Populations at risk for alveolar echinococcosis, France.

During 1982-2007, alveolar echinococcosis (AE) was diagnosed in 407 patients in France, a country previously known to register half of all European patients. To better define high-risk groups in France, we conducted a national registry-based study to identify areas where persons were at risk and spatial clusters of cases. We interviewed 180 AE patients about their way of life and compared responses to those of 517 controls. We found that almost all AE patients lived in 22 départements in eastern and central France (relative risk 78.63, 95% CI 52.84-117.02). Classification and regression tree analysis showed that the main risk factor was living in AE-endemic areas. There, most at-risk populations lived in rural settings (odds ratio [OR] 66.67, 95% CI 6.21-464.51 for farmers and OR 6.98, 95% CI 2.88-18.25 for other persons) or gardened in nonrural settings (OR 4.30, 95% CI 1.82-10.91). These findings can help sensitization campaigns focus on specific groups.

Clinical features and evolution of alveolar echinococcosis in France from 1982 to 2007: results of a survey in 387 patients.

BACKGROUND & AIMS: Alveolar echinococcosis (AE) is a rare disease in humans, caused by the larval stage of the fox tapeworm Echinococcus multilocularis. METHODS: We present here 387 detailed AE cases diagnosed in France from 1982 to 2007 actively identified by a retrospective survey performed in 1997-1998 and prospectively thereafter. RESULTS: Male:female ratio was 1.03 and mean age 57.8 years at time of diagnosis. Among the 362 complete files (including 347 non dead-out and 15 dead-out lesions), 73% of the patients were symptomatic at first admittance. Among them, 83% presented with clinical patterns evocative either of a digestive or a hepatic disorder. Other symptomatic patients presented with erratic clinical pictures, generally due to metastasis or extra-hepatic location of the parasite. Except for a few patients with particularly severe AE who died shortly after the diagnosis, most patients were treated using benzimidazoles. Their mortality tends to merge with that of the general French population, matched by sex, age, and calendar year. This study also highlights an unexpectedly high frequency of blood-tied family cases (13% of patients submitted to a specific questionnaire). CONCLUSIONS: Even though the broad set of clinical features provoked by E. multilocularis makes AE a potential diagnostic trap for many physicians, our study revealed an improvement of its prognosis. However, as shown by our findings about the frequency of family cases, there is still a need for studies aimed at better describing this uncommon parasitic disease.

Comparison of norepinephrine-dobutamine to epinephrine for hemodynamics, lactate metabolism, and organ function variables in cardiogenic shock. A prospective, randomized pilot study.

OBJECTIVE: There is no study that has compared, in a randomized manner, which vasopressor is most suitable in optimizing both systemic and regional hemodynamics in cardiogenic shock patients. Hence, the present study was designed to compare epinephrine and norepinephrine-dobutamine in dopamine-resistant cardiogenic shock. DESIGN: Open, randomized interventional human study. SETTING: Medical intensive care unit in a university hospital. PATIENTS: Thirty patients with a cardiac index of <2.2 L/min/m and a mean arterial pressure of <60 mm Hg resistant to combined dopamine-dobutamine treatment and signs of shock. Patients were not included in cases of cardiogenic shock secondary to acute ischemic events such as myocardial infarction. Noninclusion criteria also included immediate indication of mechanical assistance. INTERVENTIONS: Patients were randomized to receive an infusion of either norepinephrine-dobutamine or epinephrine titrated to obtain a mean arterial pressure of between 65 and 70 mm Hg with a stable or increased cardiac index. MAIN RESULTS: Both regimens increased cardiac index and oxygen-derived parameters in a similar manner. Patients in the norepinephrine-dobutamine group demonstrated heart rates lower (p<.05) than those in the epinephrine group. Epinephrine infusion was associated with new arrhythmias in three patients. When compared to baseline values, after 6 hrs, epinephrine infusion was associated with an increase in lactate level (p<.01), whereas this level decreased in the norepinephrine-dobutamine group. Tonometered PCO2 gap, a surrogate for splanchnic perfusion adequacy, increased in the epinephrine-treated group (p<.01) while decreasing in the norepinephrine group (p<.01). Diuresis increased in both groups but significantly more so in the norepinephrine-dobutamine group, whereas plasma creatinine decreased in both groups. CONCLUSIONS: When considering global hemodynamic effects, epinephrine is as effective as norepinephrine-dobutamine. Nevertheless, epinephrine is associated with a transient lactic acidosis, higher heart rate and arrhythmia, and inadequate gastric mucosa perfusion. Thus, the combination norepinephrine-dobutamine appears to be a more reliable and safer strategy.

Roles and practices of general practitioners and psychiatrists in management of depression in the community.

BACKGROUND: Little is known about depressed patients' profiles and how they are managed. The aim of the study is to compare GPs and psychiatrists for 1 degrees) sociodemographic and clinical profile of their patients considered as depressed 2 degrees) patterns of care provision. METHODS: The study design is an observational cross-sectional study on a random sample of GPs and psychiatrists working in France. Consecutive inclusion of patients seen in consultation considered as depressed by the physician. GPs enrolled 6,104 and psychiatrists 1,433 patients. DATA COLLECTED: sociodemographics, psychiatric profile, environmental risk factors of depression and treatment. All clinical data were collected by participating physicians; there was no direct independent clinical assessment of patients to check the diagnosis of depressive disorder. RESULTS: Compared to patients identified as depressed by GPs, those identified by psychiatrists were younger, more often urban (10.5% v 5.4% - OR = 2.4), educated (42.4% v 25.4% - OR = 3.9), met DSM-IV criteria for depression (94.6% v 85.6% - OR = 2.9), had been hospitalized for depression (26.1% v 15.6% - OR = 2.0) and were younger at onset of depressive problems (all adjusted p < .001). No difference was found for psychiatric and somatic comorbidity, suicide attempt and severity of current depression. Compared to GPs, psychiatrists more often prescribed tricyclics and very novel antidepressants (7.8% v 2.3% OR = 5.0 and 6.8% v 3.0% OR = 3.8) with longer duration of antidepressant treatment. GPs' patients received more "non-conventional" treatment (8.8% v 2.4% OR = 0.3) and less psychotherapy (72.2% v 89.1% OR = 3.1) (all adjusted p < .001). CONCLUSION: Differences between patients mainly concerned educational level and area of residence with few differences regarding clinical profile. Differences between practices of GPs and psychiatrists appear to reflect more the organization of the French care system than the competence of providers.

[Management of urinary tract infections in women. Epidemiologic survey of 7916 women in general practice]. / Les infections urinaires de la femme en médecine générale. Résultats d'un observatoire réalisé auprès de 7916 patientes.

OBJECTIVE: To evaluate the management of urinary tract infections in women by general practitioners and compare it with official French guidelines. METHODS: This survey enrolled 1587 general practitioners in France and 7916 adult women. Exclusion criteria for patients included: pregnancy, diabetes, neurogenic bladder, or urinary catheters. During the visit at which the diagnosis was made, physicians completed a questionnaire that included diagnostic and management details, in particular, prescription of further examinations. RESULTS: According to the French guidelines, 37% of women had an upper or complicated urinary tract infection, although one third of the complicated infections were so defined only by the patient's age (>65 years). Additional testing was prescribed for 36% of the women with acute uncomplicated cystitis. CONCLUSION: This study shows that the management of urinary tract infections in women does not comply with current guidelines, especially in cases of acute uncomplicated cystitis. The use of age alone as a complicating factor should be reconsidered.

[Determining the optimal fluorine dose in the drinking water of the South Center hydrological region of Haiti]. / Détermination de la dose optimale de fluor de l'eau destinée à la consommation humaine de la région hydrographique Centre-Sud de la république d'Haïti.

This study aims at determining the optimal dose of fluorine in the drinking water in the South Center region of Haiti. This region has an average daily temperature ranging from 17 to 33 C. Water samples were collected from November 15th to December 20th 2000 on the water resource of some of the counties of the hydrological South Center region of Haiti. The results show that the concentration of fluorine in this region varies between 0 and 0.83 mg/litre. However, the calculated optimal dose based on the temperature measured show that fluorine concentration of water should be between 0.7 and 1 mg/litre.

Disability in patients consulting for anxiety or mood disorders in primary care: response to antidepressant treatment.

BACKGROUND: The primary objective of this prospective observational study was to evaluate changes in self-reported disability in patients with anxiety or mood disorders 3 months after initiating antidepressant treatment. METHODS: This study included 8396 patients consulting 2433 general practitioners in France for a major mood episode, generalized anxiety disorder, social anxiety disorder, panic disorder, or obsessive-compulsive disorder. Treatment was initiated with the antidepressant that the physician considered appropriate. Patients were evaluated with the Sheehan Disability Scale (SDS), Hospital Anxiety and Depression Scale, and Clinical Global Impression-Severity (CGI-S) at baseline and after 6 and 12 weeks. RESULTS: At 12 weeks, 6617 patients (78.8%) were evaluable. At inclusion, the mean SDS subscores were 6.5 ± 2.2 on the work/school activities dimension, 6.8 ± 1.9 on the social activities dimension, and 6.5 ± 2.0 on the family life dimension. At the 12-week follow-up visit, the mean change in score on these three dimensions was -3.9 ± 2.6, -4.2 ± 2.5, and -4.0 ± 2.5, respectively. At the 12-week follow-up visit, 90.0% of patients were responders (defined as patients whose SDS dimension scores decreased by at least one point) on the work/school SDS subscores; 92.8% were responders on the social life SDS subscores, and 91.1% were responders on family life/home responsibilities SDS subscores. Functional remission (defined as an SDS subscore of 0 at study end) rates were 18.0% for the work/school dimension, 16.8% for the social activities dimension, and 19.5% for the family life dimension. Using a cutoff of ≤2, remission rates were 56.8%, 55.0%, and 58.0%, respectively. Improvements in self-rated disability were correlated with improvements in symptoms measured with clinician-rated CGI-S. CONCLUSION: Patients consulting for anxiety or mood disorders report significant disability, which can be effectively reduced by antidepressant treatment.

[Nursing management of ventilation and sedation in patients suffering from septic shock]. / La prise en charge infirmière de la ventilation et de la sédation chez le patient en choc septique.

A significant number of intubated, ventilated and sedated patients suffering from septic shock develop acute respiratory distress syndrome (ARDS). The supervision by a multidisciplinary team optimises both the management of ventilation and the sedation analgesia of the patient. The nursing supervision and care related to this pathology are specific.

Increased muscle-to-serum lactate gradient predicts progression towards septic shock in septic patients.

PURPOSE: During septic shock, muscle produces lactate and pyruvate by way of an exaggerated Na(+), K(+)-ATPase-stimulated aerobic glycolysis associated with epinephrine stimulation. We hypothesized that patients with sepsis without shock and increased epinephrine levels or an increased muscle-to-serum lactate gradient are likely to evolve towards septic shock. Thus, in sepsis patients, we investigated (1) whether muscle produces lactate and pyruvate, and (2) whether muscle lactate production is linked to epinephrine levels and the severity of the patient's condition. METHODS: We studied 40 ventilated patients with sepsis without shock or hyperlactatemia and a control group of 10 ICU patients without infection. A microdialysis probe was inserted into the quadriceps muscle. Plasma lactate and pyruvate concentrations were measured in both the dialysate fluid and arterial blood samples every 6 h. RESULTS: There was no gradient between muscle and arterial levels for lactate and pyruvate in the control group. In the sepsis group, muscle lactate and pyruvate concentrations were consistently higher than the arterial levels (P < 0.01). Plasma epinephrine concentrations were also elevated (P < 0.05). A total of 15/40 patients further developed septic shock, and on admission these patients had significantly higher musculo-arterial gradients of lactate (2.9 ± 0.3 vs. 0.7 ± 0.2 mmol/l) (P < 0.05) and pyruvate (740 ± 60 vs. 200 ± 20 µmol/l) (P < 0.05), and higher levels of epinephrine concentrations (6.2 ± 0.7 vs. 2.5 ± 0.24 nmol/l) (P < 0.05). Both the lactate gradient and epinephrine concentrations measured on admission were good predictors of the evolution towards septic shock. CONCLUSIONS: Muscle produces lactate and pyruvate during sepsis, and this production is highly correlated with plasma epinephrine secretion and severity of illness.