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Objective From 2009 to 2013, the French colorectal cancer screening program (CRCSP) provided for a medical phase and a phase of systematic mailing of the test kit (SMTK) to people who could not participate in the medical phase. After 2013, the SMTK was abandoned in most districts. This study aims to analyze the impact of this termination. Study design This was a descriptive and cohort study. Methods The study concerned a cohort of 143,989 people (aged 50–74 years) living in Seine-Saint-Denis (France), invited to participate in the 2013 campaign (with SMTK) and in the 2015 campaign (without SMTK). The impact of SMTK termination was analyzed in terms of the difference between the participation rates and between the delay (expected vs observed) in performing the screening test in 2015. These differences were described based on previous solicitation in the CRCSP. Expected rates and expected delay were estimated in a Monte Carlo simulation. Results The participation rate observed (20.0%) was higher than expected (16.1% [15.9–16.3]). People who have never had a SMTK between 2007 and 2013 (80.0% [79.3–80.7] vs 69.6%) and those who participated in all campaigns before 2015 (97.0% [96.7–97.3] vs 82.6%) had an observed rate lower than expected. The delay observed (4.2 months) was longer than expected (2.5 months). Conclusion The sudden termination certainly contributed to the extension of the delay. However, it did not have a major impact on the participation rate, partly due to information campaigns on the new screening test. In this cohort, the low participation would be explained better by the behavior in the previous campaigns than by the lack of SMTK.

Preoperative information is a key to adherence to treatment for the patients, but may be misunderstood because of its density and complexity. The aim of this study was to assess comprehension and satisfaction of patients about preoperative information of benign prostatic hyperplasia (BPH) surgery. Factors influencing patient understanding were also studied.It was a monocentric study on questionnaires including every patients planned for BPH surgery, whatever the surgical technique. A survey was sent at patient's home after the preoperative consultation.One hundred and six of 210 patients (50,5 %) returned the questionnaire. 38,68 % (n=41) found the quality of information excellent (9 or 10 out of 10), and 45,28 % (n=48) found the quality of information good (7 or 8 out of 10). The main recalled complications were retrograde ejaculation (39.6 %, n=42/106), and bleeding (29,2 %, n=31/106). 57.6 % of patients (n=61) remembered receiving the written information sheet of the French Association of Urology. 5.7 % (n=6) hesitated having the procedure. Only patient's age was significantly associated with difference of comprehension (p0.005).Information given before a BPH surgery seems satisfactory although it was poorly understood, notably about complications. Providing complete oral information, insisting on complications, and giving the written information sheet are essential for a good doctor-patient relationship and a forensic serenity.3.

Tester la non-inferiorite de la cryotherapie (Froid Sec Alkantis®, Lyon, France) seule ou en association avec un traitement antalgique vs un traitement antalgique seul de palier superieur, pour permettre de diminuer d’un palier la puissance des antalgiques utilises en traumatologie. Cette etude prospective randomisee de non-inferiorite a inclus des patients âges d’au moins 12 ans pour prise en charge d’un traumatisme, selon deux bras. Ils ont recu soit un antalgique seul: palier 1 (paracetamol) si EVA 7; soit des antalgiques de palier inferieur systematiquement associes a la cryotherapie: cryotherapie seule si EVA 7. Cent soixante-dix-huit patients ont ete analyses. La difference d’EVA finale entre le groupe « antalgiques seuls » et le groupe « antalgiques de palier inferieur et cryotherapie » a ete estimee a 0,70 IC 95 % [0,10; 1,31]. La meme analyse a ete realisee en stratifiant sur le palier d’EVA initiale, la difference d’EVA finale entre le groupe « antalgiques seuls » et le groupe « antalgiques de palier inferieur et cryotherapie » a ete estimee a 0,68 IC 95 % [0,17; 1,20]. Cette etude demontre que la cryotherapie seule ou en association avec un antalgique est non inferieure mais aussi superieure a un traitement antalgique seul de palier superieur sur la douleur d’origine traumatique.

Supplemental material for Improving survival in end-stage renal disease: A case study by MH Elsensohn, E Dantony, J Iwaz, E Villar, C Couchoud and R Ecochard in Statistical Methods in Medical Research

Objectifs L’objectif de notre etude est d’evaluer l’interet et la securite de l’absence de sondage urinaire pour les chirurgies de tumorectomie renale par voie robot-assistee (rapn) dans le cadre d’un protocole rehabilitation amelioree apres chirurgie (raac). Methodes Il s’agit d’une etude monocentrique et comparative non randomisee. Tous les patients operes consecutivement d’une rapn en raac entre fevrier 2015 et decembre 2017 ont ete inclus dans l’etude. La cohorte a ete divisee en deux groupes : le groupe de patients non sondes (ns) et le groupe controle avec sonde urinaire (s) en peroperatoire. Nous avons compare entre les deux groupes : le taux de retentions aigues urinaires postoperatoires (rau), le taux d’infections urinaires postoperatoires (iu), la duree d’hospitalisation ainsi que les complications dans les 30 jours suivant la chirurgie. Resultats Au total, 145 patients ont ete inclus dans le protocole raac pour rapn (49 groupe ns versus 96 groupe s). Il n’y avait pas de difference significative entre le groupe ns et le groupe s en termes d’incidence de rau (6,1 versus 3,1 % respectivement ; p = 0,393) ; d’infections urinaires (2 versus 3,1 % ; p = 0,707) ; de complications postoperatoires (18,4 versus 14,6 % ; p = 0,445). La duree d’hospitalisation moyenne etait plus courte dans le groupe ns (2,16 versus 2,56 jours ; p = 0,058). Onze (7,6 %) patients ont du etre rehospitalises dans les 30 jours postoperatoires : [8 (8,3 %) du groupe s versus 3 (6,1 %) du groupe ns ; p = 0,636]. La duree moyenne d’hospitalisation totale (incluant les jours de rehospitalisation) etait inferieure dans le groupe ns (2,27 versus 3,4 jours ; p Tableau 1 , Tableau 2 , Tableau 3 ). Conclusion Notre etude remet en cause le caractere systematique du sondage urinaire pour les rapn. L’absence de sondage vesical ne semble pas augmenter l’incidence des retentions aigues d’urines postoperatoires et la sonde urinaire pourrait etre reservee uniquement pour des populations ciblees a risque.

Resume Introduction L’objectif de cette etude a ete d’evaluer l’apport de l’IRM prostatique telle qu’elle etait realisee en routine en preoperatoire dans le bilan du cancer de prostate cliniquement localise. Patients et methode Entre juin 2006 et avril 2011, tous les patients operes d’une prostatectomie radicale dans le service ont eu une IRM de prostate (1,5 T, sequences T1 et T2 avec antenne endorectale). Les examens ont ete realises avec un delai de huit semaines au moins apres les biopsies et ont ete interpretes par le meme radiologue. L’existence de cancer pour chaque zone, le franchissement capsulaire et l’atteinte des vesicules seminales ont ete repertoriees. La correlation entre les donnees de l’IRM et l’anatomopathologie de la piece operatoire a ete etudiee. Resultats Deux cent quinze patients ont ete inclus, soit 1290 sextants analyses. Les sensibilites et specificites etaient les suivantes : pour la prediction du franchissement capsulaire (EEC) 26 % et 96 % ; pour l’atteinte des vesicules seminales (SVI) 17 % et 98 % ; pour la localisation du cancer 64 % et 74 % ; pour la prediction de la lateralite 81 % et 48 %. Discussion La comparaison de ces resultats avec les nomogrammes existants (Partin, Kattan) mettait en evidence des resultats equivalents de l’IRM pour le staging . La prediction de la lateralite etait superieure avec les biopsies (sensibilite 88 %, specificite 70 %). L’IRM telle qu’elle a ete realisee dans notre centre offrait des resultats dans les limites basses des donnees de la litterature. Son apport pratique etait limite. Realisee selon ces modalites, elle offre peu d’interet par rapport aux outils existants.

Resume Il peut s’averer interessant de recourir a une plastie extra-articulaire anterolaterale venant renforcer la necessaire reconstruction du ligament croise anterieur (LCA), quand la laxite anterieure est globale, soit a cause des lesions peripheriques initiales soit secondairement par distension de l’enveloppe peripherique avec une composante anterolaterale, mais la controverse existe. Les auteurs ont compare, avec un recul de 7 ans, 2 series randomisees de reconstructions du LCA, l’une intra-articulaire (autogreffe libre au ligament patellaire, groupe 1, 34 patients), l’autre intra et extra-articulaire (Mac-InJones, groupe 2, 29 patients), avec comme critere d’inclusion, une laxite differentielle mediale d’importance moyenne, comprise entre 7 et 12 mm sur des radiographies dynamiques passives a 20 de flexion. Le score fonctionnel subjectif IKDC, pour 72 % du groupe 1, etait de 83,6 ± 3,5 et ±pour 68 % du groupe 2, il etait de 83,5 ± 3,5. Pour le score IKDC global, dans le groupe 1 : 0 % classes A, 52,4 % B, 28,6 % C, 19 % D et pour le groupe 2 : 5,5 % classes A, 50 % B, 33,3 % C, 11,1 % D. Le ressaut dans le groupe 1 etait absent dans 61,9 % des cas, de stade 1 : 28,6 %, de stade 2 : 9,5 %. Dans le groupe 2, le ressaut etait absent dans 78,9 % des cas, de stade 1 : 15,8 %, de stade 2 : 5,3 %. Le KT-1000 ne montrait pas de difference de gain sur la laxite : 31 % pour le groupe 1 et 27 % pour le groupe 2. Il n’y avait pas de difference non plus pour les mesures radiologiques avec un gain de 43,9 % sur la laxite differentielle initiale du compartiment medial et 45,3 % sur celle du compartiment lateral dans le groupe 1, contre un gain medial de 51,9 % et lateral de 41,8 % dans le groupe 2. Le positionnement des tunnels n’etait pas different dans les 2 groupes selon la methode d’Aglietti. Les criteres d’inclusion seraient aujourd’hui differents et seraient bases sur l’importance de la laxite du compartiment lateral.

Resume La maladie de Horton est la plus frequente des vascularites. Elle peut se compliquer par des accidents cardiovasculaires (infarctus du myocarde, accidents vasculaires cerebraux), mais leur incidence reelle et leur risque relatif par rapport a la population generale sont inconnus. Objectif. – Evaluer l'incidence des accidents cardiovasculaires dans une etude en double cohorte prospective de patients avec maladie de Horton par rapport a des temoins, apres ajustement sur les facteurs de risque cardiovasculaire. Patients et methodes. – Quatre cent trente-deux patients nouvellement diagnostiques ont ete inclus sur des criteres preetablis, et apparies par âge et par sexe a des temoins tires au sort dans la population generale. Les facteurs de risque cardiovasculaire majeurs etaient mesures a l'inclusion : tabagisme, maladie atheromateuse, diabete, hypertension arterielle, hypercholesterolemie. Les cas et les temoins ont ete suivis pendant 24 mois avec recueil de la survenue d'accidents cardiovasculaires : infarctus du myocarde, angor, accidents vasculaires cerebraux constitues ou transitoires, arteriopathie obliterante des membres inferieurs. La survenue d'accidents cardiovasculaires au cours du temps a ete etudiee en analyse univariee par un test du log-rank apres stratification sur les facteurs de risque cardiovasculaire et en analyse multivariee par un modele de survie parametrique. Resultats. – Les accidents cardiovasculaires sont globalement plus frequents chez les cas que chez les temoins (RR = 2,15 [1,21–3,81], p = 0,009) ; ils sont lies a l'âge (p = 0,0001), aux antecedents d'accidents cardiovasculaires (p = 0,023) et a la maladie de Horton (p = 0,009). Pris separement, les accidents neurologiques (RR = 2,42 [0,84–7]) et les accidents cardiaques (RR = 1,67 [0,72–3,89]) sont plus frequents sans que les ecarts soient cependant significatifs. Conclusion. – La mise en evidence d'un surrisque d'accidents cardiovasculaires en cas de maladie de Horton doit faire discuter l'adjonction d'un traitement antiagregant preventif au long cours.

Objective The aim of this study was to assess the usefulness of color Doppler energy in the preoperative diagnosis of ovarian malignancy using multivariate logistic regression analysis. Methods One hundred and thirty adnexal masses were studied with transvaginal B-mode, color energy, and pulsed Doppler ultrasonography before surgery in order to develop a model that could be used to determine malignancy. Each ultrasonographic variable (tumor size, wall thickness, septal structure, echogenicity, papillary projection, density (solid or not)) was included individually or combined together as part of the Sassone ultrasound score. Intratumoral blood flow velocity waveforms were obtained to determine pulsatility index and resistance index and a more subjective parameter, location of tumor vascularity, was also assessed. Menopausal status and serum CA 125 levels were also entered as categorical variables. Sonographic parameters were entered alone, then associated with menopausal status and CA 125 serum levels, and finally with Doppler energy measurements. Our model was then validated in a group of 68 adnexal masses and compared to the model of Alcazar. Results Eighteen adnexal masses (13.8%) were malignant or of low malignant potential. Multivariate analysis showed that papillary projection of the tumor wall, cyst with solid parts, resistance index with a cut-off value of 0.53, CA 125, and central blood flow location, were the only factors to be independent predictors of malignancy. Menopausal status was not an independent factor. For the final model including the Doppler energy parameter the best sensitivity and specificity were 83% and 93%, respectively, at a cut-off value of 10% probability of malignancy compared to 83% and 87% for the morphological variables alone. Validation of the model showed its diagnostic performance to be as good as that reported in the original population and better than the model of Alcazar. Conclusion Sonographic analysis of adnexal masses including color Doppler energy shows the best predictive properties according to histological diagnosis, and improves preoperative diagnosis of malignancy. Copyright © 2002 International Society of Ultrasound in Obstetrics and Gynecology

Introduction Les voies aeriennes distales (VAD) sont responsables de moins de 25 % des resistances totales chez un sujet sain et sont le principal site d’obstruction chez l’asthmatique (plus de 50 % des resistances totales). L’asthme est une maladie heterogene et plusieurs phenotypes ont ete decrits. A ce jour, l’exploration fonctionnelle respiratoire est peu prise en compte dans ces evaluations phenotypiques et l’analyse des petites voies aeriennes n’a pas ete etudiee. L’objectif de cette etude est d’analyser les caracteristiques phenotypiques de l’asthme avec atteinte des VAD. Methodes Notre etude retrospective s’est deroulee entre novembre 2014 et avril 2015, au sein de 2 services de pneumologie francais. Un asthme avec atteinte des VAD etait defini par : VEMS/CVF ≥ 70 %, VEMS ≥ 80 % de la theorique et soit VR > valeur predite + 1,64 RSD, soit DEM50 [1] . Une atteinte des voies aeriennes proximales (VAP) etait definie par : VEMS/CVF Resultats Sur 69 patients asthmatiques, 44 ont ete inclus dans le groupe VAP et 25 dans le groupe VAD. Une large majorite des asthmatiques du groupe VAD etait des femmes (80 %, p = 0,041), vivant en milieu urbain (79 %, p = 0,073). L’indice de masse corporelle etait plus bas dans le groupe VAD que dans le groupe VAP (24,3 vs 27,4 kg/m 2 , p = 0,032). Une atopie familiale etait presente chez 84 % et 60 % des patients du groupe VAD et VAP respectivement ( p = 0,044). Un antecedent atopique personnel etait present chez 80 % et 54,5 % des patients du groupe VAD et VAP respectivement ( p = 0,041). L’asthme etait plus severe dans le groupe VAP que dans le groupe VAD ( p p = 0,027). Conclusion Nos resultats demontrent que l’asthme avec atteinte des VAD est davantage associe a l’atopie, avec un meilleur controle et une moindre severite que l’asthme avec atteinte des VAP, dans une population a predominance de femmes, sans surpoids. Ces resultats suggerent l’existence d’un phenotype original d’asthme avec atteinte des VAD, qui doit etre confirme par des etudes de plus grande ampleur.

Purpose: To evaluate the effects of contrast media pharmokinetic differences on aortic enhancement at abdominal CT angiography and to determine whether these effects are of clinical relevance. Material and Methods: Two hundred and twelve patients referred for abdominal CT angiography were included in the study. All abdominal CT angiograms were performed with the same parameters (collimation 3 mm, pitch ratio 1.7, scan delay 30 s) after i.v. injection of 120 ml of contrast medium at 3 ml/s. After randomization, patients received either iobitridol 300 (low-osmolar, 300 mg I/ml), iobitridol 350 (low-osmolar, 350 mg I/ml) or ioxithalamate 350 (high-osmolar, 350 mg I/ml). The time attenuation curves obtained with the three contrast media were compared. Results: The time attenuation curve obtained with ioxithalamate 350 was not parallel to those obtained with iobitridol 300 and iobitridol 350. Mean peak enhancements obtained with iobitridol 350 and ioxithalamate 350 were not significantly different but iobitridol 350 provided higher mean peak enhancement than iobitridol 300. Mean delays of the peak enhancements were the same with the three contrast media. After peak enhancement, the decrease of aortic opacification under a selected threshold of 200 HU was significantly slower with iobitridol 350 than with iobitridol 300 and ioxithalamate 350, whereas iobitridol 300 and ioxithalamate 350 showed no significant differences. Conclusion: For a given iodine concentration, low-osmolality contrast media provide longer aortic opacification and may be recommended for CT angiography when long acquisition times are needed.

Purpose: To evaluate the effects of contrast media pharmokinetic differences on aortic enhancement at abdominal CT angiography and to determine whether these effects are of clinical relevance. Material and Methods: Two hundred and twelve patients referred for abdominal CT angiography were included in the study. All abdominal CT angiograms were performed with the same parameters (collimation 3 mm, pitch ratio 1.7, scan delay 30 s) after i.v. injection of 120 ml of contrast medium at 3 ml/s. After randomization, patients received either iobitridol 300 (low-osmolar, 300 mg I/ml), iobitridol 350 (low-osmolar, 350 mg I/ml) or ioxithalamate 350 (high-osmolar, 350 mg I/ml). The time attenuation curves obtained with the three contrast media were compared. Results: The time attenuation curve obtained with ioxithalamate 350 was not parallel to those obtained with iobitridol 300 and iobitridol 350. Mean peak enhancements obtained with iobitridol 350 and ioxithalamate 350 were not significantly different but iobitridol 350 provided higher mean peak enhancement than iobitridol 300. Mean delays of the peak enhancements were the same with the three contrast media. After peak enhancement, the decrease of aortic opacification under a selected threshold of 200 HU was significantly slower with iobitridol 350 than with iobitridol 300 and ioxithalamate 350, whereas iobitridol 300 and ioxithalamate 350 showed no significant differences. Conclusion: For a given iodine concentration, low-osmolality contrast media provide longer aortic opacification and may be recommended for CT angiography when long acquisition times are needed.

The aim of the study was to assess the added value of a prostatic MRI performed in a non-expert center before radical prostatectomy for prostate cancer.All patients considered for a radical prostatectomy for a clinically localised prostate cancer in our institution between June 2006 and April 2011 were analysed. They underwent a systematic endorectal 1.5 T MRI [eMRI] (T2 and diffusion-weighted imaging). The procedure was performed at least 8 weeks after transrectal ultrasound guided prostate biopsies. They were analyzed by a single experimented genitourinary radiologist. The preoperative characteristics and biopsy data were collected, as the eMRI interpretation using a systematic scale. Correlation between eMRI and final histopathology has been analyzed (standardized pathological report using the Stanford procedure). We considered the following points: extracapsular extension, seminal vesicle invasion and cancer localisation. Cancer localization was analyzed both by halves (left/right) and on sextant-basis (base, middle, apex, left and right respectively). For each data, sensitivity, specificity, positive (PPV) and negative predictive value (NPV) were calculated. Finally, we compared the results with those from the Partin's table and the Kattan's nomogram for T stage.Two hundred and fifteen patients underwent a radical prostatectomy, having a mean age of 63 ± 6 years, a mean PSA: 7.8 ± 3.8 ng/mL. One hundred and fifty-nine patients had organ confined disease. Fifty-six had pT3 disease (50 pT3a and 6 pT3b). Sensibilities and specificities were the following: for extracapsular extension 26% and 96%; for seminal vesicle invasion 17% and 98%; for cancer localisation 64% and 74%; for prediction of left or right side 81% and 48%.MRI showed equal performances compared to the Partin's table and the Kattan's nomogram for T stage. It showed lower performance compared to biopsy results for cancer localization (sensitivity 88%, specificity 70%). Literature provides wide ranges of results for eMRI. The results of this study were at the low limit of these ranges but reflect everyday practice. When performed, as it was in our study, eMRI did not seem to be accurate for staging. It had at best a very limited added value compared to the existing tools.

ObjectiveTo develop a classification for neuromuscular disease patients in each of the three motor function domains (D1: standing and transfers; D2: axial and proximal function; D3: distal function).Materials and methodsA draft classification was developed by a study group and then improved by qualitative validation studies (according to the Delphi method) and quantitative validation studies (content validity, criterion validity and inter-rater reliability). A total of 448 patients with genetic neuromuscular diseases participated in the studies.ResultsOn average, it took 6.3minutes to rate a patient. The inter-rater agreement was good when the classification was based on patient observation or an interview with the patient (Cohen's kappa=0.770, 0.690 and 0.642 for NM-Score D1, D2 and D3 domains, respectively). Stronger correlations (according to Spearman's coefficient) with the respective “gold standard” classifications were found for NM-Score D1 (0.86 vs. the Vignos Scale and −0.88 vs. the Motor Function Measure [MFM]-D1) and NM-Score D2 (−0.7 vs. the Brooke Scale and 0.64 vs. MFM D2) than for NM-Score D3 (0.49 vs. the Brooke scale and −0.49 vs. MFM D3).Discussion/conclusionsThe NM-Score is a reliable, reproducible outcome measure with value in clinical practice and in clinical research for the description of patients and the constitution of uniform patient groups (in terms of motor function).

Objectifs Des 1996, les hospices civils de Lyon (HCL) ont etabli un recueil des accidents d’exposition au sang (AES) aupres de 24 000 professionnels de sante. Un systeme sentinelle etait necessaire pour detecter les variations de ces AES. Methodes Divers parametres (geste, materiel en cause, etc.) sont saisis sur CHIMED (logiciel de sante au travail), extraits avec business objects et analyses sous SAS v9.3. Avec la loi de Poisson, nous donnons chaque annee, geste par geste, un seuil de baisse ou de hausse, c’est-a-dire un nombre en dessous ou au-dessus duquel il est possible d’evoquer une diminution ou une augmentation des AES. Si la probabilite de survenue d’un accident varie d’une annee a l’autre, alors il y a surdispersion (effet fixe et aleatoire). Des modeles non lineaires a effets mixtes (distribution negative binomiale) analysent cette variation et prennent en compte l’effet lie a chaque modalite (effet aleatoire). Nous pouvons ainsi indiquer une tendance a plus long terme, refletant le succes de l’introduction de moyens de prevention ou une aggravation en lien avec certaines procedures. Ces resultats sont presentes par des tableaux de classement (league tables) qui donnent, pour les circonstances a l’origine d’AES, les rapports de risque avec leurs intervalles de confiance, et permettent un reperage rapide des procedures liees a une variation d’AES ou bien, comparent les circonstances d’AES deux a deux. Un graphique en entonnoir permet de visualiser les pentes relatives aux modalites et de detecter les changements significatifs. Resultats En 20 ans, 17 315 AES ont ete analyses. Leur nombre annuel a diminue de 30 %. La politique promouvant le materiel de securite, tot introduite par les HCL, a ete generalisee, conformement a la directive europeenne de 2010. Ce systeme sentinelle a montre l’impact de nouveaux materiels de securite pour les prelevements sanguins (capillaires, hemocultures) ou celui du rappel des precautions standard et des protocoles d’evacuation des materiels et de transport des dechets. Ce systeme a signale aussi de brusques baisses (prelevements veineux et capillaires, rangement-evacuation du materiel) ou augmentations (injections sous-cutanees) des AES. Conclusions Le systeme est souple car applicable a chaque duree, service, categorie de personnel, processus de soins, etc. Bien que perfectible, il a montre l’efficacite des mesures de prevention et permet de cibler des actions vers des tâches specifiques ou un personnel expose.

La litterature scientifique s'est developpee de facon considerable, specialement dans le domaine de la sante et de la medecine. En parallele, la recherche medicale est devenue de plus en plus complexe. Les medecins ont de ce fait besoin d'avoir a leur disposition des methodes de lecture critique. Le principe de la lecture critique de la litterature medicale est d'evaluer la valeur des publications qui sont susceptibles d'influencer la pratique medicale du lecteur. Le lecteur a un double objectif: evaluer la credibilite de ces publications et definir l'applicabilite des informations qu'elles contiennent. Grâce a une methode de lecture en huit etapes, le lecteur est capable d'eliminer rapidement ce qui n'est pas valide, et d'avoir un regard objectif sur la qualite des resultats qui lui sont proposes. Ces huit etapes sont l'analyse des objectifs de l'etude, du type de l'etude, du facteur etudie, du critere de jugement, de la population etudiee et de son echantillon, des biais et facteurs de confusion, des resultats avec leur signification statistique et clinique ainsi que la puissance de l'etude, et enfin la synthese des jugements du lecteur. Cette methode a le merite de s'adapter a tout les types de publication. A travers cette approche le dernier mot appartient au clinicien face a son malade.

Nous avons analyse les resultats de 492 cycles d'Insemination Artificielle avec sperme du Conjoint (IAC) par voie Intra-Uterine (IU) chez 152 couples en utilisant la methode des courbes de survie en modele de Cox. 36 grossesses ont ete obtenues. Le taux cumule de grossesse etait de 20% a 3 cycles et de 31% a 6 cycles. L'analyse univariee n'a pas revele de facteur pronostique de succes. L'analyse multivariee a fait apparaitre que l'âge de l'homme ≥ 35 ans etait un facteur de mauvais pronostic (p=0,04) de meme que l'existence d'une dysovulation. L'âge de la femme > 35 ans contrairement a notre attente n'est pas apparu comme un facteur de pronostic statistiquement significatif apres prise en compte des autres facteurs.

La meta-analyse est une methode utilisant des techniques statistiques pour combiner les resultats de plusieurs etudes differentes, afin d’obtenir une estimation de l’effet global d’un processus etudie. Cette technique offre un gain de puissance, et l’on peut ainsi obtenir une information pertinente que ne peut pas fournir une etude seule. Deux approches sont possibles et souvent intriquees: l’approche quantitative et l’approche qualitative. La meta-analyse offre une plus grande aptitude a generaliser les resultats. Elle diminue la part de subjectivite et oblige a plus de rigueur. Elle aide les medecins, comme les responsables de la politique de sante, a repondre a des questions specifiques.

Resume Une enquete visant a decrire l'incidence et les caracteristiques demographiques, cliniques, bacteriologiques, et evolutives de l'endocardite infectieuse en France a ete conduite entre le 1er novembre 1990 et le 31 octobre 1991, de facon exhaustive, dans trois regions francaises — Ile de France, Lorraine, et Rhone-Alpes —. Selon les criteres de Von Reyn modifies par l'echocardiographie, 386 cas d'EI certaine, probable, ou possible ont ete retenus, ainsi que 24 cas d'EI survenues moins d'un an apres la pose d'une prothese valvulaire. L'incidence etait de 23,6 cas / million d'habitants, plus elevee chez les hommes — 31,9 cas / million d'hommes — que chez les femmes — 15,7 cas / million de femmes. L'âge etait de 56,3 ± 19,0 ans; 65 % etaient des hommes; 57 % provenaient de la region Ile de France, 13 % de la region Lorraine, 30 % de la region Rhone-Alpes; 31 % etaient considerees comme certaines, 53 % comme probables, et 16 % comme possibles. Le cœur etait presume sain dans 36,5 % des cas; 10,9 % des patients etaient porteurs d'une cardiopathie non valvulaire, 52,6% d'une atteinte valvulaire, pour laquelle 65 sujets (16,8 % du total) ont recu une ou plusieurs protheses valvulaires. Le siege de l'EI etait mitral dans 39 %, aortique dans 37 %, mitro-aortique dans 13 %, tricuspide dans 6 %. Le micro-organisme a ete retrouve dans 89,0 %. Il s'agissait dans 20,6 % des cas d'un staphylocoque, Staphylococcus aureus dans plus de trois quarts des cas, et dans 58,7 % d'un streptocoque, surtout non groupable (48 % des streptocoques), ou du groupe D (42 % des streptocoques). La porte d'entree fut retrouvee ou presumee chez 66,9 %, dentaire (26,0 %), digestive (12,7 %), iatrogene (9,1 %), cutanee (5,0 %), urinaire (3,9 %). Dans 19 cas (5,2 %), il s'agissait d'un toxicomane. Sur le plan evolutif, 16,7 % ont ete operes au cours du premier mois, 24,7 % au cours des 2 premiers mois; 12,2 % sont decedes au cours du premier mois, 16,1 % au cours des 2 premiers mois.

Cancers of the ENT, oesophagus and lungs are caused mainly by alcohol and/or tobacco consumption but have potentially heterogeneous latencies and dose-incidence relationships. The incidence of cancers having the same risk factors may vary in a similar way over time and space. The aim of the study was to identify groups of cancers with similar spatio-temporal incidence trends.Fifty thousand nine hundred and eighty cases of ten cancer types were collected between 1982 and 2002 in six French departments. The incidence levels and trends were assessed using an age-cohort random-effect model that took into account heterogeneity of incidence levels and trends between departments.Three groups of cancer sites/types with similar spatio-temporal incidence trends were identified: (1) oral cavity, oropharynx, hypopharynx, larynx, oesophagus, and lung squamous cell carcinomas in which the incidence decreased similarly in time and space; (2) other types of lung cancer and lung adenocarcinomas whose incidence increased similarly; and (3) lung large- and small-cell carcinomas whose incidence trends were heterogeneous.Using the tools of descriptive epidemiology different cancer groups with different temporal and spatial incidence trends were identified. This diversity suggests different latencies and different sensitivities of those groups to the main risk factors, alcohol and tobacco.

Cataract surgery is a usually successful procedure that restores vision by replacing the natural lens with an intraocular lens (IOL). Acute postoperative endophthalmitis is still one of the most serious complications of cataract surgery. Its incidence has been reported to be between 0.04% and 0.32%. Precisely why bacteria induce endophthalmitis is not entirely understood. Indeed the risk of its development may be influenced by several factors. Among them, bacterial adhesion to the IOL has been recently emphasized in the ophthalmology literature. Indeed, the ability of an organism to adhere to the IOL surface is believed to be associated with a risk of infection at the implantation site. Several studies have demonstrated that bacterial adhesion is influenced by IOL materials. Ever since, numerous studies have investigated the interactions between bacteria and different types of IOLs to determine which biomaterial would be most permissive to bacterial adherence. This article reviews all the epidemiological and experimental data relating to the study of the relationship between bacterial adhesion, IOL material, and risk of developing postoperative endophthalmitis. Even if discrepancies between these studies exist, mainly stemming from the use of different experimental conditions and protocols, it seems that bacterial adhesion is strongly influenced by IOL material. Epidemiological studies suggest that the implantation of silicone IOLs might be associated with increased rates of endophthalmitis. Experimental studies reach similar conclusions showing that hydrophobic IOLs such as silicone or acrylic hydrophobic IOLs are more permissive to bacterial adhesion and growth than hydrophilic IOLs such as acrylic hydrophilic IOLs. Among the interactions that govern bacterial attachment to the IOLs, it seems that hydrophilic-hydrophobic interactions have the greatest influence. Nevertheless, since bacterial adhesion is a complicated process affected by many factors, the conclusions drawn by these results have to be interpreted with care. Further investigations are still needed to understand the connections between IOL material and endophthalmitis.

Crosses were made between two tetraploid wheats, Ensat-508, an Ethiopian line with a high percentage of protein, and 'Opale', a French cultivar obtained in our laboratory. Reciprocal F1, F2, and backcrosses and the parents were grown in a greenhouse, and the heredity of percentage of grain protein was determined. Reciprocal effects were not significant; narrow- and broad-sense heritabilities were rather high (37.89 and 69.83%, respectively). Ensat-508 has brown, hairy (i.e., with a long pilose brush at the apical end) kernels whereas 'Opale' has amber, glabrous kernels. Our studies show that hairiness of kernels is controlled by a gene with intermediate dominance (proposed designation: Hgr) and brown color of kernels by a dominant gene (temporary designation: Br). Considering the high correlations observed between these two characters and the percentage of grain protein, both Hgr and Br genes should be considered as new genetic markers for breeding programs. Selection for hairy kernel in progenies should improve the percentage of protein.Key words: protein, hairy kernel, markers, linkage.

Genetic Variability for Some Brewing Quality Characters in Barley Malting and brewing quality of six different barley genotypes and their F1 hybrids were investigated in a diallel cross programme. Plants were grown in pots in a randomized block design with four replications. General and specific combining abilities were determined for 1000 grain weight, percentage of proteins of the grain, percentage of water uptake, and, after micromalting, for β-glucanase and α-amylase activities. Significant general and specific combining abilities were observed for all the traits studied. 1000 grain weight, percentage of proteins and water uptake have been found to be essentially controlled by genetic additive effects, while enzymatic activities of malt have been found to be mostly controlled by dominance effects. ‘Karl’ has interesting characteristics for all traits and general combining abilities, except for 1000 grain weight, and has been introduced in a three-way cross programme with ‘Plaisant’ and ‘Clarine’, also showing interesting values for malting quality and productivity.

A retrospective, population-based study was conducted in Lyon, France, to elucidate the benefits and risks of a treatment for prostatic adenoma (benign prostatic hyperplasia). Case records were reviewed for all prostatectomies performed on patients in Lyon in 1988 for benign prostatic hyperplasia. Data were obtained from all records of public and private hospitals. Of 408 procedures, 312 involved endourethral resection (transurethral resection) and 96 open surgery. The mean weight of resected tissue was 20.3 +/- 0.9 g after endourethral resection and 71.7 +/- 6.4 g after open surgery. About 20% of the resections took place in a university hospital center, 43% in a not-for-profit private hospital, and 37% in a private clinic; there were eight deaths in the first 3 postoperative months, and 11 patients required hospitalization for urologic complications. Length of hospital stay uniquely correlated with age and type of surgery.

Seven barley varieties, differing widely in their geographic origin, were analysed at the seedling stage under controlled conditions for the following traits: Soluble leaf protein content, Rubisco content, Total carboxylase activity, as well as for combinations of these basic characteristics: relative Rubisco concentration, relative carboxylase activity, and specific carboxylase activity of the enzyme

To estimate the probabilities of intrapartum and postpartum HIV-1 mother-to-child-transmission according to various feeding practices (formula feeding, exclusive breastfeeding, or mixed-feeding) and to other mother and infant covariates.We used the promotion time model extended to multiple exposures to study the probability of infection attributable to each transmission occasion. Blood samples from 551 infants from Durban (South Africa) born to HIV-1 positive untreated mothers between 1995 and 1998 were sequentially tested until 15 months.The probability of infection attributable to in utero and intrapartum transmission was 21.88% (18.71-25.20) and was not significantly associated with the feeding practice. The probability of infection attributable to postnatal transmission through exclusive breastfeeding was negligible -0.7% (0-2.5) for 6 months of exclusive breastfeeding-- in comparison with that observed with mixed-feeding -6.15% (3.16-9.57) for 6 months of mixed-feeding. Maternal CD4 cell count and gestational age were significant predictors of intrapartum transmission probability while maternal CD4 cell count and maternal haemoglobin concentration were significant predictors of postpartum transmission probability.Decisions about appropriate infant feeding practices should take into account the difference in postpartum transmission risk between exclusive and mixed-feeding. Mixed-feeding should be all the more avoided that mothers have poor immunological statuses and low haemoglobin concentrations.

Reconstruction of the anterior cruciate ligament (ACL) is a common procedure, but use of lateral reinforcement is still a subject of debate. The purpose of this study was to compare two randomized series of ACL reconstructions, one using an intra-articular method (patellar tendon autograft) and the other an intra- and extra-articular method (Mac-InJones).From January 1995 to March 1998, 63 knees underwent surgery for ACL reconstruction. Inclusion criteria was significant medial differential laxity measured between 7 and 12 mm on passive dynamic x-rays as 20 degrees flexion. Group 1 (patellar tendon intra-articular reconstruction) included 34 patients (27.1+/-7.5 years) and group 2 (intra-articular reconstruction plus extra-articular quadircipital tendon plasty) included 29 patients (28.5+/-12 years). The IKDC score was determined for 72% of the knees in group 1 and 68% in group 2 at seven years follow-up on average (102 and 93 months respectively). Anterior laxity was measured radiographically and with KT-1000. The position of the tunnels was controlled using the Aglietti method.The subjective functional score was 83.6+/-3.5 in group 1 and 83.5+/-3.5 in group 2. The overall IKDC knee score classes for group 1 were 0% A, 52.4% B, 28.6% C, and 19% D and for group 2 were 5.5% group A, 50% group B, 33.3% group C, and 11.1% group D. In group 1, the pivot test was negative in 61.9% and noted stage 1 in 28.6% and stage 2 in 9.5%. In group 2, the pivot test was negative in 78.9% and noted stage 1 in 15.8% and stage 2 in 5.3%. The KT-1000 showed no difference in gain in laxity: 31% for group 1 and 27% for group 2. Similarly, radiographically there was no difference with a 43.9% gain in differential laxity for the medial compartment and 45.3% for the lateral compartment in group 1. In group 2 the corresponding values were 51.9% and 41.8%. The position of the tunnels was the same in the two groups.In a preliminary study with two years follow-up, the results in these two series were not significantly different. It was concluded that there was not clear advantage to adding the extra-articular lateral plasty. At the present 7-year follow-up, pivoting appears to be better controlled in the lateral plasty group (p=0.23), but with no significant difference for laxity for both knee compartments. The inclusion criteria would be different today and would be based on the laxity of the lateral compartment.

Introduction L’anemie est une complication frequente de l’insuffisance renale chronique. Les recommandations de la HAS preconisent un traitement avec des agents stimulant l’erythropoiese (ASE) chez les patients insuffisants renaux (IR) ayant un taux d’Hb ≤ 10 g/dL. L’objectif therapeutique est de maintenir la valeur d’Hb entre 10 et 12 g/dL. Les effets therapeutiques d’un traitement par ASE sont variables selon les patients et 5 % a 10 % des IR sont meme consideres comme « resistants a l’EPO » ce qui augmente leur risque de mortalite. Cette etude vise a evaluer l’impact des comorbidites d’une cohorte de patients hemodialyses sur la reponse aux ASE. Patients et methodes Une association de dialyse hors centre a mene une etude retrospective incluant 278 patients hemodialyses dans 26 unites de dialyse, rattaches a 11 centres prescripteurs, traites par ASE et suivis pendant un an (2014). Les donnees d’administration des ASE sont issues du service de pharmacie, les donnees concernant les comorbidites du registre REIN et les donnees de biologie des bilans biologiques. Les patients hyporepondeurs aux ASE ont ete identifies a l’aide d’un modele lineaire mixte puis leurs comorbidites ont ete comparees a celles du reste de la population grâce a une regression logistique. Les analyses concernant les determinants de la variabilite sont en cours. Resultats Les patients ont en moyenne 63,3 ± 14,2 ans, 1,9 ± 1,7 comorbidites. Vingt-sept patients (10 %) ont ete identifies comme hyporepondeurs aux ASE. L’analyse des comorbidites a permis de mettre en evidence deux facteurs de risque d’hyporeponse : l’AVC (OR = 7,6 [2,3–24,6]) et le cancer (OR = 4,8 [1,1–21,7]). Aucune association n’a pu etre etablie avec les autres comorbidites, l’âge, le sexe ou les parametres du bilan martial et du syndrome inflammatoire. Aucun effet centre n’a ete demontre. Discussion Ces resultats different de ceux rapportes dans la litterature pour des populations traitees en centre lourd. La survenue d’evenements cliniques intercurrents dans ces populations instables pourrait, en partie, expliquer cette difference. Conclusion Cette etude menee sur une cohorte homogene de patients hors centre et peu comorbides met en evidence un impact prononce de l’AVC et du cancer sur la reponse aux ASE.

Giant cell arteritis is the most frequent vasculitis. Cardiovascular events such as cerebrovascular accident or ischemic heart disease may occur in patients with giant cell arteritis. However, their real incidence, as well as their relative risk compared to the general population, remains unknown.To assess in a prospective, double cohort study, the incidence of cardiovascular events in giant cell arteritis patients compared to controls, after controlling for cardiovascular risk factors.We included on predefined criteria 432 newly diagnosed patients with giant cell arteritis, each assigned to sex- and age-matched controls randomly selected from the general population. Cardiovascular risk factors (high-blood pressure, diabetes, smoking, hypercholesterolemia and preexisting peripheral vascular disease) were collected at inclusion. During the 24-month follow-up, all cardiovascular events were collected. After stratification for cardiovascular risk factors, a log-rank test was performed to compare cases and controls. A parametric survival model was used for multivariate analysis.Cardiovascular events all combined were significantly increased in patients with giant cell arteritis (RR = 2.15 [1.21-3.81], P = 0.009), and were mainly associated with age (P = 0.0001), past history of cardiovascular disease (P = 0.023) but also with giant cell arteritis (P = 0.009). However, each subset of cerebrovascular accident (RR = 2.42 [0.84-7]) or ischemic heart disease (RR = 1.67 [0.72-3.89]) increased but did not significantly.Cardiovascular events incidence is increased in patients with giant cell arteritis, and prescription of preventive antiagregant treatment may be discussed.

Protein sparing, the major goal of nutritional support, may be affected by the glucose/lipid ratio. This study in critically ill patients compared the efficacy and tolerance of two isocaloric isonitrogenous total parenteral nutritions (TPN) having different glucose/lipid ratios. Multicentric prospective randomized study. 47 patients with SAPS I score higher than 8 and requiring exclusive TPN. Patients received glucose/lipid ratios of 50/50 or 80/20. For 7 days all patients received 32 glucidolipidic kcal/kg and 0.27 g/kg nitrogen daily. All-in-one bags were prepared using industrial mixtures and a fat emulsion. We determined TPN efficacy by nitrogen balance, urinary 3-methylhistidine/creatinine ratio, transthyretin and tolerance by glycemia, and liver enzymes. After controlling for five variables with significant effects, patients receiving the 50/50 ratio during TPN had significantly higher nitrogen balance than those receiving the 80/20 ratio. The daily difference in mean nitrogen sparing effect in favor of the latter group was 1.367 g (95% CI 0.0686–2.048). Glycemia on day 4 and γ-glutamyltranspeptidase on day 8 were higher in group receiving the the 80/20 ratio. In critically ill patients TPN at a glucose/lipid ratio of 80/20 ratio induces a small nitrogen sparing effect compared to the ratio of 50/50, at the expense of poorer glycemic control. The clinical significance is unclear.

Health related quality of life is becoming of greater importance in the medical field. Nevertheless, methodological problems persist, and particularly when it comes to processing missing data on quality of life questionnaires. In fact, this leads to three difficulties: (i) loss of power; (ii) bias; (iii) choice of the most adequate method for treating missing data. Prevention is the best recommendation in order to avoid unanswered questions. Unfortunately, this does not guarantee the absence of missing data. Therefore, the treatment of missing data depends on: i) identification of the missing data mechanism and ii) choice of the most appropriate method to correct the data. The main objective of this article is to illustrate the identification of non-response items as described in the SF-36 questionnaire items in the SU.VI.MAX study.A logistic regression on the characteristics of the subjects was used to distinguish between two missing data mechanisms: missing completely at random (MCAR) and missing at random (MAR). Two global Chi-2 tests on MCAR mechanism were proposed. The missing data not at random (MNAR) mechanism was also analysed considering the questionnaire features.The percentage of non-responses was small (1.7%), with a maximum equal to 3% for four questions of the General Health dimension (GH2 to GH5). Both global Chi-2 tests rejected the hypothesis that all SF-36 non-responses were MCAR. As to the 32 items with less than 2.3% of non-responses, the mechanisms were: MCAR for 29 items, MAR for 2 items, and probably MNAR for 1 item. The logistic regression indicates that the factors related to non-responses were gender (female), age (or =50 years), attention problem, and number of children (or =3). The hierarchical feature of item PF5 (climb one flight of stairs) in relation to PF4 (climb several flights of stairs) would be a generator MNAR non-responses. The "I don't know" response modality of bloc GH2 to GH5 would also be generator of non-responses of the MNAR type.The identification of missing data mechanisms through statistical analysis and through further reflection on the questionnaire's features is a necessary preliminary in the treatment of non-responses.

The aim of this study was to assess the usefulness of color Doppler energy in the preoperative diagnosis of ovarian malignancy using multivariate logistic regression analysis.One hundred and thirty adnexal masses were studied with transvaginal B-mode, color energy, and pulsed Doppler ultrasonography before surgery in order to develop a model that could be used to determine malignancy. Each ultrasonographic variable (tumor size, wall thickness, septal structure, echogenicity, papillary projection, density (solid or not)) was included individually or combined together as part of the Sassone ultrasound score. Intratumoral blood flow velocity waveforms were obtained to determine pulsatility index and resistance index and a more subjective parameter, location of tumor vascularity, was also assessed. Menopausal status and serum CA 125 levels were also entered as categorical variables. Sonographic parameters were entered alone, then associated with menopausal status and CA 125 serum levels, and finally with Doppler energy measurements. Our model was then validated in a group of 68 adnexal masses and compared to the model of Alcazar.Eighteen adnexal masses (13.8%) were malignant or of low malignant potential. Multivariate analysis showed that papillary projection of the tumor wall, cyst with solid parts, resistance index with a cut-off value of 0.53, CA 125, and central blood flow location, were the only factors to be independent predictors of malignancy. Menopausal status was not an independent factor. For the final model including the Doppler energy parameter the best sensitivity and specificity were 83% and 93%, respectively, at a cut-off value of 10% probability of malignancy compared to 83% and 87% for the morphological variables alone. Validation of the model showed its diagnostic performance to be as good as that reported in the original population and better than the model of Alcazar.Sonographic analysis of adnexal masses including color Doppler energy shows the best predictive properties according to histological diagnosis, and improves preoperative diagnosis of malignancy.

Worsening of heart failure in patients with myocardial infarction is seldom studied, elderly patients often are not included, and multivariate analysis is uncommon.The prospective PRIMA study (Prise en charge de l'Infarctus du Myocarde Aigu; management of acute myocardial infarction) sought to determine the incidence of heart failure worsening, its risk factors, and its prognostic importance in patients with myocardial infarction, regardless of age and hospital facilities, in the "real world" in a region in France, using multivariate analysis.Data were prospectively collected in all patients with myocardial infarction admitted in all hospitals in three departments in the Rhône-Alpes region in France between September 1, 1993 and January 31, 1995.Among 2,507 patients, 33% were in Killip classes II-IV at admission. Four hundred and sixteen patients (17%) had worsening of Killip class during the first five days. In-hospital mortality (overall: 14%) increased dramatically with Killip class at admission (9% in class I; 62% in class IV) and with worsening of Killip class during the first five days (36% vs 8% if no worsening). In multivariate analysis, older age, diabetes mellitus and anterior Q-wave myocardial infarction were significant predictors of Killip class at admission and of its worsening. The significant predictors of in-hospital mortality were older age, Killip class III at admission and worsening of Killip class during the first five days.This large, unselected cohort revealed that among patients with myocardial infarction, heart failure and its worsening are frequent, especially in the elderly, and dramatically worsen the in-hospital mortality.

Our objective was to assess the impact of selected geographic factors and patients' characteristics on thrombolysis rates in patients resident and hospitalised for acute myocardial infarction in three departments of the Rhĵne-Alpes Region (France). We used a two-level hierarchical model to estimate and explain geographic areas' specific effects. Old subjects and women were less frequently treated than young subjects and men. Severe, non-anterior and non-Q-wave myocardial infarctions were associated with lower thrombolysis rates. It was also lower in patients with a pulmonary chronic disease, a cancer, a peripheral arterial disease, a history of cerebrovascular accident or transient ischaemia attack, and in patients with a psychiatric disorder. After adjusting for patients' characteristics, significant variations in thrombolysis rates remained between geographic areas (up to 3.2 times). These variations seem to be partly explained by distance or isolation: a longer distance to the closest hospital or a high degree of isolation seem to lower the probability of thrombolytic therapy. Several other sources of treatment variation between the studied geographic areas remain unexplored. These factors, especially those that augment the delay to treatment, are to be identified in order to augment fibrinolysis usage and reduce inter-area heterogeneity.

Introduction La morbidite precoce de la transplantation rein pancreas est principalement liee au risque hemorragique et thrombotique du greffon pancreatique. Un taux de reprise chirurgicale de 44,3 % a precedemment ete retrouve a partir de donnees francaises [1] . Le thromboelastogramme (ROTEM ® ) pourrait permettre d’identifier des troubles de l’hemostase en periode peri-operatoire et guider les therapeutiques. L’objectif de cette etude etait d’evaluer la capacite du ROTEM ® a detecter les troubles de coagulation en peri-operatoire de transplantation rein-pancreas, en comparant les profils du ROTEM ® des transplantes renaux (TR) et des transplantes rein-pancreas (TRP). Patients et methodes Etude prospective, monocentrique, de soins courants. Accord du CPP. Statistiques par analyse de variances pour mesures repetees et analyse post-hoc par tests de Bonferonni . Population : 85 patients inclus, 22 TRP et 63 TR entre fevrier 2013 et fevrier 2014. Un ROTEM® et un bilan de coagulation etaient effectues a l’accueil du receveur (T0), a 45 min apres declampage vasculaire de greffon (renal ou pancreatique selon le groupe) (T1), a l’arrivee en reanimation ou en service de nephrologie (T2), puis au 2 e et 3 e jour post-operatoire (T3 et T4). Resultats L’âge median etait de 40 ± 8 ans pour les TRP et de 49 ± 13 ans pour les TR. L’evolution du CFT (clot formation time en secondes) de l’EXTEM au cours du temps etait statistiquement differente entre les 2 groupes a T2, T3, T4. Le MCF-A10 (maximum clot firmness en millimetres a 10 minutes) du FIBTEM etait significativement different entre les groupes a T1 et T2 ( Fig. 1 ). Discussion Le monitorage de l’hemostase en perioperatoire par le ROTEM ® pourrait permettre d’identifier des troubles chez les TRP. Parmi les differents parametres, le CFT de l’EXTEM et l’A10 du FiBTEM semblent modifies en post-operatoire precoce. D’autres etudes sont souhaitables pour clarifier l’impact therapeutique du ROTEM ® en transplantation rein pancreas.

The localisation of aldosterone-producing adenomas (APA's) remains difficult. Indeed, CT scan may not detect small APA's while CT detected tumours do not necessarily produce aldosterone.To evaluate the value of adrenal vein catheterization (AVC) for the diagnosis of APA's and also the rates of unsuccessful procedures and complications.One-hundred-and-nine hypertensives with biological features of primary hyperaldosteronism were included. Plasma sodium, potassium, aldosterone and renin levels were obtained after one night in lying position. Aldosterone and renin levels were also measured after a one-hour walking period and after a sodium expansion with saline. All patients underwent a CT scan and AVC. For adrenal samples, the ratio of aldosterone to cortisol concentrations was calculated for both sides. Both ratios were divided by the opposite one and the higher was retained as an index of laterization (IL). For lack of a golden standard variable, we have taken as a working hypothesis that operated patients had an APA (n = 38) and the non operated ones bilateral hypereplasia (n = 71).Operated patients had a shorter history of hypertension, more frequently a left ventricular hypertrophy on ECG, and lower serum creatinine and potassium levels, along with a higher sodium level. None of these features appeared discriminant, however. Presence of a 10-mm tumour on CT scan was not significantly different between the 2 groups. Operated patients had more than a five-fold higher IL compared with that of non-operated patients. Analysis using a ROC curve showed that the value of 12 for "IL" was an acceptable operational criterium of lateralization, producing a specificity of 90%, while maintaining a sensitivity of 62%. AVC appeared most useful in case of middle-range pre-test probability of an APA being present, that is when when clinical, biological, or radiological features are not fully concordant. The rate of unsuccessful procedure and the rate of complications were low (1.8% and 3.6%, respectively).With a low iatrogenicity, AVC appears helpful in indicating surgery mostly when clinical, biological, and CT scan features are not fully concordant. A value of 12 for IL appears to allow a high specificity while retaining an acceptable sensitivity.

This prospective study sought to determine the rate of thrombolysis in myocardial infarction and the factors that influenced it in everyday practice.Data were prospectively collected in all patients admitted in all (48) university, community, and private hospitals in three departments in the Rhĵne-Alpes region in France between September 1, 1993 and January 31, 1995. Data from 2,515 patients were included. Overall, 36% of the patients received thrombolysis. The decrease of the thrombolysis rate with age was very regular. The difference between men and women disappeared almost completely when age was taken into account in a bivariate analysis. Among 19 variables introduced in the logistic regression, only the following ones were significant predictors (odds ratio1 means less thrombolysis): age (odds ratio: 0.60 per decade), administrative department, type of hospital (community/tertiary: 0.74; private/tertiary: 0.58), history of myocardial infarction or of angina pectoris (0.67), location of myocardial infarction (Q wave non anterior/Q wave anterior: 0.75; non Q wave/Q wave anterior: 0.18), delay between symptoms onset and first medical intervention (0.06), history of cancer (0.47), and history of psychiatric disorder (0.38).In France as in other countries, the rate of thrombolysis is low. In order to increase this rate, we have to find ways to be more "aggressive" in older patients, and to precisely describe the health care pathways in order to shorten delays.

This study sought to compare characteristics and management of myocardial infarction in men and women, and whether a difference in management would translate into a difference in in-hospital mortality.Data were prospectively collected in 2,519 patients (801 women) admitted in all hospitals in three departments in the Rhĵne-Alpes region in France between September 1, 1993 and January 31, 1995. Women were older than men (76 vs. 64 years). The interval between symptom onset and initial medical intervention was longer in women than in men (median: 180 vs. 135 minutes), as was the interval between symptom onset and hospital admission (median: 315 vs. 255 minutes). After age-adjustment, women were less often smokers, and more often hypertensive or diabetic than men, location of infarction was more often anterior in women, as congestive heart failure at admission. In multivariate analysis, thrombolysis rate was not significantly different in both sexes, whereas noninvasive tests, coronary arteriography, percutaneous transluminal coronary angioplasty, and coronary artery bypass grafting were significantly less often performed in women than in men. Although in-hospital mortality was higher in women than in men (21% vs. 11%), this difference disappeared after age-adjustment (relative risk = 0.99). In multivariate analysis, gender was not an independent predictor of survival.Although in-hospital mortality after myocardial infarction was similar in both sexes, rates of diagnostic and therapeutic procedures were lower in women than in men. This raises the question of whether mortality would decrease in women if management were similar in both sexes.

The aim of this study was to evaluate the use of H 2 18 O for total-body-water (TBW) determination in patients with short bowel because ileostomy losses of labeled water can falsify TBW. Thirteen adult short-bowel patients were studied after an overnight fast. Saliva, blood, urine and ileostomy output were collected before and 30, 60, 90, 120, 240, and 360 min after oral ingestion of 0.88 g/kg of 2.5% H 2 18 O to measure 18 O abundance by isotope-ratio mass spectrometry. TBW was calculated from the dilution of the isotopic water in saliva and plasma. The quantity of labeled water lost in the ileostomy was calculated from the isotopic enrichment of the ileostomy output from T0 to T360. The values obtained from saliva or plasma with (corrected) and without (uncorrected) considering H 2 18 O lost in the ileostomy output were compared with a paired t test. Agreement was evaluated using the Bland-Altman method. From T0 to T360, the ileostomy output and the percentage of lost labeled water were 490 ± 314 mL and 6.38 ± 8.52%, respectively. TBW calculated from plasma or saliva isotopic enrichment was different, and a significant difference was also observed between corrected and uncorrected TBW values (saliva: uncorrected TBW = 32.35 ± 7.52 L, corrected TBW = 30.29 ± 6.09 L; plasma; uncorrected TBW = 30.80 ± 7.29 L, corrected TBW = 28.79 ± 5.79 L). The agreement between the values obtained from the two dilution spaces or between the two calculation methods was poor. Because of the large discrepancies between calculation methods, determination of TBW from oral ingestion of 18 O-labeled water in patients with short bowel should be calculated only from plasma 18 O space dilution and should consider ileostomy losses.

This study sought to examine the use of treatments at discharge in patients hospitalized for myocardial infarction in a French region.Data from 2,102 patients discharged after myocardial infarction were prospectively collected at 48 university, community, and private hospitals in three departments in the Rh ne-Alpes region between September 1, 1993 and January 31, 1995. Beta-blockers were prescribed in 59% of the patients, calcium channel blockers in 22%, nitrates in 59%, antiplatelet agents in 82%, anticoagulants in 26%, angiotensin-converting enzyme inhibitors in 36%, diuretics in 33%. Beta-blockers were prescribed less often in older patients, and in patients with higher Killip classes or a history of pulmonary disease. Calcium channel blockers were prescribed more often in older patients, and in patients with a history of diabetes, pulmonary disease, or non-Q wave myocardial infarction. Nitrates were prescribed more often in older patients. Angiotensin-converting enzyme inhibitors were prescribed more often in patients with a history of diabetes, hypertension, or anterior myocardial infarction, and less often in patients with a history of renal failure. Diuretics were prescribed more often in older patients, and in patients with a history of renal failure, diabetes, hypertension, or higher Killip classes.There is still underuse of beneficial treatments, particularly in elderly patients.

Worsening of heart failure in patients with myocardial infarction is seldom studied, elderly patients often are not included, and multivariate analysis is uncommon. The prospective PRIMA study (Prise en charge de l'Infarctus du Myocarde Aigu; management of acute myocardial infarction) sought to determine the incidence of worsening heart failure, its risk factors, and its prognostic importance in patients with myocardial infarction, regardless of age and hospital facilities, in the 'real world' in a region in France, using multivariate analysis. Data were prospectively collected in all patients with myocardial infarction admitted in all hospitals in three departments in the Rhône--Alpes region in France between 1 September 1993 and 31 January 1995. Among the 2507 patients included, 33% were in Killip classes II--IV at admission. After exclusion of patients with admission Killip class IV, 416 patients (17% of the cohort, 24% of women and 14% of men) had worsening of Killip class during the first 5 days. In-hospital mortality (overall, 14%) increased dramatically with Killip class at admission (9% in class I, 62% in class IV) and with worsening of Killip class during the first 5 days (36.5 vs. 8.5% if no worsening). In multivariate analysis, older age, diabetes mellitus and anterior Q-wave myocardial infarction were significant predictors of Killip class at admission and of its worsening; Killip classI at admission was a significant predictor of Killip-class worsening. The significant predictors of in-hospital mortality were older age, Killip class III at admission and worsening of Killip class during the first 5 days. This large, unselected cohort revealed that, among patients with myocardial infarction, heart failure and its worsening are frequent, especially in the elderly, and dramatically worsen the in-hospital mortality.

The prospective PRIMA study (Prise en charge de l'Infarctus du Myocarde Aigu; management of acute MI) sought to determine characteristics, management, and in-hospital mortality of myocardial infarction (MI), regardless of age and hospital facilities, in the "real world" in a region in France.Data were prospectively collected in all patients with MI admitted in all hospitals in three departments in the Rh ne-Alpes region between September 1, 1993 and January 31, 1995. 2,519 patients (68% men; mean +/- SD: 68 +/- 14 years) were included. Time from onset of symptoms to admission was6 h in 56% of the patients (median: 4 h 30 min). MI was non-Q wave in 12%. Among Q wave MI, location was anterior in 44%. At admission, Killip class was1 in 33%. The overall rate of thrombolysis was 36%. It was significantly higher in men than in women, in younger patients than in older patients, in lower Killip classes, in Q wave MI, and when the delay before initial medical intervention was6 hours. After age-adjustment, there was no difference between men and women for thrombolysis rate (odds ratio women/men: 0.92; p = 0.10). During the first 5 days, Killip class worsened in 17%. In-hospital mortality rate was 14%. Multivariate analysis identified age, anterior location, presence of Q waves, and higher Killip classes as significant predictors of in-hospital mortality.This large unselected cohort revealed that among patients with MI in a French region, there was a high proportion of elderly patients, a low rate of thrombolysis, and a high in-hospital mortality.