Effect of COVID-19 lockdown on maternity care and maternal outcome in the Netherlands: a national quasi-experimental study.

OBJECTIVES: The COVID-19 pandemic and associated lockdowns disrupted health care worldwide. High-income countries observed a decrease in preterm births during lockdowns, but maternal pregnancy-related outcomes were also likely affected. This study investigates the effect of the first COVID-19 lockdown (March-June 2020) on provision of maternity care and maternal pregnancy-related outcomes in the Netherlands. STUDY DESIGN: National quasi-experimental study. METHODS: Multiple linked national registries were used, and all births from a gestational age of 24+0 weeks in 2010-2020 were included. In births starting in midwife-led primary care, we assessed the effect of lockdown on provision of care. In the general pregnant population, the impact on characteristics of labour and maternal morbidity was assessed. A difference-in-regression-discontinuity design was used to derive causal estimates for the year 2020. RESULTS: A total of 1,039,728 births were included. During the lockdown, births to women who started labour in midwife-led primary care (49%) more often ended at home (27% pre-lockdown, +10% [95% confidence interval: +7%, +13%]). A small decrease was seen in referrals towards obstetrician-led care during labour (46%, -3% [-5%,-0%]). In the overall group, no significant change was seen in induction of labour (27%, +1% [-1%, +3%]). We found no significant changes in the incidence of emergency caesarean section (9%, -1% [-2%, +0%]), obstetric anal sphincter injury (2%, +0% [-0%, +1%]), episiotomy (21%, -0% [-2%, +1%]), or post-partum haemorrhage: >1000 ml (6%, -0% [-1%, +1%]). CONCLUSIONS: During the first COVID-19 lockdown in the Netherlands, a substantial increase in homebirths was seen. There was no evidence for changed available maternal outcomes, suggesting that a maternity care system with a strong midwife-led primary care system may flexibly and safely adapt to external disruptions.

Experimental surgery as part of the development of degradable biomaterials for cardiovascular surgery

Introduction: Cardiovascular diseases are responsible for significant morbidity and mortality in the population. Artificial vascular grafts are often essential for surgical procedures in radical or palliative treatment. Many new biodegradable materials are currently under development. Preclinical testing of each new material is imperative, both in vitro and in vivo, and therefore animal experiments are still a necessary part of the testing process before any clinical use. The aim of this paper is to present the options of using various experimental animal models in the field of cardiovascular surgery including their extrapolation to clinical medicine. Methods: The authors present their general experience in the field of experimental surgery. They discuss the selection process of an optimal experimental animal model to test foreign materials for cardiovascular surgery and of an optimal region for implantation. Results: The authors present rat, rabbit and porcine models as optimal experimental animals for material hemocompatibility and degradability testing. Intraperitoneal implantation in the rat is a simple and feasible procedure, as well as aortic banding in the rabbit or pig. The carotid arteries can also be used, as well. Porcine pulmonary artery banding is slightly more difficult with potential complications. The banded vessels, explanted after a defined time period, are suitable for further mechanical testing using biomechanical analyses, for example, the inflation-extension test. Conclusion: An in vivo experiment cannot be avoided in the last phases of preclinical research of new materials. However, we try to strictly observe the 3R concept ­ Replacement, Reduction and Refinement; in line with this concept, the potential of each animal should be used as much as possible to reduce the number of animals.

Effectiveness of a community-based health programme on the blood pressure control, adherence and knowledge of adults with hypertension: A PRECEDE-PROCEED model approach.

AIMS AND OBJECTIVES: To determine the effectiveness of a community-based health programme grounded on the PRECEDE-PROCEED model, on the knowledge, adherence and blood pressure control of community-dwelling adults with hypertension. BACKGROUND: Hypertension has consistently been a leading cause of morbidity and mortality in different countries and has continuously increased in prevalence. Albeit manageable with lifestyle modification and anti-hypertensive medications, adequate knowledge and poor adherence to these treatment regimens are issues that have led to poor blood pressure control. DESIGN: Quasi-experimental, one-group pretest-post-test design. METHODS: The PRECEDE-PROCEED model was used to develop and evaluate the effectiveness of the community-based health programme. From August to October 2017, a total of 50 community-dwelling adults with hypertension participated in the programme which included blood pressure monitoring, targeted health educations, motivational interviews, individualised lifestyle modification plans and house-to-house visits. Knowledge, adherence and blood pressure were assessed at the start and at the end of the 2-month programme. Gathered data were analysed using descriptive statistics and RM-MANOVA. The TREND checklist was followed in reporting this study (See Appendix S1). RESULTS: After 2 months, the mean adherence, systolic blood pressure and diastolic blood pressure significantly improved, attributing more than 25% of the change. Although knowledge scores were significantly higher after the programme, it only accounted 9% of the improvement. CONCLUSION: This study provides evidence on the effectiveness of a community-based health programme grounded on the PRECEDE-PROCEED model on the knowledge, adherence and blood pressure control of community-dwelling adults with hypertension. RELEVANCE TO CLINICAL PRACTICE: The community-based health programme is beneficial to community-dwelling adults with hypertension in promoting knowledge and adherence to treatment regimen and improving BP control. This study also provides a framework for developing new or enhancing existing programmes on hypertension in the Philippines.

[Biomechanical screening for injury prevention : The importance of 3D-motion analysis in high performance sports]. / Biomechanisches Screening zur Verletzungsprävention : Die Bedeutung der 3D-Bewegungsanalyse im Hochleistungssport.

Standardized clinical diagnostic procedures cannot assess the functionality of the anatomical structures in sport-specific movement. Biomechanical screening is able to detect deficits but is not sufficiently and objectively precise with the current clinical examination tools including conventional imaging techniques. The fields of use of functional testing methods are versatile and range from injury prevention analysis, screening during rehabilitation phases up to the return-to-play decision. Using simple musculoskeletal function analysis it is difficult to assess the risk of injuries. The main advantage of instrumented 3D-motion analysis is its potential to generate objective, reliable and reproducible data with exact joint angles, muscle activity, as well as loading inside the joints during movement. These marker-based motion analysis procedures are more time-consuming and more cost intensive and necessitate in particular biomechanical and medical knowledge to assess the analytical data in terms of clinical relevance. In the absence of scientific studies on biomechanical analyses in professional sports, this study shows preliminary approaches to this topic.

Veno-arterial extracorporeal membrane oxygenation in addition to primary PCI in patients presenting with ST-elevation myocardial infarction.

INTRODUCTION: Primary percutaneous coronary intervention (pPCI) in ST-elevation myocardial infarction (STEMI) can cause great haemodynamic instability. Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) can provide haemodynamic support in patients with STEMI but data on outcome and complications are scarce. METHODS: An in-hospital registry was conducted enrolling all patients receiving VA-ECMO. Patients were analysed for medical history, mortality, neurological outcome, complications and coronary artery disease. RESULTS: Between 2011 and 2016, 12 patients underwent pPCI for STEMI and received VA-ECMO for haemodynamic support. The majority of the patients were male (10/12) with a median age of 63 (47-75) years and 4 of the 12 patients had a history of coronary artery disease. A cardiac arrest was witnessed in 11 patients. The left coronary artery was compromised in 8 patients and 4 had right coronary artery disease. All patients were in Killip class IV. Survival to discharge was 67% (8/12), 1­year survival was 42% (5/12), 2 patients have not yet reached the 1­year survival point but are still alive and 1 patient died within a year after discharge. All-cause mortality was 42% (5/12) of which mortality on ECMO was 33% (4/12). Patient-related complications occurred in 6 of the 12 patients: 1 patient suffered major neurological impairment, 2 patients suffered haemorrhage at the cannula site, 2 patients had limb ischaemia and 1 patient had a haemorrhage elsewhere. There were no VA-ECMO hardware malfunctions. CONCLUSION: VA-ECMO in pPCI for STEMI has a high survival rate and neurological outcome is good, even when the patient is admitted with a cardiac arrest.

Perioperative management of antiplatelet treatment in patients undergoing isolated coronary artery bypass grafting in Dutch cardiothoracic centres.

BACKGROUND: International guidelines do not provide uniform recommendations regarding the use of antiplatelet treatment in the perioperative period in patients undergoing coronary artery bypass grafting (CABG). METHODS: A questionnaire was sent to all 16 cardiothoracic centres in the Netherlands to determine which antiplatelet treatment is used in the perioperative setting. Furthermore, a single-centre prospective observational cohort study was performed which included all patients undergoing isolated CABG in July 2014. RESULTS: Eleven centres responded to the survey. Acetylsalicylic acid monotherapy was discontinued before surgery in 6 centres. In patients with an acute coronary syndrome receiving dual antiplatelet therapy (DAPT), most centres discontinued the P2Y12 inhibitor preoperatively. DAPT was restarted after surgery in 4 centres. However, 6 centres continued DAPT in patients who had undergone coronary stenting within one month of surgery. In patients with coronary stents, variation in the management of antiplatelet therapy increased in proportion to the interval between stenting and surgery. A total of 70 patients were included in the registry. Acetylsalicylic acid monotherapy was discontinued in 51% of patients and restarted in all patients. P2Y12 inhibitor treatment was discontinued before surgery in 70% of patients and re-initiated after CABG in 29%. CONCLUSIONS: Major differences were observed in the preoperative and postoperative management of antiplatelet treatment between different Dutch cardiothoracic centres and within a single centre. Part of this variation is probably due to lack of evidence and differences between the current guidelines; however, many of the strategies were not in accordance with any of these guidelines.

The last frontier: transcatheter devices for percutaneous or minimally invasive treatment of chronic heart failure.

Heart failure has a high prevalence in the general population. Morbidity and mortality of heart failure patients remain high, despite improvements in drug therapy, implantable cardioverter-defibrillators and cardiac resynchronisation therapy. New transcatheter implantable devices have been developed to improve the treatment of heart failure. There has been a rapid development of minimally invasive or transcatheter devices used in the treatment of heart failure associated with aortic and mitral valve disease and these devices are being incorporated into routine clinical practice at a fast rate. Several other new transcatheter structural heart interventions for chronic heart failure aimed at a variety of pathophysiologic approaches are currently being developed. In this review, we focus on devices used in the treatment of chronic heart failure by means of left ventricular remodelling, left atrial pressure reduction, tricuspid regurgitation reduction and neuromodulation. The clinical evaluations of these devices are early-stage evaluations of initial feasibility and safety studies and additional clinical evidence needs to be gathered in appropriately designed clinical trials.

Qigong in cancer care: a systematic review and construct analysis of effective Qigong therapy.

PURPOSE: This review (a) assesses the strength of evidence addressing Qigong therapy in supportive cancer care and (b) provides insights for definition of effective Qigong therapy in supportive cancer care. METHODS: This mixed-methods study includes (a) a systematic review of randomized clinical trials (RCTs) following PRISMA guidelines and (b) a constant-comparative qualitative analysis of effective intervention protocols. RESULTS: Eleven published randomized clinical trials were reviewed. A total of 831 individuals were studied. Geographic settings include the USA, Australia, China, Hong Kong, and Malaysia. Qigong therapy was found to have positive effects on the cancer-specific QOL, fatigue, immune function, and cortisol levels of individuals with cancer. Qigong therapy protocols varied supporting a plurality of styles. Qualitative analyses identified common programming constructs. Content constructs included exercise (gentle, integrated, repetitious, flowing, weight-bearing movements), breath regulation, mindfulness and meditation, energy cultivation including self-massage, and emphasis on relaxation. Logistic constructs included delivery by qualified instructors, home practice, and accommodation for impaired activity tolerance. CONCLUSIONS: There is global interest and a growing body of research providing evidence of therapeutic effect of Qigong therapy in supportive cancer care. While Qigong therapy protocols vary in style, construct commonalities do exist. Knowledge of the common constructs among effective programs revealed in this research may be used to guide future research intervention protocol and community programming design and development.

[Asylum seekers and the healthcare situation]. / Asylbewerber und ihre Versorgungssituation.

Medical healthcare for refugees is strictly regulated by law in Germany but the great regional variation in the implementation is currently a huge challenge for healthcare providers. Providers are often not familiar with the specific local regulations and especially in emergencies it is often not possible to clarify open questions before treating patients. The high influx of refugees in the summer and fall of 2015 led to a situation that could only be managed with the voluntary and pragmatic help of all healthcare personnel involved. This article explains the most relevant regulations covering medical healthcare for refugees and asylum seekers. In addition, the procedure for the approval of asylum status in itself can have a direct or indirect impact on the health status of these individuals; therefore, some comments are made regarding this aspect.

COMPliance and Arthralgia in Clinical Therapy: the COMPACT trial, assessing the incidence of arthralgia, and compliance within the first year of adjuvant anastrozole therapy.

BACKGROUND: This prospective study evaluated the relationship between arthralgia and compliance during the first year of adjuvant anastrozole therapy in postmenopausal women with hormone receptor-positive early breast cancer. PATIENTS AND METHODS: COMPliance and Arthralgia in Clinical Therapy (COMPACT) was an open-label, multicenter, noninterventional study conducted in Germany. Patients had started adjuvant anastrozole 3-6 months before the study start. The primary end points were arthralgia, compliance, and the relationship between compliance and arthralgia, assessed at specific time points. RESULTS: Overall, 1916 patients received upfront anastrozole. Mean arthralgia scores were increased from baseline at each visit up to 9 months. Compliance with anastrozole therapy gradually decreased over time from baseline to 9 months (P<0.001). At 9 months, investigators estimated that >95% of patients were compliant versus patient reports of <70%. There was a significant association between arthralgia mean scores and noncompliance at 6 months (P<0.0001), 9 months (P<0.0001), and overall (P<0.0001). Over time, new events or impairment of existing arthralgias were reported in 14% (3 months), 11% (6 months), and 9% (9 months) of patients. CONCLUSION: Arthralgia is important in the clinical management of women with early breast cancer and may contribute to noncompliance and clinical outcomes. CLINICALTRIALSGOV IDENTIFIER: NCT00857012.

Subchronic treatment with phencyclidine in adolescence leads to impaired exploratory behavior in adult rats without altering social interaction or N-methyl-D-aspartate receptor binding levels.

Although both the onset of schizophrenia and human phencyclidine (PCP) abuse typically present within the interval from adolescence to early adulthood, the majority of preclinical research employing the PCP model of schizophrenia has been conducted on neonatal or adult animals. The present study was designed to evaluate the behavioral and neurochemical sequelae of subchronic exposure to PCP in adolescence. Male 35-42-day-old Sprague Dawley rats were subcutaneously administered either saline (10 ml · kg(-1) ) or PCP hydrochloride (10 mg · kg(-1) ) once daily for a period of 14 days (n = 6/group). The animals were allowed to withdraw from treatment for 2 weeks, and their social and exploratory behaviors were subsequently assessed in adulthood by using the social interaction test. To examine the effects of adolescent PCP administration on the regulation of N-methyl-D-aspartate receptors (NMDARs), quantitative autoradiography was performed on brain sections of adult, control and PCP-withdrawn rats by using 20 nM (3) H-MK-801. Prior subchronic exposure to PCP in adolescence had no enduring effects on the reciprocal contact and noncontact social behavior of adult rats. Spontaneous rearing in response to the novel testing arena and time spent investigating its walls and floor were reduced in PCP-withdrawn animals compared with control. The long-term behavioral effects of PCP occurred in the absence of persistent deficits in spontaneous locomotion or self-grooming activity and were not mediated by altered NMDAR density. Our results document differential effects of adolescent PCP administration on the social and exploratory behaviors of adult rats, suggesting that distinct neurobiological mechanisms are involved in mediating these behaviors.

A rare case of a simultaneous post-dissection saccular aneurysm of the ascending aorta and large pulmonary artery aneurysm with secondary embolism: a case report.

BACKGROUND: Aneurysms of the pulmonary arteries and the ascending aorta are rare, and both bear a high mortality risk if left untreated. In general, these entities are primarily caused by etiologies such as hypertension, pulmonary arterial hypertension, infection or congenital disorders. Treatment requires a rapid diagnostic work-up or even immediate surgical intervention in acute cases. Nevertheless, surgery entails serious perioperative risks, in particular in patients with multiple comorbidities. CASE PRESENTATION: We discuss a 70-year-old woman presented with decompensated heart failure based on severe pulmonary artery hypertension, coincided by a massive pulmonary artery aneurysm with secondary embolism. Additional diagnostic imaging also showed a chronic post-dissection, saccular aneurysm of the ascending aorta. To our knowledge, this simultaneous diagnosis of a saccular aneurysm of the ascending aorta and a large aneurysm of the pulmonary artery with secondary embolism has not yet been described. Nonetheless, conservative treatment was chosen due to extensive pulmonal and cardiovascular comorbidities and the high-risk profile of surgery. CONCLUSIONS: Extensive aneurysmatic disease of the pulmonary arteries and ascending aorta come with a serious burden of disease, especially if coincided by severe pulmonal and cardiovascular comorbidities. Both conditions can be curatively treated by surgical intervention. However, in every case the risk of surgery and the patient's vitality, comorbidities and wishes should be taken into account to formulate an adequate treatment plan. Therefore, shared decision making is of utter importance.

ENerGetIcs in hypertrophic cardiomyopathy: traNslation between MRI, PET and cardiac myofilament function (ENGINE study).

INTRODUCTION: Hypertrophic cardiomyopathy (HCM) is an autosomal dominant heart disease mostly due to mutations in genes encoding sarcomeric proteins. HCM is characterised by asymmetric hypertrophy of the left ventricle (LV) in the absence of another cardiac or systemic disease. At present it lacks specific treatment to prevent or reverse cardiac dysfunction and hypertrophy in mutation carriers and HCM patients. Previous studies have indicated that sarcomere mutations increase energetic costs of cardiac contraction and cause myocardial dysfunction and hypertrophy. By using a translational approach, we aim to determine to what extent disturbances of myocardial energy metabolism underlie disease progression in HCM. METHODS: Hypertrophic obstructive cardiomyopathy (HOCM) patients and aortic valve stenosis (AVS) patients will undergo a positron emission tomography (PET) with acetate and cardiovascular magnetic resonance imaging (CMR) with tissue tagging before and 4 months after myectomy surgery or aortic valve replacement + septal biopsy. Myectomy tissue or septal biopsy will be used to determine efficiency of sarcomere contraction in-vitro, and results will be compared with in-vivo cardiac performance. Healthy subjects and non-hypertrophic HCM mutation carriers will serve as a control group. ENDPOINTS: Our study will reveal whether perturbations in cardiac energetics deteriorate during disease progression in HCM and whether these changes are attributed to cardiac remodelling or the presence of a sarcomere mutation per se. In-vitro studies in hypertrophied cardiac muscle from HOCM and AVS patients will establish whether sarcomere mutations increase ATP consumption of sarcomeres in human myocardium. Our follow-up imaging study in HOCM and AVS patients will reveal whether impaired cardiac energetics are restored by cardiac surgery.

Autologous Mesenchymal Stromal Cells Immobilized in Plasma-Based Hydrogel for the Repair of Articular Cartilage Defects in a Large Animal Model.

The treatment of cartilage defects in trauma injuries and degenerative diseases represents a challenge for orthopedists. Advanced mesenchymal stromal cell (MSC)-based therapies are currently of interest for the repair of damaged cartilage. However, an approved system for MSC delivery and maintenance in the defect is still missing. This study aimed to evaluate the effect of autologous porcine bone marrow MSCs anchored in a commercially available polyglycolic acid-hyaluronan scaffold (Chondrotissue®) using autologous blood plasma-based hydrogel in the repair of osteochondral defects in a large animal model. The osteochondral defects were induced in twenty-four minipigs with terminated skeletal growth. Eight animals were left untreated, eight were treated with Chondrotissue® and eight received Chondrotissue® loaded with MSCs. The animals were terminated 90 days after surgery. Macroscopically, the untreated defects were filled with newly formed tissue to a greater extent than in the other groups. The histological evaluations showed that the defects treated with Chondrotissue® and Chondrotissue® loaded with pBMSCs contained a higher amount of hyaline cartilage and a lower amount of connective tissue, while untreated defects contained a higher amount of connective tissue and a lower amount of hyaline cartilage. In addition, undifferentiated connective tissue was observed at the edges of defects receiving Chondrotissue® loaded with MSCs, which may indicate the extracellular matrix production by transplanted MSCs. The immunological analysis of the blood samples revealed no immune response activation by MSCs application. This study demonstrated the successful and safe immobilization of MSCs in commercially available scaffolds and defect sites for cartilage defect repair.

Domain wall dynamics in amorphous and nanocrystalline FeCoMoB microwires.

We have studied the domain wall dynamics in amorphous and nanocrystalline FeCoMoB microwires. The domain wall propagation velocity has been found very fast (up to 5000 m/s) for the as-cast sample. Annealing at 575 K/1 h leads to the stress relief and sample homogenization and the domain wall velocity even increases to 5300 m/s. However, the domain wall dynamics is highly sensible to the temperature of a measurement. Annealing at 775 K/1 h leads to the appearance of the nanocrystalline structure with much higher temperature stability. The maximum domain wall velocity decreases (2800 m/s), however the domain wall dynamics is much stable with the temperature.

Safety and Efficacy Profile of Echinacea purpurea to Prevent Common Cold Episodes: A Randomized, Double-Blind, Placebo-Controlled Trial.

Objective. To investigate the safety (risk) and efficacy (benefit) of Echinacea purpurea extract in the prevention of common cold episodes in a large population over a 4-month period. Methods. 755 healthy subjects were allocated to receive either an alcohol extract from freshly harvested E. purpurea (95% herba and 5% root) or placebo. Participants were required to record adverse events and to rate cold-related issues in a diary throughout the investigation period. Nasal secretions were sampled at acute colds and screened for viruses. Results. A total of 293 adverse events occurred with Echinacea and 306 with placebo treatment. Nine and 10% of participants experienced adverse events, which were at least possibly related to the study drug (adverse drug reactions). Thus, the safety of Echinacea was noninferior to placebo. Echinacea reduced the total number of cold episodes, cumulated episode days within the group, and pain-killer medicated episodes. Echinacea inhibited virally confirmed colds and especially prevented enveloped virus infections (P < 0.05). Echinacea showed maximal effects on recurrent infections, and preventive effects increased with therapy compliance and adherence to the protocol. Conclusions. Compliant prophylactic intake of E. purpurea over a 4-month period appeared to provide a positive risk to benefit ratio.

Amplified fragment length polymorphism reveals specific epigenetic distinctions between Mycobacterium avium subspecies paratuberculosis isolates of various isolation types.

Amplified fragment length polymorphism (AFLP) was employed as a genetic analysis tool for the study of the genetic relatedness of Mycobacterium avium subsp. paratuberculosis isolates harvested from bovine fecal samples and from bovine or human tissues. This analysis revealed genetic differences between these two isolate types that were confirmed through cluster analysis. Dendrogram analysis separated these two isolate types based on the isolation scheme (tissue-associated versus fecal M. avium subsp. paratuberculosis isolates). Further sequence analysis of unique genetic regions from each isolation type revealed no genetic sequence differences. However, Clustal DNA alignments identified AFLP restriction enzyme sites that were undigested in the tissue-associated isolates. AFLP analysis also disclosed that the same AFLP restriction sites were digested in all of the fecal isolates. Sequence analysis further revealed a consensus sequence upstream of the undigested restriction sites for possible methyltransferase recognition in the tissue-associated M. avium subsp. paratuberculosis isolates.

Mapping and characterization of Rf 5: a new gene conditioning pollen fertility restoration in A1 and A2 cytoplasm in sorghum (Sorghum bicolor (L.) Moench).

With an aim to further characterize the cytoplasmic male sterility-fertility restoration system in sorghum, a major fertility restoration gene was mapped along with a second locus capable of partial restoration of pollen fertility. The major fertility restoration gene, Rf(5), was located on sorghum chromosome SBI-05, and was capable of restoring pollen fertility in both A(1) and A(2) male sterile cytoplasms. Depending on the restorer parent, mapping populations exhibited fertility restoration phenotypes that ranged from nearly bimodal distribution due to the action of Rf(5), to a more normalized distribution reflecting the action of Rf(5) and additional modifier/partial restoration genes. A second fertility restoration locus capable of partially restoring pollen fertility in A(1) cytoplasm was localized to chromosome SBI-04. Unlike Rf(5), this modifier/partial restorer gene acting alone resulted in less than 10% seed set in both A(1) and A(2) cytoplasms, and modified the extent of restoration conditioned by the major restorer Rf(5) in A(1) cytoplasm. In examining the genomic regions spanning the Rf(5) locus, a cluster of pentatricopeptide gene family members with high homology to rice Rf (1) and sorghum Rf (2) were identified as potential candidates encoding Rf(5).

Retiform purpura in a patient with a history of cocaine use.

There have been rare published cases of retiform purpura related to cocaine use. Levamisole, a common adulterant, has been implicated as the etiologic agent. We describe a female patient, aged 48 years, with cocaine-related retiform purpura involving her face, abdomen, and legs and alert physicians to the dangers of levamisole-contaminated cocaine.

[Osteopathic medicine]. / Intérêt de l'ostéopathie.

Osteopathy is originated in the 19th century in the United States. Andrew Taylor Still seek for an alternative medical system to the orthodox medicine largely empirical and advocating bloodletting, calomel, etc., all of which was resumed with terms like" heroic medicine". Osteopathy as other alternative medical practices (homeopathy, eclecticism, etc.) based on rational and metaphysical postulates as vitalism or the fact that man is a divinely ordained machine. Still's approach was essentially manual and based on manipulation of the joints. Today osteopaths challenge these dogmas and seek to agree their practice within scientific biomedical standards. Even if strong randomized clinical trials are lacking, several surveys report how osteopathy gained public notoriety. Several recent meta-analyses pinpoint the benefit of the spinal manipulative treatment and even if there is no evidence that such an approach is superior to other advocated therapies there is no evidence that these therapies are more effective than the first one. The major indications for such a treatment are cervical and low back pain, either chronic or acute. The quality of the relationship between the practitioner and patient together with the placebo effect are important components of a treatment effect. Osteopathic education is an important aspect and only higher education institutions, i.e. universities can achieve and maintain adequate standards. Materia medica and surgery represent the two major therapeutic mainstreams in medicine; osteopathy considered as manual medicine could be the third one.