Search

We lack data on how physicians can instill confidence in patients.We aimed to determine whether dress style (professional white coat or formal, semiformal or casual attire) affects confidence in the physician by patients (children, teenagers, adults) with dermatology complaints consulting in the hospital or private practice.Design. Descriptive prospective cross sectional study carried out from July 1, 2008 to July 1, 2009. Setting. Outpatients in the department of dermatology of a French tertiary care hospital, and two dermatological private consulting rooms. Participants and design. Consulting patients were ≥ 7 years and classified as children 7-11 years old, accompanying parents, teenagers (12-17 years), and adults ≥ 18 years consulting alone. Subjects viewed two iconographic boards containing 4 photographs in a random order of a male physician on 1 board and a female physician on the other board in 4 different dress styles: professional (white coat and stethoscope), formal (shirt and tie for men), semiformal, and casual (T-shirt, jeans). Subjects then completed a questionnaire asking them to rate, on a scale of 0-10, their confidence in the physicians portrayed and answered whether they considered physician dress important. Main outcomes and measures. The main outcome was subjects' ranking of photos of physicians by dress style, according to the confidence they felt. For children 7-11 years old, we considered the frequency of the chosen dress style. The secondary outcome was whether physician dress was important to patients.We included 329 patients. Children at the hospital most frequently chose the photo of the physician, both male (62%) and female (64%), with the white coat. Teenagers' choices were professional dress, then semiformal, formal, and casual attire. Accompanying adults and adults consulting alone had the same ranking.In France, patients of all ages who consult for dermatology complaints in hospital and in private practice have the most confidence in a physician who wears a professional white coat.

Our university hospital serves a population of 300 000 inhabitants. Stroke is the leading cause of admission in our department of neurology. In June 2003, when the Emergency Department (ED) was closed in our institution, was created an acute stroke network (ASN), comprising 2 beds of direct admission and thrombolysis in the intensive care unit, and 4 beds dedicated to stroke care in the department of neurology, in which standardized stroke care protocols were implemented.The aim of this study was to evaluate changes in stroke care related to the creation of the ASN in terms of delays of arrival, imaging, use of intravenous (IV) thrombolysis, and outcome of patients. We conducted a prospective study during 18 months to evaluate characteristics of patients admitted with suspected stroke or transient ischemic attack (TIA) in the newly created ASN and to assess conditions of treatment with IV thrombolysis in terms of safety and efficacy. We also compared the outcome data before and after the creation of the ASN.For each patient admitted in our hospital for suspected stroke or TIA, were prospectively collected clinical and outcome data (age, mode of transport, delay of arrival after the onset of symptoms (OS), treatment with IV thrombolysis, outcome and discharge). This study was conducted in the ED during six months in 2002, and in the ASN during 18 months, for all patients admitted for stroke.Three hundred and sixty four patients were admitted in the ASN. Emergency medical services (EMS) were used in half of cases for transport, and median delay of admission after the OS was 2h and 52 min. Median delay of imaging was 1 h and 45 min. Seventeen patients (8.5 p. 100 of ischemic stroke patients) were treated with IV thrombolysis, with an initial good outcome in 9 patients, 7 with a dramatic recovery). The main reason for therapeutic abstention for untreated patients admitted in the first 3 hours was a mild deficit with a NIHSS6. Compared with the previous management in the ED, patients in the ASN were younger, had more severe neurological symptoms, the EMS transport was the main mode of transport (versus used in 17 p. 100 of cases in 2002), and the delay of admission was significantly lower: 2 h 52 versus 5 h 10 (p0.02). After adjustment on the main predictive factors, only patients with hemorrhagic strokes had a better outcome after the creation of the ASN.Creation of an ASN was associated with a significant decrease of admission and imaging delays, due to a strong collaboration with EMS, and with a better outcome for hemorrhagic stroke patients. Treatment with intravenous thrombolysis in the first 3 hours could be used widely and was efficient and safe. However, the creation of dedicated stroke units for all stroke patients remains necessary to improve quality of care and outcome.

To assess the performance of a power doppler vascularity index in the preoperative diagnosis of ovarian malignancy.Two successive series of adnexal masses (N=101 and N=82) were examined prospectively with power Doppler before surgical treatment. A vascularity index, called Power Doppler Index (PDI), based on the number of colored pixels, was estimated on selected frames (defined region of interest covering the entire tumor) of the tumors using an in house color-quantifying program. The first study was monocentric to test the inter- and intraobserver reproducibilities and the availability of the parameter. The second was multicentric to validate the first results. The sensitivity and specificity of PDI, resistance index (RI) and subjective visual scoring were compared using receiver operating characteristic (ROC) curves.Histology identified 23 malignant and 78 benign lesions in the first study and 34 malignant and 48 benign tumors in the second. PDI was considerably higher in malignant than in benign lesions (0.34+/-0.04 vs 0.12+/-0.06 (P0.001)). Intra-observer and interobserver variability of PDI was low (intraclass correlation coefficients estimated at 0.99 and 0.98, respectively). The PDI cut-off value for differential diagnosis was set at 0.265 (26.5% of the tumor is colored) in the first study and 0.107 in the second. Sensitivity and specificity were 100% (95% CI [87.8; 100.0]) and 97.4% (95% CI [91.0; 99.7]), respectively, for PDI in the first study compared to 75% (95% CI [72.9; 90.7]) and 60% (95% CI [56.3; 92.5]) in the second study. Using logistic regression, visual Doppler scoring performed best.The Power Doppler Index obtained using our color quantifying software has discriminating power for adnexal masses but visual Doppler scoring performs best.

A new matrix-based quantitative ultrasound (QUS) device was developed for the assessment of two parameters: BUA (Broadband Ultrasound Attenuation) and SOS (Speed Of Sound). This device, called Beam scanner, is a contact imaging device designed to evaluate the calcaneus. The aim of this preliminary study was to evaluate the reproducibility of results in a sample of patient with heterogeneous age distribution.Seventy-six subjects were included: 18 healthy young males, 18 healthy young women and 40 women aged over 50 years old, including 19 osteoporotic patients according to WHO criteria. Five measurements were made for each patient after foot repositioning. Short-term precision was estimated using the coefficient of variation (CV), standardized CV (SCV) and intra-class correlation coefficient (ICC).SCV varied with the group of subjects between 2.0 and 4.3% for BUA, and between 3.1 and 4.5% for SOS. Mean values of BUA and SOS were statistically lower for osteoporotic women compared with healthy young women or healthy young males (p0.001). For BUA, only SCV and ICC were better for women aged over 50 years old but without statistical difference.This study shows that the heterogeneity of the studied sample population is not a significant factor when assessing precision. This new device has a precision similar to others QUS devices.

Methylphenidate (MPH) is a potential therapeutic tool for Attention Deficit with Hyperactivity Disorders (ADHD). In addition to the immediate-release formulation, Ritalin, two extended-release formulations, Ritalin LA and Concerta are available and allow a once-daily administration. We compared the respective benefits of both formulations for the patients and their family in terms of efficacy, handling and tolerance.This prospective study was based on 30 children aged 6 to 15 years. All patients had a confirmed ADHD and were efficiently treated with Ritalin. The children were consecutively treated with Ritalin LA and Concerta, with a comparable MPH daily dosage, during 2 months for each molecule. The 3 drugs were evaluated individually and comparatively through a battery of questionnaires submitted to the parents and the teachers of each child.Extended-release MPH efficacy was comparable to the immediate-release formulation, Ritalin. For both of them, the once-daily administration appeared beneficial. Concerta was finally prescribed in 18 children, Ritalin LA in 8 cases and Ritalin in 4 cases. In each case the medical choice was consistent with the parents preference. Concerta was appreciated for its persisting efficacy in late afternoon during homework. Concerta and Ritalin LA did not induce significant adverse effects, especially regarding alimentation and sleep.MPH therapy in ADHD carries an excellent risk/benefit ratio without addictive induced behaviours. The extended-release MPH formulations provide an improvement for the patients in keeping with Ritalin efficacy through a once-daily administration. Regardless of its formulation, MPH indications and guidelines must be respected.

Stroke is a leading cause of death and disability. Patients with suspected stroke are usually managed in emergency departments (ED). Stroke units must be created in our country, but only few French epidemiological data are available to define needs in stroke care.A prospective study was planned to evaluate epidemiology and stroke care for patients with suspected stroke admitted in the 22 ED of our region in the center of France during a two-month period.Patients with suspected stroke seen at the 22 ED were prospectively followed until discharge or one month after admission. Data on demographic characteristics, mode of transport, delay of arrival and imaging, clinical findings at arrival, department of admission, diagnosis, Rankin scale at day 7, in-hospital mortality, and outcome at a month were collected. A global statistical analysis and a comparison between rural and urban ED were performed.Five hundred and ninety-eight patients were included. Mean age was 75 years. Median admission delay was 4 hours and 52 minutes. Predominant mode of transport was a private ambulance. A CT scan was obtained in 91 p.cent of cases with a median delay of 2 hours and 30 minutes. Only a third of the patients were admitted in departments of Neurology. Final diagnosis was: ischemic stroke (61 p.cent), transient ischemic attack (16 p.cent), hemorrhagic stroke (10 p.cent), other vascular disease (3 p.cent), non vascular disease (10 p.cent). In-hospital mortality was 20 p.cent, factors significantly associated with death rate were elevated age and a Glasgow coma scale10 at admission. Mean length of stay was 12 days for stroke patients. At one month, 63 percent of patients were discharged to their home, 28 percent were transferred to an institution or in a rehabilitation unit, and 15 percent were still hospitalized. Significant differences in stroke care were found between rural and urban ED.This prospective study provides epidemiological data for our region. Creation of stroke units and definition of acute stroke networks are necessary to improve stroke care.

Limb lymphedema results from incompetence of the lymphatic system, and treatment of both primary and secondary forms involves manual lymphatic drainage and support. The effectiveness of treatment varies from patient to patient and can be unpredictable.To investigate clinical and paraclinical criteria able to predict responses to combined physical treatment (lymphatic drainage and multilayered support) during hospitalization.A retrospective study was performed in 45 patients admitted for one week's intensive treatment of limb lymphedema in the Lymphology Unit of the Department of Dermatology of the University Hospital of Tours. Lymphoscintigraphy was performed for all patients on admission. Loss of volume in affected limbs was studied to evaluate the effectiveness of treatment.Two criteria were predictive of resistance to combined treatment, i.e. venous insufficiency and continuing lymph node evidence of scintigraphic activity four hours after lymphoscintigraphy. The two factors were significantly related.Failure of combined physical treatment for lymphedema appears to be related to venous insufficiency. It is therefore essential to investigate and treat venous insufficiency, particularly in patients with continuing evidence of scintigraphic activity in lymph nodes.

Since benzodiazepines (BZD) are largely prescribed during pregnancy, the Regional Pharmacovigilance Center (RPVC) of Tours regularly deals with questions about the risk of their administration to pregnant women and the monitoring of the newborns exposed in utero to these drugs. During the third trimester, we recommend a switch in the BZD maternal treatment to oxazepam, which has an intermediary half-life and no active metabolite, and a hospitalisation of the newborn in order to monitor his respiratory rate. The purpose of our study was to evaluate the neonatal consequences of BZD used at the end of pregnancy and to analysed if our recommendations were taken into account and if they were appropriate.From 1989 to the end of 2002, we studied the files in which women had received a BZD during the 30 days prior to delivery. We analysed maternal treatments, the outcome of pregnancy and the development of the newborn, the therapeutically attitude recommended and whether or not it was respected.A total of 73 files were selected. Seventy neonates were born to 73 women. The newborns were hospitalised (73%) and they developed adverse reactions possibly related to the use of BZD (51,5%) : an impregnation syndrome (42%) characterized by hypotonia and hypoventilation, and a withdrawal syndrome (20%) with tremulations as the main symptom.Considering the most frequent neonatal manifestations, hospitalization and the respiratory monitoring recommended by the RPVC seemed adequate. However, the switch to oxazepam was seldom done and its advantages should be pointed out.

To analyse neonatal effects after in utero selective serotonin reuptake inhibitors exposure and the pertinence of recommendations delivered by our team.We report a series of 27 pregnancies exposed late in pregnancy including the period of delivery, to the Selective Serotonin Reuptake Inhibitors (SSRI) and having been the subject of a call to the Regional Center of Pharmacovigilance of Tours (CRPV).Twenty-seven children were born without malformation. Twelve children were hospitalized because of prematurity (two), exposure to other drugs imposing particular surveillance (eight) or in view of abnormal neonatal effects (two). Five newborns (18.5%) of which three had also been exposed to other drugs (benzodiazepine, neuroleptic, H1-antagonist) had presented one or more neonatal adverse effects compatible with the role of the SSRI (irritability, agitation, shivering, hypotonia) but with uncertainty about a clear discrimination between withdrawal syndrome and serotonin impregnation. All the symptoms disappeared spontaneously. One of the five children had a described in treated adults but two neonatal observations were published. No child had hemorrhagic symptoms as described in treated adults despite the fact that two neonatal observations were reported.This study confirms the relative benignity of SSRI exposure during late pregnancy. Our recommendations for monitoring the newborns during their stay in maternity wards were well respected. The risk of hemorrhagic symptoms or hyponatremia, not well known by pediatricians, deserves to be recalled to medical teams who take in charge newborns exposed to SSRI.

To analyse neonatal effects after in utero betablockers exposure and the pertinence of recommendations delivered by our team.We report 44 pregnancies exposed to betablockers during the late pregnancy including the period of delivery about which the Regional Pharmacovigilance Center of Tours (CRPV) was questionned.Among the 39 children for whom we know the follow up, 22 had neonatal adverse effects of which 19 could be explained by in utero exposure to betablockers i.e. an hypoglycaemia (11 times), a bradycardia (six times), a bradycardia and hypoglycemia (one time) and an hypotension (one time). A drug-related effect was retained for eleven newborns (27%) and another etiology could be evoked in the eight others. The risk of neonatal adverse effects seems to increase in newborns exposed to labetalol (5/11), to betaxolol (1/2) or to propranolol (2/6) or when the dose is high. The eight newborns who had intrauterine growth retardation were generally more often exposed to atenolol than eutrophic newborns. Four babies had malformations.Our recommendation was an hospitalization 44 times (100%) to monitor heart rate, blood pressure and glycemia. When the follow-up is known, hospitalization was performed in 88% of the cases. Glycemia, heart rate and blood pressure were monitored in all the hospitalized children and in three of the five not hospitalized children. Our recommendation seems particularly justified with regard to hypoglycemia which is often asymptomatic but whose consequences can be severe. Atenolol often provider of intrauterine growth retardation and labetalol more often at the origin of neonatal adverse effects are probably to avoid during pregnancy.

The aim of this study was to assess the usefulness of color Doppler energy in the preoperative diagnosis of ovarian malignancy using multivariate logistic regression analysis.One hundred and thirty adnexal masses were studied with transvaginal B-mode, color energy, and pulsed Doppler ultrasonography before surgery in order to develop a model that could be used to determine malignancy. Each ultrasonographic variable (tumor size, wall thickness, septal structure, echogenicity, papillary projection, density (solid or not)) was included individually or combined together as part of the Sassone ultrasound score. Intratumoral blood flow velocity waveforms were obtained to determine pulsatility index and resistance index and a more subjective parameter, location of tumor vascularity, was also assessed. Menopausal status and serum CA 125 levels were also entered as categorical variables. Sonographic parameters were entered alone, then associated with menopausal status and CA 125 serum levels, and finally with Doppler energy measurements. Our model was then validated in a group of 68 adnexal masses and compared to the model of Alcazar.Eighteen adnexal masses (13.8%) were malignant or of low malignant potential. Multivariate analysis showed that papillary projection of the tumor wall, cyst with solid parts, resistance index with a cut-off value of 0.53, CA 125, and central blood flow location, were the only factors to be independent predictors of malignancy. Menopausal status was not an independent factor. For the final model including the Doppler energy parameter the best sensitivity and specificity were 83% and 93%, respectively, at a cut-off value of 10% probability of malignancy compared to 83% and 87% for the morphological variables alone. Validation of the model showed its diagnostic performance to be as good as that reported in the original population and better than the model of Alcazar.Sonographic analysis of adnexal masses including color Doppler energy shows the best predictive properties according to histological diagnosis, and improves preoperative diagnosis of malignancy.

The aim of this retrospective study was to evaluate the 38 month-results of laparoscopic fundoplication for gastroesophageal reflux disease (GERD).Two hundred forty three consecutive patients were operated laparoscopically. The surgical procedures were complete fundoplication with division of short vessels (Nissen: 80 patients), without division of short vessels (Nissen-Rossetti: 68 patients) or partial fundoplication of 270 degrees (Toupet: 95 patients). The mean follow-up was 38 months. Functional results were evaluated in 225 patients (92.5%) using a questionnaire with visual analog scales.The morbidity rate was 5%, higher after Nissen procedure (6.5%). With a follow-up of 3 months: a dysphagia coted 5/10, a gas bloat syndrome coted 4/10 and colon distension present in 61% of patients, were significantly more frequent after Nissen procedure. GERD recurred early in 4.5% of patients. With a follow-up of 38 months: dysphagia rate (coted 1/10) was significantly higher after Nissen. Dysphagia still persisted in 8 patients (9%) after Nissen. Colon distension and flatulence were more present after Nissen fundoplication. GERD recurrence rate was 12%. Pyrosis was significantly higher after Toupet fundoplication. Continuous medical treatment was necessary in 19 patients (8%). The satisfaction of patients was coted 7.5/10 without difference between to the three types of fundoplication.The total laparoscopic fundoplication for GERD seems to be a safe and efficient operation. This procedure proves to be more effective than partial fundoplicature but with a grater morbidity. Whatever the type of fundoplicature, the satisfaction of patients was good.

Interpreting changes in continuous structural outcome measures is a common problem in clinical research and in daily practice. We propose a method for estimating whether difference observed between two successive measures in an individual constitutes a statistically relevant change or a change induced by variability. This statistically relevant change is based on an analysis of reproducibility. The continuous structural outcome measure investigated as an example was joint space width (JSW) measurement on standard X-rays, which is known to be the primary end-point for assessing structural osteoarthritis progression. The results of the present study demonstrate that cutoffs are closely dependent on all sources of variabilities in JSW measurement such as joint positioning, radiographic procedure, and the measurement process itself. Therefore, we suggest to determine cutoffs for each study using a representative sample of the population studied and using the procedures and methods of measurement of the specific study. This approach may easily be extended to other continuous structural outcome measures.