[Review of the literature on intrauterine and birthweight charts]

OBJECTIVES

To describe the main intrauterine and birthweight charts and review the studies comparing their performance for the identification of infants at risk of adverse perinatal outcomes.

METHODS

We carried out a literature search using Medline and selected the charts most frequently cited in the literature, French charts and those recently published.

RESULTS

Current knowledge on the association between mortality and morbidity and growth anomalies (small and large for gestational age) mostly relies on the use of descriptive charts which describe the weight distribution in unselected populations. Prescriptive charts, which describe ideal growth in low risk populations, have been constructed more recently. Few studies have evaluated whether the thresholds used to identify infants at risk with descriptive charts (such as the 3^rd or the 10^th percentile) are applicable to prescriptive charts. There is a large variability in the percentage of fetuses or newborns identified as being at risk by each chart, with from 3 to 25% having with a weight under the 10^th percentile, regardless of whether descriptive or prescriptive charts are used. The sensitivity and specificity of antenatal screening for small or large for gestational age newborns depends on the chart used to derive estimated fetal weight percentiles.

CONCLUSION

There is marked variability between intrauterine growth charts that can influence the percentage of infants identified as having abnormal growth. These results show that before the adoption of a growth chart, it is essential to evaluate whether it adequately describes the population and its performance for identifying of infants at risk because of growth anomalies.

[COSA 80: Oncologic surgery in the elderly patients]

INTRODUCTION

Due to longer life expectancy, an increasing number of older people are at risk of developing cancer. Surgical resection of a non-metastatic and resectable digestive tumor remains the main therapeutic weapon. The objective of our study is to assess the possibility of curative oncological surgery in patients over 80years of age, to study its impact in terms of morbidity and mortality, and to look for risk factors for the occurrence of complications.

PATIENTS AND METHODS

The study-included patients aged 80 and over operated on for digestive cancer in a curative situation. This was a multicenter prospective cohort study. A total of 230 patients were included in the study. In addition to demographic and medical data, the patients all benefited from an onco-geriatric assessment with the performance of various tests: WHO score, G8 score, IADL score, ADL score, mobility score, nutritional assessment, clock, thymic evaluation (Mini-GDS). Data collection of geriatric scores was repeated 3months postoperatively.

RESULTS

Of a total of 230 patients, 51% were male and 49% female. The average age was 84.7years. Tumor localization was mainly colorectal (65.81%). Age had no influence on the mortality rate, with a mean age with no significant difference in the event of an unfavorable outcome or not (84.6 vs. 85years). The results at the different scores were then analyzed in search of a significant difference between preoperative and at 3months. The only significant difference found was in the number of patients with a WHO status of 0 (P=0.021).

CONCLUSION

Our study shows that curative oncological surgery is possible in elderly patients without any adverse effect on their quality of life and level of postoperative autonomy. The multidisciplinary geriatric approach to the patient must make it possible to distinguish the patients who will benefit from a curative treatment and those in whom the benefit-risk balance is unfavorable.

[Cardiovascular protection of diabetic patient with chronic renal disease and particular case of end-stage renal disease in elderly patients]

Type 2 diabetes has an increasing prevalence. Life expectancy is dominated by cardiovascular risk, which is the leading cause of death in these patients. Up to one third of diabetic patients will develop diabetic nephropathy related to micro-angiopathy. Renal impairment further increases cardiovascular risk. Reducing cardiovascular morbidity and mortality is a major public health issue, as well as early preventing and managing chronic kidney disease (CKD). Good glycemic control prevents the micro-vascular complications of the disease (retinopathy, nephropathy, etc.) and, more recently recognized through prolonged monitoring of the VADT cohort, prevents cardiovascular complications. Control of blood pressure and dyslipidemia are essential in primary or secondary cardiovascular prevention. In addition, the blockers of the renin-angiotensin system slow down the progression of the MRC. Elderly patients with chronic kidney disease (CKD) form another growing group of the nephrologist daily patient pool. Especially for very elderly patients with comorbidities, the question of favoring conservative treatment rather than starting or pursuing dialysis may arise. Survival and quality of life are indeed not necessarily better in elderly patients undergoing dialysis, complications can occur eventually leading to discontinuation, and are occasionally associated with a feeling of stubbornness. Creation of prognostic score is a useful tool to help the decision-making process. However, dialogue with the patient and his/her family, as well as multidisciplinary collaboration remain fundamentals to determine the most suitable care.

[Do initial experience with an enhanced recovery program after surgery (ERAS) improve postoperative outcomes after cystectomy?]

OBJECTIVE

To estimate the feasibility and the impact of an ERAS program after radical cystectomy for bladder cancer.

MATERIALS AND METHODS

This was a retrospective study comparing a historical pre ERAS group, including all the patients undergoing cystectomy for bladder cancer from January 2013 to December 2015 with a classic procedure, and an interventional ERAS group after introducing an enhanced recovery protocol before, during and after surgery, from February 2016. The principal outcome was the postoperative length of stay. Secondary outcomes mesures were impact on perioperative complication rate (Clavien classification≥3B), readmission rate, reanimation length of stay, ileus rate and adherence to the ERAS protocol.

RESULTS

There were no differences between the 2 groups as far as demographics characteristics are concerned. In total, 97 patients were included, 56 in the control group, and 41 in the ERAS group. The adherence to the protocol was about 65.8%. The ERAS group had statistically significantly shorter median length of stay (D19 versus D14; P: 0.021). The major complications rate (Clavien≥3B) were about 23.2% for the control group and 12.1% for the ERAS group (P: NS). The reinsertion of nasogastric tube were higher in the control group (39.3% vs 21.9%; P: NS) and the readmission rate was about 7.1% in the control group versus 14.6% in the ERAS group (P: NS).

CONCLUSION

In conclusion, introduction and application of an enhanced recovery protocol (ERAS) after cystectomy for bladder cancer allowed for better management of postoperative outcomes. It is clearly feasible in cystectomy, and improve significantly the median postoperative length of stay. Moreover, it may be effective in terms of faster return of bowel function and reduction of majors complications.

LEVEL OF EVIDENCE

4.

[Caesarean at the Gabriel Touré University Hospital of Bamako: factors of morbi-mortality]

INTRODUCTION

Following the progress made regarding anesthesia reanimation, caesarean have become a much safer procedure. However, factors of mobi-mortality are still numerous. The main objective of this study was to analyze the factors of morbi-mortality arising during a caesarean.

PATIENT AND METHOD

A retrospective cross-sectional study was conducted from January 2007 to December 2011 in the gynecology-obstetric and anesthesia reanimation services of the Gabriel TOURE University Hospital. The analysis looked at the medical files of women undergoing a caesarean and hospitalized in the gynecology-obstetric and anesthesia reanimation services. Data analysis was carried out with SPSS.19 (Statistical Package for Social Sciences) and the Epiinfo.7 softwares. Chi² tests were performed to compare frequencies where a value of p≤0.05 was considered statistically significant.

RESULTS

269 medical files were analysed. Mean age was of 28.46 ± 6.702. The most frequent peroperative morbidity factors were cardiovascular. Death rate was of 5.2%. The most frequent cause of these deaths was eclampsia. Factors influencing morbi-mortalities were iterative caesareans and urgency of the caesarean. The evacuated mothers had presented complications in 37.3% of cases.

CONCLUSION

The caesarean is a procedure that is not sufficiently safe in our services and there are a lot of factors of mobi-mortality.

[Cardiac rehabilitation after myocardial infarction]

Although the proofs of the benefits of cardiac rehabilitation accumulate, many patients are not sent to rehabilitation units, especially younger and very elderly patients. As the length of stay in acute care units decreases, rehabilitation offers more time to fully assess the patients' conditions and needs. Meta-analyses of randomised trials suggest that mortality can be improved by as much as 20-30%. In addition, rehabilitation helps managing risk factors, including hyperlipidemia, diabetes, smoking and sedentary behaviours. Physical training also helps improving exercise capacity. Because of all of these effects, cardiac rehabilitation for post-myocardial infarction patients has been given a class IA recommendation in current guidelines.