Pannus sign on ultrasound and magnetic resonance imaging predicts placenta percreta and is associated with high estimated blood loss

Objective: Antenatal identification of the placenta accreta spectrum (PAS) has been estimated to be approximately 50% in multicenter and population based data, with sensitivity and specificity far lower than that reported from referral center cohorts. Easily obtained, objective markers are key to improving antenatal detection. We noted that in many PAS cases, the placenta bulges over the cervical os, like an abdominal pannus over a belt. The depth of the “pannus” can be measured on ultrasound (US) and magnetic resonance imaging (MRI). We predicted that a positive sign can differentiate between percreta and increta/accreta. Study Design: Retrospective chart review of a database of patients with PAS from Jan 2012-Jun 2019. Demographic and clinical data were abstracted.” for US and MRI images were reviewed and measurements recorded by trained researchers blinded to clinical data. The pannus sign was measured in sagittal plane (Figure). The pannus measurement (PM) drawn parallel to the cervical canal from the most caudal placental point to the IOL is the “pannus,” when positive, measured in mm. Negative (-) values indicate placenta cephalad to and positive (+) values were at or more caudal to the IOL. Sensitivity, specificity, PPV and NPV were calculated using the Chi-squared test. Results: Of 164 women who had pathology proven PAS, 131 had adequate images, of which 120 had US, 54 had MRI and 43 had both. One with fundal PAS was excluded. 90 women had a (+) value, and 30 a (–) value on US. MR agreed with US in all but 4 cases (91%, mean difference 7.4mm.) The sensitivity and specificity were: 82.7% [95% CI, 72.5-89.6%] & 37.7% [95% CI, 25.1-77.5%] with a PPV of 68.9 and NPV of 57%. The PM was associated with Conclusion: A positive pannus sign is senstitive for percreta, but not specific; cases of parametrial or high invasion will not be detected using this sign. There is excellent agreement between US and MRI measurements and it was easily obtained when the cervical canal could be seen. Studies of reproducibility and use with other markers of PAS are needed

Perinatal assessment of complex cesarean delivery: beyond placenta accreta spectrum

Multiple cesarean deliveries are known to be associated with long-term postoperative consequences because of a permanent defect of the lower uterine segment wall and the development of thick pelvic adhesions. Patients with a history of multiple cesarean deliveries often present with large cesarean scar defects and are at heightened risk in subsequent pregnancies of cesarean scar ectopic pregnancy, uterine rupture, low-lying placenta or placenta previa, and placenta previa accreta. Moreover, large cesarean scar defects will lead to progressive dehiscence of the lower uterine segment with the inability to effectively reapproximate hysterotomy edge and repair at birth. Major remodeling of the lower uterine segment associated with true placenta accreta spectrum at birth, whereby the placenta becomes inseparable from the uterine wall, increases the rates of perinatal morbidity and mortality, especially when undiagnosed before delivery. Ultrasound imaging is currently not routinely used to evaluate the surgical risks of patients with a history of multiple cesarean deliveries, beyond the risk assessment of placenta accreta spectrum. Independent of accreta placentation, a placenta previa under a scarred, thinned partially disrupted lower uterine segment, covered by thick adhesions with the posterior wall of the bladder, poses a surgical risk and requires fine dissection and surgical expertise; however, data on the use of ultrasound to evaluate uterine remodeling and adhesions between the uterus and other pelvic organs are scarce. In particular, transvaginal sonography has been underused, including in patients with a high probability of placenta accreta spectrum at birth. Based on the best available knowledge, we discuss the role of ultrasound imaging in identifying the signs suggestive of major remodeling of the lower uterine segment and in mapping the changes in the uterine wall and pelvis, to enable the surgical team to prepare for all different types of complex cesarean deliveries. The need for postnatal confirmation of the prenatal ultrasound findings for all patients with a history of multiple cesarean deliveries, regardless of the diagnosis of placenta previa and placenta accreta spectrum, is discussed. We propose an ultrasound imaging protocol and a classification of the level of surgical difficulty at elective cesarean delivery to stimulate further research toward the validation of ultrasound signs by which these signs may be applied to improve surgical outcomes

Adults With Cerebral Palsy Who Had a Rhizotomy as a Child: Long‐term Follow‐up

Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/147123/1/pmr2s3.pd

Quality of life among cancer inpatients 80 years and older: a systematic review

Objective The aim of this systematic review was to summarize and assess the literature on quality of life (QoL) among cancer patients 80 years and older admitted to hospitals and what QoL instruments have been used. Methods We searched systematically in Medline, Embase and Cinahl. Eligibility criteria included studies with any design measuring QoL among cancer patients 80 years and older hospitalized for treatment (surgery, chemotherapy or radiation therapy). Exclusion criteria: studies not available in English, French, German or Spanish. We screened the titles and abstracts according to a predefined set of inclusion criteria. All the included studies were assessed according to the Critical Appraisal Skills Programme checklists, and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Statement checklist was used to ensure rigor in conducting and reporting. This systematic review was registered in PROSPERO (CRD42017058290). Results We included 17 studies with 2005 participants with various cancer diagnoses and Classification of Malignant Tumors stages (TNM). The included studies used a range of different QoL instruments and had different aims and outcomes. Both cancer-specific and generic instruments were used. Only one of the 17 studies used an age-specific instrument. All the studies included patients 80 years and older in their cohort, but none specifically analyzed QoL outcomes in this particular subgroup. Based on findings in the age-heterogeneous population (age range 20–100 years), QoL seems to be correlated with the type of diagnosed carcinoma, length of stay, depression and severe symptom burden. Conclusion We were unable to find any research directly exploring QoL and its determinants among cancer patients 80 years and older since none of the included studies presented specific analysis of data in this particular age subgroup. This finding represents a major gap in the knowledge base in this patient group. Based on this finding, we strongly recommend future studies that include this increasingly important and challenging patient group to use valid age- and diagnosis-specific QoL instruments.publishedVersio

Maternal mental health:a key area for future research among women with congenital heart disease

In this viewpoint, we respond to the recently published national priorities for research in congenital heart disease (CHD) among adults, established through the James Lind Alliance Priority Setting Partnership, with specific attention to priority 3 (mental health) and priority 5 (maternal health). Our recent policy impact project explored how maternal mental health is currently addressed in adult congenital heart disease (ACHD) services in the National Health Service, identified gaps and discussed possible ways forward. Our multidisciplinary discussion groups, which included women with lived experience of CHD and pregnancy, cardiology and obstetrics clinicians and medical anthropologists, found that while pregnancy and the postnatal period increase the mental health challenges faced by women with CHD, current services are not yet equipped to address them. Based on this work, we welcome the prioritisation of both mental health and maternal health in ACHD, and suggest that future research should focus on the overlaps between these two priority areas

Emotional orientation, brain function and genetics in adults and children : implications for development, and psychopathology

The ability to attend or avoid emotional stimuli is important to our survival. Attending to potential threats can help us avoid danger; while attending to positive stimuli is important for our social function. For example, when we see a man with a knife it is important to run away, or avoid the threat so we are not harmed. Just as the knife warns us of the threatening stiuation, a smiling face indicates a friendly person. We are drawn to this cue to possibly receive a rewarding social interaction. Attention orientation to both negative and positive stimuli may be impacted by development, psychopathology and genetics. The dot probe task yields both behavioral and neural indices of attention biases towards or away from an emotional cue (angry or happy face). This thesis includes three studies to determine the effects of development, psychopathology, and genetics on attention orientating. In Study I, we examined age-related correlations in attention-orienting biases to negative and positive faces in a healthy sample using functional magnetic resonance imaging (fMRI) and a dot probe task. Behavioral response data indicated a positive correlation between age and attention bias towards happy faces, such that younger participants showed less bias towards happy, relative to neutral, faces, than older subjects. Attention bias towards angry faces did not correlate with age. Relative to older, younger participants demonstrated greater activation in the left cuneus and left caudate on the contrast of trials used to assess happy-face attention bias. In Study II, using the dot probe task in a home setting, we studied parents that were highly exposed to the attack on the World Trade Center in 2001 and their children. We found that psychiatrically healthy parents who experienced severe trauma showed greater attention bias towards threat than parents experiencing no such trauma, but trauma experienced by parents did was not predictive of attention bias in their children. In Study III, using an fMRI on 5-HTTLPR genotyped adults performing dot probe task; we compared amygdala response to threat bias contrasts. The 5- HTTLPR has been previously linked to amygdala reactivity and the amygdala has been implicated in the orienting of attention towards threat. Behavioral data indicated no difference between the two genotyped subject populations for the 5-HTTLPR polymorphism (l/l and s-carrier). However, fMRI data did reveal between-group differences in the amygdala activation. Specifically, relative to l/l, s-carriers showed greater right amygdala activation to trials with angry faces. Because similar levels of threat bias were found in the two genotype groups, these findings suggest that s-carriers exhibit a lower threshold for engaging the amygdala within the context of the task. In total, these three studies explore the effect of both the environment and genes on behavior and brain function. Studies I and II focus on environment, specifically, how their environment affects their emotional orientation. On the genetic side, Study III focuses on the effect of genetics on emotional orientation

Evaluation of the zucker diabetic fatty (ZDF) rat as a model for human disease based on urinary peptidomic profiles

Representative animal models for diabetes-associated vascular complications are extremely relevant in assessing potential therapeutic drugs. While several rodent models for type 2 diabetes (T2D) are available, their relevance in recapitulating renal and cardiovascular features of diabetes in man is not entirely clear. Here we evaluate at the molecular level the similarity between Zucker diabetic fatty (ZDF) rats, as a model of T2D-associated vascular complications, and human disease by urinary proteome analysis. Urine analysis of ZDF rats at early and late stages of disease compared to age- matched LEAN rats identified 180 peptides as potentially associated with diabetes complications. Overlaps with human chronic kidney disease (CKD) and cardiovascular disease (CVD) biomarkers were observed, corresponding to proteins marking kidney damage (eg albumin, alpha-1 antitrypsin) or related to disease development (collagen). Concordance in regulation of these peptides in rats versus humans was more pronounced in the CVD compared to the CKD panels. In addition, disease-associated predicted protease activities in ZDF rats showed higher similarities to the predicted activities in human CVD. Based on urinary peptidomic analysis, the ZDF rat model displays similarity to human CVD but might not be the most appropriate model to display human CKD on a molecular level

Ectopic Over-expression of Oncogene Pim-2 Induce Malignant Transformation of Nontumorous Human Liver Cell Line L02

In order to prove that ectopic over-expression of Pim-2 could induce malignant transformation of human liver cell line L02, three groups of cells were set up including human liver cell line L02 (L02), L02 cells transfected with Pim-2 gene (L02/Pim-2) and L02 cells transfected with empty-vector (L02/Vector). Pim-2 expression levels were detected. The morphology, proliferation level, apoptosis rate and migration ability of the cells were detected respectively. Then the cells were subcutaneously inoculated into athymic mice and the microstructures of the neoplasm were observed. Compared with the controls, Pim-2 expression levels were significantly higher in L02/Pim-2 cells (P<0.05), and their morphology had obvious malignant changes. They also showed a significantly increased proliferation rate (P<0.05) and migration capacity (P<0.05), as well as a significantly decreased apoptosis rate (P<0.05). Only the athymic mice inoculated with L02/Pim-2 cells could generate neoplasm, and the morphology of the neoplasm coincided with that of the hepatoma. The results manifest that ectopic Pim-2 gene could be stably expressed in L02/Pim-2 cells. Both the morphological and biological changes of L02/Pim-2 cells demonstrate the trend of malignant transformation. L02/Pim-2 cells could generate hepatoma in athymic mice. In conclusion, Pim-2 could induce malignant transformation of human liver cell line L02

A simple guide to ultrasound screening for placenta accreta spectrum for improving detection and optimizing management in resource limited settings

Publisher Copyright: © 2022 The Authors. International Journal of Gynecology & Obstetrics published by John Wiley & Sons Ltd on behalf of International Federation of Gynecology and Obstetrics.Placenta accreta spectrum is a pregnancy complication associated with severe morbidity and maternal mortality especially when not suspected antenatally and appropriate management instigated. Women in resource-limited settings are more likely to face adverse outcomes due to logistic, technical, and resource inadequacies. Accurate prenatal imaging is an important step in ensuring good outcomes because it allows adequate preparation and an appropriate management approach. This article provides a simple three-step approach aimed at guiding clinicians and sonographers with minimal experience in placental accreta spectrum through risk stratification and basic prenatal screening for this condition both with and without Doppler ultrasound.Peer reviewe

Association of peripartum management and high maternal blood loss at cesarean delivery for placenta accreta spectrum (PAS) : A multinational database study

Introduction Placenta accreta spectrum (PAS) carries a high burden of adverse maternal outcomes, especially significant blood loss, which can be life-threatening. Different management strategies have been proposed but the association of clinical risk factors and surgical management options during cesarean delivery with high blood loss is not clear. Material and methods In this international multicenter study, 338 women with PAS undergoing cesarean delivery were included. Fourteen European and one non-European center (USA) provided cases treated retrospectively between 2008 and 2014 and prospectively from 2014 to 2019. Peripartum blood loss was estimated visually and/or by weighing and measuring of volume. Participants were grouped based on blood loss above or below the 75th percentile (>3500 ml) and the 90th percentile (>5500 ml). Results Placenta percreta was found in 58% of cases. Median blood loss was 2000 ml (range: 150-20 000 ml). Unplanned hysterectomy was associated with an increased risk of blood loss >3500 ml when compared with planned hysterectomy (adjusted OR [aOR] 3.7 [1.5-9.4], p = 0.01). Focal resection was associated with blood loss comparable to that of planned hysterectomy (crude OR 0.7 [0.2-2.1], p = 0.49). Blood loss >3500 ml was less common in patients undergoing successful conservative management (placenta left in situ, aOR 0.1 [0.0-0.6], p = 0.02) but was more common in patients who required delayed hysterectomy (aOR 6.5 [1.7-24.4], p = 0.001). Arterial occlusion methods (uterine or iliac artery ligation, embolization or intravascular balloons), application of uterotonic medication or tranexamic acid showed no significant effect on blood loss >3500 ml. Patients delivered by surgeons without experience in PAS were more likely to experience blood loss >3500 ml (aOR 3.0 [1.4-6.4], p = 0.01). Conclusions In pregnant women with PAS, the likelihood of blood loss >3500 ml was reduced in planned vs unplanned cesarean delivery, and when the surgery was performed by a specialist experienced in the management of PAS. This reinforces the necessity of delivery by an expert team. Conservative management was also associated with less blood loss, but only if successful. Therefore, careful patient selection is of great importance. Our study showed no consistent benefit of other adjunct measures such as arterial occlusion techniques, uterotonics or tranexamic acid.Peer reviewe