Estimating the number of probable new SARS-CoV-2 infections among tested subjects from the number of confirmed cases.

OBJECTIVES: In most African countries, confirmed COVID-19 case counts underestimate the number of new SARS-CoV-2 infection cases. We propose a multiplying factor to approximate the number of biologically probable new infections from the number of confirmed cases. METHODS: Each of the first thousand suspect (or alert) cases recorded in South Kivu (DRC) between 29 March and 29 November 2020 underwent a RT-PCR test and an IgM and IgG serology. A latent class model and a Bayesian inference method were used to estimate (i) the incidence proportion of SARS-CoV-2 infection using RT-PCR and IgM test results, (ii) the prevalence using RT-PCR, IgM and IgG test results; and, (iii) the multiplying factor (ratio of the incidence proportion on the proportion of confirmed -RT-PCR+- cases). RESULTS: Among 933 alert cases with complete data, 218 (23%) were RT-PCR+; 434 (47%) IgM+; 464 (~ 50%) RT-PCR+, IgM+, or both; and 647 (69%) either IgG + or IgM+. The incidence proportion of SARS-CoV-2 infection was estimated at 58% (95% credibility interval: 51.8-64), its prevalence at 72.83% (65.68-77.89), and the multiplying factor at 2.42 (1.95-3.01). CONCLUSIONS: In monitoring the pandemic dynamics, the number of biologically probable cases is also useful. The multiplying factor helps approximating it.

Arterial endofibrosis in endurance athletes: Prospective comparison of the diagnostic accuracy of intra-arterial digital subtraction angiography and computed tomography angiography.

PURPOSE: To prospectively compare the diagnostic capabilities of computed tomography angiography (CTA) to those of digital subtraction angiography (DSA) in endurance athletes with suspicion of arterial endofibrosis. MATERIALS AND METHODS: Forty-five athletes (39 men, 6 women; median age: 30 years, interquartile range: 23-42 years) prospectively underwent DSA and CTA without (n=5) or with (n=40) electrocardiogram gating. DSA was interpreted by a single expert (experience of 15 years). CTA was independently interpreted by three other readers (experience of 5-8 years). Readers assessed the presence and degree of stenoses on iliac and femoral arteries and the overall diagnosis (negative, uncertain, positive) of endofibrosis at the limb level. Sensitivities and specificities of DSA and CTA were estimated at the limb level using histological findings and long-term follow-up as reference, and compared using the McNemar test. RESULTS: For diagnosing and quantifying stenoses, concordance between DSA and CTA was moderate-to-good for common and external iliac arteries, moderate for lateral circumflex arteries and poor-to-moderate for the other branches of the deep femoral artery. It was good for all readers for the overall diagnosis of endofibrosis. After long-term follow-up (median, 95 months; interquartile range: 7-109 months), DSA sensitivity and specificity were respectively 88.6% (39/44; 95% confidence interval [CI]: 76-95%) and 75% (24/32; 95% CI: 57.9-86.7%); CTA sensitivity and specificity were respectively 88.6% (39/44; 95% CI: 76-95%; P>0.99) and 84.4% (27/32; 95% CI: 68.2-93.1%; P=0.51), 86.3% (38/44; 95% CI: 73.3-93.6%; P>0.99) and 75% (24/32; 95% CI: 57.9-86.7%; P>0.99), and 84.1% (37/44; 95% CI: 70.6-92.1%; P=0.68) and 75% (24/32; 95% CI: 57.9-86.7%; P>0.99) for the three readers. CONCLUSION: CTA shows performances similar to those of DSA in predicting the long-term diagnosis of endofibrosis in endurance athletes with suggestive symptoms.

Postsurgery analgesic and sedative drug use in a French neonatal intensive care unit: A single-center retrospective cohort study.

OBJECTIVE: To describe pain assessment, the pattern of analgesic and sedative drug use, and adverse drug reactions in a neonatal intensive care unit (NICU) during the postsurgery phase. METHOD: Demographic characteristics, pain scores, and drug use were extracted and analyzed from electronic patient medical files for infants after surgery, admitted consecutively between January 2012 and June 2013. RESULT: One hundred and sixty-eight infants were included. Acute (DAN score) and prolonged (EDIN score) pain assessment scores were used in 79% and 64% of infants, respectively, on the 1st day. This percentage decreased over the 7 days following surgery. The weekly average scores postsurgery were 2/15 (±2.2) for the EDIN score and 1.6/10 (±2.0) for the DAN score. The rates of pain control were 88% for the EDIN and 72% for the DAN. The most prescribed opiate drug was fentanyl (98 patients; 58%) with an average dose of 1.8 (±0.6) µg/kg/h. Midazolam was used in 95 patients (56%), with an average dose of 35 (±14) µg/kg/h. A bolus was administered in 7% (±7.4) of the total dose for fentanyl and 8% (±9.3) for midazolam. Similar doses were used in term and preterm neonates. Of 118 patients receiving fentanyl and/or midazolam, 40% presented urinary retention, 28% a weaning syndrome. Paracetamol (155 patients; 92%) and nalbuphine (55 patients; 33%) were the other medications most often prescribed. CONCLUSION: The off-label use of fentanyl and midazolam was necessary to treat pain after surgery. Pain assessment should be conducted for all neonates in order to optimize their treatment. Research on analgesic and sedative medicine in vulnerable neonates seems necessary to standardize practices and reduce adverse drug reactions.

Real study: Re-treatment evaluated on visual acuity for Lucentis® in neovascular AMD.

PURPOSE: To assess the value of a monthly injection of Lucentis® until stable visual acuity (VA) is obtained for three consecutive months without exudation in patients with neovascular age macular degeneration (AMD). METHODS: Prospective, single-center, non-controlled trial including naïve AMD patients with neovascularization. An assessment of VA and a spectral domain optical coherence tomography (SD-OCT) were performed at baseline and every month. Monthly injections of Lucentis® were performed over three months. The monthly injections were then continued until three consecutive stable VA results were obtained with no signs of exudation. RESULTS: Fifteen out of the 21 patients included were anatomically good responders. A mean gain of +14Le (9) was obtained up to the point at which there was no exudation. There was no additional gain from this point until 3 consecutive stable VA results were obtained. During the PRN phase, an additional mean gain of +3.2Le (7.7) was obtained. CONCLUSION: This initial VA-guided regimen with ranibizumab might prevent the slight decrease in VA observed during the first year of PRN studies.

[Management of post-traumatic aphakia and aniridia: Retrospective study of 17 patients undergoing scleral-sutured artificial iris intraocular lens implantation. Management of aphakia-aniridia with scleral-sutured artificial iris intraocular lenses]. / Prise en charge de l'aphakie et de l'aniridie post-traumatiques. Étude rétrospective de 17 patients opérés d'implants intraoculaires suturés à la sclère à iris artificiel. Gestion de l'aphakie-aniridie par implants suturés à la sclère à iris artificiel.

PURPOSE: To evaluate the long-term outcomes of artificial iris intraocular lenses sutured to the sclera for managing traumatic aphakia and aniridia. METHODS: All consecutive cases receiving a Morcher® combination implant from June 2008 to February 2016 in Edouard-Herriot Hospital (Lyon, France) were included in this single-center retrospective study. Visual acuity, subjective degree of glare, quality of life and surgical complications were evaluated. RESULTS: Seventeen eyes of 17 patients were included, among which 82% were male. The mean age was 42 years. The injuries consisted of 23.5% contusion and 70.5% open globe injuries, of which 41% were globe ruptures. There was one postoperative case. A penetrating keratoplasty was performed at the same time for eight eyes. The mean follow-up was 32 months. Best-corrected visual acuity improved in 41.2%, remained the same in 17.6% and decreased in 41.2% of our cases. Distance vision averaged 1±0.25 line better and near vision 2.2±0.32 lines better when visual acuity was quantifiable before surgery. Glare improved in 80% of patients and remained stable in 20%, decreasing on average from 3.3/5 [min. 3-max. 4; SD: 0.48] before surgery to 1.9/5 [min. 0-max. 4; SD: 1.197] after surgery. Regarding the esthetic results, 78% of the patients declared themselves reasonably to very satisfied; 57% reported no limitation of activities of daily living, and 43% reported mild limitation. Ocular hypertension and glaucoma, found in 40% of eyes, were the main postoperative complications. CONCLUSION: Implantation of prosthetic iris device combined with an intraocular lens appears to be safe and effective in reducing glare disability and improving visual acuity. Close, long-term monitoring is essential for the success of this surgery.

Prevalence of pain in 240 non-ambulatory children with severe cerebral palsy.

BACKGROUND: Several studies have given frequencies of pain in children with cerebral palsy, but comparing the findings is difficult. We aimed to estimate the prevalence of pain in non-ambulatory children with cerebral palsy and describe their characteristics by presence or absence of pain. METHODS: Data were extracted from an ongoing longitudinal national cohort following non-ambulatory children with severe cerebral palsy aged 3 to 10years over 10years. We described and compared data for the first 240 children at inclusion by presence or absence of pain. Pain was assessed by a visual analog scale and the Douleur Enfant San Salvadour scales and by investigator interview. RESULTS: Overall, 65 children experienced pain, for a prevalence of 27.1% (95% confidence interval 22-33%). All children experiencing pain had orthopaedic pain and 45.6% had pain from another origin. The main pain sites were hips (43.4%) and feet (26.9%). Joint mobilisation was the source of pain for 58.3% of children experiencing pain, and sitting was identified as painful for 10.3%. Pain was greater with scoliosis (43.1% vs 24.1% with and without pain; P=0.006) and spasticity treatment (32.3% vs 17.2%; P=0.020). CONCLUSION: Children with cerebral palsy frequently experience pain and also early pain, mostly articular and orthopedic. The assessment of pain should be systematic because of its high prevalence. Interventions to prevent scoliosis, hip luxation, and foot deformities and to reduce spasticity, such as the use of analgesics before joint mobilization exercises, may reduce the prevalence of this pain.

Introduction of a paediatric anaesthesia comic information leaflet reduced preoperative anxiety in children.

BACKGROUND: The aim of the study was to determine whether the introduction of a paediatric anaesthesia comic information leaflet reduced preoperative anxiety levels of children undergoing major surgery. Secondary objectives were to determine whether the level of understanding of participants and other risk factors influence STAIC-S (State-Trait Anxiety Inventory for Children-State subscale) score in children. METHODS: We performed a randomized controlled parallel-group trial comparing preoperative anxiety between two groups of children aged >6 and <17 yr. Before surgery, the intervention group received a comic information leaflet at home in addition to routine information given by the anaesthetist at least 1 day before surgery. The control group received the routine information only. The outcome measure was the difference between STAIC-S scores measured before any intervention and after the anaesthetist's visit. A multiple regression analysis was performed to explore the influence of the level of education, the anxiety of parents, and the childrens' intelligence quotient on STAIC-S scores. RESULTS: One hundred and fifteen children were randomized between April 2009 and April 2013. An intention-to-treat analysis on data from 111 patients showed a significant reduction (P=0.002) in STAIC-S in the intervention group (n=54, mean=-2.2) compared with the control group (n=57, mean=0.90). The multiple regression analysis did not show any influence on STAIC-S scores of the level of education, parental anxiety, or the intelligence quotient of the children. CONCLUSIONS: A paediatric anaesthesia comic information leaflet was a cheap and effective means of reducing preoperative anxiety, measured by STAIC-S, in children. CLINICAL TRIALS REGISTRATION: NCT 00841022.

Reduced bone volumetric density and weak correlation between infection and bone markers in cystic fibrosis adult patients.

UNLABELLED: In our current adult CF population, low BMD prevalence was only 20 %, lower than that historically described. We found a mild increase of serum RANK-L levels, independent from the bone resorption level. The increased fracture risk in CF may be explained by a lower tibial cortical thickness and total vBMD. INTRODUCTION: Bone disease is now well described in cystic fibrosis (CF) adult patients. CF bone disease is multifactorial but many studies suggested the crucial role of inflammation. The objectives of this study were, in a current adult CF population, to assess the prevalence of bone disease, to examine its relationship with infections and inflammation, and to characterize the bone microarchitecture using high resolution peripheral scanner (HR-pQCT). METHODS: Fifty-six patients (52 % men, 26 ± 7 years) were assessed in clinically stable period, during a respiratory infection, and finally 14 days after the end of antibiotic therapy. At each time points, we performed a clinical evaluation, lung function tests, and biochemical tests. Absorptiometry and dorso-lumbar radiographs were also performed. A subgroup of 40 CF patients (63 % men, 29 ± 6 years) underwent bone microarchitecture assessment and was age- and gender-matched with 80 healthy controls. RESULTS: Among the 56 CF patients, the prevalence of low areal BMD (T-score < -2 at any site), was 20 % (95 % CI: [10.2 %; 32.4 %]). After infections, serum RANK-L (+24 %, p = 0.08) and OPG (+13 %, p = 0.04) were increased with a stable ratio. Microarchitectural differences were mostly observed at the distal tibia, with lower total and cortical vBMD and trabecular thickness (respectively -9.9, -3.0, and -5 %, p < 0.05) in CF patients compared to controls, after adjustment for age, gender, weight, and height. CONCLUSIONS: In this study, bone disease among adult CF patients was less severe than that previously described with only 20 % of CF patients with low BMD. We found a mild increase of biological marker levels and an impaired volumetric density of the tibia that may explain the increased fracture risk in CF population.

Ventilator-associated pneumonia in ARDS patients: the impact of prone positioning. A secondary analysis of the PROSEVA trial.

BACKGROUND: The goal of this study was to assess the impact of prone positioning on the incidence of ventilator-associated pneumonia (VAP) and the role of VAP in mortality in a recent multicenter trial performed on patients with severe ARDS. METHODS: An ancillary study of a prospective multicenter randomized controlled trial on early prone positioning in patients with severe ARDS. In suspected cases of VAP the diagnosis was based on positive quantitative cultures of bronchoalveolar lavage fluid or tracheal aspirate at the 10(4) and 10(7) CFU/ml thresholds, respectively. The VAP cases were then subject to central, independent adjudication. The cumulative probabilities of VAP were estimated in each position group using the Aalen-Johansen estimator and compared using Gray's test. A univariate and a multivariate Cox model was performed to assess the impact of VAP, used as a time-dependent covariate for mortality hazard during the ICU stay. RESULTS: In the supine and prone position groups, the incidence rate for VAP was 1.18 (0.86-1.60) and 1.54 (1.15-2.02) per 100 days of invasive mechanical ventilation (p = 0.10), respectively. The cumulative probability of VAP at 90 days was estimated at 46.5 % (27-66) in the prone group and at 33.5 % (23-44) in the supine group. The difference between the two cumulative probability curves was not statistically significant (p = 0.11). In the univariate Cox model, VAP was associated with an increase in the mortality rate during the ICU stay [HR 1.65 (1.05-2.61), p = 0.03]. HR increased to 2.2 (1.39-3.52) (p < 0.001) after adjustment for position group, age, SOFA score, McCabe score, and immunodeficiency. CONCLUSIONS: In severe ARDS patients prone positioning did not reduce the incidence of VAP and VAP was associated with higher mortality.

Value of prostate multiparametric magnetic resonance imaging for predicting biopsy results in first or repeat biopsy.

AIM: To assess multiparametric magnetic resonance imaging (mp-MRI) in predicting prostate biopsy results. MATERIALS AND METHODS: Patients who underwent mp-MRI prior to prostate biopsy were prospectively included. The prostate was subdivided into 14 sectors and mp-MRI findings assessed using a five-level subjective suspicion score (SSS). Biopsy included targeted samples of abnormal sectors and systematic samples of normal peripheral zone sectors. RESULTS: Two hundred and eighty-eight patients were included [153 biopsy naïve, 135 with negative (n = 51) or positive (n = 84) prior biopsy]. Biopsy was positive in 168 patients. mp-MRI area under the receiver operating characteristic (ROC) curve (AUC) was 69.1% (95% CI: 67.1-70.9%), 72.5% (95% CI: 69.5-76%), and 73.8% (95% CI: 68.3-79.3%) at per sector, per lobe, and per patient analysis, respectively. At the per sector level, the AUC was significantly larger if detection was limited to cancers with a Gleason score of ≥7 (72.6%; 95% CI: 69.8-75.8%; p < 0.01) or ≥8 (87.1%; 95% CI: 78.3-95.7%; p < 0.01). mp-MRI performance was significantly influenced by prostate volume (p = 0.02), the presence of a concordant hypoechoic area (p < 0.001), but not by prostate-specific antigen (PSA) value, status of prior biopsy, or radiologists' experience. SSS was significantly associated with the Gleason score in true-positive lobes and patients (p < 0.0001). Using a SSS threshold of ≥3, cancer was missed in 13/102 lobes and 4/72 patients with cancers of Gleason score ≥7. CONCLUSION: mp-MRI provides a good detection of cancers with a Gleason score of ≥7 in candidates suitable for prostate biopsy.

[Frequency, causes and risk factors of postpartum haemorrhage: a population-based study in 106 French maternity units]. / Incidence, étiologies et facteurs de risque de l'hémorragie du post-partum : étude en population dans 106 maternités françaises.

OBJECTIVE: To estimate the incidence, to describe the aetiology and to identify the risk factors of postpartum haemorrhage (PPH). MATERIAL AND METHOD: Prospective study conducted in 106 French maternity units of six perinatal networks between December 2004 and November 2006. PPH was defined by a blood loss superior to 500 mL or necessitating an examination of the uterus, or a peripartum haemoglobin drop superior to 2 g/dL. Severe PPH was defined by at least one of these criteria : peripartum haemoglobin drop superior or equal to 4 g/dL, embolization, conservative surgical procedure, hysterectomy, transfusion, transfer to intensive care or death. RESULTS: The incidence of PPH was 6.4% [CI 95% 6.3-6.5] with variations between maternity units from 1.5% to 22.0%; incidence of severe PPH was 1.7% [CI 95% 1.6-1.8] with variations between units from 0% to 4%. Atony was the main aetiology of PPH, whatever the mode of delivery and severity. The risk factors identified were those classically described in the literature. CONCLUSION: In these six French perinatal networks, in 2005-2006, the PPH profile was characterized by an incidence of severe forms higher than previous population-based estimates from other countries. This suggests a more frequent aggravation of PPH and the implication of inadequate PPH management.

Rehabilitation of 190 non-ambulatory children with cerebral palsy in structures of care or in liberal sector.

AIMS: To describe the rehabilitation of non-ambulatory children with cerebral palsy and to explore adjustability on their individual needs. MATERIAL AND METHOD: Data described are extracted from an on-going national cohort study, following during 10years 385 children with cerebral palsy, aged from 4 to 10, Gross Motor Function Classification System IV and V. We analysed data from the first 190 patients (mean age 6years 10months (SD 2.0), 111 boys), focusing on physiotherapy, ergotherapy, psychomotility and speech therapy in medico-social and liberal sectors. RESULTS: In medico-social sector, duration of paramedical care is significantly more important than in liberal sector (structure of care: median=4.25h/week, liberal sector: median=2.00h/week) (P<0.0001). More than 4 different types of care per week are given in medico-social sector, while in liberal sector children benefit from only 2 different types of care a week. In investigators opinion, rehabilitation in structures of care is 71.65% adapted as opposed to 18.75% in the liberal sector (P<0.001). Children level V have less time of rehabilitation than the others (P=0.0424). INTERPRETATION: Rehabilitation of children with cerebral palsy who are not able to walk, with an objective to improve quality of life, is truly multidisciplinary and suitable in medico-social sector.

Benchmarking French regions according to their prevalence of healthcare-associated infections.

OBJECTIVE: To propose an original method of benchmarking regions based on their prevalence of healthcare-associated infections (HAIs) and to identify regions with unusual results. DESIGN: To study between-region variability with a three-level hierarchical logistic regression model and a Bayesian non-parametric method. SETTING: French 2006 national HAIs point prevalence survey. PARTICIPANTS: A total of 336 858 patients from 2289 healthcare facilities in 27 regions. Patients with an imported HAI (1% of the data, 20.7% of infected patients), facilities with <5 patients and patients who had at least one missing value for the variables taken into account were excluded (5.0% of patients). MAIN OUTCOME MEASURE: Binary outcome variable indicates whether a given patient was infected. RESULTS: Two clusters of regions were identified: one cluster of five regions had a lower adjusted prevalence than the other one of 22 regions, while no region with unusually high prevalence could be identified. Nevertheless, the degree of heterogeneity of odds ratios between facilities for facility-specific effects of use of invasive devices was more important in some regions than in others. CONCLUSIONS: The adjusted regional prevalence of HAIs can serve as an adequate benchmark to identify regions with concerning results. Although no outlier regions were identified, the proposed approach could be applied to the data of the 2012 national survey to benchmark regional healthcare policies. The estimation of facility-specific effects of use of invasive devices may orient future regional action plans.

Clonidine and dexmedetomidine increase the pressor response to norepinephrine in experimental sepsis: a pilot study.

OBJECTIVE: During septic shock, vasopressors are a cornerstone of therapy. In septic shock, very high doses of vasopressors sometimes have to be used due to vascular desensitization, the mechanisms of which are poorly understood. This study assesses whether α-2 agonists increase pressor responsiveness following lipopolysaccharide administration. DESIGN: Parallel groups of animals (n = 7 per group) subjected to pharmacologic interventions. SETTING: Physiology laboratory. SUBJECTS: Rats. INTERVENTIONS: In anesthetized rats, the pressor responses to increasing doses of norepinephrine (norepinephrine-systolic pressure curve) were assessed during a baseline period, after injection of saline or lipopolysaccharide, and after subsequent injection of saline, dexmedetomidine (100 µg/kg IV), or clonidine (200 µg/kg IV). MEASUREMENTS AND MAIN RESULTS: Differences in the slopes of the norepinephrine-pressure curves were assessed across drug treatments and intervals. The pressor dose of norepinephrine necessary to increase systolic pressure by 33 and 100 mm Hg (pressor dose 33 and pressor dose 100) was determined. Pressor responsiveness to norepinephrine decreased slightly over time in the saline-saline group (saline 1 or 2 vs baseline: mean decrease of the slope, 2 mm Hg/µg/kg norepinephrine; p < 0.05), whereas there was a large decrease after lipopolysaccharide (lipopolysaccharide vs baseline: mean decrease of the slope, 7.2; p < 0.001). Clonidine alone had no effect, but when administered following lipopolysaccharide, it caused a striking increase in pressor responsiveness (mean slope after lipopolysaccharide, 10.7 [95% CI, 9.9-11.6]; after clonidine, 17.5 [95% CI, 16.7-18.4]). Similarly, dexmedetomidine administered after lipopolysaccharide caused a large increase in pressor responsiveness above lipopolysaccharide values. Accordingly the pressor dose 33 and pressor dose 100 values were lowered following lipopolysaccharide and restored by α-2 agonists. CONCLUSIONS: The pressor response to norepinephrine was reduced following lipopolysaccharide and increased to baseline levels following α-2 agonists.

Differentiation of transitional zone prostate cancer from benign hyperplasia nodules: evaluation of discriminant criteria at multiparametric MRI.

AIM: To assess topographical and magnetic resonance imaging (MRI) features in characterizing prostate transitional zone (TZ) nodules. MATERIALS AND METHODS: Two radiologists evaluated all TZ nodules visible at multiparametric MRI in 52 consecutive patients who underwent radical prostatectomy. The radiologists assessed topographical (anteroposterior and superior-inferior location, crossing of the sagittal midline) and T2-weighted (shape, presence and distinctness of capsule, distinctness of contours, presence of cysts) features, the apparent diffusion coefficient (ADC), and eight semi-quantitative and quantitative enhancement parameters derived from dynamic contrast-enhanced (DCE) imaging. The nature of the nodules was assessed using prostatectomy specimens. Five statistical methods taking into account multiple testing were used. RESULTS: One hundred and thirty-seven nodules (117 benign, 20 malignant) were evaluated. Mean ADC, all topographical, and all T2-weighted features were significant predictors of malignancy according to at least four out of the five statistical methods. Particularly, 20/20 and 18/20 cancers involved the anterior and apical third of the TZ, respectively. None of the enhancement parameters was significantly different between cancers and benign nodules. By assessing the presence of cysts, the nodules' capsule, and their anteroposterior and superior-inferior location, 111/117 benign nodules were correctly diagnosed, without misclassifying any cancer. CONCLUSION: Topographical, T2-weighted, and diffusion-weighted features can be used to characterize TZ nodules. DCE imaging does not seem to provide additional information.

[Congenital toxoplasmosis: long-term ophthalmologic follow-up praised by patients]. / Toxoplasmose congénitale; le suivi ophtalmologique à long terme plébiscité par les patients.

INTRODUCTION: Ocular lesions of congenital toxoplasmosis may occur and relapse unpredictably even a long time after birth. There is no consensus concerning the necessity or timing of ophthalmologic follow-up for these patients. We surveyed adults with congenital toxoplasmosis followed regularly since birth, in order to learn their perceptions of this follow-up. The goal of this study was to provide doctors with patient-reported information on how they perceived the long-term monitoring of their disease. METHODS: Enrolled patients were given a two-question questionnaire addressing the way they perceived the long-term follow-up and their attitudes toward continuing it. Eligible patients had to be 18 years or older and to have undergone ophthalmologic follow-ups, including funduscopy, every year since birth. The last ophthalmologic examination had to be within one year of the patient's inclusion in the study. RESULTS: Of the 102 patients finally included in the study, 98% stated that the follow-up was useful and 92% reassuring. Among the 11% of patients who found the follow-ups frightening, the proportion of patients with low visual acuity and low score on the visual function test was significantly higher than among the others. All patients except two wished to continue with regular follow-up. CONCLUSION: Without general agreement or guidelines on how patients with congenital toxoplasmosis should be monitored, the patient's wishes are important in making a decision. Our study brought out a clear fact; the majority of patients found long-term follow-up useful and reassuring and wished to continue.

[Practices for management of grave postpartum haemorrhage after vaginal delivery: a population-based study in 106 French maternity units]. / Prise en charge des hémorragies graves du post-partum après un accouchement par voie basse : étude en population dans 106 maternités françaises.

OBJECTIVES: Describe management of severe postpartum haemorrhages (PPH) and its compliance with national guidelines and identify determinants of non-optimal care. PATIENTS AND METHOD: Population-based cohort study of 1379 women with severe PPH due to uterine atony after vaginal delivery, conducted in 106 French maternity units between December 2004 and November 2006. Severe PPH was defined by a peripartum haemoglobin drop of 4g/dL or more, blood loss of 1000 mL or more, hysterectomy, or transfer to intensive care for PPH. The frequency of each recommended procedure for the management of PPH was described. Associations between quality of care and both individual and institutional characteristics were assessed by univariate analysis and multivariate logistic regression. RESULTS: Management of severe PPH was not optimal in 65.9% of cases. The recommended components that were applied least often were administration of second line uterotonics, and transfusion of patients with a low haemoglobin. After adjustment for individual characteristics, the risk of either non- or suboptimal care was significantly higher in non-university public maternity units (aOR 2.62 [95% CI: 1.49-4.54]) compared with university hospital units, in units with fewer than 2000 annual deliveries (aOR 2.32 [95% CI: 1.49-3.57]), and in units without an obstetrician always present (aOR 1.96 [95% CI: 1.26-3.03]). CONCLUSIONS: Management practices for severe PPH can be improved, to an extent that varies by component of care and type of hospital. A qualitative approach should help to identify the individual and organizational factors explaining why guidelines are not fully applied.

Does weight loss predict accuracy of setup in head and neck cancer patients treated with Intensity-Modulated Radiation Therapy?

PURPOSE: This prospective study reports the impact of weight loss on setup of head and neck (H&N) cancer patients treated by Intensity-Modulated Radiation Therapy (IMRT). MATERIALS AND METHODS: Setup errors of H&N cancer patients treated by IMRT from January to June 2010 were prospectively analysed and statistically related to weight loss. A mixed linear model was used for statistical evaluations. Setup margins of our institute were also calculated. RESULTS: Twenty-two patients and 128 pairs of Electronic Portal Images (EPI) were analysed. Setup errors varied between -0.6 and +0.6, -0.7 and +0.8 and -0.2 and +0.8 in the anterior-posterior, superior-inferior and right-left direction, respectively. Median and mean weight loss were 2.1 and 3.1 kg (range 0-12 kg), respectively; median and mean percent of weight loss were 2.95% and 4.64% (range 0.3-19.7%), respectively. No statistical relation was seen between weight loss and the setup errors. CONCLUSIONS: Weight loss is not a good clinical parameters for predicting an increase of setup errors. Other clinical and/or anthropometrical features should be prospectively evaluated in order to assess the need for re-planning.

Multifaceted intervention to decrease the rate of severe postpartum haemorrhage: the PITHAGORE6 cluster-randomised controlled trial.

OBJECTIVE: Decreasing the prevalence of severe postpartum haemorrhages (PPH) is a major obstetrical challenge. These are often considered to be associated with substandard initial care. Strategies to increase the appropriateness of early management of PPH must be assessed. We tested the hypothesis that a multifaceted intervention aimed at increasing the translation into practice of a protocol for early management of PPH, would reduce the incidence of severe PPH. DESIGN: Cluster-randomised trial. POPULATION: 106 maternity units in six French regions. METHODS: Maternity units were randomly assigned to receive the intervention, or to have the protocol passively disseminated. The intervention combined outreach visits to discuss the protocol in each local context, reminders, and peer reviews of severe incidents, and was implemented in each maternity hospital by a team pairing an obstetrician and a midwife. MAIN OUTCOME MEASURES: The primary outcome was the incidence of severe PPH, defined as a composite of one or more of: transfusion, embolisation, surgical procedure, transfer to intensive care, peripartum haemoglobin decrease of 4 g/dl or more, death. The main secondary outcomes were PPH management practices. RESULTS: The mean rate of severe PPH was 1.64% (SD 0.80) in the intervention units and 1.65% (SD 0.96) in control units; difference not significant. Some elements of PPH management were applied more frequently in intervention units-help from senior staff (P = 0.005), or tended to - second-line pharmacological treatment (P = 0.06), timely blood test (P = 0.09). CONCLUSION: This educational intervention did not affect the rate of severe PPH as compared with control units, although it improved some practices.

Robust non-linear mixed modelling of longitudinal PSA levels after prostate cancer treatment.

The objective of this study was to develop a robust non-linear mixed model for prostate-specific antigen (PSA) measurements after a high-intensity focused ultrasound (HIFU) treatment for prostate cancer. The characteristics of these data are the presence of outlying values and non-normal random effects. A numerical study proved that parameter estimates can be biased if these characteristics are not taken into account. The intra-patient variability was described by a Student-t distribution and Dirichlet process priors were assumed for non-normal random effects; a process that limited the bias and provided more efficient parameter estimates than a classical mixed model with normal residuals and random effects. It was applied to the determination of the best dynamic PSA criterion for the diagnosis of prostate cancer recurrence, but could be used in studies that rely on PSA data to improve prognosis or compare treatment efficiencies and also with other longitudinal biomarkers that, such as PSA, present outlying values and non-normal random effects.