Riesgo cardiometabólico en niños con obesidad grave / Cardiometabolic risk in children with severe obesity

Introducción: la obesidad grave ha tenido un mayor aumento que la obesidad no grave en los escolares chilenos durante los últimos años. Desconocemos si el punto de corte actualmente utilizado para definir la obesidad grave (IMC ≥ + 3 DE, curvas OMS-2007) se asocia a un mayor daño biológico en nuestra población pediátrica. Objetivo: describir y comparar el riesgo cardiometabólico en escolares con obesidad grave y no grave. Método: se realizó un análisis secundario de una muestra de 3325 escolares en los que se estudiaron los factores de riesgo cardiometabólico. Se comparó la prevalencia de estos factores en los que presentaban obesidad según fuera esta grave o no, calculándose los OR respectivos. Resultados: de los 589 sujetos con obesidad, con una media de edad de 11,4 ± 0,98 años, el 46 % eran de género femenino y el 11,5 % presentaban obesidad grave, con mayor prevalencia de la mayoría de los factores estudiados y sin diferencias en cuanto a antecedentes parentales de enfermedad crónica u obesidad, educación de los padres y actividad física del niño. Los niños con obesidad grave tenían un mayor riesgo de obesidad central (OR: 12,9), resistencia insulínica (OR: 3,2), HTA (OR: 2,67) y síndrome metabólico (OR:1,92). Conclusión: esta definición de obesidad grave en la niñez favorece la identificación de los niños con mayor comorbilidad cardiometabólica, lo cual permite focalizar los esfuerzos de prevención secundaria y su tratamiento más oportuno (AU)

Introduction: severe obesity has had a greater increase than non-severe obesity in Chilean schoolchildren during the last years. We do not know whether the cut-off point currently used to define severe obesity in children (BMI ≥ + 3 DE, WHO-2007 curves) is associated with a greater biological risk in our population. Objective: to describe and compare cardiometabolic risk in schoolchildren with severe vs. non-severe obesity. Methods: a secondary analysis of a sample of 3,325 schoolchildren was performed, in which cardiometabolic risk factors were studied. The prevalence of these was compared in the subsample of 589 schoolchildren with obesity according to whether it was severe or not, and the respective ORs were calculated. Results: mean age was 11.4 ± 0.98 years, 46 % were girls, and 11.5 % of the sample had severe obesity, with a higher prevalence of most of the factors studied and no differences in chronic disease, obesity or education in parents, or physical activity of the child. The risk of those with severe obesity for central obesity, insulin resistance, high blood pressure, and metabolic syndrome reached an OR of 12.9, 3.2, 2.67, and 1.92, respectively, as compared to those with non-severe obesity. Conclusion: this definition of severe obesity in childhood favors the identification of children with higher cardiometabolic comorbidity, which allows to focus the efforts of secondary prevention and its most timely treatment (AU)

Evaluation of ceftiofur crystalline free acid sterile suspension for control of metritis in high-risk lactating dairy cows.

Two studies were conducted to determine if clinical metritis could be prevented or decreased in at-risk lactating dairy cows by a single treatment with Excede Sterile Suspension (ceftiofur crystalline free acid sterile suspension [CCFA-SS]) administered within 24 hours after an abnormal calving. Study 1 was a preliminary study and study 2 was a clinical trial (designed to confirm the results of study 1). In both studies, abnormal calving was defined as cows that had dystocia (required assistance), twins, abortion, retained fetal membranes for 12 hours or more, or any combination thereof. A randomized block design with cows blocked on order-of-entry within dairy without regard to parity was used in both studies. In study 1, cows that had abnormal calving from six commercial dairies were randomly assigned to either untreated control (N = 122) or 6.6 mg ceftiofur equivalents/kg of body weight sc in the base of the ear (CCFA-SS, N = 121), within 24 hours after calving. Cows with normal calving during the enrollment period received no treatment and were included for observational purposes (N = 122). Health observations and rectal temperatures were recorded daily, and physical examinations were conducted on Days 1 ± 1, 7 ± 2, 14 ± 2, and 21 ± 2, and uterine swabs (for bacterial culture) were collected from a subsample of cows on Days 3 or 4, 7 ± 2, 14 ± 2, and 21 ± 2. These observations were made by treatment-blinded personnel. In study 2, cows with abnormal calving from 12 commercial dairies were assigned to receive either saline (control, N = 247) or CCFA-SS (N = 247) within 24 hours after calving. Health observations and rectal temperatures were recorded daily, and physical examinations were conducted on Days 0 to 2, 7 ± 1, and 14. In study 1, the incidence of metritis on Day 14 ± 2 was 20.2% versus 36.8% for CCFA-SS and control, respectively, with an odds ratio of 2.30 (P < 0.05). In study 2, incidences of metritis on Day 14 were 28.7% versus 43.5% for CCFA-SS and saline, respectively, with an odds ratio of 1.92 (P < 0.05). Rectal temperatures on Days 1 and 2 and the average for the first 6 days were lower (P < 0.05) for CCFA-SS compared with control cows for both studies. Treatment of cows with a single dose of CCFA-SS within 24 hours after abnormal calving reduced the incidence of subsequent metritis in lactating dairy cows.

Evaluation of two doses of ceftiofur crystalline free acid sterile suspension for treatment of metritis in lactating dairy cows.

The objectives of this study were to evaluate efficacy of a 2-dose regimen of ceftiofur crystalline free acid sterile suspension (CCFA-SS) for treatment of acute metritis in lactating dairy cows under field conditions and to provide additional safety and injection site tolerance data for injections at the base of the ear. Cows at 15 dairies with rectal temperature ≥ 39.5°C and fetid uterine discharge ≤ 10 d postcalving were randomly assigned by blocks of 2, based on order of entry and without regard to parity, to treatment with saline (1.5 mL/45.5 kg of body weight, n=509) or CCFA-SS (6.6 mg of ceftiofur equivalents/kg of body weight, n=514). Treatments were administered by subcutaneous injection in the posterior aspect of the ear where it attaches to the head; the first dose was administered on study d 0 and the second dose was administered in the contra lateral ear on study d 3. Rectal temperatures were recorded on study d 1 to 4 and 5 or 6 and cows were clinically evaluated daily from study d 1 to 13. Cows that exhibited increased adverse clinical signs of poor health or complications associated with metritis were categorized as a treatment failure and administered escape therapy. Each cow received a veterinary physical examination on study d 5 or 6 to determine if she should be removed from the study and on study d 14 to determine clinical cure or failure to cure. Clinical cure was defined as rectal temperature <39.5°C and non-fetid and purulent or mucopurulent discharge on study d 14 and no escape therapy administered. The injection procedure was scored after each injection (study d 0 and 3) and injection sites and ear carriage were scored on study d 5 or 6, 14, and 57±3. Of the 1,023 cows enrolled, 7 were completely censored due to protocol deviations and 34 were removed for protocol deviations or medical conditions not related to metritis. Clinical cure rate was higher for CCFA-SS than for saline (74.3 vs. 55.3%) and rectal temperatures for each of study d 1 to 5 or 6 were lower for CCFA-SS than saline. Injection procedure indices showed that CCFA-SS could be practically and safely administered using commercial dairy facilities. Although injection site scores were higher for CCFA-SS than saline at study d 5 or 6 and 14, ≥98.6% of ears were normal on d 57±3. Thus, a 2-dose treatment with CCFA-SS given 72h apart increased metritis clinical cure rate and was well tolerated in dairy cows.

[Opsoclonus-myoclonus-ataxia syndrome: two anatomo-clinical case reports]. / Sindrome opsoclono-mioclono-ataxia: dos casos anatomoclinicos.

INTRODUCTION: Opsoclonus-myoclonus-ataxia syndrome (OMAS) is characterised by the acute or subacute development of chaotic eye movements and diffuse myoclonus. On some occasions it is associated with ataxia and encephalopathy. In adults there are multiple causations and a possible paraneoplastic origin must always be taken into account. CASE REPORTS: We report two cases of OMAS of a paraneoplastic origin with a post mortem study. In the first case, the syndrome was associated to a small-cell carcinoma in the lungs, and in the second patient it was associated to a digestive lymphoma. Neuroimaging studies did not reveal any kind of alterations in either of the two cases. In our cases, none of the antibodies that are relatively frequently associated to this syndrome were found. In both of them, an immunomodulator treatment regimen was established; only the patient with the lymphoma showed an initial improvement with antineoplastic therapy. In the pathological study, alterations were observed in the brain stem, and in the second patient alterations were also found in the cerebellum. CONCLUSIONS: This is a rare condition that obliges the specialist to think in order to reach a correct diagnosis, and to search for the primary tumour and establish early treatment in order to bring about an improvement and even the remission of the neurological signs and symptoms. The pathological findings are not pathognomonic, but they are typical of this syndrome.

Síndrome opsoclono-mioclono-ataxia: dos casos anatomoclínicos / Opspclonus. Myoclonuz-ataxia syndrome: Two anatomo-clinical case reports

Introducción. El síndrome opsoclono-mioclono-ataxia (SOMA) se caracteriza por el desarrollo agudo o subagudode movimientos oculares caóticos y mioclono difuso. En algunas ocasiones, asocia ataxia y encefalopatía. En el adulto existen múltiples etiologías, y hay que tener siempre en cuenta el posible origen paraneoplásico. Casos clínicos. Presentamos dos casos de SOMA de origen paraneoplásico con estudio post mortem. En el primer caso, el síndrome se asoció a un carcinomade células pequeñas de pulmón, y en el segundo paciente a un linfoma digestivo. Los estudios de neuroimagen no mostraron alteraciones en ninguno de los dos casos. No se descubrió en nuestros casos ninguno de los anticuerpos asociados con relativa frecuencia a este síndrome. En ambos se pautó tratamiento inmunomodulador; únicamente el paciente con linfoma mejoró inicialmente con el tratamiento antineoplásico. En el estudio anatomopatológico se observaron alteraciones en el tronco del encéfalo, y en el segundo paciente también en el cerebelo. Conclusión. Se trata de una entidad rara, en la que hay que pensar para lograr un diagnóstico correcto, búsqueda del tumor primario y su tratamiento precoz, con el fin de producir mejoría e inclusoremisión del cuadro neurológico. Los hallazgos anatomopatológicos no son patognomónicos, pero sí típicos de este síndrome

Introduction. Opsoclonus-myoclonus-ataxia syndrome (OMAS) is characterised by the acute or subacute development of chaotic eye movements and diffuse myoclonus. On some occasions it is associated with ataxia and encephalopathy. In adults there are multiple causations and a possible paraneoplastic origin must always be taken into account. Case reports. Wereport two cases of OMAS of a paraneoplastic origin with a post mortem study. In the first case, the syndrome was associated to a small-cell carcinoma in the lungs, and in the second patient it was associated to a digestive lymphoma. Neuroimaging studies did not reveal any kind of alterations in either of the two cases. In our cases, none of the antibodies that are relativelyfrequently associated to this syndrome were found. In both of them, an immunomodulator treatment regimen was established; only the patient with the lymphoma showed an initial improvement with antineoplastic therapy. In the pathological study, alterations were observed in the brain stem, and in the second patient alterations were also found in the cerebellum. Conclusions. This is a rare condition that obliges the specialist to think in order to reach a correct diagnosis, and to search forthe primary tumour and establish early treatment in order to bring about an improvement and even the remission of the neurological signs and symptoms. The pathological findings are not pathognomonic, but they are typical of this syndrome

[Electrooculography findings in Friedreich's ataxia]. / Hallazgos electrooculográficos en la ataxia de Friedreich.

INTRODUCTION: Friedreich's ataxia (FA) is the most frequent of the recessive hereditary ataxias. AIMS. Our aim was to analyse the findings from electrooculography studies in subjects with FA attended in our Service over a 30-year period. PATIENTS AND METHODS: Between the years 1970 and 1999, 51 patients with FA diagnosed in the Neurology Service of our hospital were examined. All of them were submitted to an electronystagmography study and an examination of the oculomotor system using electrooculography (EOG). In the EOG study, saccades, (square-wave) saccadic intrusions, spontaneous, triggered, positional and optokinetic nystagmus (OKN), visual suppression of the vestibulo-ocular reflex (VOR) and following were all evaluated. RESULTS: The disorders that were found most often were ataxic following (72.5%), abnormalities in rotational testing (56.8%) and dysmetria in the saccades (52.9%). The presence of square waves was observed in just over half the traces (52.9%). CONCLUSIONS: In FA the predominant EOG findings are those suggesting a cerebellar disease.

[Facial nerve tumours]. / Tumores del nervio facial.

INTRODUCTION: Tumours originating in the facial nerve are extremely rare and their therapeutic approach requires the aid of specialists from a number of disciplines. AIMS: Our aim was to analyse the cases treated in our centre over a five-year period. PATIENTS AND METHODS: All the subjects submitted to surgical interventions to treat facial nerve tumours between January 1992 and December 1996 were evaluated retrospectively. Data recorded from all patients included age, sex, side affected, time prior to diagnosis, presenting symptom and symptoms observed at the time of diagnosis, previous history of disorders affecting the facial nerve and associated neurological symptoms. We also noted the location of the lesion, the surgical technique used, pathology findings, post-operative complications, length of post-operative stay in hospital, facial sequelae and surgical repair procedures used on the facial nerves involved in the intervention. RESULTS: Six cases, with a mean age of 29 years (range: 16-46 years), were treated. Three of the patients were males (50%). Symptoms of the disease included facial palsy (4), neurosensory hypoacusis (1) and tinnitus (1). All six individuals (100%) had alterations affecting facial functioning in the course of the disease. The pathological diagnosis was schwannoma in four cases and hemangioma in the other two. Neural grafts were carried out in three patients and some kind of deficit was observed at the end of the follow-up in all the cases. CONCLUSIONS: Facial nerve tumours are very infrequent. An early diagnosis is needed to diminish the facial sequelae following surgery performed to treat this clinical entity.

El uso del teléfono en pacientes con implante coclear / Telephone use in cochlear implanted patients

El uso del teléfono supone un reto importante para los pacientes con implante coclear ya que pueden aparecer distintas limitaciones que deberán superar: falta de apoyo visual, la eliminación de las frecuencias agudas en la señal telefónica, ruido ambiental, interferencias de los teléfonos móviles con el procesador externo del implante, la ansiedad producida ante un interlocutor que muchas veces es desconocido, etc. El propósito de este estudio es analizar el uso que los pacientes implantados en el Hospital Universitario La Paz hacen del teléfono y averiguar cuáles son los aspectos que presentan una mayor dificultad, así como su posible solución para mejorar su percepción de las conversaciones telefónicas. También realizamos una comparativa de las interferencias que los pacientes sufren con diferentes modelos de móvil, con el fin de descubrir cuáles son los terminales mas recomendados para minimizar dichas interferencias. Con este fin se envió un cuestionario a 21 pacientes implantados con un COMBI 40+ de MED-EL. Todos los pacientes del estudio utilizaban el teléfono fijo en alguna medida y, un porcentaje de ellos (66,7 por ciento), también el móvil. Los modelos de telefonía móvil más modernos parecen ser los más recomendables para estos pacientes, ya que producen menos interferencias con el implante (AU)

A randomized trial of labor analgesia in women with pregnancy-induced hypertension.

OBJECTIVE: The purpose of this study was to compare the peripartum and perinatal effects of epidural with intravenous labor analgesia in women with pregnancy-induced hypertension. STUDY DESIGN: Women with pregnancy-induced hypertension who had consented to participate were randomized to receive either epidural or intravenous analgesia for labor pain. Both methods were given according to standardized protocols. All women received magnesium sulfate seizure prophylaxis. Obstetric and neonatal outcomes were compared according to intent-to-treat allocation. RESULTS: Seven hundred thirty-eight women were randomized: 372 women were given epidural analgesia, and 366 women were given intravenous analgesia. Maternal characteristics were similar, including the severity of hypertension. Epidural analgesia was associated with a significantly prolonged second-stage labor, an increase in forceps deliveries, and an increase in chorioamnionitis. Cesarean delivery rates and neonatal outcomes were similar. Pain relief was superior with the epidural method. Hypotension required treatment in 11% of women in the epidural group. CONCLUSION: Epidural labor analgesia provides superior pain relief but no additional therapeutic benefit to women with pregnancy-induced hypertension.

[Electrooculographic findings in patients with neurofibromatosis]. / Alteraciones electro-oculográficas en pacientes con neurofibromatosis.

Neurofibromatosis are frequent genetic syndromes, with the electrooculographic examination (EOG) as an useful tool in their evaluation. We present the EOG findings of 16 patients with this entity which were seen at our Department between 1969 and 1991. Mean of age was 31 years. Nine patients were female (56%). The most frequent pathologic findings were: spontaneous nystagmus (37.5%) and abnormalities in the pursuit tracking test (31.2%). These results are discussed and the main literature concerning this matter is reviewed.

Diabetes complicating pregnancy.

Despite the well-documented relationship between morbidity in pregnancy and pregestational maternal diabetes, the corrected perinatal outcome is, in most series, equal to or better than that of the general reference obstetric population. No single aspect or element of contemporary management is responsible for this improvement; rather, a combination of interventions seems responsible. Targeting delivery early in term, improved compliance, better glycemic control during pregnancy, improved control at conception, improved neonatal care, family planning, and early screening for fetal abnormalities all likely contribute to improved outcome. The currently observed rates of perinatal mortality suggest that an irreducible minimum mortality rate may be reached; however, large disparities in access to care and treatment continue to result in a wide range in rates of morbidity and mortality, a fact that pertains to outcomes in general as well as to pregnancies complicated by diabetes. The identification of women with lesser degrees of hyperglycemia as diabetic by lowering the thresholds for glucose tolerance test abnormality suggests an importance of the diagnosis that is not supported by evidence of either related morbidity or therapeutic benefit. The extrapolation of risk to women with lesser degrees of hyperglycemia seems to have little basis, and the management of women with mild glucose intolerance as if they had overt diabetes is unwarranted. The excess of resources dedicated to the identification and monitoring of an increasing number of women with mild abnormalities of glucose metabolism should prompt a reevaluation of these practices. Perinatal benefits of this expenditure are difficult to document or nonexistent, and there is a predictable increase in iatrogenic morbidities associated with the diagnosis. The exception in the most recent recommendations is the addition of a random glucose measure to screen for the rare women with overt undiagnosed diabetes who presents for prenatal care, because these women are at increased risk of morbidities related to diabetes. A curious statement was made in the summary and recommendations of the fourth International Congress on Gestational Diabetes: "There remains a compelling need to develop diagnostic criteria for GDM [gestational diabetes mellitus] that are based on the specific relationships between hyperglycemia and risk of adverse outcome." If these relationships are undefined, what is the import of the diagnosis? At the author's center, application of the new diagnostic thresholds for the diagnosis of gestational diabetes mellitus has increased the incidence to over 6%. Without a clear expectation of benefit, this increase represents an unsupportable investment of resources. What are the prospects for improving understanding of the relationships between glucose intolerance and pregnancy risks? The direction of new guidelines and recommendations seems to be moving away from resolution of the relationships. The new criteria result in the diagnosis of gestational diabetes in an increasing number of women who were previously normal. It is easier to differentiate women at an extreme of hyperglycemia from normal. Investigations will be even less able to identify attributable effects of glucose intolerance in pregnancy with the inclusion of women with lesser degrees of hyperglycemia. As evidenced in O'Sullivan's original series, women with fasting hyperglycemia in pregnancy are still presumed to be at increased risk of fetal death. This risk factor remains important in clinical management if insulin treatment, fetal surveillance, and early term delivery can reduce the risk of fetal loss. At the author's center, the relationships among outpatient measures of fasting glycemia, glucose tolerance testing results, and perinatal outcomes are evaluated. Preliminary results suggest that fasting glycemia measured at the time of a 50-g glucose tolerance test is significantly correlated with and as sensitive and predictive of morbidity as the glucose tolerance test diagnosis of gestational diabetes. If these results are confirmed, it will be difficult to rationalize continued glucose tolerance testing.

Renal disease in pregnancy.

Women with renal disease who conceive and continue a pregnancy are at significant risk for adverse maternal and fetal outcomes. Risk is inversely related to the degree of renal insufficiency. Pregnancy-induced changes in the urinary tract can temporarily increase renal function compromise, such as nephrosis, but most often results in no net increase in dysfunction. Common complications of pregnancy--such as hypertension and hypovolemia--can be associated with acute renal injury or aggravation of pre-existing disease.

Neutrophil activation induced by placental factors in normal and pre-eclamptic pregnancies in vitro.

Increased neutrophil activation has been demonstrated in women with pre-eclampsia. Activated neutrophils may play a significant role in the vascular endothelial pathophysiology in this disorder of pregnancy. How neutrophils become activated in pre-eclampsia is unknown. It has been proposed that activating factors could be produced and released by the placenta. To test if placental factors could stimulate neutrophil activation and what mechanism might be involved, neutrophils isolated from healthy female volunteers were exposed to the conditioned medium (CM) derived from either normal (Nor) or pre-eclamptic (PE) placental villous culture. Neutrophil-endothelial adhesion, neutrophil superoxide generation, elastase activity and integrin expression were measured. The data were analysed by ANOVA. A P value less than 0.05 was considered statistically significant. All values are expressed as a mean+/-s.e. We found: (1) neutrophil-endothelial adhesion was significantly increased in neutrophils exposed PE-CM than those exposed to Nor-CM and non-CM, P< 0.01; (2) both Nor-CM and PE-CM could stimulate neutrophils to generate more superoxide radicals; (3) there was no difference in elastase activity after neutrophil exposure to Nor-CM compared to PE-CM, P> 0.1; (4) significant changes in CD62L and CD11b expression were found in neutrophils exposed to PE-CM. We conclude that factors produced by the placenta can activate neutrophils by an increase in superoxide generation and modulation of adhesion molecule expression. Upregulation of surface adhesion molecule CD11 expression may be responsible for the increased neutrophil-endothelial adhesion induced by factors derived from pre-eclamptic placentae.

Spanish family with Machado-Joseph disease: neurophysiological features and neuropathy study.

OBJECTIVES: We have carried out electrophysiological studies and sural nerve biopsy evaluation in a Spanish family with genetically proven Machado-Joseph disease (SCA3/MJD) phenotype III. PATIENTS AND METHODS: Two symptomatic and other two asymptomatic members of the family were clinically examined. Electrophysiological evaluation included multimodal evoked potentials, quantitative electromyography and nerve conduction studies, and central motor conduction time. We also report neuropathological findings in the sural nerve biopsy in the proband. RESULTS: Analysis of the SCA3/MJD CAG trinucleotide repeat at the ataxin 3 gene in the DNA of the proband and one of his daughters demonstrated an expanded allele of 63 CAG repeat units. Ataxic pursuit was primary disturbed in MJD, followed by gaze evoked nystagmus, hypermetric saccades and glissades. Limitation of vertical and horizontal gaze, impaired sinusoidal vestibulo-ocular reflex and vestibulo-ocular reflex-fixation-suppression, and active and passive optokinetic nistagmus loss appeared at later stages. Evoked potential studies showed multimodal abnormalities. Electrophysiological and sural nerve biopsy findings correspond well to a pattern of both anterior horn and root ganglion cell distal dominant degeneration. Central motor conduction time was normal in our patients up to advanced stages of the disease. CONCLUSIONS: Electrophysiological and neuropathological studies suggested widespread peripheral and central affection in MJD. Repeated application of electrophysiological techniques may prove useful for monitoring disease progress.

Effects of symmetric and asymmetric fetal growth on pregnancy outcomes.

OBJECTIVE: To assess the prevalence of head circumference to abdomen circumference (HC/AC) asymmetry among small for gestational age (SGA) fetuses, and to determine the likelihood of adverse outcomes among asymmetric and symmetric SGA infants compared with their appropriate for gestational age (AGA) counterparts. METHODS: In a retrospective cohort study, we analyzed consecutive live-born singletons of women who had antepartum sonography within 4 weeks of delivery and delivered between January 1, 1989 and September 30, 1996. A gestational age-specific HC/AC nomogram was derived from our sonographic database of 33,740 nonanomalous live-born singletons. Asymmetric HC/AC was defined as greater than or equal to the 95th percentile for gestational age. RESULTS: Among 1364 SGA infants, 20% had asymmetric HC/AC and 80% were symmetric. Asymmetric SGA infants were more likely to have major anomalies than symmetric SGA infants or AGA infants (14% versus 4% versus 3%, respectively; P <.001). After exclusion of anomalous infants, pregnancy-induced hypertension at or before 32 weeks' gestation and cesarean delivery for nonreassuring fetal heart rate were more common in the asymmetric SGA than the AGA group (7% versus 1% and 15% versus 3%, respectively; both P <.001). A neonatal outcome composite, including one or more of respiratory distress, intraventricular hemorrhage, sepsis, or neonatal death, was more frequent among asymmetric SGA than AGA infants (14% versus 5%, P =.001). Symmetric SGA infants were not at increased risk of morbidity compared with AGA infants. CONCLUSION: The minority of SGA fetuses with HC/AC asymmetry are at increased risk for intrapartum and neonatal complications.

Enfermedad de machado-joseph en una familia española: datos neurofisiológicos y estudio de la neuropatía / Spanish family with Machado-Joseph disease: neurophysiological features and neuropathy study

Objetivos: Se han realizado estudios neurofisiológicos y biopsia del nervio sural en una familia española con diagnóstico genético de enfermedad de Machado-Joseph (SCA3/MJD) y fenotipo clínico III. Pacientes y métodos: Se examinaron dos miembros de la familia clínicamente afectados y dos asintomáticos. El estudio neurofisiológico incluyó los siguientes estudios: potenciales evocados multimodales, electromiografía y conducción de nervio, tiempo de conducción motora central y otoneurología. Se realizó biopsia del nervio sural en el caso índice. Resultados: El análisis de la expansión del triplete CAG en el gen de la ataxina 3 de la SCA3/MJD demostró en el ADN del caso índice y de una de sus hijas una expansión alélica de 63 repeticiones. La presencia de un seguimiento ocular atáxico parece ser el primer signo oculomotor de la SCA3/MJD, seguido del nistagmo espontáneo, las sacadas hipermétricas y glissades. La limitación de los movimientos oculares conjugados verticales y horizontales, y las alteraciones del reflejo vestíbulo-ocular en la prueba pendular, de la supresión visual del reflejo vestíbulo-ocular y del nistagmo optocinético (activo y pasivo) se presentan en los estadios posteriores. Los estudios electromiográficos y de conducciones de nervios y los resultados de la biopsia del nervio sural concuerdan con un patrón de afectación degenerativa de las neuronas del asta anterior y del ganglio raquídeo. El tiempo de conducción motora central se mantuvo normal hasta estadios avanzados de la enfermedad. Conclusiones: El resultado de los estudios neurofisiológicos y los hallazgos de la biopsia del nervio sural sugieren una participación extensa del sistema nervioso central y del periférico en la SCA3/MJD. La valoración periódica mediante técnicas neurofisiológicas resulta útil para la monitorización del progreso de esta enfermedad. (AU)

Pregnancy outcomes after antepartum diagnosis of oligohydramnios at or beyond 34 weeks' gestation.

OBJECTIVE: Our purpose was to assess whether antepartum oligohydramnios is associated with adverse perinatal outcomes. STUDY DESIGN: Women delivered between July 1, 1991, and September 30, 1996, who underwent ultrasonography at >/=34 weeks' gestation were analyzed. Oligohydramnios was defined as an amniotic fluid index 50 mm. RESULTS: In our analysis of 6423 pregnancies, 147 (2.3%) were complicated by oligohydramnios. This complication was associated with increased labor induction (42% vs 18%; P <.001), stillbirth (1. 4% vs 0.3%; P <.03), nonreassuring fetal heart rate (48% vs 39%; P <. 03), admission to the neonatal intensive care nursery (7% vs 2%; P <. 001), meconium aspiration syndrome (1% vs 0.1%; P <.001), and neonatal death (5% vs 0.3%; P <.001). CONCLUSION: Antepartum oligohydramnios is associated with increased perinatal morbidity and mortality.

Color flow mapping for myometrial invasion in women with a prior cesarean delivery.

OBJECTIVES: Our aim was to evaluate the utility of color flow mapping in the prediction of placental myometrial invasion in women with Cesarean delivery. METHODS: Ultrasound color flow mapping was performed on placental implantations in potential proximity to the hysterotomy scar. The smallest myometrial thickness was measured under the placenta to evaluate the degree of myometrial attenuation in this area and note was made of unusual vascular lakes. RESULTS: Two hundred fifteen women with placentas in proximity to the prior hysterotomy scar underwent color Doppler mapping. Of 20 women with placenta previa and Cesarean delivery, 15 had Cesarean hysterectomy for bleeding complications and nine had the pathological diagnosis of placental invasion. The measurement of <1 mm for the smallest myometrial thickness or presence of large intraplacental lakes was predictive of myometrial invasion (sensitivity 100%, specificity 72%, PPPV 72%, and NPV 100%). CONCLUSIONS: Color flow mapping predicted myometrial invasion when the smallest myometrial thickness was <1 mm and large intraplacental lakes were demonstrated.

Gestational diabetes. Is a 50-g screening result > or = 200 mg/dL diagnostic?

OBJECTIVE: To evaluate the diagnosis of gestational diabetes based on a 50-g, one-hour glucose screening test result > or = 200 mg/dL. STUDY DESIGN: Retrospective ascertainment of pregnant women who had a 50-g, one-hour glucose screening test result > or = 200 mg/dL was performed among prenatal care registrants. The diagnosis of gestational diabetes was determined by 100-g, three-hour oral glucose tolerance test (GTT) results and/or repeated fasting serum glucose measures. RESULTS: In 1995, 69 women were referred to the gestational diabetes clinic with a 50-g result > or = 200 mg/dL. Four women could not be classified, two had pregestational glucose intolerance and four charts were unavailable. Of the remaining 59 women, 11 (19%) had normal three-hour GTTs, and 48 (81%) were diagnosed with gestational diabetes (35 [59%], A1; 13 [22%], A2). There was one large-for-gestational-age (LGA) infant born in the nondiabetic group (9%), 13 LGA infants born in the A1 group (37%) and 6 LGA infants born to the A2 diabetics (46%). The relationship between maternal diagnosis and LGA outcome was statistically significant. CONCLUSION: A 50-g screening test result > or = 200 mg/dL is not diagnostic of gestational diabetes. Nearly one of five such women had a normal three-hour oral GTT. Overdiagnosis of gestational diabetes may lead to unnecessary pregnancy surveillance and intervention.

Weekly administration of prostaglandin E2 gel compared with expectant management in women with previous cesareans. Prepidil Gel Study Group.

OBJECTIVE: To compare the clinical effectiveness and safety of outpatient administration of intracervical prostaglandin (PG) E2 gel with expectant treatment for women desiring vaginal births after cesareans. METHODS: This was a randomized, multicenter investigation involving term pregnant women who each had one previous low-transverse cesarean and an unfavorable cervix (Bishop score no more than 6), and who was a candidate for vaginal delivery. They were assigned to receive 0.5 mg of PGE2, (Prepidil; Pharmacia-Upjohn, Kalamazoo, MI) intracervically at 39 weeks' gestation, repeated at weekly office visits for up to three doses, or expectant treatment. The main outcome variable was vaginal birth. RESULTS: Of 294 cases, 143 received gel and 151 were treated expectantly. No differences between groups were found for maternal age, race, or Bishop score. Compared with the expectant treatment group, the PGE2 gel group was not more likely to deliver sooner or vaginally (57% versus 55%, P = .68). The onset of labor, duration of labor among those delivering vaginally, and 1- and 5-minute Apgar scores were not different between groups. No uterine ruptures occurred, and adverse effects were equally likely in both groups. CONCLUSION: Although its safety was confirmed for outpatient use, weekly doses of intracervical PGE2 did not improve the likelihood of vaginal births after cesareans.