The role of perinatal palliative care following prenatal diagnosis of major, incurable fetal anomalies: a multicentre prospective cohort study.

OBJECTIVE: To describe prenatal decision-making processes and birth plans in pregnancies amenable to planning perinatal palliative care. DESIGN: Multicentre prospective observational study. SETTING: Nine Multidisciplinary Centres for Prenatal Diagnosis of the Paris-Ile-de-France region. POPULATION: All cases of major and incurable fetal anomaly eligible for TOP where limitation of life-sustaining treatments for the neonate was discussed in the prenatal period between 2015 and 2016. METHODS: Cases of congenital defects amenable to perinatal palliative care were prospectively included in each centre. Prenatal diagnosis, decision-making process, type of birth plan, birth characteristics, pregnancy and neonatal outcome were collected prospectively and anonymously. MAIN OUTCOME MEASURE: Final decision reached following discussions in the antenatal period. RESULTS: We identified 736 continuing pregnancies with a diagnosis of a severe fetal condition eligible for TOP. Perinatal palliative care was considered in 102/736 (13.9%) pregnancies (106 infants); discussions were multidisciplinary in 99/106 (93.4%) cases. Prenatal birth plans involved life-sustaining treatment limitation and comfort care in 73/736 (9.9%) of the pregnancies. The main reason for planning palliative care at birth was short-term inevitable death in 39 cases (53.4%). In all, 76/106 (71.7%) infants were born alive, and 18/106 (17%) infants were alive at last follow-up, including four with a perinatal palliative care birth plan. CONCLUSIONS: Only a small proportion of severe and incurable fetal disorders were potentially amenable to limitation of life-sustaining interventions. Perinatal palliative care may not be considered a universal alternative to termination of pregnancy. TWEETABLE ABSTRACT: Perinatal palliative care is planned in 10% of continuing pregnancies with a major and incurable fetal condition eligible for TOP.

[A suspected case of in utero transmission of influenza A (H1N1) 2009]. / Un possible cas de transmission in utero du virus de la grippe A (H1N1).

A 34-year-old woman consulted the day before a scheduled caesarean for dry cough. A positive rhinopharyngeal sample for PCR testing for influenza A H1N1 led to a curative oseltamivir (Tamiflu®) treatment. At delivery a direct contact between the newborn and mother lasted only few seconds. The first healthy baby boy developped dry cough with a rhinopharyngeal sample positive for A H1N1. The minimal contact between mother and child and the positive neonatal sample only four hours after birth allow to think that it is a rare case of prenatal transmission of influenza A H1N1 to the fetus.

Encuesta iberoamericana sobre delirium en pacientes críticos / Latin American survey on delirium in critical patients

Objetivos El objetivo del presente estudio es establecer los conceptos y prácticas de los intensivistas en el diagnóstico, manejo y prevención del delirium en Unidades de Cuidado Intensivo (UCI). Diseño Se distribuyó una encuesta entre las sociedades miembro de la FEPIMCTI, para que la distribuyeran entre sus socios médicos. Resultados Un total de 854 intensivistas de 12 países respondieron la encuesta. La mayor parte de Argentina, México, Chile y Colombia. Hubo mayoría de UCI académicas (70,5%). El 56,55% respondió que evaluaba el diagnóstico de delirium siempre y solo el 10,2% respondió que nunca. El 69,5% hacia una evaluación clínica general y solo el 19,6% empleaba la escala CAM-ICU y el 9% usaba la lista de chequeo de evaluación de delirio. El 88,3% estuvo de acuerdo o totalmente de acuerdo en que el delirium era un evento esperado en UCI. El 90,1% estuvo de acuerdo que el delirium es subdiagnosticado en UCI. El 97% respondió que es un problema prevenible que requiere intervención. El 74,5% opinó que se seda en forma excesiva en UCI y 70,5% consideró que los opioides se asocian con la aparición del delirium, mientras que el 87,1% que algunos sedantes favorecen su desarrollo. Resultados El 70,2% consideró que es un factor de riesgo para NAV y que dificulta la extubación el 87,8% de los consultados. Conclusiones A pesar de considerar al delirium como un problema frecuente, prevenible y con graves repercusiones para el paciente crítico, los intensivistas encuestados no emplean una herramienta para su evaluación en UCI. Son necesarios esfuerzos educacionales para difundir la eficacia y la utilidad de las escalas que permiten el diagnóstico precoz y preciso del delirium en UCI (AU)

Objectives This study has aimed to establish the intensivist physician's concepts and practices in this region regarding the diagnosis, management and prevention of delirium in intensive care units (ICU). Design A survey was distributed among the FEPIMCTI member societies for distribution among its medical members. Results Eight hundred fifty-four intensive care physicians from 12 Latin America countries, most of them from Argentina, Mexico, Chile and Colombia, responded to the survey. There was a majority of academic ICUs (70.5%). A total of 56.55% responded that they always evaluated the diagnosis of delirium and only 10.2% answered never. A general clinical assessment was made by 69.5%, only 19.6% used the CAM-ICU scale and 9% the checklist assessment of delirium. It was agreed or strongly agreed by 88.3% that delirium was an expected event in the ICU and by 90.1% that delirium was underdiagnosed in ICU. A total of 97% responded that it was a problem that requires intervention and which is preventable (66.5%). It was considered that excessive sedation is given in the ICU by 74.5% and 70.5% believed that opiates are associated with the onset of delirium, while 87.1% considered that some sedatives are associated with its development. Results Ventilator-associated pneumonia (VAP) was considered as a risk factor by 70.2% of the respondents and 87.8% considered that it made extubation difficult. Conclusions Although delirium is considered to be a common and preventable problem with serious implications for critically ill patients, the intensivist physicians surveyed do not use a tool for its evaluation in the ICU. Educational efforts are needed to disseminate the effectiveness and usefulness of the scales that allow for early and accurate diagnosis of delirium in the ICU (AU)

[Latin American survey on delirium in critical patients]. / Encuesta iberoamericana sobre delirium en pacientes críticos.

OBJECTIVES: This study has aimed to establish the intensivist physician's concepts and practices in this region regarding the diagnosis, management and prevention of delirium in intensive care units (ICU). DESIGN: A survey was distributed among the FEPIMCTI member societies for distribution among its medical members. RESULTS: Eight hundred fifty-four intensive care physicians from 12 Latin America countries, most of them from Argentina, Mexico, Chile and Colombia, responded to the survey. There was a majority of academic ICUs (70.5%). A total of 56.55% responded that they always evaluated the diagnosis of delirium and only 10.2% answered never. A general clinical assessment was made by 69.5%, only 19.6% used the CAM-ICU scale and 9% the checklist assessment of delirium. It was agreed or strongly agreed by 88.3% that delirium was an expected event in the ICU and by 90.1% that delirium was underdiagnosed in ICU. A total of 97% responded that it was a problem that requires intervention and which is preventable (66.5%). It was considered that excessive sedation is given in the ICU by 74.5% and 70.5% believed that opiates are associated with the onset of delirium, while 87.1% considered that some sedatives are associated with its development. Ventilator-associated pneumonia (VAP) was considered as a risk factor by 70.2% of the respondents and 87.8% considered that it made extubation difficult. CONCLUSIONS: Although delirium is considered to be a common and preventable problem with serious implications for critically ill patients, the intensivist physicians surveyed do not use a tool for its evaluation in the ICU. Educational efforts are needed to disseminate the effectiveness and usefulness of the scales that allow for early and accurate diagnosis of delirium in the ICU.

Delayed onset of severe neonatal toxoplasmosis.

We report a case of severe neonatal infection on day 6 of life due to Toxoplasma gondii mimicking septic shock syndrome associated with multiple organ failure such as acute respiratory distress syndrome with persistent pulmonary hypertension, neurological distress, thrombocytopenia with disseminated intravascular coagulopathy and transaminitis. Clinicians facing an unexplained life-threatening condition in the first week of life should take into consideration the possibility of neonatal toxoplasmosis.

[Retrospective diagnosis of congenital CMV infection in DBS from Guthrie cards: French experience]. / Le diagnostic rétrospectif de l'infection congénitale à cytomégalovirus sur le sang séché des cartes de Guthrie: l'expérience en France.

Systematic screening for cytomegalovirus congenital infection is not performed in France. For children with hearing loss or other neurological CMV compatible symptoms, retrospective diagnosis is possible by PCR detection of CMV DNA in dried blood spot of neonatal Guthrie cards. We report here the results obtained with this technique in the French national reference laboratory for cytomegalovirus.

Molecular cytogenetic characterization of a 4p15.1-pter duplication and a 4q35.1-qter deletion in a recombinant of chromosome 4 pericentric inversion.

To date, 10 cases of recombinant of chromosome 4 pericentric inversion involving sub-bands p14p15 and q35 have been described. We report on the first case analyzed using array-CGH in a female infant presenting psychomotor and growth retardation, facial anomalies, axial hypotonia, short neck, wide spaced nipples and cardiac defects. Conventional karyotype associated to FISH revealed a recombinant chromosome 4 with partial 4p duplication and 4q deletion derived from a paternal pericentric inversion. Array-CGH allowed us to precise rec4 breakpoints: the proposita carried a small 4.82-4.97 Mb 4q35.1 terminal deletion and a large 35.3-36.7 Mb 4p15.1 terminal duplication. Duplications of the distal 2/3 of short arm of chromosome 4 give rise to recognizable craniofacial features but no specific visceral malformation. A contrario small terminal 4q deletions are associated with cardiac defects. This case and review of literature suggest that two genes ArgBP2 and PDLIM3, located at 4q35.1 and both involved in cardiac and muscle development, could be responsible for cardiac defects observed in terminal 4q35.1 deletions.

[Factors associated to breastfeeding up to 6 months in the maternity of Antoine-Béclère Hospital, Clamart]. / Facteurs associés à l'allaitement maternel du nourrisson jusqu'à 6 mois à la maternité de l'hôpital Antoine-Béclère, Clamart.

OBJECTIVES: In order to improve the frequency and duration of breastfeeding, various public health initiatives have been established at local and national levels in France. In 2002, we conducted a study in the maternity center of the Antoine Beclere Hospital with the aim to describe breastfeeding practices and to identify factors associated with its duration. METHODS: This prospective study was conducted among newborns of immediate postpartum women admitted to the maternity center of the Antoine Beclere Hospital (Clamart, France). Extremely premature newborns were excluded (<31 weeks of amenorrhea). Mothers were interviewed at delivery, at one month and 6 months postpartum. Data were collected on maternal medical history, pregnancy and delivery, the newborn's health status, feeding practices, and the reasons for their choice in feeding practices. RESULTS: Between January 7 and April 7, 2002, 562 newborns were included in the study. At birth, 73% were breastfed, whereas 68% were breastfed at discharge from the maternity center. Among the latter, 89% of infants were still being breastfed at one month, and 37% at 6 months of age. Factors associated with breastfeeding at one month were as follows: a secondary level of education (OR(a): 2.4 [1.0-5.7] compared to primary level), multiparity (OR(a): 3.0 [1.2-8.0] compared to primiparity), full-term birth (OR(a): 6.6 [2.4-18.4] compared to premature birth), treatment during pregnancy (OR(a): 0.2 [0.04-0.6]), and medical history (OR(a): 0.4 [0.2-1.0]). Among women who were breastfeeding at one month, the continuation of breastfeeding at 6 months was associated with a secondary education level (OR(a): 2.2 [1.0-5.0]), the choice of feeding practice during pregnancy (OR(a): 2.5 [1.1-5.0] compared to those who did not choose), and to medically assisted reproduction (OR(a): 5.0 [1.2-14.3] compared to spontaneous procreation). DISCUSSION: The prevalence of breastfeeding observed in this study is higher than it was observed at the national level. Factors associated with continuation of breastfeeding at 6 months allow identifying women who should be encouraged to breastfeed by the maternity team involved during pregnancy. Interventions should therefore involve maternity healthcare professionals as a first step in breastfeeding promotion.

Evaluación del test de estimulación con TRH (Hormona liberadora de Tirotropina) para el estudio de disfunción tiroidea / Evaluation of TRH (thyrotropin-releasing hormone) stimulation test for diagnosis of thyroideal disfunction

El test TRH es una prueba de estimulación hormonal útilpara el diagnóstico diferencial de patología tiroidea. Presentamosuna evaluación de sus resultados en 163 casos.Hemos comprobado una relación casi perfecta entre el valormáximo de TSH alcanzado y el valor basal, definida por la ecuaciónTSH máxima = 5.9 x TSH basal. Esto supone que la respuesta alestímulo expresada como TSH máxima es muy predecible, inclusoen pacientes con concentraciones muy bajas de TSH. La relaciónTSH máxima/TSH basal (ratio máxima) es más independiente de losniveles basales de TSH, aunque presenta una relación inversa debílque se podría relacionar con un agotamineto de respuesta hipófisario.Respecto al diagnóstico, la ratio y no la TSH máxima presentadiferencias entre las patologías contempladas, observandose quelos pacientes con tumoración hipofisaria presentan ratios disminuidascompatibles con una situación de hipotiroidismo central.En nuestra experiencia, el test TRH supone molestias levespara el paciente y su realización puede ser de utilidad enpacientes con estudio funcional compatible con disfunción deorigen central. Consideramos patológica una ratio máxima TSHmáxima/TSH basal inferior a 3,5 o superior a 12

TRH stimulation test is a useful diagnostic tool in thyroiddisease. Results of 163 TRH test were evaluated here.We find a almost perfect relation between the maximun TSHvalue reached along the test and the basal TSH value. (TSMmax. = 5.9 x TSH basal). That means the response to TRH stimulation,expressed as maximun TSH, is very predictable, evenin patients with very low basal TSH. Fold responses (estimulated/basal TSH) shows a mild inverse relatión to TSH basallevels, possibly related to hypothalamic exhaustion. Respectdiagnostics, Fold response, but not maximun TSH, shows differencesbetween groups. Patients with hypothalamic tumorspresents disminished fold responses related to central hypothyroidism.In our experience, TRH test yield little discomfort to thepatient, beeing useful as diagnostic test in patients with suspectcentral thyroid disfunction. We find pathological a foldresponse (TSH maximun/TSH basal) lower than 3,5 or higherthan 12

[Air or oxygen for neonatal resuscitation in the delivery room?]. / Air ou oxygène pour le nouveau-né en salle de naissance?

Most of the contemporary guidelines on newborn resuscitation are based on experience but lack scientific evidence. The use of 100% oxygen is one of the more evident. Today, these practices are questioned, particularly for the resuscitation of moderately depressed full term or near term newborns. Results of recent meta-analysis of trials that compared ventilation with air versus pure oxygen at birth suggests current practices should be revisited. On the basis of these data, air can be the initial gas to use for these babies. Large scale trials, including preterm and cause and/or severity of initial asphyxia, must now be undertaken before the publication of new guidelines for these populations. Particularly severely asphyxiated infants might require supplemental oxygen with titration of oxygen delivery and continuous monitoring of oxygen saturation.

[Cardiorespiratory arrest in full term newborn infants: six case reports]. / Malaises graves et morts subites après une naissance normale à terme: à propos de six cas.

Cardiorespiratory arrest occurring within the first two hours of life of a perfectly normal newborn is a very seldom event hitherto unreported. Six infants born after an uneventful pregnancy by normal vaginal delivery, with a normal Apgar score and physical examination, were found with unexpected cardiorespiratory arrest requiring cardiac and respiratory resuscitation early after birth. All were lying in the prone position, their face covered up while facing mother's abdomen, breast or neck. All mothers were primipara. All newborns but one died. Biological and bacteriological samples were normal and early onset neonatal sepsis was ruled out. Autopsy, performed in five infants, was not contributive. We hypothesize that the sudden and unexpected cardiorespiratory arrest occurring in these normal newborns was secondary to acute upper airway obstruction. To prevent this life threatening post-natal asphyxic episode, it is essential to ensure that the face of a newborn lying down upon mother's breast and abdomen is properly and continuously cleared.

Physical alginate hydrogels based on hydrophobic or dual hydrophobic/ionic interactions: bead formation, structure, and stability.

Hydrophobically associating alginate (AA) derivatives were prepared by covalent fixation of dodecyl or octadecyl chains onto the polysaccharide backbone (AA-C12/AA-C18). In semidilute solution, intermolecular hydrophobic interactions result in the formation of physical hydrogels, the physicochemical properties of which can be controlled through polymer concentration, hydrophobic chain content, and nonchaotropic salts such as sodium chloride. The mechanical properties of these hydrogels can then be reinforced by the addition of calcium chloride. The combination of both calcium bridges and intermolecular hydrophobic interactions leads to a decrease in the swelling ratio accompanied by an increase of elastic and viscous moduli. Beads made of hydrophobically modified alginate were obtained by dropping an aqueous solution of alginate derivative into a NaCl/CaCl2 solution. As compared to unmodified alginate beads, modified alginate particles proved to be stable in the presence of nongelling cations or calcium-sequestering agents. However, evidence is presented for a more heterogeneous structure than that of plain calcium alginate hydrogels with, in particular, an increase in the effective gel mesh size, as determined by partition and diffusion coefficient measurements.

[Preventing dehydration with oral rehydration therapy (ORT) in less than 15-day-old newborns: safety, efficiency and limits]. / Soluté de réhydratation orale (SRO) et hydratation entérale du nouveau-né dans les 15 premiers jours de vie: tolérance, efficacité et limites.

OBJECTIVES: We conducted a retrospective evaluation of enteral infusion with a marketed hypoosmolar oral rehydration solution (HORS), as an alternative to intravenous infusion. POPULATION AND METHODS: Premature infants, with difficult venous condition, 30 weeks or more during HORS infusion. Enteral ORS started after well-tolerated milk gastric gavage. Gradual increase of enteral feeding. RESULTS: January 1999 to April 2001, 105 neonates 28 weeks to 36 weeks, birth weight 1050 to 2700g, including 71.5% eutrophic newborns 30 to 34 weeks; 13.3% hypotrophic<10th P. More than 90% had a physiological weight curve: weight loss vs birth<15%, back to birth weight at day 15. No significant pathology during ORS. Failure of ORS for 7/105 children. Relative risk increased 8 fold if term was less than 30 weeks, 7 folds in the event of enteropathy before ORS. In 26.7% of the infants, gastric enteral residuals exceeded 1/3 of intake, vomiting and/or abdominal ballooning lasted less than 48 hours. There were 4 deaths during follow-up (periventricular leucomalacia, myocardial infarctus) and 1 necrotizing enterocolitis. At theoretical birth date, 25% of the neonates were hypotrophic<10th P. At one and 2 years of age, less than 5% were still hypotrophic: relative risk increased 18 fold when birth weight was<5th P. CONCLUSION: HORS is an efficient, well-tolerated, low-cost and less invasive alternative to intravenous infusion. It must be reserved for eutrophic neonates born>30 weeks gestation due to risk of failure and insufficient growth. Validation with a multicentric clinical trial is in progress.

[Orientation after peripartum asphyxia in the maternity ward: which infants should be transferred to pediatric care units?]. / Orientation en salle de naissance après une asphyxie per-partum: quels nouveau-nés garder? quels nouveau-nés transférer?

Per-partum anoxia is a frequent situation facing the pediatrician in the maternity ward. The question is to decide which infants require care in a specialized unit. If transfer is decided, the infant must be referred to an appropriate pediatric unit (intensive care or neonatal unit). Cases of severe anoxia are exceptional. Intermediary situations are however much more frequent and raise difficult evaluation problems due to the lack of any specific test. The pediatrician must rely on a combination of elements from the clinical presentation, the medical history, the clinical course, and laboratory tests. Different elements suggest a prudent approach with referral to a pediatric unit. These elements include: imperfect clinical recovery (5-min Agpar <7), major intensive care at delivery (intubation, ventilation, vasoactive agents), anomalies in the cord blood or first hour blood tests (cord pH<7, base deficit 12, cord or blood lactate 9 mmol/l). Obstetrical circumstances which led to per-partum anoxia must be well identified because those interrupting placental flow (abruptio placenta, uterine rupture) suggest prudence is necessary even if the infant appears to have recovered well. All neonatal disorders (macrosomia, prematurity, infection, respiratory distress) increase the risk of rapid decompensation and may argue for hospitalization. Likewise, if even minimal signs of neurological, respiratory or hemodynamic disorders are present from birth to two hours, surveillance in a specialized unit is required, the level depending on local facilities. Certain situations nevertheless always require referral to a pediatric intensive care unit: use of vasoactive drugs, respiratory distress, abnormal neurological exam, poor recovery (5-min Agpar <4).Finally, it must be remembered that per-partum anoxia is rarely predictable and can occur any at any time of day or night. The pediatrician must also train other delivery room personnel, including the midwives, in intensive care techniques.

[Organization of patient management in level II centers in the Paris area: a prospective survey]. / Organisation de la prise en charge dans les centres de niveau II en région parisienne: enquête prospective.

Perinatal asphyxia is a common emergency for both obstetricians and pediatricians. A prospective study was conducted in 14 maternity hospitals (type II centres) in the Paris suburbs in order to assess pediatric activity and neonatal morbidity associated with supposed perinatal asphyxia in term newborns. Pediatricians were called in at birth very frequently: 1/20 deliveries. Intubation and/or resuscitation procedures were needed in 20% of cases and 20% of infants were referred to a neonatal unit for birth asphyxia or associated pathology. Moderate encephalopathy was observed in 1.5% of all term newborns who needed medical intervention for supposed birth asphyxia.

[Leiomyosarcoma of the small intestine. Review of the literature apropos of 3 cases]. / Le léïomyosarcome du grêle. Revue de la littérature à propos de trois cas.

This study reports three cases of leiomyosarcoma of the small intestine (a rare malignant neoplasm) presenting in our department of general surgery over a period of ten years. Tumors in these three patients were located in the jejunum and clinical features included severe gastrointestinal bleeding, intestinal obstruction and/or abdominal pain. All three patients underwent radical surgery. None received radiotherapy and chemotherapy in addition. One is alive and in complete remission for four years while the other two died, after two and twenty-two months respectively. There follows a discussion, based upon the literature, of epidemiological, histopathological, clinical, diagnostic and treatment aspects. Particular stress is placed upon the difficulty of establishing the diagnosis before surgery, since symptoms are often absent or non-specific and vague until the malignant small bowel tumor has progressed to the point of causing a complication. Surgery continues to play a primary role in the treatment of leiomyosarcoma. Further studies are required to identify prognostic factors and to assess the efficacy of radiotherapy and chemotherapy in this type of malignant neoplasia.

Nitroprusside, its metabolites and red cell function.

The effects on metabolism and red cell function of blood levels of thiocyanate (SCN-) and cyanide (CN-) were studied in 42 patients undergoing surgery under controlled hypotension (CH) induced by sodium nitroprusside (SNP). The mean dosage of SNP administered was 21.38 mg (SD = 12). The durating of perfusion was 121 minutes (SD = 11). All operations were performed under neuroleptanalgesia without complications. No tachyphylaxis was encountered. Under SNP a slight increase of blood SCN- (from 13.9 mg/l +/- 1.1 to 23 mg/l +/- 2.6) was found. Blood levels of CN- are increased mostly in the red cell, the mean value being 0.300 mg/l +/- 0.10 for whole blood after two hours of perfusion. This value decreased when perfusion was stopped. All blood samples were negative for methaemoglobin and cyanmethaemoglobin. Carbonic anhydrase activity was not modified, CN- toxicity levels for this enzyme being 50 times higher than those found during our study. 2,3-DPG levels did not vary. Blood gases, acid-base balance and Davo2 did not change significantly, although a slight increase in blood lactate was measured. As shown by this study, appreciable amounts of CN- are detected in blood during SNP perfusion while SCN- stays at relatively low levels. Fortunately most of the CN- released from SNP moves into the red cell and does not alter its functions at clinical concentrations. The low plasma concentration of CN- is not sufficient to cause important metabolic disturbances. However, dosages of SNP higher than those administered during this study could increase the blood and tissue CN- to toxic levels. A toxicity study shows that, during a relatively short period of time, SNP dosage should not exceed 1.16 mg/kg or a maximum of 10 microgram/kg/min for a period of two hours.