Progression of Doppler abnormalities in intrauterine growth restriction

OBJECTIVE

To identify the sequence of progression of arterial and venous Doppler abnormalities from the onset of placental insufficiency in intrauterine growth restriction (IUGR).

METHODS

Prospective observational study of singletons with IUGR (abdominal circumference < 5(th) percentile) who underwent serial standardized umbilical artery (UA), middle cerebral artery (MCA), ductus venosus (DV) and umbilical vein (UV) Doppler surveillance. Time intervals between progressive Doppler abnormalities and patterns of deterioration were related to UA Doppler status and gestational age.

RESULTS

Six hundred and sixty-eight longitudinal examinations were performed in 104 fetuses, identifying three patterns of progression: (1) Mild placental dysfunction (n = 34) that remained confined to the UA/MCA. The UA became abnormal at a median of 32 weeks' gestation but the pulsatility index never exceeded 3 SD above normal. Progression took a median of 33 days, requiring delivery at a median of 35 weeks. (2) Progressive placental dysfunction (n = 49). Initially normal UA Doppler PI at 29 weeks' gestation increased beyond 3 SD, progressing to abnormal MCA, absent/reversed UA diastolic flow, abnormal DV, UV pulsations in 9-day intervals requiring delivery by 33 weeks. (3) Severe early-onset placental dysfunction (n = 21). Markedly elevated UA PI established by 27 weeks' gestation was associated with rapid (7-day intervals) progression to abnormal venous Doppler with median delivery at 30.6 weeks. Gestational age at onset, time to delivery and progression intervals were different between patterns (all P < 0.05).

CONCLUSION

The characteristics of cardiovascular manifestations in IUGR are determined by the gestational age at onset and the severity of placental disease. Recognition of these factors is critical for planning fetal surveillance in IUGR.

Congenital heart disease is a feature of severe infantile spinal muscular atrophy

OBJECTIVE

Homozygous deletions/mutations of the SMN1 gene cause infantile spinal muscular atrophy (SMA). The presence of at least one SMN2 gene copy is required for normal embryogenesis. Lack of SMN protein results in degeneration of motor neurons, while extraneuronal manifestations have been regarded as a chance association with SMA. We report on heart defects in the subgroup of congenital SMA type I patients.

METHODS

Data were recruited from 65 unselected SMA I patients whose diagnosis had been confirmed genetically within the first 6 months of age. SMN2 copy numbers were analysed retrospectively and correlated with clinical findings including heart malformations.

RESULTS

Four (6%) patients had one copy of SMN2, 56 (86%) had two and five (8%) had three SMN2 copies. Three out of four (75%) patients with a single SMN2 copy had congenital SMA with haemodynamically relevant atrial or ventricular septal defects.

CONCLUSIONS

Previous case reports of SMA I patients with congenital heart defects did not clarify whether the cardiac malformations were coincidental. Given the respective incidences of congenitally lethal SMA with a single SMN2 copy and of cardiac septal defects in humans, a chance association of both conditions would occur in less than one out of 50 million individuals. Our findings suggest that the SMN protein is relevant for normal cardiogenesis.

Orofaciodigital syndrome Type IV (Mohr-Majewski): early prenatal diagnosis in siblings

We report the sonographic and autopsy findings in two sibling fetuses with autosomal recessive orofaciodigital syndrome (OFDS) Type IV (Mohr-Majewski) diagnosed at 11-13 weeks' gestation. The first-trimester anomaly scan showed a markedly increased nuchal translucency (NT) thickness in both fetuses (4.7 mm and 5.1 mm). Both fetuses had multiple anomalies involving the brain, cranium, heart and skeletal system and their karyotypes were normal. The pregnancies were terminated and the autopsies showed findings consistent with Mohr-Majewski syndrome. These cases show the overlap between OFDS Type II (Mohr) and lethal short-rib-polydactyly syndrome Type II (Majewski) and confirm both the autosomal recessive inheritance of the condition and our ability to diagnose it early in pregnancy using detailed fetal ultrasonography.

Spectrum and outcome of prenatally diagnosed fetal tumors

OBJECTIVE

To describe the spectrum of prenatally diagnosed fetal tumors, and the course and fetal outcome in affected pregnancies.

METHODS

This was a retrospective study in two German tertiary referral centers of 84 fetuses with tumors diagnosed in the prenatal period. The tumors were classified according to their location and histology.

RESULTS

The most common site of origin was the heart (20/84, 23.8%), followed by the face and neck region (19/84, 22.6%) and the abdomen (16/84, 19%). Lymphangiomas (21/84, 25%) and rhabdomyomas (19/84, 22.6%) comprised half of the tumor histology. Less frequently, teratomas (14/84, 16.6%) and hemangiomas (12/84, 14.2%) were seen. Complications included arrhythmia in cases with rhabdomyoma (8/19, 42%) and signs of heart failure in cases with hemangioma (4/12, 33%) and teratoma (4/14, 28.6%). The overall survival rate was 75%. Cases with either a histological diagnosis of teratoma or tumor located in the brain had the worst prognosis.

CONCLUSION

The combination of sonographic features and their location allows reliable prediction of the histological type in the vast majority of fetal tumors. Malignancy, associated malformations and aneuploidy are observed infrequently. Knowledge of the presence of a fetal tumor facilitates close surveillance by a specialized team, which might lead to early recognition of problems and improve perinatal outcome.

Computerized fetal heart rate analysis, Doppler ultrasound and biophysical profile score in the prediction of acid-base status of growth-restricted fetuses

OBJECTIVE

To investigate the performance of non-stress test (NST), computerized fetal heart rate analysis (cCTG), biophysical profile scoring (BPS) and arterial and venous Doppler ultrasound investigation in the prediction of acid-base status in fetal growth restriction.

METHODS

Growth-restricted fetuses, defined by abdominal circumference < 5(th) percentile and umbilical artery (UA) pulsatility index > 95(th) percentile, were tested by NST, cCTG, BPS, and UA, middle cerebral artery (MCA), ductus venosus (DV) and umbilical vein (UV) Doppler investigation. The short-term variation (STV) of the fetal heart rate was calculated using the Oxford Sonicaid 8002 cCTG system. Relationships between antenatal test results and cord artery pH < 7.20 were investigated, using correlation, parametric and non-parametric tests.

RESULTS

Fifty-six of 58 patients (96.6%) received complete assessment of all variables. All were delivered by pre-labor Cesarean section at a median gestational age of 30 + 6 weeks. The UA pulsatility index (PI) was negatively correlated with the cCTG STV (Pearson correlation - 0.29, P < 0.05). The DV PI was negatively correlated with the pH (Pearson correlation - 0.30, P < 0.02). The cCTG mean minute variation and pH were not significantly correlated (Pearson correlation 0.13, P = 0.34). UV pulsations identified the highest proportion of neonates with a low birth pH (9/17, 53%), the highest number of false positives among patients with an abnormal BPS, abnormal DV Doppler and a STV < 3.5 ms, and also stratified false negatives among patients with an equivocal or normal BPS. Abnormal DV Doppler correctly identified false positives among patients with an abnormal BPS. cCTG reduced the rate of an equivocal BPS from 16% to 7.1% when substituted for the traditional NST. Elevated DV Doppler index and umbilical venous pulsations predicted a low pH with 73% sensitivity and 90% specificity (P = 0.008).

CONCLUSION

In fetal growth restriction with placental insufficiency, venous Doppler investigation provides the best prediction of acid-base status. The cCTG performs best when combined with venous Doppler or as a substitute for the traditional NST in the BPS.

The area behind the heart in the four-chamber view and the quest for congenital heart defects

OBJECTIVE

To evaluate the spectrum of fetal cardiac defects associated with abnormal sonographic findings in the area behind the heart (ABTH) in the four-chamber view.

METHODS

This study included a retrospective review of 393 fetuses with congenital heart defects (CHD) detected in 2003-2005 at our tertiary referral center and a prospective evaluation of 4666 fetal echocardiograms, including 220 cases of CHD, performed between January 2006 and February 2007. The retrospective and prospective groups did not differ significantly with respect to cardiac anomalies or abnormal findings in the ABTH, allowing us to combine the 613 fetuses with CHD investigated over a 50-month period.

RESULTS

In the study period, 69 fetuses had abnormalities of the ABTH (75% with major CHD). In 28 fetuses, two equally sized vessels ran behind the heart. Of these, 26 had an interrupted inferior vena cava with azygos continuation and two had total anomalous infracardiac pulmonary venous connection. In 41 fetuses, only one vessel was visualized, but the descending thoracic aorta was positioned contralateral to the cardiac apex. Of these, 29 had levocardia with right descending aorta. All of them had a right aortic arch. The remaining 12 had dextrocardia with left descending aorta.

CONCLUSIONS

The ABTH in the four-chamber view is easy to evaluate and offers important diagnostic markers for fetal CHD. Thus, it might enhance the screening performance of the four-chamber view. Attention must be paid to the number of vessels behind the heart and their laterality.

Reversed end-diastolic flow in the umbilical artery at 10-14 weeks of gestation is associated with absent pulmonary valve syndrome

OBJECTIVE

To determine the incidence of reversed end-diastolic flow (REDF) in the umbilical artery in high-risk first-trimester pregnancies and evaluate associated conditions.

METHODS

This was a prospective evaluation of the umbilical artery Doppler waveforms of 614 consecutive high-risk pregnancies between 10 and 14 weeks of gestation, to determine those with REDF. The associated anomalies and characteristics of these fetuses were then investigated.

RESULTS

In 278/614 (45.3%) fetuses, there was positive end-diastolic flow in the umbilical artery; in 331/614 (53.9%) end-diastolic flow was absent and in 5/614 (0.8%) there was REDF. Three of the five fetuses with REDF had tetralogy of Fallot (TOF) with absent pulmonary valve syndrome (APVS) and a patent ductus arteriosus, and all three showed signs of cardiac failure, with reversed blood flow in the ductus venosus during atrial systole and generalized skin edema. Another fetus had a large ventricular septal defect and the remaining fetus had agenesis of the ductus venosus. Three fetuses had trisomy 18 and one had trisomy 13.

CONCLUSIONS

REDF in the umbilical artery is very rare in early pregnancy and mostly occurs in association with major fetal vascular anomalies and cardiac defects, particularly TOF with APVS and patent arterial duct. We propose that the patency of the arterial duct in TOF with APVS leads to heart failure with subsequent demise early in pregnancy. Therefore, the frequent absence of the arterial duct observed in APVS in later pregnancy is more likely to be a result of early selection than a prerequisite for the development of this lesion as has been proposed previously.

Demonstration of autoantibodies to recombinant human sulphite oxidase in patients with chronic liver disorders and analysis of their clinical relevance

It has been shown previously that sera from patients with cholestatic liver diseases react with sulphite oxidase (SO) prepared from chicken liver. In order to analyse this reactivity and the clinical relevance of anti-SO antibodies in more detail, we produced human recombinant SO. Human recombinant SO (60 kDa) was expressed in Escherichia coli and applied to enzyme-linked immunosorbent assay and Western blot. Sera from patients with autoimmune liver disorders [primary biliary cirrhosis (PBC) n = 96; autoimmune hepatitis (AIH) n = 77; primary sclerosing cholangitis (PSC) n = 39], and from patients with other hepatic (n = 154) and non-hepatic chronic inflammatory disorders (n = 113) were investigated. Highest incidence and activities of IgG-anti-SO antibodies were observed in PSC patients. Nine of 16 untreated (56%) and four of 23 PSC patients treated with ursodeoxycholic acid (UDCA) (17%) were positive. Antibody activity decreased significantly during UDCA treatment. Five per cent of PBC and 9% of AIH patients, but also 15% of patients with alcoholic liver disease, were IgG anti-SO-positive. In patients with viral hepatitis and non-hepatic disorders they could be hardly detected. Anti-SO antibodies are further anti-mitochondrial antibodies in chronic liver diseases. They occur predominantly in PSC, and UDCA treatment seams to decrease antibody activity. Whether these antibodies are primary or secondary phenomena and whether they are related to the aetiology or pathogenesis, at least in a subgroup of patients with chronic liver diseases, has still to be evaluated.

Reaction of foster cows to prevention of suckling from and separation from four calves simultaneously or in two steps

The aim of this study was to investigate if a 2-step method of preventing suckling and cow-calf separation reduces the stress reaction in foster cows compared with a simultaneous separation method. Seven Swedish Holstein and 5 Swedish Red dairy cows were used as foster cows, each having a group of 4 calves. The foster cow-calf group was formed when calves were 1 wk old, and the calves were prevented from suckling at 10 wk of age. In 6 of the cow-calf groups, calves were prevented from suckling by simultaneous separation from the cow (control). In the other 6 groups, calves were fitted with a nose-flap, which prevented them from suckling while they were kept together with the cow for another 2 wk before they were separated (2-step). The behavior of the foster cows was observed at 4 observation periods, 0 to 2, 8.5 to 9.5, 24 to 26, and 72 to 74 h after the calves were prevented from suckling (2-step), after separation (2-step), and after calves were prevented from suckling by simultaneous separation (control). For both treatments, saliva cortisol was sampled once daily for 5 d at wk 10. This was repeated at wk 12 for the 2-step treatment. Heart rate was measured with the behavioral observations. Control foster cows vocalized more (P < 0.001) and walked more (P = 0.005) than the 2-step foster cows after prevention of suckling and after separation from the calves. When control cows were separated from their calves, they more frequently (P < 0.001) held their head out of the pen than was the case with 2-step cows when separated 2 wk after prevention of suckling. The variation in heart rate was larger in the control group compared with 2-step cows at 0 to 2 h after separation/prevention of suckling (P = 0.002). No effect of treatment was found on cortisol concentration. Our conclusion is that separating the 2 events "prevention of suckling" and "separation" reduces the stress experienced by the foster cow at weaning.

Partial amniotic carbon dioxide insufflation (PACI) facilitates fetoscopic interventions in complicated monochorionic twin pregnancies

BACKGROUND

Adequate visualization of the placenta or umbilical cord during fetoscopic procedures in complicated monochorionic twin pregnancies may be difficult because of placental position and spatial constraints, as well as stained amniotic fluid. Partial amniotic carbon dioxide insufflation (PACI) has made it possible to overcome these obstacles in other fetoscopic procedures, but its value has not yet been reported in monochorionic twins.

METHODS

Partial amniotic carbon dioxide insufflation was carried out in five expectant women with complicated monochorionic twin pregnancies between 19 + 6 to 29 + 4 weeks of gestation when adequate fetoscopic visualization of pathological placental surface vessels or the umbilical cord was impossible because of stained or too little amniotic fluid. In four cases, five fetoscopic laser ablations of pathological placental vessels in twin-to-twin transfusion syndrome (TTTS) were performed. In one discordant twin pregnancy with TTTS, PACI was carried out in order to achieve umbilical cord ligation in a recipient with omphalocele and cardiac malformation.

RESULTS

Partial amniotic carbon dioxide insufflation offered superior visualization and did not result in any acute maternal or fetal complications. After fetoscopic laser coagulation, three women delivered one fetus at 27 + 5, two fetuses at 28 + 6, and two fetuses at 35 + 4 weeks of gestation, respectively. One set of twins with TTTS was lost. Following umbilical cord ligation, the surviving twin was delivered at 37 + 2 weeks of gestation.

CONCLUSIONS

Partial amniotic carbon dioxide insufflation may facilitate fetoscopic procedures in complicated monochorionic twin pregnancies when conventional fetoscopic approaches within amniotic fluid meet difficulties. Further studies are required to allow assessment of benefits, risks, and safety margins of the new approach before it can generally be recommended.

Clinical application of grey scale and colour Doppler sonography during abnormal third stage of labour

AIM

The purpose of the study was to investigate whether colour Doppler sonography is helpful in the surveillance of abnormal third stage of labour.

MATERIALS AND METHODS

20 patients were enrolled in the prospective study. Inclusion criteria were third stage of labour > 15 min and/or clinical suspicion of retained placenta. By means of grey scale and colour Doppler sonography the length of distinct phases of third stage of labour and length of visualisation of blood flow between myometrium and placenta were measured. These data were compared with previously published normal values.

RESULTS

The patients were allocated into four groups: 1. Patients with prolonged third stage of labour, but normal vaginal delivery of the placenta (Group 1, 8 cases). 2. Patients with clinically suspected retained placental parts (Group 2, 4 cases). 3. Patients with manual removal of the placenta without confirmation of placenta accreta (Group 3, 4 cases). 4. Patients with manual removal of the placenta with confirmation of placenta accreta (Group 4, 4 cases). A significant longer latent phase was responsible for the prolonged third stage of labour in Group 1 (p < 0.05). Blood flow between myometrium and placenta was significantly longer visible in Group 4 than in the normal cohort (p < 0.0001).

CONCLUSION

Grey scale sonography can help to distinguish between uncomplicated and complicated prolonged third stage of labour. Colour Doppler sonography can detect persistent blood flow between myometrium and placenta during third stage of labour in cases of placenta accreta. In these instances, the patient may benefit from colour Doppler sonography-guided curettage.

First-trimester treatment of fetal anemia secondary to parvovirus B19 infection

Here we report two cases of first-trimester parvovirus B19 (PV-B19) infection that were successfully treated by intrauterine blood transfusion into the umbilical vein. At 13 weeks' gestation both fetuses presented with increased nuchal translucency (NT) and cardiomegaly. In both cases pulsed Doppler ultrasound examination of the fetal middle cerebral artery (MCA) revealed increased peak systolic velocity (PSV), which led to a suspicion of fetal anemia. Maternal PV infection was confirmed by a positive polymerase chain reaction result. Each fetus received a 3-mL intravenous transfusion of packed red blood cells into the umbilical vein, using a 25-G spinal needle. Follow-up ultrasound and Doppler examination demonstrated fetal well-being, decline of the MCA-PSV and resolution of the NT. Case 1 was readmitted at 25 weeks' gestation with severe hydrops fetalis, and both mother and fetus still tested positive for PV-B19 DNA. Three more intrauterine blood transfusions were performed and the fetal hydrops resolved. In Case 2 no additional transfusions were needed. Both babies had a good neonatal outcome and uneventful follow-up. Our findings demonstrate that the MCA-PSV is helpful in establishing the diagnosis of first-trimester fetal anemia. Intravasal transfusion can be attempted as early as the first trimester.

Changing attitudes towards non-invasive aneuploidy screening at advanced maternal age in a German tertiary care center

OBJECTIVE

To evaluate attitudes towards non-invasive aneuploidy screening at advanced maternal age in a German tertiary care centre and to compare the rate of invasive testing over a period of four years.

METHODS

A retrospective analysis of 2657 singleton pregnancies with targeted first and second trimester ultrasound examination at 11-14, 15-18 and 19-23 weeks' gestation.

RESULTS

The number of patients at or beyond 35 years increased by 36 % over this period. Concomitant with an increasing proportion of first trimester examinations (+ 13 %), a decrease in 15-18 weeks' examinations (- 14 %), but no changes regarding the 19-23 weeks' examination were observed. A total of 78 (2.9 %) abnormal karyotypes were found and 92 % (56/61) of the cases with autosomal trisomy had sonographic markers suggestive of foetal aneuploidy. The proportion of diagnosed chromosomal abnormalities at 11-14 weeks increased from 14 % in the first half to 49 % in the second half of the study period (p < 0.01). We observed a significant decrease in the rate of invasive procedures, especially in women reassured by a normal ultrasound examination (54 % versus 37 %, p < 0.01).

CONCLUSION

There is an increasing acceptance of first trimester targeted ultrasound examination with the potential advantage of an earlier diagnosis of foetal aneuploidy. Furthermore, we observed annually increasing numbers of women who used the results of the ultrasound examination to guide their final decision about invasive testing, rather than undergo genetic testing as a primary option.

Right aortic arch detected in fetal life

OBJECTIVE

To evaluate the prenatal distribution, associated conditions and outcome of the different types of right aortic arch (RAA) detected in fetal life.

METHODS

This was a retrospective review of all cases of RAA detected prenatally between 1998 and 2005 in two tertiary referral centers.

RESULTS

In the study period 71 cases of RAA were detected; 26 (37%) had RAA with aberrant left subclavian artery, 23 (32%) had RAA with mirror-image branching, 20 (28%) had RAA of unknown type and two (3%) had double aortic arch. While 20/26 cases with RAA and aberrant left subclavian artery were isolated findings, all 23 cases with RAA and mirror-image branching were associated with cardiac defects, namely tetralogy of Fallot (43%) or pulmonary atresia with ventricular septal defect (22%). Of the 20 cases with RAA, 19 of unknown type were associated with heterotaxy syndromes and had additional cardiac malformations and ambiguities of the situs. The two cases with DAA were isolated findings. Seven cases in our series (10%) had a microdeletion 22q11 and these were significantly associated with extracardiac malformations. The outcome in our series depended solely on the associated cardiac and extracardiac malformations, with the exception of one infant with isolated DAA, in whom a surgical correction was warranted.

CONCLUSIONS

RAA detected in fetal life is associated frequently with other cardiac/non-cardiac malformations, heterotaxy syndromes and microdeletions 22q11. The associated conditions vary depending on the branching type of the brachiocephalic vessels and the presence of extracardiac malformations.

Intrapericardial teratoma in the newborn--3D-echocardiography and course of disease

Intrapericardial teratoma is a rare tumour which may become life threatening when it causes mediastinal compression. Early sonographic detection and careful evaluation is necessary for further management. In this paper, we present a case with a large intrapericardial teratoma diagnosed in utero (25 + 0 weeks). After birth, 3D-echocardiography was particularly helpful in obtaining a comprehensive view of the three-dimensional structure of this complex tumour, in order to determine tumour extension and attachment before surgical excision. This case illustrates the opportunities which new, noninvasive echocardiographic tools create to aid therapeutic management and surgical therapy of critically ill patients.

Absence of ductus venosus-importance of umbilical venous drainage site

OBJECTIVE

To evaluate the conditions associated with absent ductus venosus (ADV) diagnosed by prenatal ultrasonography.

METHODS

Retrospective review of 23 cases with ADV diagnosed in two tertiary referral centers with a general screening policy concerning Doppler assessment of the ductus venosus. The results are discussed together with 63 cases from a review of the literature.

RESULTS

In 19 fetuses the umbilical vein connected to the portal sinus, while the remaining four fetuses had extrahepatic umbilical venous drainage. Associated anomalies were present in 15 out of 23 fetuses: complex malformation syndromes (n = 6), chromosomal anomalies (n = 4), isolated cardiac defects (n = 4) and isolated extracardiac anomalies (n = 1). Eight fetuses had either no associated anomalies or minor anomalies. Hydropic changes were present in 12 of the 23 fetuses. In common with the reviewed cases, the presence of cardiac malformations, complex non-chromosomal malformation syndromes and hydrops was significantly associated with intrauterine or postnatal death while the type of umbilical venous drainage was not significantly different between survivors and non-survivors. However, among fetuses with no or minor associated anomalies the outcome was significantly better in the group without liver bypass.

CONCLUSIONS

ADV is significantly associated with fetal cardiac and extracardiac anomalies, aneuploidies and hydrops. Fetuses with liver bypass have an additional risk of developing congestive heart failure that significantly affects outcome, even if the fetal cardiovascular anatomy is otherwise normal. ADV without liver bypass seems to have a more favorable prognosis if it is not associated with other malformations.

Ductus venosus blood flow alterations in fetuses with obstructive lesions of the right heart

OBJECTIVE

To assess the impact of isolated lesions of the fetal right heart on ductus venosus (DV) blood flow profiles.

METHODS

Retrospective evaluation of DV blood flow profiles in 83 fetuses with isolated right-sided cardiac lesions. Cases were divided into two groups. Group A had right-sided cardiac lesions associated with a large ventricular septal defect that equalized interventricular pressures (double outlet right ventricle (n = 12), tetralogy of Fallot (n = 19), pulmonary atresia (n = 5)). Group B had right-sided cardiac lesions with obstruction of the inflow (tricuspid atresia with ventricular septal defect (n = 14)) or obstruction of the outflow with intact ventricular septum (Ebstein's anomaly (n = 13), pulmonary stenosis (n = 13) and pulmonary atresia (n = 7)). Comparisons were made with 585 uneventful singleton pregnancies and previously published normative values.

RESULTS

Fetuses in Group B had significantly higher rates of abnormal DV flow profiles compared to Group A and controls (P < 0.01). Conversely, there were no significant differences concerning DV parameters between fetuses in Group A and controls. Despite these different DV flow characteristics, there were no significant differences concerning signs of cardiac failure and/or survival to the perinatal period between the two groups.

CONCLUSIONS

Right-sided cardiac lesions with obstruction of the inflow or outflow with intact ventricular septum are significantly associated with abnormally high pulsatilities in the DV and may even cause a reversal of flow during atrial contraction. These changes do not necessarily indicate cardiac failure, as they are primarily attributable to the special hemodynamics of the cardiac defect.

Re-treatment of chronic hepatitis C patients after relapse: efficacy of peginterferon-alpha-2a (40 kDa) and ribavirin

We conducted a randomized multinational study to determine whether 48 weeks of re-treatment with peginterferon-alpha-2a (40 kDa) plus ribavirin would induce a sustained virological response (SVR) in relapsed chronic hepatitis C patients. Patients who had previously relapsed during 24 weeks of untreated follow-up, after having achieved an end-of-treatment virological response with 24 weeks of peginterferon-alpha-2a (40 kDa)/ribavirin combination therapy, within a phase III trial, were studied. Although the recommended dosage was the same as that used at the end of the initial trial, adjustments were permitted. Data on serious adverse events, or adverse events that resulted in dose reductions or discontinuations, were collected. Following re-treatment, the overall SVR rate in the 64 patients was 55%. The SVR rates in patients infected with hepatitis C virus (HCV) genotype 1 and non-1 genotypes were 51% and 63%, respectively. Early (week 12) virological responses were seen in 39 patients (61%) and were predictive of an SVR. Re-treatment was well tolerated. The most frequent adverse events recorded were fatigue (5%) and abdominal pain (3%). Dosages of peginterferon-alpha-2a (40 kDa) and/or ribavirin were modified because of adverse events in 3% and 13% of patients, and because of laboratory abnormalities in 23% and 5% of patients, respectively. Thus, a 48-week course of peginterferon-alpha-2a (40 kDa) plus ribavirin induces an SVR in 55% of patients who relapsed during follow-up after 24 weeks of combination therapy. Physicians should not hesitate to offer re-treatment to patients who relapse after an initial, 24-week course of combination therapy, or who have prematurely stopped treatment because, for example, of laboratory abnormalities.

Analysis of the stepwise clinical introduction of experimental percutaneous fetoscopic surgical techniques for upcoming minimally invasive fetal cardiac interventions

BACKGROUND

This study assessed the feasibility and safety of surgical techniques developed in sheep for fetoscopic fetal cardiac interventions during three selected less complex procedures for noncardiac fetal conditions in humans. On the basis of this assessment, the implications for the clinical introduction of minimally invasive fetoscopic fetal cardiac interventions in the near future are discussed.

METHODS

The authors performed 16 percutaneous fetoscopic procedures in 13 human fetuses at between 19 + 2 and 34 + 6 weeks of gestation, then analyzed various parameters of surgical relevance for minimally invasive fetoscopic fetal cardiac interventions. Each of the three noncardiac malformations posed typical surgical challenges that will be critical for the technical success of minimally invasive fetoscopic cardiac interventions.

RESULTS

Overall technical success was achieved in 14 of the 16 procedures. Percutaneous fetoscopic surgery did not result in any untoward effects and was well tolerated by all but two pregnant women: one with bleeding complication and one with mild postoperative pulmonary edema. No fetal complications or injuries from the various percutaneous fetoscopic surgical approaches were observed.

CONCLUSIONS

The author's experience with surgical techniques introduced for percutaneous fetoscopic fetal cardiac intervention in selected noncardiac fetal lesions has led them to believe the time has come for the clinical introduction of fetoscopic fetal cardiac interventions. After an adequate learning curve supervised by committees of human research, the overall outcome and quality of postnatal life for the unborn patients ultimately will determine whether fetoscopic or other fetal cardiac interventions will be better therapeutic alternatives to currently available postnatal procedures.

Influence of increased feeding frequency on behavior and integument lesions in growing-finishing restricted-fed pigs1

This study evaluated how feeding frequency affects behavior and the occurrence of skin lesions in growing-finishing pigs. One hundred eighty pigs (27 to 112 kg of BW) were reared in one environmentally controlled room (20 pens; 9 pigs/pen). Pigs in 10 pens were fed 3 times daily (reference group), whereas the others were fed 9 times daily (experimental group). Both groups received the same total amount of liquid feed. Rations were adjusted to the mean pen weights. Behavioral observations (scan sampling, as well as continuous focal pig observations) were made in wk 4, 10, and 14 of the growing-finishing period. After each observation, skin lesions were assessed individually for each pig. Pigs fed 9 times daily tended to lie laterally for less time (P = 0.083) and tended to be active (P = 0.054) during the day, especially in growing-finishing wk 4 (P = 0.007). With continuously observed focal pigs, no differences in time allocations for feeding were found between groups. During feeding in growing-finishing wk 4, focal pigs belonging to the experimental group displayed more aggressive actions (P = 0.019), tended to perform aggressive actions for a longer time (P = 0.076), and tended to be belly-nosed for a longer time (P = 0.083) compared with the reference group. In addition, in growing-finishing wk 14, pigs in the experimental group had greater scores for skin lesions (head, P = 0.001; belly, P < 0.001; caudal part, P < 0.001) and tended to be belly-nosed for a longer time (P = 0.084). In the case of pigs restricted-fed liquid feed, a greater frequency of feeding per day appears to be a condition that results in greater competitive feeding than with a lower feeding frequency.

The syndrome of right isomerism -- prenatal diagnosis and outcome

OBJECTIVE

To evaluate the accuracy of the prenatal diagnosis of right isomerism and to assess possible diagnostic and prognostic markers.

METHODS

Retrospective review of all cases of right isomerism identified between 1989 and 2003 in two tertiary referral centres in Germany.

RESULTS

Among 21 foetuses, 16 had a correct prenatal diagnosis of right isomerism. 19 showed different types of viscerocardiac heterotaxy, 12 of them in combination with juxtaposition of vena cava inferior and aorta. 20 had cardiac defects, with a high prevalence of atrioventricular septal defect (CAVSD) (62 %), right outflow tract obstruction (48 %), anomalous pulmonary venous return (33 %) and double outlet right ventricle (29 %). 4 out of 6 cases with total anomalous pulmonary venous return were overseen on prenatal ultrasound. Only 6 children survived. The highest loss occurred in the neonatal period. Two out of 6 survivors underwent single ventricle palliation, while another two had a biventricular repair. One child is awaiting mitral valve replacement. The remaining case has no cardiac defect and lives with supraventricular re-entry tachycardia. Only the presence of CAVSD was significantly correlated with non-survival (p < 0.05).

CONCLUSIONS

The prenatal diagnosis of right isomerism remains a difficult task. Important sonographic markers are viscerocardiac heterotaxy, complex cardiac malformations and juxtaposition of vena cava inferior and aorta. Special attention has to be paid to the pattern of pulmonary venous drainage, as it is often misdiagnosed. The mortality in neonates is high, especially in the presence of CAVSD. Survivors suffer from significant morbidity.

Defective Reproductive Organ Morphology and Function in Domestic Rooster Embryonically Exposed to o,p′-DDT or Ethynylestradiol1

Environmental pollutants with estrogenic activity have a potential to disrupt estrogen-dependent developmental processes. The objective of this study was to investigate if embryonic exposure to the environmental estrogens o,p'-DDT (1-(2-chlorophenyl)-1-(4-chlorophenyl)-2,2,2-trichloroethane; 37, 75, 150 or 300 microg/g egg) and EE2 (17alpha-ethynyl estradiol; 60 ng/g egg) affects the reproductive system in domestic roosters. Following egg injection on Embryonic Day 4, the newly hatched chicks were sexed by cloacal inspection. A skewed phenotypic sex ratio with overrepresentation of chicks deemed as females was observed in the groups exposed to the three highest doses of o,p'-DDT but not in the EE2-exposed group. Normal sex ratios were observed in all groups at adulthood. However, a cloacal deformation seemed to remain in the adult roosters, causing an abnormal semen flow upon semen collection. Semen yield was significantly reduced in both o,p'-DDT-exposed and EE2- exposed birds, whereas semen quality was unaffected. When killed, deformations of the left testis were found in all treatment groups. Image analysis revealed a reduced seminiferous tubular area in the roosters exposed to the two highest doses of o,p'-DDT. Embryonic exposure to o,p'-DDT caused decreased comb weight and right-spur diameter, while EE2 only affected right-spur diameter. In conclusion, this study shows that embryonic exposure to estrogenic compounds can induce permanent effects in male birds. The effects of the two studied compounds were partly similar but o,p'-DDT also induced alterations not seen in the EE2-treated birds.

Prenatal diagnosis of persistent left superior vena cava and its associated congenital anomalies

OBJECTIVE

To evaluate the associated conditions and the outcome of persistent left superior vena cava (PLSVC) detected in fetal life.

METHODS

This was a retrospective review of all cases of PLSVC detected prenatally between 1998 and 2004 in two tertiary referral centers in Germany. Patient charts, ultrasound video recordings and still frames of all cases were reviewed for associated conditions and outcome.

RESULTS

Eighty-two cases of PLSVC were detected in the study period. Thirty-seven cases (45%) were associated with heterotaxy syndromes, 19 (23%) with isolated cardiac malformations, seven (9%) with aneuploidy, six (7%) with complex malformation syndromes and six (7%) with isolated extracardiac malformations. Seven cases (9%) had no associated condition. Eighty-three percent of the fetuses in this series had associated cardiac malformations; the most frequent cardiac malformations in those with heterotaxy syndromes were complete atrioventricular septal defect (75%) and right outflow tract obstruction (58%). After exclusion of cases with heterotaxy, most congenital heart defects were ventricular septal defects (41%) and coarctation (34%). The outcome of PLSVC was determined solely by the associated conditions. After exclusion of terminated cases, heterotaxy syndromes as well as complete atrioventricular septal defects were associated significantly with perinatal and infant death. In contrast, all cases with isolated PLSVC or associated correctable extracardiac malformations survived and were doing well at the time of writing.

CONCLUSIONS

PLSVC detected in fetal life has to be followed by a meticulous inspection of the fetal anatomy as it is frequently associated with heterotaxy syndromes, other cardiac/non-cardiac malformations and aneuploidy that determine the outcome. Isolated PLSVC is a benign vascular anomaly and may not affect the outcome.