Reducing perinatal complications and preterm delivery for patients undergoing in utero closure of fetal myelomeningocele: further modifications to the multidisciplinary surgical technique.

UNLABELLED: OBJECT.: As more pediatric neurosurgeons become involved with fetal myelomeningocele closure efforts, examining refined techniques in the overall surgical approach that could maximize beneficial outcomes becomes critical. The authors compared outcomes for patients who had undergone a modified technique with those for patients who had undergone fetal repair as part of the earlier Management of Myelomeningocele Study (MOMS). METHODS: Demographic and outcomes data were collected for a series of 43 delivered patients who had undergone in utero myelomeningocele closure at the Fetal Center at Vanderbilt from March 2011 through January 2013 (the study cohort) and were compared with data for 78 patients who had undergone fetal repair as part of MOMS (the MOMS cohort). For the study cohort, no uterine trocar was used, and uterine entry, manipulation, and closure were modified to minimize separation of the amniotic membrane. Weekly ultrasound reports were obtained from primary maternal-fetal medicine providers and reviewed. A test for normality revealed that distribution for the study cohort was normal; therefore, parametric statistics were used for comparisons. RESULTS: The incidence of premature rupture of membranes (22% vs 46%, p = 0.011) and chorioamnion separation (0% vs 26%, p < 0.001) were lower for the study cohort than for the MOMS cohort. Incidence of oligohydramnios did not differ between the cohorts. The mean (± SD) gestational age of 34.4 (± 6.6) weeks for the study cohort was similar to that for the MOMS cohort (34.1 ± 3.1 weeks). However, the proportion of infants born at term (37 weeks or greater) was significantly higher for the study cohort (16 of 41; 39%) than for the MOMS cohort (16 of 78; 21%) (p = 0.030). Compared with 10 (13%) of 78 patients in the MOMS cohort, only 2 (4%) of 41 infants in the study cohort were delivered earlier than 30 weeks of gestation (p = 0.084, approaching significance). For the study cohort, 2 fetal deaths were attributed to the intervention, and both were believed to be associated with placental disruption; one of these mothers had previously unidentified thrombophilia. Mortality rates did not statistically differ between the cohorts. CONCLUSIONS: These early results suggest that careful attention to uterine entry, manipulation, and closure by the surgical team can result in a decreased rate of premature rupture of membranes and chorioamnion separation and can reduce early preterm delivery. Although these results are promising, their confirmation will require further study of a larger series of patients.

Stomatal uptake of O3 in aspen and aspen-birch forests under free-air CO2 and O3 enrichment.

Rising atmospheric carbon dioxide (CO2) may alleviate the toxicological impacts of concurrently rising tropospheric ozone (O3) during the present century if higher CO2 is accompanied by lower stomatal conductance (gs), as assumed by many models. We investigated how elevated concentrations of CO2 and O3, alone and in combination, affected the accumulated stomatal flux of O3 (AFst) by canopies and sun leaves in closed aspen and aspen-birch forests in the free-air CO2-O3 enrichment experiment near Rhinelander, Wisconsin. Stomatal conductance for O3 was derived from sap flux data and AFst was estimated either neglecting or accounting for the potential influence of non-stomatal leaf surface O3 deposition. Leaf-level AFst (AFst(l)) was not reduced by elevated CO2. Instead, there was a significant CO2 x O(3) interaction on AFst(l), as a consequence of lower values of gs in control plots and the combination treatment than in the two single-gas treatments. In addition, aspen leaves had higher AFst(l) than birch leaves, and estimates of AFst(l) were not very sensitive to non-stomatal leaf surface O3 deposition. Our results suggest that model projections of large CO2-induced reductions in gs alleviating the adverse effect of rising tropospheric O3 may not be reasonable for northern hardwood forests.

Diabetic ketoacidosis in pregnancy.

OBJECTIVE: The development of diabetic ketoacidosis in pregnancy is a medical emergency, requiring treatment in an intensive care setting. Both the mother and the fetus are at risk for significant morbidity and mortality. Physiologic changes unique to pregnancy provide a background for the development of diabetic ketoacidosis. An understanding of these physiologic changes assists in the management of the two patients being treated. Treatment of the patient with diabetic ketoacidosis includes insulin therapy and careful fluid management; recommendations for management are presented. PATIENTS: Pregnant women, either with preexisting diabetes or with diabetes diagnosed during pregnancy. CONCLUSIONS: Prompt recognition of the clinical manifestations of diabetic ketoacidosis, followed by appropriate, timely treatment will optimize outcome for the pregnant woman and her fetus.

Missing OH reactivity in a forest: evidence for unknown reactive biogenic VOCs.

Forest emissions of biogenic volatile organic compounds (BVOCs), such as isoprene and other terpenes, play a role in the production of tropospheric ozone and aerosols. In a northern Michigan forest, the direct measurement of total OH reactivity, which is the inverse of the OH lifetime, was significantly greater than expected. The difference between measured and expected OH reactivity, called the missing OH reactivity, increased with temperature, as did emission rates for terpenes and other BVOCs. These measurements are consistent with the hypothesis that unknown reactive BVOCs, perhaps terpenes, provide the missing OH reactivity.