Cardiac output changes with phenylephrine and ephedrine infusions during spinal anesthesia for cesarean section: A randomized, double-blind trial

Hypotension is a common side effect of spinal anesthesia. Phenylephrine and ephedrine are the two most frequently used vasopressors to treat spinal hypotension during cesarean delivery. In this randomized double-blind study, we aimed to evaluate cardiac output (CO) changes with phenylephrine or ephedrine infusions titrated to maintain baseline systolic blood pressure (bSBP) during spinal anesthesia. Women (n = 40) scheduled for elective cesarean delivery received either phenylephrine 100 μg/min or ephedrine 5 mg/min infusions. Baseline hemodynamics (cardiac output, heart rate, systolic blood pressure) were recorded in the left lateral tilt position before fluid preload, and recorded every minute after spinal anesthesia until delivery. Umbilical cord blood gases were analyzed within 5 minutes of delivery. Good systolic blood pressure control was attained in both groups with minimal periods of hypotension (SBP <80% of bSBP) or hypertension (SBP >120% of bSBP). Cardiac output and heart rate increased over time with ephedrine, but decreased with phenylephrine. The maximum increase in CO from the baseline was 12%, in the ephedrine group, and this occurred 20 minutes after spinal injection. Cardiac output fell by more than 17% in the phenylephrine group, maximal at 10 minutes following spinal injection. Despite good systolic blood pressure control and increased cardiac output with ephedrine, administration of ephedrine was associated with significantly more fetal acidosis [Median (Interquartile range, IQR) UApH - phenylephrine = 7.33 (7.31-7.34) and ephedrine = 7.22 (7.16-7.27), P < .05].

About the in vivo quantitation of skin anisotropy

BACKGROUND/PURPOSE

Human skin anisotropy is difficult to quantify. The Cutiscan^® , is allegedly, the first biometrical system to provide information on the elastic and viscoelastic properties, as well as on anisotropy and directionality of the human skin in vivo. Thus, this study aims to contribute to characterize this new device and its applicability, and to compare its behavior with two other well-known devices-the Cutometer^® and the Reviscometer^® .

METHODS

Measurements were conducted with each device in three different anatomical sites (forehead, forearm and leg) of 20 female volunteers engaged after informed consent. The participants in the study were aged 19-73 years (mean age 37 ± 18.7 years old), and were divided in two groups (n = 10), based on their age - Group I, mean age 22 ± 1.3 years; Group II, mean age 52 ± 13.7 years.

RESULTS

All devices were useful tools to explore the anatomical and the age dependant changes in biomechanical terms, showing different discriminative capacities. Interesting correlations were established between the variables provided by the equipment.

CONCLUSION

The Cutiscan^® descriptors delivered excellent relationships with those from Cutometer^® and Reviscometer^® , while providing more detailed information about skin anisotropy through a full 360° analysis.

Inflammation and Epidural-Related Maternal Fever: Proposed Mechanisms

Intrapartum fever is associated with excessive maternal interventions as well as higher neonatal morbidity. Epidural-related maternal fever (ERMF) contributes to the development of intrapartum fever. The mechanism(s) for ERMF has remained elusive. Here, we consider how inflammatory mechanisms may be modulated by local anesthetic agents and their relevance to ERMF. We also critically reappraise the clinical data with regard to emerging concepts that explain how anesthetic drug-induced metabolic dysfunction, with or without activation of the inflammasome, might trigger the release of nonpathogenic, inflammatory molecules (danger-associated molecular patterns) likely to underlie ERMF.

Endogenous GABAA receptor activity suppresses glioma growth

Although genome alterations driving glioma by fueling cell malignancy have largely been resolved, less is known of the impact of tumor environment on disease progression. Here, we demonstrate functional GABA_A receptor-activated currents in human glioblastoma cells and show the existence of a continuous GABA signaling within the tumor cell mass that significantly affects tumor growth and survival expectancy in mouse models. Endogenous GABA released by tumor cells, attenuates proliferation of the glioma cells with enriched expression of stem/progenitor markers and with competence to seed growth of new tumors. Our results suggest that GABA levels rapidly increase in tumors impeding further growth. Thus, shunting chloride ions by a maintained local GABA_A receptor activity within glioma cells has a significant impact on tumor development by attenuating proliferation, reducing tumor growth and prolonging survival, a mechanism that may have important impact on therapy resistance and recurrence following tumor resection.

Beyond Fullerenes: Designing Alternative Molecular Electron Acceptors for Solution-Processable Bulk Heterojunction Organic Photovoltaics

Organic photovoltaics (OPVs) are promising candidates for providing a low cost, widespread energy source by converting sunlight into electricity. Solution-processable active layers have predominantly consisted of a conjugated polymer donor blended with a fullerene derivative as the acceptor. Although fullerene derivatives have been the acceptor of choice, they have drawbacks such as weak visible light absorption and poor energy tuning that limit overall efficiencies. This has recently fueled new research to explore alternative acceptors that would overcome those limitations. During this exploration, one question arises: what are the important design principles for developing nonfullerene acceptors? It is generally accepted that acceptors should have high electron affinity, electron mobility, and absorption coefficient in the visible and near-IR region of the spectra. In this Perspective, we argue that alternative molecular acceptors, when blended with a conjugated polymer donor, should also have large nonplanar structures to promote nanoscale phase separation, charge separation and charge transport in blend films. Additionally, new material design should address the low dielectric constant of organic semiconductors that have so far limited their widespread application.

Fibrinogen concentrate versus placebo for treatment of postpartum haemorrhage: study protocol for a randomised controlled trial

Background

Postpartum haemorrhage (PPH) is a major cause of maternal morbidity. Bleeding is caused by a combination of physical causes, such as failure of the uterus to contract or operations, and is made worse by impairment of the blood clotting system. A number of studies have shown that low levels of the blood clotting factor fibrinogen are associated with progression of bleeding, the need for invasive interventions and transfusions of red blood cells and fresh frozen plasma (FFP). This trial will investigate whether early infusion of fibrinogen concentrate during a major PPH, with the aim of correcting a low fibrinogen to a level that is normal for delivery, based on the Fibtem test, reduces the total number of allogeneic blood products (red blood cells, FFP, cryoprecipitate and platelets) transfused after study medication until discharge, compared to placebo.

Methods/design

This is a prospective, randomised, double-blind placebo controlled trial. Women will enter an observational phase and if their Fibtem levels fall they will be randomised in the interventional phase. A total of 60 women will be randomised and women are eligible for the trial if they meet all of the following inclusion criteria: age 18 years or over, gestation ≥24 + 0 weeks, haemorrhage of about 1500 ml and on-going bleeding without another complication or haemorrhage of about 1000 ml and caesarean section/uterine atony/placental abruption/placenta praevia/cardiovascular instability or microvascular oozing. Participants with a Fibtem A5 < 16 mm will be randomly allocated to receive either a bolus infusion of fibrinogen concentrate or placebo (isotonic saline). The dose of fibrinogen concentrate or placebo will be calculated based on the woman’s ideal body weight for height and the measured Fibtem A5 with the aim of increasing the Fibtem A5 to 23 mm.

Discussion

The trial aims to provide evidence on the efficacy and safety of fibrinogen concentrate during acute bleeding in an obstetric setting.

Trial registration

ISRCTN ref: ISRCTN46295339 (01.07.2013); EudraCT: 2012-005511-11 (28.11.2012), UKCRN ref: 13940.

Tuning the optoelectronic properties of core-substituted naphthalene diimides by the selective conversion of imides to monothioimides

Molecules with a low optical gap and high electron affinity were obtained via selective thionation of the distal carbonyls of 2,6-dialkylamino core-substituted naphthalene diimide.

Tuning the optical and electrochemical properties of core-substituted naphthalenediimides with styryl imide substituent

Unusually broad thin-film visible absorption (500–800 nm) for naphthalenediimide molecules was obtained by using the combination of alkylamino core substituents and styryl imide substituents.

Fetal effects of combined spinal-epidural vs epidural labour analgesia: a prospective, randomised double-blind study

We have compared fetal heart rate patterns, Apgar scores and umbilical cord gas values following initiation of labour analgesia using either combined spinal-epidural or epidural. One hundred and fifteen healthy women requesting neuraxial analgesia in the first stage of labour were randomly assigned to receive either combined spinal-epidural (n = 62) or epidural analgesia (n = 53). Fetal heart rate traces, recorded for 30 min before and 60 min after neuraxial block, were categorised as normal, suspicious or pathological according to national guidelines. Sixty-one fetal heart rate tracings were analysed in the combined spinal-epidural group and 52 in the epidural group. No significant differences were found in fetal heart rate patterns, Apgar scores or umbilical artery and vein acid-base status between groups. However, in both combined spinal-epidural and epidural groups, there was a significant increase in the incidence of abnormal fetal heart rate patterns following neuraxial analgesia (p < 0.0001); two before compared with eight after analgesia in the combined spinal-epidural group and zero before compared with 11 after in the epidural group. These changes comprised increased decelerations (p = 0.0045) (combined spinal-epidural group nine before and 14 after analgesia, epidural group four before and 16 after), increased late decelerations (p < 0.0001) (combined spinal-epidural group zero before and seven after analgesia, epidural group zero before and eight after), and a reduction in acceleration rate (p = 0.034) (combined spinal-epidural group mean (SD) 12.2 (6.7) h(-1) before and 9.9 (6.1) h(-1) after analgesia, epidural group 11.0 (7.3) h(-1) before and 8.4 (5.9) h(-1) after). These fetal heart rate changes did not affect neonatal outcome in this healthy population.

Analysis of egg production in layer chickens using a random regression model with genomic relationships

Random regression models allow for analysis of longitudinal data, which together with the use of genomic information are expected to increase accuracy of selection, when compared with analyzing average or total production with pedigree information. The objective of this study was to estimate variance components for egg production over time in a commercial brown egg layer population using genomic relationship information. A random regression reduced animal model with a marker-based relationship matrix was used to estimate genomic breeding values of 3,908 genotyped animals from 6 generations. The first 5 generations were used for training, and predictions were validated in generation 6. Daily egg production up to 46 wk in lay was accumulated into 85,462 biweekly (every 2 wk) records for training, of which 17,570 were recorded on genotyped hens and the remaining on their nongenotyped progeny. The effect of adding additional egg production data of 2,167 nongenotyped sibs of selection candidates [16,037 biweekly (every 2 wk) records] to the training data was also investigated. The model included a 5th order Legendre polynomial nested within hatch-week as fixed effects and random terms for coefficients of quadratic polynomials for genetic and permanent environmental components. Residual variance was assumed heterogeneous among 2-wk periods. Models using pedigree and genomic relationships were compared. Estimates of residual variance were very similar under both models, but the model with genomic relationships resulted in a larger estimate of genetic variance. Heritability estimates increased with age up to mid production and decreased afterward, resulting in an average heritability of 0.20 and 0.33 for pedigree and genomic models. Prediction of total egg number was more accurate with the genomic than with the pedigree-based random regression model (correlation in validation 0.26 vs. 0.16). The genomic model outperformed the pedigree model in most of the 2-wk periods. Thus, results of this study show that random regression reduced animal models can be used in breeding programs using genomic information and can result in substantial improvements in the accuracy of selection for trajectory traits.

Statement on access to relevant medical and other health records and relevant legal records for forensic medical evaluations of alleged torture and other cruel, inhuman or degrading treatment or punishment

In some jurisdictions attempts have been made to limit or deny access to medical records for victims of torture seeking remedy or reparations or for individuals who have been accused of crimes based on confessions allegedly extracted under torture. The following article describes the importance of full disclosure of all medical and other health records, as well as legal documents, in any case in which an individual alleges that they have been subjected to torture or other forms of cruel, inhuman or degrading treatment of punishment. A broad definition of what must be included in the terms medical and health records is put forward, and an overview of why their full disclosure is an integral part of international standards for the investigation and documentation of torture (the Istanbul Protocol). The fact that medical records may reveal the complicity or direct participation of healthcare professionals in acts of torture and other ill-treatment is discussed. A summary of international law and medical ethics surrounding the right of access to personal information, especially health information in connection with allegations of torture is also given.

Changes in nerve growth factor level and symptom severity following antibiotic treatment for refractory overactive bladder

INTRODUCTION AND HYPOTHESIS

Overactive bladder (OAB) has a multifactorial aetiology, and for some women symptoms may be associated with chronic urothelial inflammation secondary to bacterial colonisation. One marker of such inflammation may be urinary nerve growth factor (NGF). We hypothesised that for women with OAB and urothelial inflammation, urinary NGF would be reduced following antibiotic therapy.

METHODS

Women with overactive bladder and urodynamic diagnosis of detrusor overactivity who were refractory to anticholinergics, and had histological evidence of urothelial inflammation were treated with a 6-week course of rotating antibiotics. Urinary NGF was measured by ELISA before and after treatment. Three-day bladder diaries, the Patients' Perception of Intensity of Urgency Scale, the King's Health Questionnaire and the Patients' Perception of Bladder Condition questionnaire were used to assess subjective and objective outcomes of therapy.

RESULTS

Thirty-nine women with refractory DO were recruited. The NGF levels decreased significantly after antibiotic therapy (Wilcoxon signed rank test; p = 0.015). There were significant improvements in daytime frequency, nocturia and urgency (p < 0.05), and 74 % of women reported improvement in perception of their bladder condition.

CONCLUSIONS

Urinary NGF is responsive to antibiotic therapy. Women with refractory overactive bladder and elevated NGF may benefit from antibiotic treatment.

Genetic parameters for energy balance, feed efficiency, and related traits in Holstein cattle

Objectives of the current study were to estimate genetic parameters in Holstein cows for energy balance (EB) and related traits including dry matter intake (DMI), body weight (BW), body condition score (BCS), energy-corrected milk (ECM) production, and gross feed efficiency (GFE), defined as the ratio of total ECM yield to total DMI over the first 150 d of lactation. Data were recorded for the first half of lactation on 227 and 175 cows in their first or later lactation, respectively. Random regression models were fitted to longitudinal data. Also, each trait was averaged over monthly intervals and analyzed by single and multivariate animal models. Heritability estimates ranged from 0.27 to 0.63, 0.12 to 0.62, 0.12 to 0.49, 0.63 to 0.72, and 0.49 to 0.53 for DMI, ECM yield, EB, BW, and BCS, respectively, averaged over monthly intervals. Daily heritability estimates ranged from 0.18 to 0.30, 0.10 to 0.26, 0.07 to 0.22, 0.43 to 0.67, and 0.25 to 0.38 for DMI, ECM yield, EB, BW, and BCS, respectively. Estimated heritability for GFE was 0.32. The genetic correlation of EB at 10d in milk (DIM) with EB at 150 DIM was -0.19, suggesting the genetic regulation of this trait differs by stage of lactation. Positive genetic correlations were found among DMI, ECM yield, and BW averaged over monthly intervals, whereas correlations of these traits with BCS depended upon stage of lactation. Total ECM yield for the lactation was positively correlated with DMI, but a negative genetic correlation between total ECM yield and EB was found. However, the genetic correlation between total ECM yield and EB in the first month of lactation was -0.02, indicating that total production is not genetically correlated with EB during the first month of lactation, when negative EB is most closely associated with diminished fitness. The genetic correlation between GFE and EB ranged from -0.73 to -0.99, indicating that selection for more efficient cows would favor a lower energy status. However, the genetic correlation between EB in the first month of lactation and GFE calculated from 75 to 150 DIM was not significant, indicating that the unfavorable correlation between GFE and EB in early lactation may be minimized with alternative definitions of efficiency. Thus, EB, GFE and related traits will likely respond to genetic selection in Holstein cows. However, the impact of selection for improved feed efficiency on EB must be carefully considered to avoid potential negative consequences of further reductions in EB at the onset of lactation.