Emergency Cesarean delivery for umbilical cord prolapse: the head-down, knee-chest prone position for spinal anesthesia

OBJECTIVE: Umbilical cord prolapse in a parturient is an emergency, where the need for immediate fetal delivery may conflict with maternal anesthetic risk factors. We describe the anesthetic management of a parturient who was rushed to the operating room, in the knee-chest prone position, because of cord prolapse with variable decelerations of fetal heart rate. CLINICAL FEATURES: A 28-yr-old multiparous patient presented at 37 weeks gestation. Her co-morbidities included morbid obesity and asthma. She had a Mallampati class IV airway. She required emergency Cesarean delivery, in view of umbilical cord prolapse, with evidence of fetal compromise. In light of the airway concerns, the urgency to proceed with delivery, and the presence of a palpable umbilical cord pulse in this position, we performed a spinal anesthetic in the knee-chest prone position, and immediately thereafter turned the patient supine, with lateral uterine displacement. Fetal heart rate was monitored throughout the procedure. The spinal anesthetic required less than five minutes to perform, from the time of skin preparation, until readiness for surgery. The subsequent surgical and anesthetic course was unremarkable. CONCLUSIONS: Performing spinal anesthesia in the knee-chest prone position served as an innovative solution for emergency Cesarean delivery in this case. Both the head-down lateral, and the head-down knee-chest prone positions, are compatible with spinal anesthesia, and the maternal position that achieves relief of cord compression, determined by the presence of a palpable umbilical cord pulse, may be the most important factor to determine the optimal approach to spinal anesthesia.     

Neuropsychological profile of DYT1 dystonia.

The common belief that primary dystonia is a purely motor disorder has recently been challenged. We examined separately the cognitive profiles of symptomatic (SYM) and nonsymptomatic (N-SYM) groups of carriers of DYT1 mutation using a comprehensive neuropsychological test battery. Self-report inventories of anxiety, depression, and pain levels were also administered, as well as manual motor dexterity assessment. Each group was matched with healthy controls by age, sex, mother tongue, and education. No significant differences between the SYM group to its control group were found on cognitive tests evaluating verbal and nonverbal abstract abilities, attention, information processing speed, and spatial organization. However, the SYM group showed increased verbal memory retroactive interference. Interestingly, the patients also showed higher semantic fluency performance. No significant differences between the N-SYM group to controls were found. It was concluded that symptomatic DYT1 mutation carriers do not suffer the distinctive cognitive decline that is seen in other primary degenerative extrapyramidal disorders.     

Osteonecrosis of the jaws in patients with bone metastasis receiving intravenous bisphosphonates. A rising concern

Osteonecrosis of the jaws (ONJ) is a recognized complication of bisphosphonates (BP) therapy in cancer patients with bone metastasis. We report 2 additional cases of ONJ in women with breast cancer after long-term exposure to BP, discussing some considerations about the presentation and management of this rare and new complication.     

The QuantiFERON<Superscript>?</Superscript>-TB-GOLD Assay for Tuberculosis Screening in Healthcare Workers: A Cost-Comparison Analysis

The aim of this study was to assess the costs of screening healthcare workers (HCWs) for tuberculosis (TB) using the novel interferon-γ release assay QuantiFERON^®-TB Gold In-tube (QFT) versus the tuberculin skin test (TST). We used a prospective observational study with a cost-comparison analysis. The study was conducted at a regional center for ambulatory TB treatment. The study included 100 Israeli HCWs who were referred for routine TB screening. The participants were tested with both TST and QFT. For the TST, induration of 10 mm or more was considered a positive test. For the QFT, a threshold of 0.35 IU/ml interferon-γ above background levels was a positive test. We developed a computerized model of the present TST-only screening method versus the QFT either alone (instead of the TST) or as a confirmatory test for a positive TST. Of the 100 subjects, 34 had a positive TST result and 17 had a positive QFT result. There was poor agreement between the TST and the QFT (κ = 0.19). Assuming adherence to treatment of 50%, costs were minimized by using the QFT to confirm a positive TST (€4155). The QFT-only model was cheaper than the TST-only model (€7280 vs. €8217, respectively). The QFT-only method required the fewest clinic visits (121) compared to the TST (344). Adherence to treatment in the QFT-positive group was 47% compared with 12% for the TST-positive group. Screening HCWs with the QFT test compared to the TST resulted in fewer possible cases being identified, lower costs, and increased adherence to treatment. Costs were minimized by using the QFT to confirm a positive TST. A QFT-based screening program for HCWs is feasible and should be evaluated systematically.     

Differential impact of the CD45 juxtamembrane wedge on central and peripheral T cell receptor responses

The cooperative activity of protein tyrosine kinases and phosphatases plays a central role in regulation of T cell receptor (TCR) signal strength. Perturbing this balance, and thus the threshold for TCR signals, has profound impacts on T cell development and function. We previously generated mice containing a point mutation in the juxtamembrane wedge of the receptor-like protein tyrosine phosphatase CD45. Demonstrating the critical negative regulatory function of the wedge, the CD45 E613R (WEDGE) mutation led to a lymphoproliferative disorder (LPD) and a lupus-like autoimmune syndrome. Using genetic, cellular, and biochemical approaches, we now demonstrate that the CD45 wedge influences T cell development and function. Consistent with increased TCR signal strength, WEDGE mice have augmented positive selection and enhanced sensitivity to the CD4-mediated disease experimental autoimmune encephalitis (EAE). These correspond with hyperresponsive calcium and pERK responses to TCR stimulation in thymocytes, but surprisingly, not in peripheral T cells, where these responses are actually depressed. Together, the data support a role for the CD45 wedge in regulation of T cell responses in vivo and suggest that its effects depend on cellular context.     

Regulation of porphyrin synthesis and photodynamic therapy in heavy metal intoxication.

Protoporphyrin IX (PpIX) synthesis by malignant cells is successfully exploited for photodynamic therapy (PDT) following administration of 5-aminolevulinic acid (ALA) and light irradiation. The influence of two environmental heavy metal poisons, lead and gallium, on PpIX-synthesis and ALA-PDT was studied in two neu-ronal cell lines, SH-SY5Y neuroblastoma and PC12 pheochromocytoma. The heavy metal intoxication affected two of the heme-synthesis enzymes, ALA-dehydratase (ALAD) and porphobilinogen deaminase (PBGD). The present results show that lead poisoning significantly decreased the PBGD cellular level and inhibited its enzymatic activity, whereas the effects of gallium were less prominent. Although, the protein levels were reduced, the mRNA levels of PBGD remained unchanged during metal intoxication. These findings show additional inhibitory activity of lead on top of its classical effect on ALAD. Proteasome activity was enhanced during lead treatment, as measured by the AMC fluorigenic proteasome assay. The reduction in PBGD levels was not a consequence of PBGD mRNA reduced synthesis, which remained unchanged as shown by RT-PCR analysis. As a result of the lead poisoning, marked alterations in the cell cycle were observed, including a decreased G1 phase and an increased number of S phase cells. The efficacy of ALA-PDT was reduced in correlation with decreased activities of the enzymes during lead intoxication. We may conclude that lead poisoning adversely affects the outcome of ALA photodynamic therapy of cancer.     

The chimpanzee brain shows human-like perisylvian asymmetries in white matter

Modern neuroimaging technologies allow scientists to uncover interspecies differences and similarities in hemispheric asymmetries that may shed light on the origin of brain asymmetry and its functional correlates. We analyzed asymmetries in ratios of white to grey matter in the lateral aspect of the lobes of the brains of chimpanzees. We found marked leftward asymmetries for all lobar regions. This asymmetry was particularly pronounced in the frontal region and was found to be related to handedness for communicative manual gestures as well as for tool use. These results point to a continuity in asymmetry patterns between the human and chimpanzee brain, and support the notion that the anatomical substrates for lateralization of communicative functions and complex manipulative activities may have been present in the common hominid ancestor.