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.