Effects of web-based adapted physical activity on hippocampal plasticity, cardiorespiratory fitness, symptoms, and cardiometabolic markers in patients with schizophrenia: a randomized, controlled study

Among the lifestyle interventions, the physical activity (PA) has emerged as an adjuvant non-pharmacological treatment improving mental and physical health in patients with schizophrenia (SZPs) and increasing the hippocampus (HCP) volume. Previously investigated PA programs have been face-to-face, and not necessary adapted to patients' physiological fitness. We propose an innovative 16-week adapted PA program delivered by real-time videoconferencing (e-APA), allowing SZPs to interact with a coach and to manage their physical condition. The primary goal was to demonstrate a greater increase of total HCP volumes in SZPs receiving e-APA compared to that observed in a controlled group. The secondary objectives were to demonstrate the greater effects of e-APA compared to a controlled group on HCP subfields, cardiorespiratory fitness, clinical symptoms, cognitive functions, and lipidic profile. Thirty-five SZPs were randomized to either e-APA or a controlled group receiving a health education program under the same conditions (e-HE). Variables were assessed at pre- and post-intervention time-points. The dropout rate was 11.4%. Compared to the e-HE group, the e-APA group did not have any effect on the HCP total volumes but increased the left subiculum volume. Also, the e-APA group significantly increased cardiorespiratory fitness (VO2max), improved lipidic profile and negative symptoms but not cognitive functions. This study demonstrated the high feasibility and multiple benefits of a remote e-APA program for SZPs. e-APA may increase brain plasticity and improve health outcomes in SZPs, supporting that PA should be an add-on therapeutic intervention. ClinicalTrial.gov on 25 august 2017 (NCT03261817).

Autonomic cardiac function in children and adolescents with long COVID: a case-controlled study

Although the mechanisms underlying the pathophysiology of long COVID condition are still debated, there is growing evidence that autonomic dysfunction may play a role in the long-term complications or persisting symptoms observed in a significant proportion of patients after SARS-CoV-2 infection. However, studies focused on autonomic dysfunction have primarily been conducted in adults, while autonomic function has not yet been investigated in pediatric subjects. In this study, for the first time, we assessed whether pediatric patients with long COVID present abnormalities in autonomic cardiac function. Fifty-six long COVID pediatric patients (mean age 10.3 ± 3.8 y) and 27 age-, sex-, and body surface area-matched healthy controls (mean age 10.4 ± 4.5y) underwent a standard 12-lead electrocardiography (ECG) and 24-h ECG Holter monitoring. Autonomic cardiac function was assessed by time-domain and frequency-domain heart rate variability parameters. A comprehensive echocardiographic study was also obtained by two-dimensional echocardiography and tissue Doppler imaging. Data analysis showed that pediatric patients with long COVID had significant changes in HRV variables compared to healthy controls: significantly lower r-MSSD (root mean square of successive RR interval differences, 47.4 ± 16.9 versus 60.4 ± 29.1, p = 0.02), significant higher values VLF (very low frequency, 2077.8 ± 1023.3 versus 494.3 ± 1015.5 ms, p = 0.000), LF (low frequency, 1340.3 ± 635.6 versus 354.6 ± 816.8 ms, p = 0.000), and HF (high frequency, 895.7 ± 575.8 versus 278.9 ± 616.7 ms, p = 0.000). No significant differences were observed between the two groups both in systolic and diastolic parameters by echocardiography.  Conclusion: These findings suggest that pediatric patients with long COVID have an imbalance of cardiac autonomic function toward a relative predominance of parasympathetic tone, as already reported in adult patients with long COVID. Further studies are needed to clarify the clinical significance of this autonomic dysfunction and demonstrate its role as a pathophysiological mechanism of long COVID, paving the way for effective therapeutic and preventive strategies. What is Known: • Long Covid in children has been described globally, but studies have mostly focused on collecting the temporal evolution of persisting symptoms. What is New: • Cardiac autonomic imbalance toward a relative predominance of parasympathetic tone is a mechanism underlying Long Covid in children, as also described in adults.

Evaluation of a simplified pharmacovigilance tool for general practitioners: 5 years of insight

Spontaneous reporting of adverse drug reactions (ADRs) is the cornerstone of pharmacovigilance. However, major underreporting exists. The main objective of this study was to assess the use of a pharmacovigilance simplified reporting tool (PSRT) by general practitioners (GPs) and, secondarily, to describe the quality of ADR reports during this period. The PSRT was proposed on June 1st, 2015, for the 1290 GPs in the Western Normandy Region. The number and quality of ADRs reported monthly by GPs were prospectively collected from June 1st, 2015, to May 31st, 2020 (Period 2), and compared to those reported during a control period (June 1st, 2010, to May 31st, 2015, Period 1). During all the periods, 920 reports were made by 307 GPs (198 reports in Period 1 and 722 reports in Period 2), with 477 reports (51.8%) using the PSRT. During Period 2, the monthly number of reports was multiplied by 3.5 (p < 0.0001), and the number of GPs was 1.4 compared to that in Period 1 (p = 0.01). Our PSRT showed effectiveness in quantitative and qualitative terms. It must now go further and be integrated into GP software to facilitate ADR reporting nationwide.

Prevalence and factors associated with active cybersexuality among teenagers between 15 and 17 years old: a cross sectional study in Normandy, France

OBJECTIVE

Teenagers use the Internet to obtain and exchange information in multiple fields, including about taboo subjects such as sexuality. Our objectives were to determine the prevalence and vulnerability factors related to active cybersexuality among teenagers aged between 15 and 17 years in western Normandy.

MATERIAL AND METHODS

This was an observational, cross-sectional, multicenter study integrated into sexual education classes for teenagers between 15 and 17 years old. An anonymous questionnaire, designed for the study, was given at the beginning of each session.

RESULTS

The study had a 4-month duration and involved 1,208 teenagers. The results revealed that 66% of them engaged in cybersex, with sexting being the most widespread practice: 21% sent such sexts, 60% received such sexts, and 12% of boys shared such texts with others. Other practices, such as dedipix, dating websites, and skin parties, were more marginal, but 12% of teenagers had met someone in real life after meeting them first online. A history of experiencing violence, a lack of parental control, female gender, poor self-esteem, and consuming toxic drugs were associated with a higher risk of cybersexuality with an odds ratio (OR) of 1.63, 1.95, 2.07, 2.27, and 2.66, respectively. Number of friends on social networks >300 and daily viewing of pornography were also strongly associated with cybersexuality with an OR of 2.83 and 6.18, respectively.

CONCLUSIONS

This study shows that cybersex is practiced by two thirds of teens. Vulnerability factors most strongly associated with cybersexuality were female gender, poor self-esteem, consuming toxic drugs, number of friends on social networks >300, and daily viewing of pornography. Cybersexuality involves risks (social exclusion, bullying, dropout, poor self-esteem, breakdown) that are possible to prevent by highlighting this theme during sexual education classes.

Early infectious risk in patients with anti-neutrophil cytoplasmic antibody-associated vasculitis according to remission-induction therapy

OBJECTIVE

Few comparative data exist on early infections secondary to remission-induction therapy (RIT) with rituximab (RTX) versus cyclophosphamide (CYC) in newly diagnosed anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) patients. We compared and analysed the rates and predictors of severe infection in such patients within the first 6 months following RIT.

METHOD

From the Caen University Hospital databases, we included all consecutive adults newly diagnosed with ANCA-positive granulomatosis with polyangiitis or microscopic polyangiitis between January 2006 and December 2019. We compared rates of survival without severe infection and survival without infections of any severity within 6 months of RIT and used a multivariate Cox analysis to identify predictors of infection.

RESULTS

We included 145 patients, 27 in the RTX and 118 in the CYC group. Patients in the RTX group more frequently had pneumococcal vaccination (p < 0.01) and creatinine < 150 µmol/L; other characteristics were comparable between the two groups. Overall, 37 severe infections and 65 infections of any severity were recorded. Rates of survival without severe infection were similar in both groups (p = 0.69), but survival without infections of any severity was lower in the RTX group (p = 0.005). In multivariate analysis, risk factors at diagnosis for severe infections included chronic urinary tract disease, dialysis, and absence of trimethoprim-sulfamethoxazole prophylaxis (p < 0.01 each).

CONCLUSIONS

Within 6 months of RIT, rates of survival without severe infection were similar in newly diagnosed ANCA-positive AAV patients treated with RTX or CYC, but survival rates without infections of any severity appeared to be lower with RTX treatment.

[ECOVIR: Study of a primary care cohort in of patients with Acute Respiratory Infections in Normandy, an example of pluri-professional hospital-primary care coordination]

Acute Respiratory Infections (ARI) need be better understood and more effectively treated, especially insofar as they are of pivotal importance in public health, particularly during a crisis such as the SARS-CoV2 pandemic. The prospective, multicentric cohort study of viral codetections in respiratory samples study known as ECOVIR was conducted in Normandy, France during two winters (2018-2019, 2019-2020). The objective of the project was to create a biobank of respiratory tract samples from patients consulting their general practitioner (GP) for ARI symptoms. ECOVIR involved 36 GP investigators (GPI), from 8 health care centers throughout Normandy. Six hundred and eighty-five patients with ARI symptoms were included; naso-pharyngeal samples were taken by the GPIs and subsequently analyzed in virology laboratories for the purposes of viral codetection. The median of inclusions was 16 patients for each of the 31 actively participating GPIs over the two winters (CI25-75% [4.75; 27]). By D7, 92% of the patients contacted had responded to our call for participation, enabling us to obtain clinical, environmental and socio-demographic data. Through this study, we created an original functional network, thereby establishing a viable link between research and primary care, which is generally underrepresented in research protocols, even though it constitutes the cornerstone of the French health care system, especially during this prolonged period of sanitary crisis.

POS0831 EARLY INFECTIOUS RISK IN PATIENTS WITH NEWLY-DIAGNOSED ANTI-NEUTROPHILCYTOPLASMIC ANTIBODY-ASSOCIATED VASCULITIS ACCORDING TO THE REMISSION-INDUCTIONTHERAPY: A FRENCH MONOCENTRIC RETROSPECTIVE STUDY INCLUDING 145 PATIENTS

Background:

Few comparative data exist on early infections secondary to remission-induction therapy (RIT) with rituximab versus cyclophosphamide in newly-diagnosed ANCA-associated vasculitis (AAV) patients.

Objectives:

We compared and analyzed the rate and predictors of severe infections in such patients within the first six months following RIT.

Methods:

We included, from the databases of Caen University Hospital, all consecutive adults newly-diagnosed with granulomatosis with polyangiitis or microscopic polyangiitis between January 2006 and December 2019. We compared the survival without severe infections (WSI) and the survival without infection of any severity (WIOAS) within 6 months from the RIT, and used a multivariate cox analysis to identify predictors of infection.

Results:

We included 145 patients, 27 in rituximab group and 118 in cyclophosphamide group. Patients in the rituximab group more frequently had pneumococcal vaccination (p<0.01) and creatinine level <150 µmol/L, while other characteristics, including Birmingham Vasculitis Activity Score, were comparable between both groups.

Overall, 37 severe infections and 65 infections of any severity were recorded. The survival WSI was similar in both groups (p=0.69), but survival WIOAS was lower in rituximab group (p=0.005).

In multivariate analysis, risk factors at diagnosis for severe infections were chronic urinary tract disease, dialysis and absence of prophylaxis with trimethoprim-sulfamethoxazole (p<0.01 each).

Conclusion:

The survival WIS within the 6 months following RIT was similar in patients with newly-diagnosed AAV treated by rituximab or cyclophosphamide, but survival WIOAS appeared to be lower within the 6 months following rituximab despite a better pneumococcal vaccination coverage.

Figure 1.

Comparison of the 6-month survival without severe infection (A) or without infection of any severity (B) in patients with newly-diagnosed ANCA-associated vasculitis treated by rituximab or cyclophosphamide

Disclosure of Interests:

None declared

Early continuous glucose monitoring for predicting remission of type 2 diabetes 1 year after bariatric surgery

BACKGROUND

Bariatric surgery in obese subjects can result in remission of type 2 diabetes (T2D) at a distant time post-surgery. The aim of our observational prospective single-centre study was to examine glycaemic patterns in adult T2D candidates for bariatric surgery using a continuous glucose monitoring (CGM) sensor for 14 days after surgery to search for indicators predictive of T2D remission 1 year later.

METHODS

Patients underwent CGM preoperatively and for 14 days postoperatively. Thereafter, body weight and glycated haemoglobin (HbA1c) levels were monitored at 3, 6 and 12 months after surgery.

RESULTS

A total of 31 patients (mean age 47±2 years) were analyzed. After surgery, mean interstitial glucose levels fell rapidly from 157±31mg/dL preoperatively to 109±35mg/dL postoperatively (P<0.001), reaching nadir levels from day 3 after surgery. Successful bariatric surgery (loss of excess weight ≥50%) was observed in 28 (90%) patients, and diabetes remission (HbA1c≤6% with no antidiabetic treatment) 1 year after surgery was noted in 21 (68%) patients. CGM for 14 days post-surgery allowed prediction of diabetes remission 1 year after surgery: time spent above range <14% and standard deviation (SD) of glucose levels <33mg/dL were both strong predictors of T2D remission. Indeed, the association of these two criteria predicted diabetes remission with a 100% positive predictive value, 81% sensitivity and 100% specificity and, when combined with the advanced Diabetes Remission (Ad-DiaRem) score, further increased predictive accuracy.

CONCLUSION

The use of 14-day postoperative CGM recordings together with presurgical clinical scores can help to predict diabetes remission 1 year after bariatric surgery.

Acetic acid disinfection as a potential adjunctive therapy for non-severe COVID-19

Purpose

SARS-CoV-2 is a new pandemic influenza caused by a coronavirus which main route of transmission is through exhaled droplets that primarily infect the nose and the nasopharynx. The aim of this paper is to evaluate the effect of acetic acid, the active component of vinegar, as a potential disinfectant agent for upper airways.

Methods

Twenty-nine patients were enrolled and divided into two groups: group 1 (14 patients) was composed of patients treated with off-label hydroxychloroquine and lopinavir/ritonavir, whereas group 2 (15 patients) was composed of patients treated with hydroxychloroquine only, combined with the inhalation of acetic acid disinfectant at a 0.34% concentration. A questionnaire-based evaluation of symptoms was performed after 15 days in both groups.

Results

It appears that the number of patients treated with acetic acid (group 2) that experienced improvement in individual symptoms was double that of the other group of patients (group 1), although numbers are too small for robust statistical analysis.

Conclusions

Considering its potential benefits and high availability, acetic acid disinfection appears to be a promising adjunctive therapy in cases of non-severe COVID-19 and deserves further investigation.

[Coercive stress in psychiatric intensive care unit: What link with insight?]

The aim of this work was to study the correlations between the coercive experience level in patients in a psychiatric intensive care unit and clinical insight. We included 40 patients without specific diagnosis criteria at the end of their hospitalization in the intensive care unit. We assessed patients with the Coercion Experience Scale (CES) to measure their coercive stress level, and the Scale to Assess Unawareness of Mental Disorder (SUMD) which measures clinical insight. A total of 42.5 % of our sample suffered from mood disorders, 50 % suffered from psychotic disorders and 7.5 % from other disorders. On the one hand, we found that patients' coercive stress level was neither correlated with the awareness of their mental disorder nor with the awareness of social consequences of their mental disorder. On the other hand, we found that coercive stress level was significantly correlated with patients' awareness of treatment efficacy and that the specific CES factor measuring coercion showed a strong trend to significantly correlate with patients' awareness of treatment efficacy. These results seem to show that education about benefits of treatment is a key point to improve patients' coercive stress in a psychiatric intensive care unit, more than an education about awareness of the mental disorder itself.

Tongue carcinoma in young adults: a review of the literature

SUMMARY

A recent reduction in the number of smoke-related tumours has been observed thanks to the diffusion of anti-tobacco campaigns carried out in the majority of developed countries. Nevertheless, as demonstrated by recent global epidemiologic studies, squamous cell carcinoma of the mobile tongue appears to be progressively increasing in incidence, particularly among young adults and especially in females. The driving mechanism responsible for such changes is still to be precisely defined. Several genetic studies have compared the mutational pattern of tongue squamous cell carcinoma in young adults to that of more elderly patients, without identifying significant differences that may help in better characterising this subgroup of subjects. Tongue squamous cell carcinomas in young adults have been historically considered as particularly aggressive clinical entities, with a high risk of loco-regional relapse, survival rates inferior to those of the general head and neck cancer group and need for a more aggressive therapy. However, considering the most recent studies, prognostic results in this patient group are heterogeneous and it is not possible to confirm this tendency. Thus, it is not justified to embrace different therapeutic approaches according to patient age. Eventually, an additional element to consider when examining young subjects affected by tongue cancer is the possibility of genetic predisposition. Alterations affecting pathways involved in DNA repair, surveillance of genetic stability or regulation of cellular growth may determine an increased likelihood of developing head and neck cancers.

[State of immunization against measles among health professionals in at-risk units of the Caen University Hospital]

BACKGROUND

France is facing a new resurgence of measles. Since November 2017, the number of cases has been increasing sharply. Immunization coverage in the general population, all ages combined, is below the threshold required for a rapid decline of the virus propagation. Regarding health professionals, the rate of immunization against this disease is insufficiently documented. In this context, the Occupational Health Service of the University Hospital of Caen has carried out an inventory of health personnel knowledge of immunization against measles in the units the most exposed to risk.

METHODS

Knowledge of immunization against measles was studied in pediatric, imaging, and pediatric and adult emergencies departments of the University Hospital of Caen, and the Hematology Institute of Lower Normandy (IHBN). The analysis included all health professionals present within these units during the study period: March and April 2018. Data collection was carried out by consulting the medical files of the occupational health unit and considering the set of responses to postal inquiries sent to staff.

RESULTS

Measured immunization status data refer to 1017 health professionals. Based on the criteria specific to the recommendations, 234 (50.6%) of the 462 professionals born before 1980 and 437 (78.7%) of the 555 professionals born in or after 1980 could be considered as immune. Of the total sample, 115 (11.3%) had positive measles serology. Among these 1017 professionals, information on the state of immunization against measles was lacking for 174 (17.1%).

CONCLUSION

The state of immunization of the nursing staff remains insufficient to prevent the occurrence of measles cases and the staff is also insufficiently informed. It is essential to have knowledge of the immunization status of this population, to organize the vaccination of non-immunized personnel within the occupational health unit, to prevent the emergence of new cases of measles and to reinforce the information regarding the importance of precautions related to airborne transmission in case of measles.

Correlation between Human Papillomavirus Status and Quantitative MR Imaging Parameters including Diffusion-Weighted Imaging and Texture Features in Oropharyngeal Carcinoma

BACKGROUND AND PURPOSE

The incidence of Oropharyngeal Squampus Cell Carcinoma (OPSCC) cases is increasing especially in the Western countries due to the spreading of human papilloma virus (HPV) infection. Radiological investigations, MRI in particular, are used in the daily clinical practice to stage OPSCC. The aim of this study was to investigate the association of quantitative MR imaging features including diffusion-weighted imaging and human papillomavirus status in oropharyngeal squamous cell carcinoma.

MATERIALS AND METHODS

We retrospectively analyzed 59 patients with untreated histologically proved T2-T4 oropharyngeal squamous cell carcinoma. Human papillomavirus status was determined by viral DNA detection on tissue samples. MR imaging protocol included T2-weighted, contrast-enhanced T1-weighted (volumetric interpolated brain examination), and DWI sequences. Parametric maps of apparent diffusion coefficient were obtained from DWI sequences. Texture analysis was performed on T2 and volumetric-interpolated brain examination sequences and on ADC maps. Differences in quantitative MR imaging features between tumors positive and negative for human papillomavirus and among subgroups of patients stratified by smoking status were tested using the nonparametric Mann-Whitney U test; the false discovery rate was controlled using the Benjamini-Hochberg correction; and a predictive model for human papillomavirus status was built using multivariable logistic regression.

RESULTS

Twenty-eight patients had human papillomavirus-positive oropharyngeal squamous cell carcinoma, while 31 patients had human papillomavirus-negative oropharyngeal squamous cell carcinoma. Tumors positive for human papillomavirus had a significantly lower mean ADC compared with those negative for it (median, 850.87 versus median, 1033.68; P < .001). Texture features had a lower discriminatory power for human papillomavirus status. Skewness on volumetric interpolated brain examination sequences was significantly higher in the subgroup of patients positive for human papillomavirus and smokers (P = .003). A predictive model based on smoking status and mean ADC yielded a sensitivity of 83.3% and specificity 92.6% in classifying human papillomavirus status.

CONCLUSIONS

ADC is significantly lower in oropharyngeal squamous cell carcinoma positive for human papillomavirus compared with oropharyngeal squamous cell carcinoma negative for it. ADC and smoking status allowed noninvasive prediction of human papillomavirus status with a good accuracy. These results should be validated and further investigated on larger prospective studies.

Is pathological complete response after a trimodality therapy, a predictive factor of long-term survival in locally-advanced esophageal cancer? Results of a retrospective monocentric study

OBJECTIVE

To evaluate long-term (5- and 10-year) survival and recurrence rates on the basis of the pathological complete response (pCR) in the specimens of patients with esophageal carcinoma, treated with trimodality therapy.

METHODS

Between 1993 and 2014, all consecutives patients with esophageal locally-advanced non-metastatic squamous cell carcinoma (SCC) or adenocarcinoma (ADC) who received trimodality therapy were reviewed. According to histopathological analysis, patients were divided in two groups with pCR and with pathological residual tumor (pRT). The primary endpoint was overall survival (OS). The secondary endpoints included the disease-free survival (DFS), the recurrence rate, and the predictive factors of overall survival and recurrence.

RESULTS

One hundred and three patients were included: 49 patients with pCR and 54 patients with pRT. The median OS was significantly longer in pCR group than in pRT group (132±22.3 vs. 25.5±4 months), with both 5- and 10-years OS rates of 75.2% vs. 29.1%, and 51.1% vs. 13.6%, respectively (P<0.001). Also, pRT, major postoperative complications (Dindo-Clavien grade>IIIb) and recurrence were the 3 independent predictive factors for worse OS.

CONCLUSIONS

Patients with locally-advanced oesophageal carcinoma, who responded to trimodality therapy with a pCR, could be achieved a 10-year survival rate of 51%.

Should the rectal defect be closed following transanal local excision of rectal tumors? A systematic review and meta-analysis

BACKGROUND

Transanal local excision (TLE) has become the treatment of choice for benign and early-stage selected malignant tumors. However, closure of the rectal wall defect remains a controversial point and the available literature still remains unclear. Our aim was to determine through a systematic review of the literature and a meta-analysis of relevant studies whether or not the wall defect following TLE of rectal tumors should be closed.

METHODS

Medline and the Cochrane Trials Register were searched for trials published up to December 2016 comparing open versus closed management of the surgical rectal defect after TLE of rectal tumors. Meta-analysis was performed using Review Manager 5.0.

RESULTS

Four studies were analyzed, yielding 489 patients (317 in the closed group and 182 in the open group). Meta-analysis showed no significant difference between the closed and open groups regarding the overall morbidity rate (OR 1.26; 95% CI 0.32-4.91; p = 0.74), postoperative local infection rate (OR 0.62; 95% CI 0.23-1.62; p = 0.33), postoperative bleeding rate (OR 0.83; 95% CI 0.29-1.77; p = 0.63), and postoperative reintervention rate (OR 2.21; 95% CI 0.52-9.47; p = 0.29).

CONCLUSIONS

This review and meta-analysis suggest that there is no difference between closure or non-closure of wall defects after TLE.

[Can we reduce the decision-to-delivery interval in case of emergency cesarean sections by optimizing the premises' architecture?]

OBJECTIVE

To study the influence of architectural premises' improvements on decision-to-delivery interval (DDI) in case of emergency cesarean sections.

METHODS

A retrospective observational Before-After study conducted in a type III maternity, first from 2004 to 2009 (Period 1, P1) then after moving our unit to new premises from 2009 to 2013 (P2). DDI, maternal and neonatal outcomes of every emergency cesarean section were studied.

RESULTS

The mean DDI of extremely urgent cesarean significantly decreased from 21.3±10.3minutes during P1 (n=294) to 14.9±7.14minutes during P2 (n=165). During P2 there was an increase in the proportion of extreme emergency cesarean sections done in less than 30minutes (85.1% versus 93.5%, P=0.003) as according to the ACOG recommendations, and also an increase of DDI of less than 15minutes (25.8% versus 61.1%, P<0.001). Also during P2 if there was a reduction of umbilical cord pHs, which were correlated to DDI, we observed a reduction of neonatal hospitalizations (42.2% versus 35.7%, P<0.001). Apgar score was correlated to umbilical cord pH and birth weight, but not to DDI.

CONCLUSION

The space optimization has allowed our level III maternity to improve the rate of extreme emergency cesarean sections performed with DDI of less than 30 and even 15minutes, according to international recommendations. These results were obtained by reducing the transfer time to the operating room. Despite a positive correlation between DDI and umbilical cord pH, there was an improvement in neonatal outcomes associated with a decrease of neonatal hospitalizations.

Intervention of the obstetrician during childbirth in a supposedly low-risk population and influence of parity

OBJECTIVE

Compare obstetrician intervention and calling rates during labour and delivery between low-risk and high-risk women and study the influence of parity on these rates.

MATERIAL AND METHODS

Descriptive retrospective study conducted on 227 patients in a university maternity unit (level 3 university hospital maternity unit) between 1st and 30th January 2014. The low- and high-risk populations were characterised according to the French National Authority for Health (HAS) and NICE guidelines. The obstetrician intervention criteria were: Caesarean section, instrumental vaginal delivery, artificial delivery/uterus examination and postpartum haemorrhage. The obstetrical team also had to call the obstetrician in case of foetal heart rate abnormalities, scalp blood pH measurement, third and/or fourth degree perineal tears, labour dystocia, or any other severe event occurring during labour or delivery.

RESULTS

In univariate analysis, the obstetrician intervention rates were respectively 44.5% and 34.4% in the high- and low-risk groups (P=0.13). The obstetrician calling rates were similar between the two groups. Using logistic regression model including parity, the obstetrician intervention rate became significantly higher in the "high-risk" group (OR 2.044, 95% CI 1.129-3.703, P=0.018). In the low-risk population, the intervention rate was significantly increased for nulliparous women compared with multiparas (47.5% versus 9.7%, P<0.001, OR=8.2, CI 95% 2.2 to 46.9).

CONCLUSION

One third of the women defined as low-risk patients appear to need an obstetrician intervention during labour and delivery, with a major influence of parity.

[Profile of bacterial resistance in pediatric urinary tract infections in 2014]

In pediatric units, bacteria-producing extended-spectrum-betalactamase (ESBL) have an increasing prevalence among bacteria causing febrile urinary tract infections (UTIs). The purpose of this study was to evaluate the epidemiology of bacteria resistance patterns observed in UTIs, in order to assess the current antibiotic treatment protocols. This study is based upon a single-center retrospective chart review of the cytobacteriological urine cultures performed in UTIs between 1 January and 31 December 2014, in the medical pediatric unit of the Caen University Hospital. Out of the total of 219 cases of UTI, 26.9% were recurrences of UTI, 18.3% were infections in infants less than 3 months old, 21% of the patients suffered from underlying uropathy, and 16.4% of the patients had recently been exposed to antibiotics. In 80.3% of the cases, Escherichia coli was found, while Enterococcus faecalis was found in 5.6%. The antibiograms proved that 33.5% of the bacteria were sensitive. Half of E. coli were resistant to ampicillin, 4.9% to cefixime, 4.9% to ceftriaxone, 1.1% to gentamicin, and 27.8% to trimethoprim-sulfamethoxazole. Nine E. coli and one Enterobacter cloacae produced ESBL, accounting for 4.6% of the UTIs. We did not find any bacteria-producing high-level cephalosporinase. Cefixime resistance was statistically linked to ongoing antibiotic treatment (OR=5.98; 95% CI [1.44; 24.91], P=0.014) and underlying uropathy (OR=6.24; 95% CI [1.47; 26.42], P=0.013). Ceftriaxone resistance was statistically related to ongoing antibiotic treatment (OR=6.93; 95% CI [1.45; 33.13], P=0.015). These results argue in favor of maintaining intravenous ceftriaxone for probabilistic ambulatory treatment. However, in case of hospitalization, cefotaxime can replace ceftriaxone, due to its lower ecological impact. Moreover, it is necessary to continue monitoring bacterial resistance and regularly review our treatment protocols.

[Analysis of the anatomical sites of 172 lower-limb venous thromboses occurring in a hormonal context in 996 young women; impact of the duplex-Doppler exploration]

AIM

To analyze localizations of duplex ultrasonography-diagnosed lower-limb venous thrombosis in young women in hormonal periods in order to optimize the ultrasound exploration.

PATIENTS AND METHODS

From 42,018 standardized ultrasonography report forms, incremented in a database (January 2001 - July 2013), those performed for a first diagnosis of venous thrombosis in women ≤ 45 years were selected (n = 996). Among those, diagnosed venous thrombosis (n = 172) were classified into three groups: oral contraception (n = 74), pregnancy (n = 39) and post-partum period (n = 59). Clinical symptoms and thrombosis distribution were analyzed.

RESULTS

In the contraception group, pulmonary symptoms at presentation were much more frequent than in the obstetrical group: 69% vs 20% (P < 0.001). The thrombosis was limited to the iliac veins in 31% (23/74) and to the left internal iliac vein in six patients. During pregnancy, the thrombosis was limited to the iliac veins in 28% (11/39), and to the left internal iliac vein in two patients. In the post-partum period, superficial venous thromboses were found more frequently (37/59). Among the 22 deep venous thromboses, nine were limited to the proximal segment, including four in the vena cava coming from a right ovarian vein thrombosis.

CONCLUSION

Duplex ultrasonography in young women taking oral contraception, as during pregnancy, must target iliac venous segments, especially on the left side, otherwise one thrombosis out of three may be missed; in the post-partum period, the inferior vena cava and superficial veins are to be explored too.

French sclerotherapy and compression: Practice patterns

Based on the recommendations of experts, and supported by a low level of proof, compression after sclerotherapy is applied all over the world.

OBJECTIVE

Investigating the practice of French vascular physicians for sclerotherapy and the use of post-sclerotherapy compression.

METHODS

A questionnaire concerning their practices was sent to French vascular physicians through their regional vascular medicine professional development associations.

RESULTS

A total of 366 vascular physicians replied to the questionnaire, of whom 63% (229/366) were in private practice, 6% (21/366) in hospitals and 31% (115/366) had a mixed private-hospital practice. Sclerotherapy was practised by 88% (323/366) of them. Two-thirds of the vascular physicians used sclerosing foam and practised sclerotherapy using ultrasound guidance. Less than one-third of the vascular physicians regularly applied compression after sclerotherapy. When compression was applied, it was usually after treatment of saphenous or accessory saphenous veins and, in most cases, medical compression stockings of 15-20 mm Hg were used. With respect to the period recommended for wearing compression, this ranged from 48 h to 1 week for 65% (193/299) of the vascular physicians questioned.

CONCLUSION

The great majority of vascular physicians who answered the questionnaire employ ultrasound guidance to perform sclerotherapy and use sclerosing foam. Compression after sclerotherapy is diversely applied in France and does not comply with the recommendations of the French Health Authorities who recommend wearing a stocking of 15-20 or 20-36 mm Hg for a period of 4-6 weeks. Thus, less than one-third of the vascular physicians regularly used elastic compression and when they did, it was usually a medical compression stocking of 15-20 mm Hg, for 1 week or less.

Longitudinal left ventricular strain impairment in type 1 diabetes children and adolescents: a 2D speckle strain imaging study

AIM

Type 1 diabetes (T1D) involves complex metabolic disturbances in cardiomyocytes leading to morphological and functional abnormalities of the myocardium. The relationship between T1D and cardiac structure and function in children is not well established. Our study investigated whether T1D is associated with early subclinical myocardial disturbances in children and adolescents, and whether the state of metabolic control and diabetes duration are influential factors.

METHODS

Standard echocardiography, tissue Doppler imaging (TDI) and two-dimensional (2D) strain imaging were prospectively performed in 100 T1D children (age: 11.3 ± 3.6 years, 52 boys) and compared with 79 controls.

RESULTS

The diabetic and control children were comparable with respect to age, gender, heart rate and blood pressure. There were no significant differences between the two groups in left ventricular (LV) ejection fraction, LV remodelling and TDI parameters. Conventional mitral Doppler demonstrated significantly fewer diastolic filling abnormalities with an early filling wave in the diabetes group. Global longitudinal strain (GLS) was also significantly lower in the T1D children, while circumferential strain and radial strain did not differ. GLS correlated with HbA1c (r=0.52; P<0.01), but there was no correlation with diabetes duration.

CONCLUSION

Our results suggest that LV longitudinal myocardial deformation is decreased in young patients with T1D, and glycaemic control may be the main risk factor for these changes. Further follow-up is now necessary to precisely determine the clinical significance of these myocardial changes detected by 2D strain imaging in T1D children.

Geographical variation in incidence of knee arthroscopy for patients with osteoarthritis: a population-based analysis of Victorian hospital separations data

BACKGROUND/AIM

To evaluate the frequency and geographical variation in knee arthroscopy for adults (>25 years) with a concomitant diagnosis of osteoarthritis.

METHODS

This was a retrospective cohort study of hospital separations involving an elective knee arthroscopy in public and private hospitals in Victoria, Australia. Participants included patients receiving knee arthroscopies with a diagnosis code indicating osteoarthritis (OA) from 1 July 2008 to 30 June 2009. Records were excluded if the patient was under 25 years or their arthroscopy involved a ligament reconstruction. Crude rates per 100 000 population and negative binomial regression offset by total knee arthroscopy volume were used to analyse differences by region.

RESULTS

There were 9620 arthroscopic procedures meeting the inclusion criteria. There were 5500 (57.2%) admissions where the principal diagnosis was knee OA (gonarthrosis) and 3510 (36.5%) where the principal diagnosis indicated a mechanical derangement and there was a primary or associated diagnosis of OA. When we examined the incidence rate ratios (IRR) by region, after adjustment for relevant factors and accounting for the total knee arthroscopy volume within each region, we identified significant variation in knee arthroscopy rates for patients with OA. The region with the highest adjusted IRR was Barwon South Western (IRR: 1.26, 95% confidence interval (CI): 1.16-1.36) and the region with lowest adjusted incidence rate ratio was the Gippsland region (IRR: 0.89, 95% CI: 0.80-0.98).

CONCLUSIONS

We identified considerable geographical variation in arthroscopies for people with OA across Victoria. Further investigation is needed to understand whether this variation is a reflection of differences in OA prevalence, clinical decision-making or access.

High prevalence of diabetes mellitus and hospital-related hyperglycaemia in French general wards

AIM

The study evaluated the in-hospital prevalence of diabetes and hospital-related hyperglycaemia in a variety of French general wards.

METHODS

The multicentre cross-sectional study involving nine French hospitals measured venous fasting plasma glucose (FPG) on a single day in patients hospitalized in adult medical and surgical short-term wards. Diabetes status and length of stay were recorded.

RESULTS

Of the 2141 inpatients included in the study, 355 (16.5%) had known diabetes, 156 (7.3%) had screened diabetes (FPG ≥7 mmol/L with no diabetes history), 515 (24.1%) had impaired fasting glucose (IFG; FPG 5.5-6.9 mmol/L) and 1115 (52.1%) had normal glucose values (FPG < 5.5 mmol/L). Diabetes prevalence varied from 11% in hospitals in the west of France to 21% in hospitals in northern and eastern regions. The highest known diabetes prevalence was observed in units for cardiovascular surgery (33%), infectious diseases (27%) and kidney disorders (26%). In cancer units, one-fifth of patients had screened diabetes and one-sixth had known diabetes. Among the known diabetes patients, 127 (36%) were already being treated with insulin, while an additional 41 (12%) started insulin therapy during their hospital stay. Patients with known and screened diabetes were older (70.8 ± 12.2 and 71.1 ± 15.6 years, respectively) than the normal-glucose patients (65.6 ± 18.9 years; P<0.001). Average length of stay was no different between known diabetes and normal-glucose patients after adjusting for age (11.3 ± 7.7 vs 10.0 ± 7.4 days; NS).

CONCLUSION

Overall, metabolic glucose disorders (known or screened diabetes and IFG) were found in 48% of inpatients in various French hospital general wards.

[Failure of vacuum extractions: risk factors, maternal and fetal issues]

OBJECTIVES

Determine cases which are at risk of vacuum extraction failure as well as maternal and foetal issues depending on the delivery outcome.

MATERIAL AND METHODS

It was a retrospective study comparing 147 vacuum failures, from January 2002 to December 2010, with a control group randomly composed of 526 successful vacuum extractions. The outcomes were high risk situations of vacuum failure, maternal and neonatal morbidity depending on the delivery method (caesarean section or other instrumental extraction).

RESULTS

The global vacuum failure rate was 3.3 %. During labour, we identified several situations at risk of vacuum extraction failure: cephalhematomas prior to extraction (P<0.001), deflexion attitude (P<0.001), posterior variety (P<0.001), entering above the inlet strait (P<0.001), occiput posterior delivery (P<0.001), fœtal weight greater than 3500g (P=0.023). Neonatals consequency were more Apgar score below 7 at five minutes life (P=0.007), fœtal acidosis (pH<7,20) (P=0.032), neonatal resuscitation (P<0.001), and craniofacial damages (P<0.001).

CONCLUSION

Many dystocic situations occurring during labour require intense care when practicing vacuum extraction since they more frequently result in failure. In case of vacuum extraction failure, immediate adaptation to extra-uterine life seems to be more difficult for new-born babies.

Beware of suboptimal medical management of patients with atherosclerosis requiring revascularization

AIM

The aim of this paper was to assess a daily-life evaluation of vascular risk factor control, pharmacological treatment and prognosis in patients with atherosclerosis referred for revascularization.

METHODS

Prospective observational study conducted in a French University Hospital with collection of atherosclerosis referral site information, reported patient history, documented atherosclerosis sites seen on examination, biological data, and clinical outcomes.

RESULTS

956 patients (82.6% men, 64.5±10.1 years) were enrolled for supra-aortic vessel disease (SVD, 24.6%), coronary heart disease (CHD, 40.4%), peripheral artery occlusive disease (PAOD, 34.2%), and visceral artery disease (1.7%). Involvement of >2 vascular territories was documented in 85%. Vascular risk factor frequency results were: previous (65.7%) or current (10.6%) tobacco use, hypertension (64.3%), hyperlipidaemia (75.4%), diabetes (25.8%), overweight (43.8%), and obesity (25.2%). LDL-cholesterol was >100 mg/dL for 38.1%, most frequently seen in patients with PAOD referral (P<0.001) or history (P=0.002), and for 29.2% of the patients taking a statin. HbA1c levels were >6.5% for 53.8% of patients with diabetes. The triple combination of an antiplatelet agent, a statin, and a renin-angiotensin-system inhibitor was not prescribed often enough, especially for PAOD referrals (PAOD referrals, 45.1%; SVD referrals, 48.1%; CHD referrals, 65.9%). Independent risk factors for all-cause mortality were: a previous CHD or PAOD clinical event, body mass index <25 kg/m2, HbA1c >6.5%, and no aspirin treatment.

CONCLUSION

Even at the time of revascularization, medical management of atherosclerosis was not optimal. The need for continuing education of physicians and patients remains essential.

[From the impact of French guidelines to reduce episiotomy's rate]

OBJECTIVES

Following the publication of the French Guidelines on episiotomy in 2005 by the French National College of Gynaecologists and Obstetricians (CNGOF), our unit decided to adopt a restrictive politics to replace the former liberal one. The goal of this study was to evaluate the impact of this modification of trend in the Unit of Gynaecology and Obstetrics of the teaching hospital from Caen. This was the start point of an internal audit with the objective of an enhancement of the care during delivery.

PATIENTS AND METHODS

It was a retrospective study concerning the period going from January, 2004 till December, 2009, measuring the impact of the guidelines on the episiotomy rates and perineal tears. The totality of the population of the women naturally delivered at a term superior or equal to 37 weeks of gestation and a cephalic presentation was included. To modify the practices, after diffusion of the guidelines by some obstetrical leaders, we imposed to notify the indication of the episiotomy in the computerized obstetrical files. Moreover, we published monthly screenboards with all the detailed results to all the practioners acting in the delivery room (obstetricians, midwives).

RESULTS

Between 2004 and 2009, we observed a dramatic decline of the episiotomy rates from 55.7 to 13.3%. This trend was the same for primiparae and multiparae, as wall as for spontaneous or assisted delivery (mostly vacuum extraction in our unit). We noticed a slight increased in minor perineal tears without functional consequences. There was no statistically significant difference between severe perineal tear (1.3% vs. 1.1%). By contrary, the rate of intact perineum significantly raised (17.6% vs. 21.7%, p<0.001), especially in vacuum extractions.

DISCUSSION

Our results are in accordance with those of the national guidelines. However, our rate does not decrease in 2007 and 2008 (20%), contrary to some results obtained in the literature. Some reports mentioned the weak impact of the publication of national guidelines to modify the usual practice. However, we believe that retro-information to practitioners has a real impact on their daily current practice. Hence we insisted again on the importance of these national guidelines at the end of 2008 and we could demonstrate a real decline of the rate of episiotomy. Our efforts have to be continued, especially for instrumental delivery.

Severe osteogenesis imperfecta caused by a small in-frame deletion in CRTAP

Mutations of proteins involved in posttranslational modification of collagen type I can cause osteogenesis imperfecta (OI) inherited in a recessive pattern. The cartilage-associated protein (CRTAP) is part of a heterotrimeric complex (together with prolyl-3-hydroxylase-1 [P3H1] and cyclophilin B) that 3-hydroxylates the alpha 1 chain of collagen type I at proline residue 986 and plays a collagen chaperon role. CRTAP mutations usually cause severe OI. We report on a patient with OI and a homozygous in-frame deletion in CRTAP and a severe form of OI. The girl was born with markedly deformed long bones. Despite intravenous bisphosphonate treatment, she developed multiple vertebral compression fractures and severe scoliosis and at 4 years of age was able to sit only with support. Although CRTAP transcript levels were normal in the patient's fibroblasts, protein levels of both CRTAP and P3H1 were severely reduced. The degree of 3-hydroxylation at proline residue 986 was also decreased. This report characterizes a patient with a CRTAP small in-frame deletion. We are unaware of prior reports of this finding. We suggest that this deletion affects crucial amino acids that are important for the interaction and/or stabilization of CRTAP and P3H1.