Area of the right atrium of the fetal heart and its significance in fetuses with tricuspid regurgitation.

OBJECTIVES: The first aim was to develop a nomogram for the area of the right atrium (ARA) of the fetal heart in uncomplicated singleton pregnancies. The second aim was to assess diagnostic indices of ARA to distinguish between tricuspid regurgitation (TR) with and without concomitant congenital heart defect (CDH). METHODS: The study was conducted between 2014 and 2019. Fetal echocardiography was performed on fetuses with and without TR. For the first aim, ARA was measured in 460 fetuses without proven structural and chromosomal abnormalities, and for the second aim, ARA was measured in 1077 fetuses with TR. RESULTS: A nomogram for the ARA of fetuses with normal hearts was developed. TR was observed in 4.5% (1077/23,771) of euploid fetuses; 4.3% (1020/23,771) of fetuses had TR without a concomitant CHD, and 0.2% (57/23,771) fetuses had TR with a concomitant CHD. No significant differences in ARAs were found between fetuses with normal hearts without TR (n = 22,694) and fetuses with TR without CHD (n = 1020; p = .751). Fetuses with TR and CHDs had different ARA than fetuses with normal hearts without TR and fetuses with TR without CHD (p < .0005 in both cases). CONCLUSIONS: ARA seems to be an auxiliary marker to distinguish the presence of CHD in fetuses with TR.

Hydrocephalus Caused by Primary Fourth Ventricle Outlet Obstruction: Our Experience and Literature Review.

OBJECTIVE: Primary fourth ventricle outlet obstruction (PFVOO) is a rare cause of hydrocephalus with an unclear etiopathogenesis, and thus, consensus regarding the recommended treatment protocol is lacking. This study aims to summarize current knowledge of this condition in the light of our own treatment experience. METHODS: Retrospective analysis was carried out of all patients treated for noncommunicating tetraventricular hydrocephalus between 2006 and 2019, from which a subgroup of patients with PFVOO was created. A literature review of PFVOO cases was also carried out. RESULTS: A total of 62 patients with PFVOO were discovered, of whom 8 were treated at our institution, representing 3.8% of our patients with noncommunicating hydrocephalus. Patients most commonly presented with headaches, gait disturbance, or symptoms of intracranial hypertension. The mean follow-up duration was 75.4 months among our patients and 29.9 months in the literature. Most patients (54.8%) were treated by endoscopic third ventriculostomy (ETV), with the remainder undergoing suboccipital craniotomy alone (17.7%) or in combination with shunt surgery (9.7%), or endoscopic magendieplasty (12.9%). Treatment failure was noted in 28.6% of ETVs and 9% of craniotomies. No failures were recorded after endoscopic magendieplasty. The risk of treatment failure was found to be significantly higher with ETV compared with other treatment modalities (P < 0.0005). CONCLUSIONS: Despite the fact that PFVOO can be defined as an obstructive hydrocephalus, there seems to be a higher risk of ETV failure in such cases. The alternative treatment modalities presented are still recommended. Confirmation of these findings requires a larger multicenter study.

Parents' request for termination of pregnancy due to a congenital heart defect of the fetus in a country with liberal interruption laws.

Objectives: This study aimed to evaluate the prenatal rate of congenital heart defects (CHDs) and the frequency of termination of pregnancy (TOP) due to a CHD, depending on the severity of the defect and concomitant diseases of the fetus.Methods: The data were assessed retrospectively between 2002 and 2017. Ultrasound examination was performed mostly in the second trimester. For analysis, the CHDs were divided into three groups of severity and three groups of fetus impairment.Results: A total of 40,885 fetuses underwent echocardiography. The CHDs were detected in 1.0% (398/40,885) and were an isolated anomaly in 69% (275/398). Forty-nine percent (197/398) of families decided to TOP. In all groups of severity, the rate of TOP rose linearly when comparing isolated defects and cases with associated morphological and genetic impairments. The TOP was significantly dependent on the associated anomalies in patients with the most correctable defects (p < .001) and the severity of CHDs in isolated cases without any other impairment (p < .001).Conclusion: The parents' decision to terminate increased with the severity of the defect and the associated anomalies of the fetus. The parents were mostly influenced by the associated anomalies when the CHD was correctable, and genetic factors played a more important role than morphological ones.

The role of third ventricle bowing in the success of endoscopic third ventriculostomy in pediatric and adult patients.

OBJECTIVE: Preoperative third ventricle deformation (known as 'bowing') is associated with higher endoscopic third ventriculostomy (ETV) success. In children, the effect of bowing has not to date been systematically studied. Aim of of this study is to determine the effect of bowing on ETV success in adult and child patients. PATIENTS AND METHODS: In this retrospective, monocentric study were included 135 (70 adults and 65 children) of 157 patients who underwent ETV between 2008-2016, with mean follow-up 4.3 years. Presence and extent of bowing and its impact on ETV outcome were evaluated. Third ventricular anatomy was assessed on pre- and postoperative MR imaging. RESULTS: In patients > 6 months old, the ETV success rate was 91% in bowing-positive cases and 47.6% in bowing-negative cases. Among patients < 6 months old, ETV was successful in 37% of those with bowing and 36.4% of those without. Presence of bowing strongly indicates ETV success in patients older than 6 months (p < 0.000 5), including children of 7 months and older (p 0.001). This relationship was not confirmed in pediatric patients up to 6 months old (p 1.000). The extent of bowing does not influence ETV success (p 0.559). Bowing correction strongly correlates with ETV success (p < 0.000 5). CONCLUSION: We confirmed significant correlation between bowing and ETV success in patients over 6 months old. This relationship was not determined in those younger than 6 months and therefore we do not recommend bowing in ETV indication criteria for this patient cohort.

Cytarabine + G-CSF is more effective than cyclophosphamide + G-CSF as a stem cell mobilization regimen in multiple myeloma.

Cyclophosphamide (Cy) plus granulocyte-colony stimulating factor (G-CSF) is currently a standard regimen for hematopoietic stem cell (HSC) mobilization in patients with multiple myeloma (MM). However, cytarabine (AraC) in intermediate doses plus G-CSF seems to have a higher mobilization efficacy. The aim of this study was to retrospectively compare mobilization using AraC and Cy. Thirty consecutive MM patients were mobilized by Cy + G-CSF, and the subsequent 40 patients by AraC + G-CSF. Both groups were comparable. The target yield of 10 × 106 CD34+ cells/kg (for tandem and 2 additional transplantations) was achieved in 98% (AraC) and 57% (Cy) of patients (p < 0.0001) by 1.2 and 2.1 apheresis (means), and by single apheresis in 83 and 17% of patients, respectively. AraC mobilization resulted in higher peak concentration of CD34+ cells in blood (median 238.0 vs. 87.9/µL, p < 0.0001) and higher CD34+ yield (median 28.6 × 106 vs. 10.4 × 106/kg, p < 0.0001) compared to Cy mobilization. Toxicities were comparable except for thrombocytopenia gr. 4, observed in 50% of patients after AraC (Cy 7%). In view of these results, we conclude that mobilization with AraC plus G-CSF is very effective with acceptable toxicity and could be considered in MM patients with planned or expected higher numbers of transplantations.

Diffusion-weighted magnetic resonance imaging is more sensitive than dimercaptosuccinic acid scintigraphy in detecting parenchymal lesions in children with acute pyelonephritis: A prospective study.

INTRODUCTION: Static renal scintigraphy is the gold standard for detection of inflammatory changes in the renal parenchyma in acute pyelonephritis. Our aim was to determine whether diffusion-weighted magnetic resonance imaging (DW-MRI) was comparable with static renal scintigraphy (DMSA-SRS) to demonstrate acute renal parenchymal lesions. OBJECTIVE: To compare 99mTc-dimercaptosuccinic acid static renal scintigraphy (DMSA-SRS) with diffusion-weighted magnetic resonance imaging (DW-MRI) for detecting acute inflammatory changes in the renal parenchyma in children with febrile urinary tract infection. METHODS: Thirty-one children (30 girls) aged 3-18 years with a first episode of febrile UTI without a previously detected congenital malformation of the urinary tract, were prospectively included. DMSA-SRS and DW-MRI were performed within 5 days of diagnosis to detect renal inflammatory lesions. The DW-MRI examination was performed without contrast agent and without general anesthesia. Late examinations were performed after 6 months using both methods to detect late lesions. RESULTS: DW-MRI confirmed acute inflammatory changes of the renal parenchyma in all 31 patients (100%), mostly unilateral. DMSA-SRS detected inflammatory lesions in 22 children (71%; p = 0.002). The lesions were multiple in 26/31 children (84%) on DW-MRI and in 9/22 (40%) on DMSA-SRS. At the control examination, scarring of the renal parenchyma was found equally by DW-MRI and DMSA-SRS in five patients (16%), three of whom were the same patients. The overall concordance of positive and negative late findings occurred in 87% of patients. There was correspondence in the anatomical location of acute and late lesions. DISCUSSION: The clinical significance of acute and late parenchymal findings on DWI-MR is yet to be determined. A limitation of our study is the age of the patients (older than 3 years) who are less sensitive to scar development; therefore, a smaller number of patients with scars could be analyzed during control examination. Further studies using the DW-MRI should confirm its reliability to detect acute and late lesions in younger children and infants and determine the clinical consequences. CONCLUSION: DW-MRI has higher sensitivity for detecting acute renal inflammatory lesions and multifocal lesions than DMSA-SRS. The incidence of scars was low and corresponded with the anatomical location of acute and late lesions.

Lactate as an early predictor of psychomotor development in neonates with asphyxia receiving therapeutic hypothermia.

AIMS: This prospective study aimed to evaluate the relationship between persistently elevated lactate values in the arterial blood of newborns with grade II and III hypoxic ischemic encephalopathy (treated with therapeutic hypothermia) and psychomotor development at 24 months. METHODS: 51 neonates of gestational age from 36 to 41 weeks receiving therapeutic hypothermia for moderate to severe hypoxic ischaemic encephalopathy had arterial blood lactate levels regularly analysed. At 24 months the infants' psychomotor development was evaluated and they were divided into two groups - those where the outcome was favourable (i.e. normal psychomotor development) and adverse (severe motor or sensory impairment or death). The lactate dynamics over time were retrospectively evaluated from the data collected, with the normal upper limit set at 4 mmol/L. RESULTS: Of the 51 affected neonates, 7 died over the course of the study. 34 of the remaining 44 infants demonstrated normal psychomotor findings at 2 years old, with adverse findings in 10 cases. Although both groups experienced significant reductions in lactate over time, there were statistically significant differences between them regarding currently measured lactate levels. CONCLUSION: Absolute lactate values and their development over time can be a used as an auxiliary factor in making early estimates of the long-term outcome for newborns with neonatal asphyxia being treated with therapeutic hypothermia.

Vacuum-assisted vaginal delivery and levator ani avulsion in primiparous women.

OBJECTIVE: We compared the incidence and type of levator ani avulsion diagnosed by translabial ultrasound evaluation in primiparous women six months after vacuum-assisted or spontaneous vaginal delivery. MATERIAL AND METHODS: This retrospective observational study was performed between January 2011 and December 2013. Primiparous women six months after vacuum-assisted vaginal delivery and after spontaneous vaginal delivery underwent translabial ultrasound evaluation. The distance between the urethra and fibers of the musculus levator ani puborectalis (levator-urethra gap) was measured. A levator-urethra gap >25 mm was considered a musculus levator ani avulsion. RESULTS: In total, 184 women participated in the study. Among them, 92 had vacuum extraction and 92 had uncomplicated spontaneous delivery. A longer levator-urethra gap on both sides of the pubic bone was found in women after vacuum-assisted vaginal delivery (p < 0.0001 for both sides). Musculus levator ani avulsion was identified in 20 women (unilateral in 16 cases and bilateral in four cases). No difference in an incidence of musculus levator ani avulsion was identified in women after vacuum-assisted vaginal delivery [11/92 (12%)] compared to spontaneous delivery [9/92 (10%); p = 0.81]. CONCLUSION: Vacuum-assisted vaginal delivery in primiparous women is associated with a longer levator-urethra gap but not with a higher frequency of avulsion of the musculus levator ani.

The time factor in the LDI (Laser Doppler Imaging) diagnosis of burns.

BACKGROUND AND OBJECTIVE: The not quite rare occurrence of inaccurate clinical diagnoses of burns in early post-burn days leads to an inappropriate conservative treatment strategy, or unnecessary surgery. LDI (Laser Doppler Imaging) objectively evaluates skin blood circulation, which correlates with the depth of the burn and the length of healing. The aim of this work was to suggest cutoff values for detecting burns without healing potential within 3 weeks, which should have undergone surgery. METHOD: The burned area's average blood perfusion of 148 burns was measured on 115 patients, using the Laser Doppler Imager PIM III. A total of 268 measurements were performed from the one to the ninth post-burn day (PBD). The perfusion values were compared to the healing time or histology in the case of the surgical treatment. Cutoff values indicating surgery were investigated in various post-burn days; the ROC analysis was used. RESULTS: This work suggest statistically significant increasing cutoff values for indication to surgery (P = 0.05). From the third to the fifth day 148.5 perfusion units (PU), from the sixth to the seventh day 186.0 PU, from the eighth to the ninth PBD 269.5 PU. The cutoff value is not possible to establish until the second day. CONCLUSION: LDI is a useful method for wound healing prediction and an indication of the necessity of surgery. We have demonstrated that the diagnosis of the healing capacity of LDI needs to take into account the factor of time.

Technical development of a new semispherical radiofrequency bipolar device (RONJA): ex vivo and in vivo studies.

The aim of this study is to inform about the development of a new semispherical surgical instrument for the bipolar multielectrode radiofrequency liver ablation. Present tools are universal; however they have several disadvantages such as ablation of healthy tissue, numerous needle punctures, and, therefore, longer operating procedure. Our newly designed and tested semispherical surgical tool can solve some of these disadvantages. By conducting an in vivo study on a set of 12 pigs, randomly divided into two groups, we have compared efficiency of the newly developed instrument with the commonly used device. Statistical analysis showed that there were no significant differences between the groups. On average, the tested instrument RONJA had shorter ablation time in both liver lobes and reduced the total operating time. The depth of the thermal alteration was on average 4 mm larger using the newly tested instrument. The new radiofrequency method described in this study could be used in open liver surgery for the treatment of small liver malignancies (up to 2 cm) in a single application with the aim of saving healthy liver parenchyma. Further experimental studies are needed to confirm these results before clinical application of the method in the treatment of human liver malignancies.

Addition of platelet concentrate to dermo-epidermal skin graft in deep burn trauma reduces scarring and need for revision surgeries.

BACKGROUND: [corrected] Deep skin burn injuries, especially those on the face, hands, feet, genitalia and perineum represent significant therapeutic challenges. Autologous dermo-epidermal skin grafts (DESG) have become standard of care for treating deep burns. Additionally, human autologous thrombin activated autologous platelet concentrate (APC) has gained acceptance in the setting of wounds. While each of these interventions has been independently shown to accelerate healing, the combination of the two has never been evaluated. We hypothesized that the addition of platelets (source of growth factors and inhibitors necessary for tissue repair) to the DESG (source of progenitor cells and of tissue proteases necessary for spatial and temporal control of growth regulators released from platelets) would create the optimal environment for the reciprocal interaction of cells within the healing tissues. METHODS: We used clinical examination (digital photography), standardised scales for evaluating pain and scarring, in combination with blood perfusion (laser Doppler imaging), as well as molecular and laboratory analyses. RESULTS: We show for the first time that the combination of APC and DESG leads to earlier relief of pain, and decreased use of analgesics, antipruritics and orthotic devices. Most importantly, this treatment is associated with earlier discharges from hospital and significant cost savings. CONCLUSIONS: Our findings indicate that DESG engraftment is facilitated by the local addition of platelets and by systemic thrombocytosis. This local interaction leads to the physiological revascularization at 1-3 months. We observed significant elevation of circulating platelets in early stages of engraftment (1-7 days), which normalized over the subsequent 7 and 90 days.