Maternal Death: Audit in a Tertiary Hospital.

Maternal death audit in a tertiary hospital was conducted to improve the quality of maternal health care. In this descriptive type cross sectional study, maternal deaths were reviewed and factors responsible for maternal death were identified and noted in Rajshahi Medical College Hospital from July 2008 to June 2009. During the study period total 63 maternal deaths recorded among 7560 deliveries. Almost 43% deceased mother was less than 25 years of age. 39.7% mother died during their first pregnancy. Among the delivery group 46% cases delivered vaginally. Regarding time interval 33.3% of death occurred within six hours of admission to hospital. The main causes of death were eclampsia (46%), PPH (17.5%), septic abortion (12.7%). One or more Institutional factors were identified and among them lack of obstetric ICU facility was related to73% cases. Delayed or lack of blood transfusion was responsible for 46% cases and delayed attendance by senior doctors were related to 30% cases. Substantial number of maternal death occurred at or <25 years of age. Eclampsia, hemorrhage, septic abortions along with substandard care was identified as the major cause of maternal death.

Isosorbide Mononitrate versus Misoprostol for Cervical Ripening and Induction of Labour at Term.

To assess the efficacy and safety of isosorbide mononitrate (IMN) compared with misoprostol for cervical ripening and labour induction at term. In this comparative study two hundred term pregnant women with indication for induction of labour were randomly divided to receive either 40 mg IMN tablet vaginally (n=100) or 50 µg misoprostol tablet vaginally (n=100) every 6 hours interval for a maximum of 4 doses. Progress & outcome of cervical ripening, labour induction and adverse effects were assessed. Change in cervical score was higher in misoprostol group than IMN group. Time from start of medication to vaginal delivery in IMN group was significantly longer, 28.66 ± 5.283 hours, than in misoprostol group, 16.12 ± 5.581 hours. Vaginal delivery occurred in 77% in IMN group and 69% in misoprostol group. There were no tachysystole or uterine hyper stimulation in the IMN group while in misoprostol group it was 17% and 11% respectively. Maternal satisfaction was higher in IMN group. Cervical ripening is satisfactory with IMN. Though misoprostol is singly more effective than IMN but IMN with oxytocin results in more vaginal delivery. Fetal and maternal side effects are less in IMN group.

Comparison study of branch versus main trunk repetitive nerve stimulation of facial nerve in normal subjects.

PURPOSE: Repetitive stimulation of the facial nerve is performed in neuromuscular junction disorders. Main nerve stimulation is currently used. There is more discomfort and artifact than stimulation of a branch. We stimulated the temporal branch of the facial nerve to the frontalis and compared the responses with that of main trunk stimulation. We compared the amplitudes and the corresponding amperage. METHODS: Eleven normal volunteers between 18 and 65 years of age were studied. Repetitive nerve stimulation of both the main trunk and the temporal branch to the frontalis muscle was performed at a frequency of 3 Hz, and waveforms were recorded from the frontalis muscle using adhesive surface electrodes. The amplitudes and corresponding amperages were compared. RESULTS: The amplitude comparison between the main trunk and that of the temporal branch to the frontalis yielded a paired two-tail P-value of 0.33. The comparison of corresponding stimulus intensities used yielded a paired two-tail P-value of 4.2 × 10. CONCLUSIONS: We concluded that the stimulus intensity required to achieve similar amplitudes in small branch stimulation is much lower than that required in main trunk stimulation.

The impact of age on clinical outcomes following cardiac resynchronisation therapy.

BACKGROUND: Cardiac resynchronisation therapy (CRT) is an established treatment for selected patients with symptomatic left ventricular (LV) systolic dysfunction. Heart failure (HF) is primarily a disease of the elderly; however, these patients are underrepresented in CRT trials. Our aim was to evaluate the impact of age on clinical outcomes following CRT. METHODS: A consecutive series of 177 patients was identified and divided into those aged ≤ 7 5 years (n = 131, mean ± SD 62.1 ± 11.2 years) and those aged >75 years (n = 46, mean ± SD 80.7 ± 4.1 years). The primary end point was a composite of all-cause mortality or HF hospitalisation. RESULTS: During a median ± IQR follow up of 28.5 ± 33.7 months, the event rate for the primary end point was significantly higher in the elderly compared to younger patients (20.1 vs. 11.1 %, respectively, logrank p = 0.020). This was mainly driven by an excess mortality rate among those aged >75 years (10 vs. 4.7%, respectively, logrank p = 0.018) whereas HF hospitalisation rates were similar between groups (10 vs. 6.4%, respectively, logrank p = 0.301). After adjusting for comorbidities and ICD status, the difference in the composite end point rates was attenuated and no longer significant (HR 1.580, 95% CI 0.899-2.778; p = 0.112 for >75 vs. ≤ 75 years). Notably, both groups demonstrated similar response rates to CRT in terms of symptomatic improvement, reverse LV remodelling and neurohormonal activation. CONCLUSIONS: CRT is equally effective in the elderly as in younger patients to reduce adverse clinical outcomes. For those who fulfil the prerequisite selection criteria, it should be considered as a valid therapeutic option.

Heart failure epidemiology: European perspective.

Heart failure poses an increasing problem for global healthcare systems. The epidemiological data which has been accrued over the last thirty years has predominantly been accumulated from experience within North America and Europe. Initial large cohort, prospective longitudinal studies produced the first publications; however latterly the focus has shifted onto epidemiological data governing hospitalisation and mortality. The emphasis behind this shift has been the resource implications with regards to repetitive, costly and prolonged hospitalisation. The European experience in heart failure, though similar to North America has recently demonstrated differences in hospitalisation which may underlie the differences between healthcare system configuration. Heart failure however remains an increasing global problem and the endpoint of a variety of cardiovascular diseases. Allied with the fact of increasingly elderly populations and prior data demonstrating a steep rise in prevalent cases within more elderly populations, it is likely that the increasing burden of disease will continue to pose challenges for modern healthcare. Despite the predicted increase in the number of patients affected by heart failure, over the last thirty years, a clear management algorithm has evolved for the use of pharmacotherapies (neuro-hormonal antagonists), device based therapies (Implantable Cardioverting Defibrillator (ICD) and Cardiac Resynchronisation Therapy (CRT)) and mechanical therapies including left ventricular assist devices and cardiac transplantation. Though the management of such patients has been clearly delineated in national and international guidelines, the underuse of all available and appropriate therapies remains a significant problem. When comparing various epidemiological studies from different settings and timepoints, it should be remembered that rates of prevalence and incidence may vary depending upon the definition used, methods of accumulating information (with the possibility of bias) and the chosen cut point of defining left ventricular systolic dysfunction (LVSD).

A retrospective analysis of the impact of azithromycin maintenance therapy on adults attending a UK cystic fibrosis clinic.

BACKGROUND: Azithromycin is widely used as an immunomodulatory agent in the treatment of cystic fibrosis with previous literature documenting improvements in lung function and a reduction in infective exacerbations. The maximal study period in adults has been six months. METHODS: 81 adult patients taking continuous azithromycin were retrospectively identified. Percentage predicted FEV(1) and courses of intravenous antibiotics were examined at yearly intervals two years prior to and two years after azithromycin initiation. RESULTS: FEV(1) deteriorated in the two years before starting azithromycin by a mean of 2.02% per year. In the year following initiation, FEV(1) increased by 1.15% (P=0.01). However, a mean 2.58% reduction was observed in year two. There was no statistically significant effect on courses of intravenous antibiotics. CONCLUSIONS: Azithromycin resulted in an improved FEV(1) at year one. This effect was not sustained beyond the first year of treatment.

Two cases of delayed-onset transient global amnesia after saline-contrast transthoracic echocardiography.

INTRODUCTION: We present 2 cases of transient global amnesia (TGA) with delays of 1 and 2 hours after saline-contrast transthoracic echocardiography. The unique presentation in these cases may help elucidate the possible mechanisms underlying TGA. CASES: (1) A 63-year-old woman admitted for lower extremity arterial thrombosis with TGA onset 1 hour after saline-contrast echocardiography. (2) A 75-year-old woman admitted to rule out myocardial infarction with TGA onset 2 hours after saline-contrast echocardiography. CONCLUSIONS: The precipitating events of TGA are varied and an understanding of the mechanism(s) underlying the phenomenon is incomplete. However, the presence of a delay after the trigger event as described in these cases is unique and informative in that it lends strength to some proposed mechanisms over others in this subset of TGA presentations.

An atypical course of myasthenia gravis.

Myasthenia gravis (MG) is a chronic neuromuscular disease which leads to varying degrees of weakness in the skeletal muscles. Some of the symptoms of the disorder include weakness of the eye muscles, difficulty in swallowing and slurred speech. When only the muscles of the eyes are affected, the illness is termed ocular myasthenia, which is often characterized by abrupt onset of diplopia and ptosis of the eyelid. In most patients with ocular-onset MG, there is a progression to involvement of other muscle groups within the first two years (generalized myasthenia). In the case reported here, a 39-year-old male of Ecuadorian descent complained of difficulty seeing, double vision, dizziness, unsteady gait, difficulty maintaining balance and fatigue for the previous two days. Neurological examination was remarkable for total external ophthalmoplegia. There was no external bulbar muscle paralysis, motor weakness, muscle wasting, sensory deficits or sphincter dysfunction. His laboratory workup was significant for elevated acetylcholine receptor antibody. He was diagnosed with ocular MG after differential diagnoses were ruled out based on the onset and presentation of symptoms, the patient's age and a normal magnetic resonance imaging exam. No signs of generalized myasthenia were detected. His symptoms improved dramatically after treatment with Acetyl cholinesterase (AchE) inhibitors and steroids, regaining much of his ocular mobility and ability to walk without gait imbalance. At follow-up visits, the patient remained healthy with no evidence development of other myasthenic signs. This case is atypical since ocular MG does not normally occur in the absence of other myasthenic forms.

Acid phosphatases in the mouse testis: activity changes during development.

The histology and acid phosphatase activities of the developing testes in the mouse, from 4 days of age until maturity, were analyzed. The specific enzyme activity with p-nitrophenyl phosphate as substrate increased after 3 weeks of age and then reached a plateau. Cobalt and zinc markedly increased the specific activity after the third week. After fractionation the testicular homogenate revealed four acid phosphatases. Enzyme I maintained a high activity during the first 3 weeks but steadily declined thereafter. Enzyme II, present in all age groups, showed a moderate increase after the fourth week. Enzymes III and IV were low and declined further during the first 3 weeks with a subsequent increase. This occurred concomitantly with the appearance of spermatids and mature sperm cells. Changes in enzyme activities seem to reflect the alterations in cellular composition of the testis during the developmental process. Enzymes III and IV were probably associated with spermatids and sperm cells.

Acid phosphatases of dog testis and a Leydig cell tumor.

Acid phosphatase activities were measured with five different substrates after fractionation with Sepharose 6B and DE-52 cellulose chromatography of homogenate from normal adult dog testis and a testicular tumor. The tumor showed a positive 3 beta-hydroxysteroid dehydrogenase reaction and was diagnosed as a Leydig cell adenoma. The fractionations gave three separate enzyme activities in the normal testis and two enzymes in the tumor. All were sensitive to sodium fluoride, but differed from each other in pH-optima and the response to Co2+ and Zn2+. Enzymes I and II were identical in both tissues. The latter with a smaller molecular weight was activated by Zn2+ but not by Co2+ and had slightly higher pH-optimum (4.5) than enzyme I (optimum at pH 3.5). The third enzyme was activated by Co2+ and Zn2+ and had the highest pH-optimum (pH 5.5). It was called enzyme IV due to its resemblance to a similar activity in other mammalian species.

Further studies on human testicular acid phosphatases.

Four acid phosphatases were separated by gel filtration on Sepharose 6B and subsequent chromatography on DE-52 cellulose from human homogenate. The enzymes differed from each other in substrate preference, Km-values, modifier characteristics and molecular weights. The evidence obtained confirms that also in the human testis acid phosphatases of multiple molecular forms are present. Some of these may be specific for the testicular tissue.

Testicular acid phosphatases in cattle, sheep, guinea pig, and rabbit.

Acid phosphatase activities were measured with five different substrates in the total homogenates as well as after gel filtration on Sepharose 6B and cellulose chromatography of bull, guinea pig, rabbit, and ram testes. The response of the hydrolysis rate to NaF (5 mmol/l), Co2+ (5 mmol/l) and Zn2+ (5 mmol/l) was also tested. In the total homogenate the hydrolysis of p-nitrophenyl phosphate was markedly activated by Co2+, while in the presence of Zn2+ an activation was recorded in guinea pig and some inhibition in the bull, rabbit, and ram testes. NaF caused a decline in the total acid phosphatase activity, particularly in guinea pig and ram. The gel filtration resulted in three separate activity peaks with p-NPP and beta-NP as substrates. N-ASBI-P, alpha-NP, and Tym-P gave only two peaks. After subsequent cellulose chromatography of the activities only peak II gave rise to two further activities. Peak I of gel filtration (enzyme I) was able to hydrolyze all substrates tested and was highly sensitive to NaF. Peak I of cellulose chromatography (enzyme II) also hydrolyzed p-NPP and beta-NP. It was rather resistant to NaF but sensitive to Zn2+. It was slightly activated by Co2+. Peak II of cellulose chromatography (enzyme IV) hydrolyzed only p-NPP and was markedly activated by Co2+ and Zn2+. The adult testes of bull, guinea pig, rabbit, and ram have a closely similar testicular acid phosphatase pattern. Due to relative differences in the concentrations of the four enzymes in the tissue, varying activity levels are recorded in the presence of different substrate and modifier combinations.

Acid phosphatases in the human testis after prolonged estrogen treatment.

The testes of 2 autopsied adult men and 6 subjects, suffering from prostatic carcinoma, were analysed for acid phosphatase activities, Two of the prostatic patients had been receiving estrogen treatment at least for a year and had completely regressed testes. Testes of other subjects contained well-defined tubules with different spermatogenic cells in abundance. The total acid phosphatase activity, assayed in the homogenate, showed a marked reduction in the testes of estrogen-treated subjects. Enzymes were separated by cellulose chromatography or by gel filtration combined with cellulose chromatography. Three activity peaks were resolved by the former and four by the latter technique, when homogenates of the control testes were used. In contrast, two to three strongly reduced activities could be discerned from the testes of estrogen-treated subjects. The specific activity of each enzyme after fractionation was compared between control and regressed testes. No difference was observed in the activities of enzyme I. Enzyme II was markedly reduced in the regressed testes, but was clearly present. Enzymes III and IV were either totally absent or showed a marked reduction in the regressed testes. It is suggested that a correlation exists between the destruction of germ cells, as a consequence of estrogen treatment, and the marked reduction in the activity of enzymes III and IV.

Testicular acid phosphatases of the mouse. Characterization after chromatographic fractionation.

The testicular homogenate of adult mice was eluted by DEAE-cellulose chromatography. Four peaks of acid phosphatase were identified. The pooled samples of each peak were used to determine substrate specificity, pH-optima, modifier characteristics, thermal stability, and Km-values. The results obtained suggest that each peak may represent a separate and distinct type of acid phosphatase. These observations are very similar to those previously obtained with the rat testis. The acid phosphatase activities in the mouse seem, however, to differ biochemically to some extent from those in the rat.