Survey on infectious disease telephone hotlines in primary care: General practitioners' satisfaction and compliance with advice

OBJECTIVES

Infectious disease (ID) advice is a major part of antimicrobial stewardship programs. The objective of this study was to assess general practitioners' (GPs)' opinions and compliance with advice given by ID hotlines.

PATIENTS AND METHODS

This multicenter survey was based on the 7-day assessment of initial advice requested by GPs to a hotline set up by volunteer hospital ID teams to record advice for 3 years. The primary endpoint was the GPs' satisfaction with the advice given by ID specialists.

RESULTS

Ten ID teams participated in the study and recorded 4138 requests for advice, of which 1325 requests included a proposal for antibiotic therapy and justified a follow-up call at seven days. Only 398 follow-up calls (30%) were carried out because many GPs were not reachable. GPs were very satisfied with ID hotlines: 58% considered them indispensable and 38% very useful. The recommendations provided by ID specialists were followed by GPs in more than 80% of cases. The two main motivations for GPs to call the hotline were to get quick advice (86%) and to receive help in managing a patient (76%).

CONCLUSIONS

The ID telephone consultations and advice systems for GPs are highly appreciated and are effective in terms of following the recommendations.

Prevalence of post-acute coronavirus disease 2019 symptoms twelve months after hospitalization in participants retained in follow-up: analyses stratified by gender from a large prospective cohort

OBJECTIVES

Persistent post-acute coronavirus disease 2019 (COVID-19) symptoms (PACSs) have been reported up to 6 months after hospital discharge. Herein we assessed the symptoms that persisted 12 months (M12) after admission for COVID-19 in the longitudinal prospective national French coronavirus disease cohort.

METHODS

Hospitalized patients with a confirmed virological diagnosis of COVID-19 were enrolled. Follow-up was planned until M12 after admission. Associations between persistence of ≥3 PACSs at M12 and clinical characteristics at admission were assessed through logistic regression according to gender.

RESULTS

We focused on participants enrolled between 24 January 2020 and 15 July 2020, to allow M12 follow-up. The M12 data were available for 737 participants. Median age was 61 years, 475 (64%) were men and 242/647 (37%) were admitted to intensive care units during the acute phase. At M12, 27% (194/710) of the participants had ≥3 persistent PACS, mostly fatigue, dyspnoea and joint pain. Among those who had a professional occupation before the acute phase, 91 out of 339 (27%) were still on sick leave at M12. Presence of ≥3 persistent PACS was associated with female gender, both anxiety and depression, impaired health-related quality of life and Medical Muscle Research Council Scale <57. Compared with men, women more often reported presence of ≥3 persistent PACSs (98/253, 39% vs. 96/457, 21%), depression and anxiety (18/152, 12% vs. 17/268, 6% and 33/156, 21% vs. 26/264, 10%, respectively), impaired physical health-related quality of life (76/141, 54% vs. 120/261, 46%). Women had less often returned to work than men (77/116, 66% vs. 171/223, 77%).

CONCLUSIONS

One fourth of the individuals admitted to hospital for COVID-19 still had ≥3 persistent PACSs at M12 post-discharge. Women reported more often ≥3 persistent PACSs, suffered more from anxiety and depression and had less often returned to work than men.

Impact of therapeutic drug monitoring of antibiotics in the management of infective endocarditis

Treatment of infective endocarditis (IE) is based on high doses of antibiotics with a prolonged duration. Therapeutic drug monitoring (TDM) allows antibiotic prescription optimization and leads to a personalized medicine, but no study evaluates its interest in the management of IE. We conducted a retrospective, bicentric, descriptive study, from January 2007 to December 2019. We included patients cared for IE, defined according to Duke's criteria, for whom a TDM was requested. Clinical and microbiological data were collected after patients' charts review. We considered a trough or steady-state concentration target of 20 to 50 mg/L. We included 322 IE episodes, corresponding to 306 patients, with 78.6% (253/326) were considered definite according to Duke's criteria. Native valves were involved in 60.5% (185/306) with aortic valve in 46.6% (150/322) and mitral in 36.3% (117/322). Echocardiography was positive in 76.7% (247/322) of cases. After TDM, a dosage modification was performed in 51.5% (166/322) (decrease in 84.3% (140/166)). After initial dosage, 46.3% (82/177) and 92.8% (52/56) were considered overdosed, when amoxicillin and cloxacillin were used, respectively. The length of hospital stay was higher for patient overdosed (25 days versus 20 days (p = 0.04)), and altered creatinine clearance was associated with overdosage (p = 0.01). Our study suggests that the use of current guidelines probably leads to unnecessarily high concentrations in most patients. TDM benefits predominate in patients with altered renal function, but probably limit adverse effects related to overdosing in most patients.

Incidence of Avoidable 30-Day Readmissions Following Hospitalization for Community-Acquired Pneumonia in France

IMPORTANCE

Rates of 30-day readmissions following hospitalization for pneumonia are used to publicly report on hospital performance and to set financial penalties for the worst-performing hospitals. However, the rate of avoidable readmission following hospitalization for pneumonia is undefined.

OBJECTIVE

To assess how often 30-day readmissions following hospitalization for community-acquired pneumonia (CAP) are avoidable.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study analyzed the results of an independent review of readmissions following hospitalization for CAP within 30 days among patients discharged from 2 large hospitals in France in 2014. Structured clinical records including clinical information (ie, baseline characteristics, physical examination, laboratory findings, x-ray or computed tomography scan findings, discharge plan, and treatments) for both index and readmission stays were independently reviewed by 4 certified board physicians. All consecutive adult patients hospitalized in 2014 with a diagnosis of CAP in our 2 eligible hospitals were eligible. All analyses presented were performed in March 2021.

MAIN OUTCOMES AND MEASURES

Avoidable readmission within 30 days of discharge from index hospitalization. The likelihood that a readmission was avoidable was quantified using latent class analysis based on the independent reviews. A readmission was considered avoidable if Bayes posterior probability exceeded 50%.

RESULTS

The total analytical sample consisted of 1150 index hospital stays with a diagnosis of CAP, which included 651 (56.6%) male patients. The median (IQR) age for all patients was 77.8 (IQR, 62.7-86.4) years. Out of the 1150 index hospital stays, 98 patients (8.5%) died in hospital, and 108 (9.4%) unplanned readmissions were found. Overall, 15 readmissions had a posterior probability of avoidability exceeding 0.50 (13.9% of the 108 unplanned readmissions; 95% CI, 8.0%-21.9%). The median (IQR) delay between the hospital discharge index and readmission was considerably shorter when readmission was deemed avoidable (4 [6-21] days vs 12 [2-18] days; P = .02).

CONCLUSIONS AND RELEVANCE

Only a small number of readmissions following hospitalization for CAP were deemed avoidable, comprising less than 10% of all readmissions. Shorter time interval between hospitalization discharge and readmission was associated with avoidability.

Development of a risk prediction model of potentially avoidable readmission for patients hospitalised with community-acquired pneumonia: study protocol and population

INTRODUCTION

30-day readmission rate is considered an adverse outcome reflecting suboptimal quality of care during index hospitalisation for community-acquired pneumonia (CAP). However, potentially avoidable readmission would be a more relevant metric than all-cause readmission for tracking quality of hospital care for CAP. The objectives of this study are (1) to estimate potentially avoidable 30-day readmission rate and (2) to develop a risk prediction model intended to identify potentially avoidable readmissions for CAP.

METHODS AND ANALYSIS

The study population consists of consecutive patients admitted in two hospitals from the community or nursing home setting with pneumonia. To qualify for inclusion, patients must have a primary or secondary discharge diagnosis code of pneumonia. Data sources include routinely collected administrative claims data as part of diagnosis-related group prospective payment system and structured chart reviews. The main outcome measure is potentially avoidable readmission within 30 days of discharge from index hospitalisation. The likelihood that a readmission is potentially avoidable will be quantified using latent class analysis based on independent structured reviews performed by four panellists. We will use a two-stage approach to develop a claims data-based model intended to identify potentially avoidable readmissions. The first stage implies deriving a clinical model based on data collected through retrospective chart review only. In the second stage, the predictors comprising the medical record model will be translated into International Classification of Diseases, 10th revision discharge diagnosis codes in order to obtain a claim data-based risk model.The study sample consists of 1150 hospital stays with a diagnosis of CAP. 30-day index hospital readmission rate is 17.5%.

ETHICS AND DISSEMINATION

The protocol was reviewed by the Comité de Protection des Personnes Sud Est V (IRB#6705). Efforts will be made to release the primary study results within 6 months of data collection completion.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov Registry (NCT02833259).

Cerebrospinal fluid lactate concentration and bacterial encephalitis diagnosis

OBJECTIVES

A French national study on infectious encephalitis enrolled 253 patients in 2007. Fifty-two per cent of patients had a proven etiological diagnosis; 16% had bacterial encephalitis. We aimed to assess the predictive value of CSF lactate concentration to diagnose bacterial encephalitis.

PATIENTS AND METHODS

Patients from the 2007 cohort whose CSF lactate concentration was available were included. Clinical and biological features associated with a bacterial etiology were assessed using univariate analysis and multivariate logistic regression. The ROC curve of CSF lactate concentration was used to define the most appropriate cut-off associated with bacterial etiology.

RESULTS

Fifty-seven patients (37 men, 20 women) were included. Ten patients had bacterial encephalitis, 20 patients had viral encephalitis. The mean CSF white blood cells (WBC), protein, glucose, and lactate levels were respectively 92 cells/mm³ (range: 0-450), 1.2g/L (range: 0.2-8.2), 3.9mmol/L (range: 0.8-8.8), and 2.8mmol/L (range: 0-9.4). In univariate analysis, CSF protein level (P<0.01), WBC count (P=0.02), and lactate concentration (P<0.01) were significantly associated with bacterial etiology. The only factor independently associated with bacterial etiology in the multivariate analysis was CSF lactate concentration. The area under the ROC curve of CSF lactate for the diagnosis of bacterial encephalitis was 0.86. The cut-off value of 3.4 mmol/L correctly classified 87.8% of patients with 70% sensitivity, 91.5% specificity, 64% positive predictive value, and 93% negative predictive value.

CONCLUSION

A high CSF lactate level seems to be a better predictor than WBC or proteins to differentiate bacterial encephalitis from other etiologies.

mcr-1 Colistin Resistance in ESBL-Producing Klebsiella pneumoniae, France

We report intestinal carriage of an extended-spectrum β-lactamase−producing Klebsiella pneumoniae strain with high-level resistance to colistin (MIC 24 mg/L) in a patient in France who had been hospitalized for fungal meningitis. The strain had the mcr-1 plasmid gene and an inactivated mgrB gene, which are associated with colistin resistance.

Is brain angio-MRI useful in infective endocarditis management?

In infective endocarditis (IE), brain magnetic resonance imaging (MRI) is helpful to diagnose clinically silent neurological events. We assessed the usefulness of systematic early brain MRI in IE diagnosis and medico-surgical management. Over a period of 1 year, all patients admitted in one of the three hospitals participating in and fulfilling the Duke criteria for definite or possible IE underwent cerebral MRI within 7 days of IE suspicion. Eight panels of experts analyzed the records a posteriori. For each case, one record with and one record without the MRI results were randomly assigned to two panels, which determined the theoretical diagnosis and treatment. Paired comparisons were performed using a symmetry test. Thirty-seven brain MRIs were performed within a median of 5 days after inclusion. MRI was pathological in 26 patients (70 %), showing 62 % microischemia and 58 % microbleeds. The expert advice did not differ significantly between the two evaluations (with or without the MRI results). The therapeutic strategies determined diverged in five cases (13.5 %). Diagnosis differed in two cases (5.4 %), with an upgrading of diagnosis from possible to definite IE using MRI results. Early brain MRI did not significantly affect the IE diagnosis and medico-surgical treatment plan. These results suggest that systematic use of early brain MRI is irrelevant in IE. Further studies are necessary to define whether MRI is mandatory in IE management within a multidisciplinary approach, with particular attention paid to better timing and the subset of patients in whom this imaging examination could be beneficial.

Is prosthesis retention effective for chronic infections in hip arthroplasties? A systematic literature review

The success rate of prosthesis removal as the standard approach to manage chronic infection in hip arthroplasties (HA) is 80-90 %. The effectiveness of prosthesis retention, with or without surgical debridement, to treat patients with chronic HA infection (symptom duration of more than 4 weeks) has not been well established, whereas this strategy is sometimes used in clinical practice. This study aimed to explore the cumulative incidence of failure of chronic HA infections treated with prosthesis retention, with or without debridement. A systematic literature review was conducted in accordance with the methods described in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). Studies concerning patients with chronically infected HA treated with prosthesis retention were included. The primary outcome was the cumulative risk of failure. We searched the MEDLINE, Embase, and Cochrane databases up to April 2014. The database searches provided a total of 1,213 studies for potential inclusion in the review. Six relevant studies were finally identified, corresponding to 29 patients included. Their treatments consisted of prosthesis retention with debridement. This strategy failed for 14 out of these 29 patients after a 1-year follow-up. The failure rate of the prosthesis retention approach associated to debridement for chronic infection in HA is 48.3 % in this review. Debridement and prosthesis retention in association with prolonged antimicrobial treatment may be an advantageous alternative to arthroplasty exchange for frail patients. The difficulty in finding relevant studies illustrates the challenges of interpreting the existing literature for the management of chronic prosthetic joint infection (PJI).

Mumps outbreak and laboratory diagnosis

BACKGROUND

Several mumps outbreaks have been reported in Europe and in the United States among highly vaccinated populations. Biological diagnosis is classically based on the detection of mumps-specific IgM, but the ability of serological tests to confirm mumps infection seems to be limited among vaccinated patients.

OBJECTIVES

We aim to report a mumps outbreak in an engineering school in Grenoble, France, from February to June 2013 and results of the biological testing.

STUDY DESIGN

WHO definitions were used to define cases. Mumps--specific IgM and IgG were assessed by a commercially available EIA. Mumps RNA detection by real time reverse transcriptase polymerase chain reaction tests (RT-PCR) and mumps genotyping were performed by the French National Reference Centre for Paramyxoviridae.

RESULTS

Sixty two mumps patient-cases were identified using WHO case definitions, 20 being biologically explored, of which 17 were confirmed by biological tests. Vaccination status was documented for 27 patients/62: 4 (14.8%) patients had received one dose of MMR vaccine, and 23 (85.2) two doses of MMR vaccine. Among the biologically explored patients, 83% had a positive RT PCR at the first sampling whereas only 45% had positive or equivocal IgM. All the genotyped strains were genotype G.

CONCLUSIONS

Mumps laboratory diagnosis in a highly vaccinated population is challenging. Serological tests among vaccinated patients should be interpreted cautiously and confirmed by RT-PCR tests at the beginning of a mumps outbreak.

Pneumocystis jirovecii (Pj) quantitative PCR to differentiate Pj pneumonia from Pj colonization in immunocompromised patients

Conventional polymerase chain reaction (PCR) in respiratory samples does not differentiate between Pneumocystis pneumonia (PCP) and Pneumocystis jirovecii (Pj) colonization. We used Pj real-time quantitative PCR (qPCR) with the objective to discriminate PCP from Pj colonization in immunocompromised patients. All positive Pj qPCR [targeting the major surface glycoprotein (MSG) gene] obtained in respiratory samples from immunocompromised patients presenting pneumonia at the Grenoble University Hospital, France, were collected between August 2009 and April 2011. Diagnoses were retrospectively determined by a multidisciplinary group of experts blinded to the Pj qPCR results. Thirty-one bronchoalveolar lavages and four broncho aspirations positive for the Pj qPCR were obtained from 35 immunocompromised patients. Diagnoses of definite, probable, and possible PCP, and pneumonia from another etiology were retrospectively made for 7, 4, 5, and 19 patients, respectively. Copy numbers were significantly higher in the “definite group” (median 465,000 copies/ml) than in the “probable group” (median 38,600 copies/ml), the “possible group” (median 1,032 copies/ml), and the “other diagnosis group” (median 390 copies/ml). With the value of 3,160 copies/ml, the sensitivity and specificity of qPCR for the diagnosis of PCP were 100 % and 70 %, respectively. With the value of 31,600 copies/ml, the sensitivity and specificity were 80 % and 100 %, respectively. The positive predictive value was 100 % for results with more than 31,600 copies/ml and the negative predictive value was 100 % for results with fewer than 3,160 copies/ml. qPCR targeting the MSG gene can be helpful to discriminate PCP from Pj colonization in immunocompromised patients, using two cut-off values, with a gray zone between them.

Spontaneously chosen crank rate variations in submaximal arm exercise with inexperienced subjects. Effects on cardiorespiratory and efficiency parameters

The aim of the present study was to compare the physiological responses during arm exercises when the crank rate was chosen spontaneously (TS) or set at +/- 20 % (T-20, T+ 20) of the spontaneously chosen crank rate (SCCR). Eight physical education male students, aged 22 +/- 3.2 years, performed an upper body exercise in which intensities ranged from unload to 80 % of maximal power. No significant difference was observed in oxygen uptake, ventilation, gross and net efficiency values between TS and T+ 20 or T-20. Nevertheless, oxygen uptake and ventilation were significantly (p < 0.05) lower and gross and net efficiencies higher (p < 0.05) during T-20 than T+ 20. No significant difference was noticed for heart rate, delta and work efficiency between TS, T-20 and T+ 20. The hypothesis that SCCR is the most economical one according to the efficiency parameters was not quite verified. However, crank rates lower than SCCR could be interesting because they increase gross efficiency compared to higher crank rates. Moreover, the selection of crank rates depends on power output. Indeed, SCCR increased significantly (p < 0.05) with power output. In the physical reconditioning of injured or handicapped subjects, the latter are very sensitive to the power output, and the crank rate could be another constraint.

Nongenomic actions of estrogens and xenoestrogens by binding at a plasma membrane receptor unrelated to estrogen receptor alpha and estrogen receptor beta

The molecular mechanism used by environmental chemicals to exert their hormone-like actions is still only partially resolved. Although it generally is accepted that xenoestrogens act at the genomic level by binding to intracellular estrogen receptors, we have shown here that they trigger nongenomic effects in pancreatic beta cells. Both xenoestrogens and the circulating hormone, 17beta-estradiol, bind with high affinity to a common membrane binding site unrelated to the intracellular estrogen receptors ERalpha and ERbeta. This binding site is shared by dopamine, epinephrine, and norepinephrine and has the pharmacological profile of the gammaadrenergic receptor. This study provides an outline of the membrane receptor involved in rapid xenoestrogen actions.

Histopathologic findings in cutaneous cytomegalovirus infection

When cytomegalovirus (CMV) involves the skin, viral inclusions are typically present within mesenchymal cells, e.g., endothelial cells, fibrocytes, and sometimes within inflammatory cells, e.g., macrophages, in contrast to infection in other organs in which inclusions are usually present within ductal epithelial cells. Two cases of cutaneous CMV are presented, one showing prominent findings within eccrine ductal epithelium and the other revealing mostly endothelial cells affected by CMV. Due to the range of cytologic changes induced by CMV observed in these cases, there seem to be early, fully developed, and late cellular changes brought about by CMV analogous to how herpesvirus (varicella, zoster, simplex) induces different changes depending on its stage of infection.

[Reconstruction of the anterior cruciate ligament: arthrotomy versus arthroscopy]

The aim of this study was to compare the results of arthroscopic with open arthrotomy reconstruction of the anterior cruciate ligament, as treatment of chronic anterior laxity. 54 knees (among 63) were evaluated, 33 reconstructions were performed according to Kenneth Jones technique with arthrotomy (from 1990 to may 1993) and 21 were arthroscopically-assisted (from may 1993 to 1996). Meniscectomy was associated respectively in 22 and 7 cases. The average interval between initial injury and surgery was 18 and 18.6 months. Follow-up was one year at least. We evaluated mobility, amyotrophy and quadriceps and hamstrings muscular deficit: static at 1 month and using Cybex isokinetic tests at 2, 3 and 6 months and 1 year. Postoperative residual laxity and Arpege cotation were evaluated at 1 year. Student and Mann Whitney tests were used for statistical evaluation. As complication we noted respectively after arthrotomy and after arthroscopy: 7 (21.2 p. 100) and 4 (19 p. 100) algodystrophy, 1 (3 p. 100) and 1 (4., 7 p. 100) Cyclops syndrome, and 2 (6 p. 100) and 1 (4.7 p. 100) anterior knee pain. Lack of extension and flexion were respectively -5.4 degrees/130 degrees and -1.9 degrees/136 degrees at 3 months (p = 0.04) and -3.5/134 degrees and -1.5 degrees/138 degrees at 6 months (not significative). At 1 month, static hamstrings deficit was 41.3 p. 100 after open arthrotomy and 29.6 p. 100 after arthroscopic assisted (p = 0.05). At 2 months, isokinetic hamstrings deficit was lower after arthroscopic assisted (21.6 p. 100 at 60 degrees; 20.8 p. 100 at 180 degrees) than after open arthrotomy (32.8 p. 100; 32.5 p. 100) (p = 0.039 and 0.008). This difference was found for hamstrings until 3 months. At 6 months and 1 year, no difference was found for Cybex tests. In Arpege score, at 1 year, 73.3 p. 100 were very satisfied or satisfied after open arthrotomy and 77.7 p. 100 after arthroscopy. Global results were excellent or good in 66 p. 100 after open arthrotomy and 83 p. 100 after arthroscopy. Radiological laxity was less than 5 mm in 88 p. 100 after open arthrotomy and 92 p. 100 after arthroscopic assisted. So, after arthroscopically assisted procedure, the number of algodystrophy and anterior knee pain was lower, and until 3 months, range of motion was better and hamstrings deficit was lower. After 6 months, difference about range of motion or muscular deficit were not significative. At 1 year, after arthroscopic procedure, results seemed better with a lower rate of residual laxity and better global results, but the number of medial meniscectomies was lower in this group. In conclusion, the arthroscopic-assisted procedure seems to allow a faster rehabilitation.

[Ultrastructure of the kidney in paraquat-poisoned rats. Comparative study with literature data on man and animal]

This study was designed to assess the effect of paraquat on the rat kidney. The experimental animals used were Wistar rats, a strain selected and maintained at the Institut d'hygiène alimentaire. Their diet was well defined and their state of health monitored. Female animals with mean weight of 200 g were used in this study. Doses of 20, 30 and 50 mg/kg were administered via the gastrointestinal route. In this experimentation, performed on 12 rats plus 3 controls, the dose considered to be sublethal was 30 mg/kg administered by gavage. These animals were sacrificed after 24 h, 48 h, 4, 8, 15, 30 and 60 day, selecting those animals with the most severely altered state, at each time. Tubular lesions started to appear by the 24th hour; the proximal tubule was the most sensitive. Lesions of the distal tubule were observed slightly later, from the 48th hour. Lesions became more intense from the 4th day onwards and reached a maximum on the 8th day. The first signs of repair of the proximal tubule and distal tubule were observed on the 15th day, but were less marked for the proximal tubule. This repair was slow and progressive. Persistent lesions of the proximal or distal tubules were still observed after two months. The glomeruli presented several alterations, which were always only moderate. Overall, paraquat induces serious life-threatening lesions of acute tubular necrosis in the absence of adequate intensive care.

The active site region of the vitamin K-dependent carboxylase includes both the amino-terminal hydrophobic and carboxy-terminal hydrophilic domains of the protein

In order to localize the active site of the vitamin K-dependent carboxylase, we developed an affinity probe containing the propeptide and the first two carboxylatable glutamate residues conserved in many native substrates. This probe crosslinked to both the hydrophobic amino-terminal and hydrophilic carboxy-terminal domains of the carboxylase, in contrast with previous work which localized both the catalytic and the propeptide binding site within the amino-terminal hydrophobic domain. Amino acid analysis revealed that the mass of an amino-terminal fragment is seriously underestimated by SDS-PAGE. Reanalysis of the published data in light of this information suggests that a portion of the propeptide binding site resides within the carboxy-terminal hydrophilic domain.

H-ras-1 point mutations in soft tissue sarcomas

The H-ras-1 protooncogene is activated by single base substitutions occurring in either codon 12, 13, or 61. These mutations have been described with varying frequencies in several human tumor types. Since ras oncogenes were first discovered as the transforming sequences of Harvey and Kirsten murine sarcoma viruses (which also contain activating point mutations compared to the homologous cellular sequences), we wished to investigate the possibility that ras mutations might also occur in human sarcomas. We extracted DNA from six malignant fibrous histiocytomas (MFH), three embryonal rhabdomyosarcomas (ER), one alveolar rhabdomyosarcoma, one pleomorphic rhabdomyosarcoma, and one leiomyosarcoma. The DNA from regions flanking codons 12/13 and codon 61 was amplified by the polymerase chain reaction and sequenced with an automated DNA sequencer. As controls, we amplified and sequenced normal DNA (placenta) and DNA with known point mutations (T24 bladder carcinoma cells). We found three cases with mutations, all occurring in codon 12. One ER showed a G-to-T mutation in the second position of codon 12 (coding for valine instead of glycine). Two MFHs showed G-to-A mutations in the second position of codon 12 (coding for aspartic acid instead of glycine). Although a limited number of cases were sampled, we conclude that study of H-ras-1 mutations may be relevant to MFH and ER. Additional studies of N and K-ras mutations as well as more cases investigating H-ras will be required before we can ascertain the significance of ras mutations in the oncogenesis of human soft tissue sarcomas.

[Aspects of facial morphogenesis in the rat]

The facial morphogenesis of the rat has been observed by scanning microscopy on embryos taken every day from the 10th post-coitum day to term. Three points should be noted. Firstly the muzzle has at the beginning of the development an individuality which tends to diminish later. Secondly the vibrissae, whose primary elements are grouped in plates, are of great importance in the development of the muzzle. Finally, the opening between the internal parts of the nasal ridges is elevated with at the top a sharp angle, contrary to that of man which is little elevated and is arched. This could express the difference relating in each of the two cases the mesenchymatous naso-dorsal center, to which divergence between the two types of face, one with muzzle and the other without, would be linked. The primates presenting these two types, the tendency at the moment is to classify them using this discrimination. The study of the two corresponding aspects would supply a precious addition to these observations.

Scanning electron microscopy of femoral ossification in the human foetus

The ossification of human femoral bone was studied in 10 fetuses aged from 8 to 40 weeks, and in a 3 1/2 month-old child. After dissection and radiographic examination, each femur was sectioned in a sagittal plane. One part was processed for routine histology, the remaining one for scanning electron microscopy. By comparing the radiographic, light microscopic and scanning electron microscopic pictures, it is possible to precise the pattern of ossification and to define 3 main periods during human fetal development (pure cartilage, metaphyseal and diaphyseal ossification, constitution of a cortex and a medulla in the diaphysis).

[Quantification of the diameter of muscular fibres in the course of the development of the quadriceps]

Muscle biopsies were taken from the medium portion of the vastus lateralis of a hundred fetuses (aged between 10 and 40 weeks), children, adolescents and adults without any neuro-muscular disease. Diameters of the muscle fibers were measured with a Leitz ASM 68K on frozen sections which had been stained for myofibrillar ATPase. The results have been expressed as average diameters and histograms. The results demonstrated a gradual increase in diameter of the fibers during fetal development. At the birth, the average diameter of the type I and II fibers is 10-15 microns. Growth continues during postnatal development up until puberty, when the fibers reach their final diameter of 60-65 microns. Analysis of the histograms shows that before 18 weeks of gestation, there is a large dispersion in the diameter of the fibers. The first type I fibers are larger than the others and correspond to Wohlfart type b fibers. This is followed by the appearance of a second population of smaller type I fibers. These fibers gradually increase in diameter and one observes a homogenous population of type I fibers at the birth.

[Scanning electron microscopic study of the coxofemoral articular surfaces in the human fetus]

A scanning electron microscopic study of the coxo-femoral articular cartilage was performed in ten human fetuses aged from 15 to 40 weeks. An irregular surface was observed at the level of both femoral head and acetabulum. These surface irregularities are modified during development.

Scanning electron microscopy of human prenatal muscle development

A scanning electron microscopic study of the development of the human quadriceps was performed in 30 fetuses ranging from 6 to 40 weeks gestation. The results clearly illustrate the hyperplastic phase of myogenesis, showing the differentiation, multiplication and fusion of the myoblasts and the subsequent formation of different generations of myotubes. The myoblasts decrease relatively in number within the developing quadriceps until the 19th week of gestation, and remain afterwards as quiescent satellite cells. The maturation of the myotubes to myofibers and the metabolic differentiation of the fibers are not accompanied by significant changes in their external form in terms of scanning electron microscopy. The hypertrophic phase of myogenesis and general fetal growth can be followed with scanning electron microscopy by the increase in size of the fibers or bundles of fibers, as well as by the differentiation of the connective tissue components of the muscle.

[Ambulatory anesthesia and induced abortion. Comparative study of propofol-alfentanyl and ketamine-midazolam combinations]

The use of propofol alone or with alfentanil in the day-case anaesthesia for abortion was compared with that of ketamine with midazolam. Two hundred young women were assigned to two successive series of two groups each. The four groups were: group 1 (2 mg . kg-1 propofol only); group II (0.5 mg . kg-1 ketamine with 0.25 mg . kg-1 midazolam); group III (2 mg . kg-1 propofol with 4 micrograms . kg-1 alfentanil); group IV (1 mg . kg-1 ketamine with 0.1 mg . kg-1 midazolam). All the patients were premedicated one hour before anaesthesia with 0.25 mg . kg-1 midazolam orally. All the patients were asleep at the end of the propofol injection (60 s), and 10 to 15 s later for the ketamine-midazolam groups. The haemodynamic parameters did not vary much during induction with ketamine-midazolam. In the propofol groups, the heart rate remained steady, with an 8 to 12% fall in blood pressure. A fall of the mandible was seen in 40 and 84% of the patients in the propofol groups, with a short apnoea in 32 and 48% of these same patients. Clinical recovery was very quick, less than 12 min for all groups. The four psychomotor and sensory tests were carried out at the 30th min by 95% of the patients in the propofol groups, whereas only 50% of those in the ketamine-midazolam groups did so. Speed and quality were significantly better in the propofol groups. The most frequent adverse effect of propofol was pain during injection in 32 and 14% of patients.(ABSTRACT TRUNCATED AT 250 WORDS)

[Effect of collagenase, hyaluronidase and pronase, alone or combined with cationic markers, on the renal filtration barrier in the rat]

The authors investigate the effect of collagenase, hyaluronidase and pronase, used either alone or associated with cationic tracers such as Alcian Blue, Ruth enium Red and Polyethyleneimine on the Rat glomerular filtration barrier. Collagenase appears to promote the perviousness of the three constitutive layers of the glomerular basement membrane. The effects of hyaluronidase and pronase seem to be specific and permit to suppose that the glomerular basement membrane supports several types of anionic sites. The affinity of cationic tracers seems to fluctuate according to the constitution of these sites.

Maternal and fetal concentration of morphine after intrathecal administration during labour

Twenty-five healthy women in labour received morphine 1-1.75 mg in normal saline intrathecally. The residual pain was evaluated on a scale from 0 to 5 at 10 min (score 2.5) and at 25 min (score 1.5). After delivery the maternal and fetal plasma morphine concentrations were measured by radioimmunoassay in 14 parturients. Twenty-three women of 25 had vaginal deliveries, 20 of them without forceps. The maternal and fetal plasma concentrations of morphine were 6 ng ml-1 or less. The intrathecal (but not extradural) administration of morphine is effective and could provide an interesting alternative for pain relief in labour.

Microfilamentous carcinoid of the thymus: correlation of ultrastructural study with Grimelius stain

We observed a carcinoid of the thymus that was remarkable for the presence of intracytoplasmic inclusions-readily visible by light microscopy-in the majority of tumor cells. The inclusions were best seen in Grimelius-stained preparations, which also revealed argyrophilic granules present within or close to the masses. On electron microscope examination the inclusions were found to be composed of aggregates of filaments, probably of the intermediate type, which were at times accompanied by neurosecretory granules. The observed incompatibility between the presence of such inclusions and a homogeneous distribution of secretory granules in the cytoplasm is suggestive of a dysfunction of intracellular movements. Microfilamentous carcinoids may represent a class of tumor having a pathologic excretory process.

Significant hormonal changes in patterns of lipid granules in vaginal exfoliated cells

In vaginal exfoliative cytology, the routine Papanicolaou and Shorr's staining procedures do not reliably indicate the post-ovulatory phase. An experimental study of 100 female albino rats and a clinical study of 190 women was initiated to establish an easier method for identifying the post-ovulatory phase. It was found that the appearance of intracytoplasmic lipid granules in vaginal cells stained by Oil Red 0 may serve as a sensitive indicator of the post-ovulatory phase.