Nontuberculous mycobacterial lung disease in a high tuberculosis incidence setting in Brazil.

OBJECTIVE: The incidence of lung disease caused by nontuberculous mycobacteria (NTM) has been increasing worldwide. In Brazil, there are few studies about nontuberculous mycobacterial lung disease (NTMLD), and its prevalence is yet to be known. Our objective was to determine the specific etiology of the disease in the state of Rio Grande do Sul, Brazil, as well as the frequency and diversity of NTM species in our sample of patients. METHODS: This is a retrospective analysis of the medical records of patients diagnosed with NTMLD treated in a referral center located in the city of Porto Alegre, Brazil, between 2003 and 2013. RESULTS: Our sample comprised 100 patients. The most prevalent NTM species were Mycobacterium avium complex (MAC), in 35% of the cases; M. kansasii, in 17%; and M. abscessus, in 12%. A total of 85 patients had received previous treatment for tuberculosis. Associated conditions included structural abnormalities in the lungs, such as bronchiectasis, in 23% of the cases; COPD, in 17%; and immunosuppressive conditions, such as AIDS, in 24%. CONCLUSIONS: MAC and M. kansasii were the most prevalent species involved in NTMLD in the state, similarly to what occurs in other regions of Brazil. Data on regional epidemiology of NTMLD, its specific etiology, and associated conditions are essential to establish appropriate treatment, since each species requires specific regimens. Most patients with NTMLD had received previous tuberculosis treatment, which might lead to development of resistance and late diagnosis.

Nontuberculous mycobacterial lung disease in a high tuberculosis incidence setting in Brazil / Doença pulmonar por micobactérias não tuberculosas em uma região de alta incidência de tuberculose no Brasil

ABSTRACT Objective: The incidence of lung disease caused by nontuberculous mycobacteria (NTM) has been increasing worldwide. In Brazil, there are few studies about nontuberculous mycobacterial lung disease (NTMLD), and its prevalence is yet to be known. Our objective was to determine the specific etiology of the disease in the state of Rio Grande do Sul, Brazil, as well as the frequency and diversity of NTM species in our sample of patients. Methods: This is a retrospective analysis of the medical records of patients diagnosed with NTMLD treated in a referral center located in the city of Porto Alegre, Brazil, between 2003 and 2013. Results: Our sample comprised 100 patients. The most prevalent NTM species were Mycobacterium avium complex (MAC), in 35% of the cases; M. kansasii, in 17%; and M. abscessus, in 12%. A total of 85 patients had received previous treatment for tuberculosis. Associated conditions included structural abnormalities in the lungs, such as bronchiectasis, in 23% of the cases; COPD, in 17%; and immunosuppressive conditions, such as AIDS, in 24%. Conclusions: MAC and M. kansasii were the most prevalent species involved in NTMLD in the state, similarly to what occurs in other regions of Brazil. Data on regional epidemiology of NTMLD, its specific etiology, and associated conditions are essential to establish appropriate treatment, since each species requires specific regimens. Most patients with NTMLD had received previous tuberculosis treatment, which might lead to development of resistance and late diagnosis.

RESUMO Objetivo: A incidência de doença pulmonar causada por micobactérias não tuberculosas (MNT) tem aumentado em todo o mundo. No Brasil, há poucos estudos sobre doença pulmonar por MNT, e sua prevalência ainda não é conhecida. Nosso objetivo foi determinar a etiologia específica da doença no estado do Rio Grande do Sul, bem como a frequência e a diversidade das espécies de MNT em nossa amostra de pacientes. Métodos: Análise retrospectiva dos prontuários de pacientes diagnosticados com doença pulmonar por MNT atendidos em um centro de referência localizado na cidade de Porto Alegre, RS, entre 2003 e 2013. Resultados: Nossa amostra foi composta por 100 pacientes. As espécies de MNT mais prevalentes foram Mycobacterium avium complex (MAC, complexo M. avium), em 35% dos casos; M. kansasii, em 17%; e M. abscessus, em 12%. Um total de 85 pacientes havia feito tratamento anterior para tuberculose. Condições associadas incluíram anormalidades estruturais nos pulmões, como bronquiectasias, em 23% dos casos; DPOC, em 17%; e condições imunossupressoras, como AIDS, em 24%. Conclusões: MAC e M. kansasii foram as espécies mais prevalentes envolvidas na doença pulmonar por MNT no estado, à semelhança do que ocorre em outras regiões do Brasil. Dados sobre a epidemiologia regional da doença pulmonar por MNT, sua etiologia específica e condições associadas são fundamentais para se estabelecer um tratamento adequado, já que cada espécie requer um esquema específico. A maioria dos pacientes com doença pulmonar por MNT havia feito tratamento anterior para tuberculose, o que pode levar a desenvolvimento de resistência e diagnóstico tardio.

Lack of association between rrl and erm(41) mutations and clarithromycin resistance in Mycobacterium abscessus complex.

BACKGROUND: Mycobacterium abscessus complex (MABC) includes species with high resistance rates among mycobacterial pathogens. In fact, MABC infections may not respond to clarithromycin treatment, which has historically been very effective against MABC infection. Molecular markers have been proposed to detect both acquired (rrl polymorphisms) and inducible (erm(41) polymorphisms) clarithromycin resistance in MABC isolates. OBJECTIVES: This study aimed to evaluate the susceptibility profile and molecular markers of clarithromycin resistance in MABC. METHODS: The clarithromycin susceptibility profile was determined by broth microdilution with reads on days 3, 5, 7 and 14. Mutations in the rrl and erm(41) genes were evaluated by polymerase chain reaction (PCR) using specific primers, followed by sequencing. FINDINGS: A total of 14 M. abscessus subsp. abscessus isolates and 28 M. abscessus subsp. massiliense isolates were evaluated, and clarithromycin resistance was observed in all isolates for up to three days of incubation. None of the 42 isolates exhibited a point mutation in the rrl gene, while all the isolates had a T28 polymorphism in the erm(41) gene. Moreover, all 28 M. abscessus subsp. massiliense isolates had a deletion in the erm(41) gene. MAIN CONCLUSIONS: While all the MABC isolates exhibited acquired clarithromycin resistance, no isolates exhibited a point mutation in the rrl gene in this study. The M. abscessus subsp. massiliense isolates demonstrated clarithromycin resistance, which is an uncommon phenotype. The molecular data for the rrl and erm(41) genes were not consistent with the phenotypic test results of clarithromycin susceptibility, indicating a lack of correlation between molecular clarithromycin resistance markers for both acquired and inducible resistance.

Lack of association between rrl and erm(41) mutations and clarithromycin resistance in Mycobacterium abscessus complex

BACKGROUND Mycobacterium abscessus complex (MABC) includes species with high resistance rates among mycobacterial pathogens. In fact, MABC infections may not respond to clarithromycin treatment, which has historically been very effective against MABC infection. Molecular markers have been proposed to detect both acquired (rrl polymorphisms) and inducible (erm(41) polymorphisms) clarithromycin resistance in MABC isolates. OBJECTIVES This study aimed to evaluate the susceptibility profile and molecular markers of clarithromycin resistance in MABC. METHODS The clarithromycin susceptibility profile was determined by broth microdilution with reads on days 3, 5, 7 and 14. Mutations in the rrl and erm(41) genes were evaluated by polymerase chain reaction (PCR) using specific primers, followed by sequencing. FINDINGS A total of 14 M. abscessus subsp. abscessus isolates and 28 M. abscessus subsp. massiliense isolates were evaluated, and clarithromycin resistance was observed in all isolates for up to three days of incubation. None of the 42 isolates exhibited a point mutation in the rrl gene, while all the isolates had a T28 polymorphism in the erm(41) gene. Moreover, all 28 M. abscessus subsp. massiliense isolates had a deletion in the erm(41) gene. MAIN CONCLUSIONS While all the MABC isolates exhibited acquired clarithromycin resistance, no isolates exhibited a point mutation in the rrl gene in this study. The M. abscessus subsp. massiliense isolates demonstrated clarithromycin resistance, which is an uncommon phenotype. The molecular data for the rrl and erm(41) genes were not consistent with the phenotypic test results of clarithromycin susceptibility, indicating a lack of correlation between molecular clarithromycin resistance markers for both acquired and inducible resistance.

Recent transmission of drug-resistant Mycobacterium tuberculosis in a prison population in southern Brazil.

We conducted a cross-sectional, retrospective study, characterized by classical and molecular epidemiology, involving M. tuberculosis isolates from a regional prison in southern Brazil. Between January of 2011 and August of 2014, 379 prisoners underwent sputum smear microscopy and culture; 53 (13.9%) were diagnosed with active tuberculosis. Of those, 8 (22.9%) presented with isoniazid-resistant tuberculosis. Strain genotyping was carried out by 15-locus mycobacterial interspersed repetitive unit-variable-number tandem-repeat analysis; 68.6% of the patients were distributed into five clusters, and 87.5% of the resistant cases were in the same cluster. The frequency of drug-resistant tuberculosis cases and the rate of recent transmission were high. Our data suggest the need to implement an effective tuberculosis control program within the prison system. RESUMO Estudo transversal, retrospectivo, com isolados de M. tuberculosis de pacientes de um presídio regional no sul do Brasil, caracterizado através de epidemiologia clássica e molecular. Entre janeiro de 2011 e agosto de 2014, 379 detentos foram submetidos a baciloscopia e cultura, sendo 53 (13,9%) diagnosticados com tuberculose ativa. Desses, 8 (22,9%) apresentavam tuberculose resistente a isoniazida. A genotipagem das cepas foi realizada por 15-locus mycobacterial interspersed repetitive units-variable number of tandem repeat analysis; 68,6% dos pacientes estavam distribuídos em cinco clusters, e 87,5% dos casos resistentes estavam em um mesmo cluster. Verificou-se uma frequência elevada de casos de resistência e alta taxa de transmissão recente. Estes dados sugerem a necessidade da implantação de um programa efetivo de controle da tuberculose no sistema prisional.

Recent transmission of drug-resistant Mycobacterium tuberculosis in a prison population in southern Brazil / Transmissão recente de Mycobacterium tuberculosis resistentes aos antimicrobianos em população carcerária no sul do Brasil

ABSTRACT We conducted a cross-sectional, retrospective study, characterized by classical and molecular epidemiology, involving M. tuberculosis isolates from a regional prison in southern Brazil. Between January of 2011 and August of 2014, 379 prisoners underwent sputum smear microscopy and culture; 53 (13.9%) were diagnosed with active tuberculosis. Of those, 8 (22.9%) presented with isoniazid-resistant tuberculosis. Strain genotyping was carried out by 15-locus mycobacterial interspersed repetitive unit-variable-number tandem-repeat analysis; 68.6% of the patients were distributed into five clusters, and 87.5% of the resistant cases were in the same cluster. The frequency of drug-resistant tuberculosis cases and the rate of recent transmission were high. Our data suggest the need to implement an effective tuberculosis control program within the prison system.

RESUMO Estudo transversal, retrospectivo, com isolados de M. tuberculosis de pacientes de um presídio regional no sul do Brasil, caracterizado através de epidemiologia clássica e molecular. Entre janeiro de 2011 e agosto de 2014, 379 detentos foram submetidos a baciloscopia e cultura, sendo 53 (13,9%) diagnosticados com tuberculose ativa. Desses, 8 (22,9%) apresentavam tuberculose resistente a isoniazida. A genotipagem das cepas foi realizada por 15-locus mycobacterial interspersed repetitive units-variable number of tandem repeat analysis; 68,6% dos pacientes estavam distribuídos em cinco clusters, e 87,5% dos casos resistentes estavam em um mesmo cluster. Verificou-se uma frequência elevada de casos de resistência e alta taxa de transmissão recente. Estes dados sugerem a necessidade da implantação de um programa efetivo de controle da tuberculose no sistema prisional.

Outbreaks due to Mycobacterium abscessus subsp. bolletii in southern Brazil: persistence of a single clone from 2007 to 2011.

Outbreaks associated with rapidly growing mycobacteria (RGM) have been increasingly reported worldwide, including in Brazil. Among the RGM, the Mycobacterium abscessus complex is the most pathogenic and related to multidrug resistance. The aim of this study was to evaluate the antimicrobial susceptibility and molecular profile of RGM isolates involved in new postsurgical infection outbreaks in Brazil since 2007. Of the 109 cases reported in the state of Rio Grande do Sul between 2007 and 2011, 43 (39 %) had confirmed mycobacterial growth in culture. Clinical isolates were obtained from biopsy specimens or abscess aspirates. PRA-hsp65 restriction pattern identified the isolates as M. abscessus type 2, and partial rpoB sequencing confirmed the identification as M. abscessus subsp. bolletii. All isolates were susceptible to amikacin and resistant to ciprofloxacin, doxycycline, sulfamethoxazole, moxifloxacin and tobramycin. Most isolates (72 %) were fully susceptible to cefoxitin but six isolates (14 %) were fully resistant to clarithromycin. The latter differed from the susceptibility profiles of the previously described BRA100 clone from other Brazilian regions. Nevertheless, pulsed-field gel electrophoresis analysis revealed that these isolates belonged to a single BRA100 clone. In conclusion, our study reports the persistence of an emergent single and highly resistant clone of M. abscessus subsp. bolletii for several years even after national implementation of infection control measures.

Workplace bullying and psychotropic drug use: the mediating role of physical and mental health status.

OBJECTIVES: The association between workplace bullying and psychotropic drug use is not well established. This study was aimed at exploring the association between workplace bullying, and its characteristics, and psychotropic drug use and studying the mediating role of physical and mental health. METHODS: The study population consisted of a random sample of 3132 men and 4562 women of the working population in the south-east of France. Workplace bullying, evaluated using the validated instrument elaborated by Leymann, and psychotropic drug use, as well as covariates, were measured using a self-administered questionnaire. Covariates included age, marital status, presence of children, education, occupation, working hours, night work, physico-chemical exposures at work, self-reported health, and depressive symptoms. Statistical analysis was performed using logistic regression analysis and was carried out separately for men and women. RESULTS: Workplace bullying was strongly associated with psychotropic drug use. Past exposure to bullying increased the risk for this use. The more frequent and the longer the exposure to bullying, the stronger the association with psychotropic drug use. Observing bullying on someone else at the workplace was associated with psychotropic drug use. Adjustment for covariates did not modify the results. Additional adjustment for self-reported health and depressive symptoms reduced the magnitude of the associations, especially for men. CONCLUSIONS: The association between bullying and psychotropic drug use was found to be significant and strong and was partially mediated by physical and mental health.

[Pain evaluation in office hysteroscopy: comparison of two techniques]. / Avaliação da dor em histeroscopia ambulatorial: comparação entre duas técnicas.

PURPOSE: to compare the pain reported by patients submitted to hysteroscopy by the standard technique with carbon dioxide (CO2) and to vaginal hysteroscopy with physiological saline (0.9% NaCl). METHODS: this was a prospective cohort study conducted at an ambulatory hysteroscopy service. A total of 117 patients with indication for the exam were included, being randomly assigned to one of the groups. All patients answered an epidemiological questionnaire and scored the pain expected before the exam and that felt after the end of the procedure on a verbal pain scale from 0 to 10. A speculum, traction of the cervix, insertion of a 30 masculine light source and a diagnostic shirt with a total diameter of 5 mm were used for the standard technique. The cavity was distended with CO2 under a pressure of 100 mmHg controlled with a hysteroflator, and a biopsy was obtained with a Novak curette. Vaginoscopy was performed without a touch by distention of the vagina with fluid, direct visualization of the cervix and introduction of the light source with two continuous-flow shirts, with an accessory channel with an oval profile, the whole set measuring 5 mm in diameter. The medium distention was 0.9% NaCl and the pressure used was that considered to be necessary for an adequate visualization of the canal and of the cavity with an external pneumatic pressurizer. The biopsy was obtained in a directed manner using an endoscopic clamp. The mean and standard deviation were calculated for the quantitative variables and the frequency was calculated for the qualitative variables. The Student's t-test was used to compare the means, and the chi-square or exact Fisher test was used (when n<5) for the categorical analysis using the SPSS 15.0 software. The study was designed for a 95% test power, with the level of significance set at p<0.05. RESULTS: the groups were similar regarding age, parity, previous uterine surgeries, menopausal status, and the need for a biopsy. In comparison to the group submitted to the standard technique, the vaginoscopy group involved a lower technical difficulty (5.1 versus 17.2%, p=0.03), a higher rate of exams considered to be satisfactory (98.3 versus 89.7%, p=0.04) and a lower pain index (4.8 versus 6.1; p=0.01), as the difference were more evident when patients who never had a previous normal delivery were compared (4.9 versus 7.1; p=0.0001). When the pain scale was stratified as mild (0-4), moderate (5-7) or intense (8-10), the vaginoscopy technique was found to be associated with a 52% reduction of the frequency of intense pain (p=0.005). CONCLUSIONS: vaginohysteroscopy was proved to be a less painful procedure than the technique based on the use of a speculum and CO2, regardless of age, menopause or parity, with more satisfactory results and lower technical difficulty.

Evaluation of pain in outpatient diagnostic hysteroscopy with gas / Avaliação da dor na histeroscopia diagnóstica ambulatorial com gás

Objective: To evaluate the intensity of pain reported by patients undergoing outpatient diagnostic hysteroscopy. Methods: Exam performed with a 5-mm lens hysteroscope, vaginal speculum, tenaculum and uterine distention with carbon dioxide gas. Before and after the examination, patients were interviewed to define, in a verbal scale from 0 to 10, pain values that they expected to feel and that they experienced after the end, and also if they would repeat it if indicated. Data were analyzed using Statistical Package for the Social Sciences 15.0, statistic significance was defined as p < 0.05 with a study power of 95%. Results: Fifty-eight patients were included with mean age of 50.9 years, with 32.8% at postmenopause and 6.9% nulliparous. Among those with previous deliveries, mean parity was 2.21 and at least one vaginal delivery had occurred in 63.8%. Only 24.1% of patients knew how the exam would be done, 62.1% needed an endometrial sample and the result was considered satisfactory in 89.7%. The means of expected and experienced pain were similar (6.0 versus 6.1), and 91.4% of women would repeat the hysteroscopy if necessary. The only factor associated with less pain after the exam was previous vaginal delivery, with a decrease of pain score from 7.1 to 5.5 (p = 0.03). Mean pain was significantly lower in those who agreed to repeat the exam (5.8 versus 9.4; p = 0.003). Conclusions: Outpatient diagnostic hysteroscopy with gas can be associated with moderate but tolerable discomfort and satisfactory results.

Objetivo: Avaliar a intensidade da dor referida pelas pacientes submetidas à histeroscopia diagnóstica ambulatorial. Métodos: Exame realizado com ótica de 5 mm, espéculo, pinçamento do colo com Pozzi e distensão da cavidade uterina com dióxido de carbono. Antes e depois do exame, as pacientes foram entrevistadas para definir, em uma escala verbal de 0 a 10, valores para espectativa de dor e dor experimentada após seu término, e também se elas o repetiriam se houvesse indicação. Os dados foram analisados no Statistical Package for the Social Sciences 15.0, com significância estatística definida como p < 0,05 e poder do teste de 95%. Resultados: Foram incluídas 58 pacientes, com idade média de 50,9 anos, sendo 32,8% na pós-menopausa e 6,9% nulíparas. Dentre as pacientes com partos anteriores, a paridade média foi 2,21 e pelo menos um parto normal ocorreu em 63,8%. Apenas 24,1% das pacientes sabiam como o exame seria feito, 62,1% necessitaram de biópsia endometrial e o resultado foi considerado satisfatório em 89,7% dos casos. As médias de dor esperada e referida pelas pacientes foram semelhantes (6,0 versus 6,1), e 91,4% das mulheres repetiriam a histeroscopia quando necessário. O único fator associado à redução da dor após o exame foi o antecedente de parto normal, com queda de 7,1 para 5,5 (p = 0,03). A média de dor foi significativamente menor nas pacientes que aceitariam repetir o exame (5,8 versus 9,4; p = 0,003). Conclusões: A histeroscopia diagnóstica ambulatorial com gás pode estar associada a desconforto moderado, porém tolerável, com resultados satisfatórios.

Avaliação da dor em histeroscopia ambulatorial: comparação entre duas técnicas / Pain evaluation in office hysteroscopy: comparison of two techniques

OBJETIVO: comparar a dor referida pelas pacientes submetidas à histeroscopia pela técnica convencional com gás carbônico (CO2) e a vaginohisteroscopia com soro fisiológico (SF 0,9 por cento). MÉTODOS: estudo prospectivo de coorte, realizado em um serviço de histeroscopia ambulatorial. Foram incluídas 117 pacientes com indicação para realizarem o exame, alocadas aleatoriamente em dois grupos. Todas responderam a um questionário epidemiológico e quantificaram a dor esperada antes do exame e sentida após seu término em uma escala verbal de dor de 0 a 10. Para a técnica convencional, foram utilizados espéculo, tração do colo, inserção de ótica de 30º e camisa diagnóstica com diâmetro total 5 mm. A cavidade foi distendida com CO2 sob pressão de 100 mmHg controlada por histeroinsuflador e a biópsia realizada com cureta de Novak. A vaginoscopia foi realizada sem toque, por distensão da vagina com líquido, visualização direta do colo e introdução de ótica com duas camisas de fluxo contínuo com canal acessório de perfil ovalado, totalizando também 5 mm de diâmetro para o conjunto. Foi utilizado SF 0,9 por cento como meio de distensão e a pressão, definida como a necessária para adequada visualização do canal e da cavidade com pressurizador pneumático externo. A biópsia foi realizada de forma dirigida com pinça endoscópica. Foram calculados média e desvio padrão para as variáveis quantitativas e frequência para as qualitativas. O teste t de Student foi utilizado para comparar médias e o teste do qui-quadrado ou exato de Fischer (quando n<5), para análise categórica usando o SPSS 15.0. O estudo foi desenhado para 95 por cento de poder do teste com significância se p<0,05. RESULTADOS: os grupos foram similares quanto a: idade, paridade, cirurgia uterina prévia, estado menopausal e necessidade de biópsia. No grupo vaginoscopia, comparado ao da técnica convencional, houve menor dificuldade técnica (5,1 versus 17,2 por cento, p=0,03), maior taxa de ...

PURPOSE: to compare the pain reported by patients submitted to hysteroscopy by the standard technique with carbon dioxide (CO2) and to vaginal hysteroscopy with physiological saline (0.9 percent NaCl). METHODS: this was a prospective cohort study conducted at an ambulatory hysteroscopy service. A total of 117 patients with indication for the exam were included, being randomly assigned to one of the groups. All patients answered an epidemiological questionnaire and scored the pain expected before the exam and that felt after the end of the procedure on a verbal pain scale from 0 to 10. A speculum, traction of the cervix, insertion of a 30º light source and a diagnostic shirt with a total diameter of 5 mm were used for the standard technique. The cavity was distended with CO2 under a pressure of 100 mmHg controlled with a hysteroflator, and a biopsy was obtained with a Novak curette. Vaginoscopy was performed without a touch by distention of the vagina with fluid, direct visualization of the cervix and introduction of the light source with two continuous-flow shirts, with an accessory channel with an oval profile, the whole set measuring 5 mm in diameter. The medium distention was 0.9 percent NaCl and the pressure used was that considered to be necessary for an adequate visualization of the canal and of the cavity with an external pneumatic pressurizer. The biopsy was obtained in a directed manner using an endoscopic clamp. The mean and standard deviation were calculated for the quantitative variables and the frequency was calculated for the qualitative variables. The Student's t-test was used to compare the means, and the chi-square or exact Fisher test was used (when n<5) for the categorical analysis using the SPSS 15.0 software. The study was designed for a 95 percent test power, with the level of significance set at p<0.05. RESULTS: the groups were similar regarding age, parity, previous uterine surgeries, menopausal status, and the ...

Evaluation of pain in outpatient diagnostic hysteroscopy with gas.

OBJECTIVE: To evaluate the intensity of pain reported by patients undergoing outpatient diagnostic hysteroscopy. METHODS: Exam performed with a 5-mm lens hysteroscope, vaginal speculum, tenaculum and uterine distention with carbon dioxide gas. Before and after the examination, patients were interviewed to define, in a verbal scale from 0 to 10, pain values that they expected to feel and that they experienced after the end, and also if they would repeat it if indicated. Data were analyzed using Statistical Package for the Social Sciences 15.0, statistic significance was defined as p < 0.05 with a study power of 95%. RESULTS: Fifty-eight patients were included with mean age of 50.9 years, with 32.8% at postmenopause and 6.9% nulliparous. Among those with previous deliveries, mean parity was 2.21 and at least one vaginal delivery had occurred in 63.8%. Only 24.1% of patients knew how the exam would be done, 62.1% needed an endometrial sample and the result was considered satisfactory in 89.7%. The means of expected and experienced pain were similar (6.0 versus 6.1), and 91.4% of women would repeat the hysteroscopy if necessary. The only factor associated with less pain after the exam was previous vaginal delivery, with a decrease of pain score from 7.1 to 5.5 (p = 0.03). Mean pain was significantly lower in those who agreed to repeat the exam (5.8 versus 9.4; p = 0.003). CONCLUSIONS: Outpatient diagnostic hysteroscopy with gas can be associated with moderate but tolerable discomfort and satisfactory results.

Workplace bullying and sleep disturbances: findings from a large scale cross-sectional survey in the French working population.

STUDY OBJECTIVES: The purpose of this study was to explore the associations between workplace bullying, the characteristics of workplace bullying, and sleep disturbances in a large sample of employees of the French working population. DESIGN: Workplace bullying, evaluated using the validated instrument developed by Leymann, and sleep disturbances, as well as covariates, were measured using a self-administered questionnaire. Covariates included age, marital status, presence of children, education, occupation, working hours, night work, physical and chemical exposures at work, self-reported health, and depressive symptoms. Statistical analysis was performed using logistic regression analysis and was carried out separately for men and women. SETTING: General working population. PARTICIPANTS: The study population consisted of a random sample of 3132 men and 4562 women of the working population in the southeast of France. RESULTS: Workplace bullying was strongly associated with sleep disturbances. Past exposure to bullying also increased the risk for this outcome. The more frequent the exposure to bullying, the higher the risk of experiencing sleep disturbances. Observing someone else being bullied in the workplace was also associated with the outcome. Adjustment for covariates did not modify the results. Additional adjustment for self-reported health and depressive symptoms diminished the magnitude of the associations that remained significant. CONCLUSIONS: The prevalence of workplace bullying (around 10%) was found to be high in this study as well was the impact of this major job-related stressor on sleep disturbances. Although no conclusion about causality could be drawn from this cross-sectional study, the findings suggest that the contribution of workplace bullying to the burden of sleep disturbances may be substantial.

The contribution of occupational factors to social inequalities in health: findings from the national French SUMER survey.

Social inequalities in health have long been demonstrated, but the understanding of these inequalities remains unclear. Work and its related occupational factors may contribute to these inequalities. The objective of this study was to study the contribution of work factors using an integrated approach (including all types of exposures) to social inequalities in three health outcomes: poor self-reported health, long sickness absence, and work injury. Respondents were 14,241 men and 10,245 women drawn from a survey of the national French working population (response rate: 96.5%). Work factors included job characteristics, and occupational exposures of the physical, ergonomic, biological, chemical, and psychosocial work environment. All work factors were measured through expert evaluation by occupational physicians, except psychosocial work factors, which were self-reported. Strong social gradients were found for all work factors, except for psychological demands, workplace bullying, and aggression from the public. Marked social gradients were also observed for the health outcomes studied, blue collar workers being more likely to report poor self-reported health, long sickness absence, and work injury. The social differences in health were reduced strongly after adjustment for work factors (psychological demands excluded) by 24-58% according to sex and health outcomes. The strongest impacts were found for decision latitude, ergonomic, physical, and chemical exposures, as well as for work schedules. A detailed analysis allowed us to identify more precisely the contributing occupational factors. It suggests that concerted prevention of occupational risk factors would be useful not only to improve health at work, but also to reduce social inequalities in health.

Study of the validity of a job-exposure matrix for psychosocial work factors: results from the national French SUMER survey.

OBJECTIVE: To construct and evaluate the validity of a job-exposure matrix (JEM) for psychosocial work factors defined by Karasek's model using national representative data of the French working population. METHODS: National sample of 24,486 men and women who filled in the Job Content Questionnaire (JCQ) by Karasek measuring the scores of psychological demands, decision latitude, and social support (individual scores) in 2003 (response rate 96.5%). Median values of the three scores in the total sample of men and women were used to define high demands, low latitude, and low support (individual binary exposures). Job title was defined by both occupation and economic activity that were coded using detailed national classifications (PCS and NAF/NACE). Two JEM measures were calculated from the individual scores of demands, latitude and support for each job title: JEM scores (mean of the individual score) and JEM binary exposures (JEM score dichotomized at the median). RESULTS: The analysis of the variance of the individual scores of demands, latitude, and support explained by occupations and economic activities, of the correlation and agreement between individual measures and JEM measures, and of the sensitivity and specificity of JEM exposures, as well as the study of the associations with self-reported health showed a low validity of JEM measures for psychological demands and social support, and a relatively higher validity for decision latitude compared with individual measures. CONCLUSION: Job-exposure matrix measure for decision latitude might be used as a complementary exposure assessment. Further research is needed to evaluate the validity of JEM for psychosocial work factors.

Importance of psychosocial work factors on general health outcomes in the national French SUMER survey.

AIM: To examine the associations between psychosocial work factors and general health outcomes, taking into account other occupational risk factors, within the national French working population. METHODS: The study was based on a large national sample of 24 486 women and men of the French working population who filled in a self-administered questionnaire in 2003 (response rate: 96.5%). Psychosocial work exposures included psychological demands, decision latitude, social support, workplace bullying and violence from the public. The three health indicators studied were self-reported health, long sickness absence (>8 days of absence) and work injury. Adjustment was made for covariates: age, occupation, work status, working hours, time schedules, physical, ergonomic, biological and chemical exposures. Men and women were studied separately. RESULTS: Low levels of decision latitude, and of social support, and high psychological demands were found to be risk factors for poor self-reported health and long sickness absence. High demands were also found to be associated with work injury. Workplace bullying and/or violence from the public also increased the risk of poor health, long sickness absence and work injury. CONCLUSION: Psychosocial work factors were found to be strong risk factors for health outcomes; the results were unchanged after adjustment for other occupational risk factors. Preventive efforts should be intensified towards reducing these psychosocial work exposures.

Economic activities and occupations at high risk for workplace bullying: results from a large-scale cross-sectional survey in the general working population in France.

OBJECTIVES: To evaluate the prevalence of workplace bullying in the general working population in France, and explore this prevalence across economic activities and occupations. METHODS: The studied population consisted of a sample of 3,132 men and 4,562 women of the general working population in the southeast of France. A self-administered anonymous questionnaire included the 45-item inventory of workplace bullying elaborated by Leymann, frequency and duration of bullying, and self-report of being exposed to bullying. Cases of bullying were defined using both Leymann's definition (exposure to at least one form of bullying within the previous 12 months, weekly or more, and for at least 6 months) and self-report of bullying. RESULTS: The 12 month prevalence of workplace bullying was 9% for men and 11% for women. The point prevalence was 7.5% on the day of the survey for men and women, and varied from 3 to 18% according to economic activities and occupations among men. High-risk groups for bullying included activities of services for men, and various categories of associate professionals, and of low levels of white and blue collar workers for men, and government associate professionals for women. CONCLUSIONS: This first study on workplace bullying in France showed that around 10% of the population studied, and more women than men, had been exposed to bullying within the last 12 months. This study also found that some economic activities and occupations would be at elevated risk for bullying, pointing out the need to better understand and prevent bullying in these high-risk groups.

Tratamento de gestação cervical viável com aplicação intra-amniótica de metotrexato: relato de um caso / Treatment of a viable cervical pregnancy with a single-intraamniotic methotrexate injection: a case report

Gestação cervical é uma condição rara, em que ocorre implantação do ovo no canal cervical distendendo-o à medida que cresce. Corresponde a menos de 1 por cento de todas as gestações ectópicas. A hemorragia indolor é sua característica clínica habitual e ao exame físico visualiza-se um colo hipertrófico e vascularizado, com tecido saindo pelo orifício externo do colo. Ultra-sonografia pode ser usada para complementar o diagnóstico, mostrando a presença do saco gestacional. Relatamos um caso de tratamento bem sucedido de gestação cervical viável de sete semanas. Morte fetal foi conseguida com uma injeção intra-amniótica única de metotrexato (25 mg) guiada por ultra-sonografia transvaginal. Metotrexato sistêmico em dose única intramuscular (50 mg/m²) foi associado. O tratamento conservador da gestação cervical com metotrexato foi efetivo e seguro.

Cervical pregnancy is a rare condition in which the egg is implanted in the cervical canal causing it to distend as the egg grows. Cervical pregnancy constitutes less than 1 percent of all ectopic pregnancies. Painless hemorrhage is a habitual clinical characteristic and on physical examination a very vascularized hypertrophic cervix is observed with a tissue surpassing the external orifice. Ultrasonography may be used as a complementary diagnostic tool to show directly the presence of a gestational sac. A successful management of a viable seven-week gestation cervical pregnancy is reported herein. Feticide was performed with a single intraamniotic methotrexate injection (25 mg) guided by transvaginal ultrasonography. Systemic methotrexate in a single dose intramuscular (50 mg/m²) was associated. The conservative management of cervical ectopic pregnancy with methotrexate was effective and safe.

Association between workplace bullying and depressive symptoms in the French working population.

OBJECTIVE: The objective was to explore the association between the characteristics of the exposure to workplace bullying and depressive symptoms in a large sample of employees of the French working population. METHODS: The study sample consisted of 3132 men and 4562 women of the French general working population in the southeast of France. Inclusion criterion was to have a work experience of at least 3 months. Cases of bullying were defined using both Leymann's definition and self-report of being exposed to bullying. Depressive symptoms were measured using the CES-D scale. RESULTS: After adjustment for covariates, which were age, marital status, presence of children, educational level, and occupation, exposure to bullying was found to be a risk factor for depressive symptoms for both men and women. The more frequent the exposure, the higher the risk of depressive symptoms. Past exposure to bullying increased the risk of depressive symptoms. Observing bullying was found to be a risk factor for depressive symptoms and increased the risk further still among women exposed to bullying. All these associations were found to be highly significant (P<.001). CONCLUSION: Workplace bullying was found to be a strong risk factor for depressive symptoms for men and women. Although any conclusion about the causal nature of the association could not be drawn because of the cross-sectional design of the survey, this study suggested that efforts to prevent bullying should be intensified.

Psychosocial work environment and mental health: Job-strain and effort-reward imbalance models in a context of major organizational changes.

This study explored the association between the two job-stress models, job-strain and effort-reward imbalance, and mental health outcomes in a working population exposed to major organizational changes. The cross-sectional study was based on 680 subjects, 504 men and 176 women. Psychosocial factors at work included: psychological demands, decision latitude, social support, effort, reward, and overcommitment. Mental health outcomes were depressive symptoms (CES-D) and psychiatric disorders (GHQ-12). Job strain, low decision latitude, effort-reward imbalance, and low reward (especially job instability) were found to be associated with depressive symptoms and/or psychiatric disorders among men. Overcommitment at work was a risk factor for both men and women. Social support at work played a role to reduce depressive symptoms for women. These findings emphasize the deleterious effects of psychosocial work environment on mental health during major organizational changes.