[Influence of the instillation of two versus three eyedrops of cyclopentolate 0.5% on refraction of Caucasian nonstrabismic children]. / Influence de l'instillation de 2 ou 3 gouttes de cyclopentolate à 0,5% sur la réfraction de l'enfant caucasien non strabique.

INTRODUCTION: Children's refraction can usually be measured using cyclopentolate 0.5%. Instilling three drops is time-consuming and inconvenient to both the clinical staff and the child. To remedy this situation, we investigated the refractive results of instilling two drops of cyclopentolate 0.5% at a 10-min interval compared with three drops at a 5-min interval in a group of a Caucasian nonstrabismic children. The kinetics of refraction in this population was also assessed. PATIENTS AND METHODS: We conducted a randomized cross-over study on 36 children aged between 4 and 13 years from March 1st to August 1st, 2003 at the University of Tours School of Ophthalmology. In protocol I, two cyclopentolate eyedrops were instilled in both eyes at a 10-min interval. In protocol II, three eyedrops were instilled at a 5-min interval. The refractive results were evaluated in terms of sphere and cylinder strength and axis. We used an auto-kerato-refractometer every 15 min from the first instillation for both protocols until the 90th min. RESULTS: Before the first drop instillation, there was no significant influence on skiascopy results for both eyes (-0.30+/-0.20 D for the right eye; -0.37+/-0.24 D for the left eye). The strength and the axis of the cylinder were comparable and stable (-0.5+/-0.18 D for strength; 5 degrees +/-22 for the axis) for all protocols and subjects tested. Sphere variation reached +1+/-0.6 D between t0 and t30 min for both protocols and remained stable between t30 and t90 min (+0.01+/-0.2 D). CONCLUSION: Instilling two eyedrops of cyclopentolate 0.5% at a 10-min interval in Caucasian nonstrabismic children aged 4-13 years is as effective as instilling three eyedrops at a 5-min interval in terms of kinetics and depth of cycloplegia. In addition, skiascopy can be performed as early as 30 min after the first instillation and until the 90th minute with the same effectiveness. The stability of astigmatism should be underlined in this population. Since these refractive results cannot be extrapolated for strabismic and ametropic children, we recommend, especially for the latter, instilling three drops for the first exam and only two thereafter, depending on the results.

[How long can we wait at full dilatation. A study of maternal and neonatal morbidity related to the duration of the second stage of labour in nulliparous women]. / Combien de temps peut-on attendre à dilatation complète? Analyse de la morbidité maternelle et foetale selon la durée de la seconde phase du travail chez la primipare.

OBJECTIVES: To determine the statistical association, in nulliparous patients, between maternal and fetal morbidity and the length of the second stage of labour. To precise whether a prolongation of this period of more than 2h may results in a dramatic increase of this morbidity. MATERIALS AND METHODS: Retrospective cohort study conducted in a level III referral centre between 1 April 2004 and 30 April 2005, including all nulliparous, term, cephalic, live singleton birth without fetal malformation in patients reaching the second stage of labour (n=1191). All deliveries were performed without restrictions in the length of the second stage of labour in the absence of fetal heart rate abnormalities. Maternal and neonatal morbidity were examined according to the duration of the second stage of labour with univariate analysis and after statistical adjustment with multivariate logistic regression for potential confounding variables. RESULTS: Global maternal morbidity ranged from 5.7% after 1h to 20.4% after more than 3h of full cervical dilatation. After a second stage duration of 2h, each additional completed hour resulted in a significant increase in global maternal morbidity (OR 1.78; IC 95% [1.59-1.97]), postpartum haemorrhage (OR 1.72; IC 95% [1.21-2.23]) and level three or four perineal lacerations (OR 1.24; IC 95% [1.7-1.41]). In the same time, caesarean section rate (OR 2.09; IC 95% [1.84-2.34]) and operative vaginal deliveries (OR 1.82; IC 95% [1.59-2.05]) increased significantly. Conversely, our study didn't demonstrate any significant association between neonatal morbidity and the length of the second stage of labour. CONCLUSION: Our study confirmed the association between the duration of the second stage of labour and the increase of maternal but not neonatal morbidity. Such an association, predominantly after 3h spend at full cervical dilatation, needs to be taken into account and, according to our experience, may justify caesarean section.

[Treatment of Hailey-Hailey disease with carbon dioxide laser vaporization]. / Traitement de la maladie de Hailey-Hailey par laser ablatif CO2.

INTRODUCTION: Only ablative methods lead to long term remission of areas affected by Hailey-Hailey disease: excision/skin graft, cryosurgery, dermabrasion... The method using the CO2 laser is a recent addition in the management of this dermatitis. We report our experience with this technique in 4 patients. PATIENTS AND METHODS: Carbon dioxide laser vaporization was proposed to 4 patients exhibiting Hailey-Hailey disease resistant to classical treatments. A test under local anesthesia was performed beforehand in all the patients. A 60 year-old man had an immediate reaction and refused to continue treatment. In the other 3 cases, the result of the test at 6 months was considered satisfactory. These patients were treated under general anesthesia in a single area of 50 to 70 cm2, and a half-body for comparison. The CO2 laser was used in pulse mode, with successive irradiations, until a homogenous, whitish-yellow aspect with first retraction was obtained. RESULTS: Although the healing delays were long (a mean of 1 month) and required major analgesics over the first few days, the cosmetic results were satisfactory and no abnormal scarring was observed. After a median follow-up of 27 months, no relapse of the disease other than punctiform elements was noted. All the patients wanted treatment of the other remaining affected areas be continued. In 2 patients, CO2 laser vaporization permitted treatment of areas not easily accessible to other ablative methods (around the mouth, the anus and the vulva) with anatomy and normal function spared. DISCUSSION: These results are globally good. Although the time to healing was long, the cosmetic and functional results were always satisfactory, without abnormal scarring. Moreover, in 2 of the patients, CO2 laser was able to treat areas inaccessible to other methods. The reason for the efficacy of ablative methods is debated. Re-epidermization with keratinocytes of appendices and not expressing the molecular defect, and the constitution of dermal cicatricial tissue, are two currently proposed hypotheses.

[Acute gastro-enteritis in children in France: estimates of disease burden through national hospital discharge data]. / Le poids médico-économique des gastro-entérites aiguës de l'enfant: l'éclairage du Programme de Médicalisation des Systèmes d'Information (PMSI).

OBJECTIVES: To estimate the burden of hospitalized infectious gastroenteritis of children younger than 5 years of age and associated costs. METHODS: We analyzed 1997 hospital discharges with a primary diagnosis of gastroenteritis or a secondary diagnosis of gastroenteritis with gastroenteritis symptoms or complications as primary diagnosis and compared the deaths with those of the national mortality data. RESULTS: Gastroenteritis was associated with 51,125 hospitalizations which accounted for 11.4% of hospitalization discharges for this age group and an annual rate of 1,385 per 100,000 children <5-year-old. Most gastroenteritis (56%) were registered as "probably infectious", 36% as "viral" (43% of which were coded "rotavirus") and 8% as "bacterial" (of which 60% were coded "Salmonella"). The seasonal peak was winter for rotaviral, viral and "probably infectious" gastroenteritis, summer for those related to salmonellosis. Incidence increased inversely with age: 3606/100,000 infants <1-year-old, 257/100,000 4-year-old children. Complications (especially dehydration) were observed in 21% of viral gastroenteritis and 17% of bacterial gastroenteritis. At least, 14 deaths were found in both hospital discharge and mortality data. The mean duration of stay (3.2 days) was significantly higher in infants <1-year-old, viral etiology, association with complications or bronchiolitis. The costs of hospitalization could be estimated to 62 million Euros. DISCUSSION: Our results are similar to those obtained in other developed countries. Despite variations in encoding the discharge reports, data has proven to be effective to describe national trends for this health event. Our study indicates that the public health burden and economic impact of prevention and control measures can be monitored through hospital discharge surveillance.

Automated quantitative analysis of nocturnal jejunal motor activity identifies abnormalities in individuals and subgroups of patients with slow transit constipation.

OBJECTIVE: Small bowel dysmotility has previously been demonstrated in some patients with slow transit constipation (STC), suggesting a generalized intestinal disorder. However, no study has addressed whether the incidence of small intestinal dysfunction differs between subgroups of patients in this heterogeneous population. Using appropriate methodology, we aimed to determine prospectively the proportion of individuals with abnormal small bowel motility, and to assess whether heterogeneity in terms of pattern of colonic transit delay (based on (111)In diethylene-triamine-pentaacetic acid (DTPA) isotope scintigraphy), or mode of onset (based on clinical history) is of importance. METHODS: Thirty-seven patients with STC underwent 24-h ambulatory jejunal manometry; data were compared with those obtained in 38 healthy controls. Automated quantitative analysis of seven variables of the nocturnal migrating motor complex was performed, to assess whether differences existed between groups, and whether individual patients had evidence of small intestinal dysmotility, defined as two or more measures of migrating motor complex variables outside the normal range. Four variables differed significantly between STC patients and controls: in phase III, propagation was slower, duration was longer, and contraction amplitude was higher; in phase II, contraction frequency was increased. Seven of 24 patients with a generalized pattern of colonic transit delay had abnormal small bowel motility compared with none of 13 with a left-sided delay (p < 0.04). These included four patients with chronic idiopathic symptoms and three with acquired symptoms. Approximately one third of patients with a generalized delay in colonic transit had evidence of jejunal enteric neuromuscular dysfunction. Individual patients with a left-sided colonic delay did not satisfy the criteria for nocturnal small bowel dysmotility, but as a group, some differences were noted from controls. In contrast to previous reports, evidence of generalized enteric dysmotility may be present irrespective of the mode of onset.

Reproductive behaviour of HIV-infected women living in France, according to geographical origin.

Pregnancy rates were compared before and after HIV diagnosis according to geographical origin (sub-Saharan Africa versus Europe) among 533 HIV-infected women followed in the French SEROCO/SEROGEST cohorts between 1988 and 1996. Among European women, the incidence of deliveries and terminations decreased, respectively, by nearly twofold and fourfold after HIV diagnosis. Conversely, the pregnancy incidence increased among African women with fewer than two children. This study should help refine the reproductive counselling and management of HIV-infected women in France.

[Medical and economic evaluation of organ transplantation in France. The example of liver transplantation]. / L'évaluation médico-économique des greffes d'organe en France. L'exemple de la transplantation hépatique.

BACKGROUND: Organ transplantation is an expensive and risky medical procedure. Estimating the cost is difficult because the care is complex and involves many actors. We present a methodological framework for the economic evaluation of organ transplantation in France which include a detailed collection of all the direct costs and the simultaneous analysis of health status. It was applied to evaluate the cost of liver transplantation in France. METHODS: All consecutive adults transplanted or placed on the waiting list of liver transplantation in the Department of Surgery of Cochin Hospital, Paris, between 1994 and 1996 were included. All resource use was measured during one year: staff wages, pharmacy and blood, laboratory and radiology, supplies, overhead hospital services. Mean quality of life was estimated by the survival weighted by the Karnofsky index. RESULTS: Transplantation: 38 patients were included. The first year mean cost after transplantation was 561,000FF (included rehospitalizations cost of 120,000FF). Care outside the hospital induced 10% of the total cost. Mean quality of life was 63% (from 0% to 93%) and increased with time, whereas cost decreased. Waiting list: 26 of 33 patients on waiting list were transplanted. The first year mean cost was 95,000FF (included 32,000FF for first evaluation) and increased with time. 44% of cost was supported by another hospital than the transplanting one. Sickness allowance added 20% to the cost. The mean quality of life was 56% during the first year. CONCLUSIONS: This complete approach of organ transplantation cost respected the medical procedure over the time. Detailed costs take into account the care outside the hospital. This method can be used in other countries and generalised to all surgical or medical procedure as heavy as the organ transplantation.

Evolution of clinical and radiological features at diagnosis of achalasia during a 19-year period in central France.

OBJECTIVES: Symptoms of achalasia are often misinterpreted, resulting in delayed diagnosis. The aims of our study were (1) to estimate the evolution of clinical and radiological features of a large population of achalasic patients between two successive periods; and (2) to determine the influence of symptoms on diagnostic delay. METHODS: Between 1980 and 1998, all achalasia patients treated in our unit were assessed at the time of manometric diagnosis for clinical and radiological features. These data were compared between two successive periods (1980-1994 and 1994-1998). Then, a correlation between the diagnostic delay, clinical and radiological data and symptoms was investigated. RESULTS: Three hundred and forty-five consecutive achalasia patients were assessed (mean age at diagnosis, 56 years; mean diagnostic delay, 5.7 years). The duration of the disease was correlated with the oesophageal diameter (P = 0.0001). Dysphagia, chest pain and heartburn were more frequent in young patients (respectively, P = 0.003, 0.0001 and 0.001). Women had 1.7 times the risk of men for suffering of chest pain (95% CI, 1.1 -2.6) and 2.2 times the risk for heartburn (95% CI, 1.2-4.0). Pulmonary involvement was more frequent when the oesophagus was dilated (P = 0.0002), and 3.4 times more frequent when associated with regurgitations (95% CI, 1.3-8.9). The oesophageal diameter was significantly smaller (38 vs 48 mm) in the last period, but we have not observed any significant shortening of the diagnostic delay. No symptoms influenced the diagnostic delay. CONCLUSIONS: Despite a smaller oesophageal diameter at the time of diagnosis, during the period 1994-1998, diagnostic delay was not reduced. No clinical features associated with late diagnoses could be identified.

[Epidemiology of apparently benign ovarian cysts]. / Epidémiologie des kystes de l'ovaire apparemment bénins.

The incidence of ovarian cysts in the general population is difficult to estimate. Certain cysts are functional and generally not operated, except in case of complications. Others are organic cysts which are usually, but not always operated. Data is available only from surgical series or pathology reports. An analysis of the literature shows that for operated cysts, approximately 75% are organic, 25% are function and 1 to 4% of the supposed benign cysts are found to be malignant. In France, the PMSI database on public and private institutions is available on the net (www.le-pmsi.fr). The number of hospital stays for benign ovarian tumors or ovarian cysts was to the order of 45,000 in 1998 and 1999. Twenty-one percent of these patients were discharged without surgery. Most had a functional cyst of the ovary. This leaves 32,000 women who underwent surgery annually for an ovarian cyst. Nearly 7000 women were hospitalized for follicular or yellow body cysts, i.e. 15%, with an incidence of 29/100,000 women over the age of 15 years. The abstention rate for hospitalized women with a follicular cyst or a yellow body cyst was 30 to 40%. For endometrioma, there were 5218 hospitalizations in 1999 (2137 in the public hospitals and 3081 in private clinics) (11% of the hospitalizations). The rate of abstention was 11% (15% in the public hospitals and 8% in private clinics). Approximately 4100 women thus underwent surgery, including 13% for ovarian cysts. According to data in the literature, serous and mucinous cysts account for 20 to 30% of the operated cysts and dermoid cysts for 10 to 20%. The type of cyst cannot be identified with the international WHO classification used in the PMSI.

Costs and outcomes of liver transplantation in adults: a prospective, 1-year, follow-up study. GRETHECO study group.

BACKGROUND: Orthotopic liver transplantation (OLT) is widely used to treat patients with end-stage liver disease. However, data on the cost of the procedure are fragmentary. We evaluated the costs, as calculated from resource use, and outcomes of OLT in adults, from registration on the transplant waiting list to the end of the 1st-year of follow-up after the transplant. METHODS: Two parallel cohort studies were conducted from 1994 to 95. All patients ages 18 years and older, on the waiting list (n=33) according to national criteria or having undergone transplants (n=38) were followed for 1 year or until either the transplant (waiting list cohort) or death (waiting list and transplantation cohorts). RESULTS: Eighty percent of the patients undergoing transplants were alive after 1 year, and no patient died while on the waiting list. However, the estimated cost of the procedure was high: more than 55,000 pound silver for the 1st year after OLT, to be added to 5,500 pound silver for evaluation and further costs motivated by the planned transplant during an average 6.5 months on the waiting list. Age over 40 and a baseline Child-Pugh score of 10 and over were predictive of high costs. The proportion of costs associated with immunosuppressive therapy and rejection were very high. CONCLUSIONS: This medical and economic cohort study suggests that OLT is still expensive; the study identifies sources of extra cost that could be limited either by improved selection of patients or, in the future, by technological advances in immunosuppressive therapy that help avoid medical complications. It also suggests the situation is precarious, with outcomes and costs being very sensitive to variation in graft availability.

[The educated societies and the development of medical evaluation]. / Les sociétés savantes et le développement de l'évaluation médicale.

The French National Agency for Medical Evaluation (ANDEM) is regularly cooperating with scientific societies. In 1995, for the clinical guidelines and medical references program, ANDEM sent a request to 167 scientific societies. Societies were asked to select topics in which they had an involvement, to provide their guidelines, or recommendations they published, and to provide experts' names. 73 (44%) out of 167 scientific societies answered: 53 (77%) out of the 73 proposed themes, 20 (27%) sent a documentation, and 53 (73%) provided experts' names. Twenty (27%) out of the 73 wished to cooperate with ANDEM to draft clinical guidelines. Thirty (41%) out of the 73 gave a similar answer with less information. Twelve wished to cooperate but did not show any evidence for such a goal. The answering lag time, the presence of scientific society headings on the letter, the absence of arguments against the request showed that some scientific societies were better organized. It seems that many scientific societies did not have a good organization to efficiently answer to ANDEM request; they have not sufficient resources to afford all their objectives. Learned societies are not well defined, and their functioning is unknown. They wish to be recognized by professionals, institutions and all organizations. The scientific production does not seem to be much developed, even if such production is their first objective.