Does dystocia during labor pose a risk factor for another non-progressive labor during the subsequent delivery?

Objective: To establish whether failure to progress during labor poses a risk factor for another non-progressive labor (NPL) during the subsequent delivery.

Methods: A retrospective cohort study including singleton pregnancies that failed to progress during the previous labor and resulted in a cesarean section (CS) was conducted. Parturients were classified into three groups for both previous and subsequent labors: CS due to NPL stage I, stage II and an elective CS as a comparison group.

Results: Of 202?462 deliveries, 10?654 women met the inclusion criteria: 3068 women were operated due to NPL stage I and 1218 due to NPL stage II. The comparison group included 6368 women. Using a multivariable logistic regression models, NPL stage I during the previous delivery was found as an independent risk factor for another NPL stage I in the subsequent labor (adjusted odds ratio [OR]?=?2.9; 95% confidence interval [CI]?=?2.4–3.7; p?p?=?0.033; adjusted OR?=?5.3; 95% CI?=?3.7–7.5; p?Conclusion: A previous CS due to a NPL is an independent risk factor for another NPL in the subsequent pregnancy and for recurrent cesarean delivery.     

Neutropenia as a Complication of Tumefactive Demyelinating Disease: A Case Report

Tumefactive demyelination is an aggressive, localized, generally solitary area of demyelination that often mimics a neoplasm. We present a case of a 13-year-old female patient who presented with sudden-onset progressive hemiplegia and hemianopsia. Magnetic resonance imaging of the brain showed tumefactive demyelination with partial rim of enhancement. During inpatient rehabilitation, she developed myalgias, rash, and abdominal and mouth pain with evidence for severe neutropenia. The neutropenia was determined to be a secondary complication of the tumefactive disease process. This scenario may be concerning in an inpatient rehabilitation setting, as patients share common areas, increasing the risk of acquired infection while neutropenic.

Maldistribution of pulmonary blood flow in patients after the Fontan operation is associated with worse exercise capacity

Background

Maldistribution of pulmonary artery blood flow (MPBF) is a potential complication in patients who have undergone single ventricle palliation culminating in the Fontan procedure. Cardiovascular magnetic resonance (CMR) is the best modality that can evaluate MPBF in this population. The purpose of this study is to identify the prevalence and associations of MPBF and to determine the impact of MPBF on exercise capacity after the Fontan operation.

Methods

This retrospective single-center study included all patients after Fontan operation who had maximal cardiopulmonary exercise test (CPET) and CMR with flow measurements of the branch pulmonary arteries. MPBF was defined as >?20% difference in branch pulmonary artery flow. Exercise capacity was measured as percent of predicted oxygen consumption at peak exercise (% predicted VO₂). Linear and logistic regression models were used to determine univariate and multivariable predictors of exercise capacity and correlates of MPBF, respectively.

Results

A total of 147 patients who had CMR between 1999 and 2017 were included (median age at CMR 21.8?years [interquartile range (IQR) 16.5–30.6]) and the median time between CMR and CPET was 2.8?months [IQR 0–13.8]. Fifty-three patients (36%) had MPBF (95% CI 29–45%). The mean % predicted VO₂ was 63?±?16%. Patients with MPBF had lower mean % predicted VO₂ compared to patients without MPBF (60?±?14% versus 65?±?16%, p?=?0.04). On multivariable analysis, a lower % predicted VO₂ was independently associated with longer time since Fontan, higher ventricular mass-to-volume ratio, and MPBF. On multivariable analysis, only compression of the branch pulmonary arteries by the ascending aorta or aortic root was associated with MPBF (OR 6.5, 95% CI 5.6–7.4, p?<?0.001).

Conclusion

In patients after the Fontan operation, MPBF is common and is independently associated with lower exercise capacity. MPBF was most likely to be caused by pulmonary artery compression by the aortic root or the ascending aorta. This study identifies MPBF as an important risk factor and as a potential target for therapeutic interventions in this fragile patient population.

     

Cadazolid: A new hope in the treatment of Clostridium difficile infection

Clostridium difficile infection (CDI) is a potential life-threatening consequence of antibiotic therapy. Although the risk increases with duration of treatment, it can also occur after a short treatment course. In addition to broad-spectrum antibiotics, anti-neoplastic agents, proton pump inhibitors, H² blockers, and several other drugs have been reported to induce intestinal dysbiosis, which is central to the pathogenesis of CDI. There is an increase in incidence and mortality attributed to CDI globally. Moreover, the epidemiology of C. difficile-associated diseases has changed significantly with an increasing occurrence of community-acquired CDI. Metronidazole and oral vancomycin are the first-line antibiotics used to treat CDI. However, metronidazole has limited effectiveness in severe cases and vancomycin use is associated with increasing risk of vancomycin resistance among Enterococcus spp. Cadazolid, a novel oxazolidinone antibiotic, has recently shown potent antimicrobial activity against C. difficile and has a lower propensity to induce resistance. The implications of its use in treating CDI have been reviewed based on current evidence.     

Problem-based learning in occupational therapy curriculum – implications and challenges

Purpose: Problem-based learning (PBL) is an educational method that fosters self-directed study in small groups. The purpose of this study was to describe the Tel Aviv University’s occupational therapy (OT) program and the challenges implementing such program. In addition, the study compared the PBL grades obtained by students who are native Hebrew speakers with those students who are native Arabic speakers; and, assessed the correlation between the grades in the PBL course and the grades in the clinical fieldwork studies.

Method: 166-second year OT undergraduate students participated. All completed three PBL courses and seven weeks of clinical fieldwork studies. Data collection included students’ grades in PBL course (based on PBL evaluation forms) and in clinical fieldwork studies (based on preceptor’s evaluation and a written assignment).

Results: Pearson correlations revealed significant correlations between PBL grades and clinical fieldwork studies grades. T-test analysis between students who are native Hebrew speakers and those who are native Arabic speakers revealed significant differences in PBL grades.

Conclusions: Findings imply partial congruence between students’ grades in the PBL course and their achievements in the fieldwork studies. Findings might suggest that adjustments should be made in order to assist students from minorities (challenged by language requirements) in gaining higher grades in the PBL program.

• Implications for Rehabilitation

• Problem-Based Learning (PBL) is an educational method, which fosters independent, self-directed study in small groups.

• PBL studies have the potential to prepare students for their clinical experience during studies.

• The PBL program should be adjusted for students from minorities (challenged by language requirements and different cultural backgrounds) in order to assist them in gaining more benefits from the program.

     

TNFerade,an innovative cancer immunotherapeutic

Tumor necrosis factor-α (TNF-α) is a chemokine with effective tumoricidal properties. However, severe systemic toxicity limits its use of as anticancer agent. TNFerade is a novel replication deficient adenovector based gene therapy, which enables the radiation inducible translation of human TNF-α gene specifically in cancer cells. When injected intratumorally, it has least systemic distribution. Consequently, it lacks TNF-α related systemic toxicity. Evidence suggests that it has superior tumoricidal activity and tolerability with minimum adverse effects. It has demonstrated its beneficial role in the treatment of a variety of cancers in terms of improving the disease free and overall survival, delaying tumor progression, and inducing tumor regression when used with concurrent radiotherapy or chemotherapy.KEY WORDS: Cancer immunotherapy, gene therapy, TNFerade, tumor necrosis factor-α     

Short-term effect of morphine on the thyroid gland in male rats

Experiments were designed to demonstrate that morphine may exert a direct short-term effect on the hormone release of the thyroid gland. Groups of male rats were injected with single doses of 1, 5 and 10 mg/kg morphine, or with 2 mg/kg naloxone and in addition with morphine 30 min after naloxone and/or with naloxone 30 min after morphine pre-treatment. The rats were killed by decapitation 15, 30 and 60 min after the injection and serum was collected and stored for subsequent TSH, T4 and T3 radioassays. All doses of morphine resulted in an increase of serum T4 and T3 concentrations 15 and 30 min after the injection, with a tendency to return to control levels by the 60 min samples. Serum TSH concentrations were to suppressed by administration of 5 and 10 mg/kg but not by 1 mg/kg morphine. Naloxone treatment did not increase the T4 and T3 concentrations; however, serum TSH was elevated in the 15 min sample. Naloxone pre-treatment inhibited the morphine induced release of T4 and T3 into the serum, but naloxone administration after morphine pre-treatment failed to prevent the increase of T4 and T3 secretion. These data suggest that morphine may exert a short-term stimulatory effect on the thyroid gland with a concomitant inhibitory action on the hypothalamo-pituitary TSH system.     

Efficient maternal to neonatal transfer of antibodies against SARS-CoV-2 and BNT162b2 mRNA COVID-19 vaccine

BACKGROUNDThe significant risks posed to mothers and fetuses by COVID-19 in pregnancy have sparked a worldwide debate surrounding the pros and cons of antenatal SARS-CoV-2 inoculation, as we lack sufficient evidence regarding vaccine effectiveness in pregnant women and their offspring. We aimed to provide substantial evidence for the effect of the BNT162b2 mRNA vaccine versus native infection on maternal humoral, as well as transplacentally acquired fetal immune response, potentially providing newborn protection.METHODSA multicenter study where parturients presenting for delivery were recruited at 8 medical centers across Israel and assigned to 3 study groups: vaccinated (n = 86); PCR-confirmed SARS-CoV-2 infected during pregnancy (n = 65), and unvaccinated noninfected controls (n = 62). Maternal and fetal blood samples were collected from parturients prior to delivery and from the umbilical cord following delivery, respectively. Sera IgG and IgM titers were measured using the Milliplex MAP SARS-CoV-2 Antigen Panel (for S1, S2, RBD, and N).RESULTSThe BNT162b2 mRNA vaccine elicits strong maternal humoral IgG response (anti-S and RBD) that crosses the placenta barrier and approaches maternal titers in the fetus within 15 days following the first dose. Maternal to neonatal anti-COVID-19 antibodies ratio did not differ when comparing sensitization (vaccine vs. infection). IgG transfer ratio at birth was significantly lower for third-trimester as compared with second trimester infection. Lastly, fetal IgM response was detected in 5 neonates, all in the infected group.CONCLUSIONAntenatal BNT162b2 mRNA vaccination induces a robust maternal humoral response that effectively transfers to the fetus, supporting the role of vaccination during pregnancy.FUNDINGIsrael Science Foundation and the Weizmann Institute Fondazione Henry Krenter.