Anaesthetic management of tetraplegic pregnant patients during child delivery: A systematic review

BACKGROUND

Pregnancy in spinal cord injured patients has specific issues that must be carefully addressed. However, guidelines for their management are scarce.

METHODS

A systematic review of the literature regarding the anaesthetic management during delivery of pregnant patients with cervical spinal cord injury was performed on the electronic databases of PubMed (Medline) and Cochrane.

RESULTS

Twenty-two papers were included. A higher incidence of preterm birth and caesarean delivery were seen. Anaesthetic management was diverse, although most pregnant patients received epidural analgesia. Autonomic dysreflexia symptoms were present in 51% of pregnancies.

CONCLUSION

Timely management of these patients could possibly reduce caesarean and preterm delivery rates, avoid or minimize common complications, as well as reduce costs. An early reference to anaesthesiology consultation and a multidisciplinary approach is recommended.

B-lines by lung ultrasound is associated with pulmonary symptoms and cardiac function in acute malaria: a prospective cohort study

Background

Malaria patients are at risk of cardiopulmonary complications, but diagnosis and management are difficult in resource limited environments. B-lines by lung ultrasonography (LUS) can identify pulmonary alterations, however, little is known about the usefulness in malaria.

Purpose

We aimed to investigate the occurrence of B-lines in acute malaria patients at baseline and at follow-up, and whether they are associated with shortness of breath and impaired left ventricular ejection fraction (LVEF).

Methods

Adult patients with non-severe acute malaria were prospectively enrolled from June to December 2020 in community healthcare clinics in a remote area. Patients were age- and sex-matched to controls without a prior history of malaria. We examined patients prior to anti-malaria treatment and at follow-up. Malaria treatment was administered according to national guidelines. Patients were excluded if they were pregnant, had concomitant infections or recent chest trauma. Patients underwent LUS (8-zones), echocardiography and peripheral blood smear. Measurements were blinded to clinical variables and outcomes.

Results

We included a total of 99 patients (median age 40±15 years, 55% men). Patients suffered from Plasmodium vivax (n=75), P. falciparum (n=22), and a mix of the two (n=2) and median parasite density was 1,595 parasites/mL (interquartile range [IQR] 528–6,585/mL). Follow-up was completed in 71 patients and the median follow-up time was 31 days (IQR 27–40 days).

Patients with acute malaria had significantly more B-lines at baseline than matched controls (P-value<0.001) and fewer B-lines at follow-up (P-value<0.001) (Figure 1). In acute malaria patients, number of B-lines at baseline correlated significantly with shortness of breath (OR 1.20, [1.04 to 1.39], P-value=0.01) and with LVEF (adjusted for age and sex: +8% [+1% to +15%], P-value=0.016 per 1% decrease in LVEF). There was no correlation between number of B-lines and parasite density (+2% [−5% to +11%], P-value=0.53 per 1000 increase in parasite density).

Conclusion

B-lines detected by LUS are more frequent in patients with acute malaria than in age- and sex-matched controls and decrease in response to treatment. B-lines also correlate with shortness of breath and lower LVEF at baseline. Because LUS is a quick and accessible examination, it may potentially facilitate risk stratification and therapeutic decisions regarding cardiopulmonary complications in patients with acute malaria.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): Danish Heart Association

A Dilatometric Study of Tempering Complemented by Mössbauer Spectroscopy and other Characterization Techniques

A new approach for non-isothermal tempering analysis utilizing dilatometry is proposed and was carried out on a medium carbon steel with high silicon and additions of Mo and V for secondary hardening. The method includes a second non-isothermal step performed with the same heating rate (2 °C/min) used for the first step in order to create a baseline for analysis. The results were correlated with several other characterization techniques. Mössbauer spectroscopy confirmed the formation of transition carbides by auto-tempering as well as the presence of retained austenite decomposition (stage II) and cementite precipitation (stage III), which demonstrated significant overlap. Electrical resistivity measurements were correlated with dislocation densities obtained through X-ray diffraction analysis. Transmission electron microscopy dark field images confirmed the secondary hardening assessment from dilatometry.

Expression of CYP2E1 in human lung and kidney during development and in full-term placenta: a differential methylation of the gene is involved in the regulation process

Methylation of dinucleotide CG residues located in the 5' end of the CYP2E1 gene has been demonstrated to play a role in the control of gene expression in the human developing liver. This study was undertaken to examine the CYP2E1 RNA content of human lung, kidney and full-term placenta and to determine whether the expression of CYP2E1 was controlled by its methylation status in these tissues. CYP2E1 was expressed at a very low level in the lung and kidney at whatever age, and at a variable level in full-term placentas. The restriction profile of genomic DNA was identical in lung and kidney and corresponded to a heavy methylation of HpaII/MspI sites located within the promoter, the first exon and first intron of the CYP2E1 gene. A different pattern of methylation was obtained in full-term placentas, indicating that CpG residues located in the 5' end of the gene were predominantly but not fully demethylated. However, the variable level of CYP2E1 RNA in full-term placentas suggests the involvement of other elements in the regulation process of CYP2E1 in this tissue.

Developmental expression of CYP2E1 in the human liver. Hypermethylation control of gene expression during the neonatal period

Cytochromes P-450 are responsible for the biotransformation of drugs and other hydrophobic molecules by the liver. Several isoforms coexist which display an asynchronous onset during the perinatal period suggesting the involvement of multiple mechanisms of regulation. In this paper, we have shown that the CYP2E1 protein and its associated activity could not be detected in the fetal liver and rise during the first few hours following birth independently of the gestational age (between 25-40 weeks). During this period, the CYP2E1 RNA content remains fairly low: the stabilization of the low amount of existing CYP2E1 protein by endogenous ketone bodies could explain the early neonatal rise of the protein level. From 1 month to 1 year, the protein content gradually increases and is accompanied by the accumulation of CYP2E1 RNA, suggesting a transcriptional activation of the gene during the late neonatal period. We examined the methylation status of CpG residues in the 5' flanking region, first exon and first intron of CYP2E1 gene cleaved with HpaII/MspI. Genomic DNA from fetal liver shows several hypermethylated spots in the first-exon-first-intron region, which progressively disappear in neonatal samples. We conclude that during the neonatal period, the accumulation of hepatic CYP2E1 RNA is correlated with the degree of methylation at the 5' end of the CYP2E1 gene.

Taxol metabolism by human liver microsomes: identification of cytochrome P450 isozymes involved in its biotransformation

The biotransformation of taxol by human liver was investigated in vitro with microsomes isolated from adult and developing human tissues. In vitro, no metabolism was detected with kidney microsomes, whereas two metabolites were generated by liver microsomes. The most prominent metabolite, termed M5, corresponded to an hydroxylation at the C6 position on the taxane ring, while the other metabolite, termed M4, corresponded to an hydroxylation at the para-position on the phenyl ring at the C3'-position of the C13 side chain. These two taxol derivatives have been shown to be the major metabolites recovered in bile from a patient infused with taxol. Several approaches have been used to identify the cytochrome P450 (CYP) isozymes involved in these reactions. No positive correlation was observed between the in vitro synthesis of these two metabolites, suggesting that two cytochrome P450 isozymes could be involved, although they could not be distinguished by their apparent affinities (Km approximately 15 microM). The formation of metabolite M4 was substantially reduced both by antibody directed against CYP3A and by the addition of CYP3A substrates such as orphenadrine, erythromycin, troleandomycin, and testosterone. Conversely, the formation of metabolite M5 remained unaffected by antibodies against CYP3A and by CYP3A substrates but was sensitive to diazepam inhibition, a preferential substrate of CYP2C. Correlation between CYP2C content or diazepam demethylation and the synthesis of metabolite M5 was highly positive. The formation of metabolite M4 developed during the early postnatal period. In contrast, the synthesis of metabolite M5 rose only after 3 months of age. These data clearly implicate CYP3A in the formation of metabolite M4 and CYP2C in the synthesis of metabolite M5. Microsomes from patients treated with barbiturates and benzodiazepines increased the formation of metabolite M4 to the level of metabolite M5, demonstrating that drug interactions could modify the human metabolism of taxol.