French High Health Authority Research Articles

Eligibility Rates for Ambulatory EVAR

The current results of endovascular repair of abdominal aortic aneurysms (EVAR) and the wide use of percutaneous closure systems suggest that ambulatory treatment is feasible in selected patients. The objective of this study was to evaluate the rate of eligibility to ambulatory EVAR (EVAR-Ambu) and its potential medicoeconomic impact. Between January 2014 and December 2016, 245 patients were operated of an abdominal aortic aneurysm (AAA) in our center. The 128 patients whose anatomy was unfavorable with EVAR, which were operated in urgency or who were classified as American society of anesthesiologists 4, were excluded from the study. The 117 remaining files were reexamined to evaluate the eligibility for EVAR-Ambu retrospectively. The patients were considered as eligible if they presented all the following criteria: (1) normal surgical risk, (2) logistic feasibility of an ambulatory procedure (home <1 hr away from the hospital, available relatives), and (3) anatomical criteria of percutaneous feasibility according to angio-computed tomography. The surgical risk was evaluated according to the French High Health Authority (HAS) and the Society for Vascular Surgery (SVS) score. The balance between costs and revenue was evaluated for each patient according to the length of stay. Among the 117 patients, 43 (37%) and 57 (49%) were eligible for EVAR-Ambu by percutaneous route according to whether the surgical risk was assessed according to the HAS or the SVS criteria. If a conventional surgical approach was considered as compatible with EVAR-Ambu, 12 (10%) and 13 (11%) additional patients were eligible according to whether the surgical risk was assessed according to the HAS or the SVS criteria, respectively. In terms of medicoeconomic evaluation, the cost of the initial intervention depended was mainly on the cost of the stent graft and the operating room services. The cost spent of 1 night conventional hospitalization (CH) after EVAR was 603€ per day versus 490€ in the Day Surgery Unit (DSU). In comparison, the revenue for the institution was identical for DSU and a 1-night CH. According to our estimates, the balance between revenue and expenditures amounted to +122€ per patient for EVAR-Ambu versus +10€ or +119€ per patient hospitalized 1 or 2 nights, respectively. EVAR-Ambu is possible in a substantial proportion of patients treated for infrarenal AAA. Its medicoeconomic interest is real for the health system although it appears low at the individual level. The safety of this approach in clinical practice must be confirmed by a prospective study in selected patients.

Behavioral disorders after TBI: Evaluation of pharmacological intervention 2 years after French guidelines of July 2013

Behavioral disorders (BD) after Traumatic Brain Injury (TBI) are common and have a major impact on the patient, his family and caregivers, leading to longer length of stay in hospitalization, and difficulties of social rehabilitation. The usual psychoactive drugs are not efficient, leading to side effects harmful for neurological recovery. French guidelines about management of these BD have been elaborated by the French Society of Physical and Rehabilitation Medicine and the French High Authority for Health in July 2013. We focused on pharmacological interventions of disruptive behavior by excess (aggressiveness, agitation, irritability). Propranolol is recommended in first-line treatment, mood regulating antiepileptics in second. The purpose of this work was to evaluate the impact of the guidelines on the practitioner's prescriptions for BD in intensive care, neurosurgery and physical and rehabilitation medicine (PRM) units. We compared the period 2011–2012 versus 2014–2015. This was a retrospective, descriptive, multicentric study. All adult patients with TBI hospitalized at primary stage in PRM, in the PRM center of Nantes and Angers University Hospitals were included. Among 208 patients analyzed, 84 (40,4%) had BD by excess. Propranolol was more prescribed after the guidelines: 34% vs 13.5% ( P = 0.03). It was prescribed at the average dose of 45 mg, guidelines recommend 40 to 80 mg. Over 21 prescriptions of Propranolol, 10 were stopped, 3 for cardiovascular side effects. Patients with BD had more psychoactive drugs prescribed (2.7 vs. 0.93, P < 0.05) and there was no difference between before and after the guidelines (2.95 vs. 2.51, P = 0.33). PRM specialists prescribed more psychoactive drugs than the others. Intensive care specialists never prescribed mood regulating antiepileptics. There is a need to inform all the doctors who take care of these patients about the guidelines. Propranolol is more prescribed but at the limit of the efficient dose, and psychoactive drugs are still long-term prescribed.

Gestion des erreurs médicamenteuses en médecine générale : étude en maison de santé pluridisciplinaire

Medication errors are the most frequent medical care adverse events in France. Their management process used in hospital remains poorly applied in primary ambulatory care. The main objective of our study was to assess medication error management in general ambulatory practice. The secondary objectives were the characterization of the errors and the analysis of their root causes in order to implement corrective measures. The study was performed in a pluriprofessionnal health care house, applying the stages and tools validated by the French high health authority, that we previously adapted to ambulatory medical cares. During the 3months study 4712medical consultations were performed and we collected 64medication errors. Most of affected patients were at the extreme ages of life (9,4% before 9years and 64% after 70years). Medication errors occurred at home in 39,1% of cases, at pluriprofessionnal health care house (25,0%) or at drugstore (17,2%). They led to serious clinical consequences (classified as major, critical or catastrophic) in 17,2% of cases. Drug induced adverse effects occurred in 5patients, 3of them needing hospitalization (1patient recovered, 1displayed sequelae and 1died). In more than half of cases, the errors occurred at prescribing stage. The most frequent type of errors was the use of a wrong drug, different from that indicated for the patient (37,5%) and poor treatment adherence (18,75%). The systemic reported causes were a care process dysfunction (in coordination or procedure), the health care action context (patient home, not planned act, professional overwork), human factors such as patient and professional condition. The professional team adherence to the study was excellent. Our study demonstrates, for the first time in France, that medication errors management in ambulatory general medical care can be implemented in a pluriprofessionnal health care house with two conditions: the presence of a trained team coordinator, and the use of validated adapted and simple processes and tools. This study also shows that medications errors in general practice are specific of the care process organization. We identified vulnerable points, as transferring and communication between home and care facilities or conversely, medical coordination and involvement of the patient himself in his care.

Élaboration d’un document d’information écrit pour les personnes ayant un trouble de la personnalité borderline

IntroductionBorderline personality disorder affects 10% of ambulatory patients and 15 to 25% of patients hospitalized in psychiatry. Therapeutic recommendations include informing patients about the characteristics of the disorder, its evolution and the effectiveness of psychotherapies. This information can promote self-understanding, therapeutic alliance and the involvement of the patient in his/her care. Despite these recommendations, people with borderline personality disorder are generally not well-informed about their disorder in France. We find a few written document delivering information about the disorder destined for patients in French, but we did not find it with a detailed elaboration methodology and none developed with patient involvement. The objective of this work was to develop and to evaluate, an information leaflet for patients with Borderline Personality Disorder, involving patients in these two stages. MethodWe developed and evaluated an information document with a step-by-step approach, similar to that described in the methodological guide of the French High Authority for Health (Haute Autorité de santé). We first designed an initial version, which we then modified with a working group with 4 patients and 2 health professionals. Finally, we evaluated and modified this document through 6 individual interviews with patients. Patients were recruited through psychiatrists and psychologists from the department of Toulouse, who were contacted by email. Concerning the analysis of the data, the answers to the closed questions were quantified. The answers to the open-ended questions were analyzed qualitatively through a thematic analysis, in order to organize in a structured and synthetic way all the subjects covered by the patients during the various interviews. ResultsThe working group led to 19 changes to the original version of the document, including the addition of “other ways to feel better”, the addition of the concepts of hypersensitivity and intense emotional crisis, and rewording to simplify the document. Individual interviews led to 23 changes including: the removal of percentages on the evolution of the disorder (in view of their pessimistic nature), the development of the criterion on affective instability (considered as central), the development of the “other ways to get better” section (with a crisis management board through a soothing activity); several rephrasings, reorganizations or deletions. Patients evaluated the document, they judged it as easy to understand, interesting and its reading was well experienced. On the other hand, the presentation was judged to be insufficiently attractive and is being improved by graphists. We can emphasize the particular attention shown by the patients to the document being optimistic. ConclusionWe have elaborated with patients an informative document. This document is to be used as a support to oral information, in order to reinforce the patient's knowledge. It cannot replace the oral information that remains essential. Concerning the limitations of this work, it might have been interesting to involve other health professionals in the development of the initial version of the document, such as experts on the disorder. It would be interesting to evaluate the impact of the information approach on the therapeutic alliance or the involvement of patients in care, as well as the impact of the written document on these parameters.

Therapeutic recommendations of the International Homeopathic Society of Supportive Care in Oncology (IHSSCO)

Summary Homeopathy is the complementary medicine most widely used by patients with cancer in France. However, there are as yet no supportive care guidelines for this therapy. The International Homeopathic Society of Supportive Care in Oncology (IHSSCO) has developed recommendations adapted to oncology, respecting the principle of similitude, individualisation and infinitesimality proper to homeopathy. We used the method of “recommendations by formal consensus” proposed by the French High Health Authority. Seven steering groups studied respectively cancer disclosure, surgery, chemotherapy, targeted therapies, radiation therapy, hormone therapy and post-cancer. Thirty recommendations were discussed, amended and unanimously adopted during the plenary session. However, certain situations require an individualised homeopathic consultation. These recommendations are part of a program to improve good practice in supportive care. They are indicative and do not replace in any way an individualised homeopathic consultation. They are very safe to use as there are no medicine interactions or side effects of the homeopathic medicine. The low cost of homeopathy makes them accessible to all. They should be tested against practice and future clinical studies.

Séjours courts et longs en ASPPI : comparaison des données cliniques et extracliniques issues de 250 certificats initiaux

BackgroundOn July 5, 2011, France introduced a law permitting the involuntary admission of patients considered to be in “imminent danger” into psychiatric care without the consent of the family. This is known as “admission en soins psychiatriques pour péril imminent”(ASPPI). ASPPI authorizes all physicians to hospitalize a patient without his or her consent nor the consent of a third party. This differs from previous measures as only one certificate is needed. The law also requires involuntarily admitted patients to present themselves before a judge specialized in Liberties and Detentions (juge des libertés et des détentions), 12 days following their admission. Although there has been an increase in the number of ASPPI admissions when compared to other types of involuntary admission, patients admitted by ASPPI have been hospitalized for a shorter time than others. Some authors, however, have pointed out that decision criteria are frequently interpreted in a loose manner by physicians. This study was conducted at Sainte Anne hospital in Paris. ObjectiveThis study tried to determine if there were different clinical and non-clinical characteristics associated with the length of hospitalization under ASPPI. MethodsThis study analyzed all administrative files for patients admitted under ASPPI from January 1, 2015 to December 31, 2015. These files contained the medical certificates and the court orders. The sample was split into two groups: patients hospitalized for a shorter stay and who did not present themselves to the judge and patients hospitalized for a longer stay and who did present themselves to the judge. The certificates were analyzed with a criteria grid, which includes clinical and non-clinical items. Clinical items were taken from the French High Authority of Health (Haute Autorité de Santé) 2005 recommendations. These include suicidal risk, risk to others, drug abuse, delusions or hallucinations, mood disorder and lack of selfcare. Non-clinical items include other information found in the certificate and sociodemographic information found in the administrative file. ResultsAmong the 250 certificates analyzed, 172 (68.8%) were associated with a long stay and 78 (31.2%) with a short stay. A bivariate analysis found no significant differences between the two groups for non-clinical characteristics and for drug abuse and mood disorder. When no suicidal risk was present, the stay was short in 21% of the certificates and long for 79%. When a suicidal risk was present the stay was short in 43% of the certificates and long for 57% (P=0.0002). When a risk to others was present the stay was short for 19% of the certificates and long for 81% (P=0.003). When delusions and hallucinations were present the stay was short in 15% of the certificates and long in 85 % (P=5×10e–14). When a lack of selfcare was present the stay was short in 10% of the certificates and long for 90% (P=0.01). ConclusionThis study identified two types of situations linked with the length of hospitalization for patients under ASPPI. In one situation, associated with a longer stay, we found acute psychiatric disorders exhibited by more delusions, hallucinations, drug abuse, and lack of selfcare. In the second situation, associated with a shorter stay, this study found more episodic situations with suicidal risk. This study suggests that some involuntary admissions could be avoided if physicians could monitor episodic situations in appropriate structures. Moreover the criteria grid we used in this study should be validated to further analyze the quality of the certificates in order to lead to more precise recommendations.

Adequate transition of health care from child to adult for patients with motor disability: Environmental, medical and social challenges

Objective: Aging is a part of life that is inevitable for all of young patients with a motor disability. The time comes to leave pediatric teams for the adult's word, and it doesn't get without some fears and brakes from both sides. A group from the SOFMER (French society for Physical and Rehabilitation medicine) proposed a set of recommendations for good practices for the transition of health care from child to adult for patients with motor disability. Many domains were relevant: medical care but even training, independent living, education, employment and social/community life. Methods: A 3-step study was performed including i) a revue of the existing literature, ii) a public conference to include the professional participants remarks and comments following the literature review, iii) an approach by committee to review and valid the proposed recommendations. Results: The first step took place from February to October 2010. The recommendations, which emerged from this review and analysis, were discussed at the Marseille public conference on October 13th 2010 and further enhanced by the professional attendees practices and experiences. A multidisciplinary group reviewed these recommendations before a final submission to HAS (French High Health Authority) labelling. Conclusion: This stage requires anticipation and preparation. It must be started by child-centered health care sector in close relation with the adult medical team. The young (and his/her family) remains central to the process which will take some years. Two major periods were identified: the transition period and the transfer period. Some specific recommendations were developed according to epidemiology of motor disabilities, medical and administrative criteria, legal issues, emotional and psychological factors.

Prévalence et diversité de la prise en charge des patients atteints de cancer de la prostate classés à faible risque selon la classification de d’Amico ou le score de CAPRA : étude française multicentrique

Currently, the French High Authority for Health does not recommend mass screening for prostate cancer (PCa), due to the risk of over-treatment, notably of low risk patients. Our study is intended to reflect the therapeutic attitudes for the management of patients classified as low risk of progression in French clinical centers. For all positive prostate biopsies performed during 2012 and 2013 in five French departments of urology, clinicopathological characteristics required to calculate the d'Amico risk group and the Cancer of the Prostate Risk Assessment (CAPRA) score were filled. Information on the first treatment of "low risk" patients was collected. A total of 1035 patients were included, with a median age at diagnosis of 66 years old. According to d'Amico and CAPRA classifications, 30.4% and 35.0% of patients were at low, 34.5% and 33.2% at intermediate, 35.1% and 31.8% at high risk. The diagnosis severity increased with age (P<0.0001). The main treatment for low risk patients was radical prostatectomy (41.6% and 42.0% for d'Amico and CAPRA, respectively), but active surveillance was the most frequent treatment if diagnosed after 75 years old. The management of low risk patients varied significantly between centers (P<0.0001), according to the therapeutic platforms available within the hospital. In absence of strong progression predictor, the management of low risk PCa remains based on center habits and local therapeutic platforms. New predictive markers, such as multiparametric MRI or molecular tests, are needed to guide rational management of low risk PCa. 4.

Laparoscopic Surgery versus Endovascular Treatment for Abdominal Aortic Aneurysms in Patients with a Normal Surgical Risk and a Favorable Anatomy

Laparoscopic treatment (LT) and endovascular treatment with a stentgraft (EVAR) are two mini-invasive techniques for the treatment of abdominal aortic aneurysms (AAA). The patients with a normal surgical risk and presenting an anatomy compatible with the two techniques appear to be good candidates for LS or EVAR. The aim of this study was to compare the early and late results of these two techniques in this sub-group of patients. Between February 2006 and July 2015, 646 AAAs were operated in our service and were collected in a prospective base. The 138 (21%) patients with a normal surgical risk and presenting an anatomy compatible with LS and EVAR according to the criteria of the French High Health Authority were selected. The principal criterion of judgment was the occurrence of a death or a major systemic complication at 30 days. The two groups were compared with a statistical analysis with parametric tests. p<0.05 was considered significant. The results were expressed as mean ± standard deviation. The series included 109 patients treated by LS and 29 patients treated by EVAR. Demographic data, comorbidities and aneurysmal anatomy were not different between the two groups except the age (67.4±7.9 for the LS group vs. 70.7±7.4 years for the EVAR group; p=0.046). At 30 days, there was no death in the two groups. There was no difference concerning the principal criterion of judgment (5.5% in LS the group vs. 0% in the EVAR group; p=0.536). The duration of full hospitalization was significantly lower in the EVAR group (7.2 vs. 4.8 days; p<0.00001), as well as the duration of intensive care monitoring (27.6 hours in the LS group vs. 0 hour in the EVAR group; p=0.023). With an average follow-up of 52.9 months in the LS group and 30.2 months in the EVAR group, no significant difference was found between the groups regarding the mortality and reintervention rates (p=0.136), with however a tendency in favor of LS. In this study, we did not find a significant difference between the two techniques concerning the principal criterion of judgment. EVAR seems to allow a faster recovery. In the longer term however LS tends to being more durable. A study with more patients is desirable to conclude as for the most adapted mini-invasive technique in this population.

“The psychological evaluation” in a chronic clinical pain: a new figure of paradoxality?

Through a definition of psychodynamic psychological assessment in clinic pain, the authors reveal paradoxical points at work between patients and the expression of their chronic pain, the position of clinical psychologist and his evaluation, and psychic temporality of the subject along with the order of the French High Authority of Health and its logic of profitability. This will not only highlight these stumbling blocks, but also attempt to unravel issues in order to show the emergence of an additional paradoxality written in the patient’s relation to himself.

Compliance of Computed Tomography Scan Requests in Sub-Saharan Africa

>Objective: To investigate the compliance of computed tomography (CT) scan requests in the X-ray units of Sub-Saharan Africa. Methods: Multi-centric, exhaustive, descriptive and cross-sectional study (Burkina Faso and Benin) focused on CT scan requests implemented and interpreted from May 1 to July 31, 2014. Request compliance was assessed according to the criteria of the French High Authority for Health to which was added a criterion for fulfillment of description of patient clinical information. An exam was deemed compliant when all criteria were met. Ratios were compared by means of Chi2 test at 0.05% significance level. Results: Among the 426 colligated computed tomography prescriptions, the least filled fields were allergy concept (0%), creatinine-mia (0.3%), examination purpose (50.2%). The overall compliance rate was 35%. The requests made by medical specialists were more compliant than those made by general practitioners and students (p = 0.003). Fulfillment of clinical information description was also better among medical specialists compared to the other prescribers (p = 0.002). Conclusion: It is important to improve the quality of computed tomography (CT) scan requests in the hospitals of Bobo-Dioulasso (Bur-kina Faso) and Parakou (Benin).

Pancréatites d’origine médicamenteuse. Revue des notifications spontanées en France

PurposeIdentify the main pharmacological classes inducing pancreatitis using spontaneous reports recorded in the French pharmacovigilance database (FPVD). MethodsCases of pancreatitis recorded in FPVD between January 1st 1985 and December 31st 2013 were selected using the 2001 consensus conference criteria of the French High Health Authority. ResultsDuring this period, 2975 observations were selected with 1151 fulfilling criteria of drug-induced pancreatitis (i.e. 0.22% of total notifications in the FPVD). According to ATC classification, the pharmacological classes most frequently found were antiretroviral, analgesic, lipid-lowering, immunosuppressive and insulin secreting drugs. For some drugs (metformin, omeprazole, etc.) pancreatitis was “unlabelled” in the summary of product characteristics. ConclusionThis review allows to identify the main drug classes currently involved in spontaneous reporting of pancreatitis in France.

Le modèle de Denver (Early Start Denver Model). Une approche d’intervention précoce pour les troubles du spectre autistique

The Early Start Denver Model for young children with autism (ESDM) is an early intervention program that integrates developmental, relationship-based, behavioral and learning concepts emerging from research on autism spectrum disorder (ASD), in order to provide a comprehensive intervention in particular for the very young children, from the age of 12months on. In close collaboration with parents and family, the ESDM aims to decrease the child's ‘social deprivation’ and its perpetuating impact on the neuronal and psychological development, in order to rekindle the altered developmental processes during this period of maximal brain plasticity. Designed as a naturalistic model that can be transposed into different contexts, the EDSM aims to stimulate in an intensive manner previously deficient functions such as social engagement, imitation, communication etc., through play sequences based on the child's interests. Following a precise evaluation of each child's developmental profile every three months, an individual intervention program is elaborated through a highly structured and standardized procedure using the ESDM curriculum. The ESDM is one of the only treatment approaches that have been scientifically validated in a randomized controlled trial, and it is one of the major programs recommended by the French High Authority of Health (HAS) for the treatment of children with ASD (since 2012). Questions remain regarding the necessary treatment intensity in order to obtain satisfying results with the ESDM (20–25hours per week or less), especially within the context of the French public health system, regarding its treatment modalities (one-on-one or small group settings) and regarding the profile of children that would benefit most from this intervention (e.g. ASD with or without associated developmental delay). As an example, we report here the results of a study on 16 children with ASD participating over at least one year in an early intervention program with flexible treatment hours based on ESDM principles.

Assessment of the completeness of medical imaging request forms in a sub-Saharan African setting

The technical quality, interpretation, and clinical utility of diagnostic imaging examinations can increase considerably when the request forms are correctly filled out. This study sought to evaluate the completeness of these request forms at the Women and Children's Hospital in Yaoundé, Cameroon, to the 8 criteria established by the French High Health Authority (HAS, France). This cross-sectional study evaluated 118 request forms for ultrasounds, 110 for conventional radiography, and 34 for computed tomography (CT scans), all completed by physicians at our university-affiliated hospital. They were sampled consecutively three days a week for several weeks, on days randomly selected at the beginning of each week, to minimize bias and ensure that as many different physicians as possible were assessed. We doubled the sample size recommended by the HAS. Conformity was defined by the presence of the required data on the request forms (data classified as either administrative or clinical). Overall, 52 request forms (19.8%) had all 5 administrative items, but only 9.2% had all 3 clinical components. Only 3 forms (1.1%) were 100% complete, including all 8 items; 85% included at least 5 components, and 35.1% had 6. The patient's last name was always included. Only 4.2% of the request forms included the prescriber's telephone number; 8% did not include the date and 17.2% (n = 45) did not state the clinical findings. On 30% of the forms, symptoms were the only clinical information listed; 23.7% (n = 62) stated the purpose of the examination (that is, the diagnosis to be confirmed or ruled out). The rate of missing information was highest in the requests for conventional radiography (49.5% compared to 38% with ultrasound and 12.3% for CT scans). The request forms for imaging examinations provided inadequate administrative and clinical data, especially those for conventional radiography. This missing information makes it harder to perform and interpret these examinations. An electronic request form with mandatory fields might improve the overall quality of the forms.

Les sites internet français sur la chirurgie bariatrique sont-ils de bonne qualité ?

IntroductionInternet has become a capital source of health information as almost three patients out of four make research on health care. Moreover, obese patients seem to be particularly interested by this tool. We analysed the quality of the most popular French bariatric surgery websites.MethodsBetween September to October 2013, we selected 20 websites on bariatric surgery. The research was conducted using Google® and using the following keywords: “obesity surgery”, “gastric bypass”, “gastric banding”, and “sleeve”. Retrieved websites were assessed with an evaluation tool recommended by the French High Authority for Health (HAS) and classified in 3 categories “very good”, ”good” and “low”. Affiliation and Health On the Net (HON) label were retrieved for each website. The French and French-Speaking Society of Obesity Surgery and Metabolic Disease (SOFFCO-MM) website was automatically included.ResultsAlmost half of the retrieved studies (9/20) belong to private hospitals, eight to media, two are institutional and only one is drafted by a public hospital. Seven websites (35%) have been noted as “very good”, five (25%) as “good”, and eight (40%) as “low”. Hospitals (public or private) make better websites than institutions or media (p<0.05). Websites with a HON label had a significantly higher score (p<0.05). Popularity and quality of websites are poorly correlated (r= −0.493, p=0.27).ConclusionQuality of French websites on bariatric surgery is disparate. Almost one third has a good quality, particularly when written by health professionals. Nevertheless public hospitals seem to be poorly involved in this mean of communication.

Challenging behaviour following traumatic brain injury: Symptoms and assessments

injury hindering family, work and social relationship. Care management of these symptoms at hospital, in medico-social facilities or at home faces the diversity and the low efficiency of usual treatments. The French Physical and Rehabilitation Medicine Society (SOFMER) proposed to elaborate good practice recommendations under the aegis of the French High Health Authority (HAS). On the basis of a systematic and critical review of the literature, performed by four project-managers, recommendations have been proposed by a working group composed of 23 experts. A reading group will give his opinion before the final validation in the context of the on-going HAS label process.

Identification des freins à la prescription du test de dépistage de l’infection au VIH par les sages-femmes et médecins en Guadeloupe

Guadeloupe is the second highest French area for diagnosis and prevalence of HIV infection and AIDS. In October 2009, the French High Health Authority has published guidelines for a more systematic HIV screening. The goal of this study is to identify the limitations in HIV testing prescription by the Guadeloupian prescribers according to these new recommendations. Data were collected with a questionnaire submitted to physicians and midwives after random selection. Among 285 randomly selected prescribers, 67 midwives and 40 physicians participated from August to December 2010. The main limitations to HIV testing prescription were: a consultation for another purpose, patient or his life style were known, and lack of HIV infection symptoms. Some characteristics of more easily screened patient did not match with those who had been newly diagnosed in Guadeloupe. Finally, both quantitative and qualitative knowledge of these new recommendations was insufficient. Implementation of these new testing recommendations should give emphasis to the systematic and annual nature of HIV testing for whole population. It should also insist on distinction between HIV testing and diagnosis of a symptomatic patient.

Pitfalls in the diagnosis of congenital rubella syndrome in the first trimester of pregnancy

A 29-year-old woman, gravida 3 para 0, was referred at 19 weeks of gestation because of a maternal rubella infection during the first trimester of pregnancy. She consulted at 5 weeks for a rash, which, at that time, was considered to be urticaria. Her serological status for rubella was unknown at that time, and as rubella infection was not considered, serological investigations were not conducted. At 6 weeks, toxoplasma and rubella testings were performed as recommended by the French High Health Authority [Haute Autorité de Santé (HAS)]. HAS only recommends IgG testing for routine Rubella screening and both IgG and IgM testings for toxoplasma.1 Her results were negative for rubella-specific IgG and positive for toxoplasma-specific IgG [104 IU/mL (cutoff: 10.5 IU/mL)] and IgM [5.23 (cutoff: 1), Access 2, Beckman Coulter, Fullerton, CA, USA]. Because these findings suggested a recent toxoplasma infection, spiramycine was started pending the results of the IgG avidity test. The avidity index was high, 0.48 (cutoff: 0.30; Vidas bioMérieux, Marcy-l'Étoile, France), thus making postconceptional toxoplasma seroconversion very unlikely, and spiramycine was stopped. As recommended by HAS, all rubella seronegative patients have a subsequent rubella testing at around 20 weeks. Her second serology performed at 16 weeks indicated a seroconversion leading to IgM testing: rubella-specific IgG, 181.6 IU/mL (cutoff: 10 IU/mL; Architect Abbott, Wiesbaden Germany) and rubella-specific IgM, 1.48 (cutoff: 1.2; Vidas bioMérieux). Retrospective analysis of the serum collected at 6 weeks indicated that rubella-specific IgM was already positive at that time (3.15). The IgG avidity index was measured using our in-house urea wash method. This method is based on adding 6 M urea as a denaturing agent to the washing buffer to prevent the binding of low-avidity antibody to the antigen. Results are expressed as a ratio of absorbance of a single serum dilution with and without denaturing agent. An avidity index of <30% is considered as very low, between 30% and 70% as low, between 70% and 90% as moderate, and >90% as high.2 The IgG avidity index was 78% (moderate) at 16 weeks. Together with the analysis of IgM kinetics on both samples,2 the primary infection was dated at around 5 weeks, coinciding with the rash described by the patient. The ultrasound at 16 weeks was unremarkable. Amniocentesis at 18 weeks detected rubella viral RNA by RT-nested-PCR analysis3 indicating congenital rubella infection. The ultrasound scan at 19 weeks revealed intrauterine growth restriction, together with asymmetric bilateral microphthalmia (below the 5th percentile),4 opacity of the right lens (Figures 1 and 2), and an isolated hyperechogenic mitral focus. Because these signs indicated symptomatic fetal rubella infection, the couple asked for termination of pregnancy. The male fetus weighed 190 g (below the 5th percentile for 20 weeks). The pathology examination confirmed bilateral microphthalmia and the fetal infection with biopsies from the liver and the brain being positive for rubella viral RNA.

Optimizing methotrexate therapy in rheumatoid arthritis: A systematic literature review

Objective To describe the means of optimizing methotrexate therapy for rheumatoid arthritis in daily clinical practice, based on a systematic literature review. Methods We systematically reviewed the literature by searching the PubMed, Embase, and Cochrane databases and reviewing communications to ACR and EULAR meetings for studies on methotrexate starting dosages, dosage increment sizes and intervals, maximum dosages, and routes of administration in patients with rheumatoid arthritis. We used an appropriate scoring system to assess the methodological quality of each selected study. Results We identified 519 studies of which 11 were selected based on the titles and abstracts then on the full-length articles. Methotrexate was optimally effective when started in a high dosage (more than 10 mg/week orally) that was subsequently increased by 5 mg/month up to 25–30 mg/week, 1 1 The French High Health Authority recommends a maximum dosage of 25 mg/week with appropriate adjustments based on clinical effectiveness and tolerance. with appropriate adjustments based on clinical disease activity and tolerance of each patient. For a given methotrexate dosage, parenteral administration was more effective and produced fewer gastrointestinal adverse effects than oral administration. Conclusion The information supplied by this systematic review support higher starting dosage, an intensive dosage increase schedule and recourse to parenteral administration in case of unresponsiveness or intolerance to oral methotrexate. They should improve the management of patients given methotrexate therapy for rheumatoid arthritis.

Personal protection against biting insects and ticks

Recent events with the first cases of local transmission of chikungunya and dengue fever virus in southern France by Aedes albopictus, adding to the nuisance and potential vectors that can be encountered when traveling in tropical or sub-tropical countries, has shown the value of a reflection on the Personal protection against vectors (PPAV). It is seen during an outbreak of vector-borne disease, or simply because of nuisance arthropods, that our fellow citizens try to protect themselves individually by using an arsenal of resources available on the market. Yet most of these means have been neither checked for effectiveness or safety tests, however, essential. Travellers, staff on mission or assignment, are looking for specific information on how to protect themselves or their families. Health workers had at their disposal so far indications that vary widely from one source to another. Therefore it seemed important to the Society of Travel Medicine (SMV) and the French Society of Parasitology (SFP) to initiate a reflection on this theme. This reflection took the form of recommendations for good practice, following the outline established by the French High Health Authority (HAS). The aim was to gather all relevant information, verified and validated and the format to be used not only by health personnel (doctors, pharmacists, nurses), but also by travel agents and individuals. This document highlights the need to take into account the risk of vector-borne diseases, some deadly, and the benefit of various methods of personal protection. The choice of methods is clearly oriented towards those whose effectiveness has been proven and potential risks assessed. The paper finally proposes two decision trees based on the transmission type (day or night) and kind of stay (short or roaming, long and steady). It concerns travellers, but also expatriates, residents and nomads.