Intensive Care Admissions in Pregnancy: Analysis of a Level of Support Scoring System.

OBJECTIVES: Development of a validated triaging system that can be used by obstetric providers to identify obstetric patients at risk of developing severe morbidity during an admission is urgently required. Maternal Critical Care Working Group (MCCWG) recommended a "level of care" strategy that based patient acuity needs on number of individual organ systems requiring support. The objective of this study was to apply the MCCWG level of support for critical care (MCCWG LOC) scoring to pregnant women admitted to an intensive care unit (ICU) to predict maternal outcomes and to compare it to the Acute Physiology and Chronic Health Evaluation (APACHE) II scoring system. METHODS: In this retrospective study, we applied the MCCWG LOC scoring to pregnant women admitted to an ICU at the Detroit Medical Center, between January 2006 and December 2010. The MCCWG LOC was scored on admission to the ICU, and patients were subsequently divided into two groups (Group 1, patients requiring Level 1 and 2 support and Group 2, patients requiring level 3a and 3b support) and their outcome variables were compared. The MCCWG LOC scores were also compared to APACHE II scoring, an ICU scoring system, to test if an alignment of the two systems existed, and if they were able to predict outcomes such as death, hospital and intensive care stay. RESULTS: Sixty-nine pregnant women (0.25% of deliveries) required admission to the ICU and 3 maternal deaths were reported. Sixty-four (92.7%) patients had pre-existing medical problems. Fifty-eight (84%) of admissions were secondary to a medical diagnosis. Mean APACHE II score (p < 0.018) and APACHE II predicted mortality rate were significantly higher in Group 2 (p < 0.018). The hospital length of stay (LOS) (p < 0.017) and ICU LOS (p < 0.0001) were significantly longer in Group 2 as compared to Group 1. Group 2 patients required more interventions while in the ICU (p < 0.0001). All the patients who died were classified as Group 2. CONCLUSIONS FOR PRACTICE: In a cohort of women requiring intensive care admission during pregnancy, MCCWG LOC, a simplified organ system based, triaging scoring system, predicted maternal outcomes and correlated with APACHE II score. Our data support initiatives for further development and testing of global obstetric triaging scoring systems for the purposes of risk stratification, monitoring of quality and resource allocation.

The Parallel World of Dyspnea: A Case Report.

Dyspnea can be found as a symptom of a wide range of diseases. Clinical thinking usually leads us to more common or frequent syndromes and diseases. This case report alerts us to keep investigating when faced with therapeutic failure or the arising of new symptoms. The subject in this case had dyspnea as an initial presentation of his disease and was treated initially as a case of heart dysfunction. Nevertheless, because his symptoms did not respond to the treatment and even got worse, he was sent to the emergency room where he was medicated and discharged with the same diagnostic hypothesis. In light of a new characteristic symptom - ptosis - the hospital team expanded its clinical and laboratory investigation to neuromuscular diseases, reaching out the diagnosis of myasthenia gravis.

Genetic associations of relaxin: preterm birth and premature rupture of fetal membranes.

OBJECTIVE: Relaxin H2 (RLN2) is a systemic hormone (sRLN) that is produced by the corpus luteum, whereas decidual RLN (dRLN) acts only locally. Elevated sRLN is associated with spontaneous preterm birth (sPTB) and elevated dRLN with preterm premature rupture of membranes (PPROM). Associations were sought between single nucleotide polymorphisms (SNPs) in the RLN2 promoter with levels of dRLN and sRLN in Filipino patients with sPTB, PPROM, or normal term delivery. STUDY DESIGN: Stringent selection of women with sPTB (n = 20) or PPROM (n = 20) and term control subjects (n = 20) was made from >8000 samples from Filipino patients who delivered at 34-36 weeks' gestation. Twelve SNPs were genotyped on maternal blood, with 9 excluded based on the high linkage disequilibrium or being the same as in the control population. Quantitative immunocytochemistry on parietal decidual tissue was performed (n = 60); sRLN was measured by enzyme-linked immunosorbent assay in a subset of patients (n = 21). RESULTS: SNP rs4742076 was associated significantly with PPROM (P < .001) and increased expression of dRLN (P < .001). The genotype TT had increased dRLN in PPROM (P < .05). SNP rs3758239 was associated significantly with both PPROM and sPTB (P < .01), and genotype AA had increased dRLN expression (P < .05). The sRLN showed a trend of higher levels in PPROM and sPTB, but was not significant. CONCLUSION: SNP rs4742076 in the RLN2 promoter was associated with increased dRLN expression and PPROM; SNP rs3758239 was associated with both PPROM and sPTB in these Filipino patients. Specific homozygous genotypes were identified for both SNPs and were shown to be associated with increased dRLN tissue expression.

Impact of Pectoralis Nerve Block (PECS) on postoperative pain in patients submitted to mastectomy with lymphadenectomy.

OBJECTIVE: Breast cancer is the most common malignant neoplasm in women worldwide. Surgery has been traditional treatment and, generally, it´s mastectomy with lymphadenectomy, that can causes postoperative pain. Therefore, we seek to study regional anesthesic techniques that can minimize this effect, such as the interpectoral block (PECS). METHODS: randomized controlled study with 82 patients with breast cancer who underwent mastectomy with lymphadenectomy from January 2020 to October 2021 in oncology hospital. INTERVENTIONS: two randomized groups (control - exclusive general anesthesia and PECS group - received PECS block with levobupivacaine/ropivacaine and general anesthesia). We applied a questionnaire with Numeric Rating Scale for pain 24h after surgery. We used Shapiro-Wilk, Mann-Whitney and Chi-square tests, and analyzed the data in R version 4.0.0 (ReBEC). RESULTS: in the PECS group, 50% were pain-free 24h after surgery and in the control group it was 42.86%. The majority who presented pain classified it as mild pain (VAS from 1 to 3) - (42.50%) PECS group and (40.48%) control group (p=0.28). Only 17.50% consumed opioids in the PECS group, similar to the control group with 21.43%. (p=0.65). There was a low rate of complications such as PONV in both groups. In the subgroup analysis, there was no statistical difference between the groups that used levobupivacaine or ropivacaine regarding postoperative pain and opioid consumption. DISCUSSION: the studied group had a low rate of pain in the postoperative period and it influenced the statistical analysis. There wasn´t difference in postoperative pain in groups. CONCLUSION: was not possible to demonstrate better results with the association of the PECS block with total intravenous analgesia. Need further studies to assess the efficacy of the nerve block.

Placental mesenchymal dysplasia.

Placental mesenchymal dysplasia is a benign condition that can be confused with a molar pregnancy by ultrasound scanning and gross examination. Conservative management should be considered with a normal-appearing singleton fetus and a cystic-appearing placenta. We present a case of placental mesenchymal dysplasia with a favorable outcome.

Correction: Is the public sector of your country a diffusion borrower? Empirical evidence from Brazil.

[This corrects the article DOI: 10.1371/journal.pone.0185257.].

The place for prophylactic cerclage in the infertile patient with established cervical incompetence who conceived twins after septum reduction.

INTRODUCTION: It is well known that cervical incompetence and associated preterm birth confers greater morbidity and mortality on birth outcomes, with an additional increased risk of cervical incompetence in higher order gestations. While the pathophysiology of cervical incompetence has yet to be elucidated, research has identified risk factors and assessed outcomes of numerous interventions. Cervical cerclage has been shown, in certain situations involving singleton pregnancies, to improve outcomes. Conversely, rescue cerclage increases the risk of preterm birth in twin gestations. However, these studies did not consider the unique situation of infertile patients, with known cervical incompetence, who have utilized assisted reproductive technologies to attain pregnancy. This study aims to describe the outcomes of infertile patients with known cervical incompetence, carrying twin gestation, who have undergone cervical cerclage. METHODS: This case series includes eight infertile patients who have cervical incompetence resulting in fetal loss between 20-24 weeks after in vitro fertilization embryo transfer (IVF-ET). These patients continued with IVF treatments and subsequently conceived twins. All patients underwent prophylactic cervical cerclage placement before 12 weeks. The outcomes of these pregnancies are reviewed. RESULTS: All pregnancies resulted in the delivery of viable twins. Six of the eight pregnancies (75%) were carried beyond 34 weeks. One pregnancy delivered at 31 weeks and one pregnancy delivered at 25 weeks after placental abruption. CONCLUSIONS: This data suggest that the use of prophylactic cervical cerclage may be beneficial in improving reproductive outcomes in infertile patients with known cervical incompetence that subsequently conceived twin gestations via IVF-ET treatment.

Is the public sector of your country a diffusion borrower? Empirical evidence from Brazil.

We propose a diffusion process to describe the global dynamic evolution of credit operations at a national level given observed operations at a subnational level in a sovereign country. Empirical analysis with a unique dataset from Brazilian federate constituents supports the conclusions. Despite the heterogeneity observed in credit operations at a subnational level, the aggregated dynamics at a national level were accurately described by the proposed model. Results may guide management of public finances, particularly debt manager authorities in charge of reaching surplus targets.

Impact of Pectoralis Nerve Block (PECS) on postoperative pain in patients submitted to mastectomy with lymphadenectomy / Impacto do Bloqueio Peitoral (PEC) na dor pós-operatória em pacientes submetidos a mastectomia com linfadenectomia

ABSTRACT Objective: Breast cancer is the most common malignant neoplasm in women worldwide. Surgery has been traditional treatment and, generally, it´s mastectomy with lymphadenectomy, that can causes postoperative pain. Therefore, we seek to study regional anesthesic techniques that can minimize this effect, such as the interpectoral block (PECS). Methods: randomized controlled study with 82 patients with breast cancer who underwent mastectomy with lymphadenectomy from January 2020 to October 2021 in oncology hospital. Interventions: two randomized groups (control - exclusive general anesthesia and PECS group - received PECS block with levobupivacaine/ropivacaine and general anesthesia). We applied a questionnaire with Numeric Rating Scale for pain 24h after surgery. We used Shapiro-Wilk, Mann-Whitney and Chi-square tests, and analyzed the data in R version 4.0.0 (ReBEC). Results: in the PECS group, 50% were pain-free 24h after surgery and in the control group it was 42.86%. The majority who presented pain classified it as mild pain (VAS from 1 to 3) - (42.50%) PECS group and (40.48%) control group (p=0.28). Only 17.50% consumed opioids in the PECS group, similar to the control group with 21.43%. (p=0.65). There was a low rate of complications such as PONV in both groups. In the subgroup analysis, there was no statistical difference between the groups that used levobupivacaine or ropivacaine regarding postoperative pain and opioid consumption. Discussion: the studied group had a low rate of pain in the postoperative period and it influenced the statistical analysis. There wasn´t difference in postoperative pain in groups. Conclusion: was not possible to demonstrate better results with the association of the PECS block with total intravenous analgesia. Need further studies to assess the efficacy of the nerve block.

RESUMO Introdução: o câncer de mama é a neoplasia maligna mais comum em mulheres no mundo. A cirurgia tem sido o tratamento tradicional e, geralmente consiste em mastectomia com linfadenectomia, podendo causar dor pós-operatória. Por isso, buscamos estudar técnicas anestésicas regionais que possam minimizar esse efeito, como o bloqueio interpeitoral (PEC). Métodos: estudo controlado randomizado com 82 pacientes com câncer de mama submetidos à mastectomia com linfadenectomia de Janeiro de 2020 a Outubro de 2021, em hospital oncológico. Intervenções: dois grupos randomizados (controle - anestesia geral exclusiva e grupo PECS - anestesia geral e bloqueio PEC com levobupivacaína/ropivacaína). Aplicou-se um questionário com Escala Visual Analógica da dor 24h pós-cirurgia. Utilizamos os testes de Shapiro-Wilk, Mann-Whitney e Quiquadrado e analisamos os dados em R versão 4.0.0. Estudo registrado em Ensaios Clínicos Brasileiros (REBec). Resultados: no grupo PEC, 50% não apresentava dor 24 horas após a cirurgia enquanto no grupo controle, 42,86% negava quadro álgico. A maioria que apresentou dor classificou-a como dor leve (EVA de 1 a 3) - (42,50%) grupo PEC e (40,48%) controle (p=0,28). Apenas 17,50% consumiram opioides no grupo PEC, semelhante ao grupo controle com 21,43%. (p=0,65), (17,50%) grupo PEC e (21,43%) grupo controle (p=0,65). Houve baixo índice de complicações como PONV (náuseas, vômitos, cefaleia) em ambos os grupos. Na análise de subgrupo, não houve diferença estatística entre os grupos que usaram Levobupivacaína ou Ropivacaína quanto a dor pós-operatória e o consumo de opioides. Discussão: o grupo estudado apresentou baixa taxa de dor no pós-operatório e isso influenciou na análise estatística. Não houve diferença estatística quanto a dor pós-operatória entre grupos. Conclusão: não foi possível demonstrar melhores resultados com a associação do bloqueio PEC com analgesia intravenosa total. São necessários novos estudos para avaliar a eficácia do bloqueio anestésico no intraoperatório e pós-operatório.

Propofol-Related Infusion Syndrome in the Peripartum Period.

Background Propofol is a widely known, commonly used drug. Complications can occur with the use of this drug, including propofol-related infusion syndrome (PRIS). PRIS, in the obstetric population, has not been documented; however, we report a case of a patient who developed PRIS after an emergent cesarean delivery of a preterm infant. Case Study A 35-year-old multigravida woman presented complaining of leakage of fluid and decreased fetal movement. Her pregnancy was complicated by methadone maintenance therapy due to a history of opioid abuse. Complications after admission for prolonged monitoring and a prolonged fetal heart tone deceleration was noted with no recovery despite intrauterine resuscitation. An emergent cesarean delivery was performed using general anesthesia and endotracheal intubation after which she developed aspiration pneumonia. She was admitted to the intensive care unit and reintubation and sedation were required secondary to respiratory distress. Sedation was achieved using propofol infusion. She subsequently developed changes in her electrocardiogram, an increase of her serum creatinine, creatinine protein kinase, lipase, amylase, and triglycerides, making the diagnosis of PRIS. Conclusion PRIS should be included in the differential diagnosis of intubated or postoperative patients in the obstetric population.

Should Prophylactic Anticoagulation Be Considered with Large Uterine Leiomyoma? A Case Series and Literature Review.

Introduction. Uterine leiomyomas, also called uterine fibroids or myomas, are the most common pelvic tumors in women. They are very rarely the cause of acute complications. However, when complications occur they cause significant morbidity and mortality. Thromboembolic disease has been described as a rare complication of uterine leiomyomas. DVT is a serious illness, sometimes causing death due to acute PE. Cases. We report a case series of 3 patients with thromboembolic disease associated with uterine leiomyoma at Hurley Medical Center, Flint, Michigan, during 2015 and conduct a literature review on the topic. A literature search was conducted using Medline, PubMed, and PMC databases from 1966 to 2015. Conclusion. The uterine leiomyoma is a very rare cause of PE and only few cases have been reported. DVT secondary to uterine leiomyoma should be considered in a female presenting with abdominal mass and pelvic pressure, if there is no clear common cause for her symptoms. Thromboembolic disease secondary to large uterine leiomyoma should be treated with acute stabilization and then hysterectomy. Prophylactic anticoagulation would be beneficial for lowering the risk of VTE in patients with large uterine leiomyoma.

Expression of constitutively active nuclear-kappa B RelA transcription factor in blasts of acute myeloid leukemia.

The nuclear transcription factor NF-kappa B regulates cell survival, proliferation, and differentiation. Little is known about NF-kappa B in myeloid malignancies. In this report, we assessed NF-kappa B in a group of myeloid neoplasms by using an electrophoretic mobility shift assay (EMSA) and immunofluorescence methods in freshly isolated leukemia cells. We analyzed 30 cases of acute myeloid leukemia (AML), 5 cases of myelodysplastic syndrome (MDS), 3 cases of chronic myelomonocytic leukemia (CMML), 15 cases of chronic myeloid leukemia in chronic phase (CML-CP), and 2 cases of chronic myeloid leukemia in blast crisis (CML-BC). Unstimulated cells (bone marrow and peripheral blood) from 17 normal donors and apheresis samples from 6 peripheral blood stem cell donors treated with granulocyte colony-stimulating factor (G-CSF) were used as controls. When EMSA was used, NF-kappa B was elevated in 14 of 30 (47%) cases of AML, in both cases of CML-BC, and in all reference donors treated with G-CSF, but it was at basal levels in all cases of MDS and CML-CP and in normal donors (P = <.01). Immunofluorescence analysis confirmed strong nuclear RelA/NF-kappa B immunoreactivity in AML blasts but not in normal bone marrow. Bcl-2, a downstream molecule, was expressed in cases with elevated NF-kappa B, but not in cases with basal levels of NF-kappa B, suggesting that NF-kappa B is active and provides the cells with survival advantages in vivo. These results suggest that suppression of NF-kappa B may be a useful therapeutic strategy for a subset of patients with AML.

[Detection of phospholipidolytic Candida albicans isolated from saliva of children with Down's syndrome]. / Detecção de Candida albicans fosfolipidolíticas isoladas da saliva de crianças com síndrome de Down.

The childhood is one of the most propitious period of the life to the occurrence of infection by yeasts of the genus Candida. In children with Down's syndrome, besides the predispose factors to bucal candidiasis; macroglossia, bucal muscular incompetence, frequent respiratory diseases, motor difficulty and immunologic deficit are mentioned as additional elements for this fungus disease. It was verified that the children attacked by this syndrome have much more strains of Candida than other children. The aim of this study was to detect the prevalence of phospholipase producer, Candida on the saliva of children with Down's syndrome. Candida albicans was the only identified specie of Candida. The phospholipase production was found in isolated strains from both of study and control. However, the isolated strains of the group of children with Down's syndrome have strongly present phospholipidolitic.

Ethnic variation of gastroschisis and omphalocele in the United States of America.

OBJECTIVE: Gastroschisis and omphalocele are the most common fetal abdominal wall defects (AWDs). Ethnic factors have been implicated in the incidence data from some states in the United States. Our aim was to examine ethnic variation in the prevalence of gastroschisis and omphalocele in the US live birth population between 2006 and 2010. METHODS: AWDs were identified through gastroschisis and omphalocele checkboxes from publicly available US Natality data (2006 to 2010). Ethnicity was evaluated by individual category using National Center for Health Statistics (NCHS) definitions. Adjusted multinomial logistic regression (SPSS v.19) was used to generate odds ratios (OR) in order to quantify the disparities. RESULTS: In the US, 7867 live births were identified with AWD. All ethnic groups showed a significantly higher OR when compared with women of East/South Asian descent, which experienced the lowest prevalence. Women of indigenous ethnicity had the highest individual OR while their adjusted OR remained greater than 4.0. CONCLUSIONS: Women of indigenous origin from North America and the Pacific had the highest rates of AWD. Within this group, women of Hawaiian descent had the highest point estimate of AWD when compared with other ethnic groups, though not significant.

Acute liver failure and self-medication.

INTRODUCTION: Not responsible self-medication refers to drug use in high doses without rational indication and often associated with alcohol abuse. It can lead to liver damage and drug interactions, and may cause liver failure. AIM: To warn about how the practice of self-medication can be responsible for acute liver failure. METHOD: Were used the Medline via PubMed, Cochrane Library, SciELO and Lilacs, and additional information on institutional sites of interest crossing the headings acute liver failure [tiab] AND acetaminophen [tiab]; self-medication [tiab] AND acetaminophen [tiab]; acute liver failure [tiab] AND dietary supplements [tiab]; self-medication [tiab] AND liver failure [tiab] and self-medication [tiab] AND green tea [tiab]. In Lilacs and SciELO used the descriptor self medication in Portuguese and Spanish. From total surveyed were selected 27 articles and five sites specifically related to the purpose of this review. CONCLUSIONS: Legislation and supervision disabled and information inaccessible to people, favors the emergence of cases of liver failure drug in many countries. In the list of released drugs that deserve more attention and care, are some herbal medicines used for the purpose of weight loss, and acetaminophen. It is recommended that institutes of health intensify supervision and better orient their populations on drug seemingly harmless, limiting the sale of products or requiring a prescription for release them.

Relaxin and preterm birth.

Preterm birth (PTB) is a global problem with a high incidence in the developing world. Relaxin (RLN) has classically been associated with parturition, but its role(s) in the human have been difficult to determine. For the first time, we bring together the systemic (ovarian) and autocrine/paracrine (intrauterine) sources of RLN, in an attempt to understand how RLN contributes to PTB in women.

Condilectomia alta associada à discopexia, com âncoras, no tratamento da hiperplasia condilar: relato de caso / Highcondilectomy associated to discopexy with anchor for conylar hyperplasia treatment: a case report

Introdução: A hiperplasia condilar (HC) é uma patologia rara caracterizada por crescimento não neoplásico que afeta a morfologia do côndilo mandibular com deformação progressiva. Dentre os sinais mais comuns destacam-se a assimetria facial e mandibular, além de possíveis alterações oclusais como mordida aberta ipsilateral e transversal contralateral. A combinação de exames clínicos com a análise de modelos de gesso, fotografias, radiografias panorâmicas, cintilografias e cefalogramas são essenciais para definição do correto diagnóstico. Objetivo: O objetivo do estudo foi demonstrar a eficácia terapêutica da condilectomia alta no tratamento da hiperplasia condilar. Relato de caso: paciente jovem, 24 anos de idade, apresentando assimetria facial, déficit e incompetência funcional mastigatória, mordida aberta posterior ipsilateral e mordida cruzada posterior contralateral. A proposta terapêutica escolhida foi o tratamento cirúrgico com condilectomia alta e discopexia com âncora para estabilização do disco articular, através de acesso endaural para o côndilo afetado. Conclusão: A condilectomia alta preveniu a deformidade facial progressiva, minimizando as sequelas funcionais e estéticas, favorecendo o tratamento das deformidades faciais.

Introduction: Condylar hyperplasia is a rare disorder characterized by a non-neoplastic pathological growth that affects the morphology of the mandibular with progressive deformation. Clinical examination, plaster model's analysis, clinical photographs, panoramic radiography, scintigraphyandcephalograms in combination are essential to make a correct diagnosis. Among the most common signs and symptoms of the condition are facial and mandibular asymmetry, and occlusal changes such as contralateral ipsilateral and cross open bite. Objective: The aim of the study was to describe the efficacy of high condilectomy in the treatment of condylar hyperplasia. Relato de caso: Young patient, 24 years-old, presenting facial asymmetry, functional masticatory deficit and functional incompetence, ipsilateral posterior open bite and contralateral posterior crossbite. The therapeutic proposal chosen was the surgical treatment with high condilectomy and discopexy with anchor for stabilization of the articular disc through endaural access to the affected condyle. Conclusion: The high condylectomy, prevents progressive facial deformity minimizing the functional and aesthetic sequelae, which favors the treatment of facial deformities.

Chemoprevention by celecoxib in reflux-induced gastric adenocarcinoma in Wistar rats that underwent gastrojejunostomy.

PURPOSE: To evaluate chemoprevention by celecoxib in cases of reflux-induced gastric adenocarcinoma, in Wistar rats that underwent gastrojejunostomy. METHODS: Sixty male Wistar rats of average age three months underwent surgery and were distributed into three groups: group 1, exploratory laparotomy; group 2, gastrojejunostomy; and group 3, gastrojejunostomy and daily celecoxib administration. After 53 weeks, the animals were sacrificed. Changes in the mucosa of the gastric body of group 1 and in the gastrojejunal anastomosis of groups 2 and 3, observed in histopathological and immunohistochemical examinations, were compared. All statistical analyses were performed using Epi-Info, version 3.4.3. RESULTS: Comparison between groups 2 and 3 relative to the presence of adenocarcinoma showed a statistically significant difference (p=0.0023). Analysis of the association between groups 2 and 3 relative to COX-2 expression also showed a statistically significant difference (p=0.0018). CONCLUSION: Celecoxib had an inhibiting effect on gastric carcinogenesis induced by enterogastric reflux in an animal model.