Estetrol is a weak estrogen antagonizing estradiol-dependent mammary gland proliferation

Estetrol (E4) is a natural estrogen produced exclusively by the human fetal liver during pregnancy. Its physiological activity remains unknown. In contrast to ethinyl estradiol and estradiol (E2), E4 has a minimal impact on liver cell activity and could provide a better safety profile in contraception or hormone therapy. The aim of this study was to delineate if E4 exhibits an activity profile distinct from that of E2 on mammary gland. Compared with E2, E4 acted as a low-affinity estrogen in both human in vitro and murine in vivo models. E4 was 100 times less potent than E2 to stimulate the proliferation of human breast epithelial (HBE) cells and murine mammary gland in vitro and in vivo respectively. This effect was prevented by fulvestrant and tamoxifen, supporting the notion that ERα (ESR1) is the main mediator of the estrogenic effect of E4 on the breast. Interestingly, when E4 was administered along with E2, it significantly antagonized the strong stimulatory effect of E2 on HBE cell proliferation and on the growth of mammary ducts. This study characterizes for the first time the impact of E4 on mammary gland. Our results highlight that E4 is less potent than E2 and exhibits antagonistic properties toward the proliferative effect of E2 on breast epithelial cells. These data support E4 as a potential new estrogen for clinical use with a reduced impact on breast proliferation.

Impact of follicular G-CSF quantification on subsequent embryo transfer decisions: a proof of concept study

BACKGROUND

Previous experiments have shown that granulocyte colony-stimulating factor (G-CSF), quantified in the follicular fluid (FF) of individual oocytes, correlates with the potential for an ongoing pregnancy of the corresponding fertilized oocytes among selected transferred embryos. Here we present a proof of concept study aimed at evaluating the impact of including FF G-CSF quantification in the embryo transfer decisions.

METHODS

FF G-CSF was quantified with the Luminex XMap technology in 523 individual FF samples corresponding to 116 fresh transferred embryos, 275 frozen embryos and 131 destroyed embryos from 78 patients undergoing ICSI.

RESULTS

Follicular G-CSF was highly predictive of subsequent implantation. The receiving operator characteristics curve methodology showed its higher discriminatory power to predict ongoing pregnancy in multivariate logistic regression analysis for FF G-CSF compared with embryo morphology [0.77 (0.69–0.83), P < 0.001 versus 0.66 (0.58–0.73), P = 0.01)]. Embryos were classified by their FF G-CSF concentration: Class I over 30 pg/ml (a highest positive predictive value for implantation), Class II from 30 to 18.4 pg/ml and Class III <18.4 pg/ml (a highest negative predictive value). Embryos derived from Class I follicles had a significantly higher implantation rate (IR) than those from Class II and III follicles (36 versus 16.6 and 6%, P < 0.001). Embryos derived from Class I follicles with an optimal morphology reached an IR of 54%. Frozen-thawed embryos transfer derived from Class I follicles had an IR of 37% significantly higher than those from Class II and III follicles, respectively, of 8 and 5% (P < 0.001). Thirty-five per cent of the frozen embryos but also 10% of the destroyed embryos were derived from G-CSF Class I follicles. Non-optimal embryos appear to have been transferred in 28% (22/78) of the women, and their pregnancy rate was significantly lower than that of women who received at least one optimal embryo (18 versus 36%, P = 0.04).

CONCLUSIONS

Monitoring FF G-CSF for the selection of embryos with a better potential for pregnancy might improve the effectiveness of IVF by reducing the time and cost required for obtaining a pregnancy.

[Herpes hepatic failure during the third quarter of pregnancy]

Acute liver diseases of pregnancy are common and usually transient and reversible. Given the number of different possible diagnoses, performing a large biological screening and a proper iconographic documentation is key. It makes sure no etiology fatal to the mother and her fetus is missed.

[Obstetrical epidural analgesia and postpartum backache]

Backache is a common problem in the general population. The prevalence of backpain is increased during pregnancy and after delivery. Early studies have suggested that labor epidural analgesia might be associated with an increased incidence of backache in the postpartum period. However, these initial studies were retrospective and their design included several methodological deficiencies. All the prospective studies published afterwards (prospective cohort studies and 3 randomized controlled trials) yield the same result: there is no relationship between labor epidural analgesia and long-term postpartum backpain. Pregnant women must be aware of this in order to make an informed and appropriate choice about labor epidural analgesia, the most effective technique for intrapartum pain relief.

[The usefulness of combined gynecologic and endocrinologic consultation in pediatrics: a retrospective study of the reasons for consultation and the practical approach]

The gynaecological issues encountered in children and teenagers lay at the intersection of paediatric endocrinology and gynaecology. More than ten years ago, an outpatient clinic in paediatric endocrinology and gynaecology has been created. Here, we review the last 6 years. 214 girls were included, considering only the first visit for each patient. Collected data are initial concern for this consultation, age at first consultation and confirmed or suspected diagnosis. A classification is done according to the initial concern of patients in six categories. Principal queries concern pubertal development, precocious pilosity or abnormalities in menstrual cycles. Vulvovaginitis and morphologic abnormalities are also frequently encountered. This consultation suggests a paediatric approach with a child feeling confident and a gynaecological examination with a specialist knowing the anatomy particularities and the development of the children. This article focuses on the importance of specific gynaecological examination in children and reviews the main diseases encountered.

Whole slide quantification of stromal lymphatic vessel distribution and peritumoral lymphatic vessel density in early invasive cervical cancer: a method description

Peritumoral Lymphatic Vessel Density (LVD) is considered to be a predictive marker for the presence of lymph node metastases in cervical cancer. However, when LVD quantification relies on conventional optical microscopy and the hot spot technique, interobserver variability is significant and yields inconsistent conclusions. In this work, we describe an original method that applies computed image analysis to whole slide scanned tissue sections following immunohistochemical lymphatic vessel staining. This procedure allows to determine an objective LVD quantification as well as the lymphatic vessel distribution and its heterogeneity within the stroma surrounding the invasive tumor bundles. The proposed technique can be useful to better characterize lymphatic vessel interactions with tumor cells and could potentially impact on prognosis and therapeutic decisions.

[Pseudoxanthoma elasticum and obstetric epidural analgesia: report of a case]

Pseudoxanthoma elasticum is a rare inherited disorder of the elastic tissue characterised by multisystem manifestations. Skin, eyes, gastro-intestinal system and cardiovascular system are the major affected systems. We describe the anaesthetic management of a parturient affected by this disease.

Aetiology and physiopathology of preeclampsia and related forms

Preeclampsia, a pregnancy-specific syndrome characterized by hypertension, proteinuria and oedema, resolves on placental delivery. Its pathogenesis is thought to be associated to a hypoxic placenta. Placental hypoxia is responsible for the maternal vascular dysfunction via the increased placental release of anti-angiogenic factors such as soluble flt1 and endoglin. These soluble receptors bind VEGF, PLGF and TGFbeta1 and 3 in the maternal circulation, causing endothelial dysfunction in many maternal tissues. Despite these recent and important new molecular findings, it is important to consider that normal pregnancy is also characterized by systemic inflammation, oxidative stress and alterations in levels of angiogenic factors and vascular reactivity. Both the placenta and maternal vasculatures are major sources of reactive oxygen and nitrogen species which can produce powerful pro-oxidants that covalently modify proteins and alter vascular function in preeclampsia. Finally, the recent demonstration of activating auto-antibodies to the Angiotensin 1 receptor that experimentally play a major pathogenic role in preeclampsia further indicates the pleiotropism of aetiologies of this condition.

[Therapeutic inertia in contraception]

The efficiency of contraception is linked to the method and the patient's compliance. The advice given by the physician about contraception use is essential to avoid unintended pregnancy. The accuracy of contraceptive choice and the individualized adaptation over time contribute to safe contraception.

[Non-observance and therapeutic inertia in obstetrics]

Observance around pregnancy includes two parts: what can be done before conception and what must be done during pregnancy. Preconception care, if efficaciously performed, offerss real benefits for foetal and child development. Its efficacy will depends on the involvement and motivation of physicians and particularly also on the patient's observance. In this article we summarize essential pieces of advice to be given to each patient before pregnancy. Therapeutic inertia in obstetrics presents two differents aspects: on the one hand, the delay to initiate a therapeutic strategy when a complication arises such as a postpartum hemorrhage; on the other hand, the continuation of obsolete practices, such as the therapy of uterine hypersystolia.

Management of severe preeclampsia

Features of severe preeclampsia include severe proteinuric hypertension and symptoms of central nervous system dysfunction, hepatocellular injury, thrombocytopenia, oliguria, pulmonary oedema, cerebrovascular accident and severe intrauterine growth restriction. Women with severe preeclampsia must be hospitalized to confirm the diagnosis, to assess the severity of the disease, to monitor the progression of the disease and to try to stabilize the disease. Severe preeclampsia may be managed expectantly, in selected cases. The objective of expectant management in these patients is to improve neonatal outcome. Expectant management is based on antihypertensive treatment and prevention of end organ dysfunction. Antihypertensive treatment improves maternal outcome but has the potential to be deleterious for the foetus. Plasma volume expansion has been suggested for severe preeclampsia but trials failed to show any benefit. Magnesium sulfate is the anticonvulsivant of choice to treat or prevent eclampsia when indicated. Antenatal corticosteroids are recommended in severely preeclamptic women with 26-34 weeks gestation. Timing of delivery is based upon gestational age, severity of preeclampsia, maternal and foetal risks.

[Diabetes and pregnancy: impact of medical inertia and therapeutic compliance]

Pregnancy and infant outcomes are related to maternal blood glucose profile. Managing preexisting diabetes and achieving euglycaemia before and during the pregnancy reduce the risk for complications. Screening, diagnosis and treatment of gestational diabetes are important issues from a public health point of view, more particularly because of the progression of this disease due to obesity epidemics among young people. Pregnancy in a diabetic woman is a critical situation where neither clinical inertia nor patient's non-compliance could be accepted.

[Treatment of severe preeclampsia: until when and for what risks/benefits?]

The four major hypertensive disorders related to pregnancy are preeclampsia, chronic hypertension, preeclampsia superimposed upon chronic hypertension, and gestational hypertension. The development of hypertension and proteinuria in pregnancy is usually due to preeclampsia, particularly in a primigravida. These findings typically become apparent in the latter part of the third trimester and progress until delivery, but some women develop symptoms in the latter half of the second trimester, or intrapartum, or the early postpartum period. Preeclampsia is characterized as mild or severe. Severe hypertension, coagulopathy, thrombocytopenia, liver function abnormalities, and fetal growth restriction are features of severe disease. Laboratory evaluation should assess haemoglobin/hematocrit and platelet count, renal and hepatic function, as well as assessment of fetal well-being and growth. Timing of delivery is based upon gestational age, maternal and fetal condition, and the severity of preeclampsia. Maternal end organ dysfunction and nonreassuring tests of fetal well-being are indications for delivery at any gestational age. Antihypertensive treatment aims at protecting the mother from severe hypertensive encephalopathy, but may jeopardize the fetus. We recommend antenatal corticosteroids (betamethasone) be given to women with preeclampsia at 26 to 34 weeks of gestation. Magnesium sulfate is more effective than phenytoin for prevention of eclamptic seizures.

[How I explore ... the bleeding of vaginal origin in childhood]

Prepubertal vaginal bleeding is considered as isolated menarche, when thorough medical examination does not show other signs of sexual development or any detectable uterine or vaginal abnormalities (infection, foreign bodies, tumors, trauma...). If other puberty signs (thelarche, pubarche, peak of growth...) develop, the vaginal bleeding will not be isolated any more and we will consequently speak of true early puberty. It is thus the follow-up of the patient which will allow to make the differential diagnosis between precocious and benign isolated menarche and true early puberty determining the statural future and requiring a specific treatment. The etiology of prepubertal menarche remains unclear, and more research is needed to establish causation. Several complementary examinations must be carried out in order to exclude tumoral, infectious, traumatic or hormonal pathologies and those must be repeated during the follow-up of the patient.

[Predictive value of antenatal ultrasound for the neonatal diagnostic of renal and ureteral anomaly]

Pyelectasis is a dilatation of the renal pelvis. It must be differentiated from hydronephrosis which is a dilation of the renal pelvis and of the renal calyces. In this retrospective study, we focused on the treatment and follow up of 31 newborns in whom a pyelectasis had been diagnosed in utero. At the end of the study, 20 babies showed no sign of an urologic disorder whereas 11 babies did. Our study suggests that it is crucial to search for an urologic disorder in the neonatal period when a fetal pyelectasis has been diagnosed.

Controlled release of drugs from multi-component biomaterials

In order to control their release, drugs are encapsulated into systems which are expected to provide a certain site with a predetermined amount of drug over a well-defined period of time. Here we report on a multi-component drug delivery biomaterial that consists of a hydrogel matrix in which drug-loaded biodegradable microcarriers are dispersed, and whose potential applications could be found in the design of implantable devices with long-term activity, as required by contraceptive and hormone replacement treatments. The release profile of the drug can actually be tuned by the complex interplay of several release mechanisms, including the permeability and eventually the degradation rate of the microcarriers and the diffusion through the hydrogel. The hydrogel consisted of 2-hydroxyethyl methacrylate cross-linked by ethylene glycol dimethacrylate. The microcarriers were biodegradable poly-epsilon-caprolactone (PCL) microspheres in which active molecules, such as levonorgestrel (LNG), were encapsulated. The hydrogels were characterized by water swelling, thermal properties, LNG diffusion through drug-free and drug-depleted hydrogel membranes and LNG release from devices with drug dispersed in the hydrogel. The PCL microspheres were observed by scanning electron microscopy; their size distribution, LNG loading and release were also investigated. The hydrogel-microsphere assemblies were characterized in terms of the distribution of the microspheres within the hydrogel, water swelling and the release of the encapsulated molecules. The developed device, due to its composite structure, has the ability to combine several release mechanisms, leading to drug release obeying zero-order kinetics for most of the time.

[Secondary amenorrhea and cerebral ventriculomegaly]

Cerebral ventriculomegaly and hydrocephalus are not frequently associated with endocrine disorders of the gonadotropic axis. The mechanism of this association is not clarified. The most probable cause is however a partial hypothalamic dysfunction. The examination of the few reported cases is in favour of this explanation. We present the case of a young woman with a cerebral ventriculomegaly and suffering from secondary amenorrhea. Shunt was not necessary from the neurological point of view, the problem of secondary amenorrhea and anovulatory infertility was solved by clomiphen citrate therapy.

[Four clinical cases of dysgerminoma]

Dysgerminoma is an ovarian germ cell tumor occurring more frequently among young women. The efficacy of chemotherapy allows conservative surgery sparing fertility. A stadification surgery will avoid chemotherapy for patients with stage Ia. The others stages will receive a cisplatine-based regime. A ct-scan is performed twice a year and, in case of recurrence, a first or a second chemotherapy should be prescribed.

[How I explore...the benefit of 3D/4D ultrasound in obstetrics]

During recent years, 3D has become an important tool in ultrasound. In obstetrics, the classic 2D examination with Doppler is now often completed by 3D. In this article the strengths and weaknesses of this technique are discussed.

Safety of tibolone in the treatment of vasomotor symptoms in breast cancer patients--design and baseline data 'LIBERATE' trial

Many patients with a history of breast cancer (BC) will suffer from vasomotor symptoms, which can be induced or exacerbated by treatment with tamoxifen or aromatase inhibitors. The LIBERATE trial was designed as a randomized, double-blind, multicenter trial to demonstrate that tibolone 2.5mg/day (Livial) is non-inferior to placebo regarding BC recurrence in women with vasomotor symptoms surgically treated for primary BC within the last 5 years. Secondary objectives are effects on vasomotor symptoms as well as overall survival, bone mineral density and health-related quality of life. Mean age at randomization was 52.6 years, and the mean time since surgery was 2.1 years. The mean daily number of hot flushes and sweating episodes was 7.3 and 6.1, respectively. For the primary tumor, Stage IIA or higher was reported for >70% of the patients. In subjects whose receptor status was known, 78.2% of the tumors were estrogen receptors positive. At randomization, tamoxifen was given to 66.2% of all patients and aromatase inhibitors to 7%. Chemotherapy was reported by 5% at randomization. The adjuvant tamoxifen use in LIBERATE allows a comparison with the Stockholm trial (showing no risk of BC recurrence associated with hormone therapy), which was stopped prematurely subsequent to HABITS. The LIBERATE trial is the largest, ongoing, well-controlled study for treatment of vasomotor symptoms in BC patients.

[New methods of prenatal screening for trisomy 21]

Down syndrome is the most commonly recognized genetic cause of mental retardation. The risk of trisomy 21 is directly related to maternal age which can be viewed as the first screening test in the 1970's. New strategies for Down syndrom, have emerged with higher sensitivity and lower false-positive rate. These strategies are based on sonographic and maternal serum markers. The most specific but complex strategy is based on the integrated test, i.e., the integration of the quadruple test performed in the second trimester to the first trimester combined screening: for a 85% detection rate, the false positive rate is estimated to 0.9%. This strategy deprives the patient of an early diagnosis. Alternatives strategies do exist which can perform similar detection rate but with increasing false positive rate. To date Down syndrom, screening has not been coordinated by a national body; it would be usefull to ensure the sonographist formation, perform quality audit and decrease variations in practice.

Quantification of in vivo tumor invasion and vascularization by computerized image analysis

The matrix-inserted surface transplantation model is an in vivo assay used to analyse the kinetics of tumor-vessel interactions during different stages of skin carcinoma progression. This system allows the study of host-tumor interface, i.e. penetration of tumor cells into normal host tissue as well as infiltration of normal host cells into the tumor. In the present study, image analysis algorithms for processing and quantifying the extent of such migratory and tissue remodeling events are presented. The proposed method is non-parametric and its originality lies in its particularity to take into account the specific geometry of tumor-host interface. This methodology is validated by evaluating the contribution of matrix metalloproteases (MMPs) in skin carcinoma invasion and vascularization through pharmacological and genetic approaches.

[Treatment of didelphys uterus with imperforated obstructed hemivagina]

Didelphys uterus with imperforated obstructed hemivagina is a rare condition. Most often, it is diagnosed a few months after the menarche. Hematocolpos, hematometria and sometimes hematosalpinx are responsible for pelvic pain and dysmenorrhea. Symptoms can be delayed when a fistulisation from the hematocolpos to permeable contralateral vagina is present. Sometimes, diagnosis is not made before adulthood during an infection of the hematocolpos. Useful additional exams include pelvic ultrasound and, in some cases, MRI, which is the best exam to precisely describe the type of malformation. An ipsilateral agenesia of the kidney is always associated. Hysterography can usually demonstrate the fistulous courses. Treatment consists in a large resection of the vaginal septum in order to allow a permanent drainage of the hemiuterus. A laparoscopy should be performed to check for the presence of associated tubal or pelvic damage.

[Update in tocolysis]

Preterm birth is the most common underlying cause of perinatal morbidity and mortality in nonanomalous infants. Treatment of preterm labor with tocolytic medication is an important part of improving perinatal outcome. Choosing a tocolytic agent requires consideration of efficacy and safety. It is the aims of the present research.

Defensins induce the recruitment of dendritic cells in cervical human papillomavirus-associated (pre)neoplastic lesions formed in vitro and transplanted in vivo

In addition to their direct antimicrobial activity, defensins might also influence adaptive immunity by attracting immature dendritic cells (DC). As these cells have been shown to be deficient in uterine cervix carcinogenesis, we evaluated the ability of alpha-defensin (HNP-2, human neutrophil defensin 2) and beta-defensin (HbetaD2, human beta defensin 2) to stimulate their migration in human papillomavirus (HPV)-associated (pre)cancers. We first observed, using RT-PCR and immunohistology, that HbetaD2 is absent in HPV-transformed keratinocytes and that it is weakly expressed in cervical (pre)neoplastic lesions in comparison with normal keratinocytes. We next demonstrated that defensins exert a chemotactic activity for DC in a Boyden Chamber assay and stimulate their infiltration in an in vitro-formed (pre)neoplastic epithelium (organotypic culture of HPV-transformed keratinocytes). To evaluate the ability of defensins also to recruit DC in vivo, we developed a model of immunodeficient mice grafted with organotypic cultures of HPV+ keratinocytes, which form an epithelium similar to a high-grade neoplastic lesion, with tumoral invasion and neovascularization. Intravenously injected human DC were able to infiltrate grafts of HPV+ keratinocytes after administration of HNP-2 in the transplantation chamber. Taken together, these results suggest that defensins could reverse a frequent immune alteration observed in cancer development.

[Genetic variation and recombination have profound medical implications]

In the family Herpesviridae, the subfamily Alphaherpesvirinae contains numerous pathogenic viruses, i.e. herpes simplex and varicella-zoster viruses. These double-stranded DNA viruses exhibit a complex cycle combining lytic and latent infections. Moreover, both intranuclear replication and a sophisticated DNA replication machinery allow an efficient proof-reading mechanism of correction. A low mutation rate is therefore encountered by these viruses. Recombination can be identified as a key element of the genetic biodiversity of alphaherpesviruses, together with mutations. The experimental data recently obtained in the bovine herpesvirus 1 homologous model support the importance of recombination in alphaherpesvirus evolution and its role in the mechanisms involved by the virus to escape from medical tools of prevention and treatment.

[Fetal RHD in maternal plasma in prenatal follow-up]

Since the beginning of RHD genotyping in maternal plasma, no Rh D positive baby was diagnosed RHD negative in our institution. Genotyping from circulating DNA in maternal plasma is as efficient as genotyping on amniocyts but without the associated risks. We propose a prophylactic injection based on fetal genotyping RHD in maternal blood with 300 microg anti-D immunoglobulin at 28 weeks of amenhorrea in all of Rh D negative pregnant women whitch fetuses positive RHD.

[How I treat: an ectopic pregnancy]

Nowadays, the management of ectopic pregnancy should be codified as often as possible. Two types of treatment are possible. One surgical and the other medical. Our study is concerned with a series of 97 patients hospitalized for suspicion of ectopic pregnancy for whom the risk factors and treatment were analyzed. Our conclusion is that the medical treatment should be more frequently proposed and surgery should prefer the conservative treatment whenever it is still possible.

[New approaches to prenatal diagnosis of rhesus incompatibility]

Despite generalisation of anti-D immunoprophylaxis, RhD allo-immunisation still remains the major cause of severe haemolytic disease of the fetus and of the newborn (HDFN). The routine follow up of pregnant women comprises: the ABO/D, Rh/Kell red cells typing and the search for irregular antibodies. In case of anti-D immunisation, the paternal Rh phenotype, when known, provides useful information regarding the probability for the fetus to have inherited the D antigen and thereby to be exposed to the risk of HDFN. The antibody titre, which is predictive of possible in vivo haemolysis, must be interpreted in the light of the previous obstetric history, and can lead to the decision of invasive amniocentesis. Then the measurement of the optical density (deltaOD450 nm) and the fetal RhD typing can be realised on amniotic fluid. New molecular techniques make it possible now to demonstrate the presence of fetal DNA in maternal plasma. These methods lying on non invasive procedures could advantageously be applied to the genotyping of fetal RHD during pregnancy. The present paper aims to discuss the predictive values of RHD fetal genotype in maternal plasma of RhD negative mothers. The ante-partum management of immunised pregnant women is reviewed in the light of this new molecular approach combined to Doppler ultrasonography of the fetal middle cerebral artery. This non invasive method for determining fetal RHD genotype could be systematically proposed to all RhD negative pregnant women for a better targeted prenatal follow-up and an increased efficacy of RhD prophylaxis.

[Uterine perforation by an intrauterine device]

The intrauterine device (IUD) is a widely used, effective and reversible means of birth control. Its insertion can be associated with perforation of the utuerus. This is a rare complication, but with possible serious clinical consequences. There is an increased risk of uterine perforation if the IUD is inserted during 6 months of post-partum or after uterine evacuation. A follow up by sonography is essential. The surgical removal of the ectopic IUD is imperious.

[What's new at the maternal-foetal interface: role of the hCG/LH-hCG receptor couple during embryo implantation]

Implantation of the embryo into the maternal endometrium represents a unique biological process, combining an immunological (tolerance of an allograft) and biological (adhesion of two epitheliums) paradox. The success of implantation depends on a receptive endometrium, a functionally normal blastocyst and a synchronized cross-talk between embryonic and maternal tissues. Though sexual steroids control the process, a cascade of growth factors or cytokines are the prime paracrine mediators of the dialogue at the maternal-embryonic interface. HCG is one of the molecules most precociously produced by the embryo and is the most specific marker of its presence. HCG is a luteotropic factor which relays the inadequate support provided by the reduced rates of LH, but also influences the pregnancy on a paracrine mode by a local action on implantation process, probably by interacting with its receptor, the LH/hCG-R that we have evidenced on endometrial epithelium. We demonstrate that embryo actively participate into its implantation, tolerance and placentation.

[Vulvovaginal candidiasis: prevalence of different Candida species in the Liege region]

We calculated the prevalences of different yeast species isolated from more than 20,000 vulvovaginal specimens carried out at the CHR hospital in Liege. To assess the value of the observed relative frequencies, the culture results of 149 samples were confronted with those of a real-time PCR technique of fungal identification. With a prevalence close to 90%, Candida albicans remains the largely dominant species. In contrast with other teams, we observed no increase of the prevalences of Candida non-albicans species.

[A bilateral dysgerminoma: a rare presentation of the Swyer syndrome]

Swyer syndrome is a pure gonad dysgenesis associating 46 XY karyotype, primary amenorrhea, presence of female internal genital tract and bilateral streak gonads in a phenotypic female. The diagnosis is usually made at adolescence when the primary amenorrhea is investigated. We report the case of a 25-year-old XY woman who developed a bilateral dysgerminoma from undifferentiated gonads.

[Gestational diabetes: an update]

Gestational diabetes mellitus is one of the major medical complications of pregnancy. This review describes the short and long term consequences of this affection, the screening strategy and the diagnosis approach. The obstetrical management and the diabetes treatment with dietary strategies reducing carbohydrate intake and minimising the postprandial glucose levels are explained. Insulin treatment indication, place of insulin analogues, and use of oral antihyperglycaemic agents are also discussed.

Le streptocoque du groupe B en clinique anténatale et en salle de travail : un problème d’attitude systématique

OBJECTIVES

We wanted to evaluate the compliance to the local recommendations, similar to the CDC (Centers for Disease Control and prevention) recommendations launched in 1996, for the prevention of perinatal group B streptococcal (GBS) disease in the clinical practice of a academic maternity and to identify the causes of missed screening and antibiotic prophylaxis.

MATERIALS AND METHODS

Retrospective study of 1249 consecutive pregnancies between 1st January and 31th August 2002. The screening methods for GBS colonisation were the culture of rectovaginal swabs collected between 35 and 37 weeks and/or a rapid antigenic screening performed on a vaginal swab collected at the patient's admission for labor.

RESULTS

Rate of global screening was very high (97.8%): 28.8% of antenatal screening versus 90.3% during labor. An appropriate antibiotic prophylaxis was administered to only one-third of positive women when the screening was performed at admission to the labor room, whereas two-thirds of GBS-positive women screened between 35 and 37 weeks received their antibiotic prophylaxis. 2.4%o of the newborns were infected and 2.9% were colonized. Among the different risk factors, intrapartum fever was more often associated with maternal GBS colonisation. The observed sensitivity of the rapide antigenic test was 20.4%.

CONCLUSION

Compliance to guidelines is sometimes difficult in the clinical practice of an academic maternity. In our hands the rapid test for GBS screening had low sensitivity. The analysis of these data led to introducing a computerized algorithm in our maternity to improve the prevention of perinatal group B streptococcal disease.

The effect of tibolone in postmenopausal women receiving tamoxifen after surgery for breast cancer: a randomised, double-blind, placebo-controlled trial

OBJECTIVE

To assess the effects of tibolone on climacteric symptoms, endometrium and serum lipid/lipoproteins in postmenopausal women receiving tamoxifen after surgery for breast cancer.

DESIGN

Double-blind, randomised, placebo-controlled, multicentre pilot study.

SETTING

Hospital outpatient clinic.

SAMPLE

Seventy postmenopausal women receiving tamoxifen following surgery for early breast cancer.

METHODS

Women received 20 mg/day oral tamoxifen plus either 2.5 mg/day oral tibolone or placebo for 12 months.

MAIN OUTCOME MEASURES

Frequency and severity of hot flushes (diary cards); intensity of hot flushes and sweats (Landgren scale); interference of hot flushes and sweats with normal life; frequency and intensity of other climacteric symptoms; endometrial thickness and histology; vaginal bleeding; breast cancer recurrence and serum lipid/lipoproteins.

RESULTS

Daily card data showed no change in the daily number of hot flushes with either tibolone or placebo (P= 0.219) after three months. There was a significant reduction in the severity of flushes with tibolone compared with placebo (-0.4 vs 0.2, P= 0.031). The Landgren scale showed a mean change in the number of hot flushes of -0.6 with tibolone and +1.1 with placebo after 12 months (P= 0.022). Endometrial biopsies were normal and vaginal bleeding was similar in both groups. A significant decrease in triglycerides (-23% vs 1.4%) and HDL (-12% vs 19%) was seen with tibolone compared with placebo after 12 months.

CONCLUSIONS

Tibolone prevented an increase in hot flushes in postmenopausal women given tamoxifen following surgery for breast cancer without untoward effects on the endometrium. Beneficial effects on serum lipid profile were noted.

Membrane associated proteases and their inhibitors in tumour angiogenesis

Cell surface proteolysis is an important mechanism for generating biologically active proteins that mediate a range of cellular functions and contribute to biological processes such as angiogenesis. Although most studies have focused on the plasminogen system and matrix metalloproteinases (MMPs), recently there has been an increase in the identification of membrane associated proteases, including serine proteases, ADAMs, and membrane-type MMPs (MT-MMPs). Normally, protease activity is tightly controlled by tissue inhibitors of MMPs (TIMPs) and plasminogen activator inhibitors (PAIs). The balance between active proteases and inhibitors is thought to determine the occurrence of proteolysis in vivo. High concentrations of proteolytic system components correlate with poor prognosis in many cancers. Paradoxically, high (not low) PAI-1 or TIMP concentrations predict poor survival in patients with various cancers. Recent observations indicate a much more complex role for protease inhibitors in tumour progression and angiogenesis than initially expected. As knowledge in the field of protease biology has improved, the unforeseen complexities of cell associated enzymes and their interaction with physiological inhibitors have emerged, often revealing unexpected mechanisms of action.

Percutaneous stereotactic en bloc excision of nonpalpable breast carcinoma: a step in the direction of supraconservative surgery

Recently, the advanced breast biopsy instrumentation (ABBI) system has been introduced as an alternative to conventional breast biopsy techniques. This study was prospectively conducted to evaluate the potential of the ABBI method in locoregional management of a consecutive series of patients with nonpalpable mammographically detected breast carcinomas. Sixty-one consecutive patients underwent an ABBI procedure as a first step before possible surgery for nonpalpable breast lesions that would in any case require complete excision. For the 27 patients in whom the ABBI biopsy revealed malignancy further surgery was recommended, including re-excision of the biopsy site and axillary dissection in cases of infiltrating carcinoma. We calculated the probabilities that the ABBI specimen would have tumor-free margins and that a definitely complete excision had been achieved as a function of the mammographic or pathological diameter of the cancer. For cancer with a pathological diameter less than 10 mm measured on the ABBI specimen, the probability (92%) of obtaining complete resection was significantly better than for larger lesions (P=0.01, Fisher's exact test). Although the therapeutic perspectives for the ABBI method are limited at present, we suggest that this approach is a first step in the direction of a surgical strategy that is better adapted to the pathological characteristics peculiar to these small tumors, whose incidence is increasing.

Mode d’accouchement des femmes avec une présentation du siège à terme dans l’étude PREMODA (PREsentation et MODe d’accouchement)

OBJECTIVES

The purpose of this work was to report labor and birth management practices for term breech presentation in France and Belgium in 2001-2002 and to describe indications for cesarean sections (before labor, emergency situations) in breech presentations.

MATERIAL AND METHODS

The PREMODA cohort is a survey population which included 19408 deliveries, 8108 of which were term breech presentations.

RESULTS

Infants were delivered by cesarean section before labor (59.1%), emergency cesarean section during labor (18.4%) or vaginally (22.5%). The decision for cesarean section before labor was empirical (breech presentation) in 44.3% of the cases. Half of the cesarean sections performed during labor (n=704, 49.3%) were planned C-sections. Overall, 67.8% of the breech presentations were delivered during planned cesarean sections (before or during labor). When vaginal delivery was attempted, the rate of vaginal birth was 70%.

CONCLUSION

These early results reveal a high rate of cesarean section as well as differences in inter-regional practices. Considering all cesarean sections performed before labor, the most frequent indication was an empirical decision because of the breech presentation. An increased rate of planned cesarean section does not reduce the rate of vaginal delivery when attempted.

[Comparison of changes in biochemical markers of bone turnover after 6 months of hormone replacement therapy with either transdermal 17 beta-estradiol or equine conjugated estrogen plus nomegestrol acetate]

OBJECTIVE

To compare changes in biochemical markers of bone turnover in postmenopausal women who received sequential discontinuous hormone replacement therapy (HRT) with either transdermal 17 beta-estradiol gel (group 1) or oral equine sulfoconjugated estrogen (group 2), plus nomegestrol acetate.

PATIENTS AND METHOD

Prospective, open, randomized, controlled trial, conducted on 3 parallel groups of 106 postmenopausal women. All treated groups received estrogen therapy for 25 consecutive days every month. The estrogen used was either 1.5 mg/day of transdermal 17 beta-estradiol gel (group 1) [N = 42, average age (AA) = 51.6 years, average duration of menopause (ADM = 21.5 months)], or 0.625 mg/day of oral equine sulfoconjugated estrogen (group 2) [N = 39, AA = 51.3 years, ADM = 16.8 months]. In all cases nomegestrol acetate 5 mg/day was added for 12 consecutive days every month. The control group comprised 25 patients, [AA = 53.4 years, ADM = 33.7 months]. Two bone resorption markers: urinary cross-linked N-telopeptide and C-telopeptide of type I collagen (U-NTX/Cr, U-CTX/Cr), and a bone formation marker: serum bone specific alkaline phosphatase activity were measured before and 6 months after treatment start.

RESULTS

Significant decreases from baseline values were observed for the 3 biochemical markers in both treated groups compared with control (P < 0.001). There were no significant differences in changes between the 2 treated groups for the 3 biochemical markers. The mean percentage change in the 3 biochemical markers was: from -9.3 to -45.5% in group 1, from -20.5 to -39% in group 2, and from -3.3 to 2% in control group. In group 1, the mean percentage decreases in U-CTX reached optimal threshold of bone turnover change (-45%) which is considered by the International Osteoporosis Foundation as clinically relevant because it predicts an increase in BMD greater than 3% when treatment is maintained over a long term.

DISCUSSION AND CONCLUSION

Both treated groups induced a significant comparable decrease of bone turnover markers after 6 months of intervention, compared with control. The group treated with cyclic administration of transdermal 17 beta-estradiol (1.5 mg/day) and nomegestrol acetate (5 mg/day) showed a bone resorption markers decrease corresponding to the threshold of clinical relevance described in the international literature and predictive of positive BMD response in long term.

[Anemia associated with malaria and intestinal helminthiasis in Lubumbashi]

The purpose of this study is to evaluate and determine the prevalence of anemia and associated factors (malaria and intestinal helminthiasis) in some high risk groups, especially in pregnant and breast-feeding women and in children aged 1-2 years old from within a deprived semi-urban population of Lubumbashi (Bongonga and Sendwe). These results were compared to those obtained from an urban population having a more satisfying socio-economic situation (University Clinics). The overall frequency of anemia in the subjects studied from the three centres varies from 50-80%. The proportion of anemic cases is clearly higher in the Bongonga and Sendwe populations (70-80%) than in that of the urban group (50%) (P < 0.05). Among all of the subjects examined, pregnant women are found to be the group with the highest proportion of anemic patients (P < 0.05). All things considered, anemia is associated with malaria in 40% of the cases and with intestinal parasitism (Ascaris and/or Ankylostome infestation) in 9%. Faced with such a situation, the strategy to fight against anemia and associated parasitosis demands and requires multi-disciplinary actions centred on health education, collective screening and specific anti-parasite treatment.

[Hormone replacement therapy one year after the results of the Women's Health Initiative]

The currently reported data concerning the large WHI randomized controlled trial compare the impact of continuous combined conjugated estrogens + medroxyprogesterone acetate vs placebo in postmenopausal women. These results appear largely pessimistic. After 5.2 years of hormone replacement, an excess of coronary heart disease, cerebrovascular disease, venous thromboembolism, breast cancer incidence and extension, mild cognitive impairment and dementia is recorded. By contrast, osteoporotic fracture risk and colorectal cancer are decreased during hormone replacement. Accordingly, this hormonal treatment can no longer be recommended on a long term basis, except after extensive risk-benefit balance evaluation. It should no longer be prescribed for prevention of chronic diseases. It remains indicated during 4-5 years for relief of vasomotor symptoms, genital atrophy and, potentially, for some aspects of quality of life. HRT should probably be prescribed in minimal-effective dosages; new regimens, routes of administration, new compounds and associations should be envisaged in order to avoid cardiovascular or breast problems. However these new approaches ask for thorough validation studies.