Descriptive epidemiology of 13,038 newly diagnosed and histologically confirmed meningiomas in France: 2006-2010.

PURPOSE: This work describes the clinical epidemiology and pathology for patients undergoing surgery for newly diagnosed meningiomas in France between 2006 and 2010. METHODS: The methodology is based on a multidisciplinary national network previously established by the French Brain Tumor DataBase (FBTDB) (in French: Recensement national histologique des tumeurs primitives du système nerveux central [RnhTPSNC]), and the active participation of the scientific societies involved in neuro-oncology in France. RESULTS: From 2006 to 2010, 13,038 incident cases of meningioma with histological validation were identified and analyzed (9769 women, 3269 men, resection 98.2%, cryopreservation 20.5%). For each histological subtype of meningioma (meningothelial, fibrous, transitional, psammomatous, angiomatous, rare variety, microcystic, secretory, lymphoplasmacyte-rich, clear-cell, chordoid, rhabdoid, metaplastic, atypical, papillary, anaplastic and not otherwise specified), number of cases, sex, median age, cryopreservation and surgery were reported. Among the various histological subtypes, atypical meningioma (grade II) slightly, but significantly, increased after 2007. Headache, sensory-motor impairments and seizures were the most frequent clinical symptoms. Time between the first clinical symptom and surgery ranged from 0 to 314 months, and was <3 months in 37% of cases. At the time of surgery, 9% of patients were asymptomatic. DISCUSSION/CONCLUSION: Given the number of meningiomas not histologically-validated, we can estimate that the gross incidence rate for meningiomas operated in France is about 4.2 per 100,000 person/year. To our knowledge, this work is the most important study evaluating the different subtypes of meningiomas and it validates the relevance of histological databases for central nervous system tumors.

Recombinant human FVIIa for reducing the need for invasive second-line therapies in severe refractory postpartum hemorrhage: a multicenter, randomized, open controlled trial.

BACKGROUND: Case reports on recombinant human factor VIIa (rhuFVIIa) use in women with severe postpartum hemorrhage (PPH) showed encouraging results, but no randomized controlled trial (RCT) is available. PATIENTS AND METHODS: Eighty-four women with severe PPH unresponsive to uterotonics were randomized to receive one early single rhuFVIIa infusion (n = 42) or standard care (no rhuFVIIa; n = 42). The primary efficacy outcome measure was the reduction of the need for specific second-line therapies, such as interventional hemostatic procedures, for blood loss and transfusions. The primary safety outcome measure was the number of deaths and thrombotic events during the 5 days following rhuFVIIa infusion. RESULTS: rhuFVIIa was associated with a reduction in the number of patients who needed second-line therapies compared with controls (standard care). Specifically, 39/42 (93%) patients in the standard care arm received second-line therapies and 22/42 (52%) patients in the rhuFVIIa arm (absolute difference, 41%; range, 18-63%; relative risk RR, 0.56 [0.42-0.76]). The delivery mode (vaginal or Cesarean section) did not affect the primary outcome. No death occurred. Two venous thrombotic events were recorded in the rhuFVIIa arm: one ovarian vein thrombosis and one deep vein thrombosis with a non-severe pulmonary embolism. CONCLUSION: This open RCT in women with severe PPH refractory to uterotonics shows that rhuFVIIa reduces the need for specific second-line therapies in about one in three patients, with the occurrence of non-fatal venous thrombotic events in one in 20 patients.

[Use of indicators of fluid responsiveness in septic shock: a survey in public emergency departments]. / Indices de réponse au remplissage vasculaire lors de la prise en charge d'un choc septique : utilisation par les médecins urgentistes.

INTRODUCTION: Fluid therapy is one of the major elements of severe sepsis and septic shock management. A systematic initial fluid bolus is recommended before evaluation of left ventricular filling pressure by the use of indicators of fluid responsiveness, preferentially dynamic ones. A massive fluid therapy could be damaging for the patient. Dynamic indicators of fluid responsiveness are not often relevant in the emergency department. This study was aimed to evaluate the use of indicators of fluid responsiveness by emergency practitioners during septic shock management. STUDY DESIGN: Cross sectional survey using anonymous self-questionnaire. METHODS: We included all practitioners working in public emergency department of Languedoc-Roussillon (France). Primary-end point was the use of one indicator of fluid responsiveness at least. Uni- and multivariate analysis was conducted to find associated factors. RESULTS: Of 232 practitioners included, we collected 149 questionnaires (response rate=64%). Hundred and eight practitioners (72% [64-79%]) used at least one indicator of fluid responsiveness. Fifty-six practitioners (38% [30-46%]) used echocardiography, 54 practitioners (36% [29-44%]) used blood lactate concentration, 45 practitioners (30% [23-38%]) used passive leg raising. The use of indicators of fluid responsiveness is associated with easy access to echography device (odd ratio=2.94 [1.16-7.62], P=0.03). CONCLUSION: Emergency practitioners use preferentially less invasive and less time-consuming indicators of fluid responsiveness.

[French brain tumor database: general results on 40,000 cases, main current applications and future prospects]. / Recensement national histologique des tumeurs primitives du système nerveux central : résultats généraux sur 40 000 cas, principales applications actuelles et perspectives.

BACKGROUND AND PURPOSE: This work aimed at prospectively record all primary central nervous system tumor (PCNST) cases in France, for which histological diagnosis was available. The objectives were to (i) create a national database and network to perform epidemiological studies, (ii) implement clinical and basic research protocols, and (iii) harmonize the health care of patients affected by PCNST. METHODS: The methodology is based on a multidisciplinary national network already established by the French Brain Tumor DataBase (FBTDB) (Recensement national histologique des tumeurs primitives du système nerveux central [RnhTPSNC]), and the active participation of the Scientific Societies involved in neuro-oncology in France. RESULTS: From 2004 to 2009, 43,929 cases of newly diagnosed and histologically confirmed PCNST have been recorded. Histological diagnoses included gliomas (42,4%), all other neuroepithelial tumors (4,4%), tumors of the meninges (32,3%), nerve sheath tumors (9,2%), lymphomas (3,4%) and others (8,3%). Cryopreservation was reported for 9603 PCNST specimens. Tumor resections were performed in 78% cases, while biopsies accounted for 22%. Median age at diagnosis, sex, percentage of resections and number of cryopreserved tumors were detailed for each histology, according to the WHO classification. DISCUSSION/CONCLUSION: Many current applications and perspectives for the FBTDB are illustrated in the discussion. To our knowledge, this work is the first database in Europe, dedicated to PCNST, including clinical, surgical and histological data (with also cryopreservation of the specimens), and which may have major epidemiological, clinical and research implications.

Clinical predictors of dual aspirin and clopidogrel poor responsiveness in stable cardiovascular patients from the ADRIE study.

BACKGROUND: Poor response to both aspirin and clopidogrel (dual poor responsiveness [DPR]) is a major risk factor for recurrent ischemic events. OBJECTIVES: The aim of this study was to identify factors associated with DPR, defined with specific tests, and derive a predictive clinical score. METHODS: We studied 771 consecutive stable cardiovascular patients treated with aspirin (n = 223), clopidogrel (n = 111), or both drugs (n = 37). Aspirin responsiveness was evaluated by serum thromboxane (Tx)B2 assay, and clopidogrel responsiveness by calculating the platelet reactivity index (PRI) on the basis of the phosphorylation status of the vasodilator phosphoprotein. The analysis was focused on patients treated with both drugs, and on independent predictors of DPR. RESULTS: Among patients on dual therapy, there was no relevant correlation between TxB2 levels and PRI values (r = 0.11). Sixty-seven patients (15.4%) had DPR. Diabetes [odds ratio (OR) 1.89, 95% confidence interval (CI) 1.06-3.39], high body weight (> 86 kg vs. < 77 kg, OR 4.74, 95% CI 2.49-9.73), low aspirin dose (75-81 mg vs. ≥ 160 mg, OR 0.12, 95% CI 0.09-0.93) and high C-reactive protein (CRP) level (> 1.6 mg L⁻¹ vs. < 0.6 mg L⁻¹, OR 3.66, 95% CI 1.74-8.72) were independently associated with DPR, via increased TxB(2) levels, increased PRI, or both. These associations with TxB2 and PRI were reproduced across the whole population. With use of a factor-weighed score (c-index = 0.74), the predicted prevalence of DPR was 57% in the highest strata of the score as compared with < 4% for the lowest strata. CONCLUSIONS: Diabetes, body weight, the aspirin dose and CRP levels are readily available independent predictors of DPR, and some are potential targets for reducing its prevalence.

[Impact of Express study on clinical practice in ARDS patients: a single French ICU experience]. / Evolution des pratiques ventilatoires chez les patients en SDRA lors de la participation à un essai clinique randomisé: l'expérience d'une unité de réanimation française.

INTRODUCTION: The French Express study compared two alveolar recruitment managements (maximal versus standard) in Acute Respiratory Distress Syndrome (ARDS) patients ventilated with 6 ml/kg of ideal body weight (IBW). The objective of the present study was to assess in a single intensive care unit, the impact of Express study on the mechanical ventilation settings in non-included ARDS patients. PATIENTS AND METHODS: From 16 October 2002 to 14 January 2005 all consecutive eligible but non-included patients in Express study were studied. The maximal and minimal tidal volumes, and the minimal and maximal respiratory rates were retrospectively recorded. These parameters were compared according to the date of patient's admission and then the patients were separated in four quartiles (14, 15, 15, 15 patients). RESULTS: From the first to the last study period separated by 26 months, the mean maximal tidal volume decreased from 9.0+/-1.3 to 7.4+/-1.0 ml/kg of IBW (p=0.03), the proportion of patients ventilated with a maximal tidal volume greater than 8 ml/kg decreased from 93% to 20% (p<0.01), the median minimal respiratory rate increased from 14 to 18 b/min (p=0.03) and the proportion of patients with a respiratory rate less than 20 b/min decreased from 100% to 73% (p<0.01). There were correlations between the time of patient's admission and the maximal tidal volume (r=-0.43, p<0.01), the minimal tidal volume (r=-0.28, p<0.04) and the minimal respiratory rate (r=0.33, p<0.02). CONCLUSION: The participation in Express study led physicians to modify their mechanical ventilation settings. The maximal tidal volume decreased and the minimal respiratory rate increased in the ARDS eligible but non-included patients.

Reduction of the severe sepsis or septic shock associated mortality by reinforcement of the recommendations bundle: a multicenter study.

INTRODUCTION: We determined whether the implementation of a bundle of 10 recommendations leads to the reduction of mortality in ICU patients with severe sepsis or septic shock. METHODS: All patients with severe sepsis or septic shock during two consecutive phases: a 6-month quality control period (observational) and secondly a 6-month intervention period based on the implementation of a bundle of 10 recommendations adapted from the Surviving Sepsis Campaign guidelines (initial bacteriological samples and initiating antibiotics, measurement of arterial lactate, volume expansion > or =20 ml/kg, targeted mean arterial pressure > or =65 mmHg and the assessments of central venous pressure and Scv(O2); glucose control, low doses of corticosteroids, a tidal volume < or =8 ml/kg in mechanically ventilated patients with ALI; adequate use of recombinant human activated protein C) were evaluated in 15 ICUs. The primary endpoint was the 28-day mortality rate and the secondary endpoint was the compliance with the recommendations of the care bundle. MEASUREMENT AND RESULTS: Four hundred and forty-five patients (230 and 215 in the observational and intervention periods, respectively) were included. In the two periods, the patients had similar characteristics. The 28-day mortality rate significantly decreased from 40% in the observational period to 27% in the intervention period (P=0.02). According to each recommendation, compliance with the care bundle was achieved in 9 to 100% of patients. CONCLUSION: The implementation of a care bundle adapted from the Surviving Sepsis Campaign guidelines decreases the 28-day mortality rate in patients with severe sepsis and/or septic shock.

Paternal endothelial protein C receptor 219Gly variant as a mild and limited risk factor for deep vein thrombosis during pregnancy.

BACKGROUND: Half of all venous thromboembolism (VTE) cases during pregnancy are associated with a maternal thrombophilia. The influence of paternal genotype on the placenta and in the genesis of VTE has not been described. OBJECTIVES: To determine if the maternal and paternal Ser219Gly dimorphism of the endothelial protein C receptor (EPCR), evaluated through detection of the PROCR 6936G allele, is a risk factor for VTE during pregnancy. METHODS: Using a case-control study nested in the NOHA first cohort of primigravidae, 66 patient couples with a first episode of gestational VTE and randomly selected non-thrombotic control couples were investigated. For each couple, factor V gene (F5) G1691A, factor II gene (F2) G20210A, factor XII gene (F12) C46T and PROCR A6936G polymorphisms were determined. RESULTS: Only maternal F5 1691A, F2 20210A and F12 46T alleles were independently associated with iliac and infra-iliac deep vein thromboses (DVT). The maternal PROCR 6936G allele was a mild risk factor for iliac DVT (OR = 5.5 [2.3-13.0]). The paternal PROCR 6936G allele was also a mild independent risk factor for iliac DVT (OR = 2.6 [1.1-6.2]) and only during pregnancy (rather than postpartum) among maternal carriers of the F5 1691A allele (OR = 77.6 [4.2 to > 999.9]). CONCLUSIONS: The paternal PROCR 6936G allele could be a risk factor for maternal iliac DVT. Its impact was milder than the F5 1691A and F2 20210A polymorphisms in mothers. We hypothesize that the prothrombotic effect of the paternal PROCR 6936G allele is localized. Therefore, DVT during pregnancy may be influenced by trophoblastic cell-surface proteins inherited from both maternal and paternal alleles.

Clinical implications of clopidogrel non-response in cardiovascular patients: a systematic review and meta-analysis.

UNLABELLED: BSUMMARY BACKGROUND: Previous studies have shown an important risk of cardiovascular events in patients with clopidogrel biological non-response, and data have shown considerable, unexplored heterogeneity. OBJECTIVES: To evaluate the magnitude of cardiovascular risk associated with clopidogrel non-response and to explore heterogeneity. METHODS: This was a systematic review and meta-analysis of prospective studies of patients treated with clopidogrel for symptomatic atherothrombosis, evaluated by light transmission aggregometry with ADP and monitored prospectively for clinical ischemic events. RESULTS: Fifteen studies were included, totaling 3960 patients, of whom 25% were considered to be clopidogrel non-responders. The global relative risk (RR) for recurrent ischemic events in clopidogrel non-responders was 3.5 [95% confidence interval (CI) 2.4-5.2, P < 0.0001]. The results of the different studies were heterogeneous (Cochran P = 0.01 and I(2) = 52%). The most recent studies yielded lower RRs [global RR = 2.9 (95% CI 2.3-3.8) after 2007, and global RR = 6.6 (95% CI 3.7-11.9) before 2007, P = 0.01]. Heterogeneity was present in the group of studies in which more than 10% of patients took glycoprotein (GP)IIb-IIIa inhibitors [Cochran P = 0.003 and I(2) = 70%; RR = 3.8 (95% CI 2.9-5.1)] and was absent in the other studies [Cochran P = 0.88 and I(2) = 0; RR = 2.5 (95% CI 1.7-3.6)]. The RR was significantly higher in studies using higher ADP maximal aggregation cut-offs (> 65%) for clopidogrel non-response than in studies using lower cut-offs [RR = 5.8 (95% CI 3.2-10.3) and RR = 2.9 (95% CI 2.2-3.7), respectively, P = 0.03]. CONCLUSIONS: The risk of ischemic events associated with clopidogrel non-response is now more precisely defined. The risk is heterogeneous across studies, possibly because of an interaction with GPIIb-IIIa inhibitors and the use of different cut-offs to identify non-responders.

[Second surgery for glioblastoma. A 4-year retrospective study conducted in both the Montpellier and Nice Departments of Neurosurgery. A literature review]. / Intérêt d'une seconde chirurgie d'exérèse dans les glioblastomes. Etude rétrospective sur quatre ans aux centres hospitalo-universitaires de Montpellier et de Nice et revue de la littérature.

BACKGROUND AND PURPOSE: Glioblastoma, the most common malignant primary brain tumor in adults, is usually rapidly fatal. The current care standards for newly diagnosed glioblastoma consist, when feasible, in surgical resection, radiotherapy, and chemotherapy, as described in the Stupp protocol. Despite optimal treatment, nearly all malignant gliomas recur. If the tumor is symptomatic for mass effect, repeated surgery may be proposed. METHODS: We retrospectively analyzed the survival of patients with histologically confirmed primary glioblastoma (WHO grade 4) who were operated in two centers between January 2004 and December 2007. All patients who underwent a second resection for recurrent glioblastoma were included. RESULTS: During this period, 320 patients were operated in the two centers, with 240 surgical resections and 80 surgical biopsies. In the surgical resection group, 8.3% (20 patients) underwent a second surgical resection for glioblastoma. The mean age was 52 years. At the end of the study, seven patients were alive. The median survival was 24 months and progression-free survival was 7.5 months. CONCLUSIONS: The effect of resection of recurrent glioblastoma on survival has not been extensively studied. No randomized trials have been conducted. Our data were globally identical to other retrospective studies. Selected patients with recurrent glioblastoma may be candidates for repeated surgery when the situation appears favorable based on assessment of the individual patient's factors. Factors such medical history, neurological status, location of the tumor, and progression-free survival have been proven in retrospective studies to give better results.

Observational study of pregnant women with a previous spontaneous abortion before the 10th gestation week with and without antiphospholipid antibodies.

BACKGROUND: A clinical subtype of purely obstetrical antiphospholipid antibody (aPL-Ab) syndrome (APS) requires three or more unexplained consecutive embryonic losses before the 10th week of gestation associated with persistently positive lupus anticoagulant (LAC), and/or anticardiolipin IgG or IgM, and/or anti-beta2-glycoprotein I (abeta2GpI) IgG or IgM. Although this diagnostic classification of APS appeared to be the most sensitive, the APS-associated serological criteria are still debated. PATIENTS/METHODS: We prospectively observed the second pregnancy of 284 women with a previous embryonic loss, both with and without aPL-Ab. RESULTS: aPL-Ab-positive women were more prone to pregnancy loss, embryonic loss, pre-eclampsia, placental abruption and intrauterine fetal growth restriction. Type IIa aPL-Ab positivity (LAC present alone) was associated with the highest risk of recurrent embryonic loss and intrauterine growth restriction. Type I aPL-Ab positivity (combinations of aPL-Ab type positivity) was associated with the strongest risks of late complications, pre-eclampsia and placental abruption. Finally, abeta2GpI-M positivities were not clinically relevant in these women. CONCLUSION: Patients with a first unexplained pregnancy loss before the 10th week of gestation who are also positive for aPL-Abs have a higher risk of various complications in their second pregnancy. In this study, measurement of abeta2GpI-M had a questionable prognostic value.

Some hemostasis variables at the end of the population distributions are risk factors for severe postpartum hemorrhages.

BACKGROUND: Severe postpartum hemorrhages (PPH) represent a significant cause of maternal morbidity/mortality, but little is known about its hemostasis-related risk factors. Among the 32 463 women enrolled in the NOHA First cohort, 317 developed severe PPH (S-PPH group), 1269 non-severe PPH (NS-PPH group) and the remaining individuals were considered as control women (C group). METHODS: We performed a case-control study, including 317 triplets of women allocated from the three groups that shared the same clinical characteristics as the S-PPH group. RESULTS: From values obtained 6-9 months after delivery, low (but not-deficient) levels of fibrinogen, von Willebrand factor (VWF) antigen, factor (F) XI, platelet CD42b, TRAP-induced increase of platelet CD41a and high values of serum residual prothrombin activity or closure aperture times using the collagen-ADP cartridge on the PFA-100 system, and blood group O, were independently associated with a significant risk of severe PPH. Being positive for at least two of these eight variables was found in 1.6%, 3.5% and 20.8% of the women from the C, the NS-PPH and the S-PPH groups, respectively, the odds ratio for S-PPH in such a case being 16.4, 95%CI (6.5-41), P < 0.0001. CONCLUSIONS: Women with some hemostasis-related variables at the low or high end of the population distributions are prone to the severe forms of PPH. Clinical trials will allow us to know if acting on these risk factors can lower the clinical severity of PPH.

Impact of the use of propofol remifentanil goal-directed sedation adapted by nurses on the time to extubation in mechanically ventilated ICU patients: the experience of a French ICU.

AIM: Inappropriate sedation could prolong the duration of mechanical ventilation. The present "before-after" study assessed the impact of a goal-directed sedation using an algorithm with a combination of propofol and remifentanil on the time to extubation. METHODS: During 16 months, ICU-patients requiring sedation greater than 24 h were prospectively studied. In the first eight months, sedation was achieved using continuous infusions of a benzodiazepine (flunitrazepam or midazolam) and an opioid (fentanyl or sufentanil). In the following eight months, sedation using a propofol-remifentanil combination was given and adapted by the nurses according to the Ramsay score and a pain scale. The main endpoint was the time to extubation (from the cessation of sedation to extubation). The secondary endpoints were the duration of mechanical ventilation, the length of ICU stay, the ICU mortality rate, the need of vasopressive support, the occurrence of self-extubations and Ventilator-Associated Pneumonia (VAP). RESULTS: Forty-six and 39 patients were included in the first and second periods, respectively. The durations of sedation were similar. The time to extubation was shorter in the second period (10 versus 92h, p<0.0001). The duration of mechanical ventilation, the length of stay in ICU, the mortality rate, the need for vasopressor support and the occurrence of VAP were similar. Five self-extubations occurred in the second period versus one in the first one (p=0.02). CONCLUSION: Sedation with adapted infusions of propofol and remifentanil according to the Ramsay score and a pain scale decreases the time to extubation in ICU patients requiring sedation longer than 24h but increases the rate of self-extubations.

Access to electronic hepatitis C medical files by general practitioners.

OBJECTIVES: Hepatitis C virus (HCV) infection is a recognized public health issue in France. Institutional networks were created to improve healthcare practices and facilitate multi-disciplinary care for chronic diseases. The electronic medical file is one of the tools used by the networks to optimize patient care. METHODS: The main objective of this study was to determine what proportion of general practitioners in the Languedoc-Roussillon region of southern France would be interested in using the electronic medical files for patients with HCV infection. A random sample of 20% of the general practitioners in the region was selected and stratified by administrative district of practice. Among them, a telephone survey identified those interested in the hepatitis electronic medical files and following patients with hepatitis C. A more detailed questionnaire was sent to these interested physicians in order to obtain further information. RESULTS: Thirty-seven percent of the general practitioners concerned by the question followed patients with HCV infection. The advantages and disadvantages the physicians associated with use of these files were mostly related to the physician's age, attendance of continuing education courses and internet access. CONCLUSION: This study highlighted the fact that a significant number of general practitioners would be interested in accessing electronic medical files for patients with HCV infection. Considering these findings it might be useful to propose a working group including general practitioners and specialists in order to develop a concrete project for implementing electronic medical files for patients with HCV infection.

The number of lymph nodes is correlated with mesorectal morphometry.

BACKGROUND: Lymph node involvement is one of the most significant prognostic factors of patients with rectal cancer. However, the distribution of mesorectal lymph nodes is not well known. This study was designed to assess lymph nodes in the mesorectum and to evaluate the correlation between the volume and weight of the mesorectum and the number of lymph nodes. METHODS: The mesorectums of 20 human cadavers were studied. The volume and weight of the superior rectal mesentery, superior mesorectum and inferior mesorectum were measured. Lymph nodes were sought by manual dissection and were submitted for histological examination. The correlation between the number of lymph nodes and the volume and weight of the mesorectum was evaluated by non-parametric Spearman test. RESULTS: A total of 178 lymph nodes were identified. The mean number of lymph nodes per specimen was 9.2 +/- 4.5. The lymph nodes were mostly smaller than 3 mm and located in the superior and posterior parts of the mesorectum. A positive correlation was found between the number of mesorectal lymph nodes and the volume and weight of the mesorectum. The number of lymph nodes in the superior rectal mesentery was independent of its volume and its weight. CONCLUSIONS: Mesorectal lymph nodes are mainly located above the peritoneal reflection within the posterior mesorectum. The positive correlation between the volume or the weight of the mesorectum and the number of mesorectal lymph nodes should be considered as a possible means to determine the minimum number of mesorectal lymph nodes required for histological examination.

Additional direct medical costs of nosocomial infections: an estimation from a cohort of patients in a French university hospital.

We estimated the direct additional medical costs of nosocomial infections (NI) using a cohort study in acute and longer-term care at Nîmes University Hospital in France. Patients hospitalised between May 2001 and January 2003 with NI were considered as exposed; all others were eligible as non-exposed. Thirty patients were randomly chosen for each site of infection: respiratory tract, bloodstream, surgical site, urinary tract and other sites for a total of 150 exposed patients. Each exposed patient was matched with a non-exposed patient according to gender, age, severity of the underlying disease, diagnosis according to hospital discharge records, ward type and length of hospitalisation before inclusion. Additional direct medical costs for the exposed patients compared to the non-exposed and the difference between actual costs and the diagnosis-related group rate were measured. Costs resulting from laboratory tests, radiology, surgery and exploratory examinations, and antimicrobial agents were estimated to be Euro2421 for a respiratory tract infection, Euro1814 for a surgical site infection, Euro953 for a bloodstream infection and Euro574 for a urinary tract infection. Total additional costs of NI (direct medical costs and costs of extra length of stay) in acute care were estimated to be up to Euro3.2 million per year (95% confidence interval: 2,275,063-4,132,157). In conclusion, both prevention of avoidable NI and better estimation of the actual costs of NI should be priorities for all healthcare facilities.

[In vitro fertilization and smoking: use of urinary cotinine and expired air carbon monoxide measurements]. / Fécondation in vitro et tabac: intérêt de la cotininurie et de l'analyseur de monoxyde de carbone expiré.

OBJECTIVE: To study the correlation between expired air carbon (EACO) and urinary cotinine, and to determine the impact of tobacco smoking on in vitro fertilization (IVF) results. PATIENTS AND METHODS: We studied prospectively 221 patients in our ART center from October 2002 to October 2004: 51 active smokers, 85 passive smokers, and 85 non-smokers. Patients were classified into active, passive smokers, or non-smokers, based on a questionnaire. We measured urinary cotinine and EACO on the embryo transfer day and we recorded the IVF parameters. RESULTS: Two hundred and twenty-one patients were included. We observed a 17.2% reduction of estradiolemy (P=0.05), a 1.5% reduction of pregnancies (NS), a 7.8% reduction of infants born alive (NS), a 28.5% reduction of twin pregnancies (P=0.06), as well as a 10% increase of miscarriages (NS) in the active smokers in comparison with non-smokers (the same trends were observed between active and passive smokers). EACO and urinary cotinine were well correlated. There was a negative correlation between estradiolemy and urinary cotinine (R=-0.15, P=0.02). DISCUSSION AND CONCLUSION: Tobacco smoking intensity may be dilatory on IVF results. There is a high correlation between EACO and urinary cotinine. Other larger studies would probably obtain results more statistically significant.

[General practitioners' and intensivists' relationships: intensivists' point of view from eight French southern regional areas]. / Relations entre médecin traitant et médecin réanimateur: l'opinion des réanimateurs de huit départements du sud de la France.

OBJECTIVES: Assessment of relationship between general practitioners and intensivists. STUDY DESIGN: Intensivists were questioned by phone from June 14th to September 28th 2004. METHODS: 245 out of 264 intensivists from 8 French Southern regional areas were questioned concerning their relationship with critically ill patients' general practitioner. RESULTS: Patients were mainly admitted into Intensive care Unit (ICU) from the Emergency Department (55%). An information letter from the general practitioner was reported for 20% of admitted patients but 50% of these letters was assumed as not informative. The informations concerning the patient's medical history, therapies, and disease leading to admission and the patient's status were assessed with 6.5, 7.0, 6.0 and 2.0, respectively (maximal note=10). The intensivists contacted the general practitioner for 30% of admitted patients. During the stay in ICU, 33% general practitioners were reported to request informations by phone or visit in ICU. When the stay in ICU was>10 days, the general practitioner was nearly never regularly informed about patient's status. When the patient was discharged from the ICU, 80% of intensivists used an exhaustive typed report to inform the general practitioner. The overall relationship between the general practitioner and the intensivist was assessed as 5.5/10. Insufficient information in the general practitioner's letter at admission, the lack of request for information during the stay in ICU, the lack of contact with the general practitioner by the intensivist and an intensivist's age between 46 and 55 were associated with a relationship assessment<4/10).

Factor V Leiden and prothrombin G20210A polymorphisms as risk factors for miscarriage during a first intended pregnancy: the matched case-control 'NOHA first' study.

Factor V Leiden (FVL) and prothrombin G20210A (FIIG20210A) mutations are associated with a higher risk of miscarriage: we sought to understand whether this association differs by clinical time of unexplained miscarriage, and by ethnic origin, among women with no previous thrombotic episode, during the first intended pregnancy. We performed a case-control study nested in a cohort of 32 683 women. We analyzed 3496 pairs of women matched for classical confounding factors. The FVL and FIIG20210A mutations were associated with an increased risk of miscarriage in Caucasian women [odds ratio (OR) 3.19, 95% confidence interval (CI) 2.37-4.30, P < 0.001 and OR 2.36, 95% CI, 1.72-3.24, P < 0.001, respectively]. Among non-Caucasian women, the mutations were rare and the associations with risk of miscarriage less clear. FVL and FIIG20210A mutations were independent risk factors for miscarriages only for women with related clinical signs occurring from the 10th week of gestation on (OR 3.46, 95% CI 2.53-4.72, P < 0.001 and OR 2.60, 95% CI 1.86-3.64, P < 0.001, respectively). These results indicate that FVL and FIIG20210A mutations are associated with a significant risk of spontaneous abortion which clinical signs occur from the 10th week on of the first intended pregnancy.