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BACKGROUND: The COVID-19 pandemic is an ongoing global health threat, caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Questions remain about how SARS-CoV-2 impacts pregnant individuals and their children. OBJECTIVE: To expand our understanding of the effects of SARS-CoV-2 infection during pregnancy on pregnancy outcomes, regardless of symptomatology, by using serological tests to measure IgG antibody levels. METHODS: The Generation C Study is an ongoing prospective cohort study conducted at the Mount Sinai Health System. All pregnant individuals receiving obstetrical care at the Mount Sinai Healthcare System from 20 April 2020 onwards are eligible for participation. For the current analysis, we included participants who had given birth to a liveborn singleton infant on or before 22 September 2020. For each woman, we tested the latest prenatal blood sample available to establish seropositivity using a SARS-CoV-2 serologic enzyme-linked immunosorbent assay. Additionally, RT-PCR testing was performed on a nasopharyngeal swab taken during labour. Pregnancy outcomes of interest (i.e., gestational age at delivery, preterm birth, small for gestational age, Apgar scores, maternal and neonatal intensive care unit admission, and length of neonatal hospital stay) and covariates were extracted from medical records. Excluding individuals who tested RT-PCR positive at delivery, we conducted crude and adjusted regression models to compare antibody positive with antibody negative individuals at delivery. We stratified analyses by race/ethnicity to examine potential effect modification. RESULTS: The SARS-CoV-2 seroprevalence based on IgG measurement was 16.4% (95% confidence interval 13.7, 19.3; n=116). Twelve individuals (1.7%) were SARS-CoV-2 RT-PCR positive at delivery. Seropositive individuals were generally younger, more often Black or Hispanic, and more often had public insurance and higher pre-pregnancy BMI compared with seronegative individuals. None of the examined pregnancy outcomes differed by seropositivity, overall or stratified by race/ethnicity. CONCLUSION: Seropositivity for SARS-CoV-2 without RT-PCR positivity at delivery (suggesting that infection occurred earlier during pregnancy) was not associated with selected adverse maternal or neonatal outcomes among live births in a cohort sample from New York City.
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COVID-19 , Complicações Infecciosas na Gravidez , Nascimento Prematuro , COVID-19/diagnóstico , COVID-19/epidemiologia , Criança , Estudos de Coortes , Feminino , Humanos , Recém-Nascido , Pandemias , Gravidez , Complicações Infecciosas na Gravidez/diagnóstico , Complicações Infecciosas na Gravidez/epidemiologia , Resultado da Gravidez/epidemiologia , Nascimento Prematuro/epidemiologia , Estudos Prospectivos , SARS-CoV-2 , Estudos SoroepidemiológicosRESUMO
Pregnant women with diabetes are at higher risk of adverse outcomes. Prevention of such outcomes depends on strict glycemic control, which is difficult to achieve and maintain. A variety of technologies exist to aid in diabetes management for nonpregnant patients. However, adapting such tools to meet the demands of pregnancy presents multiple challenges. This article reviews the key attributes digital technologies must offer to best support diabetes management during pregnancy, as well as some digital tools developed specifically to meet this need. Despite the opportunities digital health tools present to improve the care of people with diabetes, in the absence of robust data and large research studies, the ability to apply such technologies to diabetes in pregnancy will remain imperfect.
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The COVID-19 pandemic exposed and exacerbated persistent health inequities in perinatal populations, resulting in disparities of maternal and fetal complications. In this narrative review, we present an adapted conceptual framework of perinatal social determinants of health in the setting of the COVID-19 pandemic and use this framework to contextualize the literature regarding disparities in COVID-19 vaccination and infection. We synthesize how elements of the structural context, individual socioeconomic position, and concrete intermediary determinants influence each other and perinatal COVID-19 vaccination and infection, arguing that systemic inequities at each level contribute to observed disparities in perinatal health outcomes. From there, we identify gaps in the literature, propose mechanisms for observed disparities, and conclude with a discussion of strategies to mitigate them.
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Vacinas contra COVID-19 , COVID-19 , Disparidades em Assistência à Saúde , Complicações Infecciosas na Gravidez , SARS-CoV-2 , Vacinação , Humanos , COVID-19/prevenção & controle , Gravidez , Feminino , Complicações Infecciosas na Gravidez/prevenção & controle , Determinantes Sociais da Saúde , Recém-Nascido , Fatores Socioeconômicos , Assistência Perinatal/métodos , Disparidades nos Níveis de SaúdeRESUMO
BACKGROUND: Placenta accreta spectrum is associated with significant maternal and neonatal morbidity and mortality. There is limited established data on healthcare inequities in the outcomes of patients with placenta accreta spectrum. OBJECTIVE: This study aimed to investigate health inequities in maternal and neonatal outcomes of pregnancies with placenta accreta spectrum. STUDY DESIGN: This multicentered retrospective cohort study included patients with a histopathological diagnosis of placenta accreta spectrum at 4 regional perinatal centers between January 1, 2013, and June 30, 2022. Maternal race and ethnicity were categorized as either Hispanic, non-Hispanic Black, non-Hispanic White, or Asian or Pacific Islander. The primary outcome was a composite adverse maternal outcome: transfusion of ≥4 units of packed red blood cells, vasopressor use, mechanical ventilation, bowel or bladder injury, or mortality. The secondary outcomes were a composite adverse neonatal outcome (Apgar score of <7 at 1 minute, morbidity, or mortality), gestational age at placenta accreta spectrum diagnosis, and planned delivery by a multidisciplinary team. Multivariable logistic regression was used to estimate the associations of race and ethnicity with maternal and neonatal outcomes. RESULTS: A total of 408 pregnancies with placenta accreta spectrum were included. In 218 patients (53.0%), the diagnosis of placenta accreta spectrum was made antenatally. Patients predominantly self-identified as non-Hispanic White (31.6%) or non-Hispanic Black (24.5%). After adjusting for institution, age, body mass index, income, and parity, there was no difference in composite adverse maternal outcomes among the racial and ethnic groups. Similarly, adverse neonatal outcomes, gestational age at prenatal diagnosis, rate of planned delivery by a multidisciplinary team, and cesarean hysterectomy were similar among groups. CONCLUSION: In our multicentered placenta accreta spectrum cohort, race and ethnicity were not associated with inequities in composite maternal or neonatal morbidity, timing of diagnosis, or planned multidisciplinary care. This study hypothesized that a comparable incidence of individual risk factors for perinatal morbidity and geographic proximity reduces potential inequities that may exist in a larger population.
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Disparidades em Assistência à Saúde , Placenta Acreta , Adulto , Feminino , Humanos , Recém-Nascido , Gravidez , Cesárea/estatística & dados numéricos , Etnicidade/estatística & dados numéricos , Idade Gestacional , Disparidades em Assistência à Saúde/etnologia , Placenta Acreta/diagnóstico , Placenta Acreta/epidemiologia , Resultado da Gravidez/epidemiologia , Estudos Retrospectivos , Grupos Raciais/estatística & dados numéricosRESUMO
Associations between antenatal SARS-CoV-2 infection and pregnancy outcomes have been conflicting and the role of the immune system is currently unclear. This prospective cohort study investigated the interaction of antenatal SARS-CoV-2 infection, changes in cytokine and HS-CRP levels, birthweight and gestational age at birth. 2352 pregnant participants from New York City (2020-2022) were included. Plasma levels of interleukin (IL)-1ß, IL-6, IL-17A and high-sensitivity C-reactive protein (HS-CRP) were quantified in blood specimens obtained across pregnancy. Quantile and linear regression models were conducted to 1) assess the impact of antenatal SARS-CoV-2 infection, overall and by timing of detection of SARS-CoV-2 positivity (< 20 weeks versus ≥ 20 weeks), on birthweight and gestational age at delivery; 2) examine the relationship between SARS-CoV-2 infection and maternal immune changes during pregnancy. All models were adjusted for maternal demographic and obstetric factors and pandemic timing. Birthweight models were additionally adjusted for gestational age at delivery and fetal sex. Immune marker models were also adjusted for gestational age at specimen collection and multiplex assay batch. 371 (15.8%) participants were infected with SARS-CoV-2 during pregnancy, of which 98 (26.4%) were infected at < 20 weeks gestation. Neither SARS-CoV-2 infection in general nor in early or late pregnancy was associated with lower birthweight nor earlier gestational age at delivery. Further, we did not observe cytokine or HS-CRP changes in response to SARS-CoV-2 infection and thus found no evidence to support a potential association between immune dysregulation and the diversity in pregnancy outcomes following infection.
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Peso ao Nascer , COVID-19 , Inflamação , Complicações Infecciosas na Gravidez , Resultado da Gravidez , SARS-CoV-2 , Humanos , Gravidez , Feminino , COVID-19/imunologia , COVID-19/sangue , Adulto , Estudos Prospectivos , Cidade de Nova Iorque/epidemiologia , SARS-CoV-2/imunologia , Complicações Infecciosas na Gravidez/imunologia , Complicações Infecciosas na Gravidez/sangue , Complicações Infecciosas na Gravidez/epidemiologia , Complicações Infecciosas na Gravidez/virologia , Inflamação/imunologia , Inflamação/sangue , Proteína C-Reativa/análise , Proteína C-Reativa/metabolismo , Idade Gestacional , Recém-Nascido , Citocinas/sangueRESUMO
Research suggest prenatal vaccination against coronavirus disease-19 (COVID-19) is safe. However, previous studies utilized retrospectively collected data or examined late pregnancy vaccinations. We investigated the associations of COVID-19 vaccination throughout pregnancy with delivery and neonatal outcomes. We included 1,794 mother-neonate dyads enrolled in the Generation C Study with known prenatal COVID-19 vaccination status and complete covariate and outcome data. We used multivariable quantile regressions to estimate the effect of prenatal COVID-19 vaccination on birthweight, delivery gestational age, and blood loss at delivery; and Poisson generalized linear models for Caesarean delivery (CD) and Neonatal Intensive Care Unit (NICU) admission. Using the above methods, we estimated effects of trimester of vaccine initiation on these outcomes. In our sample, 13.7% (n = 250) received at least one prenatal dose of any COVID-19 vaccine. Vaccination was not associated with birthweight (ß = 12.42 g [-90.5, 114.8]), gestational age (ß = 0.2 days [-1.1, 1.5]), blood loss (ß = -50.6 ml [-107.0, 5.8]), the risks of CD (RR = 0.8; [0.6, 1.1]) or NICU admission (RR = 0.9 [0.5, 1.7]). Trimester of vaccine initiation was also not associated with these outcomes. Our findings suggest that there is no associated risk between prenatal COVID-19 vaccination and adverse delivery and neonatal outcomes in a cohort sample from NYC.
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Vacinas contra COVID-19 , COVID-19 , Resultado da Gravidez , Feminino , Humanos , Recém-Nascido , Gravidez , Peso ao Nascer , COVID-19/prevenção & controle , Vacinas contra COVID-19/efeitos adversos , Cidade de Nova Iorque/epidemiologia , Estudos RetrospectivosRESUMO
We examined differences in severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) antibody responses in pregnant individuals with natural, vaccine-induced, or combined immunity. Participants had live or nonlive births between 2020 and 2022, were seropositive (SARS-CoV-2 spike protein, anti-S), and had available mRNA vaccination and infection information (n=260). We compared titer levels among three immunity profiles: 1) natural immunity (n=191), 2) vaccine-induced immunity (n=37), and 3) combined immunity (ie, natural and vaccine-induced immunity; n=32). We applied linear regression to compare anti-S titers between the groups, controlling for age, race and ethnicity, and time between vaccination or infection (whichever came last) and sample collection. Anti-S titers were 57.3% and 94.4% lower among those with vaccine-induced and natural immunity, respectively, compared with those with combined immunity ( P <.001, P =.005).
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Vacinas contra COVID-19 , COVID-19 , Complicações Infecciosas na Gravidez , Feminino , Humanos , Gravidez , Anticorpos Antivirais , COVID-19/prevenção & controle , Complicações Infecciosas na Gravidez/prevenção & controle , SARS-CoV-2 , Vacinação , Vacinas contra COVID-19/administração & dosagemRESUMO
BACKGROUND: Several available compositional MRIs seem to detect early osteoarthritis before radiographic appearance. Delayed gadolinium-enhanced MRI of cartilage (dGEMRIC) has been most frequently used in clinical studies and reportedly predicts premature joint failure in patients undergoing Bernese periacetabular osteotomies (PAOs). QUESTIONS/PURPOSES: We asked, given regional variations in biochemical composition in dysplastic hips, whether the dGEMRIC index of the anterior joint would better predict premature joint failure after PAOs than the coronal dGEMRIC index as previously reported. METHODS: We retrospectively reviewed 43 hips in 41 patients who underwent Bernese PAO for hip dysplasia. Thirty-seven hips had preserved joints after PAOs and six were deemed premature failures based on pain, joint space narrowing, or subsequent THA. We used dGEMRIC to determine regional variations in biochemical composition. Preoperative demographic and clinical outcome score, radiographic measures of osteoarthritis and severity of dysplasia, and dGEMRIC indexes from different hip regions were analyzed in a multivariable regression analysis to determine the best predictor of premature joint failure. Minimum followup was 24 months (mean, 32 months; range, 24-46 months). RESULTS: The two cohorts were similar in age and sex distribution. Severity of dysplasia was similar as measured by lateral center-edge, anterior center-edge, and Tönnis angles. Preoperative pain, joint space width, Tönnis grade, and coronal and sagittal dGEMRIC indexes differed between groups. The dGEMRIC index in the anterior weightbearing region of the hip was lower in the prematurely failed group and was the best predictor. CONCLUSIONS: Success of PAO depends on the amount of preoperative osteoarthritis. These degenerative changes are seen most commonly in the anterior joint. The dGEMRIC index of the anterior joint may better predict premature joint failure than radiographic measures of hip osteoarthritis and coronal dGEMRIC index. LEVEL OF EVIDENCE: Level II, prognostic study. See Instructions for Authors for a complete description of levels of evidence.
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Cartilagem Articular/cirurgia , Meios de Contraste , Gadolínio DTPA , Luxação Congênita de Quadril/cirurgia , Articulação do Quadril/cirurgia , Imageamento por Ressonância Magnética , Osteoartrite do Quadril/cirurgia , Osteotomia/efeitos adversos , Adolescente , Adulto , Artroplastia de Quadril , Cartilagem Articular/diagnóstico por imagem , Cartilagem Articular/patologia , Distribuição de Qui-Quadrado , Feminino , Luxação Congênita de Quadril/diagnóstico por imagem , Luxação Congênita de Quadril/patologia , Articulação do Quadril/anormalidades , Articulação do Quadril/diagnóstico por imagem , Humanos , Modelos Lineares , Modelos Logísticos , Masculino , Análise Multivariada , Osteoartrite do Quadril/diagnóstico por imagem , Osteoartrite do Quadril/patologia , Valor Preditivo dos Testes , Radiografia , Reoperação , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Índice de Gravidade de Doença , Fatores de Tempo , Falha de Tratamento , Adulto JovemRESUMO
INTRODUCTION: Maternal SARS-CoV-2 infection during pregnancy is associated with adverse pregnancy outcomes and can have effects on the placenta, even in the absence of severe disease or vertical transmission to the fetus. This study aimed to evaluate histopathologic and molecular effects in the placenta after SARS-CoV-2 infection during pregnancy. METHODS: We performed a study of 45 pregnant participants from the Generation C prospective cohort study at the Mount Sinai Health System in New York City. We compared histologic features and the expression of 48 immune and trophoblast genes in placentas delivered from 15 SARS-CoV-2 IgG antibody positive and 30 IgG SARS-CoV-2 antibody negative mothers. Statistical analyses were performed using Fisher's exact tests, Spearman correlations and linear regression models. RESULTS: The median gestational age at the time of SARS-CoV-2 IgG serology test was 35 weeks. Two of the IgG positive participants also had a positive RT-PCR nasal swab at delivery. 82.2% of the infants were delivered at term (≥37 weeks), and gestational age at delivery did not differ between the SARS-CoV-2 antibody positive and negative groups. No significant differences were detected between the groups in placental histopathology features. Differential expression analyses revealed decreased expression of two trophoblast genes (PSG3 and CGB3) and increased expression of three immune genes (CXCL10, TLR3 and DDX58) in placentas delivered from SARS-CoV-2 IgG positive participants. DISCUSSION: SARS-CoV-2 infection during pregnancy is associated with gene expression changes of immune and trophoblast genes in the placenta at birth which could potentially contribute to long-term health effects in the offspring.
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COVID-19 , Complicações Infecciosas na Gravidez , Anticorpos Antivirais , Feminino , Humanos , Imunoglobulina G , Recém-Nascido , Transmissão Vertical de Doenças Infecciosas , Placenta/patologia , Gravidez , Complicações Infecciosas na Gravidez/patologia , Resultado da Gravidez , Estudos Prospectivos , SARS-CoV-2 , Trofoblastos/patologiaRESUMO
BACKGROUND: Structural racism and pandemic-related stress from the COVID-19 pandemic may increase the risk of adverse birth outcomes. OBJECTIVE: Our objective was to examine associations between neighborhood measures of structural racism and pandemic stress with 3 outcomes: SARS-CoV-2 infection, preterm birth, and delivering small-for-gestational-age newborns. Our secondary objective was to investigate the joint association of SARS-CoV-2 infection during pregnancy and neighborhood measures with preterm birth and delivering small-for-gestational-age newborns. STUDY DESIGN: We analyzed data of 967 patients from a prospective cohort of pregnant persons in New York City, comprising 367 White (38%), 169 Black (17%), 293 Latina (30%), and 87 Asian persons (9%), 41 persons of other race or ethnicity (4%), and 10 of unknown race or ethnicity (1%). We evaluated structural racism (social/built structural disadvantage, racial-economic segregation) and pandemic-related stress (community COVID-19 mortality, community unemployment rate increase) in quartiles by zone improvement plan code. SARS-CoV-2 serologic enzyme-linked immunosorbent assay was performed on blood samples from pregnant persons. We obtained data on preterm birth and small-for-gestational-age newborns from an electronic medical record database. We used log-binomial regression with robust standard error for clustering by zone improvement plan code to estimate associations of each neighborhood measure separately with 3 outcomes: SARS-CoV-2 infection, preterm birth, and small-for-gestational-age newborns. Covariates included maternal age, parity, insurance status, and body mass index. Models with preterm birth and small-for-gestational-age newborns as the dependent variables additionally adjusted for SARS-CoV-2 infection. RESULTS: A total of 193 (20%) persons were SARS-CoV-2-seropositive, and the overall risks of preterm birth and small-for-gestational-age newborns were 8.4% and 9.8%, respectively. Among birthing persons in neighborhoods in the highest quartile of structural disadvantage (n=190), 94% were non-White, 50% had public insurance, 41% were obese, 32% were seropositive, 11% delivered preterm, and 12% delivered a small-for-gestational-age infant. Among birthing persons in neighborhoods in the lowest quartile of structural disadvantage (n=360), 39% were non-White, 17% had public insurance, 15% were obese, 9% were seropositive, 6% delivered preterm, and 10% delivered a small-for-gestational-age infant. In adjusted analyses, structural racism measures and community unemployment were associated with both SARS-CoV-2 infection and preterm birth, but not small-for-gestational-age infants. High vs low structural disadvantage was associated with an adjusted relative risk of 2.6 for infection (95% confidence interval, 1.7-3.9) and 1.7 for preterm birth (95% confidence interval, 1.0-2.9); high vs low racial-economic segregation was associated with adjusted relative risk of 1.9 (95% confidence interval, 1.3-2.8) for infection and 2.0 (95% confidence interval, 1.3-3.2) for preterm birth; high vs low community unemployment increase was associated with adjusted relative risk of 1.7 (95% confidence interval, 1.2-1.5) for infection and 1.6 (95% confidence interval, 1.0-2.8) for preterm birth. COVID-19 mortality rate was associated with SARS-CoV-2 infection but not preterm birth or small-for-gestational-age infants. SARS-CoV-2 infection was not independently associated with birth outcomes. We found no interaction between SARS-CoV-2 infection and neighborhood measures on preterm birth or small-for-gestational-age infants. CONCLUSION: Neighborhood measures of structural racism were associated with both SARS-CoV-2 infection and preterm birth, but these associations were independent and did not have a synergistic effect. Community unemployment rate increases were also associated with an increased risk of preterm birth independently of SARS-CoV-2 infection. Mitigating these factors might reduce the impact of the pandemic on pregnant people.
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COVID-19 , Doenças do Recém-Nascido , Nascimento Prematuro , COVID-19/diagnóstico , COVID-19/epidemiologia , COVID-19/prevenção & controle , Feminino , Humanos , Lactente , Recém-Nascido , Obesidade , Pandemias , Gravidez , Nascimento Prematuro/epidemiologia , Nascimento Prematuro/etiologia , Estudos Prospectivos , SARS-CoV-2 , Racismo SistêmicoRESUMO
Primary segmental intestinal volvulus is a rare condition that may affect neonates. This condition occurs when a loop of bowel torses around the axis of its mesentery without any other abnormality or malrotation. In the earlier stages, the diagnosis can be challenging due to the lack of specific clinical and radiographic signs. Prompt surgical management is critical as a delay in diagnosis may result in bowel loss or death. We present a series of three cases of extremely low birth weight infants with primary segmental volvulus. A sentinel bowel loop was critical in guiding each patient's surgical management as there were no other clinical markers concerning a pending intra-abdominal catastrophe. This case series suggests that a sentinel bowel loop may be a radiographic marker for primary segmental intestinal volvulus in extremely low birth weight infants.
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Volvo Intestinal , Biomarcadores , Humanos , Recém-Nascido de Baixo Peso , Recém-Nascido , Volvo Intestinal/diagnóstico por imagem , Volvo Intestinal/cirurgiaRESUMO
Paragangliomas (PGLs) are rare tumors with an incidence of 0.007% in pregnant women. Patients with PGLs commonly present with hypertension and tachycardia. This case report describes the evaluation and management of a multiparous woman at 32 weeks of gestation with syncope, hypoxia, and tachycardia as unusual presenting symptoms of PGL. Her symptoms were attributable to paradoxical effects of circulating catecholamines on downregulated alpha-adrenergic receptors resulting in decreased systemic vascular resistance.
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Paraganglioma , Catecolaminas , Feminino , Humanos , Hipóxia/etiologia , Paraganglioma/complicações , Paraganglioma/diagnóstico , Paraganglioma/cirurgia , Gravidez , Síncope/etiologiaRESUMO
Obese women have an approximately twofold higher risk to deliver an infant with neural tube defects (NTDs) despite folate supplementation. Placental transfer of folate is mediated by folate receptor alpha (FR-α), proton coupled folate transporter (PCFT), and reduced folate carrier (RFC). Decreased placental transport may contribute to NTDs in obese women. Serum folate levels were measured and placental tissue was collected from 13 women with normal BMI (21.9±1.9) and 11 obese women (BMI 33.1±2.8) undergoing elective termination at 8-22 weeks of gestation. The syncytiotrophoblast microvillous plasma membranes (MVM) were isolated using homogenization, magnesium precipitation, and differential centrifugation. MVM expression of FR-α, PCFT and RFC was determined by western blot. Folate transport capacity was assessed using radiolabeled methyl-tetrahydrofolate and rapid filtration techniques. Differences in expression and transport capacity were adjusted for gestational age and maternal age in multivariable regression models. P<.05 was considered statistically significant. Serum folate levels were not significantly different between groups. Placental MVM folate transporter expression did not change with gestational age. MVM RFC (-19%) and FR-α (-17%) expression was significantly reduced in placentas from obese women (P<.05). MVM folate transporter activity was reduced by-52% (P<.05) in obese women. These differences remained after adjustment for gestational age. There was no difference in mTOR signaling between groups. In conclusion, RFC and FR alpha expression and transporter activity in the placental MVM are significantly reduced in obese women in early pregnancy. These results may explain the higher incidence of NTDs in infants of obese women with adequate serum folate.
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Receptor 1 de Folato/metabolismo , Ácido Fólico/sangue , Obesidade/sangue , Placenta/metabolismo , Complicações na Gravidez , Transportador de Folato Acoplado a Próton/metabolismo , Proteína Carregadora de Folato Reduzido/metabolismo , Adulto , Índice de Massa Corporal , Membrana Celular/metabolismo , Feminino , Ácido Fólico/análogos & derivados , Ácido Fólico/metabolismo , Humanos , Incidência , Microvilosidades/metabolismo , Análise Multivariada , Obesidade/complicações , Gravidez , Primeiro Trimestre da Gravidez , Segundo Trimestre da Gravidez , Serina-Treonina Quinases TOR/metabolismo , Trofoblastos/metabolismo , Adulto JovemRESUMO
PURPOSE: To determine the feasibility of assessing early osteoarthritis (OA) in hips with femoroacetabular impingement (FAI) using delayed Gadolinium enhanced MRI of Cartilage (dGEMRIC). MATERIALS AND METHODS: Thirty-seven hips in 30 patients who had a dGEMRIC scan and radiographic evidence of FAI were identified. Clinical symptoms were assessed. Radiographic measurements were performed to determine acetabular and femoral morphology. The severity of radiographic OA was determined using Tönnis grade and minimum joint space width (JSW). On MRI, the alpha angle was measured on the sagittal oblique slices. Correlations between dGEMRIC index, patient symptoms, morphologic measurements, radiographic OA, and age were determined. RESULTS: Significant correlations were observed between dGEMRIC index, pain (P < 0.05), and alpha angle (P < 0.05). The correlation of dGEMRIC with alpha angle suggests that hips with more femoral deformity show signs of early OA. CONCLUSION: The results of osteoplasty for FAI depend on the amount of pre-existing OA in the joint. dGEMRIC may be a useful technique for diagnosis and staging of early osteoarthritis in hips with impingement.
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Acetábulo/patologia , Cartilagem/patologia , Meios de Contraste/farmacologia , Gadolínio/farmacologia , Quadril/patologia , Imageamento por Ressonância Magnética/métodos , Osteoartrite/patologia , Adolescente , Adulto , Feminino , Quadril/diagnóstico por imagem , Humanos , Processamento de Imagem Assistida por Computador , Artropatias/diagnóstico por imagem , Artropatias/patologia , Masculino , Osteoartrite/diagnóstico por imagem , Radiografia , Estudos RetrospectivosRESUMO
BACKGROUND: Hip dysplasia leads to abnormal loading of articular cartilage, which results in osteoarthritis. Pelvic osteotomies such as the Bernese periacetabular osteotomy can improve the mechanics of the joint, but the results are variable and appear to depend on the amount of preexisting arthritis. Delayed gadolinium-enhanced magnetic resonance imaging of cartilage (dGEMRIC) is a technique designed to measure early arthritis, and it potentially could be used to select hips with too severe arthritis to benefit from a joint-preserving reconstructive procedure. The purpose of our study was to identify radiographic, clinical, and magnetic resonance imaging measurements that predict failure after pelvic osteotomy. METHODS: We performed a cohort study of forty-seven patients undergoing a Bernese periacetabular osteotomy for the treatment of hip dysplasia. Our goal was to identify preoperative radiographic factors, such as the grade of arthritis, joint congruency, and the dGEMRIC index, that are associated with a poor outcome after osteotomy. RESULTS: Hips in which the osteotomy did not fail had a significant decrease in pain compared with their status preoperatively (p < 0.0001). Hips in which the osteotomy did fail had had significantly more arthritis on preoperative radiographs (as demonstrated by the joint space width and the Tönnis grade [p = 0.01]), more subluxation (p = 0.02), and a lower dGEMRIC index (p < 0.001) than the hips in which the osteotomy did not fail. Multivariate analysis identified the dGEMRIC index as the most important predictor of failure of the osteotomy. CONCLUSIONS: Bernese periacetabular osteotomy for the treatment of hip dysplasia can decrease pain and improve function in symptomatic dysplastic hips. The dGEMRIC index, as an early measure of osteoarthritis, appears to be useful for identifying poor candidates for a pelvic osteotomy. LEVEL OF EVIDENCE: Prognostic Level II. See Instructions to Authors for a complete description of levels of evidence.
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Acetábulo/cirurgia , Doenças do Desenvolvimento Ósseo/cirurgia , Cartilagem Articular/patologia , Meios de Contraste , Gadolínio DTPA , Imageamento por Ressonância Magnética , Osteotomia , Acetábulo/patologia , Adulto , Doenças do Desenvolvimento Ósseo/diagnóstico por imagem , Doenças do Desenvolvimento Ósseo/patologia , Feminino , Humanos , Masculino , Valor Preditivo dos Testes , Radiografia , Falha de TratamentoRESUMO
BACKGROUND: Absence of the lower vagina occurs from abnormal development of the sinovaginal bulbs and vaginal plate. CASE: We present a case of an adolescent girl, with a history of VACTERL and VATER status post flap vaginoplasty at 8 m of age and correction of vaginal-urethral fistula, with primary amenorrhea and cyclic pelvic pain. MRI showed a right hematocolpos. On exam the obstructed vagina was deviated to the right. Given prior urologic and rectal surgery, and laterality of unicornuate system, intra-operative ultrasonography (US) was performed. A needle was used to enter the inferior aspect of the obstructed vagina. A pull-through vaginoplasty was performed. SUMMARY AND CONCLUSION: Vaginal pull-through is the standard treatment for lower vaginal agenesis. In a unicornuate system, the use of intra-operative US is helpful to determine the appropriate angle of dissection.
Assuntos
Cardiopatias Congênitas/complicações , Hematocolpia/etiologia , Deformidades Congênitas dos Membros/complicações , Procedimentos de Cirurgia Plástica/métodos , Útero/anormalidades , Vagina/anormalidades , Doenças Vaginais/etiologia , Adolescente , Canal Anal/anormalidades , Canal Anal/cirurgia , Esôfago/anormalidades , Esôfago/cirurgia , Feminino , Cardiopatias Congênitas/cirurgia , Hematocolpia/diagnóstico , Hematocolpia/cirurgia , Humanos , Rim/anormalidades , Rim/cirurgia , Deformidades Congênitas dos Membros/cirurgia , Coluna Vertebral/anormalidades , Coluna Vertebral/cirurgia , Traqueia/anormalidades , Traqueia/cirurgia , Útero/cirurgia , Vagina/cirurgia , Doenças Vaginais/diagnóstico , Doenças Vaginais/cirurgiaRESUMO
OBJECTIVE: The purpose of this study was to assess the effect of DT56a (Femarelle), a selective estrogen receptor modulator, on platelet function in normal and thrombophilic women being treated for severe menopausal symptoms. METHODS: The Platelet Function Analyzer-100 (PFA-100) was used to asses platelet reactivity at baseline and after 8 weeks of treatment with Femarelle (644 mg/d in divided doses) in 25 symptomatic postmenopausal women with normal clotting times and seven symptomatic women with shortened clotting times (<61 s). The PFA-100 measure of closure time is considered equal to clotting time in assessing clotting function and platelet adhesion, aggregation, and blood coagulation factors. Closure times were measured after 3 and 8 weeks in all participants and at 1 year in the women with shortened clotting times. The nonparametric Wilcoxon signed rank test was used to assess the changes between baseline and each of the three subsequent measurements. RESULTS: Pretreatment study of all seven women with shortened closure times confirmed abnormalities associated with thrombophilia: four women were heterozygous for the factor V Leiden gene mutation, one was heterozygous for the prothrombin gene mutation, one was found to have protein S deficiency, and one had increased anticardiolipin antibodies. All participants reported improved symptoms during the treatment period. No significant change in closure times was found in the normally clotting participants after 3 or 8 weeks of Femarelle therapy (P > 0.26). No significant change in closure time was seen in the seven thrombophilic women after 3 or 8 weeks or 1 year of Femarelle treatment (P > 0.26). The regression curve for measures over time was not significant (P = 0.26). CONCLUSIONS: Femarelle, whose active ingredient is DT56a, did not adversely affect platelet reactivity as measured by PFA closure times in symptomatic thrombophilic postmenopausal women or normal controls. Femarelle, a novel selective estrogen receptor modulator that inhibits menopausal symptoms without thrombogenicity, may offer a new clinical choice for therapy of symptomatic postmenopausal women.
Assuntos
Plaquetas/efeitos dos fármacos , Plaquetas/fisiologia , Extratos Vegetais/efeitos adversos , Extratos Vegetais/uso terapêutico , Pós-Menopausa/fisiologia , Trombofilia/sangue , Adulto , Idoso , Anticorpos Anticardiolipina/sangue , Estudos de Casos e Controles , Contraindicações , Terapia de Reposição de Estrogênios , Fator V/genética , Feminino , Humanos , Pessoa de Meia-Idade , Mutação , Pós-Menopausa/sangue , Deficiência de Proteína S , Protrombina/genética , Moduladores Seletivos de Receptor Estrogênico/uso terapêutico , Trombofilia/etiologia , Trombofilia/genéticaRESUMO
BACKGROUND: Hip dysplasia leads to abnormal loading of articular cartilage, which results in osteoarthritis. The purpose of this study was to investigate the anatomic and demographic factors associated with the early onset of osteoarthritis in dysplastic hips by utilizing the delayed gadolinium-enhanced magnetic resonance imaging of cartilage (dGEMRIC) index as a marker of the disease. METHODS: Ninety-six symptomatic dysplastic hips in seventy-four patients were assessed with standard radiographs and a dGEMRIC scan. The lateral center-edge angle of Wiberg, the acetabular index of Tönnis, and the break in the Shenton line were measured on a standing anteroposterior radiograph. Anterior undercoverage was assessed by measuring the anterior center-edge angle on a Lequesne false-profile view. A labral tear was considered to be present when contrast agent was seen through the entire thickness of the labrum on magnetic resonance arthrography. Osteoarthritis was defined as a dGEMRIC value of <390 msec (two standard deviations below the dGEMRIC index in normal hips). RESULTS: The mean dGEMRIC index (and standard deviation) for this cohort (473 +/- 104 msec) was significantly lower than that of a morphologically normal hip (570 +/- 90 msec). The anterior center-edge angle, the joint space width, and the presence of a labral tear were all found to be associated with osteoarthritis in the univariate analysis. Multivariate analysis identified age, the anterior center-edge angle, and the presence of a labral tear as independent factors associated with osteoarthritis. A second model was fitted with omission of the anterior center-edge angle because the lateral and anterior center-edge angles were highly correlated and the lateral center-edge angle is a more common clinical measure. This model identified age, the lateral center-edge angle, and the presence of a labral tear as significant independent factors associated with osteoarthritis. CONCLUSIONS: As has been demonstrated in previous studies of the hip, this investigation showed osteoarthritis to be associated with increasing age and the severity of dysplasia, as demonstrated both by the Wiberg lateral center-edge angle and the Lequesne anterior center-edge angle. Additionally, we identified a labral tear as being a risk factor for osteoarthritis.
Assuntos
Luxação Congênita de Quadril/complicações , Luxação Congênita de Quadril/diagnóstico por imagem , Osteoartrite do Quadril/etiologia , Adulto , Fatores Etários , Feminino , Gadolínio DTPA , Luxação Congênita de Quadril/patologia , Humanos , Imageamento por Ressonância Magnética/métodos , Masculino , Radiografia , Estudos Retrospectivos , Fatores de RiscoRESUMO
Eight asymptomatic volunteers and 10 patients with early hip osteoarthritis (OA) were investigated with hip delayed gadolinium-enhanced MRI of cartilage (dGEMRIC) at 30, 65, 100, and 135 min after IV injection with Gd-DTPA(2-). In asymptomatic volunteers there was a decrease in the dGEMRIC index (T(1)(Gd)) between 30 and 100 min. In patients the wash-in of Gd-DTPA(2-) was faster, with a low T(1)(Gd) at 30 min that did not change significantly over time. Therefore, earlier time points showed a larger separation in T(1)(Gd) between asymptomatic and OA hips, with more convenient timing logistics. However, T(1)(Gd) at 30 min had a larger standard deviation (SD) in the OA group, possibly due to variability of the steep slope of wash-in. This sensitivity to the imaging window may be less desirable for longitudinal studies in which reproducibility is a concern. At all time points, T(1)(Gd) was 20-30% lower in patients than in asymptomatic volunteers (P < 0.003), which demonstrates the sensitivity of dGEMRIC to early hip OA.
Assuntos
Cartilagem Articular/patologia , Meios de Contraste/farmacocinética , Gadolínio DTPA/farmacocinética , Imageamento por Ressonância Magnética/métodos , Osteoartrite do Quadril/diagnóstico , Adulto , Análise de Variância , Cartilagem Articular/metabolismo , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Osteoartrite do Quadril/metabolismo , Estatísticas não ParamétricasRESUMO
BACKGROUND: This study surveyed microsurgeons on treatments chosen for infants with brachial plexus birth palsies who have had failure of antigravity biceps and/or triceps function due to nerve surgery or natural history. METHODS: Questionnaires were sent to surgeons participating in a prospective multicenter brachial plexus birth palsy study. With a response rate of 82 percent, the sample comprised 22 surgeons with extensive experience in treating brachial plexus birth palsy. The survey gathered collective information on two unique clinical groups: (1) infants with no antigravity biceps function but intact antigravity deltoid and radial nerve function and (2) infants with no antigravity radial nerve function (wrist and digital extension, triceps) but intact antigravity biceps and deltoid function. Analysis of data and age-based trends was performed using the Fisher's exact test. RESULTS: With failure of biceps recovery, surgeons preferred microsurgery for children 6 to 18 months old and tendon transfers for children older than 18 months. Both procedures were preferred over observation alone (p < 0.001). With regard to microsurgery techniques, with increasing age, surgeons used nerve transfers more than resected neuroma and grafting. With tendon transfers, regional transfers were performed more than 90 percent of the time at all ages. For patients with no antigravity radial nerve function, most cases at all ages were managed by observation rather than microsurgery or tendon transfers (p < 0.001). CONCLUSIONS: The authors' data indicate a general consensus in treatment choices for the two cases of microsurgical failure in infants with brachial plexus birth palsies as well as in satisfaction among experienced surgeons in using these treatments.