Neonatal complications associated with use of fetal scalp electrode: a retrospective study.

OBJECTIVES: To estimate the incidence and risk of complications associated with a fetal scalp electrode and to determine whether its application in the setting of operative vaginal delivery was associated with increased neonatal morbidity. DESIGN: Retrospective cohort study. SETTING: Twelve clinical centers with 19 hospitals across nine American Congress of Obstetricians and Gynecologists US districts. POPULATION: Women in the USA. METHODS: We evaluated 171 698 women with singleton deliveries ≥ 23 weeks of gestation in a secondary analysis of the Consortium on Safe Labor study between 2002 and 2008, after excluding conditions that precluded fetal scalp electrode application such as prelabour caesarean delivery. Secondary analysis limited to operative vaginal deliveries ≥ 34 weeks of gestation was also performed. MAIN OUTCOME MEASURES: Incidences and adjusted odds ratios with 95% confidence intervals of neonatal complications were calculated, controlling for maternal characteristics, delivery mode and pregnancy complications. RESULTS: Fetal scalp electrode was used in 37 492 (22%) of deliveries. In non-operative vaginal delivery, fetal scalp electrode was associated with increased risk of injury to scalp due to birth trauma (1.2% versus 0.9%; adjusted odds ratios 1.62; 95% confidence intervals 1.41-1.86) and cephalohaematoma (1.0% versus 0.9%; adjusted odds ratios 1.57; 95% confidence intervals 1.36-1.83). Neonatal complications were not significantly different comparing fetal scalp electrode with vacuum-assisted vaginal delivery and vacuum-assisted vaginal delivery alone or comparing fetal scalp electrode with forceps-assisted vaginal delivery and forceps-assisted vaginal delivery alone. CONCLUSIONS: We found increased neonatal morbidity with fetal scalp electrode though the absolute risk was very low. It is possible that these findings reflect an underlying indication for its use. Our findings support the use of fetal scalp electrodes when clinically indicated. TWEETABLE ABSTRACT: Neonatal risks associated with fetal scalp electrode use were low (injury to scalp 1.2% and cephalohaematoma 1.0%).

Does increasing body mass index affect cerclage efficacy?

OBJECTIVE: To study the relationship between body mass index (BMI) and gestational age (GA) at delivery in patients with cervical insufficiency (CI) undergoing cerclage. STUDY DESIGN: We accessed a database of patients with singleton gestations undergoing cerclage (N=168) for a well-characterized history of CI, shortened cervix <2.5 cm with a history of prior preterm delivery or prolapse of membranes through the external os. Univariate and multivariate logistic regression analysis were performed to compare obstetrical outcomes between obese and normal-weight patients. RESULT: Prior preterm delivery <35 weeks in obese vs normal-weight patients was significantly higher (44% vs 9%), odds ratio=6.9 (95% CI: 2.5, 18.5), with lower mean GA at delivery (32.6±7.0 vs 37.2±3.4 weeks, P<0.001). After controlling for confounders, BMI remained significantly predictive of prematurity (coefficient: -0.12, adjusted R (2)=0.24), such that every additional 1 unit of BMI was associated with a 1-day reduction in GA at delivery (P=0.03). CONCLUSION: An inverse correlation exists between BMI and GA at delivery in patients with CI receiving cerclage. The findings are unexpected given the protective effect of obesity on spontaneous preterm delivery.

Patient decisions regarding prenatal aneuploid fluorescence in situ hybridization results.

OBJECTIVE: To determine an appropriate risk cut-off to offer prenatal aneuploid FISH, and if FISH results affect patient decisions regarding pregnancy management. METHOD: Retrospective evaluation of 707 patients presenting for diagnostic prenatal testing. Studied parameters included gestational age, indication for testing, aneuploid risk, procedure performed, FISH (whether offered, requested, and/or performed), result turn-around time, karyotype results, decision after obtaining results, and the timing of that decision. Patients who were offered FISH were compared to those not offered FISH (student T-test). RESULTS: Twenty-five clinically significant abnormalities were detected by karyotype and/or FISH analysis. Thirteen out of 17 patients electing pregnancy interruption had FISH performed. There were no differences between the group that interrupted following FISH (n=7) and the group that interrupted following final karyotype results (n=6). Turn-around times for those abnormal samples with FISH testing was significantly shorter than for those without FISH testing (p=0.02). Risk thresholds of >or=0.5%, >or=1%, >or=2%, or >or=3%, would detect 92%, 84%, 48%, and 32% of the clinically significant anomalies with 663, 317, 118, and 66 FISH analyses performed, respectively. CONCLUSION: Acting on FISH results alone afforded a significantly shorter interval between test and pregnancy interruption. A risk cut-off >or=1% appears to optimize the detection rate and the yield of abnormal results.

Predictive value of transvaginal cervical length in triplet pregnancies for spontaneous preterm delivery at < or = 32 weeks.

OBJECTIVE: To establish whether cervical length is a predictor of spontaneous preterm delivery at < or = 32 weeks in triplet pregnancies. METHODS: This was a case-control study of all triplet pregnancies followed with more than three sonographic assessments of cervical length at 4-week intervals from 1995 to 2000. Cervical length in women delivered spontaneously at < or = 32 weeks (cases) was compared with that of the remaining women (controls). Statistical analysis included Fisher's exact test, chi2 test, one-way analysis of variance, logistic regression and receiver operating characteristic (ROC) curve to determine optimal cervical length thresholds for spontaneous preterm delivery at < or = 32 weeks. RESULTS: Of the 58 women included in the study, 17 (29%) delivered spontaneously at < or = 32 weeks. The preterm delivery group had similar demographic and obstetric variables, but a higher rate of cerclage placement (65% vs 17%, p < 0.001) than controls. Mean +/- standard deviation cervical length was significantly shorter among cases than controls at 16-20.0 weeks (3.0 +/- 1.2 vs. 3.9 +/- 0.8 cm, p = 0.01), but not at 20.1-24.0 weeks (3.5 +/- 1.1 vs. 3.8 +/- 1.0 cm, p = 0.76). Logistic regression analysis determined that cervical length at 16-20 weeks had an odds ratio of 0.43 (95% CI = 0.23, 0.80) for the prediction of spontaneous preterm delivery at < or = 32 weeks. ROC curve analysis identified a cervical length of < or = 2.6 cm as the optimal threshold for the prediction of spontaneous preterm delivery at < or = 32 weeks (sensitivity 41%, specificity 92%). CONCLUSIONS: In a population of triplet gestations with a 29% rate of preterm delivery, cervical length at 16-20.0 weeks, but not at 20.1-24.0 weeks, was inversely correlated with the probability of preterm delivery at < or = 32 weeks.

Gender-specific responses of lean body composition and non-gender-specific cardiac function improvement after GH replacement in GH-deficient adults.

GH deficiency (GHD) in adulthood is accompanied by physical and psychological impairments. One hundred fifteen patients (67 male, 48 female) with pronounced GHD were enrolled in a randomized, double-blind, placebo-controlled study with objectives that included effects on body composition, cardiac structure, and function and safety of replacement therapy with recombinant human GH (Saizen). Sixty patients (31 male, 29 female) received GH at a dose of 0.005-0.010 mg/kg.d, and 55 patients (36 male, 19 female) received placebo for 6 months. Assessment of body composition by dual-energy x-ray absorptiometry demonstrated a treatment difference in lean body mass increase of 2.1 kg (between-group comparison, P < 0.0001), which was significantly greater among males than females (P < 0.0001) [males: GH, +3.13 kg (2.42, 3.84); placebo, +0.11 kg (-0.60, 0.82); and females: GH, +0.64 kg (-0.15, 1.44); placebo: -0.90 kg (-2.20, 0.39)] [mean change 0-6 months (95% confidence limits)] and was associated with IGF-I changes. The decrease in fat mass of 2.8 kg (between-group comparison, P < 0.0001) noted by DEXA was also evident from bioelectric impedance and anthropometric measurements. Echocardiography showed comparable improvement in left ventricular systolic function after GH treatment in both genders. End-systolic volume decreased by 4.3 +/- 10.5 ml (from 35.8 +/- 17.6 ml; between-group comparison, P = 0.035) and ejection fraction increased by 5.1 +/- 10.0% (from 55.0 +/- 11.2%; between-group comparison, P = 0.048), approaching normalcy. Diastolic function did not change as assessed by isovolumic relaxation time, early diastolic flow, diastolic flow secondary to atrial contraction, or ratio of peak mitral early diastolic and atrial contraction velocity. GH treatment was well tolerated, with adverse events primarily related to effects on fluid balance. No apparent relationship between IGF-I levels and the occurrence or severity of adverse events was identified. In conclusion, GH replacement therapy in adults with GHD demonstrated beneficial effects on lean body mass composition that was more pronounced in males than females. In contrast, cardiac function improvement appears to benefit both genders equally.

Favorable final height outcome in girls with Ullrich-Turner syndrome treated with low-dose growth hormone together with oxandrolone despite starting treatment after 10 years of age.

The objective of this study was to find out whether moderate doses of growth hormone (GH) in combination with oxandrolone (Ox) and late initiation of puberty could improve adult height even in relatively old patients with Ullrich-Turner syndrome (UTS). Ninety-one patients with UTS were randomly assigned to receive either GH alone (Saizen, Ares-Serono, Geneva) 18 IU/m2/week (0.2 mg/kg/week) by daily s.c. injections (group GH) or a combination of GH and Ox 0.1 mg/kg/day p.o. (group GH + Ox). Prior to treatment mean age was 10.2 years (GH) and 10.5 years (GH + Ox), mean projected adult height (PAH) was 146.4 cm (GH) and 146.7 cm (GH + Ox). During year 2 the GH dose was increased in the GH group to 24 and later to 28 IU/m2/week (0.27 mg and later 0.31 mg/kg/week). In group GH + Ox, the Ox dose was reduced to 0.05 mg/kg/day after the first 12 months of therapy, and during the last treatment years the GH dose was raised to 24-28 IU/m2/week (0.27-0.31 mg/kg/week) due to declining growth promotion. Some of the patients of group GH were later given Ox in addition to GH because of waning growth velocity, whereas some of the patients of group GH + Ox were taken off Ox due to virilizing side-effects of the high Ox dose, thus making up a third group of patients: group GH + transient Ox. Puberty was induced at a mean age of 14.9 years. In group GH + Ox, cumulative growth during 5 years of therapy was twice the growth anticipated from standards of untreated patients with UTS. Forty-seven patients are now near or at final height: in group GH (n = 7), mean final height was 151.7 cm (PAH 148.1 cm, gain 3.6 cm); in group GH + Ox (n = 15), 155.1 cm (PAH 147.2 cm, gain 7.9 cm); and in group GH + transient Ox (n = 25), 152.8 cm (PAH 146.4 cm, gain 6.4 cm). These results should be regarded as an underestimate of true final height since some the patients are still growing. Moderate doses of GH plus Ox and late induction of puberty definitely improved final height even in patients with UTS treated relatively late.

Threshold-level repetitive transcranial electrical stimulation for intraoperative monitoring of central motor conduction.

OBJECT: The authors conducted a study to evaluate repetitive transcranial electrical stimulation (TES) to assess spinal cord motor tract function in individuals undergoing spine surgery, with emphasis on safety and efficacy. METHODS: Somatosensory evoked potentials (SSEPs) were elicited using standard technique. Muscle electromyographic values were measured in response to a three- or four-pulse train of stimulation delivered to the motor cortex via subdermal electrodes. They also evaluated whether changes in the minimum stimulus intensity (that is, threshold level) needed to elicit a response from a given muscle predict motor status immediately postoperatively, as well as whether changes in SSEP response amplitude and latency predict sensory status immediately postoperatively. Anesthesia was routinely induced with intravenous propofol and remifentanil, supplemented with inhaled nitrous oxide. Use of neuromuscular block was avoided after intubation. Satisfactory monitoring of muscle response to threshold-level repetitive TES was achieved in all but nine of the 194 patients studied. In contrast, cortical SSEP responses could not be elicited in 42 of 194 individuals. In cases in which responses were present, TES-based evoked responses proved to be extremely accurate for predicting postoperative motor status. Somatosensory evoked potential monitoring was nearly as accurate for predicting postoperative sensory status. There were frequent instances of postoperative motor or sensory deficit that were not predicted by SSEP- and TES-based monitoring, respectively. There were no adverse events attributable to TES-based monitoring, although since this study ended we have had a single adverse event attributable to threshold-level repetitive TES. CONCLUSIONS: Intraoperative threshold-level repetitive TES-based monitoring of central motor conduction has proven to be a simple, safe, and highly accurate technique for the prevention or minimization of inadvertent motor deficit during surgery involving the spine or spinal cord.

Long-term therapy with recombinant human growth hormone (Saizen) in children with idiopathic and organic growth hormone deficiency.

In an open-label study, 69 children with organic or idiopathic growth hormone deficiency (GHD) were treated with recombinant human growth hormone (Saizen) for an average of 64.4 mo, with treatment periods as long as 140.9 mo. Auxologic measurements, including height velocity, height standard deviation score, and bone age, were made on a regular basis. The data suggest that long-term treatment with Saizen in children with GHD results in a positive catch-up growth response and proportionate changes in bone age vs height age during treatment. In addition, long-term Saizen therapy was well tolerated, with the majority of adverse events related to common childhood disorders or existing baseline medical conditions and not to study treatment. There were no significant changes in laboratory safety data or vital signs, and no positive antibody tests for Saizen.

Outcome of growth hormone therapy in children with growth hormone deficiency showing an inadequate response to growth hormone-releasing hormone.

Saizen (recombinant growth hormone [GH]), 0.2 mg/(kg x wk), was given in an open-label fashion for an average of 51 mo to 27 children with presumed idiopathic GH deficiency who had withdrawn from a trial of Geref (recombinant GH-releasing hormone [GHRH] 1-29) because of inadequate height velocity (HV) (25 children), the onset of puberty (1 child), or injection site reactions (1 child). Measurements were made every 3-12 mo of a number of auxologic variables, including HV, height standard deviation score, and bone age. The children in the study showed excellent responses to Saizen. Moreover, first-year growth during Saizen therapy was inversely correlated with the GH response to provocative GHRH testing carried out 6 and 12 mo after the initiation of Geref treatment. These findings indicate that GH is effective in accelerating growth in GH-deficient children who do not show or maintain a satisfactory response to treatment with GHRH. In addition, they suggest that the initial response to GH therapy used in this way can be predicted by means of provoc-ative testing.

Electromyography during stereotactic pallidotomy for Parkinson's disease.

In stereotactic pallidotomy for Parkinson's disease, care must be taken to avoid internal capsule injury while maximizing improvement of rigidity and tremor. In 21 patients, intraoperative electromyography (EMG) was used to assess stimulation thresholds required for capsular responses and to monitor muscle tone and tremor. Surface EMG electrodes were placed on the face and multiple muscle groups of the extremities. The stimulation and lesion electrode was introduced via MRI-guided stereotaxis toward a point 2-3 mm anterior to the midcommissural point, 5-6 mm inferior to the AC-PC plane, and 21-22 mm lateral to the midline. Exact targets were modified according to MRI-visualized anatomy. With stimulation at 5 and 50 Hz, thresholds for detection of EMG responses were usually seen at 4-5 mA. EMG responses were consistently seen prior to visual observation of muscle activity. Timing of EMG response relative to stimulus aided in differentiating stimulus-related movement from spontaneous tremor. Resting spontaneous EMG activity was seen to decrease as rigidity was improved by incremental lesion production. EMG activity related to tremor was recorded; tremor decrease by lesion production was documented by EMG recording. Patient cooperation with physiologic testing during stimulation and lesion production may become limited. Intraoperative EMG monitoring provides an adjunct to improve reliability of assessment of capsular stimulation and rigidity while providing documentation of lesion impact on rigidity and tremor.

Correlation of a unique 220-kDa protein with vitamin D sensitivity in glioma cells.

We have investigated the antitumor and apoptotic effects of 1, 25-dihydroxyvitamin D(3) (VD(3)) in glioma cell lines and in primary cultures derived from surgical specimens from patients. Our results showed that certain glioma cells underwent apoptosis, whereas others were resistant. In an attempt to search for parameters that dictate VD(3) sensitivity, we discovered a unique 220-kDa protein in glioma cells that were sensitive to VD(3). This protein was not a classical vitamin D receptor (VDR), but was recognized by two different anti-VDR monoclonal antibodies. Furthermore, the level of the 220-kDa protein was inversely correlated with the IC(50) of VD(3) in these glioma cells. This 220-kDa protein was also present in frozen brain tumor samples, and the level of expression appeared to correlate with their corresponding primary cultures. Thus, our findings suggest that this 220-kDa protein may play an important role in determining VD(3) sensitivity in malignant glioma.

Early MRI findings in high grade glioma.

Magnetic resonance imaging (MRI) is more sensitive than computerized tomography in the detection of many intracerebral lesions; however, the significance of some MRI findings may be unclear. Over four years, nine patients, aged 40-79 years, have been encountered whose initial MRI scans were negative or had minimal abnormalities and soon thereafter had high grade glioma. Initial MRI was performed in eight patients for new-onset seizures and one patient for a focal deficit. MRI was negative in four of the patients and mildly abnormal in five of the patients (small areas of increased T2 and/or minimal enhancement). The initial diagnoses usually included inconclusive differentials of stroke and infection with neoplasm less frequently considered. Radiographic progression leading to the diagnosis of high grade glioma became evident on repeat MRI in 1-8 months with six patients showing progression within three months. All patients underwent surgery and had histologic diagnosis of glioma. Although MRI is quite sensitive, four of the initial scans were negative with reasonable quality studies. Conversely, in five of the initial scans, the tumors were detected when so small that the radiographic findings were not typically diagnostic. Glioma must be considered as a possible cause of initial seizures or new neurologic deficits in adults with normal or minimally abnormal MRI. In this group, seizures were the overwhelming hallmark of presentation. In such a clinical situation, close follow-up with short interval repeat MRI should be performed.

Association of sex of the fetus in isolated fetal choroid plexus cysts.

We sought to determine if an association exists between sex of the fetus and the finding of isolated fetal choroid plexus cysts. Of 131 fetuses, 62 were male (47.3%) and 69 were female (52.7%). No statistically significant differences were found in the maternal demographic parameters studied (age, race, gravidity, parity, sonogram timing) or descriptive cyst information obtained (location, number, dimensions, resolution), although bilaterality was more common in male fetuses. The determination that isolated choroid plexus cysts are seen equally frequently in male and female fetuses adds to basic information about such a common sonographic finding.

Treatment of AIDS-related primary central nervous system lymphoma with zidovudine, ganciclovir, and interleukin 2.

AIDS-related primary central nervous system lymphoma (AIDS PCNSL) is a rapidly fatal disease. Conventional therapeutic modalities offer little and new approaches are needed. Previous work has shown that zidovudine (AZT) in combination with other agents is active in retroviral lymphomas. Epstein-Barr virus (EBV) is detected in tumor tissue and cerebrospinal fluid of AIDS PCNSL patients. In a preliminary in vitro study we found that an Epstein-Barr virus-positive B cell line underwent apoptosis on coculture with AZT. This effect was accentuated by the addition of ganciclovir (GCV). We treated five patients with AIDS PCNSL with a regimen consisting of parenteral zidovudine (1.6 g twice daily), ganciclovir (5 mg/kg twice daily), and interleukin 2 (2 million units twice daily). Four of five had an excellent response. Two patients are alive and free of disease 22 and 13 months later; another responded on two separate occasions, 5 months apart, and the last patient responded with a 70-80% regression of tumor but could not be maintained on therapy owing to myelosuppression. We conclude that parenteral zidovudine, ganciclovir, and interleukin 2 is an active combination for AIDS-related central nervous system lymphoma.

Spinal metastases of malignant intracranial meningioma.

BACKGROUND: Spinal metastasis of intracranial meningiomas has rarely been reported. Three out of ten previously reported cases of malignant meningioma metastasizing to the spine had undergone surgical debulking with no neurological improvement. The authors retrospectively reviewed the treatment course of three patients with malignant meningioma metastasizing to the spine who underwent early magnetic resonance imaging (MRI) and radiotherapy without surgical debulking. CASE DESCRIPTION: Three patients with intracranial malignant meningiomas underwent multiple resections of intracranial lesions, and developed spinal intradural metastases an average of 64 months (range, 27-102 months) from their initial presentation. All three patients had at least two operations for recurrent intracranial tumors. All had localized back pain with motor weakness, and MRI scans demonstrated spinal involvement. No surgical exploration was performed for the spinal lesions; rather, all patients received steroids and radiotherapy for the spinal lesions. All three patients improved neurologically after the steroid and radiation treatments, and went on to survive from 3 to 18 months. CONCLUSION: Early MRI should be performed in patients with spinal symptoms and signs after the treatment of intracranial meningiomas. Radiotherapy is an effective palliative treatment for spinal metastases.

Gamma knife radiosurgery for large volume brain tumors: an analysis of acute and chronic toxicity.

Gamma Knife radiosurgery is often used to treat intracranial tumors <4 cm (approximately 13.5 cm3) in mean diameter. Larger lesions are rarely treated because of the expectation that increasing target volume will increase toxicity. We retrospectively analyzed 35 patients with primary or metastatic brain tumors of more than 13.5 cm3 treated with the Gamma Knife. Only 3 (8.5%) patients developed acute clinical toxicity. Nine (25%) patients developed post-Gamma Knife radionecrosis based on imaging studies, with only 3 of these patients (9% of the study population) having clinical progression of symptoms. Necrosis was not found to be related to prescribed dose, treatment volume or number of treated isocenters. We found no undue toxicity from the treatment of large brain tumors with the Gamma Knife.