[What are the prognostic factors in the delivery of the second twin?]

Objective: To evaluate the prognosis of the second twin according to different criteria [presentation, mode of delivery, term, weight, weight difference between twins ,twin to twin delivery time interval, studying the Apgar scores at birth and neonatal morbidity and mortality

Materials and Methods: This is a retrospective study of 183 parturients carrying twin pregnancies collected at the department of Obstetrics-Gynecology in Mahmoud Matri Hospital [Ariana] over a period of 9 years [1st January 2001 to 31st December, 2009]

Results: We recorded 357 live births [181 J1 and J2 176] and 9 stillbirths. The relationship between the order of the twin and the modality of delivery on the one hand, and between the order of twin and type of presentation was considered significant [p < 0.001]. We found no significant difference in Apgar score at 1 minute and 5 minutes between the 1st and the 2nd twins. A term = 34 weeks was a poor prognostic factor for the Apgar score at the first and the fifth minute for the 2 twins but no significant difference between the 1st and 2nd twins [1st min p=0.4623; 5th min p = 0.2899]. Low birth weight = 1500g were significantly more at risk of foetal suffering [p < 0.001]. A birth weight discordance of 25% or more was observed 36 cases [19.7 %]. The Apgar score was significantly influenced by the birth weight difference only in the first minute [p = 0.043]. Thereafter, this difference disappears in the 5th minute. The type of presentation and methods of delivery did not influence significantly the second twin morbidity. A time interval between the birth of the first and second twin greater than 15 minutes was a bad prognostic factor for the Apgar score in the 1st min [p = 0.001] and 5th min [p = 0.019]. Transfer rate in neonatology and neonatal distress was 31.2 %.The term of birth [ before 34 weeks], low birth weight [= 1500 g], and twin-to-twin delivery time interval [ >/= 15 min] are parameters that influenced significantly the rate of neonatal distress and transfer to pediatric health care unit [p <0.001, p<0.001, p = 0.004]. We found a significant increase in the transfer to pediatrics when the birth weight difference was larger than 25% [p = 0.005]. However, no significant difference was found concerning the neonatal respiratory distress [p = 0.22]. The different modes of delivery and the type of presentation of the second twin did not significantly alter the rate of neonatal respiratory distress [p = 0.28, p = 0.53] and transfer Pediatrics [p = 0,63, p = 0.38 ]. Among the live births, 5 twins had died in labor room: 1st twin in two cases and in 2nd twin in 3 cases and there was no significant correlation between neonatal mortality and the twin's order [p = 0.629]

Conclusion: A term = 34 weeks, a low birth weight = 1500g and a delay of more than 15 mn were factors that influenced significantly the Apgar score at 1st and 5th minute, and were responsible for more neonatal distress and transfer in pediatrics. A birth weight difference larger than 25% between the two twins influenced the Apgar score at the first minute and was responsible for an increase in the transfer rate

[Radiation exposure in Crohn's disease patients]

Introudction: Crohn's disease [CD] is a lifelong condition. Multiple imaging investigations are often performed during follow-up. This could cause overexposure to radiation. The aim of our study was to determine mean radiation dose in patients with at least a 5-year course of CD and to determine possible risk factors associated with exposure to high doses of radiation

Methods: We conducted a retrospective study including patients whose CD was diagnosed between 1998 and 2005. Epidemiologic features of patients, characteristics of the disease, types of imaging investigations that were performed during follow-up and cumulative radiation effective dose were determined. Risk factors associated with exposure to high doses of radiation were then determined

Results: One hundred sixty seven patients were included. There were 92 males [55.1%] and 75 females [44.9%] with mean age at dianosis of 31.4 +/- 12.3years. Global radiation dose was 18.8 +/- 18.9 mSv. Twenty seven patients [16,2%] were exposed to more than 35 mSv and 4 patients [2.4%] had an exposure of more than 75 mSv. Use of Infliximab, age at disease onset /= 8 were independent risk factors of radiation exposure more than 35 mSv with adjusted Odds ratios [OR]: 2.5 [2.1- 5.3]; 1.6 [1.2- 4.7] and 3.2 [2.1- 7.8] respectively. Similarly, use of Infliximab and number of flares >/= 8 were independent risk factors of radiation exposure more than 75 mSv with adjusted OR: 4.3 [2.8-9.5] and 7 [3.2-11.2] respectively

Conclusion: Radiation risk seems to be increased with severe course of CD. Both referring physicians and radiologists have the responsibility to minimise radiation exposure. Entero-magnetic resonance imaging [Entero-MRI] may reduce this risk

Stem cell transplantation as rescue therapy for refractory Crohn's disease: a sytematic review

Crohn's disease is a chronic relapsing- remitting affection. It has a strong immunologic component which represent the target of standard therapies including immunosppressants and biological therapies. However, many patients remain refracory or intolerant to these therapies. The aim of this review is to determine the effects of stem cell transplantation in patients with refractory Crohn's disease. Systematic review of observational studies, clinical trials and case reports that focused on the effectiveness and safety of stem cell transplantation in patients with refractory Crohn's disease. Hematopoietic stem cell transplantation seems to be efficient in maintaining clinical and endoscopic remission in patients with Crohn's disease refractory or intolerant to current therapies. However, it has been associated to high morbidity and mortality due to chemotherapy. Mesenchymal stem cell transplantation could induce remission in patients with fistulising refractory Crohns disease with no severe side effects. Its impact on luminal Crohns disease is still controversial. Stem cell transplantation seems to hold promising in patients with refractory Crohn's disease. However, because of the high morbidity and mortality related to chemotherapy, hematopoietic stem cell transplantation should be used as last resort to control this disease. Effectiveness of mesenchymal stem cell transplantation in luminal Crohn's disease has yet to be proven

[Diffuse oesophageal spasms: results of a retrospective manometric study]

Diffuse esophageal spasms is a primary motor disrder of the esophagus of unknown etiology characterized by intermettent peristalsis. This is rare condition which represents 3-5% if primary disorders of the esophagus. Diagnosis and treatment of this entity are difficult. To evaluate the frequency and the clinical and the manometric features of diffuse esophageal spasms. Methods: We conducted a retrospective study related to esophageal manometry performed between January 2000 and December 2011 regardless of the indication. Patients with meeting criteria for diffuse esophageal spasms [> 20% simultaneous waves with greater than 30 mmHg pressure in the esophagus] were included. Out of 1188 patients, 13 [1,09%] met the manometric criteria for diffuse esophageal spasms. It was 8 women and 5 men with a median age of 57 years. Dysphagia was the most relevant symptom and chest pain was only noted in 1 patient. The frequency of simultaneous waves was between 20 and 80%. The pressure of the lower esophageal sphincter was normal in most cases. In this Tunisian manometric study, the diffuse esophageal spasms is rare. Dysphagia was the most relevant symptom and the pressure of the lower esophageal sphincter was normal in most cases

[Management of ovarian endometriomas: intraperitoneal cystectomy versus fenestration and coagulation]

Ovarian endometriomas is a common condition among women of reproductive age and represents a major cost in terms of public health. Despite these implications for public health, it remains difficult to arrive at a consensus on the optimal surgical treatment. To study the clinical and paraclinical characteristics of this pathology and to compare two major surgical techniques: the intraperitoneal cystectomy and fenestration -coagulation in terms of recurrence and prognosis for future fertility. A retrospective study of 31 patients who underwent surgical treatment for ovarian endometrioma histologically proved. The study period covers 10 years from January 2000 to December 2009. Laparoscopy was performed in 27 patients. The endometrioma was located to the left side in 64% of cases. The main strategy performed is intraperitoneal cystectomy in 18 patients [58.8%]. In second place we find the fenestration-coagulation. The mean duration of postoperative follow-up is 10.3 months. The recurrence of the cyst and the persistence of pain symptoms were significantly less frequent in the group of patients who underwent intraperitoneal cystectomy. The laparoscopic surgery remains the first line approach in terms of ovarian endometrioma.Cystectomy offers performance equal or superior to the fenestration-coagulation technique, and exposes to fewer recurrences. For these reasons, it should be recommended. The fenestration-coagulation is possible in case the cystectomy is difficult or incomplete

Gastric perforation in the newborn

Gastric perforation in neonates is an uncommon condition. It could be spontaneous but a contributing cause should be sought. To review our experience of treating 8 neonates with gastric perforation over the past 20 years. We reviewed the records of all newborns admitted to our hospital between 1990 and 2010 with regard to gender, age at admission, contributing factors, associated anomalies, site of perforation, type of operation, and outcome. Of the eight neonates, five were female and three male. The average weight was 2130 g. Four babies were premature. Three infants were ventilated for respiratory difficulty. Five patients had associated anomalies. Perforation occurred in the lesser curvature in 4, at the greater curvature in 3, and at the anterior antrum surface in 1. All patients were treated with gastrorrhaphy. Four neonates required additional gastrostomy. Mortality was 75% [6 infants]. Active perinatal management, early treatment of primary pathologies, and protection of the stomach against distension in neonates at risk are essential in the management of neonatal gastric perforation

Ropivacaine 0.2% versus bupivacaine 0.25% in para-umbilical block in children

Para-umbilical block was an old block that regains a new interest. No study was available using Ropivacaine in this block. To compare quality of analgesia after using Ropivacaine 0.2% to Bupivacaine 0.25% in para-umbilical blocks. In a prospective randomized double blind study we included one to six years old children, scheduled for umbilical herniorrhaphy. The children were randomized in two groups to receive in para-umbilical block by side: Ropivacaine 0.2%: 0.2 ml.kg-1 [group GR] or Bupivacaine 0.25%: 0.2 ml.kg-1 [group GB]. The data of 75 children [GR= 38; GB= 37] were analyzed. The groups were comparable regarding the demographics' characters. The scores of Children's Hospital of Eastern Ontario Pain Scale in different postoperative times were comparable between the two groups. No difference was noted in the time of the first analgesic request. The two groups were comparable regarding the peroperative analgesia. No complication was recorded in this study. Ropivacaine 0.2% is equivalent to the Bupivacaine 0.25% concerning postoperative and peroperative analgesia in the para-umbilical block for umbilical herniorrhaphy

[Delivery in breech presentation: what way should we choose?]

The breech delivery is considered dangerous because of the higher rates of perinatal mortality and morbidity which become attached to it, consequences of obstetric traumas bound to the obstetric operations. What way of delivery is it necessary to privilege? What are the arguments which we have to support our choice? To assess the maternal and fetal outcome according to the way of delivery. In this retrospective study, 194 women with a singleton pregnancy in a breech presentation delivered at term in our maternity unit in Ariana's Hospital from January 2007 to December 2009. Breech presentation was noticed in 2, 59%. The main factors favoring this presentation are: the primipara, the uterine deformations, the pathological ponds, the abnormalities of the amniotic liquid, the fetal weight and the fetal deformations. Vaginal delivery was accepted in 57,7% of women and 75% from them delivered in natural way. The rate of caesarians was 56,7 %. Among these patients, 74, 5 % were indications in a cold caesarian [scar womb, pathological pond, RPM > 12 hours, estimated [esteemed] fetal weight > 3800g]. The Apgar's score was superior to seven in 97.6% of cases. There was no significant difference in fetal morbidity, Apgar's score or in the need of transfer in intensive care unit. When the acceptance conditions of the vaginal delivery are combined and when the surveillance of the labour is rigorous, it seems that there is no excess of neonatal risk by the natural ways

[Bone metabolism, biochemical markers of bone resorption and formation processes and interleukine 6 cytokin level during coeliac disease]

Celiac disease [CD] is characterized by a malabsorption syndrom. The bone anomalies are one of the principal complications of this disease. The osteoporosis frequency is high: 3.4% among patients having with CD versus 0.2% in the general population. To study the bone mineral density during the CD, to compare it to a control group and to determine the anomalies of biochemical markers of bone turn over and level of interleukin 6 cytokin [IL6] in these patients. All patients with CD have a measurement of bone mineral density by dual-energy x-ray absorptiometry [DXA], a biological exam with dosing calcemia, vitamin D, parathormone [PTH], the osteoblastic bone formation markers [serum osteocalcin, ALP phosphates alkaline], bone osteoclastic activity [C T‚lopeptide: CTX] and of the IL6. 42 patients were included, with a median age of 33.6 years. 52. 8% of the patients had a low level of D vitamine associated to a high level of PTH. An osteoporosis was noted in 21.5% of patients. No case of osteoporosis was detected in the control group. The mean level of the CTX, ost‚ocalcine and the IL6 was higher among patients having an osteoporosis or ost‚openia compared to patients with normal bone [p = 0,017]. The factors associated with an bone loss [osteopenia or osteoporosis] were: an age > 30 years, a weight < 50 kg, a level of ALP phosphates alkaline > 90 UI/ml, an hypo albuminemia < 40 g/l and a level of CTX higher than 1.2. Our study confirms the impact of the CD on the bone mineral statute. The relative risk to have an osteopenia or an osteoporosis was 5 in our series. The measurement of the osseous mineral density would be indicated among patients having a CD

[Efficacy and safety of adalimumab in Crohn's disease]

Adalimumab is the first subcutaneously self-administered fully human anti-TNFalpha. To determine efficacy and safety of Adalimumab therapy in Crohn disease. Literature review. Adalimumab has been evaluated for its effect in inducing and maintaining remission and its steroid-sparing effect of refractory Crohn's disease. In addition, it offers a significant treatment option in patients who have lost response to or become intolerant to Infliximab. Results also suggest efficacy of Adalimumab in fistulising Crohn's disease but more studies are needed. Adalimumab was well tolerated and studies show that all anti-TNF inhibitors have similar safety profiles

[Ovarian drilling in treatment of infertility with dystrophic ovaries]

Dystrophic ovaries represent the main cause of female infertility in Tunisia. To assess the contribution of ovarian drilling in the treatment of infertility in patients with ovarian dystrophy. A retrospective study of 23 patients with dystrophic ovaries that have benefited through their subfertility of laparoscopic ovarian drilling, in the gynecology-obstetrics hospital Mahmoud EL Matri, Ariana, Tunisia. Our study spans a period of 3 years from January 2004 to December 2006. Among the 23 patients who underwent drilling for clomiphene citrate resistance, 9 have been pregnant. The average age of patients having had a pregnancy after ovarian drilling was 29.6 years, the average delay was 7.1mois. Regarding prognostic factors, only infertility's duration lower than 3 years was predictive of a good result. Ovarian drilling is an interesting alternative to induction by FSH for patients with dystrophic ovaries

Selective salpingography and tubal catheterization in infertile women

Use of selective salpingography [SS] and fallopian tube catheterization [TC] has revolutionized the diagnosis and treatment of proximal tubal infertility. To evaluate results of women treated for proximal tubal obstruction by selective salpingography and tubal catherization. Selective salpingography was performed in women with proximal bilateral tubal obstructions. Follow-up ranged from 4 to 12 months. Twelve patients had been shown to have bilateral proximal obstruction of the fallopian tube. After SS/TC, patency was achieved in 8 cases. Spontaneous conceptions occurred in 4 women. SS and TC should be used more widely because it is simple and effective in case of proximal tubal blockage