Pediatric hospital care organization: Cross-sectional enquiry in four regions in France.

OBJECTIVE: The aim of this study was to characterize conventional pediatric care capacities in French public hospitals and identify the main difficulties in guiding upcoming health policies. The secondary objective was to assess the quality of care by the implementation of the European Charter of the Rights of Children in Hospital. METHOD: Multicenter cross-sectional study using a questionnaire survey sent by e-mail to the heads of conventional pediatric departments in four French regions identified on the French Hospital Federation's website. The survey was conducted between 25 September and 25 October 2018. RESULTS: Fifty-six of 113 heads of departments participated in the survey. The mean annual number of admissions per unit in 2017 was 2066 (SD, 1433), with a median length of stay of 2.7 days (range, 1-10). Children were admitted up to age 18 years in 76% of the departments, and 83% of the departments had an individualized pediatric emergency department. The nurse care load was very high, specifically during the night shift (9.5 patients/nurse). Inpatient education and academic teaching were unavailable in 38% of the departments. Overall, 89% of department heads declared knowing the European Charter of the Rights of Children in Hospital, and a copy of it was posted in all units in 57% (95% confidence interval, 44-70) of the services/departments. At all times and in all departments, parents were allowed to be with their children, and for 34% (95% CI, 21-47) of the departments, an accommodation for parents was available close to the hospital. CONCLUSION: Public hospital pediatric departments lack sufficient medical and nonmedical caregivers. Department heads were well aware of the European Charter, and it was well disseminated but should be updated to address today's challenges in pediatrics. An area of improvement would be to include parents in their child's care more effectively.

[Percutaneous pancreatic pseudocyst drainage: a combined sonographic-endoscopic procedure]. / Perkutane Pankreaspseudozysten-Drainage: ein sonographisch-endoskopisch kombiniertes Verfahren.

Certain pancreas-pseudocysts can be effectively drained either transgastrically or transduodenally using endoscopic procedures. Applicable methods include repeated fine needle punctures, insertion of a drainage tube or the percutaneous pseudocyst-drainage according to Hancke. The percutaneous sonographic pancreas-pseudocyst drainage represents an alternative or an adjunct to the classical surgical cyst drainage employing a cysto-jejunostomy or cysto-gastrostomy. The indications are analog to the surgical cysto-enterostomy, whereas the optimal method for each individual patient should be decided by interdisciplinary consultation. The following report presents 21 case studies of pancreas-pseudocysts which were treated conservatively using ultrasonographical procedures.

Continuous postoperative epidural analgesia for gynecologic oncology patients.

The efficacy of continuous postoperative epidural analgesia (CPEA) was assessed in 193 patients who collectively underwent 254 gynecologic oncology procedures. Seventy-five patients elected to receive CPEA; 118 did not. The CPEA patients received an epidural catheter the morning of surgery. Postoperatively, a bolus of meperidine was placed in each catheter. An IVAC pump continued to deliver meperidine at the rate of 14 to 20 mg per hour. The 193 patients also received a total of 655 postoperative intramuscular narcotic injections. CPEA patients were three times less likely to request injections, and those who did required an average of 6.58 compared with 12.42 for non-CPEA patients. The presence or absence of CPEA was the only significant variable. The use of CPEA led to no secondary complications, and it greatly enhanced mood and ability to participate in postoperative care. We conclude that CPEA provides excellent postoperative analgesia for such high-risk patients.

A comparison between peritoneal sheathing of the ureters (Ohkawa technique) and retroperitoneal pelvic suction drainage in the prevention of ureteral damage during radical abdominal hysterectomy.

Sixty patients had a radical abdominal hysterectomy with or without a bilateral salpingo-oophorectomy. The Ohkawa procedure was utilized in 26 (43.3%) of the patients and retroperitoneal ureteral placement with suction drainage in 34 (56.7%) of the patients. These two operative procedures were evaluated for complications such as fistula, obstruction, and hydronephrosis by comparing preoperative and postoperative intravenous pyelograms. Five of the 60 patients (8.3%) had surgical complications within one postoperative month. A ureteral obstruction occurred in two patients, and a uretrovaginal fistula occurred in two patients. Hydronephrosis was found in both sets of patients. All of these complications occurred in an additional two patients, both of whom had an Ohkawa procedure. The study led us to conclude that retroperitoneal ureteral placement is not only quicker to perform but also leads to fewer complications than the Ohkawa technique.

Para-aortic node biopsy in cervical and endometrial cancers: does it affect survival?

Two hundred ten patients with endometrial and cervical carcinoma had para-aortic node biopsies. Nineteen of the 210 patients (9.0%) had positive para-aortic nodes. These 19 patients received pelvic irradiation, and 18 patients received para-aortic irradiation. The incidence of para-aortic nodal involvement in cervical carcinoma was directly related to the stage of the disease. Eleven of the 12 patients with cervical carcinoma and positive para-aortic nodes received both pelvic and para-aortic irradiation. Three of these patients are alive without disease, resulting in a survival rate of 25%. These patients are surviving for 16, 30, and 41 months. The incidence of positive para-aortic nodes in endometrial adenocarcinoma was related to the uterine length and the histologic grade. The survival rate for patients with endometrial adenocarcinoma and positive para-aortic nodes in this study was 57.1%. Four patients have survived for 1, 30, 60, and 71 months. There were no surgical deaths or radiation therapy complications directly attributable to para-aortic biopsy or irradiation.

[Cyclosporin A and hyperlipidemia after kidney transplantation. Prospective study]. / Cyclosporin A und Hyperlipidämie nach Nierentransplantation. Eine prospektive Untersuchung.

Hyperlipidemia is common after renal transplantation and has been attributed, at least in part, to corticosteroid therapy. We therefore studied serum lipids in a group of nondiabetic transplant recipients on conventional immunosuppression with azathioprin and prednisone (Aza/P), in comparison with a transplanted group on cyclosporin A monotherapy (CyA) without steroids. Frequency and degree of hyperlipidemia in the two groups showed no significant difference. Atherogenic hypercholesteremia was found as frequently in patients on CyA as in those on Aza/P. Possible factors preventing normalization are discussed.

[Tumors and kidney transplantation]. / Tumoren und Nierentransplantation.

Incidence and type of de novo tumours were studied retrospectively in 187 consecutive patients who had received kidney transplants between 1967 and 1981 and undergone immunosuppressive therapy for 2 months or longer. Up to the end of June 1983, 18 patients (9.6%) had developed 22 malignancies and 7 of them had died from the tumour. The risk of developing a malignancy appeared to increase with prolonged immunosuppression. No significant difference was noted between patients with and without tumours regarding primary renal disease, duration of pretransplant dialysis, and type or total dose of immunosuppressive drugs. The risk of developing any malignancy appeared to be some 20 times that in the general population. The practical management of patients with de novo tumours is described in the light of our own patient material and the recent literature. Finally, two further oncological problems are discussed: first, the incidental grafting of malignant cells with the transplant, and second, how to proceed in a transplant candidate with a previous malignancy.

Colposcopic and pathologic features in two cases of DES-related vaginal clear-cell adenocarcinoma.

Two cases of vaginal clear-cell adenocarcinoma occurred as a result of maternal ingestion of diethylstilbestrol during pregnancy. The first case was diagnosed during the patient's first office visit. The second patient was first seen by the authors in 1976 and was followed at six-month intervals during the ensuing six years; the adenocarcinoma developed during this interval. Colposcopy and cytology were important in the diagnosis of both cases.

PIP: 2 cases of vaginal clear-cell adenocarcinoma, occurring as a result of maternal ingestion of diethylstilbestrol during pregnancy, are presented. The 1st case was diagnosed during the patient's 1st office visit, but the other patient's disease was diagnosed only after she had been followed regularly for 6 years. In utero exposure to diethylstilbestrol (DES) was documented during the 1st office visit of case 1. Medical records established that the 22-year old patient's mother had begun consuming Ensalstilbestrol, 25 mg daily, and increased the dosage to 25 mg t.i.d. during the 12th-14th week of gestation. She remained on this dosage throughout the pregnancy. 2 vaginal lesions were observed and examined colposcopically. A 1x1 cm mass on the right lateral vaginal wall was colsposcopically benign. A colposcopically directed biopsy of the posterior vaginal wall mass was performed, and histologic examination revealed a vaginal clear-cell adenocarcinoma. The patient had a clinical stage I cancer. Radical abdominal hysterectomy, periaortic node biopsy, bilateral pelvic lymphadenectomy, and total vaginectomy were performed. The resection margins and all lymph nodes were free of disease. A split thickness skin graft vaginoplasty was performed with 90-95% success. The mother of the 18-year old, nulliparous case 2 patient began injections of progesterone and DES at the time of her last menstrual period on February 18, 1956. The patient's physical examination on colposcopy clinic on May 29, 1975 was normal, but it soon became apparent that she was socially retarded and mentally slow. Pelvic examination on the 1st visit was not possible due to her inability to cooperate. Pelvic and colposcopic examination performed under general anesthesia 4 weeks later revealed gross and microscopic DES related changes. Colposcopically directed biopsies confirmed the diagnosis of vaginal adenosis and nabothian cysts. The cervix was also involved. The patient was examined colposcopically, and a Papanicolaou smear was performed approximately every 6 months. These smears were negative, and the colposcopic examinations were unchanged. The patient was hospitalized and again examined under anesthesia on December 8, 1978. Vaginal biopsies revealed vaginal adenosis and chronic inflammation. A Papanicolaou smear performed in 1980 showed focal endocervical cell atypia. On August 26, 1981 the patient was seen because of a vaginal discharge. A mass on the posterior wall was palpated on digital vaginal examination. Colposcopically directed biopsies confirmed the diagnosis of a clear-cell adenocarcinoma arising from the posterior vaginal wall ring. There was no evidence of cancer elsewhere in the vagina or on the cervix. On September 10, 1981 a radical abdominal hysterectomy, bilateral pelvic lymphadenectomy, periaortic node biopsy, and total vaginectomy were performed. The patient was treated wiht 5000 rads to an 8x10 cm midpelvic field, but vaginal reconstruction was not performed due to the patient's asocial lifestyle. An incidence of 0.14-1.4 tumors/1000 DES exposed females through age 24 is generally accepted.