Association of epidural analgesia with cesarean delivery in nulliparas

OBJECTIVE

To evaluate whether epidural analgesia during the first stage of labor is associated with an increased risk of cesarean delivery.

METHODS

The association of epidural analgesia and cesarean delivery was examined in a retrospective study of 1733 low-risk, term nulliparas with singleton infants in vertex presentations, in which labor began spontaneously. To evaluate the effect of epidural analgesia on cesarean deliveries, independent of other factors influencing the use of epidural analgesia, we used propensity scores to create five subgroups (quintiles) of women who, based on characteristics discernible at admission, appeared equally likely to receive epidural analgesia. Multivariate logistic regression analysis was used to control for confounding.

RESULTS

Overall, the cesarean rate among women receiving epidural analgesia was 17% (168 of 991), compared with 4% (30 of 742) among those who did not receive epidural analgesia. An increased cesarean rate among women receiving epidural analgesia was present in all propensity quintiles. In an adjusted logistic regression analysis, women receiving epidural analgesia were 3.7 times more likely to undergo a cesarean (95% confidence interval 2.4, 5.7). The greatest increase in cesarean risk was noted when epidural analgesia was administered earlier in labor, but there was a more than twofold increase regardless of the dilation and station at administration of epidural analgesia.

CONCLUSIONS

Epidural analgesia may increase substantially the risk of cesarean delivery. Although the causal nature of this association remains open to debate, prenatal care providers should routinely discuss the risks and benefits of epidural analgesia with women during their pregnancies so that they can make informed decisions about the use of pain relief during labor.

Prior exposure to superantigen can inhibit or exacerbate autoimmune encephalomyelitis: T-cell repertoire engaged by the autoantigen determines clinical outcome

Experimental allergic encephalomyelitis (EAE) is inducible in experimental animals immunized with myelin basic protein (MBP), proteolipid protein (PLP) or their peptides. We compared T-cell responses to encephalitogenic epitopes of PLP(43-64) and MBP(Ac1-11) in a single mouse strain, (PL/J x SJL)F1. MBP(1-11)-specific T-cell hybridomas expressed predominantly TCR V beta 8 or V beta 4, while PLP(43-64)-specific hybridomas expressed a diverse TCR repertoire. To analyze the biologic significance of the TCR repertoire (limited vs. diverse) to disease susceptibility, we pretreated mice with a superantigen (SEB), and then induced disease with these autoantigens. Mice injected with SEB and immunized with MBP(Ac1-11) showed significant inhibition of EAE, whereas SEB-pretreated mice immunized with PLP(43-64) had an increased severity of EAE and developed a chronic disease. These data demonstrate that prior exposure to microbial superantigens can significantly alter the autoimmune disease course depending upon the TCR repertoire used by the autoantigen.

NCCN Colorectal Cancer Practice Guidelines. The National Comprehensive Cancer Network

In summary, the committee believes that a multidisciplinary approach is necessary for the management of the patient with colorectal cancer. The committee endorses the concept that treatment of patients on a clinical trial has priority over standard or accepted therapy. The recommended surgical procedure for managing resectable colon cancer is an en bloc resection; laparoscopic surgery should be done only in the context of a clinical trial. For patients with stage III disease, 5-FU-based adjuvant chemotherapy is recommended. A patient who has metastatic disease in the liver or lung should be considered for surgical resection if he or she is a candidate for surgery and if surgery can extend survival. The committee advocates a conservative post-treatment surveillance program for colon and rectal cancer patients. A determination of CEA should be done only if CEA was elevated at baseline and decreased following primary resection. Abdominal and pelvic CT scans should be utilized only when there are clinical indications of possible recurrence. Patients whose disease progresses during 5-FU-based therapy should be considered for treatment with irinotecan or encouraged to participate in a phase I or II clinical trial.

Sleep architecture as related to temperature changes in neonates at term

Sleep architecture was assessed under different environmental temperatures in 10 full-term and 10 preterm infants who reached term. Five 30-min periods of baseline, normothermia heating, peak temperature, cooling and normothermia were analysed. A significant decrease in the proportion of active sleep (AS) and an increase in quiet sleep (QS) was noted among the full-term infants during the heating and peak temperature conditions, whereas, among the preterm infants, a similarly significant difference was noted during the heating and cooling stages of the study, but not during the stage of peak temperature. This differential response to environmental hyperthermia is possibly related to maturational factors. This phenomenon may be related to the increased vulnerability of low birth weight infants to apnoea and sudden infant death syndrome.

Identification of a mutation in a GATA binding site of the platelet glycoprotein Ibbeta promoter resulting in the Bernard-Soulier syndrome

Bernard-Soulier Syndrome (BSS) is a rare congenital bleeding disorder due to absent or decreased expression of the glycoprotein Ib-IX-V (GpIb-IX-V) receptor complex on the platelet surface. To date, only mutations in GpIbalpha or GpIX have been reported in patients with BSS. GpIbbeta differs from the other proteins in this receptor in that the gene is more complex, and an alternative form is expressed in cells of non-megakaryocytic lineage, including endothelial cells. It appears that the megakaryocytic and endothelial cell mRNA species are transcribed from different start sites and have different proximal promoter regions. We have identified a patient with BSS who has a deletion on one chromosome 22, resulting in velocardiofacial syndrome. The GpIbbeta gene has been mapped to this deleted (22q11.2) region of chromosome 22. The patient has greatly reduced levels of GpIbbeta mRNA and no detectable platelet GpIbbeta protein, suggesting that his BSS results from a mutation in his remaining GpIbbeta allele. Sequence analysis revealed that the coding region of GpIbbeta is normal, but the 5'-upstream region contains a C to G transversion at base -133 from the transcription start site used in megakaryocytes. The mutation changes a GATA consensus binding site, disrupts GATA-1 binding to the mutated site, and decreases promoter activity by 84%. Thus, in this patient, Bernard-Soulier syndrome results from a deletion of one copy of GpIbbeta and a mutated GATA binding site in the promoter of the remaining allele, resulting in decreased promoter function and GpIbbeta gene transcription.

Dorsal penile nerve block in children undergoing circumcision in a day-care surgery

PURPOSE

Circumcision is performed under general anaesthesia (GA) with dorsal penile nerve block (DPNB) as an analgesic technique for postoperative pain. The purpose of this study was to compare DPNB as the sole anaesthetic procedure vs GA and DPNB for circumcision in children as an outpatient procedure.

METHODS

In a six-month prospective study, 250 boys aged 6 to 17 yr (mean age 11.5 +/- 3.5 yr) were randomized into two groups. Group A (n = 122) received DPNB only prior to circumcision, and Group B (n = 128) received GA + DPNB. The groups were compared for complications of the block, effectiveness of anaesthesia, operating room time, postoperative time and ease of recovery.

RESULTS

There were no major operative complications in the two groups. Minor block complications, including oedema and haematoma, occurred in 16 (13.1%) boys in Group A and 27 (21.10%) boys in Group B (NS). At surgery, 3 (2.6%) from Group A received additional GA and 1 (0.8%) received additional local anaesthesia. They represent a DPNB failure rate of 3.3%. Mean operating room time was 11 +/- 2.5 min in Group A and 19 +/- 3.5 min in Group B, and post-anaesthesia care unit (PACU) time was 51 +/- 10 min in Group A and 101 +/- 14.5 min in Group B (P < 0.001). Nausea and vomiting in the PACU were noted in one patient in Group A and in 15 in Group B (P < 0.05). Only patients in Group B required additional analgesia and tranquilizers in the PACU (0 versus 20; P < 0.05).

CONCLUSIONS

These data confirm that DPNB has advantages over GA + DPNB for paediatric circumcision in day-care surgery.

Determinants of loneliness in Jerusalem's 70-year-old population

This study aims to find the determinants of feelings of loneliness in 70 year olds living in Jerusalem. Results based on home interviews (n = 605) of a 40% systematic sample of 70 year olds in the electoral register showed that around 46.3% of females and 21.3% of males reported being lonely. Persons of European/North American origin felt less lonely than those of Asian or African origin, probably due to the former's wider social support network, perceiving friends, neighbors or other relatives as being available to back up children in an emergency. The major factors associated with loneliness were: being depressed, having a poor self-assessed health status, not attending synagogue, and being widowed but not remarried. Factors that did not reduce loneliness included having paid employment, watching TV or listening to the radio. No association was found between cognitive status and loneliness. Our systems model suggests a strong reciprocal relationship between loneliness and depression.

The nutritional status of 70 year olds in Jerusalem

Inadequate nutrition is a major problem of elderly people today, a rapidly growing segment of western societies. Yet information on the nutritional state of the elderly in the community is much needed. We surveyed the nutritional status of a cohort of 70 year olds living in western Jerusalem. A total of 605 persons were interviewed in their home regarding socioeconomic variables, education, self-assessed global health status, use of medicines, and activities of daily living (ADL). In the second stage, a subsample of 463 of the above attended an outpatient geriatric clinic where a medical history was taken and a physical examination, a cognitive test, a psychological profile, blood and urine tests, electrocardiogram, pulmonary function tests, and grip strength measurement performed. Most of the sample population lived at home. Twelve percent reported having severe financial problems. Approximately 14% exhibited some cognitive problems, 83% were totally independent in ADL, and only 15% were housebound with 2.5% being bedbound. Body mass index (BMI) of < 19 kg/m2 was found in 1.1% of the population, while obesity, defined as a BMI > 30 kg/m2, was found in 13.5% of males and 28.6% of females. Polypharmacy was prevalent. A quarter of the study population were taking three or more prescription drugs. Serum triglycerides were below the normal limit in 7.3% of males and 4.7% of females, while total serum cholesterol concentrations were low in 13.9% and 4.7% of males and females respectively. Serum albumin was found below the lower limit of normal (35 g/l) in 16.9% of females and 11.4% of males. The significance of these results, their relation to other nutritional surveys, and their implications for the future are discussed.

Hypertension in the Jerusalem 70 year olds study population: prevalence, awareness, treatment and control

As part of the Jerusalem 70 year olds study, we evaluated the prevalence, awareness, treatment and control of hypertension (blood pressure > or = 160 mm Hg systolic and/or > or = 95 mm Hg diastolic, or current treatment with prescribed antihypertensive medications). The study cohort consisted of 448 participants, 224 of whom had hypertension. Relative to other populations, awareness was high (87%). Although the treatment rate was also relatively high (86%), the control rate was only 43%. Untreated isolated systolic hypertension was uncommon (5%), as was orthostatic hypotension (6.9%). Thus, despite a remarkable degree of awareness and treatment rate of hypertension, control levels were disappointingly low. This finding, if confirmed, requires further elucidation.

The Jerusalem 70 year olds longitudinal study: gastrointestinal findings

The objective of this part of the first cross-section of the longitudinal study of a cohort of 70 year olds in Jerusalem was to survey the gastrointestinal symptoms and signs of this heterogeneous population and thus contribute to the knowledge of the development of gastrointestinal diseases in this age group. A total of 605 persons replied to a home-visit questionnaire gathering data on socioeconomic and migration variables. Later on, 463 of these attended an examination at the Geriatric Research Institute where an in-depth anamnesis and physical examination were conducted. A battery of biochemical and hematologic blood tests were performed as well as urine analysis, ECG, and pulmonary function tests. At 3 year follow-up, the interviewed subjects, subjects examined in the hospital, and the control group consisting of 70 year olds who were not examined, were compared. By the measures of disease-specific mortality and hospital morbidity, the three groups were found to be similar, demonstrating that the sample population does represent the total Jerusalem 70-year-old population. This paper describes the symptoms, signs and laboratory results of the gastrointestinal part of this study. Up to a third of the subjects complained of upper gastrointestinal symptoms, most prominent of which was heartburn. Almost 10% of subjects complained of abdominal pain occurring at least once a week, but less than 1% noted left lower quadrant pain. There was a direct association between upper abdominal pain and symptoms of ischemic heart disease. The second part of this study, which began in 1996, will provide additional information regarding the natural history of these complaints.

Characteristics of falls in 70 year olds in Jerusalem

Falling is a serious and common problem among the elderly and may result in injury and functional deterioration. The characteristics and risk factors for falling were studied in a cross-sectional study of a cohort of 70-year-old community-dwelling Jewish elderly in Jerusalem. The cohort was found to be representative of the total 70-year-old population of Jerusalem by virtue of having similar hospitalization and mortality rates. Around 28.2% of the cohort reported falling during the past year. Women were more likely than men to have fallen during the past year (39 vs. 19%; P < 0.001). Falls occurred mainly outside of the home, resulting in fractures in 8.4% of persons who fell, all of them women. A female gender, low visual efficiency, poor self-reported general health status, low serum hemoglobin levels, and low lymphocyte counts were associated with a higher incidence of falls. There was no relationship between the pattern of pharmaceutic drug use or utilization of health care services and the risk of falling. We conclude that among the younger elderly, characteristics of falls and risk factors may be different from those in the older elderly.

Poland sequence in two siblings suggesting an autosomal inheritance transmission

We report on Poland sequence observed in two siblings (a girl and a boy) in the same family. This suggests an inheritance pattern consistent with an autosomal recessive or dominant trait transmission with reduced penetrance.

Factors predicting emergency room utilization in a 70-year-old population

Emergency room (ER) utilization in a representative sample (n = 605) of 70-year-old Jerusalem residents was investigated using multiple and logistic regression techniques. Around 23% of the study population visited an ER during the pre-interview year. Problems associated with ER use were heart diseases (mainly ischemic), asthma, renal disorders, psychiatric problems, headaches, and nocturia. Also associated with increased ER use were prior hospital admissions, taking sleeping pills, driving a car, distance from one's general practitioner, and low self-assessed health status. The availability of help from children increased ER use, possibly by sharing in the decision-making process or by helping with post-visit financial bureaucracy. Persons with cognitive problems had decreased ER use, possibly due to their inability to cope with the related complex decision-making process. The inclusion of interaction terms improved the models fit, in keeping with the general philosophy of geriatric care which often deals with cases presenting multiple diagnoses in addition to various social problems. Information on key variables identified as predictors of ER use in order to predict ER use as a basis for budget allocation to specific sick funds, was collected by means of a postal questionnaire or by phone.

Laboratory reference values for the 70 year olds

Reference values for common laboratory tests were determined as part of a cross-sectional survey of 70 year olds in Jerusalem in 1991. Subjects were systematically chosen from electoral lists. They were extensively interviewed regarding demographic, socioeconomic and health characteristics. Subsequently, 456 underwent a thorough medical examination including hematologic, biochemical and endocrinologic testing. Analysis of disease-specific mortality and hospital morbidity at 3 year follow-up proved these subjects to be representative of the overall Jerusalem Jewish population of 70 year olds. Test-specific reference subgroups were determined to exclude effects of known diseases and drug consumption. Reference values in these subgroups differ significantly from reference values currently used for adults without regard to age. The determination of disease for subjects provided the opportunity to identify changes that might reflect normal aging and those that might be affected by subclinical pathology. Interpretation of laboratory testing of older adults must consider the age-related differences in reference values.

A comparison of risk factors for preterm labor and term small-for-gestational-age birth

This study estimates the effects of 23 factors on the prevalence of premature labor and fetal growth retardation across the entire birthweight spectrum. We studied risk factors for premature labor within the domain of babies of appropriate size for their gestational age (N = 9,490). We also studied risk factors for fetal growth retardation among babies born at term (N = 10,889). Preterm labor was associated independently with young maternal age, low pre-pregnant weight, low weekly weight gain, nulliparity, previous preterm birth, histories of two or more induced abortions, spontaneous abortions, or stillbirths, uterine exposure to diethylstilbestrol (DES), incompetent cervix, uterine anomaly, and pyelonephritis. Odds ratios ranged from 1.7 to 5.9. Fetal growth retardation, as estimated by small-for-gestational-age birth, was associated independently with black race, young maternal age, short maternal height, low prepregnancy weight, low weekly weight gain, and smoking, as well as nulliparity, previous preterm birth, three or more abortions, uterine anomaly, and uterine exposure to DES. Odds ratios ranged from 1.6 to 2.8. Our study shows the importance for etiologic understanding of separating diverse routes to low birthweight and considering the occurrence of adverse pregnancy outcomes along the entire birthweight spectrum. The findings reinforce the need for comprehensive control of confounding in studies of pregnancy outcome.

Altered mRNA binding activity and decreased translational initiation in a nuclear mutant lacking translation of the chloroplast psbA mRNA

Translational regulation has been identified as one of the key steps in chloroplast-encoded gene expression. Genetic and biochemical analysis with Chlamydomonas reinhardtii has implicated nucleus-encoded factors that interact specifically with the 5' untranslated region of chloroplast mRNAs to mediate light-activated translation. F35 is a nuclear mutation in C. reinhardtii that specifically affects translation of the psbA mRNA (encoding D1, a core polypeptide of photosystem II), causing a photosynthetic deficiency in the mutant strain. The F35 mutant has reduced ribosome association of the psbA mRNA as a result of decreased translation initiation. This reduction in ribosome association correlates with a decrease in the stability of the mRNA. Binding activity of the psbA specific protein complex to the 5' untranslated region of the mRNA is diminished in F35 cells, and two members of this binding complex (RB47 and RB55) are reduced compared with the wild type. These data suggest that alteration of members of the psbA mRNA binding complex in F35 cells results in a reduction in psbA mRNA-protein complex formation, thereby causing a decrease in translation initiation of this mRNA.

Late-onset keratoconjunctivitis sicca syndrome after bone marrow transplantation: incidence and risk factors. European Group or Blood and Marrow Transplantation (EBMT) Working Party on Late Effects

The incidence, time course and risk factors associated with late-onset keratoconjunctivitis sicca syndrome after bone marrow transplantation (BMT) was evaluated in a multicenter retrospective cohort study conducted by the European Group for Blood and Marrow Transplantation (EBMT) Working Party on Late Effects. Data were requested from participating European centers on all patients transplanted up to December 1980 and on all patients treated during the year of 1984. Twenty-eight centers reported data on 258 patients and 248 could be evaluated for keratoconjunctivitis. Forty-eight of the 248 (19%) patients developed a keratoconjunctivitis sicca syndrome between 3 and 127 months (13.8 months) after BMT. The actuarial probability of developing dry eyes was 21 +/- 3% at 15 years. Thirty-three of the 48 (69%) patients with sicca syndrome had graft-versus-host disease (GVHD) compared to 60 of 200 (30%) patients without keratoconjunctivitis (P < 0.0001). The probability of developing keratoconjunctivitis sicca syndrome at 15 years was 38 +/- 6% for patients with and 10 +/- 3% (P < 0.0001) for those without chronic GVHD. Factors associated with an increased risk for late-onset of keratoconjunctivitis are chronic GVHD (relative risk 3.5; CI, 1.9-6.9), female patients (5.6; CI, 1.6-18.8), age older than 20 years (3.1; CI, 1.6-5.6), single dose irradiation for preparation to BMT (3.8; CI, 1.3-11.3) and methotrexate for prevention of GVHD (3.6, CI, 1.05-12.8). Late-onset kerato- conjunctivitis is a frequent ocular complication of BMT. With adequate treatment, severe corneal defects can be avoided. It occurs more frequently in patients with chronic GVHD, but, independent of chronic GVHD, more frequently in older patients and in females as it is observed in de novo Sjögren's syndrome. These data support the current concept that chronic GVHD is a reaction of both, allo- and autoimmunity.

The significance of microbial cultures of the hematopoietic support for patients receiving high-dose chemotherapy

The use of hematopoietic support for patients receiving high-dose chemotherapy has increased over the past 10 years. Various quality controls are performed on the hematopoietic cells, including microbiologic cultures. There is considerable expense associated with the serial cultures performed at different times during the collection, processing, and use of the cells. We reviewed all the microbiologic cultures performed on bone marrow harvests and leukaphereses over a 17 month period. Of the 227 bone marrow harvests, 16 cultures were positive, but only 3 (1.3%) were repeat positives with the same organism after processing or at the time of reinfusion. Of the 560 leukaphereses, 4 (0.7%) were cultured positive at the time of collection and reinfusion. Two patients were bacteremic with gram-negative bacilli at the time of leukaphereses despite being asymptomatic, and these were the only two products that had to be collected again. No patient suffered an adverse clinical result after receiving culture-positive cells. Bone marrow and peripheral blood progenitor cells can be safely collected, and a culture after processing is adequate to ensure the safety of the product.

Atherosclerotic disease of the aortic arch as a risk factor for recurrent ischemic stroke

BACKGROUND

Atherosclerotic disease of the aortic arch is found in 60 percent of patients 60 years of age or older who have had brain infarction. The aim of this study was to determine whether atherosclerotic plaques in the aortic arch are a risk factor for recurrent brain infarction and for vascular events in general (i.e., brain infarction, myocardial infarction, peripheral embolism, and death from vascular causes).

METHODS

For a period of two to four years, we followed a cohort of 331 patients 60 years of age or older who were consecutively admitted to the hospital with brain infarction (a total of 788 person-years of follow up). All patients underwent transesophageal echocardiography to determine whether atherosclerotic plaques were present in the aortic arch proximal to the ostium of the left subclavian artery. The patients were divided into three groups according to the thickness of the wall of the aortic arch ( < 1 mm, 1 to 3.9 mm, and > or = 4 mm).

RESULTS

The incidence of recurrent brain infarction was 11.9 per 100 person-years in patients with an aortic-wall thickness of > or = 4 mm, as compared with 3.5 per 100 person-years in patients with a wall thickness of 1 to 3.9 mm and 2.8 per 100 person-years in patients with a wall thickness of < 1 mm (P < 0.001). The overall incidence of vascular events was 26.0, 9.1, and 5.9 per 100 person-years of follow-up in the respective groups (P < 0.001). After adjustment for the presence of carotid stenosis, atrial fibrillation, peripheral arterial disease, and other risk factors, aortic plaques > or = 4 mm thick (including the thickness of the aortic wall) were found to be independent predictors of recurrent brain infarction (relative risk, 3.8; 95 percent confidence interval, 1.8 to 7.8; P = 0.0012) and of all vascular events (relative risk, 3.5; 95 percent confidence interval, 2.1 to 5.9; P < 0.001).

CONCLUSIONS

Atherosclerotic plaques > or = 4 mm thick in the aortic arch are significant predictors of recurrent brain infarction and other vascular events.

Final height of patients who underwent bone marrow transplantation during childhood

OBJECTIVE

To determine the impact on final adult height of bone marrow transplantation.

METHODS

The final height of 28 long term survivors (18 males; 10 females), allografted before or at the onset of puberty, at a median age of 10.8 years (range 6.3 to 14.6) and who did not receive growth hormone (GH) treatment or other growth promoting agents, was evaluated. Median follow up period after bone marrow transplantation was 7.9 years (range 3.2 to 11.4), and age at the most recent evaluation 18.1 years (range 15.6 to 24.5). Height values were expressed in standard deviation score (SDS) from the mean of the normal population. Height at bone marrow transplantation was compared with final height as well as with parental genetic height. Patients were divided into three groups: severe aplastic anaemia (SAA): three patients given no radiotherapy; leukaemia-total body irradiation (TBI): 14 patients with acute or chronic leukaemia conditioned with chemotherapy and TBI; leukaemia-TBI with previous cranial radiation therapy (CRT): 11 patients. None of the patients had solid tumour.

RESULTS

There was a decrease in final height SDS compared to pre-transplantation height SDS (paired t test, p < 0.0001). All patients except one reached an adult height above -2.0 SDS. A significant decrease in height SDS was found in the TBI and the CRT groups (paired t test, p = 0.02 and p = 0.0002, respectively). Whereas height SDS value at the time of transplant was higher than the genetic height SDS, final height SDS values were lower.

CONCLUSIONS

Despite the decrease in height SDS found after bone marrow transplantation, 27 of the 28 patients spontaneously achieved what is considered to be a normal height SDS (above -2.0 SDS). This should be taken into account when considering GH treatment in children who underwent bone marrow transplantation for malignant haematological diseases.