Impact of tracheostomies on the long-term survival of patients with trisomy 13 syndrome

In this retrospective cohort study, we investigated the impact of tracheostomies on the long-term survival of children with trisomy 13 syndrome at a Japanese tertiary pediatric center. We compared survival and survival to discharge rates between patients who underwent tracheostomies during their NICU stays (T group, n = 8) and those who did not (non-T group, n = 11). A total of 19 patients enrolled. Median survival in all patients was 673 (266-1535) days. Significant differences in the 1-, 2-, and 3-year survival rates were found between the T and the non-T groups (100% vs. 46%, p = 0.018; 88% vs. 18%, p = 0.006; 63% vs. 9%, p = 0.041, respectively). The survival to discharge rate was higher in the T versus non-T group (75% vs. 45%, p = 0.352). This study highlights a significantly higher long-term survival of patients with trisomy 13 syndrome who underwent tracheostomies during their NICU stays.

Sustained lower bilirubin-binding affinity of albumin in extremely preterm infants

BACKGROUND

Elevated albumin-free or unbound bilirubin (UB) levels beyond the first week of life have been associated with the development of bilirubin encephalopathy in preterm infants. However, the mechanism(s) that induces this prolonged unbound bilirubinemia has remained unknown. We hypothesized that it may due to a sustained lower bilirubin-binding affinity of albumin in extremely premature infants.

METHODS

Twenty-two very preterm infants born at 28-31 weeks' gestational age (GA) (VPT Group) and 21 extremely preterm infants born at 22-27 weeks' GA (EPT Group) were retrospectively studied. On days 14, 21, and 28, bilirubin-binding affinity of albumin was assessed by calculating of the UB/total bilirubin ratio, bilirubin-albumin molar ratio (BAMR), and binding affinity (Ka).

RESULTS

On days 14, 21, and 28, significantly higher UB/total bilirubin ratios were found in the EPT than in the VPT Group. Although BAMRs were comparable, significantly lower Ka values on days 14, 21, and 28 were observed in the EPT than those in the VPT Group (56.1 vs. 70.9 L/μmol, p < 0.001; 55.2 vs. 74.7 L/μmol, p < 0.001; 53.0 vs. 86.5 L/μmol, p < 0.001, respectively).

CONCLUSIONS

EPT infants have a sustained lower bilirubin-binding affinity of albumin beyond the first week of life.

IMPACT

Bilirubin encephalopathy is still reported in extremely preterm (EPT) infants. EPT infants often have prolonged unbound bilirubinemia beyond the first week of life. Sustained lower bilirubin-binding affinity of albumin, regardless of the bilirubin-albumin molar ratio (BAMR), is observed in EPT infants. BAMRs should not be used as a surrogate marker of unbound bilirubinemia, especially in EPT infants at a later postnatal period.

Time-Fixed Glucose Oxidase-Peroxidase Method for Measurement of Serum Unbound Bilirubin Levels

BACKGROUND

In the original glucose oxidase-peroxidase (GOD-POD) protocol, the time required to decrease the initial total bilirubin (TB) level by 20% is used for unbound bilirubin (UB) calculation. However, it needs to continuously monitor the TB levels by spectrometry.

METHODS

Here, we hypothesized that the TB decrease during fixed time periods can also be used to extrapolate UB values (fixed-time protocol). Serum UB levels measured by the different protocols were compared using 10 newborn serum samples.

RESULTS

Serum UB levels determined using the fixed-time protocol, especially using periods of 10 - 40 seconds, were strongly correlated with those determined using the original protocol (coefficient of determination > 0.9). The fixed-time protocol, using periods of 20 - 60 seconds, showed the high measurement precision (coefficient of variation < 5%).

CONCLUSIONS

The fixed-time protocol, using periods of 20 - 40 seconds, can help determine serum UB levels as effectively as the original protocol.

Improving survival in patients with trisomy 18

The effects of medical and surgical interventions on the survival of patients with trisomy 18 have been reported, leading to changes in perinatal management and decision-making. However, few studies have fully reported the recent changes in survival and treatment of trisomy 18. We examined how treatment and survival of patients with trisomy 18 have changed over a decade in a Japanese pediatric tertiary referral center. This retrospective cohort study included patients with trisomy 18 who were admitted within the first 7 days of life at the Hyogo Prefectural Kobe Children's Hospital between 2008 and 2017. The patients were divided into early period (EP) and late period (LP) groups based on the birth year of 2008-2012 and 2013-2017, respectively. Changes in treatment and survival rates were compared between the two groups. A total of 56 patients were studied (29 in the EP group and 27 in the LP group). One-year survival rates were 34.5% and 59.3% in the EP and LP groups, respectively. The survival to discharge rate significantly increased from 27.6% in the EP group to 81.5% in the LP group (p < 0.001). The proportion of patients receiving surgery, especially for congenital heart defects, significantly increased from 59% in the EP group to 96% in the LP group (p = 0.001). In our single-center study, survival and survival to discharge were significantly improved in patients with trisomy 18, probably because of increased rate of surgical interventions. These findings may facilitate better decision-making by patients' families and healthcare providers.

Improvement of oral hypofunction by a comprehensive oral and physical exercise programme including textured lunch gatherings

The deterioration of oral function to a state of oral hypofunction (OHF) is reportedly associated with malnutrition and frailty. Thus, we Investigated the association of OHF with physical characteristics and function and test the effects of a programme including comprehensive oral and physical exercises and textured lunch gatherings (COPE-TeL programme) on oral and physical function in older adults with OHF. Eighty-six community-dwelling older adults were randomly assigned into control (n = 43) or intervention (n = 43) groups. The participants were further divided into OHF and normal oral function (NOF) sub-groups based on initial oral examinations. The intervention group participated in the 12-week COPE-TeL programme, while the control group performed the physical exercise regimen only. The differences in measured variables for physical and oral function between the OHF and NOF groups were statistically tested, and changes in the proportion of participants with OHF were examined. Physical function, such as hand grip strength and walking speed, was significantly lower in the OHF group at the initial assessment. The proportion of participants with OHF was 56% in the intervention group and 67% in the control group before the trial, which became significantly reduced after completing the COPE-TeL programme in the intervention group (26%, P = .002), but not in the controls (61%, P = .549). Older adults with OHF may have diminished physical function. The COPE-TeL programme of oral and physical exercises along with textured lunch gatherings may be effective for older adults with OHF.

Positive Effects of "Textured Lunches" Gatherings and Oral Exercises Combined with Physical Exercises on Oral and Physical Function in Older Individuals: A Cluster Randomized Controlled Trial

OBJECTIVES

Proper nutrition and physical exercises are essential to prevent frailty in older adults. Proper masticatory performance and oral function may influence on physical activities as well since the mouth is the entrance of nutrition and digestion. Thus, the present study aimed to test the combined program of specially devised lunch gatherings containing textured foods with oral and physical exercises on the improvement of oral and physical function in community-dwelling older adults.

DESIGN

A Cluster randomized controlled trial; Setting and Participants: Eighty-six community-dwelling older adults in Daito city, Japan, were randomly assigned into control (n = 43) or intervention (n = 43) groups.

INTERVENTION

The control group performed the physical exercise regimen only. The intervention group participated in a 12-week physical and oral exercise program and ate a so-called "munchy lunch" that introduced textured foods with proper nutrients together after performing the physical exercise twice a week following brief dietary instruction at the intervention onset. Physical training and lunch gatherings were held at local public centers.

MEASUREMENTS

The differences in measured variables for physical and oral function between baseline and 12 weeks of intervention were statistically tested.

RESULTS

Oral function as measured by tongue pressure increased significantly in the intervention group (p=0.031), but not in the control group. Physical properties and activities, including body fat percentage and results of the timed up and go test, decreased more significantly in the intervention group than in controls (p<0.05).

CONCLUSIONS

Our findings suggest that a combined program of textured lunch gatherings with oral and physical exercises may improve physical and oral function as a preventative approach for frailty in community-dwelling older adults.

An anatomical study of the levator veli palatini and superior constrictor with special reference to their nerve supply

We dissected 50 head halves of 25 Japanese cadavers (10 males, 15 females) to investigate the innervations of the levator veli palatini (LVP) and superior constrictor pharyngis. The branches supplying the LVP were classified into the following three types according to their origins: supplying branches that originated from the pharyngeal branch of the glossopharyngeal nerve (type I, four sides, 8%), branches that originated from a communicating branch between the pharyngeal branches of the glossopharyngeal and vagus nerves (type II, 36 sides, 72%), and those that originated from the pharyngeal branch of the vagus nerve (type III, 10 sides, 20%). In previous studies, supplying branches of type I were seldom described. Regarding the innervation of the superior constrictor, some variations were observed, and we consider it likely that there is a close relationship between these variations and the type of innervation of the LVP.

Glucose-6-phosphate dehydrogenase in rat lung alveolar epithelial cells. An ultrastructural enzyme-cytochemical study

Glucose-6-phosphate dehydrogenase (G6PD) is the key enzyme of the pentose phosphate pathway in carbohydrate metabolism, and it plays an important role in cell proliferation and antioxidant regulation within cells in various organs. Although marked cell proliferation and oxidant/antioxidant metabolism occur in lung alveolar epithelial cells, definite data has been lacking as to whether cytochemically detectable G6PD is present in alveolar epithelial cells. The distribution pattern of G6PD within these cells, if it is present, is also unknown. The purpose of the present study was to investigate the subcellular localization of G6PD in alveolar cells in the rat lung using a newly-developed enzyme-cytochemistry (copper-ferrocyanide) method. Type I cells and stromal endothelia and fibroblasts showed no activities. Electron-dense precipitates indicating G6PD activity were clearly visible in the cytoplasm and on the cytosolic side of the endoplasmic reticulum of type II alveolar epithelial cells. The cytochemical controls ensured specific detection of enzyme activity. This enzyme may play a role in airway defense by delivering substances for cell proliferation and antioxidant forces, thus maintaining the airway architecture.

Hofbauer cell activation and its increased glucose-6-phosphate dehydrogenase activity in second trimester-spontaneous abortion: an ultrastructural dual staining enzyme-cytochemical study

PROBLEM

While activated/phagocytosing phagocytes infiltrating to the chorioamnion are considered to be one of the causal agents of preterm labor onset, whether placental villous macrophages (Hofbauer cells) are activated/phagocytosing in this condition is not known.

METHOD OF STUDY

We concomitantly localized two important phagocytosis-related enzymes, acid phosphatase (ACP) and glucose-6-phosphate dehydrogenase (G6PD), in Hofbauer cells in second trimester placental villi, and compared them with those from infection-related second trimester-spontaneous abortion (miscarriage) placentas.

RESULTS

There were two types of Hofbauer cells. The first cells exhibited ACP stainings confined to the lysosomes, suggesting that they are dormant/non-activated cells. Approximately two-thirds of these cells showed weak G6PD labeling on the cytosolic side of endoplasmic reticula, and G6PD labeling was hardly recognizable in the remaining one-third. The second cells, possessing large phagosomes, showed marked ACP labeling in the phagosomes, suggesting that they are activated/phagocytosing cells. All these cells exhibited G6PD labeling, and in 'bursting cells' (possibly hyperactivated cells) G6PD deposits were marked. The percentage of activated cells in miscarriage placentas was significantly higher (44.8 +/- 6.0%) than that in gestational age-matched controls (17.4 +/- 5.3%).

CONCLUSIONS

These observations indicated that (1) G6PD activity increased in activated/phagocytosing Hofbauer cells, and (2) the percentage of phagocytosing cells increased in infection-related miscarriage placentas. Hofbauer activation and G6PD may play an role in the pathogenesis/pathophysiology of preterm labor onset.

Umbilical cord pseudocyst in a fetus with trisomy 18

An umbilical cord pseudocyst was detected in the 28th week of gestation in a fetus complicated with growth restriction and polyhydramnios. The combination of cord pseudocysts, growth restriction, and polyhydramnios prompted us to perform a detailed ultrasonographic examination (gray scale and three-dimensional), which revealed the presence of micrognathia, overlapping fingers, and congenital heart defects, features characteristic of trisomy 18. Karyotyping confirmed a diagnosis of trisomy 18. After spontaneous labor onset, the infant was delivered at 31 weeks of gestation, and died soon after delivery. An umbilical cord pseudocyst is a good marker for the prenatal detection of trisomy 18.

Chorion laeve trophoblasts of preeclamptic fetal membranes: histochemically detectable enzyme activities do not change at a subcellular level

We examined the subcellular localization of ADP-degrading activity and cytochrome c oxidase (CCO) activity in chorion laeve trophoblasts from term and near term human fetal membranes, and compared them with those from severe preeclamptic fetal membranes. The methods used for the detection of enzyme activities were the lead nitrate method for ADP-degrading activity and the diaminobenzidine method for CCO. Precipitates indicative of ADP-degrading activity were visible on surface microvillous plasma membranes of chorion laeve trophoblasts both from normal and preeclamptic fetal membranes. The intensity and distribution patterns were the same in the normal and preeclamptic subjects. CCO labeling was visible in almost all laeve trophoblastic mitochondria both in normal and preeclamptic cases. Previously, we demonstrated that in preeclamptic villous trophoblasts there were decreases in ADP-degrading activity and the presence of CCO-negative mitochondria, which were proposed to lead to dysfunction of each villous trophoblast, and finally to placental insufficiency in preeclampsia. Reductions or changes in enzyme intensities/distribution patterns, which are characteristic features of preeclamptic villous trophoblasts, were absent in chorion laeve trophoblasts in preeclampsia. These results suggest that in preeclampsia there are no, or at least less severe, abnormalities in the enzyme activities of chorion laeve trophoblasts, compared with villous trophoblasts, as far as enzyme-histochemically detectable enzymes are concerned.

Gene expression induced by BO-653, probucol and BHQ in human endothelial cells

2, 3-Dihydro-5-hydroxy-2, 2-dipentyl-4, 6-di-tert-butylbenzofuran (BO-653) and probucol, which act as radical scavenging antioxidants, were developed as anti-atherosclerotic medicines. In order to investigate the effect of these antioxidants on cell functions, we analyzed their ability to regulate gene expression in cultured human umbilical vein endothelial cells (HUVECs) using an oligonucleotide chip. Among 6,416 genes, 17 genes including those encoding mitochondrial proteins and proteins related to oxidative stress response were induced more than 3 fold by BO-653, probucol and tert-butylated hydroquinone (BHO). On the other hand, genes of three subunits of proteasome (PSMA2, PSMA3, PSMA4) were down-regulated by these antioxidants. A gene of cytochrome P-450 1A1 isozyme, a drug-metabolizing phase I enzyme, was expressed only by BHQ treatment. These results suggested that anti-atherogenic antioxidants affected gene expression in HUVECs by which they might regulate cell functions against oxidative stress.

Liver dysfunction in late pregnancy: cytomegalovirus-induced hepatitis or the HELLP syndrome?

A 27-year-old primiparous preeclamptic woman developed a skin rash in late pregnancy and was persistently febrile for 10 days after giving birth. Blood tests suggested that she developed the HELLP syndrome and had concomitant cytomegalovirus (CMV) infection. Hemolysis, slightly impaired liver function, and thrombocytopenia were explainable by either only the CMV infection or only the HELLP syndrome. A literature review of a limited number of such cases and our case suggests that laboratory data in patients with CMV infection can mimic those of the HELLP syndrome. Thus, it may be important to consider CMV infection as a possible cause of abnormal laboratory data similar to the HELLP syndrome.

In vivo complex formation of oxidized alpha(1)-antitrypsin and LDL

An inactivated form of alpha(1)-antitrypsin (AT) and LDL coelutes in gel permeation chromatography. To characterize and to quantify the amount of this fraction of AT, a monoclonal antibody was established against chloramine T-oxidized AT and named OxAT-4. OxAT-4 recognized the oxidatively modified AT, including hexylaldehyde- or 4-hydroxy-2-nonenal-modified AT, but neither normal active AT nor trypsin/AT complex. Comigration of apoB and oxidized AT was demonstrated by Western blotting analysis of AT-LDL by means of anti-apoB monoclonal antibody and OxAT-4. A complex of oxidized AT and LDL (AT-LDL) was isolated from human plasma LDL by affinity column with an OxAT-4 antibody-coated carrier. AT-LDL was degraded 4 times more effectively by mouse peritoneal macrophages, but this was not mediated by scavenger receptor class A type I. Localization of AT-LDL was detected in human atherosclerotic lesions of the coronary artery, but distribution of it was not completely identical to that of macrophages. In situ hybridization revealed AT expression by macrophages, which were present in intimal layers of the coronary artery. From these findings, we concluded that AT is produced and oxidized by macrophages, then attached to LDL in the intimal layer of the arterial wall. Although AT-LDL that escapes into the blood stream can be cleared by hepatocytes, the remaining AT-LDL may be taken up by macrophages and contribute to the lipid accumulation in arterial wall cells as the early stage of atherogenesis.

Immuno-electron microscopic localization of endothelial nitric oxide synthase in human placental terminal villous trophoblasts-normal and pre-eclamptic pregnancy

We demonstrated the subcellular localization of endothelial nitric oxide synthase (eNOS) in human placental terminal villous trophoblasts at near term period, and compared the distribution pattern with that in pre-eclamptic trophoblasts, using immunogold electron microscopy. Immunolabelling for eNOS was visible markedly in the syncytial microvilli and syncytial cytoplasm. Semiquantitative analysis showed that the concentration and the distribution pattern of gold particles for eNOS did not significantly differ between normal and pre-eclamptic placental trophoblasts. These results indicated that syncytiotrophoblastic microvilli and cytoplasm were the subcellular localization sites of syncytium-derived eNOS in terminal villi, and that there were no significant differences in this eNOS subcellular distribution pattern between normal and pre-eclamptic syncytiotrophoblasts in regard to immunohistochemically detectable eNOS.

Visually guided facial actions in rhesus monkeys

We trained 2 monkeys to display facial actions in response to corresponding arbitrary visual cues. Each monkey executed the task successfully, and each displayed two different facial actions corresponding to either hand-sign or color cues. More than 90% of the responses were correct for each monkey. These results provide evidence that monkeys can execute facial actions in response to conditioned visual cues in the absence of social context. These data suggest that facial actions of monkeys are flexible enough for use in further laboratory investigations--for example, in studies on the neural mechanisms underlying the execution of actions.

Relative pitch perception in Japanese monkeys (Macaca fuscata)

To investigate whether monkeys perceive relative pitch, the author trained 3 Japanese monkeys (Macaca fuscata) to detect changes from rising to falling contours of 3-tone sequences. Tone sequences were presented serially with transposition, so monkeys were urged to attend to cues other than the absolute frequency of a component tone. Results from probe tests with novel sequences showed that monkeys discriminated by the relative pitch when the frequency ranges of sequences were within the training range, showing a similar tendency as birds in previous studies (e.g., S. H. Hulse, J. Cynx, & J. Humpal, 1984).

Object discrimination learning in aged Japanese monkeys

The authors investigated the behavioral aging effects of Japanese macaques in 3 object discrimination learning tasks: learning-set (LS) formation, go/no-go discrimination learning, and multiple discrimination reversals. Aged monkeys showed deteriorated performance in these tasks compared with younger controls. Hypothesis analysis of LS showed that aged monkeys had difficulty learning the lose-shift component of the hypothesis win-stay-lose-shift with respect to object. Deficits in go/no-go successive discrimination were clear in no-go trials only in the first 2 pairs of 5 tasks. Performance of aged monkeys was severely disturbed from a chance to criterion level in discrimination reversals. These results are attributed not only to increased tendency for perseveration but also to difficulty in associating the reward and the object in aged monkeys and may be related to the decline in the functions of the ventral frontal cortex.

Prenatal MRI in a fetus with a giant neck hemangioma: a case report

We report a fetus with a giant neck hemangioma which was examined by MRI in utero. The initial diagnosis was made by ultrasonography. The sonolucent aspect of the mass, together with the presence of pulsating Doppler flow signals, was highly suggestive of a fetal hemangioma. In late pregnancy, fetal MRI revealed the location, size and characteristics of the neck tumor. Following prenatal corticosteroid treatment and premature delivery of the pregnancy due to fetal cardiac failure, the newborn received angiography and coil embolization of the tumor vessels. Despite vigorous treatments, the newborn died 12 h after birth. Evaluation of a fetal neck hemangioma by MRI is recommended late in pregnancy for precise information on the tumor and adjacent organs since the image is valuable for planning optimal perinatal treatment.

Japanese monkeys perceive sensory consonance of chords

Consonance/dissonance affects human perception of chords from early stages of development [e.g., Schellenberg and Trainor, J. Acoust. Soc. Am. 100, 3321-3328 (1996)]. To examine whether consonance has some role in audition of nonhumans, three Japanese monkeys (Macaca fuscata) were trained to discriminate simultaneous two-tone complexes (chords). The task was serial discrimination (AX procedure) with repetitive presentation of background stimuli. Each tone in a chord was comprised of six harmonics, and chords with complex ratios of fundamental frequency (e.g., frequency ratio of 8:15 in major seventh) resulted in dissonance. The chords were transposed for each presentation to make monkeys attend to cues other than the absolute frequency of a component tone. Monkeys were initially trained to detect changes from consonant (octave) to dissonant (major seventh). Following the successful acquisition of the task, transfer tests with novel chords were conducted. In these transfer tests, the performances with detecting changes from consonant to dissonant chords (perfect fifth to major seventh; perfect fourth to major seventh) were better than those with detecting reverse changes. These results suggested that the consonance of chords affected the performances of monkeys.

Comparative changes in uterine artery blood flow waveforms in singleton and twin pregnancies

We prospectively studied 99 women with uncomplicated singleton pregnancies and 24 women with uncomplicated twin pregnancies to examine the effect of the location of the placenta on the pulsatility index (PI) in the uterine arteries in twin pregnancies and to compare singleton and twin pregnancies with regard to changes in the PI of uterine arteries over the course of the pregnancy. The flow velocity waveforms in both the right and left parametrial uterine arteries were recorded longitudinally at 2-week intervals from a gestational age of 19 weeks until delivery. The location of the placenta was determined by real-time ultrasonography at 18-20 weeks of gestation to determine which uterine artery was the ipsilateral artery. In both the ipsilateral and contralateral uterine arteries, the PI exhibited a steady decrease toward term in singleton pregnancies. In twin pregnancies, the PI exhibited a steady decrease until 27 weeks of gestation and remained unchanged thereafter. The PI in the ipsilateral artery was consistently lower than that in the contralateral artery in singleton as well as twin pregnancies. The mean values of PI of the ipsilateral and contralateral uterine arteries of twin pregnancies was consistently lower than that of singleton pregnancies at any gestational week. These results suggest that the ipsilateral uterine artery contributes more to placental perfusion than does the contralateral uterine artery in twin as well as in singleton pregnancies. Twin pregnancies differed from singleton pregnancies with respect to changes in PI in the uterine artery according to gestational age. The PI of uterine arteries declined more rapidly and reached a plateau earlier in twin than in singleton pregnancies.

Relation between gestational thrombocytopenia and the syndrome of hemolysis, elevated liver enzymes, and low platelet count (HELLP syndrome)

OBJECTIVE

To define the clinical features of gestational thrombocytopenia and to determine its relationship to the syndrome of hemolysis, elevated liver enzymes, and low platelet count (HELLP syndrome).

STUDY DESIGN

Retrospective cohort study. We reviewed the records of 24 women with gestational thrombocytopenia among 637 nonpreeclamptic women who had serial determinations of the platelet count during pregnancy between 1992 and 1995. Gestational thrombocytopenia was defined as an antenatal gradual decline in the platelet count to <150 x 10(9)/l in nonpreeclamptic women. The control group consisted of 213 nonpreeclamptic women whose platelet counts were > or = 150 x 10(9)/l at -3 to 0 days from delivery and in whom the perinatal serum level of aspartate transaminase (AST) had been determined.

RESULTS

The platelet count decreased gradually, from 210+/-31 x 10(9)/l at < 13 weeks' gestation to 127+/-24 x 10(9)/l at -3 to 0 days from delivery, in the 24 women with gestational thrombocytopenia. The platelet count was 251+/-62 x 10(9)/l at -3 to 0 days from delivery in the 213 control women. The serum level of AST was elevated perinatally in 5 (21%) of 24 women with gestational thrombocytopenia compared with 6 (2.8%) of the 213 control subjects (p < 0.001). There had been 28 previous term or near-term pregnancies among 17 women with gestational thrombocytopenia, 14 of which were complicated by gestational thrombocytopenia or a decline in the platelet count by > 50 x 10(9)/l; 1 pregnancy was associated with the features typical of the HELLP syndrome.

CONCLUSION

Gestational thrombocytopenia may be a risk factor for the development of the HELLP syndrome and is likely to recur in subsequent pregnancies.

Severe hypoproteinemia in a fetus after pleuro-amniotic shunts with double-basket catheters for treatment of chylothorax

The prognosis of a fetus with hydrothorax at mid-trimester is extremely poor. We encountered a fetus who developed bilateral chylothoraxes at 23 weeks of gestation. Bilateral pleuroamniotic shunts with double-basket catheters were successfully installed at 25 weeks of gestation. Hydrothorax did not recur in this fetus. After the shunting, however, polyhydroamnios, fetal hypoproteinemia, and placental edema developed, and the hydrops worsened. The drainage of the fetal pleural effusion into the amniotic cavity was believed to have contributed to these complications. The infant, born at 29 weeks of gestation, died of cardiac failure and pulmonary hypoplasia. Thus, the shunts did not ameliorate the adverse conditions in this patient.

Emergency cervical cerclage: relation between its success, preoperative serum level of C-reactive protein and WBC count, and degree of cervical dilatation

OBJECTIVE

To assess the relation between the preoperative serum level of C-reactive protein (CRP) and the WBC count and the efficacy of emergency cervical cerclage.

STUDY DESIGN

We retrospectively reviewed the medical records of 17 women (16 singleton pregnancies and 1 twin pregnancy) who underwent emergency cervical cerclage (McDonald technique) between 21 and 26 weeks of gestation. The uterine cervix was dilated >/=3.0 cm and the intact (not ruptured) fetal membranes were visible or protruded into the vagina in all patients. The serum level of CRP and the WBC count were determined preoperatively and postoperatively. Emergency cervical cerclage was considered successful if delivery occurred >/=14 days after the procedure.

RESULTS

Emergency cervical cerclage was successful in 12 women, including the woman with a twin pregnancy, but failed in 5 women. The preoperative serum level of CRP and the WBC count were significantly lower and dilatation of the cervix was significantly less in the success group than in the failure group. Cerclage was successful in all eight patients with cervical dilatation </=4.0 cm, but in only 4 of 9 patients with cervical dilatation >4.0 cm (p < 0. 05). Cerclage was successful in all 11 women with a preoperative serum level of CRP </=4.0 mg/dl and a WBC count </=14,000/ microl compared with 1 of 6 women with either a CRP level >4.0 mg/dl or a WBC count >14,000/ microl (p < 0.01).

CONCLUSION

A preoperative CRP value </=4.0 mg/dl, a WBC count </=14,000/ microl, and cervical dilatation </=4.0 cm were significantly associated with prolongation of pregnancy after emergency cervical cerclage.

The effect of marker frequency disparity on the discrimination of gap duration in monkeys

Duration-discrimination thresholds of the silent interval (gap) between two successive tones (markers) were measured in four Japanese monkeys. The task was serial discrimination, and monkeys were required to release the lever when the gap duration decreased from 200 ms. Monkeys successfully acquired the task, and gap thresholds of monkeys were revealed to be larger than previous data with human subjects. Gap thresholds were not affected by marker frequency when the two markers were identical in frequency, though the thresholds increased when large frequency differences existed between markers. The effect of marker frequency disparity on gap thresholds in monkeys is discussed in terms of the difficulty in integrating information from discrete frequency channels.

Uterine leiomyoma in pregnancy: its influence on obstetric performance

OBJECTIVE

To assess the effects of uterine leiomyoma on obstetrical performance.

METHODS

We reviewed the medical records of 102 women with singleton pregnancies who were found ultrasonographically to have uterine leiomyomas during the first half of their pregnancy and who gave birth at our hospital at > or = 22 weeks of gestation between January 1990 and December 1997.

RESULTS

The 102 women gave birth to 101 healthy infants, weighing 2,974 +/- 579 g at 38.8 +/- 2.6 weeks of pregnancy. One woman experienced an unexplained antepartum fetal death at 24 weeks of gestation. Bleeding at the first trimester occurred in 16% of the women. Pain localized in the lower abdomen and requiring relief occurred in 28% of the women during the first or second trimester. Tocolytic treatment was required in 25% of the pregnancies, and preterm delivery occurred in 12% thereof. A cesarean section was performed in 39% of the pregnancies. Bleeding > or = 500 ml occurred at delivery in 48% of the cases. The largest fibroid, > 6 cm in diameter, which was seen in 51 women, was associated with higher frequencies of tocolytic treatment (41%), preterm delivery (24%), bleeding > or = 500 ml at delivery (59%), and cesarean delivery (51%). In 76 women (75%) who attempted vaginal delivery, the obstetrical outcome was comparable to that of 115 control women who were matched regarding age, parity, and gestational week.

CONCLUSIONS

Although pain in the lower abdomen, the requirement of tocolytic treatment, preterm delivery, and cesarean delivery were common, the neonatal outcome was fairly good in women with uterine leiomyomas. The present data might be encouraging to pregnant women with uterine leiomyomas.

Fetus with long QT syndrome manifested by tachyarrhythmia: a case report

We encountered a fetus who exhibited transient (at most 30 s), repeated episodes of tachyarrhythmia (240 bpm). This female neonate was born at 36 weeks of gestation and showed a markedly prolonged QT interval and transient, repeated episodes of polymorphic ventricular tachycardia. Congenital long QT syndrome was diagnosed. Retrospective analysis of the videotape showing fetal cardiac movement revealed that atrio-ventricular dissociation was present prenatally and thus, the fetal tachyarrhythmia was due to ventricular tachycardia. To our knowledge, there are few reports of a fetus with the long QT syndrome who exhibited ventricular tachycardia in utero. In the presence of unexplained fetal tachyarrhythmia, long QT syndrome should be considered as a possible underlying cause disorder. The presence of atrio-ventricular dissociation may be useful in prenatal diagnosis of long QT syndrome.

Gestational age-specific normal birth weight for Japanese twins. Risk of early neonatal death in small-for-gestational-age and large-for-gestational-age twins

OBJECTIVE

To construct nomograms for birth weight in Japanese twins and to investigate the risk of early neonatal death (death within seven days of birth) in small-for-gestational-age (SGA) and large-for-gestational-age (LGA) twins as compared with appropriate-for-gestational-age (AGA) twins.

STUDY DESIGN

Of 89,253 infants born at > or = 24 weeks of gestation to women with multifetal pregnancies (96% twins) between 1989 and 1993 in Japan, 1,804 were stillborn, and 891 died within seven days of birth (early neonatal death [END] group). The remaining 86,558 infants were defined as the normal group. We constructed growth curves for the normal and END groups and compared the incidence of early neonatal death among the SGA, AGA and LGA infants.

RESULTS

Birth weights in the END group were similar to those in the normal group until 33 weeks of gestation, but was lower than the birth weights of the normal group after 33 weeks. Both SGA and LGA infants had an increased risk of death within 7 days of birth as compared with AGA infants throughout gestation.

CONCLUSION

Both SGA and LGA twins were at increased risk of death as compared with AGA twins. We recommend the use of birth weight nomograms in the management of twin pregnancies.

Association of a decrease in antithrombin III activity with a perinatal elevation in aspartate aminotransferase in women with twin pregnancies: relevance to the HELLP syndrome

BACKGROUND/AIMS

Decreased antithrombin III (AT-III) activity and/or thrombocytopenia associated with an elevated serum level of aspartate aminotransferase in late pregnancy can threaten the lives of both the mother and the fetus. We investigated whether antenatal declines in AT-III activity and the platelet count occur in late twin pregnancy and whether reduced AT-III activity and/or thrombocytopenia precedes an increase in the serum level of aspartate aminotransferase.

METHODS

The platelet count, AT-III activity, and the serum level of aspartate aminotransferase were determined weekly or biweekly in 237 women with twin pregnancies in a longitudinal and partly prospective study.

RESULTS

Both AT-III activity and the platelet count decreased gradually in the last month of pregnancy, irrespective of the presence or absence of clinical signs of pre-eclampsia. A perinatal elevation in aspartate aminotransferase occurred in 36 (15%) of 237 women. The risk of a perinatal elevation in aspartate amino-transferase increased as the antenatal AT-III activity and/or the platelet count decreased. Pre-eclampsia developed in 60 women (25%). The relative risk of a perinatal aspartate aminotransferase elevation (95% confidence interval) for the 60 women with pre-eclampsia, the 60 women with a platelet count < or = the 25th percentile (164 x 10(9)/1), and the 60 women with AT-III activity < or = the 25th percentile (76% of normal) was 1.9 (1.0 to 3.4), 4.1 (2.3 to 7.5), and 5.9 (3.2 to 11.1), respectively, compared with the remaining 177 women.

CONCLUSIONS

AT-III activity and platelet count gradually decreased in the last month of twin pregnancies. A perinatal aspartate aminotransferase elevation was preceded by marked decreases in these parameters in women with twin pregnancies. The monitoring of AT-III activity and platelet count in women who exhibit a gradual decline in these parameters may help to avoid the development of severe HELLP syndrome.

Bilateral superficial median arteries

A superficial artery may be present in the forearm, arising from the axillary, brachial or superficial brachial arteries and crossing over the origin of the flexor muscles of the forearm to reach the palm (Adachi, 1928; Bergman et al. 1988). When this superficial artery continues as the normal ulnar artery accompanying the ulnar nerve at the wrist, it is referred to as the superficial ulnar artery, with an incidence of ∼4%. When the artery passes below or superficial to the flexor retinaculum in the middle of the forearm, sometimes continuing to join the superficial palmar arch, it is called the superficial median artery, with an incidence of ∼1%. We have observed a relatively rare variation involving the presence of a superficial median artery in both upper limbs. We discuss the clinical importance and the developmental aspects of this arterial variation.

Hyperechoic renal papillae as a physiological finding in neonates

AIM

The increased echogenicity of medullary pyramids in neonates and children is poorly understood. Hence we conducted a prospective ultrasound study of the kidneys of neonates and fetuses. Hence we conducted a prospective ultrasound study of the kidneys of neonates and fetuses.

PATIENTS AND METHODS

Ultrasound images of kidneys in neonates and fetuses in late pregnancy were analysed.

RESULTS

Thirteen percent of the studied neonates showed hyperechogenicity in the renal papillae that disappeared spontaneously within 1 week, although no hyperechoic papillae were seen in any of the fetuses. Urine volume of the neonates with hyperechogenicity was significantly less than that of those without it.

CONCLUSION

The fact that no hyperechoic findings appeared before the 34th week of gestation suggests that maturation of renal tubules and ability to concentrate urinary substances were contributing factors. Because only the tips of the pyramids were hyperechogenic, however, the term hyperechoic papillae would seem more appropriate than hyperechoic pyramids, the term generally used today.

Relation between hemoglobin discordance and adverse outcome in monochorionic twins

BACKGROUND

The effects of discrepancies in the birth weight and hemoglobin concentration ([Hb]) at the birth on infant outcome have not been fully investigated in monochorionic (MC) and dichorionic (DC) twins.

METHODS

A retrospective study of 95 twin pregnancies. All 190 neonates (68 MC twins and 122 DC twins) were admitted to the neonatal intensive care unit, and the [Hb] was determined soon after birth. The [Hb] discordance represents the [Hb] of the smaller twin expressed as a percentage of the [Hb] of the larger twin. Infants were followed-up until 1 year of corrected age and their psychomotor development was evaluated between 12 and 18 months.

RESULTS

One DC infant died by 1 year of age. Twelve MC infants and eight DC infants had disabilities by 1.5 year of age. In the MC group, 11 infants (28%) of 20 pairs with an intertwin [Hb] discordance >100 had disabilities compared with one (3.6%) of 14 pairs with an [Hb] discordance < or = 100 (p<0.05). A similar trend was observed in the DC group, but the difference was not significant. The incidence of disabled infants increased as the intertwin birth weight discordance increased in MC twins.

CONCLUSIONS

An adverse outcome at 1 year of age in MC twins was associated with a greater birth weight discordance and an [Hb] disordance that indicated polycythemia in the smaller twin.

Difference in outcome of twins between early and delayed referrals

Data on the prognosis of twins from tertiary institutions may not represent the general incidence of adverse infant outcomes. We retrospectively investigated the infant outcome in 32 twin gestations referred to us at 29.9 +/- 3.7 weeks of gestation (range, 21 to 38 weeks) (late referral group) and 237 twin gestations that had been monitored by us since < 20 weeks' gestation (control group). The physical and neurological status of infants was assessed at 1 year of corrected age. Delivery occurred 3.1 weeks earlier in the late referral group than in the control group (32.4 +/- 3.9 vs 35.5 +/- 2.4 weeks, p < 0.001). Deaths by 1 year of age and disabilities such as cerebral palsy, mental retardation, and epilepsy occurred in 16 (25%) of 64 infants in the late referral group compared with 24 (5.1%) of 474 infants in the control group (p < 0.001). Thus, the inclusion of data on women who were referred late increased the incidence of adverse infant outcomes in our tertiary hospital from 5.1% to 7.4% (40/538). It was not known whether an early referral to a tertiary hospital would have improved the outcome in the late referral group. These findings suggest that data from tertiary institutions on the prognosis of twins may be affected adversely by the inclusion of data on women who are referred because of complications.

Triplet pregnancy complicated by a gradual decline in antithrombin-III activity and HELLP syndrome: a case report

We prospectively evaluated the antenatal changes in antithrombin-III (AT-III) activity and liver enzymes in a woman with a triplet pregnancy. A gradual decline in AT-III activity occurred in the absence of clinical signs of preeclampsia and preceded the onset of the typical HELLP syndrome in this patient. Monitoring of AT-III activity might help to avoid the development of severe HELLP syndrome.

Segmental distribution of the motoneurons innervating trunk muscles in the spinal cord of the cat and rat

The current progress in developmental biology suggests a genetically stable peripheral pathway formation. However, this may be incompatible with the variations or anomalies observed in the segmental origins of motor nerves in the mammals including the human. For the consideration of the causes raising this inconsistency, we examined the distribution of motoneurons for the serratus dorsalis cranialis muscle of the cat using a retrograde labeling method because this muscle consists of segmentally-arranged parts which receive segmental dual innervation. Consequently, the distribution of the labeled motoneurons for one part spread throughout the full extent of two spinal cord segments, while the distributions for the intercostal muscles in the cat and rat were segmental and in accordance with each spinal cord segment. This may indicate the more precise correspondence between the spinal nerve segments and the distribution of motoneurons projecting axons through them. We think, therefore, that segments of the spinal nerves supplying a given target exactly indicate the segmental levels of supplying motoneurons and suggest the segments of somites from which primordial cells of the target migrate.

Calcium-to-creatinine ratio in spot urine samples in early pregnancy and its relation to the development of preeclampsia

We investigated the relation between an alteration in calcium (Ca) excretion in early pregnancy and the risk of preeclampsia in 1,147 pregnant women. We measured Ca and creatinine (Cr) concentrations in spot urine samples obtained at 12 weeks or less of gestation. Seventy-one (6.2%) had hypertension alone, nine (0.8%) developed superimposed preeclampsia, 39 (3.4%) developed proteinuria alone, and 13 (1.1%) developed preeclampsia; 1,015 women did not develop hypertension or proteinuria. The Ca/Cr ratio was significantly reduced in the 39 women who eventually developed proteinuria (0.116 +/- .103) and 13 who developed preeclampsia (0.121 +/- .063) compared with 1,015 women who had neither hypertension nor proteinuria (0.158 +/- .239). The relative risk of development of preeclampsia, proteinuria, or superimposed preeclampsia was 1.98 (95% confidence interval, 1.22 to 3.22) for women with a Ca/Cr ratio less than the 30th percentile (0.082) compared with women with a Ca/Cr ratio greater than the 30th percentile. These results suggest that preeclampsia may be related, in part, to a relative Ca intake deficiency. Determination of the Ca/Cr ratio in spot urine samples in the first trimester is of only limited clinical value for identifying women with an increased risk of preeclampsia.

Accuracy and utility of a new reflectance pulse oximeter for fetal monitoring during labor

OBJECTIVE

To evaluate the accuracy of a new pulse oximeter in estimating the oxyhemoglobin (O2Hb) concentration in fetal arterial blood (SaO2) with either a high concentration of hemoglobin F (HbF) or a low concentration of O2Hb during labor.

PATIENTS AND METHODS

Fetal forehead arterial oxygenation was determined in 44 fetuses by reflectance pulse oximeter (SpO2) during labor and was compared with SaO2 determined immediately after birth. Because HbF has little or no known effect on pulse oximetry, but does affect the laboratory multiwavelength "CO-oximeter" type reading, the SaO2 was corrected by HbF concentration. SpO2 and SaO2 were simultaneously measured in five hypoxic adult volunteers achieved by inhaling 11% oxygen.

RESULTS

A gradual decline in HbF concentration was seen during weeks 37 to 40 of gestation. HbF concentration varied near term, ranging between 53 and 88% of the fetal hemoglobin concentration (mean +/- SD = 74.6 +/- 6.3%). This alteration produced a lower %O2Hb percent by 4% at the most. The corrected SaO2 in cord blood correlated with fetal SpO2 (y = 0.974, x -7.279, r = 0.90). In five adults, SpO2 reflected well SaO2 with a mean +/- SD of bias of -1.1 +/- 2.9%.

CONCLUSIONS

SpO2 determined by a new reflectance pulse oximeter at the end of labor correlated with an immediate post-natal cord arterial blood sample before the first breath, with a mean and SD of bias of 8.5 +/- 6.2%. Reflectance pulse oximetry is a useful tool for continuous noninvasive monitoring of the fetal oxygen status during labor.

Fetal heart rate decelerations precede a decrease in fetal oxygen content

To determine the relationship between abnormal fetal heart rate (FHR) patterns, fetal oxygen content by reflectance pulse oximetry, and the effects of maternal oxygen administration, 158 intrapartum women consisting of 120 women with normal FHR patterns, and 38 women with varying degrees of variable FHR decelerations were examined. A new reflectance pulse oximetry probe was attached to the fetal forehead to continuously monitor fetal oxygen saturation (SpO2) during labor. Oxygen was administered for 30 min at 5 liters/min by nasal canula in 32 women. No significant change in fetal SpO2 was seen in women with normal FHR patterns, but a significant decline in SpO2 was observed shortly before births. FHR decelerations less than 90 bpm occurred prior to the decline in fetal SpO2. Maternal oxygen administration was effective in increasing fetal SpO2 in fetuses with decreased SpO2 (SpO2 < 50%), but not in fetuses with high SpO2 (SpO2 > 60%). It is concluded that fetal SpO2 exhibits no change during normal labor but significantly declines shortly before birth, that relatively severe variable decelerations (<90 bpm) can decrease fetal SpO2, and that maternal oxygen treatment at 5 liters/min is effective in augmenting fetal oxygen tension in fetuses with decreased oxygen tension.