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Hôpital-Camfrout, France

Roussel R.,University Paris Diderot | Travert F.,University Paris Diderot | Pasquet B.,University Paris Diderot | Wilson P.W.F.,Emory University | And 7 more authors.
Archives of Internal Medicine | Year: 2010

Background: Metformin is recommended in type 2 diabetes mellitus because it reduced mortality among overweight participants in the United Kingdom Prospective Diabetes Study when used mainly as a means of primary prevention. However, metformin is often not considered in patients with cardiovascular conditions because of concerns about its safety. Methods: We assessed whether metformin use was associated with a difference in mortality among patients with atherothrombosis. The study sample comprised 19 691 patients having diabetes with established atherothrombosis participating in the Reduction of Atherothrombosis for Continued Health (REACH) Registry between December 1, 2003, and December 31, 2004, treated with or without metformin. Multivariable adjustment and propensity score were used to account for baseline differences. The main outcome measure was 2-year mortality. Results: The mortality rates were 6.3% (95% confidence interval [CI], 5.2%-7.4%) with metformin and 9.8% 8.4%-11.2%) without metformin; the adjusted hazard ratio (HR) was 0.76 (0.65-0.89;P < .001). Association with lower mortality was consistent among subgroups, noticeably in patients with a history of congestive heart failure (HR, 0.69; 95% CI, 0.54-0.90; P = .006), patients older than 65 years (0.77; 0.62-0.95; P = .02), and patients with an estimated creatinine clearance of 30 to 60 mL/min/1.73 m2 (0.64; 95% CI, 0.48-0.86; P = .003) (to convert creatinine clearance to mL/s/m2, multiply by 0.0167). Conclusions: Metformin use may decrease mortality among patients with diabetes when used as a means of secondary prevention, including subsets of patients in whom metformin use is not now recommended. Metformin use should be tested prospectively in this population to confirm its effect on survival. ©2010 American Medical Association. All rights reserved.

Azria E.,Service de gynecologie obstetrique | Azria E.,University Paris Diderot | Guittet L.,Biostatistics and Clinical Research | Delahaye M.,Service de gynecologie obstetrique | And 6 more authors.
European Journal of Obstetrics Gynecology and Reproductive Biology | Year: 2011

Introduction: The North Paris community-based Perinatal Network was set up in 2003 to improve the quality of prenatal care in an area surrounding the Bichat Claude Bernard University Hospital characterized by high social deprivation. The aim of this study is to assess the impact of the network on early perinatal care. Materials and methods: A retrospective observational study on medical records was conducted over four periods: one year before the setting up of the network (2002), the year the network became operational (2003), and one year (2004) and five years (2008) after implementation. Endpoints were the proportion of women delivered in the institution who underwent first-trimester ultrasound screening and the proportion of nuchal translucency measurements deemed acceptable (image quality score from 4 to 9 according to the Herman scoring system). Results: Between 2002 and 2004, substantial improvements were noted in access to first-trimester ultrasound screening (55.8% in 2002, 65.9% in 2003, 71.9% in 2004, P < 0.05) and in the quality of nuchal translucency measurement (acceptable measurement over this period, 51.1%, 67.8% and 77.8%, respectively, P < 0.001). Five years after network set-up, indicators remained unchanged from those of 2004. The rate of first ultrasound screening performed was 72.1% and the rate of acceptable measurement 71.1%, both non-statistically different from 2004 rates. Conclusion: This perinatal network seems to be associated with an improvement in early prenatal care. However, the rate of first ultrasound performed remained unsatisfactory and to further improve these indicators, upstream social interventions are needed. Copyright © 2011 Published by Elsevier Ireland Ltd. All rights reserved.

Merad F.,Unit of General and Digestive Surgery | Baron G.,French Institute of Health and Medical Research | Baron G.,University of Paris Descartes | Pasquet B.,Biostatistics and Clinical Research | And 8 more authors.
World Journal of Surgery | Year: 2012

Background The P-POSSUM score, the most well known of predictive scores for postoperative mortality, requires validation for population and setting. Methods Validation methods included discrimination (C-index statistic), observed:expected (O:E) ratio, calibration with the Hosmer-Lemeshow test, and subgroup analysis (emergency surgery, cancer, age, organs). The study included 3,881 multisite patients undergoing major digestive surgery in France. Results Discrimination via the receiver operating characteristic curve was good (C-index = 0.87). The overall O:E ratio was 1 (95% confidence interval ([95 % CI]: 0.88-1.13), and therefore the quality of the surgical performance is within normal ranges. The O:E ratio, calculated by risk ranges, showed overestimation in the low risk range, especially in the 3 % to 6 % and 6 % to 10 % ranges. Calibration was poor (p<0.001). The model deviated from the normal pattern of calibration, with mortality lower than expected in the high-risk range. Subgroup analysis found reasonable to good discrimination of populations (C-index ranging from 0.78 to 0.93 except for liver surgery [0.67]) while calibration of individuals remained poor (p<0.001 to 0.02). Conclusions Good discrimination, as well as nonsignificant overall O:E values, makes P-POSSUM a valuable tool when it is used for surgical audit to compare mortality between populations for major digestive surgery. Conversely, poor calibration (goodness-of-fit), especially in subgroup analysis, and underestimation or overestimation of O:E ratios considerably limits the value of P-POSSUM for prediction of mortality in individuals. Therefore P-POSSUM should not be used to predict outcomes for one particular patient. © Société Internationale de Chirurgie 2012.

Venketasubramanian N.,National University Hospital Singapore | Bhatt D.L.,Harvard University | Pasquet B.,Biostatistics and Clinical Research | Mas J.-L.,University of Paris Descartes | And 4 more authors.
Cerebrovascular Diseases | Year: 2011

Background and Purpose: Few practice-based studies have reported vascular outcome events among patients with cerebrovascular disease (CeVD). We describe 2-year vascular outcomes among symptomatic CeVD patients from the REduction of Atherothrombosis for Continued Health (REACH) Registry. Methods: Vascular events (stroke; myocardial infarction, MI; cardiovascular death, CV death; hospitalization) were studied among symptomatic CeVD patients from a prospective cohort of stable outpatients with established atherothrombosis or ≥3 atherothrombotic risk factors. Results: Of the 69,055 patients in REACH, 18,992 (28%) had symptomatic CeVD, of which outcome data were available for 18,189 patients. At 2 years, the frequency of non-fatal stroke was 5.93% (95% CI 5.22-6.64), non-fatal MI 2.21% (95% CI 1.65-2.76), CV death 4.45% (95% CI 3.66-5.22), combined vascular endpoint 11.48% (95% CI 10.46-12.49), and all deaths 7.39% (95% CI 6.34-8.42). The frequency of stroke, MI, CV death, or hospitalization for atherothrombotic events was 21.05% (95% CI 20.05-22.03). Event rates were lowest among patients with CeVD alone and highest among patients with CeVD, coronary artery disease, and peripheral artery disease. Other predictors of the primary outcome were increasing age, history of diabetes, current smoking, asymptomatic carotid stenosis, and carotid plaque. Outcomes were similar across geographical regions. Conclusions: Symptomatic CeVD patients encounter high vascular event rates despite treatment. Recurrent nonfatal stroke is more common than nonfatal MI. Copyright © 2011 S. Karger AG, Basel.

Legrain S.,Geriatric Unit | Legrain S.,University Paris Diderot | Tubach F.,University Paris Diderot | Tubach F.,Biostatistics and Clinical Research | And 16 more authors.
Journal of the American Geriatrics Society | Year: 2011

Objectives To determine whether a new multimodal comprehensive discharge-planning intervention would reduce emergency rehospitalizations or emergency department (ED) visits for very old inpatients. Design Six-month prospective, randomized (Zelen design), parallel-group, open-label trial. Setting Six acute geriatric units (AGUs) in Paris and its surroundings. Participants Six hundred sixty-five consecutive inpatients aged 70 and older (intervention group (IG) n = 317; control group (CG) n = 348). Intervention Intervention-dedicated geriatricians different from those in the study centers implemented the intervention, which targeted three risk factors for preventable readmissions and consisted of three components: comprehensive chronic medication review, education on self-management of disease, and detailed transition-of-care communication with outpatient health professionals. Measurements Emergency hospitalization or ED visit 3 and 6 months after discharge, as assessed by telephone calls to the participant, the caregiver, and the general practitioner and confirmed with the hospital administrative database. Results Twenty-three percent of IG participants were readmitted to hospital or had an ED visit 3 months after discharge, compared with 30.5% of CG participants (P =.03); at 6 months, the proportions were 35.3% and 40.8%, respectively (P =.15). Event-free survival was significantly higher in the IG at 3 months (hazard ratio (HR) = 0.72, 95% confidence interval (CI) = 0.53-0.97, P =.03) but not at 6 months (HR = 0.81, 95% CI = 0.64-1.04, P =.10). Conclusion This intervention was effective in reducing rehospitalizations and ED visits for very elderly participants 3 but not 6 months after their discharge from the AGU. Future research should investigate the effect of this intervention of transitional care in a larger population and in usual acute and subacute geriatric care. © 2011, The American Geriatrics Society.

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