Paradigm shifts in multiple sclerosis management: Implications for daily clinical practice.

Multiple sclerosis (MS) is the most common chronic inflammatory neurological disease. The emergence of disease-modifying therapies (DMTs) has greatly improved disease activity control and progression of disability in MS patients. DMTs differ in their mode of action, route of administration, efficacy, and safety profiles, offering multiple options for clinicians. Personalized medicine aims at tailoring the therapeutic strategy to patients' characteristics and disease activity but also patients' needs and preferences. New therapeutic options have already changed treatment paradigms for patients with active relapsing MS (RMS). The traditional approach consists in initiating treatment with moderate-efficacy DMTs and subsequently, escalating to higher-efficacy DMTs when there is evidence of clinical and/or radiological breakthrough activity. Recent real-world studies suggest that initiation of high-efficacy DMTs from disease onset can improve long-term outcomes for RMS patients. In this article, we review different treatment strategies and discuss challenges associated with personalized therapy.

Secondary progressive multiple sclerosis: A national consensus paper on diagnostic criteria.

BACKGROUND: In clinical practice, the diagnosis of secondary progressive multiple sclerosis (SPMS) is often delayed, retrospective and non-reproducible, as there are no consensus criteria that define the advent of SPMS. Early identification of SPMS is essential to improve patient care. METHODS: Eight regional board meetings in France involving 56 multiple sclerosis (MS) experts (neurologists) were convened to discuss diagnostic criteria for SPMS. Subsequently, a national board meeting of 13 neurologists (with an expert representing each geographical region) was held to review points of convergence or divergence between regions and to develop a national consensus document. RESULTS: Based on the discussions from the regional boards, the MS experts at the national board retained the worsening of the EDSS score, with compatible clinical features, as the only consensus criterion for the diagnosis of SPMS in clinical practice. The patient should have experienced during at least the previous 6 months and in the absence of any relapse, a worsening in the EDSS score of +1.0 point (if the previous EDSS was≤5.0) or of +0.5 point (if the previous EDSS was≥5.5), with a pyramidal or cerebellar functional system score≥2 and without setting a minimum EDSS score; or, in case of a stable EDSS score≥4.0, a worsening of a functional score. This worsening should be confirmed within 3 to 6 months. According to the MS experts, the patient's age, duration of illness and a minimal threshold EDSS score are only risk factors for transition to SPMS. Patient reports during consultation and cognitive impairment are important warning signs, which should trigger an objective assessment with specific tests or closer monitoring. Clinical relapse and/or MRI activities are non-discriminatory for making the diagnosis of SPMS. CONCLUSIONS: The experts defined precise diagnostic criteria adapted to clinical practice for earlier identification of SPMS, paving the way for better management of this stage of the disease.

Acute idiopathic optic neuritis: not always benign.

BACKGROUND AND PURPOSE: Few recent data are available concerning idiopathic optic neuritis (ON). We aimed to describe a large cohort of patients with idiopathic ON. We compared this cohort with patients with ON related to myelin oligodendrocyte glycoprotein (MOG) or ON related to aquaporin-4 (AQP4) antibodies. METHODS: This was a monocentric retrospective observational study. Inclusion criteria for idiopathic ON were as follows: age ≥ 16 years, follow-up of at least 2 years, negative for antibodies against MOG and AQP4 immunoglobulin G, and no magnetic resonance imaging (MRI) lesions suggestive of demyelination (two brain MRI scans, one at baseline and one during follow-up, and one spinal cord MRI scan). RESULTS: Among 23 patients with idiopathic ON (female, 82.6%; median age, 36 years; median follow-up time, 41.4 months), 56.5% had recurrent ON (median time to a second ON episode, 6 months). The final visual acuity in this group (median, 0; mean, 0.43; range, 0-3) was similar to that in the AQP4 group (n = 18; P-value after Bonferroni correction = 0.936) but worse than that in the MOG group (n = 25; P-value after Bonferroni correction = 0.019). At the last evaluation, visual acuity levels were ≤0.5 and <0.2, respectively, in 36.8% and 21% of the idiopathic ON group, 58.3% and 26.7% of the AQP4 group, and 0% and 0% of the MOG group. CONCLUSION: The recovery of visual acuity among patients with idiopathic ON was poor, similar to that observed in the AQP4 group.

Etiologies of acute demyelinating optic neuritis: an observational study of 110 patients.

BACKGROUND AND PURPOSE: New criteria for the diagnosis of multiple sclerosis (MS) and discovery of myelin oligodendrocyte glycoprotein (MOG) or aquaporin-4 (AQP4) antibodies (Abs) have changed the management of optic neuritis (ON). Our aim was to specify, in view of these recent advances, the etiologies of acute demyelinating ON for consecutive patients. METHODS: Retrospective database analysis was undertaken of consecutive adult patients with acute ON admitted from 1 December 2014 to 31 January 2016. Diagnosis of MS was made according to the 2010 McDonald criteria. Patients with Abs to AQP4 or MOG were classified as ON-AQP4 and ON-MOG, respectively. Patients who did not fulfill the diagnostic criteria and were negative for AQP4 and MOG Ab tests were classified as having idiopathic ON. RESULTS: Of 110 patients assessed, 78 had ON related to MS (70.9%). All patients without MS were tested for AQP4 and MOG Abs: 11 had MOG Ab (10%), 5 had AQP4 Ab (4.5%) and 16 were considered as having idiopathic ON (14.5%). Presence of intrathecal IgG oligoclonal bands was strongly associated with MS (mean, 88.4% vs. 34.4% in patients without MS; after Bonferroni correction, P < 0.0001). CONCLUSIONS: Optic neuritis related to MOG Ab was the second cause identified of demyelinating ON in our center. Idiopathic ON was as frequent as both ON-AQP4 and ON-MOG combined.

A two-phase sampling survey for nonresponse and its paradata to correct nonresponse bias in a health surveillance survey.

BACKGROUND: The decline in participation rates in surveys, including epidemiological surveillance surveys, has become a real concern since it may increase nonresponse bias. The aim of this study is to estimate the contribution of a complementary survey among a subsample of nonrespondents, and the additional contribution of paradata in correcting for nonresponse bias in an occupational health surveillance survey. METHODS: In 2010, 10,000 workers were randomly selected and sent a postal questionnaire. Sociodemographic data were available for the whole sample. After data collection of the questionnaires, a complementary survey among a random subsample of 500 nonrespondents was performed using a questionnaire administered by an interviewer. Paradata were collected for the complete subsample of the complementary survey. Nonresponse bias in the initial sample and in the combined samples were assessed using variables from administrative databases available for the whole sample, not subject to differential measurement errors. Corrected prevalences by reweighting technique were estimated by first using the initial survey alone and then the initial and complementary surveys combined, under several assumptions regarding the missing data process. Results were compared by computing relative errors. RESULTS: The response rates of the initial and complementary surveys were 23.6% and 62.6%, respectively. For the initial and the combined surveys, the relative errors decreased after correction for nonresponse on sociodemographic variables. For the combined surveys without paradata, relative errors decreased compared with the initial survey. The contribution of the paradata was weak. CONCLUSION: When a complex descriptive survey has a low response rate, a short complementary survey among nonrespondents with a protocol which aims to maximize the response rates, is useful. The contribution of sociodemographic variables in correcting for nonresponse bias is important whereas the additional contribution of paradata in correcting for nonresponse bias is questionable.

Impact of diabetes mellitus onset on sickness absence from work--a 15-year follow-up of the GAZEL Occupational Cohort Study.

AIMS: Previous studies do not provide an accurate estimate of the burden of diabetes on sickness absence. The aim of this study was to measure the impact of diabetes onset on absenteeism starting from the earliest occurrence of the disease. METHODS: The authors used data from a subsample of the French GAZEL cohort of 506 employees with incident diabetes and 2530 matched diabetes-free participants. Medically certified sickness absence data were obtained from company records (1989-2007). Number of sickness absence days and incidence rates of overall and cause-specific absence spells were compared according to diabetes status across three 5-year periods ranging from 10 years before to 5 years after onset of cases' diabetes. RESULTS: The mean number of sickness absence days was persistently higher in participants with diabetes compared with those without diabetes. This difference increased from 16.4 days (95% confidence interval 7.2-25.5) during the 5-year period preceding diabetes onset to 28.5 days (95% CI 16.1-40.9) during the following 5-year period (P = 0.04). This was due to a steeper relative increase in the incidence of long (but not short) absence spells in participants with diabetes versus those without diabetes [incidence rate ratios 1.33 (95% CI 1.08-1.64) and 1.75 (95% CI 1.43-2.14), respectively; P = 0.02]. Diabetes onset was associated with increased rates of circulatory and metabolic absence spells. CONCLUSIONS: Onset of diabetes is associated with a substantial increase in sickness absence. This suggests that in addition to its burden on work cessation, diabetes weighs heavily on working ability among people who manage to remain employed.

[Intracranial hypertension and lupus]. / Hypertension intracrânienne et lupus.

INTRODUCTION: Idiopathic intracranial hypertension (IH) occurs most commonly in women and overweight subjects. It must be reported associated to general diseases, like systemic lupus erythematosus (SLE). METHODS: We report an observation of a patient with lupus complicated by glomerulonephritis and IH. OBSERVATION: A 29 years old woman, without overweight, was followed for a SLE with skin and arthritic involvement . Four years after onset, a renal complication appeared with severe nephrotic syndrome. Six weeks after, bilateral papillar oedema was discovered, revealing an IH, as the patient was treated by oral steroids at 1mg/kg/d and bimonthly intravenous cyclophosphamide. The patient was completely asymptomatic. Brain MRI with veino-RMN was normal, without cerebral venous thrombosis. Lumbar punction showed an elevated opening pressure of 30,5 cmH(2)0 but with normal cerebrospinal fluid (CSF) contents. Evacuation of 30 mL of CSF and immunosuppressive treatment allowed symptoms regression. DISCUSSION/CONCLUSION: Twenty-seven cases of IH associated to SLE with nephritis have been reported in literature. Young women are more frequently involved with in half of cases a diffuse proliferative glomerulonephritis. Predisposing factors, like anaemia, must be associated. IH allows SLE diagnose in more than the third of the cases. Then, SLE has to be searched as an etiology of IH, in particular in non-obese patients and when nephritis is associated.

Optimizing 3D FLAIR to detect MS lesions: pushing past factory settings for precise results.

BACKGROUND: To assess the diagnostic value of three 3D FLAIR sequences with differing repetition-times (TR) at 3-Tesla when detecting multiple sclerosis (MS) lesions. METHODS: In this prospective study, approved by the institutional review board, 27 patients with confirmed MS were prospectively included. One radiologist performed manual segmentations of all high-signal intensity lesions using three 3D FLAIR data sets with different TR of 4800 ms ("FLAIR4800"), 8000 ms ("FLAIR8000") and 10,000 ms ("FLAIR10,000") and two radiologists double-checked it. The main judgment criterion was the overall number of lesions; secondary objectives were the assessment of lesion location, as well as measuring contrast-to-noise ratio (CNR) and signal-to-noise ratio (SNR). A non-parametric Wilcoxon's test was used to compare the differing FLAIR. RESULTS: The FLAIR8000 and FLAIR10,000 detected significantly more overall lesions per patient as compared with the FLAIR4800 [116.1 (± 61.7) (p = 0.02) and 115.8 (± 56.3) (p = 0.03) versus 99.2 (± 66.9), respectively]. The FLAIR8000 and FLAIR10,000 detected four and eight times more cortical or juxta-cortical lesions per patient as compared with FLAIR4800 [1.6 (± 2.2) (p = 0.001) and 4.1 (± 5.9) (p = 6 × 10-5) versus 0.4 (± 1.1), respectively]. CNR was significantly correlated to the TR value. It was significantly higher with FLAIR10,000 than it was with FLAIR8000 and FLAIR4800 [16.3 (± 3.5) versus 15 (± 2.4) (p = 0.01) and 12 (± 2.2) (p = 2 × 10-6), respectively] CONCLUSION: An optimized 3D FLAIR with a long TR significantly improved both overall lesion detection and CNR in MS patients as compared to a 3D FLAIR with factory settings.

A 3T Phase-Sensitive Inversion Recovery MRI Sequence Improves Detection of Cervical Spinal Cord Lesions and Shows Active Lesions in Patients with Multiple Sclerosis.

BACKGROUND AND PURPOSE: Magnetic Resonance Imaging is the modality of choice to detect spinal cord lesions in patients with Multiple Sclerosis (MS). However, this imaging is challenging. New sequences such as phase-sensitive inversion recovery have been developed to improve detection. Our aim was to compare a 3D phase-sensitive inversion recovery and a conventional imaging dataset including postcontrast T2WI and T1WI to detect MS spinal cord lesions. MATERIALS AND METHODS: This retrospective single-center study included 100 consecutive patients with MS (mean age, 41 years) from January 2015 to June 2016. One senior neuroradiologist and 1 junior radiologist blinded to clinical data checked for new spinal cord lesions, individually analyzing conventional and 3D phase-sensitive inversion recovery datasets separately, placing a 3-week delay between the 2 readings. A consensus reading was done with a third senior neuroradiologist. A Wilcoxon test was used to compare the 2 imaging datasets. Intra- and interobserver agreement was assessed by the κ coefficient. RESULTS: 3D phase-sensitive inversion recovery detected significantly more lesions than conventional imaging (480 versus 168, P < .001). Eleven patients had no detected lesions on T2WI, whereas 3D phase-sensitive inversion recovery detected at least 1 lesion. All postcontrast T1WI enhancing lesions were also visible on 3D phase-sensitive inversion recovery. The signal-to-noise ratio was significantly higher using 3D phase-sensitive inversion recovery (0.63 versus 0.46, P = .03). Mean reading confidence was significantly higher using 3D phase-sensitive inversion recovery. Inter- and intraobserver agreement was good for both datasets. CONCLUSIONS: Our study showed that 3D phase-sensitive inversion recovery significantly improved detection of cervical spinal cord lesions, including both enhancing and nonenhancing lesions in patients with MS.

Disease severity, self-reported experience of workplace discrimination and employment loss during the course of chronic HIV disease: differences according to gender and education.

OBJECTIVES: Evidence for the existence of a harmful effect of chronic disease on employment status has been provided. Although this effect of chronic illness on employment has been reported to be higher among the groups with the lowest position on the labour market, the mechanisms of such inequalities are poorly understood. The present study aimed at investigating social inequalities in the chances of maintaining employment during the course of HIV infection and at examining the correlates of such inequalities. METHODS: The authors used data from a national representative sample of people living with HIV in France (ANRS-EN12-VESPA survey). Retrospective information on social trajectory and disease characteristics from the time of HIV diagnosis was available. The risk of employment loss associated with indicators of disease severity and HIV-related workplace discrimination was computed over time since HIV diagnosis according to sociodemographic and occupational factors, using Cox proportional hazards models. RESULTS: Among the 478 working-age participants diagnosed as being HIV-infected in the era of multitherapies and employed at the time of HIV diagnosis, 149 experienced employment loss. After adjusting for sociodemographic and occupational factors, disease severity and self-reported HIV-related discrimination at work were significantly associated with the risk of employment loss in a socially-differentiated manner: advancement in HIV disease was associated with an increased risk of employment loss among women (HR 4.45, 95% CI 2.10 to 9.43) but not among men; self-reported experience of HIV-related discrimination at work was associated with an increased risk of employment loss among individuals with a primary/secondary educational level (HR 8.85, 95% CI 3.68 to 21.30) but not among those more educated. CONCLUSIONS: Chronic HIV disease affects the chances of maintaining employment in a socially-differentiated manner, resulting in increasing inequalities regarding workforce participation. Disease severity and workplace HIV-related discrimination, particularly affecting the employment status of the most socioeconomically disadvantaged, may play a major role.

Improved Detection of New MS Lesions during Follow-Up Using an Automated MR Coregistration-Fusion Method.

BACKGROUND AND PURPOSE: MR imaging is the key examination in the follow-up of patients with MS, by identification of new high-signal T2 brain lesions. However, identifying new lesions when scrolling through 2 follow-up MR images can be difficult and time-consuming. Our aim was to compare an automated coregistration-fusion reading approach with the standard approach by identifying new high-signal T2 brain lesions in patients with multiple sclerosis during follow-up MR imaging. MATERIALS AND METHODS: This prospective monocenter study included 94 patients (mean age, 38.9 years) treated for MS with dimethyl fumarate from January 2014 to August 2016. One senior neuroradiologist and 1 junior radiologist checked for new high-signal T2 brain lesions, independently analyzing blinded image datasets with automated coregistration-fusion or the standard scroll-through approach with a 3-week delay between the 2 readings. A consensus reading with a second senior neuroradiologist served as a criterion standard for analyses. A Poisson regression and logistic and γ regressions were used to compare the 2 methods. Intra- and interobserver agreement was assessed by the κ coefficient. RESULTS: There were significantly more new high-signal T2 lesions per patient detected with the coregistration-fusion method (7 versus 4, P < .001). The coregistration-fusion method detected significantly more patients with at least 1 new high-signal T2 lesion (59% versus 46%, P = .02) and was associated with significantly faster overall reading time (86 seconds faster, P < .001) and higher reader confidence (91% versus 40%, P < 1 × 10-4). Inter- and intraobserver agreement was excellent for counting new high-signal T2 lesions. CONCLUSIONS: Our study showed that an automated coregistration-fusion method was more sensitive for detecting new high-signal T2 lesions in patients with MS and reducing reading time. This method could help to improve follow-up care.

Longitudinal study of associations between perceived health status and self reported diseases in the French Gazel cohort.

STUDY OBJECTIVE: Although perceived health status is an indicator widely used in epidemiological studies, its relation to various diseases is not well known. The objective of this study is to examine these relations in detail. DESIGN: Marginal models used for a longitudinal study of the association between three health scales and 47 diseases among 12 164 men and 44 diseases among 4415 women. SETTING: French Gazel cohort during the period from 1991 to 1996. MAIN RESULTS: The general health status scale was significantly associated with 43 diseases among men, and 31 among women. Some of these significantly associated diseases were physical (for example, cancer and cerebrovascular accident) and others, psychological (for example, depression). The mental fatigue scale was more specifically associated with psychological disorders, including sleep problems, depression, and nervous diseases. Moreover, modifications in subjects' assessment of their health from one year to the next were generally associated with modifications in reported diseases. CONCLUSION: Although the mechanism that relates the presence of a disease to perceived health status remains in question, these results show clearly that there is a close association between these two domains that justifies the use of perceived health as a proxy for self reported diseases.

Occupational mobility and risk factors in working men: selection, causality or both? Results from the GAZEL study.

OBJECTIVE: To explore the relation between risk factors (RF) and occupational mobility in working men. SETTING: 20 000 volunteers working at the French National Electricity and Gas Company (GAZEL cohort). PARTICIPANTS: Men aged 43 to 53 years in 1992. DESIGN: Three designs were used for analysis. (1) The association between occupational mobility experienced before 1992 and RF reported at that date was analysed among 10 383 men. (2) The predictive role of RF on occupational mobility over 1992-1999 was studied in a subsample of 4715 men. (3) Reciprocally, occupational mobility in 1985-1992 was analysed in relation to RF changes over 1993-1999. MAIN OUTCOME MEASURES: Self reported smoking status, excessive alcohol consumption, arterial hypertension, and overweight. Occupational mobility defined by any upward transition between senior executives and professionals/middle executives/employees, and workers. RESULTS: (1) Cross sectionally, non-mobile men as their entry into the company had a higher risk of being smokers, excessive alcohol drinkers, and overweight in 1992 than mobile men. (2) Longitudinally, smokers and excessive alcohol drinkers in 1992 had a higher risk of non-mobility than, respectively, non-smokers and non-excessive alcohol drinkers. (3) Non-mobile men in 1985-1992 had a higher risk of becoming smokers, excessive alcohol drinkers, and hypertensive in 1993-1999 than upwardly mobile men. CONCLUSION: These results suggest a complex relation between RF and occupational mobility. A high level of RF, particularly health behaviours, might account for a selection process reducing upward occupational mobility. In turn, a lack of upward occupational mobility might be associated with an increased incidence of RF.

Using a representative sample of workers for constructing the SUMEX French general population based job-exposure matrix.

BACKGROUND: Job-exposure matrices (JEMs) applicable to the general population are usually constructed by using only the expertise of specialists. AIMS: To construct a population based JEM for chemical agents from data based on a sample of French workers for surveillance purposes. METHODS: The SUMEX job-exposure matrix was constructed from data collected via a cross-sectional survey of a sample of French workers representative of the main economic sectors through the SUMER-94 survey: 1205 occupational physicians questioned 48 156 workers, and inventoried exposure to 102 chemicals. The companies' economic activities and the workers' occupations were coded according to the official French nomenclatures. A segmentation method was used to construct job groups that were homogeneous for exposure prevalence to chemical agents. The matrix was constructed in two stages: consolidation of occupations according to exposure prevalence; and establishment of exposure indices based on individual data from all the subjects in the sample. RESULTS: An agent specific matrix could be constructed for 80 of the chemicals. The quality of the classification obtained for each was variable: globally, the performance of the method was better for less specific and therefore more easy to assess agents, and for exposures specific to certain occupations. CONCLUSIONS: Software has been developed to enable the SUMEX matrix to be used by occupational physicians and other prevention professionals responsible for surveillance of the health of the workforce in France.

Past occupational exposure to asbestos among men in France.

OBJECTIVES: This study aimed at reconstructing changes in the frequency and levels of occupational asbestos exposure in France over the past century. METHODS: Work histories were collected during 11 population-based case-referent studies recently carried out in France, and an asbestos-specific job-exposure matrix including 10 625 jobs was used to estimate indices of past occupational asbestos exposure. The results were estimated from a sample of 4287 subjects, bootstrapped 200 times. RESULTS: The distribution of socioeconomic categories within the sample was compared with that of the general population in 1954, 1962, 1968, 1975, and 1982. The proportion of blue-collar workers was similar. The highest proportion of exposed subjects was found between 1950 and 1980. Around 10% of each 10-year age class was exposed to asbestos. For those born in 1930-1939, 15.2% was exposed between the ages of 20 and 29 years. For each age class born in 190-1939, the proportion exposed at least once by 60 years of age ranged from 18.2% to 24.5 % and, of those exposed, the cumulative duration of exposure ranged from 11.3 to 15.4 years by the age of 60 years. A population exposure index showed that the heaviest exposure occurred between 1960 and 1970 and that the age classes born between 1920 and 1929 were the most heavily exposed. Time trends showed that the mean value of this index for the men aged 20-59 years reached a peak in the 1960s and then decreased. CONCLUSIONS: This study presents data of reasonable validity about occupational asbestos exposure in France and its trends over the past century; the data are being used to forecast the development of male mortality from mesothelioma in France.

Alcohol consumption and marital status of French women in the GAZEL cohort: a longitudinal analysis between 1992 and 1996.

OBJECTIVE: The purpose of this research was to describe women's consumption of alcoholic beverages as it related to their marital status over a 5-year period (1992 through 1996) and to study alcohol consumption around the time of marriage or divorce. METHOD: The study sample comprised 4,782 women who worked for Electricité de France-Gaz de France and belonged to the GAZEL cohort. The relevant variables collected by five successive annual questionnaires included marital status and alcohol consumption characteristics. Marginal models were used, reflecting the fact that the data were not independent. RESULTS: Divorcees and widows drank less than married women as measured in fewer glasses per day and fewer days per week drinking wine. Women in the oldest generation drank more than the younger women. Getting married was accompanied by an increased level of drinking, especially of wine, beginning a year before the wedding and lasting until 4 years after it. Consumption declined briefly during the year after a divorce. CONCLUSIONS: These results may be useful for designing prevention programs aimed at groups of women in the general population in France.

[Aid to the clinical and biological diagnosis of malignancy in a nodular hepatic image discovered by echography]. / Aide au diagnostic clinique et biologique de malignité devant une image nodulaire hépatique découverte par échographie.

When ultrasound examination of the upper abdomen detects a liver nodule, the malignancy of this lesion must be discussed. If past history of cancer is known, a benign lesion cannot be excluded. Conversely, if the examination is performed without a history of cancer, we must raise the possibility of a malignant lesion. We attempted to demonstrate that the simple clinical and biological findings allow, if well used, a diagnosis of malignancy or benign nature, rather than performing further investigations, sometimes costly or invasive. We therefore compared three different methods: the well known bayesian diagnostic process; the multivariate analysis using logistic regression model; the Decision Theory, constructing a binary discrimination tree. The three methods lead to approximately the same rate of well classified patients (93 to 95%). Advantages and disadvantages are discussed.

[Prevalence, significance and prognosis of ventricular arrhythmia in 236 cases of dilated myocardiopathy]. / Prévalence, signification et pronostic des troubles du rythme ventriculaire dans 236 myocardiopathies dilatées.

The prevalence on ECG, Holter monitoring and stress testing and the prognosis of ventricular arrhythmias were assessed in 236 patients with dilated cardiomyopathy (DCM). This diagnosis was confirmed by haemodynamic and coronary angiographic criteria in 218 cases. Analysis of ECG recordings confirmed the high incidence of ventricular extrasystoles (VES) which were observed in 56% of cases, with doublets in 28% and salvoes in 5% of cases. Sustained VT was observed in 5 cases before the diagnosis was established and in 9 cases during follow-up. Ventricular fibrillation was documented in 8 patients without overt cardiac failure. Holter monitoring over 24 hours (N = 76) showed less than 30 VES per hour in 32% of cases, greater than 100 per hour in 36% of cases, predominantly diurnal in 36% of cases, doublets in 40% of cases and salvoes in 15% of cases. A significant correlation was observed (p less than 0.01) between repetitive activity and the frequency of VES. Exercise stress testing (N = 113) showed aggravation of the ventricular arrhythmia in 28% cases. Of the 72 clinical and paraclinical variables that were analysed, the group of patients with VES and doublets on ECG had lower left ventricular ejection fractions and higher pulmonary pressures. Eighty patients died of cardiac causes during follow-up of 38.8 +/- 27 months. Taking into account the haemodynamic differences, the presence of doublets on the ECG was a poor prognostic factor in subjects with ejection fractions greater than 40% (p less than 0.06); this was even more significant when greater than 50% (p less than 0.027).(ABSTRACT TRUNCATED AT 250 WORDS)

[Working conditions of nurses at public hospitals 1980 to 1990]. / Evolution des conditions de travail des infirmières des hôpitaux publics de 1980 à 1990.

The 1988 and 1991 strikes among nurses were motivated by claims concerning the status of the nursing profession, wages and working conditions. A study of working conditions was carried out from two samples: 1) a cohort of nurses (N = 571) recruited in 7 hospitals and followed up in 1980 (follow up rate: 85%) and in 1990 (follow up rate: 69%); 2) a sample of nurses who began to work in the same settings between 1985 and 1989 (N = 108). The results indicate no improvement in the organisation of shiftwork on the 10 years period. Working conditions deteriorated during the last 5 years. These findings are discussed in the light of the global evolution of hospital and of the specific problems of the nursing profession.