Visual biofeedback for shortening second stage of labor: randomized controlled trial.

OBJECTIVE: To determine whether visual biofeedback can be used during labor as an effective tool for shortening the second stage of labor and reducing the need for instrumental delivery. METHODS: This was a single-center randomized controlled trial. Nulliparous women under epidural anesthesia were randomized at the point of full dilation into the biofeedback group (n = 50) or the control group (n = 50). Both groups received coached maternal pushing during four consecutive contractions, while an experienced obstetrician performed transperineal ultrasound. Only women in the biofeedback group observed the ultrasound display screen. Following this intervention, labor was managed routinely by the obstetric team. Angle of progression (AOP) was measured at rest and while pushing, before and during the first and fourth contractions. Second-stage duration and delivery outcomes were compared between groups. RESULTS: Visual biofeedback did not affect the duration of the second stage, which lasted for a median of 2.28 (interquartile range (IQR), 1.25-3.10) h in the biofeedback group vs 2.08 (IQR, 1.58-3.02) h in the control group (P = 0.981). AOP was significantly higher in the biofeedback group compared with the control group, both at rest before the fourth contraction (mean ± SD, 142.6° ± 15.9° vs 136.8° ± 13.1°; P = 0.049) and while pushing during the fourth contraction (mean ± SD, 159.3° ± 19.2° vs 149.4° ± 15.1°; P = 0.005). The increase in AOP was significantly higher in the biofeedback compared with the control group between rest and pushing at the last push (mean ± SD, 16.6° ± 11.0° vs 12.6° ± 8.3°; P = 0.041) and between the first rest and last push (mean ± SD, 24.4° ± 13.6° vs 17.9° ± 11.3°; P = 0.011). The rate of intact perineum was similar between groups (12% vs 8%; P = 0.505). CONCLUSIONS: Visual biofeedback during the second stage of labor may facilitate descent of fetal head during maternal pushing without affecting second-stage duration, possibly due to the short duration of the intervention. Future studies should focus on continuous intervention throughout the second stage of labor. © 2023 International Society of Ultrasound in Obstetrics and Gynecology.

Immune response to natural and recombinant antigens of Helicobacter pylori in patients with dyspeptic complaints.

Sera of 223 dyspeptic patients with endoscopic findings of nonulcer dyspepsia (72%), gastric ulcer (15%) and duodenal ulcer (13%) were tested for antibodies against Helicobacter pylori with an enzyme immunoassay and an immunoblot technique using lysates of Helicobacter pylori cells as antigen source. One hundred and fifty-one (68%) sera were found to be positive for Helicobacter pylori IgG with both methods; 5% of the positive results in the enzyme immunoassay were false-positive due to cross-reactions mainly of proteins with a molecular mass of 43-66 kDa. Since cross-reactivity not only reduces the diagnostic value of the immunoassay but also complicates evaluation of the immunoblot results, an attempt was made to overcome these problems by using specific purified recombinant proteins instead of the crude cell preparations as antigens. Of the commonly recognised immunogens of Helicobacter pylori, antibodies against a cell surface protein of 26 kDa, the small urease subunit (29 kDa) and the cytotoxin-associated protein (130 kDa) were identified as highly sensitive serological markers for inclusion in a recombinant antigen mixture for Helicobacter pylori screening. Only the cytotoxin-associated protein was confirmed to be an indicator immunogen for ulcerogenic strains. To assess the reliability of recombinant fragments of this protein in serological screening, the reactivity of antibody to purified fragments of the cytotoxin-associated protein was compared with that to the natural protein. A C-terminal recombinant fragment of 58 kDa showed results identical to those obtained with the natural protein and was thus considered to be an appropriate component of an antigen mixture for serological detection of Helicobacter pylori.

[Functional detection of P-glycoprotein expressing cells with flow cytometry]. / Funktionelle Erfassung P-Glykoprotein-exprimierender Zellen mittels Durchflusszytometrie.

Classical multidrug resistance (MDR) is associated with the overexpression of a membrane glycoprotein termed P-glycoprotein (P-gp) that transports a variety of apparently unrelated anti-cancer drugs out of cells. Based on the fluorescent properties of the dye rhodamine 123 (Rh 123) we aimed to develop a functional flow cytometric assay for the detection of MDR-expressing cells. Using drug sensitive cell lines (KB-3-1) and MDR mutants (KB-8-5, KB-C1) experimental conditions were established enabling demonstration of significant differences in Rh 123 accumulation/efflux. Using two-colour flow cytometry we subsequently analysed 42 consecutive patients suffering from B-cell chronic lymphocytic leukemia (B-CLL). 34/42 (81%) cases showed a marked Rh 123 efflux which was completely abolished in the presence of the MDR inhibitor verapamil. The percentage of Rh 123 effluxing cells ranged from 10 to 70% with a median of 32%. In 26 cases extracted RNA was analysed by quantitative polymerase chain reaction to evaluate the expression of MDR 1 mRNA. In 25 of 26 (96%) cases MDR 1 mRNA was detectable. The levels of MDR 1 mRNA expression correlated well with the results of the Rh 123 efflux assay (r = 0.72; p < 0.0001). In addition, 37 cases of acute myeloid leukemia were analysed and demonstrated Rh 123 efflux in 18/37 (49%) cases. In this entity the percentage of Rh 123 effluxing cells ranged from 12 to 80% (median 45%). Additionally, we evaluated the Rh 123 efflux/retention in peripheral blood cells of healthy volunteers.(ABSTRACT TRUNCATED AT 250 WORDS)

Activity of P-glycoprotein in B-cell chronic lymphocytic leukemia determined by a flow cytometric assay.

BACKGROUND: Chemoresistance in some hematologic malignancies has been associated with overexpression of P-glycoprotein, which is encoded by the MDR1 gene (also known as PGY1). However, inconsistencies in data on frequency and clinical relevance of multidrug resistance in B-cell chronic lymphocytic leukemia (B-CLL) may reflect a need for improved techniques to detect this overexpression. PURPOSE: Our purpose was to measure P-glycoprotein activity in peripheral blood cells of B-CLL patients and to analyze possible clinical correlations (disease duration, prior treatment, Rai disease stage, lymphocyte counts, and disease progression). METHODS: P-glycoprotein activity was assayed in peripheral blood cells of 42 consecutive B-CLL patients (22 treated and 20 untreated). We used dual fluorescence in a flow cytometric assay that detects efflux of the fluorescent dye rhodamine 123, which is transported from the cell by the P-glyprotein pump. Leukemia cells were costained with monoclonal antibody Leu12/CD19, and rhodamine 123 efflux was measured. Expression of MDR1 and MDR3 (also known as PGY3) messenger RNA (mRNA) was quantitatively evaluated by polymerase chain reaction (PCR) in 26 cases. RESULTS: Marked rhodamine 123 efflux was observed in 34 (81%) of the 42 cases and was abolished in the presence of multidrug resistance inhibitors. Rhodamine 123 efflux was not associated with Rai stage, lymphocyte counts, duration of disease, or disease progression. Although rhodamine 123-negative cases were about equally distributed among untreated and previously treated patients, the percentage of cells with rhodamine 123 efflux was significantly lower for untreated patients than for those treated with chemotherapy regimens including at least one multidrug resistance-associated drug. MDR1 mRNA was detected in 25 of 26 cases and MDR3 mRNA in all 26. MDR1 mRNA expression was significantly correlated with rhodamine 123 efflux, whereas MDR3 mRNA expression was not significantly correlated; MDR1 and MDR3 mRNA expression was not significantly associated with Rai stage, prior treatment, or disease progresssion. CONCLUSIONS: These findings suggest that P-glycoprotein overexpression in B-CLL is intrinsic rather than acquired and that P-glycoprotein activity is enhanced after exposure to multidrug resistance-associated drugs. This enhanced activity does not seem to be associated with more aggressive disease. Our results also indicate that an assay of P-glycoprotein function combined with PCR is suitable for clinical multidrug resistance screening. IMPLICATIONS: Additional studies are needed to determine whether functional activity of P-glycoprotein, measured by rhodamine 123 efflux, is directly related to clinical drug resistance.

High-resolution liquid chromatography of DNA fragments on non-porous poly(styrene-divinylbenzene) particles.

DNA restriction fragments and PCR products were separated by means of ion-pair reversed-phase high-performance liquid chromatography on alkylated non-porous poly(styrene-divinylbenzene) particles with a mean diameter of 2.1 microns. Optimum resolution was obtained by using an acetonitrile gradient in 100 mM of triethylammonium acetate and a column temperature of 50 degrees C. This allowed the separation of DNA fragments differing in chain length by 1-5% up to a size of 500 base pairs. PCR products could be analyzed directly in less than two minutes with a concentration sensitivity of at least 300 ng/ml. Compared with anion-exchange chromatography or gel electrophoresis no desaltation of the purified DNA molecules is required because the volatile buffer system can be readily evaporated. Subsequently, the method was used for the semiquantitative evaluation of the expression of multidrug resistance genes in mononuclear white blood cells.

[The effect of glycerol trinitrate on the arterial pressure of the fingers]. / Einfluss von Glyceroltrinitrat auf den Fingerarteriendruck.

In 35 patients with healthy vessels, 52 patients with vasospasm and 42 patients with stenoses or obliteration of the finger arteries with the help of the Parks-ultrasound-Doppler device model 806-A and a finger cuff of the size of 3.5 X 5 cm the systolic pressure of the finger arteries was measured before and after the administration of glycerol trinitrate. Since in test persons with healthy vessels no significant differences of the radial and ulnar volar finger artery, of the single fingers of one hand or in the comparison of the sides of the two hands was found, a concentration could be done. The relative and absolute increase of the pressure of the finger artery under glycerol trinitrate was most conspicuous in patients with vasospasm. No essential changes, as we expected, occurred in patients with organic disturbances of the arterial blood supply. Under variation of the lower limits of the norm of the pressure of the finger arteries the high values of the sensitivity, specificity and efficiency which are characteristic for the ultrasound-Doppler pressure measurement, lying over 0.90 particularly after pharmacologic vasodilation.

[Findings of pulse palpation and non-invasively measured blood pressure values of the posterior tibial artery in arterial occlusive disease]. / Pulstastbefund und nichtinvasiv gemessene Blutdruckwerte der A. tibialis posterior bei arterieller Verschlusskrankheit.

In 37 test persons with healthy vessels and 103 patients with arterial obstructive disease the clinical findings of the pulse palpation were related to the results of the systolic Doppler pressure measurement in the region of the posterior tibial artery. The experience of the investigator, physical influences, local extravascular factors as well as parameters of the central haemodynamics proved to be significant. A palpation of the pulse was successful in peripheral systolic pressure values lying higher than 90 Torr, so that here a judgement of the function alone became possible with the help of the palpatory pressure measurement of the posterior tibial artery. Unfavourable local conditions, however, can be followed by negative tactile findings of the pulse also in higher pressure values.

[Differential diagnosis of inflammation-induced arterial vascular diseases]. / Zur Differentialdiagnose entzündlich bedingter arterieller Gefässerkrankungen.

The clarification of non-arteriosclerotic inflammatory vascular diseases is based on angiological, angiographical, immunological and immunohistological methods and parameters. As causes of the arterial occlusive disease of younger patients are taken into consideration the obliterating endangiitis and Takayasu's aortoarteriitis. To the clinical manifestations of the giant cell arteriitis belong the temporal arteriitis and the rheumatic polymyalgia. Hypersensitivity and panangiitides are to be delimited from the group of the pathergic granulomatoses. The secondary Raynaud's syndrome on the basis of a digital arteriitis is of differential-diagnostic and prognostic importance in collagenoses and rheumatoid arthritis.

[Hemorheologic studies for evaluating microcirculation in patients with peripheral arterial circulatory disorders and diabetes mellitus]. / Hämorheologische Untersuchungen zur Beurteilung der Mikrozirkulation bei Patienten mit peripheren arteriellen Durchblutungsstörungen und Diabetes mellitus.

Haemorheological investigations in 73 male patients with chronic disturbances of the arterial blood supply of the lower extremities and 54 male non-insulin-requiring (type-II-) diabetics with and without micro- and macroangiopathy resulted in significant changes of the flow properties of the blood in contrast to 20 comparable clinically healthy males. In all groups of patients a clear increase of the aggregation of erythrocytes and the viscosity of plasma as well as a decrease of the deformability of erythrocytes were to be proved. The size of the deviations of all three parameters from the normal correlated with the degree of severity of the arterial obstructive disease and in diabetics with the occurrence of vascular complications (macroangiopathy, retinopathy) as well as with the situation of metabolism. The decreased fluidity of blood may lead to the development of further enlargement of disturbances of microcirculation. Therefore, haemorheological viewpoints should be included into the total diagnostic and therapeutic concept of the arterial obstructive disease and the diabetes mellitus.

[Kasabach-Merritt syndrome]. / Das Kasabach-Merritt-Syndrom.

The Kasabach-Merritt syndrome is a rare, congenital disease, characterized by giant haemangiomatosis and disseminated intravasal coagulation. It is reported on an at present 34-year-old patient with such a disease and the long-term course is described. Complications with haemorrhages can be prevented by means of anticoagulants.

[Theses on the evaluation of arterial circulatory disorders of the extremities]. / Thesen zur Begutachtung arterieller Durchblutungsstörungen der Extremitäten.

In an expert opinion of disturbance of the arterial blood supply concerning invalidity the vascular disease must be proved with sufficient ascertainment as well as the functional capacity remained must be estimated. Every expert opinion should contain as far as possible concrete data already in the angiologic-diagnostic minimum programme. In problematic cases supplementations by a special angiological diagnostics are necessary. The criteria of evaluation of arterial obstructive diseases for an expert opinion concerning invalidity are also summarized in theses. Also the relations between disturbances of the peripheral blood supply and effects of injury are discussed. The paper concludes with references to the acknowledgement of a disability card in arterial obstructive diseases and to the motor-car driving ability of patients with vascular diseases.

[Clinical aspects and differential diagnosis of primary and secondary microangiopathies]. / Klinik und Differentialdiagnose der primären und sekundären Mikroangiopathien.

Diseases of the terminal vascular system are of particular diagnostic and differential-diagnostic importance in clinical angiology. While in the functional microangiopathies of the skin as a rule disturbances of the vasomotor function without an essential value of the disease are concerned, secondary organic changes of the wall of the vessel not infrequently determine the course and the prognosis of the basic disease (rheumatoid arthritis, collagenoses, hypertension and diabetes). Vasomotor trophic disturbances are observed also post-traumatically, post-operatively, after exposition to cold, in a lesion of the central nervous system and vertebra nerve irritations. For the allergic hyperergic vasculitides, which show an extraordinary polymorphism in the clinical picture in characteristic histological findings, an auto-immune pathogenesis is to be supposed. The chronic arterial hypertension leads to arteriolosclerosis and necrosis with adequate organic symptoms. In the diabetic microangiopathy we may demarcate functional pre-stages from irreversible structural changes of the vessels, in which case apart from the peripheral microangiopathy of the skin the retinopathy and nephropathy are to be classified as particularly important clinical manifestations.

[Differential diagnostic problems in secondary acral circulatory disorders]. / Differentialdiagnostische Probleme bei den sekundären akralen Durchblutungsstörungen.

The broadly subdivided symptomatology of disturbances of the secondary acral blood supply, in which Raynaud's syndrome with its variants occupies a preferred position, demands solid basic knowledge of the physician, since triggering function or supporting permanent disturbance belong to a great number of basic diseases or primary disturbing factors. Thus the practicing physician has to do with comprehensive differential-diagnostic considerations with the aim of the correct recognition of the primary basic disease or noxa for the purpose of consequent induction of therapy. Angiological basis examinations, simple functional tests, a fundamental general physical examination, X-ray pictures granted for necessary and ECG-records as well as chemical laboratory findings alleviate the finding of the diagnosis like an exactly got anamnesis. In this therapeutic management subspecialists have then certainly only for a smaller part the task of further diagnostic clarification and therapeutic advice.

[Diagnostically relevant effect and disturbance factors in Doppler ultrasound studies of the arterial system]. / Diagnostisch relevant Einfluss- und Störfaktoren der Ultraschall-Doppler-Untersuchung im arteriellen Gefässbereich.

For the clinical use of the Doppler-sonography besides the knowledge of evident criteria of judgment also the consideration of important sources of error and factors of influence is necessary. Functional effects of obstructions of the arterial system depend on the actual flow time volume, the elasticity of the arteries and on the peripheral flow resistance. The derivation and registration of the Doppler-signals must be performed under standardized conditions. Particularly important are multifactorial changes of the width of the vessels and of the resistance in the regions of the arterioles which influence the poststenotic pressure-flow-behaviour and the results of Doppler-sonographic measurements. Apart from the central haemodynamics the functional changes depending on age concern the elasticity of the vessels and the degree of efficacy of the muscular blood supply. Patients with hypertension react on stimuli increasing the blood supply with a smaller increase of their functionally effective cross-section of the vessels. Disturbances of the peripheral haemodynamics in diabetics are to be referred to a deficit of the tonus of sympathetic vasoconstrictors due to an autonomous and may, moreover, be regarded as vasomotor compensation mechanisms in primarily haemorheologically conditioned disturbance of the microcirculation.