Overdrive ventricular pacing in pacemaker recipients with permanent atrial fibrillation and sleep apnea.

STUDY OBJECTIVES: Cardiac pacing is ineffective in obstructive sleep apnea (SA), but it can alleviate central SA/Cheyne-Stokes respiration (CSA) in patients with heart failure (HF). We examined whether overnight overdrive ventricular pacing (OVP) has an effect on SA in pacemaker recipients with permanent atrial fibrillation (AF). METHODS: An apnea-hypopnea index (AHI) ≥ 15 was confirmed in 28/38 patients screened by finger pulse oximetry during overnight ventricular pacing at a backup rate of 40 bpm (BUV40). These patients (23 men, 77.9 ± 7.6 y, BMI 27.6 ± 5.1 kg/m(2)) were randomly assigned to 2 consecutive nocturnal ventilation polygraphies with BUV40 versus OVP at 20 bpm above the mean nocturnal heart rate observed during screening. RESULTS: During BUV40 versus OVP, (1) mean heart rate was 49 ± 8 versus 71 ± 8 bpm (p < 0.0001) and percent ventricular pacing 36% ± 38% versus 96% ± 6% (p < 0.0001); (2) AHI was 35.4 ± 11.9 versus 32.5 ± 15.5 (p = ns), central AHI 23.9 ± 11.8 versus 19.1 ± 12.7 (p < 0.001), and obstructive AHI 11.6 ± 13.1 versus 13.5 ± 15.9 (p = ns). In 15/28 patients without HF, mean left ventricular ejection fraction (LVEF) was 51% ± 17%, AHI was 37.6 ± 11.0 during BUV40 and 39.0 ± 11.5 during OVP, versus 32.8 ± 12.9 and 24.9 ± 16.5 in 13/28 patients with HF (p = 0.02) and mean LVEF 35% ± 15% (p = 0.01). Between the 2 subgroups, (1) central AHI was 23.6 ± 12.4 during BUV40 and 21.5 ± 14.0 during OVP versus 24.1 ± 11.6 and 16.2 ± 10.7 (p = 0.05); (2) obstructive AHI was 14.0 ± 13.7 during BUV40 and 17.6 ± 16.5 during OVP versus 8.8 ± 12.3 and 8.7 ± 14.3 (p = ns). CONCLUSIONS: The prevalence of SA, predominantly central, was high in our pacemaker recipients with permanent AF. In those with HF, a single overnight OVP resulted in modest improvement in central events.

Is behavioral audiometry achievable in infants younger than 6 months of age?

BACKGROUND AND GOAL: When carried out in addition to objective tests, behavioral audiometry performed in children with the so-called "Delaroche protocol" [IJORL 68 (2004) 1233-1243] enables to determine hearing thresholds by air and bone conduction over the whole auditory frequency range. In the present report, seventy-three hearing-impaired infants with different levels of motor and cognitive development were tested behaviorally before 6 months of age. Reliability of these early determined behavioral thresholds was then after analyzed using: (a) cross-sectional study, and (b) longitudinal study. METHODS: Cross-sectional study compared click-evoked ABR thresholds in the better ear with binaural high-frequency hearing thresholds. In longitudinal study, early measured binaural hearing thresholds from 500 through 4000 Hz were reassessed at 18 months. RESULTS: In 13% of babies behavioral testing was not fully completed by 6 months of age. Nevertheless, both cross-sectional and longitudinal studies yielded intraclass correlation coefficients above 0.80, suggesting that behavioral testing is applicable to this very young population. CONCLUSIONS: Assessment of hearing after newborn screening should not be restricted to objective tests before 5 ½ months. It should also include bone- and air-conduction behavioral tests adjusted to developmental stage and performed in presence of parents.

Severe community-acquired Enterobacter pneumonia: a plea for greater awareness of the concept of health-care-associated pneumonia.

BACKGROUND: Patients with Enterobacter community-acquired pneumonia (EnCAP) were admitted to our intensive care unit (ICU). Our primary aim was to describe them as few data are available on EnCAP. A comparison with CAP due to common and typical bacteria was performed. METHODS: Baseline clinical, biological and radiographic characteristics, criteria for health-care-associated pneumonia (HCAP) were compared between each case of EnCAP and thirty age-matched typical CAP cases. A univariate and multivariate logistic regression analysis was performed to determine factors independently associated with ENCAP. Their outcome was also compared. RESULTS: In comparison with CAP due to common bacteria, a lower leukocytosis and constant HCAP criteria were associated with EnCAP. Empiric antibiotic therapy was less effective in EnCAP (20%) than in typical CAP (97%) (p < 0.01). A delay in the initiation of appropriate antibiotic therapy (3.3 ± 1.6 vs. 1.2 ± 0.6 days; p < 0.01) and an increase in duration of mechanical ventilation (8.4 ± 5.2 vs. 4.0 ± 4.3 days; p = 0.01) and ICU stay were observed in EnCAP patients. CONCLUSIONS: EnCAP is a severe infection which is more consistent with HCAP than with typical CAP. This retrospectively suggests that the application of HCAP guidelines should have improved EnCAP management.

Salvage radiotherapy after high-intensity focussed ultrasound for recurrent localised prostate cancer.

BACKGROUND: Radiotherapy is a treatment option in the case of local failure following treatment for localised prostate cancer with high-intensity focussed ultrasound (HIFU). OBJECTIVE: Our aim was to evaluate tolerance and oncologic control with salvage radiotherapy (SRT) after HIFU failure and to identify predictive factors of success. DESIGN, SETTING, AND PARTICIPANTS: From March 1995 to March 2008, all patients who presented with histologically proven persistent local disease following HIFU and were treated with curative intent SRT (with or without hormonal treatment) were included in this single-centre retrospective study. INTERVENTION: Patients underwent conformal radiotherapy. The median dose of conformal treatment was 72 Gy (65-78 Gy). MEASUREMENTS: The primary outcome measure was progression-free survival (PFS) defined as no biochemical relapse (three consecutive rises in prostate-specific antigen [PSA] with a velocity >0.4 ng/ml per year or PSA >1.5 ng/ml) and no additional treatment. Predictive factors of failure were examined in univariate and multivariate analyses. Adverse events in terms of urinary and digestive toxicity, urine incontinence, and erectile dysfunction (ED) were reported. RESULTS AND LIMITATIONS: The median (range) and mean (standard deviation) follow-up of the 100 patients analysed was 33 mo (5-164 mo) and 37.2 mo (23.6 mo), respectively. Eighty-three patients received SRT alone, and 17 received SRT and androgen-deprivation therapy. For the 83 patients treated with exclusive radiation therapy, PFS was 72.5% at 5 yr and 93%, 67%, and 55% for the low-, intermediate-, and high-risk groups, respectively. In the univariate analysis, PSA level prior to SRT, risk status, PSA nadir after SRT, PSA nadir after SRT >0.2 ng/ml, and time to achieve this nadir were all predictive of failure. In the multivariate analysis, PSA nadir post-SRT with a threshold at 0.2 ng/ml and time to achieve this nadir were the significant predictive factors of failure. Gastrointestinal toxicity was low; urinary toxicity grade < or =2 was 34.5%. Four were grade 3 (4.7%), one was grade 4 (1.2%), and one was grade 5 (1.2%). The incidence of severe ED (International Index of Erectile Dysfunction-5 score 5-10) was 14% pre-HIFU, and 51.9% and 82.3% pre- and post-SRT, respectively. Because our study was retrospective, results have to be interpreted cautiously. CONCLUSIONS: SRT provides satisfactory oncologic control after HIFU failure with little (or mild) additional toxicity. These results warrant further investigation.

Predictive factors for ipsilateral recurrence after nephron-sparing surgery in renal cell carcinoma.

BACKGROUND: Ipsilateral recurrence after nephron-sparing surgery (NSS) is rare, and little is known about its specific determinants. OBJECTIVE: To determine clinical or pathologic features associated with ipsilateral recurrence after NSS performed for renal cell carcinoma (RCC). DESIGN, SETTING, AND PARTICIPANTS: We analysed 809 NSS procedures performed at eight academic institutions for sporadic RCCs retrospectively. MEASUREMENTS: Age, gender, indication, tumour bilaterality, tumour size, tumour location, TNM stage, Fuhrman grade, histologic subtype, and presence of positive surgical margins (PSMs) were assessed as predictors for recurrence in univariate and multivariate analysis by using a Cox proportional hazards regression model. RESULTS AND LIMITATIONS: Among 809 NSS procedures with a median follow-up of 27 (1-252) mo, 26 ipsilateral recurrences (3.2%) occurred at a median time of 27 (14.5-38.2) mo. In univariate analysis, the following variables were significantly associated with recurrence: pT3a stage (p=0.0489), imperative indication (p<0.01), tumour bilaterality (p<0.01), tumour size >4cm (p<0.01), Fuhrman grade III or IV (p=0.0185), and PSM (p<0.01). In multivariate analysis, tumour bilaterality, tumour size >4cm, and presence of PSM remained independent predictive factors for RCC ipsilateral recurrence. Hazard ratios (HR) were 6.31, 4.57, and 11.5 for tumour bilaterality, tumour size >4cm, and PSM status, respectively. The main limitations of this study included its retrospective nature and a short follow-up. CONCLUSIONS: RCC ipsilateral recurrence risk after NSS is significantly associated with tumour size >4cm, tumour bilaterality (synchronous or asynchronous), and PSM. Careful follow-up should be advised in patients presenting with such characteristics.

Screening of forme fruste keratoconus with the ocular response analyzer.

PURPOSE: To evaluate the performance of the Ocular Response Analyzer (ORA) in the screening of forme fruste keratoconus (FFKc). METHODS: A retrospective comparative study was conducted involving 180 eyes. ORA preoperative data were analyzed for 125 normal control eyes (64 patients) undergoing laser in situ keratomileusis (LASIK) without corneal ectasia after 24 months of follow-up and 55 case eyes with unilateral keratoconus from a database (BCVA of 1.0, KISA index <60%). All eyes were matched in four groups of central corneal thickness (CCT): group 1, <500 microm; group 2, 500 to 539 microm; group 3, 540 to 579 microm; and group 4 >580 microm. Corneal hysteresis (CH), the corneal resistance factor (CRF), the air pressure curve, and the infrared signal were compared between FFKc and normal eyes in each group. RESULTS: The mean CH was 9.1 +/- 1.8 mm Hg for FFKc and 10.3 +/- 1.9 mm Hg for control eyes (P < 0.001), and the mean CRF was 9.2 +/- 1.8 and 11.1 +/- 2 mm Hg (P < 0.001), respectively. Sensitivity in each group was as follows: group 1, CH < 9.5 mm Hg (91%) and CRF < 9.5 mm Hg (81%); group 2, CH < 10.5 mm Hg (91%) and CRF < 10 mm Hg (87%); group 3, CH < 11.5 mm Hg (79%) and CRF < 11 mm Hg (74%); group 4 had two cases of FFKc, and the difference was not significant. Air pressure levels at inward and outward applanation and the maximum air pressure level were significantly lower and shorter in time in FFKc (P < 0.001), whereas the shape of the infrared signal was more variable. CONCLUSIONS: The ORA provides additional information in the screening of FFKc, with an accurate analysis of the corneal biomechanical properties according to CCT, air pressure, and infrared curves.

Risk factors for overweight and obesity in French adolescents: physical activity, sedentary behavior and parental characteristics.

OBJECTIVE: We determined the prevalence by age and sex and associated factors of overweight and obesity in French adolescents. METHODS: We conducted a cross-sectional study of 2385 adolescents aged 11-18 y (1213 boys and 1172 girls) from middle and high schools in the Aquitaine region (southwest France) in 2004-2005. Weight and height were measured, and adolescents filled in a questionnaire about their characteristics and those of their parents. Overweight and obesity were defined according to the age- and sex-specific body mass index cutoff points of the International Obesity Task force. RESULTS: Prevalence of overweight (obesity included) was greater in boys and younger children. The odds ratio (OR) for an adolescent being overweight increased with parents' being overweight (at least one parent overweight, OR 1.97, 1.48-2.62, P<0.0001), low paternal socioeconomic status (OR 1.78, 1.22-2.60, P<0.01) and sedentary behavior (22 h/wk, OR 1.33, 1.02-1.74, P<0.05), and decreased with physical activity of parents (at least one parent active, OR 0.67, 0.51-0.89, P=0.01). CONCLUSION: Our data support the hypothesis that parental overweight and low socioeconomic status and adolescents' sedentary behavior are strong risk factors for adolescent overweight and obesity, and that parents active lifestyle is associated with a lower risk of overweight in their adolescents.

Predictive risk factors for pain during extracorporeal shockwave lithotripsy.

PURPOSE: Extracorporeal shockwave lithotripsy (SWL) is a noninvasive but painful procedure. The aim of this study was to identify predictive risk factors for pain during SWL. PATIENTS AND METHODS: Two hundred twenty-two SWL treatments with the Lithostar lithotripter (Siemens) were included in a monocentric study. Patient and stone characteristics were prospectively collected in a database, and a standardized pain control protocol was administered 1 hour before treatment: paracetamol, nefopam, ketoprofen, and alprazolam. Subjective pain level was assessed with visual analog scale (VAS, 0-10). If VAS was >or=3, tramadol was added. If VAS was still >or=3, shockwave intensity was decreased or treatment was interrupted. The efficacy on stone fragmentation was evaluated 1 month after treatment. The need for adjuvant analgesia was compared with patient and stone characteristics to find out predictive risk factors for pain. RESULTS: The average subjective pain was 3.1. The need for supplementary analgesia was more frequent in women (p = 0.035), younger patients (p < 0.001), anxious and depressed patients (p = 0.018), in patients with previous SWL (p = 0.0185), in patients with a rib projected stone (p < 0.001), in patients with renal stones (p = 0.0535), and finally in patients with homogeneous stones (p = 0.02). Multivariate analysis revealed two independent risk factors for pain: young age (odds ratio = 5; p < 0.001) and rib projected stone (odds ratio = 5.23; p < 0.001). Stone fragmentation was worse in patients with an adjuvant analgesia requirement (p = 0.0311). CONCLUSION: Predictive risk factors for pain during SWL treatments were found: young age, rib projected stones, anxious and depressed patients, previous SWL treatment, and homogeneous stones. A higher analgesic requirement is necessary for these preselected patients to perform SWL and optimize its efficacy.

Anthropometric and behavioral patterns associated with weight maintenance after an obesity treatment in adolescents.

OBJECTIVE: To identify anthropometric and behavioral characteristics associated with weight maintenance after an obesity treatment. STUDY DESIGN: Adolescents (n = 72) enrolled in a 9-month obesity treatment were observed 1 and 2 years after discharge. Two groups, "successful" versus "limited or no success," were created on the basis of the differences in body mass index (BMI) z-score between inclusion and end of follow-up. Anthropometric and behavioral characteristics were compared between groups. RESULTS: Both groups showed a decrease in BMI z-score between inclusion and end of follow-up, 2.09 +/- 0.68 SD for the successful group and 0.65 +/- 0.43 SD for the group with limited or no success. Groups did not differ during treatment for any of the anthropometric characteristics considered, whereas differences clearly appeared 1 year after treatment and generally stabilized during the second year. Later adiposity rebound, trend for lower BMI in the mother, and, during follow-up, lower total energy intake, more energy at breakfast, and less snacking and television were recorded in the successful group. CONCLUSIONS: Weight loss maintenance can neither be predicted with anthropometry during treatment nor with behavioral characteristics at inclusion, but can be estimated 1 year after discharge. Early life factors should also be taken into account for predicting treatment outcome.

Correlations between corneal hysteresis, intraocular pressure, and corneal central pachymetry.

PURPOSE: To analyze the correlation between corneal hysteresis (CH) measured with the Ocular Response Analyzer (ORA, Reichert) and ultrasonic corneal central thickness (CCT US) and intraocular pressure measured with Goldmann applanation tonometry (IOP GA). SETTING: Bordeaux 2 University, Ophthalmology Department, Bordeaux, France. METHODS: This study comprised 498 eyes of 258 patients. Corneal hysteresis, corneal resistance factor (CRF), and IOP corneal-compensated (IOPcc) were provided by the ORA device; CCT US and IOP GA were also measured in each eye. The study population was divided into 5 groups: normal (n = 122), glaucoma (n = 159), keratoconus (n = 88), laser in situ keratomileusis (LASIK) (n = 78), and photorefractive keratectomy (n = 39). The Pearson correlation was used for statistical analysis. RESULTS: Corneal hysteresis was not strongly correlated with IOP or CCT US. The mean CH in the LASIK (8.87 mm Hg) and keratoconus (8.34 mm Hg) groups was lower than in the glaucoma (9.48 mm Hg) and normal (10.26 mm Hg) groups. The lower the CH, the lower its correlation with IOPcc and IOP GA. A CH higher than the CRF was significantly associated with the keratoconus and post-LASIK groups. CONCLUSIONS: Corneal hysteresis, a new corneal parameter, had a moderate dependence on IOP and CCT US. Weaker corneas could be screened with ORA parameters, and low CH could be considered a risk factor for underestimation of IOP. The CCT US should continue to be considered a useful parameter.

[Home care of childhood malaria: proposals for improving management based on a survey of mothers in Notsé (Togo)]. / Prise en charge à domicile du paludisme chez l'enfant : propositions d'actions à partir des résultats d'une enquête CAP menée auprès des mères d'enfants de moins de 5 ans à Notsé (Togo).

BACKGROUND: Malaria is a common and frequently fatal disease in sub-Saharan Africa and children suffer the consequences of their family's erroneous therapeutic decisions. OBJECTIVE: To assess knowledge, attitudes and practices related to malaria treatment and prevention among mothers of children younger than 5 years old. METHODS: Cross-sectional survey conducted from July to September 2000, in Notsé (Togo) among a sample of 385 mothers of children aged younger than 5 years. Investigators completed environmental evaluation cards and used a questionnaire to interview mothers. RESULTS: Mothers' level of knowledge was qualified as high among 53% of the subjects, intermediate among 30%, and poor among 17%. It was associated with the mothers' level of education. All mothers considered malaria to be a serious disease; 79% said that they were favourable to drug use for malaria prevention in children; 81% preferred mosquito nets as the means of prevention; 94% of them preferred that their child receive modern medical treatment for malaria. Mothers' global practices for malaria prevention and treatment were qualified as good among 5%, intermediate among 23%, and poor among 73%. Practices were associated with educational and level of knowledge and inversely associated with the number of children she had. CONCLUSION: These results suggest that improved communication with the population and promotion of intra- and inter-sector collaborations and literacy in mothers, together with active participation by the population, might be useful measures for reaching the objectives of antimalaria program in Togo.

Anxiety and depression in juvenile diabetes: a critical review.

A critical examination of the recent literature on anxiety and depression in juvenile diabetes is presented. The objectives of this review are: (1) to determine the general association of psychological factors, especially anxiety and depression, with diabetes, (2) to examine the specific association of anxiety and depression with metabolic control, and (3) to propose methodological changes that are needed to advance future research in this field. The major conclusions of this review support the notion of a general association of psychological disorders with juvenile diabetes. However, while anxiety and depression appear to play an important and complex role in determining adaptation to the disease, their relationship to metabolic control does not yet appear clear. Additional prospective and controlled studies as well as multivariate models of chronic disease are now necessary to more fully understand the etiology and impact of these disorders in the adolescent population.