Risk factors for accidental dural puncture during epidural anesthesia for laboring women

BACKGROUND AND OBJECTIVES

Accidental dural puncture (ADP) during epidural analgesia is a debilitating complication. Symptoms of ADP post-dural puncture headache (PDPH) are headache while rising from supine to upright position, nausea, and neck stiffness. While age, gender and needle characteristics are established risk factors for ADP, little is known about risk factors in laboring women.

METHODS

All cases of ADP during epidural analgesia treated with blood-patching during a 3-years period were retrospectively reviewed. Each case was matched to two controls according to delivery period.

RESULTS

Forty-nine cases of blood patches after ADP out 17 977 epidural anesthesia procedures were identified (0.27%). No differences were found between cases and controls with regards to body mass index, labor stage at time of epidural, length of second stage, location of epidural along the lumbar vertebrae, anesthesiologist's experience or time when epidural was done. In cases of ADP, significantly lower doses of local anesthetics were injected (10.9 versus 13.5 cc, p < 0.001); anesthesiologists reported significantly more trials of epidurals (70 versus 2.8% more than one trial, p < 0.001), more patient movement during the procedure (13 versus 0%, p < 0.001), more intra-procedure suspicion of ADP (69 versus 0%, p < 0.001) and more cases where CSF/blood was drawn with the syringe (57 versus 2.4%, p < 0.001).

CONCLUSION

ADP during labor is a rare but debilitating complication. Risk factors for this iatrogenic complication include patient movement and repeated epidural trials. Intra-procedure identification of ADP is common, allowing early intervention with blood patching where indicated.

Pain experience of adults with intellectual disabilities--caregiver reports

BACKGROUND

Pain is a problem for individuals with intellectual and developmental disability (IDD), secondary to their impairments, due to invasive medical procedures that these individuals undergo on a regular basis. Current literature indicates pain as a common experience for children with IDD, yet no such reports have been made in regard to adults with IDD.

PURPOSES

This study aimed (1) to re-establish the reliability of caregivers as proxy observers; (2) to evaluate the pain experience of adults with IDD by caregivers' proxy report; and (3) to assess the sensitivity of the Non-Communicating Adult Pain Checklist (NCAPC) as a pain scale for chronic pain (CP) in individuals with IDD.

METHOD

Frothy-three caregivers, working for more than 3 years with adults with IDD, performed pain assessments of 187 individuals living in a residential facility. Two caregivers evaluated whether each resident suffers from pain and assessed the intensity, causes and duration of pain experience. Furthermore, 52/187 residents [26 with CP and 26 pain free (PF) based on medical record and caregiver reports] were evaluated by an additional seven caregivers using the NCAPC in order to establish the reliability of caregivers as proxy observers.

RESULTS

According to caregivers' report, 48% of adults with IDD suffer from pain at a mean level of 6/10, with more than 10% suffering from high levels of pain on a constant basis. Inter-rater agreement was found mostly high with intraclass correlation values ranging between 0.73 and 0.93. Using the NCAPC, we were able to identify CP and PF individuals with a significant score difference (P = 0.003).

CONCLUSIONS

The results support the use of the NCAPC as a scale to evaluate CP in adults with IDD. The findings reiterate the reliability of caregivers as proxy observers and the importance of involving them in identifying pain behaviours of their protégées. Our findings reiterate the need for an immediate action for appropriate pain management protocols for adult with IDD.

Osteoporosis in Rett syndrome: a case study presenting a novel management intervention for severe osteoporosis

The present article describes a successful novel therapeutic intervention with Aredia with one child with Rett syndrome, after suffering from six pathological fractures within less than 3 years due to severe osteoporosis. Since the initiation of the treatment (3 years ago), the child has not suffered any fractures. Patients with chronic diseases and those with disabilities or on anticonvulsant medications are at risk for low bone density and possibly for the resultant pathologic fractures that define osteoporosis in children. Individuals with Rett syndrome (RS) have been shown to have low bone mineral density (or osteopenia) at a young age. If osteoporosis occurs in a girl with RS, it can inflict pain and seriously impair the child's mobility and quality of life. The present article describes a case study of a child with RS (showing an average of 1.75 fractures annually for the 4 years preceding the treatment) before and after a treatment with Aredia. Patient received 30 mg/day for 3 days on a once every 3-month cycle. There was a 45 % improvement in bone mass density (BMD) values from pre-post-intervention. The child had no fractures in the 3 years posttreatment. This finding is significant (p < 0.03). The BMD Z-scores of the child showed severe osteoporosis (Z-score of -3.8) at pre-intervention and are elevated to osteopenia levels (Z-score of -1.3) at post-intervention measurements. All measurements suggest that the treatment successfully reversed the osteoporotic process and prevented further fractures. This change caused great relief to the child and her family and an improvement in their quality of life. The findings support the ability (in one case) to reverse the progression of osteoporosis in individuals with Rett syndrome showing severe osteoporosis with multiple fractures.

Measurement properties of the Non-Communicating Adult Pain Checklist (NCAPC): a pain scale for adults with Intellectual and Developmental Disabilities, scored in a clinical setting

The 18 items' Non-Communicating Adult Pain Checklist (NCAPC) has been developed from the 27 items Non-Communicating Children Pain Checklist to better capture pain behavior of adults with Intellectual and Developmental Disabilities (IDD). As part of the NCAPC's measurement properties, internal consistency, reliability and sensitivity to pain have been evaluated and found satisfactory, using scores based on video-uptakes. The aim of the article therefore was to examine the instrument's discriminative ability and sensitivity to pain of adults at different levels of IDD when scored within a clinical situation as well as through video-uptakes. Participants were 59 adults at different levels of IDD who were observed for pain behavior, before and during dental hygiene treatment (scored directly) and influenza injection (scored from video-uptakes), using the NCAPC. The results suggest that the NCAPC differentiated between pain and non-pain situations, as well as between pain reaction during two different medical procedures expected to cause more or less pain, and it was found sensitive to pain at all levels of IDD. We conclude that the present findings add to previous findings of measurement properties of the NCAPC, and support that it can be scored directly in a clinical setting.

Reliability of the Non-Communicating Adult Pain Checklist (NCAPC), assessed by different groups of health workers

Evaluating pain in adults with intellectual and developmental disability (IDD) is a challenge. The Non-Communicating Adults Pain Checklist (NCAPC) was recently developed from the Non-Communicating Children's Pain Checklist (NCCPC) and examined in a group of adults with IDD (N=228) and found to hold satisfactory construct validity, internal consistency and sensitivity to pain. To further explore its basis for clinical use, intra and interrater reliability of the NCAPC was investigated. Data collection was done by videotaping the participants before and during influenza vaccination. Intrarater reliability was evaluated by the first author on a group of 50 randomly selected individuals (mean age 42.5, range 19-72) and was found at 0.94. Interrater reliability was investigated in two stages. In the initial step different groups of health care workers (caregivers, nurses, case managers, and therapists), each including five raters, viewed a sample of 12 adult participants with IDD (3 at each level of IDD mean age was 49 years, range 16-72), that were extracted from the population sample. Interrater reliability of all raters within the groups varied from low to very high (ICC(1,1)=0.40-0.88). Interrater reliability was very high in caregivers. The Physical -and Occupational therapists are one group were considered potential users of the measure. In the second stage 3 participants from each of the groups showing high interrater reliability (caregivers and therapist) evaluated interrater reliability in a randomly selected group of 40 individuals (mean age 41.2, range 15-72). Interrarter reliability for the therapists and caregivers was found at 0.91 and 0.92 correspondingly. The researchers conclude that that the NCAPC have been found to hold high reliability values.

Physical activity for adolescents with intellectual disability

Numerous studies have described an association between participation in physical activity and an enhanced sense of well-being. These findings have been documented in both genders across the lifespan. Connections between exercise and positive physical, psychological, emotional and educational outcomes have also been found. New findings indicate that is an ongoing and increasing tendency for sedentary lifestyles across age groups and gender in many countries. In addition, there are many factors that work together to contribute to a sedentary lifestyle in individuals with intellectual and developmental disability (ID/DD). These findings are concerning, and indicate that people with ID/DD are at relatively high risk for the development of multiple negative consequences of physical inactivity. This review presents current literature that addresses the question of physical activity in adolescents with ID/DD. In addition, this review presents the connection between higher levels of physical fitness and better health in youths with ID/DD. Strategies to promote physical activity in the adolescent population with ID/DD are presented. The available evidence base strongly supports the high need for the establishment of community based, easily accessible physical activity programs for children and adolescents with ID/DD.

Improving functional skills and physical fitness in children with Rett syndrome

BACKGROUND

To investigate the feasibility of a physical exercise programme with treadmill for persons with Rett syndrome (RS) in order to promote fitness and health.

METHODS

A daily training programme on a treadmill was designed for four females with RS over a period of 2 months with tests performed in three intervals, at time 1, 2 and 3, 2 months apart with intervention taking place between tests 2 and 3. Participants were four girls with RS aged 8.5-11 years (mean: 10 years) attending the educational facility Beit Issie Shapiro, Raanana, Israel, all with independent mobility and with typical characteristics of RS stage III. The training took place at the educational facility, on a 1400 model treadmill (Trimline, capable of very low speeds < 0.5 k/h), with very long side rails. Special low side rails were adapted to the treadmill in order to fit the height of the children and velcro straps were added to assist in safely placing the hands. Pulse was monitored constantly during exercise by an A3 polar pulse belt. Pulse measurements at rest during training were considered as evaluators of aerobic physical condition. Functional measurement was based on a scale specially established for the present study. The scale was a 31-item motor-functioning tool that measures the ability of participants to knee walk and knee stand, to get up to a standing position, duration of walking different paths, and to go up and down stairs and slopes.

RESULTS

The study showed that physical fitness of the children at the end of the training programme had improved considerably (P < 0.05). Tests showed that general functional abilities had improved considerably (P < 0.0001). Although all items of the functional ability measure showed impressive positive change, some of the 31 items on it showed statistically significant improvement (knee walking, going up and down stairs and speed of walking for 25 m. Pearson correlation showed high linkage (r = -0.76) between functional improvement and change in physical fitness.

CONCLUSIONS

Physical fitness programme executed on a daily basis is capable of improving functional ability of children with RS. Nonprofessional personnel can execute such a programme under supervision of a qualified physical therapist.

Interleukin-2 transcripts in human and rodent brains: possible expression by astrocytes

Cytokines have been suggested to be involved in the cross talk between the immune and the nervous systems, under normal and pathological conditions. For example, the cytokine interleukin-2 was suggested to be involved in response to CNS trauma and spontaneous regeneration. Here, we examined whether mammalian CNS has an intrinsic potential to produce interleukin-2 and, if so, what its cellular origin is. mRNA sequences encoding for interleukin-2 were detected in brains of humans and rodents. Northern blot analysis revealed the presence of several interleukin-2 transcripts of different sizes in the brain, all recognized by lymphocyte-derived interleukin-2 cDNA probes. One of the transcripts, a high molecular weight form of approximately 5 kb, appeared to be unique to the brain. Reverse transcription and amplification by PCR of human fetal brain mRNA revealed one cDNA product that, upon sequence analysis, showed a high degree of homology with the human lymphocyte-derived interleukin-2 coding sequence. To identify the possible cellular source of the interleukin-2 transcripts within the mammalian brain, we similarly analyzed mRNA of rat brain cells in culture. Northern blot analysis revealed that astrocytes contain transcripts that hybridize with interleukin-2 cDNA probe. These findings point to the astrocytes as a possible source of brain interleukin-2.

Cross talk between the immune system and the nervous system in response to injury: implications for regeneration

The central nervous system has long been regarded as an immunologically privileged site. Accumulating evidence suggests, however, that the privilege is not total, and that certain immune functions involving immune components and resident glial cells can operate in the central nervous system. The nervous and immune systems interact during normal development, but in the mature brain their interaction is restricted mainly to cases of pathogenic infections and traumatic lesions. The focus of this review is on bidirectional interactions between immune and neuroglial components in response to nerve injury. The macrophage is the most ubiquitous of the immune-derived cell types associated with injury. Its role, as in any other organ, is tissue remodeling and promotion of healing. Macrophage activities include removal of dead tissue and debris by phagocytosis, lipid recycling, and secretion of a wide spectrum of cytokines possessing trophic, mitogenic, and chemotactic properties. These activities affect the behavior of resident cells in the vicinity of the wound. We discuss the possible association of these cytokines with the ability of injured nerves to regenerate. Finally, we consider the apparently conflicting effects of posttraumatic inflammation on the recovery of function.

Cytokines modulate the inflammatory response and change permissiveness to neuronal adhesion in injured mammalian central nervous system

Axonal injury of peripheral nerves has been shown to be followed by rapid and massive invasion of the nerves by macrophages, which appear to play an important role in the subsequent ability of these nerves to regenerate. In contrast, macrophage invasion of injured nerves of the central nervous system is limited, and the relationship between the post-traumatic inflammatory response of central nervous system nerves and their poor ability to regenerate is not fully understood. We used the proinflammatory cytokine tumor necrosis factor-alpha and the macrophage growth factor, colony stimulating factor-1, to examine whether the inflammatory response can be augmented in the optic nerve following injury, and whether such augmentation is accompanied by regeneration-associated changes. It appeared that the two cytokines caused a significant increase in the number of macrophages invading the optic nerve immediately after injury. Interestingly, however, in the nerve treated with tumor necrosis factor-alpha (but not in the nerve treated with colony stimulating factor-1) this increase was accompanied by an increased permissiveness of the nerve to neuronal adhesion, which we examined in vitro using longitudinal sections of the nerve on which PC12 cells were seeded. The results are discussed with respect to the ability of tumor necrosis factor-alpha to modify the nonpermissive nature of central nervous system white matter.

Identification of an interleukin 2-like substance as a factor cytotoxic to oligodendrocytes and associated with central nervous system regeneration

Axons of the central nervous system in adult mammals do not regenerate spontaneously after injury, partly because of the presence of oligodendrocytes that inhibit axonal growth. This is not the case in lower vertebrates (e.g., in fish), where regeneration of the optic nerve does occur spontaneously and has been correlated with the presence of factors cytotoxic to oligodendrocytes. The present study provides evidence that the substance originating from the fish optic nerves, which is cytotoxic to oligodendrocytes, is an interleukin 2-like substance.

Postinjury changes in platelet-derived growth factor-like activity in fish and rat optic nerves

The poor regenerative ability of the CNS of mammals has been attributed, at least in part, to the presence of mature oligodendrocytes, which have been shown to inhibit axonal growth. Proliferation of oligodendrocyte progenitor cells in the rat optic nerve during development, and thereby the timing of oligodendrocyte differentiation, has been shown to depend on a factor derived from type 1 astrocytes, later characterized as platelet-derived growth factor (PDGF). In the present study we examine whether injury to the optic nerve induces changes in the levels of PDGF in spontaneously regenerating systems, compared with nonregenerating systems. Soluble substances, derived from nonneuronal cells surrounding injured fish and rat optic nerves, were prepared and examined for the presence of PDGF immunoreactivity and biological mitogenic activity on PDGF-responsive cells. The results suggest that PDGF-like mitogenic activity and immunoreactivity are present in both fish and rat optic nerves. However, in the rat optic nerve PDGF levels increased after axonal injury, whereas in the fish optic nerve injury was accompanied by an apparent decrease in PDGF-like levels. The results are discussed with respect to the possible role of PDGF in regeneration.

Ectopic pregnancy, the new gynecological epidemic disease: review of the modern work-up and the nonsurgical treatment option

Over the past few decades, the incidence of ectopic pregnancy has increased almost to the extent of an "epidemic disease." Early diagnosis of tubal pregnancy, with the aid of serum human chorionic gonadotropin, high-resolution ultrasound, and the more liberal use of laparoscopy, has dramatically reduced both maternal mortality and the need for radical surgery. Despite this, women with previous ectopic pregnancies still have reduced fertility potential. We report on some current aspects of the epidemiology, etiology, and work-up of ectopic pregnancy. In a review of 328 patients, gleaned from the literature, who were treated with various nonsurgical options, 283 (86%) were able to avoid surgery. The benefits, safety, and efficacy of the various treatment options are discussed, with appropriate recommendations for their use.

Conservative treatment of ectopic pregnancy and its effect on corpus luteum activity

Corpus luteum activity was monitored in 15 women undergoing nonsurgical management of ectopic pregnancy with local methotrexate injection followed by alternating oral methotrexate and citrovorum factor (group A, n = 8) or local methotrexate injection alone (group B, n = 7). All patients initially demonstrated a viable corpus luteum (plasma progesterone ranged from 1.4 to 19 ng/ml). The treatment was successful in 14, with the exception of one whose tube ruptured 11 days after local administration of methotrexate, despite a continuous decrease in beta human chorionic gonadotropin, 17 beta-estradiol and plasma progesterone levels. There seems to be no correlation between the success of the treatment and the behavior of beta human chorionic gonadotropin, 17 beta-estradiol and plasma progesterone. Three patients from group A and two from group B displayed an initial rise in beta human chorionic gonadotropin following the initiation of the therapy, but the corpus luteum response differed. In group B patients, 17 beta-estradiol and plasma progesterone levels increased in parallel with beta human chorionic gonadotropin. Group A patients displayed a continuous decrease in 17 beta-estradiol and plasma progesterone levels despite the elevation of beta human chorionic gonadotropin, suggesting a possible effect of the systemic methotrexate on corpus luteum activity.

Fertility impairment and improved fetal survival induced by a tumor cell line in mice

The BL6-T2 tumor, a regressor melanoma line in C57BL/6J mice shown by us previously to be abortifacient, has been cloned in vitro. Clones obtained have been tested in vivo for tumorigenicity and effect on gestations, in order to correlate the immunogenicity of the tumor and its effect on fetal survival. Results demonstrate that high immunogenicity and impairment of fertility do not occur in the same tumor clones. We also show that this tumor produces and secretes GM-CSF and CSF-1 and that trophoblast cells express in situ mRNA encoding for the CSF-1 receptor. We consequently hypothesize that this tumor exerts its abortifacient effect not via its strong immunogenicity but via cytokines it secretes.

Normal pregnancy complicated by vaginal ectopic trophoblastic implantation; a case report

We describe a rare case of ectopic placental tissue, presenting as a vaginal tumor during normal intra-uterine pregnancy. Its clinicopathological features, and its possible relation to placental site trophoblastic tumors are discussed. To the best of our knowledge, this is the first case to be reported in the English literature of such a lesion occurring at this site.

Recurrent hematuria during multiple pregnancies

A 33-year-old woman presented left ureteral gross hematuria under two conditions: before the second trimester of her last three gestations, and after therapy with an oral contraceptive. We believe that left renal vein varicosities, influenced by mechanical and hormonal factors, produced the hematuria.

Gonadotropin-releasing hormone activates a rapid Ca2+-independent phosphodiester hydrolysis of polyphosphoinositides in pituitary gonadotrophs

Addition of gonadotropin releasing hormone (GnRH) to pituitary cells prelabeled with [32P]Pi or with myo-[2-3H]inositol, resulted in a rapid decrease in the level of [32P]phosphatidylinositol 4,5-bisphosphate (approximately 10 s), and in [32P]phosphatidylinositol 4-phosphate (approximately 1 min), followed by increased labeling of [32P]phosphatidylinositol and [32P]phosphatidic acid (1 min). GnRH stimulated the appearance of [3H]myo-inositol 1,4,5-trisphosphate (10 s), [3H]myo-inositol 1,4-bisphosphate (15 s), and [3H]myo-inositol 1-phosphate (1 min) in the presence of Li+ (10 mM). Li+ alone stimulated the accumulation of [3H]myo-inositol 1-phosphate and [3H]myo-inositol 1,4-bisphosphate but not [3H]myo-inositol 1,4,5-trisphosphate, but had no effect on luteinizing hormone release. The effect of GnRH on inositol phosphates (Ins-P) production was dose-related (ED50 = 1-5 nM), and was blocked by a potent antagonist [D-pGlu,pClPhe,D-Trp]GnRH. Elevation of cytosolic free Ca2+ levels ([Ca2+]i), by ionomycin and A23187 from intracellular or extracellular Ca2+ pools, respectively, had no significant effect on [3H]Ins-P production. GnRH-induced [3H]Ins-P production was not dependent on extracellular Ca2+ and was noticed also after extracellular or intracellular Ca2+ mobilization by A23187 or ionomycin, respectively. The effect of GnRH on [3H]Ins-P accumulation was not affected by prior treatment of the cells with the tumor promoter phorbol ester 12-O-tetradecanoylphorbol-13-acetate or with islet-activating protein pertussis toxin. These results indicate that GnRH stimulates a rapid phosphodiester hydrolysis of polyphosphoinositides. The stimulatory effect is not mediated via an islet-activating protein-substrate, is not dependent on elevation of [Ca2+]i, neither is it negatively regulated by 12-O-tetradecanoylphorbol-13-acetate which activates Ca2+/phospholipid-dependent protein C kinase. The results are consistent with the hypothesis that GnRH-induced phosphoinositide turnover is responsible for Ca2+ mobilization followed by gonadotropin release.

Vulvar hemangiopericytoma. A case report and review of previous cases

Hemangiopericytoma is a rare vascular tumor that can be found in almost every site or organ in the body. To our knowledge, however, this is only the third reported case of hemangiopericytoma of the vulva.

Umbilical cord damage and placental abruption during amniocentesis

A case of umbilical cord laceration and placental damage during amniocentesis for maturity studies is presented, with a review of the complications of amniocentesis.