Cardiac Pacemaker Activity and Aging.

A progressive decline in maximum heart rate (mHR) is a fundamental aspect of aging in humans and other mammals. This decrease in mHR is independent of gender, fitness, and lifestyle, affecting in equal measure women and men, athletes and couch potatoes, spinach eaters and fast food enthusiasts. Importantly, the decline in mHR is the major determinant of the age-dependent decline in aerobic capacity that ultimately limits functional independence for many older individuals. The gradual reduction in mHR with age reflects a slowing of the intrinsic pacemaker activity of the sinoatrial node of the heart, which results from electrical remodeling of individual pacemaker cells along with structural remodeling and a blunted ß-adrenergic response. In this review, we summarize current evidence about the tissue, cellular, and molecular mechanisms that underlie the reduction in pacemaker activity with age and highlight key areas for future work.

Obstetric and anesthetic management in parturients with ventriculoperitoneal shunt: a case series.

Further study is needed to determine the safest mode of delivery and anesthetic management for parturients with ventriculoperitoneal shunts (VP). Prior recommendation for delivery in women with ventriculoperitoneal shunts was cesarean delivery. However, both vaginal delivery and neuraxial anesthesia have been shown to be safe in women with appropriately functioning VP shunts. We present a case series of parturients with VP shunt. Parturients with VP shunts were identified and VP shunt placement indications, neurologic symptoms during pregnancy, delivery mode, anesthetic type, and postpartum complications were reviewed. Forty patients were identified, and fifteen women with twenty deliveries were included. Two women experienced neurological symptoms during pregnancy and one required postpartum shunt revision for blurry vision and ataxia. There were ten cesarean deliveries and ten vaginal deliveries (eight normal spontaneous, one vacuum assisted, and one forceps assisted). Assisted vaginal deliveries were performed to decrease Valsalva including the patient with neurological symptoms related to shunt malfunction. Of the vaginal deliveries, six (60%) had epidural analgesia. Anesthesia for cesarean delivery included neuraxial anesthesia (n = 5) and general anesthesia (n = 5). In our cohort, women with VP shunt received neuraxial blockade without complication. Neuraxial techniques should be offered to women with appropriately functioning VP shunt.

Screening for peripartum cardiomyopathies using artificial intelligence in Nigeria (SPEC-AI Nigeria): Clinical trial rationale and design.

BACKGROUND: Artificial intelligence (AI), and more specifically deep learning, models have demonstrated the potential to augment physician diagnostic capabilities and improve cardiovascular health if incorporated into routine clinical practice. However, many of these tools are yet to be evaluated prospectively in the setting of a rigorous clinical trial-a critical step prior to implementing broadly in routine clinical practice. OBJECTIVES: To describe the rationale and design of a proposed clinical trial aimed at evaluating an AI-enabled electrocardiogram (AI-ECG) for cardiomyopathy detection in an obstetric population in Nigeria. DESIGN: The protocol will enroll 1,000 pregnant and postpartum women who reside in Nigeria in a prospective randomized clinical trial. Nigeria has the highest reported incidence of peripartum cardiomyopathy worldwide. Women aged 18 and older, seen for routine obstetric care at 6 sites (2 Northern and 4 Southern) in Nigeria will be included. Participants will be randomized to the study intervention or control arm in a 1:1 fashion. This study aims to enroll participants representative of the general obstetric population at each site. The primary outcome is a new diagnosis of cardiomyopathy, defined as left ventricular ejection fraction (LVEF) < 50% during pregnancy or within 12 months postpartum. Secondary outcomes will include the detection of impaired left ventricular function (at different LVEF cut-offs), and exploratory outcomes will include the effectiveness of AI-ECG tools for cardiomyopathy detection, new diagnosis of cardiovascular disease, and the development of composite adverse maternal cardiovascular outcomes. SUMMARY: This clinical trial focuses on the emerging field of cardio-obstetrics and will serve as foundational data for the use of AI-ECG tools in an obstetric population in Nigeria. This study will gather essential data regarding the utility of the AI-ECG for cardiomyopathy detection in a predominantly Black population of women and pave the way for clinical implementation of these models in routine practice. TRIAL REGISTRATION: Clinicaltrials.gov: NCT05438576.

Effect of an oxytocin protocol on secondary uterotonic use in patients undergoing Cesarean delivery.

PURPOSE: Protocol-driven oxytocin regimens can reduce oxytocin administration compared with a nonprotocol free-flow continuous infusion. Our aim was to compare secondary uterotonic use between a modified "rule of threes" oxytocin protocol and a free-flow continuous oxytocin infusion after Cesarean delivery. METHODS: We conducted a retrospective before-and-after study to compare patients who underwent Cesarean delivery between 1 January 2010 and 31 December 2013 (preprotocol) with patients who underwent Cesarean delivery between 1 January 2015 and 31 August 2017 (postprotocol). The preprotocol group received free-flow oxytocin administration and the postprotocol group received oxytocin according to a modified rule of threes algorithm. The primary outcome was secondary uterotonic use and the secondary outcomes included blood transfusion, hemoglobin value < 8 g·dL-1, and estimated blood loss. RESULTS: In total, 4,010 Cesarean deliveries were performed in 3,637 patients (2,262 preprotocol and 1,748 postprotocol). The odds of receiving secondary uterotonic drugs were increased in the postprotocol group (odds ratio [OR], 1.33; 95% confidence interval [CI], 1.04 to 1.70; P = 0.02). Patients in the postprotocol group were less likely to receive a blood transfusion. Nevertheless, the two groups were similar for the composite end point of transfusion or hemoglobin < 8 g·dL-1 (OR, 0.86; 95% CI, 0.66 to 1.11; P = 0.25). The odds of an estimated blood loss greater than 1,000 mL were reduced in the postprotocol group (OR, 0.64; 95% CI, 0.50 to 0.84; P = 0.001). CONCLUSIONS: Patients in the modified rule of threes oxytocin protocol group were more likely to receive a secondary uterotonic than those in the preprotocol group. Estimated blood loss and transfusion outcomes were similar.

RéSUMé: OBJECTIF: Les schémas thérapeutiques d'ocytocine basés sur un protocole peuvent réduire l'administration d'ocytocine par rapport à une perfusion continue en débit libre hors protocole. Notre objectif était de comparer l'utilisation secondaires d'agents utérotoniques entre un protocole modifié d'ocytocine en « règle de trois ¼ et une perfusion continue d'ocytocine à débit libre après un accouchement par césarienne. MéTHODE: Nous avons mené une étude rétrospective avant-après pour comparer les personnes ayant bénéficié d'une césarienne entre le 1er janvier 2010 et le 31 décembre 2013 (pré-protocole) avec les personnes ayant subi une césarienne entre le 1er janvier 2015 et le 31 août 2017 (post-protocole). Le groupe pré-protocole a reçu une administration d'ocytocine en débit libre et le groupe post-protocole a reçu de l'ocytocine selon un algorithme de règle de trois modifié. Le critère d'évaluation principal était l'utilisation secondaire d'agents utérotoniques et les critères d'évaluation secondaires incluaient la transfusion sanguine, un indice d'hémoglobine < 8 g·dL­1 et les pertes de sang estimées. RéSULTATS: Au total, 4010 accouchements par césarienne ont été réalisés chez 3637 patient·es (2262 pré-protocole et 1748 post-protocole). Les chances de recevoir des médicaments utérotoniques secondaires étaient plus élevées dans le groupe post-protocole (rapport de cotes [RC], 1,33; intervalle de confiance [IC] à 95 %, 1,04 à 1,70; P = 0,02). Les patient·es du groupe post-protocole étaient moins susceptibles de recevoir une transfusion sanguine. Néanmoins, les deux groupes étaient similaires en ce qui touchait au critère d'évaluation composite de transfusion ou d'hémoglobine < 8 g·dL­1 (RC, 0,86; IC 95, 0,66 à 1,11; P = 0,25). Les risques d'une perte de sang estimée supérieure à 1000 mL ont été réduits dans le groupe post-protocole (RC, 0,64; IC 95 %, 0,50 à 0,84; P = 0,001). CONCLUSION: Les patient·es du groupe du protocole d'ocytocine en règle de trois modifiée étaient plus susceptibles de recevoir un utérotonique secondaire que les personnes du groupe pré-protocole. Les pertes sanguines estimées et les résultats transfusionnels étaient similaires.

Dexmedetomidine-associated diabetes insipidus during skull base surgery in a pediatric patient.

Diabetes insipidus is characterized by polyuria due to an inability to auto-regulate water balance resulting in dangerous metabolic derangements. Intraoperative anesthetics have been increasingly identified as a cause of diabetes insipidus in adult patients; however, it is rare in pediatrics. We present a case of a 16-year-old male undergoing resection of a recurrent left juvenile nasopharyngeal angiofibroma who experienced intraoperative polyuria concerning diabetes insipidus. Urine output drastically decreased following discontinuation of dexmedetomidine with complete resolution within 24 h. We conclude that this case of transient diabetes insipidus was associated with dexmedetomidine administration.

Perioperative Diabetes Insipidus Caused by Anesthetic Medications: A Review of the Literature.

Diabetes insipidus (DI) is an uncommon perioperative complication that can occur secondary to medications or surgical manipulation and can cause significant hypovolemia and electrolyte abnormalities. We reviewed and evaluated the current literature and identified 29 cases of DI related to medications commonly used in anesthesia such as propofol, dexmedetomidine, sevoflurane, ketamine, and opioids. This review summarizes the case reports and frequency of DI with each medication and presents possible pathophysiology. Medication-induced DI should be included in the differential diagnosis when intraoperative polyuria is identified. Early identification, removal of the agent, and treatment of intraoperative DI are critical to minimize complications.

Congenital Athymia: Genetic Etiologies, Clinical Manifestations, Diagnosis, and Treatment.

Congenital athymia is an ultra-rare disease characterized by the absence of a functioning thymus. It is associated with several genetic and syndromic disorders including FOXN1 deficiency, 22q11.2 deletion, CHARGE Syndrome (Coloboma, Heart defects, Atresia of the nasal choanae, Retardation of growth and development, Genitourinary anomalies, and Ear anomalies), and Complete DiGeorge Syndrome. Congenital athymia can result from defects in genes that impact thymic organ development such as FOXN1 and PAX1 or from genes that are involved in development of the entire midline region, such as TBX1 within the 22q11.2 region, CHD7, and FOXI3. Patients with congenital athymia have profound immunodeficiency, increased susceptibility to infections, and frequently, autologous graft-versus-host disease (GVHD). Athymic patients often present with absent T cells but normal numbers of B cells and Natural Killer cells (T-B+NK+), similar to a phenotype of severe combined immunodeficiency (SCID); these patients may require additional steps to confirm the diagnosis if no known genetic cause of athymia is identified. However, distinguishing athymia from SCID is crucial, as treatments differ for these conditions. Cultured thymus tissue is being investigated as a treatment for congenital athymia. Here, we review what is known about the epidemiology, underlying etiologies, clinical manifestations, and treatments for congenital athymia.

Obstetric Anesthetic Management for Parturients with Hereditary Angioedema: A Case Report and Suggested Protocol.

Hereditary angioedema (HAE) is a disease manifested by repeated episodes of localized submucosal or subcutaneous edematous episodes, potentially triggered by emotional stress, mechanical trauma, or intake of estrogens. We present our experience managing two parturients with HAE. Multidisciplinary care is essential for planning and executing the specialized care of these patients, and management included extensive planning among obstetric, anesthesiology, and allergy and immunology teams. Pregnancy has been shown to have a variable effect on triggering HAE episodes. First-line treatment includes C1 esterase inhibitor concentrate, which can also be used for prophylaxis in high-risk patients. Neuraxial analgesia is recommended to avoid general anesthesia and was established early in both individuals. Vaginal delivery was well tolerated without need for emergent treatment for angioedema symptoms.

The Society for Obstetric Anesthesia and Perinatology Coronavirus Disease 2019 Registry: An Analysis of Outcomes Among Pregnant Women Delivering During the Initial Severe Acute Respiratory Syndrome Coronavirus-2 Outbreak in the United States.

BACKGROUND: Early reports associating severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection with adverse pregnancy outcomes were biased by including only women with severe disease without controls. The Society for Obstetric Anesthesia and Perinatology (SOAP) coronavirus disease 2019 (COVID-19) registry was created to compare peripartum outcomes and anesthetic utilization in women with and without SARS-CoV-2 infection delivering at institutions with widespread testing. METHODS: Deliveries from 14 US medical centers, from March 19 to May 31, 2020, were included. Peripartum infection was defined as a positive SARS-CoV-2 polymerase chain reaction test within 14 days of delivery. Consecutive SARS-CoV-2-infected patients with randomly selected control patients were sampled (1:2 ratio) with controls delivering during the same day without a positive test. Outcomes were obstetric (eg, delivery mode, hypertensive disorders of pregnancy, and delivery <37 weeks), an adverse neonatal outcome composite measure (primary), and anesthetic utilization (eg, neuraxial labor analgesia and anesthesia). Outcomes were analyzed using generalized estimating equations to account for clustering within centers. Sensitivity analyses compared symptomatic and asymptomatic patients to controls. RESULTS: One thousand four hundred fifty four peripartum women were included: 490 with SARS-CoV-2 infection (176 [35.9%] symptomatic) and 964 were controls. SARS-CoV-2 patients were slightly younger, more likely nonnulliparous, nonwhite, and Hispanic than controls. They were more likely to have diabetes, obesity, or cardiac disease and less likely to have autoimmune disease. After adjustment for confounders, individuals experiencing SARS-CoV-2 infection exhibited an increased risk for delivery <37 weeks of gestation compared to controls, 73 (14.8%) vs 98 (10.2%) (adjusted odds ratio [aOR], 1.47; 95% confidence interval [CI], 1.03-2.09). Effect estimates for other obstetric outcomes and the neonatal composite outcome measure were not meaningfully different between SARS-CoV-2 patients versus controls. In sensitivity analyses, compared to controls, symptomatic SARS-CoV-2 patients exhibited increases in cesarean delivery (aOR, 1.57; 95% CI, 1.09-2.27), postpartum length of stay (aOR, 1.89; 95% CI, 1.18-2.60), and delivery <37 weeks of gestation (aOR, 2.08; 95% CI, 1.29-3.36). These adverse outcomes were not found in asymptomatic women versus controls. SARS-CoV-2 patients (asymptomatic and symptomatic) were less likely to receive neuraxial labor analgesia (aOR, 0.52; 95% CI, 0.35-0.75) and more likely to receive general anesthesia for cesarean delivery (aOR, 3.69; 95% CI, 1.40-9.74) due to maternal respiratory failure. CONCLUSIONS: In this large, multicenter US cohort study of women with and without peripartum SARS-CoV-2 infection, differences in obstetric and neonatal outcomes seem to be mostly driven by symptomatic patients. Lower utilization of neuraxial analgesia in laboring patients with asymptomatic or symptomatic infection compared to patients without infection requires further investigation.

Effect of penicillin allergy on prophylactic antibiotic administration in the parturient undergoing cesarean delivery.

BACKGROUND: Administering antibiotics is often difficult in patients with specific medication allergies. This investigation aimed to determine if a penicillin or cephalosporin allergy increased the risk for not receiving correct timing of prophylactic antibiotics at cesarean delivery. We hypothesized that patients with a penicillin or cephalosporin allergy would be less likely to receive antibiotics prior to incision for cesarean delivery. METHODS: All women undergoing cesarean delivery at Mayo Clinic Hospital, from 1 March 2008, to 28 February 2018 were retrospectively identified by electronic medical record query. Patients were grouped based on allergy status to penicillin/cephalosporins. Data recorded included the type and time of antibiotic given in relation to surgical incision. The primary outcome of this study was administration of antibiotics within 60 minutes prior to surgical incision. Characteristics potentially associated with the primary outcome were assessed using logistic regression. RESULTS: Of the 818 patients with a penicillin or cephalosporin allergy, 75 (9.2%) did not receive prophylactic antibiotic within 60 minutes prior to skin incision. Conversely, 326 (6.9%) of the 4744 patients without a penicillin or cephalosporin allergy did not receive their prophylactic antibiotic within 60 minutes prior to skin incision (P = .019). Patients undergoing an emergent cesarean delivery were also at an increased risk of not receiving their prophylactic antibiotic within 60 minutes prior to skin incision (P < .001). CONCLUSION: Patients with a penicillin or cephalosporin allergy were less likely to receive prophylactic antibiotics within the recommended 60 minutes prior to surgical incision. Clear plans and communication are important for ensuring proper antibiotic administration at cesarean delivery to prevent surgical site infection.

A cross-sectional survey study of United States residency program directors' perceptions of parental leave and pregnancy among anesthesiology trainees.

PURPOSE: Little is known about program directors' knowledge, attitudes, and beliefs regarding parental leave policies in anesthesiology training. This study sought to understand program director perceptions about the effects of pregnancy and parental leave on resident training, skills, and productivity. METHODS: An online 43-question survey was developed to evaluate United States anesthesiology program directors' perceptions of parental leave policies. The survey included questions regarding demographics, anesthesiology program characteristics, parental leave policies, call coverage, and the perceived effects of parental leave on resident performance. Data were collected by Qualtrics (Qualtrics, Provo, UT, USA). RESULTS: Fifty-six of 145 (39%) anesthesiology program directors completed the survey. Forty-eight of 54 (89%) program directors had a female resident take maternity leave in the past three years. When asked how parental leave affects residents' futures, 24/50 (48%) program directors felt it delayed board certification and 28/50 (56%) thought it affected fellowship opportunities. Program directors were split on their perceived impact of becoming a parent on a trainee's work. Yet, when compared with male trainees, program directors perceived that becoming a parent negatively affected female trainees' timeliness, technical skills, scholarly activities, procedural volume, and standardized test scores and affected training experience of co-residents. Program directors perceived no difference in impact on female trainees' dedication to patients and clinical performance. CONCLUSIONS: Program directors perceived that becoming a parent negatively affects the work performance of female but not male trainees. These negative perceptions could impact evaluations and future plans of female residents.

RéSUMé: OBJECTIF: On ne sait que peu de choses concernant les connaissances, les attitudes et les croyances des directeurs de programme au sujet des politiques relatives aux congés parentaux dans le cadre de la formation en anesthésiologie. Cette étude visait à comprendre les perceptions des directeurs de programme au sujet des effets de la grossesse et du congé parental sur la formation, les compétences et la productivité des résidents. MéTHODE: Un sondage en ligne comportant 43 questions a été élaboré afin d'évaluer les perceptions des directeurs de programme d'anesthésiologie aux États-Unis à l'égard des politiques en matière de congé parental. Le sondage comprenait des questions sur les données démographiques, les caractéristiques du programme d'anesthésiologie, les politiques relatives au congé parental, la couverture des gardes et les effets perçus du congé parental sur la performance des résidents. Les données ont été recueillies par Qualtrics (Qualtrics, Provo, UT, USA). RéSULTATS: Cinquante-six (39 %) des 145 directeurs de programme d'anesthésiologie ont répondu au sondage. Quarante-huit des 54 (89 %) directeurs de programme ont eu une résidente ayant pris un congé maternité au cours des trois dernières années. Lorsqu'on leur a demandé comment le congé parental affectait l'avenir des résidents, 24/50 (48 %) des directeurs de programme estimaient que cela retardait la certification médicale et 28/50 (56 %) pensaient que cela affectait les possibilités de fellowship. Les directeurs de programme étaient divisés quant à la question de l'impact perçu de devenir parent sur le travail d'un résident. Pourtant, par rapport aux résidents de sexe masculin, les directeurs de programme étaient d'avis que le fait de devenir parent affectait négativement les résidentes en matière de ponctualité, de compétences techniques, d'activités académiques, de volume procédural, de résultats aux tests standardisés et de l'expérience de formation de leurs co-résidents. Les directeurs de programme n'ont perçu aucune différence d'impact sur le dévouement des résidentes à l'égard de leurs patients ou sur leur performance clinique. CONCLUSION: Selon les directeurs de programme, le fait de devenir parent a une incidence négative sur la performance professionnelle des résidentes, mais non des résidents. Ces perceptions négatives pourraient avoir une incidence sur les évaluations et les plans futurs des résidentes.

Intrathecal Morphine versus Intrathecal Hydromorphone for Analgesia after Cesarean Delivery: A Randomized Clinical Trial.

BACKGROUND: Intrathecal opioids are routinely administered during spinal anesthesia for postcesarean analgesia. The effectiveness of intrathecal morphine for postcesarean analgesia is well established, and the use of intrathecal hydromorphone is growing. No prospective studies have compared the effectiveness of equipotent doses of intrathecal morphine versus intrathecal hydromorphone as part of a multimodal analgesic regimen for postcesarean analgesia. The authors hypothesized that intrathecal morphine would result in superior analgesia compared with intrathecal hydromorphone 24 h after delivery. METHODS: In this single-center, double-blinded, randomized trial, 138 parturients undergoing scheduled cesarean delivery were randomized to receive 150 µg of intrathecal morphine or 75 µg of intrathecal hydromorphone as part of a primary spinal anesthetic and multimodal analgesic regimen; 134 parturients were included in the analysis. The primary outcome was the numerical rating scale score for pain with movement 24 h after delivery. Static and dynamic pain scores, nausea, pruritus, degree of sedation, and patient satisfaction were assessed every 6 h for 36 h postpartum. Total opioid consumption was recorded. RESULTS: There was no significant difference in pain scores with movement at 24 h (intrathecal hydromorphone median [25th, 75th] 4 [3, 5] and intrathecal morphine 3 [2, 4.5]) or at any time point (estimated difference, 0.5; 95% CI, 0 to 1; P = 0.139). Opioid received in the first 24 h did not differ between groups (median [25th, 75th] oral morphine milligram equivalents for intrathecal hydromorphone 30 [7.5, 45.06] vs. intrathecal morphine 22.5 [14.0, 37.5], P = 0.769). From Kaplan-Meier analysis, the median time to first opioid request was 5.4 h for hydromorphone and 12.1 h for morphine (log-rank test P = 0.200). CONCLUSIONS: Although the hypothesis was that intrathecal morphine would provide superior analgesia to intrathecal hydromorphone, the results did not confirm this. At the doses studied, both intrathecal morphine and intrathecal hydromorphone provide effective postcesarean analgesia when combined with a multimodal analgesia regimen.

Management of Supraventricular Tachycardia in Pregnancy.

Supraventricular tachycardia is a common arrhythmia in pregnancy. During labor and delivery, neuraxial analgesia is important to prevent arrhythmia recurrence. We present the case of a 27-year-old gravida 2 para 1 woman at 35 weeks' gestation presenting with supraventricular tachycardia that converted to normal sinus rhythm with adenosine. To prevent recurrence of the arrhythmia, an early epidural was provided during labor to minimize catecholamine release.

Labor Analgesia in a Patient with Severe Dystrophic Calcinosis Cutis.

INTRODUCTION: Calcinosis cutis is a condition characterized by pathologic calcium deposition into superficial dermal skin layers. It is often associated with an autoimmune disease. However, it may also occur after minor localized trauma and infection. DESCRIPTION OF PROBLEM: We report a case of lumbar epidural placement of labor analgesia in a parturient with severe dystrophic calcinosis cutis without apparent complications. CLINICAL SOLUTION: We recommend fastidious optimization of epidural placement conditions for all patients who may be at high risk for neuraxial anesthesia, including consideration of ultrasound use, use of an experienced anesthesia provider for neuraxial placement, and placement in early labor. Additionally, judicious discussion of risks, benefits, and alternatives when obtaining informed consent is critical, ideally with the patient identified for a comprehensive visit in a preoperative obstetric anesthesia clinic before delivery.

Exophthalmos due to sterile neutrophilic dermatosis in a dog.

An 8-year-old castrated male Bichon Frise was presented to the Kansas State University Veterinary Health Center for evaluation of unilateral right-sided exophthalmos, suspected secondary to a retrobulbar abscess. The dog had acutely developed right-sided periorbital swelling, exophthalmos with pain on retropulsion, as well as multiple cutaneous exudative plaques on the feet and tail base. On ophthalmic examination, the dog also exhibited mild left-sided exophthalmos with decreased, nonpainful retropulsion. Orbital ultrasound and CT were performed to evaluate the extent of bilateral orbital disease. Incisional biopsies were obtained from the affected right periorbital tissues and skin of the feet, and histopathology revealed severe neutrophilic inflammation of the dermis with no organisms detected. Histologic changes were consistent with sterile neutrophilic dermatosis. The dog achieved clinical remission following treatment with initial immunosuppressive doses of corticosteroids and subsequent long-term maintenance therapy using oral cyclosporine.

Indolizine-Squaraines: NIR Fluorescent Materials with Molecularly Engineered Stokes Shifts.

The development of deep red and near infrared emissive materials with high quantum yields is an important challenge. Several classes of squaraine dyes have demonstrated high quantum yields, but require significantly red-shifted absorptions to access the NIR window. Additionally, squaraine dyes have typically shown narrow Stokes shifts, which limits their use in living biological imaging applications due to dye emission interference with the light source. Through the incorporation of indolizine heterocycles we have synthesized novel indolizine squaraine dyes with increased Stokes shifts (up to >0.119 eV, >50 nm increase) and absorptions substantially further into the NIR region than an indoline squaraine benchmark (726 nm versus 659 nm absorption maxima). These materials have shown significantly enhanced water solubility, which is unique for squaraine dyes without water-solubilizing substituents. Absorption, electrochemical, computational, and fluorescence studies were undertaken and exceptional fluorescence quantum yields of up 12 % were observed with emission curves extending beyond 850 nm.

Epidural Labor Analgesia and Maternal Fever.

Women receiving an epidural for labor analgesia are at increased risk for intrapartum fever. This relationship has been supported by observational, before and after, and randomized controlled trials. The etiology is not well understood but is likely a result of noninfectious inflammation as studies have found women with fever have higher levels of inflammatory markers. Maternal pyrexia may change obstetric management and women are more likely to receive antibiotics or undergo cesarean delivery. Maternal pyrexia is associated with adverse neonatal outcomes. With these consequences, understanding and preventing maternal fever is imperative.

Photocatalytic Reduction of CO2 with Re-Pyridyl-NHCs.

A series of Re(I) pyridyl N-heterocyclic carbene (NHC) complexes have been synthesized and examined in the photocatalytic reduction of CO2 using a simulated solar spectrum. The catalysts were characterized through NMR, UV-vis, cyclic voltammetry under nitrogen, and cyclic voltammetry under carbon dioxide. The complexes were compared directly with a known benchmark catalyst, Re(bpy) (CO)3Br. An electron-deficient NHC substituent (PhCF3) was found to promote catalytic activity when compared with electron-neutral and -rich substituents. Re(PyNHC-PhCF3) (CO)3Br was found to exceed the CO production of the benchmark Re(bpy) (CO)3Br catalyst (51 vs 33 TON) in the presence of electron donor BIH and photosensitizer fac-Ir(ppy)3. Importantly, Re(PyNHC-PhCF3) (CO)3Br was found to function without a photosensitizer (32 TON) at substantially higher turnovers than the benchmark catalyst Re(bpy) (CO)3Br (14 TON) under a solar simulated spectrum.

The use of a lot quality assurance sampling methodology to assess and manage primary health interventions in conflict-affected West Darfur, Sudan.

BACKGROUND: Organizations working in conflict-affected areas have a need to monitor and evaluate their programs, however this is often difficult due to the logistical challenges of conflict areas. Lot quality assurance sampling may be a suitable method of assessing programs in these situations. METHODS: We conducted a secondary data analysis of information collected during Medair's routine program management functions. Medair's service area in West Darfur, Sudan was divided into seven supervisory areas. Using the available population information, a sampling frame was developed and interviews were conducted from randomly selected caretakers of children in each supervisory area every six months over 19 months. A survey instrument with questions related to key indicators for immunizations and maternal, newborn, and child health was used for the interviews. Based on Medair's goals for each indicator, decision rules were calculated for the indicators; these decision rules determined which supervisory areas and indicators performed adequately in each assessment period. Pearson's chi-squared tests, adjusted for the survey design using STATA "svy: tab" commands, were used to detect overall differences in coverage in this analysis. RESULTS: The coverage of tetanus toxoid vaccination among pregnant women increased from 47.2 to 69.7 % (p value = 0.046), and births attended by a skilled health professional increased from 35.7 to 52.7 % (p value = 0.025) from the first to last assessment periods. Measles vaccinations declined from 72.0 to 54.1 % (p value = 0.046). The estimated coverage for the proportion of women receiving a postpartum dose of vitamin A (54.7 to 61.3 %, p value = 0.44); pregnant women receiving a clean delivery kit (54.6 to 47.1 %, p value = 0.49); and pentavalent vaccinations (49.7 to 42.1 %, p value = 0.28) did not significantly change. CONCLUSIONS: Lot quality assurance sampling was a feasible method for Medair staff to evaluate and optimize primary health programs in a conflict-affected area. Medair managers were able to collect, analyze, and disseminate data to staff alongside the routine work of the organization. These results suggest LQAS may be used in other complex humanitarian emergencies in which there are logistical challenges and limited resources.

Culture and adenoviral infection of sinoatrial node myocytes from adult mice.

Pacemaker myocytes in the sinoatrial node of the heart initiate each heartbeat by firing spontaneous action potentials. However, the molecular processes that underlie pacemaking are incompletely understood, in part because of our limited ability to manipulate protein expression within the native cellular context of sinoatrial node myocytes (SAMs). Here we describe a new method for the culture of fully differentiated SAMs from adult mice, and we demonstrate that robust expression of introduced proteins can be achieved within 24-48 h in vitro via adenoviral gene transfer. Comparison of morphological and electrophysiological characteristics of 48 h-cultured versus acutely isolated SAMs revealed only minor changes in vitro. Specifically, we found that cells tended to flatten in culture but retained an overall normal morphology, with no significant changes in cellular dimensions or membrane capacitance. Cultured cells beat spontaneously and, in patch-clamp recordings, the spontaneous action potential firing rate did not differ between cultured and acutely isolated cells, despite modest changes in a subset of action potential waveform parameters. The biophysical properties of two membrane currents that are critical for pacemaker activity in SAMs, the "funny current" (If) and voltage-gated Ca(2+) currents (ICa), were also indistinguishable between cultured and acutely isolated cells. This new method for culture and adenoviral infection of fully-differentiated SAMs from the adult mouse heart expands the range of experimental techniques that can be applied to study the molecular physiology of cardiac pacemaking because it will enable studies in which protein expression levels can be modified or genetically encoded reporter molecules expressed within SAMs.