Primary vs patch-based skin closure for in-utero spina bifida repair.

OBJECTIVE: During in-utero spina bifida (SB) repair, closure of large defects is often challenging, requiring tissue graft for watertight skin closure. No prior studies have compared primary skin closure vs patch-based repair. Our objective was to compare neonatal and 1-year outcomes associated with these two types of skin closure for in-utero SB repair. METHODS: This was a prospective cohort study of 102 patients undergoing open prenatal SB repair from September 2011 to August 2021 at a single institution. All patients met the inclusion criteria of the Management of Myelomeningocele Study (MOMS), and the surgical procedure for in-utero SB repair was similar to that described in the MOMS trial. During the surgery, if primary skin approximation was not feasible due to the large size of the defect, the decision was at the discretion of the pediatric neurosurgeon to utilize a patch for closure. Neonatal outcomes at birth and 1-year outcomes were compared between the primary skin and patch-based closure groups. RESULTS: Of 102 patients included in the study, 70 (68.6%) underwent primary skin closure and 32 (31.4%) patch-based closure. The patch type included acellular bovine skin matrix (Durepair®; n = 31) and human acellular dermal matrix (Alloderm®; n = 1). Fetuses with myeloschisis were more likely to require patch-based repair than those with myelomeningocele. The median time of fetal repair was 4 min longer for patch-based compared with primary skin closure (37 vs 33 min; P = 0.001). Following patch-based repair, neonates had a longer length of stay in the neonatal intensive care unit (NICU) by 24 days (adjusted risk ratio, 2.40 (95% CI, 1.41-4.29)) compared to those that underwent primary skin closure. There was no difference between the two groups in the other neonatal outcomes, including the need for ventriculoperitoneal shunt placement and cerebrospinal fluid leakage. Outcome at 1 year of age was available for 90 infants. Need for wound revision within their first year after birth was more common in infants who underwent patch-based vs those with primary skin closure (19.4% vs 5.1%; P = 0.05). There was no difference between the two groups in other 1-year outcomes, including the need for ventriculoperitoneal shunt placement by 1 year of age and surgery for tethered cord. CONCLUSIONS: Patch-based closure during SB repair is often needed in fetuses with myeloschisis and is associated with prolonged fetal surgery time, long NICU stay and need for wound revision within the first year after birth. Further studies are required to identify optimal patches for SB repair or alternative methods to improve outcome. © 2022 International Society of Ultrasound in Obstetrics and Gynecology.

Doppler evaluation of normal and abnormal placenta.

Doppler techniques are needed for the evaluation of the intraplacental circulation and can be of great value in the diagnosis of placental anomalies. Highly sensitive Doppler techniques can differentiate between the maternal (spiral arteries) and fetal (intraplacental branches of the umbilical artery) components of the placental circulation and assist in the evaluation of the placental functional units. A reduced number of placental functional units can be associated with obstetric complications, such as fetal growth restriction. Doppler techniques can also provide information on decidual vessels and blood movement. Abnormal decidual circulation increases the risk of placenta accreta. Doppler evaluation of the placenta greatly contributes to the diagnosis and clinical management of placenta accreta, vasa previa, placental infarcts, placental infarction hematoma, maternal floor infarction, massive perivillous fibrin deposition and placental tumors. However, it has a limited role in the diagnosis and clinical management of placental abruption, placental hematomas, placental mesenchymal dysplasia and mapping of placental anastomoses in monochorionic twin pregnancies. © 2021 International Society of Ultrasound in Obstetrics and Gynecology.

Can middle cerebral artery peak systolic velocity predict polycythemia in monochorionic-diamniotic twins? Evidence from a prospective cohort study.

OBJECTIVE: The antenatal diagnosis of twin anemia-polycythemia sequence (TAPS) in monochorionic-diamniotic (MCDA) twin pregnancies is based on elevated peak systolic velocity in the middle cerebral artery (MCA-PSV) in the donor twin and decreased MCA-PSV in the recipient twin. However, the association between these parameters and polycythemia has not yet been established. The aim of this study was to determine whether MCA-PSV can predict polycythemia in MCDA pregnancies. METHODS: This was a prospective cohort study of MCDA pregnancies recruited at 14-18 weeks' gestation from a single tertiary care center between January 2011 and June 2014. Fetal MCA Doppler waveforms were recorded every 2 weeks from 18 weeks' gestation until delivery. Only those with an MCA-PSV measurement within 1 week of delivery were included in the analysis. Neonatal hematocrit level was determined in all twins from venous blood obtained within 4 h of delivery. Polycythemia was defined as a hematocrit of > 65%, and anemia as a hematocrit of < 45%. TAPS was diagnosed when an intertwin hemoglobin difference of > 8 g/dL and reticulocyte count ratio of > 1.7 were observed. RESULTS: Of 162 MCDA pregnancies followed during the study period, 69 had an MCA-PSV measurement within 1 week of delivery and were included in the study. Twenty-five neonates were diagnosed with polycythemia and nine twin pairs met the criteria for TAPS. In a pooled analysis, MCA-PSV was negatively correlated with neonatal hematocrit (P = 0.017, r = -0.215) and was significantly higher in anemic fetuses than in normal controls (1.15 multiples of the median (MoM) vs 1.02 MoM, respectively; P = 0.001). However, MCA-PSV was similar among polycythemic and normal fetuses (0.95 MoM vs 1.02 MoM, respectively; P = 0.47). Intertwin difference in MCA-PSV (delta MCA-PSV) was positively correlated with intertwin hematocrit difference (P = 0.002, r = 0.394). Moreover, twin pregnancies with an intertwin hematocrit difference of > 24% had a significantly greater delta MCA-PSV than did those with an intertwin hematocrit difference of ≤ 24% (delta MCA-PSV, 19 vs 5 cm/s; P < 0.001). CONCLUSIONS: MCA-PSV is not significantly decreased in polycythemic MCDA twins. However, delta MCA-PSV is associated with a large intertwin difference in hematocrit, and its use may be better than conventional methods for the risk assessment of TAPS. Copyright © 2015 ISUOG. Published by John Wiley & Sons Ltd.

Influence of wheat ash on the MCPA immobilization in agricultural soils.

Burning of crop residues in the fields is a routine post-harvest practice and results in accumulation of ashes in soils. Recent studies have shown that the ashes may significantly contribute to the herbicide sorption in soils. This study was conducted to evaluate the potential role of wheat ash in immobilization of anionic herbicide MCPA in soils. The results showed that wheat ash is highly effective sorbent for herbicide MCPA. Amendment of Fluvi-Gleyic Phaeozem and Eutric Regosol with 1% wheat ash caused a 8-fold and 16-fold increase in MCPA sorption, respectively. Desorption of MCPA was also influenced by wheat ash in soils. The addition of wheat ash to both soils increased the resistant fraction to desorption up to 80%. Generally, the field burning of crop residues appears to increase the sorption of pesticides in agricultural soils and decrease their leaching.

COPD and tobacco smoke.

Chronic obstructive pulmonary disease (COPD) is a chronic inflammation of the airways, including the parenchyma and the pulmonary vasculature. The burden of COPD is increasing around the world in terms of morbidity and mortality in adult population. Active smoking is a major risk factor for COPD, although there is individual susceptibility to the effects of tobacco smoke. This variability could result from host as well as environmental factors. Even passive smoking in early childhood as well as intrauterine exposure could pave the way for COPD. Tobacco smoke induces a specific, persistent inflammation, different from that of asthma. Three other processes accompany and interact with inflammation: imbalance of both the proteases-antiproteases, the oxidants-antioxidants, and improper repair mechanisms. These processes respectively lead to mucus hypersecretion and alveol wall destruction, dysfunction and death of biological molecules, damage to the extracellular matrix and pulmonary fibrosis with adventitial, submucosal and smooth muscle thickening. The earlier the smoke exposure, the greater the level of decline in lung function. Combined mucus hypersecretion, reduced clearance, and impairment of the lung defence mechanisms explain why COPD patients even with stable condition, carry potential respiratory pathogens in significant concentration, paving the way for infection and acute exacerbations of COPD. Every additional exacerbation in a smoker deteriorate more the lung function. Fortunately, smoking cessation, which is a part of the respiratory rehabilitation could reduce the number of hospitalisations and the decline of lung function, and thus reduce the management cost of the disease and improve the quality of life. The earlier the quitting, the better the improvement of FEV1. "Smoking cessation is the single effective and cost effective way to reduce exposure to COPD risk factors" (GOLD, evidence A).

[Smoking in Casablanca hospitals: knowledge, attitudes and practices]. / Tabagisme dans les hôpitaux de Casablanca: connaissances, attitudes et pratiques.

This cross sectional study took place with a self administered questionnaire between June and September 1999 and involved 1,388 subjects of whom 62.4% were men and 37.6% women. The total prevalence of smoking was 14.9%, ranging from 12.5% in paramedical staff to 15.5% in manual workers, 16.2% in doctors, 17.1% in laboratory staff, and 22.2% in administrators. The prevalence was 35.9% among men as against 2.2% among women. The study of smokers showed that 51.5% had started before the age of 21. The most common motive for starting smoking was "pleasure". Among the 45.5% who smoked at the workplace 60.5% felt concerned about it. Evaluation of the degree of nicotine dependence using the Fagerstrom score found high dependence in 21.3% of subjects. Only 24.5% of doctors warned patients against smoking in the absence of smoking related diseases or symptoms. In more than 75% of cases doctors advised against smoking in the workplace and in the home. 66.8% of staff were aware of the anti-smoking law but the legislative measures were poorly understood. Only 9% of those interviewed had taken part in an anti-smoking campaign. In conclusion, the prevalence of smoking in the hospitals of Casablanca has definitely diminished in the past 10 years but it remains relatively high in men. Hospital staff should be more involved in the fight against smoking.

Health effects of tobacco use and exposure.

Tobacco is still widely consumed in a variety of different ways, mainly as smokeless tobacco and cigarette smoking. Four traits characterize tobacco use whatever the way of using it: 1) addiction linked to nicotine is behind all the tobacco hazards; 2) individual variation in tobacco susceptibility; 3) dose-response relationship; 4) time-lag effect. Smokeless tobacco, chewed or snuffed can lead mainly to inflammation of the oral cavity and oral cancers. Cigarette smoking accounts for 65-85% of global tobacco consumption. Active smoking can cause: 1) respiratory disorders culminating in chronic obstructive pulmonary disease (COPD) and emphysema; 2) cardiovascular hazards by way of increased vascular spasm and atherosclerosis leading to acute and chronic myocardial events, cerebral and peripheral vascular diseases; 3) cancers: twelve types are caused or related to cigarette smoking. Lung cancer is still the leading cause of cancer death in most high-income countries where data are available. An excess mortality is associated with smoking, with a 2-fold greater risk in smokers than in nonsmokers throughout middle age. The exposed pregnant woman subjects herself and her pregnancy to risks, and her fetus to growth retardation and perinatal morbidity and mortality. Passive smoking implicates 20-80% of the whole population. It can be nearly as harmful as active smoking depending upon risk factors, and can lead to short as well as to long-term effects. Children are the most vulnerable population particularly during the first years of life. Passive smoking increases risks for higher and lower respiratory tract illness but a smoke-free environment improves all these disorders. Ischemic heart diseases and lung cancer are the main risks for non smoking adults exposed to cigarette smoke. Tobacco use and exposure is the single most important source of preventable morbidity, disability and premature mortality. But giving up smoking helps at any time, the sooner the better. Health professionals should be the key advocates in tobacco prevention.

[Skin sensitization to pollens in Morocco. Multicenter study]. / La sensibilisation cutanée aux pollens au Maroc. Etude multicentrique.

The objective of this study was to determine the prevalence of skin sensitization to certain pollens in some regions of Morocco. This multicentric study involving 10 centres included a consecutive series of 640 patients consulting for the first time between february and april 1998 for asthma and/or rhinitis and/or conjunctivitis. Skin prick tests (SPT) were performed with stallerpointes (Stallergenes) and interpreted according to standard procedures. Pollinosis was ascertained when SPT was positive to one or more pollens. Epi-Info was used to analyze the data. SPT were positive in 75.9% and prevalence of sensitization to pollens was equal to 28% (179 cases). It ranked second after house dust mites (63%), olive, 5 grass, cupressus, parietaria and corylus sensitization were encountered in 19.8%, 10.9%, 3.8%, 1.7% and 1.3% respectively. Prevalence of sensitization to pollens didn't vary significatively according to age: 25.4% in females versus 31.1% in males (p = 0.13). Prevalence of pollen sensitization was 26.6% in case of asthma versus 30.9% in non asthmatics patients (p = 0.30), 30.1% in case of rhinitis versus 16.9% in non rhinitics (p = 0.009), 36.4% in case of conjunctivitis versus 22.7% in case without conjunctivitis (p < 0.0002). According to the regions, prevalence was significatively high in areas like Meknes (56%), Beni-Mellal (48.1%), Marrakech (43.5%) where olive is abundant in comparison with Oujda (30.8%), Agadir (30.8%), Tanger (27.3%), Rabat (21.8%), Safi (21.3%), Casablanca (11.6%) and El Jadida (10%). The prevalence was up to 84.3% when symptoms were predominant in spring versus 16.8% in other seasons (p < 0.0001). Thus, although SPT did not include numerous other pollens, olive pollinosis seems to be prevalent in Morocco, followed by allergy to grass pollen. Such studies need to be carried out in line with pollen count.

[Smoking knowledge, attitudes, and behaviors of patients in Morocco]. / Connaissances, attitudes et comportements de patients vis-à-vis du tabagisme au Maroc.

Smoking is a serious public health problem. In Morocco, the number of smokers varies from 24% to 52% depending on different social categories (school children, university students, public health workers, industrial workers, civil servants). The aim of our descriptive study was to analyze knowledge about smoking and smoking habits in patients hospitalized or followed by two units in the Ibn Rochd Hospital, cardiology and respiratory diseases. A questionnaire was given to a consecutive series of 200 patients between January and March 1997 (100 patients in each unit). Twenty percent of the patients were smokers and 23% were former smokers. The most well known health risks of smoking in the two groups of patients were respiratory and cardiovascular risks (88% and 71% respectively). Smokers and former smokers were more aware of these health risks. 86% of the smokers and former smokers had attempted to stop smoking at least once, mainly for a "health" reasons. 60% of smokers and former smokers decided to never smoke or never take a cigarette again. 66% of the patients said they had not been advised at the hospital about the risk of smoking. Our study provides a basis for further studies. It points out the importance of the smoking phenomena and the minimal role played by health personnel in advising patients. Health care workers should participate in antismoking activities during their consultation activities at the hospital in order to help patients stop smoking and also help implement rigorous antismoking laws in Morocco.

[Smoking among medical students in Casablanca]. / Tabagisme chez les étudiants en médecine de Casablanca.

OBJECTIVES: Smoking is a real public health problem, even in the medical profession. Our work was aimed at determining the prevalence of smoking in medical students in Casablanca and assess their attitude towards this problem. MATERIALS AND METHODS: A questionnaire enquiry was carried out during the 1994-1995 university year. All medical students in Casablanca (2,640) were invited to participate the questionnaire but only 1,321 (50%) responded. RESULTS: Prevalence of occasional or regular smoking was 13%. It increased progressively from first year students (13%) to sixth year students (21.5%) and was significantly higher in male students (25.7% versus 3.2% in females). 53.8% of the smokers were trying to stop. Ex-smokers accounted for 10.3% of the total 76.3% of the smokers hoped they would not be smoking within five years although level was 90% in ex-smokers. 90.9% of the students admitted that smoking is dangerous to health, (76% of the first year students and 94% of the fifth and sixth year students). The respiratory risks of smoking were well understood. 73.6% of students thought that convincing others not to smoke is a responsibility of doctors, but only 31.6% would do this in the absence of disease linked to smoking. CONCLUSIONS: There has been a net fall in the prevalence of smoking since 1982 (34% at that time compared with 13% in 1994) and the dangers of tobacco are better understood. Medical students understand the problem better. Courses about the pathology of tobacco smoking since 1983 have certainly contributed.

[Phantom thoracic opacity]. / Opacité thoracique fantôme.

The etiology of the respiratory distress syndrome is dominated by pulmonary edema and the septic shock. We report a rare etiology of a respiratory distress secondary to a rupture of a well treated tuberculous latero-tracheal adenopathy. A 24-year-old woman was treated a year ago for a peripheral and mediastinal lymph node tuberculosis confirmed by the biopsy of a left supra clavicular adenopathy, by two months of isoniazid-rifampicin-pyrazinamide-ethambutol and seven months of isoniazid-rifampicin. The patient completed 9 month treatment with a good clinical and radiology course. Two months after stopping the antibacillary treatment, the patient was admitted to an intensive care unit with a respiratory distress syndrome requiring both intubation and artificial ventilation. The bronchial aspiration brought back plain pus. The telethorax from admission was normal and the retrospective history suggested the diagnostic of a ganglio-bronchial fistula which was confirmed by bronchial fibroscopy demonstrating right latero-tracheal fistula. The course was good with recovery of consciousness on the seventh day. Direct bacilloscopies and culture were negative. The digestive fibroscopy was normal. Finally, fistulization of a tuberculous adenopathy must be considered among the etiologies of respiratory distress even in a patient appropriately treated for mediastinal lymph node tuberculosis.

[Aneurysms of the pulmonary artery in Behçet disease. Apropos of 5 new cases]. / Anévrysmes e l'artére pulmonaire au cours de la maladie de Behçet. A propos de 5 nouvelles observations.

Behçet's disease is a systemic vascularitis generally involving the venous system. Many organs may be involved, but pulmonary localizations are uncommon. We report 5 cases of pulmonary artery aneurysms observed in a series of Behçet's disease collected over a 10-year period. All patients were males, age range 18-41 years. Hempotysia was the inaugural event in all cases. Behçet's disease was recognized in only 2 of the patients initially. The diagnosis was made after recognition of the pulmonary artery aneurysms in the others. Chest x-ray showed round perihilar opacities varying in number from 2 to 4. Computed tomography with vascular opacification was performed in 4 patients and confirmed the aneurysmal nature of the opacities. Angiography was performed in 3 cases. Medical treatment with corticosteroids and/or colchicine was prescribed in all cases. One patient had left inferior lobectomy. In one case regression of the aneurysms precluded embolization. Two patients refused surgery and in one, surgery was not retained due to the large number of aneurysms. Outcome was fatal in one patient who died after cataclysmic hemoptysia. These findings underline the uncommon nature of pulmonary aneurysms in Behçet's disease and the diagnostic difficulties encountered in absence of specific signs as well as the poor prognosis of such localizations.

[Pneumocystis infection in a non-immunocompromised patient]. / Pneumocystose chez un patient non immunodéprimé.

Pneumocystis is typically described in the immunodepressed. We report a case of pneumocystis occurring in a patient without known depression of the immune system. The patient, aged 50, was hospitalised for a diffused infiltration pneumonia which developed sub-acutely, and presented with increasing dyspnoea of effort, thoracic pain and a disturbances of general health. The initial assessment did not reveal any risk factors for HIV infection nor any past history of note. The diagnosis of pneumocystis was confirmed by the presence of Pneumocystis carinii in the bronchoalveolar lavage from two samples. There was a favourable outcome following the prescription of Cotrimoxazole for three months and steroid therapy. HIV serology was negative and the sub-population of lymphocytes was normal. A search for neoplasia or systematic disease remained negative.

House dust mite allergen content in two areas with large differences in relative humidity.

BACKGROUND: Striking differences in mite counts and mite-allergen levels have been documented between dwellings located at sea level and high altitude. Apart from relative humidity (RH), several other factors, ie, temperature, UV exposure, and altitude per se could account for this difference. OBJECTIVE: To evaluate whether RH by itself could influence mite infestation by comparing mite-allergens levels in two towns differing only with respect to RH. METHODS: We compared group I allergen content in two Moroccan towns: Casablanca, located on the seashore and Marrakech located at 1404 feet. Mean (+/- SD) RH in years 1990 and 1991 was 81.2 +/- 2.9% in Casablanca and 56.0 +/- 7.6% in Marrakech. Mean annual temperatures were 17.7 +/- 4.0 degrees C and 20.2 +/- 6.4 degrees C in Casablanca and Marrakech, respectively. In each town, 20 asymptomatic subjects agreed to participate in the study. Their mattresses were vacuum-cleaned for a standardized duration (2 min/m2). Mite allergen-content was evaluated using monoclonal antibodies and ELISA and results expressed as micrograms of group I (Der pI+Der f I) allergens per gram of dust (micrograms/g dust). RESULTS: Mean (+/- SD) group I allergen level was 8.3 +/- 8.8 micrograms/g in Casablanca and 0.6 +/- 0.6 micrograms/g dust in Marrakech, a difference that is highly significant (P = .001). In both areas, mean Der f I allergen level was low (0.7 +/- 0.5 and < 0.1 micrograms/g dust, in Casablanca and Marrakech, respectively). CONCLUSION: This study shows that house dust mite allergen content in households depends on RH rather than on temperature.