Medication use in pregnancy: a cross-sectional, multinational web-based study.

OBJECTIVES: Intercountry comparability between studies on medication use in pregnancy is difficult due to dissimilarities in study design and methodology. This study aimed to examine patterns and factors associated with medications use in pregnancy from a multinational perspective, with emphasis on type of medication utilised and indication for use. DESIGN: Cross-sectional, web-based study performed within the period from 1 October 2011 to 29 February 2012. Uniform collection of drug utilisation data was performed via an anonymous online questionnaire. SETTING: Multinational study in Europe (Western, Northern and Eastern), North and South America and Australia. PARTICIPANTS: Pregnant women and new mothers with children less than 1 year of age. PRIMARY AND SECONDARY OUTCOME MEASURES: Prevalence of and factors associated with medication use for acute/short-term illnesses, chronic/long-term disorders and over-the-counter (OTC) medication use. RESULTS: The study population included 9459 women, of which 81.2% reported use of at least one medication (prescribed or OTC) during pregnancy. Overall, OTC medication use occurred in 66.9% of the pregnancies, whereas 68.4% and 17% of women reported use of at least one medication for treatment of acute/short-term illnesses and chronic/long-term disorders, respectively. The extent of self-reported medicated illnesses and types of medication used by indication varied across regions, especially in relation to urinary tract infections, depression or OTC nasal sprays. Women with higher age or lower educational level, housewives or women with an unplanned pregnancy were those most often reporting use of medication for chronic/long-term disorders. Immigrant women in Western (adjusted OR (aOR): 0.55, 95% CI 0.34 to 0.87) and Northern Europe (aOR: 0.50, 95% CI 0.31 to 0.83) were less likely to report use of medication for chronic/long-term disorders during pregnancy than non-immigrants. CONCLUSIONS: In this study, the majority of women in Europe, North America, South America and Australia used at least one medication during pregnancy. There was a substantial inter-region variability in the types of medication used.

Varicelle pendant la grossesse: quelles conséquences pour la mère et l'enfant [Varicella during pregnancy: consequences for the mother and the newborn].

In our area, varicella is a frequent and essentially benign childhood disease. In contrast, the disease course is likely to be more severe or complicated in the adult, particularly so in the pregnant woman. There is a definite risk of congenital varicella syndrome when the chickenpox occurs during the first 20 weeks of pregnancy. This syndrome predominantly affects the skin, the subcutaneous tissue, muscles and bones, as well as the central nervous system, and can bring about major functional sequellae. In case of chickenpox occurring at the very end of pregnancy, transplacental transfer of the virus may result in a perinatal varicella disease. We propose a approach of each of these different situations.

Social dysfunctioning after mild to moderate first-ever stroke at vocational age.

BACKGROUND: With improvements in stroke treatments, the number of patients with dramatic recovery is increasing. However, many of them are still complaining of difficulties in returning to work and every day activities. The aim was to assess work and social dysfunctioning in patients with minor to moderate stroke and explore its contributing factors. METHODS: Consecutive patients were prospectively included at a median 7 months after a first-ever stroke. Scores on the Work and Social Adjustment Scale (WSAS), a generic self-reported scale for assessing social functioning, were correlated with scores on the National Institutes of Health Stroke Scale (NIHSS), activities of daily living, Hospital Anxiety and Depression scale (HAD) and MMSE, Iowa Scale of Personality Changes and return to work at 1 year. RESULTS: Among the 84 included patients (mean age 43.5 years), 57 (68%; 95% CI 57 to 78%) complained of significant perturbation of functioning attributed to stroke. WSAS was highly significantly related to modified Rankin scale, daily living activities, Iowa Scale of Personality Changes and return to work at 1 year. Using ordinal logistic regression, the contributors to WSAS were initial neurological severity (NIHSS at admission), HAD and MMSE. CONCLUSIONS: The study showed that up to 68% of our patients complained of significant work and social dysfunction due to stroke, despite a good clinical outcome. This self-estimation was correlated to external validation criteria, stressing the high burden of stroke from the patient's viewpoint. Moreover, when compared across diseases, social dysfunctioning after mild stroke was as important as in other major disabling diseases.

Dosimetry of 90Y-ibritumomab tiuxetan as consolidation of first remission in advanced-stage follicular lymphoma: results from the international phase 3 first-line indolent trial.

The objective of this analysis was to assess the radiation exposure associated with (90)Y-ibritumomab tiuxetan when used as consolidation therapy in adults with low or minimal tumor burden after first-line therapy of advanced follicular lymphoma (FL). METHODS: The patients who were enrolled in the phase 3 first-line indolent trial were 18 y or older, with CD20(+) grade 1 or 2 stage III or IV FL, and a partial response, complete response, or unconfirmed complete response to first-line chemotherapy. The patients were allocated randomly to receive a single infusion of unlabeled rituximab 250 mg/m(2) on day -7 and consolidation on day 0 with a single dose of (90)Y-ibritumomab tiuxetan, 14.8 MBq/kg, immediately after unlabeled rituximab, 250 mg/m(2), or no further treatment. On day -7, a subset of patients received an injection of 185 MBq of (111)In-ibritumomab tiuxetan immediately after unlabeled rituximab, 250 mg/m(2), for central dosimetry analysis. Correlations were assessed between organ radiation absorbed dose and toxicity, body weight, body mass index, and progression-free survival. RESULTS: Central dosimetry evaluations were available from 57 of 70 patients. Median radiation absorbed doses were 100 cGy (range, 28-327 cGy) for the red marrow and 72 cGy (range, 46-106 cGy) for the whole body. Radiation absorbed doses did not differ significantly between patients who had a partial response or complete response to initial therapy. Progression-free survival correlated significantly with the whole-body (r = 0.4401; P = 0.0006) and bone marrow (r = 0.2976; P = 0.0246) radiation dose. Body weight was significantly negatively correlated with whole-body radiation dose (r = -0.4971; P < 0.0001). Neither the whole-body radiation dose nor the bone marrow radiation dose correlated with hematologic toxicity. CONCLUSION: In patients with low or minimal residual tumor burden after first-line chemotherapy of advanced FL, whole-body and bone marrow exposure after (90)Y-ibritumomab tiuxetan consolidation showed a significant positive correlation with progression-free survival, whereas dosimetric data could not predict hematologic toxicity.

Outcome of long-axis percutaneous sacroplasty for the treatment of sacral insufficiency fractures.

Our aim was to assess the clinical outcome of patients who were subjected to long-axis sacroplasty for the treatment of sacral insufficiency fractures. Nineteen patients with unilateral (n = 3) or bilateral (n = 16) sacral fractures were involved. Under local anaesthesia, each patient was subjected to CT-guided sacroplasty using the long-axis approach through a single entry point. An average of 6 ml of polymethylmethacrylate (PMMA) was delivered along the path of each sacral fracture. For each individual patient, the Visual Analogue pain Scale (VAS) before sacroplasty and at 1, 4, 24 and 48 weeks after the procedure was obtained. Furthermore, the use of analgesics (narcotic/non-narcotic) along with the evolution of post-interventional patient mobility before and after sacroplasty was also recorded. The mean pre-procedure VAS was 8 +/- 1.9 (range, 2 to 10). This rapidly and significantly (P < 0.001) declined in the first week after the procedure (mean 4 +/- 1.4; range, 1 to 7) followed by a gradual and significant (P < 0.001) decrease along the rest of the follow-up period at 4 weeks (mean 3 +/- 1.1; range, 1 to 5), 24 weeks (mean 2.2 +/- 1.1; range, 1 to 5) and 48 weeks (mean 1.6 +/- 1.1; range, 1 to 5). Eleven (58%) patients were under narcotic analgesia before sacroplasty, whereas 8 (42%) patients were using non-narcotics. Corresponding values after the procedure were 2/19 (10%; narcotic, one of them was on reserve) and 10/19 (53%; non-narcotic). The remaining 7 (37%) patients did not address post-procedure analgesic use. The evolution of post-interventional mobility was favourable in the study group as they revealed a significant improvement in their mobility point scale (P < 0.001). Long-axis percutaneous sacroplasty is a suitable, minimally invasive treatment option for patients who present with sacral insufficiency fractures. More studies with larger patient numbers are needed to explore any unrecognised limitations of this therapeutic approach.

Traitement de l'asthme et de la rhinite durant la grossesse et l'allaitement [Treatment of asthma and rhinitis during pregnancy and breast feeding]

Inhaled therapies are preferred to systemic ones during pregnancy and breast feeding. A real paradox exists however between the necessity to ensure an optimal treatment for pregnant women with asthma, in order to prevent fetal hypoxia, and the precaution linked to any drug prescription during pregnancy. Thus, the use of topical corticosteroids remains the first choice for asthma as well as rhinitis. Inhaled beta2-agonists are also recommended. Systemic corticosteroids may however be prescribed without hesitation when their use is required for asthma treatment. It is also interesting to note that oral second-generation antihistamines are currently allowed during pregnancy and breast feeding. This type of antihistamines is indeed to be preferred to first-generation ones that generate more side-effects and generally are thus not to be prescribed during breast feeding.

Lymphome et grossesse: quelle prise en charge [Management of lymphoma and pregnancy]

With an incidence of 1/6000 pregnancies, per-partum lymphoma is a rare but not an exceptional event, which gynaecologists and family physicians can be confronted in the course of their career The diagnosis, without a peripheral adenopathy, can be challenging because symptoms, such as fatigue or dyspnoea, can easily be attributed to the pregnancy. Although the therapeutic management is complex, because it involves the mother and her embryos, it can be optimal in the majority of cases. The multidisciplinary management, with modern diagnostic and therapeutic approaches, greatly improved the prognosis of these young women. Today, it generally allows the safekeeping of the baby with an outcome for the mother identical to the one observed in the population at large.

Prevalence, predictors, and consequences of long-term refusal of antipsychotic treatment in first-episode psychosis.

OBJECTIVE: Studies investigating medication adherence in psychosis are limited by the need of a certain degree of medication adherence and the inclusion of mostly multiple-episode patients. By contrast, noninformed consent, epidemiological studies in first-episode psychosis (FEP) allow the assessment of an important subgroup of patients who persistently refuse antipsychotic medication and thereby never receive an adequate antipsychotic trial. The present study aims to assess the prevalence and predictors of such a "medication refusal" subgroup and its association with illness outcome. METHODS: The present file audit study assessed medication adherence in an epidemiological cohort of 605 FEP patients who were treated within the Early Psychosis Prevention and Intervention Centre for up to 18 months. Medication adherence was categorized into full adherence, nonadherence, and persistent medication refusal. Predictors were analyzed using logistic regression models. RESULTS: During the 18-month treatment period, 204 patients (33.7%) were fully adherent, 287 (47.4%) displayed at least 1 phase of nonadherence, and 114 patients (18.8%) were persistent medication refusers. Poor premorbid functioning, comorbid substance use, and poor insight predicted both medication refusal and nonadherence; a forensic history and no previous contact to psychiatric care were specifically predictive of medication refusal. With respect to illness outcome, nonadherent patients were worse off when compared with fully adherent patients, and medication refusers were even worse off compared with nonadherent patients. CONCLUSIONS: Within a nonselected epidemiological FEP cohort, almost 20% of patients are persistent medication refusers. The found predictors may help to identify the individual risk of persistent medication refusal and may enable an early (preventive) treatment adaptation.

Hypertension et grossesse [Hypertension in pregnancy]

Hypertension in pregnancy Hypertension in pregnancy, whether chronic or recently diagnosed, is always a matter of concern for the general practitioner or the obstetrician. Even if this situation often evolves favorably, and although a "wait and see" attitude may be preferred to an aggressive one in such cases, one should also be aware of how dramatic the outcome may also be. As a matter of fact, what is considered as one of the most frequent complications of pregnancy can run out of control, a possibility which shouldn't be dismissed. In this article, we shall discuss the various strategies for managing this disorder.

Avulsion fracture of peroneus longus tendon at the first metatarsal insertion: a case report : P16

Introduction: Isolated avulsion fracture at the plantar lateral base of the first metatarsal (M1) is very rare. Case report: A 35 year old overweight woman sustained an eversion strain of her right foot. Despite pain along M1 she was able to continue walking for three days before presenting to her family doctor. Swelling on the plantar aspect of the foot was noticed, there was also pain at eversion of the foot and extension of the ankle. Plain X-ray showed no abnormalities. A MRI showed minimal bone bruise at the basis of M1 and a partial rupture of the peroneus longus tendon at its insertion. The patient was allowed to walk with partial weight bearing with a soft ankle brace. After 6 months she presented at our hospital because of persistent pain. There was still a painful insertion of the peroneus longus but active plantarflexion of M1 was possible. Plain X-rays were poorly contributive except for a discrete flattening of the longitunal arch. CT-scan showed a non displaced fracture at the M1-basis. A protocol with partial weight-bearing in a short-leg cast and partial weight-bearing orthosis each for 6 weeks was unsuccessfully attempted. Therefore, an excision of the non healed bone fragment at the basis of M1 and a first tarsometatarsal joint arthrodesis were performed. Postoperatively the patient wore a partial weight-bearing short leg cast for 6 weeks followed by a weight-bearing short leg cast for 6 weeks with favourable outcome. Discussion: Initial internal fixation has been reported to lead to good results [1, 2]. In our case the conservative treatment failed and leaded to non union. At that time we considered as too risky (overweight) to excise the fragment and reattach the peroneus longus tendon. Therefore, we excised the fragment and fused the first tarsometatarsal joint. This procedure allowed, at least partially, to compensate for the function of the peroneus longus tendon. 1 Murakami T, et al. Avulsion fracture of the peroneus longus at the first metatarsal insertion: a case report. Br J Sports Med. 2004. 2 Kwak HY, and Bae SW. Isolated avulsion fracture at the plantar lateral base of the first metatarsal: a case report. Foot Ankle Int 2000.

Effects of prior repeated-sprints with different recovery duration on oxygen uptake kinetics during subsequent heavy-exercise

Introduction: Prior repeated-sprints (6) has become an interesting method to resolve the debate surrounding the principal factors that limits the oxygen uptake (V'O2) kinetics at the onset of exercise [i.e., muscle O2 delivery (5) or metabolic inertia (3)]. The aim of this study was to compare the effects of two repeated-sprints sets of 6x6s separated by different recovery duration between the sprints on V'O2 and muscular de-oxygenation [HHb] kinetics during a subsequent heavy-intensity exercise. Methods: 10 male subjects performed a 6-min constant-load cycling test (T50) at intensity corresponding to half of the difference between V'O2max and the ventilatory threshold. Then, they performed two repeated-sprints sets of 6x6s all-out separated by different recovery duration between the sprints (S1:30s and S2:3min) followed, after 7-min-recovery, by the T50 (S1T50 and S2T50, respectively). V'O2, [HHb] of the vastus lateralis (VL) and surface electromyography activity [i.e., root-mean-square (RMS) and the median frequency of the power density spectrum (MDF)] from VL and vastus medialis (VM) were recorded throughout T50. Models using a bi-exponential function for the overall T50 and a mono-exponential for the first 90s of T50 were used to define V'O2 and [HHb] kinetics respectively. Results: V'O2 mean value was higher in S1 (2.9±0.3l.min-1) than in S2 (1.2±0.3l.min-1); (p<0.001). The peripheral blood flow was increased after sprints as attested by a higher basal heart rate (HRbaseline) (S1T50: +22%; S2T50: +17%; p≤0.008). Time delay [HHb] was shorter for S1T50 and S2T50 than for T50 (-22% for both; p≤0.007) whereas the mean response time of V'O2 was accelerated only after S1 (S1T50: 32.3±2.5s; S2T50: 34.4±2.6s; T50: 35.7±5.4s; p=0.031). There were no significant differences in RMS between the three conditions (p>0.05). MDF of VM was higher during the first 3-min in S1T50 than in T50 (+6%; p≤0.05). Conclusion: The study show that V'O2 kinetics was speeded by prior repeated-sprints with a short (30s) but not a long (3min) inter-sprints-recovery even though the [HHb] kinetics was accelerated and the peripheral blood flow was enhanced after both sprints. S1, inducing a greater PCr depletion (1) and change in the pattern of the fibres recruitment (increase in MDF) compared with S2, may decrease metabolic inertia (2), stimulate the oxidative phosphorylation activation (4) and accelerate V'O2 kinetics at the beginning of the subsequent high-intensity exercise.

Treatment of adult-onset Still's disease: a review

Adult-onset Still's disease (AOSD) is a rare inflammatory disorder that has been recently classified as a polygenic autoinflammatory disorder. The former classification, based on the disease course, seems to be quite dated. Indeed, there is accumulating evidence that AOSD can be divided into two distinct phenotypes based on cytokine profile, clinical presentation, and outcome, ie, a "systemic" pattern and an "articular" pattern. The first part of this review deals with the treatments that are currently available for AOSD. We then present the different strategies based on the characteristics of the disease according to clinical presentation. To do so, we focus on the two subsets of the disease. Finally, we discuss the management of life-threatening complications of AOSD, along with the therapeutic options during pregnancy.

Cross-cultural clinical competence and post-graduate teaching: any impact(s) on doctors?

Context: Cross-cultural clinical competence (CCC) requires a mixtureof "knowledge" (K), "attitude" (A) and "skills" (S), in order to develop theability to give quality care to patients of different cultures. Theseattributes allow, while providing medical care, consideration of thepatient's medical, social, cultural and language needs. The LausanneUniversity Medical Policlinic (PMU) provides approximately 30000consultations per year to migrant patients and over the past five yearshas implemented a training course on CCC that focuses on trialogue,stereotypes and administrative procedures for the healthcare ofmigrants.Method: A quantitative survey of 18 new residents, was carried outusing a validated questionnaire, the "Multicultural AssessmentQuestionnaire" (the MAQ, 16 questions on K, A and S) to evaluate theimpact of CCC training. The questionnaire was distributed before theCCC course (J-1), three days after (J+3) and three months later (J+90).A descriptive univariate analysis of the difference in MAQ scoresbetween the times J-1 - J+3 and J-1 - J+90 was made. Three FocusGroups were conducted, at three months, to explore residents' thoughtsabout the course.Results: A significant increase was observed in global performancedeclared by residents. Following the intervention, the score of the MAQincreased from 31.4 points to 38.0 points at three days (p = 0.004) andto 37.7 points at three months (p = 0.003). This increase was mostnoticeable in the field of acquiring K: total score J-1: 118, J+3: 189,J+90: 190 (difference J-1 - J+3 and J-1 - J+90: p <0.005). There was nosignificant difference in acquiring A (J-1: 222, J+3: 228, J+90: 229), andS increases in a significant way at first (J-1: 222, J+3: 265, J-1 - J+3:p = 0.035), then comes back to the start value (J+90: 217). The residentswere interested by the course which they felt provides useful informationfor clinical practice. They had a great number of expectations in varyingfields (medical anthropology, cultural differences, epidemiology, etc.),hoping a "ready-made" solution for the approach of migrant patients.Conclusions: A unique training of CCC at the post-graduate level,upgraded K, and to a lesser extent A and S, for these 18 residents. Theywere interest and they had many expectations. Subsequent coursesshould consolidate these acquisitions. Future study should demonstratethe impact on patients' clinical outcome.

Prevalence and impact of cannabis use disorders in adolescents with early onset first episode psychosis.

BACKGROUND: Previous studies on the impact of cannabis use disorders (CU) on outcome in psychosis were predominantly based on non representative samples, often have not controlled for confounders and rarely focused on adolescent patients. Thus, the aims of the present study were to assess: (i) prevalence of CU; (ii) baseline and pretreatment differences between CU and those without CU (NCU); (iii) the impact of baseline and course of CU on 18-month outcomes in a representative cohort of adolescents with early onset first episode psychosis (EOP). METHODS: The sample comprised 99 adolescents (age 14 to 18) with EOP (onset age 14 to 17), admitted to the Early Psychosis Prevention and Intervention Centre in Australia. Data were collected from medical files using a standardized questionnaire. RESULTS: Prevalence of lifetime CU was 65.7%, of current CU at baseline 53.5%, and of persistent CU throughout treatment 26.3%. Baseline CU compared to NCU had significantly higher illness-severity, lower psychosocial functioning, less insight, lower premorbid functioning and longer duration of untreated psychosis. Compared to all other groups, only persistent CU was linked to worse outcomes and more service disengagement. Effect sizes were medium controlling for relevant confounders. Medication non-adherence did not explain the association between persistent CU and worse outcome. CONCLUSIONS: Baseline CU was associated with worse baseline characteristics, but only persistent CU was linked with worse outcome. About half of those with baseline CU reduced cannabis during treatment. For these, effectively treating the psychotic disorder may already be beneficial. However, future research is necessary on the reasons for persistent CU in EOP and its treatment.

Long-term prognosis in patients with vasculopathic sixth nerve palsy.

PURPOSE: To better define the long-term prognosis in patients with a vasculopathic sixth nerve palsy (6NP), specifically addressing the degree of recovery and incidence of recurrent similar episodes. DESIGN: Observational case series. METHODS: Retrospective chart review. SETTING: An outpatient neuroophthalmic practice. STUDY POPULATION: Patients with one or more vascular risk factors and an acute, isolated 6NP that spontaneously recovered. OBSERVATION PROCEDURE: Information regarding resolution of the 6NP, subsequent vascular events and recurrent ocular motor nerve palsy was obtained from chart review of follow-up clinic visits, mailed questionnaires and telephone interviews. The duration of follow-up ranged from 2 to 13 years. MAIN OUTCOME MEASURES: Resolution of 6NP (complete or incomplete) and incidence of recurrent ocular motor nerve palsy. RESULTS: Fifty-nine patients were identified with a mean age of 65.3 years +/- 11.6 (range 34-90 years). Fifty-one patients (86%) experienced complete resolution of their first episode of vasculopathic 6NP and eight patients (14%) had incomplete resolution. A subsequent episode of ocular motor mononeuropathy occurred in 18 of 59 (31%) patients. The number of recurrences ranged from one (in 14 patients) to four (in one patient). There was no association between any risk factor and recurrence of ocular motor nerve palsy. Similarly, incomplete resolution of the vasculopathic 6NP was not associated with any risk factor. CONCLUSIONS: Patients with a vasculopathic 6NP usually have complete resolution of their ophthalmoplegia, but nearly one third of patients in our study later experienced at least one episode of recurrent vasculopathic ocular motor nerve palsy.