Contemporary management of prenatally diagnosed spina bifida aperta — an update

Spina bifida aperta is a relatively common congenital defect that occurs in the general population. Once the disorder hasbeen diagnosed, a discussion, that can be emotionally-charged, ensues about whether to treat it prenatally or to only offer surgery postnatally. Given that there are good arguments for and against both options, it is of paramount importance to gain a good understanding of the major advantages and disadvantages of the various surgical approaches. The aim of our paper is to summarize current knowledge about spina bifida and the potential benefits of prenatal surgery

The chorionic bump associated with acrania – case report

The chorionic bump is a rare abnormality of the gestational sac, presenting as a convex bulge from the choriodecidual surface into the sac, correlated with poor prognosis for the pregnancy. We report a case of a 36-year-old pregnant woman, with a history of spontaneous abortion, who presented for an early scan at 6 weeks and 4 days of gestation. The pregnancy was spontaneous and unplanned. The patient conceived in less than 3 months after discontinuing oral contraceptives. No folic acid was taken before or in the pregnancy. An ultrasound scan revealed a chorionic bump with a hypoechoic center and echogenic border, measuring 18.3 x 14.7 x 21.9 mm. No motion within the chorionic bump was detected upon color and power Doppler examination. The second scan was performed a week later, at 7+4 wks. The chorionic bump had not changed in terms of size and sonographic appearance. An acranial fetus of CRL 45.5 mm was diagnosed at 11+2 wks. The concentration of free β-hCG was 17.2 IU/L, corresponding to 0.37 MoM and PAPP-A levels were 1.31 IU/L, corresponding to 0.82 MoM. After counseling the patient opted for termination of pregnancy. Very few cases of chorionic bumps have been described so far and, to the best of our knowledge, its coexistence with neural tube defects has been reported for the first time. We postulate a possibility of an underlying pathological mechanism for such coexistence. The chorionic bump is a focal convex bulge with irregular borders, protruding from the choriodecidual surface into the gestational sac and with different degrees of echogenicity, usually a hypoechoic middle and echogenic border. The chorionic bump might represent the following: a hematoma, an area of hemorrhage, a non-embryonic gestation, or a demise of an embryo in a twin pregnancy. The presence of the bump is associated with a four-fold increase in the spontaneous abortion rate as compared with the general population. Decreased folate levels increase the incidence of neural tube defects. Oxidative stress resulting from folic acid deficiency may be responsible for neural tube defects through impairment of factors inhibiting apoptosis in the neuroepithelium. Fetuses with neural tube defects are at an increased risk of being aborted spontaneously. Furthermore, women who deliver children with neural tube defects frequently have a history of miscarriage. Our patient did not take any folic acid and also had a history of spontaneous miscarriage. In the case we herein presented, the coexistence of acrania and placental pathology could be attributed to folate deficiency. Such coexistence is described for the first time and could be accidental, but there is possible theoretical association between these two pathologies

Niewydolność szyjki macicy u pacjentki w ciąży bliźniaczej jednokosmówkowej jednoowodniowej skutecznie leczona szwem szyjkowym ratunkowym i pessarium – opis przypadku i przegląd piśmiennictwa

A monochorionic monoamniotic (MCMA) twin pregnancy is the rarest form of twin gestation, accounting for around 1:10000 to 1:20000 of all deliveries regardless of the region of the world. All multiple gestations have a higher risk of preterm delivery due to either preterm uterine contractions or asymptomatic cervical shortening (cervical incompetence). A case of a 28-year-old primigravida in MCMA twin pregnancy with cervical incompetence diagnosed at 22 weeks of gestation is presented. After obtaining cervical swabs, negative laboratory infection parameters and confirming concordant gestational age on ultrasound scan with no structural abnormalities of both fetuses, the patient was qualified for an emergency cervical cerclage according to Wurm-Hefner method. Five days after the procedure, a cervical pessary was additionally inserted. She was administered antibiotics and steroids. The wellbeing of both fetuses was strictly monitored by means of cardiotocography tracing and ultrasound examinations, on which they were both eutrophic, with no abnormalities in Doppler blood flow patterns. Spontaneous premature rupture of membranes took place at 32 weeks of gestation, a cesarean section was performed and two female fetuses of 1740g and 1760g were delivered. They both required antibiotics because of congenital pneumonia, but no respiratory support was necessary. The twins were discharged from the hospital 22 days after birth in good general condition. This case of a rescue cervical cerclage and pessary used simultaneously can be an example of an effective method of cervical incompetence treatment in twin pregnancies.Ciąża bliźniacza jednokosmówkowa jednoowodniowa (JKJO) jest najrzadszym wariantem ciąży bliźniaczej. Porody ciąż jednoowodniowych stanowią około 1:10000 do 1:20000 wszystkich porodów niezależnie od regionu świata. Ciąże mnogie obarczone są wyższym ryzykiem porodu przedwczesnego w mechanizmie przedwczesnej czynności skurczowej macicy lub bezobjawowego skracania i niewydolności cieśniowo-szyjkowej. Przedstawiono przypadek 28-letniej pierwiastki w ciąży bliźniaczej JKJO, u której zdiagnozowano niewydolność cieśniowo-szyjkową w 22. tygodniu ciąży. Po pobraniu posiewów z kanału szyjki macicy oraz uzyskaniu negatywnych wykładnikow stanu zapalnego, pacjentkę zakwalifikowano do założenia ratunkowego szwu szyjkowego metodą Wurm-Hefnera. Pięć dni po operacji dodatkowo założono pessar szyjkowy. Zastosowano antybiotykoterapię oraz sterydoterapię. Dobrostan obu płodów ściśle monitorowano przy użyciu kardiotokografii oraz badań ultrasonograficznych, w których potwierdzono prawidłowy rozwój płodów oraz brak odchyleń w badaniach dopplerowskich. W 32. tygodniu ciąży samoistnie odpłynął płyn owodniowy. Pacjentkę rozwiązano cięciem cesarskim. Urodzono dwa noworodki płci żeńskiej o masie 1740g oraz 1760g, które wymagały antybiotykoterapii z powodu wrodzonego zapalenia płuc. Niemniej jednak nie wymagały żadnego wsparcia oddechowego. Bliźnięta wypisano do domu 22 dni po porodzie w stanie ogólnym dobrym. Prezentowany przypadek zastosowania szwu szyjkowego ratunkowego oraz pessarium może stanowić przykład skutecznej metody leczenia niewydolności cieśniowoszyjkowej w ciąży bliźniaczej

The Role Of Culture In International Relationship Marketing

International relationships are increasingly critical to business performance. Yet despite a recent surge in international research on relationship marketing (RM), it is unclear whether or how RM should be adapted across cultures. The authors adopt Hofstede's dimensions of culture to conduct a comprehensive, multivariate, metaregression analysis of 47,864 relationships across 17 studies, 36 countries, and six continents. To guide theory, they propose four tenets that parsimoniously capture the essence of culture's effects on RM. Study 1 affirms these tenets and emphasizes the importance of taking a fine-grained perspective to understand the role of culture in RM because of the high degree of heterogeneity across different cultural dimensions and RM linkages. For example, the magnitude of individualism's effect is 71% greater on RM than other cultural dimensions, whereas masculinity has almost no effect; however, accounting only for individualism ignores significant moderating effects of power distance and uncertainty avoidance dimensions. To guide managers, Study 2 adopts a country-level approach and reveals that RM is much more effective outside the United States such that relationships are 55% more effective, on average, for increasing business performance in Brazil, Russia, India, and China.Journal of Marketing 78(5), 78-98. (2014)0022-242

Ocena przepływów w tętnicy wątrobowej płodu w diagnostyce prenatalnej. Przegląd literatury

Standards of screening tests for the most frequent fetal chromosomal defects in modern non-invasive prenatal diagnostics provide sensitivity of about 93-96%, with the false positive rate of 2.5%. During the first trimester scan, routinely performed between 11 and 13+6 week of pregnancy, the calculation of the risk for chromosomal aberrations is based on maternal age (MA), nuchal translucency (NT), levels of free β human chorionic gonadotropin (free β-hCG), pregnancy associated plasma protein A (PAPP-A) in maternal blood, as well as the parameters from extended ultrasound examination like evaluation of the nasal bone (NB), blood flow in ductus venosus (DV), visualization of the tricuspid valve with potential regurgitation (TR) or measurement of the frontomaxillary facial angle (FMFA). The 100% detection rate remains unachievable at present, despite constantly improving guidelines for specialists, quality of imaging, and advancement in ultrasound technology. Therefore, several studies have been undertaken to establish the group of ‘additional markers’ of chromosomal defects which, when combined with basic markers of routine screening tests, might increase the detection rate and approach it to 100%. Results of recent studies imply that evaluation of blood flow in fetal hepatic artery performed during the first trimester scan may become a new additional marker for chromosomal defects.Standardy badań przesiewowych stosowane w nowoczesnej nieinwazyjnej diagnostyce prenatalnej zapewniają czułość wykrywania najczęstszych wad chromosomowych u płodów sięgającą 93-96% z odsetkiem wyników fałszywie pozytywnych 2,5%. W trakcie rutynowego badania ultrasonograficznego pierwszego trymestru wykonywanego pomiędzy 11 i 13+6 tygodniem ciąży, kalkulacja ryzyka wystąpienia zaburzeń chromosomowych opiera się na wieku matki (MA – Maternal Age), przezierności karku (NT – Nuchal Translucency), poziomie wolnej podjednostki β ludzkiej gonadotropiny kosmówkowej (free-hCG) i ciążowego białka osoczowego A (PAPP-A) oraz parametrach wchodzących w zakres badania rozszerzonego takich jak: ocena kości nosowej (NB – Nasal Bone), ocena przepływu w przewodzie żylnym (DV – Ductus Venosus), wizualizacja zastawki trójdzielnej i jej ewentualna niedomykalność (TR – Tricuspid Regurgitation) czy pomiar kąta twarzowo-szczękowego (FMFA – Frontomaxillary Facial Angle). Mimo tego, że rekomendacje dla specjalistów są nieustannie udoskonalane, a jakość obrazowania przy pomocy aparatów ultrasonograficznych ciągle rośnie, w praktyce nie udaje się uzyskać 100% detekcji. Z tego względu podejmuje się badania mające na celu znalezienie tzw. „markerów dodatkowych” aberracji chromosomowych, które w połączeniu z markerami wchodzącymi w skład rutynowych badań przesiewowych mogłyby podnieść czułość i zbliżyć ją do poziomu 100%. Wyniki przeprowadzonych badań sugerują, że kolejnym markerem dodatkowym może stać się ocena przepływu w tętnicy wątrobowej wykonywana w czasie badania ultrasonograficznego pierwszego trymestru ciąży

TabAttention: Learning Attention Conditionally on Tabular Data

Medical data analysis often combines both imaging and tabular data processing using machine learning algorithms. While previous studies have investigated the impact of attention mechanisms on deep learning models, few have explored integrating attention modules and tabular data. In this paper, we introduce TabAttention, a novel module that enhances the performance of Convolutional Neural Networks (CNNs) with an attention mechanism that is trained conditionally on tabular data. Specifically, we extend the Convolutional Block Attention Module to 3D by adding a Temporal Attention Module that uses multi-head self-attention to learn attention maps. Furthermore, we enhance all attention modules by integrating tabular data embeddings. Our approach is demonstrated on the fetal birth weight (FBW) estimation task, using 92 fetal abdominal ultrasound video scans and fetal biometry measurements. Our results indicate that TabAttention outperforms clinicians and existing methods that rely on tabular and/or imaging data for FBW prediction. This novel approach has the potential to improve computer-aided diagnosis in various clinical workflows where imaging and tabular data are combined. We provide a source code for integrating TabAttention in CNNs at https://github.com/SanoScience/Tab-Attention.Comment: Accepted for the 26th International Conference on Medical Image Computing and Computer Assisted Intervention (MICCAI) 202

Varying the rate of intravenous cocaine infusion influences the temporal dynamics of both drug and dopamine concentrations in the striatum

The faster drugs of abuse reach the brain, the greater is the risk of addiction. Even small differences in the rate of drug delivery can influence outcome. Infusing cocaine intravenously over 5 vs. 90â 100 s promotes sensitization to the psychomotor and incentive motivational effects of the drug and preferentially recruits mesocorticolimbic regions. It remains unclear whether these effects are due to differences in how fast and/or how much drug reaches the brain. Here, we predicted that varying the rate of intravenous cocaine infusion between 5 and 90 s produces different rates of rise of brain drug concentrations, while producing similar peak concentrations. Freely moving male Wistar rats received acute intravenous cocaine infusions (2.0 mg/kg/infusion) over 5, 45 and 90 s. We measured cocaine concentrations in the dorsal striatum using rapidâ sampling microdialysis (1 sample/min) and highâ performance liquid chromatographyâ tandem mass spectrometry. We also measured extracellular concentrations of dopamine and other neurochemicals. Regardless of infusion rate, acute cocaine did not change concentrations of nonâ dopaminergic neurochemicals. Infusion rate did not significantly influence peak concentrations of cocaine or dopamine, but concentrations increased faster following 5â s infusions. We also assessed psychomotor activity as a function of cocaine infusion rate. Infusion rate did not significantly influence total locomotion, but locomotion increased earlier following 5â s infusions. Thus, small differences in the rate of cocaine delivery influence both the rate of rise of drug and dopamine concentrations, and psychomotor activity. A faster rate of rise of drug and dopamine concentrations might be an important issue in making rapidly delivered cocaine more addictive.Varying the rate of i.v. cocaine delivery between 5 and 90 s determines the drug’s effects on brain and behaviour. We show that injecting cocaine between 5 and 90 s in rats alters the rates of rise of cocaine and dopamine in the dorsal striatum, without significantly changing peak concentrations. Faster injections also increase locomotor behaviour earlier than slower injections. Thus, beyond achieved dose, differences in the rates of rise of cocaine and dopamine can determine outcome.Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/151808/1/ejn13941-sup-0002-reviewer-Comments.pdfhttps://deepblue.lib.umich.edu/bitstream/2027.42/151808/2/ejn13941.pdfhttps://deepblue.lib.umich.edu/bitstream/2027.42/151808/3/ejn13941-sup-0001-FigS1-S3.pdfhttps://deepblue.lib.umich.edu/bitstream/2027.42/151808/4/ejn13941_am.pd

Transformational Relationship Events

Exchange events are fundamental building blocks of business relationships and essential to relationship development. However, some events contribute to incremental relationship development, as predicted by life cycle theories, whereas others spark "turning points" with dramatic impacts on the relationship. Such transformational relationship events are encounters between exchange partners that significantly disconfirm relational expectations (positively or negatively); they result in dramatic, discontinuous change to the relationship's trajectory and often reformulate the relationship itself. With a three-study, multimethod design, the authors (1) establish a foundation for differentiating dramatic and incremental exchange events on the basis of relational versus product expectations and disconfirmations, thus revealing that strong relationships benefit product disconfirmations but harm relational disconfirmations, and (2) conceptualize, define, and differentiate transformational relationship events from other types of disconfirming events and then link them to exchange performance.Journal of Marketing 79(5), 39-62. (2015)0022-242

Is the sFlt-1/PlGF ratio efficient in predicting adverse neonatal outcomes in small-for-gestational-age newborns? A prospective observational multicenter cohort study

IntroductionFetuses with growth abnormalities are at an increased risk of adverse neonatal outcomes. The aim of this study was to investigate if placental growth factor (PlGF), soluble fms-like tyrosine kinase-1 (sFlt-1), or the sFlt-1/PlGF ratio were efficient predictive factors of adverse neonatal outcomes in small-for-gestational-age (SGA) newborns.MethodsA prospective observational multicenter cohort study was performed between 2020 and 2023. At the time of the SGA fetus diagnosis, serum angiogenic biomarker measurements were performed. The primary outcome was an adverse neonatal outcome, diagnosed in the case of any of the following: <34 weeks of gestation: mechanical ventilation, sepsis, necrotizing enterocolitis, intraventricular hemorrhage grade III or IV, and neonatal death before discharge; ≥34 weeks of gestation: Neonatal Intensive Care Unit hospitalization, mechanical ventilation, continuous positive airway pressure, sepsis, necrotizing enterocolitis, intraventricular hemorrhage grade III or IV, and neonatal death before discharge.ResultsIn total, 192 women who delivered SGA newborns were included in the study. The serum concentrations of PlGF were lower, leading to a higher sFlt-1/PlGF ratio in the adverse outcome group. No significant differences in sFlt-1 levels were observed between the groups. Both PlGF and sFlt-1 had a moderate correlation with adverse neonatal outcomes (PlGF: R − 0.5, p < 0.001; sFlt-1: 0.5, p < 0.001). The sFlt-1/PlGF ratio showed a correlation of 0.6 (p < 0.001) with adverse outcomes. The uterine artery pulsatility index (PI) and the sFlt-1/PlGF ratio were identified as the only independent risk factors for adverse outcomes. An sFlt-1/PlGF ratio of 19.1 exhibited high sensitivity (85.1%) but low specificity (35.9%) in predicting adverse outcomes and had the strongest correlation with them. This ratio allowed the risk of adverse outcomes to be assessed as low with approximately 80% certainty.DiscussionThe sFlt-1/PlGF ratio seems to be an efficient predictive tool in adverse outcome risk assessment. More studies on large cohorts of SGA-complicated pregnancies with and without preeclampsia are needed to develop an optimal and detailed formula for the risk assessment of adverse outcomes in SGA newborns