[Pregnant women's assessment and level of knowledge of prenatal counseling]. / Wie beurteilen Schwangere die pränatale Beratung und was wissen sie im Anschluss daran?

PURPOSE: Informed decision making and informed consent prior to any intervention are crucial in the ethically and psychologically complex field of prenatal diagnosis (PND). The aim of this study was to investigate whether and to what extent pregnant women understand the information provided by their physicians. MATERIALS AND METHODS: Fifty pregnant women in the first trimester answered a structured questionnaire after their first visit between 7 to 10 weeks of gestation that routinely includes basic prenatal counseling. A special focus was put on information transfer, knowledge about and understanding of prenatal tests, as well as previous experiences with PND. The results were analyzed with regard to differences due to background, educational level and previous experiences with PND. RESULTS: The maternal mean age was 31.1 years (SD 6.7). 38 patients (76 %) had at least one previous pregnancy and two thirds of them had experiences with PND. Their experience was mainly positive. About three quarters of the women stated that they had been informed about the test methods during the consultation and had understood the explanations. Uncertainty was reported in 12.2 % and 23.3 % of the women said they had further questions. The percentage of questions related to appropriate understanding that were answered correctly was only 44 % to 77.5 %. The percentage of correct answers was lower in women without experience with PND, with a lower educational level and born in countries outside the EU and Switzerland. CONCLUSION: Pregnant women are relatively well informed about prenatal tests. Their actual knowledge of the meaning of the tests, however, seems to be incomplete. Especially in the case of immigrants and women without previous experience with PND, it is therefore doubtful whether the preconditions for an informed consent are met. Further research needs to focus on more helpful information and individually adapted counseling concepts for decision making in PND.

[Review of patients studied for coagulopathy in a Hematology/Oncology unit]. / Revisión de los pacientes estudiados por coagulopatía en una unidad de Oncohematología.

INTRODUCTION: Symptoms/signs suggestive of coagulopathy is a frequent complaint in Pediatric Hematology units. Both the clinical and family history are essential for diagnosis. PATIENTS AND METHODS: Retrospective and descriptive study of patients referred to a Pediatric Hematology unit of a tertiary hospital for possible coagulopathy during 2012. RESULTS: A total of 47 children were studied, of whom 61.7% had not previously suffered bleeding. The most frequent reason for referral was an eloganted activated partial thromboplastin time without any hemorrhage (42.5%), of these, 25% were diagnosed of a coagulopathy with a real risk of bleeding. While patients referred due to an eloganted activated partial thromboplastin time with bleeding more frequently (41.7%) have a coagulopathy with a real risk of bleeding. Children with a family history of bleeding are diagnosed more frequently with a coagulopathy with a real risk of bleeding: 37.5% (family history) vs. 14.3% (without). The most frequent diagnoses were: healthy children (48.9%), von Willebrand type 1 disease (19.1%), factor xii deficiency (19.1%), factor xi deficiency (4.2%), prekalikrein/high molecular weight kininogen deficiency (2.1%), acquired deficiency of factor x (2.1%), and factor ix deficiency (2.1%). CONCLUSIONS: A thorough personal and family bleeding history and physical examination are the first steps for a correct differential diagnosis. The reason for referral should be based more on clinical bleeding and not just on an abnormal coagulation time. The most frequent diagnoses were type 1 von Willebrand disease and factor xii deficiency.

Lassa fever in Guinea: I. Epidemiology of human disease and clinical observations.

The arenavirus Lassa is found in West Africa, where it sometimes causes a severe illness called Lassa fever. Lassa fever has been seldom investigated outside of a few hyperendemic regions, where the described epidemiology may differ from that in areas of low or moderate incidence of disease. Through a prospective cohort study, we investigated the epidemiology and clinical presentation of Lassa fever in Guinea, where the disease has been infrequently recognized. A surveillance system was established, and suspected cases were enrolled at five Guinean hospitals. Clinical observations were made, and blood was taken for enzyme-linked immunosorbent assay testing and isolation of Lassa virus. Lassa fever was confirmed in 22 (7%) of 311 suspected cases. Another 43 (14%) had Lassa IgG antibodies, indicating past exposure. Both sexes and a wide variety of age and ethnic groups were affected. The disease was more frequently found, and the IgG seroprevalence generally higher, in the southeastern forest region. In some areas, there were significant discrepancies between the incidence of Lassa fever and the prevalence of antibody. Clinical presentations between those with Lassa fever and other febrile illnesses were essentially indistinguishable. Clinical predictors of a poor outcome were noted, but again were not specific for Lassa fever. Case-fatality rates for those with Lassa fever and non-Lassa febrile illnesses were 18% and 15%, respectively. Seasonal fluctuation in the incidence of Lassa fever was noted, but occurred similarly with non-Lassa febrile illnesses. Our results, perhaps typical of the scenario throughout much of West Africa, indicate Lassa virus infection to be widespread in certain areas of Guinea, but difficult to distinguish clinically.

[Malaria prevalence survey in 24 Guinean villages in the Kindia area]. / Etude de la prévalence du paludisme dans 24 villages de la Guinée.

The authors report the results of a survey of malaria prevalence carried out from October to December 1998 in 24 villages located upstream of the Garafiri dam, in the Kindia area. The parametre used for the assessment of prevalence was the Plasmodium index. The gametocyte and spleen indexes were also recorded. The prevalence observed (34,7%) confirms the presence in this area of stable malaria mostly transmitted by Anopheles gambiae in tropical Africa. This prevalence rate is compatible with the epidemiological data of the Ministry of Health.

[Malaria in the infant in a rural area of maritime Guinea (Guinea Conakry). I. Immune and parasitic status of the mother and the newborn]. / Impaludation du nourrisson dans une zone rurale de Guinée maritime (Guinée Conakry). I. Statuts immunitaire et parasitaire de la mère et du nouveau-né.

Among 216 women who had given birth in the rural health maternity centre of Maférinyah (Guinea), 32% had parasitemia with no clinical signs. Antimalarial antibodies could be measured only for 156 women and were present in all of them. Serological antimalarial tests were carried out on 133 newborns, all of whom had antibodies. The serological results of 122 mother infant pairs are given in this article. The absence of parasitemia in 122 newborns confirms the rarity of congenital malaria and would seem to favour the protective role of transmitted maternal antibodies.

[Malaria in infants in a rural area of maritime Guinea (Guinea Conakry). II. Development of antimalarial antibodies and malaria during the first year of life]. / Impaludation du nourrisson dans une zone rurale de Guinée maritime (Guinée Conakry). II-Evolution des anticorps antipaludéens et impaludation au cours de la première année de vie.

A transversal investigation carried out on 551 children and a longitudinal study of 55 infants showed the disappearance of maternal anti-plasmodium antibodies during the first year of life. Out of 212 new-borns surveyed for one year, 59 (28%) were infested by Plasmodium, but never during the first two months of life. This infestation was not related to the age of the infant nor to the season. For 46% of cases, infestation was completely asymptomatic, for 18% of cases respiratory signs were present and for 20% digestive signs not specific to malaria. Fever was present in 14 cases (24%) and isolated in 6 cases. Only 7 infants received a specific antimalarial treatment. Evolution under medical surveillance was favourable in all cases. These findings prove the difficulties inherent to the diagnosis of malaria, especially in the absence of laboratories for diagnosing other infections--such as typhoid--which do not appear in sanitary statistics. The findings also raise the question as to the efficiency of systematic antimalarial treatment in case of fever in the infant or child. Asymptomatic parasitemia can be explained by the existence of antitoxic immunity different from antiplasmodia immunity.

Revisión de los pacientes estudiados por coagulopatía en una unidad de Oncohematología / Review of patients studied for coagulopathy in a Hematology/Oncology unit

INTRODUCCIÓN: Los síntomas/signos indicativos de una coagulopatía son un motivo de consulta frecuente en las unidades de Hematología Pediátrica. Tanto la clínica como los antecedentes familiares son fundamentales para el diagnóstico. PACIENTES Y MÉTODOS: Estudio retrospectivo y descriptivo de los pacientes derivados a una consulta de Hematología Pediátrica de un hospital de tercer nivel por posible coagulopatía durante el año 2012. RESULTADOS: Se estudiaron 47 niños. El 61,7% no había presentado previamente sangrado. El motivo de derivación más frecuente fue un tiempo de tromboplastina parcial activada alargado sin hemorragia (42,5%); de estos, un 25% fue diagnosticado de una coagulopatía con riesgo real de sangrado. En los pacientes derivados por tiempo de tromboplastina parcial activada alargado con clínica hemorrágica se detecta una coagulopatía con riesgo real de sangrado con mayor frecuencia (41,7%). En los niños con antecedentes familiares de sangrado se diagnostica con más frecuencia una coagulopatía con riesgo real de sangrado: 37,5 vs. 14,3% (niños sin antecedentes familiares). Los diagnósticos han sido: sano (48,9%), enfermedad de von Willebrand tipo1 (19,1%), déficit de factor XII (19,1%), déficit de factor XI(4,2%), déficit de precalicreína/cininógeno de alto peso molecular (2,1%), déficit adquirido de factor X (2,1%) y déficit de factor IX (2,1%). CONCLUSIONES: Los antecedentes personales y familiares de sangrado orientan el diagnóstico de una coagulopatía. El motivo de derivación debería basarse en mayor medida en la clínica hemorrágica y no solo en un tiempo de laboratorio alterado. Los diagnósticos más frecuentes han sido enfermedad de von Willebrand tipo 1 y déficit de factor XII

INTRODUCTION: Symptoms/signs suggestive of coagulopathy is a frequent complaint in Pediatric Hematology units. Both the clinical and family history are essential for diagnosis. PATIENTS AND METHODS: Retrospective and descriptive study of patients referred to a Pediatric Hematology unit of a tertiary hospital for possible coagulopathy during 2012. RESULTS: A total of 47 children were studied, of whom 61.7% had not previously suffered bleeding. The most frequent reason for referral was an eloganted activated partial thromboplastin time without any hemorrhage (42.5%), of these, 25% were diagnosed of a coagulopathy with a real risk of bleeding. While patients referred due to an eloganted activated partial thromboplastin time with bleeding more frequently (41.7%) have a coagulopathy with a real risk of bleeding. Children with a family history of bleeding are diagnosed more frequently with a coagulopathy with a real risk of bleeding: 37.5% (family history) vs. 14.3% (without). The most frequent diagnoses were: healthy children (48.9%), von Willebrand type 1 disease (19.1%), factor XII deficiency (19.1%), factor XI deficiency (4.2%), prekalikrein/high molecular weight kininogen deficiency (2.1%), acquired deficiency of factor X (2.1%), and factor IXdeficiency (2.1%). CONCLUSIONS: A thorough personal and family bleeding history and physical examination are the first steps for a correct differential diagnosis. The reason for referral should be based more on clinical bleeding and not just on an abnormal coagulation time. The most frequent diagnoses were type 1 von Willebrand disease and factor XII deficiency

[Problems of metabolic control in type I diabetic patients with chronic renal failure]. / Probleme der Stoffwechselführung bei Typ-I-Diabetikern mit chronischer Niereninsuffizienz.

The aetiopathogenesis of the diabetic nephropathy today is still unknown. Uncontested is the contribution of chronic hyperglycemia in the pathogenesis of diabetic nephropathy. For this, there are convincing evidences from clinical and experimental experiences including transplantation surgery. The quality of the metabolic adjustment of the diabetics from the first time of diabetes manifestation is important to prevent the development of diabetic nephropathy. For this, an almost normoglycemic compensation of the glucose metabolism is mandatory. More problematically is the management of the diabetic metabolism during chronic renal insufficiency. Considerable fluctuations of the blood glucose concentration are predominately in the daily profile. The intensive conventional metabolic therapy by multiple insuline injections under self control of the blood glucose level are indicated absolutely in those patients. The therapeutic aim is a smoothing of the blood glucose fluctuation. With that it is possible--together with the elimination of hemodynamic risk factors--to delay effectively a progradient decline of the glomerulo-filtration rate and to improve the assumption to an invasive therapy.

The progression of diabetic nephropathy in type I diabetics: relationship to metabolic control and blood pressure.

This study was designed to investigate the importance of risk factors such as hyperglycemia and elevated systolic and diastolic blood pressures on the progression of renal insufficiency in diabetics suffering from diabetic nephropathy. Seventeen patients with Type I, insulin-dependent diabetes mellitus (IDDM) (8 women and 9 men) undergoing chronic hemodialysis were investigated by retrospective follow-up and compared with 17 age and sex matched IDDM patients without diabetic nephropathy (controls). According to the time interval of creatinine increase from 200 to 600 mumol/l, the patients were divided arbitrarily into two groups with rapidly (group I less than 20 months) or slowly progressive (group II greater than or equal to 20 months) renal insufficiency. This period was 13.4 +/- 2.05 months in group I (age 36.67 +/- 2.47 years, diabetes duration 23.55 +/- 2.37 years) and 32.75 +/- 4.34 months in group II (age 40.62 +/- 2.63 years, diabetes duration 26.62 +/- 2.63 years, P.n.s.), respectively. The IDDM patients studied exhibited individually differing progressions of renal insufficiency at different times after manifestation of diabetes. After 15 years of diabetes duration, both risk factors, that is blood pressure and blood glucose concentrations, were elevated in nephropathic diabetics when compared with controls (p less than 0.01). During the phase of declining kidney function, mean blood pressures were found to be higher in IDDM patients with rapid progression of renal insufficiency when compared with slowly progressing diabetics. Although both risk factors were related to diabetic nephropathy, during the phase of renal insufficiency hypertension appeared to be more closely related to the further deterioration of kidney function.

The effect of antihypertensive treatment on kidney function in insulin-dependent (type I) diabetics with renal failure.

Diabetic nephropathy is the dominant cause of hypertension in insulin-dependent diabetics, and long-term rigid antihypertensive treatment inhibits the progression of nephropathy, probably even when there is renal insufficiency. In our clinical study 14 insulin-dependent diabetics with diabetic nephropathy and renal failure (glomerular filtration rate [GFR] 0.39 +/- 0.12 ml/sec) underwent rigid blood pressure treatment. Antihypertensive therapy included furosemide, propranolol, dihydralazine and nifedipine. The whole group showed a lowering in mean blood pressures from 150.1 +/- 2.3/91.3 +/- 1.4 mm Hg to 139.8 +/- 3.1/86.5 +/- 2.0 mm Hg (p less than 0.01). During the observation period the mean decline in glomerular filtration rate decreased from -0.022 +/- 0.003 ml/sec per month to -0.010 +/- 0.007 ml/sec per month. In 10 out of 14 patients with very advanced nephropathy the further decline of GFR halted markedly. Thus, vigorous blood pressure control is able to postpone endstage renal disease even in advanced diabetic nephropathy.

Methods and effects of improved conventional insulin treatment in labile insulin-dependent diabetes (IDDM).

In 92 particularly unstable IDDM patients we have tried to avoid any gap in daily insulin supply by applying one out of four newly designed combinations of regular and depot insulin. The short-term effect after three weeks and the long-term effect after greater than or equal to 12 months (data from 30 patients only) of these new regimens were compared with those of the traditional regimen in a retrospective evaluation: Glycemia (level and excursions) was significantly improved both after three weeks of inpatient treatment and after greater than or equal to 12 additional months on outpatient regimen. Serum beta-LP and HbA1 showed slight decrease during long-term follow-up. The majority of the patients reported improved well-being under conditions of daily life. However, the glycemia achieved was still far from the permanent euglycemia aimed at. For the avoidance of any gap in insulin supply in labile diabetics four insulin injections are necessary in most cases. For this, individually tailored combinations of regular and depot insulin must be drawn up carefully together with the patients to avoid a " strait -jacket" system which would not work under conditions of daily life.

Complicaciones de la cirugía de la pancreatitis aguda / Complications in acute pancreatitis surgery

La pancreatitis aguda grave constituye en la actualidad un reto terapéutico todavía sin resolver. Un 20 por ciento de los pacientes afectados de pancreatitis aguda presentan numerosas complicaciones, tanto locales como sistémicas, con elevada mortalidad. Es fundamental identificar las formas graves para indicar la monitorización y el tratamiento en unidades de cuidados intensivos, a fin de detectar y tratar precozmente el fracaso multiorgánico. En la actualidad se acepta que, en fase aguda, la cirugía queda restringida a las complicaciones regionales de la enfermedad, en su mayor parte de carácter séptico, ya que la intervención indiscriminada inicial se asocia a una mayor morbimortalidad, superior al 60 por ciento. Incluso el fracaso multiorgánico precoz sin infección demostrada no se beneficia de tratamiento quirúrgico. Cuando se ha establecido el diagnóstico de infección pancreática, las técnicas de necrosectomía, desbridamiento y drenaje abierto de la cavidad abdominal se asocian con menor mortalidad (12 por ciento), infección recurrente y necesidad de reintervención. En los pacientes a los que se indica intervención se siguen detectando numerosas complicaciones, tanto asociadas a la pancreatitis, como al propio tratamiento quirúrgico. Las más frecuentes son la infección residual o recurrente, la hemorragia, las necrosis y fístulas intestinales y pancreáticas, que contribuyen con una gran frecuencia al fracaso multiorgánico y la muerte (AU)