Factors associated with hospital mortality in community-acquired legionellosis in France.

The aims of this study were to describe the clinical, biological and radiological features of community-acquired (CA) Legionnaires' disease (LD) and identify the predictors of mortality in hospitalised patients. Demographic data, risk factors, clinical and biological features, medical management, complications, and outcome from 540 hospitalised patients with confirmed CA LD were prospectively recorded. 8.1% of patients (44 out of 540) died. The predictors of survival after Kaplan-Meier analysis were male sex (p = 0.01), age <60 yrs (p = 0.02), general symptoms (p = 0.006), intensive care unit (ICU) stay (p<0.001), and class II-III Pneumonia Severity Index score (p = 0.004). Six predictors of death were identified by multivariate analysis: age (per 10-yr increment) (relative hazard (RH) 1.50, 95% CI 1.21-1.87), female sex (RH 2.00, 95% CI 1.08-3.69), ICU admission (RH 3.31, 95% CI 1.67-6.56), renal failure (RH 2.73, 95% CI 1.42-5.27), corticosteroid therapy (RH 2.54, 95% CI 1.04-6.20) and C-reactive protein (CRP) >500 mg · L(-1) (RH 2.14, 95% CI 1.02-4.48). Appropriate antibiotic therapy was prescribed for 70.8% (292 out of 412) of patients after admission and for 99.8% (537 out of 538) of patients after diagnosis confirmation. In conclusion, female sex, age, ICU stay, renal failure, corticosteroid treatment and increased level of CRP are significant risk factors for mortality in CA LD.

Can patients really do sport after TKA?

Function and sport participation was analyzed via a self-administered questionnaire in 347 patients with unilateral noncomplicated TKA. It was 227 women and 120 men with a mean age of 75 (range, 28 to 94) and a mean follow-up of 44 months (range 13-71). Two hundred and thirty-seven patients (68%) reported that their knee was "normal", 56% that their activities were limited by their knee, and 66% that they were as active as they expected to be before the intervention. Of them, 98% were satisfied. Of the patients who were insufficiently active, 52% were not satisfied with their outcome (P < 0.0001). Neither the duration of preoperative pain, the age at evaluation or the number of previous surgeries influenced the subjective result or the degree of patient satisfaction. Among patients under 75 years, 10% regularly participated in strenuous sports but only 13% felt that this ability was important. When participation was analyzed in the motivated patients subgroup, 63% regularly took part in at least one impact sport.

[A positioning pillow to improve lumbar puncture in paediatric haematology-oncology patients: a randomized controlled trial.]. / Coussin de positionnement pour ponctions lombaires en oncohématologie pédiatrique : résultats d'un essai randomisé

ObjectivesLumbar punctures (LPs) are common in children with cancer. Although pain management during the LP has been well standardised, dealing with stress and anxiety is not well addressed yet. Our objective was to evaluate the potential improvement of the LPs success rate using a positioning pillow, to ensure maximum lumbar flexion, and allow paravertebral muscles to relax, in children who are awake, with either conscious sedation or no sedation.Patients and methodsChildren aged 2-18 years undergoing LPs were randomly assigned to a positioning pillow or no intervention. The primary outcome was the rate of success, i.e. achieving the LPs (sampling or injection) at the first attempt, without bleeding (RBC < 50/mm3). The secondary outcomes included: the child's pain, assessed by a self-administered visual analogical scales (VAS) for children over 6 years of age; the parents' and caregivers' perception of the child's pain; the satisfaction of the children, the parents, the caregivers and the physician. The child's cooperation and the occurrence of post-LP syndrome were also evaluated.ResultsOne hundred twenty-four children (62 in each group) were included. The LP pillow tended to increase the success rate of LPs (67 vs 57%; P = 0.23), and decreased the post-LP syndromes (15 vs 24%; P = 0.17) but the differences were not statistically significant. In children over 6-year of age (N = 72), the rate of success was significantly higher in the pillow group (58.5 vs 41.5%; P = 0.031), with a tendency to feel less pain (for less pain and better satisfaction) [median VAS: 25 vs 15 mm; P = 0.39] and being more satisfied (84.4 vs 75.0%; P = 0.34).ConclusionEven if the results presented here are not as optimistic as we might have wished, we can confirm that there is a benefit in using this pillow for LPs. It is especially promising in children over 6-year of age.

Factors affecting the adherence to an antenatal screening programme: an experience with toxoplasmosis screening in France.

Monthly serological testing is mandatory in France for pregnant women not immune to toxoplasmosis. We assessed for the first time the adherence to this national programme, using data from antenatal tests for Toxoplasma antibodies collected by the Union of Health Insurance Services in the French Rhone-Alpes region.

SEEG-guided thermocoagulations: a palliative treatment of nonoperable partial epilepsies.

OBJECTIVE: Intracranial stereotactic EEG recordings (SEEG) in presurgical epilepsy assessment are currently carried out in our department. The SEEG method generally used for exploration can also be used to perform radiofrequency thermocoagulations (RFTC) of the epileptic foci. To assess the indications of the RFTC procedure in the therapeutic arsenal of drug-resistant epilepsies, we report the results obtained in 41 patients to whom RFTC was proposed as a first therapeutic step before surgery or as a palliative treatment when surgery was not possible. METHODS: RFTC were produced by applying a 50-volt, 110 mA current, during 10-30 seconds within the epileptogenic zone, as identified by the SEEG investigation. Two to 31 RFTC (mean, 12) were performed per patient. The median follow-up was 19 months (range: 4 to 72). RESULTS: Twenty patients (48.7%) experienced a seizure frequency decrease of at least 50%, which was over 80% in eight of them. One patient was seizure-free. The tolerance was excellent. A total of 67% of the 21 patients presenting a cortical development malformation benefited from RFTC (p = 0.052). In the group of noneligible patients for resective surgery (n = 13), six were responders to SEEG-guided RFTC and one of them was seizure-free. CONCLUSIONS: This study suggests that stereotactic EEG-guided radiofrequency thermocoagulations can be proposed only as a palliative procedure, able to bring a substantial improvement of seizure frequency, to drug-resistant patients with epilepsy for whom conventional resection surgery is risky or contraindicated on the basis of invasive presurgical evaluation.

Influence of the docetaxel administration period (neoadjuvant or concomitant) in relation to HIFU treatment on the growth of Dunning tumors: results of a preliminary study.

The objective of this study was to evaluate mechanisms of the synergy between high intensity-focused ultrasound (HIFU) and docetaxel and to determine the best sequence of chemotherapy administration in relation to HIFU treatment for obtaining optimum control of tumoral growth. A total of 15 days after s.c. implantation of the tumor, 52 Copenhagen rats studied were randomized in 4 groups of 13: controls, docetaxel alone (group 1), HIFU and docetaxel concomitant (group 2) and HIFU and docetaxel administered 24 h before treatment (group 3). The number of HIFU shots was calculated in order to cover 75% of the tumor volume. The effects of docetaxel, HIFU and their interaction on tumor volumes were analyzed using a linear regression. The distributions of the tumor volumes were significantly greater in the control group than in the group 1 (P=0.002) and than in both groups 2 and 3 (P < 0.0001 and P = 0.0001). These volumes were also significantly greater in group 1 than in both groups 2 and 3 and there was no difference between the groups 2 and 3. The tumor doubling times were 7.8 days for the group 1, 43.8 days for the group 2, 16.1 days for the group 3 and 5.9 days for the controls. The mechanism of the synergy between HIFU and docetaxel on the growth of Dunning tumors is apparently multifaceted. The results are encouraging because in the two groups of rats treated with the combination of HIFU and docetaxel, the percentage of complete remission was approximately 30%.

Impact of spiramycin treatment and gestational age on maturation of Toxoplasma gondii immunoglobulin G avidity in pregnant women.

The objective of the present study was to investigate the maturation of immunoglobulin G (IgG) avidity after Toxoplasma gondii seroconversion during pregnancy and the factors that affect IgG avidity over time. The study used 309 serum samples from 117 women and a multiple linear mixed regression analysis to show the patterns of variation of IgG avidity throughout gestation. The IgG avidity ratios and the patterns of their evolution with time were quite diverse among the women and were statistically heterogeneous (P = 0.011); however, the trend was toward a statistically significant increase (P < 0.0001). On average, a 1.0167-fold increase was observed for each additional gestational week after the putative date of infection. At 12 weeks after putative infection (the expected IgG avidity maturation time), the mean avidity ratio was 16.6% (95% confidence interval, 15.4 to 17.9%). At all times, the avidity ratio remained significantly heterogeneous among the women (P < 0.05); for 95% of them, that ratio ranged from 7.8 to 35.3% at 12 weeks after putative infection. Maternal age at the putative time of infection did not influence the maturation of IgG avidity. However, on average, a 1.009-fold decrease (P = 0.03) in that avidity was observed for each additional week of gestational age before infection and a 1.03-fold increase (P = 0.0003) was observed for each additional week of delay to the onset of spiramycin treatment. The rate of increase in the avidity ratio was lower if infection occurred late in pregnancy and higher if the delay to treatment was long. This information cannot allow accurate determination of the delay since the time of infection. The present results provide support for interpretation of the assay and caution against overinterpretation.

Impact of initial surgical access on staging and survival of patients with stage I ovarian cancer.

The aim of this study was to compare staging by laparoscopy and laparotomy, and to compare survival in patients with laparoscopy versus laparotomy as the first surgical access. We conducted a retrospective analysis of patients with stage I ovarian cancer treated surgically between 1985 and 2001, and we included those patients with stage I epithelial cancer for whom follow-up data were available. For each patient, we recorded whether initial surgical staging was by laparoscopy or by laparotomy, the procedures done at initial staging surgery, and the outcomes. The data were evaluated by analysis of variance, Chi-square test or Fisher's exact test, logistic regression, Cox model, and log-rank test, using SPSS 7.5 and STATA. Initial staging was by laparoscopy in 34 patients, laparotomy in 114 patients, and laparoscopy converted to laparotomy in 30 patients. In the laparotomy group, patient age was significantly greater and tumor size significantly larger, as compared to the laparoscopy group. Staging after first surgery was often inadequate; most notably para-aortic lymph node dissection was done in 0% of laparoscopy patients, 18% of laparotomy patients, and 33% of conversion patients. Restaging surgery has been indicated in 88% of laparoscopy patients, 48% of laparotomy patients, and 46% of conversion ones. After a mean follow-up of 40 months, survival rates were not significantly different among the three patient groups. No deleterious influence of laparoscopy as first surgical access was detected by univariate or multivariate analysis. Despite of inaccurate radicality and staging during initial laparoscopy, this study found no harmful influence of laparoscopy as first initial access on outcomes of patients with stage I ovarian cancer.

Monitoring air sampling in operating theatres: can particle counting replace microbiological sampling?

Microbiological contamination of air in the operating room is generally considered to be a risk factor for surgical site infections in clean surgery. Evaluation of the quality of air in operating theatres can be performed routinely by microbiological sampling and particle counting, but the relationship between these two methods has rarely been evaluated. The aim of this study was to determine whether particle counting could be predictive of microbiological contamination of air in operating rooms. Over a three-month period, air microbiological sampling and particle counting were performed simultaneously in four empty operating rooms belonging to two surgical theatres equipped with conventional ventilation via high-efficiency particulate air filters. Correlation between the two methods was measured with Spearman's correlation coefficient. The ability of particle counting to discriminate between microbiological counting values higher and lower than 5 colony-forming units (CFU)/m3 was evaluated using receiver-operating characteristic (ROC) analysis. Microbiological counting ranged from 0 to 38CFU/m3, while the particle counts ranged from 0 to 46 262/m3. Methods of microbiological and particle counting did not correlate (Spearman correlation coefficient=0.06, P=0.6). Using the ROC curve, no particle count value could be predictive of a microbiological count higher than 5CFU/m3. The results of the current study suggest that there is no reason to replace microbiological sampling with particle counting for routine evaluation of microbiological contamination in conventionally ventilated operating theatres.

Perception of the damaging effects of smoking, and brief cessation counselling by doctors.

An open prospective study was conducted among the patients visiting an urban medical policlinic for the first time without an appointment to assess whether the immigrants (who represent more than half of our patients) are aware of the health effects of smoking, whether the level of acculturation influences knowledge, and whether doctors give similar advice to Swiss and foreign smokers. 226 smokers, 105 Swiss (46.5%), and 121 foreign-born (53.5%), participated in the study. 32.2% (95% CI [24.4%; 41.1%]) of migrants and 9.6% [5.3%; 16.8%] of Swiss patients were not aware of negative effects of smoking. After adjustment for age, the multivariate model showed that the estimated odds of "ignorance of health effects of smoking" was higher for people lacking mastery of the local language compared with those mastering it (odds ratio (OR) = 7.5 [3.6; 15.8], p < 0.001), and higher for men (OR = 4.3 [1.9; 10.0], p < 0.001). Advice to stop smoking was given with similar frequency to immigrants (31.9% [24.2%; 40.8%] and Swiss patients (29.0% [21.0%; 38.5%]). Nonintegrated patients did not appear to receive less counselling than integrated patients (OR = 1.1 [0.6; 2.1], p = 0.812). We conclude that the level of knowledge among male immigrants not integrated or unable to speak the local language is lower than among integrated foreign-born and Swiss patients. Smoking cessation counselling by a doctor was only given to a minority of patients, but such counselling seemed irrespective of nationality.

Microbiological evaluation of two hand hygiene procedures achieved by healthcare workers during routine patient care: a randomized study.

The aim of this study was to evaluate the comparative microbiological efficacy of hand rubbing and handwashing in healthcare workers from different wards, with particular emphasis on transient flora, and to assess predisposing factors for hand contamination after patient care in everyday practice. Over a six-month period, 50 healthcare workers were randomly assigned, using a crossover design, to perform handwashing with unmedicated soap and hand rubbing with an alcoholic solution following a healthcare procedure. Imprints of palms and fingertips were taken separately before and after each hand hygiene procedure. The number of colonies per plate was counted and transient pathogens were identified. Risk factors for hand contamination were determined. Hand rubbing produced a significantly greater reduction in microbiological load than handwashing (P<0.0001 for palms and P=0.0003 for fingertips). In multivariate analysis, working in a medical ward rather than in an intensive care unit was significantly associated with increased hand contamination (P=0.03 for palms and P=0.02 for fingertips). Transient pathogens were found on 15% of healthcare workers' hands before hand hygiene. The only factor associated with hand contamination by transient pathogens was the absence of gloving during the healthcare procedure (odds ratio 4.8; 95% confidence interval 1.2-19; P=0.03). After hand rubbing, no transient pathogens were recovered, while these were found in two cases after handwashing. Hand rubbing is more efficacious than handwashing for the decontamination of healthcare workers' hands following contact with patients and patients' environments. Gloving may reduce microbiological hand contamination by transient pathogens.

Risk factors for positive tuberculin skin tests among migrant and resident children in Lausanne, Switzerland.

SETTING: Ambulatory paediatric clinic in Lausanne, Switzerland, a country with a significant proportion of tuberculosis (TB) among immigrants. AIM: To assess the factors associated with positive tuberculin skin tests (TST) among children examined during a health check-up or during TB contact tracing, notably the influence of BCG vaccination (Bacille Calmette Guérin) and history of TB contact. METHOD: A descriptive study of children who had a TST (2 Units RT23) between November 2002 and April 2004. Age, sex, history of TB contact, BCG vaccination status, country of origin and birth outside Switzerland were recorded. RESULTS: Of 234 children, 176 (75%) had a reaction equal to zero and 31 (13%) tested positive (>10 mm). In a linear regression model, the size of the TST varied significantly according to the history of TB contact, age, TB incidence in the country of origin and BCG vaccination status but not according to sex or birth in or outside Switzerland. In a logistic regression model including all the recorded variables, age (Odds Ratio = 1.21, 95% CI 1.08; 1.35), a history of TB contact (OR = 7.31, 95% CI 2.23; 24) and the incidence of TB in the country of origin (OR = 1.01, 95% CI 1.00; 1.02) were significantly associated with a positive TST but sex (OR = 1.18, 95% CI 0.50; 2.78) and BCG vaccination status (OR = 2.97, 95% CI 0.91; 9.72) were not associated. CONCLUSIONS: TB incidence in the country of origin, BCG vaccination and age influence the TSTreaction (size or proportion of TST > or = 10 mm). However the most obvious risk factor for a positive TST is a history of contact with TB.

Stage I ovarian cancer: comparison of laparoscopy and laparotomy on staging and survival.

OBJECTIVE: The aim of this study was to compare staging accurateness as well as survival when managing early ovarian cancers by laparoscopy or laparotomy. MATERIAL AND METHODS: We have conducted a retrospective and multicentric study in France. Only Stage I ovarian epithelial cancers operated on from January 1, 1985 to December 31, 1999 were taken into account. Respondents had to fill in a form detailing in each case the surgical access; the surgical acts performed during the initial intervention as well as data on the patient's follow-up. Lack of follow-up or final Stage > I were considered as exclusion criteria. Data were recorded and analysed with SPSS 7.5 and STATA (Stata statistical sofware 7.0). (ANOVA, chi-square test or Fisher's exact test and log-rank test). RESULTS: 105 cases were included: 14 patients were exclusively operated on by laparoscopy (group 1), 13 other patients were subjected to a conversion from laparoscopy to laparotomy (group 2) and 78 patients exclusively underwent laparotomy (group 3). Patients in group 3 were significantly more frequently postmenopausal and had larger lesions. Cyst rupture was rare during laparoscopy (21%) and the use of an endobag was achieved in only 21% of the patients in group 1. Radical treatment was significantly more frequent in group 3 when compared to group 1 (67% vs 23%, p < 0.05). Laparoscopy was not adequate for staging since no lymphadenectomy was carried out by this approach. However, only 27% of patients subjected to an open approach underwent lymphadenectomy and omentectomy. The outcome in terms of survival was similar in the three groups with a mean follow-up period of 1,221 days (+/- 832) (p = 0.1). CONCLUSION: Laparoscopic management of early ovarian cancer is poorly efficient in staging although disease-free survival does not seem to be affected. Further evaluation of laparoscopy in this indication is needed.

The factor II G20210A gene polymorphism, but not factor V Arg506Gln, is associated with peripheral arterial disease: results of a case-control study.

BACKGROUND: The FIIG20210A polymorphism has been associated with arterial wall thickness and atherothrombotic diseases in selected subgroups. The FVArg506Gln polymorphism does not seem to be associated with arterial diseases. Few data are available on these polymorphisms and the risk of peripheral arterial disease (PAD). OBJECTIVES: To study the association between the FIIG20210A and FVArg506Gln polymorphisms and PAD and its clinical severity. To examine the potential interactions with traditional vascular risk factors. PATIENTS AND METHODS: We studied 184 consecutive male patients under 70 years of age with symptomatic PAD and 330 age-matched male controls free of symptomatic PAD and with no cardiovascular history. We evaluated the FIIG20210A and FVArg506Gln polymorphisms in all subjects. RESULTS: Mean age was 57.1 +/- 7.2 years (cases) and 56.7 +/- 7.6 years (controls). The FII20210A allele was more frequent in PAD patients with odds ratios (OR) of 3.77 (1.39-10.2) in univariate analysis and 4.30 (1.3-14.7) after adjustment for diabetes, smoking, hypertension and hypercholesterolemia. In smokers or past smokers the magnitude of the association was markedly increased but there was no evidence of an interaction between tobacco exposure and FIIG20210A. In case subjects, the FII20210A allele was also associated with critical ischemia [OR = 4.1 (1.1-15.7), P = 0.039 in multivariate analysis]. FVArg506Gln was not associated with PAD [OR = 0.65 (0.27-1.54) and 0.77 (0.28-2.1) in univariate and multivariate analyses, respectively]. CONCLUSIONS: The FIIG20210A gene polymorphism may be a risk factor for PAD and its severity. In contrast, the FVArg506Gln polymorphism is not associated with PAD.

Comparison of health care professionals' self-assessments of standards of care and patients' opinions on the care they received in hospital: observational study.

OBJECTIVES: To compare the views of healthcare professionals and patients regarding compliance with standards of care concerning patient information. DESIGN: Self-rated questionnaire survey. SETTING: Nine wards in short stay French hospitals. PARTICIPANTS: 939 patients and 359 healthcare professionals (physicians, nurses, assistants and other professionals). MAIN OUTCOME MEASURE: Patients' and healthcare professionals' views of compliance with 20 standards of patient care described in the French accreditation manual. Comparison of the rank order of the standards within the two samples. RESULTS: The response rate was 61.5% in the patient group and 85.8% in the healthcare professionals. The rank orders for the 20 items were similar in both groups (Spearman rank order correlation 0.6, p = 0.004). The two items ranked highest by healthcare professionals ("consent request for a surgical procedure" and "the doctors ask the visitors to leave the room before examining a patient") were also the two ranked highest by the patients. Three items were ranked low by both groups: "consent request for students to be present", "health education given to patients", and "possibility to express satisfaction during discharge". Patients were more satisfied with their pain management than were healthcare providers. Professionals were more satisfied with the social services than the patients. CONCLUSION: There are both similarities and differences between patients' and healthcare professionals' views of care. Accurate assessments of quality performed during the accreditation procedure require that both patients' and professionals' views be taken into account.

Incidence and prognosis of cancer associated with bilateral venous thrombosis: a prospective study of 103 patients.

BACKGROUND: A strong association between bilateral deep vein thrombosis (DVT) and cancer had been found in one retrospective study. To confirm this finding, consecutive patients with an objective diagnosis of bilateral DVT were followed over 12 months. PATIENTS AND METHODS: One-hundred and three patients, hospitalized for bilateral DVT, were included in the study. Twenty-six patients (25.2%) were already known to have a cancer, 26 (25.2%) had a previous history of venous thromboembolic disease, 44 (42.7%) had a symptomatic pulmonary embolism. The patients were scheduled to be prospectively followed up at 3, 6 and 12 months as outpatients. Information on recurrence, evidence of a new overt cancer and the cause of death were recorded for all patients. RESULTS: A new cancer was diagnosed in 20 (26%) of the 77 patients without known cancer at admission. The risk of cancer was significantly more important in idiopathic thrombosis than in patients with secondary thrombosis (40.5% vs. 12.5%; odds ratio 4.8, 95% confidence interval 1.4, 18.8). Seventy percent of the cancers discovered had already spread. Age, gender, presence of pulmonary embolism, recurrence and location of the thrombosis were not statistically associated with the risk of cancer. The 1-year survival rates of patients with a previously known cancer and patients with a newly discovered cancer were, respectively, 26% and 35% (P = 0.33). CONCLUSIONS: Bilateral DVT is a significant risk indicator of malignancy. Cancer is present in 45% of patients with bilateral DVT and is associated with a poor prognosis.

Hip-spine relationship: a radio-anatomical study for optimization in acetabular cup positioning.

The criteria for acetabular cup positioning during total hip replacement are a matter of considerable discussion, particularly with regards to the optimal degree of anteversion. "Anatomical anteversion" is defined in the transverse plane, and "surgical anteversion" in the sagittal plane. Computed tomography measurements of anteversion are characteristic of a given transverse section plane and fail to take into account the position of the pelvis. We suggest a simple method for evaluating acetabular cup position in both the transverse and sagittal planes during standing and sitting. By shedding new light on the relationships between the pelvis and the spine, this method may help to understand some cases of impingement, instability or abnormal wear.

[Pheochromocytoma: 25 years of experience. Report of 199 cases]. / Phéochromocytomes: 25 ans d'expérience. A propos de 199 cas.

The methods for diagnosing pheochromocytoma have progressed in 25 years, so changing the clinical, biological and tumoral presentations. The authors compare the features of 199 patients with pheochromocytoma operated between 1975 and 2001 by quartiles. The frequency and known duration of hypertension, plasma adrenaline, the tumour size and proportion of cases which were malignant from the outset, have decreased over the observation period (p < 0.01). The average age and proportion of familial cases or associated with diabetes or those of asymptomatic patients (with incidentaloma), has not changed significantly. The pheochromocytoma were adrenal (104 right, 60 left, 12 bilateral) or ectopic (23) and 13 were malignant from the outset. Over a median 5 year follow-up, 35 pheochromocytomas recurred either in the benign or malignant forms. Recurrences of tumours of the right adrenal were more common than those of the left adrenal gland (p = 0.03). In conclusion, pheochromocytomas are diagnosed earlier, at a stage when the tumours are smaller and less secreting. The higher incidence and recurrence rate of right adrenal pheochromocytoma remain unexplained.

Reinforced interferon alpha-2b and ribavirin is more effective than standard combination therapy in the retreatment of chronic hepatitis C previously nonresponsive to interferon: a randomized trial.

Interferon-alpha (IFN) monotherapy results in sustained virological clearance in a minority of patients with chronic hepatitis C. The aim of this study was to assess the effect of a reinforced regimen combining ribavirin and high-dose IFN for 48 weeks compared with a nonreinforced regimen combining a standard IFN regimen and ribavirin for 24 weeks in nonresponders with chronic hepatitis C. A total of 231 patients with chronic hepatitis C and previous nonresponse to IFN monotherapy were randomized. The reinforced group (n = 114) received IFN-2b 6 million units (MU) thrice weekly (TIW) and ribavirin for 48 weeks, and the nonreinforced group (n = 117) received IFN-2b 3 MU TIW and ribavirin for 24 weeks. The main outcome measure was a sustained virological response, defined as negative serum hepatitis C virus (HCV)-RNA 24 weeks following the end of treatment. This endpoint was determined in 98 patients of the reinforced group and 105 patients of the nonreinforced group. At the end of follow-up, a sustained virological response was observed in 29 of the 98 patients (29.6%) in the reinforced group vs 16 of the 105 patients (15.2%) in the nonreinforced group (P = 0.014). In multivariate analysis, factors associated with a sustained virological response were treated with a reinforced regimen [odds ratio (OR) 2.9; P = 0.06] and genotype 2 or 3 (OR 8.8; P < 0.0002). A total of 160 patients had paired biopsies before and after treatment. Histological activity improvement was observed in 32 of 80 patients (40%) and fibrosis worsening in 26 of 80 patients (33%) in the reinforced group vs 13 of 80 (16%) and 19 of 80 (24%) in the nonreinforced group (P = 0.30 and 0.20, respectively). Hence in nonresponders, a high-dose 48-week regimen of IFN and ribavirin combination was more effective than a regimen with interferon at lower dose and ribavirin for 24 weeks only.

Comparison of two diagnostic tests for gestational diabetes in predicting macrosomia.

OBJECTIVES: To validate a diagnostic test for gestational diabetes which predicts the risk of macrosomia. METHODS: A prospective study was carried out among 354 women at risk for gestational diabetes to compare two glucose tests diagnosing pregnancies at risk of macrosomia. The "practical" test consisted in glucose measurement in the fasting state and two hours after an usual breakfast and the "reference" test was the test proposed in France (O'Sullivan test with or without a 100 g oral glucose tolerance test). Both tests were made between the 24(th) and 28(th) week of gestation. Women at high risk for macrosomia were treated. The first assessment criterion was macrosomia (babies large for gestational age). Because of the presence of women treated for gestational diabetes in our sample, the sensitivity and specificity of the tests in diagnosing pregnancies at risk of macrosomia were calculated using either the incidence of macrosomia observed in our population, or the incidence of macrosomia observed theoretically in the absence of treatment (22% in literature). RESULTS: Macrosomia was diagnosed in 49 neonates (14%). The "practical" test was significantly more sensitive than the reference test (respectively 46.9% versus 16.3%, p=0.0001 in the first case, and 54.3% versus 20.1%, p=0.0001 in the second case). The "reference" test was significantly more specific than the "practical" test (respectively 80% versus 68.2%, p=0.0001 in the first case, and 80.6% versus 70%, p=0.0001 in the second case). CONCLUSION: Our study shows that the simplified "practical" test is more sensitive than the "reference" test currently used in France in screening women at risk of macrosomia.