Eikenella corrodens bone and hip joint infection. A case report and literature review.

Eikenella corrodens (EC) is a human commensal microorganism of the mouth flora. This bacterium is rarely reported in bone and joint infections in children, but the consequences on the joint function can be devastating and irreversible. We report the case of septic arthritis of the hip following an oral wound in a 12-year-old boy. The progression of the condition was favorable with no complications or pain observed after antibiotic treatment. Clinical and radiological examinations showed a satisfactory outcome at 6 months with no sign of recurrence or complication (growth disorder). Children's osteomyelitis and arthritis caused by EC have been mostly reported after human bites or extremity pricks. This slow-growing organism is rarely diagnosed but should be considered as a potential pathogenetic agent and treated aggressively, especially since the antibiotic therapy is simple and achieves good results. LEVEL OF EVIDENCE: Level IV.

Ruling out nosocomial transmission of Cryptosporidium in a renal transplantation unit: case report.

BACKGROUND: Cryptosporidium spp. is a ubiquitous parasite affecting humans as well as domestic and wild vertebrates, causing diarrhea in both immunocompetent and immunocompromised hosts worldwide. Its transmission occurs primarily by the fecal-oral route. In humans, C. parvum and C. hominis are the most prevalent species, whereas immunocompetent and immunocompromised individuals can also be infected by other zoonotic species. Renal transplant patients are prone to develop cryptosporidiosis, which can induce severe and life-threatening diarrhea. CASE PRESENTATION: We report here a series of nearly concomitant cases of acute symptomatic cryptosporidiosis in three renal transplant patients attending the Strasbourg University Hospital Nephrology Unit. The clinical presentation was persistent diarrhea and acute renal failure. The diagnosis was confirmed by microscopic stool examination using a modified Ziehl-Neelsen staining method and species identification by molecular tools. All patients were treated with nitazoxanide and recovered from diarrhea after 14 days of therapy. CONCLUSION: Genotypic species identification was not consistent with an epidemic context, thus underlining the need for genotyping to monitor at risk patients.

[Place of surgery in the management of gestational trophoblastic tumors]. / Place de la chirurgie dans la prise en charge des tumeurs trophoblastiques gestationnelles.

Gestational trophoblastic tumors are authentic malignant tumors of the conception. They are mostly chemosensitive. For young women, the place of the surgery seems now restricted and more and more codified. Hysterectomy keeps a certain interest for women who do not wish to preserve their fertility. Hysterectomy limits then the complications of chemotherapy. It optimizes the chances of recovery without recurrence. If chemotherapy must nevertheless be carried out, hysterectomy decreases the necessary number of cures to obtain complete remission of the disease. Surgery is also indispensable to chemoresistant tumors. It allows exeresis of localized residual sites or isolated metastases. Other indications for surgery include uncontrollable vaginal or intra-abdominal bleedings and placental site trophoblastic tumors.

[Does tension-free vaginal tape (TVT) have a place in the treatment of sphincter incompetence?]. / Le TVT (tension-free vaginal tape) a-t-il une place dans le traitement de l'insuffisance sphinctérienne?

OBJECTIVE: The objective of this article is to estimate results and place of TVT in female stress urinary incontinence with intrinsic sphincter incompetence. MATERIAL AND METHOD: This was a retrospective study over a period of 57 months in a population of 38 patients treated by TVT for sphincter incompetence with or without inefficient pressure transmission. Mean patient age was 52 years. Fourteen patients (37%) had a history of incontinence surgery. The physical examination demonstrated urethral mobility in 22 patients (58%) and positive Bonney or Jacquetin tests in 15 patients (39%). Mean maximum urethral closure pressure was 40 cm H2O, with 12 patients (32%) 30 cm. Six patients (16%) had detrusor instability. Seven patients (18%) had pure sphincter incompetence. RESULTS: Median follow-up was eight months (two months to 32 months). Twenty five patients (66%) were cured, nine (24%) improved and treatment failed in four (10%). Results are less satisfactory for patients with preliminary failure of incontinence surgery, fixed urethra, pure sphincter incompetence or with detrusor instability without inefficient pressure transmission. The only major complication was an expulsion of the prosthesis. CONCLUSION: Results of TVT in sphincter incompetence are slightly less satisfactory than in pure urinary stress incontinence. In a short follow-up, they are comparable in sphincter incompetence to those of sling procedures which are the current gold standard. Risk of urinary retention is lesser. The minimally invasive nature of TVT suggests that it will replace sling procedures in the future for this particular indication. Longer follow-up will be necessary for confirmation.

Menses, fertility and pregnancy after arterial embolization for the control of postpartum haemorrhage.

BACKGROUND: The long-term effects of uterine artery embolization for the control of postpartum haemorrhage on menses, fertility and future pregnancy evolution have not been assessed. METHODS: Between November 1993 and July 1999, 31 women with obstetric haemorrhage underwent arterial embolization. Four patients underwent a hysterectomy. Gynaecological information on 25 of the 27 patients who did not undergo hysterectomy was obtained by interview. RESULTS: All women had a return of normal menses. Nine of the 25 patients desired subsequent pregnancy and five patients became pregnant with normal delay of conception. Moreover, two other patients who did not plan another pregnancy became pregnant. A total of 10 pregnancies was studied, four ended during the first trimester. For the six others, the maternal evolution of the pregnancy was uneventful until term. No case of pre-eclampsia was observed. The ultrasonographic examinations revealed normal fetal growth and umbilical and uterine Doppler studies showed no anomaly. No repetition of obstetric haemorrhage was observed. All full-term, newborns were healthy, weighing from 3220 to 4100 g. CONCLUSION: Our results suggest that women who undergo arterial embolization for obstetric haemorrhage should expect to have a return of normal menses with preservation of future fertility and successful uneventful pregnancies.

[Pregnancy, tuberculosis and inappropriate antidiuretic hormone secretion]. / Grossesse, tuberculose et sécrétion inappropriée d'hormone antidiurétique.

We report a pregnant woman presenting with seizure secondary to hyponatremia by inappropriate antidiuretic hormone secretion. Aetiology was unknown urinary and lung tuberculosis. This case report presents diagnosis strategy of inappropriate antidiuretic hormone secretion and the arguments for its aetiology.

Abnormal placentation and selective embolization of the uterine arteries.

OBJECTIVE: Abnormal placentation accounts for more than 50% of uterine artery embolization failure. The authors report their experience in this situation. STUDY DESIGN: Seven women presented with abnormal placentation. Uterine artery embolization was carried out in emergency or prophylactic control of postpartum bleeding. RESULTS: In five patients, control of postpartum hemorrhage was obtained without hysterectomy. In two cases with no placental removal and prophylactic procedures, hysterectomy and blood transfusion were not necessary. The manual removal of the placenta was achieved secondarily, respectively on the 25th and the 12th day. CONCLUSIONS: The success rate of uterine artery embolization for postpartum bleeding appears to be lower with abnormal placentation. In none of the cases with the placenta present was it possible to leave the residual placenta in place. However, embolization may permit a safe waiting period and spontaneous migration of the placenta. When the diagnosis is made before delivery, prophylactic uterine artery embolization without placental removal should be considered to reduce blood transfusion and preserve fertility.

Adnexal torsion: a report on forty-five cases.

OBJECTIVES: To evaluate the clinical findings, evolution of treatment and ovarian function following conservative therapy. STUDY DESIGN: A case series of 45 patients presenting with adnexal torsion between January 1989 and June 1999. All patients were surgically treated, either conservatively or radically. Patients who had received conservative treatment, interviewed by phone and underwent ovarian sonographic examination. RESULTS: Adnexal torsion is more frequent in young women with adnexal pathology. Conservative therapy by laparoscopy has gained increasing preference as a surgical procedure. It is safe and preserves ovarian function. CONCLUSIONS: Conservative therapy by laparoscopy is recommended to preserve ovarian function in young women.

False aneurysm of the uterine pedicle: an uncommon cause of post-partum haemorrhage after caesarean section treated with selective arterial embolization.

We report three cases of post-partum haemorrhage following caesarean delivery attributed to a false aneurysm of the uterine pedicle and treated with artery embolization. These lesion were probably post-traumatic in origin related to hysterotomy. Angiographic study of the anterior division of hypogastric arteries confirmed the diagnosis and embolization of the false aneurysm was successful in controlling the haemorrhage.

Plasma progesterone kinetics following surgical treatment of ectopic pregnancies.

OBJECTIVES: Comparative study of plasma progesterone and betaHCG kinetics following surgical treatment of ectopic pregnancy. STUDY DESIGN: Prospective study involving 62 patients with tubal ectopic pregnancies. Study of the kinetics of plasma progesterone and betaHCG, and the correlation coefficient between plasma progesterone and betaHCG levels during post-operative follow-up. RESULTS: Thirty-nine patients were treated by salpingostomy and 23 by salpingectomy. Analyzing the betaHCG kinetics according to treatment revealed that both curves were convergent on day 2. Progesterone kinetics differed greatly in that they appeared "parallel and confused". Analyzing the correlation between betaHCG and progesterone levels proved the absence of a significant link. CONCLUSIONS: Studying the kinetics of plasma progesterone after surgical treatment of ectopic pregnancies revealed a fast decrease in progesterone. Statistical analysis of the progesterone concentration showed that post-operative kinetics is fully independent from that of betaHCG. Progesterone therefore cannot be substituted to betaHCG for post-operative follow-up.

[Evaluation of clinical competence in gynecology obstetrics: an innovative approach using the Objective Structured Clinical Examination]. / Evaluation au cours de la formation initiale de la compétence clinique en Gynécologie Obstétrique: approche innovatrice basée sur l'observation de la performance par l'examen clinique objectif et structuré (ECOS).

OBJECTIVE: The evaluation of medical student clinical competence in Obstetrics and Gynaecology using Objective Structured Clinical Examination (OSCE). MATERIAL AND METHODS: Development of OSCE with definition of an assessment of subject, choice of clinical stations sampling, identification of components of clinical competence to be evaluated, the level of performance required, development of specification table, editing of OSCE presentation page and assessment of praticability and results exploitation. RESULTS: Eleven station stimuli with simulated patient participation were carried out, 2 stations with a mannequin model and 1 questionnaire station. CONCLUSION: Our experience suggests OSCE feasibility for Obstetrics and Gynaecology during the initial course of education presents adequate psychometric characteristics. This gold standard can no longer be overlooked and should be considered as a useful tool to assess medical student competence. Nevertheless, OSCE remains to be further evaluated in France.

[Which initial tests should be performed to evaluate meno-metrorrhagias? A comparison of hysterography, transvaginal sonohysterography and hysteroscopy]. / Quelle exploration réaliser de première intention face aux méno-métrorragies? A propos d'une série prospective comparant l'hystérographie, l'hystérosonographie et l'hystéroscopie.

OBJECTIVE: Evaluate the feasibility and the value of hysterography, sonohysterography and hysteroscopy for investigation of abnormal uterine bleeding. Method. Longitudinal blind study of thirty-eight patients consulting for abnormal uterine bleeding during pre- and post menopause. All patients underwent an hysterography and transvaginal sonohysterography, in random order, followed by an hysteroscopy with histological sample. The results were compared with the histo-pathological examination that was used for reference diagnosis. Statistical study of sensitivity, specificity and Positive and Negative Predictive Value (PPV-NPV) of each investigation; rate of agreement by the coefficient of Kappa. RESULTS: The hysterography offers a PPV of 83% and a NPV of 100%. The interpretation errors were associated with the simple mucous hypertrophy interpreted as "hyperplasy". The limits correspond to a contrast agent allergy. The sonohysterography had a VPP of 89% and a VPN of 100%. The false positive is due to the difficulties of distinguishing the clots from the polyps. The limits correspond to the difficulties of cervix catheterization (13%). As regards the hysteroscopy, the VPP was 81.5% and the VPN of 75%. The interpretation mistakes were associated with mucous hypertrophy and the hyperplasy. CONCLUSIONS: The most useful examination for abnormal uterine bleeding, in the first instance, is transvaginal sonography with saline instillation. A complement by Doppler study would probably make it possible to limit the false positives.

Bladder exstrophy: gynecological and obstetrical characteristics with reference to three cases.

The authors report three cases of pregnancy in women treated for bladder exstrophy. Based on a review of the literature, and the follow-up of these cases, the aim of this study was to determine the prognosis of pregnancy, which is currently possible due to the progress in antibiotherapy and surgery. Nevertheless, these pregnancies need to be carefully followed-up, not only because of the complications that may occur to the mother and the infant, but also because of the type of delivery involved.

[Primary breast MALT lymphoma : apropos of one case]. / Lymphome du MALT primatif du sein. A propos d'une observation.

A 46-year-old patient was referred for a right mammary nodule associated with a chronic mastopathy. Cytological examination suggested an inflammatory process but frozen sections concluded to carcinoma with lymphoid stroma. Histological examination found characteristic features of MALT lymphoma: reactive lymphoid follicles, lymphoplasmocytoid lymphoid proliferation and lymphoepithelial lesions. Immunohistochemistry and in situ hybridation revealed a monotypic IgGk immunoglobulin. Molecular biology techniques found a rearrangement of IgH locus. Lymphocytic perigalactophoritis was found in the remaining breast tissue. After 33 months, no tumoral recurrence occurred. Primary MALT lymphoma of the breast is exceptional and its histogenesis is unclear. The role of pre-existent inflammatory lesions in the genesis of this tumour is not established. Our observation illustrates the diagnostic difficulty and the usefulness of complementary techniques in this diagnosis. The existence of inflammation close to tumour is interesting to emphasize.

[Missed diagnosis of postpartum hemorrhage]. / Les hémorragies non-diagnostiquées du post-partum.

OBJECTIVE: The purpose of this work was to search for the reasons why the diagnosis of post-partum hemorrhage may be missed. PATIENTS AND METHODS: We reviewed retrospectively the files 5,517 vaginal delivery patients cared for in our Gynecology and Obstetrics Unit at the Rouen University Hospital between January 1, 1997 and September 30, 1999. Among these patients, 90 (1.63%) developed anemia during the post-partum period with a 10-point fall in the hematocrit from the pre-delivery level, which corresponds to a 1 liter loss of blood, but for whom no diagnosis of hemorrhage was made. We compared this group with the population of patients who had had a diagnosis of hemorrhage. The chi-squared or Fischer's exact text were used where appropriate to compare means and calculate z. RESULTS: Significant risk factors were: primiparity, anemia before delivery, labor induction, locorregional anesthesia, use of ocytocin, long labor with a long active phase, fever during labor, episiotomy and prolonged delay between delivery and onset of suture. CONCLUSIONS: Missed diagnosis appeared to be related to use of visual assessment to determine the degree of bleeding, a very mediocre indicator, particularly when no means of blood collection or quantification is used. In addition, factors having an impact on the development of hemorrhage should be revisited with particular attention given to primiparous patients.

[Influence of the type of breech presentation on delivery in selected primiparous women at term]. / Influence du mode de la présentation dans l'accouchement du siège chez la primipare à terme sélectionnée.

OBJECTIVE: Study the effect of the type of breech presentation on the prognosis of delivery in selected primiparous women at term. PATIENTS AND METHODS: We reviewed retrospectively 146 breech presentations seen between January 1, 1993 and December 12, 1999 in our unit. We limited our study to primiparous mothers at term (> or = 37 weeks gestation) who had had a normal single fetus pregnancy and who had accepted a trial of labor. We analyzed the mode of labor termination, and maternal, fetal, ovular, obstetrical and neonatal features by type of breech presentation and by type of delivery. We collected data by manual search of the patients' registered files (AUDIPOG). The chi-squared and Fisher's tests were used as appropriate for statistical analysis. RESULTS: Spontaneous vaginal delivery was achieved in 10.3% of the cases and non-spontaneous vaginal delivery in 56.2%. Cesarean section during labor was required in 33.5%. There was no significant difference between frank breech presentation (27.4%) and incomplete breech presentation (72.6%). Maternal, fetal, ovular, obstetrical and neonatal features were not significantly different. CONCLUSIONS: Unlike data reported by others, our series did not demonstrate any significant feature predictive of obstetrical and neonatal prognosis irrespective of the type of breech presentation in selected primiparous women at term who had had a normal pregnancy.

Amniotic fluid alpha-fetoprotein is not a useful biological marker of pregnancy outcome.

The aim of our study was to determine if the amniotic fluid alpha-fetoprotein (AFP) level could be a useful predictive biochemical marker of pregnancy outcome. Amniotic fluid AFP measurement was prospectively carried out over a three-year period. After excluding factors susceptible to modifying AFP measurements, 587 subjects with gestational age between 14 and 20 weeks were selected to compare the amniotic fluid AFP mean levels depending on the occurrence of an adverse outcome. No significant associations between amniotic fluid AFP level and poor pregnancy outcome, i.e. pre-eclampsia, preterm delivery, premature rupture of fetal membranes, fetal growth retardation and placental abnormalities were observed. The routine measurement of amniotic fluid alpha-fetoprotein during an amniocentesis procedure was not considered useful in predicting pregnancy complications.

[Study of 27 endometrial samples taken with the Inocurette. Value of the method]. / Etude de 27 prélèvements endométriaux par l'Inocurette. Intérêt de la méthode.

The authors have tested a new disposable device, the inocurette, for a histological study of the endometrium, performed on ambulatory patients without anesthesia. The indications were always the occurrence of menorrhagias or metrorrhagias and a subsequent control by curetage or hysterectomy was carried out on the first 27 cases included in this study. Sampling was done without difficulty with a preliminary dilatation of the cervix in only 4 cases and, in the whole, the procedure was not considered as painful. The reliability of the diagnosis appears satisfactory with 92% of matching results. The possibility of false negative results, even though low, urges however to pursue explorations by hysteroscopy and curetage every time there is a clinical or radiological suspicion.