The First 1000 Days: Impact of Prenatal Tobacco Smoke Exposure on Hospitalization Due to Preschool Wheezing

Preschool wheezing and related hospitalization rates are increasing. Prenatal tobacco smoke exposure (PTSE) increases the risk of wheezing, yet >20% of French women smoke during pregnancy. In this observational retrospective monocentric study, we assessed the link between PTSE and hospital admissions. We included infants <2 years of age admitted for acute wheezing. A phone interview with mothers was completed by electronic records. The primary endpoint was the ratio of cumulative duration of the hospitalization stays (days)/age (months). 129 children were included (36.4% exposed to PTSE vs. 63.6% unexposed). There was a significant difference in the duration of hospitalization/age: 0.9 days/month (exposed) vs. 0.58 days/month (unexposed) (p = 0.008). Smoking one cigarette/day during pregnancy was associated with an increase in hospitalization duration of 0.055 days/month (r = 0.238, p = 0.006). In the multi-variable analysis, this positive association persisted (β = 0.04, p = 0.04; standardized β = 0.27, p = 0.03). There was a trend towards a dose-effect relationship between PTSE and other important parameters associated with hospital admissions. We have demonstrated a dose-effect relationship, without a threshold effect, between PTSE and duration of hospitalization for wheezing in non-premature infants during the first 2 years of life. Prevention campaigns for future mothers should be enforced

BMJ Support Palliat Care

Terminally ill patients may require sedation to relieve refractory suffering. The prevalence and modalities of this practice in palliative care services remain unclear. This study estimated the prevalence of all sedation leading to a deep unconsciousness, whether transitory, with an undetermined duration, or maintained until death, for terminally ill patients referred to a home-based or hospital-based palliative care service. We conducted a national, multicentre, observational, prospective, cross-sectional study. In total, 331 centres participated, including academic/non-academic and public/private institutions. The participating institutions provided hospital-based or home-based palliative care for 5714 terminally ill patients during the study. In total, 156 patients received sedation (prevalence of 2.7%; 95% CI, 2.3 to 3.2); these patients were equally distributed between 'transitory', 'undetermined duration' and 'maintained until death' sedation types. The prevalence was 0.7% at home and 8.0% in palliative care units. The median age of the patients was 70 years (Q1-Q3: 61-83 years); 51% were women and 78.8% had cancers. Almost all sedation events occurred at a hospital (90.4%), mostly in specialised beds (74.4%). In total, 39.1% of patients were unable to provide consent; only two had written advance directives. A collegial procedure was implemented in 80.4% of sedations intended to be maintained until death. Midazolam was widely used (85.9%), regardless of the sedation type. This nationwide study provides insight into sedation practices in palliative care institutions. We found a low prevalence for all practices, with the highest prevalence among most reinforced palliative care providers, and an equal frequency of all practices

Proportionate universalism : evolution, appropriation and application of the principle, towards a reduction of social health inequalities

Les inégalités sociales de santé (ISS), sont une problématique ubiquitaire, dont certains chercheurs en santé publique, mais également d’autres disciplines se saisissent. Dans son rapport Fair Society, Healthy Lives, commandité par le gouvernement britannique, Michael Marmot, formalise et propose pour la première fois le concept d’universalisme proportionné (UP) comme une solution permettant de réduire ces ISS. Il faudrait selon lui, que les actions soient universelles, mais avec une intensité proportionnelle au niveau de désavantage, c’est l’universalisme proportionné. Le rapport de M. Marmot et ses conclusions, ont soulevé une certaine controverse dans différents domaines de recherche (épidémiologie, sociologie, sciences politiques…), et les réactions contradictoires ou encourageantes ont été nombreuses. Toutefois, si suite à la formalisation du concept, quelques autorités locales britanniques ont tenté d’appliquer ce principe dans leurs politiques, peu de chercheurs ont analysé les tenants et aboutissants d’interventions répondant à ce principe. Ce concept a été interprété de différentes façons par certains acteurs de santé publique, et plusieurs définitions en pratique sont possibles. L’objectif de ce travail de thèse est d’évaluer l’évolution, l’appropriation et la mise en pratique effective du principe par différents acteurs de santé publique : chercheurs issus de différentes disciplines, acteurs du soin, et acteurs de terrain en prévention promotion de la santé. La finalité de ce travail est de pouvoir à partir de l’analyse des cas pratiques et de l’identification des freins et leviers à sa mise en place, ébaucher un cadre opérationnel pour que toute intervention de santé publique puisse respecter le principe d’universalisme proportionné.Health inequalities are an ubiquitous problem, which some public health researchers, but also other disciplines, are addressing. In its "Fair Society, Healthy Lives" report, Michael Marmot, proposes for the first time the concept of proportionate universalism (UP) as a solution to reduce health inequalities. According to him, "actions must be universal, but with a scale and intensity that is proportionate to the level of disadvantage", it is proportionate universalism. Mr. Marmot's report and its conclusions raised some controversy in different fields of research (epidemiology, sociology, political science, etc.), and there were many contradictory or encouraging reactions. However, while some British local authorities tried to apply this principle in their policies, few researchers in the field of intervention research have analysed interventions that comply with this principle. This concept has been interpreted in different ways by some interventional research actors, and several definitions are possible in practice. The objective of this thesis is to evaluate the evolution, appropriation and effective implementation of the principle by different public health actors: researchers, health care professionals and health promotion professionals. The aim of this work is to propose an operational framework of practical proportionate universalism for any public health intervention that aim to reduce social health inequalities

Proportionate universalism : evolution, appropriation and application of the principle, towards a reduction of social health inequalities

Les inégalités sociales de santé (ISS), sont une problématique ubiquitaire, dont certains chercheurs en santé publique, mais également d’autres disciplines se saisissent. Dans son rapport Fair Society, Healthy Lives, commandité par le gouvernement britannique, Michael Marmot, formalise et propose pour la première fois le concept d’universalisme proportionné (UP) comme une solution permettant de réduire ces ISS. Il faudrait selon lui, que les actions soient universelles, mais avec une intensité proportionnelle au niveau de désavantage, c’est l’universalisme proportionné. Le rapport de M. Marmot et ses conclusions, ont soulevé une certaine controverse dans différents domaines de recherche (épidémiologie, sociologie, sciences politiques…), et les réactions contradictoires ou encourageantes ont été nombreuses. Toutefois, si suite à la formalisation du concept, quelques autorités locales britanniques ont tenté d’appliquer ce principe dans leurs politiques, peu de chercheurs ont analysé les tenants et aboutissants d’interventions répondant à ce principe. Ce concept a été interprété de différentes façons par certains acteurs de santé publique, et plusieurs définitions en pratique sont possibles. L’objectif de ce travail de thèse est d’évaluer l’évolution, l’appropriation et la mise en pratique effective du principe par différents acteurs de santé publique : chercheurs issus de différentes disciplines, acteurs du soin, et acteurs de terrain en prévention promotion de la santé. La finalité de ce travail est de pouvoir à partir de l’analyse des cas pratiques et de l’identification des freins et leviers à sa mise en place, ébaucher un cadre opérationnel pour que toute intervention de santé publique puisse respecter le principe d’universalisme proportionné.Health inequalities are an ubiquitous problem, which some public health researchers, but also other disciplines, are addressing. In its "Fair Society, Healthy Lives" report, Michael Marmot, proposes for the first time the concept of proportionate universalism (UP) as a solution to reduce health inequalities. According to him, "actions must be universal, but with a scale and intensity that is proportionate to the level of disadvantage", it is proportionate universalism. Mr. Marmot's report and its conclusions raised some controversy in different fields of research (epidemiology, sociology, political science, etc.), and there were many contradictory or encouraging reactions. However, while some British local authorities tried to apply this principle in their policies, few researchers in the field of intervention research have analysed interventions that comply with this principle. This concept has been interpreted in different ways by some interventional research actors, and several definitions are possible in practice. The objective of this thesis is to evaluate the evolution, appropriation and effective implementation of the principle by different public health actors: researchers, health care professionals and health promotion professionals. The aim of this work is to propose an operational framework of practical proportionate universalism for any public health intervention that aim to reduce social health inequalities

Eur J Pediatr

To describe healthcare professionals' perceptions of social health inequalities in the context of pediatric chronic disease and their insights regarding proportionate universalism as a potential solution to reduce them. Semi-directive interviews were conducted with healthcare professionals from different pediatric chronic disease departments of a single French academic hospital. This qualitative study was based on an inductive thematic analysis; an interview topic guide was used for the interviews and the analysis. In this study, we highlighted three main themes: the healthcare professionals' perceptions of social health inequalities in their practices, their beliefs regarding the causality of those inequalities, and potential solutions proposed by healthcare professionals to reduce them. Healthcare professionals very often associated inequalities with socio-economic precariousness or geographical disparities but were not familiar with the notion of a social gradient. Paradoxically, while they claimed not to differentiate among patients in their practice, they did report adapting care, depending on the social situation. For healthcare professionals, inequalities were the result of misunderstood problems, a lack of family support, a failure of the prevention system, and a lack of financial resources. CONCLUSION: We still need to develop solutions to tackle those inequalities at every level of the healthcare system, and healthcare professionals must be more actively involved in this effort. One approach is to adapt public health principles such as proportionate universalism to individual care. WHAT IS KNOWN: • Social health inequalities exist in pediatric care and a social gradient has been shown in many clinical situations. • Exploring health professionals' perceptions of social health inequalities can lead to solutions to tackle them. WHAT IS NEW: • Pediatricians and pediatric nurses were not fully aware of the social gradient of health. • Although they claimed not to differentiate between patients in their practice, healthcare professionals did adapt care when complicated social situations arose

Desafíos teóricos y prácticos del universalismo proporcional: una revisión

Objective. In 2010, the principle of proportionate universalism (PU) has been proposed as a solution to reduce health inequalities. It had a great resonance but does not seem to have been widely applied and no guidelines exist on how to implement it. The two specific objectives of this scoping review were: (1) to describe the theoretical context in which PU was established, (2) to describe how researchers apply PU and related methodological issues. Methods. We searched for all articles published until 6th of February 2020, mentioning “Proportionate Universalism” or its synonyms “Targeted universalism” OR “Progressive Universalism” as a topic in all Web of Science databases. Results. This review of 55 articles allowed us a global vision around the question of PU regarding its theoretical foundations and practical implementation. PU principle is rooted in the social theories of universalism and targeting. It proposes to link these two aspects in order to achieve an effective reduction of health inequalities. Regarding practical implementation, PU interventions were rare and led to different interpretations. There are still many methodological and ethical challenges regarding conception and evaluation of PU interventions, including how to apply proportionality, and identification of needs. Conclusion. This review mapped available scientific literature on PU and its related concepts. PU principle originates from social theories. As highlighted by authors who implemented PU interventions, application raises many challenges from design to evaluation. Analysis of PU applications provided in this review answered to some of them but remaining methodological challenges could be addressed in further research.Objetivo. En 2010 se propuso el principio del universalismo proporcional como solución para reducir las desigualdades en materia de salud. Aunque tuvo una gran resonancia, no parece haber sido aplicado ampliamente y no existen directrices sobre cómo aplicarlo. Los dos objetivos específicos de esta revisión sistemática exploratoria fueron: 1) describir el contexto teórico en el que se estableció el universalismo proporcional, y 2) describir cómo los investigadores aplican el universalismo proporcional y las cuestiones metodológicas relacionadas. Métodos. Se buscó en todas las bases de datos de la Web of Science los artículos publicados hasta el 6 de febrero de 2020 que tuvieran como tema “universalismo proporcional” o sus sinónimos “universalismo dirigido” o “universalismo progresivo”. Resultados. Esta revisión de 55 artículos permitió tener una visión global del universalismo proporcional en cuanto a sus fundamentos teóricos y su aplicación práctica. El principio del universalismo proporcional se basa en las teorías sociales del universalismo y el direccionamiento, y propone vincular estos dos aspectos para lograr una reducción efectiva de las desigualdades en materia de salud. Respecto de su aplicación práctica, las intervenciones basadas en este principio son poco frecuentes y dan lugar a diferentes interpretaciones. Todavía existen muchos desafíos metodológicos y éticos en relación con la concepción y la evaluación de las intervenciones relacionadas con el universalismo proporcional, incluida la forma de aplicar la proporcionalidad y la identificación de las necesidades. Conclusión. En esta revisión se llevó a cabo un mapeo de la literatura científica disponible sobre el universalismo proporcional y sus conceptos relacionados. Este principio se basa en teorías sociales. Tal como lo destacaron autores que implementaron intervenciones de universalismo proporcional, su aplicación plantea muchos desafíos, desde el diseño hasta la evaluación. El análisis de las aplicaciones del universalismo proporcional presentado en esta revisión respondió a algunos de ellos, pero los desafíos metodológicos restantes requieren ser abordados en futuras investigaciones

Rev Epidemiol Sante Publique

La mise à disposition récente de bases de données massives en santé, ainsi que le développement de méthodes et d’outils adaptés à leurs traitements, vient remettre en question le modèle français des registres de morbidité. Mis en place il y a plusieurs dizaines d’années, ils font partie intégrante du système de surveillance et répondent à des missions de recherche et d’évaluation. Sous l’influence d’avancées technologiques récentes, des bases de données massives sont rendues accessibles aux chercheurs et permettent ou permettraient de répondre à des questions initialement dévolues aux registres. Quelle est la place des registres dans ce nouveau contexte : sont-ils obsolètes ou toujours utiles, doit-on les opposer aux nouveaux outils ou en sont-ils complémentaires, et le cas échéant, quelle est désormais leur place dans le nouvel écosystème de la santé publique française ? L’objectif de ce travail a été de réaliser un bilan des rôles et missions des registres existants et de réfléchir à leur positionnement dans ce nouvel environnement. Le modèle français des registres est parfois remis en question pour la lourdeur de ses circuits, nécessitant de nombreux moyens humains. Cependant, les données qui les constituent, validées par un recoupement d’informations à partir de plusieurs sources, sont d’une très grande qualité et permettent de valider les données des nouvelles bases (Système national des données de santé (SNDS) ou entrepôts de données hospitaliers). Registres et nouvelles bases de données sont en fait complémentaires, et loin de mettre en péril ce modèle, l’ouverture récente de ces bases constitue pour les registres, une opportunité de moderniser leur fonctionnement et de répondre à de nouvelles missions.The recent opening of massive health databases, as well as the development of methods and tools adapted to their data processing, questions the French model of “morbidity registry”. In France in 2019, nearly 61 health registries were operating. As defined by law, these registries identify exhaustively all patients with a given disease in a given territory. Established several decades ago, these registries are part of the French surveillance system that is used for research and evaluation purposes. Since the advent of recent technological progress, large-scale databases are made available to researchers and it is possible with these databases to answer questions initially assigned to the registries. What is the place of such registries in this new context: are they obsolete or still useful? Should they be opposed to the new tools or are they complementary to them, and if so, what is their place in the new French public health ecosystem? The objective of this work was to assess the roles and missions of existing registries and to reflect on their positioning in this new environment. The French model of registry is sometimes questioned because of the complexity of its circuits, requiring a significant amount of human resources. However, the data that constitute them, validated by cross-checking information from several sources, are of very high quality, and make it possible to validate the data in the new databases (National Health Data System (NSDS) or Hospital Data Warehouses). Registries and new databases are in fact complementary, and far from jeopardizing this model, the recent opening of these databases represents an opportunity for registries to modernize their operations and respond to new missions

Eur J Vasc Endovasc Surg

Objective A significant decrease in aneurysm related survival is observed at long term follow up after infrarenal endovascular aneurysm repair (EVAR) compared with open repair. Therefore, longer term results with new generation endografts are essential. The aim of this post-approval French multicentre prospective observational study (EPI-ANA-01) was to evaluate the technical success and five year mortality and secondary intervention rates of the third generation AnacondaTM endograft. Methods From June 2012 to October 2013, 176 consecutive unruptured infrarenal abdominal aortic aneurysms were included (160 male patients, mean age 75.3 ± 8.4 years). Survival, freedom from type Ia endoleak, limb events, and re-interventions were estimated using the Kaplan–Meier method. Anatomical and clinical characteristics were compared according to the occurrence of migration, conversion, adverse limb events, endoleak, and sac enlargement. Results The primary technical and clinical success rates were 98.3% and 94.9%, respectively. A hostile neck was identified in 33.9% of patients and 10.7% were treated outside instructions for use (IFU). An early post-operative (≤30 days) mortality rate of 1.7% was observed. At one and five years, respectively, the overall survival rate was 94.9% and 65.9% (aneurysm related in four patients [2.3%]) and the clinical success rate was 90.9% and 70.6%. Secondary interventions were performed in 35 of 176 patients (19.9%). The overall limb occlusion rate was 7.9% and the aneurysm sac diameter decreased significantly (pre-operative diameter 53.9 ± 8.6 mm vs. 42.3 ± 14.7 mm at five years; p < .001). Patients treated outside the instructions for use (IFU) had significantly higher rates of migration, surgical conversion, and aneurysm sac expansion (p = .03). Conclusion The Anaconda endograft provides high technical success and satisfactory five year aneurysm exclusion and clinical success rates. However, implantation outside the IFU should be avoided, as it leads to significantly worse outcomes, and caution over the risk of limb occlusion and distal embolisation should be observed

Development and evaluation of the accuracy of an indicator of the appropriateness of interventional cardiology generated from a French registry

BACKGROUND: Development of appropriateness indicators of medical interventions has become a major quality-of-care issue, especially in the domain of interventional cardiology (IC). The objective of this study was to develop and evaluate the accuracy of an indicator of the appropriateness of interventional cardiology acts (invasive coronary angiographies (ICA) and percutaneous coronary interventions (PCI)) in patients with coronary stable disease and silent ischemia, automated from a French registry. METHODS: All ICA and PCI recorded in a Regional IC Registry (ACIRA) and operated for a stable coronary artery disease or silent ischemia from January 1st to December 31th 2013 in eight IC hospitals of Aquitaine, southwestern France, were included. The indicator was developed to reflect European guidelines. Classification of appropriateness by the indicator, measured on the registry database, was compared to the classification of a reference standard (expert judgment applied through complete record review) on a random sample of 300 interventions. Accuracy parameters were estimated. A second version of the indicator was defined, based on the analysis of false negative and positive results, and its accuracy estimated. RESULTS: The second indicator accuracy was: sensitivity 63.5% (95% confidence interval CI [51.7-75.3]), specificity 76.0% (95%CI [70.4-81.6]), PPV 43.0% (95% CI [33.0-53.0]) and NPV 88.0% (95% CI [83.4-92.6]). When stratified on the type of act, parameters were better for ICA alone than for PCI. CONCLUSIONS: Accuracy of the indicator should raise with improvement of database quality. Despite its average accuracy, it is already used as a benchmark indicator for cardiologists. It is sent annually to each IC center with value of the indicator at the region level to allow a comparison