Do children and adolescents with type 1 diabetes suffer from a lack of resources in France? Results from a benchmark study in the New Aquitaine region.

BACKGROUND: A benchmark study was conducted in the southwest of France, in the New Aquitaine region, to investigate metabolic outcomes and availability of resources in pediatric diabetes units. We assessed whether the level of care was in accordance with the International Society for Pediatric and Adolescent Diabetes recommendations. METHODS: Demographic and clinical data were collected, as were all HbA1c tests for the 2017 calendar year. Pediatricians specialized in diabetes care were invited to complete an online survey concerning means allocated to the management of type 1 diabetes in their centers. RESULTS: Sixteen centers provided data for 1277 patients and 3873 clinical visits. A total of 1115 children suffering from diabetes for more than 1 year were studied. Median HbA1c was 8% (7.4-8.6) for the whole region. Only 29.2% of children had good metabolic control in accordance with the <7.5% target. We identified slight but significant variation in glycemic control among centers (P=0.029). The use of an insulin pump varied greatly among centers but did not explain HbA1c differences. We did not identify a correlation between medical or paramedical time dedicated to the follow-up of diabetic patients and the mean HbA1c of each center. For 100 diabetic patients, follow-up was provided by 0.42 physicians (0.23-1.50), 0.15 nurses (0-0.56), 0.12 dietitians (0-0.48), and 0.07 psychologists (0-0.30). CONCLUSION: This study demonstrates a lack of human resources allocated to the management of type 1 diabetes in the region that is far below international recommendations. The proportion of children achieving the international glycemic target is low. There is a clear need to improve glycemic control in children, which will only be possible with improved professional practices, encouraged by benchmark studies, and by increasing the size of our multidisciplinary teams.

Use of intraoperative CT scanning for quality control assessment of cochlear implant electrode array placement.

Background: Imaging of cochlear implant (CI) electrode arrays (EAs) consists of intraoperative fluoroscopy to rule out tip fold-over and/or post-operative computerized tomography (CT) if concern exists regarding extrusion or misplacement of the EA. Intraoperative CT (iCT) can satisfy these current needs and enables specification of final intracochlear position.Aims/objectives: To describe iCT scanning of CI recipients at an academic medical center.Materials and methods: iCT was used to scan CI recipients within the operating room before recovering from general anesthesia.Results: In fiscal year 2019, 301 CI were placed (83 children, 218 adult). One hundred, seventy-five iCTs were performed (58% of total CIs) of which 52 were children (63% of pediatric CIs) and 123 were adult (57% of adult CIs). Of 7 CI surgeons, use of iCT ranged from 14% to 100% (mean 60%). Four tip fold-overs were identified and corrected intraoperatively. Surgeons reported using the images to improve technique (i.e. pulling back precurved EAs to improve perimodiolar positioning).Conclusion and significance: The current standard of care for CI is to insert EAs without feedback as to final location. iCT provides surgeons with rapid post-insertion feedback which allows detection and correction of suboptimally placed EAs as well as refinement of surgical technique.

Comparison of 2015 Medicare relative value units for gender-specific procedures: Gynecologic and gynecologic-oncologic versus urologic CPT coding. Has time healed gender-worth?

BACKGROUND: In 1992, Congress implemented a relative value unit (RVU) payment system to set reimbursement for all procedures covered by Medicare. In 1997, data supported that a significant gender bias existed in reimbursement for gynecologic compared to urologic procedures. The present study was performed to compare work and total RVU's for gender specific procedures effective January 2015 and to evaluate if time has healed the gender-based RVU worth. METHODS: Using the 2015 CPT codes, we compared work and total RVU's for 50 pairs of gender specific procedures. We also evaluated 2015 procedure related provider compensation. The groups were matched so that the procedures were anatomically similar. We also compared 2015 to 1997 RVU and fee schedules. RESULTS: Evaluation of work RVU's for the paired procedures revealed that in 36 cases (72%), male vs female procedures had a higher wRVU and tRVU. For total fee/reimbursement, 42 (84%) male based procedures were compensated at a higher rate than the paired female procedures. On average, male specific surgeries were reimbursed at an amount that was 27.67% higher for male procedures than for female-specific surgeries. Female procedure based work RVU's have increased minimally from 1997 to 2015. CONCLUSION: Time and effort have trended towards resolution of some gender-related procedure worth discrepancies but there are still significant RVU and compensation differences that should be further reviewed and modified as surgical time and effort highly correlate.

Direct and indirect impacts of crop-livestock organization on mixed crop-livestock systems sustainability: a model-based study.

Crop-livestock production is claimed more sustainable than specialized production systems. However, the presence of controversial studies suggests that there must be conditions of mixing crop and livestock productions to allow for higher sustainable performances. Whereas previous studies focused on the impact of crop-livestock interactions on performances, we posit here that crop-livestock organization is a key determinant of farming system sustainability. Crop-livestock organization refers to the percentage of the agricultural area that is dedicated to each production. Our objective is to investigate if crop-livestock organization has both a direct and an indirect impact on mixed crop-livestock (MC-L) sustainability. In that objective, we build a whole-farm model parametrized on representative French sheep and crop farming systems in plain areas (Vienne, France). This model permits simulating contrasted MC-L systems and their subsequent sustainability through the following indicators of performance: farm income, production, N balance, greenhouse gas (GHG) emissions (/kg product) and MJ consumption (/kg product). Two MC-L systems were simulated with contrasted crop-livestock organizations (MC20-L80: 20% of crops; MC80-L20: 80% of crops). A first scenario - constraining no crop-livestock interactions in both MC-L systems - permits highlighting that crop-livestock organization has a significant direct impact on performances that implies trade-offs between objectives of sustainability. Indeed, the MC80-L20 system is showing higher performances for farm income (+44%), livestock production (+18%) and crop GHG emissions (-14%) whereas the MC20-L80 system has a better N balance (-53%) and a lower livestock MJ consumption (-9%). A second scenario - allowing for crop-livestock interactions in both MC20-L80 and MC80-L20 systems - stated that crop-livestock organization has a significant indirect impact on performances. Indeed, even if crop-livestock interactions permit improving performances, crop-livestock organization influences the capacity of MC-L systems to benefit from crop-livestock interactions. As a consequence, we observed a decreasing performance trade-off between MC-L systems for farm income (-4%) and crop GHG emissions (-10%) whereas the gap increases for nitrogen balance (+23%), livestock production (+6%) - MJ consumption (+16%) - GHG emissions (+5%) and crop MJ consumption (+5%). However, the indirect impact of crop-livestock organization doesn't reverse the trend of trade-offs between objectives of sustainability determined by the direct impact of crop-livestock organization. As a conclusion, crop-livestock organization is a key factor that has to be taken into account when studying the sustainability of mixed crop-livestock systems.

[Assessment of anesthesiologist intervention during cataract surgery under topical anesthesia]. / Évaluation du recours à l'anesthésiste-réanimateur lors de la chirurgie de la cataracte réalisée sous anesthésie topique.

OBJECTIVES: The current demographic situation in France regarding anesthesiologists calls for a reconsideration of anesthesia management for patients undergoing cataract surgery under topical anesthesia. This prospective observational study aimed to assess the requirement for anesthesiologist intervention during cataract surgery performed under topical anesthesia. PATIENTS AND METHODS: Patients operated between November 2, 2011 and July 31, 2012 were included after indication of topical anesthesia for phacoemulsification proposed by the surgeon and confirmed by the anesthesiologist. Each patient was premedicated. All patients were monitored and supervised during the surgery by a nurse anesthesiologist. An anesthesiologist could be called at any time at the request of the surgeon or nurse anesthesiologist. For each patient, medical histories were recorded as well as the event "anesthesiologist called", along with the reason and the treatment performed. RESULTS: Five hundred and seventy-five phacoemulsifications were performed in 486 patients. The event "anesthesiologist called" was recorded 20 times: 18 times for hypertension, once for anxiety and once for non-emergent conversion to general anesthesia after a surgical complication. Each episode of hypertension was successfully treated by following the nicardipine protocol. Preoperatively uncontrolled hypertension was the only significant predictive risk factor for anesthesiologist requirement. CONCLUSIONS: These results question the usefulness of preoperative anesthesia consultation for all patients who underwent phacoemulsification under topical anesthesia, since this consultation does not lead to an anesthesiologist service. Intraoperative medical complications may be treated according to medical protocols developed jointly by surgeons and anesthesiologists. This practice may free up anesthesiologists' time, without compromising patient safety.

Assessment of electrode placement and audiological outcomes in bilateral cochlear implantation.

OBJECTIVE: The goal of this study was to use highly accurate nonrigid algorithms to locate the position of cochlear implant (CI) electrodes and correlate this with audiological performance. PATIENTS: After obtaining institutional review board approval, adult patients who had bilateral CIs were identified, and those with preoperative temporal bone computed tomographic scans were asked to return for a postintervention computed tomography. Sixteen adult patients agreed. Demographics, cause of deafness, length of auditory deprivation, and audiological performance were recorded. INTERVENTION: Using a nonrigid model of the shape variations of intracochlear anatomy, the location of the basilar membrane was specified in relationship to the electrode array. The number of electrodes within each compartment of the cochlea was correlated with hearing in noise and consonant-noun-consonant scores for the known confounding variable: length of deafness. MAIN OUTCOMES: Mann-Whitney U tests of differences were used to compare the hearing performance resulting from implants completely in the scala tympani (ST) versus those not completely in the ST. RESULTS: Of all implants, 62.5% were fully inserted in the ST; 34.4% were partially inserted into the ST and 3.1% was fully inserted in the scala vestibuli. Controlling for the known contributing variable of length of auditory deprivation, our results show that the location of electrodes in relationship to the scala is not predictive of audiological performance. CONCLUSION: We have assessed electrode placement and correlated it with audiological outcome. The presence of the electrodes solely in the ST was not predictive of outcome. We estimate that it would take analyzing data of thousands of CI patients before any valid correlations can be made.

Automatic Identification of Cochlear Implant Electrode Arrays for Post-Operative Assessment.

Cochlear implantation is a procedure performed to treat profound hearing loss. Accurately determining the postoperative position of the implant in vivo would permit studying the correlations between implant position and hearing restoration. To solve this problem, we present an approach based on parametric Gradient Vector Flow snakes to segment the electrode array in post-operative CT. By combining this with existing methods for localizing intra-cochlear anatomy, we have developed a system that permits accurate assessment of the implant position in vivo. The system is validated using a set of seven temporal bone specimens. The algorithms were run on pre- and post-operative CTs of the specimens, and the results were compared to histological images. It was found that the position of the arrays observed in the histological images is in excellent agreement with the position of their automatically generated 3D reconstructions in the CT scans.

Current management of farms and internal parasites by conventional and organic meat sheep French farmers and acceptance of targeted selective treatments.

Sheep meat production in France is characterized by large flocks and a limited supply of labour. Digestive-tract strongyles are considered as one of the main health problems and control relies mostly on the use of anthelminthics, although resistance to at least the benzimidazoles is increasing. We conducted interviews on nine conventional and seven organic farms regarding whether an anthelmintic targeted selective treatment program could fit within the operations of the farms. In addition, necropsies of lambs were performed on three organic farms, and faecal egg counts and small lungworm counts were performed on all farms in autumn in ewes. Each interview consisted of an open discussion on sheep health and was terminated with comments on digestive-tract helminth infection as detected in parallel with the interview. Factors likely to affect the adoption of the targeted selective treatment approach were subjected to cluster analysis. Conventional farms were mostly advised by veterinarians and relied on systematic planning of anthelmintic treatments. The frequency of treatments was up to once a month for lambs and two to three times a year for ewes. The concept of selecting animals to be treated according to a scheme of targeted selective treatments based on phenotypic markers (e.g., anaemia, diarrhoea, weight gains) was not seen as feasible by these farmers. Conversely, organic farmers, with greater use of advisors and a restricted range of anthelmintic treatments were more susceptible to integrating phenotypic markers into their practices for controlling digestive-tract strongyles.

Nutritional status assessment during Alzheimer's disease: results after one year (the REAL French Study Group).

OBJECTIVES: Weight loss and malnutrition are frequent and serious complications of Alzheimer's disease. The aim of the present article was to describe the cognitive and behavioural characteristics of the test population within the frame of the PHRC REAL.FR cohort (for Réseau sur la Maladie d'Alzheimer Français), depending on their nutritional state, and to consider their evolution one year after the original inclusion. METHOD: The study population' stratification was done in three groups according to their Mini Nutritional Assessment (MNA) score: malnutrition group (MNA < 17.5), at risk of malnutrition group (MNA 17.5-23.5), and normal nutritional status group (MNA > or = 23.5). 561 patients were evaluated at inclusion time, 393 at one year. The evaluation included the following scales: Mini Nutritional Assessment (MNA), Mini Mental State Examination (MMSE), Activities Daily Living (ADL), Instrumental Activities Daily Living (IADL), Neuro Psychiatric Inventory (NPI) and Zarit scale (ZARIT). Comparison and descriptive analysis for each MNA group at baseline and at one year has been performed. RESULTS: at baseline, the well-nourished and the malnutrition risk groups are significantly different concerning age, IADL and NPI; the well-nourished and undernutrition groups are different concerning MMSE, NPI and Zarit; the malnutrition risk and undernutrition groups are only different concerning NPI. At one year, the well-nourished and the malnutrition risk and undernutrition groups are different concerning one lonely variable, the NPI, in a significant way. The comparison of the three groups between baseline and one-year evaluation demonstrate for the well-nourished group an aggravation of MMSE, ADL, IADL, NPI, for the malnutrition risk group of MMSE and IADL, and for the undernutrition group of MMSE, IADL and NPI. CONCLUSION: Among the patients suffering from Alzheimer's disease, the most malnutritioned worsen highly on cognitive and functional capacities. Furthermore, the nutritional aggravation seems strongly linked to behavioural disorders aggravation. The improvement of those disorders has therefore to be part of every improvement strategy applied to the nutritional status of the demented patients.

The apathy inventory: assessment of apathy and awareness in Alzheimer's disease, Parkinson's disease and mild cognitive impairment.

OBJECTIVE: This study was designed to establish the validity and reliability of the apathy inventory (IA), a rating scale for global assessment of apathy and separate assessment of emotional blunting, lack of initiative, and lack of interest. METHOD: Information for the IA can be obtained from the patient or from a caregiver. We evaluated 115 subjects using the IA, consisting of 19 healthy elderly subjects, 24 patients with Mild Cognitive Impairment (MCI), 12 subjects with Parkinson's disease (PD) and 60 subjects with Alzheimer's disease (AD). RESULTS: Internal consistency, item reliability, and between-rater reliability were high. A test-retest reliability study demonstrated that caregiver responses to IA questions were stable over short intervals. A concurrent validity study showed that the IA assesses apathy as effectively as the Neuro Psychiatric Inventory apathy domain. In the caregiver-based evaluation, AD subjects had significantly higher scores than controls, both for global apathy score and for the lack of interest dimension. When the AD patients were subdivided according to diagnostic criteria for apathy, apathetic patients had significantly higher scores than non apathetic patients. With the patient-based evaluations, no differences were found among the AD, MCI and control groups. The scores in the patient-based evaluations were only higher for the PD group versus the control subjects. The results also indicated that AD patients had poor awareness of their emotional blunting and lack of initiative. CONCLUSIONS: The IA is a reliable method for assessing in demented and non-demented elderly subjects several dimensions of the apathetic syndrome, and also the subject's awareness of these symptoms.

Assessing African American adolescents' risk for suicide attempts: attachment theory.

The threat of separation from a parent theoretically increases the risk of adolescent suicide attempts. The present study evaluated this and other hypothesized risk factors in a sample of adolescent suicide attempters and nonsuicidal controls, using the Psychiatric Consultation Checklist (Lyon, 1987). Stepwise logistic regression was used to predict group membership. It was found that threat of separation from a parental figure, insomnia, neglect, substance abuse, suicidal ideation, and failing grades were the strongest predictors of suicide attempt. Ten predictor variables correctly identified 97% of suicide attempters and 86% of nonattempters. Unexpected findings included high levels of truancy, threatening others, and separation from a parent before the age of 12 among nonattempters.

Differences in zero-force and force-driven kinetics of ligand dissociation from beta-galactoside-specific proteins (plant and animal lectins, immunoglobulin G) monitored by plasmon resonance and dynamic single molecule force microscopy.

Protein-carbohydrate interactions are involved in diverse regulatory processes. To help understand the mechanics and kinetics of dissociation of receptor-ligand complexes, we have analyzed the separation of lactose and the N-glycan chains of asialofetuin (ASF) from three lectins and an immunoglobulin G fraction by surface plasmon resonance at zero force and by atomic force microscopy with variations of the external force. While the (AB)2 agglutinins from Ricinus communis (RCA) and Viscum album (VAA) show structural homology, the homodimeric galectin-1 from bovine heart (BHL) has no similarity to the two plant lectins except for sharing this monosaccharide specificity. The beta-galactoside-binding immunoglobulin G (IgG) fraction from human serum provides a further model system with distinct binding-site architecture. The k(off) constants for the two plant agglutinins were independent of the nature of the ligand at 1.1-1.3 x 10(-3) s(-1), whereas the geometry of ligand and binding site presentation affected this parameter for BHL (0.5 x 10(-3) s(-1) for lactose and 1 x 10(-3) s(-1) for ASF) and IgG (1.3 x 10(-3) s(-1) for lactose and 0.55 x 10(-3) s(-1) for ASF). When assessing comparatively the rupture forces at a loading rate of 3 nN/s with lactose as ligand, 34 +/- 6 pN (BHL), 36 +/- 4 pN (IgG), 47 +/- 7 pN (VAA), and 58 +/- 9 pN (RCA) were measured. For the same loading rate the rupture forces for the receptor-ASF interactions were found to be 37 +/- 3 pN (BHL), 43 +/- 5 pN (VAA), 45 +/- 6 pN (IgG), and 65 +/- 9 pN (RCA). The variation of the pulling velocity revealed in all cases a linear dependence between the rupture force and the natural logarithm of the loading rate. Performing probability density and Monte Carlo calculations, the potential barrier widths, which determine the inverse dynamic dependence with the rate of force elevation, increased from 4 A (RCA) and 7 A (VAA and IgG) to 10 A (BHL) for the receptor-lactose interactions. Presenting ASF as ligand potential widths of 4 A for RCA and IgG and 6 A for VAA and BHL were obtained. Since the dissociation kinetics at zero force apparently cannot predict the behavior in force-driven experiments, these results reveal new insights into biological functions. The dissociation kinetics under force helps to explain the difference in the toxic potency of VAA and RCA and points to a function of the galectin in cis-crosslinking and in transient trans-bridging.

Evaluation of a four-year bicycle helmet promotion campaign in Quebec aimed at children ages 8 to 12: impact on attitudes, norms and behaviours.

OBJECTIVE: This study evaluated a four-year bicycle helmet promotion campaign. METHODS: Children's attitudes, social norms, intentions to wear a bicycle helmet as well as helmet ownership were measured. Evaluation was based on a pre-experimental static group comparison design repeated at two (1991) and four years (1993) after implantation, with a non-randomized control group. 3,424 students completed a self-administered questionnaire (experimental: 2,097, control: 1,327). RESULTS: The program had a significant impact on helmet ownership (1989: 4%; 1991: 26%; 1993: 56%). The program was the principal predictor of high intention to use a bicycle helmet. Time was the principal predictor of ownership with exposure to the program being the next predictor. CONCLUSION: This study showed that time is an important factor in bicycle helmet acquisition, and that a long-term community-based program can accelerate the process of adopting this behaviour.