Minimally Invasive Surgical Technique for the Management of Giant Dumbbell Spinal Schwannoma.

BACKGROUND: Completely extradural spinal schwannomas have a unique morphology (dumbbell tumors) with an intra- and extraspinal component. When they compromise two contiguous vertebral bodies or have an extraspinal extension >2.5 cm, they are classified as giant spinal schwannomas. The aim of this study is to present our experience in the surgical management of completely extradural giant spinal schwannomas with a minimally invasive approach. METHODS: This study is a case series of patients treated at the Neurosurgery Department of the University Clinical and Provincial Hospital of Barcelona, Spain, between January 2016 and December 2019. RESULTS: Fifteen patients met the inclusion criteria, with thoracic and lumbar spines being the most frequent locations. All patients underwent surgical treatment, with a mini-open interlaminar and far-lateral technique. Total gross resection was accomplished in all patients and spine instrumentation was not necessary. CONCLUSIONS: Microsurgery is the treatment of choice for spinal schwannomas, and gross total resection with low morbidity must be the surgical goal. Mini-open interlaminar and far-lateral access is a valid surgical option, with low morbidity in experienced hands, and there is no need for spinal instrumentation.

Clinical and Radiological Outcome in a Series of Patients Treated by Anterior Cervical Discectomy and Fusion: Retrospective Controlled Study With 2 Different Stand-Alone Cages.

BACKGROUND: Cervical spine balance and alignment targets after cervical spine surgery are poorly established in patients with cervical spine degenerative disease surgically treated by anterior cervical discectomy and fusion (ACDF). The objective of the study is to determine the correlation between radiological and clinical outcomes in patients surgically treated by ACDF with 2 different stand-alone cervical cages. METHODS: Clinical outcomes were evaluated using visual analog scale (VAS), Neck Disability Index (NDI), Nurick Scale, and Japanese Orthopedic Association score for myelopathy. Radiological evaluation included cervical and segmental Cobb angles, cervical sagittal vertical axis (cSVA), T1 slope (T1s), C0-C2 angle, fusion rates, adjacent segment degeneration, and cage subsidence. RESULTS: A total of 80 patients were included with an average age of 53 years. There was a statistically significant improvement in both clinical and radiological evaluations. There was a statistical significant correlation between cervical pain on cervical VAS and cSVA. There was a significant correlation between postoperative T1s and cSVA, related to the improvement in cervical angles. There was no significant difference in rates of fusion, adjacent segment changes, or reoperation between both cervical cages, and there was a higher rate of subsidence in the Aleutian group. There were significant differences between both groups on postoperative NDI and VAS, but this difference is not maintained during follow-up. CONCLUSIONS: Cervical sagittal balance is directly related to clinical outcome in patients with cervical spine degenerative disease. Both cervical implants analyzed were comparable in clinical and radiological outcomes. CLINICAL RELEVANCE: There are important clinical and radiological parameters that should be taken into account for the analysis of the surgical outcome of patients treated by ACDF; this is one of the few studies that report the results with 2 different cervical cage designs.

Obesity and Gestational Diabetes in Pregnant Care and Clinical Practice.

Obesity and Gestational Diabetes Mellitus (GDM) are the most frequent pathologies affecting mothers and offspring during pregnancy. Both conditions have shown a sustained increase in their prevalence in recent years, and they worsen the outcome of pregnancy and the long-term health of mothers. Obesity increases the risk of GDM and pre-eclampsia during pregnancy and elevates the risk of developing metabolic syndrome in later life. Offspring of obese mothers have an increased risk of obstetric morbidity and mortality and, consistent with the developmental origins of health and disease, a long term risk of childhood obesity and metabolic dysfunction. On the other hand, GDM also increases the risk of pre-eclampsia, caesarean section, and up to 50% of women will develop type 2 diabetes later in life. From a fetal point of view, it increases the risk of macrosomia, large-for-gestational-age fetuses, shoulder dystocia and birth trauma. The insulin resistance and inflammatory mediators released by a hypoxic trophoblast are mainly responsible for the poor pregnancy outcome in obese or GDM patients. The adequate management of both pathologies includes modifications in the diet and physical activity. Drug therapy should be considered when medical nutrition therapy and moderate physical activity fail to achieve treatment goals. The antenatal prediction of macrosomia is a challenge for physicians. The timing and the route of delivery should consider adequate metabolic control, gestational age, and optimal conditions for a vaginal birth. The best management of these pathologies includes pre-conception planning to reduce the risks during pregnancy and improve the quality of life of these patients.

Rescue Surgery in the Flow Diverter Era: Partial Trapping Plus Revascularization Technique for a Giant Carotid-Ophthalmic Aneurysm.

BACKGROUND: Flow diverters (FDs) are an excellent option for the management of giant carotid artery aneurysms. However, in a nonnegligible percent of cases, the aneurysm may continue to grow despite multiple endovascular treatments and apparent occlusion on the angiogram. Due to the recent introduction of FDs, surgical experience after their failure is scarce and neurosurgeons have to face these challenging cases without much previous reference. Here we describe a giant ophthalmic-carotid aneurysm that presented with new severe mass effect 5 years after initially successful treatment with FDs and coils. We investigate the likely advantages of partial trapping versus complete trapping in this particular type of case. CASE DESCRIPTION: A 63-year-old patient with a subarachnoid hemorrhage from a 26-mm left carotid-ophthalmic aneurysm was initially embolized with coils. One year later a recanalization was observed and treated with an FD. Five years afterward, the patient's mild cognitive impairment prompted a magnetic resonance image that showed significant aneurysm growth despite apparent occlusion on angiogram. Rescue surgery consisted of partial trapping + extracranial-intracranial bypass and aneurysm debulking. The patient recovered from his deficits and remains asymptomatic 2 years later. CONCLUSIONS: In selected patients with previous long-term FDs, partial trapping may be a choice even if aneurysm debulking is needed. After years of stent placement, some endothelialization and neointimal membrane formation could have a summing effect to facilitate surgical exclusion and enable a safe thrombectomy. Classic revascularization techniques must be rethought and retested in this new FD era scenario.

Neonates from women with pregestational maternal obesity show reduced umbilical vein endothelial response to insulin.

OBJECTIVE: Pregestational maternal obesity (PGMO) associates with foetoplacental vascular endothelial dysfunction and higher risk for insulin resistance in the neonate. We characterised the PGMO consequences on the insulin response of the human foetoplacental vasculature. METHODS: Umbilical veins were from pregnancies where the mother was with PGMO (body mass index 30-42.3 kg/m2, n = 33) or normal pregestational weight (PGMN) (body mass index 19.5-24.4 kg/m2, n = 21) with total gestational weight gain within the physiological range. Umbilical vein ring segments were mounted in a myograph for isometric force measurements. Primary cultures of human umbilical vein endothelial cells were used in passage 3. Vessel rings and cells were exposed to 1 nmol/L insulin (20 min) in the absence or presence of 100 µmol/L NG-nitro-l-arginine methyl ester (inhibitor of nitric oxide synthase, NOS). RESULTS: Vessel rings from PGMO showed reduced nitric oxide synthase-activity dependent dilation to insulin or calcitonin-gene related peptide compared with PGMN. PGMO associated with higher inhibitor phosphorylation of the insulin receptor substrate 1 (IRS-1) and lower activator phosphorylation of protein kinase B/Akt (Akt). Cells from PGMO also showed lower nitric oxide level and reduced activator serine1177 but increased inhibitor threonine495 phosphorylation of endothelial nitric oxide synthase (eNOS) and saturable transport of l-arginine. HUVECs from PGMO were not responsive to insulin. CONCLUSION: The lack of response to insulin by the foetoplacental endothelium may result from reduced IRS-1/Akt/eNOS signalling in PGMO. These findings may result in higher risk of insulin resistance in neonates to PGMO pregnancies.

Evaluación por médicos especialistas de curso de urgencias gineco-obstétricas utilizando metodología de simulación clínica / Evaluation by emergency medical specialists gyneco-obstetricians using clinical simulation methodology

Introducción: La simulación clínica es una herramienta de aprendizaje complementaria a los métodos tradicionales en la práctica clínica. Permite desarrollar habilidades y destrezas en escenarios seguros. La división de ginecología y obstetricia de la Universidad Católica (UC) imparte un curso de emergencias obstétricas para especialistas utilizando esta metodología. Presentamos la evaluación de los especialistas que realizaron el curso en el año 2016. Materiales y métodos: se realizó un curso de simulación de escenarios de emergencia en obstetricia, con un total de 16 horas separadas en 2 días. Con simuladores de alta y mediana complejidad. Tutoriados por instructores acreditados por el Institute of medical simulation de la Universidad de Harvard. Al finalizar el curso los participantes respondieron una encuesta escrita de diversos tópicos del curso. Resultados: participaron 93 especialistas. 76 por ciento de los participantes estuvo completamente de acuerdo y 23 por ciento de acuerdo con que la práctica con modelos simulados mejora la destreza relacionada con la realización de los procedimientos propuestos en el curso. El 100 por ciento de ellos indica que recibió retroalimentación considerada como útil durante las sesiones de entrenamiento y consideran que están completamente de acuerdo o de acuerdo con que esta metodología les permite cometer errores en forma segura. Conclusiones: la implementación de la metodología de simulación clínica en la docencia de emergencias obstétricas es muy bien evaluada por los especialistas, ya que entrega retroalimentación académica útil de cada caso y les permite cometer errores sin riesgos para los pacientes con un alto nivel de realismo.(AU)

Introduction: Clinical simulation is a learning tool complementary to traditional methods in clinical practice. It allows the development of skills and abilities in safe scenarios. The department of obstetrics and gynecology at the Catholic University offers an obstetrics emergency course for specialists using this methodology. Below we present the evaluation of the specialists who completed the course in 2016. Methods and Materials: A simulation course of emergency scenarios in obstetrics was carried out, distributed in clinical stations, with high and medium complexity simulators for a total of 16 hours' duration in 2 days. The tutors where instructors accredited by the Institute of medical simulation of Harvard University. At the end of the course the participants answered a written survey including various topics of the course. Results: Ninety-three specialists participated. 76 percent of the participants were in complete agreement and 23 percent agreed that the practice with simulated models improved the skills related to the clinical procedures proposed in the course. One hundred percent of them considered that the feedback received was useful during the training sessions and completely agreed that this methodology allows them to make mistakes in a safe form. Conclusions: The implementation of the methodology of clinical simulation in the teaching of obstetrical emergencies was very well evaluated by the specialists, since it provides useful academic feedback of each case and allows them to make mistakes without risks for the patients with a high level of realism.(AU)

Utilidad de factores pronósticos antenatales en pacientes con hernia diafragmática congénita aislada / Usefulness of antenatal prognostic factors in patients with hernia congenital diaphragmatic isolated

La Hernia Diafragmática Congénita (HDC) corresponde a una malformación del diafragma por la cual los órganos abdominales protruyen hacia la cavidad torácica durante el desarrollo intrauterino. Los recién nacidos afectados presentan grados variables de insuficiencia respiratoria e hipertensión pulmonar, asociándose a una alta morbilidad y mortalidad. Materiales y métodos: Se revisaron los casos de HDC controlados en los períodos pre y post-natal en el Hospital Clínico UC durante el período 2012-2016. Se analizaron los resultados perinatales según distintos factores pronósticos. Resultados: Fueron analizadas 26 embarazadas con diagnóstico de HDC. La sobrevida global fue de un 77% (20/26). La mortalidad global de las pacientes con herniación hepática fue de un 45% (5/11) versus 7% (1/15) en los fetos con hígado no herniado. La mortalidad neonatal fue de un 14% (3/21) en las pacientes con la relación pulmón cabeza (LHR), (observado/ esperado) o/e ≥ a 45% y 60% (3/5) cuando el LHR o/e es < 45%. De las pacientes con LHR o/e ≥ 45%, la necesidad de ECMO fue de un 33% (8/21) mientras que un LHR o/e < 45% fue de un 20% (1/5). Conclusión: La obtención antenatal de un LHR o/e ≥ 45% y ausencia de herniación hepática, son buenos predictores de sobrevida neonatal. La medición de LHR o/e no es capaz de discriminar que pacientes desarrollarán morbilidad respiratoria grave, por lo que debemos buscar nuevos y mejores modelos que permitan seleccionar que pacientes requerirán nacer en un centro con disponibilidad de terapias de soporte vital avanzado como el ECMO neonatal. (AU)

Congenital Diaphragmatic Hernia (CDH) is a malformation of the diaphragm muscle in which the abdominal organs protrude into the thoracic cavity during intrauterine development. Affected newborns have varying degrees of respiratory failure and pulmonary hypertension, associated with high morbidity and mortality. Materials and methods: Controlled HDC cases were reviewed in the pre and post-natal periods at the Clinical Hospital UC during the period 2012-2016. Perinatal results were analyzed according to different prognostic factors. Results: During the 2012-2016 period, 26 pregnant women with a diagnosis of CDH were monitored. The overall mortality of patients with hepatic herniation was 45% (5/11) versus 7% (1/15) in fetuses with a non-herniated liver. Neonatal mortality was 14% (3/21) in patients with o/e (observed/expected) LHR ≥ 45% and 60% (3/5) when the o/e LHR <45%. Of the patients with o/e LHR ≥ 45%, the need for ECMO was 33% (8/21), while a LHR o/e <45% was 20% (1/5). Conclusion: An o/e LHR ≥ 45% and absence of hepatic herniation are good predictors of neonatal survival. The o/e LHR measurement is not capable of identifying which patients will develop severe respiratory morbidity, so we must explore new and better models that allow us to select patients who need to give birth in centers with available advanced life support therapies, such as neonatal ECMO. (AU)

Preventive letter: doubling the return rate after gestational diabetes mellitus.

To measure the impact of a "Preventive Letter" designed to encourage the return of gestational diabetes mellitus (GDM) mothers to follow up visit after delivery, in the context of a worldwide concern about low return rates after delivery of these patients. Mothers with GDM require medical evaluation and an oral glucose tolerance test (OGTT) 6 weeks after delivery, in order to: [a] confirm remission of GDM and [b] provide advice on the prevention of type 2 diabetes. In the year 2003 we developed a "Preventive Letter", containing three aspects: [a] current treatment, [b] suggested management during labor, and [c] a stapled laboratory order for OGTT to be performed 6 weeks after delivery. The return rate after delivery was assessed in two groups of GDM mothers: [a] "Without Preventive Letter" (n = 253), and "With Preventive Letter" (n = 215). Both groups, similar with respect to age (33.0 ± 5.4 and 32.3 ± 4.9 years respectively, p = 0.166) and education time (14.9 ± 1.8 and 15.0 ± 1.8 years respectively, p = 0.494), showed a significant difference in the 1-year return rate after delivery, as assessed by the Kaplan-Meier test: 32.0 % for the group "Without Preventive Letter", and 76.0 % for the group "With Preventive Letter" (p < 0.001). The 1-year return rate after delivery of GDM mothers was 2.4 times higher in the group "With Preventive Letter" than in the group without it. We believe that this low-cost approach could be useful in other institutions caring for pregnant women with diabetes.

A three-dimensional computer-based perspective of the skull base.

OBJECTIVE: To describe our designed protocol for the reconstruction of three-dimensional (3D) models applied to various endoscopic endonasal approaches that allows performing a 3D virtual dissection of the desired approach and analyzing and quantifying critical surgical landmarks. METHODS: All human cadaveric heads were dissected at the Laboratory of Surgical Neuroanatomy of the University of Barcelona. The dissection anatomic protocol was designed as follows: 1) virtual surgery simulation systems, 2) navigated cadaver dissection, and 3) postdissection analysis and quantification of data. RESULTS: The virtual dissection of the selected approach, the preliminary exploration of each specimen, the real dissection laboratory experience, and the analysis of data retrieved during the dissection step provide a complete method to improve general knowledge of the main endoscopic endonasal approaches to the skull base, at the same time allowing the development of new surgical techniques. CONCLUSIONS: The methodology for surgical training in the anatomic laboratory described in this article has proven to be very effective, producing a depiction of anatomic landmarks as well as 3D visual feedback that improves the study, design, and execution in various neurosurgical approaches. The Dextroscope as a virtual surgery simulation system can be used as a preoperative planning tool that can allow the neurosurgeon to perceive, practice reasoning, and manipulate 3D representations using the transsphenoidal perspective acquiring specifically visual information for endoscopic endonasal approaches to the skull base. The Dextroscope also can be used as an advanced tool for analytic purposes to perform different types of measurements between surgical landmarks before, during, and after dissection.

Impact of an antimicrobial stewardship program on patients with acute bacterial skin and skin structure infections.

PURPOSE: The impact of an antimicrobial stewardship program (ASP) on the management of therapy and hospital resources for patients with acute bacterial skin and skin structure infections (ABSSSIs) at a community teaching hospital was evaluated. METHODS: A retrospective, observational chart review was performed to evaluate the impact of the ASP on patients admitted to Akron City Hospital with a diagnosis of ABSSSI between February 1 and August 20, 2012. Information on patient demographic characteristics, comorbidities, ABSSSI subtype, antibiotic therapy, microbiology, surgical interventions, and ASP recommendations was collected from medical records and the ASP intervention log. ASP recommendations were organized into five categories: dosage changes, de-escalation, antibiotic regimen change (i.e., change antibiotic regimen to a broad-spectrum antimicrobial or target a pathogen not being covered), infectious diseases (ID) formal consultation, and other. RESULTS: A total of 62 patients were included in the study. A total of 85 recommendations were made to attending physicians for these 62 patients, with an acceptance rate of 95%. The most common interventions included dosage changes, de-escalation, antibiotic regimen change, and ID consultation. When compared with historical data for 1149 patients, the intervention group had a significantly lower mean length of stay (LOS). The 30-day all-cause readmission rate was also significantly lower in the intervention group; however, the 30-day ABSSSI readmission rate did not differ significantly between groups. CONCLUSION: Interventions made by an ASP including a clinical pharmacist were associated with significant reductions in the mean LOS and 30-day all-cause readmission rate for patients with an ABSSSI compared with historical data.

Maternal hypertriglyceridemia: A link between maternal overweight-obesity and macrosomia in gestational diabetes.

OBJECTIVE: Infants born from overweight and obese mothers with glucose-controlled gestational diabetes (GDM) tend to be large-for-gestational age (LGA). It is hypothesized that this is due to an excessive rise in maternal triglyceride levels. METHODS: Two-hundred and seventy nine singleton GDM pregnancies were divided into three groups according to prepregnancy BMI: normal weight (BMI = 20-24.9; n = 128), overweight (BMI = 25-29.9; n = 105), and obese (BMI ≥ 30; n = 46). Individual z-scores (ZS) of maternal triglycerides and of newborn weight (NWZS) were calculated as deviations from published 50th percentiles. Mean z-scores (MZS) were the average of triglyceride ZSs. MZS of triglycerides, HbA1c and NWZS were compared. Variables are expressed as mean ± SD. RESULTS: In the three groups respectively: LGA (%) = 10.1%, 19.0% and 30.4% (P = 0.015). Birth weight (g) = 3274.2 ± 501.3, 3342.4 ± 620.2 and 3366.3±644.7 (RSPEARMAN = 0.111, P = 0.027). HbA1c (%) = 5.2 ± 0.39, 5.3 ± 0.50 and 5.4 ± 0.47 (P = NS). Triglyceride MZS = 1.20 ± 1.13, 1.52 ± 1.37 and 1.62 ± 1.42 (RSPEARMAN = 0.116, P = 0.024). Correlations between triglyceride MZS and NWZS were, respectively: r = 0.12 (P = NS), r = 0.42 (P <0.001), and r = 0.47 (P < 0.001). CONCLUSIONS: In overweight and obese GDM mothers, maternal triglycerides are partially responsible for LGA infants despite good maternal glucose control during pregnancy.

[Women age as a risk factor for maternal, fetal, neonatal and infant mortality]. / La edad de la mujer como factor de riesgo de mortalidad materna, fetal, neonatal e infantil.

BACKGROUND: Adolescent pregnancy and advanced maternal age are associated with increased risk for maternal, perinatal and infant death. However, the maternal age with the lowest reproductive risk has not been established. AIM: To determine the range of maternal age with the lowest reproductive risk. MATERIAL AND METHODS: A population-based study (2005-2010) was performed analyzing raw data from vital statistics yearbooks of the National Institute of Statistics of Chile. The association of maternal, fetal, neonatal and infant mortality with maternal age was analyzed. The latter was stratified in quinquenniums, between ages 10 and 54 years. Maternal, fetal, neonatal and infant mortality rates were calculated for each quinquennium. The lowest rate was selected as a control group for risk analysis, which was estimated according to Odds Ratio with 95% confidence intervals. RESULTS: Women of 20-29, 25-34 and under 30 years, had the lowest rate of fetal, neonatal/infant and maternal death, respectively. Women aged 45-49 years had the higher rate of maternal, fetal, neonatal and infant mortality. The risk of fetal, neonatal and infant mortality doubled from 40-44 years onwards, and maternal mortality from the age of 30-34 years. CONCLUSIONS: Our results suggest that the maternal age range with the lesser general reproductive risk is between 20-29 years. This finding should be considered in future studies of reproductive risk and for an appropriate counseling about conception.

Contact precautions: more is not necessarily better.

OBJECTIVE: To determine whether increases in contact isolation precautions are associated with decreased adherence to isolation practices among healthcare workers (HCWs). DESIGN: Prospective cohort study from February 2009 to October 2009. SETTING: Eleven teaching hospitals. PARTICIPANTS: HCWs. METHODS: One thousand thirteen observations conducted on HCWs. Additional data included the number of persons in isolation, types of HCWs, and hospital-specific contact precaution practices. Main outcome measures included compliance with individual components of contact isolation precautions (hand hygiene before and after patient encounter, donning of gown and glove upon entering a patient room, and doffing upon exiting) and overall compliance (all 5 measures together) during varying burdens of isolation. RESULTS: Compliance with hand hygiene was as follows: prior to donning gowns/gloves, 37.2%; gowning, 74.3%; gloving, 80.1%; doffing of gowns/gloves, 80.1%; after gown/glove removal, 61%. Compliance with all components was 28.9%. As the burden of isolation increased (20% or less to greater than 60%), a decrease in compliance with hand hygiene (43.6%-4.9%) and with all 5 components (31.5%-6.5%) was observed. In multivariable analysis, there was an increase in noncompliance with all 5 components of the contact isolation precautions bundle (odds ratio [OR], 6.6 [95% confidence interval (CI), 1.15-37.44]; P = .03) and in noncompliance with hand hygiene prior to donning gowns and gloves (OR, 10.1 [95% CI, 1.84-55.54]; P = .008) associated with increasing burden of isolation. CONCLUSIONS: As the proportion of patients in contact isolation increases, compliance with contact isolation precautions decreases. Placing 40% of patients under contact precautions represents a tipping point for noncompliance with contact isolation precautions measures.

La edad de la mujer como factor de riesgo de mortalidad materna, fetal, neonatal e infantil / Women age as a risk factor for maternal, fetal, neonatal and infant mortality

Background: Adolescent pregnancy and advanced maternal age are associated with increased risk for maternal, perinatal and infant death. However, the maternal age with the lowest reproductive risk has not been established. Aim: To determine the range of maternal age with the lowest reproductive risk. Material and Methods: A population-based study (2005-2010) was performed analyzing raw data from vital statistics yearbooks of the National Institute of Statistics of Chile. The association of maternal, fetal, neonatal and infant mortality with maternal age was analyzed. The latter was stratified in quinquenniums, between ages 10 and 54 years. Maternal, fetal, neonatal and infant mortality rates were calculated for each quinquennium. The lowest rate was selected as a control group for risk analysis, which was estimated according to Odds Ratio with 95% confidence intervals. Results: Women of 20-29, 25-34 and under 30 years, had the lowest rate of fetal, neonatal/infant and maternal death, respectively. Women aged 45-49 years had the higher rate of maternal, fetal, neonatal and infant mortality. The risk of fetal, neonatal and infant mortality doubled from 40-44 years onwards, and maternal mortality from the age of 30-34 years. Conclusions: Our results suggest that the maternal age range with the lesser general reproductive risk is between 20-29 years. This finding should be considered in future studies of reproductive risk and for an appropriate counseling about conception.

Spontaneous chronic epidural hematoma of the lumbar spine mimicking an extradural spine tumour.

PURPOSE: Spontaneous chronic epidural hematomas are extremely rare and can be extremely challenging to diagnose and differentiate. The clinical findings, computed tomographic scan and magnetic resonance imaging does not always enough to complete differentiate this condition. Our purpose is to report a case of a spontaneous chronic epidural hematoma presenting as an extradural mass leading to compressive radicular symptoms with images of bony scalloping which are sparsely reported in the literature. METHODS: We describe a 61-year-old woman who was evaluated after 18-month history of pain, disestesias and mild weakness in both lower extremities with significant radicular symptoms on the right side associated to neurogenic claudication. RESULTS: CT scans revealed a nodular image of soft tissue density located in the right anterolateral epidural space at the L4-L5 level demonstrating resorption of the bony margins. MRI studies revealed a round mass in the vertebral canal displacing the dural sac and scalloping the posterior wall of the L4 vertebral body. Diagnosis was established between a degenerative cyst versus an atypical neurinoma. Surgical findings demonstrated an isolated well-formed chronic hematoma. CONCLUSION: Spontaneous chronic epidural hematomas are rare, even more when they produce scalloping of bony structures becoming a diagnostic challenge. Therefore they should be always considered as a differential diagnosis in patients with extradural chronic compressions taking into account that also chronic epidural hematomas can cause bone involvement.

Isoform α of PKC may contribute to the maintenance of pregnancy myometrial quiescence in humans.

We postulate that protein kinase C α (PKCα) may contribute to the maintenance of pregnancy myometrial quiescence in humans. We studied the changes in myometrial PKCα gene products (messenger RNA [mRNA] and protein) in 4 groups of women: preterm not in labor (PT-NL), preterm in labor (PT-L), term not in labor (T-NL), and term in labor (T-L). The degree of PKCα activation was studied by comparing the levels of particulate (active) PKCα with the total PKCα protein levels and by measuring PKCα activity in the cytosolic and particulate fractions. Protein kinase Cα abundance (mRNA and protein) did not increase during myometrial quiescence (PT-NL), whereas the level of PKCα activity significantly increased during quiescence. The activity of PKCα significantly decreased in the T-NL, T-L, and PT-L groups. These findings suggest that PKCα plays a significant role in the maintenance of myometrial quiescence and that PKCα activity must decrease at the end of pregnancy allowing myometrial activation. Additionally, our data demonstrate an association between reduced PKCα activity and preterm labor, which merits further investigation.

Mechanical stretch increases brain natriuretic peptide production and secretion in the human fetal membranes.

Brain natriuretic peptide (BNP) is synthesized by human fetal membranes, both the amnion and chorion. This locally produced BNP inhibits the contraction of the human myometrium, contributing to the maintenance of myometrial quiescence during pregnancy. We tested the hypothesis that BNP production is increased by fetal membrane stretching, which is predicted to occur in the expanding uterus, and inhibited by epidermal growth factor (EGF), whose production in the fetal membranes increases in late pregnancy. Term fetal membranes were obtained during elective cesarean delivery before labor. Sections of membranes were placed in an isolated chamber containing DMEM: F12 medium (37°C) and stretched with a 35 g weight. Medium and tissue samples were collected at 0, 3, 6, 18, and 24 hours for measurement of messenger RNA (mRNA) and BNP levels in the presence/absence of EGF (2 × 10(-9 )mol/L). Inducible nitric oxide synthase (iNOS) and ß-actin were also evaluated to discard a nonspecific effect of mechanical stretch on protein expression. We found that amnion and chorion stretching increased the BNP mRNA (reverse transcription-polymerase chain reaction [RT-PCR]) and protein (radioimmunosorbent assay [RIA]) levels from 18 hours onward. The effect of stretching was inhibited by EGF (2 × 10(-9) mol/L). Stretch did not increase iNOS or ß-actin protein levels. We concluded that chorion and amnion stretching may increase BNP expression in the fetal membranes during pregnancy, while increasing biological activity of EGF may decrease BNP production in the chorion and amnion late in pregnancy. We postulate BNP is an important regulator of myometrial contractility during pregnancy, and its production is modulated by both stretch and progressive increase in EGF levels during pregnancy.