6% Hydroxyethyl starch (130/0.4) vs Ringer's lactate preloading before spinal anaesthesia for Caesarean delivery: the randomized, double-blind, multicentre CAESAR trial.

BACKGROUND: Vasopressor administration is recommended to prevent hypotension during spinal anaesthesia (SA) for elective Caesarean delivery. We aimed to test the superior efficacy and ensure safety of a hydroxyethyl starch (HES) vs a Ringer's lactate (RL) preloading, when combined with a phenylephrine-based prophylaxis. METHODS: A total of 167 healthy parturients undergoing elective Caesarean delivery under SA were included in this multicentre, randomized, double-blind study. Patients received 500 ml of 6% HES (130/0.4)+500 ml of RL (HES group) or 1000 ml of RL (RL group) i.v. before SA. After SA, i.v. phenylephrine boluses were titrated when systolic arterial pressure (SAP) was below 95% of baseline. The primary outcome was the incidence of maternal hypotension (SAP <80% of baseline). RESULTS: The incidence of both hypotension and symptomatic hypotension (i.e. with dizziness, nausea/vomiting, or both) was significantly lower in the HES group vs the RL group: 36.6% vs 55.3% (one-sided P=0.025) and 3.7% vs 14.1%. There was no significant difference in total phenylephrine requirements [median (range): 350 (50-1800) vs 350 (50-1250) µg]. The decrease in maternal haemoglobin value the day after surgery was similar in the two groups [1.2 (1.0) vs 1.0 (0.9) g dl(-1)]. There was no detectable placental transfer of HES in six umbilical cord blood samples analysed in the HES group. Neonatal outcomes were comparable between the groups. CONCLUSIONS: Compared with a pure RL preloading, a mixed HES-RL preloading significantly improved prevention of both hypotension and symptomatic hypotension based on early phenylephrine bolus administration and did not induce adverse effects. CLINICAL TRIAL REGISTRATION: NCT00694343 (http://clinicaltrials.gov).

Knowledge, attitudes and behaviours related to HIV/AIDS among female migrant workers in the restaurant industry in Guangzhou, China.

OBJECTIVE: The goal of the present study was to assess knowledge and attitudes related to HIV/AIDS among the migrant female workers in the restaurant industry in Guangzhou City, China. METHODS: We performed a questionnaire survey using a judgmental sampling method in the health examination clinic of Yuexiu District of Guangzhou during March 2011. A total of 428 participants completed and returned the questionnaires and data were analysed by descriptive statistics, t-test, one way ANOVA, and Wilcoxon test. RESULTS: Of 428 respondents, the average score of HIV/AIDS-related knowledge was 19.6 (full marks, 26). Knowledge on HIV/AIDS among respondents was classified as poor for 8.2%, fair for 42.5%, and good for 49.3%. The average score of AIDS-related attitudes of respondents was 7.2 (full marks, 10). Most of the respondents (88.8%) had relatively positive attitudes toward AIDS. Unmarried status, ages less than 30 years old and higher levels of education had higher scores of knowledge. Among the respondents who had sex experiences, 57.7% (130/225) reported that they never or only some of the time used condom. The young, unmarried women had significantly higher proportion of condom use than those above 30 years old, and/or married ones. CONCLUSION: Overall, a half of respondents had only moderate and low levels of awareness about HIV/AIDS knowledge, although most of them had tolerant and positive attitudes toward HIV/AIDS. In addition, a relatively lower rate of condom use was reported. The findings indicate that there exists broad space for improvement of knowledge and behaviours toward HIV/AIDS for migrant women in China.

[Reprint of: Severe pre-eclampsia: guidelines for clinical practice from the French Society of anesthesiology and intensive care (SFAR) and the French College of gynaecologists and obstetricians (CNGOF)]. / Republication de : recommandations formalisées d'experts. Prise en charge de la patiente avec une pré-éclampsie sévère­RFE communes Société française d'anesthésie-réanimation (SFAR)­Collège national des gynécologues et obstétriciens français (CGNOF).

OBJECTIVE: To provide national guidelines for the management of women with severe preeclampsia. DESIGN: A consensus committee of 26 experts was formed. A formal conflict of interest (COI) policy was developed at the onset of the process and enforced throughout. The entire guidelines process was conducted independently of any industrial funding. The authors were advised to follow the principles of the Grading of Recommendations Assessment, Development and Evaluation (GRADE®) system to guide assessment of quality of evidence. The potential drawbacks of making strong recommendations in the presence of low-quality evidence were emphasized. METHODS: The last SFAR and CNGOF guidelines on the management of women with severe preeclampsia was published in 2009. The literature is now sufficient for an update. The aim of this expert panel guidelines is to evaluate the impact of different aspects of the management of women with severe preeclampsia on maternal and neonatal morbidities separately. The experts studied questions within 7 domains. Each question was formulated according to the PICO (Patients Intervention Comparison Outcome) model and the evidence profiles were produced. An extensive literature review and recommendations were carried out and analyzed according to the GRADE® methodology. RESULTS: The SFAR/CNGOF experts panel provided 25 recommendations: 8 have a high level of evidence (GRADE 1±), 9 have a moderate level of evidence (GRADE 2±), and for 7 recommendations, the GRADE method could not be applied, resulting in expert opinions. No recommendation was provided for 3 questions. After one scoring round, strong agreement was reached between the experts for all the recommendations. CONCLUSIONS: There was strong agreement among experts who made 25 recommendations to improve practices for the management of women with severe preeclampsia.

[Factors justifying the choice of labor epidural analgesia by nulliparous women: experience at a maternity center in Antananarivo, Madagascar]. / Quels facteurs motivent le choix de l'analgésie péridurale par les primipares: experience d'un centre de maternité d'Antananarivo, Madagascar.

Epidural analgesia is the most effective method for pain relief during labor. This 10-year exploratory descriptive study on factors underlying women's decisions to request or refuse labor epidural analgesia (LEA) was carried out at a level III maternity hospital in Antananarivo, Madagascar. All patients underwent a pre-anesthesia check-up (PAC) between 32 and 34 weeks of amenorrhea. During the PAC, a questionnaire was administered to determine socio-economic aspects, level of education, and knowledge about labor pain and LEA. In addition, LEA was proposed and patients were asked to explain their reasons for accepting or refusing the procedure. The purpose of this report was to describe the factors underlying acceptance or refusal of EA by nulliparous women. A total of 41 nulliparous women were included. Fourteen (34.14%) accepted LEA and 27 (63.86%) refused. Mean age was 27 years in the acceptance group and 25 years in the refusal group. No patient had good knowledge about LEA. Nulliparous women that accepted EA had a higher socio-economic level, expected stronger labor pain, were better informed about EA, and expressed greater confidence in medical care. In addition to economic aspects, the main reasons for refusing EA involved fear and family background.

[Descriptive study of COVID-19 cases in the third Municipality of Bamako, from March 26 to August 27, 2020]. / Etude descriptive des cas de COVID-19 en Commune III de Bamako du 26 Mars au 27 Aout 2020.

INTRODUCTION: A public health emergency of international concern, COVID-19 is an acute respiratory disease responsible in eight months of approximately 843,158 deaths worldwide, including 29,425 deaths in Africa. The objective was to describe the COVID-19 cases in the health district of Commune III of Bamako. METHODS: This was a descriptive cross-sectional study of COVID-19 surveillance data from March 26 to August 27, 2020. Our variables were extracted from the surveillance database and analyzed on Epi-Info 7.2. Frequencies, rates and proportions were calculated. RESULTS: A positivity rate of 14.86% identified 126 confirmed cases out of an 848 notified suspect. The median age of confirmed cases was 34 years with a minimum of 8 months and a maximum of 93 years. The sex ratio was 2.7 males to females. Civil servants accounted for 32.54% of the positive cases. All the health subdistricts have recorded positive cases. The lethality was 7.94% affecting those over 65 years old. Among asymptomatic people 10.75% were confirmed positive for COVID-19. CONCLUSION: Our study suggests that young males were more likely to be infected with COVID-19. We recommend systematic screening of all contacts and involvement of the community in surveillance.

INTRODUCTION: Urgence de santé publique de portée internationale, la COVID-19 est une maladie respiratoire aiguë responsable en huit mois d'environ 843 158 décès dans le monde dont 29 425 décès en Afrique. L'objectif était de décrire les cas de la COVID-19 en Commune III de Bamako. MÉTHODES: Il s'agissait d'une étude transversale descriptive des données de surveillance de la COVID-19 du 26 Mars au 27 Août 2020. Nos variables ont été extraites de la base de données de surveillance et analysées sur Epi-Info 7.2. Les fréquences, taux et proportions ont été calculés. RÉSULTATS: Un taux de positivité de 14,86% a permis d'identifier 126 cas confirmés sur un 848 suspect notifié. L'âge médian des cas confirmés était de 34 ans avec un minimum de 8 mois et un maximum de 93 ans. Le sex-ratio était de 2,7 en faveur des hommes. Les fonctionnaires représentaient 32,54% des positifs. Toutes les aires de santé ont enregistré des cas confirmés. La létalité était de 7,94% affectant les plus de 65 ans. Parmi les personnes asymptomatiques 10,75% ont été confirmés positives à la COVID-19. CONCLUSION: Notre étude suggère que les jeunes de sexe masculin étaient plus susceptibles d'être infectés par la COVID-19. Nous recommandons le dépistage systématique de tous les contacts et une implication de la communauté dans la surveillance.

Mallampati class changes during pregnancy, labour, and after delivery: can these be predicted?

BACKGROUND: An increase in Mallampati class is associated with difficult laryngoscopy in obstetrics. The goal of our study was to determine the changes in Mallampati class before, during, and after labour, and to identify predictive factors of the changes. METHODS: Mallampati class was evaluated at four time intervals in 87 pregnant patients: during the 8th month of pregnancy (T(1)), placement of epidural catheter (T(2)), 20 min after delivery (T(3)), and 48 h after delivery (T(4)). Factors such as gestational weight gain, duration of first and second stages of labour, and i.v. fluids administered during labour were evaluated for their predictive value. Mallampati classes 3 and 4 were compared for each time interval. Logistic regression was used to test the association between each factor and Mallampati class evolution. RESULTS: Mallampati class did not change for 37% of patients. The proportion of patients falling into Mallampati classes 3 and 4 at the various times of assessment were: T(1), 10.3%; T(2), 36.8%; T(3), 51.7%; and T(4), 20.7%. The differences in percentages were all significant (P<0.01). None of the evaluated factors was predictive. CONCLUSIONS: The incidence of Mallampati classes 3 and 4 increases during labour compared with the pre-labour period, and these changes are not fully reversed by 48 h after delivery. This work confirms the absolute necessity of examining the airway before anaesthetic management in obstetric patients.

Age-adapted morphine titration produces equivalent analgesia and adverse effects in younger and older patients.

BACKGROUND: To determine the efficacy and safety of intravenous postoperative morphine titration in the elderly compared with younger patients. METHODS: In the post-anaesthesia care unit, patients complaining of pain received morphine until adequate pain relief. Intravenous morphine was titrated as 3 mg boluses in young (age 65 yr) and 2 mg in elderly patients (>65 yr) every 5 min. RESULTS: We studied 350 young and 68 elderly patients. There were no significant differences between the two age groups for pain intensity at the onset of titration (numerical rating scale, 7.4 +/- 1.7 in young vs. 7.5 +/- 1.7 in elderly patients), area under the curve of numerical rating scale vs. morphine boluses (97.7 +/- 59.6 vs. 98.2 +/- 62), number of boluses required to obtain pain relief (3 +/- 1.3 vs. 3 +/- 1.3), percentage of titration failures (10% vs. 9%) and incidence of excessive sedation (18% vs. 21%). Renal clearance was significantly reduced in elderly compared with young patients (55 +/- 21 vs. 85 +/- 15 mL min(-1); P < 0.0001). CONCLUSION: Using lower bolus doses, pain relief in the immediate postoperative period with morphine was as efficacious and safe in elderly patients as in younger patients. The decrease in renal clearance of morphine in the elderly justifies the reduction of intravenous morphine boluses for the treatment of postoperative pain.

[Use of sismotherapy during pregnancy for severe depression]. / Place de la sismothérapie dans la prise en charge des dépressions graves de la grossesse.

Electroconvulsive therapy (ECT), also known as electroshock, is a treatment option for patients with severe depression. It involves inducing a comitial crisis under short general anesthesia with curarization. Its use during pregnancy is a rare event and a poorly studied one. A primigravida with a prior bipolar disorder presented a major depressive episode during the second trimester, slightly improved by medical treatment. Electroshocks were performed (10 sessions planned from 26 to 30 weeks of amenorrhea [WA]), with the agreement of the patient. A marked improvement in her condition was recorded in the early sessions. Following a threat of premature birth, the last session was not carried out. She received antidepressant medical treatment in the months preceding childbirth. At 36 WA, the birth was natural and fast to a healthy child (3120 g, Apgar 10-10-10). The mother-child relationship was good. Even if publications are reassuring, the case of a child with multiple cerebral infarctions in a preeclamptic patient was recently reported. The occurrence of any superimposed obstetrical pathology (preeclampsia, premature delivery) should revise this treatment. Given the possible complications, it requires strict supervision of the pregnancy in a hospital setting.

The decrease of fibrinogen is an early predictor of the severity of postpartum hemorrhage.

BACKGROUND: Postpartum hemorrhage (PPH) is a major source of maternal morbidity. OBJECTIVES: This study's objective was to determine whether changes in hemostasis markers during the course of PPH are predictive of its severity. PATIENTS AND METHODS: We enrolled 128 women with PPH requiring uterotonic prostaglandin E2 (sulprostone) infusion. Two groups were defined (severe and non-severe PPH) according to the outcome during the first 24 hours. According to our criteria, 50 of the 128 women had severe PPH. Serial coagulation tests were performed at enrollment (H0), and 1, 2, 4 and 24 hours thereafter. RESULTS: At H0, and through H4, women with severe PPH had significantly lower fibrinogen, factor V, antithrombin activity, protein C antigen, prolonged prothrombin time, and higher D-dimer and TAT complexes than women with non-severe PPH. In multivariate analysis, from H0 to H4, fibrinogen was the only marker associated with the occurrence of severe PPH. At H0, the risk for severe PPH was 2.63-fold higher for each 1 gL(-1) decrease of fibrinogen. The negative predictive value of a fibrinogen concentration >4 gL(-1) was 79% and the positive predictive value of a concentration

Laparoscopy in the second and third trimesters of pregnancy for abdominal surgical emergencies.

OBJECTIVE: To assess complications and outcomes of pregnancies following laparoscopic abdominal surgery during the second and third trimesters of pregnancy. MATERIAL AND METHODS: Retrospective single-center study of 23 cases of laparoscopic surgery in the second or third trimesters of pregnancy between January 2005 and May 2016. RESULTS: The laparoscopies were performed between 15 and 33 weeks of gestation, a mean of 23 weeks+2 days, with 6 cases in the 3rd trimester. The operations were: 11 cholecystectomies, 6 appendectomies, 1 intestinal occlusion (volvulus on a gastric band), 3 adnexal torsions, 1 ovarian cyst and 1 paratubal cyst with torsion. No secondary laparotomy was required. The postoperative courses were favorable in most cases. However, 3 appendectomies were complicated, one by chorioamnionitis and miscarriage at 20½ weeks of gestation and 2 by right iliac fossa abscesses requiring percutaneous radiological drainage, one of these women delivered a healthy term baby and the other had chorioamnionitis and preterm delivery at 34 weeks, followed by neonatal death. CONCLUSION: Laparoscopy can be safely performed for surgical indications in the second and third trimesters of pregnancy. In case of abdominal symptoms, a timely diagnosis is required to decide whether or not to operate and imaging should not be withheld particularly in case of suspected appendicitis which has a high risk of complications.

An observational study of agreement between percentage pain reduction calculated from visual analog or numerical rating scales versus that reported by parturients during labor epidural analgesia.

BACKGROUND: This study aimed to determine the level of agreement between calculated percentage pain reduction, derived from visual analog or numerical rating scales, and patient-reported percentage pain reduction in patients having labor epidural analgesia. METHODS: In a prospective observational study, parturients were asked to rate their pain intensity on a visual analog scale and numerical rating scale, before and 30min after initiation of epidural analgesia. The percentage pain reduction 30min after epidural analgesia was calculated by the formula: 100×(score before epidural analgesia-score 30min after epidural analgesia)/score before epidural analgesia. To evaluate agreement between calculated percentage pain reduction and patient-reported percentage pain reduction, we computed the concordance correlation coefficient and performed Bland-Altman analysis. RESULTS: Ninety-seven women in labor were enrolled in the study, most of whom were nulliparous, with a singleton fetus and in spontaneous labor. The concordance correlation coefficient with patient-reported percentage pain reduction was 0.76 (95% CI 0.6 to 0.8) and 0.77 (95% CI 0.6 to 0.8) for the visual analog and numerical rating scale, respectively. The Bland-Altman mean difference between calculated percentage pain reduction and patient-reported percentage pain reduction for the visual analog and numerical rating scales was -2.0% (limits of agreement at 29.8%) and 0 (limits of agreement at 28.2%), respectively. CONCLUSION: The agreement between calculated percentage pain reduction from a visual analog or numerical rating scale and patient-reported percentage pain reduction in the context of labor epidural analgesia was moderate. The difference could range up to 30%. Patient-reported percentage pain reduction has advantages as a measurement tool for assessing pain management for childbirth but differences compared with other assessment methods should be taken into account.

Hyperthermic intraperitoneal chemotherapy with cisplatin: Amifostine prevents acute severe renal impairment.

UNLABELLED: Surgical cytoreduction combined with intraperitoneal chemo-hyperthermia (HIPEC) has shown to provide survival benefits in the management of some peritoneal carcinomatosis. The cisplatin (CP) used in HIPEC carries a risk of renal impairment (RI). This risk could be reduced by administration of amifostine (A). The aim of our study was to assess the utility of A in preventing RI during IPCH with CP. PATIENTS AND METHODS: Retrospective study including patients who underwent HIPEC between January 2007 and June 2013. The HIPEC involved administration of CP and mitomycin C, between 41 and 43 °C. The peri-anaesthetic management was consistent to use A after 2010. Renal function was assessed from the measured creatinine clearance (CreatCl) and the change between D0 and D4 was compared between patients who received A (group A+) and those who did not (group A-). Severe RI was defined as the development of a CreatCl of <30 ml/min. The statistical analysis used a Student t-test and Fischer's exact test. A p-value of <0.05 was deemed to be statistically significant. RESULTS: Over the studied period, seventy five patients underwent HIPEC and the findings from fifty two patients were analysed: thirty one in group A+ and twenty one in group A-. The change in mean CreatCl from D0 to D4 did not differ between the two groups although between D1 and D4 a significantly higher percentage of severe RI was seen in group A-. CONCLUSIONS: This study has shown A to offer benefit in terms of reducing severe RI when CP is used in HIPEC. These results, however, will need to be confirmed in prospective series on larger numbers of patients.

Estrous and sex variations in vocalization thresholds to hindpaw and tail pressure stimulation in the rat.

This study examined sex and estrous differences in vocalization thresholds of rats to hindpaw and tail pressure stimulation tested daily throughout at least 3 weeks. When all the measures were pooled, compared to males, female rats had higher thresholds for tail pressure (499 +/- 6 g, n = 188 measures vs. 466 +/- 2 g, n = 144 measures, respectively), but equal thresholds for hindpaw pressure (321 +/- 6 g, n = 188 measures vs. 319 +/- 2 g, n = 144 measures, respectively). Thresholds of female rats in proestrus and estrus were lower than those of rats in metestrus and diestrus for both tail and hindpaw stimulation, whereas those of males did not vary systematically. Thresholds at the two stimulation sites covaried in females but not in males. These results add to the growing list of important interacting factors that underly behavioral sensitivity to noxious somatic stimulation.

Anesthetic concentrations of riluzole inhibit neuronal nitric oxide synthase activity, but not expression, in the rat hippocampus.

We hypothesized that anesthetic dose of riluzole, an inhibitor of glutamate neurotransmission, may affect the activity and/or expression of neuronal NOS (nNOS). Riluzole, N(G)-nitro-L-arginine-methyl ester (L-NAME) and 7-nitro indazole (7-NI) produced a concentration-related inhibition of nNOS activity in vitro. Riluzole competed with 7-NI for inhibition of nNOS activity, but had no effect on nNOS or endothelial NOS (eNOS) protein expression. Also, nNOS activity was significantly decreased in riluzole-anesthetized rats (40 mg kg(-1) i.p., -32+/-6% from controls, P<0.05). Therefore, blockade of nNOS activity may be involved in the anesthetic effects of riluzole in vivo.

Effects of riluzole on N-methyl-D-aspartate-induced tyrosine phosphorylation in the rat hippocampus.

Since increased tyrosine phosphorylation has been observed in response to brain ischemia, we investigated whether riluzole (an inhibitor of glutamate neurotransmission with neuroprotective properties) affects tyrosine phosphorylation stimulated by N-methyl-D-aspartate (NMDA) in rat hippocampal slices. Riluzole produced an extremely potent concentration-related inhibition of NMDA (1 mM)-stimulated protein tyrosine phosphorylation (IC(50)=0.5+/-0.03 microM, mean+/-S.D.), but failed to affect that evoked by phorbol 12-myristate 13-acetate (PMA, an activator of protein kinase C, 0.1 and 1 microM). These results suggest that inhibition of tyrosine phosphorylation may contribute to the neuroprotective effects of riluzole against excitotoxic injury.

Antinociceptive effect of a kappa-opioid receptor agonist that minimally crosses the blood-brain barrier (ICI 204448) in a rat model of mononeuropathy.

The antinociceptive effect of intraplantar (i.pl.) ICI 204448 ((R,S)-N-[2-(N-methyl-3,4-dichloro-phenylacetamido)-2-(3-carbox yph enyl)- ethyl]pyrrolidine hydrochloride)) (20, 30, 40 and 50 micrograms), a kappa-opioid receptor agonist which has limited access to the central nervous system, was studied in a well-established rat model of peripheral mononeuropathy produced by moderate constriction of the sciatic nerve. Vocalization thresholds to paw pressure were used as a nociceptive test. On the injected nerve-injured paw, ICI 204448 at 20 and 30 micrograms had no significant effect, but higher doses (40 micrograms) produced a significant antinociceptive effect, which plateaued at 50 micrograms. By contrast, no antinociceptive effect was observed on the contralateral paw. The effect of ICI 204448 (40 micrograms) was significantly antagonised by the specific kappa-opioid receptor antagonist nor-binaltorphimine (20 and 30 micrograms), when co-injected in the nerve-injured paw.

[Management of placenta previa and accreta]. / Prise en charge des placenta praevia et accreta.

OBJECTIVE: Produce recommendations for the management of placenta previa and placenta accrete. METHODS: A literature search was conducted using Medline and the Cochrane Library over a period from 1950 to 31/12/2013. Recommendations of the latest scientific societies have also been consulted. RESULTS: In cases of placenta previa, if bleeding episode before 34weeks gestation occurs, a short hospitalization and tocolysis may help stop bleeding (grade C). Vaginal delivery is preferable when the distance between the internal cervical os and the placental edge is greater than 20mm. When this distance is less than 20mm, vaginal delivery is possible (professional consensus). Caesarean section is recommended in cases of placenta overlapping the internal os (professional consensus). Antenatal screening placenta accreta could improve care (EL3). Upon discovery of a placenta accreta during childbirth, it is better to avoid a forced removal of the placenta (grade C). Conservative treatment or cesarean hysterectomy are possible (grade C). The management of placental abnormalities should be planned and managed with a multidisciplinary team (professional consensus). The use of blood-saving techniques such as "cell saver" is possible in situations where early intraoperative bleeding would be>1500mL (grade C). There are no studies that have sufficient methodological value to recommend an anesthetic technique [general anaesthesia (GA) or neuraxial anaesthesia] over another in the context of placental abnormalities (grade B). When a major bleeding risk is identified, GA can be chosen in order to avoid emergency conversions in difficult conditions (professional consensus). CONCLUSION: Placental insertion abnormalities require anesthetic and obstetric coordination. Delivery must be planned in a suitable structure.