Hysterectomy with Fetus In Situ for Uterine Rupture at 21-Week Gestation due to a Morbidly Adherent Placenta.

BACKGROUND: Uterine rupture due to a morbidly adherent placenta is a rare obstetrical cause of acute abdominal pain in the pregnant patient. We present a case to add to the small body of published literature describing this diagnosis. CASE: A 32-year-old G5T2P1A1L2 with multiple prior cesarean sections presented at 21+3 weeks' gestation with abdominal pain and presyncope. Ultrasound showed a large volume of complex intraabdominal free fluid and a heterogenous placenta with irregular lacunae and increased vascularity extending to the posterior bladder wall. Exploratory laparotomy identified a uterine defect and a hysterectomy was performed due to significant bleeding. Pathology confirmed a diagnosis of placenta percreta. CONCLUSION: Early recognition and management of uterine rupture due to a morbidly adherent placenta are essential to prevent catastrophic hemorrhage.

Postnatal dilatation of umbilical cord vessels and its impact on wall integrity: Prerequisite for the artificial placenta.

INTRODUCTION: A lung assist device, which acts as an artificial placenta, can provide additional gas exchange for preterm and term newborns with respiratory failure. The concept of the lung assist device requires a large bore access via umbilical vessels to allow pumpless extracorporeal blood flow rates up to 30 mL/kg/min. After birth, constricted umbilical vessels need to be reopened for vascular access. The objective is to study the impact of umbilical vessel expansion on vessel integrity for achieving large bore access. METHODS: Umbilical cords from healthy term deliveries were cannulated and dilatated with percutaneous transluminal angioplasty catheters in 1 mm increments from 4 to 8 mm for umbilical artery and from 4 to 15 mm for umbilical vein, n = 6 per expansion diameter. Paraffin-embedded transverse sections of dilated and control samples were HE & Van Gieson stained. Effects of dilatation, shown by splitting, were measured. RESULTS: Umbilical vessel expansion led to concentric splitting, shown by areas devoid of extracellular matrix and nuclei in the tunica intima and media. No radial splitting was observed. Results suggest an expansion threshold of umbilical artery at 6 mm and umbilical vein at 7 mm, while maximal splitting was observed above this threshold (3.6 ± 0.8%, p = 0.043 for umbilical artery 7 mm and 6.3 ± 1.8%, p = 0.048 for umbilical vein 8 mm). Endothelial cell sloughing was present in all dilated samples but not in the control samples. CONCLUSION: The suggested thresholds for safe expansions are similar to in utero umbilical vessel diameters and demonstrate a proof of concept for attaining large bore access for the lung assist device.

Neurocognitive profiles in older adults with and without major depression.

OBJECTIVES: To delineate the differences between older persons with and without a diagnosis of major depression. METHODS: Participants were recruited from three outpatient clinics serving older patients at St Michael's Hospital. To be included in the study, participants had to speak English and have no evidence of significant sensory deficits that would interfere with neuropsychological testing. Participants were excluded if they had active delirium, active CNS disease (including dementia), active substance abuse, unstable medical disease, recent ECT treatment and a current/past diagnosis of a psychotic disorder. The diagnosis of major depression was made by qualified professionals in accordance with established guidelines. Participants were administered structured measures assessing global cognition, medical co-morbidity, subjective memory complaints, mood and detailed neurocognitive testing evaluating working memory, attention and speed of processing. Differences between depressed and non-depressed subjects with respect to these measures were analyzed using analysis of variance (ANOVA). RESULTS: Thirty-six participants were included in this study. The depressed (n = 17) and non-depressed (n = 19) groups were well matched in terms of age, education, medical co-morbidity and mini-mental state exam (MMSE) score. While the depressed subgroup had significantly higher subjective memory, language and cognitive complaints, there were no significant differences observed between the two subgroups on measures of memory and learning, attention and speed of information processing, fine motor dexterity and verbal fluency. CONCLUSION: This study suggests that while significant depressive symptoms are strongly associated with increased cognitive complaints, they are not associated necessarily with objective cognitive impairment.

Treatment of delusions in dementia with Lewy bodies - response to pharmacotherapy.

BACKGROUND: Delusions are clinically important symptoms in dementia with Lewy bodies (DLB). The purpose of this review is to examine the level of evidence for treatment of delusions in DLB. METHODS: To achieve this objective Medline was searched. Studies were included in the review if they were prospective, separated delusions from hallucinations and were tested in patients with DLB. RESULTS: The review yielded a total of six studies. Although all studies showed effectiveness, only one study using rivastigmine had an adequate patient sample size and used a randomized controlled design. CONCLUSION: Further studies are required before a definitive conclusion can be reached about effective treatments.

Treatment of delusions in Alzheimer's disease--response to pharmacotherapy.

Delusions are commonly encountered symptoms in patients with Alzheimer's disease and may lead to significant morbidity. The purpose of this article is to review all clinical trials to date focusing on the management of delusions in patients with Alzheimer's disease to determine the level of evidence for treatment. To achieve this objective, Medline was searched using the key words delusions, dementia, Alzheimer's disease and psychosis. Three main categories of treatment were identified: atypical antipsychotics, cholinesterase inhibitors, and other miscellaneous treatments. It was concluded that all forms of treatment were effective although the greatest burden of evidence existed for risperidone and donepezil. Side effects were noted in all forms of treatment and included somnolence and extrapyramidal effects for antipsychotic medications, whereas gastrointestinal effects were more prevalent in studies involving cholinesterase inhibitors. Further large scale, double-blind, randomized, controlled studies are required before a definitive conclusion can be reached. To our knowledge this is the only systematic review of this area.