Quantification of Posterior Risk Related to Intrapartum FIGO 2015 Criteria for Cardiotocography in the Second Stage of Labor.

INTRODUCTION: Intrapartum cardiotocography (CTG) was used for several decades to detect a stressed fetus so that delivery can be expedited to prevent birth asphyxia. The main aim of the study was to calculate the risk of neonatal acidemia (pH ≤ 7.10) according to duration of the 2nd stage of labor and occurrence of the International Federation of Gynecology and Obstetrics (FIGO) 2015 CTG classification parameters. MATERIALS AND METHODS: This was a retrospective case-control study on 552 pregnancies receiving continuous CTG monitoring in labor and immediate hemogasanalysis at birth. Cases with umbilical artery (UA) pH ≤ 7.10 and controls with UA pH ≥ 7.10 were matched for parity and gestational age at delivery, with ratio 1:5. Logistic regression analysis, adjusted for the expected risk in the general population, was used to calculate the baseline risk of UA pH ≤ 7.10 in the absence of any CTG pathological feature and those associated with pathological CTG patterns occurring in the 2nd stage according to FIGO 2015. RESULTS: Seventy-three cases and 387 controls reached 2nd stage and were included in the analysis. For those reaching 2nd stage, the mean adjusted risk of acidemia associated with nonpathological CTG was 1.6%. Stratification of risk according to duration of the 2nd stage yielded risks of neonatal acidemia of 1.23, 2.08, 5.81, and 15.22% at 30, 60, 120, and 180 min, respectively. Bradycardia >10 min was associated with risk of neonatal acidemia of 9.9 and 15.8% for 2nd-stage durations of 30 and 60 min, respectively. Risks associated with 1 prolonged deceleration >5 min were 6.80, 11.08, 27.0, and 51.0% at 30, 60, 120, and 180 min, respectively. Repetitive late or prolonged decelerations >30 min were associated with risk of neonatal acidemia of 2.43, 4.14, 11.17, and 26.45% at 30, 60, 120, and 180 min, respectively. CONCLUSION: The risk of neonatal acidemia is directly proportional to duration of the 2nd stage, irrespective of the presence of CTG abnormalities, increasing 12-fold (1.2-15.3%) from 30 to 180 min. Occurrence of FIGO 2015 pathological CTG patterns showed a decreasing impact from bradycardia >10 min to decelerations >5 min, recurrent later or prolonged decelerations >30 min, and nonpathological CTG.

Psychological effect of COVID-19 on medical health-care workers.

OBJECTIVE: To review the psychological Effect of COVID-19 on medical health-care workers. CONCLUSIONS: Social support is a cornerstone in facing COVID-19 and uplifting the spirits of both patients and their doctors along with the whole medical staff dealing with the pandemic.

Percutaneous Device Closure of Paravalvular Leak: Combined Experience From the United Kingdom and Ireland.

BACKGROUND: Paravalvular leak (PVL) occurs in 5% to 17% of patients following surgical valve replacement. Percutaneous device closure represents an alternative to repeat surgery. METHODS: All UK and Ireland centers undertaking percutaneous PVL closure submitted data to the UK PVL Registry. Data were analyzed for association with death and major adverse cardiovascular events (MACE) at follow-up. RESULTS: Three hundred eight PVL closure procedures were attempted in 259 patients in 20 centers (2004-2015). Patient age was 67±13 years; 28% were female. The main indications for closure were heart failure (80%) and hemolysis (16%). Devices were successfully implanted in 91% of patients, via radial (7%), femoral arterial (52%), femoral venous (33%), and apical (7%) approaches. Nineteen percent of patients required repeat procedures. The target valve was mitral (44%), aortic (48%), both (2%), pulmonic (0.4%), or transcatheter aortic valve replacement (5%). Preprocedural leak was severe (61%), moderate (34%), or mild (5.7%) and was multiple in 37%. PVL improved postprocedure (P<0.001) and was none (33.3%), mild (41.4%), moderate (18.6%), or severe (6.7%) at last follow-up. Mean New York Heart Association class improved from 2.7±0.8 preprocedure to 1.6±0.8 (P<0.001) after a median follow-up of 110 (7-452) days. Hospital mortality was 2.9% (elective), 6.8% (in-hospital urgent), and 50% (emergency) (P<0.001). MACE during follow-up included death (16%), valve surgery (6%), late device embolization (0.4%), and new hemolysis requiring transfusion (1.6%). Mitral PVL was associated with higher MACE (hazard ratio [HR], 1.83; P=0.011). Factors independently associated with death were the degree of persisting leak (HR, 2.87; P=0.037), New York Heart Association class (HR, 2.00; P=0.015) at follow-up and baseline creatinine (HR, 8.19; P=0.001). The only factor independently associated with MACE was the degree of persisting leak at follow-up (HR, 3.01; P=0.002). CONCLUSION: Percutaneous closure of PVL is an effective procedure that improves PVL severity and symptoms. Severity of persisting leak at follow-up is independently associated with both MACE and death. Percutaneous closure should be considered as an alternative to repeat surgery.

Leakage of ruptured silicone breast implants through abdominal laparoscopic port sites: A rare complication following transabdominoplasty breast augmentation.

BACKGROUND: Abdominoplasty and breast augmentation are two of the most commonly performed aesthetic procedures in the UK. When performed as a combined procedure, separate inframammary and abdominoplasty incisions are most frequently used. Transabdominoplasty breast augmentation, performed via a single abdominoplasty incision is also described. CASE: A 69-year-old female, having undergone a transabdominoplasty breast augmentation 20 years previously, was diagnosed with ascending colon cancer and admitted for a laparoscopic-assisted, right hemi-colectomy. Despite all the port sites being abdominal and below the inframammary fold, on their removal, silicone from ruptured breast implants was leaking through the port sites. OUTCOME: The patient subsequently underwent an uneventful explantation of bilateral, ruptured, subglandular implants and recovered well. LEARNING POINTS: We recommend that breast implant explantation should be considered when patients indicated for elective intra-abdominal surgery are noted to have ruptured breast implants on staging CT imaging, especially when inserted via an abdominoplasty approach.

Rare presentation of Fabry disease as 'burnt-out' hypertrophic cardiomyopathy.

We herein report the case of a 53-year-old man who was historically diagnosed with hypertrophic cardiomyopathy (HCM) and was lost to follow-up, before presenting with end-stage heart failure. This was initially suspected as dilated cardiomyopathy and then 'burnt-out phase' of HCM but subsequently the underlying diagnosis was Fabry disease. Fabry disease is an uncommon lysosomal-storage disease due to reduced or absent activity of the alpha-galactosidase A enzyme. Cardiac involvement most frequently comprises left ventricular hypertrophy. Early treatment of the underlying condition with enzyme replacement therapy may prevent the progression to end-stage heart failure. Fabry disease should be considered in all patients presenting with a clinical phenotype of HCM and a historical diagnosis should be re-evaluated in light of new diagnostic tools. Untreated Fabry can progress to a 'burnt out' phase, whereby initial hypertrophy undergoes eccentric remodelling to a dilated, severely impaired left ventricle.

The underestimated problem of using serum magnesium measurements to exclude magnesium deficiency in adults; a health warning is needed for "normal" results.

BACKGROUND: A major use of serum magnesium measurements in clinical practice is to identify patients with deficiency. However, numerous studies have shown that magnesium deficiency is common and may be present in over 10% of hospitalized patients, as well as in the general population. An important cause for under diagnosis of deficiency is that serum magnesium, the most commonly used test, can be normal despite negative body stores. This article focuses on the limitations of "normal" magnesium results and highlights the importance of lifestyle or "modus vivendi" as a pragmatic means of identifying those individuals potentially at risk for negative body magnesium stores. METHODS: Researched peer reviewed articles on magnesium published between 1990 and 2008 in MEDLINE and EMBASE, using database keywords "magnesium, deficiency, diagnosis, treatment and hypomagnesaemia". Bibliographies of retrieved articles have been searched and followed. We have also performed a manual search of each individual issue in which most of these reports have appeared. RESULTS: In 183 peer reviewed studies published from 1990 to 2008, magnesium deficiency was associated with increased prevalence and risk in 11 major conditions. Similarly, in 68 studies performed over the same period, magnesium deficiency was found to predict adverse events and a decreased risk of pathology was noted when supplementation or treatment was instituted. CONCLUSIONS: The perception that "normal" serum magnesium excludes deficiency is common among clinicians. This perception is probably enforced by the common laboratory practice of highlighting only abnormal results. A health warning is therefore warranted regarding potential misuse of "normal" serum magnesium because restoration of magnesium stores in deficient patients is simple, tolerable, inexpensive and can be clinically beneficial.

Vulnerable atherosclerotic plaque metalloproteinases and foam cell phenotypes.

Plaque rupture underlies most myocardial infarctions. Plaques vulnerable to rupture have thin fibrous caps, an excess of macrophages over vascular smooth muscle cells, large lipid cores, and depletion of collagen and other matrix proteins form the cap and lipid core. Production of matrix metalloproteinases from macrophages is prominent in human plaques, and studies in genetically modified mice imply a causative role for metalloproteinases in plaque vulnerability. Recent in-vitro studies on human monocyte-derived macrophages and on foam-cell macrophages generated in vivo suggest the existence of several macrophage phenotypes with distinct patterns of metalloproteinase expression. These phenotypes could play differing roles in cap, core and aneurysm formation.

Low tissue inhibitor of metalloproteinases 3 and high matrix metalloproteinase 14 levels defines a subpopulation of highly invasive foam-cell macrophages.

OBJECTIVE: An excess of metalloproteinases (MMPs) over tissue inhibitors of metalloproteinases (TIMPs) may favor atherosclerotic plaque rupture. We compared TIMP levels in nonfoamy and foam-cell macrophages (FCM) generated in vivo. METHODS AND RESULTS: In vivo generated rabbit FCM exhibited 84% reduced TIMP-3 protein compared to nonfoamy macrophages, and immunocytochemistry revealed a TIMP-3 negative subset (28%). Strikingly, only TIMP-3 negative FCM invaded a synthetic basement membrane, and invasion was inhibited by exogenous TIMP-3. TIMP-3 negative FCM also had increased proliferation and apoptosis rates compared to TIMP-3 positive cells, which were retarded by exogenous TIMP-3; this also reduced gelatinolytic activity. TIMP-3 negative FCM were found at the base of advanced rabbit plaques and in the rupture-prone shoulders of human plaques. To explain the actions of low TIMP-3 we observed a 26-fold increase in MT1-MMP (MMP-14) protein in FCM. Adding an MT1-MMP neutralizing antibody reduced foam-cell invasion, apoptosis, and gelatinolytic activity. Furthermore, MT1-MMP overexpressing and TIMP-3 negative FCM were found at the same locations in atherosclerotic plaques. CONCLUSIONS: These results demonstrate that TIMP-3 is downregulated in a distinct subpopulation of FCM which have increased MMP-14. These cells are highly invasive and have increased proliferation and apoptosis, all properties expected to destabilise atherosclerotic plaques.

Genomics of foam cells and nonfoamy macrophages from rabbits identifies arginase-I as a differential regulator of nitric oxide production.

OBJECTIVE: Conversion of macrophages to foam cells is a critical step in the initiation and progression of atherosclerosis. We sought to identify genes differentially regulated in foam cells, since these are likely to include new targets for intervention. METHODS AND RESULTS: We used suppression subtraction hybridization to compare foam cells and nonfoamy macrophages isolated from subcutaneous granulomas of rabbits fed a cholesterol-rich or normal chow diet and confirmed upregulation of 3 genes, including matrix metalloproteinase-12 (mRNA 2.0-fold, P<0.005; protein 3.9-fold, P<0.03). Arginase-I mRNA showed the biggest decrease among 11 downregulated genes in foam cells (2.7-fold, P<0.001) and was accompanied by significantly reduced arginase enzymatic activity (60-fold, P<0.01). Arginase-I competes for substrate L-arginine with nitric oxide synthase and consequently nitric oxide production was significantly increased (3-fold, P<0.02) in foam cells compared with nonfoamy macrophages despite no difference in nitric oxide synthase isoenzyme expression. We validated upregulation of matrix metalloproteinase-12 and downregulation of arginase-1 in foam cells of rabbit and human atherosclerotic plaques. CONCLUSIONS: Our study identified several differentially expressed genes in foam cells and nonfoamy macrophages derived from live rabbits. The altered pattern of gene expression in foam cells is likely to influence atherosclerosis formation and stability.

Erroneous laboratory results: what clinicians need to know.

Laboratory tests such as 'conventional biochemistry' are analytically robust and trusted, however, some common tests performed by immunoassays, eg thyroid function tests, are inherently more prone to analytical interference, giving rise to incorrect results. Interfering antibodies capable of causing potentially misleading results in immunoassay varied from about 0.4% to 4%. Furthermore, this form of interference cannot be predicted a priori and cannot be detected even by most stringent laboratory quality control assurance schemes because it is unique to an individual sample. Since more than 10 million immunoassay tests are carried out yearly in the UK alone, the impact of this problem on delivering appropriate patient care can no longer be ignored. Clinicians tend to perceive all laboratory data in the same light. Because of this, increased awareness of the inherent limitations of these laboratory tests should trigger a more measured and thoughtful approach, thus ensuring patients receive appropriate investigations and treatment.

Deceptive potassium and magnesium measurements.

Potassium and magnesium are important circulating cations and are predominantly intracellular elements. Only a small fraction of these elements is present in extracellular fluids including blood (∼1%). Measurement of the concentration of such small fractions in blood is commonly used to assess and reflect their body content levels. However, some of these measurements can be flawed and a failure to recognise the limitations of these tests may result in misdiagnosis and/or unnecessary follow-up investigations and/or expensive hospital admissions. The focus of this note is three-fold (a) to highlight and discuss separately the less appreciated pitfalls of potassium and magnesium measurements per se, (b) suggestions to identify and rectify these snags and to improve their clinical interpretation, and finally

Accessory mitral valve tissue: appearance on cardiac computed tomography.

Accessory mitral valve tissue is an uncommon congenital malformation and a rare cause of left ventricular outflow tract obstruction. Although echocardiography provides a "gold standard" for evaluation of valves, the high temporal and spatial resolutions of computed tomography technology makes it useful in the assessment of valvular structure and function.

Probabilistic Bayesian reasoning can help identifying potentially wrong immunoassays results in clinical practice: even when they appear 'not-unreasonable'.

BACKGROUND: Immunoassays are susceptible to analytical interferences including from endogenous immunoglobulin antibodies at a rate of ∼0.4% to 4%. Hundreds of millions of immunoassay tests (>10 millions in the UK alone) are performed yearly worldwide for measurements of an array of large and small moieties such as proteins, hormones, tumour markers, rheumatoid factor, troponin, small peptides, steroids and drugs. METHODS: Interference in these tests can lead to false results which when suspected, or surmised, can be analytically confirmed in most cases. Suspecting false laboratory data in the first place is not difficult when results are gross and without clinical correlates. However, when false results are subtle and/or plausible, it can be difficult to suspect with adverse clinical sequelae. This problem can be ameliorated by using a probabilistic Bayesian reasoning to flag up potentially suspect results even when laboratory data appear "not-unreasonable". RESULTS: Essentially, in disorders with low prevalence, the majority of positive results caused by analytical interference are likely to be false positives. On the other hand, when the disease prevalence is high, false negative results increase and become more significant. To illustrate the scope and utility of this approach, six different examples covering wide range of analytes are given, each highlighting specific aspect/nature of interference and suggested options to reduce it. CONCLUSION: Bayesian reasoning would allow laboratorians and/or clinicians to extract information about potentially false results, thus seeking follow-up confirmatory tests prior to the initiation of more expensive/invasive procedures or concluding a potentially wrong diagnosis.

Analysis of complications following surgical treatment of benign parotid disease.

BACKGROUND: The objective of the study was to study the incidence of, and risk factors for developing complications following parotidectomy for benign disease, to improve preoperative patient counselling and better inform future surgical management. METHODS: An 11-year retrospective review of 162 parotidectomies for benign disease, collecting and analysing data about presentation, investigations, surgical treatment, postoperative facial nerve function, Frey's syndrome and other surgical complications. RESULTS: The mean age at presentation was 58 years. The commonest pathology was benign pleomorphic adenoma (43%), followed by Warthin's tumour (30%) and chronic sialadenitis (22%). Sialadenitis was a significant risk factor for facial nerve palsy and increased the incidence of salivary fistulas. Parotid duct ligation increased the risk of nerve palsy in the distribution of zygomatic and buccal branches. Operations for Warthin's tumour were associated with an increased risk of dysfunction of the cervical branch of the nerve. Half the patients had intraoperative facial nerve stimulation and this did not influence the likelihood of facial paresis. The recovery of facial nerve function showed a biphasic distribution, with 90% of patients having normal function within 12 months, followed by a slower recovery rate for up to 2 years. CONCLUSION: The incidence of postoperative complications was influenced by the pathology, with inflammatory lesions significantly increasing the risk of facial nerve dysfunction and other complications, but also by variations in surgical practice, such as parotid duct ligation. Overall, the incidence of permanent facial paralysis was less than 2%, but temporary nerve palsy was common at 40%, with most patients regaining normal function within 1 year of the operation.

Long-term outcome of skull base surgery with microvascular reconstruction for malignant disease.

BACKGROUND: Successful resection of malignant skull base disease depends implicitly on the ability to reconstruct the resulting defects in the craniovisceral diaphragm, to support neural structures, and to prevent ascending intracranial infections. Microsurgery reliably achieves these objectives and has increased the scope of curative oncologic surgery. The authors assessed the reconstructive results and the long-term oncologic outcome of patients having skull base surgery with free tissue transfer. METHODS: A retrospective review of cases between 1989 and 2001 was undertaken. Demographics, histology, surgical management, complications, locoregional control, and survival were analyzed. RESULTS: Predominantly male patients (n = 53; 62 percent) with an average age of 60 years had microvascular reconstruction following oncologic surgery. There was a preponderance of cutaneous malignancies (56 percent), and most lesions involved the anterior skull base (53 percent). Tumors were mostly resected with a combined intracranial or extracranial approach, and reconstruction was undertaken with radial forearm, rectus abdominis, or latissimus dorsi flaps with 94 percent success. Complications occurred in 23 percent of patients, and no specific risk factors for developing intracranial complications were identified. Specifically, extensive reconstructions did not increase the complication rate. The 5-year locoregional control and survival rates were 74 percent and 60 percent, respectively. A positive resection margin significantly increased the risk of locoregional recurrence and worsened disease-specific survival on Cox regression. Survival was also influenced by grade of malignancy. CONCLUSIONS: Microsurgery is highly reliable for reconstructing defects resulting from oncologic resections of the cranial base. It can and should be undertaken using a small number of highly dependable flaps.