Macrosomie au Centre Hospitalier Universitaire de Libreville

La macrosomie constitue un problème de santé publique en Afrique subsaharienne, en raison de l'importance de sa morbidité et mortalité néonatales. Dans le monde, sa fréquence est en augmentation et peu d'études ont été réalisées au Gabon. Objectif : déterminer la fréquence, évaluer le pronostic materno-foetal et identifier les facteurs associés aux risques de la macrosomie. Patients et méthodes : il s'agissait d'une étude descriptive, analytique et prospective qui a été réalisée entre janvier et décembre 2017 au Centre Hospitalier Universitaire de Libreville. Les nouveaux nés de poids supérieur ou égal à 4 000 grammes ou supérieur au 90ème percentile des courbes de référence pour l'âge gestationnel ont été inclus. Les variables étudiées étaient sociodémographiques, les antécédents, le mode d'accouchement et les complications cliniques chez la mère. Pour le nouveau-né, elles concernaient, les paramètres anthropométriques, le score d'Apgar et le profil évolutif. Le test Khi 2 a été utilisé pour la comparaison des proportions avec un seuil de signification de p≤ 0,05. Résultats : la fréquence de la macrosomie était de 3,85%. L'âge moyen des mères était de 29,3 ± 6,1 ans. Un antécédent de macrosomie était retrouvé dans 47 cas (15,6%) et un de diabète gestationnel dans deux cas (0,7%). L'accouchement était par voie basse dans 247 cas (81,8 %) et en présentation céphalique dans 297 cas (98,3%). Une déchirure périnéale était notée dans 67 cas (22,2 %). Les nouveau-nés étaient à terme dans 182 cas (60,2%), de sexe masculin dans 201 cas (66,6%) et de sexe féminin dans 101 cas (33,4%). Ils avaient un poids moyen de 4257 ± 275,3 grammes, le score d'APGAR était ≥ 7 à la 1ère minute dans 253 cas (83,8%). Une élongation du plexus brachial était notée dans 22 cas (7,3%) et un décès dans neuf 9 cas (3,0%). Un poids de naissance supérieur à 4 500 grammes augmentait le risque de complications associé à la macrosomie. Conclusion : La macrosomie est peu fréquente dans notre contexte hospitalier mais la morbi-mortalité maternelle et néonatale qui en découle n'est pas négligeable. Le diagnostic précoce de macrosomie et une prise en charge multidisciplinaire permettrait de réduire la survenue de complications

Open access colonoscopy in the training setting: which factors affect patient satisfaction and pain?

BACKGROUND AND STUDY AIM: Patient satisfaction with colonoscopy is important for quality assurance; it may be affected by various factors, including patient characteristics, physician training level, and procedural or organizational features. We aimed to analyze how these factors influenced patient satisfaction and pain in an outpatient training setting. METHODS: Consecutive patients for open access colonoscopy (OAC) were enrolled in a prospective, single-blinded, controlled study. Primary and secondary outcomes were satisfaction and pain scores with and without trainee participation. A multivariate analysis was designed to achieve an 80 % power with an alpha value of 0.05. RESULTS: 368 patients were enrolled. Satisfaction with the procedure was high (mean score 1.36; 1 = best to 5 = worst). In the multivariate analysis only waiting time in the endoscopy suite was significantly associated with lower satisfaction scores ( P = 0.024). Satisfaction was unaffected by patient factors (gender, American Society of Anesthesiologists' [ASA] score, anxiety, etc). Higher pain scores were associated with higher anxiety levels ( P = 0.02), female gender ( P = 0.02), longer procedure ( P< 0.001), and lower sedation levels ( P = 0.001); trainee involvement (49 % of procedures) did not adversely affect satisfaction or pain scores. CONCLUSIONS: Patient satisfaction with OAC using sedation appears to depend primarily on organizational factors (waiting time beforehand). In contrast, pain is associated with patient characteristics (female gender, anxiety) and procedural factors (lower sedation, longer procedure). Trainee participation did not affect satisfaction or pain scores, a finding which may help to reassure patients undergoing OAC with trainee participation.

Interobserver agreement for EUS in the evaluation and diagnosis of submucosal masses.

INTRODUCTION: EUS is an accurate means of evaluating and diagnosing submucosal lesions of the GI tract. The aim of this study was to prospectively determine interobserver agreement for the EUS classification of submucosal masses among endosonographers with different levels of training and experience from multiple centers. METHODS: Twenty patients with submucosal mass lesions diagnosed by upper endoscopy underwent EUS. Surgical findings were available for 16 patients. In 4 patients with obvious cystic/vascular structures (i.e., varices) no surgical specimen was necessary. A blinded observer developed a study videotape of critical endoscopic and EUS real-time imaging for each lesion. The videotape was distributed to 10 endosonographers, each with at least 1 year of experience, who independently reviewed the videotape and recorded their diagnosis based on EUS features. These endosonographers used previously agreed-upon standardized EUS diagnostic criteria for each category of lesion. A kappa (kappa) statistic, used to evaluate agreement, was calculated for each lesion category for the 10 endosonographers as a group and individually. An overall kappa statistic was also calculated. Significance was analyzed with a two-tailed t test. RESULTS: Agreement was excellent for cystic lesions (kappa = 0.80) and extrinsic compressions (kappa = 0.94), good for lipoma (kappa = 0.65), fair for leiomyoma and vascular lesions (kappa = 0.53 and 0.54, respectively), and poor for other submucosal lesions (kappa = 0.34). Overall agreement among observers was good (kappa = 0.63). Furthermore, a significant association was noted between total years of EUS experience and the number of correct answers (p = 0.01). CONCLUSIONS: Interobserver agreement is good for characterizing submucosal masses by EUS. However, it appears to be better for some lesions than others. The overall length of experience with EUS appears to play an important role in the accuracy of this modality in the evaluation of submucosal lesions.

Interventional endoscopy.

Interventional endoscopy is a general label given to endoscopic procedures used to deal with a variety of gastrointestinal disorders. The interventional endoscopic procedures of interest in this review are those used specifically with gastric disorders. They include hemostasis, endoscopic ultrasound, endoscopic mucosal resection, stenting, percutaneous endoscopic gastrostomy tube placement and photodynamic laser therapy. Here, we review the latest data related to (a) a number of general issues having an impact on this diverse group of procedures (eg, such as proper patient selection criteria, consent in the era of open access endoscopy, protocol for anticoagulation, and sedation); (b) the methodology and outcomes of each of these unique procedures as they apply to the stomach; and (c) some of the latest technologic advances and developments that will potentially have an impact the future use of these procedures.

Interventional procedures.

During the past year, numerous articles were published on interventional procedures of the stomach, focusing on upper gastrointestinal tract bleeding, gastric cancer, gastric outlet obstruction, and benign disease. In the area of upper gastrointestinal tract bleeding, early endoscopy is warranted for early therapeutic intervention and for triage. In patients with bleeding related to peptic ulcer disease, combination therapy (epinephrine injection in conjunction with electrocoagulation therapy) remains the standard of care. Hemoclipping is a new technique that may be helpful in cases in which conventional therapy fails. Repeat endoscopy should always be considered in patients in whom the first attempt at endoscopic therapy fails. In patients with bleeding related to portal hypertension, prophylactic antibiotics may decrease the risk of infections. Banding remains the therapy of choice for this group of patients. There is no documented benefit for combination therapy (banding and sclerotherapy). Transjugular intrahepatic portosystemic shunts may be helpful in the treatment of hypertensive portal gastropathy but not gastric vascular ectasias. In the area of gastric cancer, management revolves around staging. This can be accomplished best through the use of CT scan and endoscopic ultrasound. In patients with early limited disease, attempt at endoscopic mucosal resection should be considered. This technique can be performed in a variety of ways: the most common method seems to be through the use of a saline injection, to separate the mucosa-submucosal layer, followed by a cap-assisted snare resection with suction. The safety, efficacy, and outcome of this technique are reviewed. Gastric outlet obstruction remains a difficult problem to treat endoscopically. However, there is some evidence that endoscopic therapy may be successful in benign disease and should be considered prior to surgical intervention.

Endoscopic ultrasound.

Endoscopic ultrasound is currently an accepted part of the clinical practice of gastroenterology. It is used to evaluate submucosal lesions, thickened gastric folds, and depth of gastrointestinal tumor penetration. As the capabilities of the instruments improve, their role in the practice of gastroenterology widens. This review is designed to update the practicing physicians on this rapidly evolving field, pertaining to instrumentation for endosonography, clinical indications for endosonography, and future directions.

Gallstone pancreatitis: an update.

Gallstone pancreatitis is one of the more prevalent causes of pancreatitis. It accounts for more than two thirds of the cases of acute pancreatitis worldwide and 25 to 45% of the cases in the United States. Furthermore, it is one of the most important treatable causes of pancreatitis. These two important features of the disease make its recognition and proper management critical. Key to recognition and proper management of gallstone pancreatitis is understanding that this disease can exist in three different forms. It can exist as impacted gallstone pancreatitis, as nonimpacted gallstone pancreatitis, or as sludge-related pancreatitis. Each of these forms of the disease will have some unique features relating to their pathogenesis, diagnosis, and treatment. This update focuses on "take-home" features that will allow (1) clinical differentiation between the three forms of the disease and (2) understanding the unique features that relate to their pathogenesis, diagnosis, and management.

Thymocyte involvement in spleen colony formation by subpopulations of hematopoietic stem cells.

Murine marrow preparations depleted of stem cells by prior incubation with rabbit, anti-mouse serum show augmented spleen colony-forming ability when exposed to fresh thymocytes. A 2- to 4-fold increase in colonies was observed when marrow-thymocyte interaction occurred under either in vivo or in vitro conditions. Colony augmentation was shown to be independent of both the strain used and the age of the thymocyte donor. In our hands, approximately one-half of the marrow stem cells surviving an exposure to the antiserum appear responsive to thymocyte interaction.