Outcomes at 3 months after planned cesarean vs planned vaginal delivery for breech presentation at term: the international randomized Term Breech Trial

Context  The Term Breech Trial found a significant reduction in adverse perinatal outcomes without an increased risk of immediate maternal morbidity with planned cesarean delivery compared with planned vaginal birth. No randomized controlled trial of planned cesarean delivery has measured benefits and risks of postpartum outcomes months after the birth. Objective  To compare maternal outcomes of planned cesarean delivery and planned vaginal birth at 3 months post partum. Design  Follow-up study to the Term Breech Trial, a randomized controlled trial conducted between January 9, 1997, and April 21, 2000. Setting and Participants  A total of 1596 of 1940 women from 110 centers worldwide who had a singleton fetus in breech presentation at term responded to a follow-up questionnaire at 3 months post partum. Main Outcome Measures  Breastfeeding; infant health; ease of caring for infant and adjusting to being a new mother; sexual relations and relationship with husband/partner; pain; urinary, flatal, and fecal incontinence; depression; and views regarding childbirth experience and study participation. Results  Baseline information was similar for both the cesarean and vaginal delivery groups. Women in the planned cesarean delivery group were less likely to report urinary incontinence than those in the planned vaginal birth group (36/798 [4.5%] vs 58/797 [7.3%]; relative risk, 0.62; 95% confidence interval, 0.41-0.93). Incontinence of flatus was not different between groups but was less of a problem in the planned cesarean delivery group when it occurred (P = .006). There were no differences between groups in other outcomes. Conclusions  Planned cesarean delivery for pregnancies with breech presentation at term may result in a lower risk of incontinence and is not associated with an increased risk of other problems for women at 3 months post partum, although the effect on longer-term outcomes is uncertain.      

Simplified quantification of dopamine transporters in humans using [99mTc]TRODAT-1 and single-photon emission tomography

Quantification of dopamine transporters (DAT) using [99mTc]TRODAT-1 and single-photon emission tomography (SPET) requires full kinetic modeling of the data, using complex and invasive arterial blood sampling to provide an input function to the model. We have shown previously that a simpler reference tissue model provides accurate quantitative results, using a reference region devoid of DAT as the input to the model and thereby obviating the need for blood sampling. We now extend this work into humans, and develop further simplifications to make the imaging protocol much more practical as a routine procedure. Fourteen healthy subjects (age 29.8 +/- 8.4 years, range 18.7-45.5 years) underwent dynamic SPET for 6 h following injection of 752 +/- 28 MBq [99mTc]TRODAT-1. The kinetic data were analyzed using nonlinear regression analysis (NLRA) and Logan-Patlak graphical analysis. In addition, simple average ratios of striatal-to-background counts were obtained for three 1-h periods (3-4 h, 4-5 h, 5-6 h), and compared against the kinetic models. All methods gave an index of specific binding, proportional to the binding potential, known as the distribution volume ratio (DVR). The reference tissue NLRA gave mean values of k3=0.013 +/- 0.003 min(-1), k4=0.011 +/- 0.002 min(-1), and DVR=2.29 +/- 0.17. Graphical analysis gave a value of DVR=2.28 +/- 0. 16, and the three ratio values of DVR were: 3-4 h, 2.18 +/- 0.15; 4-5 h, 2.34 +/- 0.13; and 5-6 h, 2.46 +/- 0.19. Graphical analysis was highly correlated with NLRA (R2=0.91, slope=0.90 +/- 0.08). The ratio methods correlated well with NLRA (3-4 h, R2=0.71, slope= 0.73 +/- 0.13; 4-5 h, R2=0.86, slope=0.73 +/- 0.09; 5-6 h, R2=0.80, slope=1.00 +/- 0.15), and also with graphical analysis (3-4 h, R2=0.65, slope=0.74 +/- 0.16; 4-5 h, R2=0.85, slope=0.78 +/- 0.09; 5-6 h, R2=0.88, slope=1.11 +/- 0.12). The optimum equilibrium time point for obtaining a simple ratio was approximately 4.5-5.5 h. In conclusion, the simple ratio techniques for obtaining a quantitative measure of specific binding correlated well with the reference tissue kinetic models, using both NLRA and graphical analysis. The optimum time for obtaining a ratio appeared to be in the range 4.5-5.5 h. Earlier time points, while still relatively accurate, had a lower sensitivity and may not be optimized for measuring small changes in DAT concentrations.     

Raised maternal serum placenta growth factor concentration during the second trimester is associated with Down syndrome.

OBJECTIVES: To compare early second-trimester maternal serum placenta growth factor concentrations in Down syndrome pregnancies and those in normal pregnancies. METHODS: A case-control study was performed to evaluate the maternal serum placenta growth factor concentrations in 36 Down syndrome and 320 normal pregnancies with matched gestational age during the second trimester. For the detection of serum concentrations of placenta growth factor, a quantitative sandwich enzyme immunoassay technique (R & D Systems Inc., Minneapolis, Minnesota, USA) was performed. RESULTS: Using a multiple linear regression model, maternal serum placenta growth factor level was associated with gestational age (p<0.001) and the existence of Down syndrome pregnancy (p<0.001). After converting maternal serum placenta growth factor concentrations of each analyte to multiples of the appropriate gestational median (MoM), placenta growth factor MoM (p<0.001) was revealed to be an independent variable for Down syndrome pregnancies after adjusting for the effects of maternal age (p<0.001), free beta-hCG (p<0.001) and AFP (p=0.014) by multivariate logistic regression analysis. CONCLUSIONS: Maternal serum placenta growth factor concentration was elevated in Down syndrome pregnancies during the early second trimester. Placenta growth factor might be a novel marker for maternal serum Down syndrome screening.     

Echocardiographic Guidance for Transcatheter Coil Embolization of Congenital Coronary Arterial Fistulas in Children

Congenital coronary arterial fistulas are rare anomalies that have traditionally been managed by surgical ligation. However, in recent years endovascular therapy has been employed with encouraging results. Between 1993 and 1996, we performed transcatheter coil embolization of coronary arterial fistulas to the right atrium or ventricle in four children ranging in age from 4.5 to 9.8 years. Cardiac and coronary arterial anatomy were diagnosed correctly on the preoperative echocardiogram in all patients, including the origin, course, and termination of the fistulas. The fistula was occluded completely in three of the patients, whereas trivial residual flow remained in the fourth. Transesophageal echocardiography was useful for monitoring the embolization procedure. In one of the patients, the fistula reopened while the child was on overnight heparin, although the magnitude of flow was less than that before the embolization. At follow-up ranging from 10 to 43 months, there was no flow through the fistula in any patient. We present our experience with these patients, with a focus on the importance of echocardiographic evaluation before, during, and after transcatheter therapy of coronary arterial fistulas.     

Suprasellar ectopic pituitary adenoma presenting as cranial diabetes insipidus.

We describe the occurrence of a supracellar ectopic pituitary adenoma in a 34 year old woman who presented with cranial diabetes insipidus and subsequently developed galactorrhoea-amenorrhoea. The tumour was demonstrated by both contrast computed tomography scan and magnetic resonance imaging with gadolinium enhancement and was confirmed at operation. Histological examination showed that the suprasellar lesion consisted of a pituitary adenoma while the pituitary biopsy revealed an unrelated pituitary microadenoma embedded in normal pituitary tissues. A review is made of the reported cases of ectopic pituitary adenomas.     

Application of I-123 HIPDM as a lung imaging agent

N,N,N'-Trimethyl-N'-(2-Hydroxyl-3-Methyl-5-123I Iodobenzyl)-1,3-Propanediamine.Hcl (123I-HIPDM) has been used for diagnosis of patients with strokes and dementias. Since this radiopharmaceutical is also accumulated in the lung, we routinely performed a lung image or images immediately prior to cerebral planar and SPECT images after a 3-5 mCi 123I-HIPDM injection. During the past 14 months, we obtained 78 (age from 41 to 92 years, average 66.7 +/- 8.9 years; 64 males, 14 females) suspected stroke or dementia patients' lung images. All lung images were correlated to chest X-ray (CXR) or CT and other clinical data. Sixty five of 78 patients had normal lungs showing homogeneous distribution of activity throughout the lungs which correlated well to normal CXR and/or CT studies. Abnormal scintigraphic patterns of the 13 patients included lung defect (5 bronchogenic carcinoma with or without atelectasis) and decreased uptake in apices (8 chronic obstructive pulmonary disease). The findings of pulmonary intrathoracic pathologies on lung images with 123I-HIPDM suggests further evaluation of the agent for detection of localized pulmonary diseases and pulmonary physiological studies relating to amine metabolism.     

Optimal formalin fixation and processing schedule of cell blocks from fine needle aspirates

In fine needle aspiration cytology, cell blocks may provide diagnostic information complementary or additional to that obtained from examination of cell smears. However, the morphological preservation is often unsatisfactory in cell blocks processed by routine schedules used for surgical specimens. This study investigates the effects of different formalin concentrations and processing schedules on cellular morphology. We conclude that 7.5% buffered formalin is the optimal formalin solution and a shortened processing time through xylene is desirable.