[What's the optimal time of cesarean section antibiotic prophylaxis, before skin incision or after umbilical cord clamping? A prospective randomized study]. / Quel est le moment optimal de l'antibioprophylaxie pour césarienne élective, avant l'incision cutanée ou après clampage du cordon ombilical ? Étude prospective randomisée.

OBJECTIVES: To compare the effect of antibiotics prophylaxis within 30 mins before skin incision (A) and after umbilical cord clamping (C) on the incidence of postoperative infections in patients undergoing elective caesarean section at Farhat Hached university teaching hospital. MATERIALS AND METHODS: We conducted a randomised clinical trial evaluating 279 patients undergoing elective caesarean section. Patients were randomly assigned a group number that allocated them to either arm of the study. They received the same prophylactic antibiotic (cefazol® 2g) according to their allotment. They were followed up to detect infection up to 30 days postoperatively. The primary outcome was postoperative infection. The data collected were analysed with SPSS version 18.0 using univariate and bivariate analysis. RESULTS: The risk of overall postoperative infection was not significantly lower when prophylaxis was given before skin incision (4.37 % (A) vs 9.85 % (C); P=0.07; OR=0.42 [0.15-1.12]). We also found wound infections to be significantly reduced in the pre-incision group (2.2 % [A] vs 8.45 % [C]; P=0.03; OR=0.24 [0.06-0.88]). However, there was no difference in the endometritis infectious. On the other hand, there was no negative impact on the neonatal features. CONCLUSIONS: Giving prophylactic antibiotics before skin incision reduces risk of postoperative infection, in particular of wound infections.

Chorioamnionitis due to Lactococcus lactis cremoris: A case report.

Lactococcus lactis cremoris is rarely involved in human pathology. A thirty two-year old pregnant woman with premature rupture of membrane history presented with chorioamnionitis due to L. lactis cremoris. She underwent an emergency caesarian section and was treated with antibiotics including the association of amoxicillin and clavulanic acid. She was completely recovered. This is the first case to our knowledge of chorioamnionitis due to this organism.

[Efficacy and safety of Adalimumab in Crohn's disease]. / Indications et résultats de l'adalimumab au cours de la maladie de Crohn.

BACKGROUND: Adalimumab is the first subcutaneously self administered fully human anti-TNFa. AIM: To determine efficacy and safety of Adalimumab therapy in Crohn disease. METHODS: Literature review. RESULTS: 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.

[Systemic congenital candidiasis, a rare condition in neonates: case report in a premature infant]. / Candidose congénitale systémique, forme rare de candidose néonatale : à propos d'une observation chez un nouveau-né prématuré

UNLABELLED: Congenital cutaneous candidiasis presenting at birth is very uncommon and is due to intra-uterine infection. The systemic form has to be considered when cutaneous signs are associated with sepsis symptoms. CASE REPORT: A female infant was born by vaginal delivery at 35 weeks' gestation to a mother whose pregnancy had been complicated by urinary tract infection treated 3 days before delivery. The infant was admitted because of respiratory distress. Clinical features consisted of respiratory retraction signs associated with hepatomegaly and rash on the trunk. The white blood cell (WBC) count was 50 × 10(9)/L and C-reactive protein was negative. Maternofetal bacterial infection was suspected and intravenous antibiotics were prescribed. Over the next 6h, macules appeared on the trunk, back, and limbs, which changed after 24h into papulovesicular lesions over the trunk, back, limbs, palms, and scalp. Congenital candidiasis was suspected, confirmed by cultures from vesicle swabs and maternal vaginal discharge. The systemic form was considered because of respiratory distress requiring oxygen therapy for 4 days, hepatomegaly, elevated WBC count, and chest X-ray infiltrates. The infant was started on intravenous systemic antifungal therapy (fluconazole, 6 mg/day). Treatment was continued for 3 weeks. The rash resolved by desquamation after about 1 week and hepatomegaly disappeared. The infant remained well at follow-up.

Metabolic syndrome is associated with gastroesophageal reflux disease based on a 24-hour ambulatory pH monitoring.

Several studies have focused on the relationship between metabolic syndrome and gastroesophageal reflux disease (GERD). They were based on GERD complications, whereas little is known about the association between metabolic syndrome and objectively measured esophageal acid exposure. The aim of our study was to assess the relationship between metabolic syndrome and GERD based on a 24-hour pH testing. It was a cross-sectional study including 100 consecutive patients who underwent a 24-hour pH-metry monitoring and were assessed for the five metabolic syndrome components as well as for body mass index (BMI). Among the 100 patients, 54 had a pathological acid GERD. The 46 GERD-free patients represented control group. Sex distribution was comparable between both groups but GERD patients were older than controls (44.59 vs. 37.63 years, P= 0.006) and more often obese or with overweight (83.3 vs. 60.9%, P= 0.01). Frequency of metabolic syndrome as a whole entity was higher among patients with GERD than those without GERD (50 vs. 19.56%; P= 0.002) with a crude odds ratio of 4.11 (95% confidence interval: 1.66-10.14). Multivariate regression analysis showed that metabolic syndrome as well as an age ≥ 30 years were independent factors associated to GERD but not BMI and sex. Abnormal waist circumference and fasting glucose level ≥ 100 mg/L were the only independent factors among the five components of metabolic syndrome. Metabolic syndrome but not BMI was an independent factor associated to GERD. These results confirm the hypothesis that central obesity is associated to GERD.

[Role of deambulation during labour: A prospective randomized study]. / Intérêt de la déambulation au cours du travail obstétrical : étude prospective randomisée de 200 cas.

OBJECTIVE: To assess the effects of ambulation during the first stage of labor on the duration of labor and other maternal and infant outcomes. PATIENTS AND METHODS: A prospective randomized trial conducted from 1st November 2008 to 31st March 2009 at the department of obstetrics and gynecology, CHU Farhat Hached, Sousse, Tunisia. Two hundred mothers with uncomplicated term pregnancies were randomly assigned to one of two groups: first group (100 parturients) authorized to ambulate until 6cm of cervical dilation and a second group (100 parturients) confined to bed in dorsal or lateral recumbence. RESULTS: Upright position reduces significantly (for about 34%) the duration of the first stage of labor (P<0.0001), the pain intensity, the oxytocin consumption (P=0.001), the rate of delivery by cesarean section and of instrumental deliveries. Upright position leads also to a net improvement of the maternal outcome (7% side effects versus 13%) and the fetal outcome (net improvement of the Apgar's score at first and fifth minute, and reduction of a factor 5 of the rate of transfer to the neonatology clinical care unit. CONCLUSION: Our study allowed to confirm the benefits of ambulation on labor progress as well as on the maternal comfort and the maternofetal outcome.

Seroprevalence of Helicobacter pylori among Tunisian blood donors (outpatients), symptomatic patients and control subjects.

OBJECTIVES: Helicobacter pylori is a worldwide infection, although little data are available in the Tunisian population. The aims of our study were to detect the prevalence of H. pylori in a blood-donor population (n=250) and in another population of hospital-consulting patients comprising 87 symptomatic patients and 59 controls, and to determine the factors that influence the prevalence. MATERIALS AND METHODS: Study subjects answered a standardized questionnaire, and IgG anti-H. pylori and anti-cag were detected by ELISA. In the second population, culture and cagA polymerase chain reaction were performed. RESULTS: The seroprevalence of H. pylori in blood donors was 64%, and 11% had anti-cag. All patients positive for anti-cag were also positive for anti-H. pylori antibodies. The seroprevalence of H. pylori was 99.3% in the hospital-consulting patients, of whom 55.5% were positive for anti-cag. The difference between the anti-cag and symptomatic patients (66.7%) and controls (39%) was significant. Symptomatic patients had a higher rate of anti-cag (66.7%) compared with the controls (39%) and blood donors (11%). CONCLUSION: H. pylori seroprevalence in blood donors is low (64%) compared with symptomatic patients (99.3%), and anti-cag was statistically associated with symptomatic patients and pathology. Also, some environmental factors were correlated with H. pylori seroprevalence.

[Correction of breast Poland's anomalies. About eight cases and literature review]. / Correction des anomalies mammaires du syndrome de Poland. A propos de huit cas et revue de la littérature.

PURPOSE: The objective of the present study was to analyze current indications and results of different methods for breast anomaly correction of Poland's syndrome. PATIENTS AND METHODS: Eight patients with this deformity were operated between 1997 and 2008: seven females and one male. The mean age was 22. According to Foucras et al. classification, four patients revealed Poland's syndrome grade II, three patients grade I and two patients grade III. Three patients received silicone implants (two with Poland's syndrome grade II, one with grade III). Autologous fat injection was used for a male adolescent who was very embarrassed by his deformity. Controlateral lipo-aspiration was carried out in three cases with moderate Poland's syndrome breast asymmetry. For one patient, correction was achieved by controlateral breast resection. RESULTS: No intraoperative or postoperative complications occurred for the eight patients. Aesthetic results were overall satisfactory. CONCLUSION: The simplest and the fastest breast deformity correction technique in Poland's syndrome patients, the one with the least complications and cosmetic sequella and the most practiced by the surgeon, remains the best method for breast anomaly correction of Poland's syndrome.

[Benefit of misoprostol for prevention of postpartum hemorrhage in cesarean section: a randomized controlled trial]. / Intérêt du misoprostol dans la prévention de l'hémorragie du post-partum immédiat en cas de césarienne : essai prospectif randomisé

OBJECTIVES: To assess the benefit of sublingual misoprostol in addition to standard oxytocin in the prevention of post-partum hemorrhage at caesarean section. PATIENTS AND METHODS: This was a prospective randomized controlled clinical trial conducted from March to June 2007 at our department of obstetrics-Sousse-Tunisia, including 250 single low risk pregnant women undergoing caesarean section at gestational age>32 weeks gestation. Patients were randomly assigned to receive at cord clamping either sublingual 200microg misoprostol (Cytotec) with 20UI intravenous oxytocin (Oxytocin): bolus 10UI and infusion 10UI in 500ml Ringer Lactate): Group I, or only oxytocin at the same dose: Group II. The main outcome was total blood loss assessed by decrease in perioperative hematocrit. Secondary outcomes included measured collected blood loss, drop in hemoglobin level, additional oxytocin, side-effects and postoperative complications. RESULTS: The two groups were similar in demographic and obstetrical patient characteristics. Drop in hematocrit was more important in group II than in group I: 4.30%+/-3.14 versus. 1.10%+/-3.25; P=0.013. Drop in hemoglobin level was also more important in group II than in group I: 1.03g/dl+/-1.19 versus 0.54g/dl+/-1.17; P<0.01. Collected blood loss was less important in group I than in group II: 669.68cc+/-333.01 versus 852.52cc+/-295.08 ; P<0.01. Need for additional oxytocin and postoperative complications rate were more frequent in group II than in group I but the differences weren't significant. The rate of transient shivering, nausea and fever was significantly higher among women receiving misoprostol. CONCLUSIONS: Sublingual misoprostol (in addition to oxytocin) is effective in prevention of post-partum hemorrhage at caesarean sections when compared to oxytocin alone, without major side-effects. Larger studies are needed to confirm our results.

[Yolk sac tumor revealed by an ascite of great abundance]. / Tumeur vitelline de l'ovaire révélée par une ascite de grande abondance.

We report the case of a 16-year-old girl explored for an ascite of great abundance responsible for a respiratory embarrassment. Its symptomatology proved to be secondary to a vitelline tumour of the ovary. It required several drainings of ascite before surgical operation. She had a conservative treatment followed up by a chemotherapy which allowed a clinical and biological remission. We report this observation considering the originality of the mode of revelation of the tumour. We insist in addition on the possibility of a conservative treatment.

[Comparing two Prepidil gel regimens for cervical ripening before induction of labor at term: a randomized trial]. / Comparaison de deux régimes d'administration intracervicale de Prépidil dans le déclenchement artificiel du travail à terme : essai prospectif randomisé

OBJECTIVES: To compare efficacy and safety of two regimens of intracervical dinoprostone (Prepidil) in cervical ripening before labor induction at term. PATIENTS AND METHODS: This was a prospective randomized clinical study including 148 patients with single pregnancy, viable fetus at gestational age greater than 36 weeks gestation and a Bishop score less than five, who required induction of labor. Patients were randomised to receive either repeated doses of dinoprostone gel 0.5mg (Prepidil) every 6 hours (group I) or every 12 hours (group II) for maximum three times before inducing labor with Oxytocin. The main outcome was the rate of caesarean sections. RESULTS: The two groups were similar in patient characteristics, indication for labor induction and preinduction Bishop scores. The caesarean rate was lower in group I (20.3%) than in group II (23%); though the difference did not reach statistical difference: p=0.69. Delivery rate in the first 24 hours was significantly higher in group I (62.2%) than in group II (40.5%); p=0.009. Prepidil secondary effects were experienced in 8.1% of patients in group I versus 1.4% in group II; p=0.11. Median umbilical artery pH at birth was 7.232+/-0.47 in group I and 7.294+/-0.58 in group II; p=0.30. Maternofetal infections rate was lower in group I (1.4%) than in group II (2.7%) without significant difference (p=0.56). CONCLUSIONS: Repeated intracervical doses of Prepidil every 6 hours, in cervical ripening before labor induction at term, enables higher delivery rate in the first 24 hours without inducing excess of caesarean sections or maternofetal morbidity when compared to its administration every 12 hours.

Familial cases of glomerulonephritis complicating Crohn's disease.

A part from nephrolithiasis, renal involvement is rare in the course of Crohn's disease, particularly glomerulonephritis. On the other hand, while onset of Crohn's disease is strongly influenced by environmental and genetic factors, little is known regarding influence of these factors on extra intestinal manifestations. We report a familial case of glomerulonephritis that occurred in a 38-year old woman and her mother, 59 years old with a 7-year and a 37 year history of stenosing ileocolonic disease, respectively. Both of them developed peripheral oedema with nephrotic syndrome during the course of their Crohn's disease while they had no intestinal symptoms and were not receiving any maintenance therapy. Renal function was conserved in the former while the latter developed renal failure and had already small size kidneys on abdominal sonography. Thus, renal biopsy had been performed only in the former patient and had showed membranous glomerulonephritis. Investigations showed no other underlying disease than Crohn's disease. Through this report we emphasis possible genetic influence on extra intestinal manifestations, particularly glomerulonephritis, in Crohn's disease patients.

Correlation between levels of C-reactive protein and clinical activity in Crohn's disease.

AIMS: To determine the factors associated with an increased C-reactive protein level in Crohn's disease patients and to seek a correlation between the C-reactive protein value and the Crohn's disease activity index. METHODS: We prospectively studied 103 Crohn's disease patients, 76% of whose disease was active at the time of inclusion. C-reactive protein measurement was carried out on all patients. An increased C-reactive protein level was defined as >/=10mg/L. RESULTS: The median C-reactive protein rate was 53.9mg/L (ranging from 1 to 228mg/L). An increased C-reactive protein was found in 77 patients (75%). By univariate analysis, ileocolic localization, severity of the flare, erythrocyte sedimentation rate, leukocyte and platelet count, fibrinogen, albumin, serum calcium and Crohn's disease activity index were found to be associated to elevated C-reactive protein values. By multivariate analysis, independent factors associated with an increased C-reactive protein level were: ileocolic localization (p=0.02; OR [95% CI]: 2.84 [1.25-9.52]) and moderate or severe disease activity (p=0.001; OR [95% CI]: 4.20 [1.92-8.64]). A statistically significant association between the Crohn's disease activity index score and the C-reactive protein level was found in our study (r=0.302; p=0.001). The optimal C-reactive protein threshold value that separates patients with moderate to severe disease (Crohn's disease activity index>220) from the others was calculated to be 19mg/L with a sensitivity of 76.4% and a specificity of 56.2%. CONCLUSION: The C-reactive protein level is correlated to disease activity in Crohn's disease. Its role seems to be essential in predicting moderate and severe disease activity.

Lupus anticoagulant and antibodies to beta 2-glycoprotein I, annexin V, and cardiolipin as a cause of recurrent spontaneous abortion.

The prevalence of lupus anticoagulant (LAC), anticardiolipin (ACA), anti-beta(2) glycoprotein I (beta(2)GPI), and antiannexin V antibodies were determined in 200 recurrent spontaneous abortion (RSA) patients and 200 age-matched control women. ACA IgG was associated with early, while antiannexin V IgG and LAC were associated with late, and ACA IgG, antiannexin V IgG, and LAC were associated with combined early + late RSA, thereby recommending inclusion of their screening in RSA workout.

Antibodies to beta2-glycoprotein I and annexin V in women with early and late idiopathic recurrent spontaneous abortions.

Anti-phospholipid antibodies (APA) are heterogeneous group of autoantibodies that target phospholipid or phospholipid-binding proteins. APAs were previously shown to induce several thrombotic states, including idiopathic recurrent spontaneous abortion (RSA). Unlike the contribution of the classical lupus anticoagulant (LAC) and anticardiolipin antibodies (ACA), the contribution of anti-beta2 glycoprotein 1 (beta2GPI) and anti-annexin V antibodies to RSA risk remain poorly understood. We assessed anti-beta2GPI and anti-annexin V IgM and IgG antibodies as RSA risk factors for RSA in 172 Tunisian women with >3 consecutive idiopathic pregnancy losses, together with 173 matched control women. The prevalence of anti-beta2GPI IgG (P=0.41, OR=1.64) and IgM (P=0.50, OR=1.70) were comparable between cases and controls. Higher anti-annexin V IgG (P=0.02, OR=5.28), but not IgM (P=0.25, OR=1.78), levels were seen in cases. Regression analysis showed that anti-beta2GPI IgM (OR=8.90; 95% CI=1.23-64.63) was associated with early RSA, while anti-annexin V IgG (OR=9.35, 95% CI=1.44-60.86) was associated with late RSA. For combined early + late RSA, the only variable selected was BMI (OR=0.93; 95% CI=0.87-0.99), and neither anti-annexin V nor anti-beta2GPI IgM and IgG were associated with early + late RSA. Anti-annexin V and anti-beta2GPI appear to be independent risk markers of RSA.

[Mifepristone 100 mg for early medical abortion]. / Mifépristone à la dose de 100 mg dans les avortements médicamenteux.

OBJECTIVES: To assess the clinical efficacy of mifepristone 100 mg followed two days later by misoprostol 400 microg orally in women undergoing medical termination of pregnancy up to 56 days gestational age. MATERIALS AND METHODS: Retrospective study over 8.5 months of 762 cases early medical abortion. 100 mg mifepristone was used on day 1 after clinic visit and vaginal ultrasonography. Misoprostol 400 microg was administered orally on day 3. Following administration of prostaglandin, women were observed in the ward for 4 hours. A control visit on day 15 was systematic. Success was defined as a complete uterine evacuation without the need for surgical intervention. RESULTS: Medical terminations accounted for 42% of all abortions. 16% of women were pregnant for < 42 days, 76% for 43 to 49 days and 8% for 50 to 56 days. Termination occurred within 4 hours after administration of misoprostol in 80.2% of the women. Only one woman aborted within 48 hours of mifepristone administration only. The success rate in this study was 94.4% and the failure rate increased with the gestational age. Pain was the predominant side effect. Six cases of bleeding required a surgical intervention. No patient required transfusion. 96% of patients attended a control visit on day 15. The acceptability rate of the method has been 94%. CONCLUSION: Mifepristone 100 mg followed two days later by misoprostol 400 microg orally is safe and effective for early termination of pregnancy.

[Intracardiac thrombus in Behçet's disease. A report of three cases]. / Thrombus intracardiaque au cours de la maladie de Behçet. A propos de trois cas.

Intracardiac thrombus formation is exceptional in Behçet's disease (less than 50 cases had been reported). Among 180 patients with Behçet's disease (according to the criteria of the international study group for Behçet's disease), three were diagnosed as having intracardiac thrombus. All were male, the mean age at the time of the diagnosis of the intracardiac thrombus was 27 years and the mean disease duration was 4.8 years. The presenting symptom was hemoptysis in two patients and heart failure in the third. Surgery was the first attempted treatment in two patients but thrombus recurred and resolved after medical treatment. The third patient was given corticosteroids and anticoagulants as the first line treatment. The thrombus did not resolve and the patient declined surgery. Intracardiac thrombus formation should be considered when a young Behçet's disease patient presents with an intracardiac mass. Medical treatment including corticosteroids, immunosuppressive drugs and anticoagulants should be considered as the first line treatment and surgery should be considered when there is no resolution of the thrombus or when it becomes massive and extensive. In certain cases, thrombolytic treatment becomes an interesting alternative to surgery.