annees pour les femmes. Le nombre d'annees vecues avec ou sans incapacite varie selon la categorie professionnelle : en 2003, un homme cadre de 35 ans peut esperer vivre encore 47 ans dont 34 indemne de toute incapacite, un ouvrier, 41 ans dont 24 ans sans incapacite. Ces differences se renforcent avec l'avancee en âge : apres 60 ans, les ouvriers et les ouvrieres vivent en moyenne plus d'annees avec que sans incapacite et endureront aussi plus d'incapacites severes que les cadres. Au sein d'une vie deja plus courte, les ouvriers passent donc a la fois moins de temps sans incapacite que les cadres, et vivent plus longtemps qu'eux avec des incapacites et des handicaps.

Modélisation de l'impact de la vaccination sur l'épidémiologie de la varicelle et du zona

Abstract: Background The soon to come the availability of a combined MMR-varicella vaccine has re-stimulated the debate around universal infant vaccination against varicella. In France, the incidence of varicella is estimated at about 700,000 cases per year, with approximately 3500 hospitalisations and 15–25 deaths, the latter mainly occurring in those over 15 years. Vaccination would certainly decrease the overall incidence of the disease but concerns about vaccination leading to a shift in the average age at infection followed by an increase in incidence of severe cases and congenital varicella, still remain. In order to provide support for decision-making, a dynamic mathematical model of varicella virus transmission was used to predict the effect of different vaccination strategies and coverages on the epidemiology of varicella and zoster. Methods A deterministic realistic age-structured model was adapted to the French situation. Epidemiological parameters were estimated from literature or surveillance data. Various vaccine coverages and vaccination strategies were investigated. A sensitivity analysis of varicella incidence predictions was performed to test the impact of changes in the vaccine parameters and age-specific mixing patterns. Results The model confirms that the overall incidence and morbidity of varicella would likely be reduced by mass vaccination of 12-month-old children. Whatever the coverage and the vaccine strategy, the vaccination will cause a shift in age distribution with, for vaccination coverage up to at least 80% in the base-case analysis, an increased morbidity among adults and pregnant women. However, the total number of deaths and hospitalisations from varicella is predicted to remain below that expected without vaccination. The model is very sensitive to the matrix of contacts used and to the parameters describing vaccine effectiveness. Zoster incidence will increase over a number of decades followed by a decline to below prevaccination levels. Conclusion Mass varicella vaccination, in France, will result in an overall reduction of varicella incidence but will cause a shift in age distribution with an increase in adult cases. Due to the uncertainties in key parameters values, the exact magnitude of this shift is difficult to assess.

Plusieurs centaines de milliers de chutes chez les personnes âgées chaque année en France

Abstract: Accidents de la vie courante, epidemiologie, chutes, personnes âgees / Home and leisure injuries, epidemiology, falls, elderly people Introduction – Les personnes âgees de 65 ans et plus sont victimes chaque annee en France de 550 000 accidents de la vie courante (AcVC) avec recours aux urgences. Elles contribuent pour plus des trois quarts aux 20 000 deces annuels par AcVC. Une grande majorite de ces AcVC sont le resultat de chutes. Methodes – L’Enquete permanente sur les accidents de la vie courante repose sur l’enregistrement des recours aux urgences pour AcVC dans quelques hopitaux en France. La collecte des donnees est exhaustive. Les donnees des annees 2004 et 2005 ont ete traitees pour fournir des resultats sur les chutes des personnes âgees. Resultats – Les chutes constituaient 84 % des mecanismes a l’origine d’un AcVC chez les 65 ans et plus. Le taux d’incidence des chutes accidentelles avec recours aux urgences est de 4,5 pour 100 personnes, 3 pour 100 hommes et 5,6 pour 100 femmes. Elles sont survenues principalement a domicile (78 %). Les fractures ont represente 41 % des lesions et les membres inferieurs ont ete les plus leses (34 % des cas). Les chutes ont donne lieu a une hospitalisation dans 37 % des cas. Discussion – L’enquete Epac est la seule source en France qui permet de fournir des estimations de taux d’incidence des chutes. Ces resultats dependent des caracteristiques des hopitaux collectant les donnees. Dans son extension actuelle, Epac rend toutefois mal compte des evolutions dans le temps du nombre de chutes chez les personnes âgees.

Les conséquences à long terme de la violence sexuelle, physique et psychologique vécue pendant l'enfance

Abstract: Background The co-occurrence of child victimization experiences is not a rare phenomenon. However, few studies have explored the long-term consequences of such experiences. Empirical studies present important methodological limitations, namely the fact that few studies have documented more than two forms of victimization, that they rely on non representative samples and have not used multivariate analyses. The present study aims to evaluate the specific contribution of each form of child victimization (sexual, physical and psychological) on the outcomes in adulthood. Moreover, the study explores the role of co-occurrence on these symptoms. Methods A phone survey was conducted with a representative sample of 804 adults from the province of Quebec. Households were randomly selected among those having a telephone. Sociodemographic variables, child victimization experiences (sexual, physical and psychological) and partner violence were evaluated to explore their links with psychological distress, post-traumatic stress symptoms and physical health of participants. Results Higher psychological distress in men is associated with younger age, lower education level and having experienced sexual and physical violence in childhood. For women, psychological distress is linked to younger age, having experienced partner violence, childhood physical and psychological violence. Only experiencing partner violence and childhood sexual and psychological victimization are linked to greater post-traumatic stress symptoms in men and women. Finally, lower education level and childhood sexual and physical victimization increase physical health problems for men, while for women, only lower education level contributes to the prediction. Conclusion The results of this study show that experiencing more than one form of childhood victimization increases the negative outcomes in adulthood, underlying the relevance of considering the phenomenon of co-occurring victimization in the elaboration and dissemination of intervention programs.

[Development of a job exposure matrix for the epidemiological follow-up of workers in the French nuclear industry.]

Abstract: BACKGROUND: A pilot study was carried out in the AREVA NC Pierrelatte nuclear facility in order to investigate a possible carcinogenic effect of internal radiation exposure among nuclear workers in France. The objective of this study was to develop a method for retrospective reconstruction of the occupational exposure to internal radiation from uranium and associated chemical exposures. METHODS: A plant- and period-specific job exposure matrix (JEM) was designed. Job groups and exposure agents groups including uranium compounds and other chemical agents known as being carcinogenic, mutagenic or toxic were defined by an expert committee. Exposure was evaluated by active and retired workers included in the evaluator committee. A quantitative assignment of quantity and frequency of handling (both coded from 0 to 3) was performed for each agent groups using a method derived from the Delphi technique. RESULTS: In all, 23 experts and 353 evaluators participated to the JEM elaboration. A final JEM involved 232 "job-periods" presenting throughout the plant period 1960-2006 and 22 exposure agents groups in use at the plant. Six of them involved uranium compounds classified by their blood-transferability and toxicity characteristics. A first validation of the JEM by experts in radiological protection and industrial hygiene showed an acceptable internal consistency. CONCLUSION: In the context of missing past exposure measurement data, the plant- and period-specific job exposure matrices may be considered as a valid alternative for exposure estimation. This method may be applied to other nuclear plants and offers allowance to investigate a possible carcinogenic effect of internal radiation exposure among nuclear workers.

Prisma France* : programme d’implantation d’une innovation dans un système de soins et de services aux personnes en perte d’autonomie. Adaptation d’un modèle d’intégration basé sur la gestion de cas

Abstract: Background The French health and services system to maintain at home is characterized by its fragmentation, whereas the need of the people for intervention is generally total. This fragmentation have consequences: delay in services delivery, inadequate transmission of information, redundant evaluation, service conditioned by the entrance point solicited rather than by the need of the person and inappropriate use of expensive resources by ignorance or difficulty of access to the less expensive resources. Presentation of the innovation The purpose of integration is to improve continuity of interventions for people in loss of autonomy. It consists in setting up a whole of organisational, managerial and clinical common tools. Organisational model “Projet et Recherches sur l’Integration des Services pour le Maintien de l’Autonomie” (Prisma) tested in Quebec showed a strong impact on the prevention of the loss of autonomy in term of public health on a population level. This model rests on six principal elements: partnership, single entry point, case-management, a multidimensional standardized tool for evaluation, an individualized services plan and a system for information transmission. Contextual analysis Thus, it was decided to try to implement in France this organisational model. The project is entitled Prisma France and is presented here. The analysis of the context of implementation of the innovation which represents integration in the field of health and services for frail older reveals obstacles (in particular because of diversity of professional concerned and a presentiment of complexity of the implementation of the model) and favourable conditions (in particular the great tension towards change in this field). Conclusion The current conditions in France appear mainly favourable to the implementation of integration. The establishment of Prisma model in France requires a partnership work of definition of a common language as well on the diagnoses as on the solutions. The strategic and operational dialogue is thus a key element of the construction of integration. This stage currently occurs in parallel in three areas contrasted in France. The results of associated qualitative research should make it possible to define the factors fostering or hindering the realization of integration according to each site (analyzes contrasted) and in all the sites (related to the particular context of care and French services as a whole).

Migration, santé et recours aux soins à Mayotte en 2007 : enseignements d’une enquête représentative en population générale

Abstract: Background Mayotte Island, located in the Indian Ocean, is a French overseas departmental community with certain specificities: recent development of sanitary institutions, significant immigration, free access to care for legal residents but with co-payments for irregular residents, the absence of many of the social benefits which exist in mainland France and poor or non-existent health information systems. We report here the first population-based survey describing the links between health, migration and healthcare utilization in this territory. Methods Cross sectional population-based study using a three-stage random sample (geographic areas, households, individuals). In all, 2105 individuals were interviewed either in French, Shimaore or Kibushi (response rate = 96%), using a questionnaire adapted to the context of Mayotte Island after a preliminary qualitative survey. Descriptive analyses and logistic regression models were performed. Results Foreigners make up 40% of the Mayotte population (total 186,452 inhabitants), of which one-quarter are children born in Mayotte and 80% have no regular residence status. The median length of residence of migrant foreigners is 10 years. Foreigners represent a majority of the female population, of the 20 to 35 years old population and of the urban areas. Main determinants for migration were economical (50%) or family-related (26%). Health was stated as a cause of migration by 11% of migrants. The social situation of foreigners is more precarious and their perceived health poorer than those of the French. Their access to care is also perceived as more difficult. We did not observe any notable difference in terms of frequency of healthcare attendance over the last 12 months between the two groups, but foreigners have consulted less often private GPs and more often traditional practitioners than French. Conclusion In this overseas French island, the migrant population is numerous and resident for a long time. Their main motivations to immigrate are economic and family-related. They report hurdles to healthcare related with their precarious living conditions, including their illegal residence status.

General ReviewConsensus methods: Review of original methods and their main alternatives used in public healthMéthodes de consensus : revue des méthodes originales et de leurs grandes variantes utilisées en santé publique

Abstract: Background Consensus-based studies are increasingly used as decision-making methods, for they have a lower production cost than other methods (observation, experimentation, modeling) and provide results more rapidly. The objective of this paper is to describe the principles and methods of the four main methods – Delphi, nominal group, consensus development conference and RAND/UCLA – their use as reported in peer-reviewed publications and validation studies published in the healthcare literature.

Le rôle du statut scolaire et professionnel dans les usages de drogues des hommes et des femmes de 18 à 25 ans

Abstract: Background In France, drug use levels of college students remain quite unknown, mainly because of the lack of representative samples of this specific part of the population. There is also a lack of studies concerning gender and drug use. Methods The Health barometer 2005 is a wide national telephone survey which is representative of the 12–75-year-olds ( n = 30,514). Among the 18–25-year-olds, 1290 students were surveyed, besides 1480 employed and 538 unemployed people. Various licit and illicit drug use levels of these three groups were compared using logistic regression models for men and women, controlling for age, level of diploma, category of area of residence, living in couple, religion and type of phone equipment. These results were compared with those obtained in the Health Barometer 2000, with exactly the same variables and definitions. Results Analysis showed that among women, alcohol and cannabis use as well as drunkenness were more frequent among unemployed and college students than among workers. For men, drug use, and especially illicit drug use, appeared more frequent among unemployed. As a consequence, gender differences for alcohol and cannabis use were lower among students than among workers or unemployed. For both sexes, logistic models controlling for age showed that alcohol consumption as well as daily tobacco smoking were less frequent among students than among employed people, contrarily to drunkenness and cannabis use. For almost all drug uses, differences between genders are smaller among students. Except for alcohol and tobacco use, these differences disappeared when controlling for other sociodemographic variables. Compared with data from year 2000, differences among the three groups appeared smaller, especially for drunkenness and cannabis smoking among college students. Conclusion Alchol and tobacco uses are less frequent among students than active people, employed or not, but there is no significant difference for drunkenness and cannabis use. For both genders, unemployment is associated with increased levels of drug use, but pursuing higher education is associated with an increased level of alcohol and cannabis use among women, which is not the case among men.

Intérêt de la détection et de la prise en compte d’une surdispersion dans un modèle de Poisson : illustration à partir d’un exemple

Abstract: Background Researchers often use the Poisson regression model to analyze count data. Overdispersion can occur when a Poisson regression model is used, resulting in an underestimation of variance of the regression model parameters. Our objective was to take overdispersion into account and assess its impact with an illustration based on the data of a study investigating the relationship between use of the Internet to seek health information and number of primary care consultations. Methods Three methods, overdispersed Poisson, a robust estimator, and negative binomial regression, were performed to take overdispersion into account in explaining variation in the number (Y) of primary care consultations. We tested overdispersion in the Poisson regression model using the ratio of the sum of Pearson residuals over the number of degrees of freedom (χ 2 /df). We then fitted the three models and compared parameter estimation to the estimations given by Poisson regression model. Results Variance of the number of primary care consultations (Var[Y] = 21.03) was greater than the mean (E[Y] = 5.93) and the χ 2 /df ratio was 3.26, which confirmed overdispersion. Standard errors of the parameters varied greatly between the Poisson regression model and the three other regression models. Interpretation of estimates from two variables (using the Internet to seek health information and single parent family) would have changed according to the model retained, with significant levels of 0.06 and 0.002 (Poisson), 0.29 and 0.09 (overdispersed Poisson), 0.29 and 0.13 (use of a robust estimator) and 0.45 and 0.13 (negative binomial) respectively. Conclusion Different methods exist to solve the problem of underestimating variance in the Poisson regression model when overdispersion is present. The negative binomial regression model seems to be particularly accurate because of its theorical distribution ; in addition this regression is easy to perform with ordinary statistical software packages.

Internet et santé : les enseignements de l’enquête permanente sur les conditions de vie des ménages, France, 2005

Abstract: Background The Internet is a major source of information for the general public in the field of health. However despite ever-increasing connection rates, a digital divide persists in the industrialised countries. The objective of this study was to assess the determinants involved in Internet access and then in Internet use for health information seeking. Methods This study is based on a cross-sectional survey of a representative random sample of French inhabitants: the Enquete permanente sur les conditions de vie des menages conducted by Insee in 2005, which included a specific investigation on information and communication technology. Results Fifty-two percent of the French adult population had Internet access, and 28.5% of the Internet users had previously searched for medical information during the month before the survey. A first level of socioeconomic divide has been shown in Internet access: poor socioeconomic status, health problems. In terms of health information seeking among Internet users, the divide was not socioeconomic but more related to gender, the health care system utilization, and the diversified use of the Internet. Conclusion In a public health perspective, this study suggests that promoting Internet access and utilization is still necessary in order to make it a widely used tool for prevention and health promotion.

Créer des liens : les relations soignants–soignants dans les réseaux de soins informels

Abstract: Background During the last years, the french health system has been developing formal health networks. So, it was necessary to study informal health networks as «social actors» networks. More precisely, we studied the nature of relationships between various stakeholders around general practionners wich are commonly considering as the «pivot» stakeholder of the health system private sector. Methods Fieldwork (ethnography based on direct observations and interviews) was conducted between October 2002 and april 2004, in the South-East of France. Ten monographs of general practioner's offices were achieved in a rural area; then, we achieved fieldwork of the informal health networks identified. Results There is a cultural frame wich is common to all private professionals. This frame includes a triple ideal (teamwork built up the hospital model, independance, and an relational approach with patients). This frame does not square with the real practices. In fact, regulation mechanisms preserve the balance of relashionships between professionnal groups, by restricting/promoting exchanges and complex alliance strategies. These mecanisms include: (1) a few professionnal's rule as disponibility (to the patients and to the professionnals), as communication about patient, as patient's reference, as obligation to communicate between professionals; (2) some constraints such as territory superposition and competition with other professional groups; (3) some needs for: rileiving (of emotions and worries connected to work), sharing (decisions, responsabilities), of delegation (medical treatment, practices), protection against social and legal risk through the creation of trust relationships. These trust relationships are based on several logics (affinity, solidarity, similarity). The study shows the major place of the patient who is often the main organizer of his network, and even though he makes an important structuring work between medical staff, and an information transfer (on his diagnosis, on his treatment, and « on » professionals). The patient's role of «coordination» is underestimated. Conclusion The results show that in studied informal networks, professionnals do not have a transversal view of the patient's care management. This is due to the lack of knowledge of each health agent about the work of others, to the symbolic compartmentalization between professional groups, and because the difficulties encountered (i.e. burden work).

Analyse qualitative et quantitative des déterminants à l'application de recommandations professionnelles (RP) par les médecins

Abstract: Position du probleme. - Les objectifs du projet etaient d'identifier dans les services de medecine polyvalente des etablissements de sante d'Aquitaine les facteurs locaux freinant ou favorisant l'application des Recommandations Professionnelles (RP) et de determiner les facteurs locaux les plus fortement associes a l'application des RP. Methodes. - La population d'etude etait constituee des professionnels medecins et soignants des services de medecine polyvalente de 12 etablissements de sante (ES) volontaires de la region Aquitaine. Des analyses qualitatives des facteurs associes a l'application des RP ont ete menees apres l'envoi de deux recommandations utilisees comme exemple. Elles ont ete realisees aupres d'un echantillon compose des professionnels medecins et soignants des services de medecine polyvalente de cinq ES selectionnes parmi les 12 volontaires pour representer la diversite des situations. Les facteurs releves lors des analyses qualitatives ont ete adjoints a ceux retrouves dans la litterature et compiles en un questionnaire qui a ete envoye aux medecins de la population d'etude. L'analyse des associations statistiques entre la presence des facteurs et le degre d'application des RP a permis d'identifier les facteurs locaux les plus frequents et les plus fortement associes a l'application des RP. Resultats. - Les analyses qualitatives ont mis en exergue que l'appropriation des RP semblait modulee par deux facteurs determinants : 1) le rayonnement scientifique national et loco-regional du service lui-meme determinant le positionnement des medecins au sein de la hierarchie professionnelle et 2) le type de management. Un fort degre d'echanges au sein des equipes et des prises de decision collegiales constituaient un terrain favorable a l'application des RP. Des difficultes organisationnelles telles une rotation importante du personnel et de patients, une surcharge de travail, de mauvaises coordinations entre services ou un absenteisme medical constituaient des freins organisationnels a l'application des RP. L'enquete quantitative a confirme le role des facteurs manageriaux et organisationnels dans l'application des RP. Conclusions. - Les contextes locaux, notamment organisationnels et manageriaux influent fortement sur l'application des RP par les medecins. Pour adapter les actions de mise en oeuvre des RP a ces contextes, les services ont besoin d'un outil leur permettant d'identifier les freins organisationnels et manageriaux les plus forts. Un tel outil est encore a construire et a valider.

Construction d’une matrice emplois–expositions pour le suivi épidémiologique des travailleurs de l’industrie nucléaire en France : Résultats d’une étude pilote

Abstract: Background A pilot study was carried out in the AREVA NC Pierrelatte nuclear facility in order to investigate a possible carcinogenic effect of internal radiation exposure among nuclear workers in France. The objective of this study was to develop a method for retrospective reconstruction of the occupational exposure to internal radiation from uranium and associated chemical exposures. Methods A plant- and period-specific job exposure matrix (JEM) was designed. Job groups and exposure agents groups including uranium compounds and other chemical agents known as being carcinogenic, mutagenic or toxic were defined by an expert committee. Exposure was evaluated by active and retired workers included in the evaluator committee. A quantitative assignment of quantity and frequency of handling (both coded from 0 to 3) was performed for each agent groups using a method derived from the Delphi technique. Results In all, 23 experts and 353 evaluators participated to the JEM elaboration. A final JEM involved 232 “job-periods” presenting throughout the plant period 1960–2006 and 22 exposure agents groups in use at the plant. Six of them involved uranium compounds classified by their blood-transferability and toxicity characteristics. A first validation of the JEM by experts in radiological protection and industrial hygiene showed an acceptable internal consistency. Conclusion In the context of missing past exposure measurement data, the plant- and period-specific job exposure matrices may be considered as a valid alternative for exposure estimation. This method may be applied to other nuclear plants and offers allowance to investigate a possible carcinogenic effect of internal radiation exposure among nuclear workers.

La violence envers les personnes atteintes de troubles mentaux : revue de la littérature et des notions connexes

Abstract: Position du probleme. - On tend generalement a voir dans les personnes souffrant de troubles mentaux graves de possibles auteurs plutot que d'eventuelles victimes d'actes de violence, la maladie mentale etant associee a l'idee d'un comportement violent et dangereux. En France, les autorites competentes tendent a insister sur la dangerosite des individus affectes de troubles mentaux plutot qu'a concentrer leur attention sur les cas ou ces personnes sont victimes de violences. En meme temps, le rapport entre violence, victimation, harcelement et discrimination reste ignore. Methodes. - Cet article fait le point sur nos connaissances en ce qui concerne la violence exercee sur des personnes souffrant de troubles psychiques graves, clarifie ce que recouvre la notion de violence, et pose la question de la necessite d'etudes locales et nationales. Le premier volet compare les definitions et operationnalisations des principales variables, les echantillons, la methodologie et les resultats des etudes publiees depuis 1990 sur la violence envers des adultes atteints de troubles mentaux. Le deuxieme volet utilise les etudes qualitatives pour clarifier les problemes conceptuels souleves par les etudes quantitatives.

Aspects méthodologiques et statistiques des essais d’équivalence et de non-infériorité

Abstract: Background. – The existence of effective reference treatments means that the superior therapeutic efficacy of new treatments is less marked and thus more difficult to demonstrate statistically. Moreover, the potential value of a new treatment is also based on other criteria, such as costs, ease of use, non invasiveness, and immediate or long-term side effects. In this context, methodological issue becomes one of looking for equivalence or non inferiority of the new treatment in comparison with an existing, high-performance reference treatment. Methods. – In the present work, we reexamine the statistical rational and methodological features of equivalence and noninferiority trials. Results. – We address equivalence margin choice, hypotheses building, and the different approaches for establishing equivalence (hypothesis testing and confidence intervals). We then discuss key aspects of equivalence trial design and the important methodological quality criteria involved in performing such studies: choice of the reference treatment, subject eligibility criteria, primary endpoint, study population and the required sample size. Lastly, we consider the possibility of adopting a new analytical strategy (noninferiority/superiority). Conclusion. – A checklist of items to include when reporting the results of randomized controlled trials (Consolidated Standards of Reporting Trials, the CONSORT recommendations) has been adapted for use in noninferiority and equivalence randomized controlled trials.

COMPAQH : recherches sur le développement des indicateurs qualité hospitaliers

Abstract: After three years, the coordination de la mesure de la performance pour l’amelioration de la qualite hospitaliere (COMPAQH) project can deliver its first findings and consider new perspectives of development. Which indicators are diffused? Under which criteria are they assessed? Which interhospital variability is observed? How to consider their application into hospitals? Which balance can we define between internal and external use? And finally, which consideration can we give to this program of quality measurement? This article addresses these different questions, giving a state of the development of this program.

[Real time epidemiological surveillance within the armed forces: concepts, realities and prospects in France].

Abstract: BACKGROUND In 2002, the North Atlantic Treaty Organization took five initiatives in order to enhance the defence capacities against the massive destruction weapons, one of them concerned the development of an interoperable surveillance system, giving in real time some informations permitting early warning to the commanders. Thoughts in France to improve the military surveillance system, methodological constraints and first results are shown. METHODS Medical, technological, human and organisational aspects had to be taken into account to develop real time surveillance within the armed forces, and also specific military constraints. In order to evaluate the validity of its methodology, the "Institut de medecine tropicale du service de sante des armees" developed a prototype, set up in French Guyana and which took part in a second time at a multinational exercise. RESULTS The "surveillance spatiale des epidemies au sein des forces armees de Guyane" has been set up in 2004, formed by both a recording and an analysis networks. This system permits to provide in real time some dashboards directly operational for the commanders. The exhaustiveness rate has been evaluated at 104%, compared to the traditional surveillance. It permitted three times to detect outbreaks several weeks before the other systems. Some limits have been identified, as the use of personal digitalized assistants. The involvement in a multinational exercise showed the system's efficacy, by detecting two simulated outbreaks, but also its interoperability. In 2006, it has been decided to extend the concept by deploying its second generation within the French armed forces in Djibouti. The "alerte et surveillance en temps reel" disposal permitted to take into account multiple geographical localizations. CONCLUSION A real time surveillance system is an essential alarm disposal, however it is only an information tool within the complex activity of piloting the sanitary situation. It must be integrated within the whole situation expertise supports, represented also by medical intelligence, epidemiological investigations and prediction of the epidemiological phenomenon evolution.

Implantation d’une démarche qualité dans les services médicaux d’un hôpital universitaire : facteurs d’accélération et de frein

Abstract: Background The aims of this study were to assess the level of implementation of continuous quality management program and to identify the factors associated with its failure in the medical departments of a teaching hospital. Methods Semi-directive interviews were conducted with 52 hospitalists, including 16 department heads and 36 staff members in charge of quality management, in 30 medical departments that implemented a continuous quality management program from 1998 to 2002. The interviews were analyzed using a manual thematic method and a computerized semantic method. Results At the study endpoint (i.e., 2003), the continuous quality management program was still working in six departments and was stopped in 24 departments. The professionals complied with the model of intervention based on the identification and the resolution of department problems by multiprofessional working groups. The main external factors associated with the failure of the continuous quality management program included shortage in staff and the lack of time to devote to this activity. In addition, professionals cited the defect of commitment by the top management, the lack of acknowledgment of their efforts, and the hospital accreditation as factors with negative impact on staff motivation. The main internal factors associated with the failure of the continuous quality management program were related to the leadership in quality management. The personal involvement of the department head played a key role in the continuation of the quality management program. Most of the staff regretted the lack of involvement of the physicians and stated that methodological support was needed. Conclusion The implementation of quality management in the medical departments remains difficult in the absence of institutional support. The leadership within the department plays a major role in the continuation of the process.

Personnes âgées dépendantes en attente d’entrée en EHPAD depuis un service hospitalier : étude prospective sur la communauté urbaine de Strasbourg, France

Abstract: Objectives Our aim was to estimate the number of non-satisfied instutionalization requests for inpatients and to describe the strategies elaborated to compensate for the waiting time. Methods This prospective follow-up study concerning all requests for institution admission for inpatients aged 75 years or older hospitalized in acute care and rehabilitation wards. Descriptive data were gathered throughout the social support process conducted during the hospitalization. A three months follow-up was conducted. Results Among 5200 hospitalizations, a social support process was initiated for 270 patients aged 75 years and over. Two thirds of the sample were women (n = 163). Mean age was 82 years. Fifty-two percent of the subjects met the criteria for iso-resource grades (IRG) 1 to 2 and 90% in IRG 1 to 4. The mean length of hospitalized stay (MLOS) was 56.8 ± 10.2 days; the MLOS of unjustified stay of 23.5 ± 5.6 (n = 222). The average time before the social worker was informed of the patient's situation was 13.6 ± 2.0 days; in addition, the time required to establish the administrative documents necessary for initiation of the social support progress was 15.0 ± 1.8. The principal reasons for social support were physical dependence (77%), mental dependence (60%), insufficient family support (36%) and/or disease progression (21%). At three months, 104 patients were institutionalized, 128 were still on institution waiting list (in hospital: 48%; at home: 16%) and 38 had died (14%). The estimated annual institutional deficit for disabled elderly people was 512 beds. Conclusion In light of demographical perspectives, an overall re-organization of the geriatric network is absolutely necessary. A simple increase in the capacity to fulfil the institutional beds deficit would be insufficient.

Éléments d’interprétation des estimations régionales de l’incidence du cancer en France sur la période 1980–2005

Abstract: Francim Network has already provided French national estimations of cancer incidence then regional estimations for Metropolitan France The present technical note summarizes the underlying hypotheses and the limits of the method and suggests some aspects of interpretation of those regional results in terms of absolute numbers and of standardized rates Results on "all cancers" illustrate those comments

Le Test Du Sénégal: Un Instrument Valide Et Fiable Pour Le Dépistage De La Démence Dans Une Population De Personnes Âgées Sénégalaises

Abstract: Description Face au vieillissement de la population et au developpement de la demence, il est necessaire de disposer d\'outil de depistage valide et fiable qui soit adapte au contexte socio-culturel. Objectif Valider le Test du Senegal, un instrument de depistage de la demence aupres de la population âgee senegalaise. Methode Le Test du Senegal est un instrument de depistage de la demence incluant des items en rapport avec l\'orientation, la memoire, l\'attention/calcul, la praxie et le langage avec un score de 0-39 points. Sa validation s\'est deroulee en deux phases aupres de personnes âgees de 55 ans et plus frequentant le Centre Medicosocial et Universitaire de l\'IPRES (Institut de Prevoyance Retraite du Senegal) pour des soins : 1) etude transversale aupres de 872 patients interviewes avec le questionnaire \"Vieillir au Senegal\" pour identifier les cas selon les criteres DSM IV-R; 2) une etude cas-temoins avec 116 patients (58 sujets dements et 58 temoins apparies par le sexe) pour la validation proprement dite. Le Test du Senegal a ete administre lors de la premiere phase, re-administre une semaine puis deux semaines apres lors de la deuxieme phase. La validite de critere, la validite de construit et la fidelite du test ont ete estimees. L\'effet de l\'âge et de l\'instruction sur la performance du test pour depister la demence a ete etudie avec des analyses de regression logistique. Resultat Le Test du Senegal identifiait les cas de demence avec les caracteristiques suivantes au point de coupure de 28/29 : sensibilite : 93,1%, specificite : 89,6%, valeur predictive positive : 93,1%, valeur predictive negative : 92,8%, surface sous la courbe caracteristique de performance: 0,967; kappa : 0,82; coefficient de correlation intraclasse variant entre 0,67 et 0,87. L\'âge et l\'education n\'avaient aucune influence sur la performance au Test du Senegal. Conclusion Le Test du Senegal est un instrument valide et fiable pour le depistage de la demence dans la population âgee senegalaise. Il pourra etre utilise comme outil de depistage de la demence dans les services de sante. Background With the aging of the population and the development of dementia, it is necessary to have a valid, reliable and socioculturally acceptable tool to screen for dementia. Methodology The \"Test of Senegal\" is a dementia screening tool with items on orientation, memory, attention, praxis and language for a score of 0-39 points. It was applied to Senegalese elderly patients aged 55 years and plus utilizing the Health and Social Center of IPRES (Institution de Prevoyance Retraite du Senegal), Dakar-Senegal for health care through a two steps: 1) a cross-sectional study among 872 patients to identify the cases of dementia using the DSM IV-R criteria; 2) a case-control study with 58 cases of dementia and 58 control of the same sex for the validation of the tool. The \"Test of Senegal\" was administered at the first step and re-administered blindly 1 and 2 weeks later at the second step. Criterion validity, construct validity and reliability of the tool were evaluated. The confounding effects of age and education on the tool were assessed by logistic regression analysis. Results The \"Test of Senegal\" identified dementia at the best cut-off point of 28/29 with the following criteria: sensitivity (93.1%), specificity (89.6%), positive predictive value (93.1%), negative predictive value (92.8%). The area under the ROC curve was 0.967. Kappa coefficient was 0.82; the intraclass correlation coefficients were 0.84 and 0.87 (inter-rater and test-retest reliability for the first rater), 0.72 and 0.67 (inter-rater and test-retest reliability for the second rater). Age and education had no confounding effect. Conclusion The \"Test of Senegal\" is a simple, valid and reliable tool to assess for dementia in a Senegalese elderly population useful as a screening tool in health care settings. Keywords : Dementia-Elderly population-Neuropsychological assessment- screening; Senegal. African Journal of Neurological Sciences Vol. 27 (1) 2008: pp. 1-5

Surveillance épidémiologique en temps réel dans les armées ; concepts, réalités et perspectives en France

Abstract: Background In 2002, the North Atlantic Treaty Organization took five initiatives in order to enhance the defence capacities against the massive destruction weapons, one of them concerned the development of an interoperable surveillance system, giving in real time some informations permitting early warning to the commanders. Thoughts in France to improve the military surveillance system, methodological constraints and first results are shown. Methods Medical, technological, human and organisational aspects had to be taken into account to develop real time surveillance within the armed forces, and also specific military constraints. In order to evaluate the validity of its methodology, the “Institut de medecine tropicale du service de sante des armees” developed a prototype, set up in French Guyana and which took part in a second time at a multinational exercise. Results The “surveillance spatiale des epidemies au sein des forces armees de Guyane” has been set up in 2004, formed by both a recording and an analysis networks. This system permits to provide in real time some dashboards directly operational for the commanders. The exhaustiveness rate has been evaluated at 104%, compared to the traditional surveillance. It permitted three times to detect outbreaks several weeks before the other systems. Some limits have been identified, as the use of personal digitalized assistants. The involvment in a multinational exercise showed the system's efficacy, by detecting two simulated outbreaks, but also its interoperability. In 2006, it has been decided to extend the concept by deploying its second generation within the French armed forces in Djibouti. The “alerte et surveillance en temps reel” disposal permitted to take into account multiple geographical localizations. Conclusion A real time surveillance system is an essential alarm disposal, however it is only an information tool within the complex activity of piloting the sanitary situation. It must be integrated within the whole situation expertise supports, represented also by medical intelligence, epidemiological investigations and prediction of the epidemiological phenomenon evolution.

Focalisation de la transmission de Schistosoma haematobium au sein des périmètres irrigués de la vallée du Niger (Niger) : importance des facteurs malacologiques

Abstract: Background Currently, the control of urinary schistosomiasis is mostly based on mass treatment. Characterization of Schistosoma haematobium transmission could lead to adding new methods to the control strategy. Methods We carried out malacological and cercariometrical surveys in irrigated perimeters of the Niger River valley. A semi-monthly follow-up was performed in three main sites of human-water contact in a village located at the border of the irrigated perimeter. Bulinids were collected during 20 min; after identification based on the shell morphology, their parasites were characterized by isoelectrofocalisation. The cercariometrical technique by differential filtration was used to evaluate the density of cercariae in every site with two 20 litres samples of water collected at various periods of the day (9, 12, 15 and 18 h). Results In the arm of the river, the cercariometry never showed cercariae whereas only some Bulinus truncatus, all negative, were collected. In the channels, B. truncatus and B. globosus were observed and highest density was found during the dry season. Only B. truncatus was naturally infested. Homozygote BB phenotype (characteristic of S. haematobium) was observed in all positive molluscs. Using cercariometry, more than two third of cercariae were collected at 3:00 PM. Conclusion Transmission of S. haematobium was primarily focused in the irrigating channels during the dry hot season at the beginning of afternoon. These results should lead to improve the output of S. haematobium control methods within irrigated areas.