In severe head injury early tracheostomy decreases total days of mechanical ventilation or mechanical ventilation time after development of pneumonia.
BackgroundGestational Diabetes Mellitus (GDM) testing and management in Morocco is associated with delays resulting in late commencement of treatment. To reduce delays and to increase access of women to GDM care, a country-adapted intervention targeting primary health care providers was designed to test the hypothesis that detection and initial management of GDM at the primary level of care improves newborn outcomes in terms of lower birthweights and less cases of macrosomia and impacts on maternal weight gain, glucose balance and pregnancy outcomes.Materials and methodsWe conducted a cluster randomized controlled trial in two districts of Morocco. In each district, 10 health centers were randomly selected to serve either as intervention or control sites. Pregnant women attending antenatal care in the study facilities were eligible to participate. At the intervention sites, women were offered GDM screening by capillary glucose testing following International Association of Diabetes in Pregnancy Study Groups/WHO criteria. Women diagnosed with GDM received counselling on nutrition and exercise and were followed up through their health center whereas at control facilities routine practice was applied. Primary outcome was birthweight and secondary outcomes maternal weight gain, glucose control and pregnancy complications. We further assessed GDM prevalence in the intervention arm. Statistical analysis was performed on 210 recruited women. Continuous variables were reported using means while categorical variables using frequencies with tests of independence applying chi-squared tests. Differences of outcome variables between the two groups were estimated by mixed-effects regression models and effect sizes adjusted for confounders. The trial is registered under NCT02979756 at ClinicalTrials.gov.ResultsGDM prevalence reached 23.7% in Marrakech. Birthweight in the intervention group was 147grams lower than in the control group (p = 0.08) as was the proportion of macrosomes (3.5% versus 18.4%; p< 0.001). In the intervention arm, women did two times more follow-ups than at control sites (p = 0.001) and mean follow-up intervals were shorter (11.3 days versus 18.7 days; p < 0.001). Overall, 30% more fasting blood sugar values were balanced (p = 0.005) and mean weekly maternal weight gain 49 grams lower (p = 0.032) in the intervention group. More women from control facilities had a delivery complication whereas more newborn complications were observed in women from intervention facilities. No difference between the two groups existed regarding mode of delivery and mean gestational age at delivery. One of the main limitations of the study was the Hawthorn-effect at control sites that might have led to an underestimation of the effect size.ConclusionA high GDM prevalence in Morocco calls for a context-adapted screening and management approach to enable early interventions. GDM detection and care through antenatal care at primary health facilities may have positively impacted on newborn birthweight but findings are inconclusive. ...
Intracystic papillary carcinoma is a rare malignant tumor of the breast. It occurs communally in postmenopausal women. Clinically it can be asymptomatic or manifested by a breast mass or a nipple discharge. On imaging intracystic papillary carcinoma has usually benign features. Pathologic diagnosis can be difficult at classical histological examination and identification of myoepithelial cells layer by immunohistochemical study can be useful. In the majority of cases of pure intracystic papillary carcinoma, conservative management is possible. Adjuvant therapy is still controversial and prognosis is excellent. We report three cases of intracystic papillary carcinoma diagnosed on immunohistochemical examination and managed with conservative surgery.
BackgroundPrimary breast angiosarcoma is defined as malignant proliferation showing endothelial differentiation. It is a very rare tumour (0.05% of primary mammary cancers), whose diagnosis can be difficult.Case presentationWe report the observation of a patient with no previous history, aged 27 years. The clinical examination finds a right breast discreetly increased in volume. The trucut biopsy was in favour of a lactating tubular adenoma. However, an immunohistochemical complement was requested. An absence of pancytokeratin labelling contrasted with strong expression of CD31, CD34 (endothelial markers) are described. The proliferation index (Ki67) was estimated at 30%. This led to the conclusion that the phenotypic aspect is related to a vascular proliferation that evokes an angiosarcoma. After a multidisciplinary assessment, the patient benefited from an enlarged excision of the tumour. The histopathological examination of the surgical specimen found an infiltrating mesenchymal proliferation made of vessels of variable sizes anastomosed to vascular slits with lesional limits. The immunohistochemical examination on the surgical specimen showed to the same phenotypic profile on biopsy. The final diagnosis was a high-grade mammary angiosarcoma of incomplete excision. The patient refused any additional surgical management; external radiotherapy and close supervision were prescribed. After eight months of evolution, no local or remote recurrence was reported.ConclusionPrimary breast angiosarcoma is a mesenchymal malignant tumour of rare vascular origin. Our observation is peculiar by the absence of any prior radiotherapy, its clinical presentation, its morpho-phenotypic characteristics, its management and its evolutive aspects.
Postpartum hemorrhage (PPH) is a life-threatening complication of delivery. It is the leading cause of maternal mortality. During the last 15 years, several total uterine compressive sutures were described in literature. They have proven their effectiveness and safety in the management of severe PPH as an alternative to hysterectomy. We present in this paper a new technique of uterine compressive sutures based on removable uterine brace compressive sutures with compression of the uterus against the pubis. This technique may be more effective by using two mechanisms of uterine bleeding control and also may prevent uterine synechia by respecting the uterine cavity and the removal of the suture 1 or 2 days later. We also present the results of a 15 patients’ series using this new suture.
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