Plasma D-dimer concentration in patients with systemic sclerosis.

BACKGROUND: It has been reported that increased plasma D-dimer is a reliable marker of systemic prothrombotic state in patients with cardiovascular diseases. OBJECTIVES: To evaluate plasma D-dimer concentration in patients with systemic sclerosis (SSc) and healthy controls. We also investigated a possible relationship between the presence of a high plasma D-dimer concentration and clinical and biological parameters in patients with SSc. METHODS: Measurements of plasma D-dimer concentration were performed in 69 consecutive patients with SSc and 69 age- and sex-matched controls. Clinical and biological findings were compared between patients with and without a high concentration of plasma D-dimer (i.e. >or=500 ng mL(-1)). RESULTS: Median plasma D-dimer concentrations appeared significantly increased in patients with SSc compared with control subjects (506 vs. 211 ng mL(-1); P<0.001). Furthermore, a high concentration of plasma D-dimer (>or=500 ng mL(-1)) was detected more frequently in patients with SSc than in healthy controls (47.8% vs. 4.5%; P<0.0001). Among vascular manifestations related to SSc, macrovascular impairment responsible for peripheral ischaemia was more frequent in patients with SSc with high levels of D-dimer (>or=500 ng mL(-1)), compared with those without (21% vs. 6%; P=0.05). CONCLUSIONS: The association between high levels of plasma D-dimer (>or=500 ng mL(-1)) and macrovascular involvement in patients with SSc is likely to be an innovative issue. We suggest that D-dimer levels may be a helpful additional test to identify patients with SSc at risk to develop thrombotic arterial complications (peripheral arterial disease, stroke and coronary event); such patients with high levels of plasma D-dimer (>or=500 ng mL(-1)) may require close monitoring of vascular parameters, including especially macrovascular impairment.

Anticardiolipin and anti-beta2 glycoprotein I antibodies and lupus-like anticoagulant: prevalence and significance in systemic sclerosis.

BACKGROUND: It has been suggested that both anticardiolipin (aCL) and anti-beta(2) glycoprotein I (abeta(2)GPI) antibodies may play a critical role in the pathogenesis of systemic sclerosis (SSc)-related vascular impairment. OBJECTIVES: To evaluate the prevalence of aCL and abeta(2)GPI antibodies and lupus-like anticoagulant (LAC) in patients with SSc and healthy controls. We also investigated a possible relationship between clinical and biological variables of patients with SSc and the presence of aCL/abeta(2)GPI antibodies and/or LAC. METHODS: Measurements of aCL and abeta(2)GPI antibodies, and LAC were performed in 69 consecutive patients with SSc and 69 age- and sex-matched controls. Clinical and biological findings were compared between patients with and without antiphospholipid antibodies. RESULTS: aCL and abeta(2)GPI antibodies and/or LAC were detected in 13 (19%) of 69 consecutive patients with SSc; in the healthy control group, aCL antibody was found in only one (2%) subject (P = 0.0007). None of the healthy controls had abeta(2)GPI antibody and/or LAC. Moreover, pitting scars, pulmonary arterial hypertension, macrovascular involvement as well as severity of capillary impairment (using nailfold videocapillaroscopy) were more frequent in SSc patients with aCL/abeta(2)GPI antibodies and/or LAC compared with those without. CONCLUSIONS: Our findings suggest that antiphospholipid antibodies may have a role in the genesis of vascular involvement related to SSc. Finally, the assessment of antiphospholipid antibodies (aCL and abeta(2)GPI antibodies, as well as LAC) may contribute to a better recognition of clinical features in patients with SSc; in essence, the patients with aCL/abeta(2)GPI antibodies and/or LAC may require close monitoring of vascular changes, including in particular pulmonary arterial hypertension and digital infarcts.

Weight loss and quality of life after bariatric surgery: a study of 200 patients after vertical gastroplasty or adjustable gastric banding.

BACKGROUND AND OBJECTIVES: Long term evaluation of bariatric surgery must include quality of life measurement. METHODS: Quality of life (QoL) was evaluated using the original Moorehead-Ardelt questionnaire for 200 patients operated for massive obesity in a single centre between 1994 and 2003. QoL and physical data were obtained by retrospective mail questionnaire. Surgical procedures were vertical-banded gastroplasty according to Mason (VBGM) and adjustable gastric banding (AGB) in 61 and 39% of patients, respectively. The aim of the study was to assess the nutritional outcome and QoL according to the procedure. RESULTS: Overall, the body mass index (BMI) decreased from 50+/-8 kg/m(2) before surgery to 35.2+/-7.5 kg/m(2) at the time of the questionnaire. The percentage of weight loss was 28.8+/-12.2%. In the group treated with VBGM, the mean initial weight (P=0.003) and the percentage of weight loss (P<0.001) were significantly higher, and the QoL was better (P=0.003) than in the group treated with AGB. On the basis of the time spent since surgery, a regular weight loss was observed during the first 5 years, whereas weight subsequently increased over the five following years. Similarly, the total QoL score gradually improved during the first 5 years and worsened thereafter. However, it remained better than before surgery. A linear regression analysis showed a positive correlation between the percentage of weight loss and the QoL score (P<0.001). CONCLUSIONS: This study suggests that the bariatric surgery, particularly the VBGM technique, improved the QoL of obese patients, at least in the first 5 years following surgery.

[Current reasons for in-patient psoriasis management]. / Motifs d'hospitalisation des malades atteints de psoriasis.

BACKGROUND: Currently, out-patient care is the traditional approach for the management of patients with psoriasis. However, some patients still require hospitalization. The aim of this study was to assess the main reasons for hospitalization of psoriasis patients. PATIENTS AND METHODS: Data are presented from a retrospective study performed in a single centre over a 15-year period (1990-2005). Hospitalizations of psoriasis patients were identified using the coding L 40.X from the CM10 (out-patients were excluded). For each hospitalization, the following details were recorded: age, sex, associated disorders, mean length of stay, number of re-hospitalizations, clinical type of psoriasis (vulgaris, pustular or erythrodermic), onset factors and treatments. RESULTS: One hundred and twenty-two patients corresponding to 211 hospitalizations were included in this study. Two distinct patient populations could be identified. The first consisted of patients with chronic psoriasis vulgaris (143/211 hospitalizations, 67.8%), chiefly male (n=95, sex-ratio=1.98, p=0.001), alcoholic in 47/95 hospitalizations, 49.5% (p=0.004) and requiring frequent re-hospitalization. The second consisted of patients with acute forms of psoriasis, either pustular (38/211 hospitalizations, 18%) or erythrodermic (30/211 hospitalizations, 14.2%). Most of these patients were female (sex-ratio=0.66) and the onset of their psoriasis was sometimes triggered by an infection (7/38 hospitalizations, 18% of psoriasis pustular, p=0.16) or intake of a new drug (6/30 hospitalizations, 20% of erythrodermic psoriasis, p=0.007). DISCUSSION: Hospitalization in acute care hospitals is not often used in the management of patients with psoriasis. Hospitalizations concern two different populations: the first with chronic psoriasis vulgaris and commonly associated disorders (alcohol abuse), and the second with acute forms of psoriasis, namely pustular and erythrodermic.

Double stenting of oesophagus and airways in palliative treatment of patients with oesophageal cancer is efficient but associated with a high morbidity.

BACKGROUND: Double stenting of oesophagus and airways may be required in palliative treatment of patients with locally advanced oesophageal cancer. AIM: To assess feasibility, efficacy and complications occurring in patients with locally advanced oesophageal cancer receiving both oesophagus and airways stenting. METHODS: In one single centre between 1997 and 2005, among 180 patients with locally advanced oesophageal cancer treated by the palliative placement of a self-expanding metal stent, patients requiring double stenting of oesophagus and airways were identified. Clinical efficacy, complications and survival were retrospectively collected. RESULTS: Fifteen patients (8.3% of 180) required a double stenting at follow-up. Symptomatic efficacy of oesophagus and airways stenting was 86.7% for dysphagia and 100% for dyspnoea. Median survival after the second stent insertion was 99 days. Life-threatening early complications occurred in three patients after double stenting (20%), including two deaths following oesophageal perforation and massive haemoptysis, respectively. Procedure-related mortality was 13.3%. CONCLUSIONS: Double stenting of oesophagus and airways is feasible in patients with locally advanced oesophageal cancer, with a relevant clinical efficacy. However, early major complications including procedure-related death may occur in as many as 20% of patients. This treatment should be reserved to very selected patients with severe symptoms and end-stage disease.

Outcome of small-bowel motor impairment in systemic sclerosis--a prospective manometric 5-yr follow-up.

OBJECTIVE: To assess the 5-yr course of small-bowel motor disorders, using manometry in patients with systemic sclerosis (SSc), and to investigate for an association between small-bowel motor dysfunction outcome and other clinical manifestations of SSc. METHODS: Fasting and post-prandial motor activity of the small-bowel was systematically assessed in eight consecutive patients with SSc, using 24 h manometry: initially and at 5-yr follow-up. RESULTS: At 5-yr follow-up, the eight SSc patients (100%) exhibited deterioration of small-bowel motor activity on manometry as follows: (1) more severe abnormalities of migrating motor complex phase III during the fasting period; (2) decreased median duodenal and duodeno-jejunal index during the post-prandial period; and (3) more frequent alterations of small-bowel motor activity in response to octreotide infusion. Furthermore, an association could be found between the deterioration of small-bowel motor function and pitting scars' onset. CONCLUSION: Our study underscores the rapid deterioration of small-bowel motor impairment in SSc patients (100%). It also highlights the usefulness of small-bowel manometry in symptomatic SSc patients in objectively defining both the characteristics and degree of motor impairment, which may influence the choice of medical treatment in patients, particularly octreotide therapy.

[Validity of proton pump inhibitors' prescriptions in a department of internal medicine]. / Adéquation aux recommandations des prescriptions des inhibiteurs de la pompe à protons dans un service de médecine interne.

INTRODUCTION: Proton pump inhibitors (PPIs) are an efficient therapy, being widely used by physicians. In 2004, cost of PPIs' therapy was as high as 748 millions of euros (for The Caisse primaire d'Assurance Maladie) in France. Although validated indications of PPIs are well known, numerous un-necessary prescriptions of PPIs are common. The aim of this prospective study was to evaluate PPIs' prescriptions of patients in a department of internal medicine. PATIENTS AND METHODS: This is a 12-week assessment of medical charts of patients, receiving PPI therapy in patients in our department of internal medicine. Data were collected by a standardized questionnaire, with regards to: PPIs' nature and regimen, PPIs' indications as well as duration of therapy. RESULTS: The medical charts of 729 consecutive patients, with a mean age of 67 years, were collected. Two hundred (and) twenty-four patients (30.7%) received PPI therapy; 157 of these patients were given PPI before admission in our department. Omeprazole was used in 71% of patients. Duration of PPI therapy was over one year in 45% of cases. Thirty-five per cent of family physicians' PPI prescription were validated and 23.8% of those of physicians working in the department of internal medicine. The main non-conform PPI's indications, by family physicians and internists were as follows: prevention of hemorrhagic risk of anti-platelet agent (21 vs 16.4%), anticoagulant (17.8 vs 16.4%), steroids (8.3 vs 13.4%) or non-steroid anti-inflammatory therapy without risk factor (1.9 vs 9%). Finally, in patients receiving PPI therapy before admission, this therapy was maintained in 76% of cases. CONCLUSION: This prospective study confirms the frequent prescription of PPI therapy in a department of internal medicine (31% of patients). It also underscores the importance of PPIs' use by family physicians and physicians working in a department of internal medicine; this series further highlights the difficulties to interrupt this well tolerated therapy. To date, PPI therapy should be prescribed with a cautious consideration of cost and benefit.

Magnesium sulphate given before very-preterm birth to protect infant brain: the randomised controlled PREMAG trial*.

OBJECTIVE: To evaluate whether magnesium sulphate (MgSO(4)) given to women at risk of very-preterm birth would be neuroprotective in preterm newborns and would prevent neonatal mortality and severe white-matter injury (WMI). DESIGN: A randomised study. SETTING: Eighteen French tertiary hospitals. Population Women with fetuses of gestational age < 33 weeks whose birth was planned or expected within 24 hours were enrolled from July 1997 to July 2003 with follow up of infants until hospital discharge. METHODS Five hundred and seventy-three mothers were randomly assigned to receive a single 40-ml infusion of 0.1 g/ml of MgSO(4) (4 g) solution or isotonic 0.9% saline (placebo) over 30 minutes. This study is registered as an International Standard Randomised Controlled Trial, number 00120588. MAIN OUTCOME MEASURES: The primary endpoints were rates of severe WMI or total mortality before hospital discharge, and their combined outcome. Analyses were based on intention to treat. RESULTS: After 6 years of enrolment, the trial was stopped. Data from 688 infants were analysed. Comparing infants who received MgSO(4) or placebo, respectively, total mortality (9.4 versus 10.4%; OR: 0.79, 95% CI 0.44-1.44), severe WMI (10.0 versus 11.7%; OR: 0.78, 95% CI 0.47-1.31) and their combined outcomes (16.5 versus 17.9%; OR: 0.86, 95% CI 0.55-1.34) were less frequent for the former, but these differences were not statistically significant. No major maternal adverse effects were observed in the MgSO(4) group. CONCLUSION: Although our results are inconclusive, improvements of neonatal outcome obtained with MgSO(4) are of potential clinical significance. More research is needed to assess the protective effect of MgSO(4) alone or in combination with other neuroprotective molecules.

The value of clinical characteristics from a standard questionnaire to discriminate cardiac from neurological syncope in the elderly.

OBJECTIVES: To identify signs and symptoms to differentiate cardiac from neurological syncope in patients over 70 using a standardized questionnaire. DESIGN: Prospective cohort study. SETTING: Five short-stay units in a French university hospital. PARTICIPANTS: One hundred thirty-one in-patients with syncope aged 70 and older. MEASUREMENTS: Patients were interviewed about the signs and symptoms that had been present before, during or after syncope. When possible, a witness who had been present during syncope was also interviewed to compare theirs and the patients' answers. The sensitivity and specificity of 35 questions were calculated among 3 groups defined according to the cause of syncope: cardiac (n = 58), neurological (n = 31) and syncope of unknown origin (n = 42). Statistical analyses were performed to determine discriminating signs and symptoms among the causes and crude agreement was calculated for answers from patients and witnesses. RESULTS: Only 8 and 3 of 35 questions had a sensitivity of at least 0.5 for cardiac and neurological causes respectively. A feeling of impending syncope, thoracic oppression, recall of events preceding syncope and a history of arrhythmia were independently and significantly discriminant among groups. Recall of events preceding syncope (Odds Ratio (OR) = 7.5; 95% confidence interval (CI) = 2.2-25.3) and a personal history of arrhythmia (OR = 4.8; 95% CI = 1.6-14.2) were discriminant between cardiac and neurological causes suggesting mostly a cardiac cause. Agreement between patients and witnesses was only found for questions on the patient's medical history or the circumstances surrounding the onset of syncope. CONCLUSIONS: Recall of events preceding syncope and a history of arrhythmia are strongly suggestive of a cardiac rather than a neurological cause of syncope. Interviews of witnesses are not helpful in suggesting a cause for syncope.

Intravenous immunoglobulin-associated arterial and venous thrombosis; report of a series and review of the literature.

BACKGROUND: To date, the prevalence of intravenous immunoglobulin (IvIg)-related thrombotic complications has not been evaluated in patients with autoimmune disorders followed up in Departments of Internal Medicine. OBJECTIVES: To assess prevalence and characteristics of IvIg-related thrombotic complications in patients with autoimmune disorders receiving IvIg therapy; to evaluate the predictive factors for onset of IvIg-related thrombotic manifestation in patients, and to detect patients at risk for these types of complications. PATIENTS AND METHODS: The medical records of 46 patients with autoimmune disorders who were given IvIg therapy at our Department of Internal Medicine between January 2002 and December 2004 were reviewed. RESULTS: Among the 46 patients, nine exhibited IvIg-associated severe complications (19.6%). Six patients (13%) developed IvIg-related thrombotic complications. Thrombotic complications frequently occurred during IvIg infusion (50%), although they were also observed within 1-8 days following IvIg infusion in other patients. IvIg-related thrombotic complications consisted of: deep venous thrombosis or pulmonary embolism (n = 3), myocardial infarction (n = 2) and stroke (n = 1). The outcome of thrombotic complications was favourable in all patients, after appropriate therapy institution. Older age, history of associated arterial hypertension and hypercholesterolaemia were more common in the group of patients with IvIg-related thrombotic complications. CONCLUSIONS: Our study demonstrates that IvIg-related thrombotic arterial/venous complications are not uncommon in patients with autoimmune disorders (13% of patients). Nevertheless, patients, who are followed up in Departments of Internal Medicine often have concomitant disorders placing them at increased risk to develop IvIg-related thrombotic complications; the latter may also explain the high rate of IvIg-related thrombosis in our cohort. Our series further indicates that patients should be monitored closely for these types of adverse events during the whole period of IvIg therapy, as thrombotic manifestations occurred in patients who had received multiple IvIg infusions without exhibiting complications. In addition, our results suggest that it is questionable to initiate IvIg therapy in patients presenting with predictive factors of thrombotic complications; in this subgroup of patients, IvIg should be prescribed cautiously, after re-weighing risk-benefit considerations.

Induction cisplatin-irinotecan followed by concurrent cisplatin-irinotecan and radiotherapy without surgery in oesophageal cancer: multicenter phase II FFCD trial.

A recent phase I study showed that weekly cisplatin, irinotecan and concurrent radiotherapy can be administered with moderate toxicity in patients with oesophageal cancer. Patients with no prior treatment and oesophageal cancer stage I to III, performance status <3, caloric intake >1,500 kcal day(-1) were included. Chemotherapy, with cisplatin 30 mg m(-2) and irinotecan 60 mg m(-2), was administered at days 1, 8, 22, 29, and concurrently with radiotherapy at days 43, 50, 64 and 71. Radiotherapy was delivered with 50 or 50.4 Gy in 25 fractions/5 weeks. Forty-three patients were included, 10 stage I, 19 stage II and 14 stage III. Mean age was 59.2 years (range 44-79). A total of 30 out of 43 (69.8%) patients underwent all planned treatment. During induction chemotherapy, 14 severe toxicities of grade 3 or 4 in 10 patients (23.3%) were reported with 57.1% due to haematoxicity. During chemoradiotherapy, 31 severe toxicities of grade 3 or 4 with 64.5% due to haematotoxicity were reported in 18 patients. One toxic death occurred (diarrhoea grade 4). The complete clinical response rate was 58.1% (95% CI: 43.4-72.8%). Overall survival rate at 1 and 2 years was 62.8%, (95% CI, 58.3-77.3%) and 27.9% (95% CI, 13.4-41.3%), respectively. In conclusion, cisplatin-irinotecan-radiotherapy is an active and well-tolerated regimen feasible in out-patients.

Changes in severity and organ failure scores as prognostic factors in onco-hematological malignancy patients admitted to the ICU.

OBJECTIVE: To determine whether severity and organ failure scores over the first 3 days in an ICU predict in-hospital mortality in onco-hematological malignancy patients. DESIGN AND SETTING: Retrospective study in a 22-bed medical ICU. PATIENTS: 92 consecutive patients with onco-hematological malignancies including 20 hematopoietic stem cell transplantation (HSCT) patients (11 with allogenic HSCT). MEASUREMENTS: Simplified Acute Physiology Score (SAPS) II, Organ Dysfunction and/or Infection (ODIN) score, Logistic Organ Dysfunction System (LODS), and Sequential Organ Failure Assessment (SOFA) score were recorded on admission. The change in each score (Delta score) during the first 3 days in the ICU was calculated as follows: severity or organ failure score on day 3 minus severity or organ failure score on day 1, divided by severity or organ failure score on day 1. RESULTS: In-hospital mortality was 58%. Using multivariate analysis in-hospital mortality was predicted by all scores on day 1 and all Delta scores. Areas under the receiver operating characteristics curves were similar for SAPS II (0.78), ODIN (0.78), LODS (0.83), and SOFA (0.78) scores at day 1. They were also similar for DeltaSAPS II, DeltaODIN, DeltaLODS, and DeltaSOFA. Similar results were observed when excluding patients with allogenic HSCT. CONCLUSION: Severity and three organ failure scores on day 1 and Delta scores perform similarly in predicting in-hospital mortality in ICU onco-hematological malignancy patients but do not predict individual outcome. Decision to admit such patients to the ICU or to forgo life-sustaining therapies should not be based on these scores.

Prior chemoradiotherapy is associated with a higher life-threatening complication rate after palliative insertion of metal stents in patients with oesophageal cancer.

BACKGROUND: Self-expanding metal stents are used routinely to palliate dysphagia due to oesophageal cancer. STUDY AIM: To compare the frequency of life-threatening complications after self-expanding metal stent insertion, depending on whether patients received prior chemoradiotherapy or no treatment. PATIENTS AND METHODS: During 7 years, 116 consecutive patients were treated at a single centre in a palliative intent by insertion of self-expanding metal stent for dysphagia due to an oesophageal cancer. Patients were retrospectively separated into two groups: patients with chemoradiotherapy before self-expanding metal stent insertion (group 1, n = 56) and patients with no treatment before or after self-expanding metal stent insertion (group 2, n = 60). Life-threatening complications were compared and predictive risk factors of postprocedure complications were identified. RESULTS: Median dysphagia was significantly improved during the first month (grade 3 to grade 1 in the two groups). Early and late major complications occurred more frequently in group 1 (23.2% vs. 3.3%; P < 0.002 and 21.6% vs. 5.1%; P < 0.02 respectively). Prior chemoradiotherapy was the only independent predictive factor of postprocedure major complications, with an odds ratio of 5.59 (CI 95% 1.7-18.1). CONCLUSIONS: Life-threatening complications after palliative self-expanding metal stent placement seem to occur more frequently in patients with prior chemoradiotherapy. Prevention of these severe complications should be considered before stenting.

Oesophageal mucosal involvement in patients with systemic sclerosis receiving proton pump inhibitor therapy.

AIM: To assess the prevalence of oesophagitis, Barrett's oesophagus (BE) and other oesophageal mucosal abnormalities in patients with systemic sclerosis (SSc) without prior selection on digestive clinical presentation. We also investigated the association between oesophageal endoscopic and manometric data with clinical manifestations of SSc. METHODS: Oesophageal endoscopy and manometry were performed in 133 consecutive patients with SSc, receiving proton pump inhibitor (PPI) therapy since SSc diagnosis. RESULTS: Endoscopy revealed oesophagitis in 43 patients (32.3%), BE in 9 patients (6.8%), candidiasis in 7 patients (5.3%) and hyperplastic polyp arising in ectopic gastric mucosa in 1 patient. Patients with severe oesophageal motor impairment further exhibited a higher prevalence of interstitial lung disease (ILD) when compared with those without. CONCLUSION: Our study underlines the high frequency of oesophageal mucosal abnormalities in unselected SSc patients receiving long-term PPI therapy. A relationship between oesophagitis/BE and severe manometric motor disturbances was established; these patients may require a higher regimen of PPI. Finally, our series indicates a correlation between severe oesophageal motor disturbances and evidence for ILD in patients, suggesting that gastro-oesophageal reflux may be one of the contributing factors of ILD in SSc; this subgroup of patients may require close monitoring of lung parameters.

Dependency on mask ventilation after acute respiratory failure in the intermediate care unit.

The predictive factors for long-term dependency (LTD) on noninvasive ventilation (NIV) immediately after acute hypercapnic respiratory failure (AHRF) have not been identified. The present authors studied 42 patients with chronic obstructive pulmonary disease (COPD) and 58 non-COPD patients successfully treated by NIV for an AHRF episode. Parameters at stable state, at admission for AHRF and during a 1-yr follow-up were compared in patients with or without LTD-NIV at discharge. The incidence of LTD-NIV was 39% in non-COPD patients and 19% in COPD patients. Based on multivariate analysis with stepwise logistic regression, lower baseline pH values and noninfectious causes of AHRF were independently associated with LTD-NIV. Mutually adjusted odds ratios were found to be 1.316 (95% confidence interval (CI) = 1.127-1.536) for a 0.01 decrease of baseline pH value and 5.1 (95% CI = 1.8-14.0) for a noninfectious cause of AHRF. Outcome after 1 yr was poor in COPD patients. Long-term dependency on noninvasive ventilation is not an uncommon situation after resolution of an acute hypercapnic respiratory failure episode, especially in patients with non-chronic obstructive pulmonary disease causes of respiratory failure. The present study raises the need for prospective validation of a weaning protocol in patients managed by noninvasive ventilation for an acute hypercapnic respiratory failure episode.

[The script concordance test: a new evaluation method of both clinical reasoning and skills in internal medicine]. / Le test de concordance de script: un nouvel outil d'évaluation du raisonnement et de la compétence clinique en médecine interne ?

OBJECTIVE: The script concordance test is designed to evaluate knowledge organization, which constitutes a crucial parameter of clinical skills. The objective of the present study was to assess the value of a new written evaluation tool to measure clinical skills in Internal Medicine. MATERIALS AND METHODS: A 95-item examination was completed by a group of medical students (N =17), a group of residents in Family practice (N =9), a group of residents in Internal Medicine (N =5), and a group of experienced physicians in Internal Medicine (N =7). The scores obtained were compared by analysis of variance. The reliability of the test was studied by calculating Cronbach's coefficient alpha. RESULTS: The mean score was 220.3 +/-41.7 for medical students, 230.5 +/-31.7 for residents in Family practice, 274.2 +/-32.2 for residents in Internal Medicine, and 352.1 +/-22.9 for experienced physicians in Internal Medicine. The differences observed between the scores for the various groups were significant (P <0.0001). Moreover, the value of Cronbach's coefficient alpha was 0.81 in the whole examination. CONCLUSION: Our data indicate that the script concordance test may easily allow to differentiate various levels of clinical skills in Internal Medicine. Moreover, because of Cronbach's coefficient alpha as high as 0.81, our findings suggest the validity of this test in Internal Medicine.

Concentration of neuron-specific enolase and S100 protein in the subretinal fluid of rhegmatogenous retinal detachment.

BACKGROUND: Neuron-specific enolase and S100 protein are markers of neuronal lysis. To assess the neuronal suffering in rhegmatogenous retinal detachment we quantified neuron-specific enolase and S100 protein in the subretinal fluid. METHODS: The puncture was performed in the sclera with a Merseture 5/0 round needle, and the fluid was collected with a glass capillary tube. Twelve subretinal fluid samples were obtained from 12 eyes with rhegmatogenous retinal detachment undergoing retinal detachment surgery. Vitreous from ten eyes with macular hole or epimacular membrane served as negative control group, and vitreous collected during cornea procurement from ten deceased patients served as positive control group. RESULTS: The mean concentration of neuron-specific enolase (in nanogrammes per millilitre) was 602 in the subretinal fluid of rhegmatogenous retinal detachment, 10.2 in the serum of these patients, 2.9 in the vitreous of the negative control group, and 364 in the positive control group. The mean concentration of S100 protein (in nanogrammes per millilitre) was 104 in the subretinal fluid of rhegmatogenous retinal detachment, <0.1 in the serum of these patients and in the vitreous of the control negative group, and 11.18 in the positive control group. CONCLUSION: Neuron-specific enolase (NSE) and S100 are known to be good markers of brain stress and, thus, are good markers of retinal stress.

Determinants of severity for superficial cellutitis (erysipelas) of the leg: a retrospective study.

BACKGROUND: Superficial cellulitis (erysipelas) of the leg is a frequent infectious disease with a favorable outcome, whereas some patients present a serious disease. The determinants of severity for superficial cellulitis (erysipelas) of the leg have not yet been clearly established. In order to determine the characteristics of patients presenting with severe superficial cellulitis of the leg, we analyzed patients with favorable and unfavorable outcome. METHODS: The records of 167 patients referred to Rouen University Hospital for non-superficial cellulitis of the leg were analyzed. Two severity groups of patients were retrospectively defined. Patients in the severe group either died secondary to infection during hospital stay or were hospitalized for a duration at least equal to the 90th percentile (i.e., >21 days of hospitalization). The remaining patients were considered as presenting with non-severe cellulitis. Potential determinants of severity were analyzed by univariate and multivariate analysis based on logistic regression. RESULTS: From univariate analysis, the following general factors were positively associated with severity: advanced age, arterial hypertension, diabetes mellitus, elevated leukocytosis, and elevated neutrophilia. The local factors associated with severity were ulcer of the leg and arteriosclerosis obliterans of the leg. From multivariate analysis, only age (P=0.004), diabetes mellitus (P=0.01), and leukocytosis (P=0.04) appeared to be independently associated with severity. A close to significant association was also found with arteriosclerosis obliterans of the leg (P=0.07). Whereas general complications occurred more frequently in the severe group, no such difference was observed for local complications. CONCLUSIONS: Determinants of severity for superficial cellulitis of the leg include high age and associated medical conditions. Aged patients and patients with diabetes mellitus, elevated leukocytosis, or possibly arteriosclerosis obliterans of the leg should preferably be hospitalized for specific care of associated conditions to avoid the occurrence of general complications.

[Intraocular pressure results of contact transscleral cyclophotocoagulation with Neodymium YAG laser for refractory glaucoma]. / Résultats tensionnels du cycloaffaiblissement par laser Néodyme YAG sur des glaucomes réfractaires.

PURPOSE: To evaluate the effects of contact transscleral cyclophotocoagulation with neodymium YAG laser for refractory glaucoma. METHOD: This was a retrospective study with 36 patients (37 eyes) who were treated at the Rouen Hospital from February 1996 to February 2001. Patients had various types of glaucoma: glaucoma in pseudophakia (12), primary open-angle glaucoma (16), posttraumatic glaucoma (6), glaucoma associated with uveitis (4), neovascular glaucoma (3), and glaucoma after silicone oil (1). The Neodymium YAG laser (Alcon) was used for treatment. Energy was delivered in up 32 applications of 7-9 W for 0.7 seconds each. All patients except one 10-year-old child received retrobulbar anesthesia. Intraocular pressure was measured after 4 hours, 1 month, and 10 years. RESULTS: The mean preoperative intraocular pressure of 30.3 (+/-1.3) mmHg decreased to 19.4 (+/-2) mmHg at 1 month and to 22.2 (+/-2.4) mmHg at 1 year. Seven patients underwent a second treatment during the year, since the first one was insufficient. Treatment lowered the number of medications used to decrease intraocular pressure from a pretherapy mean of 2.7 mmHg to 1.8 mmHg at 1 month and 2.07 mmHg at 1 year. In three patients who were treated for a painful sightless eye, the treatment failed. DISCUSSION: Neodymium YAG laser necroses ciliary bodies. Treatment must be dosed to achieve the greatest efficacy without hypotonia, although hypotonia is rare, as is non-response to treatment. A few patients will be retreated during the year. The subgroup of sightless painful eyes had a high failure rate (75%), with half undergoing evisceration. We found no other differences according to the origins of refractory glaucoma. CONCLUSION: Midterm results of contact transscleral cyclophotocoagulation with Neodymium YAG laser are encouraging in the treatment of refractory glaucoma.

Influence of medical speciality and experience on interpretation of helicoidal thoracic computed tomography in blunt chest trauma.

OBJECTIVE: To compare the quality of interpretation of chest helicoidal computed tomography (HCT) by physicians with different levels of experience and medical specialty. DESIGN: Prospective observational study. SETTING: Trauma critical care unit at a French university hospital (US equivalent: level 1). PATIENTS: HCT of 50 consecutive patients with blunt chest trauma were assessed by four groups of physicians [residents in anaesthesiology (n=5), residents in radiology (n=5), senior anaesthesiologists (n=5), and senior radiologists (n=5)]. Interpretation from each physician was compared with a grid obtained from an expert interpretation by a senior radiologist and a senior anaesthesiologist. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: No group of observers performed better than another in their interpretation of lung and parietal injuries on HCT. In contrast, senior radiologists were better than anaesthesiologists for the diagnosis of pneumomediastin. However, residents in radiology performed better than other physicians in detecting the presence of gastric and tracheal tubes. CONCLUSIONS: Compared with anaesthesiologists, senior radiologists seem more expert in the diagnosis of HCT mediastinal injuries whereas residents in radiology were better at detecting resuscitation materials in thoracic trauma patients. This article reinforces the usefulness of the interpretation of the HCT by a senior radiologist in the case of blunt chest trauma. This also reinforces the usefulness of an aspect team of radiologists and anaesthesiologists in the case of trauma. The logical usefulness of a systematic interpretation of the images should be borne in mind.