A novel method to improve prenatal diagnosis of abnormal systemic venous connections using three- and four-dimensional ultrasonography and 'inversion mode'

OBJECTIVE

The precise prenatal diagnosis of abnormal venous connections of the fetal heart is challenging. Anatomical accuracy may be important in determining the best route for postnatal angiography, as well as the prognosis and treatment. This study was designed to determine the value of 'inversion mode', a new three- and four-dimensional (4D) rendering algorithm, in the visualization of the spatial relationships of an interrupted inferior vena cava (IVC) with azygos or hemiazygos vein continuation associated with and without heterotaxic syndromes.

METHODS

Heart volumes were acquired using 4D ultrasonography and spatiotemporal image correlation in cases of interrupted IVC with azygos/hemiazygos continuation (n = 3). Volume datasets were rendered using the 'inversion mode' algorithm and abnormal images were compared to those generated from a library of normal fetuses.

RESULTS

The 'inversion mode' rendering algorithm allowed the visualization of dilated azygos or hemiazygos veins and their spatial relationships with the descending aorta, the aortic arch, the superior vena cava, and the atria in cases of interrupted IVC with and without heterotaxic syndromes.

CONCLUSIONS

The 'inversion mode' algorithm improves prenatal visualization of both dilated azygos and hemiazygos veins, as well as their spatial relationships with the surrounding vascular structures. This has implications for the accurate prenatal diagnosis and management of neonates with abnormal systemic venous connections.

First-trimester three-dimensional ultrasonographic findings in a fetus with frontonasal malformation

A case of a frontonasal malformation observed during the first trimester with three-dimensional ultrasonography and fetoscopy is reported. Absence of the nasal bone and a poorly characterized nose were visualized at 11 5/7 weeks by two-dimensional ultrasonography. Rendered three-dimensional ultrasound images revealed absence of the nasal bridge, widely spaced frontal bones and hypertelorism. Fetoscopy, performed at 12 3/7 weeks, confirmed the hypertelorism and showed a broad translucent nose with a flat nasal bridge. The final diagnosis of frontonasal malformation was made at autopsy after pregnancy termination. A review of prenatally diagnosed cases as well as the various syndromes having frontonasal malformation as a common denominator is presented.

Fetal cardiac dysfunction in preterm premature rupture of membranes

BACKGROUND

Preterm premature rupture of membranes (PROM) is associated with one-third of preterm births. In about 50% of preterm PROM cases, the fetuses will elicit a fetal inflammatory response syndrome (FIRS). FIRS is associated with the impending onset of preterm labor, periventricular leukomalacia, neonatal sepsis, and long-term handicap, including the development of bronchopulmonary dysplasia and cerebral palsy. The fetal myocardium is a potential target organ of proinflammatory cytokines released during FIRS. The objective of this study was to determine whether preterm PROM is associated with functional changes in the fetal heart, as determined by fetal echocardiography.

METHODS

A retrospective study was conducted to assess the diastolic function of fetuses with preterm PROM with documented microbial invasion of the amniotic cavity (n = 25), preterm PROM without microbial invasion of the amniotic cavity (n = 42), and fetuses from normal pregnancies (control group = 150). Pregnancies with multiple gestation, fetal distress, fetuses that were small for gestational age, and major congenital anomalies were excluded. Fetal echocardiography studies were performed with two-dimensional ultrasound, color Doppler imaging and pulsed Doppler ultrasound. Non-parametric statistics were used for comparisons. A p value of < 0.05 was considered significant.

RESULTS

The prevalence of positive amniotic fluid cultures for micro-organisms in patients with preterm PROM was 35.8% (24/67). Ureaplasma urealyticum was the most frequent isolate, either alone (41.7%; 10/24) or with other micro-organisms (29.2%; 7/24). Fetuses with preterm PROM had a higher delta early diastolic filling/atrial contraction (E/A) peak velocity ratio, a higher delta E/A velocity-time integral (VTI) ratio, a lower delta A peak velocity, a lower delta A VTI, and a lower A VTI/total VTI ratio in the mitral valve compared to those with uncomplicated pregnancies. The delta E/A peak velocity ratio was significantly higher and the delta A VTI significantly lower in fetuses with preterm PROM and microbial invasion of the amniotic cavity than in those with preterm PROM without microbial invasion of the amniotic cavity.

CONCLUSIONS

Preterm PROM is associated with changes in fetal cardiac function consistent with increased left ventricular compliance. These observations were also noted in fetuses with microbial invasion of the amniotic cavity. Our findings suggest that fetal cardiac function is altered in preterm PROM and, in particular, in cases with intra-amniotic infection.

Determination of the age of sherry wines by regression techniques using routine parameters and phenolic and volatile compounds

This paper describes a study of the possibility of obtaining regression models by means of partial least squares (PLS) and multiple linear regression (MLR) that would enable us to correlate a series of parameters, such as the concentration of short-chain organic acids, higher alcohols, and phenolic compounds with the age of vintage Sherry wines or "anadas". The aim of this study is to characterize how these parameters evolve with aging. If this could be done, it would then be possible to guarantee the age of such wines using objective variables. A PLS regression model was established that allows the age to be predicted with a mean deviation of 1.6 years with respect to the age of the wines. In the case of the MLR, a model with 6 variables was obtained that gives a mean deviation of 3.3 years in the predictions.

The prevalence and clinical significance of amniotic fluid 'sludge' in patients with preterm labor and intact membranes

OBJECTIVE

To determine the prevalence and clinical significance of amniotic fluid (AF) 'sludge' observed during transvaginal ultrasound examination of the cervix in patients with preterm labor and intact membranes, and in those with uncomplicated pregnancies.

METHODS

This retrospective study included patients with preterm labor and intact membranes (n = 84) and those with uncomplicated term pregnancies (n = 298). The outcome variables included the occurrence of documented microbial invasion of the amniotic cavity (MIAC), histological chorioamnionitis, examination-to-delivery interval, admission to the neonatal intensive care unit (NICU), a composite neonatal morbidity, perinatal death, and delivery within 48 h, 7 days, and < 35 weeks and < 32 weeks. Statistical analysis included Chi-square test, stepwise logistic regression analysis and survival analysis.

RESULTS

The prevalence of AF 'sludge' was 1% (3/298) in patients with uncomplicated term pregnancies and 22.6% (19/84) in those with preterm labor and intact membranes. Among patients with preterm labor and intact membranes: (1) cervical length < or = 15 mm was present in 58.3% (49/84) of the patients; (2) the prevalence of MIAC and histological chorioamnionitis was 12.1% (7/58) and 32.9% (25/76), respectively; (3) the rate of spontaneous preterm delivery within 48 h, 7 days, and < 32 weeks and < 35 weeks of gestation was 13.6% (8/59), 28.8% (17/59), 39.5% (17/43) and 50.8% (30/59), respectively; (4) patients with AF 'sludge' had a higher frequency of positive AF cultures [33.3% (6/18) vs. 2.5% (1/40), P = 0.003] and histological chorioamnionitis [77.8% (14/18) vs. 19% (11/58), P < 0.001] than those without AF 'sludge'; (5) a higher proportion of neonates born to patients with AF 'sludge' was admitted to the NICU [64.3% (9/14) vs. 12.9% (8/62), P < 0.01], had a composite neonatal morbidity [36.8% (7/19) vs. 13.8% (9/65), P = 0.04] and died in the perinatal period [36.8% (7/19) vs. 4.6% (3/65), P = 0.001] than those born to women without 'sludge'; (6) a higher proportion of patients with AF 'sludge' had spontaneous delivery within 48 h [42.9% (6/14) vs. 4.4% (2/45), P = 0.001], within 7 days [71.4% (10/14) vs. 15.6% (7/45), P < 0.001], < 32 weeks [75% (9/12) vs. 25.8% (8/31), P = 0.005] and < 35 weeks [92.9% (13/14) vs. 37.8% (17/45), P < 0.001] than those without AF 'sludge'; and (7) patients with AF 'sludge' had a shorter examination-to-delivery interval than those without AF 'sludge' [AF 'sludge' median, 1 (IQR, 1-5) days vs. no AF 'sludge' median, 33 (IQR, 18-58) days; P < 0.001].

CONCLUSION

The presence of AF 'sludge' in patients with preterm labor and intact membranes is a risk factor for MIAC, histological chorioamnionitis and impending preterm delivery.

Paediatric trauma in Spain: a report from the HUGM Trauma Registry

OBJECTIVES

To analyse the characteristics of the infant population suffering trauma in our setting. To evaluate the importance of the different aetiological mechanisms. To study the pre- and intra-hospital management of these children. To describe the relative significance of the different lesions. To establish the magnitude of paediatric trauma as a social problem in terms of morbidity and mortality.

MATERIAL AND METHODS

From January 1995 to April 2002, a total of 2633 children admitted to our Centre (Hospital Universitario Gregorio Maranon) after suffering some type of injury were included in our Trauma Register. 108 variables have been analysed, including the identification of the patient, type, site and mechanism of the accident, pre-hospital care, transport, complete evaluation on admission, indices of injury severity, diagnostic tests, lesions, treatments performed and morbidity and mortality.

RESULTS

The accidents were more frequent in boys than in girls (68.5 % versus 31.5 %). The predominant age group was the 12 - 15 year old group (36.8 %). There was a higher frequency of accidents in the street (37.2 %) than at home (19.4 %) or at school (13.8 %). The most frequent mechanism was a fall (35.6 %), followed by road traffic accidents (23.7 %). On admission, 14.7 % of the children had a Paediatric Trauma Score (P.T.S.) < or = 8 (n = 388). 3.8 % were considered severe multiple trauma patients, presenting an Injury Severity Score (I.S.S.) > or = 15 (n = 101). 4.2 % of the children required intensive care. The most frequent lesions were those of the locomotor system (58.1 %) and head injuries (34.9 %). Some type of surgical or orthopaedic procedure was performed under general anaesthesia in 1522 patients (57.8 %). The mean length of stay was 4.4 days (range 1 - 214 days). Sequelae of some form were detected in 36.4 % of the patients over 3 years of age. The total mortality was 0.5 % (n = 13), being 12.8 % in the group of patients with an I.S.S. > or = 15.

CONCLUSIONS

Analysis of the data in our Registry has helped us to define the characteristics of the paediatric trauma population in our setting, to monitor the management of trauma in the different care levels and to develop prevention programmes. It has also enabled us to compare the results with those of other centres in terms of morbidity and mortality with the aim of identifying and correcting any possible deficiencies in the care system.

[Behaviour of vancomycin with the new techniques in haemodialysis]

When using high convection dialysis techniques it arouses the necessity of considering the suitability of the regular protocols when administrating drugs, such as vancomycin.

OBJECTIVES

To confirm if the usual guideline of vancomycin is efficient in patients undergoing treatments with acetate free biofiltration (AFB) and haemodiafiltration on-line (on-line). To propose an alternative guideline of administration.

MATERIAL AND METHODS

13 patients treated with AFB or On-line. 10 of them used filters of polysulfone and 3 of them of AN69. First part: 6 patients were administered 1 g iv during the last hour of dialysis. Second part: 7 patients were given a loading dose of 30 mg/kg iv with a reinforcement of 500 mg post-dialysis. The blood levels of the antibiotic were monitorized during the week following the administration.

OUTCOMES

During the first phase it was noticed a decrease of 41% in the serum level of vancomycin during dialysis, conditioning subtherapeutic levels in the 83% of the patients until the end of the study. As for the second phase, therapeutic non-toxic levels were maintained during the whole study. The existence of a post-dialysis rebound of the 21 % was confirmed. A bigger clearance of vancomycin was obtained with the On-line technique rather than with AFB (176 vs 135 ml/min). We find a strong correlation between the decrease of the antibiotic and the volume ultrafiltrated with the On-line technique.

CONCLUSIONS

The usual guideline of vancomycin may not be enough with the new convective dialysis techniques. A guideline based on a loading dose of 30 mg/kg and a reinforcement of 500 mg at the end of each dialysis could be adequate. The antibiotic clearance with the On-line technique is probably made by convective transport.

[Risk factors for refusing kidneys in Galicia. Is it possible to increase its use?]

INTRODUCTION

Demographic changes along with an increase in the demand of organs and an increase in the expertise of transplantation teams, lead to a constant modification of donors' characteristics and, accordingly, of the supply of the organs used and refused.

OBJECTIVE

Analyze the use and refusal of kidneys generated in Galicia. Subjects and method. A follow-up of kidney donors was carried out between 1996 and 2000, studying the reasons for non extraction and refusal of kidneys and analyzing the influence that donors' characteristics have on them. In order to evaluate the risk factors of not using grafts, multiple logistic regression patterns were made, assessing odds ratios with confidence intervals at 95%.

RESULTS

836 kidneys were recovered from 433 donors, and 697 were implanted out of them. 17% of the organs extracted, a percentage approaching 25% in the two latest years, were discarded, due to the biopsy findings (27%), donor's previous conditions (22%), anatomical disorders (16%), prolonged cold ischemia (12%) or recipient not located or unsuitable (14%). The average age of refused grafts was significantly higher than that of implanted ones, in such a way that having more than 45 years old was an independent risk for refusing kidneys (OR = 1.76 and p = 0.05, for 45-59 years old; OR = 6.1 and p = 0.000, for older than 60 years old). The same happened with history of hypertension (OR = 1.59 and p = 0.044), high serum creatinine level (OR = 1.83 and p = 0.005) and positive serology for HCV (OR = 5.65 and p = 0.001) and anti-HBc (OR = 2.91 and p = 0.017).

CONCLUSIONS

Elderly donors and donors with concomitant diseases enable us to increase the number of grafts, although they also lead to an increase in refusals, which nearly amounts to 20% of the ones generated. However, more than the half were refused due to pontentially avoidable reasons and therefore these could have been valued for transplantation to limit recipients.

[Variability in Epstein-Barr virus serological markers in adult kidney transplant recipients]

Epstein-Barr virus (EBV) infection is associated with the development of post-transplant lymphoproliferative disorders (PTLD). However, the clinical relevance and criteria for EBV serological reactivation in EBV-seropositive transplant recipients is unclear. EBV-specific antibodies: viral capsid immunoglobulm G [IgG (VCA)], nuclear antigen (EBNA) IgG, immunoglobulin M [IgM (VCA)] and early antigen IgG (EA) were prospectively analyzed in 71 adult kidney transplant recipients, before starting immunosuppression, when they were uraemic, and after transplantation. A total of 351 serum samples were tested. Relevance of different EBV reactivation-related variables were analyzed using the chi-square test. In 37 of 71 (52.1%) patients IgM (VCA) or IgG (EA) were detected when they were uraemic. EBV reactivation occurred in 25 of 71 (35.2%) patients, with clinical symptoms (fever, leukopenia, kidney function impairment, and increase in transaminases) in nine cases. One of 71 patients developed a PTLD, without detection of serologically EBV reactivation, but with an increase in EBV viral load. Absence of mycophenolate mofetil, that inhibits lymphocyte proliferation and antibody production, in immunosuppression was statistically significantly associated with EBV reactivation (p = 0.015). Serological diagnosis of EBV reactivation should be based on strict criteria (IgM (VCA) seroconversion, four-fold increase in IgM (VCA) or IgG (EA), or four-fold decrease in IgG (EBNA) titers and on analysis of serial samples. Some EBV-seropositive patients at high risk of developing PTLD could benefit from this diagnostic methodology.

[IgA nephropathy with crescentic glomerulonephritis and ANCA positive]

We present a case of IgA nephropathy diagnosed by renal biopsy that presents after 2 years of folow-up an impairment of the renal function associate histoligically to a crescentic glomerulonephritis. The immunologic determinations showed of high titers of antineutrophil cytoplamic antibodies (ANCA) (P-ANCA IgG antiMPO and P-ANCA IgA anti-MPO). The patient began treatment with haemodyalisis and one year later she received a cadaveric kidney transplantation with good result. Two years later she had normal urine sediment, negative proteinuria, normal renal function but high titers of IgG and IgA PANCA anti-MPO. In summary, we believe that the determination ANCA in acute renal failure due to IgA nephropathy can indicate the existence of a IgA crescentic glomerulonephritis superimposed or an associated small vessel vasculitis and it confers a worse prognosis. The positive maintenance of IgG P-ANCA anti-MPO IgG anti-MPO titers during the course suggests that the sequential determination of ANCA in this entity is not useful to the monitoring of the clinical activity.

Individualized growth assessment of fetal soft tissue using fractional thigh volume

OBJECTIVES

The main goals of this study were to introduce fractional thigh volume (TVol) as a new soft tissue parameter for fetal growth evaluation, define its relationship to menstrual age, and develop individualized fetal growth standards based on Rossavik growth models.

METHODS

A prospective, longitudinal study of 22 fetuses was conducted with conventional biometry and TVol measurements by three-dimensional ultrasonography. Infant growth outcomes were determined from modified neonatal growth assessment scores. Rossavik functions (P = c(t)k+s(t)) were used to fit complete datasets to examine relationships between TVol and model coefficients. Second-trimester models were subsequently specified from the linear slopes of growth curves before 28.0 menstrual weeks with each fetus acting as its own control. Third-trimester trajectories and birth measurements were predicted for standard growth parameters and TVol. Observed and predicted measurements were compared using percent deviations and growth potential realization index values. Four additional infants, with serial prenatal scans and postnatal evidence of intrauterine growth restriction (IUGR), were also evaluated.

RESULTS

All 22 fetuses had no evidence of growth abnormalities after delivery. Accelerated soft tissue deposition occurred in the fetal thigh by 28 menstrual weeks. A mean TVol start point of 9.0 +/- 1.4 menstrual weeks was consistent with embryological studies of thigh development. Rossavik functions fitted all TVol trajectories well (mean R2 = 0.998 +/- 0.002). By fixing the coefficient k at its mean value (2.976), the fit did not change and the variabilities of coefficients c and s were reduced. The mean percent deviation between observed and predicted third-trimester TVol measurements was -0.048 +/- 7.5%. Relatively early pathological deviations were observed for TVol in all four fetuses with IUGR; in these cases the abdominal circumference was abnormal in only one fetus and thigh circumference in none.

CONCLUSIONS

Individualized growth assessment can be used to accurately predict TVol during the third trimester of pregnancy and at birth. Expected growth trajectories, from second-trimester data, do not rely on population-based standards because each fetus serves as its own control. This new parameter may allow earlier detection and improved monitoring of fetal soft tissue abnormalities such as IUGR.

Prenatal diagnosis of membranous ventricular septal aneurysms and their association with absence of atrioventricular valve 'offsetting'

Congenital aneurysm of the membranous portion of the ventricular septum in association with absence of atrioventricular valve 'offsetting' was diagnosed in two fetuses at 29 and 34 weeks. In the first case the fetus had a normal karyotype and no other structural heart defects, whereas in the second case there was a partial deletion of the long arm of chromosome 5 and an absent pulmonary valve syndrome. The association of absence of 'offsetting' with aneurysms of the membranous ventricular septum may represent spontaneous closure of ventricular septal defects initially extended to the inlet.

Transfusion of post-operative shed blood: laboratory characteristics and clinical utility

Increased awareness of the potential hazards of allogenic blood transfusion, such as incompatibility reactions, metabolic and immunologic disorders, or transmission of viral diseases, has led to an emphasis on allogeneic blood alternatives. For orthopaedic surgery, several autologous transfusion modalities have emerged as alternatives to allogeneic blood transfusion, avoiding its immunomodulatory effects. Among them, transfusion or return of post-operative salvaged shed blood has become popular in major orthopaedic procedures. However, although the effectiveness of this blood-saving method is well documented, several authors have questioned its safety and recommended the use of washed blood. Therefore, this review analyses the haematologic characteristics of unwashed filtered shed blood, including metabolic status and survival of red blood cells, the components of the haemostatic system, the content of fat particles, bacterial and tumour cells and the possibility of their removal, the content of inflammatory mediators, and the effects on the patient's immune system. From data reviewed in this paper, it can be concluded that post-operative salvage of blood seems to be an excellent source of functional and viable red cells without many of the transfusion-related risks and with some immuno-stimulatory effects. In addition, from our experience, post-operative re-infusion of unwashed shed blood after major spine procedures has proved to reduce post-operative homologous transfusion requirements and to complement pre-operative autologous blood donation, without any clinically relevant complication.

Optical microscopy of isothermally decomposed beta copper based SM alloys

The usefulness of two etching procedures for revealing the microstructural features in thermal treated beta copper-based SM alloys is shown. Colour etching is used to improve the detection of the phases and achieve a higher accuracy in their identification.

Acute phase response in patients undergoing lumbar spinal surgery: modulation by perioperative treatment with naproxen and famotidine

In orthopaedic surgery, perioperative administration of non-steroidal anti-inflammatory drugs has been shown to reduce postoperative pain and analgesic consumption. In addition, preoperative administration of ibuprofen has proved to reduce interleukin-6 (IL-6) release, while that of ranitidine reduced postoperative IL-6-induced C-reactive protein synthesis in patients undergoing abdominal surgery. However, it has not been established whether the preoperative administration of both types of drugs may reduced the postoperative inflammatory reaction after instrumented spinal surgery. Accordingly, our objective was to investigate the effects of preoperative treatment with naproxen plus famotidine on the postoperative systemic inflammatory reaction in patients undergoing instrumented lumbar spinal surgery. Forty consecutive patients scheduled for elective instrumented spinal fusion were alternately assigned to receive either naproxen (500 mg/day, p.o.) plus famotidine (40 mg/day, p.o.) for 7 days before operation, or no adjuvant treatment. Haematological parameters, acute phase proteins, complement fractions, immunoglobulins and cytokines were determined 7 days and immediately before surgery, and on days 0, 1, 2 and 7 after surgery. Haematological parameters, clinical data, duration of surgery, blood loss, perioperative blood transfusion and postoperative complications were similar in the two groups, although pretreated patients showed lower increases in body temperature and required less analgesic medication. Compared with preoperative levels, IL-6 levels were significantly increased postoperatively in all patients with no differences between groups. C-reactive protein, alpha(1)-acid-glycoprotein and haptoglobin levels were also significantly increased postoperatively in all patients; however, they were significantly lower in pretreated patients. In conclusion, perioperative treatment with naproxen plus famotidine was well tolerated and reduced the acute phase response after instrumented spinal surgery. However, further research is needed to determine the best dose and timing of preoperative treatment administration, and to correlate these changes with long-term clinical results.

Postcolectomy ileitis

A case is presented of a patient who had classic ulcerative colitis, both clinically and on detailed pathologic study, that underwent an ileo-pouch anal anastomosis and then developed pouchitis followed by ileitis. The patient has done fairly well on routine medications, but this case represents ileitis developing post colectomy that did not exist previous to colectomy and raises the questions for the following presentations and discussions in this workshop symposium.

Neonates born to pre-eclamptic mothers have a higher percentage of natural killer cells (CD3-/CD56+16+) in umbilical cord blood than those without pre-eclampsia

OBJECTIVE

Maternal endothelial dysfunction and intravascular inflammation have been implicated in the mechanisms of disease responsible for the clinical syndrome of pre-eclampsia. Recently, the activation of the innate limb of the immune response (neutrophils and monocytes) in the fetal circulation has been reported in neonates born to mothers with pre-eclampsia. Natural killer (NK) cells are identified morphologically as a subpopulation of lymphocytes, but functionally as one component of the innate immune system. NK cells participate in the control of viral or bacterial infection, regulation of hematopoiesis, production of cytokines and cytotoxicity of neoplastic cells. Accumulating evidence suggests that the innate system is required for mounting an adequate adaptive response. NK cells, originally defined as effector cells of the innate immune system, may also play a role as regulatory cells for the adaptive immune system. This study was designed to determine the proportion of the NK cell subset of lymphocytes in umbilical cord blood of neonates born to mothers with and without pre-eclampsia.

METHODS

A cross-sectional study including neonates of mothers with (n = 48) and those without pre-eclampsia (control group) (n = 72) was conducted. Pre-eclampsia was diagnosed in the presence of hypertension and proteinuria. The control group consisted of neonates (premature and term) with no evidence of acute inflammation within the extraplacental membranes (chorioamnionitis). Umbilical cord blood was collected at the time of delivery, and assayed using monoclonal antibodies for selective cluster differentiation (CD) antigens in order to determine the proportion of NK cells as a percentage of total lymphocytes. The immunophenotypic characteristic was determined using flow cytometry, and NK cells were identified by positivity of CD16 and CD56 without CD3 (CD3-/CD56+16+). Log transformation of the percentage of NK cells was performed. Parametric statistics were used for analysis. Multiple regression analysis was utilized to examine the contribution of potentially confounding factors on the proportion of NK cells. A p value of < 0.05 was considered statistically significant.

RESULTS

Neonates born to mothers with pre-eclampsia had a significantly higher percentage of NK cells (CD3-/CD56+16+) than those in the control group (pre-eclampsia, mean +/- SD 17 +/- 9% vs. control, mean +/- SD 12 +/- 7.5%; p = 0.001). Multiple regression analysis suggested that umbilical cord blood pH of < 7.2, labor with vaginal delivery and maternal pre-eclampsia were associated with an increased percentage of NK cells in umbilical cord blood.

CONCLUSIONS

Pre-eclampsia is associated with a higher NK cell (CD3-/CD56+16+) subset of lymphocytes in umbilical cord blood than in the control group. This difference cannot be explained by fetal acidosis or the presence of labor.

Maternal and fetal inflammatory responses in unexplained fetal death

OBJECTIVE

The role of intra-amniotic infection in the etiology of fetal death has been proposed. This study was conducted to determine the prevalence of microbial invasion of the amniotic cavity (MIAC) and the frequency of maternal and/or fetal inflammation in patients presenting with a fetal death.

METHODS

A prospective study was conducted in patients with a fetal death. Amniocenteses were performed for clinical indications (karyotype), as well as to assess the microbiological and cytological state of the amniotic cavity. Fluid was cultured for aerobic and anaerobic bacteria and genital mycoplasmas. An amniotic fluid white blood cell count and glucose determinations were also performed. Histological examination of the placenta was conducted to identify a maternal inflammatory response (acute chorioamnionitis) or a fetal inflammatory response (funisitis).

RESULTS

This study included 44 patients with intrauterine fetal death. The median gestational age at diagnosis was 30.1 weeks (range 16.3-40.4 weeks). One patient had documented MIAC (1/44). Acute histological chorioamnionitis was found in 20.9% (9/43), but a fetal inflammatory response was observed in only 2.3% (1/43) of cases. One patient had a positive amniotic fluid culture for Streptococcus agalactiae (group B streptococcus).

CONCLUSION

Histological chorioamnionitis was present in 20.9% of cases, but MIAC could be demonstrated with conventional microbiological techniques in only one case. A fetal inflammatory response was nine times less frequent than a maternal inflammatory response (maternal 20.9% vs. fetal 2.3%, p = 0.008) in cases of fetal death.

C-reactive protein in umbilical cord blood: a simple and widely available clinical method to assess the risk of amniotic fluid infection and funisitis

OBJECTIVE

The purpose of this study was to determine whether concentrations of C-reactive protein (CRP) in umbilical cord plasma at birth were elevated in neonates with sepsis, an inflammatory lesion of the umbilical cord (funisitis) or who were born to mothers with microbial invasion of the amniotic cavity.

METHODS

Umbilical cord plasma was collected at birth from 313 singleton preterm neonates (20-35 weeks of gestation). The results of amniotic fluid culture performed within 5 days of birth, the occurrence of congenital neonatal sepsis and the presence of funisitis were assessed. Amniocentesis was performed in 152 patients within 5 days of birth. Amniotic fluid was cultured for aerobic and anaerobic bacteria and for mycoplasmas. The CRP concentration was measured with a highly sensitive immunoassay.

RESULTS

The median cord plasma CRP concentration was significantly higher in neonates with a positive amniotic fluid culture than in those with negative culture (median 245.9 (range 11.6-4885.5) ng/ml vs. median 44.3 (range 2.3-7401.8) ng/ml; p < 0.001), in those with congenital proven sepsis than in those without this complication (median 789.5 (range 20.4-2584.3) ng/ml vs. median 41.5 (range 1.3-7401.8) ng/ml; p < 0.005) and in neonates with funisitis than in those without funisitis (median 403.8 (range 4.9-10897.4) ng/ml vs. median 31.0 (range 1.3-7401.8) ng/ml; p < 0.001). The sensitivity of CRP in the identification of amniotic fluid infection, neonatal sepsis and funisitis was similar to that of interleukin-6 (> 17.5 pg/ml). However, the specificity of CRP in the identification of neonatal sepsis and funisitis was significantly higher than that of interleukin-6 (74% vs. 69%, p < 0.05; 83% vs. 76%, p < 0.01).

CONCLUSION

Umbilical cord plasma CRP concentrations were elevated in patients with amniotic fluid infection, congenital neonatal sepsis and funisitis.

[Events related with injury severity in pediatric multiple trauma]

AIMS

Epidemiological analysis of main factors affecting multiple trauma in children in our environment.

METHODS

We reviewed the data collected from the patients (n = 2.166) admitted to our hospital because of trauma and included in our Registry from January 1995 to December 2000. Among this group 79 patients were considered severely injured trauma patients according Injury Severity Score (ISS) (ISS > 15) and selected for the study. Statistical analysis was done using chi2 and Student t test, p values under 0.01 were considered significant.

RESULTS

Group gender distribution was 49 males and 30 females, age average was 9.7 years (range 0-15 years) Traffic related injuries were the leading cause of trauma in this group (77,2%). Initial triage by using the Pediatric Trauma Score allowed identifying the injury severity in 73,4% of patients (58 children obtained a PTS < or = 8). In 32,9% of the cases the patient was in coma at admission in the Emergency (Glasgow Coma Scale < or = 8, n = 26). ISS average was 23.4 (range 16-75). Most patients suffered from multiple injuries (87,3%), average of injuries number was 4,7 (range 1-9). The most frequent trauma localization was cranial trauma. Admission in the intensive care unit was necessary in 65,8% of patients, and any kind of surgical procedure was done in 35,4%. Average length of stay was 17,1 days (range 0-214 days). Injury severity was higher in automotive patients without restraining systems (I.S.S. average 27,2, mortality 16,6%). Overall mortality was 11,4% (n = 9), and 94.3% of patients presented any functional or anatomic disability.

CONCLUSIONS

Traffic related injuries are the main cause of multiple trauma in children. The severity and high mortality of these injuries make imperative polytonal education systems and the use of restraining devices.

[Impact of formation programs in initial management of injured children]

INTRODUCTION

In 1997 we developed the "Pediatric Trauma Life Support Course"applied to every one who provide care for the pediatric trauma patient. Since November 1997 until December 2000, 14 courses were imparted inside of the "Comunidad de Madrid" with total number of 289 students. Thirty-eight students have been people who worked in the prehospital area inside of our Community. The aim of this paper is to determinate the possible impact of these Courses in the prehospital management of the pediatric trauma patient.

MATERIAL AND METHODS

We reviewed the Pediatric Trauma Registry inputs of our hospital since January 1995 until December 2000. A total number of 2166 patients required admission in our hospital after the injuries. 495 patients which moved to our Institution by medical people and a special transport (ambulance/medical van) were enrolled. The patients were classified into two groups. In the first group were included the children admitted between 1995 to 1997 (group 1, n = 232), before we had applied our Courses and in the second group, the patients admitted between 1998 to 2000 (group II, n = 263), after The Pediatric Trauma Life Support Course was conducted. Both groups seems to be equal if we compare the age, sex and severity of the injuries. We analysed the infant orotracheal intubation in a coma patient, gastric intubation in the several trauma patient, vascular access and apply a semirigid cervical collar into a head injury. If we think that the application of these manouvers will be a good quality index of the management of these patients in the prehospital area, we compare the index of application of these variables according to the years before and after the Courses were imparted. For this pourpose we used the X2 test shows significant differences within both groups if p < 0.05.

RESULTS

All paramethers analyzed were better in group II than in group I (p < 0.05).

CONCLUSIONS

The results of this paper shows that the use of this program for the management of the pediatric trauma patient is going well and the assessment is doing better than few years before.

[Abdominal bruit associated with hypertension]

First cause of secondary hypertension is renovascular hypertension which presents abdominal bruit in 16 to 20% of cases. This clinical sign is also associated with other vascular disease of the abdomen such as celiac trunk stenosis and/or aneurysms located on the pancreaticoduodenal or gastroduodenal arcs level, with little representation among aneurysm. They usually appear on a context of digestive complications like neoplasias, chronic pancreatitis or gastric obstructions possibly with obstructive icterus, hemorrhage and acute abdomen episodes. Its presentation in other contexts is rare and constitutes a diagnostic challenge. Diagnosis is made by abdominal arteriography which is the best method because you can locate the problem as well as intervene therapeutically with embolization of the aneurysme. We would like to emphasize the importance of a quick diagnosis due to the risk of rupture and the high morbi-mortality associated.

Amniotic fluid levels of immunoreactive monocyte chemotactic protein-1 increase during term parturition

OBJECTIVE

Parturition is characterized by an influx of inflammatory cells into gestational tissues, a phenomenon conducive to increased myometrial contractility, cervical ripening and decidual/membrane activation. Monocyte chemotactic protein-1 (MCP-1), a potent chemoattractant and activator of monocytes/macrophages, is expressed in gestational tissues and, thus, may participate in the final common pathway of labor. This study was undertaken to determine whether the amniotic fluid concentrations of immunoreactive MCP-1 are altered with gestational age or spontaneous labor at term with and without prelabor rupture of the gestational membranes. We also sought to identify intrapartum differences in the concentrations of immunoreactive MCP-1 between the upper and lower amniotic fluid compartments.

METHODS

A cross-sectional study was conducted to assess the concentrations of immunoreactive MCP-1 in amniotic fluid. Amniotic fluid samples were obtained from 225 women as follows: (1) women undergoing mid-trimester (14-18 weeks of gestation) amniocentesis for genetic indications, whose pregnancy outcome was normal (n = 84); (2) women in labor (n = 52) and not in labor (n = 31) at term, with intact gestational membranes; (3) women with rupture of the gestational membranes in labor (n = 18) and not in labor (n = 26), at term; and (4) women in labor at term for whom paired amniotic fluid samples were obtained through transvaginal and transabdominal amniocenteses (n = 14). Immunoreactive MCP-1 was assessed with a specific and sensitive immunoassay that had been validated for amniotic fluid. Non-parametric statistics were used for analysis.

RESULTS

Immunoreactive MCP-1 was detected in all amniotic fluid samples. Spontaneous human parturition was associated with a significant increase in the amniotic fluid concentrations of immunoreactive MCP-1 (not in labor: median 595 pg/ml, range 183-3579 pg/ml vs. in labor: median 862 pg/ml, range 183-9609 pg/ml; p = 0.01). The median amniotic fluid concentrations of immunoreactive MCP-1 were significantly higher in the lower amniotic fluid compartment than in the upper amniotic fluid compartment (lower compartment: median 2913 pg/ml, range 1360-17080 pg/ml vs. upper compartment: median 1603 pg/ml, range 1070-8062 pg/ml; p = 0.004.). Spontaneous rupture of the gestational membranes at term was not associated with a significant change in the amniotic fluid concentrations of immunoreactive MCP-1.

CONCLUSIONS

Immunoreactive MCP-1 is a physiological constituent of the amniotic fluid. The amniotic fluid levels of immunoreactive MCP-1 increase during spontaneous labor at term. A topographic difference in the concentration of immunoreactive MCP-1 was observed in the amniotic cavity, with higher concentrations being noted in the lower amniotic fluid compartment, as compared with the upper amniotic fluid compartment. These findings support the hypothesis that MCP-1 may play a role in the final common pathway of spontaneous labor.

The effect of antibiotic therapy on intrauterine infection-induced preterm parturition in rabbits

OBJECTIVE

The purpose of this study was to determine whether early antibiotic administration to pregnant rabbits with intrauterine infection could prevent preterm delivery and perinatal mortality.

STUDY DESIGN

Under hysteroscopic guidance, pregnant rabbits at 70% gestation (21 days) were allocated to three groups: (1) control group, transcervical inoculation of 0.2 ml phosphate-buffered saline (n = 16); (2) infection group, transcervical inoculation of 0.2 ml of 10(5) colony-forming units (CFU) of Escherichia coli (n = 21); (3) infection and antibiotics group, transcervical inoculations of 0.2 ml of 10(5) CFU of E. coli and ampicillin-sulbactam 150 mg/kg every 8 h intramuscularly (n = 32). To examine the consequences of treatment delay, animals in the latter group were subdivided to receive antibiotics at different time intervals of 0, 6, 11 and 18 h after bacterial inoculation. The intervals from bacterial inoculation to delivery and litter survival were documented. Systemic (rectal) temperatures were recorded at 4 h intervals through the first 36 h and every 12 h until delivery. A p value of < 0.05 was considered significant.

RESULTS

All rabbits inoculated with E. coli without antibiotic treatment delivered prematurely. The median inoculation-to-delivery interval was significantly shorter in the infected group than in the control group (median 32 h, range 14.9-76.5 h vs. median 219 h, range 173-246 h, respectively; p < 0.0001). Antibiotic administration within 12 h of inoculation, but not after 18 h, increased duration of pregnancy (by reducing the rate of preterm delivery) and neonatal survival (0% vs. 71%; p < 0.0001). The mean temperatures at delivery of animals whose treatments began at 6 and 11 h post-inoculation were significantly lower than those untreated with antibiotics or those treated at 18 h post-inoculation (p < 0.0001 for each comparison).

CONCLUSIONS

Antibiotic administration can prolong pregnancy and reduce perinatal mortality if administered early (within 12 h of microbial inoculation) in a rabbit model of ascending intrauterine infection.

[Hepatic tuberculosis in a patient with diabetic nephropathy. An unusual clinical presentation]

Hepatic tuberculosis is an exceptional form of presentation of extrapulmonary tuberculosis, but in the last years a greater incidence has been found in patients with HIV infection and/or consumptive diseases or immunosuppressive treatment. For this condition, the diagnosis of hepatic tuberculosis in other population groups represents a true clinical challenge because of the scarce specificity of both the clinical and biological manifestations. Despite deferral of the diagnosis, fast improvement is observed in the clinical symptomatology in most cases following initiation of tuberculostatic treatment.

Vasculitides with predominantly renal involvement: influence of age on the mode of presentation

Vasculitis with predominant renal involvement are increasingly observed in elderly patients. It predominantly involves patients with microscopic polyangiitis, Wegener's granulomatosis, renal limited vasculitis and, in a smaller proportion, Churg Strauss syndrome. The elderly patients present very few obvious symptoms or signs of vasculitis such as hemoptysis and pulmonary infiltrates, and they are often submitted to: 1/renal biopsy when renal failure is already advanced; 2/ have more severe renal disease than do young and middle-aged patients (81% of acute and/or rapidly progressive renal failure versus 62%, and 30% of oliguria versus 6%); and 3/ a worse prognosis compared with younger individuals (probability of survival at 3 months, 1 year and 5 years of 93%, 93% and 92% in patients under 65, versus 67%, 62% and 46% in the elderly). Management of all patients with vasculitis and predominant renal involvement requires a quick diagnosis and immunosuppressive treatment aimed at controlling the disease. Treatment is mantained for 18 to 24 months. Nevertheless, relapses do occur (between 20% to 52%) of all patients with microscopic polyangiitis and Wegener's granulomatosis.

Tumor necrosis factor-related apoptosis-inducing ligand (TRAIL), TRAIL receptors, and the soluble receptor osteoprotegerin in human gestational membranes and amniotic fluid during pregnancy and labor at term and preterm

We have studied TNF-related apoptosis-inducing ligand (TRAIL) and its membrane-bound (R1-R4) and soluble receptors [osteoprotegerin (OPG)] in gestational membranes to assess their significance in preterm parturition and premature rupture of membranes (PROM). TRAIL was detected by ELISA in extracts of term choriodecidual (but not amnion) tissues and explant-conditioned media. Concentrations of OPG (determined using ELISA) in gestational membranes were 20- to 50-fold greater than those of TRAIL. Median OPG concentrations in amniotic fluid (AF) at 15-17 wk gestation were similar to those at term before and during labor, whereas levels in pregnancies sampled preterm were significantly elevated. OPG levels in AF from women with preterm PROM were similar to those from women in preterm labor. In contrast, in pooled AF samples (n = 23-33), TRAIL concentrations at term with and without labor were elevated compared with samples from preterm deliveries. TRAIL-R3 and -R4 decoy receptors were detected in term amnion and choriodecidual extracts by immunoblotting and were localized by immunohistochemistry to amnion epithelial cells and chorionic trophoblasts. TRAIL (100 ng/ml) had little or no effect on amnion or choriodecidual cell viability or apoptosis, although these tissues responded to TNF-alpha with increased prostaglandin E(2) production. Our findings suggest that OPG is abundant in gestational membranes and, in concert with TRAIL decoy receptors, may protect resident cells of the fetal membranes against the proapoptotic effects of TRAIL and other related ligands during pregnancy.

Disseminated varicella infection in adult renal allograft recipients: role of mycophenolate mofetil

Disseminated varicella zoster virus (VZV) infection is a rare complication after renal transplantation in adults. We report 4 cases diagnosed in our transplant patients. One of which was a primary infection (chicken pox) with multivisceral involvement (hepatitis, pneumonitis, myocarditis, and disseminated intravascular coagulation). The other 3 patients VZV-seropositive before transplantation suffered from disseminated zoster. No immunosuppressive drug was significantly associated with a higher risk of disseminated VZV infection. However, from our experience, we believe that mycophenolate mofetil (MMF), plays a part in the clinical presentation of the disease. Early treatment with high doses of acyclovir is fundamental in infection control. It is essential to perform a pretransplantation serological VZV study on all patients.

[Fiberoptic bronchoscopy, 3-D reconstruction of the airway and virtual bronchoscopy in patients with airway malformations. Preliminary report]

Bronchoscopy is the diagnostic gold standard in patients with airway malformations. Helical CT scan has produced studies such as virtual bronchoscopy or 3-D reconstruction of the airway. The purpose of this study is to analyze the correlation between fiberoptic bronchoscopy, virtual bronchoscopy and 3-D reconstruction of the airway in patients with airway malformations.

METHODS

From January 2001 to March 2002 we evaluated the airway of 17 patients with airway malformations by means of a diagnostic protocol consisting on fiberoptic bronchoscopy, and Helical CT scan with 3-D reconstruction of the airway and virtual bronchoscopy. The radiologist had no access to bronchoscopic information. Age at study, associated cardiovascular anomalies, indications, localization, degree of diagnostic concordance, etiology and influence in treatment were analyzed.

RESULTS

20 studies were done to 17 patients whose mean age was 1.64 +/- 0.48 years (7 days-7 years). Twelve patients had associated anomalies of the aorta, pulmonary arteries or supraortic vessels. Excellent concordance was obtained in 13 cases (65%), good in 6 (30%) and poor in one (5%). 3-D reconstruction of the airway and adjacent vascular structures provided additional information in 14 cases (70%): in 3 exact length of the tracheal lesion and in 11 defined the cause of the compression. In all the cases, absolute concordance in localization was obtained. CT scan information modified treatment in 6 patients (35%). In 7 patients with associated vascular anomalies, no further image studies were done, confirming the anatomy concordance during surgery.

CONCLUSIONS

3-D reconstruction of the airway and virtual bronchoscopy are excellent diagnostic tools in patients with airway malformations, and contribute to define the etiology, length and diameter of the lesion. Excellent diagnostic correlation was obtained between analogic and virtual bronchoscopies, although further multicentric studies should be conducted.

Adult and pediatric liver transplantation for autoimmune hepatitis

BACKGROUND

Due to the early age that pediatric patients with autoimmune hepatitis (AIH) are transplanted, it is theorized that older AIH patients may have different outcomes than pediatric patients following liver transplantation.

METHODS

This is a retrospective review of both the adult and pediatric liver transplant programs consisting of 56 patients. Rejection and recurrence of AIH were determined by biopsy.

RESULTS

The autoimmune patient having rejection episodes had a 1.76-fold increase in relative risk to develop autoimmune recurrence when compared to patients without rejection [RR = 1.76; 95% CIRR (1.08, 2.86)]. The pediatric group had a 6.62-fold increase in relative risk to develop colitis following liver transplantation [RR = 6.62; 95% C.I.R.R. (1.36, 32.13); P =.02]. Mean days to recurrence of AIH were similar in both groups (1364 +/- 1074 vs 936; P = NS). There were more hospitalized days in the pediatric group compared to the adults (20.5 +/- 13.3 days vs 51.7 +/- 22.2 days, P =.039). OKT-3 was rarely used (n = 5) in either group (9.3% vs 7.7%, P = NS) and was not correlated with which patients would be weaned from steroids or recurrence.

CONCLUSIONS

Based on this review, pediatric patients were more likely to develop ulcerative colitis following liver transplantation and they incurred longer hospital stays than adults. The adult group was more likely to be weaned from steroids, with AIH recurrence unrelated to weaning.

Hepatic artery thrombosis in pediatric liver transplantation

PURPOSE

Children have been reported to be at greater risk for hepatic artery thrombosis when compared to adults due to small arterial size, nonuse of intraoperative microscope, and postoperative hypercoagulable state.

METHODS

We evaluated arterial anastomosis type, intraoperative field magnification, and hepatic artery complications and how they were managed. All patients underwent ultrasound, anticoagulation consisted of 41 mg aspirin once a day, and 35 patients received alprostadil (PGE) for the first 7 days after transplantation. No patients were administered intravenous heparin following liver transplantation.

RESULTS

Of the 74 livers transplanted, 36 grafts (48.6%) were whole organ transplants and 38 grafts (51.4%) were partial livers. We observed HAT in 1 of 74 (1.35%) transplants in our pediatric liver transplant population. The only patient with HAT was a young girl with a history of biliary atresia. The occurrence of a hepatic artery thrombosis on day 7 was caused by the migration of an intimal plaque dissection within the artery graft. She was emergently taken back into the operating room for graft revision. This individual currently has a survival time of 426 days following her last transplant.

CONCLUSIONS

Hepatic artery thrombosis may be minimized in pediatric liver transplantation without the use of microsurgery. Anticoagulation utilizing ASA and alprostadil is sufficient to avoid HAT. Accurate use of ultrasound is crucial to avoid this complication. Graft and patient salvage is possible with expedient surgical treatment; microsurgery, anticoagulant therapy, site of arterial inflow, and recipient size and weight.

Biliary complications after pediatric liver transplantation revisited

BACKGROUND

Biliary complications in pediatric liver transplantation (PLT) are associated with increased morbidity and mortality.

METHODS

Prospectively, data was collected on 89 consecutive liver transplants performed in 82 children. Eighty-nine consecutive PLTs were tracked for transplant type (partial versus whole), recipient age/weight, duct anastomosis type, surgical technique, and biliary complications. Treatments of biliary complications (surgical versus interventional radiology) were also evaluated.

RESULTS

Forty-six children (51.7%) received partial transplants and 43 (48.3%) children received whole organs. The average age for whole liver transplanted children was 8.95 +/- 6.62 years and average weight was 36.2 +/- 28.7 kg; for those receiving partial livers, 3.19 +/- 3.52 years and 14.1 +/- 13.0 kg. Duct-to-duct anastomosis was performed for 26 grafts and Roux-en-Y choledochojejunostomy for 63 grafts. Biliary complications occurred in 10 of 89 (11.2%) grafts. Complications included anastomotic strictures in four (40%), bile leak in five (50%), intraparenchymal biloma in one (10%). The complication rate for whole organs was 1/43 (2.3%) and 9/46 (19.6%) for partial organ (P =. 015). No difference in complication rates were seen in type of ductal anastomosis (7.7% vs 12.7%, P = NS). Reoperation for biliary complication was necessary in only 2/10 (20%) of grafts.

CONCLUSIONS

Technical advances have reduced the incidence of biliary complications in PLT. Partial liver grafts have a statistically higher risk of biliary complication than whole grafts. Most biliary complications can be managed with radiological intervention without surgical exploration. Pediatric biliary complications are not associated with graft loss.