Biomedical subjects

Joël Coste

Publications and source records attributed to Joël Coste.

At least 19 recordsLinked to original sources

PubMed2007

Care pathways for ectopic pregnancy: a population-based cost-effectiveness analysis.

OBJECTIVE: To define care pathways in terms of frequency, costs, and outcomes and to assess their cost-effectiveness. DESIGN: Population-based cost-effectiveness study. SETTING: Auvergne EP registry (France). PATIENT(S): Women (n = 1,664) registered between 1994 and 2003. INTERVENTION(S): Standard diagnosis and treatment of EP. MAIN OUTCOME MEASURE(S): Costs before, during, and after hospitalization were assessed from data concerning medical costs of examinations and treatments. One-year fertility was used for effectiveness assessment. We assessed cost-effectiveness for the healthcare system. RESULT(S): Diagnostic ultrasound (47% of scans were nondiagnostic) was essential for the use of methotrexate as a first-line treatment for subacute EP. Hospital and ambulatory care costs were similar for all surgical-care pathways (diagnostic or nondiagnostic ultrasound scan followed by conservative or radical laparoscopy). Hospital and ambulatory-care costs associated with methotrexate treatment were less than half those for surgical-care pathways. In subacute cases, conservative treatments, and methotrexate in particular, were associated with better fertility at similar or lower cost to salpingectomy for EP for reproductive failure. CONCLUSION(S): Conservative treatments are cost-effective with respect to salpingectomy, when subsequent fertility is at stake. Efforts should be made to increase the frequency of diagnostic ultrasound scans, making it possible to increase methotrexate use and cost-effectiveness.

Adolescent↗

PubMed2006

Corticotroph tumor progression after adrenalectomy in Cushing's Disease: A reappraisal of Nelson's Syndrome.

CONTEXT: Adrenalectomy is a radical treatment for hypercortisolism in Cushing's disease. However, it may lead to Nelson's syndrome, originally defined by the association of a pituitary macroadenoma and high plasma ACTH concentrations, a much feared complication. OBJECTIVE: The objective of the study was to reconsider Nelson's syndrome by investigating corticotroph tumor progression based on pituitary magnetic resonance imaging scan and search for predictive factors. DESIGN: This was a retrospective cohort study. SETTING: The complete medical records of Cushing's disease patients at Cochin Hospital were studied. PATIENTS: Patients included 53 Cushing's disease patients treated by adrenalectomy between 1991 and 2002, without previous pituitary irradiation. MEASUREMENTS: Clinical data, pituitary magnetic resonance imaging data, and plasma ACTH concentrations for all patients and pituitary gland pathology data for 25 patients were recorded. Corticotroph tumor progression-free survival was studied by Kaplan-Meier, and the influence of recorded parameters was studied by Cox regression. INTERVENTION: There was no intervention. RESULTS: Corticotroph tumor progression ultimately occurred in half the patients, generally within 3 yr after adrenalectomy. A shorter duration of Cushing's disease (adjusted hazard ratio: 0.884/yr), and a high plasma ACTH concentration in the year after adrenalectomy [adjusted hazard ratio per 100 pg/ml (22 pmol/liter): 1.069] were predictive of corticotroph tumor progression. In one case, corticotroph tumor progression was complicated by transitory oculomotor nerve palsy. During follow-up, corticotroph tumor progression was associated with the increase of corresponding ACTH concentrations (odds ratio per 100 pg/ml of ACTH variation: 1.055). CONCLUSION: After adrenalectomy in Cushing's disease, one should no longer wait for the occurrence of Nelson's syndrome: modern imaging allows early detection and management of corticotroph tumor progression.

Adolescent↗

PubMed2006

A gray zone assigned to inconclusive results of quantitative diagnostic tests: Application to the use of brain natriuretic peptide for diagnosis of heart failure in acute dyspneic patients.

BACKGROUND: Most quantitative diagnostic tests do not perfectly differentiate between persons with and without a given disease. We present a simple method to construct a 3-zone partition for quantitative tests results, including positive and negative zones and a gray zone between, and we describe its use in the diagnosis of heart failure by brain natriuretic peptide (BNP) measurement in acute dyspneic patients. METHODS: We conducted a prospective cohort study of 699 consecutive patients with acute dyspnea who were treated at the emergency department of 3 participating hospitals. Heart failure (acute or decompensated) was assessed independently at discharge by cardiologists blind to the results of BNP measurements. RESULTS: The discriminatory performance of BNP was insufficient to provide a single cutoff value that could be used to correctly diagnose heart failure in clinical practice. Also, the discriminatory performance differed between patients with and without a history of chronic heart failure. The gray zone of inconclusive results was 167-472 ng/L for those without and 0-334 ng/L for those with such a history. Diagnosis of the current episode of heart failure by BNP results and history of heart failure was not enhanced by data from any other sources, including electrocardiography. CONCLUSIONS: The gray zone approach applied to the diagnosis of heart failure by BNP might allow sensible cutoff values to be determined for clinical practice according to relevant subgroups of patients. The gray zone approach might be usefully applied to many other quantitative tests and clinical diagnostic or screening problems.

Acute Disease↗

PubMed2006

Development and testing of a specific quality-of-life questionnaire for knee and hip osteoarthritis: OAKHQOL (OsteoArthritis of Knee Hip Quality Of Life).

OBJECTIVE: To design a quality-of-life (QOL) instrument specific for patients with knee or hip osteoarthritis and to assess its validity and reproducibility. METHODS: One-on-one or group interviews were conducted with 79 patients and 28 healthcare professionals. Of the 80 potential items identified from the results, 46 were selected based on their content and were used to develop version 1 of the OsteoArthritis of Knee and Hip Quality of Life Scale (OAKHQOL). The psychometric characteristics of the scale were evaluated in patients who met Altman's criteria for knee or hip osteoarthritis. RESULTS: Based on the results of psychometric analyses in 263 patients, three items were excluded, leaving 43 items in the final version (2.3) of the OAKHQOL. Principal components analysis identified four domains: physical activities, mental health, social functioning, and social support. A pain domain was individualized later. Construct validity, reproducibility, and discriminating power of the domains were satisfactory. Standardized response means after joint replacement surgery were close to 1 for the pain and physical functioning domains and equal to 0.7 for the mental health domain, indicating good sensitivity to change. CONCLUSIONS: The OAKHQOL is the first QOL tool specifically dedicated to lower-limb osteoarthritis. It captures specific aspects of QOL in patients with knee or hip osteoarthritis and exhibits psychometric properties consistent with use in longitudinal studies.

Aged↗

PubMed2006

Self-esteem and social adjustment in young women with Turner syndrome--influence of pubertal management and sexuality: population-based cohort study.

CONTEXT: Pediatric management of patients with Turner syndrome focuses on height, frequently resulting in a delay of pubertal induction. The influence of pubertal management on psychosocial adjustment and sex life has not been evaluated in Turner syndrome patients. OBJECTIVE: The objective of the study was to identify the determinants of self-esteem, social adjustment, and initiation of sex life in patients with Turner syndrome, particularly those related to pubertal management. DESIGN: This was a prospective evaluation, the StaTur study. SETTING: The study was conducted with a population-based registry of GH-treated patients. PARTICIPANTS: Participants included 566 young adult women with Turner syndrome, aged 22.6 +/- 2.6 yr (range, 18.3-31.2). MAIN OUTCOME MEASURES: Measures used in the study were Coopersmith's Self-Esteem Inventory, Social Adjustment Scale Self-Report, questions on sexual experience, and extensive data on pediatric management. RESULTS: Low self-esteem was associated with otological involvement and limited sexual experience. Low social adjustment was associated with lower paternal socioeconomic class and an absence of sexual experience. Late age at first kiss or date was associated with cardiac involvement and a lack of spontaneous pubertal development. Age at first sexual intercourse was related to age at puberty and paternal socioeconomic class. Delayed induction of puberty had a long-lasting effect on sex life. Height and height gain due to GH treatment had no effect on outcomes. CONCLUSIONS: Puberty should be induced at a physiologically appropriate age in patients with Turner syndrome to optimize self-esteem, social adjustment, and initiation of the patient's sex life. Therapeutic interventions altering normal pubertal development in other groups of patients should be reconsidered in light of these findings.

Adolescent↗

PubMed2006

Determinants of mortality for adults with cystic fibrosis admitted in Intensive Care Unit: a multicenter study.

BACKGROUND: Intensive care unit (ICU) admission of adults with cystic fibrosis (CF) is controversial because of poor outcome. This appraisal needs re-evaluation following recent changes in both CF management and ICU daily practice. Objectives were to determine long-term outcome of adults with CF admitted in ICU and to identify prognostic factors. METHODS: Retrospective multicenter study of 60 ICU hospitalizations for 42 adult CF patients admitted between 2000 and 2003. Reason for ICU admission, ventilatory support provided and one-year survival were recorded. Multiple logistic analysis was used to determine predictors of mortality. RESULTS: Prior to ICU admission, all patients (mean age 28.1 +/- 8 yr) had a severe lung disease (mean FEV1 28 +/- 12% predicted; mean PaCO2 47 +/- 9 mmHg). Main reason for ICU hospitalization was pulmonary infective exacerbation (40/60). At admission, noninvasive ventilation was used in 57% of cases and was successful in 67% of patients. Endotracheal intubation was implemented in 19 episodes. Overall ICU mortality rate was 14%. One year after ICU discharge, 10 of the 28 survivors have been lung transplanted. Among recognized markers of CF disease severity, only the annual FEV1 loss was associated with a poor outcome (HR = 1.47 [1.18-1.85], p = 0.001). SAPSII (HR = 1.08 [1.03-1.12], p < 0.001) and endotracheal intubation (HR = 16.60 [4.35-63.34], p < 0.001) were identified as strong independent predictors of mortality. CONCLUSION: Despite advanced lung disease, adult patients with CF admitted in ICU have high survival rate. Endotracheal intubation is associated with a poor prognosis and should be used as the last alternative. Although efforts have to be made in selecting patients with CF likely to benefit from ICU resources, ICU admission of these patients should be considered.

Adult↗

PubMed2006

Impaired erythropoietin production in liver transplant recipients: the role of calcineurin inhibitors.

Anemia is common following liver transplantation. Because cyclosporine inhibits erythropoietin (Epo) production in experimental models, we investigated whether Epo production was impaired in liver transplant recipients receiving a cyclosporine- or tacrolimus-based immunosuppressive regimen. First, serum Epo levels were measured before and 1 year after transplantation in 35 liver transplant recipients. Second, serum Epo levels were compared in a large series of liver transplant recipients with stable graft and renal functions: 27 receiving a cyclosporine-based and 31 receiving a tacrolimus-based immunosuppressive regimen. A reference group was made up of 22 blood donors and 21 nontransplanted subjects with iron-deficiency anemia. Serum Epo levels were significantly lower after than before liver transplantation, especially in cyclosporine-treated patients. Serum Epo concentrations correlated with hematocrit values in both transplant recipients and control subjects. Using multiple linear regression models, the polynomial relationship between hematocrit and serum Epo values was similar to the control group in patients under tacrolimus, whereas Epo production was significantly reduced in patients under cyclosporine-based immunosuppression. Hematocrit values and the type of calcineurin inhibitor were the only parameters independently related to Epo levels. In conclusion, cyclosporine, but not tacrolimus, inhibits Epo production at the doses used in clinical practice.

Adult↗

PubMed2006

Seasonal variations in onset of Wegener's granulomatosis: increased in summer?

OBJECTIVE: Investigators have reported significant seasonal variations of onset of Wegener's granulomatosis (WG), but those data were not confirmed by others. We reexamined the hypothesis of a seasonal pattern of onset of WG. METHODS: We conducted telephone interviews with 59 patients with newly diagnosed WG fulfilling the American College of Rheumatology criteria. Patients were identified having been enrolled from 2001 to 2004 by French hospitals in 2 multicenter therapeutic trials. The interviews investigated precisely how and when their disease had appeared to establish an index date, defined as the year and month of the first symptom(s) attributable to WG. Once telephone interviews had been completed, index dates were also retrieved from medical records. RESULTS: Among the 59 patients interviewed, 14 (24%) were unable to specify an exact month of WG onset. Based on the remaining 45 "informative" patients, the month of onset distribution varied significantly (p = 0.03, exact goodness-of-fit chi-square test), notably with a higher onset rate in August (p = 0.001). Seasonal distributions also differed significantly (p = 0.01), with an increased rate of summer onset (June-August) (p = 0.001). Index dates extracted from medical files showed that onset was also more frequent in summer (p = 0.01). CONCLUSION: Our results confirm the seasonality in onset of WG, but unlike previous reports indicating an increase in winter, instead suggest that this vasculitis preferentially appears in summer. These findings might support an allergic mechanism in the pathogenesis of WG.

Clinical Trials as Topic↗

PubMed2005

Adult height and pubertal growth in Turner syndrome after treatment with recombinant growth hormone.

OBJECTIVE: The objective of this study was to evaluate factors affecting adult height (AH) in patients with Turner syndrome treated with GH. DESIGN: The study design was a population-based cohort study. SETTING: The setting was The StaTur Study, a register of patients treated in France between 1986 and 1997, followed for a mean of 9.3 yr. PATIENTS: We followed 704 of the 891 eligible patients (79%) to AH. INTERVENTION: GH (0.8 +/- 0.2 IU/kg.wk; 0.26 +/- 0.06 mg/kg.wk; mean +/- sd) was administered for 5.0 +/- 2.2 yr. Puberty was classified as spontaneous (10%), spontaneous with secondary estrogens (13%), or induced (77%). Estrogen treatment was initiated at 15.0 +/- 1.9 yr of age in those with induced puberty. MAIN OUTCOME MEASURE: The main outcome measure was multivariate analysis of AH after grouping potential predictors. RESULTS: The mean AH was 149.9 +/- 6.1 cm, 8.5 cm above projected height. The model explained 90% of the variance, with major effects of age at initiation and duration of treatment. Other factors included birth length, target height, bone age delay and weight at initiation of treatment, age at pubertal onset, GH dose, and number of injections per week. Age at introduction of estrogens was not a predictor, and the use of percutaneous vs. oral estrogens was associated with greater height (+2.1 cm; 95% confidence interval, 1.00-3.25). CONCLUSIONS: Our results support the early initiation of GH treatment and induction of puberty at a physiological age to achieve optimal AH. They suggest that GH should be injected daily, and percutaneous estrogens used. These results should be considered in the context of the lack of demonstrable influence of AH on psycho-social outcomes, uncertainties regarding long-term safety, and treatment cost.

Adolescent↗

PubMed2005

Quality of life determinants in young women with turner's syndrome after growth hormone treatment: results of the StaTur population-based cohort study.

GH is used to increase adult height in children with Turner's syndrome with little knowledge of the impact on quality of life. We carried out a population-based cohort study of quality-of-life determinants in young women with Turner's syndrome, all previously treated with GH. Of 891 eligible women aged over 18 yr and recorded in the French Growth Hormone Register, 818 were available and 568 participated (69%). They were assessed for demographic characteristics, health status, sexual life, treatment expectations, scores for Medical Outcome Study Short Form 36 (SF-36), and General Health Questionnaire 12. Participants were 22.6 +/- 2.6 yr old (mean +/- sd), measured 150.9 +/- 5.6 cm, and had received GH for 4.8 +/- 2.2 yr. SF-36 scores were similar in participants and French women of the general population. Cardiac (12% of participants) or otological (26% of participants) involvement or induction of puberty after 15 yr of age was associated with lower scores for at least one of the SF-36 dimensions. Height and estimated height gain from treatment were not associated with quality-of-life scores. Higher expectations from treatment were associated with lower quality of life. We conclude that quality of life is normal and unaffected by height in young adults with Turner's syndrome treated with GH. These data emphasize the need to give appropriate attention to general health and otological care rather than focus on stature in the care of children with Turner's syndrome.

Adolescent↗

PubMed2005

Cost-effectiveness of liquid-based cytology with or without hybrid-capture II HPV test compared with conventional Pap smears: a study by the French Society of Clinical Cytology.

Many articles concerning conventional Pap smears, ThinPrep liquid-based cytology (LBC) and Hybrid-Capture II HPV test (HC II) have been published. This study, carried out by the French Society of Clinical Cytology, may be conspicuous for several reasons: it was financially independent; it compared the efficiency of the conventional Pap smear and LBC, of the conventional Pap smear and HC II, and included an economic study based on real costs; for all the women, a "gold standard" reference method, colposcopy, was available and biopsies were performed whenever a lesion was detected; The conventional Pap smear, the LBC (split-sample technique), the colposcopy, and the biopsies were done at the same time. This study included 2,585 women shared into two groups: a group A of a high-risk population, a group B of a screening population. The statistical analysis of the results showed that conventional Pap smears consistently had superior or equivalent sensitivity and specificity than LBC for the lesions at threshold CIN-I (Cervical Intraepithelial Neoplasia) or CIN-II or higher. It underlined the low specificity of the HC II. Finally, the LBC mean cost was never covered by the Social Security tariff.

Adult↗

PubMed2005

Methodological issues in determining the dimensionality of composite health measures using principal component analysis: case illustration and suggestions for practice.

During the early steps of the construction of composite health measures, principal component analysis (PCA) is commonly used to identify 'latent' factors that underlie observed variables and to determine the dimensionality of the instruments. The determination of the number of components to retain is critical to PCA: it markedly influences the factorial model identified and further conditions the validity of the constructed instrument. However, many researchers developing composite health measures seem to be unaware of the importance of this determination. The purposes of the paper are to illustrate (1) the variability of the factorial models obtained by using different published rules (n = 10) for determining the number of components to retain in PCA applied to two quality-of-life datasets, and (2) the value of a careful and diversified approach to the problem of the number of components to retain in PCA that we suggest, instead of the unsatisfactory 'rule-of-thumb' that many researchers use. This involves: (1) using robust rules (including parallel analysis and minimum average partial procedure) to generate a set of possible values for the number of components to retain, (2) repeating the analysis across samples, (3) comprehensively assessing the models obtained, and (4) considering complementary methods to PCA and especially confirmatory factor analysis.

Factor Analysis, Statistical↗

PubMed2005

The first images of atopic dermatitis: an attempt at retrospective diagnosis in dermatology.

BACKGROUND: Atopic dermatitis was defined in 1933. Earlier descriptions have yet not been thoroughly studied. OBJECTIVE: Our purpose was to identify the first images of atopic dermatitis among historical illustrations of skin diseases. METHODS: We posted 20 selected images on an Internet site and asked experts in pediatric dermatology to decide whether or not they represented atopic dermatitis. RESULTS: By means of the Delphi technique, a consensus could be reached for 19 of the 20 images. The experts' accuracy was good. LIMITATIONS: Thirty-one experts participated. No validated criteria were used for the selection of the images. CONCLUSION: The first representations of atopic dermatitis are engravings of skin diseases described under the names of strophulus confertus (Willan, 1796), lichen agrius (Willan, 1796), porrigo larvalis (Bateman, 1816), and eczema rubrum (Rayer, 1835). Teledermatology techniques can be reliably applied to retrospective diagnosis.

Anatomy, Artistic↗

PubMed2005

OAKHQOL: a new instrument to measure quality of life in knee and hip osteoarthritis.

OBJECTIVE: To develop a questionnaire with which to measure quality of life (QoL) in patients with knee and hip osteoarthritis (OA). STUDY DESIGN AND SETTING: Thirty-two caregivers and 96 OA patients were interviewed individually (using cognitive and face-to-face techniques) and in focus groups. A group of experts working independently at first and then consensually used the interview transcripts to generate a 46-item questionnaire. RESULTS: Analysis of questionnaires completed by 263 patients with hip or knee OA resulted in the exclusion of three items (two because of low reliability and one because of a low response rate). Principal component analysis revealed four factors: physical activity, mental health, social functioning, and social support. A pain dimension was individualized. Preliminary testing showed the reliability of the five dimensions to be satisfactory (intraclass correlation coefficients: 0.70-0.85), construct validity was adequate when correlated with the SF36 (Spearman correlation coefficients: 0.43-0.75), and discrimination was satisfactory. The osteoarthritis knee and hip quality of life questionnaire (OAKHQOL) consists of 43 items in five dimensions and three independent items. CONCLUSION: The OAKHQOL is the first specific knee and hip OA quality of life instrument. Its development followed an a priori structured strategy to ensure content validity. It meets psychometric requirements for validity and reliability.

Activities of Daily Living↗

PubMed2004

Outcome of severe adult thrombotic microangiopathies in the intensive care unit.

OBJECTIVE: Thrombotic microangiopathies, namely thrombotic thrombocytopenic purpura and hemolytic uremic syndrome, are uncommon microvascular occlusive diseases. Despite the dramatic improvement in the outcome by exogenous plasma supply, either through plasma infusion or through plasma exchange, patients frequently require support in the intensive care unit. In the present study, we evaluated the outcome of a large cohort of patients with severe thrombotic microangiopathies. DESIGN: A retrospective multicenter study from January 1998 to June 2001. SETTING: Fourteen French university hospital medical intensive care units. PATIENTS: Sixty three adult patients with severe thrombotic microangiopathies. MEASUREMENTS AND RESULTS: Of the 63 patients, 19 had a clinical presentation of thrombotic thrombocytopenic purpura, 18 had hemolytic uremic syndrome and 26 had combined neurologic and renal failures. Infections were the main etiology associated with thrombotic microangiopathies. The mortality rate was 35%. Of the survivors, all achieved complete remission. Whereas neurologic failure assessed through the Glasgow coma scale was an independent predictor of mortality [HR=0.845 (CI 95%: 0.759-0.940), P=0.002], renal impairment did not appear to be an adverse prognostic factor. The use of plasma exchange was independently associated with survival [HR=0.269 (CI 95%: 0.104-0.691), P=0.006]. CONCLUSIONS: Thrombotic microangiopathies with severe organ dysfunctions leading to hospitalization in the intensive care unit are associated with high mortality. Neurologic impairment appears to be the main adverse prognostic factor correlated to mortality, and the study confirms the importance of plasma exchange in the treatment of high-risk patients.

Adult↗

PubMed2004

One-year outcome after severe pulmonary exacerbation in adults with cystic fibrosis.

We retrospectively studied the outcomes of adult patients with cystic fibrosis (CF) hospitalized for severe pulmonary exacerbations (69 cases) between January 1997 and June 2001. Cases were treated either in the Pulmonary Department (n = 46) or in the intensive care unit (ICU) (n = 23) depending on severity. Noninvasive mechanical ventilation was used in 61% (14 of 23) and 33% (15 of 46) of cases treated in the ICU and the Pulmonary Department groups, respectively. Invasive ventilation was necessary in 4 of 23 cases treated in the ICU. The 1-year survival rate was 52% (12 of 23) and 91% (42 of 46) in the ICU and the Pulmonary Department groups, respectively. Lung transplantation was performed in two patients from the ICU group and in five patients from the Pulmonary Department group after hospital discharge. Factors predictive of death were prior colonization with Burkholderia cepacia and rapid decline in FEV1 before admission and severity of exacerbations (severity of hypoxemia and hypercapnia, simplified acute physiology score II and logistic organ dysfunction (LOD) scores, requirement of noninvasive mechanical ventilation, and hospitalization in the ICU) in the univariate analysis and were prior colonization with B. cepacia, the severity of hypoxemia at admission, and hospitalization in the ICU in the multivariate analysis. In 1-year survivors, pulmonary exacerbation did not affect the progression of the disease.

Adolescent↗

PubMed2004

Validity of the childhood health assessment questionnaire is independent of age in juvenile idiopathic arthritis.

OBJECTIVE: To determine whether the Childhood Health Assessment Questionnaire (CHAQ) is valid for the comparison of different age subgroups and for longitudinal studies in juvenile idiopathic arthritis (JIA). METHODS: A CHAQ was administered to 306 children with JIA. Rasch analyses were used to compare the difficulty of each of the 30 items of the questionnaire for children of 2 age groups (> or =10 years old and <10 years old). RESULTS: Independent of the physical disability level assessed by the Rasch model, 8 of the 30 items (27%) of the CHAQ were rated significantly different in the 2 age groups. Despite this age-related variation in item difficulty, the impact on the CHAQ disability index using its original scoring system remained low (about 0.25 points on a scale of 0-3). CONCLUSION: The difficulty of 8 of 30 items of the CHAQ depends on the respondent's age. Nevertheless, the design of the CHAQ and its scoring system remove most of the expected physical development bias.

Adolescent↗

PubMed2004

Ectopic pregnancy is again on the increase. Recent trends in the incidence of ectopic pregnancies in France (1992-2002).

BACKGROUND: We aimed to assess the recent incidence trends of ectopic pregnancies (EP) in France (1992-2002). METHODS: A population-based register of all women aged 15-44 years with EP was set up in Auvergne (central France). We calculated rates of EP as a 'reproductive failure' or as a 'contraceptive failure', frequencies of exposure to the two main risk factors for EP (cigarette smoking and chlamydial infection) and contraceptive methods between 1992 and 2002. RESULTS: The overall EP rate decreased by 2%, from 96.4 per 100 000 women aged 15-44 in 1992 to 95.3 per 100 000 in 2002. However, the rate of 'reproductive failure' EP increased by 17%, while the rate of 'contraceptive failure' EP, mostly intrauterine device failure, decreased by 29%. CONCLUSION: Appropriate analysis reveals that the rate of EP as reproductive failure is increasing again in France. This result is of interest for many European and North America countries where chlamydial infections or smoking or both are increasing in women of reproductive age. The rates of EP as contraceptive failure and of that as reproductive failure evolve differently in the population and should not be confused in epidemiological studies.

Adolescent↗