Stillbirth and fetal anomalies: secondary analysis of a case-control study

OBJECTIVE

Approximately 10% of stillbirths are attributed to fetal anomalies, but anomalies are also common in live births. We aimed to assess the relationship between anomalies, by system and stillbirth.

DESIGN

Secondary analysis of a prospective, case-control study.

SETTING

Multicentre, 59 hospitals in five regional catchment areas in the USA.

POPULATION OR SAMPLE

All stillbirths and representative live birth controls.

METHODS

Standardised postmortem examinations performed in stillbirths, medical record abstraction for stillbirths and live births.

MAIN OUTCOME MEASURES

Incidence of major anomalies, by type, compared between stillbirths and live births with univariable and multivariable analyses using weighted analysis to account for study design and differential consent.

RESULTS

Of 465 singleton stillbirths included, 23.4% had one or more major anomalies compared with 4.3% of 1871 live births. Having an anomaly increased the odds of stillbirth; an increasing number of anomalies was more highly associated with stillbirth. Regardless of organ system affected, the presence of an anomaly increased the odds of stillbirth. These relationships remained significant if stillbirths with known genetic abnormalities were excluded. After multivariable analyses, the adjusted odds ratio (aOR) of stillbirth for any anomaly was 4.33 (95% CI 2.80-6.70) and the systems most strongly associated with stillbirth were cystic hygroma (aOR 29.97, 95% CI 5.85-153.57), and thoracic (aOR16.18, 95% CI 4.30-60.94) and craniofacial (aOR 35.25, 95% CI 9.22-134.68) systems.

CONCLUSIONS

In pregnancies affected by anomalies, the odds of stillbirth are higher with increasing numbers of anomalies. Anomalies of nearly any organ system increased the odds of stillbirth even when adjusting for gestational age and maternal race.

TWEETABLE ABSTRACT

Stillbirth risk increases with anomalies of nearly any organ system and with number of anomalies seen.

Acute ischaemic stroke: challenges for the intensivist

PURPOSE

To provide an update about the rapidly developing changes in the critical care management of acute ischaemic stroke patients.

METHODS

A narrative review was conducted in five general areas of acute ischaemic stroke management: reperfusion strategies, anesthesia for endovascular thrombectomy, intensive care unit management, intracranial complications, and ethical considerations.

RESULTS

The introduction of effective reperfusion strategies, including IV thrombolysis and endovascular thrombectomy, has revolutionized the management of acute ischaemic stroke and transformed outcomes for patients. Acute therapeutic efforts are targeted to restoring blood flow to the ischaemic penumbra before irreversible tissue injury has occurred. To optimize patient outcomes, secondary insults, such as hypotension, hyperthermia, or hyperglycaemia, that can extend the penumbral area must also be prevented or corrected. The ICU management of acute ischaemic stroke patients, therefore, focuses on the optimization of systemic physiological homeostasis, management of intracranial complications, and neurological and haemodynamic monitoring after reperfusion therapies. Meticulous blood pressure management is of central importance in improving outcomes, particularly in patients that have undergone reperfusion therapies.

CONCLUSIONS

While consensus guidelines are available to guide clinical decision making after acute ischaemic stroke, there is limited high-quality evidence for many of the recommended interventions. However, a bundle of medical, endovascular, and surgical strategies, when applied in a timely and consistent manner, can improve long-term stroke outcomes.

P109 Experience of tunnelled vs. bolt EVDs on the intensive care unit

Objectives

The placement of an external ventricular drain (EVD) is a common neurosurgical operation that carries great benefit in acute hydrocephalus but is not without risk. In our centre, bolt EVDs (B-EVD) are being placed in favour of tunnelled EVDs (T-EVD). The former has allowed for urgent CSF diversion in ITU. We compared EVD survival and complication rates between the two types of EVDs.

Design

Single centre prospective case-cohort.

Subjects

Twenty-five patients with B-EVDs and thirty-four patients with T-EVDs.

Methods

Clinical notes and radiographic reports were collected before and after the placement of EVDs for patients in ITU between January 2017 and June 2018.

Results

Fourteen of the 25 B-EVDs were placed on ITU, of which 2 were under stealth guidance. All 34 T-EVDs were placed in theatre. Mean time to CSF access after decision for diversion was 134 min in the B-EVD group and 227 min in the T-EVD group (p<0.05). Mean survival was 35 days for B-EVDs and 29 days for T-EVDs (p<0.05). Eight T-EVDs went onto be replaced as B-EVDs due to retraction or infection. Complications including infection, detachment or retraction were higher in the T-EVD group at 32% compared to 20% in the B-EVD group.

Conclusions

Bolt EVDs have a lower frequency of complications and higher survival compared to tunnelled EVDs. Since B-EVDs require fewer resources they can be placed faster and on ITU.

WM1-7 Brain parenchymal oxygen monitoring in delayed cerebral ischaemia

Objectives

At this single centre, tri-modal monitoring of ICP, temperature and direct brain tissue oxygen tension (PbtO2) is used to guide management of delayed cerebral ischaemia (DCI). We describe our experience of PbtO2 monitoring and its relationship with symptoms of DCI, regional cerebral blood flow (rCBF, perfusion imaging), intra-arterial chemical angioplasty and CSF diversion.

Design

Prospective cohort.

Subjects

Patients with aSAH who underwent over 24 hours of multi-modal PbtO2, temperature and intracranial pressure (ICP) monitoring via a Raumedic NEUROVENT-PTO probe.

Methods

Longitudinal analysis of PbtO2 values, presented as mmHg (mean±SD).

Results

Analysis of 1392 hours of tri-modal monitoring in 13 SAH patients. PbtO2 decreases >50% consistently reproduced focal neurological deficit. Symptomatic PbtO2 values ranged from 12–20 mmHg. Of the six patients who had reduced rCBF, all had a mean PbtO2 <15 mmHg. Five patients underwent intra-arterial chemical angioplasty (10 mg Verapamil in 100 ml NaCl over 30–40 mins). PbtO2 increased by at least 30% for 3.4±0.47 hours. CSF diversion resulted in a sustained mean increase in PbtO2 of 7.6±2.94 mmHg over the first 5 min (p=0.034).

Conclusions

PbtO2 <15 mmHg may predict development of a clinical deficit. Chemical angioplasty resulted in a pronounced but short-lived increase in PbtO2. CSF diversion resulted in a persistent increase in PbtO2. PbtO2 targeted management may be a valuable addition to the clinicians’ arsenal against DCI.

Targeted temperature management in patients with intracerebral haemorrhage, subarachnoid haemorrhage, or acute ischaemic stroke: consensus recommendations

BACKGROUND

A modified Delphi approach was used to identify a consensus on practical recommendations for the use of non-pharmacological targeted temperature management in patients with intracerebral haemorrhage, subarachnoid haemorrhage, or acute ischaemic stroke with non-infectious fever (assumed neurogenic fever).

METHODS

Nine experts in the management of neurogenic fever participated in the process, involving the completion of online questionnaires, face-to-face discussions, and summary reviews, to consolidate a consensus on targeted temperature management.

RESULTS

The panel's recommendations are based on a balance of existing evidence and practical considerations. With this in mind, they highlight the importance of managing neurogenic fever using a single protocol for targeted temperature management. Targeted temperature management should be initiated if the patient temperature increases above 37.5°C, once an appropriate workup for infection has been undertaken. This helps prevent prophylactic targeted temperature management use and ensures infection is addressed appropriately. When neurogenic fever is detected, targeted temperature management should be initiated rapidly if antipyretic agents fail to control the temperature within 1 h, and should then be maintained for as long as there is potential for secondary brain damage. The recommended target temperature for targeted temperature management is 36.5-37.5°C. The use of advanced targeted temperature management methods that enable continuous, or near continuous, temperature measurement and precise temperature control is recommended.

CONCLUSIONS

Given the limited heterogeneous evidence currently available on targeted temperature management use in patients with neurogenic fever and intracerebral haemorrhage, subarachnoid haemorrhage, or acute ischaemic stroke, a Delphi approach was appropriate to gather an expert consensus. To aid in the development of future investigations, the panel provides recommendations for data gathering.

Increased Frequency of BK Virus-Specific Polyfunctional CD8+ T Cells Predict Successful Control of BK Viremia After Kidney Transplantation

BACKGROUND

BK virus infection remains an important cause of loss of allograft function after kidney transplantation. We sought to determine whether polyfunctional T cells secreting multiple cytokines simultaneously, which have been shown to be associated with viral control, could be detected early after start of BK viremia, which would provide insight into the mechanism of successful antiviral control.

METHODS

Peripheral blood mononuclear cells collected during episodes of BK viral replication were evaluated by multiparameter flow cytometry after stimulation by overlapping peptide pools of BK virus antigen to determine frequency of CD8+ and CD4+ T cells expressing 1 or more cytokines simultaneously, as well as markers of T-cell activation, exhaustion, and maturation.

RESULTS

BK virus controllers, defined as those with episodes of BK viremia of 3 months or less, had an 11-fold increase in frequency of CD8+ polyfunctional T cells expressing multiple cytokines, as compared with patients with prolonged episodes of BK viremia. Patients with only low level BK viremia expressed low frequencies of polyfunctional T cells. Polyfunctional T cells were predominantly of the effector memory maturation subtype and expressed the cytotoxicity marker CD107a.

CONCLUSIONS

Noninvasive techniques for immune assessment of peripheral blood can provide insight into the mechanism of control of BK virus replication and may allow for future patient risk stratification and customization of immune suppression at the onset of BK viremia.

International issues in stillbirth

The phenomenon of stillbirth has been poorly addressed in terms of reported statistics and as a clinical issue. A Study Group of the European Association of Perinatal Medicine reviewed the topic and highlighted specific issues. Such proposal was discussed in an open workshop held in Modena, Italy last year and this paper reports the final recommendations. Briefly, at least 22 completed weeks of gestation was endorsed as definition for including SB in statistics and for clinical studies. A minimum diagnostic work-up was suggested together with the emphasis toward a local, multidisciplinary audit process, in order to comprehend causality. Attention for parents emotional support and appropriate counselling was believed as essential part of the clinical process. Finally, the need for funding comprehensive research programs in SB through international, multidisciplinary involvement was believed mandatory for developing effective preventative strategies to avert the devastating occurrence of stillbirth.

Tetrahydrobiopterin: a novel antihypertensive therapy

Tetrahydrobiopterin (BH(4)) is a cofactor for the nitric oxide (NO) synthase enzymes, such that its insufficiency results in uncoupling of the enzyme, leading to release of superoxide rather than NO in disease states, including hypertension. We hypothesized that oral BH(4) will reduce arterial blood pressure (BP) and improve endothelial function in hypertensive subjects. Oral BH(4) was given to subjects with poorly controlled hypertension (BP >135/85 mm Hg) and weekly measurements of BP and endothelial function made. In Study 1, 5 or 10 mg kg(-1) day(-1) of BH(4) (n=8) was administered orally for 8 weeks, and in Study 2, 200 and 400 mg of BH(4) (n=16) was given in divided doses for 4 weeks. Study 1: significant reductions in systolic (P=0.005) and mean BP (P=0.01) were observed with both doses of BH(4). Systolic BP was 15+/-15 mm Hg (P=0.04) lower after 5 weeks and persisted for the 8-week study period. Study 2: subjects given 400 mg BH(4) had decreased systolic (P=0.03) and mean BP (P=0.04), with a peak decline of 16+/-19 mm Hg (P=0.04) at 3 weeks. BP returned to baseline 4 weeks after discontinuation. Significant improvement in endothelial function was observed in Study 1 subjects and those receiving 400 mg BH(4). There was no significant change in subjects given the 200 mg dose. This pilot investigation indicates that oral BH(4) at a daily dose of 400 mg or higher has a significant and sustained antihypertensive effect in subjects with poorly controlled hypertension, an effect that is associated with improved endothelial NO bioavailability.

Heritability of flow-mediated dilation: a twin study

BACKGROUND

Endothelial dysfunction assessed by brachial artery flow-mediated dilation (FMD) is a marker for early atherosclerotic vascular disease and future cardiovascular events.

OBJECTIVE

To estimate the heritability of brachial artery FMD using a twin design.

METHODS

We estimated the heritability of FMD using 94 middle-aged male twin pairs. FMD was measured by ultrasound, and traditional coronary heart disease risk factors were measured. Genetic modeling techniques were used to determine the relative contributions of genes and environment to the variation in FMD.

RESULTS

The mean age of the twin participants was 54.9 +/- 2.8 years. The mean FMD was 0.047 +/- 0.030. The intraclass correlation coefficient was higher in MZ twins [0.38, 95% confidence interval (CI) 0.32-0.43] than in DZ twins (0.19, 95% CI 0.11-0.26), suggesting a role of genetic influence in FMD variation. Structural equation modeling showed that both genetic and unique environmental factors contributed significantly to the variation in FMD. The crude FMD heritability was 0.37 (95% CI 0.15-0.54). After adjustment for traditional cardiovascular risk factors, including age, total cholesterol, blood pressure, and body mass index, the heritability of FMD was 39% (95% CI 0.18-0.56). The remaining variation in FMD could be explained by individual-specific environment.

CONCLUSION

This is the first study using twins to estimate the relative contributions of genetics and environment to the variation in FMD in a US population. Our results demonstrate a moderate genetic effect on brachial artery FMD, independent of traditional coronary risk factors. Our data also highlight the importance of unique environment on the variability in FMD.

Antiangiogenic therapy with interferon alfa for neovascular age-related macular degeneration

BACKGROUND

Antiangiogenic therapy is a new approach to the treatment of neovascular age-related macular degeneration. Interferon alfa is one antiangiogenic agent thought to function by inhibiting the migration and proliferation of vascular endothelial cells. It has been used in the treatment of hepatitis, solid tumors and hematologic malignancies.

OBJECTIVES

The aim of this review was to investigate interferon alfa as a treatment modality for neovascular age-related macular degeneration.

SEARCH STRATEGY

We searched and identified trials from the Cochrane Central Register of Controlled Trials (CENTRAL), which contains the Cochrane Eyes and Vision Group Trials Register, in The Cochrane Library (Issue 2, 2005), MEDLINE (1966 to 2005/06 week 1), EMBASE (1980 to 2005/week 23), LILACS (Latin American and Caribbean Health Science Literature Database) (June 2005) and the reference lists of included studies.

SELECTION CRITERIA

This review included randomized controlled trials evaluating interferon alfa therapy in people with neovascular age-related macular degeneration who were followed for at least one year.

DATA COLLECTION AND ANALYSIS

Both review authors independently extracted data and assessed trial quality. No data synthesis was conducted as only one trial met the inclusion criteria.

MAIN RESULTS

The one included trial enrolled and randomized 481 participants from 45 centers worldwide into four groups. The study allowed for analysis of the number of participants who had lost three or more lines of vision at 52 weeks in three interferon alfa-2a groups versus placebo. The results show an odds ratio of 1.60 (95% Confidence Interval 1.01 to 2.53) indicating that interferon is associated with a 60% increased odds of losing three or more lines at 52 weeks. This finding is marginally statistical with a P value of 0.04 and indicates that the treatment has the potential for harm rather than benefit.

AUTHORS' CONCLUSIONS

At present there is not enough evidence to recommend the use of interferon alfa-2a for the treatment of age-related macular degeneration.

Does transvaginal ultrasound of the cervix predict preterm premature rupture of membranes in a high-risk population?

OBJECTIVES

To determine in patients with a cervical length < 25 mm on transvaginal ultrasound if the severity of cervical length shortening can be used to predict preterm premature rupture of membranes (PPROM) and the contribution of PPROM to preterm delivery in these patients.

METHODS

We retrospectively reviewed asymptomatic singleton pregnancies between 14 and 24 weeks at high risk of preterm delivery by obstetric history and transvaginal cervical length < 25 mm. Cases developing subsequent PPROM were compared with controls for transvaginal sonographic cervical characteristics.

RESULTS

Of 69 patients identified to have a cervical length < 25 mm, 27 (39%) had PPROM, and 42 (61%) did not. Mean +/- standard deviation (SD) cervical length was 12.7 +/- 8.7 mm and 17.0 +/- 7.6 mm in the two groups, respectively (P = 0.04). Mean +/- SD cervical funneling was 57.4 +/- 31.4% and 40.0 +/- 28.1%, respectively (P = 0.01). The characteristics most predictive of PPROM were: cervical length of < 10 mm (sensitivity, specificity, positive and negative predictive values of 33, 90, 69, and 68%, respectively; odds ratio, 4.8; 95% confidence interval, 1.3-17.5) and cervical funneling > 75% (sensitivity, specificity, positive and negative predictive values of 33, 93, 75 and 68%, respectively; odds ratio, 6.5; 95% confidence interval, 1.6-26.9). Stepwise logistic regression revealed cervical length to be a significant predictor of PPROM (odds ratio, 4.0; 95% confidence interval, 1.1-14.2).

CONCLUSION

In patients at high risk for preterm delivery because of obstetric history and transvaginal sonographic cervical length < 25 mm, a cervical length < 10 mm and cervical funneling > 75% were most predictive of PPROM. PPROM was the major contributor to preterm delivery in these patients.

Evaluation of trovafloxacin in the treatment of Klebsiella pneumoniae lung infection in tumour-bearing mice

Trovafloxacin, a new trifluoroquinolone, was evaluated for its therapeutic efficacy against Klebsiella pneumoniae lung infection in tumour (P388 murine leukaemia cells)-bearing mice, treated with or without a chemotherapeutic agent, daunorubicin (DNR) and in mice without tumour. Its activity was compared with ciprofloxacin and cephazolin. The effect on therapeutic efficacy of the addition of recombinant granulocyte colony stimulating factor (rGCSF) was also examined. Our study showed that both quinolones successfully cured pneumonia owing to infection with K. pneumoniae in mice without tumours but that all antibiotics failed in tumour-bearing mice if DNR was withheld. Substantial differences were noted in DNR-treated tumour-bearing mice with infection-the cure rate with trovafloxacin was 91% whereas the cure rate with ciprofloxacin or cephazolin was 57%. Addition of rGCSF to ciprofloxacin did not substantially improve its efficacy (when assessed by protection against death owing to infection; the survival rate was 41%). Trovafloxacin cure rates ranged from 80 to 90% whether or not rGCSF was added to the treatment regimen. Our results suggest that prior cancer chemotherapy had no adverse effect on the therapeutic efficacy of trovafloxacin, and that trovafloxacin may be a promising therapeutic agent for treatment of bacterial infections in the presence of leucopenia.

Efficacy of trovafloxacin for treatment of experimental Bacteroides infection in young and senescent mice

We investigated the efficacy of trovafloxacin, a new quinolone, in comparison with that of clindamycin in the treatment of intra-abdominal abscesses caused by Bacteroides fragilis in young and senescent mice. The development of abscess formation, the number of viable organisms, and antibiotic concentrations were measured, and the values for young and old mice were compared. Trovafloxacin was well distributed to the tissues in both young and old animals. Although the pharmacokinetics and concentrations of trovafloxacin in serum were similar between young and old mice, the levels in tissue were higher in senescent mice than in young mice. Trovafloxacin therapy sterilized abscesses in 94% of young mice and in 73% of old mice, but this difference was not significant. This therapeutic response to trovafloxacin was similar to that seen with clindamycin. These results suggest that aging may not have any adverse effect on the therapeutic outcome for intra-abdominal abscesses caused by B. fragilis.

In vivo efficacy of trovafloxacin (CP-99,217), a new quinolone, in experimental intra-abdominal abscesses caused by Bacteroides fragilis and Escherichia coli

The efficacy of trovafloxacin in treating Bacteroides fragilis and Escherichia coli infections was investigated and compared to the efficacy of combined clindamycin and gentamicin therapy in an experimental model of intra-abdominal abscesses in rats. Rats were treated with different doses of CP-116,517-27, a parenteral prodrug of trovafloxacin. Response to treatment was evaluated by mortality rate and elimination of infection (cure rate). Mortality in the control group was 85.4%, whereas in rats treated with trovafloxacin, it was close to 0%. The highest cure rate (89.3%) resulted from the administration of 40 mg of CP-116,517-27 per kg of body weight three times a day (TID) for 10 days (equivalent to 18.15 mg of active drug trovafloxacin per rat per day). The therapeutic response with trovafloxacin was comparable to that of a combination therapy of clindamycin (75 mg/kg) plus gentamicin (20 mg/kg) TID (cure rate, 74%; mortality rate, 5%). The measured peak levels of trovafloxacin in serum and abscess pus were 2.6 +/- 0.3 and 5.2 micrograms/ml, respectively. The tumor necrosis factor alpha levels in the untreated animals were high compared to those for rats treated with trovafloxacin or clindamycin plus gentamicin. These results demonstrate that trovafloxacin as a single agent appears to be as successful as clindamycin plus gentamicin in the treatment of experimental intra-abdominal abscesses in rats.

Chromatin and cell surface receptors mediate melanoma cell growth response to nerve growth factor

Growth response to nerve growth factor (NGF) was tested in the primary melanoma cell line WM 164, which expressed a low level of NGF cell-surface receptor, and in WM 164 cells transfected with cDNA for the cell-surface receptor (TrWM 164 cells), which expressed a higher level of the cell-surface receptor. Neither cell line expressed the chromatin receptor for NGF or internalized NGF. Both cell lines were stimulated to growth by NGF. After 10 d of exposure to NGF, a 230,000 Mr chromatin protein (receptor) was induced in both cell lines; as a result, NGF bound to the chromatin, and ribosomal RNA synthesis and cell proliferation were inhibited. We suggest that the cell-surface and chromatin receptors each mediate a different function of NGF.

Pyridoxal phosphate protects against an irreversible temperature-dependent inactivation of hepatic delta-aminolevulinic acid synthase

The stability of hepatic delta-aminolevulinic acid synthase (ALAS), the first and rate-limiting enzyme of the heme biosynthetic pathway, was investigated. Incubation of the mitochondrial matrix fraction obtained from either control or allylisopropylacetamide-induced rats at 37 degrees C in Tris-Cl, pH 7.4, EDTA, and dithiothreitol resulted in a rapid decrease in ALAS activity such that 50-70% of the activity was lost after 30 min. Similar decreases in ALAS activity were observed when a cytosolic fraction from the induced animals was incubated at 37 degrees C. Addition of 0.1 mM pyridoxal-P, the cofactor of ALAS, to the preincubation medium completely prevented the observed loss of activity; however, dialysis of the inactive matrix fraction against several changes of buffer containing pyridoxal-P did not restore activity, suggesting that the inactivation was irreversible. These decreases in ALAS activity in the absence of pyridoxal-P were temperature dependent, as a 55% loss of ALAS activity was observed after a 60-min incubation at 30 degrees C, while the enzyme was completely stable when preincubated at 22 degrees C for 60 min. This inactivation of ALAS does not appear to involve proteolytic digestion, as addition of a wide spectrum of protease inhibitors to the preincubation medium in the absence of pyridoxal-P did not protect against the inactivation. The suggestion is made that the cofactor, pyridoxal-P, may dissociate from the enzyme during the preincubation and, consequently, the apoenzyme may be irreversibly inactivated at temperatures above 22 degrees C.