[Multidisciplinary management of the pediatric sickle cell patient in 2019]

Sickle cell disease is a common genetic disorder that affects haemoglobin. It is manifested by haemolytic anaemia and vaso-occlusive crisis. It can affect all organs and its evolution is unpredictable. The multidisciplinary management of pediatric patients who suffer from it is essential to adapt their treatment and optimize their evolution. One of the major challenges is to succeed the transition to adult medicine. New therapeutic perspectives are in development and look promising.

[Female Genital Mutilations : the condition in Liege]

Due to current migration flows, the practising obstetrician is likely to encounter parturient women carriers of female genital mutilations (FGM). This article describes the obstetrical complications related to the latter. We compared a group of mutilated patients (n = 69) to a control group (n = 162) and studied the data concerning pregnancy, childbirth, newborn, postpartum and length of hospital stay. Among the mutilated patients, 44% were group B streptococcus carriers against 23 % in the control group (p inferior to 0.01). As regards the perineum, an episiotomy was performed in 31 % of patients in the FGM group versus 35 % of the control group; a tear occurred in 42 % of vaginal deliveries in the FGM group against 26 % in the control group.

Neonatal encephalopathy in New Zealand: Demographics and clinical outcome

AIM

To establish the incidence of moderate to severe neonatal encephalopathy (NE) in term infants from New Zealand and to document demographic characteristics and neonatal outcomes.

METHODS

Cases were reported monthly via the New Zealand Paediatric Surveillance Unit (NZPSU). Data were collected from paediatricians for neonatal items and lead maternity carers for pregnancy and birth details. Term neonatal deaths in the Perinatal and Maternal Mortality Review Committee dataset that were because of hypoxia and/or neonatal deaths from hypoxic ischaemic encephalopathy were added to the cases identified via the NZPSU, if they had not previously been ascertained.

RESULTS

For the period January 2010 to December 2012, there were 227 cases, equivalent to a rate of 1.30/1000 term births (95% CI 1.14-1.48). Rates of NE were high in babies of Pacific and Indian mothers but only reached statistical significance for the comparison between Pacific and NZ European. There was also a significant increase in NE rates with increasing deprivation. Resuscitation at birth was initiated for 209 (92.1%) infants with NE. Mechanical ventilation was required, following neonatal unit admission, in 171 (75.3%) infants. Anticonvulsants were used in 157 (69.2%) infants with phenobarbitone (65.6%), phenytoin (14.5%) and benzodiazapines (21.1%), the most common. Cooling was induced in 168 infants (74%) with 145 (86.3%) reported as commenced within a 6-h window.

CONCLUSIONS

The rate of NE in New Zealand is consistent with reported international rates. Establishing antecedent factors for NE is an important part of improving care, which may inform strategic efforts to decrease rates of NE.

Plantar keloids: diagnostic and therapeutic issues in six patients

BACKGROUND

Keloids are benign fibro-proliferative skin lesions that very rarely occur on the soles. Because of their rarity, the diagnosis of plantar keloids can be difficult. We describe the clinical and histopathological characteristics of eight plantar keloids.

METHODS

All patients presenting with plantar keloids between 2005 and 2012 in our Dermatology unit were retrospectively included. Diagnosis was definitely established by re-reading of pathological slides in all cases. Clinical characteristics, histopathological features, treatments given and their results were collected.

RESULTS

Six patients were included. Five patients had a single plantar keloid and one had three lesions. They all were of African descent. Only one patient remembered of a previous injury at the site of the keloid. Three patients presented with associated extra-plantar keloids. In four patients, the diagnosis of keloid was not initially suspected clinically or histologically. Re-reading of the clinical photographs showed that the eight plantar keloids shared common morphological features, leading to a distinctive clinical picture, defined by a hardened lesion of rounded or polycyclic shape, with a pink surface crossed by keratotic furrows and the presence of a hyperkeratotic rim. Concerning pathological features, typical hyalinized collagen can be missing and deep fibrosis should not rule out the diagnosis of keloid. Intralesional injection of triamcinolone acetonide and orthopaedic shoes were useful. All patients who had surgical excision presented recurrence.

CONCLUSION

The knowledge of the clinical features of plantar keloids is helpful to the diagnosis. There is no well-established treatment, but supportive measures are important.

[Addictions and pregnancy : how to ruin a pregnancy]

Pregnant women are well aware that any addiction during pregnancy can be harmful to the child. In spite of this knowledge, many continue to smoke, to drink alcohol, to consume illicit drugs or to absorb medicines because these dependences are particularly strong. Tobacco, alcohol, cocaine and ecstasy represent the most dangerous substances as regards foetal damage. The period of pregnancy is the optimal moment to stop these addictions. It is therefore essential to raise awareness among the general public, policy makers, and physicians of the fact that addictions during pregnancy cause a disparity in terms of future health and life expectancy of the unborn child.

[Reduction mammaplasty in ambulatory: A prospective study of feasibility]

OBJECTIVE

The French Ministry of Health and its regional agencies decided on December 27th, 2010 to develop the ambulatory surgery in the purpose to eliminate 48,000 beds of surgery in France. This evolution, which results from Anglo-Saxon countries, is inevitable in front of the financial deficit of our health insurance. Like the Canadian plastic surgeons, who were forced to it for 7 years, we wanted to study the feasibility of an ambulatory care of the reduction mammaplasties in a hospitalo-university department.

METHODS

Between January and June, 2012, 25 patients, of less than 65 years old, were operated for a reduction mammaplasty scheduled in ambulatory. None presented particular anesthetic risk. All lived unless 1h of the hospital, went out accompanied, were revised the day after the intervention, then in a usual way. Our criterias of evaluation were the following ones: global satisfaction of the care in ambulatory, weight of glandular resection, postoperative complications, rate of readmission.

RESULTS

The average age of the patients was 32 years (19-56 years). The average weight of resection was 400g by breast (140-1000g). Twenty patients went out on evening (80%). Among them, 19 (95%) expressed their satisfaction and would accept again this intervention in ambulatory. No major complication arose in this series. Five other patients saw their release repelled by the anaesthetists for the following motives: score of Aldrete lower than 9, pain not relieved by the analgesic (I or II), nausea and uncontrollable vomitings.

CONCLUSION

This first clinical study realized in France, confirms that when certain conditions are filled, the reduction mammaplasty can be realized in ambulatory with complete safety. The rate of satisfaction shows a very strong support of the patients for the ambulatory care.

Modeling the potential benefits of catch-crop introduction in fodder crop rotations in a Western Europe landscape

Among possible mitigation options to reduce agricultural-borne nitrate fluxes to water bodies, introduction of catch crop before spring crops is acknowledged as a cost-efficient solution at the plot scale, but it was rarely assessed at the catchment level. This study aims to evaluate a set of catch crop implantation scenarios and their consequences in a coastal catchment prone to eutrophication. The objectives are (i) to discuss the potential benefits of catch crop introduction taking into account the limitations due to the physiographic and agricultural context of the area (ii) to propose a multicriteria classification of these scenarios as a basis for discussion with stakeholders. We used the distributed agro-hydrological model TNT2 to simulate 25 scenarios of catch crop management, differing in length of catch crop growing period, place in the crop rotation and residue management. The scenarios were classified considering the variations in main crop yields and either nitrogen fluxes in stream or the global nitrogen mass balance at the catchment level. The simulations showed that in the catchment studied, little improvement can be expected from increasing the catch crop surface. Catch crop cultivation was always beneficial to reduce nitrogen losses, but led to adverse effects on main crop yields in some cases. Among the scenarios involving additional catch crop surface, introducing catch crop between two winter cereals appeared as the most promising. The classification of scenarios depended on the chosen criteria: when considering only the reduction of nitrogen fluxes in streams, exporting catch crop residues was the most efficient while when considering the global nitrogen mass balance, soil incorporation of catch crop residues was the most beneficial. This work highlights the interest, while using integrated models, of assessing simulated scenarios with multicriteria approach to provide stakeholder with a picture as complete as possible of the consequences of prospective policies.

[Non-observance and therapeutic inertia in obstetrics]

Observance around pregnancy includes two parts: what can be done before conception and what must be done during pregnancy. Preconception care, if efficaciously performed, offerss real benefits for foetal and child development. Its efficacy will depends on the involvement and motivation of physicians and particularly also on the patient's observance. In this article we summarize essential pieces of advice to be given to each patient before pregnancy. Therapeutic inertia in obstetrics presents two differents aspects: on the one hand, the delay to initiate a therapeutic strategy when a complication arises such as a postpartum hemorrhage; on the other hand, the continuation of obsolete practices, such as the therapy of uterine hypersystolia.

[Roles of serine proteases and matrix metalloproteinases in tumor invasion and angiogenesis]

The remodelling of extracellular matrix and angiogenesis represent two essential processes for tumor growth and metastatic dissemination. These phenomena imply many interactions between tumor cells and host cells via action of various proteases including metalloproteinases (MMPs) whose activity is controlled by TIMPs and serine proteases (tissue type Plasminogen Activator (tPA), urokinase type Plasminogen Activator (uPA) and plasmin) inhibited in particular by PAI-1 (Plasminogen Activator Inhibitor- 1). Evolution of tumors depends on the joint action of these enzymes, as well as precise balance between these proteases and their physiological inhibitors. Proteases regulate the fate and activity of many proteins by controlling appropriate intra- or extracellular localization; shedding from cell surfaces ; activation or inactivation of proteases and other enzymes, cytokines, hormones or growth factors and exposure of cryptic neoproteins. Hence, proteases initiate, modulate and terminate a wide range of important cellular functions by processing bioactive molecules an thereby control essential biological processes, such as DNA replication, cell-cycle progression, cell proliferation, differentiation and migration, morphogenesis and tissue remodelling, neuronal outgrowth, haemostasis, wound healing, immunity, angiogenesis and apoptosis. Work completed has for objective to elucidate the specific part played by serine proteases and MMPS produced by the host cells in the processes of tumor growth and angiogenesis. By using an original model of transplantation of malignant murine keratinocytes (PDVA cell line) into deficient mice (-/-) and wild type mice (+/+), we showed the essential proteolytic role of PAI-1 produced by host cells in the tumor progression and angiogenesis. This mechanism of PAI-1 action was confirmed by using the model in vitro aorta rings. By using deficient mice for one or two MMPs combined (MMP-2, MMP-3, MMP-9, MMP-11, MMP-2&9, MMP3&9), we demonstrated that only the combined deficiency of MMP-2 and -9 showed an absence of tumor invasion and angiogenesis. These data suggest the existence of compensatory mechanisms of a MMP by another MMP or another proteolytic way. These phenomena of redundancy are to be known and detailed to elaborate in a near future, the development of specific inhibitors of MMPS.

Role of plasminogen activator-plasmin system in tumor angiogenesis

New blood formation or angiogenesis has become a key target in therapeutic strategies aimed at inhibiting tumor growth and other diseases associated with neovascularization. Angiogenesis is associated with important extracellular remodeling involving different proteolytic systems among which the plasminogen system plays an essential role. It belongs to the large serine proteinase family and can act directly or indirectly by activating matrix metalloproteinases or by liberating growth factors and cytokines sequestered within the extracellular matrix. Migration of endothelial cells is associated with significant upregulation of proteolysis and, conversely, immunoneutralization or chemical inhibition of the system reduces angiogenesis in vitro. On the other hand, genetically altered mice developed normally without overt vascular anomalies indicating the possibility of compensation by other proteases in vivo. Nevertheless, they have in some experimental settings revealed unanticipated roles for previously characterized proteinases or their inhibitors. In this review, the complex mechanisms of action of the serine proteases in pathological angiogenesis are summarized alongside possible therapeutic applications.

[Clinical studies using the combination atovaquone-proguanil as malaria prophylaxis in non-immune adult and child travelers]

Prophylaxis for short-term travel in malaria-endemic areas can be difficult for two reasons. The first is that currently available antimalarial drugs are becoming less effective because of the ability of the parasite to adapt to drug pressure. The second involves poor compliance with chemoprophylactic regimens due to the highly restrictive conditions of administration and adverse drug side-effects, especially in "healthy" subjects. The combination of atovaquone/proguanil (Malarone) could provide an answer to both these problems since it is not only effective on multiresistant strains of Plasmodium falciparum but also simplifies the conditions of administration and shows good tolerance in adults and children.

[Role of plasminogen activator inhibitor type 1 in tumor angiogenesis]

The plasminogen/plasmin system plays a key role in cancer progression, presumably via mediating extracellular matrix degradation and tumour cell migration. High levels of components of the plasminogen activation system, and paradoxically also its inhibitor, plasminogen activator inhibitor 1 (PAI-1), have been correlated with a poor prognosis for patients with cancers of different types. Recent findings clearly suggest that PAI-1 is essential for capillary sprouting during tumour angiogenesis. Moreover, there is accumulating evidence that both the urokinase receptor and PAI-1 are multifunctional proteins involved not only in extracellular matrix proteolysis but also in cellular adhesion and migration through their binding site for vitronectin. The understanding of whether PAI-1 plays a regulatory role in angiogenesis by tightly controlling proteolytic activity or by influencing cell migration could allow a new anti-angiogenic approach for tumour therapy.

New functions of stromal proteases and their inhibitors in tumor progression

Acquisition of invasive metastatic potential through protease expression is a key event in tumor progression. In carcinomas, the production of metalloproteinases and serine proteinases is regulated by a cross talk between stromal cells and cancer cells. Paradoxically, high rather than low levels of their inhibitors predict poor survival of patients suffering from a variety of cancers. Recent observations suggest a much more complex role of these inhibitors in tumor progression than expected initially.

The ability of preoperative serum CA-125 to predict optimal primary tumor cytoreduction in stage III epithelial ovarian carcinoma

PURPOSE

The aim of this study was to determine the ability of preoperative serum CA-125 to predict optimal primary tumor cytoreduction in patients with Stage III epithelial ovarian carcinoma.

METHODS

We performed a retrospective chart review of 100 consecutive patients with Stage III ovarian carcinoma who had a serum CA-125 drawn prior to primary cytoreductive surgery. We used a receiver operating characteristic curve to determine the CA-125 level with the maximal prognostic power in predicting optimal versus suboptimal cytoreduction.

RESULTS

The median CA-125 level for the 100 patients was 819 U/ml (range 5.6-26,200 U/ml). Optimal cytoreduction (diameter of largest residual tumor nodule < or =1 cm) was obtained in 45 cases (45%). The probability of performing optimal cytoreduction decreased with increasing CA-125 levels. A preoperative CA-125 level of 500 U/ml was identified as the value with the most predictive power. Optimal cytoreduction was achieved in 33 of the 45 cases (73%) with a CA-125 less than 500 U/ml compared to only 12 of the 55 cases (22%) with a CA-125 greater than 500 U/ml. Using a threshold level of 500 U/ml, the preoperative serum CA-125 level was able to predict optimal versus suboptimal cytoreduction with a sensitivity of 78%, specificity of 73%, positive predictive value of 78%, and negative predictive value of 73%.

CONCLUSION

The probability of performing optimal cytoreduction in patients with Stage III ovarian carcinoma and a preoperative CA-125 greater than 500 U/ml was approximately one in five. These patients may be candidates for initial laparoscopic evaluation to obtain a confirmatory tissue diagnosis and to determine resectability.

Absence of host plasminogen activator inhibitor 1 prevents cancer invasion and vascularization

Acquisition of invasive/metastatic potential through protease expression is an essential event in tumor progression. High levels of components of the plasminogen activation system, including urokinase, but paradoxically also its inhibitor, plasminogen activator inhibitor 1 (PAI1), have been correlated with a poor prognosis for some cancers. We report here that deficient PAI1 expression in host mice prevented local invasion and tumor vascularization of transplanted malignant keratinocytes. When this PAI1 deficiency was circumvented by intravenous injection of a replication-defective adenoviral vector expressing human PAI1, invasion and associated angiogenesis were restored. This experimental evidence demonstrates that host-produced PAI is essential for cancer cell invasion and angiogenesis.

Bodies of knowledge

I learned the hard way, the old-fashioned way. I did my first pelvic exam on a colleague, who then did her first on me. We were terrified amateurs, willing to endure all just to get through. "You did great!" we congratulated each other, masking the inevitable discomfort with hearty words of encouragement. I did my second pelvic exam on a patient. What that patient experienced, I'll never know, because she didn't tell and I didn't ask. It took a year or two for me to begin to feel comfortable with the procedure and more years to feel skilled at it. And still I couldn't gauge my patient's experience. I'd say, casually, "You okay?" as I inserted the speculum. She'd say "Uh huh." Sometimes she convinced me, sometimes not.

Art of the paradigm shift

How long has it been since you've had a good paradigm shift? No, it's nothing you can plan. Nothing you can simply tick off that perennial list of To Do's tucked away in your pocket or some unoccupied sulcus of your brain. Paradigm shifts simply happen when you are on a journey of discovery. Once they happen, they change forever the way you look at the world.

Influence of sterilization processes on poly(epsilon-caprolactone) nanospheres

Polymeric vectors and especially poly(epsilon-caprolactone) nanoparticles have already shown promising results in the optimization of the ophthalmic bioavailability of drugs. Any formulation instilled in the eye must be sterile, and preferentially isotonic. Poly(epsilon-caprolactone) nanospheres were thus formulated with Synperonic PE/F68, Synperonic PE/F127, or Cremophor RH40. A tonicity agent, a preservative and, in some cases, a viscosifiant were then added. The pH was finally adjusted to pH 4 or buffered to pH 7. Different sterilization processes were studied to investigate their influence on the physicochemical characteristics of vectors. Autoclaving did not induce any modification on polymer molecular weight or Synperonic nanospheres diameter, but catalysed some reactions with surfactants and tonicity agents. This method could thus be used if the nanosphere excipients are chosen with care. gamma radiation induced preservative degradation and viscosifiant depolymerization. A cross-linking of poly(epsilon-caprolactone) chains was observed, as reflected by a sharp increase of its molecular weight. However, no variation of the mean particle size was detected. Finally, sterile filtration was the only process which ensured the conservation of physicochemical integrity of nanospheres. This process was successfully applied on non-viscosified vectors with a sufficiently small diameter.

[Malignant lymphoma of the testicles]

Between January 1980 and January 1990, a tumour of the testis in 12 of our patients was found to be a non-Hodgkin's malignant lymphoma (NHL). Age varied from 16 to 83 years, with 9 of them aged over 50. In 7 cases the pretherapeutic evaluation disclosed one or more other visceral sites of the tumour, and in 6 cases the tumoral diameter reached or exceeded 10 cm. Staging according to the Ann Arbor classification was: IE: 3 cases; IIE: 1 case and IV: 8 cases. The histological type assessed according to the international classification was: lymphoblastic (2 cases), small cell non cleaved of Burkitt's type (1 case), immunoblastic (2 cases), large cell diffuse (3 cases), mixed diffuse (3 cases), small lymphocyte diffuse (1 case) and unclassifiable (1 case). Seven patients underwent orchiectomy which, in 3 of them, was not followed by any other treatment. Nine patients were put on polychemotherapy which was intensive in 6 cases. Median survival was 30 months. Four patients, all treated intensively, are now in persistent complete first remission. This study confirms that NHL of the testis is rare and its malignancy in almost every case is either high or intermediate grade NHL. It occurs predominantly in elderly men. Advance prognostic factors are often present at diagnosis. However, the advent of intensive polychemotherapy seems to have transformed the course of the disease as well as that of other aggressive NHL's in more common sites.