The effect of a rapid change in availability of epidural analgesia on the cesarean delivery rate: a meta-analysis

OBJECTIVE

This study was undertaken to quantitatively estimate the effect of a rapid introduction or withdrawal of on-demand epidural analgesia on the cesarean delivery rate.

STUDY DESIGN

MEDLINE and meeting abstracts were searched for studies reporting the cesarean delivery rate immediately before and after a rapid change in the availability of epidural analgesia. Nine studies reporting data on 37,753 patients were selected. Meta-analysis was performed to estimate the means and 95% confidence intervals for the changes in rates of total cesarean deliveries, cesarean deliveries among nulliparous women, cesarean deliveries for dystocia, and operative vaginal deliveries.

RESULTS

There was no significant change in the overall cesarean delivery rate with an increase in the availability of epidural analgesia. Similarly, the rates of cesarean deliveries among nulliparous patients, of cesarean deliveries for dystocia, and of operative vaginal deliveries did not significantly differ between periods of high and low epidural analgesia availability.

CONCLUSION

A rapid change in the availability of epidural analgesia is not associated with any increase in the cesarean delivery rate.

Cleft lip in the Talmud

The authors address the problem of why the cleft lip anomalad is not mentioned even once in the Talmud, which contains detailed reports of numerous other forms of pathology and congenital anomalies. It also attempts to define the Sandal deformity, one of the most common congenital anomalies mentioned in the Talmud. It is assumed that cleft lip, the most common major facial defect, existed at the time of the Talmud. It is proposed that the Sandal deformity was actually made up of a number of entities grouped together because of a theorized common etiology, and that the cleft lip entity is included in the Sandal anomalad. This deformity, in its various forms, included, besides cleft lip, aborted tissue and products of gestation. They are all related to the common etiology of a twin gestation during which one fetus presses against the other causing the deformity. The Sandal was noted to look like the Sandal fish or sole, for which it is named. When photos of the Sandal fish and the cleft lip deformity are compared, a similarity is seen. In addition, this deformity apparently was thought to be fatal, and none of these babies survived. It is theorized that cleft lip babies were allowed to die because they were considered nonviable in the eyes of Jewish law. Supporting evidence for the ideas presented by the authors is derived from the talmudic texts and commentaries. If the Sandal does indeed include the cleft lip entity, the citation in the Mishnah (70-200 AD) makes it the earliest historical reference to the cleft lip deformity.

Galactose breath testing distinguishes variant and severe galactose-1-phosphate uridyltransferase genotypes

A galactose breath test that quantitates [1-(13)C]galactose conversion to 13CO2 provides information on the whole body galactose oxidative capacity. As there is little information on the relationship between whole body oxidation and the genotype in patients with galactosemia, we measured the 13CO2 excretion for 2 h after administration of [1-(13)C]galactose in 37 patients (3-48 y old) with galactose-1-phosphate uridyltransferase (GALT) deficiency and 20 control subjects (3-37 y old). Eleven patients with the common Q188R/Q188R genotype and no detectable erythrocyte GALT activity eliminated <2% of a bolus of [1-(13)C]galactose as 13CO2 compared with 8.47 to 28.23% in controls. This defines a severe metabolic phenotype. Seven patients with one Q188R allele and a second mutant allele such as L195P, E308K, V151A, M142K, or Q344K and one patient with a K285N/unknown genotype also released <2% as 13CO2 in 2 h. The presence of N314D or S135L as the second mutant allele does not impair total body galactose oxidation, as individuals with the GALT genotype of Q188R/N314D, K285N/N314D, and Q188R/S135L had normal 2-h galactose breath tests. Subjects with S135L/S135L, N314D/N314D, S135L/deltaT2359 as well as other rarer genotypes such as R258C/Y209C, E203K/IVSC-N314D, K285N/T138M, Q188R/D113N, S135L/F171S, R148W/N314D, and IVSC-N314D/N314D oxidized galactose comparable to controls. The dissociation of residual erythrocyte GALT activity and whole body galactose oxidative capacity is exemplified by blacks with a S135L/S135L genotype and absent erythrocyte GALT activity. An oral 2-h [1-(13)C]galactose breath test distinguishes severe and variant GALT genotypes and enables delineation of the extent of impaired galactose metabolism in an array of patients who possess diverse GALT mutations. It may prove to be useful in establishing whether a patient is capable of manifesting disease similar to patients with a Q188R/Q188R genotype.

Galactose metabolism by the mouse with galactose-1-phosphate uridyltransferase deficiency

The ability of mice deficient in galactose-1-phosphate uridyltransferase (GALT) to metabolize galactose was determined in animals weaned to a mouse chow diet for a 4-wk period. When given [14C]galactose intraperitoneally, these animals slowly oxidized the sugar, excreting only 5.5% of the dose as 14CO2 in 4 h, whereas normal animals excreted 39.9%. These results mimic those seen in human galactosemic patients given isotopic galactose. When given 10 micromol of [1-13C]galactose, normal animals excrete small amounts of labeled galactose and galactonate but no galactitol in urine whereas GALT-deficient mice excrete significant amounts of all of these as labeled compounds in urine. When challenged with galactose, only about 20% of the dose is excreted in urine, and even on the chow diet, significant amounts of galactose, galactonate, and galactitol are excreted in urine. These compounds are also found to be present in liver, kidney, and brain, except that galactonate is not found in brain. Galactose-1-phosphate accumulates in red blood cells to levels found in humans exposed to large amounts of galactose, and galactose-1-phosphate is found in increased amounts in liver, kidney, and brain of GALT-deficient animals. There was no difference in the hepatic concentration of uridine diphosphate galactose and uridine diphosphate glucose between normal and GALT-deficient mice. The explanation for the presence of galactose and its conversion products in tissues and urine of affected mice appears to be related to the presence of approximately 1.75% of galactose-containing carbohydrates in the chow, which becomes bioavailable to mice. Despite the presence of galactose and its metabolites in tissues and urine and impaired ability to oxidize the sugar, the GALT-deficient animals are indistinguishable from normal animals and do not exhibit the phenotype of humans with GALT-deficiency galactosemia.

Apparent galactose appearance rate in human galactosemia based on plasma [(13)C]galactose isotopic enrichment

Determination of endogenous galactose formation in galactosemic subjects provides important information in understanding the etiology of the long-term complications. To accomplish this task a sensitive method for measurement of isotopic enrichment of plasma galactose was developed. The aldononitrile pentaacetate derivative of galactose was utilized for gas chromatography/mass spectrometry analysis. Using a phenyl-methylsilicone capillary column, adequate separation of galactose from glucose was obtained by temperature programming of the chromatography. The specific fragmentation pattern of m/z 212, 225, 314 from d-[(12)C]galactose and m/z 213, 226, 315 from l-[(13)C]galactose was used for the galactose enrichment measurement by atom percent excess (APE). There was good correlation between expected enrichment and determined APEs at galactose concentrations of 1, 2, and 5 micromol/L with a coefficient of variation ranging from 0.22 to 7.17%. The method provides an accurate estimation of plasma [(13)C]galactose enrichment from which the galactose production rate can be calculated. The steady-state plasma l-[(13)C]galactose isotopic enrichment of three individuals with galactosemia, two males ages 33 and 13, and one female age 9, during constant infusion of l-[(13)C]galactose was 55, 41, and 55%, allowing the estimation of the apparent galactose appearance rate of 0.62, 1.09, and 0.82 mg/kg/h, respectively. The reanalysis of three previous studies by the present method found that APE values determined by the method then employed, butylboronate acetate derivatization, were systemically lower than those determined with aldononitrile pentaacetate derivatization, making for an overestimation of the apparent galactose appearance rate. The small plasma sample volumes needed make it feasible to perform these studies in infants and young children with galactosemia.

Hemodynamic effects of simultaneous administration of intravenous ephedrine and spinal anesthesia for cesarean delivery

STUDY OBJECTIVE

To evaluate the hemodynamic effects of an intravenous (IV) ephedrine bolus given simultaneously with spinal anesthesia for cesarean delivery.

DESIGN

Randomized, prospective, double-blind study.

SETTING

Tertiary-care academic medical center.

PATIENTS

40 ASA physical status I and II nonlaboring women undergoing elective cesarean delivery of term, uncomplicated, singleton pregnancies.

INTERVENTIONS

After a 10 mL/kg IV lactated Ringers bolus given over 15 minutes, patients simultaneously received an IV dose of 2 mL (10 mg) ephedrine or 2 mL saline, and an intrathecal dose of 12 mg (1.6 mL 0.75%) bupivacaine with 10 microg of fentanyl. Hypotension, defined as a 20% decrease in mean arterial pressure (MAP), was treated with 10-mg IV doses of ephedrine.

MEASUREMENTS

Hemodynamic (heart rate and MAP) and non-invasive thoracic impedance (cardiac index, stroke index, and systemic vascular resistance index) measurements at baseline and at 1-minute intervals until the time of delivery. Total fluid, supplemental ephedrine, and Apgar scores were recorded. Data were evaluated using analysis of variance (ANOVA), ANOVA for repeated measures, and Mann-Whitney U-tests where appropriate, with p < 0.05 considered significant.

MAIN RESULTS

Significant changes from baseline in MAP, systemic vascular resistance index, heart rate, and cardiac index were observed in both groups after spinal anesthesia. However, there were no differences between the ephedrine and saline groups in the incidence and severity of change from the baseline. The overall incidence of hypotension was 70% in both groups. No difference in total fluid or supplemental ephedrine use was observed.

CONCLUSIONS

10 mg of IV ephedrine given at the time of spinal anesthesia, and after a 10 mL/kg lactated Ringers fluid bolus, does not diminish the incidence or severity of hypotension in parturients undergoing cesarean delivery.

Lycopene interferes with cell cycle progression and insulin-like growth factor I signaling in mammary cancer cells

Recent studies have shown that high insulin-like growth factor I (IGF-I) blood level is a risk factor in breast and prostate cancer. The aim of this study was to determine whether the mitogenic activity of IGF-I in mammary cancer cells can be reduced by the dietary carotenoid lycopene. The anticancer activity of lycopene, the major tomato carotenoid, has been suggested by in vitro, in vivo, and epidemiological studies. Growth stimulation of MCF7 mammary cancer cells by IGF-I was markedly reduced by physiological concentrations of lycopene. The inhibitory effects of lycopene on MCF7 cell growth were not accompanied by apoptotic or necrotic cell death, as determined by annexin V binding to plasma membrane and propidium iodide staining of nuclei in unfixed cells. Lycopene treatment markedly reduced the IGF-I stimulation of tyrosine phosphorylation of insulin receptor substrate 1 and binding capacity of the AP-1 transcription complex. These effects were not associated with changes in the number or affinity of IGF-I receptors, but with an increase in membrane-associated IGF-binding proteins, which were previously shown in different cancer cells to negatively regulate IGF-I receptor activation. The inhibitory effect of lycopene on IGF signaling was associated with suppression of IGF-stimulated cell cycle progression of serum-starved, synchronized cells. Moreover, in cells synchronized by mimosine treatment, lycopene delayed cell cycle progression after release from the mimosine block. Collectively, the above data suggest that the inhibitory effects of lycopene on MCF7 cell growth are not due to the toxicity of the carotenoid but, rather, to interference in IGF-I receptor signaling and cell cycle progression.

A mouse model of galactose-induced cataracts

Galactokinase (GK; EC 2.7.1.6) is the first enzyme in the metabolism of galactose. In humans, GK deficiency results in congenital cataracts due to an accumulation of galactitol within the lens. In an attempt to make a galactosemic animal model, we cloned the mouse GK gene (Glk1) and disrupted it by gene targeting. As expected, galactose was very poorly metabolized in GK-deficient mice. In addition, both galactose and galactitol accumulated in tissues of GK-deficient mice. Surprisingly, the GK-deficient animals did not form cataracts even when fed a high galactose diet. However, the introduction of a human aldose reductase transgene into a GK-deficient background resulted in cataract formation within the first postnatal day. This mouse represents the first mouse model for congenital galactosemic cataract.

Alternative medicine use in presurgical patients

BACKGROUND

A dramatic increase in the use of complementary and alternative medicines has been observed. The use of such remedies in the presurgical population has implications for the anesthesiologist because of the potential for drug interactions, side effects, and medical liability. This study was undertaken to quantify the use of herbal remedies and vitamins in the presurgical population of a large tertiary care center.

METHODS

A one-page questionnaire was distributed to all patients presenting for evaluation in the preoperative clinic over an 11-week period. Patients answered questions regarding use of prescription and nonprescription medications, herbal remedies, and vitamins.

RESULTS

Twenty-two percent of presurgical patients reported the use of herbal remedies, and 51% used vitamins. Women and patients aged 40-60 yr were more likely to use herbal medicines. Over-the-counter medication use was strongly associated with herbal preparation use. The most commonly used compounds, from highest to lowest, included echinacea, gingko biloba, St. John's wort, garlic, and ginseng.

CONCLUSIONS

Alternative medicine use is common in the preoperative period.

The current clinical presentation of complete molar pregnancy

OBJECTIVE

To study the current clinical presentation of complete molar pregnancy.

METHOD

Retrospective study of the clinical and ultrasonographic records of 41 patients with complete hydatidiform mole.

RESULTS

17 (41%) patients were asymptomatic. 24 patients (58%) presented with vaginal bleeding, 6 (15%) had excessive uterine size, 1 (2%) had anemia and 1 (2%) had hyperemesis. Non of the patients had any other systemic manifestation. Pre-evacuation ultrasound was performed in all cases and molar pregnancy was diagnosed in 36 (88%).

CONCLUSIONS

Currently with routine first trimester ultrasonography a significant proportion of patients with molar pregnancy are asymptomatic at the time of diagnosis.

Preoperative diagnosis of intestinal intussusception in pregnancy. A case report

BACKGROUND

Intestinal intussusception is a rare event during pregnancy. The diagnosis of intestinal obstruction from any cause in pregnancy is made more difficult by the common overlapping complaints of nausea, vomiting and abdominal pain, which may persist during the second trimester.

CASE

Intestinal obstruction occurred at 17 weeks' gestation. A preoperative diagnosis of intussusception was made by ultrasound by demonstrating multiple ecodense and ecolucent rings in the right lower quadrant of the abdomen.

CONCLUSION

Ultrasonography may support the diagnosis of intussusception in pregnant women with intestinal obstruction.

Mad1 function is regulated through elements within the carboxy terminus

Myc and Mad are basic helix-loop-helix leucine zipper (bHLH-LZ) proteins that heterodimerize with Max to bind DNA and thereby influence the transcription of Myc-responsive genes. Myc-Max dimers transactivate whereas Mad-Max-mSin3 complexes repress Myc-mediated transcriptional activation. We have previously shown that the N-terminal mSin3 binding domain and the centrally located bHLH-LZ are required for Mad1 to function during a molecular switch from proliferation to differentiation. Here we demonstrate that the carboxy terminus (CT) of Mad1 contains previously unidentified motifs necessary for the regulation of Mad1 function. We show that removal of the last 18 amino acids of Mad1 (region V) abolishes the growth-inhibitory function of the protein and the ability to reverse a Myc-imposed differentiation block. Moreover, deletion of region V results in a protein that binds DNA weakly and no longer represses Myc-dependent transcriptional activation. In contrast, deletion of the preceding 24 amino acids (region IV) together with region V restores DNA binding and transcriptional repression, suggesting a functional interplay between these two regions. Furthermore, phosphorylation within region IV appears to mediate this interplay. These findings indicate that novel regulatory elements are present in the Mad1 CT.

Determination of [(13)C]galactose enrichment in human plasma by gas chromatography/positive chemical ionization tandem mass spectrometry

Galactosemia is a potentially fatal disease resulting from a deficiency of galactose-1-phosphate uridyl transferase. In order to perform mechanistic studies designed to elucidate further the etiology of the disease, we required a method to monitor (13)C enrichment in plasma galactose following a single oral dose or intravenous infusion of [1-(13)C]galactose. Determinations of plasma [(13)C]galactose enrichment requires methodology with extremely high specificity because of potential interference from other low molecular mass plasma constituents and from glucose, an isomer which is present in much higher concentrations. We have developed a method based on gas chromatography/positive chemical ionization tandem mass spectrometry (GC/PCI-MS/MS) for the precise and accurate determination of plasma [(13)C]galactose enrichment. The method employed a pentaacetylaldononitrile derivative of galactose in order to improve its GC and MS characteristics. Peak areas resulting from the transitions m/z 328 --> 106 and m/z 329 --> 107 were used to quantify the relative abundance of labeled and unlabeled galactose. Validation of the method was performed by determination of the precision and accuracy over a wide range of galactose concentrations and (13)C enrichments. The GC/PCI-MS/MS method was able to determine accurately enrichments at galactose concentrations down to 0.8 microM in the presence of 4 mM glucose, making it both highly selective and the most sensitive method currently available.

Transcutaneous electrical nerve stimulation does not augment combined spinal epidural labour analgesia

PURPOSE

The spinal portion of the combined spinal epidural technique (CSE) provides dramatic but limited labour analgesia. Transcutaneous Electrical Nerve Stimulation (TENS) has been noted to modulate pain, in part by the frequency of stimulation chosen. Because nerve action potentials are blocked by local anesthetics in a frequency dependent manner, we speculated that a TENS unit could increase the quality and duration of the spinal portion of a CSE.

METHODS

Forty parturients in active spontaneous labour, with a singleton, vertex, term fetus, requesting analgesia were enrolled in a randomized, double blind fashion to receive a standardized CSE with either an active or inactive TENS unit. Prior to CSE placement, TENS intensity thresholds were determined with electrodes placed on the paraspinus muscles at T10-L1, and S2-4; TENS settings for mode, cycle, and pulse width were standardized. Data were collected at timed intervals on pain (VAS), sensory level (pinprick), motor blockade (Bromage), cervical dilatation, and duration of analgesia, and at delivery on fetal and neonatal outcome.

RESULTS

The duration of the spinal portion of the CSE did not differ between groups (TENS off 91.1+/-33 [mean +/- SD] vs. TENS on 83.1+/-28 min, P = .42). Kaplan-Meier survival analysis and Mantel-Cox log rank analysis showed no difference between the two treatments (P = .28). Analgesia was comparable throughout the first hour of spinal analgesia.

CONCLUSION

In healthy labouring parturients, the application of a TENS unit did not alter the quality or duration of labour analgesia provided by the spinal portion of CSE analgesia.

Epidemiological characteristics of spotted fever in Israel over 26 years

During the summer of 1997, 2 confirmed and several suspected fatal cases of spotted fever (SF) occurred in previously healthy young adults in Israel. This unusual cluster of events stimulated the current study. The incidence of SF in Israel from 1971-98 was analyzed. Incidence increased until 1980, declined until 1994, and increased slightly from 1994-97. Incidence was higher during the summer, among children aged 0-9 years, and in rural settlements in central Israel. From 1971-1997, 31 deaths were reported, mostly in the elderly. The deaths that occurred in 1997 are a reminder that, despite the fact that morbidity due to SF is described mainly in children, SF can have a rapidly fatal outcome in healthy young adults. Thus, even during periods of low incidence, careful monitoring and high awareness for prompt diagnosis and treatment are needed.

Urine and plasma galactitol in patients with galactose-1-phosphate uridyltransferase deficiency galactosemia

Urinary excretion of galactitol was determined in 95 normals (N/N), 67 galactosemic (G/G), and 39 compound heterozygotes for the Duarte and galactosemia genotype (D/G). Galactitol excretion is age-dependent in both normal individuals and patients with classic galactosemia on lactose-restricted diets. In galactosemic patients who are homozygous for the Q188R mutation, urinary galactitol levels were fivefold to 10-fold higher than those of normal subjects of comparable age. All but a few patients with classic galactosemia with the Q188R mutation and another mutant G allele had urinary excretion comparable to the Q188R homozygous patients. African-American galactosemic patients with the S135L mutation of the galactose-1-phosphate uridyltransferase (GALT) gene also excreted abnormal quantities of galactitol. Most subjects with a Duarte allele and a G allele excrete normal amounts of the sugar alcohol. There is a correlation between galactitol excretion and red blood cell (RBC) galactose-1-phosphate (gal-1-P). Plasma galactitol was also elevated in galactosemic patients (3.4 to 23.2 micromol/L; undetectable in normal individuals). In contrast to the decrease in urinary galactitol with age, plasma levels remain in a narrow concentration range with no significant difference with age. Urine and plasma galactitol distinguish galactosemic patients from normals. In addition, urinary galactitol excretion may be an important parameter for the assessment of steady-state galactose metabolism in galactosemia.

The demographic transition then and now: processes, perspectives, and analyses

Fifty years have passed since the post-World War II development of demography as an academic field. During this time, one of the central focuses of research has been the study of demographic and fertility transitions. The authors review a selection of research developments and analytic issues that have appeared in the literature. After presenting, in roughly chronological order, the general development of this research work, they raise questions concerning theory and methodology. In doing so, they argue that some research directions have been overemphasized to the neglect of others.

Is combined spinal-epidural analgesia associated with more rapid cervical dilation in nulliparous patients when compared with conventional epidural analgesia?

BACKGROUND

The combined spinal-epidural technique provides rapid onset of labor analgesia and, anecdotally, is associated with labors of shorter duration. Epidural analgesia, by contrast, has been suggested to prolong labor modestly. It is unclear, however, whether more rapid cervical dilation in patients who receive combined spinal-epidural analgesia is a physiologic effect of the technique or an artifact of patient selection. The authors hypothesized that anesthetic technique may influence the rate of cervical dilation, and we compared the effects of combined spinalepidural with those of epidural analgesia on the rate of cervical dilation.

METHODS

One hundred healthy nulliparous parturients in spontaneous labor with singleton, vertex, full-term fetuses were enrolled in a double-blinded manner when their cervical dilation was less than 5 cm. The patients were randomly assigned to receive analgesia via a standardized combined spinal-epidural (n = 50) or epidural (n = 50) technique. Data were collected on cervical dilation, pain, sensory level, and motor blockade.

RESULTS

When regional analgesia was induced in comparable groups at a mean of 3 cm cervical dilation, the mean initial cervical dilation rates were significantly faster in the combined spinal-epidural group (mean values, 2.1 +/- 2.1 cm/h vs. 1 +/- 1 cm/h; P = 0.0008). Five parturients in the combined spinal-epidural group had a very rapid (> 5 cm/h) rate of mean initial cervical dilation, compared with none of the women in the epidural group. Overall mean cervical dilation rates in patients who achieved full cervical dilation were 2.3 +/- 2.6 cm/h and 1.3 +/- 0.71 cm/h (P = 0.0154) in the combined spinal-epidural and epidural groups, respectively.

CONCLUSIONS

In healthy nulliparous parturients in early labor, combined spinal-epidural analgesia is associated with more rapid cervical dilation compared with epidural analgesia. Further study is needed to elicit the cause and overall effect of this difference.

Prevalence of hydronephrosis in patients with genital prolapse

OBJECTIVE

To determine the prevalence of hydronephrosis in patients with genital prolapse and evaluate contributing factors.

METHODS

Retrospective study of the records of 189 patients with pelvic organ prolapse who underwent preoperative renal imaging studies.

RESULTS

Of the 189 patients 31 (17.4%) had hydronephrosis; in 20 (10.6%) patients the hydronephrosis was mild, in 7 (3.7%) it was moderate and in 4 (2.7%) it was severe. The patients with hydronephrosis were older (mean age 68+/-9.5 SD vs. 60.5+/-10.8 SD, P<0.001) had a higher creatinine levels (0.84+/-0.4 SD vs. 0.78+/-0.3 SD P<0.005) and had a higher degree of uterine prolapse (mean 2.6+/-0.9 SD vs. 1.1+/-1.2 SD, P<0.005). After adjusting for age and type of prolapse, only patients with uterine prolapse remained significantly more likely to suffer from hydronephrosis (adjusted odds ratio 1.9, 95% CI 1.1, 3.2).

CONCLUSION

The prevalence of hydronephrosis in patients with genital prolapse is appreciable and is related primarily to degree of uterine prolapse.

Platysma myocutaneous flap for intraoral reconstruction: an option in the compromised patient

The platysma myocutaneous flap is an infrequently used flap in head and neck reconstruction. This flap should be considered for reconstruction of small and medium-sized defects of the oral cavity. We present two cases demonstrating the utility of this local flap in reconstruction. Advantages, contraindications and limitations of the platysma myocutaneous flap are discussed.

The influence of the obstetrician in the relationship between epidural analgesia and cesarean section for dystocia

BACKGROUND

The association between epidural analgesia for labor and the risk of cesarean section for dystocia remains controversial The authors hypothesized that if epidural analgesia were an important factor in determining cesarean section rates, then obstetricians with higher rates of utilization of epidural analgesia for labor would have higher rates of cesarean section for dystocia.

METHODS

The frequency of use of epidural analgesia and frequency of occurrence of various patient risk factors for cesarean section were calculated for 110 obstetricians caring for > or = 50 low-risk parturients. These frequencies were compared by linear regression to obstetricians' rates of cesarean section for dystocia. Stepwise regression was used to attempt to predict obstetricians' cesarean rates from the incidence of various patient and provider risk factors.

RESULTS

There was no relationship between frequency of epidural analgesia and rate of cesarean section for dystocia across practitioners (R2 = 0.019; P = 0.156). Weighting each obstetrician's data for the number of patients cared for during the study period did not change this result. Stepwise linear regression only modestly predicted obstetricians' cesarean section rates for dystocia, yielding a model containing 12 variables not including epidural analgesia (gestational age, induction of labor, maternal age, provider volume, nulliparity, and seven interactions; adjusted R2 = 0.312; P < 0.0001).

CONCLUSIONS

The frequency of use of epidural analgesia does not predict obstetricians' rates of cesarean section for dystocia. After accounting for a number of known patient risk factors, obstetrical practice style appears to be a major determinant of rates of cesarean section.

Viagra for temporary erectile dysfunction during treatments with assisted reproductive technologies

During treatments with assisted reproductive technologies (ART), some men may have difficulties in producing spermatozoa on demand at the time of insemination, either for intrauterine insemination (IUI) or for in-vitro fertilization (IVF). This situation imposes tremendous stress on the couple and may cause cancellation of the treatment. Here we describe, for the first time, the use of sildenafil citrate (ViagraTM) for temporary erectile dysfunction in couples undergoing ART. The first case was a man who could not produce spermatozoa for the first IVF treatment after an exhausting trial for 12 h, despite the fact that he never had problems in providing sperm samples during previous IUI cycles. Using Viagra enabled him to provide spermatozoa, but the delay in oocyte insemination resulted in no embryonic development. This prompted us to be more alert to this option and to suggest the use of Viagra to men who had a history of erectile dysfunction during previous ART cycles. In these cases, the use of Viagra was planned in advance and it successfully solved any unpredictable erectile dysfunction on the day of insemination. Such cases emphasize the need to think in advance of this potential use of Viagra during ART.

Utilization of the nuchal translucency image-scoring method during training of new examiners

Training of new examiners, utilizing 1st-trimester nuchal translucency ultrasound screening, is mandatory for obtaining reproducible measurements. This study examined the contribution of the nuchal translucency image-scoring method to the process of training and its utilization as an objective tool of image evaluation and a tool for approving qualification. The study included an evaluation of the performance of two new examiners (examiners A and B) before and after intervention, using the image-scoring method. The preintervention period included 75 images evaluated by two reviewers using general evaluation and the scoring method. The report of the scoring method was submitted to the examiners and was applied to 55 images performed afterwards. The agreement between two reviewers in classifying the first 75 images as 'accepted' or 'rejected' was tested using general evaluation versus the scoring method. The effect of the intervention was examined by comparing the quality of the images between the two time periods. A chart indicating final scores of 80 successive images analyzed by examiner A was used to set criteria for assessing qualification. Using general evaluation, the reviewers disagreed on 19 (25%) of the images, whereas using the scoring method they disagreed on only 5 (7%, p < 0.01). Comparison before and after application of the intervention demonstrated significant improvement expressed by the increased rate of better quality groups (p < 0.001) and improved mean scores from 4.31 +/- 0.31 to 6.15 +/- 0.32 (p < 0. 001). Enhanced improvement of examiner's A performance could be attributed to the intervention rather than to his learning curve. Improvement was demonstrated in all the criteria examined; however, it was significant only for images size (from 33 to 98%), amnion demonstration (from 13 to 42%), and caliper placement (from 49 to 71%). Examiner's A chart enabled us to set standards for assessing competence, based on the scoring method. These included a minimum of 40 scans, followed by more than ten sequential images of acceptable quality. The scoring method contributed to the process of training, as it made possible to objectively evaluate the images, pointed out specific errors, served as an efficient tool of intervention, and might be used for ascertaining competence. We recommend to consider its utilization in centers running 1st-trimester ultrasound screening during training new examiners.

TRA-1 regulates the cellular distribution of the tra-2 mRNA in C. elegans

The GLI protein family is involved in several key developmental processes in both vertebrates and invertebrates. The Drosophila GLI protein, Cubitus interuptus (Ci), regulates segment polarity and wing and leg development. In vertebrates, the GLI proteins control neural, lung, bone and gut development. In the nematode Caenorhabditis elegans, the GLI family member TRA-1 is necessary for normal sexual development. GLI, Ci and TRA-1 each contain five zinc-finger domains and bind the identical DNA sequence. Previous analyses are consistent with these proteins being transcription factors. Here we show that TRA-1 can act posttranscriptionally to govern gene activity. Our results indicate that the binding of TRA-1 to the 3' untranslated region of tra-2 regulates the export of tra-2 messenger RNA from the nucleus. The fact that TRA-1 is part of a conserved family of proteins raises the possibility that GLI family members are both transcriptional and post-transcriptional regulators of gene expression.

Sonographically diagnosed pelvic hematomas and postcesarean febrile morbidity

OBJECTIVE

To evaluate the incidence of ultrasonographically-diagnosed postcesarean hematomas and correlate their presence with febrile morbidity.

METHODS

Prospective study of 111 consecutive patients who had a pelvic ultrasound 4-6 days post-operatively. Ultrasonographic findings were correlated with clinical data.

RESULTS

Postoperative fever was diagnosed in 28 (25%) patients. Fifteen (13.5%) women had hematomas; 10 (9%) had bladder-flap and five (4.5%) had subfascial hematomas. Only subfascial hematomas were significantly associated with post-operative fever (P = 0.01).

CONCLUSIONS

Postcesarean bladder-flap hematomas are not predictive of post-operative fever. The presence of subfascial hematomas should be specifically sought in the evaluation of a febrile postcesarean patient.

Antitumor and immunotherapeutic effects of activated invasive T lymphoma cells that display short-term interleukin 1alpha expression

Expression of cytokines in malignant cells represents a novel approach for therapeutic treatment of tumors. Previously, we demonstrated the immunostimulatory effectiveness of interleukin 1alpha (IL-1alpha) gene transfer in experimental fibrosarcoma tumors. Here, we report the antitumor and immunotherapeutic effects of short-term expression of IL-1alpha by malignant T lymphoma cells. Activation in culture of T lymphoma cells with lipopolysaccharide-stimulated macrophages induces the expression of IL-1alpha. The short-term expression of IL-1alpha persists in the malignant T cells for a few days (approximately 3-6 days) after termination of the in vitro activation procedure and, thus, has the potential to stimulate antitumor immune responses in vivo. As an experimental tumor model, we used the RO1 invasive T lymphoma cell line. Upon i.v. inoculation, these cells invade the vertebral column and compress the spinal cord, resulting in hind leg paralysis and death of the mice. Activated RO1 cells, induced to express IL-1alpha in a short-term manner, manifested reduced tumorigenicity: approximately 75% of the mice injected with activated RO1 cells remained tumor free. IL-1 was shown to be essential for the eradication of activated T lymphoma cells because injection of activated RO1 cells together with IL-1-specific inhibitors, i.e., the IL-1 receptor antagonist or the M 20 IL-1 inhibitor, reversed reduced tumorigenicity patterns and led to progressive tumor growth and death of the mice. Furthermore, activated RO1 cells could serve as a treatment by intervening in the growth of violent RO1 cells after tumor take. Thus, when activated RO1 cells were injected 6 or 9 days after the inoculation of violent cells, mortality was significantly reduced. IL-1alpha, in its unique membrane-associated form, in addition to its cytosolic and secreted forms, may represent a focused adjuvant for potentiating antitumor immune responses at low levels of expression, below those that are toxic to the host. Further assessment of the immunotherapeutic potential of short-term expression of IL-1alpha in activated tumor cells may allow its improved application in the treatment of malignancies.

Vasomotor rhinitis following trauma to the nose

Complaints of nasal obstruction following nasal trauma without any deformation have been noticed by rhinologists for many years. However, neither an epidemiologic nor a pathophysiologic connection has ever been established. The complaints and physical examination findings of these patients resemble those of vasomotor rhinitis. Only very few articles suggesting nasal trauma as a possible cause for vasomotor rhinitis have ever been published. We present a retrospective study that found 87 of 802 patients to suffer from vasomotor rhinitis following nasal trauma. No other factors known to cause vasomotor rhinitis were present in these patients. None had any previous nasal problems. We therefore suggest that nasal trauma was the causative factor in their vasomotor rhinitis.

Effect of a baseline ovarian cyst on the outcome of in vitro fertilization-embryo transfer

OBJECTIVE

To determine the significance of prestimulation ovarian cysts on the response to controlled ovarian hyperstimulation and the outcome of IVF.

DESIGN

Retrospective study.

SETTING

In vitro fertilization unit in an academic center.

PATIENT(S)

One hundred thirty-seven patients undergoing IVF.

INTERVENTION(S)

The outcome of 71 patients who had an ovarian cyst of >10 mm detected at ultrasound examination performed on day 3 was compared with that of 66 patients who underwent a similar protocol and did not have an ovarian cyst.

MAIN OUTCOME MEASURE(S)

Parameters evaluated were the E2 level on the day of hCG administration, the number of follicles, the number of oocytes retrieved, the number of embryos transferred, and the pregnancy rate.

RESULT(S)

The E2 level on the day of hCG administration and the number of mature oocytes retrieved were lower in the group with a baseline cyst. The pregnancy rate also was significantly lower in the group with a cyst (24% versus 41%). The presence of a baseline ovarian cyst decreases the odds of pregnancy 0.37-fold (95% confidence interval, 0.16-0.87).

CONCLUSION(S)

A baseline ovarian cyst on cycle day 3 was associated with a poorer outcome after IVF-ET.

Goitre presenting as an oropharyngeal mass: an unusual finding in the elderly

Thyroid goitre presentation in the neck with extension inferiorly to the mediastinum is well-known. Extension superiorly into the retropharyngeal space is very rare and may be accompanied by change in voice and/or airway compromise. A case is described of a patient with change in voice and mild airway compromise secondary to a goitre presenting in the oropharynx. Computed tomography (CT) and physical findings are discussed with the need to recognize this rare entity.

Use of intranasal endoscopic surgery to relieve ostiomeatal complex obstruction in fibrous dysplasia of the paranasal sinuses

The use of endoscopic nasal surgery for debulking ethmoidal fibrous dysplasia, blocking the right ostiomeatal complex is presented. Removal of the obstructing bony mass was done by ear curette and drills. The procedure was limited to the ostiomeatal complex in order not to violate the orbital contents. The advantages of this method over the external approach are outlined in this paper.

AIDS and reproductive health

Over 24 million adults worldwide have been infected with HIV. Primarily a sexually transmitted disease, AIDS is inexorably linked to reproductive health and care. Because HIV tends to infect those who are in their reproductive years, the impact of this disease on population growth and life expectancy is projected to be immense in some parts of the world, especially in sub-Saharan Africa. Not least is the challenge to individual families and infant care programs to care for AIDS babies. Estimates of the rate of vertical transmission of HIV range from < 10 to 46%. Transmission through sexual contact accounts for 75-85% of HIV infection worldwide, and today, nearly 20 years into the epidemic, the main tool to stall the spread is advocating change in sexual conduct. Numerous studies leave no doubt that the attributable risk of co-infection with other STDs--both ulcerative and non-ulcerative--in heterosexual transmission is substantial. The only known contraceptive method proven to reduce both infectiousness and susceptibility to HIV is barrier contraception. Spermicidal agents currently available have not been shown to reduce HIV concentrations in genital secretions, or to reduce transmission of the virus. The challenges that lie ahead are tremendous: we must continue to focus on development of affordable preventive measures; urge policy-makers to back further research in prevention to complement condom use; and advocate for continued support of basic research to learn more about fundamental mechanisms of HIV transmission.

Elevation of erythrocyte redox potential linked to galactonate biosynthesis: elimination by Tolrestat

Alternate pathways of galactose metabolism were explored in erythrocytes from normal subjects and patients with galactose-1-phosphate uridylyltransferase (GALT) deficiency incubated with galactose. Micromolar quantities of galactonate accumulated in both normal and mutant cells linearly with time up to 5 hours and with concentrations of galactose up to 25 mmol/L. Galactitol also was found at levels less than one third of the galactonate level, while galactose-1-phosphate concentrations comparable to those of galactonate were found in galactosemic cells. Concomitant with the formation of these galactose metabolites, the erythrocyte redox potential based on measurement of lactate and pyruvate increased fourfold in both cell types. This was due to a 60% to 72% decrease in pyruvate and a 24% to 26% increase in lactate. The oxidation of galactose to galactonate, which is known to generate NADH, is the most likely explanation for the increase in the redox state. The aldose reductase inhibitor (ARI), Tolrestat (Wyeth Ayerst Research, Princeton, NJ), at 70 micromol/L inhibited the formation of both galactonate and galactitol in both cell types without affecting galactose-1-phosphate, and eliminated the increase in the redox potential as indicated by restoration of pyruvate and lactate levels to the levels obtained before exposure of the cells to galactose. A functioning galactonate pathway is a route of galactose disposal in patients with GALT deficiency, but by altering the cellular redox potential, it may also contribute to galactose toxicity.

Massive pleomorphic adenoma of the maxillary sinus. A case report

A case of pleomorphic adenoma of the maxillary sinus in a 78-year-old man with associated mucocele is reported. The diagnosis and treatment of this rare lesion is discussed.

The tocolytic effect of catecholamines in the gravid rat uterus

Maternal catecholamines increase dramatically in labor because of pain and emotional stress. Because the uterus is richly endowed with both alpha- and beta-adrenergic receptors, catecholamines could alter uterine activity. We assessed the effect of clinically encountered concentrations of these catecholamines on uterine activity and modeled the effect of the abrupt reduction in circulating epinephrine that occurs during effective labor analgesia. Term pregnant rat uteri were excised, and cross-sectional rings were mounted for isometric force recording. Log concentration-response curves for epinephrine, norepinephrine, and their combination on uterine activity were constructed from 10(-12) to 10(-6) M. Catecholamine responses were repeated in the presence of phentolamine, an alpha-adrenergic blocker or propranolol, a beta-adrenergic blocker. The abilities of oxytocin and of washout of catecholamines to reverse catecholamine-induced changes in uterine activity were also assessed. Epinephrine caused dose-dependent reductions in uterine activity, blocked by propranolol. Epinephrine concentrations in the clinical range(10(-9) to 10(-8) M; 100-1000 pg/mL) decreased uterine activity to 49.6% +/- 6.6% (mean +/- SE) of control. Norepinephrine caused a dose-dependent increase in uterine activity, which was blocked by phentolamine. In the clinical range (10(-8) M), uterine activity was 139.2% +/- 13.40% of control. The combination of both catecholamines, however, was nearly as tocolytic as epinephrine alone. Oxytocin antagonized catecholamine-induced tocolysis, and washout of epinephrine or both catecholamines increased uterine activity. We conclude that mixed catecholamines are significantly tocolytic at concentrations encountered in laboring women. In this in vitro model, reduction in epinephrine concentration, comparable to that which occurs during effective analgesia, significantly increases uterine activity.

IMPLICATIONS

Maternal catecholamines increase in labor, but epinephrine decreases dramatically after regional analgesia. In this study, we found that norepinephrine and epinephrine together decrease uterine contractile activity and that decreased epinephrine causes significantly increased uterine activity.

Incidence of epidural catheter replacement in parturients: a retrospective chart review

We noted in our practice of obstetric anesthesia at a large teaching hospital that the epidural catheter failure rate was higher than previously reported. We undertook this study to determine the incidence of epidural catheter failure in parturients and to determine the primary causes of failure. After institutional approval, we evaluated the charts of parturients who received epidural analgesia for labor or anesthesia for cesarean section for 6 randomly selected months spanning one year. We examined 4240 anesthesia records for patient-related data, operator-related data (years of training) and technical information. The participants were unaware there was a study in progress, and data were collected in a systematic fashion so as to minimize data collection related biases. Chi2, Mantel-Haenszel chi2, analysis of variance and univariate logistic regression were used to analyze data. P<0.05 was considered statistically significant. Overall epidural catheter failure rate was 13.1% with a dural puncture rate of 1.03%. The major causes of catheter failure were no analgesia and unilateral block. The experience of the anesthesiologist, the mode of delivery, patient age, patient weight, type of epidural catheter, occurrence of paresthesia and the use of CSE were all associated with significantly different epidural catheter replacement rates. Despite the initially high failure rate, the overall patient satisfaction rate was greater than 98%.

Transnasal endoscopic drainage of a medial subperiosteal orbital abscess

The exact incidence of orbital complications due to sinusitis in children is unknown. However, a medial subperiosteal orbital abscess is the most common serious complication to occur. Surgical intervention is mandatory whenever antibiotic treatment fails. Most authors prefer open surgical procedures such as external ethmoidectomy, while others recommend transnasal endoscopic drainage as the first attempt at sinus decompression. Five out of 12 children with proven subperiosteal orbital abscess and sinusitis on computed tomographic scans failed antibiotic treatment and required surgical drainage. Transnasal endoscopic drainage of the abscess was performed on four patients, while one child underwent external ethmoidectomy. Our experience with endoscopic surgery in these four cases is discussed, along with a brief review of the advantage of this procedure over external surgery.