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Obesity is associated with a number of chronic diseases such as cardiovascular diseases and cancers. The association of obesity with occupational accidents has been suggested although the evidence is less convincing. The objective of the study is to analyse the relationship between BMI values and ergonomic accidents in a large University Hospital.The relationship between body mass index (BMI) and the incidence of ergonomic occupational accidents over a period of 8 years was investigated in a cohort of employees of a large University Hospital, covering almost 27,000 person-years of observation. This relationship was stratified according to the variables age, gender, functional status within the organization and work schedule (part-time or full time). Height and weight were objectively measured, demographic data were obtained from the human resource department and the registration of ergonomic accidents was carried out by the safety and prevention department of the hospital.The number of ergonomic accidents, expressed as number/1000 person-years was higher for female employees compared to male employees, increased with age and markedly increased from functional class A (leading or expert function and higher educational level) to D (executive function in patient care and technical department). However, the incidence of ergonomic accidents accompanied by loss of working time was not significantly associated with BMI, independently of age and gender. In addition, the type of accident and the severity of the accidents expressed as the number of days absent from work were unrelated to BMI.No independent relationship between BMI and the incidence of ergonomic accidents could be identified in our cohort. Tailoring working conditions to individual BMI levels is not recommended.

Resume Introduction La medecine interne est une specialite hospitaliere. A cote de son expertise dans les maladies rares, cette specialite partage avec la medecine generale la prise en charge globale des patients. Son positionnement dans le virage ambulatoire reste a preciser. L’objectif de notre travail etait d’evaluer l’interet d’un hopital de jour de medecine interne ouvert sur la medecine de ville. Methodes Nomme Centre Vi’TAL (ville–hopital), cet hopital de jour s’adresse aux medecins traitants qui font face a des difficultes diagnostiques, therapeutiques, ou de synthese chez un patient complexe. La demande du medecin, adressee par courriel entraine une concertation avec un interniste le jour meme. Si la demande releve bien d’un hopital de jour, le patient est accueilli dans les 7 jours. Dans les autres situations, les patients sont diriges vers la consultation, l’hospitalisation complete voire les urgences. Resultats En 14 mois, le centre Vi’TAL a accueilli 213 (144 femmes, 69 hommes) patients, d’âge moyen 53,6 ans, adresses par 88 medecins de ville pour un nombre total de 282 seances d’hopital de jour. Les motifs de demande etaient un probleme diagnostique (n = 105), therapeutique (n = 43) ou de synthese (n = 65). Conclusion Dans le virage ambulatoire prone par les tutelles, la medecine interne a toute sa place dans la valorisation de l’hopital de jour comme lieu de diagnostic et de synthese en lien avec la ville, tout en laissant le medecin traitant coordonnateur des soins de leur patient. Ce temps de synthese est utile pour les patients et efficient pour le systeme de sante.

Few data are available to describe the changes in incidence of pediatric-onset inflammatory bowel disease (IBD). The aim of this study was to describe changes in incidence and phenotypic presentation of pediatric-onset IBD in northern France during a 24-year period.Pediatric-onset IBD (17 years) was issued from a population-based IBD study in France between 1988 and 2011. Age groups and digestive location were defined according to the Paris classification.1,350 incident cases were recorded (8.3% of all IBD) including 990 Crohn's disease (CD), 326 ulcerative colitis (UC) and 34 IBD unclassified (IBDU). Median age at diagnosis was similar in CD (14.4 years (Q1=11.8-Q3=16.0)) and UC (14.0 years (11.0-16.0)) and did not change over time. There were significantly more males with CD (females/males=0.82) than UC (females/males=1.25) (P=0.0042). Median time between onset of symptoms and IBD diagnosis was consistently 3 months (1-6). Mean incidence was 4.4/10In this population-based study, CD and UC incidences increased dramatically in adolescents across a 24-year span, suggesting that one or more strong environmental factors may predispose this population to IBD.

Cervical cancer is the leading cause of cancerrelated death in Sub-Saharan African women. HIV-infected women are at increased risk for cervical intraepithelial lesions and invasive cervical cancer. WHO guidelines for screening and treatment of precancerous cervical lesions are regularly actualized. There are no data on cervical squamous intraepithelial lesions in Chad. Between August 2013 and May 2015, screening for cervical squamous intraepithelial lesions was proposed to HIV-infected women living in Moundou (Chad). Cytology examination was performed after with Papanicolaou coloration. Three hundred and eleven HIV-seropositive women accepted the screening without refusal. Mean age of the patients was 38 years (95% Confidence Interval: 37.7-39.9). The women declared a mean of 4.1 pregnancies (range: 0-12). The patients had been followed-up for their seropositivity for 8 years (range: 0-25). All were on highly active antiretroviral therapy (HAART). Of the patients whose results were known (N = 231), 98% had a CD4 lymphocyte nadir count less than 350/mm(3). Cytological results were as follows: normal smear (N = 59; 19%), inflammatory or hemorrhagic smear (N = 139; 44%), low grade squamous intraepithelial lesion (N = 58; 19%), high grade squamous intraepithelial lesion (N = 28; 9%), epidermoid carcinoma (N = 13; 4%), and uninterpretable smear (N = 14; 5%). The inflammatory lesions were due to cervicitis (N = 54), vaginosis (N = 22), and trichomonas infection (N = 3). The patients' age, CD4 lymphocyte nadir count, and CD4 count at the time of the cervical smear were not different according to the cytological results. Only five patients had a cone biopsy. Three patients deceased during the study of whom two from a gynaecological cancer diagnosed too late. The screening of dysplasia and cervical cancer in HIV-seropositive women is possible in Chad. In our study, 13% of the women had highgrade dysplasia or carcinoma needing curative care. We also showed that simple cytology did not permit the interpretation of half of the smears. The performance of cervical smear would have increased if it had been preceded by the visualization of the cervix with coloration.

Internal medicine is an in-hospital speciality. Along with its expertise in rare diseases, it shares with general medicine the global care of patients but its place in the ambulatory shift has yet to be defined. The objective of our work was to evaluate the benefits of an internal medicine day-hospital devoted to general medicine.Named "Centre Vi'TAL" to underline the link between the city and the hospital, this novel activity was implemented in order to respond quickly to general practitioners having difficulties to synthesize their complex patients or facing diagnostic or therapeutic problems. Using preferentially email for communication, the general practitioners can contact an internist who is committed to respond on the same day and take over the patient within 7 days if day-hospital is appropriate for his condition. The other patients are directed either to the emergency department, consultation or full hospitalization.In 14 months, the center has received 213 (144 women, 69 men) patients, mean age 53.6, addressed by 88 general practitioners for 282 day-hospital sessions. Requests included problem diagnoses (n=105), synthesis reviews for complex patients (n=65), and treatment (n=43).In the ambulatory shift advocated by the authorities, this experience shows that internal medicine should engage in the recognition of day-hospital as a place for diagnosis and synthesis reviews connected with the city while leaving the general practitioners coordinator of their patient care. This activity of synthesis in day-hospital is useful for the patients and efficient for our healthcare system.

Objectives The aim of this study was to describe the proportion of liver-related diseases (LRDs) as a cause of death in HIV-infected patients in France and to compare the results with data from our five previous surveys. Methods In 2010, 24 clinical wards prospectively recorded all deaths occurring in around 26 000 HIV-infected patients who were regularly followed up. Results were compared with those of previous cross-sectional surveys conducted since 1995 using the same design. Results Among 230 reported deaths, 46 (20%) were related to AIDS and 30 (13%) to chronic liver diseases. Eighty per cent of patients who died from LRDs had chronic hepatitis C, 16.7% of them being coinfected with hepatitis B virus (HBV). Among patients who died from an LRD, excessive alcohol consumption was reported in 41%. At death, 80% of patients had undetectable HIV viral load and the median CD4 cell count was 349 cells/μL. The proportion of deaths and the mortality rate attributable to LRDs significantly increased between 1995 and 2005 from 1.5% to 16.7% and from 1.2‰ to 2.0‰, respectively, whereas they tended to decrease in 2010 to 13% and 1.1‰, respectively. Among liver-related causes of death, the proportion represented by hepatocellular carcinoma (HCC) dramatically increased from 5% in 1995 to 40% in 2010 (p = 0.019). Conclusions The proportion of LRDs among causes of death in HIV-infected patients seems recently to have reached a plateau after a rapid increase during the decade 1995−2005. LRDs remain a leading cause of death in this population, mainly as a result of hepatitis C virus (HCV) coinfection, HCC representing almost half of liver-related causes of death.

Resume Introduction Une surdite de perception d’apparition rapide chez un patient ayant un risque d’exposition au treponeme (par voie genitale ou buccale) peut etre secondaire a une neurosyphilis precoce dont le retard therapeutique peut entrainer des sequelles irreversibles. Resume du cas clinique Un patient de 40 ans, seropositif pour le VIH avec un taux de lymphocytes CD4 superieur a 500/mm 3 , s’est presente pour une surdite de perception bilaterale apparue en une semaine. L’examen ORL etait normal. L’audiogramme montrait une perte bilaterale de 25 et 30 decibels respectivement. Secondairement est apparue une baisse de l’acuite visuelle amenant a diagnostiquer une meningo-radiculite syphilitique atteignant les nerfs auditifs et optiques. Discussion L’atteinte neurologique de la syphilis est pres d’une fois sur deux, une manifestation precoce de la maladie survenant quelques semaines ou mois apres la contamination. La presence d’une surdite d’apparition rapide voire brutale peut temoigner d’une nevrite du nerf auditif. L’interrogatoire et la prescription d’une serologique syphilitique chez un patient ayant pris des risques d’exposition permettent de poser rapidement le diagnostic et d’entreprendre le traitement compose de 14 jours de penicilline injectable. La recuperation auditive est inconstante mais peut etre totale.

Bowel symptoms (constipation and incontinence) are frequent in patients with a neurologic disease, but rarely assessed in rehabilitation centres.To study the prevalence of neurogenic bowel dysfunction (NBD) in those patients, and to assess its severity with the Patient Global Impression of Severity (PGI-S).Prospective study by questionnaires, with the Neurogenic Bowel Dysfunction Score (0-47) and the PGI-S, a 1-item questionnaire (absent, mild, moderate, severe) for the severity of the bowel symptoms, and the Bristol Stool Chart for stool consistency. All patients presenting a chronic (2months) neurological disease were included.Inclusion of 169 patients, 97 with spinal cord injury, 42 with multiple sclerosis and 30 with hemiplegia. In each population, prevalence of constipation was 67 %, 45 % and 17 %, of pelvic floor dyssynergia 82 %, 45 % and 27 %, and leakages (gas or stools) de 74 %, 48 % and 43 %, respectively. Moderate to severe bowel symptoms were seen in 61 % of spinal cord injury, 43 % of multiple sclerosis and 23 % of hemiplegic patients, with NBD scores of 11.9±6.5, 5.7±4.9 and 3.7±4.2, respectively (P0.01). There was a significant relation between PGI-S and NBD score (P0.01). Significant lower NBD scores were associated with normal stool consistency (Bristol type 3 or 4) (P0.01). In case of severe bowel symptoms, the use of transanal irrigation was hampered by patients' motivation and acceptation, and their autonomy.PGI-S and Bristol Stool Chart are reliable tools to assess the presence of bowel symptoms in clinical practice.

Cervical cancer is the leading cause of cancerrelated death in Sub-Saharan African women. HIV-infected women are at increased risk for cervical intraepithelial lesions and invasive cervical cancer. WHO guidelines for screening and treatment of precancerous cervical lesions are regularly actualized. There are no data on cervical squamous intraepithelial lesions in Chad. Between August 2013 and May 2015, screening for cervical squamous intraepithelial lesions was proposed to HIV-infected women living in Moundou (Chad). Cytology examination was performed after with Papanicolaou coloration. Three hundred and eleven HIV-seropositive women accepted the screening without refusal. Mean age of the patients was 38 years (95% Confidence Interval: 37.7-39.9). The women declared a mean of 4.1 pregnancies (range: 0-12). The patients had been followed-up for their seropositivity for 8 years (range: 0-25). All were on highly active antiretroviral therapy (HAART). Of the patients whose results were known (N = 231), 98% had a CD4 lymphocyte nadir count less than 350/mm(3). Cytological results were as follows: normal smear (N = 59; 19%), inflammatory or hemorrhagic smear (N = 139; 44%), low grade squamous intraepithelial lesion (N = 58; 19%), high grade squamous intraepithelial lesion (N = 28; 9%), epidermoid carcinoma (N = 13; 4%), and uninterpretable smear (N = 14; 5%). The inflammatory lesions were due to cervicitis (N = 54), vaginosis (N = 22), and trichomonas infection (N = 3). The patients' age, CD4 lymphocyte nadir count, and CD4 count at the time of the cervical smear were not different according to the cytological results. Only five patients had a cone biopsy. Three patients deceased during the study of whom two from a gynaecological cancer diagnosed too late. The screening of dysplasia and cervical cancer in HIV-seropositive women is possible in Chad. In our study, 13% of the women had highgrade dysplasia or carcinoma needing curative care. We also showed that simple cytology did not permit the interpretation of half of the smears. The performance of cervical smear would have increased if it had been preceded by the visualization of the cervix with coloration.

Culture and resistance testing of Mycobacterium tuberculosis are not regularly performed in Chad. Sputa were obtained from three different categories of hospitals (district, regional and national) in Chad. All examined sputa were smear-positive and were investigated by culture and drug resistance testing for first-line antituberculosis drugs. From 232 sputa positive for acid-fast bacilli, 135 isolates of M. tuberculosis from different patients (46 women, 89 men, mean age 34 years) were analyzed. All the patients except one corresponded to new cases of tuberculosis. In total, 27 out of 135 isolates (20%) were resistant to at least one major antituberculosis drug. Resistance to isoniazid was the most frequent resistance observed, with 18 isolates (13%) presenting at least this resistance. Three isolates (2.2%) were resistant to isoniazid and rifampicin (multidrug resistance MDR) including one isolate being concomitantly resistant to streptomycin and ethambutol. The resistance rate differed in relation to the category of the hospital; the most important resistance rate was observed in regional hospitals (33%), while it was 16% and 14% in the national and district hospitals, respectively. HIV serology was performed in 81 patients, among whom 20 (25%) were positive. This is the first study that shows that drug resistance of M. tuberculosis is present in Chad. Besides single drug-resistant isolates, multidrug-resistant strains of M. tuberculosis could also be identified. This result highlights the urgency of initiating actions to detect drug resistance and limit the spread of drug-resistant strains.

Resume Introduction L’infection a parvovirus humain B19 (erythrovirus B19) est une maladie commune de l’enfance souvent asymptomatique et conferant une immunite durable. Elle peut etre responsable d’un erytheme febrile (5e maladie) ou d’anemie aregenerative. La survenue d’un nouveau tableau aigu est rare mais possible en cas d’immunodepression et le mecanisme physiopathologique n’est pas toujours connu. Observation Une femme de 46 ans, infectee par le VIH, presentait a cinq ans d’ecart deux infections aigues a parvovirus B19 malgre une immunite restauree (taux de lymphocytes CD4 superieur a 500/mm3). L’absence de production d’anticorps specifiques apres le premier episode et la persistance d’une viremie a parvovirus permettait de conclure a une reactivation virale plutot qu’a une reinfestation. Le second episode entrainait la production d’anticorps specifiques. Conclusion Comme pour la plupart des virus a ADN, la reactivation a parvovirus B19 est possible chez les patients infectes par le VIH malgre une tritherapie antiretrovirale efficace.

Introduction Le virus Zika est principalement transmis par piqure de moustique du genre Aedes. La transmission par transfusion est possible. La transmission verticale in utero est decrite a l’origine d’anomalie fœtale. La transmission par l’allaitement n’a pas ete decrite. Quelques cas de transmission sexuelle homme vers femme ont ete rapportes lie a la presence du virus dans le sperme, jusqu’a 188 jours apres l’infection. Le 1 er cas suspecte de transmission sexuelle du virus Zika de la femme vers l’homme a ete rapporte en juillet 2016 et serait survenu au moment de la phase silencieuse de la primo infection. Patients et methodes A l’occasion d’un infection par le virus Zika chez une femme de 42 ans, au retour d’un sejour en Guadeloupe, une etude de la cinetique de la presence du virus, detecte par PCR au niveau du sang, des urines et des secretions vaginales par auto-prelevement a ete realisee. Resultats Tableau 1 . Discussion Ce cas montre la presence du virus ZIKA au niveau vaginal 11 jours apres le debut des symptomes et conforte la possibilite d’une transmission sexuelle du Virus. Il s’agit du 2 e cas rapporte de presence du virus au niveau des secretions vaginales. Conclusion Meme si la transmission heterosexuelle de certaines maladies virales est generalement plus importante de l’homme vers la femme, la possibilite d’une transmission de la femme vers l’homme du virus Zika est probable, en particulier dans la phase initiale de la maladie. Une etude plus approfondie de la clairance du virus au niveau vaginal permettrait de connaitre la periode potentielle de contagiosite et de renseigner les patientes sur la duree des mesures de prevention a adopter.

International audience; Background - Chronic kidney disease (CKD) is frequent in individuals infected with human immunodeficiency virus (HIV). Progression to end-stage renal disease can be slowed by appropriate medical management. Methods - To assess whether active promotion of guidelines improves CKD management, we conducted a cluster randomized controlled trial within the French Hospital Database on HIV (FHDH-ANRS CO4). We randomized 46 centers participating in the FHDH to either simple information on guideline availability or active promotion with a multifaceted and repeated intervention comprising reminders and audit feedback and targeting of local opinion leaders carried out between April 2009 and April 2010. Outcome measure was CKD management adequacy assessed before and 2 years after the beginning of the intervention in HIV-infected patients with moderate to severe CKD. CKD management was considered adequate in case of referral to a nephrologist or if proteinuria, blood pressure, low-density lipoprotein cholesterol level, and glycemia had been measured during the previous year and medications had been prescribed when necessary. Results - Three hundred six patients were enrolled, of whom 238 (78%) completed the 2 years of follow-up. During the study period, the percentage of patients receiving adequate CKD management improved from 64.1% to 70.4% (+6.3%) in the active arm and from 68.3% to 75.6% (+7.3%) in the control arm (adjusted mean difference, -0.7 percentage points [95% confidence interval: -9.2 to 7.9]; P = .95). The biggest impact of active promotion was on the management of proteinuria and blood pressure. Conclusions - Adequate compliance with CKD management guidelines improved slightly between 2009 and 2011, with no difference between the simple information and active promotion arms. Clinical trials registration - CCTIRS 10.150 and CNIL DR-2010-379.

Objective: To analyze the utility of quick intraoperative parathyrc id hormone (PTH) measurement in the surgical management of primary hyperparathyroidism. Background Data: The use of intraoperative PTH monitoring is well established in the surgery of primary hyperparathyroidism. However, some false-negative predictions lead to unnecessary explorations; furthermore, surgeons are becoming increasingly dependent on hormone measurement for intraoperative decisions, which raises concerns about the cost-effectiveness of the method. Methods: A retrospective analysis of 268 neck explorations performed for primary hyperparathyroidism using intraoperative PTH monitoring from April 2001 to February 2003 was done. We used the criterion of biologic recovery of hyperfunctioning tissue, defined as a more than 50% decrease in PTH level from baseline value at 5 minutes after excision to predict the outcome of successful parathyroidectomy documented by normal postoperative serum calcium level. Additionally, we also sampled PTH at 10 minutes, 30 minutes, and the morning after surgery to compare the predictive value of delayed sampling. Patients were classified according to the prediction being concordant or discordant with the outcome. The data were analyzed using a 2 × 2 table construct for each of the sampling times, therefore providing sequential sensitivity, specificity, positive and negative predictive values, and overall accuracy of the predictions. Results: Concordance or overall accuracy of prediction (true positives and negatives) was obtained in 229 cases (85.4%), and discordance or failure of prediction (false positives and negatives) was obtained in 34 cases (12.7%) at T5. On analyzing the iPTH pred c-tion at T10, T30, and Dl among the group of 33 false negatives, we found that 28 (10.4%) patients reached the concordance at 30 minutes, while by the first day 32 patients (12.3%) had achieved concordance. Thus, there was a progressive increase in sensitivity and overall accuracy, but more importantly, in the negative predictive value reaching 88.9% on the day after surgery. Conclusions: The method of sampling PTH intraoperatively at 5 minutes has a high positive predictive value (99.5%) but a low negative predictive value (19.5%), which can lead to unnecessary explorations and a delay in the operative procedure. The negative predictive value increases substantially at 30 minutes and is best on the day after surgery. We suggest giving up the intraoperative measurement of PTH to adopt the first day postoperative measurement of PTH as a predictor of successful parathyroidectomy.

We assessed the "late" results after unilateral parathyroidectomy (PTX) performed for selected indications. From October 1998 throughout March 2001 we operated on 454 patients for hyperparathyroidism (HPT). A positive unifocal (99m)tc-MIBI scan was required for the unilateral approach to be used. Intact parathormone (PTH) measurements were done intraoperatively. Postoperative calcium and PTH serum levels of unilaterally operated patients were checked. Follow-up has been 16.2 months (range 6-40 months). Of the 454 patients, 336 (74.0%) were not eligible for the unilateral approach; and 125 (27.5%) of the 454 patients had renal HPT. Among the 329 patients with primary HPT, 125 (38.0%) were excluded for well established reasons, and in 77 other cases (23.5%) preoperative imaging results did not allow the unilateral approach. Altogether, 126 patients (38.3%) with primary HPT were selected for the unilateral approach. Of the 126 unilateral operations, 8 (6.3%) had to be converted to a bilateral procedure. Among the 118 patients with a unilateral approach, 3 patients have been reoperated for overlooked contralateral disease, and 13 dropped out of the study. A total of 102 postoperative calcium and PTH serum late levels are known: 90 (88.2%) patients had normal levels; 10 (9.8%) had a high PTH level, and 2 (1.9%) had high ionized calcium levels. The failure rate in selected cases was 4.2% (5/118) (three were reoperated, and two had a supranormal postoperative ionized Ca level). Even with stringent indications, the late results of unilateral surgery (95.8% cure rate) barely matched those of conventional bilateral surgery (97.6% cure rate). The economic impact of such a surgical strategy should be clarified.

INTRODUCTION AND METHOD Fifty-five patients (17 adults, 38 children) with meningococcal infection were admitted between 1986 and 2002 in a university hospital (500 beds). Fourteen of them (nine adults, five children) presented with an extra-meningeal infection. We compared adults and children presentations. RESULTS All adults had immunodeficiency. Septic locations were various (three bacteriemia, four pneumoniae, one infected ascitis, one cutaneous abscess). All patients received amoxicillin or third generation cephalosporin. Hospitalisation was prolonged (mean: 47 days). Seven patients required intensive care unit admission, and two of them died. All children (all were less than 36-month-old) presented with fever. Only one was immunodeficient (infected by human immunodeficiency virus). Neisseria meningitidis grew from blood in four, and in the throat for the remaining one. Hospitalisation was of short duration (mean: 4 days) and none of the children required intensive care unit. All the children recovered rapidly with antibiotics. CONCLUSION Outcome of extra-meningeal infection with N. meningitidis is different in adults and children. Adults present with immunodeficiency, infection is severe and patients present with various clinical features; children have a more homogeneous clinical presentation (fever) and outcome is excellent.

A 26-year-old nurse presented with a three-day history of sudden onset of pyrexia of 39 °C, malaise, and a patchy maculopapular rash, after returning from a monthlong work in Senegal. A tourniquet was applied to help locate the vein for diagnostic blood sampling. After the procedure, a petechial rash erupted with a demarcation line below the level of the tourniquet. A diagnostic test for dengue fever was performed and confirmed by the polymerase chain reaction (PCR) to be positive for serotype DEN-1. The tourniquet test is performed by inflating a blood pressure cuff tied on the upper arm to a point midway between systolic and diastolic blood pressure for five minutes. The test is considered positive when there are 20 or more petechiae per square inch (6.25 cm(2)) on the forearm, and is one of several clinical parameters considered by the World Health Organization to be important in the diagnosis of dengue fever.

Resume Les malades en situation de precarite dans les poches le pauvrete existantes dans les pays riches cumulent des facteurs de precarite : chomage de longue duree, absence de logement fixe, absence de protection sociale effective, solitude. Ceux-ci constituent autant de facteurs de vulnerabilite aux pathologies infectieuses, premiere cause de morbidite et de mortalite dans ce contexte. Resurgence de maladies infectieuses anciennes (tuberculose mais aussi rickettsioses, diphterie ou pneumococcies) curables si correctement traitees; emergence de pathologies recentes (VIH, VHB, VHC) necessitent des soins et des traitements longs et couteux; leur survenue chez des personnes en situation de precarite impose une prise en charge adaptee. La detection doit etre systematique, la prevention specifique, l'hospitalisation supplantee par le suivi ambulatoire; la prise en charge necessite le developpement des dispositifs medico-sociaux de proximite au sein des hopitaux publics et des dispensaires municipaux. L'acces aux soins des plus vulnerables est la condition d'une diminution de la mortalite des pathologies infectieuses et du controle des epidemies emergentes ou resurgentes qui se d'eveloppent dans les poches de pauvrete et sont un risque pour tous.

Nocardia cyriacigeorgica is a recently characterized species within the genus of Nocardia . We report a brain abscess, following a primary pulmonary colonization, due to this species in a human immunodeficiency virus-infected patient. This case confirms that isolation of Nocardia in sputum is associated with a high risk of disseminated infection in immunocompromised patients.

Introduction Rapid-onset of sensorineural hearing loss in a patient at risk of genital or oral exposure to treponema can be secondary to early neurosyphilis, for which delayed treatment may result in irreversible sequelae. Summary of the case report A 40-year-old, HIV seropositive man with a CD4 lymphocyte count greater than 500/mm 3 presented with rapid-onset of bilateral sensorineural hearing loss over a period of one week. Otorhinolaryngological examination was normal. The audiogram showed bilateral hearing loss of 25 and 30 decibels, respectively. He subsequently developed loss of visual acuity, leading to the diagnosis of syphilitic meningitis affecting the optic and auditory nerves. Discussion In about one half of cases, neurosyphilis is an early manifestation of the disease occurring several weeks or months after contamination. Rapid- or even sudden-onset of hearing loss may be due to auditory neuritis. Clinical interview and syphilis serology in a patient at risk of exposure can allow rapid diagnosis and treatment, consisting of two weeks parenteral penicillin. Recovery of hearing loss is inconstant but can be complete.

A 26-year-old nurse presented with a three-day history of sudden onset of pyrexia of 39 °C, malaise, and a patchy maculopapular rash, after returning from a monthlong work in Senegal. A tourniquet was applied to help locate the vein for diagnostic blood sampling. After the procedure, a petechial rash erupted with a demarcation line below the level of the tourniquet. A diagnostic test for dengue fever was performed and confirmed by the polymerase chain reaction (PCR) to be positive for serotype DEN-1. The tourniquet test is performed by inflating a blood pressure cuff tied on the upper arm to a point midway between systolic and diastolic blood pressure for five minutes. The test is considered positive when there are 20 or more petechiae per square inch (6.25 cm(2)) on the forearm, and is one of several clinical parameters considered by the World Health Organization to be important in the diagnosis of dengue fever.

A new anesthesia machine incorporates a "coasting mode", but the extent to which a coasting technique can maintain anesthesia at the end of a procedure under optimal conditions (closed circuit anesthesia) remains unknown. Sixty-nine patients undergoing peripheral or abdominal surgery were assigned to 1 of 9 groups, depending on when desflurane coasting (in O2/air) was started (after 4, 9, 16, 25, 36, 49, 64, 81, or 100 min). The end-expired desflurane concentration was maintained at 4.5% in O2/air prior to coasting with a conventional anesthesia machine. After initiating coasting (using a closed-circuit technique), we examined when the end-expired desflurane concentration reached 70, 60, 50, and 40% of its value during maintenance (= 30, 40, 50 and 60% decrement times, respectively). Decrement times increased with increasing duration of anesthesia, and varied widely. After 64 min of maintenance anesthesia, the end-expired desflurane concentration remained at or above 70, 60, 50, and 40% of its maintenance value during 10.3 +/- 2.3, 16.0 +/- 3.5, 25.0 +/- 5.9, and 45.4 +/- 19.3 min, respectively (average +/- standard deviation). Coasting can briefly maintain anesthesia towards the end of a procedure. While savings with an automated coasting mode are likely to be modest per patient, they may become substantial when multiplied by the number of procedures per day per operating room with no increase in the clinical workload of the anesthesia provider.

International audience; OBJECTIVES: To compare virological effectiveness in patients who continued on a virologically successful first-line boosted protease inhibitor (PI)-containing combination antiretroviral therapy (cART) regimen or who switched to a PI-free cART including efavirenz, nevirapine or abacavir. METHODS: From the French Hospital Database on HIV, we selected 439 patients with undetectable viral load (VL) on a first-line boosted PI-containing cART regimen who switched to a PI-free combination including efavirenz, nevirapine or abacavir. Each of these patients was matched with three patients who continued to take their first-line cART regimen, on the basis of gender, age, CD4 cell count, VL, date of cART initiation and the duration of VL undetectability. Time to virological failure (VF) was analysed with Kaplan-Meier curves and Cox models. RESULTS: The 12 month probabilities of VF were 3.7% and 5.7% in non-switch and switch patients, respectively, and 3.9%, 7.2% and 9.0% in patients switching to efavirenz-, nevirapine- and abacavir-containing cART, respectively. After adjustment, only patients switching to abacavir-containing cART had a higher risk of VF than non-switch patients (adjusted hazard ratio, 1.99; 95% confidence interval, 1.05-3.79). CONCLUSIONS: Switching from a virologically successful first-line boosted PI-containing cART regimen to a non-nucleoside reverse transcriptase inhibitor-containing cART regimen containing either efavirenz or nevirapine is virologically safe, while switching to abacavir-containing cART should be avoided.

Culture and resistance testing of Mycobacterium tuberculosis are not regularly performed in Chad. Sputa were obtained from three different categories of hospitals (district, regional and national) in Chad. All examined sputa were smear-positive and were investigated by culture and drug resistance testing for first-line antituberculosis drugs. From 232 sputa positive for acid-fast bacilli, 135 isolates of M. tuberculosis from different patients (46 women, 89 men, mean age 34 years) were analyzed. All the patients except one corresponded to new cases of tuberculosis. In total, 27 out of 135 isolates (20%) were resistant to at least one major antituberculosis drug. Resistance to isoniazid was the most frequent resistance observed, with 18 isolates (13%) presenting at least this resistance. Three isolates (2.2%) were resistant to isoniazid and rifampicin (multidrug resistance MDR) including one isolate being concomitantly resistant to streptomycin and ethambutol. The resistance rate differed in relation to the category of the hospital; the most important resistance rate was observed in regional hospitals (33%), while it was 16% and 14% in the national and district hospitals, respectively. HIV serology was performed in 81 patients, among whom 20 (25%) were positive. This is the first study that shows that drug resistance of M. tuberculosis is present in Chad. Besides single drug-resistant isolates, multidrug-resistant strains of M. tuberculosis could also be identified. This result highlights the urgency of initiating actions to detect drug resistance and limit the spread of drug-resistant strains.

Introduction L’hopital de jour (HDJ) se positionne comme une alternative a l’hospitalisation complete. L’admission des patients en hopital de jour est actuellement en France le plus souvent initiee par un medecin hospitalier. Nous presentons les resultats d’une etude pilote evaluant l’ouverture d’une structure d’HDJ de medecine interne a des medecins de ville. Patients et methodes Une sensibilisation des medecins liberaux sur les objectifs d’un HDJ pluridisciplinaire pour les aider a prendre en charge leur patient pour des traitements ou des explorations, a ete menee au printemps 2012. Les medecins pouvaient communiquer a un medecin referent par mail, fax ou telephone pour preciser leur attente. Ce 1 er contact permettait de retenir ou non l’HDJ comme la reponse adaptee a la demande. A defaut, les patients etaient orientes en consultation, aux urgences ou en hospitalisation complete. Resultats De juillet 2012 a juin 2014, 119 seances d’HDJ pour 88 patients ont ete organisees a la demande de 37 medecins generalistes differents. Les motifs d’HDJ les plus frequents etaient les difficultes diagnostiques (30 %), les patients polypathologiques dependants (30 %), et les transfusions programmees (10 %). Un diagnostic de maladie neoplasique a ete porte chez 7 patients (bilan de pleuresie, d’adenopathie). Onze patients ont ensuite ete pris en charge en hospitalisation complete dans un service hospitalier une fois le diagnostic pose en HDJ. Discussion Pour les patients, l’HDJ a evite une hospitalisation complete et certains patients ont pu etre pris en charge uniquement en HDJ. Les medecins liberaux ont adresse entre 1 et 10 patients (moyenne : 3,5), temoignant de leur interet bien que cette approche nouvelle ne soit pas encore installee dans les habitudes. Pour les soignants habitues a des pathologies chroniques, il s’agit d’une offre nouvelle a la fois federatrice mais destabilisante et qui demande du temps et de la souplesse. Ces HDJ demandent en amont une preparation avec un contact avec le medecin demandeur, du temps et de la reactivite le jour de la venue du patient (le patient sortant avec un compte rendu) voire un complement de synthese a posteriori (discussion en staff, relecture d’images avec des specialistes). Conclusion Un HDJ de medecine interne pluriprofessionnel a toute sa place pour repondre aux besoins des medecins de ville et eviter des hospitalisations completes a leurs patients. Il peut etre un lieu de stage tres formateur pour les futurs medecins generalistes. Cette offre nouvelle necessite des reorganisations au niveau d’un service et au-dela d’un hopital.

The objectives of the study were to describe the medical and social characteristics of patients consulting for the first time after diagnosis of HIV-infection and to compare the medical and social characteristics between French and migrant patients. From 1 January 2001 to 31 December 2002, all consecutive adults consulting for the first time for HIV infection in two HIV outpatient clinics located in the western suburb of Paris, agreed to an interview based on an administered questionnaire regarding their medical and socioeconomic characteristics. Of the 203 patients (98 women, 105 men), one-third (n=70) was of French nationality. Delay (+/-SD) in access to HIV outpatient clinic after diagnosis was shorter in migrant than in French patients, respectively 7.6+/-29.6 months (median=0.5, range=0 to 196.6) and 23.8+/-51.4 months (median=0.9, range=0 to 199.7); p=0.005. There was no significant difference in the medical characteristics between the two groups of patients on their first consultation. However, most of the migrants were living in very poor socio-economic conditions with minimal resources thus sometimes delaying initiation of HAART. The development of social facilities for HIV-positive migrants should be a public health priority.

Simplification of combined antiretroviral therapy in HIV-infected patients is possible, but virological success can be compromised by the development or emergence of resistant viruses.Worsening renal functioning in a patient under successful combination antiretroviral therapy resulted led to the replacement of indinavir by abacavir. Eight weeks later, his viral load rose and he developed a mutant virus resistant to all the nucleoside analogs.Our case report illustrates the danger of streamlining combined antiretroviral therapy composed only of nucleoside analogs in patients already successfully treated with nucleoside analogs, by exposing them to the risk of the emergence of a mutant virus.

Fifty-five patients (17 adults, 38 children) with meningococcal infection were admitted between 1986 and 2002 in a university hospital (500 beds). Fourteen of them (nine adults, five children) presented with an extra-meningeal infection. We compared adults and children presentations.All adults had immunodeficiency. Septic locations were various (three bacteriemia, four pneumoniae, one infected ascitis, one cutaneous abscess). All patients received amoxicillin or third generation cephalosporin. Hospitalisation was prolonged (mean: 47 days). Seven patients required intensive care unit admission, and two of them died. All children (all were less than 36-month-old) presented with fever. Only one was immunodeficient (infected by human immunodeficiency virus). Neisseria meningitidis grew from blood in four, and in the throat for the remaining one. Hospitalisation was of short duration (mean: 4 days) and none of the children required intensive care unit. All the children recovered rapidly with antibiotics.Outcome of extra-meningeal infection with N. meningitidis is different in adults and children. Adults present with immunodeficiency, infection is severe and patients present with various clinical features; children have a more homogeneous clinical presentation (fever) and outcome is excellent.

For ophthalmic surgery we have to deal with a wide range of different patient characteristics. We treat young healthy children, in some cases even neonates, but on the other hand we have debilitated aging patients with multiple concomitant diseases. Treatment of postoperative pain is imperative for inpatients, but is even more important for patients who are treated on an outpatient basis. There also is a wide range of different types of ophthalmic surgical procedures. The postoperative care after a cataract extraction is only seldom complicated by severe pain and is completely different of that after a vitrectomy with scleral buckling. More aggressive surgery as enucleation or evisceration of an eye often is a very stressful and painful procedure. We certainly have some excellent strategies to cope with postoperative pain. We can use topical anesthetics or non-steroidal anti-inflammatory medication. Regional anesthesia of the globe is extremely useful for anticipating on postoperative pain, especially when long-acting agents are used. We can administer analgesics by mouth or parenterally. Acetaminophen or paracetamol is widely used and can be supplemented with NSAIDs or opioids. Especially for children one has to use optimal doses of minor analgesics by an adequate route of administration in order to achieve a timely and efficient analgesia.

Cardiac catheterization of children with congenital heart disease is increasingly being performed under general anesthesia. Haemodynamic stability during anesthesia and fast and adequate recovery after the procedure is crucial in these patients. We performed a pilot study to evaluate hemodynamic stability when using remifentanil for anesthesia during cardiac catheterization. We also evaluated extubation times and recovery characteristics.In a randomized, prospective, double-blind study 30 children (aged 1.5-20 months) received a continuous infusion of either 0.2 (group 0.2) or 0.3 microg/kg/min remifentanil (group 0.3) as part of a balanced anesthesia with 0.6 MAC sevoflurane. Heart rate, noninvasive arterial blood pressure, end tidal CO2 and pulse oxymetry were monitored throughout the procedure. Extubation times were noted, and recovery from anesthesia was evaluated using Aldrete scores.: Haemodynamic response to intubation was well blunted in both groups. No significant changes in hemodynamic variables were noted from induction of anesthesia until 10 min after intubation. From then on there was a decrease in HR and systolic arterial pressure, which remained significant throughout the procedure in both groups. Extubation times were similar in both groups: 7.3 min (2,1) in group 0.2 vs. 6.6 min (2,1) in group 0.3 (NS). The number of patients with an Aldrete score of nine or more was 14 (group 0.2) vs. 15 (group 0.3), 10 min after extubation (NS).Both dose regimens of remifentanil provided stable hemodynamic conditions during anesthesia for cardiac catheterization of children with congenital heart disease and allowed for rapid and adequate recovery.

Malignant tumors have been associated with the development of nephrotic syndrome. We report a 73-year-old man with nephrotic syndrome who had a malignant stromal gastric tumor. Curative resection of the sarcoma resulted in remission of the nephrotic syndrome.

Some surgical patients are at an increased risk for developing cerebral ischaemia. A subset of these patients is believed to benefit from putative cerebroprotective effects of anaesthetic agents. Therefore, in this setting these drugs could have therapeutic modalities, besides their auxiliary functions to make surgery possible. However, both animal and especially human data are very disappointing. Only the barbiturates and isoflurane have an experimental record warranting further research to delineate proper indications for their use as neuroprotective agents in surgical patients.

During low-flow or closed-circuit anesthesia with the fluorinated inhalation anesthetic sevoflurane, compound A, an olefinic degradation product with known nephrotoxicity in rats, is generated on contact with alkaline CO(2) adsorbents. To evaluate compound A formation and thus potential sevoflurane toxicity, a reliable and reproducible assay for quantitative vapor-phase compound A determination was developed.Compound A concentrations were measured by fully automated capillary gas chromatography-mass spectrometry with cryofocusing. Calibrators of compound A in the vapor phase were prepared from liquid volumetric dilutions of stock solutions of compound A and sevoflurane in ethyl acetate. 1,1,1-Trifluoro-2-iodoethane was chosen as an internal standard. The resulting quantitative method was fully validated.A linear response over a clinically useful concentration interval (0.3-75 microL/L) was obtained. Specificity, sensitivity, and accuracy conformed with current analytical requirements. The CVs were 4.1-10%, the limit of detection was 0.1 microL/L, and the limit of quantification was 0.3 microL/L. Analytical recoveries were 100.6% +/- 10.1%, 102.5% +/- 7.3%, and 99.0% +/- 4.1% at 0.5, 10, and 75 microL/L, respectively. The method described was used to determine compound A concentrations during simulated closed-circuit conditions. Some of the resulting data are included, illustrating the practical applicability of the proposed analytical approach.A simple, fully automated, and reliable quantitative analytical method for determination of compound A in air was developed. A solution was established for sampling, calibration, and chromatographic separation of volatiles in an area complicated by limited availability of sample volume and low concentrations of the analyte.

With rocuronium optimal intubating conditions are earlier achieved than the adductor pollicis muscle onset time. Using the transition time we defined a better parameter for clinical relaxation. The onset of relaxation was determined in 20 patients. After a stable response was achieved with a 0.1 Hz single twitch stimulation 0.60 mg/kg rocuronium was injected. The three different stades during the onset of relaxation were determined. These are the lag time, transition time (transition between second and third phase) and onset time. Whether the transiton time corresponds with optimal intubating conditions was evaluated in 40 other patients. The median transition time was 67.4 (P25:52.5, P75:76.3) seconds with a corresponding relaxation of 76.2 (P25:81.4, P75:70.7)%. The intubating conditions were significantly better at a relaxation level corresponding with the transition time. We conclude that the transition time approximates the intubating time and corresponds with fair intubating conditions. This parameter can be preferred to define the moment with optimal intubating conditions.

Contemporary multigas analyzers determine anesthetic gas concentrations using (near) infrared analysis at either 3.3 or 8-9 microns. Methane also absorbs infrared light at 3.3 microns, but not at 8-9 microns. Consequently, erroneous anesthetic agent readings may result when methane is present in the circuit (e.g. during closed circuit anesthesia), potentially compromising patient safety. We have analyzed in laboratory conditions the influence of different known methane concentrations (100, 500 and 1000 ppm) on the gas-analysis readings provided by some clinical monitoring devices that use infrared absorption for the measurement of inhalation anesthetic concentration. At 3.3 microns wavelength the influence on the measurement of halothane was important, whereas the influence on that of enflurane and isoflurane was less pronounced. For desflurane and sevoflurane measurements, the influence of methane at 3.3 microns wavelength proved to be minimal. At higher wavelengths (8-9 microns) no influence of methane could be demonstrated.