Postnatal survival after endoscopic equatorial laser for the treatment of twin-to-twin transfusion syndrome

Background Endoscopic laser coagulation of placental anastomoses is the first-line treatment for severe twin-to-twin transfusion syndrome. A recent randomized controlled trial reported that laser coagulation along the entire vascular equator was associated with a similar dual survival and survival of at least 1 twin compared with the group that was treated with the selective technique. In addition, there was a significantly lower incidence of postoperative recurrence of twin-to-twin transfusion syndrome and the development of twin anemia-polycythemia sequence in the equatorial group. Objective The purpose of this study was to report on neonatal survival in twin-to-twin transfusion syndrome pregnancies that were treated with endoscopic laser therapy with the use of the equatorial technique and to examine the relationship between preoperative factors and twin loss. Study Design Endoscopic equatorial laser therapy was carried out as the primary treatment for twin-to-twin transfusion syndrome in all consecutive monochorionic diamniotic twin pregnancies that were referred at a single fetal surgery Center over a 4-year period. All visible placental anastomoses were coagulated; additional laser ablation of the placental tissue between the coagulated vessels was carried out. Pre-laser ultrasound data, periprocedural complications, pregnancy outcome, and postnatal survival at hospital discharge were recorded and analyzed. Results A total of 106 pregnancies were treated during the study period. Median gestational age at laser therapy was 19.7 weeks (range, 15.1-27.6 weeks). There was postoperative recurrence of twin-to-twin transfusion syndrome or the development of twin anemia-polycythemia sequence in 2 (1.9%) and 2 (1.9%) cases, respectively. The survival rates of both and at least 1 twin were 56.6% and 83.0%, respectively. Donor survival was significantly lower compared with the recipient co-twin (64.2% vs 75.5%, respectively; P <.05). The rate of fetal death, which was the most common cause of twin loss, was significantly higher in donors compared with recipient fetuses (23.6% vs 10.4%, respectively; P <.05). In cases with absent or reversed end-diastolic velocity in the donor umbilical artery, dual and donor survival rates were significantly lower compared with the remaining twin-to-twin transfusion syndrome pregnancies (40.0% vs 64.8% and 40.0% vs 76.1%, respectively; P <.05). There were no significant differences between the 2 groups in the survival of at least 1 twin and in the recipient survival. Conclusions Endoscopic equatorial laser therapy was associated with a survival of both and at least 1 twin of approximately 55% and 83%, respectively, with a low rate of recurrent twin-to-twin transfusion syndrome and twin anemia-polycythemia sequence. In addition, the preoperative finding of abnormal donor umbilical artery Doppler on ultrasound identified a subgroup of twin-to-twin transfusion syndrome pregnancies with a lower dual survival rate caused by increased intrauterine deaths of donor twins

Stratificazione del rischio negli infarti senza onde-Q: ruolo dell'ecocardiografia a riposo e da sforzo

To assess the relation between the extent of myocardial necrosis and the presence of myocardium at risk in myocardial infarction without Q waves (NQMI) we studied by echocardiography the prevalence of jeopardized myocardium in a group of NQMI stratified on the basis of left ventricular wall motion (akinesis, hypokinesis, normal kinesis). We have studied 60 consecutive patients with non-Q myocardial infarction. Patients were examined by 2D echo at rest (V-VI day from the acute episode) and during symptoms limited bicycle ergometric test (ExT) (XX-XXX day). Regional left ventricular wall motion was evaluated as normal or asynergic (severe hypokinetic, akinetic) and the ExT was considered positive in case of new asynergic areas or ECG criteria. 2D echo at rest was technically satisfactory in 56 patients, 19 showed almost an akinetic segment (Aci) 17 had hypokinetic areas (Ipo) and 20 had normal left ventricle kinesis (Norc). Wall motion abnormalities were localized more frequently in the apex and lateral areas. During exercise 2D echo was performed in 46 patients (82%) with 23 positive tests (50%). Stratifying the population on the basis of left ventricle wall motion we observed a major number of positive tests in the group of patients with normal wall motion in comparison with those with asynergic areas at rest (Norc 66.6%, Ipo 35.7%, Aci 42.6% p less than 0.05 Nore vs Ipo and Nore vs Aci) despite the same CAD extension. These data show the heterogeneity of the NQMI that likely includes patients with transmural (asynergy group) and subendocardial MI (normal kinesis group), the latter with a higher degree of myocardium at risk

Fetal Doppler changes one week after endoscopic equatorial laser for twin-to-twin transfusion syndrome: a longitudinal study

Objective: To investigate sequential Doppler changes in donors and recipients before and 1 week after endoscopic laser for twin\u2010to\u2010twin transfusion syndrome (TTTS) and to examine factors that may be associated with such changes. Methods: In TTTS pregnancies undergoing laser treatment, we examined fetal Doppler changes before and 1 week postintervention. Intrauterine death rates and preoperative factors were analyzed in relation to Doppler changes. Results: Among 129 (85.4%) donors surviving at 1 week after laser, there was normalization of umbilical artery flow in 26 (72.2%) of 36 cases with preoperative abnormal Dopplers. In the remaining 10 (27.8%) fetuses, abnormal findings persisted. The rate of later intrauterine death was significantly higher in the latter group (6 of 10, 60.0%) compared with fetuses in which Doppler findings normalized (4 of 26, 15.4%; P < .05), with no difference in the rate of severe donor growth restriction between the 2 groups (80.0% vs 65.4%, respectively; P = .688). Conclusions: In about 70% of TTTS donors with preoperative abnormal umbilical artery Doppler, there was normalization 1 week after endoscopic laser. The incidence of fetal growth restriction was not significantly different in donors with persistence of Doppler abnormalities compared with those with normalized findings

Dynamics of a faceted nematic-smectic B front in thin-sample directional solidification

We present an experimental study of the directional-solidification patterns of a nematic - smectic B front. The chosen system is C_4H_9-(C_6H_{10})_2CN (in short, CCH4) in 12 \mu m-thick samples, and in the planar configuration (director parallel to the plane of the sample). The nematic - smectic B interface presents a facet in one direction -- the direction parallel to the smectic layers -- and is otherwise rough, and devoid of forbidden directions. We measure the Mullins-Sekerka instability threshold and establish the morphology diagram of the system as a function of the solidification rate V and the angle theta_{0} between the facet and the isotherms. We focus on the phenomena occurring immediately above the instability threshold when theta_{0} is neither very small nor close to 90^{o}. Under these conditions we observe drifting shallow cells and a new type of solitary wave, called "faceton", which consists essentially of an isolated macroscopic facet traveling laterally at such a velocity that its growth rate with respect to the liquid is small. Facetons may propagate either in a stationary, or an oscillatory way. The detailed study of their dynamics casts light on the microscopic growth mechanisms of the facets in this system.Comment: 12 pages, 19 figures, submitted to Phys. Rev.

Evidences of +896 A/G TLR4 Polymorphism as an Indicative of Prevalence of Complications in T2DM Patients

T2DMis today considered as world-wide health problem, with complications responsible of an enhanced mortality and morbidity. Thus, new strategies for its prevention and therapy are necessary. For this reason, the research interest has focused its attention on TLR4 and its polymorphisms, particularly the rs4986790. However, no conclusive findings have been reported until now about the role of this polymorphism in development of T2DM and its complications, even if a recent meta-analysis showed its T2DM association in Caucasians. In this study, we sought to evaluate the weight of rs4986790 polymorphism in the risk of the major T2DMcomplications, including 367 T2DMpatients complicated for the 55.6%. Patients with A/A and A/G TLR4 genotypes showed significant differences in complication\u2019s prevalence. In particular, AG carriers had higher risk prevalence for neuropathy (P = 0.026), lower limb arteriopathy (P = 0.013), and the major cardiovascular pathologies (P = 0.017). Their cumulative risk was significant (P = 0.01), with a threefold risk to develop neuropathy, lower limb arteriopathy, and major cardiovascular events in AG cases compared to AA cases.The adjusted OR for the confounding variables was 3.788 (95% CI: 1.642\u20138.741).Thus, the rs4986790 polymorphism may be an indicative of prevalence of complications in T2DM patients

Sphenofrontal distance on three-dimensional ultrasound in euploid and trisomy-21 fetuses at 16-24 weeks&apos; gestation

Objective: To compare the distance between the sphenoid and frontal bones on three-dimensional (3D) ultrasound in euploid and trisomy-21 fetuses at 16-24 weeks' gestation. Methods: We acquired 3D volumes of the fetal profile from 80 normal and 30 trisomy-21 fetuses at 16-24 weeks' gestation. We used the multiplanar mode to obtain the mid-sagittal plane and measured the sphenofrontal distance as the shortest distance between the most anterior edge of the sphenoid bone and the lowest edge of the frontal bone. Results: In normal fetuses, the sphenofrontal distance increased linearly with gestational age, from 15.1mm at 16 weeks to 18.2mm at 24 weeks. In fetuses with trisomy 21, the mean sphenofrontal distance delta value was significantly smaller than in normal cases (-3.447mm (95% CI, -5.684 to -1.211mm); P<0.01). The sphenofrontal distance was below the 5th and 1st percentiles of the normal range in 29 (96.7%) and 27 (90.0%) trisomy-21 fetuses, respectively. Conclusions: The sphenofrontal distance is shorter at 16-24 weeks' gestation in fetuses with trisomy 21 than in normal fetuses. A reduction in the growth of the anterior cranial base contributes to the mid-facial hypoplasia observed in fetuses with trisomy 21

A maChine and deep Learning Approach to predict pulmoNary hyperteNsIon in newbornS with congenital diaphragmatic Hernia (CLANNISH): Protocol for a retrospective study

Introduction Outcome predictions of patients with congenital diaphragmatic hernia (CDH) still have some limitations in the prenatal estimate of postnatal pulmonary hypertension (PH). We propose applying Machine Learning (ML), and Deep Learning (DL) approaches to fetuses and newborns with CDH to develop forecasting models in prenatal epoch, based on the integrated analysis of clinical data, to provide neonatal PH as the first outcome and, possibly: Favorable response to fetal endoscopic tracheal occlusion (FETO), need for Extracorporeal Membrane Oxygenation (ECMO), survival to ECMO, and death. Moreover, we plan to produce a (semi)automatic fetus lung segmentation system in Magnetic Resonance Imaging (MRI), which will be useful during project implementation but will also be an important tool itself to standardize lung volume measures for CDH fetuses. Methods and analytics Patients with isolated CDH from singleton pregnancies will be enrolled, whose prenatal checks were performed at the Fetal Surgery Unit of the Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico (Milan, Italy) from the 30th week of gestation. A retrospective data collection of clinical and radiological variables from newborns' and mothers' clinical records will be performed for eligible patients born between 01/01/2012 and 31/12/2020. The native sequences from fetal magnetic resonance imaging (MRI) will be collected. Data from different sources will be integrated and analyzed using ML and DL, and forecasting algorithms will be developed for each outcome. Methods of data augmentation and dimensionality reduction (feature selection and extraction) will be employed to increase sample size and avoid overfitting. A software system for automatic fetal lung volume segmentation in MRI based on the DL 3D U-NET approach will also be developed. Ethics and dissemination This retrospective study received approval from the local ethics committee (Milan Area 2, Italy). The development of predictive models in CDH outcomes will provide a key contribution in disease prediction, early targeted interventions, and personalized management, with an overall improvement in care quality, resource allocation, healthcare, and family savings. Our findings will be validated in a future prospective multicenter cohort study

Maternal Subcutaneous and Visceral Adipose Ultrasound Thickness in Women with Gestational Diabetes Mellitus at 24-28 Weeks&apos; Gestation

BACKGROUND: Preeclampsia is a major pregnancy complication with adverse short- and long-term implications for both the mother and baby. Screening for preeclampsia at 11-13 weeks' gestation by a combination of maternal demographic characteristics and medical history with measurements of biomarkers can identify about 75% of women that develop preterm-preeclampsia with delivery at <37 weeks' gestation and 90% of those with early-preeclampsia at <32 weeks, at a screen positive rate of 10%. A recent trial (Combined Multimarker Screening and Randomized Patient Treatment with Aspirin for Evidence-Based Preeclampsia Prevention) has reported that in women identified by first-trimester screening as being at high-risk for preeclampsia, use of aspirin (150 mg/day from the first to the third trimester), compared to placebo, reduced the incidence of preterm-preeclampsia, which was the primary outcome, by 62% (95% confidence interval, 26-80%) and the incidence of early-preeclampsia by 89% (95% confidence interval, 53-97%). The surprising finding of the trial was that despite the reduction in preeclampsia the incidence of admission to the neonatal intensive care unit, which was one of the secondary outcomes, was not significantly affected (odds ratio 0.93, 95% confidence interval, 0.62-1.40). OBJECTIVE: To examine the effect of prophylactic use of aspirin during pregnancy in women at high-risk of preeclampsia on length of stay in the neonatal intensive care unit. STUDY DESIGN: This was a secondary analysis of data from the Aspirin for Evidence-Based Preeclampsia Prevention trial to assess evidence of differences in the effect of aspirin on length of stay in neonatal intensive care. Bootstrapping was used for the comparison of mean length of stay between the aspirin and placebo groups. Logistic-regression was used to assess treatment effects on stay in the neonatal intensive care unit. RESULTS: In the trial there were 1620 participants and 1571 neonates were liveborn. The total length of stay in neonatal intensive care was substantially longer in the placebo than aspirin group (1696 vs. 531 days). This is a reflection of significantly shorter mean lengths of stay in babies admitted to the neonatal intensive care unit from the aspirin than the placebo group (11.1 vs. 31.4 days; a reduction of 20.3 days (95% confidence interval, 7.0-38.6; p=0.008). Neonatal intensive care of babies born at <32 weeks' gestation contributed 1856 (83.3%) of the total of 2227 days in intensive care across both treatment arms. These occurred in 9 (1.2%) of the 777 livebirths in the aspirin group and in 23 (2.9%) of 794 in the placebo group (odds ratio 0.42; 95% confidence interval, 0.19-0.93; p=0.033). Overall, in the whole population, including zero lengths of stay for those that were not admitted to the neonatal intensive care unit, the mean length of stay was longer in the placebo than aspirin group (2.06 vs 0.66 days; reduction of 1.4 days (95% confidence interval, 0.45-2.81; p=0.014). This corresponds to a reduction in length of stay of 68% (95% confidence interval, 20-86%). CONCLUSIONS: In pregnancies at high-risk of preeclampsia administration of aspirin reduces the length of stay in the neonatal intensive care unit by about 70%. This reduction could essentially be attributed to a decrease in the rate of births at <32 weeks' gestation, mainly because of prevention of early preeclampsia. The findings have implications for both short- and long-term healthcare costs as well as infant survival and handicap

Surface effects in nucleation and growth of smectic B crystals in thin samples

We present an experimental study of the surface effects (interactions with the container walls) during the nucleation and growth of smectic B crystals from the nematic in free growth and directional solidification of a mesogenic molecule ($C_4H_9-(C_6H_{10})_2CN$) called CCH4 in thin (of thickness in the 10 $\mu$m range) samples. We follow the dynamics of the system in real time with a polarizing microscope. The inner surfaces of the glass-plate samples are coated with polymeric films, either rubbed polyimid (PI) films or monooriented poly(tetrafluoroethylene) (PTFE) films deposited by friction at high temperature. The orientation of the nematic and the smectic B is planar. In PI-coated samples, the orientation effect of SmB crystals is mediated by the nematic, whereas, in PTFE-coated samples, it results from a homoepitaxy phenomenon occurring for two degenerate orientations. A recrystallization phenomenon partly destroys the initial distribution of crystal orientations. In directional solidification of polycrystals in PTFE-coated samples, a particular dynamics of faceted grain boundary grooves is at the origin of a dynamical mechanism of grain selection. Surface effects also are responsible for the nucleation of misoriented terraces on facets and the generation of lattice defects in the solid.Comment: 15 pages, 24 figures, submitted to PR