Is it feasible to avoid suction before spontaneous breathing is established?

BACKGROUND: Suctioning of the posterior pharynx immediately after birth during neonatal resuscitation can produce a vagal response resulting in bradycardia or apnea. The feasibility of delaying any airway suctioning and avoiding deep suctioning has not been studied. OBJECTIVES: To test the hypothesis that newborn resuscitation is feasible with the following two guidelines: 1) avoiding any suctioning until the infant establishes spontaneous respiration, and 2) avoiding the use of deep suction with catheters. STUDY DESIGN: A quality improvement project was implemented using these two guidelines. Infants' mouth was cleaned with a dry cloth. No suction was started until infants establish spontaneous breathing. Then, bulb suction was used to clear secretions from the sides of the mouth and the nose without reaching the back of the pharynx. Deep suction using catheters was not used. Neonatal staff and physicians received biweekly training to support these changes. Resuscitation data before and after the practice change were compared. RESULTS: A total of 999 sequential cases were compared; of them 501 and 498 infants were resuscitated before and after the implementation of the new practice, respectively. Suction before spontaneous breathing occurred in 12.4% in the first cohort. There were no differences between groups except for less use of oxygen with the new guidelines (12.4% vs 4.4%, P < 0.001). CONCLUSION: Avoidance of any suction prior to spontaneous breathing and not applying deep suction with catheters are feasible during newborn resuscitation. These practices are associated with decreased exposure to oxygen in the delivery room.

The efficacy of metformin as adjuvant to chemotherapy on IGF levels in non-diabetic female patients with progressive and non-progressive metastatic breast cancer.

OBJECTIVE: Some studies have shown that metformin inhibits the proliferation of breast cancer (BC) cells via multiple ways. One of these mechanisms is through the indirect control of the IGF-route mediated via the activation of the AMPK-LKB1 pathway in the liver, which leads to a decrease in blood glucose and insulin levels. The objective of this study was to investigate the effects of metformin as adjuvant to chemotherapy on IGF levels in female patients with progressive and non-progressive metastatic BC. PATIENTS AND METHODS: In this trial, 107 women receiving chemotherapy for metastatic breast cancer (MBC) were divided into two groups: the metformin group received 500 mg of metformin twice daily, whereas the control group did not receive any metformin. All patients received chemotherapy according to the South Egypt Cancer Institute's (SECI) established regimen. The level of IGF-1 was determined in the blood at the initiation of therapy (baseline) and at six months post treatment. RESULTS: No substantial differences were noted regarding IGF-1 levels in both groups at baseline (IGF-1 average level was 40.74 ± 36.16 vs. 32.06 ± 20.00 in the metformin and the placebo group, respectively, p = 0.462). While after six months, the mean IGF-1 level was 37.62 ± 31.35 vs. 39.12 ± 2 5.93 in the metformin and placebo groups, respectively, (p = 0.170). CONCLUSIONS: Metformin as an adjuvant to chemotherapy in MBC patients had no significant effect on reducing IGF-l levels which promotes the inhibition of the proliferation of BC cells in MBC patients.

Lung ultrasound versus chest radiography for the diagnosis of pneumothorax in critically ill patients: A prospective, single-blind study.

BACKGROUND: Radiologic data remains the gold standard for the diagnosis of pneumothorax (PTX). The use of ultrasonography (US) has recently emerged as the method of choice with physicians who can perform bedside US. PURPOSE: To compare the diagnostic accuracy of lung US against bedside chest radiography (CR) for the detection of PTX using thoracic computed tomography (CT) as the gold standard. MATERIALS AND METHODS: We conducted a prospective, single-blind study on 192 critically ill patients; each patient received lung US examination, bedside CR, followed by thoracic CT scan searching for PTX. RESULTS: Of the studied patients, CT of the chest confirmed the diagnosis of PTX in 36 (18.75%) patients of which 31 were diagnosed by thoracic US while CR detected only 19 cases. Overall lung US showed a considerable higher sensitivity than bedside CR (86.1% vs. 52.7%), lung US also showed higher, negative predictive values, and diagnostic accuracy against CR (96.8% vs. 90.1%), and (95.3% vs. 90.6%), respectively. CR had a slightly higher specificity than lung US (99.4% vs. 97.4%), and higher positive predictive values (95.0% vs. 88.6%). CONCLUSION: Lung US is an accurate modality more than anteroposterior bedside CR in comparison with CT scanning when evaluating critically ill mechanically ventilated patients, patients underwent thoracocentesis, central venous catheter insertion, or patients with polytrauma.

An ERK-dependent pathway to Noxa expression regulates apoptosis by platinum-based chemotherapeutic drugs.

Cisplatin is a widely used cancer chemotherapeutic that promotes DNA damage-associated apoptosis. Although platinum compounds are known to form DNA adducts and provoke DNA damage, the molecular mechanism of cisplatin-induced cell death remains unclear. In this article, we show that the BH3-only protein Noxa is strongly transcriptionally upregulated in response to cisplatin and related platinum compounds. Cisplatin-induced Noxa expression was ERK dependent, but p53 independent, and inhibition of ERK activation markedly attenuated cisplatin-induced cell death, as well as Noxa expression. Furthermore, siRNA-mediated ablation of Noxa expression also inhibited cisplatin-induced cell death and permitted clonogenic survival. These observations reveal a novel ERK-regulated route to Noxa expression that is important for the cell killing activity of platinum-based chemotherapeutic drugs.

Reducing the dose of gonadotrophin-releasing hormone agonist on starting ovarian stimulation: effect on ovarian response and in-vitro fertilization outcome.

The aim of this study was to examine if lowering the dose of gonadotrophin-releasing hormone agonist (GnRHa) on starting ovarian stimulation could be beneficial in in-vitro fertilization (IVF) programmes. A total of 64 normally ovulating patients entering an IVF programme were randomized to receive GnRHa (nafarelin acetate/Synarel) as an intranasal spray commencing in the midluteal phase, either at a dosage of 200 microg three times daily until the day of human chorionic gonadotrophin (HCG) administration, or to be reduced to 200 microg twice daily as ovarian stimulation was initiated. Patients in both groups were below 35 years with a body mass index below 30. All patients received three ampoules of Metrodin HP per day. Blood samples were taken on the day of HCG administration to measure luteinizing hormone (LH), oestradiol, and progesterone. LH and oestradiol were found to be significantly higher in the lower Synarel dose group. Our results show that reducing the GnRHa dose during ovarian stimulation in IVF might be beneficial in terms of significantly more oocytes recovered, and significantly greater number of embryos available for transfer and freezing, with no incidence of premature luteinization.

Is bed rest following embryo transfer necessary?

OBJECTIVE: To evaluate the effect of no bed rest following ET on the results of an IVF program. DESIGN: Historical cohort-control study. SETTING: A University-based assisted conception unit. PATIENT(S): One thousand and nineteen (1019) IVF cycles were performed at our unit from June 1994 to August 1996. The historical control consisted of all the 19,697 IVF cycles reported in the United Kingdom national database from April 1994 to March 1995. INTERVENTION: No bed rest following ET in our patients. MAIN OUTCOME MEASURE(S): Pregnancy rate (PR) and clinical PR per cycles started and per ET procedure. RESULT(S): The clinical PR per ET was significantly higher in our patients than in the national data (30% versus 22.9%), as was the clinical PR per cycle (23.5% versus 18.6%). The implantation rate in our patients was 17.2%. CONCLUSION(S): The favorable PR in our patients despite no bed rest following ET suggests the bed rest is not necessary.

Age and basal follicle stimulating hormone as predictors of in vitro fertilisation outcome.

OBJECTIVE: To examine the relative effect of basal follicle stimulating hormone (FSH) concentration and the woman's age on predicting the ovarian response to gonadotrophin stimulation, normal fertilisation rate and pregnancy rate in in vitro fertilisation (IVF) treatment following pituitary desensitisation. DESIGN: Descriptive cohort study. PARTICIPANTS: Three hundred and forty-four women undergoing their first IVF cycle. METHODS: Basal (menstrual-day 3) FSH concentration was measured and the woman's age calculated before she underwent pituitary desensitisation followed by gonadotrophin ovarian stimulation and IVF treatment. MAIN OUTCOME MEASURES: Cancellation rate due to poor ovarian response, total dose of gonadotrophin required to achieve follicular maturity, number of oocytes collected, normal fertilisation rate and pregnancy rate were compared between banded values of the variables studied. RESULTS: Increasing basal FSH concentration was associated significantly with increased cancellation rate, but increasing age was not. Both increasing basal FSH and age were associated significantly with increased total gonadotrophin dose, and reduced number of oocytes collected and pregnancy rate. Analysis of variance showed that the association for basal FSH with the number of oocytes was significant, independent of, and stronger than the effects of age. Logistic regression analysis showed that age, but not basal FSH, was independently associated with pregnancy rate. Neither basal FSH, nor age had significant association with normal fertilisation rate. CONCLUSION: Basal FSH concentration is a better predictor of cancellation rate and of the number of oocytes collected in IVF treatment than age, but age is a stronger predictor of pregnancy rate.