Patterns of endocardial fibroelastosis without atrioventricular block in fetuses exposed to anti-Ro/SSA antibodies

Anti-Ro/SSA-antibody-mediated endocardial fibroelastosis (EFE) without atrioventricular (AV) block at presentation is a rare cardiac phenotype. We report on 11 fetuses with this rare type of anti-Ro/SSA-antibody-mediated cardiac involvement, presenting with a distinctive echocardiographic pattern of EFE. Eleven fetuses with isolated EFE at presentation were included from four cardiac centers, and experienced fetal cardiologists reached a consensus regarding EFE location on echocardiography at presentation. Interval changes to subsequent fetal and postnatal echocardiograms were assessed to evaluate response to therapy. Echocardiographic markers of cardiac performance, including diastolic function and AV conduction, were reviewed. Ten fetuses were found to have EFE of the aortic root, proximal aorta and/or left ventricular outflow tract. In the same 10 cases, EFE of the pulmonary root, pulmonary artery and/or right ventricular outflow tract was identified. Six cases had atrial EFE and six had EFE of the crux. Four cases were known to be positive for anti-Ro/SSA antibodies prior to diagnosis, whereas, in the remaining seven, echocardiographic findings prompted testing, which was positive in all cases. The AV interval at presentation was normal in all cases, but one fetus subsequently developed AV block. Nine patients were treated with transplacental dexamethasone, five of which also received intravenous immunoglobulin (IVIG), and one received IVIG only. Of the 10 treated cases, six had improvement in EFE as shown by serial imaging and, in four cases, the severity was unchanged. All patients were liveborn. In our cohort, EFE of the aortic and pulmonary arteries and outflow tracts was nearly universal, and involvement of the atria and the crux of the heart was also common. The high survival rate and low burden of AV block are also suggestive of a distinct phenotype of anti-Ro/SSA-antibody-mediated cardiac disease with a favorable prognosis. © 2023 International Society of Ultrasound in Obstetrics and Gynecology.

Long-term functional and clinical outcomes following transanal advancement flap for complex anal fistula repair: are there predictors of recurrence and incontinence?

AIM

Transanal flap is an attractive technique for complex fistulas. The aim of this study was to identify factors associated with poor outcome, recurrence and incontinence.

METHOD

All patients who underwent an advancement flap for the treatment of a complex anal fistula between 1995 and 2019 were prospectively enrolled. The patient data obtained included age, sex, body mass index, comorbid conditions and smoking history. The fistula characteristics analysed included previous anal surgery, anatomy of the fistula according to Park's classification, horseshoe or supralevator extension and preoperative seton drainage. The postoperative data registered included complications, postoperative stay, recurrence and incontinence. Predictive factors for recurrence and incontinence were identified using univariate and multivariate analysis.

RESULTS

One hundred and ninety patients were included; 134 (70.5%) were men and the mean patient age was 50 years. The median length of follow-up was 44.6 months. The fistula recurred in 14 patients (7.3%). Before surgery, 20 patients (10.5%) reported incontinence symptoms. In the continent patients a Wexner postoperative score of 0 was identified in 79.4%. Wexner scores between 1 and 3 were observed in 17% and scores of 4 or more in five patients (3%). Factors associated with recurrence included age < 50 years (OR = 4.8, P = 0.02, 95% CI 1.2-19), smoking (OR = 4.1, P = 0.03, 95% CI 1-16.5) and suprasphincteric fistula (OR = 0.5, P = 0.01, 95% CI 0.2-0.8) in multivariate log regression analysis. Major incontinence was influenced by female sex and previous anal surgery (OR = 7.5, P = 0.003, 95% CI 1.6-34 and OR = 0.1, P = 0.007, 95% CI 0.1-0.7, respectively).

CONCLUSION

Full-thickness transanal advancement flap is a good treatment for complex anal fistula repair. This study provides relevant information on risk factors for failure of therapy and incontinence, which can help in advising patients before surgery and planning a good treatment strategy.

[Voluntariness and blood donation: Proceedings of an ethics seminar held at the National Institute for Blood Transfusion]

Voluntariness stands for one of the four pillars of ethics in blood donation; it is, however, more related to tradition than to legislation. Because it seems necessary to apply "marketing" techniques to blood collection in order to meet the needs in blood components, both in terms of quantity and quality, one wonders if this may be at the expense of this principle of voluntariness. This seminar-belonging actually to a series of seminars in Ethics in Transfusion Medicine-aimed at questioning the possible weakness of voluntariness in the field of blood donation. To achieve this goal, specialists of numerous disciplines in medical sciences, law and humanities gathered to discuss all related issues to voluntariness in blood donation.

Heart rate perturbation in the stage 17-27 chick embryo: effect on stroke volume and aortic flow

Heart rate (HR), stroke volume (SV), and aortic flow increase linearly between developmental stages 17 and 27, as the embryonic chick heart progresses from a bent tube to a rudimentary four-chambered structure and cardiac mass increases fourfold. We hypothesized that HR perturbation, expressed as percent of intrinsic HR (%HR), would have a developmentally dependent effect on flow and SV. HR was transiently perturbed to 40-250% of intrinsic rate with a 1-mm cooled or heated steel probe applied to the sinus venosus of 81 embryos. Aortic blood velocity, cross-sectional area, and HR were used to calculate flow and SV. At each stage, flow was maximal at intrinsic HR. The %HR vs. SV relationship was linear, inverse, and developmentally dependent. In spite of a tremendous change in ventricular shape, mass, and volume, HR control during development of the preinnervated heart maximizes blood flow to the developing embryo.

Heart rate perturbation in chick embryos: a comparison of two methods

This report compares the effects of two methods of heart rate (HR) perturbation on stroke volume and dorsal aortic flow in the Hamburger-Hamilton stage 24 chick embryo. The sinus venosus was paced at intrinsic HR and at 150, 125, 75, and 50% of intrinsic HR (n = 23). Alternatively, a 1-mm steel probe heated to increase and cooled to decrease HR was applied to the sinus venosus (n = 15). All studies were performed in ovo at 37-38 degrees C. Aortic flow (mm3/S) and stroke volume (mm3/beat) were calculated from aortic velocity, aortic cross-sectional area, and HR. Atrioventricular (AV) inflow velocities were measured during pacing (n = 10) or probe application (n = 11) technique. Dorsal aortic flow was maximum at intrinsic HR and decreased at both increased and decreased HR. Stroke volume decreased proportionally to HR during rate increase. At decreased HR, when AV synchrony was disrupted (pacing), stroke volume was unchanged from intrinsic values. However, when AV synchrony was maintained at decreased HR (cold probe), the embryonic ventricle significantly increased stroke volume.

The effect of cardiac cycle length on ventricular end-diastolic pressure and maximum time derivative of pressure in the stage 24 chick embryo

We hypothesized that developmental increases in both ventricular end-diastolic pressure (EDP) and the maximum time derivative of pressure (dP/dt) observed in stage 12 to 29 chick embryos are the result of observed cardiac cycle length (CL) decrease (heart rate increase). To test this hypothesis, we evaluated EDP and dP/dt changes that occur during acute CL alterations in the Hamburger-Hamilton stage 24 chick embryo (n = 18). Ventricular pressure measurements were obtained with a servo-null pressure system and digitally recorded at 500 samples/s. A 1-mm steel probe, heated (decrease CL) or cooled (increase CL), was applied to the sinus venosus. The average baseline CL was 454 ms. The heart rate perturbation resulted in CL that varied over a range of 200-2966 ms, assimilating the range of CL change observed during development. Changes in EDP ranged from 0.014 to 0.130 kPa (baseline = 0.061 kPa) and maximum dP/dt ranged from 0.33 to 13.33 kPa/s (baseline = 5.99) kPa/s). In each study, EDP varied directly with CL (R2 = 0.70). Conversely, maximum dP/dt changes were inversely related to CL alterations (R2 = 0.54). Thus, we found that there is a direct relationship between changes in CL and EDP in the stage 24 chick embryo, whereas CL and dP/dt vary inversely. During cardiac development, observed increases in maximum dP/dt may be attributed to CL decreases. In contrast, developmental increases in EDP cannot be explained by CL decrease and must be accounted for by maturational changes in cardiac function in the chick embryo.