Risk factors for placenta accreta spectrum disorders in women with any prior cesarean and a placenta previa or low lying: a prospective population-based study.

This study aimed to identify the risk factors for placenta accreta spectrum (PAS) in women who had at least one previous cesarean delivery and a placenta previa or low-lying. The PACCRETA prospective population-based study took place in 12 regional perinatal networks from 2013 through 2015. All women with one or more prior cesareans and a placenta previa or low lying were included. Placenta accreta spectrum (PAS) was diagnosed at delivery according to standardized clinical and histological criteria. Of the 520,114 deliveries, 396 fulfilled inclusion criteria; 108 were classified with PAS at delivery. Combining the number of prior cesareans and the placental location yielded a rate ranging from 5% for one prior cesarean combined with a posterior low-lying placenta to 63% for three or more prior cesareans combined with placenta previa. The factors independently associated with PAS disorders were BMI ≥ 30, previous uterine surgery, previous postpartum hemorrhage, a higher number of prior cesareans, and a placenta previa. Finally, in this high-risk population, the rate of PAS disorders varies greatly, not only with the number of prior cesareans but also with the exact placental location and some of the women's individual characteristics. Risk stratification is thus possible in this population.

Breastfeeding and respiratory, ear and gastro-intestinal infections, in children, under the age of one year, admitted through the paediatric emergency departments of five hospitals.

Background: Breastfeeding is a protective factor against respiratory and intestinal infections in developing countries. In developed countries, proof of this protection is more difficult to show. The objective of the study is to compare the proportion of children breastfed during their first year in groups of children with infectious pathologies supposedly prevented by breastfeeding and children free of these infectious pathologies. Method: Questionnaires about diet, socio-demographic data and the motive for consultation were given to the parents upon arrival in the paediatric emergency departments of 5 hospitals located in Pays de Loire (France) in 2018 and 2019. Children with lower respiratory tract infections, acute gastroenteritis and acute otitis media were included in the case group (A), children admitted for other reasons were included in the same control group (B). Breastfeeding was classified as exclusive or partial. Results: During the study period, 741 infants were included, of which 266 (35.9%) in group A. In this group, children were significantly less likely to have been breastfed at the time of admission than children in group B: for example, for children under 6 months, 23.3% were currently breastfed in group A, vs. 36.6% (weaned BF or formula diet) in group B [OR = 0.53 (0.34-0.82); p = 0.004]. Similar results were found at 9 and 12 months. After taking into account the age of the patients, the same results were confirmed with an aOR = 0.60 (0.38-0.94) (p = 0.02) at 6 months, but with when considering six variables six variables, aOR was not significative aOR = 0.65 (0.40-1.05); p = 0.08), meaning that factors such as the childcare out of home, socio-professional categories, and the pacifier decrease the protective effect of breastfeeding. Sensitivity analyses (age-matching, analysis by type of infection) showed the same protection effect provided by breastfeeding when it was pursued for at least 6 months and also that the protective effect of breastfeeding is especially true against gastro-enteritis. Conclusion: Breastfeeding is a protective factor against respiratory, gastrointestinal and ear infections when pursued at least 6 months after birth. Other factors such as collective childcare, pacifiers and low parental professional status can reduce the protective effect of breastfeeding.

Conservative management or cesarean hysterectomy for placenta accreta spectrum: the PACCRETA prospective study.

BACKGROUND: Placenta accreta spectrum is a life-threatening condition that has increased dramatically in recent decades along with cesarean rates worldwide. Cesarean hysterectomy is widely practiced in women with placenta accreta spectrum; however, the maternal outcomes after cesarean hysterectomy have not been thoroughly compared with the maternal outcomes after alternative approaches, such as conservative management. OBJECTIVE: This study aimed to compare the severe maternal outcomes between women with placenta accreta spectrum treated with cesarean hysterectomy and those treated with conservative management (leaving the placenta in situ). STUDY DESIGN: From a source population of 520,114 deliveries in 176 hospitals (PACCRETA study), we designed an observational cohort of women with placenta accreta spectrum who had either a cesarean hysterectomy or a conservative management (the placenta left in situ) during cesarean delivery. Clinicians prospectively identified women meeting the inclusion criteria and included them at delivery. Data collection started only after the women had received information and agreed to participate in the study in the immediate postpartum period. The primary outcome was the transfusion of >4 units of packed red blood cells within 6 months after delivery. Secondary outcomes were other maternal complications within 6 months. We used propensity score weighting to account for potential indication bias. RESULTS: Here, 86 women had conservative management and 62 women had cesarean hysterectomy for placenta accreta spectrum during cesarean delivery. The primary outcome occurred in 14 of 86 women in the conservative management group (16.3%) and 36 of 61 (59.0%) in the cesarean hysterectomy group (risk ratio in propensity score weighted model, 0.29; 95% confidence interval, 0.19-0.45). The rates of hysterectomy, total estimated blood loss exceeding 3000 mL, any blood product transfusion, adjacent organ injury, and nonpostpartum hemorrhage-related severe maternal morbidity were lower with conservative management than with cesarean hysterectomy (all adjusted, P≤.02); but, the rates of arterial embolization, endometritis, and readmission within 6 months of discharge were higher with conservative management than with cesarean hysterectomy. CONCLUSION: Among women with placenta accreta spectrum who underwent cesarean delivery, conservative management was associated with a lower risk of transfusion of >4 units of packed red blood cells within 6 months than cesarean hysterectomy.

[Study on the integration of mental health support into primary health care in Guinea]. / Expérience d´intégration de la santé mentale en première ligne de soins en Guinée.

INTRODUCTION: the low coverage of specialized mental health services and the shortage of human resources for mental health are enormous challenges for the health care system in Africa. The integration of mental health support into primary health care is a substantial and feasible complementary intervention to specialized services. We collected and analyzed data from 5 Health Care Centers (HCC) that had integrated this care package in Guinea. METHODS: we conducted a descriptive study of new cases of mental health issues between 2012 and 2017. The reasons for consultations and diagnoses were identified and analyzed on the basis of consultation registries and individual medical records. RESULTS: a total of 4.995 patients with mental health problems received consultations (2.8% of general consultations; 0.5 -7.7% according to the centers). The average age of patients was 27,9 years (± 16.1). The most common reasons for consultations were: insomnia 44.4% (n = 2081), seizures 39% (n = 1827), behavioral disorders 31.9% (n = 1263) and hallucinations 26.1% (n = 1224). The most common diagnoses were: epilepsy 36.8% (n = 1773) and psychotic disorders 33.5% (n = 1613). Eighty eight point four per cent (n = 4418) of patients received medical treatment, most often combined with psychological support. CONCLUSION: this study highlights that in the Guinean context, where access to specialized mental health care is very limited, patients with mental ill, even with severe medical conditions, can be followed up in the health centers by non-specialized but trained mental health professionals.

R-CHOP 14 with or without radiotherapy in nonbulky limited-stage diffuse large B-cell lymphoma.

The benefit of radiotherapy (RT) after chemotherapy in limited-stage diffuse large B-cell lymphoma (DLBCL) remains controversial. We conducted a randomized trial in patients with nonbulky limited-stage DLBCL to evaluate the benefit of RT after rituximab plus cyclophosphamide, doxorubicin, vincristine, and prednisone (R-CHOP). Patients were stratified according to the modified International Prognostic Index, including lactate dehydrogenase, Eastern Cooperative Oncology Group performance status, age, and disease stage. The patients received 4 or 6 consecutive cycles of R-CHOP delivered once every 2 weeks, followed or not by RT at 40 Gy delivered 4 weeks after the last R-CHOP cycle. All patients were evaluated by fluorodeoxyglucose-positron emission tomography scans performed at baseline, after 4 cycles of R-CHOP, and at the end of treatment. The primary objective of the trial was event-free survival (EFS) from randomization. The trial randomly assigned 165 patients in the R-CHOP arm and 169 in the R-CHOP plus RT arm. In an intent-to-treat analysis with a median follow-up of 64 months, 5-year EFS was not statistically significantly different between the 2 arms, with 89% ± 2.9% in the R-CHOP arm vs 92% ± 2.4% in the R-CHOP plus RT arm (hazard ratio, 0.61; 95% confidence interval [CI], 0.3-1.2; P = .18). Overall survival was also not different at 92% (95% CI, 89.5%-94.5%) for patients assigned to R-CHOP alone and 96% (95% CI, 94.3%-97.7%) for those assigned to R-CHOP plus RT (P = not significant). R-CHOP alone is not inferior to R-CHOP followed by RT in patients with nonbulky limited-stage DLBCL. This trial was registered at www.clinicaltrials.gov as #NCT00841945.

Multifaceted intervention to improve obstetric practices: The OPERA cluster-randomized controlled trial.

OBJECTIVE: Suboptimal care contributes to perinatal morbidity and mortality. We investigated the effects of a multifaceted program designed to improve obstetric practices and outcomes. STUDY DESIGN: A cluster-randomized trial was conducted from October 2008 to November 2010 in 95 French maternity units randomized either to receive an information intervention about published guidelines or left to apply them freely. The intervention combined an outreach visit with a morbidity/mortality conference (MMC) to review perinatal morbidity/mortality cases. Within the intervention group, the units were randomized to have MMCs with or without clinical psychologists. The primary outcome was the rate of suboptimal care among perinatal morbidity/mortality cases. The secondary outcomes included the rate of suboptimal care among cases of morbidity, the rate of suboptimal care among cases of mortality, the rate of avoidable morbidity and/or mortality cases, and the incidence of, morbidity and/or mortality. A mixed logistic regression model with random intercept was used to quantify the effect of the intervention on the main outcome. RESULTS: The study reviewed 2459 cases of morbidity or mortality among 165,353 births. The rate of suboptimal care among morbidity plus mortality cases was not significantly lower in the intervention than in the control group (8.1% vs. 10.6%, OR [95% CI]: 0.75 [0.50-1.12], p=0.15. However, the cases of suboptimal care among morbidity cases were significantly lower in the intervention group (7.6% vs. 11.5%, 0.62 [0.40-0.94], p=0.02); the incidence of perinatal morbidity was also lower (7.0 vs. 8.1‰, p=0.01). No differences were found between psychologist-backed and the other units. CONCLUSIONS: The intervention reduced the rate of suboptimal care mainly in morbidity cases and the incidence of morbidity but did not succeed in improving morbidity plus mortality combined. More clear-cut results regarding mortality require a longer study period and the inclusion of structures that intervene before and after the delivery room. (ClinicalTrials.gov ID: NCT02584166).

Neonatal EEG and neurodevelopmental outcome in preterm infants born before 32†weeks.

OBJECTIVE: To assess the value of neonatal EEG for predicting non-optimal neurodevelopmental outcomes in very preterm infants, using a multimodal strategy of evaluation comprising brain imaging and clinical assessment. DESIGN AND SETTING: Between 2003 and 2009, we performed an observational, population-based study. Out of 2040 eligible preterm infants born before 32 weeks, 1954 were enrolled in the French regional Loire Infant Follow-Up Team (LIFT) cohort. 1744 (89%) of these completed the follow-up. Neonatal EEGs were recorded prospectively as two EEGs during the first 2 weeks of life and then one every 2 weeks up to 33 weeks. MAIN OUTCOME MEASURES: The neurodevelopmental outcome was assessed by physical examination, the Brunet-Lézine Test and/or the Age and Stages Questionnaire at 2 years of corrected age. RESULTS: Of the 1744 infants assessed at 2 years, 422 had a non-optimal outcome. A total of 4804 EEGs were performed, and 1345 infants had at least one EEG. EEG abnormalities were predictive of non-optimal outcomes after controlling for confounding factors such as severe intracranial lesions detected by brain imaging. Transient moderate and severe abnormalities were independent predictors of non-optimal outcomes with an OR and 95% CI of 1.49 (1.08 to 2.04) and 2.38 (1.49 to 3.81), respectively. In the validation group, the predictive risk stratification tree identified severe abnormalities as a factor contributing to the prognosis of two subgroups: infants with severe cranial lesions and infants with a normal examination at discharge and without severe cranial lesions.

Predictive value of the parent-completed ASQ for school difficulties in preterm-born children <35 weeks' GA at five years of age.

BACKGROUND: Preterm infants are at greater risk of developmental impairment and require close follow-up for early and optimal care. OBJECTIVES: The objective of the present study was to determine from which age the parental Ages and Stages Questionnaire (ASQ) allows detection of school difficulties in preterm children <35 weeks' gestational age. METHODS: Preterm children from the regional Loire Infant Follow-up Team network were evaluated with the Global School Adaptation (GSA) assessment tool at 5 years of age and at least one parental-completed ASQ at 18, 24, or 36 months. Children belonging to the first decile of the GSA score (<38) were considered to have severe school difficulties. Using overall ASQ scores as continuous variables, receiver operating characteristic (ROC) curves were generated at every age in order to identify preterm children with severe school difficulties. RESULTS: GSA scores were obtained in 1,775 infants at 5 years of age, and at least one ASQ score at 18, 24, or 36 months was completed. Upon ROC analysis, we observed that the 18-, 24-, and 36-month ASQ scores produced respective area under the ROC curve values of 0.66 (0.64-0.69), 0.72 (0.70-0.75), and 0.77 (0.75-0.80) for predicting a GSA score in the first decile. An ASQ cutoff value of 255 at 36 months showed optimal discriminatory power for identifying significant school difficulties at 5 years of age. CONCLUSIONS: The 36-month ASQ is a simple and cost-effective tool that can be employed to help predict future severe school difficulties at 5 years of age in preterm-born children.

Characterizing early detection of language difficulties in children born preterm.

BACKGROUND: The optimal age for assessing language difficulties in premature children remains unclear. AIMS: To determine the most predictive and earliest screening tool for later language difficulties on children born preterm. STUDY DESIGN: A prospective population-based study in the Loire Infant Follow-up Team LIFT SUBJECTS: All children born <35weeks of gestation between 2003 and 2005 were assessed at corrected ages by four screening tools: the Ages & Stages Questionnaire (ASQ) communication scale at 18 and 24months, the language items of Brunet Lezine test at 24months, and the "Epreuves de Repérage des Troubles du Langage" (ERTL) at 4years. OUTCOME MEASURES: After 5years, the kindergarten teacher evaluated the vocabulary, grammar and pronunciation capacities of the child in comparison with the classroom performances. RESULTS: Among 1957 infants enrolled at discharge, 947 were assessed by their teacher with 12.2% (n=116) of language difficulties. Full data at all time points were available for 426 infants. The area under curve of the receiver operator characteristic curve obtained for the ASQ communication scale at 18months was significantly lower (0.65±0.09) than that obtained at 24months (0.77±0.08) and the languages items of Brunet Lezine test at 24months (0.77±0.08), and the ERTL at 4years (0.76±0.09). The optimal cut-off value for ASQ communication at 24months is ≤45 [sensitivity of 0.79 (95%CI: 0.70-0.86); specificity of 0.63 (95%CI: 0.59-0.66)]. CONCLUSIONS: The Ages & Stages Questionnaire communication scale at 24 corrected months appears as an acceptable test at an early time point to identify preterm children at risk of later language difficulties.

Usefulness of parent-completed ASQ for neurodevelopmental screening of preterm children at five years of age.

INTRODUCTION: Preterm children are at greater risk of developmental impairment and require close follow-up for early and optimal medical care. Our goal was to examine use of the parent-completed Ages and Stages Questionnaire (ASQ) as a screening tool for neurodevelopmental disabilities in preterm infants at five years of age. PATIENTS AND METHODS: A total of 648 preterm children (<35 weeks gestational age) born between 2003 and 2004 and included in the regional Loire Infant Follow-up network were evaluated at five years of age. ASQ was compared with two validated tools (Intelligence Quotient and Global School Adaptation Score) and the impact of maternal education on the accuracy of this questionnaire was assessed. RESULTS: Overall ASQ scores for predicting full-scale IQ<85 and GSA score produced an area under the receiver operating characteristic curve of 0.73±0.03 and 0.77±0.03, respectively. An ASQ cut-off value of 285 had optimal discriminatory power for identifying children with IQ scores<85 and GSA scores in the first quintile. ASQ values<285 were significantly associated with a higher risk of non-optimal neurologic outcomes (sensitivity of 0.80, specificity of 0.54 for IQ<85). ASQ values>285 were not distinctive for mild delay or normal development. In children with developmental delay, no difference was found when ASQ scores according to maternal education levels were analyzed. CONCLUSIONS: ASQ at five years is a simple and cost-effective tool that can detect severe developmental delay in preterm children regardless of maternal education level, while its capacity to identify children with mild delay appears to be more limited.

Quality indicators for continuous monitoring to improve maternal and infant health in maternity departments: a modified Delphi survey of an international multidisciplinary panel.

OBJECTIVE: Measuring the quality of inpatient obstetrical care using quality indicators is becoming increasingly important for both patients and healthcare providers. However, there is no consensus about which measures are optimal. We describe a modified Delphi method to identify a set of indicators for continuously monitoring the quality of maternity care by healthcare professionals. METHODOLOGY AND MAIN FINDINGS: An international French-speaking multidisciplinary panel comprising 22 obstetricians-gynaecologists, 12 midwives, and 1 paediatrician assessed potential indicators extracted from a medical literature search, using a two-round Delphi procedure followed by a physical meeting. Each panellist rated each indicator based on validity and feasibility. In the first round, 35 panellists from 5 countries and 20 maternity units evaluated 26 indicators including 15 related to the management of the overall population of pregnant women, 3 to the management of women followed from the first trimester of pregnancy, 2 to the management of low-risk pregnant women, and 6 to the management of neonates. 25 quality indicators were kept for next step. In the second round, 27 (27/35: 77%) panellists selected 17 indicators; the remaining 8 indicators were discussed during a physical meeting. The final set comprised 18 indicators. CONCLUSION: A multidisciplinary panel selected indicators that reflect the quality of obstetrical care. This set of indicators could be used to assess and monitor obstetrical care, with the goal of improving the quality of care in maternity units.

The Global School Adaptation score: a new neurodevelopmental assessment tool for very preterm children at five years of age.

OBJECTIVE: To determine the usefulness of a neurodevelopmental assessment tool consisting of a questionnaire administered to teachers to measure the Global School Adaptation (GSA) scores of very preterm children at the age of 5 years. STUDY DESIGN: A sample of 445 very preterm children (<35 weeks of gestation) was assessed at 5 years of age using GSA and IQ scores. According to the consistency between the scores, children were determined to be well classified, intermediately classified, or misclassified. The differences between groups were assessed through univariate and multivariate logistic regression. RESULTS: The GSA score was highly or intermediately consistent with the IQ score for 89.2% of the children, and 10.8% were considered misclassified. Children with a higher GSA than IQ score had more autonomy and self-confidence (P < .01), and those with a lower GSA than IQ score had more behavioral problems (P < .01). Analysis by logistic regression showed that sex and gestational age significantly affected the consistency between the 2 scores. Thus, girls were less likely to have a lower GSA than IQ score (aOR = 0.45; 95% CI: 0.24-0.84; P = .01), and a lower gestational age significantly increased the likelihood of having a higher GSA than IQ score (for children born between 24 and 28 weeks of gestation: aOR = 2.70; 95% CI: 1.23-5.92; P = .01). CONCLUSIONS: The GSA score is a simple, inexpensive, and reliable screening tool for assessing neurodevelopment in very preterm children at 5 years of age.

Neurological assessment of preterm infants for predicting neuromotor status at 2 years: results from the LIFT cohort.

OBJECTIVE: To develop a predictive risk stratification model for the identification of preterm infants at risk of 2-year suboptimal neuromotor status. DESIGN: Population-based observational study. SETTING: Regional preterm infant follow-up programme (Loire Infant Follow-up Team (LIFT) cohort) implemented in 2003. PARTICIPANTS: 4030 preterm infants were enrolled in the LIFT cohort, and examined by neonatologists using a modified version of the Amiel-Tison neurological assessment tool. MAIN OUTCOME CRITERIA: 2 year neuromotor status based on clinical examinations was conducted by trained paediatricians and parents' responses to the Ages and Stages Questionnaire were reported. RESULTS: At 2 years of corrected age, 3321 preterm infants were examined, and suboptimal neuromotor status was found in 355 (10.7%). The study population was divided into training and validation sets. In the training set, 13 neonatal neurological items were associated with a 2-year suboptimal neuromotor status. Having at least one abnormal item was defined as an abnormal neurological status at term. In the validation set, these data predicted a 2-year suboptimal neuromotor status with a sensitivity of 0.55 (95% CI 0.47 to 0.62) and a specificity of 0.65 (95% CI 0.62 to 0.67). Two predictive risk stratification trees were built using the training set, which were based on the neurological assessment at term along with either gestational age or severe cranial lesions or birth weight. Using the validation set, the first tree identified a subgroup with a relatively low risk of suboptimal neuromotor status (3%), representing 32% of infants, and the second tree identified a subgroup with a risk of 5%, representing 42% of infants. CONCLUSION: A normal neurological assessment at term allows the identification of a subgroup of preterm infants with a lower risk of non-optimal neuromotor development at 2 years.

The apparent breastfeeding paradox in very preterm infants: relationship between breast feeding, early weight gain and neurodevelopment based on results from two cohorts, EPIPAGE and LIFT.

CONTEXT: Supplementation of breast milk is difficult once infants suckle the breast and is often discontinued at end of hospitalisation and after discharge. Thus, breastfed preterm infants are exposed to an increased risk of nutritional deficit with a possible consequence on neurodevelopmental outcome. OBJECTIVE: To assess the relationship between breast feeding at time of discharge, weight gain during hospitalisation and neurodevelopmental outcome. DESIGN: Observational cohort study. SETTING: Two large, independent population-based cohorts of very preterm infants: the Loire Infant Follow-up Team (LIFT) and the EPIPAGE cohorts. PATIENTS: 2925 very preterm infants alive at discharge. MAIN OUTCOME MEASURE: Suboptimal neurodevelopmental outcome, defined as a score in the lower tercile, using Age and Stages Questionnaire at 2 years in LIFT and Kaufman Assessment Battery for Children Test at 5 years in EPIPAGE. Two propensity scores for breast feeding at discharge, one for each cohort, were used to reduce bias. RESULTS: Breast feeding at time of discharge concerned only 278/1733 (16%) infants in LIFT and 409/2163 (19%) infants in EPIPAGE cohort. Breast feeding is significantly associated with an increased risk of losing one weight Z-score during hospitalisation (LIFT: n=1463, adjusted odd ratio (aOR)=2.51 (95% CI 1.87 to 3.36); EPIPAGE: n=1417, aOR=1.55 (95% CI 1.14 to 2.12)) and with a decreased risk for a suboptimal neurodevelopmental assessment (LIFT: n=1463, aOR=0.63 (95% CI 0.45 to 0.87); EPIPAGE: n=1441, aOR=0.65 (95% CI 0.47 to 0.89) and an increased chance of having a head circumference Z-score higher than 0.5 at 2 years in LIFT cohort (n=1276, aOR=1.43 (95% CI 1.02 to 2.02)) and at 5 years in EPIPAGE cohort (n=1412, aOR=1.47 (95% CI 1.10 to 1.95)). CONCLUSIONS: The observed better neurodevelopment in spite of suboptimal initial weight gain could be termed the 'apparent breastfeeding paradox' in very preterm infants. Regardless of the mechanisms involved, the current data provide encouragement for the use of breast feeding in preterm infants.

Randomized comparison of 2 protocols to prevent acquisition of methicillin-resistant Staphylococcus aureus: results of a 2-center study involving 500 patients.

OBJECTIVE: To compare an interventional protocol with a standard protocol for preventing the acquisition of methicillin-resistant Staphylococcus aureus (MRSA) in the intensive care unit (ICU). DESIGN: Prospective, randomized, controlled, parallel-group, nonblinded clinical trial. SETTING: Medical ICUs of 2 French university hospitals. PARTICIPANTS: Five hundred adults with an expected length of stay in the ICU greater than 48 hours. INTERVENTIONS: For the intervention group, the protocol required repeated MRSA screening, contact and droplet isolation precautions for patients at risk for MRSA at ICU admission and for MRSA-positive patients, and decontamination with nasal mupirocin and chlorhexidine body wash for MRSA-positive patients. For the standard group, the standard precautions protocol was used, and the results of repeated MRSA screening in the standard group were not communicated to investigators. MAIN OUTCOME MEASURE: MRSA acquisition rate in the ICU. An audit was conducted to assess compliance with hygiene and isolation precautions. RESULTS: In the intent-to-treat analysis ([Formula: see text]), the MRSA acquisition rate in the ICU was similar in the standard (13 [5.3%] of 243) and intervention (16 [6.5%] of 245) groups ([Formula: see text]). The audit showed that the overall compliance rate was 85.5% in the standard group and 84.1% in the intervention group ([Formula: see text]), although compliance was higher when isolation precautions were absent than when they were in place (88.2% vs 79.1%; [Formula: see text]). MRSA incidence rates were higher without isolation precautions (7.57‰) than with isolation precautions (2.36‰; [Formula: see text]). CONCLUSIONS: Individual allocation to MRSA screening, isolation precautions, and decontamination do not provide individual benefit in reducing MRSA acquisition, compared with standard precautions, although the collective risk was lower during the periods of isolation. TRIAL REGISTRATION: Clinicaltrials.gov identifier: NCT00151606.

Parent-completed developmental screening in premature children: a valid tool for follow-up programs.

Our goals were to (1) validate the parental Ages and Stages Questionnaires (ASQ) as a screening tool for psychomotor development among a cohort of ex-premature infants reaching 2 years, and (2) analyse the influence of parental socio-economic status and maternal education on the efficacy of the questionnaire. A regional population of 703 very preterm infants (<35 weeks gestational age) born between 2003 and 2006 were evaluated at 2 years by their parents who completed the ASQ, by a pediatric clinical examination, and by the revised Brunet Lezine psychometric test with establishment of a DQ score. Detailed information regarding parental socio-economic status was available for 419 infants. At 2 years corrected age, 630 infants (89.6%) had an optimal neuromotor examination. Overall ASQ scores for predicting a DQ score ≤85 produced an area under the receiver operator curve value of 0.85 (95% Confidence Interval:0.82-0.87). An ASQ cut-off score of ≤220 had optimal discriminatory power for identifying a DQ score ≤85 with a sensitivity of 0.85 (95%CI:0.75-0.91), a specificity of 0.72 (95%CI:0.69-0.75), a positive likelihood ratio of 3, and a negative likelihood ratio of 0.21. The median value for ASQ was not significantly associated with socio-economic level or maternal education. ASQ is an easy and reliable tool regardless of the socio-economic status of the family to predict normal neurologic outcome in ex-premature infants at 2 years of age. ASQ may be beneficial with a low-cost impact to some follow-up programs, and helps to establish a genuine sense of parental involvement.

Anemia normalization in patients with type 2 diabetes and chronic kidney disease: results of the NEPHRODIAB2 randomized trial.

STATEMENTS OF THE PROBLEM: Correction of anemia in type 2 diabetes (T2DM) patients with chronic kidney disease stages 3-4 may slow the decline of kidney function but may increase cardiovascular risk through higher hematocrit. The NEPHRODIAB2 study was designed to assess efficacy and safety of complete hemoglobin (Hb) normalization in these patients. METHODS: We randomly assigned 89 T2DM patients with an estimated glomerular filtration rate (eGFR; abbreviated 175 Modification of Diet in Renal Disease formula) of 25 to 60 ml/min per 1.73 m(2) and moderate anemia (Hb, 100-129 g/l) to a target Hb value in subnormal range (110-129g/l, group 1, n=43) or normal range (130-149 g/l, group 2, n=46). The primary end point was eGFR decline after 2 years of follow-up. Secondary end points included iron and erythropoietin dosage, quality of life (Medical Outcomes Study 36-item Short-Form Health Survey scores) and adverse events. RESULTS: Six months after randomization, the mean Hb levels were <120 g/l in group 1 and >130 g/l in group 2 (P<.05 at 6, 12, 18 and 24 months). Blood pressure, 24-h proteinuria and HbA1c did not differ during follow-up (P>.05). Two-year declines in eGFR were -8.7±12.2 in group 1 and -5.1±7.8 ml/min per 1.73 m(2) in group 2 (P=.29). Mean weekly use of erythropoietin was 7.8±11.6 µg in group 1 and 30.1±33.6 µg in group 2 (P<.0001). There was no significant difference regarding Medical Outcomes Study 36-item Short-Form Health Survey score change or adverse event occurrence. CONCLUSIONS: In this trial, normalization of Hb level in T2DM patients with chronic kidney disease was safe but did not significantly slow renal function decline and increased treatment cost due to erythropoietin use.

[Tunnelled internal jugular vein catheters with taurolidine lock: an acceptable challenge to arterio-venous fistula in 70 years old haemodialyzed patients: a prospective pilot study]. / Les cathéters jugulaires internes tunnellisés avec verrou antiseptique par taurolidine : une alternative acceptable aux fistules artérioveineuses chez les hémodialysés de plus de 70ans : résultats d'une étude pilote prospective.

Arteriovenous fistula (AVF) is still in 2010 the gold standard of vascular(2) access in haemodialysis (HD) patients. Nevertheless it may be difficult to obtain and/or to use AVF in elderly. With this prospective randomised pilot study, we compare two strategies of vascular access in 70 years old or more new HD patients. AVF were compared to tunnelled jugular vein catheters (TIJC) with taurolidine as bacterial lock solution. Results were as follow: [table: see text] The responses with the visual analogic scale of comfort was 8/10 for TIJC and 5/10 with AVF * P<0.05. In five TIJC patients, heparin was added with success to taurolidine because of partial clotting of catheters. Albuminemia was significantly lower in AVF failure patients compared to AVF success patients (24.8g/L vs 31.1g/L). This pilot study allows to conclude that TIJC is an acceptable challenge to AVF in haemodialysed patients of 70 years or more in a two years long use.

Formative evaluation to improve prevention of sudden infant death syndrome (SIDS): a prospective study.

AIM: To evaluate formative evaluation, a pedagogic method that sensitizes mothers to sudden infant death syndrome (SIDS), as a new way to improve prevention of SIDS. METHODS: Prospective and randomized study. Mothers in a test group (n = 148) received an educative questionnaire about SIDS during maternity stay. Three months later, we evaluated, by a telephonic interview, their scores of knowledge and observance of the recommendations in comparison with a control group (n = 144). RESULTS: Mothers' scores at the educative questionnaire was 5.12 (1.52) [mean(standard deviation)]. The scores performed 3 months later were better in test group for knowledge [7.64 (1.56) vs. 7.16 (1.61), p < 0.01] and for observance [8.28 (1.51) vs. 7.62 (1.72), p < 0.001]. Logistic regression analysis confirmed the benefits in test group regarding knowledge of SIDS risk factors [ORa = 1.69 (1.02-2.77), p < 0.05], of the advice to avoid overheating infants [ORa = 2.50 (1.43-4.38), p < 0.01] and of the risks of bed sharing [ORa = 2.7 (1.6-4.5), p < 0.001]. There was a significant association between non-compliance with the sleeping position recommendation and unemployment (p < 0.01) and absence of postsecondary school education (p < 0.01). CONCLUSION: Formative evaluation using an educative questionnaire could improve maternal awareness on SIDS risk factors and their compliance with recommendations about SIDS prevention.

Procalcitonin as a marker of bacterial infection in children undergoing cardiac surgery with cardiopulmonary bypass.

BACKGROUND: Owing to systemic inflammatory response syndrome, the diagnosis of post-operative infection after cardiopulmonary bypass is difficult to assess in children with the usual clinical and biological tools. Procalcitonin could be informative in this context. METHODS: Retrospective study in a paediatric intensive care unit. Blood samples were collected as soon as infection was clinically suspected and a second assay was performed 24 hours later. Using referenced criteria, children were retrospectively classified into two groups: infected and non-infected. RESULTS: Out of the 95 children included, 14 were infected. Before the third post-operative day, procalcitonin median concentration was significantly higher in the infected group than in the non-infected group - 20.24 nanograms per millilitre with a 25th and 75th interquartile of 15.52-35.71 versus 0.72 nanograms per millilitre with a 25th and 75th interquartile of 0.28 to 5.44 (p = 0.008). The area under the receiver operating characteristic curve was 0.89 with 95% confidence intervals from 0.80 to 0.97. The best cut-off value to differentiate infected children from healthy children was 13 nanograms per millilitre with 100% sensitivity - 95% confidence intervals from 51 to 100 - and 85% specificity - 95% confidence intervals from 72 to 91. After the third post-operative day, procalcitonin was not significantly higher in infected children - 2 nanograms per millilitre with a 25th and 75th interquartile of 0.18 to 12.42 versus 0.37 nanograms per millilitre with a 25th and 75th interquartile of 0.24 to 1.32 (p = 0.26). The area under the receiver operating characteristic curve was 0.62 with 95% confidence intervals from 0.47 to 0.77. A procalcitonin value of 0.38 nanograms per millilitre provided a sensitivity of 70% with 95% confidence intervals from 39 to 89 for a specificity of 52% with 95% confidence intervals from 34 to 68. After the third post-operative day, a second assay at a 24-hour interval can improve the sensitivity of the test. CONCLUSIONS: Procalcitonin seems to be a discriminating marker of bacterial infection during the post-operative days following cardiopulmonary bypass in children.