A multicenter assessment of 1,177 cases of shoulder dystocia: lessons learned.

The purposes of this review were to describe deliveries complicated by shoulder dystocia (SD) at three tertiary centers and discern the differences between SD with and without brachial plexus injury (BPI). The inclusion criteria for this multicenter, retrospective study were singletons, delivered vaginally with SD. To discern the risk factors for SD with and without injury, a case (SD and BPI) versus control (3 SD without injury at the same institution) design was used. Multiple linear regression was employed. Over a 7-year period, among 46,637 vaginal deliveries, SD occurred in 1,177 cases (2.5%) and BPI was noted in 11%. The results of multiple regression indicate that gestational age, operative delivery, and the number of maneuvers and concomitant fracture (4%) were statistically associated with BPI following SD (p < 0.001). SD was not associated with BPI in 89% and 88% of the cases that were resolved with McRoberts maneuver and suprapubic pressure, whereas only 0.2% of cases were litigated.

Impaired thymic output in patients with chronic hepatitis C virus infection.

Altered T cell homeostasis in chronic hepatitis C virus (HCV) infection has been demonstrated. However, it is unknown whether fibrosis is associated with more perturbed T cell homeostasis in chronic HCV infection. The aim of this study was to examine and compare T cell subsets including recent thymic emigrants (RTE), naive, memory, senescent, apoptotic and IL-7 receptor α (CD127) expressing CD4⁺ and CD8⁺ T cells as well as telomere length and interferon-γ production in HCV-infected patients with (n = 25) and without (n = 26) fibrosis as well as in healthy controls (n = 24). Decreased proportions of CD4⁺ and CD8⁺ RTE were found in HCV-infected patients, especially in HCV-infected patients with fibrosis (14.3% (9.7-23.0) and 28.8% (16.1-40.5), respectively) compared with healthy controls (24.2% (16.3-32.1), P = 0.004 and 39.1% (31.6-55.0), P = 0.010, respectively). Furthermore, HCV-infected patients with fibrosis presented with a higher proportion of CD4⁺ T cells expressing CD127 compared with HCV-infected patients without fibrosis [88.4% (84.5-91.0) versus 83.8% (79.9-86.8), P = 0.016]. Thus, impaired thymic output in HCV infection was found, and high proportion of CD127⁺ T cells may illustrate a compensatory mechanism to preserve T cell counts.

Lack of adequate appreciation of physical exercise's complexities can pre-empt appropriate design and interpretation in scientific discovery.

Two major issues are presented. First, a challenge is made by us that a misunderstanding of physiology has led to incomplete or wrong functional designations of genes in some cases. Normal physiological processes are dynamic, integrated and periodic, and, therefore, it is difficult to define normal physiological function by looking at a single time point or single process in a non-stressed subject. The ability of the organism to successfully respond to homeostatic disruptions defines normal physiology. Genes were selected for survival and to appropriately respond to stresses, such as physical activity. Omitting gene functions by restricting them to non-stressful conditions could lead to less than optimal primary preventions, treatments and cures for diseases. Physical exercise, as a stressor, should be used to better demonstrate the complete functional classifications of some genes. Second, the challenge from others of an 'exercise pill' as a mimetic of natural physical activity will be shown to be lacking a scientific basis. The concept of an 'exercise pill'/'exercise mimetic' demonstrates an inadequate appreciation of the complexities in integrating cell, tissue, organ and systems during both acute disruptions in homeostasis by a single bout of exercise, and longer-term chronic adaptations to different types of exercise such as resistance and endurance. It is our opinion that those promoting drugs targeting a single or few molecules should not redefine the term 'exercise' and exercise concepts in an attempt to sensationalize findings. Additionally, the scientific criteria that the authors demand to be met to legitimately use the terms 'exercise pill' and 'exercise mimetic' are presented.

Prenatal diagnoses and outcomes of congenital diaphragmatic hernia.

OBJECTIVE: To describe the prenatal diagnoses and clinical outcomes of congenital diaphragmatic hernia (CDH). METHODS: A retrospective case series was developed by reviewing 16,983 ultrasounds performed between March 2003 and January 2006 for the prenatal diagnosis of CDH. Medical records of each mother/infant pair were reviewed for demographic information, ultrasound findings, obstetric management, and outcomes. RESULTS: Nineteen fetuses were diagnosed with CDH. Only one was lost to follow-up. Median gestational age at diagnosis was 28.4W (range 17.6-36.6). Fifteen cases (79%) were left sided, 3 (16%) were right-sided, and 1 (5%) was bilateral. Seven fetuses (39%) had additional abnormalities, the most common being a single umbilical artery. Ten patients (52.6%) underwent amniocentesis for karyotype; none were aneuploid. Three patients developed hydramnios. All 18 infants were liveborn. Seven infants (39%) died shortly after birth, 6 (33%) underwent surgery with subsequent discharge, and 5 (28%) were transferred to another center. Three of these died after transfer. CONCLUSION: Prenatal diagnosis of CDH portends a poor prognosis. Thirty-nine percent of infants with this diagnosis (7/18) did not survive to undergo surgery or transfer to another facility and overall mortality was 56% (10/18). Targeted ultrasonography, extensive counseling of parents, and delivery at a tertiary care center is recommended.

Timing of scheduled cesarean delivery in patients on a teaching versus private service: adherence to American College of Obstetricians and Gynecologists guidelines and neonatal outcomes.

OBJECTIVE: The purpose of this study was to compare adherence to American College of Obstetricians and Gynecologists guidelines for the timing of scheduled cesarean delivery in patients of a resident teaching service and patients of a private service to determine the neonatal intensive care unit admission rate and the most frequent admission diagnoses after scheduled cesarean delivery and to compare neonatal outcomes between the groups. STUDY DESIGN: A retrospective cohort was reviewed by medical record at a tertiary care center. The cases of 609 patients who were delivered by scheduled cesarean delivery were reviewed, and 296 patients were included. Data regarding demographics, dating, delivery, and outcome were collected and compared with the use of statistical software. RESULTS: Significant differences were noted between patients of a teaching service and patients of a private service, with respect to patient age (26.9 vs 30.7 years; P < .001), body mass index (33.7 vs 31.9 kg/m2; P = .030), race (40.4% white patients in resident teaching services vs 86.0% white patients in private services; P < .001), primary elective cesarean delivery (4 vs 23 deliveries; P = .013), and adherence to American College of Obstetricians and Gynecologists guidelines for the timing of elective delivery (96.3% vs 62%; P < .001), with no significant difference in number of neonatal intensive care unit admissions, severity of neonatal disease, or length of stay in the neonatal intensive care unit. The overall neonatal intensive care unit admission rate for all deliveries by scheduled cesarean delivery was 3.7%. The most frequent neonatal intensive care unit admission diagnoses were hypoglycemia and transient tachypnea of the newborn infant, with no severe sequelae of prematurity in either group. When controlled for fetal anomalies and infants who were born to pregestational diabetic mothers, no significant differences in number of admissions or outcomes were noted; however, 50% of the admissions to the neonatal intensive care units in both groups resulted from violations in American College of Obstetricians and Gynecologists criteria. CONCLUSION: The overall neonatal intensive care unit admission rate after scheduled cesarean delivery in this study is consistent with that reported in the neonatology literature. Patients of a teaching service were a demographically different group than those on the private service, were less likely to get an elective primary cesarean delivery, and were more likely to be delivered in adherence to American College of Obstetricians and Gynecologists guidelines, although this did not significantly affect the rates of admission to the neonatal intensive care unit or neonatal outcome.

Relearning of Activities of Daily Living: A Comparison of the Effectiveness of Three Learning Methods in Patients with Dementia of the Alzheimer Type.

This study examined the effectiveness of three different learning methods: trial and error learning (TE), errorless learning (EL) and learning by modeling with spaced retrieval (MR) on the relearning process of IADL in mild-to-moderately severe Alzheimer's Dementia (AD) patients (n=52), using a 6-weeks randomized controlled trial design. The participants had to relearn three IADLs. Repeated-measure analyses during pre-intervention, post-intervention and 1-month delayed sessions were performed. All three learning methods were found to have similar efficiency. However, the intervention produced greater improvements in the actual performance of the IADL tasks than on their explicit knowledge. This study confirms that the relearning of IADL is possible with AD patients through individualized interventions, and that the improvements can be maintained even after the intervention.

Physical activity enhances metabolic fitness independently of cardiorespiratory fitness in marathon runners.

High levels of cardiovascular fitness (CRF) and physical activity (PA) are associated with decreased mortality and risk to develop metabolic diseases. The independent contributions of CRF and PA to metabolic disease risk factors are unknown. We tested the hypothesis that runners who run consistently >50 km/wk and/or >2 marathons/yr for the last 5 years have superior metabolic fitness compared to matched sedentary subjects (CRF, age, gender, and BMI). Case-control recruitment of 31 pairs of runner-sedentary subjects identified 10 matched pairs with similar VO2max (mL/min/kg) (similar-VO2max). The similar-VO2max group was compared with a group of age, gender, and BMI matched pairs who had the largest difference in VO2max (different-VO2max). Primary outcomes that defined metabolic fitness including insulin response to an oral glucose tolerance test, fasting lipids, and fasting insulin were superior in runners versus sedentary controls despite similar VO2max. Furthermore, performance (velocity at VO2max, running economy), improved exercise metabolism (lactate threshold), and skeletal muscle levels of mitochondrial proteins were superior in runners versus sedentary controls with similar VO2max. In conclusion subjects with a high amount of PA have more positive metabolic health parameters independent of CRF. PA is thus a good marker against metabolic diseases.

Impedance cardiography facilitates differentiation of severe and superimposed preeclampsia from other hypertensive disorders.

OBJECTIVE: To determine if hemodynamic profiling using noninvasive impedance cardiography (ICG) reliably identifies the patient with severe (SPRE) or superimposed (SuPRE) preeclampsia. METHODS: Late gestation hypertensive pregnant patients underwent immediate ICG evaluation. Findings were compared between patients subsequently achieving or not achieving American College of Obstetricians and Gynecologists criteria for SPRE or SuPRE. RESULTS: Patients with severe disease were more likely to have depressed cardiac function and higher systolic blood pressure, mean arterial blood pressure, systemic vascular resistance, and thoracic fluid content compared to nonsevere hypertensive disease. CONCLUSION: ICG hemodynamic profiling of late gestation hypertensive patients can rapidly and reliably identify those with SPRE or SuPRE.

Elective preterm delivery as a management option in cryptogenic organizing pneumonia.

Bronchiolitis obliterans organizing pneumonia, now termed as cryptogenic organizing pneumonia (COP), is a fibrotic lung disease of the small airways with the potential to progress to end-stage lung disease. COP in pregnancy carries a high risk of maternal and neonatal complications and only two prior cases have been reported. This is the first case of pre-existing COP in pregnancy. We report a 16-year-old primigravid with COP who elected inpatient management and preterm delivery as a successful management option.

The future: genes, physical activity and health.

The assigned title for the Lindhard presentation was to examine the future of genes, physical activity and health. The current review is a summary of this presentation. Caution is expressed that technology is improving so rapidly that a future view is limited to a few years as opposed to the 100 years passing since Lindhard's achievements. The near futuristic opportunities and challenges for four major topic topics are reviewed here. Concerns are expressed over current usage of the terms 'control' group and 'non-responders' in exercise research. Our view is that 'control' needs to be differentiated between its usage for treatments of exercise to restore natural functions in individuals with less than healthy levels of physical activity and the inherited genome's expectation for physical activity levels to maintain normal function. For the second discussed topic, it is proposed that the term 'non-responders' should be replaced by the term 'low sensitivity' as there may be no such human who is a non-responder to every exercise adaptation. The third futuristic topic is exercise prescription as envisioned for individualized medicine. However, numerous limitations and challenges exist to truly optimal exercise medicine at the level of one individual. Finally, preventative physical activity medicine is discussed. Physical activity as a therapy now exists to prevent most of the chronic diseases. The future needs to understand the molecular basis for how the body becomes dysfunctional when its level of physical activity does not match the norm of physical activity that selected our inherited genome.

In vitro evaluation of SiC nanoparticles impact on A549 pulmonary cells: cyto-, genotoxicity and oxidative stress.

Silicon carbide (SiC) is considered a highly biocompatible material, consequently SiC nanoparticles (NPs) have been proposed for potential applications in diverse areas of technology. Since no toxicological data are available for these NPs, the aim of this study was to draw their global toxicological profile on A549 lung epithelial cells, using a battery of classical in vitro assays. Five SiC-NPs, with varying diameters and Si/C ratios were used, and we show that these SiC-NPs are internalized in cells where they cause a significant, though limited, cytotoxic effect. Cell redox status is deeply disturbed: SiC-NP exposure cause reactive oxygen species production, glutathione depletion and inactivation of some antioxidant enzymes: glutathione reductase, superoxide dismutase, but not catalase. Finally, the alkaline comet assay shows that SiC-NPs are genotoxic. Taken together, these data prove that SiC-NPs biocompatibility should be revisited.

Fetal macrocrania: diagnosis, delivery and outcomes.

OBJECTIVE: To describe fetal macrocrania including prenatal diagnosis, delivery considerations and clinical outcomes. STUDY DESIGN: A retrospective case series was developed by reviewing 26 885 ultrasounds performed between 1 March 2003 and 30 June 2007 for the prenatal diagnosis of macrocrania. Medical records of each mother/infant pair were reviewed for demographic information, ultrasound findings, obstetric management and outcomes. RESULT: Twenty-three fetuses were diagnosed with macrocrania. Median gestational age at diagnosis was 31.1 weeks (range 18.3-38.1) and at delivery was 36.9 weeks (range 30.7-39.9). Fifteen patients (65%) underwent amniocentesis for karyotype; none were aneuploid but one had a duplication on chromosome 7. All the 23 infants were liveborn. Twenty-one deliveries were by Cesarean (91%), with thirteen of these by classical incision (62%). Of the infants, 5 (22%) died shortly after birth, 16 (70%) were stabilized in the neonatal intensive care unit and were discharged alive and 2 (8%) were transferred to another center and subsequently died. Eighteen babies required ventriculoperitoneal shunting (78%). CONCLUSION: Macrocrania is a diagnosis usually made in children but can also be made prenatally. Fetal macrocrania is usually a result of ventriculomegaly due to an obstructive process to cerebrospinal fluid flow. Abdominal delivery is usually required, often necessitating a classical uterine incision. Targeted ultrasonography, extensive counseling of parents and delivery at a tertiary care center with availability of neurosurgery is recommended.

Shoulder dystocia with and without brachial plexus injury: experience from three centers.

This article compares the maneuvers used to relieve shoulder dystocia (SD) at three centers and discerns risk factors for brachial plexus injury (BPI) following SD. Retrospectively SD managed at three tertiary centers was identified and charts reviewed. Unconditional logistic regression was used to identify risk factors for BPI. SD was encountered in 2% of vaginal deliveries (624/29,591), and BPI followed impacted shoulders in 6% (38/624). The rate of SD among the three institutes varied significantly (1.5%, 2%, 0.8% of vaginal births; P < 0.0001). The use of the McRoberts' maneuver to relieve SD differed significantly by center (98%, 80%, 90%; P < 0.0001) as did the use of suprapubic pressure (83%, 66%, 54%; P < 0.0001). The rate of BPI per case of SD (10%, 3%, 5%) was significantly different at the three centers ( P = 0.009). A multivariate predictive model indicates that among those with and without concomitant fractures, there is a significantly increased risk of BPI if three or more maneuvers are used rather than two or fewer. In conclusion, not only does the rate of SD and BPI following it occur at significantly different rates, the management differs too. Compared with two maneuvers or fewer, there is an increased risk of BPI if three or more maneuvers are used to relieve SD.