Management practices for postdural puncture headache in obstetrics: a prospective, international, cohort study

BACKGROUND

Accidental dural puncture is an uncommon complication of epidural analgesia and can cause postdural puncture headache (PDPH). We aimed to describe management practices and outcomes after PDPH treated by epidural blood patch (EBP) or no EBP.

METHODS

Following ethics committee approval, patients who developed PDPH after accidental dural puncture were recruited from participating countries and divided into two groups, those receiving EBP or no EBP. Data registered included patient and procedure characteristics, headache symptoms and intensity, management practices, and complications. Follow-up was at 3 months.

RESULTS

A total of 1001 patients from 24 countries were included, of which 647 (64.6%) received an EBP and 354 (35.4%) did not receive an EBP (no-EBP). Higher initial headache intensity was associated with greater use of EBP, odds ratio 1.29 (95% confidence interval 1.19-1.41) per pain intensity unit increase. Headache intensity declined sharply at 4 h after EBP and 127 (19.3%) patients received a second EBP. On average, no or mild headache (numeric rating score≤3) was observed 7 days after diagnosis. Intracranial bleeding was diagnosed in three patients (0.46%), and backache, headache, and analgesic use were more common at 3 months in the EBP group.

CONCLUSIONS

Management practices vary between countries, but EBP was more often used in patients with greater initial headache intensity. EBP reduced headache intensity quickly, but about 20% of patients needed a second EBP. After 7 days, most patients had no or mild headache. Backache, headache, and analgesic use were more common at 3 months in patients receiving an EBP.

Can acetylcholinesterase activity be considered as a reliable biomarker for the assessment of cadmium-induced neurotoxicity?

Gonçalves et al. (2012) recently reported the findings of a long-awaited study on the effects of long-term dietary-induced exposure to cadmium (Cd) on the acetylcholinesterase (AChE) activity of adult rodents' brain regions. Their study can be regarded as a significant contribution to the field, as there is paucity of information on the AChE activity in brain regions following exposure to Cd. However, the Cd-induced modulation of AChE activity is an issue surrounded by controversy. We, herein, discuss and summarize the relative in vivo and in vitro experimental data, and set out to answer the straightforward question: can AChE activity be considered as a reliable biomarker for the assessment of Cd-induced neurotoxicity? At this time, we can not answer in the affirmative because of the variation in techniques used and conclusions reached. We make a plea that authors aiming to explore this potential use of brain AChE activity in the future: (a) are aware of the biases that their experimental approach might exert upon this neurochemical parameter, (b) avoid the use of anaesthesia as a mode of sacrifice and clarify its timing, (c) decide upon the use of previously-studied in vivo experimental schemes (so that they can provide comparable results), and finally, (d) identify pharmacological, biochemical and molecular approaches that are appropriate to clarify the implicated mechanism(s) through which Cd modifies AChE activity.

Cancer cachexia: global awareness and guideline implementation on the web

BACKGROUND

Cancer cachexia is a common associate of cancer and has a negative impact on patients' survival. Nonetheless, cancer cachexia assessment and management are frequently less than satisfactory in daily practice.

AIM

To scrutinise global cancer cachexia awareness and relative web guideline implementation among oncology societies.

METHODS

Systematical identification of scientific and policymaker oncology societies and their guideline implementation on cancer cachexia. Assessment of the general level of awareness on cancer cachexia and evaluation of intercontinental and national variations on guideline implementation.

RESULTS

144,000 web pages were scrutinised, and 275 oncology societies identified covering a large array of oncology setting (educational/clinical/research/policymaker); 71 were international (African, American, Asian, European, Oceania and Intercontinental), 110 belonged to the top 10 countries with the highest development index and 94 pertained to 10 countries with a long lasting tradition in medical oncology (not included in the top 10 high developed countries). Overall, only 10/275 web sites provided guidelines; six of them (2.2%) provided guidelines for physicians and four (0.7%) for patients. Half of the guidelines (4/10) were outdated. All guidelines for physicians reported references, while only one of the recommendations for patients reported references to support its sentences.

CONCLUSIONS

Cancer cachexia global awareness appears extremely low; guideline implementation on the web was inconsistent for any category analysed (nation vs continent vs international vs society type vs physician vs patient oriented) and for updating.

Ketamine-induced neurotoxicity in neurodevelopment: A synopsis of main pathways based on recent in vivo experimental findings

Ketamine, a phencyclidine derivative and N-methyl-D-aspartate (NMDA) receptor antagonist, is widely used as an anesthetic, analgesic, and sedative agent in daily pediatric practice. Experimental studies have suggested that early prenatal or postnatal exposure to ketamine can induce neuroapoptosis, and establish neurobehavioral deficits that are evident in adulthood. However, most of the currently available clinical evidence is derived from retrospective and observational clinical studies. We, herein, attempt a brief review of the cellular and molecular mechanisms suggested to mediate ketamine-induced developmental neurotoxicity, utilizing a selected number of recent in vivo experimental evidence.

Regulation of Gene Expression via Triple Helical Formations

Triplex-forming oligonucleotides (TFOs) are a challenging and very promising subject in modern biochemistry and molecular genetics. Over the last decade, several studies have stated that TFOs: a) can bind to DNA in a sequence-specific manner; b) can provoke DNA repair and recombination in mammalian cells, and c) can be a very effective biological tool in embryonic and oncogenic research on gene expression pathways. Herein we review the basic modes in which TFOs exist, their gene-regulation properties, as well as the obstacles that should be overcome before they become useful in clinical practice (chemotherapy and/or gene therapy).

Exposure to ethanol during neurodevelopment modifies crucial offspring rat brain enzyme activities in a region-specific manner

The experimental simulation of conditions falling within "the fetal alcohol spectrum disorder" (FASD) requires the maternal exposure to ethanol (EtOH) during crucial neurodevelopmental periods; EtOH has been linked to a number of neurotoxic effects on the fetus, which are dependent upon the extent and the magnitude of the maternal exposure to EtOH and for which very little is known with regard to the exact mechanism(s) involved. The current study has examined the effects of moderate maternal exposure to EtOH (10 % v/v in the drinking water) throughout gestation, or gestation and lactation, on crucial 21-day-old offspring Wistar rat brain parameters, such as the activities of acetylcholinesterase (AChE) and two adenosine triphosphatases (Na(+),K(+)-ATPase and Mg(2+)-ATPase), in major offspring CNS regions (frontal cortex, hippocampus, hypothalamus, cerebellum and pons). The implemented experimental setting has provided a comparative view of the neurotoxic effects of maternal exposure to EtOH between gestation alone and a wider exposure timeframe that better covers the human third trimester-matching CNS neurodevelopment period (gestation and lactation), and has revealed a CNS region-specific susceptibility of the examined crucial neurochemical parameters to the EtOH exposure schemes attempted. Amongst these parameters, of particular importance is the recorded extensive stimulation of Na(+),K(+)-ATPase in the frontal cortex of the EtOH-exposed offspring that seems to be a result of the deleterious effect of EtOH during gestation. Although this stimulation could be inversely related to the observed inhibition of AChE in the same CNS region, its dependency upon the EtOH-induced modulation of other systems of neurotransmission cannot be excluded and must be further clarified in future experimental attempts aiming to simulate and to shed more light on the milder forms of the FASD-related pathophysiology.

Intraoperative Myomectomy during Caesarean Section

<p><strong>Objective</strong>. The aim of this article is to support intracaesarian myomectomy as an alternative method of treatment.</p><p><strong>Case Report</strong>. This article presents a case of myomectomy during a caesarean section at 38+1 weeks’ gestation, with a subserosal myoma on the left wall of the uterus.</p><p><strong>Conclusion</strong>. The postoperative period was free of complications, lending credit to the possibility that intracaesarean myomectomy can have a favourable outcome.</p>

Management of a Pregnant Patient With Central Poststroke Pain Syndrome Ultimately Having a Cesarean Delivery: A Case Report

Cerebrovascular events, along with the early presentation of central pain, during pregnancy, are uncommon. We report a case of a parturient with intense central poststroke pain after an ischemic cerebrovascular incident at 15 weeks of gestation, attributed to cerebral venous thrombosis. After a multidisciplinary team consultation, she was scheduled for cesarean delivery at 35 weeks of gestation, under combined spinal-epidural anesthesia. Due to severe left-sided neurological deficits and ipsilateral intense neuropathic pain, the neuraxial technique was successfully performed using the paramedian approach.

Colloid Preload versus Crystalloid Co-Load in the Setting of Norepinephrine Infusion during Cesarean Section: Time and Type of Administered Fluids Do Not Matter

Background and Goal of Study: Spinal anesthesia for cesarean section is frequently associated with a high incidence of hypotension, which may bring about untoward effects for both the mother and fetus. Recently, norepinephrine has emerged as a promising alternative in maintaining blood pressure in the obstetric setting. Fluid administration is another technique still widely used to prevent maternal hypotension. The optimal fluid strategy to prevent maternal hypotension has not been elucidated yet. It has been recently suggested that the main strategy in the prevention and management of hypotension should be the combination of vasoconstrictive medications and fluid administration. The aim of this randomized study was to compare the incidence of maternal hypotension in parturients receiving either colloid preload or crystalloid co-load in the setting of prophylactic norepinephrine infusion during elective cesarean section under combined spinal-epidural anesthesia. Materials and Methods: After ethics committee approval, 102 parturients with full-term singleton pregnancies were randomly allocated to either 6% hydroxyethyl starch 130/0.4 5 mL/kg before the onset of spinal anesthesia (colloid preload group) or Ringer's lactate solution 10 mL/kg concurrent with the subarachnoid injection (crystalloid co-load group). In both groups, norepinephrine 4 μg/min starting simultaneously with the administration of the subarachnoid solution was also administered. The primary outcome of the study was the incidence of maternal hypotension, defined as systolic arterial pressure (SAP) <80% of baseline. The incidence of severe hypotension (SAP < 80 mmHg), total dose of vasoconstrictive agents administered, as well as the acid-base status and Apgar score of the neonate and any incidence of maternal side effects were also recorded. Results: Data analysis was performed on 100 parturients: 51 in the colloid preload group and 49 in the crystalloid co-load group. No significant differences were demonstrated between the colloid preload group and the crystalloid co-load group in the incidence of hypotension (13.7% vs. 16.3%, p = 0.933) or the incidence of severe hypotension (0% vs. 4%, p = 0.238). The median (range) ephedrine dose was 0 (0-15) mg in the colloid preload group and 0 (0-10) mg in the crystalloid co-load group (p = 0.807). The incidence of bradycardia, reactive hypertension, requirement for modification of vasopressor infusion, time to the first occurrence of hypotension, and maternal hemodynamics did not differ between the two groups. There were no significant differences in other maternal side effects or neonatal outcomes between groups. Conclusions: The incidence of hypotension with a norepinephrine preventive infusion is low and comparable with both colloid preload and crystalloid co-load. Both fluid-loading techniques are appropriate in women undergoing cesarean delivery. It appears that the optimal regimen for prevention of maternal hypotension is a combined strategy of a prophylactic vasopressor such as norepinephrine and fluids.

Paracentesis of an Ovarian Cyst During Second-Trimester Pregnancy

A common issue is that modern obstetricians are required to manage ovarian cysts during pregnancy. Most lesions are benign and will spontaneously resolve, with a few exceptions. Management practices include conservative observation or surgery. Asymptomatic women with an ovarian cyst larger than 5 cm should undergo serial ultrasounds up to 16 weeks of pregnancy and, if the mass does not regress, further management with imaging or surgery is to be considered. This article presents a case of an ovarian cyst sized 21 cm in a second-trimester pregnancy and its management. Paracentesis was performed due to persisting symptoms. The procedure was performed with no complications for the mother and no adverse effects for the fetus. The patient was discharged in good health.

Cancer pain… who cares? International and national patterns of evidence-based global guidelines recommendations for physicians on the Web (2011 vs. 2018)

PURPOSE

Although pain is a common event during treatment of cancer, its assessment and management remains suboptimal in everyday clinical practice at global level.

METHODS

Considering both the important role of internet in daily life and that clinical guidelines are important for translating evidence in clinical practice, we performed a prospective study to scrutinize the magnitude of updated evidence-based cancer-pain guideline recommendation for physicians on the web. Changes over-time at a global level were scrutinized at two time points: 2011 for baseline and 2018 at first follow-up. Both anesthesiology and oncology societies were analyzed.

RESULTS

In 2011 we scrutinized 181,00 WebPages and 370 eligible societies were identified; 364 of these were eligible for analyses both in 2011 and 2018. The magnitude of cancer pain updated and evidence-based guideline recommendations on the web for health care providers was extremely low at global level and at any time point considered: 1.1% (4/364) in 2011 and 4.7% (17/364) in 2018. Continental and intercontinental patterns, National's highest developmental index, oncology tradition and economic-geographic areas were not found to influence cancer pain web-guideline provision. In 2018, pain & supportive care societies provided the highest rate of updated evidence-based cancer-pain guidelines for clinicians. Only 3/25 medical oncology societies and 1/34 radiation oncology societies, provided own or e-link (to other societies') evidence-based guidelines in their websites.

CONCLUSIONS

Major medical oncology and radiation oncology societies - at global level - fail to produce updated cancer pain recommendations for their physicians, with most of these providing no or inconsistent or outdated guidelines.

Peripartum Management of Gitelman Syndrome for Vaginal Delivery: A Case Report and Review of Literature

We describe the anesthetic management of a spontaneous vaginal delivery at 38 weeks' gestation in a 36-year-old patient with Gitelman syndrome (GS). GS is a rare autosomal recessive renal tubulopathy characterized by hypomagnesemia, hypocalciuria, and secondary aldosteronism, which results in hypokalemia and metabolic alkalosis. To minimize any increase in catecholamine levels and consequent risk of ventricular arrhythmias, a labor epidural analgesia was administered using ropivacaine and fentanyl, along with intravenous magnesium and potassium supplementation. Ropivacaine was substituted for routine bupivacaine to decrease the risk of drug-induced cardiotoxicity. In the event of a cesarean section, the anesthetic plan was to continue with top-up epidural anesthesia and in case of failure, to convert to general anesthesia using propofol and rocuronium for induction. Delivery outcome was successful and uneventful.

Facing internet fake-medicine and web para-pharmacy in the total absence of official recommendations from medical societies

PURPOSE

Internet fake information, parapharmacy and counterfeit drugs are a market of hundreds of billion dollars. Misleading internet data decrease patients' compliance to medical care, promote use of questionable and detrimental practices, and jeopardize patient outcome. This is particularly harmful among cancer patients, especially when pain and nutritional aspects are considered. Provision of Web recommendations for the general audience (patients, relatives, general population) from official medical-providers might be useful to outweigh the detrimental internet information produced by non-medical providers.

METHODS

370 oncology and anesthesiology related societies were analyzed. Our objective was to evaluate the magnitude of web-recommendation for cancer cachexia and cancer pain for the general audience provided by official medical organizations' web sites at global level.

RESULTS

Magnitude of web-recommendations at global level was surprisingly scant both for coverage and consistency. Seven official medical societies provided updated web-recommendation for cancer cachexia to their patients/family members, and 15 for cancer pain. Scantiness was unrelated by continent, developmental index, oncology tradition, economic-geographic area and society type scrutinized.

CONCLUSIONS

Patients need expert advice when exposed to fake internet information largely dominated by paramedical market profits. In this era of "new media" the patients' net-education represents a new major educational challenge for medical societies.

Peripartum Ηysterectomy: A Four-Year Obstetric and Anesthetic Experience in a Tertiary Referral Hospital in Greece

Background

Although peripartum hysterectomy (PH) is a life-saving procedure in cases of abnormal placentation and postpartum hemorrhage, it can be associated with major obstetric and anesthetic complications. This retrospective study aimed to evaluate the incidence, etiology, perioperative anesthetic and obstetric management, complications, and fetal outcomes in women undergoing PH in a single tertiary referral hospital in Greece.

Methodology

This was a retrospective analysis of medical records of women who underwent emergency or elective PH in our hospital between January 2015 and December 2018.

Results

During the study period, 69 women who underwent a PH were identified. The incidence rate of elective and emergency PH was 4 and 1.2 per 1,000 deliveries, respectively. The main indication for PH was abnormal placentation (81.2%), followed by uterine atony (13%). Conversion to general anesthesia (GA) was performed in 21 (30.4%) cases.

Conclusions

This study showed a high prevalence of PH in our hospital compared to high-income countries. A neuraxial-only technique may be a safe alternative in individual cases of abnormal placentation. Conversion to GA can be reserved for complex surgical cases when massive hemorrhage is anticipated and, if possible, after the neonate has been delivered.

Reply to Akça, B.; Bilotta, F. Time and Type of Administered Fluids during Cesarean Section Might Not Matter for Hemodynamic Outcomes, but There Are Significant Patient Safety Concerns Regarding Colloid Use in Parturients. Comment on "Theodoraki et al. Colloid Preload versus Crystalloid Co-Load in the Setting of Norepinephrine Infusion during Cesarean Section: Time and Type of Administered Fluids Do Not Matter. J. Clin. Med. 2023, 12, 1333"

We would like to take this opportunity to thank Drs Akça and Bilotta for their interest and their insightful comments [...].

Researching the Phenomenon of Poor Ovarian Responders and Management Strategies in IVF: A Narrative Review

This narrative review aims to summarize all the latest studies published between 2015-2021 concerning the management protocols adopted for poor ovarian response (POR) cases. Patients defined as "poor responders" show minimal response to controlled ovarian hyperstimulation, although there is no standard definition for POR. Although infertility specialists are endeavoring to improve cycle outcomes in poor responders by adopting multiple management strategies, still the estimated risk of cycle cancellation is about 20%. All the studies performed during this study period were evaluated and their results were recorded. The latest published protocols to improve oocyte retrieval in poor responders include: anti-Mϋllerian hormone, clomiphene citrate, co-enzyme Q10, corifollitropin, dehydroepiandrosterone, double stimulation, Follicle Stimulation Hormone, Growth Hormone, Gonadotropin-releasing hormone agonists, letrozole, human chorionic gonadotropin, Luteinizing Hormone, progesterone and testosterone. CONCLUSION: Although many strategies have been suggested to manage POR, none has been proven superior to the others. Further large-scale randomized studies are needed to validate experimental techniques leading towards successful individualized treatment regimens.