A comparison of vaginal ultrasound and digital examination in predicting preterm delivery in women with threatened preterm labor: a cohort study.

INTRODUCTION: The aim of this study is to evaluate the utility of digital examination in addition to ultrasonic measurement of cervical length for predicting spontaneous preterm delivery in women with threatened preterm labor. MATERIAL AND METHODS: This was a prospective cohort study in Strasbourg University Hospital, France, between January 2013 and January 2015. All women with a singleton pregnancy hospitalized with threatened preterm labor between 23 and 34 weeks of gestation were included. Cases of iatrogenic preterm delivery were excluded. A multivariable logistic regression model to estimate the significant predictive parameters of spontaneous preterm delivery was performed. The primary endpoint of our study was a preterm birth before 34 weeks of gestation. RESULTS: A total of 395 women were included in our study. The rate of preterm delivery before 34 weeks was 13%. In univariate analysis every single cervical parameter assessed by the digital examination and all the ultrasound parameters were significantly associated with preterm delivery. The final model included five variables predicting preterm birth: visualization of the membranes at the speculum examination (OR 15.8, 95% CI 2.43-146), ultrasound cervical length (OR 0.82, 95% CI 0.75-0.89), signs of inflammation (OR 6.23, 95% CI 2.07-22.9), gestational age on admission (OR 0.84, 95% CI 0.71-1.0), and presence of vaginal infection (OR 4.28, 95% CI 1.52-12.7). None of the cervical parameters assessed by the digital examination provided additional predictive value of preterm delivery. CONCLUSION: Our study suggests that digital examination does not add to the information given by vaginal ultrasound evaluation in predicting preterm labor.

Acupuncture version of breech presentation: a randomized sham-controlled single-blinded trial.

BACKGROUND: Several studies have investigated the efficacy of moxibustion with or without acupuncture for fetal version, but the results are discordant. Meta-analyses pointed out the need for robust, methodologically sound, randomized controlled trials. OBJECTIVE: The objective of this study was to assess the effectiveness of acupuncture with fire needling on acupoint BL67 for version of breech presentation. STUDY DESIGN: This was a randomized, sham-controlled, single-blinded trial, which took place in Strasbourg teaching maternity hospital, France. A total of 259 patients between 32 and 34 weeks of gestation have been randomized and analyzed. Patients were randomized to either acupuncture with fire needling or sham group, and were analyzed in their initial allocation group. Statistical analysis was conducted using Bayesian methods, in univariate analysis and in multivariate analysis after adjustment on parity. RESULTS: The primary outcome was the rate of cephalic presentations at ultrasound examination performed between 35 and 36 weeks of gestation. A total of 49 (37.7%) fetuses were in cephalic presentation in the acupuncture group, versus 37 (28.7%) in the sham group: RR 1.34 [0.93-1.89], Pr RR>1=94.3%. After adjustment on parity, the acupuncture did not increase the rate of fetal cephalic version: OR 1.47 [0.84-2.42], Pr OR>1=90.3%. CONCLUSIONS: Our study suggests that acupuncture with fire needling on acupoint BL67 does not promote fetal cephalic version. Further studies might investigate effectiveness of other protocols of acupuncture. Randomization should be stratified for nulliparous and parous patients.

Intracystic papillary carcinoma of the breast: a diagnostic challenge with major clinical impact.

BACKGROUND: Intracystic papillary carcinoma (IPC) is a ductal carcinoma of papillary variety that develops in a cystic space surrounded by a fibrous capsule. It is a rare clinicopathological entity, the in situ or invasive character of which is difficult to establish, particularly on biopsy. The treatment is surgical and breast conservation depends on the tumor size. Lymph node exploration is still debated. The diagnosis of IPC is a challenge for the pathologist: the negativity of the basement membrane markers and of myoepithelial cells carries a risk of over-diagnosis on biopsy that can lead to over-treatment. CASE REPORT: To illustrate this risk, we report the case of a breast mass of 8 cm; its biopsy evoked invasive papillary carcinoma (no hormone receptors and overexpression of Human Epidermal Receptor-2 (HER-2) and for which neoadjuvant chemotherapy associated with trastuzumab was firstly proposed. RESULTS: The analysis of all anatomical radio-clinical data in a multidisciplinary context, however, allowed suspecting IPC, thus leading to first-line surgery (mastectomy with negative sentinel lymph nodes). With this diagnosis being confirmed on surgical specimen, no systemic treatment was then necessary. After 48 months, the patient is in complete remission.

Amniotic fluid embolism: 10-year retrospective study in a level III maternity hospital.

OBJECTIVE: To provide updated data on amniotic fluid embolism (AFE) based on our population over a 10 year period, and to propose steps for improving current practice. STUDY DESIGN: Retrospective study carried out in the Department of Gynaecology and Obstetrics at the Strasbourg University Teaching Hospital between 1 January 2000 and 31 December 2010. Dossiers of patients with AFE were identified using medical information system programme (MISP) coding and cross-checked with the pathology reports (hysterectomy, post-mortem examination). RESULTS: Eleven dossiers were found (0.28/1000). Eight cases (73%) of AFE occurred during labour, two (18%) in the post-partum period and one (9%) outside of parturition. Induction was initiated in four patients (45%) and labour sustained with oxytocin in 9 patients (90%). Acute circulatory collapse with cardio-respiratory arrest (CRA) was the herald symptom of AFE in 2 patients, and secondary cardio-respiratory arrest occurred rapidly in 6 patients (55%) following a relatively non-indicative prodromal phase. Disseminated intravascular coagulopathy (DIC) was observed in 10 cases (91%) and massive transfusion was necessary in all patients. Seven haemostatic hysterectomies (63%) were performed, with secondary arterial embolisation in 2 cases (22%). Although all patients presented a clinical picture of AFE, confirmation through histology or laboratory test results was forthcoming in only 7 cases (63%). Three patients died (27%). When AFE occurred during labour, 8 fetuses (75%) received intensive care support. In all, 11 newborns survived (85%). Their pH was less than 7.00 in 3 cases (27%) and 4 fetuses (36%) had an Apgar score of less than 5 at 5 minutes of life. CONCLUSION: AFE is a rare but extremely serious disease. Some risk factors for AFE have been identified but they do not allow its occurrence to be predicted. The diagnosis may be supported by specific laboratory test results but only a post-mortem examination provides a pathognomonic diagnosis: unfortunately it is always retrospective. Obstetrical and intensive care management is complex and must be adapted to the situation bearing in mind the significant risk of haemorrhage and DIC. Hysterectomy must be performed if there is the least doubt.

Myo-InositolTrisPyroPhosphate treatment leads to HIF-1α suppression and eradication of early hepatoma tumors in rats.

Myo-inositol trispyrophosphate (ITPP), a synthetic allosteric effector of hemoglobin, increases the regulated oxygen-releasing capacity of red blood cells (RBCs), leading to suppression of hypoxia-inducible factor 1α (HIF-1α) and to down-regulation of hypoxia-inducible genes such as vascular endothelial growth factor (VEGF). As a consequence, tumor growth is markedly affected. The effect of weekly intravenous injection of ITPP on an orthotopic, syngenic rat hepatocellular carcinoma (HCC) model was compared to that for untreated animals and animals subjected to conventional Doxorubicin chemotherapy. The longitudinal examination of HCC was performed by microCT imaging, and the cellular and molecular changes were evaluated by histology and Western blotting analysis of HIF-1α, VEGF, and caspase-3 gene expression in the tumor and in the surrounding liver. Hematologic impact was evaluated by blood cell-count measurement and determination of P50 (oxygen partial pressure for a 50 % oxygen saturation of hemoglobin). The HCC evaluation by microCT revealed a high potency of ITPP for tumor growth inhibition, thus allowing long-term survival and even cure of almost all the treated animals. The P50 value of hemoglobin in RBCs underwent a shift of 30 % following ITPP injection. Under these conditions, HIF-1α activity was strongly decreased, VEGF expression was down-regulated, and apoptosis was induced in HCC and surrounding liver cells, as indicated by Caspase-3 expression. ITPP did not affect hematologic parameters during treatment. The observations of in vivo tumor eradication suggest a significant clinical potential for ITPP in cancer therapy.

Laparoscopic sacrocolpopexy for female genital organ prolapse: establishment of a learning curve.

OBJECTIVE: The widespread diffusion of laparoscopic sacrocolpopexy in the management of female genital organ prolapse is hampered by its presumed length and technical difficulties. The aim of our study was to analyse the learning curve of a senior urogynecologic surgeon who was initiated into this technique. STUDY DESIGN: The first 48 laparoscopic sacrocolpopexies performed by the same surgeon were analysed retrospectively for pre-operative, operative and post-operative data. At the time of the study, patients were asked about their degree of satisfaction by an anonymous questionnaire. To discover a turning point, the duration of each procedure was reported and the study population was divided into 8 equal groups of 6 interventions each, classed chronologically. Statistical analysis was carried out by Mauchly's sphericity test and then by Student-Newman-Keul's test. Other descriptive statistics were computed with the use of standard methods for means, medians and proportions. RESULTS: The mean operative time was of 236.9 min. The learning curve showed a linear decrease in the duration of surgery with a turning point after 18-24 procedures (p<0.001). It was marked by 2 (4.1%) minor operative complications (2 cystostomies) and 2 immediate post-operative ones: one port-site hernia and one case of urinary retention. At 1 month, 1 patient (2.2%) presented an erosion of the posterior mesh. The mean follow-up was of 15.8 months. During this period, 2 patients (4.1%) presented with a recurrence of prolapse and 6 (12.5%) with de novo stress urinary incontinence. Forty-five patients (93.7%) answered an anonymous questionnaire regarding satisfaction: 40/45 (88.8%) were totally satisfied, 4 (8.8%) moderately and 1 (2.2%) not satisfied. CONCLUSIONS: The learning curve of laparoscopic sacrocolpopexy shows a steady decrease in the duration of surgery. A turning point is observed after 18-24 procedures. During the learning curve there is no increased morbidity. Anatomical and functional results at short and medium terms are similar to those reported in the literature.