Search

Introduction: Few data on the educational needs and practices of the French hospital doctors have been obtained through surveys. Considering that the CME information is now available on www.cnfmc.fr and that providers were accredited, we investigated, on a representative sample of hospital doctors, the CME practices and the knowledge of the CME system., Methods: A questionnaire was prepared during 2 working sessions organised by TNS Healtcare Sofres in July 2007. A sample of 300 doctors was set to be representative of hospital doctors through the 5 main regions, and hospital types. Telephone numbers were dialled by an automat in respect of the objectives of quotas. Questionnaires were administered by telephone between August 30 and September 7, 2007, and done by trained operators., Results: Among the 300 interviewed doctors, 218 (73%) were from general or specialised hospitals and 82 (27%) were from Universitary hospitals. They were equally installed all over France. Their specialties were: medicine 130 (43%); biology 51 (17%); pharmacy 45 (15%); surgery 15 (5%); psychiatry 9 (3%); others 49 (16%) including emergency and radiology. Among the 300 doctors, 125 (42%) declared having continuing education for more than 10 days per year, 122 (41%) between 6 and 10 days per year, and 51 (17%) less than 5 days, 2 (<1%) did not answer. 214 (71%) doctors were subscribing medical specialised or general journals, and 86 (29%) did not subscribe to any journal. For the sessions called " présentielles ", about 65% of the funding of the pedagogic expenses, the travel and housing were supported by the doctors and hospitals. The pharmaceutical industry supported 25% of these expenses. To the question " did you performed a clinical audit in your hospital? ", 75 (25%) answered yes (16% for the 82 doctors in Universitary hospitals, and 29% for the 211 doctors in general hospitals), 210 (70%) answered no, including the 134 (45% of the 300) who said that it was programmed. 15 (5%) did not answer. The educational methods that were preferred were congresses, and interactive workshops were demanded for the future, as well as the e-learning methods. Among the 300 doctors, 165 (55%) had organisational difficulties for their education, 143 (48%) had personal difficulties such as availability, and 135 (45%) had financial difficulties. 54 (18%) had no difficulty at all for their education., Discussion: This survey through telephone interviews of 300 hospital doctors showed that they followed many educational programmes, and they had difficulties to organize their education, with personal and financial difficulties. The e-learning development could be a solution that gives facilities to doctors.

Objective: The objective of the study was to describe the surgical anatomy of infraureteral parametrium., Study Design: Findings of laparoscopic dissections during 12 type III radical hysterectomies were compared with findings obtained by bilateral pelvic dissections of 5 fresh and 5 embalmed female cadavers and to magnetic resonance imaging of 10 healthy controls., Results: Two anatomical entities of the parametrium were distinguished: (1) the lateral mesometrium corresponding to the blade containing vessels and lymph nodes of the uterus; and (2) the infraureteral parametrium extending dorsally from cervix and vagina. The lateral paracervix classically described under the ureter was never identified. Infraureteral parametrium appeared as a fibrous tissue extending in a lateral, dorsal, and caudal direction on both sides of the rectum and very close to the pelvic plexus., Conclusion: Our results attest to the absence of infraureteral parametrium, raising the issue of the surgical relevance of radical hysterectomy classification and the redefinition of the concept of radical hysterectomy.

Objective: The aim of this study was to assess hourly fetal urine production rates (HFUPRs) and establish a nomogram by measuring bladder volumes with 3-dimensional ultrasound., Study Design: Fetal urine bladder volume was estimated in 167 normal singleton pregnancies with neither oligohydramnios nor polyhydramnios, at a gestational age of 20-41 weeks. HFUPR was estimated in a regression analysis that included at least 3 volumes calculated during the filling phase with the Virtual Organ Computed-aided AnaLysis (VOCAL) technique. We estimated interoperator variability for HFUPR less than 10 mL/h and HFUPR greater than 10 mL/h., Results: Fetal urine production rates at 25, 30, 35, and 40 weeks were 7.5, 22.2, 56.1, and 125.1 mL/h, respectively. The intraclass correlation coefficients for interoperator variability were 99.2% for HFUPR less than 10 mL/hour and 97.1% for HFUPR greater than 10 mL/h., Conclusion: Prenatal measurement of HFUPR with 3-dimensional VOCAL ultrasound is reproducible and may help to determine the cause and prognosis of amniotic fluid volume abnormalities.

We conducted a large nationwide postal survey to estimate the prevalence of chronic pain with or without neuropathic characteristics in the French general population. A questionnaire aimed at identifying chronic pain (defined as daily pain for at least 3 months), evaluating its intensity, duration and body locations, was sent to a representative sample of 30,155 subjects. The DN4 questionnaire was used to identify neuropathic characteristics. Of the questionnaires, 24,497 (81.2%) were returned and 23,712 (96.8%) could be assessed. Seven thousand five hundred and twenty-two respondents reported chronic pain (prevalence=31.7%; [95%CI: 31.1-32.3]) and 4709 said the pain intensity was moderate to severe (prevalence=19.9%; [95%CI: 19.5-20.4]). Neuropathic characteristics were reported by 1631 respondents with chronic pain (prevalence=6.9%; [95%CI: 6.6-7.2]), which was moderate to severe in 1209 (prevalence=5.1% [95%CI: 4.8-5.4]). A higher prevalence of chronic pain with neuropathic characteristics was associated with middle age (50-64 years), manual professions and those living in rural areas. It was more frequently located in the lower limbs and its intensity and duration were higher in comparison with chronic pain without neuropathic characteristics. This large national population-based study indicates that a significant proportion of chronic pain patients report neuropathic characteristics. We identified distinctive socio-demographic profile and clinical features indicating that chronic pain with neuropathic characteristics is a specific health problem.

Objective: Since July 2006, it has been recommended to give a booster of a pertussis vaccine to women just after delivery, if they have received their last dose more than 10 years before. The aim of this study was to evaluate the pertussis vaccine coverage in a cohort of women just after delivery., Patients and Methods: All patients (n=31) hospitalized in postpartum unit on the 15th September 2006 were included in the study. They were submitted a questionnaire and medical records available in the department were reviewed., Results: The vaccination coverage was not indicated in any medical records. Only six patients claimed they knew their pertussis vaccination status (less than five years: two patients, between five and 10 years: two patients, more than 10 years: two patients). Two patients had their vaccination booklet. The pertussis vaccine coverage is probably very low., Discussion and Conclusion: The information about pertussis vaccine status in postpartum women is not available currently because it is not recorded by medical team and is unknown by patients themselves. An effort in educating obstetricians and corrective actions are necessary if we want the recent vaccine schedule to be followed.

Background: The objective of this study was to assess efficacy and determine the optimal indication of selective arterial embolisation (SAE) in patients with life-threatening post-partum haemorrhage (PPH)., Methodology/principal Findings: One hundred and two patients with PPH underwent SAE and were included from January 1998 to January 2002 in our university care center. Embolisation was considered effective when no other surgical procedure was required. Univariate and multivariate statistical analysis were performed. SAE was effective for 73 patients (71.5%), while 29 required surgical procedures. SAE was effective in 88.6% of women with uterine atony that was associated with positive outcome (OR 4.13, 1.35-12.60), whereas caesarean deliveries (OR 0.16, 0.04-0.5) and haemodynamic shock (OR 0.21, 0.07-0.60) were associated with high failure rates, 47.6% and 39.1%, respectively., Conclusions/significance: Success rate for SAE observed in a large population is lower than previously reported. It is most likely to succeed for uterine atony but not recommended in case of haemodynamic shock or after caesarean section.

Introduction: Ovarian cancer is the leading cause of death from gynaecological malignancy, especially because of late diagnosis. The objective of the study was to provide the clinician with current concepts regarding prevention of ovarian cancer., Material and Methods: A computerized search of articles published was performed using the Medline database We performed a review of the literature (PubMed, Embase) using the following search terms (MeSH and non-MeSH): prevention, chemoprevention, chemoprevention, ovarian cancer, ovarian, ovary, carcinoma, tumor, tumour., Results: Oral contraceptive and acetaminophen use may provide substantial protection against ovarian cancer, whereas aspirin, carotenoids and non-steroidal anti-inflammatory agents do not decrease the risk. However, to date, there is no recommendation concerning low risk population. At the opposite, young women (<35-40 years old) presenting with BRCA1 or 2 mutation or Lynch syndrome may be counseled for chemoprevention using oral contraceptive. For high risk women over 35-40 years old, prophylactic bilateral salpingo-oophorectomy should be performed. Indeed, it has been showed that prophylactic surgery significantly decrease mortality rates in high risk women., Conclusion: Large randomized studies are required to assess the efficacy of ovarian cancer chemoprevention in low risk women. High-risk women over 35-40 years old should be counseled for prophylactic salpingo-oophorectomy or for chemoprevention using oral contraceptive.

Our aim was to assess the long-term outcomes of infants born out of a pregnancy complicated by unexplained polyhydramnios. We retrospectively analysed a cohort of 173 singleton pregnancies with polyhydramnios. There were 24 singletons with unexplained polyhydramnios, defined as polyhydramnios where prenatal testing was negative. Infants were examined by a paediatrician at a median age of 12 months (range 12-64 months). Of the 24 infants, 19 (79%) had a normal outcome. West syndrome, polyuria and pulmonary stenosis were diagnosed in three children during follow up, while there were two perinatal deaths. Paediatric follow up of children born out of pregnancies complicated by unexplained polyhydramnios should be carried out systematically.

Objective: To determine preoperative risk factors of postoperative voiding dysfunction after tension-free vaginal tape (TVT) procedure., Methods: In 2004, 100 patients with genuine stress urinary incontinence underwent surgery by the TVT procedure. Preoperative and postoperative urodynamic study was performed for each patient. Postoperatively, patients' perception of result and quality of life were assessed on two validated scales, namely, Mesure du Handicap Urinaire (MHU) and Ditrovie. Voiding dysfunction was defined by a postoperative peak flow rate of <15 ml/s at 3 mo. Clinical and urodynamic parameters were compared and analysed., Results: At 3 mo, 20 patients (20%) showed evidence of voiding dysfunction despite the absence of clinical symptoms in 14 of them (70%). Multivariate analysis showed that age (p<0.038) and preoperative peak flow rate (p<0.001) were independent risk factors for voiding dysfunction. Parity, menopausal status, body mass index, and maximal urethral closure pressure were not statistically related to the risk of voiding dysfunction., Conclusions: This study confirms the existence of an important rate of postoperative voiding dysfunction, mostly asymptomatic, and identifies age and preoperative maximal peak flow rate as independent preoperative risk factors. Identification of voiding dysfunction in patients may lead to better follow-up and early detection of late potential complications of suburethral procedures.

Objectives: Deletion of short arm of chromosome 4 is difficult to ascertain prenatally, and can be missed., Methods: A prenatal suspicion of 4p- syndrome was thoroughly investigated by using two-dimensional and three-dimensional sonography, with a description of the fetal face dysmorphological pattern. The cytogenetic confirmation, obtained by karyotype and FISH technique, allowed a precise description of the prenatal abnormalities. Post-termination tridimensional helicoidal scanner of the fetal face was performed., Results: The main anomaly discovered using two-dimensional sonography was the presence of a strikingly thick prefrontal edema (8 mm, twice the normal values, at 22 weeks: 3.81 +/- 0.62 mm). Three-dimensional sonography showed the classical postnatal profile, with the phenotypic aspect of a 'Greek warrior helmet'. Nasal bones were normal in size and placement, confirmed by helicoidal scanner., Conclusion: Prenatal diagnosis of 4p deletion syndrome can be difficult, and it is the presence of prefrontal edema, associated with more subtle facial anomalies (short philtrum, microretrognathia) which should trigger cytogenetic investigation for 4p- deletion, even with only borderline growth retardation., (Copyright 2005 John Wiley & Sons, Ltd)

We report a case of severe Beckwith-Wiedemann syndrome (BWS) in a fetus at 16 weeks of gestation. This presentation, incompatible with life, included a giant omphalocele and absence of abdominal wall musculature with extremely dilated bladder, as in the "prune belly" sequence. Adrenal cytomegaly pointed to BWS. Molecular analysis confirmed the diagnosis of BWS and showed an isolated demethylation of the KCNQ1OT1 gene. This report demonstrates that lethal fetal abdominal wall defects associated with adrenal cytomegaly are linked to epigenetic change of the 11p15 imprinted region., (Copyright 2004 Wiley-Liss, Inc.)

The congenital mesoblastic nephroma is a very rare benign congenital renal tumor. It is the most common renal tumor before the age of 6 months (50%) and it constitutes only 5% of renal tumors before 15 years. The authors report a case of prenatal diagnosis of congenital mesoblastic nephroma revealed by an acute polyhydramnios at 33 weeks of pregnancy. After a preterm labor, the patient delivered at 35 weeks. The newborn underwent a radical nephrectomy. No recurrence was noticed at 10 months. This case of prenatal diagnosis is compared to the 12 cases previously reported. The prognosis of CMN depends on histologic findings, but also on the severity of prematurity induced by the polyhydramnios. The main treatment of this pathology if diagnosed during pregnancy remains the prevention of preterm labor, and after birth the removal of the kidney.

Myxoid liposarcoma is a rare soft tissue tumour. The authors report one case of retroperitoneal tumour discovered during pregnancy, which recurred after initial surgery. Clinical features, clinical course and prognosis of this disease are examined together with management procedures.

A randomized clinical study was designed to test the relative efficacy of preinduction cervical ripening with 0.25 mg prostaglandin E2 (PGE2), repeated if necessary (group 1) compared to a single maturation with 0.50 mg PGE2 (group 2). In group 1 (n = 42), the ripening process was repeated every day until spontaneous onset of labor occurred or induction with oxytocin was decided (for improved Bishop score above 5, or maternal or fetal distress). In group 2 (n = 42) the patients who had not labored 12 h after the maturation procedure had labor induced with oxytocin, irrespective of their cervical status. In group 1, 28 patients experienced repeated maturations (from 2 to 9). Thirty patients had an induction of labor with oxytocin in group 2 and only 12 in group 1 (P < 0.0001). There were four failures of induction of labor in group 2 and none in group 1 (P < 0.05). Three episodes of myometrial hyperstimulation requiring an emergency cesarean section for acute fetal distress occurred in group 2 and none in group 1. There were 13 cesarean sections in group 2 and eight in group 1. The outcome of pregnancy was otherwise similar in both groups. In order to avoid failure of induction of labor, pre-induction cervical ripening with 0.25 mg PGE2, repeated daily if necessary, is therefore recommended in high risk pregnancy unless a severe maternal or a fetal distress call for a prompt delivery irrespective of the cervical status.

A retrospective analysis of 83 records of patients with Buerger's disease is presented. There were 71 men and 12 (14.5 percent) women. Compared with men, women with Buerger's disease had a significantly more frequent vasomotor disorder, but they had less trophic disorders and a lower risk of amputation. After a 42-month follow-up, it appeared that tobacco plays a major role in the prognosis: patients who continued to smoke had significantly more numerous acute episodes than those who ceased smoking. The degree of intoxication is an element of prognosis, but good medical management contributes to reduction in the number of major amputations: only 5 patients (6 percent), all male, had a leg (4 cases) or a thigh (1 case) amputated.

Objective: To assess the effects of nicardipine, a dihydropyridine calcium channel blocker, on the fetus and mother in hypertensive pregnant women., Methods: Forty pregnant patients with mild or moderate hypertension received oral nicardipine 20 mg three times a day (mean duration of treatment 9 +/- 2.1 weeks). Twenty patients with severe preeclampsia (diastolic blood pressure greater than 110 mmHg and 24-hour proteinuria greater than 500 mg) received intravenous (IV) nicardipine at 2, 4, or 6 mg/hour according to body weight (mean duration of treatment 5.3 +/- 3.6 days)., Results: Oral nicardipine induced a significant decrease in both systolic and diastolic blood pressures compared with pre-treatment values (P < .001). Intravenous nicardipine decreased diastolic blood pressure below 90 mmHg, at least temporarily, in all 20 patients. Nine patients taking IV nicardipine complained of headaches. Doppler velocimetry remained stable with both oral and IV nicardipine. Neonatal outcome showed no deleterious effect of the treatment., Conclusions: Oral or IV nicardipine seems to be safe in hypertensive pregnant patients with the doses used in our study. Assessment of its efficacy will necessitate further clinical randomized trials.

An attempt was made to ripen the uterine cervix in 100 high-risk pregnancy patients (pregnancy between 34 to 41 weeks' gestation), with the use of intracervical instillations of 0.25 mg of prostaglandin E2 mixed with a tylose gel. The maturation process was repeated every 48 hours. Forty-nine patients were delivered of infants after the first maturation and 51 patients required between two and nine instillations. In patients requiring multiple instillations, the mean delay between the first procedure and delivery was 9 +/- 4 days (range, 2.4 to 16 days). Among the 59 nulliparous women, only 23 were delivered of infants after a single maturation and 36 required multiple maturations (p less than 0.02). When the group of patients who were delivered of infants after a single maturation process was compared with the group requiring multiple maturations, no difference could be seen with regard to age, term of pregnancy, or Bishop cervical score at the time of inclusion in the study. The myometrial activity and the onset labor induced by prostaglandin E2, were similar in both groups. Fetal heart rate decelerations occurred in 16.3% (8/49) of the patients with single maturations and in 17.6% (9/51) of the patients who required multiple maturations. The outcome of the pregnancy and the rate of cesarean sections (24% and 27%) were similar in both groups. No patients required cesarean sections because of failed induction of labor. Cervical ripening after repeated applications of 0.25 mg of prostaglandin E2 seems to be safe for the fetus, providing that the patient is closely supervised.

Carotid endarterectomy can be complicated by neurological events due to different mechanisms. Monitoring cerebral function is difficult under general anaesthesia. By contrast, the monitoring of awareness and neurological deficit is very easy under regional anaesthesia. The aim of this study was to assess the requirement for arterial shunting during endarterectomy performed under cervical epidural anaesthesia, to analyse the neurological events and to compare the value of clinical and electroencephalographic monitoring. Sixty-four patients were included in this study. Cervical epidural anesthesia was performed with 0.375% bupivacaine and 100-150 micrograms fentanyl. In 19 high risk patients, a one-channel electroencephalographic filter processor (Cerebral function monitor, Critikon) was placed over the affected hemisphere. Before surgery, it was estimated, on angiographic and Doppler data, that 18 patients needed an arterial shunt for carotid clamping. An arterial shunt was in fact inserted during surgery in only four patients, because of cerebral ischaemia after carotid clamping. Transient obnubilation was observed during carotid clamping in three other patients; it disappeared on unclamping in two, and on increasing blood pressure in the third. An additional patient suffered from a very short loss of awareness after declamping, due to cerebral embolism. The cerebral function monitor never documented false positive results, but failed to detect one out of every five neurological events. Controlateral carotid occlusion and preoperative stroke were documented to correlate with peroperative neurological events. Cervical epidural anaesthesia, which maintains consciousness during surgery, reduced in high-risk patients the need for arterial shunting as well as that for the analysis of neurological events.

The seven patients described where suffering from simultaneous occlusion of the central retinal vein and cilioretinal artery. All underwent complete ocular examination including fluorescein angiography and visual field assessment, and general investigation with special emphasis on blood and vascular disorders. All patients had been observed for at least one year. Their age ranged from 35 to 60 years (mean: 46 years); fundus examination showed a common pattern consisting of mild edematous central retinal vein occlusion with few hemorrhages as well as a large area of retinal infarction due to cilioretinal artery occlusion. Despite the presence of this large infarcted area, this cases were very different from the ischemic forms of central retinal vein occlusion since in all cases perfusion of the retinal capillaries in the cilioretinal area recovered in a few days. In 4 of 7 cases, fluorescein angiography also disclosed sectorial hypoperfusion of the optic disc at the acute stage. Recovery of venous occlusion occurred in 3 to 14 weeks and the visual acuity outcome was fairly good, as in 5 of the 7 patients, visual acuity reached at last 0.5. No embolic disease was detected but 3 patients had severe migraine. The pathogenesis of this condition remains unclear. Although cilioretinal infarction is usually thought to be secondary to central retinal vein occlusion, the possible role of primary occlusion of the cilioretinal artery is considered.

Baroreceptor (BR) reactivity was studied in 16 patients scheduled for carotid artery surgery performed under cervical epidural anesthesia with 0.375% bupivacaine (15 mL). In the first seven patients, BR reactivity was assessed by measurement of the slopes of the linear relationship between systolic arterial pressure (SAP) and the RR interval on the electrocardiogram. Alterations of blood pressure (BP) were produced using sequential intravenous (IV) doses of nitroglycerin (NTG; 100 to 200 micrograms) or phenylephrine (PHE; 100 to 200 micrograms), before and 30 minutes after epidural anesthesia. The changes in SAP and heart rate (HR) determined during the four phases of a Valsalva maneuver were evaluated in a second set of measurements before and after cervical epidural blockade. In nine additional patients, a third set of measurements studying BR reactivity after carotid clamping and unclamping was performed in order to assess the effect of carotid handling on BP control. Cervical epidural anesthesia induced moderate decreases in BP (SAP, 150 +/- 18 mmHg before cervical block, 143 +/- 27 mmHg after cervical block, P less than 0.05) and HR (RR, 812 +/- 120 ms before cervical block, 938 +/- 130 ms after cervical block, P less than 0.05). Cervical epidural anesthesia depressed BR reactivity during deactivation as assessed by the decrease in the BR slope after PHE injection (6.6 +/- 4.4 ms/mmHg before cervical block v 2.5 +/- 1.8 ms/mmHg after cervical block, P less than 0.01) and activation as assessed by the changes in SAP and HR during phases II and IV of the Valsalva maneuver.(ABSTRACT TRUNCATED AT 250 WORDS)

The analgesic effect of extradural clonidine was evaluated in a double-blind study. In the recovery room, following orthopaedic or perineal surgery 20 ASA I and II patients were allocated randomly to two groups. The extradural clonidine (EC) group received clonidine 2 micrograms kg-1 in isotonic saline solution 15 micrograms ml-1. The extradural saline (ES) group received the equivalent volume of plain isotonic saline solution. Pain was evaluated by a visual analogue scale (VAS) at 15-min intervals for the first 2 h and subsequently at 30-min intervals for the following 4 h. Morphine 5 mg was given s.c. when patients complained of pain after extradural saline or clonidine. In the EC group, the mean (SD) maximum pain relief was 68.2 (24.1)% of the initial VAS score, but it was only 14.7 (25.2)% in the ES group. The mean duration of analgesia, before injection of morphine, was significantly longer in the EC group (210 (87) min) compared with the ES group (45 (27) min) (P less than 0.001). Drowsiness and moderate hypotension were observed in the EC group.

Smoking and chronic obstructive disease are common in patients who undergo vascular surgery. These patients seem especially at risk for postoperative respiratory complications (PRCs). The value of preoperative spirometric tests to determine the risk of PRC has been recently challenged. The current prospective study was undertaken to identify the risk factors of PRC in these patients. One hundred fifty-one patients, including 67 patients who underwent abdominal aortic surgery, were included in this study. Preoperative and peroperative parameters were collected and analyzed in a multivariate analysis. PRCs were classified as minor and major. A significantly prolonged postoperative hospital stay was associated with major complications (21.3 +/- 9.0 vs 14.3 +/- 6.0 days). The overall incidence of PRC was 37.1%, and the incidence of major PRC was 15.2%. Patients who underwent abdominal aortic surgery had a higher incidence of PRC (53%; major PRC, 24%). In addition to abdominal aortic surgery, other risk factors were chest deformation, recent bronchitis, duration of surgery, and FEV1/VC. In patients who underwent abdominal aortic surgery, the risk factors for major PRC were decreases in preoperative FEV1/VC and PaO2. This study confirms the importance of an evaluation of a patient's respiratory condition, especially by preoperative spirometry and blood gas analysis, to determine the risk of PRC in a given population. General risk factors, such as the American Society of Anesthesiologists' classification, fail to achieve this task. The identification of patients with unacceptable risks remains a challenge.