Lior Drukker

Iron deficiency anemia at admission for labor and delivery is associated with an increased risk for Cesarean section and adverse maternal and neonatal outcomes.

Maternal iron deficiency anemia (IDA) impacts placenta and fetus. We evaluated effects of IDA at admission for delivery on cesarean rates, and adverse maternal and neonatal outcomes.

A 67-Year-Old Woman with BRCA 1 Mutation Associated with Pancreatic Adenocarcinoma

IntroductionThere are approximately 40,000 new cases of pancreatic adenocarcinoma diagnosed in the USA each year. It is estimated that 5–10% of all patients with pancreatic cancer have a first-degree relative with the disease, while up to 20% of cases have a hereditary component. Individuals who carry a germline mutation in the BRCA 1 or 2 genes have an increased lifetime risk of developing pancreatic adenocarcinoma when compared with the general population.Case reportHere, we present a case of metastatic pancreatic adenocarcinoma arising in a 67-year-old carrier of a BRCA 1 germline mutation.DiscussionIn patients with known BRCA 1 or 2 mutation-associated pancreatic adenocarcinoma, the addition of a DNA cross-linking agent such as cisplatin, oxaliplatin, or mitomycin to a standard gemcitabine chemotherapy backbone should be considered. Poly ADP-ribose inhibitors are a novel class of drug, which have demonstrated promising efficacy in trials of BRCA 1 and 2 mutant breast and ovarian cancer, and are currently undergoing prospective evaluation in advanced pancreatic cancer.

Perimortem cesarean section for maternal and fetal salvage: concise review and protocol.

Cardiopulmonary arrest is a rare event during pregnancy and labor. Perimortem cesarean section has been resorted to as a rare event since ancient times; however, greater awareness regarding this procedure within the medical community has only emerged in the past few decades. Current recommendations for maternal resuscitation include performance of the procedure after five minutes of unsuccessful cardiopulmonary resuscitation. If accomplished in a timely manner, perimortem cesarean section can result in fetal salvage and is also critical for maternal resuscitation. Nevertheless, deficits in knowledge about this procedure are common. We have reviewed publications on perimortem cesarean section and present the most recent evidence on this topic, as well as recommending our “easy‐to‐access protocol” adapted for resuscitation following maternal collapse.

Leiomyosarcoma of the inferior vena cava: radical surgery without vascular reconstruction.

Leiomyosarcoma of the inferior vena cava (IVC) is a rare tumor of mesenchymal origin, occurring most frequently in middle-aged women. Insidious complaints delay diagnosis, prognosis is poor, and the only curative modality remains an aggressive surgical resection yielding clear margins of disease. Commonly, radical tumor excision mandates caval repair or reconstruction, with significant related morbidity and mortality. We present a case of a 50-year-old woman with a leiomyosarcoma arising from the lower segment of the IVC, managed by surgical en-bloc resection of the tumor and IVC segment without further caval repair or reconstruction. During 14 months of follow-up the patient is well, had not had any complications, and is disease free.

Changes of PI3K/AKT/BCL2 signaling proteins in congenital Giant Nevi: melanocytes contribute to their increased survival and integrity

Abstract Congenital Giant Nevi (CGN) are rare melanocytic lesions with the potential to regress into malignant melanoma. Simultaneous up-regulation and cooperative interactions of signaling pathways are crucial events in the pathogenesis of melanocytes. Our study aimed to identify changes in the expression and activation of proteins controlling survival and/or apoptosis of the key signaling pathways PI3K/AKT/BCL2 and Wnt/β-catenin of CGN melanocytes. We applied a model of cultured melanocytes from paired CGN and normal appearing skin, and Western blot (WB) analyzed the expression and activation profile of survival and anti-apoptotic proteins of these signaling pathways, growth pattern, cell cycle and apoptosis. WB analysis demonstrated a significant higher expression level of activated AKT and of BCL2 proteins in the CGN melanocytes compared with paired melanocytes from normal appearing skin. A relative increase in the level of GSK3 and FOXO1 proteins, down stream targets of AKT, as well as of pβ-catenin was also detected in the CGN melanocytes compared with the controls. These changes were not affected by growth of the CGN melanocytes in reduced serum (starvation). Both cell populations shared a similar growth pattern, with no significant differences in the proportion of apoptotic cells and in cell cycle fractions. These data demonstrate for the first time, changes in signaling proteins of cultured CGN melanocytes. Further, suggesting that the changes in AKT/BCL2 signaling molecules might mediate growth and anti-apoptosis processes at least in part, thus increasing the survival potential of CGN melanocytes and maintaining their integrity.

Preliminary evaluation of novel skin closure of Pfannenstiel incisions using cold helium plasma and chitosan films

Abstract Objective: To assess the safety and performance of a new energy-based skin closure system (BioWeld1TM) for the surgical Pfannenstiel incision in patients scheduled for elective cesarean section. Methods: This prospective, single center, non-randomized study included 20 patients who were scheduled for elective cesarean section. The BioWeld1 system was performed after suturing the internal layers of the cesarean section incision. A clinical evaluation of safety and efficacy was performed for 1, 2, 4–7, 21, and 45 d after the procedure. The Vancouver Scar Scale (VSS) was used to evaluate scarring. Results: Up to 21 d after the procedure, no safety device-related adverse events were reported. All patients had full closure of the epidermis, a very low total VSS score, and no evidence of discharge, redness, edema, or thermal damage. None of the patients exhibited more than a mild degree of encrustation. Conclusion: The BioWeld1 System has been shown to be safe and effective for skin closure in cesarean section.

The next-generation: Long-term reproductive outcome of adults born at a very low birth weight.

BACKGROUND Preterm birth at very low birth weight (VLBW, <1500g) has a multitude of consequences that extend to various aspects of adult life. Little is known about the long-term reproductive outcome of VLBW that survive to adulthood. AIMS To evaluate the reproductive outcome of VLBW infants who survive to adulthood (next-generation). STUDY DESIGN Retrospective cohort. SUBJECTS Infants born at a single tertiary center between the years 1982-1997 who survived to 18years of age (first-generation). OUTCOME MEASURES The number and the birth weight of offspring from adults born with VLBW were compared to those of other birth weight groups born in the same epoch: 1500-2499g, 2500-3799g (reference group) and ≥3800g. We calculated the ratio of actual compared to expected number of children in the next-generation for extreme birth weight parents, using the reference group as a control group and adjusting for birth year. Thereafter, we measured whether first-generation VLBW had an increased risk for a VLBW in the next-generation. RESULTS After exclusions, we identified first-generation 67,183 births, including 618 (9.2%) VLBW. There were 193 males and 184 female VLBW infants who survived to adulthood. Both female and male first-generation patients from the VLBW group had half the reproductive rate relative for the normal birth weight group. After adjusting for parental age, male and female VLBW survivors had no significant risk for a VLBW neonate in the next-generation, however, the overall number of are small and may limit any conclusion. CONCLUSION VLBW children who reach adulthood may be at a significantly lower reproductive capacity.

Adenocarcinoma of the small bowel in a patient with occlusive Crohn’s disease

A 40-year-old male, diagnosed with mild Crohns disease (CD) 11 years ago but with no prior abdominal surgeries, was diagnosed with a small bowel stricture, due to ongoing abdominal pain and intolerance of enteral diet, and referred for surgical treatment. Exploratory laparoscopy revealed a white solid mass causing a near total jejunal obstruction with significant proximal dilatation. An adjacent small node was sampled for frozen biopsy, revealing a lymph node infiltrated with adenocarcinoma. Laparoscopic assisted small bowel resection and appendectomy were carried out. Final pathological results supported the initial report of diffuse small bowel adenocarcinoma. In conclusion, once a small bowel stricture associated with CD is suspected, rapid action should be considered to avoid late diagnosis of a neoplasia.

Fetal Urine Production Rate in Preterm Premature Rupture of Membranes Is Associated with Adverse Neonatal Outcome: A Pilot Study

Aim: In this study, we evaluate the associations between fetal urinary production rate (FUPR), measured by ultrasound, and adverse neonatal outcome in women with preterm premature rupture of membranes (PPROM). Methods: We conducted a prospective pilot cohort of singleton pregnancies complicated by PPROM occurring at gestational week 24 or later managed until spontaneous labor (after 48 h of admission), chorioamnionitis, or induction by protocol at 35 + 0 weeks. FUPR was evaluated by 2D sonography at admission (corrected for gestational age). The main neonatal outcome measures were chorioamnionitis, placental inflammatory grading, first neonatal creatinine value, first neonatal dextrose value, length of neonatal intensive care unit (NICU) stay, necrotizing enterocolitis (NEC), intraventricular hemorrhage (IVH) (grades I-IV), blood transfusions, reduced neonatal urine production rate (<4 mL/kg/h), and early neonatal sepsis. Samples of maternal (at admission) and umbilical cord blood were analyzed for interleukin-6 (IL-6) level. Results: The study included 38 women. Low FUPR was associated with clinical chorioamnionitis, longer NICU hospitalization (p = 0.01), higher rates of NEC or IVH (p = 0.008), and blood transfusion (p = 0.004). Conclusions: A finding of FUPR on in utero ultrasound examination in pregnancies complicated by PPROM may be indicative of adverse neonatal outcome.

Epidural analgesia at trial of labor after cesarean (TOLAC): a significant adjunct to successful vaginal birth after cesarean (VBAC).

Abstract Introduction: Epidural analgesia has been considered a risk factor for labor dystocia at trial of labor after cesarean (TOLAC) and uterine rupture. We evaluated the association between exposure to epidural during TOLAC and mode of delivery and maternal-neonatal outcomes. Materials and methods: A single center retrospective study of women that consented to TOLAC within a strict protocol between 2006 and 2013. Epidural “users” were compared to “non-users”. Primary outcome was the mode of delivery: repeat in-labor cesarean or vaginal birth after cesarean (VBAC). Secondary outcomes were maternal/neonatal morbidities. Univariate/multivariate analyses for associations between epidural and mode of delivery were adjusted for significant covariates/mediators. Results: Of a total of 105,471 births registered, 9464 (9.0%) were eligible for TOLAC; 7149 (75.5%) women consented to TOLAC, among which 4081 (57.1%) had epidural analgesia. The in labor cesarean rate was significantly lower for the epidural “users” 8.7% vs. “non-users” 11.8%, P<0.0001, with a parallel increased rate of instrumental delivery. Uterine rupture rates were comparable: 0.4% and 0.29%, respectively (P=0.31). The adjusted multivariate model showed that epidural “users” were more likely to experience a VBAC, odds ratio (OR) 4.58 [3.67; 5.70]; P<0.0001 with a similar rate of adverse maternal-neonatal outcomes. Conclusion: Epidural analgesia at TOLAC may emerge as a safe and significant adjunct for VBAC.