Predictive index for adverse perinatal outcome in pregnancies complicated by fetal growth restriction.

OBJECTIVES: To develop and validate an index predictive of adverse perinatal outcome (APO) in pregnancies meeting the consensus-based criteria for fetal growth restriction (FGR) endorsed by the International Society of Ultrasound in Obstetrics and Gynecology (ISUOG). METHODS: This was a retrospective analysis of consecutive singleton non-anomalous gestations meeting the ISUOG-endorsed criteria for FGR at a single tertiary care center from November 2010 to August 2020. The dataset was divided randomly into a development set (two-thirds) and a validation set (one-third). The primary composite APO comprised one or more of: perinatal demise, Grade III-IV intraventricular hemorrhage (IVH), periventricular leukomalacia (PVL), seizures, hypoxic ischemic encephalopathy (HIE), necrotizing enterocolitis (NEC), sepsis, bronchopulmonary dysplasia (BPD) and length of stay in the neonatal intensive care unit (NICU) > 7 days. Regression analysis incorporated clinical factors readily available at the time of FGR diagnosis. The sum of ß coefficient-based weights yielded an index score, the performance of which was assessed in the validation set. Score cut-offs were selected to identify 'high-risk' and 'low-risk' ranges for which positive (PPV) and negative (NPV) predictive values and positive (LR+) and negative (LR-) likelihood ratios were calculated. RESULTS: Of the 875 consecutive pregnancies that met the criteria for FGR and were included in the study cohort, 405 (46%) were complicated by one or more components of the composite APO, including 54 (6%) perinatal deaths, 22 (3%) neonates with Grade III-IV IVH and/or PVL, nine (1%) with seizures and/or HIE, 91 (10%) with BPD, 57 (7%) with sepsis, 21 (2%) with NEC, and 361 (41%) who remained in the NICU > 7 days. In addition, 270 (31%) pregnancies were delivered by Cesarean section for non-reassuring fetal status, 43 (5%) were admitted to the NICU for < 7 days, 79 (9%) had 5-min Apgar score < 7, 125/631 (20%) had a cord gas pH ≤ 7.1 and 35/631 (6%) had a base excess ≥ 12 mmol/L. The predictive index we developed included seven factors available at the time of FGR diagnosis: hypertensive disorder of pregnancy (HDP) (+8 points), chronic hypertension without HDP (+4 points), gestational age ≤ 32 weeks (+5 points), absent or reversed end-diastolic flow in the umbilical artery (+8 points), prepregnancy body mass index ≥ 35 kg/m2 (+3 points), isolated abdominal circumference < 3rd percentile (-4 points) and non-Hispanic black race (-2 points). The bias-corrected bootstrapped (1000 replicates) area under the receiver-operating-characteristics curve (AUC) of the predictive index for composite APO in the validation group was 0.88 (95% CI, 0.84-0.92), which was similar to that in the development group (AUC, 0.86 (95% CI, 0.82-0.89); P = 0.34). In the total cohort, 40% of pregnancies had a low-risk index score (≤ 2), associated with a NPV of 85% (95% CI, 81-88%) and a LR- of 0.21 (95% CI, 0.16-0.27), and 23% had a high-risk index score (≥ 10), associated with a PPV of 96% (95% CI, 93-98%) and a LR+ of 27.36 (95% CI, 14.33-52.23). Of the remaining pregnancies that had an intermediate-risk score, 50% were complicated by composite APO. CONCLUSION: An easy-to-use index incorporating seven clinical factors readily available at the time of FGR diagnosis is predictive of APO and may prove useful in counseling and management of pregnancies meeting the ISUOG-endorsed criteria for FGR. © 2022 International Society of Ultrasound in Obstetrics and Gynecology.

Early brain spect in patients after minor craniocerebral trauma.

A prospective study made 57 measurements of cerebral blood flow (CBF) by Single Photon Emission Computed Tomography (SPECT) in post-traumatic patients. The aim of the investigation was to evaluate CBF in patients after minor craniocerebral trauma (mCCT) to ascertain the clinicotopographic correlation of the CBF changes, and to study SPECT in comparison with computed tomography (CT) findings. In addition, evaluation of the usefulness of SPECT for forensic medicine, assessment of secondary brain injury by SPECT and the predictive value of hypofrontalism were performed. A direct correlation was shown between mCCT and the observed CBF disorders, and between the CBF disorders and clinical symptoms as well as better SPECT sensitivity in comparison with CT. The usefulness of SPECT for forensic medicine purposes was also shown. Secondary brain injuries were disclose and the predictive value of hypofrontalism was confirmed. No correlation between GCS and CBF changes was found.

[Preventable deaths after severe trauma]. / Zgony do unikniecia po ciezkim urazie.

A detailed analysis of 234 trauma patients who died after being admitted to the Department of Trauma Surgery in 1990-1996 has been performed in prospective studies. Among all fatalities multiple injuries have been diagnosed in 86 persons (36.7%) while single injuries have been found in 148 persons (63.3%). The mean Injury Severity Score (ISS) was 18. Consequences of severe head injuries, cardio-pulmonary complications, shock and pulmonary artery embolism have been identified as the main causes of death. All fatal cases have been reviewed by a multidisciplinary panel of physicians and judged as nonpreventable or preventable. In 28 cases errors and deficiencies leading to death have been identified and thus the overall preventable death rate (PDR) was 11.9%. PDR has been much higher among multiply injured patients than in patients with single injuries. Preventable diagnostic errors and deficiencies in management of multiply injured patients have been committed mainly in the early resuscitative phase. A decrease of PDR in fatalities treated lately in our Department has been recorded. Other aspects concerning studies on preventability in trauma patients have been discussed.

[Enzymatic markers in peritoneal lavage fluid for diagnosis of blunt abdominal trauma]. / Oznaczenia enzymatyczne w plynie uzyskanym z diagnostycznego plukania otrzewnej w rozpoznaniu obrazen jamy brzusznej.

Value of Diagnostic Peritoneal Lavage (DPL) in blunt abdominal trauma has been analysed in the studies. The material included 84 patients who were subjected to DPL since 1990 till 1994, and who were treated in the Department of Trauma Surgery Medical University of Gdansk. The enzymatic examination of the lavage perfusate performed in this study revealed that the level of the activity of the aspartic transaminase and the alanine transaminase over 10 IU/L indicate hepatic injury, and the level of the alkaline phosphatase over 3 IU/L point at the injury of the large intestine, small intestine and mesentery.

[Thrombotic complications of arterio-venous fistulas in chronically hemodialysed patients]. / Powiklania zakrzepowe przetok tetniczo-zylnych u chorych przewlekle hemodializowanych.

Treatment by means of repeated haemodialysis has been accepted as the basic method of renal substitution treatment in our country. Thrombosis has been found as the most frequent local complication in arterio-venous (A-V) fistulas. The purpose of this study has been to analyse the frequency of thrombosis in relation to the type of A-V fistula and occurrence of early thrombosis (within 24 postoperative hours). Studies have been based in 186 patients (31 children) in whom 545 A-V surgical procedures have been performed to create and maintain permanent vascular access for haemodialysis. The mean age of the patients was 37 years. Thrombosis has been detected in 41.5% of fistulas and has been found as the main cause of 49.4% secondary procedures. Most frequently they have been observed in A-V fistulas using PTFE prosthesis. Rare complications have been found in brachio-basilic and brachio-cephalic fistulas. Early thrombosis has been observed in 4.5% of A-V fistulas. The causes of early thrombosis and within 30 postoperative days have been discussed in detail. In these complications thrombectomy (60.5%) and thrombectomy combined with creating new anastomosis (31.9%) have been performed most frequently. It has concluded that the condition of anastomosed vessels is the most important factor influencing early thrombosis.