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1. Préparation du placenta à la livraison <ol><li> Étiqueter les cordons ombilicaux des jumeaux avec une (pour le premier-né) ou deux (pour le second-né) pinces. </li><li> Inspectez la surface maternelle et fœtale du placenta par souci d&#39;exhaustivité ou de perturbation. </li><li> Enregistrer les données suivantes: type d&#39;insertion du cordon (central, excentrique, marginal ou vélamenteuse), le nombre de vaisseaux sanguins dans le cordon ombilical (généralement une veine et deux artères, parfois une seule artère) et de différence de couleur entre les deux parts du placenta. Une section de la division membranes peuvent être envoyés à la pathologie pour confirmer le type de chorionicité. </li><li> Le placenta peut alors être placé dans un bol en plastique et réfrigérer jusqu&#39;à ce que l&#39;examen final (le meilleur dans la semaine) et l&#39;injection de colorant couleur. </li><li> Le placenta ne doit pas être congelé ou fixes (ne pas utiliser le formol). </li></ol> 2. Cathétérisme des vaisseaux ombilicaux <ol><li> Lavez le placenta à l&#39;eau tiède ou une solution saline. </li><li> Couper les membranes périphériques, retirez la membrane inter-twin divisant et de décoller les amnions (pour une meilleure visualisation des anastomoses vasculaires et une meilleure qualité des images du placenta). </li><li> Transect de chaque cordon ombilical à environ 5 cm de distance de l&#39;insertion du cordon. </li><li> Appuyez doucement sur les caillots de sang des vaisseaux ombilicaux et des vaisseaux placentaires. </li><li> La veine ombilicale est généralement facile à identifier en raison de son plus grand diamètre, comparé à plus petit diamètre des deux artères ombilicales. </li><li> Cathétériser la veine ombilicale avec un cathéter de taille appropriée. Evitez les passages faux. </li><li> Cathétériser une artère ombilicale avec un petit cathéter. Utilisez une pince à épiler pour élargir la lumière de l&#39;artère ombilicale. Evitez les passages faux. Seule l&#39;une des deux artères ombilicales doit être cathétérisés depuis une anastomose (de Hyrtl) relie les deux artères à proximité de l&#39;insertion du cordon. </li><li> Répétez les deux étapes pour le cordon ombilical d&#39;autres. </li><li> Placement de la sonde peut être facilitée par revenir doucement et vient masser des vaisseaux ombilicaux. Tout type de cathéter peut être utilisé pour cette procédure. Nous avons choisi d&#39;utiliser (et recycler) les cathéters utilisés à notre paroisse de néonatalogie pour le cathétérisme ombilical chez le nouveau-né. </li><li> Attachez un morceau de ruban adhésif autour de deux cordons pour éviter le reflux de la teinture de couleur lors de l&#39;injection de colorant. </li></ol> 3. Injection avec colorant <ol><li> Connecter une seringue de 20 ml remplie de colorant de couleur pour chaque cathéter. </li><li> Tout colorant visqueux de couleur peut être utilisé pour visualiser le placenta angio-architecture. Utilisez des couleurs contrastantes pour permettre une bonne visualisation de l&#39;anastomose (couleurs sombres pour les artères, les couleurs vives pour les veines). </li><li> Doucement injecter (à basse pression), le colorant dans une veine pendant qu&#39;un assistant pousse doucement le colorant pour permettre au colorant de remplir tous les vaisseaux placentaires, également les plus petits. </li><li> Portez une attention particulière aux petits vaisseaux près de l&#39;équateur vasculaire (l&#39;équateur vasculaire est l&#39;endroit où les anastomoses des deux jumelles se connecter les uns aux autres). </li><li> Répétez les étapes précédentes pour injecter colorant dans l&#39;artère. À noter: les artères peuvent être plus difficiles à injecter et exigent plus de patience. </li><li> Répétez les deux étapes pour le cordon ombilical d&#39;autres. </li></ol> 4. Évaluation et documentation du placenta après injection de colorant de couleur <ol><li> Examinez attentivement l&#39;équateur vasculaire et enregistrer le nombre et les types d&#39;anastomoses. </li><li> Placez un ruban à mesurer sur le placenta pour mesurer le diamètre et la part du placenta sur l&#39;image numérique. </li><li> Utilisez un appareil photo numérique haute résolution et prendre des photos du placenta injecté. Assurez-vous que les photos sont prises perpendiculairement à la barrière placentaire. </li></ol> 5. Les résultats représentatifs: L&#39;angio-placentaire architecture jumeaux monozygotes varie selon le type de grossesse gémellaire monochoriale. Des études ont démontré que l&#39;injection anastomoses AA, AV et VV sont présents dans respectivement 80%, 95% et 20% des grossesses gémellaires monozygotes simple 1 (figure 1). Anastomoses AA sont considérés pour se protéger contre le développement de la STT et les robinets 6. Des études ont montré que les injections anastomoses AA se produisent dans seulement 20% des placentas STT et 10% des placentas 1,2,7 TAPS (figure 2). Dans les placentas STT traitée par chirurgie au laser fetoscopic, les cicatrices causées par la coagulation au laser des anastomoses vasculaires peuvent être observées à la surface placentaire (figure 3 et 4). Placentas TAPS sont caractérisés par la présence de seulement quelques anastomoses AV minuscules 2 (figure 5). La part du placenta du destinataire TAPS est souvent pléthorique, tandis que la part du placenta du donneur est pâle (figure 6). Dans les grossesses gémellaires monozygotes avec discordance de poids de naissance, la croissance limitée du fœtusa souvent une insertion du cordon vélamenteuse et une part beaucoup plus petite placentaire (figure 7). Anastomoses AA sont souvent présents dans les placentas de jumeaux monozygotes avec discordance de poids de naissance 8. Monochoriales-monoamniotic placentas ont une caractéristique angio-architecture avec une courte distance entre les deux insertions du cordon (figure 8). L&#39;incidence des anastomoses AA dans monoamniotic-monochorioniques placentas est pratiquement de 100% et empêche le développement de STT en monoamniotic jumeaux 9. Les chiffres dans cet article montrent les résultats caractéristique de placentas monochorioniques injecté dans notre centre avec de la teinture de couleur. Nous utilisons régulièrement les couleurs foncées (bleu ou vert) pour les artères et les couleurs claires (jaune, rose ou orange) pour les veines. <img alt="Figure 1" src="/files/ftp_upload/3208/3208fig1.jpg" /> Figure 1. Placenta monochoriales d&#39;une normale, grossesse sans complication jumelles monozygotes montrant plusieurs anastomoses AV artères aux veines vertes rose (étoiles blanches), plusieurs anastomoses VA artères aux veines bleues jaune (étoiles vertes) et une grande AA anastomose (identifié par le le mélange du bleu et vert colorant; étoile bleue). <img alt="Figure 2" src="/files/ftp_upload/3208/3208fig2.jpg" /> Figure 2. Placenta monochoriales dans une grossesse STT traitée avec amnioreduction série montrant la présence de seulement AV (étoiles blanches) et VA (étoiles vertes) anastomoses sans anastomose AA. <img alt="Figure 3" src="/files/ftp_upload/3208/3208fig3.jpg" /> Figure 3. STT placenta après la coagulation au laser fetoscopic de l&#39;anastomoses vasculaires en utilisant la technique laser sélectif dans laquelle une anastomose petite résiduel a été laissé par inadvertance des brevets (étoile blanche). Avec la technique du laser sélectif, les anastomoses vasculaires sont d&#39;abord identifiés et ensuite coagulé, un par un. <img alt="Figure 4" src="/files/ftp_upload/3208/3208fig4.jpg" /> Figure 4. STT placenta après la coagulation au laser fetoscopic utilisant la technique de Salomon dans lequel, après l&#39;identification et la coagulation de chaque anastomose individuel, l&#39;équateur complète vasculaire est coagulé d&#39;une marge de placenta à l&#39;autre. <img alt="Figure 5" src="/files/ftp_upload/3208/3208fig5.jpg" /> Figure 5. TAPS placenta dans lequel seuls quelques-uns, minuscule anastomoses VA (étoiles blanches) sont visibles le long de l&#39;équateur vasculaire. <img alt="Figure 6" src="/files/ftp_upload/3208/3208fig6.jpg" /> Figure 6. Le côté maternel du placenta TAPS (figure 5) montre la différence entre les deux couleur caractéristique part placentaire. <img alt="Figure 7" src="/files/ftp_upload/3208/3208fig7.jpg" /> Figure 7. Placenta monochoriales d&#39;une grossesse gémellaire avec restriction intra-utérine de croissance sélective d&#39;un jumeau. Le fœtus a une croissance limitée insertion du cordon vélamenteuse et une part beaucoup plus petite placentaire. L&#39;étoile blanche indique une anastomose AA. <img alt="Figure 8" src="/files/ftp_upload/3208/3208fig8.jpg" /> Figure 8 placenta monoamniotiques:. Notez les différents AV (étoile verte), VA (étoile bleue) et les 2 piles AA anastomoses (blanc étoiles), et la courte distance entre les deux insertions du cordon.

<ol>
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G. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Monoamniotic-versus+diamniotic-monochorionic+twin+placentas:+anastomoses+and+twin-twin+transfusion+syndrome.">Monoamniotic-versus diamniotic-monochorionic twin placentas: anastomoses and twin-twin transfusion syndrome.</a> Am. J. Obstet. Gynecol. 189, 1325-1329 (2003).</li><li>Senat, M. V., Deprest, J., Boulvain, M., Paupe, A., Winer, N., Ville, Y. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Endoscopic+laser+surgery+versus+serial+amnioreduction+for+severe+twin-to-twin+transfusion+syndrome.">Endoscopic laser surgery versus serial amnioreduction for severe twin-to-twin transfusion syndrome.</a> N. Engl. J. Med. 351, 136-144 (2004).</li><li>Lopriore, E., Sueters, M., Middeldorp, J. M., Vandenbussche, F. P., Walther, F. J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Haemoglobin+differences+at+birth+in+monochorionic+twins+without+chronic+twin-to-twin+transfusion+syndrome.">Haemoglobin differences at birth in monochorionic twins without chronic twin-to-twin transfusion syndrome.</a> Prenat. Diagn. 25, 844-850 (2005).</li><li>Papathanasiou, D., Witlox, R., Oepkes, D., Walther, F. J., Bloemenkamp, K. W., Lopriore, E. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Monochorionic+twins+with+ruptured+vasa+previa:+double+trouble!.">Monochorionic twins with ruptured vasa previa: double trouble!.</a> Fetal Diagn. Ther. 28, 48-50 (2010).</li><li>Weingertner, A. S., Kohler, A., Kohler, M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Clinical+and+placental+characteristics+in+four+new+cases+of+twin+anemia-polycythemia+sequence.">Clinical and placental characteristics in four new cases of twin anemia-polycythemia sequence.</a> Ultrasound Obstet. Gynecol. 35, 490-494 (2010).</li><li>Lewi, L., Cannie, M., Blickstein, I. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Placental+sharing,+birthweight+discordance,+and+vascular+anastomoses+in+monochorionic+diamniotic+twin+placentas.">Placental sharing, birthweight discordance, and vascular anastomoses in monochorionic diamniotic twin placentas.</a> Am. J. Obstet. Gynecol. 197, 587-588 (2007).</li><li>Lewi, L., Gucciardo, L., Huber, A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Clinical+outcome+and+placental+characteristics+of+monochorionic+diamniotic+twin+pairs+with+early-+and+late-onset+discordant+growth.">Clinical outcome and placental characteristics of monochorionic diamniotic twin pairs with early- and late-onset discordant growth.</a> Am. J. Obstet. Gynecol. , (2008).</li><li>De Paepe, M. E., Friedman, R. M., Poch, M., Hansen, K., Carr, S. R., Luks, F. I. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Placental+findings+after+laser+ablation+of+communicating+vessels+in+twin-to-twin+transfusion+syndrome.">Placental findings after laser ablation of communicating vessels in twin-to-twin transfusion syndrome.</a> Pediatr. Dev. Pathol. 7, 159-165 (2004).</li><li>De Paepe, M. E., DeKoninck, P., Friedman, R. M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Vascular+distribution+patterns+in+monochorionic+twin+placentas.">Vascular distribution patterns in monochorionic twin placentas.</a> Placenta. 26, 471-475 (2005).</li><li>Nikkels, P. G., Hack, K. E., vanGemert, M. J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Pathology+of+twin+placentas+with+special+attention+to+monochorionic+twin+placentas.">Pathology of twin placentas with special attention to monochorionic twin placentas.</a> J. Clin. Pathol. 61, 1247-1253 (2008).</li><li>Quintero, R. A., Martinez, J. M., Lopez, J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Individual+placental+territories+after+selective+laser+photocoagulation+of+communicating+vessels+in+twin-twin+transfusion+syndrome.">Individual placental territories after selective laser photocoagulation of communicating vessels in twin-twin transfusion syndrome.</a> Am. J. Obstet. Gynecol. 192, 1112-1118 (2005).</li><li>Quintero, R. A., Comas, C., Bornick, P. W., Allen, M. H., Kruger, M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Selective+versus+non-selective+laser+photocoagulation+of+placental+vessels+in+twin-to-twin+transfusion+syndrome.">Selective versus non-selective laser photocoagulation of placental vessels in twin-to-twin transfusion syndrome.</a> Ultrasound Obstet. Gynecol. 16, 230-236 (2000).</li></ol>

Aucun conflit d&#39;intérêt déclaré.

STT et les robinets sont deux troubles graves qui peuvent survenir chez des jumeaux monozygotes. Ces deux troubles sont dus à des anastomoses AV provoquant un déséquilibre du flux sanguin intertwin. Dans les 2 dernières décennies, la chirurgie au laser fetoscopic devenu disponible et a été montré pour être la meilleure méthode pour le traitement du STT 10. L&#39;objectif du traitement au laser est fetoscopic pour interrompre la circulation inter-twin par coagulation des anastomoses vasculaires à la...

<table border="1"><tbody><tr><th> Nom de réactif </th><th> Société </th><th> Numéro de catalogue </th><th> Commentaires </th></tr><tr><td> Cathéters ombilicaux (différentes dimensions, longueur 40 cm) </td><td> Vygon </td><td> 1270,08 (8 F) 1270,08 (5 F) 1270,04 (4 F) 1270,03 (3,5 F) 1270,02 (2,5 F) </td><td> Tout type de cathéter peut être utilisé </td></tr><tr><td> 20 ml seringues </td><td> BD Plastipak </td><td> 300613 </td><td></td></tr><tr><td> Couleur colorant (couleurs différentes) </td><td> Royal Talens Schoolverf </td><td> 36716010 (en bleu) 36715010 (vert) 36712350 (jaune) 36713570 (rose) </td><td> Toute teinture de couleur visqueux peut être utilisé </td></tr></tbody></table>

accurate and simple evaluation of vascular anastomoses in monochorionic placenta using colored dye

La présence d&#39;anastomoses vasculaires placentaires est une condition sine qua non pour le développement du syndrome de transfusion jumeau à jumeau (STT) et twin séquence polycythémie anémie (TAPS) 1,2. Des études d&#39;injection des placentas jumeaux ont montré que ces anastomoses sont presque invariablement présent dans jumeaux monozygotes et extrêmement rare dans dichorioniques jumeaux 1. Trois types d&#39;anastomoses ont été documentés: à partir de l&#39;artère à artère, de veine à veine et de l&#39;artère à la veine. Artério-veineux (AV) anastomoses sont unidirectionnelles et sont désignés comme «profond» anastomoses, car ils passent par un cotylédon placentaire partagés, alors que artério-artériels (AA) et la maladie veino-veineuse (VV) anastomoses sont bi-directionnels et sont visés comme «superficielle», car ils se trouvent sur la plaque choriale. Les deux STT et les robinets sont causées par un déséquilibre net de la circulation sanguine entre les jumeaux à cause de anastomoses AV. Sang d&#39;un jumeau (le donateur) est pompée à travers une artère dans le cotylédon placentaire et partagée ensuite drainée par une veine dans la circulation de l&#39;autre jumeau (le bénéficiaire). Sauf si le sang est pompé par le bénéficiaire au donneur par sens opposés profonde anastomoses AV ou par l&#39;intermédiaire des anastomoses superficielles, un déséquilibre des volumes de sang se produit, conduisant progressivement à l&#39;élaboration de STT ou les robinets. La présence d&#39;une anastomose AA a été démontré de protection contre le développement de la STT et les robinets en compensant le déséquilibre causé par la circulation de l&#39;uni-directionnel 1,2 AV anastomoses. L&#39;injection de placentas monochorioniques tôt après la naissance est un moyen utile de comprendre l&#39;étiologie de diverses (hématologie) des complications chez les jumeaux monozygotes et est un test nécessaire pour atteindre le diagnostic de TAPS 2. En outre, l&#39;injection de placentas STT traitée par chirurgie au laser permet fetoscopic identification d&#39;éventuelles anastomoses résiduelle 3-5. Cette information supplémentaire est d&#39;une importance primordiale pour tous les périnatologistes impliqués dans la gestion et le soin des jumeaux monozygotes avec STT ou les robinets. Plusieurs techniques d&#39;injection du placenta sont actuellement utilisés. Nous fournissons un protocole simple d&#39;évaluer avec précision la présence d&#39;anastomoses vasculaires (résiduel) à l&#39;aide d&#39;injection de colorant de couleur.

Watch this Scientific Journal Video about Accurate and Simple Evaluation of Vascular Anastomoses in Monochorionic Placenta using Colored Dye at JoVE.com

Accurate and Simple Evaluation of Vascular Anastomoses in Monochorionic Placenta using Colored Dye

Syndrome de transfusion jumeau à jumeau et double séquence polycythémie anémie sont deux problèmes potentiellement dévastateurs de la médecine périnatale. Les deux troubles se produisent seulement dans les jumeaux monozygotes et résultent de la circulation sanguine par le biais du placenta déséquilibrée anastomoses vasculaires. Nous fournissons un protocole simple d&#39;évaluer avec précision la présence d&#39;anastomoses vasculaires en utilisant l&#39;injection de colorant couleur des vaisseaux placentaires après la naissance.

Évaluation précise et simple des anastomoses vasculaires dans le placenta monochoriales utilisant colorant

The presence of placental vascular anastomoses is a conditio sine qua non for the development of twin-to-twin transfusion syndrome (TTTS) and twin anemia ...

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26.6K vues.  Leiden University Medical Center. Syndrome de transfusion jumeau à jumeau et double séquence polycythémie anémie sont deux problèmes potentiellement dévastateurs de la médecine périnatale. Les deux troubles se produisent seulement dans les jumeaux monozygotes et résultent de la circulation sanguine par le biais du placenta déséquilibrée anastomoses vasculaires. Nous fournissons un protocole simple d'évaluer avec précision la présence d'anastomoses vasculaires en utilisant l'inje...

Vidéo: Accurate and Simple Evaluation of Vascular Anastomoses in Monochorionic Placenta using Colored Dye

Accurate and Simple Measurement of the Pro-inflammatory Cytokine IL-1&beta; using a Whole Blood Stimulation Assay

Inflammatory processes resulting from the secretion of soluble mediators by immune cells, lead to various manifestations in skin, joints and other tissues as well as altered cytokine homeostasis. The innate immune system plays a crucial role in recognizing pathogens and other endogenous danger stimuli. One of the major cytokines released by innate immune cells is Interleukin (IL)-1. Therefore, we utilize a whole blood stimulation assay in order to measure the secretion of inflammatory cytokines and specifically of the pro-inflammatory cytokine IL-1&beta; 1, 2, 3.
Patients with genetic dysfunctions of the innate immune system causing autoinflammatory syndromes show an exaggerated release of mature IL-1&beta; upon stimulation with LPS alone. In order to evaluate the innate immune component of patients who present with inflammatory-associated pathologies, we use a specific immunoassay to detect cellular immune responses to pathogen-associated molecular patterns (PAMPs), such as the gram-negative bacterial endotoxin, lipopolysaccharide (LPS). These PAMPs are recognized by pathogen recognition receptors (PRRs), which are found on the cells of the innate immune system 4, 5, 6, 7. A primary signal, LPS, in conjunction with a secondary signal, ATP, is necessary for the activation of the inflammasome, a multiprotein complex that processes pro-IL-1&beta; to its mature, bioactive form 4, 5, 6, 8, 9, 10.
The whole blood assay requires minimal sample manipulation to assess cytokine production when compared to other methods that require labor intensive isolation and culturing of specific cell populations. This method differs from other whole blood stimulation assays; rather than diluting samples with a ratio of RPMI media, we perform a white blood cell count directly from diluted whole blood and therefore, stimulate a known number of white blood cells in culture 2. The results of this particular whole blood assay demonstrate a novel technique useful in elucidating patient cohorts presenting with autoinflammatory pathophysiologies.

Accurate and Simple Measurement of the Pro-inflammatory Cytokine IL-1&amp;#946; using a Whole Blood Stimulation Assay

We describe a simple immunoassay to measure the production of pro-inflammatory cytokines, such as IL-1 beta production, in patients presenting with autoinflammatory phenotypes. By activating cells in whole blood cultures with pathogen-associated molecular patterns, specifically with lipopolysaccharide, cytokine secretion can be conveniently evaluated in whole blood supernatants.

Mesure précise et simple de la cytokine pro-inflammatoire IL-1β en utilisant un dosage de sang total Stimulation

Inflammatory processes resulting from the secretion of soluble mediators by immune cells, lead to various manifestations in skin, joints and other tissues ...

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Médecine

Guide Wire Assisted Catheterization and Colored Dye Injection for Vascular Mapping of Monochorionic Twin Placentas

Monochorionic (MC) twin pregnancies are associated with significantly higher morbidity and mortality rates than dichorionic twins. Approximately 50% of MC twin pregnancies develop complications arising from the shared placenta and associated vascular connections1. Severe twin-to-twin syndrome (TTTS) is reported to account for approximately 20% of these complications2,3. Inter-twin vascular connections occur in almost all MC placentas and are related to the prognosis and outcome of these high-risk twin pregnancies. The number, size and type of connections have been implicated in the development of TTTS and other MC twin conditions. Three types of inter-twin vascular connections occur: 1) artery to vein connections (AVs) in which a branch artery carrying deoxygenated blood from one twin courses along the fetal surface of the placenta and dives into a placental cotyledon. Blood flows via a deep intraparenchymal capillary network into a draining vein that emerges at the fetal surface of the placenta and brings oxygenated blood toward the other twin. There is unidirectional flow from the twin supplying the afferent artery toward the twin receiving the efferent vein; 2) artery to artery connections (AAs) in which a branch artery from each twin meets directly on the superficial placental surface resulting in a vessel with pulsatile bidirectional flow, and 3) vein to vein connections (VVs) in which a branch vein from each twin meets directly on the superficial placental surface allowing low pressure bidirectional flow. In utero obstetric sonography with targeted Doppler interrogation has been used to identify the presence of AV and AA connections4. Prenatally detected AAs that have been confirmed by postnatal placental injection studies have been shown to be associated with an improved prognosis for both twins5. Furthermore, fetoscopic laser ablation of inter-twin vascular connections on the fetal surface of the shared placenta is now the preferred treatment for early, severe TTTS. 
Postnatal placental injection studies provide a valuable method to confirm the accuracy of prenatal Doppler ultrasound findings and the efficacy of fetal laser therapy6. Using colored dyes separately hand-injected into the arterial and venous circulations of each twin, the technique highlights and delineates AVs, AAs, and VVs. This definitive demonstration of MC placental vascular anatomy may then be correlated with Doppler ultrasound findings and neonatal outcome to enhance our understanding of the pathophysiology of MC twinning and its sequelae. Here we demonstrate our placental injection technique.

Vascular mapping of monochorionic (MC) twin placentas after birth provides a means for detailed demonstration of vascular connections between the twins&#x2019; circulations. 
Imbalance of these connections is thought to play a pivotal role in the development of complications of MC twinning including twin-to-twin transfusion syndrome.

Cathétérisme Guide fil assistée et coloré pour la cartographie d&#39;injection de colorant vasculaires de monochoriales placentas jumelles

Monochorionic (MC) twin pregnancies are associated with significantly higher morbidity and mortality rates than dichorionic twins. Approximately 50% of MC ...

A Simple Method of Mouse Lung Intubation

A simple procedure to intubate mice for pulmonary function measurements would have several advantages in longitudinal studies with limited numbers or expensive animal. One of the reasons that this is not done more routinely is that it is relatively difficult, despite there being several published studies that describe ways to achieve it. In this paper we demonstrate a procedure that eliminates one of the major hurdles associated with this intubation, that of visualizing the trachea during the entire time of intubation. The approach uses a 0.5 mm fiberoptic light source that serves as an introducer to direct the intubation cannula into the mouse trachea. We show that it is possible to use this procedure to measure lung mechanics in individual mice over a time course of at least several weeks. The technique can be set up with relatively little expense and expertise, and it can be routinely accomplished with relatively little training. This should make it possible for any laboratory to routinely carry out this intubation, thereby allowing longitudinal studies in individual mice, thereby minimizing the number of mice needed and increasing the statistical power by using each mouse as its own control.

This paper describes a striaghforward and efficient method of intubating mice for pulmonary function measurements or pulmonary instillation, that allows the mice to recover and be studied at later times. The procedure involves an inexpensive fiberoptic light source that directly illuminates the trachea.

Une méthode simple d&#39;intubation poumon de souris

A  simple procedure to intubate mice for pulmonary function measurements would  have several advantages in longitudinal studies with limited numbers or  ...

Technical Aspects of the Mouse Aortocaval Fistula

Technical aspects of creating an arteriovenous fistula in the mouse are discussed. Under general anesthesia, an abdominal incision is made, and the aorta and inferior vena cava (IVC) are exposed. The proximal infrarenal aorta and the distal aorta are dissected for clamp placement and needle puncture, respectively. Special attention is paid to avoid dissection between the aorta and the IVC. After clamping the aorta, a 25 G needle is used to puncture both walls of the aorta into the IVC. The surrounding connective tissue is used for hemostatic compression. Successful creation of the AVF will show pulsatile arterial blood flow in the IVC. Further confirmation of successful AVF can be achieved by post-operative Doppler ultrasound.

The goal is to produce an arteriovenous fistula that is simple and reproducible. This method does not use sutures or glue adhesive. Therefore the samples can be used with the least amount of foreign materials for analysis.

Aspects techniques de la fistule aorto-cave de la souris

Technical aspects of creating an arteriovenous fistula in the mouse are discussed. Under general anesthesia, an abdominal incision is made, and the aorta ...

Fast and Accurate Exhaled Breath Ammonia Measurement

This exhaled breath ammonia method uses a fast and highly sensitive spectroscopic method known as quartz enhanced photoacoustic spectroscopy (QEPAS) that uses a quantum cascade based laser. The monitor is coupled to a sampler that measures mouth pressure and carbon dioxide. The system is temperature controlled and specifically designed to address the reactivity of this compound. The sampler provides immediate feedback to the subject and the technician on the quality of the breath effort. Together with the quick response time of the monitor, this system is capable of accurately measuring exhaled breath ammonia representative of deep lung systemic levels. 
Because the system is easy to use and produces real time results, it has enabled experiments to identify factors that influence measurements. For example, mouth rinse and oral pH reproducibly and significantly affect results and therefore must be controlled. Temperature and mode of breathing are other examples. As our understanding of these factors evolves, error is reduced, and clinical studies become more meaningful. This system is very reliable and individual measurements are inexpensive. 
The sampler is relatively inexpensive and quite portable, but the monitor is neither. This limits options for some clinical studies and provides rational for future innovations.

Ammonia is an important physiologic metabolite relevant to various disease and wellness states. It is also a difficult molecule to measure in breath, which demands particular precautions be taken to obtain accurate results. Not all factors influencing ammonia are known, but progress can be difficult without accounting for these factors.

Rapide et précis expiré Breath ammoniac mesure

This exhaled breath ammonia method uses a fast and highly sensitive spectroscopic method known as quartz enhanced photoacoustic spectroscopy (QEPAS) that ...

Evaluation of Tumor-infiltrating Leukocyte Subsets in a Subcutaneous Tumor Model

Specialized immune cells that infiltrate the tumor microenvironment regulate the growth and survival of neoplasia.&#160; Malignant cells must elude or subvert anti-tumor immune responses in order to survive and flourish. Tumors take advantage of a number of different mechanisms of immune &#8220;escape,&#8221; including the recruitment of tolerogenic DC, immunosuppressive regulatory T cells (Tregs), and myeloid-derived suppressor cells (MDSC) that inhibit cytotoxic anti-tumor responses. Conversely, anti-tumor effector immune cells can slow the growth and expansion of malignancies: immunostimulatory dendritic cells, natural killer cells which harbor innate anti-tumor immunity, and cytotoxic T cells all can participate in tumor suppression. The balance between pro- and anti-tumor leukocytes ultimately determines the behavior and fate of transformed cells; a multitude of human clinical studies have borne this out. Thus, detailed analysis of leukocyte subsets within the tumor microenvironment has become increasingly important. Here, we describe a method for analyzing infiltrating leukocyte subsets present in the tumor microenvironment in a mouse tumor model. Mouse B16 melanoma tumor cells were inoculated subcutaneously in C57BL/6 mice. At a specified time, tumors and surrounding skin were resected en bloc and processed into single cell suspensions, which were then stained for multi-color flow cytometry. Using a variety of leukocyte subset markers, we were able to compare the relative percentages of infiltrating leukocyte subsets between control and chemerin-expressing tumors. Investigators may use such a tool to study the immune presence in the tumor microenvironment and when combined with traditional caliper size measurements of tumor growth, will potentially allow them to elucidate the impact of changes in immune composition on tumor growth. Such a technique can be applied to any tumor model in which the tumor and its microenvironment can be resected and processed.

This protocol describes a method for the detailed evaluation of leukocyte subsets within the tumor microenvironment in a mouse tumor model. Chemerin-expressing B16 melanoma cells were implanted subcutaneously into syngeneic mice. Cells from the tumor microenvironment were then stained and analyzed by flow cytometry, allowing for detailed leukocyte subset analyses.

Évaluation des leucocytes infiltrant les tumeurs sous-ensembles dans un Modèle de tumeur sous-cutanée

Specialized immune cells that infiltrate the tumor microenvironment regulate the growth and survival of neoplasia.&#160; Malignant cells must elude or ...

Using the Sleeve Technique in a Mouse Model of Aortic Transplantation - An Instructional Video

Orthotopic aortic transplantation using the sleeve technique reduces injury to the aorta with failure rate of only 10-20%. The time to anastomose the aorta in mice using the sleeve method was short and easy averaging 20 min, permitting studies of iso/allo grafts. The following article describes the aortic transplantation procedure used in our laboratory. The mice were anesthetized with a mixture of 1.5% volume isoflurane and 100% oxygen through a face mask. At this point, the segment of the aorta between the renal arteries and its bifurcation was separated from the vena cava, freely prepared and clampedat the proximal and distal segments with a single silk suture. Prior to the removal of the aorta, a saline solution containing heparin was injected into the inferior vena cava. Then the aorta was cut between the clamps and a saline heparin solution was used to flush the lumen. The sleeve technique with monofilament sutures was used in order to transplant the abdominal aorta in the orthotopic position.

We present an orthotopic aortic transplantation model using the sleeve technique in mice. It is a very rapid anastomosis method, which can be employed in studies of vascular disease.

Utilisant la Technique de la manche dans un modèle murin de la greffe aortique - une vidéo d’instruction

Orthotopic aortic transplantation using the sleeve technique reduces injury to the aorta with failure rate of only 10-20%. The time to anastomose the ...

Model Surgical Training: Skills Acquisition in Fetoscopic Laser Photocoagulation of Monochorionic Diamniotic Twin Placenta Using Realistic Simulators

Fetoscopic laser coagulation of arterio-venous anastomoses (AVA) in a monochorionic placenta is the standard of care for twin-twin transfusion syndrome (TTTS), but is technically challenging and can lead to significant complications. Acquiring and maintaining the necessary surgical skills require consistent practice, a critical caseload, and time. Training on realistic surgical simulators can potentially shorten this steep learning curve and enables several proceduralists to acquire procedure-specific skills simultaneously. Here we describe realistic simulators designed to allow the user familiarity with the equipment and specific steps required in the surgical treatment of TTTS, including fetoscopic handling, approaches to anterior and posterior placenta, recognition of anastomoses, and efficient coagulation of vessels. We describe the skills that are especially important in conducting placental laser coagulation that the surgeon can practice on the model and apply in a clinical case. These models can be adapted easily depending on the availability of materials and require standard fetoscopy equipment. Such training systems are complementary to traditional surgical apprenticeships and can be useful aids for fetal medicine units that provide this clinical service.

Practicing the specific skills required for fetoscopic laser coagulation of monochorionic placental anastomoses on realistic models can aid less experienced surgeons in overcoming the steep learning curve associated with this procedure that is now regarded as the standard of care for twin-twin transfusion syndrome.

Modèle de formation chirurgicale : Acquisition de compétences en Photocoagulation Laser Fetoscopic du Placenta de jumeaux monochorioniques Diamniotic à l’aide de simulateurs réalistes

Fetoscopic laser coagulation of arterio-venous anastomoses (AVA) in a monochorionic placenta is the standard of care for twin-twin transfusion syndrome ...

Noninvasive Determination of Vortex Formation Time Using Transesophageal Echocardiography During Cardiac Surgery

Trans-mitral blood flow produces a three-dimensional rotational body of fluid, known as a vortex ring, that enhances the efficiency of left ventricular (LV) filling compared with a continuous linear jet. Vortex ring development is most often quantified with vortex formation time (VFT), a dimensionless parameter based on fluid ejection from a rigid tube. Our group is interested in factors that affect LV filling efficiency during cardiac surgery. In this report, we describe how to use standard two-dimensional (2D) and Doppler transesophageal echocardiography (TEE) to noninvasively derive the variables needed to calculate VFT. We calculate atrial filling fraction (&#946;) from velocity-time integrals of trans-mitral early LV filling and atrial systole blood flow velocity waveforms measured in the mid-esophageal four-chamber TEE view. Stroke volume (SV) is calculated as the product of the diameter of the LV outflow track measured in the mid-esophageal long axis TEE view and the velocity-time integral of blood flow through the outflow track determined in the deep transgastric view using pulse-wave Doppler. Finally, mitral valve diameter (D) is determined as the average of major and minor axis lengths measured in orthogonal mid-esophageal bicommissural and long axis imaging planes, respectively. VFT is then calculated as 4 &#215; (1-&#946;) &#215; SV/(&#960;D3). We have used this technique to analyze VFT in several groups of patients with differing cardiac abnormalities. We discuss our application of this technique and its potential limitations and also review our results to date. Noninvasive measurement of VFT using TEE is straightforward in anesthetized patients undergoing cardiac surgery. The technique may allow cardiac anesthesiologists and surgeons to assess the impact of pathological conditions and surgical interventions on LV filling efficiency in real time.

We describe a protocol to measure vortex formation time, an index of left ventricular filling efficiency, using standard transesophageal echocardiography techniques in patients undergoing cardiac surgery. We apply this technique to analyze vortex formation time in several groups of patients with differing cardiac pathologies.

Non invasive détermination du temps de Formation de Vortex utilisant l’échocardiographie transoesophagienne au cours de la chirurgie cardiaque

Trans-mitral blood flow produces a three-dimensional rotational body of fluid, known as a vortex ring, that enhances the efficiency of left ventricular ...

Echocardiographic Evaluation of Atrial Communications before Transcatheter Closure

Transthoracic (TTE) and transesophageal echocardiography (TEE) is the standard imaging method for atrial septal defect (ASD) and patent foramen ovale (PFO) detection, for patient selection for transcatheter ASD/PFO closure,&#160;for intraoperative guidance and for long-term follow-up. The size, shape, location and the number of the atrial communications schould be determined. The accuracy of PFO detection can be improved by using agitated saline together with maneuvers to transiently increase the right atrial (RA) pressure. The appearance of microbubbles in the left atrium (LA) within 3 cardiac cycles after opacification of the RA is considered positive for the presence of an intracardiac shunt. Three dimensional TEE identifies further septal fenestrations and describes the dynamic morphology of ASD/PFO and atrial septal aneurysm. Follow-up evaluations with TTE is recommended at 1, 6, and 12 months after the procedure, with a subsequent evaluation every year. Previous studies showed an increased incidence of atrial arrhythmias early after device closure. Speckle tracking analysis may help to understand functional left atrial remodeling following percutaneous closure and its impact on atrial arrhythmias.

Transthoracic (TTE) and transesophageal (TEE) echocardiography represent the basic imaging tools for interatrial septum examination. Three dimensional (3D) TEE provides incremental information in the assessment of the interatrial septum. Further advanced echocardiography techniques using speckle tracking echocardiography are applied for sensitive volumetric and functional assessment of the heart chambers.&#160;

Évaluation échocardiographique des communications auriculaires avant la fermeture du transcathéter

Transthoracic (TTE) and transesophageal echocardiography (TEE) is the standard imaging method for atrial septal defect (ASD) and patent foramen ovale ...