Durvalumab impacts progression-free survival while high-dose radiation >66 Gy improves local control without excess toxicity in unresectable NSCLC stage III: Real-world data from the Austrian radio-oncological lung cancer study association registry (ALLSTAR)

BACKGROUND

Chemo-radioimmunotherapy with total radiation doses of 60-66 Gy in 2 Gy fractions is the standard of care for non-small cell lung cancer (NSCLC) UICC stage III. The Austrian radio-oncological lung cancer study association registry (ALLSTAR) is a prospective multicentre registry intended to document clinical practice at the beginning of the Durvalumab era.

PATIENTS AND METHODS

Patients were eligible if they had pathologically verified unresectable NSCLC stage III with a curative treatment option. Chemo-radiation combined with immunotherapy was performed according to local treatment practices. The endpoints were local control (LC), progression-free survival (PFS) and toxicity.

RESULTS

Between 2020/03 and 2023/04, 12/14 (86 %) Austrian radiation-oncology centres recruited 188 patients (median 17, range: 1-89). PD-L1 testing was performed in 173/188 (93 %) patients. The median interval between the end of chemoradiotherapy and start of Durvalumab was 14 days (range: 1-65). About 40 % (75/188) of the patients received a total radiation dose of > 66 Gy (range: 67.1-100), which improved 2-year LC (86 % versus 60 %, HR = 0.41; 95 %-CI: 0.17-0.98; log-rank p-value < 0.05). Median PFS for patients with Durvalumab was 25.8 months (95 %-CI: 21.9-not reached) compared to 15.7 months (95 %-CI: 13.2-27.8) for those without (HR = 1.88; 95 %-CI: 1.16-3.05; log-rank p-value < 0.01). The rates of esophageal and pulmonary toxicities were 34.6 % and 23.9 %, respectively, including one case of grade 4 pneumonitis. In the subcohort of 75 patients who received > 66 Gy, 19 (25 %) cases of pulmonary toxicity grades 1-3 were observed.

CONCLUSION

While Durvalumab impacts PFS, LC can be improved by total radiation doses > 66 Gy without excess toxicity.

Coagulation factor XIII is a critical driver of liver regeneration after partial hepatectomy

BACKGROUND

Activation of coagulation and fibrin deposition in the regenerating liver appears to promote adequate liver regeneration in mice. In humans, perioperative hepatic fibrin deposition is reduced in patients who develop liver dysfunction after partial hepatectomy (PHx), but the mechanism underlying reduced fibrin deposition in these patients is unclear.

METHODS AND RESULTS

Hepatic deposition of cross-linked (ie, stabilized) fibrin was evident in livers of mice after two-thirds PHx. Interestingly, hepatic fibrin cross-linking was dramatically reduced in mice after 90% PHx, an experimental setting of failed liver regeneration, despite similar activation of coagulation after two-thirds or 90% PHx. Likewise, intraoperative activation of coagulation was not reduced in patients who developed liver dysfunction after PHx. Preoperative fibrinogen plasma concentration was not connected to liver dysfunction after PHx in patients. Rather, preoperative and postoperative plasma activity of the transglutaminase coagulation factor (F)XIII, which cross-links fibrin, was lower in patients who developed liver dysfunction than in those who did not. PHx-induced hepatic fibrin cross-linking and hepatic platelet accumulation were significantly reduced in mice lacking the catalytic subunit of FXIII (FXIII-/- mice) after two-thirds PHx. This was coupled with a reduction in both hepatocyte proliferation and liver-to-body weight ratio as well as an apparent reduction in survival after two-thirds PHx in FXIII-/- mice.

CONCLUSION

The results indicate that FXIII is a critical driver of liver regeneration after PHx and suggest that perioperative plasma FXIII activity may predict posthepatectomy liver dysfunction. The results may inform strategies to stabilize proregenerative fibrin during liver resection.

Inelastic mean-free path and mean escape depth of 10-140 eV electrons in SiO2 nanoparticles determined by Si 2p photoelectron yields

We report on photoelectron spectra of SiO₂ nanoparticles (d = 157 ± 6 nm) above the Si 2p threshold in the photon energy range 118-248 eV with electron kinetic energy 10-140 eV and analyze the photoelectron yield as a function of photon energy. Comparison of the experimental results with Monte-Carlo simulations on electron transport allows us to quantify the inelastic mean-free path and mean escape depth of photoelectrons in the nanoparticle samples. The influence of the nanoparticle geometry and electron elastic scattering on photoelectron yields is highlighted. The results show that the previously proposed direct proportionality of the photoelectron signal to the inelastic mean-free path or the mean escape depth does not hold for photoelectron kinetic energies below 30 eV due to the strong influence of electron elastic scattering. The present results deviate for photoelectron kinetic energies below 30 eV from the previously proposed direct proportionality of the photoelectron signal to the inelastic mean-free path or the mean escape depth, which is the result of a strong influence of electron elastic scattering. The presented inelastic mean-free paths and mean escape depths appear to be useful for the quantitative interpretation of photoemission experiments on nanoparticles and for modeling of the experimental results.

An adapted passive model of anti-MPO dependent crescentic glomerulonephritis reveals matrix dysregulation and is amenable to modulation by CXCR4 inhibition

Anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitides (AAV) are severe inflammatory disorders that often involve focal necrotizing glomerulonephritis (FNGN) and consequent glomerular scarring, interstitial fibrosis, and chronic kidney disease. Robust murine models of scarring in FNGN that may help to further our understanding of deleterious processes are still lacking. Here, we present a murine model of severe FNGN based on combined administration of antibodies against the glomerular basement membrane (GBM) and myeloperoxidase (MPO), and bacterial lipopolysaccharides (LPS), that recapitulates acute injury and was adapted to investigate subsequent glomerular and interstitial scarring. Hematuria without involvement of other organs occurs consistently and rapidly, glomerular necrosis and crescent formation are evident at 12 days, and consequent glomerular and interstitial scarring at 29 days after initial treatment. Using mass-spectrometric proteome analysis, we provide a detailed overview of matrisomal and cellular changes in our model. We observed increased expression of the matrisome including collagens, fibronectin, tenascin-C, in accordance with human AAV as deduced from analysis of gene expression microarrays and tissue staining. Moreover, we observed tissue infiltration by neutrophils, macrophages, T cells and myofibroblasts upon injury. Experimental inhibition of CXCR4 using AMD3100 led to a sustained histological presence of fibrin extravasate, reduced chemokine expression and leukocyte activation, but did not markedly affect ECM composition. Altogether, we demonstrate an adapted FNGN model that enables the study of matrisomal changes both in disease and upon intervention, as exemplified via CXCR4 inhibition.

Murine Ex Vivo Cultured Alveolar Macrophages Provide a Novel Tool to Study Tissue-Resident Macrophage Behavior and Function

Tissue-resident macrophages are of vital importance as they preserve tissue homeostasis in all mammalian organs. Nevertheless, appropriate cell culture models are still limited. Here, we propose a novel culture model to study and expand murine primary alveolar macrophages (AMs), the tissue-resident macrophages of the lung, in vitro over several months. By providing a combination of granulocyte-macrophage colony-stimulating factor, TGFβ, and the PPARγ activator rosiglitazone, we maintain and expand mouse ex vivo cultured AMs (mexAMs) over several months. MexAMs maintain typical morphologic features and stably express primary AM surface markers throughout in vitro culture. They respond to microbial ligands and exhibit an AM-like transcriptional profile, including the expression of AM-specific transcription factors. Furthermore, when transferred into AM-deficient mice, mexAMs efficiently engraft in the lung and fulfill key macrophage functions, leading to a significantly reduced surfactant load in those mice. Altogether, mexAMs provide a novel, simple, and versatile tool to study AM behavior in homeostasis and disease settings.

Clinical profiles of placenta accreta spectrum: the PACCRETA population-based study

OBJECTIVE

To describe and compare the characteristics of women with placenta accreta spectrum (PAS) and their pregnancy outcomes according to the presence of placenta praevia and a prior caesarean section.

DESIGN

Prospective population-based study.

SETTING

All 176 maternity hospitals of eight French regions.

POPULATION

Two hundred and forty-nine women with PAS, from a source population of 520 114 deliveries.

METHODS

Women with PAS were classified into two risk-profile groups, with or without the high-risk combination of placenta praevia (or an anterior low-lying placenta) and at least one prior caesarean. These two groups were described and compared.

MAIN OUTCOME MEASURES

Population-based incidence of PAS, characteristics of women, pregnancies, deliveries and pregnancy outcomes.

RESULTS

The PAS population-based incidence was 4.8/10 000 (95% CI 4.2-5.4/10 000). After exclusion of women lost to follow up from the analysis, the group with placenta praevia and a prior caesarean included 115 (48%) women and the group without this combination included 127 (52%). In the group with both factors, PAS was more often suspected antenatally (77% versus 17%; P < 0.001) and more often percreta (38% versus 5%; P < 0.001). This group also had more hysterectomies (53% versus 21%, P < 0.001) and higher rates of blood product transfusions, maternal complications, preterm births and neonatal intensive care unit admissions. Sensitivity analysis showed similar results after exclusion of women who delivered vaginally.

CONCLUSION

More than half the cases of PAS occurred in women without the combination of placenta praevia and a prior caesarean delivery, and these women had better maternal and neonatal outcomes. We cannot completely rule out that some of the women who delivered vaginally had placental retention rather than PAS; however, we found similar results among women who delivered by caesarean.

TWEETABLE ABSTRACT

Half the women with PAS do not have both placenta praevia and a prior caesarean delivery, and they have better maternal outcomes.

[Propositions for perinatal care at extremely low gestational ages - Working group on "Extremely low gestational ages" for SFMP, CNGOF, and SFN]

OBJECTIVES

International literature suggests that active perinatal management at extremely low gestational ages improves survival without increasing the risk of impairment in survivors, compared to less active management. Although these results are limited to a small number of countries, they question current practices in France. New propositions on perinatal management of extremely preterm infants have carried out by the French Society of Perinatal Medicine, the French Society of Neonatology and the National College of French Obstetricians and Gynecologists.

METHODS

This group was set up in 2015 on the initiative of the professional societies and in collaboration with parents' and users' associations. The work was based on a review of the literature on the prognosis of extremely preterm children, as well as on recommendations by European societies. Based on this information, a text was produced, submitted to all members of the working group and definitively validated in April 2019.

RESULTS

This text offers a decision-making guideline for the management at extremely low gestational ages. Its principles are: the administration of steroids independently of management (resuscitation or comfort care); a prognostic evaluation and a collegial decision, outside the context of the emergency; a consensus on the information to be given to parents before going to inform them and gather their opinion.

CONCLUSIONS

These new propositions will contribute to modifying perinatal care at extremely low gestational ages in France.

Size-dependent ion emission asymmetry of free NaCl nanoparticles excited by intense femtosecond laser pulses

We report on asymmetric ion emission of size-selected NaCl nanoparticles (d = 100-600 nm) ionized by intense femtosecond laser pulses (λ = 800 nm, peak intensity ∼1013 W cm-2). Velocity map imaging indicates that a higher ion yield is observed in the propagation direction of the laser pulses than in the opposite direction. This asymmetric ion emission is found to be size-dependent and increases with particle size. This pronounced size dependence is interpreted in terms of discrete dipole simulations of the internal electric field in the nanoparticles, which reveal that the internal field is enhanced in the forward propagation direction of the laser pulses, occurring for nanoparticles >100 nm. The ion emission asymmetry is further found to depend on the peak intensity of the laser radiation. Nanoparticles of 100 nm show a symmetric distribution of ion emission, while the ion emission for 600 nm particles is found to become increasingly symmetric as the peak intensity is increased. In addition to single pulse ionization experiments, we explore the angular distribution of ion emission of resonantly heated NaCl nanoparticles using a pump-probe setup. Here, ion emission is found to be more symmetric for resonantly heated nanoparticles than for single pulse excitation. These differences are explained by the absorption mechanism, where the probe pulse in a dual pulse experiment can be efficiently absorbed by plasmonic excitation for suitable delays between both laser pulses.

Aspects of the Ageing of Elastomeric Materials

Rising raw materials prices and increasing customer demands for reliability and durability mean that there is huge interest in finding more and more ways of improving the service life of elastomeric products, for economic and environmental reasons, by boosting their resistance under the relevant operating conditions. The material-dependent oxygen absorption capacity and oxygen permeability play an important role in oxidative ageing processes and their modelling. Thus, ageing resistance is substantially dependent on the rate of oxygen diffusion into the bulk of the material in the case of thermo-oxidative attack. To evaluate the resistance of materials to external influences, artificial ageing methods are used in practice. The advantage of these methods is that, as a result of intensifying the test parameters, e.g. temperature and humidity, the ageing processes in the vulcanisate are accelerated. Within the scope of this study, the influence of accelerated ageing on the mechanical and viscoelastic properties of mainly carbon-black-filled natural rubber (NR) vulcanisates was studied in an oxygen atmosphere at elevated temperature and in oxygen with solar radiation. The filler content was varied and the antioxidant IPPD was used. The analyses showed that, as well as mechanical properties such as hardness and tensile strength, the viscoelastic properties are also affected, depending on the ageing time and the type of ageing. In addition to the investigation of mechanical properties, a direct evaluation of the material change was carried out for selected samples by means of analytical tests. The investigations showed the deterioration of the antioxidant activity.

Lymphatic exosomes promote dendritic cell migration along guidance cues

Inflammation stimulates lymphatic endothelial cells to release exosomes, which accumulate in the perivascular stroma. Brown et al. show that these exosomes promote the directional migration of dendritic cells along guidance cues in complex environments by enhancing dynamic cellular protrusions in a CX3CL1-dependent manner.

Lymphatic endothelial cells (LECs) release extracellular chemokines to guide the migration of dendritic cells. In this study, we report that LECs also release basolateral exosome-rich endothelial vesicles (EEVs) that are secreted in greater numbers in the presence of inflammatory cytokines and accumulate in the perivascular stroma of small lymphatic vessels in human chronic inflammatory diseases. Proteomic analyses of EEV fractions identified >1,700 cargo proteins and revealed a dominant motility-promoting protein signature. In vitro and ex vivo EEV fractions augmented cellular protrusion formation in a CX3CL1/fractalkine-dependent fashion and enhanced the directional migratory response of human dendritic cells along guidance cues. We conclude that perilymphatic LEC exosomes enhance exploratory behavior and thus promote directional migration of CX3CR1-expressing cells in complex tissue environments.

Surface Composition of Free Mixed NaCl/Na2SO4 Nanoscale Aerosols Probed by X-ray Photoelectron Spectroscopy

The local chemical surface composition of unsupported mixed solid NaCl/Na₂SO₄ aerosols ( d ∼ 70 nm) is studied by X-ray photoelectron spectroscopy. The solid aerosols are generated by drying aqueous droplets containing mixtures of the two salts in different mole fractions. The mole fraction of these salts is found to deviate at the solid aerosol surface significantly from the initial droplet composition. The minority species in the droplets are found to be enhanced at the surface of the solid mixed aerosols. This surface enhancement is rationalized in terms of the nucleation/crystallization process, where the salts evidently do not cocrystallize, rather than each salt forms pure crystal moieties. Characteristic variations of the surface ion concentration as a function of the mole fraction of the salts in the initial droplet are observed in the nanometer size regime. This is unlike core-shell architectures previously found in mixed micron salt aerosols, indicating that aerosol models derived from micron-sized aerosols are evidently not fully reliable to describe the surface composition of nanosized aerosols. Furthermore, surface enhancement of the minority component in mixed NaCl/Na₂SO₄ aerosols is also different from previous results on surface segregation of mixed NaCl/NaBr aerosols, where one of the anionic species is surface segregated for all mole fractions, which was explained in terms of the ability of the involved salts to cocrystallize and forming solid solutions. The present results rather indicate that mixed NaCl/Na₂SO₄ aerosols do not cocrystallize. Electron microscopy of deposited mixed salt aerosols reveals mostly a cubic structure of pure NaCl aerosols, whereas mixed salt aerosols are found to show a grainy structure composed of multiple small crystals which supports the present findings obtained from photoelectron spectroscopy.

Photoelectron angular distribution from free SiO2 nanoparticles as a probe of elastic electron scattering

In order to gain quantitative information on the surface composition of nanoparticles from X-ray photoelectron spectroscopy, a detailed understanding of photoelectron transport phenomena in these samples is needed. Theoretical results on the elastic and inelastic scattering have been reported, but a rigorous experimental verification is lacking. We report in this work on the photoelectron angular distribution from free SiO₂ nanoparticles (d = 122 ± 9 nm) after ionization by soft X-rays above the Si 2p and O 1s absorption edges, which gives insight into the relative importance of elastic and inelastic scattering channels in the sample particles. The photoelectron angular anisotropy is found to be lower for photoemission from SiO₂ nanoparticles than that expected from the theoretical values for the isolated Si and O atoms in the photoelectron kinetic energy range 20-380 eV. The reduced angular anisotropy is explained by elastic scattering of the outgoing photoelectrons from neighboring atoms, smearing out the atomic distribution. Photoelectron angular distributions yield detailed information on photoelectron elastic scattering processes allowing for a quantification of the number of elastic scattering events the photoelectrons have undergone prior to leaving the sample. The interpretation of the experimental photoelectron angular distributions is complemented by Monte Carlo simulations, which take inelastic and elastic photoelectron scattering into account using theoretical values for the scattering cross sections. The results of the simulations reproduce the experimental photoelectron angular distributions and provide further support for the assignment that elastic and inelastic electron scattering processes need to be considered.

[Fetoscopic laser coagulation in 200 consecutive monochorionic pregnancies with twin-twin transfusion syndrome]

OBJECTIVES

To report preoperative data, surgical characteristics, complications and perinatal outcome of twin-twin transfusion syndrome (TTTS) managed with laser ablation surgery, to analyze predictors of neonatal survival and to compare the 100 most recent cases with the older 100.

MATERIALS AND METHODS

Observational cohort moncentric study of 200 cases of TTTS consecutively treated with fetoscopic laser coagulation between January 2004 and December 2014.

RESULTS

There were 49 stage I, 88 stage II, 55 stage III and eight stage IV. Median gestation at time of laser was 20.1±3.0 weeks' gestation (WG) whereas median gestation at delivery was 31.6±5.4 WG. Overall perinatal survival rate was 68.0% and 84.0% have one or more surviving twins. Preterm premature rupture of membranes occurred in 39 cases with and the median gestational age for this complication was 28.8±4.6 SA. Predictive factors to have at least one living birth were Quintero stage and gestational age at delivery. In the most recent period, there were significantly more TTTS Quintero stage I treated with laser, more coagulation by the Solomon technique and a larger number of coagulated vessels.

CONCLUSION

The neonatal survival of TTTS is improved by fetoscopic laser coagulation, preferely by using Solomon tecnhique. The use of active management of stage I is currently on research.

LAMP-2 is required for incorporating syntaxin-17 into autophagosomes and for their fusion with lysosomes

Autophagy is an evolutionarily conserved process used for removing surplus and damaged proteins and organelles from the cytoplasm. The unwanted material is incorporated into autophagosomes that eventually fuse with lysosomes, leading to the degradation of their cargo. The fusion event is mediated by the interaction between the Qa-SNARE syntaxin-17 (STX17) on autophagosomes and the R-SNARE VAMP8 on lysosomes. Cells deficient in lysosome membrane-associated protein-2 (LAMP-2) have increased numbers of autophagosomes but the underlying mechanism is poorly understood. By transfecting LAMP-2-deficient and LAMP-1/2­-double-deficient mouse embryonic fibroblasts (MEFs) with a tandem fluorescent-tagged LC3 we observed a failure of fusion between the autophagosomes and the lysosomes that could be rescued by complementation with LAMP-2A. Although we observed no change in expression and localization of VAMP8, its interacting partner STX17 was absent from autophagosomes of LAMP-2-deficient cells. Thus, LAMP-2 is essential for STX17 expression by the autophagosomes and this absence is sufficient to explain their failure to fuse with lysosomes. The results have clear implications for situations associated with a reduction of LAMP-2 expression.

Summary: LAMP-2 is required for autophagosome-lysosome fusion. Its absence does not affect the lysosomal SNARE VAMP8 while its interacting partner STX17 is absent from the autophagosomes providing a molecular explanation for this fusion failure.

[Accuracy of placenta accreta prenatal diagnosis by ultrasound and MRI in a high-risk population]

OBJECTIVES

Main objective was to compare accuracy of ultrasonography and MRI for antenatal diagnosis of placenta accreta. Secondary objectives were to specify the most common sonographic and RMI signs associated with diagnosis of placenta accreta.

MATERIAL AND METHODS

This retrospective study used data collected from all potential cases of placenta accreta (patients with an anterior placenta praevia with history of scarred uterus) admitted from 01/2010 to 12/2014 in a level III maternity unit in Strasbourg, France. High-risk patients beneficiated antenatally from ultrasonography and MRI. Sonographic signs registered were: abnormal placental lacunae, increased vascularity on color Doppler, absence of the retroplacental clear space, interrupted bladder line. MRI signs registered were: abnormal uterine bulging, intraplacental bands of low signal intensity on T2-weighted images, increased vascularity, heterogeneous signal of the placenta on T2-weighed, interrupted bladder line, protrusion of the placenta into the cervix. Diagnosis of placenta accreta was confirmed histologically after hysterectomy or clinically in case of successful conservative treatment.

RESULTS

Twenty-two potential cases of placenta accreta were referred to our center and underwent both ultrasonography and MRI. All cases of placenta accreta had a placenta praevia associated with history of scarred uterus. Sensibility and specificity for ultrasonography were, respectively, 0.92 and 0.67, for MRI 0.84 and 0.78 without significant difference (p>0.05). The most relevant signs associated with diagnosis of placenta accreta in ultrasonography were increased vascularity on color Doppler (sensibility 0.85/specificity 0.78), abnormal placental lacunae (sensibility 0.92/specificity 0.55) and loss of retroplacental clear space (sensibility 0.76/specificity 1.0). The most relevant signs in MRI were: abnormal uterine bulging (sensitivity 0.92/specificity 0.89), dark intraplacental bands on T2-weighted images (sensitivity 0.83/specificity 0.80) or placental heterogeneity (sensitivity 0.92/specificity 0.89). Association of two sonographic or MRI signs had the best sensitivity/specificity ratio.

DISCUSSION AND CONCLUSION

Ultrasonography and RMI represent two interesting and complementary diagnostic tools for antenatal diagnosis of placenta accreta. Because of its cost and accessibility, ultrasonography remains the first in line to be used for diagnosis. Use of an analytical grid for diagnosis of placenta accreta could be helpful.

[Cervical cerclage]

Cervical cerclage aims to strengthen not only the mechanical properties of the cervix, but also its immunological and anti-infectious functions. The demonstration of a strong interrelation between cervical insufficiency as well as decreased cervical length at endo-vaginal ultrasonography and infection has changed the indications cerclage. Actually we can distinguish three indications for cerclage: prophylactic, for obstetrical history; therapeutic, for shortened cervical length at ultrasonography in patients at risk and; emergency cerclage in case of threatening cervix at physical examination. The McDonald's technique is the most recommended. In case of failure, it is proposed to realize cerclage at a higher level on the cervix either by vaginal or abdominal route.

Fetal growth restriction and intra-uterine growth restriction: guidelines for clinical practice from the French College of Gynaecologists and Obstetricians

Small for gestational age (SGA) is defined by weight (in utero estimated fetal weight or birth weight) below the 10th percentile (professional consensus). Severe SGA is SGA below the third percentile (professional consensus). Fetal growth restriction (FGR) or intra-uterine growth restriction (IUGR) usually correspond with SGA associated with evidence indicating abnormal growth (with or without abnormal uterine and/or umbilical Doppler): arrest of growth or a shift in its rate measured longitudinally (at least two measurements, 3 weeks apart) (professional consensus). More rarely, they may correspond with inadequate growth, with weight near the 10th percentile without being SGA (LE2). Birthweight curves are not appropriate for the identification of SGA at early gestational ages because of the disorders associated with preterm delivery. In utero curves represent physiological growth more reliably (LE2). In diagnostic (or reference) ultrasound, the use of growth curves adjusted for maternal height and weight, parity and fetal sex is recommended (professional consensus). In screening, the use of adjusted curves must be assessed in pilot regions to determine the schedule for their subsequent introduction at national level. This choice is based on evidence of feasibility and the absence of any proven benefits for individualized curves for perinatal health in the general population (professional consensus). Children born with FGR or SGA have a higher risk of minor cognitive deficits, school problems and metabolic syndrome in adulthood. The role of preterm delivery in these complications is linked. The measurement of fundal height remains relevant to screening after 22 weeks of gestation (Grade C). The biometric ultrasound indicators recommended are: head circumference (HC), abdominal circumference (AC) and femur length (FL) (professional consensus). They allow calculation of estimated fetal weight (EFW), which, with AC, is the most relevant indicator for screening. Hadlock's EFW formula with three indicators (HC, AC and FL) should ideally be used (Grade B). The ultrasound report must specify the percentile of the EFW (Grade C). Verification of the date of conception is essential. It is based on the crown-rump length between 11 and 14 weeks of gestation (Grade A). The HC, AC and FL measurements must be related to the appropriate reference curves (professional consensus); those modelled from College Francais d'Echographie Fetale data are recommended because they are multicentere French curves (professional consensus). Whether or not a work-up should be performed and its content depend on the context (gestational age, severity of biometric abnormalities, other ultrasound data, parents' wishes, etc.) (professional consensus). Such a work-up only makes sense if it might modify pregnancy management and, in particular, if it has the potential to reduce perinatal and long-term morbidity and mortality (professional consensus). The use of umbilical artery Doppler velocimetry is associated with better newborn health status in populations at risk, especially in those with FGR (Grade A). This Doppler examination must be the first-line tool for surveillance of fetuses with SGA and FGR (professional consensus). A course of corticosteroids is recommended for women with an FGR fetus, and for whom delivery before 34 weeks of gestation is envisaged (Grade C). Magnesium sulphate should be prescribed for preterm deliveries before 32-33 weeks of gestation (Grade A). The same management should apply for preterm FGR deliveries (Grade C). In cases of FGR, fetal growth must be monitored at intervals of no less than 2 weeks, and ideally 3 weeks (professional consensus). Referral to a Level IIb or III maternity ward must be proposed in cases of EFW <1500g, potential birth before 32-34 weeks of gestation (absent or reversed umbilical end-diastolic flow, abnormal venous Doppler) or a fetal disease associated with any of these (professional consensus). Systematic caesarean deliveries for FGR are not recommended (Grade C). In cases of vaginal delivery, fetal heart rate must be monitored continuously during labour, and any delay before intervention must be faster than in low-risk situations (professional consensus). Regional anaesthesia is preferred in trials of vaginal delivery, as in planned caesareans. Morbidity and mortality are higher in SGA newborns than in normal-weight newborns of the same gestational age (LE3). The risk of neonatal mortality is two to four times higher in SGA newborns than in non-SGA preterm and full-term infants (LE2). Initial management of an SGA newborn includes combatting hypothermia by maintaining the heat chain (survival blanket), ventilation with a pressure-controlled insufflator, if necessary, and close monitoring of capillary blood glucose (professional consensus). Testing for antiphospholipids (anticardiolipin, circulating anticoagulant, anti-beta2-GP1) is recommended in women with previous severe FGR (below third percentile) that led to birth before 34 weeks of gestation (professional consensus). It is recommended that aspirin should be prescribed to women with a history of pre-eclampsia before 34 weeks of gestation, and/or FGR below the fifth percentile with a probable vascular origin (professional consensus). Aspirin must be taken in the evening or at least 8h after awakening (Grade B), before 16 weeks of gestation, at a dose of 100-160mg/day (Grade A).

[Twin pregnancy with complete hydatiform mole and coexistent fetus: Report of 4 cases and review of literature]

OBJECTIVE

Twin pregnancy with complete hydatiform mole and coexistent fetus is a rare clinical condition, occurring in 1 in 22,000 to one in 100,000 pregnancies. Continuation of pregnancy in these cases is controversial because of a high risk of immediate and long-term maternal morbidity. It allows, however, in 33 % of the case the delivery of a healthy child.

METHODS

This retrospective study included all patients presenting a complete hydatiform mole coexisting with a live twin fetus antenatally diagnosed between 2007 and 2012 in the level III maternity of the Strasbourg University Hospital. Informations concerning diagnostic circumstances, pregnancy follow-up and outcome were studied.

RESULTS

Four pregnancies were included in the study, all of them were spontaneous. Medical termination of pregnancies was related to maternal reasons in the four cases. One before 17 weeks of gestation, the three other after 2 weeks of gestation, leading to delivery of a healthy child. All patients developed a mild to severe preeclampsia. One patient developed a gestational trophoblastic disease, requiring chemotherapy by methotrexate. There was no fatal evolution.

CONCLUSION

Twin pregnancy with complete hydatifom mole and coexistent fetus is associated with increased risk of gestational trophoblastic disease. This risk is not increased by continuation of pregnancy. In case of prenatal diagnosis of complete hydatiform mole coexisting with a live twin fetus, patients should be aware of the potential high risk of morbidity and a regular follow-up during and after the pregnancy should be intaured. In absence of maternal complications, continuation of the pregnancy is possible.

[A rare case of caudal appendage]

Caudal appendage is a rare malformation which has since ever been interesting. We present the case of a girl in which a caudal appendage was discovered before birth. A throughout checking found an extension from this abnormality to the cordal spine. The baby is operated when 2months old. Differential diagnosis are spina bifida, teratoma and pilonidal sinus. Caudal appendage is one of the typical cutaneous finding with underlying spinal dysraphism, such as hair tuft or pigmented macule. The risk is a tethered cord syndrome that can lead to severe complication. The treatment is either surgery or expectation.

Predictive value of cardiovascular parameters in twin-to-twin transfusion syndrome

OBJECTIVE

To evaluate the prognostic value of the Children's Hospital Of Philadelphia (CHOP) cardiovascular score and the modified myocardial performance index (MPI), in determining the risk of recipient fetal loss in twin-to-twin transfusion syndrome (TTTS).

METHODS

This cohort study was based on data collected prospectively from 105 pregnancies complicated by TTTS (Quintero stages I-IV) and treated with laser photocoagulation between May 2008 and February 2013. Fetuses underwent detailed anatomical and Doppler ultrasonography with cardiac assessment as part of routine care. CHOP score and right MPI were calculated and cut-offs selected using receiver-operating characteristics curve analysis. These were compared according to loss of recipient fetus, using univariate and multivariate logistic regression. The correlation between CHOP score, MPI and Quintero stage was determined and we investigated differences in MPI before and after laser coagulation in a cohort of 90 recipient fetuses.

RESULTS

Rates of recipient fetal loss were significantly higher when the CHOP score was ≥ 3 (39.5% vs 12.9%, P = 0.002) and when MPI z-score was > 1.645 (34.5% vs 10.6%, P = 0.004). After adjustment for Quintero stage, the risk of recipient fetal loss remained significantly higher when the CHOP score was ≥ 3 (odds ratio, 3.09; 95% CI, 1.035-9.21). There was a positive correlation between CHOP score, MPI and Quintero stage. MPI was significantly lower after compared with before laser coagulation.

CONCLUSION

CHOP score and MPI are predictors of recipient fetal loss in TTTS and may be used to supplement Quintero's classification.

Fetoscopic laser coagulation for twin-twin transfusion syndrome before 17 weeks' gestation: laser data, complications and neonatal outcome

OBJECTIVE

To compare laser data, complications and neonatal outcome in pregnancies that undergo 'early' (≤ 17 weeks' gestation) fetoscopic laser ablation of placental vascular anastomoses for twin-twin transfusion syndrome (TTTS) with those from 'conventional' cases treated after 17 weeks.

METHODS

This was a cohort study of data collected prospectively between January 2004 and December 2012. We included monochorionic diamniotic twin pregnancies complicated by TTTS and treated by fetoscopic laser coagulation. Pregnancies were grouped according to laser treatment ≤ 17 gestational weeks or > 17 weeks and obstetric and neonatal outcomes were compared between groups.

RESULTS

A total of 178 pregnancies with TTTS underwent laser therapy: 40 at or before 17 weeks and 138 after 17 weeks. There was no statistically significant difference between these two groups with respect to the rate of preterm prelabor rupture of membranes (PPROM), gestational age at PPROM and rate of PPROM occurring in the 7 days following fetoscopic laser coagulation. In the early group, the interval between performing fetoscopic laser coagulation and the time of delivery was significantly longer (104 days vs 74 days, P=0.0002) and the delivery rate within 7 days of laser treatment was significantly lower (2.5% vs 15.9%, P=0.026). There was no significant difference between the two groups with regard to the rates of pregnancy without live birth (15.4% vs 15.4%, P=0.993), with one live birth (84.6% vs 84.6%, P=0.993) and with two live births (64.1% vs 58.1%, P=0.500).

CONCLUSION

In the event of early TTTS, fetoscopic laser coagulation is technically feasible before 17 gestational weeks and obstetric and neonatal outcomes are comparable with those in cases of laser treatment performed after 17 weeks.

Efficacy and safety of labour induction in patients with a single previous caesarean section: a proposal for a clinical protocol

PURPOSE

To evaluate the efficacy and safety of induction in women with a single prior Caesarean section.

METHODS

This was a cohort study in which we included all singleton pregnancies in patients with a single prior Caesarean who delivered between 2007 and 2012. Methods of induction were ocytocic infusion plus amniotomy (if Bishop score ≥6) or insertion of a Foley catheter (Bishop <6).

RESULTS

Of the 2,075 patients included, 806 (38.8 %) had an elective repeat Caesarean, 1,045 (50.4 %) went into spontaneous labour, 89 (4.3 %) were induced by artificial rupture of the membranes and infusion of ocytocics and 135 (6.5 %) were induced using a Foley catheter. Rates of vaginal delivery were 79.2, 79.8 and 43.7 %, respectively. Six cases of uterine rupture were reported in the group of patients who went into spontaneous labour. There was no difference between groups with regard to neonatal morbidity. On multivariate analysis, risk factors for Caesarean delivery were macrosomia (OR 2.04, 95 % CI 1.31-3.18) and induction by Foley catheter (OR 3.73, 95 % CI 2.47-5.62); protective factors were previous vaginal delivery (OR 0.41, 95 % CI 0.29-0.57) and cervical dilatation (OR 0.84, 95 % CI 0.78-0.91).

CONCLUSIONS

Uterine induction after a single Caesarean section with ocytocic infusion and amniotomy where the cervix is favourable does not appear to entail any significant added risk in terms of maternal or foetal morbidity. Foley catheter induction is a reasonable option if the cervix is not ripe.

Prediction of spontaneous preterm delivery in singleton pregnancies: where are we and where are we going? A review of literature

Prematurity is the chief cause of neonatal morbidity and mortality. The objective of this study is to review the different methods for predicting preterm delivery in asymptomatic pregnant women and in situations of threatened preterm delivery. A search of the PubMed/Medline database was carried out for the years 1980-2012. We included studies for predicting preterm birth in asymptomatic and symptomatic patients. Models for predicting preterm delivery based on maternal factors, cervical length and obstetric history in first trimester of pregnancy is a valuable avenue of research. Nevertheless, prediction accuracy still needs to be improved. In the second and third trimesters, routine digital vaginal examination is of no value in asymptomatic women. Echography of the cervix is not useful except in patients with a history of late miscarriage or preterm delivery in order to offer them a preventive treatment. In symptomatic women, the combination of digital vaginal examination, cervical echography and fibronectin gives the best predictive results. Electromyography of the uterus and elastography of the cervix are interesting avenues for future research. Identifying patients at risk of preterm delivery should be considered differently at each stage of pregnancy.

Angular momentum sensitive two-center interference

In quantum mechanics the Young-type double-slit experiment can be performed with electrons either traveling through a double slit or being coherently emitted from two inversion symmetric molecular sites. In the latter one the valence photoionization cross sections of homonuclear diatomic molecules were predicted to oscillate over kinetic energy almost 50 years ago. Beyond the direct proof of the oscillatory behavior of these photoionization cross sections σ, we show that the angular distribution of the emitted electrons reveals hitherto unexplored information on the relative phase shift between the corresponding partial waves through two-center interference patterns.

[Abruptio placentae. Diagnosis, management and maternal-fetal prognosis: a retrospective study of 100 cases]

OBJECTIVES

To update knowledge on placental abruption because there are few recent series published although the perinatal care has progressed.

PATIENTS AND METHODS

A retrospective observational study has been conducted on 100 consecutive cases of abruptio placentae, occurring from January 2008 to June 2011, in the two maternity units of the University Hospital of Strasbourg (France).

RESULTS

One hundred and five births among which five twin pregnancies were included. Clinical context was evident in 91% of cases, but the classic clinical triad was present in only 4% of cases. Clots were found at immediate placenta examination in 77% of cases. Pathological diagnosis was directly in accordance with clinical diagnosis in half the cases. Mean date of childbirth was 33 weeks of amenorrhea and 6 days. Sixty-seven patients gave birth prematurely. Among them, 50 patients delivered before 34 weeks. Sixty caesareans were performed in emergency before labor, including 47 with general anesthesia. Twelve patients had post-partum haemorrhage and ten coagulation disorders. There was no maternal death. Perinatal mortality was 19% with 13 fetal deaths in utero (12.4%), four children born in an apparent death state with resuscitation failure (3.8%) and three neonatal deaths (2.8%).

DISCUSSION AND CONCLUSION

Placental abruption is a serious and unpredictable situation. Joint medical care of obstetricians and intensivists is often required. Perinatal mortality mainly occurs in utero.

[Management of patients with a history of late abortion or very premature delivery]

Patients have a very late abortion or premature delivery in 2-3 % of pregnancies. Management in a subsequent pregnancy should seek an infection, a fetal cause (aneuploidy, malformation syndrome, intrauterine death) or vascular pathology (preeclampsia, IUGR, intrauterine death). In women with a late abortion or very premature childbirth history, several preventive treatments of prematurity are now available. The main cause of prematurity is ascending infection from the vagina. Cerclage or pessary is designed to better isolate the uterine cavity. Their effectiveness has been validated in patients for whom the repeated measurement of cervical length by transvaginal ultrasound shows a cervical length <25mm. Early pregnancy vaginosis and treatment with Dalacin(®) seem to significantly reduce the risk of prematurity. Finally, the routine administration of intramuscular or vaginal progesterone at the beginning of the 2(nd) quarter also proved effective in several randomized studies.

[Obstetric and neonatal outcomes in a home-like birth centre: a case-control study]

OBJECTIVES

To compare intervention rates associated with labor in low-risk women who began their labor in the "home-like birth centre" and the traditional delivery room.

PATIENTS AND METHODS

This retrospective study used data that were collected from January 2005 through June 2008, from women admitted to the "home-like birth centre" (n=316) and compared to a group of randomly selected low-risk women admitted to the traditional labor ward (n=890) using the Baysian Information Criterion to select the best predictive model.

RESULTS

Women in the "home-like birth centre" had spontaneous vaginal deliveries more often (88.6% versus 82.8%, P value 0.034) and perineal lesions less often (60.1% versus 62.5%, P value 0.013). The frequency of adverse neonatal outcomes did not differ statistically between the two groups, although mean clamped at birth umbilical arterial pH level was higher in the "home-like birth centre" group. The transfer rate from "home-like birth centre" to traditional labor ward was 31.3%.

DISCUSSION AND CONCLUSIONS

It appears that women could benefit from "home-like birth centre" care in settings such as the one studied. Larger observational studies are warranted to validate these results.