La coloscopie en France en 2008: résultats de l’enquête de deux jours d’endoscopie en France

Objectives

Obtaining an evaluation of the number of endoscopies of the lower digestive tract in France in 2008, and the reasons for carrying them out.

Patients and methods

It was a forward-looking survey carried out by sending questionnaires to all the French gastroenterologists (N = 3,125), asking them to forward information about their endoscopy activities over a given period; 1,039 sets of complete, analysable replies were received from 1,039 gastroenterologists, covering 7,247 endoscopies carried out on 6,250 patients.

Results

Sixty-one million four hundred sixty-six thousand nine hundred fifty-one colonoscopies were carried out in 2008, i.e. 2.5% or 30,000 fewer colonoscopies than in 2006. The overall number of endoscopies of the lower digestive tract fell by 5.2%, from 1,323,200 in 2006 to 1,253,002 in 2008. The main therapeutic endoscopic act was polypectomy, which remained stable at 311,757 colonoscopies with polypectomy, i.e. 27% of the 1,148,000 colonoscopies. Six hundred eight thousand (54%) of the 1,253,002 endoscopies of the lower digestive tract, i.e. 57% of the colonoscopies, were carried out within the framework of primary or secondary screening for monitoring and checks after polypectomy or monitoring after treatment of colorectal cancers. The colonoscopies carried out within 24 months after a previous colonoscopy made up 8% of the total of 1,147,951 colonoscopies, i.e. 91,023 examinations, whereas in all 46% of the patients had already had a full prior colonoscopy, 68% of which had been carried out more than three years beforehand. During 1,254,000 lower endoscopies to remove 951,535 polyps on the basis of the largest polyps, 77% lower endoscopies involved removal of at least one polyp measuring less than 10 mm or 29 and 48% measuring between 5 and 10 mm and less than 5 mm respectively.

Conclusions

Ten years after the first survey carried out by the SFED in 1998, the highest level of participation by gastroenterologists was in 2008. The number of colonoscopies carried out in 2008 was lower than in 2006, which shows rationalization of the practice of colonoscopy and the gastroenterologists’ compliance with the indications, together with the various measures implemented to distribute the recommendations. The Acbus (Agreement Covering Rational Use of Care) target of 0.5% for colonoscopy does not seem realistic, as in practice 8% of the colonoscopies were carried out less than two years after a previous colonoscopy on indisputable grounds (insufficient preparation of the examination or risk of haemorrhage due to failure to stop taking anticoagulants, justifying a second procedure for patients to remove polyps) in 3.5% of the cases.     

Pratique de la coloscopie en France en 2011 : résultats de l’enquête électronique « une semaine d’endoscopie en France »

Context

There is little data available on colonoscopy practices and its diagnostic performance in Europe. We have carried out a national prospective study, evaluating colonoscopy practices and the diagnostic performance of this examination.

Method

An online questionnaire was sent to 2,600 French gastroenterologists. Information from healthcare professionals who responded was collected and compared with national data from the Ordre des Médecins (French equivalent of the General Medical Council in the UK). Over a one week period, data on all gastrointestinal endoscopies carried out, including histological results, were recorded online. The results were extrapolated for a whole year of endoscopy in France, and factors linked to adenoma detection rates (ADR), polyps or colorectal cancer (CRC) were determined.

Results

342 gastroenterologists representing the speciality provided data on 3,266 colonoscopies. In 90% of cases, this was a full colonoscopy. 48% percent of patients were male, aged over 50 years in 77% of cases. Colonoscopy was indicated to investigate colorectal cancer in 40% of cases, gastrointestinal symptoms in 39% of cases and following a positive Hemoccult® test in 5% of cases. Polyp resection was performed in 31.3% of cases, with lesions being > 10 mm in 21% of cases, n > 3 in 14% of cases and occurring in the right colon in 47% of cases. Adenoma and adenocarcinoma detection rates were 17.7% and 2.9% of cases respectively. Factors associated with an increased ADR were: being male (p < 0.0001), being > 50 years old (p < 0.0001), family risk factors of colorectal cancer (p = 0.0002), a previous personal history of polyps or colorectal cancer (p < 0.001) and a positive Hemoccult® test (p = 0.0008). CCR rates were three times higher for patients who had never had a colonoscopy before (4.2% vs 1.4%, p < 0.0001).

Conclusion

This prospective national data on colonoscopy practices, including for the first time in France histological results, underlines the importance of improvements to colon preparation, resulting in an overall ADR of 17.7% and confirming the preventive role of colonoscopic monitoring in the appearance of CRC.     

La performance en réanimation. Le point de vue du réanimateur

To evaluate the performance of intensive care units (ICU) the severity scores are measured on the first day or organ system dysfunctions are measured several times during the stay. The severity scores are developed from large database of thousands of patients. They include the patients’ age, previous health status, severity and sometimes the main diagnosis. Prediction models are published to evaluate the risk of death for each patient. By adding the risk of death of each patient and dividing by the number of patients, the expected mortality rate is calculated. By comparing the observed and expected mortality rates the standard mortality ratio (SMR) may be measured. The data collection must be rigorous, the studied population must be similar to the population of the large database. Other elements of performance may be evaluated, such as the cost-efficiency or the quality of life of surviving patients.     

Le point de vue du neuropédiatre prenant en charge les enfants atteints d’affections neuromusculaires

Caring for a child with a neuromuscular disorder can start as early as the first few days of a their life and continue all the way through adulthood: care is modified to meet the needs of the disorder, which is defined as accurately as possible, based on knowledge of the natural progress of the disease. The child is monitored across all areas: physical health, education and learning, social and emotional environments. The family directly in charge of care is a valuable ally, especially when it comes to continuity of care, for both the medical and paramedical teams. Indeed, there is a multidisciplinary approach to care (neurological, orthopaedics, cardiological, respiratory, digestive, functional and nutritional, educational, psychological and social etc.) which is put in place as early as possible. The role of the paediatrician is to maintain the most functional capacity as possible, taking into account the independence and comfort of the child. The aim of care involves the three concepts of prevention, maintenance and correction of the disorders arising from the neuromuscular condition, affecting the musculoskeletal, cardiorespiratory and digestive systems… Pain, which is often underestimated, can be a sign of a possible worsening of the neuromuscular disease, but may also be the result of inappropriate physiotherapy or poorly adapted equipment. All medical care is carefully considered so that it is realistic and therefore accepted by the child. Care should be centered around the needs of the individual and the teamwork fitted in around this. The carers should also aim to provide psychological support to the child and their family.     

Organisation et perspectives des SMUR pédiatriques en France — Résultats de l’enquête du GFRUP

Since 35 years, transportation of critically ill children is provided by neonatal and paediatric specialized mobile intensive care units (SMUR), which significantly improved patient support and transfer. Since 2005, the French regulation progressed when the Directorate for Hospitalization and Organization of Care classified interhospital transport into three categories according to the health care provider present during the transport (doctor in medicine, nurse or paramedics). It also detailed the objectives as well as the human and material resources required for each kind of transport. Further, a study conducted in 2011 by the French-speaking group of paediatric intensive care and emergency medicine (GFRUP) showed that most of the French regions have already got specialized SMUR teams, although their organization and activity reports still considerably varied according to their location. The dedicated medical staffs remained limited, while nursing staffs increased. Currently, the main paediatric SMUR teams perform primary transports and secondary transports of older children and take part in the regulation of paediatrician calls. The national group of paediatric SMUR coordinates various projects, aiming to develop teaching, evaluation and research within the speciality.     

Données épidémiologiques sur la douleur du cancer en France. Évolution sur deux décennies de la prévalence et de l’intensité de la douleur chez les malades atteints de cancer

Pain is frequently encountered in patients with cancer, due to cancer itself, to cancer treatment, or to an independent cause. It is linked with various mechanisms as inflammatory, neuropathic, somatic or visceral, acute or chronic. It has a negative impact on patients’ quality of life, and probably on patients’ survival. Cancer pain treatment is based on the efficacy of various approaches such symptomatic or specific interventions. Cancer pain management is often considered as poor, as found in the results of French surveys. Some explanations and proposals are offered.     

Les caractéristiques psychométriques du Questionnaire de douleur de Saint-Antoine en consultation d’algologie chez les personnes atteintes de cancer

Purpose

The purpose of this study was to assess the psychometric characteristics of the French Saint-Antoine Pain Questionnaire (Long-Form and Short-Form) in cancer patients consulting for pain-relief.

Method

71 patients completed the pain intensity measures and the long and short versions of the Saint-Antoine Pain Questionnaire (QDSA-LF and QDSA-SF) at the Claudius-Regaud Institut in Toulouse. Demographic and medical information about patients was collected. Several psychometric analyses were considered. Convergent and divergent validity were assessed using Pearson’s correlation coefficient. Construct validity was measured by Principal Component Analysis. The internal consistency was estimated using coefficient alpha. The stability was measured using correlations over time.

Results

The results show that the psychometric analyses are acceptable (convergent and divergent validity, construct validity, internal consistency and stability). The psychometric qualities of both versions of the QDSA are satisfactory and comparable to results from studies carried out in other countries on cancer patients.

Conclusion

This study shows that the QDSA is an important and useful tool for measuring pain because it includes investigation of sensory and emotional aspects and goes beyond a simple measurement of intensity.     

Avis de la CE-SRLF sur la démarche de prise de décision de limitation ou d’arrêt des thérapeutiques chez l’adulte en coma postanoxique après un arrêt cardiaque

Since early evaluation of middle to long-term prognosis of patients remaining in coma after resuscitation following cardiac arrest has become a major concern for critical care physicians in terms of patient care as well as for ethical reasons, it appears necessary for the ethics committee (EC) of the Société de réanimation de langue fran?aise (SRLF) to issue recommendations regarding the decision making process to be respected in all deliberations for limitation or discontinuation of life support in patients; the aim is to avoid decisions based only on decision making algorithms such as those recommended by the American Society of Neurology. Additionally, since clinicians must document prognoses of patients remaining in coma after cardiac arrest, the CE-SRLF considers important to underline that there is always some worry and uncertainty in predicting patient??s outcome and that decision to limit or discontinue life support is difficult and cannot merely be based on a recommended flowchart. Due to these concerns, the CE-SRLF recognizes several clearly identified prognostic signs, each associated with a poor neurological outcome in patients remaining comatose after cardiac arrest. Nevertheless, an approach based on the detection of several among these signs should be a priority in order to help clinicians getting an opinion on the most likely outcome of a patient remaining comatose after cardiac arrest, allowing them to inform patient??s family members and friends with sincerity. It should be emphasized that each of such decisions is unique and should always result from a decision-making process among peers and conform to the current SRLF recommendations (2009) on limitation and discontinuation of life support in adult patients in the critical care unit.     

Collégialité dans les décisions de limitation ou d’arrêt de traitement en réanimation

A French law about patient’s rights at end of life was published in 2005 and ratified that physicians could withdraw or withhold inappropriate life sustaining treatments and that the decision-making process (DMP) had to be collegial when the patient was not competent. A decree in 2006 stated that nurses, because of their proximity to the patients, should be involved in DMP. The term “pluridisciplinarity” is used rather than “collegiality” because of the different status and skills of the participants in DMP. In critical care medicine, interdisciplinarity includes physicians and nurses. Interdisciplinary communication in DMP is essential to guarantee that ethical aspects are not considered solely from the perspective of a single professional practice that remains medical but from a more holistic approach of the patient by nurses. Validity of each professional’s opinion should be recognized. Nurse involvement in DMP remains poor. Poor collaboration between physicians and nurses in end-of-life situation is associated with moral distress, burnout, and conflicts. Improvement in collaboration between nurses and physicians is required to promote an accomplished interdisciplinary communication in DMP at the end of life.