Altitude healing effect in severe asthmatic children.

BACKGROUND: The beneficial effect of a climatic treatment in children with asthma was established quite some time ago, but the mechanism of this beneficial effect has not been fully elucidated. We investigated the role of the cytokines of the TH2 pathway, reactive oxygen species (ROS) and reactive nitrogen species (RNS) over the course of a high-altitude climatic therapy. METHODS: A group of 67 children originating from various French towns suffering from uncontrolled severe asthma was sent via their medical specialists, to the Briançon climatic area. They were monitored over the course of an entire school year. During this time, they returned home for 15 days during the Christmas holidays. At each stage, assessment of asthma control, lung function examination (peak flow meter and spirometry), and measurement of exhaled NO, ROS and RNS in exhaled breath condensate (EBC), and the level of cytokines in the plasma of the TH2 pathway were carried out. RESULTS: The degree of asthma control improved at high altitude and worsened upon returning home. The average value of the peak expiratory flow also improved during the first 3 months but then worsened upon returning home, while the other spirometric parameters did not change. The level of expired NO and the scores for quality of life underwent a similar change. The level of RNS and ROS in the EBC did not change significantly. Besides, a marked and statistically significant decrease in the level of IL-13 and IL-10 was noted. CONCLUSION: The beneficial effect of a climatic stay of children suffering from allergic asthma at altitude appears to be linked with less allergenic stimulation.

Morphological Analysis of Healthy Aortic Arch.

OBJECTIVE/BACKGROUND: This study aimed to describe an arch morphology protocol in a healthy population, and to assess the impact of age and sex. METHODS: A retrospective morphology evaluation was conducted in a population with no personal history of thoracic aorta surgery or pathology, through computed tomography (CT) imaging analysis, using a standardised protocol. Based on centreline three dimensional coordinates, a single investigator calculated a series of parameters in the arch zones and in the total arch, using Matlab scripts. These were categorized as: (i) morphometric data: diameter, length and aortic angle of each zone, total arch angle, and length; (ii) geometric data: tortuosity index (TI), arch width, assimilated curvature radius (CRi), and attachment zone angles. Student or Mann-Whitney tests were used to compare parameter means. Their variability with age and sex was assessed through univariate and multivariate regression analysis. RESULTS: CT images from 123 subjects (mean ± SD age 53 ± 19 years) were reviewed. Significant correlation between age and morphology was found. The aorta expanded homogeneously and stretched heterogeneously with age because of posterior arch elongation. TI decrease, CRi, and attachment zone angle increase were also observed with aging. Age remained significantly associated with these morphological parameters, independently of body surface area and hypertension. Sex also affected morphology: longer total arch length and higher CRarch in men; lower zone 3 attachment angle in women CONCLUSION: Using mathematical algorithms, and with a view to improving endovascular arch treatment, this study provides a standardised arch morphology protocol and objectively identifies both age related evolution and sex related variation in the different zones.

Risk Factor Analysis for the Mal-Positioning of Thoracic Aortic Stent Grafts.

OBJECTIVE: The present study aimed at quantifying mal-positioning during thoracic endovascular aortic repair and analysing the extent to which anatomical factors influence the exact stent graft positioning. METHODS: A retrospective review was conducted of patients treated between 2007 and 2014 with a stent graft for whom proximal landing zones (LZ) could be precisely located by anatomical fixed landmarks, that is LZ 1, 2, or 3. The study included 66 patients (54 men; mean age 51 years, range 17-83 years) treated for traumatic aortic rupture (n = 27), type B aortic dissection (n = 21), thoracic aortic aneurysm (n = 8), penetrating aortic ulcer (n = 5), intramural hematoma (n = 1), and floating aortic thrombus (n = 4). Pharmacologic hemodynamic control was systematically obtained during stent graft deployment. Pre- and post-operative computed tomographic angiography was reviewed to quantify the distance between planned and achieved LZ and to analyze different anatomical factors: iliac diameter, calcification degree, aortic angulation at the proximal deployment zone, and tortuosity index (TI). RESULTS: Primary endoleak was noted in seven cases (10%): five type I (7%) and two type II (3%). Over a mean 35 month follow up (range 3-95 months), secondary endoleak was detected in two patients (3%), both type I, and stent graft migration was seen in three patients. Mal-positioning varied from 2 to 15 mm. A cutoff value of 11 mm was identified as an adverse event risk. Univariate analysis showed that TI and LZ were significantly associated with mal-positioning (p = .01, p = .04 respectively), and that aortic angulation tends to reach significance (p = .08). No influence of deployment mechanism (p = .50) or stent graft generation (p = .71) or access-related factors was observed. Multivariate analysis identified TI as the unique independent risk factor of mal-positioning (OR 241, 95% CI 1-6,149, p = .05). A TI >1.68 was optimal for inaccurate deployment prediction. CONCLUSION: TI calculation can be useful to anticipate difficulties during stent graft deployment and to reduce mal-positioning.

Risk Factor Analysis of Bird Beak Occurrence after Thoracic Endovascular Aortic Repair.

OBJECTIVES: The aim was to analyze the role played by anatomy and stent graft in the incidence of incomplete apposition to aortic arch. METHODS: Between 2007 and 2014 data including available and suitable computed tomographic angiography (CTA) imaging of patients who had undergone thoracic endovascular aortic repair were reviewed. The study included 80 patients (65 men, 54 ± 21 years) treated for traumatic aortic rupture (n = 27), thoracic aortic aneurysm (n = 15), type B aortic dissection (n = 24), penetrating aortic ulcer (n = 5), intramural hematoma (n = 2), aorto-oesophageal fistula (n = 2), and aortic mural thrombus (n = 5). Pre- and post-operative CTA images were analyzed to characterize bird beak in terms of length and angle, and to calculate aortic angulation within a 30 mm range at the proximal deployment zone. RESULTS: Bird beak configuration was detected in 46 patients (57%): mean stent protrusion length was 16 mm (range: 8-29 mm) and mean bird beak angle was 20° (range: 7-40°). The bird beak effect was significantly more frequent after traumatic aortic rupture treatment (p = .05) and in landing zone 2 (p = .01). No influence of either stent graft type or generation, or degree of oversizing was observed (p = .29, p = .28, p = .81 respectively). However, the mean aortic angle of patients with bird beak was higher in the Pro-form group than that in the Zenith TX2 group (62° vs. 48°, p = .13). Multivariate analysis identified the aortic angle of the deployment zone as the unique independent risk factor of malapposition (HR = 1.05, 95% CI 1-1.10, p = .005). The cutoff value of 51° was found to be predictive of bird beak occurrence with a sensitivity of 58% and a specificity of 85%. CONCLUSIONS: Assessment of proximal landing zone morphology to avoid deployment zones generating an aortic angle of over 50° can be recommended to improve aortic curvature apposition with the current available devices.

[Value of routine identification of respiratory infectious agents in children hospitalized with an acute asthma exacerbation]. / Intérêt de l'identification en routine des agents pathogènes respiratoires chez les enfants hospitalisés pour une exacerbation d'asthme.

BACKGROUND: Asthma is the most common chronic disease in childhood. With its high economic burden, it is considered a disease of major public health importance by the World Health Organization. The link between respiratory tract infections and acute exacerbation has been recognized for a long time. The aim of this retrospective study in routine care was to evaluate our practices concerning microbiological prescriptions in children hospitalized for asthma exacerbation. STUDY DESIGN: All children aged from 2 to 15 years hospitalized for asthma exacerbation between January 2010 and December 2011 in our unit were included in the study. Microbiological prescriptions, their indications, their results, and their cost were studied. RESULTS: One hundred ninety-seven children were included in the study. A potential causative agent was sought in 79.7% of the children (n=157) by immunofluorescence assay (IFA) and/or polymerase chain reaction (PCR). The main indications were upper airway infections, hypoxemia, and pneumonia. Viruses were detected in 23.8% of them (30/126). Mycoplasma pneumoniae was detected by PCR in only 3.2% of these patients (4/125). No other bacterial agent was identified. There was no correlation between the severity of asthma exacerbation and the microbiological diagnosis of infection. The results did not influence the therapy given. These prescriptions represented a substantial cost for each child. CONCLUSION: These analyses do not seem to have a real advantage for the patient except for epidemiology. It would be important to conduct a new study analyzing the role of rhinovirus, and of other viruses such as coronavirus, bocavirus, and enterovirus, not routinely investigated in our hospital, and to question the value of these costly microbiological tests.

Circulating endothelial cells and progenitors as prognostic factors during autoimmune thrombotic thrombocytopenic purpura: results of a prospective multicenter French study.

BACKGROUND: Autoimmune thrombotic thrombocytopenic purpura (AI-TTP) is characterized by an excess of circulating ultralarge von Willebrand factor (VWF) caused by anti-ADAMTS-13 autoantibodies. Animal studies, however, have shown that endothelial cell activation may also be an important trigger of AI-TTP. OBJECTIVES: To prospectively study circulating biomarkers of endothelial lesion and activation, such as circulating endothelial cells (CECs), soluble P-selectin (sP-selectin), or VWF, and of endothelial repair, such as circulating progenitor cells (CPCs) and endothelial progenitor cells (EPCs), in AI-TTP, in relation to disease severity and prognosis. RESULTS: Twenty-two patients were included in this study. CEC (P < 0.01), VWF (P < 0.05) and sP-selectin (P < 0.01) levels were significantly increased during crisis, and returned to baseline levels during remission. Both CEC (P < 0.05) and sP-selectin (P < 0.05) levels were significantly higher in patients who died or developed neurologic sequelae. CPC levels were substantially increased during the acute phase of the disease (P < 0.001), and returned to baseline levels during remission. Among CPCs, EPC levels were also increased during crisis (P < 0.05) and significantly decreased during remission. Patients who received < 16 plasma exchanges (PEs) had significantly higher EPC counts (P < 0.05) than those who needed more numerous PEs to obtain remission, suggesting that initial EPC counts may be associated with faster endothelial repair. CONCLUSION: The profile of circulating endothelial markers shows massive endothelial activation and repair/remodeling during AI-TTP, and suggests that CECs and EPCs may be promising prognostic biomarkers of the disease.

Subintimal recanalization plus stenting or bypass for management of claudicants with femoro-popliteal occlusions.

OBJECTIVE: To assess a practice of claudicant revascularization with either subintimal angioplasty (SIA) plus stenting or femoropopliteal bypass. METHODS: All claudicants related to femoropopliteal occlusions treated either with above-the-knee femoropopliteal (AKFP) bypass (group 1) or SIA and stent (group 2) between 2004 and 2011 were reviewed. The two groups were analyzed with regard to patency and freedom from re-intervention. RESULTS: One hundred and fifty limbs were consecutively treated with AKFP bypass (n = 82), SIA plus stenting (n = 58), or SIA (n = 10). Bypasses were performed with synthetic grafts in 49 limbs (59.7%). Covered stents were used in 34 limbs (63%) and self-expandable stents in the remainder. Mean follow-up was 26 and 36 months, respectively, in group 1 and 2. At 24 months, primary, primary-assisted, and secondary patency for bypass versus SIA + stent groups was, respectively, 66.6 versus 70.1%, 76.5 versus 90.1%, and 88.2 versus 90.1%. Freedom from re-intervention rates at 12 and 36 months were, respectively, 78.8 and 68.4% for group 2 and 86.4% and 65.2% for group 1. CONCLUSION: SIA plus stenting is an effective and useful option for the management of claudicants with femoropopliteal occlusions, and can be considered as complementary to surgical bypass.

Iron overload of hematological origin: validation of a screening procedure for cardiac overload by MRI in routine clinical practice.

PURPOSE: Screening for cardiac iron overload is generally done by magnetic resonance imaging (MRI) and demonstrated by a shortening of the myocardial T2* below 20 ms at 1.5 Tesla. This measurement was validated with a specific sequence and the CMRTools(®) calculation software (reference technique). The objective of this study was to validate the use of sequences and software programs that are available in routine clinical practice to screen for iron overload. MATERIAL AND METHODS: First, a phantom of 11 tubes with a T2* between 4 and 33 ms was tested at three sites that had MRI machines of different brands. Second, the myocardial T2* values of 75 patients were measured in routine clinical practice using two methods. The first method used the reference sequence specially installed in the machines associated with the CMRTool software. The second method used the standard acquisition sequences available in the machines followed by calculation on a computer spreadsheet. RESULTS: In the phantom, the mean of the differences in T2* between each machine was 0.6 ms. Thirteen patients had a lowered T2* value with the reference technique. Three cases were poorly classified using the routine technique and corresponded with false positives of low overload (T2* between 18 and 20 ms). CONCLUSION: Screening for myocardial iron overload can be done by MRI by using sequences and calculation software available in routine clinical practice during the same examination as the one for the evaluation of hepatic iron overload.

[A preliminary validation of a new French instrument to assess quality of life for caregivers of patients suffering from schizophrenia]. / Validation française d'un questionnaire de qualité de vie des aidants naturels de patients schizophrènes.

INTRODUCTION: Since psychiatric institutions began discharging mentally ill patients into the community, family of patients suffering from schizophrenia are more and more involved in the therapeutic process. The adverse consequences of having a patient suffering from schizophrenia at home are called "burden of care" and have been studied by numerous authors. We were interested in the quality of life of caregivers and its evaluation. This concept represents a more complex, multidimensional approach in which many variables are taken into account. We propose the development of a French self-administered instrument of quality of life for caregivers of individuals with schizophrenia, the caregiver schizophrenia quality of life questionnaire (S-CGQoL). METHODS: Data were collected through the departments of six psychiatric hospitals in France (n=246). The item reduction and validation processes were based on both item response theory and classical test theory. The study of external validity used the generic Short Form 36 questionnaire. Scores of isolated dimensions were also confronted with caregivers' and patients' demographic data and with patients' clinical data. RESULTS: The S-CGQoL contains 25 items describing seven dimensions (psychological and physical well-being; burden and daily routine; relationships with spouse; relationships with psychiatric team; relationships with family; relationships with friends; and material burden). The seven-factor structure accounted for 74.4% of the total variance. Internal consistency was satisfactory; Cronbach's alpha coefficients ranged from 0.79 to 0.92 in the whole sample. The scalability was satisfactory, with INFIT statistics within an acceptable range. In addition, the results confirmed the absence of DIF and supported the invariance of the item calibrations. Acceptability was good. The study of external validity found significant correlation between S-CGQoL index and all SF-36 dimension scores. Certain dimensions of the S-CGQoL are associated with caregivers' characteristics (age, sex, number of children, living situation, and employment status). Moreover, some domains of caregiver's quality of life are dependant on subtype of schizophrenia (paranoid) and symptomatology (positive factor and general psychopathology). We did not find any correlation with negative factor. DISCUSSION: The content of the S-CGQoL encompasses experiences of great importance to patients and is substantially different from other generic quality of life or burden instruments. In our questionnaire, the focus on the different aspect of the social life permits a precise analytical description of the social dimension that is not assessed as much in other questionnaires. LIMITATIONS: The psychometric properties need to be studied in a wider population. Some parameters of internal validity are missing, such as reproductibility (test-retest reliability) and sensibility to change. The external validity needs to study relationships between S-CGQoL and burden. CONCLUSION: The S-CGQoL is the first self-administered quality of life questionnaire for caregivers of patients suffering from schizophrenia. It presents satisfactory psychometric properties, which can be completed in five minutes and, therefore, fulfils the goal of brevity sought in research and clinical practice.

Quality of life in a heterogeneous sample of caregivers of cancer patients: an in-depth interview study.

To establish the best approach to develop a quality of life (QoL) questionnaire for cancer-patient caregivers, this study attempts to identify primary domains of QoL in terms of their impact on a purposive sample of caregivers. Seventy-seven informal adult caregivers of cancer patients (breast cancer, paediatric haematological malignancies or melanoma) with different relationships with the patients (parents, children, spouses, siblings, and friends) were recruited at three specialised French centres and extensively interviewed. Caregivers' lives were altered in several domains: psychological well-being, leisure and everyday activities, relationships with institutional caregivers, occupation and finances, relationships with family and friends, physical well-being, and relationship with the patient. The relative importance of these domains varied mainly in association with the caregiver-patient relationship. Multiple correspondence analysis identified two isolated clusters: children, and, most significantly, friends and siblings. The latter groups emphasised the repercussions on their psychological well-being and their relationship with the patient, but were less willing to discuss the impact on their relationship with caregivers and on occupation, finances, leisure, and everyday activities. This study focuses on the caregiver's perspective and advocates the development of a short QoL core questionnaire. Additional modules should be cancer-specific or dedicated to specifics of the caregiver-patient relationship.

[Immune profile of elderly patients admitted in a geriatric short care unit]. / Étude du profil immunitaire de sujets âgés hospitalisés en unité de court séjour gériatrique.

INTRODUCTION: Immunosenescence embraces the whole of age-induced changes observed in the immunomodulatory functions of a living organism, and is mostly characterized by a decrease in cell-mediated immunity and important modifications of the immunological repertoire. The impact of the pathology on ageing immunity is poorly understood and few data are available on the immunological status of old polypathological patients. METHODS: We report the results of a prospective study aiming at characterizing several established immunological parameters in patients of 75 years old or more, and admitted for diverse pathologies in a unit of acute geriatric ward. RESULTS: Among the 51 included patients (35 women and 16 men), 90% displayed poly-pathologies. We found a prevalence of 86% of immunological abnormalities, with lymphopenia among 41% of the patients (<1500/mm(3)) and abnormal lymphocytes phenotypes among 95% of the oldest patients (>85 years). A strong skewing towards memory T lymphocytes (CD45RO+) over naive T lymphocytes (CD45RA+) was found in 80% of the cases and inverted CD4/CD8 T cells ratio was observed in 12% of our patients. Vitamin D insufficiency (<30ng/ml), which is frequent among the patients (94%), is a predictive factor for T and B cell lymphopenia. CONCLUSION: Immunological abnormalities are frequent in this frail population and lymphopenia, in particular, could constitute a reinforcing factor of fragility. Vitamin D deficiency could also affect elderly patients' immunity.

Congenital scoliosis: a frontal plane evaluation of 251 operated patients 14 years old or older at follow-up.

INTRODUCTION: Congenital scoliosis, carrying an incidence between 0.5 and 1 per 1000 births, raise the problem of their evolutive potential. HYPOTHESIS: Some predictive factors for the evolution of scoliotic curvature due to congenital vertebral malformation (CVM) can be found. MATERIAL AND METHODS: This was a retrospective multicenter study of 251 patients, at least 14 years old when evaluated at end of follow-up, with CVM and spinal deformity predominating in the frontal plane. RESULTS: 38.8% of patients showed associated neurologic, visceral or orthopedic abnormalities. CVM was single in 60.6%, double in 20.3%, triple in 6.4% and multiple in 12.7% of cases. 34.1% of CVMs were thoracic. Congenital scoliosis curvature was single in 88.8% of patients, double in 10% and triple in 1.2%. Mean curvature angle was 31.7° at diagnosis (range, 0-105°) and 41.3° preoperatively (range, 10-105°). Sixty-one patients showed associated kyphosis. Mean change in postoperative curvature angle over follow-up was 1.6° (range, -20° to 38°) in the 73 patients managed by arthrodesis, -0.4° (-24° to 30°) in the 64 managed by epiphysiodesis, and 0.4° (-18° to 35°) in the 49 managed by hemivertebral (HV) resection. Results were found to correlate significantly with age at surgery for patients managed by epiphysiodesis, but not for those managed by HV resection or arthrodesis. DISCUSSION: More than 30% of congenital scolioses involve associated intraspinal abnormality. All CVM patients should therefore undergo medullary and spinal MRI to assess the CVM in all three planes, and the medullary canal and its content. The evolution of scoliotic curvature induced by CVM is hard to predict. Several factors are to be taken into account: CVM type, number and location, and patient age. Curvature progression may be slow or very fast. It accelerates during the peak of puberty, stabilizing with bone maturity. Surgery is mandatory in evolutive scoliosis. Four procedures may be recommended, according to type of CVM and especially to patient age: arthrodesis, convex epiphysiodesis, HV resection or rib distraction. Surgery seeks to correct the spinal deformity induced by the CVM and prevent compensatory curvature and neurologic complications, while conserving sagittal and frontal spinal balance and sparing as many levels as possible. In case of HV involvement, the procedure of choice is CVM resection, which provides 87.5% good results in this indication; the procedure is relatively safe, conservative of spinal levels, and without age limit. LEVEL OF EVIDENCE: Level IV. Retrospective study.

[Pediatric thoracic spine radiographs: Comparison of two scintillators]. / Radiographies thoraciques pédiatriques: comparaison de deux détecteurs à mémoire.

PURPOSE: To compare image quality and radiation exposure from pediatric thoracic spine radiographs from two systems, one using a granular structure scintillator and another using a needle structure scintillator with 40% reduction of exposure. PATIENTS AND METHODS: Randomized prospective study of 296 patients divided into 2 groups of 5 weight categories from 4 to 60 kg. Standard technique parameters are used for granular structure scintillators with dose reduction of 40% applied for needle structure scintillators based on results from a phantom study. Image quality based on detectability of 8 anatomical structures for both types of scintillators was assessed by 6 blinded radiologists. Exposure was expressed by DLP. Results underwent statistical analysis. RESULTS: Overall, image quality was superior with corresponding dose reduction between 33-46% according to weight with needle structure scintillators. For the 4 lower weight categories, image quality was identical. CONCLUSION: With image quality at least equal, new needle structure scintillator units allow a dose reduction of about 40%.

Endovascular management of chronic disabling ilio-caval obstructive lesions: long-term results.

OBJECTIVE: To report the long-term results of stenting for chronic ilio-caval obstructive lesions. MATERIAL AND METHODS: From January 1996 to January 2008, 89 patients (72 women, 17 men; median age 43 years) were admitted for endovascular treatment of chronic disabling non-malignant obstructive ilio-caval lesions. Patients were classified as C2 in 15 cases, C3 in 59, C4 in seven, C5 in two and C6 in six. Median preoperative venous disability score (VDS) and venous clinical severity score (VCSS) were 2 and 9, respectively. Aetiology was primary in 52 patients, secondary in 35 and congenital in two. Lesions were bilateral in seven cases, eight patients had inferior vena cava (IVC) involvement and 18 had common femoral vein (CFV) obstructive lesions. Complete occlusion was found in 30 cases. RESULTS: Technical success was achieved in 98%. The median hospital stay was 2 days. During a median follow-up of 38 months (range: 1-144 months), one patient died and five cases of thromboses occurred. Iterative stenting was performed for restenosis in six cases. Primary, assisted-primary and secondary patency rates, in terms of intention to treat, were 83%, 89% and 93%, respectively, at 3 and 10 years, with a median VDS of 1. Univariate analysis found that significant factors affecting patency were CFV involvement for primary patency and history of deep venous thrombosis (DVT) and CFV involvement for secondary patency. The last 46 patients had statistically more severe lesions than the first 43 (higher VDS, more secondary lesions, more occlusions, more stented segments, higher length of stented vein), and in spite of which patency rates are not different. CONCLUSION: Endovenous angioplasty, combined with stenting, is a sure, safe, effective and very minimally invasive technique which provides good long-term patency rates. Currently, it is recognised as the technique of choice for the treatment of ilio-caval obstructive lesions. Surgery should be proposed only in case of failure.

[Informative value of the popliteal angle in walking cerebral palsy children]. / Peut-on se fier à l'angle poplité chez l'enfant paralysé cérébral marchant?

PURPOSE OF THE STUDY: In clinical practice, it is generally accepted that hamstring tightness results in incomplete knee extension when the hip is in flexion and in smaller conventional and modified popliteal angles. Similarly, a difference between the conventional popliteal angle and the modified popliteal angle (popliteal differential) would be associated with a permanent deficit in knee extension. The purpose of this study was to determine whether these two hypothesis correlate with clinical findings. MATERIAL AND METHODS: The series was composed of 35 walking cerebral palsy children, 16 girls and 19 boys, mean age 11+/-3.6 years with a pathological conventional popliteal angle. These children walked using the jump knee (n=24) or the crouch knee (n=11) pattern. Permanent hip flexion and the conventional and modified popliteal angles were noted. SPSS version 10.1.3 for Window was used to search for a correlation between the popliteal differential and the presence of permanent hip flexion using several values for the popliteal differential (5, 10, 15, 20, and 30 degrees ). Data were adjusted for age and gender. RESULTS: The statistical analyses demonstrated a significant relationship between the presence of permanent hip flexion and a popliteal differential strictly less than 10 degrees and between the absence of permanent hip flexion and a popliteal angle greater or equal to 10 degrees . These statistically significant results, which demonstrated the opposite of what was expected, were independent of age and gender. DISCUSSION: Our findings demonstrate that examination of the knee joint is indispensable but insufficient. The conventional popliteal angle is not a reliable indicator of hamstring tightness. The normal value of the modified popliteal angle has not been established so that it is impossible to determine what a pathological angle is. We do not know whether measurement of this angle is sufficient to establish indications for surgery. In the future, the development of muscle models coupled with gait analysis should enable more reliable prediction of outcome after surgery. At the present time, we recommend repeated physical examination using a standardized protocol, taking into consideration, several parameters including spasticity, selectivity and muscle force and to perform quantified gait analysis before scheduling hamstring lengthening surgery for walking cerebral palsy children.

[Causes of hospitalization and death in the MANIF 2000 cohort, composed of HIV-infected patients contaminated by intravenous drug use, 1995-1999]. / Motifs d'hospitalisation et mortalité dans la cohorte MANIF 2000, composée de sujets infectés par le VIH et contaminés par usage de drogues en intraveineux, 1995-1999.

OBJECTIVE: To describe the causes of hospitalization and mortality among the MANIF 2000 cohort study, composed of HIV-infected patients contaminated through intravenous drug use. METHOD: Data collection with a standardized questionnaires with clinical, biological, therapeutic and psycho-sociologic data on inclusion and every six months. Dates and causes of hospitalization and death were collected retrospectively by nurses from the hospital clinical records. Comparison were made using the chi(2) or Mann-Whitney tests with 5% significance threshold. RESULTS: The MANIF 2000 cohort study included, between October 1995 and June 1998, 467 patients with a median age of 33 years, 30% of whom were women. On inclusion, 42.2% were still injecting drugs (half of them were on substitution therapy), 10.5% had stopped injections of drugs, 32% exhibited more than 500CD4/mm(3) and 55.7% had not taken antiretroviral treatment. As of December 31(st) 1999, 21 patients had died, i.e. a mortality rate of 19% persons/years of follow-up (10-fold greater than that expected in the general population). Less than 5 deaths were due to HIV (n=4). Suicides and liver disease each represented the same number of deaths. Out of the 335 patients not having missed more than one follow-up throughout the 24 month period, 120 had been hospitalized at least once (n=223 hospitalizations), i.e., a hospitalization rate of 2.8 per 100 persons/month of follow-up. A quarter of hospitalizations were due to benign infections or stage B or C pathologies according to the 1993 classification of HIV infections and one hospitalization out of 5 was due to psychiatric problems (in majority depressive syndromes). Other predominant causes were worsening of general state of health, trauma, problems related to alcohol consumption, drugs abuse or hepatic decompensation. CONCLUSION: HIV-infected patients contaminated by intravenous drug use represent a particular population that cumulates many risk factors and which requires careful monitoring of co-morbidities such as hepatic and psychiatric diseases in order to avoid premature death.

Physician recognition of active drug use in HIV-infected patients is lower than validity of patient's self-reported drug use.

A French survey of 325 HIV-infected subjects with a history of injecting drugs allowed us to study the recognition of patients' injection drug use (IDU) by physicians providing HIV-infection care, and to analyze the correlation between patient demographics and incorrect IDU identification. Kappa for concordance of physician's reports of their patient's IDU with patient's declaration was 0.37; concordance was lower among socially vulnerable patients. This contrasted with a nested study of validity of patient's self-report of opioid use: Kappa for patient's declaration of opioid use within the past two days against a biological assay was 0.61, and concordance was higher among socially vulnerable patients. Concordance of physicians' ratings and patients' reports of IDU was not more than fair, even though physicians were knowledgeable about their patient's IDU history. This concordance varied with social status in a way that did not correspond with variations in self-reported opioid use validity, suggesting that identification of active IDU might be partly based on incorrect interpretation of subjective cues.