Stress perceived by pregnant and decision-making factors of maternal caesarean section request

Background

Pregnancy is a time of psychological vulnerability which can generate intense stress. This represents a maternal and child public health problem. Prenatal stress has harmful impacts on the foetus, the newborn and can cause an increased maternal request for caesareans sections, with nonmedical grounds. The perceived level of prenatal stress factors was assessed in women, as well as mothers’ incentives and decision-making factors for a caesarean section on maternal request.

Methods

A descriptive study on 203 pregnant women, then a comparative study between primiparas (n = 72) and multiparas (n = 131) were carried out with the Antenatal perceived stress inventory. Incentives and decision-making factors for a caesarean on the mother’s demand were studied by in-depth interviews with primiparas mothers (n = 16) who had made this choice.

Results

The perception of stress level during pregnancy is higher at the first quarter regarding the foetus’ health, medical and obstetric risks and reverses with the perception of projections linked to giving birth at the last quarter. Primiparas are significantly (p < 0.001) more stressed. All the elements of the three assessed factors are very significantly (p < 0.001) correlated for the whole population. Among them, 75% choose a caesarean section on maternal request during the first quarter. This choice is confirmed at the end of the second quarter or during the third one for 50% of them, with a one-month time to think for 58.3% of them. The main incentives are tokophobia (66.7%) and preserving the baby’s health (50%).

Conclusions

Pregnancy causes important stress, which is pronounced in primiparas. In France, these results speak in favour of screening tokophobia and an earlier start of birth and parenthood preparation classes in order to handle stress from the first quarter of pregnancy, when medical and prenatal exams are initiated. Birth preparation should be taken on at the last quarter.

Key messages

Investigate stress perceived and identification incentives and decision-making factors of maternal caesarean section request it’s a solution to building bridge for solidarity with tokophobic women. The relation enter stress perceived by pregnant women and decision-making factors of maternal caesarean section request, represents a maternal and child public health problem.

Evaluation of surgical treatment for ruptured Achilles tendon in 31 athletes

INTRODUCTION

In the past few decades, the incidence of Achilles tendon rupture has increased in parallel with increased sports participation. Although the optimal treatment remains controversial, there is a trend towards surgical treatment in athletes.

HYPOTHESIS

Surgical repair of ruptured Achilles tendon in athlete results in good functional and objective recovery, irrespective of the type of surgery performed. Subsidiarily, are the results different between percutaneous surgery (PS) and standard open surgery (OS)?

MATERIALS AND METHODS

This was a cross-sectional study of 31 patients who presented with a ruptured Achilles tendon that occurred during sports participation. Percutaneous surgery was performed in 16 patients and open surgery in 15 patients between 2005 and 2009. The objective recovery status was evaluated by open chain goniometry, measurement of leg muscle atrophy and assessment of isokinetic strength. The functional analysis was based on the delay, level of sports upon return, AOFAS and VAS for pain.

RESULTS

Our series of Achilles tendon rupture patients consisted of 88% men and 12% women, with an average age of 38 years. In 71% of cases, the rupture occurred during eccentric loading. After a follow-up of 15 months, the muscle atrophy was 13 mm after PS and 24 mm after OS (P=0.01). A strength deficit of 19% in the plantar flexors was found in the two groups. No patient experienced a rerupture. The return to sports occurred at 130 days after PS and 178 days after OS (P=0.005). The average AOFAS score was 94 and the VAS was 0.5. There were no differences in ankle range of motion between the two groups. The majority (77%) of patients had returned to their preinjury level of sports activity.

DISCUSSION

The return to activities of daily living was slower in our study than in studies based in Anglo-Saxon countries; this can be explained by the different sick leave coverage systems. Percutaneous surgery resulted in a faster return to sports (about 130 days) and less muscle atrophy than open surgery. Our results for return to sports and return to preinjury levels were similar to published results for athletes and were independent of the type of surgery performed. The AOFAS score was comparable to published studies. We found no difference in muscle strength between the two surgery groups 15 months after the procedure. Apart from venous thrombosis typically described after lower-limb immobilization, secondary postoperative complications mostly consisted of sural paresthesia, which had resolved at the 15-month postoperative follow-up evaluation.

CONCLUSION

The results of surgical treatment for ruptured Achilles tendon are good overall. By combining the simplicity of conservative treatment and the reliability of standard surgical treatment, percutaneous surgery is the treatment of choice to achieve excellent results. The return to sports occurred earlier, the muscle atrophy was less and the functional score was better in our patients treated by percutaneous surgery.

LEVEL OF EVIDENCE

Level IV.

Percutaneous iliosacral screw fixation in unstable pelvic ring lesions: the interest of O-ARM CT-guided navigation

INTRODUCTION

The reference surgical treatment for unstable posterior pelvic fracture is percutaneous iliosacral screw fixation, isolated or in association with other techniques. As there is a risk of passage outside the bone when performing screw fixation under fluoroscopy, new image-guidance techniques have been developed: fluoronavigation, peroperative 3D navigation, CT-linked navigation, etc. Since September 2011, our department has performed iliosacral screw fixation under CT control linked to navigation so as to optimize screw positioning. This innovative technology has been used in neurosurgery in our center since 2007, for disc implants, spinal fracture, vertebral arthrodesis and intracerebral localization.

MATERIAL AND METHODS

Six patients were treated by iliosacral screw fixation for posterior pelvic ring fracture lesion. The O-ARM (Medtronic(®)) computer-assisted surgical navigation system was used, combining surgical navigation and peroperative 3D imaging. This kind of osteosynthesis is suitable for non-displaced or prereduced fracture. A radiation dose report is drawn up at end of surgery.

DISCUSSION

Postoperative course does not differ from other percutaneous osteosynthesis techniques, combing the advantages of a percutaneous approach (reduced infection and blood-loss rates, etc.) while optimizing iliosacral screw positioning. To date, no radiation overexposure has been found.

CONCLUSION

The precision and safety of iliosacral screw fixation are now unequalled, meeting the basic computer-assisted surgery principles of reduced morbidity without overexposure to ionizing radiation. Indications for computer-assisted surgery should therefore be extended to iliosacral pathologies (arthritic, tumoral and inflammatory), non-displaced acetabular fracture, etc.

Single-file diffusion of interacting particles in a finite-sized channel

We study the dynamics of charged macroscopic particles (millimetric steel balls) confined in a linear channel of finite length, sufficiently narrow to avoid particles crossing. We show that their individual response to thermal fluctuations strongly depends either on their position in the channel or the local potential they experience. Three different dynamical regimes are identified. At small times, a "free regime" takes place, with the outermost particles exhibiting the highest diffusion coefficient. This effect results from an "echo" of the thermal fluctuations reflected by the channel wall. Then, forbidden crossing induces a correlated regime similar to single file diffusion. Surprisingly, the corresponding mobility increases with the local potential. Lastly, the finite length of the channel induces the saturation of fluctuations. We show that those behaviors may be described heuristically with the help of models for N hard-core interacting particles diffusing in a finite channel of length L, provided that we replace the uniform interparticle distance L/N by a characteristic distance (k(B)T/K)(1/2) built upon the temperature T and the stiffness K of the local potential. It provides a very satisfactory estimate for the fluctuations sizes, whereas they are greatly overestimated assuming hard-core interactions.

Single-file diffusion of macroscopic charged particles

In this paper, we study a macroscopic system of electrically interacting metallic beads organized as a sequence along an annulus. A random mechanical shaking mimics the thermal excitation. We exhibit non-Fickian diffusion (single-file diffusion) at large time. We measure the mobility of the particles and compare it to theoretical expectations. We show that our system cannot be accurately described by theories assuming only hard-sphere interactions. Its behavior is qualitatively described by a theory extended to more realistic potentials [M. Kollmann, Phys. Rev. Lett. 90, 180602 (2003)]. A correct quantitative agreement is shown and we interpret the discrepancies by the violation of the assumption of overdamped dynamics, which is a key point in the theory. We recast previous results on colloids with known interaction potentials and compare them quantitatively to the theory. Focusing on the transition between ordinary and single-file diffusions, we exhibit a dimensionless crossover time that is of order 1 both for colloids and our system, although the time and length scales differ by several orders of magnitude.

[Ochronosis or black cartilage disease]

We report two cases of ochronosis. This rare disease (1/1,000,000) transmitted by recessive autosomic inheritance results from an enzyme disorder. Clinically, the disease begins by black deposits in connective tissue followed by a group of symptoms, particularly involving the joints, and then destructive joint disease affecting the larger joints. Diagnosis is often established late. Early detection is important, preoperatively if possible, in order to avoid the serious complication of infectious endocarditis. These patients require adapted multidisciplinary care associating social support and symptomatic treatment. Drug therapy is currently under study and appears to provide effective symptom relief.

Safety of Oxygreen®, an ozone treatment on wheat grains. Part 2. Is there a substantial equivalence between Oxygreen-treated wheat grains and untreated wheat grains?

The Oxygreen process is a new process based on wheat grain treatment by ozone (produced in situ), in a closed sequential batch reactor. The Oxygreen process offers a close, homogeneous, and controlled contact between the gas and the grain. It is proposed for use for wheat grain decontamination (insects, fungi, bacteria, mycotoxins, pesticides). It takes place in classical milling diagram, and occurs after grain cleaning and before milling. The aim of the study reported here was to determine if Oxygreen treatment could induce in the grain the formation of processing-related compounds, and if these compounds are specific or could be recognized as classical modifications already used in the cereal industry (milling, baking). Studies were performed in order to evaluate any effect of Oxygreen treatment on vitamins, ferulic acid, phytates, proteins, carbohydrates, and lipids. It was concluded that there was no detectable substantial difference between ozone-treated grains and the untreated ones, although some quantitative differences can occur. The more detectable differences concern concentration of free sugars, and inhibition of some oxidative enzymes. These quantitative differences are very slight compared to the modifications that occur in dough, after addition of oxidative products directly in flour, or during kneading and dough fermentation.

Safety of Oxygreen®, an ozone treatment on wheat grains.Part 1. A four-week toxicity study in rats by dietary administration of treated wheat

The Oxygreen process is a new treatment approved by The French Food Safety Authority (AFSSA) as a processing aid for flour quality improvement, based on treatment by ozone, in a closed sequential batch reactor. This treatment takes place in the classical milling sequence, after the grain-cleaning step and before milling. The Oxygreen process could also be used for its properties in wheat grain decontamination (insects, fungi, bacteria, mycotoxins, storage insecticides residues). The aim of this study was to determine if Oxygreen treatment could induce in the grain the formation of processing-related substances, able to provoke adverse effects, after ingestion of the wheat and/or derived products, and to establish the safety of the Oxygreen process for animals and consumers. A four-week toxicity study, according to OECD guideline No. 407, was performed on Dark agouti rats fed exclusively with wheat grains, treated or untreated with Oxygreen. Clinical, haematological, blood biochemical, urinary and histopathological parameters were investigated during the study. The few modifications observed in animals given treated wheat were an increase of rectal temperature in females, a slight decrease of calcium concentration in males and slight decrease of certain blood cell number without clinical significances. This work shows that wheat treated by Oxygreen does not induce adverse effects in Dark agouti rats after oral administration. Therefore wheat and derived products from wheat, after Oxygreen treatment on grain, could be considered as safe for the consumer.

Shearing of a confined granular layer: tangential stress and dilatancy

We study the behavior of a confined granular layer under shearing, in an annular cell, at low velocity. We give evidence that the response of the granular layer under shearing is described by characteristic length scales. The tangential stress reaches its steady state on the same length scale as the dilatancy. Stop-and-go experiments performed at several driving velocities show a logarithmic increase of the static friction coefficient with waiting time, followed by rejuvenation on a characteristic length of the order of the magnitude of a Hertz contact between adjacent grains. The dilatancy does not evolve during the stop, neither during the elastic reloading when the driving is resumed. There is a small variation when sliding sets anew, which corresponds to the rejuvenation of the layer, and this variation is independent of the waiting time. We argue that aging is due to the behavior of individual contacts between grains, not global evolution of the piling. Under an instantaneous increase of the velocity, the tangential stress reaches a new steady state, exhibiting velocity strengthening behavior. An increase of dilatancy is also observed. It is much larger than fluctuations in the steady state, variations in a stop and-go-experiment, but much less than for shearing of freshly poured grains. The dilatancy variation during a velocity jump is not due to structural rearrangements of the piling. The evolutions of tangential stress and dilatancy are logarithmic in the ratio of upper and lower velocities.

[Delayed discovery of congenital diaphragmatic hernia: diagnostic difficulties. A report of two cases]

Delayed revelation of congenital diaphragmatic hernias (CDH) is not uncommon and can represent 5-30% of total CDHs. Time before diagnosis may be prolonged, sometimes to the adult period. Respiratory and gastrointestinal symptoms are frequent but not specific. The clinical presentation of delayed CDH may thus mislead the practitioner. Diagnosis can be approached and/or confirmed by plain radiography. Outcome is usually favorable after surgery. We report two cases of delayed CDH and we discuss the difficulty of diagnosis.

Using a partial-wave method for sound-mean-flow scattering problems

We present a semianalytical method, based on a partial-wave expansion and valid in the short wavelength limit for small Mach number flows, to analyze sound-vortical-flow interactions. It is more powerful than ray-tracing methods because it gives both amplitude and phase of the sound wave, and because it is less restrictive on the smallness of the wavelength. In contrast with the Born approximation approach, this method allows the computation of the sound field in the whole interaction domain (including the near field), and preserves energy conservation. Vortical flows with finite circulation are amenable to our analysis, which gives a satisfactory description of wave front dislocation by vorticity, in good agreement with direct numerical simulations. We extend previous versions of this method to the case of smooth vorticity profiles which are observed in aeroacoustics experiments.

Normal-mode-vortex interactions

Standing surface waves that interact with a confined, vertical, vorticity field with zero net circulation are studied both analytically and experimentally. The surface waves are generated by vertical vibration, and constant vorticity injection is achieved by a rotating disk flush mounted in the cell. Experimental results are indicative of a local wave-vortex interaction (no dislocation), and a simple theoretical model is able to explain them in quantitative detail.

Efficacy of macrolides vs. metronidazole against Entamoeba histolytica clinical isolates

Current treatment of Entamoeba histolytica infection requires the use of several agents that are effective at different sites of the body. Commonly administered agents such as nitroimidazoles have a high rate of gastrointestinal side effects and their use is restricted during pregnancy. In order to offer new choices, four macrolide antibiotics (erythromycin, clarithromycin, azithromycin, josamycin) and metronidazole were tested for their in vitro activity against E. histolytica. Ten clinically isolated strains from an endemic area (Santo Domingo, Dominican Republic) were tested after polyxenical culture. Protozoan viability was significantly reduced by josamycin after 24 and 48 hours of incubation at a concentration of > or = 50 mg/l, which was slightly higher than that of metronidazole (25 mg/l). No resistance to metronidazole was found. The antiamebic activity of azithromycin, clarithromycin and erythromycin was significant at drug concentrations > or = 100 mg/l. High doses of josamycin, which is a very well tolerated drug, may serve as a useful therapeutic agent in the presence of E. histolytica infection.

Reduced isoflurane consumption with bispectral index monitoring

BACKGROUND

Bispectral index (BIS) monitoring has been found to decrease the requirements for propofol, sevoflurane and desflurane and to improve recovery. We wanted to assess the effect of BIS monitoring on intraoperative isoflurane utilisation, and the early recovery profile.

METHODS

Eighty patients undergoing various surgical procedures were studied. In the first phase of the study, patients were anaesthetised without the use of BIS, the anaesthetists being blinded to the BIS readings, and isoflurane being administered according to standard clinical practice (control group). In a second phase, isoflurane was titrated to maintain a BIS value between 40 and 60 during surgery, and then 60-70 during 15 min prior to the end of surgery (BIS group). Isoflurane consumption was measured. Recovery times and the time to achieve a modified Aldrete score of 9 were recorded.

RESULTS

Despite similar mean BIS levels during maintenance of anaesthesia, the cumulative time spent with BIS values between 40 and 60 during maintenance of anaesthesia was significantly longer in the BIS group as compared with the control group (P<0.001). The isoflurane usage in the BIS group was 12-25% lower than in the control group (P<0.05). The time to awakening and extubation were comparable in the two groups. Although the patients were less sedated (P<0.01) during the three postoperative hours in the BIS (vs. control) group, no significant differences were observed in the time to obtain an Aldrete score of 9.

CONCLUSION

The addition of BIS to standard monitoring decreases isoflurane consumption. However, we found only a small advantage in using BIS with respect to recovery from isoflurane anaesthesia.

Acute opioid tolerance: intraoperative remifentanil increases postoperative pain and morphine requirement

BACKGROUND

Rapid development of acute opioid tolerance is well established in animals and is more likely to occur with large doses of short-acting drugs. The authors therefore tested the hypothesis that intraoperative remifentanil administration results in acute opioid tolerance that is manifested by increased postoperative pain and opioid requirement.

METHODS

Fifty adult patients undergoing major abdominal surgery were randomly assigned to two anesthetic regimens: (1) desflurane was kept constant at 0.5 minimum alveolar concentrations and a remifentanil infusion was titrated to autonomic responses (remifentanil group); or (2) remifentanil at 0.1 microg. kg-1. min-1 and desflurane titrated to autonomic responses (desflurane group). All patients were given a bolus of 0.15 mg/kg morphine 40 min before the end of surgery. Morphine was initially titrated to need by postanesthesia care nurses blinded to group assignment. Subsequently, patients-who were also blinded to group assignment-controlled their own morphine administration. Pain scores and morphine consumption were recorded for 24 postoperative h.

RESULTS

The mean remifentanil infusion rate was 0.3 +/- 0.2 microg. kg-1. min-1 in the remifentanil group, which was significantly greater than in the desflurane group. Intraoperative hemodynamic responses were similar in each group. Postoperative pain scores were significantly greater in the remifentanil group. These patients required morphine significantly earlier than those in the desflurane group and needed nearly twice as much morphine in the first 24 postoperative h: 59 mg (25-75% interquartile range, 43-71) versus 32 mg (25-75% interquartile range, 19-59; P < 0.01).

CONCLUSIONS

Relatively large-dose intraoperative remifentanil increased postoperative pain and morphine consumption. These data suggest that remifentanil causes acute opioid tolerance and hyperalgesia.

Nitrous oxide prevents movement during orotracheal intubation without affecting BIS value

We sought to determine whether the addition of nitrous oxide (N(2)O) to an anesthetic with propofol and remifentanil modifies the bispectral index (BIS) during the induction of anesthesia and orotracheal intubation. Thirty ASA physical status I or II patients were randomly allocated to receive either 50% air in oxygen (control group) or 60%-70% N(2)O in oxygen (N(2)O group) that was commenced via a mask simultaneously with the induction of anesthesia. Anesthesia was performed in all the patients with IV propofol at the target effect compartment site concentration of 4 microg/mL throughout the study. A target-controlled infusion (TCI) of remifentanil was initiated 3 min after the TCI of propofol and maintained at the effect-site concentration of 4 ng/mL until the end of the study. After loss of consciousness, and before the administration of vecuronium 0.1 mg/kg, a tourniquet was applied to one arm and inflated to a value more than the systolic blood pressure. An examiner, blinded to the presence of N(2)O, sought to detect any gross movement within the first minute after tracheal intubation, which was performed 10 min after remifentanil TCI began. Inspired and expired oxygen, N(2)O, and carbon dioxide were continuously monitored. A BIS value was generated every 10 s. Arterial blood pressure and heart rate (HR) were measured noninvasively every minute. Measures of mean arterial pressure (MAP), HR, and BIS were obtained before the induction, before the start of the remifentanil TCI, before laryngoscopy, and 5 min after intubation. No significant intergroup differences were seen in BIS, HR, and MAP throughout the study. Maximum changes in BIS, HR, and MAP with intubation were significant (P < 0.01) for both groups but comparable. Six patients in the control group and none in the N(2)O group moved after intubation (P < 0.05).

IMPLICATIONS

We demonstrated that 0.6 minimal alveolar concentration of nitrous oxide combined with a potent anesthetic and an opioid prevents movement after orotracheal intubation without affecting the bispectral index. This demonstrates that the bispectral index is not a useful neurophysiologic variable to monitor the level of anesthesia when nitrous oxide is added to a general anesthetic regimen using propofol and remifentanil.

Scattering of dislocated wave fronts by vertical vorticity and the Aharonov-Bohm effect. I. Shallow water

When a surface wave interacts with a vertical vortex in shallow water the latter induces a dislocation in the incident wave fronts that is analogous to what happens in the Aharonov-Bohm effect for the scattering of electrons by a confined magnetic field. In addition to this global similarity between these two physical systems there is scattering. This paper reports a detailed calculation of this scattering, which is quantitatively different from the electronic case in that a surface wave penetrates the inside of a vortex while electrons do not penetrate a solenoid. This difference, together with an additional difference in the equations that govern both physical systems, lead to a quite different scattering in the case of surface waves, whose main characteristic is a strong asymmetry in the scattering cross section. The assumptions and approximations under which these effects happen are carefully considered, and their applicability to the case of the scattering of acoustic waves by vorticity is noted.

Scattering of dislocated wave fronts by vertical vorticity and the Aharonov-Bohm effect. II. Dispersive waves

Previous results on the scattering of surface waves by vertical vorticity on shallow water are generalized to the case of dispersive water waves. Dispersion effects are treated perturbatively around the shallow water limit, to first order in the ratio of depth to wavelength. The dislocation of the incident wave front, analogous to the Aharonov-Bohm effect, is still observed. At short wavelengths the scattering is qualitatively similar to the nondispersive case. At moderate wavelengths, however, there are two markedly different scattering regimes according to whether the depth is smaller or larger than sqrt[3] times capillary length. In the latter case, dispersion and advection may compensate leading to a spiral interference pattern. The dislocation is characterized by a parameter that depends both on phase and group velocity. The validity range of the calculation is the same as in the shallow water case: wavelengths small compared to vortex radius, and low Mach number. The implications of these limitations are carefully considered.

Morphological significance of associated epithelial cords and ductlike structures in certain tumors of the pancreatic islets

The association of epithelial cord cells and ductlike structures in 2 cases of pancreatic islet tumors is presented. The first case was characterized by multiple pancreatic nodes of beta cell insulinoma in a 35-year-old woman. The second case was a Zollinger-Ellison syndrome in a 10-year-old male child with perforated duodenal ulcer due to an islet cell tumor of an aberrant pancreas in the omentrum. Stress is laid upon the striking continuity of the tumorous endocrine and exocrinelike histological formations reproducing the morphological pattern of ducto-insular relationships in histogenesis and islet regeneration.