Visual biofeedback for shortening second stage of labor: randomized controlled trial.

OBJECTIVE: To determine whether visual biofeedback can be used during labor as an effective tool for shortening the second stage of labor and reducing the need for instrumental delivery. METHODS: This was a single-center randomized controlled trial. Nulliparous women under epidural anesthesia were randomized at the point of full dilation into the biofeedback group (n = 50) or the control group (n = 50). Both groups received coached maternal pushing during four consecutive contractions, while an experienced obstetrician performed transperineal ultrasound. Only women in the biofeedback group observed the ultrasound display screen. Following this intervention, labor was managed routinely by the obstetric team. Angle of progression (AOP) was measured at rest and while pushing, before and during the first and fourth contractions. Second-stage duration and delivery outcomes were compared between groups. RESULTS: Visual biofeedback did not affect the duration of the second stage, which lasted for a median of 2.28 (interquartile range (IQR), 1.25-3.10) h in the biofeedback group vs 2.08 (IQR, 1.58-3.02) h in the control group (P = 0.981). AOP was significantly higher in the biofeedback group compared with the control group, both at rest before the fourth contraction (mean ± SD, 142.6° ± 15.9° vs 136.8° ± 13.1°; P = 0.049) and while pushing during the fourth contraction (mean ± SD, 159.3° ± 19.2° vs 149.4° ± 15.1°; P = 0.005). The increase in AOP was significantly higher in the biofeedback compared with the control group between rest and pushing at the last push (mean ± SD, 16.6° ± 11.0° vs 12.6° ± 8.3°; P = 0.041) and between the first rest and last push (mean ± SD, 24.4° ± 13.6° vs 17.9° ± 11.3°; P = 0.011). The rate of intact perineum was similar between groups (12% vs 8%; P = 0.505). CONCLUSIONS: Visual biofeedback during the second stage of labor may facilitate descent of fetal head during maternal pushing without affecting second-stage duration, possibly due to the short duration of the intervention. Future studies should focus on continuous intervention throughout the second stage of labor. © 2023 International Society of Ultrasound in Obstetrics and Gynecology.

Activity of P-glycoprotein in B-cell chronic lymphocytic leukemia determined by a flow cytometric assay.

BACKGROUND: Chemoresistance in some hematologic malignancies has been associated with overexpression of P-glycoprotein, which is encoded by the MDR1 gene (also known as PGY1). However, inconsistencies in data on frequency and clinical relevance of multidrug resistance in B-cell chronic lymphocytic leukemia (B-CLL) may reflect a need for improved techniques to detect this overexpression. PURPOSE: Our purpose was to measure P-glycoprotein activity in peripheral blood cells of B-CLL patients and to analyze possible clinical correlations (disease duration, prior treatment, Rai disease stage, lymphocyte counts, and disease progression). METHODS: P-glycoprotein activity was assayed in peripheral blood cells of 42 consecutive B-CLL patients (22 treated and 20 untreated). We used dual fluorescence in a flow cytometric assay that detects efflux of the fluorescent dye rhodamine 123, which is transported from the cell by the P-glyprotein pump. Leukemia cells were costained with monoclonal antibody Leu12/CD19, and rhodamine 123 efflux was measured. Expression of MDR1 and MDR3 (also known as PGY3) messenger RNA (mRNA) was quantitatively evaluated by polymerase chain reaction (PCR) in 26 cases. RESULTS: Marked rhodamine 123 efflux was observed in 34 (81%) of the 42 cases and was abolished in the presence of multidrug resistance inhibitors. Rhodamine 123 efflux was not associated with Rai stage, lymphocyte counts, duration of disease, or disease progression. Although rhodamine 123-negative cases were about equally distributed among untreated and previously treated patients, the percentage of cells with rhodamine 123 efflux was significantly lower for untreated patients than for those treated with chemotherapy regimens including at least one multidrug resistance-associated drug. MDR1 mRNA was detected in 25 of 26 cases and MDR3 mRNA in all 26. MDR1 mRNA expression was significantly correlated with rhodamine 123 efflux, whereas MDR3 mRNA expression was not significantly correlated; MDR1 and MDR3 mRNA expression was not significantly associated with Rai stage, prior treatment, or disease progresssion. CONCLUSIONS: These findings suggest that P-glycoprotein overexpression in B-CLL is intrinsic rather than acquired and that P-glycoprotein activity is enhanced after exposure to multidrug resistance-associated drugs. This enhanced activity does not seem to be associated with more aggressive disease. Our results also indicate that an assay of P-glycoprotein function combined with PCR is suitable for clinical multidrug resistance screening. IMPLICATIONS: Additional studies are needed to determine whether functional activity of P-glycoprotein, measured by rhodamine 123 efflux, is directly related to clinical drug resistance.

[Functional detection of P-glycoprotein expressing cells with flow cytometry]. / Funktionelle Erfassung P-Glykoprotein-exprimierender Zellen mittels Durchflusszytometrie.

Classical multidrug resistance (MDR) is associated with the overexpression of a membrane glycoprotein termed P-glycoprotein (P-gp) that transports a variety of apparently unrelated anti-cancer drugs out of cells. Based on the fluorescent properties of the dye rhodamine 123 (Rh 123) we aimed to develop a functional flow cytometric assay for the detection of MDR-expressing cells. Using drug sensitive cell lines (KB-3-1) and MDR mutants (KB-8-5, KB-C1) experimental conditions were established enabling demonstration of significant differences in Rh 123 accumulation/efflux. Using two-colour flow cytometry we subsequently analysed 42 consecutive patients suffering from B-cell chronic lymphocytic leukemia (B-CLL). 34/42 (81%) cases showed a marked Rh 123 efflux which was completely abolished in the presence of the MDR inhibitor verapamil. The percentage of Rh 123 effluxing cells ranged from 10 to 70% with a median of 32%. In 26 cases extracted RNA was analysed by quantitative polymerase chain reaction to evaluate the expression of MDR 1 mRNA. In 25 of 26 (96%) cases MDR 1 mRNA was detectable. The levels of MDR 1 mRNA expression correlated well with the results of the Rh 123 efflux assay (r = 0.72; p < 0.0001). In addition, 37 cases of acute myeloid leukemia were analysed and demonstrated Rh 123 efflux in 18/37 (49%) cases. In this entity the percentage of Rh 123 effluxing cells ranged from 12 to 80% (median 45%). Additionally, we evaluated the Rh 123 efflux/retention in peripheral blood cells of healthy volunteers.(ABSTRACT TRUNCATED AT 250 WORDS)

[Functional peripheral ischemia]. / Funktionelle periphere Durchblutungsstörungen.

The terminal circulation which plays an important role in the thermoregulation particularly at the periphery of the extremities is not infrequently irritated by false multifactorial regulations. As their sequela an increased tonus of vasoconstrictors and pathological vasodilatation lead to idiopathic and symptomatic functional angiolopathies. Transitions into organic vascular processes are no rarity. From the extreme functional behaviour patterns complaints and symptoms of the individual angiolopathies may be derived. Clinic, differential diagnostics and therapeutic possibilities of the angiopathic reaction position, of the acrocyanosis and its variants, of the intermittent functional acrosyndromes and of the erythromelalgia are treated from practical points of view. In contrast to the secondary functional angiolopathies, in which the basic disease is of decisive importance in questions concerning expertise, the idiopathic forms alone are scarcely of high significance concerning the restriction of the physical function.

[Diagnostic possibilities in aortic arch syndrome in ambulant care]. / Diagnostische Möglichkeiten beim Aortenbogensyndrom in der ambulanten Sprechstunde

The diagnostic possibilities in the syndrome of the aortic arch in the surgery of the outpatient department are described. The importance of the leading symptoms in the anamnesis, the pulse palpation and auscultation, the inspection and the bilateral measurement of the blood pressure is elaborated. It is referred to the value of the simple functional test. Apparative investigation methods which are also used in the outpatient department are mentioned. The exhaustion of all possibilities which are at disposal for diagnosing already the early stages of the syndrome of the aortic arch is regarded as prognostically important in order to prevent irreversible cerebral lesions by a timely induction of necessary therapeutic measures.

[Differential diagnosis of the aortic arch syndrome]. / Differentialdiagnose des Aortenbogensyndroms

With the aid of the complexes of principle signs of the pulseless disease, the cerebrovascular insufficiency and the ischaemic-brachialgiformous symptomatology the different basic diseases, which are to be taken into consideration differential-diagnostically in a large number can clearly be recognized. With the cerebrovascular insufficiency compete intracranial organic processes and reductions of the volume of the cardiac output. In the brachialgiformous ischaemic syndrome further angiopathies, neurovascular syndromes of the shoulder girdle, nervously caused pain in the arm and a series of other very different starting-points must finally be taken into consideration. By means of a good interdisciplinary cooperation a clarification can be achieved also in difficult situations.

[Thrombosis of the vena cava inferior. Etiological and clinical contribution]. / Vena-cava-inferior-Thrombose. -- Ein ätiologischer und klinischer Beitrag.

On the basis of two observations of courses is demonstrated that not in the least only hypercoagulability and retardation of the movement of the blood but also contusions of the femoral and hip region by fall and thrown which first of all appear as harmless may become the starting-point for alterations of the venous wall with extended thromboses of the veins of leg and pelvis under inclusion of the infrarenal section of the lower vena cava with a distinct picture of the postthrombotic condition of the lower extremities and a threatening embolism of the lungs. The author deal with expert's problems of the restriction of the function conditioned by accident. For the collateral venous circulation in the thrombosis of the vena cava inferior several accessory ways are at disposal of which the superficial collateral veins of the abdominal wall have diagnostically a high valency, haemodynamically they are, however, only of little importance. In partial thrombosis in the region of the lower vena cava clinically evident collateral circulations may stay away due to good possibilities of compensation as it is proved at a postoperative complication of thrombosis by oligosymptomatology.

[Findings of pulse palpation and non-invasively measured blood pressure values of the posterior tibial artery in arterial occlusive disease]. / Pulstastbefund und nichtinvasiv gemessene Blutdruckwerte der A. tibialis posterior bei arterieller Verschlusskrankheit.

In 37 test persons with healthy vessels and 103 patients with arterial obstructive disease the clinical findings of the pulse palpation were related to the results of the systolic Doppler pressure measurement in the region of the posterior tibial artery. The experience of the investigator, physical influences, local extravascular factors as well as parameters of the central haemodynamics proved to be significant. A palpation of the pulse was successful in peripheral systolic pressure values lying higher than 90 Torr, so that here a judgement of the function alone became possible with the help of the palpatory pressure measurement of the posterior tibial artery. Unfavourable local conditions, however, can be followed by negative tactile findings of the pulse also in higher pressure values.

[Clinical aspects and differential diagnosis of primary and secondary microangiopathies]. / Klinik und Differentialdiagnose der primären und sekundären Mikroangiopathien.

Diseases of the terminal vascular system are of particular diagnostic and differential-diagnostic importance in clinical angiology. While in the functional microangiopathies of the skin as a rule disturbances of the vasomotor function without an essential value of the disease are concerned, secondary organic changes of the wall of the vessel not infrequently determine the course and the prognosis of the basic disease (rheumatoid arthritis, collagenoses, hypertension and diabetes). Vasomotor trophic disturbances are observed also post-traumatically, post-operatively, after exposition to cold, in a lesion of the central nervous system and vertebra nerve irritations. For the allergic hyperergic vasculitides, which show an extraordinary polymorphism in the clinical picture in characteristic histological findings, an auto-immune pathogenesis is to be supposed. The chronic arterial hypertension leads to arteriolosclerosis and necrosis with adequate organic symptoms. In the diabetic microangiopathy we may demarcate functional pre-stages from irreversible structural changes of the vessels, in which case apart from the peripheral microangiopathy of the skin the retinopathy and nephropathy are to be classified as particularly important clinical manifestations.

[Angiological criteria of the functional capacity in arterial occlusive diseases of extremities after vascular surgery]. / Angiologische Kriterien der Leistungsfähigkeit arteriell durchblutungsgestörter Extremitäten nach gefässrekonstruktiven Eingriffen

In order to avoid wrong estimations of the functional capacity of extremities with successfully reconstructed vessels in angioorganopathies, the use of reliable angiological measuring sizes in a broad spectrum is needed. Oscillography and longitudinal rheography as well as determinations of the arterial blood pressure deliver such qualitatively reliable parameters. For the judgment of the postreconstructive functional capacity one must not renounce the occlusion plethysmography of the veins which delivers quantitative measuring sizes. Other disturbances of the organs by the vascular basic disease present and concomitant diseases of middle and older age independent on the basic disease must always be taken into consideration in the general judgment.

[Disorders of the arterial blood supply in the upper extremities]. / Arterielle Durchblutungsstörungen der oberen Extremitäten.

Arteriopathies of the upper half of the body may lead to considerable functional disturbances of the arm and severe deficits on the part of the central nervous system. Due to good comparison they scarcely cause or do not cause any complaints in a no unconsiderable part. The clinical material consisting of 4,162 patients from five annual courses had in 9.2% occlusion and stenoses localized in the supraaortic and brachial region. The in most cases systemic angiopathy here explains the frequently combined appearance with arterial processes in the pelvic and the leg region. According to the height of the occlusion we clinically differ types of carotis, shoulder girdle, upper arm and peripheral-acral obliteration, which in each case show differences concerning frequency, age of manifestation, etiology, distribution of sex and clinical degree of severity. The angiological basic diagnostics is based on the inspection, palpation of the arteries, auscultation of the vessels, bilateral measuring of the blood pressure after Riva-Rocci and functional examinations, such as fist closure test and Allen test, as well as clinical proofs or exclusions of neurovascular syndromes of the shoulder girdle. The special apparative angiological methods comprise the oscillo-, rheo- and vein occlusion plethysmography, the Doppler ultrasound technique, estimations of the ophthalmic pressure, isotopic methods and angiographic exploration. --The individual angiological examination methods are of different importance according to the height localisation of the angioorganopathy. --The incomplete syndrome of the aortic arch is taken into consideration. In short the author adopts a definite attitude to the demands of therapy.

[Hemodynamics and metabolic parameters during use of the antihypertensive agent diazoxide]. / Hämodynamik und Stoffwechselparameter bei Anwendung des Antihypertonikums Diazoxid.

The antihypertensive remedy diazoxide (hyperstat) was applied in 11 patients with hypertension of the clinical stages III and IV. The patients were applied a single intravenous injection of 20 ml = 300 mg diazoxide. The behaviour of blood pressure, pulse, blood sugar and cortisol level as well as of the blood supply in rest of the musculature of the extremities was tested and evaluated. Within 1 minute after the injection the systolic blood pressure decreased by 12%, the diastolic by 20%. After an above all show increase of the diastolic blood pressure once more a slight decrease of the systolic blood pressure followed after 90 minutes, which lasted several hours. Also after 24 hours the blood pressure did not reach the original value. The increase of the pulse rate was clinically not relevant. The blood glucose increased in the 5th minute, after 15 minutes it reached its culmination point and, beginning with the 30th minute it showed a decreasing tendency. The initial values were got after 180 minutes. After the 15th minute began a relative short-term decrease of the plasma cortisol, which, however, again increased after 60 minutes. On the other hand the occlusion-plethysmographic investigations of the veins showed an increasing blood flow in rest up to 3 hours after the injection.

[The effect of glycerol trinitrate on the arterial pressure of the fingers]. / Einfluss von Glyceroltrinitrat auf den Fingerarteriendruck.

In 35 patients with healthy vessels, 52 patients with vasospasm and 42 patients with stenoses or obliteration of the finger arteries with the help of the Parks-ultrasound-Doppler device model 806-A and a finger cuff of the size of 3.5 X 5 cm the systolic pressure of the finger arteries was measured before and after the administration of glycerol trinitrate. Since in test persons with healthy vessels no significant differences of the radial and ulnar volar finger artery, of the single fingers of one hand or in the comparison of the sides of the two hands was found, a concentration could be done. The relative and absolute increase of the pressure of the finger artery under glycerol trinitrate was most conspicuous in patients with vasospasm. No essential changes, as we expected, occurred in patients with organic disturbances of the arterial blood supply. Under variation of the lower limits of the norm of the pressure of the finger arteries the high values of the sensitivity, specificity and efficiency which are characteristic for the ultrasound-Doppler pressure measurement, lying over 0.90 particularly after pharmacologic vasodilation.

[Investigation by borrowing-lending-phenomenon under conditions of intraarterial induced vasodilatation (author's transl)]. / Untersuchungen zum Borrowing-Lending-Phnomen unter den Bedingungen einer intraarteriell induzierten Vasodilation.

In fourty patients with peripheric atherosclerosis obliterans blood flow was measured by means of venous occlusion plethysmography during an intraarterial and an intravenous infusion of ATP. The intraarterial application showed a significantly higher increase of blood flow than the intravenous in the sick extremities. The "borrowing-lending-phenomenon" happened more seldom than after an intravenous load. This withdrawal of blood occurred most frequently in patients with proximal occlusions, when the infusion reached casually the arteria femoralis profunda only. The "borrowing-lending-phenomenon" can be measured by the poststenotic pressure and by the volume of blood flow in time. Then the patients complain about a begining or an increasing of an ischemic pain at rest.

[Evaluation of function in the clinically early stages of arterial occlusive disease]. / Funktionsbeurteilung in klinischen Frühstadien der arteriellen Verschlusskrankheit.

In order to prove inhibitions of the arterial system in the region of the lower extremities and for the judgement of their haemodynamic efficacy Doppler-sonographic measurements of the systolic pressure in patients in the asymptomatic stage I after Fontaine were performed. With regard to the early recognition and judgment of the function the behaviour of the peripheral blood pressure concerning the standardized work of the muscles of the arterial ischaemia, measured at size and duration of the induced decrease of pressure, proved to be particularly evident. Diagnostic informations going beyond the examination under conditions of rest could be brought so that the functional test is particularly suitable for the recognition of early clinical stages the arterial obturation disease in the region of the extremities.