Factors that Influence Placement of Gastrostomy Tube in Infants with Complex Congenital Heart Disease: A Single Center Study

BACKGROUND

Factors that determine the need for Gastrostomy tube (G-tube) placement in infants with complex congenital heart defects (CHD) are variable. We aim to identify factors that improve counseling of expectant parents regarding postnatal outcomes and management.

METHODS

We performed a retrospective review of medical record of infants with prenatal diagnoses of complex CHD between 2015-2019 in a single tertiary care center and assessed risk factors for G-tube placement with linear regression.

RESULTS

Of the 105 eligible infants with complex CHD, 44 infants required G-tube (42% ). No significant association was observed between G-tube placement and chromosomal abnormalities, cardiopulmonary bypass time or type of CHD. Median days on noninvasive ventilation (4 [IQR 2-12] vs. 3 [IQR 1-8], p = 0.035), time at which gavage-tube feeds were started postoperatively (3 [IQR 2-8] vs. 2 [IQR 0-4], p = 0.0013), time to reach full-volume gavage-tube feeds (6 [IQR 3-14] vs. 5 [IQR 0-8], p = 0.038) and intensive care unit (ICU) length of stay (LOS) (41 [IQR: 21 - 90] vs. 18 [IQR: 7 - 23], p <  0.01) were associated with G-tube placement. Infants with ICU LOS duration longer than median had almost 7 times the odds of requiring a G-tube (OR: 7.23, 95% CI: 2.71-19.32; by regression).

CONCLUSIONS

Delay in initiation and in reaching full-volume gavage-tube feeds after cardiac surgery, increased number of days spent on non-invasive ventilation and in the ICU were found to be significant predictors for G-tube placement. The type of CHD and the need for cardiac surgery were not significant predictors for G-tube placement.

Prediction of dual survival following fetoscopic laser photocoagulation for twin-twin transfusion syndrome

OBJECTIVE

To develop a model based on factors available at the time of diagnosis of twin-twin transfusion syndrome (TTTS) for predicting the probability of dual twin survival following fetoscopic laser photocoagulation (FLP) using a machine-learning algorithm.

METHODS

This was a retrospective study of data collected at two university-affiliated tertiary fetal centers between 2012 and 2021. The cohort included monochorionic diamniotic twin pregnancies complicated by TTTS that underwent FLP. Data were stratified based on survival 30 days after delivery, and cases with dual survival were compared to those without dual survival. A random forest machine-learning algorithm was used to construct a prediction model, and the relative importance value was calculated for each parameter that presented a statistically significant difference between the two study groups and was included in the model. The holdout method was applied to check overfitting of the random forest algorithm. A prediction model for dual twin survival 30 days after delivery was presented based on the test set.

RESULTS

The study included 537 women with monochorionic diamniotic twin pregnancy, of whom 346 (64.4%) had dual twin survival at 30 days after delivery and were compared with 191 (35.6%) cases that had one or no survivors. Univariate analysis demonstrated no differences in demographic parameters between the groups. At the time of diagnosis, the dual-survival group had lower rates of estimated fetal weight (EFW) < 10th centile for gestational age in the donor twin (56.4% vs 69.4%; P = 0.004), intertwin EFW discordance > 25% (40.8% vs 56.5%; P = 0.001) and anterior placenta (40.5% vs 50.0%; P = 0.034). Comparison of Doppler findings between the two groups demonstrated significant differences in the donor twin, with a lower rate of pulsatility index (PI) > 95th centile in the umbilical artery and ductus venosus and a lower rate of PI < 5th centile in the fetal middle cerebral artery in the dual-survival group. Relative importance values for each of these six parameters were calculated, allowing the construction of a prediction model with an area under the receiver-operating-characteristics curve of 0.916 (95% CI, 0.887-0.946).

CONCLUSIONS

We developed a predictive model for dual survival in monochorionic twin pregnancies following FLP for TTTS, which incorporates six variables obtained at the time of diagnosis of TTTS, including donor EFW < 10th centile, intertwin EFW discordance > 25%, anterior placenta and abnormal PI in the umbilical artery, ductus venosus and middle cerebral artery of the donor twin. This clinically applicable tool may improve treatment planning and patient counseling. © 2022 International Society of Ultrasound in Obstetrics and Gynecology.

Clinical outcome and mortality in patients with ICD for primary prevention

Background

ICD (Implantable Cardiac Defibrilator) for primary prevention is indicated in patients with EF ≤35% and NYHA class II–III heart failure despite at least 3 months of optimal medical therapy.However, the studies that form the basis of this recommendation belong to more than 20 years ago. These studies may not reflect the characteristics and treatment of current heart failure patients. Therefore, the effect of ICD for primary prevention on prognosis may have been changed. Recent studies have called into question the effectiveness of the ICD in primary prevention.

Aim

The aim of our study is to evaluate the patients who had ICD for primary prevention implanted retrospectively.

Method

The primary outcomes of all-cause death and sudden death were compared in patients who underwent ICD for primary prevention at our clinic between 01.01.2015 and 01.03.2020 and patients with ICD indication but who did not accept this treatment.

Results

Of the 228 patients who had ICD for primary prevention implanted, 175 (76.8%) were male.The mean age of the patients was 65.63±11.94 years. The mean follow-up period of the patients was 39.45±18.89 months. The mean left ventricular ejection fraction of the patients was found to be 24.30±6.19%. Procedural complications developed in 36 (15.8%) of 228 patients. When these complications were analyzed according to the gender of the patients, complications developed in 21 (12%) of 175 male patients and 15 (28.3%) of 53 female patients (p: 0.004). When the ICD implanted group and the control group were compared in terms of all cause mortality, 67 (29.4%) of 228 patients in the ICD arm and 39 (26%) of 150 patients in the control group died due to all causes mortality (p: 0.473) (Figure 1). When the ICD implanted group and the control group were compared in terms of sudden death, 2 patients in the ICD arm and 8 patients in the control group had sudden death (p: 0.017). Age, left ventricular ejection fraction, BNP value, and previous hospitalization due to decompensation heart failure were found to be independent predictors of all-cause mortality by multiple logistic regression method. Mortality was 3.4 times higher in patients who were hospitalized with decompensated heart failure before the procedure. In the ICD implanted group, the all-cause mortality of patients with a BNP value above 508.5, LVEF value below 24.5%, and age greater than 68.5 was 25 times higher than in other patients (Wald: 9.938 OR (95% Cl): 0.039 (0.005–0.293) p: 0.002) (Table 1). It was found that the presence of coronary artery disease was not an independent risk factor.

Conclusion

Our patient population and our findings are compatible with current life data. We think that the recommendations for ICD for primary prevention implantation in the guidelines may be downgraded in the future with current treatment options. It will be important to determine which patient population will most benefit from the ICD treatment for primary prevention.

Funding Acknowledgement

Type of funding sources: None.

The prevalence of concealed Brugada Syndrome in patients with paroxysmal atrial fibrillation

Funding Acknowledgements

Type of funding sources: None.

Background

Brugada Syndrome (BS) is an inherited rhythm-disorder with risk of sudden-cardiac-death defined by a specific ST-segment elevation pattern in precordial ECG-leads either spontaneous or provoked by Na-channel-blocker-drug-provocation-test with Ajmaline and/or higher-precordial-intercostal-space (HICS)-ECGs. Scarce data denote that the prevalence of atrial fibrillation (AF) is higher in BS and most of the antiarrhythmic-drugs used in AF are contraindicated in BS.

Purpose

Our aim was to elucidate the frequency of BS in paroxysmal-AF (PAF) patients without heart-disease and reveal possible clinical/genetic relations.

Methods

Adult patients with an history of PAF less than 55-years-old were prospectively and consecutively evaluated with resting and HICS-ECGs, cardiac-examination and routine Ajmaline-drug-provocation-test (if not contraindicated). After the exclusion of subjects with any cardiac-disease, anti-arrhythmic-use, bundle-branch-blocks, pre-excitations and ventricular hypertrophies; 96 subjects ([mean±SD] age, 37.3±18, [range]18-55 years) were enrolled in the study (male n [%overall]:55 [57.2%]). All ECGs were interpreted manually by two experienced cardiologists for BS and Brugada-type-ECG-patterns (BTEPs). In 32 patients SCNA5A genetic tests were done (n: 15 BS(+) 17 BS(-) patients). In BS(+) patients, electrophysiological-study (EPS) with programmed-ventricular-stimulation (PVS) was also done and compared with the EPS parameters of BS(-) PAF patients that undergone AF-catheter-ablation-strategy (n: 30).

Results

Overall frequency of concealed-BS was 22,9% (n: 22 [male n: 14]). No spontaneous type-1 BTEP was found with HICS-ECGs and all BS diagnosis were Ajmaline-induced. The clinical characteristics of PAF patients with and without BS and statistical findings are presented in Table-1 and Figure-1. BS(+) patients were predominantly male, younger, slimmer, significantly more suffering from situational syncopal episodes and revealing more BTEPs by baseline HICS-ECGs. The SCN5A-mutation positivity was non-significant between BS(+) and (-) PAF patients (p= 0,80). Baseline heart-rates were lower and PR-intervals, P-wave-duration and Sinus-node-recovery-times were significantly higher in BS(+) patients. Only one BS(+) PAF patient with an history of syncope developed VF with 2 extra-beats in PVS and received an ICD.

Conclusions

Concealed-BS is found to be highly prevalent in middle-aged-subjects and especially males with PAF without an apparent cardiac-disorder. Knowing this considerably lethal condition might protect a vulnerable sub-group of patients from the deleterious effects of antiarrhythmics and risk stratification might confer an increased risk. Non-invasive/invasive indices regarding the delayed conduction features in atrial electrophysiological characteristics of BS(+) patients and a higher vagal state might be suggested as one of the probable mechanisms underlying the higher prevalence of AF in BS.

Iatrogenic chorioamniotic separation and septostomy following fetoscopic laser photocoagulation for twin-twin transfusion syndrome

OBJECTIVE

To compare the perinatal outcomes of pregnancies complicated by chorioamniotic separation (CAS) vs septostomy following fetoscopic laser photocoagulation (FLP) for twin-twin transfusion syndrome (TTTS).

METHODS

This was a retrospective cohort analysis of monochorionic diamniotic twin pregnancies with TTTS that underwent FLP at one of two university-affiliated tertiary medical centers between January 2012 and December 2020. CAS and septostomy were diagnosed either during the procedure or by ultrasonography within 24-48 h after FLP. Data on procedure and postprocedure parameters, pregnancy outcomes and survival were collected from the patients' electronic medical records. Pregnancies were stratified according to the presence of CAS, septostomy or neither. Patients diagnosed with both CAS and septostomy were analyzed separately.

RESULTS

Of the 522 women included in the cohort, 38 (7.3%) were diagnosed with CAS, 68 (13.0%) with septostomy and 23 (4.4%) with both CAS and septostomy. The remaining 393 (75.3%) women comprised the control group. Groups did not differ in demographic characteristics. The septostomy group had a lower rate of selective fetal growth restriction than did the CAS and control groups (24.2% vs 36.8% vs 42.7%, respectively; P = 0.017). Moreover, intertwin size discordance was lower in the septostomy group (15.1% vs 23.4% in the CAS group and 25.5% in the control group; P = 0.001). Median gestational age at FLP was significantly lower in the CAS group (19.3 weeks vs 20.4 weeks in controls and 20.9 weeks in the septostomy group; P = 0.049). The rate of delivery prior to 34 weeks was significantly higher in the CAS group (89.2%), followed by the septostomy group (80.9%), compared with the control group (69.0%) (P = 0.006). A secondary analysis demonstrated that patients with both CAS and septostomy presented the highest rates of delivery prior to 34 weeks (100%) and 32 weeks (68.2%).

CONCLUSIONS

CAS and septostomy following laser surgery for TTTS are independently associated with higher rates of preterm delivery. The presence of these two findings in the same patient enhances the risk of prematurity. © 2021 International Society of Ultrasound in Obstetrics and Gynecology.

Early laser surgery is not associated with very preterm delivery or reduced neonatal survival in TTTS

OBJECTIVE

To evaluate the association of laser photocoagulation of placental anastomoses (LPA) prior to 18 weeks' gestation (early LPA) with very preterm delivery and neonatal survival in pregnancies with twin-twin transfusion syndrome (TTTS).

METHODS

This was a retrospective cohort study of monochorionic diamniotic twin pregnancies with TTTS undergoing LPA between 2002 and 2018 at two institutions. The rates of delivery < 28, < 30 and < 32 weeks' gestation, preterm prelabor rupture of membranes (PPROM) and 30-day survival of one or both infants were compared between pregnancies undergoing early LPA and those undergoing LPA ≥ 18 weeks' gestation. Regression analysis was performed to determine the association of early LPA with very preterm delivery and 30-day survival, adjusted for Quintero stage, study phase, selective fetal growth restriction, gestational age at delivery, maternal age ≥ 35 years, body mass index > 35 kg/m² , placental location, use of Seldinger method to place the operative trocar, size of the trocar, participating center, use of Solomon technique, cerclage and PPROM. Survival analysis using the Cox proportional hazard model was applied to examine the LPA-to-delivery interval according to the timing of surgery, adjusted for confounding variables.

RESULTS

A total of 414 TTTS pregnancies were included in the study, of which 68 (16.4%) underwent early LPA. In the total cohort, the incidence of delivery at < 28, < 30 and < 32 weeks' gestation was 22.7%, 39.6% and 53.4%, respectively. Survival of both twins and survival of at least one twin at 30 days were 67.5% and 90.8%, respectively. No significant difference was noted between pregnancies that underwent early LPA and those that had LPA ≥ 18 weeks in the rate of delivery < 28 weeks (19.1% vs 23.4%; P = 0.4), < 30 weeks (38.2% vs 39.9%; P = 0.8) and < 32 weeks (44.1% vs 55.2%; P = 0.1) and PPROM (29.0% vs 24.1%; P = 0.4), or in the incidence of double-twin survival (63.9% vs 68.1%; P = 0.5) and survival of at least one infant (91.8% vs 90.6%; P = 0.7) at 30 days. Early LPA was not associated with very preterm delivery or neonatal survival in the regression analyses. Early LPA was associated with a longer LPA-to-delivery interval compared with LPA performed ≥ 18 weeks (median, 106.9 days (range, 2-164 days) vs median, 69.3 days (range, 0-146 days); P < 0.001) when adjusted for confounding variables (hazard ratio, 2.56 (95% CI, 1.76-3.73); P < 0.001).

CONCLUSION

Laser surgery before 18 weeks is not associated with an increased rate of very preterm delivery and PPROM or with reduced neonatal survival when compared with LPA after 18 weeks. © 2020 International Society of Ultrasound in Obstetrics and Gynecology.

Telemedicine-based early rule out and followup ECG algorithm for COVID-19 patients

Funding Acknowledgements

Type of funding sources: None.

Background

Drugs with the potential to prolong QT are used in the treatment of coronavirus 19 (COVID-19) pneumonia. We have developed a telemedicine-based corrected QT (QTc) follow-up algorithm that allows early rule out for follow up.

Aims

In this study, we investigated the availability and safety of the algorithm.

Study design

Retrospective cohort

Methods

Consecutive patients; administered hydroxychloroquine (HCQ) for COVID-19 pneumonia were enrolled into digital ECG recording program which includes QTc follow-up algorithm.

Results

Patients were classified into three groups as those, excluded promptly from the QTc follow-up based on two consecutive ECG findings (early rule out, n = 92) and those, for whom the follow-up was continued (n = 12) and usual care group (n = 68). Of note, 237 ECG tracings were performed in our algorithm population contrary to standard practice of daily recommended ECG monitoring which could have yielded 975 ECG tracings along with accompanied risks of exposure. This way; we ended in 738 (75.7%) fewer ECG tracings. Sustained ventricular arrhythmia or sudden cardiac death was not observed in the entire patient population.

Conclusions

It is safe to rely on telemedicine-based early rule out algorithm in COVID-19 patients, receiving hydroxychloroquine treatment. This algorithm abolished the need for further ECG in majority of patients without increased risk during follow up. These algorithms can significantly reduce the healthcare worker exposures by eliminating the need for ECG follow-up promptly.

Transitions between COPD groups: A cross-sectional study in Turkey

INTRODUCTION

Since GOLD 2017 separates spirometry results from 'ABCD' groups, there have been some changes to the stages of COPD patients. Our aim was to investigate the shifts in COPD groups after GOLD 2017.

METHODS

COPD patients from outpatient clinics of 3 hospitals in Turkey were stratified into old and new ABCD groups according to exacerbation history, mMRC evaluation and spirometry results for both GOLD 2011 and 2017 assessments. Treatment protocols were also evaluated if they were suitable for both classifications.

RESULTS

There were 578 patients (334 men, 244 women) with a mean age of 65.21±10.42. The distribution of patients from group A to D was 28%, 15%, 15%, 42% (GOLD 2011) and 36%, 22%, 7% and 35% (GOLD 2017) respectively. There were shifts from group C to A (53.4%) and D to B (18.4%). The treatment suitability was 66.3% in GOLD 2011 and 60.9% in GOLD 2017. The most common inappropriate treatment protocol was triple therapy. Presence of exacerbations in last year, mMRC score, FEV1 level (p < 0.01 for three parameters) and proportion of males (p = 0.029) were statistically significantly higher in groups C and D of GOLD 2017 compared with new patients in group A and B of GOLD 2017 (shifted from GOLD 2011's C-D groups).

CONCLUSION

There were shifts from group C to A and D to B with GOLD 2017, which means some high-risk COPD patients were reclassified into low-risk groups. Despite guideline updates, there are still many COPD patients with overtreatment. To our knowledge, this is the first study examining transitions between COPD groups after GOLD 2017 in Turkey.

P351Therapeutic inefficacy and pro-arrhythmic nature of metoprolol succinate and carvedilol therapy in patients with idiopathic, frequent, monomorphic premature ventricular contractions

Funding Acknowledgements

None

Background

Anti-arrhythmic drugs remain the first-line therapy for treatment of idiopathic ventricular arrhythmias in clinical practice.

Purpose

The aim of this study was to assess the therapeutic efficacy of extended-release metoprolol succinate (MetS) and carvedilol for idiopathic, frequent, monomorphic premature ventricular contractions (PVCs).

Methods

Study population consisted of 115 consecutive patients: 72 received MetS and 43 received carvedilol.  All patients underwent 24-hour Holter monitoring at baseline and during drug therapy.  PVC burden response to drug therapy was categorized as "Good" (≥80% reduction), "Poor" (either &lt; 80% reduction or ≤ 50% increase) and "Pro-arrhythmic" response (&gt; 50% increase) based on change in PVC burden compared to baseline.

Results

Presenting symptoms were palpitations in 69 (60%), shortness of breath/chest pain/syncope in 12 (10.5%), and coincidentally discovered in 34 (29.5%) patients.  Mean MetS and carvedilol dosages were 65.57 ± 30.67 mg/day and 23.66 ± 4.26 mg/day, respectively.  "Good", "Poor" and "Pro-arrhythmic" response was observed in 13.9% and 23.3%, 61.1% and 60.5%, and 25% and 16.2% of patients treated with MetS and carvedilol, respectively.  In patients with relatively high (≥16%) PVC burden, "Poor" response was observed in 86.9% and 76% of patients treated with MetS and carvedilol, respectively.  Side-effects and/or intolerance were observed in 5.5 % and 13.9 % of patients treated with MetS and carvedilol, respectively.

Conclusions

MetS and carvedilol for idiopathic, frequent, monomorphic PVCs is frequently inefficient.  Therapeutic efficacy decreases further in patients with relatively high (≥16%) PVC burden.  "Pro-arrhythmic" response was observed in approximately one quarter of the patients.

All patients Metoprolol Succinate (n = 71) Carvedilol (n = 43) p value Good response,n (%) 7 (9.9) 7 (16.3) 0.38 Poor response,n (%) 46 (64.8) 29 (67.4) 0.38 Pro-arrhythmic response,n (%) 18 (25.4) 7 (16.3) 0.38 Patients with PVC burden≥%16 Metoprolol Succinate (n = 22) Carvedilol (n = 25) Good response,n (%) 1 (4.5) 3 (12) 0.56 Poor response,n (%) 20 (91) 20 (80) 0.56 Pro-arrhythmic response,n (%) 1 (4.5) 2 (8) 0.56 Therapeutic response to Metoprolol Succinate and Carvedilol

Treatment of glioblastoma using multicomponent silica nanoparticles

Glioblastomas (GBMs) remain highly lethal. This partially stems from the presence of brain tumor initiating cells (BTICs), a highly plastic cellular subpopulation that is resistant to current therapies. In addition to resistance, the blood-brain barrier limits the penetration of most drugs into GBMs. To effectively deliver a BTIC-specific inhibitor to brain tumors, we developed a multicomponent nanoparticle, termed Fe@MSN, which contains a mesoporous silica shell and an iron oxide core. Fibronectin-targeting ligands directed the nanoparticle to the near-perivascular areas of GBM. After Fe@MSN particles deposited in the tumor, an external low-power radiofrequency (RF) field triggered rapid drug release due to mechanical tumbling of the particle resulting in penetration of high amounts of drug across the blood-brain tumor interface and widespread drug delivery into the GBM. We loaded the nanoparticle with the drug 1400W, which is a potent inhibitor of the inducible nitric oxide synthase (iNOS). It has been shown that iNOS is preferentially expressed in BTICs and is required for their maintenance. Using the 1400W-loaded Fe@MSN and RF-triggered release, in vivo studies indicated that the treatment disrupted the BTIC population in hypoxic niches, suppressed tumor growth and significantly increased survival in BTIC-derived GBM xenografts.

Delivery of drugs into brain tumors using multicomponent silica nanoparticles

Glioblastomas are highly lethal cancers defined by resistance to conventional therapies and rapid recurrence. While new brain tumor cell-specific drugs are continuously becoming available, efficient drug delivery to brain tumors remains a limiting factor. We developed a multicomponent nanoparticle, consisting of an iron oxide core and a mesoporous silica shell that can effectively deliver drugs across the blood-brain barrier into glioma cells. When exposed to alternating low-power radiofrequency (RF) fields, the nanoparticle's mechanical tumbling releases the entrapped drug molecules from the pores of the silica shell. After directing the nanoparticle to target the near-perivascular regions and altered endothelium of the brain tumor via fibronectin-targeting ligands, rapid drug release from the nanoparticles is triggered by RF facilitating wide distribution of drug delivery across the blood-brain tumor interface.

Precise targeting of cancer metastasis using multi-ligand nanoparticles incorporating four different ligands

Metastasis displays a highly heterogeneous cellular population with cancer cells continuously evolving. As a result, a single-ligand nanoparticle cannot account for the continuously changing expression of targetable biomarkers over time and space. To effectively direct nanoparticles to metastasis, we developed a multi-ligand nanoparticle by using four different types of ligands on the same nanoparticle that target biomarkers on the endothelium associated with metastatic disease. These vascular targets included αvβ3 integrin, P-selectin, EGFR and fibronectin. Using terminal and in vivo imaging studies, the targeting performance of the multi-ligand nanoparticles was compared to the single-ligand nanoparticle variants. All four single-ligand nanoparticle variants achieved significant targeting of lung metastasis in the 4T1 mouse model of breast cancer metastasis with about 2.5% of the injected dose being deposited into metastasis. A dual-ligand nanoparticle resulted in a nearly 2-fold higher deposition into lung metastases than its single-ligand counterparts. The multi-ligand nanoparticle significantly outperformed its targeting nanoparticle counterparts achieving a deposition of ∼7% of its injected nanoparticles into lung metastases. Using the high sensitivity of radionuclide imaging, PET imaging showed that a multi-ligand nanoparticle labeled with [18F]fluoride was able to precisely target metastatic disease at its very early stage of development in three different animal models of metastatic breast cancer.

Our experience with McKusick-Kaufman syndrome patients

AIM

McKusick-Kaufman syndrome (MKKS) is a rare autosomal recessive disorder. Less than one hundred cases have been reported in the English literature to date. We report three different aged children with a large hydrometrocolpos and postaxial polydactyl.

PATIENTS AND RESULTS

These children had various degrees of associated renal disorders. Bardet Biedl syndrome (BBS) is characterized by retinal dystrophy or retinitis pigmentosa, postaxial polydactyl, obesity, nephropathy, mental disturbances or mental retardation. Typically MKKS is diagnosed in young children especially in neonates whereas the diagnosis of BBS is delayed until the teenage years.

CONCLUSION

All MKKS cases should be re-evaluated for Retinitis pigmentosa, other signs of BBS and for disorders that may worsen with time (Ref. 12).

A neonatal case of left ventricular noncompaction associated with trisomy 18

A neonatal case of left ventricular non-compaction associated with trisomy 18: Left ventricular noncompaction (LVNC) is a rare congenital cardiomyopathy and exact etiology is still unknown. Trisomy 18 is the second most common autosomal trisomy in live-born infants. LVNC has been described in association with other dysmorphic features, association with trisomy 18 has not been reported previously in a neonate. LVNC broadens the cardiac anomalies associated with trisomy 18.

Where should the normal position of the umbilicus be in the neonate?

INTRODUCTION

The aim of this study was to determine the normal position of the umbilicus so as to offer a guide to improve cosmetic results after the repair of congenital abdominal wall defects.

MATERIALS AND METHODS

The position of the umbilical center was determined in 187 neonates with respect to the xiphoid process, the center of the umbilicus and the pubis. The distance between the xiphoid process and the center of the umbilicus (XU), between the pubis and the center of the umbilicus (PU) and from the xiphoid process to the pubis (XP) were measured while the babies lay in a supine position. The PU:XU ratio was calculated based on these measurements.

RESULTS

Mean XP was 11.93±1.40 cm, mean XU was 7.41±1.08 cm and mean PU was 4.52±0.70 (mean±SD). The PU:XU ratio was calculated as 0.61±0.12 (ratio±SD).

CONCLUSION

We suggest that the PU:XU ratio should be 0.61 offering an ideal localization in umbilical reconstruction.

Placental growth factor in the first trimester: relationship with maternal factors and placental Doppler studies

OBJECTIVE

Placental growth factor (PlGF) is a potent angiogenic factor that impacts on early placental vascular development. It was our aim to clarify relationships between PlGF and first-trimester maternal/placental factors that are related to placental development.

METHODS

Prospectively enrolled patients at 11-14 weeks' gestation had serum PlGF measurement by enzyme-linked immunosorbent assay. Results were related to maternal age, parity, race, body mass index, mean arterial blood pressure (MAP), smoking/caffeine use and parameters of placental blood flow resistance.

RESULTS

In 110 consecutive patients PlGF levels ranged between 1.0 and 176.1 pg/mL, showing a linear relationship with gestational age (GA) (PlGF = (1.4251 x GA) -74.951, r(2) = 0.0765, F = 8.941, P = 0.03). PlGF did not relate to maternal demographics but negatively correlated with MAP (Spearman rho = -0.191, P < 0.05). Bilateral uterine artery notching was associated with lower PlGF (40.7 (range, 1.01-131.6) vs. 51.1 (range, 6.4-176.1) pg/mL; Mann-Whitney P = 0.034.). A trend to lower levels was also observed when umbilical artery end-diastolic flow was absent (37.1 (range, 6.8-95) vs. 49.3 (range, 1.01-176.1) pg/mL; P = 0.05).

CONCLUSION

PlGF in the first trimester is related to maternal cardiovascular factors and placental Doppler findings that are associated with subsequent placental dysfunction. The utility of this parameter as a first-trimester screening tool on a population basis requires further investigation.

Treatment of postoperative enterocutaneous fistulas with octreotide in two neonates

Enterocutaneous fistula (EF) in newborns and prematures is a well-recognized complication after necrotizing enterocolitis and other abdominal surgical procedures. Conservative management consists of bowel rest, antibiotics, wound care, and the administration of drugs that either reduce gastrointestinal motility or secretions. Octreotide decreases gastrointestinal secretions, inhibits or blocks the effects of gastrointestinal hormones, diminishes gut motility and thus reduces the flow through the fistula. We used octreotide and were able to report successful spontaneous closure of a fistula in our 2 neonatal patients, one a premature neonate with necrotizing enterocolitis (NEC) and the other with meconium peritonitis.

Susceptibility to seasickness

This paper explains part of the observed variability in passenger illness ratings aboard ships by gender, age and sickness history. Within the framework of a European project, 2840 questionnaires, gathered on several ships operating all over Europe, were analysed. Gender, age and sickness history all had a highly significant effect on seasickness. Furthermore, these effects could be characterized by two fixed parameters describing a general age effect, a third parameter dependent on sickness history and a fourth parameter dependent on gender. Female illness ratings peaked at an age of 11 years, 1.5 times as high as male ratings, which peaked at an age of 21 years. At higher ages, illness ratings decrease to only 20% of their maximum, reducing gender differences to zero. Passengers with a previous history of seasickness rated their illness about two times higher than those who had not felt sick before.

A case of sciatic neuropathy after caesarean section under spinal anaesthesia

We present a rare case in which a healthy parturient developed a left sciatic neuropathy after spinal anaesthesia for caesarean section. Intraoperatively, a wedge was placed under her right buttock to tilt the pelvis and uterus to the left, to minimise aortocaval compression. Postoperatively, she complained of being unable to move her left foot. Neurologic examination revealed a left lower leg paresis. Electromyography showed denervation potentials on muscles innervated by left sciatic nerve. Seven weeks after surgery the patient had made a full recovery. We conclude that the prolonged lateral tilt position might cause compression neuropathy of the sciatic nerve. After childbirth, re-positioning the patient supine or shortening the time of lateral tilt may reduce the risk of sciatic nerve injury.

Maternal cardiac function in fetal growth restriction

OBJECTIVE

To assess the maternal central haemodynamics in normotensive women with pregnancies complicated by severe fetal growth restriction (FGR).

DESIGN

Cross-sectional study.

SETTING

A tertiary referral fetal medicine unit.

POPULATION

The study groups comprised 107 women with normal singleton pregnancies and 20 with singleton pregnancies complicated by FGR at 25-37 weeks. In the latter group, assessment was carried out within 10 days prior to their delivery. All the women were normotensive, without any medical problems.

METHODS

Two-dimensional and M-mode echocardiography of the left ventricle.

MAIN OUTCOME MEASURES

Maternal left ventricular systolic and diastolic function.

RESULTS

In the FGR group, compared with the normal group, there was increased total vascular resistance (TVR), reduced systolic function characterised by lower cardiac output, stroke volume, heart rate, ejection time and septal and lateral long-axis shortening. Mean arterial pressure (MAP) was not significantly different between the groups.

CONCLUSIONS

Severe FGR is associated with reduced maternal systolic function and increased TVR but no change in MAP. TVR may be a useful tool in the classification and management of FGR. The findings suggest that in FGR, there is increased blood viscosity due to lack of intravascular space expansion.

Patient and staff doses in interventional neuroradiology

Radiation doses for interventional examinations are generally high and therefore necessitate dose monitoring for patients and staff. Relating the staff dose to a patient dose index, such as dose-area product (DAP), could be quite useful for dose comparisons. In this study, DAP and skin doses of 57 patients, who underwent neurointerventional examinations, were measured simultaneously with staff doses. Although skin doses were comparable with the literature data, higher DAP values of 215 and 188.6 Gy cm2 were measured for the therapeutical cerebral and carotid examinations, respectively, owing to the use of biplane system and complexity of the procedure. Mean staff doses for eye, finger and thyroid were measured as 80.6, 77.6 and 28.8 microGy per procedure. The mean effective dose per procedure for the radiologists was 32 microSv. In order to allow better comparisons to be made, DAP normalised doses were also presented.

Doppler assessment of cardiac function at 11-14 weeks' gestation in fetuses with normal and increased nuchal translucency

OBJECTIVE

To investigate cardiac dysfunction as a potential underlying mechanism for increased nuchal translucency (NT) in fetuses with chromosomal abnormality or heart defects.

METHODS

Myocardial performance index (MPI) and atrioventricular valve E/A ratios for both sides of the heart were measured by Doppler echocardiography in fetuses at 11-14 weeks' gestation. The study groups consisted of 159 normal control fetuses, 199 otherwise normal fetuses but with increased NT > or = 4 mm, 142 fetuses with trisomy 21, 58 with trisomy 18, 19 with trisomy 13, 37 with Turner's syndrome and 24 with isolated heart defects. Groups were compared using Student's t-test and confidence intervals for differences between groups were calculated.

RESULTS

Otherwise normal fetuses with increased NT showed no difference in any of the cardiac Doppler parameters from normal controls. Mean E/A ratio was slightly but significantly increased in trisomy 21 fetuses compared with normal controls (0.604 vs. 0.578 on the right, P = 0.011; 0.581 vs. 0.542 on the left, P = 0.0001). E/A ratio was not significantly different between any of the other groups and the normals but there was a small increase in absolute E-wave velocity in trisomy 18 fetuses. MPI was significantly decreased in trisomy 21 fetuses, (0.330 vs. 0.378, P = 0.002 on the left) and also in Turner's syndrome fetuses (0.301 vs. 0.352 on the right, P = 0.04; 0.320 vs. 0.378 on the left, P = 0.034) implying better performance, but not in the other groups.

CONCLUSIONS

The magnitude and/or direction of the differences shown do not support a major role for cardiac functional abnormality in the development of NT. Important cardiac dysfunction could not be demonstrated in association with increased NT in normal or abnormal fetuses.

Waardenburg-Syndrom

BACKGROUND

Waardenburg syndrome (WS) is an autosomal dominant disorder characterised by pigmentary anomalies of the skin, hairs, eyes and various defects of other neural crest derived tissues. It accounts for over 2% of congenital hearing impairment. At least four types are recognized on the basis of clinical and genetic criteria.

PATIENTS AND METHODS

Based on a screening of congenitally hearing impaired children, 12 families with WS type II were detected. Of special interest was the phenotype of these families, in particular the reduced penetrance of hearing impairment within the families.

RESULTS AND CONCLUSION

In all cases a high variability of the disease phenotype was detected and the penetrance of the clinical traits varied accordingly. Therefore, it is not possible to predict the clinical phenotype even in a single family. Based on these studies, we plan to identify the pathogenetic cause of the disease in order to perform a detailed genotype/phenotype analysis.

Electrorhinomanometric evaluation of nasal functions in transseptal-transsphenoidal hypophysectomy

OBJECTIVE

The prospective study in 23 patients, who were undergone transseptal-transsphenoidal hypophysectomy, underlines the rhinologic aspects of this technique.

MATERIALS AND METHODS

Preoperative and postoperative subjective complaints were compared, postoperative nasal respiratory functions were evaluated by means of electrohinomanometry.

RESULTS

Nasal respiratory functions were preserved postoperatively in the patients with normal preoperative nasal anatomy (no statistical difference); while, in patients with obstructive deviation of the nasal septum, an improvement in nasal respiratory functions were noted as a result of simultaneously performed septoplasty (p < 0.01).

CONCLUSION

Our results emphasize the importance of the collaboration of otorhinolaryngology and neurosurgery teams for the sake of postoperative nasal functions.

Clinical evidence for dystrophin dysfunction as a cause of hearing loss in locus DFN4

OBJECTIVE

Locus DFN4 is an X-linked nonsyndromic hearing loss locus originally mapped to Xp21.2. Recently, we have mapped deafness in a second family from Turkey to the same region, refining the location to within the Duchenne muscular dystrophy (DMD) locus. The objective of this study was to characterize the clinical phenotype of the Turkish family with comprehensive audiovestibular testing and high-resolution temporal bone computerized tomography.

METHODS

Fourteen members of a three-generation family were studied in detail including two deaf affected males. Members of the family underwent general physical and otologic examination, vestibular testing, pure-tone audiometry, otoacoustic emissions, and immitance testing. An affected male underwent high-resolution computerized tomography of the temporal bone, electroretinogram (ERG), electromyography, electroneurography, and determination of serum creatinine phosphokinase level.

RESULTS

Affected males were congenitally deaf with normal vestibular function. Carrier females showed a mild sensorineural hearing loss affecting all frequencies and absent otoacoustic emissions. Otoacoustic emissions in a younger, 3-year-old carrier girl were normal. In an affected male, ERG demonstrated subnormal scotopic b-wave typically seen in DMD. Computerized tomography of the temporal bone was normal. With the exception of the ERG finding, there was no clinical or laboratory evidence of DMD or Becker muscular dystrophy (BMD).

CONCLUSION

The abnormal ERG in the Turkish family in conjunction with mapping of the DFN4 locus to within DMD strongly suggests that a defect in dystrophin is responsible for the hearing loss in this family. Patients with DMD and BMD should be screened systematically for sensorineural hearing loss. This family provides additional evidence for the critical role of cytoskeletal proteins in normal hearing.

A second family with nonsyndromic sensorineural hearing loss linked to Xp21.2: refinement of the DFN4 locus within DMD

X-linked inherited hearing impairment is a group of heterogeneous disorders accounting for less than 2% of hereditary hearing loss. DFN4, a sex-linked hearing impairment associated with profound sensorineural hearing loss, has been previously mapped to Xp21.2, a region containing the DMD locus. We have identified a family from Turkey with deafness in which the disease maps to and refines the DFN4 locus. In contrast to the previous family, the crossover points are entirely within the DMD locus. Two-point lod score analysis for the markers DXS 997, DXS 1214, and DXS 1219 showed a lod score of 2. 59. 5' and 3' crossovers were between DMD 44 and DXS 1219 and between DXS 1214 and DXS 985, respectively, suggesting that DFN4 is either an allele of DMD or a mutation in a DMD nested gene. The restriction of the DFN4 locus to DMD suggests that dystrophin may play an important role in hearing.

Prevalence of hepatitis B virus infection in pregnant Turkish women and their families

A total of 5,366 pregnant Turkish women were screened for hepatitis B surface antigen (HBsAg) and 225 (4.2%) of them were found to be positive. Hepatitis B e antigen (HBeAg) was detected in 6.2% of HBsAg-positive pregnant women. the overall prevalence of HBsAg and antibody to HBsAg (anti-HBs) among the spouses, previous children, mothers and first degree relatives of the HBsAg-positive pregnant women was 56%, 49%, 79% and 74% respectively. The prevalence of HBsAg is thus high in pregnant Turkish women with familial clustering of hepatitis B virus infection.

Results of vaccinated infants born to HBsAg-positive mothers with different hepatitis B vaccines and doses

Seventy-eight infants born to HBsAg-positive women were randomly assigned to receive either the plasma-derived vaccine or 0.5 ml (10 micrograms HBsAg) yeast-derived recombinant hepatitis B vaccine within 24 hours of birth, simultaneously with hepatitis B hyperimmunoglobulin. In 67 infants who received the plasma-derived vaccine, one of the doses of 0.5 ml (25 micrograms HBsAg) was used randomly. In all of the infants, the second and third doses of both vaccines were given at one and two months of age, respectively. The booster doses were given at 12 month of age in all of the infants. These vaccinated infants were followed up until 13 months of age. There were differences in the seroconversion rates with different vaccines and doses. The recipients of the half-dose of plasma-derived vaccine showed lower seroconversion rates than the others, and the newborns in this group showed more seronegativity (13.2%) than the others (p < 0.05). The lowest anti-HBs geometric mean titers (GMTs) were obtained in newborns vaccinated with Hevac B 0.5 ml. Sixty percent of the anti-HBs GMTs in this group were under 100 mlU/ml. There were statistically significant differences between males and females in anti-HBs seronegativity rates, with males having lower anti-HBs GMTs than females. The difference was particularly significant among male newborns vaccinated with a half-dose of plasma-derived vaccine.

The occurrence of lipid droplets in the proximal and distal tubules of the rat kidney after folic acid treatment

Folic acid in high doses gives rise to an accumulation of lipid droplets in the kidney in addition to other changes in the epithelial of both proximal and distal tubules. With the administration of methionine a decrease of lipid droplets and an improvement of the structures of most of the membranes and mitochrondria are observed. These findings have been discussed in regard to the theory of the "chemically induced hyperplasia of the kidneys" related to folic acid.