Fetal heart rate and umbilical artery flow velocity variability in intrauterine growth restriction: a matched controlled study.

OBJECTIVES: To study heart rate and umbilical artery blood flow velocity variability in growth-restricted fetuses and investigate the influence of the autonomic nervous system on these parameters. METHODS: Doppler velocity waveforms were collected from long-lasting umbilical artery recordings in 15 fetuses with growth restriction and 15 normal age-matched controls at 23-35 weeks of gestation. Absolute heart rate and umbilical artery blood flow velocity as well as the coefficient of variation were determined. Using power spectral analysis the low- and high-frequency bands of heart rate variability and blood flow velocity variability were calculated. The low-to-high (LH) ratio of heart rate variability and blood flow velocity variability were examined as a measure of sympathovagal balance. RESULTS: In growth-restricted fetuses umbilical artery velocities were significantly reduced. Heart rate variability was significantly reduced in the presence of growth restriction, but no significant difference was demonstrated for blood flow velocity variability. The LH ratio for heart rate variability was significantly decreased in growth restriction, but no difference in LH ratio was demonstrated for blood flow velocity variability. CONCLUSION: Flow velocity variability in growth restriction seems not to be predominantly influenced by the autonomic nervous system, whereas the decreased heart rate variability seems to be influenced by altered sympathetic-parasympathetic balance.     

Reduction in length of stay for patients undergoing oesophageal and gastric resections with implementation of enhanced recovery packages

Introduction

The high mortality and morbidity associated with resection for oesophagogastric malignancy has resulted in a conservative approach to the postoperative management of this patient group. In August 2009 we introduced an enhanced recovery after surgery (ERAS) pathway tailored to patients undergoing resection for oesophagogastric malignancy. We aimed to assess the impact of this change in practice on standard clinical outcomes.

Methods

Two cohorts were studied of patients undergoing resection for oesophagogastric malignancy before (August 2008 – July 2009) and after (August 2009 – July 2010) the implementation of the ERAS pathway. Data were collected on demographics, interventions, length of stay, morbidity and in-hospital mortality.

Results

There were 53 and 55 oesophagogastric resections undertaken respectively for malignant disease in each of the study periods. The median length of stay for both gastric and oesophageal resection decreased from 15 to 11 days (Mann– Whitney U, p<0.001) following implementation of the ERAS pathway. There was no significant increase in morbidity (gastric resection 23.1% vs 5.3% and oesophageal resection 25.9% vs 16.7%) or mortality (gastric resection no deaths and oesophageal resection 1.8% vs 3.6%) associated with the changes. There was a significant decrease in the number of oral contrast studies used following oesophageal resection, with a reduction from 21 (77.8%) in 2008–2009 to 6 (16.7%) in 2009–2010 (chi-squared test, p<0.0001).

Conclusions

The introduction of an enhanced recovery programme following oesophagogastric surgery resulted in a significant decrease in length of median patient stay in hospital without a significant increase in associated morbidity and mortality.     

High frequency oscillation in newborn infants with respiratory failure

Objective: To report ventilation strategies, survival and complications in 39 outborn infants treated with high frequency oscillatory ventilation (HFOV).
Methodology Data were collected prospectively between 1 May 1992 and 31 December 1993 on all infants treated with HFOV who had severe respiratory failure despite optimal conventional ventilation.
Results Twenty-eight out of 39 (72%) survived. Of the 15 infants with birthweights <1500g, eight survived. Best survival rates were for infants with pulmonary interstitial emphysema with air leak (4/5) and for infants of birthweight >1500g with hyaline membrane disease (8/8), and meconium aspiration syndrome (7/7). Three infants deteriorated while on HFOV and required extracorporeal membrane oxygenation. Complications were: (i) development of pulmonary interstitial emphysema (1); (ii) recurrence of pneumothorax (3); (iii) hypotension (2); and (iv) bronchopulmonary dysplasia (9). One of the eight infants weighing <1500g who received HFOV in the first week of life developed periventricular haemorrhage.
Conclusion The initial results of HFOV for severe respiratory failure were encouraging although a learning curve was encountered with its introduction.     

Periconceptional use of folic acid amongst women of advanced maternal age

Between February 1994 and February 1997 a group of 881 women completed a questionnaire on the use of folic acid. During the study period the percentage of women who had been informed about the benefits of folic acid rose from 41 per cent to 90 per cent and the percentage taking supplementation rose from 18 per cent to 60 per cent. Nevertheless, few women used folic acid at the right time and dose and although 90 per cent would have been willing to follow recommendations, correct use did not exceed 25 per cent. It is concluded that effective folic acid supplementation requires food fortification rather than information provided by healthcare workers.     

A rapid agglutination assay to detect anti-streptokinase antibodies

Background Streptokinase resistance may cause suboptimal thrombolytic therapy. Aim To develop a rapid latex-bead assay to detect streptokinase antibodies. Methods Sera were obtained from 16 patients presenting with acute myocardial infarction (MI) before treatment with streptokinase and 1 and 6 months post treatment, and from 100 controls. Sera were assayed for anti-streptokinase antibodies using a functional streptokinase-neutralising assay. Results Streptokinase-neutralising activity was low in controls (54±5U/ml) and patients prior to treatment (101±18), increasing to 2,110±823 and 1,017±169 at 1 and 6 months (mean±SEM). The latex assay had a sensitivity of 94% and a specificity of 93% for detecting individuals with >350U/ml of streptokinase resistance, which is sufficient to neutralise the drug clinically. Conclusions Estimation of streptokinase resistance using an enzyme immunoassay and a latex bead assay correlated well with serum neutralising activity. This assay can rapidly identify patients who have a high level of streptokinase-neutralising activity.     

Polymorphisms in genes related to folate and cobalamin metabolism and the associations with complex birth defects

OBJECTIVE: To investigate the associations between biomarkers and genetic variants involved in homocysteine metabolism and the risk of complex birth defects. METHODS: Total homocysteine (tHcy), folate, cobalamin, apo-transcobalamin (apo-TC) and apo-haptocorrin (apo-HC) were measured in the amniotic fluid of 82 women who were pregnant with a child having a complex birth defect, such as neural tube defect, cleft lip and/or palate, heart defect or omphalocele, and in 110 women pregnant with a non-malformed child. The determined genotypes of the child comprised of 5, 10-methylenetetrahydrofolate reductase (MTHFR 677C > T, 1298A > C), methionine synthase (MTR 2756A > G), methionine synthase reductase (MTRR 66A > G) and transcobalamin (TCN2 776C > G). Univariate and multivariate logistic regression analyses were performed. RESULTS: Significantly lower cobalamin and higher apo-TC, apo-HC, tHcy and folate concentrations were determined in amniotic fluids of cases compared with controls (p< or =0.001). Logistic regression analysis revealed that after adjustment for maternal age, children carrying the MTHFR 677T allele showed a four-fold increased risk of having a complex birth defect, OR (95% CI) = 4.0 (1.1-15.4). Other genotypes did not show significant associations. CONCLUSION: The MTHFR 677C > T polymorphism in conjunction with reduced folate- and/or cobalamin status may increase the risk of complex birth defects.