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OBJECTIVES: Twin pregnancy is currently an exclusion criterion for prenatal repair of open spina bifida (OSB). The main objective of this study was to report on our experience of treating twin pregnancies with OSB using the skin-over-biocellulose for antenatal fetoscopic repair (SAFER) technique. We also discuss reconsideration of the current exclusion criteria for fetal OSB repair. METHODS: Eight fetuses with OSB from seven twin pregnancies underwent successful prenatal repair. Six pregnancies were dichorionic diamniotic with only one twin affected, and one was monochorionic diamniotic with both twins affected. Percutaneous fetoscopy was performed under CO2 insufflation of the sac of the affected twin. Neurosurgical repair was performed using a biocellulose patch to protect the placode, with the skin sutured to hold the patch in place, with or without a myofascial flap. Neurodevelopment was assessed using the pediatric evaluation of disability inventory scale in babies older than 6 months of adjusted age, whereas the Alberta scale was used for babies younger than 6 months of adjusted age. RESULTS: All 14 fetuses were liveborn and none required additional repair. Gestational age at surgery ranged from 27.3 to 31.1 weeks, and gestational age at birth ranged from 31.6 to 36.0 weeks. Four out of eight affected twins developed sepsis, but had a good recovery. No sequela of prematurity was found in any of the unaffected twins. Short-term neurodevelopment was normal in all evaluated unaffected twins (5/5) and in all but one affected twins (7/8). In the affected group, only one baby required ventriculoperitoneal shunt placement. CONCLUSIONS: Prematurity is frequent after fetal surgery, and the risk is increased in twin pregnancy. Nevertheless, prenatal surgery using the SAFER technique is feasible, with low risk to both twins and their mother when performed by a highly experienced team. Long-term cognitive assessment of the unaffected twin is needed. © 2023 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

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OBJECTIVE: We have described previously our percutaneous fetoscopic technique for the treatment of open spina bifida (OSB). However, approximately 20-30% of OSB defects are too large to allow primary skin closure. Here we describe a modification of our standard technique using a bilaminar skin substitute to allow closure of large spinal defects. The aim of this study was to report our clinical experience with the use of a bilaminar skin substitute and a percutaneous fetoscopic technique for the prenatal closure of large OSB defects. METHODS: Surgery was performed between 24.0 and 28.9 gestational weeks with the woman under general anesthesia, using an entirely percutaneous fetoscopic approach with partial carbon dioxide insufflation of the uterine cavity, as described previously. If there was enough skin to be sutured in the midline, only a biocellulose patch was placed over the placode (single-patch group). In cases in which skin approximation was not possible, a bilaminar skin substitute (two layers: one silicone and one dermal matrix) was placed over the biocellulose patch and sutured to the skin edges (two-patch group). The surgical site was assessed at birth, and long-term follow-up was carried out. RESULTS: Percutaneous fetoscopic OSB repair was attempted in 47 consecutive fetuses, but surgery could not be completed in two. Preterm prelabor rupture of membranes (PPROM) occurred in 36 of the 45 (80%) cases which formed the study group, and the mean gestational age at delivery was 32.8 ± 2.5 weeks. A bilaminar skin substitute was required in 13/45 (29%) cases; in the remaining 32 cases, direct skin-to-skin suture was feasible. There were 12 cases of myeloschisis, of which 10 were in the two-patch group. In all cases, the skin substitute was located at the surgical site at birth. In five of the 13 (38.5%) cases in the two-patch group, additional postnatal repair was needed. In the remaining cases, the silicone layer detached spontaneously from the dermal matrix (on average, 25 days after birth), and the lesion healed by secondary intention. The mean operating time was 193 (range, 83-450) min; it was significantly longer in cases requiring the bilaminar skin substitute (additional 42 min on average), although the two-patch group had similar PPROM rate and gestational age at delivery compared with the single-patch group. Complete reversal of hindbrain herniation occurred in 68% of the 28 single-patch cases and 33% of the 12 two-patch cases with this information available (P < 0.05). In four cases there was no reversal; half of these occurred in myeloschisis cases. CONCLUSIONS: Large OSB defects may be treated successfully in utero using a bilaminar skin substitute over a biocellulose patch through an entirely percutaneous approach. Although the operating time is longer, surgical outcome is similar to that in cases closed primarily. Cases with myeloschisis seem to have a worse prognosis than do those with myelomeningocele. PPROM and preterm birth continue to be a challenge. Further experience is needed to assess the risks and benefits of this technique for the management of large OSB defects. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.

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The relationships between morphology, performance, behavior and ecology provide evidence for multiple and complex phenotypic adaptations. The anuran body plan, for example, is evolutionarily conserved and shows clear specializations to jumping performance back at least to the early Jurassic. However, there are instances of more recent adaptation to habit diversity in the post-cranial skeleton, including relative limb length. The present study tested adaptive models of morphological evolution in anurans associated with the diversity of microhabitat use (semi-aquatic arboreal, fossorial, torrent, and terrestrial) in species of anuran amphibians from Brazil and Australia. We use phylogenetic comparative methods to determine which evolutionary models, including Brownian motion (BM) and Ornstein-Uhlenbeck (OU) are consistent with morphological variation observed across anuran species. Furthermore, this study investigated the relationship of maximum distance jumped as a function of components of morphological variables and microhabitat use. We found there are multiple optima of limb lengths associated to different microhabitats with a trend of increasing hindlimbs in torrent, arboreal, semi-aquatic whereas fossorial and terrestrial species evolve toward optima with shorter hindlimbs. Moreover, arboreal, semi-aquatic and torrent anurans have higher jumping performance and longer hindlimbs, when compared to terrestrial and fossorial species. We corroborate the hypothesis that evolutionary modifications of overall limb morphology have been important in the diversification of locomotor performance along the anuran phylogeny. Such evolutionary changes converged in different phylogenetic groups adapted to similar microhabitat use in two different zoogeographical regions.

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PURPOSE: To select a group of patients with brain metastases for whom stereotactic radiosurgery (SRS) may not be beneficial. PATIENTS, MATERIALS, AND METHODS: Actuarial survival of 87 patients with brain metastases treated with SRS between July 1993 and May 1999 was retrospectively analyzed under stratification by the Score Index for Stereotactic Radiosurgery for Brain Metastases (SIR). To identify the group of patients most likely to survive less than 6 months after SRS, Cox model survival curves were calculated for all SIR values, and Kaplan-Meier survival curves were calculated for two SIR subsets (0-5 and 6-10) and were compared by log-rank test. RESULTS: Overall median survival after SRS was 6.88 months. The stratification of patients into two SIR subsets (0-5 and 6-10) sustained statistical significance regarding survival with p = 0.0001. The median survival time for the group of patients with SIR between 0 and 5 was 4.52 months (95% confidence interval of 2.82 to 5.84 months). Survival probability at 6 months for this group of patients with poor prognosis was 35.6%. CONCLUSION: Patients with brain metastases and SIR of 5 or lower have an expected median survival of less than 6 months after treatment with radiosurgery. Thus, radiosurgery may not be beneficial for this group of patients.

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PURPOSE: To analyze a prognostic score index for patients with brain metastases submitted to stereotactic radiosurgery (the Score Index for Radiosurgery in Brain Metastases [SIR]). METHODS AND MATERIALS: Actuarial survival of 65 brain metastases patients treated with radiosurgery between July 1993 and December 1997 was retrospectively analyzed. Prognostic factors included age, Karnofsky performance status (KPS), extracranial disease status, number of brain lesions, largest brain lesion volume, lesions site, and receiving or not whole brain irradiation. The SIR was obtained through summation of the previously noted first five prognostic factors. Kaplan-Meier actuarial survival curves for all prognostic factors, SIR, and recursive partitioning analysis (RPA) (RTOG prognostic score) were calculated. Survival curves of subsets were compared by log-rank test. Application of the Cox model was utilized to identify any correlation between prognostic factors, prognostic scores, and survival. RESULTS: Median overall survival from radiosurgery was 6.8 months. Utilizing univariate analysis, extracranial disease status, KPS, number of brain lesions, largest brain lesion volume, RPA, and SIR were significantly correlated with prognosis. Median survival for the RPA classes 1, 2, and 3 was 20.19 months, 7.75 months, and 3. 38 months respectively (p = 0.0131). Median survival for patients, grouped under SIR from 1 to 3, 4 to 7, and 8 to 10, was 2.91 months, 7.00 months, and 31.38 months respectively (p = 0.0001). Using the Cox model, extracranial disease status and KPS demonstrated significant correlation with prognosis (p = 0.0001 and 0.0004 respectively). Multivariate analysis also demonstrated significance for SIR and RPA when tested individually (p = 0.0001 and 0.0040 respectively). Applying the Cox Model to both SIR and RPA, only SIR reached independent significance (p = 0.0004). CONCLUSIONS: Systemic disease status, KPS, SIR, and RPA are reliable prognostic factors for patients with brain metastases submitted to radiosurgery. Applying SIR and RPA classifications to our patients' data, SIR demonstrated better accuracy in predicting prognosis. SIR should be further tested with larger patient accrual and for all patients with brain metastases subjected or not to stereotactic radiosurgery.

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The determination of the nuclear DNA content (S-phase fraction (SPF) and ploidy) was carried out by image analysis (IA). The morphometric and densitometric features of Feulgen-stained nuclei were determined from stored formalin-fixed and paraffin-embedded specimens of 66 patients with intracranial astrocytomas. Our results suggest a strong relationship between patient age, histological grade, survival and DNA ploidy and SPF. The analysis of the proliferative activity of intracranial astrocytomas is very helpful in understanding biological stractification and prognostication to assess tumor behaviour and planning of treatment strategies.

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A qualidade da assitência à saúde tem sido especialmente motivo de muitos debates em todo o mundo e tem envolvido todos os profissionais ligados a essa área. Paralelamente, o interesse por análises de custos, especificamente em Unidade de Terapia Intensiva, tem mostrado aumento crescente. A busca por aquisição, manutenção e melhora da qualidade de forma sistematizada e profissional tem sido uma das metas mais recentes nas instituiçöes hospitalares. Toda qualidade real implica custos razoáveis, não sendo mais permitido conceituar qualidade quando são empregados recursos de grande porte para aquisição da mesma. O princípio "quanto mais se paga, mais se obtém" gradativamente tem sido substituído por "fazer mais com menos", sendo este considerado um bom indicador de qualidade na prática médica diária. Discutiremos, neste artigo, o princípio de escassez, liberdade clínica, custo de oportunidade, eficácia, efetividade, eficiência, adequação, como também os diferentes tipos de custos. Complementarmente, discutiremos itens como racionalidade e tipos de avaliaçöes econômicas, modelo de contenção de custos e destinação de recursos em terapia intensiva. Por fim, serão considerados tópicos relacionados à conceituação e às dimensöes de qualidade, e à medicina intensiva baseada em evidências como instrumento facilitador na obtenção de qualidade.

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Radiosurgery is the precise radiation of a known intracranial target with a high dose of energy, sparing the adjacent nervous tissue. Technological advances in the construction of linear accelerators, stereotactic instruments and in computer sciences made this technique easier to perform and affordable. The main indications for radiosurgery are inoperable cerebral vascular malformations, vestibular and other cranial schwannomas, skull base meningiomas, deep seated gliomas and cerebral metastases. More recently, the development of fraccionated stereotactic radiotherapy increased the spectrum of indications to bigger lesions and to those adjacent to critical nervous structures. We present our initial experience in the treatment of 31 patients. An adequate control of the neoplastic lesions was obtained and the adequate time of observation is still needed to evaluate the results in arteriovenous malformations.

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Four patients with fixed neurological deficits due to occlusion of the middle cerebral or the internal carotid arteries, and with collateral circulation to their territory diagnosed by angiography, recovered after extra-intracranial arterial anastomosis. Functional recovery was seen since the first hours after bypass in three cases and the first few days in the other. Angiographic demonstration of collateral circulation to the territory of an occluded cerebral artery seems to be useful in the selection of patients with fixed neurological deficits for extra-intracranial arterial anastomosis, mainly when other methods are not available.

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The post-operative infection-rate in neurosurgical patients who received prophylactic antibiotics was compared to the infection-rate of patients who received no antibiotics. None of the 73 studied patients had pre-operative infection. Infections occured in 26,4% of the patients in the first group and in none of the second group (p less than 0,2); 27,5% of the patients with intracranial lesions and 9% of the patients with spinal lesions in the frist group had post-operative infections, and none in the second group (p less than 0,05 and 0.05 less than p less than 0.1). 67% of all the patients had severe neurological lesions; 27% of these had post-operative infections; only 4% of the patients with mild lesions had infections (p less than 0.05). Post-operative infections were severe and fatal in most of these cases. Prophylactic broad-spectrum antibiotics were of no value in preventing post-operative infections in these neurosurgical patients and those who received no antibiotics had a significantly lower rate of infections.

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The clinical, laboratorial and radiological features of a 3-month-old child with neurocutaneous melanosis are described. The patient was born with multiple disseminated benign cutaneous nevi, proven by skin-biopsy, and presented with drug-resistant seizures and psycho-motor retardation. Serial cerebrospinal fluid studies showed high protein and low glucose levels, with pleocytosis and malignant cells in the fluid. Pneumoencephalogram showed mild non-obstructive hydrocephalus. Immunological studies showed normal immunological activity at three months of age and very poor activity at one year. The patient died at 16 months of age, after the sudden onset of intracranial hypertension and meningeal signs. Immunotherapy and chemotherapy were suggested but not accepted by the family. Some comments are made based on this and other 43 cases described in the literature; the value of laboratory studies in detecting malignant transformaiton in the meninges in patients with benign skin nevi is stressed.

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Serum vitamin A was determined in premature and term neonates by a specific spectrofluorometric method. Premature neonates (N = 42; gestational age = 32 +/- 0.4 weeks) had a serum vitamin A level (14.9 +/- 0.98 microgram/dl) significantly lower (P less than 0.001) than that of term neonates (N = 51; 22.4 +/- 0.99 microgram/dl). The vitamin A mean serum values of infants of 36 weeks' gestational age were not statistically different from those of the term neonates. Linear regression analysis for serum vitamin A values vs gestational age showed no significant correlation. A linear correlation (P less than 0.05), however, was found between serum vitamin A and serum protein protein concentrations, perhaps indicative of a lower concentration of retinol-binding protein. Since vitamin A is involved in the promotion of mucous-secreting cells, the premature neonate may be at greater risk than the term infant for diseases involving the mucosal epithelium, including necrotizing enterocolitis.

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The case of a 34-year-old caucasian male with subarachnoid hemorrahge is reported. The right carotid arteriogram shows the typical internal carotid artery occlusion at the syphon, whith an abnormal vascular network at the base of the brain; the right anterior and middle cerebral arteries fill from the vascular network and through meningocortical anastomoses; the right posterior communicating and cerebral arteries are tortuous and hypertrophic. The left carotid arteriogram shows hypertrophy of the common and internal carotid arteries; both anterior and middle cerebral arteries fill from this side; the anterior communicating artery is thick (foetal type) and a median anterior cerebral artery to the corpus callosum is present. It is the authors' view that the "moyamoya" disease is a congenital one, since the abnormal vascular network at the base of the brain would not be necessary, in this case, to preserve good collateral circulation to the right cerebral hemisphere. No other case with the typical findings of "moyamoya" disease on one side and hypertrophy of the carotid arteries on the other was found in the literature.

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One hundred and forty-one patients with cervical spondylosis were studied, looking for a possible prognostic value in preoperative signs and symptoms. Duration of symptoms lasting from one month to five years until surgical treatment and spinal fluid protein level had no prognostic value in these patients. In those with radiculopathy, the degree of upper limb pareses, muscle atrophy, absent or diminished reflexes, sensory involvement, number of myelographic defects and age had prognostic value. In those with myelopathy, the degree of lower limbs pareses and spasticity, sensory involvement, number of myelographic defects and age had prognostic value. Surgery is a definite method of treatment for patients with progressive signs and symptoms due to cervical spondylosis; some of the preoperative signs and symptoms are valuable in establishing their prognosis.

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Os autores estudaram os resultados do teste de Bender, do eletroencefalograma e do teste Metropolitano de Prontidão em um grupo de 44 crianças de 6 a 8 anos de idade. Não foi encontrada qualquer correspondência entre os resultados eletroencefalográficos e os do teste de Bender sob qualquer um de seus aspectos de avaliação segundo KOPPITZ no diagnóstico de lesão cerebral, verificação esta considerada de valor, por ser o teste de Bender constantemente utilizado com a finalidade de diagnosticar lesão cerebral em nosso meio. Por outro lado, encontrou-se uma associação vidente entre os resultados obtidos no teste de Bender e no teste Metropolitano de Prontidão, resultado que está de acordo com a maioria dos autores que os estudaram. Chamou a atenção dos autores a alta incidência de lesão cerebral diagnosticada pelo eletroencéfalograma nas crianças estudadas, distribuidas de maneira equitativa nos dois grupos extremos classificados pelo teste Metropolitano de Prontidão, concluindo pela ausência de relação entre alterações eletoencefalográficas e aparecimento de dificuldades na alfabetização. (AU)