Proposed cutoff for fetal scalp blood lactate in intrapartum fetal surveillance based on neonatal outcomes: a large prospective observational study.

OBJECTIVE: Determination of lactate in fetal scalp blood (FBS) during labour has been recognised since the 1970s. The internationally accepted cutoff of >4.8 mmol/l indicating fetal acidosis is exclusive for the point-of-care device (POC) LactatePro™, which is no longer in production. The aim of this study was to establish a new cutoff for scalp lactate based on neonatal outcomes with the use of the StatstripLactate® /StatstripXpress® Lactate system, the only POC designed for hospital use. DESIGN: Observational study. SETTING: January 2016 to March 2020 labouring women with indication for FBS were prospectively included from seven Swedish and one Australian delivery unit. POPULATION: Inclusion criteria: singleton pregnancy, vertex presentation, ≥35+0 weeks of gestation. METHOD: Based on the optimal correlation between FBS lactate and cord pH/lactate, only cases with ≤25 minutes from FBS to delivery were included in the final calculations. MAIN OUTCOME MEASURES: Metabolic acidosis in cord blood defined as pH <7.05 plus BDecf >10 mmol/l and/or lactate >10 mmol/l. RESULTS: A total of 3334 women were enrolled of whom 799 were delivered within 25 minutes. The areas under the receiver operating characteristics curves (AUC) and corresponding optimal cutoff values were as follows; metabolic acidosis AUC 0.87 (95% CI 0.77-0.97), cutoff 5.7 mmol/l; pH <7.0 AUC 0.83 (95% CI 0.68-0.97), cutoff 4.6 mmol/l; pH <7.05 plus BDecf ≥12 mmol/l AUC 0.97 (95% CI 0.92-1), cutoff 5.8 mmol/l; Apgar score <7 at 5 minutes AUC 0.74 (95% CI 0.63-0.86), cutoff 5.2 mmol/l; and pH <7.10 plus composite neonatal outcome AUC 0.76 (95% CI 0.67-0.85), cutoff 4.8 mmol/l. CONCLUSION: A scalp lactate level <5.2 mmol/l using the StatstripLactate® /StatstripXpress® system will safely rule out fetal metabolic acidosis. TWEETABLE ABSTRACT: Scalp blood lactate <5.2 mmol/l using the StatstripLactate® /StatstripXpress system has an excellent ability to rule out fetal acidosis.

Education and age-related decline in cognitive performance: Systematic review and meta-analysis of longitudinal cohort studies.

Central theories of cognitive aging propose that education is an important protective factor for decline in cognitive performance in older age. We conducted a systematic review and meta-analysis of reported estimates of an association between educational attainment and change in performance in six cognitive domains (episodic memory, processing speed, verbal fluency, crystallized intelligence, fluid intelligence, and global ability) in the general population of older individuals. The systematic search (11th of October 2019) identified 92 eligible articles. The episodic memory domain had the highest number of estimates (37 estimates from 18 articles, n = 109,281) included in the meta-analysis. The fewest estimates (6 estimates from 6 articles, n = 5263) were included for fluid intelligence. Pooled mean estimates from an inverse-variance weighted random effects analysis were not statistically significant and indicated that any association between education and change in cognitive performance is likely of a negligible magnitude. The estimates for education's role (one additional year) for change in cognitive performance ranged from -0.019 (95 % confidence interval, CI = -0.047, 0.010) to 0.004SD (CI = -0.003, 0.012) per decade. Even if the larger positive point estimates (i.e., protective effects) are selectively considered, the influence of education on change is still at least 12 times less important for the cognitive functioning of an older individual than the association between education and level of cognitive performance. Sensitivity analyses did not substantially alter these results. However, heterogeneity was substantial, and remained largely unexplained by mean age, mean educational attainment, Gini coefficient, GDP per capita, maximum follow-up period, and publication year. Overall, education is an important factor in aging due to its robust association with level of performance, but the current base of empirical evidence is not revealing a consistent and substantial association between educational attainment and changes in cognitive performance in the general population. Theories of cognitive aging must be updated to incorporate this pattern of findings.

Emergence of systemic lupus erythematosus after initiation of highly active antiretroviral therapy for human immunodeficiency virus infection.

Systemic lupus erythematosus (SLE) may be influenced by human immunodeficiency virus type-1 (HIV) infection. It has been suggested that the immunosuppression resulting from HIV infection can prevent the emergence of SLE. There appear to be fewer cases of SLE in the HIV infected population than would be predicted, based on the overall incidence of SLE. We describe a person with HIV infection who developed SLE after the initiation of highly active antiretroviral therapy.

Extraintestinal dissemination of Salmonella by CD18-expressing phagocytes.

Specialized epithelia known as M cells overlying the lymphoid follicles of Peyer's patches are important in the mucosal immune system, but also provide a portal of entry for pathogens such as Salmonella typhimurium, Mycobacterium bovis, Shigella flexneri, Yersinia enterocolitica and reoviruses. Penetration of intestinal M cells and epithelial cells by Salmonella typhimurium requires the invasion genes of Salmonella Pathogenicity Island 1 (SPI1). SPI1-deficient S. typhimurium strains gain access to the spleen following oral administration and cause lethal infection in mice without invading M cells or localizing in Peyer's patches, which indicates that Salmonella uses an alternative strategy to disseminate from the gastrointestinal tract. Here we report that Salmonella is transported from the gastrointestinal tract to the bloodstream by CD18-expressing phagocytes, and that CD18-deficient mice are resistant to dissemination of Salmonella to the liver and spleen after oral administration. This CD18-dependent pathway of extraintestinal dissemination may be important for the development of systemic immunity to gastrointestinal pathogens, because oral challenge with SPI1-deficient S. typhimurium elicits a specific systemic IgG humoral immune response, despite an inability to stimulate production of specific mucosal IgA.

HIV gp120-specific cell-mediated immune responses in mice after oral immunization with recombinant Salmonella.

Salmonella is of great interest as a potential human immunodeficiency virus vaccine vector because of its ability to elicit potent mucosal and systemic immune responses when administered orally. To determine whether such a vaccine could elicit an immune response in mice, plasmids expressing HIV gp120-LAI were introduced into attenuated S. typhimurium. Three serial doses of 10(10) recombinant organisms were administered orally to BALB/c mice at 2-week intervals. Immunized mice but not control mice demonstrated proliferative T cell responses to gp120-LAI, comparable in magnitude to the proliferative responses to Salmonella antigens. Immunized mice had detectable serum and intestinal Salmonella-specific IgA and serum Salmonella-specific IgG. However, no gp120-specific antibody was detected in either serum or intestinal washes. These results indicate that live recombinant Salmonella-based vaccine constructs can induce HIV-specific cellular immune responses in vivo.

Breast reduction for symptomatic macromastia: can objective predictors for operative success be identified?

The purpose of this paper is to assess symptomatic macromastia, the relief of symptoms by operation, and predictors of symptom relief. The methods used have been retrospective chart review and a self-assessment patient questionnaire. One-hundred and thirty-three patients underwent an average 1660-gm reduction. Ninety-three percent reported a postoperative decrease in symptoms such as shoulder grooves and shoulder, neck, and back pain. Correlation between breast size and sign or symptom severity achieved significance only for the preoperative submammary rash (r = 0.33, p < 0.001). Patients lost an average of 8.9 lb postoperatively and were less overweight (49 versus 40 percent). Activity level increased postoperatively in 63 percent. Postoperative chest size correlated inversely with activity level (r = 0.35, p < 0.001). Thirty-nine percent of patients who took pain medications preoperatively were able to eliminate these postoperatively. The quantity of tissue removed did not correlate with outcome. A model predictive of symptom relief could not be developed (total R2 = 0.03). Reduction mammaplasty promoted relief of signs and symptoms of macromastia, but a predictive model of successful operation could not be developed.

Liposuction. What it will and won't do.

Liposuction is used most often to contour the body. Usually, it is done on an outpatient basis under general or regional anesthesia. Results are better in patients who have good skin turgor and are at or near their ideal weight. The recovery period is short and relatively pain-free. While there have been serious complications in a few cases, the procedure is safe when done by experienced physicians who are careful in selecting patients and cautious about the magnitude of the procedure they perform. Patient satisfaction is high, particularly when patients are selected carefully and are well-informed concerning the expected outcome.

Metastatic basal cell carcinoma: review and report of a case.

Basal cell carcinomas are usually slow growing, locally aggressive tumors that rarely metastasize. If these tumors are not treated or are inadequately treated they occasionally metastasize to regional lymph nodes or distant sites. It is important to treat basal cell carcinomas promptly and adequately and to have attentive follow-up, since large, deeply invasive tumors are the ones most likely to metastasize. In the case presented, a large basal cell carcinoma of the scalp invaded through the skull and into the sagittal sinus and posterior right occipital lobe of the brain. Several pulmonary metastases were present.

Innervated cross-leg tensor fascia lata fasciocutaneous flap for foot reconstruction.

A traumatic, extended first ray amputation in a child was treated with an innervated cross-leg tensor fascia lata fasciocutaneous flap. The flap provided thin composite tissue coverage, immobilization in a position of relative comfort, and sensory innervation to the weight-bearing surface. Consideration of this flap is recommended when dealing with large defects of the foot.

Sexual identity and prophylactic mastectomy.

The psychological adjustment of women following prophylactic mastectomy with reconstruction has not been evaluated. This study reviews this problem in 9 women chosen at random from the practice of two surgeons. The sexual identity of the women and its effect upon the outcome of their surgery was of particular interest. The surgeon's perception of problems of adjustment and the difference in the patient's and surgeon's evaluation of operative results were considered. The study included interviews with a psychiatrist, a questionnaire for the surgeon, and a subjective evaluation of operative results by both patient and surgeon. A high degree of psychopathology, particularly depression, was encountered. Most women had a relatively weak sexual identity preoperatively. In most instances the surgeon was not alerted to the patient's troubled feelings. Though psychopathology was evident, it does not seem to indicate that the patient will have difficulty accepting the results of surgery. We suggest that women who deny their sexuality might adjust to this surgery more easily. Psychiatric consultation appears to aid patient management.

A competency-based curriculum in business practice management.

Business management skills are an essential part of an efficient medical practice, but they are largely neglected or ignored in residency training programs. In order to realistically prepare physicians for their future community practices, the Family Practice Residency Training Program at the University of California, Los Angeles, includes a business practice management curriculum based on 12 behavioral objectives. Through observation, seminars, consultation, and practice design, the resident becomes competent in the skills and behaviors necessary for effective management. Over the three-year period, the resident completes a handbook with research findings, and designs elements of his/her own future practice. The instructor's manual is included to illustrate and clarify methods of implementation and evaluation of the curriculum.