Biomechanical analysis of different back-supporting exoskeletons regarding musculoskeletal loading during lifting and holding

Industrial back support exoskeletons (BSEs) are a promising approach to addressing low back pain (LBP) which still affect a significant proportion of the workforce. They aim to reduce lumbar loading, the main biomechanical risk factor for LBP, by providing external support to the lumbar spine. The aim of this study was to determine the supporting effect of one active (A1) and two passive (P1 and P2) BSEs during different manual material handling tasks. Kinematic data and back muscle activity were collected from 12 subjects during dynamic lifting and static holding of 10 kg. Mean and peak L5/S1 extension moments, L5/S1 compression forces and muscle activation were included in the analysis. During dynamic lifting all BSEs reduced peak (12-26 %) and mean (4-17 %) extension moments and peak (10-22 %) and mean (4-15 %) compression forces in the lumbar spine. The peak (13-28 %) and mean (4-32 %) activity of the back extensor muscles was reduced accordingly. In the static holding task, analogous mean reductions for P1 and P2 of L5/S1 extension moments (12-20 %), compression forces (13-23 %) and muscular activity (16-23 %) were found. A1 showed a greater reduction during static holding for extension moments (46 %), compression forces (41 %) and muscular activity (54 %). This pronounced difference in the performance of the BSEs between tasks was attributed to the actuators used by the different BSEs.

Blood in milk in horned dairy cows-Exploration of incidences and prevention opportunities

Husbandry of horned cows is one alternative to disbudding that respects the animals´ integrity. Concurrently, housing and management should be aligned with the animals' needs to minimize social interactions that can result in integument damage (ID) and udder injuries associated with blood in milk (BM). No information is available on incidences of BM, nor on specific preventive measures. Thus, this study aimed at investigating BM incidences in horned herds and testing whether compliance with guideline recommendations on the prevention of ID also contributes to mitigate BM. Twenty-one farms documented BM, cows' parity, social rank, and udder damage over seven months covering part of summer with pasture and winter in the barn. A total of 52 factors relating to the guideline were recorded and grouped into 'milking', 'feeding', 'lying', 'walking/activity' and 'herd management'. Each factor was categorised into fulfilled or not, and for each group percentages of fulfilment were calculated. Monthly BM incidences varied from 0.3 to 7.8% with 38% being associated with visible udder damage (BMvD). Most cows affected were in the 2nd to 4th lactation (44%) and middle-ranking (58%). A mixed model regarding 'monthly binomial BMvD' per farm revealed a higher BMvD risk during the barn season (OR = 2.39), highlighting the importance of pasture to alleviate social conflicts. Higher fulfilment of recommendations concerning 'feeding' and 'walking/activity' was associated with a lower risk (OR = 0.94 and 0.95), indicating that the conflict potential in these areas also plays a role for BMvD and can be lowered by a combination of improvement measures.

The significance of low first trimester serum progesterone in ongoing early pregnancies presenting as pregnancies of unknown location

OBJECTIVES

The primary objective of this study was to ascertain whether there is association between low initial serum progesterone, sonographic parameters and clinical outcomes in women presenting with pregnancies of unknown location (PUL), which are found to be ongoing at their follow up scans in the first trimester.

STUDY DESIGN

This was a non-interventional retrospective cohort study of 1056 patients spanning a 14-year period, conducted in the Early Pregnancy Unit (EPU) of an inner-city teaching hospital. Patients who had an ongoing singleton first trimester pregnancy after presenting with PUL were identified and categorised as having low progesterone if it was 32 nmol/l or lower. The crown-rump length (CRL), mean gestational sac diameter (MGSD) and gestational sac volume (GSV) were measured when the embryo was first seen, and the pregnancy outcome recorded.

RESULTS

Pregnancies with low progesterone tended to have smaller gestational sacs (GS) on follow up scan (p = 0.001) and the sac was smaller than expected for a given CRL (p = 0.000). There was no ultrasound parameter that was characteristic of low progesterone. The observation of a smaller than expected MGSD for a given CRL remained even when only pregnancies with normal outcomes were analysed. Clinical outcome data were available for 854 (80.9 %) women. Overall, 81.4 % (n = 34/43) of pregnancies with low progesterone resulted in livebirth, compared to 91.7 % (n = 744/811) livebirths in pregnancies with higher levels (p = 0.0454).

CONCLUSION

Pregnancies with low progesterone tend to have a smaller GS compared to those with a higher progesterone, and the GSs are smaller than expected for a given CRL. The current study shows that women with low progesterone at the start of pregnancy remain at higher risk of miscarriage, even when the pregnancy is initially found to be viable in the first trimester. These pregnancies also tend to be associated with the sonographic finding of a smaller GS than expected for a given gestational age, regardless of eventual outcome.

Hip fractures in centenarians: a multicentre review of outcomes

INTRODUCTION

Advances in healthcare have resulted in an increasing UK population, with the proportion of elderly individuals expanding significantly, including centenarians. Hospitals can expect to see growing numbers of so-called 'super-elderly' patients with trauma, a majority of whom will have hip fractures. We performed a multicentre review of hip fracture outcomes in centenarians to assess whether being an outlier in age correlates with poorer prognosis.

METHODS

Centenarians admitted to Basingstoke, Southampton, Dorset, and Salisbury district hospitals with hip fractures between January 2014 and June 2019 were included. Electronic records were searched to obtain demographics, functional status, and admission details.

RESULTS

A total of 60 centenarians were included, with a median age of 101 years (range 100-108 years), 85% of whom were female; 29 were admitted from their own home or sheltered housing and 31 from nursing or residential care; 33 had some outdoor mobility, 26 only mobilised indoors, and 1 had no mobility. Common comorbidities were renal and heart disease and dementia. Of the total, 56 underwent surgery, 51 within 36 hours. In terms of accommodation, 63.4% returned to their pre-injury level of independence. At 30 days, three months, and one year, mortality rates were 27% (n = 16), 40% (n = 24) and 55% (n = 33), respectively.

CONCLUSION

Trauma in the elderly population is an area of growing interest, yet few studies address centenarians with hip fractures. This work demonstrates that mortality rates within one year of injury were high, but almost half survived beyond a year. Two-thirds of patients regained their pre-injury level of independence, suggesting that functional recovery may not be as poor as previously reported.

The cost-effectiveness of progesterone in preventing miscarriages in women with early pregnancy bleeding: an economic evaluation based on the PRISM trial

OBJECTIVES

To assess the cost-effectiveness of progesterone compared with placebo in preventing pregnancy loss in women with early pregnancy vaginal bleeding.

DESIGN

Economic evaluation alongside a large multi-centre randomised placebo-controlled trial.

SETTING

Forty-eight UK NHS early pregnancy units.

POPULATION

Four thousand one hundred and fifty-three women aged 16-39 years with bleeding in early pregnancy and ultrasound evidence of an intrauterine sac.

METHODS

An incremental cost-effectiveness analysis was performed from National Health Service (NHS) and NHS and Personal Social Services perspectives. Subgroup analyses were carried out on women with one or more and three or more previous miscarriages.

MAIN OUTCOME MEASURES

Cost per additional live birth at ≥34 weeks of gestation.

RESULTS

Progesterone intervention led to an effect difference of 0.022 (95% CI -0.004 to 0.050) in the trial. The mean cost per woman in the progesterone group was £76 (95% CI -£559 to £711) more than the mean cost in the placebo group. The incremental cost-effectiveness ratio for progesterone compared with placebo was £3305 per additional live birth. For women with at least one previous miscarriage, progesterone was more effective than placebo with an effect difference of 0.055 (95% CI 0.014-0.096) and this was associated with a cost saving of £322 (95% CI -£1318 to £673).

CONCLUSIONS

The results suggest that progesterone is associated with a small positive impact and a small additional cost. Both subgroup analyses were more favourable, especially for women who had one or more previous miscarriages. Given available evidence, progesterone is likely to be a cost-effective intervention, particularly for women with previous miscarriage(s).

TWEETABLE ABSTRACT

Progesterone treatment is likely to be cost-effective in women with early pregnancy bleeding and a history of miscarriage.

Regular Exposure to Cowbells Affects the Behavioral Reactivity to a Noise Stimulus in Dairy Cows

In alpine regions, cows are often equipped with bells during pasture season to ensure that farmers can locate them. Constant exposure to the chime of a bell may affect cows' acoustic perception in general. The aim of this study is to test whether routine bell exposure affects the reactivity to a noise stimulus and might be associated with hearing impairment in cows. For the assessment, behavioral and cardiac indicators were used as indirect measures of hearing capacity. Cows that were either used to wearing a bell or not were exposed to a playback of low and high amplitude (=varying loudness). In addition, we tested whether wearing earplugs, mimicking hearing impairment, reduced the cows' reactivity toward the playback. On 24 farms, half of them routinely using cowbells, 96 Brown Swiss cows were tested in a 2 × 2 factorial cross-over design (65 or 85 dB, without or with earplugs) in a balanced order. The effects of bell experience, amplitude, and earplugs on the latency to the first behavioral and cardiac response to a 5-s playback were analyzed using linear mixed-effects models, considering dependencies within the data set. Cows reacted faster without earplugs and when they were exposed to 85 dB compared with 65 dB. The proportion of cows leaving the feeding rack after onset of the playback was reduced by bell experience and earplugs and was increased when exposed to 85 dB compared with 65 dB. Exposure without earplugs to 85 dB but not to 65 dB increased heart rate. Heart rate and heart rate variability indicated increased sympathetic activation during the exposure to 85 dB compared with 65 dB. In general, behavioral and cardiac indicators did not indicate severe hearing impairment due to routine bell exposure. The 85-dB stimulus increased arousal and avoidance compared with the 65-dB stimulus, with bell experience and earplugs leading to a general decrease in avoidance of the stimulus. This may reflect an altered acoustic perception of the playback stimulus in dairy cows that are routinely exposed to bells.

Natural history of early first-trimester pregnancies implanted in Cesarean scars

OBJECTIVE

To describe the ultrasound findings and natural history of pregnancies implanted within or on Cesarean section scars in the first trimester of pregnancy.

METHODS

This was a prospective observational study of 10 women diagnosed with a pregnancy implanted in or on a Cesarean section scar in the first trimester, who declined medical intervention because of their desire to continue the pregnancy. The study population comprised women at < 12 weeks' gestation who were seen in our early pregnancy unit between January 2011 and September 2013. Nine women were followed up by serial ultrasound examinations and had detailed care plans for delivery at King's College Hospital (KCH). One woman was followed up and delivered at another teaching hospital. The first-trimester ultrasound findings were compared with the clinical outcome of the pregnancy.

RESULTS

The nine patients who were followed up at KCH developed ultrasound findings of morbidly adherent placenta (MAP) in the second and third trimesters. All 10 patients were diagnosed with MAP at the time of delivery by Cesarean section. The gestational age at delivery ranged from 26 to 38 weeks. The uterus was conserved in five patients, and Cesarean hysterectomy was performed in the remaining five. All three women with complete implantation of the gestational sac within the scar and two of three cases with placental lakes in the first trimester had hysterectomies. The two cases with bulging of the gestational sac out of the uterine contour had a preterm emergency hysterectomy due to placenta percreta. Histology confirmed placenta accreta in the five hysterectomy specimens. There were no fetal or neonatal complications.

CONCLUSIONS

Implantation of a pregnancy on or in a Cesarean section scar is a precursor of MAP; however, the degree of morbidity associated with this implantation is variable and difficult to predict based on first-trimester ultrasound findings only. The assessment of ongoing pregnancies implanted in Cesarean scars is most beneficial when performed between 7 and 9 weeks' gestation. Complete implantation within the myometrial defect, bulging of the trophoblast from the uterine contour and large placental lakes in the first trimester are ultrasound findings that may predict severe placenta accreta or percreta and consequently a poor outcome.

Do bells affect behaviour and heart rate variability in grazing dairy cows?

In alpine regions cows are often equipped with bells. The present study investigated the impact of wearing a bell on behaviour and heart rate variability in dairy cows. Nineteen non-lactating Brown-Swiss cows with bell experience were assigned to three different treatments. For 3 days each, cows were equipped with no bell (control), with a bell with inactivated clapper (silent bell) or with a functional bell (functional bell). The bells weighed 5.5 kg and had frequencies between 532 Hz and 2.8 kHz and amplitudes between 90 and 113 dB at a distance of 20 cm. Data were collected on either the first and third or on all 3 days of each treatment. Whereas duration of rumination was reduced with a functional bell and a silent bell compared with no bell, feeding duration was reduced with a silent bell and was intermediate with a functional bell. Head movements were reduced when wearing a silent bell compared with no bell and tended to be reduced when wearing a functional compared to no bell. With a functional bell, lying duration was reduced by almost 4 hours on the third day of treatment compared with the first day with a functional bell and compared with no bell or a silent bell. All additional behavioural measures are consistent with the hypothesis of a restriction in the behaviour of the cows wearing bells, although this pattern did not reach significance. There was no treatment effect on heart rate variability, suggesting that the bells did not affect vago-sympathetic balance. An effect of experimental day was found for only 1 out of 10 behavioural parameters, as shown by a decrease in lying with a functional bell on day 3. The results indicate behavioural changes in the cows wearing a bell over 3 days, without indication of habituation to the bell. Altogether, the behavioural changes suggest that the behaviour of the cows was disturbed by wearing a bell. If long-lasting, these effects may have implications for animal welfare.

How feasible is expectant management of interstitial ectopic pregnancy?

OBJECTIVE

To review the success rate of expectant management in a series of interstitial pregnancies.

METHODS

We identified all women with an ultrasound diagnosis of interstitial pregnancy seen within a 9-year period (January 2004 to April 2013). The clinical history, ultrasound findings and biochemical results were reviewed. The outcome of all interstitial pregnancies managed conservatively was recorded. Treatment was considered as successful when the serum β-human chorionic gonadotropin (β-hCG) level declined below 20 IU/L without the need for further intervention.

RESULTS

A total of 48 interstitial pregnancies were diagnosed during the study period. Surgery was the first-line treatment in nine (18.8%) cases. Thirty-eight (79.2%) women were offered non-surgical management: 19 (39.6%) had methotrexate (MTX) and 19 (39.6%) were managed expectantly. One (2.1%) woman returned to her local hospital following diagnosis and we were unable to obtain any follow-up information regarding her care. The median initial serum β-hCG level and ectopic size were not significantly different between any of the groups according to initial treatment. The overall success rate of expectant management was 89.5%. There were no cases of ectopic rupture in this group. Length of follow-up ranged from 7 to 141 days with a median duration of follow-up of 50.6 days.

CONCLUSION

Our data show that expectant management is an option for selected women with non-viable interstitial pregnancies and declining serum β-hCG levels, irrespective of ectopic mass size and initial serum β-hCG levels.

Clinical significance of first-trimester chorionic bumps: a matched case-control study

OBJECTIVE

To determine the clinical significance of a chorionic bump diagnosed by ultrasound in women attending an early pregnancy unit in a teaching hospital.

METHODS

This was a retrospective case-control study over an 8-year period (2003-2010). Cases of chorionic bump were identified by searching our early pregnancy database and were matched to controls in a ratio of 1:3. The primary outcome measure was miscarriage vs ongoing pregnancy. Secondary outcomes were gestational age at delivery and the presence or absence of fetal abnormality.

RESULTS

A total of 37 798 pregnancies were examined over the study period and 57 pregnancies with a chorionic bump were identified, giving an estimated prevalence of 1.5 per 1000 pregnancies (0.15%; 95% CI, 0.01-0.73%). Of the 52 women with follow-up data, 20 (38.5%; 95% CI, 26.4-52.1%) miscarried vs 31/151 (20.5%; 95% CI, 14.8-27.7%) in the control group (P = 0.01). There were four second-trimester miscarriages in the study group and none in the controls (P < 0.01). Out of 52 pregnancies in the study group there were 32 live births (62%; 95% CI, 47.9-73.6%) vs 118/151 (78%; 95% CI, 70.9-84.0%) in the control group (P = 0.02). There were no differences in preterm delivery rates or fetal anomalies. No significant relationship was found between size of the bump or location in relation to the umbilical cord insertion and risk of miscarriage.

CONCLUSIONS

Women presenting to early pregnancy units with a chorionic bump discovered at first-trimester ultrasound examination had approximately double the risk of miscarriage compared with matched controls, the difference being due to a greater number of miscarriages during the second trimester of pregnancy.

Marantic endocarditis presenting with multifocal neurological symptoms

Non-bacterial thrombotic endocarditis (NBTE), also known as marantic endocarditis, has been reported to occur in 0.3-9.3% of the adult population at autopsy. NBTE associated with malignancy is an underrecognised cause of thromboembolic disorders. The clinical spectrum encountered and investigation results can be non-specific, often mimicking other acute conditions such as infective endocarditis. We describe the case of a 34-year-old woman with non-localising and multifocal neurological symptoms, who was subsequently diagnosed with NBTE secondary to a resectable primary lung adenocarcinoma.

Pregnancy in a woman with proportionate (primordial) dwarfism: a case report and literature review

Primordial dwarfism is a rare form of severe proportionate dwarfism which poses significant challenges in pregnancy. A 27-year-old with primordial dwarfism (height 97 cm, weight 22 kg) and coexisting morbidities of familial hypercholesterolaemia and hypertension presented to our unit. Early pregnancy was complicated by difficult blood pressure control, sinus tachycardia, biochemical hyperthyroidism and insulin-requiring gestational diabetes. Delivery was indicated at 24 weeks with uncontrollable hypertension, progressive renal impairment and intrauterine growth restriction. A caesarean section was performed under general anaesthesia, resulting in the delivery of a 486 g male infant. This case highlights the difficulties of managing pregnancy in a woman with primordial dwarfism. Her limited capacity to respond to the physiological demands of pregnancy created a life-threatening situation, culminating in profound preterm birth.

Regioselective acylation of 3-O-angeloylingenol by Candida antarctica Lipase B

Acylation of 3-O-angeloylingenol (1) with vinyl acetate, vinyl decanoate and vinyl cinnamate, catalyzed by Candida antarctica Lipase B, was investigated. In each case, compound 1 was quantitatively and regioselectively acylated to afford a single product, 3-O-angeloyl-20-O-acetylingenol (1a), 3-O-angeloyl-20-O-decanoylingenol (1b) and 3-O-angeloyl-20-O-cinnamoylingenol (1c), respectively. The structures of the novel compounds 1b-1c were determined by MS and NMR, and product 1a by comparison of RP-HPLC and TLC with a standard. Compounds 1b-1c induced a bipolar morphology of MM96L melanoma cells at a similar concentration as compound 1, as well as having activity in inhibiting the growth of MM96L melanoma cells.

Can dual energy X-ray absorptiometry provide a valid assessment of changes in thigh muscle mass with strength training in older adults?

OBJECTIVE

To determine how dual-energy X-ray absorptiometry (DXA) compares to computed tomography (CT) for measuring changes in total thigh skeletal muscle (SM) mass with strength training (ST) in older adults.

SUBJECTS

Fifty previously sedentary, relatively healthy older men (n=23, 60 (s.d.=7.5) years) and women (n=27, 60 (s.d.=9.3) years).

RESULTS

Results indicate that there was a significant increase in thigh SM mass with ST measured by both CT (3.9+/-0.4%) and DXA (2.9+/-0.6%) methods (both P<0.001), and there was not a significant difference in percent change between the two methods, although there was a substantial absolute difference ( approximately 2 kg) at baseline between the two methods. Although Bland-Altman plots indicate overall agreement between the percent thigh SM mass changes of DXA vs CT methods, the 3.4% error associated with DXA was greater than the thigh SM mass change from DXA. However, the CT measured change in thigh SM mass was greater than its error (0.6%).

CONCLUSIONS

DXA overestimates baseline and after ST thigh SM mass, and may not be able to detect small changes in thigh SM mass with ST due to its higher error. Although DXA has certain advantages that warrant is used in epidemiologic and intervention studies, improvements to DXA are needed for the accurate assessment of small changes in thigh SM mass.

Results of primary percutaneous coronary intervention in a consecutive group of patients with acute ST elevation myocardial infarction at a tertiary Australian centre

BACKGROUND

Multicentre randomized controlled trials (RCT) of primary percutaneous coronary intervention (PCI) for ST elevation myocardial infarction (STEMI) have consistently shown lower mortality compared with fibrinolysis, if carried out in a timely manner. Although primary PCI is now standard of care in many centres, it remains unknown whether results from RCT of selected patients are generalizable to a 'real-world' Australian setting. The primary goal of this study was to evaluate whether a strategy of routine invasive management for patients with STEMI can achieve 30-day and 12-month mortality rates comparable with multicentre RCT. Secondary goals were to determine 30-day mortality rates in prespecified high-risk subgroups, and symptom-onset- and door-to-balloon-inflation times.

METHODS

A retrospective observational study of 189 consecutive patients treated with primary PCI for STEMI in a single Australian centre performing PCI for acute STEMI.

RESULTS

All-cause mortality was 6.9% at 30 days, and 10.4% at 12 months. Mortality in patients presenting without cardiogenic shock was low (2.4% at 30 days; 5.0% at 12 months), whereas 12-month mortality in patients with shock was higher, particularly in the elderly (29.4% for patients <75 years; 85.7% for patients > or =75 years, P = 0.01). Symptom-onset-to-balloon-inflation time was < or =4 h in 56% of patients (median 231 min); however, a door-to-balloon time of <90 min was achieved in only 20% (median 133 min).

CONCLUSION

Mortality and symptom-onset-to-balloon-inflation times reported in RCT of primary PCI for STEMI are generalizable to 'real-world' Australian practice; however, further efforts to reduce door-to-balloon times are required.

Maternal serum hormone concentrations for prediction of adverse outcome in threatened miscarriage

Many serum markers have been investigated in attempts to predict the outcome of pregnancy in the first trimester, with varying degrees of success. The objective of this study was to investigate whether they can be related to pregnancy outcome in women presenting with first trimester threatened miscarriage. A cohort study of women attending the Early Pregnancy Unit of a London teaching hospital was studied. A total of 122 women presenting with bleeding in the first trimester and an ongoing pregnancy, and 33 women undergoing termination of pregnancy, were recruited. The main outcome measures were gestation at delivery, birth weight and the incidence of adverse pregnancy outcome. Inhibin A, activin A, human chorionic gonadotrophin (HCG), pregnancy-associated plasma protein-A and follistatin concentrations were all significantly lower in women who subsequently miscarried when compared with live births. Serum HCG concentrations were significantly higher in cases of threatened miscarriage compared with controls (P = 0.0009). Logistic regression analysis indicated that inhibin A alone provided the best predictor for first trimester miscarriage. This pilot study suggests that placental hormone concentrations could be useful in predicting adverse pregnancy outcome in women presenting with threatened miscarriage. Inhibin A was best at predicting the likelihood of subsequent miscarriage in this group.

Development of a sensitive enzyme immunoassay for anti-Müllerian hormone and the evaluation of potential clinical applications in males and females

BACKGROUND AND OBJECTIVE

Recent studies have found anti-Müllerian hormone (AMH) to be a potentially important marker for the assessment of ovarian reserve and prediction of the success of in vitro fertilization (IVF) treatment. The objectives of this study were to develop a sensitive and specific assay for AMH and to evaluate the potential application of the assay. This assay will be then available to our collaborators in the UK and overseas.

DESIGN

Samples obtained as part of another prospective cross-sectional study from infertility patients and another prospective longitudinal study from pregnant women were used in this study to measure AMH using a new double-antibody enzyme-linked immunosorbent assay (ELISA).

PATIENTS AND MEASUREMENTS

AMH levels were evaluated in (i) serum and seminal fluid from males (normal and male factor infertility males), (ii) serum and follicular fluid from females (normal and female with unexplained infertility) and (iii) serum, amniotic fluid (AF) and coelomic fluid (CF) from pregnant women. AMH levels in the samples were measured by a newly developed ELISA.

RESULT

The assay had a detection limit of<0.078 ng/ml. High recoveries of spiked recombinant protein were observed from male and female sera and also from follicular, seminal, coelomic and amniotic fluids. The intra- and interassay coefficients of variation (CVs) were 3.6% and 4.0%, respectively. Serially diluted human samples gave dose-response curves parallel to the standard curve. Immunoreactivity was stable to sample storage at room temperature for several days and to multiple cycles of freezing and thawing. In seminal fluid, the AMH concentrations in a group of men with male factor infertility were insignificantly different from those in fertile men. By contrast, serum AMH concentrations were lower in the male factor infertility group than the normal group of patients. Women with unexplained infertility had similar concentrations of AMH in serum and follicular fluid compared to controls. Pregnant women had higher concentrations of AMH in the circulation in early pregnancy compared with nonpregnant women, suggesting a foeto-placental contribution and a possible biological role for this molecule in early pregnancy.

CONCLUSION

We have developed a sensitive and specific assay for AMH. Serum AMH in men with male factor infertility is lower than in normal men. Levels of AMH in pregnancy are higher than normal menstrual cycle levels suggesting a foeto-placental contribution.

The role of ultrasound imaging in diagnosing and investigating early pregnancy failure

The advent of high-resolution transvaginal ultrasound (TVS) has revolutionized our understanding of the pathophysiology and the management of early pregnancy failure. Knowledge of the ultrasound appearances of normal early pregnancy development and a good understanding of its pitfalls are essential for the diagnosis and management of early pregnancy failure. Ultrasound imaging has rapidly replaced all other techniques used to study normal human development in the first trimester, and ultrasound features of the early gestational sac have corroborated anatomical studies showing that the first structures to appear are the celomic cavity and the secondary yolk sac. No single ultrasound measurement of the different anatomical features in the first trimester has been shown to have a high predictive value for determining early pregnancy outcome. Similarly, Doppler studies have failed to demonstrate abnormal blood flow indices in the first-trimester uteroplacental circulation of pregnancies that subsequently end in miscarriage. Ultrasound parameters combined with maternal serum hormone levels, maternal age, smoking habits, obstetric history and the occurrence of vaginal bleeding have all been combined in multivariate analyses, with mixed results. Combined ultrasound and in-vitro experiments have demonstrated that the maternal circulation inside the placenta starts at the periphery at around 9 weeks of gestation and that this is associated with a physiological oxidative stress which could be the trigger for the formation of the placental membranes. Abnormal development of these membranes can result in subchorionic hemorrhage and threatened miscarriage with subsequent long-term consequences such as preterm rupture of the membranes and preterm labor, irrespective of the finding of a hematoma on ultrasound. In both euploid and aneuploid missed miscarriages there is clear ultrasound evidence for excessive entry of maternal blood at a very early stage inside the developing placenta resulting in oxidative stress and subsequent degeneration of villous tissue. The finding of blood flow in the intervillous space in cases of first-trimester miscarriage using color Doppler also appears to be useful in the prediction of success of expectant management. Miscarriages with blood flow within the intervillous space are up to four times more likely to complete with expectant management. TVS is considered the gold standard in the diagnosis and management of incomplete miscarriage. Expectant management of miscarriage, using ultrasound parameters to determine eligibility, could significantly reduce the number of unnecessary evacuations of the retained products of conception, depending on the criteria used.

A prospective study of ultrasound screening for molar pregnancies in missed miscarriages

OBJECTIVE

To examine the relationship between ultrasound and histological features in the screening for molar changes in missed miscarriage.

METHODS

A prospective cohort study was conducted on all missed miscarriages, with features suspicious of molar pregnancy, on transvaginal ultrasound and/or on histological examination over a 5-year period. All cases of molar pregnancy diagnosed histologically were examined and cross-referenced with cases diagnosed on ultrasound and with the supplementary report from the regional referral center. When available, maternal serum beta-human chorionic gonadotropin (hCG) levels were recorded.

RESULTS

Fifty-one cases of suspected molar pregnancy were referred to the regional center for further histological opinion and follow-up, and five cases were subsequently excluded from the final analysis because of the diagnosis of hydropic abortion (HA). In 33 cases a molar pregnancy was suspected at the initial scan. Of these, 26 (78.8%) were confirmed on histology, resulting in a 56% detection rate using ultrasound alone. In 15 cases hCG results were available, of which nine were greater than two multiples of the median.

CONCLUSIONS

The diagnosis of both complete (CHM) and partial (PHM) hydatidiform moles in first-trimester miscarriages is difficult. hCG is significantly higher in both CHM and PHM and, in conjunction with transvaginal ultrasound, could provide the screening test required to enable clinicians to counsel women more confidently towards non-surgical methods of management of their miscarriage, where histopathological examination is not available.

Inhibin, activin, follistatin, activin receptors and β-glycan gene expression in the villous tissue of miscarriage patients

Maternal circulating levels of inhibin A are significantly lower in patients with clinical symptoms of miscarriage. The objective of this study was to quantify relative expression of inhibin alpha, inhibin/activin betaA, betaB, betaC, follistatin, activin receptors and beta-glycan genes and content of inhibin A, activin A and follistatin protein in villous tissue of first trimester miscarriages and gestation-matched normal pregnancies. Twelve women with clinical symptoms of miscarriage were matched with 12 normal pregnancies for gestational age. Total RNA was isolated from placental samples. Complementary DNA produced by reverse transcription was used in the real-time PCR to quantify the expression of the genes. The ratio between the target and rRNA 18S was calculated to provide relative gene expression. Villous tissue homogenates were used for the determination of the content of inhibin A, activin A and follistatin protein. Maternal serum was assayed for inhibin A, activin A and follistatin. All villous samples expressed inhibin alpha, inhibin/activin betaA, betaB, betaC, follistatin, activin receptors (ACTRIA, ACTRIB, ACTRIIA, ACTRIIB) and beta-glycan genes. There was no significant difference in the relative expression of these genes between the groups. Villous content of inhibin A, activin A and follistatin were also not different between the two groups. Maternal serum levels of inhibin A were significantly lower in the miscarriage group compared to the controls. The decreased maternal levels of inhibin A in miscarriage patients could be due to a decrease in placental mass prior to embryonic demise. This finding also confirms that the trophoblast is the major source of inhibin A after the luteo-placental shift in early pregnancy.

Trust: key to acculturation in corporatized health care environments

Widespread restructuring of health care organizations often results in corporatization and associated cultures to which nurse administrators must adapt. Acculturation may be facilitated through understanding key aspects of traditional and emerging corporate cultures. One of these aspects is trust, which is requisite for persistently successful organizational performance in dynamic environments. This article defines trust, assesses its significance within organizational settings, delineates specific ways in which it affects organizations, and discusses the implications for nurse administrators of varying levels of trust associated with organizations.

Acute regional myocardial ischemia and recovery after cardiopulmonary bypass: effects of intensity of antecedent ischemia

Aortic cross-clamping with inadequate myocardial preservation has been shown to cause postoperative decreases in myocardial performance following coronary artery bypass graft surgery. We have demonstrated a mild decrement in myocardial beta-receptor function associated with cold cardioplegia in a normal animal model; in normal human hearts, however, response to beta-adrenergic inotropic stimulation was diminished significantly. Beta-receptor dysfunction also is associated with chronic myocardial ischemia that is associated with severe ischemic heart disease. Although the change in beta-receptor function with acute regional myocardial ischemia associated with severe ischemic heart disease is not understood fully, we found that the intensity of regional ischemia significantly affects functional recovery after cardiopulmonary bypass (CPB). Myocardial stunning does not appear to be significant in this dysfunction; however, alterations in beta-receptor density and function may play a critical role in post-CPB ventricular function.

Structure and DNA sequence of the mouse MnSOD gene

Oxidative damage to the cell has been implicated in the pathogenesis of a number of disorders, including chronic inflammation, aging, and cancer. Manganese superoxide dismutase (Mn-SOD) plays a major role in the protection of the mitochondrion from oxidative damage due to superoxide radicals and other excited oxygen species. In this report we describe the genomic organization and DNA sequence of the murine MnSOD gene. This gene is interrupted by four introns. The coding sequence of this gene was examined in C57BL/6J and C3H/HeJ mice that are SUSCEPTIBLE AND RESISTANT, respectively, to the pulmonary injuries induced by the inhaled oxidants, ozone, and hyperoxia. Since the predicted amino acid sequence for MnSOD does not differ for these strains, nor does the size or steady-state level of this transcript, biologic variability in the pulmonary inflammatory response to ozone and hyperoxia does not arise from an altered gene structure. Examination of the noncoding sequence revealed a dC.dA polymorphism in intron 2 and a StyI RFLV in intron 4 of the MnSOD gene. These sequence and mapping data provide the basis for continued study of biologic variability in the MnSOD gene as a cause of disease.

The effects of selective and non-selective monoamine oxidase (MAO) inhibitors on conflict behavior in the rat

Conflict behavior in rats was examined over the course of several weeks of chronic treatment with selective and non-selective monoamine oxidase inhibitors (MAOIs). In daily 10min sessions, rats were trained to drink from a tube which was occasionally electrified (0.5mA). Electrification was signalled by the presence of a tone. Within 3-4 weeks, control (i.e. non-drug) conflict behavior had stabilized (30-40 shocks and 8-12ml water/session) and drug testing began. Chronic administration (two injections/day for 8 weeks) with a non-selective (i.e. MAO-A and MAO-B inhibiting) dose of pargyline (15mg/kg) resulted in a time-dependent increase in punished responding. In contrast, chronic administration of the MAO-A selective inhibitor (clorgyline; 1.0mg/kg, 2mg/kg), the MAO-B selective inhibitor deprenyl (5mg/kg) or MAO-B inhibiting doses of pargyline (1.0mg/kg, 5mg/kg) were without effect. Finally, chronic treatment with the combination of a low dose of clorgyline (1.0mg/kg) and a low dose of pargyline (1.0mg/kg) did result in a time-dependent increase in punished responding. These results suggest that inhibition of both MAO-A and MAO-B is required for the eventuation of the anxiolytic effect resulting from chronic MAOI treatment.