Inflammatory pain in peripheral tissue depends on the activation of the TNF-α type 1 receptor in the primary afferent neuron.

The mechanism underlying the role of tumor necrosis factor alpha (TNF-α) in the development of inflammatory hyperalgesia has been extensively studied, mainly the role of TNF-α in the release of pro-inflammatory cytokines. The current concept relies in the fact that TNF-α stimulates the cascade release of other pro-inflammatory cytokines, such as IL-1ß, IL-6, and IL-8 (CINC-1 in rats), triggering the release of the final inflammatory mediator prostaglandin E2 (PGE2 ) and sympathetic amines that directly sensitize the nociceptors. However, this may not be the sole mechanism involved as the blockade of TNF-α synthesis by thalidomide prevents hyperalgesia without interrupting the synthesis of IL-1ß, IL-6, and CINC-1. Therefore, we hypothesized that activation of TNF-α receptor type 1 (TNFR1) by TNF-α increases nociceptors' susceptibility to the action of PGE2 and dopamine. We have found out that intrathecal administration of oligodeoxynucleotide-antisense (ODN-AS) against TNFR1 or thalidomide prevented carrageenan-induced hyperalgesia. The co-administration of TNF-α with a subthreshold dose of PGE2 or dopamine that does not induce hyperalgesia by itself in the hind paw of Wistar rats pretreated with dexamethasone (to prevent the endogenous release of cytokines) induced a robust hyperalgesia that was prevented by intrathecal treatment with ODN-AS against TNFR1. We consider that the activation of neuronal TNFR1 by TNF-α decisively increases the susceptibility of the peripheral afferent neuron to the action of final inflammatory mediators - PGE2 and dopamine - that ultimately induce hyperalgesia. This mechanism may also underlie the analgesic action of thalidomide.

Development of New Analgesics: An Answer to Opioid Epidemic.

Management of pain is a fundamental imperative in medicine. Current analgesics suffer from limitations related to efficacy and adverse events of which abuse potential has assumed an important role. Here we highlight the factors that drive the development of novel analgesics and the advances made in the field.

Lifestyle factors, cardiovascular disease and all-cause mortality in middle-aged and elderly women: a systematic review and meta-analysis.

Cardiovascular disease (CVD) risk factors, incidence and death increases from around the time of menopause comparing to women in reproductive age. A healthy lifestyle can prevent CVD, but it is unclear which lifestyle factors may help maintain and improve cardiovascular health for women after menopausal transition. We conducted a systematic review and meta-analysis of prospective cohort studies to evaluate the association between modifiable lifestyle factors (specifically smoking, physical activity, alcohol intake, and obesity), with CVD and mortality in middle-aged and elderly women. Pubmed, Embase, among other databases and reference lists were searched until February 29th, 2016. Study specific relative risks (RR) were meta-analyzed using random effect models. We included 59 studies involving 5,358,902 women. Comparing current versus never smokers, pooled RR were 3.12 (95% CI 2.15-4.52) for CHD incidence, 2.09 (95% CI 1.51-2.89) for stroke incidence, 2.76 (95% CI 1.62-4.71) for CVD mortality and 2.22 (95% CI 1.92-2.57) for all-cause mortality. Physical activity was associated with a decreased risk of 0.74 (95% CI 0.67-0.80) for overall CVD, 0.71 (95% CI 0.67-0.75) for CHD, 0.77 (95% CI 0.70-0.85) for stroke, 0.70 (95% CI 0.58-0.84) for CVD mortality and 0.71 (95% CI 0.65-0.78) for all-cause mortality. Comparing moderate drinkers versus non-drinkers, the RR was 0.72 (95% CI 0.56-0.91) for CHD, 0.63 (95% CI 0.57-0.71) for CVD mortality and 0.80 (95% CI 0.76-0.84) for all-cause mortality. For women with BMI 30-35 kg/m2 the risk was 1.67 (95% CI 1.24-2.25) for CHD and 2.3 (95% CI 1.56-3.40) for CVD mortality, compared to normal weight. Each 5 kg/m2 increase in BMI was associated with 24% (95% CI 16-33%) higher risk for all-cause mortality. This meta-analysis suggests that physical activity and moderate alcohol intake were associated with a reduced risk for CVD and mortality. Smoking and higher BMI were associated with an increased risk of these endpoints. Adherence to a healthy lifestyle may substantially lower the burden of CVD and reduce the risk of mortality among middle-aged and elderly women. However, this review highlights important gaps, as lack of standardized methods in assessing lifestyle factors and lack of accurate information on menopause status, which should be addressed by future studies in order to understand the role of menopause on the association between lifestyle factors and cardiovascular events.

[Obesity, high blood pressure, hypercholesterolaemia, and untreated diabetes in HIV-infected and HIV-uninfected Adults in Mbuji-Mayi (Democratic republic of congo)]. / Obésité, hypertension artérielle, hypercholestérolémie et diabète non traités chez les adultes infectés ou pas par le VIH à Mbuji-Mayi (République démocratique du Congo).

Little is known about the major cardiovascular risk factors in HIV-infected as compared to the HIV-uninfected patients in the Democratic Republic of Congo (DR Congo). We determined the prevalence of hypertension, obesity (BMI ≥ 30 kg/m2), total cholesterol > 200 mg/dl, HDLcholesterol &≤ 40 mg/dl, and glycemia > 126 mg/dl. We also calculated the average and/or median of total cholesterol, HDL-cholesterol, and glycemia among HIV-infected and HIV-uninfected patients.We conducted a cross-sectional study that enrolled 592 HIV-uninfected and 445 HIV-infected patients of whom 425 (95.5%) were on first-line antiretroviral therapy based on stavudine-lamivudine-nevirapine. Clinical and laboratory data of the patients were collected. The results were analyzed by chi-square, t-student, and Wilcoxon rank sum tests. 11.5% of HIV-infected patients had an average blood pressure suggesting hypertension versus 10.6% of HIV-uninfected (P = 0.751). But in absolute value, HIVinfected patients had a median of diastolic blood pressure of 90 mmHg versus 85 mmHg of HIV-uninfected (P < 0.001). 4.04% of HIV-infected patients had a BMI suggesting obesity versus 6.08% of HIV-uninfected patients (P = 0.187). For fasting glucose: 2.50% of HIV-infected patients versus 4.20% of HIV-uninfected patients had a serum fasting glucose suggesting diabetes (P<0.176). 11.9% of HIV-infected patients had a total cholesterol greater than 200 mg/dl versus 7.4% of HIVuninfected patients (P=0.019). For HDL-cholesterol: 36.40% of HIV-infected patients had a serum fasting ≤ 40 mg/dl versus 15.70% of HIV-uninfected patients (P < 0.001). HIV-infected patients had a median fasting total cholesterol higher (140 mg/ dl) thanHIV-uninfected patients (133mg/dl) [P=0.015].HIVuninfected patients had a median fasting HDL-cholesterol higher (58.5 mg/dl) than HIV-infected patients (49 mg/dl) [P < 0.001]. HIV-infected women were more likely to have a higher mean of total cholesterol: 147.70 #x00B1; 52.09 mg/dl versus 135.72 ± 48.23 mg/dl for the HIV-infected men (P = 0.014) and of HDL-cholesterol: 55.80 ± 30.77 mg/dl versus 48.24 ± 28.57mg/dl for the HIV-infected men (P = 0.008). In this study population, prevalence of hypertension was elevated in HIVinfected versus HIV-uninfected patients. Being HIV positive on first-line antiretroviral therapy based on stavudine-lamivudine-nevirapine was associated with high prevalence of total cholesterol > 200 mg/dl and HDL-cholesterol ≤ 40 mg/dl. Proactive screening and prompt management of dyslipidemia and hypertension in this population should be a priority.

Baseline dietary glutamic acid intake and the risk of colorectal cancer: The Rotterdam study.

BACKGROUND: Animal studies have shown that glutamine supplementation may decrease colon carcinogenesis, but any relation with glutamine or its precursors has not been studied in humans. The primary aim of this study was to assess whether dietary glutamic acid intake was associated with colorectal cancer (CRC) risk in community-dwelling adults. A secondary aim was to evaluate whether the association could be modified by the body mass index (BMI). METHODS: This study was embedded in the Rotterdam study, which included a prospective cohort from 1990 onward that consisted of 5362 subjects who were 55 years old or older and were free of CRC at the baseline. Glutamic acid was calculated as a percentage of the total protein intake with a validated food frequency questionnaire at the baseline. Incident cases of CRC were pathology-based. RESULTS: During follow-up, 242 subjects developed CRC. Baseline dietary glutamic acid intake was significantly associated with a lower risk of developing CRC (hazard ratio [HR] per percent increase in glutamic acid of protein, 0.78; 95% confidence interval [CI], 0.62-0.99). After stratification for BMI, the risk reduction for CRC by dietary glutamic acid was 42% for participants with a BMI ≤ 25 kg/m(2) (HR per percent increase in glutamic acid of protein, 0.58; 95% CI, 0.40-0.85), whereas no association was found in participants with a BMI > 25 kg/m(2) (HR per percent increase in glutamic acid of protein, 0.97; 95% CI, 0.73-1.31). CONCLUSIONS: Our data suggest that baseline dietary glutamic acid intake is associated with a lower risk of developing CRC, but this association may be mainly present in nonoverweight subjects.

[Introduction of noninvasive prenatal testing for fetal trisomies: preliminary results and consequences on invasive samplings]. / Introduction du dépistage sanguin des trisomies foetales par recherche d'ADN foetal circulant: Résultats préliminaires d'une année et évolution des prélèvements invasifs.

Noninvasive prenatal testing (NIPT) has marked a revolution in aneuploidy screening because it allows a simple maternal blood test to detect trisomy 21, 18 and 13 in a foetus with a very high level of accuracy. After one year of NIPT utilisation with 683 samples, we analyzed retrospectively the performance of the test for 2014 : 3 positive samples (2 trisomies 21 and 1 trisomy 18) were correctly detected (100% sensitivity) and no foetal aneuploidy was missed for the pregnancies having already resulted in delivery by decembre 2014 (280 true negatif, 100% specificity). However, the additionnally available analysis of the sex chromosomes resulted in 2 erronous results: 1 uncorrect sex determination (1 male resulting in a female phenotype at birth) and 1 result suggesting a Turner syndrome was not confirmed by amniocentesis. The failure rate leading to a resampling was at 1.46% (10/683). The test used was the NIFTY of the BGI laboratory in Hong-Kong. By comparison to the year 2013, the utilisation of NIPT lead to a significant diminution of invasive samples performed by amniocentesis or choriocentesis 144 vs. 239 (- 63%). We confirmed that NIPT is a high-performance tool for the screening of the main foetal aneuploidies and report that during its first year of utilisation, 63% of invasive samples collected could be avoided. The test is expensive, not reimboursed by Luxembourg social security and therefore prohibitive for a number of women and their families.

SU-E-T-593: VMAT Vs. IMRT for Treatment of Neoplasms of the Brain: Dosimetric Quality and Delivery.

PURPOSE: A retrospective study was performed to determine any dosimetric or delivery benefits for treatment planning with intensity-modulated radiotherapy (IMRT) versus volumetric-modulated arc therapy (VMAT) for the treatment of brain neoplasms. METHODS: Eighteen patients treated with modulated brain radiotherapy treatments were included in this study (primary treatment volumes of 15.3 to 374.9 cc). IMRT and VMAT plans were generated for each patient using the same criteria for prescription coverage and normal tissue sparing. IMRT optimizations ranged from five to seven fields and VMAT from two to four arcs. Plans were generated with Varian Eclipse treatment planning system utilizing AAA-8615 dose calculation algorithm. RESULTS: VMAT optimizations provided limited dosimetric advantages versus IMRT. VMAT provided superior treatment volume coverage (volumes receiving 95%, 100% of prescription dose (V95%, V100%)) over IMRT, but differences were not statistically significant (paired t-test p > 0.05). Relative maximum dose values, conformity and homogeneity indices also exhibited no statistical differences. IMRT plans resulted in similar mean brain minus treatment volume (Brain- TV) dose (mean = 1460.1 vs. 1506.3 cGy; p = 0.056). The volume of Brain- TV receiving 40Gy was lower for VMAT than IMRT (average = 38.96 vs. 44.97 cc; p = 0.050). Maximum skin dose was lower for VMAT (mean = 4568.8 vs. 5063.3cGy; p = 0.006), as well as skin V20Gy (6.56% vs 7.69%; p = 0.027) and V40Gy (0.56% vs. 0.35%; p = 0.017). VMAT plans required fewer fields along with fewer MU than IMRT (mean = 388.2 vs. 721.1 MU, respectively), allowing for approximately 20% faster delivery times. CONCLUSIONS: VMAT treatments significantly reduced treatment time due to reduced MU and fewer fields. Certain skin and Brain-TV high dose spread parameters were superior for VMAT as compared to IMRT plans. All other dosimetric parameters tested were statistically equivalent for VMAT and IMRT techniques.

Wavelet analysis for wind fields estimation.

Wind field analysis from synthetic aperture radar images allows the estimation of wind direction and speed based on image descriptors. In this paper, we propose a framework to automate wind direction retrieval based on wavelet decomposition associated with spectral processing. We extend existing undecimated wavelet transform approaches, by including à trous with B(3) spline scaling function, in addition to other wavelet bases as Gabor and Mexican-hat. The purpose is to extract more reliable directional information, when wind speed values range from 5 to 10 ms(-1). Using C-band empirical models, associated with the estimated directional information, we calculate local wind speed values and compare our results with QuikSCAT scatterometer data. The proposed approach has potential application in the evaluation of oil spills and wind farms.

A study to determine the accuracy of a computerized algorithm for interpretation of EEGs.

The main use of computerized EEG has been in sleep studies. A comprehensive system of interpreting routine EEGs by computers has not yet been developed and is technically difficult. We have tried to incorporate computers in the analysis and interpretation of EEGs by using information obtained from visual analysis of EEG in the present work. The purpose of this study was to determine the accuracy of such an algorithm. An electroencephalographer visually analyzed routine EEGs and the data was entered into an EEG Worksheet. The electroencephalographer then interpreted the data and a report was dictated and transcribed. Data from the EEG Worksheet was entered into a computer for interpretation, clinical correlation, and report preparation. Results indicate that the algorithm used with the EEG Worksheet can correctly interpret and clinically correlate visually-analyzed EEG data entered into a computer and reduce time for EEG report generation.

Mandated preterm delivery: its prevalence and impact at a tertiary referral center.

OBJECTIVE: To determine the prevalence and impact of mandated preterm deliveries at a tertiary referral center. METHODS: A chart review was conducted at our institution on all livebirths from 24 weeks to completion of 37 weeks' gestation between 1 January 1998 and 31 December 1999. Mandated delivery was defined as intentional intervention because of a deteriorating maternal or fetal condition. Reasons for intervention and intrapartum courses were compared with two other preterm groups (premature ruptured membranes, spontaneous labor) delivering during the same period. Statistical analyses included the Student t test, univariate ANOVA, X2 test and Mann-Whitney test. RESULTS: A total of 894 pregnancies delivered preterm, with 132 (14.8%) being mandated. Primary reasons for mandated delivery included severe pre-eclampsia (69.0%), vaginal bleeding (11.4%), deteriorating maternal illness (10.6%), worsening fetal growth restriction (6.1%) or major fetal malformation (3.0%). Delivery at less than 34 weeks was more common in the mandated group (68.9%) than in the ruptured membranes group (41.2%, p < 0.005) or in the spontaneous labor group (46.5%; p < 0.01). Cesarean section rates were higher in the mandated group (69.7%) than in the ruptured membranes group (18.3%; p <0.001) or in the spontaneous labor group (21.5%; p < 0.001). The presence of an unfavorable cervix, unsuccessful trial of labor, non-cephalic fetal presentation, or fetal intolerance of labor explained the high rate of surgery. CONCLUSIONS: Conditions mandating delivery accounted for 14.8% of all preterm births. Mandated delivery is associated with a greater need for delivery before 34 weeks, often by Cesarean section.

Is high-dose misoprostol able to lower the incidence of cesarean section? A randomized controlled trial.

OBJECTIVE: To determine whether high-dose (100 microg) misoprostol was able to increase the rate of successful labor induction and lower the incidence of Cesarean section without adverse fetal effects. METHODS: A total of 360 women were randomized to receive either oxytocin (n = 192) by intravenous infusion, or misoprostol (n = 168) 100 microg intravaginally every 4 h. The Cesarean section rate was the primary end-point. Incidences of uterine and fetal heart rate abnormalities during labor and adverse neonatal outcomes were assessed as secondary end-points. RESULTS: Compared with those women receiving oxytocin, patients given misoprostol had a significantly shortened labor (10.7+/-6.0 vs. 15.4+/-10.4 h, p < 0.001). The Cesarean section rate did not differ between patients receiving misoprostol or oxytocin (36 (21.4%) vs. 38 (19.8%), p = 0.79) despite a sample size adequate to detect a 13 percentage point difference in this outcome. Patients receiving misoprostol had a higher incidence of the hyperstimulation syndrome (27 (16.1%) vs. 9 (4.7%), p < 0.001), and of fetal intolerance of labor as an indication for Cesarean delivery (23 (63.9%) vs. 15 (39.5%), p = 0.06), and had a greater number of umbilical artery cord blood pH findings of< 7.20 (20 (43.5%) vs. 6 (17.1%), p = 0.02). These worrisome trends on interim analysis resulted in our prematurely terminating the study. CONCLUSION: High-dose intravaginal misoprostol did not reduce the Cesarean section rate and was associated with a greater hazard of fetal intolerance of labor.

Active management of labor: a cost analysis of a randomized controlled trial.

OBJECTIVE: To compare the costs of a protocol of active management of labor with those of traditional labor management. DESIGN: Cost analysis of a randomized controlled trial. METHODS: From August 1992 to April 1996, we randomly allocated 405 women whose infants were delivered at the University of New Mexico Health Sciences Center, Albuquerque, to an active management of labor protocol that had substantially reduced the duration of labor or a control protocol. We calculated the average cost for each delivery, using both actual costs and charges. RESULTS: The average cost for women assigned to the active management protocol was $2,480.79 compared with an average cost of $2,528.61 for women in the control group (P = 0.55). For women whose infant was delivered by cesarean section, the average cost was $4,771.54 for active management of labor and $4,468.89 for the control protocol (P = 0.16). Spontaneous vaginal deliveries cost an average of $27.00 more for actively managed patients compared with the cost for the control protocol. CONCLUSIONS: The reduced duration of labor by active management did not translate into significant cost savings. Overall, an average cost saving of only $47.91, or 2%, was achieved for labors that were actively managed. This reduction in cost was due to a decrease in the rate of cesarean sections in women whose labor was actively managed and not to a decreased duration of labor.

Prevention of group B streptococcus early-onset neonatal sepsis: comparison of the Center for Disease Control and prevention screening-based protocol to a risk-based protocol in infants at greater than 37 weeks' gestation.

OBJECTIVE: To compare the Center for Disease Control consensus guidelines' screening-based strategy to a risk-based strategy as regards the incidence of early-onset group B streptococcus (GBS) infection among term infants. STUDY DESIGN: A cohort of university hospital prenatal clinic mother-infant pairs who were screened for GBS at 35 to 37 weeks' gestation were compared to a matched control group of unscreened mother-infant pairs from the outreach satellite prenatal clinics who delivered at the same institution during the same time period. GBS screening was carried out with rectovaginal cultures plated on selective media. GBS-positive women received antimicrobial prophylaxis in labor whereas women of unknown GBS status were only treated intrapartum if they had a risk factor for GBS infection. Principal outcome variables included incidence of cases of neonatal early-onset GBS sepsis (blood, urine, or cerebrospinal fluid positive for GBS), incidence of cases of strongly suspected GBS sepsis (culture negative), and incidence of neonatal sepsis with non-GBS organisms. RESULTS: There were 3164 screened mother-infant pairs who were compared to 2684 unscreened pairs. The incidence of GBS carriage was 13.3%. A random sample of 420 screened women were compared to a matched sample of 407 women of unknown GBS carrier status for characterization of demographics and risk factors. No cases of documented GBS sepsis occurred in the infants of the screened women, but four cases occurred among the infants of the women who did not undergo screening (incidence 1.5/1000) (p = 0.04), only one of whom had a risk factor for GBS infection. Cases of suspected but culture negative sepsis were not more common in the screened population when compared to the unscreened. There was one case of Escherichia coli sepsis in an infant of a mother in the unscreened group. CONCLUSIONS: GBS screening at 35 to 37 weeks, with intrapartum antimicrobial prophylaxis of carriers, decreased the incidence of neonatal early-onset GBS sepsis and appears to have advantages over treatment based on risk factors alone in term infants.

Will cervicovaginal interleukin-6 combined with fetal fibronectin testing improve the prediction of preterm delivery?

OBJECTIVE: We sought to investigate if determination of cervicovaginal interleukin-6 (IL-6) levels would enhance the positive predictive value of fetal fibronectin (fFN) for preterm birth. METHODS: A prospective cohort study was undertaken of 135 women between 24 and 34 weeks gestation with symptoms of suspected preterm labor. Cervicovaginal secretions were collected for both IL-6 and fFN and measured by immunoassay and ELISA, respectively. Outcome variables included preterm delivery in less than 48 h, within 7 days, and prior to 37 weeks. Statistical analysis was performed with Fisher's exact test, regression for logarithmic transform levels, and multivariate logistic regression. ROC curves were created for IL-6 levels. RESULTS: IL-6 and fFN levels were both elevated in cervicovaginal secretions of women with symptoms of preterm labor. IL-6 values >100 pg/ml resulted in a odds ratio for delivery at <37 weeks of 1.57 (95%CI=0.89-2.75, P=.11), whereas fFN values >50 ng/ml resulted in a preterm delivery risk of 4.58 (95%CI=1.54-13.35, P=.003). Combining IL-6 and fFN results did not improve upon the predictive value of fFN alone for preterm birth [odds ratio 4.00 (95%CI=1.31-12.17, P=.015)]. CONCLUSION: Cervicovaginal IL-6 levels did not provide any additional, independent effect on the prediction of preterm birth beyond that of fFN testing alone.

Late second stage rupture of the uterus and bladder with vaginal birth after cesarean section: a case report and review of the literature.

Rupture of a uterine scar during labor with concomitant severe injury to the maternal bladder has been reported sporadically. Previously reported cases have been diagnosed under a variety of conditions, commonly at the time of repeat Cesarean delivery. A case of maternal bladder rupture diagnosed following forceps-assisted vaginal delivery after Cesarean is presented. Severe bradycardia developed suddenly in the second stage of labor. Rupture of the uterine scar was diagnosed after sudden onset of severe lower abdominal pain with delivery of the placenta. At laparotomy, extensive injury to the bladder was found and successful repair of both injuries was performed. A review of previously reported similar cases with their mechanism of injury and presentation is presented. Serious maternal bladder injury at the time of uterine rupture remains a risk of attempted vaginal delivery after prior Cesarean section.

Epidural analgesia and active management of labor: effects on length of labor and mode of delivery.

OBJECTIVE: To determine whether cervical dilatation at the time of placement of patient-requested epidural affects cesarean rates or lengths of labors in actively managed parturients. METHODS: The charts of 255 women randomized to active management of labor (n = 125) or control protocols (n = 130) were reviewed and stratified to early epidural placement (up to 4 cm cervical dilatation) versus late placement (more than 4 cm). RESULTS: Women with early epidural placement had shorter labors than those with late placement (11.6 +/- 4.6 versus 13.2 +/- 5.6 hours; P = .02). Active management reduced the length of labor compared with controls regardless of epidural timing, with a reduction of 1.4 hours in early epidural placement (10.9 +/- 4.7 versus 12.3 +/- 4.3 hours; P = .04) and 3.6 hours in those with later placement (11.0 +/- 3.6 versus 14.6 +/- 6.2 hours; P = .004). Cesarean rates did not vary significantly (early 14.5% versus late 7.9%; P = .21). Early epidural placement did not lengthen the second stage of labor or increase operative vaginal delivery rates. CONCLUSION: Early epidural placement did not affect lengths of labor or cesarean rates and was actually associated with shorter labor compared with late epidural placement. Women managed actively in labor, regardless of timing of epidural placement, had shorter labors than controls.

Assessing clinical competence of medical students in women's health care: use of the objective structured clinical examination.

OBJECTIVE: To assess clinical competency of third-year medical students completing a problem-oriented, primary care emphasis clerkship in obstetrics and gynecology using an objective structured clinical examination, and to determine the feasibility of implementing the objective structured clinical examination in the curriculum. METHODS: Sixteen groups of third-year medical students were evaluated prospectively on their exit performances with a six-station objective structured clinical examination designed to test clinical competency in basic primary care obstetrics-gynecology. Consistency of scores across stations, differences in performance for separate groups, and relationship of objective structured clinical examination scores compared with other indicators of medical proficiency, such as written examinations and faculty evaluations, were assessed. RESULTS: One hundred ninety-eight students were evaluated over 25 months. Test reliability across stations revealed alpha values ranging between .50 and .56. Correlations between performance on the objective structured clinical examination and the written test (r = .10) were low, demonstrating that the objective structured clinical examination clearly tests a separate domain of student capability. Cost of the objective structured clinical examination was $81.66 per student. CONCLUSION: The objective structured clinical examination is a reliable and valid test of the clinical competence of medical students in the primary health care of women. It provides information that is not obtained by more traditional assessment modalities at a reasonable cost.

[Prostatic cancer in the Grand Duchy of Luxembourg. Role of PSA]. / Le cancer prostatique au Grand-Duché de Luxembourg. Rôle du PSA.

We reviewed the trends in prostate cancer incidence and mortality in Luxembourg between 1983 and 1995 to discuss the importance of total and free PSA in early detection. The study was performed on all the new cases recorded by the National Cancer Registry (Registre Morphologique des Tumeurs). Total and free PSA were measured with the automated Immulite System (DPC, Los Angeles) using a chemoluminescent immunometric assay. The performance of free-to-total serum PSA was analysed by a hospital based study of 113 patients (55 PC, 58 BPH). The age standardized incidence rate increased from 29.3/100,000 in 1983 to 71.5/100,000 in 1995. Mortality rates only changed slightly. The widespread use of PSA testing from 1988 on is probably the main cause of this incidental increase; however no major changes in the age-specific-incidence have been found suggesting the absence of a systematic screening policy by the PSA. The superiority of free-to-total serum PSA ratio in discriminating between cancer and benign condition was confirmed. Early health-conscious man over 50 should be proposed prostate cancer screening by digital rectal examination and PSA. However a systematic screening policy cannot been recommended since a benefit in survival after early treatment has not yet been proven.