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The aim of this study was to assess the cost of the first management of inflammatory bowel disease (IBD) from the onset of first symptoms until 6 weeks after the diagnosis. This cost was calculated in French francs (FF) for all IBD and namely for Crohn's disease (CD), ulcerative colitis (UC), and ulcerative proctitis (UP).Data concerning 258 patients were collected by the mean of a standardized questionnaire from 3 different sources: the patient, his general practitioner, and his gastroenterologist.Two hundred and fifty eight patients were included: 144 CD (55.8%), 76 UC (29.5%), 30 UP (11.6%), and 8 chronic unclassifiable colitis (CUC) (3.1%). The mean direct costs of the diagnosis (m +/- SD) were 23,116 +/- 40,820 FF for CD, 10,628 +/- 17,316 FF for UC and 3,451 +/- 2,743 FF for UP. Although unplanned hospitalizations occurred in only 38% of the patients (98/258), they represented the 3/4 of the mean costs: 78.2% for CD and 64% for UC. Indirect costs generated by days off work were 4,719 +/- 6,610 FF for CD, 2,996 +/- 6,897 FF for UC and 1,230 +/- 3,622 FF for UP.The first management of a patient with CD was twice more expensive than the one with UC and 6.5 times than the one with UP.

The period of time required for the diagnosis of a chronic illness depends on initial clinical symptoms and their perception by the patient and the physicians. The aim of this study was to describe the procedures of diagnosis of incident cases of Inflammatory Bowel Disease (IBD).Patients reported by the Registry of inflammatory bowel disease of northern France (EPIMAD) in 1994 were included. Standardized questionnaires describing clinical history, patient behavior, medical consultations and examinations were collected by an interviewer practitioner from three sources: patients, general practitioners (GP) and gastroenterologists (GE). Patients were divided in 2 groups according to the time between symptom onset and diagnosis: more than 9 months or less than 9 months (D9 and Dor = 9).258 patients were included: 144 Crohn's disease (CD) (56%), 106 ulcerative colitis (UC) (41%) and 8 chronic unclassifiable colitis (CUC). Median time between symptom onset and diagnosis was 3 months, 196 (76%) patients belonged to the group Dor = 9 and 62 (24%) to the group D9. There was no difference between the 2 groups for initial clinical symptoms. The delay between symptom onset and the consultation to the GP and the GE was longer in the group D9: respectively 1 month vs 0 and 7.6 vs 2. Thirty-five percent of patients in the group D9 had consulted more than one GP vs 14% (p0.05). Diagnosis management by the GE was the same in both groups. Patients of group Dor = 9 had more often perceived their symptoms as serious (p0.05).Delay to diagnosis in a quarter of patients with IBD was more than 9 months. This later diagnosis was not due to patient management by the GE but rather to a longer delay to consulting the GP and between GP and GE referral. Patient interpretation of the symptoms could also explain the variability of this delay.

Acute unclassified colitis could be the first attack of inflammatory bowel disease, particularly chronic ulcerative colitis or acute non specific colitis regarded as being of infectious origin without recurrence. The aim of this work was to determine the outcome of 104 incidental cases of acute unclassified colitis diagnosed during the year 1988 at a census point made 2.5 to 3 years later and to search for demographic and clinical discriminating data for final diagnosis. Thirteen patients (12.5%) were lost to follow up. Another final diagnosis was made in three other patients: two had salmonellosis and one diverticulosis. Of the remaining 88 patients, 46 (52.3%) relapsed and were subsequently classified as inflammatory bowel disease: 54% ulcerative colitis, 33% Crohn's disease and 13% chronic unclassified colitis. Forty-two (47.7%) did not relapse and were considered to have acute non specific colitis. The mean age at onset was significantly lower in patients with inflammatory bowel disease (32.3 years) than in patients with acute non specific colitis (42.6 years) (P0.001). No clinical data (diarrhea, abdominal pain, bloody stool, mucus discharge fever, weight loss) was predictive of the final diagnosis. In this series, 52.3% of patients initially classified as having an acute unclassified colitis had a final diagnosis of inflammatory bowel disease after a 2.5-3 years follow-up. These data warrant a thorough follow up of acute unclassified colitis, especially when it occurs in patients40 years.

The incidence of inflammatory bowel disease (IBD) in French children is not known. Therefore we conducted a prospective epidemiologic study of IBD in the region Nord-Pas-de-Calais (3.9 millions inhabitants). During the first 17 months of the study each new suspected case was reported by all (private and public) gastroenterologists in the region (n = 104) and a questionnaire was filled up at the gastroenterologist office by an epidemiologist. The final diagnosis of Crohn's disease (CD), ulcerative colitis (UC) or proctitis was made in a blind manner by two expert gastroenterologists. During the period under study, 47 new cases of IBD were registered in children (less than 17 years of age); 31 (66%) had CD, 7 (15%) had UC, and 9 (19%) had unclassified colitis. The incidence was 2.07/100,000 children/year for CD and 0.46/100,000 children/year for UC. These preliminary data suggest that the incidence of CD is high in Northern France.

The MONICA project is an international study coordinated by the WHO, designed to explain the important variations of coronary mortality observed in the industrialised countries over the last 20 years. Thirty-nine centres in 27 countries are participating in the project which, over a 10 year period will, in geographically determined zones; a) record the numbers of acute myocardial infarcts and coronary deaths, b) analyse the treatment of acute cardiac events, and c) evaluate the cardiovascular risk factors and preventive measures in the general population. The MONICA-France project comprises three registers (Bas-Rhin, Haute-Garonne and the urban community of Lille), and a coordinating centre. The preliminary results confirm the wide geographic variability of coronary mortality with a prevalence slightly higher in Alsace and the North than in the South-West of France. The approximative frequency of coronary events in France is estimated at 112,000 infarcts and over 175,000 acute coronary episodes and deaths. Information is provided about the severity of the principal coronary risk factors and the conditions of their treatment in the register zones. A study of the accessibility of emergency treatment of acute infarction in the Bas-Rhin area, has demonstrated the key role of the general practitioner as the first contact but confirmed the long delay to hospital admission which nullified the potential benefits of thrombolysis in a high proportion of cases. However, the significant decrease in hospital mortality of acute infarction observed over a 3 year period in the three register zones, is probably related to the number of patients thrombolysed in that time.

Mortality rates for ischaemic heart disease, as estimated from death certificates, show highly significant differences between countries. In order to study the validity of mortality rates for ischaemic heart disease, the authors, involved in the MONICA project, have compared the results obtained from the conventional death certificate code with the data collected in a complementary enquiry conducted for all deaths possibly due to ischaemic heart disease. Three hundred and thirty patients, aged from 25 to 64 years, belonging to the urban community of Lille, and who died between October 1 and December 31, 1984, were included in this study. The sensitivity of the death certificate for the diagnosis of ischaemic heart disease was 77.9 percent and its specificity was 95.9 percent. The concordance rate between death certificate and complementary enquiry was not modified by age, sex, socio-professional category, family situation, place of death and doctor who signed the certificate. The complementary study proved impossible in 31.8 percent of the cases, usually because the doctor who signed the death certificate was not fully conversant with the patient's condition. Our results therefore confirm that death certificates are valid to study mortality from ischaemic heart disease.

The relationship between vigilance and pedagogy was studied in 3 middle classes of primary school (children aged between 8 and 9 yrs). Three different types of pedagogy, belonging to 3 major pedagogic currents were evaluated: the pedagogy of Maria Montessori, the traditional one and the so-called "open" pedagogy. The vigilance of children was tested with the psychometric test of Zazzo. The rate of performance of the test was significantly different according to the nature of pedagogy after adjustment of the only 2 confusing factors between the 3 schools: the age of the children and the degree of the mother. This difference was in favor of the pedagogy of Maria Montessori compared with the 2 others. It was observed on the results to the tests but also on learning.

No epidemiological data on inflammatory bowel disease (IBD) are available in France. We therefore conducted a prospective epidemiologic study of IBD in the Nord-Pas de Calais region and the Somme department of France (4.5 million inhabitants). Each suspected new case was reported by all (private and public) gastroenterologists (n = 120) and a questionnaire was filled out at the gastroenterologist office by an epidemiologist. The final diagnosis of Crohn's disease (CD), ulcerative colitis (UC), or proctitis (UP) was made in a blind manner by two gastroenterologists. During 1988, 576 IBD patients were identified; 281 (49 percent) had CD, 207 (36 percent) had UC including 75 UP; and 88 (15 percent) had unclassified colitis. The incidence rate per 10(5) was 6.3 for CD and 4.6 for UC. The female/male ratio was 1.4 for CD and 0.9 for UC. The mean age at the time of diagnosis was 31 years for CD and 40.5 years for UC. The mean time between onset of symptoms and diagnosis was longer for CD (15 months) than for UC (6.8 months). These preliminary data suggest that the incidence of IBD is high in Northwestern France and comparable, for CD, to the highest incidence of Northern Europe.

Previously reported cases of peripheral neuropathies occurring during almitrine therapy had only a few weeks follow-up after having stopped the drug. We have studied clinical and electrophysiological data 6 to 12 months after almitrine had been given up in 9 patients from a group of 14 whose epidemiologic, clinical, electrophysiological and pathological data had been registered. In 7 of them, without any chronic respiratory deficiency, almitrine was administered as almitrine bismésilate and raubasine, and in 7 others (6 with chronic respiratory deficiency) as almitrine bismesilate alone. In patients who had another possible cause of neuropathy, clinical disorders appeared after a lesser total quantity of almitrine (p less than 0.05). Clinical data were suggestive of sensory peripheral neuropathies of feet and lower third of legs. Electrophysiological data suggested distal axonopathy in spite of the absence of denervation: amplitudes of sensory potentials were reduced and nerve conduction velocities were moderately decreased. Biopsies revealed mild neurogenic atrophy of muscles and distal axonopathy. Clinical improvement was very slow and 6 to 12 months later, most of the patients still presented decreased vibration sense and ankle reflexes loss, but all of them were still improving. Amplitudes of sensory potentials and sensory nerve conduction velocities were significantly improved (p less than 0.05) but motor nerve conduction velocities were not (p greater than 0.05). Our study shows: 1) clinical, electrophysiological and pathological data similar to those previously reported; 2) subclinical disturbances of motor functions in lower limbs and sensory functions in upper limbs; 3) some patients presented with unusual signs: posture tremor (3 cases), painful legs and moving toes (1 case); 4) peripheral neuropathies may occur during almitrine therapy even in patients without any chronic respiratory insufficiency; 5) peripheral neuropathies occurred with lower doses in patients with other factors predisposing to neuropathies; 6) patients' improvement was very slow; 7) in 9 cases the imputability of these peripheral neuropathies to almitrine is plausible. We suggest not to prescribe almitrine without caution, especially in patients with other factors of neuropathy. Treatment should be regularly interrupted.

A 38 year old alcoholic patient presented meningitis, loss of consciousness, pneumopathy and multiple cerebral lesions on a CT scan. He improved with ofloxacin and corticosteroid therapy, before the administration of anti-tuberculin treatment. Magnetic resonance imaging was used to follow the course of the lesions once the CT scan had become normal. This case demonstrates the efficacy of ofloxacin against central nervous system tuberculosis.

In 1985, the age-standardized (25-64) attack rate (per 100,000) for myocardial infarction, among men was 240 in the Bas-Rhin, 219 in the Haute-Garonne and 231 in the urban community of Lille and among women, respectively, 58, 28 and 51. The mortality rate for men (per 100,000) was 66 (Bas-Rhin), 57 (Haute-Garonne), 69 (Lille) and among women 18, 7 and 14. Among women, these differences are significant. A regional significant difference appears among men when cases with insufficient data are included. The sex ratio (men/women) was higher in the Haute-Garonne. 38% of death cases occurred within one hour, 76% within one day, and 89% in the first week after the first symptoms. The case fatality rate at 28 days does not differ significantly between the three registries (from 26% to 30%). The highest case fatality rates were observed in patients aged 25-34 and 55-64. The frequency of previous history of cardiovascular disease and the management of the cases were not different between regions. Diagnostic criteria problems are discussed.

Single photon emission tomography with Hm PAO Tc99m was used in 27 patients with probable Alzheimer's disease, 9 patients with multi-infarct, dementia, and 11 healthy volunteers. The data were quantified in 4 regions of interest (using the basal ganglia as an internal standard): left and right prefrontal areas (Fg and Fd), and left and right parietal areas (Pg and Pd). Pg and Pd indices were lower in patients with Alzheimer's disease than in patients with multi-infarct dementia, and healthy volunteers (p less than 0.05). The ratio (Fd + Pd)/(Fg + Pg) was lower in patients with dressing apraxia (p less than 0.02), anosognosia (p less than 0.001), spatial agnosia (p less than 0.01), ideomotor apraxia (p less than 0.02), ideatory apraxia (p less than 0.01), and constructive apraxia (p less than 0.01). No correlation could be established between this ratio and the severity of aphasia, or between the indices and mini mental state scores. With Pg and Pd indices lower than 0.90, sensitivity for Alzheimer's disease was 70 p. 100 and specificity, 75 p. 100.

From a regional survey (northwestern part of France 3,9 millions population) and from recent publications, the authors described clinical and epidemiologic aspects useful for genetic counselling. Besides the chronic chorea, the other clinical features justified the denomination "Huntington's disease". Misdiagnosis is frequent especially if the familial disorder is unknown. A prevalence of 50 X 10(-6) corresponds to 2750 choreics and 14.000 at risk descendants in France. Interfamilial heterogeneity is described from mean age of death which is 54.2 for the whole study: one third of families of late onset, around fifty (mean age of death: 64.6), one third of early onset, around thirty (mean age of death: 44.6). The 17 juvenile and infantile cases of the survey belong to this last group. The influence of gene-transmitters sex is more obvious if two generations are taken in account with a preponderance of fathers and grand-fathers in the early onset group and, to a lesser degree, of mothers and grand-mothers in the late onset group. The authors criticize the preclinical detection tests and, from attitudes of families, underline the ethical problems for the future predictive tests by genetic markers. The role of lay organisations is all the more important.

Two cases of cervico-occipital malformation revealed by syncopes are reported. The first patient has an Arnold-Chiari type I malformation and the second has a basilar impression. The paroxysmal clinical manifestations are triggered by head-turning or exertion. In the second case Doppler vertebral artery recordings show circulatory arrest during a moderate turning motion of the head. A vascular mechanism may explain the occurrence of paroxysmal symptoms in cervico-occipital malformations.