[Postoperative comfort in pediatric outpatient tonsillectomy]

OBJECTIVE

Evaluate the comfort in children after ambulatory tonsillectomy, disregarding the surgical technique and with a systematic prescription of paracetamol and codeine. The study lasted 4 days including the day of surgery.

STUDY DESIGN

[corrected] Prospective study during 5 months.

PATIENTS AND METHODS

We performed a prospective study over a five-month period to evaluate the comfort in children after ambulatory tonsillectomy. Opioids were used for analgesia during surgery, morphine and propacetamol in the recovery room, and a systematic prescription of paracetamol-codeine between Day 0 to Day 3 at home. The assessment of pain was made by nurses and the family, considering 6 endpoints: spontaneous pain and when swallowing by verbal scale (0 to 4), occurrence of PONV (0 or 1), quality of sleep (0 or 1), quality of feeding (0 or 1) and play (0 or 1), combined in a global score of 0 to 12, with a score < or = 4 very satisfactory.

RESULTS

78 children were included, 49 tonsillectomy by dissection, 29 by Sluder. The score were < or = 4 at Day 0 and Day 1 in 53 children, but statistical analysis (univariate analysis) showed difference between the two surgical procedures with a global comfort score better and PONV lower with dissection procedure.

CONCLUSION

The use of paracetamol-codeine after tonsillectomy offers a reliable analgesia with very satisfactory scores of comfort. Such prescription is effective in ambulatory tonsillectomy if a rigorous selection of patients is made.

Incidence of postoperative nausea and vomiting in paediatric ambulatory surgery

BACKGROUND

We performed a prospective descriptive study over a 5-month period to determine the incidence of postoperative nausea and vomiting (PONV) during the first 24 h following elective ambulatory paediatric surgery, excluding head and neck procedures.

METHODS

Four hundred and seven patients, aged 15 days to 16 years, were analysed prospectively.

RESULTS

The incidence of PONV was 9.4%, occurring most frequently during the first 3 h after anaesthesia and in hospital but rarely during the journey home. It was associated with age, previous history of PONV, tracheal intubation or use of the laryngeal mask airway (LMA trade mark ), controlled or manual ventilation, opioids and absence of oral intake of liquids or solids. Conversely, type of surgery, premedication, induction mode, association of regional anaesthesia, inhaled nitrous oxide, duration of anaesthesia, stay in the postanaesthesia care unit and duration of journey after discharge were not significantly associated with PONV.

CONCLUSIONS

PONV never induced complications or delayed patient discharge and curative treatment was rapidly effective.

[Emergency unilateral mydriasis]

UNEQUAL PUPILS: Or anisocoria is frequent and can be physiological, benign or life threatening. VARIATIONS IN THE PUPIL: Constriction depends on the parasympathetic system and dilatation on the sympathetic system. IN PARASYMPATHETIC DISORDERS: Peripheral or central neurological causes can be distinguished, among which acute cerebral lesions with compression of the trunk are the most dramatic. Differential diagnosis can be made by studying the local causes, which may represent ophthalmologic emergencies (acute glaucoma or lesions of the retina). AMONG THE SYMPATHETIC DISORDERS: Claude-Bernard-Horner's syndrome is the most classical example. Other particular cases exist, such as Adie's pupil, affecting young women (1/20,000), associating mydriasis and occasionally tendinous areflexia. Diagnosis is generally confirmed by the ophthalmologist, following a normal or evocative of the disease neurological examination.

IN PRACTICE

Rapid but careful clinical examination permits orientation of the diagnosis and appropriate treatment.

Demographic analysis of tree colonization in a 20-year-old right-of-way

Past tree colonization dynamics of a powerline-right-of-way (ROW) corridor in the Haut-Saint-Laurent region of Quebec was studied based on the present age distribution of its tree populations. This colonization study spans 20 years, from 1977 (ROW clearance) to 1996. The sampled quadrats were classified into six vegetation types. Tree colonization dynamics were interpreted in each type, and three distinct patterns were identified. (1) Communities adapted to acidic conditions were heavily colonized by Acer rubrum, at least for the last 12 years. (2) Communities adapted to mesic or to hydric conditions were more intensely colonized in the period 1985-1987 than in the following 9 years; this past success in tree colonization may have been caused by herbicide treatments, which could have facilitated tree establishment by damaging the herbaceous and shrub vegetation. (3) Cattail, vine-raspberry, and reed-dominated communities contained few tree individuals, with almost all trees establishing between 1979 and 1990; those three vegetation types appear as the most resistant to tree invasion in the ROW studied. This study supports the need for an integrated approach in ROW vegetation management, in which the selection of vegetation treatment methods would depend on the tree colonization dynamics in each vegetation type. Minimizing disturbances inflicted on ROW herbaceous and shrub covers should be the central strategy because disturbances jeopardize natural resistance to future tree invasion, except in communities adapted to acidic conditions where the existing vegetation does not prevent invasion by A. rubrum. Many trees are surviving the successive cutting operations by producing new sprouts each time, particularly in communities adapted to mesic and hydric conditions. In these cases, mechanical cutting should be replaced by a one-time stump-killing operation, to avoid repeated and unsuccessful treatments of the same individuals over time.

Tumorigenicity of the mixed spindle-epithelioid SP6.5 and epithelioid TP17 uveal melanoma cell lines is differentially related to alpha5beta1 integrin expression

PURPOSE

It has been suggested that the epithelioid morphology and high aggressiveness that is typical of the uveal melanoma cell line TP17 is dependent on the loss of alpha5beta1 integrin expression at the cell surface. The purpose of the current study was to test this hypothesis in the TP17 cell line and investigate the role this integrin may play in the tumorigenicity of the SP6.5 cells, a mixed spindle-epithelioid culture-type human uveal melanoma that shows tumorigenic properties clearly distinct from that of TP17 cells.

METHODS

Expression of the alpha5 integrin subunit was restored in the alpha5-TP17 cell line by stably transfecting the cells with a recombinant plasmid encoding the integrin subunit. Flow cytometry and adhesion assays on fibronectin (FN)-coated culture plates were used to monitor alpha5 expression in the cells. The effect of alpha5 expression on both tumorigenicity and cell proliferation was evaluated in vivo in nude mice. In vitro growth properties of the alpha5(+) TP17 cells was evaluated by cell counting and compared with that of the alpha5 parental TP17 cell line. The influence exerted by the alpha5 integrin subunit on the tumorigenic and proliferative properties of the SP6.5 cells was evaluated in vivo in nude mice by exposing the cells to increasing doses of a blocking antibody directed against the alpha5-subunit before subcutaneous injection, and compared with the results obtained with untreated SP6.5 cells.

RESULTS

Expression of the alpha5 integrin subunit in the alpha5-TP17 cells was successfully achieved, as evidenced by both flow cytometry and adhesion assays on FN-coated culture plates. Restoring expression of alpha5 in TP17 cells enhanced epithelioid cell morphology and increased the growth properties of this cell line in vivo. The ability of the SP6.5 cells to yield subcutaneous tumors was found to be concentration dependent and was reduced in a dose-dependent manner when the cells were exposed to the anti-alpha5 blocking antibody.

CONCLUSIONS

Restoring expression of alpha5 in the alpha5-negative TP17 uveal melanoma cell line influenced the proliferative properties of these cells but did not alter its tumorigenic potential. In contrast, the ability of the SP6.5 cells to yield tumors in vivo in nude mice appeared to be related to expression of this integrin.

[Clonidine combined with flunitrazepam before carotid endarterectomy decreases cerebrovascular CO2 reactivity]

OBJECTIVE

Assess cerebrovascular CO2 reactivity changes using transcranial Doppler sonography (TCD) after oral premedication associating clonidine (2 micrograms.kg-1) and flunitrazepam (70 micrograms.kg-1) in patients scheduled for carotid stenosis surgery.

STUDY DESIGN

Prospective study, not randomized, the patient being his own "control".

PATIENTS AND METHODS

Thirteen patients undergoing carotid endarterectomy under cervical plexus block were included. The monitoring included: automated arterial pressure cuff, ECG, radial artery catheter, TCD with probe secured in temporal window. The study of the cerebrovascular CO2 reactivity was performed with TCD recording on the side of operation, on the day before, and on the day of carotid endarterectomy, 90 min after the premedication, immediately before surgery. To change PaCO2, four ventilatory states were successively performed: (1) normoventilation, (2) hyperventilation, (3) hypoventilation, (4) "breath-holding test". At each state, it was noted: HR, MAP, PaCO2, mean blood flow velocity in the middle cerebral artery (Vm-MCA), resistance index of Pourcelot (RI), cerebrovascular reactivity (slope Vm-MCA/PaCO2). The results (+/- SEM) were analyzed by Wilcoxon test or t test.

RESULTS

After premedication, cerebrovascular CO2 reactivity decreased (0.043 +/- 0.019 vs 0.034 +/- 0.013; p < 0.05) without modification of RI (0.578 +/- 0.291 vs 0.612 +/- 0.025; NS). No complication during carotid clamping was reported.

CONCLUSION

Inclusion of clonidine in premedication before carotid stenosis surgery must be questioned because a decrease of cerebrovascular CO2 reactivity could be deleterious in case of intraoperative stroke.

[Hope and deficiency: community mental health and severe mental disorders]

Over the second half of the twentieth century, the way in which Canadian society treats people with mental challenges has changed radically, from exclusion and containment in asylums to reintegration and maintenance in the community. Now that deinstitutionalization is practically complete, the objective has increasingly shifted from reintegrating people with severe mental challenges in their communities to upholding their rights and ensuring that they have access to resources allowing them to assume their responsibilities and roles as citizens. This change of vision results in a completely different set of issues for community mental health. Given the prejudices surrounding mental illness, the capacity of community mental health professionals to play a mediating and facilitating role becomes a determining factor in successfully reestablishing and re-empowering people with severe mental challenges. The advances that have clearly been made give cause for hope, but in the context of the unwanted effects of deinstitutionalization and unfavourable socioeconomic conditions, significant obstacles still need to be overcome before people with severe mental challenges can participate fully in the life of the collectivity.

International development of the Quality of Life in Depression Scale (QLDS)

BACKGROUND

The Quality of Life in Depression Scale (QLDS) employs the needs-based model of quality of life (QoL) and was developed in the UK and The Netherlands as an outcome measure for clinical trials. This paper describes the production and psychometric assessment of nine new language versions for Canada (French and English), Denmark, France, Germany, Italy, Morocco, Spain and the US.

METHODS

Three adaptation stages were employed; production of conceptually equivalent translations, field-test interviews and assessment of reliability and construct validity by survey of patients with major depression.

RESULTS

Few problems were experienced with producing conceptually equivalent translations, except in Morocco. Patients in the field-test interviews found the instrument to have appropriate content and to be easy to complete. Internal consistency and test-retest reliability were excellent for all language versions and scores were found to relate appropriately to measures of depression severity and health status.

LIMITATIONS

Further investigation is required of the ability of the measure to assess individuals at the extremes of the QoL continuum. Data collected with the Arabic QLDS should not be combined with those from other countries.

CONCLUSIONS

The QLDS is the first instrument designed to assess QoL in depression based on a coherent model of the construct. Each language version has been shown to be well accepted by respondents and to have excellent psychometric properties. As the instrument is now available in a large number of languages, the QLDS is the QoL instrument of choice for inclusion in clinical trials of interventions for depression.

Postmenopause hormone treatment in women with NIDDM or impaired glucose tolerance: the MEDIA randomized clinical trial

OBJECTIVE

To assess the biological safety of four hormone replacement treatment (HRT) combinations in women with non insulin dependent diabetes mellitus (NIDDM) or impaired glucose tolerance (IGT).

SUBJECTS AND METHODS

Randomized, double-blind, placebo-controlled trial to analyze the variation of fibrinogen, factor VII, PAI1, and TG blood levels in women (n=99), with NIDDM or IGT, receiving a 3-month course of either oral oestradiol (1 or 2 mg) combined with Chlormadinone Acetate 5 mg, or transdermal oestradiol 50 microg/24 h in association with Norethisterone Acetate (11.2 or 22.4 mg), or placebo. Follow-up lasted 3 months.

RESULTS

Ninety nine patients, mean age 56 years (SD 5), mean diabetes duration 7 years (S.D. 7), mean glycated hemoglobin (7.3%) were enrolled. There was no significant difference between the groups for any of the primary hemostasis criteria (n=77). Triglycerides (TG) variation significantly differed between groups, P=0.01, from -21% in the large patch group, to +22% in the placebo group (n=82). Treatment administration routes did not significantly differ for any of the criteria. There was a significant difference in the total cholesterol variation between groups, from +8.7% in the placebo group to -10.8% in the oral 1 mg group (P=0.001).

CONCLUSION

The treatments had no highly deleterious effect in these patients with NIDDM or with IGT. Long-term trials can be performed with such patients, and an hormone treatment can be prescribed to relieve symptoms. Since these patients had a well-controlled NIDDM, results might be different in less well-controlled diabetes. The data do not support the hypothesis of an impaired oestrogen effect in patients with NIDDM.

Enzyme-linked immunosorbent assays using the recombinant dense granule antigens GRA6 and GRA1 of Toxoplasma gondii for detection of immunoglobulin G antibodies

The potential of the dense granule antigens GRA1 and GRA6 of Toxoplasma gondii to be used as diagnosis reagents in a recombinant form was evaluated. Both proteins were expressed in Escherichia coli as glutathione-S-transferase (GST) fusions. The GST-GRA1 fusion comprises the entire GRA1 sequence devoid of its N-terminal signal peptide. Separate expression of the two N- and C-terminal hydrophilic regions of GRA6 showed that only the N-terminal hydrophilic part of the protein was recognized by a pool of positive human sera in an immunoblot. One hundred T. gondii-positive and 98 negative human sera were tested in two separate immunoglobulin G (IgG)-direct enzyme-linked immunosorbent assays (ELISAs) using either GST-GRA1 or GST-GRA6-Nt recombinant protein. Whereas the sensitivity of the GST-GRA1 IgG ELISA was low (68%), the GST-GRA6-Nt IgG ELISA reached a sensitivity of 96%. The reactivity to GRA6-Nt was shown to be high even with human sera of low IgG titers. In addition, comparison of the optical density values for each serum revealed that GRA1 may complement GRA6-Nt to reach an overall sensitivity of 98%. Therefore, the GST-GRA6-Nt ELISA could be used together with another antigen like GRA1 for the development of a recombinant antigen-based test for serodiagnosis of toxoplasmosis.

Effects of a muramidase on a mixed bacterial community

In bacterial communities one bacterium can influence the growth of other members of the population. These interactions may be based on nutritional factors or may occur via bacterial signaling molecules that are released in the medium. We present an example, showing that in addition to the above means of interactions, muramidases, enzymes that specifically cleave peptidoglycan chains, can also mediate interactions between bacteria. Using fluorescent in situ hybridization we demonstrate that Lactococcus lactis muramidase AcmA can hydrolyze the cell wall of Streptococcus thermophilus, without affecting viability. This intercellular activity of the lactococcal muramidase results in chain disruption of streptococci in vivo. Our data lead us to propose that chains can give growth advantages to streptococci in aerobic conditions.

[Pediatric anesthesia practice in France: a survey of 1,526 anesthesiologists]

OBJECTIVES

To assess the individual activity of anaesthetists in paediatric anaesthesia (PA), and collect their wishes about continuing education and recommendations in PA.

STUDY DESIGN

Transversal, prospective study.

METHODS

A questionnaire of 33 items, sent to 4,360 anaesthetists, spread over 15 health districts, working in a public or private institution.

RESULTS

We gathered 1,526 replies (35%) of which 34% university hospitals, 32% public institutions and 31% private institutions. 943 physicians (63%) had no specific structure, and 1,119 (87%) considered a specialized nurse to be essential for PA. 1,127 physicians (74%) had undertaken a specific session during their formation. The practice of PA depends upon age and context. Above 1 year old, the surgery that is performed weekly was ENT (38%), abdominal and urologic surgery (28%). Mask induction was performed by 60% of the physicians in children under 5 years. 63% of the anaesthetists dreaded a laryngospasm during induction. 625 physicians undertook regional anaesthesia in children under 5 years (87% caudal anaesthesia, 48% peripheral nerve blocks). 1,029 physicians (67%) wished for recommendations in PA in children under 12 months.

CONCLUSIONS

This survey showed that most of the anaesthetists wished for recommendations in their paediatric anaesthesia practice.

An application of theory-driven evaluation to a drop-in youth center

This article reports on the theory-driven evaluation of a drop-in center for youth that incorporated a literature search, concept mapping with staff, and focus groups with youth. Findings revealed strong agreement among the three sources of data around specific elements identified as critical components of a program theory of global prevention in after-school-hours initiatives, such as drop-in centers. These results are used to illustrate how a theory-driven approach was relevant for the context and objectives of this evaluation, as well as how it was used to develop knowledge useful for action, social intervention theory, and further research.

The role of ultrasonography in imaging of paediatric head trauma

Ultrasound appears to be a promising tool for assessment of the state of the dura in patients suffering from a diastatic skull fracture. Our goal is to identify patients who are at a high risk of developing the complications associated with this type of fracture as early as possible in order to keep the neurosurgical repair as simple as possible.

An evaluation of psychometric properties of the client's questionnaire of the Wisconsin Quality of Life Index-Canadian version (CaW-QLI)

Psychometric properties of Client's questionnaire from the Canadian version of the Wisconsin Quality of Life-Index (CaW-QLI) were assessed with two groups, 89 English (E) and 94 French (F) individuals with schizophrenia or schizoaffective disorder. Sub-samples of 40 E and 36 F were re-interviewed within a 2-week period. Spearman correlations-SC between each domain and CaW-QLI global Score ranged from 0.39 to 0.76, while interdomain correlations were low, confirming the multi-dimensional properties of the scale. Cronbach's alpha (internal consistency) were 0.78 (E) and 0.70 (F) for the CaW-QLI global scores and, from 0.45 to 0.88 among seven of eight domains. Test-retest (Concordance Correlation Coefficient--CCC) ranged from 0.36 to 0.80 among the domains, and from 0.80 (E) and 0.85 (F) between CaW-QLI global scores. Regarding convergent validity, SC between CaW-QLI global score and Spitzer's QOL-Index were 0.72 (E) and 0.58 (F). As hypothesized, there were higher correlations between CaW-QLI global scores (E and F) and SF-36 scales related to mental health than those related to physical health. Minor changes in the scoring are proposed to enhance face and content validity.

Differential membrane targeting of the secretory proteins GRA4 and GRA6 within the parasitophorous vacuole formed by Toxoplasma gondii

Following secretion into the parasitophorous vacuole, dense granule proteins, referred to as GRA proteins, are targeted to different locations including a complex of tubular membranes that are connected with the vacuolar membrane. To further define the formation of this intravacuolar network, we have investigated the secretion, trafficking and membrane association of GRA4 and GRA6 within the parasitophorous vacuole. In extracellular parasites, GRA4 and GRA6 were found exclusively in dense secretory granules where they were packaged primarily as soluble proteins. Following release into the vacuole, GRA6 was rapidly translocated to the posterior end of the parasite where, like previously reported for GRA2, it bound to a cluster of multi-lamellar vesicles that give rise to the network. In contrast, GRA4 was distributed throughout the lumen of the vacuole and only later became associated with the mature network that is found dispersed throughout the vacuole. Cell fractionation and treatment with denaturing agents established that the association of GRA4 with the network membranes was mediated by strong protein-protein interactions. In contrast, GRA6 was predominantly influenced by hydrophobic interactions, and a phosphorylated form of this protein present within the vacuole showed increased association with the network membranes. Cross-linking studies established that GRA4 and GRA6 specifically interact with GRA2 to form a multimeric complex that is stably associated with the intravacuolar network. Formation of this protein complex, which is based on both protein-protein and hydrophobic interactions, may participate in nutrient or protein transport within the vacuole.

[Prognostic importance of ambulatory arterial pressure monitoring in France. Initial results of the OCTAVE II study. OCTAVE II Research Group]

RATIONALE

Ambulatory blood pressure measurement (ABPM) is commonly used in clinical practice, whereas its added value to the management of hypertension is not definitely documented.

OBJECTIVE

The OCTAVE II study was launched in 1991 to explore the prognostic value of ABPM, compared to that of the gold standard, the clinical blood pressure measurement.

METHODS

Two hundred and six French cardiologists recruited 3569 participants over 18 years of age, provided they deemed ABPM was useful (mean age of 56 years, 52% of men, 65% already treated by antihypertensive drugs). The prognostic value of various blood pressure measurements, systolic or diastolic, clinical or ambulatory (diurnal, nocturnal or during 24 hours), has been assessed in multivariate models adjusted on the baseline characteristics associated with risk. The outcome was the occurrence of a major cardiovascular event, including stroke, myocardial infarction and cardiovascular death.

RESULTS

After an average follow-up of five years, cardiovascular morbidity was known for 85% of the participants, and their vital status for 91%. On the whole population, the best prognostic indicators were systolic blood pressure compared with diastolic, ABPM compared with clinical blood pressure measurements, and nocturnal ABPM compared with diurnal ABPM. In the untreated participants at baseline, cardiovascular risk regularly increased among the four groups: normotensives, white-coat hypertensives, dippers, non-dippers. Between the extreme categories, the cardiovascular event rate was multiplied by 6.5.

CONCLUSION

In this French population, ABPM and most of all its nocturnal component, was better correlated with cardiovascular prognosis. It remains to assess: 1) the general value of our findings, 2) the respective values of self blood pressure measurement versus ABPM, and 3) whether ABPM allows a better risk prevention.