Maternal intrapartum temperature elevation as a risk factor for cesarean delivery and assisted vaginal delivery

OBJECTIVES

This study investigated the association of intrapartum temperature elevation with cesarean delivery and assisted vaginal delivery.

METHODS

Participants were 1233 nulliparous women with singleton, term pregnancies in vertex presentations who had spontaneous labors and were afebrile (temperature: 99.5 degrees F [37.5 degrees C]) at admission for delivery. Rates of cesarean and assisted vaginal deliveries according to highest intrapartum temperature were examined by epidural status.

RESULTS

Women with maximum intrapartum temperatures higher than 99.5 degrees F were 3 times as likely to experience cesarean (25.2% vs 7.2%) or assisted vaginal delivery (25.2% vs 8.5%). The association was present in epidural users and nonusers and persisted after birthweight, epidural use, and labor length had been controlled. In adjusted analyses, temperature elevation was associated with a doubling in the risk of cesarean delivery (odds ratio [OR] = 2.3, 95% confidence interval [CI] = 1.5, 3.4) and assisted vaginal delivery (OR = 2.1, 95% CI = 1.4, 3.1).

CONCLUSIONS

Modest temperature elevation developing during labor was associated with higher rates of cesarean and assisted vaginal deliveries. More frequent temperature elevation among women with epidural analgesia may explain in part the higher rates of cesarean and assisted vaginal deliveries observed with epidural use.

The clinical utility of invasive diagnostic techniques in the setting of ventilator-associated pneumonia. Canadian Critical Care Trials Group

OBJECTIVE

To evaluate the clinical utility of bronchoscopy with protected brush catheter (PBC) and BAL for patients with ventilator-associated pneumonia (VAP).

DESIGN

Prospective cohort study.

SETTING

Ten tertiary care ICUs in Canada.

PATIENTS

Ninety-two mechanically ventilated patients with a clinical suspicion of VAP who underwent bronchoscopy were compared with 49 patients with a clinical suspicion of pneumonia who did not.

INTERVENTIONS

None.

MEASUREMENTS AND RESULTS

We compared antibiotic use, duration of mechanical ventilation, ICU stay, and mortality. In addition, for patients who received bronchoscopy, we administered a questionnaire (before and after bronchoscopy) to evaluate the effect of PBC or BAL on (1) physician perception of the probability of VAP, (2) physician confidence in the diagnosis of VAP, and (3) changes to antibiotic management. After bronchoscopy results became available, from the physician's perspective, the diagnosis of VAP was deemed much less likely (p < 0.001), confidence in the diagnosis increased (p = 0.03), and level of comfort with the management plan increased (p = 0.02). Following the results of invasive diagnostic tests, in the group that underwent bronchoscopy, patients were receiving fewer antibiotics (31/92 vs 9/49, p = 0.05) and more patients had treatment with all their antibiotics discontinued (18/92 vs 3/49, p = 0.04) compared with the group that did not undergo bronchoscopy. Duration of mechanical ventilation and ICU stay were similar between the two groups, but mortality was lower in the group that underwent bronchoscopy with PBC or BAL (18.5% vs 34.7%, p = 0.03).

CONCLUSIONS

Invasive diagnostic testing may increase physician confidence in the diagnosis and management of VAP and allows for greater ability to limit or discontinue antibiotic treatment. Whether performing PBC or BAL affects clinically important outcomes requires further study.

Intrathoracic tracheal rupture

This paper reports five new cases of intrathoracic tracheal rupture in cats, and summarizes these cases in conjunction with 11 cases from the literature. Most cats had no obvious respiratory signs at the time of injury, and in half of them the tracheal rupture was the only injury. The interval from trauma to onset of dyspnoea ranged from 1 to 28 days (median 12.5 days). Radiographic findings include loss of continuity of the trachea, often with a gas-filled diverticulum present between separated tracheal rings. With careful attention to surgical technique and anaesthetic management the prognosis for these cats is excellent. All eight of the cats reported in the last 14 years having surgical correction survived and returned to normal. The surgical anatomy, approach and tracheal anastomosis technique is described and recommendations for anaesthetic management are made.

Immunogenicity and safety of low-dose intradermal rabies vaccination given during an Expanded Programme on immunization session in Viet Nam: results of a comparative randomized trial

The World Health Organization recently recommended a rabies vaccine pre-exposure schedule using 3 intradermal (i.d.) injections of one-fifth the standard intramuscular (i.m.) dose of current cell culture vaccines as a cost-reducing alternative for developing countries. As a strategy to improve further the acceptability of childhood rabies immunization, we assessed, in a controlled, randomized trial performed in 240 Vietnamese infants, the possibility of associating i.d. administration of a one-fifth dose of purified Vero-cell rabies vaccine (PVRV) with routine Expanded Programme on Immunization vaccines given at 2, 3 and 4 months of age (diphtheria, tetanus, whole-cell pertussis and inactivated poliomyelitis combined vaccine, DTP-IPV). Safety and immunogenicity results were compared with a group of infants given 2 i.m. doses of PVRV (2, 4 months) in association with DTP-IPV (2, 3, 4 months). After i.d. injection, more infants experienced local reactions, particularly redness, but these reactions were generally mild and transient. The rate of systemic reactions was the same in both groups. Although the rabies antibody titres (rapid fluorescent focus inhibition test) were higher 1 month after the third vaccine dose in the i.m. group (30.6 IU/mL vs 12.0 IU/mL in the i.d. group), all infants in both groups had achieved WHO-acceptable protective antibody titres (> or = 0.5 IU/mL) at this time. There was no evidence for any interference between DTP-IPV and rabies vaccine, supporting the interest of a low-dose i.d. PVRV pre-exposure regimen in infants living in rabies-endemic developing countries.

Neutralization, by a monospecific Bothrops lanceolatus antivenom, of toxic activities induced by homologous and heterologous Bothírops snake venoms

A monospecific Bothrops lanceolatus antivenom, currently used in Martinique, was tested for its efficacy in the neutralization of several toxic and enzymatic activities of the venoms of B. lanceolatus, B. atrox and B. asper. When tested by the i.p. route in mice, B. lanceolatus venom had an LD50 of 12.8 microg/g. In addition, it induced local tissue damage (hemorrhage, edema and myotoxicity) and showed indirect hemolytic activity, but was devoid of coagulant effect on human plasma in vitro and of defibrinating activity in mice. Antivenom was fully effective in the neutralization of lethal, hemorrhagic, edema-forming, myotoxic and indirect hemolytic effects of B. lanceolatus venom in assays involving preincubation of venom and antivenom. When tested against the venoms of B. asper and B. atrox, the antivenom completely neutralized the lethal, hemorrhagic, myotoxic and indirect hemolytic effects, and was partially effective in neutralizing edema-forming activity. In contrast, the antivenom was ineffective in the neutralization of in vitro coagulant and in vivo defibrinating effects induced by these two venoms.

Acute effects of the selective cholinergic channel activator (nicotinic agonist) ABT-418 in Alzheimer's disease

To explore further the potential for cognitive enhancement utilizing nicotinic stimulation in Alzheimer's disease (AD), six otherwise healthy subjects with moderate AD received placebo and three doses (6, 12, and 23 mg) of the novel selective cholinergic channel activator (ChCA) (nicotinic agonist) ABT-418 over 6 h in a double-blind, within-subjects, repeated-measures design. Subjects showed significant improvements in total recall and a decline in recall failure on a verbal learning task. Qualitatively similar improvements were seen in non-verbal learning tasks such as spatial learning and memory, and repeated acquisition. No significant behavioral, vital sign, or physical side effects were seen. These results confirm that stimulating central nicotinic receptors has acute cognitive benefit in AD patients. These findings suggest that selective ChCAs have a potential therapeutic role in dementing disorders, and that further studies with this or similar agents in AD and/or Parkinson's disease are warranted.

Encapsulation of Inorganic Particles by Dispersion Polymerization in Polar Media

Following a previous work (Bourgeat-Lami, E., and Lang, J., J. Colloid Interface Sci. 197, 293 (1998)), encapsulation of silica beads has been achieved by dispersion polymerization of styrene in an aqueous ethanol medium using poly(N-vinyl pyrrolidone) as stabilizer. Silica beads, prepared according to the Stöber method, were coated prior to polymerization by grafting 3-(trimethoxysilyl)propyl methacrylate onto the surface. A great number of silica beads per composite particle were previously found using beads that had diameters between 49 and 120 nm. In the present work, larger silica beads with diameters between 191 and 629 nm are investigated. We demonstrate by transmission electron microscopy that, consequently, only a small number of silica beads are contained in the composite particles. By counting the composite particles containing precisely zero, one, two, three, four, and more than four silica beads, it clearly appears that the encapsulation of only one silica bead can be obtained simply by increasing the size of the beads. Under our experimental conditions, the optimal bead diameter for achieving composite particles containing only one silica bead turns out to be around 450 nm. We show that increasing the silica bead size above this value results in an increased number of composite particles without silica beads. In contrast, the number of composite particles with two, three, four, or more than four silica beads increases with decreasing silica bead size. In addition to the above variations in composition of the composite particles, changes in particle shapes were also observed as a function of the size of the silica beads and the styrene concentration in the polymerization medium. Hypotheses concerning these variations are presented. Copyright 1999 Academic Press.

[Diagnosis and treatment of endodermal sinus tumor of the vagina]

OBJECTIVES

To describe the clinical characteristics and the role of chemotherapy in endodermal sinus tumor of the vagina.

METHOD

Two patients with endodermal sinus tumor of the vagina were presented focusing on the clinical manifestations and outcome of the chemotherapy.

RESULTS

Patient's age was quite young, 2 and 3 years old respectively. Vaginal bleeding and a polypoid and fragile tumor of the vagina were main clinical features. Elevated serum alpha-FP was found before chemotherapy and dropped dramatically to normal if the tumor was sensitive to chemotherapy. Diagnosis was made by pathology and alpha-FP immunohistochemical staining. Both two patient was well responded to cisplatin vincristine bleomycin (PVB) and cisplatin etoposide bleomycin (PEB) chemotherapy. Clinical and pathological complete remission was obtained after 2-3 courses of chemotherapy without radical surgery and radiotherapy.

CONCLUSIONS

Endodermal sinus tumor of vagina in infant was very sensitive to the chemotherapy. Serum alpha-FP was very useful in diagnosis and monitoring of the disease.

Molecular mechanisms and regulation of insulin exocytosis as a paradigm of endocrine secretion

Secretion of the peptide hormone insulin from pancreatic beta cells constitutes an important step in the regulation of body homeostasis. Insulin is stored in large dense core vesicles and released by exocytosis, a multistage process involving transport of vesicles to the plasma membrane, their docking, priming and finally their fusion with the plasma membrane. Some of the protein components necessary for this process have been identified in beta cells. The export of potent and potentially harmful substances has to be tightly controlled. The secretory response in pancreatic beta cells requires the concerted action of nutrients together with enteric hormones and neurotransmitters acting on G-protein coupled receptors. It is well established that glucose and other metabolizable nutrients depolarize the beta-cell membrane and the ensuing Ca2+ influx through voltage-dependent channels constitutes a main stimulus for insulin exocytosis. Theoretical considerations and recent observations suggest in addition an organizing role for the Ca2+ channel similar to neurotransmission. A second regulatory control on exocytosis is exerted by monomeric and heterotrimeric G-proteins. The monomeric GTPase Rab3A controls insulin secretion through cycling between a guanosine triphosphate liganded vesicle-bound form and a guanosine diphosphate liganded, cytosolic form. The effect of neurohormones is transduced by the heterotrimeric GTPases. Whereas pertussis-toxin sensitive alpha-subunits exert direct inhibition at the level of exocytosis, the Gbeta gamma-subunits are required for stimulation. It is possible that these GTPases exert immediate regulation, while protein kinases and phosphatases may modulate long-term adaptation at the exocytotic machinery itself. The molecular nature of their activators and effectors still await identification. Insights into the progression of the exocytotic vesicle from docking to fusion and how these processes are precisely regulated by proteins and second messengers may provide the basis for new therapeutic principles.

Development of orphan vaccines: an industry perspective

The development of vaccines against rare emerging infectious diseases is hampered by many disincentives. In the face of growing in-house expenditures associated with research and development projects in a complex legal and regulatory environment, most pharmaceutical companies prioritize their projects and streamline their product portfolio. Nevertheless, for humanitarian reasons, there is a need to develop niche vaccines for rare diseases not preventable or curable by other means. The U.S. Orphan Drug Act of 1983 and a similar proposal from the European Commission (currently under legislative approval) provide financial and practical incentives for the research and development of drugs to treat rare diseases. In addition, updated epidemiologic information from experts in the field of emerging diseases; increased disease awareness among health professionals, patients, and the general public; a list of priority vaccines; emergence of a dedicated organization with strong leadership; and the long-term pharmacoeconomic viability of orphan products will be key factors in overcoming the complexity of orphan status and the limited need for vaccine.

[Recurrent epithelial ovarian cancer]

OBJECTIVE

To evaluate the factors of influence on recurrent epithelial ovarian cancer and to make strategy of treatment.

METHODS

Retrospective study of 189 cases of ovarian cancer admitted in our hospital from Jan, 1987 to Dec, 1997. All of these cases had postoperative pathological diagnosis.

RESULTS

Of 31 recurrent cases, 19 cases had first cytoreductive surgery in our hospital, while other 12 cases were done in other hospitals. According to FIGO criteria, stage I, II 4 cases (12.9%), III, IV 27 cases (87.1%). The mean recurrent time of no-residual disease was 17.2 months, while that of residual disease < or = 2 cm was 10.1 months (P < 0.01). The mean recurrent time of those having chemotherapy > or = 6 cycles was 13.1 months, while that of those having chemotherapy < 6 cycles was 10.1 months (P > 0.05). The five-year survival rate of 18 cases having secondary cytoreductive surgery was 27.3%, while that of 4 cases having chemotherapy only was 7.1% (P < 0.01). The five-year survival rate of 7 cases abandoning any therapy was 4.8% (P < 0.01). 2 cases had only irradiation therapy.

CONCLUSIONS

Histology, stage, degree of tumor differentiation, chemotherapy and the residual disease of cytoreductive surgery all influence recurrence of epithelial ovarian cancer. Secondary cytoreductive surgery along with chemotherapy can raise recurrent epithelial ovarian cancer's five-year survival rate.

Dynamic cardiomyoplasty in patients with end-stage heart failure: anaesthetic considerations

Dynamic cardiomyoplasty is used increasingly for patients with chronic heart failure, with approximately 500 cases having been performed. The latissimus dorsi muscle is prepared maintaining its vascular supply and the muscle flap is wrapped around the heart and connected to a cardiomyostimulator. The muscle is later stimulated synchronously with ventricular systole to augment the heart. Our experience of 22 patients with chronic heart failure (NYHA III-IV) undergoing dynamic cardiomyoplasty is described from the anaesthetist's point of view. Two patients are reported as case reports. The challenge is to manage patients with severely impaired left ventricular function, who do not obtain immediate benefit from the operation. Our experience supports the importance of early use of inotropic agents.

The immunogenicity and safety of a new combined diphtheria, tetanus and poliomyelitis booster vaccine (Td-eIPV)

In view of the continuing risk of contracting tetanus, diphtheria and poliomyelitis, and the well-documented decline in immunity with time, the need for booster vaccinations is substantial. The immunogenicity and safety of a new combined booster vaccine against tetanus, diphtheria and poliomyelitis (REVAXIS) developed by Pasteur Mérieux Connaught (Lyon, France) were evaluated in four clinical studies. This vaccine (Td-eIPV) combines an adsorbed tetanus toxoid and low-dose diphtheria toxoid vaccine (Td) with an enhanced, inactivated polio vaccine against poliovirus types 1, 2 and 3 (eIPV). In 256 healthy young adults, a single dose of Td-eIPV was shown to be immunogenic, eliciting antibody levels considered protective against disease for each vaccine component in > or = 99.6% of the subjects. In 112 healthy older subjects (> 40 years of age), two doses of Td-eIPV elicited seroprotective levels of antibodies in 94% of the subjects for diphtheria, and in all subjects for tetanus and poliovirus types 1, 2 and 3. Safety data from all 368 subjects, as well as 31 phase I volunteers and 1,742 subjects included in a safety study, reveal that the vaccine is safe. Most reactions were predictable, temporary and mild. There was no evidence that the vaccine was associated with any clinically serious event or modification of clinical laboratory parameters. The data reviewed here show that Td-eIPV is immunogenic and safe when administered as a booster vaccination in healthy adults of all ages.

[Clinical observation of conservative surgery for adenomyosis]

OBJECTIVE

To study the clinical value of conservative surgery for adenomyosis in reducing symptoms and raising pregnancy rate.

METHODS

26 women with histologically proven adenomyosis who wanted to preserve their reproductive capacity had conservative surgery (adenomyomectomy or remove part lesion). The patient's average age was 35.8 years. The main complaints were dysmenorrhea and hypermenorrhea. Of the 22 married patients, 7 had primary infertility (31.8%), 10 had secondary infertility (45.5%) and 3 had habitual abortion (13.6%).

RESULTS

10 patients had adenomyoma, the lesion were completely removed. Sixteen patients had adenomyosis, the part of lesion were removed. The rate of the severe dysmenorrhea and hypermenorrhea after operation were significantly lower than that before (P < 0.001). After operation, 7 patients with adenomyoma wanted to have a baby, 5 patients conceived, of the total 9 pregnancies, 5 ended in term pregnancy; 14 patients with diffuse adenomyosis wanted to have a baby, 3 patients had 3 pregnancies. One of which ended in term pregnancy. The rate of pregnancy and term delivery in adenomyoma patients were significantly higher than that of adenomyosis patients (P = 0.03, P = 0.002). Among 26 patients, 3 relapsed. The average relapse time was 49.6 months.

CONCLUSIONS

The conservative surgery for adenomyoma can reduce symptom and raise pregnancy rate significantly, it can be accepted by young women who want to preserve their reproductive capacity. Though the pregnancy rate of conservative surgery for diffused adenomyosis was low, it still has therapeutic value.