Gasless fetoscopy: A new approach to endoscopic closure of a lumbar skin defect in fetal sheep

Objective: To develop a new endoscopic approach to the correction of a myelomeningocele-like defect in fetal sheep. Methods: The fetuses of 9 pregnant ewes, with an average gestational age of 115 days, were subjected to a 3.0 x 2.0 cm removal of the skin over the lumbar spine, performed through hysterotomy. The uterus was closed, and three 5-mm endoscopic cannulas, without valve mechanisms, were inserted. In the pilot phase (2 animals), we initially worked exclusively in the amniotic fluid space. In the study phase, we partially withdrew the fetus from the amniotic fluid to completely expose its back. By simply allowing air to enter the amniotic cavity (without gas injection), a working space was created using a uterine lift device. The skin around the defect was dissected, and a biosynthetic cellulose material was applied to cover the area. A continuous suture of the skin was performed to completely hide the material. Results: The combined air/fluid space allowed the skin to be successfully closed in 6 out of 7 cases in the study phase. All fetuses were alive at the end of the procedures. Time to complete the endoscopic part of the procedure fell from 3 to 1 h by the end of this series. Premature birth occurred in 2 of the 4 cases allowed to continue with the pregnancy. Conclusion: A new gasless fetoscopic surgery technique was developed as an alternative to current techniques used for fetal endoscopic surgery. Copyright (C) 2008 S. Karger AG, Basel.

Prenatal diagnosis and natural history of fetuses presenting with pleural effusion

Objective To describe the natural history of fetuses presenting with pleural effusion. Methods Between January 2005 and December 2009 all fetuses diagnosed with pleural effusion were followed up. Fetuses were divided into three groups: I, isolated pleural effusion; II, associated structural anomalies but normal karyotype; and III, chromosomal anomalies. Univariate and multivariate analyses were performed to determine the association between prenatal ultrasound findings and perinatal death. Results Fifty-six fetuses were included in the study. Associated structural or chromosomal anomalies occurred in 75.0% (42/56) of cases. Bilateral pleural effusion and fetal hydrops were associated with each other (p < 0.01) and with perinatal death (p < 0.05). Multivariate analysis indicated that only the presence of associated abnormalities was a statistical determinant of perinatal death (OR, 3.56; 95% CI, 1.48-5.64; p < 0.01). Conclusion Fetal pleural effusion is often associated with other abnormalities, and this association has poor perinatal outcome. Copyright (C) 2011 John Wiley & Sons, Ltd.

Sao Paulo Lung Transplantation Waiting List: Patient Characteristics and Predictors of Death

Introduction. Nowadays, lung transplantation (LTx) allocation in Brazil is based mainly oil waiting time. There is a need to evaluate the equity of the current lung allocation system. Objectives. We sought to (1) determine the characteristics of registered patients on the waiting list and (2) identify predictors of death on the list. Materials and Methods. We analyzed the medical records as well as clinical and laboratory data of 164 patients registered on the waiting list from 2001 to June 2008. Predictors of mortality were obtained using Cox proportional hazards analysis. Results. Patients who were registered on the waiting list showed a mean age of 36.1 +/- 15.0 vs. 42.2 +/- 15.7 years, considering those who did versus did not, die on the list, respectively (P = .054). Emphysema was the most prevalent underlying disease among the patients who did not die on the list (28.8%); its prevalence was low among the patients who died on the list (6.5%; P = .009). The following variables correlated with the probability of death on the waiting list: emphysema or bronchiectasis diagnosis (hazard ratio [HR] = 0.15; P = .002); activated partial thromboplastin time > 30 seconds (HR = 3.28; P = .002); serum albumin > 3.5 g/dL (HR = 0.41; P = .033); and hemoglobin saturation > 85% (HR = 0.44; P = .031). Conclusions. Some variables seemed to predict death on the LTx waiting list; these characteristics should be used to improve the LTx allocation criteria in Brazil.

Sudden unexpected death in an adolescent with epilepsy: All roads lead to the heart?

The incidence of sudden unexpected death in epilepsy (SUDEP) has been estimated from 0.5-1.4/1,000 person-years in people with treated epilepsy, and 9/1,000 person-years in candidates for epilepsy surgery. Potential risk factors for SUDEP include: age, early onset of epilepsy, duration of epilepsy, uncontrolled seizures, seizure type and winter temperatures. The arrythmogenic side-effect of antiepileptic drugs and seizures may increase the risk of SUDEP. In this report, we describe a patient with prolonged post-ictal tachycardia in EEG video recordings with a typical case of SUDEP: a 16-year-old boy with medically intractable complex partial seizures. Magnetic resonance imaging revealed left mesial temporal sclerosis. During non-invasive video-EEG monitoring, the patient presented a post-ictal heart rate increased for five hours. Two months after video-EEG, he died from SUDEP during a tonic-clonic secondary generalized seizure. The possibility of cardiac involvement in the pathogenesis of SUDEP has been suggested by many studies. Evaluation of this patient with EEG-video monitoring, including measurement of heart rate, contributed to an identification of ictal tachycardia that may have played a role in the SUDEP. Premature mortality seems to be increased in patients with epilepsy, and cardiac abnormalities may be a possible cause of SUDEP. (Cardiol J 2011; 18, 2: 194-196)

Pediatric epilepsy surgery and sudden unexpected death epilepsy: the contribution of a Brazilian epilepsy surgery program

Individuals with epilepsy are at higher risk of death than those from the general population, and sudden unexpected death in epilepsy (SUDEP) is the most important direct epilepsy-related cause of death. Epilepsies in the pediatric group are more frequently associated with known potentially risk factors for SUDEP, and a treatment resulting in an improved seizure control may also decrease mortality. The aim of this study is to identify the incidence of SUDEP in a group of operated-on children and adolescents. We analyzed 267 patients up to 18 years old, with medically intractable epilepsy submitted to surgery. We considered the age at surgery, the seizure type, the pathological findings, and the seizure outcome. Data were prospectively collected, according to the protocols of our institution`s ethics committee. The percentage of boys was 58.05. A good outcome was achieved in 72.6% of the cases and a bad outcome in 27.4%. Nine patients died during follow-up, six from clinical complications, and one from SUDEP. All patients who died during the long-term follow-up had persisted with refractory postoperative seizures. The patient who died from SUDEP died during a generalized tonic-clonic seizure. Of the patients, 72.6% had excellent postoperative outcome, and one patient died of SUDEP. All patients who died had had disabling seizures` persistence. The surgical treatment of epilepsy in children and adolescents is an efficient therapy for the medically intractable symptomatic epilepsies and also for the reduction of mortality and SUDEP risks.

Subclinical hyperthyroidism and sudden unexpected death in epilepsy

Epilepsy is the most common serious neurological condition and sudden unexpected death in epilepsy (SUDEP) is the most important direct epilepsy-related cause of death. Information concerning risk factors for SUDEP is conflicting, but high seizure frequency is a potential risk factor. Additionally, potential pathomechanisms for SUDEP are unknown, but it is very probable that cardiac arrhythmias during and between seizures or transmission of epileptic activity to the heart via the autonomic nervous system potentially play a role. In parallel, several studies have shown a link between hormones and epilepsy. However, exact knowledge regarding the association of thyroid hormones and epilepsy is lacking. As subclinical hyperthyroidism has been linked with increased risk of cardiovascular disease, we propose in this paper that SUDEP, at least in some cases, could be related with subclinical thyroid dysfunction. (C) 2009 Elsevier Ltd. All rights reserved.

Benefits of sunlight: Vitamin D deficiency might increase the risk of sudden unexpected death in epilepsy

Epilepsy is the most common serious neurological condition and sudden unexpected death in epilepsy (SUDEP) is the most important direct epilepsy-related cause of death. information concerning risk factors for SUDEP is conflicting, but high seizure frequency is a potential risk factor. Additionally, potential pathomechanisms for SUDEP are unknown, but it is very probable that cardiac arrhythmias during and between seizures or transmission of epileptic activity to the heart via the autonomic nervous system potentially play a role. In parallel, studies have shown a link between vitamin D dysfunction and epilepsy. Moreover, several evidences in the literature suggest an association between low vitamin D and seizures, indicating the possibility of anticonvulsant properties of this hormone. Quite interesting, a growing body of data suggests that low vitamin D levels may adversely affect cardiovascular health, directly associated with death from heart failure and sudden cardiac death. In view of the above findings, our research group focused in this review article that SUDEP, at least in some cases, could be related with low vitamin D levels. (C) 2009 Elsevier Ltd. All rights reserved.

Does the lunar phase have an effect on sudden unexpected death in epilepsy?

The incidence of sudden unexpected death in epilepsy (SUDEP) in Our epilepsy unit over an 8-year period was analyzed to determine a possible association between phase of the moon and SUDEP. Analysis revealed that the number of SUDEPs was highest in full moon (70%), followed by waxing moon (20%) and new moon (10%). No SUDEPs Occurred during the waning cycle. These preliminary findings suggest that the full moon appears to correlate with SUDEP. (C) 2008 Elsevier Inc. All rights reserved.

CHANGES IN FETAL AND MATERNAL DOPPLER PARAMETERS OBSERVED DURING ACUTE SEVERE HYPERTENSION TREATMENT WITH HYDRALAZINE OR LABETALOL: A RANDOMIZED CONTROLLED TRIAL

We evaluated 16 pregnant women with gestational age between 20 and 32 weeks in acute severe hypertension which were randomly allocated to receive either hydralazine or labetalol. Blood pressure and Doppler ultrasound parameters from maternal uterine and fetal middle cerebral and umbilical arteries were assessed during acute severe hypertension and after treatment. A significant reduction in systolic and diastolic blood pressure was observed in both groups. A significant change in Doppler parameters was observed only in pregnant women who received hydralazine: an increase in uterine arteries resistance index. We concluded that both drugs were highly effective in reducing blood pressure in these women. Despite the observed increase in resistance index of uterine arteries associated with hydralazine, the use of hydralazine and labetalol were not related to any significant changes in fetal Doppler, which is reassuring about the safety of these drugs when treating acute severe hypertension in pregnancy. (E-mail: wpmartins@gmail.com) (C) 2011 World Federation for Ultrasound in Medicine & Biology.

Distribution of fentanyl in the placental intervillous space and in the different maternal and fetal compartments in term pregnant women

Fentanyl is used in obstetrical practice to promote analgesia and anesthesia during labor and in cesarean delivery, with rapid and short-term effects. To determine fentanyl concentrations in maternal plasma, in the placental intervillous space, and in the umbilical artery and vein in term pregnant women. Ten healthy pregnant women underwent epidural anesthesia with fentanyl plus bupivacaine and lidocaine, and fentanyl concentrations were determined in the various maternal and fetal compartments, including the placental intervillous space, which has not been previously studied in the literature. The ratios of fentanyl concentrations in the various maternal and fetal compartments revealed an 86% rate of placental fentanyl transfer. The highest fentanyl concentrations were detected in the placental intervillous space, being 2.19 times higher than in maternal plasma, 2.8 times higher than in the umbilical vein and 3.6 times higher than in the umbilical artery, with no significant differences between the umbilical vein and artery, demonstrating that there was no drug uptake by fetal tissues nor metabolism of the drug by the fetus despite the high rates of placental transfer. The present study demonstrated that the placental intervillous space acted as a site of fentanyl deposit, a fact that may be explained by two hypotheses: (1) the blood collected from the placental intervillous space is arterial and, according to some investigators, the arterial plasma concentrations of the drugs administered to patients undergoing epidural anesthesia are higher than the venous concentrations, and (2) a possible role of P-glycoprotein (P-gp).

Fetal volume and crown-rump length from 7 to 10 weeks of gestational age in singletons and twins

Objective(s): We intend to verify if fetal volume and crown-rump length were different between singletons and twins in pregnancies aged from 7 to 10 weeks and to evaluate if fetal volume is more accurate to determine the gestational age than crown-rump length at this gestational age. Study design: From 52 days (7 weeks and 3 days) to 73 days (10 weeks and 3 days) weekly three-dimensional Ultrasonography was per-formed in 20 twin fetuses and 20 singletons. Crown-rump length and fetal volume using VOCAL were assessed in all examinations. The `true` gestational age was based on oocyte retrieval. Results: At the age of 52 days, the crown-rump length was 11.74 +/- 0.27 mm (mean +/- S.D.) and 11.48 +/- 0.22 mm (singletons and twins, respectively), while the fetal volume was 0.354 +/- 0.015 cm(3) and 0.324 +/- 0.012 cm(3). At the gestational age of 73 days, the crown-rump length was 36.19 +/- 0.90 mm and 35.87 +/- 0.54 mm and the fetal volume was 6.204 +/- 0.090 cm(3) and 6.083 +/- 0.081 cm(3). The total relative increase observed was much higher for fetal volume than for CRL: 1705 +/- 301% vs. 210 +/- 33% in singletons and 1827 +/- 305% vs. 214 +/- 25% in twins. The 95% limits of agreement (+/- 2.3 days vs. +/- 3.2 days, fetal volume vs. crown-rump length) and the intraclass correlation coefficients (0.989 vs. 0.978) between the ""true"" gestational age and that predicted by fetal volume were better than those predicted by crown-rump length. No significant difference was identified between singletons and twins for both fetal volume and crown-rump length. Conclusion(s): Twins and singletons had similar fetal volume and crown-rump length between the 7th and 10th week of gestational age. Additionally, fetal volume assessed by VOCAL was better than crown-rump length to estimate the gestational age at the evaluated period. However, the improvement was small and probably without clinical significance. Condensation: Fetal volume and crown-rump length were similar between singletons and twins. Fetal volume relative increase was higher and the predicted gestational age was better. (c) 2009 Elsevier Ireland Ltd. All rights reserved.

First trimester fetal volume and crown-rump length: Comparison between singletons and twins conceived by in vitro fertilization

The aim of this study was to compare the crown-rump length (CRL) and the fetal head and trunk (HT) volume between singletons and twins conceived after in vitro fertilization. Thirty pregnant patients submitted to embryo transfer were enrolled in this research. Ten conceived twins (20 dichorionic fetuses) while other 20 conceived singletons. The gestational age was calculated by adding 14 d to the number of days between the oocyte retrieval and the scheduled ultrasound. Three-dimensional ultrasound scans were performed weekly from 73 d (10 wk and 3 d) to 101 d (14 wk and 3 d) of gestational age. HT volume was assessed by VOCAL using 15 degrees step rotation on the manual mode. The measurement of CRL was performed by using the longitudinal plane of the fetus in the multiplanar view. The CRL and HT volume weekly relative increase were evaluated to compare the growth between singletons and twins. No significant difference was identified, in any analyzed week, when comparing the mean of CRL and HT volume between singletons and twins. Additionally, no significant difference between singletons and twins was noticed when comparing the weekly relative increase, both for CRL and HT volume. However, the weekly relative increase was significantly higher for HT volume than for CRL in every week studied for both singletons and twins. The total relative increase observed between 73 and 101 d was much higher for HT volume than for CRL: 679 +/- 39% versus 138 +/- 18% in singletons and 689 +/- 58% versus 139 +/- 21% in twins (HT volume and CRL, respectively), suggesting that HT volume could more accurately determine the gestational age.