Anatomical and physiological bases of labor onset

The induction of labor involves a series of complex mechanisms, the control of which is only partially explained in humans. It is accepted today that the maturing of the uterine cervix is independent of the onset of uterine contractions. These two phenomena are regulated by a complex system where prostaglandins play a key role.     

Precocious cervical ripening and preterm labor

A group of 8303 women was studied to determine the timing of cervical ripening. It was confirmed that these signs of cervical change can be observed several weeks before preterm births. The precocious signs of external ripening can be recognized during a vaginal examination and may be useful in predicting preterm labor.     

Secular trend in the rate of small-for-gestational-age infants: Haguenau Study 1971-1985

Between 1971 and 1985, at the Haguenau Maternity Hospital, a 20% decrease was observed in the rate of small-for-gestational-age infants (birthweight less than 10th centile using figures from all the study births) among 20,101 births between 28 and 42 weeks. This decrease could not be explained by simultaneous changes in socio-demographic and anthropometric characteristics of the pregnant women, nor a recruitment bias. The earliness of prenatal care at the Maternity Hospital may have played a role in the downward trend. Further research is needed to confirm the influence of prenatal care on the rate of small-for-gestational-age babies.     

Severe neonatal thrombopenia. Analysis of the etiologic data on 64 cases

In many cases of neonatal thrombocytopenia, etiology does not fit with usually known causes. Analyzing, in an intensive care unit, 64 cases of severe neonatal thrombocytopenia (platelets less than 50 x 10(9)/l before hour 72), the authors attempted to determine other possible causes of the disorder. In this study, classical etiologies were present in 33% of cases. In the other 67%, hypotrophy and/or hypoxia were significantly more frequent (p less than 0.01) than in the first group. With reference to clinical and experimental data in the literature, the possible role of acute or chronic hypoxia as a cause of thrombocytopenia is discussed.     

Lidocaine induces a reversible decrease in alveolar epithelial fluid clearance in rats

BACKGROUND: Lidocaine is widely used in patients with acute cardiac disorders and has also been recently implicated as a possible cause of pulmonary edema after liposuction. The objective of this study was to assess the effect of lidocaine on alveolar fluid clearance, the primary mechanism responsible for the resolution of alveolar edema. METHODS: Alveolar fluid clearance was measured in 29 ventilated rats using our well-validated method over 1 h using a 5% albumin solution instilled into the distal air spaces of the lung. Lidocaine was added to the instilled albumin solution (10(-5) M) or administered intravenously at a dose estimated to achieve a clinically relevant plasma concentration of 10(-5) M. Standard agonists and antagonists were used to determine the effect of lidocaine on alveolar fluid clearance. To determine whether lidocaine acted predominantly on the apical or basal surface, we also used QX314, lidocaine n-ethyl bromide quaternary salt, an analog of lidocaine, which is unable to cross the alveolar epithelium. The effect of lidocaine on the apical epithelial sodium channel transfected in Xenopus oocytes was also studied. RESULTS: Alveolar or intravenous lidocaine decreased alveolar fluid clearance by 50%, an effect that was reversible with the beta2 agonist, terbutaline. Lidocaine acted predominantly on the basal surface of the epithelium because n-ethyl bromide quaternary salt decreased alveolar fluid clearance only when it was given intravenously and because lidocaine did not inhibit the apical epithelial sodium channel when expressed in oocytes. CONCLUSIONS: Lidocaine decreased alveolar fluid clearance by 50%, an effect that may have major clinical implications in the care of patients with cardiac disease or during the perioperative period in some patients. Importantly, the effect of lidocaine was completely reversible with beta2-adrenergic therapy.     

The influence of rotator cuff disease on the results of shoulder arthroplasty for primary osteoarthritis: results of a multicenter study

BACKGROUND: Rotator cuff disease is uncommon in primary glenohumeral osteoarthritis. Consequently, the prognostic implications of rotator cuff disease in patients undergoing prosthetic replacement for the treatment of primary glenohumeral osteoarthritis are uncertain. The purpose of this study was to report the effects of the condition of the supraspinatus tendon and the rotator cuff musculature on the results of shoulder arthroplasty in the treatment of primary osteoarthritis. METHODS: Five hundred and fifty-five shoulders in 514 patients who had an arthroplasty for the treatment of primary glenohumeral osteoarthritis as part of a multicenter study were evaluated. Forty-one shoulders had a partial-thickness tear of the supraspinatus, and forty-two had a full-thickness tear. Ninety shoulders had moderate (stage-2) fatty degeneration of the infraspinatus, and nineteen had severe (stage-3 or 4) degeneration. Eighty-four shoulders had moderate fatty degeneration of the subscapularis, and fifteen had severe degeneration. The influence of the condition of the supraspinatus tendon and the infraspinatus and subscapularis musculature on the postoperative outcome was evaluated with respect to the scores according to the system of Constant and Murley, active mobility, subjective satisfaction, radiographic result, and rate of complications. RESULTS: The shoulders were evaluated at a mean of 43.1 months postoperatively. With the numbers available, supraspinatus tears were not found to influence the postoperative outcome with respect to the total Constant score, active mobility, subjective satisfaction, radiographic result, or rate of complications. Additionally, the treatment of these tears did not markedly influence the outcome parameters. Conversely, both shoulders with moderate fatty degeneration and those with severe degeneration of the infraspinatus were associated with poorer results than those with no degeneration with respect to the total Constant score (p < 0.0005), active external rotation (p < 0.0005), active forward flexion (p = 0.001), and subjective satisfaction (p = 0.031). Similar although less dramatic results were seen with fatty degeneration of the subscapularis. CONCLUSIONS: This study demonstrates that minimally retracted or nonretracted rotator cuff tears that are limited to the supraspinatus tendon do not appreciably affect most shoulder-specific outcome parameters in shoulder arthroplasty performed for the treatment of primary osteoarthritis. Conversely, fatty degeneration of the infraspinatus and, less importantly, subscapularis musculature adversely affects many of these parameters.     

General competencies and accreditation in graduate medical education

Many have recommended changing the professional development of physicians. Concluding that further educational process specification was inadequate, the Accreditation Council for Graduate Medical Education (ACGME) decided to specify six general competencies of graduate medical education (GME): patient care; medical knowledge; practice-based learning and improvement; professionalism; interpersonal skills and communication; and systems-based practice. Coupling them with a developmental view of professional knowledge and skill acquisition, the ACGME invited further specification and development of desired learning from the extended medical specialty community, including the specialty boards. This collaborative process offers a model of the role accrediting agencies can play in fostering workforce developmental change.     

Prevalence and consequences of sleep disorders in a shift worker population

INTRODUCTION: Irregular work schedules often results in a disruption of the normal circadian rhythm that can causes sleepiness when wakefulness is required and insomnia during the main sleep episode. METHOD: Two physicians using the Sleep-EVAL system interviewed 817 staff members of a psychiatric hospital. The interviews were done during the working hours. In addition to a series of questions to evaluate sleep and mental disorders, the evaluation included a standard questionnaire assessing work conditions, work schedule and their consequences. Three work schedules were assessed: (1) fixed daytime schedule (n=442), (2) rotating daytime shifts (n=323) and (3) shift or nighttime work (n=52). RESULTS: Subjects working on rotating daytime shifts were younger than the two other groups and had a higher proportion of women. Participants working on rotating daytime shifts reported more frequently than the fixed daytime schedule workers to have difficulty initiating sleep (20.1% vs. 12.0%). The sleep duration of shift or nighttime workers was shorter than that of the two other groups. Furthermore, subjects working rotating daytime schedule reported to have shorter sleep duration of about 20 min when they are assigned to the morning shift. Work-related accidents were two times more frequent among the rotating daytime workers (19.5%) compared with the fixed daytime schedule workers (8.8%) and the group of nighttime or shift workers (9.6%). Sick leaves in the previous 12 months were also more frequently reported in the rotating daytime schedule group (62.8%) as compared with the daytime group (38.5%, P<.001); 51.9% of nighttime or shift workers took sick leave. CONCLUSIONS: Working on a rotating daytime shifts causes significant sleep disturbances. As consequences, these workers are more likely to feel sleepy at work and are more likely to have work-related accidents and sick leaves.     

Prothrombin index decrease: a useful and reliable marker of extensive fibrosis?

Non-invasive serum markers of extensive liver fibrosis are required in clinical practice for several reasons: (1) although histological analysis is considered to be the gold standard for the diagnosis of extensive fibrosis and cirrhosis, the rate of false-negative results is approximately 15-20%; (2) liver biopsy is an invasive method with a 1/10 000 mortality rate, even though occurrence of death is exceptional in patients with diffuse liver disease; (3) patients with chronic viral hepatitis have to undergo multiple liver biopsies during follow-up to assess the progression of tissue injury. In this leading article, we briefly overview the recent progress in non-invasive serum markers for the prediction of the extent of liver fibrosis. Among those serum markers, we focused on prothrombin index, which seems to be a reliable and non-expansive marker for the diagnosis of extensive fibrosis.