Characteristics of respiratory viruses' circulation through a six-year period (2016-2022) in a pediatric population in Normandy, France, and the impact of COVID-19 pandemic

IMPORTANCE

The report highlights an epidemiological change in the circulation of respiratory viruses in pediatric populations due to strategies adopted against COVID-19 pandemic. COVID-19 has resulted in a significant increase in requests for multiplex respiratory research to identify the virus responsible for the symptoms. The diagnostic needs have increased, and the number of samples analyzed in 2021-2022 is equal to the samples analyzed over the four epidemic periods preceding the pandemic. The report suggests the importance of active surveillance of respiratory viruses' circulation and new recommendations for respiratory virus detection in pediatric patients.

VEGFR2 and CD34 expression associated with longer survival in patients with pleural mesothelioma in the IFCT-GFPC-0701 MAPS phase 3 trial

OBJECTIVES

VEGF/VEGFR autocrine loop is a hallmark of pleural mesothelioma (PM). We thus assayed the prognostic and predictive values of VEGFR-2 [vascular endothelial growth factor receptor 2 or Flk-1] and CD34, a marker of endothelial cells, in samples from patients accrued in the Mesothelioma Avastin Cisplatin Pemetrexed Study ('MAPS', NCT00651456).

MATERIALS AND METHODS

VEGFR2 and CD34 expression were assayed using immunohistochemistry in 333 MAPS patients (74.3%), and their prognostic value was evaluated in terms of overall survival (OS) and progression-free survival (PFS) in univariate and multivariate analyses, before validation by bootstrap methodology.

RESULTS

Positive VEGFR2 or CD34 staining was observed in 234/333 (70.2%) and 322/323 (99.6%) of tested specimens, respectively. VEGFR2 and CD34 staining correlated weakly, yet significantly, with each other (r = 0.36, p < 0.001). High VEGFR2 expression or high CD34 levels were associated with longer OS in PM patients in multivariate analysis (VEGFR2: adjusted [adj.] hazard ratio [HR]: 0.91, 95% confidence interval [CI] [0.88; 0.95], p < 0.001; CD34: adj. HR: 0.86, 95 %CI [0.76; 0.96], p = 0.010), with only high VEGFR2 expression resulting in significantly longer PFS (VEGFR2: adj. HR: 0.96, 95 %CI [0.92; 0.996], p = 0.032). Stability of these results was confirmed using bootstrap procedure. Nevertheless, VEGFR2 expression failed to specifically predict longer survival in bevacizumab-chemotherapy combination trial arm, regardless of whether the VEGFR2 score was combined or not with serum VEGF concentrations.

CONCLUSION

VEGFR2 overexpression independently correlated with longer OS or PFS in PM patients, such biomarker deserving prospective evaluation as stratification variable in future clinical trials.

FRENCH versus ESI: comparison between two nurse triage emergency scales with referent scenarios

OBJECTIVES

Acute triage is needed to prioritize care and achieve optimal resource allocation in busy emergency departments. The main objective is to compare the FRench Emergency Nurse Classification in Hospital scale (FRENCH) to the American scale Emergency Severity Index (ESI). Secondary objectives are to compare for each scale the over and under-triage, the triage matching to the gold standard and the inter-individual sorting reproducibility between the nurses.

METHODS

This is a prospective observational study conducting among the nursing staffs and nursing students, selected from Caen University College Hospital and Lisieux Hospital Center emergency departments between two months. Each group individually rank 60 referent clinical cases composed by scales designers. An assessment of scale practicality is collected after for each tool. The collected parameters are analyzed by a Cohen kappa concordance test (κ).

RESULTS

With 8151 triage results of gold standard scenarios sorting in two scales by the same nurses, the FRENCH scale seems to give better triage results than the US ESI scale (nurse: FRENCH 60% and ESI 53%, p = 0.003 ; nursing students: FRENCH 49% and ESI 42%, p < 0.001). In the two groups ESI has also a big tendency to under-sort (p = 0.01), particularly for the most severe patients (p < 0.01). The interobserver sorting concordance for any experience gives good results for the FRENCH and the ESI without any difference (nurses : FRENCH K_PQ=0.72 ESI K_PQ=0.78; p = 0.32 ; students K_PQ=0.44 K_PQ=0.55; p = 0.22).

CONCLUSION

The ESI and FRENCH scales comparison on 8151 sorting results shows direct validity in favor of FRENCH one and similar interobserver agreement for both scales.

A Defect of Amphiregulin Release Predicted Longer Survival Independently of YAP Expression in Patients with Pleural Mesothelioma in the IFCT-0701 MAPS Phase 3 Trial

The Hippo pathway effector YAP is dysregulated in malignant pleural mesothelioma (MPM). YAP's target genes include the secreted growth factor amphiregulin (AREG), which is overexpressed in a wide range of epithelial cancers and plays an elusive role in MPM. We assayed the expression of YAP and AREG in MPM pathology samples and that of AREG additionally in plasma samples of patients from the randomized phase 3 IFCT‐0701 Mesothelioma Avastin Cisplatin Pemetrexed Study (MAPS) using immunohistochemistry and ELISA assays, respectively. MPM patients frequently presented high levels of tumor AREG (64.3%), a high cytosolic AREG expression being predictive of a better prognosis with longer median overall and progression‐free survival. Surprisingly, tumor AREG cytosolic expression was not correlated with secreted plasma AREG. By investigating the AREG metabolism and function in MPM cell lines H2452, H2052, MSTO‐211H and H28, in comparison with the T47D ER+ breast cancer cell line used as a positive control, we confirm that AREG is important for cell invasion, growth without anchorage, proliferation and apoptosis in mesothelioma cells. Yet, most of these MPM cell lines failed to correctly execute AREG posttranslational processing by metalloprotease ADAM17/tumor necrosis factor‐alpha‐converting enzyme (TACE) and extracell secretion. The favorable prognostic value of high cytosolic AREG expression in MPM patients could therefore be sustained by default AREG posttranslational processing and release. Thus, the determination of mesothelioma cell AREG content could be further investigated as a prognostic marker for MPM patients and used as a stratification factor in future clinical trials.

Rothia spp. infective endocarditis: A systematic literature review

OBJECTIVE

To describe the epidemiological, clinical, microbiological, and therapeutic features and outcomes of Rothia infective endocarditis (RIE) and extracardiac infections (ECRI).

METHODS

We performed a systematic literature review of published cases of RIE and ECRI.

RESULTS

After inclusion of a personal case report, 51 cases of RIE and 215 cases of ECRI were reported. Compared with ECRI patients, RIE patients were significantly more often males (80% versus 59%), intravenous drug users (IVDU) (20% versus 3%), immunocompetent (76% versus 31%), and infected with R. dentocariosa (55% versus 13%) but lacked significant differences with regard to median age (45 years [6-79]), rate of orodental abnormalities (33%), and six-month mortality (14%). Following microbiological documentation, RIE was most often treated with a beta-lactam antibiotic alone (39%) for a median duration of six weeks and required surgery in 39% of cases.

CONCLUSION

RIE is rare and likely secondary to a dental portal of entry or cutaneous inoculation in IVDU. Its prognosis seems to be favorable.

Intravenous versus subcutaneous route pharmacokinetics of paracetamol (acetaminophen) in palliative care patients: study protocol for a randomized trial (ParaSCIVPallia)

BACKGROUND

Among palliative care (PC) patients who are administered paracetamol, the subcutaneous (SC) route is often an alternative to the intravenous (IV) route. Yet pharmacological and clinical data on whether these are equivalent pharmacokinetically are lacking. Many French palliative teams are now empirically using paracetamol by the SC route, but there are no data to support this practice. This trial aims to compare the pharmacokinetic (PK) parameters of paracetomol between the IV and SC routes in PC patients.

METHODS/DESIGN

This is a randomized, open, crossover study in two PC centers. The primary endpoints are AUC0-t, AUC0-∞, Cmax, Vd, and t1/2. All adverse events will be reported for a safety analysis. Twenty adult PC patients with an IV device having spontaneous pain not related to care, with a numeric pain rate scale > 3/10, or having a systematic prescription of paracetamol as the usual treatment will be included. All patients also have to meet all eligibility criteria.

CONCLUSION

This is the first study comparing PK parameters for IV paracetamol versus SC paracetamol in PC patients.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT03944044. Registered on 4 June 2019. Committee for the protection of persons (CPP) 18.09.05.58206 approval 4 October 2018. National Drug Safety Agency (ANSM; Agence Nationale de Sécurité Médicament) MEDAECNAT-2018-09-00009 approval 29 November 2018.

Neuropsychological management of multiple sclerosis: evaluation of a supervised and customized cognitive rehabilitation program for self-used at home (SEPIA): protocol for a randomized controlled trial

Background

Cognitive and mood disorders negatively impact daily life in patients with multiple sclerosis (MS). Pharmacological treatments did not demonstrate any effect on cognition compared with cognitive rehabilitation (CR). However, if CR programs offer promising results on cognition, they are less consistent concerning mood and quality of life (QoL). In this context, we designed a randomized controlled trial to evaluate the efficacy of an innovative computerized CR program, conducted at home, on QoL. Secondary objectives will estimate the improvement, or the stabilization over time, of patients’ cognitive performances and their emotional affects.

Methods

Forty MS patients (relapsing-remitting or secondary progressive forms) who have cognitive impairment will be recruited for the trial (called SEPIA-NCT03471338) and randomly assigned to either the experimental group or the control group. Patients randomly assigned in the experimental group will perform a home-based CR program with psychological support during eight consecutive weeks. CR will be based on computerized cognitive exercises from the PRESCO® software developed by HAPPYneuron^©. Training sessions (three sessions of 45 min per week) will consist of short exercises evaluating a broad range of cognitive domains and will be personalized for each patient (tracking tool and supervised guidance). The control group, designed to control for non-specific elements of the intervention, will receive only psychological support consisting of various issues related to MS, such as everyday cognitive-related difficulties or management of emotions. QoL, assessed by the MUSIQOL (Multiple Sclerosis International Quality Of Life) questionnaire, will be evaluated three times (at baseline and after 1 week and 25 weeks after home-based intervention) as well as secondary outcomes measuring self-esteem, cognition, depression, anxiety, metacognition, fatigue, and sleep quality. Given the expected MUSIQOL variation, the inclusion of 20 patients per group (alpha risk 5% and power 80%) will be required.

Discussion

Evidence suggests that computerized programs may be a practice option for CR for people with MS, but there is a paucity of studies evaluating QoL. We hope that this innovative program will highlight such benefits over time in patients’ daily life. In the future, such programs will allow a wider range of available therapeutic options for MS patients with cognitive impairment and for practitioners in charge of their care.

Trial registration

ClinicalTrials.gov identifier: NCT03471338. Retrospectively registered on 25 April 2018. https://clinicaltrials.gov/ct2/show/NCT03471338?term=NCT03471338&cond=Multiple+Sclerosis&draw=2&rank=1.

Assessment of concordance between diffusion of carbon monoxide through the lung using the 10 s breath-hold method, and the simultaneous NO/CO technique, in healthy participants

INTRODUCTION

There is limited, large sample size, healthy control data comparing measurement of diffusing capacity of the lungs for carbon monoxide (DLCO) via the 10 s single-breath carbon monoxide uptake method (DLCO₁₀) and using a DLCO-DLNO double diffusion test performed with a 5 s time of apnoea (DLCO₅).

OBJECTIVES

The primary objective was to compare DLCO₅ and DLCO₁₀ in healthy participants. The secondary objective was to evaluate the reproducibility of DLCO₅.

MATERIAL AND METHODS

We included medical students at Caen University Hospital, from 2008 to 2011. We performed a standard single-breath carbon monoxide uptake and combined DLCO and DLNO measurement for each participant. The combined test was repeated one week later.

RESULTS

Among the 153 study participants, there was no statistically significant difference between the mean values of DLCO₁₀ (10.2 ± 2.2 mmol.min^-1 kPa^-1) and DLCO₅ (10.3 ± 2.2 mmol.min^-1 kPa^-1; paired t-test p = 0.19). Corrected for the same FiO₂, DLCO₅ was calculated at 10.5 ± 2.3 mmol.min^-1 kPa^-1 and was significantly different from DLCO₁₀ (paired t-test p < 0.001). DLCO₅ deviates from 1,6 mmol.min^-1 kPa^-1 (4,6 mL.min^-1. mmHg^-1) or 15 % of DLCO₁₀ (17 % above and 13% below, for 95 % of the subjects). Forty-seven participants were included in the DLCO₅ reproducibility test. The 2 test sessions were carried out at 6 ± 2 day intervals. Reproducibilities for DLCO, DLNO, DmCO and Vc was respectively 1.2 (11 %), 6.8 (13%), 16.5 (32 %), 12.5 (17 %) mmol.min^-1 kPa^-1.

CONCLUSION

In healthy participants, discrepancies between DLCO measured during the double diffusion and DLCO measured on an apnoea of 10 s are quite large. It may be an indication that the Roughton and Forster interpretation to describe this type of measurements is inadequate.

Promoter Hypermethylation of Genes Encoding for RASSF/Hippo Pathway Members Reveals Specific Alteration Pattern in Diffuse Gliomas

Ras association domain family (RASSF)/Hippo pathway alterations are poorly characterized in diffuse gliomas. We assayed promoter methylation of LATS1/2, MST1(STK4)/MST2(STK3), RASSF1, RASSF2, Nore1A/RASSF5, RASSF6, and RASSF10 genes in 133 diffuse gliomas. The RASSF/Hippo pathway was highly silenced in gliomas, particularly RASSF1A (79.4%) and LATS2 (35.9%). The most frequent combination of promoter hypermethylation of one RASSF gene and one Hippo pathway member's gene was RASSF1/LATS2-coupled hypermethylation [n = 44 (33.08%)]. Hypermethylated profiles were related to IDH mutation, yet not randomly in IDH-mutated gliomas, because LATS2 promoter hypermethylation was more frequent in oligodendroglioma than in astrocytoma. RASSF1 and LATS2 promoter hypermethylation predicted a longer overall survival (OS). Considering hypermethylation of these two promoters, Cox proportional hazard regression analysis categorized the patients into three prognostic groups: i) high risk of death (n = 24; both RASSF1 and LATS2 unmethylated promoters; median OS, 13 months); ii) intermediate risk of death (n = 65; RASSF1 or LATS2 hypermethylated promoter; median OS, 50.5 months; HR = 3.3; 95% CI, 1.6-6.4; P = 0.001); and iii) low risk of death (n = 44; both RASSF1 and LATS2 hypermethylated promoters; median OS, 119 months; HR = 75.1; 95% CI, 3.3-15.1; P = 0.001). We have thus highlighted a simple two-gene (RASSF1/LATS2) methylation signature as a tool to stratify different prognostic groups of patients with diffuse glioma, adding further prognostic information within the IDH-mutated group.

Autologous Adipose Tissue Graft to Treat Hypertensive Leg Ulcer: A Pilot Study

BACKGROUND

Adipose tissue is an abundant source of mesenchymal stem cells, called adipose-derived stem cells, which have anti-inflammatory and trophic effects to enhance overall tissue repair.

OBJECTIVE

To determine the healing effects of autologous adipose tissue graft on hypertensive leg ulcers.

METHODS

Prospective pilot study in 1 French dermatology department. Ten patients with a hypertensive leg ulcer were enrolled from April 2013 to June 2015. The primary end point was the wound closure rate at each follow-up visit. The secondary end points were wound characteristics, pain assessment and adverse events.

RESULTS

One patient, the only smoker, was lost to follow-up at month 5 (M5). For the 9 non-smokers, wound surfaces constantly and significantly decreased: the median wound closure rate was 73.2% at M3 and 93.1% at M6, p < 0.001. The median wound closure rate of the 10 patients was 63.2% at M3, p < 0.001. Percentages of fibrin and necrosis decreased, granulation tissue increased significantly. Pain rapidly and significantly decreased. No recurrence or adverse event was observed.

CONCLUSION

Our data suggest that autologous adipose tissue grafting induces pain relief and promotes wound healing with a good skin quality. Large prospective controlled randomized studies are required to confirm these results.

[Caesarean section at full dilatation: What are the risks to fear for the mother and child?]

OBJECTIVES

Caesarean section is associated with increased maternal morbidity compared to a vaginal delivery, especially if it occurs during labour. Little data on caesarean section performed at full dilatation is available.

METHODS

This was a retrospective study done in University Hospital of type 3 over a period of ten years, including future primiparous patients who had a caesarean section performed at full dilatation, compared to a control group of patients whose caesarean section was conducted in first part of the labour. We collected different maternal data per- and postoperative and neonatal.

RESULTS

In total, 824 patients were enrolled including 412 in each group. For caesarean section at full dilatation, foetal extraction required more manoeuvres (RR=3.05; 95% CI: 2.1; 4.39; P<0.001); we noted more extension of hysterotomy (RR=1.79; 95% CI: 1.30; 2.46; P<0.001). Postoperative and neonatal maternal morbidity was not different, except more frequent neonatal trauma for caesarean section at full dilatation.

CONCLUSION

A caesarean section at full dilatation has an excess intraoperative risk and requires great caution. Nevertheless, no significant increase of postoperative and neonatal complications can be proved.

Influence of factor VIII level and its inhibitor titer on the therapeutic response to corticosteroids alone in the management of acquired hemophilia: A retrospective single-center study

The treatment of acquired hemophilia (AH) involves discussing whether corticosteroids should be administered alone or combined with immunosuppressant drugs, which increase the risk of infection especially in elderly patients and/or those with autoimmunity or neoplastic diseases, who represent the target population of the disease. Prognostic factors highlighting adequate responses to corticosteroids alone must be identified for satisfactory clinical response and lower infectious risk.We aimed to evaluating the efficacy of corticosteroids alone in the management of AH depending on factor VIII (FVIII, ≥ or <1 IU/dL) levels and/or inhibitor (INH, ≤ or >20 Bethesda units per milliliter [BU/mL]) titer.We conducted a retrospective single-center study including 24 patients treated for AH with corticosteroids alone.Time to achieve partial remission (PR: absence of hemorrhage and FVIII levels >50 IU/dL) was significantly shorter in the FVIII ≥ 1 IU/dL group than in the FVIII < 1 IU/dL group (20 [10-55] vs 39 [20-207] days, P = 0.044) and in the INH ≤ 20 BU/mL and FVIII ≥ 1 IU/dL group than in the FVIII < 1 IU/dL and/or INH > 20 BU/mL group (15 [11-35] vs 41 [20-207] days, P = 0.003). In both subgroups, time to achieve complete remission (CR: negative INH and corticosteroids below 10 mg/d) was also significantly shorter than that observed in the opposite subgroups. INH titer, considered alone, did not affect the length of time to onset of PR or CR. CR and PR rates did not differ significantly depending on these variables.Our study suggests that in AH, patients with FVIII levels ≥1 IU/dL considered alone or combined with INH titer ≤20 BU/mL could be treated by corticosteroids alone, given that this subgroup of patients displayed faster therapeutic responses to this strategy.

Performance Evaluation of the VIDAS(®) Measles IgG Assay and Its Diagnostic Value for Measuring IgG Antibody Avidity in Measles Virus Infection

The objective of this study is primarily to compare the performance of the VIDAS(®) Measles immunoglobulin (Ig)G assay to that of two other serological assays using an immunoassay technique, Enzygnost(®) Anti-measles Virus/IgG (Siemens) and Measles IgG CAPTURE EIA(®) (Microimmune). The sensitivity and the agreement of the VIDAS(®) Measles IgG assay compared to the Enzygnost(®) Anti-measles Virus/IgG assay and the Measles IgG CAPTURE EIA(®) assay are 100%, 97.2% and 99.0%, 98.4%, respectively. The very low number of negative sera for IgG antibodies does not allow calculation of specificity. As a secondary objective, we have evaluated the ability of the VIDAS(®) Measles IgG assay to measure anti-measles virus IgG antibody avidity with the help of the VIDAS(®) CMV IgG Avidity reagent, using 76 sera from subjects with measles and 238 other sera. Different groups of populations were analyzed. In the primary infection measles group, the mean IgG avidity index was 0.16 (range of 0.07 to 0.93) compared to 0.79 (range of 0.25 to 1) in the serum group positive for IgG antibodies and negative for IgM. These data allow to define a weak anti-measles virus IgG antibody avidity as an avidity index (AI) < 0.3 and a strong avidity as an AI > 0.6. The VIDAS(®) Measles IgG assay has a performance equivalent to that of other available products. Its use, individual and quick, is well adapted to testing for anti-measles immunity in exposed subjects.

Bevacizumab for newly diagnosed pleural mesothelioma in the Mesothelioma Avastin Cisplatin Pemetrexed Study (MAPS): a randomised, controlled, open-label, phase 3 trial

BACKGROUND

Malignant pleural mesothelioma is an aggressive cancer with poor prognosis, linked to occupational asbestos exposure. Vascular endothelial growth factor is a key mitogen for malignant pleural mesothelioma cells, therefore targeting of vascular endothelial growth factor might prove effective. We aimed to assess the effect on survival of bevacizumab when added to the present standard of care, cisplatin plus pemetrexed, as first-line treatment of advanced malignant pleural mesothelioma.

METHODS

In this randomised, controlled, open-label, phase 3 trial, we recruited patients aged 18-75 years with unresectable malignant pleural mesothelioma who had not received previous chemotherapy, had an Eastern Cooperative Oncology Group performance status of 0-2, had no substantial cardiovascular comorbidity, were not amenable to curative surgery, had at least one evaluable (pleural effusion) or measurable (pleural tumour solid thickening) lesion with CT, and a life expectancy of >12 weeks from 73 hospitals in France. Exclusion criteria were presence of central nervous system metastases, use of antiaggregant treatments (aspirin ≥325 mg per day, clopidogrel, ticlopidine, or dipyridamole), anti-vitamin K drugs at a curative dose, treatment with low-molecular-weight heparin at a curative dose, and treatment with non-steroidal anti-inflammatory drugs. We randomly allocated patients (1:1; minimisation method used [random factor of 0·8]; patients stratified by histology [epithelioid vs sarcomatoid or mixed histology subtypes], performance status score [0-1 vs 2], study centre, or smoking status [never smokers vs smokers]) to receive intravenously 500 mg/m(2) pemetrexed plus 75 mg/m(2) cisplatin with (PCB) or without (PC) 15 mg/kg bevacizumab in 21 day cycles for up to six cycles, until progression or toxic effects. The primary outcome was overall survival (OS) in the intention-to treat population. Treatment was open label. This IFCT-GFPC-0701 trial is registered with ClinicalTrials.gov, number NCT00651456.

FINDINGS

From Feb 13, 2008, to Jan 5, 2014, we randomly assigned 448 patients to treatment (223 [50%] to PCB and 225 [50%] to PC). OS was significantly longer with PCB (median 18·8 months [95% CI 15·9-22·6]) than with PC (16·1 months [14·0-17·9]; hazard ratio 0·77 [0·62-0·95]; p=0·0167). Overall, 158 (71%) of 222 patients given PCB and 139 (62%) of 224 patients given PC had grade 3-4 adverse events. We noted more grade 3 or higher hypertension (51 [23%] of 222 vs 0) and thrombotic events (13 [6%] of 222 vs 2 [1%] of 224) with PCB than with PC.

INTERPRETATION

Addition of bevacizumab to pemetrexed plus cisplatin significantly improved OS in malignant pleural mesothelioma at the cost of expected manageable toxic effects, therefore it should be considered as a suitable treatment for the disease.

FUNDING

Intergroupe Francophone de Cancérologie Thoracique (IFCT).

Prenatal diagnosis of clubfoot: Chromosomal abnormalities associated with fetal defects and outcome in a tertiary center

PURPOSE

Our aim was to evaluate the rate of occurrence of chromosomal abnormalities, associated findings, and outcome in a series of cases of prenatally diagnosed clubfoot.

METHODS

We conducted a retrospective study of all cases of clubfoot diagnosed prenatally in the ultrasound unit of a French tertiary center from January 2004 through December 2011. Clubfoot was scored as complex or isolated depending on the presence or absence of another structural abnormality observed on sonographic examination.

RESULTS

Data from 90 fetuses prenatally diagnosed with clubfoot were included in this study. Thirty-four cases were considered complex (38%) and 56 were considered isolated (62%). A chromosomal abnormality was identified in 10 of 33 of the fetuses with complex clubfoot and in 1 of 45 of those with isolated clubfoot (p < 0.001). Clubfoot was associated with a poor outcome in 5 of 52 cases of isolated clubfoot and in 31 of 34 cases associated with other structural defects (p < 0.001). The deformity was bilateral in 62 cases (69%) and unilateral in 28 (31%). No statistically significantly higher rate of poor outcome was identified when the deformity occurred bilaterally nor was a significantly higher rate of chromosomal abnormality noted in this condition.

CONCLUSIONS

Aneuploidy and adverse pregnancy outcomes occur more commonly in prenatally diagnosed cases of complex clubfoot than in those of isolated clubfoot. Fetal karyotyping is required in cases of complex clubfoot, but the need for that procedure in isolated clubfoot remains controversial.

Impact of prolonged dinoprostone cervical ripening on the rate of artificial induction of labor: a prospective study of 330 patients

AIM

The aim of this study was to evaluate two regimens of administration of sustained-release dinoprostone on the need for oxytocin induction of labor.

MATERIAL AND METHODS

We carried out an open prospective study comparing labor, maternal and neonatal outcomes after 12 h of prostaglandin cervical ripening insert versus 24 h of prostaglandin cervical ripening insert in 284 patients (142 ripenings at 12 h [P12 group] and 142 ripenings at 24 h [P24 group]).

RESULTS

The two groups were demographically similar. There was a significant difference in the need for artificial rupture of membranes/oxytocin induction of labor between the groups (49.3% for the P12 group vs 38% for the P24 group, P = 0.03). The delay between the beginning of ripening and delivery was significantly decreased in the P12 group, but the duration of active labor (6.6 h), the dose of oxytocics used (1326 UI), the rate of cesarean section, the rate of uterine hyperstimulation, the rates of hemorrhaging from delivery, the neonatal state and the experience of induction were similar in the two groups.

CONCLUSION

This study allows us to show for the first time that sustained-release of dinoprostone leads to spontaneous induction of labor without increasing the obstetrical risk in a majority of patients.

Is there a place for cyclophosphamide in the treatment of giant-cell arteritis? A case series and systematic review

OBJECTIVE

To report on the effectiveness of cyclophosphamide (CYC) to treat glucocorticoid (GC)-dependent giant-cell arteritis (GCA) and/or severe GC-related side effects.

METHODS

Fifteen patients with GCA and treated with CYC were retrieved from the computerized patient-record system. Glucocorticoid dependence was defined as a prednisone dose of >20mg/day for 6 months or >10mg/day for 1 year in order not to relapse. Response to CYC was defined as improved clinical and biological findings. Remission was defined as a sustained absence (>12 months) of active signs of vasculitis at a daily GC dose of <7.5mg. A literature review searched PubMed for all patients diagnosed with GCA and who received CYC.

RESULTS

Our 15 patients responded to monthly pulses of CYC, and all experienced a GC-sparing effect, including five patients who discontinued GC long term. At a median follow-up of 43 (range: 14-75) months after CYC, nine (53%) patients were still in remission and six (40%) had relapsed at 6 (3-36) months after the last CYC infusion. Twelve (80%) patients experienced side effects, leading to discontinuation of CYC in two (13%). A literature review retrieved 88 patients who received CYC: 66 for GC-dependent disease, 53 for GC toxicity, and 14 for severe organ involvement. Their median follow-up time was 24 (4-60) months. Among the 88 patients, 74 (84%) were responsive to CYC and 17 (19%) relapsed, although all were receiving a maintenance therapy with immunosuppressive agents (such as methotrexate). Twenty-nine (33%) patients experienced side effects and 11 (12.5%) discontinued treatment.

CONCLUSION

Cyclophosphamide is an interesting option for GCA patients with GC-dependent disease or with severe GC-related side effects, especially when conventional immunosuppressive agents have failed.

IFCT-GFPC-0701 MAPS trial, a multicenter randomized phase III trial of pemetrexed-cisplatin with or without bevacizumab in patients with malignant pleural mesothelioma (MPM)

TPS7112

Background: MPM median OS does not exceed 13 months with pem/CDDP doublet. U.S. Intergroup phase II trial of gemcitabine/CDDP, with or without bevacizumab, gave an appealing 15.6 months median OS in the bevacizumab arm. French Intergroup aimed to test pem/CDDP with bevacizumab (PCB), in a randomized phase III trial. Methods: Eligible patients had unresectable histologically proved MPM, no prior chemo, PS 0-2, no thrombosis, nor bleeding. Primary endpoint: The primary outcome will be survival. The secondary endpoint will be Progression-Free Survival. Patients received pem 500 mg/m2, CDDP 75 mg/m2 (PC),at D1, and vitamin B12 +B9 substitution, with (arm B) or without bevacizumab (arm A), 15 mg/kg Q21D, for 6 cycles. Arm B nonprogressive patients received bevacizumab maintenance therapy until progression or toxicity. 445 patients to be recruited during a period 48 months, with at least 24 months of follow-up, and 385 events (deaths), will be needed to assure a power of 80% and detect at least a 4.3 months of median survival increase. This hypothesis leads to a Hazard Ratio (HR) of 1.33 and a 3-years survival of 14.7% in control arm and 23.6 % in experimental arm, with an absolute difference of 8.9% in survival rates. Accrual status: The first patient was included in February 2008. On January 31, 2012, 257 patients from 85 French centers had been enrolled. The end of accrual can be expected for September 2013. Ancillary studies: For molecular biomarker analyses, thoracoscopic tissue specimens (TS, ERCC1, MSH2, TUBB3, NF2, p16, RASSF1A methylation,15 microRNAs ) and blood samples (micro-RNAS, VEGF, osteopontin, SRMP) at diagnosis are centrally collected. Finally, a prospective study comparing PET-CT to standard CT with central blinded analysis, is currently on-going for evaluation of response, and accuracy of modified RECIST criteria for mesothelioma.

High TUBB3 expression, an independent prognostic marker in patients with early non-small cell lung cancer treated by preoperative chemotherapy, is regulated by K-Ras signaling pathway

We assessed the prognostic and predictive value of β-tubulin III (TUBB3) expression, as determined by immunohistochemistry, in 412 non-small cell lung cancer (NSCLC) specimens from early-stage patients who received neoadjuvant chemotherapy (paclitaxel- or gemcitabine-based) in a phase III trial (IFCT-0002). We also correlated TUBB3 expression with K-Ras and EGF receptor (EGFR) mutations in a subset of 208 cryopreserved specimens. High TUBB3 protein expression was associated with nonsquamous cell carcinomas (P < 0.001) and K-Ras mutation (P < 0.001). The 127 (30.8%) TUBB3-negative patients derived more than 1 year of overall survival advantage, with more than 84 months median overall survival versus 71.7 months for TUBB3-positive patients [HR, 1.58; 95% confidence interval (CI), 1.11-2.25)]. This prognostic value was confirmed in multivariate analysis (adjusted HR for death, 1.51; 95% CI, 1.04-2.21; P = 0.031) with a bootstrapping validation procedure. TUBB3 expression was associated with nonresponse to chemotherapy (adjusted HR, 1.31; 95% CI, 1.01-1.70; P = 0.044) but had no predictive value (taxane vs. gemcitabine). Taking account of these clinical findings, we further investigated TUBB3 expression in isogenic human bronchial cell lines only differing by K-Ras gene status and assessed the effect of K-Ras short interfering RNA (siRNA) mediated depletion, cell hypoxia, or pharmacologic inhibitors of K-Ras downstream effectors, on TUBB3 protein cell content. siRNA K-Ras knockdown, inhibition of RAF/MEK (MAP-ERK kinase) and phosphoinositide 3-kinase (PI3K)/AKT signaling, and hypoxia were shown to downregulate TUBB3 expression in bronchial cells. This study is the first one to identify K-Ras mutations as determinant of TUBB3 expression, a chemoresistance marker. Our in vitro data deserve studies combining standard chemotherapy with anti-MEK or anti-PI3K drugs in patients with TUBB3-overexpressing tumors.

[Prognostic and predictive biomarkers in non-small cell lung cancers. From conditioned registrations to routine molecular mapping of lung cancers: Methodological issues]

Targeted therapies booming and new efficacious cytotoxics emergence in non-small cell lung cancers (NSCLC) deeply changed prognosis in some subsets of patients experiencing long survival. A priori identification (at time of diagnosis) of patients the most beneficiating from those often costly therapies is the new issue in thoracic oncology. For EGFR tyosine kinase inhibitors (TKI), molecular targeting relies on EGFR mutations diagnosis, that led to the first conditioned molecular-based registration for a drug in thoracic oncology, that was made easier in France by French NCI huge effort to sponsor the 28 regional molecular biology platforms. For the majority of classical cytotoxics used in adjuvant treatment after lung cancer surgical resection, biomarkers relying on immunohistochemistry still need further prospective validation steps before routine use. Prospective validation studies aimed to evaluate the ability of those biomarkers to predict not only response to therapy, but also survival with a specific treatment (predictive value), need large phase 3 trials with centralized biomarker analyses and rigorous statistical methods. French Intergroup (IFCT) has initiated such studies that will help to validate new biomarkers that we may use routinely in lung cancer in near future.

Prenatal depression: role of childhood stressors, current stressors and past emotional disorders

Background

Very few studies have conducted a multivariate analysis incorporating both the major predictors of depression in women, in accordance with comprehensive developmental models of depression, and specific stressors associated with the biological and psychosocial state of the mother-to-be.

Methodology

We used a cross-sectional cohort design to analyze the associations between prenatal depression and potential risk factors. 693 French-speaking women with singleton pregnancies at 20–28 weeks’ gestation were consecutively recruited. Fifty women with missing values were subsequently excluded from the analysis. Depressive symptoms were assessed on the Edinburgh Postnatal Depression Scale. Risk factors were either extracted from the computerized obstetric records or assessed by means of self-administered questionnaires. The associations between prenatal depression and the potential risk factors were assessed using log-binomial regression models to obtain a direct estimate of relative risk.

Principal findings

The following factors were found to be significant in the multivariate analysis: level of education, past psychiatric history, stress related to the health and viability of the fetus and stress related to severe marital conflicts or to serious difficulties at work. An association was also found with the previous delivery of a child with a major or minor birth defect. Univariate analyses revealed a strong association with childhood adversity (parental rejection and family secrets).

Conclusions

Our study identifies several risk factors that could easily be assessed in clinical practice. It draws attention to the impact of previously delivering a child with a birth defect and to the association with childhood adversity.

Developmental model of depression applied to prenatal depression: role of present and past life events, past emotional disorders and pregnancy stress

Background

Several risk factors for depression during pregnancy have already been established. However, very few studies have conducted a multivariate analysis incorporating both the major predictors of depression in women, in accordance with comprehensive developmental models of depression, and specific stressors associated with the biological and psychosocial state of the mother-to-be.

Methodology/Principal Findings

We used a cross-sectional cohort design to analyze the associations between prenatal depression and potential risk factors. 693 French-speaking women with singleton pregnancies at 20–28 weeks' gestation were consecutively recruited at Caen University Hospital. Fifty women with missing values were subsequently excluded from the analysis. Depressive symptoms were assessed on the Edinburgh Postnatal Depression Scale. Risk factors were either extracted from the computerized obstetric records or assessed by means of self-administered questionnaires. The associations between prenatal depression and the potential risk factors were assessed using log-binomial regression models to obtain a direct estimate of relative risk (RR). The following factors were found to be significant in the multivariate analysis: level of education (p<0.001), past psychiatric history (adjusted RR = 1.8, 95% confidence interval (CI): 1.1;2.8, p = 0.014), stress related to the health and viability of the fetus (adjusted RR = 2.6, 95% CI: 1.6;4.1, p<0.001), and stress related to severe marital conflicts (adjusted RR = 2.4, 95% CI: 1.5;3.9, p<0.001) or to serious difficulties at work (adjusted RR = 1.6, 95% CI :1.04;2.4, p = 0.031). An association was also found with the previous delivery of a child with a major or minor birth defect (adjusted RR = 2.0, 95% CI: 1.04;4.0, p = 0.038). Univariate analyses revealed a strong association with childhood adversity (parental rejection: RR = 1.8, 95% CI: 1.2;2.8, p = 0.0055 and family secrets: RR = 2.0, 95% CI: 1.2;3.1, p = 0.0046) and with lack of partner support (RR = 0.50, 95% CI: 0.30;0.84, p = 0.0086).

Conclusions/Significance

Our study identifies several risk factors that could easily be assessed in clinical practice. It draws attention to the impact of previously delivering a child with a birth defect. The association with childhood adversity warrants further study.

Evaluation of class III beta-tubulin (bTubIII) expression as a prognostic marker in patients with resectable non-small cell lung cancer (NSCLC) treated by perioperative chemotherapy (CT) in the phase III trial IFCT-0002

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Background: IFCT-0002 phase III trial compared two timings of CT in early lung cancer, all before surgery (PRE) versus PERIoperative, and two CT regimens, CDDP-Gem vs. CBDCA-Pac. 528 patients were randomized. Paraffin embedded post- chemo pathological specimens were collected in the 490 non complete responder patients for tissue expression of the putative biomarker beta-tubulin III (bTubIII). Methods: 423 surgical pathological specimens with enough remaining viable tumor tissue after neoadjuvant chemo were processed for immunohistochemistry as published in the Bio-IALT study. A semi-quantitative score was attributed taking account the number of stained cells and the intensity of staining. Semi-quantitative scores were studied as continuous variables, without any pre- determined cut-off. Multivariate analysis for progression-free (PFS) and overall survival (OS) were corrected with Bonferroni-Holm method for multiple analyses. Median follow-up was 42 months. Results: bTubIII was the only IHC marker significantly associated with poor PFS in univariate (p=0.014) or multivariate analysis, adjusted for histology, T and stage (HR= 1.50 [1.07–2.10]; p=0.020). In patients with a pathological specimen showing a bTubIII positive immunostaining, median PFS was 30.6 months, versus 60.1 months (HR=1.46 [1.08–1.99]) for bTubIII negative patients. bTubIII IHC score remained predictive of poor OS in univariate (p= 0.0065) as in multivariate analysis (p=0.019 with Bonferroni correction, HR=1.75 [1.15–2.68] ). Median OS was not reached for bTubIII negative patients whereas it was 71.7 months in patients with bTubIII immunostaining of any intensity score (HR=1.61, [1.11–2.35]). Conclusions: This study showed a dramatic negative prognostic impact for bTubIII immunostaining in resectable early lung cancer. A subset of bTubIII expressing patients with poor prognosis did not take any advantage from perioperative chemo. Hence, those patients could rather have beneficiated from personalized adjuvant treatment with alternative approaches.

No significant financial relationships to disclose.

Discontinuation of oxytocin in the active phase of labor

OBJECTIVE

To show that early discontinuation of oxytocin will not increase the mean duration of the active labor phase in a clinically significant way.

DESIGN

Controlled non-inferiority study.

SETTING

Department of Obstetrics and Gynecology, University of Caen, Clemenceau Hospital, France.

POPULATION

A total of 138 women with singleton pregnancy and a vertex presentation of over 34 gestational weeks, presenting a medical indication of induction of labor or a dystocia at onset of labor, from May 2005 to June 2006.

METHODS

Two parallel groups were compared: continuation of oxytocin until delivery versus discontinuation of oxytocin at the onset of the active phase. The clinically acceptable increase in mean duration of the active phase of labor (non-inferiority margin) was set at 60 minutes.

MAIN OUTCOME MEASURES

Primary outcome measure was duration of the active labor phase. Secondary outcome measures included total duration of labor, parameters concerning oxytocin use, rates of uterine hyperstimulation and fetal heart rate (FHR) abnormalities, and mode of delivery. Some neonatal outcomes were also analyzed.

RESULTS

Equivalence of the two strategies (continuation vs. discontinuation of oxytocin) was not demonstrated (p=0.97 testing for non-inferiority), the active phase even being significantly longer by a mean of 113 minutes (p=0.0001 testing for superiority). The rates of cesarean sections, alterations of FHR and delivery hemorrhage were higher when oxytocin was continued, but not significantly. There were significantly more infants hospitalized in neonatology when oxytocin was continued (p=0.028).

CONCLUSIONS

Discontinuation of oxytocin at the onset of the active phase prolongs labor. We found no argument for discontinuing the infusion of oxytocin at the onset of the active phase.

[Fetal pulse oximetry: clinical practice]

OBJECTIVE

To assess in current practice the application of our protocol of using fetal pulse oximetry during labor, to evaluate whether fetal scalp blood sampling can be reduced and to determinate reliability of fetal pulse oximetry on the prediction of poor neonatal outcomes.

STUDY DESIGN

Prospective observational unicenter cohort including 449 patients during two years. All pregnancies were singleton, greater than or equal to 37 weeks' gestation, cephalic presentation, and had non reassuring fetal heart rate. The poor neonatal outcome was defined by one of the followings: arterial umbilical cord pH<or=7.15, umbilical cord base deficit greater than or equal to 12 mmol/l, 5 min Apgar score less than or equal to 7, transfer in neonatal intensive care unit, secondary respiratory distress and death.

RESULTS

The use of fetal pulse oximetry was concordant with our protocol in more than 80% of cases. The frequency of fetal scalp blood sampling was significantly reduced from 9.9 to 8.6% after the introduction of our protocol. With a 30% threshold, diagnostical values of fetal oximetry for a poor neonatal outcome were 9.1% for sensitivity, 93.1% for specificity, 79.4% for negative predictive value and 25.9% for positive predictive value. With a 40% threshold, the diagnostic values were 74, 51.6, 88.2 and 28.9% respectively.

CONCLUSION

The strict application of our protocol allow a less aggressive management of labor with a significant decrease in fetal scalp blood sampling. This study shows that with a 40% threshold, fetal pulse oximetry could be considered as a reliable tool for the management of labor with no increase of poor neonatal outcomes. On the other hand, the threshold which could determine whether an abnormal fetal heart rate needs immediate intervention still remains unclear.

Évaluation de la radiofréquence (TUNA™) dans le traitement de l’hypertrophie bénigne de prostate en chirurgie ambulatoire

OBJECTIVE

Evaluating the effectiveness and feasibility of transurethral needle ablation (TUNA) for young patients with symptomatic benign hyperplasia (BPH) in outpatient care.

MATERIAL AND METHODS

From 2004 to 2005, 9 patients (mean age: 59.7 years) were treated with the TUNA device. The urinary function using the IPSS (International Prostate Symptom Score), the quality of life score (QOL-UR), the uroflowmetry, and the post-void residue, and the sexual function using the International Index of Erectile Function score (IIEF-5) were assessed.

RESULTS

Prior to thermotherapy, the mean IIEF-5 was 20.2. The mean preoperative IPSS and QOL-UR scores were respectively 25.2 and 5,6. Regarding uroflowmetry, the mean pre-treatment maximal urinary flow was 6 ml/s and the mean post-void residue was 167.1 mL. Patients' follow-up was at intervals of 3 months. With a mean follow-up of 9.5 months, 8 patients have achieved a better urinary status with a mean IPSS and QOL-UR score of 9.5 and 1.6 respectively (p<0.05). The mean maximal flow rate was improved (14 ml/s, p< 0,05). The post-void residue decreased but had no statistical significance. The IIEF-5 score remained unchanged. Only 4 complications including 3 urinary retentions and 1 prostatitis were revealed for 3 patients. No failure with radiofrequency thermal therapy was observed.

CONCLUSION

TUNA as a mini-invasive outpatient treatment for symptomatic BPH proved reliable and reproducible for young patients with preserved sexual function.

Management of premature rupture of membranes before 25 weeks

OBJECTIVES

The aim of our study was to define the benefits and risks related to expectant management in the midtrimester rupture of membranes and to assess the prognostic factors in order to give objective informations to parents facing these obstetrical situations.

STUDY DESIGN

We conducted a retrospective study. The study population included 49 patients with premature rupture of membranes at 16-23 weeks' gestation during the period January 1998-June 2003. The main criterion for judgement was neonate survival. Statistical analysis included chi2-test for the qualitative variables and Student's test for the quantitative variables. The threshold for significance was 5%.

RESULTS

Twenty couples out of 49 chose medical termination of pregnancy. Among the 29 other pregnancies, the mean latency period was 2.1 weeks. The mean gestational age at delivery was 23.2 weeks. Nineteen patients were delivered after 22 weeks. The main prognostic factors were the initial amniotic fluid index (2.9 cm versus 0.8 cm) (p=0.042) and gestational age at delivery (26.7 weeks versus 22.6 weeks) (p<0.001). About 2% of the pregnancies were complicated by maternal infection. Eighty-three percent of the survivors had neonatal respiratory distress syndrome. 41.2% of them presented sepsis. We observed no cases of severe intraventricular haemorrhage. The number of infants born after 24 weeks of gestation and still alive at 1 week was 12, representing 24% of pregnancies and 63% of the infants born after 24 weeks.

CONCLUSION

Expectant management can be widely suggested to patients. However, termination of pregnancy is acceptable, in cases with a poor prognosis including anamnios and premature rupture of membranes before 21 weeks.

Rupture of the scarred uterus

OBJECTIVE

To assess the risk of uterine rupture of the scarred uterus according to mode of delivery in subsequent births recorded as spontaneous labour, labour induced by oxytocin, labour after ripening with prostaglandin E2, and planned cesarean section.

METHODS

Retrospective study of 2,128 births with a low transversal scar after a previous cesarean section. The study population was realised in a level III university hospital from 1995 to 2003. The association between mode of delivery and uterine rupture was studied in a multivariate logistic regression model, and adjusted for specific antenatal confounding factors.

RESULTS

Over 9 years, we collected 22 cases (1%), including 11 asymptomatic ruptures in a population of 2,128 scarred uteri out of 28,248 deliveries. Uterine rupture occurred at a rate of 0.3 per 100 among women with repeated cesarean delivery without labour, 1 per 100 among women with spontaneous onset of labour, 1.4 per 100 among women with oxytocin-induced labour, and 2.2 per 100 among women with prostaglandin cervical ripening. Compared to women with a planned cesarean section, women with spontaneous onset of labour were more likely to have uterine rupture (OR: 4.0; 95% CI: 0.8-42.0). A greater relative risk was observed among women with oxytocin-induced labour (OR: 4.3; 95% CI: 0.3-60.0), and particularly those with prostaglandin-induced labour (OR: 8.7; 95% CI: 1.5-97.3, p=0.01).

CONCLUSION

In women with a scarred uterus, prostaglandin E2 induction of labour is a risk factor for uterine rupture. The practice of a systematic cesarean section in cases with Bishop score<3, appropriate induction procedure, and rigorous monitoring of the labour, could make for a safer delivery.

Prenatal depression, prenatal anxiety, and spontaneous preterm birth: a prospective cohort study among women with early and regular care

OBJECTIVE

This article investigates the effects of antenatal depression and anxiety on spontaneous preterm birth resulting either from preterm labor or preterm premature rupture of membranes.

METHODS

We conducted a prospective cohort study of 681 women with singleton pregnancies consecutively recruited between 20 and 28 weeks of gestation in the Obstetrics Department of the French University Hospital of Caen. Most were of European ethnic origin and received early and regular antenatal care. The assessment of gestational age was based on ultrasound examination (occurring before 13 weeks of gestation for 94.9% of the women). Depression and anxiety were assessed using self-administered questionnaires: the Edinburgh Postnatal Depression Scale and the Spielberger State-Trait Anxiety Inventory. Logistic regression analysis, controlling for sociodemographic factors (e.g., maternal age, occupation) and obstetric factors (e.g., previous preterm birth, cervical or vaginal infection), provided adjusted odds ratios (ORs) and 95% confidence intervals (CIs).

RESULTS

Spontaneous preterm birth occurred in 31 women (4.8%). The rate of spontaneous preterm birth was significantly higher among women with high depression scores (9.7%) as opposed to other women (4.0%) even after adjustment for potential confounding factors (adjusted OR = 3.3, 95% CI = 1.2-9.2, p = .020). Anxiety was not significantly associated with the outcome. There were no significant interaction effects between psychological and biomedical factors.

CONCLUSIONS

These findings provide evidence that antenatal depression is significantly associated with spontaneous preterm birth in a population of European women receiving early and regular care.

[Complications of vacuum extractor deliveries]

OBJECTIVES

To describe maternal and neonatal complications following deliveries assisted by vacuum extraction and to compare outcomes with those obtained after spontaneous vaginal delivery. We wanted to know if vacuum extractor was a risk factor by itself.

MATERIALS AND METHODS

We conducted a retrospective study of two years activity involving 4524 deliveries of which 845 (18.7%) were vacuum extractor assisted. We precisely defined maternal and neonatal complications to compare their rates in spontaneous vaginal delivery and vacuum extractor groups.

RESULTS

There were 1333 maternal complications and 114 neonatal complications. The adjusted risks of maternal complications were significantly higher in the vacuum extractor group for simple vaginal tears (OR=3.0; p<0.001), the simple perineal tears (OR=1.8; p<0.001) and third degree perineal tears (OR=2.7; p<0.01). For neonatal complications, the difference was significant for cephalhematomas (OR=10; p<0.001) and scalp abrasions (OR=53; p<0.001). No cases of skull fracture or subgaleal subaponeurotic hemorrhage were recorded.

CONCLUSION

Our rates of maternal and neonatal complications after vacuum extractor were similar to those described in the literature. We have been able to show that vacuum extraction is itself a risk factor for third degree perineal tears and cephalhematoma. However, these complications are so infrequent that the advantages of this method of extraction argue in favor of wide use in obstetrics.