Global obstetric anaesthesia: bridging the gap in maternal health care inequities through partnership in education.

Maternal mortality rates are unacceptably high globally. Low- and middle-income countries (LMICs) face challenges of an inadequate anaesthesia workforce, under-resourced healthcare systems and sub-optimal access to labour and delivery care, all of which negatively impact maternal and neonatal outcomes. In order to effect the changes in surgical-obstetric-anaesthesia workforce numbers advocated by the Lancet Commission on Global Surgery to support the UN sustainable development goals, mass training and upskilling of both physician and non-physician anaesthetists is imperative. The implementation of outreach programmes and partnerships across organisations and countries has already been shown to improve the provision of safe care to mothers and their babies, and these efforts should be continued. Short subspecialty courses and simulation training are two cornerstones of modern obstetric anaesthesia training in poorly resourced environments. This review discusses the challenges to accessing quality maternal healthcare in LMICs and the use of education, outreach, partnership and research to protect the most vulnerable women from coming to harm in the peripartum period.

Why are women still dying from obstetric hemorrhage? A narrative review of perspectives from high and low resource settings.

The possibility of hemorrhage will always co-exist with pregnancy, whether anticipated or not. It remains the unwelcome guest in the corner of every delivery room, stealing the lives of young women every day across the globe. In 2014, the World Health Organization reported that hemorrhage was the leading contributor to maternal mortality worldwide, with nearly 75% of maternal deaths due to postpartum hemorrhage. In low resource settings, while maternal mortality is decreasing, hemorrhage remains the single most important contributor to maternal death. Hospital-based deliveries with skilled birth attendants have been encouraged to improve outcomes and, as a result, hospital births have dramatically increased. However, access to higher levels of emergency obstetric care as well as blood products and therapeutic resources remain limiting factors. Meanwhile, in high resource settings, maternal mortality from hemorrhage is increasing, particularly among women of color. While very rare, mortality from hemorrhage generally follows medical interventions such as surgical management of placenta accreta or emergency cesarean section. Primary prevention therefore requires careful selection and conduct of medical interventions, as well as the provision of high quality, supportive, and safe maternity care. It is clear that there is not one single solution in preventing obstetric hemorrhage on a global scale. The international community must employ creative solutions to reduce this ever-present problem.

Refractory status epilepticus after inadvertent intrathecal injection of tranexamic acid treated by magnesium sulfate.

We present a case of accidental injection of tranexamic acid during spinal anesthesia for an elective cesarean delivery. Immediately following intrathecal injection of 2mL of solution, the patient complained of severe back pain, followed by muscle spasm and tetany. As there was no evidence of spinal block, the medications given were checked and a 'used' ampoule of tranexamic acid was found on the spinal tray. General anesthesia was induced but muscle spasm and tetany persisted despite administration of a non-depolarizing muscle relaxant. Hemodynamic instability, ventricular tachycardia, and status epilepticus developed, which were refractory to phenytoin, diazepam, and infusions of thiopental, midazolam and amiodarone. Magnesium sulfate was administered postoperatively in the intensive care unit, following which the frequency of seizures decreased, eventually stopping. Unfortunately, on postoperative day three the patient died from cardiopulmonary arrest after an oxygen supply failure that was not associated with the initial event. This report underlines the importance of double-checking medications before injection in order to avoid a drug error. As well, it suggests that magnesium sulfate may be useful in stopping seizures caused by the intrathecal injection of tranexamic acid.

Comparison of the inhibitory effects of diverse amino acids and amino acid analogs on 12-O-tetradecanoylphorbol-13-acetate-induced ornithine decarboxylase activity in isolated epidermal cells.

At a concentration of 1.25 mM, 14 amino acids were capable of inhibiting the induction of ornithine decarboxylase (L-ornithine carboxy-lyase, EC 4.1.1.17) activity by the tumor promoter 12-O-tetradecanoylphorbol-13-acetate (TPA) in isolated epidermal cells. The greatest percentages of inhibition of TPA-induced epidermal ornithine decarboxylase activity were as follows: cysteine, 98%; tryptophan, 74%; methionine, 64%; phenylalanine, 51%; glycine, 44%; asparagine, 43%; glutamic acid, 42%; leucine, 40%; and arginine, 39%. These amino acid treatments did not alter the time- and concentration-response curves for induction of ornithine decarboxylase activity by TPA. Moreover, there was no difference between the rates at which [3H]arginine, [3H]leucine, [3H]phenylalanine, [3H]methionine, [3H]tryptophan and [14C]cysteine were taken up by freshly isolated epidermal cells or incorporated into epidermal proteins. Arginine, phenylalanine and methionine inhibited the induction of ornithine decarboxylase activity by the tumor promoter to degrees comparable to those elicited by their analogs canavanine and homoarginine, beta-2-thienyl-DL-alanine, and ethionine, respectively. These amino acids and amino acid analogs did not alter the overall rate of protein synthesis. In contrast, both the amino acids and their analogs increased the rates of proteolysis in isolated epidermal cells, an effect which correlated well with the abilities of these different compounds to inhibit TPA-induced ornithine decarboxylase activity. Moreover, both methionine and phenylalanine decreased the half-life and increased the rate of heat denaturation of the TPA-induced enzyme, a result identical to that obtained after treatment with the analogs ethionine and beta-2-thienyl-DL-alanine, respectively. Taken together, these results suggest that millimolar concentrations of exogenous amino acids might induce the synthesis of abnormal proteins and nonfunctional enzymes. Therefore, it is speculated that the uptake of unbalanced amounts of amino acids into the epidermal target cells might alter the stability and the ultrastructure of the TPA-stimulated enzyme just as the amino acid analogs do.

Ultraviolet radiation and the risks of cutaneous malignant melanoma and non-melanoma skin cancer: perceptions and behaviours of Danish and American adolescents.

The highest prevalence rates of skin malignancy in the northern hemisphere occur in Scandinavia and the United States (USA). Most Danes and Americans receive 50% of their lifetime ultraviolet (UV) radiation before the age of 21, making it important to address sun exposure risks with adolescents. The project was undertaken to determine differences between Danish and American adolescents in knowledge of sun exposure and skin malignancy, activities accounting for sun exposure, and means used for sun protection. Questionnaires regarding skin cancer and sun exposure were distributed to 674 secondary school age students in Hilleroed, Denmark, and to 483 similarly aged students in Winston-Salem, North Carolina, USA. Differences in responses between and within groups were compared. American adolescents had more knowledge of the characteristics and malignant potential of melanoma than did Danish adolescents. Danish youth and females from both countries were significantly more likely to engage in sunbathing and tanning bed use. Black Danish students reported significantly more sunburn and were more likely to sunbathe or use a tanning bed than were black American students. Danish students were more likely than Americans to use sunscreen, however, Americans were more likely to apply sun protective factor (SPF) 15 or greater. In conclusion, given that sunbathing and tanning bed use are associated with the development of precancerous lesions and skin malignancy, Danish teens are at increased risk. The rates of skin malignancy are relatively high in Scandinavia and efforts to improve understanding of exposure and cancer risks should be undertaken in adolescents.

Effect of cerebrospinal fluid hyperosmolality on sweating in the heat-stressed patas monkey.

Dehydration increases the osmolality of body fluids and decreases the rate of sweating during thermal stress. By localizing osmotic stimuli to central nervous system tissues, this study assessed the role of central stimulation on sweating in a heat-stressed nonhuman primate. Lenperone-tranquilized patas monkeys (Erythrocebus patas n = 5), exposed to 41 +/- 2 degrees C, were monitored for calf sweat rate, rectal and mean skin temperatures, oxygen consumption, and heart rate during infusions (255-413 microliters) of hypertonic artificial cerebrospinal fluid (ACSF) into the third cerebral ventricle. ACSF made hypertonic with NaCl to yield osmolalities of 800 and 1,000 mosmol/kgH2O significantly decreased sweat rate compared with control ACSF (285 mosmol/kgH2O), achieving maximal reductions during infusion of 37 and 53%, respectively. Rectal temperature significantly increased during the recovery period, reaching elevations of 0.69 and 0.72 degrees C, respectively, at 20 min postinfusion. In contrast, ACSF made hypertonic with sucrose (800 mosmol/kgH2O) failed to change sweat rate or rectal temperature during infusion in three animals. Thus, intracerebroventricular infusions of hypertonic ACSF mimicked dehydration-induced effects on thermoregulation. The reduction in heat loss during infusion appeared to depend on an elevation in cerebrospinal fluid [Na+] and not osmolality per se.

Effects of CSF ANG II and AVP on sweating in the heat-stressed patas monkey.

Increasing cerebrospinal fluid [Na+] reduces sweat rate (msw) in the heat-stressed patas monkey (Erythrocebus patas). This study determined the potential role of two neuropeptides, angiotensin II (ANG II) and arginine vasopressin (AVP), in mediating this response. Artificial cerebrospinal fluid, containing either ANG II or AVP, was infused into the third cerebral ventricle of lenperone-tranquilized monkeys (n = 4) exposed to 41 +/- 2 degrees C. Solutions were infused at 16.5 microliters/min for 25 min (total vol approximately 413 microliters). ANG II (1.25, 2.5, 5, and 10 ng/microliters) tended to decrease .msw. However, during infusion, only the decline at 10 min associated with the 1.25-ng/microliters dose (26%) was different (P less than 0.004) from control. This dose elevated (P less than 0.004) core rectal temperature by 1.14 degrees C at 20 min postinfusion. In contrast, AVP (0.5 and 1.5 micrograms/microliters artificial cerebrospinal fluid) had no significant effect on .msw compared with control infusions. Both doses of AVP produced a slight but significant increase in rectal temperature of 0.14 and 0.22 degrees C, respectively, at 20 min postinfusion. In conclusion, the magnitude and time course of the change in .msw with central ANG II suggest that it does not act as the sole mediator of the decline in .msw observed with elevated cerebrospinal fluid [Na+]. The minimal effects produced by third ventricular AVP exclude this route as a means by which AVP could modulate .msw during dehydration.

Autonomic effects of central injections of D-Ala2-Met-enkephalinamide (DAME) in the conscious monkey.

The use of naloxone (NAL), an opioid receptor antagonist, has provided indirect evidence that endogenous opioids contribute to cardiovascular depression during shock. To determine if endogenous opioids act centrally to influence cardiovascular function, injections of D-Ala2-Met-enkephalinamide (DAME), a potent Met-enkephalin analog, were made into the 3rd cerebral ventricle (ICV) of 5 conscious cynomulgus monkeys restrained in primate chairs. Systolic blood pressure (SBP) and heart rate (HR) were determined every 10 min during a 30-60 min control period and for up to 5 hr post-injection. Colonic temperature (Tc) was monitored continuously. SBP declined from baseline values with 50 and 100 micrograms (85.2 and 170.4 nM) doses but was significant (p less than 0.001) for only the 100 micrograms dose between 15-125 min post-injection. HR also decreased but did not exhibit any significant variation with time. However, when averaged across time, HR fell significantly (p less than 0.001) from baseline: -9.1 +/- 2.3 and -15.0 +/- 2.1 b/min for 50 and 100 micrograms DAME, respectively. Tc displayed a nonsignificant, delayed (greater than 2 hr) rise in Tc with the 50 micrograms dose, whereas the 100 micrograms dose caused a significant (p less than 0.001) decline in Tc (from 65-125 min post-injection). NAL injected ICV attenuated the effects of DAME but had no effect on SBP, HR or Tc when injected alone. Systemic injection of DAME (300 micrograms) in one monkey produced a transient decline in SBP (26 mmHg within 2 min) which returned to baseline values 4 min post-injection. HR and Tc were unchanged.(ABSTRACT TRUNCATED AT 250 WORDS)

Cyclo(Gly-Gln) inhibits the cardiorespiratory depression produced by beta-endorphin and morphine.

Glycyl-L-glutamine (Gly-Gln; beta-endorphin 30-31) is an endogenous dipeptide that is synthesized through the post-translational processing of beta-endorphin. Previously, we showed that Gly-Gln inhibits the hypotension and respiratory depression produced by central beta-endorphin administration. In this study, we tested whether cyclo(Gly-Gln), a non-polar, cyclic Gly-Gln derivative, was similarly effective following intracerebro-ventricular (i.c.v.) or intra-arterial (i.a.) administration to pentobarbital-anesthetized rats pretreated with beta-endorphin (0.5 nmol i.c.v.). Intracerebroventricular cyclo(Gly-Gln) (0.3, 0.6 or 1.0 nmol) injection produced a dose-dependent inhibition of beta-endorphin-induced hypotension, but not bradycardia, with a potency similar to that of Gly-Gln. Cyclo(Gly-Gln) (5 mg/kg) was also effective following i.a. injection and significantly attenuated the fall in arterial pressure elicited by i.c.v. beta-endorphin, consistent with evidence that cyclic dipeptides permeate the blood-brain barrier; i.a. Gly-Gln was ineffective. Intra-arterial cyclo(Gly-Gln) (5 mg/kg) and i.c.v. Gly-Gln (10 nmol) also attenuated the hypotension and respiratory depression induced by morphine (50 or 100 nmol i.c.v.). Cyclo(Gly-Gln) (0.5, 5.0 or 50.0 mg/kg i.a.) had no effect on arterial pressure or heart rate when given alone. These findings indicate that cyclo(Gly-Gln) is a biologically active peptide capable of reversing the cardiorespiratory depression produced by beta-endorphin or morphine.

Effects of changing hypothalamic temperature on eccrine sweating in the patas monkey.

Two male (10-13 kg) patas monkeys (Erythrocebus patas) were implanted with bilateral thermodes to control hypothalamic temperature. Animals were restrained in primate chairs and instrumented to yield hypothalamic (THYPO), colonic (Tc), and mean skin (Tsk) temperatures, chest sweat rate (mSW), and heart rate (HR). THYPO was monitored using a thermocouple inserted to the tip of a non-perfused thermode; mSW was measured using resistance hygrometry. After the monkey equilibrated to a selected ambient temperature, four thermodes were perfused with water from a temperature-controlled bath. Increasing THYPO from 37 to 41 degrees C increased mSW from 0.05 to 0.30 mg.cm-2.min-1. Reducing Tsk shifted the THYPO:mSW relationship to the right (p less than 0.05) without significantly altering its slope. Activity-induced changes in HR, when THYPO was constant, caused fluctuations in ongoing sweating that closely tracked HR. We conclude that mSW in the patas monkey is controlled by both peripheral and central thermal inputs and nonthermal factors.

Catecholamines in honey bee (Apis mellifera L.) and various vespid (Hymenoptera) venoms.

Liquid chromatography with electrochemical detection was used to separate, identify and quantitate the levels of dopamine (DA) and noradrenaline (NA) present in the venoms of honey bees of known ages and of DA and 5-hydroxytryptamine (5-HT) in various species of vespid wasps. Fluorescence histochemistry corroborated the presence of amines in honey bee venom glands and reservoirs and supported the quantitative results. The results show: (i) There is an age dependent variation in DA and NA levels in honey bee venom and there may be a similar variation in DA and 5-HT in the venom of queen Dolichovespula arenaria. (ii) There appears to be a seasonal variation in the quantities of DA and NA present in honey bee venom. Such a seasonal variation may be one of the factors involved in the variation in the levels of amine components present in the various vespid wasp venom samples. (iii) 5-HT is present in much greater quantities than DA in vespid venoms. Low levels of NA and DOPA are present in vespid venoms.

5-Hydroxytryptamine in the venom of the honey bee (Apis mellifera L.): variation with season and with insect age.

We used liquid chromatography with electrochemical detection to show that 5-HT is present in the venom of worker honey bees (Apis mellifera L.). Immunohistochemical demonstration of 5-HT-like immunoreactivity within the venom reservoir supports this finding. Measurements were made on bees of known age at various times during the summer season. The amount of 5-HT in the venom system varies with the age of the bee and with the time of year at which the bees reached a specific age. 5-HT is shown to be a component of pure venom, rather than simply present in venom gland and reservoir tissues, by its presence in venom collected by electrical 'milking' of worker bees.

Melittin synthesis in the venom system of the honey bee (Apis mellifera L.).

The amount of melittin (measured by a direct hemolytic assay) contained in the venom system of single honey bees (Apis mellifera), of known age, increases from the time of eclosion to an age of about 4 weeks when about 500 micrograms of melittin is present. In older bees (5-6 weeks) the melittin level falls to about 250 micrograms. Measurements of the incorporation of [3H]leucine (injected into the haemolymph) into melittin show that melittin synthesis is most active in bees aged between 1 and 2 weeks after eclosion. The melittin content of the venom system changes as the summer progresses. Melittin levels in a bee of any age greater than 1 week are lower in mid-August than in a bee of the same age in early June.

Phospholipase A2 in venom extracts from honey bees (Apis mellifera L.) of different ages.

We measured phospholipase A2 activity in the venom of worker honey bees (Apis mellifera L.) of known ages using chemical (titrimetric) and radioallergosorbent methods. The two techniques give similar results. Low levels of phospholipase A2 are present in the venom system at the time of eclosion. Phospholipase A2 activity in the venom increases steadily through the 10 days after eclosion. Maximal phospholipase A2 levels (about 40 micrograms phospholipase A2/venom sac) are maintained through the rest of the life of a worker bee in summer.

Effects of ingesting carbohydrate beverages during exercise in the heat.

Ingesting carbohydrate beverages during exercise in cool temperatures can improve endurance performance. However, because hyperosmotic solutions leave the stomach more slowly than water, carbohydrate beverages could be less effective in minimizing the dehydration and hyperthermia that accompany exercise in the heat. To determine the effect of osmotically different beverages on prolonged (2 h) treadmill exercise (65% VO2max) in the heat (T db = 35 degrees C), five male runners (age 24 to 41 yr) performed three separate runs drinking 200 ml every 20 min of either 10% glucose polymer (GP), 10% glucose (G), or saccharin-sweetened water (WH). A fourth run was performed in a cool (T db = 25 degrees C) room and included drinking saccharin-sweetened water (WC). Drink osmolalities (Osm) for runs GP, G, WH, and WC were 194, 586, 94, and 71 mmol . kg-1, respectively. No significant differences were observed between runs in the heat (GP, G, and WH) for heart rate, rectal and mean skin temperatures, sweat rate, percent change in plasma volume, and gastric residue volume. When compared to the WC run, both the GP and G runs yielded greater (P less than 0.05) declines in percent change in plasma volume, but only the G run had a greater (P less than 0.05) gastric residue volume. Neither plasma osmolality, total protein, nor [Na+] varied between runs. Plasma glucose, insulin, and respiratory exchange ratios were similar between the GP and G runs. However, the GP run yielded the lowest (P less than 0.05) plasma glycerol values. Although gastric residue volume (r = 0.68) and final percent change in plasma volume (r = 0.69) were significantly correlated with drink osmolality, thermoregulation was similar between runs in the heat despite the beverage consumed.

Ropivacaine.

Ropivacaine (Naropin, AstraZeneca) is a long-acting amide local anaesthetic released for clinical use in 1996. Similar to bupivacaine, ropivacaine is equally effective for s.c. infiltration, epidural and peripheral nerve block for surgery, obstetric and post-operative analgesia. Ropivacaine differs from most other amide-type local anaesthetics in that it is marketed as a pure S-enantiomer, instead of as a racemate. This feature improves the safety of ropivacaine, and, indeed, studies have shown ropivacaine to have less cardiovascular and CNS toxicity than bupivacaine. Ropivacaine is nearly identical to bupivacaine in onset, quality and duration of sensory block, but it produces less motor block. Whether or not the motor sparing effect of ropivacaine is due to a lower relative potency compared to bupivacaine is a matter of intense debate. Despite a better safety profile, the increased cost of ropivacaine may limit its clinical utility.

Effects of weed management systems on canopy insects in herbicide-resistant soybeans.

The effects of transgenic herbicide-resistant soybean varieties and their corresponding weed management strategies on canopy insects were examined in studies at two locations in Iowa in 1997 and 1998. Weed management systems that allowed more weed escapes typically had higher insect population densities. However, systems with fewer weeds seemingly were preferred by potato leafhoppers. Bean leaf beetles and potato leafhoppers showed preferences for certain soybean varieties, but these effects were attributed to soybean plant height. These findings indicate that although the transgenic soybean varieties did not strongly affect insect populations, weed management systems can affect insect populations in soybean. However, this impact is likely related more to weed suppression effectiveness than to a direct effect of the herbicides on the insects.

Incidence and characteristics of failures in obstetric neuraxial analgesia and anesthesia: a retrospective analysis of 19,259 deliveries.

A retrospective analysis was performed on 19,259 deliveries that occurred in our institution from January 2000 to December 2002. Anesthesia records and quality assurance data sheets were reviewed for the characteristics and failure rates of neuraxial blocks performed for labor analgesia and anesthesia. The neuraxial labor analgesia rate was 75% and the overall failure rate was 12%. After adequate analgesia from initial placement, 6.8% of patients had subsequent inadequate analgesia during labor that required epidural catheter replacement. Ultimately 98.8% of all patients received adequate analgesia even though 1.5% of patients had multiple replacements. Six percent of epidural catheters had initial intravenous placement but 46% were made functional by simple manipulations without higher subsequent failure. Unintended dural puncture occurred in 1.2% of labor neuraxial analgesia. The incidences of overall failure, intravenous epidural catheter, wet tap, inadequate epidural analgesia and catheter replacement were lower in patients receiving combined spinal-epidural versus epidural analgesia. For cesarean section, 7.1% of pre-existing labor epidural catheters failed and 4.3% of patients required conversion to general anesthesia. Spinal anesthesia for cesarean section had a lower failure rate of 2.7%, with 1.2% of the patients requiring general anesthesia. The overall use of general anesthesia decreased from 8% to 4.3% over the three-year period. Furthermore, regional anesthesia was used in 93.5% of cesarean deliveries with no anesthetic-related mortalities. Future investigations should identify acceptable international standards, risk factors associated with failure and methods to reduce failure before cesarean section.

Postoperative analgesia using a low-dose, oral-transdermal clonidine combination: lack of clinical efficacy.

STUDY OBJECTIVE: To determine if a lower than previously reported oral-transdermal clonidine regimen could reduce postoperative morphine requirements without producing systemic side effects. DESIGN: Double-blind, randomized, placebo-controlled study. SETTING: University-affiliated hospital. PATIENTS: 29 healthy, ASA physical status I and II females undergoing elective abdominal hysterectomy. INTERVENTIONS: Patients received preoperative oral clonidine 4 to 5 mu/kg and a 7 cm2 transdermal clonidine patch (0.2 mg/24 hours) or a placebo tablet and patch. MEASUREMENTS AND MAIN RESULTS: Postoperative patient-controlled analgesia pumps provided morphine during the 48-hour study period. Morphine use, hemodynamic changes, and nonhemodynamic side effects were recorded. Additionally, visual analog pain scales (VAPS) and plasma concentrations of morphine and clonidine were measured. We found that low-dose clonidine had no potentiating effect on morphine analgesia. Postoperative morphine use, VAPS, and morphine plasma levels were similar between the control and clonidine-treated groups. Nevertheless, patients in the clonidine group experienced a significantly greater incidence of intraoperative and postoperative hypotension and bradycardia than did the control group. No differences were noted in the incidence of nonhemodynamic side effects. CONCLUSIONS: The low-dose oral-transdermal clonidine regimen evaluated failed to reduce postoperative morphine requirements, although patients who received clonidine were still at risk for developing hypotension.

Influence of herbicide application to soybeans on soybean cyst nematode egg hatching.

The hatching of Heterodera glycines eggs in soybean root exudates collected after postemergence application of three herbicides, and the hatching potential of H. glycines eggs from females feeding on herbicide-treated plants, were measured in vitro. Hatching in all root exudate solutions (RES) was greater than in deionized water but less than in 0.003 M ZnSO solution. Filtering RES with a 0.22-mum-filter increased H. glycines hatching in RES. Application of acifluorfen, bentazon, and lactofen to foliage of soybean plants inhibited hatching of H. glycines eggs from the same plants. Hatching in RES from the different herbicide-treated soybeans was similar. Application of crop oil concentrate and non-ionic surfactant adjuvant to foliage did not affect hatching of H. glycines eggs from soybean plants.