The Impact of Mode of Delivery on Maternal and Neonatal Outcomes during Periviable Birth (22-25 Weeks).

OBJECTIVE: The objective of our study was to compare the maternal and neonatal complications of periviable birth by the delivery route. STUDY DESIGN: A retrospective cohort study of periviable deliveries (220/7-256/7weeks) from 2013 to 2020 at a tertiary teaching institution was conducted. Deliveries were grouped by the mode of delivery. Excluded deliveries included pregnancy termination, anomaly, or undesired neonatal resuscitation. The primary composite maternal outcome included death, intensive care admission, sepsis, surgical site infection, unplanned operation, or readmission. Secondary outcomes included maternal blood loss, length of stay, neonatal survival, bronchopulmonary dysplasia (BPD), intraventricular hemorrhage (IVH), necrotizing enterocolitis (NEC), patent ductus arteriosus (PDA), and retinopathy of prematurity (ROP). Outcomes were compared using Student's t-test, Wilcoxon-Mann-Whitney and Chi-squared tests. Relative risk (RR) and 95% confidence intervals were calculated with log-binomial regression. p-Values <0.05 were considered significant. Demographic and intervention variables associated with the outcome and the exposure were included in an adjusted relative risk (aRR) model. Subgroup analyses of singleton pregnancies and 220/7 to 236/7 weeks deliveries were conducted. RESULTS: After exclusion, 230 deliveries were included in the cohort. Maternal characteristics were similar between cohorts. For the primary outcome, cesarean delivery was associated with a trend toward increased maternal morbidity (22.6 vs. 10.7%, RR = 2.11 [1.03-4.43], aRR = 1.95 [0.94-4.03], p-value 0.07). Administration of magnesium sulfate, antenatal corticosteroids, and tocolytics were similar between cohorts. Neonatal survival to discharge was not different between the groups (54/83, 65.1% vs. 118/191, 61.8%, aRR = 0.93 [0.77-1.13]). Among the 172 neonates discharged alive, there was no difference in BPD, IVH, NEC, PDA, ROP, or intact survival. CONCLUSION: Periviable birth has a high rate of maternal morbidity with a trend toward the highest risk among women undergoing cesarean delivery. These risks should be included in shared decision-making. KEY POINTS: · Periviable birth has high maternal morbidity (19%) and is highest after cesarean delivery (23%).. · Route of delivery does not impact neonatal survival or intact neonatal survival.. · Head entrapment is rare during vaginal breech delivery..

Perimetry, retinal nerve fiber layer thickness and papilledema grade after cerebrospinal fluid shunting in patients with idiopathic intracranial hypertension.

BACKGROUND: To investigate the effect of cerebrospinal fluid (CSF) shunting on quantitative perimetry and papilledema in patients with uncontrolled idiopathic intracranial hypertension (IIH). METHODS: We retrospectively reviewed all cases of IIH with CSF shunting at our institution between 2004 and 2011. Perimetry was performed before and after surgery in 15 patients, and the mean deviation (MD) was compared before and after surgery to assess the effect of the intervention. RESULTS: Fourteen of the IIH patients were female and 1 was male. The average age was 34 years. CSF shunting resulted in significant improvement in the perimetric results with an increase in the MD of 5.63 ± 1.19 dB (P < 0.0001). Additionally, average retinal nerve fiber layer (RNFL) thickness measurement by optical coherence tomography decreased by 87.27 ± 16.65 µm (P < 0.0001), and Frisen papilledema grade decreased by 2.19 ± 0.71 (P < 0.0001). CONCLUSIONS: Our results suggest that CSF shunting results in improvement in perimetry, RNFL swelling, and papilledema grade in patients with IIH.

Pediatric internuclear ophthalmoplegia.

BACKGROUND: Internuclear ophthalmoplegia (INO) is a rare eye movement disorder in the pediatric population. METHODS: We performed a retrospective review at a university-based tertiary referral ophthalmology practice from 2004 to 2012 to identify pediatric patients with INO. RESULTS: Three patients with INO were identified. Etiologies included high-grade astrocytoma, perinantal hypoxia and neonatal intracerebral hemorrhage. One of our patients, a 2 year-old girl, is the youngest reported case of INO. CONCLUSION: While rare, INO in a pediatric patient requires a full neurologic evaluation and careful follow-up to assess eye position and potentially treat amblyopia.

The Wholesome Foods Approach to Trabeculectomy Wet Lab Training.

Purpose In an era when trabeculectomy surgeries in the United States are on the decline, ophthalmology residents may have limited opportunities to practice surgical techniques critical to success. However, key steps of trabeculectomy surgery can be introduced in a wet laboratory using a simple surgical model based on food items. Methods A fresh lime and chicken parts with skin, purchased from a grocery store, were utilized to practice trabeculectomy surgery. The white rind of a lime was used as a surrogate for human sclera and was incised to create a trabeculectomy flap. The flap was then successfully sewn down with 10-0 nylon suture using an operating microscope. The skin of the chicken part was used to re-create a fornix-based and limbus-based conjunctival incision, which was then sutured closed using 6-0 Vicryl suture. A survey of wet laboratory participants was conducted to assess the feasibility and efficacy of this technique. Results Survey respondents were divided into two groups, those who had performed ≥40 incisional glaucoma surgeries and those who had performed <40. Both groups rated the simulation a 4 (mode) out of 5 in terms of how well it prepared them for glaucoma surgery on a human eye and how well the materials replicated human tissue, with 1 being not at all and 5 being very well. Similarly, both groups rated ease of setup and material acquisition a 1 out of 5, 1 being not difficult at all and 5 being extremely difficult. Also, 93.5% of the survey respondents recommended implementing this training model at other teaching hospitals, and none of the respondents recommended against it. Conclusion This trabeculectomy teaching model is inexpensive, clean, and safe, and it provides a reasonably realistic substrate for surgical practice. It does not require cadaver or animal eyes, and no fixatives are needed, thus minimizing the risk of contact with biohazardous materials. Wet laboratory materials are easy to obtain, making this a practical model for practicing glaucoma surgery in both westernized and developing countries.

Aflatoxin B1 and/or hepatitis B virus induced tumor spectrum in a genetically engineered hepatitis B virus expression and Trp53 haploinsufficient mouse model system for hepatocarcinogenesis.

The authors investigated the spectrum of tumors and Trp53 mutations in genetically engineered models using the FVB/N mouse that expressed the hepatitis B virus genome and/or carried a Trp53 null and wildtype allele and/or were exposed to aflatoxin B1. Liver tumor incidence was increased when all three risk factors were present. Without aflatoxin B1 exposure, neither Trp53 haploinsufficiency nor HBV expression affected liver tumor development. Liver tumor prevalence increased with aflatoxin B1 exposure (p < .001), as thirteen of fourteen mice with liver tumors were initiated with aflatoxin B1. Liver tumors were more frequent in males (12/190) than females (2/170). Seventy-three mice developed sarcomas. Trp53 haploinsufficiency was associated with increased sarcoma incidence in males and females (p < .001). In Trp53 haploinsufficient mice, the HBV transgene increased the risk of sarcoma in males and females (p < .001). Lymphoma was significantly increased in Trp53 haploinsufficient FVB/N mice. There was no loss of heterozygosity at the wildtype Trp53 locus in twenty-five sarcomas or four hepatocellular tumors examined. No mutations were identified in the mRNA (exons 2-11) of Trp53 in six liver neoplasms or twenty-four sarcomas. In this model system, HBV expression affected only hepatocellular neoplasia in association with both aflatoxin B1 initiation and p53 haploinsufficiency.

Acute Encephalopathy Following Hyperbaric Oxygen Therapy in a Patient on Metronidazole.

This case describes a patient who presented to the emergency department for an acute onset of encephalopathy following hyperbaric oxygen treatment and antibiotic therapy for radiation-induced osteonecrosis of the jaw.

Patient characteristics associated with artifacts in Spectralis optical coherence tomography imaging of the retinal nerve fiber layer in glaucoma.

PURPOSE: To determine patient factors and eye conditions associated with artifacts in Spectralis optical coherence tomography (OCT) retinal nerve fiber layer (RNFL) scans. DESIGN: Retrospective cross-sectional study. METHODS: The prevalence of 12 artifact types were described in this review of 2313 eye scans from 1188 patients who underwent a complete eye examination with Spectralis OCT scanning during the period of September 2009 to July 2013. The generalized estimating equations model was used to analyze associations between increased artifact prevalence and 10 patient characteristics, which included age, sex, race, visual acuity, refractive error, astigmatism, cataract status, glaucoma staging, visual field reliability, and glaucoma diagnosis. RESULTS: A total of 1070 or 46.3% of the 2313 eye scans had at least 1 artifact. Decentration error was the most common artifact (27.8%), followed by posterior vitreous detachment artifacts (14.4%). Visual acuity of less than 20/40 (P < .0001), presence of moderate to severe cataracts (P < .0001), advanced stage of glaucoma (P < .0001), and a diagnosis of open-angle glaucoma (P = .0003) were associated with increased prevalence of artifacts. CONCLUSIONS: Clinicians should first assess scans for artifacts before making therapeutic decisions based on RNFL thickness measurements.

Diagnostic capability of peripapillary retinal thickness in glaucoma using 3D volume scans.

PURPOSE: To determine the diagnostic capability of spectral-domain optical coherence tomography (SD OCT) peripapillary retinal thickness (RT) measurements from 3-dimensional (3D) volume scans for primary open-angle glaucoma (POAG). DESIGN: Cross-sectional study. METHODS: setting: Institutional. study population: 156 patients (89 POAG and 67 normal subjects). observation procedures: One eye of each subject was included. SD OCT peripapillary RT values from 3D volume scans were calculated for 4 quadrants of 3 different sized annuli. Peripapillary retinal nerve fiber layer (RNFL) thickness values were also determined. main outcome measures: Area under the receiver operating characteristic curve (AUROC) values, sensitivity, specificity, positive and negative predictive values, and positive and negative likelihood ratios. RESULTS: The top 5 RT AUROCs for all glaucoma patients and for a subset of early glaucoma patients were for the inferior quadrant of outer circumpapillary annulus of circular grid (OCA) 1 (0.959, 0.939), inferior quadrant of OCA2 (0.945, 0.921), superior quadrant of OCA1 (0.890, 0.811), inferior quadrant of OCA3 (0.887, 0.854), and superior quadrant of OCA2 (0.879, 0.807). Smaller RT annuli OCA1 and OCA2 consistently showed better diagnostic performance than the larger RT annulus OCA3. For both RNFL and RT measurements, best AUROC values were found for inferior RT OCA1 and OCA2, followed by inferior and overall RNFL thickness. CONCLUSION: Peripapillary RT measurements from 3D volume scans showed excellent diagnostic performance for detecting both glaucoma and early glaucoma patients. Peripapillary RT values have the same or better diagnostic capability compared to peripapillary RNFL thickness measurements, while also having fewer algorithm errors.

No formation of DNA double-strand breaks and no activation of recombination repair with UVA.

Longwave UVA is an independent class I carcinogen. A complete understanding of UVA-induced DNA damage and how this damage is processed in skin cells is therefore of utmost importance. A particular question that has remained contentious is whether UVA induces DNA double-strand breaks (DSBs), either directly or through processing of other types of DNA damage, such as recombination repair of replication forks stalled at DNA photoproducts. We therefore studied activation of the recombination repair pathway by solar available doses of UVA and assessed formation of DNA DSBs in primary skin fibroblasts. We found that, unlike ionizing radiation or UVB, UVA does not activate the Fanconi anemia/BRCA DNA damage response pathway or the "recombinase" RAD51 in primary skin fibroblasts. The fact that this pathway mediates recombination repair of DNA DSBs suggests that DNA DSBs are not formed by UVA. This is further supported by findings that UVA did not induce DNA DSBs, as assayed by neutral single-cell electrophoresis or by formation of γ-H2AX nuclear foci, considered the most sensitive assay for DNA DSBs. The lack of sufficient evidence for formation of DNA DSBs underlines the pivotal role of UVA-induced DNA photoproducts in UVA mutagenesis and carcinogenesis.

Simvastatin treatment ameliorates autoimmune disease associated with accelerated atherosclerosis in a murine lupus model.

Patients with systemic lupus erythematosus develop accelerated atherosclerosis independent of traditional risk factors. The 3-hydroxy-3-methyl-glutaryl coenzyme A (HMG-CoA) reductase inhibitors are widely prescribed for hyperlipidemia, but they also exhibit anti-inflammatory actions that appear to be independent of their suppressive actions on plasma cholesterol levels. In this study, we analyzed the effect of the HMG-CoA reductase inhibitor simvastatin on disease manifestations in gld.apoE-/- mice that lack functional Fas ligand and apolipoprotein E and exhibit accelerated atherosclerosis and aggravated lupus-like features. Wild-type, gld, apoE-/-, and gld.apoE-/- mice were maintained on a high cholesterol Western diet and received daily simvastatin (0.125 mg/kg) or saline for 12 wk. Serum cholesterol levels were unaffected by simvastatin treatment, but atherosclerotic lesion area was reduced in both apoE-/- and gld.apoE-/- mice treated with simvastatin. Simvastatin also reduced the lymphadenopathy, renal disease, and proinflammatory cytokine production seen in gld.apoE-/-, but not gld, mice. The immunomodulatory effects in gld.apoE-/- mice were associated with enhanced STAT6 and decreased STAT4 induction in submandibular lymph node cells. Along with reductions in serum TNF-alpha and IFN-gamma levels, there was also an increase in IL-4 and IL-10 transcript levels in lymph nodes. These data indicate that HMG-CoA reductase inhibitors ameliorate atherosclerosis and lupus-like autoimmunity independent of their cholesterol-lowering effects via a shift from a Th1 to a Th2 phenotype in the gld.apoE-/- model. Thus, the anti-inflammatory activities of statins may have utility for the treatment of both autoimmunity and atherosclerosis in patients with systemic lupus erythematosus.