[Gynecological emergencies: etiology and degree of gravity]. / Urgences gynécologiques : nature et degré de gravité

OBJECTIVE: To evaluate the type and the emergency degree of the pathologies met in gynecological emergencies. METHODS: prospective study including 205 patients presented to the Emergency department of a maternity level 3 between the 2011 January 4 and February 15. RESULTS: One hundred and ninety-four patients (95%) came from their own initiative. One hundred and eighty-one patients (88%) consulted for abdominal/pelvic or lumbar pain and or metrorragia. The mean age of the patients was of 31 ± 11 years and the average waiting time before being examined was of 84 ± 101 minutes. For 94 patients (46%), the diagnosis was an asymptomatic intra-uterine pregnancy in 41 cases or associated with minor symptoms. 21 patients (8.9%) consulted for menstruation with or without dysmenorrhea, 17 (8,3%) had a miscarriage, 14 (7%) a genital infection, 11 (5%) an ovarian pathology and eight (4%) an ectopic pregnancy or its follow-up. Seven patients had an axillary lymphocele or a breast tumor and four symptomatic myomas. Six patients presented with non-gynecological pathologies. In 23 cases (11%) no organic cause was found. Only 24 patients (12%) were hospitalized and nine (4.5%) operated. CONCLUSION: Most of the patients consulted for minor obstetrical or gynecological pathologies without relation with the function of Emergency department. Ectopic pregnancy remains a rare event. Better information of the users on the significance of the urgency is desirable. Consultation of a referent physician before emergency services should be privileged.

[Anal sphincter tears after vaginal delivery: risks factors and means of prevention]. / Lesions sphinctériennes anales après accouchement par voie vaginale: facteurs de risque et moyens de prévention.

To identify incidence and risks factors of obstetrical anal sphincter lacerations, we reviewed all cases of 3rd and 4th degree sphincter lacerations after vaginal deliveries (VD) occured in a tertiary maternity between 2005 and 2010. 78 anal sphincter lacerations were identified (3.8/1000 deliveries). 66 women (85%) were nulliparous. The mean age of women was of 29 +/- 5 years. The mean duration of the second stage of labour was of 3.4 +/- 1,7 hour. The birth weight of 12 newborns (15%) was greater than 4000 grams. Fourty-six women (2.5%) had sphincter lacerations after instrumental delivery and 32 after spontaneous vaginal delivery (0.2%). 51 patients out of 78 (65%) had a medio-lateral episiotomy, 82% occured after instrumental extraction and 43% after spontaneous delivery. A forceps of Tarnier was used in 18 cases, a Suzor forceps in 12 cases, spatula in 12 cases and vacuum in 4 cases. 76% of foetuses were in anterior presentation and 78% at the medium part of the pelvis. 2 patients experienced anal incontinence in early post-partum. Anal sphincter lacerations are relatively frequent after VD especially after instrumental delivery. Macrosomia, nulliparous women, prolonged second stage of labor were associated with anal sphincter tears. Medio-lateral episiotomy does not protect enough anal sphincters. Anal sphincter lacerations lead to anal incontinence in some cases.A long follow-up is useful for these patients.

Autoantibodies specific for the phospholipase A2 receptor in recurrent and De Novo membranous nephropathy.

Recent findings in idiopathic membranous nephropathy (MN) suggest that in most patients, the disease is because of anti-phospholipase A(2) receptor (PLA(2) R1) autoantibodies. Our aim was to analyze the prevalence and significance of anti-PLA(2) R1 antibodies in recurrent and de novo MN after transplantation. We assessed circulating PLA(2) R1 autoantibodies by a direct immunofluorescence assay based on human embryonic kidney cells transfected with a PLA(2) R1 cDNA, and the presence of PLA(2) R1 antigen in immune deposits. We showed that PLA(2) R1 was involved in 5 of 10 patients with recurrent MN, but in none of the 9 patients with de novo MN. We also showed a marked heterogeneity in the kinetics and titers of anti-PLA(2) R1, which may relate to different pathogenic potential. We provide evidence that some patients with PLA(2) R1-related idiopathic MN and anti-PLA(2) R1 antibodies at the time of transplantation will not develop recurrence. Because PLA(2) R1 autoantibody was not always associated with recurrence, its predictive value should be carefully analyzed in prospective studies.

Ofloxacin: new applications for the prevention of urinary tract infections in renal graft recipients.

BACKGROUND: Urinary tract infections (UTIs), the most common form of bacterial infection in kidney transplant recipients, recently have been demonstrated to be detrimental for long-term graft outcome. Therefore, reinforcing antibiotic prophylaxis might be vital, in addition to basic hygiene recommendations, surgical care, and prophylaxis by trimethoprim-sulfamethoxazole. METHODS: In 2006, a Legionella pneumophila contamination of our department's water pipes meant that all the patients undergoing renal transplantation underwent a 1-month regimen of ofloxacin (OFLO) (200 mg every other day). We took this opportunity to measure the incidence of UTI, including acute pyelonephritis (APN), in 100 consecutive patients transplanted before (n = 50) and after (n = 50) this treatment decision was reached. We also studied the antimicrobial resistance profiles in our department and in the rest of the hospital. RESULTS: No patient developed Legionnaire's disease. A dramatic decrease in the incidence of UTI (-63%) was also seen in patients undergoing OFLO treatment. Logistic regression analysis demonstrated that the use of OFLO was independently associated with a reduction in UTI (odd ratio [OR] = 0.31%, 95% confidence interval [CI] 0.11-0.84, P = 0.02) and APN (OR = 0.21%, 95% CI 0.07-0.98, P = 0.045). This protection was sustained during the whole first year post transplantation. As for resistance rates, we observed a decrease in the susceptibility of Pseudomonas aeruginosa to ciprofloxacin in our nephrology department, compared with that observed in the rest of the hospital. The incidence of multi-resistant bacteria was stable. DISCUSSION: Our unintentional extension of prophylactic antibiotherapy with OFLO gave rise to a dramatic decrease in the 1-year incidence of UTI and APN in kidney recipients. Emergence of resistant strains is, however, a major concern.

Intrarenal urothelium proliferation: an unexpected early event following ischemic injury.

Identification of renal cell progenitors and recognition of the events contributing to cell regeneration following ischemia-reperfusion injury (IRI) are a major challenge. In a mouse model of unilateral renal IRI, we demonstrated that the first cells to proliferate within injured kidneys were urothelial cells expressing the progenitor cell marker cytokeratin 14. A systematic cutting of the injured kidney revealed that these urothelial cells were located in the deep cortex at the corticomedullary junction in the vicinity of lobar vessels. Contrary to multilayered bladder urothelium, these intrarenal urothelial cells located in the upper part of the medulla constitute a monolayered barrier and express among uroplakins only uroplakin III. However, like bladder progenitors, intrarenal urothelial cells proliferated through a FGF receptor-2 (FGFR2)-mediated process. They strongly expressed FGFR2 and proliferated in vivo after recombinant FGF7 administration to control mice. In addition, IRI led to FGFR phosphorylation together with the selective upregulation of FGF7 and FGF2. Conversely, by day 2 following IRI, renal urothelial cell proliferation was significantly inhibited by FGFR2 antisense oligonucleotide administration into an intrarenal urinary space. Of notice, no significant migration of these early dividing urothelial cells was detected in the cortex within 7 days following IRI. Thus our data show that following IRI, proliferation of urothelial cells is mediated by the FGFR2 pathway and precedes tubular cell proliferation, indicating a particular sensitivity of this structure to changes caused by the ischemic process.

[Management of umbilical cord prolapse and neonatal outcomes]. / Procidence du cordon: prise en charge obstétricale et conséquences néonatales.

OBJECTIVE: To evaluate the obstetrical management of umbilical cord prolapse and the neonatal outcomes. METHODS: Retrospective study of 57 prolapses of umbilical cord between 1998 and 2009. Arterial pH of umbilical cord, Apgar score and diagnosis delivery time (DDT) were analyzed. RESULTS: The incidence of the cord prolapse was of 1.25 for 1000 deliveries. Cord prolapse occurred with the artificial rupture of membranes in 24 cases (42%) out of 57. There were 48 caesarean births. There were three hydramnios and seven cases of twin pregnancy. The mean pH in the umbilical arteries was 7.15 ± 0.13 in 27 cases. The mean Apgar for the 57 newborns was 6 ± 3 at 1 min and 8 ± 3 at 5 min. The mean DDT was 18 ± 8 min (range: 3-44). In 17 cases out of 27, the mean arterial umbilical pH was 7.07 ± 0.09. Fifteen newborns (26%) had a 5-minute Apgar score less than 7 and were admitted in intensive care unit. The mean Apgar score in the nine vaginal deliveries was 8 ± 4 min. In case of cephalic presentations without associated foetal or maternal pathologies there was a tendency of a better pH when the DDT was shorter. In non-cephalic presentations (14 cases), the mean Apgar score was 8 ± 3 at 5 min. The mean pH measured in eight cases was 7.20 ± 0.13 with mean DDT of 20 minutes. CONCLUSION: The umbilical cord prolapse remains a serious event for the newborns. The reduction of the DDT in cephalic presentation seems to be correlated to a better neonatal state. The caesarean section is the preferential way of childbirth.

Genomic organisation, alternative splicing and polymorphisms of the human cardiac troponin T gene.

Troponin T (TnT) is a component of the troponin complex which regulates muscle contraction in response to alterations in intracellular calcium ion concentration. In human heart, multiple isoforms of cardiac TnT have been described on the basis of antibody studies and molecular cloning of corresponding cDNAs. These isoforms are all derived from the transcription of a single gene, TNNT2, located on chromosome 1q32, and generated by alternative splicing. We show here that isoform diversity is achieved by the use of both alternative exons and alternative acceptor sites and present the organisation of the human TNNT2 gene, which is composed of 17 exons spread over 17 kb. A potential structure of the promoter region is also presented. Several polymorphisms in both the exonic and intronic regions were identified, some of which may act as modulators of the expression of this gene.

Interactions between endothelin-1 and atrial natriuretic peptide influence cultured chick cardiac myocyte contractility.

We have previously shown that rat atrial natriuretic peptide (ANP) reduces the contractility of cultured, spontaneously beating chick embryo ventricular cells, an effect opposite to that of endothelin-1. Endothelin-1 has been described as a secretagogue for natriuretic peptides in vitro and in vivo. Natriuretic peptides can inhibit endothelin-1 secretion from cultured endothelial cells, suggesting a negative feedback mechanism between endothelial cells and cardiomyocytes. The aim of this study was to determine whether ANP attenuated the endothelin-1-induced increase in myocyte contractility. Using a video-microscopy system we studied the contractility of isolated cultured chick ventricular myocytes in response to endothelin-1, chicken natriuretic peptide (ChNP), and both. We also used Northern blot analysis to study the time course of ChNP expression in response to endothelin-1. Endothelin-1 (10(-8) M) increased chick cardiomyocyte contractility by 20-25% between 5 and 15 min (P < 0.05). Although ChNP (3 x 10(-7) M) did not significantly change the amplitude of contraction in basal conditions, it prevented the endothelin-1-induced increase in contractility (P < 0.05) when perfused prior to endothelin-1, and reversed it when perfused 5 min after endothelin-1 exposure (P < 0.05). Endothelin-1 significantly increased the accumulation of ChNP mRNA in chick ventricular myocytes as early as the 30 min after exposure (P < 0.05), with a maximal effect after 2 h of stimulation (P < 0.01); no effect was observed after 4 h. These data support an interaction between endothelin-1 and natriuretic peptides as autocrine/paracrine factors regulating the contractile function of chick cardiac myocytes, as well as their antagonistic effects on cardiac cell contractility. The early and transient expression of ChNP mRNA in response to endothelin-1 may be involved in this interaction.

Genetic linkage heterogeneity in myotubular myopathy.

Myotubular myopathy is a severe congenital disease inherited as an X-linked trait (MTM1; McKusick 31040). It has been mapped to the long arm of chromosome X, to the Xq27-28 region. Significant linkage has subsequently been established for the linkage group comprised of DXS304, DXS15, DXS52, and F8C in several studies. To date, published linkage studies have provided no evidence of genetic heterogeneity in severe neonatal myotubular myopathy (XLMTM). We have investigated a family with typical XLMTM in which no linkage to these markers was found. Our findings strongly suggest genetic heterogeneity in myotubular myopathy and indicate that great care should be taken when using Xq28 markers in linkage studies for prenatal diagnosis and genetic counseling.

Human cardiac troponin T: cloning and expression of new isoforms in the normal and failing heart.

Troponin T, like many myofibrillar proteins, exists as multiple isoforms encoded by distinct genes or generated by splicing of the same primary RNA transcript. We have previously cloned the first human cardiac troponin T (cTnT) cDNA and showed the differential expression of cTnT in cardiac and skeletal muscle during ontogenic development. In this work we located the human cTnT gene by means of fluorescent in situ hybridization to 1q32 and, by sequencing thirteen cDNAs isolated from a human fetal heart cDNA library, identified three new isoforms resulting from specific combinations of three variable regions in human cTnT cDNA. The first variable region is a 30-bp box located at the 5' end of the cDNA, which can be excised either totally or only from the first 3 bp onwards; the second is a codon which can be completely excised; and the third is a 9-bp box in the 3' half of the cDNA, which can also be excised either totally or only from the first 3 bp. The existence of the corresponding RNAs in fetal and adult ventricles was confirmed by RNase protection studies. No accumulation of the fetal isoforms was found in failing ventricles compared with controls.

A new human slow skeletal troponin T (TnTs) mRNA isoform derived from alternative splicing of a single gene.

A human muscle cDNA library was screened for slow skeletal troponin T (TnTs). Sequence analysis revealed that one of the selected clones had a cDNA coding sequence different from the two previously described. RNase protection assays confirmed the expression of this new isoform in adult skeletal muscle. In addition, results of the RNase protection assays strongly suggested the expression of a fourth isoform. These isoforms for human slow TnT most likely result from combinatorial alternative splicing of a single gene.

Molecular cloning and developmental expression of human cardiac troponin T.

We have isolated a full-size cDNA coding for cardiac troponin T (cTnT) from a human adult heart library, using a slow skeletal TnT probe. This cDNA detected a 1.2 kb mRNA in fetal and post-natal human heart, the amount of which increased during ontogenic development. Interestingly, a similar transcript was coexpressed in fetal skeletal muscle, together with the 0.9 kb slow skeletal muscle mRNA, and its expression was down-regulated during further development.

For a systematic policy of i.v. oxytocin inducted placenta deliveries in a unit where a fairly active management of third stage of labour is yet applied: results of a controlled trial.

The authors analysed the effect of the i.v. oxytocin induced third stage of labour in a controlled trial concerning 1000 patients. The appliance of such an policy in a unit that already had a fairly active management of delivery was very encouraging. The incidence of post-partum haemorrhage (greater than 500 ml) is significantly (P less than 0.001) less than in the control group; and the same for severe haemorrhage. The third stage is significantly (P less than 0.001) shorter in the oxytocin-injected group than in the control group. Moreover, there is no significant difference between the two groups for retained placenta. The economy of blood transfusion, which is a major concern nowadays, could be the real interest of this active management of the third stage of labour.

[Vasectomy and its difficulties]. / La vasectomie et ses difficultés.

PIP: There is an increasing demand for vasectomies due to personal convenience in the context of an ongoing rearrangement of roles and relationships for couples. French doctors remain divided in their attitudes when facing these demands, either because of personal convictions or due to the ambiguities of legislation and the insurance companies. A survey of vasectomies in various countries of the world is given. In the United States it is estimated that 15 million Americans have been vasectomized, more than 1 in 10 aged over 30, and some experts predict that voluntary sterilization will become more popular than oral contraception for couples of all ages. In many third world countries sterilization is considered the only effective solution to family planning. In China and South-Asian countries vasectomy is practiced and birth rates are almost down to European levels. In Spain, Greece, Portugal and Brazil vasectomy is illegal. In African countries it is considered unacceptable and a direct attack upon virility. In France no epidemiological studies have supplied even approximate figures. It has been found that 96% of vasectomized men (married or not) have lived with a partner for 5 years having an average age of 36-38 and 2.7 children. Liberal professions, managers and middle executives are overrepresented; employees and farmers are underrepresented. Before an operation most are well informed about concomitant problems. The prime motive is to limit the number of children. 10% to 20% mentioned a previous unwanted pregnancy due to failure of other contraceptive means. Various techniques for performing the operation and possible complications are described.^ieng