[Suffering at work among medical students: qualitative study using semi-structured interviews]. / Souffrance au travail des étudiants en médecine : étude qualitative par entretiens semi-dirigés.

INTRODUCTION: Suffering at work among health professionals is a hot topic. Medical students, doctors of tomorrow, are far from being spared. Prevalence of anxiety and mood disorders range from 20.3 to 69 % for the former and from 12 to 30 % for the latter. The purpose of this article is to determine these factors by qualitative research, according to medical students' points of view. METHODS: It is a qualitative study using semistructured interviews. The analysis is done according to the Grounded Theory. RESULTS: 12 medical students are interviewed. They expressed difficulties at work and positive factors. Three major themes are identified in selective coding: occupational factors, " study " factors and individual factors. All themes are both a source of well-being and ill-being according to the situations specified in the results. CONCLUSION: Studying medicine includes positive and negative aspects. Abandonment issues, lack of recognition and insufficient coaching emerge from our study. Screening of suffering at work should be systematic for medical students.

INTRODUCTION: La souffrance au travail chez les professionnels de santé est un sujet d'actualité. Les étudiants en médecine, médecins de demain, sont loin d'être épargnés. Ils présentent notamment des troubles anxieux et de l'humeur dont les prévalences s'échelonnent de 20,3 à 69 % pour les premiers et de 12 à 30 % pour les seconds. Cette étude a pour objectif de déterminer ce qui est ressenti comme positif ou négatif au travail du point de vue des étudiants hospitaliers. Matériel et méthode : Il s'agit d'une étude qualitative par entretiens semi-dirigés. L'analyse se fait selon une thématisation progressive en suivant la Grounded Theory, ou théorisation ancrée, méthode issue des sciences sociales, visant à élaborer une théorie des représentations, non à partir d'hypothèses prédéterminées, mais à partir de données de terrain recueillies par entretiens. Résultats : La variation est maximale. La saturation des données a été atteinte avec 12 sujets. Ceux-ci ont exprimé des difficultés au travail mais aussi des facteurs de ressenti positif. Trois grands thèmes ont été définis en codage sélectif : les facteurs professionnels, les facteurs " étude " et les facteurs individuels. Quelle que soit la thématique abordée, les relations avec le ressenti du travail sont à la fois source d'épanouissement et de souffrance selon les situations précisées dans les résultats. CONCLUSION: Le vécu des études médicales comprend des aspects positifs et négatifs. Les problématiques de délaissement, de manque de reconnaissance ou encore d'accompagnement insuffisant ressortent de notre étude. Ceci ouvre des pistes de prévention. Le dépistage d'un malêtre au travail devrait être systématique chez ces étudiants.

Antibiotic prophylaxis for the prevention of recurrent urinary tract infection in children with low grade vesicoureteral reflux: results from a prospective randomized study.

PURPOSE: Antibiotic prophylaxis is given to children at risk for urinary tract infection. However, evidence concerning its effectiveness in grade I to III vesicoureteral reflux is lacking. The objective of this study was to determine whether antibiotic prophylaxis reduces the incidence of urinary tract infection in young children with low grade vesicoureteral reflux. MATERIALS AND METHODS: Children 1 month to 3 years old with grade I to III vesicoureteral reflux were assigned randomly to receive daily cotrimoxazole or no treatment, and followed for 18 months. A urinary tract infection constituted an exit criterion. Infection-free survival rates were calculated using the Kaplan-Meier method and compared using the log rank test. RESULTS: A total of 225 children were enrolled in the study. Distribution of gender, age at inclusion and reflux grade were similar between the 2 groups. There was no significant difference in the occurrence of urinary tract infection between the 2 groups (17% vs 26%, p = 0.2). However, a significant association was found between treatment and patient gender (p = 0.017). Prophylaxis significantly reduced urinary tract infection in boys (p = 0.013), most notably in boys with grade III vesicoureteral reflux (p = 0.042). CONCLUSIONS: These data suggest that antibiotic prophylaxis does not reduce the overall incidence of urinary tract infection in children with low grade vesicoureteral reflux. However, such a strategy may prevent further urinary tract infection in boys with grade III reflux.

[Management of phenylketonuria and hyperphenylalaninemia: the French guidelines]. / Consensus national sur la prise en charge des enfants dépistés avec une hyperphénylalaninémie.

Phenylketonuria (PKU) is an inherited metabolic disease affecting about one birth out of 15 000. From 1978, a national systematic neonatal screening was set up in France with a regional organisation. French rational and guidelines have been established by the national PKU group with the collaboration of all the physicians responsible for the regional centres. These guidelines specify the minimal diagnosis procedures leading to an optimal treatment of all patients. A low-phenylalanine diet must be started as soon as possible in the neonatal period for all newborns whose phenylalanine levels are above 10 mg/dl. The dietary control must keep the phenylalanine plasma levels between 2 and 5 mg/dl until 10 years of age. After this age, several data argue for a progressive and controlled relaxation of the diet, keeping the phenylalanine level below 15 mg/dl until the end of the adolescence and below 20 to 25 mg/dl in adulthood. All PKU patients must be followed up for life, in order to screen those who may not bear the diet relaxation and in order to strictly prevent maternal PKU deleterious consequences.

[Prevalence of vitamin D deficiency in children aged 5-10 years in western Brittany]. / Prévalence du déficit en vitamine D chez les enfants âgés de 5 à 10ans en Bretagne Occidentale.

UNLABELLED: French guidelines do not recommend systematic supplementation of vitamin D in children aged 5-10 years old owing to the lack of data on vitamin D status in this age group. Our objective was to assess the prevalence of vitamin D deficiency in these children. METHODOLOGY: Single-center, prospective, epidemiological study including 358 children aged 0-15 years. The endpoint was the concentration of vitamin D. RESULTS: In all, 316 children were divided into four groups according to age: 0-18 months (n=113); 18 months to 5 years (n=103); 5-10 years (n=62); and 10-15 years (n=38). The median concentration of vitamin D decreased with age (P<0.001): 90.2 nmol/L in the group aged 0-18 months; 56.7 nmol/L in the group aged 18 months to 5 years; 49.05 nmol/L in the group aged 5-10 years; and 42.45 nmol/L in the group aged 10-15 years. This corresponds to an increase in the prevalence of vitamin D deficiency in children aged 5-10 years (51.6% vs. 8.8% in the group aged 0-18 months, P<0.001). For children aged 5-10 years, the prevalence of deficiency was greater in the non-supplementation group (75%) compared with the supplementation group (13%; P<0.001). CONCLUSION: This study demonstrates the high prevalence of vitamin D deficiency in children aged 5-10 years and the relationship between supplementation and vitamin D status. It provides an argument in favor of supplementation in children aged 5-10 years in this region and a reconsideration of the French recommendations.

High density lipoprotein alterations induced by bezafibrate in healthy male volunteers.

The alterations of HDL structure and metabolism induced by bezafibrate administration were studied in healthy male volunteers. As usually observed in hyperlipaemic patients, bezafibrate induced a decrease of the plasma concentrations of apo B and LDL-cholesterol and an increase of that of HDL-cholesterol. Analysis of HDL by gradient polyacrylamide gel electrophoresis revealed that bezafibrate administration resulted in a change of the particle size distribution likely suggesting a drop of the HDL2/HDL3 ratio. This was accompanied by a 30% enhancement of the plasma concentration of apoprotein A-II, while that of apoprotein A-I remained unchanged. These data suggest an increase of the HDL concentration, preferentially in the HDL3 subfraction. In spite of these HDL alterations, there was no evidence of change in the three stages of the reverse pathway of cholesterol, since bezafibrate did not induce any significant alteration in the in vitro properties of plasma with respect to (a) cholesterol transport from cultured cells, (b) cholesterol esterification, and (c) transfer of cholesteryl esters from HDL to VLDL-LDL.

Malassezia furfur-related colonization and infection of central venous catheters. A prospective study in a pediatric intensive care unit.

OBJECTIVE: To determine the incidence of Malassezia furfur-related colonization and infection of central venous catheters. DESIGN: Prospective clinical study. SETTING: A paediatric intensive care unit at a University Hospital. PATIENTS: 66 newborns with central venous catheters for parenteral nutrition including lipid emulsions (Intralipid). METHODS: When a central venous catheter was removed, it was rinsed with 1 ml of physiological saline, transported at ambient temperature to the clinical laboratory and cultured on Dixon's medium. The tip of the central venous catheter was used for a bacteriological study using Maki's technique. In case of suspected sepsis, blood cultures were obtained using an Isolator tube. RESULTS. 74 central venous catheters were included: mean duration of use of a central venous catheters and infusions of lipid emulsion (Intralipid) were 19.3 +/- 10 days and 8.6 +/- 8 days respectively. Only 2 central venous catheters (2.7%) were colonized by Malassezia furfur: (Mf) one in an asymptomatic newborn, and the other in an infected newborn with signs of sepsis, who most probably died at 4 months of age from refractory hypoxia due to pulmonary hypoplasia, but not from Mf sepsis. CONCLUSIONS: The incidence of Malassezia furfur-related colonization of central venous catheters appears to be low but not negligible, which warrants the use of specific culture techniques.

Abnormal plasma cholesterol metabolism in cigarette smokers.

Plasma cholesterol metabolism was studied in young, nonobese, normolipidemic men with a moderate level of cigarette smoking (24 +/- 5d-1) and in a comparable nonsmoking normal control group. The smokers showed a decreased cholesterol net transport from cell membranes into plasma (P less than 0.001) and a decreased ratio of cholesteryl ester transfer to low and very low density lipoprotein, relative to lecithin:cholesterol acyltransferase (P less than 0.05). Apoprotein E was increased in smokers' plasma (P less than 0.05) whereas apoprotein A-I, the major apoprotein of HDL, was decreased (P less than 0.05). This pattern of abnormalities has been previously observed in several other groups of subjects at increased risk for atherosclerotic vascular disease (diabetics, dysbetalipoproteinemics, and hyperbetalipoproteinemics). These data suggest a deleterious effect of smoking on plasma lipoprotein metabolism significant even in young smokers, which could partly explain the later incidence of atherosclerotic vascular disease in this group.

Antiketogenic effect of glucose per se in vivo in man and in vitro in isolated rat liver cells.

The in vivo effect of glucose per se on blood ketone bodies, glycerol, and nonesterified fatty acids (NEFA) has been investigated in five normal (60 hours fasted) men receiving a somatostatin (SRIF) infusion (500 micrograms/h-1). When glycemia was raised over 10 mmol/L for 180 minutes by exogenous IV glucose infusion, neither insulin nor C peptide increase. NEFA and glycerol returned to fasting value in 40 minutes and remained stable. Ketone bodies decreased continuously and were significantly below the fasting values at the end of the study (1.3 +/- 0.3 mmol/L v 2.2 +/- 0.4 mmol/L, P less than 0.05). In order to ascertain whether glucose has been acting only on lipolysis or also on the liver ketogenic capacity, its effect was studied in vitro on isolated liver cells from 24-hour starved rats incubated with various amounts of palmitate. Glucose (30 mmol/L) did not affect the maximal ketogenic capacity (80 mumol/g (w/w)/h) measured with 1.6 mmol/L palmitate but increased the apparent palmitate K 0.5 for ketogenesis from 0.16 to 0.3 mmol/L. At physiologic free fatty acids concentration (0.22 mmol/L), glucose decreased ketogenesis by 90%. The effect was time-dependent, maximum after 30 minutes of incubation. Half-maximum inhibition by glucose was obtained at 6 mmol/L, a concentration at which lactate production was unaffected. These results suggest that glucose per se inhibits ketogenesis in vivo by acting probably both on lipolysis and on liver ketogenic capacity.

Low rate of Candida parapsilosis-related colonization and infection in hospitalized preterm infants: a one-year prospective study.

We determined the rate of Candida parapsilosis colonization in preterm neonates (NN) and the relationship between colonization and systemic infection through a prospective study in the Neonatal Intensive Care Unit of a university hospital. All NN born at a gestational age of 32 weeks or less were included. Specimens from rectum, mouth and retro-auricular skin were obtained at admission and weekly thereafter. All samples were inoculated on to Sabouraud agar, CHROMagar and Dixon media. Candida species were identified using API Candida and API 20C. DNA analysis was performed using pulse field gel electrophoresis.Fifty-four patients were included (mean age: 30 +/- 1.5 weeks; mean birthweight: 1347 +/- 301 g; male: 40%). Fungal colonization was detected in 43 (79.6%). Causative agents were C. parapsilosis (N= 7);Malassezia furfur (N= 30);C. albicans (N= 21), C. guillermondii (N= 1). No sample was positive for two different yeasts at the same time. C. parapsilosis colonization included anal (N= 6), buccal (N= 1), and skin (N= 2). The average age at time of colonization was 17.8+/-9.8 days. Neither fungal septicaemia nor death were observed in colonized infants. Two central venous catheters were found to be colonized, one with C. parapsilosis and one with M. furfur. Logistic regression showed a link between colonization and gestational age alone. Three different DNA profiles were observed. This study suggests that in our units, the occurrence of C. parapsilosis colonization is low and bears no relation to systemic infection. The systematic identification of C. parapsilosis carriers for the purposes of isolation and preventive treatment does not appear to be warranted.

Neonatal screening and long-term follow-up of phenylketonuria: the French database.

BACKGROUND: In France, neonatal screening of phenylketonuria (PKU) started in 1966. A national association was created in 1978 in order to organise the neonatal screening program and to control the efficacy of the screening and patients' follow-up. AIMS: To evaluate the results of the French PKU screening program in terms of hyperphenylalaninaemia epidemiology, efficacy of the screening procedure, management and outcome of the patients. STUDY DESIGN: The national database has been filled-up first with the answers to questionnaires that were sent each year by the PKU patients' physicians, and second with the results of an additional inquiry, which was set up in 1994 in order to investigate diagnosis, treatment, and school outcome of all French PKU patients. RESULTS: PKU was diagnosed in 81.6% of patients with hyperphenylalaninaemia (HPA), non-PKU HPA in 17.2% and cofactor deficiency in 1.1%. From 1980, incidence of PKU has been stable: 1 per 17,124 live births. Sensitivity of the screening procedure was 99.3%. Age at diet initiation regularly decreased to reach 14 days as a median in 1996. Until 1990, median age at diet discontinuation was 6 years of age. Later, strict diet was continued longer (at least, up to 8-10 years). PKU patients who entered to secondary school at normal age were characterised by an earlier age at diagnosis and at diet initiation and a later age at diet discontinuation, compared to those who entered 1 year or more behind normal age. CONCLUSION: These data confirm the benefit of a nationwide organised screening program. They emphasise the importance of an early neonatal diagnosis and diet initiation in PKU patients and are consistent with the benefit of a longer period of strict diet in childhood.

[Neonatal detection of central hypothyroidism]. / Hypothyroïdie centrale de découverte néonatale.

BACKGROUND: Congenital hypothyroidism is very rare compared to primary hypothyroidism. Its early diagnosis may escape neonatal mass screening using TSH assay. CASE REPORT: Anthony was born at 37 weeks, weighing 3,060 g. He presented with hypotony, jaundice, tongue protrusion evoking congenital hypothyroidism. Thyroid function tests favored hypothyroidism central in origin, while the systematic neonatal screening was normal. CONCLUSION: Clinical signs of congenital hypothyroidism must lead to more specific tests when neonatal screening is normal.

[The CHARGE association]. / L'association CHARGE.

The CHARGE association is a polymalformative disease associating coloboma, heart disease, atresia of choanae, retarded growth and development, genital hypoplasia and ear anomalies, CHARGE being an acronym based on these different malformations. The diagnosis requires at least four of these malformations including necessarily coloboma and/or atresia of choanae. The various clinical aspects, the genetics and the therapeutics implications are described.

[Bicycle helmet effectiveness in children: qualitative analysis of the literature]. / Intérêt du casque cycliste chez l'enfant: analyse qualitative de la littérature.

In order to assess bicycle helmet effectiveness in preventing head injury in children, we performed an international qualitative and systematic review using the criteria of the French Health Accreditation and Evaluation National Agency (ANAES) developed for recommendations in clinical practice (formulation of a question, judgment criteria, collecting references, quality analysis, interpretation of results). Two hundred and thirty-four papers dealing with the subject were identified through a MEDLINE search. Two hundred and fifteen of them were eliminated as they did not meet selected criteria. Four were eliminated because of language criteria. On the 14 meeting all selection criteria, five were judged satisfactory according to qualitative criteria. All five conclude in favor of the effectiveness of the bicycle helmet even when taking bias into account. The real protection afforded by wearing a bicycle helmet militates in favor of its habitual use.

[Focalized multiple beam radiotherapy: an alternative in the treatment of deep cerebral arteriovenous malformations]. / Radiothérapie multifaisceaux focalisée: une alternative pour le traitement des malformations artérioveineuses cérébrales profondes.

BACKGROUND: Cerebral arteriovenous malformations are usually treated by excision or selective embolization. Some untreatable malformations may be presently cured by radiosurgery. CASE REPORT: A 10-year-old girl without previous illness suffered from a sudden quadriventricular hemorrhage due to arteriovenous malformation. Initially the child recovered with symptomatic treatment. Neurosurgery and arterial embolization being impossible, Gamma-Unit treatment was performed. Treatment was first well tolerated but 8 months later, left hemiparesis and language disorders occurred, due to radionecrosis. These complications were dramatically improved by corticosteroids. CONCLUSION: Gamma-Unit treatment can be successfully proposed for treating those malformations that are inaccessible to surgery or embolization.

[Severe head injuries in neonates and infants: physiopathological and therapeutic aspects]. / Traumatismes crâniens graves du nouveau-né et du nourrisson: particularités physiopathologiques et thérapeutiques.

Severe head injuries in infants have specific circumstances such as obstetrical injury, battered infant, shaken infant. Pediatric scales must be used for neurological evaluation, the Bicêtre scale being a sensitive index of clinical course. Transfontanellar ultrasound can be useful as first line tool of evaluation of brain injury, but computerized tomography scan is necessary to correctly assess the brain lesions and the presence of hematoma. Hemorragic lesions can rapidly lead to hypovolemic state which must be prevented, or treated without delay. Treatment requires hemodynamics and hydroelectrolytic support, measures to control intracranial hypertension, sedation, and neurosurgical intervention according to the hemorragic lesions.

[Nosocomial infections due to syncytial respiratory virus: which hygienic measures]. / Infections nosocomiales liées au virus respiratoire syncytial: quelles mesures d'hygiène?

Nosocomial respiratory tract infections due to respiratory syncytial virus are common among hospitalized children. The overall prevention is based on 3 points: prevention of person-to-person viral transmission, infection surveillance and staff education. Handwashing is the main protective attitude. Other measures such as gloving, gowning and wearing masks and goggles are discussed. Changes in hospital organisation during epidemic periodes must also be considered.

[Bird headed dwarfism in Seckel syndrome. Nosologic difficulties]. / Le nanisme à tête d'oiseau ou syndrome de Seckel. Difficultés nosologiques.

Seckel syndrome is a clinical picture which associates four main features: intrauterine growth retardation, microcephaly often due to craniosynostosis, orofacial dysmorphology with bird headed appearance and variable mental retardation which is present after several months. Malformations of the central nervous system, limbs, and hair, may also be observed. On the basis of 78 cases reported in the literature, the authors discuss the validity of the morphological features of the syndrome. It is likely that the variability in the expressivity of each symptom explains its heterogeneity. According to the radiological abnormalities, three different forms of the syndrome have been described. Seckel syndrome is a genetic disorder with autosomal recessive inheritance. Its ethiopatogeny remains unclear. Hopefully linkage studies will allow to map the gene in order to determine the underlying abnormal protein.

[Transitory hyperinsulinism with hypoglycemia in asphyxia neonatorum]. / Hyperinsulinisme transitoire avec hypoglycémie par asphyxie néonatale.

BACKGROUND: Hypoglycemia is a well-known complication in neonates small for gestational age and in those with diabetic mothers. Birth asphyxiated infants can develop severe hypoglycemia due to reduced glycogen stores. CASE REPORTS: The first patient was born at 41 weeks, weighing 3,780 g by emergency cesarean section because of fetal distress. He developed a pneumothorax and hypoglycemia. He was given glucose infusion (at day 4: 20 mg/kg/d). Hyperinsulinism was confirmed: blood levels at 18.3 mU/L on day 1 and 11.7 mU/L on day 2. The infusion rate was gradually decreased. The second patient was born at 39 weeks, weighing 2,780 g by emergency cesarean section because of fetal distress. She needed glucose infusion (24 g/kg/d) because of hypoglycemia with hyperinsulinism (12.8 mU/L on day 2 and 11.7 mU/L on day 3). After 5 days, the infusion of glucose was replaced by oral feeding only. CONCLUSION: Transient hypoglycemia in asphyxiated newborn infants with hyperinsulinism must be considered even when hypoglycemia may be difficult to prove.

[Prenatal diagnosis of congenital cystic adenomatoid malformation of lung: perinatal management. Apropos of 4 cases]. / Malformation kystique adénomatoïde pulmonaire congénitale de diagnostic anténatal: prise en charge périnatale. A propos de quatre observations.

BACKGROUND: Cystic adenomatoid malformation of the lung can be seen by ultrasonography during pregnancy. Surgical excision of the affected lobe is indicated during the first days of life. CASES REPORT: Four neonates were admitted to an intensive care unit from March 1988 to February 1992, due to cystic adenomatoid malformation of the lung, that had been diagnosed by ultrasonography at 19, 22, 34 and 37 weeks of gestational age, respectively. These malformations were not associated with other abnormalities and were type I (three cases) and II (one case) according to Stocker's classification. Only one patient became symptomatic, requiring intubation by 72 hours of age. Surgical excision of the affected lobe was performed in three patients at 4 hours, 2 and 7 days of life, respectively, with a normal long-term survival. A segmental resection was performed at 5 days of life in the remaining symptomatic patient but persistence of cystic lesions required lobectomy at 10 months. CONCLUSIONS: Early perinatal management of cystic adenomatoid malformations of the lung is necessary as surgical excision is indicated as soon as possible, even in asymptomatic patients.

[Clinical heterogeneity of Townes-Brocks syndrome]. / Hétérogénéité clinique du syndrome de Townes-Brocks.

BACKGROUND: Townes-Brocks syndrome (TBS) is a rare autosomal dominant entity mainly characterized by ano-rectal, ear and extremities abnormalities with variable clinical expression. CASE REPORTS: The first case had ear and extremities, but not anorectal, abnormalities; a Pierre-Robin sequence with esophageal atresia was also observed. The second case had the classical triad of abnormalities also associated with tetralogy of Fallot which has been only once reported in the literature. CONCLUSIONS: Both cases are other examples of the frequent clinical variability observed in this syndrome explaining diagnostic difficulties in the absence of a specific marker.