Long-term outcomes of endovenous laser ablation and conventional surgery for great saphenous varicose veins

BACKGROUND

Clinical guidelines recommend endovenous laser ablation (EVLA) over surgery based on short-term evidence, yet there are few studies reporting mid- to long-term outcomes. The aim of this study was to report the 5-year outcomes from an RCT of surgery versus EVLA for treatment of symptomatic great saphenous varicose veins.

METHODS

Patients with symptomatic varicose veins due to great saphenous vein (GSV) incompetence were followed up 5 years after enrolment in a randomized trial of either surgery (saphenofemoral junction ligation, GSV strip to the knee and multiple avulsions of varicosities) or EVLA plus multiple avulsions. Outcomes included: clinical recurrence, defined as new varicose veins greater than 3 mm in diameter; Venous Clinical Severity Score (VCSS); quality of life measured by means of Short Form 36, EuroQol Five Dimensions (EQ-5D™) and Aberdeen Varicose Vein Questionnaire (AVVQ); patient satisfaction; and duplex ultrasound examination (DUS) findings.

RESULTS

Some 218 of the 276 patients enrolled in the trial (79·0 per cent) were available for follow-up. Clinical recurrence was more frequent following surgery than EVLA at 5 years (34·3 versus 20·9 per cent; P = 0·010). Both groups demonstrated sustained significant improvements at 5 years over baseline in VCSS (surgery: median (i.q.r.) 1 (0-2) from 4 (3-5), P < 0·001; EVLA: 0 (0-1) from 4 (3-5), P < 0·001), AVVQ (surgery: 4·59 (0·56-9·78) from 13·69 (9·81-18·11), P < 0·001; EVLA: 3·35 (0·17 to 6·55) from 12·73 (9·41-17·32), P < 0·001) and EQ-5D™ (surgery: 1·000 (0·796-1·000) from 0·859 (0·796-1·000), P = 0·002; EVLA: 1·000 (0·796-1·000) from 0·808 (0·796-1·000), P = 0·002). VCSS was better for EVLA than surgery at 5 years (P = 0·031). Technical success assessed by DUS remained high at 5 years (85·4 per cent for surgery and 93·2 per cent for EVLA; P = 0·074). DUS-detected anatomical patterns of recurrence differed between the groups.

CONCLUSION

EVLA was more effective than surgery in preventing clinical recurrence 5 years after treatment of great saphenous varicose veins. Patient-reported outcome measures were similar. Registration number: NCT00759434 (http://www.clinicaltrials.gov).

System for on- and off-axis volumetric OCT imaging and ray tracing aberrometry of the crystalline lens

We present a new in vitro instrument for measuring shape and wavefront aberrations of the primate crystalline lens, both on- and off-axis, while simulating accommodation with a motorized lens stretching system. The instrument merges spectral domain optical coherence tomography (SD-OCT) imaging and ray tracing aberrometry using an approach that senses wavefront aberrations of the lens with the OCT probing beam. Accuracy and repeatability of aberration measurements were quantified. Preliminary experiments on two human and four cynomolgus monkey lenses demonstrate the ability of the system to measure the lens shape, spherical aberration and peripheral defocus, and their changes during simulated accommodation.

Outcomes of keratoplasty in lattice corneal dystrophy in a large cohort of Indian eyes

Purpose:

The purpose of this study is to evaluate the outcomes of keratoplasty for lattice corneal dystrophy (LCD) performed at a tertiary eye care center.

Methods:

A retrospective review of medical records of those patients who were clinically diagnosed to have LCD (72 eyes of 57 patients) and underwent either penetrating keratoplasty (PK, 58 eyes of 46 patients) or deep anterior lamellar keratoplasty (DALK, 14 eyes of 13 patients) between the years 1987 and 2014 was performed. The main outcome measures included demographics, clinical features, and outcomes of keratoplasty.

Results:

The median follow-up after keratoplasty was 3.1 years (interquartile range [IQR], 9 months to 9 years). The median best-corrected visual acuity (BCVA) was 0.18 (IQR, 0.10–0.48) (Snellen equivalent 20/30 [IQR, 20/25–20/60]) at 4 years postoperatively and 0.65 (IQR, 0.18-0.95) (Snellen equivalent 20/89 [IQR, 20/30–20/178]) at 10 years following surgery. DALK eyes had a significantly better BCVA than PK eyes at 2 years following keratoplasty. The median overall survival of grafts was 15.8 years. Late complications included recurrence of LCD (14 eyes), graft infiltrate (23 eyes), graft rejection (15 eyes), graft failure (16 eyes), and glaucoma (14 eyes).

Conclusion:

The outcomes of graft are similar following PK and deep anterior lamellar keratoplasty; however, the latter appears to provide slightly better visual outcome. Recurrence of dystrophy in the graft and graft infiltrates limit the overall graft survival in both the groups.

Microbial keratitis in Stevens-Johnson syndrome: Clinical and microbiological profile

PURPOSE

To study the clinical and microbiological profile of microbial keratitis in Stevens-Johnson syndrome (SJS).

STUDY DESIGN

Case series.

PARTICIPANTS

Patients with SJS who developed microbial keratitis.

METHODS

Medical records and microbiological data of patients with SJS who developed microbial keratitis from January 1991 to December 2012 were reviewed. We analysed the type of causative organisms and their antibiotic susceptibility along with the clinical pattern and responses to medications in this group of patients.

MAIN OUTCOME MEASURE

Clinical and microbiological profile of microbial keratitis.

RESULTS

We reviewed 65 eyes of 60 patients seen between January 1991 and December 2012. Positive microbiological culture results were obtained in 45 eyes (69.2%). Isolated bacterial infections were noted in 27 eyes (60%) while isolated fungal growth was seen in 1/45 eyes (2.2%). Polymicrobial infections were noted in 17/45 eyes (37.8%). The most common bacteria isolated were Staphylococcus species (35%). The median duration of SJS before presentation was 5 months (IQR, 2 months to 7 years) with 50% presenting within four months of the onset of SJS. Twenty-eight eyes (43%) needed treatment in addition to antibiotics for resolution of tarsorraphy, epilation, tissue adhesive application, and amniotic membrane grafting or punctal cautery. The average time for resolution was 25 days.

CONCLUSION

Microbial keratitis in SJS patients is different from patients without SJS in presentation and the response to medications. It requires a multi-disciplinary approach for healing.

Change in choroidal vascularity in acute central serous chorioretinopathy

Purpose

This study aims to compare the effect of laser photocoagulation or observation on choroidal vascularity in acute central serous chorioretinopathy (CSCR).

Methods

A retrospective analysis of 30 patients with acute CSCR treated either with laser photocoagulation (16 eyes) or sham laser (14 eyes) was performed. Demographic details, visual acuity (VA) assessment, and other relevant clinical data were considered from baseline to the 3^rd and 6^th month follow-up visits. Participants with chronic CSCR and missing follow-up or inadequate data were excluded. Choroidal analysis including choroidal thickness and choroidal vascularity index (CVI) assessment was done for each visit using Spectral Domain (SD) Optical Coherence Tomography (OCT) images.

Results

In laser arm group, there was a statistically significant change in VA, contrast sensitivity and central macular thickness (CMT) and neurosensory detachment (NSD) (P < 0.05) at the 3^rd and 6^th month visits. However, there was no statistically significant difference in subfoveal choroidal thickens (SFCT) and CVI (P > 0.05) at both the visits. In sham laser group, similarly, there was a significant improvement in VA, contrast sensitivity, CMT, and CVI (P < 0.05) at the 3^rd and 6^th month visits. There was significant reduction in NSD at the 3^rd month; however, it was not statistically significant at the 6^th month visit. SFCT did not change significantly at both the visits. There was no significant difference for the changes in parameters between the groups at the 6^th month. Regression analysis showed no significant correlation with final VA with any of the baseline parameters.

Conclusion

Early laser photocoagulation does lead to change in choroidal morphology, though insignificant, in comparison to observation. The present data, yet again, support no additional benefit of early laser photocoagulation in acute CSCR.

Observation of tt[over ¯]H Production

The observation of Higgs boson production in association with a top quark-antiquark pair is reported, based on a combined analysis of proton-proton collision data at center-of-mass energies of sqrt[s]=7, 8, and 13 TeV, corresponding to integrated luminosities of up to 5.1, 19.7, and 35.9  fb^{-1}, respectively. The data were collected with the CMS detector at the CERN LHC. The results of statistically independent searches for Higgs bosons produced in conjunction with a top quark-antiquark pair and decaying to pairs of W bosons, Z bosons, photons, τ leptons, or bottom quark jets are combined to maximize sensitivity. An excess of events is observed, with a significance of 5.2 standard deviations, over the expectation from the background-only hypothesis. The corresponding expected significance from the standard model for a Higgs boson mass of 125.09 GeV is 4.2 standard deviations. The combined best fit signal strength normalized to the standard model prediction is 1.26_{-0.26}^{+0.31}.

Ocular surface squamous neoplasia: analysis based on the 8th American Joint Committee on Cancer classification

PURPOSE

To evaluate outcomes of ocular surface squamous neoplasia (OSSN) based on American Joint Committee on Cancer (AJCC), 8th edition classification.

METHODS

Retrospective, non-randomized interventional case series of 127 patients (136 eyes) with OSSN.

RESULTS

On the basis of the AJCC (eighth edition), OSSN was classified as per T category as Tis (n = 14, 10%), T1 (n = 0), T2 (n = 4, 3%), T3 (n = 113, 83%), and T4 (n = 5, 4%). The following parameters increased with increasing T category: mean age at presentation at 37 years for Tis, 43 years for T2, 46 years for T3, and 55 years for T4 (p = 0.04); mean tumor basal diameter of 4 mm for Tis, not applicable (na) for T1, 6 mm for T2, 7 mm for T3, 20 mm for T4 (p = 0.001); extent of clock hours of corneal involvement (0, na, 0, 4, 8; p = 0.02), and conjunctival involvement (1, na, 2, 3, 9; p = 0.0005); involvement of adjacent structures including fornix (0%, na, 0, 9, 80%; p < 0.001), and caruncle (0%, na, 0, 3, 60%; p < 0.001) for Tis, T1, T2, T3, and T4, respectively. Overall, of the 136 eyes, 19 (14%) had tumor recurrence, and all tumor recurrences were seen in T3. Regional lymph node metastasis was noted in 4 (3%) patients. No systemic metastasis or death occurred in any patient during the mean follow-up period of 15 months (median, 11 months; range 6-55 months).

CONCLUSION

Increasing T category based on AJCC 8th edition classification is associated with increasing severity of disease, tumor recurrence rate, and the rate of regional lymph node metastasis.

Structural Determinants and Children's Oral Health: A Cross-National Study

Much research on children's oral health has focused on proximal determinants at the expense of distal (upstream) factors. Yet, such upstream factors-the so-called structural determinants of health-play a crucial role. Children's lives, and in turn their health, are shaped by politics, economic forces, and social and public policies. The aim of this study was to examine the relationship between children's clinical (number of decayed, missing, and filled teeth) and self-reported oral health (oral health-related quality of life) and 4 key structural determinants (governance, macroeconomic policy, public policy, and social policy) as outlined in the World Health Organization's Commission for Social Determinants of Health framework. Secondary data analyses were carried out using subnational epidemiological samples of 8- to 15-y-olds in 11 countries ( N = 6,648): Australia (372), New Zealand (three samples; 352, 202, 429), Brunei (423), Cambodia (423), Hong Kong (542), Malaysia (439), Thailand (261, 506), United Kingdom (88, 374), Germany (1498), Mexico (335), and Brazil (404). The results indicated that the type of political regime, amount of governance (e.g., rule of law, accountability), gross domestic product per capita, employment ratio, income inequality, type of welfare regime, human development index, government expenditure on health, and out-of-pocket (private) health expenditure by citizens were all associated with children's oral health. The structural determinants accounted for between 5% and 21% of the variance in children's oral health quality-of-life scores. These findings bring attention to the upstream or structural determinants as an understudied area but one that could reap huge rewards for public health dentistry research and the oral health inequalities policy agenda.

Differences in the prevalence of sarcopenia in haemodialysis patients: the effects of gender and ethnicity

BACKGROUND

There is no universal consensus definition of sarcopenia, although there is agreement that sarcopenia is a risk factor for mortality in haemodialysis (HD) patients. We aimed to determine the effect of using different operational definitions in a multiracial group of HD patients.

METHODS

We measured hand grip strength (HGS) and appendicular lean mass (ALM) by segmental bioimpedance using the Foundation for the National Institutes of Health Sarcopenia Project (FNIH), European Working Group on Sarcopenia (EWGS) and Asian Working Group on Sarcopenia definitions for HGS weakness and loss of appendicular lean mass.

RESULTS

In total, there were 600 HD patients: 373 men (62.2%), mean (SD) age 66.3 (14.7) years, 45.6% diabetic, ethnicity: 281 (48.5%) White, 167 (27.8%) Asian and 149 (24.8%) Black. On HGS criteria, 90.5% of Asian women and 88.5% of Asian men were weak according to EWGS compared to 62.3% of Black women and 52.5% of Black men and 64.5% of White women and 69.1% of White men by FNIH criteria (P < 0.001). On adding appendicular lean mass, the prevalence of sarcopenia was 68.3% for Asian, 27.1% for Black and 36.6% for White women by FNIH and 59.6% Asian, 21.3% Black and 39.9% White men by EWGS criteria.

CONCLUSIONS

Current definitions of sarcopenia report a greater prevalence of muscle weakness compared to appendicular muscle loss in female compared to male HD patients and this is greater for Asian compared to Black and White patients. Because HGS weakness is a greater risk for death, definitions of sarcopenia may underestimate risk in HD patients.

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Allen B, Apyan A, Azzolini V, Barbieri R, Baty A, Bi R, Bierwagen K, Brandt S, Busza W, Cali IA, D’Alfonso M, Demiragli Z, Gomez Ceballos G, Goncharov M, Hsu D, Iiyama Y, Innocenti GM, Klute M, Kovalskyi D, Krajczar K, Lai YS, Lee YJ, Levin A, Luckey PD, Maier B, Marini AC, Mcginn C, Mironov C, Narayanan S, Niu X, Paus C, Roland C, Roland G, Salfeld-Nebgen J, Stephans GSF, Tatar K, Velicanu D, Wang J, Wang TW, Wyslouch B, Benvenuti AC, Chatterjee RM, Evans A, Hansen P, Kalafut S, Kao SC, Kubota Y, Lesko Z, Mans J, Nourbakhsh S, Ruckstuhl N, Rusack R, Tambe N, Turkewitz J, Acosta JG, Oliveros S, Avdeeva E, Bloom K, Claes DR, Fangmeier C, Gonzalez Suarez R, Kamalieddin R, Kravchenko I, Malta Rodrigues A, Monroy J, Siado JE, Snow GR, Stieger B, Alyari M, Dolen J, Godshalk A, Harrington C, Iashvili I, Kaisen J, Nguyen D, Parker A, Rappoccio S, Roozbahani B, Alverson G, Barberis E, Hortiangtham A, Massironi A, Morse DM, Nash D, Orimoto T, De Lima RT, Trocino D, Wang RJ, Wood D, Bhattacharya S, Charaf O, Hahn KA, Kumar A, Mucia N, Odell N, Pollack B, Schmitt MH, Sung K, Trovato M, Velasco M, Dev N, Hildreth M, Hurtado Anampa K, Jessop C, Karmgard DJ, Kellams N, Lannon K, Marinelli N, Meng F, Mueller C, Musienko Y, Planer M, Reinsvold A, Ruchti R, Rupprecht N, Smith G, Taroni S, Wayne M, Wolf M, Woodard A, Alimena J, Antonelli L, Bylsma B, Durkin LS, Flowers S, Francis B, Hart A, Hill C, Ji W, Liu B, Luo W, Puigh D, Winer BL, Wulsin HW, Cooperstein S, Driga O, Elmer P, Hardenbrook J, Hebda P, Lange D, Luo J, Marlow D, Medvedeva T, Mei K, Ojalvo I, Olsen J, Palmer C, Piroué P, Stickland D, Svyatkovskiy A, Tully C, Malik S, Barker A, Barnes VE, Folgueras S, Gutay L, Jha MK, Jones M, Jung AW, Khatiwada A, Miller DH, Neumeister N, Schulte JF, Shi X, Sun J, Wang F, Xie W, Parashar N, Stupak J, Adair A, Akgun B, Chen Z, Ecklund KM, Geurts FJM, Guilbaud M, Li W, Michlin B, Northup M, Padley BP, Roberts J, Rorie J, Tu Z, Zabel J, Betchart B, Bodek A, de Barbaro P, Demina R, Duh YT, Ferbel T, Galanti M, Garcia-Bellido A, Han J, Hindrichs O, Khukhunaishvili A, Lo KH, Tan P, Verzetti M, Ciesielski R, Agapitos A, Chou JP, Gershtein Y, Gómez Espinosa TA, Halkiadakis E, Heindl M, Hughes E, Kaplan S, Kunnawalkam Elayavalli R, Kyriacou S, Lath A, Nash K, Osherson M, Saka H, Salur S, Schnetzer S, Sheffield D, Somalwar S, Stone R, Thomas S, Thomassen P, Walker M, Delannoy AG, Foerster M, Heideman J, Riley G, Rose K, Spanier S, Thapa K, Bouhali O, Celik A, Dalchenko M, De Mattia M, Delgado A, Dildick S, Eusebi R, Gilmore J, Huang T, Juska E, Kamon T, Mueller R, Pakhotin Y, Patel R, Perloff A, Perniè L, Rathjens D, Safonov A, Tatarinov A, Ulmer KA, Akchurin N, Damgov J, De Guio F, Dragoiu C, Dudero PR, Faulkner J, Gurpinar E, Kunori S, Lamichhane K, Lee SW, Libeiro T, Peltola T, Undleeb S, Volobouev I, Wang Z, Greene S, Gurrola A, Janjam R, Johns W, Maguire C, Melo A, Ni H, Sheldon P, Tuo S, Velkovska J, Xu Q, Arenton MW, Barria P, Cox B, Goodell J, Hirosky R, Ledovskoy A, Li H, Neu C, Sinthuprasith T, Sun X, Wang Y, Wolfe E, Xia F, Clarke C, Harr R, Karchin PE, Sturdy J, Zaleski S, Belknap DA, Buchanan J, Caillol C, Dasu S, Dodd L, Duric S, Gomber B, Grothe M, Herndon M, Hervé A, Klabbers P, Lanaro A, Levine A, Long K, Loveless R, Pierro GA, Polese G, Ruggles T, Savin A, Smith N, Smith WH, Taylor D, Woods N. Study of dijet events with a large rapidity gap between the two leading jets in pp collisions at s = 7 TeV

Events with no charged particles produced between the two leading jets are studied in proton-proton collisions ats = 7 TeV . The jets were required to have transverse momentump T jet > 40 GeV and pseudorapidity1.5 < | η jet | < 4.7 , and to have values of η jet with opposite signs. The data used for this study were collected with the CMS detector during low-luminosity running at the LHC, and correspond to an integrated luminosity of 8pb - 1 . Events with no charged particles withp T > 0.2 GeV in the interval - 1 < η < 1 between the jets are observed in excess of calculations that assume no color-singlet exchange. The fraction of events with such a rapidity gap, amounting to 0.5-1% of the selected dijet sample, is measured as a function of the p T of the second-leading jet and of the rapidity separation between the jets. The data are compared to previous measurements at the Tevatron, and to perturbative quantum chromodynamics calculations based on the Balitsky-Fadin-Kuraev-Lipatov evolution equations, including different models of the non-perturbative gap survival probability.

Leap forward in the treatment of Pythium insidiosum keratitis

BACKGROUND

Pythium insidiosum is a parafungus that causes keratitis resembling fungal keratitis. This study compares outcome in a large cohort of patients with P insidiosum keratitis treated with antifungal drugs, to a pilot group treated with antibacterial antibiotics.

METHODS

Between January 2014 and December 2016, 114 patients with culture positive P insidiosum keratitis were included in the study. A subset of culture isolates was tested in vitro for response to nine antibacterial antibiotics by disc diffusion and E test. Patients were treated with topical natamycin in 2014, 2015 and up until mid 2016. Thereafter, the patients received a combination of topical linezolid and topical and oral azithromycin. Therapeutic penetrating keratoplasty (TPK) was done for patients not responding to medical therapy.

RESULTS

In vitro disc diffusion assay showed linezolid to be most effective. The rate of TPK was significantly higher in 2015 compared with 2016 (43/45, 95.6% vs 22/32, 68.8%; p=0.002). Eighteen patients were treated with antibacterial and 14 were treated with antifungal antibiotic in 2016. One patient was lost to follow-up in each group. The rate of TPK was higher and proportion of healed ulcers was lower (p=0.21, Fisher's exact test) in the group on antifungal therapy (TPK-11/13, 84.6%; Healed-2/13, 15.3%) compared with the group on antibacterial therapy (TPK-11/17, 64.7%; Healed-6/17, 35.2%).

CONCLUSIONS

We report favourable but not statistically significant response of P insidiosum keratitis to antibacterial agents in a pilot series of patients. Further evaluation of this strategy in larger number of patients is recommended.

Follow-up patterns and associated risk factors after paediatric cataract surgery: observation over a 5-year period

Purpose

To study the pattern of compliance to follow-up of children less than 5 years of age undergoing surgery for congenital and developmental cataract over a period of 5 years.

Methods

It is a retrospective study of children less than 5 years of age undergoing cataract surgery between January and December 2010 for congenital or developmental cataract and followed up until 31 December 2015. Age, sex, distance from hospital and urban or rural habitat, delay in presentation, socioeconomic status, laterality, morphology and type of cataract, implantation of intraocular lens and interventions done were noted. Compliance to follow-up at postoperative 1 week, 1 month, 3 months, 6 months, 1 year and then once a year until 5 years were recorded.

Results

169 patients were included in the study. The median follow-up was 22 months. Median age at surgery was 10 months and had a negative correlation with total follow-up. Male-to-female ratio was 1.82. Logarithmic curve of follow-up was noticed with 85%, 61%, 55%, 52%, 39% and 28% patients attending 1 month, 3 months, 6 months, 1 year, 3 years and 5 years of follow-up, respectively. Low socioeconomic group had poor follow-up compared with higher socioeconomic group (P=0.009), but the curve of follow-up was similar in both groups; multiple interventions group had better follow-up (P<0.0001).

Conclusion

Curve of loss to follow-up is logarithmic in children undergoing paediatric cataract surgery. Age at surgery and low economic status are the most important factors associated with poor follow-up.

Spectral domain optical coherence tomography for measuring tear film meniscus height and its relationship with epiphora

Purpose:

To evaluate the relationship between tear meniscus height (TMH) values measured by optical coherence tomography (OCT) and the severity of epiphora (Munk scoring).

Methods:

In this prospective cross-sectional study, consecutive patients with epiphora were studied. All patients underwent Munk epiphora scoring, lacrimal syringing, and detailed ophthalmological examination. Using OCT, the TMH (i.e., the line intersecting level of tear meniscus and lower eyelid) values were calculated. The relationship between TMH and epiphora was analyzed by comparing TMH values across various grades of epiphora using Kruskal–Wallis test.

Results:

A total of 38 patients (56 eyes) were included. The mean age was 55 ± 11.1 years with equal distribution of males and females. The mean TMH values were 238 ± 141.3, 396.6 ± 159.5, 707.1 ± 288.8, and 809.5 ± 419.4 μm in grades 1, 2, 3, and 4 of epiphora, respectively. A significant difference in TMH was found among grades 2, 3, and 4 (P = 0.0007). On post hoc analysis, only grade 2 was significantly different from grades 3 and 4 (P = 0.0008 and P = 0.002 respectively), but grades 3 and 4 were comparable (P = 0.62).

Conclusion:

Levels of TMH were found to increase with increasing severity of epiphora. TMH values were comparable in Munk grades 3 and 4.

Search for new phenomena with the M T 2 variable in the all-hadronic final state produced in proton-proton collisions at s = 13 TeV

A search for new phenomena is performed using events with jets and significant transverse momentum imbalance, as inferred through the M T 2 variable. The results are based on a sample of proton-proton collisions collected in 2016 at a center-of-mass energy of 13TeV with the CMS detector and corresponding to an integrated luminosity of 35.9fb -1 . No excess event yield is observed above the predicted standard model background, and the results are interpreted as exclusion limits at 95% confidence level on the masses of predicted particles in a variety of simplified models of R-parity conserving supersymmetry. Depending on the details of the model, 95% confidence level lower limits on the gluino (light-flavor squark) masses are placed up to 2025 (1550)GeV . Mass limits as high as 1070 (1175)GeV are set on the masses of top (bottom) squarks. Information is provided to enable re-interpretation of these results, including model-independent limits on the number of non-standard model events for a set of simplified, inclusive search regions.

Use of Doppler velocimetry in diagnosis and prognosis of intrauterine growth restriction (IUGR): A Review

Intrauterine growth restriction (IUGR) is a condition which has been difficult to assess at an early stage, resulting in the delivery of children who have poor genetic growth potential. Currently, IUGR classification is based upon the system of ultrasound biometry. Doppler velocimetry allows the measurement of hemodynamic flow of major fetal vessels, comparing the flow indices and patterns of normal and IUGR cases. In this review, the effectiveness of Doppler velocimetry in assessing blood flow in major vessels including the umbilical artery, ductus venosus, and middle cerebral artery was studied for both diagnostic and prognostic screening of IUGR. The umbilical artery is the most frequently studied vessel in Doppler velocimetry due to its accessibility and the strength of its associations with fetal outcomes. Abnormalities in the ductus venosus waveform can be indicative of increased resistance in the right atrium due to placental abnormalities. The middle cerebral artery is the most studied fetal cerebral artery and can detect cerebral blood flow and direction, which is why these three vessels were selected to be examined in this context. A potential mathematical model could be developed to incorporate these Doppler measurements which are indicative of IUGR, in order to reduce perinatal mortality. The purpose of the proposed algorithm is to integrate Doppler velocimetry with biophysical profiling in order to determine the optimal timing of delivery, thus reducing the risks of adverse perinatal outcomes.

Effect of early adjunctive use of oral sildenafil and inhaled nitric oxide on the outcome of pulmonary hypertension in newborn infants. A feasibility study

INTRODUCTION

Inhaled nitric oxide (iNO) is the standard therapy for infants with persistent pulmonary hypertension of the newborn (PPHN). Recently, sildenafil has been evaluated as an alternative or adjunctive pulmonary vasodilator.

OBJECTIVE

To assess the effectiveness of adding sildenafil as an early adjunctive therapy together with iNO when treating newborns with PPHN and/or hypoxemic respiratory failure.

METHODS

This is a randomized placebo trial on newborns with gestational age > 34 weeks, postnatal age < 48 hours, and diagnosed with PPHN (oxygen index (OI) ≥ 20). Newborns were randomized to two groups: Group A- received oral sildenafil and iNO, and group B- received placebo and iNO. Initial and follow up echocardiography were performed over 14 days period.

RESULTS

A total of 24 newborns were recruited; 13 of them received sildenafil in addition to iNO and 11 received iNO and placebo. The most common causes of PPHN were meconium aspiration syndrome, pneumonia, and RDS. At the starting point, OI was marginally higher in the intervention group without statistical significance (29 vs 28). There were no differences between the two groups regarding surfactant administration, incidence of pneumothoraces, and the underlying causes of PPHN. Sildenafil or placebo treatment started within 12 hours after starting iNO (8 vs 6 hours).

CONCLUSION

Early use of oral sildenafil next to iNO in cases of PPHN was tolerated well by newborns and it did not show significant adverse effects. Further studies with a larger sample size is needed to assess its effecacy.