Optimal management strategies for placenta accreta

Objective  To determine which interventions for managing placenta accreta were associated with reduced maternal morbidity.
Design  Retrospective cohort study.
Setting  Two tertiary care teaching hospitals in Utah.
Population  All identified cases of placenta accreta from 1996 to 2008.
Methods  Cases of placenta accreta were identified using standard ICD-9 codes for placenta accreta, placenta praevia, and caesarean hysterectomy. Medical records were then abstracted for maternal medical history, hospital course, and maternal and neonatal outcomes. Maternal and neonatal complications were compared according to antenatal suspicion of accreta, indications for delivery, preoperative preparation, attempts at placental removal before hysterectomy, and hypogastric artery ligation.
Main outcome measures  Early morbidity (prolonged maternal intensive care unit admission, large volume of blood transfusion, coagulopathy, ureteral injury, or early re-operation) and late morbidity (intra-abdominal infection, hospital re-admission, or need for delayed re-operation).
Results  Seventy-six cases of placenta accreta were identified. When accreta was suspected, scheduled caesarean hysterectomy without attempting placental removal was associated with a significantly reduced rate of early morbidity compared with cases in which placental removal was attempted (67 versus 36%, P = 0.038). Women with preoperative bilateral ureteric stents had a lower incidence of early morbidity compared with women without stents (18 versus 55%, P = 0.018). Hypogastric artery ligation did not reduce maternal morbidity.
Conclusions  Scheduled caesarean hysterectomy with preoperative ureteric stent placement and avoiding attempted placental removal are associated with reduced maternal morbidity in women with suspected placenta accreta.     

Meningitis and midline facial deformity

A baby with unilateral cleft lip, midline cleft palate and hypertelorism developed meningitis in the first 48 h of life. Examination of the nasopharynx showed a soft tissue mass, which was confirmed as a basal encephalocele by computed tomography. There was also congenital hydrocephalus and the corpus callosum was absent. Surgical treatment included repair of the anterior basal skull defect, repair of the lip and palate, and ventriculo-peritoneal shunt. There is currently evidence of developmental delay and right-sided visual impairment due to Morning Glory syndrome. This case demonstrates that basal encephalocele should be considered in any baby with midline facial deformity who develops meningitis.     

Isolated congenital tuberculosis otitis in a preterm infant

We report an unusual case of localized congenital tuberculosis otitis in a preterm infant. Unlike disseminated congenital cases, the manifestations of localized otitis are associated with a triad of signs: (i) regional lymphadenopathy in the absence of typical systemic features of tuberculosis; (ii) delayed onset of presentation; and (iii) refractory otitis unresponsive to conventional antimicrobial agents. The need for greater diligence in looking for neonatal tuberculosis is emphasized, especially in an ethnic or socioeconomic environment where the disease is prevalent. Congenital tuberculosis, otitis, preterm
PC Ng, Department of Paediatrics, Level 6, Clinical Sciences Building, Prince of Wales Hospital, Shatin, NT, Hong Kong     

Liberalization of donor criteria may expand the donor pool without adverse consequence in lung transplantation

BACKGROUND: Currently the most important limitation in lung transplantation is donor availability. Although liberalization of donor criteria may aid in expanding the donor pool, the long-term effects of the use of "marginal" or "extended" donors remains unexplored. METHODS: In this study, we included all patients who underwent lung transplantation from January 1996 to December 1999 at Loyola University Medical Center. We categorized patients as either receiving lungs from an "ideal" donor or an "extended" donor. Extended donors were defined as having any 1 of the following criteria: donor age > 55 years, tobacco history > 20 pack years, presence of infiltrate on chest x-ray, donor ventilator time > 5 days, or donor use of inhaled drugs (cocaine or marijuana). We then compared the 2 groups with regard to short-term (operating room [OR] complications, intensive care unit [ICU] complications) and long-term outcomes (1-year pulmonary function and survival). RESULTS: Sixty-one (54%) patients received lungs from ideal donors and 52 (46%) patients received lungs from extended donors as defined above. We observed no significant differences between the 2 groups in OR complications (cardiopulmonary bypass, bleeding complications, life-threatening arrhythmias) or ICU complications (pneumonia, airway dehiscence, reoperation within 30 days related to transplantation). In addition, the 2 groups had similar median intubation times (21 hours in the ideal donor group and 20 hours in the extended donor group; p = n.s.), hospital length of stay (14+/-12 days in the ideal donor group and 12+/-8 days in the extended donor group; p = n.s.), and hospital survival (80% and 88% in the ideal and extended donor groups, respectively). One-year follow-up revealed similar pulmonary function (forced expiratory volume in 1 sec [FEV(1)] = 2.4 liters and 2.4 liters in the recipients of bilateral ideal and extended donors, respectively, and FEV(1) = 1.9 liters and 1.5 liters in the recipients of single ideal and extended donors) and survival (72% and 79% in the ideal and extended donor groups, respectively; p = n.s.) between the 2 groups. CONCLUSIONS: Liberalization of donor criteria does not affect outcome in the first year after lung transplantation. By liberalizing donor criteria, we can expand the donor pool while assessing other possible mechanisms to increase donor availability.     

The relationship of recent life change to seriousness of later illness

A sample of 313 college freshmen was prospectively studied to determine whether recent life change predicted the seriousness of subsequent illness. Using the Seriousness of Illness Rating Scale as the measure of seriousness, it was found that recent life change correlated at 0.33 with seriousness. This measure of seriousness also correlated with several other measures of severity and seriousness. However, the fact that seriousness was highly correlated (0.80) with the number of new health problems experienced, raises questions about the value of using both as outcome measures in life change research.