Optic nerve sheath diameter in severe preeclampsia with neurologic features versus controls.

BACKGROUND: Optic nerve sheath diameters (ONSD) have been validated as an accurate screening tool to detect elevated intracranial pressure in hypertensive encephalopathy. The neurologic manifestations of preeclampsia and/or eclampsia mimic those of hypertensive encephalopathy. This study was performed to assess the incidence of elevated optic nerve sheath diameters of patients with severe preeclampsia and neurologic criteria compared to non-preeclamptic patients. The secondary objective was to determine baseline optic nerve sheath diameters in patients with severe preeclampsia without neurologic criteria and preeclampsia without severe features. METHODS: Single site cohort study including 62 pregnant women 18 years or older and 20 weeks or further gestation. Patients with preeclampsia without severe features, preeclampsia with severe features by non-neurologic criteria, preeclampsia with severe features with neurologic criteria, and patients without preeclampsia were enrolled via convenience sampling. One blinded reviewer measured sheath diameters; baseline demographics and pregnancy data were collected by chart review. Statistical analysis was completed with STATA/IC 16. Categorical variables were compared by the χ2 test. Continuous variables were presented as mean ± standard deviation, and discrete variables were presented as medians and compared by Kruskal-Wallis testing. Normality was confirmed by Shapiro-Wilk testing. Linear and logistic regression were used to test the association between the preeclampsia groups and optic nerve sheath diameters. Models were presented as unadjusted and adjusted for BMI, gestation, hypertension, diabetes, parity, and gravidity. RESULTS: The incidence of optic nerve sheath diameters > 5.8 mm was 43.8% in the severe preeclampsia with neurologic features cohort, and 42.1% in the control cohort, with a relative risk of 1.04. Patients with severe preeclampsia without neurologic features had sheath diameters of 5.75 mm ± 1.09 mm; non-severe preeclampsia patients had sheath diameters of 5.54 mm ± 1.26 mm. CONCLUSIONS: We did not find a significant elevated optic nerve sheath diameter relative risk between severe preeclampsia patients with neurologic features and non-preeclampsia control patients. This is the first study to assess a North American population utilizing ACOG criteria for severe and non-severe preeclampsia, with severe cohorts additionally stratified by neurologic criteria.

Effect of Antibiotic Treatment of Amniotic Fluid Sludge.

BACKGROUND: Amniotic fluid sludge refers to the sonographic presence of echogenic, free-floating aggregates of debris located within the amniotic cavity near the internal cervical os of women with intact membranes. Clinically, it is independently associated with increased obstetric, infectious, and neonatal morbidity, including: short cervix, chorioamnionitis, and an increased risk of preterm birth. It is thought to be infectious in nature and has been described as an intrauterine bacterial biofilm. There is little evidence on the impact of treatment with antibiotics on outcome. OBJECTIVE: To determine whether outpatient antibiotics administered to women with amniotic fluid sludge would reduce preterm birth risk compared to no antibiotic treatment. MATERIALS AND METHODS: This was a retrospective cohort study of all patients diagnosed with amniotic fluid sludge by transvaginal sonography between 15 and 25 weeks' gestation in the outpatient ultrasound unit at a single academic center between 2010 and 2017. Patients were segregated according to whether they were treated with oral antibiotics at the time of diagnosis. Women with multiple gestation, fetal anomalies, preterm rupture of membranes prior to initial diagnosis of amniotic fluid sludge, and active preterm labor placenta previa and/or suspected accreta were excluded from analysis. Primary outcome of preterm birth at less than 37 weeks' gestation was compared by univariate and regression analysis to control for potential co-linear and/or confounding variables. Additional outcomes were compared by univariate analysis. RESULTS: A total of 181 patients were initially identified, and 97 patients met inclusion criteria. Of these patients, 51 were treated with oral antibiotics (46 azithromycin and 5 moxifloxacin), and 46 were not treated. The overall incidence of preterm birth at <37 weeks was 49.4 % (48 of 97) and preterm birth <28 weeks was 22.7% (22 of 97). There was no significant difference in preterm birth, either at <37 weeks (P = .47) or <28 weeks (P = .83) between the treated and untreated women. After adjusting for race, body mass index, tobacco use, cervical length, and preterm birth history, antibiotic treatment did not reduce the risk of preterm birth (adjusted odds ratio, 1.3; confidence interval, 0.77-1.9). No differences were seen in the incidence of preterm premature rupture of membranes (P = .94) or median latency from diagnosis to delivery (P = .47). Birthweight (P = .99), sepsis (P = .53), intraventricular hemorrhage (P = .95), and neonatal intensive care unit (NICU) admission (P = .08) were not affected by antibiotic treatment. Antibiotic treatment did not affect the incidence of either clinical or histologic chorioamnionitis (P = .92 and .14, respectively) or histologic stage 2-3 maternal or fetal inflammation (P = .94 and 0.58, respectively). Sonographic resolution of amniotic fluid sludge on first subsequent scan was seen in 34% of antibiotic-treated women and 43% of untreated women (P = .42). There was no difference in latency from diagnosis to delivery or mean gestational age at delivery according to whether sludge resolved or persisted at the first subsequent scan (P = .14 for each). CONCLUSION: Antibiotic treatment of amniotic fluid sludge is not associated with a reduction in premature birth. Likewise, antibiotic treatment of amniotic fluid sludge was not associated with improvement in other obstetric, neonatal, or pathologic variables. These findings suggest that the presumed infectious nature of sludge and subsequent adverse outcomes are not treated or improved by administration of azithromycin following midtrimester sonographic diagnosis.

D-transposition of the great arteries with right-sided pulmonary hypoplasia.

Unilateral pulmonary agenesis or aplasia (UPA) in combination with congenital heart defects is rare and has not been reported in connection with transposition of the great arteries. This case demonstrated dextroposition of the fetal heart, and subsequent scans could not clearly visualize the right pulmonary artery. UPA should be considered in the workup and counseling for a family in the setting of fetal heart malposition, as there is a significant clinical impact.

A comparison of placental pathology between small for gestational age infants at < 5 % versus 5-9.

INTRODUCTION: Among SGA newborns, those < 5th % for GA are more likely to have adverse outcomes than those at 5-9th %. The differential morbidity and mortality may be due to abnormal placental pathology between groups. Our purpose was to compare placental pathology characteristics and composite placental pathology among SGA infants with birth weights <5th % vs. 5-9th %. METHODS: This study is a secondary analysis of a multicenter, retrospective cohort study. Placental pathological variables and composite placental pathology (CPP) among SGA infants <5th % and 5-9th % were compared. Multivariable logistic regression was used to model the probability of an infant's birth weight being classified as <5th % based on pathology characteristics. RESULTS: Of 11,487 live singleton births, 925 SGA infants met inclusion criteria. Placental pathology was available for review in 407 (44 %) SGA infants: 210 (51.6 %) <5th % and 197 (48.4 %) 5-9th %. A decreased placental weight for GA, was more common in the <5th % group compared to the 5-9th % group (p = 0.0019). No significant differences in the distribution of pathological variables or in CPP (p = 0.3) was observed between the two centile groups. A decreased placental weight was the only reliable predictor of an infant's birth weight centile group (p = 0.0018). CONCLUSIONS: Placental hypoplasia, reflected by a decreased placental weight for GA, was significantly more common among SGA infants < 5th % compared to the 5-9th %. There was no difference in placental pathological features or CPP between the two centile groups of SGA infants.

Impact of dosing schedule on uptake of neuroprotective magnesium sulfate.

Background: Preterm delivery <32-week gestation is associated with significant neurodevelopmental morbidity ranging from mild delay to profound disability. Several randomized trials have shown that magnesium sulfate (MgSO4) is an effective neuroprotectant, demonstrating reduced rates of cerebral palsy, death, and gross motor dysfunction for the neonate or infant. Dosing was not consistent among the major trials and the onus was placed on institutions by ACOG to develop and implement protocols with respect to MgSO4 as a neuroprotectant. A recent study demonstrated that MgSO4 exposure <12 h prior to delivery was associated with a decrease in CP compared to more remote exposure.Objective: To assess impact of dosing schedule on uptake of neuroprotective MgSO4 in patients delivering <32 weeks gestational age.Study design: A retrospective cohort study of all deliveries occurring <32 weeks' gestation at a single academic center between March-December 2014 and March-December 2015 was conducted. Institutional policy shifted in 2015 from MgSO4 bolus with continuous infusion based on the BEAM trial to a single bolus dose based on the PREMAG trial. Patients with preeclampsia, known fetal anomalies, and/or stillbirth were excluded from this analysis. Patients were identified through query of the Medical University of South Carolina Perinatal Information System (PINS) database with respect to whether or not they had received MgSO4 within 12 h of delivery. Chi-squared analysis was performed to compare the overall rate of MgSO4 exposure and MgSO4 exposure <12 h prior to delivery between groups. Fisher's exact test was used to evaluate maternal, obstetric, and neonatal variables among those receiving MgSO4 within 12 h of delivery in each cohort. Binary logistic regression analysis was performed to control for co-linear or potential confounding variables.Results: A total of 224 patients were identified, 115 delivered between March-December 2014 and 109 delivered between March-December 2015. With respect to MgSO4 exposure prior to delivery, 27 (23.5%) received MgSO4 in the 2014 cohort compared to 44 (40.4%) in the 2015 cohort (OR: 2.2, p < .01). Of those being exposed within 12 h of delivery, there were 16 (13.9%) maternal exposures in the 2014 cohort versus 28 (26.7%) in the 2015 cohort (OR: 2.15, p = .02). Of the 18 neonates delivered in 2014 there were four cases of grade III or IV intraventricular hemorrhage versus one case among the 36 neonates (2.7%) born in 2015 (0.04). This finding holds after controlling for race, preterm labor, gestational age, corticosteroid, birthweight, and indomethacin exposure.Conclusions: Dosing of neuroprotective MgSO4 according to PREMAG trial specifications was associated with a significantly greater percentage of patients having received neuroprotective magnesium at any point prior to delivery or within the 12 h prior to delivery when compared to dosing according to BEAM trial specifications.

Fetal and Neonatal Effects of N-Acetylcysteine When Used for Neuroprotection in Maternal Chorioamnionitis.

OBJECTIVE: To evaluate the clinical safety of antenatal and postnatal N-acetylcysteine (NAC) as a neuroprotective agent in maternal chorioamnionitis in a randomized, controlled, double-blinded trial. STUDY DESIGN: Twenty-two mothers >24 weeks gestation presenting within 4 hours of diagnosis of clinical chorioamnionitis were randomized with their 24 infants to NAC or saline treatment. Antenatal NAC (100 mg/kg/dose) or saline was given intravenously every 6 hours until delivery. Postnatally, NAC (12.5-25 mg/kg/dose, n = 12) or saline (n = 12) was given every 12 hours for 5 doses. Doppler studies of fetal umbilical and fetal and infant cerebral blood flow, cranial ultrasounds, echocardiograms, cerebral oxygenation, electroencephalograms, and serum cytokines were evaluated before and after treatment, and 12, 24, and 48 hours after birth. Magnetic resonance spectroscopy and diffusion imaging were performed at term age equivalent. Development was followed for cerebral palsy or autism to 4 years of age. RESULTS: Cardiovascular measures, cerebral blood flow velocity and vascular resistance, and cerebral oxygenation did not differ between treatment groups. Cerebrovascular coupling was disrupted in infants with chorioamnionitis treated with saline but preserved in infants treated with NAC, suggesting improved vascular regulation in the presence of neuroinflammation. Infants treated with NAC had higher serum anti-inflammatory interleukin-1 receptor antagonist and lower proinflammatory vascular endothelial growth factor over time vs controls. No adverse events related to NAC administration were noted. CONCLUSIONS: In this cohort of newborns exposed to chorioamnionitis, antenatal and postnatal NAC was safe, preserved cerebrovascular regulation, and increased an anti-inflammatory neuroprotective protein. TRIAL REGISTRATION: ClinicalTrials.gov: NCT00724594.

Diagnostic accuracy of fundal height and handheld ultrasound-measured abdominal circumference to screen for fetal growth abnormalities.

OBJECTIVE: We sought to compare fundal height and handheld ultrasound-measured fetal abdominal circumference (HHAC) for the prediction of fetal growth restriction (FGR) or large for gestational age. STUDY DESIGN: This was a diagnostic accuracy study in nonanomalous singleton pregnancies between 24 and 40 weeks' gestation. Patients underwent HHAC and fundal height measurement prior to formal growth ultrasound. FGR was defined as estimated fetal weight less than 10%, whereas large for gestational age was defined as estimated fetal weight greater than 90%. Sensitivity and specificity were calculated and compared using methods described elsewhere. RESULTS: There were 251 patients included in this study. HHAC had superior sensitivity and specificity for the detection of FGR (sensitivity, 100% vs 42.86%) and (specificity, 92.62% vs 85.24%). HHAC had higher specificity but lower sensitivity when screening for LGA (specificity, 85.66% vs 66.39%) and (sensitivity, 57.14% vs 71.43%). CONCLUSION: HHAC could prove to be a valuable screening tool in the detection of FGR. Further studies are needed in a larger population.

Placental Nkx2-5 and target gene expression in early-onset and severe preeclampsia.

OBJECTIVE: Preeclampsia (PE) affects 2-8% of pregnancies worldwide and is a significant source of maternal and neonatal morbidity and mortality. However, the mechanisms underlying PE are poorly understood and major questions regarding etiology and risk factors remain to be addressed. Our objective was to examine whether abnormal expression of the cardiovascular developmental transcription factor, Nkx2-5, was associated with early onset and severe preeclampsia (EOSPE). METHODS: Using qPCR and immunohistochemical assay, we examined expression of Nkx2-5 and target gene expression in EOSPE and control placental tissue. We tested resulting mechanistic hypotheses in cultured cells using shRNA knockdown, qPCR, and western blot. RESULTS: Nkx2-5 is highly expressed in racially disparate fashion (Caucasians > African Americans) in a subset of early EOSPE placentae. Nkx2-5 mRNA expression is highly correlated (Caucasians > African Americans) to mRNA expression of the preeclampsia marker sFlt-1, and of the Nkx2-5 target and RNA splicing factor, Sam68. Knockdown of Sam68 expression in cultured cells significantly impacts sFlt-1 mRNA isoform generation in vitro, supporting a mechanistic hypothesis that Nkx2-5 impacts EOSPE severity in a subset of patients via upregulation of Sam68 to increase sFlt-1 expression. Expression of additional Nkx2-5 targets potentially regulating metabolic stress response is also elevated in a racially disparate fashion in EOSPE. CONCLUSIONS: Expression of Nkx2-5 and its target genes may directly influence the genesis and racially disparate severity, and define a mechanistically distinct subclass of EOSPE.

Costs and clinical outcomes of noninvasive fetal RhD typing for targeted prophylaxis.

OBJECTIVE: To examine the cost and clinical outcomes of noninvasive RhD typing with cell-free fetal DNA to selectively deliver antenatal and postnatal prophylaxis with anti-D immune globulin for prevention of alloimmunization in RhD-negative women. METHODS: We developed a decision tree to compare the costs and clinical outcomes of three strategies in an RhD-negative nonalloimmunized population as follows: 1) routine antenatal anti-D immune globulin prophylaxis and postpartum prophylaxis guided by cord blood typing (the current approach in most of the United States); 2) noninvasive fetal RhD typing with prophylaxis guided by test results; and 3) no screening or prophylaxis. Costs were estimated for testing and treatment algorithms using hospital billing records and information from the manufacturer of the fetal RhD genotyping test. Probability estimates were derived from published literature. The decision tree and sensitivity analyses were constructed and performed with Microsoft Excel. RESULTS: We estimated the cost of the current approach to prevention of alloimmunization to be $351 per pregnancy, and we estimated the cost of noninvasive determination of fetal RhD status to be $682. Assuming essentially perfect test performance, threshold analysis found the cost must decrease to $119 to break even. The gap widened in favor of routine prophylaxis in most other circumstances (increased false-negative test rate and decreasing prevalence of RhD negativity). CONCLUSION: Unless the cost of noninvasive fetal RhD typing is reduced substantially, routine antenatal anti-D immune globulin prophylaxis with postpartum prophylaxis guided by cord blood typing is less costly than noninvasive determination of fetal RhD status.

N-acetylcysteine prevents preterm birth by attenuating the LPS-induced expression of contractile associated proteins in an animal model.

OBJECTIVE: Intrauterine infection is associated with maternal immune activation (MIA) leading to preterm birth through upregulation of contractile associated proteins (CAPs). We hypothesized that N-acetylcysteine would decrease NF-κB activation and CAP expression in a MIA model for preterm birth. METHODS: Pregnant CD-1 mice were given intrauterine LPS or saline on day 15/20. They received NAC or saline prior to injection and were monitored until delivery. The rate of preterm birth in the control, LPS, and LPS + NAC animals was determined. In another group, animals were sacrificed 6 h after treatment and myometrium was collected. COX-2, connexin 43, and oxytocin receptor expression was determined. RESULTS: LPS administration resulted in preterm birth and this effect was attenuated by NAC. LPS increased COX-2, connexin 43, and oxytocin receptor expression. NAC significantly decreased COX-2 expression. LPS increased NF-κB activation; this was attenuated by NAC. CONCLUSION: NAC may be beneficial in prevention of MIA-related preterm birth through attenuation of NF-κB activation and COX-2 upregulation.

N-acetylcysteine attenuates the maternal and fetal proinflammatory response to intrauterine LPS injection in an animal model for preterm birth and brain injury.

OBJECTIVE: Maternal immune activation (MIA) is associated with preterm birth (PTB) and abnormal neurologic outcome. We hypothesized that N-acetylcysteine (NAC) would decrease PTB and neonatal brain injury acting as an anti-inflammatory. METHODS: Pregnant CD-1 mice received intrauterine LPS or saline on day 15/20. They received NAC or saline and were monitored until delivery. Pups were followed and sacrificed on postnatal days 1/30 and brains were collected. Immunostaining for heavy-chain neurofilament protein (NF-H), myelin basic protein (MBP), and proteolipid protein (PLP) was performed. In another group, animals were sacrificed 6 h after treatment, and fetal brain, placenta, and myometrium were collected. Il-6, Il-1ß, Il-10, and tumor necrosis factor (TNF)-α mRNA expression was determined. Nonparametric analysis was used for analysis, and pairwise comparisons were performed when appropriate. RESULTS: Lipopolysaccharide (LPS) caused PTB (79 vs. 0%, p < 0.005), and this was reduced by NAC [0.45 (95% CI: 0.26-0.83), p < 0.008]. LPS increased IL-6 expression in myometrium and placenta. This was attenuated by NAC in myometrium. IL-1ß, IL-6, and TNF-α expression increased in the fetal brain with LPS. LPS produced altered NF-H, MBP, and PLP staining, and these effects were attenuated by NAC. CONCLUSION: NAC attenuates inflammation in this MIA model and reduces PTB and white matter injury. It is an interesting candidate for study for prevention of PTB and neurologic injury.

Examining the effect of maternal obesity on outcome of labor induction in patients with preeclampsia.

OBJECTIVE: The objective of this investigation was to evaluate the effect of maternal obesity, as measured by prepregnancy body mass index (BMI), on the mode of delivery in women undergoing indicated induction of labor for preeclampsia. STUDY DESIGN: Following Institutional Review Board (IRB) approval, patients with preeclampsia who underwent an induction of labor from 1997 to 2007 were identified from a perinatal information database, which included historical and clinical information. Data analysis included bivariable and multivariable analyses of predictor variables by mode of delivery. An artificial neural network was trained and externally validated to independently examine predictors of mode of delivery among women with preeclampsia. RESULTS: Six hundred and eight women met eligibility criteria and were included in this investigation. Based on multivariable logistic regression (MLR) modeling, a 5-unit increase in BMI yields a 16% increase in the odds of cesarean delivery. An artificial neural network trained and externally validated confirmed the importance of obesity in the prediction of mode of delivery among women undergoing labor induction for preeclampsia. CONCLUSION: Among patients who are affected by preeclampsia, obesity complicates labor induction. The risk of cesarean delivery is enhanced by obesity, even with small increases in BMI. Prediction of mode of delivery by an artificial neural network performs similar to MLR among patients undergoing labor induction for preeclampsia.

Combination of microsatellite instability and lymphocytic infiltrate as a prognostic indicator for adjuvant therapy in colon cancer.

BACKGROUND: Microsatellite instability (MSI) and lymphocytic infiltrate (LI) in colon cancer are associated with less aggressive biological characteristics. Patients with stage II disease who are negative for MSI and LI have been found to have a less favorable prognosis. These patients may be candidates for more aggressive adjuvant therapy. OBJECTIVE: To evaluate the outcomes of patients with colon cancer treated with and without adjuvant chemotherapy on the basis of stage, MSI, and LI. DESIGN: Prospective evaluation of MSI and LI status with retrospective analysis of chemotherapy regimen. SETTING: Community hospital system. PATIENTS: A total of 167 patients with colon cancer. INTERVENTION: Definitive resection of colorectal cancer with or without chemotherapy. Main Outcome Measure Disease-free survival (DFS) with and without chemotherapy according to combined MSI and LI status. RESULTS: Data on MSI and LI status and chemotherapeutic regimens were available for 140 patients. The 5-year DFS was 50% for patients with stage II disease who underwent chemotherapy vs 76% for those who did not (P = .02). In the group negative for MSI and LI, 5-year DFS was 29% for those undergoing chemotherapy and 91% for those who did not (P = .001). CONCLUSIONS: Forgoing adjuvant chemotherapy should be considered in patients with stage II colon cancer who are negative for MSI and LI. The MSI and LI status shows promise as a combined prognostic marker and may prove particularly useful in selecting patients with stage II disease for adjunctive therapy.

Combination of microsatellite instability and lymphocytic infiltrate as a prognostic indicator in colon cancer.

BACKGROUND: Microsatellite instability (MSI) is a genetic aberration associated with less aggressive tumor biology. Some tumors with MSI also have lymphocytic infiltrate (LI), which suggests a heightened immune response against the tumor. OBJECTIVE: To evaluate the combined prognostic significance of MSI and LI in a colon cancer population. DESIGN: Colon cancers were prospectively evaluated for MSI by assessing 11 satellite markers and were classified as MSI+ if 2 or more satellite markers displayed instability. Tumors were classified as LI+ if at least 5 lymphocytes were observed per 10 high-power fields. SETTING: Community hospital system. PATIENTS: Individuals undergoing definitive surgery for colon cancer. MAIN OUTCOME MEASURES: Overall and disease-free survival were compared according to combined MSI and LI status. RESULTS: In 150 patients, tumors were classified as follows: 95 were MSI-/LI-, 9 were MSI-/LI+, 30 were MSI+/LI-, and 16 were MSI+/LI+. Median follow-up was 40.6 months. Five-year disease-free survival was 56.7% for patients with MSI-/LI- tumors and 88.9% for those with MSI+/LI+ tumors (P = .01). Patients with MSI+/LI- and MSI-/LI+ tumors had 5-year survival of 75.4% and 75.0%, respectively. CONCLUSIONS: Patients with colon cancer and MSI-/LI- tumors have worse disease-free survival rate regardless of stage at diagnosis. Patients exhibiting both MSI+ and LI+ tumors have more favorable disease-free survival rates. Both MSI and LI show promise as a combined prognostic marker and with further study may prove to be particularly useful in selecting patients with stage II disease for adjunctive therapy.

Duplex criteria for native superior mesenteric artery stenosis overestimate stenosis in stented superior mesenteric arteries.

OBJECTIVES: Superior mesenteric artery (SMA) duplex scanning is utilized to screen for high-grade (>or=70%) SMA stenosis (peak systolic velocity [PSV] >or=275 cm/second) and for follow-up of SMA bypass grafts and stents. Expected duplex scan findings in SMA bypass grafts have been recently reported. There is, however, little information correlating duplex scans from stented SMAs to procedural angiograms in patients treated for high-grade (>or=70%) SMA stenosis. We report validation of duplex scan criteria for high-grade native artery SMA stenosis, and also duplex scan examined results after SMA stent placement correlated with angiograms and angiographic measured pressure gradients pre- and post-SMA stent placement. METHODS AND RESULTS: Thirty-five patients with symptoms consistent with mesenteric ischemia were treated with SMA stents. Pre-intervention angiography demonstrated >70% SMA stenosis or SMA occlusion in all but 3 patients. Pre-intervention pressure gradients were obtained in 20 stenotic but patent SMAs and averaged 57 +/- 38 mm Hg; range, 15 to 187 mm Hg. Eighteen of the patients had SMA duplex scan prior to angiography, and 17 demonstrated an SMA PSV >or=275 cm/second or no flow, (mean 450 +/- 152 cm/second in patent arteries; range, 256 to 770 cm/second). Post-stent placement angiography demonstrated <30% SMA stenosis in all 35 patients. Post-stent pressure gradients were obtained in 22 patients and averaged 11 +/- 13 mm Hg; range, 0 to 45 mm Hg, (P < .001 compared to pre-stent pressure gradients in a paired test) and were elevated in patients with >or=60% celiac artery stenosis compared with those with <60% celiac artery stenosis (P < .006). Mean early post-stent duplex PSV scans obtained in 13 patients, were 336 +/- 45 cm/second; range, 279 to 416 cm/second (P = .011 compared to pre-stent PSVs). CONCLUSION: SMA stenting provides good anatomic results and significantly reduces measured pressure gradients. Duplex scans measured SMA PSVs are reduced post-stent placement but despite good angiographic results remain above criteria predicting high-grade native artery SMA stenosis. Duplex scan criteria developed to identify high-grade native artery SMA stenosis accurately predict high-grade native artery SMA stenosis but overestimate stenosis in stented SMAs. New duplex scan criteria are required to predict high-grade stenosis in stented SMAs.

The use of blunt needles does not reduce glove perforations during obstetrical laceration repair.

OBJECTIVE: The objective of the study was to compare the rate of glove perforation for blunt and sharp needles used during obstetrical laceration repair. A secondary aim was to assess physician satisfaction with blunt needles. STUDY DESIGN: This was an institutional review board-approved, randomized, prospective trial. Patients with obstetric lacerations were randomized to repair with either blunt or sharp needles. Patient demographics, operator experience, and other clinical variables were collected. Physicians reported any percutaneous injuries and were surveyed regarding satisfaction with the assigned needles. Glove perforation was determined using a validated water test method. RESULTS: There were 438 patients enrolled in the trial: 221 in the control group and 217 in the study group. There was no statistical difference between groups in patient demographics, clinical variables, severity of laceration, or experience level of the surgeon. There was no difference in the glove perforation rate between blunt and sharp needles (risk ratio, 0.79; 95% confidence interval, 0.2-2.95). There was poor correlation between reported perforations and those detected by water test (R(2) = 0.33). The physicians reported that blunt needles were more difficult to use than sharp needles (P = .0001). CONCLUSION: There was no difference in the rate of surgical glove perforation for blunt, compared with sharp, needles used during vaginal laceration repair. Physicians also reported increased difficulty performing the repair with blunt needles.

The evaluation of esophageal adenocarcinoma using dynamic contrast-enhanced magnetic resonance imaging.

Although neoadjuvant chemoradiation eradicates esophageal adenocarcinoma in a substantial proportion of patients, conventional imaging techniques cannot accurately detect this response. Dynamic contrast-enhanced magnetic resonance imaging is an emerging approach that may be well suited to fill this role. This pilot study evaluates the ability of this method to discriminate adenocarcinoma from normal esophageal tissue. Patients with esophageal adenocarcinoma and control subjects underwent scanning. Patients treated with neoadjuvant therapy underwent pre- and postchemoradiation scans. Parameters were extracted for each pixel were Ktrans (equilibrium rate for transfer of contrast reagent across the vascular wall), ve (volume fraction of interstitial space), and taui (mean intracellular water lifetime). Five esophageal adenocarcinoma patients and two tumor-free control subjects underwent scanning. The mean Ktrans value was 5.7 times greater in esophageal adenocarcinoma, and taui is 2.0 times smaller, than in the control subjects. Ktrans decreased by 11.4-fold after chemoradiation. Parametric maps qualitatively demonstrate a difference in Ktrans. DCE MRI of the esophagus is feasible. Ktrans, a parameter that has demonstrated discriminative ability in other malignancies, also shows promise in differentiating esophageal adenocarcinoma from benign tissue. The determination of Ktrans represents an in vivo assay for endothelial permeability and thus may serve as a quantitative measure of response to induction chemoradiation.

Second-trimester angiogenic factors as biomarkers for future-onset preeclampsia.

OBJECTIVE: The purpose of this study was to determine whether second-trimester soluble fms-like tyrosine kinase-1 and placenta growth factor (PlGF) are altered in patients who have preeclampsia develop compared with controls. Furthermore, soluble fms-like tyrosine kinase-1 and placenta growth factor levels in patients with chronic hypertension are described. STUDY DESIGN: With the use of a research database, 21 patients who had severe preeclampsia develop, 34 controls, and 9 patients with chronic hypertension were enrolled. Placenta growth factor and soluble fms-like tyrosine kinase-1 serum levels were determined by enzyme-linked immunosorbent assay. Appropriate statistical tests were used and results were reported as median (quartile 1-quartile 3) in picograms per milliliter. RESULTS: Placenta growth factor was significantly lower in patients in the second trimester who later had severe preeclampsia develop but soluble fms-like tyrosine kinase-1 was unchanged compared with healthy pregnancies. In patients with chronic hypertension, placenta growth factor and soluble fms-like tyrosine kinase-1 levels were not different compared with controls. CONCLUSION: Second-trimester placenta growth factor levels are altered in patients who had severe preeclampsia develop.

The effect of antireflux surgery on esophageal carcinogenesis in patients with barrett esophagus: a systematic review.

OBJECTIVE: To determine whether patients with Barrett esophagus who undergo antireflux surgery differ from medically treated patients in incidence of esophageal adenocarcinoma and probability of disease regression/progression. SUMMARY BACKGROUND DATA: Barrett esophagus is a risk factor for the development of esophageal adenocarcinoma. A question exists as to whether antireflux surgery reduces this risk. METHODS: Query of PubMed (1966 through October 2005) using predetermined search terms revealed 2011 abstracts, of which 100 full-text articles were reviewed. Twenty-five articles met selection criteria. A review of article references and consultation with experts revealed additional articles for inclusion. Studies that enrolled adults with biopsy-proven Barrett esophagus, specified treatment-type rendered, followed up patients with endoscopic biopsies no less than12 months of instituting therapy, and provided adequate extractable data. The incidence of adenocarcinoma and the proportion of patients developing progression or regression of Barrett esophagus and/or dysplasia were extracted. RESULTS: In surgical and medical groups, 700 and 996 patients were followed for a total of 2939 and 3711 patient-years, respectively. The incidence rate of esophageal adenocarcinoma was 2.8 (95% confidence interval, 1.2-5.3) per 1000 patient-years among surgically treated patients and 6.3 (3.6-10.1) among medically treated patients (P = 0.034). Heterogeneity in incidence rates in surgically treated patients was observed between controlled studies and case series (P = 0.014). Among controlled studies, incidence rates were 4.8 (1.7-11.1) and 6.5 (2.6-13.8) per 1000 patient-years in surgical and medical patients, respectively (P = 0.320). Probability of progression was 2.9% (1.2-5.5) in surgical patients and 6.8% (2.6-12.1) in medical patients (P = 0.054). Probability of regression was 15.4% (6.1-31.4) in surgical patients and 1.9% (0.4-7.3) in medical patients (P = 0.004). CONCLUSIONS: Antireflux surgery is associated with regression of Barrett esophagus and/or dysplasia. However, evidence suggesting that surgery reduces the incidence of adenocarcinoma is largely driven by uncontrolled studies.