[Patient with a Fontan circulation undergoing caesarean section: Anesthesiological management]. / Sectio caesarea bei einer Patientin mit Fontan-Zirkulation : Anästhesiologisches Management.

Adults suffering from congenital heart diseases (CHD) represent a challenge to anesthesiologists because of the diverse pathologies, complex pathophysiology and special treatment strategies. Due to improved therapeutic options for CHD, patient quality of life and life expectancy is increasing, leaving them as a growing population including pregnant patients with CHD. This article presents the main principles of the pathophysiology and anesthesiological management of pregnant patients living with a Fontan circulation based on a case report, which was complicated by an aortic coarctation and atonic uterine hemorrhage.

Structured illumination fluorescence microscopy with distorted excitations using a filtered blind-SIM algorithm.

Structured illumination microscopy (SIM) is a powerful technique for obtaining super-resolved fluorescence maps of samples, but it is very sensitive to aberrations or misalignments affecting the excitation patterns. Here, we present a reconstruction algorithm that is able to process SIM data even if the illuminations are strongly distorted. The approach is an extension of the recent blind-SIM technique, which reconstructs simultaneously the sample and the excitation patterns without a priori information on the latter. Our algorithm was checked on synthetic and experimental data using distorted and nondistorted illuminations. The reconstructions were similar to that obtained by up-to-date SIM methods when the illuminations were periodic and remained artifact-free when the illuminations were strongly distorted.

Modified patient-controlled remifentanil bolus delivery regimen for labour pain*.

To improve the analgesic efficiency and to simplify the administration of remifentanil for systemic analgesia in labour, we contrived a modified delivery regimen with a specific infusion profile and variable dosing and conducted a single-blind randomised crossover study to compare it with the previous 'classical' regimen. Parturients received both regimens in interchangeable sets, each with five contractions. We compared pain and satisfaction scores, maternal and fetal vital parameters, side-effects and other events. Twenty-three parturients completed the study. No differences in observed parameters were noticed except for slightly lower blood pressure with the modified regimen. Pain estimates were lower in women starting with the modified regimen (p = 0.005), and there were fewer requests for analgesia within the lockout period (31 vs 69, p = 0.041) and bolus adjustments (0 vs 25, p < 0.001) with the modified regimen.

Repeated transarterial chemoembolisation using different chemotherapeutic drug combinations followed by MR-guided laser-induced thermotherapy in patients with liver metastases of colorectal carcinoma.

BACKGROUND: To evaluate a treatment protocol with repeated transarterial-chemoembolisation (TACE) downsizing before MR-guided laser-induced interstitial thermotherapy (LITT) using different chemotherapeutic combinations in patients with unresectable colorectal cancer (CRC) liver metastases. METHODS: Two hundred and twenty-four patients were included in the current study. Transarterial-chemoembolisation (mean 3.4 sessions per patient) was performed as a downsizing treatment to meet the LITT requirements (number5, diameter <5 cm). The intra-arterial protocol consisted of either Irinotecan and Mitomycin (n=77), Gemcitabine and Mitomycin (n=49) or Mitomycin alone (n=98) in addition to Lipiodol and Embocept in all patients. Post TACE, all patients underwent LITT (mean 2.2 sessions per patient). RESULTS: Overall, TACE resulted in a mean reduction in diameter of the target lesions of 21.4%. The median time to progression was 8 months, calculated from the start of therapy and the median local tumour control rate was 7.5 months, calculated as of therapy completion. Median survival of patients calculated from the beginning of TACE was 23 months (range 4-110 months), in patients treated with Irinotecan and Mitomycin the median was 22.5 months, Gemcitabine and Mitomycin 23 months and Mitomycin only 24 months with a statistically significant difference between the groups (P<0.01). CONCLUSION: Repeated TACE offers adequate downsizing of CRC liver metastases to allow further treatment with LITT. The combined treatment illustrates substantial survival rates and high local tumour control with statistically significant differences between the three protocols used. Further randomised trials addressing the current study results are required.

Low-Dose Eptifibatide for Tandem Occlusion in Stroke: Safety and Carotid Artery Patency.

BACKGROUND AND PURPOSE: Maintaining carotid patency and avoiding symptomatic intracranial hemorrhage are competing concerns in tandem occlusions. This study provides data regarding the safety and efficacy of eptifibatide in stroke from tandem occlusion of the extracranial carotid artery and the intracranial carotid or middle cerebral artery. MATERIALS AND METHODS: This is a retrospective analysis of 58 consecutive patients who received low-dose eptifibatide (135-mcg/kg bolus, 1-mcg/kg/min infusion) during treatment of tandem occlusions. Brain imaging and carotid sonography were performed at 24-36 hours. mRS was documented at 90 days, and carotid sonography, at 30-60 days. RESULTS: The median age and NIHSS score were 64 years and 15, respectively. Twenty-five patients (43%) received tPA. ASPECTSs were 8-10 in 47 (81%) and 5-7 in 11 (19%) patients. Thirty-eight patients had angioplasty/stent placement acutely; 20 had angioplasty alone. Symptomatic intracranial hemorrhage occurred in 1 patient (2%). TICI 2b or higher was achieved in 56 patients (96%). Fifty-seven of 58 patients had clinical follow-up at 90 days (1 lost to follow up). The 90-day mRS was 0-2 in 42 patients (72%). There were 4/58 (7%) re-occlusions within 24-36 hours, all originally treated with stent placement. Forty-nine of 53 surviving patients had carotid sonography at 30-60 days, with 3 delayed re-occlusions, 2 with stents and 1 with angioplasty alone. The overall carotid patency at 30-60 days was 42/49 (86%). Carotid re-occlusion was not associated with clinical decline. CONCLUSIONS: Low-dose eptifibatide seemed to be safe in tandem occlusions (symptomatic intracranial hemorrhage, 2%), although asymptomatic cervical carotid artery re-occlusions still occurred in 14% of patients.

InterCarb: A Community Effort to Improve Interlaboratory Standardization of the Carbonate Clumped Isotope Thermometer Using Carbonate Standards.

Increased use and improved methodology of carbonate clumped isotope thermometry has greatly enhanced our ability to interrogate a suite of Earth-system processes. However, interlaboratory discrepancies in quantifying carbonate clumped isotope (Δ47) measurements persist, and their specific sources remain unclear. To address interlaboratory differences, we first provide consensus values from the clumped isotope community for four carbonate standards relative to heated and equilibrated gases with 1,819 individual analyses from 10 laboratories. Then we analyzed the four carbonate standards along with three additional standards, spanning a broad range of δ47 and Δ47 values, for a total of 5,329 analyses on 25 individual mass spectrometers from 22 different laboratories. Treating three of the materials as known standards and the other four as unknowns, we find that the use of carbonate reference materials is a robust method for standardization that yields interlaboratory discrepancies entirely consistent with intralaboratory analytical uncertainties. Carbonate reference materials, along with measurement and data processing practices described herein, provide the carbonate clumped isotope community with a robust approach to achieve interlaboratory agreement as we continue to use and improve this powerful geochemical tool. We propose that carbonate clumped isotope data normalized to the carbonate reference materials described in this publication should be reported as Δ47 (I-CDES) values for Intercarb-Carbon Dioxide Equilibrium Scale.

Norepinephrine methylation in fetal rat adrenals.

The activity of phenylethanolamine-N-methyl transferase, the enzyme that methylates norepinephrine to form epinephrine, increases rapidly in the fetal rat adrenal during the day preceding epinephrine accumulation. The developmental increase in enzyme activity and the accumulation of epinephrine are prevented by fetal hypophysectomy (decapitation). Administration of adrenocorticotrophic hormone or cortisol acetate largely reverses the effect of fetal decapitation.

Examining the influence of maternal bradycardia on neonatal outcome using automated data collection.

BACKGROUND: Due to the increasing number of caesarean sections, we investigated the influence of maternal bradycardia during general and regional anaesthesia on seven standard paediatric outcome parameters using our online recorded data. METHODS: Data from 1154 women undergoing caesarean section were investigated prospectively. Bradycardia was defined as a heart rate below 60 beats/min. The matched-pairs method was used to evaluate the impact of bradycardia on Apgar scores at 1, 5, and 10 min, umbilical artery pH and base excess, admission to paediatric intensive care unit, and seven-day mortality. Matched references were automatically selected among all patients from the data pool according to anaesthetic technique, sensory block height, urgency, maternal age and body mass index. Stepwise regression models were developed to predict the impact of intra-operative bradycardia on outcome variables with differences between matched pairs assessed using univariate analysis. RESULTS: Bradycardia was found in 146 women (12.7%) for whom a control could be matched in 131 cases (89.7%). Mean 5-minute Apgar score was 9.2+/-1.1 for study patients and 9.3+/-1.1 for controls. pH and base excess were not significantly different between groups. In cases of urgent surgery, neonates had an increased risk of 1.8 (95% CI 1.36-2.44, P<0.01) for an Apgar score

Effect of environmental temperature on glucose-induced insulin response in the newborn rat.

Blood glucose and plasma insulin and glucagon concentrations were determined in full-term rats delivered by cesarean section and exposed to 37 degrees C. or 24 degrees C. environmental temperature during the first hours of extrauterine life. When newborn rats were maintained at thermal neutrality (37 degrees C.), a transient period of hypoglycemia of two hours occurred, associated with a rapid fall in plasma insulin and a rise in plasma glucagon concentrations. During cold exposure (24 degrees C.), the blood glucose level remained stable over the four hours studied; the decrease of plasma insulin was sluggish while the rise of plasma glucagon was unchanged. In newborn rats maintained at 37 degrees C., an intraperitoneal glucose load one hour after delivery produced a marked rise in blood glucose and plasma insulin concentrations one hour later. The distribution of experimental points suggested a sigmoidal dose-response curve. By contrast in newborn rats kept at room temperature (24 degrees C.) the same glucose load did not induce any increase in plasma insulin in spite of hyperglycemia. However, phentolamine resulted in pronounced plasma insulin rise in hypothermic newborns in response to glucose administration. From these observations it is concluded that the in-vivo unresponsiveness of the beta cells to glucose at birth, reported by others, is mainly due to the experimental conditions.

Effect-site concentration of remifentanil during patient-controlled analgesia in labour.

BACKGROUND: Intravenous remifentanil has been described for patient-controlled analgesia in labour. Recently, the application of target-controlled infusion pumps with Minto's pharmacokinetic/pharmacodynamic model has been reported. Hypothetical effect-site remifentanil concentration during patient-controlled analgesia for labour has yet to be examined. The aim of this concept study was to explore characteristics of this parameter. METHODS: We performed a historical cohort study based on our previous randomised cross-over clinical trial and analysed hypothetical effect-site remifentanil concentration. Values at spontaneous vaginal delivery and Apgar scores were tested for correlation. The association between pain score and the corresponding effect-site remifentanil concentration before and after bolus administration, and their relative difference, was examined with a linear mixed-effects model, adjusted for other variables. RESULTS: A series of 23 parturients with uncomplicated singleton pregnancies were included. On average, effect-site remifentanil concentration was highest during the third quarter throughout our recordings (5.5ng/mL; maximum 15.8ng/mL). The mean (median) {IQR} [range] at spontaneous vaginal delivery (n=14) was 2.52 (1.32) {0.95-4.28} [0.65-6.88] ng/mL, all Apgar scores were >7, and no correlation was confirmed. A negative association between effect-site remifentanil concentration before bolus administration and pain score (scale 0-100) was observed (-3.9, 95% CI -5.16 to -2.61, P <0.01). CONCLUSIONS: The residual value of hypothetical effect-site remifentanil concentration before uterine contraction, at the beginning of bolus administration, predicted lower pain scores. Monitoring effect-site remifentanil concentration may be potentially useful when remifentanil is administered for labour analgesia. However, our results need to be confirmed with a pharmacokinetic model optimized for pregnant patients.

Growth hormone in encephalectomized rat fetuses, with comments on the effects of anesthetics.

Plasma and pituitary immunoreactive growth hormone (GH) was measured in 21.5-day-old rat fetuses under various experimental conditions. Encephalectomy on day 19.5 was used as a method for depriving the fetus of its hypothalamus. The fetuses were recovered on day 21.5 under maternal pentobarbital anesthesia. Total encephalectomy or partial encephalectomy (ablation of superficial brain structures) similarly affected fetal growth. The mean GH contents of the pituitaries were not significantly different in the four groups of fetuses studied: controls from intact females (1.38 +/- 0.19 mug/gland), controls from females submitted to surgery on day 19 (1.47 +/- 0.13 mug/gland), surgically encephalectomized fetuses (1.13 +/- 0.12 mug/gland), sham-operated fetuses (1.19 +/- 0.10 mug/gland). The mean plasma GH levels were the same in control fetuses of intact females (147 +/- 8 ng/ml) and in control fetuses of females submitted to surgery (168 +/- 9 ng/ml). The values were lower in sham-operated fetuses (118 +/- 11 ng/ml) and considerably reduced (P less than 0.001) in encephalectomized fetuses (60 +/- 8 ng/ml). Plasma GH was higher in the fetuses of females killed less than 2 min earlier, than in the fetuses of anesthetized females. In dams anesthetized with pentobarbital or ether, the fetal plasma levels of GH were not different after 15 or 45 min of maternal anesthesia. Under maternal urethane anesthesia, the fetal plasma GH was at 15 min significantly lower than it was under (P less than 0.01) or pentobarbital (P less than 0.05); 30 min later, it had increased by 40% (P less than 0.025). It appears that the release of GH in the fetus can be modified by anesthetics, and that some GH still is released by the pituitary gland in the absence of the hypothalamus.

Glucocorticosteroid receptors in the liver of normal and decapitated rabbit foetuses.

The affinity and the number of receptor sites for the synthetic steroid triamcinolone acetonide were studied in the livers of foetal rabbits. Twenty-two-, 24- and 29-day-old control and 29-day-old foetuses decapitated on day 22 were used to determine whether a change in steroid receptors occurs in the liver when it accumulates glycogen, and whether decapitation impairs such a change. Steroid receptors were found as early as day 22, when they were as numerous (0.091 pmol/mg protein) as on days 24 (0.098 pmol/mg) and 29 (0.104 pmol/mg). The binding affinity was found to be slightly higher on day 24 than on day 22 and it remained the same on days 24 and 29. The binding affinity of the receptors was the same in decapitated foetuses as in 29-day-old controls but the number of sites was slightly lower. The labelled steroid was transferred to the nucleus of the liver cells in vivo. It seems unlikely that steroid receptors are the limiting factor preventing the accumulation of glycogen in the liver of the rabbit foetus before day 26 or after decapitation.

Dissociation between testicular morphogenesis and functional differentiation of Leydig cells.

The aim of the study was to determine whether Leydig cells differentiate in vitro in gonads in which the formation of seminiferous cords is prevented by culture in a medium containing fetal calf serum. Appearance of 3 beta-hydroxysteroid dehydrogenase-positive cells and release of testosterone in the medium occurred at the same age irrespective of whether or not the gonads developed seminiferous cords. It is concluded therefore that testicular morphogenesis with the formation of seminiferous cords is not a prerequisite for the emergence and functional differentiation of Leydig cells.

Genetic and hormonal factors in sex differentiation of the brain.

The mode of chromosomal sex determination is opposite in mammals and in birds, the heterogametic sex being male in the former and female in the latter. This difference is parallel by a basic program of development of sex characters in the absence of gonads; this program is feminine in mammals and male in birds. 'Defeminization' is produced by the testes in male mammals, and 'demasculinization' is produced by the ovary in female birds. The same difference prevails in the permanent organizational effects of sex hormones on the neural structures mediating sex behavior, during a critical period. In mammals, especially in the rat, testosterone released by the testis controls the various sex characters. It can work as such, or after being converted locally into dihydrotestosterone or estradiol, in the cells of the end organ. Estradiol seems to be the actual intracellular 'defeminizing' agent in the central nervous system. In birds, especially in quail, accumulating data suggest that estradiol is the intracellular 'demasculinizing' agent.

Involvement of K(+) channels in the relaxant effects of YC-1 in vascular smooth muscle.

This study addresses the question whether K(+) channels are involved in the vasorelaxant effects of 3-(5'-hydroxymethyl-2'-furyl)-1-benzyl-indazole (YC-1 ). In rat aorta, guinea pig aorta, and guinea pig a. carotis, YC-1 inhibited contractions induced by phenylephrine (3 microM) more potently than those induced by K(+)(48 mM). In rat aorta, tetraethylammonium (10 mM), charybdotoxin (0.2 microM), and iberiotoxin (0.1 microM), but not glibenclamide (10 microM), attenuated the relaxant effects of YC-1. In guinea pig a. carotis, YC-1 (30 microM) induced a hyperpolarisation which was antagonised by 1H-[1,2,4]oxadiazolo[4, 3-a]quinoxalin-1-one (ODQ; 50 microM). In rat aorta, YC-1 (30 microM) increased the rate constant of 86Rb-efflux. The effect of YC-1 was potentiated by zaprinast (10 microM), but inhibited by ODQ (50 microM) or charybdotoxin (0.2 microM). In smooth muscle cells from rat aorta, YC-1 (10 microM) increased BK(Ca) channel activity. It is suggested that YC-1-induced vasorelaxation is partially mediated by the activation of K(+) channels.

Lip repair according to the principles of Delaire. What is its significance?

45 patients with UCLP/UCL and BCLP/BCL had a lip repair at a mean age of 4 months according to the principles of Delaire from 1989 to 1993. Their aesthetic results and the influence upon growth and symmetry of the face was evaluated by standardized checking of possible negative points of the lip, nose and alveolus, by measuring different distances of the mid-face in standardized photographs and by comparing the data with the literature. The aesthetic results are equal to other studies and there are some indications of a better stimulation of growth and harmonization of the face.

[Sertoli cells and organogenesis of the fetal testis (author's transl)]. / Cellules de Sertoli et organogenèse du testicule foetal.

In previous papers (1, 2), it was shown that in the rat fetus, testicular differentiation begins 13 days after fertilization, in the depth of the primordium near to mesonephric tubules. A few cells swell and differentiate into Sertoli cells which encompass the germ cells. In the meantime they delineate locally one part of the contour of the developing seminiferous cord, which is completed by the recruitment of new cells during the next hours. Under the electron microscope the differentiation of the Sertoli cells involves cytoplasmic and organelles changes, typical junctions and microfilaments toward the external surface of the seminiferous cord. Testicular differentiation can be obtained in vitro in cultures made in a synthetic medium without or with addition of chick embryo extract. Fetal calf serum prevents the organogenesis of the sex cords or produces the disintegration of those already differentiation (on day 14). These data clearly underline some of the cellular processes involved in the differentiation of the seminiferous cords.

Synchronized communication between people with dementia and their volunteer caregivers. A video-based explorative study on temporal aspects of interaction and the transfer to education.

Processes of demographic change are leading to decreasing human resources in professional as well as lay care; this decrease necessitates new concepts of care, especially for the growing number of people with dementia (p.w.d.). Since the amendment to the German Care Insurance Law (2002), family carers have been entitled to regular weekly relief, provided by volunteers who have been given a thirty-hour-training. As difficulties in information processing in p.w.d. form an important part of the symptoms in dementia sufferers--with a high impact on communication as well as competent functioning in activities associated with daily life, we wanted to establish how much awareness and sensitivity voluntary attendants show in "tuning in" to the p.w.d. and her/his individual capacity to interact. In an exploratory study the authors analyzed videotaped interactions between volunteer caregivers and dementia-sufferers which were recorded in everyday situations during the process of ongoing care. Using methods of Video Interaction Analysis and Grounded Theory, we developed categories which describe how in tune the helpers are with the timing skills--or lack of them--of p.w.d.. We think that understanding the different ways in which p.w.d. structure their time can improve their communication and interaction. The categories --"speed and adjustment of speed", "mutuality" and "time control"--seemed crucial in understanding the subsequent course of the interactions. In a second step, these categories have recently been used by students and staff of the Lausitz University of Applied Sciences to provide training that sensitizes volunteer attendants to the topic and to learn about volunteers; judgement on the importance of continuing education in this field.