Obesity, maternal smoking and SHBG in neonates.

BACKGROUND: Sex hormone binding globulin (SHBG), a glycoprotein produced by hepatocytes that transports testosterone and other steroids in plasma, is a marker for developing metabolic syndrome and T2DM. SHBG is present in umbilical cord blood where it may be epigenetically regulated. This study was conducted to investigate whether the fetal environment, based on maternal pre-pregnancy weight, pregnancy weight gain or smoking during pregnancy, influence SHBG in newborns. METHODS: Maternal and newborn characteristics and SHBG levels and other variables were measured in cord and day 2 heel-stick blood samples in 60 healthy full-term singleton babies (31 F, 29 M). RESULTS: SHBG levels varied nearly fivefold among male and female newborns and were unrelated to sex, neonatal adiposity, determined by the Ponderal index and skinfold thickness, nor TNF∝ in cord blood. There were also no statistically significant associations between pre-pregnancy weight or pregnancy weight gain and newborn SHBG levels. However, cord blood SHBG was higher and insulin levels were lower when mothers were smokers, but normalized by day 2. DISCUSSION: While SHBG levels are low in obese children and adults, and portend the development of metabolic syndrome and T2DM, our study of healthy babies born to normal women, found no connection between maternal obesity or newborn adiposity and SHBG levels in newborns. Insofar as women who smoked during pregnancy were thinner and had lower cord blood insulin levels than nonsmokers, higher SHBG in their newborns at birth might have been due to insulin sensitivity, or perhaps to an effect of smoking on placental gene expression. CONCLUSIONS: Factors other than maternal weight and pregnancy weight gain appear to be the major determinants of SHBG in newborns. Higher SHBG levels when mothers smoke during pregnancy may contribute to overweight beginning later in childhood. Whether newborn SHBG levels predict the development of overweight and metabolic syndrome remains to be determined.

Partial Tears of the Distal Biceps Brachii Tendon: A Systematic Review of Surgical Outcomes.

PURPOSE: To systematically review the literature regarding surgical outcomes for treatment of partial tears of the distal biceps brachii tendon. METHODS: This study was conducted in accordance with the Preferred Reporting Items for Systematic Review and Meta-Analysis guidelines. A systematic review of the literature regarding treatment of partial tears of the distal biceps tendon was conducted using PubMed, Embase, and Cochrane. Inclusion criteria consisted of studies in the English language on the treatment of partial distal biceps tendon tears. Exclusion criteria consisted of (1) studies without outcome data, (2) studies that did not specify the degree of distal biceps tendon tear (ie, complete rupture vs partial tear), and (3) studies without partial tear subgroup data. Two investigators independently reviewed the abstracts from all identified articles. RESULTS: Only 5 patients who underwent successful nonsurgical treatment were identified; all were treated with different algorithms, and because of the small number, outcomes for nonsurgical treatment are not included in this review. Therefore, 19 studies involving 86 partial tears that underwent surgical treatment are reported; at least 65 of these received a trial of nonsurgical treatment before surgery. Surgery resulted in 94% satisfactory clinical outcomes. Of the 16 studies (n = 83) that specified the presence or absence of surgical complications, lateral antebrachial cutaneous nerve paresthesia (17%), posterior interosseous nerve palsy (6%), elbow discomfort (2%), surgical revision (2%), and asymptomatic heterotopic ossification (1%) were reported. CONCLUSIONS: Surgical treatment including tendon tear completion and anatomic repair to the radial tuberosity can yield satisfactory results and appears to provide predictable outcomes. Further research is necessary to better define the optimal regimen and duration of nonsurgical treatment, as well as the indications for surgery. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

The maternal early warning criteria: a proposal from the national partnership for maternal safety.

Case reviews of maternal death have revealed a concerning pattern of delay in recognition of hemorrhage, hypertensive crisis, sepsis, venous thromboembolism, and heart failure. Early-warning systems have been proposed to facilitate timely recognition, diagnosis, and treatment for women developing critical illness. A multidisciplinary working group convened by the National Partnership for Maternal Safety used a consensus-based approach to define The Maternal Early Warning Criteria, a list of abnormal parameters that indicate the need for urgent bedside evaluation by a clinician with the capacity to escalate care as necessary in order to pursue diagnostic and therapeutic interventions. This commentary reviews the evidence supporting the use of early-warning systems and describes The Maternal Early Warning Criteria, along with considerations for local implementation.

The maternal early warning criteria: a proposal from the national partnership for maternal safety.

Case reviews of maternal death have revealed a concerning pattern of delay in recognition of hemorrhage, hypertensive crisis, sepsis, venous thromboembolism, and heart failure. Early-warning systems have been proposed to facilitate timely recognition, diagnosis, and treatment for women developing critical illness. A multidisciplinary working group convened by the National Partnership for Maternal Safety used a consensus-based approach to define The Maternal Early Warning Criteria, a list of abnormal parameters that indicate the need for urgent bedside evaluation by a clinician with the capacity to escalate care as necessary in order to pursue diagnostic and therapeutic interventions. This commentary reviews the evidence supporting the use of early-warning systems, describes The Maternal Early Warning Criteria, and provides considerations for local implementation.

Pituitary adenylate cyclase-activating polypeptide (PACAP) in fetal cord blood.

BACKGROUND: Pituitary adenylate cyclase-activating peptide (PACAP) is a centrally-acting peptide with highest concentration within the limbic area of the brain. PACAP is also expressed in and affects the functions of vascular and nervous tissues, endocrine glands, and the placenta. PACAP appears to be associated with the 'fight-or-flight' response to emergency partly through its effect on adrenal production of cortisol and catecholamines. OBJECTIVES: We sought to explore the impact of labor as a stressor on the level of PACAP in the fetus, and hypothesized that PACAP levels would be increased when labor, abnormal fetal heart tracing, or fetal growth impairment was evident. METHODS: Fetal cord venous blood samples were collected immediately after delivery from a random group of women undergoing either vaginal or Cesarean delivery. The blood was placed in chilled EDTA-aprotinin containing tubes, centrifuged, and stored at -80°C for PACAP immunoassay. Delivery data were abstracted for analysis. RESULTS: The level of PACAP in cord blood was similar in both males and females. There was a trend toward higher levels in the cord blood of fetuses delivered by Cesarean compared to those delivered vaginally. PACAP levels were unrelated to birth weight, Apgar scores, and the presence or absence of labor prior to delivery. CONCLUSIONS: While PACAP and its receptor are expressed in placenta, and PACAP protein is found in cord blood, no effect of labor stress on PACAP was found. Further research is needed to understand the role of PACAP in gestation and parturition.

Strategies to reduce maternal mortality in developed countries.

PURPOSE OF REVIEW: To review the recent literature regarding maternal mortality, especially in developed countries, and to provide suggestions for clinical action addressing the rising trend. RECENT FINDINGS: Worldwide maternal deaths declined over the past 20 years; however, it is unlikely that the United Nations' Millennium Development Goal 5 for a 75% reduction in maternal mortality by 2015 will be achieved. Ninety-nine percent of the annual preventable maternal deaths from complications of pregnancy and childbirth occur in developing countries, particularly sub-Saharan Africa. In developed countries, including the United States, numerous strategies have developed to recognize the factors leading to maternal death and to implement systems' changes allowing interventions. In many cases, maternal death is avoidable but oftentimes a patient is saddled with life-long medical consequences. Near-misses are increasing which place a burden not only on the family but also on the healthcare system and overall community. SUMMARY: The United States has a rising trend in maternal deaths. To achieve a reduction within all developed countries there must be coordinated death review activities that investigate every case along with near-misses. Recommendations for changes within the medical system will continue to improve maternal health not only in developed countries but also worldwide.

Treatment of chronic biceps tendon ruptures.

Repair of distal biceps tendon ruptures has become widely accepted. Unfortunately, care of chronic injuries remains a challenge to the orthopedic surgeon. Patients with chronic ruptures often present complaining of weakness in elbow flexion and supination. Nonoperative management of these injuries does not restore function to the elbow. Tenodesis of the biceps tendon to the brachialis may improve flexion strength but does not reliably improve supination weakness. Addressing these injuries through restoration of anatomy, either with direct repair of the tendon to the radial tuberosity or with the use of a tendon graft to regain length, results in improved functional outcomes. Complications rates appear to be increased when surgery is performed in chronic injuries compared to those operated upon acutely.

Maternal mortality in the United States--why is it important and what are we doing about it?

Following dramatic reductions between the early 1900s and the early 1980s, the maternal mortality ratio began to rise, reaching a peak of almost 17 maternal deaths per 100,000 live births. Although this number pales in comparison with that found in sub-Saharan Africa and India, the troubling rise in the United States is a surrogate for medical care in general and obstetrical care in particular. Both Healthy People 2010 and the United Nations Millennium Goals were aimed at reducing maternal mortality worldwide. This presentation will review the trends in maternal mortality along with the efforts some jurisdictions, along with the American Congress of Obstetricians and Gynecologists, have taken to address this obstetrical tragedy. Although maternal death is the tip of the iceberg, thousands more women suffer a "near-miss" but survive to deal with lifelong medical consequences. Finally, you will be reminded that each maternal death is not just an isolated medical event but rather it permanently affects an ever-enlarging circle of society.

Repair of acute and chronic distal biceps tendon ruptures using the EndoButton.

There are many ways to repair distal biceps tendon ruptures with no outcome studies demonstrating superiority of a specific technique. There are few studies reporting on the repair of acute and chronic distal biceps tendon ruptures using the EndoButton via an anterior single-incision approach. We report on 27 patients who underwent distal biceps tendon repair with an EndoButton. The average age was 50.1 years (range, 36-78). There were 17 acute repairs (within 4 weeks of injury), nine chronic repairs (greater than 4 weeks), and one revision of a previous acute repair. All chronic repairs were repaired without the need for graft augmentation. Patients were assessed postoperatively using the ASES elbow outcome instrument and isokinetic flexion and supination strength and endurance testing. Eight control subjects were also tested for comparison. At an average follow-up of 30.9 months, 26 of 27 patients returned to their previous employment and activity level. The average ASES elbow score was 98.2 (range, 81-100). Compared with the contralateral extremity, there was no loss of motion. Average flexion strength recovery was 101% and mean supination strength recovery was 99%. There was no significant difference in function or strength with repair of acute versus chronic ruptures. Using the EndoButton technique, acute and chronic distal biceps tendon ruptures can be repaired safely with excellent clinical results.

Maternal mortality in the United States.

Despite a significant improvement in the US maternal mortality ratio since the early 1900s, it still represents a substantial and frustrating burden, particularly given the fact that - essentially - no progress has been made in most US States since 1982. Additionally, the US Centers for Disease Control and Prevention has stated that most cases are probably preventable. Two disheartening issues within this topic include a gross underestimation of the magnitude of maternal mortality - particularly before 1987, but which likely persists to a lesser degree today - and the continued significant racial disparity in maternal mortality. Explanations for the plateau in maternal mortality include the recent trend of delayed childbearing, with the potential accompanying complications associated with older reproductive age (particularly over 35 years) and multiparity. The impressive increase in multifetal pregnancies related to delayed childbearing and assisted reproductive technology also plays a role. Finally, peripartum cardiomyopathy has become an increasingly recognized source of maternal mortality. Pregnancy-related mortality is largely accounted for by thromboembolic disease, hemorrhage, hypertension and its associated complications, and infection. However, since the inclusion of maternal deaths occurring after 42 days post-delivery as pregnancy related, traumatic injuries - including homicides and suicides - are an alarming source of maternal mortality. An especially important contemporary issue to consider within this topic is cesarean delivery "on maternal request", opponents of which cite concerns not only for immediate morbidity and mortality increased over that associated with a vaginal birth, but also for potential morbidity and mortality associated with future pregnancies. One particularly appealing opportunity to reduce maternal mortality is to recognize, examine, and learn from so-called "near-miss" cases.

Irreducible radial neck fracture in a child.

Pediatric radial neck fractures are relatively common injuries resulting from a fall onto an outstretched arm. However, radial neck fractures with medial displacement of the shaft are difficult and fortunately rare injuries, having only been described twice in the literature. This case report describes the presentation and treatment of a pediatric elbow fracture where the radial shaft displaced medial to the coronoid process and pierced the joint capsule, requiring open reduction with internal fixation.

Pregnancy-related mortality among women with multifetal pregnancies.

OBJECTIVE: To examine the relative risk of pregnancy-related mortality between multifetal pregnancies and singleton pregnancies. METHODS: We used data from the Centers for Disease Control and Prevention's Pregnancy Mortality Surveillance System to examine singleton and multifetal pregnancy-related deaths among women with a live birth or fetal death from 1979-2000. The plurality-specific (singleton or multifetal) pregnancy-based mortality ratio was defined as the number of pregnancy-related deaths per 100,000 pregnancies with a live birth. We analyzed the risk of death due to pregnancy for singleton and multifetal pregnancies by age, race, education, marital status, and cause of death. RESULTS: Of 4,992 pregnancy-related deaths in 1979-2000, 4.2% (209 deaths) were among women with multifetal pregnancies. The risk of pregnancy death among women with twin and higher-order pregnancies was 3.6 times that of women with singleton pregnancies (20.8 compared with 5.8). The leading causes of death were similar for women with singleton pregnancies and women with multifetal pregnancies: embolism, hypertensive complications of pregnancy, hemorrhage, and infection. CONCLUSION: Women with multifetal pregnancies have a significantly higher risk of pregnancy-related death than their counterparts with singleton pregnancies; this holds true for all women regardless of age, race, marital status, and level of education. LEVEL OF EVIDENCE: II-2.