[Burnout syndrome among third year medical students in Caen: Prevalence and associated factors]. / Syndrome de burn out chez les étudiants en pré-externat de la faculté de médecine de Caen : prévalence et facteurs associés.

BACKGROUND: Burnout syndrome is a reality in health professions. Many studies report a growing and alarming exhaustion among doctors and residents in France. However, medical studies deemed to be stressful, medical students could be also affected by this syndrome. Few studies are conducted in France at this stage of training, so we will focus our study on the sensitivity to burnout syndrome of students in pre-clerkship. METHODS: This is a descriptive cross-sectional study involving 312 students in their third year of medical school in Caen, France. These students answered a questionnaire about their lifestyle and their course, and two pre-established questionnaires, the MBI-test with the emotional exhaustion subscale (EE score) tracking burnout and the GHQ-28 evaluating psychiatric morbidity not psychotic. RESULTS: More than 4 in 10 (42.6%) students had a high EE score and a positive GHQ-28 score. More than one student in two (59.8%) had a moderate to high emotional exhaustion score. Likewise for the GHQ-28 score, 53.4% of students had a positive score. In addition, nearly one in three students (29.8%) felt threatened by burnout. Finally, various factors appeared to be related to burnout: female gender, wanting to stop studying, lack of support or changes in appetite. CONCLUSION: Burnout is a reality and many factors are associated with it. The study has allowed us to study its factors more closely to get a better understanding but many parameters remain uncertain and deserve more investigation. However, we must continue to act and implement care and support for students at risk. In the same way, it is necessary to sensitize and train students for a primary prevention against burnout from the first cycle of medical studies.

Rate of caesarean sections according to the Robson classification: Analysis in a French perinatal network - Interest and limitations of the French medico-administrative data (PMSI).

INTRODUCTION: The objective of our study was to determine, in accordance with WHO recommendations, the rates of Caesarean sections in a French perinatal network according to the Robson classification and determine the benefit of the medico-administrative data (PMSI) to collect this indicator. This study aimed to identify the main groups contributing to local variations in the rates of Caesarean sections. MATERIAL AND METHODS: A descriptive multicentric study was conducted in 13 maternity units of a French perinatal network. The rates of Caesarean sections and the contribution of each group of the Robson classification were calculated for all Caesarean sections performed in 2014. The agreement of the classification of Caesarean sections according to Robson using medico-administrative data and data collected in the patient records was measured by the Kappa index. We also analysed a 6 groups simplified Robson classification only using data from PMSI, which do not inform about parity and onset of labour. RESULTS: The rate of Caesarean sections was 19% (14.5-33.2) in 2014 (2924 out of 15413 deliveries). The most important contributors to the total rates were groups 1, 2 and 5, representing respectively 14.3%, 16.7% and 32.1% of the Caesarean sections. The rates were significantly different in level 1, 2b and 3 maternity units in groups 1 to 4, level 2a maternity units in group 5, and level 3 maternity units in groups 6 and 7. The agreement between the simplified Robson classification produced using the medical records and the medico-administrative data was excellent, with a Kappa index of 0.985 (0.980-0.990). CONCLUSION: To reduce the rates of Caesarean sections, audits should be conducted on groups 1, 2 and 5 and local protocols developed. Simply by collecting the parity data, the excellent metrological quality of the medico-administrative data would allow systematisation of the Robson classification for each hospital.

Use of censored data to monitor surgical-site infections.

OBJECTIVE: To take into account the proportion of patients lost to follow-up when calculating surgical-site infection (SSI) rates. DESIGN: A multicenter SSI monitoring network in Basse-Normandie, France, using the definitions for SSI of the National Nosocomial Infections Surveillance System of the Centers for Disease Control and Prevention. PATIENTS: Between January 1, 1998, and December 31, 1999, 3,705 patients were operated on in 25 units of 10 institutions. RESULTS: Of the patients, 41.2% (range, 5.1% to 95.5%) were seen 30 days or more after their operation. The global SSI attack rate was 2.19% (95% confidence interval, 1.72% to 2.66%). With the use of the Kaplan-Meier method, the incidence rate was 3.11% (95% confidence interval, 3.06% to 3.16%). The difference between the attack rate and the Kaplan-Meier incidence rate for each unit varied according to the percentage of patients seen on or after day 30 postoperatively and the number of SSIs diagnosed in patients seen on or after day 30. CONCLUSIONS: Practice guidelines are needed for the international monitoring for postdischarge SSIs and the calculation of SSI rates. The proportion of patients seen 30 days after their operation is a major quality criterion for SSI monitoring and should be routinely given in monitoring reports, oral communications, and publications to compare results obtained by different teams

Randomized multi-centre trial of the effects of a catheter coated with hydrogel and silver salts on the incidence of hospital-acquired urinary tract infections.

Catheters coated with hydrogel and silver salts have been proposed to prevent hospital-acquired urinary tract infections (UTI). We carried out a randomized, prospective, double-blind multi-centre trial to compare those catheters with classical urinary tract catheters. We included in the study 199 patients requiring urethral catheterization for more than three days: 109 in group 1 (classical catheter) and 90 in group 2 (catheter coated with hydrogel and silver salts). Urine from the patients was tested for 10 days after the insertion of the catheter (reactive dipsticks each day and diagnostic urinalysis every two days). The UTI associated with catheterization was defined on the basis of bacterial and cytological criteria (>10(5)cfu bacteria per mL and >10 leucocytes per mm(3)). Twenty-two UTIs were recorded: 13 in group 1 and nine in group 2. The cumulative incidence of UTI associated with catheterization was 11.1% overall, 11.9% for group 1 and 10% for group 2; the odds ratio was 0.82 (95% confidence interval: 0.30 to 2. 20); the cumulative incidence for UTI, calculated by the Kaplan-Meier method was 36.3 overall, 35.2 in group 1 and 36.0 in group 2; the overall incidence density was 19 per thousand days of catheterization, 21 in group 1 and 18 in group 2. The differences between the two groups were not significant. Overall, we feel that there is not enough evidence to conclude that catheters coated with silver salts and hydrogel give greater protection than classical catheters and to recommend widespread use.

Influence of rural environment on diagnosis, treatment, and prognosis of colorectal cancer.

STUDY OBJECTIVE: Several studies have shown that residential location (urban or rural) influences the incidence of colorectal cancer. The aim was to investigate the influence of rural environment on colorectal cancer history and survival in a well defined population. DESIGN: Patients with colorectal cancer diagnosed in the department of Calvados (France) were classified by place of residence (urban/rural) and information on clinical symptoms, tumour extension, treatment, and survival was collected. SETTING: The study was population based, in the department of Calvados in France. PATIENTS: During 1978-1984, 1445 colorectal cancers were collected by the Digestive Tract Cancer Registry of Calvados, 1047 with an urban place of residence (544 males and 503 females) and 284 with a rural place of residence (134 males and 150 females). MEASUREMENTS AND MAIN RESULTS: In both sexes, rural patients with colorectal cancers were treated less frequently in a specialised health care centre (40.0%) than patients from an urban population (53.4%). The difference was mainly but not entirely explained by distance from the specialised health care centre. In females in the rural population, cancers were diagnosed more frequently at the stage of severe clinical symptoms (22.1%) and metastases (18.8%) than they were in the urban population (15.5% and 12.3%). In addition among females a rural environment appeared to confer a worse prognosis (relative risk = 1.3). CONCLUSIONS: Our findings suggest an inequality between rural and urban populations, especially for women. The loneliness of rural women leads to a delay in diagnosis and worse survival. In health education campaigns on colorectal cancer, efforts must be made to provide medical information to rural women in order to reduce the delay in diagnosis and improve survival.

Septicemia caused by contaminated parenteral nutrition pouches: the refrigerator as an unusual cause.

Eleven patients in a hospital presented with septicemia caused by Enterobacter cloacae. The origin was the contamination of parenteral nutrition admixture from a resting place in the refrigerator of the parenteral mixture preparation room.

Comparison of vaginal examination findings in two antenatal clinics.

Findings of routine vaginal examinations during pregnancy were compared in two teaching hospitals located in the same area of Paris. We selected 2943 women who had had at least one antenatal visit between 29 and 31 weeks of gestation. Large differences in the frequency of maturation signs were observed between the two hospitals for mid-position, soft consistency and expanded lower uterine segment, although the higher frequency of each sign was not found in the same hospital. No difference was observed for dilatation of the internal os. A better reliability in assessing dilatation than other signs of maturation may explain our results and the role of dilatation in the prediction of preterm delivery.

Changing trends in preterm childbirth.

Progress in perinatal care has been accompanied recently by increasing numbers of induced premature deliveries because of fetal distress. This is confirmed by study of 26,796 consecutive births in the Caen Hospital Group between 1980 and 1987. Study of the fate of these children shows that this attitude has not led to any excess mortality when the share of the IPD before 32 weeks are regularly growing. This would imply that the prematurity rate is no longer a sufficiently accurate epidemiological index for the evaluation of prenatal care policies.

Female urinary incontinence: comparative value of history and urodynamic investigations.

In order to identify the role of urodynamic investigation in relation to urinary symptoms, the authors assessed the diagnostic value of history and of urodynamic investigation in female urinary incontinence. 154 patients presenting with urinary incontinence were investigated prospectively, by standardised history and investigation of bladder stability and investigation of bladder stability and of cervico-urethral closure function. Clinical and urodynamic diagnostic conclusions were compared. Urodynamic results were highly discordant in the presence of clinical 'erethism', whilst agreement was more marked in the case of stress incontinence. Urodynamic investigation may be indicated after failure of medical treatment in the case of 'dysfunction'. By contrast, it is essential in stress incontinence in order to identify the mechanism or detect subclinical 'dysfunction'.

[Nosocomial risk]. / Le risque nosocomial.

The risks of hospital-acquired infection were, for many years, not seriously considered. However, current conditions increase risk, and the intense media and legal interest have led to the issue becoming a major medical concern. Hospital-acquired infections can be considered from four angles: the clinical dimension is the most obvious. It involves hospitalized patients, and to an increasing degree, hospital staff; the economic impact although difficult to assess, is a largely underestimated drain on hospital budgets; the legal problems have been recently highlighted by developments in jurisprudence; finally, there are ethical considerations associated with the behaviour sometimes found among health care workers, as a consequence of workplace risks. In this article we try to define and assess the significance of the major factors. We discuss the validity of various epidemiological and economic tools, and thus highlight the role of hospital-acquired infections in the working of hospitals.

[More fetal monitoring, more cesarean sections? An attempt at meta-analysis of the problem]. / Plus de monitoring foetal, plus de césariennes? Essai de la méta-analyse du problème.

Has the introduction of continuous intrapartum fetal heart rate (F.H.R.) registration resulted in an increase of cesarean section (CS) rates? Our meta-analysis of literature published since 1970 reveals the weak intrinsic value of retrospective studies and the heterogeneity of randomised trials concerning this question. The impact of routine intrapartum FHR monitoring on CS rates is low--and even null--in selected groups; the relationship diminishes over time.

[Regionalization of health care and obstetric practice]. / Régionalisation des soins et pratiques obstétricales.

The decision to regionalize obstetric services in the Montreal metropolitan area was designed to improve the efficiency of the system. Changes in types of birth between 1981 and 1984 in this area were studied in order to evaluate the effects of this decision on cesarean section rates. Results show a sudden increase in cesarean rates, coinciding with the regionalization decision. Hypotheses put forward are linked to the characteristics of hospitals remaining after this measure, as well as the organisational disturbances which it may have caused.

[Importance of the definition of urban zones in the study of cancer risk factors]. / Importance de la définition des zones urbaines dans l'étude des facteurs de risque de cancers.

1446 cases of colorectal cancer have been collected in the Registry of digestive tract tumours in the "Department" of Calvados with the aim of studying the effect of residential location on cancer incidence. The risk-ratio was different in males and in females and between different types of urban areas. Using the urban category of "Zone de Peuplement Industriel ou Urbain" (ZPIU) increased the observed risk-ratio (1.6 for males, 1.2 for females), and enabled definition of homogeneous populations. This improved classification, thus allowed a more discriminating analysis of the effect of residential location on risk of cancer in both sexes.

[Phenylketonuria: new questions for another generation]. / Phénylcétonurie: de nouvelles questions pour une autre génération.

Young women with phenylketonuria are at risk of bearing children with mental retardation. It results from the effects of the mother's elevated blood phenylalanine on the developing fetus. These effects may be prevented if a low phenylalanine diet is maintained prior to and throughout pregnancy.

[Effect of pregnancy and delivery on the function of the cervico-urethral closure. I. Prospective study of 27 women]. / Influence de la grossesse et de l'accouchement sur la fonction de clôture cervico-urétrale. I. Etude prospective chez 27 femmes.

Urinary incontinence is a complication of pregnancy. Having carried out urodynamic studies in pregnancy and immediately after delivery in 27 primigravid women, the authors have been able to clarify the alterations that take place in narrowing and closing the neck of the bladder and urethra, and especially in the tone of the urethra and of the functional character of the organ, in connection with hormonal changes that occur in pregnancy. They also demonstrate an increasing instability of the bladder which is due to compression by the pregnant uterus and which makes the function of bladder neck closure more difficult. On the other hand no significant short-term effect of obstetrical trauma could be found.

[Effect of pregnancy and delivery on the function of the cervico-urethral closure. II. Retrospective study on late consequences of obstetrical trauma]. / Influence de la grossesse et de l'accouchement sur la fonction de clôture cervico-urétrale. II. Etude rétrospective des conséquences tardives du traumatisme obstétrical.

Adding together the obstetric histories and the urodynamic investigations carried out on 178 incontinent women has made it possible for the authors to work out the role that obstetric trauma can play in urinary symptoms. They are able to demonstrate the effects of repeated normal deliveries and also the results of traumata over and above those that occur physiologically and are sometimes undergone by the perineum.

[Does genital tuberculosis still exist? Current review]. / La tuberculose génitale existe-t-elle encore? Revue récente.

The diagnosis of female pelvic tuberculosis is seldom thought of although it is still an entity. The reason why it is so seldom considered is partly because it has greatly diminished in incidence and also because the population who suffer from it and who are becoming much older move about. Another reason is that the symptomatology has changed, and now most often shows in pure haemorrhagic forms. The authors therefore go over the system of diagnosis and show that treatment is reverting to surgery.

[Prolonged fetal monitoring, ultrasonic telemetric registering. Methodology. Applications]. / La surveillance foetale prolongée, enregistrement télémétrique par ultra-sons. Méthodologie. Applications.

Studying the fetal heart rate is the method of choice for monitoring fetal wellbeing. All the same, when repeated records are made, but only over a short time, no permanent control is carried out and this means that some very high risk fetuses are not monitored properly. but all these involved using electrocardiograms to record the fetal heart rate and this was not a practical proposition because of the number of artifacts that were produced. the authors suggest using a new method of observing the fetal heart rate over a long period of time based on telemetric transmission of the rate using an ultrasound machine. They show the results and also the difficulties of using this apparatus as well as the prospects for studying fetal physiology in this way.

[Thrombo-embolic disease of pregnancy. Methods and indications for surgical prevention]. / Maladie thrombo-embolique de la grossesse. Méthodes et indications de la prévention chirurgicale.

Thrombo-embolic disease can generally benefit from anticoagulant treatment. Nevertheless, there are circumstances that require surgical prevention of pulmonary embolism. The vena caval circulation can be interrupted using clips, which necessitates a general anaesthetic and laparotomy, or intravenous procedures such as Mobin-Udin or Greenfield filters may be inserted. The indications for these procedures depend on how advanced the pregnancy is. The authors point out the indications for interruption of the vena caval flow during pregnancy in the light of four recent case histories. The main one is failure of medical treatment. Interruption of the vena caval flow is to be recommended when there is impaired circulation or when a thrombus is threatening. The diagnosis of this condition does require invasive tests; and whether these are toxic for the fetus is discussed.

[Small oscillations in fetal cardiac rhythm: a sign of well-being? A new approach to the diagnostic value of spontaneous recordings of fetal cardiac rhythm in pregnancy]. / Le rythme cardiaque foetal à petites oscillations: signe de bien-être? Nouvelle approche de la valeur diagnostique des enregistrements spontanés du rythme cardiaque foetal au cours de la grossesse.

The authors suggest an indirect evaluation of the electrocortical activity of the fetus by looking at evidence of cyclical variations in fetal cardiac rhythm. These are shown up by periodic changes in the variability of the rhythm. The narrow association that has been established between small changes in episodes of cardiac rhythm and deep sleep--which is itself evidence of satisfactory cortical development--make this type of tracing, under certain conditions, an excellent sign of fetal wellbeing. This means that the value of small variabilities in fetal heart rhythm takes on greater importance as a prognostic feature.