Impact of maternal social vulnerability and timing of prenatal care on outcome of prenatally detected congenital heart disease.

OBJECTIVES: Early prenatal detection of congenital heart disease (CHD) allows mothers to plan for their pregnancy and delivery; however, the effect of certain sociodemographic and fetal factors on prenatal care has not been investigated thoroughly. This study evaluated the impact of maternal and fetal characteristics on the timing of prenatal diagnosis of CHD and fetal and postnatal outcomes. METHODS: This retrospective multicenter cohort study included women with a fetal echocardiographic diagnosis of CHD between 2010 and 2019. Women were grouped into quartiles of social vulnerability (quartiles 1-4; low-high) using the 2014 social vulnerability index (SVI) provided by the Centers for Disease Control and Prevention. A fetal disease severity score (range, 1-7) was calculated based on a combination of CHD severity (mild = 1; moderate = 2; severe, two ventricles = 3; severe, single ventricle = 4 points) and prenatally diagnosed genetic abnormality, non-cardiac abnormality and fetal hydrops (1 point each). Late diagnosis was defined as a fetal echocardiographic diagnosis of CHD after 24 weeks' gestation. Univariate and multivariable regression analyses were used to identify factors associated with late diagnosis, termination of pregnancy (TOP), postnatal death, prenatal-postnatal discordance in CHD diagnosis and severity and, for liveborn infants, to identify which prenatal variables were associated with postnatal death or heart transplant. RESULTS: Among 441 pregnancies included, 94 (21%) had a late diagnosis of CHD. Late diagnosis was more common in the most socially vulnerable quartile, 38% of women in this group having diagnosis > 24 weeks, compared with 14-18% in the other three quartile groups. Late diagnosis was also associated with Catholic or other Christian religion vs non-denominational or other religion and with a lower fetal disease severity score. There were 93 (21%) TOP and 26 (6%) in-utero fetal demises. Factors associated with TOP included early diagnosis and greater fetal disease severity. Compared with the other quartiles, the most socially vulnerable quartile had a higher incidence of in-utero fetal demise and a lower incidence of TOP. Among the 322 liveborn infants, 49 (15%) died or underwent heart transplant during the follow-up period (range, 0-16 months). Factors associated with postnatal death or heart transplant included longer delay between obstetric ultrasound examination at which CHD was first suspected and fetal echocardiogram at which CHD was confirmed and greater fetal disease severity. CONCLUSIONS: High social vulnerability, Catholic or other Christian religion and low fetal disease severity are associated with late prenatal CHD diagnosis. Delays in CHD diagnosis are associated with fewer TOPs and worse postnatal outcome. Therefore, efforts to expedite fetal echocardiography following abnormal obstetric screening, particularly for at-risk women (e.g. those with high SVI), have the potential to impact pregnancy and postnatal outcome among the prenatally diagnosed CHD population. © 2022 International Society of Ultrasound in Obstetrics and Gynecology.

Duodenal endoluminal barrier sleeve alters gut microbiota of ZDF rats.

BACKGROUND/OBJECTIVES: The combination of energy dense diets and reduced energy expenditure in modern society has escalated the prevalence of obesity and obesity-related comorbidities. Among these disease states, type-2 diabetics (T2D) are disproportionately associated with obesity, suggesting a shared etiology. In conjunction with defects in hormonal and inflammatory states, obesity and T2D are also characterized by dysbiosis. METHODS: We have recently described the beneficial effects of duodenal nutrient exclusion, as induced by the duodenal endoluminal sleeve (DES); including body weight loss, prevented fat mass accumulation, and improved glucose tolerance in the ZDF rat, a rodent model of obesity and type-2 diabetes (T2D). To assess the relative role of DES on hindgut microbiota in the context of these metabolic changes, we analyzed cecal samples from rats implanted with a duodenal endoluminal sleeve (DES), or a sham control of this procedure. A group of pair-fed (pf) sham controls was also included to account for changes induced by reduced body weight and food intake. RESULTS: Analysis of hindgut microbiota following DES in the ZDF rat elucidated discrete changes in several microbial populations including a reduction in Paraprevotella family members of the Clostridiales order along with an increase in Akkermansia muciniphila and species of the Allobaculum and Bifidobacterium genera. CONCLUSIONS: Altogether, these observations suggest that like Roux-en Y gastric bypass (RYGB) and Metformin, regulation of gut microbiota may be a contributing factor to the therapeutic effects of DES.

Can sugammadex save a patient in a simulated 'cannot intubate, cannot ventilate' situation?

Recent studies have shown that the use of high dose rocuronium followed by sugammadex provides a faster time to recovery from neuromuscular blockade following rapid sequence induction than suxamethonium. In a manikin-based 'cannot intubate, cannot ventilate' simulation, we studied the total time taken for anaesthetic teams to prepare and administer sugammadex from the time of their initial decision to use the drug. The mean (SD) total time to administration of sugammadex was 6.7 (1.5) min, following which a further 2.2 min (giving a total 8.9 min) should be allowed to achieve a train-of-four ratio of 0.9. Four (22%) teams gave the correct dose, 10 (56%) teams gave a dose that was lower than recommended, four (22%) teams gave a dose that was higher than recommended, six (33%) teams administered sugammadex in a single dose, and 12 (67%) teams gave multiple doses. Our simulation highlights that sugammadex might not have saved this patient in a 'cannot intubate, cannot ventilate' situation, and that difficulties and delays were encountered when identifying, preparing and administering the correct drug dose.

Cardiac troponin T levels in umbilical cord blood.

OBJECTIVE: We sought to determine cardiac troponin T concentrations in umbilical cord plasma from normal and complicated pregnancies. STUDY DESIGN: At the time of delivery, umbilical cord arterial and venous samples were collected from 209 neonates, and cardiac troponin T levels were measured by immunoassay. Comparisons of clinical factors were made between neonates with normal and elevated cardiac troponin T levels. Significance was deemed present at P <.05. RESULTS: Twelve neonates had elevated cardiac troponin T levels. Exposure to magnesium sulfate was associated with an elevated cardiac troponin T level (relative risk, 33.2; 95% confidence interval, 7.7-143). CONCLUSIONS: Cardiac troponin T levels were elevated in neonates exposed to magnesium sulfate in utero. The explanation of this finding and its clinical significance are unknown. Characterization of fetal and neonatal troponin T requires further study.

Reflotron cholesterol measurement evaluated as a screening technique.

We evaluated the analytical performance of Boehringer Mannheim Diagnostics' "Reflotron" analyzer for the measurement of cholesterol. Coefficients of variation (CVs) for whole-blood cholesterol were: within-day 2.0% and 2.2% at 1680 and 2670 mg/L, respectively; between-day 1.8% and 2.4% (n = 9 and 8). Results were similar for serum and heparinized or EDTA-treated single-donor plasma (CV 1.4% to 2.6%). CVs of results for two reconstituted commercial quality-control materials were 3.4% and 4.6%. Heparin and hematocrit were evaluated as interferents, and critical limits for interference were identified for bilirubin, hemoglobin, and triglyceride in blood and plasma or serum. When sample collection and analysis were controlled by trained personnel, results with the Reflotron (y) compared well with those by the Ektachem procedure (x) for both blood and serum samples: r = 0.950, y = 0.944x + 130 mg/L; and r = 0.955, y = 0.93x + 43.5 mg/L, respectively. The same comparability was observed when the analysis was performed by briefly trained high-school students: r = 0.980, y = 0.949x + 23 mg/L. Performance decreased when both collection and analysis were performed by laymen: r = 0.880, y = 0.870x + 186 mg/L.

Reduction of severe hypoglycemic events in type I (insulin dependent) diabetic patients using continuous subcutaneous insulin infusion.

In order to evaluate the safety and effectiveness of insulin pump treatment and to establish criteria for its use, we retrospectively studied 45 patients from a referral university diabetes clinic who were treated with either intensive subcutaneous insulin injections or continuous subcutaneous insulin infusion. Hemoglobin A1C was 8.5 +/- 0.3% (SEM) before and 8.1 +/- 0.1% during continuous subcutaneous insulin infusion (p = NS), but rose to 10.0 +/- 0.2% at a 16-month post-study follow-up. The frequency of ketoacidosis was 0.17 events/year before and 0.20 during infusion pump use (p = NS) and declined to 0.10 at the follow-up (p = NS). Severe hypoglycemia was reduced from 2.73 events/year to 0.22 during continuous subcutaneous infusion treatment (p less than 0.001), and from 3.72-0.32 (p less than 0.001) in a subgroup of 23 patients who initiated insulin pump treatment because of frequent and severe hypoglycemic events during intensive insulin injection treatment. Insulin pump use, compared to intensive insulin injections in a non-research setting, (a) is equally effective for maintenance of near normal glycosylated hemoglobin levels, (b) need not result in increased ketoacidosis, and (c) is effective for reducing hypoglycemic events. Thus, insulin pump treatment can benefit larger and randomized studies are needed to confirm these results.

Comparison of pyridoxal phosphate-supplemented reagent kits for alanine aminotransferase using centrifugal analysis.

The addition of pyridoxal-5-phosphate for assay of alanine aminotransferase has been recommended. The referral methods are inconvenient for high volume instrumentation due to use of multiple reagents and blanks. We adapted a well-documented method to the centrifugal analyzer as a reference for adaptation of two kit methods. Reference intervals obtained and linearity determined were all similar. The kit methods compared favorably to the referral method. Linear regression analysis yielded the following: DOW = 1.011 BERG + 1.666, r = 0.9965; SKI = 0.938 BERG + 4.559, r = 0.9926; and DSKI = 1.028 BERG + 1.051, r = 0.9889. Precision of the assays was acceptable. We concluded that automation of reagent kits incorporating pyridoxal-5-phosphate is feasible and the assays compared favorably to a recommended method. High volume instrumentation can be used without denigration of analytical quality and to allow comparability to a documented method for interlaboratory review.

Classification of bronchial lymphocytes from nonsmokers and smokers.

The population of lymphocytes obtained by endobronchial lavage is significantly different from the distribution of lymphocytes in the peripheral blood. Both B and T lymphocytes are found in fluids lavaged from the normal human lung. Of the lymphocytes that can be classified, the T cell population is larger than the B cell population in both nonsmokers and cigarette smokers, whereas a further increment in T cells is noted in smokers. A third population of unclassified lymphocytes, the "null" cells, also comprise a large portion of the lymphocyte population in both smokers and nonsmokers. Their significance has yet to be determined.