Short-term outcome of periviable small-for-gestational-age babies: is our counseling up to date?

OBJECTIVE: There are limited data for counseling on and management of periviable small-for-gestational-age (SGA) fetuses. We therefore aimed to investigate the short-term outcome of periviable SGA fetuses in relation to the likely underlying cause. METHODS: This was a retrospective study of data from three London tertiary fetal medicine centers obtained between 2000 and 2015. We included viable singleton pregnancies with a severely small fetus, defined as those with an abdominal circumference ≤ 3rd percentile, identified between 22 + 0 and 25 + 6 weeks' gestation. Data obtained included fetal biometry, presence of placental anomalies, uterine and fetal Doppler and neonatal outcome. We excluded cases with structural abnormalities, proven or suspected abnormal karyotype or genetic syndromes. Cases were classified according to the suspected underlying cause of the small fetal size into one of the following categories: uteroplacental insufficiency, evidence of placental damage with normal uterine artery Doppler, viral infection, or unclassied. RESULTS: There were 245 cases included in the study. Of these, at diagnosis of SGA, 201 (82%) were categorized as uteroplacental cause, 13 (5%) as suspected placental cause, one (0.4%) as suspected viral cause and 30 (12%) could not be assigned to any of these categories. Overall, 101 (41%) cases survived the neonatal period; 89 (36%) underwent in-utero fetal demise, 22 (9%) died neonatally and 33 (14%) pregnancies were terminated. The diagnosis-to-delivery interval was 8.1 weeks in those that survived and 4.5 weeks in those that died neonatally. CONCLUSIONS: Almost 90% of periviable SGA cases are associated with uteroplacental insufficiency or intraplacental damage. Survival is related to gestational age at delivery, with outcomes better than might be assumed at diagnosis and some pregnancies reaching term. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.

[Hip arthroplasty in the presence of proximal femoral deformity]. / Hüftendoprothetik bei Deformitäten des proximalen Femurs.

INTRODUCTION: Proximal femoral deformities may result in pain in the ipsilateral hip joint and profound functional disability, ultimately requiring arthroplasty.  PROCEDURE: Primary hip replacement procedures in the presence of markedly altered anatomy of the proximal femur present a technical challenge for the orthopedic surgeon. The deformity and its underlying condition, whether congenital or acquired, may complicate canal preparation and affect the choices of implant, exposure and postoperative physiotherapy protocol. Furthermore, a two- or multi-stage treatment may be required, e.g. for implant removal, for femoral osteotomy or to rule out infection. DISCUSSION: Treatment strategies must be individually tailored, respecting patient needs, the etiology, the anatomic site and the geometry of the deformity encountered, bone quality, soft tissue deficits, the presence of retained implants in the proximal femur, infection status and comorbidities.

A randomised controlled pilot trial to evaluate and optimize the use of anti-platelet agents in the perioperative management in patients undergoing general and abdominal surgery--the APAP trial (ISRCTN45810007).

PURPOSE: Surgeons are increasingly confronted by patients on long-term low-dose acetylsalicylic acid (ASA). However, owing to a lack of evidence-based data, a widely accepted consensus on the perioperative management of these patients in the setting of non-cardiac surgery has not yet been reached. Primary objective was to evaluate the safety of continuous versus discontinuous use of ASA in the perioperative period in elective general or abdominal surgery. METHODS: Fifty-two patients undergoing elective cholecystectomy, inguinal hernia repair or colonic/colorectal surgery were recruited to this pilot study. According to cardiological evaluation, non-high-risk patients who were on long-term treatment with low-dose ASA were eligible for inclusion. Patients were allocated randomly to continuous use of ASA or discontinuation of ASA intake for 5 days before until 5 days after surgery. The primary outcome was the incidence of major haemorrhagic and thromboembolic complications within 30 days after surgery. RESULTS: A total of 26 patients were allocated to each study group. One patient (3.8%) in the ASA continuation group required re-operation due to post-operative haemorrhage. In neither study group, further bleeding complications occurred. No clinically apparent thromboembolic events were reported in the ASA continuation and the ASA discontinuation group. Furthermore, there were no significant differences between both study groups in the secondary endpoints. CONCLUSIONS: Perioperative intake of ASA does not seem to influence the incidence of severe bleeding in non-high-risk patients undergoing elective general or abdominal surgery. Further, adequately powered trials are required to confirm the findings of this study.

[The German version of the satisfaction with stroke care questionnaire (SASC) for stroke patients]. / Entwicklung der deutschen Version der Patientenzufriedenheits-Skala (SASC) für den Einsatz bei Patienten nach Schlaganfall.

BACKGROUND AND PURPOSE: Patient satisfaction is an important objective to achieve in all parts of the health-care system. Patient satisfaction probably effects adherence to therapy. Until now, German-speaking countries were lacking a reliable instrument to investigate patient satisfaction. The aim of this study was to translate the English Satisfaction with Stroke Care Questionnaire (SASC), validated and created specifically for patients who had a stroke, and to assess the test-retest reliability of the German version. METHODS: The translation of the satisfaction questionnaire followed the protocol of the Medical Outcome Trust. The validation was carried out with continuously admitted inpatients who had suffered an acute stroke and were able to give written consent. Patients received two questionnaires for self-administration three months after hospital admission. The two questionnaires were compared for test-retest reliability. Reliability was measured using AC 1 values. RESULTS: Out of 202 patients continuously admitted to our hospital with the diagnosis of stroke, 33 could not give written informed consent due to aphasia (N = 29) or foreign-language (N = 4) or refused written consent (N = 8) or died during the following 3 months after the event (N = 14). Recall rate at three months was 71 % with 104 of the remaining 147 patients sending both questionnaires back. (Characteristics of responders: NIHSS = 3 [0 - 26], age = 71.5 [31 - 89] years, 40 % female, 48 % with five or more years of secondary school, 66 % paretic, 17 % with aphasia, 26 % with atrial fibrillation). The test-retest reliability of the German version of the self-administered satisfaction questionnaire was substantial (mean AC 1 = 0.612; range from 0.307 to 0.789). CONCLUSION: The German version of the SASC is a reliable tool to test patient satisfaction in stroke patients in the German language.

Origin and characteristics of haematogenous periprosthetic joint infection.

OBJECTIVES: Recognition of infectious origin of haematogenous periprosthetic joint infections (PJI) is crucial. We investigated the primary focus and characteristics of haematogenous PJI. METHODS: Consecutive patients who presented with haematogenous PJI between 01/2010 and 01/2018 were retrospectively analysed. Haematogenous PJI was defined by diagnosis of infection ≥1 month after surgery, acute manifestation after a pain-free period and positive blood or prosthetic-site culture and/or evidence of distant infectious focus consistent with the pathogen. Fisher's exact, Student's t and Mann-Whitney U tests were used, as appropriate. RESULTS: A total of 106 episodes of PJI were included, involving 59 knee, 45 hip, one shoulder and one elbow prostheses. The median time from last surgery until haematogenous PJI was 47 months (range, 1-417 months). The pathogen was identified in 105 episodes (99%), including Staphylococcus aureus (n = 43), streptococci (n = 32), enterococci (n = 13), Gram-negative bacteria (n = 9) and coagulase-negative staphylococci (n = 8). Gram-negative bacteria were significantly more often found in hip joints than in knee joints. Blood cultures grew the pathogen in 43 of 70 episodes (61%). The primary infectious focus was identified in 72 episodes (68%) and included infections of intravascular devices or heart valves (22 episodes), skin and soft tissue (16 episodes), the oral cavity (12 episodes), urogenital (12 episodes) or gastrointestinal tract (seven episodes) and other sites (three episodes). CONCLUSIONS: In acute PJI manifesting after a pain-free period, the haematogenous infection route should be considered and the primary infectious focus should be actively searched for. The cardiovascular system, skin and soft tissue, oral cavity, urogenital and gastrointestinal tracts were common origins of haematogenous PJI.

Transcription activator protein 1 (AP-1) mediates NO-induced apoptosis of adult cardiomyocytes.

Release of nitric oxide (NO) during inflammation can induce apoptosis in the heart. Here we analyzed the involvement of members of the mitogen-activated protein kinase (MAPK) family and their downstream target, the transcription factor AP-1, in induction of apoptosis by NO in isolated adult cardiomyocytes of rat. The NO-donor (+/-)-S-nitroso-N-acetylpenicillamine (100 microM SNAP)-induced apoptosis in 10.5 +/- 0.7% of cardiomyocytes and activated the transcription activator protein AP-1 by 333.6 +/- 122.3%. Intracellular scavenging of AP-1 with decoy-oligonucleotides blocked NO-induced apoptosis to control levels (3.8 +/- 0.5% apoptotic cells). Activation of AP-1 with a c-Jun amino-terminal kinase (JNK) activator (Ro318220, 10 microM) provoked apoptosis in 18.7 +/- 1.2% cardiomyocytes, which was again blocked by intracellular scavenging of AP-1. NO activated JNK by 87.0 +/- 27.3% and extracellular signal-regulated kinase (ERK) by 35 +/- 3%. Inhibition of ERK by the mitogen-activated protein kinase kinase (MEK1) inhibitor PD98059 (10 microM) abolished AP-1 activation and apoptosis induction with SNAP. Evidence that p38 MAPK plays a role in NO-induced apoptosis was not found. These results clearly demonstrate the involvement of the transcription factor AP-1 in NO-induced apoptosis in cardiomyocytes. The activation of AP-1 is mediated by the two MAP kinases JNK and ERK.

Treatment of type II hyperlipoproteinemia with d-thyroxine.

The effectiveness of a new, almost l-thyroxine free preparation of d-thyroxine (Dynothel) was tested in 15 patients with Type IIa and 4 patients with Type IIb hyperlipoproteinemia. Eleven patients with Type IIa and 3 with Type IIb were responsive to treatment and showed an average 26% decrease in plasma TC. This decrement in plasma TC was mirrored in a significant reduction of LDL cholesterol in Type IIa and IIb. While VLDL cholesterol slightly decrease in Type IIb, it remained the same in Type IIa and so did the HDL cholesterol in both types. As neither VLDL nor LDL or HDL triglyceride levels changed very much in either type, the total plasma triglycerides remained the same. The plasma phospholipids were higher in Type IIa and lower in Type IIb on therapy. Thus, Dynothel seems to be a potent d-thyroxine preparation for lowering plasma cholesterol, this decrease being brought about by reduction of LDL cholesterol levels. The effect of the drug on plasma TG and PL is less certain.

[Magnification technique in peripheral angiography (author's transl)]. / Vergrösserungstechnik in der peripheren Angiographie.

Fourteen exactly similar conventional and magnified serial angiograms were compared and the advantages and disadvantages of magnification angiography are discussed. Particular attention was paid to exact comparability of the series in order to make the analysis valid. In three patients small end-vessels and collaterals were visible on the magnification angiogram which could not be seen on the ordinary series even in retrospect. Macro-angiography was also valuable in cases of microsurgery, both before and after operation. Considering the well-known disadvantages of magnification angiography, such as increased radiation and cost, its use appears to be indicated only for the elucidation of special problems.

Axial migration of spirulina microalgae in laminar tube flow.

A dilute suspension of Spirulina Microalgae is found to exhibit radial migration in laminar flow in a 650 micron vertical tube. As the tube Reynolds number increases, the particles concentrate in a narrower region around the tube axis. When the turbulent regime is approached, the particles disperse as expected.

Inertial migration based concentration factors for suspensions of Chlorella microalgae in branched tubes.

When a dilute suspension flows in the laminar regime through a tube, under certain conditions the suspended particles migrate radially to an equilibrium radial position. Branched tubes can use this radial concentration distribution to concentrate dilute suspensions. Suspensions of microalgae, Chlorella vulgaris, were pumped through tubes of various diameters for tube Reynolds number ranging from 47-1839 and photographed. Upstream particle concentration profiles were obtained by image analysis of the photographs. The dividing stream surfaces in branched tubes were obtained from the three-dimensional numerical solutions of the Navier-Stokes equations for steady, laminar, and homogeneous flow through tubes having one and two orthogonal branches. Concentration factors for Chlorella suspensions in branched tubes, predicted by a general method, fall in the range of 1.0-1.3.

Effect of heat treatment on the elasticity of human erythrocyte membrane.

A parallel plate flow channel is employed to study the effect of heat treatment on the elasticity of human red cell membrane. An irreversible transition between 46 degrees C and 50 degrees C results in an approximately 200% increase in an elastic constant measured at 25 degrees C. This transition is attributable to irreversible protein denaturation which has been shown by other to occur at similar temperatures in calorimetric studies of red cell ghosts.

[Dietary problems in the management of type I hyperlipoproteinemia (author's transl)]. / Therapieprobleme der Hyperlipopropteinämie Typ I

The therapeutic effect of different diets varying in long chain and medium chain triglycerides, carbohydrate, and protein was tested in two siblings with type I hyperlipoproteinemia. Despite administration of an extremely fat reduced diet ( less than 5 g daily), a normalization of plasma TG could not be obtained because-as a consequence of its high carbohydrate and/or its MCT content-it resulted in a considerable increase in pre-beta-lipoproteins. As life long dietary therapy has to be maintained, the risks of a normal therapy has to be maintained, the risks of a normal fat containing diet (mainly bouts of pancreatitis) and those of a carbohydrate and MCT rich diet (premature atherosclerosis) are to be carefully considered. On the basis of our data we therefore suggest the following dietary regimen: 1. Reduced intake of long chain triglycerides (less than 30 gms per day), but with sufficient amounts of essential fatty acids (4-6 gms linoleate daily). 2. The carbohydrates should not exceed 50% of total calories and ought to consist mainly of starch. 3. The caloric deficit thus generated should be balanced by a high protein intake. This is faciliated by applying a specially protein-enriched food. 4. Medium chanin triglycerides may be necessary when adherence to the protein-rich diet turns out to be bad.

Benefit and risk of heparin for maintaining peripheral venous catheters in neonates: a placebo-controlled trial.

OBJECTIVES: Heparin addition to infusion fluids is used to prolong catheter patency in newborns. Heparin may also induce adverse effects such as bleeding complications and immune-mediated heparin-induced thrombocytopenia (HIT). One objective was peripheral venous catheter patency with heparinization of continuous infusions (0.5 IU/mL). Secondary objectives were incidences of bleeding, clinically manifest HIT, HIT antibodies, and catheter-related complications. STUDY DESIGN: Inclusion criteria were anticipated need for intravenous peripheral infusion (>or=5 days for HIT-related endpoints) and postnatal age <28 days at study entry. Exclusion criteria were bodyweight <1000 g, congenital malformation, need for therapeutic anticoagulation or mechanical ventilation, and severe bleeding. HIT antibodies were assessed by enzyme-linked immunosorbent assay. RESULTS: A total of 145 infants received heparin, and 151 infants received saline. Patient characteristics, number of additional drugs, duration of treatment, and location and size of catheters did not differ. Patency of catheters was 7.4 hours longer in the heparin group (33.8 hours vs 26.4 hours, P<.0001), but the total numbers of catheters did not differ (565 vs 692, P=.3). No infant developed HIT antibodies. Incidences of bleeding complications and thrombocytopenia were comparable between groups. CONCLUSIONS: Balancing the benefits against the risks of heparin addition and the rare complication of HIT, we will not use 0.5 IU/mL heparin addition to parenteral fluids.