Landmark publications on Sudden Infant Death Syndrome: A bibliometrics analysis.

Sudden infant death syndrome (SIDS) is a poorly understood disorder, and its pathophysiology and risk factors remain unclear. Research in the area is the key to combating the pervasive prevalence of this fatal disorder. We sought to identify the top 50 articles concerning SIDS and study their bibliometric characteristics to gain an insight into the research trends in this area. Using the Scopus database, two independent reviewers conducted a literature search using a prespecified search string. Results were arranged according to the citation count, and the top 50 relevant articles were selected. No time restrictions were set, and all types of articles were included. A detailed analysis was carried out to identify the trends and characteristics of the top 50 articles. The top 50 articles were published between 1972 and 2011, with the most productive 5-year interval being 1991-1995. These 50 papers accumulated a total of 13,703 citations (median = 236 citations per paper). Among these, about 9% were self-citations. The citations received by these core papers seemed to decline post-2009. The top 50 articles were published in 21 different journals, with Pediatrics contributing the most (n = 15). US authors were listed for 60% of the articles (n = 30). None of the articles originated from Asian authors. Our manuscript highlights the characteristics of impactful articles on SIDS - and this can act as a directive for researchers aiming to publish on this topic. Bibliometric parameters suggest a decreasing research interest in the fi eld of SIDS, which is concerning, and efforts should be made to promote research. Furthermore, the lack of influential research from Asian authors is also troubling. Funding should preferably be directed toward Asian researchers to bridge the gap in knowledge.

Autologous stem-cell transplantation after second-line brentuximab vedotin in relapsed or refractory Hodgkin lymphoma.

Background: We previously demonstrated that brentuximab vedotin (BV) used as second-line therapy in patients with Hodgkin lymphoma is a tolerable and effective bridge to autologous hematopoietic cell transplantation (AHCT). Here, we report the post-AHCT outcomes of patients treated with second-line standard/fixed-dose BV and an additional cohort of patients where positron-emission tomography adapted dose-escalation of second-line BV was utilized. Patients and methods: Patients on the dose-escalation cohort received 1.8 mg/kg of BV intravenously every 3 weeks for two cycles. Patients in complete remission (CR) after two cycles received two additional cycles of BV at 1.8 mg/kg, while patients with stable disease or partial response were escalated to 2.4 mg/kg for two cycles. All patients, regardless of treatment cohort, proceeded directly to AHCT or received additional pre-AHCT therapy at the discretion of the treating physician based on remission status after second-line BV. Results: Of the 20 patients enrolled to the BV dose-escalation cohort, 8 patients underwent BV dose-escalation. BV escalation was well-tolerated, but no patients who were escalated converted to CR. Of 56 evaluable patients treated across cohorts, the overall response rate (ORR) to second-line BV was 75% with 43% CR. Twenty-eight (50%) patients proceeded directly to AHCT without post-BV chemotherapy, and a total of 50 patients proceeded to AHCT. Thirteen patients received consolidative post-AHCT therapy with either radiation, BV, or a PD-1 inhibitor. After AHCT, the 2-year progression-free survival (PFS) and overall survival were 67% and 93%, respectively. The 2-year PFS among patients in CR at the time of AHCT (n = 37) was 71% compared with 54% in patients not in CR (p = 0.12). The 2-year PFS in patients who proceeded to AHCT directly after receiving BV alone was 77%. Conclusions: Second-line BV is an effective bridge to AHCT that produces responses of sufficient depth to provide durable remission in conjunction with AHCT (clinicaltrials.gov: NCT01393717).

Effect of irradiated sodium alginate and phosphorus on biomass and artemisinin production in Artemisia annua.

It is now being realized that irradiation products of natural bioactive agents can also be beneficially utilized to impart value addition in agriculture by converting these bioactive agents into more useful form. Polysaccharides, such as sodium alginate, have proven to be wonderful growth promoting substances in their depolymerized form for various plants. Artemisinin has been increasingly popular as an effective and safe alternative therapy against malaria; also proved effective against the highly adaptable malaria parasite, which has already become resistant to many other drugs. The drug artemisinin can be extracted from the leafy tissues of Artemisia annua. Therefore, experiments were conducted with an aim to evaluate artemisinin production and overall plant development though depolymerized sodium alginate application and nutrient supply. In the present study, sodium alginate, irradiated by Co-60 gamma rays together with various phosphorus doses, was used to study their effect on growth, physiological and biochemical processes and production of artemisinin in A. annua. Among various applied doses of phosphorus fertilizer, P40 (40 kg Pha(-1)) together with ISA80 (80 mg L(-1)) significantly improved all the parameters studied. Increase in plant height as well as weight was noted at this treatment. Dry leaf yield, artemisinin concentration in leaves and artemisinin yield was also significantly enhanced by the treatment.

Ethnomedicinal plants used for treating epilepsy by indigenous communities of sub-Himalayan region of Uttarakhand, India.

ETHNOPHARMACOLOGICAL RELEVANCE: Although many plants are claimed to possess anticonvulsant/antiepileptic (AC/AE) properties, but there is very little information available about plants used by various ethnic communities in different parts of India to treat epilepsy, one of the most common disorders of central nervous system (CNS); this communication provides significant ethnomedicinal information on the plants used by indigenous communities: Bhoxa, Tharu and nomadic Gujjars of sub-Himalayan region, Uttarakhand, India to treat epilepsy, so that it could be used as a baseline data for studying chemical constituents and biological activities of these promising plants. AIMS OF THE STUDY: To record herbal preparations used by the presently studied communities for treating epilepsy and discuss AC/AE properties of the recorded plants. RESEARCH STRATEGY AND METHODS: Ninety one traditional healers (29 Bhoxa, 35 Tharu and 27 nomadic Gujjars) in sub-Himalayan region of Uttarakhand, India were interviewed to collect information on herbal preparations used by them for treating epilepsy. For each recorded species the use value (UV) and fidelity level (FL) was calculated. RESULTS: A total of 24 plants belonging to 24 genera and 22 families were used by the presently studied communities in 26 formulations to treat epilepsy. According to FL and UV values, most preferred species for the treatment of epilepsy by Bhoxa community are Ricinus communis L. and Datura stramonium L.; by nomadic Gujjar community are Martynia annua L., Bacopa monnieri (L.) Wettst. and Ricinus communis L.; and by Tharu community are Allium sativum L., Asparagus racemosus Willd. and Achyranthes aspera L. Eight plants viz., Allium sativum L., Boerhavia diffusa L., Cassia fistula L., Clerodendrum viscosum Vent., Datura stramonium L., Inula cappa DC., Oroxylum indicum (L.) Kurz and Pavetta indica L. recorded in the present survey have been reported for the first time in treatment of epilepsy by these indigenous communities in India. Five out of these eight newly reported plants viz., Cassia fistula L., Clerodendrum viscosum Vent., Inula cappa DC., Oroxylum indicum (L.) Kurz and Pavetta indica L. have not been pharmacologically evaluated yet for their possible AC/AE properties. CONCLUSIONS: Detailed research on the listed plants and their derivatives may be undertaken to provide new alternative treatments and therapeutic uses for epilepsy or other diseases of CNS. We hope that this article will stimulate further investigations into natural products for new AC/AE agents from the recorded ethnomedicinal plants.

Plants used for treatment of dysentery and diarrhoea by the Bhoxa community of district Dehradun, Uttarakhand, India.

ETHNOPHARMACOLOGICAL RELEVANCE: Dysentery and diarrhoea are major causes of morbidity and mortality in rural communities of developing world. The Bhoxa community is an important primitive indigenous community of Uttarakhand, India. In this paper we have tried to scientifically enumerate ethnomedicinal plants and herbal preparations used by Bhoxa community to treat dysentery and diarrhoea, and discuss their antidiarrhoeal properties in the light of previous ethnomedicinal, pharmacological, microbiological and phytochemical studies. To record plants and herbal preparations used by Bhoxa community of district Dehradun, Uttarakhand, India in treatment of dysentery and diarrhoea, and to discuss antidiarrhoeal and antimicrobial properties of the recorded plants. MATERIALS AND METHODS: Ethnomedicinal survey was conducted in different villages of Bhoxa community located in district Dehradun, Uttarakhand, India. Thirty Bhoxa traditional healers were interviewed to collect information on plants used by them for treating dysentery and diarrhoea. For each of the recorded plant species the use value (UV) and fidelity level (FL) was calculated. Detailed literature survey was conducted to summarize ethnomedicinal, pharmacological, microbiological and phytochemical information on the medicinal plants listed in the present study. RESULTS: Fifty medicinal plants (45 genera and 30 families) were used by Bhoxa community to treat dysentery and diarrhoea, among which 27 species were used for dysentery, 41 for diarrhoea and 18 for both dysentery and diarrhoea. Three plants viz., Dioscorea bulbifera L., Euphorbia thymifolia L. and Prunus persica (L.) Stokes, recorded in the present survey have been reported for the first time in treatment of dysentery and diarrhoea by any indigenous communities in India. FL and UV values revealed that most preferred species for the treatment of dysentery and diarrhoea by Bhoxa community are Euphorbia hirta L. followed by Holarrhena pubescens Wall., Helicteres isora L. and Cassia fistula L. Earlier pharmacological studies confirmed that 27 of the recorded plants have some proven antidiarrhoeal properties and remaining 23 plants have to be pharmacologically evaluated for their antidiarrhoeal properties. Except 6 plants all the other recorded plants have shown antimicrobial properties in previous microbiological studies. Previous studies have corroborated the ethnomedicinal claims made by the traditional healers of the Bhoxa community. CONCLUSIONS: Present study has provided new information on many medicinal plants and their uses. All the three newly reported plants for treatment of dysentery and diarrhoea have not been pharmacologically evaluated yet for their possible antidiarrhoeal properties. Twenty-three and six plants have not been evaluated pharmacologically and microbiologically, respectively. The present information may serve as a baseline data to initiate further research for discovery of new compounds and biological activities of these potential plants. Further research on these plants may provide some important clues for development of new drugs for dysentery and diarrhoea or other related diseases.

Restructuring BOD : COD ratio of dairy milk industrial wastewaters in BOD analysis by formulating a specific microbial seed.

BOD (Biochemical oxygen demand) is the pollution index of any water sample. One of the main factors influencing the estimation of BOD is the nature of microorganisms used as seeding material. In order to meet the variation in wastewater characteristics, one has to be specific in choosing the biological component that is the seeding material. The present study deals with the estimation of BOD of dairy wastewater using a specific microbial consortium and compares of the results with seeding material (BODSEED). Bacterial strains were isolated from 5 different sources and were screened by the conventional BOD method. The selected microbial seed comprises of Enterobacter sp., Pseudomonas sp. BOD : COD (Chemical oxygen demand) ratio using the formulated seed comes in the range of 0.7-0.8 whereas that using BODSEED comes in the ratio of 0.5-0.6. The ultimate BOD (UBOD) was also performed by exceeding the 3-day dilution BOD test. After 90 days, it has been observed that the ratio of BOD : COD increased in case of selected consortium 7 up to 0.91 in comparison to 0.74 by BODSEED. The results were analyzed statistically by t-test and it was observed that selected consortium was more significant than the BODSEED.

Anti-oxidant modulation in response to gamma radiation induced oxidative stress in developing seedlings of Psoralea corylifolia L.

The seeds of Psoralea corylifolia L., an important medicinal herb in Indian and Chinese Pharmacopeia were exposed to gamma rays (2.5, 5, 10, 15 and 20 kGy) from Co(60) source at dose rate of 1.65 kGy h(-1). Enzymatic and non-enzymatic anti-oxidant responses were verified according to the developmental stages and gamma dose applied. Plants grown from seeds exposed to higher gamma doses exhibit higher activity of the antioxidants such as [Ascorbate peroxidase (APX, 1.11.1.1), superoxide dismutase (SOD, 1.15.1.1), glutathione reductase (GR, 1.6.4.2) and MDA content till flowering and declined thereafter. In contrast, CAT (1.11.1.6) activity declined in dose and age dependent manner. The correlation of gamma dose applied and oxidative stress was inferred from the increased enzymes activities and depression in total glutathione pool in seedlings developed from irradiated seeds. Nevertheless, the maintenance of high anti-oxidant capacity, psoralen accumulation seems to be an important strategy during acclimation of P. corylifolia to gamma radiation stress. Pronounced accumulation of psoralen following 15 and 20 kGy at post-flowering stage where oxidative stress is triggered modulates lipid peroxidation and proline accumulation. Further, in psoralen producing plants an increase in psoralen content can be used as a biomarker which specifies plant is under stress.

Enhancement in furanocoumarin content and phenylalanine ammonia lyase activity in developing seedlings of Psoralea corylifolia L. in response to gamma irradiation of seeds.

Gamma irradiation of seeds is known to be an important factor in stimulating biochemical and physiological processes. The aim of the present study was to investigate phenylpropanoids and associated enzymes responsible for the production of active metabolites. Furanocoumarin content was estimated in seeds of Psoralea corylifolia L. during two successive generations (G(1) and G(2)) where as phenylalanine ammonia lyase (PAL) activity was measured in leaves at different developmental stages of P. corylifolia L. raised from seeds irradiated with variable doses of gamma rays. Maximum accumulation of psoralen and isopsoralen was observed at 15 and 20 kGy doses during G(1) and G(2) generations, respectively. Psoralen proved to be the dominating metabolite in terms of its concentration, while isopsoralen was accumulated at relatively lower concentrations in successive generations. PAL activity was induced maximally following 15 and 20 kGy in G(1) plants and was preceded by psoralen and isopsoralen accumulation which peaked at the same dose rates in both generations. These effects were transmitted and prevalent in the next generation, that is, G(2) (indirectly irradiated). These long-term changes in plant metabolomics demonstrate genomic instability induced by gamma irradiation. However, no detrimental effects were seen at any irradiation dose in seeds. Furanocoumarin concentrations were also enhanced at 15 and 20 kGy. The present study further points out the persistence of changes in the biosynthesis of coumarin derivatives in the next generation. However, accumulation of these metabolites does not lead to any lethal effects.

CO2 utilizing microbes--a comprehensive review.

CO2 fixing microbes are the species primarily engaged in complexing the inorganic carbon dioxide to organic carbon compounds. There are many microorganisms from archaeal and bacterial domain that can fix carbon dioxide through six known CO2 fixing pathways. These organisms are ubiquitous and can survive in wide range of aerobic and anaerobic habitats. This review focuses on the prior research, that has been conducted in this field and presents a summarized overview of all the mechanisms (along with their genes and enzymes) used by these microbes for CO2 incorporation. In addition, this review provides a better understanding of diversity and taxonomy of CO2 fixing microorganisms. The information presented here will motivate researchers to further explore the diversity of CO2 fixing microorganisms as well as to decipher the underlying mechanisms of CO2 utilization.

Leaf biochemistry of Lycopersicon esculentum Mill. at different stages of plant development as affected by mercury treatment.

The effect of mercury (Hg) on the biochemical parameters of Lycopersicon esculentum Mill leaf was studied. Application of mercuric chloride in varying concentrations (0.5, 1.0, 1.5 and 2.0 mM HgCl2 kg(-1) sand) caused significant reduction that went up to 89% and 72% chlorophyll a and chlorophyll b contents respectively (at flowering stage), 69% in carotenoid content, 64% in total soluble protein content and 91% in nitrate reductase activity (all at post-flowering stage). The amounts of nitrate and proline increased maximally (151% and 143% respectively) at the flowering stage, whereas total soluble sugar enhanced by 57% at the post-flowering stage. Changes observed in most of the parameters, were concentration dependent. Such studies seem to be able to discover suitable bioindicators of heavy metal pollution.

The antioxidative response system in Glycine max (L.) Merr. exposed to Deltamethrin, a synthetic pyrethroid insecticide.

Forty-five-day-old plants of Glycine max (soybean) were exposed to several Deltamethrin (synthetic pyrethroid insecticide) concentrations (0.00%, 0.05%, 0.10%, 0.15% and 0.20%) through foliar spray in the field conditions. In the treated plants, as observed at the pre-flowering (10 DAT), flowering (45 DAT) and post-flowering (70 DAT) stages, lipid peroxidation, proline content and total glutathione content increased, whereas the total ascorbate content decreased, as compared with the control. Among the enzymatic antioxidants, activity of superoxide dismutase, ascorbate peroxidase and glutathione reductase increased significantly whereas that of catalase declined markedly in relation to increasing concentration of Deltamethrin applied. The changes observed were dose-dependent, showing a strong correlation with the degree of treatment.

Does the combined antenatal use of corticosteroids and antibiotics increase late-onset neonatal sepsis in the very low birth weight infant?

OBJECTIVE: The purpose of this study was to determine whether the combined use of maternal antenatal corticosteroids and antibiotic therapy is associated with an increased risk of late-onset neonatal sepsis among very low birth weight infants. STUDY DESIGN: The outcomes of infants admitted to the 3 Cincinnati neonatal intensive care units between May 1991 and May 2000 were retrospectively evaluated. Late-onset neonatal sepsis was defined either as the occurrence of a positive blood culture obtained after 72 hours of life with clinical signs of sepsis or as the need for >5 consecutive days of antibiotic therapy for presumed sepsis that initiated after 72 hours of life. Wilcoxon rank sum, chi-square test, and multiple logistic regression were used for analysis. RESULTS: Among the parturients delivering the study infants, 434 women (24%) received corticosteroids only, 175 women (9%) received antibiotics only, 819 women (46%) received both corticosteroids and antibiotics, and 370 women (20%) received neither corticosteroids nor antibiotics. Among 1978 study infants, there were 732 infants (41%) with late-onset neonatal sepsis. By univariate analysis, the odds ratio for late-onset neonatal sepsis caused by combined corticosteroid and antibiotic use was 0.96 (95% CI, 0.89%, 1.04%). Multiple logistic regression analysis was used to evaluate the risk of combined corticosteroids and antibiotic use after controlling for potential covariates and confounders. After controlling for outborn birth (odds ratio, 1.3; 95% CI, 1.0%-1.8%), increasing gestational age at delivery (odds ratio, 0.63; 95% CI, 0.60%-0.66%), interaction between white race and male gender (P =.01) and interaction between antibiotics and prolonged rupture of membranes (P =.02), the use of corticosteroids and antibiotics was not associated with an increased risk of late-onset neonatal sepsis (P =.9). CONCLUSION: The combined use of maternal corticosteroids and antibiotic therapy is not associated with an increased risk for late-onset neonatal sepsis.

A comparison of various routes and dosages of misoprostol for cervical ripening and the induction of labor.

OBJECTIVE: The purpose of this study was to compare the efficacy of different routes of misoprostol administration for cervical ripening and the induction of labor. STUDY DESIGN: Three hundred thirty women at > or = 32 weeks gestation with a Bishop score < or = 6 and an indication for induction were randomized to 1 of 3 double-blinded groups: (1) 25 microg orally administered misoprostol plus 25 microg vaginally administered misoprostol, (2) orally administered placebo plus 25 microg vaginally administered misoprostol, or (3) 25 microg orally administered misoprostol plus vaginally administered placebo. Doses were repeated every 4 hours until onset of labor or a maximum of 12 doses were given. The primary outcome of the trial was vaginal delivery within 24 hours of the initiation of induction. Secondary outcomes were the time from induction to delivery, need for oxytocin augmentation, mode of delivery, frequency of side effects, and neonatal and maternal outcome. Analysis of variance, chi-square test, and logistic regression were used for analysis. RESULTS: There were no significant differences in maternal characteristics or indications for induction. The percentage of women who achieved vaginal delivery within 24 hours was highest in the vaginally administered misoprostol group: 67% compared with 53% in the oral-plus-vaginal group (P < .05) and 36% in the oral group (P < .05). The median time to vaginal delivery was shorter in the vaginal and oral-plus-vaginal misoprostol groups, 13.5 hours and 14.3 hours, respectively, when compared with 23.9 hours in the oral group (P < .05). The rate of cesarean delivery was lowest in the vaginal misoprostol group (17% compared with 30% in the oral-plus-vaginal group and 32% in the oral group; P < .05). Uterine tachysystole occurred least frequently in the oral misoprostol group (10% compared with 32% in the vaginal group and 34% in the oral-plus-vaginal group; P < .05). Uterine hyperstimulation also occurred least frequently in the oral misopro-stol group (4% compared with 15% in the vaginal group and 22% in the oral-plus-vaginal group; P < .05). CONCLUSION: At the doses studied, induction of labor with vaginally administered misoprostol is more efficacious than either oral-plus-vaginal or oral-only route of administration.

Is human myometrial sampling at the time of cesarean delivery safe?

OBJECTIVE: The mechanism for the initiation of human labor remains unknown and is under extensive investigation. Myometrium from patients in labor and not in labor is the ideal tissue to study structural, cellular, and molecular changes that occur during parturition. This study was designed to determine whether myometrial sampling at the time of cesarean delivery increases maternal morbidity. STUDY DESIGN: This is a prospective cohort study including 118 study and 236 control patients. A full-thickness myometrial sample was obtained from the superior edge of a transverse uterine incision at the time of cesarean delivery. Demographics and standard surgical morbidity data were collected. Statistical methods used included univariate and multivariate analysis. RESULTS: The study and control groups did not differ significantly with respect to age, gravidity, parity, birth weight, and Apgar scores. The estimated intraoperative blood loss was greater in the control group (P <.02); however, the change in hematocrit level (preoperative vs postoperative values) was not different. There were no significant differences in the rates of endometritis, wound infection, and venous thrombosis up to 6 weeks post partum. When study and control patients were stratified into term in labor, term not in labor, preterm in labor, and preterm not in labor categories and compared for maternal morbidity, there were still no significant differences for any of the outcome measures evaluated. CONCLUSION: On the basis of our data, human myometrial sampling at cesarean delivery does not increase overall maternal morbidity, irrespective of gestational age and the presence or absence of labor.

Is insulin lispro associated with the development or progression of diabetic retinopathy during pregnancy?

OBJECTIVE: This study was designed to determine whether there is an association between the use of insulin lispro during pregnancy and the development or progression of diabetic retinopathy. STUDY DESIGN: This observational cohort study included women with type 1 diabetes mellitus (n = 12) who were enrolled in our diabetes mellitus in pregnancy program and were treated with insulin lispro during pregnancy. We compared these women with a historical cohort (n = 42) who were treated with regular insulin during pregnancy. All patients underwent ophthalmologic examinations before 24 weeks' gestation and post partum, and retinopathy was graded according to a previously defined scale. RESULTS: Whereas none of the patients in the insulin lispro group showed any change in retinopathy status, 6 patients in the regular insulin group (14%) demonstrated changes in retinopathy status. Mild background retinopathy (change from grade 0 to 1) developed in 3 of these patients, and extensive proliferative retinopathy developed in 1 patient after normal results of the baseline examination (change from grade 0 to 6). Two patients had progression of retinopathy--1 had progression from background retinopathy to mild proliferative retinopathy (change from grade 2 to 4) and 1 had progression from mild proliferative retinopathy to extensive proliferative retinopathy (change from grade 4 to 6). CONCLUSIONS: These preliminary findings provide no evidence that insulin lispro treatment during pregnancy is associated with the development or progression of diabetic retinopathy.

A comparison of dissection-method and diathermy tonsillectomies.

OBJECTIVE: To compare the dissection and diathermy methods of tonsillectomy and evaluate their advantages and disadvantages during surgery and convalescence. METHODS AND SETTING: Patients who had tonsillectomy at Aga Khan University Hospital, between January 1994-December 1997. RESULTS: Four year retrospective analysis was done of 200 patients who underwent tonsillectomy by either electrocautery or dissection method. One hundred and eleven underwent tonsillectomy by electrocautery and the other 79 had their tonsils removed by dissection-method and 2 had a combination of both. The average intra-operative blood loss was 10 ml with cautery and 65 ml with dissection method. The average operative time was 15.7 minutes with cautery and 26.9 minutes for dissection. We found higher amounts of blood loss and intra-operative time with dissection method than electrocautery. In comparing diathermy dissection method tonsillectomies, there was marked diffference between two, in peri-operative blood loss and operative time. CONCLUSION: Although post-operative bleeding, pain and infection are complications of both techniques and in our study their incidence in similar in both, but intra-operative blood loss and time are two important factors, based on which we can conclude that electrocautery technique is a more effective technique in our set up.

Is vaginal delivery preferable to elective cesarean delivery in fetuses with a known ventral wall defect?

OBJECTIVE: We sought to test the hypothesis that vaginal delivery compared with elective cesarean delivery results in improved neonatal outcome in fetuses with a known isolated ventral wall defect. STUDY DESIGN: We performed a retrospective chart review. RESULTS: Between 1989 and 1999, we identified 102 infants with a confirmed antenatal diagnosis of an isolated ventral wall defect with either the diagnosis of an omphalocele or gastroschisis. Sixty-six infants were delivered by cesarean and 36 were delivered vaginally. There were no significant demographic differences between the study groups or between the two sites except that one center (Cincinnati) usually delivered these fetuses by cesarean whereas the other (Louisville) usually delivered such fetuses vaginally. Overall, there were a greater number of infants with gastroschisis than omphalocele (gastroschisis, n = 71; omphalocele, n = 31). After we controlled for primary versus staged closure of ventral wall defect and gestational age at delivery; the medians and interquartile ranges for cesarean and vaginal delivery were 39 (25, 63) days versus 42 (26, 75) days, respectively (P =.32), for neonatal length of stay and 13 (9, 18) days versus 13 (9, 26) days, respectively (P =.16), for days to enteral feeding. After we controlled for the size of the defect and the amount of bowel resected, the odds of primary closure given a vaginal delivery was about half that given a cesarean delivery (odds ratio, 0.56; 95% confidence interval, 0.18-1. 69), but this was not statistically significant. There was no statistically significant difference in the rates of neonatal death (2 [3%] vs 2 [6%]; P =.61) and neonatal sepsis (2 [3%] vs 4 [11%]; P =.18) for cesarean versus vaginal delivery. Maternal length of stay after delivery was found to be 1 day less after vaginal delivery [vaginal, 2 (2, 2) days; cesarean, 3 (2, 3) days; P =.0001]. There were 5 instances of maternal complications, and all 5 pregnancies were delivered by cesarean (P =.16). CONCLUSION: Fetuses with an antenatal diagnosis of an isolated ventral wall defect may safely be delivered vaginally, and cesarean delivery should be performed for obstetric indications only.

A focused preconceptional and early pregnancy program in women with type 1 diabetes reduces perinatal mortality and malformation rates to general population levels.

OBJECTIVE: To evaluate the impact of a focused preconceptional and early pregnancy program specializing in the care of women with Type 1 diabetes on perinatal mortality and congenital malformations. METHODS: This clinical study included women with Type 1 diabetes in an interdisciplinary Diabetes in Pregnancy Program Project Grant (PPG) funded by the NIH (1978-1993); these women were enrolled preconceptionally or during the first trimester (up to 14 weeks) and had pregnancies continuing beyond 20 weeks gestation. Strict glucose control was implemented and adherence assessed. Antepartum fetal surveillance was started at 32 weeks gestation. All live-born infants and stillbirths were examined. A retrospective comparison analysis of the period before PPG I (1973-1978) and after cessation of funding (1993-1999) was performed, specifically evaluating perinatal mortality and congenital malformation rates. Data were analyzed using analysis of variance, chi2, and Fisher's exact test. RESULTS: Three hundred and six women were enrolled in three 5-year periods: PPG I (1978-1983) n = 111, PPG II (1983-1988) n = 103, and PPG III (1988-1993) n = 92. Entry and interval glycohemoglobin A1 concentrations obtained decreased with each consecutive PPG. An emphasis on preconception care began in 1984, with preconception enrollment reaching 23% for PPG II and increasing in PPG III to 37%. As preconception enrollment increased, perinatal mortality rate decreased from 3% for PPG I and 2% for PPG II, to 0% in PPG III, and the congenital malformation rate decreased to a low 2.2% by PPG III. Comparison data collected for the period before PPG 1 (1973-1978) n = 79 revealed a perinatal mortality rate of 7% and a congenital malformation rate of 14%. Also, a postprogram retrospective analysis of the period 1993-1999 (n = 82) revealed an increase in perinatal mortality, with one death compared to none in PPG III, and a congenital malformation rate of 3.65% compared to 2.2% during PPG III. The preconception enrollment for this period decreased (19.5%). CONCLUSIONS: A program emphasizing preconceptional care, strict glycemic control preconceptionally and throughout gestation, and the use of antepartum fetal surveillance was associated with a significant decrease in the rate of perinatal mortality and congenital malformations in infants of women with Type 1 diabetes. However, ongoing improved outcome appears to depend on the availability of funding for a specialized preconception program.

Sonographic EFW and macrosomia: is there an optimum formula to predict diabetic fetal macrosomia?

OBJECTIVE: To compare the accuracy of 31 published formulas for estimated fetal weight (EFW) in predicting macrosomia (birthweight 4,000 gm or more) in infants of diabetic mothers. METHODS: The study population comprised 165 women with gestational or pregestational diabetes who had sonograms to estimate fetal weight after 36 weeks of gestation and within 2 weeks of delivery. Three measures of accuracy were compared: 1) area under the receiver operating characteristic (ROC) curve relating EFW to macrosomia, 2) systematic error, and 3) absolute error. For each measure, the 31 formulas were rank-ordered from 1 (best) to 31 (worst). For each formula, the three rank scores were summed to give a total score. The formula with the lowest total score was considered the "best" formula. RESULTS: Macrosomia occurred in 49 cases (30%). Areas under the ROC curves ranged from 0.8361-0.8978. Differences in areas were not significantly different between the 31 formulas. The 1986 formula of Ott et al. had the lowest total score. Using this "best" formula, an EFW of 4,000 gm or more had a sensitivity of 45% to predict macrosomia and a positive predictive value of 81%. To achieve 90% sensitivity with this formula would have required diagnosis of macrosomia with an EFW of 3,535 gm or more, but this would have comprised 46% of the population with a 42% false-positive rate. All 31 formulas were better at predicting macrosomia than predictions based on gestational age alone, and 28 were better than predictions based on abdominal circumference alone. CONCLUSIONS: All 31 formulas for EFW had comparably poor accuracy for prediction of macrosomia. Delivery decisions based on EFW will often be in error. Future studies should determine whether specific sonographic measurements, ratios, or differences are better than EFW or birthweight as predictors of birth trauma.

In vivo ultrasonographic exposimetry: human tissue-specific attenuation coefficients in the gynecologic examination.

OBJECTIVE: The purpose of the current study was to determine in vivo, tissue-specific ultrasonic attenuation coefficients for each of the tissue layers comprising the anterior abdominal wall, uterus, and vagina with use of a quantitative multilayer tissue model. We wanted to validate the "homogeneous" tissue model-based Food and Drug Administration derating factor of 0.3 dB/cm-MHz applied to obstetric-use ultrasonography systems. STUDY DESIGN: With use of a 3. 0-MHz mechanical sector scanner and our previously tested exposimetry equipment, we obtained a set of at least 5 separate acoustic pressure waveforms from each test subject by placing a calibrated 7-element linear-array hydrophone in the anterior vaginal fornix while she was undergoing transabdominal ultrasonography. Corresponding sets of reference in vitro acoustic pressure waveforms were also recorded for each test subject in a 37 degrees C water bath. All linear measurements of individual layer thicknesses and total distances were made on-line with use of electronic calipers. A set of multiple and independent insertion loss values, denoted ILn, was calculated for path n between the abdominal surface and the hydrophone from n sonograms for each test subject. Each tissue layer type was identified and its thickness along each path n was measured. The thickness of tissue type m along path n was denoted by dnm. The only unknown quantities left were the attenuation coefficients Am of each of the m tissue layers for that test subject. The overestimated set of equations dnm Am = ILn was solved for Am with use of a nonnegative least-squares solution technique. RESULTS: With use of data from 162 independent insertion loss estimate paths, the overall tissue-specific attenuation coefficients for each of the tissue layer types, expressed as mean value +/- SD, were 2.3 +/- 1.5 dB/cm-MHz for the skin and subcutaneous layer, 3.1 +/- 2.5 dB/cm-MHz for skeletal muscle, 0.6 +/- 0.5 dB/cm-MHz for myometrium, and 3.6 +/- 2.7 dB/cm-MHz for the vaginal wall. The overall insertion loss assuming the "homogeneous" tissue model was 0.7 +/- 0.3 dB/cm-MHz. CONCLUSIONS: We have determined the specific ultrasonic attenuation coefficients for each of the tissue layers comprising the anterior abdominal wall, uterus, and vagina and validated the Food and Drug Administration derating factor of 0.3 dB/cm-MHz applied to obstetric use ultrasonography systems. Of all the models proposed, the "homogeneous" tissue model appears to be the best model for determining ultrasonic exposure risk during reproductive ultrasonographic examinations.