Neonatal outcomes in pregnancies complicated by placenta accreta- a matched cohort study

PURPOSE

Pregnancies complicated by placenta accreta spectrum (PAS) are associated with severe maternal morbidities. The aim of this study is to describe the neonatal outcomes in pregnancies complicated with PAS compared with pregnancies not complicated by PAS.

METHODS

A retrospective cohort study conducted at a single tertiary center between 03/2011 and 01/2022, comparing women with PAS who underwent cesarean delivery (CD) to a matched control group of women without PAS who underwent CD. We evaluated the following adverse neonatal outcomes: umbilical artery pH < 7.0, umbilical artery base excess ≤ - 12, APGAR score < 7 at 5 min, neonatal intensive care unit (NICU) admission, mechanical ventilation, hypoxic ischemic encephalopathy, seizures and neonatal death. We also evaluated a composite adverse neonatal outcome, defined as the occurrence of at least one of the adverse neonatal outcomes described above. Multivariable regression analysis was used to determine which adverse neonatal outcome were independently associated with the presence of PAS.

RESULTS

265 women with PAS were included in the study group and were matched to 1382 controls. In the PAS group compared with controls, the rate of composite adverse neonatal outcomes was significantly higher (33.6% vs. 18.7%, respectively, p < 0.001). In a multivariable logistic regression analysis, Apgar score < 7 at 5 min, NICU admission and composite adverse neonatal outcome were independently associated with PAS.

CONCLUSION

Neonates in PAS pregnancies had higher rates of adverse outcomes. Apgar score < 7 at 5 min, NICU admission and composite adverse neonatal outcome were independently associated with PAS.

Second stage duration and delivery outcomes among women laboring after cesarean with no prior vaginal delivery

BACKGROUND

We aimed to evaluate the association of the duration of the second stage with labor after cesarean (LAC) success and other outcomes among women with one prior cesarean delivery (CD) and no prior vaginal births.

METHODS

All women undergoing LAC that reached the second stage of labor from March 2011 to March 2020 were included in this retrospective cohort study. The primary outcome was the mode of delivery by second stage duration. The secondary outcomes included adverse maternal and neonatal outcomes. We allocated the study cohort into five groups of second stage duration. Further analysis compared <3 to ≥3 h of second stage based on prior studies. LAC success rates were compared. Composite maternal outcome was defined as the presence of uterine rupture/dehiscence, postpartum hemorrhage, or intrapartum/postpartum fever.

RESULTS

One thousand three hundred ninety seven deliveries were included. Vaginal birth after cesarean (VBAC) rates decreased as the second stage length time interval increased: 96.4% at <1 h, 94.9% at 1 to <2 h, 94.6% at 2 to <3 h, 92.1% at 3 to <4 h and 79.5% at ≥4 h (p < 0.001). Operative vaginal and CDs were significantly more likely as second stage duration time interval increased (p < 0.001). The composite maternal outcome was comparable among groups (p = 0.226). When comparing the outcomes of deliveries at <3 h versus ≥3 h, the composite maternal outcome and neonatal seizure rates were lower in the <3 h group (p = 0.041 and p = 0.047, respectively).

CONCLUSION

Vaginal birth after cesarean rates decreased as second stage time interval length increased. Even with prolonged second stage, VBAC rates remained relatively high. Increased risk of composite adverse maternal outcomes and neonatal seizures were observed when the second stage lasted 3 h or more.

Investigating two mobile just-in-time adaptive interventions to foster psychological resilience: research protocol of the DynaM-INT study

BACKGROUND

Stress-related disorders such as anxiety and depression are highly prevalent and cause a tremendous burden for affected individuals and society. In order to improve prevention strategies, knowledge regarding resilience mechanisms and ways to boost them is highly needed. In the Dynamic Modelling of Resilience - interventional multicenter study (DynaM-INT), we will conduct a large-scale feasibility and preliminary efficacy test for two mobile- and wearable-based just-in-time adaptive interventions (JITAIs), designed to target putative resilience mechanisms. Deep participant phenotyping at baseline serves to identify individual predictors for intervention success in terms of target engagement and stress resilience.

METHODS

DynaM-INT aims to recruit N = 250 healthy but vulnerable young adults in the transition phase between adolescence and adulthood (18-27 years) across five research sites (Berlin, Mainz, Nijmegen, Tel Aviv, and Warsaw). Participants are included if they report at least three negative burdensome past life events and show increased levels of internalizing symptoms while not being affected by any major mental disorder. Participants are characterized in a multimodal baseline phase, which includes neuropsychological tests, neuroimaging, bio-samples, sociodemographic and psychological questionnaires, a video-recorded interview, as well as ecological momentary assessments (EMA) and ecological physiological assessments (EPA). Subsequently, participants are randomly assigned to one of two ecological momentary interventions (EMIs), targeting either positive cognitive reappraisal or reward sensitivity. During the following intervention phase, participants' stress responses are tracked using EMA and EPA, and JITAIs are triggered if an individually calibrated stress threshold is crossed. In a three-month-long follow-up phase, parts of the baseline characterization phase are repeated. Throughout the entire study, stressor exposure and mental health are regularly monitored to calculate stressor reactivity as a proxy for outcome resilience. The online monitoring questionnaires and the repetition of the baseline questionnaires also serve to assess target engagement.

DISCUSSION

The DynaM-INT study intends to advance the field of resilience research by feasibility-testing two new mechanistically targeted JITAIs that aim at increasing individual stress resilience and identifying predictors for successful intervention response. Determining these predictors is an important step toward future randomized controlled trials to establish the efficacy of these interventions.

Length of the second stage of labor among women achieving vaginal birth after cesarean

OBJECTIVE

To characterize the length of the second stage of labor among women completing a first vaginal birth after a cesarean (VBAC), according to the stage of labor during primary cesarean delivery (CD).

METHODS

A retrospective cohort study of VBACs between 2011 and 2020. Study groups were divided as follows: CD not in labor, CD in the first stage of labor, and CD in the second stage of labor. The primary outcome was the length of the second stage.

RESULTS

A total of 1310 VBACs were included. The timing of the primary CD was not associated with the duration of the second stage. The median second stage of duration of VBACs with previous first stage CD versus previous CD not in labor was 81 versus 106 min, respectively (P = 0.050). In multivariable linear regression, maternal age, birth weight, and epidural were independently associated with second-stage length. Maternal and neonatal outcomes did not differ between study groups and were not affected by the second-stage length.

CONCLUSION

When stratified according to the labor stage of the primary CD, second-stage duration among women completing VBACs was not associated with labor stage at the primary CD. Extremes of the second-stage duration were not associated with increased morbidity.

Risk factors for bladder injury during placenta accreta spectrum surgery

OBJECTIVES

To identify risk factors associated with bladder injury during placenta accreta spectrum (PAS) surgeries.

METHODS

This retrospective cohort study was conducted at the Chaim Sheba Medical Center. The study population included pregnant women diagnosed with PAS undergoing uterine-preserving surgery or hysterectomy. Women with and without operative bladder injury were compared by univariate analysis followed by multivariate analysis. A sub-analysis of women without preoperative sonographic suspicion of bladder invasion was performed.

RESULTS

A total of 312 women were included in the study. Bladder injury incidence was 9.3% (n = 29). Uterine preservation was performed in 267/312 (85.6%) women. The number of previous cesarean deliveries and a preoperative sonogram suspicious for placenta percreta were found to be independent risk factors for intraoperative bladder injury (odds ratio [OR] 1.30, P = 0.019, and OR 5.23, P = 0.002, respectively). The number of previous cesarean deliveries and preoperative sonographic suspicion of placenta percreta were also associated with bladder injury in the sub-analysis (OR 1.30, P = 0.044 for previous cesarean deliveries, and OR 3.36, P = 0.036, for preoperative suspicion of bladder injury).

CONCLUSION

The number of previous cesarean deliveries and preoperative suspicion of placenta percreta are preoperative factors that can assist in preoperative planning and intraoperative management of PAS cases.

Sonographic fetal head circumference is associated with trial of labor after cesarean section success

PURPOSE

The purpose is to study the association of the fetal sonographic head circumference (SHC) with trial of labor after cesarean (TOLAC) success rate, among women with no prior vaginal deliveries.

METHODS

A retrospective case-control study including all women with no prior vaginal delivery undergoing TOLAC during 3/2011-6/2020 with a sonographic estimated fetal weight within one week from delivery. TOLAC success and failure groups were compared.

RESULTS

Of 1232 included women, 948 (76.9%) delivered vaginally. The mean fetal SHC was smaller in the TOLAC success group (330 ± 10 vs. 333 ± 11 mm, p < 0.001). In a multivariate regression analysis, predelivery BMI, hypertensive disorders, gestational age at prior CD, SHC and epidural analgesia administration were independently associated with TOLAC success. A ROC analysis of the multivariable model composed of the factors found independently associated with TOLAC success, excluding SHC, yielded an area under curve of 0.659 (95% CI 0.622-0.697) compared with 0.668 (95% CI 0.630-0.705) with SHC included.

CONCLUSION

Smaller SHC is independently associated with TOLAC success among women that did not deliver vaginally before, and has additive clinical value for the prediction of TOLAC success when combined with non-sonographic factors.

Predictors of successful vaginal birth after cesarean without an epidural among women with no prior vaginal delivery

BACKGROUND

Data are scarce on predictors for success of labor after cesarean (LAC) among women delivering without epidural anesthesia (EA). We aimed to study the predictors for success of LAC among women with no prior vaginal delivery that did not use EA.

METHODS

A retrospective study including all women undergoing LAC between 3/2011 and 1/2021 with no prior vaginal delivery that did not use EA. Factors associated with successful vaginal birth after cesarean were examined using multivariable analysis.

RESULTS

Of the 466 no EA LAC, 339 (72.7%) delivered vaginally. Women in the successful LAC group had lower pregestational and predelivery BMI as compared to those who had a repeat cesarean [odds ratio (OR) 95% confidence interval (CI) 0.90 (0.85-0.94), P < 0.001, and 0.89 (0.85-0.93), P < 0.001, respectively]. The rate of labor dystocia in previous cesarean was lower in the LAC success group [92 (27.1%) vs 50 (39.4%), OR 95% CI 0.57 (0.37-0.88)]. Mean gestational age at LAC was lower in the LAC success group (38^5/7  ± 2^5/7 vs 39^5/7  ± 1^5/7 , P = 0.014). In a multivariable logistic regression analysis, the following factors were negatively and independently associated with LAC success: higher predelivery BMI [adjusted odds ratio (aOR) 95% CI 0.90 (0.86-0.95)], higher gestational age at previous cesarean and at LAC [aOR 95% CI 0.81 (0.70-0.93) and 0.97 (0.94-0.98), respectively], induction of labor [aOR 95% CI 0.08 (0.03-0.25)], and duration of ruptured membranes [aOR 95% CI 0.97 (0.96-0.99)].

CONCLUSIONS

We have identified that lower BMI, lower gestational age, shorter ruptured membranes duration, and spontaneous labor are associated with successful LAC among nonusers of EA with no prior vaginal delivery at one tertiary care facility in Israel.

Prediction of vaginal birth after cesarean for labor dystocia by sonographic estimated fetal weight

OBJECTIVE

To estimate the association of the weight difference between the index trial of labor after cesarean (TOLAC) sonographic estimated fetal weight (sEFW) and prior delivery birth weight with TOLAC success rate among women with previous labor dystocia and no prior vaginal delivery.

METHODS

A retrospective cohort study including all women with prior cesarean for labor dystocia and no prior vaginal delivery undergoing TOLAC during between March 2011 and June 2020 with a sEFW within 1 week from delivery.

RESULTS

Overall, 168 women were included, of those 107 (63.7%) successfully delivered vaginally. The mean sEFW and mean birth weight were lower in the TOLAC success group (P = 0.010 and P = 0.013, respectively). The rate of higher sEFW in the current delivery compared with the previous delivery did not differ between study groups. The rate of higher TOLAC birth weight was lower in the TOLAC success group (odds ratio 0.30; 95% confidence interval 0.15-0.58). In multivariable regression analysis, maternal age older than 30 years, induction of labor, and higher birth weight were independently negatively associated with TOLAC success (adjusted odds ratio [95% confidence interval]: 0.27 [0.10-0.70], 0.27 [0.08-0.90], and 0.43 [0.19-0.94]; P = 0.008, P = 0.034, and P = 0.035, respectively).

CONCLUSIONS

sEFW characteristics did not predict the success or failure of TOLAC among women with prior labor dystocia and no previous vaginal delivery.

Prediction of successful vaginal birth after cesarean in women with diabetic disorders and no prior vaginal delivery

OBJECTIVE

To study the factors associated with successful trial of labor after cesarean (TOLAC) among women with diabetes and no prior vaginal delivery and compare with TOLAC in nondiabetic women.

METHODS

A retrospective study including all women undergoing TOLAC who had no prior vaginal delivery between March 2011 and June 2020 at Sheba Medical Center. Women with diabetic disorders were compared with those without. Multivariate regression analysis was performed to identify factors independently associated with TOLAC success.

RESULTS

Of 2144 deliveries with TOLAC, 163 (7.6%) were to women with a diabetic disorder. TOLAC success rate was comparable between diabetic and nondiabetic women (124 [76.1%] vs 1513 [76.4%], respectively; P = 0.931). Uterine rupture rate was 1.1% (23 out of 2144). Among women with diabetes the uterine rupture rate was 0.6% (1 out of 163) and did not differ between the success or fail TOLAC groups. Multivariate logistic regression showed that epidural anesthesia and cervical effacement were the only independent factors associated with TOLAC success in women with diabetes (adjusted OR 3.32; 95% CI, 1.31-8.69, P = 0.011 and aOR 1.04; 95% CI, 1.01-1.07, P = 0.007, respectively).

CONCLUSION

TOLAC in women with diabetes with no prior vaginal delivery has a high success rate. Epidural analgesia is the only modifiable independent predictor of TOLAC success.

Implementation of machine learning models for the prediction of vaginal birth after cesarean delivery

OBJECTIVE

Accurate prediction of vaginal birth after cesarean is crucial for selecting women suitable for a trial of labor after cesarean (TOLAC). We sought to develop a machine learning (ML) model for prediction of TOLAC success and to compare its accuracy with that of the MFMU model.

METHODS

All consecutive singleton TOLAC deliveries from a tertiary academic medical center between February 2017 and December 2018 were included. We developed models using the following ML algorithms: random forest (RF), regularized regression (GLM), and eXtreme gradient-boosted decision trees (XGBoost). For developing the ML models, we disaggregated BMI into height and weight. Similarly, we disaggregated prior arrest of progression into prior arrest of dilatation and prior arrest of descent. We applied a nested cross-validation approach, using 100 random splits of the data to training (80%, 792 samples) and testing sets (20%, 197 samples). We used the area under the precision-recall curve (AUC-PR) as a measure of accuracy.

RESULTS

Nine hundred and eighty-nine TOLAC deliveries were included in the analysis with an observed TOLAC success rate of 85.6%. The AUC-PR in the RF, XGBoost and GLM models were 0.351±0.028, 0.350±0.028 and 0.336±0.024, respectively, compared to 0.325±0.067 for the MFMU-C. The algorithms performed significantly better than the MFMU-C (p-values = .0002, .0004, .0393 for RF, XGBoost, GLM respectively). In the XGBoost model, eight variables were sufficient for accurate prediction. In all ML models, previous vaginal delivery and height were among the three most important predictors of TOLAC success. Prior arrest of descent contributed to prediction more than prior arrest of dilatation, maternal height contributed more than weight.

CONCLUSION

All ML models performed significantly better than the MFMU-C. In the XGBoost model, eight variables were sufficient for accurate prediction. Prior arrest of descent and maternal height contribute to prediction more than prior arrest of dilation and maternal weight.

Outcome of two sequential singleton pregnancies and twin pregnancies among primiparous women at advanced age undergoing IVF

PURPOSE

To compare the obstetrical and detailed neonatal outcomes of primipara of advanced maternal age conceiving two sequential singleton pregnancies by IVF with those of primipara conceiving twins by IVF.

METHODS

A retrospective study of all primiparous women aged ≤ 38 years and conceived by IVF who delivered sequential singletons or delivered twins at a single tertiary university affiliated medical center between 2011 and 2019. We performed two main comparisons: 1. First vs. second singleton pregnancies. 2. Two singleton pregnancies vs. twin pregnancies.

RESULTS

Overall, there were 63 women with consecutive singleton IVF pregnancies. The median age was 40.0 at first pregnancy and 42.0 in the second pregnancy. Pregnancy and delivery complications rates did not differ significantly between the first and the second singleton pregnancies, including gestational hypertensive disorders (7 (11.1%) vs. 4 (6.3%), p = 0.530), gestational diabetes mellitus (13 (20.6%) vs 18 (28.5%), p = 0.410), intrauterine growth restriction (6 (9.5%) vs. 4 (6.3%), p = 0.744), or cesarean delivery (25 (39.7%) vs. 29 (46%), p = 0.589). Rates of delivery before 32 weeks gestation were similar for both first and second singleton pregnancies (1.6%, p > 0.999). The proportion of neonatal adverse outcome in both first and second singleton pregnancies groups was low and did not differ between the groups. Compared with women who delivered sequential singletons, women with twin pregnancies had significantly higher cesarean delivery rates (113 (83.7%) vs. 29 (46%), p < 0.001) and lower gestational ages at delivery (36.2 vs. 38.4, p < 0.001) than women with two singleton deliveries. Adverse neonatal outcomes were significantly higher for twin pregnancies, including birthweight < 1500 g (17 (12.6%) vs. 2 (3.2%), p = 0.036), neonatal intensive care unit admission (57 (42.2%) vs. 4 (6.3%), p < 0.001), neonatal hypoglycemia (23 (17%) vs. 3 (4.8%), p = 0.017), and respiratory distress syndrome (14 (10.4%) vs. 1 (1.6%), p = 0.040). Length of neonatal hospitalization was significantly longer for twins (9 vs. 5 days, p < 0.001). The rate of gestational hypertensive disorders (preeclampsia and gestational hypertension) was similar between the groups, but the rates of severe preeclampsia trended higher among women who carried twins (8 (5.9%) vs. 0, p = 0.057).

CONCLUSIONS

Sequential singleton pregnancies at primipara women of advanced maternal age have an overall very good outcome, with no clinically significant difference between the pregnancies. In addition, their outcome is much better compared with twins.

Early bactericidal activity of isoniazid in pulmonary tuberculosis. Optimization of methodology. The DATRI 008 Study Group

Early bactericidal activity (EBA) of antituberculosis drugs is the rate of decrease in the concentration of tubercle bacilli sputum during the initial days of therapy. The study reported here was designed to optimize the methodology for obtaining precise EBA measurements. The study compared the results with two versus five treatment days; overnight sputum collections with early morning collections; and quantitative smears for acid-fast bacilli (AFB) with quantitative cultures. Isoniazid (INH) was used as a model drug. Among 28 smear-positive patients enrolled in the study in five cities in the United States, 16 were evaluable (INH-susceptible tuberculosis [TB] and adequate sputum collections). The mean baseline bacterial load was 6.69 log10 cfu/ml (SE = 0.24). Quantitative culture of 10- or 12-h sputum collections obtained on two baseline days and treatment Day 5 was the optimal method for EBA measurement. The mean 5-d EBA was 0.21 log10 cfu/ml/d (SE = 0.03; p < 0.001) and the EBA appeared to be constant during the first five treatment days. On the basis of these data, multiarm studies of investigational drugs will require 25 evaluable subjects per arm to detect (80% power and two-tailed alpha of 0.05) an EBA at least 50% as large as the EBA of INH. In countries with a low incidence of TB, the usefulness of this methodology for rapidly assessing new antituberculosis agents may be limited by the relatively large number of subjects required to compare EBA values across treatment arms.

Synergistic activities of clarithromycin and pyrazinamide against Mycobacterium tuberculosis in human macrophages

The combination of clarithromycin and pyrazinamide was found to be synergistic against Mycobacterium tuberculosis in human macrophages. MICs were four- to eightfold lower for this combination than they were for either drug alone. Clarithromycin and rifampin, however, had only an additive effect.

Viscosity and refractive index of follicular fluid in relation to in vitro fertilization

PURPOSE

To set the standard values of follicular fluid viscosity and refractive index, and to investigate a possible relationship between these physiological parameters and the outcome of in vitro fertilization treatment.

DESIGN AND RESULTS

128 samples of follicular fluid were collected from 40 in vitro fertilization patients. Viscosity determinations (centipoise; mean +/- SD) for shear rates of 23, 46, 115, and 230 were 2.04 +/- 0.86, 1.84 +/- 0.49, 1.48 +/- 0.27, and 1.38 +/- 0.22, respectively. The average (+/- SD) refractive index was 1.030 +/- 0.002. There was no significant difference between the values of thawed frozen fluids and fresh samples of the same specimens. The data showed no correlation between follicular fluid viscosity or refractive index and the presence of oocytes, their maturation grade or their fertilizing capacity.

CONCLUSIONS

For the first time, values of the viscosity and refractive index of follicular fluid obtained during in vitro fertilization have been determined. However, these preliminary results did not reveal any relationship between the physiological parameters examined and the outcome of in vitro fertilization treatment.

Bacteriostatic and bactericidal activities of benzoxazinorifamycin KRM-1648 against Mycobacterium tuberculosis and Mycobacterium avium in human macrophages

Inhibitory and bactericidal activities of KRM-1648 were determined against Mycobacterium tuberculosis and M. avium residing in human monocyte-derived macrophages and extracellular M. tuberculosis and M. avium. MICs and MBCs of KRM-1648 against intracellular and extracellular bacteria were substantially lower than those of rifampin. The MICs and MBCs of either drug against the intracellular bacteria were only twofold lower than or equal to the values found for extracellular bacteria. The prolonged effect of KRM-1648 found in this study is probably associated with high ratios of intracellular accumulation, which were 50- to 100-fold higher than that found for rifampin. Further studies on intracellular distribution of KRM-1648 and on the sites of actual interaction between the drug and bacteria residing in macrophages are necessary, as well as evaluation of combined effects of KRM-1648 with other drugs in long-term macrophage culture experiments.

Comparison of activities of rifapentine and rifampin against Mycobacterium tuberculosis residing in human macrophages

The activities of rifapentine and rifampin against Mycobacterium tuberculosis residing in human monocyte-derived macrophages were determined. The MICs and MBCs of rifapentine for intracellular bacteria were two- to fourfold lower than those of rifampin. For extracellular bacteria, this difference was less noticeable. Nevertheless, the more favorable pharmacokinetics of rifapentine over rifampin was addressed in other experimental models. These models showed substantial differences after short pulsed exposures of the infected macrophages to the drugs and when the infected macrophages were exposed to changing drug concentrations that imitated the pharmacokinetic curves observed in blood. Once-a-week exposures to rifapentine concentrations equivalent to those attained in blood after one 600-mg dose resulted during the first week in a dramatic decline in the number of bacteria, and this decline was maintained at a minimal level for a period of four weeks. The results of this study have shown the suitability of rifapentine for intermittent-treatment regimens. The prolonged effect of rifapentine found in this study may be associated with high ratios of intracellular accumulation, which were four- to fivefold higher than those found for rifampin. Further studies on the intracellular distribution of rifamycins and on the sites of actual interaction between the drugs and bacteria residing in macrophages are necessary.

Splinting therapy for congenital auricular deformities with the use of soft material

Congenital auricular deformities present serious esthetic problems. To avoid surgical correction, splinting during the early neonatal period has been attempted. We describe the results and follow-up of splinting therapy with a special soft material in 30 neonates, as compared with results in a control group of 20 untreated newborn infants. Good results were achieved in 85% of the patients and sufficient results in 15% when the treatment was continuous over the entire 4-week period. However, when treatment was partial or discontinuous, only 10% had good results. None of the infants in the control group showed spontaneous improvement during the period of study. Moreover, early initiation of treatment (first week of life) proved more effective than later treatment (second week of life). Strong parental cooperation and close follow-up are also important for success.

Methods for determining concentrations of antimicrobial agents in human monocytes

Human monocytes can be derived from the leukocyte-rich by-product of donors' blood available after platelet separation. Large volumes of the monocyte samples obtained from this product provided an opportunity to conduct experiments with relatively high concentrations of the antimicrobial agents sufficient for their detection in bioassays, thus avoiding the necessity of working with the radiolabelled drugs. Washing of the cells after their exposure to the drug may lead to an extraction of the tested agent from the cell, especially if it is a substance of low molecular weight. In our experiments we excluded the washing step, and separated the monocytes from the extracellular medium by velocity gradient centrifugation. In experiments with two rifamycins, the cell pellet as well as the extracellular fluid were subjected to a bioassay using Micrococcus luteus as a target organism. The method showed good reproducibility and consistency in results obtained.

Effects of clarithromycin and rifabutin alone and in combination on intracellular and extracellular replication of Mycobacterium avium

The combined effect of clarithromycin and rifabutin against Mycobacterium avium multiplying either within human monocyte-derived macrophages or extracellularly in a liquid medium was additive: both MICs and MBCs were twofold lower for the combination than they were for each drug alone. Prolonged exposure for 4 weeks of M. avium-infected macrophages to combined concentrations that were only twofold greater than the MICs resulted in a 100-fold decrease in the number of viable bacteria, while in the drug-free controls a 100-fold or greater increase in comparison with the initial viable counts took place. Comparison of this effect with the results of the prolonged exposure to each drug alone suggested that under these experimental conditions rifabutin enhanced the antimicrobial activity of clarithromycin against intracellular bacteria. At the same time, inhibition of intracellular growth by a 2-h pulsed exposure of the infected macrophages to the combination of the two drugs was not different from the effect induced by clarithromycin alone. In conclusion, clarithromycin played the major role in the antimicrobial activity of the tested combination, while rifabutin may have enhanced this effect during a prolonged exposure of the intracellular bacteria to these two agents.

Inhibitory and bactericidal activities of levofloxacin against Mycobacterium tuberculosis in vitro and in human macrophages

Levofloxacin exhibited twofold greater inhibitory and bactericidal activities than ofloxacin against either extracellular or intracellular tubercle bacilli. The activities of both drugs against extracellular and intracellular bacteria were about the same, despite the accumulation of the drugs in macrophages at a level four- to fivefold greater than that in the extracellular medium. The activities of both drugs against intracellular bacteria were largely associated with the short, 2-h pulsed exposures of the infected macrophages to the concentrations which correspond to those attainable in blood during the period of the maximum concentration of drug in serum.

Accumulation of clarithromycin in macrophages infected with Mycobacterium avium

Clarithromycin is known to accumulate in polymorphonuclear leukocytes, but no accumulation studies with macrophages have been reported. We exposed J774 macrophages, grown for 4-6 days, to clarithromycin 3.0 micrograms/ml for 2 hours. The cells were separated from the extracellular fluid, and the concentration of clarithromycin was determined in an agar diffusion bioassay. The accumulation of clarithromycin was 15.8-fold greater in the cells than it was in the extracellular fluid when the test was performed with noninfected cells, and 17.3-fold greater for cells infected with Mycobacterium avium. However, the ratio was substantially lower, only 3.7 for dead macrophages, suggesting that intracellular accumulation is probably an active process. These data may clarify the nature of the activity of clarithromycin against M. avium in macrophages.

Mycobacterium avium strains resistant to clarithromycin and azithromycin

Mycobacterium avium strains susceptible to clarithromycin and azithromycin contain mutants resistant to these macrolides with a frequency of 1.1 x 10(-10) to 1.2 x 10(-6). Cross-resistance between clarithromycin and azithromycin was demonstrated with mutants selected in the laboratory as well as with resistant strains isolated from patients. The susceptibility-resistance patterns of the macrolide-resistant strains with drugs other than macrolides were the same as those of the original susceptible strains. The emergence of clarithromycin resistance in patients was a result of multiplication of the preexisting resistant mutants that survived the elimination of bacteria during the initial period of treatment and was an exclusive cause of the relapse of bacteremia.

Inhibition of intracellular growth of Mycobacterium avium by one pulsed exposure of infected macrophages to clarithromycin

A single 2-h pulsed exposure of either human monocyte-derived macrophages or J774 cells infected with Mycobacterium avium to clarithromycin at 3.0 micrograms/ml completely inhibited the intracellular bacterial growth during the first four days of observation, and then only a slight increase in the number of CFU per milliliter took place between the fourth and seventh days. These data suggest that in vivo the intracellular bacteria can be effectively inhibited after a short period when the concentration of the drug in blood reaches its maximum. On the basis of these data, the assumptions that the elimination of bacteremia observed in clarithromycin clinical trials is a result of the activity of the drug not only against bacteria in blood but in macrophages as well and that the peak concentration attainable in blood is essential for these effects can be made.

Transient hepatic dysfunction in an infant of an epileptic mother treated with carbamazepine during pregnancy and breastfeeding

OBJECTIVE

A case is reported of a carbamazepine (CBZ)-treated epileptic mother whose newborn presented with transient hepatic dysfunction characterized by direct hyperbilirubinemia and high concentrations of gamma-glutamyltransferase (GGT).

DATA SOURCES

Information was obtained from case reports, clinical trials, and relevant bibliographic laboratory studies.

DATA EXTRACTION

Data from case reports were evaluated and compared with those from our patient. The hepatotoxic reactions together with the microsomal enzymatic induction of CBZ were reviewed.

DATA SYNTHESIS

A female infant born to an epileptic mother treated with CBZ throughout pregnancy and breastfeeding presented with transient direct hyperbilirubinemia and high concentrations of GGT. The characteristics of her transient hepatic dysfunction were: early appearance (during the first day of life); discrepancy between the normal liver enzymes and high GGT concentrations; slow decrease of GGT, which nevertheless remained at above-normal concentrations even after the complete disappearance of direct hyperbilirubinemia; and spontaneous resolution in spite of only occasional breastfeeding. The possible explanations of this transient hepatic dysfunction (like enzymatic induction) are discussed.

CONCLUSIONS

CBZ-induced hepatic dysfunction in neonates appears to have different clinical expressions. Infants of epileptic mothers treated with CBZ throughout pregnancy and breastfeeding should be carefully monitored for possible adverse effects.

MICs and MBCs of clarithromycin against Mycobacterium avium within human macrophages

The inhibitory and bactericidal activities of clarithromycin were determined quantitatively against the intracellular populations of five Mycobacterium avium strains growing in monocyte-derived human macrophages. The MICs were 1.0 microgram/ml, and the MBCs ranged from 16.0 to 64.0 micrograms/ml; these values were similar to the MICs and MBCs found in broth cultures at pH 7.4 and were substantially lower than those found in broth cultures at pHs 6.8 and 5.0. Since the intracellular environment has a neutral or even an acidic pH, relatively low MICs and MBCs found in macrophage cultures can be associated with the fact that the drug concentrations in macrophages are substantially higher than those in the medium in which these cells are cultivated. Pretreatment of the macrophages 2 days prior to infection decreased the MICs twofold in comparison with results of experiments in which the drug was added to already infected macrophages.

Concurrent mammary gland hyperplasia and adrenocortical carcinoma in a domestic ferret

Mammary gland hyperplasia associated with adrenocortical carcinoma in a domestic ferret had a histologic appearance similar to that observed in cats. It is important to consider this hyperplastic condition in the differential diagnosis of mammary gland enlargement in the ferret.

Prevalence of minor congenital anomalies in newborns of diabetic mothers

Minor congenital anomalies (MCA) were assessed in the offspring of 802 gestational diabetic mothers, 117 pre-gestational diabetic mothers, and 380 offspring born to normal mothers. The prevalence of infants with MCA ranged between 19.4% and 20.5% in the three groups without any significant difference between them. There was no correlation between the prevalence and type of MCA and the severity of the diabetic state. Neither was there any correlation between the prevalence or type of MCA and the appearance or type of major congenital anomalies.

The disease of CBA and BALB/c mice that follows inoculation of a small number of Mycobacterium lepraemurium into the hind foot pad

To learn if the lack of an immune response in mice infected with Mycobacterium lepraemurium (MLM) was a consequence of the organisms, we studied the disease that followed inoculation of less than or equal to 5000 organisms into the hind foot pads of CBA and BALB/c mice. The mice of both strains demonstrated a rapid increase of bacterial numbers soon after inoculation, with a slowing of the rate of multiplication once the number of organisms per foot pad passed 3 x 10(7). By 1 year after inoculation, the numbers of organisms had reached levels greater than or equal to 10(11) in the spleen and liver, and greater than or equal to 10(8) in the femoral bone marrow. In mice that had been inoculated with as few as 5 MLM or 50 MLM, the organisms had multiplied to numbers greater than 10(8) in the foot pads and to greater than or equal to 10(9) in the spleens, suggesting that the ID50 of viable MLM may be less than or equal to 5 organisms per foot pad. No protection against superinfection could be demonstrated. On the other hand, initial multiplication of MLM in the foot pads was followed virtually immediately by the death of at least 97% of the organisms.

Blood-stained maternal milk: prevalence, characteristics and counselling

Blood-stained maternal milk at delivery and during lactation was prospectively studied in 7774 livebirths over a period of 2 years (1986-1988). Eight mothers had this atypical breast discharge, a prevalence rate of 1:971 livebirths (0.1%). The characteristics of this phenomenon were: early appearance (frequently a short time after delivery), with normal bacteriologic and cytologic investigations, disappearance in 2 to 5 days, without adverse effects on the mothers and their babies, no recurrence after cessation, and occurrence in the previous pregnancies (3 of the 5 multipara). As a result, the best policy is to reassure the parents about the benign and transient course of this condition and to recommend continuation of breast feeding.

Possible association between acetazolamide administration during pregnancy and metabolic disorders in the newborn

Development of metabolic acidosis, hypocalcemia and hypomagnesemia in a preterm infant whose mother was treated with acetazolamide throughout pregnancy is described. These neonatal metabolic alterations possibly related to acetazolamide administration in pregnancy have not been previously described in the literature. The metabolic acidosis was transient and resolved spontaneously despite breast feeding and continued administration of acetazolamide to the mother. Hypocalcemia and hypomagnesemia resolved quickly with appropriate treatment with calcium gluconate and magnesium sulphate, respectively. At follow-up at ages 1, 3 and 8 months, the baby showed mild hypertonicity of the lower limbs requiring physiotherapy.

Necrotizing enterocolitis after intravenous immunoglobulin treatment for neonatal isoimmune thrombocytopenia

A male neonate of 38 weeks' gestation with isoimmune neonatal thrombocytopenia treated with high dose intravenous immunoglobulin (IVIG) developed necrotizing enterocolitis (NEC) at 3 days of age. The known maternal and neonatal risk factors for the development of this disease were excluded. The association between high dose IVIG and the appearance of thrombotic events might be another aetiological factor for occurrence of NEC in a newborn infant.

Influence of phagosomal contents on the apparent inhibition of phagosome-lysosome fusion mediated by polyanionic substances in mouse peritoneal macrophages

The study of fusion of phagosomes with secondary lysosomes in macrophages is facilitated by assessing transfer of fluorescent or electron-opaque markers (or both) from the lysosomes to the phagosomes. When certain virulent viable pathogens are phagocytosed by mouse peritoneal macrophages, phagosome-lysosome fusion (P-LF) is inhibited. Nonviable counterparts ordinarily cannot impose this block. A similar, but spurious, block to P-LF seems to be mediated from the lysosomal domain following sequestration of certain polyanionic substances. This block has been judged to be relieved by, for example, heat-killed yeasts and various viable bacteria designated as fusion-inducing microorganisms, acting from the phagosome. In this study we tested this concept and believed it to be unfounded. Macrophages labeled with Thorotrast and incubated with dextran sulfate were offered a variety of viable and heat-killed microorganisms for phagocytosis: Saccharomyces cerevisiae, Mycobacterium lepraemurium, Streptococcus faecalis, and Escherichia coli. By electron microscopy, a transfer of Thorotrast to phagosomes up to 18 h was seen to be highly suppressed as compared with controls, but was not notably different for any of the targets, whether viable or not. Instead, inert 0.45-micron carboxylated polystyrene beads (the smallest target) showed the most delivery of marker. If polyanionic agents truly inhibited fusion, then "fusiogenic" microorganisms should free the marker for delivery. If polyanions do not inhibit P-LF and only trap the marker, the behavior of the various targets would correspond to what we found.

Enhancement of growth of Mycobacterium lepraemurium in macrophages by gamma interferon

Gamma interferon, an immune lymphokine that protects mouse macrophages against infection by several parasites, was ineffective against Mycobacterium lepraemurium. On the contrary, it significantly stimulated multiplication of M. lepraemurium in the macrophages. Simultaneous treatment of macrophages with gamma interferon and interleukin-4 or interleukin-2 or a combination of all three did not enhance the macrophage resistance to infection with M. lepraemurium, but instead stimulated growth of M. lepraemurium.

Haemophagocytosis and other haematological aspects of Mycobacterium lepraemurium disease of mice

CBA mice inoculated i.v. with 2 x 10(8) viable MLM were observed at intervals for 5 months. In the bone marrow, haematopoietic cells were progressively displaced by MLM-laden phagocytes; depletion of erythroid cells began earlier and was more pronounced than that of myeloid cells. Transiently, mild anaemia and profound leucopenia were noted. The spleen was enlarged and the site of increasing histiocytosis and extramedullary haematopoiesis which was accompanied by displacement of splenic parenchyma. The liver was enlarged and its parenchyma contained scattered islands of haematopoietic elements. Lymph node cells had been largely replaced by MLM-laden macrophages by the end of the process. Thus, MLM infection exerts important effects on haematopoiesis of susceptible mice and is accompanied by active extramedullary haematopoiesis. In addition, the haemophagocytosis, observed most commonly in immuno-compromised patients infected with certain viral or mycobacterial pathogens, was observed late in the course of MLM disease of mice.

Mycobacterium lepraemurium activates macrophages but fails to trigger release of superoxide anion

Mycobacterium lepraemurium failed to stimulate a normal respiratory burst when presented to mouse peritoneal or bone marrow macrophages. By comparison, Mycobacterium bovis (strain Bacillus Calmette-Guerin) or Saccharomyces cerevisiae, as expected, stimulated macrophages to release a large amount of superoxide anion (O2-). M. lepraemurium did not interfere with the response to yeast when both microbes were added together to macrophages. The low release of O2- induced by M. lepraemurium was not due to failure of M. lepraemurium to activate or prime macrophages, because exposure of macrophages to M. lepraemurium caused the expected enhancement of O2- release when the macrophages were stimulated by PMA. Similarly, macrophages taken from mice infected with M. lepraemurium were activated, as indicated by high PMA-stimulated O2- release. Macrophages primed in vitro by exposure to Escherichia coli LPS for 24 h did show a moderate O2- response when stimulated by M. lepraemurium, but macrophages primed by exposure to IFN-gamma muramyl dipeptide, or M. lepraemurium showed a weak response when subsequently challenged with M. lepraemurium. The priming effect of M. lepraemurium or LPS decreased substantially after macrophages were cultured in fresh medium for 24 h. Heat killing or opsonization of M. lepraemurium caused the M. lepraemurium to stimulate a high amount of O2- release from LPS-primed macrophages, but heat killing or opsonization of M. lepraemurium had no effect on release of O2- from unprimed macrophages. The results suggest that M. lepraemurium is taken into macrophages by a mechanism that bypasses the FcR and other receptors that are capable of triggering the production of O2-.

Mycobacterium lepraemurium activates macrophages but fails to trigger release of superoxide anion

Mycobacterium lepraemurium failed to stimulate a normal respiratory burst when presented to mouse peritoneal or bone marrow macrophages. By comparison, Mycobacterium bovis (strain Bacillus Calmette-Guerin) or Saccharomyces cerevisiae, as expected, stimulated macrophages to release a large amount of superoxide anion (O2-). M. lepraemurium did not interfere with the response to yeast when both microbes were added together to macrophages. The low release of O2- induced by M. lepraemurium was not due to failure of M. lepraemurium to activate or prime macrophages, because exposure of macrophages to M. lepraemurium caused the expected enhancement of O2- release when the macrophages were stimulated by PMA. Similarly, macrophages taken from mice infected with M. lepraemurium were activated, as indicated by high PMA-stimulated O2- release. Macrophages primed in vitro by exposure to Escherichia coli LPS for 24 h did show a moderate O2- response when stimulated by M. lepraemurium, but macrophages primed by exposure to IFN-gamma muramyl dipeptide, or M. lepraemurium showed a weak response when subsequently challenged with M. lepraemurium. The priming effect of M. lepraemurium or LPS decreased substantially after macrophages were cultured in fresh medium for 24 h. Heat killing or opsonization of M. lepraemurium caused the M. lepraemurium to stimulate a high amount of O2- release from LPS-primed macrophages, but heat killing or opsonization of M. lepraemurium had no effect on release of O2- from unprimed macrophages. The results suggest that M. lepraemurium is taken into macrophages by a mechanism that bypasses the FcR and other receptors that are capable of triggering the production of O2-.

Reduction of tellurite and deesterification of fluorescein diacetate are not well correlated with the viability of mycobacteria

Both Mycobacterium leprae and M. lepraemurium (MLM) were capable of reducing tellurium as tellurite ion (Te4+) to elemental tellurium (Te), seen by electron microscopy as fine crystals within the bacterial cells. There appeared to be close correspondence between the capacity to reduce tellurite, bright green fluorescence after staining with fluorescein diacetate (FDA) and the ability of M. smegmatis to multiply in culture. Likewise, there appeared to be correspondence between tellurite reduction and fluorescence after FDA staining for MLM subjected to prolonged storage in the cold or to heating at 70 degrees C. However, correspondence with tellurite-reduction or fluorescence after FDA staining was not observed when death of MLM occurred in vivo.

Discrepancy in assessment of phagosome-lysosome fusion with two lysosomal markers in murine macrophages infected with Candida albicans

Phagosome-lysosome fusion (P-LF) was studied in cultured mouse resident peritoneal macrophages after phagocytosis of Candida albicans. The macrophages were labeled with acridine orange (AO), the electronopaque colloidal Thorotrast, or both markers. After phagocytosis of heat-killed C. albicans, both markers were delivered to more than 95% of phagosomes. After ingestion of viable C. albicans by labeled cells, delivery of AO to phagosomes was highly suppressed (90%), and yet Thorotrast delivery was almost universal. After phagocytosis and 60 min of incubation, about 10 to 20% of the yeasts were killed, and a similar fraction of phagosomes was stained by the fluorescent marker. The evidence from Thorotrast transfer and assessment of yeast viability indicates that C. albicans largely resists intracellular killing by resident macrophages in the face of entirely uninhibited P-LF. We infer that AO must transfer to nearly all of the phagosomes but that it is evidently recognizable only in those in which the yeasts have been killed or possibly severely injured. This conclusion constitutes yet another limitation in the usefulness of AO for studying P-LF.

Death of Mycobacterium lepraemurium after multiplication in CBA, BALB/c and nude mice

The unexpected death of Mycobacterium lepraemurium in the course of systemic infection of mice, previously noted in the spleens of CBA mice, has been demonstrated in the spleens of BALB/c nu/+ and BALB/c nu/nu mice and also in the livers and other organs of mice of all three strains. That the same phenomenon was observed in nu/nu mice indicates that the mechanism of bacterial death does not involve a T-lymphocyte-mediated cellular immune response on the part of the mice.

Epispadias with complete prepuce and phimosis in a neonate

A rare type of epispadias in a neonate is described in which a complete phimotic prepuce was present. In this situation, the accurate diagnosis is very difficult and may be easily overlooked in the neonatal period. The broad, spadelike glans, the dorsally directed prepucial opening, and the urinary stream are signs previously described. The special shape of the raphe penis and the depression between the corpora cavernosa felt by palpation of the glans are useful new clinical signs to suspect this type of epispadias.

Autosomal dominant cerebro-costo-mandibular syndrome: ultrasonographic and clinical findings

We describe two patients, a father and his daughter, with the cerebro-costo-mandibular syndrome. New manifestations not previously described include microstomia, long philtrum, posterior cervical skin fold, short internipple distance, and depressed sacral region. The presence of hydrocephaly in the proposita and spina bifida in the father may be other manifestations of neuraxial involvement in this syndrome. The first intrauterine ultrasonographic documentation of this syndrome showed polyhydramnios and, especially, the very unusual shape of the ribs, which were short and defective. Most characteristics of the pedigree point to autosomal dominant inheritance. The great variability of inheritance and expressivity of the very few documented familial cases described in the literature, together with the great frequency of sporadic cases, indicates genetic heterogeneity of this syndrome.

Retrospective confirmation of Mycoplasma infection by the immunoperoxidase technique

Rat tissues embedded in paraffin blocks stored for 8-10 yr were sectioned for immunoperoxidase staining. Sections of lung, trachea and endometrium of 22 of 32 rats that had exhibited clinical symptoms of mycoplasmal pneumonia prior to euthanasia, and whose organs had shown gross lesions suggesting mycoplasmal infection on necropsy, demonstrated the presence of Mycoplasma pulmonis organisms by the immunoperoxidase technique in one or more of these tissues.

Spontaneous endometrial tumours of 'Sabra' rats

In a 2 year study of 171 female (101 virgin; 70 multiparous) 'Sabra' rats, spontaneous endometrial tumours were found in 69% of 2 year old animals. Tumour development appeared to be age related, and only virgin females showed tumours before 18 months of age. Polyps were the most prevalent tumour type, followed by adenocarcinomas. The Sabra rat can be included among those rat strains having a high incidence of spontaneous endometrial neoplasia.

Types of hymen in the newborn infant

The incidence of various types of hymenal shape, its orifice and their interference with spontaneous vaginal discharge were investigated during the routine physical examination of 333 female infants within the first 24 h of life. A smooth hymen with a central orifice was observed in 53.5% of the female neonates, a folded hymen with a central orifice in 27.3%; folded hymen with eccentric orifice in 4.5%; an anterior opening of the hymen in 10.8%; posterior opening in 0.6%; hymenal band in 3%; almost imperforate hymen in 0.3% of the newborns. The presence of anterior opening, posterior opening, hymenal band or almost imperforate hymen may interfere with free vaginal discharge. A ruffled, irregular hymen and a hymenal band require a careful investigation for other genital malformations.

Multiplication of Mycobacterium marinum within phagolysosomes of murine macrophages

Both in vivo and in vitro, Mycobacterium marinum organisms were found to multiply within phagolysosomes of murine macrophages. It thus appears that M. marinum are neither killed nor inhibited from multiplying by lysosomal enzymes.

Importance of the footpad lesion in the mouse response to local inoculation of Mycobacterium marinum

The importance of the footpad lesion was studied in CBA mice inoculated in the hind footpad with viable or heat-killed Mycobacterium marinum Popliteal or popliteal and inguinal lymphadenectomy was followed by modest enhancement of the process only when node excision was carried out 6 days after inoculation of a small number of viable organisms. Following inoculation in the footpad of a large number of heat-killed organisms, only 10% of the inoculum was recovered from the site of inoculation, only 0.1% from the popliteal node and even less from the inguinal node and spleen. Despite the small proportion of inoculated M. marinum remaining in the footpad, amputation of the inoculated foot as early as 4 days after inoculation abrogated the protective effects of the inoculation, whereas amputation performed 7 days after inoculation was without effect.