[The concept of narrative insight in schizophrenia: A systematic review]. / Le concept d'insight narratif chez les personnes souffrant de schizophrénie : une revue systématique de la littérature.

AIM: The aim of this systematic revue of literature is to examine articles dealing with the narrative insight (patient's explanatory models of his difficulties) in patients suffering from schizophrenia. In addition to the theoretical interest of this work, it would make it possible to better adjust the clinical practices concerning the stories of patients about their disorders. METHOD: A study was conducted using the databases ScienceDirect, Medline, PsychInfo and PubPsych using the key words "narrative insight", "cultural insight", "subjective insight", "narrative awareness", "mental illness", and "psychiatric disorder". This search by keywords led to eighty-six results; abstracts of all the articles were consulted. Then the authors selected and studied all articles corresponding to inclusion criteria and compared their results and reached agreement by consensus in case of difference. The theme of the study was to focus on the concept of narrative insight or any other close concept mentioning an explanatory model of mental and/or psychiatric disorders, moving away from the biomedical model. Nine articles were selected based on the inclusion criteria (articles published in peer reviewed journals, where the both the resume and article are accessible; articles dealing with narrative insight of people suffering from schizophrenia). RESULTS: The authors of these articles agree that awareness of mental illness, insight, is a narrative act in which people give a personal meaning to their disorder. The most popular biomedical model used has many limitations and is the subject of many controversies. Results of the conducted study suggest considering narrative insight as adaptive strategies to mental illnesses. Indeed the process of narrative insight essentially consists in the patient adapting his life story to his conceptions and his values. To tell the story of one's own troubles with one's own values and beliefs gives meaning that helps protect identity and give back hope. This concept is considered to be dynamic and multidimensional. In addition, studies highlight its positive effects including the simultaneous presence of several models, which would have a greater favorable impact on the prognosis than the medical explanation alone. CONCLUSION: It seems necessary to take into account the concept of narrative insight in order to evaluate insight of patients suffering from mental illness. This implies that the evaluation methods of insight as well as the clinical practice must evolve to adapt to the culture and subculture of the patient. This could have beneficial effects on the well-being of patients, therapeutic relations, access to treatment as well as psychiatric research, as well as limit controversies around this topic. It would be interesting to confirm this new conception of insight and the therapeutic relations by carrying out new studies as well as by starting to take it into account in patient care.

[Dimensions of personality, attachment style and early maladaptive schemas in alcohol-dependent patients: Are there gender-specific differences?] / Dimensions de personnalité, style d'attachement et schémas précoces d'inadaptation chez des patients alcoolo-dépendants : quelles sont les spécificités liées au sexe ?

AIM: Literature reports particularities in certain psychological dimensions, such as personality traits, early maladaptive schemas and attachment styles among patients dependent on alcohol. Several international studies have also emphasized significant gender differences in psychological profiles. However, in France, only a few studies have dealt with this subject. Our aim was on the one hand to study the characteristics of alcohol-dependent patients in these variables, and on the other hand to search for gender differences. METHOD: The personality dimensions were assessed with the French Big Five Inventory (Fr-BFI), the attachment style with Bartholomew's Relationship Scales Questionnaire (RSQ), and early maladaptive schemas with the short version of Young's questionnaire (YSQ-S1). Seventy-three subjects were included: 39 alcohol-dependent patients (19 men and 20 women) and 34 healthy control subjects (17 men and 17 women). The scores of alcohol-dependent patients were compared with those of a healthy control group (n=34, 17 men, 17 women) and available standards. We also compared the scores of men and women with alcohol dependence between them, and we compared the scores of men and women to those of the control group and those of the reference sample of the same sex. RESULTS: This is an ongoing study and we publish here the first results. Compared with control subjects, and the reference sample, alcohol-dependent patients showed significantly higher levels of neuroticism and lower levels of extraversion. Furthermore, differences in attachment styles were observed compared to the control group: alcohol-dependent patients presented a less secure attachment, seemed more fearful and detached, but the results remained within the normal standards. Compared to the control subjects, alcohol-dependent patients showed a significant increase in scores regarding many schemas: emotional deprivation, abandonment, abuse/mistrust, isolation, imperfection, dependence, symbiotic relationship, subjugation, and emotional inhibition. Men and women with alcohol dependence did not show a significant difference between them concerning the dimensions of personality, the schemas, and attachment styles. In addition, the comparison of each sub-group (male/female) with the control group of the same sex and standards available showed specific features: for dimensions of personality, alcohol-dependent men presented a high level of neuroticism and a low level of extraversion, while the women showed no specific features. Concerning attachment, both men and women differed from the control group. Their attachment was more fearful and men showed a less secure and more detached attachment. As for patterns, three are higher among men and women with alcohol dependence compared to controls of the same sex: emotional deprivation, abuse/mistrust, and imperfection. In addition, these schemas seem to be more specific according to gender: alcoholic women differed from controls of the same sex at the subjugation schema, which was not the case for men, while only men differed from men of the control group by higher scores in insufficient self-control, dependency and symbiotic relationship. DISCUSSION: This study shows not only particularities in patients with alcohol dependence concerning personality dimensions, styles of attachment and early maladaptive schemas, but also gender differences when comparing each subgroup (men and women) with controls of the same sex. Even if these results need to be confirmed by using a larger sample, the particularities deserve consideration, especially gender differences in view of appropriate psychotherapeutic strategies.

[Exploring the relationship between internalized stigma, insight and depression for inpatients with schizophrenia]. / Études des liens entre la stigmatisation intériorisée, l'insight et la dépression chez des personnes souffrant de schizophrénie.

BACKGROUND: Recent studies on insight in people with schizophrenia showed that insight level is linked with treatment compliance. Therefore, many therapies are aimed at increasing the insight level, such as psycho-education. However, insight level is also probably linked with depression level. So, improving insight is at risk of increasing the level of depression. Nevertheless, results on this topic are not consensual in the scientific literature. Presumably, this could be due to the concept of insight itself, although we could hypothesise that some confounding variables are implied in the interaction between insight and depression, such as internalized stigma. AIMS: to test the hypothesis that the relationship between insight and depression is mediated by internalized stigma in people with schizophrenia. METHOD: Sixty-two patients with schizophrenia (DSM-IV or ICD-10) recruited in mental health services in Île de France (75% male), aged 20 to 64 years (m=38.71, σ=0. 43), filled in questionnaires assessing internalized stigma (ISMI), depression (CDSS and BDI) and insight (SAIQ, Q8, IS), after giving their written informed consent. Correlations between insight, depression and different variables were made (Hypothesis 1). Then we ran multiple regressions and partial correlations to test the internalized stigma mediation (Hypothesis 2). RESULTS: Insight, internalized stigma and depression are statistically significantly correlated with each scales used (except Q8). Insight is correlated with depressed mood (correlations between IS and CDSS: r=0.27, P=0.04, and BDI, r=0.40, P=0.001). We also found negative correlations between SAIQ and CDSS (r=-0.35, P=0.005) and the BDI (r=-0.4265, P=0.000) which means that good insight is linked with depression. This result validates our hypothesis 1. The statistic tests reveal other complementary results: the association between insight and depression is mediated by the level of internalized stigma: when ISMI is controlled, the correlation between insight and depression decreased moderately with CDSS and with small intensity with SAIQ, but clearly. So, ISMI is probably a mediating variable between IS and BDI-CDSS. In conclusion, internalized stigma could be a mediating variable between insight and depression. This validates our second hypothesis. CONCLUSIONS: Our results suggest that the relationship between insight and depression is mediated by internalized stigma. Patients with good insight who internalize stigma seem to be more depressed than those who don't. This result could have important consequences in clinical practice: improving insight level should be completed by a specific attention to the level and evolution of internalized stigma to avoid increasing depression. Further studies need to be conducted to confirm these results.

[The Clubhouse model for people with severe mental illnesses: Literature review and French experiment]. / Le modèle Clubhouse pour les personnes souffrant de troubles psychiques : revue de littérature et expérience française.

AIM: The aim of this article is 1) to present the Clubhouse (CH) Model and the first French CH, and 2) study the empirical background on the efficiency of the CH concerning employment, quality of life and hospitalization for people with mental illness. HISTORICAL, THEORETICAL AND INSTITUTIONAL BACKGROUND: The first Clubhouse was created sixty years ago in the U.S. The Clubhouse model of psychosocial rehabilitation is a program that offers to people with mental illness support and opportunities to find a job and return to a normal social life. The Clubhouse model has been built over the years thanks to the experiences of members and staff. It is based on "36 standards" (rules which each Clubhouse follows in order to attain its goals). Supported by associations and families of people with mental illness, health professionals, and the international federation of Clubhouses (Clubhouse International), the first Clubhouse in France has opened in November 2011. This non-medicalized association and its co-management by both members and staff are innovative in France. The aims of the Clubhouse are founded on the concept of empowerment and "peer-help", and on the fight against isolation and stigmatization. Clubhouses offer day-programs which allow people with mental illness to have a sense of community and a useful purpose within the association. Indeed, the salaried management team is voluntarily understaffed so that the participation of members is necessary and so that they can benefit from the opportunities for useful activity within the Clubhouse, developing a real opportunity of empowerment. METHOD: In order to study the efficiency of CH, we conducted a systematic review of publications on CH, first in the database of Club House International (500 publications) and second, in the scientific data base (Psycinfo, Psycarticles, Academic Search Premier, Medline et Science Direct) (205 publications included in the 500). We identified 64 scientific studies. We have selected 28 of them that focused on the variable: employment, quality of life and hospitalisation. RESULTS: Clubhouses have shown their effectiveness regarding employment, quality of life and hospitalization. Indeed, several studies compare Clubhouses with other programs of psychosocial rehabilitation. The results have demonstrated that Clubhouses' members: find more salaried work, find jobs of higher quality, have a better quality of life and face fewer hospitalizations, than people in other psychosocial rehabilitation programs. DISCUSSION: We discuss the interest of the CH in France using the experiment of the CH in Paris. This experiment in providing an innovative place of support, mutual aid, and autonomy is currently successful in France. Over 18 months, a team of 65 members and 3 staff members has come together. This enthusiasm is probably due to the fact that the Clubhouse in Paris is a place which helps people with mental illness establish a daily rhythm, social usefulness and affective links, all essential for recovery, in a context different from the usual medically supervised care in other settings: people are treated as individuals rather than as "sick persons" or "patients". This article discusses the benefits of this new model of psychosocial rehabilitation in France, by presenting the originality and complimentarity of this concept, in comparison with other health structures.

[Understanding/acceptance of radiotherapy: An ethical dilemma resolved by an ethics of care]. / Compréhension/acceptation de la radiothérapie : un dilemme éthique résolu par une éthique de la considération et de la sollicitude.

PURPOSE: Ethical questions are poorly investigated specifically in radiation oncology. The objective of the study was to identify and understand the main ethical issue in radiation oncology. MATERIALS AND METHODS: A quantitative analysis was based on the answers to a questionnaire of 200 professionals from 22 radiation oncology departments. The questionnaire mainly aimed to characterize the main ethical issue. A monocentric qualitative analysis was based on semi-structured interviews focused on the main identified ethical issue, carried out with eight technologists, and 20 patients undergoing radiotherapy. RESULTS: The main ethical issue was the understanding and/or acceptance of the treatment by the patients (71 %), which frequently arises (more than once a month) (52 %), and corresponds to an ethical tension between the principles of respect for autonomy and beneficence (the good as viewed by the patient) as defined by Beauchamp and Childress. The technologists, wish the patient to be fully involved in his treatment, with the even possibility of refusing it. However, excluding paternalism and autonomic relentlessness, the technologists have the feeling of acting for the good of the patients by treating them with radiation, even if the patients are not always aware of it, because they are within a situation of vulnerability. If the hierarchy of principles is a compromise alternative, this problem is finally well resolved by the effective implementation of an ethic of consideration and solicitude, restoring the patient capabilities, i.e. the maximum development of his potentialities in his situation of vulnerability. Beyond the legal dimension, patient information is crucial and must consider the specific temporality of the patient. CONCLUSION: The main ethical issue in radiation oncology is the understanding and/or acceptance of the treatment involving the development of an ethic of consideration and solicitude.

[Early dropout patients in psychiatric psychosocial rehabilitation treatment and their bindings with relational skills, object relation and intensity of psychopathology]. / Les ruptures de prise en charge chez des patients d'un centre de soin de réadaptation psychiatrique et leurs liens avec les capacités relationnelles, les relations d'objets intériorisées et l'intensité des troubles.

INTRODUCTION: Between 30 and 60% of patients drop-out of institutional psychiatric treatment. There are few studies on this issue and these have not provided a clear understanding of this fact. Although it is a different therapeutic setting, there are many studies on patients' dropout in psychotherapy: the influence of many patient sociodemographic variables such as gender, age, diagnostic, were studied without providing strong and regular links with early dropout. Other, more relational variables (such as object relation and interpersonal functioning), gave stronger results although insufficiently confirmed by different studies. A third kind of variable involves the concrete relationship between patient and therapist (therapeutic alliance, patient's expectations) and provided interesting results (but not easy to use in institutional treatment). AIM: The aim of this study is to provide data to understand patients' institutional dropout in a French psychiatric centre. The latter's aim is psychosocial rehabilitation for schizophrenic and borderline patients. Thirty percent of these dropout during psychosocial treatment. According to the specificities and aims of this psychiatric centre, we hypothesize that there are strong links between relational dimensions (objet relation, interpersonal functioning), subjective evaluation of pathology intensity, and early dropout. POPULATION: Thirty-one subjects; 65% schizophrenic, 23% borderline, 13% other (according to the ICD10 criteria); 71% females; mean age 34 years (min=23; max=55); mean education level=3.4 (2 years of high school university). INCLUSION CRITERIA: to have dropped out before 6 months' of the treatment, or continuing the treatment after 6 months (mean of treatment for all patients=15 months). EXCLUSION CRITERIA: patients present in the service for less than 6 months). METHODOLOGY: At the beginning of the treatment, each patient (informed consent provided) underwent a psychological assessment with: Échelle d'aptitude psychosociale (EAPS) for assessing interactional functioning; SCL90-R for assessing the intensity of psychopathology; TAT (with Social Cognition and Object Relation Scale [SCORS] scales) and Rorschach (with Mutuality Of Autonomy [MOA] scale) for assessing object relations. After 6 months of treatment, each patient was evaluated with a five-point scale (dropout and continuity scale), which assessed the investment in the treatment (criteria: dropout at 3 or 6 months or continuity; according or not to the centre's professionals; level of assiduity). We have correlated this variable with EAPS, SCORS and MOA. In addition, we have calculated statistical relationships between age, gender, diagnostic, education level and early dropout. RESULTS: Correlation was found neither between interactional functioning (EAPS) and dropout nor between object relations (SCORS and MOA) and dropout. Correlations were found between the dropout and intensity of the psychopathology (SCL90-R): the more the patient sees himself suffering, the more he invests the centre and the less he drops out (Spearman R=0.37, P<0.05). No differences were found between the dropout (N=10) and continuity group (N=21) regarding age, gender and diagnostic. However, a correlation was found regarding the education level: the more patients are educated, the more they continue the treatment (R=0.45; P<0.05). CONCLUSION: The dropout (and the continuity of treatment) seems more likely related to concrete variables such as psychological and relational suffering, educational level in this study, than structural psychological variables such as object relation, relational skills, and diagnostic. Other studies are necessary for a better understanding of these drops out. An interesting way should be the study in institution of the therapeutic alliance.

Costal cartilage graft for an unstable post-traumatic trapeziometacarpal intra-articular malunion in a pediatric patient: A case report.

Trapeziometacarpal dislocation is a rare traumatic lesion, especially in the pediatric population. Various treatments have been described for acute cases. We report the case of a 15-year-old boy who was admitted in the emergency department with chronic post-traumatic trapeziometacarpal dislocation due to an untreated first metacarpal base fracture (Bennett), with complete articular destruction. The patient was treated by open reduction, interposition of a costal cartilage graft, and intermetacarpal K-wire fixation. Follow-up at 2 years after the surgery showed excellent clinical and radiological results. This surgical technique had not been described previously in the pediatric population.

Aneurysms of the hand: Imaging and surgical technique.

Hand aneurysms are a rare entity only described as case reports in the literature. The aim of our study was to describe a series of four cases and the surgical technique using an arterial bypass. We also wanted to define an algorithm for the imaging of this pathology. We have operated on four patients with hand aneurysms in the past decade or so. One patient had an aneurysm in the thumb proper palmar digital artery, one in the superficial palmar arch and the two others in the ulnar artery. All patients had an excision surgery with direct arterial bypass; no patient had a venous graft. All patients were seen a few years after the surgery and underwent an ultrasonography to check the anastomosis permeability. All anastomoses were permeable 2 to 8 years after surgery. Through a review of the literature we discuss the best algorithm for imaging a hand aneurysm. Direct arterial suture by proximal and distal mobilization allows for long-term permeability. If a graft is necessary, a graft of arterial origin should be preferred. The additional first-line examination is ultrasonography, followed by arteriography if acute ischemia is present; otherwise, CT angiography or MR angiography is performed.

[Organization and risk management in stereotaxic body radiotherapy at the treatment station]. / Organisation et gestion des risques en radiothérapie stéréotaxique au poste de traitement.

The development of stereotaxic body radiotherapy in the last decade has forced the radiotherapy departments to redouble their efforts in the fields of quality and risk management. For this purpose, increasingly complex and rigorous controls of high performance machines as well as a solid team training must be put in place. Extreme hypofractionation requires both increased vigilance at the treatment desk and well-defined and known procedures. The in place organizations contribute to the control of the risks related to the stereotaxic body radiotherapy machines. The medical presence at the beginning of the treatment fractions has been specified as mandatory in a regulatory way since January 2017. This not only ensures security, but also transmits information to the radiation therapy technicians. At the Eugène-Marquis center, the skills of the technicians for stereotaxic body radiotherapy on two dedicated machines (Cyberknife® and Versa HD® Novalis® type) have been upgraded. An accreditation is formalized after a training period and re-evaluated annually. The communication inside and outside the radiotherapy field plays also an important role in maintaining a high level of exchange and sharing of essential information. The means implemented at the Eugène-Marquis center increase the risk control of SBRT, by paying attention to the management of skills at the treatment station.

[Effectiveness of a health network in secondary prevention among coronary patients]. / Efficacité d'un réseau pour la prévention secondaire chez les patients coronariens.

OBJECTIVE: To improve the secondary prevention, particularly hypertension management among coronary patients. METHODS: In 2004-2005, out of 175 coronary patients having taken part in a cycle of the Educoeur center of the health network Rivarance, 131 (75%) aged between 32-79 years of age (an average of 61 years with 11% women, 52% hypertensive, 24% smokers, 10% diabetics and 72% with unbalanced dyslipidemia (LDL>1g/l)) were re-examined within 12 months and were compared with a French cohort of the EuroAspire II study (365 patients - Lancet 2001). 56% were treated by angioplasty, 24% by coronary bypass and 20% by medical treatment. The 4-week ambulatory educational program consisted of a physical education with 22 meetings of cardiac rehabilitation (ergo cycle, carpet, segmentary muscular work, steps and balneotherapy) and a therapeutic and dietetic education (18 courses and cooking workshops, supermarket visits and self BP measurement). These 131 patients were re-examined 3, 6 and 12 months after by the paramedical team. The GP and nurses were taught recommendations on CV risk factors management. The patients were followed by a computerized medical file. BP (average of 3 measurements by OMRON M4), total cholesterol (CT), weight, physical activity (insufficient if less than 3 walks of 30 min per week), smoking and drugs intake were analyzed on J0 then at one year and were compared with the French results of EuroAspire II. [table: see text] CONCLUSION: The education and the follow-up of the patient in a network of health improve CV risk factors and particularly hypertension management of these coronary patients but this decreases with time.

Denervation of the wrist with two surgical incisions. Is it effective? A review of 33 patients with an average of 41months' follow-up.

The goal of wrist denervation is to decrease pain at the wrist, whether caused by an intra- or extra-articular problem or even when the reason for the pain is unknown. It is an alternative to partial or total arthrodesis and proximal row carpectomy. Our hypothesis was that wrist denervation with a two-incision technique was a reliable and efficient way to treat painful degenerative wrists. Thirty-three patients, 48years old on average, were included in this study. Indications were scapholunate advanced collapse (SLAC) in 18 cases, scaphoid nonunion advanced collapse (SNAC) in 10, distal radius fracture sequelae with advanced radiocarpal osteoarthritis in 4, and post-traumatic ulnocarpal impingement in 1 case. At 41 months' follow-up (12-161), there was a 75% reduction in pain levels, decreasing from 7.1 to 1.8 on a visual analog scale (VAS). There were no modifications related to wrist range of motion or grip strength. The QuickDASH averaged 23 points (5 to 70). Radiographic evaluation showed progression of intracarpal degeneration in 6 patients. All but 2 patients returned to their previous work. Persistent dysesthesia was observed in 7 patients; it resolved in 3 cases and persisted in 4. One patient developed complex regional pain syndrome (CRPS). A midcarpal arthrodesis with scaphoidectomy was performed in one patient because of disabling pain 5months after surgery. Wrist denervation with a two-incision technique for post-traumatic osteoarthritis led to satisfactory results in 75% of cases with reduction in pain, preservation of range of motion and grip strength. However, this technique does not stop the progression of osteoarthritis. It can be discussed as a therapeutic alternative to proximal row carpectomy or intracarpal arthrodesis to treat degenerative painful wrists. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

[Interest of positioning control in onboard imaging and its delegation to the therapists]. / Intérêt du contrôle de position par imagerie embarquée et de sa délégation de l'ASN aux manipulateurs en électroradiologie médicale.

The delegation of the on board imaging position control, from the radiation oncologist to the therapist, is justified by the generalization of the image-guided radiotherapy techniques which are particularly time consuming. This delegation is however partial. Indeed, the validation of the position by the therapist can be clearly performed when the registration is based on bony landmark or fiducial. The radiation oncologist needs however to make the validation in case of large target displacement, in more complex soft tissue-based registration, and in case of stereotactic body radiation therapy. Moreover, this delegation implies at least three conditions which are first the training of the staff, then the formalization of the procedures, responsibilities and delegations and finally, the evaluation of the practices of IGRT.

[Declarative survey about postpartum haemorrhage management by anaesthesiologists in Pays de la Loire area (France): what's the adherence to clinical practice guidelines?]. / Enquête déclarative sur la prise en charge anesthésique des hémorragies du post-partum dans la région Pays de la Loire: quelle adhésion aux recommandations pour la pratique clinique?

OBJECTIVE: To assess the management of postpartum hemorrhage (PPH) by anaesthesiologists in Pays de la Loire area. METHODS: A declarative survey was conducted from November 2011 to January 2012 with an online questionnaire to assess prevention and PPH specific care and to clarify the PPH transfusion practices and interest of new therapies. Nine indicators of adherence to clinical practice guidelines were selected to distinguish two groups: one group "adhering to the RCP" and another "not adhering to the RCP". RESULTS: Response rate 53%. One hundred and one responses were analyzed. Use of a collection bag graded blood receipt pockets 93%, start time of PPH noted: 76%, leaf specific monitoring: 67%, management of the third part of the work: 78%. The evacuation of the placenta is performed within 30minutes in 75% of cases. The transfusion strategy happens early (92% before the biological assessment results) and "aggressive" (ratio RCB/FFP is 1/1 for 72%). The use of tranexamic acid is not systematic (53%). Seventy-nine percent of respondents adhere to the RCP. Practitioners in maternity level 1 (with few deliveries) don't follow these RCP as much. CONCLUSION: Some inappropriate practices remain in structures not used to support them. The use of new therapies remain controversial. The priority at this time is the implementation and enforcement of the current RCP, not their modifications.

Is there any benefit in pre-operative urinary analysis before elective total joint replacement?

Whether patients with asymptomatic bacteriuria should be investigated and treated before elective hip and knee replacement is controversial, although it is a widespread practice. We conducted a prospective observational cohort study with urine analyses before surgery and three days post-operatively. Patients with symptomatic urinary infections or an indwelling catheter were excluded. Post-discharge surveillance included questionnaires to patients and general practitioners at three months. Among 510 patients (309 women and 201 men), with a median age of 69 years (16 to 97) undergoing lower limb joint replacements (290 hips and 220 knees), 182 (36%) had pre-operative asymptomatic bacteriuria, mostly due to Escherichia coli, and 181 (35%) had white cells in the urine. Most patients (95%) received a single intravenous peri-operative dose (1.5 g) of cefuroxime as prophylaxis. On the third post-operative day urinary analysis identified white cells in 99 samples (19%) and bacteriuria in 208 (41%). Pathogens in the cultures on the third post-operative day were different from those in the pre-operative samples in 260 patients (51%). Only 25 patients (5%) developed a symptomatic urinary infection during their stay or in a subsequent three-month follow-up period, and two thirds of organisms identified were unrelated to those found during the admission. All symptomatic infections were successfully treated with oral antibiotics with no perceived effect on the joint replacement. We conclude that testing and treating asymptomatic urinary tract colonisation before joint replacement is unnecessary.

No need to search for the source of haematogenous arthroplasty infections.

QUESTIONS UNDER STUDY/PRINCIPLES: Prosthetic joint infections (PJI) may be a potential sentinel event for an unknown neoplastic or infectious source in elderly patients. However, the value and cost-effectiveness of investigations to determine the origin of these infections is unknown. METHODS: Retrospective study at Geneva University Hospitals, evaluating associated medical examinations performed in search of the origin of all presumed surgical site and haematogenous arthroplasty infections. RESULTS: A total of 182 PJI were found in 182 patients (median age 75 years). Seventy PJI (38%) were classified as probably haematogenous, occurring more than 2 years post-implantation, with 27 (15%) due to Gram-negative pathogens. Overall, the origin of PJI was found solely by admission history in 28 cases (15%). Among the remaining 154 cases, no remote origin could be detected despite 17 echocardiograms, 17 other sonograms, 49 chest x-rays, 23 computed tomograms, 107 urinary cultures, 11 endoscopies, 9 scintigraphies and 31 medical specialist consultations. The average cost of these exams was 675 Swiss francs (845 US$) per PJI. At long-term follow-up six patients were found to have developed a neoplasm, of which only one (hepatocellular carcinoma after PJI due to Streptococcus bovis) could eventually be attributed to prior infection. CONCLUSIONS: From an epidemiologic point of view, patient history is the best way to predict the origin of PJI. Blind additional radiographic or endoscopic exams are costly, inconclusive and do not contribute to the management of these cases.

[Evaluation of the incidence of serological cross reactions between Legionella and Mycoplasma or Chlamydia]. / Evaluation de la fréquence des réactions sérologiques croisées entre Legionella et Mycoplasma ou Chlamydia.

Because of the possible serological cross reactions frequently described in the literature between L. pneumophila and M. pneumoniae or between L. pneumophila and Chlamydia, we decided to determine their frequency with our sera and our own methods. The anti M. pneumoniae and Chlamydia antibodies were researched in 162 sera samples from 46 cases of legionellosis serologically diagnosed and in 51 sera from 26 hyperimmunised rabbits. Conversely, anti L. pneumophila antibodies were researched in 165 sera from mycoplasmosis (61) or chlamydiosis (25 cases). None of the sera from mycoplasmosis or chlamydiosis tested by IFA and MA had antilegionella antibodies. None of the rabbits' sera hyperimmunised with Legionella had anti M. pneumoniae or Chlamydia antibodies. On the contrary, by complement fixation and IFA, out of the 46 cases of legionellosis under study, 6 showed a seroconversion in M. pneumoniae and 2 in Chlamydia. The Ig class determination did not show IgM titers in 7 of these 8 sera. The mechanisms of these cross reactions are discussed: antigens and methods used, booster effect during legionellosis, concurrent mycoplasmosis or chlamydiosis.