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The pathophysiological link between adiposity and blood pressure is not completely understood, and evidence suggests an influence of sex and genetic determinants. We aimed to identify the relationship between adiposity and blood pressure, independent of a robust set of lifestyle and metabolic factors, and to examine the modulating role of sex and Angiotensin-Converting Enzyme (ACE) insertion/deletion (I/D) polymorphisms. In the Relationship Between Insulin Sensitivity and Cardiovascular Disease (RISC) study cohort, 1211 normotensive individuals, aged 30 to 60 years and followed-up after 3.3 years, were characterized for lifestyle and metabolic factors, body composition, and ACE genotype. Body mass index (BMI) and waist circumference (WC) were independently associated with mean arterial pressure, with a stronger relationship in women than men (BMI: r =0.40 versus 0.30; WC: r =0.40 versus 0.30, both P ID and II ACE genotypes in both sexes ( P ACE genotype only in women ( P =0.03). A 5 cm larger WC at baseline increased the risk of developing hypertension at follow-up only in women (odds ratio, 1.56 [95% CI, 1.15–2.10], P =0.004) and in II genotype carriers (odds ratio, 1.87 [95% CI, 1.09–3.20], P =0.023). The hypertensive effect of adiposity is more pronounced in women and in people carrying the II variant of the ACE genotype, a marker of salt sensitivity.

Objective Microprolactinomas are currently treated with dopamine agonists. Outcome information on microprolactinoma patients treated by surgery is limited. This study reports the first large series of consecutive non-invasive microprolactinoma patients treated by pituitary surgery and evaluates the efficiency and safety of this treatment. Design Follow-up of a cohort of consecutive patients treated by surgery. Methods Between January 2008 and October 2020, 114 adult patients with pure microprolactinomas were operated on in a single tertiary expert neurosurgical department, using an endoscopic endonasal transsphenoidal approach. Eligible patients presented with a microprolactinoma with no obvious cavernous invasion on MRI. Prolactin was assayed before and after surgery. Disease-free survival was modeled using Kaplan–Meier representation. A cox regression model was used to predict remission. Results Median follow-up was 18.2 months (range: 2.8–155). In this cohort, 14/114 (12%) patients were not cured by surgery, including ten early surgical failures and four late relapses occurring 37.4 months (33–41.8) after surgery. From Kaplan–Meier estimates, 1-year and 5-year disease free survival was 90.9% (95% CI: 85.6–96.4%) and 81% (95% CI: 71.2–92.1%) respectively. The preoperative prolactinemia was the only significant preoperative predictive factor for remission (P < 0.05). No severe complication was reported, with no anterior pituitary deficiency after surgery, one diabetes insipidus, and one postoperative cerebrospinal fluid leakage properly treated by muscle plasty. Conclusions In well-selected microprolactinoma patients, pituitary surgery performed by an expert neurosurgical team is a valid first-line alternative treatment to dopamine agonists.

International audience; The aim of this review was to update the recommendations for optimal pain management after open and laparoscopic or robotic prostatectomy. Optimal pain management is known to influence postoperative recovery, but patients undergoing open radical prostatectomy typically experience moderate dynamic pain in the immediate postoperative day. Robot-assisted and laparoscopic surgery may be associated with decreased pain levels as opposed to open surgery. We performed a systematic review using Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) with PROcedure SPECific Postoperative Pain ManagemenT (PROSPECT) methodology. Randomised controlled trials (RCTs) published in the English language, from January 2015 until March 2020, assessing postoperative pain, using analgesic, anaesthetic and surgical interventions, were identified from MEDLINE, EMBASE and Cochrane Databases. Of the 1797 studies identified, 35 RCTs and 3 meta-analyses met our inclusion criteria. NSAIDs and COX-2 selective inhibitors proved to lower postoperative pain scores. Continuous intravenous lidocaine reduced postoperative pain scores during open surgery. Local wound infiltration showed positive results in open surgery. Bilateral transversus abdominis plane (TAP) block was performed at the end of surgery and lowered pain scores in robot-assisted procedures, but results were conflicting for open procedures. Basic analgesia for prostatic surgery should include paracetamol and NSAIDs or COX-2 selective inhibitors. TAP block should be recommended as the first-choice regional analgesic technique for laparoscopic/robotic radical prostatectomy. Intravenous lidocaine should be considered for open surgeries.

Background Mycoplasma genitalium (MG) is an emerging pathogen among men who have sex with men (MSM) with raising rates of antibiotic resistance. This study assessed the prevalence and incidence of MG infection in MSM enrolled in the open-label phase of the ANRS IPERGAY trial with on-demand tenofovir disoproxil fumarate/emtricitabine for human immunodeficiency virus prevention and the impact of doxycycline post-exposure prophylaxis (PEP). Methods 210 subjects were tested at baseline and at 6 months by real-time PCR assays for MG detection in urine samples and oropharyngeal and anal swabs. Resistance to azithromycin (AZM), to fluoroquinolones (FQs), and to doxycycline was investigated in the French National Reference Center of Bacterial Sexually Transmitted Infections (STIs). Results The all-site prevalence of MG at baseline was 10.5% (6.3% in urine samples, 4.3% in anal swabs, 0.5% in throat swabs) and remained unchanged at 6 months whether or not PEP was used: 9.9% overall, 10.2% with PEP, 9.6% without. The overall rate of MG resistance (prevalent and incident cases) to AZM and FQs was 67.6% and 9.1%, respectively, with no difference between arms. An in vivo mutation of the MG 16S rRNA, which could be associated with tetracycline resistance, was observed in 12.5% of specimens tested. Conclusions The prevalence of MG infection among MSM on pre-exposure prophylaxis was high and its incidence was not decreased by doxycycline prophylaxis with a similar high rate of AZM and FQ resistance, raising challenging issues for the treatment of this STI and supporting current recommendations to avoid testing or treatment of asymptomatic MG infection.

The affiliation details for Geltrude Mingrone are corrected below.

Psychomotor impairments in Autism Spectrum Disorders (ASD) have frequently been described in scientific literature. Such deficits impact upon the development of social motor function and interfere with the ability to adjust to everyday life. The inclusion of sensory-motor signs in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) confirms their importance in the diagnosis of ASD. Previous literature has shown the presence precocity of these signs, sometimes before the alteration of the social communication. To our knowledge, there are no existing clinical tools to measure sensory-psychomotor deficit, specifically in ASD. The current paper presents the construction and validation of a new scale, designed to evaluate sensory-psychomotor signs in Autism: 'the Sensory-psychomotor Particularities Scale in Autism' (SPSA).The scale is composed of 160 items describing common sensory-psychomotor signs in autism. These items are grouped into 20 variables: touch, nociception, vestibular sensitivity, proprioceptive sensitivity, vision, auditory, multimodality, tone, posture, balance, global coordination, manual dexterity, body schema, bodily self-consciousness, relational adjustment, emotional expression, use of objects, space, time and tonico-emotional regulation. For each item, the psychomotor therapist evaluated sensori-psychomotor signs according to a five-level Likert scale (0="the sign is never expressed by the person", 1="weakly expressed", 2="moderately expressed", 3="severely expressed" and 4="the sign is very characteristic of the person and very severely expressed"). This is completed by a family interview in order to assess the impact of these signs on everyday situations. The study included 111 children with autism. The presence of neurological and genetic diseases was exclusion criteria. For each child, a global developmental evaluation was carried out by an expert clinical team specializing in ASD. Standardized clinical tools were used: Autism Diagnostic Observation Schedule (ADOS), Childhood Autism Rating Scale (CARS), Behavior Summarized Evaluation scale (BSE-R), Repeated and Restricted Behavior scale (RRB), Movement Assessment Battery for Children (M-ABC), Motor Development Rating scale (MDR), Sensory Profile (SP). Developmental quotients (DQ) were evaluated using various tests depending on age and ability.Factor analysis produced three clinically relevant factors: F1: "sensory-emotional synchronization", F2: "multisensory integration" and F3: "motor skills": each containing a similar quantity of items. They account for roughly equal percentages of variance (18.9%, 18.0%, 16.8%, respectively). The factorial structure does not change if the 26 children with comorbid developmental coordination disorder are removed. The three factors show good internal consistency and excellent inter-rater reliability. F1 is comprised of 6 items: touch, nociception, proprioceptive sensitivity, vision, emotional expression and tonico-emotional regulation. This factor is significantly associated with items of the Sensory Profile (touch processing, poor registration, sensory seeking). F2 is comprised of 5 items: multimodality, bodily self-consciousness, relational adjustment, use of objects and space. This factor is associated with ADOS, BSE-R and RRB scores, and the item "touch processing" of the Sensory Profile. F3 is comprised of 4 items: tone, posture, global coordination, manual dexterity. This factor is associated with the M-ABC, the MDR and the item "low endurance" of the Sensory Profile.The SPSA is a relevant clinical tool to assess the severity of sensory-psychomotor clinical signs in order to describe the individual profiles of children with ASD. It represents a critical step in advancing knowledge of the complex and heterogeneous pattern of psychomotor development in autism. It could make a valuable contribution to the field, both in research and clinical practice.

Many cancer predisposition syndromes are preceded or accompanied by a range of typical skin signs. Gorlin syndrome is a rare multisystem inherited disorder which can predispose to basal cell carcinomas (BCCs), childhood medulloblastomas in addition to various developmental abnormalities; the majority of cases are due to mutations in the PTCH1 gene. Approximately 5% of cases have been attributed to a mutation in the SUFU gene. Certain phenotypic features have been identified as being more prevalent in individuals with a SUFU mutation such as childhood medulloblastoma, infundibulocystic BCCs and trichoepitheliomas. Recently hamartomatous skin lesions have also been noted in families with childhood medulloblastoma, a "Gorlin like" phenotype and a SUFU mutation. Here we describe a family previously diagnosed with Gorlin syndrome with a novel SUFU splice site deleterious genetic variant, who have several dermatological features including palmar sclerotic fibromas which has not been described in relation to a SUFU mutation before. We highlight the features more prominent in individuals with a SUFU mutation. It is important to note that emerging therapies for treatment of BCCs in patients with a PTCH1 mutation may not be effective in those with a SUFU mutation.

Assessing disease activity in patients suffering from autoimmune diseases is complex. Symptoms are multiple, often subjective and there are no reliable biomarkers. Many activity scores have been implemented to compare treatment efficacy in clinical trials. Their use in clinical practice is largely unknown. We performed a practical survey to analyze the use of activity scores in clinical practice to consider treatment response and to assess the determinants of their use.A sample of French internists answered a questionnaire about activity scores of systemic lupus erythematosus, Sjögren's syndrome, autoimmune myositis and necrotizing vasculitis of small vessels. The frequency of use of these tools, the causes of their non-use, and the general opinion of practitioners about the place of theses scores in current practice were described.The form was completed by 92 internists. Seventy percent of them supported the use of activity scores in consultations, but actually used them in less than 25% of patient visits. The reasons for the low use of these scores are mainly the ignorance of their existence (42%) and their length or complexity (28%).The discrepancy between the ratio of practitioners who believe that scores have a place in daily practice and their actual use shows that the current scores do not meet the needs. The implementation of easily usable activity scores in inflammatory diseases remains a challenge for the internists.

Interstitial lung disease, cutaneous rash and elevated serum angiotensin converting enzyme (ACE) may suggest diagnoses other than sarcoidosis.A 58-year-old man had presented dyspnoea for 2 years with increased angiotensin-converting enzyme, as well as an interstitial syndrome and micronodules. The possibility of sarcoidosis was raised. Systemic corticosteroids resulted in improvement of the dyspnoea although it recurred on dose reduction. We noted fluctuating eczematous macules of the limbs with a histology of aspecific folliculitis. The identification of Mycobacterium avium complex (MAC) in the bronchoalveolar wash prompted us to initiate antimycobacterial therapy, but this was to no avail. Review of the CT-scan and questioning of the patient (daily use of a Jacuzzi for 7 years) resulted in diagnosis of hypersensitivity pneumonitis due to MAC. The cutaneous lesions were taken to indicate "hot tub folliculitis". Discontinuation of hot-tub use and a short course of oral corticosteroids resulted in healing within 4 months, with no recurrence at 2 years.HTL is a form of hypersensitivity pneumonitis due to the presence of MAC in the water of Jacuzzis. This condition regresses spontaneously without treatment on discontinuation of Jacuzzi use. Hot-tub folliculitis due to Pseudomonas aeruginosa (PA) presents as macules and papules on covered skin areas (swimsuit) within 48hours of bathing and often declines within 2 weeks.Our case is original as regards the concomitant lung and cutaneous involvement associated with Jacuzzi use, with an immunoallergic mechanism for the MAC and probably an infectious mechanism for the PA.

Background The application of safety principles from the aviation industry to the operating room has offered hope in reducing surgical complications. This study aimed to assess the impact on major surgical complications of adding an aviation-based team training programme after checklist implementation. Methods A prospective parallel-group cluster trial was undertaken between September 2011 and March 2013. Operating room teams from 31 hospitals were assigned randomly to participate in a team training programme focused on major concepts of crew resource management and checklist utilization. The primary outcome measure was the occurrence of any major adverse event, including death, during the hospital stay within the first 30 days after surgery. Using a difference-in-difference approach, the ratio of the odds ratios (ROR) was estimated to compare changes in surgical outcomes between intervention and control hospitals. Results Some 22 779 patients were enrolled, including 5934 before and 16 845 after team training implementation. The risk of major adverse events fell from 8·8 to 5·5 per cent in 16 intervention hospitals (adjusted odds ratio 0·57, 95 per cent c.i. 0·48 to 0·68; P < 0·001) and from 7·9 to 5·4 per cent in 15 control hospitals (odds ratio 0·64, 0·50 to 0·81; P < 0·001), resulting in the absence of difference between arms (ROR 0·90, 95 per cent c.i. 0·67 to 1·21; P = 0·474). Outcome trends revealed significant improvements among ten institutions, equally distributed across intervention and control hospitals. Conclusion Surgical outcomes improved substantially, with no difference between trial arms. Successful implementation of an aviation-based team training programme appears to require modification and adaptation of its principles in the context of the the surgical milieu. Registration number: NCT01384474 (http://www.clinicaltrials.gov).

Background: The prevalence of anemia has been studied in well-defined populations, but no large study is available for less restricted populations with various disorders. Design: Two-phase nationwide study: (i) a cross-sectional study including 1351 patients aimed to define the prevalence and characteristics of anemic patients seen in France, and (ii) a prospective longitudinal study of 398 anemic patients aimed to define factors associated with survival. Results: Anemia was present in 874 (65%) patients according to WHO criteria, and 573 (42%) patients had hemoglobin levels

The aims of the present study were to estimate the prevalence of renal impairment (RI) among HIV-infected adult patients and to investigate the associated factors.A cross-sectional survey was conducted in a French hospital-based cohort. Clearance of creatinine (CC) was calculated using the Cockcroft-Gault formula. Four stages of RI were defined: mild (60-90 mL/min), moderate (30-60), severe (15-30) and end stage (15). Logistic regression models were used to investigate factors associated with RI.The male/female ratio of the 2588 patients enrolled was 3:1 and the median age was 42 years. At the time of assessment of CC, the median CD4 count was 430 cells/microL and HIV plasma viral load (VL) was50 copies/mL in 60%. The overall prevalence of RI was 39.0%: 34.2% mild, 4.4% moderate, 0.3% severe and 0.2% end-stage. Mild RI was associated with female gender [odds ratio (OR)=3.3: 95% CI 2.6-4.3)], age50 years (OR=9.8: 7.4-13.0) and 40-50 years (OR=1.9: 1.5-2.4), body mass index (BMI)22 kg/m(2) (OR=3.3: 2.7-4.3) and tenofovir exposure (OR=1.4: 1.0-1.9 for1 year and OR=1.5: 1.2-2.0 for1 year). Advanced RI (CC60 mL/min) was associated with age50 years (OR=5.6: 2.9-10.9) and 40-50 years (OR=2.2: 1.1-1.4), BMI22 kg/m(2) (OR=1.5: 1.0-2.4), hypertension (OR=2.5: 1.4-2.5) and indinavir (IDV) exposure1 year (OR=2.3: 1.5-3.6).This survey confirms the high prevalence of RI in HIV-infected patients and indicates the importance of the investigation of renal function especially in women, older patients, those with a low BMI or treated with tenofovir or IDV.

Background More than 10 years after the introduction of combination antiretroviral therapy (cART), we examined the trend in the proportion of deaths caused by end-stage liver disease (ESLD) in HIV-infected adults in France between 1995 and 2005. Design and methods In 2005, 34 departments prospectively recorded all deaths in HIV-infected patients who were followed in those departments (around 24 000). Results were compared with those of four previous cross-sectional surveys conducted since 1995 using the same methodology. Results Among 287 reported deaths in 2005, 100 (35%) were related to AIDS, and 48 (17%) to ESLD. Three out of four patients who died from ESLD-related causes had chronic hepatitis C. Excessive alcohol consumption was reported in approximately half of the patients (48%). At death, 62% of patients had undetectable HIV viral load and the median CD4 count was 237 cells/μL. From 1995 to 2005, the proportion of deaths caused by ESLD increased from 2 to 17% (P

Background After cardiac surgery adequate postoperative analgesia is necessary. We assessed analgesia using intrathecal morphine and clonidine. Methods In a double-blind randomized study, 45 patients having coronary artery bypass graft surgery were allocated randomly to receive i.v. patient-controlled analgesia (PCA) morphine (bolus, 1 mg; lock-out interval, 7 min) (control group), either alone or combined with intrathecal morphine 4 μg kg −1 or with both intrathecal morphine 4 μg kg −1 and clonidine 1 μg kg −1 . Intrathecal injections were performed before the induction of general anaesthesia. Pain was measured after surgery using a visual analogue scale (VAS). We recorded i.v. PCA morphine consumption during the 24 h after operation. Results Morphine dosage [median (25th–75th percentiles)] was less in the first 24 h in the patients who were given intrathecal morphine + clonidine [7 (0–37) mg] than in other patients [40.5 (15–61.5) mg in the intrathecal morphine group and 37 (30.5–51) mg in the i.v. morphine group]. VAS scores were lower after intrathecal morphine + clonidine compared with the control group. Time to extubation was less after intrathecal morphine + clonidine compared with the i.v. morphine group [225 (195–330) vs 330 (300–360) min, P Conclusion Intrathecal morphine and clonidine provide effective analgesia after coronary artery bypass graft surgery and allow earlier extubation.

In June 2009, the national French authority for Health reported many off-label uses of proton pump inhibitors (PPI). Our objective was to analyse the justification and modalities of PPI prescriptions in patients before their admission in a department of internal medicine.Data were prospectively collected during 5months. At admission, all prescriptions of PPI by general practitioners (GP) were recorded. The accordance of the prescriptions with the marketing authorization indications and the French guidelines in terms of duration of treatment or dosage was analyzed. These informations were obtained from computerized medical records and, if necessary, by contacting GPs.We collected 173 prescriptions. Fifty-six (32%) were in accordance with marketing authorization indications and, among them, 15 prescriptions (9% of all) respected the French guidelines about dosage and duration of treatment. One hundred and six prescriptions (61%) were not adequate and among them an off-label use was notified in 91 (53% of all); among them 33% for simple dyspeptic disorders, 23% for the prevention of NSAID-induced lesions in patients without risk factors, and finally 17% for the prevention of stress ulcer. Fifty-two prescriptions (30%) were unclassified due to incomplete data.Our study showed that a vast majority of the prescriptions for PPIs are not in accordance with French guidelines. Preventive actions against abusive prescriptions, withdrawal strategies or replacement of already prescribed PPIs should be implemented to reduce the risk of side effects and the economic impact of long term use of PPIs.

We assessed the prognostic role of plasma levels of beta2-microglobulin, TNF-alpha, sTNFR-II, and IFN-gamma on the progression to AIDS in patients mostly treated with combination antiretroviral therapies. HIV-1-infected patients with advanced HIV disease (baseline CD4+ cell count between 50 and 250 x 10(6)/L) were included in a prospective cohort followed up for 36 months. In the 113 patients included, 22 first AIDS-defining events were reported. Cumulative probability of AIDS was 12% at M12, 18% at M24, and 20% at M36. Using a Cox model, the baseline level of sTNFR-II (hazard ratio of 3.75 for sTNFR-IIor =10 ng/ml vs10 ng/ml, P = 0.01) was associated with progression to AIDS. sTNFR-II remained a prognostic factor before and after the introduction of combinations of antiretrovirals. Whether or not this marker is of value in patients exclusively treated with highly active antiretroviral therapy needs to be assessed in specific studies.

Object. The aim of this study was to reassess whether middle cerebral artery blood flow velocity (MCAv) variations measured by transcranial Doppler ultrasonography during acute PaCO2 manipulation adequately reflect cerebral blood flow (CBF) changes in patients with severe closed head injury. Methods. The study was performed by comparing MCAv variations to changes in CBF as assessed by measurements of the difference in the arteriovenous content in oxygen (AVDO2). The authors initiated 35 CO2 challenges in 12 patients with severe closed head injury during the acute stage. By simultaneous recording of systemic and cerebral hemodynamic parameters, 105 AVDO2 measurements were obtained. Patients were stratified into two groups, “high” and “low,” with respect to whether their resting values of MCAv were greater than 100 cm/second during moderate hyperventilation. Four patients displayed an elevated MCAv, which was related to vasospasm in three cases and to hyperemia in one case. The PaCO2 and intracranial pressure levels were not different between the two groups. The slope of the regression line between 1 divided by the change in (Δ)AVDO2 and ΔMCAv was not different from identity in the low group (1/ΔAVDO2 = 1.08 × ΔMCAv − 0.07, r = 0.93, p < 0.001) and significantly differed (p < 0.05) from the slope of the high group (1/ΔAVDO2 = 1.46 × ΔMCAv − 0.4, r = 0.83, p < 0.001). Conclusions. In patients with severe closed head injury, MCAv variations adequately reflect CBF changes as assessed by AVDO2 measurements in the absence of a baseline increase in MCAv. These observations indicate that both moderate variations in PaCO2 and variations in cerebral perfusion pressure do not act noticeably on the diameter of the MCA. The divergence from the expected relationship in the high group seems to be due to the heterogeneity of CO2-induced changes in cerebrovascular resistance between differing arterial territories.

Sympathetic nervous system stimulation, which releases noradrenaline, influences the nociceptor activity which develops after tissue injury. The alpha 2-adrenergic agonist, clonidine, produces analgesia through a central mechanism but also inhibits noradrenaline release at terminal nerve fibre endings. Clonidine may induce analgesia when administered at peripheral sites. This study assesses the potential analgesic effect of clonidine after intra-articular administration. Forty ASA I-III patients, scheduled for arthroscopic knee surgery under general anaesthesia were allocated randomly in 4 groups of 10 patients each, at the end of the surgical procedure. In the control group (group 1), the patients received 20 ml of intra-articular isotonic saline. In group 2, the patients received 150 micrograms of clonidine diluted in 20 ml of isotonic saline injected into the knee joint. In group 3, the patients were given 20 ml of intra-articular isotonic saline and clonidine 150 micrograms was injected subcutaneously. In group 4, morphine 1 mg, diluted in 20 ml of isotonic saline, was injected into the knee joint. Postoperative pain was assessed in a double-blind fashion using a visual analogue scale (VAS) at 1, 2, 3, 6 and 24 h after the end of surgery. VAS scores were significantly lower in groups 2 and 4, compared to groups 1 and 3, at 1 and 2 h after surgery. The delay between intra-articular injection and further postoperative analgesic administration was significantly longer (P < 0.05) in group 2 (533 +/- 488 min) compared to groups 1 and 3 (70 +/- 30 min and 132 +/- 90 min, respectively). The difference was not significant between group 4 (300 +/- 419 min) and the other groups. We conclude that a low dose of intra-articular clonidine produces analgesia unrelated to vascular uptake of the drug. This study further supports a peripheral analgesic effect of clonidine.

Nasogastric tube placement (NTP) is no more systematically recommended in patients scheduled for elective colorectal surgery but could be necessary in case of postoperative vomiting. The aim of this study was to determine independent risk factors for NTP after colorectal surgery.We performed an observational study including 290 patients scheduled for elective colorectal surgery included in an enhanced recovery programme: immunonutrition, thoracic epidural analgesia, antiemetic prophylaxis, respiratory physiotherapy, absence of NT and drainage, forced mobilization and oral nutrition. The main outcome was the occurrence of vomiting requiring NTP. Univariate analysis included: age, sex, BMI, American Society of Anesthesiologist Physical Status Classification System (ASA), duration of surgery, epidural analgesia, and mobilization, intraoperative fluid, temperature, laparotomy, use of droperidol, parenteral nutrition, stoma, diabetes, hypertension or coronary disease, COPD, type of surgery. A logistic regression was performed to determine independent risk factors of NTP.Among the 290 patients included, 277 were analyzed. The incidence of NTP was 10.5% (95%CI [7.4-14.6%]). Univariate analysis documented BMI, low temperature in PACU (35°C), ASA scores, duration of surgery and epidural analgesia, rectal and sigmoid resections, diabetes, transfusion, no use of droperidol, duration of mobilization, conversion to laparotomy. Three independent risk factors were associated with NTP: temperature in SSPI35.5°C (OR: 14.49; IC95% [4.52-45.45], P0.0001), BMI21kg/m(2) (8.40; [1.99-35.71], P=0.0038) and lack of postoperative droperidol administration (3.37 [1.02-11.39], P=0.04).After colorectal surgery tolerance to rapid oral feeding is impaired by denutrition and postoperative hypothermia. The combined used of postoperative droperidol should also be considered to avoid postoperative NTP.

Developmental dyslexia is a frequent language-based learning disorder characterized by difficulty in reading. The predominant etiologic view postulates that reading impairment is related to phonological and orthographic dysfunction. The aim of this fMRI study was to evaluate the neural bases of phonological processing impairment in remediated dyslexic adults (DD). We used a rhyming words judgment task contrasted with an unreadable fonts font-matching judgment task to compare patterns of activation and functional asymmetry in DD and normal-reading young adults. We found evidence of a link between asymmetry in inferior frontal gyrus and performance during the phonological processing. We also observed that DD recruit a network including regions involved in articulatory control in order to achieve rhyme judgment suggesting that, due to a lack of hemispheric specialization, DD recruit the latter network to achieve rhyme judgment.

Extradural clonidine produces analgesia, with sedation, hypotension and bradycardia, in postoperative patients. This study assessed if oral yohimbine would reverse these side effects. We studied 30 ASA I-II patients undergoing orthopaedic surgery. After operation they were allocated randomly to three groups to receive placebo, extradural clonidine 450 micrograms or extradural clonidine 450 micrograms plus oral yohimbine 16 mg. Pain score was measured on a visual analogue scale (VAS); sedation was assessed on a simple scale graded from 0 (awake and alert) to 3 (deeply sedated, awakening after tactile stimulations) and heart rate and arterial pressure were monitored for 5 h. Yohimbine reversed the sedation induced by extradural clonidine, but also shortened the duration of analgesia (31 (SD 15) min, 186 (72) min and 126 (52) min in the placebo, extradural clonidine and extradural clonidine+yohimbine groups, respectively) (P0.05), and did not reduce the hypotension and bradycardia related to clonidine administration. These results suggest that alpha 2 adrenoceptors are mediators of the sedation induced by clonidine and that the haemodynamic effects are not related to stimulation of supraspinal alpha 2 receptors.

Autistic syndrome is defined by several abnormalities, mainly affecting social interaction skills. Disorders of the processes of processing facial and emotional stimuli, and particularly avoidance of gaze, have also been reported in this disorder. Some authors have suggested that these abnormalities may be explained, or at least contributed to, by the social disorder observed in this syndrome. The aim of this study was therefore to improve the understanding of the processes involved in perception AND the representation of faces expressing emotion in subjects with autism spectrum disorders (ASDs).Eleven children with ASDs (mean developmental age 7 years 11 months) and eleven normally developing children (mean age 7 years 9 months) took part in three experiments. The first involved overall discrimination of emotions using photographs of faces expressing six basic emotions, the second required local emotional discrimination on the basis of isolated elements of the face (photographs of eyes and mouths isolated from the rest of the face), and for the third the children were asked to create faces expressing emotions by means of a jig-saw puzzle format, using photographs of isolated elements of the face (overall representation necessitating local discrimination).Our findings revealed that the normally developing children had difficulties with the process of local discrimination of emotions: their performance improved when overall perception was possible. In contrast, and astonishingly, the children with ASD were more able to discriminate isolated eyes expressing emotion than the controls, but their performance declined when overall processing was required.Our results suggested that the emotional disorders observed in ASDs might be explained by greater skills in the processing of local information. This might explain the inability of children with ASDs to achieve coherent perception of their social environment and might also lead to the withdrawal that is characteristic of this disorder. These results also suggest that the gaze avoidance that is characteristic of individuals with ASDs is eliminated when eyes are presented alone. This gaze avoidance therefore seems to be related to the complexity and variability of this type of stimulus and not to the social nature of the stimulus.

In order to explore new types of jet ventilation, we tested a tracheal gas injection tube (TGIT) which included six thin capillaries and provided high pressure injection. The driving pressure was chosen to yield a plateau of inspiratory tracheal pressure of 10 cm H2O. An original controller was built to monitor spirometry and trigger injection in order to deliver both pressure controlled ventilation (PCVTGIT) and a new mode of inspiratory pressure support jet ventilation (IPSTGIT). The PVCTGIT mode maintained the same end-tidal carbon dioxide concentration as conventional ventilation with the same tidal and minute ventilation. We studied 10 patients after abdominal surgery. During spontaneous breathing, the patients were allowed to breathe through the tube, successively with and without IPSTGIT. IPSTGIT, compared with spontaneous breathing increased minute ventilation (from 5.7 (SD 1.6) to 7.1 (1.7) litre min-1) (P less than 0.001). It reduced the total work of breathing (from 0.625 (0.223) to 0.263 (0.151) J litre-1, respectively) (P less than 0.01) and the occlusion pressure (from 2.62 (1.28) to 1.36 (0.74) cm H2O, respectively) (P less than 0.01). It is concluded that this TGIT used with a specific system for sensing and triggering ventilation allows inspiratory pressure support during low frequency jet ventilation.

Summary Background Lung deposition is crucial for asthma treatment. However, there is no study comparing the potential role of lung co-deposition of combination therapy (inhaled corticosteroid and long-acting β2 agonist) in the same inhaler. In moderate to severe asthmatics, an extra-fine hydrofluoroalkane combination of beclomethasone dipropionate and formoterol given via a single pressurised metered-dose inhaler (pMDI) was compared with beclomethasone dipropionate chlorofluorocarbon (CFC) pMDI and formoterol dry powder inhaler (DPI) given via separate inhalers. Methods In a double-blind, double-dummy, 24-week randomised clinical trial, 645 patients with moderate to severe asthma uncontrolled by regular treatment with inhaled corticosteroids received regular treatment with extra-fine fixed combination beclomethasone dipropionate 200μg/formoterol 12μg bid, or beclomethasone dipropionate (500μg bid) via CFC pMDI and formoterol (12μg bid) via DPI, or beclomethasone dipropionate (500μg bid) via CFC pMDI. The primary outcome was morning peak expiratory flow (PEF). Secondary outcomes included lung function measured at clinic, asthma symptoms and control, exacerbations. Results Beclomethasone dipropionate/formoterol combination via single inhaler or via separate inhalers improved morning PEF. However, the combination via single inhaler was more effective than given via separate inhalers for asthma control. Both combination treatments were superior to beclomethasone dipropionate alone in improving lung function and asthma control. All treatments were well tolerated. Interpretation In patients with moderate to severe asthma, beclomethasone dipropionate/formoterol in a single inhaler was as effective as beclomethasone dipropionate plus formoterol and superior to beclomethasone dipropionate alone in improving lung function. For the first time with a single inhaler, beclomethasone dipropionate/formoterol was significantly superior to separate components for asthma control. This trial is registered with ClinicalTrials.gov , number NCT00476268 .

The objective of this study was to analyse the influence of hospitalisation on the polypharmacy of elderly people in internal medicine.Prescriptions before hospitalisation and after discharge were prospectively collected and analysed. The percentages of pharmaceutical medication classes used before and after hospitalisation were compared using marginal homogeneity's test for paired series.One hundred and sixteen patients (mean age: 79 years) were included in this study. The number of drugs prescribed amounted to 6.4 before hospitalisation and 6.7 at discharge. Hospitalisation did not lead to reduction in the amount of prescribed drugs but some medications were modified. We observed a significant reduction in beta-blockers (25 to 19.8%, P=0.035) and lipid-lowering drugs (21.6 to 15.5%, P=0.058). On the other hand, the laxative medication was increased at discharge (19.8 to 34.5%, P=0.001). Similarly, there was an increase in psycholeptic drugs after hospitalisation (34.5 to 44%, P=0.007).These results pointed out firstly the polypharmacy observed in elderly patients and secondly the difficulty to reassess prescriptions. Our results should heighten clinicians' awareness of polypharmacy of elderly patients and of the usefulness of performing an individual assessment of the various drugs prescribed to a patient. The hierarchical organisation of disorders and drugs should allow to optimise the safety of the medications and decrease iatrogenic events.

Twenty patients were randomly anaesthetized with either thiopental 5 mg/kg followed by a 15 mg/kg/h continuous infusion, or propofol 2.5 mg/kg followed by a 9 mg/kg/h continuous infusion, paralysed with vecuronium 0.1 mg/kg, intubated and ventilated with nitrous oxide 50% in oxygen. Fifteen minutes after induction, fentanyl 5 micrograms/kg was injected. Inspiratory tracheal pressure (PT), gas flow (V) and volume (V) were continuously measured while the lungs were inflated with a constant inspiratory flow ventilator. Respiratory compliance (Crs) and resistance (Rrs) were calculated from the regression of PT on V. In both groups Crs decreased following anaesthesia. Fentanyl injection elicited an increase in Rrs (from 1.04 +/- 0.70 to 1.63 +/- 0.92 kPa x l-1 x s) and a further decrease in Crs (from 0.55 +/- 0.30 to 0.42 +/- 0.10 l x kPa-1) in the thiopental group but not in the propofol group (Rrs: 1.26 +/- 0.69 to 1.08 +/- 0.44 kPa x l-1 x s, Crs: 0.49 +/- 0.11 to 0.48 +/- 0.13 l x kPa-1). These results suggest that the dose of propofol administered in this study may prevent fentanyl-induced bronchoconstriction.

Nocardiosis is an uncommon infection, which is exceptionally present as a postoperative event. A case of postoperative pulmonary and cerebro-meningeal infection caused by Nocardia otitidiscaviarum after a leg amputation in a diabetic patient is reported. Diagnosis has been delayed and the clinical, radiological and microbiological causes of this delay are assessed from a quality of care management point of view. Recommendations are proposed regarding physicians' role and optimized microbiological procedures for recognition of slowly growing nocardial strains.

Obesity and insulin resistance are directly associated with the presence of microalbuminuria. However, the prospective relationship between abdominal adiposity and the occurrence of micro-albuminuria has been little studied in a non-diabetic population. From the DESIR cohort, we examined whether waist circumference was associated with the incidence of micro-albuminuria at 6 years (D6). The study evaluated 2738 non-diabetic subjects without micro-albuminuria at inclusion who were then followed prospectively. At 6 years, 254 individuals (9.3%) had developed pathological micro-albuminuria (or =20 mg/l) measured at micturation. In both sexes, the incidence of micro-albuminuria was associated with increased waist circumference and blood pressure, but not with blood glucose levels, lipid parameters or body mass index. Subjects with a higher waist circumference at inclusion were at a higher risk of having micro-albuminuria at 6 years compared to those with a normal waist circumference. Logical regression analysis showed that waist circumference as a continuous value, or greater than 94 cm for males and 88 cm for females, were predictive factors for the incidence of micro-albuminuria, after adjustment for age, hypertension, ACE inhibitor usage, fibrinogen, and blood glucose level. Abdominal adiposity is thus linked in both sexes to the development of microalbuminuria, which underlines the importance of measuring waist circumference when assessing risk factors for renal lesions in non-diabetic hypertensives.

The treatment of pressure ulcers complicated by osteitis in patients with paraplegia is often complex. Surgical debridement of a pressure ulcer and infected bone often creates a large wound that is left to heal by either secondary intention or covered with a flap (immediately or later). Topical negative pressure (TNP) therapy, delivered using the Vacuum Assisted Closure device (KCI International, the Netherlands), is a non-invasive technique for healing by negative pressure. We report its use in the treatment of large wounds following segmentary resection of osteitis of the lower limbs in two paraplegic patients.

To provide up-to-date and covariate-specific estimates on tobacco smoking prevalence in a representative cohort of French human immunodeficiency virus (HIV) 1 infected patients in 2002.We conducted a cross-sectional analysis of the Aquitaine Cohort of HIV-infected patients. A logistic regression model was used to estimate associations between regular tobacco smoking and sex, age, HIV transmission categories, duration and immuno-virological status of HIV infection and duration of antiretroviral therapy. Smoking prevalence estimates were compared with the general French population values after stratification on age and sex.Among 2036 patients included in the analysis, 51% were regular smokers (95%CI 49-53). Smoking prevalence was significantly higher with younger age (OR 1.7 among thoseor = 45 years of age), among injecting drug users (OR 4.3), among those whose infection was not controlled (OR 1.2) and those whose HIV infection had been diagnosed foror = 5 years (OR 1.5). The main difference with the general population was the peak smoking prevalence among HIV-positive patients infected through injecting drug use.HIV-infected patients are highly exposed to tobacco smoking, which is implicated in multiple conditions occurring in the course of HIV infection. Adapted smoking cessation programmes should become one of the priorities of the medical care of HIV-infected individuals.

Postobstructive pulmonary oedema is a complication after extubation that occurs rarely . It can be associated with haemoptysis. We report two cases of haemoptysis occuring in ASA 1 otherwise healthy patients who underwent uncomplicated anaesthesia. Understanding of the mechanism and prompt treatment lead to rapid recovery of this dramatic complication.

The authors report the case of a complex defect of the penis in children. Vacuum-Assisted Closure therapy as been shown to be very effective in enhancing wound debridement and the rate of granulation tissue formation. Complete closure of this complex wounds was obtained with a bilateral scrotal flap.

The Becker's muscular dystrophy is a genetic myopathy due to mutations of the dystrophin gene, located in the Xp21 region, with a clinical expression usually occurring in young adults.We report an atypical case of late onset Becker's muscular dystrophy diagnosed at the age of 57. The patient suffered from mild skeletal muscle involvement revealed by the use of statins and fibrates, associated with severe dilating cardiomyopathy. The DNA analysis showed a deletion of the exons 11-13 in the Xp21 gene.The diagnostic of Becker's muscular dystrophy must be considered in all patients with persistently elevated CPK and/or primitive dilated cardiomyopathy, whatever the age of the patient.

To analyse the causes of death among HIV-infected adults in France in the year 2000.Based on data from a national survey, our study describes and analyses the causes and characteristics of patients with immunological and virological response (CD4200/mm3, ARN-HIV500 copies/mL), who died during antiretroviral treatment.Among a total of 964 deaths registered, data on 864 cases were available for analysis. One hundred forty-nine patients (17%)were immunovirological responders. The underlying causes of death were non AIDS-defining malignancies for 36 (24%), mainly due to lung cancer (16 cases), hepatocarcinoma (7) and ano-rectal carcinoma (3), AIDS for 22 (15%), mainly due to Non Hodgkin Lymphoma (10 cases) and uterine cancer (3), cardiovascular diseases for 22 (15%), post hepatitis C hepatic failure for 16 (11%), suicide for 16 (11%), and bacterial infections for 14(9%). When comparing characteristics of death in the 149 responders versus the 715 other patients, the responders were significantly more frequently: co-infected by HCV+ (45 vs. 33%), injected drug addicts (40 vs. 27%),alcoholics (38 vs. 28 %), and dyslipidemics (19 vs. 11%). In 2000,around 20% of registered deaths of HIV patients in France had occurred among good immunovirological responders.To further reduce mortality among such efficiently treated patients, attention must be focused on treatable conditions such as hepatitis C, dyslipidemia and on the prevention of malignancies such as lung cancer and cervical or ano-rectal carcinoma.

Addiction behaviours in the anaesthetist population have been recognized as a significant health-related issue and its scope is a matter of concern.A national survey conducted among French anaesthetists consisted of a questionnaire designed to elicit information related to demographics, and work conditions, as well as substance consumption status. The study investigated the following: tobacco, alcohol, tranquillizers-hypnotics, and other agents such as cannabis, cocaine, opiates and anaesthetic agents. Respondents were classified in two categories: (no use and use)-(abuse and dependence). An univariate and multivariate analysis were performed to determine risk factors associated with drug abuse and dependence.3,476 physicians responded to the questionnaire (38.0% response rate); 22.7% were daily tobacco smokers; 10.9% were abuser or dependent to one or more substances other than tobacco i.e. alcohol (59.0%), tranquillizers and hypnotics (41.0%), cannabis (6.3%), opiates (5.5%), and stimulants (1.9%). Sleep disturbances and negative perception of work environment were more frequently reported among addicted anaesthetists.In French anaesthetists, addiction is mainly related to alcohol consumption but includes a broad spectrum of substances. Addicted subjects report issues around work environment that may have contributed to the development of their pathology.

Portal vein thrombosis (PVT) seems rare among HIV infected patients. Even though, the report of such cases is of great interest because it may help to determine the factors of occurrence. We describe cases of PVT in 4 HIV-infected men, aged 32 - 64. Two of them were co-infected with hepatitis C virus (HCV). The four patients had a history of disseminated mycobacterial infection (one case of tuberculosis, 3 cases of mycobacterium avium complex infection) with abdominal lymphadenitis. Despite HAART, their immunodeficiency was profound (CD4: 65 to 216/mm(3)). At the time of diagnosis, two patients were treated with protease-inhibitor containing regimen: indinavir (one case), ritonavir-saquinavir (one case). PVT was revealed by haematemesis (one case), abdominal pain (ome case), anasarca (2 cases). In three patients, the diagnosis of PVT was confirmed by imagery (echo-doppler or angio- RMI), and for the last patient, PVT was found during the transjugular intrahepatic portosystemic shunt setup. A low level of C protein was diagnosed in one case. Cirrhosis was not found in HIV-HCV co-infected patients. Two patients died early after diagnosis, one patient died 3 years after the onset of symptoms. Various factors may cause the development of a PVT in HIV infected patient. Serious immunodeficiency, opportunistic infections such as tuberculosis and mycobacterium avium complex related infection with abdominal lymphadenitis can further the development of PVT. Protease-inhibitor might have facilitated the process. Due to the severe prognosis of advanced cases, early evocation of diagnosis is needed.

To describe efficacy and safety in clinical practice of pegylated interferon plus ribavirin (INFpeg-Riba) in the treatment of hepatitis C viral infection (HCV) in HIV infected patients.Monocentric retrospective study with inclusion of all patients who received at least once INFpeg-Riba before April 1st 2003. All patients were followed up to six months after the end of HCV therapy.Thirty two HIV-positive patients (23 men and 9 women) with chronic hepatitis C treated by INFpeg-Riba were included. The mean age was 43 years. Fourteen patients carried HCV genotype 2 or 3 (43 %) and 18 patients carried genotype 1 or 4 (57%). The Metavir score of fibrosis showed fibrosis F1 (N =3), F2 (N =14), F3 (N =7) and F4 - cirrhosis (N =8). Twenty six patients (81%) were naive for anti hepatitis C drugs. Thirty one per cent of patients were at AIDS stage and 84% were receiving antiretroviral drugs. The mean CD4 cell count was 469 /ml and the plasma RNA HIV was less than 50 copies /ml in 57% of the cases. Adverse events leading to reduction of dose of drugs occurred in 40% and adverse events leading to discontinuation treatment occurred in 12%. A decline of CD4 cell count200 CD4/ml was observed in 15%. Clearance of HCV-RNA in end of treatment was seen in 46 % and sustained virological response in 34 %. The main predictors of sustained virological response were HCV genotype 2 or 3 (P =0.04) and plasma HIV RNA less than 50 copies/ml (P =0.001). The predictive value of good virological response of a CD4 cell count350/ml before treatment was very near the statistical significancy (p =0.07).The efficacy of pegylated interferon plus ribavirin in HIV-HCV co-infected patients is disappointing mainly due to a poor tolerance. In addition to HCV genotype, plasma HIV RNA level and CD4 cell count were essential to predict INFpeg-Riba response and should be taken into account in the process leading to the initiation of such therapy in HIV-HCV co-infected patients.

Polydactyly is the most common congenital limb anomaly occurring both as an isolated defect or as part of a syndrome. However mirror foot is an exceptional abnormality (14 cases reported). The authors describe two sporadic cases of mirror foot. The first case presents a mirror polydactyly of the left foot, an hexadactyly of the right foot and a central polysyndactyly of both hands. The second case presents a mirror polydactyly of both feet. Mirror foot is a very rare defect. Both sporadic and familiar cases have been reported. This malformation can affect one or both feet. Some cases are associated with other congenital anomalies. The definition of mirror foot is warying according to the authors and the review of literature shows an important variability in the patterns of mirror polydactyly. Mirror duplication of hands and feet result of aberrant positioning of the zone of polarizing activity in relation to the apical ectodermal ridge during limb bud development. Different genes encoding limb pattern have been described.

We report two cases of sudden increase in Bispectral Index (BIS) after the injection of low-dose ketamine for the prevention of postoperative hyperalgesia. The two patients were anaesthetised with a continuous infusion of remifentanil associated with propofol for one and isoflurane for the other. Changes in BIS occurred while the two patients were in a stable phase of surgery (beginning of parietal closure and suture of an anastomosis) and had a stable target concentration of anaesthetic agents. No others signs of awakening were observed. The BIS value returned progressively to 40-50 despite no increase in target concentration. None of the patients complained of intra-operative recall.

Symptomatic lactic acidosis requiring intensive care is a rare and severe adverse event related to the mitochondrial toxicity of the nucleoside analog reverse transcriptase inhibitors (NRTIs).We retrospectively investigated the clinical and biological features of HIV-infected patients who developed severe lactic acidosis syndrome at the University teaching hospital of Bordeaux and the regional community hospital, during 1996-2000.Nine patients were identified (incidence: 0,9/1000 NRTI treated patient-years), 4 men and 5 women with a median age of 36 years. They had a moderate immunodeficiency (median CD4+ T lymphocyte counts: 197/mm(3)) and only one of them presented a virological failure. The causes of hospital admission were abdominal pain (n = 6), dyspnea (n = 6), asthenia (n = 5), jaundice (n = 4), and vomiting (n = 2). Hepatomegaly was present in 6 patients. Lactic acidosis was found in all cases: median pH: 7.28, bicarbonate: 12 mmol/l, anion gap: 27 mEq/l, plasma lactic acid: 13 mmol/l. Cytolysis (n = 8), cholestasis (n = 6), hepatic failure (n = 4), rhabdomyolysis (n = 4) and pancreatitis (n = 2), were also present. Despite medical intensive care, seven patients died. The only two post-mortem examinations revealed severe hepatic steatosis. Median duration of NRTI therapy was 4 years. At presentation, five patients were receiving lamivudine, five didanosine, four stavudine and three zidovudine. Six patients were coinfected by HCV and/or HBV, four had chronic renal failure and five an immediately preceding infectious disease.The prognosis of lactic acidosis is severe. Nucleosid-analog therapy needs clinical and biological monitoring, specially in patients with comorbidities.

The commercial introduction of atypical antipsychotics (AAP) constitutes a considerable step forward in the sense that it has led to a world-wide reappraisal of the established treatment strategies for people with psychoses (including schizophrenia and affective psychoses). They have allowed refinements in the pharmacologic management of psychoses but they have a higher acquisition cost than conventional neuroleptics. The cost of the newer AAP had a substantial effect on medical resources: the AAP account for only 43.2% of neuroleptic prescriptions, but 76.1% of medical costs associated with neuroleptic drugs, and in terms of treatment costs, a reduction (50%) was found with risperidone compared with olanzapine for a same number of treated patients. The aim of this paper was to examine the use of these drugs, to compare them and to assess their impact within the context of psychiatric hospital practice, by means of analysis of prescribing practices for amisulpride, clozapine, olanzapine and risperidone for all treated patients. We conducted an observational, naturalistic study at Charles Perrens psychiatric Hospital in Bordeaux (France) that reproduced the clinical conditions in which these new drugs are used. Four photographies of all the medical prescriptions concerning atypical antipsychotic drugs were done between October 1999 (four months after the introduction in France of the olanzapine, the last of the new antipsychotics) and June 2001 (n=682 prescriptions). The total amount of these prescriptions corresponded to 527 patients. Treatment groups were compared - first overall and after by considering 2 groups: psychotic and non-psychotic patients - through descriptive analyses of sociodemographic characteristics of patients, diagnosis, percentages of patients receiving concomitant psychotropic medication and/or receiving treatment-emergent side effects and mean dosages of AAP therapy according to concomitant medication. In the same way, we compared the four AAP through their prescribing practices'evolution during the four survey.AAP drugs account for 43.2% of prescriptions (and conventional neuroleptics 56.8% of them). We recorded a significant increase between the four surveys (p0.02): 36.6% at the beginning to 47.8% at the end of the study. From the 682 collected prescriptions, 72 (10.6%) included clozapine, 130 (19.1%) amisulpride, 229 (33.6%) olanzapine and 251 (36.8%) risperidone. Sixty five percent of AAP prescriptions involved psychotic patients. A relative stability in characteristics of AAP prescriptions during the four surveys was found. So, no significant differences were observed between amisulpride, olanzapine, risperidone, in terms of age, sex, sociodemographic characteristics, unlike clozapine. However, there were statistical differences between all the AAP in the concurrent use of other neuroleptic agents (p0.02), hypnotic drugs (p0.006), mood stabilizer drugs (p0.03), and anticholinergic drugs (p0.007). Statistically, the mean dosage of amisulpride increased when a mood stabilizer drug was coprescribed (p0.0007), but it decreased with an antidepressant drug (p0.004) or an hypnotic drug (p0.02); clozapine 's one decreased every time an antidepressant drug was coprescribed (p0.02); with olanzapine, there was a significant increase every time an other neuroleptic agent (p0.03) or an anticholinergic drug (p0.006) was associated; then for risperidone, the mean dosage increased with the coprescription of an other neuroleptic agent (p0.00002), an anticholinergic (p0.00003) or an adrenolytic drug (p0.04). The pattern of prescribing practices that emerges from our four surveys suggests that these new AAP are significantly more and more often associated with a stabilizer mood drug (p0.009) (particularly the olanzapine) or/and an anxiolytic drug (p0.05) (like the amisulpride in particular). Considering the four AAP globally, but more with the risperidone, the association with a neurovegetative corrector agent decreased (p0.004) during the four surveys. Then, concerning the psychoticng the four surveys. Then, concerning the psychotic patients, the AAP were significantly more often associated with other neuroleptic agents (p0.03), the amisulpride in particular, with anticholinergic drugs (p0.00005), but significantly less with mood stabilizer drugs (p0.00003) principally the amisulpride and the risperidone, with antidepressant drugs (p0.02) particularly the risperidone. This kind of survey, however it is too much rare, is very important because it shows the clinical conditions in which these new drugs are really used. The results show that AAP appear to be the replacements of the older neuroleptics used in the treatment of psychoses, including particularly schizophrenia, but also in the treatment of mood disorders, and they reflect actual clinical practices. Other surveys must be achieved to see if our study confirms the general trend concerning the use of these drugs and so as to reassess these prescribing practices.

This study presents a tool including survey questionnaires and a specific data-processing software for the data processing, allowing health care providers to assess the quality of postoperative pain management in surgical wards.Descriptive study.A committee including anesthesiologists, nurses and epidemiologists had elaborated and tested three survey questionnaires to assess patients, nurses and medical staff satisfaction respectively. Specific data processing software was issued out of the final questionnaires. It allowed a quick analysis of items possibly, explaining inadequate postoperative pain management. After this adjustment, this tool was used in three different surgical wards, named A, B, C.The rate of answer (of investigated persons) being over 50%, data resulting from the survey performed in the surgical wards A and B were considered valid. The items which could explain insufficient pain relief were classified into 4 levels: patients assertion (ex: more than 50% of patients experienced persistent postoperative pain); practices evaluation (ex: 42 to 72% health care providers declared being aware of analgesic procedures); behavior's evaluation (ex: 19 to 34% of health care providers considered persistent postoperative pain to be useful for monitoring); and surgical wards potential (ex: 21 to 61% of health care providers took a specific course on pain management). Pros and cons of this tool were carefully examined and subsequent strategies defined.This survey's device should allow health care providers to assess the quality of postoperative pain management in surgical wards. Its validation is currently developed to improve its use, and keep the most performing indicators, showing an adequate postoperative pain management.

We assessed the correlations between some plasma markers of immune activation (soluble receptors of interleukin 2 (sIL2-R) and TNFap75 (sTNFII-R) and usual markers of HIV infection in patients treated with protease-inhibitors (PI). Forty-six PI-naive HIV-1-infected adults were included in a 1-year prospective cohort from the initiation of a P1-containing regimen (M0). Measurements of CD4+cell count, plasma HIV-RNA, sIL2-R and sTNFII-R were performed at M0, M6, and M12. The evolution of sIL2-R from baseline to M12 was significantly different between immunological responders (IR) (CD4+count above 200/mm3 for subject having less than 200 CD4 +/mm3 at inclusion, or increase of at least 50 CD4+/mm3 for others) (58 UI/ml) and non-IR (+28 UI/ml) (P =0.01). The evolution of sTNFII-R between M0 and M12 was significantly different between virological responders (VR) (plasma HIV-1 RNA less than 500 copies/ml at M12) (-2.5 ng/ml) and non-VR (+0.2 ng/ml) (P = 0.02). Our study shows significative correlations between the evolutions of soluble interleukin-2 and TNFR-II receptors and those of CD4+T-lymphocytes or HIV-RNA responses in patients under HAART.

The demand for organ transplantation exceeds organ donation in France and refusal to organ donation remains close to 30%. This study analysed risk factors associated with refusal of organ donation.Retrospective study.All potential organ donors registered by the French transplantation agency between 1996 and 1999 were included, excepted those with a contraindication to organ procurement or a logistic problem: 5,911 donors were included.Data analysed were those collected routinely on the French database. A logistic model was used to identify statistically significant factors and a stepwise procedure was performed to identify independent factors linked with refusal.In univariate analysis, age60 years and age13 years, stroke, lack of suicide, localisation in an university hospital and in others regions than the Centre-East of France were associated with a higher refusal rate. Year of harvesting, low level of organ procurement activity were not associated with refusal. In multivariate analysis, factors independently associated with refusal were age60 years [Odds-Ratio (OR) = 1.2)] or age13 years (OR = 1.5), stroke (OR = 1.2), meningitis and cranial tumour (OR = 1.4), suicide (OR = 0.5) and others French regions than Centre-East.The risk factors described should be taking into account when family's members are approached for donation. They represent the interactions between the history of the donors, harvesting organisation, and sociocultural factors.

A retrospective study was set up to investigate active pathologic processes associated with sarcoidosis diagnosed in 32 patients.Eighteen patients had two identified granulomatous localizations (56%) and 14 patients had three localizations or more (27%). Comorbidity was noticed in nine patients (28% of cases). Sarcoidosis was associated with an infectious disease five times (hepatitis C virus [HCV] infection three times, including one case after recombinant interferon alpha therapy, and HIV and HCV co-infection two times). The association of sarcoidosis with a chronic immunologic inflammatory disease was noticed four times (lupus erythematosus two times, myasthenia and primary biliary cirrhosis). Finally, in two cases sarcoidosis was associated with a neoplasia (non-Hodgkin's lymphoma in a co-infected HIV-HCV patient, ovarian cystadenocarcinoma in another patient). Sarcoidosis preceded or revealed the comorbidity four times.

Local anaesthetics used for regional anaesthesia inhibit impulse depolarisation through blockade of sodium channels. Regional anaesthesia accounts for 20% of all anaesthetic procedures performed in France. Spinal anaesthesia is the most common technique used peroperatively, while epidural anaesthesia is used in labouring women and for postoperative pain control. Nerve stimulation allows a safer an easier approach to peripheral blocks. Regional anaesthesia is mainly indicated for limb or eye surgery, and for mildly invasive surgical procedures. Regional anaesthetic techniques are the most efficient to control postoperative pain and to facilitate patient rehabilitation. The risk related to the practice of regional anaesthesia compares with that of general anaesthesia and is thus very low. Main complications are epidural haematoma, cardiac arrest due to inadvertent intravascular injection of local anaesthestics, and peripheral nerve damage. Regional anaesthesia requires the same technical environment and careful monitoring as general anaesthesia.

In order to determine prognostic factors associated with treatment failure (TF) in advanced HIV-infected patients treated with a regimen including indinavir, a prospective cohort study of 80 patients was set up between 1 March and 31 December 1996. TF time was calculated using the Kaplan-Meier method, from treatment induction to the first of the following events: treatment modification for adverse event or lack of significant virological and/or immunological response, AIDS-defining diagnosis or death. Date of point was 31 December 1998. Multivariate analysis was performed using a Cox model. At baseline, 60% of the patients were AIDS-free, median viral load and CD4+ count were respectively 4.8 log/ml and 79/microl. After a median follow-up of 26 months, 70% of the patients experienced a TF in a median time of 8 months. Seventy-two per cent presented an hyperbilirubinaemia (2 mg/dl). In multivariate analysis, initial AIDS stage (hazard ratios [HR]=1.94, P=0.04) and digestive intolerance (HR=2.32, P=0.003) were predictive of TF. Conversely, hyperbilirubinaemia was associated with a better outcome (HR=0.35, P0.0001). These 2 latter parameters very likely reflected patients' treatment compliance.

Cytomegalovirus (CMV) infection in non-immunocompromised adults can sometimes induce hematological and immunological disorders that may mislead diagnosis.Case reports of hospitalized non-immunocompromised adults with positive serology for CMV including the presence of immunoglobulin M or seroconversion were assessed in a retrospective study (1981-1998). We focused on clinical and biological abnormalities showing the role of CMV in disruption of functioning of hematological and immunological systems.Among 115 patients, lymphoma-like syndrome with large adenopathies and/or splenomegaly was diagnosed in eight patients, uncovering underlying CMV infection. Lymphoma was accompanied by hematoma in two patients. Three patients presented leg purpura (with thrombotic thrombocytopenic purpura in one case), one patient had cutaneous vasculitis and on other a Still's disease. Blood abnormalities were mononucleosis (64%), anemia (20%), and thrombopenia (25%) often of peripheral or hemolytic origin or due to hypersplenia. Electrophoresis of serum proteins showed an increase in immune globulins in 56% of the cases and monoclonal abnormality in nine cases. Immunological assessment was conducted in 18 patients. At least one abnormality was depicted in ten patients, consisting of either antinuclear, anti-platelet or anti smooth muscle antibodies, cryoglobulinemia, rheumatoid factor, or reduced complement fixation.Testing for CMV infection can be of value in case of blood or immunological disorders associated with clinical or biological signs. Although hematological disorders occur early, they are rarely severe. Immunological disorders are rarely symptomatic, but often raise issues regarding the potential genesis of immune diseases in at-risk patients.

Clonidine or epinephrine are frequently combined to epidural local anesthetics to strengthen sensory block and prolong analgesia. Both drugs impair the hemodynamic profile of central neural blockade but the effects of their combination on arterial pressure and heart rate are not known and were examined in this double-blind prospective randomised study. Forty four patients scheduled for lumbar disc surgery were allocated to two groups. Epidural anesthesia was obtained by administration of 150 micrograms clonidine in 15 ml bupivacaine 0.25% solution without (group C) or with (group C + E) 37.5 micrograms epinephrine. Systolic, mean, diastolic arterial pressure and heart rate were measured throughout the study. Combined epidural and general anesthesia induced a significant decrease in arterial pressure and heart rate in both groups. SAP and MAP decreased significantly less in the patients receiving epinephrine. Low dose epidural epinephrine decreases arterial pressure instability during combined epidural and general anesthesia.