Teratogen update: methylene blue

Updating an Overview of Teratology

In this chapter, the authors aim to update an overview of the principles of teratology, beginning with the definition of teratology, the critical point at which this process occurs, and some of the most common etiological agents that improve our understanding of teratology.Modern teratology has greatly improved in recent years with advances in new methods in molecular biology, toxicology, animal laboratory science, and genetics, increasing our knowledge of ambient influences. Nevertheless, there is a lot to do to reduce the influence of hazardous intervening agents, whether they target our genetics or not, that can negatively affect pregnancy and induce congenital development disorders, including morphological, biochemical, or behavioral defects.Certain agents might indeed be related to certain defects, but we have not been able to identify the cause of most congenital defects, which highlights the importance of finding and testing out new genetics techniques and conducting laboratory animal science to unravel the etiology and pathogenicity of each congenital defect.

Methylene blue applied to N95 respirators and medical masks for SARS-CoV-2 decontamination: What is the likelihood of inhaling methylene blue?

Background

Global shortage of personal protective equipment (PPE), as consequence of the COVID-19 global pandemic, has unmasked significant resource inequities prompting efforts to develop methods for safe PPE decontamination for reuse. The World Health Organization (WHO) in their Rational Use of PPE bulletin cited the use of a photodynamic dye, methylene blue, and light exposure as a viable option for N95 respirator decontamination. Because WHO noted that methylene blue (MB) would be applied to surfaces through which health care workers breathe, we hypothesized that little to no MB will be detectable by spectroscopy when the PPE is subjected to MB at supraphysiologic airflow rates.

Methods

A panel of N95 respirators, medical masks, and cloth masks were sprayed with 5 cycles of 1,000 uM MB solution. Mask coupons were subjected to the equivalent of 120 L/min of 100% humidified air flow. Effluent gas was trapped in an aqueous solution and the resultant fluid was sampled for MB absorbance with a level of detection of 0.004 mg/m3.

Results

No detectable MB was identified for any mask using Ultraviolet-Visible spectroscopy.

Conclusions

At 500-fold the amount of MB applied to N95 respirators and medical masks as were used for the decontamination study cited in the WHO Rational Use of PPE bulletin, no detectable MB was observed, thus providing safety evidence for the use of methylene blue and light exposure for mask decontamination.

Methaemoglobinaemia in pregnancy: Real world experience in a single centre in Malaysia

The literature on methaemoglobinaemia in pregnancy is scarce, imposing clinical challenges to both obstetricians and haematologists. We report a total of nine pregnancies with methaemoglobinaemia treated in our centre. Their methaemoglobin levels, mode of delivery, pregnancy management and outcome were summarized.

The Effect of Methylene Blue and Its Metabolite—Azure I—on Bioenergetic Parameters of Intact Mouse Brain Mitochondria

Methylene blue, a phenothiazine dye, that is widely used in medicine and is under clinical trials as an agent for treatment of Alzheimer’s disease. One of the factors of the unique therapeutic effect of methylene blue is its redox properties, allowing implementation of alternative electron transport: the dye accepts electrons from reducing equivalents in mitochondria and transfer them to other components of the respiratory chain or molecular oxygen. Azure I, an N-dimethylated metabolite of methylene blue, is potentially a more effective compound than methylene blue, but its ability for alternative electron transport has not been studied yet. We have shown that in contrast to methylene blue, azure I is unable to restore the membrane potential in isolated mouse brain mitochondria, inhibited by rotenone and, therefore, is unable to perform bypass of the respiratory chain complex I. Moreover, addition of azure I does not affect the rate of mitochondrial respiration in contrast to methylene blue, which increases the rate of non-phosphorylation respiration. At the same time, both dyes stimulate an increase in H₂O₂ production. Thus, only methylene blue is capable of alternative electron transport, while azure I does not produce complex I bypass. This limits its therapeutic application only as a mitochondrial-targeted agent, but does not question its antidepressant effects.

Recommendations for diagnosis and treatment of methemoglobinemia

Methemoglobinemia is a rare disorder associated with oxidization of divalent ferro‐iron of hemoglobin (Hb) to ferri‐iron of methemoglobin (MetHb). Methemoglobinemia can result from either inherited or acquired processes. Acquired forms are the most common, mainly due to the exposure to substances that cause oxidation of the Hb both directly or indirectly. Inherited forms are due either to autosomal recessive variants in the CYB5R3 gene or to autosomal dominant variants in the globin genes, collectively known as HbM disease. Our recommendations are based on a systematic literature search. A series of questions regarding the key signs and symptoms, the methods for diagnosis, the clinical management in neonatal/childhood/adulthood period, and the therapeutic approach of methemoglobinemia were formulated and the relative recommendations were produced. An agreement was obtained using a Delphi‐like approach and the experts panel reached a final consensus >75% of agreement for all the questions.

[Effect of methylene blue and its metabolite - azure I - on bioenergetic parameters of intact mice brain mitochondria]

Methylene blue is a phenothiazine dye that is widely used in medicine and clinical trials for the treatment of Alzheimer's disease. One of the factors of the unique therapeutic effect of methylene blue is its redox properties, allowing implementation of alternative electron transport - the dye accepts electrons from reducing equivalents in the mitochondria and transfer it them to other components of the respiratory chain or molecular oxygen. Azure I, an N-dimethylated metabolite of methylene blue, is potentially a more effective compound than methylene blue, but its ability for alternative electron transport has not been studied. We have shown that azure I, unlike methylene blue, is unable to restore the membrane potential in isolated mouse brain mitochondria, inhibited by rotenone and, therefore, is unable to perform bypass of the respiratory chain Complex I. Moreover, the addition of azure I does not affect the rate of mitochondrial respiration in contrast to methylene blue, which increases the rate of non-phosphorylation respiration. At the same time, both dyes stimulate an increase in H2O2 production. As a consequence, only methylene blue is capable of alternative electron transport, while azure I does not produce complex I bypass. This limits its therapeutic application only as a mitochondrial-targeted drug, but not as a substance with a potentially powerful antidepressant effect.

Impact of Pronase, Sodium Thiosulfate, and Methylene Blue Combinations on Development and Survival of Sodium Hypochlorite Surface-Disinfected Zebrafish (Danio rerio) Embryos

Embryo surface disinfection is utilized in aquaculture to decrease the risk of pathogen introduction into established colonies. Zebrafish embryos are commonly disinfected with unbuffered sodium hypochlorite at 25-50 ppm for 10 min with or without concurrent treatment with chemicals, including pronase (Pron), sodium thiosulfate, and/or methylene blue; however, the impact of these chemicals on embryo survival and development has not been evaluated. In this study, AB and casper embryos were exposed to disinfection protocols that used Pron, sodium thiosulfate, and/or methylene blue (given alone, in various combinations, or all three combined) with 50 and 100 ppm sodium hypochlorite performed 6 and 24 h postfertilization (HPF). All groups were evaluated for survival, hatching, and malformations at 5 days postfertilization. Maximal survival (69%-97%) and hatching rates (66%-94%) were generally observed with sodium hypochlorite disinfection followed by exposure to both Pron and sodium thiosulfate and maintenance in standard embryo medium without methylene blue. Methylene blue had variable effects on survival and hatching. Higher survival and hatching rates were seen in AB embryos disinfected at 6 HPF and casper embryos disinfected at 24 HPF. Susceptibility to sodium hypochlorite toxicity differed by strain, emphasizing the need to test disinfection protocols on small embryo cohorts.

Melanoma in pregnancy: certainties unborn

Melanoma diagnosed during childbearing period or up to 1 year after delivery is defined as pregnancy-associated melanoma (PAM). There is some evidence that PAM has worse prognosis if compared with melanoma in nonpregnant women, although literature is still inconclusive. Many biological mechanisms could explain this behavior, such as hormonal and immune status, increased lymphangiogenesis but also delay in diagnostic and therapeutic management. If PAM is suspected, a prompt excisional biopsy under local anesthesia can be performed regardless of the gestational period. Conversely, additional staging procedures (such as sentinel lymph node biopsy or imaging) and systemic therapy are still debatable during pregnancy. A multidisciplinary tailored approach should be preferred, together with exhaustive counseling of the mother.

Could methylene blue be used to manage burning mouth syndrome? A pilot case series

Objective: Burning mouth syndrome is a disabling condition of complex pathophysiology characterized by spontaneous pain felt in the oral mucosa in the absence of evident mucosal lesions which lacks efficient treatments to this day. The purpose of this study was to demonstrate the efficacy of methylene blue in the management of burning mouth syndrome. Methods: The study was conducted at the dental clinic of the Anta Diop University and Newtown dental clinic of Dakar, Senegal. A solution of methylene blue as a mouth-rinse (0.5%) was applied for 5 minutes in five patients satisfying the ICHD-3 diagnostic criteria for burning mouth syndrome. This procedure was repeated every 6 hours 3 times per 24h, during 7 days. Using numeric rating scale, pain severity was assessed as the mean pain felt during the last day of application. Results: After 7 days, the pain was significantly reduced by two-thirds and almost absent at 3 and 6 months follow-up. No secondary effects of the use of methylene blue were observed. Putative mechanisms of action and potential implications for treatment are discussed. Conclusion: Methylene blue is an old compound but a novel topical therapy that could prove beneficial in the management of burning mouth syndrome.

Cancer in Pregnancy

Cancer in pregnancy may be increasing in incidence with advancing maternal age and higher rates of obesity. The diagnosis of cancer in pregnancy provokes complex management issues balancing short- and long-term risks for both mother and baby. Every case needs to be individualized, with a multidisciplinary team of midwives, obstetricians, oncologists, surgeons, radiation oncologists, and neonatologists assisting the family to make informed decisions regarding the best treatment course for the mother and baby. The present article reviews the evidence regarding the safety of diagnostic imaging, procedures and treatment modalities for cancer for the pregnant woman and fetus. The efficacy of novel anticancer therapies highlight the need for International Registries to accumulate safety data for these agents in pregnancy as expeditiously as possible.

Local Anesthetic-Induced Methemoglobinemia During Pregnancy: A Case Report and Evaluation of Treatment Options

BACKGROUND

Methemoglobinemia is a well-recognized adverse drug reaction related to the use of certain local anesthetic agents. The mainstay of treatment for methemoglobinemia is i.v. methylene blue, along with provision of supplemental oxygen; however, methylene blue is listed as a category X teratogen. This poses an issue should methemoglobinemia develop during pregnancy.

CASE REPORT

A 35-year-old, 20-week and 5-day gravid female was transferred from an outpatient oral surgeon's office for hypoxia. She was undergoing extraction of 28 teeth and was administered an unknown, but "large" quantity of prilocaine during the procedure. Given this exposure, the concern was for methemoglobinemia. This was confirmed with co-oximetry, which showed 34.7% methemoglobin. The initial treatment plan was methylene blue; however, this drug is a category X teratogen. Thus, an interdisciplinary team deliberated and decided on treatment with high-dose ascorbic acid and transfusion of a single unit of packed red blood cells. The patient was managed with noninvasive ventilation strategies and a total of 8 g ascorbic acid. She was discharged on hospital day 3 with no obstetric issues noted. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Intravenous ascorbic acid appears to be a potential alternative to methylene blue in this patient population. The data surrounding teratogenicity of methylene blue are mostly related to intra-amniotic or intra-uterine administration. In life-threatening cases of methemoglobinemia during pregnancy, the benefits of i.v. methylene blue may outweigh the risks.

An Overview of Teratology

In this chapter, we provide an overview of the basic principles of teratology, beginning with its definition, the critical point for teratogenesis to occur and the most evident etiological agents to improve the understanding of this science.Teratology is a recent science that began in the early twentieth century, and has greatly improved over the recent years with the advancements in molecular biology, toxicology, animal laboratory science, and genetics, as well as the improvement on the knowledge of the environmental influences.Nevertheless, more work is required to reduce the influence of hazardous products that could be deleterious during pregnancy, thus reducing teratogenic defects in the newborn. While some teratogenic defects are attributed to their agents with certainty, the same for a lot of other such defects is lacking, necessitating consistent studies to decipher the influence of various teratogenic agents on their corresponding teratogenic defects. It is here that the laboratory animal science is of great importance both in the present and in the future.

Synergic in vitro combinations of artemisinin, pyrimethamine and methylene blue against Neospora caninum

Neospora caninum is a member of Apicomplexa phylum, the causative agent of neosporosis. The neosporosis combat is not well established and several strategies related to vaccine, chemotherapy and immune modulation are under development. In this work, we evaluated the effects of artemisinin (Art), methylene blue (MB) and pyrimethamine (Pyr) alone or associated, on N. caninum proliferation and elimination using LacZ tagged tachyzoites. The reactive oxygen species (ROS) production after incubation with Art were also performed. Our results indicate that combinations of classical antimalarial drugs improve the parasite control, allowing the use of three drugs in a single dose. Additionally, artemisinin demonstrated distinct ROS production patterns in intra and extracellular N. caninum forms. The drug repurposing appears as a suitable approach, allowing a fast and safe method to evaluate old drugs but novel candidates against neosporosis.

[Treatment of melanoma during pregnancy]

Melanoma diagnosed during pregnancy is a rare clinical case presentation which must be mastered. In the absence of guidelines for this clinical challenge, we performed a review of the literature and provide a practical guideline on how to manage such rare clinical cases based on our clinical experience. Expecting mothers require adequate counselling and explanation of all therapeutic options as they take responsibility for more than their own lives. However, they should be guided through the process of diagnostic and therapeutic measures in a potentially life-threatening situation. Pregnancy itself is no reason to withhold any type of necessary melanoma surgery. Perioperative management, however, requires certain adjustments in order to comply with this special situation. If indicated, even adjuvant and palliative systemic therapy need to be given to the patient, but they also have to be adapted to the specific circumstances as data is still sparse, especially for the new first and second line therapies with antibodies and targeted molecules.

Surgical treatment of melanoma in pregnancy: a practical guideline

A tumor primarily requiring surgical treatment, newly diagnosed or preexisting melanoma during pregnancy is a clinical rarity. In such cases, the surgeon faces the challenge of having to decide on the appropriate therapeutic course of action. Based on our clinical experience and a review of the literature, we herein provide a guideline on how to practically deal with this rare clinical conundrum. In our experience, pregnant melanoma patients require thorough counseling with respect to their therapeutic options. They naturally tend to put their unborn child first, and are hesitant to consent to necessary surgery despite a potentially life-threatening diagnosis. It is therefore crucial to clearly inform these patients that - based on existing medical experience - pregnancy by itself is no reason to hold off on any type of necessary melanoma surgery. However, various parameters such as preoperative imaging procedures, positioning on the operating table, monitoring, anesthesia, and perioperative medication require certain adjustments in order to comply with this special situation.

Chirurgische Behandlung von Melanomen in der Schwangerschaft: eine praktische Anleitung

Als ein Tumor, der primär eine chirurgische Behandlung erfordert, ist ein neu diagnostiziertes oder vorbestehendes Melanom in der Schwangerschaft eine klinische Rarität. In solchen Fällen steht der Chirurg vor der Herausforderung, ein geeignetes therapeutisches Vorgehen festlegen zu müssen. Auf der Grundlage unserer klinischen Erfahrung und einer Übersicht über die Literatur geben wir in der vorliegenden Arbeit eine Anleitung für das praktische Vorgehen bei dieser seltenen klinischen Konstellation. Unserer Erfahrung nach müssen schwangere Melanom-Patientinnen im Hinblick auf ihre therapeutischen Optionen ausführlich beraten werden. Naturgemäß setzen sie ihr ungeborenes Kind an die erste Stelle und zögern, der erforderlichen Operation zuzustimmen, obwohl bei ihnen eine möglicherweise lebensbedrohliche Erkrankung diagnostiziert worden ist. Daher ist es entscheidend, diese Patientinnen klar darüber zu informieren, dass, wie die vorliegenden medizinischen Erfahrungen zeigen, eine Schwangerschaft per se kein Grund ist, eine notwendige Melanom-Operation aufzuschieben. Jedoch müssen bei einigen Parametern wie den präoperativen Bildgebungsverfahren, der Positionierung auf dem Operationstisch, der Überwachung, Anästhesie und der perioperativen Medikation bestimmte Anpassungen vorgenommen werden, um der speziellen Situation Rechnung zu tragen.

EANM practice guidelines for lymphoscintigraphy and sentinel lymph node biopsy in melanoma

PURPOSE

Sentinel lymph node biopsy is an essential staging tool in patients with clinically localized melanoma. The harvesting of a sentinel lymph node entails a sequence of procedures with participation of specialists in nuclear medicine, radiology, surgery and pathology. The aim of this document is to provide guidelines for nuclear medicine physicians performing lymphoscintigraphy for sentinel lymph node detection in patients with melanoma.

METHODS

These practice guidelines were written and have been approved by the European Association of Nuclear Medicine (EANM) to promote high-quality lymphoscintigraphy. The final result has been discussed by distinguished experts from the EANM Oncology Committee, national nuclear medicine societies, the European Society of Surgical Oncology (ESSO) and the European Association for Research and Treatment of Cancer (EORTC) melanoma group. The document has been endorsed by the Society of Nuclear Medicine and Molecular Imaging (SNMMI).

CONCLUSION

The present practice guidelines will help nuclear medicine practitioners play their essential role in providing high-quality lymphatic mapping for the care of melanoma patients.

Transformation of aromatic dyes using green synthesized silver nanoparticles

Nowadays, increasing use of nanoproducts in area of human and environmental applications raises concern about safety aspects of nanoparticles synthesized using traditional physicochemical methods. Silver nanoparticles (AgNPs) synthesis at ambient parameters using latex of medicinally important plant Jatropha gossypifolia (J. gossypifolia) is reported in the present study. Potential of AgNPs in degradation of methylene blue and eosin B was also evaluated. Rapid formation of stable AgNPs was analyzed by visual color change from colorless to yellow-red after addition of latex in AgNO3 solution and by characteristic surface plasmon resonance (SPR) peak at 430 nm in UV-Vis spectroscopy. FT-IR analysis, protein coagulation test showed capping of proteins, flavonoids, terpenoids and polyphenols of latex on surface of AgNPs. FE-SEM, HR-TEM analysis revealed spherical shape of AgNPs. Narrow size range of AgNPs (5-40 nm) observed in HR-TEM analysis. EDS analysis confirms the presence of elemental silver while XRD revealed crystalline nature of AgNPs. Zeta potential of -21.4 mV indicates high stability of AgNPs. Effects of different parameters (pH, temperature, incubation time) on nanosynthesis were studied in the present study. Dye reduction studies were performed using UV-Vis spectroscopy, TLC, FT-IR and HPLC analysis showing decreased absorbance maxima of both dyes with respect to time, change in R f values, changes in wave number, transmittance, and retention time of dyes after AgNPs addition. The rate constant for methylene blue and eosin B reduction by AgNPs was found to be 0.062 and 0.022 min(-1).

Cellular and molecular actions of Methylene Blue in the nervous system

Methylene Blue (MB), following its introduction to biology in the 19th century by Ehrlich, has found uses in various areas of medicine and biology. At present, MB is the first line of treatment in methemoglobinemias, is used frequently in the treatment of ifosfamide-induced encephalopathy, and is routinely employed as a diagnostic tool in surgical procedures. Furthermore, recent studies suggest that MB has beneficial effects in Alzheimer's disease and memory improvement. Although the modulation of the cGMP pathway is considered the most significant effect of MB, mediating its pharmacological actions, recent studies indicate that it has multiple cellular and molecular targets. In the majority of cases, biological effects and clinical applications of MB are dictated by its unique physicochemical properties including its planar structure, redox chemistry, ionic charges, and light spectrum characteristics. In this review article, these physicochemical features and the actions of MB on multiple cellular and molecular targets are discussed with regard to their relevance to the nervous system.

Emergency tricuspid valve replacement during pregnancy

A 36 year-old intravenous drug user at 19 weeks' gestation required emergency tricuspid valve replacement for severe tricuspid regurgitation and cardiogenic shock refractory to medical therapy. Normothermic, pulsatile, high-flow, and pressure cardiopulmonary bypass (CPB) was used in the absence of fetal monitoring. Ten days postoperatively, the patient miscarried. She was discharged from hospital two months following surgery. High-flow (> 3.0 L/min(2)), high-pressure (> 70 mmHg), normothermic CPB using pulsatile flow and blood cardioplegia is thought to offer the best outcome to the fetus, although data to support these claims are not compelling.

Neuro- and cardioprotective effects of blockade of nitric oxide action by administration of methylene blue

Methylene blue (MB), generic name methylthioninium (C(16)H(18)ClN(3) S . 3H(2)O), is a blue dye synthesized in 1876 by Heinrich Caro for use as a textile dye and used in the laboratory and clinically since the 1890s, with well-known toxicity and pharmacokinetics. It has experimentally proven neuroprotective and cardioprotective effects in a porcine model of global ischemia-reperfusion in experimental cardiac arrest. This effect has been attributed to MB's blocking effect on nitric oxide synthase and guanylyl cyclase, the latter blocking the synthesis of the second messenger of nitric oxide. The physiological effects during reperfusion include stabilization of the systemic circulation without significantly increased total peripheral resistance, moderately increased cerebral cortical blood flow, a decrease of lipid peroxidation and inflammation, and less anoxic tissue injury in the brain and the heart. The last two effects are recorded as less increase in plasma concentrations of astroglial protein S-100beta, as well as troponin I and creatine kinase isoenzyme MB, respectively.

Characterization of swim bladder non-inflation (SBN) in angelfish, Pterophyllum scalare (Schultz), and the effect of exposure to methylene blue

Failure to inflate the swim bladder is regarded a major obstacle in the rearing of many fish species. We present a study of swim bladder non-inflation (SBN) in angelfish, Pterophyllum scalare. A normal developing primordial swim bladder was first discernable at the end of the first day post-hatch (p.h.) as a cluster of epithelial cells with a central lumen, surrounded by presumably mesenchymal cells. Initial inflation occurred on the fourth day p.h. Prior to inflation the swim bladder epithelium consisted of an outer squamous and inner columnar layer. Cells of the inner layer were filled at their basal region with an amorphous material, which disappeared upon inflation. A pneumatic duct was absent, and larvae presented no need to reach the water surface for inflation, suggesting that angelfish are pure physoclists. A model for the role of the amorphous material in normal initial inflation is proposed. Abnormal swim bladders were apparent from the fourth day p.h., and methylene blue (MB) at a concentration of 5 ppm significantly increased the prevalence of SBN. Histologically, abnormal swim bladders in larvae hatched in 5 ppm MB could not be distinguished from those in fish raised under routine conditions (0.5 ppm MB). We suggest that MB may have a teratogenic effect in angelfish.

Nitric oxide enhances salt tolerance in maize seedlings through increasing activities of proton-pump and Na+/H+ antiport in the tonoplast

Nitric oxide (NO), an endogenous signaling molecule in animals and plants, mediates responses to abiotic and biotic stresses. Our previous work demonstrated that 100 microM sodium nitroprusside (SNP, an NO donor) treatment of maize seedlings increased K(+) accumulation in roots, leaves and sheathes, while decreasing Na(+) accumulation (Zhang et al. in J Plant Physiol Mol Biol 30:455-459, 2004b). Here we investigate how NO regulates Na(+), K(+) ion homeostasis in maize. Pre-treatment with 100 muM SNP for 2 days improved later growth of maize plants under 100 mM NaCl stress, as indicated by increased dry matter accumulation, increased chlorophyll content, and decreased membrane leakage from leaf cells. An NO scavenger, methylene blue (MB-1), blocked the effect of SNP. These results indicated that SNP-derived NO enhanced maize tolerance to salt stress. Further analysis showed that NaCl induced a transient increase in the NO level in maize leaves. Both NO and NaCl treatment stimulated vacuolar H(+)-ATPase and H(+)-PPase activities, resulting in increased H(+)-translocation and Na(+)/H(+) exchange. NaCl-induced H(+)-ATPase and H(+)-PPase activities were diminished by MB-1. 1-Butanol, an inhibitor of phosphatidic acid (PA) production by phospholipase D (PLD), reduced NaCl- and NO-induced H(+)-ATPase activation. In contrast, applied PA stimulated H(+)-ATPase activity. These results suggest that NO acts as a signal molecule in the NaCl response by increasing the activities of vacuolar H(+)-ATPase and H(+)-PPase, which provide the driving force for Na(+)/H(+) exchange. PLD and PA play an important role in this process.

Flexible sigmoidoscopy and colonoscopy during pregnancy

More than 6000 pregnant women each year have an indication that warrants a flexible sigmoidoscopy or colonoscopy. In addition to the potential complications inherent in the risk of sedation and the procedures themselves, the endoscopist who performs these procedures in pregnant women must be aware of the potential to do harm to the fetus. This article reviews the existing literature as it pertains to flexible sigmoidoscopies and colonoscopies performed during pregnancy, including indications and diagnostic usefulness, safety, use of medications, and therapeutic interventions.

Invasive diagnostic procedures in twin pregnancies

The rising rate of multiple pregnancies and its association with advanced maternal age has expanded the need for prenatal diagnosis in twins and higher order gestations. The complexity of the invasive diagnostic procedures and the risk of loss of an unaffected twin raise significant clinical, technical and ethical issues. In this review we discuss the specific issues of early scanning, counseling and determination of chorionicity prior to invasive procedures in twins. We present the available data describing the risk associated with these procedures in twins and compare data of fetal loss rate from different studies. We also discuss the issues of fetal blood sampling and late karyotyping in twin pregnancies.

Inotropes and vasopressors in adults and foals

Successful treatment with inotropes and vasopressors depends on an understanding of the interplay of flow, pressure, and resistance in the cardiovascular system and an appreciation of the pathophysiologic mechanisms leading to inadequate tissue perfusion. Any treatment strategy is necessarily a compromise between the requirements of different vascular beds.Furthermore. the underlying hemodynamic derangements can change rapidly. Therefore. inotropes and vasopressors should be titrated to measures of improved hemodynamic status, and the treatments should be frequently reviewed.

Methemoglobinemia and hemolysis after enteral administration of methylene blue in a preterm infant: relevance for pediatric surgeons

A preterm infant had methaemoglobulinemia and hemolytic anemia after enteral administration of methylene blue. The dye was administered to exclude a tracheoesophageal fistula. Methylene blue is a noxious product, especially in neonates. It should be considered a potential cause of acquired methemoglobulinemia, even after enteral administration.

A novel method for marking microinjection sites using methylene blue and diaminobenzidine

A number of different compounds have been microinjected into the brains of animals for the purpose of marking injection sites. In the present study, we describe a novel method for visualising and permanently preserving sites in the brainstem of rats marked by microinjections of methylene blue. Subsequent exposure of the sections to diaminobenzidine (DAB) tetrahydrochloride in the presence of glucose oxidase or infrared light produced an insoluble black precipitate at the injection site. A major advantage of this method is that the injection sites are marked simultaneously with immunohistochemical processing.

Are there teratogenic risks associated with antidotes used in the acute management of poisoned pregnant women?

OBJECTIVE

We reviewed evidence suggesting teratogenic risk associated with the use of antidotes in the acute management of poisoned pregnant women.

METHODS

Medline, Toxline, and DART/ETIC searches; references of retrieved articles, pertinent databases and textbooks were also searched.

RESULTS

There are case reports or case series of women who received antidotes for poisoning during (*) or after (+) the period of organogenesis who showed no fetal adverse effects. Some antidotes, however, have no teratogenic risk: atropine (cohort/surveillance studies)+, calcium (oral supplement: cohort study)+ and pyridoxine (Bendectin studies). Also, ethanol+, methylene blue (intra-amniotic injection but not oral) and penicillamine* can be considered teratogens but their risks in the treatment of poisonings are unknown. There is no epidemiologic study evaluating the risk of the following antidotes during pregnancy: N-acetylcysteine(*+), BAL (dimercaprol)+, black widow spider antivenin+, calcium EDTA+, crotalidae antivenin, crotalidae polyvalent immune FAB, cyanide antidote kit (amyl and sodium nitrate, sodium thiosulfate), deferoxamine(*+), digoxin immune FAB+, DMSA+, flumazenil+, fomepizole, methylene blue (IV), naloxone, physostigmine, pralidoxime+, protamine+; and parenteral pharmacologic doses of calcium+, folinic acid*, glucagon+, hydroxycobalamin, phytonadione (vitamin K), and pyridoxine.

CONCLUSIONS

Despite the limited evidence supporting the risk of antidote use during pregnancy, antidotes should be used when there is a clear maternal indication to decrease the morbidity or mortality associated with poisoning. The only exception may be penicillamine, which is a teratogen. Better antidotes exist for most poisonings that penicillamine could potentially treat. At this time, there is no known fetal indication for all antidotes. Reporting the use of an antidote during pregnancy should be encouraged, especially if used during the critical period of organogenesis.

Nitric oxide improves internal iron availability in plants

Iron deficiency impairs chlorophyll biosynthesis and chloroplast development. In leaves, most of the iron must cross several biological membranes to reach the chloroplast. The components involved in the complex internal iron transport are largely unknown. Nitric oxide (NO), a bioactive free radical, can react with transition metals to form metal-nitrosyl complexes. Sodium nitroprusside, an NO donor, completely prevented leaf interveinal chlorosis in maize (Zea mays) plants growing with an iron concentration as low as 10 microM Fe-EDTA in the nutrient solution. S-Nitroso-N-acetylpenicillamine, another NO donor, as well as gaseous NO supply in a translucent chamber were also able to revert the iron deficiency symptoms. A specific NO scavenger, 2-(4-carboxy-phenyl)-4,4,5,5-tetramethylimidazoline-1-oxyl-3-oxide, blocked the effect of the NO donors. The effect of NO treatment on the photosynthetic apparatus of iron-deficient plants was also studied. Electron micrographs of mesophyll cells from iron-deficient maize plants revealed plastids with few photosynthetic lamellae and rudimentary grana. In contrast, in NO-treated maize plants, mesophyll chloroplast appeared completely developed. NO treatment did not increase iron content in plant organs, when expressed in a fresh matter basis, suggesting that root iron uptake was not enhanced. NO scavengers 2-(4-carboxy-phenyl)-4,4,5,5-tetramethylimidazoline-1-oxyl-3-oxide and methylene blue promoted interveinal chlorosis in iron-replete maize plants (growing in 250 microM Fe-EDTA). Even though results support a role for endogenous NO in iron nutrition, experiments did not establish an essential role. NO was also able to revert the chlorotic phenotype of the iron-inefficient maize mutants yellow stripe1 and yellow stripe3, both impaired in the iron uptake mechanisms. All together, these results support a biological action of NO on the availability and/or delivery of metabolically active iron within the plant.

Methylene Blue--a therapeutic dye for all seasons?

Since it was first synthesised in 1876, Methylene Blue (MB) has found uses in many different areas of clinical medicine, ranging from dementia to cancer chemotherapy. In addition, MB formed the basis of antimicrobial chemotherapy--particularly in the area of antimalarials--and eventually led to the discovery of the neuroleptic drug families. More recently, the photosensitising potential of MB and its congeners has been recognised, and these are being applied in various antimicrobial fields, especially that of blood disinfection. The range of activities of MB is due to the combination of its simple chemical structure and facility for oxidation-reduction reactions in situ.

Transplacental exposure to methylene blue initiates teratogenesis in the mouse: preliminary evidence for a mechanistic implication of cyclic GMP pathway disruption

BACKGROUND

The vital dye methylene blue (MB) has been shown to be teratogenic when injected into the amnion in the second trimester. On the other hand, the teratogenic potential of transplacental exposure to MB has not been determined.

METHODS

MB was administered subcutaneously to ICR (CD-1) mice at 0, 35, 50, 60, or 70 mg/kg on gestation day 8 (plug day = day 0). Teratological assessments were carried out at term gestation, on gestation day 18. Since MB inhibits soluble guanylate cyclase enzyme activity, zaprinast (ZPN), a selective cGMP-phosphodiesterase type V inhibitor, was administered to prevent developmental disorders initiated by MB at 50 mg/kg.

RESULTS

There was a dose-dependent increment of embryolethality. MB treatment also produced axial skeleton and neural tube defects. Coadministration of ZPN (20 mg/kg per three times) abolished completely MB-induced neural tube defects and reduced by one-half the incidence of fetuses exhibiting axial skeletal defects. ZPN did not provide protection against the embryocidal effects of MB.

CONCLUSIONS

This study showed that transplacental exposure to MB is teratogenic in the mouse. Coadministration of ZPN prevented partly MB-induced teratogenesis, which supports the hypothesis that imbalance of cGMP pathway accounts, in part, for the teratogenicity of MB.

Malformations reported in chorionic villus sampling exposed children: a review and analytic synthesis of the literature

PURPOSE

To determine whether the frequency of vascular disruption defects, other than limb defects, is increased in reports of chorionic villus sampling (CVS) exposed children compared with an unexposed population.

METHODS

Only studies that reported the total number of CVS-exposed pregnancies and details of pregnancy outcome, including all the malformations, were included. Twenty-five articles met these criteria.

RESULTS

The frequencies of gastroschisis, intestinal atresias, and clubfoot were significantly increased among the CVS-exposed infants as compared with the baseline unexposed population. The frequencies of other vascular disruption defects, including Poland sequence, amniotic band sequence, and cleft lip/cleft palate, were not increased.

CONCLUSION

CVS-exposed children have an increased frequency of intestinal atresia, gastroschisis, and clubfoot compared with the nonexposed population. The fact that an increased frequency of other defects attributed to vascular disruption was not found may be due to under-ascertainment, misclassification, or "lumping" of the defects identified in previous studies.