Biomedical subjects
Publications and source records attributed to H Fernandez.
The survival level of five Campylobacter coli strains isolated from bovine faeces was studied in sterilized buffalo milk kept at 4 degrees C under aerobic conditions. All strains died between 21 and 30 h of storage.
OBJECTIVES: To test the association between cytokine levels in the amniotic fluid and (i) the vascular invasion phase of intrauterine infection, (ii) the occurrence of periventricular leukomalacia; to assess the correlation between C-reactive protein levels, a recognised biological marker of inflammation in maternal serum and cytokine levels in the amniotic fluid. DESIGN: Prospective clinical study. SETTING: Fetal medicine unit and neonatal intensive care unit, Antoine Beclere Hospital, Clamart, France. SAMPLE: Thirty-one pregnancies complicated by chorioamnionitis leading to birth before 32 weeks of gestation. METHODS: Interleukin 1-beta, Interleukin 6 and TNF-alpha prospectively measured in the amniotic fluid. Histological examination of the placenta. Ultrasound examination and magnetic resonance imaging of the brains of the newborn infants performed within the first week of life. MAIN OUTCOME MEASURES: The occurrence of periventricular leukomalacia was assessed by transfontanellar ultrasound and magnetic resonance imaging. RESULTS: There was a significant positive correlation between the occurrence of histological chorioamnionitis, vascular extension of infection of the membranes, maternal inflammatory syndrome and neonatal sepsis. A strong association was found between maternal serum C-reactive protein concentrations and cytokine levels in the amniotic fluid. Interleukin-1beta was the best predictor of vascular extension of chorioamnionitis, and TNF-alpha was the best predictor of the development of severe early neonatal infection. There was no association between the amniotic fluid levels of cytokines and the development of periventricular leukomalacia. CONCLUSIONS: These data suggest that IL-1beta, IL-6 and TNF-alpha are produced in relation to intrauterine inflammation and infection, but cannot be directly implicated in the development of fetal cerebral white matter lesions.
STUDY OBJECTIVE: To investigate the alternative routes for hysterectomy for benign disease and the appropriate role of laparoscopic surgery. DESIGN: Retrospective study of hysterectomies performed between August 1991 and July 1997. SETTING: University hospital. PATIENTS: Hysterectomy for benign disease without prolapse, pelvic floor relaxation. INTERVENTION: 359 hysterectomies: vaginal (n = 211), laparoscopically-assisted vaginal (n = 56), and abdominal (n = 92). MEASUREMENTS AND MAIN RESULTS: Uterine volume was the principal indication for laparotomy. Laparoscopy was required only in cases of adnexal disorders or when the vaginal access was limited or associated with extensive adhesions. The rate of laparotomies and laparoscopies dropped steadily over the six-year study period: during the last two years, 75% of all hysterectomies were vaginal, and 90% of those for patients without a previous vaginal birth. CONCLUSION: With experienced surgeons, the number of cases in which there appears to be poor vaginal accessibility experience decreases, and indications for vaginal hysterectomies increase.
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Ten years after the Safe Motherhood Initiative has been set up, maternal morbidity and mortality remain a major public health issue in most developing countries. This presentation reviews the background of the initiative and the strategies adopted in Nairobi. Then, it undertakes an analysis of recent developments in maternal health policies. The authors discuss the comparative impact on maternal mortality of efforts aimed at a global improvement of the socio-economic and educative status of women, family planning activities, traditional birth attendants training programmes, and antenatal care. They stress the importance of the effective accessibility to life saving obstetric. Finally, they advocate a major involvement by gynecologist-obstetricians in the development and in the implementation of safe motherhood programmes.
The very high rates of maternal mortality and perinatal mortality, as well as the deficiencies and dysfunctions observed in maternity hospitals, which play the role of referential maternity wards, led the Moroccan Minister of Public Health to implement a project in order to improve the quality of care of parturient women and new-borns. This project included 8 provinces in the country. The strategy chosen was "the team approach to resolving health problems", which is a learning process which leads local teams to implement and evaluate projects they have developed themselves. This pedagogical approach, which is carried out over a period of more than a year, proved itself to be very motivating and mobilising for the professionals included, despite the obstacles that were encountered. It also contributed to creating a true team spirit. Most activities planned within these projects were carried out and many indicators improved.
BACKGROUND: Traditionally, primary surgical therapy is considered unsuitable for the treatment of patients with locally advanced breast carcinoma (LABC). Multiple reports have documented the efficacy of primary chemotherapy in this group of patients. The purpose of this study was to investigate the efficacy of a multimodality treatment program in reducing distant and local disease relapses in patients with LABC. METHODS: Fifty-five patients with large operable or inoperable Stage III breast carcinoma, median tumor greatest dimension 7 x 8 cm, were treated with neoadjuvant MVAC (methotrexate, vinblastine, doxorubicin, and cisplatin) to achieve maximum clinical response, followed by modified radical mastectomy, adjuvant MVAC for six courses, and chest wall radiation. Of these patients, 37 had Stage IIIA disease and 18 had Stage IIIB or inflammatory breast carcinoma. RESULTS: Forty-nine patients achieved overall responses to the neoadjuvant chemotherapy, including 16 complete clinical remissions. Histopathologic evaluation was performed for all patients; nine were pathologically free of disease and six had residual intraductal carcinoma only. After a median follow-up of 47 months (range, 8-76 months), 24 patients had relapsed: 6 locoregional and distant, and 18 distant only. The median disease free and overall survival have not been reached; the 5-year disease free and overall survival rates are 51% and 63%, respectively. The number of lymph nodes with metastases was found to be an independent predictor of relapse in univariate and multivariate analyses. CONCLUSIONS: This multidisciplinary approach produced an excellent local control rate and a respectable 5-year distant relapse free rate. Axillary lymphadenectomy after primary chemotherapy provides crucial prognostic information, which can be important in planning multimodality treatment of patients with LABC.
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OBJECTIVE: To evaluate fertility after salpingectomy performed for ectopic pregnancies (EPs). DESIGN: Retrospective cohort study. SETTING: Tertiary care university hospital. PATIENT(S): Three hundred forty patients (213 with surgery by laparoscopy and 127 by laparotomy) between January 1985 and July 1994, with a mean follow-up period of 73 months (36-162 months). INTERVENTION(S): Salpingectomy performed either by laparotomy or by laparoscopy as indicated. MAIN OUTCOME MEASURE(S): Rate of intrauterine pregnancy (IUP), live births, and recurrent EP. RESULT(S): Forty-seven (13.8%) patients were lost to follow-up, and 68 (20%) did not want to become pregnant. The overall rate of spontaneous conception was 70.4% in the laparoscopy group and 53.2% in the laparotomy group. The rate of live births was 50% and 37%, respectively; the mean time until conception was 11 and 17.2 months; and the rate of recurrent EP, 10.6% and 9.6%. The multivariate analysis showed a rate of IUP of 82.1% among women younger than 30 years of age with a normal contralateral tube, laparoscopic surgery, and no history of infertility. CONCLUSIONS: In this study of fertility after salpingectomy for EP, laparoscopic treatment was superior to laparotomic treatment. Fertility was equivalent to that after conservative treatment in a subgroup of young patients treated with laparoscopy and with no history of tubal pathology.
The safety/acceptability, blood pharmacokinetics and urinary excretion of the piperacillin-tazobactam (PPR-TZB) combination were studied in six patients between 25 1/7 and 31 5/7 weeks of amenorrhea. The combination was given for a materno-fetal infection due to susceptible organisms i.e. 4/0.5 g/6 h. Whenever possible, the trans-placental transfer (TPT) of the combination was assessed in several sub-compartments of the feto-placental unit i.e. maternal blood sample, cord blood, amniotic fluid, placenta tissue and fetal urine. Two series of nine blood samples were scheduled for each patient, i.e. on D1 (first dose) and D3 (at plateau). Samples were assayed by HPLC and data were analyzed by a non-compartmental method. Safety/acceptability of the treatment proved to be good. The kinetic behavior of both beta-lactams appeared to be identical. Evidence was found during pregnancy of an increase in Vss and Cl of the combination. These increases can be linked to a notable decrease in AUCs. The TPT of the combination was significant. Regarding other accessible compartments (i.e. placenta tissue, amniotic fluid and fetal urine), the ratio of PPR-TZB concentrations was invariably about 8. Maternal circulating levels of PPR-TZB were, by 4 h, less than the MIC of target organisms (i.e. < or = 8 micrograms/ml), both on D1 and at steady state. This raises the question of the pertinence of the dosage regimen. Regarding PPR, it is accepted that antibacterial protection is satisfactory when circulating concentrations are kept at a Css (steady state concentration) of the order of 20 micrograms/ml or more. PPR-TZB combination would be administered by continuous infusion i.e. 8 mg/min to obtain 3 h later a Css of more than 20 micrograms/ml. The daily dosage would then be 12/1.5 g instead of 16/2 g, which is also more satisfactory from a pharmaco-economic standpoint. This proposal must be validated in a sufficient number of patients and, could avoid disqualification of the combination PPR-TZB in the treatment of serious infections during certain pathological pregnancies.
We conducted a retrospective review of 125 patients undergoing high-dose therapy and stem cell rescue in order to evaluate the incidence of documented infection and the utility of the administration of vancomycin empirically. All patients received prophylactic oral quinolone therapy. Because neutropenia in this setting is relatively brief, 21 patients never manifested fever, and no patient died of infection. Of the remaining 104 patients, positive blood cultures were obtained in only 10, nine with a gram stain positive and one with a gram stain negative organism. Sixty-two patients without any evidence of gram positive infection received vancomycin according to the existing algorithm for care of neutropenic fevers. In this population of patients, empiric administration of vancomycin for neutropenic fevers without culture documentation appears to be unnecessary, could be discontinued safely and at substantial cost savings, and might slow the appearance of vancomycin-resistant organisms.
Methotrexate treatment was compared to laparoscopic salpingotomy for conservative management of ectopic pregnancy in a prospective randomized study. One hundred patients were randomized into two groups using random numbers. Inclusion criteria were an ectopic pregnancy visualized by ultrasound with a pre-therapeutic score <13 as assessed by the following six criteria, graded from 1 to 3: gestational age, human chorionic gonadotrophin (HCG) concentration, progesterone concentration, abdominal pain, haemoperitoneal volume and diameter of the haematosalpinx. The treatments were either 1 mg/kg of methotrexate injected transvaginally into the ectopic pregnancy without anaesthesia or administered i.m. when the pregnancy could not safely or easily be punctured (group 1), or laparoscopic salpingotomy (group 2). Success was defined as the return to normal (<10 mIU/ml) of HCG concentrations. Treatment was successful for 45 of 51 patients in group 1 (88.2%) and 47 of 49 in group 2 (95.9%). Medical treatment was significantly (P < 0.05) associated with shorter postoperative stay (24 compared with 46 h), but HCG returned to normal more quickly after laparoscopic treatment (13 compared with 29 days). Spontaneous reproductive performance was similar in both groups, but overall intrauterine pregnancy was higher, and repeat ectopic pregnancy lower, after methotrexate treatment. In selected cases of ectopic pregnancy, with a pre-therapeutic score <13, methotrexate treatment appeared as safe and efficient as conservative treatment by laparoscopy and was associated with improved subsequent fertility.
We present in this study the results of a retrospective analysis comparing a group of ongoing triplet pregnancies and a group of triplet pregnancies reduced to twins. These two groups were managed in the same way between January 1993 and April 1996 in hospital. Mean gestational age at birth was comparable in both groups of patients. Prematurity rate was lower in the reduced pregnancies group (62.5 versus 95.6%, P < 0.05). Severe prematurity (<32 weeks) was not different in the two groups. The percentage of Caesarean section was lower in the reduced group (23.5 versus 70.8%, P < 0.01). No significant difference was observed for perinatal mortality. Newborns of ongoing triplet pregnancies had a higher percentage (67.7 versus 86.8%) of hospitalization in the intensive neonatal care unit and a tendency towards lower birthweight. The differences observed in this study do not seem to represent a decisive benefit for reducing triplet pregnancies. Due to the progress in the management of multiple pregnancies and neonatal intensive care, we think that embryo reduction should no longer be justified by obstetric benefits but rather as a possibility offered to couples who could be confronted with the potential severe psychological, social and economic problems of triple births.
A multicentre study was carried out in seven top French centres for laparoscopic gynaecological surgery. This series covers a period of 9 years, in which 29,966 diagnostic and operative laparoscopic operations were performed. The risk of complications has been assessed according to the complexity of the laparoscopic procedure in question. The means of diagnosis and treatment of the complications have been analysed, together with the importance of the surgeon's degree of experience. The mortality rate was 3.33 per 100,000 laparoscopies. The overall complication rate was 4.64 per 1000 laparoscopies (n = 139). The rate of complications requiring laparotomy was 3.20 per 1000 (n = 96). The complication rate was significantly correlated with the complexity of the laparoscopic procedure (P = 0.0001). One in three complications (34.1%; n = 43) occurred while setting up for laparoscopy, and one in four (28.6%) were not diagnosed during the operation. As new indications for laparoscopic surgery in gynaecology have appeared, there has been a parallel and statistically significant increase in the rate of urological complications (P = 0.001). Increased experience by the surgeons has had three consequences: a statistically significant drop in the number of bowel injuries (P = 0.0003), a drop in the rate of complications requiring laparotomy for those laparoscopic surgical procedures that are well defined (P = 0.01), and a change in the way complications are treated, with a significant increase in the proportion of incidents treated by laparoscopy (P = 0.0001).
OBJECTIVE: To evaluate pregnancy after heart or heart-lung transplantation in France. DESIGN: A questionnaire survey of all French centres performing heart and heart-lung transplants provided an exhaustive registry on pregnancy after transplantation. METHODS: A questionnaire was sent to 36 centres. Anonymous reports on transplantation and subsequent pregnancies between 1984 and 1996 were analysed. RESULTS: Of 1290 heart and 120 heart-lung transplantation performed during the study period, 10 pregnancies (seven after heart transplantation and three after heart-lung transplantation) were reported in nine women who were delivered of 11 infants. High blood pressure complicated nine pregnancies and severe pre-eclampsia occurred in two. One woman developed Kaposi sarcoma of the cervix. Delivery at 35 weeks gestation (27-39) was by caesarean section in 50% cases. Mean birthweight was 1990 g (700-2880g) and 50% of the infants had a birthweight < tenth centile. One infant developed cardiomyopathy as a condition inherited from her mother, and congenital hepatitis B was diagnosed in another. CONCLUSIONS: Pregnancy after heart and heart-lung transplantation is feasible and can be successful, but this should be planned when cardiac and respiratory functions are stable. Adequate obstetrical and genetic counselling should be provided.
OBJECTIVE: To compare the effects of betamethasone and dexamethasone on fetal heart rate in appropriately grown fetuses. METHODS: Eighty-two pregnant women (97 fetuses) with preterm labour were randomly allocated to receive betamethasone (n=42) or dexamethasone (n=40) for fetal lung maturation in a nonblinded fashion. Computerised cardiotocogram (CTG) parameters were compared before, during and after treatment. RESULTS: A decrease in fetal heart rate variability was found with betamethasone but no significant changes were found with dexamethasone. Fetal heart rate variability returned to pre-treatment values within a week after cessation of treatment with betamethasone. Neonatal outcome was similar in the two groups. CONCLUSIONS: These findings might prove useful in the management of compromised fetuses with decreased fetal heart rate variability in which the CTG should be used together with other parameters to assess fetal wellbeing during corticosteroid treatment. Dexamethasone may be preferable as the drug of choice since it was associated with significantly less alteration in fetal heart rate variability compared with betamethasone.
The objective of this study was to analyse the relation between severity of maternal condition at the time of intensive care unit (ICU) admission and various individual and institutional factors. This study analysed data from a retrospective population-based study in three French regions during 1991. The population study included 355 patients who were admitted to an ICU during pregnancy, delivery or within 42 days after delivery, for an obstetrical cause. The main outcome measure was the severity of maternal condition at ICU admission estimated from the level of consciousness and from the Simplified Acute Physiology Score (SAPS). The most severe maternal condition was associated with a change in hospital category (from the initially chosen hospital to the hospital referring for ICU) (OR 3.8, 95% CI 1.5-9.6) and with treatment in a private hospital at ICU referral (OR 3.3, 95% CI 1.3-8.3). Foreign nationality was the only individual factor related to very severe maternal condition. These results suggest that health care organisation during pregnancy affects the prognosis of severe maternal condition. The factors involved appear to include the management of unpredictable disorders, the conditions of maternal transfers before ICU admission, and antenatal care of foreigners.
BACKGROUND: The risk associated with smoking has been studied for a long time in fertility epidemiology. This paper reviews the association between smoking and ectopic pregnancy (EP) using results collected in our previous studies. It provides arguments for a causal interpretation of this association. METHODS: Data came from three case-control studies performed between 1988 and 1996 and from the register of ectopic pregnancies in Auvergne (France) from 1992 to 1995. The methods are those classically used in the analysis of case-control studies. RESULTS: The risk of EP increased significantly with smoking (p < 0.01): the adjusted OR are 1.5 for 1-9 cigarettes a day, 2.0 for 10-19 cigarettes a day, and 2.5 for more than 20 cigarettes a day. The attributable risk of smoking ranged between 17% and 32% according to the study. Similarly, the risk of EP recurrence increased significantly with smoking (p < 0.02): after adjustment, OR = 1.3 for 1-9 cigarettes a day, OR = 1.5 for 10-19 cigarettes a day, and OR = 1.7 for more than 20 cigarettes a day. Finally, smoking was associated with the site of EP. CONCLUSIONS: Thus there is a large body of arguments towards a causal relationship between smoking and EP. This provides additional arguments to persuade women to stop or to reduce smoking, especially hypofertile women.