EXIT procedure in twin pregnancy: a series of three cases from a single center.

BACKGROUND: Indications for the ex utero intrapartum therapy (EXIT) procedure have evolved and nowadays in addition to secure the airway, obtain vascular access, administer surfactant and other resuscitation medications, EXIT is used to resect cervical or thoracic masses, for extracorporeal membrane circulation (ECMO) cannulation, as well as to rescue maximum intra-thoracic space for ventilation of the remaining functional lung tissue or in cases in which resuscitation of the neonate may be compromised. EXIT procedure in twin pregnancy has been rarely reported and some doubts have been raised about its strategy and safety in such cases. METHODS: We reviewed the medical records of 3 twin pregnancy cases where the EXIT procedure have been performed in our center. RESULTS: The mean gestational age at EXIT procedure was 34 + 4 weeks. In two out the three EXIT procedures, the affected twin was delivered first. The average time on placental bypass was 9 minutes. There were no fetal or maternal complications related to the EXIT procedure. All newborns are currently doing well. CONCLUSION: In twin pregnancies, prenatal diagnosis combined with the EXIT procedure permits the formulation of a controlled delivery strategy to secure both newborns outcome. In those pregnancies, if intervention can be accomplished without compromise of the normal twin, EXIT can be considered. Our results support that EXIT procedure, if properly planned, safely provides a good outcome for both the fetuses as well as the mother.

Data-Driven Visual Performance Analysis in Soccer: An Exploratory Prototype.

In soccer, understanding of collective tactical behavior has become an integral part in sports analysis at elite levels. Evolution of technology allows collection of increasingly larger and more specific data sets related to sport activities in cost-effective and accessible manner. All this information is minutely scrutinized by thousands of analysts around the globe in search of answers that can in the long-term help increase the performance of individuals or teams in their respective competitions. As the volume of data increases in size, so does the complexity of the problem and the need for suitable tools that leverage the cognitive load involved in the investigation. It is proven that visualization and computer-vision techniques, correctly applied to the context of a problem, help data analysts focus on the relevant information at each stage of the process, and generally lead to a better understanding of the facts that lie behind the data. In the current study, we presented a software prototype capable of assisting researchers and performance analysts in their duty of studying group collective behavior in soccer games and trainings. We used geospatial data acquired from a professional match to demonstrate its capabilities in two different case studies. Furthermore, we successfully proved the efficiency of the different visualization techniques implemented in the prototype and demonstrated how visual analysis can effectively improve some of the basic tasks employed by sports experts on their daily work, complementing more traditional approaches.

Kluyvera meningitis in a newborn.

Kluyvera is described infrequently in association with clinically significant infections in humans. It can produce a wide range of clinically significant manifestations. We describe a newborn with ventriculoperitoneal shunt, who was successfully treated for Kluyvera meningitis. We believe that this is the first case of Kluyvera central nervous system infection reported in a child.

Serum levels of insulin-like growth factor-I in relation to organochlorine pesticides exposure.

CONTEXT: Insulin-like growth factor 1 (IGF-I) and organochlorine pesticides (OCs) have been involved in the pathogenesis of several diseases like cancer, diabetes and growth disorders. OBJECTIVE AND DESIGN: The potential relationship between the serum levels of various OCs and serum IGF-I was investigated in adults (176 men and 247 women) from a representative sample of the general population of the Canary Islands (Spain). RESULTS: After adjustment for potential confounders, which include body mass index, age, and IGF-binding protein-3 (IGFBP-3), IGF-I levels were significantly lower in the 247 women who showed detectable levels of p,p'-DDD (a DDT-metabolite) than in women who presented non-detectable levels of this pesticide (p=0.030), specially in 36-50 years old women. A similar negative relationship was also found between IGF-I and aldrin (a non-DDT-derivative) in women (p=0.049). In the group of 176 men, aldrin seemed to exert a similar negative effect on IGF-I (p=0.046) and this effect was clearly significant in the oldest group (51-65 years) (p=0.009). A non-linear dose-response curve was observed between Total Cyclodienes Body Burden (Total Cyclodienes; sum of aldrin, dieldrin and endrin) and IGF-I in men (p=0.024). These findings suggest that OCs could modulate the IGF-system in a way that is highly influenced by gender, age and by chemical or combination of chemicals implicated. Such circumstances may contribute to the development of a number of diseases related to IGF-I and should be taken into account in public health decisions.

[Limitations of myocardial blush grade in the evaluation of myocardial perfusion in patients with acute myocardial infarction and TIMI grade 3 flow]. / Limitaciones del blush miocárdico para el análisis de la perfusión miocárdica en pacientes con infarto agudo de miocardio y flujo TIMI 3.

INTRODUCTION AND OBJECTIVES: An analysis was made of variability in the measurement of the angiographic index blush between a university hospital and an independent core laboratory, as well as its correlation with perfusion analyzed by intracoronary myocardial contrast echocardiography (MCE) and the ventricular function at the sixth month. METHODS: The study comprised 40 patients with a first ST-segment elevation myocardial infarction, single-vessel disease and open infarct-related artery. Perfusion was quantified by angiography (median fifth day, range 3-7) with blush in our laboratory and in an independent core laboratory. MCE was performed. Ejection fraction at the sixth month was determined with magnetic resonance imaging. RESULTS: We found a weak correlation (r=0.38) between both laboratories. In the comparison of blush measurements concordance was 80%, kappa=0.43 if normality was defined by blush 2-3; and concordance 55%, kappa=0.1 for blush 3. Neither perfusion analyzed by MCE (r= 0.23, P=.2) nor ejection fraction by resonance (r=0.20, P=.3) did correlate to blush. CONCLUSIONS: After infarction in patients with TIMI 3, variability is observed in blush measurements between a university hospital and an independent core laboratory, therefore it seems advisable to centralize blush measures in highly specialized core laboratories. A weak correlation was detected with perfusion analyzed by MCE and with late systolic function.

BKViz: A Basketball Visual Analysis Tool.

The amount of data available in the sports field is difficult for coaches, analysts, and players to comprehend using classic analytics methods. Thus, new methods are necessary to help users break down that information and analyze it at a deeper level. The BKViz visual analytics system focuses on individual basketball games using classic and novel methods to reveal how players perform together and as individuals. The information is presented in interactive visualizations that allow immediate user feedback.

Significance of exercise-induced ST segment elevation in Q leads in patients with a recent myocardial infarction and an open infarct-related artery Analysis with angiography, intracoronary myocardial contrast echocardiography and cardiac magnetic resonance.

AIMS: The significance of exercise-induced ST segment elevation in Q leads in patients with a recent myocardial infarction and without significant residual stenosis in the infarct-related artery has not been defined. We aimed to elucidate the role of myocardial perfusion and viability in this scenario. METHODS AND RESULTS: Sixty-six patients with a first myocardial infarction, single-vessel disease and an open artery were studied. Myocardial perfusion was assessed with angiographic blush, intracoronary myocardial contrast echocardiography and magnetic resonance. Myocardial viability was quantified by means of magnetic resonance (transmural extent of necrosis). Exercise-induced ST elevation in Q leads was observed only in 13 cases (20%); 53 patients (80%) did not show this finding. The group with ST elevation had fewer cases with normal perfusion: Blush 3 (15% vs. 74%, p=0.001), myocardial contrast echocardiography score >0.75 (8% vs. 81%, p=0.001) and magnetic resonance score >0.75 (31% vs. 68%, p=0.03). Similarly, myocardial viability (necrosis <50%) was less frequent in patients with ST elevation (8% vs. 72%, p=0.001). CONCLUSION: In patients with a first myocardial infarction and without residual ischemia, exercise-induced ST segment elevation in Q leads is an uncommon finding and it is related to a more damaged coronary microcirculation and to less viable myocardium.

[Study of post-infarction coronary perfusion using quantitative analysis of myocardial echocardiography with intravenous injection of contrast]. / Estudio de la perfusión coronaria postinfarto mediante análisis cuantitativo de la ecocardiografía miocárdica con inyección de contraste por vía intravenosa.

INTRODUCTION AND OBJECTIVES: After a myocardial infarction, damage to the microcirculation indicates a worse prognosis. We compared the usefulness of the quantitative analysis of myocardial contrast echocardiography with intravenous injection of contrast (MCE-iv) with intracoronary injection (MCE-ic) for analyzing coronary perfusion. PATIENTS AND METHOD: We studied 42 patients with a first ST-elevation myocardial infarction, single-vessel disease and a patent artery (TIMI 3, stenosis < 50%). Myocardial perfusion in segments in the infarct-related area was quantified (normalized scale 0-1) with MCE-ic (bolus of Levovist, real-time imaging, perfusion considered normal if > 0.75) and MCE-iv (perfusion of SonoVue, single-image capture in 1 out of each 6 cycles with trigger set at end-systole, perfusion considered normal if > 0.9). Perfusion was considered abnormal if 2 or more segments showed altered perfusion. RESULTS: Quantification with MCE-iv took 5 +/- 1 minutes. No side effects were observed. MCE-ic was normal in 141 segments (80%) out of 176 segments included in the infarcted area, whereas 35 segments (20%) showed abnormal perfusion. MCE-ic was normal in 31 patients (74%) and was altered in 11 cases (26%). Normal perfusion with MCE-iv had a sensitivity of 91%, a specificity of 84% and a kappa index of 0.67 for predicting normal perfusion with MCE-ic (r = 0.86; P < .0001 between the two techniques). CONCLUSIONS: In comparison with MCE-ic, quantitative analysis of single images captured during intravenous perfusion of contrast is an easy, rapid and valid method for analyzing postinfarction coronary perfusion.

Persistent truncus arteriosus type 4 with survival to the age of 54 years.

We describe a case of persistent truncus arteriosus type 4 in an unrepaired 54-year-old woman with the peculiarities of long survival, absence of pulmonary arteries and good clinical status.

[Myocardial echocardiography with intracoronary injection of contrast in post-infarction patients. Implications and comparison with angiography and magnetic resonance imaging]. / Myocardial echocardiography with intracoronary injection of contrast in post-infarction patients. Implications and comparison with angiography and magnetic resonance imaging.

OBJECTIVES: We analyzed the safety and feasibility of myocardial echocardiography with intracoronary injection of contrast, its effect on left ventricular remodeling and systolic function, and its relationship with angiography and magnetic resonance imaging (MRI) for the evaluation of post-infarction coronary microcirculation. PATIENTS AND METHOD: Thirty patients with a first ST-elevation myocardial infarction and a patent infarct-related artery were studied. Mean perfusion score of the infarcted area was analyzed with myocardial echocardiography. TIMI and Blush grades (angiography) were determined. Mean perfusion score (MRI-perfusion), end-diastolic volume index and ejection fraction were determined with MRI. At 6 months all studies were repeated in the first 17 patients. RESULTS: Forty-seven perfusion studies (30 in the first week and 17 after 6 months) were done without complications (6 [2] min per myocardial echocardiography study). Normal perfusion (myocardial echocardiography 0.75) was detected in 67% of the patients. Myocardial echocardiography was the best predictor of end-diastolic volume (r=-0.69; P =.002) and ejection fraction (r=0.72; P=.001) after 6 months. Normal perfusion was observed in 80% of the patients with TIMI grade 3, and in 14% of those with TIMI grade 2. Of the 40 studies in patients with TIMI grade 3, normal perfusion was seen in 85% of the patients with Blush grade 2-3 and in 50% of those with Blush 0-1. Perfusion was also normal in 90% of the patients with MRI-perfusion =1 and in 62% of those with MRI-perfusion < 1. CONCLUSIONS: Myocardial echocardiography is a feasible and relatively rapid technique with no side effects. This technique provided the most reliable perfusion index for predicting late left ventricular remodeling and systolic function. To achieve normal perfusion, TIMI grade 3 is necessary but does not guarantee success. In patients with TIMI grade 3, a normal Blush score or a normal MRI-perfusion study suggests good reperfusion.

[Reliability of cardiac magnetic resonance imaging indicators of myocardial viability for predicting the recovery of systolic function after a first acute myocardial infarction with a patent culprit artery]. / Fiabilidad de los índices de viabilidad miocárdica por resonancia magnética para predecir la mejoría de la función sistólica en pacientes con un primer infarto reciente y arteria abierta.

INTRODUCTION AND OBJECTIVE: To assess the reliability of early analysis of the most frequently used cardiac magnetic resonance (CMR)-derived indexes for predicting systolic function recovery and ventricular remodeling in patients after a first acute myocardial infarction with a patent culprit artery. PATIENTS AND METHOD: 17 patients were studied with an initial CMR protocol that included regional assessment of wall thickness and wall thickening, low-dose dobutamine response, first-pass gadolinium myocardial perfusion imaging and delayed enhancement. These results were compared with those obtained for segmental and global function in a second CMR study 6 months later. RESULTS: Of the 272 myocardial segments evaluated in the initial study, 73 showed severe systolic dysfunction. The findings were used to calculate sensitivity and specificity of each of the indexes mentioned above for predicting myocardial viability. The sensitivities and specificities for each index were wall thickness > or =5.5 mm, 100% and 12%; low-dose dobutamine response, 41% and 93%; normal myocardial perfusion, 78% and 68%; delayed enhancement, 81% and 95%. Multivariate analysis showed that delayed enhancement was the only independent predictor of contractility (r=-0.83, P=.0001), ventricular volumes (end-diastolic: r=0.61, P=.009, end-systolic: r=0.67, P=.003) and ejection fraction (r=-0.73, P=.001) at 6 months. CONCLUSIONS: Delayed enhancement seen in CMR is a reliable, quantifiable index for predicting recovery of systolic function and ventricular remodeling in patients after a first infarction with a patent culprit artery.

The relationship between dioxin-like polychlorobiphenyls and IGF-I serum levels in healthy adults: evidence from a cross-sectional study.

OBJECTIVE: Insulin-like growth factor I (IGF-I) and dioxin-like polychlorobiphenyls (DL-PCBs) have been associated with the pathogenesis of several diseases like cancer, diabetes and growth disorders. Because it has been suggested that organohalogenated contaminants could influence IGF-I levels in adults, the potential relationship between DL-PCBs and IGF-I serum levels was studied in 456 healthy adults from a representative sample of the general population of the Canary Islands (Spain). DESIGN: Free circulating serum levels of IGF-I and IGFBP-3 were measured through an ELISA methodology, while the serum levels of the 12 DL-PCBs congeners (IUPAC numbers # 77, 81, 105, 114, 118, 123, 126, 156, 157, 167, 169, and 189) were measured by gas chromatography/mass spectrometry (GC-MS). RESULTS: DL-PCBs 156 and 167, Total DL-PCBs body burden (∑PCBs: sum over the 12 measured DL-PCBs), and Total toxic burden (in terms of toxic equivalence to dioxins: ∑TEQs) showed a trend of inverse association with IGF-I serum levels in the whole studied population. After adjusting for potential confounders, including gender, body mass index (BMI), age, and IGF-binding protein-3 (IGFBP-3), younger (18-45 years) women with lower BMI (<27 kg/m(2)) and detectable levels of DL-PCB-156 showed significantly lower IGF-I levels than those in the same age and BMI subgroup with non-detectable levels of DL-PCB-156 (p<0.001). Similarly, ∑PCBs and ∑TEQs showed a tendency to an inverse association with IGF-I levels in the same group of women (p=0.017 and p=0.019 respectively). CONCLUSIONS: These findings suggest that DL-PCBs could be involved in the regulation of the IGF-system in a way possibly influenced by gender, age and BMI. Although these results should be interpreted with caution, such circumstances could contribute to explain the development of diseases associated to the IGF system.

Chryseobacterium indologenes infection in a newborn: a case report.

INTRODUCTION: Chryseobacterium indologenes is an uncommon human pathogen. Most infections have been detected in hospitalized patients with severe underlying diseases who had indwelling devices implanted. Infection caused by C. indologenes in a newborn has not been previously reported. CASE PRESENTATION: We present a case of ventilator-associated pneumonia caused by C. indologenes in a full-term Caucasian newborn baby boy with congenital heart disease who was successfully treated with piperacillin-tazobactam. CONCLUSION: C. indologenes should be considered as a potential pathogen in newborns in the presence of invasive equipment or treatment with long-term broad-spectrum antibiotics. Appropriate choice of effective antimicrobial agents for treatment is difficult because of the unpredictability and breadth of antimicrobial resistance of these organisms, which often involves resistance to many of the antibiotics chosen empirically for serious Gram-negative infections.

Diagnosis and management of fetal intrapericardial Morgagni diaphragmatic hernia with massive pericardial effussion.

Herniation of the liver into the fluid-filled pericardial sac resulting in a thoracic mass is a particularly rare form of Morgagni hernia (congenital diaphragmatic hernia of Morgagni). We report an early antenatal diagnosis of congenital diaphragmatic hernia of Morgagni with pericardium effussion at 21 weeks' gestation. Two pericardiocentesis were performed at 21 and 22 4/7 weeks' gestation because of recurrence of pericardial effussion. Regular ultrasound assessments showed progressive herniation of the liver to practically fill the right hemithorax. An ex utero intrapartum treatment procedure was performed at 37 weeks' gestation to rescue maximum intrathoracic space for ventilation of the remaining functional lung tissue and to establish an airway for postnatal support. After birth, the patient successfully underwent early correction of the hernia. Postoperative course was uneventful, and the newborn girl was discharged 18 days later without complications and is currently doing well.

Insulin-like growth factor-I (IGF-I) serum concentrations in healthy children and adolescents: relationship to level of contamination by DDT-derivative pesticides.

CONTEXT: Serum levels of Insulin-like growth factor I (IGF-I) play a critical role in children growth and in the pathogenesis of several diseases. In addition, recent studies suggest that DDT-derivative organochlorine pesticides (OC-DDTs) could influence IGF levels in human beings. OBJECTIVE AND DESIGN: Because it has been suggested that IGF-I peak levels at puberty could determine IGF-I levels in adulthood, we developed a cross-sectional study of the potential association between serum levels of OC-DDTs and IGF system in 160 serum samples from young people (81 boys and 79 girls) living in the Canary Islands (Spain). RESULTS: Multivariate tests were used adjusting for confounding variables (age, height, and weight) and stratifying by gender and age: IGF-I serum levels were significantly lower in pre-pubertal male children (6-15years) who showed detectable values of p,p'-DDE, and p,p'-DDD than in pre-pubertal male children with undetectable levels of these OC-DDTs-metabolites (p=0.023 and p=0.049, respectively). In addition, in this multivariate model, a non-linear dose-response curve was observed between Total DDT body burden (sum of the three DDT-derivatives measured: p,p'-DDT, p,p'-DDE, and p,p'-DDD) and IGF-I in pre-pubertal male children (6-15years; p=0.043). CONCLUSION: These findings suggest that OC-DDTs could modulate the IGF-system in a way that is highly influenced by gender and age. Improvements in our understanding of exogenous determinants of the IGF-system may provide new insights into the role played by environmental contaminants in IGF-related diseases.

[Acquired flat angiomas in the form of a port-wine stain]. / Angiomas planos adquiridos en mancha de vino de Oporto.

The development of flat angiomas in the form of a "port-wine stain" is an infrequent event in adults. We describe two cases of acquired flat angioma in the form of a "port-wine stain", which began in the second decade of life and grew slowly and steadily until reaching a large size. In the first case, it affected the front and back of the trunk, and in the second patient, the neck and left shoulder. Histopathology showed ectatic vessels in the papillary and reticular dermis, with no proliferation of endothelial cells.

[Papulonecrotic tuberculid]. / Tubercúlides papulonecróticas.

Papulonecrotic tuberculid (PTB) is a form of cutaneous tuberculosis with characteristic clinical and histological manifestations. The incidence of PNT is very low in Spain. We present the case of a 22-year-old male patient from a middle-class social and economic background, with clinical and histological criteria of PNT, but who showed negative for molecular traces of mycobacteria using PCR.

Usefulness of quantitative intravenous myocardial contrast echocardiography to analyze microvasculature perfusion in patients with a recent myocardial infarction and an open infarct-related artery: comparison with intracoronary myocardial contrast echocardiography.

AIMS: We analyzed the usefulness of quantitative intravenous myocardial contrast echocardiography to study microvasculature perfusion after infarction in comparison with intracoronary myocardial contrast echocardiography. METHODS AND RESULTS: Thirty-two patients with a first ST elevation myocardial infarction, single-vessel disease and an open artery (TIMI 3) were studied before discharge. Myocardial perfusion in the risk area was quantified with intracoronary and intravenous myocardial contrast echocardiography. Perfusion was normal (intracoronary contrast echocardiography normalized videointensity >0.75) in 78 out of 97 dysfunctional segments (80%). Sensitivity and specificity of intravenous contrast echocardiography to predict normal perfusion were 87% and 63% for 'first-pass myocardial blood flow' (upslope of contrast arrival x peak intensity after intravenous bolus injection of contrast) and 91% and 89% for end-systolic single-triggered images captured every 6 cycles, respectively. In an analysis per patients, normal perfusion (0 or 1 hypoperfused segments with intracoronary contrast echocardiography) was observed in 22 cases (69%). End-systolic single-triggered images showed a strong correlation with intracoronary contrast echocardiography (R2 = 0.82, p = 0.0001). CONCLUSIONS: Intravenous contrast echocardiography is a useful technique to analyze microvasculature perfusion soon after infarction. A quantitative analysis of single-triggered images is an easy-to-obtain and reliable method to define perfusion when compared with intracoronary contrast echocardiography.