[Evaluation of dental medical devices: Focus on the definition of needs]. / Évaluation des dispositifs médicaux dentaires pour un appel d'offres : privilégier la haute définition des besoins.

OBJECTIVES: As a university teaching hospital, the call for tender for dental medical devices (dental implants and consumables) is done with the help of a team of hospital pharmacists and users. In order to optimize the definition of needs and evaluation criteria, an exhaustive review of the products was carried out. METHODS: Dental medical devices suppliers were consulted in 2017 for reviewing their products. Their technical, clinical and economic data were compared. The products have been gathered into categories and its results had been submitted to a commission of dental experts of our university hospital for clinical opinion. RESULTS: More than 30,000 references from 30 different suppliers were analyzed (orthodontics, dental implants, membranes and bone substitutes, various dental consumables). Relating to oral implantology, the opinions converged on clinical studies. On the contrary, diverging opinions have been proffered on the systematic use of single-use drills and customized guides for surgery and on the implant's choice. The definition of needs has been specified for orthodontics and consumables. Other criteria played a great role: single packaging (unit doses), product's sterility, paediatric needs, presence of allergens, traceability of devices and supplier diversity. CONCLUSIONS: This review led to the identification of new needs in more precise terms. The complexity and diversity of dental products and techniques requires this careful review and a better collaboration with practitioners.

[Perspective of the transition from reusable instruments to single use ancillary in orthopedic surgery]. / Ancillaires orthopédiques : évolution du matériel restérilisable vers l'usage unique, quels impacts ?

OBJECTIVES: Since 2009, single-use (SU) ancillaries for total knee arthroplasty (TKA) and total hip arthroplasty (THA) have been marketed to replace reusable ancillaries. The concept is not innovative but their use in orthopedics is still uncommon. An assessment has been done for the use of SU ancillary in Assistance publique-hôpitaux de Paris with the consequences for the patient, the surgeon and the hospital. METHODS: A technical and a clinical review has been done with those devices in 2015. The economic and organizational impacts were identified and submitted for opinion to committee experts in orthopedics. RESULTS: Three SU ancillaries are commercialized. No clinical studies are currently available. There is no reimbursement for SU ancillaries whereas reusable ancillaries are included in prosthesis reimbursement price. Although SU ancillaries (TKA and THA) saving costs for sterilization, the annual additional budget estimated for their purchase would approximately be 2.5 times higher. Nevertheless, indirect savings could be also considered in the long-term period (global costs for sterilization, volume effect…). For the same quality, according to the experts, organizational impacts are low for the patient and the surgeon but potentially important for the hospital, the nursing and pharmaceutical staff, and logistical activities. CONCLUSIONS: On logistic, clinical and financial aspects, SU ancillaries need more evaluation. The switch to SU ancillaries allows saving sterilization costs and time, and provided an immediate mobilization of the equipment but their interest must be demonstrated by clinical and economic data.

[Review of patient-specific instrumentation for total knee prosthesis]. / Revue des guides personnalisés à usage unique dans les prothèses totales de genou.

OBJECTIVES: Single use patient-specific instruments (PSI) for total knee prosthesis are introduced as a new alternative to conventional ancillaries and computer assisted surgery by improving implants positioning. An exhaustive review was carried out to identify their specific characteristics, with their advantages and disadvantages. METHODS: Medical devices suppliers were consulted in 2015 for reviewing their PSI. Their technical, clinical and economic data were compared. The results had been submitted to an orthopaedics expert commission of our university hospital for clinical and financial opinion. RESULTS: Ten companies have provided the documentation for the analysis. PSI are manufactured by suppliers using a three dimensional printing method based on CT scans or MRI images. PSI are produced according to the surgeon's preferences after a preliminary data check, which can be performed by the suppliers' engineers, the surgeon and automatic calculation. Five suppliers can produce sterile PSI with optional delivery of 3D bone models. According to the experts, the studies failed to demonstrate the superiority of a PSI or hospital economic gain. The prices listed remain high and operating room time is not always significantly reduced. CONCLUSIONS: With the development of personalized medicine, the role of PSI grows in importance. They facilitate the surgeon's work by fully respecting the anatomy. These systems offer an interesting perspective in their technical and pedagogical aspects. But it seems premature to take them into routine use given the low number of high-level studies that were currently done.

Endoscopic injection of adrenaline for severe peptic ulcer haemorrhage in high surgical risk patients.

Endoscopic adrenaline-hypertonic injection was attempted in 40 patients admitted for oesophagogastroduodenal ulcer haemorrhage unresponsive to conventional medical treatment and presenting with severe underlying disease or advanced age (less than 80 years). The results were compared with our own historical controls (43 patients) treated by conventional therapy, meeting the same inclusion criteria. Permanent haemostasis was achieved in 32 patients in the injection group and 30 in the control group (NS) but emergency surgery was less frequent in the injection group (2 vs 25, p less than 0.001). Blood transfusion requirements were less in the injection group (8.5 +/- 6.2 vs 10.2 +/- 5.4, p less than 0.05) but length of hospital stay was not really different (15.7 days +/- 9.3 vs 20.9 +/- 14.4). Unfortunately, mortality was not reduced in the injection group (14/40 vs 17/43). Two lethal complications attributable to injection treatment occurred. This treatment could represent an alternative to conventional haemostatic treatment in high surgical risk patients with severe clinical bleeding, avoiding emergency surgery. In spite of the fact that we selected high-risk patients, endoscopic treatment was not able to lower the mortality (about 37%). Due to severe unpredictable side effects and potential risks of long-term massive rebleeding, this treatment should be performed electively in patients with severe clinical bleeding, as first line treatment when surgical risk factors exist or immediately before surgery in low risk patients.

Which patients taking non-aspirin non-steroidal anti-inflammatory drugs bleed? A case-control study.

OBJECTIVE: To identify risk factors for gastrointestinal bleeding (GIB) among users of non-aspirin, non-steroidal anti-inflammatory drugs (NANSAIDs). DESIGN: Case-control study. PARTICIPANTS: A total of 120 patients aged over 60 years and using NANSAIDs were hospitalized between January 1988 and September 1992 for GIB related to erosions or ulceration of the gastroduodenal mucosa. A group of 100 general practitioners selected two controls matched for age and sex, receiving NANSAIDs and without GIB, for each patient. METHODS: The same questionnaire was used to interview patients and controls about their medical history, use of NANSAIDs and other drugs, alcohol and tobacco use, recent stress and nutritional status. RESULTS: The adjusted odds ratios (OR) for the risk factors related to the pattern of NANSAID use were 3.39 [95% confidence interval (CI) 1.77-6.47] when the intake of NANSAIDs was followed by decubitus, 3.00 (95% CI 1.54-5.85) when NANSAIDs were taken before a meal, 6.05 (95% CI 2.10 17.43) with a high dose of NANSAIDs, 5.87 (95% CI 2.00-17.25) with recent NANSAID use, 3.35 (95% CI 1.47-7.64) with NANSAIDs associated with aspirin use, 3.46 (95% CI 1.15-10.36) with more than one NANSAID, and 10.70 (95% CI 1.06-108.07) when NANSAIDs were associated with corticosteroids. The patient-related risk factors and their OR were 9.94 (95% CI 3.29-24.28) for irregular food intake, 3.94 (95% CI 1.45-10.69) for previous peptic ulcer, 3.71 (95% CI 1.26-10.89) for recent weight loss, 4.44 (95% CI 1.48-13.30) for heavy alcohol abuse, 2.92 (95% CI 1.36-6.26) for recent stress and 5.26 (95% CI 1.19-23.33) for a past history of GIB. CONCLUSION: This study identified a group at 'high risk' for GIB which would benefit from the development of a prophylactic therapy.

["Ambulatory" ischemic colitis. Clinical course and etiologic features in 88 cases]. / Colites ischémiques "ambulatoires". Aspects cliniques, évolutifs et étiologiques de 88 cas.

From January 1983 to December 1988, 88 consecutive patients with ambulatory ischemic colitis without severe disease or surgical operation were observed. The diagnosis was established in all cases by endoscopy, and in 64 cases by histologic examination. The study included 55 women and 33 men with a mean age of 65.4 years (22-90). Symptoms included: abdominal pain (73 percent), diarrhea (60 percent) and bloody stools (85 percent). The sequence abdominal pain-diarrhea-bloody stools was noted in 41 percent of cases. Most cases of colitis were located in the sigmoid and left colon. The immediate course was uneventful in 81 patients. Six patients underwent surgery and of these, three died. The mortality rate was 4.5 percent (4 cases). Long-term outcome was known in 41 cases. None of the patients were symptomatic, but a moderate secondary stenosis was noted in 4 of 31 patients who underwent endoscopic or radiological follow-up examination. In 80 cases, one or more potentially etiological factors were observed including vascular obstruction (32 cases), low-flow states (27 cases), and drugs (78 cases). Twenty patients were taking non steroidal anti-inflammatory drugs (23 percent). Drug treatment was recent in 10 cases, and in four, it was the only possible etiological factor. This suggests the responsibility of anti-inflammatory drugs in the onset of certain cases of ischemic colitis.

[Upper gastrointestinal hemorrhage caused by anti-inflammatory agents]. / Hémorragies digestives hautes sous anti-inflammatories.

The aim of this study was to describe the clinical and evolutive characteristics of gastroduodenal bleeding occurring in patients receiving nonsteroidal anti-inflammatory (NSAI) drugs, containing salicylates or not, and to determine the relative toxicity of the NSAI drugs without salicylates. Eight hundred and fourty-five consecutive patients with upper gastrointestinal bleeding related to endoscopically proven peptic ulcer or gastroduodenal erosions were admitted between 1983 and June 1987 to an intensive care unit for digestive tract hemorrhage. Of these, 267 were using anti-inflammatory drugs; 151 (56 p. 100) were taking NSAI drugs other than salicylates, 97 salicylates (36 p. 100) and 10, steroids (4 p. 100). Patients taking nonsteroidal drugs without or with salicylates were compared with patients bleeding from gastroduodenal ulcer or erosion not receiving anti-inflammatory therapy. Patients receiving nonsteroidal drugs not containing salicylates were older (70 p. 100 over 65 years of age vs 46 p. 100, p less than 0.001) and the proportion of female patients was greater (54 p. 100 vs 33 p. 100, p less than 0.001) than in the other group. No significant difference was observed with regard to the following parameters: percentage of gastric lesions, concomitant anticoagulant therapy, need for surgical hemostasis, or mortality. Patients taking aspirin had more gastric lesions (75 p. 100 vs 64 p. 100, p less than 0.05) and less need for surgical hemostasis (7 p. 100 vs 15 p. 100, p less than 0.05); the other parameters did not differ. NSAI drugs other than salicylates were taken more often for osteoarthritis than salicylates (33.6 p. 100 vs 17.4 p. 100, p less than 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

[Lansoprazole versus ranitidine in the prevention of early recurrences of digestive hemorrhages from gastroduodenal ulcers. Randomized double-blind multicenter study]. / Lansoprazole versus ranitidine dans la prévention des récidives précoces des hémorragies digestives ulcéreuses gastro-duodénales. Etude multicentrique randomisée en double aveugle.

Strong inhibition of acid secretion could be able to decrease gastric and duodenal ulcer early rebleeding. OBJECTIVE--The aim of this double blind randomized trial was to compare early rebleeding rates of 2 groups of patients treated with ranitidine (600 mg/day) or lansoprazole (60 mg/day) per os for 6 consecutive days. METHODS--Seventy five patients with a high risk of rebleeding (clinical and endoscopical criteria) were included in this trial. These ulcers were Ia (n = 10), Ib (n = 20), IIa (n = 13), IIb (n = 32) in Forrest classification. RESULTS--Nineteen out of 75 patients rebled (25.3%): 11 out of 37 (30%) and 8 out of 38 (21%) in the ranitidine and lansoprazole groups respectively. Rates of rebleeding were 10%, 12.5%, 36% and 29% respectively in the ulcers grade Ia (previously treated with endoscopic sclerosis), Ib, IIa and IIb in the Forest classification. CONCLUSION--The rates of rebleeding were not statistically different in the 2 groups of treatment. The high rebleeding rates observed with Forrest IIa and IIb and duodenal ulcers support the need of haemostatic endoscopic therapy associated to antisecretory treatment in such patients.

[Manometric study of two Roux-en-Y hepatico-jejunostomy]. / Etude manométrique de deux anses en Y d'hépatico-jéjunostomie.

The aim of this study was to describe (during the fasting state in two patients the motor activity of the limb in Roux-en-Y hepatico-jejunostomy). In the two patients, the limb was created 15 years and 15 days prior to the study respectively. Recordings were performed with a low compliance pneumohydraulic system below the jejuno-jejunal anastomosis then in the limb. Motor studies in the limb were coupled with recordings carried out in the duodenum. In both patients, the regular occurrence of a typical phase III (PIII) activity was demonstrated in the limb whereas no retrograde or abnormal motor patterns were found. PIIIs in the limb were uncoordinated with duodenal PIIIs. Trimebutine, given intravenously, induced a typical PIII activity in the duodenum and the limb simultaneously. Spontaneous or trimebutine-induced PIIIs in the limb had a slower migration velocity (p less than 0.01) than duodenal PIIIs. Lastly, we were unable to record PIIIs in the distal jejunum below the jejuno-jejunal anastomosis despite the lack of associated abnormal motor patterns. This study demonstrates that a normally propagated PIII activity can be observed in the limb in Roux-en-Y hepatico-jejunostomy immediately or several years after the surgical procedure.

[Digestive hemorrhage caused by rupture of esophageal varices. Analysis of 47 emergency surgeries]. / Hémorragie digestive par rupture de varices oesophagiennes. Analyse de quarante-sept interventions en urgence.

Between 1 January 1984 and 31 December 1986, 47 patients out of a total of 228 patients admitted to hospital with endoscopy-proven bleeding esophageal varices, underwent an emergency operation. The indications were massive hemorrhage in 29 patients, and rebleeding early after a first serious episode in 18 patients. Four patients underwent early reoperation for recurrent variceal bleeding. Thirty-seven porto-caval shunts, 10 esophageal transections, 3 proximal gastric resections and 1 exploratory laparotomy were performed. The early results were satisfactory in 53.2% of the patients; operative morbidity and mortality were 19.1% and 27.7% respectively. Four patients died from gastric variceal bleeding soon after esophageal transection. Operative mortality was greater when the patient was Child C or operated for massive hemorrhage. Survivors were followed for at least 12 months. Two patients died from shunt occlusion and recurrent variceal bleeding. No severe encephalopathy was reported. Analysis of the results suggest that porto-caval shunt is indicated in Child A or B patients, particularly with recurrent variceal bleeding soon after a first episode controlled medically.

[In vitro changes induced by phenylmercury nitrate on fungi causing keratitis. Scanning electron microscopy study]. / Modifications induites in vitro par le nitrate de phénylmercure sur des champignons responsables de kératites. Examen en microscopie électronique à balayage.

Antifungal activity of phenylmercury nitrate was studied on fungi from keratitis. Important deterioration and bursting were observed with 2 mg/100 ml phenylmercury nitrate concentration on Aspergillus flavus, Scedosporium and Candida albicans spores.

[Hepato-splenic candidiasis in patients treated for leukemia]. / Candidose hépato-splénique chez les malades traités pour leucémie.

In patients with acute leukaemia, Candida infection may affect exclusively the liver and the spleen. Two such cases were revealed by persistent fever despite correction of bone marrow aplasia, abdominal pain, anicteric cholestasis and hypodense areas at computerized tomography suggesting hepatosplenic abscesses. Surgical liver biopsy confirmed the fungal infection and showed images of granuloma, mycelial filaments and yeasts; cultures were usually negative. The severity of these infections requires an early treatment, but amphotericin B is not very effective. Our two patients were cured after treatment with fluoconazole completed, in one of them by splenectomy.

[Cryptococcal whitlow in a HIV positive patient]. / Panaris cryptococcique chez un malade VIH positif.

INTRODUCTION: Cutaneous cryptococcosis is a systemic fungal disease; it is commonly observed in immunocompromised patients. OBSERVATION: We report the case of a cryptococcal whitlow in an HIV positive patient. The mycologic culture of the cutaneous lesion was positive for Cryptococcus neoformans serotype D. The detection of the blood antigen was positive but there was no pulmonary nor central nervous system involvement. The lesions cured with fluconazole (400 mg/day during 2 months and 200 mg/day after). DISCUSSION: This unusual clinical presentation of cutaneous cryptococcosis has never been reported in an HIV positive patient. As the dermatologic manifestations of cryptococcosis are polymorphous mycologic examination of skin lesions is very important.

[Human dirofilariasis: a new French case of Dirofilaria repens]. / Dirofilariose humaine: un nouveau cas français à Dirofilaria repens.

Dirofilariosis is an endemic filarial parasitic disease in the Mediterranean basin, unfamiliar in France. Its incidence and geographic area are increasing due to global warming. Dogs and cats are the usual hosts, but humans may be accidentally infected. We reported the 91st case of French dirofilariosis, contracted in Camargue (South France) which appeared as a subcutaneous abdominal nodule. Ultrasound strongly guided the diagnosis by showing a linear structure moving in a fibrocystic structure. Surgical excision confirmed the diagnosis of species (Dirofilaria repens) and this remains the only curative treatment.