Search

The aim of the study was to investigate the hyaluronic acid concentration in middle ear fluid of patients with cleft palate as an indicator of the severity of the disease. Hyaluronic acid was examined in the middle ear fluid of 65 children (48 boys and 17 girls) subjected to cleft lip surgery in neonatal period up to 10 days of age. Patients were divided into 3 groups according to the course of the disease. First group consists of 15 patients with favorable course, second group consist of 25 patients with moderate course, third group included 25 patients with an adverse course. Hyaluronic acid levels were determined by commercially available immunoassay. The concentrations of hyaluronic acid in the middle ear fluid were as follows (mean+SEM): favorable course: 14253+2393 µg/l, moderate course: 7503+1345 µg/l, adverse course: 5905+2393 µg/l. Patients with adverse course and moderate course had significantly decreased hyaluronic acid levels in middle ear fluid compared to the patients with favorable course (P=0.02 and P=0.0018). Hyaluronic acid concentration is related to the course of the disease and the lowest values are most frequent in patients with an adverse course.

Summary Background It has been shown that decreased expression and activity of extracellular matrix protein mindin correlate with various types of cancers including breast, colon and lung cancers. The aim of the presented study was to investigate the serum mindin levels in prostate cancer. Methods Mindin concentrations in serum were measured in 56 patients with prostate cancer (mean age 68 years) and in control group of 29 healthy men (mean age 64 years) using commercially available enzymatic immunoassay (Cusabio, WuHan, China). The patients were divided with respect to the severity of the disease into two groups according to the EAU guidelines (stage 1, 2 – less severe tumours, stage 3, 4 – severe tumours). Results Serum mindin concentrations were significantly elevated in the group of healthy individuals unlike in the patients with prostate cancer (2.12 ng/mL vs 0.78 ng/mL, with P=0.0007, AUC=0.705). Patients with less severe tumours (stage 1, 2) and severe tumours (stage 3, 4) had significantly decreased levels of S-mindin as well (P=0.0037), although the difference in serum mindin concentrations between the patients with less severe and severe tumours was not significant. Conclusions Concentrations of mindin were decreased in patients with prostate cancer and reduced in patients with less severe prostate cancer as well. Mindin appears to be a promising diagnostic marker useful in the diagnosis of prostate cancer.

Objectifs Determiner les risques et les avantages de l'accouchement du siege par voie vaginale planifie par rapport a la cesarienne planifiee et recommander des criteres de selection, des parametres de prise en charge intrapartum et des techniques d'accouchement du siege par voie vaginale. Options Accouchement du siege par voie vaginale planifie ou cesarienne planifiee en cas de grossesse monofœtale a terme. Issues Mortalite perinatale, morbidite neonatale et infantile a court et a long terme, mortalite maternelle et morbidite maternelle a court et a long terme. DONNeES PROBANTES: Des recherches ont ete effectuees dans la base de donnees Medline jusqu'a avril 2018 pour trouver des essais randomises et des etudes de cohortes qui comparent les issues apres l'accouchement du siege par voie vaginale planifie et la cesarienne planifiee, ainsi que des etudes de cohortes qui comparent les techniques d'accouchement du siege par voie vaginale. Des articles supplementaires ont ete reperes dans les bibliographies. Validation L'evaluation par les pairs de la presente directive clinique a ete realisee par des cliniciens internationaux experts en accouchement du siege par voie vaginale; la directive a egalement ete comparee a la ligne directrice du Royal College of Obstetricians and Gynecologists, Green-top Guideline No 20b : Management of Breech Presentation. Le contenu et les recommandations ont ete rediges et acceptes par les auteurs principaux. Le conseil d'administration de la Societe des obstetriciens et gynecologues du Canada a approuve la version definitive aux fins de publication. La qualite des donnees probantes utilisees dans le present document a ete evaluee au moyen des criteres du cadre methodologique GRADE (Grading of Recommendations, Assessment, Development, and Evaluation). Promoteurs Societe des obstetriciens et gynecologues du Canada. DeCLARATIONS SOMMAIRES: RECOMMANDATIONS: Criteres de selection du travailPrise en charge du travailTechnique d'accouchementSituation et consentement.

Objectives To discern the risks and benefits of planned vaginal breech birth versus planned Caesarean section and to recommend selection criteria, intrapartum management parameters, and delivery techniques for vaginal breech birth. Options Planned vaginal breech birth or planned Caesarean section for women with a singleton breech fetus at term. Outcomes Perinatal mortality, short- and long-term neonatal/infant morbidity, maternal mortality, and short- and long-term maternal morbidity. Evidence Medline was searched up to April, 2018 for randomized trials and cohort studies comparing outcomes after planned vaginal breech birth and planned Caesarean section and for cohort studies comparing vaginal breech birth techniques. Additional articles were identified through bibliography tracing. Validation This guideline was peer reviewed by international clinicians with expertise in vaginal breech birth and compared with the 2017 Royal College of Obstetricians and Gynaecologists Green Top Guideline 20b: Management of Breech Presentation. The content and recommendations were drafted and agreed upon by the principal authors. The Board of the Society of Obstetricians and Gynaecologists of Canada approved the final draft for publication. The quality of evidence was rated using the criteria described in the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology framework. Sponsors The Society of Obstetricians and Gynaecologists of Canada. SUMMARY STATEMENTS 1External cephalic version is recommended to reduce the likelihood of Caesarean section. If unsuccessful, options include planned vaginal breech birth or planned Caesarean section (high). 2In appropriately selected women in hospitals with obstetricians skilled in vaginal breech birth, perinatal mortality is between 0.8 and 1.7/1000 for planned vaginal breech birth and between 0 and 0.8/1000 for planned Caesarean section (moderate). 3In appropriately selected women, planned vaginal breech birth is associated with greater short- but not long-term neonatal neurological morbidity. Regardless of planned mode of birth, cerebral palsy occurs in approximately 1.5/1000 breech births, and any abnormal neurological development occurs in approximately 3/100 (moderate). 4During planned vaginal breech birth, a clinician experienced in vaginal breech birth should supervise the first stage of labour and be present for the active second stage of labour and delivery (IA). Staff required for rapid Caesarean section and skilled neonatal resuscitation should be in-hospital during the active second stage of labour (low). 5Vaginal breech birth requires a high degree of skill and support. To avoid the increased risk of out-of-hospital vaginal breech birth, women who choose planned vaginal breech birth should be accommodated in-hospital. To facilitate this, referral to more experienced centres, back-up on-call arrangements, and continuing medical training in vaginal breech birth skills should be promoted (very low). RECOMMENDATIONS Labour Selection Criteria 1For a woman with breech presentation near term, pre- or early-labour ultrasound should be performed to assess type of breech presentation, flexion of the fetal head, and fetal growth. If a woman presents in labour and ultrasound is unavailable and has not recently been performed, Caesarean section is recommended (strong; moderate). 2Contraindications to planned vaginal breech birth include: aCord presentation (strong; very low) bFetal growth restriction (strong; moderate) cFetal macrosomia (estimated fetal weight >4000 g) (weak; low) dFootling breech presentation (1 or both hip[s] extended) (strong; moderate) eClinically inadequate maternal pelvis (weak; very low) fFetal anomaly likely to interfere with vaginal delivery (strong; low) gHyperextended fetal head (weak; low) 3For planned vaginal breech birth at term, care should be taken to rule out growth restriction. Estimated fetal weight should be between 2800 and 4000 g (strong; moderate). 4The maternal pelvis should be clinically assessed to be adequate. Radiologic pelvimetry is not necessary for planned vaginal breech birth. Provided fetal growth is normal, good progress in labour is an indicator of adequate fetal-pelvic proportions (weak; low). Labour Management 5Upon admission in labour and immediately prior to planned Caesarean section, breech presentation should be (re)confirmed with ultrasound (strong; low). 6During planned vaginal breech birth, continuous electronic fetal monitoring is recommended in labour. When membranes rupture, immediate vaginal examination is recommended to rule out prolapsed cord (strong; moderate). 7Oxytocin augmentation is acceptable to correct weak uterine contractions. If progress in labour is poor despite adequate contractions, Caesarean section is recommended (strong; moderate). 8Although data are limited, induction of labour with breech presentation does not appear to be associated with poorer outcomes than spontaneous labour (weak; low). 9A passive second stage of up to 90 minutes before active pushing is acceptable to allow the breech to descend well into the pelvis. Once active pushing commences, delivery should be accomplished or imminent within 60 minutes; otherwise, Caesarean section is recommended (strong; moderate). 10Planned vaginal breech birth should only occur in hospitals with Caesarean section capability. During the first stage of labour, Caesarean section should be available within a time frame similar to cephalic birth. This may vary according to geographical and other factors (strong; low). 11During the active second stage of labour, anaesthesia, pediatric, and operating room personnel should be in-hospital, available for rapid Caesarean section if necessary (strong; low). Delivery Technique 12An obstetrician skilled in vaginal breech birth should be present during the active second stage and breech delivery (strong; low). 13Effective maternal and uterine power is essential to safe delivery. When vaginal delivery is imminent, oxytocin infusion may be helpful to ensure strong uterine contractions between delivery of the body and the head (weak; low). 14Fetal traction during vaginal breech birth should be avoided if possible. Any fetal manipulation should only be applied after spontaneous delivery to the level of the umbilicus (strong; moderate). 15For expulsive delay after the breech has "crowned," power from above is very likely safer than traction from below. Techniques to maximize power from above include effective maternal effort, hands and knees posture, the Bracht manoeuvre, and oxytocin augmentation (strong; low). 16Nuchal arms may be reduced by the Lovset or Bickenbach manoeuvres (strong; low). 17The fetal head may deliver spontaneously, with the assistance of suprapubic pressure, by Mauriceau-Smellie-Veit manoeuvre, or with the assistance of Piper forceps. It is recommended that an assistant be available to assist with any necessary procedures (strong; low). 18The obstetrical team should have rehearsed a plan of action for the rare trapped after-coming head or irreducible nuchal arms: symphysiotomy or Zavanelli manoeuvre can be life-saving (weak; very low). Setting and Consent 19In the absence of a contraindication to vaginal delivery, a woman with a breech fetus should be informed of the risks and benefits of planned Caesarean section and planned vaginal breech birth. A woman's choice of delivery mode should be respected and consent obtained (strong; very low). 20The consent discussion and chosen plan should be well documented and communicated to labour-room staff. A sample consent form can be found in the Appendix (strong; very low). 21Hospitals offering planned vaginal breech birth should have a written protocol for selection and intrapartum management. Experienced obstetricians willing to back up junior colleagues will maximize a hospital's ability to offer vaginal breech birth (strong; very low). 22Hospitals without obstetricians skilled in vaginal breech birth should readily refer women desiring vaginal breech birth to a centre that has colleagues with those skills (strong; very low). 23Caesarean section should be recommended to women with a contraindication to vaginal breech birth. Women who decline this recommendation should be provided the best possible in-hospital care (strong; low). 24Theoretical and simulated hands-on vaginal breech birth training should be a part of basic obstetrical curricula and post-graduate skills training programs such as ALARM, ALSO, and MOREOB (strong; very low).

Background: Common variable immunodeficiency (CVID) is an inborn error of immunity characterized by disturbed immunoglobulin production. Despite of the terrain with severe antibody deficiency, autoantibody-mediated autoimmune phenomena belong to the most frequent autoimmune manifestation. However, many unresolved issues such as prevalence, clinical relevance and origin of autoantibodies detected in CVID patients receiving immunoglobulin replacement therapy (IRT) make the diagnostics of autoimmune complications difficult.Methods: A prospective observational study evaluating the spectrum of 23 different autoantibodies in 38 CVID patients receiving IRT, and in the immunoglobulin solutions used for IRT. Results: The study reveals a high prevalence of anti-GAD (55.3%) and anti-TPO (68.4%) autoantibodes in the cohort of 38 CVID patients on regular IRT. However, the titers of anti-GAD (3.22 vs. 22 kU/L, p≤0.0001) and anti-TPO (109.7 vs. 713 kU/L, p≤0.0001) were significantly lower compared to the newly diagnosed T1D and AIT patients. Moreover, none of the CVID patients with detectable antibodies manifested with T1D and only three patients became suspected of having AIT. A high quantity of anti-GAD (3.24-24.48 kU/L) and anti-TPO (123.6-156.55 kU/L) autoantibodies was found in immunoglobulin solutions for IRT. Conclusions: The study finds a very high prevalence of anti-GAD and anti-TPO autoantibodies in CVID patients receiving regular IRT. Nevertheless, the presence of anti-GAD and anti-TPO is not associated with the manifestation of the respective autoimmune disease. As the high titers of both anti-GAD and anti-TPO were also found in the therapeutics used for IRT, we suggest that the therapeutic immunoglobulins are the source of this false positivity.

A rare case of cyanoacrylate urine bladder urolithiasis in a 60-year-old male is presented. The application of surgical glue (Glubran) as treatment of seroma one month after laparoscopic inguinal hernioplasty led to the instillation of the n-butyl cyanoacrylate into the bladder resulting in the formation of a concretion. Infrared spectroscopy of the urine stone removed by cystoscopic laser lithotripsy four months after the surgery allowed the identification of the nature of the stone and revealed cyanoacrylate as the major component and co-monomer methacryloxy sulfolane as the minor component. Polypropylene from the mesh was not detected.

A majority of deep vein thromboses identified in screening studies of hospitalized patients remain clinically insignificant. Guidelines based on these studies markedly overestimate the risk of clinical venous thromboembolism (VTE) and the benefit of heparin prophylaxis. Accordingly, in 2012, the American College of Chest Physicians (ACCP) removed screening studies from the 9th edition of its Antithrombotic and Thrombolytic Therapy guideline (AT9), and downgraded recommendations. Involvement of authors of the 8th edition (AT8) was restricted due to financial and intellectual conflicts of interest. However, the first author of AT8 subsequently wrote a “Getting Started Kit,” widely distributed to help Canadian hospitals develop VTE protocols. Based on screening studies reporting asymptomatic VTE, it lacks estimates of the magnitudes of benefit or harm from low molecular weight heparin (LMWH), yet advises prophylaxis in almost all hospitalized patients. Most Canadian hospitals have implemented guidelines based on this kit. Guidelines from the U. K National Institute for Health and Care Excellence and the U.S. Agency for Healthcare Research and Quality recommend a similar approach. However, a critical review of evidence reveals that most hospitalized patients have a risk of clinical VTE equal to or lower than the bleeding risk from LMWH. Most hospitalized patients should not receive LMWH until and unless randomized trials show more benefit than harm. Guidelines recommending liberal LMWH prophylaxis in hospitalized patients are not evidence based and should be critically re-examined. Electronic supplementary material The online version of this article (10.1186/s12959-018-0180-6) contains supplementary material, which is available to authorized users.

This chapter gives a unique obstetric perspective on the coal mine and the canary. Alison Barrett, an obstetrician from New Zealand, discusses the iatrogenesis in the coal mine of mainstream maternity care and uses an analogy to humankind’s response to climate change to parallel the blindness to the harms we are creating in childbirth. Andrew Kotaska, an obstetrician from Canada, talks about risk and how we can communicate risk to women as doctors and midwives. He argues that telling women that it is ‘my way or the highway’ can lead to them taking the highway.

The &alpha, defensins (AD) present in synovial fluid have been regarded as constituting the most accurate periprosthetic joint infection (PJI) biomarker. The methods most commonly used for estimating AD as a biomarker are the qualitative Synovasure&reg, PJI tests, based on the technique of lateral flow, and quantitative enzyme-linked immunosorbent assay (ELISA). Here, we propose a novel test based on detecting &alpha, defensins in synovial fluid by high-performance liquid chromatography (HPLC). Synovial fluid was collected from 157 patients diagnosed with PJI, infectious arthritis (IA), arthrosis, reactive arthritis, and rheumatoid arthritis. AD concentrations in the fluid were determined by HPLC, and these same samples were used for additional diagnostic analyses. The results were statistically processed to calculate cutoff concentrations for PJI and IA. HPLC testing showed a sensitivity of 94% and a specificity of 92% for diagnosis of PJI, and a sensitivity of 97% and a specificity of 87% for diagnosis of IA. Using HPLC, we detected in synovial fluid a combination of three &alpha, defensins: human neutrophil peptides HNP1, HNP2, and HNP3. All measured AD concentration values shown in this work refer to the sum of these three individual concentrations. Our study shows that the HPLC method meets the conditions for measuring precise concentrations of the sum of AD and can be recommended as part of a diagnostic array for PJI and IA diagnostics. By this method, we have verified that higher levels of AD in synovial fluid can also be seen in rheumatoid illnesses, crystal arthropathies, and reactive arthritis.

BACKGROUND Thymidine kinase-1 (TK-1) is associated with proliferation and malignancy and has been extensively studied as a diagnostic biomarker for a variety of tumors, but there are limited data for prostate cancer. METHODS TK-1 concentrations in serum were measured in 59 patients with prostate cancer (mean age 68 years) and in the control group of 28 healthy men (mean age 63 years) using commercially available enzymatic immunoassay (LSBio, Inc., Seattle, WA, USA). The patients were divided with respect to the severity of the disease into two groups according to the European Association of Urology (EAU) guidelines (Stage 1, 2 - less severe tumors, stage 3 - severe tumors). RESULTS Serum thymidine kinase-1 concentrations were significantly elevated in the group of the patients with prostate cancer compared to the healthy individuals (0.204 pmol/L vs. 0.072 pmol/L, with p < 0.0001). Diagnostic efficiency of serum TK-1 concentrations was 0.792 with the specificity of 53.6% and sensitivity of 94.9%. Patients with less severe tumors (Stage 1, 2) and severe tumors (Stage 3) had significantly increased levels of TK-1 as well (p < 0.0001). Combination of TK-1 and PSA investigation in patients with PCa improve the diagnostic validity of TK-1 (AUC = 0.87). CONCLUSIONS Concentrations of thymidine kinase 1 are increased in all patients with prostate cancer and even more in patients with severe prostate cancer. Thymidine kinase 1 appears to be a promising additional diagnostic marker promising in patients with prostate cancer.

Clinical practice guidelines hope to offer unbiased, evidence-based guidance for clinicians. This paper examines levels of evidence contained within the guidelines of the Society of Obstetricians and Gynaecologists of Canada and compares classification of the recommendation (CoR) A/B/C/D/E/L (derived from evidence and consensus) versus quality of evidence assessment (QoEA) I-III. 1250 recommendations were analysed and 43% of recommendations were graded as "good" evidence, the highest grade of CoR, while just 24.6% of recommendations were based on the highest level of QoEA (level I). The paper discusses possible reasons for this discrepancy. The authors hope that this analysis promotes greater transparency in evidence-based medicine ultimately leading to using the best quality of evidence available yet taking into account any areas of scientific uncertainty. This will enhance respectful care of patients, while taking into account their autonomy and furthering the cause of patient centre care.

Based on prediction models and expert opinion, most obstetric venous thromboembolism guidelines recommend low-molecular-weight heparin for many postpartum women, including most delivering by caesarean. Scrutiny reveals major oversights: prediction models are based on studies that report asymptomatic deep vein thrombosis; risk estimates are not adjusted for time exposure; and harm caused by heparin has been overlooked. The benefits of heparin are exaggerated and its harms are under-appreciated. Estimates of the numbers-needed-to-treat and harm are universally lacking. This paper critically reviews the evidence and quantifies the benefit and harm from low-molecular-weight heparin in postpartum women with common risk factors. Funding This work was unsponsored and unfunded. Tweetable abstract Randomised trials should demonstrate more benefit than harm before widespread postpartum low-molecular-weight heparin is recommended.

Summary Background: Increased levels of lipoprotein-associated phospholipase A2 are associated with atherosclerosis, and may contribute to cardiac disease. The aim of this study was to analyze serum levels of lipoprotein phospholipase A2 (Lp-PLA2) in patients with impaired bone resorption and correlate the findings with markers of bone metabolism (osteocalcin) and other biochemical markers (cholesterol, low density lipoprotein, triacylglycerols). Methods: Serum Lp-PLA2 was measured by a turbidimetric method in a group of currently treated 85 patients with impaired bone resorption and in a control group of 46 healthy individuals. Serum triacylglycerols was measured by the electrochemiluminescence immunoassay. Cholesterol, low density lipoprotein and triacylglycerols were measured by commercially available enzymatic assays. Bone density was investigated by dual energy X-ray densitometry performed on the lower spine and hips. Results: Concentrations of LP-PLA2 were significantly elevated in the patients with bone resorption compared to the control group of healthy individuals (225 ng/mL vs. 192 ng/mL, p>0.001) with the highest difference in patients with a T score below –2.5 SD (227 vs. 192 ng/mL). Serum levels of Lp-PLA2 also negatively correlated with decreased levels of serum osteocalcin in patients, and a significant difference in Lp-PLA2 (p=0.02) levels was observed between the control group and group with low levels of osteocalcin. Elevated Lp-PLA2 levels were significantly associated with the therapeutic procedures used, but not with age, gender and concentration of lipids. Conclusions: Lipoprotein-associated phospholipase A2 seems to play an important role also in bone metabolism.

BACKGROUND The aim of the study was to evaluate the diagnostic efficiency of cathepsins B (cathepsin B and procathepsin B) in patients with transient cell carcinoma of the urinary bladder. METHODS Serum and urine concentrations of cathepsin B and procathepsin B were measured by two commercially available enzymatic immunoassays in a group of 125 patients with bladder cell carcinoma without metastases and in a group of 72 healthy individuals. Concentrations in urine were adjusted to creatinine. RESULTS Concentrations of both cathepsin B and procathepsin B in serum and urine were significantly elevated in patients with bladder cell carcinoma (p < 0.0001 for U-procathepsin B, U-procathepsin B/creatinine, and U-cathepsin B/creatinine, p = 0.0001 for U-cathepsin B, p = 0.0002 for S-procathepsin B and p = 0.02 for S-cathepsin B). Comparison of all diagnostic efficiencies of cathepsin B and procathepsin B in serum and in urine showed the best diagnostic accuracy for procathepsin B in urine (AUC = 0.81 vs. 0.50). The ratio of U-procathepsin B/creatinine was also more efficient than the ratio of U-cathepsin B/creatinine (AUC = 0.81 vs. AUC = 0.70). The diagnostic efficiencies of both parameters in serum were low (S-procathepsin B: AUC = 0.50, S-cathepsin B: AUC = 0.60). U-procathepsin B and U-procathepsin B/creatinine ratio show significantly better diagnostic efficiency in patients with invasive bladder tumors than other parameters (S-procathepsin B, S-cathepsin B, U-cathepsin B and U-Cathepsin B/creatinine; U-procathepsin B: AUC = 0.82, U-procathepsin B/creatinine: AUC = 0.86, S-procathepsin B and cathepsin B: AUC = 0.51 - 0.68). CONCLUSIONS Procathepsin B concentration in urine is a valuable diagnostic marker in patients with bladder cell carcinoma.

Background The homeostasis of essential trace elements such as selenium and manganese may be altered in patients with severe diseases of various etiologies (trauma brain injuries, tumors, leukemias, lymphomas, neurological diseases). Methods Concentration of manganese and selenium were determined in cerebrospinal fluid by electrothermal atomic absorption spectrometry in 50 hospitalized children with various clinical ethiologies including oncological, neurological, and brain related diseases. Results The concentrations of manganese in cerebrospinal fluid of children were 0.97±0.67 μg/L. The concentrations of selenium were 13.3±3.5 μg/L. The concentrations were similar as published in adults. The values did not correlated with the age, gender and severity of the disease. Conclusion We evaluated values of selenium and manganese in cerebrospinal fluid of seriously diseased children.

The Landon et al and the Crowther et al papers are both prospective trials comparing planned vaginal birth after a previous cesarean section (VBAC) with elective cesarean section in women eligible for a trial of labor. With 33,000 women, the cohort studied by Landon et al in conjunction with the National Institute of Child Health and Human Development (NICHHD) spawned multiple publications, giving estimates of VBAC risks and success relevant to women in a wide variety of clinical situations. Data abstraction was careful and outcomes were hard and verified. With 2,300 women, the study by Crowther et al, was 6 percent the size of the Landon-NICHHD study. Although it claimed “increased risk of both fetal death or liveborn infant death prior to discharge or serious infant outcome,” there were only 2 perinatal deaths—both stillbirths prior to 39 weeks' gestation and unrelated to mode of delivery. Of the 28 infants with “serious neonatal morbidity,” only three could have resulted from uterine rupture; prior experience with this outcome indicates all three will likely escape long-term morbidity. Pseudorandomization and erroneous adherence to an intention-to-treat principle seriously hinder the study's internal validity, attributing outcomes for one quarter of women undergoing elective cesarean section to the planned VBAC group. The study by Landon and NICHHD is over 10 times larger and of much higher quality than the study by Crowther et al. The Landon-NICHHD publications should be used to help women make decisions about planned mode of delivery after cesarean. (BIRTH 39:4 December 2012)

Umbilical cord blood gas analysis (pO(2) and pCO(2)) is now recommended in all high‐risk baby deliveries and in some centers it is performed routinely following all deliveries. The aim of this study was to re‐evaluate cord blood arterial and venous reference ranges for pH, pO(2), pCO(2) in newborns, delivered by spontaneous vaginal delivery (SVD) and by cesarean section (CS) performed in Faculty Hospital Motol. Two groups of subjects were selected for the study. Group I consisted of 303 newborns with SVD. Group II consisted of 189 newborns delivered by cesarean section. Cord blood samples were analyzed for standard blood gas and pH, using the analytical device Rapid Lab 845 and Rapid Lab 865. We obtained reference values expressed as range (lower and upper reference value expressed as 2.5 and 97.5 percentiles) for cord blood in newborns with SVD: arterial cord blood: pH=7.01–7.39; pCO(2)=4.12–11.45 kPa; pO(2)=1.49–5.06 kPa; venous cord blood: pH=7.06–7.44; pCO(2)=3.33–9.85 kPa; pO(2)=1.80–6.29 kPa. We also obtained reference values for cord blood in newborns delivered by CS: arterial cord blood: pH=7.05–7.39; pCO(2)=5.01–10.60 kPa; pO(2)=1.17–5.94 kPa; venous cord blood: pH=7.10–7.42; pCO(2)=3.88–9.36 kPa; pO(2)=1.98–7.23 kPa. Re‐evaluated reference ranges play essential role in monitoring conditions of newborns with spontaneous and caesarean delivery. J. Clin. Lab. Anal. 24:300–304, 2010. © 2010 Wiley‐Liss, Inc.

The stories in this Roundtable Discussion are related by two women whose babies were born recently in Canadian hospitals. Each woman had undergone a cesarean delivery for her first child, and whereas Sophia delivered her second baby by vaginal birth after a cesarean (VBAC), Marie was unable to find a practitioner or hospital that would allow her to have a VBAC for her second birth. The women describe how they feel about their choices and experiences. Their two accounts and the issues that they raise are discussed in commentaries by a family physician, midwife, doula, and obstetrician.

Objectives: To review the physiology of breech birth; to discern the risks and benefits of a trial of labour versus planned Caesarean section; and to recommend to obstetricians, family physicians, midwives, obstetrical nurses, anaesthesiologists, pediatricians, and other health care providers selection criteria, intrapartum management parameters, and delivery techniques for a trial of vaginal breech birth.

Objectives To review the physiology of breech birth; to discern the risks and benefits of a trial of labour versus planned Caesarean section; and to recommend to obstetricians, family physicians, midwives, obstetrical nurses, anaesthesiologists, pediatricians, and other health care providers selection criteria, intrapartum management parameters, and delivery techniques for a trial of vaginal breech birth. Options Trial of labour in an appropriate setting or delivery by pre-emptive Caesarean section for women with a singleton breech fetus at term. Outcomes Reduced perinatal mortality, short-term neonatal morbidity, long-term infant morbidity, and short- and long-term maternal morbidity and mortality. Evidence Medline was searched for randomized trials, prospective cohort studies, and selected retrospective cohort studies comparing planned Caesarean section with a planned trial of labour; selected epidemiological studies comparing delivery by Caesarean section with vaginal breech delivery; and studies comparing long-term outcomes in breech infants born vaginally or by Caesarean section. Additional articles were identified through bibliography tracing up to June 1, 2008. Values The evidence collected was reviewed by the Maternal Fetal Medicine Committee of the Society of Obstetricians and Gynaecologists of Canada (SOGC) and quantified using the criteria and classifications of the Canadian Task Force on Preventive Health Care. Validation This guideline was compared with the 2006 American College of Obstetrician's Committee Opinion on the mode of term singleton breech delivery and with the 2006 Royal College of Obstetrician and Gynaecologists Green Top Guideline: The Management of Breech Presentation. The document was reviewed by Canadian and International clinicians with particular expertise in breech vaginal delivery. Sponsors The Society of Obstetricians and Gynaecologists of Canada. Summary Statements 1.Vaginal breech birth can be associated with a higher risk of perinatal mortality and short-term neonatal morbidity than elective Caesarean section. (I) 2.Careful case selection and labour management in a modern obstetrical setting may achieve a level of safety similar to elective Caesarean section. (II-1) 3.Planned vaginal delivery is reasonable in selected women with a term singleton breech fetus. (I) 4.With careful case selection and labour management, perinatal mortality occurs in approximately 2 per 1000 births and serious short-term neonatal morbidity in approximately 2% of breech infants. Many recent retrospective and prospective reports of vaginal breech delivery that follow specific protocols have noted excellent neonatal outcomes. (II-1) 5.Long-term neurological infant outcomes do not differ by planned mode of delivery even in the presence of serious short-term neonatal morbidity. (I) Recommendations Labour Selection Criteria 1.For a woman with suspected breech presentation, pre- or early labour ultrasound should be performed to assess type of breech presentation, fetal growth and estimated weight, and attitude of fetal head. If ultrasound is not available, Caesarean section is recommended. (II-1A) 2.Contraindications to labour include a.Cord presentation (II-3A) b.Fetal growth restriction or macrosomia (I-A) c.Any presentation other than a frank or complete breech with a flexed or neutral head attitude (III-B) d.d. Clinically inadequate maternal pelvis (III-B) e.Fetal anomaly incompatible with vaginal delivery (III-B) 3.Vaginal breech delivery can be offered when the estimated fetal weight is between 2500g and 4000g. (II-2B) Labour Management 4.Clinical pelvic examination should be performed to rule out pathological pelvic contraction. Radiologic pelvimetry is not necessary for a safe trial of labour; good progress in labour is the best indicator of adequate fetal-pelvic proportions. (III-B) 5.Continuous electronic fetal heart monitoring is preferable in the first stage and mandatory in the second stage of labour. (I-A) When membranes rupture, immediate vaginal examination is recommended to rule out prolapsed cord. (III-B) 6.In the absence of adequate progress in labour, Caesarean section is advised. (II-1A) 7.Induction of labour is not recommended for breech presentation. (II-3B) Oxytocin augmentation is acceptable in the presence of uterine dystocia. (II-1A) 8.A passive second stage without active pushing may last up to 90 minutes, allowing the breech to descend well into the pelvis. Once active pushing commences, if delivery is not imminent after 60 minutes, Caesarean section is recommended. (I-A) 9.The active second stage of labour should take place in or near an operating room with equipment and personnel available to perform a timely Caesarean section if necessary. (III-A) 10.A health care professional skilled in neonatal resuscitation should be in attendance at the time of delivery. (III-A) Delivery Technique 11.The health care provider for a planned vaginal breech delivery needs to possess the requisite skills and experience. (II-1A) 12.An experienced obstetrician-gynaecologist comfortable in the performance of vaginal breech delivery should be present at the delivery to supervise other health care providers, including a trainee. (I-A) 13.The requirements for emergency Caesarean section, including availability of the hospital operating room team and the approximate 30-minute timeline to commence a laparotomy, must be in accordance with the recommendations of the SOGC Policy Statement, "Attendance at Labour and Delivery" (CPG No. 89; update in press, 2009). (III-A) 14.The health care provider should have rehearsed a plan of action and should be prepared to act promptly in the rare circumstance of a trapped after-coming head or irreducible nuchal arms: symphysiotomy or emergency abdominal rescue can be life saving. (III-B) 15.Total breech extraction is inappropriate for term singleton breech delivery. (II-2A) 16.Effective maternal pushing efforts are essential to safe delivery and should be encouraged. (II-1A) 17.At the time of delivery of the after-coming head, an assistant should be present to apply suprapubic pressure to favour flexion and engagement of the fetal head. (II-3B) 18.Spontaneous or assisted breech delivery is acceptable. Fetal traction should be avoided, and fetal manipulation must be applied only after spontaneous delivery to the level of the umbilicus. (III-A) 19.Nuchal arms may be reduced by the Lovset or Bickenbach manoeuvres. (III-B) 20.The fetal head may deliver spontaneously, with the assistance of suprapubic pressure, by Mauriceau-Smellie-Veit manoeuvre, or with the assistance of Piper forceps. (III-B) Setting and Consent 21.In the absence of a contraindication to vaginal delivery, a woman with a breech presentation should be informed of the risks and benefits of a trial of labour and elective Caesarean section, and informed consent should be obtained. A woman's choice of delivery mode should be respected. (III-A) 22.The consent discussion and chosen plan should be well documented and communicated to labour-room staff. (III-B) 23.Hospitals offering a trial of labour should have a written protocol for eligibility and intrapartum management. (III-B) 24.Women with a contraindication to a trial of labour should be advised to have a Caesarean section. Women choosing to labour despite this recommendation have a right to do so and should not be abandoned. They should be provided the best possible in-hospital care. (III-A) 25.The Society of Obstetricians and Gynaecologists of Canada (SOGC), in collaboration with the Association of Professors of Obstetrics and Gynaecology (APOG), The College of Family Physicians of Canada (CFPC), and The Canadian Association of Midwives (CAM) should revise the training requirements at the undergraduate and postgraduate levels. SOGC will continue to promote training of current health care providers through the MOREOB, ALARM (Advances in Labour and Risk Management), and other courses. (III-A) 26.Theoretical and hands-on breech birth training simulation should be part of basic obstetrical skills training programs such as ALARM, ALSO (Advanced Life Support Training in Obstetrics), and MOREOB to prepare health care providers for unexpected vaginal breech births. (III-B)

SUMMARY Background and objective: Monitoring of renal function in cystic fibrosis (CF) patients is essential. The dosage regimen of amikacin is regularly modified according to the patient’s glomerular filtration rate (GFR). The aim of the study was to evaluate the use of cystatin C (CyC) for monitoring amikacin therapy along with other markers of renal tubular and glomerular function, and damage [N-acetyl-b-D glucosaminidase (NAG), creatinine level and creatinine clearance]. Methods: We compared the GFR, estimated from the serum concentrations of creatinine (Cockcroft‐Gault formula) and CyC (Grubb’s formula). Seventy-one patients (mean age 12 years; range 4‐28 years) with CF were treated by intermittent intravenous infusion of amikacin. Tubular nephrotoxicity was investigated by measurement of urine NAG ⁄urine creatinine ratio (U-NAG ⁄ U-creatinine). Concentrations of all markers were measured before starting amikacin therapy and at days 3, 5, 7, 10 and 12. Fluorescence polarization analysis, turbidimetry, enzymatic phototometric creatinine deaminase method and fluorimetry were used for determination of serum amikacin, serum CyC, creatinine and urine NAG activity. Receiver operating characteristic (ROC) analysis was performed to assess the influence of GFR estimated from serum creatinine and serum CyC for the prediction of amikacin clearance during aminoglycoside therapy. Results: Significant differences in the rate of U-NAG ⁄U-creatinine were noted before and after treatment with amikacin (P

Background: Brain natriuretic peptides are relevant markers of heart impairment. Aim: We investigated the relevance of investiging brain natriuretic peptides (NT-proBNP, BNP) in monitoring different types of cardiovascular disease (chronic heart failure due to coronary artery disease, cardiomyopathy, acquired valve disease, congenital heart diseases). Methods: The NT-proBNP assay (Roche) was performed on 280 patients (mean age 49 years; range 20–89 years) and 48 healthy controls (mean age 43 years; range 13–65 years) and BNP assay (Bayer Shionoria) was performed in a subgroup of 42 patients (mean age 50 years; range 20–79 years). Patients were divided into four groups characterized by severity of heart failure according to the New York Heart Association classification. Results: NT-proBNP concentrations differed in patients with cardiovascular diseases from controls (median 371 ng/l versus 41.5 ng/l, p < 0.0001). The cut off value of NT-proBNP determined in 280 patients with cardiovascular diseases was at 130 ng/l (AUC–area under curve = 0.93; sensitivity 98 %; specificity 79 %). Comparison of NT-proBNP and BNP values in patients showed significant correlation (r = 0.93; p < 0.0001). NT-proBNP showed significant differences between groups. Conclusions: Measurement of brain natriuretic peptides is useful and relevant in various types of heart diseases including congenital.

Historically, partial breech extraction under maternal sedation was accompanied by high perinatal mortality rates (1). With the safety of modern cesarean section techniques, many deemed the avoidance of this fetal risk worth the maternal risk of cesarean section, and the proportion of breech fetuses delivered by cesarean section steadily increased. This trend reached its peak after publication of the term breech trial in 2000 (2). This trial implied that cesarean section was safer than vaginal birth for all breech fetuses at term. Professional obstetrical associations in the United Kingdom, United States, and Canada issued guidelines mandating cesarean section for term breech presentation. Across much of the world, vaginal breech birth is no longer ‘‘offered’’ to women. A new generation of specialist obstetricians lacks the skill and confidence to attend even the most straightforward vaginal breech birth, and maternal and perinatal deaths have resulted. The conclusions of the term breech trial were simplistic and erroneous. An overly liberal selection and labor management protocol allowed poorly selected infants to labor without adequate attention to progress. Half of the perinatal deaths in the trial were in growth-restricted fetuses, and infants born after prolonged labor had poorer outcomes compared with those whose labor was shorter (1,3). Inclusion of multiple centers with disparate levels of in-house specialist and surgical capability provided an inconsistent safety net. These factors led to fetal and neonatal harm attributed erroneously to breech presentation rather than to inappropriate management. Use of short-term surrogate outcomes overestimated the long-term risk of the questionable level of care provided. Breech birth technique has evolved. Particularly in Europe, centers with consistent specialist backup and cautious protocols convincingly demonstrated that a significant proportion of breech babies can be delivered safely vaginally (4,5). The professional obstetrical associations of the United Kingdom, United States, and Canada have reversed their restrictive stances and are supportive of selected vaginal breech birth (5‐7). Given the tenuous efforts to reestablish systems to provide safe breech birth, it is important to recognize the dangers of a system that is unwilling to do so.

The aim of the study was to investigate serum NT-proBNP levels in adult patients with transposition of the great arteries (d-TGA) corrected by atrial switch procedures (Mustard or Senning) operation and to assess the relationship with ventricular impairment and NYHA class.Serum NT-proBNP levels were measured in a group of 81 consecutive adult patients (59 males, mean age 27 years and 22 females, mean age 28 years) with transposition of the great arteries (TGA) after surgical correction in childhood, and in a control group of 25 healthy individuals (16 males, mean age 32 years, and 9 females, mean age 29 years). Age-matched correlation of NT-proBNP concentrations in TGA patients after Mustard or Senning correction was performed, but this correlation was considered not significant (p=0.08).Concentrations of NT-proBNP in patients with TGA were significantly elevated compared to the control group of healthy individuals (203 ng/L vs. 41 ng/L, pElevated levels of NT-proBNP appear to be a useful tool in assessing heart failure in patients with transposition of the great arteries after atrial switch correction.

PREFACE: This ‘‘In the Literature’’ column has a different genesis from previous columns. It emanates from a discussion that began on the Maternity Care Discussion Group (MCDG), an online group of more than 600 family physicians, obstetricians, midwives, nurses, and doulas that has been hosted on the College of Family Physicians of Canada website for 20 years. Although mainly a Canadian list, international participants are welcome to join in the struggle to improve maternity care and support those who provide it. To join the MCDG List, send an e-mail to mklein@interchange. ubc.ca.

The aim of the study was to investigate genetic variants predicting cardiovascular events in patients with dyslipidemia and compare its relationship with common risk factors including hyperlipidemia, metabolic syndrome, history of acute myocardial infarction, thrombosis, obesity, and smoking.Five hundred two individuals divided into six groups corresponding with the risk factors and a control group of normolypidemic patients were analyzed for the presence of eight mutations and polymorphisms (endothelial nitric oxide synthase -786T → C and G894T; lymphotoxin A C804A; angiotensin-converting enzyme [ACE] ins/del; human platelet antigen 1 a/b; beta-fibrinogen -455G → A; apolipoprotein B [ApoB] R3500Q; APOE E2/E3/E4) using the ViennaLab CVD Strip assay.ACE deletions are the most frequent genetic variants in risk groups of dyslipidemic patients (from 58% in cardiovascular events to 51% in smokers). We found a strong relationship between genetic variants and risk factors. G894T is significantly associated with smoking (value of odds ratio [OR] = 1.62, p = 0.04), and ACE deletions are negatively associated with cardiovascular events (OR = 0.62, p = 0.03).Significant associations between genetic variants predicting cardiovascular events and common risk factors in dyslipidemic patients were found.

Aim. The aim of this study was to evaluate the diagnostic utility of natriuretic peptides of type A and B as noninvasive markers in the diagnosis and treatment of congenital and valvular heart disease. Methods. Blood samples from 82 patients with various congenital and valvular heart diseases were measured for A and B natriuretic peptide levels and levels compared with those in a reference group of blood donors. Electrochemiluminiscence immunoassay and immunoluminometric essay were used for quantification of natriuretic peptides A and B. Particular reference values in serum or plasma of blood donors were adapted from literature. Results. Natriuretic peptide levels in cardiac patients were significantly higher than reference levels. The levels of both peptides in blood serum or plasma showed positive correlation with age, gender and disease severity. Conclusions. Natriuretic peptides are efficient, non-invasive cardiac markers for facilitating diagnosis, management and treatment of valvular heart disease.

In 2001 the term breech trial led the American and Royal Colleges of Obstetricians and Gynecologists (ACOG and RCOG) to issue black-and-white “cookbook” guidelines condemning vaginal breech birth. Since then, women have been coerced, both overtly and covertly, into having cesarean sections. New evidence and a better understanding of the limitations of the term breech trial have led both the ACOG and RCOG to replace their 2001 guidelines with new ones that re-open the door for planned vaginal breech birth, acknowledge the evolving understanding of the nature of evidence, and emphasize the importance of external validity in the evaluation of complex phenomena. Parturient choice and clinical judgment are re-introduced. (BIRTH 34:2 June 2007)

We investigated the performance of brain natriuretic peptides (BNP and NT-proBNP) in detecting various degrees of left ventricular systolic dysfunction. The NT-proBNP assay (Roche) and the BNP assay (Bayer Shionoria) were performed in 46 patients (mean age 50 years; range 20-79 years) with various types of heart disease (chronic heart failure due to coronary artery disease, cardiomyopathy, acquired valve disease, congenital heart diseases) and different impairment of left ventricular systolic dysfunction was assessed by echocardiography. Patients were divided into four groups according to the left ventricular ejection fraction (LVEF) correlated with clinical severity. Significant differences in medians of NT-proBNP and BNP values between all groups were determined (P= 0.0161 for NT-proBNP and P=0.0180 for BNP). For identifying patients with severe systolic dysfunction (LVEF

A significant number of myocardial diseases are accompanied by increased synthesis and degradation of the extracellular matrix (ECM) as well as by changed maturation and incorporation of ECM components. Important groups of enzymes responsible for both normal and pathological processes in ECM remodeling are matrix metaloproteinases (MMPs). These enzymes share a relatively conserved structure with a number of identifiable modules linked to their specific functions. The most important function of MMPs is the ability to cleave various ECM components; including such rigid molecules as fibrillar collagen molecules. The amount and activity of MMPs in cardiac tissue are regulated by a range of activating and inhibiting processes. Although MMPs play multifarious roles in many myocardial diseases, here we have focused on their function in ischemic cardiac tissue, dilated cardiomyopathy and hypertrophied cardiac tissue. The inhibition of MMPs by means of synthetic inhibitors seems to be a promising strategy in cardiac disease treatment. Their effects on diseased cardiac tissue have been successfully tested in several experimental studies.

In this study, we describe changes of plasma levels of the hypothalamic neuropeptide orexin A in obese children during the reduction of body weight and its relationship to other biochemical and anthropometrical parameters. We measured orexin A fasting plasma levels by the RIA method in 58 obese children--33 girls and 25 boys; mean age 13.1+/-0.38 years (range 7-18.5) before and after 5 weeks of weight-reduction therapy. Leptin, IGF-1, and IGFBP-3 levels were measured in all the subjects and were compared to orexin A levels and anthropometrical data. Average weight in subjects before weight-reduction was 74.2+/-2.79 kg and after weight-loss 67.4+/-2.60 kg (p

Objective Randomized controlled trials suggest epidural analgesia (EA) does not increase the frequency of cesarean births compared with opioid analgesia. We analyzed trials comparing EA with opioid analgesia to determine their external validity in contemporary North American practice. Study design Randomized controlled trials comparing EA with opioid analgesia were identified from the Cochrane database and Medline and included if they reported labor outcomes and management protocols. Labor management was then compared with current obstetric practice determined from surveys of North American teaching maternity units and clinical practice guidelines. Results Of 19 trials identified, 8 were included. Seven trials used Active Management of Labor protocols that used high-dose oxytocin; each demonstrated no epidural-related increase in cesarean births. One trial that used low-dose oxytocin demonstrated a marked increase in cesarean births. Most large North American obstetric units use low-dose oxytocin. Conclusion Randomized trials showing no effect of EA on cesarean section (CS) rate lack external validity in much of North American practice. The limited data available suggest EA and low-dose oxytocin used together increase the CS rate. Early detection of dystocia and high-dose oxytocin augmentation should be considered for women receiving EA; those delivering in low-dose oxytocin settings should be advised of a probable increase in the likelihood of CS.

As randomised trials continue to ascend in the evolution of evidence based medicine, we must recognise and respect their limitations when examining complex phenomena in heterogeneous populations