Effect of Magnetic Field Strength on Plastic Scintillation Detector Response.

PURPOSE: To characterize the response of plastic scintillation detectors (PSDs) to high-energy photon radiation as a function of magnetic field strength. MATERIALS AND METHODS: PSDs were placed inside a plastic phantom held at the center point between 2 magnets and irradiated using a 6-MV photon beam from a linear accelerator. The magnetic field was varied from 0 T to 1.5 T by 0.3-T increments. The light emission and stem-effect-corrected response as a function of magnetic field strength were obtained for both a commercial PSD (Exradin W1, Standard Imaging) and an in-house hyperspectral PSD. Spectral signatures were obtained for the in-house PSD, and light emission from a bare fiber was also measured. RESULTS: Light emission increased as magnetic field strength increased for all detectors tested. The tested PSDs exhibited an increase in light intensity of 10% to 20%, mostly owing to the increase in Cerenkov light produced within and transmitted along the optical fiber. When corrected for stem effects, the increase in PSD response went down to 2.4% for both detectors. This most likely represents the change in the inherent dose deposition within the phantom. CONCLUSION: PSDs with a suitable stem-effect removal approach were less dependent on magnetic field strength and had better water equivalence than did ion chambers tested in previous studies. PSDs therefore show great promise for use in both quality assurance and in-vivo dosimetry applications in a magnetic field environment.

Relevance of routine Doppler sampling at the two umbilical arteries in the follow-up of dichorionic twin pregnancies with intrauterine growth-restricted fetuses.

OBJECTIVE: The aim of this study is to assess if the presence of bilateral absent or reverse end-diastolic velocity (AREDV) indicates a poorer prognosis than unilateral AREDV in dichorionic-diamniotic twin pregnancies complicated by intrauterine growth restriction. METHODS: A prospective observational study of 36 dichorionic-diamniotic twin pregnancies complicated by intrauterine growth restriction. One hundred and fifty seven ultrasound (US) examinations were performed. The pulsatility indexes (PI) of the two umbilical arteries (UA-perivesical site), the middle cerebral artery (MCA) and the ductus venosus (DV) were recorded. The fetal hemodynamic status was represented by the existence of a bilateral positive end-diastolic velocity (PEDV), a unilateral AREDV or a bilateral AREDV in the umbilical arteries. RESULTS: Bilateral PEDV, unilateral AREDV and bilateral AREDV represented respectively 66.0%, 10.6% and 23.4% of the US examinations. Intervals between Doppler examinations and delivery were significantly longer (P<0.005) in the bilateral PEDV group (26.5 days±19.7) than in the unilateral AREDV group (11.8 days±11.7) and in the bilateral AREDV group (11.0 days±8.6). MCA-PI, DV-PI, IFI and early neonatal outcomes did not differ between the unilateral and bilateral AREDV groups. CONCLUSION: The routine measurement of the Doppler indices of the two umbilical arteries seems to be no more relevant than unilateral measurement in fetuses of dichorionic-diamniotic twin pregnancies complicated by intrauterine growth restriction.

Sci-Thur PM: YIS - 10: A new optically encoded single-fiber plastic scintillation detector for multi-point radiation dosimetry.

PURPOSE: To develop a new multi-point plastic scintillation detector (mPSD) that allows for simultaneous dose measurements at multiple points and uses a single optical guide. MATERIALS AND METHODS: Two different prototypes were built. A two-point mPSD was built and light discrimination was based on the use of multiple color filters at the outputs of a network of optical fiber splitters. Light intensity was measured by an EMCCD camera. For the three-point mPSD, the light discrimination setup was replaced by a low-noise spectrometer. Depth-dose and profiles measurements were obtained on a 6 MV photon beam with the mPSDs inside a water phantom. An ion chamber was also used for comparison purpose. Finally, the three-point mPSD was tested under an Ir-192 high-dose-rate (HDR) brachytherapy dose delivery and compared to the treatment planning system. RESULTS: A good agreement was found between the measured and expected dose for both mPSDs. The average relative differences to the ion chamber measurement for the two-point mPSD were of (2.4 ± 1.6)% and (1.3 ± 0.8)%. For the three-point mPSD, these differences were of (2.3±1.1)%, (1.6±0.4)% and (0.32±0.19)%. The latter mPSD was shown very versatile, being able to measure dose from HDR brachytherapy with an average accuracy of (2.3±1.0)% per catheter. CONCLUSIONS: The practical feasibility of mPSDs using a single optical guide has been demonstrated under irradiation from a 6 MV photon beam and an Ir-192 HDR brachytherapy source. Their application for pre-treatment quality assurance and in vivo dosimetry will be various.

Sci-Sat AM: Brachy - 07: Plastic scintillation detector validation for kV dosimetry.

PURPOSE: To characterize the plastic scintillation detectors (PSDs) response in the diagnostic energy range. A fast and adaptable method for real-time dosimetry in superficial x-ray therapy and interventional radiology is proposed. METHOD: A PSD (1 mm diameter and 10 mm long) is coupled to a 5 m long optical fiber. Scintillation photons are guided to a polychromatic photodiode which provides an electrical current proportional to the input light signal. If the incident energy spectrum is known, the dose measured in the PSD's polystyrene sensitive volume can be converted to score dose in any other media such as air, water or soft tissues using the large cavity theory (LCT). A software simulating x-ray tube spectra and filtration has been benchmarked and is used for analysis. The method is confirmed by Monte Carlo simulations. RESULTS: PSDs cannot be assumed energy independent with low-energy photons as a factor 2 has been observed in the energy response between 80 kVp and 150 kVp. When the dose is converted to the desired medium, the PSD's energy dependence is compensated and a 2.1% standard deviation was observed upon the studied energy ranges, which is inside the measurement and calculation uncertainties. Percent depth dose (PDD) measurements are in good agreement with Monte Carlo simulations and results can be improved if the proposed method is applied to compensate beam hardening. CONCLUSION: PSDs present great potential for real-time dose measurements with radiologic photon energy.

WE-G-BRB-05: On the Importance of Fluorescence Within the Stem Effect of Scintillation Detectors.

PURPOSE: To quantify the nature and composition of the light produced in optical fibers under different irradiation conditions and evaluate its impact on dosimetry. METHODS: Irradiation of a bare PMMA optical fiber (Mitsubishi ESKA Premier) was performed using a superficial therapy unit, an Ir-192 HDR brachytherapy source, a Co-60 external-beam unit as well as photon and electron beams from a linear accelerator. Spectra of the radiation-induced visible light in the fiber were acquired and signals were compared as a function of depth and irradiation type. Irradiation of a 75 kVp beam from the superficial therapy unit was used to isolate the fluorescence spectrum. Isolation of the Cerenkov spectrum component was obtained from irradiation of a 15 MeV electron beam at a 45 degree angle. Relative composition in fluorescence and Cerenkov of the stem effect light has been determined for all irradiations. RESULTS: The total stem effect spectra can be represented by a linear superposition of the fluorescence and Cerenkov spectra. The fluorescence contribution was shown to strongly differ between the superficial therapy unit (99%±1%), the Ir-192 HDR source (25%±3%) and higher energy irradiations (3%±2%). Variations within each energy regime (kV, HDR brachytherapy and MV) were small at 3% or lower. These were observed for irradiations at angle or when the fiber was near the surface. This study suggests it is better to calibrate the stem effect of a scintillation detector using the same irradiation modality. CONCLUSIONS: Stem effect light was shown to be composed of fluorescence and Cerenkov light in different proportions depending on the geometry of the experimental setup, nature of the irradiation, and irradiation energy. Calibrating detectors separately for fluorescence and Cerenkov may lead to better performance of the stem effect removal technique.

WE-G-BRB-04: BEST IN PHYSICS (THERAPY) - A Novel Multi-Point Plastic Scintillation Detector for in Vivo Dosimetry and Quality Assurance in Radiation Therapy.

PURPOSE: To develop a novel multi-point plastic scintillation detector (mPSD) capable of accurately measuring dose at multiple positions simultaneously with the use of a single optical guide. METHODS: We built a new generation of plastic scintillation detectors composed of multiple scintillating elements along a same optical transmission line. Three different scintillating fibers were optically coupled to a single collecting optical fiber. A primary challenge for this new type of detector is that the output signal is a superposition of multiple scintillation spectra and contaminating elements. Acquisition with a spectrometry setup allows for the implementation of a new hyperspectral approach that accounts for each light-emitting component separately, and allows spectral unmixing. The mPSD and an ion chamber were irradiated in a water phantom with a 6 MV photon beam. Profiles and depth-dose curves were measured and compared between detectors. This detector and the corresponding calibration approach were also applied to Ir- 192 HDR brachytherapy. RESULTS: Doses measured with the mPSD were in good agreement with the ion chamber measurements for external beam irradiations. Average relative differences of (2.3±1.1)%, (1.6±0.4)% and (0.32±0.19)% were observed for each scintillating element. The mPSD measurements tended to be at least as accurate as published measurements from single-point PSDs. For the Ir-192 HDR brachytherapy application, the average difference between the treatment planning system and the measurements were (4.6±1.0)% per dwell-position and (2.1±1.0)% per catheter. The accuracy of each scintillating element was shown to depend on light attenuation and on the similarity of its scintillation spectrum in comparison to the other light emitters. CONCLUSIONS: The feasibility and accuracy of mPSDs using a single transmission line was demonstrated. In addition to well-documented advantages of single-point PSDs, the multi-point capability of this single-fiber detector makes mPSDs a very promising new technique for quality assurance and on-line in vivo dosimetry.

Evaluation of the CHOP cardiovascular score as a prognostic predictor of outcome in twin-twin transfusion syndrome after laser coagulation of placental vessels in a prospective cohort.

OBJECTIVE: To investigate the prognostic value of cardiac function assessment by the previously reported CHOP (Children's Hospital of Philadelphia) cardiovascular score in twin-twin transfusion syndrome (TTTS). METHODS: All consecutive monochorionic pregnancies presenting with TTTS over a 24-month period were evaluated by preoperative echocardiography before percutaneous laser coagulation of chorionic vessels. Each of the 12 items of the CHOP score was evaluated prospectively and the cardiovascular score was categorized into stages using previously published cut-offs. The outcome considered for this study was neonatal survival of neither, one or both twins. RESULTS: In total, 215 pregnancies were enrolled. Due to technical issues, CHOP evaluation was incomplete in 16% of cases and follow-up was unavailable in 12%. Overall, there was a significant relationship between the CHOP score and the Quintero staging system, although this relationship was significantly reduced when parameters used in the Quintero system were removed from the CHOP score. Based upon neonatal survival, the CHOP score did not show any prognostic value regarding overall pregnancy outcome or individual recipient survival. CONCLUSION: Cardiac function assessment using the CHOP score is not of clinical use as a prognostic marker in TTTS. This suggests that cardiac function may not be of interest for preoperative staging when laser coagulation is the first-line treatment, other than to confirm the diagnosis of TTTS requiring surgery.

Profiling fetal cardiac function in twin-twin transfusion syndrome.

OBJECTIVES: Cardiomyopathy in the recipient twin is a marker of severity in twin-twin transfusion syndrome (TTTS), making it a potentially valuable tool for staging the disease. This study aimed to provide a quantitative description of cardiac function in the recipient twin. METHODS: Consecutive monochorionic pregnancies complicated with TTTS and treated by percutaneous laser coagulation underwent fetal echocardiography before surgery. An unsupervised classification analysis was conducted to identify groups of twins with similar cardiac profiles. The predictive value of the recipient twin's preoperative cardiac function based on these profiles was assessed, using perinatal death of at least one twin as the main outcome. The cardiac function profiles that we identified were compared with the current Quintero staging. RESULTS: A total of 107 pregnancies were included, with six of these lost to follow-up; 63/107 complete cases were available for multivariate description of the recipient's cardiac function. Three different preoperative cardiac profiles were identified with increasing right and left myocardial performance index, decreasing right and left shortening fraction, and increasing ductus venosus pulsatility index. Although the three groups represented progressive stages of the syndrome-related cardiomyopathy, no correlation was found with pregnancy outcome. Of Quintero Stage 1 cases, 55% showed significant alterations of cardiac function in the recipient twin. CONCLUSIONS: Progressive cardiomyopathy can be assessed quantitatively in the recipient twin and does not influence pregnancy outcome when fetoscopic laser coagulation is the first-line treatment. Compared with the current staging, cardiac profiling allows discrimination of cases with significant myocardial dysfunction.

Feasibility and reliability of Doppler flow recordings in the fetal aortic isthmus: a multicenter evaluation.

OBJECTIVES: To evaluate the performance of three different centers with respect to their ability to identify the fetal aortic isthmus (AoI) adequately and place a Doppler sample volume in the AoI correctly, and to address the reproducibility of the isthmic flow index (IFI) calculated from Doppler waveforms recorded in the three centers. METHODS: The three collaborating centers sent several ultrasonographic recordings taken at random over a 6-week period to the Saint-Justine Fetal Cardiology Unit (StJ-FCU). A performance quotient ((number of total readings - number of unsatisfactory results)/number of total readings) was calculated for each center by each of three judges, who were experienced fetal cardiologists, to assess the ability of each center to identify the isthmus and to place the Doppler sample volume (DSV) adequately. Intraclass correlation coefficients (ICC) were computed to quantify the variability of IFI measurements ((systolic + diastolic)/systolic flow velocity integrals). RESULTS: Fifty-five recordings were available for this study. Concerning isthmus identification, there was 100% agreement between the three judges from StJ-FCU and the performance quotients of Centers A, B and C were: 0.90, 0.95 and 1.00, respectively. For DSV positioning, agreement between the judges varied; for Judge 1 vs. Judge 2, kappa = 0.836 (95% CI, 0.651-1.000); for Judge 1 vs. Judge 3, kappa = 0.773 (95% CI, 0.557-1.000); for Judge 2 vs. Judge 3, kappa = 0.941 (95% CI, 0.805-1.000). The performance quotients of the three centers for DSV positioning were consistently lower than were those for identification of the isthmus, being 0.85, 0.76 and 0.92, respectively. The ICC between the first and second measurements of the IFI by Rater 1 was 0.96 (95% CI, 0.93-0.98, P < 0.001) and that between Raters 1 and 2 was 0.97 (95% CI, 0.95-0.99, P < 0.001). CONCLUSION: Adequate imaging of the fetal AoI can be achieved easily by a trained sonographer, while DSV positioning is challenging. The intra- and interrater variability of the IFI are low.

A methodology for identifying vulnerable locations to taste and odour problems in a drinking water system.

In this research, methodology was developed to identify locations vulnerable to taste and odour problems in a distribution system. The methodology was based on a multicriteria procedure combining spatial information on consumer complaints and popular perception of tap water. The first step in the described methodology consisted of mapping complaints regarding tap water made by the population between 2002 and 2004 using a geographical information system (GIS). The second step consisted of analysing results of a questionnaire-based mail survey, also through GIS. The information generated using the above steps was integrated using a multicriteria and spatial approach allowing segregation of the distribution system into delineated zones, according to their vulnerability to occurrences of taste and odour problems. The identification of vulnerable sectors in a distribution system will help water managers to implement a better-targeted water quality monitoring programme--one that considers odours and tastes of drinking water--within the management process.

Early intertwin differences in myocardial performance during the twin-to-twin transfusion syndrome.

BACKGROUND: In the twin-to-twin transfusion syndrome (TTTS), pressure rather than volume overload is increasingly considered as a key factor in the pathogenesis of the cardiomyopathy of the recipient twin. If this is the case, cardiac dysfunction should be among the first signs observed with TTTS. The objective of this study was to determine whether intertwin differences in myocardial function are modified early in the course of TTTS and whether they can help to differentiate this condition from intrauterine growth restriction (IUGR). METHODS AND RESULTS: Eight variables were analyzed on the first fetal echocardiography on 21 pairs of twins with TTTS and 11 with IUGR. No difference was found between the 2 groups for the cardiothoracic ratio, pulsatility indices in the umbilical and middle cerebral arteries, and peak velocity of the middle cerebral artery. Significant difference was found for ventricular septal thickness, but with no association with the conditions under study. With TTTS, left ventricular shortening fraction was consistently greater in the donor twins, and myocardial performance indices (MPIs) were elevated in the recipient twins. This increase in MPI was caused by a lengthening of the isovolumic periods compared with those of the donor twin: left ventricular and right ventricular isovolumic periods 0.105+/-0.047 and 0.097+/-0.026 seconds, respectively, for the recipient twins versus 0.0561+/-0.46 and 0.065+/-0.03 seconds, respectively, for the donor twins (P<0.001). These changes in the isovolumic periods were mainly due to significant prolongation of isovolumic relaxation times. A change in left ventricular MPI > or =0.09 combined with a change in right ventricular MPI > or =0.05 would identify a TTTS with a sensitivity of 75% and a false-positive rate of 9%. CONCLUSIONS: The observed diastolic function impairment goes along with the pressure-overload pathogenic concept proposed in TTTS. Assessment of intertwin difference in MPI is a valuable tool for early differential diagnosis between TTTS and isolated IUGR.

Management of fetal tachyarrhythmia based on superior vena cava/aorta Doppler flow recordings.

OBJECTIVE: To evaluate a management protocol of fetal supraventricular tachycardia (SVT) based on prior identification of the underlying mechanism. DESIGN AND SETTING: Prospective study in a mother-child tertiary university centre. PATIENTS: During a consecutive 36 month period, 18 fetuses with sustained SVT underwent a superior vena cava/ascending aorta (SVC/AA) Doppler investigation in an attempt to determine the atrioventricular (AV) relation and to treat the arrhythmia according to a pre-established management protocol. MAIN OUTCOME MEASURE: Rate of conversion to sinus rhythm. RESULTS: Seven fetuses had short ventriculoatrial tachycardia, five of these with a 1:1 AV conduction suggesting re-entrant tachycardia. The first choice drug was digoxin and all were converted. One fetus had AV dissociation leading to the diagnosis of junctional ectopic tachycardia, which was resistant to digoxin and sotalol; amiodarone achieved postnatal conversion. One fetus had SVT and first or second AV block; the diagnosis was atrial ectopic tachycardia (AET), which responded to sotalol given as a drug of first choice. Seven fetuses had long ventriculoatrial tachycardia: one with sinus tachycardia (no treatment), one with permanent junctional reciprocating tachycardia (PJRT), and three with AET. The first choice drug was sotalol and all were converted. One AET was classified postnatally as PJRT. Six fetuses had intra-atrial re-entrant tachycardia: five with 2:1 AV conduction and one with variable block. The first choice drug was digoxin. Conversion was achieved in all but one, who died after birth from advanced cardiomyopathy. CONCLUSION: The electrophysiological mechanisms of fetal SVT can be clarified with SVC/AA Doppler. The proposed management protocol has so far yielded a good rate of conversion to sinus rhythm.

Mannan-binding lectin in children with Escherichia coli O157:H7 haemmorrhagic colitis and haemolytic uraemic syndrome.

Mannan-binding lectin (MBL) triggers complement activation upon binding to microbial surfaces. MBL deficiency has been associated with increased susceptibility to severe bacterial infections. We hypothesized that MBL deficiency may predispose children to Shiga toxin-producing Escherichia coli (STEC) O157:H7 infections and the associated haemolytic uraemic syndrome (HUS). We compared circulating levels of MBL among children with uncomplicated O157:H7 haemorrhagic colitis (HC), patients with O157:H7 HUS, normal and diseases control groups. Circulating MBL concentrations on admission were as follows: 3.22 +/- 2.43 micro g/ml among normal controls (n = 23); 2.90 +/- 2.44 micro g/ml in patients with rotavirus enteritis (n = 10); 2.78 +/- 1.65 micro g/ml in children with HC due to non-STEC bacterial pathogen (n = 15); 2.67 +/- 2.44 micro g/ml in patients with uncomplicated O157:H7 HC (n = 27); 2.80 +/- 2.97 micro g/ml in children with O157:H7 HUS (n = 15); 6.70 +/- 4.49 micro g/ml in patients with chronic renal failure unrelated to O157:H7 infection (n = 6). Higher MBL levels were found in patients with chronic renal failure compared to O157:H7 HC (P < 0.047). However, MBL concentrations <0.5 micro g/ml, which have been associated with MBL deficiency in relation to increased susceptibility to infections, were noted at comparable rates between the different groups (P = NS). Our data does not support that MBL deficiency may predispose to O157:H7 infections nor than the development of diarrhoea associated HUS.

Reference values for an index of fetal aortic isthmus blood flow during the second half of pregnancy.

OBJECTIVE: During fetal life, the parallel position of the two cardiac ventricles confers a special status to the aortic isthmus. Flow through the isthmus reflects the balance between the performances of the two ventricles and their respective peripheral impedances. This study proposes a fetal aortic isthmus flow velocity index and its reference values defined on the basis of gestational age (GA). METHODS: Video recordings of 111 normal fetuses from 18 to 39 weeks of gestation were retrospectively reviewed. An isthmus flow velocity index (IFI) was calculated as follows: IFI = (systolic + diastolic)/systolic velocity integrals. GA-specific reference ranges of IFI were constructed. RESULTS: An IFI of 1.33 +/- 0.03 was found at 18 weeks. This value decreased slightly but steadily with GA to reach 1.23 +/- 0.16 at 39 weeks. This change is mainly related to a decrease in diastolic velocity integrals. CONCLUSION: The proposed IFI provides information on the direction and, indirectly, on the volume of blood flow through the fetal aortic isthmus.

Changes in flow velocity patterns of the superior and inferior venae cavae during placental circulatory insufficiency.

OBJECTIVES: Placental circulatory insufficiency, expressed by the disappearance of the diastolic component of the umbilical artery Doppler velocity waveforms, causes blood flow redistribution that could disturb, to different extents, the systemic venous returns to the heart. The purpose of this study was to investigate the effect of an absence of diastolic blood flow in the umbilical artery on the relationship between the Doppler flow velocities of the venae cavae. METHODS: Fifteen normal fetuses (normal group) were matched for gestational age with 11 fetuses with absent diastolic flow in the umbilical artery (abnormal group). In the venae cavae, the following Doppler variables were measured and compared between groups: (a) during ventricular systole: maximum (S(max)) and minimum velocities (S(min)) and velocity integrals (SI); (b) during ventricular diastole: peak velocity of the E-wave and its integral (EI), the A-wave and its integral (AI). A venous velocity index (VVI) was defined as (S(max) + S(min))/S(max). RESULTS: In the normal group, S(min) and VVI were significantly higher in the inferior vena cava (IVC) than in the superior vena cava (SVC). The ratio SVC-VVI/IVC-VVI was therefore always less than one. In the abnormal group, S(min), SI, E, EI and VVI were higher in the SVC compared to those of the IVC. The ratio SVC-VVI/IVC-VVI was always greater than one. CONCLUSION: In the absence of umbilical artery diastolic flow, a reciprocal shift is observed between the IVC and SVC velocity waveforms characterized by a flow profile in the IVC which resembles that of a normal SVC profile and vice versa. These changes are another manifestation of blood flow redistribution towards the brain in the presence of placental circulatory insufficiency. They should be taken into account on Doppler assessment of ventricular diastolic function based on venous flow patterns during placental circulatory impairment.

[Investigation of fetal arrhythmias by simultaneous recording of ascending aortic and superior vena caval blood flow]. / Investigation des arythmies foetales par l'enregistrement simultané des vélocités sanguines dans l'aorte ascendante et la veine cave supérieure.

In a period of 18 consecutive months, all the foetus referred to our Foetal Cardiology Unit for investigation of arrhythmia were systematically assessed by M mode echocardiography and simultaneous recording of blood flow in the superior vena cava and the aorta (SVC/Ao). This study was undertaken to compare the performance of these two approaches. The foetus were classified into three groups according to the arrhythmia diagnosed: Group 1: irregular arrhythmias, Group 2: bradycardias, Group 3: tachycardias. A surface ECG was recorded in all the neonates in whom the arrhythmias persisted. In Group 1, including 50 cases of extrasystoles (49 atrial and 1 ventricular), M mode echo and the Doppler provided the diagnosis in 42 and 47 cases respectively. This difference was not statistically significant. Group 2 comprised four cases of bradycardia (2 blocked atrial bigeminy, 2 complete atrioventricular blocks); the two methods provided the diagnosis in all 4 cases. Group 3 comprised 11 cases including 7 supraventricular tachycardias (SVT), 2 flutter, 1 chaotic atrial rhythm and 1 ectopic junctional rhythm. Complete analysis of these arrhythmias was possible by M mode in 4 cases and by Doppler in all cases. This difference was significant. The distribution of the 7 cases of SVT with respect to the duration of the ventriculoatrial interval was possible by M mode in 2 cases and in all cases by Doppler. This was a decisive factor in the choice of antiarrhythmic therapy. The authors conclude that Doppler and M mode are two echocardiographic approaches which are equally effective in the investigation of foetal atrial extrasystoles and probably of sustained foetal bradycardia. However, Doppler recording of SVC/Ao gives a more detailed and precise diagnosis of more complex foetal arrhythmias.

Pathogenesis of Shiga toxin-associated hemolytic uremic syndrome.

The aim of this review is to examine recent advances in experimental and clinical research relevant to the pathogenesis of diarrhea-associated hemolytic uremic syndrome with special reference to histopathologic findings, virulence factors of Shiga toxin-producing Escherichia coli, the host response, and the prothrombotic state. Despite significant advances during the past decade, the exact mechanism by which Shiga toxin-producing E. coli leads to hemolytic uremic syndrome remains unclear. Factors such as Shiga toxin, lipopolysaccharide, the adhesins intimin and E. coli-secreted proteins A, B, and D, the 60-MD plasmid, and enterohemolysin likely contribute to the pathogenesis. Data on the inflammatory response of the host, including leukocytes and inflammatory mediators, are updated. The pathogenesis of the prothrombotic state leading to thrombocytopenia secondary to endothelial cell damage and platelet activation is also discussed. A hypothetical sequence of events from ingestion of the bacteria to the development of full-blown hemolytic uremic syndrome is proposed.

Pediatric sepsis and multiple organ dysfunction syndrome.

Systemic inflammatory response syndrome may be viewed as the systemic expression of cytokine signals that normally function on an autocrine or paracrine level. Sepsis is defined as systemic inflammatory response syndrome caused by an infection. Multiple organ dysfunction syndrome may represent the end stage of severe systemic inflammatory response syndrome or sepsis. Many cells are involved, including endothelial cells and leukocytes and multiple proinflammatory and antiinflammatory mediators (cytokines, oxygen free radicals, coagulation factors, and so forth). Various pathophysiologic mechanisms have been postulated. The most popular theory is that the inflammatory process loses its autoregulatory capacity; however, microcirculatory dysregulation and apoptosis may also be important, and a new paradigm posits a complex nonlinear system. Many new treatments have been studied recently. The usefulness of immune modulating diets remains to be evaluated. Molecular immunomodulation is still of unclear value. The therapy of sepsis and multiple organ dysfunction syndrome remains mainly supportive.

Fetal cardiac performance in uncomplicated and well-controlled maternal type I diabetes.

OBJECTIVE: To study the impact of well-controlled, uncomplicated maternal diabetes on fetal cardiac development and performance. METHODS: The following variables were studied in 45 fetuses of type I diabetic women by means of mid- and late-trimester echocardiography: interventricular septal thickness; aortic and pulmonary valve diameters; peak and time-to-peak flow velocity of the great arteries; the ratio between peak velocities during early (E) and late (A) ventricular filling at the level of the atrioventricular values; ventricular fractional shortenings; and output. The findings were compared to age-matched control groups of normal fetuses. RESULTS: A significant augmentation of interventricular septal thickness was demonstrated for mid-trimester fetuses of diabetic women, which progressed further towards the end of pregnancy. However, the indices of diastolic and systolic function remained comparable between the gestational age-matched groups. CONCLUSION: Progressive myocardial thickening occurs commonly in mid- and late-trimester fetuses of uncomplicated and well-controlled diabetic pregnancies. The observed degree of hypertrophy is generally mild and does not affect age-related changes in fetal cardiac function.