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Background Thrombocytopenia is a common perioperative clinical problem and preoperative platelet transfusion prior to surgery is standard practice. Recent platelet trials and literature reviews have found no association between platelet count and bleeding incidence except when platelet count is extremely low. Our aim was to evaluate the bleeding risk and the overall platelet transfusion management among pediatric patients with severe thrombocytopenia based on whether they were preoperatively transfused versus transfused at time of incision. Methods This is a retrospective analysis of pediatric patients with a platelet count ≤50 × 109/L in the 12 h prior to surgery at a single tertiary pediatric hospital from 2011 to 2016. Eligible patients were ≤21 years old. Patients with necrotizing enterocolitis and neonates were excluded. The primary outcome was postoperative bleeding complications. Additional outcomes were preoperative platelet change and weight adjusted transfusion volumes. Results A total of 37 patients were included in this analysis of which 29 (78%) received preoperative platelet transfusions within 12 h prior to surgery. No postoperative bleeding complications occurred 30 days after operation, regardless of preoperative transfusion status. There was no significant difference in platelet change by preoperative transfusion status and preoperative transfusion volume was a poor predictor of change in preoperative platelet count (crude: r2=0.19, age/gender adjusted: r2=0.48). Conclusion Patients transfused at time of surgical procedure did not have an increased risk of bleeding over those preoperatively transfused. This finding is in agreement with previous studies in adult populations, supporting the safety of deferring platelet transfusions until the time of incision for thrombocytopenic pediatric surgical patients. Level of evidence: III

Introduction and Background: Salmonella-IL2 (Saltikva) is an attenuated strain of orally administered Salmonella that carries the human gene for IL-2 that colonizes the tumor microenvironment and locally releases IL-2 without any untoward effects. Following significant anti-tumor responses during preclinical study in multiple tumor models; a Phase I trial in humans found a single dose to be not toxic and elevated the Natural Killer T cell populations in patients with advanced gastrointestinal (GI) cancers. Additionally, a Phase I multiple dose trial in companion dogs with metastatic osteosarcoma demonstrated a 22% complete response rate. A Phase II trial was performed studying the addition of Salmonella-IL2 to standard of care chemotherapy for stage 4 metastatic pancreatic cancer. Patients and Methods: A Health Canada and local IRB approved, non-randomized, two-arm study in patients with Stage 4 metastatic adenocarcinoma of the pancreas is currently underway. The goal is to recruit 30 patients per arm; Arm 1: Salmonella-IL2 with FOLFIRINOX and Arm 2: Salmonella-IL2 with Gemcitabine/Abraxane. The primary outcome is overall survival with secondary outcomes of response determined by CT imaging using RECIST 1.1 criteria and biomarker data. Outcomes were compared to patients with stage 4 metastatic pancreatic cancer administered FOLFIRINOX (n=37) or Gemcitabine/Abraxane (n=24) from 4 years prior to starting this trial (2016-2020) at the study site and to historical controls from the published literature. Salmonella-IL2 is orally administered concomitantly with the administration of the prescribed chemotherapy according to arm of enrollment. 109 cfu of attenuated Salmonella-IL2 was administered orally after ingestion of a gastric acid neutralizing agent and followed with 200ml of an isotonic crystalloid fluid. Results: A total of 28 patients have been enrolled into this clinical trial. 20 patients were administered Salmonella-IL2 orally every 2 weeks with FOLFIRINOX; mean age 59.4 (32-73) years; 12(60%) women, and 8 (40%) men. 8 patients were administered Salmonella-IL2 with Gemcitabine/Abraxane every 2/3 weeks; mean age is 68.8 (56-82); 6 (66.7%) women and 3 (33.3%) men. Median survival in the FOLFIRINOX arm was 24 months compared to 11.1 months in published historical controls and 13.1 months site specific controls (n=37) (P Conclusion: Addition of Salmonella-IL2 to FOLFIRINOX for stage 4 metastatic pancreatic cancer results in the near doubling of median survival when compared to historical and site-specific controls receiving FOLFIRNOX only. These findings strongly indicate that a larger pivotal phase 3 multicenter trial is warranted. Citation Format: Petr Kavan, Daniel A. Saltzman, Jule Muegge, Jordan Moradian, Gerald Batist. Addition of Salmonella-IL2 to FOLFIRINOX for metastatic stage 4 pancreatic cancer nearly doubles median survival [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2023; Part 2 (Clinical Trials and Late-Breaking Research); 2023 Apr 14-19; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2023;83(8_Suppl):Abstract nr CT035.

The ultimate goal of bacterial based cancer therapy is to achieve non-toxic penetration and colonisation of the tumour microenvironment. To overcome this efficacy-limiting toxicity of anticancer im...

Much of the bacterial anticancer therapy being developed relies on the ability of bacteria to specifically colonise tumours. Initial attempts to translate promising Salmonella enterica Typhimurium ...

Salmonella has been shown to preferentially colonize solid tumors. It is known that toxicity limits the systemic administration of immunomodulatory cytokines that have a significant anticancer effect. Therefore, we tested a unique cancer treatment strategy comprised of oral delivery of Saltikva, an attenuated strain of Salmonella typhimurium that contain the human gene for interleukin-2. In preclinical experimentation, a significant antitumor effect without toxicity was observed. A dose escalation, single dose, Phase I trial was conducted. Dose escalation (105 to 1010) while monitoring for dose limiting toxicity and response was performed. Flow cytometry was conducted to determine the immunologic effect. In total 22 patients were administered Saltikva. Eight patients did not complete the trial. No toxicity or adverse events were observed. There was no survival advantage. Flow cytometry demonstrated an increase in circulating natural killer (NK) cells and NK-T cells when comparing the prestudy period. The results of this phase I dose escalation study show that oral attenuated S. typhimurium containing the human interleukin-2 gene caused no significant toxicities up to doses of 1010 colony forming unit. There was no evidence of partial or complete response. All patients had progressive disease and eventually succumbed to their illness. Although no survival advantage was seen in this single dose study, the statistically significant increase in circulating NK and NK-T cell demonstrates an immunologic effect from this treatment regimen and suggest that a multiple dose study should be undertaken.

We describe the use of virtual reality technology for surgical planning in the successful separation of thoracopagus conjoined twins. Three-dimensional models were created from computed tomography angiograms to simulate the patient’s anatomy on a virtual stereoscopic display. Members of the surgical teams reviewed the anatomical models to localize an interatrial communication that allowed blood to flow between the two hearts. The surgical plan to close the 1-mm interatrial communication was significantly modified based on the pre-procedural spatial awareness of the anatomy presented in the virtual visualization. The virtual stereoscopic display was critical for the surgical team to successfully separate the twins and provides a useful case study for the use of virtual reality technology in surgical planning. Both twins survived the operation and were subsequently discharged from the hospital.

Purpose Rectal prolapse is a relatively common condition in infants and young children with a multifactorial etiology. Despite its prevalence, there remains clinical equipoise with respect to secondary treatment in pediatric surgery literature. We conducted a systematic review to evaluate methods of secondary treatment currently used to treat rectal prolapse in children. Methods We searched Pubmed, Medline, and Scopus with the terms “rectal prolapse” and “children” for papers published from 1990 to April 2017. Papers satisfying strict criteria were analyzed for patient demographics, intervention, efficacy, and complications. Procedures were grouped by like type. Pooled success rates were calculated. Results Twenty-seven studies documenting 907 patients were included. Injection sclerotherapy had an overall initial success rate of 79.5%. Ethyl alcohol seemed the best sclerosing agent due to a high first-injection success rate, low complication rate, and ready accessibility. Several perineal repairs were found, with operative success rates ranging from 60.8%–100%. Laparoscopic rectopexy with mesh was the most commonly reported transabdominal procedure and had an overall success rate of 96.1%. Postoperative complications from all procedures were comparable. Conclusion Though many secondary treatment options have been reported for rectal prolapse, sclerotherapy and laparoscopic rectopexy predominate in contemporary literature and appear to have high success and low complication rates. Level of Evidence IV.

Prior studies have shown an association between history of loop electrode procedures (LEEP) and spontaneous preterm delivery (SPTD) independent of mid-trimester cervical length. These studies suggest that there may be other factors beyond an individual cervical length, which contribute to identifying at-risk pregnancies.The objective of this study is to determine the association between change in cervical length and SPTD in women with a history of LEEP.This is a retrospective cohort study of singleton nulliparous women with a history of LEEP who received serial cervical length measurements at a single institution between 2012 and 2016. Women with serial cervical lengths and available outcome data were included. The cervical length at different gestational ages and the rate of change in length were compared with the risk for SPTD37 weeks using Student'sOne-hundred-thirty subjects met the inclusion criteria for the study. The mean cervical length (35.3 versus 39.8 mm,Women with a history of LEEP who had an SPTD37 weeks had a shorter cervical length at 16, 20, 24, and 28 weeks' gestation and a higher rate of change in cervical length between 16 and 28 weeks than women without a history of SPTD. Our findings support the concept of the preterm birth syndrome as an evolving biophysical process rather than a distinct event, suggesting improved prediction in the setting of prior history of a LEEP with serial imaging.

Background Gastrojejunostomy (GJ) tubes are frequently used to provide pediatric enteral nutritional support for pediatric patients. Various placement methods have been described, each with attendant advantages and disadvantages. Description of the operative technique We present a technique for primary laparoscopic/fluoroscopic GJ button tube placement designed to avoid delay in placement of the jejunal limb, and difficulties associated with endoscopic-assisted and primary fluoroscopic placement. Results There were 52 gastrojejunostomy button tubes placed via this technique in patients ranging from 3.8 to 90.3 kg in weight. Three postoperative complications were identified; one bowel perforation on postoperative day two, and two tube dislodgements within 30 days. Conclusion The described technique was uniformly effective and was associated with a low complication rate (5.8%).

Objective To identify pregnancies at increased risk for trisomy 13, trisomy 18 or triploidy attributable to low fetal fraction (FF). Methods A FF‐based risk (FFBR) model was built using data from more than 165 000 singleton pregnancies referred for single‐nucleotide polymorphism (SNP)‐based non‐invasive prenatal testing (NIPT). Based on maternal weight and gestational age (GA), FF distributions for normal, trisomy 13, trisomy 18 and triploid pregnancies were constructed and used to adjust prior risks for these abnormalities. A risk cut‐off of ≥ 1% was chosen to define pregnancies at high risk for trisomy 13, trisomy 18 or triploidy (high FFBR score). The model was evaluated on an independent blinded set of pregnancies for which SNP‐based NIPT did not return a result, and for which pregnancy outcome information was gathered retrospectively. Results The evaluation cohort comprised 1148 cases, of which approximately half received a high FFBR score. Compared with rates expected based on maternal age (MA) and GA, cases with a high FFBR score had a significantly increased rate of trisomy 13, trisomy 18 or triploidy combined (5.7% vs 0.7%; P

Objective To report the utility of the ultrasonographic biophysical profile, which includes all the components of a biophysical profile minus the nonstress test, in women with maternal indications for antepartum surveillance. Methods We conducted a case series reviewing the records of all women at 32 weeks of gestation or greater with at least one indication for antenatal testing (per the American College of Obstetricians and Gynecologists) delivered by a single maternal-fetal medicine practice between 2006 and 2018. Indications included diabetes, hypertension, lupus, antiphospholipid syndrome, sickle cell disease, renal disease, heart disease, hyperthyroidism, isoimmunization, inherited thrombophilia, and prior intrauterine fetal demise. Weekly ultrasonographic biophysical profiles were initiated at 32 weeks of gestation. We calculated the test-positive rate, the percentage of women delivered for an abnormal ultrasonography biophysical profile, and the intrauterine fetal demise rate (false-negative rate). Results Nine hundred eighty-five women underwent 3,981 ultrasonographic biophysical profiles (four per woman; range 1-11). Sixteen women had an abnormal ultrasonographic biophysical profile, for a test positive rate of 1.6% (95% CI 1.0-2.6%) per woman, or 0.4% (95% CI 0.3-0.7%) per ultrasonographic biophysical profile. Of the 16 women with abnormal ultrasonographic biophysical profiles, 13 were delivered with good outcomes and three women had normal follow-up testing and uncomplicated deliveries at a later date. There were three women with intrauterine fetal demise (false-negative rate of 0.3%, 95% CI 0.1-0.9%). One woman with intrauterine fetal demise had a factor V Leiden mutation, fetal ventriculomegaly, and fetal growth restriction. The second woman with intrauterine fetal demise had advanced maternal age, a factor V Leiden mutation, and fetal growth restriction. The third woman with intrauterine fetal demise had class B diabetes. All three intrauterine fetal demises were diagnosed antepartum with an interval from normal ultrasonographic biophysical profile to intrauterine fetal demise of 7, 7, and 6 days, respectively. Conclusion The use of ultrasonographic biophysical profile in a high-risk cohort is associated with a very low test-positive rate and a very low incidence of intrauterine fetal demise. In women with preexisting medical conditions that place them at higher risk for intrauterine fetal demise, ultrasonographic biophysical profile can be used for antenatal testing.

The ultimate goal of bacterial based cancer therapy is to achieve non-toxic penetration and colonisation of the tumour microenvironment. To overcome this efficacy-limiting toxicity of anticancer immunotherapy, we have tested a therapy comprised of systemic delivery of a vascular disrupting agent to induce intratumoral necrotic space, cannabidiol to temporarily inhibit angiogenesis and acute inflammation, and a strain of

In this White Paper, we discuss the current state of microbial cancer therapy. This paper resulted from a meeting (‘Microbial Based Cancer Therapy’) at the US National Cancer Institute in the summer of 2017. Here, we define ‘Microbial Therapy’ to include both oncolytic viral therapy and bacterial anticancer therapy. Both of these fields exploit tumor-specific infectious microbes to treat cancer, have similar mechanisms of action, and are facing similar challenges to commercialization. We designed this paper to nucleate this growing field of microbial therapeutics and increase interactions between researchers in it and related fields. The authors of this paper include many primary researchers in this field. In this paper, we discuss the potential, status and opportunities for microbial therapy as well as strategies attempted to date and important questions that need to be addressed. The main areas that we think will have the greatest impact are immune stimulation, control of efficacy, control of delivery, and safety. There is much excitement about the potential of this field to treat currently intractable cancer. Much of the potential exists because these therapies utilize unique mechanisms of action, difficult to achieve with other biological or small molecule drugs. By better understanding and controlling these mechanisms, we will create new therapies that will become integral components of cancer care.

Early-onset fetal growth restriction is associated with poor pregnancy outcomes, but frequently is due to fetal structural or chromosomal abnormalities. The objective of this study was to determine outcomes in patients with early-onset fetal growth restriction without diagnosed fetal or genetic anomalies and to identify additional risk factors for poor outcomes in these patients.This was retrospective cohort study of singleton pregnancies in women with early-onset growth restriction defined as a sonographic estimated fetal weight10% diagnosed between 16-28 weeks' gestation. We excluded all women with a fetal structural or chromosomal abnormality diagnosed prenatally. Data on pregnancy characteristics and outcomes were collected and analyzed for estimated fetal weight10% and ≤5%. A nested case-control study within the cohort of patients with ongoing pregnancies was then performed to identify risk factors associated with poor pregnancy outcome using chi-squared test.One hundred forty-two patients were identified who met inclusion and exclusion criteria and 20 patients were found to have fetal structural or chromosomal abnormalities. In the remaining 122 patients, the incidence of intrauterine fetal demise was 5.7% and there were high rates of preterm birth37 weeks (20%), birth weight10% (59.3%), and gestational hypertension (14.1%). Later gestational age at diagnosis and the presence of echogenic bowel and abnormal initial umbilical artery Dopplers were associated with poor pregnancy outcome (22.56 versus 20.86 weeks, p = .046), (17.4 versus 2.2%, OR 9.68, 95%CI 1.65-56.73), and (35.3 versus 0%, OR 4.46, 95%CI 2.65-7.50) respectively.Patients with early-onset fetal growth restriction with no fetal structural or genetic abnormality have a high risk of poor pregnancy outcomes. Gestational age at diagnosis and certain ultrasound findings are associated with poor pregnancy outcome.

Immunotherapies for cancer treatment have demonstrated substantial promise even though toxicities and development of tumor resistance limit their effectiveness. A combinatorial approach using immunotherapy with other treatment modalities may decrease side effects while maintaining maximal therapeutic effect. We aimed to determine if bacterial immunotherapy in combination with a chemotherapeutic would be efficacious and less toxic than conventional chemotherapy in an established, preclinical, autochthonous tumor model.BALB-neuT mice develop autochthonous mammary neoplasms that resemble closely the aggressive Her2-driven cancer found in human patients. Virulence-attenuated S. Typhimurium was used for bacterial immunotherapy. Doxorubicin was the chemotherapeutic agent used at the maximum tolerated dose (5 mg/kg) and low dose (1.25 mg/kg). S. Typhimurium was administered intravenously on day 0 and doxorubicin on days 0, 7, and 14. Experiments concluded on day 35. Mammary pad tumors were measured weekly to ascertain efficacy, and mice were weighed weekly to evaluate toxicity.Mice administered maximum tolerated dose doxorubicin (5 mg/kg) demonstrated a 1.4-fold increase in tumor size by day 35 and showed a nearly 25% weight loss by day 14 revealing severe toxicity. When mice were administered a single dose of S. Typhimurium combined with a low dose of doxorubicin (1.25 mg/kg), tumors increased3-fold by day 35, and mice showed only 5% weight loss, indicating no clinically relevant toxicity.Bacterial immunotherapy combined with low dose chemotherapy decreased the tumor burden when compared with low dose chemotherapy alone and was less toxic than maximum tolerated dose chemotherapy in an established, autochthonous murine model of breast cancer.

To compare wound complication rates in tertiary or higher-order cesarean delivery based on wound closure technique.We performed a retrospective cohort study of all tertiary or higher-order cesarean deliveries performed by one group practice in a large academic medical center from 2005 to 2017. We excluded patients with a vertical skin incision. Although the study was not randomized, wound closure type was relatively uniform in this practice and based on time period: before 2011, the preferred closure was staple closure; after 2011, subcuticular suture closure was preferred. All patients received preoperative antibiotics and closure of subcutaneous tissue 2 cm deep or greater. The primary outcome was a wound complication, defined as a wound infection requiring antibiotics or a wound separation requiring wound packing or reclosure any time up to 6 weeks after delivery. Regression analysis was used to control for any significant differences at baseline between the groups.There were 551 patients with tertiary or higher-order cesarean delivery, 192 (34.8%) of whom had staple closure and 359 (65.2%) of whom had suture closure. Suture closure was associated with a significantly lower rate of wound complication (4.7% [17/359, 95% CI 3.0%-7.5%] vs 11.5% [22/192, 95% CI 7.7%-16.7%], P=.003). On regression analysis controlling for the number of prior cesarean deliveries and the participation of a resident in the closure, suture closure remained independently associated with a lower risk of a wound complication (adjusted odds ratio 0.44, 95% CI 0.23-0.86).For women undergoing their third or higher-order cesarean delivery, suture closure is associated with a lower rate of wound complications.

BACKGROUND The objective was to identify risk factors associated with blood transfusion in patients undergoing high-order Cesarean delivery (CD). STUDY DESIGN AND METHODS This was a retrospective cohort study of patients undergoing third or more CD by a single maternal-fetal medicine practice between 2005 and 2016. We compared risk factors between women who did and did not receive a red blood cell transfusion during the operation or before discharge. Repeat analysis was performed after excluding women with placenta previa. RESULTS A total of 514 patients were included, 18 of whom (3.5%; 95% confidence interval [CI], 2.2%-5.5%) received a blood transfusion. Placenta previa was the most significant risk factor for transfusion (61.1% of patients who received a transfusion vs. 1% of patients who did not; p

The primary objective of this study was to evaluate whether women with double thrombophilias have a greater risk for obstetric complications as compared with women who have single thrombophilias.This is a retrospective cohort study of all patients in a single practice with a clinically significant inherited thrombophilia and treated with anticoagulation between 2005 and 2013. Thrombophilias evaluated include: factor V Leiden, prothrombin G20210A gene mutation, protein S deficiency, protein C deficiency, and antithrombin III deficiency. Double thrombophilia was defined as the presence of two thrombophilias or homozygosity for factor V Leiden or prothrombin Gene Mutation. Demographic and obstetrical outcome data were collected. Data on all patients with double thrombophilias who met inclusion criteria was reported. Data was then compared between the patients with double thrombophilias and single thrombophilias with singleton gestations. The data was analyzed with Pearson's chi-squared or Student's t-test as appropriate with p value.05 used for significance.Eighteen patients with clinically significant double thrombophilias who met inclusion criteria were identified. Most patients delivered full term (88.9%) and appropriate for gestational age (77.8%) infants. One hundred thirty-two patients with single thrombophilias and 14 patients with double thrombophilias with singleton gestations were then compared. Demographic characteristics were not significantly different between the two groups. There were no significant differences in obstetrical outcomes between patients.There were no significant differences in obstetrical outcomes for patients with clinically significant double thrombophilias versus single thrombophilias when treated with anticoagulation.

PURPOSE: Children undergoing operative intervention while induced under general anesthesia are at risk for experiencing a significant decrease in core body temperature that can lead to adverse systemic effects. Given that the head contributes an estimated 18% of a child’s body surface area, we theorized that a liquid-warming garment applied to the head could control a pediatric patient’s core body temperature during surgical procedures. METHODS: Patients undergoing elective, non-cranial, general surgical procedures were enrolled in the study. A head garment with an embedded network of tubing was placed on the patient. The garment connected to a computer-controlled water bath that managed the temperature of the water in the tubing through a feedback mechanism. RESULTS: Ten patients with ages ranging from 1 day to 3 years (mean age 10.5 months) were enrolled in this study. The average procedure length was 82.5 min. The mean core body temperature throughout the procedure for all-comers was 36.5 ± 0.9 °C with an overall mean difference in maximum and minimum temperatures of 1.32 ± 1.1 °C. CONCLUSION: A liquid-warming garment applied to the head of pediatric surgical patients is an innovative and relatively low-cost means to regulate and to maintain the ideal core body temperature of patients undergoing surgical procedures.

Purpose Despite the numerous methods of closure for giant omphaloceles, uncertainty persists regarding the most effective option. Our purpose was to review the literature to clarify the current methods being used and to determine superiority of either staged surgical procedures or nonoperative delayed closure in order to recommend a standard of care for the management of the giant omphalocele. Methods Our initial database search resulted in 378 articles. After de-duplification and review, we requested 32 articles relevant to our topic that partially met our inclusion criteria. We found that 14 articles met our criteria; these 14 studies were included in our analysis. 10 studies met the inclusion criteria for nonoperative delayed closure, and 4 studies met the inclusion criteria for staged surgical management. Results Numerous methods for managing giant omphaloceles have been described. Many studies use topical therapy secondarily to failed surgical management. Primary nonoperative delayed management had a cumulative mortality of 21.8% vs. 23.4% in the staged surgical group. Time to initiation of full enteric feedings was lower in the nonoperative delayed group at 14.6 days vs 23.5 days. Conclusion Despite advances in medical and surgical therapies, giant omphaloceles are still associated with a high mortality rate and numerous morbidities. In our analysis, we found that nonoperative delayed management with silver therapy was associated with lower mortality and shorter duration to full enteric feeding. We recommend that nonoperative delayed management be utilized as the primary therapy for the newborn with a giant omphalocele.

Objectives The performance of noninvasive prenatal screening (NIPS) for fetal aneuploidy in twin pregnancies is dependent on the amount of placentally derived cell‐free DNA, the “fetal fraction (FF),” present in maternal plasma. We report FF values in monozygotic (MZ) and dizygotic (DZ) pregnancies. Methods We reviewed FF in pregnancies at 10 to 20 completed weeks gestational age based on single‐nucleotide polymorphism (SNP)‐based NIPS where zygosity was routinely established in twin pregnancies. The cohort included 121 446 (96.3%) singleton, 1454 (1.2%) MZ, and 3161 (2.5%) DZ pregnancies. For DZ twins, individual FFs were measured. Results Combined FF for DZ and MZ fetuses were 35% and 26% greater than singletons, respectively. The individual FF contributions from each fetus in DZ twins were, on average, 32% less than singletons. FF in DZ twin pairs were moderately correlated (Pearson correlation coefficient.66). When a threshold of 2.8% FF was applied to define uninterpretable results, 1.7% (2102/121 446) of singletons, 0.8% (11/1454) of MZ pairs, and 5.6% (178/3161) of DZ pairs were uninterpretable. Conclusion For optimal aneuploidy NIPS in twin pregnancies, zygosity should be established and in DZ twins FF for both fetuses should be determined to identify those cases where results can be reliably interpreted., What's already known about this topic? Adequate cell‐free fetal DNA (fetal fraction [FF]) is essential for noninvasive prenatal screening.FFs in twin pregnancies may be higher or lower than that found in singleton pregnancies. What does this study add? In this large series of twin pregnancies, the average total FF was higher than for singletons but the per fetus FF was lower.There can be large differences in the two FFs in dizygotic twin pregnancies.Optimal prenatal aneuploidy screening in twin pregnancies requires information on both zygosity and the individual FFs.

OBJECTIVES Drowning is the second leading cause of death in children. Extracorporeal membrane oxygenation (ECMO) has become the criterion standard therapy to resuscitate the hypothermic drowning victim in cardiac arrest. We present our own experience treating 5 children with hypothermic cardiac arrest in conjunction with a systematic review to analyze clinical features predictive of survival. METHODS Our search resulted in 55 articles. Inclusion criteria were as follows: (1) younger than 18 years, (2) ECMO therapy, and (3) drowning. Ten articles met our inclusion criteria. We included studies using both central and peripheral ECMO and salt or fresh water submersions. We compared clinical features of survivors to nonsurvivors. RESULTS A total of 29 patients from the 10 different studies met our criteria. Data analyzed included presenting cardiac rhythm, time to initiation of ECMO, submersion time, pH, potassium, lactate, duration of chest compressions, and survival. There was a significant increase in mortality for presenting rhythm of asystole and with hyperkalemia (P < 0.05). CONCLUSIONS Extracorporeal membrane oxygenation is an important resuscitation tool for the hypothermic drowning victim. Hyperkalemia and presenting cardiac rhythm correlate with survival although they are not reasons to end resuscitation. More studies are needed to compare the outcomes in using ECMO for the hypothermic drowning victim.

Objective To estimate the independent association of a short cervical length (CL), positive fetal fibronectin (fFN), amniotic fluid (AF) sludge, and cervical funneling with spontaneous preterm birth in twin pregnancies. Methods Retrospective cohort study of twin pregnancies managed by a single maternal-fetal medicine practice from June 2005 to February 2014. All patients underwent transvaginal sonographic CL and fFN testing. We reviewed all images from the first CL at 22(0/7) to 25(6/7) weeks for the presence of (1) a short CL, which is defined as ≤25 mm, (2) AF sludge, and (3) cervical funneling, and also recorded (4) the fFN result from that time. Image reviewers were blinded to pregnancy outcomes. Patients with cerclage were excluded. Using logistic regression, we calculated the independent association between these four biomarkers and spontaneous preterm birth. Results A total of 635 patients with twin pregnancies were included. The markers independently associated with spontaneous preterm birth

To assess the association of a sonographic estimated fetal weight (sonoEFW) with the risk of cesarean delivery in women with macrosomic or small for gestational age (SGA) infants.Retrospective cohort of singleton deliveries24 weeks by one MFM practice from 2005 to 2014. We included all patients who delivered an infant with macrosomia (birth weight ≥4000 g) or SGA (birth weight10th percentile). We compared the risk of cesarean delivery between patients who did and did not have a sonoEFW within four weeks of delivery. Regression analysis was performed to control for any differences in baseline characteristics.In patients with macrosomic infants (n = 352), the risk of cesarean delivery was significantly higher in the sonoEFW group (45.3% versus 17.6%, aOR 2.144, 95% CI: 1.06-4.34). When we restricted the analysis to the subgroup of 265 patients who attempted vaginal delivery, our results were similar (22.3% versus 9.1%, aOR 2.73, 95% CI: 1.15-6.48). In patients with an SGA infant (n = 614), the risk of cesarean delivery was not higher in the sonoEFW group (37.4% versus 24.1%, aOR 1.23, 95% CI: 0.80-2.07), nor in those who attempted vaginal delivery (19.8% versus 13.7%, aOR 1.17, 95% CI: 0.62-2.21).A sonoEFW prior to delivery is independently associated with cesarean delivery in women with macrosomic infants, but not those with SGA infants. This should be considered when deciding to obtain a sonoEFW at the end of pregnancy, particularly if not for an accepted indication.

We conducted a prospective phase I study to evaluate safety of an orally administered Salmonella encoding IL-2 (SalpIL2) in combination with amputation and adjuvant doxorubicin for canine appendicular osteosarcoma. Efficacy was assessed as a secondary measure. The first dose of SalpIL2 was administered to 19 dogs on Day 0; amputation was done after 10 days with chemotherapy following 2 weeks later. SalpIL2 was administered concurrent with chemotherapy, for a total of five doses of doxorubicin and six doses of SalpIL2. There were six reportable events prior to chemotherapy, but none appeared due to SalpIL2. Dogs receiving SalpIL2 had significantly longer disease-free interval (DFI) than a comparison group of dogs treated with doxorubicin alone. Dogs treated using lower doses of SalpIL2 also had longer DFI than dogs treated using the highest SalpIL2 dose. The data indicate that SalpIL2 is safe and well tolerated, which supports additional testing to establish the potential for SalpIL2 as a novel form of adjuvant therapy for dogs with osteosarcoma.

A 36-year-old, gravida 8, para 6, woman with six prior cesarean sections presented at 6 weeks with a cesarean scar pregnancy. Medical management was performed initially; however, subsequent three-dimensional sonographic examinations revealed trophoblastic invasion into the bladder. This led to robotic-assisted partial cystectomy, fulguration of invaded pregnancy, and repair of the uterine defect. © 2016 Wiley Periodicals, Inc. J Clin Ultrasound 45:163-167, 2017.

To evaluate cervical pessary as an intervention to prevent preterm birth in twin pregnancies with a short cervix.This was a retrospective cohort study of twin pregnancies managed by a single maternal-fetal medicine practice from 2005 to 2015. We included patients at 28 weeks of gestation or less who were diagnosed with a cervical length less than 20 mm. At the time of diagnosis, all patients were prescribed vaginal progesterone. Starting in 2013, they were also offered pessary placement in addition to vaginal progesterone. We compared outcomes between patients who received a pessary and matched women in a control group in a one-to-three ratio. Women in the control group were matched to women in the case group according to cervical length and gestational age (within 5 mm and 1 week, respectively, of the case patient at the time of pessary placement). We excluded patients with cerclage, monochorionic-monoamniotic placentation, major fetal congenital anomalies discovered before or after birth, patients with twin-twin transfusion syndrome, and patients for whom there were no appropriate controls. Chi-square, Fisher exact, and Student's t tests were used, as appropriate. Regression analysis was performed to control for significant differences at baseline.Twenty-one patients received a cervical pessary, and they were compared with 63 matched women in the control group. As expected (as a result of matching), baseline gestational age (25.7±2.1 compared with 25.9±2.1 weeks of gestation, P=.671) and cervical length (10.9±3.6 mm compared with 11.9±4.5 mm, P=.327) were similar between the groups. Patients with a pessary had a significantly lower incidence of delivery at less than 32 weeks of gestation (1/21 [4.8%] compared with 18/63 [28.6%], adjusted P=.05), longer interval to delivery (65.2±16.8 compared with 52.1±24.3 days, adjusted P=.025), and a lower incidence of severe neonatal morbidity (2/21 [9.5%] compared with 22/63 [34.9%], adjusted P=.04).For twin pregnancies with a short cervix, the addition of a cervical pessary to vaginal progesterone is associated with prolonged pregnancy and reduced risk of adverse neonatal outcomes. A large randomized trial should be performed to verify these retrospective findings.

OBJECTIVE To estimate the effect of resident participation on outcomes in women undergoing high-order cesarean deliveries. METHODS We performed a retrospective cohort study of patients in one obstetric practice undergoing a third- or greater order cesarean delivery from 2005 to 2014. Patients with placenta previa, accreta, or failed vaginal birth after cesarean delivery were excluded. We compared outcomes between patients whose operations were performed by two attendings with patients whose operations were performed by one attending and one resident. Regression analysis was performed to control for differences at baseline. RESULTS Three hundred seventy patients were included, 189 (51%) of whom had two attendings and 181 (49%) of whom had one attending and one resident. The mean operative time was slightly but significantly less in the two=attending group (60.9±17.3 compared with 62.5±18.3 minutes, adjusted P=.038). Otherwise, there were no significant differences in measured outcomes between the groups, including wound complications, blood loss (estimated and drop in hemoglobin), blood transfusion, major maternal morbidity (hysterectomy, cystotomy, bowel injury, intensive care unit admission, thrombosis, reoperation, death), postoperative endometritis, and postoperative days in the hospital. Among patients in the resident group, there was no difference in outcomes between cases performed by a junior (first or second year) resident compared with a senior (third or fourth year) resident. CONCLUSION Resident participation does not negatively affect outcomes in patients undergoing high-order cesarean deliveries. Residents should be included in these complicated cases because they can obtain a significant learning experience without compromising patient safety.

Background On July 1st, 2012, the University of Minnesota Medical Centers adopted a policy requiring all personnel to wear cover jackets in perioperative areas. This policy is based on the Association of Perioperative Registered Nurses recommended practice for cover jacket usage. We hypothesized that the cover jacket policy had no effect on the surgical site infection rate. Methods We compared surgical site infection data from 1 year before the policy and 1 year after the policy. Twenty six thousand three hundred procedures were included: 13,302 before the policy and 12,998 after the policy. Rates between periods were compared using the z-test for proportions. Results The SSI rate precover and postcover jacket policy was 2.42% and 2.76% respectively. The P value was .1998. Our hypothesis was rejected because the change in rate was not statistically significant. Conclusions This study demonstrates that there was not a decrease in SSI rates with this cover jacket policy; in fact, the data show a trend toward an increase in SSI rate thus making the argument for the abandonment of the cover up jackets.

Peritoneal dialysis (PD) is a commonly used method for renal support in pediatric patients and can be associated with the risk of post-surgical complications. We evaluated method of placement of PD catheters with regard to post-surgical complications. PD catheters placed at two institutions between 2005 and 2017 were reviewed. Complication rates were evaluated based on method of placement, delayed usage, omentectomy, and patient age using Fisher’s exact test, two-sided, with significance set at 0.05. Factors influencing complication were evaluated with multivariate logistic regression and Kaplan–Meier survival analysis. There were 130 patients with 157 catheters placed, ranging in age from 1 day to 23 years. There was no significant difference in complication rate by method of placement or delayed usage. Infants were significantly more likely to experience leakage (21% vs 8%, p 0.036) and hernias (15% vs 5%, p 0.030). Patients that underwent an omentectomy were less likely to require a catheter replacement (7% vs 27%, p 0.004), and the catheters had a significantly higher survival rate (p 0.009). We found that laparoscopic intervention resulted in catheter salvage. Lateral exit sites may be a risk factor for catheter migration in some patients. Omentectomy is associated with longer PD catheter survival. Laparoscopic salvage of dysfunctional catheters may be a valuable adjunct in management.

The pathogenesis of necrotizing enterocolitis (NEC) remains poorly understood but is thought to be multifactorial. There are no specific recurring chromosomal abnormalities previously associated with NEC. We report 3 cases of intestinal necrosis associated with large chromosome 6 deletions. The first patient was found to have a 7.9-Mb deletion of chromosome 6 encompassing over 40 genes, arr[GRCh37] 6q25.3q26(155699183_163554531)×1. The second patient had a 19.5-Mb deletion of chromosome 6 generated by an unbalanced translocation with chromosome 18, 46,XY,der(6)t (6;18)(q25.1;p11.23), arr[GRCh37] 6q25.1q27(151639526_ 171115067)×1, 18p11.32p11.23(131700_7694199)×3, which included the whole 7.9-Mb region deleted in the first patient. The third patient was the younger sibling of the second patient with an identical derivative chromosome 6. The shared abnormal chromosome 6 region includes multiple genes of interest, particularly EZR. Mouse models have demonstrated that Ezr is expressed in microvillar epithelium and helps regulate cell-cell adhesion in the gut. We hypothesize that deletion of this shared region of 6q leads to gastrointestinal vulnerability which may predispose patients to intestinal necrosis.

Advances in technology are making virtual reality (VR) available for many different interests. Inexpensive commercially available hardware can be setup at home [1,2], while corporations are using VR to design mechanical systems and train pilots [3,4]. However, limited application is seen in the medical field.

Purpose The utility of irrigation at the time of appendectomy for acute appendicitis has been debated, with recent studies showing no benefit to irrigation. In our practice, two techniques have been used; one in which irrigation was at the discretion of the surgeon, and one in which irrigation was standardized. The standardized irrigation technique involved large volume (3–12 l) irrigation in small, focused, directed aliquots to achieve optimal dilution. We sought to retrospectively assess whether the standardized large volume irrigation technique was associated with measurably reduced intraabdominal infection. We hypothesized that there would be no difference in intraabdominal infection rate. Methods Medical records for cases of appendectomies performed for acute appendicitis, years 2007 through 2017, were reviewed (n = 432). Rate of subsequent abdominal infection was compared between patients who underwent the standardized large volume irrigation technique compared to those who did not using Fisher's exact test; p Results For patients that underwent the standardized large volume irrigation technique there were no (0/140) subsequent abdominal infections within the study period, compared with a rate of 6.2% (18/292) for all other patients (p value 0.001). Among cases that had a perforated appendix (n = 105), the rates were 0% (0/31) compared to 18.9% (14/74; p value 0.009). Conclusions Utilization of a standardized large volume irrigation technique with the objective of serial dilution is associated with a significantly lower rate of subsequent abdominal infection, even among cases with a perforated appendix. Prospective studies are needed to evaluate this technique. Level of Evidence Level III. Type of study Treatment study.

Background Umbilical hernia is a common congenital anomaly, and can result in the appearance of a protuberant umbilicus. In select cases, inversion of the umbilical skin can be impaired by the presence of thickened dermis or fascial remnants of the umbilical stalk. Description of operative technique After umbilical herniorrhaphy, the skin is everted over the left index finger and radial partial thickness incisions in the fascia and dermis of the undersurface of the umbilicus. The umbilical skin is then inverted and secured to the fascia. Conclusion This operative technique can allow complete inversion of the umbilical skin creating an aesthetically appealing umbilical hernia repair.

We conducted a prospective phase I study to evaluate safety of an orally administered Salmonella encoding IL‐2 (SalpIL2) in combination with amputation and adjuvant doxorubicin for canine appendicular osteosarcoma. Efficacy was assessed as a secondary measure. The first dose of SalpIL2 was administered to 19 dogs on Day 0; amputation was done after 10 days with chemotherapy following 2 weeks later. SalpIL2 was administered concurrent with chemotherapy, for a total of five doses of doxorubicin and six doses of SalpIL2. There were six reportable events prior to chemotherapy, but none appeared due to SalpIL2. Dogs receiving SalpIL2 had significantly longer disease‐free interval (DFI) than a comparison group of dogs treated with doxorubicin alone. Dogs treated using lower doses of SalpIL2 also had longer DFI than dogs treated using the highest SalpIL2 dose. The data indicate that SalpIL2 is safe and well tolerated, which supports additional testing to establish the potential for SalpIL2 as a novel form of adjuvant therapy for dogs with osteosarcoma.

OBJECTIVE: To evaluate whether a history of preterm birth or small for gestational age (SGA) in a singleton pregnancy is associated with an increased risk of recurrence of the same condition in a subsequent twin pregnancy. METHODS: Retrospective cohort study of twin pregnancies delivered in one maternal–fetal medicine practice from 2005 to 2014. Patients with a history of singleton preterm birth at less than 37 weeks of gestation were compared with patients with a history of singleton term birth and nulliparous patients. A similar analysis was performed for a history of SGA (birth weight less than 10%). RESULTS: Six hundred forty-seven twin pregnancies were included. The prior singleton gestational age at delivery was significantly positively correlated with the twin gestational age at delivery (P,.001), and the prior singleton birth weight was significantly positively correlated with the birth weight of the larger twin (P,.001) and the smaller twin (P,.001). The rate of twin preterm birth before 32 weeks of gestation was 3.5% in patients with a prior term birth, 9.2% in nulliparous patients, and 26% in patients with a prior preterm birth (P,.001). The rate of SGA in patients with a prior birth not complicated by SGA was 42.1%, in nulliparous women it was 54.4%, and in patients with a history of SGA it was 65.2% (P5.007). On regression analysis, prior preterm birth and SGA of a singleton pregnancy were independently associated with recurrence of the same condition in a subsequent twin pregnancy. CONCLUSION: Prior preterm birth and SGA in a singleton pregnancy increase the risk of the same condition in a subsequent twin pregnancy. We postulate that the extrinsic mechanism responsible for the pathophysiology of adverse outcomes in twin pregnancies overlaps with that in singleton pregnancies. (Obstet Gynecol 2015;125:870–5)

Attenuated Salmonella enterica serovar Typhimurium (S. Typhimurium) has been developed as a vector to deliver therapeutic agents to tumors. The potential of S. Typhimurium in cancer therapy is largely due to its reported propensity to accumulate at greater than 1,000-fold higher concentrations in tumors relative to healthy tissues. In this study, we compared bacterial colonization of tumors in a subcutaneous transplantation model with a more clinically relevant autochthonous tumor model. Following intravenous administration of attenuated S. Typhimurium strain SL3261, we observed approximately 10,000-fold less bacteria in autochthonous tumors that sporadically develop in transgenic BALB-neuT mice compared to tumors developed from subcutaneous transplantation of 4T1 murine breast cancer cells in BALB/c mice. Treatment of BALB-neuT mice with a vasculature-disrupting agent (VDA) prior to bacterial treatment caused necrosis of tumor tissue and significantly increased the bacterial targeting of autochthonous tumors by approximately 1,000-fold. These observations emphasize the importance of appropriate model selection in developing bacteria-based cancer therapies and demonstrate the potential of combining VDA pre-treatment with bacteria to facilitate targeting of clinically relevant tumors.

Objective The objective of this study was to evaluate the association of screening tests for preterm birth (short cervical length [CL], positive fetal fibronectin (FFN), and amniotic fluid [AF] sludge) in twin gestations with histologic evidence of placental inflammation. Study Design Historical cohort study of 596 twin gestations delivered in a single maternal–fetal medicine practice with CL and FFN testing from 22 to 256/7 weeks. A short CL was defined as ≤25 mm. Placental lesions evaluated were chronic and acute membrane inflammation and funisitis. Fischer's exact test and logistic regression were used. Results None of the screening tests was associated with chronic inflammation. All were associated with acute inflammation. On regression analysis, a short CL and positive FFN remained independently associated with acute inflammation (adjusted odds ratio [aOR]: 5.66 and 2.51, respectively) and funisitis (aOR: 5.66 and 7.17, respectively). AF sludge was not independently associated with acute inflammation nor funisitis. Conclusion In twin gestations, a short CL and a positive FFN at 22 to 26 weeks are associated with acute but not chronic inflammation on placental histology. These findings imply that mechanisms underlying preterm birth in twins that result in positive screening tests weeks prior to delivery are not reflected as chronic placental inflammation. Therefore, pathologic interpretation of etiologic mechanisms for preterm birth may be limited using solely histologic reports.

Prematurity is associated with adverse outcomes. However, there are less data regarding long-term outcomes of twins based on gestational age at delivery. Our objective was to identify the association between gestational age at delivery and long-term outcomes in twins.All patients with a twin pregnancy ≥24 weeks delivered by a single Maternal Fetal Medicine practice from 2005 to 2014 were surveyed regarding pediatric outcomes at or after 2 years of life. We excluded twins with aneuploidy or major fetal anomalies. The survey was mail-based, with phone follow-up for nonresponses or for clarification. Using logistic regression analysis, we compared long-term outcomes between twins born in four gestational age groups: 24 to 27-6/7 weeks, 28 to 31-6/7 weeks, 32 to 35-6/7 weeks, and 36 weeks or later.Six hundred fifty-three twin deliveries met inclusion criteria and 425 (65.1%) mothers responded. Mean age at the time of survey completion was 6.0 ± 2.4 years. Earlier gestational age was significantly associated with neonatal death (14, 2, 0, and 0% in the four groups, respectively, p .001). Prematurity was associated with a composite of major adverse outcomes (death; cerebral palsy; necrotizing enterocolitis; chronic renal, heart, or lung disease) (14, 7, 4, and 2% in the four groups, p = .036), as well as minor adverse outcomes (learning disability; need for speech, occupational, or physical therapy) (83, 69, 54, and 38%, p .001).Long-term morbidity in twin pregnancies is inversely related to gestational age at delivery. However, for twins born after 28 weeks, neonatal death and severe long-term morbidity are rare.

Objective The objective of this study was to determine if treatment of overt hypothyroidism in twin pregnancies reduces adverse outcomes associated with overt hypothyroidism in pregnancy. Methods This is a retrospective cohort study of all patients who were presented with twin gestations between 2005 and 2013 to a single obstetrical practice. Patients who were diagnosed with overt hypothyroidism were identified. Patients were followed up with serial thyroid function tests and treated appropriately. Rates of adverse pregnancy outcomes were compared between patients with and without hypothyroidism with p Results In this study, 612 twin pregnancies were included; 85 patients were diagnosed with overt hypothyroidism. Patients with overt hypothyroidism were more likely to have had in vitro fertilization (78 vs. 62%; p Conclusion Our study shows that in twin gestations, there is no increased risk of adverse pregnancy outcomes between patients with treated overt hypothyroidism and those without overt hypothyroidism.

Objective: Recent studies have shown that for twin pregnancies with a cephalic presenting first twin, planned vaginal delivery is not associated with adverse short-term neonatal outcomes, as compared to planned cesarean delivery. Our objective was to compare long-term outcomes in twins, based on planned mode of delivery. Study design: This was a prospective, observational cohort of twin pregnancies delivered by a single MFM practice. All the patients with a twin pregnancy >34 weeks delivered from 2005–2014 were surveyed regarding pediatric outcomes at or after 2 years of life. The survey was mail-based, with phone follow-up for nonresponses or for clarification of answers. Using chi-square, Student’s t-tests, and regression analysis we compared outcomes between women who planned a vaginal (with active management of the second stage) versus cesarean delivery. The main outcome measures were: (1) a composite of major adverse outcomes (death, cerebral palsy, necrotizing enterocolitis, chronic renal, heart, or lung disease); (2) a composite of minor adverse outcomes (learning disability, speech therapy, occupational therapy, physical therapy). Results: Five hundred and thirty-two women met inclusion criteria and 354 (66.5%) responded. 178 (50.3%) women planned to have a cesarean delivery (100% of whom had a cesarean delivery) and 176 (49.7%) women planned to have a vaginal delivery (83% of whom had a vaginal delivery). The average age of the children at the time of the survey was 5.9 years. There were no differences in any pediatric outcomes between the two groups. After controlling for maternal age, IVF, obesity, and preeclampsia, the planned mode of delivery was not associated with a composite of major adverse outcomes (aOR 0.673, 95% CI 0.228, 1.985), nor a composite of minor adverse outcomes (aOR 0.767, 95% CI 0.496, 1.188). Conclusions: Planned vaginal delivery with active management of the second stage of labor in twin pregnancies >34 weeks is not associated with adverse childhood outcomes.

The objective was to identify risk factors associated with blood transfusion in patients undergoing high-order Cesarean delivery (CD).This was a retrospective cohort study of patients undergoing third or more CD by a single maternal-fetal medicine practice between 2005 and 2016. We compared risk factors between women who did and did not receive a red blood cell transfusion during the operation or before discharge. Repeat analysis was performed after excluding women with placenta previa.A total of 514 patients were included, 18 of whom (3.5%; 95% confidence interval [CI], 2.2%-5.5%) received a blood transfusion. Placenta previa was the most significant risk factor for transfusion (61.1% of patients who received a transfusion vs. 1% of patients who did not; p 0.001). Patients with a placenta previa had a 68.8% likelihood of requiring a blood transfusion. After women who had placenta previa were excluded, the incidence of blood transfusion was seven of 498 (1.4%; 95% CI, 0.7%-2.9%). Risk factors significantly associated with blood transfusion in the absence of previa were prophylactic anticoagulation during pregnancy and having labored. The incidence of transfusion in patients with no placenta previa, no anticoagulation, and no labor was 0.7% (95% CI, 0.3%-2.1%). Placenta previa was the most predictive risk factor for transfusion with a positive predictive value of 68.8% and a negative predictive value of 98.4%.In patients undergoing a third or more CD, only placenta previa, prophylactic anticoagulation during pregnancy, and having labored are independently associated with requiring a blood transfusion. These data can be used to guide physician ordering of prepared blood products preoperatively.

Introduction: To evaluate whether maternal serum α-fetoprotein (MSAFP) improves the detection rate for open neural tube defects (ONTDs) and ventral wall defects (VWD) in patients undergoing first-trimester and early second-trimester fetal anatomical survey. Material and Methods: A cohort of women undergoing screening between 2005 and 2012 was identified. All patients were offered an ultrasound at between 11 weeks and 13 weeks and 6 days of gestational age for nuchal translucency/fetal anatomy followed by an early second-trimester ultrasound at between 15 weeks and 17 weeks and 6 days of gestational age for fetal anatomy and MSAFP screening. All cases of ONTD and VWD were identified via query of billing and reporting software. Sensitivity and specificity for detection of ONTD/VWD were calculated, and groups were compared using the Fisher exact test, with p < 0.05 as significance. Results: A total of 23,790 women met the criteria for inclusion. Overall, 15 cases of ONTD and 17 cases of VWD were identified; 100% of cases were diagnosed by ultrasound prior to 18 weeks' gestation; none were diagnosed via MSAFP screening (p < 0.001). First-trimester and early second-trimester ultrasound had 100% sensitivity and 100% specificity for diagnosing ONTD/VWD. Discussion: Ultrasound for fetal anatomy during the first and early second trimester detected 100% of ONTD/VWD in our population. MSAFP is not useful as a screening tool for ONTD and VWD in the setting of this ultrasound screening protocol.

To estimate the association between maternal weight gain and SPTB in twin pregnancies.A case-control study of patients with twin pregnancies and a normal prepregnancy BMI (18.5-24.9 kg/m(2)) in one maternal-fetal medicine practice from 2005 to 2013. We reviewed maternal weight in six time periods: prepregnancy, 12-15 6/7 weeks, 16-19 6/7 weeks, 20-23 6/7 weeks, 24-27 6/7 weeks and 28-31 6/7 weeks. We compared maternal weight gain patterns across pregnancy between patients who did and did not have SPTB32 weeks. Student's t-test and chi-square were used for analysis.In total, 382 patients were included, 29 (7.6%) of whom had SPTB32 weeks. The baseline height, weight and BMI did not differ between the groups, nor did maternal age, IVF status, race or chorionicity. Patients with SPTB32 weeks had significantly less weight gain as early as 15 6/7 weeks (2.9 ± 4.6 versus 7.3 ± 6.6 lb, p 0.001), and this continued until 31 6/7 weeks (25.3 ± 8.7 versus 30.8 ± 10.9 lb, p = 0.037).In twin pregnancies with a normal prepregnancy BMI, there is a significant association between SPTB32 weeks and lower maternal weight gain, particularly prior to 16 weeks. Future studies are needed to test if prepregnancy or early nutritional interventions in twin pregnancies can reduce the risk of preterm birth and improve neonatal outcomes in this high-risk population.

Objective To report the obstetrical outcomes in patients with twin pregnancies who underwent an emergency/physical exam-indicated cerclage and to compare them to patients with singleton pregnancies undergoing the same procedure. Study design Patients who underwent emergency/physical exam-indicated cerclage in the second trimester in one maternal-fetal medicine practice from July 1997 to March 2012 were reviewed. We defined an emergency/physical exam-indicated cerclage as any cerclage placed in a patient with a dilated cervix on examination or membranes visible at the external cervical os on speculum examination. We compared outcomes between patients with singleton and twin pregnancies using non-parametric testing. Results There were 43 patients (12 twin and 31 singleton pregnancies) who underwent emergency/physical exam-indicated cerclage placement. The median gestational age at cerclage placement, cervical dilation, maternal age, and cerclage type were similar between the groups. Comparing twins to singletons, the median time from cerclage placement to delivery was similar (92 vs. 106 days, p =0.330), as was the median gestational age at delivery (33.5 vs. 35.0 weeks, p =0.244). The likelihood of delivery at >32 weeks (75.0% vs. 71.0%, p >0.999) and the likelihood of neonatal survival to discharge (83.3% vs. 83.9%, p >0.999) were also similar. Conclusions Emergency/physical exam-indicated cerclage in twin pregnancies can be associated with favorable outcomes, including a high likelihood of delivery at >32 weeks and a high likelihood of survival. Their outcomes appear similar to singleton pregnancies. Cerclage should be considered an option for patients with twin pregnancies and a dilated cervix in the second trimester.

The relationship between adolescent idiopathic scoliosis (AIS) and pectus excavatum (PE) is not well understood. We hypothesize that the combined thoracic malformations of AIS and PE may lead to a “double crush to the thorax” resulting in greater cardiopulmonary impairment than either thoracic malformation in isolation. We evaluated the Haller index (HI) and thoracic volume changes that occur pre- and post-operatively for kyphoscoliosis and PE by examining the case of a 12-year-old girl who had a “double crush to the thorax.” Using posterior-to-anterior and lateral standing scoliosis films obtained before and after both operations we determined the PE severity index (HI). Using the same radiographs a Blender based computational model was used to approximate the thoracic volumes. With correction of kyphoscoliosis the HI acutely increased from 1.9 to 3.2 with a decrease in thoracic volume of 11% resulting in shortness of breath and tachycardia. With PE repair the HI was returned to normal (HI = 2.4) and the thoracic volume increased 18%, with resolution of her cardiopulmonary symptoms. When severe kyphoscoliosis and PE co-exist consideration should be given to the implication of the “the double crush to the thorax” if cardiopulmonary symptoms arise.