[Suicidality in the perinatal period: Descriptive study on factors associated with suicidal ideation among women hospitalized in the perinatal period at the specialized hospital center]. / Suicidalité en période périnatale : quels sont les facteurs associés ?

OBJECTIVES: Suicide is the leading cause of maternal mortality in high-resource countries. The onset of suicidal ideation is a major risk factor for suicide attempts. Suicidality has a major impact on the mother-baby relationship and on child development. The main objective of the study was to identify factors associated with the occurrence of perinatal suicidal ideation in women requiring hospitalization. The secondary objectives of the study were to describe the socio-demographic and clinical characteristics of this specific population, to specify the follow-up procedures at hospital discharge and to develop a semi-directed interview framework for psychiatric evaluation of perinatal patients admitted to a psychiatric hospital in order to better identify those at risk of suicide and improve overall management, particularly in terms of referral to existing perinatal care services. METHODS: Descriptive and retrospective study carried out at the Specialized Hospital Center of women hospitalized in the perinatal period between 2014 and 2019. The inclusion criteria were: inpatient pregnant or postpartum within one year of delivery, 16 to 43 years. A keyword search was performed to retrieve the computerized records. All records matching the inclusion criteria were included. We studied the occurrence of suicidal ideation according to the main known clinical and socio-demographic risk factors. RESULTS: The sample included 25 pregnant patients and 57 post-partum patients. The presence of a psychiatric history increased the risk of suicidal ideation by 4.38 (P<0.03). The association between the occurrence of a stressful life event and the risk of suicidal ideation onset was close to significant (P<0.10). One third of the patients had been admitted for a reason related to suicidality. Less than one-third of the patients had been referred to existing perinatal services. CONCLUSIONS: Suicidality in the perinatal period has a major impact on the dyad as well as on the whole family. The search for suicidal ideas must be systematic during psychiatric interviews, a fortiori when a psychiatric history has been authenticated. Every patient hospitalized in adult psychiatry should be referred to specialized outpatient perinatal psychiatry services. Prevention involves raising awareness and training of all health professionals, networking, but also informing the general public.

Sustained function of alginate-encapsulated human islet cell implants in the peritoneal cavity of mice leading to a pilot study in a type 1 diabetic patient.

AIMS/HYPOTHESIS: Alginate-encapsulated human islet cell grafts have not been able to correct diabetes in humans, whereas free grafts have. This study examined in immunodeficient mice whether alginate-encapsulated graft function was inferior to that of free grafts of the same size and composition. METHODS: Cultured human islet cells were equally distributed over free and alginate-encapsulated grafts before implantation in, respectively, the kidney capsule and the peritoneal cavity of non-obese diabetic mice with severe combined immunodeficiency and alloxan-induced diabetes. Implants were followed for in vivo function and retrieved for analysis of cellular composition (all) and insulin secretory responsiveness (capsules). RESULTS: Free implants with low beta cell purity (19 ± 1%) were non-functional and underwent 90% beta cell loss. At medium purity (50 ± 1%), they were functional at post-transplant week 1, evolving to normoglycaemia (4/8) or to C-peptide negativity (4/8) depending on the degree of beta cell-specific losses. Encapsulated implants immediately and sustainably corrected diabetes, irrespective of beta cell purity (16/16). Most capsules were retrievable as single units, enriched in endocrine cells that exhibited rapid secretory responses to glucose and glucagon. Single capsules with similar properties were also retrieved from a type 1 diabetic recipient at post-transplant month 3. However, the vast majority were clustered and contained debris, explaining the poor rise in plasma C-peptide. CONCLUSIONS/INTERPRETATION: In immunodeficient mice, i.p. implanted alginate-encapsulated human islet cells exhibited a better outcome than free implants under the kidney capsule. They did not show primary non-function at low beta cell purity and avoided beta cell-specific losses by rapidly establishing normoglycaemia. Retrieved capsules presented secretory responses to glucose, which was also observed in a type 1 diabetic recipient.

In antibody-positive first-degree relatives of patients with type 1 diabetes, HLA-A*24 and HLA-B*18, but not HLA-B*39, are predictors of impending diabetes with distinct HLA-DQ interactions.

AIMS/HYPOTHESIS: Secondary type 1 diabetes prevention trials require selection of participants with impending diabetes. HLA-A and -B alleles have been reported to promote disease progression. We investigated whether typing for HLA-B*18 and -B*39 may complement screening for HLA-DQ8, -DQ2 and -A*24 and autoantibodies (Abs) against islet antigen-2 (IA-2) and zinc transporter 8 (ZnT8) for predicting rapid progression to hyperglycaemia. METHODS: A registry-based group of 288 persistently autoantibody-positive (Ab(+)) offspring/siblings (aged 0-39 years) of known patients (Ab(+) against insulin, GAD, IA-2 and/or ZnT8) were typed for HLA-DQ, -A and -B and monitored from the first Ab(+) sample for development of diabetes within 5 years. RESULTS: Unlike HLA-B*39, HLA-B*18 was associated with accelerated disease progression, but only in HLA-DQ2 carriers (p < 0.006). In contrast, HLA-A*24 promoted progression preferentially in the presence of HLA-DQ8 (p < 0.002). In HLA-DQ2- and/or HLA-DQ8-positive relatives (n = 246), HLA-B*18 predicted impending diabetes (p = 0.015) in addition to HLA-A*24, HLA-DQ2/DQ8 and positivity for IA-2A or ZnT8A (p ≤ 0.004). HLA-B*18 interacted significantly with HLA-DQ2/DQ8 and HLA-A*24 in the presence of IA-2 and/or ZnT8 autoantibodies (p ≤ 0.009). Additional testing for HLA-B*18 and -A*24 significantly improved screening sensitivity for rapid progressors, from 38% to 53%, among relatives at high Ab-inferred risk carrying at least one genetic risk factor. Screening for HLA-B*18 increased sensitivity for progressors, from 17% to 28%, among individuals carrying ≥ 3 risk markers conferring >85% 5 year risk. CONCLUSIONS/INTERPRETATION: These results reinforce the importance of HLA class I alleles in disease progression and quantify their added value for preparing prevention trials.

Screening for insulinoma antigen 2 and zinc transporter 8 autoantibodies: a cost-effective and age-independent strategy to identify rapid progressors to clinical onset among relatives of type 1 diabetic patients.

In first-degree relatives of type 1 diabetic patients, we investigated whether diabetes risk assessment solely based on insulinoma antigen 2 (IA-2) and zinc transporter 8 (ZnT8) antibody status (IA-2A, respectively, ZnT8A) is as effective as screening for three or four autoantibodies [antibodies against insulin (IAA), glutamate decarboxylase 65 kDa (GAD) glutamate decarboxylase autoantibodies (GADA) and IA-2A with or without ZnT8A] in identifying children, adolescents and adults who progress rapidly to diabetes (within 5 years). Antibodies were determined by radiobinding assays during follow-up of 6444 siblings and offspring aged 0-39 years at inclusion and recruited consecutively by the Belgian Diabetes Registry. We identified 394 persistently IAA(+) , GADA(+) , IA-2A(+) and/or ZnT8A(+) relatives (6·1%). After a median follow-up time of 52 months, 132 relatives developed type 1 diabetes. In each age category tested (0-9, 10-19 and 20-39 years) progression to diabetes was significantly quicker in the presence of IA-2A and/or ZnT8A than in their joint absence (P < 0·001). Progression rate was age-independent in IA-2A(+) and/or ZnT8A(+) relatives but decreased with age if only GADA and/or IAA were present (P = 0·008). In the age group mainly considered for immune interventions until now (10-39 years), screening for IA-2A and ZnT8A alone identified 78% of the rapid progressors (versus 75% if positive for ≥ 2 antibodies among IAA, GADA, IA-2A and ZnT8A or versus 62% without testing for ZnT8A). Screening for IA-2A and ZnT8A alone allows identification of the majority of rapidly progressing prediabetic siblings and offspring regardless of age and is more cost-effective to select participants for intervention trials than conventional screening.

Cost-effectiveness of onabotulinumtoxinA for the treatment of wrist and hand disability due to upper-limb post-stroke spasticity in Scotland.

BACKGROUND AND PURPOSE: The objective was to evaluate the cost-effectiveness of treating upper-limb post-stroke spasticity (ULPSS) with usual care (UC) plus onabotulinumtoxinA versus UC alone in Scotland. METHODS: We developed a model to simulate costs and quality-adjusted life years (QALYs) gained from treating ULPSS. Efficacy data and health utilities were taken from clinical trials. Unit costs were taken from published Scottish sources. We compared UC plus onabotulinumtoxinA and UC alone in three scenarios: (i) a scenario from the National Health Service perspective, which included differences in onabotulinumtoxinA use, specialist visits and day-hospital visits; (ii) a scenario that only included differences in onabotulinumtoxinA use and specialist visits; and (iii) a scenario from a societal perspective that included differences in onabotulinumtoxinA use, specialist visits and caregiver burden. RESULTS: In the first scenario, the model predicted that UC plus onabotulinumtoxinA produced 0.107 QALYs at an additional cost of £1099 compared with UC alone over 5 years, resulting in an incremental cost-effectiveness ratio (ICER) of £10,271/QALY. In the second scenario, the ICER increased to £27,134/QALY. In the third scenario (societal perspective), UC plus onabotulinumtoxinA produced lower total cost and higher QALYs, and therefore was superior to UC alone. CONCLUSIONS: Based on a model, UC plus onabotulinumtoxinA improved disability, which translated into greater QALYs but also increased direct medical costs compared with UC alone; however, the resulting ICER can be considered cost-effective. Moreover, UC plus onabotulinumtoxinA can be cost-saving if reduction in caregiver burden was included. OnabotulinumtoxinA offers value for money in the management of ULPSS in Scotland.

Immune responses against islet allografts during tapering of immunosuppression--a pilot study in 5 subjects.

Transplantation of isolated islet of Langerhans cells has great potential as a cure for type 1 diabetes but continuous immune suppressive therapy often causes considerable side effects. Tapering of immunosuppression in successfully transplanted patients would lower patients' health risk. To identify immune biomarkers that may prove informative in monitoring tapering, we studied the effect of tapering on islet auto- and alloimmune reactivity in a pilot study in five transplant recipients in vitro. Cytokine responses to the graft were measured using Luminex technology. Avidity of alloreactive cytotoxic T Lymphocytes (CTL) was determined by CD8 blockade. The influence of immunosuppression was mimicked by in vitro replenishment of tacrolimus and MPA, the active metabolite of mycophenolate mofetil. Tapering of tacrolimus was generally followed by decreased C-peptide production. T-cell autoreactivity increased in four out of five patients during tapering. Overall alloreactive CTL precursor frequencies did not change, but their avidity to donor mismatches increased significantly after tapering (P = 0·035). In vitro addition of tacrolimus but not MPA strongly inhibited CTL alloreactivity during tapering and led to a significant shift to anti-inflammatory graft-specific cytokine production. Tapering of immunosuppression is characterized by diverse immune profiles that appear to relate inversely to plasma C-peptide levels. Highly avid allospecific CTLs that are known to associate with rejection increased during tapering, but could be countered by restoring immune suppression in vitro. Immune monitoring studies may help guiding tapering of immunosuppression after islet cell transplantation, even though we do not have formal prove yet that the observed changes reflect direct effects of immune suppression on immunity.

Planned caesarean in the interventional radiology cath lab to enable immediate uterine artery embolization for the conservative treatment of placenta accreta.

AIM: To evaluate the feasibility and efficacy of routine uterine artery embolization (UAE) immediately after planned caesareans performed in the cath lab for conservative treatment of placenta accreta. MATERIALS AND METHODS: A retrospective study included all patients who had a planned caesarean in the cath lab for conservative treatment of placenta accreta at Angers University Hospital, which is a tertiary care centre, from April 2001 to September 2010. Twelve patients underwent UAE immediately after caesarean with the placenta left partially or totally in situ. The success rate of embolization, blood loss, and complications were reported. RESULTS: Diagnosis of abnormal placentation was confirmed by caesarean findings in 14 cases. Four patients had a percreta form with bladder invasion. In seven cases blood loss was insignificant and UAE was prophylactic; no secondary haemorrhage was observed in this group. Postpartum haemorrhage occurred in five cases: control of immediate postpartum bleeding by embolization was successful in three and failed in two leading to hysterectomy. In one case uterine necrosis occurred 6 weeks after embolization, requiring a hysterectomy. Delayed complications resulted in hysterectomy and partial bladder resection 3 months after delivery for one of the patients with placenta percreta. CONCLUSION: UAE immediately after a caesarean performed in the cath lab is a feasible therapeutic option for conservative treatment of placenta accreta. Advantages include reducing stress and risks associated with transferring women with potentially unstable haemodynamics.

[Screening and healthcare for pregnant women with psycho-social vulnerability : A French national study]. / Dépistage et parcours de soins en cas de vulnérabilités psycho-sociales maternelles : une enquête nationale française.

INTRODUCTION: Psycho-social vulnerabilities are a medical risk factor for both fetus and mother. Association between socioeconomic status and prenatal follow-up has been well established and inadequate follow-up is associated with higher morbidity and mortality in women in unfavorable situations. OBJECTIVE: The objective is to identify screening strategies and to describe existing systems for pregnant women in psycho-social vulnerability in French maternity hospitals. MATERIAL AND METHODES: This is a national survey conducted by questionnaire in all French maternities. RESULTS: Screening by means of targeted questions is carried out by 96.7% of maternity units. Early prenatal interviews are offered systematically by 64% of maternity units and access to them is still difficult for women in vulnerable situations. In order to organize care pathways, 28.7% of maternities have a structured unit within their establishment and 81% state that they have mobilizable caregivers. Multidisciplinary meetings for the coordination of the various stakeholders are held by 85.8% of maternity units. Collaboration with networks and associations is emphasized. CONCLUSION: A large proportion of maternities seek to identify women in situation of psycho-social vulnerabilities and to organize care paths. However, the resources implemented still appear insufficient for many maternity units. Each maternity hospital has resources and is developing initiatives to deal with the difficulties of care.

[Reconstructive surgery of the clitoris after sexual mutilation]. / Chirurgie plastique reconstructrice du clitoris après mutilations sexuelles.

Ritual sexual mutilations cause gynaecologic, urologic and obstetric complications. Their surgical treatments like clitoris reconstruction or desinfibulation have been well studied. We describe the Dr Pierre Foldes's (2004, 2006a, b) surgical technique of clitoris reconstruction after ritual excision. After scar resection, clitoris knee and corporeal bodies are liberated with meticulous nerve sparing. A new clitoridian glans is created by cuneiform plasty and then reimplanted in an anatomic situation. The aim of the technique is to restore a normal anatomy and to obtain a sensory and functional organ. We also describe the desinfibulation technique in this article.

[Prolonged and post-term pregnancies: a regional survey of French clinical practices]. / Évaluation des pratiques professionnelles pour le suivi des grossesses prolongées dans un réseau de périnatalité.

OBJECTIVE: To assess professional practices of prolonged and post-term pregnancies in accordance to French guidelines. The secondary outcome was to evaluate neonatal and maternal morbidity during prolonged pregnancy. METHODS: Descriptive retrospective study was conducted in the 23 maternity hospitals of perinatal network between September and December 2018. The inclusion criterion was a birth term of≥41+0 weeks of gestation. Primary outcome was conformity to the national guidelines based on 10 items (conformity score≥80%). The secondary outcome was a composite criteria of neonatal morbidity (ventilation, resuscitation and/or Apgar score<7 at 5minutes) and maternal morbidity (obstetrical anal sphincter injury and/or postpartum hemorrhage). RESULTS: A total of 596 patients were included and the conformity was obtained in 65.3% of cases. Inconsistent criteria were amniotic fluid evaluation by the deepest vertical pocket (46.8%, n=279), and information of patients on prolonged pregnancy management (14.8%, n=88). Adverse perinatal outcome occurred for 40 newborns (6.0%) with shoulder dystocia (OR=5.2; CI 95%: 1.4-19.7) as a principal risk factor. Maternal morbidity outcome occurred in 70 cases (10.6%) primarily with increase in labour duration (OR=1.1 by hour of labour; CI 95%: 1.02-1.24) and prior caesarian section (OR=4.4; CI 95%: 1.8-11.0). CONCLUSIONS: Management of prolonged and post-term pregnancies matching with the French national guidelines. Points of improvement are amniotic fluid evaluation at term by a single deepest vertical pocket, and the information about induction of labour at term.

Beta-cell transplantation in type 1 diabetic patients: a work in progress to cure.

Type 1 diabetes is characterized by a selective destruction of the insulin producing beta-cells leading to frank hyperglycemia. Daily insulin injections are lifesaving but can often not avoid suboptimal glycemic control, an increased risk for hypoglycemia and the development of chronic diabetic complications. Therapies replacing the destroyed beta-cells aim to prevent or delay these detrimental complications while avoiding hypoglycemic episodes. The main objective of our multicenter study was to define conditions under which a beta-cell implant safely induces and maintains long-term metabolic control in type 1 diabetic recipients. We demonstrated that cultured beta-cell preparations, fully morphologically characterized by their cell number and cellular composition, and functionally correlated with beta-cell mass can be used to prepare grafts with reproducible clinical metabolic outcome. At least 2 million beta-cells per kg bodyweight were needed to achieve signs of functioning grafts, reduced glycemic variability and a reduced risk for hypoglycemic events. We demonstrated that the hyperglycemic clamp can be used to measure the in vivo functional beta-cell mass after transplantation. In insulin independent recipients of a beta-cell and pancreas-kidney graft, the functional beta-cell mass represents respectively 25 and 63% of that in healthy controls. We showed that ATG-sirolimus monotherapy resulted in a worse outcome of beta-cell transplantation compared to ATG-sirolimus-tacrolimus combination therapy. Moreover, use of sirolimus was accompanied with unacceptable side effects. In conclusion, we showed that characterizing the beta-cell graft in vitro, measuring the functional beta-cell mass in vivo and defining a save and efficient immunosuppressive regimen are important steps to a cure for diabetes.

Allograft-specific cytokine profiles associate with clinical outcome after islet cell transplantation.

Islet cell transplantation can cure type 1 diabetes, but allograft rejection and recurrent autoimmunity may contribute to decreasing insulin independence over time. In this study we report the association of allograft-specific proliferative and cytokine profiles with clinical outcome. Peripheral blood mononuclear cells were obtained of 20 islet recipients. Cytokine values in mixed lymphocyte cultures (MLC) were determined using stimulator cells with graft-specific HLA class II. Qualitative and quantitative cytokine profiles were determined before and after islet transplantation, blinded from clinical outcome. Cytotoxic T Lymphocyte precursor (CTLp) assays were performed to determine HLA class I alloreactivity. Allograft-specific cytokine profiles were skewed toward a Th2 or regulatory (Treg) phenotype after transplantation in insulin-independent, but not in insulin-requiring recipients. IFNgamma/IL10 ratio and MLC proliferation decreased after transplantation in insulin-independent recipients (p = 0.006 and p = 0.01, respectively). Production of the Treg cytokine IL10 inversely correlated with proliferation in alloreactive MLC (p = 0.008) and CTLp (p = 0.005). Production of IL10 combined with low-MLC reactivity associated significantly with insulin independence. The significant correlation between allograft-specific cytokine profiles and clinical outcome may reflect the induction of immune regulation in successfully transplanted recipients. Islet donor-specific IL10 production correlates with low alloreactivity and superior islet function.

Relevance of cytotoxic alloreactivity under different immunosuppressive regimens in clinical islet cell transplantation.

Islet or beta cell transplantation provides a promising cure for type 1 diabetes patients, but insulin-independency decreases frequently over time. Immunosuppressive regimens are implemented attempting to cope with both auto- and alloimmunity after transplantation. We analysed the influence of different immunotherapies on autoreactive and alloreactive T cell patterns and transplant outcome. Patients receiving three different immunosuppressive regimens were analysed. All patients received anti-thymocyte globulin induction therapy. Twenty-one patients received tacrolimus-mycophenolate mofetil maintenance immunosuppression, whereas the other patients received tacrolimus-sirolimus (SIR, n = 5) or SIR only (n = 5). Cellular autoreactivity and alloreactivity (CTL precursor frequency) were measured ex vivo. Clinical outcome in the first 6 months after transplantation was correlated with immunological parameters. C-peptide levels were significantly different between the three groups studied (P = 0.01). We confirm that C-peptide production was correlated negatively with pretransplant cellular autoreactivity and low graft size (P = 0.001, P = 0.007 respectively). Combining all three therapies, cellular autoimmunity after transplantation was not associated with delayed insulin-independence or C-peptide production. In combined tacrolimus-SIR and SIR-treated patients, CTL alloreactivity was associated with less insulin independence and C-peptide production (P = 0.03). The percentage of donors to whom high CTLp frequencies were measured was lower in insulin-independent recipients (P = 0.03). In this cohort of islet cell graft recipients, clinical outcome in the first 6 months after transplantation correlates with the applied immunosuppressive regimen. An association exists between insulin-independence and lower incidence of CTL alloreactivity towards donor human leucocyte antigen. This observational study demonstrates the usefulness of monitoring T cell reactivity against islet allografts to correlate immune function with graft survival.

Further validation of a pruritus severity scale for use in dogs.

A scale to assess the severity of pruritus in dogs was further validated. Comparison of the scale with one containing visible numerical markings demonstrated that owners were heavily influenced by the presence of numbers, resulting in a loss of the scale's ability to generate continuous data. The presence of a traditional visual analogue scale was therefore essential. The scale was tested on 713 owners who presented their dogs for veterinary attention. Pruritus scores in 408 dogs with skin disease covered the full range of possible values (0 to 10). In 305 dogs with no skin disease, 90 owners gave a score greater than zero. Comparison of the scores seen in pruritic dogs, and dogs with no evidence of skin disease, allowed a 'normal range' of 0-1.9 to be established. The scale was able to discriminate between conditions typically regarded as pruritic or non-pruritic. When the scale was assessed for its ability to detect changes in pruritus score following treatment, a median reduction of 4.4 points was observed. The scale was also used to determine what magnitude of response owners would expect following treatment of their pruritic dogs. Only 12% would have been satisfied with a 50% reduction, a figure that is typically quoted as a satisfactory response in clinical trials of anti-pruritic drugs. As a result, alternative methods of assessing clinical trials are proposed. This study has shown the scale to be a valuable tool for clinical assessment of patients, and for monitoring treatment responses in clinical trials.

Pilot study of the effect of individualised homeopathy on the pruritus associated with atopic dermatitis in dogs.

Twenty dogs with confirmed atopic dermatitis were treated with homeopathy. In the first phase of this pilot study, all of the dogs were treated by a veterinary homeopath with individualised remedies prescribed on the basis of the dog's cutaneous signs and constitutional characteristics. The response to treatment was assessed by scoring the severity of pruritus from 0 to 10 on a validated scale. The dogs were evaluated at monthly intervals for at least two months. In 15 cases, the owners reported no improvement following homeopathic treatment. In the other five cases, the owners believed that the homeopathic treatment was associated with a substantial improvement, and reported reductions in pruritus scores ranging from 64 to 100 per cent. These five dogs were selected for the second phase of the study, in which homeopathic remedies were tested against placebos in a randomised and blinded trial. In one of these dogs, atopic dermatitis resolved completely and so this dog could not participate in phase 2; another dog was euthanased because of status epilepticus before phase 2 could be started. In the remaining three cases, the owners correctly distinguished between the placebo and homeopathic remedies, and reported reductions in the pruritus score of 0, 0.2 and 0.8 following placebo treatment and 4.3, 2.4 and 3.0, respectively, following the remedy.

[Delivery of twins]. / Mode d'accouchement des grossesses gémellaires.

The assessment of optimal delivery for twin gestations is complex due to the relatively high frequency of obstetrical complications and to the heterogeneity of delivery management in these conditions. The extern validity of the Anglo-Saxon studies is limited in particular because delivery management of the second twin (approach of external cephalic version) differs from the French one (approach of internal version and/or total breech extraction) in cases of non-vertex second twin. Anglo-Saxon studies suggest that a planned vaginal delivery is associated to an increased risk of neonatal morbidity for second twin compared to first twin at term, in particular in cases of combined vaginal-cesarean birth. To reduce the interval twin-to-twin delivery interval and the number of combined vaginal-cesarean births, in our opinion, one must stop to perform external cephalic version and recommend a routinely active management for the second non-vertex twin delivery. With this active management, there is no evidence to support planned cesarean section for twins. Nevertheless, active management requires training as internal version might be difficult to perform, and therefore it is essential to pursue to teach junior obstetrician these obstetric maneuvers. There is limited role for trial of labor after cesarean delivery in twin gestation with a policy of active management.

Etanercept in therapy multiresistant overlapping pityriasis lichenoides.

INTRODUCTION: Pityriasis lichenoides (PL) exhibits a protean clinical presentation, particularly in its overlapping form (OPL) combining aspects of the acute and chronic types. Some patients are drug multiresistant and pose a therapeutic dilemma. The anti-tumor necrosis factor (TNF)-alpha agent etanercept, was recently introduced as an alternative treatment for psoriasis, rheumatoid arthritis, and psoriatic arthritis. CASE REPORT: A 65-year-old woman suffered from an overlapping form of pityriasis lichenoides (OPL) for 5 years. Several initial acute episodes were controlled by successive courses of oral antibiotics, topical corticosteroids, and/or psoralen ultraviolet light-A (PUVA) therapy. The disease progressively evolved to a more chronic form. Topical immune response modifiers and corticosteroids, as well as PUVA, ultraviolet light-B (UVB), methotrexate, dapsone, and cyclosporine were introduced, but all proved ineffective. Due to the therapy multiresistance, 2 weekly injections of etanercept were administered. After 2 months, a marked improvement was observed in regards to the patient's pruritus and inflammation. No treatment-related adverse effects were observed. Therapy was continued for 4 months without any new lesion development. However, 1 month after stopping treatment new OPL lesions recurred. CONCLUSION: At the time of publication, this is the first report of the effectiveness of etanercept in OPL. This drug might be considered as a therapeutic alternative for treatment multiresistant OPL.

[Indications and prerequisites for operative vaginal delivery: when, how and where?]. / Indications et prérequis à la réalisation d'une extraction instrumentale : quand, comment et où ?

OBJECTIVE: To determine the indications and prerequisites for operative vaginal delivery. METHODS: Articles were searched using PubMed and Cochrane library. RESULTS: Indications for operative vaginal delivery are non-reassuring fetal status (NP4), no progress from 30minutes of adequate active pushing, maternal exhaustion (NP5), or medical indications to avoid Valsalva (NP5). Operative vaginal delivery (Thierry's spatulas, forceps, and vacuum delivery) before that cervix is fully dilated and fetal head is fully engaged is not recommended (NP4). Obstetricians have to know patient medical record and the fetal head position before performing operative vaginal delivery (NP5). The reliability of transvaginal examination to determine the fetal engagement and intrapartum fetal head position is 88% and 80% respectively (NP2). Transabdominal ultrasound assessment is recommended in cases of doubts about the fetal head position (NP5). Available data are not sufficient to fully contraindicated midpelvic operative delivery. Each case should be considered individually and depending on the skill of the obstetrician (NP5). Obstetricians should be aware that they may wrongly consider the fetus engaged in the midpelvis in 6% of cases, whereas it is not really engaged. Moreover, the presence of factors predictive of failed operative vaginal delivery must contraindicated midpelvic operative vaginal delivery and indicated a cesarean delivery (NP5). In general, midpelvic operative vaginal delivery is not recommended. Routine instrumental delivery in theatre and episiotomy for operative vaginal delivery are not recommended (NP3 and NP4, respectively). CONCLUSIONS: Recommendations for operative vaginal delivery should be respected to minimize both fetal and maternal trauma. Obstetricians should anticipate the complications that may occurred following operative vaginal delivery.