Evaluating the Decision-to-Delivery Interval in Emergency Cesarean Sections and its Impact on Neonatal Outcome

BACKGROUND/AIM

In Germany, performance of an emergency Cesarean section (ECS) is recommended within an interval of ≤20 min from decision to delivery (DDI). The aim of the study was to assess the duration of DDI in ECS as well as its impact on neonatal outcome.

PATIENTS AND METHODS

Data from 437 patients at a single, tertiary care hospital were retrospectively analysed regarding influence on the duration of DDI. Subsequently the impact of DDI on neonatal outcome and incidence of adverse neonatal outcome was analysed.

RESULTS

DDI of ECS performed outside core working hours was significantly prolonged (p<0.001). Shorter DDI showed a statistically worse arterial cord blood pH (p=0.001, r=0.162) and base excess (p=0.05; r=0.094). Duration of DDI had no significant impact on the incidence of adverse neonatal outcome (p=0.123).

CONCLUSION

Awareness of influence on DDI might contribute to expediting DDI, but duration of DDI showed no impact on the incidence of adverse neonatal outcome. Data were not adequate to suggest a recommendation for DDI time standards.

Sleep deprivation but not a whisker trim increases nerve growth factor within barrel cortical neurons

Sleep is hypothesized to influence activity-driven changes in the brain microcircuitry. A change in the barrel cortex following the removal of the mystacial whiskers in rats is a model for synaptic plasticity. This model was combined with sleep deprivation and immunoreactivity for nerve growth factor (NGF) was determined. Sleep deprivation for 6 h after light onset significantly increased the number of NGF-immunoreactive pyramidal neurons in layer V of the barrel cortex. However, unilateral trimming of mystacial whiskers did not affect NGF immunoreactivity in the contralateral or ipsilateral barrel cortices when rats were allowed to sleep. If the rats received a unilateral whisker cut at light onset, and subsequently were deprived of sleep, increases in the NGF-immunoreactive neurons were only observed in the barrel cortex on the side that received input from the remaining intact whiskers. In contrast, NGF immunoreactivity on the side contralateral to the cut whiskers decreased in sleep-deprived animals to levels below those observed in the control animals that were allowed to sleep. These results suggest that NGF expression is influenced by the interaction of sleep, afferent input and the nature of ongoing synaptic reorganization. Further, results are consistent with the hypothesis that growth factors, such as NGF, form part of the mechanism responsible for sleep regulation and that they also form one facet of sleep-related synaptic plasticity.

Oxytocin and vasopressin neurones in principal and accessory hypothalamic magnocellular structures express Fos-immunoreactivity in response to acute glucose deprivation

Neurohypophyseal secretion of oxytocin and vasopressin is elevated in response to decreased systemic glucose availability. In these studies, dual-label immunocytochemistry was used to identify hypothalamic neuropeptidergic magnocellular neurones that are transcriptionally activated in response to glucose substrate imbalance. Two h after i.p. injection of the glucose antimetabolite, 2-deoxy-D-glucose (2DG), or the vehicle, saline, groups of adult male rats were anaesthetized by i.p. injection with sodium pentobarbital and killed by transcardial perfusion. Sections (25 microm) through anterior and tuberal levels of the hypothalamus were processed for nuclear Fos- and cytoplasmic neuropeptide immunoreactivity (-ir). A high proportion of oxytocin-ir neurones in the supraoptic, paraventricular, and adjunct structures, including the anterior commissural, periventricular magnocellular, posterior perifornical, recurrent supraoptic, medial forebrain, and circular nuclei, were colabelled for nuclear Fos-ir following administration of 2DG. Large numbers of vasopressin neurones in the supraoptic, circular, posterior perifornical, and medial forebrain nuclei, and posterior magnocellular division and posterior subnucleus of the paraventricular nucleus were also immunostained for Fos in rats injected with the antimetabolite. These results show that decreased glucose metabolism is a stimulus for activation of the Fos stimulus-transcription cascade within oxytocin-and vasopressin-immunopositive neurones in several hypothalamic loci, findings that reflect activation of the Fos-stimulus transcription cascade within large proportions of these cell populations during this metabolic challenge. These data suggest that both peripheral hormonal and central modulatory functions of these neuropeptidergic neurones may be influenced by cellular glucose availability.

Discovery of less nephrotoxic FK506 analogs and determining immunophilin dependence of immunosuppressant nephrotoxicity with a novel single-dose rat cisplatin potentiation assay

Comparing nephrotoxicity of numerous drug analogs is impractical with chronic in vivo models. We devised a new cisplatin potentiation assay (CISPA) that sensitively detects renal injury as a serum creatinine increase when only one dose of test compound is followed by cisplatin. Reference nephrotoxins known to act on various sites in kidney tubules, glomeruli or renal papilla were all detected by the CISPA at single doses that without cisplatin gave little change, which showed that this simple, sensitive assay has broad potential utility for mechanistic studies of nephrotoxicity. We used the CISPA both to probe the nephrotoxic mode of action of immunosuppressants and to search for safer compounds. Although several non-nephrotoxic immunosuppressants were inactive, cyclosporine, FK506, ascomycin (C21-ethyl-FK506) and rapamycin were nephrotoxic in the CISPA at single doses equal to the daily amounts required to reduce creatinine clearance with 14 days of treatment. Similar therapeutic indices were derived comparing toxicity by either method to prevention of rat ear-heart allograft rejection. C18-OH-ascomycin, an FK506-binding protein (FKBP) antagonist, reversed in vivo immunosuppression by FK506 and ascomycin in the rat, and pretreatment in the CISPA blocked FK506 and ascomycin nephrotoxicity, which showed a common immunophilin dependence. Rapamycin nephrotoxicity was unaffected (as with cyclosporine), which indicated that binding to FKBP was not required. Rapamycin nephrotoxicity thus appears mechanistically unrelated to its immunosuppressive mode of action. Screening with the CISPA enabled discovery of A-119435, a less nephrotoxic ascomycin analog having a 10-fold higher therapeutic index.

NMR spectroscopic studies of intermediary metabolites of cyclophosphamide. A comprehensive kinetic analysis of the interconversion of cis- and trans-4-hydroxycyclophosphamide with aldophosphamide and the concomitant partitioning of aldophosphamide between irreversible fragmentation and reversible conjugation pathways

Multinuclear (31P, 13C, 2H, and 1H) Fourier-transform NMR spectroscopy, with and without isotopically enriched materials, was used to identify and quantify, as a function of time, the following intermediary (short-lived) metabolites of the anticancer prodrug cyclophosphamide (1, Scheme I): cis-4-hydroxycyclophosphamide (cis-2), its trans isomer (trans-2), aldophosphamide (3), and its aldehyde-hydrate (5). Under a standard set of reaction conditions (1 M 2,6-dimethylpyridine buffer, pH 7.4, 37 degrees C), the stereospecific deoxygenation of synthetic cis-4-hydroperoxycyclophosphamide (cis-12, 20 mM) with 4 equiv of sodium thiosulfate (Na2S2O3) afforded, after approximately 20 min, a "pseudoequilibrium" distribution of cis-2, 3, 5, and trans-2, i.e., the relative proportions of these reactants (57:4:9:30, respectively) remained constant during their continual disappearance. NMR absorption signals indicative of "iminophosphamide" (8) and enol 6 were not detected (less than 0.5-1% of the synthetic metabolite mixture). A computerized least-squares fitting procedure was applied to the individual 31P NMR derived time courses for conversion of cis-2, 3 plus 5 (i.e., "3"), and trans-2 into acrolein and phosphoramide mustard (4), the latter of which gave an expected array of thiosulfate S-alkylation products (e.g., 16) and other phosphorus-containing materials derived from secondary decomposition reactions. This kinetic analysis gave the individual forward and reverse rate constants for the apparent tautomerization processes, viz., cis-2 in equilibrium "3" in equilibrium trans-2, as well as the rate constant (k3) for the irreversible fragmentation of 3. The values of k3 at pH 6.3, 7.4, and 7.8 were equal to 0.030 +/- 0.004, 0.090 +/- 0.008, and 0.169 +/- 0.006 min-1, respectively. Replacement of the HC(O)CH2 moiety n 3 with HC(O)CD2 led to a primary kinetic isotope effect (kH/kD = 5.6 +/- 0.4) for k3. The apparent half-lives (tau 1/2) for cis-2, "3", and trans-2 under the standard reaction conditions, at "pseudoequilibrium" (constant ratio of cis-2/"3"/trans-2), were each equal to approximately 38 min, which is considerably shorter than the widely cited colorimetrically derived half-lives reported by earlier investigators. The values of tau 1/2 for cis-2, "3", and trans-2 were affected by pH in the same manner as that found for k3 but were relatively insensitive to the presence of either K+, Na+, Ca2+, or Mg2+. The presence of certain primary amines led to marked decreases in tau 1/2 and, in some cases, the formation of acyclic adducts of aldehyde 3.(ABSTRACT TRUNCATED AT 400 WORDS)

Immunity to human cytomegalovirus measured and compared by complement fixation, indirect fluorescent-antibody, indirect hemagglutination, and enzyme-linked immunosorbent assays

The complement fixation test is currently the test employed most frequently to determine the presence of antibody to human cytomegalovirus. Several other techniques have been adapted for this purpose. A comparison of cytomegalovirus antibody titers was made between the complement fixation test, a commercially available enzyme-linked immunosorbent assay, an indirect immunofluorescent technique, and a modified indirect hemagglutination test. Forty-three serum samples were tested for antibodies by each of the above procedures. The enzyme-linked immunosorbent, immunofluorescent, and indirect hemagglutination assays were in close agreement on all samples tested; the titers obtained with these methods were all equal to or greater than the complement fixation titer for 38 of the 41 samples (92.6%). Two samples were anticomplementary in the complement fixation test but gave readable results in the other tests. The complement fixation test was the least sensitive of the procedures examined. The commercial enzyme-linked immunosorbent assay system was the most practical method and offered the highest degree of sensitivity in detecting antibodies to cytomegalovirus.

Synthesis of 3-hydroxycyclophosphamide and studies related to its possible role in the metabolism of cyclophosphamide

Hydrogenolysis of 3-(benzyloxy)cyclophosphamide (10) using Pd/C catalyst and ethyl acetate as solvent leads to the formation of 3-hydroxycyclophosphamide (3, approximately 20%) and cyclophosphamide (1, approximately 10%), accompanied by regioselective hydrogen-exchange reactions at the C-4 and C-5 positions in 3 and 1. A variety of oxidizing reagents and liver microsomal incubation failed to provide evidence (31P NMR) for conversion of 1 into 3, whereas identical incubation of 3 led to its reduction to 1. Compound 3 is stable at pH 6.5-8.2, 37 degrees C, and exhibits anticancer activity comparable to 1 when tested against L1210 leukemia in mice. Data are discussed with regard to a previously reported suggestion that metabolism of 1 may involved oxidation to give 3 followed by rearrangement of 3 to 2.

Determination of enantiomeric homogeneity (optical purity) of cyclophosphamide by nuclear magnetic resonance spectroscopy

The enantiomeric homogeneity of resolved samples of the chiral anticancer drug cyclophosphamide was evaluated directly by 1H and 31P nuclear magnetic resonance spectroscopy with the use of the optically active shift reagent tris-[3-(trifluoromethylhydroxymethylene)-d-camphorato]europlum(III). These measurements, in concert with optical rotatory dispersion spectroscopy, established that, for optically pure cyclophosphamide, [alphaD] = 2.3 +/- 0.2 degrees.