[Effectiveness of flexible ureteroscopy versus extracorporeal shock wave lithotripsy for kidney stones treatment]. / Efficacité de l'urétéroscopie souple versus lithotritie extracorporelle dans le traitement des calculs du rein.

Primary endpoint was to objective a better effectiveness of flexible ureteroscopy (fURS) compared to extracorporeal shock wave lithotripsy (ESWL) 3 months after treatment of a unique kidney stone from 5 to 20mm. Secondary endpoints were to evaluate effectiveness in subgroup and tolerance. We conducted a prospective comparative randomised trial between May 2012 and February 2014. A computerised tomography was done before treatment and another 3 months after treatment. Of the 30 randomised patients, 8 dropped out from the study and 4 were lost to follow-up. Median time of follow-up was 3.82 months. In per-protocol analysis, success rate was 60% for fURS group versus 28.6% for ESWL group (P=0.29). In intention to treat analysis, success rate was 77.8% in fURS group versus 53.8% in ESWL group (P=0.38). In ESWL group, 5 patients (41.7%) needed a second treatment versus none in fURS group but it was not significant. During follow-up, 1 patient in each group presented a complication. Results of this feasibility study did not allowed to conclude on superiority of a technic. A multicenter study with more important enrollment is necessary considering economic side and tolerance of these treatments.

Relation between unimanual capacities and bimanual performance in hemiplegic cerebral-palsied children: impact of synkinesis.

OBJECTIVE: Analyze the link between unimanual capacities and bimanual performance in cerebral-palsied (CP) hemiplegic children, aged between 5 and 18 years old, studying specifically the impact of synkinesis. MATERIAL AND METHODS: 71 CP hemiplegic children (35 boys and 36 girls - with average age of 8 years and 6 months; MACS levels from I to III; GMFCS from I to IV) took part in a transversal study, assessed - Melbourne Test (MUUL) for unimanual capacities, and Assisting Hand Assessment (AHA) for bimanual performance - with a specific scale to analyze synkinesis during Box and Block test for affected and healthy hands, collecting synkinesis type, duration and intensity. RESULTS: There is a strong correlation between unimanual capacities (MUUL) and bimanual performance (AHA) (r = 0.871). Neither age nor gender contribute to bimanual performance (AHA). Multiple linear regression shows that MUUL contributes to bimanual performance variance (AHA) by 70%. Synkinesis is partly correlated to capacities (MUUL) and accounts for 10% of the variance of the gap between capacities and bimanual performance. CONCLUSION: A high relationship between unimanual capacities and bimanual performance is confirmed by this study; some authors demonstrated impact of sensory troubles, we demonstrate that synkinesis influences the use of unimanual capacities in bimanual performance.

Which screening strategy using BMD measurements would be most cost effective for hip fracture prevention in elderly women? A decision analysis based on a Markov model.

INTRODUCTION: Hip fractures are responsible for excessive mortality, decreasing the 5-year survival rate by about 20%. From an economic perspective, they represent a major source of expense, with direct costs in hospitalization, rehabilitation, and institutionalization. The incidence rate sharply increases after the age of 70, but it can be reduced in women aged 70-80 years by therapeutic interventions. Recent analyses suggest that the most efficient strategy is to implement such interventions in women at the age of 70 years. As several guidelines recommend bone mineral density (BMD) screening of postmenopausal women with clinical risk factors, our objective was to assess the cost-effectiveness of two screening strategies applied to elderly women aged 70 years and older. METHODS: A cost-effectiveness analysis was performed using decision-tree analysis and a Markov model. Two alternative strategies, one measuring BMD of all women, and one measuring BMD only of those having at least one risk factor, were compared with the reference strategy "no screening". Cost-effectiveness ratios were measured as cost per year gained without hip fracture. Most probabilities were based on data observed in EPIDOS, SEMOF and OFELY cohorts. RESULTS: In this model, which is mostly based on observed data, the strategy "screen all" was more cost effective than "screen women at risk." For one woman screened at the age of 70 and followed for 10 years, the incremental (additional) cost-effectiveness ratio of these two strategies compared with the reference was 4,235 euros and 8,290 euros, respectively. CONCLUSION: The results of this model, under the assumptions described in the paper, suggest that in women aged 70-80 years, screening all women with dual-energy X-ray absorptiometry (DXA) would be more effective than no screening or screening only women with at least one risk factor. Cost-effectiveness studies based on decision-analysis trees maybe useful tools for helping decision makers, and further models based on different assumptions should be performed to improve the level of evidence on cost-effectiveness ratios of the usual screening strategies for osteoporosis.

Low-dose ketamine failed to spare morphine after a remifentanil-based anaesthesia for ear, nose and throat surgery.

BACKGROUND: Ketamine has been claimed to prevent acute opioid tolerance and hyperalgesia following acute exposure to opioids and its use has been proposed to decrease postoperative morphine consumption. METHODS: We conducted a randomized, double-blind, controlled study to evaluate the effect of intravenous (i.v.) ketamine on postoperative pain for 48 h after major ear, nose and throat (ENT) surgery. Thirty-one patients received i.v. ketamine 0.15 mg kg(-1) before induction and 2 microg kg(-1) min(-1) during anaesthesia, and 31 patients were administered placebo in a similar manner. Anaesthesia was standardized with remifentanil and propofol, but without nitrous oxide. Standardized postoperative analgesia included paracetamol, methylprednisolone and morphine administered via a patient controlled analgesia (PCA) device. RESULTS: Intra-operative remifentanil consumption was not different between the ketamine group (0.25 +/- 0.07 microg kg(-1) min(-1)) and the control group (0.22 +/- 0.07 microg kg(-1) min(-1)). In the postoperative period, both groups experienced an identical pain course evolution. Cumulative morphine consumption was not significantly different between groups: at 24 h it was 33.3 +/- 14.9 with ketamine and 31.9 +/- 15.3 mg in controls, at 48h it was 40.4 +/- 20.6 mg with ketamine and 42.5 +/- 25.9 mg in controls. CONCLUSION: Low-dose ketamine added to a remifentanil-based propofol anaesthesia did not reduce morphine consumption after major ENT surgery.