Les méthodes d'ajustement dans les modèles d'évaluation de la mortalité hospitalière. Partie 1, Etude descriptive : document de travail

Suite à la demande du Président de la République de disposer d'indicateurs de mortalité en établissements de santé » (discours du 18 septembre 2008 sur le thème de la politique de la santé et de la réforme du système de soins), la Direction de la recherche, des études, de l'évaluation et des statistiques (DREES) a piloté en 2009, en lien avec la Direction générale de l'offre de soins (DGOS) et la Haute autorité de santé (HAS), l'instruction des aspects méthodologiques relatifs à la construction de ces indicateurs de mortalité. Cette revue de littérature portant sur les différentes méthodes d'ajustement a été réalisée dans ce cadre, à la demande conjointe de la DREES et de la HAS.Ce rapport décrit les méthodes et modèles d'estimation et d'ajustement de la mortalité hospitalière identifiées dans la littérature.Il ressort de cette revue, que d'une manière générale, trois questions méthodologiques majeures préoccupent les épidémiologistes, les chercheurs et les décideurs s'intéressant à l'indicateur de la mortalité hospitalière : i) premièrement, sur l'opportunité d'établir l'indicateur de mortalité hospitalière à partir de groupes de population de patients homogènes définis par des pathologies et/ou des procédures médicales/chirurgicales cibles ; ii) deuxièmement, sur le type d'approche analytique et de l'intérêt de prendre en compte plusieurs niveaux dans l'analyse statistique ; iii) enfin troisièmement, sur le choix des variables d'ajustement permettant de contrôler les différences de case-mix entre plusieurs établissements ou groupes de patients pour réaliser des comparaisons. [Ed.]

Bilateral symmetry of radial pulse in high-level tennis players : implications for the validity of central aortic pulse wave analysis

Rapport de synthèse Ce travail de thèse s'articule autour de l'importance de l'évaluation de la fonction vasculaire et des répercussions au niveau central, cardiaque, des perturbations du réseau vasculaire. Les maladies cardiovasculaires sont prédominantes dans notre société et causes de morbidité et mortalité importante. La mesure de la pression artérielle classique reste le moyen le plus utilisé pour suivre la santé des vaisseaux, mais ne reflète pas directement ce qui se passe au niveau du coeur. La tonométrie d'aplanation permet depuis quelques années de mesurer l'onde de pouls radial, et par le biais d'une fonction mathématique de transfert validée, il est possible d'en déduire la forme et Γ amplitude de l'onde de pouls central, donc de la pression aortique centrale. Cette dernière est un reflet bien plus direct de la post-charge cardiaque, et de nombreuses études cliniques actuelles s'intéressent à cette mesure pour stratifier le risque ou évaluer l'effet d'un traitement vasculaire. Toutefois, bien que cet outil soit de plus en plus utilisé, il est rarement précisé si la latéralité de la mesure joue un rôle, sachant que certaines propriétés des membres supérieurs peuvent être affectées par un usage préférentiel (masse musculaire, densité osseuse, diamètre des artères, capillarisation musculaire, et même fonction endothéliale). On a en effet observé que ces divers paramètre étaient tous augmentés sur un bras entraîné. Dès lors on peut se poser la question de l'influence de ces adaptations physiologiques sur la mesure indirecte effectuée par le biais du pouls radial. Nous avons investigué les deux membres supérieurs de sujets jeunes et sédentaires (SED), ainsi que ceux de sujets sportifs avec un développement fortement asymétrique des bras, soit des joueurs de tennis de haut niveau (TEN). Des mesures anthropométriques incluant la composition corporelle et la circonférence des bras et avant-bras ont montré que TEN présente une asymétrie hautement significative aux deux mesures entre le bras dominant (entraîné) et l'autre, ce qui est aussi présent pour la force de serrage (mesurée au dynamomètre de Jamar). L'analyse des courbes centrales de pouls ne montre aucune différence entre les deux membres dans chaque groupe, par contre on peut observer une différence entre SED et TEN, avec un index d'augmentation diastolique qui est 50 % plus élevé chez TEN. Les index d'augmentation systolique sont identiques dans les deux groupes. On peut retenir de cette étude la validité de la méthode de tonométrie d'aplanation quel que soit le bras utilisé (dominant ou non-dominant) et ce même si une asymétrie conséquente est présente. Ces données sont clairement nouvelles et permettent de s'affranchir de cette variable dans la mesure d'un paramètre cardiovasculaire dont l'importance est actuellement grandissante. Les différences d'index diastolique sont expliquées par la fréquence cardiaque et la vitesse de conduction de l'onde de pouls plus basses chez TEN, causant un retard diastolique du retour de l'onde au niveau central, phénomène précédemment bien décrit dans la littérature.

EFNS guidelines on cognitive rehabilitation: report of an EFNS task force.

Disorders of language, spatial perception, attention, memory, calculation and praxis are a frequent consequence of acquired brain damage [in particular, stroke and traumatic brain injury (TBI)] and a major determinant of disability. The rehabilitation of aphasia and, more recently, of other cognitive disorders is an important area of neurological rehabilitation. We report here a review of the available evidence about effectiveness of cognitive rehabilitation. Given the limited number and generally low quality of randomized clinical trials (RCTs) in this area of therapeutic intervention, the Task Force considered, besides the available Cochrane reviews, evidence of lower classes which was critically analysed until a consensus was reached. In particular, we considered evidence from small group or single cases studies including an appropriate statistical evaluation of effect sizes. The general conclusion is that there is evidence to award a grade A, B or C recommendation to some forms of cognitive rehabilitation in patients with neuropsychological deficits in the post-acute stage after a focal brain lesion (stroke, TBI). These include aphasia therapy, rehabilitation of unilateral spatial neglect (ULN), attentional training in the post-acute stage after TBI, the use of electronic memory aids in memory disorders, and the treatment of apraxia with compensatory strategies. There is clearly a need for adequately designed studies in this area, which should take into account specific problems such as patient heterogeneity and treatment standardization.

Outcomes from studies of Antineutrophil Cytoplasm Antibody Associated Vasculitis: a systematic review by the European League Against Rheumatism systemic vasculitis task force.

Objectives: We undertook a systematic literature review as a background to the European League Against Rheumatism (EULAR) recommendations for conducting clinical trials in anti-neutrophil cytoplasm antibody associated vasculitis (AAV), and to assess the quality of evidence for outcome measures in AAV. Methods: Using a systematic Medline search, we categorised the identified studies according to diagnoses. Factors affecting remission, relapse, renal function and overall survival were identified. Results: A total of 44 papers were reviewed from 502 identified by our search criteria. There was considerable inconsistency in definitions of end points. Remission rates varied from 30% to 93% in Wegener granulomatosis (WG), 75% to 89% in microscopic polyangiitis (MPA) and 81% to 91% in Churg¿Strauss syndrome (CSS). The 5-year survival for WG, MPA and CSS was 74¿91%, 45¿76% and 60¿97%. Relapse (variably defined) was common in the first 2 years but the frequency varied: 18% to 60% in WG, 8% in MPA, and 35% in CSS. The rate of renal survival in WG varied from 23% at 15 months to 23% at 120 months. Methods used to assess morbidity varied between studies. Ignoring the variations in definitions of the stage of disease, factors influencing remission, relapse, renal and overall survival included immunosuppressive therapy used, type of organ involvement, presence of ANCA, older age and male ender. Conclusions: Factors influencing remission, relapse, renal and overall survival include the type of immunosuppressive therapy used, pattern of organ involvement, presence of ANCA, older age and male gender. Methodological variations between studies highlight the need for a consensus on terminology and definitions for future conduct of clinical studies in AAV.

Fine-Tuning Translation Kinetics Selection as the Driving Force of Codon Usage Bias in the Hepatitis A Virus Capsid

Hepatitis A virus (HAV), the prototype of genus Hepatovirus, has several unique biological characteristics that distinguish it from other members of the Picornaviridae family. Among these, the need for an intact eIF4G factor for the initiation of translation results in an inability to shut down host protein synthesis by a mechanism similar to that of other picornaviruses. Consequently, HAV must inefficiently compete for the cellular translational machinery and this may explain its poor growth in cell culture. In this context of virus/cell competition, HAV has strategically adopted a naturally highly deoptimized codon usage with respect to that of its cellular host. With the aim to optimize its codon usage the virus was adapted to propagate in cells with impaired protein synthesis, in order to make tRNA pools more available for the virus. A significant loss of fitness was the immediate response to the adaptation process that was, however, later on recovered and more associated to a re-deoptimization rather than to an optimization of the codon usage specifically in the capsid coding region. These results exclude translation selection and instead suggest fine-tuning translation kinetics selection as the underlying mechanism of the codon usage bias in this specific genome region. Additionally, the results provide clear evidence of the Red Queen dynamics of evolution since the virus has very much evolved to re-adapt its codon usage to the environmental cellular changing conditions in order to recover the original fitness.

Nanometer-scale oxidation of Si(100) surfaces by tapping mode atomic force microscopy

The nanometer¿scale oxidation of Si(100) surfaces in air is performed with an atomic force microscope working in tapping mode. Applying a positive voltage to the sample with respect to the tip, two kinds of modifications are induced on the sample: grown silicon oxide mounds less than 5 nm high and mounds higher than 10 nm (which are assumed to be gold depositions). The threshold voltage necessary to produce the modification is studied as a function of the average tip¿to¿sample distance.

Missouri River Flood Coordination Task Force Report, September 25, 2011

The Missouri River floods of 2011 will go down in history as the longest duration flooding event this state has seen to date. The combination of above normal snowfall in the upper Missouri River basin followed by the equivalent of nearly one year’s worth of rainfall in May created an above normal runoff situation which filled the Missouri River and the six main reservoirs within the basin. Compounding this problem was colder than normal temperatures which kept much of the snowpack in the upper basin on the ground longer into the spring, setting the stage for this historic event. The U.S. Army Corps of Engineers (USACE) began increasing the outflow at Gavin’s Point, near Yankton, South Dakota in May. On June 14, 2011, the outflow reached a record rate of over 160,000 cubic feet per second (cfs), over twice the previous record outflow set in 1997. This increased output from Gavin’s Point caused the Missouri River to flow out of its banks covering over 283,000 acres of land in Iowa, forcing hundreds of evacuations, damaging 255,000 acres of cropland and significantly impacting the levee system on the Missouri River basin. Over the course of the summer, approximately 64 miles of primary roads closed due to Missouri River flooding, including 54 miles of Interstate Highway. Many county secondary roads were closed by high water or overburdened due to the numerous detours and road closures in this area. As the Missouri River levels began to increase, municipalities and counties aided by State and Federal agencies began preparing for a sustained flood event. Citizens, businesses, state agencies, local governments and non‐profits made substantial preparations, in some cases expending millions of dollars on emergency protective measures to protect their facilities from the impending flood. Levee monitors detected weak spots in the levee system in all affected counties, with several levees being identified as at risk levees that could potentially fail. Of particular concern was the 28 miles of levees protecting Council Bluffs. Based on this concern, Council Bluffs prepared an evacuation plan for the approximately 30,000 residents that resided in the protected area. On May 25, 2011, Governor Branstad directed the execution of the Iowa Emergency Response Plan in accordance with Section 401 of the Stafford Act. On May 31, 2011, HSEMD Administrator, Brigadier General J. Derek Hill, formally requested the USACE to provide technical assistance and advanced measures for the communities along the Missouri River basin. On June 2, 2011 Governor Branstad issued a State of Iowa Proclamation of Disaster Emergency for Fremont, Harrison, Mills, Monona, Pottawattamie, and Woodbury counties. The length of this flood event created a unique set of challenges for Federal, State and local entities. In many cases, these organizations were conducting response and recovery operations simultaneously. Due to the length of this entire event, the State Emergency Operations Center and the local Emergency Operations Centers remained open for an extended period of time, putting additional strain on many organizations and resources. In response to this disaster, Governor Branstad created the Missouri River Recovery Coordination Task Force to oversee the State’s recovery efforts. The Governor announced the creation of this Task Force on October 17, 2011 and appointed Brigadier General J. Derek Hill, HSEMD Administrator as the chairman. This Task Force would be a temporary group of State agency representatives and interested stakeholders brought together to support the recovery efforts of the Iowa communities impacted by the Missouri River Flood. Collectively, this group would analyze and share damage assessment data, coordinate assistance across various stakeholders, monitor progress, capture best practices and identify lessons learned.

Elder Abuse Task Force Report Pursuant to HF 2387: An Act Relating to Improvements to and Implementation of Laws Concerning Elder Abuse

During its 2012 session, Iowa’s 84th General Assembly passed House File 2387. The bill was signed into law by Governor Branstad and mandated a review of occurrences of and laws relating to abuse, neglect, or exploitation of individuals who are sixty years of age or older. After conducting the review, the twenty-three member Elder Abuse Task Force presents the following recommendations. These recommendations build upon current Iowa law and practice for the purpose of protecting older Iowans from abuse, neglect, and exploitation.