Update on childhood and adult infectious tracheitis.

The trachea is a pivotal organ of the respiratory tract. Rather than a genuine anatomic border, it acts as a crossroad in all respiratory infectious processes. Even though not strictly limited to the trachea, infections such as laryngotracheitis and tracheobronchitis are frequently diagnosed in children, in particular during the winter season. Infectious tracheitis etiologies are diverse and the distinction between viral and bacterial origins, albeit difficult, remains relevant considering the substantial differences in terms of gravity and therapeutic management. This literature review summarizes the microbiological and clinical aspects of community-acquired and nosocomial tracheitis in adults and children, as well as the adequate diagnostic and therapeutic approaches. It also highlights the emergence of fungal tracheitis in immunocompromised patients, of ventilator-associated tracheitis in intensive care medicine, and beyond all that the potential short and long-term consequences of tracheitis.

[Quantitative study of phonation by aerophonoscopy: Reproducibility study on healthy volunteers]. / Exploration quantitative de la phonation par aérophonoscopie: étude de reproductibilité sur sujets sains.

INTRODUCTION: The aerophonoscope allows for recording buccal and nasal airflow during breathing and speech and the sounds emitted by the patient. It is known to be useful in the postoperative follow-up of cleft lip and palate children, but there are currently no studies that quantitatively validate its reliability in pathological or non-pathological situations. The aim of our study was to measure the reliability of aerophonoscopic measures in adult healthy volunteers. MATERIAL AND METHODS: A quantitative evaluation of the reliability of aerophonoscopy has been carried out in 30 healthy adult volunteers by measuring its inter- and intra-individual reproducibility and its sensibility in relation with the degree of the velopharyngeal sphincter constriction using a test-retest protocol. RESULTS: The aerophonoscope allows for inter- and intra-individual reproducible measures in healthy adult volunteers. Its sensibility to velopharyngeal sphincter constriction is good in healthy adult volunteers. DISCUSSION: The interest of aerophonoscopy in the treatment strategy of cleft lip and palate patients remains unclear. More reliable quantitative data would be of major interest to determine whether this device is suitable for the follow-up of cleft lips and palate patients or not. This would also allow for planning a second soft-palate operation and for assessing the efficacy of revision surgery such as superior or inferior pedicled pharyngoplasty.

[Measurement of nasal airflow and aerophonoscopy]. / Mesure du flux nasal et aérophonoscopie.

Diagnosis and treatment of rhinolalia are some of the most important elements in the follow-up of patients presenting with a cleft palate. In order to quantify the nasal airflow, speech therapists use either nasalance-measuring devices or devices related to aerophonoscopy. At the Maxillofacial Surgery Department in the Nantes University Hospital, we are currently trying to evaluate the inter- and intra-individual reproducibility of quantitative values provided by the aerophonoscope. We intend to use this device, originally designed in our department 25 years ago, as a reference tool for the measurement of nasal airflow after cleft surgery.

A comparison of the neonatal morbidity of second twins to that of a low-risk population.

OBJECTIVE: To assess the neonatal morbidity of second twins. STUDY DESIGN: Cohort study in a department of perinatalogy. The neonatal morbidity of second twins was compared to that of a low-risk population: singletons in the cephalic presentation delivered vaginally. RESULTS: Five hundred fifty-nine second twins and 18,061 vaginally delivered singletons in the cephalic presentation were studied. Of 452 (81%) second twins delivered vaginally, 310 (69%) were extracted using obstetrical maneuvers: internal version and breech extraction, breech extraction alone, or assisted breech delivery if the breech was already engaged. Before 33 weeks of gestation, there was no significant difference between the neonatal morbidity of the vaginally delivered second twins and the vaginally delivered singletons in the cephalic presentation. After 33 weeks of gestation, only the 1-min Apgar score <7 and the rate of intubation at birth were significantly higher in the second twins. Whatever the gestational age, there was no significant difference between the neonatal morbidity of the vaginally delivered second twins and that of the second twins born by cesarean section before labor. At comparable gestational ages, there was no significant difference between the death rate of the vaginally delivered second twins and that in the reference population. CONCLUSION: The neonatal morbidity of second twins was comparable to that of a low-risk population. Immediate management of the vaginally delivered second twins was, however, more intensive than that of vaginally delivered singletons in the cephalic presentation. It, therefore, requires appropriate equipment in a suitable obstetric-pediatric setting.

[Biological materials collection within population of pregnant women at delivery]. / Recueil de tissus biologiques au sein d'une population de femmes parturientes.

Little is known about biochemical mechanisms associated with the normal psychomotor development of children. Many factors of the fetal environment likely interfere with these mechanisms. A prospective cohort study is essential to explain the implications of certain disturbances of biochemical nature during gestation on the later development of the nervous system. The study that we undertook with the maternity hospital Robert Debré had several objectives. The first was to examine, on an epidemiological scale, the possible role of the monoaminergic systems and the ATPases activity during the perinatal period on the later cognitive development of the child. The second was to study the influence of environmental in utero exposure on these mechanisms and consequently on the later psychomotor performances of the child. We examine here the advantages and the specific difficulties in such an approach within a population of women in childbirth.

5-HT(2A) gene promoter polymorphism as a modifying rather than a vulnerability factor in anorexia nervosa.

The A allele of the 5-HT(2A) gene (-1438A/G polymorphism) has been associated with anorexia nervosa in four studies, but not in three others. One possibility to explain such a discrepancy is that the A allele acts as a modifying rather than a vulnerability allele. To test this hypothesis, we increased our initial sample of 102 trios left open bracket Mol. Psychiatry 7 (2002) 90 right open bracket with 43 new patients with anorexia nervosa and 98 healthy controls. In addition to confirming the absence of association on the global sample of 145 patients, we found that patients with the A allele had a significantly later age at onset of the disease (P = 0.032). Furthermore, the A allele was also transmitted with an older age at onset (P = 0.023) using a quantitative-trait TDT approach. The A allele may thus act as a modifying factor (delaying onset), potentially explaining variations of allele frequency across samples, in which differences in average age at onset are not only possible, but also expected. Taking into account vulnerability genes, but also genes modifying the expression of the disorder, will help to disentangle the complexity of the etiological factors involved in anorexia nervosa.

[Interventional radiology in managing post-partum hemorrhage]. / Place de la radiologie interventionnelle dans la prise en charge des hémorragies du post-partum.

UNLABELLED: EMBOLISATION OF THE UTERINE ARTERIES: Is the technique of choice for the management of post-partum hemorrhage, since it is efficient and virtually non-invasive. However, initial obstetrical measures and appropriate reanimation should never be neglected. The decision for embolisation must be made by all of the competent staff (obstetrician, reanimator, interventional radiologist). The clinical state of the patient must be assessed and the biological controls analyzed and eventually the decision can be made to transfer the patient to a specialized unit equipped not only with a team of interventional radiologists but also a multi-disciplinary team, experienced in the management of this type of pathology. PRACTICAL METHODS: An arterial inducer is placed in the femoral artery under local anesthesia. The angiographic exploration includes, when necessary, a global series showing the aorta and the pelvic vessels followed by the successive exploration of the two internal iliac arteries. Embolisation, conducted under scopic control, must be bilateral. Gelatin fragments or powder is the most appropriate embolus. LIMITS: Very few maternal delivery structures are able to perform an arterial embolisation at any time of the day or night. This raises the problem of transporting patients with uncontrolled hemorrhages; only those who exhibit no hemorrhagic disorders can be transported fairly easily. EFFICACY AND COMPLICATIONS: Concerning the three principle causes at the origin of post-partum hemorrhages, efficacy is constant in the case of uterine atonia; conversely, failures have been reported in the case of cervical-vaginal tearing and abnormal placental insertion (placenta accreta). In young women with healthy arteries, the complications of uterine embolisation during post-partum hemorrhage are exceptional.

[Severe post-partum hemorrhage: descriptive study at the Robert-Debré Hospital maternity ward]. / Hémorragie grave du post-partum. Etude descriptive à la maternitè de l'hôpital Robert-Debré.

OBJECTIVE: To analyze the prevalence, cause, treatment, and risk factors of severe post-partum hemorrhage (transfusion, surgery, radiology) observed at the maternity ward of the Robert-Debré Hospital, Paris. Method. This retrospective cohort was collected from a database including 19182 deliveries from 1992 to 1998. The entire medical file was reviewed in cases of severe hemorrhage. RESULTS: The prevalence of severe post-partum hemorrhage was 23 per 10,000 deliveries (44 patients). Transfusion was performed in 44/44 and hysterectomy in 3/44. Three patients were transferred to the intensive care unit. There were no deaths. At multivariate analysis, risk factors for severe post-partum hemorrhage were: abnormal placental insertion (OR=7.2; 95CI: 2.18-18.3), cesarean (OR=5.8; 95CI: 2.9-11.6), multiple pregnancy (OR=3.2; 95CI: 1.3-7.8), prematurity (OR=3, 95CI: 1.5-6.2), hypertension (OR=2.9; 95CI: 1.3-6.3). Twenty-six percent of the patients had no risk factors. CONCLUSION: The prevalence of severe pot-partum hemorrhage is low in our experience. The methodology used for this retrospective cohort does not enable an explanation. Intensive obstetrical care is necessary in case of abnormal placenta insertion. In 10 out of 44 cases, severe post-partum hemorrhage occurred in a context of insufficient monitoring, late or erroneous diagnosis, or incorrect treatment.

[Isolated antenatal pyelic dilatation: postnatal follow-up and care for vesico-ureteral reflux]. / Dilatations pyéliques isolées: diagnostic prénatal, suivi postnatal et prise en charge des reflux vésico-urétéraux.

OBJECTIVE: To assess the risk of aneuploidia in case of isolated antenatal pyelic dilatation and to detail urological care for these children. METHODS: Prenatal and postnatal follow-up was analyzed in 350 cases. RESULTS: The overall rate of chromosome anomalies was 1.3%. Trisomy 21 was found alone in one case (0.3%). The sex ratio was 26% girls and 74% boys. Vesico-ureteral reflux was similar in both sexes (13%). CONCLUSION: The question of proposing karyotyping in case of isolated pyelic dilatation remains unsolved because minimal subjective signs such as slightly excessive amniotic fluid can completely change the assessment of the risk of aneuploidia. The frequency of postnatal vesico-ureteral reflux associated with prenatal pyelic dilatation warrants complete prenatal ultrasound screening.

Monochorionic monoamnionic twins: vaginal delivery.

Monochorionic monoamnionic pregnancies are rare and have a poor obstetric prognosis. A single amniotic sac promotes cord knotting and entanglement with a high risk of fetal anoxia. The response to this risk has been obstetric management consisting of routine cesarean section at 32 weeks of gestation or when pulmonary maturity is attained. This approach is called into question by the series of seven monochorionic monoamnionic pregnancies we present here. Such pregnancies do indeed require increased surveillance to term, but we think it is possible to apply the usual obstetric management of twin pregnancies.

[Value of RHD fetal genotyping in the prevention of anti-D immunization]. / Intérêt du génotypage foetal RHD dans la prévention de l'immunisation anti-D.

Anti-D prophylaxis is currently applied in France after birth of an RhD positive infant, after interruption of pregnancy and after some antenatal immunizing events (amniocentesis...). However this program does not cover all the prenatal exposures to fetal RhD antigen, and maternal Rh immunization continues to occur. DNA RhD genotyping of the fetus is now reliably performed on amniotic fluid, and pre diagnostic studies on fetal DNA extracted from maternal plasma are promising. The widespread use of fetal RhD genotyping on maternal blood would allow the antenatal administration of Rh immunoglobuline in all Rh negative patients bearing an Rh positive fetus, insofar as it would preclude exposing the other Rh negative patients to the above plasma derived and rather expensive blood product.

Failure of cervical fibronectin to predict premature delivery in a population of monofetal pregnancies with idiopathic preterm labor.

OBJECTIVE: The purpose of the study was to evaluate the correlation between the presence of cervical fibronectin in a high-risk population of women with symptoms of preterm labor and the occurrence of preterm delivery or the need for aggressive tocolysis. STUDY DESIGN: One hundred and thirty women presenting with symptoms of threatened preterm labor were included. Cervical sampling for detection of fibronectin was performed on admission and every day until discharge or delivery. Time to delivery, length of hospital stay, use of indomethacin, delivery before 37 weeks of GA, mean term of delivery and failure of tocolysis to prevent delivery were compared to fibronectin test results. Data were analyzed using Student's t-test for continuous variables and the chi(2) test or Fisher exact test for discrete variables. RESULTS: No correlation could be found between the results of fibronectin cervical sampling on admission and any of the outcome parameters studied. Test performances were low (sensitivity 28%, specificity 57%, positive predictive value 19%, negative predictive value 69%). Results were not modified when the findings of repeated tests were taken into account. CONCLUSION: Cervical fibronectin failed to discriminate a subgroup of symptomatic women delivering prematurely. The prognostic value of fibronectin testing was not better than clinical data in our series. This observation is in disagreement with previous studies on the diagnostic value of vaginal or cervical fibronectin in preterm labor.

Pathologic and laboratory correlation in microcephaly associated with prenatal cocaine exposure.

The Authors report a case where cocaine abuse during pregnancy assessed by drug analysis at various site was associated with foetal microcephaly. Foetal pathologic findings revealed anomalies in neuronal migration and in the vascular architecture in the brain. Such anomalies might be the result of prolonged exposure to cocaine in utero, aggravated by the high concentration of cocaine metabolites in the amniotic fluid over a prolonged period.

Acyclovir prophylaxis in late pregnancy prevents recurrent genital herpes and viral shedding.

Neonatal herpes affects about 1 in 15,000 newborns and the prognosis for disseminated disease with encephalitis is poor. We investigated whether acyclovir prophylaxis in late pregnancy effectively reduces the risk of viral shedding and, hence, of mother-to-child transmission at delivery. A prospective study was conducted. Pregnant women who had at least one episode of genital herpes during pregnancy were randomly assigned to two groups: group 1 (n=167) received oral acyclovir from 36 weeks of gestation to term; group 2 (n=121) received no treatment. Group 3 (n=201) comprised women not given prophylaxis who had a history of genital herpes, but no active episodes during pregnancy. No specific instruction were set up for obstetrical management except for cesarean section in case of a suspected herpes lesion at the time of labor. The rate of Cesarean section was 8.4% in group 1, 16.5% in group 2, and 9.9% in group 3 (p<0.001). 75% of cesareans in group 2 and 10% in group 3 were done for genital herpes. Percentage of viral shedding was, respectively, 0% (group1), 5% (group2), and 0.5%(group3) (p<0.05). These findings underline the value of antiviral prophylaxis in late pregnancy for women with a known history of genital herpes. Such prophylaxis only partly prevents neonatal herpes infection, because it is not applicable to patients with no known clinical history but may excrete the virus.

Does selenium reduce the risk of threatened preterm delivery associated with placental cytochrome P450-1A1 activity?

Selenium (Se), an essential trace element in human nutrition, is thought to have an important role in the prevention of oxygen damage by organic hydroperoxides generated by oxidative metabolism. Epidemiological studies have shown an association between placental cytochrome P450-1A1 (CYP1) activity and threatened preterm delivery (TPD), and other experimental studies have shown alterations in fetal development with CYP1 activity or toxicity. The present study examined the possible protective effect of selenium on the potential toxicity of maternal exposure to polycyclic aromatic hydrocarbons (PAHs) on the normal course of pregnancy. Placental CYP1 activity was used as a risk factor resulting from maternal exposure to PAHs. TPD occurrence was used as a general indicator of troubles in the normal course of pregnancy. A group of TPD patients and a group of controls were selected from 178 pregnant women attending obstetrical care in a maternity hospital. Selenium concentrations in maternal plasma were lower in the TPD group: 63.7 ng/ml (CI 95% confidence bounds = 43.6-82.2) vs 69.2 ng/ml (CI 95% confidence bounds = 49. 3-96.3) (t test, P<0.01). When placental CYP1 was induced, an association between TPD and selenium was found, with an increase of 10 ng/ml for the latter. An adjusted odds ratio of 0.55 (CI 95% confidence bounds = 0.34-0.88; chi(2), P<0.01) was estimated. When placental CYP1 was not activated, the odds ratio was estimated at 0.99 (CI 95% confidence bounds=0.95-1.03; NS). This epidemiologic finding suggests that antioxidant Se status may be a protective factor against the potential toxic effect of PAHs on the normal course of pregnancy. The downward trend that we observed supports the hypothesis that the one-electron pathway metabolism of PAHs may explain a large fraction of TPD and some preterm deliveries.

Defect of villous cytotrophoblast differentiation into syncytiotrophoblast in Down's syndrome.

The syncytiotrophoblast (ST) is one of the major components of the human placenta, as it is involved in feto-maternal exchanges and the secretion of pregnancy-specific hormones. The aim of this study was to elucidate the formation and function of the ST in trisomy 21 (Down's syndrome). We first used the in vitro model of cytotrophoblast differentiation into ST. Cytotrophoblasts were isolated from 15 trisomy 21-affected placentas (12-35 weeks gestation) and 10 gestational age-matched control placentas. In vitro cytotrophoblasts isolated from normal placenta fused to form the ST. This was associated with an increase in transcript levels and in the secretion of hCG, human placental lactogen, placental GH, and leptin. In trisomy 21-affected placentas, we observed a defect (or a delay) in ST formation and a dramatic decrease in the synthesis and secretion of these hormones compared to those in cultured cells isolated from control age-matched placentas. These results were confirmed by a significant (P < 0.001) decrease in gene expression in total homogenates of trisomy 21-affected placentas compared to controls. These results will be of help in understanding the maternal hormonal markers of fetal trisomy 21 and the consequences of placental defects for fetal development.

[Failure of differentiation of the trophoblast in trisomy 21]. / Défaut de différenciation du trophoblaste dans la trisomie 21.

The syncytiotrophoblast is the major component of the human placenta as it is involved in the feto-maternal exchanges and the secretion of pregnancy-specific hormones. In normal placenta, the multinucleated syncytiotrophoblast is formed by fusion of mononuclear cytotrophoblast cells. In trisomy 21-affected placenta, we show that it exists a defect (or a delay) in the syncytiotrophoblast formation and a decrease of the production of pregnancy-specific hormones. We show that it is related to the over expression of the SOD-1 located on chromosome 21. These results will be of help for the understanding of maternal hormonal markers of fetal trisomy 21 and the consequences of the placental defects on the fetal development.

Management of fetal thyroid goitres: a report of 11 cases in a single perinatal unit.

Fetal thyroid goitres may reveal hormonal imbalance. This can jeopardize neurological development and fetal outcome even when early postnatal treatment is provided. We report a series of 11 goitres diagnosed antenatally in women with past or present thyroid disorders or discovered fortuitously on ultrasound scan. Fetuses presented with hyperthyroidism in three cases and hypothyroidism in eight. Hypothyroidism was iatrogenic in five cases, due to maternal anti-thyroid drugs. Hyperthyroidism was induced by transplacental transfer of thyroid stimulating antibodies (TSHrab). Accurate diagnosis of fetal thyroid status was obtained by fetal blood sampling but this invasive method was deemed necessary only in four cases as maternal clinical and biological data and ultrasound signs provided sufficient information to infer the type of thyroid disorder in the remaining patients. Fetal therapy relied on reduction of maternal antithyroid medication and, in selected cases, intra-amniotic injection of levothyroxin in hypothyroidism, and on administration of antithyroid drugs in hyperthyroidism. All newborns were healthy and none displayed consequences of severe thyroid imbalance. No caesarean section was performed for dystocia. Fetal thyroid goitres can be managed successfully with selected use of invasive diagnostic and therapeutic techniques.

Situs inversus and bowel malrotation: contribution of prenatal diagnosis and laparoscopy.

The authors report 3 different cases of prenatal diagnosis of situs inversus associated with bowel malrotation. Heterotaxy existed in 2 cardiosplenic syndromes (1 left and 1 right isomerism), and 1 isolated situs inversus. Bowel malrotation was detected at birth by ultrasonography and intestinal contrast study. Patients underwent laparoscopic LADD's procedure and abdominal exploration in the neonatal period. The authors advocate neonatal screening and early surgical management of bowel malrotation in prenatally diagnosed heterotaxic syndromes.