Analyse économique de la prise en charge de la morbidité maternelle grave dans le Languedoc-Roussillon en 2011

Introduction: La morbidité maternelle grave (MMG) représente un indicateur de santé maternelle. Il n'existe pas de données économiques de cette pathologie. L'objectif de l'étude était de décrire le coût de sa prise en charge, et ses déterminants, du point de vue de l'Assurance Maladie et du point de vue du CHU de Montpellier, dans le Languedoc·Roussilion en 20 11. Méthodes: Une étude obsvationnelle multiticentrique, appelée MOMAT, a inclus 438 fenunes enceintes ayant présenté un cas de MMG entre la 24 SA elle 42cme jour post-partum, entre le 1er janvier 2011et le 31 décembre 2011, dans les maternités du Languedoc-Roussillon. Une étude économique anxillaire a été réalisée grâce aux données PMSI des hôpitaux et de comptabilité analytique du CHU de Montpellier. Une régression logistique a été utilisée pour modélisée la probabilité de séjours très coûteux pour l'Assurance Maladie et la probabilité de séjours déficitaires pour le CHU de Montpellier. Résultats: Pour l'Assurance Maladie, la probabilité de séjours très coûteux était augmentée en cas d'antécédent de césarienne, association de plusieurs causes de MMG, durées de séjours supérieures à 7 jours, grossesse multiple et grossesse induite. Pour le CHU de Montpellier, la probabilité de séjours déficitaires était augmentée en cas de multiparité, hémoragie sévère et durées de séjours longues. Conclusion: Cette étude révèle les contradictions entre logique de planification des soins et logique d'efficience. L'efficience du système de santé nécessite une estimation des coûts de prise en charge, dont l'utilité est double : gestion interne des hôpitaux, et fixation des tarifs nationauxMONTPELLIER-BU Médecine UPM (341722108) / SudocMONTPELLIER-BU Médecine (341722104) / SudocSudocFranceF

Nutrition and mortality in the elderly over 10 years of follow-up: the Three-City study: Nutrition and mortality

International audienceIn the last 20 years, many prospective cohort studies have assessed the relationships between food consumption and mortality. Result interpretation is mainly hindered by the limited adjustment for confounders and, to a lesser extent, the small sample sizes. The aim of this study was to investigate the association between dietary habits and all-cause mortality in a multicentre prospective cohort that included non-institutionalised, community-based elderly individuals (Three-City Study). A brief FFQ was administered at baseline. Hazard ratios (HR) and 95 % CI for all-cause mortality were estimated relative to the consumption frequency of several food groups, using Cox proportional hazards models adjusted for sex, centre, socio-demographic characteristics and health status indicators. Among the 8937 participants (mean age: 74•2 years, 60•7 % women), 2016 deaths were recorded during an average follow-up of 9 years. The risk of death was significantly lower among subjects with the highest fruit and vegetable consumption (HR 0•90; 95 % CI 0•82, 0•99, P=0•03) and with regular fish consumption (HR 0•89; 95 % CI 0•81, 0•97, P=0•01). The benefit of olive oil use was found only in women (moderate olive oil use: HR 0•80; 95 % CI 0•68, 0•94, P=0•007; intensive use: HR 0•72; 95 % CI 0•60, 0•85, P=0•0002). Conversely, daily meat consumption increased the mortality risk (HR 1•12; 95 % CI, 1•01, 1•24, P=0•03). No association was found between risk of death and diet diversity and use of various fats. These findings suggest that fruits/vegetables, olive oil and regular fish consumptions have a beneficial effect on the risk of death, independently of the socio-demographic features and the number of medical conditions

A Systematic Review and Meta-Analysis of Perforator-Pedicled Propeller Flaps in Lower Extremity Defects

International audienceBACKGROUND:Currently, increased interest in the perforator-pedicled propeller flap should not obscure the fact that it is, in reality, a complex procedure requiring experience and monitoring similar to free flaps. Through a meta-analysis, the authors aimed to identify the risk factors of perforator-pedicled propeller flap failure in lower extremity defects.METHODS:The MEDLINE, PubMed Central, Embase, and Cochrane databases were searched from 1991 to May of 2014 for articles describing perforator-pedicled propeller flaps in the lower extremity. The study selection met the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. Fixed-effects models were used.RESULTS:Forty articles complied with the inclusion criteria, representing 428 perforator-pedicled propeller flaps. The most common cause was posttraumatic (55.2 percent). Most of the defects were at the distal third of the lower leg (45.6 percent). The arc of rotation was 180 degrees for 34.3 percent. Complications were found in 25.2 percent, including partial necrosis (10.2 percent) and complete necrosis (3.5 percent). Complete flap survival was found in 84.3 percent. The authors identified three significant risk factors: age older than 60 years (relative risk, 1.61; p = 0.03), diabetes (relative risk, 2.00; p = 0.02), and arteriopathy (relative risk, 3.12; p = 0.01). No significant results were found regarding smoking status other than a tendency (p = 0.06), acute cause (p = 0.59), posttraumatic cause (p = 0.97), distal third of the lower leg (p = 0.66), fascia inclusion (p = 0.70), and pedicle rotation greater than 120 degrees (p = 0.41).CONCLUSION:Age older than 60 years, diabetes, and arteriopathy are significant risk factors of perforator-pedicled propeller flap complications in the lower extremity.Risk, IV

A Nursing Survey on Nutritional Care Practices in French-Speaking Pediatric Intensive Care Units

OBJECTIVES: Malnutrition in critically ill children contributes to morbidity and mortality. The French-speaking pediatric intensive care nutrition group (NutriSIP) aims to promote optimal nutrition through education and research. METHODS: The NutriSIP-designed NutriRéa-Ped study included a cross-sectional survey. This 62-item survey was sent to the nursing teams of all of the French-speaking pediatric intensive care units (PICUs) to evaluate nurses' nutrition knowledge and practices. One nurse per PICU was asked to answer and describe the practices of their team. RESULTS: Of 44 PICUs, 40 responded in Algeria, Belgium, Canada, France, Lebanon, Luxemburg, and Switzerland. The majority considered nutrition as a priority care but only 12 of the 40 (30%) had a nutrition support team, 26 of the 40 (65%) had written nutrition protocols, and 19 of 39 (49%) nursing teams felt confident with the nutrition goals. Nursing staff generally did not know how to determine nutritional requirements or to interpret malnutrition indices. They were also unaware of reduced preoperative fasting times and fast-track concepts. In 17 of 35 (49%) PICUs, the target start time for enteral feeding was within the first 24 hours; however, frequent interruptions occurred because of neuromuscular blockade, fasting for extubation or surgery, and high gastric residual volumes. Combined pediatric neonatal intensive care units were less likely to perform systematic nutritional assessment and to start enteral nutrition rapidly. CONCLUSIONS: We found a large variation in nursing practices around nutrition, exacerbated by the lack of nutritional guidelines but also because of the inadequate nursing knowledge around nutritional factors. These findings encourage the NutriSIP to improve nutrition through focused education programs and researc

COVID-19 outbreak among French firefighters, Marseille, France, 2020

International audienceWe investigated a COVID-19 outbreak at a fire station in Marseille, France. Confirmed cases were defined as individuals with positive SARS-CoV-2 reverse transcription (RT)-PCR and/or neutralising antibodies. All 85 firefighters at work during the outbreak period were included after questioning and sampled for RT-PCR and viral neutralisation assay. Twenty-three firefighters were confirmed positive, 19 of them were symptomatic, and four asymptomatic cases were confirmed by virus neutralisation. A total of 22 firefighters had specific neutralising antibodies against SARS-CoV-2. Neutralising antibodies were found in four asymptomatic and 18 symptomatic cases. Eleven symptomatic cases had high titres (≥ 1:80). The earliest detection of neutralising antibodies was 7 days after symptom onset, and 80% had neutralising antibodies 15 days after onset. One viral culture was positive 13 days after onset. The attack rate was 27%. We identified two introductions of the virus in this outbreak, through a presymptomatic and a paucisymptomatic case. Asymptomatic cases were not the source of a third generation of cases, although they worked without wearing a mask, indicating that asymptomatic cases did not play a significant role in this outbreak. Management and strategy based on early research of clinical signs associated with self-quarantine was effective

Lessons learned from the investigation of a COVID-19 cluster in Creil, France: effectiveness of targeting symptomatic cases and conducting contact tracing around them

International audienceThis study presents the methods and results of the investigation into a SARS-CoV-2 outbreak in a professional community. Due to the limited testing capacity available in France at the time, we elaborated a testing strategy according to pre-test probability. Methods The investigation design combined active case finding and contact tracing around each confirmed case with testing of at-risk contact persons who had any evocative symptoms ( n = 88). One month later, we performed serology testing to test and screen symptomatic and asymptomatic cases again ( n = 79). Results Twenty-four patients were confirmed (14 with RT-PCR and 10 with serology). The attack rate was 29% (24/83). Median age was 40 (24 to 59), and the sex ratio was 15/12. Only three cases were asymptomatic (= no symptoms at all, 13%, 95% CI, 3–32). Nineteen symptomatic cases (79%, 95% CI, 63–95) presented a respiratory infection, two of which were severe. All the RT-PCR confirmed cases acquired protective antibodies. Median incubation was 4 days (from 1 to 13 days), and the median serial interval was 3 days (0 to 15). We identified pre-symptomatic transmission in 40% of this cluster, but no transmission from asymptomatic to symptomatic cases. Conclusion We report the effective use of targeted testing according to pre-test probability, specifically prioritizing symptomatic COVID-19 diagnosis and contact tracing. The asymptomatic rate raises questions about the real role of asymptomatic infected people in transmission. Conversely, pre-symptomatic contamination occurred frequently in this cluster, highlighting the need to identify, test, and quarantine asymptomatic at-risk contact persons (= contact tracing). The local lockdown imposed helped reduce transmission during the investigation period

Investigation of a COVID-19 outbreak on the Charles de Gaulle aircraft carrier, March to April 2020: a retrospective cohort study

International audienceBackground SARS-CoV-2 emergence was a threat for armed forces. A COVID-19 outbreak occurred on the French aircraft carrier Charles de Gaulle from mid-March to mid-April 2020. Aim To understand how the virus was introduced, circulated then stopped circulation, risk factors for infection and severity, and effectiveness of preventive measures. Methods We considered the entire crew as a cohort and collected personal, clinical, biological, and epidemiological data. We performed viral genome sequencing and searched for SARS-CoV-2 in the environment. Results The attack rate was 65% (1,148/1,767); 1,568 (89%) were included. The male:female ratio was 6.9, and median age was 29 years (IQR: 24–36). We examined four clinical profiles: asymptomatic (13.0%), non-specific symptomatic (8.1%), specific symptomatic (76.3%), and severe (i.e. requiring oxygen therapy, 2.6%). Active smoking was not associated with severe COVID-19; age and obesity were risk factors. The instantaneous reproduction rate (R t ) and viral sequencing suggested several introductions of the virus with 4 of 5 introduced strains from within France, with an acceleration of R t when lifting preventive measures. Physical distancing prevented infection (adjusted OR: 0.55; 95% CI: 0.40–0.76). Transmission may have stopped when the proportion of infected personnel was large enough to prevent circulation (65%; 95% CI: 62–68). Conclusion Non-specific clinical pictures of COVID-19 delayed detection of the outbreak. The lack of an isolation ward made it difficult to manage transmission; the outbreak spread until a protective threshold was reached. Physical distancing was effective when applied. Early surveillance with adapted prevention measures should prevent such an outbreak