[Maternal deaths due to infections in France 2013-2015]. / Mortalité maternelle par infection en France 2013­2015.

Over the 2013-2015 period, maternal mortality due to infections accounted for 10 % of direct maternal deaths and 13 % of indirect maternal deaths. Among the 21 deaths from infection, and compared to the last triennium, maternal deaths from genital infection doubled with 11 deaths during the 2013-2015 period. This included 6 cases of puerperal toxic shock syndrome, 4 of which due to Streptococcus A, and 5 cases of sepsis caused by intrauterine infection due to Gram-Negative Bacillus. Indirect maternal deaths due to infections from extragenital sources represented 10 deaths in this triennium, including four influenza infections and three infectious complications of an immunosuppressive state (uncontrolled HIV infection for two patients and CMV encephalitis during an immunosuppressive treatment for one patient). Of these 21 deaths by infectious causes, 6 direct maternal deaths and 9 indirect maternal deaths were considered preventable. The most common preventable factors were those related to medical management (13 times): diagnostic failure or delayed diagnosis leading to a delayed medical treatment, absence of influenza vaccination. The other contributory factors were related to the organization of healthcare (delayed transfer, lack of communication between clincians) as well as factors related to patient social vulnerability.

Prévention et prise en charge de l'infection herpétique au cours de la grossesse et de l'accouchement : recommandations pour la pratique clinique ­ texte des recommandations (texte court).

OBJECTIVE: Identify measures to diagnose, prevent and treat genital herpes infection during pregnancy and childbirth and neonatal infection. METHODS: Bibliographic search from Medline, Cochrane Library databases and research of international clinical practice guidelines. RESULTS: Genital herpes lesion is most often due to HSV2 (LE2). The risk of HSV seroconversion during pregnancy is 1 to 5% (LE2). Genital herpes ulceration during pregnancy in a woman with history of genital herpes corresponds with a recurrence. In this situation, there is no need for virologic confirmation (grade B). In case of genital lesions in a pregnant woman that do not report any genital herpes before, it is recommended to perform a virological confirmation by PCR and HSV type specific IgG (Professional consensus). In case of first episode genital herpes during pregnancy, antiviral treatment with acyclovir (200mg 5 times daily) or valacyclovir (1000mg twice daily) for 5 to 10 days is recommended (grade C). In case of recurrent herpes during pregnancy, antiviral therapy with acyclovir (200mg 5 times daily) or valacyclovir (500mg twice daily) can be administered (grade C). The risk of neonatal herpes is estimated between 25% and 44% in case of initial episode (LE2) and 1% in case of recurrence (LE3) at the time of delivery. Antiviral prophylaxis should be offered for women with first episode genital herpes or recurrent genital herpes during pregnancy from 36 weeks of gestation and until delivery (grade B). In case of a history of genital herpes without episode of recurrence during pregnancy, it is not recommended routinely offer a prophylactic treatment (professional consensus). A cesarean section should be performed if there is a suspicion of first episode genital herpes at the onset of labor (grade B), in the event of premature rupture of the membranes at term (professional consensus), or in case of first episode genital herpes less than 6 weeks before delivery (professional consensus). In case of recurrent genital herpes at the onset of labor, cesarean delivery will be all the more considered if the membranes are intact and vaginal delivery will be all the more considered in case of prolonged rupture of membranes (professional consensus). Neonatal herpes is rare and mainly due to HSV-1 (LE3). In most of the case of neonatal herpes, the mothers have no history of genital herpes (LE 3). In case of suspicion of neonatal herpes, different samples (blood and cerebrospinal fluid) for HSV PCR must be carried out to confirm the diagnosis (professional consensus). Any newborn suspected of neonatal herpes should be treated with intravenous acyclovir (60mg/kgs/day 3 times daily) (grade A) prior to the results of HSV PCR (professional consensus). The duration of the treatment depends on the clinical form (professional consensus) CONCLUSION: There is no formal evidence that it is possible to reduce the risk of neonatal herpes in genital herpes during pregnancy. However, appropriate care can reduce the symptoms associated with herpes, the risk of recurrence term and the cesarean rate performed to decrease the risk of neonatal herpes.

Forty years of achievement in French research on digestive physiology in the pig.

The contribution of the research group set up by Rérat in the early 1960s in Jouy-en-Josas, and then expanded to Rennes, is summarised. As digestive processes are a major key to the nutritional status of monogastric animals, original methodologies based on advanced experimental surgery were developed in the pig to quantify the digestion and absorption yield, to know their factors of variation, and to understand their physiological and nutritional consequences. The group also extended its expertise to the control of food intake, the role of the nervous system and regulatory peptides, and several biomedical gut-related topics.

Stereotaxic atlas of the pig brain.

A stereotaxic atlas of the pig brain has been established. It consists of 60 frontal and 18 sagittal drawings illustrating Nissl stained sections. A stereotaxic apparatus adapted for the Pig was used to determine the brain coordinates. Radiographic techniques were applied to verify the correct position of the central nervous structures in the apparatus. The zero horizontal plane contains the line joining the recessus preopticus and the posterior commissure (PC) images. These two landmarks were identified by ventriculography. The anterior limit of the PC is used as zero on the stereotaxic atlas. Vertical electrode trajectories implanted at a fixed depth in the brain and at different anterior and lateral levels were used to determine the lateral, vertical and height coordinates in the different planes. Then the brains were perfused and embedded to avoid major displacement of the cerebral structures. Frontal and sagittal serial sections of 100 microns were performed in two different animals. Magnified diagrams of brain sections representing the cellular architecture of the brain structures were produced, some of which are illustrated with photomicrographs. For certain areas, the limits of the nuclei were difficult to determine even when complementary electrophysiological studies were carried out. Each plate is accompanied by a list of abbreviations used to label structures on the plate, together with the terms which they represent. This work should provide a useful anatomical guide for research on the pig brain.

Measurement of gastric emptying by intragastric gamma scintigraphy.

Gastric emptying is usually measured in animals and humans by dilution/sampling or external scintigraphy. These methods are either time consuming or require expensive equipment. The capacity of a miniature gamma counter positioned in the stomach to measure emptying of liquid and solid meals was evaluated. In eight conscious pigs fitted with gastric and duodenal cannulae, gastric emptying of saline (500 mL), dextrose (20%, 500 mL), porridge (300 g) and scrambled eggs (300 g), all labelled with 3.5 MBq 99mTC, was evaluated. When positioned in the antrum the probe was unable to quantify gastric emptying. In contrast, measurements of the fractional emptying of saline over 4-min periods by the probe positioned in the corpus and quantification of radioactivity in the duodenal effluent correlated closely (r = 0.88, P < 0.05). Gastric emptying (50% emptying time) of saline and both solid meals measured by the probe was not significantly different from quantification of the duodenal effluent volume. No difference was observed also for the dextrose meal but only while gastric acid secretion was suppressed by omeprazole. We conclude that an intragastric gamma counter permits measurement of gastric emptying of homogeneous meals provided meal stimulation of gastric secretion was not extensive. This was possible probably by monitoring emptying from the proximal stomach.

Influence of jejunal nutrients on transpyloric flow and pyloric resistance in pigs.

The effects of small intestinal infusion of nutrients on the transpyloric flow and pyloric resistance were evaluated in anaesthetized pigs. Saline versus isocaloric solutions of dextrose, triglycerides and casein were infused into a jejunal loop during saline gastric loading. Antropyloroduodenal pressures were measured with a sleeve/side-hole manometric assembly and the transpyloric flow with an electromagnetic flowmeter probe. Fundic pressure was maintained constant. Although the overall gastric emptying rate was not affected by nutrients, the stroke volume of the transpyloric flow pulses was significantly increased as a consequence of larger peak flow (dextrose) or longer duration of flow pulses (triglycerides and casein). Pyloric resistance was reduced by all nutrients owing to a change in the temporal relationship between the onset of pyloric pressure events and flow pulses so that flow pulses occurred after pyloric pressure events. In conclusion, under controlled fundic pressure, nutrient infusions decrease pyloric resistance.

Proximal gastric distension modifies ingestion rate in pigs.

Control of food ingestion related to proximal gastric distension has never been demonstrated in pigs. The aim of this study was to demonstrate its existence. Meal duration, food intake rate and characteristics of non-ingestion periods were evaluated during the ingestion of a 500 g meal with simultaneous balloon distension of the proximal stomach. Distensions were performed either at fixed pressure levels or at fixed volume levels. Five pressure levels and five volume levels were tested in duplicate experiments in random order and on different days in each animal. Pressures equal or above 11 mmHg increased meal duration (656 +/- 12 vs 562 +/- 30 s, 11 mmHg vs control) because of a lower rate of food intake and longer period of non-ingestion. On the contrary, irrespective of the gastric bag volume, isovolumic distensions did not alter feeding behaviour. We concluded that a short term control of food intake exists in pigs.

Morphometry of the small intestine in pigs with ileo-rectal anastomosis.

Ileo-rectal anastomosis (IRA), which is frequently used to measure prececal digestibility in pigs, could induce some disturbances of the normal absorptive function. Our aim was to investigate the effects of different IRA surgical procedures on the main histologic characteristics of the small intestine in pigs. The 4 different IRA procedures compared to intact pigs (INT) were the following: either end to end (EE) or end to side (ES) with or without preservation of the ileocecal valve (EEV, EE, ESV, ES respectively). At 147 d after surgery, samples of the wall of the duodenum, jejunum and ileum were taken under anesthesia and histometric examinations were performed on HE- and PAS-colored sections to estimate changes mainly of mucosa and muscle layers. The values recorded for villus length, crypt depth, and whole thickness of the mucosa suggested that the EE procedures disturb the small intestine less than the ES models. A new parameter, called epithelial quotient and calculated as [(villus length/crypt depth)/mitotic index], was proposed to improve the comparisons. According to this quotient, EE procedures did not significantly affect the mucosa of the whole small intestine. An increased density of goblet cells was recorded in all operated pigs along the small intestine, but mainly in the ileum after EE-IRA. The lymphatic follicle area was reduced. These findings, which were in agreement with a reduced mitotic index in the ileum of EE-pigs, indicated a decreased effect of noxious factors on the small intestinal mucosa in IRA-pigs, especially after the EE-IRA procedure. Some atrophic or hypertrophic effects on the muscle layers were related to the absence or preservation of the ileo-cecal valve. Finally it was concluded that i) there was no major disturbance after IRA, and ii) the end to end procedure was most beneficial for the structural integrity of the small intestine.

Vagal control of pyloric resistance.

Pyloric resistance is probably a major factor regulating gastric emptying of liquids, but its nervous control is unknown. The role of efferent vagal pathways in pyloric resistance was evaluated in 13 anesthetized pigs. Pyloric resistance was assessed by simultaneous recording of gastropyloroduodenal motility and transpyloric flow during gastric emptying of saline. Cervical vagotomy suppressed all antral pressure events, increased the number of pressure events localized at the pylorus, and decreased the frequency of the flow pulses (P < 0.05), without affecting either pyloric resistance or the characteristics of flow pulses. Electrical stimulation of the cervical and the thoracic vagi both decreased pyloric resistance by about 60% and increased the stroke volume of flow pulses (P < 0.05). The reduced pyloric resistance was mainly related to an alteration of the temporal relationship between flow pulses and pyloric pressure events. These results indicate that vagal efferents could provide inhibitory inputs to pyloric resistance. A reduction in pyloric resistance contributes to the increased flow rate observed during vagal stimulation.

Vagal control of transpyloric flow and pyloric resistance.

Vagal control of pyloric resistance was evaluated in anesthetised pigs by recording gastropyloroduodenal motility and transpyloric flow during emptying of a liquid nonnutrient meal. Vagotomy did not modify pyloric resistance or the characteristics of the flow pulses. Electrical stimulation of the distal stumps of cervical or thoracic vagus nerves decreased pyloric resistance and triggered flow pulses of large stroke volume. This was associated with increased fundic tone and pressurization of the antrum. Phentolamine but not propranolol reduced the responses to vagal stimulation. These observations demonstrate that reduced pyloric resistance is one mechanism by which vagal activation promotes transpyloric flow.

Preliminary results of a magnetic resonance imaging (MRI) study of the pig brain placed in stereotaxic conditions.

Magnetic resonance imaging (MRI) of two pig brains was realized. The animals were placed in the stereotaxic conditions currently used in experiments. To allow the positioning of the animal in the MRI instrument, landmarks were previously traced on the snout of the pig. To avoid movements, animals were deeply anesthetized. MRI were taken in frontal, horizontal and sagittal directions. Afterwards, the brains of the pigs were frozen and cut into sections, frontal for one animal and sagittal for the other. Histologic and MR images were compared. The usefulness of this technique is discussed.

Exogenous and endogenous contributions to nitrogen fluxes in the digestive tract of pigs fed a casein diet. III. Recycling of endogenous nitrogen.

The aim of the present study was to measure the incorporation of infused 15N in blood fractions, urine, digesta, faeces and in the exocrine pancreatic and biliary secretions, in order to estimate the endogenous part of nitrogen in the ileal digesta and in the faeces of pigs fed a casein diet and to calculate the total endogenous nitrogen secretion as well as its recycling in the digestive tract. For 8 d 11 Large White female pigs (50.1 +/- 1.8 kg) received a continuous infusion of L-[15N]leucine via a catheter in the jugular vein. The 15N-enrichment was measured in several fractions. The 15N-level of the pancreatic juice was higher than that in the biliary secretion, TCA-blood fractions, and urine during the whole experimental period. Using the 15N-isotope dilution method it was found that casein was completely digested up to the terminal ileum and that all the nitrogen in the ileal digesta was of endogenous origin. The total endogenous secretion was estimated at approximately 11 g N/d. The reabsorption of endogenous nitrogen amounted to 79% up to the end of the small intestine and 88% over the whole digestive tract.

Exogenous and endogenous contributions to nitrogen fluxes in the digestive tract of pigs fed a casein diet. II. Ileal and faecal digestibilities and absorption of amino acids.

The present work aimed at quantifying nitrogen (N) and amino acid (AA) fluxes in the digestive tract of growing pigs fed a casein diet. In this paper we report on digesta passage at the terminal ileum, on apparent balances at the ileal and faecal levels, and on nutrients appearance in the portal vein. Digesta flow-rate at the terminal ileum was maximum between 6 and 12 h after the meal. About 10% of N and 5% of total AA ingested were recovered within 24 h. AA absorption started 30 min after the meal, and was measurable until 13 to 14 h. The total AA absorbed in 24 h accounted for 128% of the AA ingested. The AA composition of ileal digesta was very different from that of casein, closely resembling that of endogenous proteins. The AA composition of faeces was very close to that of bacterial proteins. The ileal digestibilities of AA, though lower than their faecal values, were very high. This was confirmed by AA absorption balances greater than 100%. These data suggest that casein was almost totally digested by the terminal ileum, and that endogenous AA were substantially reabsorbed. These findings are supported by data on endogenous N recycling (15N), reported in a following paper.

Galanin in porcine vagal sensory nerves: immunohistochemical and immunochemical study.

In this work, the presence of galanin was examined by immunohistochemistry, radioimmunoassay and high performance liquid chromatography (HPLC) in porcine nodose ganglia, mainly constituted of cell bodies from the vagal sensory neurons. Galanin-like immunoreactivity (Gal-LI) was revealed in 10 to 15% of the total cell bodies by the indirect immunofluorescent technique of Coons. For comparison, a positive staining was revealed in a few cell bodies of the submucous plexus and in fibers located in the different layers of the ileum. The extractable Gal-LI content in nodose ganglia was 7.2 +/- 0.8 pmol/g wet tissue, which represents a concentration about nine times lower than that found in the ileum. HPLC of extractable material revealed a predominant peak which coeluted with the synthetic peptide. We propose that, in pigs, galanin may play a role in the transmission of visceral information through the vagal afferences.

Exogenous and endogenous contribution to nitrogen fluxes in the digestive tract of pigs fed a casein diet. I. Contributions of nitrogen from the exocrine pancreatic secretion and the bile.

The aim of the present work was to study the endogenous contribution of the exocrine pancreatic and biliary secretions to the total endogenous nitrogen production in the pig. Three growing Large White pigs weighing 45 +/- 2.5 kg were fitted with permanent fistulae in the pancreatic duct, the bile duct and the duodenum. They were adapted to a semi-synthetic casein diet for 14 d before surgery. In a 7-d post-operative period and an 8-d experimental period, they were fed the same diet. Secretion rates were recorded, total nitrogen and TCA (trichloroacetic acid) insoluble nitrogen were determined in representative pancreatic juice and bile samples. Daily pancreatic juice and bile flow rates were very similar: 1,850 and 1,820 ml, respectively. The amount of endogenous total nitrogen secreted in the intestinal lumen was 3.6 g per day: 1.9 g N through pancreatic secretion and 1.7 g N through bile secretion. Pancreatic nitrogen increased after meal intake, whilst the kinetics of nitrogen production in the bile were not affected. Throughout the experiment, the mean percentage of TCA insoluble nitrogen was 78.1% in pancreatic juice and 72.3% in bile.

Vagal gastric efferent activity and its reflex changes in conscious sheep.

Electromyographical recordings from neck muscles reinnervated by the vagus nerve allowed monitoring of vagal output to the reticulo-rumen in conscious sheep. The vagus nerve was sectioned below the nodose ganglion and its central end anastomosed with the peripheral end of the spinal accessory nerve, which innervates the trapezius and mastoido-humeral muscles. Fifty-three vagal efferent units recorded were identified and classified into seven distinguishable types on the basis of their temporal relationship with gastric movements. With respect to their patterns of discharge during the primary cycles type I to type V units were similar to units of the corresponding types described by Iggo & Leek (1967a) in anaesthetized sheep. Evidence for the hypothesis that each type of gastric unit innervates a distinct region of the reticulo-rumen is strongest for types I and IV. Type I units which exhibited a bimodal pattern of discharge closely associated with reticular motility, are presumed to innervate the reticulum. Some of them, so-called Ib because of their second burst with a long tail and their activity during the secondary cycles, are considered to activate the zone of attachment of the reticulum to the rumen. Type IV units which were active during the ruminal contractions of both primary and secondary cycles are considered to innervate the dorsal rumen. Discharges in these gastric units were observed when gastric motility was partially or totally abolished after administering autonomic blocking drugs for each unit tested (n = 25). They consisted of (i) a shortening of intervals between the onset of two successive bursts, and (ii) an increase in the duration of discharge and the number of potentials in the efferent units. As the abolition of gastric motility led to a decrease of gastric afferent input, these results suggest that the gastric centres are under a permanent inhibitory influence from the afferent drive.