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OBJECTIVE To measure prospectively apparent diffusion coefficient (ADC) values between 28 and 32 weeks of gestation in different cerebral territories of fetuses with estimated fetal weight (EFW) ≤ 5th centile, and analyze their association with adverse perinatal outcome. METHODS This was a prospective study involving six tertiary-level perinatal centers. In the period 22 November 2016 to 11 September 2017, we included singleton, small-for-gestational-age (SGA) fetuses with EFW ≤ 5th percentile, between 28 and 32 weeks of gestation, regardless of the umbilical artery Doppler and maternal uterine artery Doppler findings. A fetal magnetic resonance imaging (MRI) examination with diffusion-weighted sequences (DWI) was performed within 14 days following inclusion and before 32 weeks. ADC values were calculated in the frontal and occipital white matter, basal ganglia and cerebellar hemispheres. An ultrasound examination was performed within 1 week prior to the MRI examination. The primary outcome was a composite measure of adverse perinatal outcome, defined as any of the following: perinatal death; admission to neonatal intensive care unit with mechanical ventilation > 48 h; necrotizing enterocolitis; Grade III-IV intraventricular hemorrhage; periventricular leukomalacia. A univariate comparison of median ADC values in all cerebral territories between fetuses with and those without adverse perinatal outcome was performed. The association between ADC values and adverse perinatal outcome was then analyzed using multilevel logistic regression models to adjust for other common prognostic factors for growth-restricted fetuses. RESULTS MRI was performed in 64 patients, of whom five were excluded owing to fetal movement artifacts on DWI and two were excluded for termination of pregnancy with no link to fetal growth restriction (FGR). One intrauterine death occurred secondary to severe FGR. Among the 56 liveborn neonates, delivered at a mean ± SD gestational age of 33.6 ± 3.0 weeks, with a mean birth weight of 1441 ± 566 g, four neonatal deaths occurred. In addition, two neonates required prolonged mechanical ventilation, one of whom also developed necrotizing enterocolitis. Overall, therefore, seven out of 57 (12.3%) cases had an adverse perinatal outcome (95% CI, 3.8-20.8%). The ADC values in the frontal region were significantly lower in the group with adverse perinatal outcome vs those in the group with favorable outcome (mean values of both hemispheres, 1.68 vs 1.78 × 10-3 mm2 /s; P = 0.04). No significant difference in ADC values was observed between the two groups in any other cerebral territory. A cut-off value of 1.70 × 10-3 mm2 /s was associated with a sensitivity of 57% (95% CI, 18-90%), a specificity of 78% (95% CI, 63-88%), a positive predictive value of 27% (95% CI, 8-55%) and a negative predictive value of 93% (95% CI, 80-98%) for the prediction of adverse perinatal outcome. A mean frontal ADC value

BACKGROUND: Although induction of labor (IOL) of low-risk nulliparous women at 39 weeks reduces the risk of cesarean delivery compared with expectant management, concern regarding more frequent use of labor induction remains given that this intervention historically has been thought to incur greater resource utilization. OBJECTIVE: To determine whether planned elective labor induction at 39 weeks among low-risk nulliparous women, compared with expectant management, was associated with differences in health care resource utilization from the time of randomization through 8 weeks postpartum. STUDY DESIGN: This is a planned secondary analysis of a multi-center randomized trial in which low-risk nulliparous women were assigned to IOL at 39 weeks or expectant management. We assessed resource utilization post-randomization in three time periods: antepartum (AP), delivery admission, and discharge through 8 weeks postpartum (PP). RESULTS: Of 6096 women with data available, those in the IOL group (n = 3059) were significantly less likely in the AP period after randomization to have at least one ambulatory visit for routine prenatal care (32.4% vs. 68.4%), unanticipated care (0.5% vs. 2.6%), or urgent care (16.2% vs. 44.3%), or at least one antepartum hospitalization (0.8% vs. 2.2%, p0.05 for all). CONCLUSIONS: Women randomized to IOL had longer durations in labor and delivery, but significantly fewer AP visits, tests, and treatments, and shorter maternal and neonatal hospital durations post-delivery. These results demonstrate that the health outcome advantages associated with IOL are gained without incurring uniformly greater health care resource use. TRIAL REGISTRATION: ClinicalTrials.gov number NCT01990612

Patient navigation is increasingly employed to guide patients through cancer treatment. We assessed the elements of navigation that promoted patients’ involvement in treatment among patients with breast and colorectal cancer that participated in a navigation study. We conducted qualitative analysis of 28 audiotaped and transcribed semi-structured interviews of navigated and unnavigated cancer patients. Themes included feeling emotionally and cognitively overwhelmed and desire for a strong patient-navigator partnership. Both participants who were navigated and those who were not felt that navigation did or could help address their emotional, informational, and communicational needs. The benefits of logistical support were cited less often. Findings underscore the salience of personal relationships between patients and navigators in meeting patients’ emotional and informational needs.

Patient navigation (PN) programs are being widely implemented to reduce disparities in cancer care for racial/ethnic minorities and the poor. However, few systematic studies cogently describe the processes of PN. We qualitatively analyzed 21 transcripts of semistructured exit interviews with three navigators about their experiences with patients who completed a randomized trial of PN. We iteratively discussed codes/categories, reflective remarks, and ways to focus/organize data and developed rules for summarizing data. We followed a three-stage analysis model: reduction, display, and conclusion drawing/verification. We used ATLAS.ti_5.2 for text segmentation, coding, and retrieval. Four categories of factors affecting cancer care outcomes emerged: patients, navigators, navigation processes, and external factors. These categories formed a preliminary conceptual framework describing ways in which PN processes influenced outcomes. Relationships between processes and outcomes were influenced by patient, navigator, and external factors. The process of PN has at its core relationship-building and instrumental assistance. An enhanced understanding of the process of PN derived from our analyses will facilitate improvement in navigators' training and rational design of new PN programs to reduce disparities in cancer-related care.

Objective In this study, the effects of vibration therapy (VT) on delayed-onset muscle soreness (DOMS) and associated inflammatory markers after downhill running were determined. Methods 29 male recreational runners (33 (8) years; Vo 2 peak 57 (6) ml kg −1 min −1 ) completed a 40-min downhill run and were randomly allocated to a VT group or Control group. For 5 days post-run, the VT group underwent once-daily sessions of VT on the upper and lower legs. DOMS was assessed pre-run and for 5 days post-run by visual analogue scale. Immune cell subsets and plasma inflammatory markers were assessed pre-run, post-run, 24 and 120 h post-run by full differential cell count, and by ELISA and enzyme immunoassay, respectively. Data were analysed as per cent change from pre-run (ANOVA) and the magnitude of the treatment effect (Cohen9s effect size statistics). Results VT significantly reduced calf pain 96 h post-run (−50% (40%), 90% confidence limits) and gluteal pain 96 h (−50% (40%)) and 120 h post-run (−30% (30%)); decreased interleukin 6 (IL6) 24 h (−46% (31%)) and 120 h post-run (−65% (30%)); substantially decreased histamine 24 h (−40% (50%)) and 120 h post-run (−37% (48%)); substantially increased neutrophils (8.6% (8.1%)) and significantly decreased lymphocytes (−17% (12%)) 24 h post-run. There were no clear substantial effects of VT on other leukocyte subsets and inflammatory markers. Conclusion VT reduces muscle soreness and IL6. It may stimulate lymphocyte and neutrophil responses and may be a useful modality in treating muscle inflammation.

To examine physicians' perceptions, motivations, and influences on their willingness to care for patients with human immunodeficiency virus (HIV).Interviews with 30 physicians. Qualitative content and narrative analyses were performed.Community-based primary care practices in six moderate-sized cities in the northeastern United States with at least a moderate incidence or prevalence of reported acquired immunodeficiency syndrome cases.Thirty community-based primary care physicians who had cared for at least two patients with HIV during the previous 2 years.Qualitative study designed to provide rich descriptive data.Care of patients with HIV was regarded as part of the scope of primary care, and was perceived to be similar to the care of patients with other chronic illnesses. Many physicians were motivated by personal rewards in taking care of patients, intellectual challenge, and desire to serve the underserved. Most believed that practicing physicians have an ethical obligation to care for all patients, regardless of diagnosis. No one "type" of physician could be identified who provides care to patients with HIV.Primary care physicians can apply their skills in the management of other chronic diseases to the care of patients with HIV. Practicing physicians can find caring for patients with HIV rewarding, stimulating, and enjoyable. Educational programs for physicians need to emphasize psychosocial aspects of HIV care. In addition, physicians need opportunities to recognize and deal effectively with their own emotional responses to the care of patients with HIV.

The new diagnostic criteria for ankylosing spondylitis include MRI. MRI frequently allows early diagnosis of inflammatory lesions in patients with normal plain films. In addition, MRI is useful for the detection and quantification of inflammatory and structural lesions, and to assess disease activity.

The new diagnostic criteria for spondyloarthropathy include MRI. MRI frequently allows early diagnosis of inflammatory lesions of the spine and sacroiliac joints in patients with normal plain films. Moreover, MRI is useful for the detection and quantification of inflammatory and structural lesions, and to assess disease activity.

The management of atrial arrhythmias aims not only to restore sinus rhythm but also to maintain it. Ten to thirty per cent of patients have early recurrence of atrial arrhythmias, the treatment of which remains empiric. The aim of this study was to define factors predictive of early recurrence of atrial arrhythmias and the consequences on the length of hospital stay. A series of 131 patients who underwent reduction of atrial arrhythmias by electrical cardioversion was studied retrospectively. A recurrence within 24 hours was observed in 12.2% of the patients. These recurrences significantly increased the length of hospital stay (6.8+/-6.3 versus 3.6+/-3.8 days, p=0.005). This study confirms two previously reported results with respect to more long-term recurrences. In the "early recurrence" group, the duration of the atrial arrhythmia was longer (p=0.003) and there were fewer treatments with amiodarone (p=0.03). In addition, original results were obtained. In the "early recurrence" group, the patients were more often treated with furosemide (p=0.02), class Ic antiarrhythmics (p=0.007) or anaesthetised with thiopental (p=0.002) than patients without early recurrences. Experimental data explain these results. However, they require confirmation by a prospective randomised trial.

Supraventricular arrhythmia is a major public health problem because of its prevalence and clinical consequences. The first step of the treatment usually consists in restoring sinusal rhythm. The aim of this study is to evaluate results and predictive factors of success of electrical cardioversion.We studied a series of 143 consecutive electric cardioversion preformed in 131 French patients.The rate of successful direct current cardioversion was 91.2%. Negative predictive factors are the height body mass index and the age of arrhythmia. Atrial flutter is a predictive factor of success. These results agree with published results. Our study highlights the interest of some nonantiarrhythmic drugs received by the patient during the period before the direct current cardioversion. Thus, a spironolactone treatment appears to be a new predictive factor of the success of electrical cardioversion (success in patients treated with spironolactone: 100% vs 89% without, P = 0.04).Our results agree with usual predictive factors of the success of cardioversion. Nevertheless, a new approach is that of the positive effect of spironolactone on cardioversion. A prospective randomized study is necessary to confirm this result.

Background: Keloids are clinically vexacious scars characterized by a high recurrence rate after excision alone (50–100%). Many adjuvant techniques have been used with more or less convincing results. Objective: The aim of this study is to show the efficiency of keloidectomy and postoperative interstitial radiotherapy by an iridium 192 wire. Methods: During a 14-year period, 39 patients with keloids (46 keloids) were treated by this regimen. Seven patients had been previously treated by intralesional corticosteroids, surgery alone or postoperative interstitial radiotherapy, without improvement. A dose of 12 Gy (7 keloids) to 15 Gy (22 keloids) was delivered at a point 2.5 mm from the axis of the wire. For 17 keloids the dose schedule was 15 Gy at a point 5 mm to the wire. The median follow-up was 7 months. Results: The overall success rate is close to 63%. A recurrence occurred in 14 cases without relation to the method used, the age or the localization of the lesions. There were no side effects observed. Conclusion: Postoperative interstitial radiotherapy represents an effective, unconstraining and safe treatment for keloids if the contraindications are respected.

The current clinical imaging technique applied to the sacroiliac joint (SIJ) is coronal Computed Tomography (CT). The aims of this study were: 1) to section the cartilage, the ligaments of the SIJ, and their relations to adjacent organs, in a coronal plane; 2) to correlate anatomical and magnetic resonance (MR) sections; 3) to extend these data in vivo. A topographic dissection of a 52 year-old female specimen was performed to identify the various components, and spatial relationships of the SIJ. Another fresh frozen 50 year-old female cadaver was chosen on CT criteria of normality, and examined with a high resolution (HR) T1-weighted spin echo sequence, in a plane parallel to the ventral limit of the first two sacral vertebrae. This cadaver was then sliced with a sliding gauge device (slice thickness: 5 mm, and device thickness: 1 mm). The SIJ of a 28 year-old nulliparous volunteer, were examined in HR MR imaging, and with a faster sequence, for comparison with the post mortem data. The slice study was correlated with conventional dissection. The continuity and thickness of the auricular cartilage, the complex fascicles of proximal ventral and dorsal sacroiliac ligaments, and distant sacrotuberous and sacrospinous ligaments, were studied. In each plane, coronal HR MR imaging studies were correlated with anatomical sections. The clinical relevance of this comparison was to extend these data in vivo. The auricular cartilage and the ligaments of the SIJ are clearly analyzed by MR imaging, which could contribute to the study of sacroiliitis.

We analyzed the results of dual photon absorptiometry measurements in 43 normal children. Results were correlated with age, body weight, and stature. Reference stature-specific values for bone mineral content in children are proposed. Furthermore, our results show that mineralization continues beyond the end of statural growth.

Primary vaginal cancer are infrequent and amount to 2 or 3 per cent of the gynecological cancers. Their diagnosis is difficult, because many other cancers metastasize in the vagina. The primary vaginal cancer arise mostly after climateric. Adjuvant causes would be a total hysterectomy in the past, prolapsus, prolonged use a pessary or a previous irradiation. The squamous-cell carcinomas, by far the most frequent (91%), are mostly situated in the upper third of the vagina on the anterior and posterior walls. Surgery, being difficult and mutilating is rarely indicated. So the treatment is mainly radiotherapic: external irradiation and intracavitary curietherapy. The radiation techniques are a little different according to the site of the lesion in the lower third or not. The upper lesion can be treated like a cervix cancer. The lower ones are more difficult to handle; for curietherapy, one must use molded apparatus, loaded with Iridium wire, adapted to each special case. The therapeutic results are rather poor:43 per cent for the 5-year cure rate and 36 per cent for the 10-year cure rate: less than for the cervix uteri. The upper lesions have a better prognosis than the lower ones. Results should be improved with an earlier diagnosis, a more accurate radiotherapy and a more precise dosimetry. The non-squamous-cell cancers (adenocarcinomas, sarcomas, mallignant melanomas) are generally rather radio-resistant. They are rare and their prognosis is very poor.

This study deals with 524 cases of uterine cervix (except stade IV cases) completely treated at the Foundation Curie with esclusive radiotherapy from from 1962 to 1968. The irradiation techniques, as well as the doses given to the tumor and to the critical organs are stated. The various sequelae and complications are described, according to the class and severity. The cases are divided into two groups: 257 cured patients and 267 dead patients. For the cured patients, half of them (49%) had no trouble at all. Among the 130 remaning cases, 16% presented with mild troubles, 23% with moderate sequelae, 9% with marked complications and 3% with severe complications leading to an infirmity. The rectal troubles are frequent (55% of all the troubles) in 40% of the patients; though rarely, they can be severe (6% of the cases). They appear relatively early. The bladder troubles rank second (37% of all the troubles) in 20% of the patients; never severe and without any renal effect, they are more delayed than the former. The skin and soft tissues troubles are only a few (5%) for 5% of the patients. They are mostly mild and moderate. One skin necrosis was noted due for a large part to the very poor general conditions of the patient. The bone troubles are always classified here as marked or severe; they are rare (2,6%) in 2,3% of the patients. Their treatment is satisfactory. One single case of bilateral femur neck fracture gave a permanent infirmity. We have noted no nervous trouble, nor urinary trouble other than the bladder ones, nor bowel troubles aprt from a mild and transient sigmoiditis. The genital troubles noted in 21% of the patients are mostly vaginal adhesion in women over 60 years of age. The sexual troubles, very difficult to analyse, have not been studied here. The treatments of these various troubles have generally been simple, not very compelling, and effective. Only eight patients with severe complications (3%) underwent important therapeutics (fecal diversion, none surgery) and kept an infirmity. One patient (0,4%) died during the post-operative course. For the dead patients, the study is less significant, because of the neoplastic evolution and of the rather short survival. This fact explains that 20% only of the patients (versus 51%) presented with 106 troubles (versus 304). The rectal troubles remain frequent 33%) of the cases), though the bladder troubles, more delayed, are very less numerous (1,8% of the patients). The bone complications are similar in number and quality (2,2% of the patients).

Over the past few years, the criteria defining the sleep apnea syndrome have been well delineated. This syndrome is a common affliction whose pathophysiology is usually indicative of an obstacle in the upper respiratory tract. The authors describe seven mostly serious cases, with cardiovascular and hemodynamic repercussions, that benefited from ORL surgery (uvulo-palato-pharyngoplasty and/or tonsillotomy). In each case, the consequences of this simple surgery were excellent, resulting in a sharp attenuation of the symptoms or their disappearance. In conclusion, the authors insist on the preponderant role that can be played by the ear, nose and throat specialist, both in the selection of these patients and in their treatment.

Presentation of a caucasian female (70-year-old) who suffered from urinary incontinence and orthostatic hypotension (Shy-Drager syndrome) and died six years after the onset of the dysautonomic clinical disorders. Neuropathological examination demonstrated putamino-nigral degeneration, olivo-ponto-cerebellar atrophy, neuronal depletion in the brain-stem and the spinal cord, mainly in the intermedio-lateral horns. The cerebral cortex did not exhibit senile alteration as often seen in ageing brain. A review of the literature, including 43 autopsied cases, confirmed that the Shy-Drager syndrome results from a diffuse neuronal loss mainly in the putamen, the pigmented nuclei, part of the brain-stem and the spinal cord (multiple system atrophy, with minimal cerebral cortex involvement). The disease occurs sporadically in adults, more frequently in man (sex ratio : 2.5/1). (Acta neurol. belg., 1980, 80, 271-286).

The authors report three different and rare forms of neurological complication associated with infectious mononucleosis. The first two, which are faily unusual in their clinical signs, occurred during the course of two typical cases of mononucleosis, one in the form of progressively regressive myelitis and the other in that of amyotrophic paralysis of the shoulder. The third occurred in isolation, after an encephalitic attack combined with a state of epileptic mal, with no other accompanying infectious sign. On the basis of these three single cases, and recent data in the literature about the Epstein-Barr virus, the authors briefly recapitulate the neurological clinical forms of infectious monouncleosis and the means of serological diagnosis; they discuss the frequency and pathogeny of these complications and tentatively suggest certain similarities with other nervous disorders observed in the course of proliferative or dysglobulinaemic diseases.

Pre-operative irradiation in operable cancer of the rectum remains controversial. This is a report of a retrospective study about 192 patients treated between 1958 and 1980 at the Institut Curie (Paris) for a rectal cancer. An abdomino-perineal resection was done in 144 patients, 83 as a primary procedure and 61 after a pre-operative irradiation. During the same period 48 patients had an anterior resection. We put in this study the only patients who underwent curative surgery. Irradiation was given with high voltage by a four field "box technique". The tumour received 40 to 50 grays in 5 to 6 weeks. The operation was done at least 6 weeks after the end of the irradiation. There was no difference for the sex, and age of the patients, and in the size of the tumour before treatment, between the patients irradiated and those operated on as a primary procedure. There was no difference in the operative mortality as well as the 3, 5, and 10 year survival in the two groups. Pre-operative irradiation did not change the number of perineal recurrences or the number of visceral metastases. The healing of the perineum was significantly longer in the irradiated patients (p less than 0.001). The survival was closely related to the Dukes classification. The number of Dukes A patients was significantly higher (p = 0.02) after irradiation: 26/61 (43%) vs 19/83 (23%) when the patients were not irradiated. In our experience pre-operative irradiation can shrink some large tumours helping the surgical act.(ABSTRACT TRUNCATED AT 250 WORDS)

Seventy-seven patients with inflammatory breast carcinoma were included in a randomized trial between march 1977 and september 1979. All patients were treated with the same association of chemotherapy and radiation therapy. Chemotherapy included adriamycin on day 1 (45 mg/m2), vincristine on day 2(1,2 mg/m2), cyclophosphamide on days 3, 4 and 5 (400 mg/m2/day) and 5 fluoro-uracil on days 3, 4, and 5 (500 mg/m2/day). Each course of chemotherapy was repeated every 28 days for one year. Patients were then given a maintenance course of chemotherapy for one year. Radiation therapy with CO60 was applied after 4 courses of intensive chemotherapy. The dose distributed was 70 Gy over seven weeks. During radiation therapy, chemotherapy was administered according the same scheme, but adriamycin was excluded. All the patients were randomly distributed into two groups before treatment: group I patients received chemotherapy and radiation therapy alone; group II patients received chemotherapy and radiation therapy plus living BCG vaccinations. After chemotherapy, inflammatory manifestations disappeared in 51% of cases. The mean of disease-free interval was 26 months and the overall survival mean 34 months. No difference in favor of the BCG treated group was noted. Lymph node involvement, age, hormonal status, response to tuberculin, and disappearance of inflammatory signs after 4 months of chemotherapy are of insignificant prognostic value.

Fluorescent enzyme immunoassays have been developed for antibody to either single-stranded (ssDNA) or double-stranded (dsDNA) DNA. Preliminary testing of several clinically distinct groups of persons is consistent with the suggestion that the former assay (anti-ssDNA antibody) has sufficient sensitivity and specificity to be used as a generalized test for the detection of possible systemic lupus erythematosus in a heterogeneous clinical population. Further evaluation may ultimately establish its utility in the diagnosis of other related disorders. The sensitivity and specificity of the anti-dsDNA antibody fluorescent enzyme immunoassay are compatible with its use as a confirmatory test in the laboratory diagnosis of systemic lupus erythematosus. Qualitative comparisons between both assays and the more classic laboratory procedures involved in the diagnosis and treatment of systemic lupus erythematosus were quite favorable. The enzyme immunoassay method appears to be acceptably reproducible, and rheumatoid factor has neither a suppressive nor an enhancing effect on test values.

Between 1968 and 1982, 195 patients with invasive anal canal carcinoma were treated at Institut Curie (Paris, France). There were 168 females and 27 males --sex-ratio: 5.7/1, mean age: 67 +/- 11 yrs. (range: 38-85 yrs.). The initial size of the tumors was analyzed according to the circumferential invasion of the anal canal. The tumor involved 1/4 of the circumference in 49 cases, 1/2 of the circumference in 108 cases, 3/4 of the circumference in 22 cases and the whole circumference in 16 cases. Pathological examination revealed 20 cloacogenic carcinomas and 175 squamous carcinomas. All patients received radiotherapy as initial treatment and none received chemotherapy as a curative procedure. Eight patients received only palliative treatment. Twenty-seven patients were operated on because the response of the tumor to irradiation was partial or incomplete. One hundred and sixty patients received the full course of irradiation with a complete response. Among the latter, 100 patients were alive NED with a normal anal function with at least a 2-year follow-up. Local recurrences (n = 42) underwent salvage surgery in 50 p. 100 of the cases with a 3-year survival over 50 p. 100. Actuarial survival of the 195 patients was 68.5 p. 100 at 3 years and 58 p. 100 at 5 years. Survival was highly related to the initial size of the tumor and to the presence of positive inguinal nodes (p less than 0.0002). The histologic type was not related to the response to radiotherapy, nor to local recurrence or to survival.(ABSTRACT TRUNCATED AT 250 WORDS)

The fortuitous detection of an increased activated cephalin clotting time is often dependent on defects of the blood-clotting factors synthesized by the liver, haemophilia or von Willebrand's disease, circulating anticoagulants or specific deficiencies of various factors necessary for blood-clotting mechanisms. Much more rarely, it may be due to an isolated Hageman factor defect. This deficiency does not lead to an increased bleeding tendency and surgery has proved surprisingly uneventful. On the other hand, thromboembolic events may appear. Being and inherited disease with autosomal recessive transmission, the discovery of Hageman factor deficiency must lead to a complete family investigation.

The authors report a case of atypical osteodystrophy of visceral origin (uretero-sigmoid by-pass for bladder exstrophy) which was characterized by the association of osteocondensation and looser-Milkman lines. They emphasize the rareness of osteodystrophy after uro-digestive by-pass and the exceptional character of the osteocondensation.