[Orofacial manifestations of systemic sclerosis: A study of 30 consecutive patients]. / Les manifestations buccofaciales de la sclérodermie systémique : étude de 30 patients consécutifs.

INTRODUCTION: The face is frequently involved in systemic sclerosis. The main stomatologic manifestations include limited mouth opening, xerostomia, skin atrophy, trigeminal neuralgia. The objective of this study was to describe oral and facial manifestations observed in scleroderma patients from our cohort. METHODS: Between March and October 2006, a stomatologic consultation was included in the follow-up of scleroderma patients seen during consultation or daily hospital in internal medicine or dermatology units. Demographic, clinical and biological data were collected. Stomatologic examination comprised measure of the mouth opening, sugar's and Schirmer's tests, orthopantomogram analysis, and evaluation of the repercussion of symptoms on quality of life using a visual analogical scale (VAS between 0 and 10). RESULTS: This study included 30 patients (women 87 %, mean age 58.6 + or - 13.6 years). Mean duration of systemic sclerosis (n=20 limited cutaneous form, n=10 diffuse form) was eight years. Stomatologic manifestations were: skin atrophy (n=28), peribuccal rhagades (n=25), telangiectasia (n=21), decreased mouth opening (n=20), xerostomia (n=20), xerophtalmia (n=16), periodontal ligament space widening (n=10), bone resorptions (n=2), trigeminal neuralgia (n=1). Xerostomia was considered more discomforting (mean VAS=3.8) than decreased mouth opening (mean VAS=2.6). Xerostomia was the second more discomforting sign of scleroderma and was significantly associated to the limited cutaneous form (p=0.045) and to anticentromeres antibodies expression (p=0.002). Decreased mouth opening was correlated to oesophageal involvement (p=0.025). CONCLUSION: Oral and facial manifestations are frequently observed in scleroderma patients. These manifestations lead to major functional discomfort, mainly due to decreased mouth opening that seems to be frequently associated to oesophageal involvement. Xerostomia is also frequent and is commonly observed in anticentromere antibodies positive cutaneous limited forms of systemic sclerosis. Evolution of radiographic abnormalities like periodontal ligament space widening (33 % of cases), or osteolytic lesions (7 %) is poorly known.

[Orofacial manifestations of systemic sclerosis: a study of 30 consecutive patients]. / Les manifestations buccofaciales de la sclérodermie systémique: étude de 30 patients consécutifs.

INTRODUCTION: The face is frequently involved in systemic sclerosis. The main stomatologic manifestations include limited mouth opening, xerostomia, skin atrophy, trigeminal neuralgia. The objective of this study was to describe oral and facial manifestations observed in scleroderma patients from our cohort. METHODS: Between March and October 2006, a stomatologic consultation was included in the follow-up of scleroderma patients seen during consultation or daily hospital in internal medicine or dermatology units. Demographic, clinical and biological data were collected. Stomatologic examination comprised measure of the mouth opening, sugar's and Schirmer's tests, orthopantomogram analysis, and evaluation of the repercussion of symptoms on quality of life using a visual analogical scale (VAS between 0 and 10). RESULTS: This study included 30 patients (women 87%, mean age 58.6+/-13.6 years). Mean duration of systemic sclerosis (n=20 limited cutaneous form, n=10 diffuse form) was eight years. Stomatologic manifestations were: skin atrophy (n=28), peribuccal rhagades (n=25), telangiectasia (n=21), decreased mouth opening (n=20), xerostomia (n=20), xerophtalmia (n=16), periodontal ligament space widening (n=10), bone resorptions (n=2), trigeminal neuralgia (n=1). Xerostomia was considered more discomforting (mean VAS=3.8) than decreased mouth opening (mean VAS=2.6). Xerostomia was the second more discomforting sign of scleroderma and was significantly associated to the limited cutaneous form (p=0.045) and to anticentromeres antibodies expression (p=0.002). Decreased mouth opening was correlated to oesophageal involvement (p=0.025). CONCLUSION: Oral and facial manifestations are frequently observed in scleroderma patients. These manifestations lead to major functional discomfort, mainly due to decreased mouth opening that seems to be frequently associated to oesophageal involvement. Xerostomia is also frequent and is commonly observed in anticentromere antibodies positive cutaneous limited forms of systemic sclerosis. Evolution of radiographic abnormalities like periodontal ligament space widening (33% of cases), or osteolytic lesions (7%) is poorly known.

Multicentre European study of thalamic stimulation for parkinsonian tremor: a 6 year follow-up.

AIM: To evaluate the results of ventral intermediate (Vim) thalamic deep brain stimulation (DBS) in patients with tremor predominant Parkinson's disease (PD) at 6 years post surgery. METHODS: This was a prolonged follow-up study of 38 patients from eight centres who participated in a multicentre study, the 1 year results of which have been published previously. Total scores as well as scores for individual items of the motor part and the disability part of the Unified Parkinson's Disease Rating Scale were used for evaluation. RESULTS: Tremor was still effectively controlled by DBS and appendicular rigidity and akinesia remained stable compared with baseline. Axial scores (speech, gait and postural instability), however, worsened, and in parallel the initial improvement in activities of daily living scores at the 1 year follow-up had disappeared at 6 years, despite sustained improvement of tremor. Remarkably, neither daily doses of dopaminergic medication nor fluctuations and dyskinesias had changed at 6 years compared with baseline in this particular patient group. CONCLUSION: This study confirms that patients with tremor dominant PD who do not present with fluctuations and dyskinesias may have a relatively benign progression of the disease. Vim DBS, although having no effect on akinesia and rigidity, is a relatively lenient surgical procedure and may still have a place for long term symptomatic control of PD tremor in selected patients.

Heredity: a prognostic factor for acne.

BACKGROUND: The role of heredity in acne severity and therapeutic response remains unclear. OBJECTIVE: A prospective epidemiologic study was performed to compare clinical and evolutive features of acne and response to treatment in 151 patients with acne with (A+) or without (A-) family history of acne. METHODS: A+ and A- patients were compared on clinical and therapeutic criteria. A+ patients were then distributed into subgroups (M+, F+, M+F+) following the origin of family history (father: F, mother: M). RESULTS: The clinical profile was similar in the A+ and A- populations. Acne occurred earlier and more often before puberty in the A+ population, in which oral treatments and relapse after isotretinoin were more frequent. Retentional lesions (number and extent) were more important in the M+ and M+F+ populations. CONCLUSION: This study confirms the importance of heredity as a prognostic factor for acne. Family history of acne is associated with earlier occurrence of acne, increased number of retentional lesions and therapeutic difficulties.

Prospective study of risk factors of relapse after treatment of acne with oral isotretinoin.

BACKGROUND: The effectiveness of oral isotretinoin against acne is undeniable. However, few data on the maintenance of effect after treatment termination have been published. OBJECTIVE: The purpose of the study was to identify the risk factors of relapse after stopping isotretinoin. METHOD: This prospective open study examined 52 patients with moderate to severe acne at the Dermatological Clinic of the Nantes University Hospital (France). Variables likely to influence relapse were studied using the Cox model. RESULTS: 27 patients (52%) relapsed after stopping treatment. In multivariate analysis, severe seborrhoea and a high score of inflammatory lesions at the end of the treatment, an early age, a family history of acne, prepubertal acne and acne extended to the trunk were the factors increasing significantly the risk of relapse. CONCLUSION: Our data allow to define more precisely the profile of acne patients for whom the risk of relapse is highest and who should therefore be followed up quite regularly after treatment termination.

[Local guidelines and quality of antibiotic treatment in urinary tract infections: a clinical audit in two departments of a university hospital]. / Impact de recommandations locales sur la qualité de l'antibiothérapie dans l'infection urinaire. Audit clinique dans 2 services d'un hôpital universitaire.

AIM: To assess the effect of local guidelines implemented at the Nantes University Hospital regarding antibiotic therapy for urinary tract infections. DESIGN: Before/after study of one medical ward and one urologic surgery ward. Quality was measured by two principal criteria: compliance with guidelines and medical justification in the specific clinical situation. Both criteria considered simultaneously the choice of drug, dose and duration of treatment. Deviations from the guidelines were described. RESULTS: 1086 UTI cases were identified over two 12-month periods, before and after the dissemination of guidelines (for prostatitis, pyelonephritis, indwelling catheter-associated UTIs, and other undefined UTIs). The guidelines were applicable in 313 (30%) cases. Overall, after implementation of the guidelines, the percentage of justified prescriptions did not change significantly (41.8% compared with 38.7%, p=0.299), but the percentage of correct (conforming) prescriptions fell (from 30.4% to 15.7%, p=0.0022). The percentages of correct and justified prescriptions differed in the medical (respectively 45.0% and 46.6%,) and surgical units (13.1% and 36.5%). CONCLUSIONS: Issuing guidelines does not necessarily improve the quality of antibiotic therapy for UTIs in hospitals.

[Adequate prescription of antibiotic therapy for urinary tract infections in hospital: identifying and correcting non-observance of guidelines]. / Bonnes pratiques de prescription des antibiotiques pour la prise en charge des infections urinaires en milieu hospitalier: identification des écarts aux recommandations et actions correctrices.

OBJECTIVE: We analyzed the adequacy of antibiotic therapy prescribed for urinary tract infections (UTI): prostatitis, pyelonephritis, indwelling catheter-associated UTIs, or other undefined UTIs. DESIGN: The adequacy of prescriptions to local guidelines was assessed retrospectively in two wards (Internal Medicine and Surgical Urology) of the Nantes University Hospital. The principal criteria involved simultaneously: choice of the molecule, dose, and treatment duration. Non-observances of guidelines were major (non-adequacy of the molecule, prescription of a non-active molecule according to in vitro susceptibility tests, non-appropriate treatment abstention), or minor (non-justified treatment, non-justified bitherapy, no prescription of bitherapy when requested, no treatment adaptation when requested, too short or too long treatment length, dosage mistakes). RESULTS: One thousand eighty-six infections were collected over a 24-month period. The overall rate of adequate prescriptions was 40.1% (46.6% in Internal Medicine and 36.5% in Surgical Urology). In Internal Medicine (226 non observance among 389 prescriptions), the ratio of major non-observance of guidelines was 9.8%. Among them, 44.7% were non-appropriate treatment abstentions. In Surgical Urology (539 non observance out of 695 prescriptions), non-observance related to treatment length were the most frequent. The ratio of major non-observance was 19.9%. Among them, non-adequacy of the molecule reached 60.7%. Non-justified treatment and non-appropriate bitherapies were frequent. CONCLUSIONS: For both units, indwelling catheter-related UTIs and other UTIs accounted for more than 50% of the infections although not detailed in the local guidelines. Identifying and analyzing Non observance may lead to targeted correcting actions to improve prescription quality.

[French residents in anaesthesia and critical care - a nationwide survey]. / Les internes en anesthésie-réanimation - une enquête nationale.

OBJECTIVE: We surveyed the residents in their first (R1) and fourth (R4, last) years of residency in anaesthesia and intensive care in France. METHODS: The questionnaires mailed to each resident were designed to obtain personal data, motivation for specializing in anaesthesia and their opinion of their training. RESULTS: The response rates were 48% for the R1 residents and 77% for the R4 residents. There were 40% females in this population and the R1 residents were 25 +/- 1 year old, 29 +/- 2 year-old for the R4 residents. Almost half (46%) of the R1 responders were married as were 74% of the R4 residents. They spent an average of 726 each year on books, computers and other educational items. Most (71%) had opted for anaesthesia after considering other medical specialties, but only 12% had considered surgery. Half (51%) were on a training program that was far away from their home. They thought highly of their training, with the clinical training being rated above the non-clinical component. About half of them had obtained specialized certificates (mainly additional certification in intensive care and antibiotic therapy) during their residency. Two thirds of those in R4 expected to work in a public hospital and about one third expected to work in intensive care. Money was an important factor in their choice of profession. A majority planned to remain in the area where they had graduated in anaesthesia after their residency. Finally, 96% declared that they would choose anaesthesia again if they had to do so. CONCLUSION: French residents in anaesthesia are satisfied of their initial choice for anaesthesia and don't regret it at the end of their residency training.

Human papillomavirus and extragenital in situ carcinoma.

BACKGROUND: The relation between human papillomavirus (HPV) and extragenital Bowen's disease (BD) is controversial. METHODS: This study used in situ hybridisation to evaluate the rate of HPV in extragenital cutaneous BD and investigated possible relations with immune status and exposure of skin to light. RESULTS: HPV DNA was detected in 58% of 69 samples from 50 patients. The percentage of HPV detection was not significantly higher in exposed (55%) than unexposed areas (65%), and no difference in HPV rate was found between immunosuppressed and immunocompetent patients. CONCLUSION: Thus, this study confirms the high rate of HPV detection in extragenital cutaneous BD and suggests that there is no apparent relation concerning exposed areas and immune status.

[Voice recognition applied to ICU medical reports]. / Logiciel de reconnaissance vocale pour les comptes rendus d'hospitalisation de réanimation.

OBJECTIVE: Medical reports in ICU are usually tape recorded and then typed by transcriptionist. Digital voice recognition (DVR) has considerably improved and may be a time saving method. The purpose of this study was to test IBM Viavoice (Pro Edition, Release 8, French version) for the generation of medical reports in a surgical intensive care unit. METHODS: A senior resident (Int) in anaesthesia, a senior academic (AS) anaesthesiologist and a confirmed medical secretary (Sec) all working in the same surgical ICU participated to the study. First, Int and AS trained Viavoice according to the software requirements. Then 60 medical records (text files) served to automatically train the software. For the study, we prospectively used 20 consecutive medical records, which had been dictated on tape by either Int or AS. The transcription time by Sec, the number of typing errors and time needed for corrections were recorded. Int and AS with Viavoice processed the same records. Turnaround time and errors were assessed for comparison to Sec work. RESULTS: Accuracy was 97, 92 and 95% for Sec, Int and AS, respectively. Transcription by Viavoice was always significantly faster whatever the speaker than conventional transcription by a secretary. However, Int required significantly longer time to correct recorded text than did Sec and AS. The total turnaround time was significantly faster for AS than Sec (p < 0.01) but Int did not differ from Sec. The performance of Viavoice did not rise with the number of records. CONCLUSION: Viavoice is as efficient as a confirmed transcriptionist.

Prognostic factors in Sézary syndrome: a study of 28 patients.

BACKGROUND: The new European Organization for Research and Treatment of Cancer classification considers Sézary syndrome (SS) among the aggressive epidermotropic cutaneous T-cell lymphomas (ECTLs). Recent technological advances have facilitated the diagnosis of this disease, but it remains practically incurable, with a median survival of about 2.5-5 years. Deaths are due in part to the iatrogenic effects of treatments, which suggests that the management of SS could be improved. OBJECTIVES: Retrospectively to study the prognostic criteria related to disease progression. METHODS: Thirty patients with SS were followed up in the Dermatology Department of the University Hospital in Nantes, France, between January 1989 and May 2000. The diagnosis of SS was based on at least three of the following criteria: erythroderma, histological evidence of ECTL, a level of 20% or more circulating Sézary cells, and loss of My7 antigen expression by basal cells of the epidermis. Two patients not seen again after the initial diagnosis were excluded from the statistical study. RESULTS: The median disease-specific survival of the 28 patients was 64.55 +/- 10.11 months. The prognostic factors found in univariate analysis were age at diagnosis (P = 0.0109), interval before diagnosis (P = 0.0566), lactate dehydrogenase (LDH) level (P = 0.042) and presence of the Epstein-Barr virus (EBV) genome (BHLF in in situ hybridization) in skin (P = 0.0079). The prognostic factors found in multivariate analysis were age, interval before diagnosis and presence of the EBV genome in keratinocytes. A decreased number of Langerhans cells in the epidermis did not appear to be a prognostic factor. CONCLUSIONS: Our study confirms the prognostic value of age and LDH level, and for the first time demonstrates the prognostic value of the identification of the EBV genome in the skin. This seems consistent with a marked immune deficit during severe forms of SS.

Prognostic factors in acute cardiogenic pulmonary edema.

The purpose of this study was to determine the clinical and biological findings at admission in the Department of Emergency Medicine associated with a poor prognosis, and to evaluate early response to treatment as a prognostic factor. It was a prospective cohort study with a 5-month follow-up. One hundred eighty-six patients admitted for acute cardiogenic pulmonary edema were included. Features were analyzed at the admission and on response to initial treatment. The main outcome measure was survival at 2 end-points: hospital discharge, and 5 months of follow-up. Multivariate analysis showed that in-hospital mortality was associated with marbleization (mottling) odd-ratio (OR) = 9.0), low diuresis (OR = 4.0), high breath rate 6 hours after admission (OR = 4.0), and chronic digoxin use (OR = 3.39). Five-month mortality was associated with a bedridden state (OR = 9.0), marbleization (mottling) (OR = 5.5), myocardial infarction (OR = 3), and poor early response to initial treatment (OR = 3.2). In addition to well-known factors, the response to initial treatment evaluated 6 hours after admission was a major determinant of outcome.

Long-term follow-up in 51 patients with mycosis fungoides and Sézary syndrome treated by interferon-alfa.

Although interferon-alfa (IFN-alpha) has proved effective in treating epidermotropic cutaneous T-cell lymphoma (ECTL), few studies have considered the follow-up of treated patients and whether complete remission was maintained. We studied 51 patients (one stage Ia, seven stage Ib, one stage IIa, 30 stage IIb, 11 stage III (Sézary syndrome) and one stage IV) who received low-dose IFN-alpha as monotherapy for ECTL (mean daily dose of IFN-alpha 2.7 x 106 units for 14.9 months), giving special consideration to the significance of My7 (CD13) antigen expression by epidermal basal cells in predicting the maintenance of complete remission. For a mean follow-up period of 43.4 months, the results showed 21 complete remissions, 13 partial remissions and 17 patients with stable or progressive disease. Twelve patients died during the follow-up (3-52 months). IFN-alpha led to an improved response in the early stages, with a greater number of complete remissions (P = 0.03) and partial remissions (P = 0.01). The mean time to complete remission was 4 months, regardless of clinical stage (P = 0.1). Of 21 patients in complete remission, 57% had a relapse within a mean period of 7.5 months. For patients maintained in complete remission, the mean period of response was 31 months. The length of complete remission was independent of clinical stage, and My7 antigen expression was not predictive of complete remission.

Increased pancreatic islet blood flow in 48-hour glucose-infused rats: involvement of central and autonomic nervous systems.

The pancreatic islet blood flow of rats 24 h after a prolonged (48-h) glucose infusion was investigated using a nonradioactive microsphere technique. In the basal state, islet blood flow was significantly increased in previously hyperglycemic rats (HG) compared to that in controls (C). During an i.v. glucose challenge, both plasma insulin and islet blood flow were increased in the two groups, but these increases were significantly higher in HG than in C rats. Although less pronounced, the results were similar when glucose was injected into the carotid artery toward the brain at a dose that did not modify the peripheral glucose level. The effect of this intracarotid injection was abolished after bilateral subdiaphragmatic vagotomy in both C and HG rats. Furthermore, in the latter group, both plasma insulin concentration and islet blood flow returned to values similar to those observed in the basal state in C rats. After pretreatment with the alpha2-adrenoceptor agonist clonidine, the insulin response to the intracarotid glucose load was totally blunted in the two groups of rats. By contrast, whereas such a pretreatment lowered the glucose-induced increase in islet blood flow in C rats, it was without effect in HG rats. These data suggest that a period of hyperglycemia and/or hyperinsulinemia is sufficient to induce a perturbation of pancreatic islet blood flow, which appears to be mainly due to an increased parasympathetic activity, whereas the decrease in sympathetic tone does not play a role. These modifications in autonomic nervous system activity could be due to alterations in some brain areas involved in "glucose sensing."

Replacement fluids in plasmapheresis: cross-over comparative study.

OBJECTIVE: To compare the tolerance and the cost of three replacement fluids in plasmapheresis: albumin 4% alone, albumin 4% + dextran 40, or albumin 4% + hydroxyethylstarch 6%. DESIGN: A one center randomized, cross-over, comparative study designed to explore the tolerance and the colloid oncotic pressure in patients undergoing plasmapheresis. PATIENTS: 225 plasmapheresis procedures were performed in 27 patients. MEASUREMENTS AND RESULTS: Hemodynamic tolerance was good in the three treatment groups. Serum protein concentration after plasmapheresis was significantly lower in the albumin + hydroxyethylstarch group, followed by albumin + dextran 40, versus albumin alone. Colloid oncotic pressure before and after exchange was similar in the three groups. CONCLUSIONS: The clinical use of 25-30% of hydroxyethylstarch 6% or dextran 40 with albumin 4% was clinically well tolerated and associated with a 12% decrease of the cost of substitution solutions.

Increased anti-Epstein-Barr virus antibodies in epidermotropic cutaneous T-cell lymphoma: a study of 64 patients.

Epstein-Barr virus (EBV) is often associated with non-Hodgkin's T-cell lymphomas and has recently been found in the lesions of mycosis fungoides and Sézary syndrome. We sought to determine whether the anti-EBV antibody profile was disturbed in mycosis fungoides and Sézary syndrome and whether there are particular profiles characteristic of disease stage. Anti-EBV antibodies (anti-VCA, -EA and -EBNA) were studied in the sera of 64 patients. An immunoenzymatic technique was used, and the results were compared with the same number of age- and sex-matched healthy controls. Patients with mycosis fungoides and Sézary syndrome developed higher anti-VCA antibody titres (median 1200) than controls (median 320). Thirty-seven patients had anti-VCA > or = 1200 vs. 19 controls (P < 0.01). These elevated anti-VCA antibody titres were associated with positive EA in 19 patients versus three controls. No differences were found between the illness stages. Anti-EBV antibodies were most often found in mycosis fungoides and Sézary syndrome when the serological profile was similar to that of cellular immune deficiencies and EBV-related non-Hodgkin's lymphoma. EBV could be involved, either directly on lymphocytes or, more likely, indirectly by chronic antigenic stimulation.

[Uni- and multivariate analysis of predictive survival factors in hepatocellular carcinoma. A study of a series of 122 patients]. / Analyses uni- et multivariée des facteurs prédictifs de survie des carcinomes hépatocellulaires. Etude d'une série de 122 patients.

The files of 122 patients hospitalized for hepatocellular carcinoma (HCC) were reviewed retrospectively to study survival as a function of treatment and different peri-therapeutic factors. Cirrhosis was certain or probable in 69 cases. Laparotomy was performed 77 times (13 exploratory, 64 excisions). Chemoembolization with Adriamycine was performed 18 times. Median survival was 11.6 months. The factors influencing survival in monovariate analysis were the Child-Pugh stage (p < 0.0001), the Okuda stage (p < 0.0001), ascites (p < 0.001), a post-operative complication (p < 0.0001), gamma-glutamyltransferase level (p < 0.0037), tumor site (p < 0.004), albuminemia (p < 0.008), alkaline phosphatase concentration (p < 0.0087), number of tumors (p < 0.01), portal thrombosis (p < 0.01) and alpha-foetoprotein level (p < 0.01). In multivariate study, the Okuda stage (p < 0.001), age (p < 0.001) and portal thrombosis (p < 0.037) remained significant. The Okuda 1 group was also considered in multivariate study, in which case only patient age and the possibility of therapeutic excision were significant factors. In our opinion, the Okuda classification, which is easy to establish, should be adopted for pretherapeutic evaluation of patients with hepatocellular carcinoma.