Search

Concrete structures must be designed not only to be safe against failure but also to perform satisfactorily in use. This book is written for practising engineers and students, and focuses on design methods for checking deflections and cracking which can affect the serviceability of reinforced and prestressed concrete structures. The authors present accurate and easy-to-apply methods of analysing immediate and long-term stresses and deformations. These methods allow designers to account for variations of concrete properties from project to project and from country to country, making the book universally applicable. Comprehensively updated, this third edition of Concrete Structures also includes four new chapters covering such topics as: non-linear analysis of plane frames, design for serviceability of prestressed concrete, serviceability of members reinforced with fibre polymer bars, and the analysis of time-dependent internal forces with linear computer programs that are routinely used by structural designers. A website accompanies the book, featuring three design calculation programs related to stresses in cracked sections, creep coefficients and time-dependent analysis. The book contains numerous examples, some of which are worked out in the SI units and others in the Imperial units. The input data and the main results are given in both SI and Imperial units. The book is not tied to any specific code, although the latest American and European codes of practice are covered in the appendices.

Objectives: Most of the ultrasound machines include a tool allowing real-time display of the standard value of the biometric measurement being taken. Our hypothesis was that this tool influences the sonographer as measurements are taken, by inducing a normalization, thus a tendency towards the 50th percentile. The objective of this study was to evaluate the impact of a real-time display of the standard value in prenatal ultrasound screening. Methods: We conducted an observational, prospective, controlled and open study including all patients who underwent a prenatal ultrasound scan in the 2nd or 3rd trimester at the University Hospitals in Strasbourg between December 2017 and June 2018. Exclusion criteria were the presence of a fetal morphological abnormality or a karyotypic abnormality. The tool being tested was the real-time display on screen of the gestational age, of which the measurement corresponds to the 50th percentile. The measurements were retrospectively transformed into Z-scores. The main end-point was to compare the distribution of Z-scores between the groups. Results: We included 3551 ultrasound examinations: 696 performed with the tool and 2796 performed without. Fifty-nine scans were excluded due to morphological abnormalities. There was no statistically significant difference between the Z-scores distributions of measurements performed with or without the tool, regardless of the parameter studied. There was also no difference in the detection of pathological measurements: below the 10th percentile or above the 90th percentile. Conclusion: The use of such a tool does not seem to be detrimental to biometric screening, but on the other hand does not seem useful either. Keywords: Contrôle qualité; Dépistage prénatal; Fetal biometry; Prenatal ultrasonography; Quality Control; Z-scores; Échographie.

Most of the ultrasound machines include a tool allowing real-time display of the standard value of the biometric measurement being taken. Our hypothesis was that this tool influences the sonographer as measurements are taken, by inducing a normalization, thus a tendency towards the 50th percentile. The objective of this study was to evaluate the impact of a real-time display of the standard value in prenatal ultrasound screening.We conducted an observational, prospective, controlled and open study including all patients who underwent a prenatal ultrasound scan in the 2nd or 3rd trimester at the University Hospitals in Strasbourg between December 2017 and June 2018. Exclusion criteria were the presence of a fetal morphological abnormality or a karyotypic abnormality. The tool being tested was the real-time display on screen of the gestational age, of which the measurement corresponds to the 50th percentile. The measurements were retrospectively transformed into Z-scores. The main end-point was to compare the distribution of Z-scores between the groups.We included 3551 ultrasound examinations: 696 performed with the tool and 2796 performed without. Fifty-nine scans were excluded due to morphological abnormalities. There was no statistically significant difference between the Z-scores distributions of measurements performed with or without the tool, regardless of the parameter studied. There was also no difference in the detection of pathological measurements: below the 10th percentile or above the 90th percentile.The use of such a tool does not seem to be detrimental to biometric screening, but on the other hand does not seem useful either.

Kernza intermediate wheatgrass is the first perennial grain crop in the world and has been developed with conventional breeding to increase seed yield of forage intermediate wheatgrass (Thinopyrum intermedium (Host) Barkworth & D.R. Dewey). When managed for dual-use (grain and forage), Kernza intermediate wheatgrass can produce grain, crop residue (straw) in the summer, and green forage in the spring and fall. Mixtures of this grass with legumes could increase forage yield and nutritive value and provide other environmental and economic benefits. Despite the growing interest in these dual-use production systems, forage nutritive value of Kernza intermediate wheatgrass forage in a dual-use system in the Upper Midwest is unknown. A replicated field experiment was established in two locations in southern Wisconsin (Arlington and Lancaster) with two treatments: Kernza intermediate wheatgrass grown in monoculture and mixture with red clover (Trifolium pratense L.). Forage samples were collected at late vegetative stage in the spring, at grain harvest in the summer, and at the end of the regrowth period in the fall. Forage nutritive value of the monoculture was greatest in the spring with 456, 249 and 225 g kg−1 for neutral detergent fiber (NDF), acid detergent fiber (ADF) and crude protein (CP), respectively; lowest in the summer with 702, 427 and 51 g kg−1 NDF, ADF and CP, respectively, and intermediate in the fall with 590, 337 and 119 g kg−1 NDF, ADF and CP, respectively. Predicted total-tract neutral detergent fiber digestibility (ttNDFD) was 0.53 for the spring forage and averaged 0.37 for the summer and fall forage, with no differences between the mixture and monoculture. The relative forage quality (RFQ) for the monoculture was 175 for the spring forage, 65 for the summer residue, and 116 for the fall. Intercropping red clover with Kernza intermediate wheatgrass increased CP of the summer crop residue by 69%, and increased CP and RFQ of the fall forage by 49% and 11%, respectively, while reducing NDF and ADF of the fall forage by 25% and 18%, respectively. Therefore, Kernza intermediate wheatgrass forage is suitable for lactating beef cows, dairy cows, and growing heifers when harvested in the spring and fall, and it offers high potential for dual-use grain and forage systems.

Resume Objectif L’allo-immunisation est une pathologie dont l’incidence a fortement diminue mais dont le pronostic reste sombre en l’absence de traitement. L’objectif de notre etude etait d’evaluer le pronostic fœtal, le taux ainsi que les facteurs de risque de complications des transfusions in utero (TIU). Methodes Il s’agit d’une etude observationnelle retrospective portant sur 86 TIU chez 37 fœtus entre 2001 et 2017. Notre critere de jugement principal etait la survenue d’une complication secondaire a la procedure. Le critere composite de complications etait defini comme suit : rupture prematuree des membranes ou accouchement premature dans les 7 jours suivant le geste, chorioamniotite, anomalies du rythme cardiaque fœtal indiquant la realisation d’une cesarienne en urgence dans les 24 heures suivant une TIU, et deces in utero ou neonatal secondaire a une TIU. Resultats Le taux de survie etait de 88,9 % avec un taux de complications severes de 5,8 % par TIU et de 13,5 % par grossesse. Une TIU avant 20 semaines d’amenorrhee etait un facteur de risque de complications : 50 % de complications en cas de premiere TIU avant 20SA versus 1,3 % en cas de premiere TIU apres 20SA, p = 0,8 × 10−3. Au contraire, l’anasarque ne semblait pas etre un facteur de risque de complication (16,7 % en cas d’anasarque versus 3,9 % en l’absence d’anasarque, p = 0,27) mais ce resultat est a nuancer du fait du faible effectif d’anasarque. La voie d’abord, qu’elle soit intra-abdominale ou au niveau de l’insertion placentaire, n’avait pas d’influence sur le pronostic. Conclusion La TIU est une therapeutique permettant un pronostic obstetrical favorable et peu pourvoyeuse de complications graves. Neanmoins, la necessite de realiser une TIU precoce est souvent associee a des complications.

Resume L’appendice caudal est une malformation exceptionnelle qui a toujours suscite de l’interet. Nous presentons le cas d’une decouverte antenatale d’une anomalie du rachis fœtal compatible avec un appendice caudal. Le bilan d’imagerie objectivait une extension de cette malformation superficielle a la moelle epiniere. La prise en charge obstetricale etait sans particularite. L’enfant a ete operee a 2 mois de vie. Les diagnostics differentiels sont le spina bifida, le teratome sacro-coccygien et le kyste du sinus pilonidal. L’appendice caudal est un des marqueurs de dysraphisme spinal, au meme titre qu’une touffe de poils ou qu’un hemangiome. Le risque est le syndrome de moelle attachee avec les complications neurologiques qu’il peut entrainer.

Both the improvement of pathophysiological knowledge of major fetal anomalies and the development of therapeutic tools have allowed in some specific cases in utero therapy by foetoscopy. We discuss the state of art and recent advances for four major anomalies: twin-to-twin transfusion syndrome, congenital diaphragmatic hernia, myelomeningocele and lower urinary tract obstruction. Fetoscopic laser surgery for twin-to-twin transfusion syndrome has become the gold standard for treatment of TTS. In terms of fetal surgery, severe congenital diaphragmatic hernia and myelomeningocele are the two main indications, even if open fetal surgery is still the gold standard for management of myelomeningocele. New techniques using fetal cystoscopy are currently under development. Although the maternal morbidity associated with foetoscopy is low, preterm rupture of membranes and preterm delivery remain an important problem. Long-term evaluation of those neonates remains mandatory.

Objective To evaluate the efficacy of fetal intervention using fetal cystoscopy or vesicoamniotic shunting in the treatment of severe lower urinary obstruction (LUTO). Methods A cohort of 111 fetuses with severe LUTO attending two centers between January 1990 and August 2013 were included retrospectively. Fetuses were categorized into three groups based on the method of intervention: (1) fetal cystoscopy, (2) vesicoamniotic shunting or (3) no intervention. Multivariate analyses were performed to determine the probability of survival and normal renal function until 6 months of age by comparing fetal cystoscopy and vesicoamniotic shunting to no fetal intervention. Results Of the 111 fetuses with severe LUTO that were included in the analysis, fetal cystoscopy was performed in 34, vesicoamniotic shunting was performed in 16 and there was no fetal intervention in 61. Gestational age at diagnosis, method of fetal intervention and cause of bladder obstruction were associated with prognosis. In multivariate analysis and after adjustment for potential confounders (considering all causes of LUTO) the overall probability of survival was significantly higher with fetal cystoscopy and vesicoamniotic shunting when compared to no intervention (adjusted relative risk (ARR), 1.86 (95% CI, 1.01–3.42; P = 0.048) and ARR, 1.73 (95% CI, 1.01–3.08; P = 0.04) respectively). A clear trend for normal renal function was present in the fetal cystoscopy group (ARR, 1.73 (95% CI, 0.97–3.08; P = 0.06)) but was not observed in the vesicoamniotic shunt group (ARR, 1.16 (95% CI, 0.86–1.55; P = 0.33)). In cases in which there was a postnatal diagnosis of posterior urethral valves, fetal cystoscopy was effective in improving both the 6-month survival rate and renal function (ARR, 4.10 (95% CI, 1.75–9.62; P

L’interruption selective de grossesse (ISG) correspond au fœticide d’un jumeau atteint d’une affection d’une particuliere gravite. La preservation du cojumeau sain represente un veritable enjeu et determine la prise en charge. De nombreux parametres sont a prendre en consideration afin d’evaluer au mieux la legitimite de l’indication d’ISG mais aussi la technique a privilegier et le moment opportun pour la procedure : chorionicite, type de pathologie fœtale (menace pour l’ensemble de la grossesse, danger pour la mere, caractere letal ou non) et parametres techniques (âge gestationnel, localisation placentaire, quantite de liquide amniotique et accessibilite de la poche du fœtus atteint). Dans la grossesse bichoriale, on pourra pratiquer une injection funiculaire ou intracardiaque letale, tandis que dans la grossesse monochoriale, le fœticide consiste en une interruption selective complete et permanente de la circulation au niveau du cordon du fœtus atteint (a la pince bipolaire, au laser ou par radiofrequence). Dans certains cas, le fœticide peut aussi etre realise au moment de l’accouchement. L’information doit etre complete et honnete, de maniere a ce que le couple puisse faire veritablement un choix eclaire, en fonction de ses valeurs.

Objective To describe the surgical technical aspects associated with the development of urological fistulas after fetal antegrade cystoscopic laser fulguration of the posterior urethral valves (PUV). Methods The perioperative data for all fetal cystoscopies performed between January 2004 and August 2013 at three institutions in the USA, France and Brazil were reviewed, with particular emphasis on surgical technical aspects of the procedure and the complications encountered. Results A total of 40 fetal cystoscopies were performed at the three institutions. Laser fulguration of the PUV was performed in 23 of these cases, with a survival rate of 60.9% (14/23) and normal renal function in 85.7% (12/14) of these infants. Urological fistulas were diagnosed postnatally in four (10%) newborns. The presence of fistulas was associated with a higher gestational age at diagnosis of PUV (P

Erythrocyte allo-immunization's rate has decreased but without adapted treatment the prognosis is still poor. The aim of our study was to evaluate the fetal prognosis, the complication's rate and the risk factors of complications of the intrauterine transfusion.Retrospective study about 37 fetus and 86 intrauterine transfusions between 2001 and 2017. Our main criterion in judging was the occurrence of procedure related complications: premature membrane rupture or premature delivery within seven days from the procedure, chorioamnionitis, abnormal fetal heart rate indicating an emergency ceasarean section within the 24hours from the procedure, in utero death or neonatal death related to the procedure.The survival rate was about 88.9% with a severe complication's rate of 5.8% per intrauterine transfusion and 13.5% per pregnancy. Intrauterine transfusions before 18 weeks of pregnancies was a complication risk factor: 50% of complications before 18 weeks vs. 1.3%, P=0.8×10Intrauterine transfusion complications are rare and it enhances the fetal prognosis. However, an early procedure is related to a higher rate of complications.

Resume Le syndrome de Klippel-Trenaunay (SKT) est une maladie rare, caracterisee par des hemangiomes cutanes, des malformations capillaires veineuses (veines variqueuses), une hypertrophie osseuse et des tissus mous affectant un ou plusieurs membres. Il est souvent associe a des complications hemorragiques et thrombotiques surtout au cours de la grossesse. Des anomalies vulvo-vaginales, a risque hemorragique, peuvent apparaitre en fin de grossesse posant la problematique de la voie d’accouchement. Ce choix depend de la severite des anomalies vasculaires et de l’experience de l’obstetricien. Nous rapportons le cas d’une parturiente a 38 semaines d’amenorrhee presentant un SKT avec atteinte du membre inferieur gauche remontant jusqu’a la grande levre correspondante. Elle a presente, a son accouchement par voie basse, des pertes sanguines importantes (2000 mL) secondaires a des dechirures vaginales necessitant des sutures et une embolisation arterielle. Une prise en charge multidisciplinaire est necessaire lors de l’accouchement.

Vasa previa is a rare complication of pregnancy (1/2000 to 1/6000) with a high fetal mortality rate (75 to 100%). We will discuss two case reports of vasa previa: the first was diagnosed before labor, while the second was during delivery. In the first case, the diagnosis of vasa previa was confirmed by a transvaginal ultrasound and color doppler, while the second case involved late diagnosis during delivery and after gross examination of the placenta. Risk factors for vasa previa are: low-lying placenta, bilobed or succenturiate lobed placenta, velamentous and in vitro fertilization (IVF). Antenatal diagnosis of vasa previa is crucial because it allows for prophylactic caesarean section and prevents severe Benckiser's hemorrhage responsible for a very high neonatal mortality.

L’amelioration globale du pronostic des patients et l’impulsion apportee par les deux Plans cancer ont conduit a une meilleure prise en compte de l’apres-cancer. La preservation de la fertilite avantmise en route d’un traitement potentiellement gonadotoxique en est un theme essentiel, s’integrant dans la dynamique des soins oncologiques de support. Il s’agit de pouvoir offrir aux patients la possibilite de mener a bien le moment venu un projet parental adapte a leurs attentes. La mise en oeuvre d’actions coordonnees au sein du Reseau regional de cancerologie ONCOPACACorse a pour but de leur permettre un acces rapide a cette prise en charge specifique. Ce dispositif prevoit l’acces aux techniques emergentes amenees a etendre l’offre de soins, notamment pour la population feminine et pediatrique, et le suivi des patients. L’information des equipes d’oncologie est essentielle a la reussite de ce projet.

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

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. Keywords: Diagnostic anténatal; IRM pelvienne; Pelvic MRI; Pelvic ultrasound; Placenta accreta; Prenatal diagnosis; Échographie obstétricale.

Resume Objectifs Analyse des donnees cliniques et epidemiologiques des fentes oro-faciales et evaluation du diagnostic prenatal. Materiels et methodes Etude retrospective a partir des donnees du Registre de malformations congenitales d’Alsace (departement du Bas-Rhin) entre 1995 et 2006. Resultats Trois cent vingt et une fentes ont ete colligees (prevalence globale de 2,1 pour 1000 naissances), dont 204 fentes labiales et labio-palatines (FL ± P) et 117 fentes palatines (FP). Parmi les FL ± P, 70 (34 %) etaient associees a d’autres malformations congenitales dans le cadre de syndromes chromosomiques (31 cas) ou de syndromes geniques ou apparentes (12 cas). Les 117 cas de FP se repartissaient en 50 FP totales (43 %) et 67 posterieures (57 %) ; 25 sequences de Pierre Robin ont ete recensees (21 %). Les FP etaient associees a d’autres anomalies congenitales dans 68 cas (58 %), dont 12 syndromes chromosomiques et 14 syndromes geniques identifies. Parmi les 204 cas de FL ± P, 106 avaient ete diagnostiquees par l’echographie antenatale (52 %). Seul 1 cas de FP avait ete diagnostique in utero. Parmi l’ensemble des cas, 263 (82 %) etaient nes vivants ; une interruption medicale de grossesse avait ete realisee dans 50 cas (16 %), tous associes a d’autres anomalies et 8 morts fœtales in utero avaient ete rapportees (2 %). Conclusion La prevalence globale des fentes oro-faciales est elevee (2,1 pour 1000 naissances). L’association frequente a d’autres anomalies congenitales impose la realisation d’un bilan malformatif et genetique systematique. Le diagnostic prenatal echographique reste difficile comme en temoigne le taux moyen de detection d’environ 50 %.

Journal de Gynecologie Obstetrique et Biologie de la Reproduction - Vol. 40 - N° 5 - p. 444-451

Resume L’Arrete reglementant le depistage prenatal combine de la trisomie 21 au premier trimestre de la grossesse et fixant les regles de bonnes pratiques en matiere de depistage et de diagnostic prenatal de la trisomie 21 a ete publie au Journal officiel. Toutes les etudes internationales, notamment anglaises, realisees depuis longtemps montrent l’interet de pratiquer de la sorte, c’est-a-dire de combiner l’âge maternel, la clarte nucale et les marqueurs seriques du premier trimestre (hormone chorionique gonadotrope [hCG] libre et pregnancy-associated plasma protein A [PAPP-A]) entre 11 et 13 semaines d’amenorrhees et six jours, en un calcul unique. La performance de cette strategie combinee precoce semble superieure a la strategie actuelle en augmentant le taux de detection et en diminuant le taux de faux positifs. Nous avons mis en place cette strategie depuis 2004 et nous rapportons ici nos resultats.

The risk of fetal loss is multiplied by 4 in monochorionic pregnancies by comparison with dichorionic one. The incidence of selective growth retardation (sIUGR) is between 12.5 to 25%. This variation is explained by the mixture between pure twin-to-twin transfusion syndrome (TTTS) and pregnancies without TTTS but with a pure sIUGR. The ability to diagnose prenatally sIUGR is low; the positive predictive value is only 37% (EL4). The umbilical flow velocity waveforms with absent diastolic flow (Type II) or with diastolic intermittent flow (Type III) is clearly a strong risk factor of mortality of the IUGR and also a risk factor of leucomalacia of the bigger fetus (EL3). The observed incidence of malformations in twins is 4.05% versus 2.38% for singletons (OR=1.7 [IC 95% 1.47-1.97]). Furthermore, the rate of fetal malformations is higher in monochorionic pregnancies by comparison with dichorionic one, 6.33% versus 3.43% (OR=1.8 [IC 95% 1.3-2.5]) (EL3). In the majority of the cases, the malformation is concerning only one fetus. The most frequent malformations are those of the central nervous system by comparison with singletons, those of the urinary tract and the cardiovascular malformations. Monozygotic pregnancies are not necessarily phenotypically and genetically identical. In situation of asymmetrical malformation, it is necessary to propose fetal karyotype of the malformed fetus. In case aneuploidy of the malformed fetus, secondarily it will be necessary to explore the other apparently normal one. Uniparental disomy should be suspected in such situation (EL3). In TRAP sequence, an intensive follow up should be organised with serial measurement of the respective size of the acardiac fetus and the normal one, Doppler exploration should be done to look for early sign of cardiac decompensation (expert viewpoint). In dichorionic pregnancies, when the malformation is threatening the whole pregnancy like anencephaly, a selective feticide allow a prolongation of the pregnancy, but with a risk of fetal loss of 8% and a risk of iatrogenic prematurity of 12%. In such situation, it could be wise to evaluate the evolution or to wait until the third trimester to undergo the procedure (EL3). In monochorionic pregnancies, in the same situation of anencephalic fetus the best option is bipolar cord coagulation. The result seems to be better after 18 weeks of gestation (EL4). There is a 20% risk of premature rupture of membrane. In the up to date analysis of the literature, there is no formal indication of selective feticide expect case of TRAP sequence with cardiac decompensation of the normal fetus. The very special situation of sIUGR is the object of a randomized trial. In all cases the active participation of the patients to the therapeutic option is mandatory (expert viewpoint).

Background: Hospital nurses are frequently the first care givers to receive a patient’s request for euthanasia or physician-assisted suicide (PAS). In France, there is no consensus over which medical practices should be considered euthanasia, and this lack of consensus blurred the debate about euthanasia and PAS legalisation. This study aimed to investigate French hospital nurses’ opinions towards both legalisations, including personal conceptions of euthanasia and working conditions and organisation. Methods: A phone survey conducted among a random national sample of 1502 French hospital nurses. We studied factors associated with opinions towards euthanasia and PAS, including contextual factors related to hospital units with random-effects logistic models. Results: Overall, 48% of nurses supported legalisation of euthanasia and 29%, of PAS. Religiosity, training in pallative care/pain management and feeling competent in end-of-life care were negatively correlated with support for legalisation of both euthanasia and PAS, while nurses working at night were more prone to support legalisation of both. The support for legalisation of euthanasia and PAS was also weaker in pain treatment/palliative care and intensive care units, and it was stronger in units not benefiting from interventions of charity/religious workers and in units with more nurses. Conclusions: Many French hospital nurses uphold the legalisation of euthanasia and PAS, but these nurses may be the least likely to perform what proponents of legalisation call “good” euthanasia. Improving professional knowledge of palliative care could improve the management of end-of-life situations and help to clarify the debate over euthanasia.

Resume Objectif Le but de ce travail est d'exposer la situation du don et de l'accueil d'embryons en France et dans le monde, d'en presenter les difficultes pratiques ainsi que les resultats obtenus dans notre centre trois ans apres la mise en place de cette procedure. Patients et methodes Les modalites de mise en œuvre sont regies en France par plusieurs textes legislatifs parus entre 1999 et 2004. Apres avoir contacte les couples disposant d'embryons surnumeraires congeles dans notre centre depuis au moins deux ans, les consultations obligatoires avec les couples souhaitant faire don de leurs embryons a un autre couple ont ete mises en place. Les couples receveurs ont beneficie d'une prise en charge pluridisciplinaire permettant d'evaluer l'indication d'accueil d'embryons. Resultats Parmi les couples contactes, 16,7 % optent pour le don d'embryon mais moins de la moitie d'entre eux finalise cette decision (6 % des couples ayant des embryons congeles). Les indications medicales principales retenues pour l'accueil d'embryons sont la double sterilite, les indications genetiques non etiquetees, les echecs d'AMP (pauci fecondation ou mauvaise qualite embryonnaire) et les couples candidats au don d'ovocytes pour qui l'attente parait trop longue. Un taux de grossesse de 28,6 % a ete obtenu apres 21 premiers transferts d'embryons. Discussion et conclusion Les resultats de l'accueil d'embryons en France confirment l'experience internationale tant au niveau de la penurie en embryons donnes qu'en terme d'indications et de resultats. Meme si la legitimite de l'accueil d'embryons est indeniable, certaines questions restent en suspens notamment sur le plan ethique et necessitent une reflexion nationale.

To evaluate de performances of noninvasive prenatal testing using cell free circulating fetal DNA (cffDNA) for the detection of fetal trisomy 21, 18 and 13 in a French population.cffDNA analysis was performed by massive parallel sequencing during a multicenter, non interventional, prospective study and the results were compared with a standard fetal karyotype.Results were available for 886 patients who have been classified as high- or moderate-risk depending on the presence of fetal abnormalities on ultrasound examination. For the high-risk group (n=376), the sensitivity and specificity of the test were 100% and 99.9% for trisomy 21, 88% and 99.9% for trisomy 18 and 100% and 99.9% for trisomy 13. The rate of other pathogenic chromosomal abnormalities with a negative NIPT was 7.9%. In the low-risk group (n=510), the sensitivity was 100% and the specificity 99.8% for trisomy 21, and only 0.4% of pathogenic chromosomal abnormalities were revealed by fetal karyotyping but not detected by cffDNA analysis.Noninvasive prenatal testing using cffDNA for high risk patients without fetal anomalies at ultrasound could be recommended in France after counseling on the possible risk of undiagnosed anomalies.

The objectives of this study were to evaluate the efficacy of minimally invasive ablation of high-risk large sacrococcygeal teratomas (SCT) and to compare the efficacy of vascular and interstitial tumor ablation.This was a retrospective multicenter study including a cohort of fetuses with high-risk large SCTs between 2004 and 2010. In addition, we performed a systematic literature review of all cases that underwent tumor ablation in order to compare the survival rates after 'vascular' and 'interstitial' ablation. Statistical analysis was conducted using Bayesian methods.In our cohort, a total of 13 fetuses had high-risk large SCT and five of them underwent tumor ablation. The estimated difference in hydrops resolution rate between the fetal intervention and the no fetal intervention groups was 44.6% (95% credibility interval, 1.5 to 81.0%; Pdiff0 = 97.9%). The estimated difference in survival rate between the fetal intervention and the no fetal intervention groups was 31.0% (13.9 to 48.1%; Pdiff0 = 99.9%). We analyzed our five cases together with 28 cases from the literature and estimated the difference in survival rate between the vascular and interstitial ablation groups as 19.8% (-13.1 to 50.1%; Pdiff0 = 88.3%). The estimated difference in hydrops resolution rate between the vascular and the interstitial ablation groups was 36.7% (-5.7 to 72.7%; Pdiff0 = 95.5%).Minimally invasive surgery seems to improve perinatal outcome in cases of high-risk large fetal SCT. Our findings suggest that 'vascular' ablation may improve outcome and may be more effective than 'interstitial' tumor ablation, but this hypothesis needs further investigation in a larger multicenter prospective study. Copyright © 2015 ISUOG. Published by John WileySons Ltd.

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.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.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 (p0.05). 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.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.

El uso de la ecografia endovaginal permite la practica de un verdadero examen morfologico fetal desde el final del primer trimestre de la gestacion. El periodo optimo se situa entre la 12.a y la 14.a semanas de edad gestacional (EG), momento en que ya son accesibles al estudio ecografico las principales estructuras del feto. Entonces puede demostrarse un gran numero de enfermedades congenitas del sistema nervioso central, el corazon, las paredes, el esqueleto, el aparato urinario e incluso los tejidos blandos. El estudio de 11.702 embarazos unicos explorados mediante ecografia las semanas 11.a-15.a de EG en el Departamento de Ecografia y Medicina Fetal de CMCO en Schiltigheim/Estrasburgo permitio estudiar la enfermedad malformativa que puede encontrarse en este periodo de la gestacion, ya que muchos de estos embarazos eran de algo riesgo. En las ecografias se sospecharon 1.313 malformaciones, equivalentes al 11,2% de la poblacion. Las anomalias de los tejidos blandos (translucencia nucal, higroma cervical, sindrome de Bonnevie-Ullrich) fueron las anomalias detectadas mas frecuentes, con mas del 70% de los casos. Se valoraron la sensibilidad y la especificidad del estudio de cada organo, y se llego a la conclusion de que la ecografia del primer trimestre, pese a no detectar todas las anomalias morfologicas, permite hacer el diagnostico precoz de las mas significativas o definir los grupos de riesgo que precisan estudios complementarios. Ademas, tambien permite adoptar una actitud terapeutica precoz. Sin embargo, el estudio del primer trimestre debe completarse con un examen morfologico efectuado hacia la 20.a semana de EG, ya que determinadas enfermedades no son visibles hasta ese momento.

Objectives This study compared the accuracy of ultrasound cervical assessment (cervical length and cervical index) and digital examination (Bishop score and cervical score) in the prediction of spontaneous birth before 34 weeks in twin pregnancies. Methods In a prospective multicenter study, digital examination and transvaginal sonography were performed consecutively in twin pregnancies attending for routine sonography at either 22 weeks (175 women) or 27 weeks (153 women). The digital examination took place first, and the Bishop score and cervical score (cervical length minus cervical dilatation) were calculated. Ultrasound measurements were then made of cervical length and funnel length to yield the cervical index (1 + funnel length/cervical length). The association between each variable and delivery before 34 weeks was tested by the Mann–Whitney U-test. The receiver–operating characteristics (ROC) curves of the ultrasound and digital indicators were determined for both gestational age periods, and the areas under the ROC curves compared. The best cut-off values for each indicator were used to determine predictive values for delivery before 34 weeks. Results The median gestational age at delivery among the women included in the 22-week examination period was 36.0 (range, 21–40) weeks; 10.9% (19) gave birth spontaneously before 34 weeks. The median cervical length was 40 (range, 6–65) mm. All four parameters were predictors of delivery before 34 weeks. The areas under the ROC curves for cervical index, cervical length, Bishop score and cervical score did not differ significantly. The median gestational age at delivery among the women in the 27-week examination period was 36.0 (range, 27–40) weeks; 9.2% (14) gave birth spontaneously before 34 weeks. The median cervical length was 35 (range, 1–57) mm. All parameters except the Bishop score were predictors of delivery before 34 weeks. The likelihood ratio of the positive and negative tests for cervical length ≤ 25 mm was 5.4 (range, 3.2–9.0) and 0.3 (range, 0.1–0.7), respectively, compared with 2.3 (range, 1.3–4.2) and 0.6 (range, 0.3–1.1), respectively, for cervical score ≤ 1. The area under the curve for the cervical index was significantly larger than that for the Bishop score (P = 0.008) or cervical score (P = 0.02). Conclusion Transvaginal sonography predicted spontaneous delivery before 34 weeks better than digital examination at the 27-week but not the 22-week examination. Copyright © 2005 ISUOG. Published by John Wiley & Sons, Ltd.

Resume L’utilisation de l’echographie endovaginale permet la realisation d’un authentique examen morphologique fœtal des la fin du premier trimestre de la grossesse. La periode optimale se situe entre la 12 e et la 14 e semaine d’amenorrhee (SA). Les principales structures fœtales sont alors en place et accessibles a l’examen echographique. Un large nombre de pathologies congenitales peuvent alors etre mises en evidence des cette periode. Elles concernent le systeme nerveux central, le cœur, les parois, le squelette, le tractus urinaire ou encore les tissus mous. L’etude de 11 702 grossesses uniques ayant beneficie d’une echographie entre 11 et 15 semaines d’amenorrhee au departement d’echographie et de medecine fœtale du CMCO a Schiltigheim/Strasbourg, a permis d’etudier la pathologie malformative susceptible d’etre observee a cette periode de la gestation, une large partie de ces grossesses etant a haut risque. Echographiquement, 1 313 malformations ont ete suspectees, soit un taux de 11,2 % de la population. Les anomalies des tissus mous (clarte nucale, hygroma colli, syndrome de Bonnevie-Ulrich) ont ete les anomalies les plus frequemment detectees a plus de 70 %. Les sensibilites et specificites de l’examen ont ete evaluees pour chaque organe et discutees, permettant de conclure que l’echographie du premier trimestre, si elle ne detecte pas toutes les anomalies morphologiques, permet de faire un diagnostic precoce des anomalies majeures ou de definir des groupes a risque necessitant des investigations complementaires. Elle permet ainsi une prise en charge precoce. L’examen du premier trimestre doit cependant etre complete par un examen morphologique vers 20 SA, certaines pathologies n’etant pas encore visibles a cet âge.

Resume L’experience de la maladie n’est pas neutre d’un point de vue bio-psychosocial. Les malades, en fonction de leurs pathologies, font l’objet de jugements sociaux, voire de stigmatisation. L’espace du soin n’est pas impermeable a ces processus d’evaluation et de representation. La presence des patients alcooliques dans les unites de soins palliatifs represente un terrain d’analyse des enjeux psychosociaux qui s’immiscent au sein des interactions therapeutiques. Ces enjeux questionnent la dimension ethique du regard porte sur « l’autre ». Les soignants doivent etre a meme d’identifier et de reguler ces processus dans et par leurs pratiques.

Journal de Gynecologie Obstetrique et Biologie de la Reproduction - Vol. 45 - N° 1 - p. 97-98

In 1999, the French Parliament established a “right to palliative care”, which reactivated public debate about euthanasia. In order to investigate jointly physicians’ attitude toward palliative care and euthanasia, we conducted a cross-sectional survey of a national sample of French GPs, oncologists, and neurologists. Overall, 917 physicians participated in the survey. Significant proportions of respondents, especially among GPs and neurologists, considered that palliative sedation and withdrawing life-sustaining treatments (WLST) were euthanasia. Multivariate analysis showed that the physicians who had special medical training in palliative care, and those who distinguish palliative sedation and WLST from euthanasia were more likely to oppose legalisation of euthanasia. Thus, French physicians’ attitude to the legalisation of euthanasia is strongly influenced by whether or not they distinguish palliative care from euthanasia. Improved palliative care requires better training of the entire medical profession, and clearer guidelines about which end-of-life care practices are legally and ethically acceptable.

Objective: This study aimed to examine factors associated with the prescription of opioid analgesics to terminal cancer patients, including physicians' general attitudes toward morphine and contextual factors.Methods: A survey was conducted among a sample of French general practitioners (GPs) and oncologists. Respondents were asked to describe the last three terminally ill patients they had followed up to death.Results: Overall, 526 GPs and oncologists (global response rate: 57%) described 1,082 cancer patients, among whom 85.4% received opioid analgesics. Among other significant predictors (patient age, cancer type, family assistance), this prescription was less frequent for female patients followed by male physicians (OR = 0.53), and more frequent for patients followed by physicians trained in palliative care (OR = 2.70). On the other hand, physicians' attitudes toward morphine were not associated with prescription of morphine and other opioid analgesics.Significance of results: Although nonprescription of opioid analgesics is only a crude proxy measure for undertreatment of cancer pain, our findings suggest the need to develop training in palliative care in order to standardize practices among GPs and specialists. Our results also highlight the necessity to study pain assessment as an interaction between the physician and the patient, and to consider patients' and physicians' respective genders as a key variable within this interaction.

In this retrospective analysis, we report on the detailed management of 33 recurrent osteosarcoma patients from a population of 81 adolescents and adults previously treated (between November 1979 and November 1998) at the La Timone Adults Hospital, for an extremity-localised osteosarcoma. The site of the first recurrence was limited to the lung in 24 patients (73%), was local in 4 patients (12%), at multiple sites in 4 patients (12%), and limited to the bone for 1 patient (3%). The median interval between the diagnosis of the primary osteosarcoma and the first recurrence was 16 months (range 4–108 months). For all patients, the treatment combined aggressive chemotherapy and surgical resection of the recurrences whenever possible. 19 patients (58%) achieved a second complete remission. The median follow-up time from the first recurrence was 18 months (range 4–150 months). For all patients, the median overall survival from first recurrence was 17 months (95% confidence interval (CI), 11–22 months) and the projected 3and 5-year survival rates were 31.6 and 23.7%, respectively. Patients with a second complete remission had a better 5-year survival than patients without (44.6% versus 0%, P=0.001). The achievement of a second complete remission has an independent significant prognostic value for an improved survival. Aggressive surgery with the removal of recurrence sites combined with multiagent chemotherapy can either cure patients with recurrent osteosarcoma or significantly prolong their survival. # 2003 Elsevier Ltd. All rights reserved.