Percutaneous infraclavicular subclavian vein catheters in paediatric cancer patients in comparison with critically ill children: a one-year experience from a Tunisian hospital

BACKGROUND

Paediatric cancer and critically ill patients frequently require central venous catheters for prolonged intravenous therapy. The aim of this study is to compare the difficulty of catheter insertion and the morbidity related to this procedure in these two populations and to investigate risk factors for complications.

METHODS

This prospective observational study was conducted at the Hedi Chaker University Hospital in Sfax, Tunisia, from July 2021 to July 2022. We included all patients aged three months to 14 years who required an infraclavicular subclavian vein catheterization. Patients were divided into two groups: Group 1 included children with malignancies; and Group 2 included critically ill paediatric patients. Then, we compared the demographic data, the difficulty of the catheterization procedure, and catheter-related complications. We also investigated risk factors for complications using a logistic regression model. The significance level was P<0.05.

RESULTS

We included 65 infants and children requiring central venous access, 28 of whom suffered from malignancies. The demographic parameters were comparable. However, the time for the procedure and the number of attempts were higher in the malignancy group with P<0.001. Central venous catheter complications were present 46.4% of the time in Group 1 compared to 21.6% in Group 2 (P=0.032). Malignancies were associated with an increased risk of complications (aOR = 2.95; 95%CI: 0.63-13.8).

CONCLUSIONS

This study showed increased difficulty and higher morbidity related to infraclavicular subclavian vein catheterization among infants and children suffering from cancer.

Early versus late removal of the I-Gel in paediatric patients with mild upper respiratory tract symptoms undergoing ambulatory ilioinguinal surgery: A prospective observational study

The optimal timing of I-Gel removal in children with mild respiratory symptoms remains controversial. Consequently, we tried to assess the impact of early versus late I-Gel removal on the incidence of perioperative respiratory adverse events among children aged one to five years undergoing ambulatory surgery under general anaesthesia with I-Gel airway ventilation. The anaesthesia protocol was the same for all patients. Children were divided into two groups according to the approach of I-Gel removal (early versus late). The incidence of perioperative respiratory adverse events after the I-Gel removal was the main outcome, and a multivariable regression was performed to investigate the implication of the I-Gel removal in perioperative respiratory adverse events. According to our study, the incidence of perioperative respiratory adverse events was not correlated to the timing of I-Gel removal. However, prolonged postoperative oxygen support can be seen when the I-Gel is removed in anaesthetized children.

Airway management in a rare case of congenital palate teratoma with a cleft palate: A case report

Airway management in neonates is difficult because of the risk of rapid hypoxia. It presents a challenge even for an experienced anesthesiologist. Oral tumors in neonates can obstruct the airway or feeding problems in the newborn. Surgical excision is the treatment of choice but these tumors can seriously worsen the conditions of intubation. To surmount these difficulties, a particular multidisciplinary approach and special precautions are needed. We describe the airway management and precautions taken in the anesthesia for surgical removal of a case of large congenital palate teratoma associated with a wide cleft palate in a 25-day-old girl. Impossible intubation was predicted on magnetic resonance imaging. The difficult airway management cart as well as an otorhinolaryngologist skilled in performing emergency tracheostomies in neonates were available. The patient was intubated by conventional laryngoscopy under sevoflurane inhalation anesthesia. The tumor was successfully resected. This case poses a challenge for managing the airway because of the possibility of obstruction of the airway and the difficulty of the airway that radiological exams have allowed us. So, a multidisciplinary team effort is needed for successful neonatal airway management.

Management of COVID-19-Associated Guillain-Barré Syndrome in a Full-Term Pregnant Woman: A Case Report

Guillain-Barré syndrome (GBS) can occur after viral infections. Its occurrence after COVID-19 infection in the peripartum period is a very rare co-occurrence. Therefore, there are no guidelines for the management of these patients. We report the case of a 32-year-old pregnant woman who developed COVID-19-associated GBS with aspiration pneumonia, motor weakness, and ascending paralysis at 39 weeks of gestation. Preoperative plasmatic exchange (plasmapheresis) and oxygen support were very effective and allowed for a rapid recovery within five days. Because of foetal distress during labor, the patient had a caesarean section under spinal anaesthesia with no maternal complications or adverse foetal outcomes.

Predictors of perioperative respiratory adverse events among children with upper respiratory tract infection undergoing pediatric ambulatory ilioinguinal surgery: a prospective observational research

Objectives

Anesthesia for children with an upper respiratory tract infection (URI) has an increased risk of perioperative respiratory adverse events (PRAEs) that may be predicted according to the COLDS score. The aims of this study were to evaluate the validity of the COLDS score in children undergoing ilioinguinal ambulatory surgery with mild to moderate URI and to investigate new predictors of PRAEs.

Methods

This was a prospective observational study including children aged 1–5 years with mild to moderate symptoms of URI who were proposed for ambulatory ilioinguinal surgery. The anesthesia protocol was standardized. Patients were divided into two groups according to the incidence of PRAEs. Multivariate logistic regression was performed to assess predictors for PRAEs.

Results

In this observational study, 216 children were included. The incidence of PRAEs was 21%. Predictors of PRAEs were respiratory comorbidities (adjusted OR (aOR)=6.3, 95% CI 1.19 to 33.2; p=0.003), patients postponed before 15 days (aOR=4.3, 95% CI 0.83 to 22.4; p=0.029), passive smoking (aOR=5.31, 95% CI 2.07 to 13.6; p=0.001), and COLDS score of >10 (aOR=3.7, 95% CI 0.2 to 53.4; p=0.036).

Conclusions

Even in ambulatory surgery, the COLDS score was effective in predicting the risks of PRAEs. Passive smoking and previous comorbidities were the main predictors of PRAEs in our population. It seems that children with severe URI should be postponed to receive surgery for more than 15 days.

Complications and its risk factors of percutaneous subclavian vein catheters in pediatric patients: enhancing the outcomes of a university hospital in a low-income and middle-income country

Objective

Assessing central venous catheter-related complications with regular feedback and investigating risk factors are mandatory to enhance outcomes. The aim of this study is to assess our experience in the management of pediatric subclavian vein catheters (SVCs) and to investigate the main risk factors for complications.

Methods

In this prospective observational study, we included children aged 3 months to 14 years who underwent infraclavicular subclavian vein catheterization consecutively using the anatomic landmark technique. Patients were divided into two groups: group 1 included complicated catheters and group 2 included non-complicated catheters. The management protocol was standardized for all patients. After comparing the two groups, univariate and multivariate logistic regression were used to investigate the risk factors for complications.

Results

In this study, we included 134 pediatric patients. The rate of complications was 32.8%. The main complications were central line-associated bloodstream infection (63.6%), bleeding and/or hematoma (22.7%), mechanical complications (13.6%), and vein thrombosis (13.6%). After adjustment for confounding factors, predictors of catheter-related complications were difficult insertion procedure (adjusted odds ratio (aOR)=9.4; 95% confidential interval (CI): 2.32 to 38.4), thrombocytopenia (aOR=4.43; 95% CI: 1.16 to 16.86), comorbidities (aOR=2.93; 95% CI: 0.58 to 14.7), and neutropenia (aOR=5.45; 95% CI: 2.29 to 13.0).

Conclusions

High rates of complications were associated with difficult catheter placement and patients with comorbidities and severe thrombocytopenia. To reduce catheter-related morbidity, we suggest an ultrasound-guided approach, a multidisciplinary teaching program to improve nursing skills, and the use of less invasive devices for patients with cancer.

Improvement of Broviac catheter-related outcomes after the implementation of a quality management system: A before-and-after prospective observational study

Background: Because of the high rates of Broviac catheter complications, we started an urgent quality process to reduce this morbidity. The aim is to assess the efficiency of the main actions we have taken in enhancing our practice and improving Broviac outcomes. Methods: We included all neonates and young infants requiring surgical central venous access using a Broviac tunneled catheter. We compared the catheters’ outcomes before and after the implementation of a quality program based on a nurse teaching program, patient selection, and catheter management multidisciplinary protocol. The significance threshold was set at p<0.05. Results: We included 94 patients: 51 in the protocol group and 43 in the control group. The complication rate was reduced from 60.3% to 25.5% with p=0.001. The lifetime of the catheter was improved from 11.3 ± 4.3 days to 19.1 ± 9 days with p=0.007. The catheter infection was reduced from 65.3% to 46.1% with p≤0.001. Conclusion: This quality improvement project shows the utility of a quality assurance program based on careful indications and patient selection, a nursing teaching program, and a multidisciplinary catheter management protocol, in reducing Broviac catheter-related morbidity.

Spontaneous bladder rupture after non-traumatic vaginal delivery: a rare case report

Spontaneous bladder rupture (SBR) is a rare condition and often missed diagnosis, especially after a non traumatic vaginal delivery. A 32-year-old para 3 woman, consulted for abdominal pain and anuria two days after instrumental vaginal delivery with forceps for foetal distress in second sate of labour. Blood tests were suggestive of an acute renal failure. An abdominocentesis revealed a clear fluid looking like ascites. The ultrasound and computed tomography (CT) scan showed a large abdominal effusion. An exploratory laparoscopy revealed a bladder perforation which was sutured after laparotomy. SRB is extremely rare after a non traumatic vaginal delivery. It is associated with significant morbidity and mortality. Symptoms are mostly non-specific. It is suspected when post partum abdominal pain is associated with an effusion and renal failure signs. If suspected, the uroscanner remains the gold standard for diagnostic. Laparotomy is the standard surgical approach in this condition. Abdominal pain with elevated serum creatinine should be suspicious of SBR in post-partum.

Risk factors for Hickman-Broviac catheter complications: An experience from a Tunisian hospital

Background: Hickman-Broviac catheters have improved the care of young children needing frequent and prolonged venous access, but at the same times it has substantial morbidity, particularly in a resource-constrained setup. Our study aims to describe the experience of a Tunisian hospital and investigate the main risk factors for complications. Methods: In this study, we included all the neonates and infants who underwent Broviac catheter insertion in the pediatric surgery department. The patients were divided into 2 groups according to the presence of complications. We compared these two groups and univariate logistic regression analyses were used to determine the risk factors for complications. Results: Forty-three children were included in the study. The incidence of complicated catheters was 60.4%. The following factors were significantly associated with an increased risk of complications: age 6 months [OR 3.5, 95% CI: 0.6-19.3], weight 6 kg [OR 1.54, 95% CI: 0.46-5.2], emergency circumstances [OR 1.62, 95% CI: 0.8-5.4], and antibiotic-therapy as an indication for Broviac catheter insertion [OR 1.8, 95% CI: 0.5-6.2]. Conclusion: Complications seem to be more frequent in patients younger than 6 months and those with a weight of less than 6Kg. To reduce the morbidity related to the catheters, the indications should be carefully chosen.

Management of esophageal atresia and early predictive factors of mortality and morbidity in a developing country

The aim of this study is to investigate management and outcome in esophageal atresia (EA) and to identify early predictive factors of morbidity and mortality in a developing country. Charts of neonates with repaired EA from 2007 to 2016 were reviewed. Patients' characteristics, operative details, and postoperative outcomes were collected. Statistical analyses were performed to identify predictors of complicated evolution. Forty-two cases were collected. There were 14 girls and 28 boys. Only one patient had antenatal diagnosis (2.3%). The mean gestational age was 38 weeks. Nine patients (21.4%) weighed less than 2.5 kg. Seventeen (40.4%) patients had associated malformations most commonly cardiac (9/17). Thirteen patients had delayed diagnosis (30.9%). Thirty-nine (92.8%) patients underwent primary esophageal anastomosis. Overall survival was 76.2%. Nineteen patients (57% of survivals) had complicated evolution before the age of one year and 15 patients (46.8% of survivals) developed complications after the age of one year. Perinatal variables associated with mortality were prematurity (p = 0.004, OR = 5.4, IC95% = [1.13-25.80]), low birth weight (p = 0.023, OR = 7, IC95% = [1.38-35.47]), cardiac malformations (p = 0.006, OR = 10.5, IC95% = [2.03-54.27]) and delayed diagnosis (p = 0.005, OR = 10.11, IC95% = [2.005-50.980]). Variables associated with short-term and middle-term complications were duration of intubation (p = 0.019, OR = 0.118, IC95% = [0.019-0.713]) and the presence of short-term complications (p = 0.016, OR = 7.33, IC95% = [1.467-36.664]) respectively. These factors may be used to identify patients who will benefit from more intensive follow-up program.

[Reaction to Mohamed Said Nakhli et al. concerning the article: "When the axillary block remains the only alternative in a 5 year old child". The Pan African Medical Journal. 2015;21:36]

Axillary block is an easy and recommended technique in children. Its use in children with acute hepatitis A is not risk free especially when associated with sedation using remifentanil and propofol. Similarly, the presence of a single hydatid cyst allows general anesthesia with mono-pulmonary ventilation.

Postoperative analgesia in children when using clonidine in addition to fentanyl with bupivacaine given caudally

The aim of the study was to evaluate the efficacy of clonidine in association with fentanyl as an additive to bupivacaine 0.25% given via single shot caudal epidural in pediatric patients for postoperative pain relief. In the present prospective randomized double blind study, 40 children of ASA-I-II aged 1-5 years scheduled for infraumblical surgical procedures were randomly allocated to two groups to receive either bupivacaine 0.25% (1 ml/kg) with fentanyl 1 μg/kg and clonidine 1μg/kg (group I) or bupivacaine 0.25% (1 ml/kg) with fentanyl 1 μg/kg (group II). Caudal block was performed after the induction of general anesthesia. Postoperatively patients were observed for analgesia, sedation, hemodynamic parameters, and side effects or complications. Both the groups were similar with respect to patient and various block characteristics. Heart rate and blood pressure were not different in 2 groups. Significantly prolonged duration of post-operative analgesia was observed in group I (P<0.05). Side effects such as respiratory depression, vomiting and bradycardia were similar in both groups. The adjunction of clonidine to fentanyl as additives to bupivacaine in single shot caudal epidural in children may provide better and longer analgesia after infraumblical surgical procedures.

Subarachnoid morphine versus TAP blocks for enhanced recovery after caesarean section delivery: A randomized controlled trial

INTRODUCTION

Subarachnoid morphine is widely used for pain relief in enhanced recovery program after cesarean section in spite of its side effects. However, the role of TAP block is still controversial. The aim of our study was to compare the impact of these analgesic techniques (subarachnoid morphine and TAP block) on enhanced recovery after cesarean section.

MATERIALS AND METHODS

In this randomized controlled trial, we included patients scheduled for cesarean delivery under spinal anesthesia. Patients were randomized in two groups. Group I: received spinal anesthesia with 100μg of subarachnoid morphine. Group II: received spinal anesthesia without subarachnoid morphine followed by an ultrasound-guided TAP block. We assessed the time required for mobilization, for re-establishment of gastrointestinal transit and for breast-feeding.

RESULTS

TAP block allowed earlier postoperative mobilization. Time required for getting up was significantly lower in group II (9.4h versus 6.9h; P=0.024) as well as time required for walking (12.4h versus 7.4h; P=0.001). TAP block allowed earlier re-establishment of gastrointestinal transit (11.2h in group I versus 8.1h in group II; P<0.001).

CONCLUSIONS

TAP block seems to be suitable with enhanced recovery programs.

Near-infrared spectrometry in pregnancy: progress and perspectives, a review of literature

Near-infrared spectroscopy (NIRS) allows continuous noninvasive monitoring of in vivo oxygenation in selected tissues. It has been used primarily as a research tool for several years, but it is seeing wider application in the clinical arena all over the world. It was recently used to monitor brain circulation in cardiac surgery, carotid endarteriectomy, neurosurgery and robotic surgery. According to the few studies used NIRS in pregnancy, it may be helpful to assess the impact of severe forms of preeclampsia on brain circulation, to evaluate the efficacy of different treatments. It may also be used during cesarean section to detect earlier sudden complications. The evaluation of placental function via abdominal maternal approach to detect fetal growth restriction is a new field of application of NIRS.

[Hyperemesis gravidarum with severe electrolyte disorders: report of a case]

L'hyperemesis gravidarum s'accompagne habituellement d'une perte de poids, d'une acétonurie et de troubles hydro-électrolytiques comme il peut également s'accompagner d'anomalies du bilan hépatique. Nous rapportons un cas de vomissements gravidiques à 10 semaines d'aménorrhée non traité et vu tardivement avec des troubles ioniques sévères associés à des répercussions cliniques dans un contexte de cytolyse, de cholestase et d'insuffisance rénale aigue. Ce cas a bien répondu au traitement médical.

The role of procalcitonin and N-terminal pro-B-type natriuretic peptide in predicting outcome after cardiac surgery

OBJECTIVE(S)

Determine the thresholds of procalcitonin (PCT) and N-terminal pro-B-type natriuretic peptide (Nt-pro-BNP) associated with poor prognosis after heart surgery with CPB.

DESIGN

Prospective observational study.

SETTING

Academic Medical Center Habib Bourguiba.

PARTICIPANTS

Adult patients consecutively operated for coronary or valve surgery with CPB, elective or semi-urgent.

INTERVENTIONS

Serum concentrations of PCT and Nt-pro-BNP were determined before and after CPB, in the fourth postoperative hour (H4) and every day during the first 4 days. Receiver-operating characteristic curves and cut-off values were used to assess the ability of these markers to predict length of intensive care unit (ICU) stay >3 days.

MEASUREMENTS AND MAIN RESULTS

Forty patients were included in the study. Systemic inflammatory response syndrome (SIRS) occurred in 35 (87.5%) patients. Seventeen of them (42.5%) showed severe SIRS. Significantly higher serum concentrations of Nt-pro-BNP and PCT were found in patients with severe SIRS. Receiver operating characteristic (ROC) analysis showed that the threshold of PCT was 0.737 ng/mL and that of Nt-pro-BNP was 1235 pg/mL on day 1 could predict an ICU stay of more than 3 days. The association of Nt-pro-BNP to procalcitonin (p=0.009) better predicted the ICU stay than PCT alone (p=0.02) or Nt-pro-BNP alone (p=0.03). The best combination is Nt-pro-BNP + PCT + C-reactive protein (CRP) (p=0.007).

CONCLUSIONS

PCT and Nt-pro-BNP on day 1 may be associated with severe SIRS and predict the length of stay. A biomarker approach combining PCT, CRP and BNP is superior to a traditional single marker for predicting ICU stay.

[Evaluation of the antibiotics consumption in a Tunisian university hospital]

PURPOSE

To estimate the consumption of antibiotics in our hospital and to determine the points at which will be targeted the recommendations of good practice of antibiotherapy.

PATIENTS AND METHODS

Our study is a one day prevalence study where antibiotic's prescriptions are analyzed by a group of 6 doctors referents in antibiotherapy.

RESULTS

During the study day, 443 patients were studied. Means age was 44.2 +/- 23.3 years (range: 1 and 102 years). 101 infections were diagnosed in 48 patients (10.8%). 192 patients (43.3%) received antibiotics. Antibiotherapy was curative in 44% of cases. The most prescribed antibiotics were gentamicin (85.2 DDD/1000 patients), metronidazole (79 DDD/1000 patients), and cefotaxime (73.9 DDD/1000 patients). According to the evaluation group, 30.7% of the antibiotic's prescription was considered unjustified. The antibioprophylaxis represents the category most often unjustified (49%). The molecules in which prescription was frequently considered unjustified are the ciprofloxacin (67%), the amoxicilline-clavulanate (40%) and the cefotaxime (40%).

CONCLUSION

Our results suggest that an action of good practice should be targeted at the antibioprophylaxis and should concern especially molecules in which prescription was frequently unjustified.

[Renal needle biopsy in children. Technical aspects and results]

Renal needle biopsy is still irreplaceable in children. The objectives of this retrospective study were to specify the technical aspects and the main nephropathies encountered. 152 children under the age of 16 years (13 +/- 3), 79 boys and 73 girls, underwent renal biopsy. The biopsy was performed after radiographic detection in 71 cases, and under continuous ultrasound guidance in 81 cases. The comparative study of these 2 techniques revealed the superiority of continuous ultrasound guidance, allowing biopsy of an essentially cortical fragment, rich in glomeruli with a limited number of punctures. Histological examination showed a predominance of glomerular nephropathy with, especially, visually normal kidney and membranoproliferative glomerulonephritis. These data encourage us to perform ultrasound-guided RNB in children and to eradicate sites of infection, particularly involving the upper respiratory tract.

[Predisposition to thyroid autoimmune diseases]

OBJECTIVES

Genetic predisposition is required for the expression of thyroid autoimmune disorder addition to the immune dysfunction and the environmental factors.

METHODS

In order to evaluate the role of this genetic factor, we reported the results of immunological and hormonal investigations of 62 members (TD), belonging to a large Akr family, who are related to 40 patients with Graves' disease or Hashimoto's thyroiditis.

RESULTS

The hormonal analyses showed that 19 subjects exhibited an infraclinical hypothyroidism, subdivided into 7 members with pathological rates of TSH evocative of thyroid insufficiency and 12 others with compensative thyroid insufficiency. Seventeen subjects of the Akr family who had solely antithyroid autoantibodies were considered as potential candidates to develop thyroid autoimmune diseases. The clinical follow-up, during two years, confirmed the diagnosis of Hashimoto's thyroiditis in 3 members among 19 subjects with infraclinical hypothyroidism (TD05, TD28 and TD54) and in only 1 member out of the 17 potential candidates (TD03).

CONCLUSION

Our results showed that a serological study of hormones and/or autoantibodies directed against thyroid antigens, could allow the detection of predisposed subjects to develop a thyroid autoimmune pathology. The Akr family seems to be suitable for the study of the localization of susceptibility genes to TAID.

Polymorphism of the human immunoglobulin heavy chain locus in rheumatoid arthritis

The genetic origin of Rheumatoid Arthritis (RA) is largely unknown. The purpose of this investigation was to assess the potential genetically determined involvement of the immunoglobulin (Ig) heavy chain variable region (VH) locus in the pathogenesis of RA. We tested the hypothesis of whether there is a genetic linkage between a structural abnormality of the VH gene complex and autoantibody hyperproduction in RA. We used restriction endonuclease generated polymorphism with human VH gene-family-specific probes to examine genomic DNA from a RA family and from unrelated RA patients from both the Tunisian and the European populations. The use of DNA samples from these ethnic origins permitted a further evaluation of the polymorphism of the human VH locus. While we found that the polymorphism of the VH locus was lower in the Tunisian population, we could not detect a restriction site polymorphism pattern restricted to RA. Together, our results do not support the involvement of major abnormalities of the Ig VH locus as a primary source in the development of RA.

Antibody epitopes probed by immunoselected phage-display library peptides in members of a family with various rheumatic manifestations

OBJECTIVE

The random peptide combinatorial phage library approach overcomes the problem of lack of structural information about the aetiological agent or the antigen responsible for a given disease. Here, we used such a strategy to gain insight into the aetiology of rheumatoid arthritis (RA).

METHODS

We analyzed the reactivity of serum antibodies from a family with various rheumatic manifestations against RA-immunoselected nanopeptides displayed on phage particles.

RESULTS AND CONCLUSION

We found that within the same family, there was a difference in antibody reactivity against the peptides tested. The IgG isotype of the peptide reactive antibodies indicated that the observed reactivities were not related to the presence of polyreactive IgM antibodies. Furthermore, it is unlikely that the observed reactivity was due to rheumatoid factors (RF), since two patients who were positive for the immunoselected Pep3 peptide (LSSREPQAR) were RF negative. We also found that the serum of one patient with polyarthralgias also reacted with the same peptide bound by the RA serum, which may suggest the implication of a common aetiological agent in the apparition of this antibody reactivity. Finally, we noted that one patient with Sjögren's syndrome had antibodies to the RA peptide, which may indicate a potential relationship between these two autoimmune diseases.

Hypopigmentation in hemodialysis. Acquired hair and skin fairness in a uremic patient undergoing maintenance hemodialysis: case report and review of the literature

With recent advances in medicine, uremic patients are living longer with an improving quality of life. Several skin diseases have been reported in patients with chronic renal failure, and the opportunity has been offered to elucidate newer cutaneous abnormalities among patients undergoing long-term hemodialysis. Hyperpigmentation was the most prevalent cutaneous abnormality observed in these patients, but hypopigmentation remains an exceptional event. We report here a case of a maintenance hemodialysis patient with an acquired hair and skin fairness. Although the true mechanism involved in this entity remains obscure, it can be correlated with a disturbance of phenylalanine metabolism on the basis of the current knowledge.

[Direct cost of the ambulatory management of diabetes at the outpatient clinic of the National Social Security Fund of Sfax (Tunisia)]

The direct costs were determined by conducting a retrospective study on the files of 100 diabetics (selected at random) who had attended the clinic at least once in 1991. Another study was conducted simultaneously under the same conditions on 100 non-diabetic patients. Diabetic patients attend on average 8 times a year, twice as often as nondiabetics, generally at the department of general medicine (6 times). They undergo more biological tests and receive more care procedures than nondiabetics. Drug prescriptions cost on average US$ 62 per year for the diabetic, 3 times as much as for the non-diabetic (US$ 20/year). The total direct cost of outpatient care is US$ 117 per year for the diabetic, as against only US$ 48 for the nondiabetic. The cost is much higher for diabetics with degenerative complications (US$ 144 as against US$ 92). Reduction of the cost of care requires early detection of diabetes and education of the diabetic, so as to ensure better control of blood sugar levels and freedom from complications that lead to a sharp increase in consultations and treatment procedures.

[Dermatopolymyositis induced by D-penicillamine in rheumatoid polyarthritis. Apropos of 1 case with review of the literature]

Treatment of rheumatoid arthritis (RA) with D-penicillamine (DP) is associated with development of dermatopolymyositis (DPM) in 0.2 to 1.2% of cases. A case of DPM which developed after four years DP therapy in a 58-year-old female with RA is reported. The favorable outcome after discontinuation of DP and administration of corticosteroids and the absence of recurrence or malignant disease after 4 years 9 months follow-up demonstrated the causal relationship between DP therapy and development of DPM. An analysis of 34 previously published cases of DP-induced DPM (DP/DPM) showed the following: development of DPM was not influenced by the dosage or duration of DP therapy; reported cases of DP/DPM were clinically identical with primary DPM but had a different outcome, with permanent recovery of DP/DPM occurring 1.5 to 6 months after withdrawal of DP; patients with DP/DPM had immune disorders, including antinuclear antibodies in 14 of 34 patients; the high prevalence of the B18, B35, DR4 haplotype in these patients denotes immunogenetic differences with primary DPM patients (B8-DR3) and DP-induced myasthenia (DR1).

[Gougerot-Sjögren syndrome associated with dysthyroidism]

The occurrence of Gougerot-Sjögren syndrome in a context of dysthyroidism is not a chance happening, as is reflected by the 37% rate of incidence. Routine labial biopsy, carried out in 59 cases of primary hypothyroidism due to atrophic thyroiditis, 20 of Basedow's disease and 4 of Hashimoto thyroiditis identified Gougerot-Sjögren syndrome (3-4 Chisholm grade) in 3 of the 59 cases of hypothyroidism i.e. in 5 percent, and in one Basedow case out of 20, i.e. 5 percent. Using Kaplan's criteria, the incidence of Gougerot-Sjögren syndrome rises to 22 percent in hypothyroidism and 30 percent in Basedow's disease. Consequently, the incidence of Gougerot-Sjögren syndrome is higher in Basedow disease than in primary hypothyroidism. Gougerot-Sjögren syndrome is seen particularly in dysthyroidism involving manifest and all-round clinical signs. This association does not seem to result from one disease being caused by the other, but the outcome of the onset of entities to which a genetically determined context predisposes the subject, as is shown by the prevalence of HLA DRW3 and HLA B8 groupings in Gougerot-Sjögren syndrome, in primary hypothyroidism, in Basedow's disease and in Hashimoto's thyroiditis.