Platelet-rich fibrin in rhinoplasty: A precise and standardized approach

Rhinoplasty is a complex procedure. To achieve the expected aesthetic result, surgeons often use grafts both for structural and camouflage purposes. The perfect camouflage graft should be soft, malleable and precisely tailored to the patient's needs, with as few donor sites as possible. The use of diced cartilage has been widely described, but it cannot be used as a free graft in all cases. Platelet-rich fibrin is an interesting matrix for the creation of soft grafts with great precision and high reproducibility while promoting biocellular regeneration via growth factors. This article describes the use of platelet-rich fibrin in liquid and solid forms for the creation of standardized soft grafts with diced cartilage. We detail the procedure, and present the different grafts created by the author for dorsal camouflage and augmentation, tip management, and revision rhinoplasty.

Isolated tubal twist: A case series of a rare event occurring at different times in reproductive life

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Isolated fallopian tube torsion is a rare but potentially serious event occurring at different times in reproductive life.

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This diagnosis is often overlooked before surgery.

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It should be evoked in front acute pelvic pain in patients with history of hydrosalpinx or paratubal cyst.

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Conservative management must be privileged especially in woman of childbearing age and in a pediatric population.

Introduction and importance

Isolated fallopian tube torsion (IFTT) is a rare but potentially serious cause of pelvic pain in women. Despite being a surgical emergency, this diagnosis is often overlooked before surgery. To raise awareness of this diagnosis among clinicians, we describe here five cases, which occurred at different times in reproductive life.

Cases presentation

We present five cases of isolated fallopian tube torsion at different ages (13–54 years). It often manifests with sudden onset of acute pelvic pain in four cases and chronic pelvic pain in one case.

At admission, patients were suspected of adnexal torsion (3 cases), genital infection (1 case), and renal pain (1 case). CT-scan showed IFTT in only one patient. Laparoscopic surgical management, performed by experienced surgeons, consisted of salpingectomy in 4 cases and conservative treatment in one case. The latter was complicated with hydrosalpinx 6 years later. All patients were followed in outpatient clinic at least one time after surgery and had favorable outcomes.

Clinical discussion

Given the rarity of the pathology and the lack of pathognomonic imaging, IFTT is rarely diagnosed before surgery. Its etiology is still unknown but hydrosalpinx following an infectious process seems to be a major risk factor.

Conclusion

Increasing awareness of this rare entity is advocated, especially in woman of reproductive age. Torsion should be evoked in front acute pelvic pain in patients with hydrosalpinx or paratubal cyst. Conservative management must be privileged especially in women of childbearing age and in pediatric population.

Placental infection by Zika virus in French Guiana

OBJECTIVES

To describe placental findings on prenatal ultrasound and anatomopathological examination in women with Zika virus (ZIKV) infection, and to assess their association with congenital ZIKV infection and severe adverse outcome, defined as fetal loss or congenital Zika syndrome (CZS).

METHODS

This was a prospective study of pregnancies undergoing testing for maternal ZIKV infection at a center in French Guiana during the ZIKV epidemic. In ZIKV-positive women, congenital infection was defined as either a positive reverse transcription polymerase chain reaction result or identification of ZIKV-specific immunoglobulin-M in at least one placental, fetal or neonatal sample. Placental ZIKV-infection status was classified as non-exposed (placentae from non-infected women), exposed (placentae from ZIKV-infected women without congenital infection) or infected (placentae from ZIKV-infected women with proven congenital infection). Placentae were assessed by monthly prenatal ultrasound examinations, measuring placental thickness and umbilical artery Doppler parameters, and by anatomopathological examination after live birth or intrauterine death in women with ZIKV infection. The association of placental thickness during pregnancy and anatomopathological findings with the ZIKV status of the placenta was assessed. The association between placental findings and severe adverse outcome (CZS or fetal loss) in the infected group was also assessed.

RESULTS

Among 291 fetuses/neonates/placentae from women with proven ZIKV infection, congenital infection was confirmed in 76 cases, of which 16 resulted in CZS and 11 resulted in fetal loss. The 215 remaining placentae from ZIKV-positive women without evidence of congenital ZIKV infection represented the exposed group. A total of 334 placentae from ZIKV-negative pregnant women represented the non-exposed control group. Placentomegaly (placental thickness > 40 mm) was observed more frequently in infected placentae (39.5%) than in exposed placentae (17.2%) or controls (7.2%), even when adjusting for gestational age at diagnosis and comorbidities (adjusted hazard ratio (aHR), 2.02 (95% CI, 1.22-3.36) and aHR, 3.23 (95% CI, 1.86-5.61), respectively), and appeared earlier in infected placentae. In the infected group, placentomegaly was observed more frequently in cases of CZS (62.5%) or fetal loss (45.5%) than in those with asymptomatic congenital infection (30.6%) (aHR, 5.43 (95% CI, 2.17-13.56) and aHR, 4.95 (95% CI, 1.65-14.83), respectively). Abnormal umbilical artery Doppler was observed more frequently in cases of congenital infection resulting in fetal loss than in those with asymptomatic congenital infection (30.0% vs 6.1%; adjusted relative risk (aRR), 4.83 (95% CI, 1.09-20.64)). Infected placentae also exhibited a higher risk for any pathological anomaly than did exposed placentae (62.8% vs 21.6%; aRR, 2.60 (95% CI, 1.40-4.83)).

CONCLUSIONS

Early placentomegaly may represent the first sign of congenital infection in ZIKV-infected women, and should prompt enhanced follow-up of these pregnancies. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

Association between Zika virus and fetopathy: a prospective cohort study in French Guiana

OBJECTIVE

To establish the incidence of fetal central nervous system (CNS) anomalies (including microcephaly), signs of congenital infection and fetal loss in pregnant women infected with Zika virus (ZIKV) and non-infected pregnant women in western French Guiana.

METHODS

This prospective cohort study was conducted between 1 January and 15 July 2016. We evaluated and compared clinical and fetal ultrasound examinations of 301 pregnant women with biological confirmation of ZIKV infection and 399 pregnant women who were negative for ZIKV infection.

RESULTS

Overall, the total number of fetuses with CNS involvement was higher in the infected than in the control group (9.0% vs 4.3%; relative risk, 2.11 (95% CI, 1.18-4.13)). Anomalies of the corpus callosum and presence of cerebral hyperechogenicities were significantly more common in the infected group. There was an increased risk of microcephaly in the infected compared with the control group (1.7% vs 0.3%; relative risk, 6.63 (95% CI, 0.78-57.83)), although this was not statistically significant. When the mother was infected during the first or second trimester, there was a greater risk of severe CNS involvement, more signs of infection and intrauterine fetal death than with infection in the third trimester. The rate of vertical transmission in the exposed group was 10.9%.

CONCLUSION

ZIKV infection during pregnancy is associated with a significant risk of fetal CNS involvement and intrauterine fetal death, particularly when infection occurs during the first or second trimesters. Microcephaly was not present in every case of congenital ZIKV syndrome that we observed. Until more is known about this disease, it is paramount to evaluate suspected cases by detailed neurosonography on a monthly basis, paying particular attention to the corpus callosum and the presence of hyperechogenic foci. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.

Formulation of a flush solution of heparin, vancomycin, and colistin for implantable access systems in oncology

Introduction: Because of the increased use of im plantable access systems, the incidence of blood stream and catheter infections associated with these systems has concomitantly increased. Classically, he parin-lock flush solutions were used to prevent thrombosis; more recently, vancomycin was added to the solution to prevent infections caused by Gram- positive bacteria, particularly coagulase-negative Staphylococci. Disorders due to Gram-negative organ isms have now appeared in oncologic patients. We therefore tested the addition of colistin to heparin- vancomycin solutions. Colistin was chosen for its good activity against Gram-negative bacteria (98% susceptibility in our hospital), its good tolerance due to low systemic passage, and its low cost.

Methods: We developed formulations contain ing heparin (100 IU/mL) and various concentrations of vancomycin (10-500 μg/mL) and colistin (10-100 μg/mL) in 0.9% NaCl. Each sterile solution was tested for physical and chemical compatibility (spectropho tometry, nuclear magnetic resonance, and pH mea surements) and its antibacterial activity (against ox acillin-resistant Staphylococcus aureus, Enterococcus faecium, Klebsiella pneumoniae exhibiting broad- spectrum betalactamase (BSBL), imipenem-resistant Pseudomonas aeruginosa) for 2 months at 4°C and at room temperature.

Results: The most suitable combination of drugs is heparin (100 IU/mL), vancomycin (100 μg/mL), and colistin (100 μg/mL). This flush solution main tains activity when stored at 4°C for up to 1 month.

Conclusions: We feel that the combination of heparin, vancomycin, and colistin can be used as a flush solution for indwelling catheters.

[Fetal death beyond 14 weeks of gestation: induction of labor and obtaining of uterine vacuity]

The objective of this review was to assess benefits and harms of different management options for induction of labor and obtaining of uterine vacuity in case of fetal death beyond of 14 weeks of gestation. In second-trimester, the data are numerous but low methodological quality. In terms of efficiency (induction-expulsion time and uterine evacuation within 24 hours rate) and tolerance in the absence of antecedent of caesarean section, the best protocol for induction of labor in the second-trimester of pregnancy appears to be mifepristone 200mg orally followed 24-48 hours later by vaginal administration of misoprostol 200 to 400 μg every 4 to 6 hours. In third-trimester, there is very little data. The circumstances are similar to induction of labor with living fetus. A term or near term, oxytocin and dinoprostone have a marketing authorization in this indication but misoprostol may be an alternative as the Bishop score and dose of induction of labor with living fetus. In case of previous caesarean section, the risk of uterine rupture is increased in case of a medical induction of labor with prostaglandins. The lowest effective doses should be used (100 to 200 μg every 4 to 6 hours). Prior cervical preparation by the administration of mifepristone and possibly the use of laminar seems essential in this situation.

[Acute pancreatitis and pregnancy: Cases study and literature review]

OBJECTIVE

To describe issues associated with the diagnosis of acute pregnancy-associated pancreatitis.

MATERIALS AND METHODS

Retrospective study of cases presenting at our establishment from 2002 to 2012. These cases were defined on the basis of the association of abdominal pain, serum lipase levels three times normal values, or signs of pancreatitis on ultrasound scans carried out on women pregnant at the time of diagnosis. A retrospective analysis of the medical files of these patients was carried out, considering epidemiological and etiological criteria, the treatments administered and maternal/fetal fate.

RESULTS

We identified 10 cases during the study period, corresponding to an incidence of 1/1942. In 70% of cases, the patient was in the last three months of pregnancy. The pain was atypical in 70% of cases and ultrasound revealed biliary lithiasis in 30% of cases. None of the women died. In terms of neonatal morbidity, there were five preterm births, including one of an infant that died at the age of seven days. We then carried out a literature review, from which we determined the most appropriate course of action in cases of acute pancreatitis during pregnancy.

CONCLUSION

Pancreatitis should be considered in pregnant women with abdominal pains because this diagnosis is easy to confirm and maternal and fetal outcomes are essentially dependent on the early etiological management of this condition. Preterm birth is the predominant factor for neonatal morbidity.

Telesonography: virtual 3D image processing of remotely acquired abdominal, vascular, and fetal sonograms

PURPOSE

To design and test a new telesonography technique using remote volume acquisition by untrained operators in locations without access to trained sonographers, postprocessing, and interpretation done at expert centers.

MATERIALS AND METHODS

The technique was tested with 84 sonograms of organs acquired in pregnant women (n = 8) and patients with various abdominal pathologic conditions (n = 11) located in French Guyana (France), Ceuta (Spain), and Murighiol (Romania). An operator inexperienced in sonography (US) placed the transducer over the predetermined acoustic window for each organ, then swept it from a -45° to a +45° position to scan the targeted organ. The acquired volume dataset was sent to an expert center via the Internet and reconstructed using a proprietary software, which allowed a trained sonographer to navigate through the appropriately reconstructed sonograms.

RESULTS

After three-dimensional processing at the expert center, the organs scanned in the obstetrical cases were adequately visualized by the expert in seven of eight (88%) examinations of the fetal head, femur, and umbilical cord and eight of eight (100%) examinations of the fetal abdomen and placenta, whereas in the general abdominal cases, the liver, gallbladder, portal vein, and right kidney were correctly visualized in 10 of 11 (91%) examinations.

CONCLUSIONS

Telesonography allowed untrained operators to scan and transfer the US volume datasets over the Internet to an expert center where an expert sonographer could navigate through the reconstructed US volume and visualize sonograms of diagnostic quality.

[Pregnancy, delivery and customs: transcultural approach in obstetrics]

Pregnancy and delivery are at the heart of all cultures and ethnic groups, as they assure the continuity of any community. Over the millennia, each society has elaborated a combination of prescriptions, proscriptions and protective rites for future mothers and babies, based on their observations of nature in combination with their religious and mythic convictions. Common to the majority are the vulnerability of the mother-to-be to spirits, and the crucial and symbolic importance of the placenta and the umbilical cord. Delivery in hospital, in spite of its reassurance of greater security, may be an unpleasant experience (to both mother and family) because of the impossibility of respecting traditions. Medical personnel in charge of such culturally uprooted patients should, with the help of cultural mediators, become familiar with a minimum of customs and taboos (of the patient's community) and win the patient's confidence through a respectful approach and an empathetic listening in order to adapt their necessary practices of hygiene and security.

[Contribution of volume ultrasound in the evaluation and prenatal care of fetal cardiovascular anomalies]

OBJECTIVES

To highlight the value of 3D ultrasound in the prenatal assessment of fetal cardiovascular abnormalities.

PATIENTS AND METHODS

A retrospective offline analysis of volume datasets of fetuses diagnosed with cardiovascular anomalies by 2D ultrasound was performed.

RESULTS

Thirty-four fetuses with 38 cardiac malformations were evaluated. Mean gestational age at diagnosis was 26 weeks. Isolated cardiovascular malformations were detected in 23 fetuses. Extracardiac abnormalities were identified in eight fetuses. Ten terminations of pregnancy were performed.

CONCLUSION

Offline analysis of cardiovascular anomalies conferred significant diagnostic advantages over 2D ultrasound. 3D ultrasound is a valuable tool for the prenatal diagnosis and the management of congenital heart diseases.

[Contribution of 3D-ultrasound in the heterotaxy syndromes: about four cases and review of the literature]

The position or location of the organs and vessels is usually classified into three types: situs solitus, situs inversus, and situs ambigus. Situs solitus is the usual arrangement of organs and vessels within the body. Only 0.6 to 0.8% of patients with situs solitus and levocardia have associated congenital heart diseases. Situs inversus refers to an anatomic arrangement that is the mirror image of situs solitus. The incidence of congenital heart disease is increased to 3 to 5% in the patients with situs inversus. The patients with heterotaxy have congenital heart disease in high incidence, ranging from 50 to nearly 100%. We present four cases diagnosed in our department in a period of 18 months. With these four cases and a review in the literature, we explore the definitions and characteristics of heterotaxy syndromes and we study the role of 3D ultrasound.

[Use of injectable urapidil in pregnancy-induced hypertension and preeclampsia]

OBJECTIVE

To evaluate the efficacy and tolerance of injectable urapidil (Eupressyl(®)) for the treatment of severe pregnancy-associated arterial hypertension.

MATERIALS AND METHODS

We carried out a prospective study of 100 cases encompassing the various types of severe pregnancy-associated arterial hypertension, with clinical and biological monitoring of the mother and the collection of neonatal data. Treatment was initiated if the blood pressure was higher than 160/110mmHg and efficacy was defined as a lowering of blood pressure to 150/100mmHg or below.

RESULTS

Treatment with urapidil alone was effective in 80 cases (80%). In 20% of cases, essentially the most severe forms of preeclampsia, efficacy was achieved only if urapidil was associated with labetalol or if urapidil was replaced with nicardipine. We observed no material complications other than two cases of hypotension due to excessively rapid administration of a bolus of nicardipine to replace urapidil treatment.

CONCLUSION

Injectable urapidil seems to be an antihypertensive agent that is easy to use and effective in 80% of cases and that has very few secondary effects on the mother or the foetus. Further comparative studies are required to determine the potential of this drug for use in the management of pregnancy-associated hypertension.

[Sixty-nine consecutive cases of eclampsia: prodromes and circumstances]

OBJECTIVE

To specify clinical and biological characteristics of patients developing eclampsia, and identify atypical eclampsia without prior signs and symptoms of severe preeclampsia.

PATIENTS AND METHODS

This was a retrospective observational study conducted from January 1996 to December 2008 in a maternity type IIB in French Guiana. Data of patients who experienced eclampsia were collected from obstetric records.

RESULTS

Sixty-nine patients were selected among 21,525 patients who delivered during this period, corresponding to a prevalence of 3.2 ‰. The average patient age was 21 years (range from 12 to 45 years). Sixty-six percent of patients were nulliparous. The gestational age was greater than 37 weeks of gestation for 62% of patients, between 26 and 37 weeks of gestation for 36% and less than 26 weeks of gestation for 2% of patients. Two thirds of the patients had been examined less than a month before the eclamptic seizure, blood pressure was normal in 62% of cases. Seventy-four percent of patients had at least one Doppler study of the uterine and umbilical arteries velocimetry, the Dopplers studies were normal in 78% of cases. The eclampsia occurred in ante-, peri- and post-partum in 59, 6 and 35% of the cases, respectively 10% of patients were hospitalized for preeclampsia at the time of eclamptic seizure. Less than 10% of patients developed HELLP syndrome. One patient had died of aspiration pneumonia. Newborns had a mean birth weight over 2500 g in 88% of cases. During the follow-up period, 41% of the patients had subsequent pregnancies with 62% without hypertension, 24% complicated by recurrent gestational hypertension, 24% by preeclampsia and 4% by eclampsia.

DISCUSSION AND CONCLUSION

In a majority of the patients in our study, eclampsia was the main manifestation, and only 10% were preceded by severe preeclampsia. These results are comparable to recent studies, which found in their series that 40 to 60% of eclampsia manifested without preeclamptic prodromi. Eclampsia can occur after an unremarkable pregnancy, in women without risk factors, and then it is hardly predictable. Prenatal follow-up must be very cautious paying attention to any markers such as intermittent hypertension, functional symptoms or appearance of proteinuria.

What is driving the HIV epidemic in French Guiana?

Thirty years after the first HIV case in French Guiana, the drivers of the epidemic are not clearly known, but the epidemic is usually conceptualized as generalized. Cross-linking results from a study in the general population and a study in the HIV-infected population in Cayenne suggests that in the general population of HIV-positive men, 45% of HIV cases are attributable to having sex with someone they paid. Similarly, for HIV-positive women exchanging sex for presents or money, 10.7% of HIV cases are attributable to transactional sex. A surprising finding was that 16.8% of HIV patients had tried crack cocaine before. On the Maroni river, the female-biased sex ratio suggests the drivers in that remote area may be related to cultural polygyny. These observations have important consequences on communication and prevention strategies.

[Pregnancy and delivery among adolescents under 15: a study of 181 cases in French Guiana]

OBJECTIVE

The purpose of this study were to determine the effects and consequences of premature pregnancy and childbirth among adolescents under 15 years of age in French Guyana.

MATERIAL AND METHODS

A retrospective field-case study between the 1(st) and the 31(st) December 2001 identified 181 births among adolescents aged 14 years and under. Comparisons were made with 181 births among 18-year-old first-time mothers taking place over the same period.

RESULTS

1.55% of all births in the maternity ward at St Laurent-du-Maroni Hospital involved adolescents under the age of 15. 24.6% of these young mothers were enrolled in secondary school, 21% were beneficiaries of the national social security health insurance and 61% of them were born outside Guyana. Pre-natal monitoring was less frequent among the group of teenage mothers, and preterm labor (0.04 < p < 0.05), anemia (0.02 < p < 0.03) and Chlamydiae trachomatis infections (0.03 < p < 0.04) are more frequent. There is no significant difference regarding high blood pressure, diabetes, or infectious diseases (except from Chlamydiae) or regarding labor and delivery. Mean birth weight was lower (p = 0.01) and the Apgar score was more often less than 7 at the first minute (p < 0.05) among newborn of teenage mothers.

CONCLUSION

While pregnancies among younger teenagers appear to indicate a higher level of associated medical problems, a more thorough pre-natal check-up program would certainly reduce the number of problem related cases. The extremely high proportion of teenage pregnancies in the West of French Guiana has become a major public health issue for the entire region.

[Severe maternal anemia and pregnancy outcome]

OBJECTIVES

The aim of this study was to determine the effects of severe antenatal maternal anemia on pregnancy outcome.

MATERIAL

and methods. A retrospective study comparing 2 groups of pregnant women: 111 (pregnant women) with anemia (Hb < 8 g/dl), 111 non- anemic pregnant women (Hb >10 g/dl). Clinical and biological characteristics for both groups were compared. Data on the newborn babies were collected.

RESULTS

In the anemic group: iron deficiency was the most common cause of anemia (92.7%). There was no significant difference between the 2 groups with respect to age or parity. Maternal anemia was found to be significantly associated with more frequent preterm birth (29.2% vs 9.2%) and increased low birth weight (2933 g vs 3159 g).

DISCUSSION

The literature is not conclusive on the influence of anemia in pregnant women. More frequent preterm birth and low birth weight have been reported in the majority of studies considering mild to moderate maternal anemia (in contrast to our study where the mothers had severe anemia). Many studies indicated that routine iron supplementation during pregnancy may have beneficial effects on pregnancy outcome. Severe anemia in pregnancy may have adverse effects for the newborn and should be treated or prevented early in pregnancy.

[HTLV1 infection and pregnancy]

OBJECTIVE

We report an epidemiological study with an analysis of the risk factors of the HTLV-1 seroprevalence in pregnant women and their children in the town of St Laurent du Maroni, French Guyana.

MATERIAL AND METHOD

HTLV-1 seroprevalence and risk associated factors were first studied in all the pregnant women having delivered at St. Laurent between July 1991 and June 1993. Then, a retrospective analysis was performed in the children, aged between 18 months and 12 years old, born from HTLV-1 infected mothers, focusing especially on the duration of breast feeding and the level of HTLV-1 anti body titers and proviral load.

RESULTS

The global HTLV-1 seroprevalence was 4.4% (75/1727) but it was more prevalent among ethnic groups of African origin such as the Noir Marron population (5.5%) and Haitians (6.3%). In the Noir-Marron population, which represents 70% of the studied population, HTLV-1 seropositivity was associated with a maternal age of>35 years, prior miscarriage, prior cesarean section, parity>4, gravidity>6 and negative rhesus factor. After logistic regression, HTLV-1 seropositivity remained associated with gravidity>6 and negative rhesus factor. Out of the 216 children born from 81 HTLV-1 infected mothers, only 21 were found to be HTLV-1 seropositive, giving a crude HTLV-1 transmission rate of 9.7% while among the 180 breast-fed children 10.6% were HTLV-1 seropositive. HTLV-1 seropositivity in children was associated with elevated maternal anti HTLV-1 antibody titer, high maternal HTLV-1 proviral load and child's gender, girls being more frequently HTLV-1 infected than boys.

CONCLUSION

HTLV-1 infection, which can be responsible for severe pathologies in adults (adult T cell leukemia and tropical spastic paraparesis/HTLV-1 associated myelopathy) should be screened during pregnancy in women originating from high HTLV-1 endemic areas, as for France, mainly the French West Indies, French Guyana and Intertropical Africa. In case of HTLV-1 seropositivity, mothers should be informed on the risk of transmission and promotion of bottle feeding of their children should be strongly proposed.

[Medical termination of pregnancy at 9-14 weeks gestation. Prospective study of 105 cases in Saint-Laurent-du-Maroni (French Guyana)]

OBJECTIVES

To demonstrate the effectiveness and safety of mifepristone 600mg with misoprostol 800 mg, for termination of pregnancy at 9-14 weeks gestation.

PATIENTS AND METHODS

This prospective study included 105 women at 9 to 14 weeks gestation given 800 mg of vaginal misoprostol, 2 or 3 days after a single dose of 600 mg of mifepristone for pregnancy termination. Outcomes measures included mean expulsion time, the interval between fotal and placental expulsion, adverse effects, vaginal bleeding, requirement for analgesia, and hospital stay, analyzed by parity and gestational age.

RESULTS

Pregnancy termination was successful in 92.4% of the patients without requirement for surgery. The mean time to expulsion was 6 hours. The fetus and placenta were expelled together in 79% of the cases. In 15% the conception products were retained in the cervical canal, and removed with a ring forceps. Additional misoprostol doses were necessary in 33% and analgesia (nalbuphine sublingually, mean dose was 10mg) in 56%. Significant bleeding was observed in 7.5%, leading to curettage in 2 patients. No statistically significant differences were found between the rate of success and term (9-12 versus 12-14) or parity.

CONCLUSION

Combining oral mifepristone and vaginal misoprostol is a successful alternative to surgical termination of pregnancy, even after 9 weeks' gestation. The use of nalbuphine for analgesia improves acceptability; sublingual administration helps avoid invasive procedures. Before 14 weeks gestation, the legal limit for termination of pregnancy in France, the choice between the surgical and medical alternatives should be left to the patient.

[Paraquat poisoning at the beginning of pregnancy]

Case report of a paraquat poisoning at the beginning of pregnancy (10 weeks) with mother and child survey. The baby was exempt of abnormalities and of normal weight. He was followed up to the age of 4 and did well clinically. These data are associated with a review of the literature.

Consequences of reduced umbilical and increased foetal cerebral flow during malaria crisis on foetal behaviour

The objectives of this study were (a) to evaluate the sensitivity and specificity of foetal Doppler indices for the prediction of abnormal foetal heart rate (aFHR) at delivery after malaria crisis and (b) to test Doppler parameters against crisis duration for predicting aFHR. Every day during the malaria crisis, the umbilical and cerebral vascular resistance indices were measured by Doppler. These indices allowed evaluation of the amplitude of the foetal flow redistribution induced by malaria (C/U=cerebral resistance/umbilical resistance ratio), the duration of the flow redistribution period and the hypoxic index (mean %C/U change x crisis duration). It was found that the mean duration of the flow redistribution period was: 7 +/- 2 days, mean C/U change -7% +/- 4, hypoxic index -56 +/- 37, prematures 35%, and aFHR 17%. An hypoxic index > 150 predicted occurrence of aFHR with high sensitivity and specificity (100%/91%). The highest foetal flow disturbance (max %C/U) and the duration of the period with flow disturbance (> 7 days) predicted aFHR at delivery with a sensitivity of 10% and 40% and a specificity of 77% and 78%. It was concluded that the hypoxic index was more predictive of aFHR at delivery than the amplitude or the duration (i.e. crisis duration) of the foetal flow redistribution.

[Perinatal care and mortality in French Guyana. From 1992-1999]

BACKGROUND

The purpose of this study was to describe child deliveries in French Guyana and describe changes in perinatal mortality in different population groups between 1992 and 1999.

MATERIAL AND METHODS

All deliveries in health centers and maternity wards in French Guyana between January 1, 1992 and December 31, 1999 were included in the study. Social, demographic, and clinical data were collected at the time of delivery. Infants with a birth weight of 500 g or term 22 weeks were included.

RESULTS

From 1992 to 1995, the number of deliveries in health centers declined 5.7% and the number in public maternity wards increased 69.7%. The same trend was observed in 1998 - 1999 (2.4% and 85.7% respectively), an expression of the policy of antenatal referral implemented by the network of childbirth professionals. Perinatal mortality decreased significantly between 1995 and 1998 from 35.4 to 15.2 for the Creole population (p=0.06), from 46 to 16.5 for the Black-Marron Surinam population (p<0.0007), and from 36 to 10.2 for the Black-Marron French population (p<0.009). This drop in mortality in high-risk population groups may have contributed to the overall decline in perinatal mortality observed over the study period. The rate of preterm birth remained stable (at 13.5%) and the proportion of low-weight infants increased only slightly (12.8% to 13.7%). Mortality among preterm infants declined considerably, undoubtedly because of improved neonatal intensive care.

CONCLUSION

Despite significant improvement, the perinatal mortality in French Guyana (18.9 in 1999) remains almost three times that in metropolitan France (7.4 in 1999). The mothers are young (17% aged less than 20 years) and the proportion of primiparous and grand multiparous mothers is high. With the absence or insufficiency of prenatal care, the problem of perinatal mortality remains a public health priority and challenge in French Guyana.

[Medico-economic study of percutaneous and surgical closure of ostium secundum type interatrial communications]

The aim of this study was the medico-economic evaluation of the closure of ostium secundum type interatrial communications in 32 patients, treated by cardiac catheterisation (group A: n = 17) or by surgery (group B: n = 15). The success rate was 100% with the 2 techniques. With national cost scale data we evaluated the overall cost of the 2 treatments using the information system medical program, starting from homogenous groups of patients: 150 catheterisation, 169 and 170 surgery. As the value for the homogenous group of 150 patients was much lower than the price of the material used for catheterisation, an adjusted group of 150 patients including the price of this material was created. An evaluation in terms of an artificial index of activity was also performed. The average duration of hospital stay for group A was reduced by 6.1 days compared to group B (p < 0.001). The overall cost was lower in group A than in group B (p < 0.001), using the real and "adjusted" homogenous group of 150 patients, with a respective reduction of 7,582 Euros and 3,731 Euros. Surgery and catheterisation scored 8,167 points (17,756 Euros) and 2,726 points (5,926 Euros) per patient respectively on the artificial activity index. In conclusion, catheterisation reduced the duration of hospital stay and brought an economic benefit for the Assurance Maladie compared to surgery. However, surgery is more profitable for the hospital than catheterisation because of the high cost of the prosthesis, which is not taken into account with a homogenous group of non-specific patients. This could hamper the development of this innovative technique in a hospital subjected to overall budgetary constraints.

[Trial vacuum extractor for cephalic engagement. 50 cases in French Guiana]

OBJECTIVE

Considering a population with an African culture traditionally opposed to a caesarean section, vertex engagement with a vacuum extractor could be a good alternative.

PATIENTS AND METHODS

In a retrospective study of 50 cases of trial engagement with a vacuum extractor in French Guyana, there were 94% of vaginal deliveries.

RESULTS

A high level of shoulder dystocia (14%) was noted, and the failure of this technique was the consequence of disproportions between foetus and pelvis that had not been correctly diagnosed.

CONCLUSION

In this article, feasibility and obstetrical conditions to carry out a trial engagement with a vacuum extractor are discussed.

Tubulin is an inherent component of mitochondrial membranes that interacts with the voltage-dependent anion channel

We have previously reported that anti-tubulin agents induce the release of cytochrome c from isolated mitochondria. In this study, we show that tubulin is present in mitochondria isolated from different human cancerous and non-cancerous cell lines. The absence of polymerized microtubules and cytosolic proteins was checked to ensure that this tubulin is an inherent component of the mitochondria. In addition, a salt wash did not release the tubulin from the mitochondria. By using electron microscopy, we then showed that tubulin is localized in the mitochondrial membranes. As compared with cellular tubulin, mitochondrial tubulin is enriched in acetylated and tyrosinated alpha-tubulin and is also enriched in the class III beta-tubulin isotype but contains very little of the class IV beta-tubulin isotype. The mitochondrial tubulin is likely to be organized in alpha/beta dimers and represents 2.2 +/- 0.5% of total cellular tubulin. Lastly, we showed by immunoprecipitation experiments that the mitochondrial tubulin is specifically associated with the voltage-dependent anion channel, the main component of the permeability transition pore. Thus, tubulin is an inherent component of mitochondrial membranes, and it could play a role in apoptosis via interaction with the permeability transition pore.

[Typhoid fever and pregnancy]

Typhoid fever is rare in Europe, but well-recognized endemic disease in tropical zones. We report our findings in a series of 25 cases of typhoid fever during pregnancy observed in French Guiana and reviewed the literature on clinical signs, diagnosis and treatment. Salmonellea typhi causes septicemia of digestive origin that can cross the placenta resulting in chorioamniotitis. Maternal-fetal infection with S. typhi can lead to miscarriage, fetal death, neonatal infection, as well as diverse maternal complications. In order to avoid maternal complications and possible fetal transmission, treatment with ceftriaxone should be initiated as early as possible

Involvement of microtubules and mitochondria in the antagonism of arsenic trioxide on paclitaxel-induced apoptosis

Arsenic trioxide (As(2)O(3)) at low concentrations (1-10 microM) is effective in the treatment of acute promyelocytic leukemia (APL) and lymphoma and is in clinical trials for treatment of solid tumors. Paclitaxel, an antimicrotubule agent, is highly efficacious in the treatment of adult tumors and is in clinical evaluation in childhood tumors. This study is the first to investigate the combination of arsenic and paclitaxel in the range of clinically achievable concentrations. We found that the simultaneous combination was antagonistic on proliferation of the neuroblastoma SK-N-SH cell line by using the combination index (CI) method. Moreover, a 40+/-5% decrease in paclitaxel-induced apoptosis in cells co-treated with As(2)O(3) confirmed the antagonism. The mechanism of antagonism was studied at the cellular level with 200 nM paclitaxel, twice the IC(50) value, and with 1 microM As(2)O(3) which administered singly did not affect cell survival or the microtubule network. As(2)O(3) antagonized the effects of paclitaxel on tubulin and microtubules. Paclitaxel-induced mitotic block was decreased by 20+/-2% and bundles induced by 200 nM paclitaxel were less condensed in the presence of 1 microM As(2)O(3). As(2)O(3) (10-200 microM) induced a concentration-dependent inhibition of tubulin polymerization in vitro which was maintained in presence of paclitaxel. Spectrophotometric and spectrofluorometric measurements indicated an interaction of As(2)O(3) with tubulin SH groups, without modification of the stoichiometry of paclitaxel binding to tubulin. Moreover, 4 microM As(2)O(3) inhibited the release of cytochrome c from isolated mitochondria by 78+/-10%. Our results show that As(2)O(3) and paclitaxel act antagonistically on mitochondria and microtubules and illustrate the need for careful evaluation of drug combinations.

Hyperphosphorylation of tau is mediated by ERK activation during anticancer drug-induced apoptosis in neuroblastoma cells

Phosphorylated tau protein is the major component of paired helical filaments in Alzheimer disease (AD). We have previously shown that abnormal tau phosphorylation was induced in neuroblastoma SK-N-SH cells by the anticancer drug, paclitaxel, during apoptosis [Guise et al., 1999: Apoptosis 4:47-58]. In the present study, we first demonstrated a shift from fetal tau to hyperphosphorylated tau after incubation with paclitaxel, that showed some similarities with the hyperphosphorylated tau in AD, by using several tau antibodies, N-Term, Tau-1 and AT-8. Tau phosphorylation occurred independently of caspase-3 activation. We next showed that a sustained activation of ERK (extracellular signal-regulated kinase) induced both tau phosphorylation and apoptosis during paclitaxel treatment (1 microM). The inhibition of ERK activation by using the pharmacological MEK1/2 inhibitor, PD98059 (50 microM), or an antisense strategy, reduced tau phosphorylation and neuronal apoptosis (P < 0.001), indicating a link between ERK activation, tau phosphorylation and apoptosis. Doxorubicin (0.2 microM), an anticancer drug whose mechanism of action is independent of microtubules, also induced ERK activation, tau phosphorylation and apoptosis. Moreover, doxorubicin induced some morphological features of neurodegeneration such as loss of neurites and disorganization of the cytoskeleton in apoptotic neuroblastoma cells. Altogether, our results suggest that tau phosphorylation plays a significant role in apoptosis enhancing disruption of microtubules that in turn leads to formation of apoptotic bodies, suggesting that neurodegeneration and apoptosis are related.

[Dengue fever and pregnancy. A study of 38 cases in french Guiana]

OBJECTIVES

Evaluation of the consequences of a dengue fever infection on mother and foetus during pregnancy.

PATIENTS AND METHODS

Between February 1, 1992 and December 31, 1999, 172 patients with non malaria hyperthermia were tested for dengue fever infection at the maternity of the Saint-Laurent-du-Maroni hospital in French Guyana. The diagnosis was considered positive when specific IgM was present and/or with virus isolation or viral ARN detection using RT-PCR. Among the 38 cases of mothers infected by dengue fever throughout the three trimesters of pregnancy, it was possible to take 19 fetal blood samples.

RESULTS

The major consequences for the mothers were risk of premature delivery in 55% of the cases, one case of severe hemorrhagic complications during a cesarean section, and one case of abruptio placentae. The consequences for the fetus were premature birth in 22% of the cases, 5 in utero fetal deaths, 4 cases of acute fetal distress during labor and 2 cases of mother-to-child transmission.

CONCLUSION

In case of dengue fever infection of the mother during pregnancy, there is a serious risk of premature birth and fetal death. In case of infection close to term, there is a risk of hemorrhage for both the mother and the newborn.

Caspase-8 activation independent of CD95/CD95-L interaction during paclitaxel-induced apoptosis in human colon cancer cells (HT29-D4)

Antimicrotubule agent-induced apoptosis was examined in the proliferating human colon cancer cell line HT29-D4. G2/M arrest and subsequent apoptosis were dose-dependent, both observed with 100 nM paclitaxel or docetaxel and 10 nM vinorelbine. Bcl-x(L) phosphorylation was observed simultaneously with mitotic block, then caspase-3 cleavage and poly(ADP-ribose) polymerase degradation were detected 48 hr later. By using both enzymatic assay and immunoblot detection of cleaved fragments, we showed that caspase-8, a central component of the CD95-induced apoptotic pathway, was significantly activated during paclitaxel exposure, contemporary to apoptosis occurrence. Caspase-8 activation and apoptosis were independent of CD95 ligation and evidenced only for concentrations inducing Bcl-x(L) phosphorylation and a decrease in mitochondria permeability. Similar results were obtained with docetaxel and vinca alkaloids. Thus, antimitotic drugs may induce apoptosis via caspase-8 activation independently of CD95/CD95-L. Caspase-8 may be a common mediator of anticancer drug-induced apoptosis that could represent a promising target for future therapies.

Decrease of human T-cell lymphotropic virus type I prevalence and low incidence among pregnant women from a high endemic ethnic group in French Guiana

To assess the prevalence and incidence of human T-cell lymphotropic virus type I (HTLV-I), 4,234 pregnant women of different ethnic origins were tested before each delivery between 1991 and 1997 in a high HTLV-I endemic area of French Guiana. HTLV-I was significantly more prevalent among ethnic groups of African descent as the Noir-Marrons (4.8%, 95% confidence interval [CI]: 4.0-5.6) and Haitians (5%, 95% CI 1.6-8.4). An age dependence of HTLV-I seroprevalence was observed. The mean age of Noir-Marron HTLV-I seronegative women was lower than for HTLV-I seropositive women (24. 7 vs. 28.6, p < 0.001). A decline in HTLV-I seroprevalence was observed, particularly in the Noir-Marron younger than 21 years old (p = 0.04). For five HTLV-I seroconversions observed, the incidence per 100 women-years in the Noir-Marron group was 0.19 (95% CI 0.02-0. 35) for all women, 0.32 in those 25 years old or younger (95% CI 0-0. 64), and 0.07 in those older than 25 years (95% CI 0-0.2). This observation was inconsistent with HTLV-I seroprevalence observed for those 25 years old or younger (2.8%) and those older than 25 (8.3%). These data demonstrate, for the first time outside Japan, a birth cohort effect for HTLV-I in a highly endemic ethnic group.

Mother-to-child transmission of human T-cell-leukemia/lymphoma virus type I: implication of high antiviral antibody titer and high proviral load in carrier mothers

In order to gain new insights into the risk factors influencing human-T-cell-leukemia/lymphoma-virus-type-I (HTLV-I) mother-to-child transmission, a retrospective study of HTLV-I infection among children born to HTLV-I-seropositive women was carried out in a highly HTLV-I-endemic population of African origin living in French Guyana. The study covered 81 HTLV-I-seropositive mothers and their 216 children aged between 18 months old and 12 years old. All plasma samples were tested for the presence of HTLV-I antibodies by ELISA, immunofluorescence assay and Western blot. HTLV-I provirus was detected, in the DNA extracted from peripheral-blood mononuclear cells, by polymerase chain reaction (PCR) using primers specific for 3 different HTLV-I genomic regions (LTR, gag and pX) and quantified by a competitive PCR assay. Out of the 216 children, 21 were found to be HTLV-I-seropositive, giving a crude HTLV-I transmission rate of 9.7%, while among the 180 breast-fed children 10.6% were HTLV-I-seropositive. Perfect concordance between serological and PCR results was observed, and none of the 195 HTLV-I-negative children was found HTLV-I-positive by PCR. In conditional (by family) logistic-regression models, HTLV-I seropositivity in children was associated with an elevated maternal anti-HTLV-I-antibody titer (OR 2.2, p = 0.0013), a high maternal HTLV-I proviral load (OR 2.6, p = 0.033) and child's gender, girls being more frequently HTLV-I-infected than boys: OR 3.6, p = 0.0077 in the model including maternal anti-HTLV-I-antibody titer and OR 4.1, p = 0.002 in the model including the maternal HTLV-I proviral load.

Mother-to-child transmission of human T-cell-leukemia/lymphoma virus type I: implication of high antiviral antibody titer and high proviral load in carrier mothers

In order to gain new insights into the risk factors influencing human-T-cell-leukemia/lymphoma-virus-type-I (HTLV-I) mother-to-child transmission, a retrospective study of HTLV-I infection among children born to HTLV-I-seropositive women was carried out in a highly HTLV-I-endemic population of African origin living in French Guyana. The study covered 81 HTLV-I-seropositive mothers and their 216 children aged between 18 months old and 12 years old. All plasma samples were tested for the presence of HTLV-I antibodies by ELISA, immunofluorescence assay and Western blot. HTLV-I provirus was detected, in the DNA extracted from peripheral-blood mononuclear cells, by polymerase chain reaction (PCR) using primers specific for 3 different HTLV-I genomic regions (LTR, gag and pX) and quantified by a competitive PCR assay. Out of the 216 children, 21 were found to be HTLV-I-seropositive, giving a crude HTLV-I transmission rate of 9.7%, while among the 180 breast-fed children 10.6% were HTLV-I-seropositive. Perfect concordance between serological and PCR results was observed, and none of the 195 HTLV-I-negative children was found HTLV-I-positive by PCR. In conditional (by family) logistic-regression models, HTLV-I seropositivity in children was associated with an elevated maternal anti-HTLV-I-antibody titer (OR 2.2, p = 0.0013), a high maternal HTLV-I proviral load (OR 2.6, p = 0.033) and child's gender, girls being more frequently HTLV-I-infected than boys: OR 3.6, p = 0.0077 in the model including maternal anti-HTLV-I-antibody titer and OR 4.1, p = 0.002 in the model including the maternal HTLV-I proviral load.

Mother-to-child transmission of human T-cell-leukemia/lymphoma virus type I: implication of high antiviral antibody titer and high proviral load in carrier mothers

In order to gain new insights into the risk factors influencing human-T-cell-leukemia/lymphoma-virus-type-I (HTLV-I) mother-to-child transmission, a retrospective study of HTLV-I infection among children born to HTLV-I-seropositive women was carried out in a highly HTLV-I-endemic population of African origin living in French Guyana. The study covered 81 HTLV-I-seropositive mothers and their 216 children aged between 18 months old and 12 years old. All plasma samples were tested for the presence of HTLV-I antibodies by ELISA, immunofluorescence assay and Western blot. HTLV-I provirus was detected, in the DNA extracted from peripheral-blood mononuclear cells, by polymerase chain reaction (PCR) using primers specific for 3 different HTLV-I genomic regions (LTR, gag and pX) and quantified by a competitive PCR assay. Out of the 216 children, 21 were found to be HTLV-I-seropositive, giving a crude HTLV-I transmission rate of 9.7%, while among the 180 breast-fed children 10.6% were HTLV-I-seropositive. Perfect concordance between serological and PCR results was observed, and none of the 195 HTLV-I-negative children was found HTLV-I-positive by PCR. In conditional (by family) logistic-regression models, HTLV-I seropositivity in children was associated with an elevated maternal anti-HTLV-I-antibody titer (OR 2.2, p = 0.0013), a high maternal HTLV-I proviral load (OR 2.6, p = 0.033) and child's gender, girls being more frequently HTLV-I-infected than boys: OR 3.6, p = 0.0077 in the model including maternal anti-HTLV-I-antibody titer and OR 4.1, p = 0.002 in the model including the maternal HTLV-I proviral load.

Differentiation of human colon cancer cells changes the expression of beta-tubulin isotypes and MAPs

The human colon adenocarcinoma HT29-D4 cell line is an interesting model for studies on epithelial cell differentiation. Undifferentiated cells are malignant proliferating cells, whereas differentiated cells act like epithelial polarized cells. In the present study, we first characterized the action of taxoids on the microtubular network of HT29-D4 cells according to the state of differentiation. Microtubular bundles were found in undifferentiated cells but not in differentiated cells, even with 500-fold higher taxoid concentrations for 96 h. This finding led us to study changes in microtubules according to the polarity status of the cell. E-MAP-115 was expressed only in differentiated cells; expression of beta-tubulin isotypes was altered in them relative to undifferentiated cells. Classes I, II, III, IVa and IVb isotypes were expressed in both phenotypes; however, differentiated epithelial cells displayed a specific increase in class III beta-tubulin. Thus, the increase in expression of this beta-tubulin isotype in differentiated cells is not restricted to neuronal cells. Moreover, these expression changes may reflect a higher stability of microtubular network in differentiated cells, which may explain the lower activity of anti-microtubule agents, independently of the mitotic process. These results indicate that the composition of microtubules should be considered as one of the criteria involved in the response of tumour cells to chemotherapy with anti-microtubule agents.