Examining Stressors and Available Parenting Resources for Opioid-Using Mothers: Qualitative Findings from an Inpatient Substance Use Treatment Program.

Given the alarming opioid epidemic, high prevalence of parents involved in substance use treatment programs for opioid use disorder, and critical role that parenting stress plays on opioid use and relapse, the current study examines stressors experienced by mothers enrolled in substance use treatment. Specifically, interviews were conducted with mothers with opioid use disorder (OUD) enrolled in an inpatient substance use treatment program, to identify common themes and develop recommendations related to interventions targeting common stressors among this population. A significant number of parent-related, substance use-related, and other stressors were present prior to and during substance use treatment; with more stressors reported during treatment than prior to treatment. Mothers with OUD reported that they would be interested in receiving parenting services, but that relevant parenting resources were not offered during substance use treatment.

[Correlation between prenatal and postnatal observations in case of gastroschisis: Experience in a prenatal referral diagnosis center]. / Corrélation des données anténatales et postnatales en cas de laparoschisis : expérience d'un CPDPN.

OBJECTIVES: Ultrasonography plays a key role in surveillance of gastroschisis. Indeed, ultrasound should allow an early diagnosis of its specific complications all the while avoiding their over-diagnosis which could induce an unnecessary prematurity in these fragile children. The aim of this study was to evaluate the relevance of ultrasonography in the surveillance of this malformation. METHODS: We conducted a retrospective single center study from 2008 until 2018 including all cases of apparently isolated gastroschisis followed during the prenatal period and surgically treated in our institution. Prenatal data gathered during the ultrasound follow-up were compared to those observed during surgery. RESULTS: Thirty-one cases of gastroschisis were included. Regarding the abdominal wall defect, the latter was described prenatally as tight in seven cases with a weak correlation, and as situated to the right of the umbilical cord insertion in 11 cases with a high correlation to the per-operative observations. Sonographic observations were responsible for inducing birth in 14 cases (45%), of which 12 due to the presence of a specific gastroschisis complication, confirmed in five cases (42%, weak correlation). Pre- and post-natal correlation for compression/atresia/stenosis and eviscerated bowel inflammation were very weak in both cases, with a respective tendency of over- and under-diagnosis. CONCLUSIONS: Diagnosing the specific complications of gastroschisis by ultrasound is difficult, even though ultrasonography is responsible for many anticipated births. Thus, this monitoring should be performed by experienced sonographers on devices with appropriate settings. In addition, reproducible parameters such as oligohydramnios or increased bowel dilations should alone be indications of anticipated birth.

Treatment Response and Outcomes in Post-transplantation Lymphoproliferative Disease vs Lymphoma in Immunocompetent Patients.

Posttransplantation lymphoproliferative disorder (PTLD) after solid organ transplantation may carry a poorer prognosis than lymphoma in immunocompetent individuals, but comparative data are lacking. In a retrospective, single-center, case-control study, 21 cases of PTLD were identified in patients undergoing kidney transplantation since 2000, and compared to 42 nontransplanted controls cared for in the same institution and matched for age, prognostic index, and cerebral localization. Two-year and 5-year overall survival was 57% and 44%, respectively, in PTLD patients and 71% and 58% in controls (log-rank test P = .20). On multivariable analysis, overall survival was similar for PTLD and control patients (hazard ratio 1.71, 95% confidence interval 0.81 to 3.61, P = .16). Response rate to first-line chemotherapy was similar between the 2 groups. Death was due to progression of the disease in 46% vs 94% of PTLD and control patients, respectively (P < .01), or sepsis in 31% vs 0% (P = .03). Treatment-related mortality was significantly higher in PTLD (19%) than in controls (0%, P = .03). In conclusion, response to first-line chemotherapy and overall survival are similar in PTLD and control patients, whereas causes of death were significantly different. Better prevention and management of infectious complications could improve the results in PTLD patients.

An epidemic of Pneumocystis jiroveci pneumonia in a renal transplantation center: role of T-cell lymphopenia.

Although only 2 cases of Pneumocystis jiroveci pneumonia were observed in our center between 2004 and 2009, we diagnosed 9 cases in 2010. Each patient had been in contact in the hospital with at least 1 other patient suffering P jiroveci pneumonia. Genotyping of P jiroveci pneumonia strains demonstrates a total homogeneity of the DNA sequences in the 7 patients already analyzed. CD4+ lymphocyte count was significantly lower at M3 in P jiroveci pneumonia patients than in controls. Our clinical and molecular data confirm that interhuman transmission of P jiroveci is possible, particularly to lymphopenic transplant recipients.

[Uterine arteriovenous malformations: diagnosis and treatment in 2011]. / Diagnostic et traitement des malformations artério-veineuses utérines (MAVU) en 2011.

Uterine arteriovenous malformations (UAVM) are rare. They mostly occur after endo-uterine trauma, or are less often congenital. When symptomatic, they may be a cause of uterine recurrent and massive bleeding. Diagnosis should be evoked in these cases, to avoid haemostatic curettage which will be useless and injurious. UAVM is often suspected by Doppler ultrasound, but pelvic MRI seems to be also relevant. Angiography confirms the diagnosis and allows concomitant embolization. Uterine embolization seems to be currently the best treatment, however surgery should still be performed in case of failure or hemodynamic instability. In this work, we aim to evaluate diagnosis and therapeutic modalities for UAVM.

[Reversal of Ballantyne's syndrome by selective fetal termination in a twin pregnancy]. / Syndrome de Ballantyne résolutif après interruption sélective chez une grossesse gémellaire.

OBJECTIVES: We describe Ballantyne's syndrome, a severe clinical materno-fetal entity, a pre-eclampsia-like disease. MATERIALS AND METHODS: We report the case of a woman with twin pregnancy presenting a Ballantyne's syndrome. Ultrasound examination at 22 weeks of gestation (wg), found heart abnormalities for one of the fetus. The ultrasonographic supervision revealed a fetal hydrops and at 28 wg a generalized maternal edema picture occurred. At this time, a Ballantyne's syndrome was suspected. RESULTS: A selective fetal termination of the affected twin was performed leading to a complete reversal of clinical and biochemical maternal picture, allowing the continuance of the pregnancy until 32 wg. CONCLUSION: Our article illustrates that when the diagnosis of Ballantyne's syndrome is quickly suspected and a treatable cause can be found, it allows sometimes a prenatal management and improves the materno-fetal prognosis.

New onset dyslipidemia after renal transplantation: is there a difference between tacrolimus and cyclosporine?

UNLABELLED: Lipid abnormalities including increased total cholesterol (TC), triglycerides (TG) and low density lipoprotein cholesterol (LDL-C) have been frequently reported in renal transplantation and could be involved in the high frequency of cardiovascular diseases in this population. PATIENTS AND METHODS: Two hundred ninety-five patients were transplanted between January 1995 and October 2000 in our center. Two hundred two patients were included in this study. Seventy-six patients received tacrolimus (Tac), and 126 patients cyclosporine (CsA). Lipid parameters were assessed the day of transplantation and 1 year posttransplantation. RESULTS: Serum lipids were similar between the two groups at D0. At M12, TC and LDL-C were significantly higher in the CsA group (6.14 +/- 1.37 vs 5.28 +/- 1.32 mmol/L; P < .05 and 3.98 +/- 1.05 vs 3.26 +/- 1.03 mmol/L; P < .05 CsA vs Tac, respectively). TG were comparable in both groups (1.86 +/- 1.07 vs 1.62 +/- 0.92 mmol/L; P = .55; CsA vs Tac). Incidence of de novo hypercholesterolemia was significantly higher in the CsA group (28 vs 8%) whereas incidence of hyperTG was similar in both groups. Prevalence of LDL-C was significantly higher in the CsA group (65% vs 31%; P < .001), whereas there was no difference in high density lipoprotein (HDL)-C levels. DISCUSSION: Mean serum lipid levels and incidence and prevalence of hyperTC, especially LDL-C, was significantly higher in patients receiving CsA when compared with Tac. TG and HDL-C levels were similar. Although the study was retrospective, our results confirm that CsA increases lipid levels, whereas Tac does not. CONCLUSION: Lipid disorders are frequently observed in renal transplant recipients. CsA, but not Tac, significantly increases incidence and prevalence of high TC and LDL-C.

Mechanisms of virologic failure in previously untreated HIV-infected patients from a trial of induction-maintenance therapy. Trilège (Agence Nationale de Recherches sur le SIDA 072) Study Team).

CONTEXT: In the Trilège trial, following induction with a zidovudine, lamivudine, and indinavir regimen, human immunodeficiency virus (HIV) replication was less suppressed by 2-drug maintenance therapy than by triple-drug therapy. OBJECTIVE: To identify mechanisms of virologic failure in the 3 arms of the Trilège trial. DESIGN: Case-control study conducted from February to October 1998. SETTING: Three urban hospitals in Paris, France. PATIENTS: Fifty-eight case patients with virologic failure (HIV RNA rebound to >500 copies/mL in 2 consecutive samples) randomized to 3 therapy groups: triple drug (zidovudine, lamivudine, and indinavir), 8; zidovudine-lamivudine, 29; and zidovudine-indinavir, 21; the case patients were randomly matched with 58 control patients with sustained viral suppression. MAIN OUTCOME MEASURES: At virologic failure (S1 sample) and 6 weeks later (S2 sample), assessment of protease and reverse transcriptase gene mutations, plasma indinavir level, and degree of viral load rebound; pill count during induction and maintenance periods. RESULTS: Only 1 primary resistance mutation, M184V, was detected in S1 plasma samples from 4 of 6 patients in the triple-drug and in all 22 in the zidovudine-lamivudine therapy groups and in S2 plasma samples from 3 of 6 in the triple-drug and 20 of 21 in the zidovudine-lamivudine groups. Of controls, M184V was detected in 11 of 13 S1 plasma samples and in 10 of 11 S2 plasma samples. Indinavir levels were undetectable in all S1 samples but 2 in 7 triple-drug cases tested and in the expected range in 11 of 18 S1 and 5 of 12 S2 zidovudine-indinavir case plasma samples tested. Maintenance adherence rates were lower for cases vs controls for zidovudine (P = .05) and indinavir (P = .05). Low indinavir levels, lower adherence rates for zidovudine (P = .04) and lamivudine (P = .03), and rebound to near-baseline values suggested adherence as cause of early failure for 4 of 8 triple-drug cases. In the zidovudine-lamivudine arm, for which case and control adherence rates did not differ significantly (P = .96), most failures occurred late with low rebound, suggesting suboptimal drug potency. In the zidovudine-indinavir arm, virologic failures may be related to both mechanisms. CONCLUSIONS: During the maintenance phase early and late virologic failures appeared to be related more to problems of adherence and antiretroviral treatment potency, respectively, than to selection of resistant mutant viruses.

[Risk factors of chronic rejection in kidney transplantation, results of a single center study]. / Facteurs de risque de rejet chronique en transplantation rénale, résultats d'une étude monocentrique.

Chronic rejection remains the single most important cause of renal allograft loss after the first year post-transplant. We performed a matched case control study within our cohort of 471 renal allograft recipients, comparing 66 patients with histologically proven chronic rejection with 66 controls. Analysis of immunological (transfusion, sensitisation, HLA matching, number of transplantation, number of acute rejections (AR), immunosuppression) and non-immunological (donors and recipients age and sex, CMV disease, post-transplant acute tubular necrosis, cold ischemia) factors which could predict the occurrence of chronic rejection (CR) was performed, using Wilcoxon rank test, Mac Nemar test and Cox model. Univariate analysis showed that potential risk factors for CR are: donor age > 45 years (p = 0.05), recipient age < 40 years (p = 0.008), CMV disease (p = 0.03), number of acute rejection episodes (p = 0.009), retransplantation (p = 0.002). Multivariate analysis showed that only the following factors significantly increased the risk of CR: AR episodes (p = 0.01) with an odds-ratio at 3.5 (95% CI = 1.3-3.9) for the second acute rejection episode and at 6.5 (95% CI = 1.5-29.4) for the third acute rejection episode, donor age > 45 years (p = 0.03) with an odds-ratio at 3.5 (95% CI = 1.1-10.6). Our data suggest that better matching at donor recipient age and more potent immunosuppressive protocols resulting in no acute rejection may improve the long term graft survival. They also show that the use of old donors (> 45 years), as a response to organ shortage is detrimental for long term renal function.

[Acute renal insufficiency: nutrition disorders and therapeutic consequences]. / Insuffisance rénale aiguë: désordres nutritionnels et conséquences thérapeutiques.

Catabolism is usually enhanced in acute renal failure (ARF). Its magnitude varies from one patient to another and can change significantly in the same patient from day to day, reflecting its clinical course. It depends on the severity of the ARF, the underlying process, the associated co-morbidity, and therapeutic approach. The detection of patients at high risk for malnutrition is extremely important; nutritional markers and indexes of caloric and protein requirements are useful to adapt renal replacement and nutritional support to ARF patients. Various biochemical parameters (namely, serum albumin and prealbumin), anthropometic measures, indirect calorimetry, urea and creatinine kinetics are all useful tools to evaluate metabolic status and requirements nutritional. Commonly, the caloric requirements are nearly 35 kcal/kg/24 h with correction factors applied for certain clinical situations: carbohydrates account for 50 to 60% of those needs whereas lipids account for the rest. The total amount of fluid administered has to be adapted to the possible ultrafiltration achieved by dialysis. Daily dialysis sessions and continuous renal replacement therapy allow larger volumes and thus facilitate nutritional support. Protein needs frequently exceed 1.2 g/kg/24 h to maintain the nitrogen balance, with a calorie to protein ration close to 150 kcal per g of nitrogen. Sufficient amounts of vitamins and oligo-elements are necessary. Stimulating anabolism by exogenous mediators, such as androgenic hormones or growth factors (rh-IGF1, rh-GH) is an avenue that deserves better definition in critically ill ARF patients.

[Secondary hyperparathyroidism and multiple vertebral brown tumors: cure after parathyroidectomy]. / Hyperparathyroïdie secondaire et tumeurs brunes multiples à localisation vertébrale: guérison après parathyroïdectomie.

A 46 year old man was referred for severe left cruralgia and multiple vertebral cystic defects on CT-scan. He was treated by hemodialysis since 1987 for chronic renal failure secondary to focal and segmental glomerulosclerosis, diagnosed in 1960 on renal biopsy. Dialysis schedule consisted of 3 x 4 h/week with a polysulfone dialyser and 1.75 mMol Ca containing bicarbonate dialysate. On early 1995, the patient complained of back pain and cruralgia, which gradually worsened. Vertebral column CT-scan and MRI showed multiple lytic lesions expanding into the medullary canal. Biological hyperparathyroidism was present. To differentiate between hyperparathyroidism with brown tumors, malignancy and amyloid deposition, an iliac biopsy and a biopsy of a corporeal vertebral cyst were done. They showed florid hyperparathyroidism and brown tumors. The patient was submitted to surgical parathyroidectomy. Six months after surgery, cruralgia resumed, CT-scan and MRI showed refilling of the cysts by calcic material.

[Comparative study of actual costs of radiotherapy and its value]. / Etude comparative des coûts réels des actes de radiothérapie et de leur valorisation par lettre clef.

PURPOSE: Financial costs from "Z" procedures were evaluated and compared with the amount of direct costs that are needed for the annual activity of a radiation oncology department. MATERIALS AND METHODS: The various components, particularly staff earnings that are estimated for each procedure according to their category and working time, were cumulated for calculation of direct loads. RESULTS: Comparisons between direct expenses and the total amount of Z procedures led to the following results: the global cost is the same; at analysis of therapeutic procedures, however, this apparent similarity masks some very significant gaps; valorization of Z procedures is much lower than that of the corresponding real loads, especially when therapeutic procedures are quite different from techniques that are considered as "standard"; these differences do not apply to all the components of radiation therapy procedures. In particular, medical steps would be uniformly underestimated, while irradiation per se is overestimated. CONCLUSION: The authors suggest modifications of the general objectives and items of the nomenclature of radiotherapy and brachytherapy procedures.

[The cost of radiotherapy. Evaluation of the real cost of treatments performed in a radiotherapy service of a center for fight against cancer]. / Le coût de la radiothérapie. Evaluation du coût réel des traitements réalisés dans un service de radiothérapie d'un centre de lutte contre le cancer.

The authors present a retrospective analysis dealing with the cost of therapeutic procedures achieved in the department of radiotherapy of the Centre Claudius-Regaud. This analysis was performed according to the actual cost of the different components of each treatment including the human costs. For this last purpose, serial countings of time spent by each category of employees were performed and then translated into financial terms. Results show a large discrepancy between the costs of therapeutic procedures. These differences are mainly related to the purpose of therapeutic plan, dealing with the most expensive procedures dealing with the developmental treatments. This study provides a tool that can be used by medical and/or administrative managers of radiation oncology departments when changes or innovations in therapeutic procedures. This cost accounting analysis is compared to the French administrative procedures used to pay the health care services and to determine the level of hospital resources.