[Factors associated with inadequate folic acid supplementation for the prevention of neural tube defects in eight Parisian maternity units]. / Facteurs associés à un défaut de supplémentation en acide folique pour la prévention des anomalies de fermeture du tube neural dans huit maternités parisiennes.

OBJECTIVES: Despite the guidelines in effect, too few women in France receive folic acid supplementation. The principal objective of this study was to identify the factors associated with the inadequacy of this supplementation in the periconceptional period. The secondary objective was to assess women's knowledge about the prevention of neural tube defects (NTDs). METHODS: This study included 400 women and took place in 8 Parisian maternity. Folic acid supplementation was inadequate when started after the beginning of the pregnancy. RESULTS: Among the women questioned, 68% had inadequate folic acid supplementation. They were significantly younger (ORa= 1,8; 95% IC [1,1-2,8]), didn't had health insurance (ORa=3,9; 95% IC [1,5-10,1]), had not studied after high school (ORa=2,9; 95% IC [1,2-6,9]) and had regular gynecological care less often than the women with adequate supplementation (ORa=3,0; 95% IC [1,6-5,6]). More than half (55.5%) had insufficient knowledge of the benefits of folic acid; the factors related to this lack of knowledge were the absence of regular gynecological care and of health insurance. CONCLUSION: Individual factors associated with a lack of supplementation have been identified. These results provide health professionals and supervisors with useful information for developing strategies adapted to certain subgroups of women for better prevention of AFTN in these populations.

Extremely premature infants: How does death in the delivery room influence mortality rates in two level 3 centers in France?

OBJECTIVES: Mortality rates of very preterm infants may vary considerably between healthcare facilities depending on the neonates' place of inclusion in the cohort study. The objective of this study was to compare the mortality rates of live-born extremely preterm neonates observed in two French tertiary referral hospitals, taking into account the occurrence of neonatal death both in the delivery room and in the neonatal intensive care unit (NICU). METHODS: Retrospective observational study including all pregnancy terminations, stillbirths and live-born infants within a 22- to 26-week 0/6 gestational age range was registered by two French level 3 university centers between 2009 and 2013. The mortality rates were compared between the two centers according to two places of inclusion: either the delivery room or the NICU. RESULTS: A total of 344 infants were born at center A and 160 infants were born at center B. Among the live-born neonates, the rates of neonatal death were similar in center A (54/125, 43.2%) and center B (33/69, 47.8%; P=0.54). However, neonatal death occurred significantly more often in the delivery room at center A (31/54, 57.4%) than at center B (6/33, 18.2%; P<0.001). Finally, the neonatal death rate of live-born very preterm neonates admitted to the NICU was significantly lower in center A (25/94, 26.6%) than in center B (27/63, 42.9%; P=0.03). CONCLUSIONS: This study points out how the inclusion of deaths in the delivery room when comparing neonatal death rates can lead to a substantial bias in benchmarking studies. Center A and center B each endorsed one of the two models of preferential place of neonatal death (delivery room or NICU) detailed in European studies. The reasons behind the two different models and their impact on how parents perceive supporting their neonate need further investigation.

Customized and non-customized live-born birth-weight curves of single and uncomplicated pregnancies from the Burgundy perinatal network. Part I - methodology.

OBJECTIVES: To establish non-customized and customized birth-weight curves of single and uncomplicated pregnancies according to gestational age. MATERIALS AND METHODS: We used data for 64,173 mother-infants pairs from the Burgundy perinatal network database (France) over the period 2005-2013. A validated procedure was used to link mothers with their newborns, and maternal and fetal pathologies likely to affect birth weight were excluded. Multiple regression analysis with covariate selection was used to build a customized growth curve with maternal and fetal parameters. RESULTS: Using this methodology, three different curves were generated: an unadjusted curve for birth weight, named B0, an curve adjusted for fetal gender, named B1 and a curve adjusted for fetal and maternal parameters (fetal gender, maternal height, weight and parity), named B2. CONCLUSION: We present curves showing an original distribution of birth weights for the French population in order to improve the diagnosis of small for gestational age. These curves are not based on the Gardosi in utero growth model but on actual birth weights, thus limiting bias. Nevertheless, the minimum gestational age was 25weeks as there was an insufficient number of live-borns in small gestational ages.

Validity of rotational laxity coupled with anterior translation of the knee: A cadaveric study comparing radiostereometry and the Rotab®.

BACKGROUND: In current practice, anterior cruciate ligament (ACL) tears can be diagnosed using several devices to measure anterior tibial translation and rotational knee laxity, but these measures are never collected together. The Rotab®, which yields simultaneous measurements of anterior tibial translation and passive lower limb rotation under stress, would therefore be advantageous in current practice, but its reliability has never been tested. AIM OF STUDY: To evaluate the accuracy and reliability of the Rotab® compared to the reference system, radiostereometric analysis (RSA). METHODS: This anatomical study was conducted on 14 lower limbs collected from fresh cadavers. Simultaneous measurements of anterior tibial translation and rotation were obtained with both systems, with antero-posterior (AP) forces of 134N and 250N using the Rotab®. Measurements were made on intact ACL and then repeated after ACL section. Variables were analyzed in univariate analysis by ANOVA, and the intraclass correlation coefficient (ICC) between the systems was determined by the Bland and Altman method. RESULTS: The difference between the two methods for evaluating anterior tibial translation was 0.05±0.98mm at 134N and 0.29±1.04mm at 250N. The correlation between the tests was high (r134=r250=0.97, p=0.8). The difference between the two methods for rotational laxity was 0.69±2.7° at 134N and 0.5±0.6° at 250N. The Rotab® showed a significant difference only at 250N for rotational laxity after the ACL tear. CONCLUSION: The Rotab® is a reliable device to measure rotational laxity coupled with anterior translation of the knee.

Prognostic value of metabolic parameters and clinical impact of ¹8F-fluorocholine PET/CT in biochemical recurrent prostate cancer.

PURPOSE: To evaluate the therapeutic impact of (18)F-fluorocholine (FCH) PET/CT in biochemical recurrent prostate cancer (PC) and to investigate the value of quantitative FCH PET/CT parameters in predicting progression-free survival (PFS). METHODS: This retrospective study included 172 consecutive patients with PC who underwent FCH PET/CT for biochemical recurrence. Mean rising PSA was 10.7 ± 35.0 ng/ml. Patients with positive FCH PET were classified into three groups: those with uptake only in the prostatic bed, those with locoregional disease, and those with distant metastases. Referring physicians were asked to indicate the hypothetical therapeutic strategy with and without the FCH PET/CT results. Clinical variables and PET parameters including SUVmax, SUVpeak, SUVmean, total lesion choline kinase activity (TLCKA) and standardized added metabolic activity (SAM) were recorded and a multivariate analysis was performed to determine the factors independently predicting PFS. RESULTS: In 137 of the 172 patients, the FCH PET/CT scan was positive, and of these, 29.9 % (41/137) had prostatic recurrence, 42.3 % (58/137) had pelvic lymph node recurrence with or without prostatic recurrence, and 27.7 % (38/137) had distant metastases. The FCH PET/CT result led to a change in treatment plan in 43.6 % (75/172) of the 172 patients. Treatment was changed in 49.6 % (68/137) of those with a positive FCH PET/CT scan and in 20 % (7/35) of those with a negative FCH PET/CT scan. After a median follow-up of 29.3 months (95 % CI 18.9 - 45.9 months), according to multivariate analysis age <70 years, SAM ≥23 and SUVmean ≥3 were parameters independently predicting PFS. A nomogram constructed using the three parameters showed 49 months of PFS in patients with the best scores (0 or 1) and only 11 months in patients with a poor score (score 3). CONCLUSION: This study indicates that a positive FCH PET result in PC patients with biochemical recurrence predicts a shorter PFS and confirms the major impact of the FCH PET result on the management of biochemical recurrent PC.

Molecular characterization of 39 de novo sSMC: contribution to prognosis and genetic counselling, a prospective study.

Small supernumerary marker chromosomes (sSMCs) are structurally abnormal chromosomes that cannot be characterized by karyotype. In many prenatal cases of de novo sSMC, the outcome of pregnancy is difficult to predict because the euchromatin content is unclear. This study aimed to determine the presence or absence of euchromatin material of 39 de novo prenatally ascertained sSMC by array-comparative genomic hybridization (array-CGH) or single nucleotide polymorphism (SNP) array. Cases were prospectively ascertained from the study of 65,000 prenatal samples [0.060%; 95% confidence interval (CI), 0.042-0.082]. Array-CGH showed that 22 markers were derived from non-acrocentric markers (56.4%) and 7 from acrocentic markers (18%). The 10 additional cases remained unidentified (25.6%), but 7 of 10 could be further identified using fluorescence in situ hybridization; 69% of de novo sSMC contained euchromatin material, 95.4% of which for non-acrocentric markers. Some sSMC containing euchromatin had a normal phenotype (31% for non-acrocentric and 75% for acrocentric markers). Statistical differences between normal and abnormal phenotypes were shown for the size of the euchromatin material (more or less than 1 Mb, p = 0.0006) and number of genes (more or less than 10, p = 0.0009). This study is the largest to date and shows the utility of array-CGH or SNP array in the detection and characterization of de novo sSMC in a prenatal context.

[Correlation between the perineal-to-skull measurement by tranperineal ultrasound, failure of vaginal operative delivery and maternal-fetal morbidity]. / Corrélation entre la mesure de la distance périnée-crâne à l'échographie transpérinéale, les échecs d'extraction instrumentale et la morbidité materno-fœtale.

OBJECTIVES: To assess the influence of the perineal-to-skull measurement by tranperineal ultrasound (TPU) on the outcome of vaginal operative extraction together with maternal and fetal morbidity. MATERIALS AND METHODS: Retrospective, monocentric and descriptive study was done on 272 patients, from 2009 January 1st to 2009 December 31st. It compares the failure rate of instrumental extraction, total caesarean section rate together with the maternal morbidity (type of perineal tears and post-partum hemorrhage rate) and fetal morbidity (5' Apgar score, arterial pH, transfer in neonatal intensive care unit) to the values obtained with TPU. RESULTS: There is a correlation between the perineal-to-skull measurements higher or equal to 50mm at TPU and the instrumental failure rate (<50mm 0.8% vs. ≥50mm 11.9%; P<0.0001), caesarean (0.9% vs. 33.3%; P<0.0001), post-partum haemorrhage (3% vs. 11.9%; P=0.02), et paediatric intervention (16.7% vs. 31%; P=0.03). CONCLUSION: Perineal-to-skull distance measured with TPU higher or equal to 50mm is at risk of instrumental failure and maternal morbidity. Associated with clinical examination and usual obstetrical risk factors, TPU could be useful to the decision between operative vaginal delivery and prophylactic caesarean section.

What do French patients and geneticists think about prenatal and preimplantation diagnoses in Marfan syndrome?

OBJECTIVES: Marfan syndrome (MFS) is an autosomal dominant connective tissue disorder with manifestations mainly involving the skeletal, ocular, and cardiovascular systems. The phenotypic variability observed in MFS makes genetic counselling difficult. Prenatal diagnosis (PND) and preimplantation genetic diagnosis are technically feasible when a causal mutation is identified, but both raise many ethical questions in this condition. Little is known about opinions and practices in such reproductive issues in MFS. The goal of this study was to report on patients' points of view and geneticists' standard practices. METHODS: Two different questionnaires were produced. RESULTS: Fifty geneticists filled in the questionnaire. Twenty-two per cent thought that PND was acceptable, 72% debatable and 6% not acceptable. Preimplantation genetic diagnosis was more often reported acceptable (34% of answers). Results varied according to the physician's experience with the disease. Fifty-four answers were collected for patients' questionnaires. Most of them (74%) were favourable to the development of prenatal testing, and believed that the choice should be given to parents. However, only a minority would opt for prenatal diagnosis for themselves. CONCLUSION: This study showed that the majority of patients were in favour of PND and that opinions among practitioners varied widely, but that overall, practitioners favoured a systematic multidisciplinary evaluation of the couple's request.

Arthroscopic repair of large and massive rotator cuff tears using the side-to-side suture technique. Mid-term clinical and anatomic evaluation.

UNLABELLED: PREAMBLE: Arthroscopic repair is our treatment of choice for massive rotator cuff tears. In order to reduce tension, we perform a side-to-side suture technique. The purpose of our work was to study the outcome of such technique by evaluating functional score and rotator cuff integrity using ultrasound at 2-year follow-up. HYPOTHESIS: The "side-to-side" arthroscopic repair of large and massive rotator cuff tears provides a long-term continuity of rotator cuff mechanism, enhances function and relieves pain with low morbidity. TYPE OF STUDY: Retrospective monocenter study. MATERIAL AND METHODS: We included a continuous series of 50 patients of mean age 66.6 years (46-80), operated on between January 2007 and March 2008 for full-thickness retracted tears of the supraspinatus extending or not to the infraspinatus tendon. Management consisted of arthroscopic subacromial bursectomy, acromioplasty and side-to-side repair of the rotator cuff tendons with secure anchor fixation to the tuberosity. The relative Constant score was used for clinical evaluation preoperatively and at a minimum of 24 months after surgery. The continuity of rotator cuff mechanism was evaluated using ultrasound. RESULTS: The mean relative Constant score improved significantly (p<0.05) from 40% (18-67) preoperatively to 91.7% (40-107) postoperatively. Fifty-six percent of the rotator cuffs from this series demonstrated continuity with a postoperative relative Constant score of 98.4% (74-121) and an increase in the shoulder strength score of 3.6 kg (1-6). Forty-four percent of the rotator cuffs had recurrent tear with an overall relative Constant score of 83.6% (4-126) and we did not observe any improvement in the strength score in this sub-group. Eighty-eight percent of the patients were satisfied or very satisfied with their outcome. DISCUSSION: At a minimum 24-month follow-up, the side-to-side suturing technique reported excellent functional results with a very high satisfaction rate. For these large and massive rotator cuff tears sometimes considered as irreparable, ultrasound confirmed the continuity of the repair in 56% of the cases. Unhealed patients were not disadvantaged since they experienced pain relief and functional improvement. However, in this sub-group of patients, recovery of shoulder strength was poor. LEVEL OF EVIDENCE: Level IV.

[Laparoscopic sentinel lymph node (SLN) dissection for clinically localized prostate carcinoma: results obtained in the first 70 patients]. / Détection laparoscopique des ganglions sentinelles dans le cancer localisé de la prostate: résultats obtenus chez 70 premiers patients.

OBJECTIVES: The lymph node metastasis is an important prognostic factor in prostatic cancer. The aim of this prospective study was to evaluate the relevance of the sentinel lymph node biopsy by laparoscopy in staging locoregional patients with clinically localized PC. PATIENTS AND METHODS: A transrectal ultrasound-guided injection by 0.3 mL/100 MBq (99m)Tc-sulfur rhenium colloid in each prostatic lobe was performed the day before surgery. The detection was realized intraoperatively with a laparoscopic probe (Clerad(®) Gamma Sup) followed by extensive dissection. Counts of SLN were performed in vivo and confirmed ex vivo. The histological analysis was performed by hematoxyline-phloxine-safran staining and followed by immunochemistry if SLN is free. RESULTS: Seventy patients with carcinoma of the prostate at intermediate or high risk of lymph node metastases were included. The intraoperative detection rate was 68/70 (97%). Fourteen patients had lymph node metastases, six only in SLN. The false negative rate was 2/14 (14%). The internal iliac region was the first metastatic site (40.9%). A metastatic sentinel node in common iliac region beyond the ureteral junction was present in 18.2%. A non-negligible sentinel metastatic region was the common iliac area (18.2%). Limited or standard lymph node dissection would have ignored respectively 72.7% and 59% of lymph node metastases. CONCLUSION: The laparoscopy is adapted to a broad identification of SLN and targeted dissection of these lymph nodes significantly limited the risk of surgical extended dissection while maintaining the accuracy of the information.

[Sacral neuromodulation with InterStim™ system: Results from the French national register]. / Neuromodulation sacrée avec le système InterStim™ : résultats du registre national français.

AIM: To analyse current practice patterns and to evaluate (long-term) effectiveness and adverse events of sacral neuromodulation with InterStim™ Therapy based on data collected in a national register and to discuss the strengths and weaknesses of the register. PATIENTS AND METHODS: This is a French multicenter prospective observational trial including patients with a permanent implant (2003-2009). Voiding diary variables and patient satisfaction were analysed based on last follow-up visit since implantation. RESULTS: One thousand four hundred and eighteen patients (median age: 63 years, 1206 females) were included in the database (median follow-up: 12 months). One thousand and eighty-nine patients had non-neurological disease. The principal diagnosis was overactive bladder syndrome ([OAB], n=1170) and retention (n=151). Implantation occurred in 1358 patients; 1172 patients had greater than or equal to one registered follow-up. Clinical improvement of greater than or equal to 50% was seen in 447/527 patients with OAB at 12 months follow-up (median number of voids per 24 hours decreased from 15 at baseline to 8 at 12 months) and in 42/54 of patients with retention (median number of catheterization per 24 hours dropped from 5 at baseline to 0 at 12 months). Clinical improvement remained relatively stable up to 60 months. Median patient satisfaction with treatment was between 60 and 80%. Five hundred and twenty-four patients had at least one adverse event; loss of efficacy (n=244) occurred most frequently. CONCLUSIONS: In this large database sacral neuromodulation with InterStim™ Therapy seems to be an effective treatment through routine practice in the long-term (up to 60 months) for patients refractory to medical treatment.