Ultrasonographic Diagnosis of Twin-to-Twin Transfusion Syndrome

INTRODUCTION

 Twin-twin transfusion syndrome (TTTS) is a typical complication of monochorionic twin pregnancies (MCTP). Placental vessels that communicate in the chorionic plate between donor and recipient, are responsible for the imbalance of blood flow. Circulatory imbalance causes hypovolemia in donor and hypervolemia in recipient fetus. In a typical case, recipient fetus develops polyhydramnios, weight gain, cardiomegaly and hydrops fetalis. In contrast, donor fetus develops oligohydramnios and fetal growth restriction.

AIM

 The objective of this review is to evaluate in detail the main diagnostic aspects and add other important data for diagnosis of TTTS.

SCIENTIFIC BASES

 The main diagnostic event for this condition is based on the ultrasonographic discovery of oligohydramnios-polyhydramnios sequence. Other useful elements for diagnosis, staging and prognosis are fetal urinary bladder visualization, urinary bladder volumen measurements, edema of subcutaneous and/or generalized tissue edema, Doppler flow velocity waves and cardiac evaluation.

CONCLUSION

 Considerations regarding diagnosis of TTTS make it possible to emphasize that role of physicians treating patients with MCTP is to identify ultrasound sequence of oligohydramnios-polyhydramnios. Other ultrasonographic fetal data as fetal urinary bladder visualization, urinary bladder volumen measurements, edema of subcutaneous and/or generalized tissue edema, Doppler flow velocity waves and cardiac evaluation; may help diagnosis, staging and prognosis of TTTS. It is their responsibility to accurately assess severity, therapeutic possibilities and prognosis.

KEY POINTS

· The role of physicians treating patients with MCTP, regarding diagnosis of TTTS, must be to identify ultrasound sequence of oligohydramnios-polyhydramnios.. · Other ultrasonographic fetal data may help diagnosis, staging, and prognosis of TTTS as follows: fetal urinary bladder visualization, urinary bladder volume measurements, edema of subcutaneous and/or generalized tissue edema, Doppler flow velocity waves, and cardiac evaluation.. · It is physicians' responsibility to accurately assess severity, therapeutic possibilities, and prognosis of patients with MCTP and diagnosis of TTTS..

Excess resource use and cost of drug-resistant infections for six key pathogens in Europe: a systematic review and Bayesian meta-analysis

BACKGROUND

Quantifying the resource use and cost of antimicrobial resistance establishes the magnitude of the problem and drives action.

OBJECTIVES

Assessment of resource use and cost associated with infections with six key drug-resistant pathogens in Europe.

METHODS

A systematic review and Bayesian meta-analysis.

DATA SOURCES

MEDLINE (Ovid), Embase (Ovid), Econlit databases, and grey literature for the period 1 January 1990, to 21 June 2022.

STUDY ELIGIBILITY CRITERIA

Resource use and cost outcomes (including excess length of stay, overall costs, and other excess in or outpatient costs) were compared between patients with defined antibiotic-resistant infections caused by carbapenem-resistant (CR) Pseudomonas aeruginosa and Acinetobacter baumannii, CR or third-generation cephalosporin Escherichia coli (3GCREC) and Klebsiella pneumoniae, methicillin-resistant Staphylococcus aureus, and vancomycin-resistant Enterococcus faecium, and patients with drug-susceptible or no infection.

PARTICIPANTS

All patients diagnosed with drug-resistant bloodstream infections (BSIs).

INTERVENTIONS

NA.

ASSESSMENT OF RISK OF BIAS

An adapted version of the Joanna Briggs Institute assessment tool, incorporating case-control, cohort, and economic assessment frameworks.

METHODS OF DATA SYNTHESIS

Hierarchical Bayesian meta-analyses were used to assess pathogen-specific resource use estimates.

RESULTS

Of 5969 screened publications, 37 were included in the review. Data were sparse and heterogeneous. Most studies estimated the attributable burden by, comparing resistant and susceptible pathogens (32/37). Four studies analysed the excess cost of hospitalization attributable to 3GCREC BSIs, ranging from -€ 2465.50 to € 6402.81. Eight studies presented adjusted excess length of hospital stay estimates for methicillin-resistant S. aureus and 3GCREC BSIs (4 each) allowing for Bayesian hierarchical analysis, estimating means of 1.26 (95% credible interval [CrI], -0.72 to 4.17) and 1.78 (95% CrI, -0.02 to 3.38) days, respectively.

CONCLUSIONS

Evidence on most cost and resource use outcomes and across most pathogen-resistance combinations was severely lacking. Given the importance of this evidence for rational policymaking, further research is urgently needed.

Early life corticosteroid overexposure: Epigenetic and fetal origins of adult diseases

The relationship between events occurring during intrauterine development and later-life predisposition to long-term disease, has been described. The fetus responds to excess intrauterine exposure to high levels of corticosteroids, modifying their physiological development and stopping their growth. Fetal exposure to elevated levels of either endogenous (alterations in fetal hypothalamic-pituitary-adrenal axis) or synthetic corticosteroids, is one model of early-life adversity; to developing adult disease. At the molecular level, there are transcriptional changes in metabolic and growth pathways. Epigenetic mechanisms participate in transgenerational inheritance, not genomic. Exposures that change 11β-hydroxysteroid dehydrogenase type 2 enzyme methylation status in the placenta can result in transcriptional repression of the gene, causing the fetus to be exposed to higher levels of cortisol. More precise diagnosis and management of antenatal corticosteroids for preterm birth, would potentially decrease the risk of long-term adverse outcomes. More studies are needed to understand the potential roles of factors to alter fetal corticosteroid exposure. Long-term infant follow-up is required to determine whether methylation changes in placenta may represent useful biomarkers of later disease risk. This review, summarize recent advances in the programming of fetal effects of corticosteroid exposure, the role of corticosteroids in epigenetic gene regulation of placental 11β-hydroxysteroid dehydrogenase type 2 enzyme expression and transgenerational effects.

Tumor carcinoide primario de ovario. Reporte de caso

Los tumores neuroendocrinos primarios del ovario son raros y consisten en un grupo de neoplasias heterogéneas que expresan marcadores inmunohistoquímicos similares. Los tumores carcinoides son las neoplasias neuroendocrinas más comunes, la mayoría surgen en el tracto gastrointestinal y broncopulmonar. Los tumores carcinoides primarios del ovario son entidades raras que representan aproximadamente 0,3% de todos los tumores carcinoides y menos del 0,1% de todas las neoplasias ováricas, con buen pronóstico y generalmente limitados al parénquima ovárico. Estos tumores surgen del sistema de células neuroendocrinas del estroma, epitelio superficial y teratomas ováricos. Las manifestaciones clínicas, en la mayoría de los casos, están asociadas con liberación de sustancias vasoactivas que causan síntomas, como enrojecimiento cutáneo, diarrea y broncoespasmo. Para realizar el diagnóstico es necesario el uso de imágenes radiológicas multimodales y análisis bioquímicos de marcadores tumorales neuroendocrinos. El tratamiento de primera línea es la resección del tumor siempre que sea posible. El pronóstico es generalmente favorable, excepto en algunos casos con metástasis. Se presenta un caso de tumor carcinoide primario de ovario.

Antenatal corticosteroid therapy: Historical and scientific basis to improve preterm birth management

OBJECTIVE

The purpose of this review is to describe the historical and scientific basis of antenatal corticosteroids (ACS) therapy, to improve the management of preterm birth and decreasing rates of respiratory distress syndrome, intraventricular hemorrhage, necrotizing enterocolitis and perinatal mortality in premature infants.

STUDY DESIGN

We searched MEDLINE/PubMed electronic database, the Cochrane Library, using medical subheading search words such as "ACS", "corticosteroids", "betamethasone" or "dexamethasone", matching with "preterm birth".

RESULTS

This practice was initiated by Liggins and Howie in 1972 and is supported by the initial comprehensive meta-analysis of Crowley, Chambers and Keirse, in 1990, the NIH Consensus Development Conference in 1994, the second Consensus Conference to evaluate repeated courses of corticosteroids in 2000 and the practice recommendations of obstetric societies worldwide. ACS therapy before anticipated preterm birth is one of the most important antenatal therapies and an important evidence-based practice for reducing mortality, and decreasing rates of complications in premature infants.

CONCLUSIONS

Today, there is no controversy that women with preterm birth <34 weeks should be ACS treated. Actually, rescue courses are recommended; while multiple, serial, repeated or weekly courses, are not recommended. In any clinical conditions, as preterm premature rupture of membranes, multiple pregnancies, severe preeclampsia/HELLP syndrome and fetal growth restriction; ACS is recommended.

Densidad mineral ósea y adiposidad central en premenopáusicas con sobrepeso y obesidad

Objetivo: investigar la relación entre densidad mineral ósea y adiposidad central en mujeres premenopaúsicas con sobrepeso y obesidad. Métodos: se seleccionaron 204 pacientes que fueron asignadas en tres grupos de acuerdo con el índice de masa corporal (IMC): grupo A (IMC inferior 25 k/m2; peso normal - controles), grupo B (IMC entre 25 y 30 k/m2; sobrepeso) y grupo C (IMC superior a 30 k/m2; obesidad). Se evaluaron las características generales, densidad mineral ósea y adiposidad central (grosor de tejido adiposo preperitoneal, subcutáneo y visceral). Resultados: las participantes se asignaron en los grupos A (n = 71), B (n = 67) y C (n = 66). No hubo diferencias significativas entre los grupos en relación con la edad, edad de la menarquia y talla (p = ns). El A presentó valores más bajos de densidad mineral ósea en columna lumbar y corporal total comparados con las de los grupos B y C (p < 0,0001). Los valores del grosor del tejido adiposo preperitoneal, subcutáneo y visceral en los grupos C y B presentaron valores mayores comparados con el A (p < 0,0001). La densidad mineral ósea en columna lumbar y corporal total mostraron correlaciones significativas, positivas y moderadas con todos los parámetros de adiposidad central (p < 0,05). Conclusión: existe una relación positiva entre densidad mineral ósea y adiposidad central en premenopaúsicas con sobrepeso y obesidad.

Volumen plaquetario medio en el segundo trimestre del embarazo como predictor de preeclampsia

Objetivo: establecer la utilidad de los valores del volumen plaquetario medio en el segundo trimestre del embarazo como predictor del desarrollo de preeclampsia. Materiales y métodos: investigación prospectiva en 504 pacientes nulíparas con embarazos simples entre 17 y 20 semanas que acudieron a la consulta prenatal. Se evaluaron las características generales, valores del volumen plaquetario medio y eficacia pronóstica. Resultados: los casos fueron 41 embarazadas que desarrollaron preeclampsia (grupo A) y 463 embarazadas consideradas controles (grupo B). No se encontraron diferencias estadísticas significativas en la edad materna, edad gestacional y presión arterial sistólica y diastólica al momento de la realización de la ecografía (p = ns). La edad gestacional al momento del diagnóstico de preeclampsia en el grupo A fue de 35,0 +/- 3,2 semanas. Se encontraron diferencias estadísticamente significativas en los valores del volumen plaquetario medio entre el grupo A (10,15 +/- 0,57 fL) y el B (9,65 +/- 0,61 fL; p < 0,0001). Un valor de corte de 9,50 fL presentó una cifra por debajo de la curva de 0,714 y tiene sensibilidad de 85,4%, especificidad del 40,6%, valor predictivo positivo del 11,3% y valor predictivo negativo del 96,5%. Conclusión: los valores del volumen plaquetario medio en el segundo trimestre no son útiles en la predicción del desarrollo de preeclampsia.

Grado de conocimiento sobre lactancia materna en embarazadas primigestas

Objetivo: determinar el grado de conocimiento sobre lactancia materna en embarazadas primigestas. Métodos: se realizó una investigación explicativa, prospectiva y transversal en primigestas atendidas en la consulta prenatal y que fueron sometidas a una encuesta en la cual se recolectaron las características generales (edad, estado civil y tipo de trabajo o profesión) y se evaluó el conocimiento sobre la lactancia materna a través del análisis de diferentes aspectos de esta práctica. Resultados: se seleccionaron 80 embarazadas con edad promedio de 19,7 +/- 5,1 años, la mayoría estaban casadas (55,3%) y eran amas de casa (48,7%). Mostraron alto conocimiento sobre contraindicaciones (78,8%) y posiciones correctas de lactancia (73,8%), y bajos en cuanto a extracción manual y almacenamiento de la leche materna (12,5%). La asociación entre la edad y las ventajas de lactancia materna exclusiva se encontró que era negativa, débil y significativa (r = -0,227; p < 0,05). También se observó asociación significativa, negativa y débil entre el estado civil y las ventajas de la lactancia materna exclusiva (r = -0,245), y positiva y débil con las posiciones correctas de lactancia (r = 0,290; p < 0,05). Conclusión: los resultados de la investigación demuestran que las embarazadas primigestas tienen un alto grado de conocimiento sobre ciertos aspectos de la lactancia materna, pero se deben hacer esfuerzos por mejorar la comprensión de otros aspectos importantes.

Prolactina cervicovaginal en la predicción de parto pretérmino

Objetivo: establecer la utilidad de las concentraciones cervicovaginales de prolactina en el segundo trimestre para la predicción del parto pretérmino. Métodos: las muestras cervicovaginales se tomaron entre 24 y 28 semanas de embarazo. Todos los embarazos fueron seguidos hasta el parto y divididos en grupos A (parto pretérmino) y B (parto a término). Se evaluaron las características generales, concentraciones séricas de prolactina y eficacia pronóstica. Resultados: la edad gestacional al momento de la determinación de la toma de muestra cervicovaginal fue de 26,2 +/- 1,1 semanas para el grupo A y 25,9 +/- 1,1 semanas para el B (p = ns). No se encontraron diferencias estadísticamente significativas en la edad materna, índice de masa corporal y antecedentes de parto pretérmino (p = ns). Las pacientes del grupo A (1,6 +/- 0,8 ng/mL) presentaron concentraciones cervicovaginales significativas más altas de prolactina comparadas con las del grupo B (0,5 +/- 0,3 ng/mL; p < 0,0001). Un valor de corte de 1 ng/mL presentó un valor por debajo de la curva de 0,87 con sensibilidad 73,1%, especificidad 91,6%, valor predictivo positivo 44,7% y valor predictivo negativo 97,3%. Conclusión: las concentraciones cervicovaginales de prolactina son útiles en la predicción del parto pretérmino.

Supplementation with omega-3 fatty acids and plasma adiponectin in women with polycystic ovary syndrome

OBJECTIVE

To study plasma adiponectin levels in women diagnosed with polycystic ovary syndrome given omega-3 fatty acid supplements.

PATIENTS AND METHODS

A study was conducted in 195 women diagnosed with polycystic ovary syndrome treated with omega-3 fatty acids for 12weeks (n=97; groupA) and control women given placebo (n=98, groupB). General characteristics, metabolism, lipid profile, and hormone and adiponectin levels were compared.

RESULTS

There were no significant differences between the two groups in general characteristics. No significant differences were also found in hormone, blood glucose, and HOMA levels between the groups. Women in study groupsA andB showed no statistically significant differences in total calorie, carbohydrate, protein, and total fat intake between the baseline and final values. Decreased total cholesterol, low-density lipoprotein, and triglyceride levels were found in groupA women (P<.0001). Mean of adiponectin levels also showed a statistically significant increase after treatment (P<.0001). There were no statistically significant differences in the mean values of the different variables in groupB women.

CONCLUSION

Omega-3 fatty acid supplementation for 12weeks caused a significant increase in plasma adiponectin levels in women with polycystic ovary syndrome.

Plasmatic levels of N-terminal pro-atrial natriuretic peptide in preeclamptic patients and healthy normotensive pregnant women

BACKGROUND AND OBJECTIVE

To compare plasma N-terminal pro-atrial natriuretic peptide concentrations in preeclamptic patients and healthy normotensive pregnant women.

METHODS

A cases-controls study was done with 180 patients at Hospital Central Dr. Urquinaona, Maracaibo, Venezuela, that included 90 preeclamptic patients (group A; cases) and 90 healthy normotensive pregnant women selected with the same age and body mass index similar to group A (group B; controls). Blood samples were collected one hour after admission and prior to administration of any medication in group A to determine plasma N-terminal pro-atrial natriuretic peptide and other laboratory parameters.

RESULTS

Plasma N-terminal pro-atrial natriuretic peptide concentrations in group A (mean 1.01 [0.26] pg/mL) showed a significant difference when compared with patients in group B (mean 0.55 [0.07] pg/mL; P<.001]. There was no significant correlation with systolic and diastolic blood pressure values in preeclamptic patients (P=ns). A cut-off value of 0.66ng/mL had an area under the curve of 0.93, sensitivity of 87.8%, specificity of 83.3%, a positive predictive value of 84.0% and a negative predictive value of 87.2%, with a diagnostic accuracy of 85.6%.

CONCLUSION

Preeclamptic patients have significantly higher concentrations of plasma N-terminal pro-atrial natriuretic peptide compared with healthy normotensive pregnant women, with high predictive values for diagnosis.