Evaluation of practice change following SAFE obstetric courses in Tanzania: a prospective cohort study.

Anaesthesia has been shown to contribute disproportionately to maternal mortality in low-resource settings. This figure exceeds 500 per 100,000 live births in Tanzania, where anaesthesia is mainly provided by non-physician anaesthetists, many of whom are working as independent practitioners in rural areas without any support or opportunity for continuous medical education. The three-day Safer Anaesthesia from Education (SAFE) course was developed to address this gap by providing in-service training in obstetric anaesthesia to improve patient safety. Two obstetric SAFE courses with refresher training were delivered to 75 non-physician anaesthetists in the Mbeya region of Tanzania between August 2019 and July 2020. To evaluate translation of knowledge into practice, we conducted direct observation of the SAFE obstetric participants at their workplace in five facilities using a binary checklist of expected behaviours, to assess the peri-operative management of patients undergoing caesarean deliveries. The observations were conducted over a 2-week period at pre, immediately post, 6-month and 12-month post-SAFE obstetric training. A total of 320 cases completed by 35 participants were observed. Significant improvements in behaviours, sustained at 12 months after training included: pre-operative assessment of patients (32% (pre-training) to 88% (12 months after training), p < 0.001); checking for functioning suction (73% to 85%, p = 0.003); using aseptic spinal technique (67% to 100%, p < 0.001); timely administration of prophylactic antibiotics (66% to 95%, p < 0.001); and checking spinal block adequacy (32% to 71%, p < 0.001). Our study has demonstrated positive sustained changes in the clinical practice amongst non-physician anaesthetists as a result of SAFE obstetric training. The findings can be used to guide development of a checklist specific for anaesthesia for caesarean section to improve the quality of care for patients in low-resource settings.

The activity of yeast Apn2 AP endonuclease at uracil-derived AP sites is dependent on the major carbon source.

Yeast Apn2 is an AP endonuclease and DNA 3'-diesterase that belongs to the Exo III family with homology to the E. coli exonuclease III, Schizosaccharomyces pombe eth1, and human AP endonucleases APEX1 and APEX2. In the absence of Apn1, the major AP endonuclease in yeast, Apn2 can cleave the DNA backbone at an AP lesion initiating the base excision repair pathway. To study the role and relative contribution of Apn2, we took advantage of a reporter system that was previously used to delineate how uracil-derived AP sites are repaired. At this reporter, disruption of the Apn1-initiated base excision repair pathway led to a significant elevation of A:T to C:G transversions. Here we show that such highly elevated A:T to C:G transversion mutations associated with uracil residues in DNA are abolished when apn1∆ yeast cells are grown in glucose as the primary carbon source. We also show that the disruption of Apn2, either by the complete gene deletion or by the mutation of a catalytic residue, results in a similarly reduced rate of the uracil-associated mutations. Overall, our results indicate that Apn2 activity is regulated by the glucose repression pathway in yeast.

Bilateral giant parathyroid adenoma in the absence of multiple endocrine neoplasia type 1.

INTRODUCTION: Bilateral giant parathyroid adenoma in the absence of multiple endocrine neoplasia (MEN) type 1 is extremely rare and literature on this subject is limited. CASE HISTORY: A 79-year-old man presented with acute kidney injury secondary to hypercalcaemia. Blood test results indicated primary hyperparathyroidism. Ultrasonography revealed bilateral parathyroid adenomas measuring 19.4mm x 19.5mm x 18.8mm (left) and 15.2mm x 18.3mm x 19.6mm (left) whereas on computed tomography, the measurements were 31mm x 20mm (left) and 30mm x 14mm (right). Intraoperatively, giant adenomas measuring 50mm x 25mm x 12mm (left, weighing 8.101g) and 48mm x 22mm x 10mm (right, weighing 7.339g) were identified and excised. Parathyroid hormone level dropped from 44.6pmol/l preoperatively to 8.9pmol/l postoperatively (normal range 1.3-7.6pmol/l). The patient was discharged with no complications. CONCLUSIONS: We report a rare phenomenon where bilateral giant parathyroid adenoma occurred in the absence of MEN type 1. It highlights the importance of cross-sectional imaging in delineating the anatomy of adenomas as their size can be grossly underestimated by ultrasonography alone.

Asymmetry during Functional Movement Screening and injury risk in junior football players: A replication study.

An indicator of movement quality and potential injury risk during Functional Movement Screen (FMS) testing is the presence of asymmetry when comparing the left and right sides of the body. The aim of the study was to investigate the reproducibility of the injury risk model proposed in our previous research (Chalmers et al. 2017; derivation study) that showed an increased injury risk for elite junior Australian football players demonstrating ≥2 asymmetrical FMS subtests. We used a direct replication design. Players underwent pre-season FMS testing, and an injury surveillance system monitored 277 male participants during the subsequent regular season competition. Designated club officials monitored the weekly competition participation of players. The definition of an injury was "a trauma or medical condition which caused a player to miss a competitive game". Cox proportional hazards regression models were used to investigate the relationship between asymmetry and number of games played before first injury (ie, survival time). The level of reproducibility was determined according to statistical significance, effect size, and subjective assessment. Demonstrating asymmetry during FMS testing was not associated with a significant increase in prospective injury risk in the replication study (P > .05). Moreover, effect sizes (hazard ratios) from the derivation dataset were not within the 95% confidence intervals of the respective asymmetry predictor in the replication dataset. Subjectively, researchers were in agreement that the findings from the derivation data were not successfully reproduced. Clinicians and researchers should be cautious about using FMS asymmetry findings to derive injury risk for junior football players.

Varying time-course of effects of high frequency stimulation of sub-regions of the globus pallidus in patients with parkinson's disease.

INTRODUCTION: Deep brain stimulation of the globus pallidus can be a highly effective treatment for patients with Parkinson's disease (PD), experiencing Levodopa-induced-dyskinesia (LID). Stimulation programming can focus simply on eliminating dyskinesia, or can also attempt to relieve the rigidity, tremor or akinesia of PD itself. METHODS: In this study, we explored whether additional benefit on the "off" symptoms and signs of PD, could be achieved in post-operative PD patients with good LID control, by making further adjustment to existing stimulation parameters directed towards the more superior electrode contacts, located in the Globus Pallidus pars externa (GPe). RESULTS: Acutely, GPe-DBS led to clear improvement in the akinesia, rigidity and tremor of PD in the off-medication state compared with Globus Pallidus pars interna (GPi) DBS (p = 0.003), however this was accompanied by the development of off-medication dyskinesia. Combined GPi-GPe DBS allowed maintained improvement but without dyskinesia. Follow up of patients over the subsequent 6-12 weeks showed gradual loss of this initial improvement. Switching back to GPi-DBS alone provided greater improvement in off medication symptoms than had been observed using the same GPi-DBS setting, 6-12 weeks previously. CONCLUSIONS: Benefits on the off-medication symptoms of PD obtained acutely with GPe-DBS are in general not sustained. Similarly, the effects of GPi-DBS on the off medication symptoms of PD, can evolve over short periods of time presumably as a result of changes in network-wide neuronal plasticity. These clinical observations provide further insight into DBS mechanism of action, and can also help inform optimal methods of GPi-DBS programming.

An evolutionarily conserved long noncoding RNA TUNA controls pluripotency and neural lineage commitment.

Here, we generated a genome-scale shRNA library targeting long intergenic noncoding RNAs (lincRNAs) in the mouse. We performed an unbiased loss-of-function study in mouse embryonic stem cells (mESCs) and identified 20 lincRNAs involved in the maintenance of pluripotency. Among these, TUNA (Tcl1 Upstream Neuron-Associated lincRNA, or megamind) was required for pluripotency and formed a complex with three RNA-binding proteins (RBPs). The TUNA-RBP complex was detected at the promoters of Nanog, Sox2, and Fgf4, and knockdown of TUNA or the individual RBPs inhibited neural differentiation of mESCs. TUNA showed striking evolutionary conservation of both sequence- and CNS-restricted expression in vertebrates. Accordingly, knockdown of tuna in zebrafish caused impaired locomotor function, and TUNA expression in the brains of Huntington's disease patients was significantly associated with disease grade. Our results suggest that the lincRNA TUNA plays a vital role in pluripotency and neural differentiation of ESCs and is associated with neurological function of adult vertebrates.

[Autoimmune epilepsy]. / Epilepsies d'origine auto-immune.

There is increasing recognition of an autoimmune origin of pharmacoresistant epileptic disorders. Besides the paraneoplastic limbic encephalopathies (LE), reports of syndromes of non-paraneoplastic LE are increasingly reported in the last 5-10 years. Three antibodies are now relatively well described: Voltage-gated potassium channels (VGKC), glutamic acid decarboxylase (GAD) and N-methyl-D-aspartate receptor-(NMDA) antibodies. We review clinical syndromes, associated imaging and laboratory findings. While most reports arise from adult populations, children and adolescents are also concerned as evidenced by increasing observations. Early recognition is mandatory, since early immunomodulatory treatment appears to be related to significantly better outcome.

Effect of dietary starch or micro algae supplementation on rumen fermentation and milk fatty acid composition of dairy cows.

Two experiments with rumen-fistulated dairy cows were conducted to evaluate the effects of feeding docosahexaenoic acid (DHA; C22:6 n-3)-enriched diets or diets provoking a decreased rumen pH on milk fatty acid composition. In the first experiment, dietary treatments were tested during 21-d experimental periods in a 4 x 4 Latin square design. Diets included a control diet, a starch-rich diet, a bicarbonate-buffered starch-rich diet, and a diet supplemented with DHA-enriched micro algae [Schizochytrium sp., 43.0 g/kg of dry matter intake (DMI)]. Algae were supplemented directly through the rumen fistula. The total mixed ration consisted of grass silage, corn silage, soybean meal, and a standard or glucogenic concentrate. The glucogenic and buffered glucogenic diet had no effect on rumen fermentation and milk fatty acid composition because, unexpectedly, no reduced rumen pH was detected. The algae diet had no effect on rumen pH but provoked decreased butyrate and increased isovalerate molar proportions in the rumen. In addition, algae supplementation affected rumen biohydrogenation of linoleic and linolenic acid as reflected in the modified milk fatty acid composition toward increased conjugated linoleic acid (CLA) cis-9 trans-11, CLA trans-9 cis-11, C18:1 trans-10, C18:1 trans-11, and C22:6 n-3 concentrations. Concomitantly, on average, a 45% decrease in DMI and milk yield was observed. Based on these drastic and impractical results, a second animal experiment was performed for 20 d in which 9.35 g/kg of total DMI of algae were incorporated in the concentrate and supplemented to 3 rumen-fistulated cows. Algae concentrate feeding increased rumen pH, which was associated with decreased rumen short-chain fatty acid concentrations. Moreover, a different shift in rumen short-chain fatty acid proportions was observed compared with the first experiment because molar proportions of butyrate, isobutyrate, and isovalerate increased, whereas acetate molar proportion decreased. The milk fatty acid profile changed as in experiment 1. However, the decrease in DMI and milk yield was less pronounced (on average 10%) at this algae supplementation level, whereas milk fat percentage decreased from 47.9 to 22.0 g/kg of milk after algae treatment. In conclusion, an algae supplementation level of about 10 g/kg of DMI proved effective to reduce the milk fat content and to modify the milk fatty acid composition toward increased CLA cis-9 trans-11, C18:1 trans, and DHA concentrations.

Direct atomic absorption spectrometry determination of tin, lead, cadmium and zinc in high-purity graphite with flame furnace atomizer.

This work described methodology of Sn, Pb, Cd and Zn impurities determination in high-purity graphite at direct atomic absorption spectrometry (AAS) with flame furnace (FF) atomizer. It was evidence that quality of AAS measurements are depended from sample amount, its homogeneity, particle size, as well as calibration procedure and operation parameters of FF atomizer. Prior to analysis the method has been developed and optimized with respect to the furnace heating temperature and flame composition of FF atomizer. Conditions of absorption peak areas (Q(A)) formation to each element were studied on the basis of contribution into its value some of individual parameters of analytes, including mass-transporting process from increasing mass of graphite samples into gas phase. Because particle size and homogeneous distribution of analyte in powdered materials has an enormous influence on accuracy and precision of measurement results, graphite as well as appropriate series of powdered reference standards was previously ground and investigated. Graphite samples to be analyzed and standard reference materials with mass from 0.025 to 0.200g was previously briquetted as pellet and insert on corresponding hole in furnace. The characteristic mass (g(0)) of Sn, Pb, Cd and Zn were 0.35, 0.1, 0.008 and 0.025ng, respectively, and relative standard deviation (S(r)) not more than 20%.

Early assessment of brain maturation by MR imaging segmentation in neonates and premature infants.

PURPOSE: We evaluated the impact of premature extrauterine life on brain maturation. PATIENTS AND METHODS: Twelve neonates underwent MR imaging at 40 (39.64 +/- 0.98) weeks (full term). Fifteen premature infants underwent 2 MR imaging examinations, after birth (preterm at birth) and at 40 weeks (41.03 +/- 1.33) (preterm at term). A 3D MR imaging technique was used to measure brain volumes compared with intracranial volume: total brain volume, cortical gray matter, myelinated white matter, unmyelinated white matter, basal ganglia (BG), and CSF. RESULTS: The average absolute volume of intracranial volume (269.8 mL +/- 36.5), total brain volume (246.5 +/- 32.3), cortical gray matter (85.53 mL +/- 22.23), unmyelinated white matter (142.4 mL +/-14.98), and myelinated white matter (6.099 mL +/-1.82) for preterm at birth was significantly lower compared with that for the preterm at term: the average global volume of intracranial volume (431.7 +/- 69.98), total brain volume (391 +/- 66,1), cortical gray matter (179 mL +/- 41.54), unmyelinated white matter (185.3 mL +/- 30.8), and myelinated white matter (10.66 mL +/- 3.05). It was also lower compared with that of full-term infants: intracranial volume (427.4 mL +/- 53.84), total brain volume (394 +/- 49.22), cortical gray matter (181.4 +/- 29.27), unmyelinated white matter (183.4 +/- 27.37), and myelinated white matter (10.72 +/- 4.63). The relative volume of cortical gray matter (30.62 +/- 5.13) and of unmyelinated white matter (53.15 +/- 4.8) for preterm at birth was significantly different compared with the relative volume of cortical gray matter (41.05 +/- 5.44) and of unmyelinated white matter (43.22 +/- 5.11) for the preterm at term. Premature infants had similar brain tissue volumes at 40 weeks to full-term infants. CONCLUSION: MR segmentation techniques demonstrate that cortical neonatal maturation in moderately premature infants at term and term-born infants was similar.

Palliative care in patients with multiple sclerosis.

Multiple Sclerosis (MS) is an inflammatory demyelinating disease of the central nervous system (CNS) and can be characterized by acute exacerbations or gradual worsening of neurological function and disability. The course of the disease is highly variable and unpredictable, however, there are short and long-term favorable and unfavorable predictive factors, which may provide some information about the future pattern of the disease. Palliative care in MS is directed at symptom management, psychosocial support, and rehabilitation. The goal in palliative care is to achieve a high quality of life. The disease modifying agents, interferon beta, Glatiramer acetate and Mitoxantrone are the mainstay of treatment in MS. Symptomatic relief and counseling of patients with MS have a strong impact on quality of life.

Phase 2 study of high dose etoposide (VP16-213) in hepatocellular carcinoma.

A phase II study of etoposide (VP16-213) in hepatocellular carcinoma was conducted among 18 Chinese patients. There was no observable tumour response but the treatment was relatively well tolerated with an overall median survival interval of 74 days.

A randomised cross-over trial comparing low-dose metoclopramide and chlorpromazine with high-dose metoclopramide in Chinese patients with advanced cancer receiving cisplatinum and 5-fluorouracil.

Nineteen Chinese patients receiving chemotherapy for advanced cancer were studied for chemotherapy-induced acute nausea and vomiting. The chemotherapy consisted of cisplatinum 100 mg/m2 i.v. infusion over 4 h on day 1 and 5-fluorouracil (5-FU) 1000 mg/m2 120-h continuous infusion from day 2 to day 6, repeated every 3 weeks. At the first course of chemotherapy the patients were randomized to receive either low-dose metoclopramide and chlorpromazine or high-dose metoclopramide, and then crossed over for the second course. In the high-dose metoclopramide group there was a suggestion of an earlier onset of emesis, with slightly more frequent retching and vomiting and less food consumed. However, the duration of emesis was shorter in the high-dose group. These differences were not statistically significant. There were no major side effects. Mild salutary drowsiness was noticed in patients receiving low-dose metoclopramide and chlorpromazine. This trial suggests that, in the dosage, route and schedule described, high-dose metoclopramide is no more effective than low-dose metoclopramide together with chlorpromazine in preventing cisplatinum-induced nausea and vomiting. The low-dose scheme is more economic and suitable for patients with advanced cancer.