Michael Kruger

Staging of twin-twin transfusion syndrome

OBJECTIVE:The purpose of this study was to evaluate the prognostic value of sonographic and clinical parameters to develop a staging classification of twin-twin transfusion syndrome (TTTS).STUDY DESIGN:Severe TTTS was defined as the presence of polyhydramnios (maximum vertical pocket of ≥8 cm) and oligohydramnios (maximum vertical pocket of ≤2 cm). Nonvisualization of the bladder in the donor twin (−BDT) and absence of presence of hydrops was also noted. The middle cerebral artery, umbilical artery, ductus venosus, and umbilical vein in both fetuses were assessed with pulsed Doppler. Critically abnormal Doppler studies (CADs) were defined as absent/reverse end-diastolic velocity in the umbilical artery, reverse flow in the ductus venosus, or pulsatile flow in the umbilical vein. TTTS was staged as follows: stage I, BDT still visible; stage II, BDT no longer visible, no CADs; stage III, CADs; stage IV, hydrops; stage V, demise of one or both twins. Laser photocoagulation of communicating vessels (LPCV) or umbilical cord ligation was performed depending on the severity of the condition. The study was approved by the Institutional Review Board of St. Joseph’s Hospital in Tampa and by the Fetal Therapy Board at Hutzel Hospital, Detroit, and all patients gave informed consent.RESULTS:A total of 80 of 108 referred patients met criteria for surgery, but only 65 were treated surgically: 48 with LPCV and 17 with umbilical cord ligation. Complete Doppler data were obtainable in 41 of 48 LPCV patients. Survival rates by stage for one or two fetuses were statistically different (χ-squared analysis = 12.9, df = 6, p = 0.044). Neither percent size discordance nor gestational age at diagnosis were predictive of outcome.CONCLUSION: Staging of TTTS using the proposed criteria has prognostic significance. This staging system may allow comparison of outcome data of TTTS with different treatment modalities.

Middle cerebral artery peak systolic velocity: a new Doppler parameter in the assessment of growth-restricted fetuses.

The aims of this study were to determine if there is a relationship between middle cerebral artery (MCA) peak systolic velocity (PSV) and perinatal mortality in preterm intrauterine growth‐restricted (IUGR) fetuses, to compare the performance of MCA pulsatility index (PI), MCA‐PSV and umbilical artery (UA) absent/reversed end‐diastolic velocity (ARED) in predicting perinatal mortality, to determine the longitudinal changes that occur in MCA‐PI and MCA‐PSV in these fetuses, and to test the hypothesis that MCA‐PSV can provide additional information on the prognosis of hypoxemic IUGR fetuses.

Metabolomics and first-trimester prediction of early-onset preeclampsia.

Objective: To evaluate the use of metabolomics for the first-trimester detection of maternal metabolic dysfunction and prediction of subsequent development of early-onset preeclampsia (PE). Study design: This was a case-control study of maternal plasma samples collected at 11–13 weeks’ gestation from 30 women who had subsequently developed PE requiring delivery before 34 weeks and 60 unaffected controls. Nuclear magnetic Resonance (NMR) spectroscopy was used to identify and quantify metabolomic changes in cases versus controls. Both genetic computing and standard statistical analyses were performed to predict the development of PE from the metabolite concentrations alone as well as the combination of metabolite concentrations with maternal characteristics and first-trimester uterine artery Doppler pulsatility index (PI). Results: Significant differences between cases and controls were found for 20 metabolites. A combination of four of these metabolites (citrate, glycerol, hydroxyisovalerate, and methionine) appeared highly predictive of PE with an estimated detection rate of 75.9%, at a false-positive rate (FPR) of 4.9%. The predictive performance was improved by the addition of uterine artery Doppler PI and fetal crown-rump length (CRL) and with an estimated detection rate of 82.6%, at a FPR of 1.6%. Conclusion: A profound change in the first-trimester metabolite profile was noted in women who had subsequently developed early-onset PE. Preliminary algorithms appeared highly sensitive for first trimester prediction of early onset PE.

Adverse obstetric outcomes associated with sonographically identified large uterine fibroids.

STUDY OBJECTIVE To determine the impact of sonographically identified large uterine fibroids (>5 cm in diameter) on obstetric outcomes. DESIGN Retrospective cohort study. SETTING University teaching hospital. PATIENT(S) Women with singleton gestations (n = 95) noted to have uterine fibroids on obstetric ultrasonography from September 2009 through April 2010 and age-matched controls (n = 95). INTERVENTION(S) None. MAIN OUTCOME MEASURE(S) Obstetric outcomes including short cervix, preterm premature rupture of membranes, and preterm delivery. RESULT(S) Compared to women with no fibroids or small fibroids (≤5 cm), women with large fibroids (>5 cm) delivered at a significantly earlier gestational age (38.6 vs. 38.4 vs. 36.5 weeks). Short cervix, preterm premature rupture of membranes, and preterm delivery were also significantly more frequent in the large fibroid group, and were associated with number of fibroids >5 cm in diameter. Blood loss at delivery was significantly higher in the large fibroid group (486.8 vs. 535.6 vs. 645.1 mL), as was need for postpartum blood transfusion (1.1 vs. 0.0 vs. 12.2%). CONCLUSION(S) Women with large uterine fibroids in pregnancy are at significantly increased risk for delivery at an earlier gestational age compared to women with small or no fibroids, as well as obstetric complications including excess blood loss and increased frequency of postpartum blood transfusion.

Smile Intensity in Photographs Predicts Longevity

Emotions affect personalities and life outcomes by influencing how people think, behave, and interact with others (Izard, 1971). People with positive emotions are happier and have more stable personalities, more stable marriages, and better cognitive and interpersonal skills than those with negative emotions, throughout the life span (Harker & Keltner, 2001; Hertenstein, Hansel, Butts, & Hile, 2009). Facial expressions are a barometer of the emotions (Izard, 1971), and like emotions, they vary in form and intensity. Studies by Ekman, Friesen, and their colleagues (e.g., Ekman & Friesen, 1978; Ekman, Levenson, & Friesen, 1983; Levenson, Ekman, & Friesen, 1990) have shown that it is possible to identify different emotional states from facial expressions. Previous studies have found that positive emotions, as inferred from smile intensity in childhood photos and college yearbook photos, are correlated with marriage stability and satisfaction (Harker & Keltner, 2001; Hertenstein et al., 2009). The present study is the first to link smile intensity to a biological outcome: longevity. Little information (other than smile intensity) was available regarding the individuals in the previously mentioned photo studies. In the current study, however, we were able to include many additional factors known to influence longevity because of the group we elected to evaluate. We focused on Major League Baseball (MLB) players because detailed statistics are available for each player (dating back prior to 1900), and because MLB players represent a homogeneous occupational group. We (and other researchers) have used this database to examine numerous factors related to longevity (Abel & Kruger, 2005, 2006, 2007; Kalist & Peng, 2007).

Daily coffee consumption and prevalence of nonmelanoma skin cancer in Caucasian women

The purpose of this study was to assess the relationship between daily coffee consumption and nonmelanoma skin cancer. This study was a cross-sectional analysis of women enrolled in the Womens Health Initiative Observational Study (n=93 676). As nearly all cases of self-reported nonmelanoma skin cancer occurred among Caucasian women (97.8%), we focused our analyses on this group. Compared with nondrinkers, women drinking only caffeinated coffee on a daily basis had a 10.8% lower prevalence of nonmelanoma skin cancer. Consumption of six or more cups of caffeinated coffee per day was associated with a 36% reduction in nonmelanoma skin cancer. After adjusting for various demographic and life style variables, daily consumption of six or more cups was associated with a 30% reduced prevalence of nonmelanoma skin cancer. In contrast to caffeinated coffee, daily consumption of decaffeinated coffee was not associated with a significant change in self-reported nonmelanoma skin cancer for Caucasian women. Daily caffeinated coffee consumption was associated with a dose-related decreased prevalence of nonmelanoma skin cancer in Caucasian women.

Seroprevalence of Bordetella pertussis Antibodies in Mothers and their Newborn Infants

BACKGROUND: Pertussis is a highly communicable, vaccine-preventable respiratory disease. Although the largest number of reported cases is among young infants, the most rapidly increasing incidence in the USA is in adolescents and young adults. Importantly, adult family members are the likely major reservoir, infecting susceptible infants before completion of childhood vaccination. We studied maternal-neonatal paired blood samples for the presence of pertussis-related antibodies to assess level of immunity and passive transplacental antibody passage. METHODS. Unselected maternal-neonatal cord blood samples were collected from 101 term deliveries in a single urban uninsured/underinsured hospital setting. Sera were analyzed for anti-pertussis toxin (PT), filamentous hemagglutinin (FHA) and pertactin (PRN) IgG antibodies by enzyme-linked immunosorbent assay (ELISA). Antibody titers were calculated using reference line methodology. Antibody values were log-transformed to establish geometric mean titers (GMT) for analysis. Students t-test, Mann-Whitney, Pearson correlation and chi square were used for statistical comparisons as appropriate. RESULTS. Mean (SD) maternal age, gestational age and birth weight were 26.8 (6.8) years, 38.9 (1.4) weeks and 3239 (501) g, respectively. Detectable maternal levels of anti-PT, FHA and PRN were found in 34.7%, 95.0% and 80.2%, respectively. Maternal GMT (SD) for PT, FHA and PRN were 4.4 (2.6), 26.6 (3.1) and 12.3 (2.9), respectively. There was no significant relationship between PT, FHA or PRN detection or antibody GMT and maternal age. Maternal anti-PT, FHA and PRN were highly correlated with neonatal cord blood values. CONCLUSION: Despite previous childhood immunization, a large number of parous women have low or undetectable pertussis-related antibody levels, suggesting susceptibility to infection. Even with efficient transplacental passage of these antibodies, neonates similarly have limited measurable protection as detected by cord blood sampling. These data support the need for adolescent or adult vaccination against Bordetella pertussis. Healthcare providers and their clients should be aware of the risk for infant infection via family member transmission.

First-trimester metabolomic detection of late-onset preeclampsia

OBJECTIVE We sought to identify first-trimester maternal serum biomarkers for the prediction of late-onset preeclampsia (PE) using metabolomic analysis. STUDY DESIGN In a case-control study, nuclear magnetic resonance-based metabolomic analysis was performed on first-trimester maternal serum between 11(+0)-13(+6) weeks of gestation. There were 30 cases of late-onset PE, i.e., requiring delivery ≥37 weeks, and 59 unaffected controls. The concentrations of 40 metabolites were compared between the 2 groups. We also compared 30 early-onset cases to the late-onset group. RESULTS A total of 14 metabolites were significantly elevated and 3 significantly reduced in first-trimester serum of late-onset PE patients. A complex model consisting of multiple metabolites and maternal demographic characteristics had a 76.6% sensitivity at 100% specificity for PE detection. A simplified model using fewer predictors yielded 60% sensitivity at 96.6% specificity. Strong separation of late- vs early-onset PE groups was achieved. CONCLUSION Significant differences in the first-trimester metabolites were noted in women who went on to developed late-onset PE and between early- and late-onset PE.

Trends in major modifiable risk factors for severe perineal trauma, 1996–2006

Objective: To examine what effect the major modifiable risk factors for severe perineal trauma have had on the rates of this trauma over time. Methods: A retrospective observational cohort study of singleton vaginal deliveries taken from a perinatal database for the period 1996 through 2006. Results: A total of 46 239 singleton vertex vaginal deliveries met the inclusion criteria. Major risk factors for severe perineal trauma were increased maternal age (odds ratio [OR] 1.28, 95% confidence interval [CI] 1.1–1.5), non‐African American ethnicity (OR 1.5, 95% CI 1.3–1.7), nulliparity (OR 4.8, 95% CI 4.11–5.6), fetal birth weight (OR 2.2, 95% CI 1.9–2.4), forceps (OR 8.3, 95% CI 5.4–10.8), vacuum (OR 2.9, 95% CI 1.9–4.4), and midline episiotomy (OR 5.7, 95% CI 5.0–6.4). Evaluation of the changes in rates of these factors over the study period revealed that the decline in the rates of episiotomy and the use of forceps accounted for a reduction in severe lacerations of more than 50%. Conclusion: Reduction of severe perineal trauma by restricted use of the 2 modifiable clinical variables, episiotomy and forceps, is evident over time.

Being too large for gestational age precedes childhood obesity in African Americans.

OBJECTIVE The purpose of this study was to investigate the association between large-for-gestational-age (LGA) infants and the development of childhood obesity in an inner-city primarily African American population. STUDY DESIGN Maternal, neonatal, socioeconomic, and nutritional histories were collected for mothers with children who were 2-5 years old. Associations between Alexander and customized birthweight percentiles and body mass index for the age of the child were examined. RESULTS One hundred ninety-five mother-child pairs were enrolled; the childhood obesity rate was 18%. Increasing Alexander and customized birthweight percentiles were related to increasing obesity. LGA newborn infants were 2.5 times more likely to be obese in childhood than average size newborn infants. Maternal smoking was also associated with childhood obesity. CONCLUSION LGA infants have the highest likelihood of childhood obesity in this inner-city predominantly African American population. Customized growth percentiles perform best in the identification of the highest risk population.