Incidence of all-cause adult community-acquired pneumonia in primary care settings in France.

OBJECTIVES: To estimate the incidence of all-cause outpatient community-acquired pneumonia (CAP) in adults in France from a national prospective observational study of CAP management in general practice (CAPA). METHODS: Patients aged over 18 years presenting with signs or symptoms indicative of CAP associated with recent onset of unilateral crackles on auscultation and/or a new opacity on chest X-ray were included in the CAPA study. An ancillary survey (AIMSIS) aiming at identifying family physicians' difficulties in including patients and at collecting their opinion on the use of an electronic case report form, determined the number of non-included eligible patients. A three-step analysis was then performed, including computation of the total number of eligible patients, adjustment for seasonality, and extrapolation to the French FP population using indirect standardization to adjust for differences in characteristics between CAPA FPs and French FPs. RESULTS: Between September 2011 and July 2012, 267 (63%) CAPA investigators included 886 CAP patients. Most patients presented with mild CAP. The rates of hospitalization and one-month case fatality were 7% and 0.3%, respectively. Data from 336 (79%) AIMSIS investigators identified 641 additional patients and estimated at 234,023 the number of CAP patients per year (incidence of 4.7 per 1000 persons per year). CONCLUSIONS: Using a pragmatic case definition of CAP patients, this study estimated an incidence of 4.7 per 1000 persons per year that is in the lower half of the range of estimated incidences reported in primary care settings in industrialized countries.

CAPECO: Cost evaluation of community acquired pneumonia managed in primary care.

BACKGROUND: Estimating the economic burden of community acquired pneumonia (CAP) managed in ambulatory setting is needed in France since no data are available. METHOD: A retrospective study (CAPECO) was conducted based on a prospective French study describing patients with suspected CAP managed in primary care (CAPA). The aim of the CAPECO study was to estimate and explain medical costs of a disease episode in CAP patients only followed in ambulatory care and in hospitalised patients. Primary endpoints were the direct medical costs, impact on productivity and costs of incident CAP over one year. Secondary endpoint was to describe predictive factors of costs, hospital admission and stay length. RESULTS: In this cohort of 886 patients, resulting in an incidence of CAP of 400 per 100,000 inhabitants per year, the mean direct medical cost of a disease episode of CAP was € 118.8 for strictly ambulatory patients with an equal weight for medical time, drugs, diagnostic procedures and tests. This direct cost was € 102.1 before admission for patients who were finally hospitalised. The mean cost of hospital admissions was € 3522.9. Main predictive factors of hospital admission and stay length were respectively a history of chronic respiratory disease and older age. Factors of direct medical cost were prescribing X-ray examination and having a positive X-ray. The impact of a disease episode on productivity was € 1980 (sd 1400) per ambulatory episode and € 5425 (sd 4760) per episode leading to hospital admission. CONCLUSION: Costs per ambulatory episode were modest but increased substantially in hospitalised patients, who were more numerous when chronic respiratory disorders were present and in the elderly. Indirect costs were significant. Deciders should thus consider both direct and indirect costs when assessing preventive interventions in the context of this disease.

[Vaccination coverage against hepatitis B in first-grade children, Paris, 2002-2008]. / Couverture vaccinale contre l'hépatite B des enfants scolarisés à Paris en classe préparatoire entre 2002 et 2008.

INTRODUCTION: The French controversy over the possible risks of vaccination against hepatitis B seems to have resulted in a slowdown or delay in vaccination of target populations since the mid-1990s. This article reports the results of the analysis of vaccination coverage against hepatitis B of first-grade children in Paris between 2002 and 2008. METHODOLOGY: Retrospective and descriptive study of vaccination status against hepatitis B for children born between 1997 and 2002 and attending first grade in a Paris school between 2002 and 2008, using anonymous data from the prevention service of the city of Paris. RESULTS: The analysis included 108,114 children whose Health Book (carnet de santé) included sociodemographic data and the presence of at least one diphtheria-tetanus-polio vaccination. Among these targeted children, 66,597 (61.6%) had started a vaccination against hepatitis B, 61,190 (56.6%) were considered "vaccinated" (at least three doses), and 47,489 (43.9%) "adequately vaccinated" (at least three doses respecting the prescribed intervals between injections). The sociodemographic factors associated with hepatitis B coverage were as follows: Paris arrondissement where the child attended school, year, and country of birth. CONCLUSION: Nearly 40% of the children in this cohort had not been vaccinated against hepatitis B before beginning first grade. They have now become adolescents aged 12-17 years. Current data indicate that only one-third of them have benefited from the catch-up campaign. This finding reinforces the need for vigilance on the vaccination status of adolescents against hepatitis B.

[Positive impact of a video and TV documentary on attendance of women to catch-up collective vaccinations and reasons for non-attendance]. / Impact positif d'un documentaire vidéo-TV sur la vaccination antitétanique des femmes au Cambodge et causes de non-vaccination.

The impact of medical documentaries on attendance to immunization sessions is not documented in developing countries. The impact of a video and TV medical documentary on women's vaccination during a catch-up tetanus collective immunization was studied in Cambodia (2002-2004). A medical video documentary produced locally was publicly shown in 10 villages chosen at random among 63 villages to be covered by collective tetanus immunization. In each village where the video was shown, 33 women, older than age 11, were selected at random and questioned about their tetanus vaccination records, to assess if they attended the video and to evaluate their knowledge about tetanus. A second interview was conducted after the first collective vaccination to check their attendance and to record reasons for non-attendance. The same interview was conducted 10 months later, after the documentary was shown on a local TV channel and a second collective tetanus vaccination conducted. Data were collected from 323 (98%) women. Seventy-eight (24%) women saw the video documentary and only eight (2.4%) saw it on TV. Compared to farmers, shopkeepers saw significantly less the documentary (χ² of Yates: 5.77,P = 0.016; 95% CI: 0.10 < RR = 0.29 < 0.88) and no home keeper or civil servant attended it. Women of childbearing age with no school education were significantly more attracted by the video documentary (χ² of Yates: 5.99,P = 0.01; 95% CI: 1.10 < RR = 1.57 < 2.22) than other childbearing-aged women, although their final immunization coverage was not better. The documentary did not increase the knowledge that contamination for tetanus may come from earth and tools, but not from air and water, and that all ages are at-risk for tetanus, but it increased significantly the knowledge that vaccination can prevent the disease (χ² of Yates: 13.98;P = 0.0001; 95% CI: 1.28 < RR = 1.57 < 1.93). Women who saw the video documentary attended the first collective session more often than those who did not (χ² of Yates: 11.00; P = 0.0006; 95% CI: 1.23 < RR = 1.51 < 1.84)in spite of their better vaccination status before the immunization, and this was mostly significant for farmers and women more than 45 years of age. Women who saw the documentary either on video or on TV also attended more the second collective session, but not significantly (χ² of Yates: 1.23;P = 0.266; 95% CI: 0.91 < RR = 1.23 < 1.66). Forty-nine percent of women had not attended school and the video documentary was re-run twice after the first performance. Women older than 45 years (55%) completely escaped immunization significantly more often than women of childbearing age (35%) (χ² of Yates: 17.26;P = 0.00003, 95% CI: 1.53 < RR = 2.13 < 2.97), who did it more often than schoolgirls (2%) (χ² of Yates: 9.69;P = 0.002; 95% CI: 0.01 < RR = 0.09 < 0.65). The main reasons for not being vaccinated during catch-up collective tetanus vaccinations were a too short interval between doses according to the WHO schedule (25%), agricultural task (18%), leisure travel (8%), fear of injections (7%), and being completely vaccinated according to the WHO schedule (7%). Only 2% of women were not informed, showing that vaccination was well-publicized. This educational technique should be re-used in all villages during coming catch-up tetanus collective immunizations in Cambodia, mostly in urban contexts where coverage during these sessions is lower. Video is still the best method in rural context if some education is also provided to the audience. According to the WHO schedule, the interval between two catch-up tetanus sessions should be extended to over a year to be able to give booster shots to women who already received three or more tetanus doses. Vaccination of schoolgirls is significantly easier to achieve with the help of the teachers. Vaccinating women aged over 45 should be encouraged as they are at risk of tetanus even in developed Asian countries.

Fibrovascularization of porous polyethylene (Medpor) orbital implant in a rabbit model.

PURPOSE: To evaluate the porous polyethylene (Medpor) orbital implant in a rabbit model and compare it with three other currently available porous implants: Bio-Eye coralline hydroxyapatite (HA), FCI(3) synthetic HA, and aluminum oxide (Bioceramic). METHODS: The porous polyethylene implant was examined macroscopically and microscopically (with scanning electron microscopy). Implantation was performed in 10 adult male New Zealand albino rabbits. Each animal underwent enucleation of the right globe under general halothane gas anesthesia, followed by placement of a 12-mm porous polyethylene implant. In 5 animals, the implant was encased in polyglactin 910 (Vicryl mesh); in the other 5, it was left unwrapped. The implants were moistened in saline before placement. Implant vascularization was evaluated by histopathology at 4, 8, 12, 16, and 24 weeks. RESULTS: The porous polyethylene implant was found to have a smoother exterior surface than the Bio-Eye, FCI(3) synthetic HA, and aluminum oxide implants. Rather than a uniform interconnected porous architecture, there was an extensive system of interconnected channels through the implant, ranging in size from 125 to 1000 microm. On high-power examination there was a more solid, woven appearance without any sign of the microcrystals seen in the other porous implants. One rabbit had a retrobulbar hemorrhage after surgery and was euthanized. All the other rabbits tolerated the implant well, and there were no complications. On histopathologic examination, fibrovascularization gradually increased over time. One implant was completely vascularized at 12 weeks, and both implants harvested at 16 weeks were completely vascularized. The implant harvested at 24 weeks showed only partial vascularization (14%). CONCLUSIONS: The porous polyethylene orbital implant represents an alternative implant for use after enucleation or evisceration or for secondary implantation. In our rabbit model, the porous polyethylene implant was well tolerated without complication. Complete fibrovascularization was first seen at 12 weeks. Porous polyethylene orbital implants appear to vascularize more slowly than Bio-Eye coralline HA, FCI(3) synthetic HA, and aluminum oxide implants.

Proliferation of human fibroblasts in vitro after exposure to orbital implants.

BACKGROUND: Porous orbital implants allow fibrovascular ingrowth and integration with the extraocular muscles. The available implants have different structural characteristics, which may influence orbital response. We studied the proliferation of orbital fibroblasts in vitro after exposure to four different orbital implants. METHODS: Four orbital implant biomaterials were studied: hydroxyapatite (Bio-Eye), synthetic hydroxyapatite, porous polyethylene (Medpor) (pore sizes 150 microm and 400 microm) and aluminium oxide (Bioceramic implant). Human fibroblasts obtained from orbital fat at the time of elective blepharoplasty were cultured and then exposed to the individual implants. Cell growth was assessed with immunocytochemical analysis using bromodeoxyuridine, a thymidine analogue. After DNA denaturation, the cells were washed, incubated with secondary antibody and visualized. RESULTS: The fibroblasts growing on the Bio-Eye, synthetic hydroxyapatite, and 150-microm and 400-microm Medpor implants all had debris associated with them. The Bioceramic implant was free of this debris. The Bioceramic implant and the 150-microm Medpor implant had the greatest number of fibroblasts on the coverslips. INTERPRETATION: The proliferation of fibroblasts, as determined by visualization of actively dividing cells with bromodeoxyuridine, differed on the various implants studied. The lack of debris associated with the Bioceramic implant may be related to the crystalline structure of the implant.

The bioceramic orbital implant: a new generation of porous implants.

PURPOSE: The authors describe a new generation of porous orbital implant made of aluminum oxide (Al2O3) and compare it with the hydroxyapatite orbital implants (Bio-Eye and FCI hydroxyapatite). METHODS: The authors examined the new implant macroscopically, with chemical analysis and microscopically with scanning electron microscopy. Animal implantation studies were performed using six adult male New Zealand albino rabbits. Implant vascularization was evaluated by means of magnetic resonance imaging and histopathologic sectioning. RESULTS: The Bioceramic orbital implant was found to have very uniform pore structure with an average pore size of 500 microm. The implant was 99.9% aluminum oxide on x-ray diffraction. Magnetic resonance imaging in vivo vascularization studies demonstrated enhancement of the implant to its center by 4 weeks after implantation in the rabbit. Histopathologically, fibrovascularization occurred uniformly throughout the implant and was noted by 4 weeks. CONCLUSIONS: The Bioceramic orbital implant represents a new porous orbital implant that has a very regular and extensive interconnected pore system, is as biocompatible as hydroxyapatite, is easy to manufacture, structurally strong, and free of contaminants. It is manufactured with no disruption to marine life ecosystems as may occur in the harvesting of coral for other orbital implants. It is less expensive than currently available hydroxyapatite implants and was approved by the U.S. Food and Drug Administration in April 2000.

The Molteno M-Sphere.

PURPOSE: To analyze a mammalian hydroxyapatite (HA) implant known as the Molteno M-Sphere, recently approved by the Food and Drug Administration of the United States. METHODS: The authors examined the implant macroscopically, with chemical analysis (x-ray powder diffraction, x-ray fluorescence spectrophotometry), and microscopically with scanning electron microscopy. Animal implantation of six Molteno M-Spheres was carried out in six adult male New Zealand albino rabbits. Implant vascularization was evaluated by means of magnetic resonance imaging and histopathologic sectioning. RESULTS: The M-Sphere was found to have multiple interconnected pores throughout with an average pore size of 300 microm to 600 microm. This implant was very light-weight (0.31 g) and fragile. It was made up of pure HA. Magnetic resonance imaging studies showed implant enhancement to its center by 4 weeks after implantation. Histopathologically, fibrovascularization occurred uniformly throughout the 4, 8, and 12-week rabbit implants. CONCLUSIONS: The M-Sphere is an alternative type of HA implant that recently has been reintroduced into the United States for use after enucleation, evisceration, or as a secondary implant. It has multiple interconnected pores allowing central fibrovascularization as early as 4 weeks in a rabbit model. Its light weight and fine trabecular framework, however, are associated with increased implant fragility when compared with other available HA implants (BioEye and FCI3 synthetic HA). The implant requires careful handling because routine handling may damage the implant. The implant is currently approved by the United States Food and Drug Administration.

Brazilian hydroxyapatite implant.

PURPOSE: To evaluate a synthetic hydroxyapatite (HA) (manufactured in Brazil) in a rabbit model. METHODS: Nine New Zealand white rabbits underwent enucleation of one eye followed by implantation of either a 12-mm Brazilian synthetic HA implant or a 12-mm BioEye, wrapped in polyglactin 910 mesh. Magnetic resonance imaging was performed to assess fibrovascular ingrowth 4, 8, and 12 weeks after implantation. Three animals were killed at each of the times for histopathologic examination. The Brazilian implant was also examined chemically and by scanning electron microscopy. RESULTS: The Brazilian HA was found to be heavier than either the BioEye or synthetic FCI3 HA implants. It did not have a visible, regularly arranged interconnected porous architecture. Rather, it had randomly appearing channels apparent on its external and internal surface in addition to large cystic areas within the body of the implant. Scanning electron microscopy revealed the implant to have a microporous architecture in addition to the large channels and cystic cavities. Histopathologically, central vascularization occurred by 4 weeks and was also present at 8 and 12 weeks. In three Brazilian implants an unrecognizable, nonbirefringent material was identified. The cause of it was unclear. Chemical analysis confirmed the implant to consist of pure HA. CONCLUSION: The Brazilian implant is pure HA that appears solid but has randomly arranged channels as well as a microporous architecture that allows vascularization to its center. It is heavier than other available HA implants and has the presence of an unidentified foreign material within it. Although this implant is less expensive and does not require a costly manufacturing process, the structural characteristics of the material do not offer any theoretical or clinical advantages. The implant is only available in Brazil at this time.

Hydroxyapatite implant wrapping materials: analysis of fibrovascular ingrowth in an animal model.

PURPOSE: To compare the influence of seven currently available spherical orbital implant wraps on host fibrovascularization of a hydroxyapatite (HA) orbital implant. METHODS: Five groups of 3 (15 total) adult male New Zealand albino rabbits underwent enucleation with placement of a 12-mm HA implant wrapped in high-porosity expanded polytetrafluoroethylene (e-PTFE), processed bovine pericardium, or processed human pericardium, sclera, or fascia lata. Magnetic resonance imaging before and after the intravenous administration of gadolinium-diethylenetriamine pentaacetic acid (DTPA, 0.1 mol/kg) was performed immediately before exenteration. Five rabbits (one with each of the different implant wraps) were killed at 4, 8, and 12 weeks, and the operated socket was exenterated. Histopathologic sections of the implants were then compared with the results of our previous study using polyglactin 910 mesh and autologous sclera as HA orbital implant wraps. RESULTS: Complete fibrovascularization of all the implants occurred by 12 weeks; however, HA implants wrapped with sclera, polyglactin mesh, and e-PTFE appeared to undergo more rapid fibrovascularization than spheres wrapped with other materials. CONCLUSIONS: Although all of the implant wraps studied may be suitable substitutes for donor sclera, we prefer polyglactin mesh because it is readily available, inexpensive, and without risk of transmissible diseases.

Mucoepidermoid carcinoma of the conjunctiva: a series of three cases.

OBJECTIVE: To detail the clinical presentation and outcomes of currently available treatments for mucoepidermoid carcinoma of the conjunctiva (MCC). DESIGN: Retrospective noncomparative case series. PARTICIPANTS: Three patients ranging from 40 to 63 years of age with MCC participated. INTERVENTION: Excisional biopsies and various therapies were performed. MAIN OUTCOME MEASURES: Clinical and surgical outcomes were measured. RESULTS: Patient 1 is a 55-year-old man with right temporal MCC. He underwent two local excisions with adjuvant cryotherapy and has had no recurrence at 31 months follow-up. Patient 2 is a 63-year-old man with right temporal MCC who underwent fractionated iodine 125 plaque radiotherapy. He had a recurrence approximately 8 months after plaque treatment and subsequently underwent enucleation of the right eye. Clinical follow-up examinations revealed no further recurrence at 17 months. Patient 3 is a 40-year-old woman treated for right MCC with carbon dioxide laser with recurrence at 3 weeks. She subsequently underwent radiation treatment with the development of regional lymph node metastases 16 months later. CONCLUSIONS: MCC is a rare neoplasm that displays an extraordinary capacity for aggressive local invasion. This series of three case reports demonstrates the high recurrence rate of MCC and the response of this tumor to different current modalities of treatment. Extended follow-up is required with this tumor because distant metastases can occur very late.

Complications associated with pegging hydroxyapatite orbital implants.

OBJECTIVE: Prior studies of hydroxyapatite orbital implant complications have primarily focused on complications of the implant itself with only occasional mention of the complications associated with the peg system. This in part may be because of a low rate of pegging and, thus, a small sample size to evaluate. Therefore, a full range of complications that can occur with pegging has not been presented. The objective of this study was to determine the complications associated with pegging and to discuss ways to manage them. DESIGN: Retrospective, noncomparative case series. PARTICIPANTS/INTERVENTION: The authors analyzed all of the complications associated with pegging 165 of a possible 275 hydroxyapatite implants implanted by 2 surgeons over 7 years. MAIN OUTCOME MEASURES: The following data were recorded: type of surgery performed, size of implant used, type of hydroxyapatite used, peg system used, time of pegging, follow-up duration, problems encountered, and treatment. RESULTS: Sixty-two (37.5%) of the 165 patients who had pegged implants were found to have problems with their pegs. Twenty-one (33.8%) of the 62 patients with peg problems had more than 1 peg-related problem. Complications associated with pegging included discharge (37%; 23 of 62), pyogenic granulomas (30.6%; 19 of 62), peg falling out (29%; 18 of 62), poor transfer of movement (11.2%; 7 of 62), clicking (11.2%; 7 of 62), conjunctiva overgrowing peg (4.8%; 3 of 62), poor-fitting sleeve (4.8%; 3 of 62), part of sleeve shaft visible (4.8%; 3 of 62), peg drilled on an angle (4.8%; 3 of 62), hydroxyapatite visible around peg hole (3.2%; 2 of 62), peg drilled off-center (3.2%; 2 of 62), popping peg (3.2%; 2 of 62), and excess movement of peg (3.2%; 2 of 62). The most serious complication occurring in two individuals (3.2%) was implant infection requiring implant removal. CONCLUSION: There are several potential complications that can occur after pegging the hydroxyapatite implant. These problems are generally of a minor nature but often require additional patient visits that would not ordinarily have been required if the peg was not in place. The most serious peg problem is implant infection, which may necessitate implant removal. These potential peg problems should be reviewed with the patient before the procedure is performed.

Topical versus intravenous administration of tranexamic acid: a comparison of intraocular and serum concentrations in the rabbit.

BACKGROUND: Tranexamic acid has been shown to greatly reduce the incidence of secondary hemorrhage when administered orally or intravenously. Topical administration of the drug should result in much lower serum concentrations, with fewer adverse effects. We performed a study to determine whether topical application of tranexamic acid would yield higher intraocular concentrations and lower serum concentrations of drug than intravenous administration. METHODS: Ten New Zealand white rabbits received 25 mg/kg of tranexamic acid intravenously every 8 hours for 3 days. Another group of 10 rabbits received one drop (0.05 mL) of commercially available tranexamic acid solution (100 mg/mL) every 8 hours for 3 days to one eye. Tranexamic acid levels in the aqueous humour, vitreous humour and serum 1 hour after administration of the last dose of drug were determined. RESULTS: Analysis of variance showed that aqueous concentrations of tranexamic acid were significantly higher with topical delivery than with intravenous administration (15 vs. 9 micrograms/mL)(p < 0.05). Serum concentrations were significantly lower following topical administration (9 vs. 19 micrograms/mL)(p < 0.01). The drug was not detected in the vitreous humour in either group. INTERPRETATION: Topical delivery of tranexamic acid may prove to be valuable in yielding therapeutic intraocular concentrations of drug in patients with hyphema while minimizing systemic toxicity.

A synthetic hydroxyapatite implant: the so-called counterfeit implant.

This article evaluates three generations of synthetic hydroxyapatite implants in a rabbit model. Fourteen New Zealand white rabbits received synthetic hydroxyapatite orbital implants (first, second, and third generation). The rabbits underwent enucleation of one eye and then received a 12-mm synthetic hydroxyapatite implant wrapped in Vicryl (polygalactin 910; Ethicon, Inc.) mesh or sclera. Magnetic resonance imaging was conducted to assess host fibrovascularization of the implant 4 and 12 weeks after implantation. Animals were killed at each of these times and the implant was removed for histopathologic examination. Enhancement on magnetic resonance imaging and extent of fibrovascularization by histopathologic examination were assessed. The first-generation synthetic hydroxyapatite (FCI, Issy-Les-Moulineaux, France) was not 100% hydroxyapatite as is the Bio Eye (Integrated Orbital Implants, Inc., San Diego, CA, U.S.A.). It contained 3.2% calcium oxide. The implant was heavier and much less porous than the original Bio Eye implant. Central vascularization eventually occurred but was not extensive. The second-generation implant was more porous than the first, with rapid central vascularization to the center of the implant by 4 weeks. However, the second-generation implant was very fragile and crumbled easily. The second-generation synthetic implant was chemically identical to the original Bio Eye implant with no calcium oxide. The third-generation implant was more porous than its predecessors. When compared side by side with the Bio Eye, a difference in pore uniformity and interconnectivity seems apparent. However, an early extensive vascularization pattern to the center of the implant is seen histopathologically, similar to that with the Bio Eye. Magnetic resonance imaging also shows extensive enhancement as is the case with the Bio Eye. The third-generation synthetic implant is not fragile as was the second-generation implant, and chemically it is identical to the Bio Eye with no calcium oxide present. The third-generation implant is approximately half the price of the original Bio Eye implant.