Correction of fetal umbilical vein flow imbalance following laser surgery for twin-twin transfusion syndrome.

OBJECTIVES: Twin-twin transfusion syndrome (TTTS) is characterized by unequal hemodynamics between the twins. We aimed to assess preoperatively the difference in umbilical vein flow (UVF) between the recipient and donor monochorionic diamniotic twins and evaluate the change in UVF following laser surgery in both twins. METHODS: This was a retrospective cohort study of differences in UVF that occurred following laser surgical treatment of TTTS. Sonographic assessment of the umbilical vein before and 24 h after fetoscopic laser surgery for TTTS was performed. Umbilical vein diameter and time-averaged maximum velocity were measured, and UVF per kg (UVF/kg) was converted into a Z-score by a calculator created using gestational age as an independent variable. Z-score values were converted into centiles, which were evaluated statistically. Median differences in UVF/kg centile values were adjusted for TTTS stage and presence of arterioarterial anastomoses. RESULTS: The study population consisted of 363 TTTS patients. The adjusted preoperative median difference in UVF/kg centile between the recipient vs donor twin was 17.9% (-17.1% to 57.6%), P < 0.0001. The adjusted median difference in UVF/kg centile between the postoperative vs preoperative period among recipients was 2.2% (-10.8% to 13.8%), P < 0.0001, while the adjusted median difference among donors was 27.3% (8.2%-34.6%), P < 0.0001. CONCLUSION: The preoperative difference in UVF between the recipient and donor twins confirms the pathophysiology of TTTS. Postoperatively, the substantial increase in UVF of the donor twin and the relatively small increase in UVF of the recipient twin confirm that ablation of the vascular communications resulted in rapid improvement in perfusion of the donor twin. © 2022 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Patient and procedural risk factors for increased postoperative pain after cesarean delivery under neuraxial anesthesia: a retrospective study.

BACKGROUND: There is significant interindividual variability in pain experienced after cesarean delivery. The goal of this study was to identify risk factors for increased postoperative pain in women undergoing cesarean delivery under neuraxial anesthesia with neuraxial morphine. METHODS: A retrospective chart review was conducted (June 1, 2013 to August 25, 2015). Patients were categorized into three groups, according to the weighted area-under-the-curve (AUC) of pain scores within 48 h of surgery, as mild (weighted AUC 0-3), moderate (4-6) or severe (7-10) pain. We evaluated potential factors that could influence variability in pain, including patient demographics, comorbidities, obstetric history, and surgical details. RESULTS: A total of 1899 patients were included in the analysis. Pain was mild in 896 patients, moderate in 895, and severe in 108 patients. In the multivariable analysis, the following factors were associated with increased pain severity: history of chronic pain (OR 4.12, 95% CI 1.15 to 14.75]), current tobacco use (2.52, 1.17 to 5.44), pre-existing anxiety (1.93, 1.21 to 3.07), receipt of intra-operative intravenous ketamine or fentanyl (1.56, 1.21 to 2.01), and repeat cesarean delivery (1.54, 1.18 to 2.02). Being of non-Black race and having private health insurance were associated with lower pain severity (OR 0.44, 95% CI 0.31 to 0.62 and 0.51, 0.39 to 0.68, respectively). The overall accuracy of the model was 56%. CONCLUSIONS: Certain patient and procedural factors were associated with higher levels of reported postoperative pain. Patients with those factors may require a more targeted analgesic strategy for post-cesarean delivery pain control.

Diversidad florística del bosque seco tropical en las subregiones bajo y medio Sinú, Córdoba, Colombia

Introducción: El bosque seco tropical (Bs-T) es uno de los ecosistemas más amenazados, en Colombia, presenta la mayor extensión en la región Caribe, está sometido a continua transformación, que ha ocasionado la disminución de su cobertura. Objetivo: Caracterizar la diversidad florística en términos de composición y estructura en seis fragmentos de Bs-T en las subregiones bajo y medio Sinú del Departamento de Córdoba. Métodología: Se siguió la metodología de Parcelas de Muestreo Rápido de Vegetación - RAP modificada. Se determinó la riqueza y abundancia, el Índice de valor de Importancia por especie y por familia,se construyeron clases diamétricas y altimétricas y se calculó el Índice de Diversidad α de Fisher e Índice de Similaridad de Sørensen. Resultados: Se registraron 1 336 individuos, agrupados en 68 familias, 161 géneros y 273 especies en el medio Sinú y 2 178 individuos (226 especies/151 géneros/59 familias) en el bajo Sinú. Las familias más importantes por riqueza de especies fueron: Fabaceae, Rubiaceae y Bignoniaceae, los mayores valores de abundancia se presentaron en Fabaceae, Capparaceae y en las especies: Astronium graveolens Jacq.y Capparidastrum frondosum (Jacq.) Cornejo & Iltis. La distribución por clases diamétricas y altimétricas presentó un comportamiento de J invertida. Los arbustos representaron el hábito de crecimiento dominante. Attalea butyracea (Mutis ex L.f.) Wess.Boer, Cavanillesia platanifolia (Humb. & Bonpl.) y Sterculia apetala Sterculia apetala (Jacq.) H.Karst. registraron los mayores valores de importancia. Conclusiones: Los bosques estudiados presentaron la composición florística que caracteriza el Bs-T en Colombia. La información obtenida contribuye a la gestión integral del bosque seco en Córdoba.

Introduction: The Tropical Dry Forest (TDF) is one of the most threatened ecosystems, in Colombia it has the greater extension in the Caribbean region, undergoing continuous transformation, causing the reduction of its coverage. Objective: To characterize the floristic diversity in terms of composition and structure in six TDF fragments in the lower and middle Sinú subregions of the Department of Córdoba. Methods: The methodology of Rapid Vegetation Sampling Plots - modified RAP was followed. Wealth and abundance were determined, The Importance Value Index by species and family, diametric and altimetric classes were constructed and the Fisher's α Diversity Index and Sørensen´s Similarity Index were calculated. Results: 1 336 individuals were registered, grouped into 68 families, 161 genera and 273 species in the middle Sinú and 2 178 individuals (226 species / 151 genera / 59families) in the lower Sinú. The most important families by species richness were Fabaceae, Rubiaceae and Bignoniaceae, the highest abundance values were found in Fabaceae, Capparaceae and in the species Astronium graveolens Jacq. and Capparidastrum frondosum (Jacq.) Cornejo & Iltis. The distribution by diametric and altimetric classes presented an inverted J behavior. The bushes represented the dominant growth habit. Attalea butyracea (Mutis ex L.f.) Wess.Boer, Cavanillesia platanifolia (Humb. & Bonpl.) Kunth and Sterculia apetala (Jacq.) H.Karst. recorded the highest values of importance. Conclusions: The forests studied presented the floristic composition that characterizes the TDF in Colombia. The information obtained contributes to the integral management of the Tropical Dry Forest in Córdoba.

Fludarabine-based reduced intensity regimen for matched related donor hematopoietic stem cell transplantation in acquired severe aplastic anemia.

Different conditioning regimens have been evaluated in matched-related donor allogeneic hematopoietic stem cell transplantation (allo-HSCT) for acquired severe aplastic anemia (SAA) with varying results. In this manuscript, we report our experience with fludarabine (120mg/m2), very low dose cyclophosphamide (1200mg/m2) and antithymocyte globulin (7.5mg/kg). Low dose total body irradiation (2Gy) was added to the conditioning regimen for patients older than 15 years. Nineteen patients (median age 23years) underwent transplant between 2008 and 2015. The majority (89%) were younger than 40 years. Stem cell source was BM (n=11) or PBSC (n=8). GvHD prophylaxis consisted of cyclosporine and either a short course of methotrexate (n=9) or mycophenolate mofetil (n=10). Eighteen (94.7%) patients achieved sustained engraftment. The median times to neutrophil and platelet engraftments were 19 (range: 14-34) and 17.1 (range: 12-25) days, respectively. The day-30 cumulative incidence of neutrophil and platelet engraftment was 89.4% and 94.7%, respectively. No secondary graft rejection was observed. The 1-year cumulative incidence of aGvHD (grade II-IV) and cGvHD was 11.7% and 0%, respectively. The 2-year GvHD-free survival rate was 78.6% (95% CI: 52.5-91.4%). Fludarabine-based reduced intensity regimen for MRD allo-HSCT in SAA compares favorably to other available regimens. This regimen deserves further investigations with larger cohort of patients.

Complete heart block in a patient with acute lymphoblastic leukaemia: teicoplanin as a possible cause and review of literature.

WHAT IS KNOWN AND OBJECTIVE: Teicoplanin is a glycopeptide antibiotic used against documented or presumed methicillin-resistant infections. We report a 31-month-old boy with acute lymphocytic leukaemia who developed permanent complete atrioventricular block (CAVB) necessitating pacemaker insertion after receiving teicoplanin for Staphylococcus epidermidis bacteremia. CASE SUMMARY: Clinical assessment of the child revealed febrile neutropenia. After thorough assessment and work-up, the patient was started on teicoplanin intravenously after which he had sudden onset of bradycardia. Electrocardiography showed CAVB that eventually required permanent pacemaker insertion. Twenty-nine months from the incident, the patient is doing well. WHAT IS NEW AND CONCLUSION: We report on a case of teicoplanin-associated CAVB in a child with acute lymphoblastic leukaemia (ALL). This is one of only two similar cases reported in the literature. Teicoplanin remains the most probable cause. The use of teicoplanin should be approached cautiously in the setting of immunosuppression. Whether VZV contributed and teicoplanin triggered remains speculative. Physicians should be aware of this possible complication.

Zinc and biotin deficiencies after pancreaticoduodenectomy.

We report zinc and biotin deficiencies after pancreaticoduodenectomy in a 16 year old female presenting clinically with marked alopecia, total body hair loss, dry skin with scales, and maculopathy with significant vision loss. These micronutrient deficiencies likely occurred due to resection of the duodenum and proximal jejunum, sites of primary absorption of several micronutrients and their protein carriers, including zinc and biotin. Early diagnosis is essential to prevent irreversible sequelae. Adequate supplementation of zinc and biotin as well as dietary advice is needed for clinical improvement.

Wernicke's encephalopathy during total parenteral nutrition in a child with acute lymphoblastic leukemia and acute pancreatitis.

We herein describe a 16-year-old child with acute lymphoblastic leukemia and acute pancreatitis who developed Wernicke's encephalopathy secondary to prolonged total parenteral nutrition (TPN) that lacked vitamin B1 supplementation. The patient showed a direct and complete response to thiamine therapy. Diagnostic challenges are discussed and recommendations for prophylactic vitamin B1 supplementation in children with leukemia who are placed on TPN are made.

Cortical muscle coupling in Parkinson's disease (PD) bradykinesia.

OBJECTIVES: To determine if novel methods establishing patterns in EEG-EMG coupling can infer subcortical influences on the motor cortex, and the relationship between these subcortical rhythms and bradykinesia. BACKGROUND: Previous work has suggested that bradykinesia may be a result of inappropriate oscillatory drive to the muscles. Typically, the signal processing method of coherence is used to infer coupling between a single channel of EEG and a single channel of rectified EMG, which demonstrates 2 peaks during sustained contraction: one, approximately 10 Hz, which is pathologically increased in PD, and a approximately 30 Hz peak which is decreased in PD, and influenced by pharmacological manipulation of GABAA receptors in normal subjects. MATERIALS AND METHODS: We employed a novel multiperiodic squeezing paradigm which also required simultaneous movements. Seven PD subjects (on and off L-Dopa) and five normal subjects were recruited. Extent of bradykinesia was inferred by reduced relative performance of the higher frequencies of the squeezing paradigm and UPDRS scores. We employed Independent Component Analysis (ICA) and Empirical Mode Decomposition (EMD) to determine EEG/EMG coupling. RESULTS: Corticomuscular coupling was detected during the continually changing force levels. Different components included those over the primary motor cortex (ipsilaterally and contralaterally) and over the midline. Subjects with greater bradykinesia had a tendency towards increased approximately 10 Hz coupling and reduced approximately 30 Hz coupling that was erratically reversed with L-dopa. CONCLUSIONS: These results suggest that lower approximately 10 Hz peak may represent pathological oscillations within the basal ganglia which may be a contributing factor to bradykinesia in PD.

Kinetics of lipopolysaccharide clearance by Kupffer and parenchyma cells in perfused rat liver.

We studied the kinetics of [3H]lipopolysaccharide ([3H]LPS) (endotoxin) binding to Kupffer cells and hepatocytes at the level of the microtubular system after treatment with gadolinium chloride (GdCl(3)) and colchicine. Liver perfusion in Sprague-Dawley rats involves both portal vein and thoracic inferior vena cava cannulations as inlet and outlet, respectively. The subhepatic inferior vena cava is ligated to prevent perfusate leakage. Buffer containing 2% serum and [3H]LPS is administered at 1 ml/min and collected for 50 min. Rate constants for hepatocellular clearance of [3H]LPS in controls, colchicine-treated rats, GdCl(3)-treated rats, and colchicine plus GdCl(3)-treated rats are assessed using a simplified mathematical model. Forward-binding, reversal-binding, residency time, and influx rate constants are estimated. Results show that in GdCl(3)-treated rats, the hepatocytes effectively clear endotoxin from the circulation, and its ultimate binding affinity at the hepatocyte site is somewhat reduced compared to the Kupffer cells. In colchicine-treated rats, the disruption of the microtubule network altered [3H]LPS binding with Kupffer cells, suggesting that the microfilament-microtubular network also affects Kupffer cell function. Simultaneous treatments with colchicine and GdCl(3) increased the influx rate constant, suggesting that the compiled morphological alterations up-regulated endotoxin clearance by the liver, as indicated by a drastic increase in cellular vacuolation. In conclusion, the kinetics of the trafficking process of [3H]LPS clearance are regulated by apical-sinusoidal endocytotic and canalicular routes.

Successful use of intravenous immunoglobulin as initial monotherapy in Landau-Kleffner syndrome.

PURPOSE: There is a need for new and more effective therapies for Landau-Kleffner syndrome. In this article we present the first case in which a patient with Landau-Kleffner syndrome was given intravenous immunoglobulin (IVIG) as his first and only therapy and responded to it. METHODS: This previously healthy, left-handed boy presented at 31 months of age with a 3-month history of auditory agnosia, behavioral abnormalities, and progressive, eventually complete loss of speech. Electroencephalography (EEG) showed frequent and, in sleep, continuous right central and temporal spike slow wave discharges. Metabolic workup, magnetic resonance imaging, and auditory evoked potentials were normal. Cerebrospinal fluid IgG index was high (18%). The patient was treated with IVIG, as his initial and only therapy, receiving 500 mg/kg/day over four consecutive days. RESULTS: On the third day of IVIG, the patient started using single words, and on the fourth, two-word sentences. Two weeks later his speech and behavior returned to normal. At the end of 4 days of IVIG therapy, EEG was within normal limits. Two months later, however, he had a severe relapse clinically and by EEG. He promptly responded to another course of IVIG. A subsequent cerebrospinal fluid IgG index showed normalization (6%). Three months later he had essentially normal speech and behavior. CONCLUSIONS: Repeated, immediate, and remarkable clinical and EEG responses of this patient suggest that IVIG was helpful as first-line therapy in the treatment of Landau-Kleffner syndrome. It also supports the hypothesis that immunological mechanisms contributed to his symptoms.