Ultrasound functional evaluation of fetuses with myelomeningocele: study of the interpretation of results

Objective: To assess the reliability of the interpretation of a new technique for the ultrasound evaluation of the level of neurological lesion in fetuses with myelomeningocele.

Methods: Observational study including myelomeningocele fetuses, referred to our center for the sonographic assessment of the fetal lower-limb movements, made and recorded by an expert in Maternal–fetal medicine and a specialist in Rehabilitation. Two observers, with different levels of expertise and blinded to each other’s results, interpreted each recorded scan two different times. The agreement for the segmental levels assigned between the observers and the gold standard, the inter-observer and intra-observer reproducibility were tested using the weighed Kappa (wκ) index.

Results: Twenty-eight scans were recorded and evaluated. The agreement between the observers and the gold standard remained constant for the expert observer (wκ?=?0.82) and increased (wκ?=?0.66-wκ?=?0.72) for the other one. The inter-observer and the intra-observer variability for the expert observer were wκ?=?0.72 and wκ?=?0.94, respectively.

Discussion: The agreement for the prenatal evaluation of the segmental neurological level was excellent, after a short training period, for observers with different degrees of expertise. The interpretation of this technique is reproducible enough and this supports its value for the prediction of postnatal motor function in myelomeningocele fetuses.     

No Correlation Between Ultrasound Placental Grading at 31–34 Weeks of Gestation and a Surrogate Estimate of Organ Function at Term Obtained by Stereological Analysis

We test the experimental hypothesis that early changes in the ultrasound appearance of the placenta reflect poor or reduced placental function. The sonographic (Grannum) grade of placental maturity was compared to placental function as expressed by the morphometric oxygen diffusive conductance of the villous membrane. Ultrasonography was used to assess the Grannum grade of 32 placentas at 31–34 weeks of gestation. Indications for the scans included a history of previous fetal abnormalities, previous fetal growth problems or suspicion of IUGR. Placentas were classified from grade 0 (most immature) to grade III (most mature). We did not exclude smokers or complicated pregnancies as we aimed to correlate the early appearance of mature placentas with placental function. After delivery, microscopical fields on formalin-fixed, trichrome-stained histological sections of each placenta were obtained by multistage systematic uniform random sampling. Using design-based stereological methods, the exchange surface areas of peripheral (terminal and intermediate) villi and their fetal capillaries and the arithmetic and harmonic mean thicknesses of the villous membrane (maternal surface of villous trophoblast to adluminal surface of vascular endothelium) were estimated. An index of the variability in thickness of this membrane, and an estimate of its oxygen diffusive conductance, were derived secondarily as were estimates of the mean diameters and total lengths of villi and fetal capillaries. Group comparisons were drawn using analysis of variance. We found no significant differences in placental volume or composition or in the dimensions or diffusive conductances of the villous membrane. Subsequent exclusion of smokers did not alter these main findings. Grannum grades at 31–34 weeks of gestation appear not to provide reliable predictors of the functional capacity of the term placenta as expressed by the surrogate measure, morphometric diffusive conductance.     

Variability in diagnosis of clue cells,lactobacillary grading and white blood cells in vaginal wet smears with conventional bright light and phase contrast microscopy

Objective

Study the reproducibility of wet smear interpretation of clue cells, lactobacillary grades and leukocyte dominance with conventional bright light and phase contrast microscopy.

Study design

Sets of vaginal specimens were taken from unselected consecutive women attending an outpatient gynaecology clinic. Air-dried vaginal fluid on a microscope slide was rehydrated with isotonic saline before examination by six independent international investigators. Some investigators initially used a conventional bright light microscope, followed by phase contrast technique.

Results

Using phase contrast microscopy, an excellent inter-observer agreement was obtained among all investigators for clue cells detection (Kappa values from 0.69 to 0.94) and lactobacillary grades (Kappa 0.73–0.93). When conventional light microscopes were used, poor agreement was obtained for these criteria (Kappa index 0.37–0.72 and 0.80, respectively), but switching to phase contrast microscopy by the same investigators, improved Kappa to 0.83–0.85 and 0.88, respectively. The inter-observer agreement for estimation of the leukocyte/epithelial cell ratio (Kappa index 0.17–0.67) was poor, irrespective of the type of microscopy applied. Intra-observer agreement of clue cell detection and lactobacillary grading was also found to be excellent if phase contrast microscopy was used (Kappa 0.87–0.93), and poor with conventional bright light microscopy (Kappa 0.45–0.66).

Conclusion

Clue cells and the lactobacillary grades are reliably identified by phase contrast microscopy in wet smears, with excellent intra- and inter-observer reproducibility agreement, and better than when simple bright light microscopy was used. Evaluation of leukocyte grading, on the other hand, was inconsistent among the different microscopists, irrespective of the type of microscope used. We propose to grade the leukocytes in a different way than searching for leukocyte dominance over epithelial cells, namely by counting them per high power field and per epithelial cell.     

Are there any differences in three-dimensional placental vascular indices obtained using conventional power Doppler and high-definition flow imaging?

Objective: The purpose of this study was to determine whether there are differences in values and reproducibility of three-dimensional (3D) vascular indices obtained on placental volumes using power Doppler (PD) or high-definition flow imaging (HDFI) techniques. Methods: A prospective study was performed on 121 uncomplicated singleton pregnancies at 11 + 0 to 13 + 6 weeks of gestation. Two placental volumes were acquired from each pregnancy. Vascularization index (VI), flow index (FI) and vascularization flow index (VFI) were then analyzed and compared. In order to assess the reproducibility of the measurements, two additional placental volumes obtained with both PD and HDFI were acquired in 31 pregnancies and the agreement assessed by intraclass correlation coefficients. Inter-observer variability was assessed by analyzing all the volumes by two observers blinded to each other’s. Results: A significant relationship was observed between the vascular indices values obtained with the two techniques (VI Pearson’s r?=?0.891 p?<?0.001; FI r?=?0.769 p?<?0.001; VFI r?=?0.847 p?<?0.001). The median values of VI, FI and VFI were significantly higher when obtained with HDFI imaging. In serial recordings, the ICCs resulted higher when volumes were acquired with HDFI rather than with PD techniques. Similarly, HDFI demonstrated a higher inter-observer reproducibility. Conclusions: 3D vascular indices calculated using HDFI are higher than those calculated using conventional PD. Although the relationship between the two methods is high, HDFI shows a better reproducibility suggesting its potential clinical application.     

Inter-observer variation in histopathological diagnosis and grading of vulvar intraepithelial neoplasia: results of an European collaborative study

Objective To evaluate the inter-observer variability of vulvar intraepithelial neoplasia diagnosis and grading system.
Design Prospective study.
Sample Histological sections of 66 vulvar biopsies.
Methods Six consultant pathologists working at different European institutions independently reviewed 66 vulvar biopsies. The following variables were investigated: specimen adequacy, gross categorisation into benign or neoplastic changes, presence of atypical cytological pattern, presence of neoplastic architectural pattern, grade of vulvar intraepithelial neoplasia, presence of histopathologic associated findings for human papillomavirus infection.
Main outcome measures The degree of inter-observer variation for each histopathologic parameter was assessed by Kappa (κ) statistics. The frequency and the degree of disagreement were calculated by a symmetrical agreement matrix showing the number paired classifications.
Results A good agreement (overall weighted κ= 0.65, unweighted κ= 0.46) was observed for grading vulvar intraepithelial neoplasia. Human papillomavirus infection associated findings and specimen adequacy were the variables with less inter-observer agreement (overall weighted κ 0.26 and 0.22, respectively). Exact agreement between two pathologists for grade of vulvar intraepithelial neoplasia was observed in 63.6% of paired readings; the rate of paired agreement reached 73.9% considering vulvar intraepithelial neoplasia 2 and 3 as a single class. Conversely, only 5.0% of vulvar intraepithelial neoplasia 1 diagnoses were concordant in paired analysis.
Conclusions Current terminology offers a reproducible tool in the hands of expert pathologists. While on the diagnosis of 'high grade' vulvar intraepithelial neoplasia (vulvar intraepithelial neoplasia 2 and 3) there is good agreement, the diagnostic category of vulvar intraepithelial neoplasia 1 is not reproducible.     

Galectin-3 is a potential biomarker to insulin resistance and obesity in women with polycystic ovary syndrome

Abstract

Polycystic ovary syndrome (PCOS) is the most common endocrine and metabolic disorder that affects women in reproductive age. This study aimed to evaluate Gal-3 levels and its role on metabolic parameters in women with PCOS. Gal-3 was measured in 44 PCOS and 25 women recruited as control group for the case-control study. Gal-3 levels were similar between PCOS and control groups (p?>?0.05), but showed a positive correlation with glucose levels in the oral glucose tolerance test (OGTT) (r?=?0.403, p?=?0.037), body mass index (BMI) (r?=?0.469, p?=?0.027), insulin levels (r?=?0.453, p?=?0.030) and HOMA-IR (r?=?0.738, p?=?0.037) in PCOS group. The data suggest that Gal-3 plays a role in the pathophysiology of the insulin resistance and obesity in PCOS group.     

Reproducibility of echocardiographic measurements of human fetal left ventricular volumes and ejection fractions using four-dimensional ultrasound with the spatio-temporal image correlation modality

Objectives

To determine the reproducibility, both reliability and agreement, of measurements of fetal left ventricular parameters from volumes obtained by spatio-temporal image correlation (STIC) acquisition applying virtual organ computer-aided analysis (VOCAL) and Simpson's rule (method of discs). Furthermore the success rate of STIC acquisition was determined.

Study design

In 84 pregnancies between 20 and 34 weeks of gestation the fetal heart was scanned using the STIC modality. An optimal four-chamber view in end-diastole and end-systole was obtained. Left ventricular end-diastolic volume, left ventricular end-systolic volume, stroke volume and ejection fraction were determined. For calculations based on Simpson's rule only one plane was traced, whereas for VOCAL six planes were traced. To quantify the reliability intraclass correlation coefficients were calculated for both intra- and inter-observer measurements. Agreement of measurements was evaluated by Bland-Altman plots.

Results

The STIC volumes of 54 women (64%) were excluded from the study because of poor quality, leaving 30 volumes for further analysis. Intraclass correlation coefficients for intra-observer reliability for VOCAL and Simpson were 0.99 and 0.99 for left ventricular end-diastolic volume, 0.95 and 0.92 for left ventricular end-systolic volume, 0.98 and 0.97 for stroke volume, 0.76 and 0.77 for ejection fraction, respectively. Intraclass correlation coefficients for inter-observer reliability for VOCAL and Simpson were 0.97 and 0.86 for left ventricular end-diastolic volume, 0.97 and 0.86 for left ventricular end-systolic volume, 0.95 and 0.81 for stroke volume, 0.68 and 0.63 for ejection fraction, respectively. According to Bland-Altman plots, the mean percentage difference and 95% limits of intra- and inter-observer agreement for left ventricular stroke volume measurements using VOCAL were −0.2 (−25.1, 24.7)% and 2.8 (−34.2, 39.8)%, respectively. For left ventricular stroke volume measured with Simpson versus VOCAL the mean percentage difference and 95% limits of agreement were −1.8 (−22.1, 18.5)%.

Conclusions

4D STIC enables reproducible measurements of left ventricular volumes. Reliability of the VOCAL mode is not essentially different from the single-plane method used in Simpson's rule. The large percentage of poor quality STIC volumes and the wide limits of inter-observer agreement would create obstacles for the clinical applicability of this technique.     

Echogenicity changes in the fetal brain,a 6-year follow-up study

Abstract

Objective: To asses the relation between echogenicity changes in the fetal brain and neurodevelopmental outcome until 6 years of age.

Methods: Fetuses (n?=?124) from pregnancies affected by hypertensive disorders (n?=?64) or preterm labor (n?=?60) at risk for preterm birth (26–34 weeks gestation) were studied. Moderate echogenicity changes (periventricular grade IB, II; intraventricular grade II–III; local basal ganglia/thalami) in the fetal and neonatal brain were related to neurological outcome and Griffiths mental developmental scales quotients at 1, 2 and 6 years. Multiple regression analysis tested the influence of moderate echogenicity changes and perinatal clinical characteristics on composite outcome (death or abnormal neurodevelopment).

Results: Moderate echogenicity changes were present in 37/124 (30%) fetuses. Median gestational age and weight at birth were respectively 31 weeks (range 26–43), 1314?g (range 550–4330), mortality was 19%, follow-up loss 10%. Composite outcome was abnormal in 47/124 (38%). Fetal and neonatal moderate intraventricular echodensities were related to cerebral palsy at 6 years (p?<?0.04). In the multiple regression analysis only gestational age was related to composite outcome (p?=?0.005).

Conclusions: Moderate intraventricular echodensities in the fetal brain related to cerebral palsy at 6 years of age. Gestational age at birth was the main predictor of abnormal composite outcome.     

Thymic pathology in placental abruption: an autopsy study of third trimester stillborns in a predominantly African–American population

Objective: Complete placental abruption results rapidly in fetal death through acute asphyxia, and identification of thymic lesions at autopsy may help in confirming this diagnosis. Thymic petechiae are a marker for acute asphyxia, while absence of histologically identifiable acute thymic involution (ATI), which requires several hours to develop, may help in exclusion.

Methods: We identified autopsies on 17 3rd trimester stillborns with clinical abruption; 58 stillborns with unexplained demise comprised the control group. Eighty-nine percent of the mothers were African–American. ATI was graded 0–4 (grades 0–1 and 3–4 were combined for analysis), and thymic petechiae were recorded.

Results: In the abruption group, ATI grade 0–1 was more frequent than higher grades: 13 (77%) had ATI grade 0–1 compared to 1 (6%) with ATI grade 3–4 (p?<?0.001). In contrast, in the control group, ATI grade 3–4 was more frequent than lower grades: 9 (16%) had ATI grade 0–1 compared to 30 (52%) with ATI grade 3–4 (p?<?0.001). Thymic petechiae were more frequent in the abruption compared to control group [10 (59%) versus 2 (3%)] (p?<?0.001), and were frequently seen with low ATI grade: 10 (83%) had ATI grade 0–1 (p?<?0.001).

Conclusions: The presence of thymic petechiae and ATI grade 0–1 correlates significantly with a clinical diagnosis of placental abruption.     

Correlation of rheological parameters in maternal and fetal blood at term

Objective: An association between maternal and fetal blood rheology has not yet been investigated nor is it known whether and to what extent fetal blood rheology may be affected by maternal conditions.

Methods: At delivery, blood was drawn from the cubital vein of 4985 consecutive mothers and from the umbilical cord during birth for determination of blood rheological parameters (erythrocyte aggregation stasis [E0], low shear [E1], plasma viscosity [Pv]) in addition to hemoglobin (Hb) values and hematocrit (Hct).

Results: Maternal and newborn Pv (r?=?0.2; p?r?=?0.197; p?p?p?=?0.068). Smoking mothers gave birth to neonates with significantly higher Pv (p?=?0.049), E0 (p?=?0.016) and E1 (p?=?0.013).

Conclusions: The increase of fetal plasma viscosity at advanced delivery time-points refers to a more gaining protein synthesis by the fetal liver and thus maturity of the fetus. Iron supplementation as well as smoking during pregnancy is associated with a relative hyper-viscosity in the fetus at delivery.     

Guideline choice for CTG analysis influences first caesarean decision

Objective: To compare intrapartum cardiotocography (CTG) analysis in case of first caesarean section (CS) for non-reassuring CTG according to international guidelines.

Methods: Four ObGyns retrospectively analysed first CS for non-reassuring CTG during labour blind to neonatal outcome. CTG were analysed according to French National College of Obstetricians and Gynaecologists (CNGOF) and to the FIGO guidelines. First, CTG analysis was done without obstetrical context, then secondly, it was given. ObGyns stated if CS was justified or not. Inter-operator ObGyn agreement was analysed.

Results: Among 587 CS, 100 women met the inclusion criteria with a first CS for non-reassuring CTG. The overall inter observer agreement was low but fair. ObGyns were significantly more concordant using the FIGO than the CNGOF guidelines (kappa coefficient?=?0.331 [0.27–0.39] versus 0.209 [0.16–0.26] p?p?p?=?0.026).

Conclusion: The FIGO guidelines are more reproducible than CNGOF guidelines. The overall inter-observer agreement was low but fair. The guideline choice could have an impact on first CS decision.     

Stomach position versus liver-to-thoracic volume ratio in left-sided congenital diaphragmatic hernia

Objective: To describe a new grading method for stomach position (SP) in fetuses with left-sided congenital diaphragmatic hernia (L-CDH) using ultrasound and to correlate SP to liver position and to liver-to-thoracic cavity volume ratio (LiTR) using magnetic resonance imaging.

Methods: SP were graded at the level of the 4-chamber view as following: grade 1-to-4 for stomach not visualised, visualised anteriorly at the apex of the heart, stomach showing abdominal structures anteriorly and stomach with its larger part posterior to the level of the atrial-ventricular heart valves, respectively. The LiTR was calculated and correlated to SP using the Mann–Whitney U test.

Results: Seventy-four fetuses were included. Median LiTR for grade 1 SP was 0% and was not different from median LiTR for grade 2 SP (0%, p?=?NS). Median LiTR for grade 3 SP was 14.9% and was significantly higher than for grade 2 SP (p?p?Conclusion: In L-CDH, SP as described represents a simple indirect measurement of intrathoracic position and quantification of liver.     

Impacts of β-estradiol on intestinal injury in newborn rats

Objective: Necrotizing enterocolitis has been investigated and debated extensively in recent years; however, there is still no effective treatment. The aim of this study was thus to examine the effects of β-estradiol on intestinal injury in rats.

Methods: Twenty-four newborn female rat pups were divided into three groups. In group 1 (sham), hypoxia–re-oxygenation was not performed. In group 2 (saline), the rats were injected with saline after hypoxia–re-oxygenation, and the process was repeated for 5?d. In group 3 (β-estradiol treatment), the rats were subjected to hypoxia–re-oxygenation and then given β-estradiol intraperitoneally once a day for 5?d. After these procedures, the terminal ileum was removed for analysis.

Results: Statistically significant differences in histological grades were found between groups 1 and 2 (p?=?0.000), groups 1 and 3 (p?=?0.028), and groups 2 and 3 (p?=?0.021). There were also differences in TNF-α and IL-6 levels between groups 2 and 3 (p?=?0.000 and p?=?0.038, respectively) and between groups 1 and 2 (p?=?0.000 and p?=?0.000); there was no difference between groups 1 and 3 (p?=?0.574 and p?=?0.195, respectively). Electron microscopy examination revealed a decrease in lipid droplets at the apical cytoplasm of the columnar cells in group 2; in group 3, the absorption of the lipids as lipid droplets was similar to that of group 1.

Conclusion: In this study, β-estradiol was found to decrease the intensity of intestinal injury significantly by inhibiting TNF-α and IL-6.     

Modelling umbilical vein blood flow normograms at 14–40 weeks of gestation by quantile regression analysis

Objective: To construct reference limits for gestation of umbilical vein blood flow (UVBF) in normal singleton pregnancies between 14 and 40 weeks of gestation using quantile regression.

Methods: We ultrasonographycally examined 852 fetuses from low-risk pregnancies between 16 and 40 weeks of gestation in a prospective cross-sectional study. UV diameter and time-averaged maximum velocity (TAMXV) were measured in UV intra-abdominal portion by real time and Doppler ultrasonography. A semi-automatic measurement software was used to obtain UV diameter values. UVBF was then calculated from UV diameter and TAMXV measurements and expressed both as absolute value and as value normalized for fetal abdominal circumference (UVBF/AC). Individual centile values of the variables investigated were established by quantile regression in the gestational interval considered. In 50 cases UVBF was measured twice by the same investigator or by a second investigator and the intra- and inter-observer agreement were calculated.

Results: A significant increase in UV diameter, TAMXV, UVBF absolute value and UVBF/AC was evidenced in the gestational period considered. Growth charts were established based on these measurements. The intra- and inter-observer intraclass correlation coefficients resulted as 0.92 (0.87–0.96) and 0.89 (0.84–0.97), respectively, for UBVF.

Conclusions: In this study we constructed UVBF charts using quantile regression in a large cohort of low-risk pregnancies. These charts offer the advantage of specific estimated regression parameters for each percentile, better defining the normal range of UVBF. This promises to be useful in the diagnosis and management of fetuses with abnormal fetal growth.     

Variability of nuchal translucency measurement: a multicenter study in Thailand

OBJECTIVES: To evaluate intra- and inter-observer variations of nuchal translucency (NT) measurements and study the duration of measurements. SUBJECTS: One hundred and forty-seven singleton pregnant women with 10-14 weeks of gestation who had attended antenatal clinic during January 1st, 2000-August 31st, 2001 were included. METHODS: Crown-rump length and NT were measured three times for each woman. Then, another examiner who was unaware of the previous results did the other three measurements. The duration of measurements was recorded. Intra-observer and inter-observer variations were analyzed by repeated ANOVA and paired t test, respectively. The correlation of NT measurements within each observer and between paired observers was evaluated by intraclass correlation coefficients (ICC). Kappa statistic was calculated for agreement. RESULTS: Intra-observer variation of all 10 examiners at three institutes was varied from 0.20 +/- 0.27 to 0.33 +/- 0.41 mm. Inter-observer variation at Chiang Mai University was 0.40 +/- 0.37 mm which was the highest value compared with those at Prince of Songkla and Khon Kaen University (p < 0.05). The mean duration of measurements was in range of 8-12 min. The intra-observer repeatability of the first two measurements showed ICCs varying from 0.61 to 0.94. The inter-observer repeatability of paired examiners showed a variation in ICC from 0.28-0.90. The kappa value expressing the intra- and inter-observer repeatability as being >95th or < or = 95th percentile was 0.73 and 0.72, respectively. CONCLUSIONS: NT measurement was reproducible for small variation and good agreement. The duration of measurements was acceptable.     

Levels of agreement between clinical examination and transabdominal ultrasound evaluation of fetal head position in the second stage of labor

Aim: To compare transvaginal digital examination performed by residents and attending physicians to transabdominal suprapubic ultrasound in the evaluation of fetal head position in the second stage of labor.

Methods: A prospective study was conducted at a tertiary center and included pregnant women at term, with normal singleton cephalic presentation fetuses. All patients had ruptured membranes and were evaluated during the second stage of labor. Fetal head position was assessed consecutively by two clinicians (one resident and one attending physician). Afterwards, transabdominal suprapubic ultrasound was performed by another observer. Examiners were blinded to each other’s findings. Cohen’s kappa test was used to assess the degree of agreement between the evaluation methods.

Results: One-hundred sixty-one women were included. Transvaginal examination was consistent with the ultrasound in 45.0% of cases (95% CI: 37–53%) when the examination was performed by residents (k?=?0.349) and in 67% (95% CI: 60–74%) if the attending physician carried out the evaluation (k?=?0.604). When considering only the anterior positions, the Cohen’s kappa test was 0.426 and 0.709, respectively.

Conclusion: Transabdominal suprapubic ultrasound improved the accuracy of the evaluation of fetal head position, namely when transvaginal digital examination was performed by residents. This may be important especially when instrumental deliveries are considered.     

New technique for assessing fetal heart growth using three-dimensional ultrasonography: description of the technique and reference curves

Objective: To describe a new technique for assessing fetal growth using three-dimensional ultrasonography (3DUS) using the extended imaging virtual organ computer-aided analysis (XI VOCAL) software and its respective reference curves.

Methods: We conducted a cross-sectional study on 303 normal singleton pregnancies between their 20th and 34th weeks. To assess fetal heart growth, we used the XI VOCAL software with 10 planes in which the reference lines (beginning and end) were placed at the cardiac apex, the output level of the vessels and the base above the diaphragm, respectively. To assess the correlation between distance and interval, polynomial regressions were performed with adjustments using the coefficient of determination (R²). To assess the inter-observer reproducibility, we used the intraclass correlation coefficient (ICC).

Results: The mean distance between the apex and the base of the fetal heart ranged from 14.41?±?1.24?mm to 26.24?±?2.62?mm between the 20th and 34th weeks, respectively. The mean interval between the apex and the base of the fetal heart ranged from 1.56?±?0.13?mm and 2.94?±?0.30?mm between the 20th and 34th weeks, respectively. We observed good correlation of distance and interval with the gestational age, with R²?=?0.73 and 0.74, respectively. We observed a good inter-observer to the interval and distance with ICC?=?0.983 and 0.996, respectively.

Conclusion: We described a new technique for assessing fetal heart growth using 3DUS and determined reference curves for the distance and interval between the 20th and 34th weeks of pregnancy.     

Assessment of cerebellar vermis biometry at 18–32 weeks of gestation by three-dimensional ultrasound examination

Objective: The purpose of this study was to construct reference limits for cerebellar vermis (CV) dimensions measured on images reconstructed from three-dimensional (3D) ultrasonography and to evaluate these measurements reproducibility. Methods: 3D ultrasound volumes were acquired transabdominally from an axial view of the fetal head in 342 fetuses cross-sectionally studied between 18 to 32 weeks of gestation. Offline analysis of fetal brain midsagittal plane was used to evaluate length and area of CV. The agreement between two-dimensional (2D) and 3D measurements as well as the interobserver variability in 3D measurements were assessed by interclass correlation coefficients (ICC). Results: Adequate visualization of the midsagittal plane was obtained in 96.7% of the fetuses. CV length (r?=?0.89, p?<?0.0001) and CV area (r?=?0.93, p?<?0.0001) showed a significant linear growth with gestation. A good agreement was found between measurements from either 2D or 3D ultrasound views (CV length ICC 0.943, CV area ICC 0.940) as well as between measured obtained by different observers (CV length ICC 0.965, CV area ICC 0.905). Conclusions: Measurements of the CV can be obtained from the midsagittal plane of fetal brain reconstructed from 3D volumes acquired transabdominally. The constructed nomograms may facilitate the diagnosis of cerebellar abnormalities.     

Observer variability among colposcopists from the West Midlands region

Objective To assess variation in diagnoses and management decisions among colposcopists when presented with cervical images; to see the impact of the referral cytology report on diagnostic accuracy.
Design A two-part video questionnaire study.
Participants Colposcopists from West Midlands Region
Methods Twenty cervical images displaying a range of transformation zones from normal through varying abnormalities up to cervical intraepithelial neoplasia (CIN) grade 3 were shown on video tape together with basic patient information. Two sets of videos were made, the second being identical to the first other than including the referral cytology. Participants recorded their diagnoses and management decisions on prepared questionnaires. The two sets of videos were viewed several weeks apart.
Results Completed questionnaires to both videos were received from 30 colposcopists. Diagnostic accuracy improved with knowledge of the cervical cytology result in cases of CIN 2/3 (x²= 19.45, P < 0.0001) but not where the histology was CIN 1 or less (x²= 2.64, P = 0.10). Overall inter-observer agreement improved slightly from K = 0.169 to K = 0.212 when the cytology was revealed. While only 2.6% of cases of CIN 2/3 would have been under-managed after the second questionnaire, 37.5% cases where the abnormality did not amount to CIN would have been over-treated.
Conclusion There is considerable inter-observer variability and variation in diagnostic accuracy in scoring cervical images particularly at the lower end of the spectrum of abnormality which has the potential to lead to over-treatment. We rely considerably on the cervical cytology result in forming a diagnosis. We recommend that a see-and-treat approach be abandoned when the referral smear shows minor abnormalities. The study has implications for both training and audit in colposcopy     

Correlation analysis between echocardiographic flow pattern and N-terminal-pro-brain natriuretic peptide for early targeted treatment of patent ductus arteriosus

Abstract

Objective: Echocardiographic flow patterns of patent ductus arteriosus (PDA) are useful to predict the development of hemodynamically significant ductus in premature infants. N-terminal pro-brain natriuretic peptide (NT-proBNP) concentrations seem to be useful to detect PDA. We investigated how NT-proBNP levels change on the basis of different flow patterns during the first day of life, and whether NT-proBNP might represent a reliable decision tool in PDA management.

Methods: Neonates with gestational age <32 weeks were assessed prospectively, using paired Doppler-echocardiographic evaluation and NT-proBNP values, at T0 (6–24?h of life), and daily until ductal closure.

Results: At T0, NT-proBNP concentrations of 41 neonates correlated to the kind of pattern (p?=?0.018) with the highest values in neonates with pulsatile or growing patterns. A value <9854?pg/ml identified neonates with spontaneous closure (sensitivity 71.8%, specificity 100%). Overall, 32 infants needed treatment. Pre-treatment NT-proBNP values increased compared to those at T0, significantly in neonates with growing pattern at T0 (p?=?0.001). After treatment, NT-proBNP concentrations decreased compared to pre-treatment values (p?=?0.0024), more markedly in the responders than in the non-responders (p?=?0.042).

Conclusions: NT-proBNP concentrations at T0 show a good agreement with different flow patterns and represent a useful tool to identify neonates at risk of developing hemodynamically significant PDA.