The role of perinatal palliative care following prenatal diagnosis of major, incurable fetal anomalies: a multicentre prospective cohort study.

OBJECTIVE: To describe prenatal decision-making processes and birth plans in pregnancies amenable to planning perinatal palliative care. DESIGN: Multicentre prospective observational study. SETTING: Nine Multidisciplinary Centres for Prenatal Diagnosis of the Paris-Ile-de-France region. POPULATION: All cases of major and incurable fetal anomaly eligible for TOP where limitation of life-sustaining treatments for the neonate was discussed in the prenatal period between 2015 and 2016. METHODS: Cases of congenital defects amenable to perinatal palliative care were prospectively included in each centre. Prenatal diagnosis, decision-making process, type of birth plan, birth characteristics, pregnancy and neonatal outcome were collected prospectively and anonymously. MAIN OUTCOME MEASURE: Final decision reached following discussions in the antenatal period. RESULTS: We identified 736 continuing pregnancies with a diagnosis of a severe fetal condition eligible for TOP. Perinatal palliative care was considered in 102/736 (13.9%) pregnancies (106 infants); discussions were multidisciplinary in 99/106 (93.4%) cases. Prenatal birth plans involved life-sustaining treatment limitation and comfort care in 73/736 (9.9%) of the pregnancies. The main reason for planning palliative care at birth was short-term inevitable death in 39 cases (53.4%). In all, 76/106 (71.7%) infants were born alive, and 18/106 (17%) infants were alive at last follow-up, including four with a perinatal palliative care birth plan. CONCLUSIONS: Only a small proportion of severe and incurable fetal disorders were potentially amenable to limitation of life-sustaining interventions. Perinatal palliative care may not be considered a universal alternative to termination of pregnancy. TWEETABLE ABSTRACT: Perinatal palliative care is planned in 10% of continuing pregnancies with a major and incurable fetal condition eligible for TOP.

Real-life cost-effectiveness of benralizumab in patients with severe asthma.

BACKGROUND: Availability of clinically effective and cost-effective treatments for severe asthma would be beneficial to patients and national healthcare systems. The aim of this study was to evaluate clinical outcomes and healthcare expenditure after incorporating benralizumab into the standard treatment of refractory eosinophilic asthma. METHODS: This was a cross-sectional multicentre study of consecutive patients with refractory eosinophilic asthma who received treatment with benralizumab during at least 12 months. Patient follow-up was performed in specialised severe asthma units. The main effectiveness parameters measured were: the avoidance of one asthma exacerbation, a 3-point increase in the asthma control test (ACT) score, and the difference in utility scores (health-related quality of life) between a 1-year baseline treatment and 1-year benralizumab treatment. The health economic evaluation included direct costs and incremental cost-effectiveness ratios (ICERs). RESULTS: After 1 year of treatment with benralizumab, patients with refractory eosinophilic asthma showed an improvement in all the effectiveness parameters analysed: improvement of asthma control and lung function, and decrease in the number of exacerbations, oral corticosteroid (both as corticosteroid courses and maintenance therapy), and inhaled corticosteroid use. The total annual cost per patient for the baseline and benralizumab treatment periods were €11,544 and €14,043, respectively, reflecting an increase in costs due to the price of the biological agent but a decrease in costs for the remaining parameters. The ICER was €602 per avoided exacerbation and €983.86 for every 3-point increase in the ACT score. CONCLUSIONS: All the pharmacoeconomic parameters analysed show that treatment with benralizumab is a cost-effective option as an add-on therapy in patients with refractory eosinophilic asthma.

Real-life experience with benralizumab during 6 months.

BACKGROUND: Benralizumab is a monoclonal antibody that binds to the human interleukin-5 (IL-5) receptor (IL-5R), thereby preventing IL-5 from binding to its receptor and inhibiting differentiation and maturation of eosinophils in the bone marrow. Because of its recent marketing approval, sufficient real-life evidence is lacking to confirm the efficacy and safety data from clinical trials. The purpose of this study was to evaluate the efficacy and safety of benralizumab for the treatment of severe refractory eosinophilic asthma in a real-world cohort of patients. METHODS: This was a cross-sectional multicentre study of consecutive patients with severe refractory eosinophilic asthma who received treatment with benralizumab during at least 6 months. Patient follow-up was performed in specialised severe asthma units. RESULTS: A total of 42 patients were enrolled and treated with benralizumab. Asthma control, as measured by the asthma control test (ACT), improved in all patients both at 3 months of treatment compared with baseline (13.9 ± 4 vs 20.1 ± 3.7, p < 0.001) and at 6 months of treatment compared with the results obtained at 3 months (20.1 ± 3.7 vs 21 ± 2.7, p = 0.037). Similarly, the number of emergency department visits decreased both at 3 months compared with baseline (1 [IR:0.7] vs 0 [IR:0.75], p < 0.001) and at 6 months compared with the results at 3 months (0 [IR:0.75] vs 0 [IR:0], p = 0.012). Reductions in the number of oral corticosteroid cycles, percentage of corticosteroid-dependent patients, and mean daily dose of oral or inhaled corticosteroid were also evidenced. Finally, mean lung function improvement was 291 mL (p < 0.001), and FEV1% improved both at 3 months compared with baseline (64.4 ± 9.3 vs 73.1 ± 9.1, p < 0.001) and at 6 months compared to 3 months (73.1 ± 9.1 vs 76.1 ± 12, p = 0.002). Side effects were mild and did not lead to treatment discontinuation. CONCLUSIONS: This study confirms the efficacy and safety of benralizumab in a real-life setting with improved asthma control and lung function, and a reduced oral and inhaled corticosteroid use as well as fewer emergency department visits. In addition to a rapid initial improvement, it appears that patients continue to improve during the first 6 months of treatment.

Tabaquismo y morbilidad psiquiátrica / Smoking habit and psychiatric morbidity

No disponible

Tabaquismo y asma / Smoking habit and asthma

No disponible

Determinantes de la capacidad de esfuerzo en pacientes adultos diagnosticados de fibrosis quística / Determining exertion capacity of adult cystic fibrosis patients

Introducción: La fibrosis quística (FQ) es una enfermedad hereditaria que se relaciona con un deterioro de la función pulmonar, malnutrición e intolerancia progresiva al ejercicio. La finalidad de nuestro estudio fue examinar la capacidad de esfuerzo de pacientes adultos diagnosticados de FQ y su relación con la función pulmonar, el estado nutricional y la actividad física. Método: Incluimos a 50 pacientes adultos diagnosticados de FQ, edad 24,4 (5,9) años con FEV1 60,4 (28)%. Las medidas incluyeron el índice de masa corporal (IMC), masa magra de extremidades (MMe), función pulmonar, evaluación de la capacidad de ejercicio (VO2max) y test de los 6 minutos (6MM). La actividad física fue medida mediante un acelerómetro portátil. Se calculó un modelo de regresión lineal múltiple para VO2max.Resultados: Los pacientes tenían un reducido IMC (20,6 (2,7) kg/m2) y MMe (17,2 (2,6) g/cm2). La distancia media andada en el 6MM fue 633,3 (74,5) m y el VO2max alcanzado fue 70,9 (17,7)%. La media de los pasos medios medidos fue 8.173,8 (3.776,2). La VO2max se relacionaba de forma significativa con la edad (–0,3 (–0,561 / –0,061), FEV1 (0,117; 0,059-0,175), media de pasos diarios (0,001 [0-0,001]), 6MM (0,022[0-0,045]) e IMC (–0,658[–1,2 / –0,067]). Conclusiones: En nuestro grupo de pacientes con FQ, había limitación en la realización de ejercicio, estando ésta influenciada por la función respiratoria, la actividad física y el estado nutriciona (AU)

Introduction: Cystic fibrosis (CF) is a hereditary disease linked to the deterioration of lung function, malnutrition and progressive exercise intolerance. The objective of this study was to examine the exertion capacity of CF patients and the relationship with lung function, nutritional status and physical activity. Method: Included in the study were fifty (50) patients who had been diagnosed with CF, age 24.4 (±5.9 years with FEV160.4 (28%). Measurements included body mass index (BMI), limb lean mass (LLM), lung function, assessment of exercise capacity (VO2 max) and 6-minute walk test. Physical activity was measured using a portable accelerometer. A multiple lineal regression model was calculated for VO2 max. Results: Patients had a reduced BMI (20.6 (±2.7) kg/m2) and LLM (17.2 (±2.6) g/cm2). The mean distance walked for the 6-minute walk was 633.3 (±74.5) m and the VO2 max reached was 70.9% (±17.7) The mean of the average steps measured was 8,173.8 (3,776.2). The VO2 max related significantly with the age (–0.3 (–0.561 / –0.061), FEV1 (0.117; 0.059-0.175), average of daily steps (0.001 [0-0.001]), 6-minute walk (0.022[0-0.045]) and BMI (–0.658[–1.2 / –0.067]). Conclusions: In our group of patients with CF, there were limits when exercising, with exercise being influenced by respiratory function, physical activity and nutritional status (AU)

Modificación del índice BODE tras un programa de entrenamiento al ejercicio frente a ventilación mecánica no invasiva en EPOC estable e insuficiencia respiratoria hipercápnica / BODE index modification after an exercise training programme versus non-invasive mechanical ventilation in stable COPD and hypercapnic respiratory insufficiency

Objetivos: El objetivo de nuestro trabajo fue analizar los beneficios de un programa de entrenamiento al ejercicio y la instauración de ventilación mecánica no invasiva (VMNI) en pacientes EPOC severos en situación de insuficiencia respiratoria hipercápnica. Materiales y Métodos (..) (AU)

Objectives: The aim of our study was to analyse the benefits of an exercise training programme and the introduction of non-invasive mechanical ventilation (NIMV) in patients with severe COPD (..) (AU)

[Video recording of newborn resuscitation in the delivery room: technique and advantages]. / Enregistrement vidéo de situations réelles de réanimation en salle de naissance: technique et avantages.

An extreme attentiveness is mandatory when caring about extremely-low-gestational-age neonates at birth because of their innate vulnerability. The interventions performed during resuscitation of these infants may have direct influence on the immediate survival and also on long-term morbidity. Although stressfull, each resuscitation step is crucial and needs to be precise, fast and harmless. In order to determine our compliance to the international guidelines and to assess our neonatal performances in delivery room, we used a Mobotix camera to record all resuscitations of extremely-low-gestational-age neonates during the decisive first minutes of life. Neonatal medical and nursing staff agreed to be recorded. Our local ethics committee approved that videotaping neonatal resuscitation is an audit of clinical practice and thus does not require informed consent. During debriefing sessions, we reviewed the videotaped recordings, which allowed us to identify frequent deviations from the international guidelines and to re-educate and improve performance. The most frequent errors we recognized were errors of hygiene, not re-evaluating oxygen titration and airway obstruction during mask ventilation. We observed team behaviour and coordination during resuscitation and focused on quality of care. We believe that this method may be very effective as a teaching tool.

[Neonatal seizures, buprenorphine abstinence syndrome, and substitutive treatment with morphine]. / Convulsions néonatales, syndrome de sevrage à la buprénorphine et traitement morphinique substitutif.

We report the case of a hypotrophic twin who presented neonatal abstinence syndrome to buprenorphine and developed neonatal seizures when the substitutive treatment by morphine was stopped. The other eutrophic twin did not develop withdrawal symptoms. This case demonstrates the unpredictable nature of transplacental transfer of buprenorphine. It also shows that neonatal abstinence syndrome can be potentially severe and that morphine treatment is not without risk.

[Ovarian hyperstimulation syndrome]. / Síndrome de hiperestimulación ovárica.

Experience with ovulation induction treatment and understanding of the physiopathology of ovarian hyperstimulation syndrome (OHS), the risk factors and the clinical characteristics are of key importance for preventing and managing OHS. Light manifestations ofOHS are fairly common, occurring in up to a third of the cycles with superovulation induced by exogenous gonadotropins. A worsening of the symptoms of OHS can still normally be managed in out-patient form, but frequent monitoring and evaluation are essential. Serious disease resulting from OHS is much less common, but can involve risk to life. Hospitalisation might be necessary in some cases.

Síndrome de hiperestimulación ovárica / Ovarian hyperstimulation syndrome

La experiencia con el tratamiento inductor de laovulación y el conocimiento de la fisiopatología del síndromede hiperestimulación ovárica (SHO), los factoresde riesgo y las características clínicas son claves parala prevención y el manejo del SHO. Las manifestacionesleves del SHO son bastante comunes, ocurriendo enhasta un tercio de los ciclos con superovulación inducidospor gonadotropinas exógenas.El empeoramiento de los síntomas del SHO normalmentetodavía se puede manejar de forma ambulatoria,pero es esencial la monitorización y evaluación frecuente.La enfermedad grave resultante del SHO es muchomenos común, pero puede conllevar riesgo vital. Lahospitalización puede ser necesaria, en algunos casos(AU)

Experience with ovulation induction treatmentand understanding of the physiopathology of ovarianhyperstimulation syndrome (OHS), the risk factors andthe clinical characteristics are of key importance forpreventing and managing OHS. Light manifestations ofOHS are fairly common, occurring in up to a third ofthe cycles with superovulation induced by exogenousgonadotropins.A worsening of the symptoms of OHS can still normallybe managed in out-patient form, but frequentmonitoring and evaluation are essential. Serious diseaseresulting from OHS is much less common, but caninvolve risk to life. Hospitalisation might be necessaryin some cases(AU)

Patología infecciosa: vulvovaginitis, enfermedades de transmisión sexual, enfermedad inflamatoria pélvica, abscesos tubo-ováricos / Infectious pathology: vulvovaginitis, sexually transmitted diseases, pelvic inflammatory disease, tubo-ovarian abscesses

Las enfermedades de transmisión sexual son aquellasen las que la principal vía de infección es el contactoíntimo. Son numerosas las pacientes que acuden aurgencias por esta causa, tanto por la clínica como porlas implicaciones sociales. Los síntomas más frecuentesson dolor abdominal bajo, sangrados vaginales, oflujo vaginal excesivo o molesto.Las vulvovaginitis son uno de los problemas principalesen la práctica clínica diaria del ginecólogo.La úlcera genital cuya etiología principal es el herpes,seguida de la sífilis y el chancroide incrementa elriesgo para contraer la infección por el VIH y modificael curso de otras enfermedades de transmisión sexual.La enfermedad pélvica inflamatoria engloba a lasinfecciones del tracto genital superior femenino. Laimportancia del diagnóstico precoz y su tratamientoadecuado reside tanto por las complicaciones en lafase aguda como por las secuelas, que incluyen el dolorcrónico y la esterilidad(AU)

Sexually transmitted diseases are those where theprincipal path of infection is through intimate contact.Numerous patients attend Accidents and emergenciesfor this reason, both because of the clinical featuresand because of social implications. The most frequentsymptoms are lower abdominal pain, vaginal bleedingor excessive or troubling vaginal flow.Vulvovaginites are one of the principal problems inthe everyday clinical practice of gynaecology.A genital ulcer whose principal aetiology is herpes,followed by syphilis and chancroid, increases the riskof contracting HIV infection and alters the course ofother sexually transmitted diseases.Inflammatory pelvic disease encompasses infectionsof the upper female genital tract. The importanceof early diagnosis and suitable treatment is both due tothe complications in its acute phase and to its sequels,which include chronic pain and sterility(AU)

[Infectious pathology: vulvovaginitis, sexually transmitted diseases, pelvic inflammatory disease, tubo-ovarian abscesses]. / Patología infecciosa: vulvovaginitis, enfermedades de transmisión sexual, enfermedad inflamatoria pélvica, abscesos tubo-ováricos.

Sexually transmitted diseases are those where the principal path of infection is through intimate contact. Numerous patients attend Accidents and emergencies for this reason, both because of the clinical features and because of social implications. The most frequent symptoms are lower abdominal pain, vaginal bleeding or excessive or troubling vaginal flow. Vulvovaginites are one of the principal problems in the everyday clinical practice of gynaecology. A genital ulcer whose principal aetiology is herpes, followed by syphilis and chancroid, increases the risk of contracting HIV infection and alters the course of other sexually transmitted diseases. Inflammatory pelvic disease encompasses infections of the upper female genital tract. The importance of early diagnosis and suitable treatment is both due to the complications in its acute phase and to its sequels, which include chronic pain and sterility.

[Food avoidance emotional disorder in 3 to 10-year-old children: a clinical reality]. / Evitement alimentaire et trouble affectif chez l'enfant.

We underline the clinical importance of a specific eating disorder in 3 to 10 years old children, when the majority of the works about the prepubertal eating disorders focus either on the period just preceding adolescence (often between 10 and 13 years), or on the second half of the first year of the baby. Within the eating disorders described in the literature, we compare the clinical presentation of most of these 3 to 10 years old children with the food avoidance emotional disorder described during adolescence. These problems of eating behaviour (various selective eating with or without provoked vomiting) are ignored for a long time in these young children because of quite a satisfactory growth, but these children are often seen in emergency rooms because of a brutally complete eating refusal. Therapeutic consultations allow these children to express their fears about diseases, poisoning and death, for themselves or for their close relations, in particular the mother, without endangering their body. The early recognition and care of these difficulties of conciliation between the body and the thoughts impose a narrow collaboration between paediatric and psychiatric staffs.

Use of mammography among women residing in Spanish provinces with breast cancer screening programmes.

The objective of this study was to measure use of mammography and associated factors among women living in Spanish provinces with breast cancer screening programmes. From a cross-sectional population survey in a representative sample of Spanish women aged 40-70 years, we selected all women aged 45-65 living in provinces with breast cancer screening programmes (336 women). The programmes invited women in this age group to have a mammogram every 2 years. Data were collected by oral interviews in 1994. Use of mammography was defined as having received at least one test in the previous 2 years. Factors associated with mammography were studied using a logistic regression model. In the three autonomous communities (totalling 11 provinces) with programmes, the percentage of women receiving the test was 41.1% in Castille-Leon, 41.7% in Castille-La Mancha and 87.6% in Navarre (mean: 55.4%). The programmes began in 1990 in Navarre and between 1992 and 1993 in the other two communities. The most important factors affecting mammography use in the multivariate analysis were: intention to have a mammogram [odds ratio (OR) = 5.52; 95% confidence interval (CI) = 3.17-9.63]; not rejecting the test for fear of cancer diagnosis (OR = 4.23; 95% CI = 1.64-10.9); and physician recommendation of the test (OR = 3.43; 95% CI = 1.88-6.24). In conclusion, although the more established screening programmes have higher mammography use than those more recently implemented, programmes alone may not guarantee that women receive the test. Women's attitudes about mammography, and the role of the physician, are fundamental factors in the use of mammography.

[Programs of early detection of breast cancer and access of mammography in Spain]. / Programas de detección precoz del cáncer de mama y acceso a la mamografía en España.

BACKGROUND: We studied availability to mammography among Spanish women aged 40 to 70 years, variation in use of the mammography by autonomous community, and the situation and importance of breast cancer screening programs among other factors, in the access to mammography. SUBJECTS AND METHODS: A cross-sectional population survey was conducted in 1994 in a sample of 3,218 women. A questionnaire was used to collect data on the variable access (receipt of at least one mammogram in the last 2 years) as well as different access-related variables. Information on breast cancer screening programs was collected by contacting the responsible institutions. We considered that a program had total coverage if it included all the municipalities in the province and partial if it did not include all municipalities. RESULTS: Twenty-eight percent of women had performed a mammogram. This proportion varied among autonomous communities (AACC) from 11.5 to 73.8%. Breast cancer screening programs existed in 8 AACC. The multivariant analysis revealed an association between access to mammography and the existence of a screening program, especially when the later had total coverage (OR = 7.64; 95% CI = 5.24-11.10). An association was also found between access to mammography and physician-related factors, place of residence and attitudes of women toward mammography. CONCLUSIONS: Less than one third of women aged 40-70 have performed a mammography in the last 2 years, and this proportion varies among AACC. Gynecologist visits and the existence of breast cancer screening programs are fundamental factors in the access to mammography in Spain.

Equity in the access to mammography in Spain.

The purpose of this study is to measure the access to mammography of women aged 40-70 in Spain and to analyze the factors related to access to the test. Women were considered to have access to mammography if they have received at least one mammogram in the preceding 2 years. Numerous studies have shown that breast cancer mortality is reduced in women receiving periodic mammography, although experts disagree about the most appropriate age range for screening. An equitable health care system should provide access to effective procedures to all persons who need them. A number of factors influencing the access to mammography have been described. We conducted a cross-sectional population-based survey of 3218 women residing in Spain who were between 40 and 70 years of age. The sample was selected using a multi-stage stratified cluster technique, with proportional assignment to each stratum. Data collection took place between March and May 1994 by means of individual oral interviews using a standardized questionnaire. The questionnaire included information on the dependent variable (mammography use) and the independent variable (those potentially associated with access to the test). Information on other independent variables was collected in official institutions or from existing publications. Data analysis consisted of univariate and multivariate analyses. Only about 28% of all women had received a mammogram in the last 2 years. According to the univariate analysis, access to mammography is most strongly associated with number of gynaecologist visits, residence in the autonomous community of Navarre, and physician referral for mammography. In the multivariate analysis, the factors most strongly associated with access to mammography are gynaecologist visits at least once in the last 2 years (OR = 8.71; CI = 6.84-11.10), existence of a breast cancer screening programme (OR = 7.64; CI = 5.24-11.10), and physician referral for testing (OR = 4.78; CI = 3.83-5.96). The multivariate analysis also showed a significant association with place of residence and with women's attitudes about testing. A small proportion of Spanish women who could potentially benefit from mammography have received the test in the last 2 years. Establishing breast cancer screening programs equitably throughout the nation, and carrying out educational interventions aimed at women and especially at physicians, will help to reduce inequalities and increase the access to mammography in Spain.

Clinical practice, ethics and economics: the physician at the crossroads.

In recent years health services have faced the challenge of increasingly complex services and rising costs, thus the consideration of costs is a key factor in health policy decisions. The introduction of an economic perspective has sometimes been viewed as conflicting with the ethics of the health care system, especially at the physician-patient level. this article explores the important role of the physician from the ethical and economic perspective in the distribution and allocation of services. An understanding of economic and ethical principles reveals that these two perspectives are compatible with good clinical practice: more efficient health care implies better care for the individual patient and makes it possible to increase the resources available to improve care for the population as a whole. Thus, being efficient is an ethical objective. The selective elimination of ineffective services would free resources to care for those who need effective diagnostic or therapeutic procedures. This requires a better understanding of the determinants and outcomes of clinical practice, physician motivation, the appropriate design and application of incentives, and the best use of limited resources. The physician can play a key role in increasing the efficiency, equity, and quality of the health system without restricting the provision of effective services.