sFlt-1/PlGF for prediction of early-onset pre-eclampsia: STEPS (Study of Early Pre-eclampsia in Spain).

OBJECTIVE: A high ratio of soluble fms-like tyrosine kinase-1 (sFlt-1) to placental growth factor (PlGF) has been linked to pre-eclampsia (PE). We evaluated the sFlt-1/PlGF ratio as a predictive marker for early-onset PE in women at risk of PE. METHODS: This prospective, Spanish, multicenter study included pregnant women with a risk factor for PE, including intrauterine growth restriction, PE, eclampsia or hemolysis, elevated liver enzymes and low platelet count syndrome in previous pregnancy, pregestational diabetes or abnormal uterine artery Doppler. The primary objective was to show that the sFlt-1/PlGF ratio at 20, 24 and 28 weeks' gestation was predictive of early-onset PE (< 34 + 0 weeks). Serum sFlt-1 and PlGF were measured at 20, 24 and 28 weeks. Multivariate logistic regression was used to develop a predictive model. RESULTS: A total of 819 women were enrolled, of which 729 were suitable for analysis. Of these, 78 (10.7%) women developed PE (24 early onset and 54 late onset). Median sFlt-1/PlGF ratio at 20, 24 and 28 weeks was 6.3 (interquartile range (IQR), 4.1-9.3), 4.0 (IQR, 2.6-6.3) and 3.3 (IQR, 2.0-5.9), respectively, for women who did not develop PE (controls); 14.5 (IQR, 5.5-43.7), 18.4 (IQR, 8.2-57.9) and 51.9 (IQR, 11.5-145.6) for women with early-onset PE; and 6.7 (IQR, 4.6-9.9), 4.7 (IQR, 2.8-7.2) and 6.0 (IQR, 3.8-10.5) for women with late-onset PE. Compared with early-onset PE, the sFlt-1/PlGF ratio was significantly lower in controls (P < 0.001 at each timepoint) and in women with chronic hypertension (P < 0.001 at each timepoint), gestational hypertension (P < 0.001 at each timepoint) and late-onset PE (P < 0.001 at each timepoint). A prediction model for early-onset PE was developed, which included the sFlt-1/PlGF ratio plus mean arterial pressure, being parous and previous PE, with areas under the receiver-operating characteristics curves of 0.86 (95% CI, 0.77-0.95), 0.91 (95% CI, 0.85-0.97) and 0.93 (95% CI, 0.86-0.99) at 20, 24 and 28 weeks, respectively, and was superior to models using the sFlt-1/PlGF ratio alone or uterine artery mean pulsatility index. CONCLUSIONS: The sFlt-1/PlGF ratio can improve prediction of early-onset PE for women at risk of this condition. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.

Do knowledge of uterine artery resistance in the second trimester and targeted surveillance improve maternal and perinatal outcome? UTOPIA study: a randomized controlled trial.

OBJECTIVES: To ascertain whether screening for pre-eclampsia (PE) and intrauterine growth restriction (IUGR) by uterine artery (UtA) Doppler in the second trimester of pregnancy and targeted surveillance improve maternal and perinatal outcomes in an unselected population. METHODS: This was a multicenter randomized open-label controlled trial. At the routine second-trimester anomaly scan, women were assigned randomly to UtA Doppler or non-Doppler groups. Women with abnormal UtA Doppler were offered intensive surveillance at high-risk clinics of the participating centers with visits every 4 weeks that included measurement of maternal blood pressure, dipstick proteinuria, fetal growth and Doppler examination. The primary outcome was a composite score for perinatal complications, defined as the presence of any of the following: PE, IUGR, spontaneous labor < 37 weeks' gestation, placental abruption, stillbirth, gestational hypertension, admission to neonatal intensive care unit and neonatal complications. Secondary outcomes were a composite score for maternal complications (disseminated intravascular coagulation, maternal mortality, postpartum hemorrhage, pulmonary edema, pulmonary embolism, sepsis), and medical interventions (for example, corticosteroid administration and induction of labor) in patients developing placenta-related complications. RESULTS: In total, 11 667 women were included in the study. Overall, PE occurred in 348 (3.0%) cases, early-onset PE in 48 (0.4%), IUGR in 722 (6.2%), early-onset IUGR in 93 (0.8%) and early-onset PE with IUGR in 32 (0.3%). UtA mean pulsatility index > 90(th) percentile was able to detect 59% of early-onset PE and 60% of early-onset IUGR with a false-positive rate of 11.1%. When perinatal and maternal data according to assigned group (UtA Doppler vs non-Doppler) were compared, no differences were found in perinatal or maternal complications. However, screened patients had more medical interventions, such as corticosteroid administration (relative risk (RR), 1.79 (95% CI, 1.4-2.3)) and induction of labor for IUGR (RR, 1.36 (95% CI, 1.07-1.72)). In women developing PE or IUGR, there was a trend towards fewer maternal complications (RR, 0.46 (95% CI, 0.19-1.11)). CONCLUSIONS: Routine second-trimester UtA Doppler ultrasound in an unselected population identifies approximately 60% of women at risk for placental complications; however, application of this screening test failed to improve short-term maternal and neonatal morbidity and mortality. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.

Use of a specific anti-stretch mark cream for preventing or reducing the severity of striae gravidarum. Randomized, double-blind, controlled trial.

Few studies have tested the efficacy of commercially available cosmetic products for preventing striae gravidarum. Therefore, the objective of this study was to evaluate efficacy on prevention of striae gravidarum using a specific anti-stretch mark cream containing hydroxyprolisilane-C, rosehip oil, Centella asiatica triterpenes and vitamin E. A randomized, double-blind, placebo-controlled trial was conducted between November 2009 and April 2011. Pregnant women were included and classified as treated group (emollient and moisturizer containing hydroxyprolisilane C, rosehip oil, Centella asiatica triterpenes and vitamin E) and control group (cream without the active ingredients). Overall incidence of stretch marks during pregnancy was 33.3% for the control group and 37.6% for the treated group (n.s.). Severity of previous stretch marks significantly increased in the control group during the study (17.8%, P = 0.001), but not in the treated group (6.3%, ns). In women who developed new stretch marks during the study, there was a significantly greater 'difference in severity' (between baseline and maximum severity) in control group vs. treated group (0.47 [0.57] vs. 0.14 [0.60], P = 0.031). In women without previous striae, incidence of these marks was significantly lower for the treated group patients compared with control group (5.6% vs. 35%, P = 0.031, OR: 9.2 [95% CI: 1.0-83.3]). The use of the anti-stretch mark product is proved to be effective in reducing severity of the striae during pregnancy, prevents the appearance of new striae and halts progression of those already present. In women who had no striae at baseline, use of the anti-stretch mark cream was more effective than placebo in preventing new stretch marks.

First-trimester screening for large-for-gestational-age infants.

OBJECTIVES: To examine the relationship between newborn birth weight and first-trimester uterine artery (UtA) pulsatility index (PI), maternal characteristics, serum pregnancy-associated plasma protein-A (PAPP-A), free ß-human chorionic gonadotropin (ß-hCG) and fetal nuchal translucency (NT) thickness. We also examined the results of screening for large-for-gestational-age (LGA) neonates by an integrated first-trimester approach incorporating these parameters. METHODS: We evaluated maternal characteristics, fetal NT, PAPP-A, free ß-hCG and UtA-PI in 2097 singleton pregnancies at 11 + 0 to 13 + 6 weeks' gestation. Linear models based on quasi Akaike's Information Criterion were used to determine the best predictive model for fetal birth weight. The patient-specific risk of delivering an LGA infant was derived from multiple logistic regression analysis and the performance of screening was determined by receiver-operating characteristics curve analysis. RESULTS: The best predictive models for fetal birth weight included UtA-PI, PAPP-A, NT, parity, maternal age, smoking status, weight, height and free ß-hCG. In pregnancies delivering LGA newborns compared with non-LGA pregnancies, PAPP-A and NT thickness were significantly increased (P = 0.016 and 0.001, respectively) and UtA-PI was significantly decreased (P = 0.011). A combination of maternal factors with PAPP-A, fetal NT and UtA-PI identified 34.4% of LGA newborns for a false-positive rate of 10%. CONCLUSIONS: This study showed an association between newborn birth weight and maternal factors, and first-trimester PAPP-A, ß-hCG, fetal NT and UtA-PI. Together, these factors can be used to identify over a third of pregnancies that will deliver LGA infants.

Cervical length vs VOCAL cervical volume for predicting pre-term delivery in asymptomatic women at 20-22 weeks' pregnancy.

We conducted a prospective observational study of 306 asymptomatic women at 20-22 weeks of pregnancy to compare 3-dimensional ultrasound measurements of cervical volume with 2-dimensional ultrasound measurements of cervical length to evaluate the performance of cervical volume as a predictor of pre-term delivery, compared with the current standard, cervical length. Participants underwent transvaginal ultrasound measurements of cervical length (mm) and cervical volume (cm(3)). Cervical volume as measured by 3-dimensional ultrasound was found to be a useful tool for predicting pre-term delivery; however, due to the high correlation between cervical length and cervical volume and the lack of differences in the sensitivity, specificity, positive predictive value, negative predictive value and relative risk between the two methods, replacing cervical length measurements with cervical volume calculations does not seem to be justified for this purpose, because of increased difficulty in volume acquisition.

Surveillance and risk factors on hysterectomy wound infection rate in Gran Canaria, Spain.

OBJECTIVES: Surveillance programs for nosocomial infection control may find out opportunities for improvement. The aim of this study was to determine the incidence of surgical site infection and their potential risk factors after hysterectomy in a tertiary hospital in Gran Canaria, Spain. STUDY DESIGN: Prospective study on patients undergoing abdominal or vaginal hysterectomy between 1st June 2000 and 31st December 2004. Surgical site infection incidence rates were calculated according to procedure, and National Nosocomial Infection Surveillance (NNIS) system risk categories. We also reviewed antimicrobial prophylaxis use and morbidity. To determine associate risk factors a multivariate analysis was performed. RESULTS: A total of 1540 women were surveyed; neoplasm (30.5%), obesity (24.3%), and diabetes (16.2%) grouped the main morbidity. About 81 cases (5.2%) met criteria for postoperative surgical site infection (6.0% for abdominal procedure and 3.1% for vaginal procedure). Most patients (86.4%) had adequate antimicrobial prophylaxis, but inadequacy was more frequent by vaginal (17.6%) than abdominal procedure (12.0%) (p=0.005). NNIS high-risk patients had significantly higher infection rates than did low-risk patients (p=0.01). The most common causative organism isolated was Escherichia coli (17.5%). Multivariate analysis showed obesity, inadequate antimicrobial prophylaxis, and abdominal procedure as the main risk factors. CONCLUSION: Rate of surgical site infection is high. Enhanced and multidisciplinary efforts are needed.

OnabotulinumtoxinA in urinary incontinence: Prospective Study of a Case Series. / Onabotulinumtoxin A en la incontinencia urinaria: estudio prospectivo de serie de casos.

OBJECTIVE: To assess the safety and efficacy of a single intravesical injection of onabotulinumtoxinA (OnaBTA) for treating urge urinary incontinence (UUI) in women. METHOD: We performed a prospective case-series study of consecutive patients with refractory UUI treated with an intravesical injection of OnaBTA. The patients were administered 100 units of OnaBTA injected into the bladder wall following 4 weeks of flushing with anticholinergic agents or beta 3 agonists. The urodynamic and clinical endpoints were evaluated before and 6 months after the injection of OnaBTA. The primary study endpoint was the number of episodes of urinary leakage. RESULTS: A total of 204 of the 210 selected patients conducted a valid visit 6 months after the therapeutic application. At 6 months of treatment with OnaBTA, 110 (53.9%) patients remained continent and were considered a success. However, 57 (27.9%) patients experienced one episode of urinary leakage per day, and 37 (18.2%) had 2 or more. In terms of the urodynamic parameters, we observed the following changes: increase in maximum bladder capacity (P<.0001) and reduced maximum pressure of the detrusor (P<.0001). In terms of the safety profile, 8 (3.9%) patients had self-limiting haematuria during the procedure, which resolved spontaneously, and 9 (4.4%) patients had acute urinary retention that required intermittent catheterisation. CONCLUSIONS: This study supports the use of OnabotulinumtoxinA in patients with urge urinary incontinence that does not respond to medical treatment.

[High-frequency oscillatory ventilation. A single-center study]. / Nuestra experiencia con la ventilación de alta frecuencia oscilatoria.

INTRODUCTION: High-frequency oscillatory ventilation is a safe and effective means of delivering mechanical ventilatory support. OBJECTIVE: To evaluate the safety and effectiveness of high-frequency oscillatory ventilation in pediatric patients with acute respiratory failure. PATIENTS AND METHOD: From August 2003 to July 2005, we performed a prospective observational study of 11 children older than 1 month who underwent high-frequency oscillatory ventilation. Pediatric risk of mortality scores (PRISM), Murray lung-injury scores and air leak scores were recorded at baseline before ventilation. The following variables were studied: ventilatory settings (FiO2 and mean airway pressure), gasometric (PaO2, SaO2, PaCO2, pHa, PaO2/FiO2 ratio) and hemodynamic parameters (Partm, PVC), and the oxygenation index. RESULTS: The overall survival rate was 82 %. Significant increases were found in PaO2 (p < 0.05), SaO2 (p < 0.05) and the PaO2/FiO2 ratio (p < 0.05), while mean airway pressure (p < 0.001), oxygenation index (p < 0.001), and FiO2 (p < 0.001) significantly decreased over time. CONCLUSIONS: High-frequency oscillatory ventilation significantly improved oxygenation in children with acute hypoxemic respiratory failure.

Concurrent chemotherapy and radiotherapy for cervical cancer.

OBJECTIVE: To compare the results obtained following treatment, from a group of patients with locally advanced cervical cancer (Stage IB or higher) treated with concurrent chemotherapy and radiotherapy in relation to a group of patients treated exclusively with radiotherapy. MATERIAL AND METHOD: All patients treated with concurrent chemotherapy and radiotherapy at the Gynaecologic Oncology Unit of the University Hospital Materno Infantil of the Canaries between 1999 and 2000, both inclusive, were included. The first group to be considered was formed by patients who received combined treatment. The second group of patients received radiotherapy exclusively, having been treated in previous years (1997-1998 period). The results were compared in relation to survival in the two following years from treatment (2000-2001) in the group of combined treatment and years 1999-2000 in the group that received only radiotherapy. To compare the survival of both groups the chi-square test and Odds Ratio were utilised. RESULTS: The groups compared are homogeneous when looking at the stage of the disease when diagnosed, the histological type of tumour and its degree of cellular differentiation, the CAT results and tumoral markers. Survival of more than two years was observed in the group treated with concurrent chemotherapy and radiotherapy in relation to the group treated exclusively with radiotherapy; chi-square 9.92, p < 0.01, OR: 0.1 (0.01-0.6).

[Evaluation of the surgical correction in complete atrioventricular channels]. / Evaluación de la corrección quirúrgica en los canales auriculoventriculares completos.

We review our experience of surgical correction in atrioventricular canals between 1979 and 1991. 81 patients, ranging in ages from 5 to 109 months (with an average of 33 months) and weight from 4 to 25 kg (with an average of 9 kg), underwent primary repair. Another cardiac anomalies associated were ruled out, except patency of the arterial ductus. 33 patients (46%) presented the complete form of atrioventricular canals, 27 (33%) the partial form and 17 (21%) the transitional form. 55 patients (68%) of the sample had Down's syndrome. Regarding the cases with the complete form they were frequently associated to Down's syndrome. Thus, 89% of the cases of complete form had Down's syndrome. All operations for complete form cases used a two-patch technique and physiological reconstruction of the left atrioventricular valve. No patient underwent pulmonary artery banding or was discharged from surgery correction due to pulmonary pressure or resistance. The average age of the children with complete form was 19.5 months (11 months from 1986). The main hemodynamic parameters were mean pulmonary arterial pressure of 57 +/- 12 mmHg, pulmonary-systemic pressure relation of 0.87 +/- 0.12 and total pulmonary resistance of 6.3 +/- 4.0 U/m2. The hospital mortality was 32% in the complete form, comparable to samples of similar characteristics. We related this mortality with the hemodynamic profile at the time of surgical correction, compatible with pulmonary vascular obstructive disease, with the elevated percentage of Down's syndrome and with the delay in the surgical operation age.

[Anatomic correction of transposition of great vessels with entire interventricular septum. Initial results]. / Corrección anatómica de la transposición de las grandes arterias con septo interventricular íntegro. Resultados iniciales.

INTRODUCTION: Optimal management for patients with simple transposition of great arteries is currently the arterial switch operation. We review our initial experience to evaluate the results. METHOD: From 1988 to 1993, 21 children with simple transposition of the great arteries underwent arterial switch operation. Mean age at surgery was 10.5 +/- 5.6 days, excluding two cases with two-stage arterial switch and one with late diagnosis. Patent ductus arteriosus was present in 12 cases, and a small ventricular septal defect in two. The coronary artery pattern was unusual in 9 cases. Balloon atrial septostomy was performed in 19 cases, seven of them using two-dimensional echocardiography. It was considered no necessary in the remaining two, with a large ductus arteriosus. RESULTS: Total circulatory arrest was used in 13 patients (mean time 29.7 +/- 22.6 min). Three patients died in the early postoperative period (14.3%) in a refractory cardiac failure, one of them secondary to myocardial necrosis. The coronary artery pattern was unusual in two of died patients. All patients but three were in sinus rythm. Mean age at follow-up was 21 months (follow-up range 2 months to 5 years). Seventeen of surviving patients are in a functional state grade I and one in grade II of NYHA. There haven't been late deaths. CONCLUSION: These results compared with the ones of atrial switch operation, have encouraged to us to use the arterial switch operation in all children with simple transposition of the great arteries. Increasing experience will likely lead to improve our results.

[The hypoplastic left heart syndrome. Initiation of a therapeutic program]. / Síndrome del corazón izquierdo hipoplásico. Iniciación de un programa terapéutico.

The hypoplastic left heart syndrome is a very severe congenital heart disease dependent on patency of ductus arteriosus in the newborn. The survival after neonatal period, without surgical treatment, is exceptional. Nowadays, there are basically two types of therapeutic procedures: Palliation with the Norwood operation and/or cardiac transplantation. Both methods have showed advantages and disadvantages; at present, there is not consensus of them. In our hospital, we have recently begun a medical-surgical therapeutic program for the management of neonates with hypoplastic left heart syndrome. Because of this, we report our little experience. We have treated three children in the last year: The first of them dead in the operating room; the second was exitus due to a sepsis two months after surgery, and the third, who is three-month-old now, remained well and was discharged to home.

[The surgical treatment of critical aortic stenosis in a child by the Ross-Konno technic]. / Tratamiento quirúrgico de la estenosis aórtica crítica en el niño mediante la técnica de Ross-Konno.

A twenty-nine-day old male infant suffering from critical aortic stenosis underwent aortic valvotomy by cardiopulmonary bypass. At three years of age the aortic stenosis recurred and the child underwent a balloon aortic valvuloplasty, but developed severe aortic insufficiency after the procedure. The critical condition of the patient made aortic valve replacement mandatory. The surgical technique consisted of aortoventriculoplasty with infundibular and valve pulmonary autograft for substituting the aortic root (Ross-Konno technique). As for as we know this is the first report on the Ross-Konno procedure in Spanish journals.

[An evaluation of surgical correction in tetralogy of Fallot. A study of 101 cases]. / Evaluación de la corrección quirúrgica en la tetralogía de Fallot. Un estudio de 101 casos.

INTRODUCTION: The optimal management of infants with tetralogy of Fallot continues to evolve. We review our series to evaluate the results. PATIENTS AND METHODS: From 1979 to 1992, 101 children with tetralogy of Fallot without pulmonary atresia, were operated on. Infundibular and valvar stenosis were present in 59 cases (58.4%), distal stenosis in 24 (23.7%) and trunk and/or branches hypoplasia in 14 (13.9%). Until 1985, symptomatic infants underwent palliative surgical techniques. Since then, we prefer early repair as elective treatment in all cases, using palliative techniques only in symptomatic infants with inadequate anatomy. Palliative techniques were used in 35 children (34.6%), mean age at surgery was 6.7 +/- 6.7 months; corrective surgery, after palliative technique, in 23 children (22.8%), mean age at surgery was 36.0 +/- 12.9 months and primary correction in 66 children (65.3%), mean age at surgery was 30.7 +/- 20.8 months. For 45 patients (44.6%) the right ventricular outflow tract obstruction was relieved by a transannular patch. RESULTS: Post-repair right ventricular-left ventricular pressure ratio is a usefull index to predict the short and long-term evolution of this cardiopathy. Thus, values were significantly smaller in children without postoperative cardiac failure (0.51 +/- 0.10 vs 0.59 +/- 0.15; p < 0.01), in the survivors (0.53 +/- 0.12 vs 0.72 +/- 0.13; p < 0.001) and in those with better functional status in the follow-up (0.52 +/- 0.12 vs 0.66 +/- 0.13; p < 0.001). Whole mortality was 13% for two-stage correction and 7.6% for primary correction. From 1985 mortality has reduced at 6.7 and 2.3% respectively. The follow-up was completed in 78 children with corrective surgery (96%), with a mean of 43.4 +/- 32.6 months. There were three later deaths. Actuarial survival at six years is 86%. CONCLUSION: We have proved that the optimal treatment in infants with tetralogy of Fallot and suitable size pulmonary vascular tree is the early primary repair. The pressure relation between both ventricles post-repair is a useful index for the outcome.

[Pressure support ventilation]. / Modalidades de soporte.

Assisted mechanical ventilation is highly useful in clinical practice and allows good interaction between the patient and ventilator. The major uses of this mode are to reduce the work of breathing in patients with intact spontaneous breathing and to provide additional support during weaning from mechanical ventilation, especially when this has been prolonged.

[Right varicocele as first manifestation of situs inversus]. / Varicocele derecho como primera manifestacion de un situs inversus.

Traditionally, right varicoceles have been considered a rare entity nearly always secondary to a neoplastic or retroperitoneal disease. There are other possible etiologies for right varicoceles such as the venous disease of the large veins and visceral malposition syndromes. This paper presents one case report of right varicocele as the only clinical sign of situs inversus. Revision of the literature and nomenclature of these syndromes.

[Paratesticular epithelioid hemangioendothelioma: an infrequent vascular tumor]. / Hemangioendotelioma Epitelioide paratesticular: un tumor vascular poco frecuente.

Paratesticular vascular lesions are very uncommon. One of them, the epithelioid hemangioendothelioma, is a vascular tumour which grows around a vessel and in characterized for presenting epithelioid endothelial cells. Is very rare and it has good prognosis. This paper reports one case of paratesticular epithelioid hemangioendothelioma.

[Eosinophilic cystitis: a single anatomopathologic entity and three different presentation forms. Proposed classification]. / Cistitis eosinofílica: un único cuadro anatomopatológico y tres diferentes formas de presentación. Propuesta de clasificación.

The present work was intended to be a revision of our series of Eosinophilic Cystitis and we have found that, from one single anatomicopathological picture three different clinical pictures emerge with different treatments and prognosis. Group I is constituted by young people and children with a profuse background of atopy and parasitosis, which develop mictional syndrome and haematuria and show good response to steroids. Group II includes middle-aged women, with development of chronic recurrent cystopaty and a poor response to treatment. Group III comprises elderly patients with a history of vesical injury or chronic vesical irritation, with no separate clinical signs and symptoms and requiring no treatment.

[Late adrenal gland metastasis of contralateral renal adenocarcinoma]. / Metástasis suprarrenal tardía por adenocarcinoma renal contralateral.

A case of adrenal gland metastasis caused by contralateral adenocarcinoma of kidney nephrectomized 11 years previously in a 68 years old patient is presented. The rarity of the case due to its limited frequency and the long disease-free interval is emphasized, and the possible routes of metastatic affectation of the adrenal gland by renal tumors discussed.

[Vesico-uterine fistula, a rare complication of cesarean section]. / Fístula vésicouterina, una rara complicación del parto por cesárea.

We present the case of a vesicouterine fistula secondary to a caesarean section indicated due to the disproportion the pelvis and the head of the baby. This kind of fistula is due fundamentally to obstetric causes, especially to caesarean sections in developed countries and to prolonged labour in developing countries. The commonest clinical presentation is urinary incontinence in the form of continuous or intermittent urinary leaks. Surgical treatment is generally the therapy of choice, although, in the case of small fistulas, conservative treatment is feasible. The best form of prevention is correct indication of caesarean section and careful surgical technique.