[Suffering at work among medical students: qualitative study using semi-structured interviews]. / Souffrance au travail des étudiants en médecine : étude qualitative par entretiens semi-dirigés.

INTRODUCTION: Suffering at work among health professionals is a hot topic. Medical students, doctors of tomorrow, are far from being spared. Prevalence of anxiety and mood disorders range from 20.3 to 69 % for the former and from 12 to 30 % for the latter. The purpose of this article is to determine these factors by qualitative research, according to medical students' points of view. METHODS: It is a qualitative study using semistructured interviews. The analysis is done according to the Grounded Theory. RESULTS: 12 medical students are interviewed. They expressed difficulties at work and positive factors. Three major themes are identified in selective coding: occupational factors, " study " factors and individual factors. All themes are both a source of well-being and ill-being according to the situations specified in the results. CONCLUSION: Studying medicine includes positive and negative aspects. Abandonment issues, lack of recognition and insufficient coaching emerge from our study. Screening of suffering at work should be systematic for medical students.

INTRODUCTION: La souffrance au travail chez les professionnels de santé est un sujet d'actualité. Les étudiants en médecine, médecins de demain, sont loin d'être épargnés. Ils présentent notamment des troubles anxieux et de l'humeur dont les prévalences s'échelonnent de 20,3 à 69 % pour les premiers et de 12 à 30 % pour les seconds. Cette étude a pour objectif de déterminer ce qui est ressenti comme positif ou négatif au travail du point de vue des étudiants hospitaliers. Matériel et méthode : Il s'agit d'une étude qualitative par entretiens semi-dirigés. L'analyse se fait selon une thématisation progressive en suivant la Grounded Theory, ou théorisation ancrée, méthode issue des sciences sociales, visant à élaborer une théorie des représentations, non à partir d'hypothèses prédéterminées, mais à partir de données de terrain recueillies par entretiens. Résultats : La variation est maximale. La saturation des données a été atteinte avec 12 sujets. Ceux-ci ont exprimé des difficultés au travail mais aussi des facteurs de ressenti positif. Trois grands thèmes ont été définis en codage sélectif : les facteurs professionnels, les facteurs " étude " et les facteurs individuels. Quelle que soit la thématique abordée, les relations avec le ressenti du travail sont à la fois source d'épanouissement et de souffrance selon les situations précisées dans les résultats. CONCLUSION: Le vécu des études médicales comprend des aspects positifs et négatifs. Les problématiques de délaissement, de manque de reconnaissance ou encore d'accompagnement insuffisant ressortent de notre étude. Ceci ouvre des pistes de prévention. Le dépistage d'un malêtre au travail devrait être systématique chez ces étudiants.

[Prevalence of vitamin D deficiency in children aged 5-10 years in western Brittany]. / Prévalence du déficit en vitamine D chez les enfants âgés de 5 à 10ans en Bretagne Occidentale.

UNLABELLED: French guidelines do not recommend systematic supplementation of vitamin D in children aged 5-10 years old owing to the lack of data on vitamin D status in this age group. Our objective was to assess the prevalence of vitamin D deficiency in these children. METHODOLOGY: Single-center, prospective, epidemiological study including 358 children aged 0-15 years. The endpoint was the concentration of vitamin D. RESULTS: In all, 316 children were divided into four groups according to age: 0-18 months (n=113); 18 months to 5 years (n=103); 5-10 years (n=62); and 10-15 years (n=38). The median concentration of vitamin D decreased with age (P<0.001): 90.2 nmol/L in the group aged 0-18 months; 56.7 nmol/L in the group aged 18 months to 5 years; 49.05 nmol/L in the group aged 5-10 years; and 42.45 nmol/L in the group aged 10-15 years. This corresponds to an increase in the prevalence of vitamin D deficiency in children aged 5-10 years (51.6% vs. 8.8% in the group aged 0-18 months, P<0.001). For children aged 5-10 years, the prevalence of deficiency was greater in the non-supplementation group (75%) compared with the supplementation group (13%; P<0.001). CONCLUSION: This study demonstrates the high prevalence of vitamin D deficiency in children aged 5-10 years and the relationship between supplementation and vitamin D status. It provides an argument in favor of supplementation in children aged 5-10 years in this region and a reconsideration of the French recommendations.

[Clinical presentation of inborn metabolic diseases in the neonatal period]. / Signes néonatals des maladies héréditaires du métabolisme.

Inborn metabolic diseases (IMDs) that can start in the neonatal period include various defects in numerous metabolic pathways. Such diseases are due to the genetic deficiency of an enzyme or a transporter. From a physiopathological point of view, the metabolic disorders can be divided into 3 diagnostically useful groups of diseases. The first group is due to the accumulation of endogenous toxic metabolites and includes inborn errors of amino acid metabolism, organic acidemias, urea cycle disorders, and sugar intolerances. The second one includes IMDs of intermediary metabolism causing a disturbance in energy production or utilization resulting from a defect in the liver, the muscles, the myocardium, or the brain (fatty acid oxidation defects, congenital lactic acidosis, etc.). The third group includes diseases that disturb the synthesis or the catabolism of complex molecules (lysosomal or peroxisomal disorders, etc.). IMDs are individually rare, but collectively numerous. Therefore, it is difficult to acquire extensive experience in the management of these diseases. However, the neonate has a limited repertoire of responses to severe illness and, at first, presents with nonspecific symptoms that could be easily attributed to infection or some other common cause. An IMD must be suspected in all situations of neonatal distress for which there is no apparent reason and that does not respond to symptomatic therapy. The priority is given to IMDs that are amenable to treatment, and emergency management has to be scheduled as soon as the diagnosis is suspected, even if the precise diagnosis is still unknown. In fact, emergency treatment must be undertaken in parallel with metabolic investigations, to prevent any delay in the management of the disease. The neonatologist must be able to recognize the neonatal distresses that suggest the possibility of an IMD. In such situations, an adequate diagnostic approach can be based on the proper use of only a few screening tests, which will also be useful to schedule adequate emergency treatment.

[Quantitative assessment of medical students' clinical practical learning in department of obstetrics and gynecology of Brest Hospital University]. / Évaluation quantitative de l'enseignement pratique des étudiants hospitaliers en gynécologie-obstétrique au CHU de Brest.

OBJECTIVE: The main objective of this study was to describe how medical students got progressively trained to perform the most frequent medical procedures in obstetrics and gynecology. The secondary objective was to rationalize and plan the training. METHODS: The medical students in our University Hospital were contacted either directly or by e-mail. They were given an anonymous simple choice questionnaire relating to eight most important acts in the specialty. RESULTS: Three hundred and eighty-two medical students have been consulted. We got 173 answers which means a participation rate of 45.3%. The survey showed up that the considered procedures were progressively put into practice with the exception of two: the insertion of an intrauterine contraceptive device (coil) and of an implant. CONCLUSION: The study showed off some insufficiency in the training in two of the considered procedures. An amendment was proposed with simulated performances of the acts and the setting up of a training course booklet.

Tubulopathy and pancytopaenia with normal pancreatic function: a variant of Pearson syndrome.

Out of a series of 30 French patients with Pearson syndrome, we report on two patients with an atypical presentation, which include growth deficiency, pancytopaenia, tubulopathy and absence of exocrine pancreas dysfunction. Patient 1, a 4-year-old boy with a past history of pancytopaenia and transient metabolic acidosis at 13 months of age, presented at 2(1/2) years of age with severe tubulopathy of de Toni-Debré-Fanconi type, growth retardation, metabolic lactic acidosis and mild cytolysis. Despite normal exocrine pancreatic function, study of mitochondrial DNA revealed a 3.5 kb deletion. Patient 2 had a personal history of pancytopaenia requiring blood transfusions at 11 months of age and presented with severe intractable proximal and distal tubulopathy at 2 years of age. Exocrine pancreatic deficiency could not be evidenced and post-mortem studies revealed a 4.9 kb deletion of the mitochondrial DNA. A review of the literature revealed three patients presenting with Pearson syndrome and tubulopathy with normal pancreatic function and highlights delay in diagnosis in those three patients. The series of 30 French patients with Pearson syndrome also revealed that tubulopathy was present in 7/30 cases (23%), with variable outcome. In conclusion, Pearson syndrome should be screened for in children presenting with the association of growth retardation, anaemia/pancytopaenia, lactic acidosis and tubulopathy, even in the absence of exocrine pancreatic deficiency.

Antibiotic prophylaxis for the prevention of recurrent urinary tract infection in children with low grade vesicoureteral reflux: results from a prospective randomized study.

PURPOSE: Antibiotic prophylaxis is given to children at risk for urinary tract infection. However, evidence concerning its effectiveness in grade I to III vesicoureteral reflux is lacking. The objective of this study was to determine whether antibiotic prophylaxis reduces the incidence of urinary tract infection in young children with low grade vesicoureteral reflux. MATERIALS AND METHODS: Children 1 month to 3 years old with grade I to III vesicoureteral reflux were assigned randomly to receive daily cotrimoxazole or no treatment, and followed for 18 months. A urinary tract infection constituted an exit criterion. Infection-free survival rates were calculated using the Kaplan-Meier method and compared using the log rank test. RESULTS: A total of 225 children were enrolled in the study. Distribution of gender, age at inclusion and reflux grade were similar between the 2 groups. There was no significant difference in the occurrence of urinary tract infection between the 2 groups (17% vs 26%, p = 0.2). However, a significant association was found between treatment and patient gender (p = 0.017). Prophylaxis significantly reduced urinary tract infection in boys (p = 0.013), most notably in boys with grade III vesicoureteral reflux (p = 0.042). CONCLUSIONS: These data suggest that antibiotic prophylaxis does not reduce the overall incidence of urinary tract infection in children with low grade vesicoureteral reflux. However, such a strategy may prevent further urinary tract infection in boys with grade III reflux.

[Management of phenylketonuria and hyperphenylalaninemia: the French guidelines]. / Consensus national sur la prise en charge des enfants dépistés avec une hyperphénylalaninémie.

Phenylketonuria (PKU) is an inherited metabolic disease affecting about one birth out of 15 000. From 1978, a national systematic neonatal screening was set up in France with a regional organisation. French rational and guidelines have been established by the national PKU group with the collaboration of all the physicians responsible for the regional centres. These guidelines specify the minimal diagnosis procedures leading to an optimal treatment of all patients. A low-phenylalanine diet must be started as soon as possible in the neonatal period for all newborns whose phenylalanine levels are above 10 mg/dl. The dietary control must keep the phenylalanine plasma levels between 2 and 5 mg/dl until 10 years of age. After this age, several data argue for a progressive and controlled relaxation of the diet, keeping the phenylalanine level below 15 mg/dl until the end of the adolescence and below 20 to 25 mg/dl in adulthood. All PKU patients must be followed up for life, in order to screen those who may not bear the diet relaxation and in order to strictly prevent maternal PKU deleterious consequences.

[Nosocomial infections due to human coronaviruses in the newborn]. / Infections nosocomiales à coronavirus humains chez le nouveau-né.

Human coronaviruses, with two known serogroups named 229-E and OC-43, are enveloped positive-stranded RNA viruses. The large RNA is surrounded by a nucleoprotein (protein N). The envelop contains 2 or 3 glycoproteins: spike protein (or protein S), matrix protein (or protein M) and a hemagglutinin (or protein HE). Their pathogen role remains unclear because their isolation is difficult. Reliable and rapid methods as immunofluorescence with monoclonal antibodies and reverse transcription-polymerase chain reaction allow new researches on epidemiology. Human coronaviruses can survive for as long as 6 days in suspension and 3 hours after drying on surfaces, suggesting that they could be a source of hospital-acquired infections. Two prospective studies conducted in a neonatal and paediatric intensive care unit demonstrated a significant association of coronavirus-positive nasopharyngal samples with respiratory illness in hospitalised preterm neonates. Positive samples from staff suggested either a patient-to-staff or a staff-to-patient transmission. No cross-infection were observed from community-acquired respiratory-syncitial virus or influenza-infected children to neonates. Universal precautions with hand washing and surface desinfection could be proposed to prevent coronavirus transmission.

Neonatal screening and long-term follow-up of phenylketonuria: the French database.

BACKGROUND: In France, neonatal screening of phenylketonuria (PKU) started in 1966. A national association was created in 1978 in order to organise the neonatal screening program and to control the efficacy of the screening and patients' follow-up. AIMS: To evaluate the results of the French PKU screening program in terms of hyperphenylalaninaemia epidemiology, efficacy of the screening procedure, management and outcome of the patients. STUDY DESIGN: The national database has been filled-up first with the answers to questionnaires that were sent each year by the PKU patients' physicians, and second with the results of an additional inquiry, which was set up in 1994 in order to investigate diagnosis, treatment, and school outcome of all French PKU patients. RESULTS: PKU was diagnosed in 81.6% of patients with hyperphenylalaninaemia (HPA), non-PKU HPA in 17.2% and cofactor deficiency in 1.1%. From 1980, incidence of PKU has been stable: 1 per 17,124 live births. Sensitivity of the screening procedure was 99.3%. Age at diet initiation regularly decreased to reach 14 days as a median in 1996. Until 1990, median age at diet discontinuation was 6 years of age. Later, strict diet was continued longer (at least, up to 8-10 years). PKU patients who entered to secondary school at normal age were characterised by an earlier age at diagnosis and at diet initiation and a later age at diet discontinuation, compared to those who entered 1 year or more behind normal age. CONCLUSION: These data confirm the benefit of a nationwide organised screening program. They emphasise the importance of an early neonatal diagnosis and diet initiation in PKU patients and are consistent with the benefit of a longer period of strict diet in childhood.

Low rate of Candida parapsilosis-related colonization and infection in hospitalized preterm infants: a one-year prospective study.

We determined the rate of Candida parapsilosis colonization in preterm neonates (NN) and the relationship between colonization and systemic infection through a prospective study in the Neonatal Intensive Care Unit of a university hospital. All NN born at a gestational age of 32 weeks or less were included. Specimens from rectum, mouth and retro-auricular skin were obtained at admission and weekly thereafter. All samples were inoculated on to Sabouraud agar, CHROMagar and Dixon media. Candida species were identified using API Candida and API 20C. DNA analysis was performed using pulse field gel electrophoresis.Fifty-four patients were included (mean age: 30 +/- 1.5 weeks; mean birthweight: 1347 +/- 301 g; male: 40%). Fungal colonization was detected in 43 (79.6%). Causative agents were C. parapsilosis (N= 7);Malassezia furfur (N= 30);C. albicans (N= 21), C. guillermondii (N= 1). No sample was positive for two different yeasts at the same time. C. parapsilosis colonization included anal (N= 6), buccal (N= 1), and skin (N= 2). The average age at time of colonization was 17.8+/-9.8 days. Neither fungal septicaemia nor death were observed in colonized infants. Two central venous catheters were found to be colonized, one with C. parapsilosis and one with M. furfur. Logistic regression showed a link between colonization and gestational age alone. Three different DNA profiles were observed. This study suggests that in our units, the occurrence of C. parapsilosis colonization is low and bears no relation to systemic infection. The systematic identification of C. parapsilosis carriers for the purposes of isolation and preventive treatment does not appear to be warranted.

Inheritance of a stable mutation in a family with early-onset disease.

Autosomal/dominant polycystic kidney disease (ADPKD) exhibits a high inter- and intrafamilial heterogeneity partly explained by the involvement of at least 3 different genes in the disorder transmission. PKD1, the major locus, is located on chromosome 16p. The occurrence of very early-onset cases of ADPKD (sometimes in utero) in a few PKD1 families or the increased severity of the disease in successive generations raise the question of anticipation. This is a subject of controversial discussion. This report deals with the molecular analysis in families with very early-onset ADPKD. The finding of the same stable mutation with such different phenotypes rules out a dynamic mutation. The molecular basis of severe childhood PKD in typical ADPKD families remains unclear; it may include segregation of modifying genes or unidentified factors and the two-hit mechanism.

[Bicycle helmet effectiveness in children: qualitative analysis of the literature]. / Intérêt du casque cycliste chez l'enfant: analyse qualitative de la littérature.

In order to assess bicycle helmet effectiveness in preventing head injury in children, we performed an international qualitative and systematic review using the criteria of the French Health Accreditation and Evaluation National Agency (ANAES) developed for recommendations in clinical practice (formulation of a question, judgment criteria, collecting references, quality analysis, interpretation of results). Two hundred and thirty-four papers dealing with the subject were identified through a MEDLINE search. Two hundred and fifteen of them were eliminated as they did not meet selected criteria. Four were eliminated because of language criteria. On the 14 meeting all selection criteria, five were judged satisfactory according to qualitative criteria. All five conclude in favor of the effectiveness of the bicycle helmet even when taking bias into account. The real protection afforded by wearing a bicycle helmet militates in favor of its habitual use.