[Breech presentation at term: evolution of French practices and an analysis of neonatal results in regards to obstetrical management of breech presentation, from AUDIPOG Database]. / La présentation du siège à terme: évolution des pratiques en France et analyse des résultats néonatals en fonction des pratiques obstétricales, à partir du Réseau Sentinelle AUDIPOG.

OBJECTIVES: To describe the evolution of medical practices in breech presentation at term and to compare early neonatal complications according to initial obstetrical decision on the type of delivery. METHODS: 71919 pregnancies are included in the AUDIPOG Database from 1994 to 2000. Among this cohort, pregnant women with a singleton in breech, at term were selected which represented 2136 women after the exclusion of in utero deaths and medical abortions. The first outcome was global criteria of severe early neonatal complications ("death during per or immediate post partum or transfer of the newborns to an intensive care or surgery unit"). The size of the sample authorized a power of 90%. RESULTS: The rate of cesarean section before labor was 40%. We found 2.3% of early neonatal complications in the group in which labor was accepted vs. 1.9% in the group with cesarean section performed before labor (p>0.05). After having taken into account prognostic factors, we do not see a significant difference for the risk of neonatal complications between the two groups (OR=1.33; 95% CI: 0.63-2.80). CONCLUSION: The analysis of the AUDIPOG Database describes the French obstetrical practice in breech presentation at term. We do not find a different risk in morbi-mortality as regards to the initial obstetrical choice regarding the type of delivery, but the absence of randomization in our study does not authorize a strong medical evidence to guide national recommendations.

Transvaginal ultrasonography of the uterine cervix in hospitalized women with preterm labor.

OBJECTIVE: The aim of this study was to examine the relation between cervical length and the presence of funneling and the risk of preterm delivery. METHOD: This prospective blind cohort involved 200 hospitalized women with preterm labor in a tertiary care hospital. Women were recruited for a single transvaginal ultrasonography to assess cervical length and presence of funneling. The main outcome measures were: (1) relative risks (RR) and adjusted odds ratios of preterm delivery (<37 weeks' gestation); (2) time interval between the cervical ultrasonography date to 37 weeks' gestation or to-preterm birth. RESULTS: The RR of preterm delivery according to the cervical length (cut-off of <30 mm) was 2.79 (95% CI 1.70--4.59). The RR according to the presence of funneling (cut-off of >5 mm) was 1.39 (95% CI 0.99--1.95). The adjusted odds ratio was 3.92 (95% IC 1.75--8.75) for cervical length and 0.77 (95% CI 0.35--1.67) for funneling. Women with a cervical length of <30 mm had a significantly shorter interval from ultrasonography date up to 37 weeks' gestation than did women with a cervical length of >30 mm (P<0.003). CONCLUSION: Ultrasonographic mensuration of the cervix provides predictive information on the risk of preterm delivery.

Mediterranean diet, traditional risk factors, and the rate of cardiovascular complications after myocardial infarction: final report of the Lyon Diet Heart Study.

BACKGROUND: The Lyon Diet Heart Study is a randomized secondary prevention trial aimed at testing whether a Mediterranean-type diet may reduce the rate of recurrence after a first myocardial infarction. An intermediate analysis showed a striking protective effect after 27 months of follow-up. This report presents results of an extended follow-up (with a mean of 46 months per patient) and deals with the relationships of dietary patterns and traditional risk factors with recurrence. METHODS AND RESULTS: Three composite outcomes (COs) combining either cardiac death and nonfatal myocardial infarction (CO 1), or the preceding plus major secondary end points (unstable angina, stroke, heart failure, pulmonary or peripheral embolism) (CO 2), or the preceding plus minor events requiring hospital admission (CO 3) were studied. In the Mediterranean diet group, CO 1 was reduced (14 events versus 44 in the prudent Western-type diet group, P=0.0001), as were CO 2 (27 events versus 90, P=0.0001) and CO 3 (95 events versus 180, P=0. 0002). Adjusted risk ratios ranged from 0.28 to 0.53. Among the traditional risk factors, total cholesterol (1 mmol/L being associated with an increased risk of 18% to 28%), systolic blood pressure (1 mm Hg being associated with an increased risk of 1% to 2%), leukocyte count (adjusted risk ratios ranging from 1.64 to 2.86 with count >9x10(9)/L), female sex (adjusted risk ratios, 0.27 to 0. 46), and aspirin use (adjusted risk ratios, 0.59 to 0.82) were each significantly and independently associated with recurrence. CONCLUSIONS: The protective effect of the Mediterranean dietary pattern was maintained up to 4 years after the first infarction, confirming previous intermediate analyses. Major traditional risk factors, such as high blood cholesterol and blood pressure, were shown to be independent and joint predictors of recurrence, indicating that the Mediterranean dietary pattern did not alter, at least qualitatively, the usual relationships between major risk factors and recurrence. Thus, a comprehensive strategy to decrease cardiovascular morbidity and mortality should include primarily a cardioprotective diet. It should be associated with other (pharmacological?) means aimed at reducing modifiable risk factors. Further trials combining the 2 approaches are warranted.

[The importance of lipoprotein(a) as a predictive factor of coronary atherosclerosis]. / Importance de la lipoprotéine(a) comme facteur prédictif de l'athérosclérose coronarienne.

OBJECTIVE: The predictive value of lipoprotein(a), Lp(a), for coronary artery disease, is strongly suspected, though unproven. The normal serum level is 0.3 g/l. We searched for correlations between serum Lp(a) levels and coronary artery disease in a population of patients hospitalized in a general cardiology unit. METHOD: Serum Lp(a) was assayed in all patients consecutively hospitalized during 1994 in the Valence hospital cardiology unit. Two groups were distinguished: patients with coronary artery disease (n = 444) and those presumed free of coronary artery disease (n = 555). Coronography were performed when required. Serum Lp(a) levels were compared for the following variables: age, sex, smoking habits, blood pressure, total cholesterol, HDL and LDL-cholesterol, triglycerides and apolipoproteins A1 and A2. Univariate, then multivariate analysis were performed first patients of all ages, then for those aged more and less than 60 years. RESULTS: Univariate analysis demonstrated that Lp(a) > 0.3 g/l was associated with coronary heart disease (OR = 1.33; p = 0.03), although this correlation was no longer significant after adjustment for other known risk factors (OR = 1.28; p = 0.07), except in the subgroup of patients over 60 years of age (OR = 1.37; p = 0.04). CONCLUSION: There was a non-significant trend favoring an association between serum Lp(a) level > 0.3 g/l and the development of coronary artery disease.

Mediterranean dietary pattern in a randomized trial: prolonged survival and possible reduced cancer rate.

BACKGROUND: The Mediterranean dietary pattern is thought to reduce the risk of cancer in addition to being cardioprotective. However, no trial has been conducted so far to prove this belief. METHODS: We compared overall survival and newly diagnosed cancer rate among 605 patients with coronary heart disease randomized in the Lyon Diet Heart Study and following either a cardioprotective Mediterranean-type diet or a control diet close to the step 1 American Heart Association prudent diet. RESULTS: During a follow-up of 4 years, there were a total of 38 deaths (24 in controls vs 14 in the experimental group), including 25 cardiac deaths (19 vs 6) and 7 cancer deaths (4 vs 3), and 24 cancers (17 vs 7). Exclusion of early cancer diagnoses (within the first 24 months after entry into the trial) left a total of 14 cancers (12 vs 2). After adjustment for age, sex, smoking, leukocyte count, cholesterol level, and aspirin use, the reduction of risk in experimental subjects compared with control subjects was 56% (P=.03) for total deaths, 61% (P=.05) for cancers, and 56% (P=.01) for the combination of deaths and cancers. The intakes of fruits, vegetables, and cereals were significantly higher in experimental subjects, providing larger amounts of fiber and vitamin C (P<.05). The intakes of cholesterol and saturated and polyunsaturated fats were lower and those of oleic acid and omega-3 fatty acids were higher (P<.001) in experimental subjects. Plasma levels of vitamins C and E (P<.05) and omega-3 fatty acids (P<.001), measured 2 months after randomization, were higher and those of omega-6 fatty acids were lower (P<.001) in experimental subjects. CONCLUSIONS: This randomized trial suggests that patients following a cardioprotective Mediterranean diet have a prolonged survival and may also be protected against cancer. Further studies are warranted to confirm the data and to explore the role of the different lipids and fatty acids in this protection.

Role of a 10-Gy boost in the conservative treatment of early breast cancer: results of a randomized clinical trial in Lyon, France.

PURPOSE: To define the role of a 10-Gy boost to the primary tumor in the conservative treatment of early infiltrating breast carcinoma treated by limited surgery and radiotherapy. PATIENTS AND METHODS: Between 1986 and 1992, 1,024 women with early breast carcinoma (< or = 3 cm in diameter) were treated by local excision, axillary dissection, and conventional 50-Gy irradiation given in 20 fractions over 5 weeks and then randomly assigned to receive either no further treatment or a boost of 10 Gy by electrons to the tumor bed. The median follow-up time was 3.3 years as of September 1994. The occurrence of telangiectasia was reported, and the patients were asked to evaluate the cosmetic result. RESULTS: At 5 years, 10 patients of 521 who had received the boost (Kaplan-Meier estimate of local relapse rate, 3.6%) and 20 of 503 who had received no further treatment (Kaplan-Meier estimate of local relapse rate, 4.5%) had developed a local recurrence (P = .044). After adjustment for the main prognostic variables, the relative risk was still significantly lower for the boost group (0.3; range, 0.12 to 0.95). The boost group had a higher rate of grade 1 and 2 telangiectasia (12.4% v 5.9%), but no difference was seen between the two treatment arms in the self-assessment score for the cosmetic result. CONCLUSION: Delivery of a boost of 10 Gy to the tumor bed after 50 Gy to the whole breast following limited surgery significantly reduces the risk of early local recurrence, with no serious deterioration in the cosmetic result. Additional follow-up evaluation will be required to assess the long-term results.

Control of bias in dietary trial to prevent coronary recurrences: The Lyon Diet Heart Study.

BACKGROUND AND OBJECTIVES: A major limitation of dietary trials is that double blind design is not feasible. These trials are therefore prone to biases. The Lyon diet heart study is a single-blind secondary prevention trial to test the hypothesis that a Mediterranean-type of diet may prevent recurrences after a first myocardial infarction. A surprising 73% reduction of the risk of new major cardiac events was observed in the experimental group. For this reason, it is important to describe the methods used in the trial. We now report our techniques to randomize the patients, to change their diet and to control for possible bias, in particular any investigator or attending physician bias. DESIGN: In this dietary trial, a specific design was used to recruit and randomize the patients without informing them and their physicians that they were participating in a comparative trial. The attending physician bias was evaluated by studying drug usage and the investigator bias by constructing a questionnaire from which specific scores were used to evaluate (1) how the patients appreciated their participation in the study and (2) whether this participation resulted in significant changes in their way of living. SUBJECTS: 605 survivors of a first myocardial infarction were randomized into either a control or a Mediterranean group. RESULTS: The two randomized groups were similar for all the variables of prognosis. Drug usage was not significantly different between groups, suggesting that there was no major attending physician bias. Analyses of the appreciation scores and of the change score did not detect any significant investigator bias. CONCLUSIONS: Although the study cannot be completely shielded from minor biases, the data presented here provide evidence that the dietary modifications per se were protective, not other (including psychosocial) changes resulting from the participation to the trial.

Use of mammography as a breast cancer screening tool in six districts in France.

Mass screening programs to detect breast cancer are currently under way in many countries. In France, several districts have been running mammographic screening programs since 1989. A survey was conducted in five of these districts and in a sixth district where no screening program was implemented. Using a self-addressed questionnaire mailed to a sample of 1500 women aged over 20 years, the survey was aimed at assessing women's use of mammography as well as their knowledge and perception of mammographic breast cancer screening. According to district, the compliance of the women replying to the questionnaire ranged from 72 to 82%. The proportion of women who had at least one mammography during their life ranged from 41 to 54%, according to district. The percentage of women aged 50 to 69 who had one mammography within 3 years before the survey ranged from 57 to 78% in the experimental districts and was only 48% in the control district. In all districts, women did not know exactly at what age it is recommended to start screening and with what periodicity, but, when invited to do so, they were satisfied with the program and intended to participate again.

Mass screening programs for breast cancer in France--average values of assessment criteria.

Breast cancer is the most common cancer in women worldwide. Many studies have been performed worldwide to assess the effectiveness of screening in terms of reduced mortality due to breast cancer. Since the end of 1989, 10 breast cancer mass screening programs using mammography have been carried out in France under the sponsorship of the National Fund for Health Prevention, Education, and Information (FNPEIS) from the National Health Insurance of Salaried Workers (CNAMTS). These 10 campaigns, which are on a district scale, are organized according to variable methods and are assessed using a common procedure. Four groups of criteria are measured in this procedure, which investigates the impact, quality, effectiveness, and costs of screening programs. The average and extreme values of each criterion as calculated from the campaigns are presented in this paper. In order to enlighten the judgment on the French results, a comparison with the international standards in force and with the results of foreign screening programs is proposed.

[Mass screening programs for breast cancer in France. Comparative evaluation]. / Les programmes de dépistage de masse du cancer du sein en France. Evaluation comparative.

OBJECTIVE: The purpose of this work was to comparatively assess the results of mass screening programs for breast cancer implemented in six French departments in 1986, within the scope of the National Fund for Health Prevention, Education and Information of the National Health Insurance Office of Salaried Workers. MATERIAL AND METHODS: The data collected by the screening centres were analyzed by ten assessment teams that were independent from the program promotion staff, all using the same evaluation form. A complementary population study performed in eight French districts then, allowed assessing the frequency of self-referred screening (mammography performed out of program). RESULTS: The rate of participation in screening programs, in relation to the invited population, ranged from 21 to 48%, according to the district (36% in average). This low participation was probably related to the extent of self-referred screening. In fact, 19 to 40% of women, according to the district, had previously had a screening mammographic coverage: rate was around 68% in women aged 50 to 69 years. Positive findings with mammography ranged from 4.5 to 15.8% (10.1% in average), while intervention rates ranged from 0.7 to 1.6% and detection rates from 3.8 to 6.2%. The ratio between benign tumors and cancers ranged from 0.7 to 2.1 according to the district. In order to enlighten the judgement on French results, we propose a comparison with the international standards in force. CONCLUSION: The various experiences with breast cancer screening in France show that this screening is technically feasible on the basis of existing medical structures. However, some criteria are still below the expected values, especially if compared with international standards. This result is probably accounted for by the high rate self-referred screening before age 40 in France. In these conditions, the question is whether extending breast cancer screening programs in France is an appropriate course of action.

[Experience in mass screening of breast cancer with mammography in France]. / Les expériences de dépistage de masse du cancer du sein par mammographie en France. Un protocole commun d'évaluation.

In the framework of the National Fund for Prevention, Health Education and Information, the setting-up in France, on an experimental basis, of mass breast cancer screening programs by mammography in ten departments leads to suggest a common protocol for the evaluation of these programs, before an eventual generalization to the whole country. These programs are based on common principles: local screening based on existing medical facilities, single view mammography with double reading. However, the screening organisation is different in each department according to the target population, the screening interval, the mode of invitation, the methods for arranging double reading, etc. The purpose of this article is to report on the work of the evaluation group of the ten programs, and to propose a methodology for comparing the screening experiences in order to measure the role of the organisation methods. It gives definitions and modes of calculations for the evaluation criteria in four fields: impact, quality, efficacy and cost (with details about the feasibility of data collection) and proposes a reflection on analysis techniques in order to develop an optimum mass screening strategy.

[Life style of children and obesity in a population of 5-year-old children]. / Mode de vie de l'enfant et obésité dans une population d'enfants de cinq ans.

The increasing level of childhood obesity has prompted some research into the early risk factors likely to lead to preventive measures. A case-control study was conducted of a five year-old population in the Rhône and Isère administrative "départements" of France during the children's first visit to primary school, with the participation of 327 obese children and 704 controls. Anthropometric data on the children since birth, together with data on their lifestyles, were collected in interviews with parents. "Family obesity" and "obesity at birth" were found to be closely related to the child's obesity at five years old (adjusted OR = 2.7 and 2.1 respectively). Of the environmental factors, the hypothesis tested paid specific attention to television viewing, snacks between meals and lack of sleep. These three variables were all found to be risk factors of obesity at five years old. However after allowing for parental obesity, the only remaining significant risk factor for obesity at five was lack of sleep (adjusted OR = 1.4). The pathogenic assumptions raised by these results are discussed.

[Risk factors for condylomata. A case control study]. / Facteurs de risque de condylomes. Etude cas-témoins.

The present study involves 214 patients whose cervical smear showed signs of human papilloma virus infection (HPV), matched with 1042 controls. We demonstrate increasing odds ratio with the total number of sexual partners since first sexual intercourse (p less than 0.0001). Moreover the cases have more often changed partners in the year preceding the diagnosis (odds ratio 2.6 p less than 0.0001). Their male partners more often have occupations that expose them to "extra-conjugal adventures" (p = 0.0005). Using a logistic regression analysis we demonstrate the independence of the masculine and feminine risk factors. After adjustment for age, reason for consulting and marital status the following factors are related to HPV infection: new partner, total number of sexual partners since first sexual intercourse and partner's occupation.

[Detection of flat condylomata of the cervix uteri in the Department of Rhône]. / Dépistage des condylomes plans du col utérin dans le département du Rhône.

In France's Rhône Department, the prevalence of cervical condylomas detected through cervical smears was measured in a systematic study. The rate determined was 1.67% of the women examined. This rate declines slightly with age among women up to 50 years of age, and declines more among those over 50. The study shows a higher frequency of cases in spring (May and June) and in autumn (September and October). We found important geographical variations, with overall higher rates in urban zones. However, there were certain notable exceptions (high rates in some rural areas and low rates in some urban zones). This survey will be followed up to examine the variation of this rate in time. The study has formed the basis of new hypotheses which must be verified by subsequent surveys.

[Risk factors of prematurity related life style. Apropos of INSERM surveys in the Rhone-Alpes area]. / Facteurs de risque de prématurité liés au mode de vie. A propos des enquêtes de l'INSERM dans la région Rhône-Alpes.

Based on INSERM epidemiological surveys, the authors study the risk of prematurity related to the maternal way of life. The prematurity rate is higher in women younger than 20 years, in women of foreign overseas origin, in unmarried women living in couple or alone, and in women of low socio-economic classes. Work during pregnancy is not in itself a risk factor as women at home present a higher prematurity rate than women at work. However, the strenuous working conditions, which concern about 20% of pregnant women at work, lead to a higher prematurity rate. Other factors such as smoking, alcohol consumption, travelling and housework are studied. The role of psychological modifications linked to pregnancy is discussed, particularly in women who do not present any medical factor. From these data, suggestions are made in order to improve prematurity prevention.

[A prospective study of malignancy criteria in 407 surgical patients (author's transl)]. / Nodules froids thyroïdiens. Etude prospective des critères de malignité chez 407 malades opérés.

A prospective study of 407 patients with "cold" solitary thyroid nodule seen over 4 1/2 years and systematically operated upon was undertaken with the view of determining the pre-operative criteria of malignancy. Thirty-nine nodules were malignant. Since various methods of multidimensional statistical analysis failed to give satisfactory results, an attempt was made to base rational surgical indications on purely descriptive criteria. Neither the patient's age, morphology, personal or family history of thyroid disorders, nor the size of the nodule, the circumstances in which it was discovered and the presence of calcification made it possible to distinguish between malignant and non-malignant nodules. Cervical lymph node involvement, paralysis of the recurrent nerve, previous irradiation of the neck and site of the nodule equally had no discriminative value. Only two clinical findings, softness of the nodule and liquid content, were clearly associated with the absence of malignancy.