[Systematic analysis of evaluations of Objective Structured Clinical Exam (OSCE) multiple circuits: Explanatory variables and inter-rater correlations]

INTRODUCTION

Objective Structured Clinical Examinations (OSCEs) assess professional performance in a simulated environment. Following their integration into the reform of the 2nd cycle of medical studies (R2C), this pedagogical modality was implemented in France. This study investigates the variability of students' OSCE scores, as well as their inter-rater reproducibility.

METHODS

This single-center retrospective study covered several sessions of evaluative OSCE circuits conducted between January 2022 and June 2023. Variables collected were: baseline situation family, competency domain, presence of a standardized participant for stations; gender and professional status for evaluators; scores (global, clinical and communication skills), number of previously completed OSCE circuits and faculty scores for students.

RESULTS

The variability of the overall score was explained mainly (79.7%, CI95% [77.4; 82.0]) by the station factor. The student factor and the circuit factor explained 7.5% [12.9; 20.2] and<0.01% [2.10-13; 2.10-9] respectively. The inter-rater intra-class correlation coefficient was 87.2% [86.4; 87.9] for the global score. Station characteristics (starting situation, domain) and evaluator characteristics (gender, status) were significantly associated with score variations.

CONCLUSION

This first study on the variability of OSCE circuit scores in France shows good reproducibility with influence of station characteristics. In order to standardize circuits, variability linked to the domain competency should be considered as well.

Facteurs associés à la détresse psychologique des étudiants en médecine lors de la crise sanitaire de la COVID-19 : une étude transversale

Objectifs

Les modifications organisationnelles liées à la crise sanitaire COVID-19 (cours en distanciel et stage en service d’unités COVID pour certains externes) ont pu favoriser la détresse psychologique des étudiants inscrits en médecine habituellement exposés à une charge de travail intense. L’objectif de cette étude était d’évaluer la prévalence de la détresse psychologique chez les étudiants en médecine pendant la crise sanitaire du COVID-19, et d’identifier les facteurs associés à la détresse psychologique.

Méthodes

Une étude observationnelle transversale a été proposée à 1814 étudiants en médecine (de la première à la sixième année) dans un centre hospitalier universitaire français du 10 mars au 25 mars 2021. Un avis favorable du comité d’éthique a été obtenu (IRBN272021/CHUSTE). Des informations sociodémographiques, professionnelles et médicales (détresse psychologique mesurée sur l’échelle française GHQ12) ont été recueillies par le biais d’un questionnaire anonyme auto-administré en ligne. Les variables associées à la détresse psychologique ont été étudiées en utilisant une analyse univariée (test du Chi² et Fisher). Les variables avec une valeur p < 0,2 ont été inclues dans un modèle de régression de Poisson modifiée et les variables avec une valeur de p < 0,05 ont été conservées dans le modèle.

Résultats

Au total, 832 étudiants en médecine ont répondu (46 %) et 699 ont rempli le questionnaire en entier (39 %) : 625 (75 %) ont montré des signes de détresse psychologique et 109 (15 %) ont rapporté des idées suicidaires. Le sexe féminin, un traumatisme psychologique lors de la crise sanitaire COVID-19, une modification de la consommation d’alcool et des difficultés liées à l’enseignement en distanciel étaient positivement associés à la détresse psychologique, alors qu’un sentiment d’entraide et de coopération dans le cadre des études, la reconnaissance du travail effectué étaient négativement associés à la détresse psychologique. Un stage dans une unité COVID n’apparaît pas significativement associé à la détresse psychologique.

Conclusions

Des soins de santé mentale intégrant la prévention du suicide devraient être proposés aux étudiants à risque dans ce contexte de crise sanitaire COVID-19. Connaître les facteurs éducatifs et médicaux associés à la détresse psychologique permet d’identifier des axes de prévention.

Psycho-organizational and medical factors in burnout in French medical and surgery residents

Hospital residency is stressful, with a risk of burnout. To assess the prevalence of burnout in medical and surgical residents and identify psycho-organizational and medical risk factors with a view to prevention. A transverse study was conducted in France between September 2018 and November 2018, targeting 633 hospital residents. A self-administered questionnaire was delivered by e-mail. Burnout was assessed on the Maslach Burnout Inventory, anxiety/depression on the Hospital Anxiety and Depression Scale (HAD) and stress on a visual analogue scale (VAS). Two-hundred and sixteen of the targeted residents (34%) responded. Twenty-three (12%) showed severe burnout in all three dimensions, severe loss of empathy being the most frequent. Almost one-third showed symptoms of anxiety. Residents exposed to psycho-organizational constraints (stress, time pressure, intense work rhythm) and/or with symptoms of anxiety/depression more frequently showed burnout. Prevention of burnout requires reinforced medical monitoring and reduced psycho-organizational constraints.

SARS-CoV-2 infection: advocacy for training and social distancing in healthcare settings

This article reports the observed rate of infection with severe acute respiratory syndrome coronavirus-2 in healthcare workers (HCWs) who worked on wards dedicated to care of patients with coronavirus disease 2019 (COVID-19) compared with HCWs who worked on non-COVID-19 wards. The infection rate was significantly higher among HCWs who worked on non-COVID-19 wards (odds ratio 2.3, P=0.005), illustrating the need to strengthen social distancing measures and training.

Working conditions and risk exposure of employees whose occupations require driving on public roads - Factorial analysis and classification

INTRODUCTION

Several studies of the working conditions of drivers, and in particular on their pace of work, have enabled a better understanding of the risk factors for road accidents that occur during work. However, few studies are available on the risk exposure and working conditions of employees whose occupations involve driving. The purpose of this paper is to identify the different groups of employees occupationally exposed to road risk and to classify them according to working conditions.

METHODOLOGY

A Multiple Correspondence Analysis (MCA) was implemented on the 41,727 individuals from the SUMER 2010 survey (Medical Monitoring of Occupational Risk Exposure: SUrveillance Médicale des Expositions aux Risques professionnels) and for 45 variables about working conditions. The analysis used 5 categories of weekly driving exposure as a supplementary variable (variable which is not used to perform the MCA): Non-exposure; Exposed <2 h; Exposed 2-10 hours; Exposed 10-20 hours; and Exposed >20 h. The results of the MCA were used to construct an ascending hierarchical classification.

RESULTS

The first factorial axis differentiates between conventional and unconventional work schedules. Axis 2 differentiates modalities corresponding to the working hours of the most recent working week. The third axis chiefly contrasts persons who have rules to follow with those who have none. An ascending hierarchical classification distinguishes 10 clusters of individuals according to working conditions. Four clusters of employees were excessively exposed to occupational driving. Clusters also have distinct demographic, occupational and psychosocial characteristics.

CONCLUSION

Analysis of data from the SUMER survey confirms that employees exposed to road risk are particularly affected by atypical work time characteristics, but can be found in all activity sectors and in all types of job.

Neuraxial analgesia is not associated with an increased risk of post-partum relapses in MS

Background:

Obstetrical analgesia remains a matter of controversy because of the fear of neurotoxicity of local anesthetics on demyelinated fibers or their potential relationship with subsequent relapses.

Objective:

To assess the impact of neuraxial analgesia on the risk of relapse during the first 3 months post-partum, with a focus on women who experienced relapses during pregnancy.

Methods:

We analyzed data of women followed-up prospectively during their pregnancies and at least 3 months post-partum, collected in the Pregnancy in Multiple Sclerosis (PRIMS) and Prevention of Post-Partum Relapses with Progestin and Estradiol in Multiple Sclerosis (POPARTMUS) studies between 1992–1995 and 2005–2012, respectively. The association of neuraxial analgesia with the occurrence of a post-partum relapse was estimated by logistic regression analysis.

Results:

A total of 389 women were included, 215 from PRIMS and 174 from POPARTMUS. In total, 156 women (40%) had neuraxial analgesia. Overall, 24% experienced a relapse during pregnancy and 25% in the 3 months post-partum. Women with a pregnancy relapse were more likely to have a post-partum relapse (odds ratio (OR) = 1.83, p = 0.02), independently of the use of neuraxial analgesia. There was no association between neuraxial analgesia and post-partum relapse (OR = 1.08, p = 0.78).

Conclusion:

Neuraxial analgesia was not associated with an increased risk of post-partum relapses, whatever multiple sclerosis (MS) activity during pregnancy.

Changes in body composition during post-menopausal hormone therapy: a 2 year prospective study

BACKGROUND

Post-menopausal hormone therapy (pHT) induces changes in both body composition and bone mineral density (BMD).

METHODS

In 109 post-menopausal women beginning either tibolone 2.5 mg (n=29), tibolone 1.25 mg (n=42) or estradiol 2 mg plus norethisterone acetate 1 mg (E2 + NETA) (n=38), we assessed body composition, total and regional BMD by dual energy X-ray absorptiometry, and the serum bone alkaline phosphatase (BAP), osteocalcin and the urinary excretion to type I collagen C-telopeptide (CTX) at baseline and after 2 years.

RESULTS

At baseline, BMD at all sites correlated negatively with age and years since menopause, and positively with lean mass and fat mass (r=0.42, P<0.001 and r=0.26, P=0.006 at the total femur). During treatment, BMD increased at all sites (P<0.001), and serum BAP, osteocalcin, and urinary CTX decreased in all groups (P<0.001). Lean mass increased whereas android fat and android obesity index decreased. The increase in BMD at all sites correlated positively with changes of lean mass at 2 years.

CONCLUSIONS

Both fat mass and lean mass are related to BMD in post-menopausal women, the relationship being strongest with lean mass; an increase in lean mass and a change in distribution of body fat are observed during treatment with E2 + NETA and tibolone.

Randomized, double-masked, 2-year comparison of tibolone with 17beta-estradiol and norethindrone acetate in preventing postmenopausal bone loss

In this 2-year, randomized study, we compared the efficacy and tolerability of tibolone 2.5 mg (n = 75), tibolone 1.25 mg (n = 76) and estradiol 2 mg plus norethindrone acetate 1 mg (E2/NETA: n = 74) for preventing bone loss in postmenopausal women. Bone mineral density (BMD), measured by dual-energy X-ray absorptiometry, and bone remodeling markers were assessed every 6 months. Side-effects were assessed quarterly. After 24 months, the mean increase (+/- SD) in lumbar spine BMD from baseline was 3.6% +/- 2.9%, 1.9% +/- 3.5% and 6.8% +/- 4.5% in the tibolone 2.5 mg, tibolone 1.25 mg and E2/NETA groups, respectively. All pairwise differences were significant. The proportion of responders (women with a change from baseline in lumbar spine BMD of > or = -2% after 2 years) was 95.7%, 89.0% and 98.5% with tibolone 2.5 mg, tibolone 1.25 mg and E2/NETA, respectively. Similar results were obtained for femoral BMD, although the difference between tibolone 2.5 mg and E2/NETA was not significant at 24 months. Decreases in bone remodeling markers were similar in the three groups. Vaginal bleeding was more common in the E2/ NETA group (33.8%) than with tibolone 2.5 mg (12.0%) or tibolone 1.25 mg (9.2%), as was breast pain (23.0%, 2.7% and 2.6%, respectively). Each treatment effectively prevented bone loss. Overall, tolerability of tibolone was better than with E2/NETA, because of less frequent vaginal bleeding and breast pain. This may promote long-term adherence.

Dose-ranging studies of a novel intranasal estrogen replacement therapy

OBJECTIVE

To study the efficacy and tolerability of Aerodiol, a novel intranasal estradiol spray, and to determine an appropriate dose range.

METHODS

An exploratory, parallel-group, dose-finding study was followed by a large-scale, double-blind, placebo-controlled study. In the exploratory study, 134 postmenopausal women were allocated to receive a daily dose of 100--900 microg of Aerodiol for 12 weeks. Efficacy was determined by an overall assessment of estrogenization. In the placebo-controlled study, 420 postmenopausal women were randomized to receive 100, 200, 300, or 400 microg of Aerodiol, or oral estradiol 1 or 2 mg, or placebo, daily for 12 weeks. Efficacy was assessed by the Kupperman Index and the number of hot flushes per day after 12 weeks.

RESULTS

In the exploratory study, the level of estrogenization was sufficient for 23% of women in the 100 microg/day group, excessive for 36% of the 900 microg/day group, and good for more than 80% of women receiving 200--600 microg/day. In the placebo-controlled study, the Kupperman Index at week 12 was significantly lower than placebo (P<0.01) for all Aerodiol groups except the 100 microg/day group. The efficacy of Aerodiol 300 microg/day was similar to oral estradiol 2 mg/day. The variability in exposure to estradiol was lower with Aerodiol than with oral estradiol. Aerodiol therapy was well tolerated in both studies. Premature withdrawals were approximately equally distributed among treatment groups in the placebo-controlled study.

CONCLUSIONS

Aerodiol was effective in reducing climateric symptoms at doses between 100 and 600 microg/day. Treatment was well tolerated and well accepted. A dose of 300 microg/day is recommended for initiating hormone replacement therapy.

Clinical evaluation, dose-finding and acceptability of AERODIOL, the pulsed estrogen therapy for treatment of climacteric symptoms

S21400 (AERODIOL) is a new intranasal formulation of 17beta-estradiol. It provides a pulsed estrogen therapy that ensures sufficient estrogenisation of tissues to treat estrogen deficiency symptoms, particularly those of the menopause. This multicentric study was designed to determine dose-range, efficacy and acceptability of S21400. One hundred and thirty four women were allocated a daily dose of 100-900 microg for 12 weeks. The doses of 100, 600 and 900 microg were given in two daily administrations, the doses of 200, 300 and 450 microg were given in one and two daily administrations. Oral progestogen was added the last 10-14 days of each cycle of estrogen therapy in all non-hysterectomized women. S21400 showed a dose-effect relationship and provided adequate estrogenisation in more than 80% of patients receiving a dose ranging from 200 to 600 microg daily. Hormonal impregnation was judged sufficient in 23% of women receiving the lowest dose (100 microg). It was often considered excessive for daily doses of 900 microg (36%). After 12 weeks of treatment, efficacy was similar whether the total daily dose was given in one or two administrations. Treatment was well tolerated and accepted, with only minor nasal events (prickling, sneezing). It was perceived by 92% of patients as good or excellent and 81% chose to continue the nasal treatment when it was offered to them. An initial dose of 300 microg per day provides an optimal efficacy/tolerability ratio. In summary, the pulsed estrogen therapy with AERODIOL in one daily administration offers a safe, well accepted and highly effective treatment to alleviate climacteric symptoms. It can be adapted easily to ensure optimal clinical efficacy.

Effects of intranasal 17beta-estradiol on bone turnover and serum insulin-like growth factor I in postmenopausal women

Estrogen therapy, using either oral or transdermal routes, decreases bone turnover and prevents postmenopausal bone loss. It has been suggested that oral and transdermal 17beta-estradiol (E2) may have different effects on serum insulin-like growth factor I (IGF-I), a potent bone-forming growth factor. In this study we investigated the effects of a new route of administration, the intranasal E2 spray (S21400), on bone turnover and circulating IGF-I and IGF-binding protein-3 (IGFBP-3). Four hundred and twenty early postmenopausal women (<5 yr since menopause; mean age, 52 yr) were enrolled in a 3-month, double blind, placebo-controlled study of four doses of intranasal E2 (100, 200, 300, and 400 microg/day), two doses of oral E2 valerate (1 or 2 mg/day), and placebo. One hundred and twelve women were further treated for 12 months with intranasal E2 (300 microg/day, i.e. the dose that has been shown to be adequate for the majority of postmenopausal women). Markers of bone resorption (urinary type I collagen C telopeptides) and formation [serum osteocalcin, serum type I collagen N-terminal extension propeptide (PINP), and serum bone alkaline phosphatase (BAP)] were measured at baseline, 1 month, 3 months, and 15 months. Serum IGF-I and IGFBP-3 were measured at baseline, 1 month, and 3 months. Urinary type I collagen C telopeptides decreased significantly in all active treatment groups as soon as 1 month (P<0.001 vs. placebo) and continued to decrease at 3 months with a dose effect for intranasal E2. Serum osteocalcin and PINP did not change at 1 month for oral E2 (1 and 2 mg), but decreased significantly at 3 months. In contrast, formation markers increased significantly at 1 month for the two highest doses of intranasal E2 (P<0.01 vs. placebo for osteocalcin and BAP) and did not decrease at 3 months. Oral E2 induced a marked decrease in circulating IGF-I as early as 1 month, which was amplified at 3 months (-29% and -32% for 1 and 2 mg, respectively), whereas no significant change from placebo was observed for intranasal E2 during the 3-month period. Changes in circulating IGF-I correlated significantly (P<0.01) with changes in osteocalcin, PINP, and BAP at 3 months. Oral and intranasal E2 did not induce any significant change from placebo in serum IGFBP-3 at both 1 and 3 months. After 1 yr of treatment with intranasal E2 (300 microg/day), both resorption and formation markers decreased, reaching the levels in premenopausal women, regardless of the type of treatment during the first 3 months. We conclude that E2 administered by this new nasal route normalizes bone turnover to premenopausal levels. The delayed decrease in bone formation observed with intranasal E2 compared to oral E2 may be related to different effects on serum IGF-I levels.

[Prevalence of urogenital mycoplasma infection in women infected with HIV in Bangui (Central African Republic)]

Urogenital mycoplasma (UGM) infections have often been reported in HIV patients. Little is known about UGM colonization and infection. We assessed the level of UGM colonization and infection in a cohort of HIV-positive women living in Bangui, Central African Republic. We studied 146 women of child-bearing age, some of whom were pregnant. All were HIV-positive but asymptomatic and attended one of the urban health centers and the National Center for Sexually Transmitted Diseases in Bangui in April or May 1995. Colonization was defined as an endocervical mycoplasma concentration of less than 10(4) color change units per milliliter (CCU/ml) and infection was defined as an endocervical mycoplasma concentration of at least 10(4) CCU/ml. 58 of the 146 HIV-positive women were pregnant (group A). Group B comprised the other 88 women who were not pregnant. The mean age of the women in group A was 22.7 years (range: 15 to 41) and that for the women in group B was 25.8 years (range: 17 to 40). 134 of the 146 women were carrying one or both of the two types of UGM. There were 53 (91.4%) cases in group A and 81 (92%) in group B. Overall, 40% of the women were colonized and 51.4% were infected. UGM infections frequently affect HIV-positive pregnant women in Bangui. Our results suggest that women should be screened for UGM as well as for other sexually transmitted diseases, to improve the care of HIV-infected women attending antenatal clinics in developing countries.

Fibrinogen and plasminogen modifications during oral estradiol replacement therapy

OBJECTIVE

To assess the effects of oral E2 replacement therapy on various hemostatic parameters and cardiovascular risk factors in healthy, postmenopausal women.

DESIGN

A double-blind, randomized, prospective study comparing the effect of a placebo and of oral micronized E2 (2 mg daily) during a 6-month period. Evaluations were performed before treatment and after 3 and 6 months.

SETTING

Departments of Gynecology, Hemostasis, and Nutrition, Hôtel-Dieu, Paris, France.

PATIENT(S)

Thirty-six healthy women with natural or surgical menopause.

RESULT(S)

Compared with placebo, oral E2 replacement therapy resulted in a significant decrease in fibrinogen and apo B and a significant increase in plasminogen.

CONCLUSION(S)

Besides the effects on lipoproteins, oral estrogen replacement therapy modifies parameters involved in coagulation and fibrinolysis.

A twelve-month comparative clinical investigation of two low-dose oral contraceptives containing 20 micrograms ethinylestradiol/75 micrograms gestodene and 20 micrograms ethinylestradiol/150 micrograms desogestrel, with respect to efficacy, cycle control and tolerance

The aim of this study was to compare contraceptive reliability, cycle control and tolerance of an oral contraceptive containing 20 micrograms ethinylestradiol and 75 micrograms gestodene, with a reference preparation containing the same dose of estrogen combined with 150 micrograms desogestrel. This article presents interim data from centers in France and Austria, involving a total of 479 women and 4,991 cycles. Contraceptive reliability was good with both preparations. Two pregnancies occurred in the gestodene group, but neither were due to method failure. In the desogestrel group there were also two pregnancies, of which one was due to method failure. With respect to cycle control, there is a trend towards a lower incidence of intermenstrual bleeding in the gestodene group. The incidence of spotting (scanty bleeding) during the important first three cycles was 3.5% lower in the gestodene group, and over the first six cycles, it was 7.6% lower. Amenorrhea was similar in both groups, but the incidence of dysmenorrhea was significantly lower in the gestodene group (p=0.001). Adverse events were similar in both groups, with headache, breast tension and nausea the most frequently reported symptoms. Body weight remained relatively constant during treatment in both groups, and no hypertension was reported for any woman during the course of the study. In each treatment group, 19 women discontinued because of adverse events. It is concluded that both preparation are reliable and well tolerated oral contraceptives are reliable and well tolerated oral contraceptives; however, there is a more favourable effect on dysmenorrhea by the gestodene formulation.

Bone loss during gonadotropin releasing hormone agonist treatment and use of nasal calcitonin

Gonadotropin releasing hormone (GnRH) agonists have shown to be effective in the treatment of several sex-hormone-dependent conditions. However, their use could be limited by the bone loss they induce. To evaluate the use of nasal salmon calcitonin (sCT) in preventing this bone loss, 40 patients with endometriosis were treated for 6 months with triptoreline (3.75 mg monthly) and calcium (1 g daily), and randomized in three groups-placebo, sCT 100 IU daily and sCT 200 IU daily-in a prospective double-masked study. Dual-energy X-ray absorptiometry and biochemical parameters were used to evaluate the benefit of the treatment. At baseline, there were no statistically significant differences between the groups. After 6 months, estradiol and biochemical markers of bone metabolism were at postmenopausal levels, with no difference between the groups. There was no difference in bone loss in the three groups, at all sites. Mean lumbar bone loss was 4.01 +/- 2.59% (mean +/- SD) in this population. In this study dosages of 100 IU and 200 IU daily of nasal sCT were insufficient to prevent bone loss during GnRH agonist treatment.

Full-term pregnancy with embryos from donated oocytes in a 36-year-old woman allografted for chronic myeloid leukemia

We report the first case of full-term pregnancy arising from donated oocytes in a 36-year-old woman with chronic myeloid leukemia (CML), 6 years after allogeneic bone marrow transplantation (BMT) following total body irradiation (TBI) (12 Gy) and cyclophosphamide 120 mg/kg. The first attempt at implantation with her own cryopreserved ovocytes was unsuccessful. Thereafter, she became pregnant after donated oocyte implantation using estradiol and progesterone support replacing the defective ovarian function. The baby was normal. Unfortunately, 6 months later, she relapsed in chronic phase of CML.

[Antiovulatory action of chlormadinone acetate]

Antiovulatory action of chlormadinone acetate (5 mg twice daily from day 7 to day 25) has been assessed in 6 healthy volunteers by daily determination of plasma FSH, LH, estradiol and progesterone. Hormonal profiles during the second treated cycle show that preovulatory gonadotropin surge is blunted and that no significant progesterone secretion occurs. Estradiol production is variable up to the middle of the cycle, and then homogeneously low normal. Menstrual cyclicity is respected and ovarian function is restored during the first cycle after treatment disruption.

Hemostatic and metabolic effects of lowering the ethinyl-estradiol dose from 30 mcg to 20 mcg in oral contraceptives containing desogestrel

The metabolic and hemostatic effects of two oral contraceptives containing 150 mcg desogestrel and 20 mcg ethinyl-estradiol (EE) (MERCILON) or 30 mcg EE (MARVELON) were compared in order to examine the effect of reducing the EE dose in contraceptive pills. Forty-nine women participated in this randomized study during 6 cycles. In both groups, there was a significant increase in triglycerides, HDL-cholesterol and apoprotein A1; the same increase was observed for SBP and CBG. Slight and transient variations of fasting blood glucose levels were seen in the 30 mcg EE group and in the two groups for fasting insulin levels. The increase in renin substrate was significantly higher with the 30 mcg EE than with the 20 mcg EE pill. In both groups, plasminogen increased significantly, but antithrombin III, total and free protein S and fibrinogen decreased significantly only in women taking the 30 mcg EE pill, whereas there was no significant change in the 20 mcg EE group. Reducing the dose of EE in oral contraceptives from 30 mcg to 20 mcg minimizes their impact on renin substrate and hemostatic parameters.

Effects of nomegestrol acetate (5 mg/d) on hormonal, metabolic and hemostatic parameters in premenopausal women

The effects of nomegestrol acetate on circulating hormone levels, metabolic and hemostatic parameters and blood pressure were studied in 36 premenopausal women. The progestogen was administered from day 7 to 25 of the cycle during six cycles at a dosage (5 mg/d) known to inhibit ovulation. Analysis were performed before and in the third and sixth cycles. Estradiol and progesterone levels decreased significantly (p less than 0.001) during treatment. Body weight, fasting blood glucose and insulin, total HDL and LDL cholesterol, apolipoprotein B, fibrinogen and plasminogen did not change significantly. Triglycerides in the third cycle (p less than 0.05) and apolipoprotein A1 levels (p less than 0.01) in both periods of sampling decreased significantly. There was a significant increase in antithrombin III (p less than 0.01). These results indicate that nomegestrol acetate has no deleterious effect on blood glucose and lipids. The decrease in apolipoprotein A1 and increase in antithrombin III may be related either to the decrease in estradiol levels induced by the treatment or to the effect of the progestogen itself.

[Anti-angina effect of amiodarone versus delayed-action propranolol. A double-blind randomized study]

Long-acting Propranolol (160 mg/day) and Amiodarone (200 mg/day after impregnation) were compared in chronic stable angina pectoris. Forty-three patients with stable angina of effort were included in a randomised double blind trial (19 in the amiodarone and 24 in the propranolol group). The duration of the study was 8 weeks; the placebo phase (2 weeks) was followed by 6 weeks of active treatment. An exercise stress test was performed before and after the treatment period. The number of episodes of angina and the consumption of glyceryl trinitrate decreased significantly (p less than 0.001) in the same proportion with both drugs with respect to the placebo period. The time to the appearance of criteria of positivity of the exercise stress test increased from 6.82 +/- 0.50 mn to 8.35 +/- 0.50 mn with amiodarone, and from 7.15 +/- 0.47 mn to 9.50 +/- 0.52 with the propranolol preparation. This improvement was very significant compared with the placebo phase (p less than 0.001) but the difference between the two drugs was not statistically significant (p = 0.39). The other parameters which were studied (time to onset of angina, total duration of exercise, maximum heart rate, double product, maximum ST depression) changed in a parallel fashion significantly versus placebo. There were no differences between the two treatment groups with the exception of the resting heart rate which decreased more in patients on propranolol (80.94 +/- 3.92 to 62.47 +/- 1.97) than in patients on amiodarone (84.87 +/- 2.63 to 73.41 +/- 2.01; p less than 0.0005).(ABSTRACT TRUNCATED AT 250 WORDS)

Comparative metabolic study of percutaneous versus oral micronized 17 beta-oestradiol in replacement therapy

The aim of this study was to compare the metabolic effects of two presentations of 17 beta-oestradiol (E2) which are of recognized effectiveness in the prevention of post-menopausal bone loss, one being administered via the oral and the other via the percutaneous route. During this prospective, randomized study, 32 patients were treated for 2 mth with either 2 mg/day of oral micronized E2 (n = 16) or 1.5-3 mg/day of percutaneous E2 (n = 16). Both regimens proved efficacious, since significant increases in oestrone (E1) and E2 concentrations ranging up to mid-follicular values were observed. In the percutaneous-treatment group we noted a significant decrease in triglycerides (TG), without any significant changes in high-density lipoprotein cholesterol (HDL-C) or low-density lipoprotein cholesterol (LDL-C). In the oral-treatment group, we saw no significant increase in HDL-C, although significant increases were observed in body weight, TG, plasma renin substrate (PRS) and sex-hormone-binding globulin (SHBG) as well as significant decreases in antithrombin III (AT III) activity and antigen. All of these metabolic variations led us to the conclusion that oral E2 at the dose established as effective in preventing post-menopausal osteoporosis may, even when micronized, alter certain metabolic and haemostatic parameters in a population characterized by increases in cardiovascular risk factors and morbidity. Oral oestrogen replacement therapy should therefore continue to be used only in carefully selected patients and be strictly followed up by systematic checks on a series of metabolic criteria.

[Herpetic manifestations: diagnosis, treatment, prevention]

Herpes virus infection is an extremely common disease that affects between 90 to 100% of the population above the age of 15. The authors propose studying successively the clinical and virological diagnosis of this infection, it's treatment, and finally it's prevention in the dental clinic where there is a large possibility of transmitting the infective diseases.

Hormonal modulation in systemic lupus erythematosus. Preliminary clinical and hormonal results with cyproterone acetate

We prospectively studied the effects of hormonal modulation using the antigonadotropic drug, cyproterone acetate (CA), in 7 female patients who had moderately active systemic lupus erythematosus. CA was taken orally at a mean daily dose of 50 mg for 21-33 months by 6 patients (9 months by the seventh patient) without any side effects. The number of clinical lupus exacerbations during CA treatment was lower than that during the corresponding pretreatment period (15 of 170 patient-months versus 27 of 156 patient-months; P less than 0.05), despite a reduction in the daily maintenance dose of corticosteroids or antimalarial drugs. Mean plasma testosterone levels were low initially and remained unchanged (0.66 +/- 0.31 to 0.59 +/- 0.23 nmoles/liter), whereas plasma estradiol decreased markedly (from 0.6 +/- 0 38 to 0.11 +/- 0.03 nmoles/liter), resulting in a significant reduction in the estradiol:testosterone ratio (from 1.19 +/- 0.68 to 0.23 +/- 0.12) and in the plasma concentration of the sex hormone-binding protein. Thus, cyproterone acetate induced improvement in clinical lupus activity in parallel with the expected lower estradiol:testosterone balance.

[Effect of temephos on the acetylcholinesterase activity of the brain of Tilapia guineensis. 1: Experimental study at operative doses]

After having exposed during 10 minutes the Tilapia guineensis to a concentration of 0,05 mg/l of temephos (concentration of a larvicide used for the field test), the authors note a lowering of the acetylcholinesterastic activity of the brain to an order of 25%. The return to a normal activity is achieved within 20 to 25 days. A new exposure, happening one week after the first, provokes a further lowering before the return to a normal value. The authors question themselves on the consequences of these chemical attacks repeated on a weekly basis during antilarval treatments in the struggle against the onchocercose.

[Effect of temephos on the acetylcholinesterase activity of the brain of Tilapia guineensis. 2: Experimental study of 24-hour exposure to the toxic compound]

The exposition of the Tilapia guineensis to concentrations used in the field to destroy the simulium larvae in their aquatic biotopes is 0,05 mg/l/10 minutes. The authors have previously remarked a significant lowering of acetylcholinesterasic brain activity in this fish. In the case of a much prolonged contact (24h corresponding 144 times the theoretic time of contact), it is noticed that, if this immediate effect is not more pronounced, on the other hand it is noticeable for a much longer acetylcholinesterasic activity extends beyond forty days. In the same conditions, three successive weekly treatments lead the acetylcholinesterasic activity to the level of vital activity.

[Virilizing ovarian tumours. Contribution of selective venous catheterization to the diagnosis]

The presence of a virilizing ovarian hilum cell tumours was suspected on account of a rise of plasma testosterone level above 3.5 ng/ml in one patient and a rise of plasma androstenedione level above 3.0 ng/ml in another. The diagnosis was made by selective catheterization of the ovarian and adrenal veins, which showed a high androgen concentration gradient in the vein of the ovary affected as compared with that observed in the adrenal and peripheral veins, and was confirmed by histological examination after ovariectomy. These two cases are contrasted with two other cases with high testosterone plasma levels but without gradient on selective catheterization. One of the patients had abnormal hepatic metabolism (porto-caval shunt) and the other had taken high doses of androgens.

Aminopeptidase N from Escherichia coli. Unusual interactions with the cell surface

The subcellular localization of aminopeptidase N (previously called aminoendopeptidase) has been investigated. This enzyme was found to be partially released (30-40%) by osmotic shock or by converting Escherichia coli K10 cells to spheroplasts. However, in all other E. coli strains (K12, B/r, MRE 600, ML 308) tested, this enzyme is not released at all by these procedures and thus behaves like a cytoplasmic enzyme. The crypticity of aminopeptidase N is surprisingly low, 75-85% of the enzyme activity is directly assayable in intact cells of any E. coli strain. Various inhibitors of transport systems do not interfer with this assay. Aminopeptidase activity could also be assayed in spheroplasts, even when an insolubilized substrate was used, which suggests a surface location of this enzyme. As well, N-ethylmaleimide (0.4 mM), under conditions which do not allow penetration in the cytoplasm, caused 70% inhibition of aminopeptidase N. Binding of 125I-labeled antiaminopeptidase N antibody to spheroplasts (from K12 strain) was used to assay the orientation of aminopeptidase N in the membrane. This enzyme is exposed on the outer surface of the cytoplasmic membrane. Confirmation of this orientation was obtained by comparing the accessibility of aminopeptidase, alkaline phosphatase and beta-galactosidase to fluorescamine in intact cells. Only 16% of the total beta-galactosidase was labeled with this fluorescent reagent whereas 44-45% of the aminopeptidase N and 59% of the alkaline phosphatase were labeled. Electron microscopic visualization of insolubilized reaction products of aminopeptidase N within the cells showed that these products are located at the poles of the cells. Neither mutant cells which were devoid of aminopeptidase N activity nor parental strains with the enzyme activity inhibited with phenylmercuric chloride contained the characteristic black caps. Thus, it appears that the periplasm is enlarged at the poles of the cells and that the reaction product is mainly located in these places. Investigation of the type of interactions of aminopeptidase N with the plasma membrane only revealed that aminopeptidase N has mainly an electrostatic interaction with the outer surface, probably mediated by magnesium ion bridges. Additional interactions are involved since disruption of the integrity of the cytoplasmic membrane is required to totally release this enzyme.

Existence, localization and regulation of the biosynthesis of aminoendopeptidase in gram-negative bacteria

An enzyme capable of hydrolyzing the substrate L-alanine p-nitroanilide has been found in 18 gram-negative Enterobacteriaceae and Pseudomonas that we tested. This enzyme might be located near the cell surface. Contrastingly we have not detected this activity on colonies of the 8 gram-positive Bacillus that we tested, which suggest a taxonomic value for this test. The aminoendopeptidases found in the various gram-negative bacteria showed similar electrophoretic mobilities and immunological cross-reactivity when tested again Escherichia coli anti-aminoendopeptidase antiserum. The regulation of aminoendopeptidase biosynthesis by the endogenous level of inorganic phosphate that we previously demonstrated in E. coli has been found to exist in all gram-negative organisms tested.