Anaesthesia in a parturient with systemic mastocytosis

Mastocytosis is characterized by clonal expansion of mast cells, with abnormal accumulation in different organs. Perioperatively, numerous stimuli may lead to the release of vasoactive substances by mast cells. Parturients with systemic mastocytosis pose a challenge to the anesthesiologist: on one hand, the pain and stress of labor may lead to greater mast cell activation and, on the other, the administration of drugs that may possibly trigger the release of mast cell mediators. The authors describe a case of a 34-year-old pregnant woman with systemic mastocytosis who requests labor analgesia. An epidural analgesia was performed after induction of labor, after considering anesthetic particularities. The epidural procedure, labor and delivery were uneventful. A review of systemic mastocytosis is provided and its anesthetic considerations are discussed.

Paliperidone palmitate-induced enuresis: a case report

Introduction

Schizophrenia is a severe mental illness that requires long-term treatment with antipsychotics and the intramuscular (IM) long-acting injectable (LAI) formulations may enhance treatment adherence. Some antipsychotics have been associated with enuresis, including atypical antipsychotics such as risperidone(6.2%), quetiapine(6.7%), olanzapine (9.6% ) and clozapine (20.7%) [1]. Although oral paliperidone has been related to urinary incontinence, there is only 1 report of urinary incontinence linked to monthly paliperidone palmitate [2]. [1] Harrison-Woolrych, M., Skegg, K., Ashton, J., Herbison, P., Skegg, D.C., 2011. Nocturnal enuresis in patients taking clozapine, risperidone, olanzapine and quetiapine: comparative cohort study. British Journal of Psychiatry 199, 140–144. doi:10.1192/bjp.bp.110.087478 [2] Karslıoǧlu, E.H., Özalp, E., Çayköylü, A., 2016. Paliperidone Palmitate-induced Urinary Incontinence: A Case Report. Clinical Psychopharmacology and Neuroscience 14, 96–100. doi:10.9758/cpn.2016.14.1.96

Objectives

To establish an association between paliperidone palmitate and enuresis.

Methods

Case report and a narrative review of the literature.

Results

The patient was a 25-year-old healthy man when he was diagnosed with schizophrenia. Doctors prescribed paliperidone palmitate (LAI) 200mg monthly and he started to complain of enuresis. He was clearly suffering with this unpleasant and embarrassing adverse effect so the LAI was reduced to 150mg. Enuresis remained, so it was prescribed oxybutynin 20 mg/day and the patient improved.

Conclusions

We reported a case in which enuresis is likely to be associated with high-dose paliperidone LAI (with no clinical evidence of an organic cause). To treat it, the most effective strategy was oxybutynin 20 mg/day. This case is also important to show the impact of this symptom, which is not actively investigated.

Disclosure

No significant relationships.

Anesthetic considerations in a laboring woman with systemic mastocytosis

Mastocytosis is characterized by clonal expansion of mast cells, with abnormal accumulation in different organs. Perioperatively, numerous stimuli may lead to the release of vasoactive substances by mast cells. Parturients with systemic mastocytosis pose a challenge to the anesthesiologist: on one hand, the pain and stress of labor may lead to greater mast cell activation and, on the other, the administration of drugs that may possibly trigger the release of mast cell mediators. The authors describe a case of a 34-year-old pregnant woman with systemic mastocytosis who requests labor analgesia. An epidural analgesia was performed after induction of labor, after considering anesthetic particularities. The epidural procedure, labor and delivery were uneventful. A review of systemic mastocytosis is provided and its anesthetic considerations are discussed.

Small for gestational age-cognitive performance from infancy to adulthood: an observational study

OBJECTIVE

To determine whether cognitive performance from infancy to adulthood is affected by being born small for gestational age (SGA), and if this depends on the SGA reference used. Furthermore, to determine SGA's effect while considering the effects of very preterm/very low birthweight (VP/VLBW), socio-economic status (SES) and parent-infant relationship.

DESIGN, SETTING AND POPULATION

A total of 414 participants (197 term-born, 217 VP/VLBW) of the Bavarian Longitudinal Study.

METHODS

Small for gestational age was classified using neonatal or fetal growth references. SES and the parent-infant relationship were assessed before the infant was 5 months old.

MAIN OUTCOME MEASURES

Developmental (DQ) and intelligence (IQ) tests assessed cognitive performance on six occasions, from 5 months to 26 years of age.

RESULTS

The fetal reference classified more infants as SGA (<10th centile) than the neonatal reference (n = 138, 33% versus n = 75, 18%). Using linear mixed models, SGA was associated with IQ -8 points lower than appropriate for gestational age, regardless of reference used (95% CI -13.66 to -0.64 and 95% CI -13.75 to -1.98). This difference narrowed minimally into adulthood. Being VP/VLBW was associated with IQ -16 (95% CI -21.01 to -10.04) points lower than term-born participants. Low SES was associated with IQ -14 (95% CI -18.55 to -9.06) points lower than high SES. A poor parent-infant relationship was associated with IQ -10 points lower than those with a good relationship (95% CI -13.91 to -6.47).

CONCLUSIONS

Small for gestational age is associated with lower IQ throughout development, independent of VP/VLBW birth, low SES or poor parent-child relationship. Social factors effects on IQ comparable to those of SGA and should be considered for interventions.

TWEETABLE ABSTRACT

Small for gestational age is associated with lower cognitive performance from infancy to adulthood.

54 Altrenogest supplementation during early pregnancy improves swine embryonic development

Progesterone (P4) is of paramount importance in the establishment and maintenance of pregnancy for mammals. Progesterone stimulates the endometrial secretion of several molecules involved in conceptus growth and development during the peri-implantation period. Indeed, several studies involving ruminants have reported that exogenous P4 supplementation is related to increased early embryo development, higher levels of interferon tau, and improved pregnancy rate. However, there is a lack of information about P4 supplementation during early pregnancy regarding swine embryonic development. Additionally, some of the few studies involving pigs have shown an impaired pregnancy rate when supplementation was performed before Day 6 of pregnancy. Thus, the objective of this study was to evaluate the effects of progesterone/progestin supplementation from Day 6 of pregnancy on total number of embryos (TE), pregnancy rate (PR), embryo development, and maternal serum 17β-oestradiol concentration (17β-E). A total of 31 crossbred, 2 to 6 parity sows were used. All sows were inseminated every 24h through the first oestrus following a 21-day lactation, and ovulation was detected by transrectal real-time ultrasound to determine Day 0 of pregnancy. On Day 6 of pregnancy, animals were randomly allocated to one of the following groups: CON (n=11), non-supplemented sows; RU (n=11), sows supplemented daily with 20mg of Altrenogest-Regumate® from Day 6 to 12 of pregnancy; and PG (n=9), sows supplemented with 2.15 mg/kg of long-acting P4 IM on Day 6 of pregnancy. Sows were treated with altrenogest p.o. as a top dressing over a small portion of feed. Blood samples were collected from 12 sows (4 per group) on Day 12 of pregnancy to measure the level of plasma 17β-E by radioimmunoassay. Sows were slaughtered on Day 28 of pregnancy. The uterus from each sow was collected and embryos were counted to determine TE. Embryos were individually separated from their placentas, weighed, and crown-to-rump length was determined. Data were analysed by the SAS program. All variables were analysed by PROC-MIXED t-test. Statistical difference was considered when P&lt;0.05. The PR did not differ among groups (91, 90, and 88%, for CON, RU, and PG, respectively; P&gt;0.05). No difference was observed among groups for TE and 17β-E level (P&gt;0.05). However, embryonic weight and crown-to-rump length differed among the 3 groups (P&lt;0.001). The RU-treated sows had heavier and bigger embryos when compared with the other groups. In contrast, PG-treated sows had the lowest averages for the same variables (weight: 1.39±0.01, 1.46±0.02, and 1.22±0.01; crown-to-rump: 21.07±0.08, 21.61±0.11, and 20.66±0.11; for CON, RU, and PG, respectively). In conclusion, altrenogest supplementation from Day 6 to 12 of pregnancy increases size and weight of porcine embryos, whereas 2.15mg kg−1 of long-acting P4 on Day 6 of pregnancy decreased these variables when compared with non-supplemented sows. Research was supported by FAPESP Grant 2017/00290-0.

Listeria monocytogenes isolates from food and food environment harbouring tetM and ermB resistance genes

Listeria monocytogenes is a foodborne pathogen that has become an important cause of human and animal diseases worldwide. The purpose of this study was to evaluate the serotypes, virulence potential, antimicrobial resistance profile, and genetic relationships of 50 L. monocytogenes isolates from food and food environment in southern Brazil. In this study, the majority of L. monocytogenes isolates belonged to the serotypes 1/2b (42%) and 4b (26%), which are the main serotypes associated with human listeriosis. In addition, all isolates harboured internalin genes (inlA, inlC, inlJ), indicating a virulence potential. The isolates were sensitive to most of the antimicrobial compounds analysed, and five isolates (10%) were multi-resistant. Two isolates harboured antimicrobial resistance genes (tetM and ermB) and in one of them, the gene was present in the plasmid. Moreover, according to the pulsed field gel electrophoresis assay, two multi-resistant isolates were a single clone isolated from food and the processing plant. The isolates were susceptible to the most frequently used antibiotics for listeriosis treatment. However, the presence of multidrug-resistant isolates and antimicrobial resistance genes including in the plasmid could even be transferred between bacterial species, suggesting a potential health risk to consumers and a potential risk of spreading multi-resistance genes to other bacteria.

SIGNIFICANCE AND IMPACT OF THE STUDY

Listeria monocytogenes is an important agent of foodborne diseases. The results of this study suggest a potential capacity of L. monocytogenes isolates from food and food environment to cause human infections. Antimicrobial multi-resistance profiles were detected in 10%, and two isolates harboured tetM and ermB resistance genes. Moreover, the present research can help to build up a better knowledge about antimicrobial resistance of L. monocytogenes. Additionally, we found one isolate carrying tetM resistance gene in a plasmid, that suggests a possible transmission between commensal and/or other pathogenic bacteria of food environment, thereby raising up concerns regarding bacterial resistance.

Injury of primary afferent neurons may contribute to osteoarthritis induced pain: an experimental study using the collagenase model in rats

OBJECTIVE

Pain exacerbated by movement and loading on the joint is the major symptom of osteoarthritis (OA), but the mechanisms of chronic pain in this pathology are still poorly understood. Using the intra-articular (i.a.) injection of collagenase in the knee of rats as a model of OA, we aimed at evaluating whether injury of sensory neurons may contribute to the development of OA-associated nociception.

DESIGN

OA was induced by i.a. injection of collagenase into the left knee joint of adult male Wistar rats. Histopathological changes and movement and loading-induced nociception were assessed for 6 weeks. A time-course analysis of the expression of the neuronal injury markers activating transcription factor-3 (ATF-3) and neuropeptide Y (NPY) and of the neuropeptide SP in the dorsal root ganglion (DRG) was performed. Gabapentin's effect on nociception was evaluated, as well as the expression of the α2δ-1 voltage-gated calcium channel subunit.

RESULTS

Collagenase induced the development of OA-like histopathological changes and of movement-induced nociception. Altered expression of ATF-3, NPY and SP was observed in the DRG, correlating with the degree of articular degeneration after 6 weeks of disease progression. Repeated administration of gabapentin reversed the nociceptive responses 6 weeks after the induction of OA. α2δ-1 was upregulated in the DRG.

CONCLUSION

By inducing nociceptive behaviours associated with relevant joint structural changes, the i.a. injection of collagenase presents itself as a pertinent model for the study of OA pain. The findings in this study support the hypothesis that injury of sensory neurons innervating OA joints may be a significant element in the mechanisms of OA-associated pain.

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.

Characteristics of Lactobacillus and Gardnerella vaginalis from women with or without bacterial vaginosis and their relationships in gnotobiotic mice

The objectives of the present study were to evaluate in vitro the production of antagonistic compounds against Gardnerella vaginalis by Lactobacillus strains isolated from women with or without bacterial vaginosis (BV), and to select one of the better Lactobacillus producers of such a substance to be tested in vivo using a gnotobiotic animal model challenged with one of the more sensitive G. vaginalis isolates. A total of 24 isolates from women with and without BV were identified as G. vaginalis. A higher frequency (P<0.05) of this bacterium was observed in women with BV (56.7%) when compared to healthy women (17.6%). A total of 86 strains of Lactobacillus were obtained from healthy women and women with BV. Lactobacillus strains were more frequently present (P<0.05) in healthy women (97.5%) than in women with BV (76.7%). Lactobacillus crispatus was the predominating strain in both healthy women and women with BV. Lactobacillus jensenii, Lactobacillus johnsonii, Lactobacillus gasseri and Lactobacillus vaginalis were isolated with an intermediate frequency in the two groups. In vitro antagonism assays were performed using as indicators 17 reference strains and the G. vaginalis strains isolated from women with BV and from healthy women. Lactobacillus isolated from healthy women showed the higher antagonistic activity against all the indicator strains when compared with isolates from women with BV. Concerning the indicator strains, G. vaginalis found in women with BV was more resistant to the antagonism, particularly when Lactobacillus isolates from women with BV were used as producer strains. A high vaginal population level of G. vaginalis was obtained by intravaginal inoculation of germ-free mice, and this colonization was accompanied by vaginal histopathological lesions. A tenfold decrease in vaginal population level of G. vaginalis and a reduction of histological lesions were observed when the pathogenic challenge was performed in mice previously monoassociated with an L. johnsonii strain. Concluding, results of the present study suggest that progression of G. vaginalis-associated BV depends in part on a simultaneous presence of Lactobacillus populations with a low antagonistic capacity and of a G. vaginalis strain with a high resistance to this antagonism. The results could also explain why G. vaginalis is frequently found in the vaginal ecosystem of healthy women.

Antagonism and synergism in Gardnerella vaginalis strains isolated from women with bacterial vaginosis

Antagonistic and synergistic substances are important for interactions between micro-organisms associated with human body surfaces, either in healthy or in diseased conditions. In the present study, such compounds produced by Gardnerella vaginalis strains isolated from women with bacterial vaginosis (BV) were detected in vitro and the antagonistic ones were partially characterized. Among 11 G. vaginalis strains tested, all showed antagonistic activity against at least one of the 22 indicator bacteria assayed. Interestingly, for some of these strains, antagonism reverted to synergism, favouring one of the indicator strains (Peptostreptococcus anaerobius) when the growth medium was changed. Partial characterization of antagonistic substances suggested a bacteriocin-like chemical nature. Depending on growth conditions, G. vaginalis isolated from women with BV produced antagonistic or synergistic compounds for other bacterial components of the vaginal ecosystem. This is the first report to our knowledge of the production of antagonistic and/or synergistic substances by G. vaginalis. This ability may be a pivotal factor in understanding BV and the ecological role of this bacterium in the vaginal environment.

Successful HAART is associated with high B-chemokine levels in chronic HIV type 1-infected patients

Chemokine receptors are used by HIV-1 for entry into CD4+ T cells. The beta-chemokines are capable of inhibiting HIV replication. This study measured beta-chemokine macrophage inflammatory protein (MIP)-1alpha and MIP-1beta levels and determined the CCR5 and CXCR4 expression on T cells in HIV-1-infected patients treated with HAART. The time of known HIV infection and time of HAART use were similar between failure and successful groups. The CD4+ T cell nadir was 163 vs. 251 cells/mm3, p = 0.07, for failure and successful groups, respectively. The successfully treated group, when compared with the failure group, had a higher median CD4+ T cells count (667 vs. 257 cells/mm3; p = 0.003) as well as higher spontaneous MIP-1alpha (median of 4390 vs. 802 pg/ml, p = 0.03) and MIP-1beta (median of 2416 vs. 1117 pg/ml, p = 0.001) levels. The untreated patients had a higher number and intensity of CCR5- and CXCR4-expressing T cells. Higher levels of chemokines were not related to nadir CD4+ T and current CD8+ T cell counts. Successfully treated patients were able to produce higher amounts of beta-chemokines and normalize the coreceptor overexpression on T cells. These findings may have clinical implications, such as a new strategy of using chemokines as adjuvants in anti-HIV therapy.

[Iatrogenic vascular injuries]

Iatrogenic vascular injuries include an extremely broad group of lesions with multiple etiology and polymorphic manifestations. We present a series of 44 patients with iatrogenic vascular lesions that result from arterial and venous catheterizations and surgical interventions. The arterial catheterization for coronariography and arteriography and orthopaedic surgery were the agents that most frequently caused vascular injury. Arterial and venous reconstructive surgery were the predominant treatment procedures. In our series, morbidity and mortality were 4.6% and 2.3%, respectively.

Effect of scorpion toxin from Tityus serrulatus on the contraction of the isolated rat uterus

Scorpion toxin T1 from Tityus serrulatus was tested for its effects on the isolated rat uterus preparation. T1 (5 micrograms/ml) caused a contraction of the uterus, which was potentiated by neostigmine (1.64 x 10(-6) M) and abolished by atropine (1.4 x 10(-7) M). After addition of neostigmine to the bath, we noted a higher amplitude of the toxin-induced contractions, and the appearance of repetitive rhythmic contractions. The scorpion toxin-induced contraction was not prevented by previous addition to the bath of hexamethonium or bradykinin, 5-HT and angiotensin II antagonists. The uterine contraction was prevented by previous addition to the bath of either tetrodotoxin (5 x 10(-8) M) or lidocaine (4.2 x 10(-5) M). These data seem to indicate that scorpion toxin-induced rat uterus contractions are due to actions on post-ganglionic autonomic nerve endings, with acetylcholine release and stimulation of muscarinic receptors.

Severe acute paracoccidioidomycosis in children

This report describes clinical and immunologic features of five illustrative cases of paracoccidioidomycosis in previously healthy children. All had disseminated disease and two of them died despite treatment. The major clinical presentation in four patients was fever and diffuse superficial and intraabdominal adenopathy, with or without hepatosplenomegaly. Other sites were also affected: three patients had multiple osteoarticular lesions, occasionally with intense tissue destruction; two had cutaneous eruptions; two had pericardial effusions; and two had pulmonary involvement, once considered an organ spared in the young. We detected variable lymphocyte responses to mitogens and to Candida albicans antigen and non-responsiveness to Paracoccidioides brasiliensis cell wall antigen. High concentrations of serum immunoglobulins and anti-P. brasiliensis antibodies were present. These immune alterations tended to resolve with treatment, suggesting a reversible nature of the immune defect. We conclude that this mycosis has a high morbidity and mortality in children, which is probably related to an antigen-specific immunodeficiency. Further studies are needed to increase knowledge of this mycosis in children.

Seasonal fluctuations in brain nuclei in the red-sided garter snake and their hormonal control

In many vertebrates, breeding seasons are protracted and mating behavior is temporally associated with gonadal growth and increased sex steroid hormone secretion. In the red-sided garter snake (Thamnophis sirtalis parietalis), mating behavior is restricted to the 2-4 weeks immediately following emergence from winter dormancy. During this period mating behavior is sex-specific: chin-rubbing is exhibited only by males and receptivity to chin-rubbing is exhibited only by females. It is remarkable that mating occurs when the gonads are small and circulating concentrations of gonadal hormones are low. As in other vertebrate species, limbic nuclei are involved in the mediation of mating behaviors. To determine if limbic nuclei are sexually dimorphic and, further, whether they fluctuate in size with the seasons, the volume of brain areas was measured in both sexes at different times of the year (spring, fall, hibernation) and after hormone manipulation (gonadectomy and gonadectomy plus hormone treatment). The areas of interest were the preoptic area (POA), ventromedial hypothalamus (VMH), and the nucleus sphericus (NS or amygdala); control areas included the external nucleus of the optic tract (a cell-rich area) and medial forebrain bundle (a fiber-rich area). Comparisons according to season and manipulation revealed only two instances of sexual dimorphism: the POA of females was significantly smaller than that of males during hibernation and the NS of females was significantly smaller than that of males in those animals not subjected to hibernation. This general lack of sexual dimorphisms in the brain despite the sex-specificity of the behavior patterns and their marked seasonality may reflect the dissociated reproductive pattern characteristic of this species.(ABSTRACT TRUNCATED AT 250 WORDS)

Renal arteriovenous fistula after nephrectomy

Postnephrectomy renal arteriovenous fistulas are rare. An arteriovenous fistula of the right renal pedicle was discovered in a 37-year-old woman who had undergone nephrectomy for renal tuberculosis nine months previously, after she had complained of dyspnea and pain in the right flank. The fistula was confirmed on arteriograms. Proximal ligation of the artery and distal ligation of the vein were followed by an uneventful recovery. Twelve months later, the patient was asymptomatic. Even though complete excision of the fistula represents the ideal treatment of this type of lesion, simple ligation can provide good results when the size of the fistula contraindicates embolization.