Anesthetic management of placenta accreta in a low-resource setting: a case series

BACKGROUND

Current recommendations for the anesthetic management of placenta accreta support a conservative approach with neuraxial anesthesia and uterine artery embolization. These are based on case series from experienced centers in developed countries. The aim of this study was to describe the anesthetic management of placenta accreta in a low-resource setting.

METHODS

A retrospective case note review was performed. From 1 August 2006 to 31 July 2011 placentas from cases of suspected placenta accreta were reassessed histologically to confirm the diagnosis. Patient charts were reviewed and information on anesthetic technique, monitoring, blood transfusion, maternal and fetal outcomes was extracted.

RESULTS

Thirty-nine cases were identified. Mean (± SD) maternal age was 33 ± 5.4 years. Hysterectomy was performed at the time of cesarean section in all cases. Thirty-four patients received neuraxial anesthesia, of whom 15 required conversion to general anesthesia. Invasive blood pressure monitoring was used in all patients and a central venous catheter was inserted in 33 cases. Complications associated with monitoring occurred in five patients. Median [IQR] blood loss was 2000 [1100-2700] mL and the median [IQR] number of units of red blood cell transfused was 2 [0-6]. Vasoactive medication was used in 14 patients and 15 patients were transferred to the intensive care unit postoperatively. No maternal or newborn deaths occurred.

CONCLUSION

A multidisciplinary approach can prove valuable when placenta accreta is suspected before delivery. In low-resource settings, lack of interventional radiology services and prenatal diagnostic capability may have an impact on anesthetic management in patients with placenta accreta. However, other than greater blood loss, our study demonstrated that good maternal and neonatal outcomes are possible in spite of limited resources.

[The impact of neurological and medical complications on the mortality and functional situation of acute stroke patients]

INTRODUCTION

Stroke patients have a high risk of presenting complications, the appearance of which can condition the prognosis of the stroke. We studied the frequency and impact of the onset of several different complications on the early and mid-term prognosis of these patients.

PATIENTS AND METHODS

We conducted an observation-based study of the patients admitted to a stroke unit. The complications that occurred while hospitalised were recorded, a distinction being drawn between neurological and medical complications. The study examined their influence, according to the subtype of stroke, on intra-hospital mortality and that at 90 days, as well as on the functional situation at 90 days, by analysing the clinical factors that are predictive for the appearance of complications.

RESULTS

The sample consisted of 847 patients. Altogether, 29.5% of the patients presented complications, which were more frequent in haemorrhagic stroke (50.5% versus 26.6%; p < 0.0001). The most usual complications were of a neurological nature (21%). For both subtypes, the presence of complications was associated with a higher rate of mortality both in hospital (2.1% versus 12.6%; p < 0.0001) and at 90 days (5.7% versus 29.6%; p < 0.0001), and a lower probability of independence at 90 days (72.9% versus 30.4%; p < 0.0001). The severity of the stroke on admission revealed itself as the most powerful predictor of the onset of any type of complication.

CONCLUSIONS

The appearance of complications during the acute phase of the stroke has an adverse influence on mortality and on the functional prognosis. The identification of predictive factors could reduce the impact upon the progress of acute stroke patients.

Field testing, gene flow assessment and pre-commercial studies on transgenic Solanum tuberosum spp. tuberosum (cv. Spunta) selected for PVY resistance in Argentina

Solanum tuberosum ssp. tuberosum (cv. Spunta) was transformed with a chimeric transgene containing the Potato virus Y (PVY) coat protein (CP) sequence. Screening for PVY resistance under greenhouse conditions yielded over 100 independent candidate lines. Successive field testing of selected lines allowed the identification of two genetically stable PVY-resistant lines, SY230 and SY233, which were further evaluated in field trials at different potato-producing regions in Argentina. In total, more than 2,000 individuals from each line were tested along a 6-year period. While no or negligible PVY infection was observed in the transgenic lines, infection rates of control plants were consistently high and reached levels of up to 70-80%. Parallel field studies were performed in virus-free environments to assess the agronomical performance of the selected lines. Tubers collected from these assays exhibited agronomical traits and biochemical compositions indistinguishable from those of the non-transformed Spunta cultivar. In addition, an interspecific out-crossing trial to determine the magnitude of possible natural gene flow between transgenic line SY233 and its wild relative Solanum chacoense was performed. This trial yielded negative results, suggesting an extremely low probability for such an event to occur.

Effects of arbuscular-mycorrhizal glomus species on drought tolerance: physiological and nutritional plant responses

The tolerance of lettuce plants (Lactuca sativa L. cv. Romana) to drought stress differed with the arbuscular-mycorrhizal fungal isolate with which the plants were associated. Seven fungal species belonging to the genus Glomus were studied for their ability to enhance the drought tolerance of lettuce plants. These fungi had different traits that affected the drought resistance of host plants. The ranking of arbuscular-mycorrhizal fungal effects on drought tolerance, based on the relative decreases in shoot dry weight, was as follows: Glomus deserticola > Glomus fasciculatum > Glomus mosseae > Glomus etunicatum > Glomus intraradices > Glomus caledonium > Glomus occultum. In this comparative study specific mycorrhizal fungi had consistent effects on plant growth, mineral uptake, the CO(inf2) exchange rate, water use efficiency, transpiration, stomatal conductance, photosynthetic phosphorus use efficiency, and proline accumulation under either well-watered or drought-stressed conditions. The ability of the isolates to maintain plant growth effectively under water stress conditions was related to higher transpiration rates, levels of leaf conductance, and proline, N, and P contents. Differences in proline accumulation in leaves among the fungal symbioses suggested that the fungi were able to induce different degrees of osmotic adjustment. The detrimental effects of drought were not related to decreases in photosynthesis or water use efficiency. Neither of these parameters was related to P nutrition. The differences in P and K acquisition, transpiration, and stomatal conductance were related to the mycorrhizal efficiencies of the different fungi. Our observations revealed the propensities of different Glomus species to assert their protective effects during plant water stress. The greater effectiveness of G. deserticola in improving water deficit tolerance was associated with the lowest level of growth reduction (9%) under stress conditions. The growth of plants colonized by G. occultum was reduced by 70% after a progressive drought stress period. In general, the different protective effects of the mycorrhizal isolates were not associated with colonizing ability. Nevertheless, G. deserticola was the most efficient fungus and exhibited the highest levels of mycorrhizal colonization, as well as the greatest stimulation of physiological parameters.

Diet and exercise in the prevention of diabetes

BACKGROUND

Individuals with impaired fasting glucose or impaired glucose tolerance are at high risk of progression to type 2 diabetes. Lifestyle modification through change to diet and exercise habit has considerable potential to prevent or delay the onset of this disease.

METHODS

A systematic literature search was undertaken of Medline, EMBASE, the Cochrane library and the Cumulative Index to Nursing and Allied Health Literature for journal articles relevant to the question of whether type 2 diabetes can be prevented by lifestyle change.

RESULTS

Four cohort studies in a total of 4864 high risk individuals followed for a period of 2.5-6 years were identified. These showed that lifestyle change may reduce the incidence of type 2 diabetes by 28-59%. Moreover, follow-up studies also indicate that diabetes incidence rates continue to be depressed many years after the discontinuation of a lifestyle intervention. Evidence from a meta-analysis confirms this evidence and suggests that it would be necessary to treat 6.4 (95% confidence interval 5.0-8.4) individuals to prevent or delay one case of diabetes through lifestyle intervention. An examination of weight loss diets (low fat, high protein or Mediterranean) suggests each may be effective but each has limitations requiring care in food selection. Evidence also suggests that the maintenance of weight loss also requires regular exercise with an additional expenditure of approximately 8.4 MJ week(-1) (2000 kcal week(-1)).

CONCLUSIONS

Diabetes can be prevented by lifestyle change. The challenge is to develop public health approaches to support individuals with respect to incorporating the lifestyle changes needed to reduce the risk of diabetes into their everyday life.

Comparison of alternative treatments for 4-chlorophenol removal from aqueous solutions: use of free and immobilized soybean peroxidase and KrCl excilamp

The removal of 4-chlorophenol (4-CP) from industrial wastewater continues to be an important environmental issue and some interesting results have been obtained using oxidoreductive enzymes such as peroxidases and UV, generated by novel excilamps. In this study enzyme (free and immobilized soybean peroxidase) and UV (produced by a KrCl excilamp) were used to treat 4-CP solutions at concentrations ranging from 50 to 500 mg L(-1). It was shown that the excilamp can facilitate higher removal efficiencies in all cases with complete 4-CP elimination taking place between 5 and 90 min. The enzyme removed approximately 80% of the 4-CP concentrations in both the free and immobilized state up to concentrations of 250 mg L(-1). At 500 mg L(-1) the immobilized system shows much higher removal efficiency due to increased enzyme stability in the presence of higher formation of by-products.