Obstetric anaesthesiology: manpower and service provision issues in India.

Obstetric anaesthesiologists play a pivotal role as peripartum physicians steering the team of obstetric healthcare providers towards a continuum of medical education, enhanced training and safer patient care. However, in resource-limited countries, deficiency of human resources and hence services available poses challenges to those attempting to reduce maternal mortality rates. Measures to fill the gap include creating a cadre of uniformly well-trained and certified non-physician anaesthesia providers (NPAPs) supervised by a physician obstetric anaesthesiologist and well-equipped rural and urban health care facilities. The Association of Obstetric Anaesthesiologists of India needs to upscale their outreach programs with regular knowledge updates and practical skill training to the NPAPs, medical graduates and postgraduate doctors in these regions. A combination of strong local administrative will, legislation for the provision of essential supplies and a global collaborative effort using checklists and protocols may help to stem gaps in the provision of safe maternal care.

Use of the Arctic Sun™ 5000 targeted temperature management system to achieve rewarming during a prolonged hypothermic cardiorespiratory arrest.

Cardiorespiratory arrest due to severe hypothermia may require prolonged cardiopulmonary resuscitation whilst the patient is rewarmed. There are reported cases of successful resuscitation with good neurological outcomes after prolonged arrests and resuscitation up to 9 h. However, in the majority of these cases, extracorporeal life support was used to maintain perfusion and rewarm the patient. Here, we report a case of successful cardiopulmonary resuscitation lasting 6.5 h, following cardiac arrest secondary to severe hypothermia, with rewarming using an Arctic Sun™ 5000. The Arctic Sun 5000 is a targeted temperature management device which is conventionally used to prevent hyperthermia post-cardiac arrest. In this report, we discuss the reasons why the device was used in this case and the effects of severe hypothermia on cardiac arrest management. We believe that this is the longest reported successful cardiopulmonary resuscitation in a severely hypothermic patient without the use of extracorporeal life support.

Gold Chain Formation via Local Lifting of Surface Reconstruction by Hot Electron Injection on H2(D2)/Au(111).

The hexagonal close packed surface of gold shows a 22 × 3 "herringbone" surface reconstruction which makes it unique among the (111) surfaces of all metals. This long-range energetically favored dislocation pattern appears in response to the strong tensile stress that would be present on the unreconstructed surface. Adsorption of molecular and atomic species can be used to tune this surface stress and lift the herringbone reconstruction. Here we show that herringbone reconstruction can be controllably lifted in ultrahigh vacuum at cryogenic temperatures by precise hot electron injection in the presence of hydrogen molecules. We use the sharp tip of a scanning tunneling microscope (STM) for charge carrier injection and characterization of the resulting chain nanostructures. By comparing STM images, rotational spectromicroscopy and ab initio calculations, we show that formation of gold atomic chains is associated with release of gold atoms from the surface, lifting of the reconstruction, dissociation of H2 molecules, and formation of surface hydrides. Gold hydrides grow in a zipper-like mechanism forming chains along the [11̅0] directions of the Au(111) surface and can be manipulated by further electron injection. Finally, we demonstrate that Au(111) terraces can be transformed with nearly perfect terrace selectivity over distances of hundreds of nanometers.

Risk of brainstem necrosis in pediatric patients with central nervous system malignancies after pencil beam scanning proton therapy.

Background: Radiation therapy (RT) plays an important role in management of pediatric central nervous system (CNS) malignancies. Centers are increasingly utilizing pencil beam scanning proton therapy (PBS-PT). However, the risk of brainstem necrosis has not yet been reported. In this study, we evaluate the rate of brainstem necrosis in pediatric patients with CNS malignancies treated with PBS-PT.Material and methods: Pediatric patients with non-hematologic CNS malignancies treated with PBS-PT who received dose to the brainstem were included. All procedures were approved by the institutional review board. Brainstem necrosis was defined as symptomatic toxicity. The actuarial rate was analyzed by the Kaplan Meier method.Results: One hundred and sixty-six consecutive patients were reviewed. Median age was 10 years (range 0.5-21 years). Four patients (2.4%) had prior radiation. Median maximum brainstem dose in the treated course was 55.4 Gy[RBE] (range 0.15-61.4 Gy[RBE]). In patients with prior RT, cumulative median maximum brainstem dose was 98.0 Gy [RBE] (range 17.0-111.0 Gy [RBE]). Median follow up was 19.6 months (range, 2.0-63.0). One patient who had previously been treated with twice-daily radiation therapy and intrathecal (IT) methotrexate experienced brainstem necrosis. The actuarial incidence of brainstem necrosis was 0.7% at 24 months (95% CI 0.1-5.1%).Conclusion: The rate of symptomatic brainstem necrosis was extremely low after treatment with PBS-PT in this study. Further work to clarify clinical and dosimetric parameters associated with risk of brainstem necrosis after PBS-PT is needed.

Differential promoter methylation of DAZL gene in bulls with varying seminal parameters.

In India, cross-breeding of indigenous cattle with exotic cattle such as Holstein Friesian and Jersey has been going on since last four decades to improve milk production. Although it has led to increased milk yield, the subfertility in male cross-bred progeny has remained a significant problem. Epigenetic modifications (DNA methylation, histone modifications and chromatin remodelling) are regarded as key players influencing gene expression. DAZL gene plays an important role in germline development and gametogenesis. The methylation and mRNA expression level of this gene have been significantly negatively correlated in the testes of cattle-yak hybrids and their parents. This study analysed the methylation profile of DAZL gene promoter in bull spermatozoa in an attempt to speculate its role in cross-bred cattle subfertility. Semen samples from Sahiwal, Holstein Friesian and Frieswal bulls (Sahiwal X Holstein Friesian) with varying semen motility parameters were collected, and DNA was isolated. Methylation-specific primers were used to amplify part of promoter and exon 1 of DAZL gene using bisulphite-converted DNA. The amplified products were sequenced after cloning in pTZ57R/T vector. Sequence analysis revealed significantly higher DNA methylation of DAZL gene in Frieswal bulls with poor motility (28.26%) as compared to medium (15.21%) and high motility phenotype (6.52%). In pure-bred counterparts, Sahiwal and Holstein Friesian, epigenetic marks were more in the former (15.21%) than the latter (4.34%), but in both cases, the values were lower as compared to the poor motility Frieswal bulls. This suggests that differential hypermethylation of the CpG islands could possibly influence reproductive parameters in bovines.

Remote monitoring of blood pressure to reduce the risk of preeclampsia related complications with an innovative use of mobile technology.

OBJECTIVE: Assess suitability of remote self-monitoring of blood pressure with an innovative use of technology in detecting raised blood pressure in pregnancy. STUDY DESIGN: Assess ease of use and safety of the newly developed kit which included a Bluetooth enabled blood pressure machine and an android based mobile phone. The phone was modified to have only one application in it which showed the blood pressure readings with a traffic light system. The study was a proof of concept for wider use of the kit. We provided 50 women who were admitted with the kit. We assessed ease of use of the blood pressure machine and accuracy of readings including remote transfer to a computer. MAIN OUTCOME MEASURE: Technological feasibility and acceptance by women. RESULTS: The technology provides accurate data and visual cues including safe remote transfer instantaneously. 90% of the women agreed that the Kit was simple to use and 78% would prefer this model of testing at home. CONCLUSION: In a relatively resource rich setting the machine can reduce the number of patient visits for women who are at risk for preeclampsia. In resource poor settings it helps to triage resources to women who need it the most. It also is a valuable tool for research. Studies of the Kit in both developed and developing world will be needed to show reduction in perinatal and maternal morbidity or mortality secondary to preeclampsia.

Necrotizing fasciitis after spinal anesthesia.

Regional anesthesia is the preferred technique for Cesarean delivery. Strict aseptic precautions should be taken; otherwise, infectious complications including abscess formation, meningitis and necrotizing fasciitis may result. We report a case of a 26-year-old post-partum female who presented with necrosis of the skin of back following spinal anesthesia, which was administered for Cesarean delivery 5 days prior at a private nursing home. On presentation, she was drowsy, appeared dehydrated and febrile. Examination of her back revealed necrosis of skin extending from just below the scapula to the gluteal region. Debridement of skin over the back was performed, and intravenous antibiotics started. After three debridements following which skin grafting was performed, she made complete recovery. Infectious complications following regional anesthesia are rare, and most of the literature focuses on colonization of epidural catheters or epidural abscess. There is no report of necrotizing fasciitis following spinal anesthesia so far. Sources of infection that are suspected in our case include: local anesthetic solution used for subcutaneous infiltration, nonadherence to aseptic precautions, skin flora of patient, endogenous source and nasopharyngeal flora of anesthesiologist. We considered each possibility, and the most likely cause in our case appears to be infection from an already-used vial of a local anesthetic agent. Local anesthetics have bacteriostatic properties, but infection may still be transmitted through contaminated solutions. The present case highlights the importance of maintaining strict aseptic precautions, avoiding reusing multidose vials and early recognition of this complication as timely intervention can be lifesaving.

Morning light therapy for postpartum depression.

Postpartum depression (PPD) is a frequent complication of childbirth, but many women refuse pharmacological treatment. Little data exists on bright light therapy for PPD. Fifteen outpatient women with PPD were randomly assigned to bright light (10,000 lux, n = 10) or dim red light (600 lux, n = 5) and completed a 6-week trial and weekly assessments using self-report depression scales and clinician ratings of symptom course. Both groups showed significant improvement over time on all measures, with no significant difference between conditions.

Status of lipid peroxidation, some antioxidant enzymes and erythrocytic fragility of crossbred cattle naturally infected with Theileria annulata.

Erythrocytic lipid peroxidation, activities of some antioxidant enzymes and osmotic fragility of red blood cells was studied in adult (>1 year) crossbred cattle naturally infected with Theileria annulata. Twenty clinically healthy animals (group I) and 15 clinical cases (group II) of tropical theileriosis were selected. Cattle suffering from theileriosis had significantly higher (p<0.01) erythrocytic lipid peroxidation and osmotic fragility. Activities of antioxidant enzymes, viz. glucose-6-phosphate dehydrogenase (G6PD) and glutamate peroxidase (GPx) were also significantly increased (p<0.01) in group II. However, superoxide dismutase and catalase did not show significant changes. The results indicated that infection with theileria led to increased oxidative stress to the animals, and even a significant rise in the activities of antioxidant enzymes. G6PD and GPx could not lower this oxidative stress. However, the increase in the activities of antioxidant enzymes pointed towards the body's defence mechanism against lipid peroxidation during oxidative stress in theileriosis.

Three-legged pair of pants anastomosis: a rare technique for renal transplantation.

Because of the shortage of donors, kidneys previously judged to be unsuitable are now accepted for transplantation. Successful engraftment of kidneys with multiple renal arteries is one of the challenges and requires meticulous vascular surgical technique. In one of our case of renal allograft with three renal arteries, we created a single lumen by suturing three arteries together, like a three-legged pair of pants. The end of the single lumen was anastomesed to the side of external iliac artery. There was brisk diuresis on table after transplantation. Postoperatively, the patient had an uneventful course and normal graft function.

Identification of ARAP3, a novel PI3K effector regulating both Arf and Rho GTPases, by selective capture on phosphoinositide affinity matrices.

We show that matrices carrying the tethered homologs of natural phosphoinositides can be used to capture and display multiple phosphoinositide binding proteins in cell and tissue extracts. We present the mass spectrometric identification of over 20 proteins isolated by this method, mostly from leukocyte extracts: they include known and novel proteins with established phosphoinositide binding domains and also known proteins with surprising and unusual phosphoinositide binding properties. One of the novel PtdIns(3,4,5)P3 binding proteins, ARAP3, has an unusual domain structure, including five predicted PH domains. We show that it is a specific PtdIns(3,4,5)P3/PtdIns(3,4)P2-stimulated Arf6 GAP both in vitro and in vivo, and both its Arf GAP and Rho GAP domains cooperate in mediating PI3K-dependent rearrangements in the cell cytoskeleton and cell shape.

Effects of alpha-methyl-para-tyrosine-induced catecholamine depletion in patients with seasonal affective disorder in summer remission.

Noradrenergic and dopaminergic mechanisms have been proposed for the pathophysiology of seasonal affective disorder (SAD). We investigated the effects of catecholamine depletion using alpha-methyl-para-tyrosine (AMPT), an inhibitor of tyrosine hydroxylase, in patients with SAD in natural summer remission. Nine drug-free patients with SAD by DSM-IV criteria, in summer remission for at least eight weeks, completed a double-blind, crossover study. Behavioral ratings and serum HVA and MHPG levels were obtained for 3-day sessions during which patients took AMPT or an active control drug, diphenhydramine. The active AMPT session significantly reduced serum levels of HVA and MHPG compared with the control diphenhydramine session. The AMPT session resulted in higher depression ratings with all nine patients having significant clinical relapse, compared with two patients during the diphenhydramine session. All patients returned to baseline scores after drug discontinuation. Catecholamine depletion results in significant clinical relapse in patients with SAD in the untreated, summer-remitted state. AMPT-induced depressive relapse may be a trait marker for SAD, and/or brain catecholamines may play a direct role in the pathogenesis of SAD.

Studies on some blood parameters of crossbred calves with experimental Theileria annulata infections.

Subcutaneous inoculation of 1 ml of ground Theileria annulata tick tissue stabilate (0.75 tick equivalent) into crossbred calves (n = 6, average age 53 days) resulted in the development of acute theileriosis. The percentage parasitaemia was 71.7% +/- 3.3% on day 20 after inoculation. Macroschizonts were observed in lymphocytes and monocytes. Phagocytosed schizonts were observed in neutrophils, along with cytoplasmic vacuolation in monocytes and neutrophils. There was progressive decrease (p < 0.05) in the haemoglobin and packed cell volume, along with a marked reticulocytosis. Serum analysis revealed a decrease (p <0.05) in the concentrations of calcium, cholesterol and triglycerides, while there was an increase (p < 0.05) in the concentrations of blood urea nitrogen as compared to day 0 values. The total serum proteins, albumin and serum immunoglobulin concentrations and the albumin-to-immunoglobulin ratio showed marked decreases (p<0.05). Coagulopathies included thrombocytopenia and an increased prothrombin time, along with a non-significant increase in the bleeding time and activated partial thromboplastin time during the terminal stages of the disease. There was an increase in the osmotic fragility of erythrocytes during the disease. Morphological alterations in the erythrocytes were observed with the developing parasitaemia.

An open trial of light therapy for women with seasonal affective disorder and comorbid bulimia nervosa.

OBJECTIVE: Many patients with seasonal affective disorder (SAD) have dysfunctional eating behaviors. Conversely, many women with bulimia nervosa have marked winter worsening of mood and bulimic symptoms. Controlled studies of light therapy in SAD and in bulimia nervosa have shown beneficial effects on mood and binge/purge symptoms. We explored the clinical use of light therapy in women with SAD who also had comorbid bulimia nervosa. METHOD: Twenty-two female patients diagnosed using DSM-IV criteria with both bulimia nervosa and major depressive disorder with a seasonal (winter) pattern were treated with an open design, 4-week trial of light therapy (10,000 lux fluorescent light box with an ultraviolet filter, 30 to 60 minutes per day in the early morning). Patients were assessed before and after treatment with depression scales and with binge/purge diaries. RESULTS: Light therapy resulted in significant improvement in mood, with a mean 56% reduction in 29-item Hamilton Rating Scale for Depression scores following treatment (p < .001). The frequency of binges and purges per week also significantly decreased (p < .001) from baseline by a mean of 46% and 36%, respectively. Two (9%) of 22 patients became abstinent of binge/ purge episodes, compared with 10 (45%) of 22 patients who met criteria for remission of depressive symptoms. The light therapy was well tolerated by patients. CONCLUSION: These results suggest that therapeutic effects of light therapy on mood and bulimic symptoms in patients with SAD and comorbid bulimia nervosa are sustained over at least 4 weeks. However, the low abstinence rate in bulimic symptoms indicates that light therapy may be most effectively used as an adjunctive treatment to medications and/or psychotherapy for bulimia nervosa.

DAPP1 undergoes a PI 3-kinase-dependent cycle of plasma-membrane recruitment and endocytosis upon cell stimulation.

BACKGROUND: Phosphoinositide (PI) 3-kinase and its second messenger products, phosphatidylinositol 3,4,5-trisphosphate (PtdIns(3,4,5)P(3)) and phosphatidylinositol 3,4-bisphosphate (PtdIns(3,4)P(2)), play important roles in signalling processes crucial for cell movement, differentiation and survival. Previously, we isolated a 32kDa PtdIns(3,4,5)P(3)-binding protein from porcine leukocytes. This protein contains an amino-terminal Src homology 2 (SH2) domain and a carboxy-terminal pleckstrin homology (PH) domain, and is identical to the recently described DAPP1 (also known as PHISH or Bam32) protein. Here, we characterised the subcellular distribution of DAPP1 in response to cell stimulation. RESULTS: When expressed transiently in porcine aortic endothelial (PAE) cells, DAPP1 translocated from the cytosol to the plasma membrane in response to platelet-derived growth factor (PDGF). This translocation was dependent on both PI 3-kinase activity and an intact DAPP1 PH domain. Following recruitment to the plasma membrane, DAPP1 entered the cell in vesicles. Similar responses were seen in DT40 chicken B cells following antibody treatment, and Rat-1 fibroblasts following epidermal growth factor (EGF) or PDGF treatment. Colocalisation studies in PAE cells suggested entry of DAPP1 by endocytosis in a population of early endosomes containing internalised PDGF-beta receptors. DAPP1 also underwent PI 3-kinase-dependent phosphorylation on Tyr139 in response to PDGF stimulation, and this event was involved in the vesicular response. CONCLUSIONS: This is the first report of plasma-membrane recruitment and endocytosis of a PI 3-kinase effector protein in response to cell stimulation. The results suggest a novel role for DAPP1 in endosomal trafficking or sorting.

Conservation skills among preschool children in Umtata, South Africa.

To 41 boys and 29 girls (M age = 5.2 yr.) in a South African preschool a test of conservation of liquid was given. Analysis showed conservation skills had not been acquired as only 5 children showed such skills and only one knew why.

Effectiveness of lipopolysaccharide as an intrauterine immunomodulator in curing bacterial endometritis in repeat breeding cross-bred cows.

Antibiotics are usually used to combat microbial infections of the uterus, responsible for hindering establishment of pregnancy in cross-bred cows. The major disadvantages of antibiotics are: development of bacterial resistance, high costs and diminishing uterine defense mechanisms (UDM). As an alternative therapy, intrauterine application of Escherichia coli Lipopolysaccharide (E. coli LPS) as a uterine defense stimulator was used in this study in confirmed clinical cases of repeat breeding associated with bacterial endometritis. In the treated group (n=12), on the day of estrus, 100 microg of E. coli LPS dissolved in 30-ml sterile phosphate buffer saline (PBS) was infused intrauterine; while in the control group (n=12), only 30 ml of PBS was infused. Six-hour post-treatment, in the treatment group uterine washings showed a 100-fold increase in the total leucocytic count (TLC). Out of the cellular contents, more than 80% of the cells were recognised as neutrophils; above 60% were alive and their phagocytic activity was five bacteria/neutrophil. Such a cellular response was maintained until 72-h post-treatment. At the subsequent estrus period, the cervicovaginal mucus (CVM) became clear in 9 out of 12 cows (75%) and showed no bacterial growth. In the control group, similar micro-organisms were present in CVM of all the 12 cows before and after the PBS infusions. During the subsequent estrus, all nine cows with sterile CVM in the treatment group conceived while only one cow conceived from the control group. It was concluded that, administration of intrauterine E. coli LPS as single infusion in cows with bacterial endometritis stimulated UDM and cleared the infection within one estrous cycle, and thereby restoring fertility.

Cloning, heterologous expression, and distinct substrate specificity of protein farnesyltransferase from Trypanosoma brucei.

Protein prenylation occurs in the protozoan that causes African sleeping sickness (Trypanosoma brucei), and the protein farnesyltransferase appears to be a good target for developing drugs. We have cloned the alpha- and beta-subunits of T. brucei protein farnesyltransferase (TB-PFT) using nucleic acid probes designed from partial amino acid sequences obtained from the enzyme purified from insect stage parasites. TB-PFT is expressed in both bloodstream and insect stage parasites. Enzymatically active TB-PFT was produced by heterologous expression in Escherichia coli. Compared with mammalian protein farnesyltransferases, TB-PFT contains a number of inserts of >25 residues in both subunits that reside on the surface of the enzyme in turns linking adjacent alpha-helices. Substrate specificity studies with a series of 20 peptides SSCALX (where X indicates a naturally occurring amino acid) show that the recombinant enzyme behaves identically to the native enzyme and displays distinct specificity compared with mammalian protein farnesyltransferase. TB-PFT prefers Gln and Met at the X position but not Ser, Thr, or Cys, which are good substrates for mammalian protein farnesyltransferase. A structural homology model of the active site of TB-PFT provides a basis for understanding structure-activity relations among substrates and CAAX mimetic inhibitors.

Effects of rapid tryptophan depletion in patients with seasonal affective disorder in natural summer remission.

BACKGROUND: Serotonergic mechanisms have been proposed for the pathophysiology of seasonal affective disorder (SAD) and the therapeutic effect of bright-light treatment. Previously, we showed that SAD patients, in clinical remission with light therapy during the winter, experienced transient depressive relapses after a rapid tryptophan depletion (RTD) technique, which results in decreased brain serotonin levels. The objective of this study was to investigate the effect of RTD in SAD patients who were in natural summer remission. METHODS: Twelve drug-free patients with SAD by DSM-IV criteria and 10 normal subjects participated in this double-blind, placebo-controlled, crossover study. SAD patients were in natural summer remission for at least 8 weeks. Behavioural ratings and plasma tryptophan levels were obtained before, and 5 h after, ingesting an amino acid (AA) mixture +/- tryptophan. Experimental RTD and control sessions were scheduled 1 week apart. RESULTS: The RTD session resulted in significant reduction in total and free plasma tryptophan levels compared to the control session. The behavioural data were analysed using repeated measures analysis of variance. This analysis found significant main effects of time (higher scores after AA ingestion) and diagnosis (higher scores in SAD patients), but no main effect of session or significant interaction effects between the three factors. Thus, there were no significant behavioural effects of RTD compared to the sham depletion control session. CONCLUSIONS: The summer remission experienced by SAD patients is not dependent on plasma tryptophan levels (and presumably brain serotonin function) in the same manner as that of remission after light therapy. These results conflict with those of other laboratories, perhaps because of differences in study samples.