Cochlear Fibrosis after Vestibular Schwannoma Resection via the Middle Cranial Fossa Approach

OBJECTIVE

The aim of this study was to determine the incidence of cochlear fibrosis after vestibular schwannoma (VS) resection via middle cranial fossa (MCF) approach.

DESIGN

A retrospective case review was conducted.

SETTING

The review was conducted in a tertiary care academic medical center.

PARTICIPANTS

Patients who (1) underwent resection of VS via MCF approach between 2013 and 2018, (2) had complete pre- and post-audiometric testing, and (3) had clinical follow-up with magnetic resonance imaging (MRI) for at least 1 year after surgery were included.

MAIN OUTCOME MEASURE(S)

The main outcome of this study was cochlear fibrosis as assessed by MRI 1 year after surgery.

RESULTS

Fifty-one patients underwent VS resection via MCF technique during the study period. Of 31 patients with AAO-HNS class A or B preoperative hearing ability, 18 (58.0%) maintained class A, B, or C hearing postoperatively. Of 16 patients who lost hearing and had MRI 1 year after surgery, 11 (61.1%) had MRI evidence of fibrosis in at least some portion of the labyrinth and 4 (22.2%) showed evidence of cochlear fibrosis. Of 16 patients with preserved hearing and MRI 1 year after surgery, 4 (25%) had fibrosis in some portion of the labyrinth, with no fibrosis in the cochlea.

CONCLUSIONS

In patients who lose hearing during VS resection with the MCF approach, there is usually MRI evidence of fibrosis in the labyrinth 1 year after surgery. However, there is also, but less commonly, fibrosis involving the cochlea. It is unclear if this will affect the ability to insert a cochlear implant electrode array.

Critical role of mitochondrial aldehyde dehydrogenase 2 in acrolein sequestering in rat spinal cord injury

Lipid peroxidation-derived aldehydes, such as acrolein, the most reactive aldehyde, have emerged as key culprits in sustaining post-spinal cord injury (SCI) secondary pathologies leading to functional loss. Strong evidence suggests that mitochondrial aldehyde dehydrogenase-2 (ALDH2), a key oxidoreductase and powerful endogenous anti-aldehyde machinery, is likely important for protecting neurons from aldehydes-mediated degeneration. Using a rat model of spinal cord contusion injury and recently discovered ALDH2 activator (Alda-1), we planned to validate the aldehyde-clearing and neuroprotective role of ALDH2. Over an acute 2 day period post injury, we found that ALDH2 expression was significantly lowered post-SCI, but not so in rats given Alda-1. This lower enzymatic expression may be linked to heightened acrolein-ALDH2 adduction, which was revealed in co-immunoprecipitation experiments. We have also found that administration of Alda-1 to SCI rats significantly lowered acrolein in the spinal cord, and reduced cyst pathology. In addition, Alda-1 treatment also resulted in significant improvement of motor function and attenuated post-SCI mechanical hypersensitivity up to 28 days post-SCI. Finally, ALDH2 was found to play a critical role in in vitro protection of PC12 cells from acrolein exposure. It is expected that the outcome of this study will broaden and enhance anti-aldehyde strategies in combating post-SCI neurodegeneration and potentially bring treatment to millions of SCI victims. All animal work was approved by Purdue Animal Care and Use Committee (approval No. 1111000095) on January 1, 2021.

Aging- and Tumor-Mediated Increase in CD8+CD28- T Cells Might Impose a Strong Barrier to Success of Immunotherapy in Glioblastoma

Clinical use of various forms of immunotherapeutic drugs in glioblastoma (GBM), has highlighted severe T cell dysfunction such as exhaustion in GBM patients. However, reversing T cell exhaustion using immune checkpoint inhibitors in GBM clinical trials has not shown significant overall survival benefit. Phenotypically, CD8⁺ T cells with downregulated CD28 coreceptors, low CD27 expression, increased CD57 expression, and telomere shortening are classified as senescent T cells. These senescent T cells are normally seen as part of aging and also in many forms of solid cancers. Absence of CD28 on T cells leads to several functional irregularities including reduced TCR diversity, incomplete activation of T cells, and defects in Ag-induced proliferation. In the context of GBM, presence and/or function of these CD8⁺CD28^- T cells is unknown. In this clinical correlative study, we investigated the effect of aging as well as tumor microenvironment on CD8⁺ T cell phenotype as an indicator of its function in GBM patients. We systematically analyzed and describe a large population of CD8⁺CD28^- T cells in both the blood and tumor-infiltrating lymphocytes of GBM patients. We found that phenotypically these CD8⁺CD28^- T cells represent a distinct population compared with exhausted T cells. Comparative transcriptomic and pathway analysis of CD8⁺CD28^- T cell populations in GBM patients revealed that tumor microenvironment might be influencing several immune related pathways and thus further exaggerating the age associated immune dysfunction in this patient population.

C-67 Cognitive Function in an 8-Year-Old Girl with Gray Matter Heterotopia Without Evidence of Seizures

Objective

Heterotopia is a rare condition typically identified in the context of seizures. This case study presents a cognitive profile in a child with a history of heterotopia and hearing problems but without any known seizure history.

Method

An 8-year-old referred for evaluation by her neurologist due to concerns about persistent academic and social difficulties. Medical history was remarkable for small size, hearing problems, multiple pressure equalization tube placements, food allergies, and a left lateral ventricle gray matter heterotopia found on brain MRI. EEG was normal. Genetic testing found no dysmorphia. Developmental history was remarkable for delayed speech and early intervention, as well as social delays. She began receiving special education for learning disability and speech/language impairment in first grade.

Results

WISC-V IQ was Low Average and significantly lower than GAI. WMI was Below Average and PSI was Low. Language performance was variable. Visual scanning was Below Average. Verbal memory ranged from Below Average to Impaired, with worse performance on WRAML-2 Story Memory subtests. Attention and hyperactivity deficits were found on a continuous performance task. Executive function was Average to Above Average on phonemic fluency, category switching and Stroop tasks. BASC-3 parent ratings indicated greatest concerns in areas of atypicality, withdrawal, and adaptive skills. ABAS-3 indicated Low conceptual skills and Average to Low Average skills on other composites.

Conclusions

Aside from language deficits likely related to hearing problems, these findings indicated deficits in visual scanning, attention/hyperactivity, visually-based processing speed, and memory in the context of heterotopia without seizures. Social delays may be multifactorial.

Single Nucleotide Polymorphisms in Chemosensory Pathway Genes GNB3, TAS2R19, and TAS2R38 Are Associated with Chronic Rhinosinusitis

BACKGROUND

Chronic rhinosinusitis (CRS) is a multifaceted disease with a significant genetic component. The importance of taste receptor signaling has recently been highlighted in CRS; single nucleotide polymorphisms (SNPs) of bitter tastant-responsive G-protein-coupled receptors have been linked with CRS and with altered innate immune responses to multiple bacterially derived signals.

OBJECTIVE

To determine in CRS the frequency of six SNPs in genes with known bitter tastant signaling function.

METHODS

Genomic DNA was isolated from 74 CRS volunteers in West Virginia, and allele frequency was determined and compared with demographically matched data from the 1,000 Genomes database.

RESULTS

For two SNPs in a gene recently associated with bitterant signaling regulation, RGS21, there were no associations with CRS (although the frequency of the minor allele of RGS21, rs7528947, was seen to increase with increasing Lund-Mackay CT staging score). Two TAS2R bitter taste receptor gene variants (TAS2R19 rs10772420 and TAS2R38 rs713598), identified in prior CRS genetics studies, were found to have similar associations in this study.

CONCLUSION

Unique to our study is the establishment of an association between CRS in this patient population and GNB3 SNP rs5443, a variation in an established G protein component downstream of bitterant receptor signal transduction.

Efficacy of pre-operative stereotactic radiosurgery followed by surgical resection and correlative radiobiological analysis for patients with 1-4 brain metastases: study protocol for a phase II trial

BACKGROUND

Stereotactic radiosurgery (SRS) has emerged as a common adjuvant modality used with surgery for resectable brain metastases (BMs). However, the optimal sequence of the multi-modality therapy has not been established. The goal of the study is to evaluate 6-month local control utilizing pre-operative SRS followed by surgical resection for patients with 1-4 brain metastases.

METHODS

This prospective, single arm, phase II trial will recruit patients with up to 4 brain metastases and at least one resectable lesion. All lesions will be treated with SRS and symptomatic lesions will be resected within 1-4 days after SRS. Patients will be monitored for 6-month local control, in-brain progression free survival, distant in-brain failure, rate of leptomeningeal spread, radiation necrosis and overall survival. Additionally, we will also perform correlative radiobiological molecular studies to assess the effect of radiation dosing on the tumor tissue and clinical outcomes. We expect that pre-operative SRS to the gross tumor prior to surgical resection will improve local control and decrease leptomeningeal failure.

DISCUSSION

Our study is the second prospective trial to investigate the efficacy of pre-operative SRS in the treatment of multiple BMs. In addition, the correlative molecular studies will be the first to investigate early response of BMs at a cellular and genetic level in response to radiation doses and potentially provide molecular prognostic markers for local control and overall survival.

TRIAL REGISTRATION

Clinicaltrials.gov identifier: NCT03398694 (registration date: January 12, 2018).

Oxygen-Induced Consumptive Coagulopathy and its Enhancement by Lead Acetate

The exposure of rats to 100% oxygen at 1 atmosphere leads to a prolongation of prothrombin times and activated partial thromboplastin times. This development is associated with a consumption of factor XII, VIII, and VII activities and with the appearance of fibrin monomers and fibrinogen degradation products. Lead acetate enhances all oxygen-induced changes of the coagulation systems drastically. The O2 survival time of chicks which are naturally deficient in factor XII is greatly increased over that of rats and is not affected by lead acetate. Oxygen survival times of rats suffering from chronic respiratory disease (CRD) are also significantly increased when compared with normal rats. It appears that consumptive coagulopathy and disseminated intravascular coagulation are early events in oxygen exposure, and that their development is accelerated by lead ions.

Fibrinolysis, Fibrinogen and Factor XIII in New Born Infants

Fibrinolysis and the last stage of clotting were examined in 20 healthy infants on days 1-4 after birth. Plasminogen was constantly at half its normal level: 1.2-1.4 u/ml. The euglobulin lysis was increased only on day 1 in 50% of the cases. The mean values on days 1 and 4 showed a statistically significant difference: 0.45 ± 0.20 and 0.14 ± 0.05 (t = 2.1 p < 0.05). Fibrinogen was low or low normal at birth (mean values: 230 ± 57 mg%) but increased significantly in the next days reaching a mean of 293 ± 41 mg% on day 4 (t = 3.6 ρ < 0.001). Factor XIII was normal in all cases. Increased fibrinolysis in day 1 is probably due to a high level of activator at birth and the low plasminogen and fibrinogen are probably a consequence of the physiological „immaturity” of the liver.

Cost-effectiveness of Gene Expression Classifier Testing of Indeterminate Thyroid Nodules Utilizing a Real Cohort Comparator

Objective

To predict the cost-effectiveness of implementing routine gene expression classifier testing for thyroid nodules with indeterminate fine-needle aspiration cytology, by utilizing a real cohort of patients as a comparator.

Study Design

Cost-effectiveness analysis of a retrospective cohort compared with a simulated cohort.

Setting

Tertiary academic medical center.

Subjects and Methods

We reviewed the records of all patients who underwent ultrasound-guided fine-needle aspiration from 2010 to 2014 at a tertiary academic medical center. All patients with Bethesda class III or IV cytopathology had the details of their management catalogued over the subsequent 2 years of care. These patients were assigned to the standard-of-care arm of the study. We compared the third-party payer costs of care and the proportion of patients who underwent surgery with a simulated cohort who underwent gene expression classifier testing after an initial indeterminate fine-needle aspiration (molecular test arm).

Results

The cost of managing 1 nodule over 2 years was $2399 higher (range, $397-$4399) for the molecular test group than the standard of care group. The molecular test group had a 13.1% decrease (base parameters; range, 0.73%-45.09%) in the number of patients undergoing surgery.

Conclusion

When applied to a real cohort of patients, routine gene expression classifier is predicted to reduce the number of patients undergoing surgery but will increase cost of care. Cost-effectiveness is heavily dependent on prevalence of malignancy and gene expression classifier specificity.

Reversal of direct oral anticoagulants

An understanding of how to counteract the anticoagulant effect of direct oral anticoagulants is essential in the event of haemorrhage, emergency surgery and overdose. This review summarizes strategies for the reversal of direct oral anticoagulants, including the use of novel agents.

Co-expression of fibulin-5 and VEGF165 increases long-term patency of synthetic vascular grafts seeded with autologous endothelial cells

Small caliber synthetic vascular grafts are commonly used for bypass surgery and dialysis access sites but have high failure rates because of neointima formation and thrombosis. Seeding synthetic grafts with endothelial cells (ECs) provides a biocompatible surface that may prevent graft failure. However, EC detachment following exposure to blood flow still remains a major obstacle in the development of biosynthetic grafts. We tested the hypothesis that induced expression by the seeded EC, of vascular endothelial growth factor165 (VEGF165) and of fibulin-5, an extracellular matrix glycoprotein that has a crucial role in elastin fiber organization and increase EC adherence to surfaces, may improve long-term graft patency. Autologous ECs were isolated from venous segments, and were transduced with retroviral vectors expressing fibulin-5 and VEGF165. The modified cells were seeded on expanded polytetrafluoroethylene (ePTFE) grafts and implanted in a large animal model. Three months after transplantation, all grafts seeded with modified EC were patent on a selective angiography, whereas only a third of the control grafts were patent. Similar results were shown at 6 months. Thus, seeding ePTFE vascular grafts with genetically modified EC improved long-term small caliber graft patency. The biosynthetic grafts may provide a novel therapeutic modality for patients with peripheral vascular disease and patients requiring vascular access for hemodialysis.

Structured inquiry-based learning: Drosophila GAL4 enhancer trap characterization in an undergraduate laboratory course

This education article describes a modular laboratory exercise in which undergraduates use fruit flies to generate novel experimental data while learning to perform advanced molecular techniques.

We have developed and tested two linked but separable structured inquiry exercises using a set of Drosophila melanogaster GAL4 enhancer trap strains for an upper-level undergraduate laboratory methods course at Bucknell University. In the first, students learn to perform inverse PCR to identify the genomic location of the GAL4 insertion, using FlyBase to identify flanking sequences and the primary literature to synthesize current knowledge regarding the nearest gene. In the second, we cross each GAL4 strain to a UAS-CD8-GFP reporter strain, and students perform whole mount CNS dissection, immunohistochemistry, confocal imaging, and analysis of developmental expression patterns. We have found these exercises to be very effective in teaching the uses and limitations of PCR and antibody-based techniques as well as critical reading of the primary literature and scientific writing. Students appreciate the opportunity to apply what they learn by generating novel data of use to the wider research community.

Prevention of diseases after menopause

Women may expect to spend more than a third of their lives after menopause. Beginning in the sixth decade, many chronic diseases will begin to emerge, which will affect both the quality and quantity of a woman's life. Thus, the onset of menopause heralds an opportunity for prevention strategies to improve the quality of life and enhance longevity. Obesity, metabolic syndrome and diabetes, cardiovascular disease, osteoporosis and osteoarthritis, cognitive decline, dementia and depression, and cancer are the major diseases of concern. Prevention strategies at menopause have to begin with screening and careful assessment for risk factors, which should also include molecular and genetic diagnostics, as these become available. Identification of certain risks will then allow directed therapy. Evidence-based prevention for the diseases noted above include lifestyle management, cessation of smoking, curtailing excessive alcohol consumption, a healthy diet and moderate exercise, as well as mentally stimulating activities. Although the most recent publications from the follow-up studies of the Women's Health Initiative do not recommend menopause hormonal therapy as a prevention strategy, these conclusions may not be fully valid for midlife women, on the basis of the existing data. For healthy women aged 50-59 years, estrogen therapy decreases coronary heart disease and all-cause mortality; this interpretation is entirely consistent with results from other randomized, controlled trials and observational studies. Thus. as part of a comprehensive strategy to prevent chronic disease after menopause, menopausal hormone therapy, particularly estrogen therapy may be considered as part of the armamentarium.

Risks and benefits of hormone therapy: has medical dogma now been overturned?

BACKGROUND

In an integrated overview of the benefits and risks of menopausal hormone therapy (HT), the Women's Health Initiative (WHI) investigators have claimed that their 'findings … do not support use of this therapy for chronic disease prevention'. In an accompanying editorial, it was claimed that 'the WHI overturned medical dogma regarding menopausal [HT]'.

OBJECTIVES

To evaluate those claims.

METHODS

Epidemiological criteria of causation were applied to the evidence.

RESULTS

A 'global index' purporting to summarize the overall benefit versus the risk of HT was not valid, and it was biased. For coronary heart disease, an increased risk in users of estrogen plus progestogen (E + P), previously reported by the WHI, was not confirmed. The WHI study did not establish that E+ P increases the risk of breast cancer; the findings suggest that unopposed estrogen therapy (ET) does not increase the risk, and may even reduce it. The findings for stroke and pulmonary embolism were compatible with an increased risk, and among E+ P users there were credible reductions in the risk of colorectal and endometrial cancer. For E+ P and ET users, there were credible reductions in the risk of hip fracture. Under 'worst case' and 'best case' assumptions, the changes in the incidence of the outcomes attributable to HT were minor.

CONCLUSIONS

Over-interpretation and misrepresentation of the WHI findings have damaged the health and well-being of menopausal women by convincing them and their health professionals that the risks of HT outweigh the benefits.

Pharmacologic Manipulation of Emergence after Adenotonsillectomy for Pediatric Obstructive Sleep Apnea: A Prospective Controlled Study

Objectives:

1) Elucidate the factors affecting emergence from anesthesia after adenotonsillectomy for obstructive sleep apnea (OSA) in children. 2) Highlight the advantages of a standardized anesthetic protocol in controlling peri-operative events.

Methods:

A non-randomized, prospective, observational study (n = 64) was designed to examine the relationship between the severity of OSA, as determined by apnea-hypopnea index (AHI) and oxygen saturation (SpO2) nadir, and indices of recovery, including time to 1) emergence after surgery, 2) extubation following emergence, and 3) discharge from the post-anesthesia care unit. A standardized anesthetic protocol was used in all patients using doses of opioids that inversely correlated with OSA severity.

Results:

A paradoxical yet significant reduction in recovery time was observed among patients with severe OSA following surgery; this reflected in quicker emergence, accelerated extubation, and shortened postanesthesia care unit discharge times (analysis of variance, Tukey-Kramer post-hoc tests, P < 0.001) besides a reduction in adverse events. In addition, the relationship between polysomnography (PSG)-derived AHI and SpO2 nadir varied inversely with each of the recovery indices, as determined by a linear regression analysis (t-tests, P <0.001).

Conclusions:

Emergence from anesthesia after adenotonsillectomy can be controlled by a standardized anesthesia protocol using different combinations of sedation and analgesia. The severity of sleep apnea and hypoxemia do not independently appear to play a significant role in recovery from anesthesia. By using a standardized anesthetic protocol with diminishing doses of opioids with increasing severity of OSA, our results indicate a striking departure from previously observed findings relating to post-procedural respiratory complications following adenotonsillectomy.

Stimulating myocardial regeneration with periostin Peptide in large mammals improves function post-myocardial infarction but increases myocardial fibrosis

AIMS

Mammalian myocardium has a finite but limited capacity to regenerate. Experimentally stimulating proliferation of cardiomyocytes with extracellular regeneration factors like periostin enhances cardiac repair in rodents. The aim of this study was to develop a safe method for delivering regeneration factors to the heart and to test the functional and structural effects of periostin peptide treatment in a large animal model of myocardial infarction (MI).

METHODS AND RESULTS

We developed a controlled release system to deliver recombinant periostin peptide into the pericardial space. A single application of this method was performed two days after experimental MI in swine. Animals were randomly assigned to receive either saline or periostin peptide. Experimental groups were compared at baseline, day 2, 1 month and 3 months. Treatment with periostin peptide increased the EF from 31% to 41% and decreased by 22% the infarct size within 12 weeks. Periostin peptide-treated animals had newly formed myocardium strips within the infarct scar, leading to locally improved myocardial function. In addition the capillary density was increased in animals receiving periostin. However, periostin peptide treatment increased myocardial fibrosis in the remote region at one week and 12 weeks post-treatment.

CONCLUSION

Our study shows that myocardial regeneration through targeted peptides is possible. However, in the case of periostin the effects on cardiac fibrosis may limit its clinical application as a viable therapeutic strategy.

Is that a rodent in your luggage? A mixed method approach to describe bushmeat importation into the United States

Bushmeat, defined as meat derived from wild animals, is a potential source of zoonotic pathogens. Bushmeat from restricted animals is illegal to import into the United States under US federal regulations. We reviewed US Centers for Disease Control and Prevention (CDC) port of entry surveillance records from September 2005 through December 2010 and conducted focus group studies to describe trends in and reasons for bushmeat importation into the United States. In total, 543 confiscated bushmeat items were recorded. Half of the confiscated bushmeat items identified were rodents. Africa was the most frequent continent of origin. Seasonality was evident, with bushmeat confiscations peaking in late spring to early summer. Four times more bushmeat was confiscated during an enhanced surveillance period in June 2010 compared with the same period in previous years, suggesting that routine surveillance underestimated the amount of bushmeat detected at US Ports of Entry. Focus groups held in three major US cities revealed that bushmeat importation is a multifaceted issue. Longstanding cultural practices of hunting and eating bushmeat make it difficult for consumers to acknowledge potential health and ecologic risks. Also, US merchants selling African goods, including bushmeat, in their stores have caused confusion among importers as to whether importation is truly illegal. Enhancing routine surveillance for bushmeat and consistent enforcement of penalties at all ports of entry, along with health education aimed at bushmeat importers, might be useful to deter illegal importation.

A review of oscillating field stimulation to treat human spinal cord injury

OBJECTIVE

To report the results of use of a human oscillating field stimulator (OFS) in a phase 1 trial of 14 human patients with complete motor and sensory spinal cord injury.

METHODS

Entry criteria were complete spinal cord injury between C5 and T10 in patients 18-65 years old with no transection on magnetic resonance imaging. All patients received the National Acute Spinal Cord Injury Study III methylprednisolone protocol. Cord compression or instability was treated before entry. All patient injuries remained complete (based on American Spinal Cord Injury scoring) with no somatosensory evoked potentials (SSEPs) below the injury after surgery or for 48 hours. All patients were implanted with the OFS within 18 days. Patients were checked every 2 weeks after implantation. The OFS was explanted at 15 weeks. Independent neurologic examinations (American Spinal Cord Injury score, visual analog scale for pain, and SSEPs) were done at 6 weeks, 6 months, and 1 year. Statistical analyses were done by Wilcoxon rank sum test and analysis of variance (ANOVA).

RESULTS

There were no complications at insertion, and one wound infection occurred after explant for a 3.5% infection rate. One patient was lost to follow-up after 6 months. All 14 patients had a mean visual analog scale score of 8 at implant and 2 at 6 months, and 13 remained a mean score of 2 at 1 year. Mean improvement in light touch score at 1 year was 25.9 points (ANOVA, P < 0.001; Wilcoxon, P = 0.02). Mean improvement in pinprick score at 1 year was 15.2 points (ANOVA, P < 0.001; Wilcoxon, P = 0.02). Mean improvement in motor score was 6.9 (ANOVA, P < 0.01; Wilcoxon, P = 0.02). Of eight patients with cervical cord injuries, six had improvement in arm SSEPs, and one recovered a tibial SSEP. Of six patients with thoracic injuries, one recovered an abnormal lower SSEP.

CONCLUSIONS

Treatment of human spinal cord injury with an OFS is safe, reliable, and easy. Compared with National Acute Spinal Cord Injury Study III compliant paralyzed patients, our results suggest efficacy.

Interaction of mineral salts with the skin: a literature survey

There is growing scientific evidence that the health, well-being and the attractiveness of the skin are strongly influenced by nutrition. Consumers recognize this and have supported the creation of a global cosmeceuticals market estimated in 2010 at $27.2 billion. Early in 2011, the US Department of Health and Human Services and Department of Agriculture issued the Dietary Guidelines for Americans, 2010. Twelve vitamins and nine minerals were recognized as essential. The minerals include calcium, copper, iron, magnesium, phosphorus, selenium, zinc, potassium and sodium. Although the topical benefits of several minerals such as zinc, magnesium and iron are recognized and, in some cases, approved by the FDA, the topical benefits of the others to the skin are largely unexplored and unexploited. This review attempts to summarize what has been published in the literature on the interactions of the eight of the nine essential elements with the skin.

Correlation between cord insertion type and superficial choriovasculature in diamniotic-monochorionic twin placentas

BACKGROUND

Non-central cord insertion has been associated with diminished chorionic vascular distribution in singleton placentas. The choriovascular correlates of peripheral cord insertion in diamniotic-monochorionic twin placentas remain undetermined.

AIM

To study the association between type of cord insertion and choriovascular distribution of both twin territories in diamniotic-monochorionic twin placentas.

DESIGN

A prospective cohort of 138 monochorionic placentas was examined at Women and Infants Hospital between 2009 and early 2011. Thirty-five cases (25%), including disrupted placentas, placentas from higher order multiples and placentas from pregnancies complicated by twin-to-twin transfusion syndrome, were excluded. The correlation between cord insertion type and superficial choriovascular distribution was studied in the remaining 103 dye-injected diamniotic-monochorionic placentas. Cord insertion was categorized as paracentral, marginal or velamentous. The choriovascular distribution of each individual twin territory was assessed by analysis of number and density (number per surface area) of perforating chorionic arteries (PCA).

RESULTS

In contrast with singleton placentas, there was no correlation between cord insertion type and a twin's own choriovascular distribution in diamniotic-monochorionic placentas. However, a strong correlation was found between the choriovascular distribution of one twin and the cord insertion type of the opposite twin. For a twin with paracentral or marginal cord insertion, the PCA density was significantly higher if the co-twin had a velamentous cord insertion than if the co-twin had a paracentral cord insertion (P < 0.001 and P < 0.05, respectively). Similarly, the PCA density of a twin with velamentous cord insertion tended to be higher if the co-twin had a velamentous, rather than paracentral cord insertion (P = 0.09).

CONCLUSIONS

This is the first study to suggest that in diamniotic-monochorionic twin gestations, the choriovascular architecture correlates with the cord insertion type of the co-twin. In general, velamentous cord insertion is associated with expanded choriovascular distribution in the opposite twin territory. Our observations may reflect novel manifestations of twin interdependence in monochorionic pregnancies.

Placental intravascular organisms: a case report

Ascending amniotic fluid bacterial infection is a cause of perinatal morbidity and mortality. A diagnosis of amniotic cavity infection can be inferred by documenting maternal (acute chorioamnionitis) and/or fetal (chorionic plate vasculitis; umbilical vasculitis/funisitis) inflammatory response. A definitive diagnosis of intrauterine/neonatal sepsis as a cause of stillbirth requires positive blood cultures obtained at postmortem examination. However, if postmortem examination is not performed, acute chorioamnionitis with/without fetal inflammatory response cannot be classified as a cause of demise. We present a case of intrauterine demise associated with acute chorioamnionitis, villitis, and intervillositis of the placenta. Although postmortem examination was denied, a conclusive diagnosis of intrauterine sepsis could be rendered by demonstration of gram-positive cocci within fetal vessels of umbilical cord, chorionic plate, and stem villi. This report highlights the importance of identification of placental intravascular organisms as unequivocal evidence of fetal sepsis, especially in cases where cultures cannot be obtained.