Contrôle de la qualité des soins: aspects épidémiologiques. [Quality control of health care: epidemiological aspects].

Quality control in health care should be performed by health professionals. To do so they must define indicators, set up studies aimed at measuring and analyzing quality of care, and implement quality assurance programs in health care systems. The elements of a quality improvement program of this kind are described, with special emphasis on the contribution of epidemiology in this field.

Vitamine D et maladie cardiovasculaire: aspects épidémiologiques. [Vitamin D and cardiovascular disease: epidemiological aspects].

The quasi-ubiquitous distribution of vitamin D receptors in the human tissues and the high prevalence of vitamin D deficiency worldwide have generated much enthusiasm about the opportunity of cardiovascular disease prevention through vitamin D supplementation. However, reported associations between vitamin D and cardiovascular disease present important limitations and are prone to confounding and reverse causation. Results from ongoing randomized clinical trials testing the efficacy of vitamin D supplementation to reduce cardiovascular events will not be available before year 2015. This article reviews the epidemiology of vitamin D and provides a brief overview on the relationship between vitamin D and cardiovascular disease.

Histiocytose X faussement diagnostiquée comme silicose

The observation concerns a patient who was professionally exposed to silica dust. Radiologically he presented a diffuse interstitial infiltrate and clinically an obstructive syndrome with emphysem. The diagnosis of silicosis was made. The development was followed during 12 years without important modification of the X-ray or the respiratory functions. The patient died of a ruptured aortic aneurysm. At the autopsy the examination of the lungs permitted to exclude the initial diagnosis of silicosis and to conclude to an histiocytosis X. This diagnostic mistake allows to get on some radiological, clinical and epidemiological aspects, characteristic or these both pathologies.

Epidemiology of pulmonary hypertension: new data from the Swiss registry.

since 1999 data from pulmonary hypertension (PH) patients from all PH centres in Switzerland were prospectively collected. We analyse the epidemiological aspects of these data. PH was defined as a mean pulmonary artery pressure of >25 mm Hg at rest or >30 mm Hg during exercise. Patients with pulmonary arterial hypertension (PAH), PH associated with lung diseases, PH due to chronic thrombotic and/or embolic disease (CTEPH), or PH due to miscellaneous disorders were registered. Data from adult patients included between January 1999 and December 2004 were analysed. 250 patients were registered (age 58 +/- 16 years, 104 (41%) males). 152 patients (61%) had PAH, 73 (29%) had CTEPH and 18 (7%) had PH associated with lung disease. Patients <50 years (32%) were more likely to have PAH than patients >50 years (76% vs. 53%, p <0.005). Twenty-four patients (10%) were lost to followup, 58 patients (26%) died and 150 (66%) survived without transplantation or thrombendarterectomy. Survivors differed from patients who died in the baseline six-minute walking distance (400 m [300-459] vs. 273 m [174-415]), the functional impairment (NYHA class III/IV 86% vs. 98%), mixed venous saturation (63% [57-68] vs. 56% [50-61]) and right atrial pressure (7 mm Hg [4-11] vs. 11 mm Hg [4-18]). PH is a disease affecting adults of all ages. The management of these patients in specialised centres guarantees a high quality of care. Analysis of the registry data could be an instrument for quality control and might help identify weak points in assessment and treatment of these patients.

Maladie de Weil: à propos d'un cas de leptospirose acquise en Suisse [Weil's disease: a case report of acquired leptospirosis in Switzerland].

Leptospirosis is a rare disease in Switzerland. However its incidence is probably underestimated, due to its broad spectrum of presentations, including subclinical benign forms and the ictero-hemorragic form of the Weil's syndrome, whose mortality is high. We describe here a case of Weil's syndrome acquired in Switzerland with a favourable outcome under antibiotherapy. Even in the absence of any travel, the association of an acute renal insufficiency and jaundice with only moderate hepatic cytolysis should lead to the suspicion of leptospirosis. Clinical and epidemiological aspects of the disease are discussed in the article.

Epidemiological traits of the malaria-like parasite Polychromophilus murinus in the Daubenton¿s bat Myotis daubentonii.

BackgroundThe great diversity of bat haemosporidians is being uncovered with the help of molecular tools. Yet most of these studies provide only snapshots in time of the parasites discovered. Polychromophilus murinus, a malaria-like blood parasite, specialised on temperate-zone bats is a species that is being `rediscovered¿. This study describes the infection dynamics over time and between host sex and age classes.MethodsFor three years we followed the members of three breeding colonies of Myotis daubentonii in Western Switzerland and screened them for the prevalence and parasitemia of P. murinus using both molecular tools and traditional microscopy. In order to identify more susceptible classes of hosts, we measured, sexed and aged all individuals. During one year, we additionally measured body temperature and haematocrit values.ResultsJuvenile bats demonstrated much higher parasitemia than any other age class sampled, suggesting that first exposure to the parasite is very early in life during which infections are also at their most intense. Moreover, in subadults there was a clear negative correlation between body condition and intensity of infection, whereas a weak positive correlation was observed in adults. Neither body temperature, nor haematocrit, two proxies used for pathology, could be linked to intensities of infection.ConclusionIf both weaker condition and younger age are associated with higher infection intensity, then the highest selection pressure exerted by P. murinus should be at the juvenile stage. Confusion over the identities and nomenclature of malarial-like parasites requires that molecular barcodes are coupled to accurate morphological descriptions.

Menarche, menopause, and breast cancer risk: individual participant meta-analysis, including 118 964 women with breast cancer from 117 epidemiological studies.

BACKGROUND: Menarche and menopause mark the onset and cessation, respectively, of ovarian activity associated with reproduction, and affect breast cancer risk. Our aim was to assess the strengths of their effects and determine whether they depend on characteristics of the tumours or the affected women. METHODS: Individual data from 117 epidemiological studies, including 118 964 women with invasive breast cancer and 306 091 without the disease, none of whom had used menopausal hormone therapy, were included in the analyses. We calculated adjusted relative risks (RRs) associated with menarche and menopause for breast cancer overall, and by tumour histology and by oestrogen receptor expression. FINDINGS: Breast cancer risk increased by a factor of 1·050 (95% CI 1·044-1·057; p<0·0001) for every year younger at menarche, and independently by a smaller amount (1·029, 1·025-1·032; p<0·0001), for every year older at menopause. Premenopausal women had a greater risk of breast cancer than postmenopausal women of an identical age (RR at age 45-54 years 1·43, 1·33-1·52, p<0·001). All three of these associations were attenuated by increasing adiposity among postmenopausal women, but did not vary materially by women's year of birth, ethnic origin, childbearing history, smoking, alcohol consumption, or hormonal contraceptive use. All three associations were stronger for lobular than for ductal tumours (p<0·006 for each comparison). The effect of menopause in women of an identical age and trends by age at menopause were stronger for oestrogen receptor-positive disease than for oestrogen receptor-negative disease (p<0·01 for both comparisons). INTERPRETATION: The effects of menarche and menopause on breast cancer risk might not be acting merely by lengthening women's total number of reproductive years. Endogenous ovarian hormones are more relevant for oestrogen receptor-positive disease than for oestrogen receptor-negative disease and for lobular than for ductal tumours. FUNDING: Cancer Research UK.

Aspects génétiques de la consommation de tabac et prise en charge clinique [Genetic aspects of smoking and impact on clinical care]

Tobacco smoking is a major public health issue and a better understanding of tobacco addiction represents an important challenge. Many factors are involved in tobacco addiction, including genetic factors. Taking them into account in smoking cessation programs would allow to better adapt these programs to individual characteristics and improve their rate of success. Given enzymatic induction by tobacco smoke, smoking cessation can nevertheless have important consequences on the metabolism of some drugs, that have to be taken into consideration. Here we present different clinical and genetic aspects of smoking and of smoking cessation. A dose adjustment of drugs influenced by tobacco smoke is proposed when quitting smoking.

Hyperesthésie et apaisement: aspects historiques et psychologiques

L'auteur fait une synthèse des contributions, actuelles ou passées, décrivant la tendance chez un individu à exacerber ses sensations (hyperesthésie), agréables ou douloureuses, y compris les éprouvés émotionnels. Il met l'accent sur l'effet antagoniste ou inhibiteur que les sensations peuvent avoir les unes sur les autres. Puisque l'angoisse implique, elle aussi, une dimension sensorielle, il insiste sur le but paradoxal d'apaisement et donc défensif qui peut motiver la recherche de sensations, en se référant à la notion de « procédé autocalmant » développée par l'école psychosomatique de Paris.¦Ce travail se divise en deux parties consacrées respectivement à l'enfant et à l'adulte, elles-mêmes déclinées sur deux versants, l'un « normal » et l'autre pathologique. Il y est question :¦- des comportements de l'enfant susceptibles d'être produits pour les sensations apaisantes qu'ils procurent : succion, ingestion d'aliments, balancement, masturbation, etc.¦- des auto-agressions dans certains troubles du développement de l'enfant et de l'adolescent¦- de l'hypersensibilité ou émotivité dans les typologies du tempérament ou du caractère proposées dans l'histoire; de la passion également, envisagée comme un embrasement lui aussi potentiellement défensif¦- de deux parmi les troubles de l'adulte qui ont le plus été décrits en termes d'hyperesthésie, à savoir l'hystérie et la manie.¦Il s'agit d'un travail théorique, qui intègre des aspects historiques, et qui peut servir de base à des explorations cliniques ou des recherches plus spécifiques.¦The author presents a summary of past and recent publications describing the disposition in the individual to exacerbate sensations (hyperesthesia), whether pleasurable or painful, including emotional experiences. He emphasizes the possible opposing or inhibiting action these sensations can have between them.¦As anxiety also implies a sensory dimension, the author underlines the paradoxically alleviating, and hence defensive purpose driving the pursuit of sensations, by reference to the notion of self-soothing procedures (procédés auto-calmants), conceptualized by the Paris Psychosomatic School.¦This work is divided into two parts focusing on childhood and adulthood respectively, each in its turn concentrating on both the « normal » and pathological aspects. Topics covered include:¦- behaviours that children may engage in for the soothing effects they produce ; sucking, consumption of food, rocking, masturbation, etc.¦- self-harm in some cases of developmental disorders in children and adolescents¦- hypersensibility and emotivity as described in historical temperament and character types ; passion, also regarded as another defensive excitement.¦- two of the most commonly described disorders of hyperesthesia in adults, namely hysteria and mania.¦This thesis constitutes a research of a theoretical nature. It integrates historical aspects, which can be used as a basis for clinical exploration or further more specific research.

Intérêt de l'éthylglucuronide comme marqueur d'abus d'alcool, aspects analytiques, diagnostiques et médico-légaux

RESUMEUne consommation excessive et chronique d'alcool est associée à une augmentation significative de la morbidité et de la mortalité. L'identification de marqueurs biologiques fiables, permettant de mettre en évidence une consommation excessive et chronique, présente donc un intérêt certain pour prévenir les conséquences néfastes de l'abus d'alcool. L'approche couramment employée consiste à mesurer les marqueurs biologiques indirects dans le sang, tels que les marqueurs hépatiques dont l'augmentation peut résulter d'une consommation chronique et excessive d'alcool. Cependant, leur valeur diagnostique est souvent limitée par leur manque de sensibilité et/ou de spécificité et leur combinaison est généralement recommandée pour améliorer le diagnostic. A ce jour, il n'existe pas de marqueur biologique permettant le diagnostic fiable d'une consommation chronique et excessive d'alcool.L'objectif principal de cette thèse était d'évaluer la pertinence de l'éthylglucuronide (EtG), un métabolite direct de l'éthanol présentant la particularité d'être incorporé dans les cheveux, comme marqueur d'une consommation chronique et excessive d'alcool. Dans un premier temps, une revue de la littérature a permis de dresser un état des lieux de l'usage de l'EtG et d'identifier les axes de réflexion. L'EtG s'est révélé être un marqueur efficace pour identifier une consommation chronique et excessive d'alcool. Cependant, l'absence de seuil de positivité fiable et une méconnaissance des facteurs influençant l'incorporation de l'EtG dans les cheveux ont été mises en évidence. Afin d'investiguer ces différents points, deux études ont été conduites : (1) une étude chez le rat pour tenter de comprendre les facteurs influençant l'incorporation de l'EtG dans les cheveux et étudier la relation entre la quantité d'alcool administrée et la concentration d'EtG mesurée dans les cheveux; et (2) une étude clinique afin de déterminer les performances diagnostiques de l'EtG comme marqueur d'une consommation excessive et chronique d'alcool. Une méthode analytique sensible et sélective par chromatographic gazeuse couplée à la spectrométrie de masse en tandem a été développée et appliquée à l'analyse de l'EtG dans les cheveux.Le sang semblait jouer un rôle majeur dans l'incorporation de l'EtG dans les poils. Son incorporation n'était pas influencée par la pigmentation. La concentration d'EtG mesurée dans les poils de rats reflétait la dose d'éthanol administrée. De plus, la mesure de l'EtG dans les cheveux humains a démontré de très bonnes performances diagnostiques pour détecter une consommation excessive et chronique d'alcool. Les performances diagnostiques de l'EtG surpassaient celles des marqueurs hépatiques usuels seuls ou combinés. L'EtG n'était pas influencé par l'âge, le sexe ou l'indice de masse corporelle. Un seuil de positivité de 25 pg/mg permettait de détecter les consommateurs à usage nocif avec une grande fiabilité. Un seuil de positivité de 9 pg/mg permettait de détecter les consommateurs à risque.SUMMARYChronic and excessive alcohol consumption is associated with a significant increase of morbidity and mortality. The identification of a reliable biomarker to detect chronic and excessive alcohol consumers would be valuable to prevent alcohol's harmful effects. The combined analysis of 2 or more hepatic biomarkers, which are known to be increased following sustained alcohol consumption, is usually applied to enhance the diagnostic performance in identifying chronic and excessive alcohol consumers. However, their diagnostic value is often limited by their lack of sensitivity and / or specificity and their combination is generally recommended to improve diagnosis. To date, there are no reliable biomarkers available for diagnosing chronic and excessive alcohol consumption.The main objective of this research was to evaluate the relevance of EtG, a direct alcohol metabolite, as a biomarker of chronic and excessive alcohol consumption, thanks to its characteristic to incorporate into hair. First, a review of literature on the use of EtG was carried out. EtG demonstrated strong potential in detecting chronic and excessive alcohol consumption. However, the lack of reliable cutoff and the unawareness of factors that affect the EtG incorporation into hair were stressed. To investigate these points, two studies have been conducted: (1) a nonclinical study in rats to determine the factors affecting the incorporation of EtG into hair as well as to investigate the relationship between the amount of alcohol administered and the EtG concentration measured in hair; and (2) a clinical study to determine the diagnostic performance of EtG as a biomarker for the identification of chronic and excessive alcohol consumers. A sensitive and specific Gas Chromatography-Mass Spectrometry coupled to tandem Mass Spectrometry method has been developed and applied to hair EtG analysis.Bloodstream seemed to play a major role in the EtG incorporation into hair. EtG incorporation into rat hair was not affected by hair pigmentation. EtG concentration in rat hair appeared to reflect the EtG concentration in blood. Besides, EtG demonstrated strong diagnostic performance in detecting both heavy alcohol consumption and at-risk alcohol consumption, and clearly outperformed diagnostic performance of hepatic biomarkers. In contrast with hepatic biomarkers, EtG was not associated with age, gender or body mass index. A reliable cutoff value of 25 pg/mg allowed to detect heavy drinkers; a reliable cutoff value of 9 pg/mg allowed to detect at-risk drinkers.

Medical aspects of helicopter rescue missions involving winching of a physician

Introduction: Whereas the use of helicopters as a rapid means toreach victims and to bring them to a secure place is well-recognized,very few data are available about the value of winching physicians toprovide medical care for the victims directly on-site. We sought to studythe medical aspects of alpine helicopter rescue operations involving thewinching of an emergency physician to the victim.Methods: We retrospectively reviewed the medical reports of a singlehelicopter-based emergency medical service. Data from 1 January 2003to 31 December 2008 were analyzed. Cases with emergency callindicating that the victim was deceased were excluded. Data includedthe category (trauma or illnesses), and severity (NACA score) of theinjuries, along with the main medical procedures performed on site.Results: 9879 rescue missions were conducted between 1 January2003 and 31 December 2008. The 921 (9.3%) missions involvingwinching of the emergency physician were analysed. 840 (91%)patients suffered from trauma-related injuries. The cases of the 81 (9%)people presenting with medical emergencies were, when compared tothe trauma victims, significantly more severe according to the NACAindex (p <0.001). Overall, 246 (27%) patients had a severe injury orillness, namely, a potential or overt vital threat (NACA score between4-6, table 1). A total of 478 (52%) patients required administration ofmajor analgesics: fentanyl (443 patients; 48%), ketamine (42 patients;5%) or morphine (7 patients; 1%). The mean dose of fentanyl was 188micrograms (range 25-750, SD 127). Major medical interventions wereperformed 72 times on 39 (4%) patients (table 2).Conclusions: The severity of the patients' injuries or illnesses alongwith the high proportion of medical procedures performed directlyon-site validate emergency physician winching for advanced life supportprocedures and analgesia.