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Summary Background Cataract surgery is one of the most common operations in health care. Femtosecond laser-assisted cataract surgery (FLACS) enables more precise ocular incisions and lens fragmentation than does phacoemulsification cataract surgery (PCS). We hypothesised that FLACS might improve outcomes in cataract surgery compared with PCS despite having higher costs. Methods We did a participant-masked randomised superiority clinical trial comparing FLACS and PCS in two parallel groups (permuted block randomisation stratified on centres via a centralised web-based application, allocation ratio 1:1, block size of 2 or 4 for unilateral cases and 2 or 6 for bilateral cases). Five French University Hospitals enrolled consecutive patients aged 22 years or older who were eligible for unilateral or bilateral cataract surgery. Participants, outcome assessors, and technicians carrying out examinations were masked to the surgical treatment allocation until the last follow-up visit and a sham laser procedure was set up for participants randomly assigned to the PCS arm. The primary clinical endpoint was the success rate of surgery, defined as a composite of four outcomes at a 3-month postoperative visit: absence of severe perioperative complication, a best-corrected visual acuity (BCVA) of 0·0 LogMAR (logarithm of the minimum angle of resolution) or better, an absolute refractive error of 0·75 dioptres or less, and unchanged postoperative corneal astigmatism power (≤0·5 dioptres) and axis (≤20°). The primary economic endpoint was the incremental cost per additional patient who had treatment success at 3 months. Primary outcomes were assessed in all randomly assigned patients who met all eligibility criteria (missing data considered as failure). We used mixed logistic regression models or mixed linear regression models for statistical comparisons, adjusted on centres and whether cataract surgery was bilateral or unilateral. The study is registered with ClinicalTrials.gov , NCT01982006 . Findings Of the 907 patients (1476 eyes) randomly assigned between Oct 9, 2013, and Oct 30, 2015, 870 (704 eyes in FLACS group and 685 eyes in the PCS group) were analysed. We identified no significant difference in the success rate of surgery between the FLACS and PCS groups (FLACS: 41·1% [289 eyes]; PCS: 43·6% [299 eyes]); adjusted odds ratio 0·85, 95% CI 0·64–1·12, p=0·250). The incremental cost-effectiveness ratio was €10 703 saved per additional patient who had treatment success with PCS compared with FLACS. We observed no severe adverse events during the femtosecond laser procedure, and most of the complications in the FLACS group related to the primary outcome measures occurred during the phacoemulsification phase or postoperatively. Interpretation Despite its advanced technology, femtosecond laser was not superior to phacoemulsification in cataract surgery and, with higher costs, did not provide an additional benefit over phacoemulsification for patients or health-care systems. Funding French Ministry of Social Affairs and Health.

Summary Background In France about 32% of hospitalized patients have a vascular access placement. However, a common complication associated with these is catheter-related bloodstream infection (CRBI) due to the introduction of microorganisms from the skin during catheter insertion. There is no consensus on the best way to clean the skin prior to catheter insertion, which could be a key element of CRBI prevention. The two techniques most commonly used to apply antiseptic to the skin are the concentric circle and back-and-forth techniques, but these have not been compared in clinical trials. Hence, this study conducted this comparison. Methods This single-center, non-comparative, randomized, matched pilot study investigated the levels of cutaneous microorganisms before and after antiseptic application using both techniques in a population of healthy French volunteers. The two application methods were used on each participant's arms at the elbow fold, with randomization for the application side (right or left). Quantification of cutaneous microorganisms was performed in a blinded manner with regard to the technique used. Findings From April 8 to July 17, 2019, 132 healthy volunteers participated in the study. For the whole study population, the mean initial colonization level was 2.68 log10 colony forming units (CFU)/mL (SD 0.82) before the back-and-forth technique, and 2.66 log10 CFU/mL (SD 0.85) before the concentric circle technique. The mean differences in number of microorganisms between the initial sample and the final sample were 2.45 log10 CFU/mL (95% CI: 2.29 to 2.61) for the back-and-forth technique and 2.43 log10 CFU/mL (95% CI: 2.27 to 2.59) for the concentric circle technique. The mean difference in reduction in microorganisms between the back-and-forth technique and the concentric circle technique was 0.02 log10 CFU/mL (95% CI: –0.11 to 0.15). Interpretation There was no clinically difference in reduction of microorganisms between the concentric circle and back-and-forth techniques at the bend of the healthy volunteer's elbow, after the 30 s of drying of the antiseptic. These findings have a significant impact on time required to achieve antiseptic application before catheter insertion because there is yet no argument to justify application for 30 s, because a single concentric circle pass was much faster with similar results. Future studies should investigate the impact of skin application technique on the prevention of infectious risk associated with catheter insertion on admission to health care facilities (conventional, outpatient, or emergency) and throughout the period of stay in a health care facility.

ObjectiveTo determine whether the use of nasal, high-frequency percussive ventilation (nHFPV) to manage neonatal respiratory distress decreases the regional cerebral oxygen saturation (rScO2) below that afforded by nasal continuous positive airway pressure (nCPAP).DesignMonocentric, prospective, randomized, monocentric, open-label, non-inferiority crossover trial.PatientsNewborns of gestational age (GA) ≥ 33 weeks exhibiting persistent respiratory distress after 10 min of life (Silverman score ≥ 4).InterventionnHFPV and nCPAP, in succession and in random order.Main outcome measureMean rScO2, as revealed by near-infrared spectroscopy (NIRS) performed over the last 5 min of each ventilation mode. To show that nHFPV was not inferior to nCPAP, our a priori calculations required that the lower boundary of the bilateral 95% confidence interval (CI) of the difference between the mean rScO2 values of each ventilation mode should exceed –5.ResultsForty-nine newborns were randomized and 46 were analyzed. The mean (± standard deviation [SD]) GA and birth weight were 36.4 ± 1.9 weeks and 2,718 ± 497 g. The diagnosis was transient tachypnea in 65% of cases and respiratory distress syndrome in 35%. The mean rScO2 difference during the last 5 min of each ventilation mode (nHFPV minus nCPAP) was – 0.7 ± 5.4% (95% CI –2.25; 0.95). Neither a period effect nor a period-treatment interaction was evident. The mean transcutaneous carbon dioxide values (n = 26) for nCPAP and nHFPV were 7.1 ± 4.8 and 7.9 ± 5.1 kPa, respectively. No harmful or unintentional effect was observed.ConclusionIn our study on newborns of GA ≥ 33 weeks treated for respiratory distress, cerebral oxygenation via nHFPV was not inferior to nCPAP.What is already known on the topicNon-invasive high-frequency ventilation is feasible in preterm newborns and seems to improve ventilation compared to nasal CPAP.We previously showed that nasal high-frequency percussive ventilation (nHFPV) was more efficient that nCPAP for respiratory distress management in newborns of gestational age (GA) ≥ 35 weeks.The impact of mechanical ventilation, especially high-frequency modes, on cerebral blood flow in neonates is of concern.What this study addsnHFPV was well-tolerated and non-inferior to nasal CPAP as measured by rScO2 levels when used to manage respiratory distress at birth in newborns of GA ≥ 33 weeks.

INTRODUCTION: No randomized controlled clinical trial of therapeutic plasma exchanges (TPE) has yet been performed for moderate-to-severe relapses of multiple sclerosis (MS). OBJECTIVE: To compare TPE to sham-TPE in patients with a recent steroid-resistant moderate-to-severe MS relapse. METHODS: Patients presenting with an MS relapse of less than 2 months without improvement and 15 days after a course of steroids were randomized. Specific criteria were used for each relapse type to define moderate-to-severe disability. The primary endpoint was the proportion of patients with at least a moderate improvement based on objective and functional evaluation after 1 month. RESULTS: Thirty-eight patients were randomized. The intention-to-treat analysis included 14 patients in the TPE group and 17 in the Sham-TPE group. The proportion of patients with at least moderate improvement at 1 month did not differ between the groups (P = .72), although 57.1% of the TPE group had full recovery compared with 17.6% of the sham group. Considering optic neuritis (ON), a significant difference in the proportion of different levels of improvement was observed in favor of the TPE group (P = .04). The combined Kurtzke's functional systems scores were significantly more improved in the TPE group than in the sham-TPE group at months 1 (P

To assess the effect of pelvic drainage after rectal surgery for cancer.Pelvic sepsis is one of the major complications after rectal excision for rectal cancer. Although many studies have confirmed infectiveness of drainage after colectomy, there is still a controversy after rectal surgery.This multicenter randomized trial with 2 parallel arms (drain vs no drain) was performed between 2011 and 2014. Primary endpoint was postoperative pelvic sepsis within 30 postoperative days, including anastomotic leakage, pelvic abscess, and peritonitis. Secondary endpoints were overall morbidity and mortality, rate of reoperation, length of hospital stay, and rate of stoma closure at 6 months.A total of 494 patients were randomized, 25 did not meet the criteria and 469 were analyzed: 236 with drain and 233 without. The anastomotic height was 3.5 ± 1.9 cm from the anal verge. The rate of pelvic sepsis was 17.1% (80/469) and was similar between drain and no drain: 16.1% versus 18.0% (P = 0.58). There was no difference of surgical morbidity (18.7% vs 25.3%; P = 0.83), rate of reoperation (16.6% vs 21.0%; P = 0.22), length of hospital stay (12.2 vs 12.2; P = 0.99) and rate of stoma closure (80.1% vs 77.3%; P = 0.53) between groups. Absence of colonic pouch was the only independent factor of pelvic sepsis (odds ratio = 1.757; 95% confidence interval 1.078-2.864; P = 0.024).This randomized trial suggests that the use of a pelvic drain after rectal excision for rectal cancer did not confer any benefit to the patient.

Germain-Donnat Christine. Les acquisitions du musée. In: Sèvres. Revue de la Société des Amis du musée national de Céramique, n°28, 2019. pp. 174-175.

International audience; Avec ses Territoires d’Outre-Mer, la France est présente dans trois des sept bassins d’activité cyclonique (Atlantique Nord, Pacifique Sud et Océan Indien). Les autorités de l’Etat régionales et locales sont donc régulièrement confrontées à des situations de gestion de crise cyclonique dont la fréquence est susceptible d’augmenter avec le changement climatique. Néanmoins, à l'heure actuelle, ils ne disposent pas d'outils dédiés à la prévision des inondations liées aux cyclones tropicaux.La prévision des inondations côtières d’origine cyclonique dans les Territoires d’Outre-Mer soulève donc des questions bien spécifiques qui méritent d’être traitées conjointement :Les cyclones tropicaux étant des phénomènes encore difficile à prévoir en termes de trajectoire, intensité et précipitation, l’exploitation de prévisions cycloniques pour l’estimation du risque d’inondation nécessite à la fois l’utilisation de modèles météorologiques à haute résolution spatiale et temporelle et une appréciation adéquate des incertitudes.Les Territoires d’Outre-mer comme La Réunion sont généralement situés sur des îles volcaniques présentant (1) une orographie complexe et un réseau hydrographique dense avec des cours d’eau à régime torrentiel (2) une absence de plateau continental qui expose plus particulièrement le littoral aux fortes houles et aux franchissements par paquets de mer (3) de fortes interactions entre les phénomènes marins et fluviaux au niveau des embouchures. Aussi, la prévision des conditions océaniques, hydrologiques et du risque d’inondation requiert la mise en place de modèles numériques adaptés.Enfin, la gestion d’une crise cyclonique, organisée notamment via le plan ORSEC Cyclones et les Plans Communaux de Sauvegarde, présente des particularités dues à la cinétique de l’évènement et au contexte insulaire. Une réflexion doit être menée sur la mise en forme et l’utilisation de prévisions sur l’inondation dans ce cadre précis. Au-delà de l'élaboration d'un outil, SPICy intègre une réflexion sur les besoins concrets des gestionnaires locaux afin de mieux définir la nature et les processus de production des informations pertinentes et utiles en période de crise. L’objectif de ce projet est donc de développer les briques technologiques nécessaires à la mise en place d'un système de prévision des inondations côtières et fluviales cycloniques pour les Territoires d'Outre-Mer. Pour cela, les 5 partenaires du projet ont mis en place une approche transdisciplinaire permettant de travailler simultanément sur toute la chaine de prévision, des modèles météorologiques aux modèles d’inondation et la gestion de crise. Deux échelles de travail ont été abordées : une échelle régionale correspondant à l’île et aux différents bassins versants, et une échelle locale sur deux sites tests dont (1) la commune de Sainte-Suzanne (2) la commune de Saint-Paul. Un démonstrateur a été réalisé et plusieurs exercices de crise impliquant les opérationnels des communes et de la sécurité civile ont permis de tester, adapter, et évaluer la pertinence et l'applicabilité des différents développements du projet.

Détrez Louise, Germain-Donnat Christine. Une acquisition du musée national de céramique sèvres - Cité de la Céramique en 2017. Deux «nestorides» de porcelaine. In: Sèvres. Revue de la Société des Amis du musée national de Céramique, n°27, 2018. pp. 162-165.

Background Irreversible pulpitis is a highly painful inflammatory condition of the dental pulp which represents a common dental emergency. Recommended care is partial endodontic treatment. The dental literature reports major difficulties in achieving adequate analgesia to perform this emergency treatment, especially in the case of mandibular molars. In current practice, short-course, orally administered corticotherapy is used for the management of oral pain of inflammatory origin. The efficacy of intraosseous local steroid injections for irreversible pulpitis in mandibular molars has already been demonstrated but resulted in local comorbidities. Oral administration of short-course prednisolone is simple and safe but its efficacy to manage pain caused by irreversible pulpitis has not yet been demonstrated. This trial aims to evaluate the noninferiority of short-course, orally administered corticotherapy versus partial endodontic treatment for the emergency care of irreversible pulpitis in mandibular molars. Methods/design This study is a noninferiority, open-label, randomized controlled clinical trial conducted at the Bordeaux University Hospital. One hundred and twenty subjects will be randomized in two 1:1 parallel arms: the intervention arm will receive one oral dose of prednisolone (1 mg/kg) during the emergency visit, followed by one morning dose each day for 3 days and the reference arm will receive partial endodontic treatment. Both groups will receive planned complete endodontic treatment 72 h after enrollment. The primary outcome is the proportion of patients with pain intensity below 5 on a Numeric Scale 24 h after the emergency visit. Secondary outcomes include comfort during care, the number of injected anesthetic cartridges when performing complete endodontic treatment, the number of antalgic drugs and the number of patients coming back for consultation after 72 h. Discussion This randomized trial will assess the ability of short-term corticotherapy to reduce pain in irreversible pulpitis as a simple and rapid alternative to partial endodontic treatment and to enable planning of endodontic treatment in optimal analgesic conditions. Trial registration ClinicalTrials.gov, identifier: NCT02629042. Registered on 7 December 2015. (Version n°1.1 28 July 2015) Electronic supplementary material The online version of this article (doi:10.1186/s13063-017-1883-x) contains supplementary material, which is available to authorized users.

Background Chronic severe tinnitus can be greatly detrimental to quality of life. Some authors have reported benefit of repetitive transcranial magnetic stimulation, others of electrical cortical stimulation by stimulating the Heschl's gyrus or secondary auditory areas. Objective To evaluate the efficacy of chronic electrical epidural stimulation of the auditory cortex on severe and disabling tinnitus. Method In this double-blind randomized cross-over, patients with chronic (at least 2 years), severe (Strukturierte Tinnitus-Interview, STI score > 19), unilateral or strongly lateralized tinnitus were included. After open-phase stimulation for 4 months, patients were randomized into 2 groups for double-blind stimulation with cross-over between significant and non-significant phases and wash-out in between. Each of the 3 phases was 2 weeks in duration. Patients were chronically stimulated and followed if not explanted. A decrease of STI score >35% was considered as clinically significant. Results None of the 9 patients included achieved significant improvement during the double-blind phase. Four were explanted, 2 owing to lack of effect, one for breast cancer under the stimulator, and another for psychiatric decompensation. Five are still stimulated. Three felt slight to great subjective effectiveness, the remaining 2 reported benefits and still requested stimulation. Conclusions This study did not find an objective efficiency of chronic cortical stimulation for severe and resistant tinnitus. The discordance between the results in double-blind and open evaluations could be related to a placebo effect of surgery, but may also be explained by a poorly defined target, a too short randomized phase, or inappropriate outcome measures. Clinical trial reference: NCT00486577

International audience; Recent data suggest that the nutritional status of patients who are on the waiting list for kidney transplantation, influence outcomes after renal transplantation. Body composition (BC) analysis is rarely included in pretransplant evaluation. The aim of this study was to determine how alteration of the BC of these patients could influence pretransplant and post-transplant care. We compared the BC of French patients on a waiting list for kidney transplantation to a sex- and age-matched healthy, European control population. Patients were included when listed for kidney grafting in a prospective longitudinal study (CORPOS). Biological nutritional parameters, fat free mass (FFM) and fat mass (FM) estimated by dual-energy x-ray absorptiometry (DXA) were assessed on the day of wait-list registration. FFM and FM index (FFMi - FMi) are the ratio of FFM and FM to height squared. Results are expressed as median (range). These indexes were compared with previous study values used as a normal range in nutritional assessment and clinical practice. The study included 28 women and 70 men aged 25.3 to 65.9 y. Body mass index ranged from 16.8 kg/m² to 39.4 kg/m². Compared with controls, FMi was higher in women (10.6 kg/m² [3.7-18.6 kg/m²]) than in men (8.1 kg/m² [3.5-13.3 kg/m²] in M) and FFMi was lower in women (14.3 kg/m² [11.8-21.4 kg/m²]) than in men (17.9 kg/m² [13.9-24.2 kg/m²]) (P < 0.01), reflecting an abnormal distribution of body compartments. All biological parameters were within the normal range. BC abnormalities, which can only be detected with the use of DXA, are present in patients on a kidney transplantation waiting list. Detection of these abnormalities could influence the post-transplantation survey in order to prevent the frequent risk for developing metabolic complications after the procedure.

Background During on-pump cardiac surgery, hemorrhagic complications occur frequently. Fresh-frozen plasma (FFP) is widely transfused to provide coagulation factors. Yet, no randomized clinical trial has demonstrated its benefits on mortality. We assessed the relationship between therapeutic transfusion of FFP and 30-day mortality in cardiac surgery patients suffering from excessive bleeding in a prospective cohort study. Study Design and Methods Adult patients who underwent on-pump cardiac surgery and experienced excessive bleeding during the 48-hour perioperative period were recruited from 15 French centers between February 2004 and January 2006. Patients who received a preventive FFP transfusion were excluded. The association between FFP transfusion and all cause 30-day mortality was estimated using a Cox proportional hazards model, adjusted for confounding. A propensity score (PS) sensitivity analysis was also performed. Results Among 967 patients included in this study, 58.1% received FFP. The median dose was 11.3 mL/kg (interquartile range, 7.6-19.5). The cumulative 30-day mortality rate was 11.3% (95% confidence interval [CI], 9.5-13.5). FFP transfusion was associated with a higher 30-day mortality (hazard ratio [HR], 3.2; 95% CI, 1.7-6.1) in univariate analysis; however, after adjusting for prognostic factors, there was no longer any association (HR, 1.5; 95% CI, 0.8-3.0, p = 0.20). The results of the PS analysis were consistent with the adjusted analysis. Conclusion Among on-pump cardiac surgery patients experiencing excessive perioperative bleeding, there is no evidence of a beneficial impact of FFP transfusion on mortality.

PURPOSE:The MNA (Mini Nutritional Assessment) is known as a prognosis factor in older population. We analyzed the prognostic value for one-year mortality of MNA items in older patients with cancer treated with chemotherapy as the basis of a simplified prognostic score. METHODS:The prospective derivation cohort included 606 patients older than 70 years with an indication of chemotherapy for cancers. The endpoint to predict was one-year mortality. The 18 items of the Full MNA, age, gender, weight loss, cancer origin, TNM, performance status and lymphocyte count were considered to construct the prognostic model. MNA items were analyzed with a backward step-by-step multivariate logistic regression and other items were added in a forward step-by-step regression. External validation was performed on an independent cohort of 229 patients. RESULTS:At one year 266 deaths had occurred. Decreased dietary intake (p = 0.0002), decreased protein-rich food intake (p = 0.025), 3 or more prescribed drugs (p = 0.023), calf circumference

Background It is no longer safe to use large tidal volumes ( V T ) (>8 ml kg −1 ) for one-lung ventilation (OLV), and limiting plateau pressure should be a major objective. Due to the specificity of OLV, the use of positive end-expiratory pressure (PEEP) remains controversial. This study determined whether at the same low plateau pressure, reducing V T and increasing PEEP were not inferior to larger V T and lower PEEP ventilation in terms of oxygenation. Methods This prospective, randomized, non-inferiority, cross-over trial included 88 patients undergoing open thoracotomy who received two successive ventilatory strategies in random order: V T (8 ml kg −1 of ideal body weight) with low PEEP (5 cm H 2 O), or low V T (5 ml kg −1 ) with a high PEEP. Respiratory rate and PEEP were, respectively, adjusted to maintain constant ventilation and plateau pressure. The primary endpoint was the P a O 2 / F I O 2 ratio under each ventilatory strategy. Results The non-inferiority of low- V T ventilation could not be established. The mean adjusted P a O 2 / F I O 2 ratio was lower overall during low- V T ventilation, and differences between the two ventilatory modes varied significantly according to baseline (T0) P a O 2 / F I O 2 . Decreased oxygenation during low V T was smaller when baseline values were low. Systolic arterial pressure was not lower during low- V T ventilation. Conclusion During OLV, lowering V T and increasing PEEP, with the same low plateau pressure, reduced oxygenation compared with larger V T and lower PEEP. This strategy may reduce the risk of lung injury, but needs to be investigated further.

Introduction L’insuffisance renale chronique est associee a des alterations de la reponse immunitaire humorale et une reponse vaccinale diminuee. Une etude preliminaire chez 15 patients non immunises apres au moins une vaccination anterieure et dialyses pendant trois mois sur polymethylmetacrylate (PMMA) a montre une reponse vaccinale chez 60 % d’entre eux nettement superieure a ce qui est rapporte dans la litterature. Cette reponse etait associee a une baisse du CD40 soluble, inhibiteur naturel de la reponse humorale. Nous avons voulu confirmer ces resultats par une etude randomisee multicentrique. Patients et methodes Vingt-cinq patients ont ete inclus (14 sur PMMA [BKF2.1], 11 sur polysulfone haute permeabilite). Selon le protocole, les patients devaient etre dialyses pendant 40 semaines et ont recu deux doses d’Engerix B20 a Semaine 12, S16, S20 et S36. Le critere de jugement principal est la reponse vaccinale a S40 definie par un taux d’Ac anti-HbS > 10 UI/L. La cinetique de la reponse vaccinale a ete evaluee. Le taux de CD40s a ete evalue a S0 et S12. Resultats A l’issue de l’etude, 58,3 % des patients sous PMMA vs 75 % des patients sous Polysulfone ont repondu a la vaccination (p = 0,64). Le taux median d’AC anti-HbS a S40 chez les repondeurs est de 496 (min–max : 81;750) vs 395 (26;750) UI/mL pour la PMMA et la polysulfone respectivement (p = 0,46). Le taux median de CD40s a S12 est de 306 (93;814) vs 491 (142;726) pg/mL (p = 0,21). La variation mediane du CD40s entre S0 et S12 est de 5 (−425;255) vs 64 (−189;357) pg/mL (p = 0,55). Il y a une tendance a un taux plus bas de CD40s a S12 chez les patients non repondeurs a la vaccination : mediane = 193 (142;470) vs 413 (93;814) pg/mL ; p = 0,08. Pour l’ensemble de la cohorte, les patients repondeurs a la vaccination ont tendance a etre plus jeunes (âge median 64 ans vs 76 ans ; p = 0,16). Discussion L’hypothese d’une epuration du CD40s par adsorption sur PMMA qui permettrait une meilleure reponse vaccinale n’est pas confirmee dans notre etude. Il est possible que la bonne reponse vaccinale observee dans les deux groupes et particulierement sous Polysulfone, soit liee a l’epuration d’autres substances par les membranes haute permeabilite ou a un meilleur suivi de la vaccination dans le cadre d’un protocole. Conclusion Nous n’avons pas observe de superiorite de la membrane en PMMA sur la reponse vaccinale contre le virus de l’hepatite B comparee a la polysulfone haute permeabilite.

Des etudes preliminaires laissent penser que le thermalisme a orientation psychosomatique pourrait etre efficace pour traiter le trouble d’anxiete generalisee. Nous avons compare le thermalisme a orientation psychosomatique a la Paroxetine dans un essai randomise muticentrique pendant 8 semaines. Deux cent trente-sept patients presentant un trouble d’anxiete generalisee (DSM-IV) ont ete inclus dans l’essai, 117 ont ete randomises dans le groupe thermalisme et 120 dans le groupe Paroxetine. L’efficacite a ete evaluee a partir des scores obtenus a l’echelle d’appreciation de l’anxiete d’Hamilton (HAMA). Deux cent sept patients ont ete suivis jusqu’a la fin de l’etude. Les scores obtenus a l’HAMA montrent une amelioration dans les deux groupes avec une superiorite en faveur du traitement par thermalisme par rapport a la Paroxetine (p < 0,0001). La mise en place de cette etude s’est heurtee a differents problemes methodologiques (notamment parce que l’utilisation d’un placebo n’etait pas possible) qui sont discutes par les auteurs.

Background: There is insufficient data to reliably assess the benefit of bronchodilators in ventilated premature neonates. Objectives: To compare the efficacy/tolerance of inhaled ipratropium bromide (IB) vs. terbutaline (T) and to describe factors associated with their efficacy. Methods: A cross-over randomized controlled double-blind trial including intubated neonates with respiratory distress syndrome. Two puffs of IB or T were administered at 0, 20, 40 min. Passive respiratory system resistance (Rrs) and compliance (Crs) were measured at 0, 20, 40, 60 min. A positive response was defined as a >2 individual coefficients of variation decrease in Rrs or increase in Crs. Results: Twenty-one infants (gestational age (mean ± SD): 27.3 ± 1.6 weeks; birth weight: 947 ± 250 g; postnatal age: 20 ± 9 days) were included. At 60 min, no treatment effect for Rrs and Crs could be identified (cross-over analysis). Overall data (irrespective of order of administration) showed that after 6 puffs, the decrease in Rrs was greater in the IB vs. T group (–17.0 ± 22.2% vs. –11.3 ± 26.7%, respectively (NS)). Thirty-eight percent of infants responded to IB vs. 43% to T. However, in 19% of patients, decreased Crs was observed after 6 puffs of T. No marker of a positive or paradoxical response could be identified. Treatment was well-tolerated. Conclusion: High doses of bronchodilators are required in ventilated neonates, but the positive response rate was

Objectives The objectives were to estimate the prevalence of Chlamydia trachomatis infection in subfertile couples and to study the relationship between markers of C. trachomatis infection and male infertility as well as pregnancy rates after in vitro fertilization (IVF). Study design All consecutive couples consulting for infertility and IVF in Pellegrin Hospital were screened for C. trachomatis by direct (PCR test) and serological methods. Results Two hundred and seventy-seven couples were included in the study (mean age in years: 35 for men, 32 for women; mean duration of infertility: 4 years). The most frequent indication for IVF was tubal factor in 33%, endometriosis in 6%, dysovarian function in 12%, male infertility in 36% and others in 13%. C. trachomatis PCR was positive in 1.2% of men, 95% confidence interval (CI 95% ): (0.2%; 3.3%) and in 2.7% of women, CI 95% : (1.1%; 5.5%). When combining all chlamydial markers, 17.3% of men, CI 95% : (12.7%; 22.8%) and 20.4% of women, CI 95% : (15.6%; 25.9%) had at least one positive marker. The presence of positive markers was not associated with altered semen characteristics. Couples with positive markers had a pregnancy rate of 23.1% (12 out of 52) compared with 20.2% (24 out of 119) among those with negative markers. Conclusion In this population, the presence of past or current C. trachomatis infection was associated with neither semen characteristics nor outcome of IVF in subfertile couples.

International audience; OBJECTIVE: We tested the effect of dietary advice dedicated to increase intake in older patients at risk for malnutrition during chemotherapy, versus usual care, on one-year mortality. METHOD: We conducted a multicentre, open-label interventional, stratified (centre), parallel randomised controlled trial, with a 1ratio1 ratio, with two-year follow-up. Patients were aged 70 years or older treated with chemotherapy for solid tumour and at risk of malnutrition (MNA, Mini Nutritional Assessment 17-23.5). Intervention consisted of diet counselling with the aim of achieving an energy intake of 30 kCal/kg body weight/d and 1.2 g protein/kg/d, by face-to-face discussion targeting the main nutritional symptoms, compared to usual care. Interviews were performed 6 times during the chemotherapy sessions for 3 to 6 months. The primary endpoint was 1-year mortality and secondary endpoints were 2-year mortality, toxicities and chemotherapy outcomes. RESULTS: Between April 2007 and March 2010 we randomised 341 patients and 336 were analysed: mean (standard deviation) age of 78.0 y (4.9), 51.2% male, mean MNA 20.2 (2.1). Distribution of cancer types was similar in the two groups; the most frequent were colon (22.4%), lymphoma (14.9%), lung (10.4%), and pancreas (17.0%). Both groups increased their dietary intake, but to a larger extent with intervention (p\textless0.01). At the second visit, the energy target was achieved in 57 (40.4%) patients and the protein target in 66 (46.8%) with the intervention compared respectively to 13 (13.5%) and 20 (20.8%) in the controls. Death occurred during the first year in 143 patients (42.56%), without difference according to the intervention (p = 0.79). No difference in nutritional status changes was found. Response to chemotherapy was also similar between the groups. CONCLUSION: Early dietary counselling was efficient in increasing intake but had no beneficial effect on mortality or secondary outcomes. Cancer cachexia antianabolism may explain this lack of effect. TRIAL REGISTRATION: ClinicalTrials.gov NCT00459589.

Introduction et but de l’etude La transplantation renale (TR) est le traitement de choix de l’insuffisance renale chronique terminale. Elle s’accompagne de modifications de la composition corporelle, en particulier d’une augmentation de la masse grasse. Le devenir de la masse cellulaire active (MCA) dans cette population ainsi que ses determinants sont moins bien connus. Nous presentons ici les resultats de l’etude prospective CORPOS decrivant l’evolution de la MCA avant et apres greffe renale. Les parametres cliniques et biologiques l’influencant sont analyses. Materiel et methodes La masse maigre (MM) et la masse grasse (MG) ont ete mesurees par absorptiometrie bi photonique (DEXA). L’eau corporelle totale et l’eau extra cellulaire (EEC) ont ete evaluees par bioimpedancemetrie multifrequence (Imp SFB7 − Impedimed Pty Ltd. Queensland, Australia). La masse cellulaire active (MCA) a ete calculee selon MCA = MM – EEC. Les apports alimentaires, le score global d’activite physique (auto questionnaire de Baecke), les parametres nutritionnels ont ete recueillis simultanement aux mesures anthropometriques, au moment de l’inscription sur liste d’attente de greffe, M12 apres l’inscription, a M1, M6, M12, M. 24 post greffe. Les resultats sont exprimes en moyenne +/ – ecart-type. Un modele mixte avec changements de pente est utilise pour l’analyse des variables explicatives. Resultats et Analyse statistique 80 patients (25 femmes et 55 hommes) âges de 51,9 +/−11 ans ont ete inclus. La duree moyenne d’attente avant greffe est de 17 +/−11 mois. La MCA diminue pendant la periode pre greffe (33,4 +/−7,1 kg a 32,9 +/−8,1 kg), avec un nadir a M1 post greffe (30,2 +/−6,5 kg). Elle remonte ensuite avec un maximum a M. 12 post greffe (31,7 +/−7,1kg). L’evolution des autres parametres est decrite dans le tableau ci-dessous : Inclusion M12 pre TR M1 post TR M6 post TR M12 post TR M24 post TR IMC (kg/m2) 25,7+/− 4,0 26,2 +/−4,7 24,8 +/−3,8 25,1 +/−3,8 25,5 +/−3,9 25,9 +/−4,4 CRP (mg/l) 6,2 +/− 9,1 4,1 +/−5,3 9,9 +/−12,4 6,2 +/−6,8 8,0 +/−13,4 4,2 +/−4,1 Apports proteiques (g/kg/j) 1,1+/−0,3 1,0+/−0,3 1,1+/−0,3 1,1 +/−0,2 1,1 +/−0,3 1,1 +/−0,3 Activite physique (UA) 6,4 +/− 2,1 5,8 +/−1,8 4,9 +/−1,8 5,8 +/−1,84,9 5,8 +/−1,8 5,8 +/−1,8 Dose corticoides (mg/j) 0,9 +/− 3,6 1,0 +/−3,8 36,2 +/−20,3 9,7 +/−7,6 6,3 +/−5,4 4,3 +/−4,5 L’utilisation d’un modele mixte avec changements de pente (M1 et M12 post greffe) prenant en compte l’âge, le sexe, l’albuminemie, la CRP, les apports proteiques et energetiques, le score d’activite physique et la dose de corticoides permet de conclure que l’evolution avant et apres TR de la MCA est significativement influencee par le sexe (p Conclusion La MCA diminue avant la TR, pour re augmenter ensuite la premiere annee post greffe. Cette evolution est plus marquee chez les hommes, positivement correlee a l’activite physique et negativement influencee par la corticotherapie. L’activite physique, faible dans la population des insuffisants renaux, doit etre encouragee.

To correlate the short-term neurological outcome of early cerebral abnormalities using cranial ultrasonography (US) in premature newborns at their hospital discharge.Each newborn born33 weeks of gestational age (GA) included in a prospective cohort benefited of 3 US: two early in the first week of life (D3 and D8) and one later (Months 1-2) standardized US pulsed Doppler. A US abnormality was ≥one morphologic abnormality (moderate: intra-ventricular hemorrhage (IVH) grades 1-2; severe: IVH 3-4, periventricular leukomalacia, persistent flares). Correlates of having a severe adverse neurological outcome were analyzed using a stepwise backward logistic regression adjusted model with gestational age, early cerebral abnormality at Days 3-8, velocity and with variables with correlation probabilities with p0.25 in the univariate analysis among occurring co-morbidity events previously defined. Two adjusted logistic regression analyses were conducted including or not velocity data because of missing information.Among 452 premature included, 11.3% did not have an early US, 74.8% had a normal early US, 13.9% ≥one early morphological US abnormality (10.0% moderate, 3.9% severe). At hospital discharge, 40% were still alive with a normal late US, 33% alive with ≥one late morphological US abnormality (10% moderate, 23% severe), and 10% died. Adjusted correlates of a late US severe abnormality or a neurological related death at hospital discharge were: early US abnormality (aOR: 8.7, 95% CI: 2.3-33.6), GA29 weeks (aOR: 2.8 95% CI: 1.4-5.4).This study shows that early US morphological abnormalities increase significantly when the GA decreases and is highly predictive of the occurrence of a further late US severe abnormality or neurological related death at hospital discharge.

Objective The ERAMS study addressed the value of arterial stiffness in predicting the severity of systemic sclerosis. Methods ERAMS was a prospective multicentre cohort study including patients with definite systemic sclerosis. Arterial stiffness was measured by the standardized non-invasive QKd 100-60 method. Clinical evaluation, biological measurements, functional respiratory tests and cardiac Doppler echography were performed at inclusion then each year until 3 years' follow-up was completed. Progression was defined as mild (articulations, muscle, oesophagus or skin involvement) or severe (lung, heart or kidney involvement) by a critical event committee. The prediction of severe progression was studied for QKd 100-60 as well as clinical and biological data at baseline by univariate and multivariate analysis. Results Ninety-nine patients were included (81 women, 18 men, mean age 57 years, standard deviation 12.5). Although their blood pressure profile was normal, half the patients had increased arterial stiffness (QKd 100-60 < 200ms). There was a significant relationship between age-adjusted arterial stiffness and decrease in carbon dioxide diffusion (P

Objective To investigate whether truncal distribution of fat mass (TDFM) is associated with variations of the hypothalamic-pituitary-adrenocortical (HPA) axis activity in prepubertal obese children. Study design TDFM, assessed with dual energy X-ray absorptiometry and a comprehensive set of measures of HPA axis activity and reactivity have been studied in 45 prepubertal obese children aged 6 to 11 years (girls) and 6 to 13 years (boys). Results After adjustment for whole body fat mass (%) (WBFM), TDFM correlated positively with insulin (r = 0.50, 95% CI [0.23; 0.70]) and homeostasis model assessment of insulin resistance (r = 0.52, 95% CI [0.25; 0.71]). When adjusted for WBFM, TDFM correlated positively with morning plasma cortisol (r = 0.38, 95% CI [0.15; 0.64]) in the total population. TDFM correlated negatively with the rise of salivary cortisol after a standard meal (r = −0.43, 95% CI [−0.71; −0.02]), obviously in girls. When adjusted for WBFM and TDFM, morning plasma cortisol correlated positively with total cholesterol (r = 0.41, 95% CI [0.11; 0.65]) and triglyceride (r = 0.44, 95% CI [0.14; 0.67]). The rise of salivary cortisol after a standard meal was negatively (r = −0.56, 95% CI [−0.85; −0.01]) and positively (r = 0.74, 95% CI [0.16; 0.94]) correlated with homeostasis model assessment of insulin resistance in boys and girls, respectively. Conclusions Association exists in prepubertal obese children between TDFM and markers of HPA axis activity. These data suggest that HPA axis could be involved early in life in obesity associated with pejorative metabolic profile.

Objective To assess the effects of delirium on the institutionalization rate, taking into account geriatric syndromes and nutritional status. Methods This population-based study took place in an acute care unit and included participants older than 75 years, arriving from home and later discharged. Confusion Assessment Method (CAM) symptoms were recorded by the nurses within 24 hours after admission and every 3 days. Delirium was defined using the CAM algorithm, and subsyndromal delirium responded to symptoms not fulfilling the CAM algorithm. These delirium categories were either present at admission (prevalent) or occurred during the hospital stay (incident). Participants were classified as having a low dietary intake when energy intake was at any time lower than 600 kcal/d. Age, sex, known cognitive impairment, weight, functional dependency, and laboratory testing as well as diagnoses were also recorded. Step-by-step backward logistic regression was used to identify predictors of institutionalization. Results Among 427 patients, 310 (72.6%) were discharged and were compared with 117 (27.4%) participants admitted to an institution. Female sex (odds ratio [OR]: OR 2.15, 95% confidence interval [CI]: CI 1.22-3.78), prevalent delirium (OR 3.19, 95% CI 1.33-7.64), subsyndromal delirium (OR 2.72, 95% CI 1.48-5.01), incident subsyndromal delirium (OR 4.27, 95% CI 2.17-8.39), low dietary intake (OR 2.50, 95% CI 1.35-4.63), and a fall (OR 2.16, 95% CI 1.22-3.84) or a diagnosis of stroke (OR 2.03, 95% CI 1.04-3.94) were independent predictors of institutionalization. Conclusions Symptoms of delirium and severe nutritional impairment led patients to geriatric institutions. Therefore, these institutions need to implement policies that address both of these issues.

Notice d'un catalogue d'exposition; International audience; Notice du catalogue d'éxposition et traduction de la lettre paléo-babylonienne du Musée du Louvre AO 632 (K. Veenhof, AbB 14 67).

Food, drinking and precious vessels were always used to show political power and cultural influence. THe case of the ancient capital city of Mari (Tell Hariri, Syria) in the 18th century BC is examined., A toutes les époques les arts de la table pouvaient être au service de la diplomatie et de la représentation du pouvoir. L'article traite le cas de l'ancienne capitale Mari (Tell Hariri, Syrie). Les archives retrouvées dans cette ville combinée aux données issues de fouilles permettent de retracer une image assez complète.

The theme of the hunting king is a classic element in the construction of the image of the monarchy. The royal iconography shows Philip IV hunting, and the same strategy animates the Anfiteatro de Felipe el Grande (Madrid, 1631), which relates and stages, by magnifying it, a hunting exploit of Philip IV in a perspective of monarchic propaganda. The treatises devoted to the education of the prince also emphasise the role of hunting in the training of the prince. This will be contrasted with the scandal caused by the photos of King Juan Carlos of Bourbon taking part in an elephant hunt in April 2012: these images caused a sharp deterioration in the monarch's image in public opinion and were one of the elements leading to his abdication on 19 June 2014. The contrasting analysis of these two phenomena (the presence of hunting in the construction of the king's image and in monarchical propaganda, and hunting as an element that precipitated the king's fall from grace in 2012) will make it possible to highlight the evolution of representations of hunting (and of the monarchy) in the minds, El tema del rey cazador es un elemento clásico en la construcción de la imagen de la monarquía. La iconografía real muestra a Felipe IV cazando, y la misma estrategia anima el Anfiteatro de Felipe el Grande (Madrid, 1631), que relata y escenifica, magnificándola, una hazaña de caza de Felipe IV en una perspectiva de propaganda monárquica. Los tratados dedicados a la educación del príncipe también destacan el papel de la caza en la formación del príncipe. Estas representaciones se contrastan con el escándalo provocado por las fotos del rey Juan Carlos de Borbón participando en una cacería de elefantes en abril de 2012: estas imágenes provocaron un fuerte deterioro de la imagen del monarca en la opinión pública y fueron uno de los elementos que llevaron a su abdicación el 19 de junio de 2014. El análisis contrastado de estos dos fenómenos (la presencia de la caza en la construcción de la imagen del rey y en la propaganda monárquica, y la caza como elemento que precipitó la caída en desgracia del rey en 2012) permitirá destacar la evolución de las representaciones de la caza (y de la monarquía) en las mentalidades., Le thème du roi chasseur et les images du roi à la chasse sont des éléments classiques dans la construction de l’image de la monarchie. L’iconographie royale montre Philippe IV à la chasse, et la même stratégie anime l’Anfiteatro de Felipe el Grande (Madrid, 1631), qui relate et met en scène, en le magnifiant, un exploit cynégétique de Philippe IV dans une perspective de propagande monarchique. Les traités consacrés à l’éduction du prince soulignent aussi le rôle de la chasse dans la formation du prince. On contrastera ces représentations avec le scandale provoqué par les photos du roi Juan Carlos de Bourbon, participant à une chasse à l’éléphant, en avril 2012 : ces images furent à l’origine d’une forte dégradation de l’image du monarque dans l’opinion publique et constituèrent un des éléments conduisant à son abdication, le 19 juin 2014. L’analyse contrastée de ces deux phénomènes (la présence de la chasse dans la construction de l’image du roi et dans la propagande monarchique et la chasse comme élément ayant précipité la chute du roi dans l’opinion, en 2012) permettra de mettre en évidence l’évolution des représentations de la chasse (et de la monarchie) dans les mentalités