Hepatic arterial infusion of chemotherapy for metastatic colorectal cancer.
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Adenocarcinoma↗
Biomedical subjects
S Briançon
Publications and source records attributed to S Briançon.
Differential clinical prognostic classifications in dilated and ischemic advanced heart failure: the EPICAL study.
BACKGROUND: The clinical management of severe congestive heart failure (CHF) should be graded according to the prognosis of each individual patient. Our objective was to elaborate a prognostic rating system for severe CHF. METHODS: The EPICAL program (Epidémiologie de l'Insuffisance Cardiaque Avancée en Lorraine) identified patients with severe CHF defined by hospitalization accompanied by class III/IV dyspnea, edema, or hypertension; an ejection fraction </=30% or a cardiothoracic index >/=60%. Baseline variables were tested in Cox multivariate models. RESULTS: Patients with ischemic heart disease (n = 219) had a lower 1-year survival rate (57.6%) than patients with dilated cardiomyopathy (n = 182) (69. 1%). Multivariate analysis identified 5 prognostic factors for ischemic CHF and 7 for CHF caused by dilated cardiomyopathy. These variables were used to classify patients within prognostic subgroups of good (>75%), intermediate, or poor (</=25%) 1-year survival. CONCLUSION: A score for prognostic prediction was further derived from readily available data to help physicians improve decision making and to assist in clinical trials as a stratification tool.
Adult↗
Determinants of angiotensin-converting enzyme inhibitor prescription in severe heart failure with left ventricular systolic dysfunction: the EPICAL study.
BACKGROUND: Angiotensin-converting enzyme (ACE) inhibitors have been demonstrated to reduce morbidity and mortality rates in patients with heart failure with left ventricular systolic dysfunction. Nevertheless, these drugs are underutilized in current practice and prescribed at doses below those usually recommended. The aim of this work was to identify the social, demographic, laboratory, clinical, and therapeutic factors associated with nonprescription of ACE inhibitors and/or their prescription at doses below those recommended in the treatment of severe long-term congestive heart failure (CHF). METHODS AND RESULTS: An epidemiologic observational study, EPICAL (EPidémiologie de l'Insuffisance Cardiaque Avancée en Lorraine), studied 417 patients with severe CHF surviving after the index hospitalization. Multivariate logistic regression determined the factors associated with ACE inhibitor nonprescription and with their prescription at lower-than-recommended doses. ACE inhibitors were taken by 75% of the patients but 38% took lower-than-recommended doses. Factors shown to be associated with nonprescription included patients >65 years of age with renal impairment (odds ratio 19.5, confidence interval [CI] 7.9-48.0), nonsinus cardiac rhythm (odds ratio 2.0, CI 1.2-3.2), and prescription of potassium-sparing diuretics (odds ratio 2.4, CI 1. 2-4.7). Renal impairment was the single most important factor associated with prescription of lower-than-recommended doses, particularly in elderly patients. CONCLUSIONS: Our results underline the need for optimal and better use of ACE inhibitor therapy. CHF treatment guidelines must be more uniformly applied by all physicians caring for patients with heart failure.
Aged↗
Selection of quality-of-life measures for a prevention trial: a psychometric analysis.
Quality-of-life (QoL) outcomes have become increasingly important in the evaluation of health interventions. The objective of the present study was to determine which of three generic QoL instruments was most suitable for use in an 8-year nutritional primary prevention trial. We compared the Duke Health Profile, the Nottingham Health Profile, and the Short Form Health Survey Questionnaire (SF36). We conducted the comparison in two stages: (1) a statistical analysis of data from a pilot study (n = 963) comparing the psychometric properties of the three instruments; and (2) an assessment of the practicality of the tools. With regard to psychometric properties, convergent validity was comparable for the three scales, and the correlation with Global Health Assessment ranged from 0.24 to 0.72. Discriminant validity was best for the SF36, with a difference between scores in healthy subjects and those with chronic disease in the range of 4.4 to 15.8 (scores could range from 0 to 100, where 100 indicates perfect health). Reproducibility was good for all three instruments, with a test-retest intraclass correlation coefficient of over 0.60 for most dimensions. DHP and SF36 performed best in terms of responsiveness. We judged the practicality of the three tools as satisfactory. We chose the SF36 for its high responsiveness. We also selected the Duke Health Profile for its practicality and favorable psychometric properties.
Cardiovascular Diseases↗
Factors determining the use of hormone replacement therapy in recent naturally postmenopausal women participating in the French SU.VI.MAX cohort.
The determinants of hormone replacement therapy (HRT) were studied in a cohort of recently postmenopausal women participating, in France, in a nutritional study (SU.VI.MAX Study). Analysis was performed-analysis on 592 women aged 45 years or more, who had undergone natural menopause which appeared in the 2 previous years. No differences were observed in education level, socio-professional categories, marital status, geographic residence, smoking habits, physical activity, or past contraceptive practice. Past regular gynecologic follow-up appeared to be the strongest determinant of HRT use (odds ratio [OR]: 3.18). Women who reported having had at least one of the studied pathologies (past history of breast cancer, phlebitis, anger, uterine fibroma, hypertension, diabetes or hypercholesterolemia), past abundant menstrual blood losses, and with body mass index (BMI) > or = 25 were less likely to be taking HRT than women free of pathology, with no history of past abundant menstrual blood losses and with low BMI (OR respectively of 0.40, 0.64, 0.62). Women over 51.3 years of age were less likely to use HRT than younger women (OR: 0.92). Finally, in our population, while socio-economic level was not a major determinant of HRT use, the regularity of gynecological follow-up before menopause, overweight, and the existence of a definite or possible contra-indication were strong determinants of HRT use.
Age Factors↗
Compliance with drug therapy in rheumatoid arthritis. A longitudinal European study.
OBJECTIVE: To delineate compliance with drug therapy in rheumatoid arthritis patients, determine specific characteristics of compliant and noncompliant patients, and look for changes in compliance over time. PATIENTS AND METHODS: A prospective European cohort study (EURIDISS) recruited 556 patients in four countries over three years. Compliance with drug dosages and dosing times was evaluated yearly using a questionnaire. RESULTS: Of the 556 patients, 429 (77.2%) were on drug therapy at all three evaluation time points. Use of steroids, nonsteroidal anti-inflammatory drugs, and second-line drugs varied significantly across countries. The compliance behavior was stable over time in 59.5% of them (35.7% of patients were consistently compliant and 23.8% consistently noncompliant); it was independent of disease duration and from the clinical features of the disease. Older patients and women were more likely to be compliant (odds ratios, 2.5 and 2, respectively). CONCLUSION: Compliance with drug therapy can be measured using two simple questions. Compliance is more closely dependent on individual behavior than on responses to specific features of rheumatoid arthritis.
Arthritis, Rheumatoid↗
[Evaluation of professional practices].
Concepts and methods in professional practices evaluation are often confused. After a description of the classical conceptual framework, we present these methods in an approach in which practice is the principal result to be measured. Thus it makes it possible to apply the traditional epidemiological concepts to the evaluation of the professional practices with their three traditional fields: 1) In the descriptive approach, cross-sectional practice studies allow an observation and description of the usual behaviors, possibly compared to references. The methodological constraints are the same as which of descriptive epidemiological studies; 2) In the analytical approach, factors associated with practice - simple or conformed to criteria - are evidenced on a representative sample; 3) In the evaluative approach of practices improvement, the objectives are the assessment of formative, organizational or structural interventions, aiming at modifying practices. Three types of studies are to be used: quasi experimental in which clinical audit is the reference method in the field of medical care. The six main steps of clinical audit are described; experimental, based on the community randomized trial scheme, which have the advantage to provide results that can be immediately generalized; observational in which no control on the implementation of intervention is done. "Here and else" and "before and after" studies are used. To be effective for evaluation of professional practice, theses methods must come within the scope of a favorable institutional context.
Epidemiologic Methods↗
Bias and precision in visual analogue scales: a randomized controlled trial.
Various types of visual analogue scales (VAS) are used in epidemiologic and clinical research. This paper reports on a randomized controlled trial to investigate the effects of variations in the orientation and type of scale on bias and precision in cross-sectional and longitudinal analyses. This trial was included in the pilot study of the SU.VI.MAX (supplementation by antioxidant vitamins and minerals) prevention trial in France in 1994. Six types of VAS (simple, middle-marked, graphic rating, graduated, graduated-numbered, and numerical rating) and two orientations (horizontal and vertical) were used to measure three symptoms of ear, nose, and throat infection at 2-month intervals in 870 subjects. Differences between scales were analyzed by comparing variances (Levene's test) and means (variance-covariance analysis for repeated measures). Scale characteristics were shown to influence the proportion of zero and low values (i.e., there was a floor effect), but not mean scores. The precision of measurements varied cross-sectionally according to the type of scale, but no differences were observed in the precision of measurement of change over time. In conclusion, the characteristics of VAS seem to be important in cross-sectional studies, particularly when symptoms of low or high intensity are being measured. Researchers should try to reach a consensus on what type of VAS to use if studies are to be compared.
Adult↗
[Improvement in prevention of venous thromboembolism in medical environment. Mission impossible?].
PURPOSE: In France, low molecular weight heparins are widely used for prophylaxis of venous thromboembolism. This practice is not based on strong evidence supporting the use of this technique, thus leading to important difficulties in defining accurate guidelines. Improvement in the prophylaxis must focus on the process leading to prescription or non-prescription. Our primary objective was to identify and describe this process. We also analyzed the causes for dysfunction and implemented corrective actions. METHODS: Basic tools and methods specific to improvement of quality were used including: flow charting for process description, causes-effect diagram for updating and analysis of dysfunction, weighted vote for decisions regarding corrective actions, and agenda and designation of leaders for the implementation of corrective actions. RESULTS: The theoretical process beginning with the recognition of a risk and ending with the adequate treatment or prevention of this risk was demonstrated. The most important dysfunction was the lack of epidemiological and clinical trials. Key corrective actions were the following: standardization of practices where evidence was available; if not, collaborative efforts to collect valid epidemiological data through multicenter surveys and clinical trials; systematic appraisal of the quality of published data; assessment of the risk for venous thromboembolism during hospitalization. To achieve real improvement in practice, priority was given to repeated measures of the risk for thromboembolism. The use of low molecular weight heparins has been so wide however, that it has led to some difficulties. We must draw lessons from this experience. CONCLUSION: Improvement of quality in terms of healthcare is not only based on auditing the practices or modifying the defective processes, but also on our ability not to use new drugs before fully assessing their validity.
Anticoagulants↗
Compliance to drug treatment of patients with rheumatoid arthritis: a 3 year longitudinal study.
OBJECTIVE: Patient compliance is considered necessary for the success of drug treatment in chronic diseases. We document compliance with drug treatment and the factors affecting it in a cohort of patients with rheumatoid arthritis (RA). METHODS: A prospective cohort study of 556 patients with RA followed for 3 years in 4 counties: Oslo, Norway; Groningen, The Netherlands; and Nancy and Reims, France. Compliance to treatment was assessed annually by interview in terms of adherence to the dose and timing of the prescribed drug regimen. RESULTS: Of the 556 subjects, 429 (77.2%) were taking medication for RA throughout the observation period. Consistent behavior was recorded in 59.5% of cases: 35.7% were consistently compliant, and 23.8% consistently noncompliant. Factors significantly associated with good compliance were older age (p = 0.00), female sex (p = 0.03), decreased disability (p = 0.04), very satisfactory contacts with health care professionals (p = 0.03), and more personal knowledge about the disease and its treatment (p = 0.03). CONCLUSION: This longitudinal study identified compliance behavior as consistent over time in 60% of patients, determined by quality of contact with professionals and the amount of patient information available.
Age Factors↗
[Prevention of venous thromboembolism. Survey of in-hospital medical practice].
OBJECTIVES: In an effort to improve the prevention of venous thromboembolism, the Nancy University Hospitals conducted a survey of medical practice concerning indications for preventive therapy and surveillance of platelet counts and anti Xa activity. METHODS: The survey involved 163 medical files. Questionnaires were filled out in 6 units (3 medical wards and 3 intensive care units). RESULTS: Indications for preventive therapy were found to be quite variable with the exception of very low risk of thromboembolism where the treat/do not treat ratio was 0.1/1, indicating a clear tendency for abstention. This ratio was 0.77/1 and 0.38/1 respectively for low and moderate risk and 2/1 for high risk. There was undoubtedly a ward effect. The attitudes in practice tended toward non-prevention in patients without limited mobility. For platelet counts, an initial count was performed in 95% of the cases and during treatment in 38% although the specific rates were not the same for different types of units. Anti-Xa activity, which according to prevention recommendations need not to be determined, was not monitored in 88% of the cases. In accordance with prevention recommendations, anti-Xa activity was not determined in 88% of the cases. CONCLUSION: Further progress is needed in the prevention of venous thromboembolism and should be based on wider use of existing methods.
France↗
A primary prevention trial using nutritional doses of antioxidant vitamins and minerals in cardiovascular diseases and cancers in a general population: the SU.VI.MAX study--design, methods, and participant characteristics. SUpplementation en VItamines et Minéraux AntioXydants.
The SUpplementation en VItamines et Minéraux AntioXydants (SU.VI.MAX) Study is a randomized, double-blind, placebo-controlled, primary-prevention trial designed to test the efficacy of daily supplementation with antioxidant vitamins (vitamin C, 120 mg; vitamin E, 30 mg; and beta-carotene, 6 mg) and minerals (selenium, 100 microg; and zinc, 20 mg) at nutrition-level doses (one to three times the daily recommended dietary allowances) in reducing several major health problems in industrialized countries, especially the main causes of premature death, cancers and cardiovascular diseases. The present report describes the design, implementation, and baseline characteristics of participants in this 8-year cohort study, which started in 1994 in France; 12,735 eligible subjects (women aged 35-60, and men aged 45-60) were included in 1994 and will be followed for 8 years. Participants undergo a yearly visit consisting, every other year, of either biological sampling or clinical examination. They also regularly provide information on health events and dietary intake by filling out computerized questionnaires using the Minitel Telematic Network. Data on baseline characteristics of the participants suggest that the present sample is close to the national population in terms of geographic density, socioeconomic status, and the distribution of various major risk factors for the diseases under study. The choice of the study population should allow the results of this trial to apply to adult populations of both sexes in France and other industrialized countries.
Adult↗
Determining factors in the iron status of adult women in the SU.VI.MAX study. SUpplementation en VItamines et Minéraux AntioXydants.
The iron status of a national sample of adults living in France and participating in the SU.VI.MAX cohort, was assessed using serum ferritin and hemoglobin concentrations. Complete data were obtained for 6648 women 35-60 y old and for 3283 men 45-60 y old. Assessment of iron dietary intakes was realized on a subsample of 3111 women and 2337 men who reported six 24 h dietary records during a one-year period; 22.7% of menstruating women and 5.3% of post-menopausal women presented a total depletion of iron stores (serum ferritin < 15 microg/l). Iron-deficient anemias were found in, respectively, 4.4% and less than 1% of these women. Three-quarters of the anemias were related to iron deficiency in menstruating women. In men, iron depletion and iron deficiency anemia were very rare. Post-menopausal women had much higher serum ferritin levels than menstruating women. In menstruating women, those using intrauterine devices had significantly lower serum ferritin levels than those without contraception, and much lower than those using oral contraception. The frequency of iron depletion reached 28.1% in women using intrauterine devices, but only 13.6% in those using oral contraceptives. The mean iron intake was 16.7 +/- 5.7 mg/d in men and 12.3 +/- 3.4 mg/d in women. Heme iron represented respectively, 11.1 and 10.4% of iron intake. Ninety-three percent of menstruating women had dietary iron intakes lower than recommended dietary allowances (RDA); 52.6% consumed less than two thirds of these RDA. In post-menopausal women and men, respectively 27.7% and 3.6% had dietary intakes lower than RDA. Serum ferritin was positively correlated with meat, fish and total iron intake, and negatively correlated with dietary products consumption, calcium and fiber intake.
Adult↗
Shear stress abnormalities contribute to endothelial dysfunction in hypertension but not in type II diabetes.
BACKGROUND: The relative contribution of the various hemodynamic and metabolic mechanisms leading to endothelial dysfunction may be different in specific vascular diseases. Since shear stress is one of the main mechanical stimuli of endothelial cells, the aim of this study was to investigate its contribution to endothelial dysfunction in two distinct vascular diseases, hypertension and type II diabetes. SUBJECTS AND METHODS: We measured the radial artery diameter at baseline, after ischemic vasodilation and after nitroglycerin vasodilation in 16 untreated patients with high blood pressure, in 15 type II normotensive diabetic patients and in 17 healthy controls. Wall shear stress was evaluated by simultaneous measurements of whole blood viscosity and blood flow velocity. RESULTS: In diabetic patients, whole blood viscosity was significantly higher whereas wall shear stress was similar compared to controls. In hypertensive patients, whole blood viscosity was higher and wall shear stress was lower than in controls. Endothelium-dependent vasodilation was impaired in both hypertensive and diabetic patients (P < 0.01) after adjustment for age, sex, body mass index and postnitroglycerin vasodilation. When adjustments were made for maximal systolic shear stress, endothelium-dependent vasodilation remained lower in the diabetic patients (P < 0.01), but not in those with high blood pressure compared to controls. CONCLUSIONS: In hypertension, endothelium-dependent vasodilation is mainly due to a chronic decrease in shear stress (the most important physiological stimulus of the endothelial cells) with no major intrinsic endothelial cell dysfunction. In contrast, in diabetics, the lower endothelium-dependent vasodilation was not the result of an altered shear stress.
Adult↗
Background and rationale behind the SU.VI.MAX Study, a prevention trial using nutritional doses of a combination of antioxidant vitamins and minerals to reduce cardiovascular diseases and cancers. SUpplementation en VItamines et Minéraux AntioXydants Study.
The "SUpplementation en VItamines et MinérauxAntioXydants" (SU.VI.MAX) study is a randomized double-blind, placebo-controlled, primary prevention trial designed to test the efficacy of daily supplementation with antioxidant vitamins (vitamin C, 120 mg; vitamin E, 30 mg; and beta-carotene, 6 mg) and minerals (selenium, 100 micrograms; and zinc, 20 mg), at nutritional doses (one to three times the daily recommended dietary allowances), in reducing the frequency of major health problems in industrialized countries, and especially the main causes of premature death (cancers and cardiovascular diseases). The study involves 12,735 eligible subjects (women aged 35 to 60 years; men aged 45 to 60 years) included in 1994 in France. They will be followed up for 8 years. The objectives and the specific design of this intervention study are linked to its public health aim. The targeted population is the general population (not simply high-risk subjects) and the antioxidant agents tested are being administered at a level which is not pharmacologic and which may be attained by dietary intake of natural sources of these micronutrients and/or enriched foods. The amounts we are testing in the SU.VI.MAX study are those which, in observational studies have been associated with the lowest risk of diseases. This report presents the rationale and discusses the justification of the design, doses and combination of antioxidant micronutrients chosen in the SU.VI.MAX study.
Adult↗
[Therapeutic approach of French practitioners to rectal cancer].
OBJECTIVES: Improvements in treatment of rectal cancer have enabled a better control of locoregional disease. Our objective was to describe the therapeutic decisions of different specialists implied through clinical cases and the influence of their professional characteristics. METHODS: In spring 1996, a questionnaire was mailed to a random sample of 621 French physicians, presenting 3 clinical cases of rectal cancer at different stages. The present analysis deals with a clinical case concerning a 46 year-old man bearing a T3N0 tumor, at 7 cm from the anal verge. Statistical analysis (uni and multivariate, by logistic regression) was performed with SPSS software. RESULTS: Three hundred fifty two exploitable responses were returned (response rate: 57%). Half of the physicians chose a pluridisciplinary decision modality. There were differences according to the speciality (P < 0.003), to the type of practice (public/private) (P < 10(-4)) and to the proximity of specialized units (P = 0.03). Therapeutic attitudes consisted in a combination of radiotherapy and surgery (RT-SU) for 95% of the physicians. The therapeutic choice was in agreement with the French consensus conference for 71% of physicians. Two main attitudes emerged for this clinical case: exclusive RT-SU combination (43.5%) and RT-SU with optional or systematic chemotherapy (CT) (52%). The latter choice appeared to be closely dependent on medical speciality (P = 0.0004) and background (P = 0.002). CONCLUSION: Decision making is mainly related to the place of work, whereas the therapeutic attitude depends on physicians' own characteristics. Until 1990, multiple therapeutic options for rectal cancer were performed in France. Nowadays, for a T3N0 tumor, the argumentation is rather focused on the indication of CT combined with the standard RT-SU treatment. Results from ongoing controlled studies will help update consensual recommendations.
Adult↗
Health-related quality of life in long-term oxygen-treated chronic obstructive pulmonary disease patients.
Chronic obstructive pulmonary disease (COPD) induces changes in daily activities and mood. Health-related quality of life (HRQL) measures are of particular relevance in the management of such patients, but predictors of HRQL have rarely been investigated. The aim of this study was to seek factors predicting HRQL in severe COPD patients under long term oxygen therapy (LTOT). The pulmonary function parameters at the start of LTOT were studied as potential predictors of future HRQL. HRQL was assessed after an average of 40 months follow-up by the Duke Health Profile (Duke) and by the St. George Respiratory Questionnaire (SGRQ). Sixty-one patients (47 males and 14 females) with a mean age of 66 years were included in the study. Stepwise multiple regression analyses conducted in each HRQL dimension identified few significantly predictive factors. By the Duke, higher Self-esteem scores were associated with higher Pao2 (p < 0.01) and with older age (p < 0.05); higher Social Health scores were associated with older age (p < 0.005), and higher Pain scores were associated with a higher FEV1/FVC ratio (p < 0.05). By the SGRQ, the Activity score correlated with FEV1/FVC (p < 0.05). The proportion of the variance in each score accounted for by covariates in the model did not exceed 10%. No other significant regression models could be identified using the other HRQL dimensions. Our findings demonstrated weak relations between lung function at the start of LTOT and some dimensions of HRQL measured by the Duke and the SGRQ at the end of follow-up.
Aged↗
IgA nephropathy: prognostic classification of end-stage renal failure. L'Association des Néphrologues de l'Est.
BACKGROUND: As yet, no clinical or morphological prognostic classification of IgA nephropathy (IgAN) has been generally accepted. The objective of our study was to quantify the risk of developing end-stage renal failure (ESRF) in IgAN. METHODS: We report a prospective longitudinal study of 210 patients with IgAN confirmed by biopsy between 1987 and 1991. Thirty-two (15.2%) patients were lost to follow-up. Mean follow-up after renal biopsy was 5.6 (SD = 2.6) years. The variables included age, gender, illnesses prior to discovery of IgAN, clinical features at IgAN discovery, 24-h proteinuria, serum creatinine, IgA level, and antihypertensive drugs taken at the time of renal biopsy. Sixty-six renal biopsies were classified by light-microscopy according to Lee's morphological classification. The end-point was ESRF. Survival was analysed by a backward and forward stepwise procedure using the Cox model. The most accurate determination of relative risk was obtained by assessing collinearity of the variables. RESULTS: Thirty-three patients (15.7%) (31 men) developed ESRF. The five univariately significant variables: gender, gross haematuria, 24-h proteinuria (24-P), serum creatinine (SC), and antihypertensive treatment, were candidates for multivariate analysis. The final model used SC (< or = 100, 100-150, > 150 mumol/l), 24-P (< 1, > or = 1 g/day) and gender (female vs male) as independent variables (relative risk and 95% confidence interval were 3.5 (2.1, 5.9) for SC; 5.1 (1.9, 13.6) for 24-P; and 3.5 (0.9, 15) for gender). These estimates were used to construct a prognostic classification of ERSF for men with IgAN: stage 1 (SC < or = 150 mumol/l and 24-P < 1 g/day), stage 2 ((SC > 150 mumol/l and 24-P < 1 g/day) or (SC < or = 150 mumol/l and 24-P > or = 1 g/day)); stage 3 (SC > 150 mumol/l and 24-P > or = 1 g/day). The ESRF-free survival was estimated with Kaplan-Meier analysis. It was 98.5% for stage 1, 86.6% for stage 2, 21.3% for stage 3 (P < 0.001), 7 years after histological diagnosis. The validity of Lee's prognostic classification was confirmed using an independent sample. CONCLUSIONS: These classifications identify groups at high risk of ESRF. Therapeutic studies should focus on these groups.
Adult↗