Choice of local anaesthetic for epidural caesarean section: a Bayesian network meta-analysis.

Rapid-onset epidural local anaesthesia can avoid general anaesthesia for caesarean delivery. We performed a Bayesian network meta-analysis of direct and indirect comparisons to rank speed of onset of the six local anaesthetics most often used epidurally for surgical anaesthesia for caesarean delivery. We searched Google Scholar, PubMed, EMBASE, Ovid, CINAHL and CENTRAL to June 2019. We analysed 24 randomised controlled trials with 1280 women. The mean (95%CrI) onset after bupivacaine 0.5% was 19.8 (17.3-22.4) min, compared with which the mean (95%CrI) speed of onset after lidocaine 2% with bicarbonate, 2-chloroprocaine 3% and lidocaine 2% was 6.4 (3.3-9.6) min faster, 5.7 (3.0-8.3) min faster and 3.9 (1.8-6.0) min faster, respectively. Speed of onset was similar to bupivacaine 0.5% after ropivacaine 0.75% and l-bupivacaine 0.5%: 1.6 (-1.4 to 4.8) min faster and 0.4 (-2.2 to 3.0) min faster, respectively. The rate (95%CrI) of intra-operative hypotension was least after l-bupivacaine 0.5%, 315 (236-407) per 1000, and highest after 2-chloroprocaine 3%, 516 (438-594) per 1000. The rate (CrI) of intra-operative supplementation of analgesia was least after ropivacaine 0.75% 48 (19-118) per 1000 and highest after 2-chloroprocaine 3%, 250 (112-569) per 1000.

Monozygotic twins discordant for trisomy 18.

We report on the pre- and postnatal cytogenetic, molecular genetic and clinical findings in monochorionic-diamniotic twins discordant for trisomy 18. Structural anomalies were identified in one of the twins on prenatal ultrasound examination at 20 weeks' gestation and sampling of amniotic fluid from both sacs was performed for karyotyping. This revealed trisomy 18 in the twin with abnormalities and a normal karyotype in the other twin. Elective Cesarean section was performed at 31 + 5 weeks and the aneuploid twin died shortly after delivery. The surviving twin showed low-grade mosaicism for trisomy 18 on postnatal analysis but has shown normal development. For prenatal diagnosis in monochorionic-diamniotic twin pregnancy the sampling of both amniotic sacs is recommended, especially if one twin has structural anomalies on ultrasound scan.

Vestibulospinal reflexes as a function of microgravity.

The idea that sustained microgravity will result in altered otolith input requiring a modification of postural control was explored by using the pathway that links the otolith organs and spinal motoneurons. Two related methods were used. First, the Hoffmann reflex was used to measure at specific times the excitability of the soleus-spinal motoneuron pool during a brief unexpected linear acceleration. Second, extensive dynamic postural testing with a moving platform was done before and after flight. The Hoffmann reflex amplitude, reflecting otolith-modulated motoneuron sensitivity, was low in flight after adaptation, and its postflight potentiation may have been dependent on rate of adaptation. The strength of inflight motion sickness symptoms was related to postflight Hoffmann reflex amplitude. Dynamic posture tests showed significant deviations from the results obtained before flight. The strategy used for balance on the moving platform was modified, and the behavior of the subjects suggested a decrease in awareness of the direction and magnitude of the motion.

Spinal anesthesia performed for cesarean delivery after external ventricular drain placement in a parturient with symptomatology from an intracranial mass.

We describe a case in which spinal anesthesia was undertaken in a pregnant patient with a space-occupying tumor and significant symptomatology. The collaborative efforts of all medical disciplines involved and the willingness of the neurosurgeon to discuss and help determine the safety of neuraxial anesthesia, culminated in placing an external ventricular drain to help monitor and manage intracranial pressure, so that we could proceed with spinal anesthesia and more easily monitor neurologic status.

Distribution of noradrenaline in the brain of the teleost Gasterosteus aculeatus L.: an immunohistochemical analysis.

The distribution of noradrenergic neurons in the brain of the three-spined stickleback was demonstrated with the indirect peroxidase-antiperoxidase (PAP) immunohistochemical method with antibodies against a noradrenaline-bovine serum albumin conjugate. Noradrenergic neuronal somata were exclusively located in the isthmal area of the brain stem and in the lower medulla. Noradrenergic varicose axons innervate the reticular formation, motor nuclei, and interpeduncular nucleus of the brain stem, the hypothalamus and habenular nuclei, various parts of the area dorsalis telencephali (forebrain pallium), and the olfactory bulbs. Scattered noradrenergic axons were observed in the optic tectum and in various parts of the cerebellum. It is concluded that the isthmal cell group of the stickleback is, on topological and cytoarchitectonic grounds, equivalent to the ventral portion of the locus coeruleus/subcoeruleus area of amniotes, but that its efferent connections display features characteristic both of those originating in the locus coeruleus, and in the lateral tegmental cell groups of mammals.

Constitutive expression of human cytomegalovirus (HCMV) glycoprotein gpUL75 (gH) in astrocytoma cells: a study of the specific humoral immune response.

The humoral immune response to gpUL75 (gH) was determined in different groups of human cytomegalovirus (HCMV) infected subjects using a full-length glycoprotein constitutively expressed in an astrocytoma cell line. The recombinant molecule consisted of two distinct isoforms resembling the authentic protein of infected cells. Separated from the interactions of other viral gene products gH failed to form an oligomeric complex, thus exhibiting exclusively epitopes present on the monomer. Ninety five percent of serum samples from latently-infected healthy adults revealed the presence of gH-specific IgG. Moreover, examination of sequential sera from immunocompromised and immunocompetent individuals undergoing active HCMV infection demonstrated that antibodies to gH occurred in most cases simultaneously with those to the abundant surface antigen gpUL55 (gB) and at similar titres. Appearance of this response was correlated with a considerable increase of the virus-neutralizing activity and most likely associated with restriction of viral dissemination during subsequent viremic episodes. Together, these results suggest that glycoprotein H of HCMV is like gB, a highly immunogenic component of the infectious particle.

Recovery of postural equilibrium control following spaceflight.

Decreased postural stability is observed in most astronauts immediately following spaceflight. Because ataxia may present postflight operational hazards, it is important to determine the incidence of postural instability immediately following landing and the dynamics of recovery of normal postural equilibrium control. It is postulated that postflight postural instability results from in-flight adaptive changes in central nervous system (CNS) processing of sensory information from the visual, vestibular, and proprioceptive systems. The purpose of the present investigation was to determine the magnitude and time course of postflight recovery of postural equilibrium control and, hence, readaptation of CNS processing of sensory information. Thirteen crew members from six spaceflight missions were studied pre- and postflight using a modified commercial posturography system. Postural equilibrium control was found to be seriously disrupted immediately following spaceflight in all subjects. Readaptation to the terrestrial environment began immediately upon landing, proceeded rapidly for the first 10-12 hours, and then proceeded much more slowly for the subsequent 2-4 days until preflight stability levels were reachieved. It is concluded that the overall postflight recovery of postural stability follows a predictable time course.

Space flight and neurovestibular adaptation.

Space flight represents a form of sensory stimulus rearrangement requiring modification of established terrestrial response patterns through central reinterpretation. Evidence of sensory reinterpretation is manifested as postflight modifications of eye/head coordination, locomotor patterns, postural control strategies, and illusory perceptions of self or surround motion in conjunction with head movements. Under normal preflight conditions, the head is stabilized during locomotion, but immediately postflight reduced head stability, coupled with inappropriate eye/head coordination, results in modifications of gait. Postflight postural control exhibits increased dependence on vision which compensates for inappropriate interpretation of otolith and proprioceptive inputs. Eye movements compensatory for perceived self motion, rather than actual head movements have been observed postflight. Overall, the in-flight adaptive modification of head stabilization strategies, changes in head/eye coordination, illusionary motion, and postural control are maladaptive for a return to the terrestrial environment.

Facilitation of adaptation and acute tolerance to stressful sensory input by doxepin and scopolamine plus amphetamine.

This work characterizes a new methodologic and pharmacologic approach to control terrestrial and space motion sickness (SMS). The experimental design allowed separate evaluation of drug action on susceptibility and adaptability, and used repeated measures to approximate the chronic stressful motion of microgravity. Daily exposure to cross-coupled angular acceleration for 5 consecutive days demonstrated that the efficacy of doxepin and scopolamine plus amphetamine in the prevention of autonomic system dysfunction was not only apparent on the first test day (P < .01), but was also evident in the substantially enhanced resistance developed over the 5-day test period (P < .01) as compared with placebo. This indicates that daily use of these medications does not diminish therapeutic efficacy (tolerance). The efficacy of doxepin was anticipated because it possesses pharmacologic properties similar to those of established anti-motion sickness drugs. Comparable efficacy after doxepin loading for 4 hours, 3 days, or 21 days suggests a mechanism distinct from its antidepressant effects, possibly related to its potent antihistaminergic actions. Use of doxepin has operational significance to the National Aeronautics and Space Administration, in comparison with current preparations of scopolamine plus amphetamine, because of doxepin's minimal impact on cognitive performance, and most importantly, its favorable pharmacokinetic profile, particularly its long half-life.

Motion sickness and development of synergy within the spatial orientation system. A hypothetical unifying concept.

Adaptation to research paradigms such as rotating rooms and optical alteration of visual feedback during movement results in development of perceptual-motor programs that provide the reflexive assistance that is necessary to skilled control of movement and balance. The discomfort and stomach awareness that occur during the adaptation process has been attributed to conflicting sensory information about the state of motion. Vestibular signals depend on the kinematics of head movements irrespective of the presence or absence of signals from other senses. We propose that sensory conflict when vestibular signals are at least one component of the conflict are innately disturbing and unpleasant. This innate reaction is part of a continuum that operates early in life to prevent development of inefficient perceptual-motor programs. This reaction operates irrespective of and in addition to reward and punishment from parental guidance or goal attainment to yield efficient control of whole body movement in the operating environment of the individual. The same mechanism is involved in adapting the spatial orientation system to strange environments. This conceptual model "explains" why motion sickness is associated with adaptation to novel environments and is in general consistent with motion sickness literature.

Relationship between selected orientation rest frame, circular vection and space motion sickness.

Space motion sickness (SMS) and spatial orientation and motion perception disturbances occur in 70-80% of astronauts. People select "rest frames" to create the subjective sense of spatial orientation. In microgravity, the astronaut's rest frame may be based on visual scene polarity cues and on the internal head and body z axis (vertical body axis). The data reported here address the following question: Can an astronaut's orientation rest frame be related and described by other variables including circular vection response latencies and space motion sickness? The astronaut's microgravity spatial orientation rest frames were determined from inflight and postflight verbal reports. Circular vection responses were elicited by rotating a virtual room continuously at 35 degrees/s in pitch, roll and yaw with respect to the astronaut. Latency to the onset of vection was recorded from the time the crew member opened their eyes to the onset of vection. The astronauts who used visual cues exhibited significantly shorter vection latencies than those who used internal z axis cues. A negative binomial regression model was used to represent the observed total SMS symptom scores for each subject for each flight day. Orientation reference type had a significant effect, resulting in an estimated three-fold increase in the expected motion sickness score on flight day 1 for astronauts who used visual cues. The results demonstrate meaningful classification of astronauts' rest frames and their relationships to sensitivity to circular vection and SMS. Thus, it may be possible to use vection latencies to predict SMS severity and duration.

Assessment of cytomegalovirus infections using neopterin and a new immunoblot.

Human cytomegalovirus (HCMV) infections are a major cause of morbidity and mortality in immunocompromised patients despite advances in diagnostic tests and antiviral therapies. The underlying study investigates the diagnostic value of the immune marker neopterin and a recently developed HCMV-specific western blot to detect HCMV infections and to differentiate them into either syndromes or diseases. The mean period of observation was 1428 days. Thirteen HCMV diseases and nine syndromes were diagnosed retrospectively. The first appearance of clinical signs or symptoms was always associated with a marked increase of serum and urine neopterin. The HCMV-specific IgM response followed in the mean 9 days later. Median values and the course of the neopterin levels were significantly higher during the HCMV diseases. In addition, the strength of the humoral immune response was related to the severity of the HCMV infection. Patients with HCMV diseases developed antibodies against a higher number of epitopes. The anti-HCMV IgM response persisted in more than 80% of the patients for longer than 3 years. In conclusion, combining the HCMV-specific western blot and neopterin permit detection of the immune response against HCMV, reflect the severity of the infection and might guide the anti-viral therapy.

Postural equilibrium following exposure to weightless space flight.

Postural equilibrium performance by the Skylab 1/2, 3, and 4 crewmen following exposure to weightlessness of 28, 59, and 84 days respectively was evaluated using a modified version of a quantitative ataxia test developed by Graybiel and Fregly. Performance for this test was measured under two sets of conditions. In the first, the crewman was required to maintain postural equilibrium on narrow metal rails (or floor) with his eyes open. In the second condition, he attempted to balance with his eyes closed. A comparison of the preflight and postflight data indicated moderate postflight decrements in postural equilibrium in three of the crewmen during the eyes open test condition. However, in the eyes closed condition, a considerable decrease in ability to maintain balance on the rails was observed postflight for all crewmen tested. The magnitude of the change was most pronounced during the first postflight test day. Improvement was slow; however, on the basis of data obtained, recovery of preflight baseline levels of performance was evidently complete at the end of approximately two weeks for all crewmen. The findings are explained in terms of functional alterations in the kinesthetic, touch, vestibular and neuromuscular sensory mechanisms induced by the prolonged absence of a normal 1-G gravitational environment.

Directional conflict between vestibular and visual inputs in the squirrel monkey.

The directional conflict between vestibular and visual stimuli was studied in the squirrel monkey. Sinusoidal rotation was given to the subject and the direction of his visual target movement was reversed by installing a mirror in a 45 degree plane in front of the eyes. A large interindividual variance was noticed in controlling vestibular-visual conflict. The degree of vestibular-visual conflict and stimulus magnitude had no linear relationship. Also no relationship existed between vestibular-visual conflict and the provocation of vestibular nystagmus. Under the situation of vestibular-visual conflict, visual target pursuit failed to improve when two daily trials were given twice a week, for five weeks. The reduction of vestibular input created by surgery resulted in the reduction of vestibular evoked nystagmus and vestibular-visual conflict. However, their degrees were not necessarily parallel. Inter-individual difference in response of vestibular-visual conflict was related to vestibular-visual coordination.

Further study of physical exercise and locomotor balance compensation after unilateral labyrinthectomy in squirrel monkeys.

The effect of physical exercise on compensation for locomotor asymmetry after unilateral labyrinthectomy was studied in squirrel monkeys. Five monkeys were assigned to the motor-driven rotating cage exercise, and another five, non-exercise control. Daily exercise (cumulative time of 2 1/2 hours) was given for three weeks preoperatively and continuously (daily) post-operatively. The average number of calendar days to attain the locomotor balance compensation was 20 days in the exercise group, and 35 days in the non-exercise control group. Statistical analysis showed the former compensated (according to the previously established criterion) significantly faster than the latter ( less than 0.05). Furthermore, faster reduction of gait deviation was found in the exercise group. Therefore, when physical exercise was given extensively and continuously, and locomotor balance function was measured by the squirrel monkey platform runway test (Igarashi, 1974), physical exercise application enhanced the locomotor equilibrium compensation.

Vestibular-visual conflict sickness in the squirrel monkey.

When combined vestibular and visual (optokinetic) stimuli were given to squirrel monkeys in a direction and phase mismatching sinusoidal mode (in yaw plane), five of six monkeys exhibited actual emesis during three repeated exposures on separate trial days. Two animals vomited on two trial days and three animals, on one day. The incidence took place in 38.9% of the total trial days. When the identical vestibular and visual stimuli were given individually, the effect was negligible, thus confirming each stimulus magnitude was not stressful enough to produce emesis when used separately.

Locomotor head-trunk coordination strategies following space flight.

During locomotion, angular head movements act in a compensatory fashion to oppose the vertical trunk translation that occurs during each step in the gait cycle. This coordinated strategy between head and trunk motion serves to aid gaze stabilization and perhaps simplifies the sensory coordinate transformation between the head and trunk, allowing efficient descending motor control during locomotion. Following space flight, astronauts often experience oscillopsia during locomotion in addition to postural and gait instabilities, suggesting a possible breakdown in head-trunk coordination. The goal of the present investigation was to determine if exposure to the microgravity environment of space flight induces alteration in head-trunk coordination during locomotion. Astronaut subjects were asked to walk (6.4 km/h, 20 s trials) on a motorized treadmill while visually fixating on a centrally located earthfixed target positioned either 2 m (FAR) or 30 cm (NEAR) from the eyes. In addition, some trials were also performed during periodic visual occlusion. Head and trunk kinematics during locomotion were determined with the aid of a video-based motion analyzing system. We report data collected preflight (10 days prior to launch) and postflight (2 to 4 hours after landing). The coherence between pitch head and vertical trunk movements during gaze fixation of both FAR and NEAR targets was significantly reduced following space flight indicating decreased coordination between the head and trunk during postflight locomotion. Astronauts flying on their first mission showed greater alterations in the frequency spectra of pitch head movements as compared to their more experienced counterparts. These modifications in the efficacy of head movement control may account for the reported disruption in gaze performance during locomotion and may contribute to postflight postural and gait dysfunction.

Microgravity vestibular investigations: perception of self-orientation and self-motion.

Four astronauts experienced passive whole-body rotation in a number of test sessions during a 7-day orbital mission. Pitch (Y-axis) and roll (X-axis) rotation required subject orientations on the rotator in which the otolith system was at radius of 0.5 m. Thus subjects experienced a constant -0.22 Gz stimulus to the otoliths during the 60 s constant-velocity segments of "pitch" and "roll" ramp profiles. The Gz stimulus, a radius-dependent vector ranging from -0.22 Gz at the otoliths to +0.36 Gz at the feet, generated sensory information that was not interpreted as inversion in any of the 16 tests carried out in flight (12 in pitch and 4 in roll orientation). None of the subjects was rotated with head off-center during the first 33 h of the mission. In the state of orbital adaptation of these subjects, a -0.22 Gz otolith stimulus did not provide a vertical reference in the presence of a gradient of +Gz stimuli to the trunk and legs.

Effects of body orientation and rotation axis on pitch visual-vestibular interaction.

Spatial transformations of the vestibular-optokinetic system must account for changes in head position with respect to gravity in order to produce compensatory oculomotor responses. The purpose of this experiment was to study the influence of gravity on the vestibulo-ocular reflex (VOR) in darkness and on visual-vestibular interaction in the pitch plane in human subjects using two different comparisons: (1) Earth-horizontal axis (EHA) rotation about an upright versus a supine body orientation, and (2) Earth-horizontal versus Earth-vertical (EVA) rotation axes. Visual-vestibular responses (VVR) were evaluated by measuring the slow phase velocity of nystagmus induced during sinusoidal motion of the body in the pitch plane (at 0.2 Hz and 0.8 Hz) combined with a constant-velocity vertical optokinetic stimulation (at +/- 36 degrees/s). The results showed no significant effect on the gain or phase of the VOR in darkness or on the VVR responses at 0.8 Hz between EHA upright and EHA supine body orientations. However, there was a downward shift in the VOR bias in darkness in the supine orientation. There were systematic changes in VOR and VVR between EHA and EVA for 0.2 Hz, including a reduced modulation gain, increased phase lead, and decreased bias during EVA rotation. The same trend was also observed at 0.8 Hz, but at a lesser extent, presumably due to the effects of eccentric rotation in our EVA condition and/or to the different canal input across frequencies. The change in the bias at 0.2 Hz between rotation in darkness and rotation with an optokinetic stimulus was greater than the optokinetic responses without rotation. During EHA, changes in head position relative to gravity preserve graviceptor input to the VVR regardless of body orientation. However, the modifications in VVR gain and phase when the rotation axis is aligned with gravity indicate that this graviceptive information is important for providing compensatory eye movements during visual-vestibular interaction in the pitch plane.

Yaw and pitch visual-vestibular interaction in weightlessness.

Both yaw and pitch visual-vestibular interactions at two separate frequencies of chair rotation (0.2 and 0.8 Hz) in combination with a single velocity of optokinetic stimulus (36 degrees/s) were used to investigate the effects of sustained weightlessness on neural strategies adopted by astronaut subjects to cope with the stimulus rearrangement of spaceflight. Pitch and yaw oscillation in darkness at 0.2 and 0.8 Hz without optokinetic stimulation, and constant velocity linear optokinetic stimulation at 18, 36, and 54 degrees/s presented relative to the head with the subject stationary, were used as controls for the visual-vestibular interactions. The results following 8 days of space flight showed no significant changes in: (1) either the horizontal and vertical vestibulo-ocular reflex (VOR) gain, phase, or bias; (2) the yaw visual-vestibular response (VVR); or (3) the horizontal or vertical optokinetic (OKN) slow phase velocity (SPV). However, significant changes were observed: (1) when during pitch VVR at 0.2 Hz late inflight, the contribution of the optokinetic input to the combined oculomotor response was smaller than during the stationary OKN SPV measurements, followed by an increased contribution during the immediate postflight testing; and (2) when during pitch VVR at 0.8 Hz, the component of the combined oculomotor response due to the underlying vertical VOR was more efficiently suppressed early inflight and less suppressed immediately postflight compared with preflight observations. The larger OKN response during pitch VVR at 0.2 Hz and the better suppression of VOR during pitch VVR at 0.8 Hz postflight are presumably due to the increased role of vision early inflight and immediately after spaceflight, as previously observed in various studies. These results suggest that the subjects adopted a neural strategy to structure their spatial orientation in weightlessness by reweighting visual, otolith, and perhaps tactile/somatic signals.