Utilización del soporte nutricional parenteral en pacientes oncológicos al final de la vida / Use of parenteral nutritional support in cancer patients at the end of life

Objetivo: De acuerdo con la evidencia disponible sobre soporte nutricional parenteral (SNP) en pacientes oncológicos, el tratamiento en los últimos días de vida debe basarse en el confort, y el SNP no aporta beneficios ni está exento de riesgos. El objetivo del estudio es analizar el uso del SNP en pacientes oncológicos durante la última semana de vida. Metodología: Estudio observacional retrospectivo. Se incluyeron todos los pacientes oncológicos que recibieron SNP en un servicio de salud con 350.000 habitantes entre 2016-2021. Se seleccionaron aquellos que habían recibido SNP en la última semana de vida. Se registraron las variables demográficas: edad, sexo, peso, talla; variables clínicas: diagnóstico, estado funcional; variables relacionadas con el SNP: duración, acceso venoso, días desde la retirada hasta el exitus. Resultados: 287 pacientes con cáncer recibieron SNP. 75 pacientes (26%) mantuvieron SNP en la última semana de vida, mediana de edad de 69 años (60-75). Diagnósticos más frecuentes: cáncer de colon (29,3%) y de pulmón (20%). Mediana de duración de 8,1 días (2-9). De los pacientes con SNP en la última semana de vida, el 28% lo recibieron hasta el día del exitus. Conclusión: Más de la cuarta parte de los pacientes oncológicos que recibieron SNP lo mantuvieron hasta la última semana de vida. El objetivo en estos pacientes no debe ser tratar de corregir la desnutrición sino controlar los síntomas y mejorar la calidad de vida. Se deben evitar enfoques intervencionistas como el SNP, que pueden prolongar el sufrimiento y aumentar los costes asociados innecesarios. (AU)

Objetive: According to the available evidence on parenteral nutritional support (PNS) in cancer patients, treatment in the last days of life should be based on comfort, and the PNS does not provide benefits or is free of risks. The objective of the study is to analyze the use of the SNP in cancer patients during the last week of life. Methodology: Retrospective observational study. All cancer patients who received PNS in a health service with 350,000 inhabitants between 2016-2021 are included. Those who had received PNS in the last week of life were selected. Demographic variables recorded: age, sex, weight, height; clinical variables: diagnosis, functional status; PNS-related variables: duration, venous access, days from removal to death. Results: 287 cancer patients received PNS. 75 patients (26%) maintained PNS in the last week of life, median age 69 years (60-75). Most frequent diagnoses: colon cancer (29.3%) and lung cancer (20%). Median duration of 8.1 days (2-9). Of the patients with SNP in the last week of life, 28% received it until the day of death. Conclusion: More than a quarter of cancer patients who received PNS maintained it until the last week of life. The goal in these patients should not be to try to correct malnutrition but to control symptoms and improve quality of life. Interventional approaches such as PNS, which can prolong suffering and increase the necessary associated costs, should be avoided. (AU)

[Indications of primary cesarean deliveries in a regional teaching hospital and reasonable strategies for reducing them]. / Indications des premières césariennes dans un centre hospitalo-universitaire régional et stratégies raisonnables pour les diminuer.

OBJECTIVES: To characterize the indications of primary cesarean sections and discuss the various possibilities to reduce them. MATERIALS AND METHODS: Retrospective study, carried out over a period of 1 year in a university hospital having a level 3 perinatal activity, including the 499 primary cesarean sections of 2013. Two groups were defined by parity: nulliparous patients (group 1) and multiparous patients who had never previously been delivered by cesarean section (group 2). We have assessed the indication of every primary cesarean section and health status of newborns in each group. RESULTS: Groups 1 and 2 respectively included 369 and 130 patients. The cesarean section rate in 2013 was 24.7% with a primary cesarean section rate of 17%. Seventy-four percent of the primary caesarean deliveries were performed on nulliparous women and 26% on multiparous (P<0.001). Sixty-three percent of the primary caesarean deliveries were performed on nulliparous women with a singleton fetus in cephalic presentation. The most common indications for primary cesarean delivery were non-reassuring fetal heart rate tracing (47.1%), failure to progress (24.8%) for which nulliparous women were more involved (29% vs. 13%, P<0.001) and fetal malpresentation (9.6%). CONCLUSION: Further analysis of fetal heart rate during labor, a larger use of second line means to evaluate the fetal status during labor, using 6cm as the cut off for active labor, and encouraging vaginal operative delivery constitute the best way to decrease the primary cesarean section rate.

[Usefulness of a rapid intrapartum real-time PCR assay in comparison with the group B Streptococcus culture screening at the end of pregnancy in pregnant women]. / Intérêt d'un test de PCR en temps réel en intrapartum en comparaison à la culture de fin de grossesse pour le dépistage du streptocoque du groupe B chez la femme enceinte.

OBJECTIVES: The objectives were to evaluate and compare the diagnostic accuracy of a rapid real-time PCR assay at the onset of labor with those of the current antenatal culture-based test at 34-38 weeks gestation for group B Streptococcus (GBS) screening. MATERIALS AND METHODS: A prospective study including all pregnant women admitted for delivery after a 34-week gestation period was conducted in October 2012 at the Grenoble University Hospital Centre. A first culture-based GBS screening test was performed between 34 and 38 weeks of gestation followed by a second screening test at the onset of labor, using a real-time PCR Assay and a culture-based method (gold standard) in order to calculate the diagnostic accuracy. RESULTS: One hundred an fifty-seven patients were enrolled. The sensitivity was 94.4% (95% CI, 72.7-99.9%) with intrapartum PCR assay and 50% (95% CI, 26-74%) with antepartum culture. Prevalence of GBS colonization was 7.6% with the antepartum culture method, 11.5% with intrapartum culture and 16.6% by using PCR-test. CONCLUSION: Intrapartum PCR shows a much higher sensitivity compared to the antepartum culture-based screening mainly due to variations in GBS colonization and could allow us to target patients requiring intrapartum antibiotic prophylaxis more effectively.

[Introducing a daily obstetric audit: A solution to reduce the cesarean section rate?]. / L'introduction d'un audit obstétrical quotidien: une solution pour diminuer le taux de césarienne ?

OBJECTIVE: To evaluate the impact of a medical audit assessing the accuracy of caesarean indications on the final caesarean section rate of an obstetrics department. MATERIAL AND METHOD: Comparative observational study conducted in a regional university teaching hospital on the two first quadrimester periods of 2013. During the first quadrimester, there was no cesarean section audit introduced for the daily reports meetings, while an audit was introduced during the second quadrimester. The caesarean rate and the instrumental delivery rate on both quadrimesters were compared. RESULTS: In the first quadrimester period, there were 248 caesarean sections for 947 deliveries (26.2%), while in the second quadrimester period, there were 246 for 1033 deliveries (23.8%), P=0.014. The emergency caesarean rate decreased from 19.6 to 16.7%, P=0.02 in the second quadrimester period while the instrumental delivery rate increased from 14.4 to 17.2%, P=0.0004. Mothers and children's health was not modified between the two periods. CONCLUSION: In our experience, the introduction of a daily obstetric audit of the caesarean indications is effective to decrease the emergency caesarean section rate and it encourages us to be active in the first like in the second part of the labor.

[Best practices for the safe use of parenteral nutrition multi-chamber bags. Spanish Society of Hospital Pharmacist's Clinical Nutrition Group]. / Buenas prácticas para el uso seguro de las bolsas tricamerales de nutrición parenteral.

Patient security is one of the key aspects of the Health-System. Parenteral Nutrition is included in the ISMP's list of high-alert medication, being its appropiate use an essential element in maximizing effectiviness while minimizing the potential risk of errors associated with its use. Multi-chamber bags offer several advantages versus pharmacy bespoke bags. However, their apparent simplicity may induce to misuse, asuming their use requires limited consideration, thus increasing the risk of potential errors. For this reason, the Spanish Society of Hospital Pharmacist's Clinical Nutrition Group considered it essential to develop a list of safety practices regarding the use of parenteral nutrition multi-chamber bags. These recommendations are based on practices globally accepted to diminish errors in PN therapy.

La seguridad del paciente es un aspecto clave de la asistencia sanitaria. La Nutrición Parenteral está incluida en la lista de medicamentos de alto riesgo del ISMP, siendo su uso apropiado un elemento esencial para maximizar su efectividad y minimizar el riesgo potencial de errores asociados con su empleo. Las bolsas tricamerales presentan numerosas ventajas frente a las elaboradas en los Servicios de Farmacia. Sin embargo, su aparente simplicidad puede inducir a un uso inadecuado de las mismas, al asumir que su utilización requiere considerar menos aspectos, incrementando con ello el riesgo potencial de errores. Por este motivo, el Grupo de Nutrición Clínica de la SEFH consideró necesario elaborar una relación de buenas prácticas para el uso seguro de las bolsas tricamerales de NP. Estas recomendaciones están basadas en prácticas globalmente aceptadas para disminuir los errores con el empleo de NP.

[A comparative study between two procedures of TVT retropubic mid-urethral sling placement for treatment of female stress urinary incontinence]. / Étude comparative entre deux procédures de mise en place d'une bandelette sous-urétrale rétropubienne TVT dans le traitement de l'incontinence urinaire d'effort féminine.

OBJECTIVE: To evaluate complications and functional outcomes at 1 year and more of a modified Tension-free Vaginal Tape (TVT) technique from that of classic TVT. PATIENTS AND METHODS: Retrospective study comparing the two techniques. For the modified TVT technique, a peri-urethrovesical hydrodissection was performed. An 18-gauge hollow needle, in which a thread was introduced, was used as an ancillary for the placement of the sling. The sling was secured to the thread and then positioned with it. Bladder filling objectified perforations. An absorbable suture around the sling allowed its descent if necessary. RESULTS: One hundred and eighteen procedures were performed (54 classic TVT and 64 modified TVT). For the standard TVT and the modified TVT, the vesico-urethral perforation rates were respectively 7.4% and 1.5% (P<0.05), those of reoperations for pulling the sling downward 11.1% and 1.5% (P<0.05). A 1 year and more, healing and satisfaction rates were respectively 83.3% and 79.2% for the standard TVT versus 88.2% and 90% for the modified TVT (NS). The dissatisfaction rate was lower for the modified TVT (P<0.05). CONCLUSION: By modifying the placement of the classic TVT, it is possible to reduce its complications while maintaining its efficacy.

[Ovarian cryopreservation: evaluation of two surgical procedures]. / Cryoconservation ovarienne: évaluation de deux techniques chirurgicales.

OBJECTIVES: To evaluate various surgical techniques for partial oophorectomy cryopreservation. To evaluate the consequences of prior exposure to cytotoxic therapy on the quality of the ovary removed. PATIENTS AND METHODS: Single center retrospective observational study over 4 years of women who had ovarian cryopreservation surgery for chemotherapy or radiotherapy which were at high risk of premature ovarian failure. Several techniques have been proposed: partial oophorectomy with clamping of the vascular gonadal pedicle (indirect tissue sample) without clamping (direct tissue sample) and partial oophorectomy with an automatic stapler. Ovarian tissue was immediately prepared for cryopreservation in the operating theatre. The whole sample was divided into small slices. For each ovary, a count of small slices was made. Additionally, one slice was examined to determine the presence of primordial follicles. RESULTS: Ovary was successfully removed and cryopreserved in 13 patients. Two bleeding events occurred with the direct technique, without consequences for patients. The number of fragments obtained between indirect and direct techniques was respectively 19 vs 15, P=0.18; the number of primordial follicles was 38 vs 36, P=0.87. The automatic stapler consumed too much ovarian tissue to be interesting. There were fewer fragments, 15 vs 20, P<0.05 and primordial follicles, 35 vs 40, P=0.65, after a first cycle of chemotherapy. DISCUSSION AND CONCLUSION: The vascular clamping technique is safer but with no difference in the quality of the sample tissue. One cycle of chemotherapy has a pejorative impact on the quality of the sample tissue.

[Premature rupture of membranes at term on unfavourable cervix: immediate or delayed induction?]. / Rupture prématurée des membranes à terme sur col défavorable: quel délai pour déclencher ?

OBJECTIVES: To define the optimal delay before inducing labor in the management of premature rupture of the membranes (PRM) at term with unfavourable cervix in order to reduce the risk of caesarean section as well as the risk of maternal and foetal infection. MATERIALS AND METHODS: Retrospective study of three homogeneous groups carried out over on a period of 4years in two centres. All the patients were included after premature rupture of membranes at term with unfavourable cervix (Bishop score<6). We defined three expected delays after PRM at term: less than 7h (group 1), between 7 and 12h (group 2) and more than 12h (group 3). We have assessed the obstetrical, maternal and foetal consequences for each group. RESULTS: Sixty patients were allocated in group 1, 49 in group 2 and 46 in group 3. There was no significant difference in the rate of caesarean between the three groups but it was lower in group 2: 6.1% versus 18.3% in group 1 and 21.7% in group 3. No statistical difference was observed concerning maternal or foetal infections. CONCLUSION: In PRM at term, neither our study nor literature data allow us to conclude about the optimal delay before inducing labor.

[Spontaneous rupture of uterine vessels during pregnancy, about three cases]. / Rupture spontanée des vaisseaux utérins pendant la grossesse : à propos de trois cas.

Spontaneous rupture of uterine vessels during pregnancy is an exceptional event which remains little known by the gynecologists. Being given its important morbi-mortality, we wanted to make a reminder of this pathology through three cases arisen in the CHU of Grenoble. All patients experienced acute abdominal pain. In two cases out of three, birth followed vaginal delivery. No maternal death was deplored. Fetal prognosis remains poor, as one is dead among our three cases. Clinical signs are sensible but not specific. Early management requires efficient resuscitation then surgical haemostasis, and has to be teatched in order to improve its prognosis.

On-chip integration of high-frequency electron paramagnetic resonance spectroscopy and Hall-effect magnetometry.

A sensor that integrates high-sensitivity micro-Hall effect magnetometry and high-frequency electron paramagnetic resonance spectroscopy capabilities on a single semiconductor chip is presented. The Hall-effect magnetometer (HEM) was fabricated from a two-dimensional electron gas GaAsAlGaAs heterostructure in the form of a cross, with a 50 x 50 microm2 sensing area. A high-frequency microstrip resonator is coupled with two small gaps to a transmission line with a 50 Omega impedance. Different resonator lengths are used to obtain quasi-TEM fundamental resonant modes in the frequency range 10-30 GHz. The resonator is positioned on top of the active area of the HEM, where the magnetic field of the fundamental mode is largest, thus optimizing the conversion of microwave power into magnetic field at the sample position. The two gaps coupling the resonator and transmission lines are engineered differently--the gap to the microwave source is designed to optimize the loaded quality factor of the resonator (Q

Elective abortions for minors: impact of the new law in France.

OBJECTIVE: This study in a French family planning centre assessed the impact of the new law (July 2001) concerning minors seeking elective abortions. STUDY DESIGN: We compared two historical cohorts of adolescents (<18 years). The "before" (n=61) and "after" (n=81) cohorts comprise the patients seen for the year before and the year after the effective date of the new statute. The data came from medical records. We compared the girls' obstetrical history and their social, demographic and medical characteristics. RESULTS: Obstetrical history did not differ significantly between the two cohorts (p>0.05), nor did most of the social and demographic characteristics. Fewer adolescents in the "before" (29.5%) than in the "after" (51.2%) (p<0.05) cohort did not use contraceptives. There were no significant differences between the two study periods for the adult selected to accompany the minor or for the reasons given for refusing to inform a parent. In the "before" cohort, the girl's legal representative always provided consent, while only 63% did so in the "after" cohort. CONCLUSION: The scope of application of the new law substantially exceeded the legislative intent, since recourse to non-parental adults was not rare, even though the reasons for not informing parents did not differ during the two study periods.

[Are there any factors predicting failure or complications rates of trans-obturator surgery for stress urinary incontinence?]. / Existe-t-il des facteurs prédictifs d'échec ou de complications dans la chirurgie de l'incontinence urinaire d'effort par voie transobturatrice?

OBJECTIVE: Since 2001 and the publication by Delorme of the trans-obturator route in the stress urinary incontinence (SUI), this technique has known an increasing development in France. The aim of this study is to evaluate the impact of different predicting factors on results and complications of trans-obturator surgery. PATIENTS AND METHODS: It is a retrospective, multicentric study, including 4 centers, 14 surgeons and 196 patients operated between February 2003 and August 2005. We have realized a univariate (Chi2 test) and multivariate (logistic regression test) statistic analysis concerning 7 sub-groups defined according to the literature on the TVT. RESULTS: Age>55 years (P=0,044) and SUI grade>2 (P=0,028) are statistically associated with a decrease of surgical success, age>55 years is also associated with an increase of complications rate in univariate (P=0,033) and multivariate (P=0,048) analysis. DISCUSSION AND CONCLUSION: Age>55 years should be considered, according to us, as a risk factor of surgical failure and complications in the trans-obturator surgery for SUI, none of the others risk factors found in the literature on the TVT seems to have an influence, in this study, on the results of trans-obturator surgery for SUI.

[Twin delivery: a survey of French obstetrical policies]. / Accouchement des grossesses gémellaires: enquête sur les politiques des maternités françaises.

OBJECTIVES: To describe obstetrical policy variations concerning the delivery management in the case of twins, at term. PATIENTS AND METHODS: A mail survey was undertaken among the medical supervisors of the maternity wards belonging to the AUDIPOG Network (N=170). RESULTS: The participating rate was 73.35%. 124 answers were analysed. Elective caesarean was realized by 0.8% of participants for diamniotic twins and by 57% of cases for monamniotic twins An elective caesarean is planned for respectively 74% of answers if first (J1) and second twin (J2) are in a breech presentation, 81% if J1 is in breech and J2 in cephalic presentation, and 68% if J1 is in breech and J2 in transverse presentation. Delivery with J1 in breech and J2 in cephalic presentation had a higher risk than a delivery of a single breech at term. When J1 and J2 had a breech presentation 73% of participants thought that this delivery is more difficult than a delivery of a single breech at term. However, they were only 17.5% to consider that a delivery of twin with J1 in cephalic and J2 in breech presentation had a higher risk than a single breech delivery. DISCUSSION AND CONCLUSION: Medical policy variations are not extensive except for X-ray pelvimetry and the presence for the delivery of one paediatrician and one anaesthesiologist. An elective caesarean policy for twins is infrequent in France.

The term breech presentation: Neonatal results and obstetric practices in France.

OBJECTIVE: Compare neonatal complications according to the planned mode of delivery and according to whether the women gave birth at a maternity unit that applied "consensus" guidelines. STUDY DESIGN: The study used the database of the AUDIPOG Sentinel Network (n=71,919 pregnancies between 1994 and 2000). The principal outcome was a composite variable that included neonatal morbidity and mortality. A survey of obstetric practices was sent to 175 maternity units belonging to the network. Consensus guidelines were defined from the survey responses and taken into account in the database analysis. RESULTS: Neonatal complications did not differ between the group of women with term babies in breech presentation for whom vaginal delivery was planned and those for whom an elective caesarean was planned (adjusted OR=1.33; 95% CI: 0.63-2.80). The survey allowed us to define a set of six criteria for deciding on mode of delivery; it established a consensus, followed by 42% of the maternity units in the study. The rate of neonatal complications among the women with planned vaginal delivery was lower for those giving birth in units that applied the consensus guidelines than among those in the other units: adjusted OR=0.27 (95% CI: 0.09-0.85). CONCLUSION: The risk of neonatal morbidity according to planned mode of delivery for term breech babies was lower for those giving birth in units that applied the consensus guidelines than among those in the other units.

[Acute pulmonary edema during nicardipine and salbutamol therapy for preterm labor in twin pregnancy]. / Oedème aigu du poumon au décours d'une tocolyse par nicardipine et salbutamol lors d'une menace d'accouchement prématuré sur grossesse gémellaire.

We report the case of a 38-year-old parturient at 30 weeks 2 days term of a multiple pregnancy who experienced acute pulmonary edema more than 48 hours after tocolytic treatment with nicardipine and salbutamol. The patient was transferred from a level 1 perinatal center to a level 3 perinatal center by the Grenoble mobile intensive care unit in application of the in utero transfer protocol for preterm labor before 33 weeks with twin pregnancy. This case illustrates the risk of tocolytic treatment and potential adverse effects in the event of preterm labor on twin pregnancy. The question of associating a second tocolytic after failure of the first is also raised.

[Management of 103 limb reduction defects: a French-speaking fetal medicine club enquiry]. / Prise en charge de 103 anomalies réductionnelles de membre: une étude du Club Francophone de Médecine Foetale.

OBJECTIVES: Prenatal diagnosis of a limb reduction defect poses difficult medical and ethical problems. Prenatal diagnosis can be at the origin of two opposing medical attitudes, either a medical termination of pregnancy, or the specific management of the child at birth. The objective is to carry out an enquiry of practices and to determine whether there is a threshold in the gravity of the malformation from which the medical termination of pregnancy is accepted. MATERIAL AND METHOD: The study was carried out by a questionnaire addressed to the members of the French-speaking Club of Fetal Medicine. RESULTS: Outcome of 103 fetuses with limb reduction defect was described. Prenatal diagnosis and management of observed malformations were explained. CONCLUSION: Decisions concerning the outcome of the pregnancy are very variable from one couple to another and from one medical team to another. Parents making a request must be given complete information and accompanying psychological support. Collegial with a multidisciplinary team is necessary. For the parents, it is the physician's duty to avoid judgement errors related to anxiety and ignorance of the medical consequences. The physician should guide the parents towards the continuation of the pregnancy or its interruption. The proper decision proceeds from the reunion of the confidence of the couple and the conscience of the physician.

[Role of "subtle" ultrasonographic signs during antenatal screening for trisomy 21 during the second trimester of pregnancy: meta-analysis and CPDPN protocol of the Grenoble University Hospital]. / Quelle est la place des signes d'appels échographiques dits "mineurs" dans le dépistage prénatal de la trisomie 21 au 2e trimestre de la grossesse? Méta-analyse de la littérature et protocole du Centre pluridisciplinaire de Dignostic Prénatal (CPDPN) du CHU de Grenoble.

OBJECTIVE: A meta-analysis about subtle ultrasonographic signs in second trimester of pregnancy. MATERIALS AND METHODS: 196 articles dealing with the subject--from 1985 to July 2002--were studied. Data on the 11 reported signs were collected from 92 theoretically and/or statistically valid studies. Then, the studies were selected according to several criteria: isolated characteristic, defined thresholds, calculable sensitivity and specificity. After checking for homogeneity, a likelihood ratio was calculated for some of the signs. RESULTS: This meta-analysis of the second trimester ultrasonographic signs of Down's syndrome enabled us to estimate the likelihood ratio (LHR) of six signs. At 22 weeks'gestation (WG) these signs are: pyelectasis equal to or greater than 5 mm; nuchal fold thickness equal to or greater than 6 mm; persistence of choroid plexus cysts; shortness of the femur and humerus below the tenth percentile; hyperechogenic bowe; and nasal bone length less than 2.5 mm. CONCLUSION: These validated ultrasonographic signs are independent of nuchal translucency thickness at 12 WG and of maternal serum biochemistry. This allows to calculate a combinate risk for nuchal translucency, maternal serum biochemistry and second trimester ultrasonographic signs when they are validated.