[Adverse obstetric and perinatal outcome with in vitro fertilization technology: A French nationwide population-based study]. / Risques de morbidité maternelle et périnatale en fécondation in vitro : une étude nationale de cohorte française.

OBJECTIVES: The objective of this study was to quantify the risk of maternal and perinatal morbidity with in vitro fertilization (IVF) technology compared to non-IVF pregnancies in a recent French national cohort. METHOD: The data was extracted from the hospital information data system, including all pregnancies with a delivery from 2013 to 2016. The risks of preterm birth, maternal morbidity (venous and arterial thrombosis, gestational diabetes, vascular disorders, placenta previa, placenta abruption), hypotrophy and congenital malformation were compared in both groups in univariate and multivariate analysis after adjustment on the characteristics of women (age, parity, obesity, tobacco dependence, history of diabetes or high blood pressure), multiple deliveries and sex of children. RESULTS: In all, 2,875,662 pregnancies and 2,922,712 births were analyzed, of which 49,224 were derived from IVF (1.7%). In multivariate analysis, all risks were significantly higher in IVF: premature deliveries (ORajusted=1.28; CI95%=1.24-1.32), maternal morbidity (ORajusted=1.24; CI95%=1.21-2.28), (mainly for thrombosis venous, placenta previa and placenta abruption). The risks of hypotrophy (ORajusted=1.13; CI95%=1.10-1.16) and congenital malformations (ORajusted=1.11; CI95%=1.05-1.17) were slightly increased. CONCLUSION: The results of this study on a large cohort of recent births in France confirm that there was an increased risk of maternal and perinatal morbidities in IVF. These risks were similar to those published in the international literature. This study is the starting point for a forthcoming surveillance.

A simple clinico-histopathological composite scoring system is highly predictive of graft outcomes in marginal donors.

The predictive value of pre-implantation biopsies versus clinical scores has not been studied extensively in marginal donors. Pre-implantation biopsies were performed in 313 kidneys from donors that were > or = 50 years of age (training set, n = 191; validation set, n = 122). The value of the donor clinical parameters and histological results in predicting 1-year estimated glomerular filtration rate (eGFR) <25 mL/min/1.73 m(2) was retrospectively evaluated. In multivariate analysis, the only clinical parameters associated with low eGFR were donor hypertension and a serum creatinine level > or =150 micromol/L before organ recovery. Clinical scores (Nyberg and Pessione) were not significantly associated with graft function. Regarding histological parameters, univariate analysis showed that glomerulosclerosis (GS) (p = 0.02), arteriolar hyalinosis (p = 0.03) and the Pirani (p = 0.02) and chronic allograft damage index (CADI) (p = 0.04) histological scores were associated with low eGFR. The highest performance in predicting low eGFR was achieved using a composite score that included donor serum creatinine (> or =150 micromol/L or <150 micromol/L), donor hypertension and GS (> or =10% or <10%). The validation set confirmed the critical importance of taking into account biopsy and clinical parameters during marginal donor evaluation. In conclusion, clinical scores are weak predictors of graft outcomes with marginal donors. Instead, a simple and convenient composite score strongly predicts graft function and survival and may facilitate optimal allocation of marginal donors.

Post-transplant lymphoproliferative disorders occurring after renal transplantation in adults: report of 230 cases from the French Registry.

Post-transplant lymphoproliferative disorders (PTLD) are a rare but serious complication after organ transplantation. A French Registry of PTLD was set up in a nationwide population of kidney transplant recipients. We prospectively enrolled all adult kidney recipients developing PTLD between January 1, 1998, and December 31, 2003. We analyzed the incidence, risk and prognostic factors of PTLD by Kaplan-Meier and Cox analyses. Totally 230 cases of PTLD were referred to the French Registry. Cumulative incidence was 1.18% after 5 years. Older age (per year, AHR = 2.19, CI = 1.22-3.94) and recipient Epstein-Barr virus seronegativity (AHR = 3.01, CI = 1.57-5.08) were associated with an increased risk of PTLD. Patients with PTLD had a reduced survival rate (61% at 5 years). Graft PTLD had the best prognosis with an 81% survival rate after 5 years. Infection with hepatitis C or B virus (HCV or HBV), late-onset PTLD, multiple sites involvement and high Ann Arbor staging were risk factors for patient death. Use of azathioprine was associated with a poorer survival rate. PTLD incidence and risk factors in French recipients are in line with the international or American PTLD series. We highlighted the role of HBV or HCV in patient mortality and described the relevant prognosis factors for patients with post-transplant lymphoproliferations.

Five-year survival predictive factors in patients with excessive alcohol intake and cirrhosis. Effect of alcoholic hepatitis, smoking and abstinence.

AIM: To evaluate 5-year survival predictive factors in hospitalised patients with excessive alcohol intake and cirrhosis, including in a multivariate analysis the severity of the liver disease, gastrointestinal bleeding, concomitant viral B or C infection, smoking status, presence of alcoholic hepatitis at inclusion and abstinence from alcohol during follow-up. METHODS: In a non-concurrent cohort study, 122 patients with excessive alcohol intake and cirrhosis were followed up at least five years or till death. Two patients were lost to follow-up. RESULTS: The 5-year survival rates were 43% in the 122 patients and 66%, 50% and 25% in Child-Pugh class A, B and C patients, respectively. In multivariate analysis, age (P = 0.01), Child-Pugh score (P = 0.0001), gastrointestinal bleeding (P = 0.01), presence of HBs Ag and/or anti-HCV (P = 0.03), smoking (P = 0.01), absence of histologically proven alcoholic hepatitis (P = 0.05) and persistent alcohol intake (P = 0.002) were associated with significantly increased risk ratios of death. CONCLUSIONS: In hospitalised patients with excessive alcohol intake and cirrhosis: (1) age, liver failure, gastrointestinal bleeding, concomitant viral B or C infection and persistent alcohol intake are independent poor prognostic markers, (2) smoking may contribute to the aggravation of cirrhosis, and (3) alcoholic hepatitis, being a potentially reversible cause of liver failure, has a favourable prognostic significance.

Risk of pancreatic adenocarcinoma in chronic pancreatitis.

BACKGROUND: The risk of pancreatic cancer in patients with chronic pancreatitis (CP) is difficult to assess. Previous studies, mostly case control studies or studies relying on data case registers, reported relative risks varying from 2.3 to 18.5. METHODS: We studied a prospective, single centre, medical-surgical cohort of 373 consecutive patients (322 (86%) men, median age 40 years) with proven CP (alcoholic origin 85%) and a follow up of at least two years (median follow up 9.2 years; range 2.0-34.8) in order to exclude pancreatitis revealing pancreatic cancer. We calculated the age and sex standardised incidence ratio (SIR) as the ratio of the number of observed cases of pancreatic cancer in this cohort to the number of expected cases, as provided by the French National Cancer Register. RESULTS: Four cases of pancreatic adenocarcinoma (1.1% of patients) were observed in 3437 patient years (expected number of cases 0.15; SIR 26.7, 95% confidence interval (CI) 7.3-68.3; p=0.00002). In a second analysis in which patients lost to follow up were considered to be followed up until the end point without having developed pancreatic adenocarcinoma (4762 patient years), SIR was 19.0 (CI 5.2-48.8; p=0.00007). CONCLUSION: Patients with CP have a markedly increased risk of pancreatic cancer compared with the general population.

Cigarette smoking and hepatic lesions in patients with chronic hepatitis C.

A possible hepatotoxicity of cigarette smoke has been recently suggested by epidemiological and experimental studies. Our aim was to study the possible relationships between smoking and liver fibrosis and activity in patients with chronic hepatitis C. A cross-sectional study was performed in a group of 310 patients with chronic hepatitis C consecutively hospitalized for their first liver biopsy. The relationships between age, gender, alcohol consumption, route of contamination, tobacco consumption, and Knodell fibrosis and activity scores were examined in univariate, age-adjusted, and multivariate analyses. One hundred and seventy-six patients (57%) were current smokers. Smokers were younger (P <.001), more often of male gender (P =.001), more often alcohol consumers (P =.001), and more often had a history of intravenous drug use (P =.0001) than never smokers. Smoking was related to increased fibrosis and activity scores in age-adjusted (P =.009 and P =.005, respectively) and multivariate analyses (P =.03 and P =.04, respectively). Smoking increases the severity of hepatic lesions in patients with chronic hepatitis C.

[Patients with alcoholic liver disease hospitalized in gastroenterology. A national multicenter study]. / Maladies alcooliques du foie hospitalisées en Hépato-Gastroentérologie. Enquête multicentrique nationale.

OBJECTIVES: To describe the characteristics of in-patients with alcoholic liver disease in Hepatogastroenterology and to evaluate whether geographic location was a risk factor for cirrhosis. METHODS: A French, national, multicenter, prospective investigation was performed in the last quarter of 1997. To be included in the study, patients had to have drunk at least 50 g of alcohol per day for the past year or to have cirrhosis. RESULTS: Seventeen centers included 802 patients, 20% had histologically proven cirrhosis or probable cirrhosis. Thirty-five percent had undergone liver biopsy. Twenty five percent of these patients had cirrhosis without acute alcoholic hepatitis and 37% had cirrhosis with acute alcoholic hepatitis. After dividing France along a Bordeaux-Strasbourg axis, there was more histologically proven or probable cirrhosis in the North (46%) than in the South (36%) (P<0.005) while daily alcohol intake was greater the South (150 +/- 6 g) than in the North (129 +/- 4 g) (P<0.0001). When the six variables (age, sex, daily consumption of alcohol over the past 5 years, presence of hepatitis B surface antigen and antibodies to hepatitis C virus, total duration of alcohol abuse) were considered together in stepwise logistic regression analysis, geographic location changed the prediction of cirrhosis. The odds ratio for cirrhosis in patients living to the North of the Bordeaux-Strasbourg axis was 1.9 (95% confidence interval range 1.1-3.2) (P<0.02), suggesting the role of nutritional factors.

Recent portal or mesenteric venous thrombosis: increased recognition and frequent recanalization on anticoagulant therapy.

Characteristics and outcomes of recent portal or mesenteric venous thrombosis are ill-known. We intended to compare these features with those of patients with portal cavernoma, and also to assess the incidence of recanalization of recent thrombosis on anticoagulation therapy. All patients seen between 1983 and 1999 were enrolled into this retrospective study if recent portal or mesenteric venous thrombosis or portal cavernoma had been documented, and if cancer of the liver, pancreas, or bile duct, intrahepatic block including cirrhosis, and obstruction of the hepatic veins had been ruled out. The proportion of recent thrombosis was 7% in patients seen before 1990 and 56% after 1994 (P <.05). Patients with recent thrombosis (n = 33) or cavernoma (n = 108) did not differ with regard to age, sex ratio, or prevalence of prothrombotic states and of previous thrombotic events. In patients with recent thrombosis, septic pylephlebitis was more common and the incidence of gastrointestinal bleeding was lower (2.4 vs. 12.7/100 patient-years). Recanalization occurred in 25 of 27 patients given anticoagulation and 0 of 2 patients not given anticoagulation. The probability of recanalization was related to the extent of thrombosis (P =.003). In conclusion, mesenteric or portal venous thrombosis is increasingly recognized at an early stage. The features differentiating recent thrombosis and cavernoma are related to silent onset precluding early recognition and therapy in the latter. Frequent association with prothrombotic states and frequent recanalization on anticoagulation support the recommendation of early anticoagulation therapy in all patients with recent portal vein thrombosis.

[Problem drinking]. / Les consommateurs d'alcool à problème.

The seriousness and the difficult care of the alcohol-dependent persons often occult an other category of persons drinking too much: the problem drinkers. Nevertheless, these persons are as many in the practice of all the physicians and their various pathologies concern all the medical specialties. Their identifying is based on the self declared consumption. Their lack of dependence and their attendance with their general practitioner make their care easier. A brief intervention aiming to reduce their consumption is a primary or secondary prevention which is more often enough to resolve all or part of their complaints.

Effect of alcohol consumption on serum hepatitis C virus RNA and histological lesions in chronic hepatitis C.

The role of alcohol intake in the occurrence of severe liver disease in chronic hepatitis C virus (HCV) carriers is still debated. A cross-sectional study has been conducted in 233 chronic hepatitis C virus carriers. Weekly self-reported alcohol consumption (SRAC) was evaluated, serum HCV RNA levels were measured by a branched DNA technique (Quantiplex 2.0) and HCV genotypes were determined. A liver biopsy was performed simultaneously and liver lesions were graded with the Knodell histological activity index. Data were examined by uni- and multivariate analyses. Alcohol consumption was relatively low (< 140 g/per week in 193/233 patients [80%]). We found a highly significant correlation between SRAC and serum HCV RNA levels (r = .26, P = .001). Fibrosis was significantly correlated with age and alcohol consumption. These results suggest that in HCV carriers, alcohol consumption, even with low alcohol intake, increases viremia and hepatic fibrosis. Chronic HCV carriers should be advised to avoid regular alcohol intake.

Relationship between alcohol and tobacco dependencies among alcoholics who smoke.

Outpatients followed in an alcoholic clinic and who fulfilled DSM-III-R criteria for alcohol dependence and had used both tobacco (at least one cigarette every day) and alcohol in the preceding week were studied. For each patient, two experimenters assessed: (1) the amount of tobacco and alcohol used; (2) the severity of dependence for each product. Results showed that: (a) The prevalence of smoking in this population of current alcohol dependents was 88%; (b) 91.6% of this sample of smoker alcoholics were dependent on nicotine; (c) the amount of tobacco smoked was correlated to the amount of alcohol consumed and the severity of alcohol dependence; and (d) there was a correlation between the severity of alcohol and nicotine dependencies. The results of this study may help to clarify the difficulty of treating tobacco dependence in alcoholics.

[Chlamydia trachomatis: risk factors in women in the Parisian region. Importance of smoking and cervical ectropion]. / Chlamydia trachomatis: facteurs de risque chez les femmes de la région parisienne. Importance du tabagisme et de l'ectropion cervical.

A study of chlamydial infection and its clinical correlates was undertaken collaboratively among french women attending sexually transmitted disease (STD, prenatal, and teen clinics (n = 148). A complete sexual and gynecologic history and pelvic exam was performed on all women. Endocervical and urethral cultures were obtained for C. trachomatis and N. gonorrhoeae. Reason for visit included suspected STD in 97% of STD, 5% of prenatal and 17% of teen women. N. gonorrhoeae was isolated from STD clinic patients only (17%). C. trachomatis was found in 22% of teen, 17% of STD and 2% of prenatal clinic women. C. trachomatis was significantly associated with smoking, a history of urethral discharge in the male partner, and endocervical ectopy > 50% of total cervical surface.

Lead-exposed workmen and fertility: a cohort study on 354 subjects.

A cohort study was conducted in a French battery factory in 1977-1982 to explore the relationship between occupational lead exposure and fertility. A total of 354 battery workers, divided into 229 lead-exposed subjects (corresponding with 886 person-years) and 125 non-lead-exposed subjects (corresponding with 598 person-years) were compared, in a person-year analysis, for the risk of infertility. Lead exposure, at any level of absorption, did not appear significantly associated with a reduction in fertility after controlling for potential confounders: age, French origin, educational level, number of children at start of the period, cigarette smoking and exposure to heat. The apparent inconsistency between our results and those of several studies involving biological data and semen analysis is partially explained by recent knowledge relating to predictive value on the pregnancy of semen abnormalities.

[Prognosis of spontaneous ascitic infection in cirrhotic patients]. / Pronostic de l'infection spontanée d'ascite chez le cirrhotique.

The aim of this retrospective study was to define prognostic factors for cure and survival after spontaneous bacterial peritonitis. In a 4-year period from 1982 to 1986, spontaneous bacterial peritonitis was diagnosed in 38 consecutive hospitalized cirrhotic patients (positive ascites culture and polymorphonuclear cell concentration greater than 250 cells per mm3). Twenty-five patients recovered from their infection (69 p. 100) in a mean time of 9 +/- 7 days. The cumulative survival was 68 p. 100 at one week, 50 p. 100 at one month, and 25 p. 100 at one year. The best independent prognostic factors for lack of cure from peritonitis were a low ascitic pH value (p less than 0.001), an elevated serum creatinine level (p = 0.01) and the presence of hepatocellular carcinoma (p less than 0.05). The best prognostic factors for death were low ascitic pH value (p = 0.001) and gastrointestinal hemorrhage (p = 0.005). A low ascitic pH value was correlated with other signs of severe infection (signs of generalized infection, ongoing infection during the first week after diagnosis), with signs of severe liver disease (encephalopathy, hepatocellular carcinoma) or severe renal dysfunction (high serum creatinine level, low arterial pH value). Because of the late high-death rate associated with spontaneous bacterial peritonitis, liver transplantation should be considered in these patients.

Score tests for homogeneity of regression effect in the proportional hazards model.

A simple model, containing the proportional hazards regression model as a special case, is presented. The purpose of the model is to provide a framework in which specific alternatives to the proportional hazards assumption may be tested. Rank-invariant score tests for linear, quadratic, or exponential trends can, for instance, all be undertaken within this framework. In the case of the two-sample problem the required calculations are shown to take a particularly simple form. Special consideration is given to the two-sample case in which there is an inversion of the regression effect, i.e., where the hazard functions cross at some given point. Both of the motivating examples are concerned with this problem. Computational aspects are relatively straightforward and some discussion on this is provided.

Sexual behavior and smoking: risk factor for urethritis in men.

Two hundred men who had symptoms of urethritis and 207 controls were interviewed. Because 60% of the men were of foreign nationality, the analysis of risk factors for urethritis was undertaken separately for the French and foreign subpopulations. The risk factors for urethritis were different for the French and foreign men. For the French men who had smoked, the risk of infection was 2.9 times greater than that for men who had never smoked (95% confidence interval, 1.2-7.6), after taking type of sexual behavior into account. There is a significant increase in the risk of urethritis when the amount of tobacco consumed daily increases (P less than 0.02). This finding suggests that smoking is an independent risk factor.