Effect of Foot Reflexology on Reduction of Labour Pain Among Primigravida Mothers.

BACKGROUND: Reflexology may help induce labour and reduce pain during childbirth. Fear of pain associated with childbirth leads to increase in the irregular use of cesarean method. PURPOSE: This study was performed to evaluate the effect of reflexology on relieving labour pain and assess the recipient's opinion regarding foot reflexology. SETTING: The study taken place in the labour room, Amrita Institute of Medical Sciences, Kerala, South India. PARTICIPANTS: 50 primigravida patients experiencing labour. RESEARCH DESIGN: A quasi-experimental study design was used. Subjects were selected by convenience sampling technique with the first 25 patients allocated to the experimental group and the successive 25 primigravida mothers to a time-control group, to avoid data contamination. INTERVENTION: Intervention consisted of foot reflexology applied by a trained therapist to five pressure points of both feet that correspond to the uterus. Total intervention time lasted 20 minutes. Control group rested quietly for 20 minutes to serve as a time control. MAIN OUTCOME MEASURES: Pain associated with labour was recorded on a visual analogue scale immediately prior to intervention, and at 20- and 40-minutes postintervention. Patient satisfaction with reflexology treatment was recorded. RESULTS: Mean baseline pain score in foot reflexology group was significantly reduced across the study timeframe relative to control group (p < .001). Post hoc tests confirmed a reduction in labour pain at both the 20-min (p < .001, 95%CI 0.764-1.796) and 40-min (p < .001, 95%CI 0.643-1.677) time points. Eighty-one per cent of patients would recommend reflexology during labour. CONCLUSION: The findings showed that foot reflexology was effective in relief of labour pain, with a high degree of patient satisfaction in primigravida mothers.

Clinical effectiveness of a sedation protocol minimizing benzodiazepine infusions and favoring early dexmedetomidine: a before-after study.

INTRODUCTION: Randomized controlled trials suggest clinical outcomes may be improved with dexmedetomidine as compared with benzodiazepines; however, further study and validation are needed. The objective of this study was to determine the clinical effectiveness of a sedation protocol minimizing benzodiazepine use in favor of early dexmedetomidine. METHODS: We conducted a before-after study including adult surgical and medical intensive care unit (ICU) patients requiring mechanical ventilation and continuous sedation for at least 24 hours. The before phase included consecutive patients admitted between 1 April 2011 and 31 August 31 2011. Subsequently, the protocol was modified to minimize use of benzodiazepines in favor of early dexmedetomidine through a multidisciplinary approach, and staff education was provided. The after phase included consecutive eligible patients between 1 May 2012 and 31 October 2012. RESULTS: A total of 199 patients were included, with 97 patients in the before phase and 102 in the after phase. Baseline characteristics were well balanced between groups. Use of midazolam as initial sedation (58% versus 27%, P <0.0001) or at any point during the ICU stay (76% versus 48%, P <0.0001) was significantly reduced in the after phase. Dexmedetomidine use as initial sedation (2% versus 39%, P <0.0001) or at any point during the ICU stay (39% versus 82%, P <0.0001) significantly increased. Both the prevalence (81% versus 93%, P =0.013) and median percentage of days with delirium (55% (interquartile range (IQR), 18 to 83) versus 71% (IQR, 45 to 100), P =0.001) were increased in the after phase. The median duration of mechanical ventilation was significantly reduced in the after phase (110 (IQR, 59 to 192) hours versus 74.5 (IQR, 42 to 148) hours, P =0.029), and significantly fewer patients required tracheostomy (20% versus 9%, P =0.040). The median ICU length of stay was 8 (IQR, 4 to 12) days in the before phase and 6 (IQR, 3 to 11) days in the after phase (P =0.252). CONCLUSIONS: Implementing a sedation protocol that targeted light sedation and reduced benzodiazepine use led to significant improvements in the duration of mechanical ventilation and the requirement for tracheostomy, despite increases in the prevalence and duration of ICU delirium.

Separating fact from factitious hemoptysis: a case report.

A 61-year-old man with a history of testicular carcinoma and more recently diagnosed metastatic renal cell carcinoma was admitted because of recurrent submassive hemoptysis as evidenced by bright red blood in his bedside basin. Despite an exhaustive workup, including multiple invasive procedures, no cause of the bleeding was found. The diagnosis was Münchausen syndrome manifested as factitious hemoptysis via unusual and modern means. The case is a reminder to all members of the critical care team, from nurses to physicians: When dealing with the frustration of a recurrent problem with no clear answer, remain vigilant and remember the age-old advice to look at the patient… and trust your gut.

IL-4 suppresses the responses to TLR7 and TLR9 stimulation and increases the permissiveness to retroviral infection of murine conventional dendritic cells.

Th2-inducing pathological conditions such as parasitic diseases increase susceptibility to viral infections through yet unclear mechanisms. We have previously reported that IL-4, a pivotal Th2 cytokine, suppresses the response of murine bone-marrow-derived conventional dendritic cells (cDCs) and splenic DCs to Type I interferons (IFNs). Here, we analyzed cDC responses to TLR7 and TLR9 ligands, R848 and CpGs, respectively. We found that IL-4 suppressed the gene expression of IFNß and IFN-responsive genes (IRGs) upon TLR7 and TLR9 stimulation. IL-4 also inhibited IFN-dependent MHC Class I expression and amplification of IFN signaling pathways triggered upon TLR stimulation, as indicated by the suppression of IRF7 and STAT2. Moreover, IL-4 suppressed TLR7- and TLR9-induced cDC production of pro-inflammatory cytokines such as TNFα, IL-12p70 and IL-6 by inhibiting IFN-dependent and NFκB-dependent responses. IL-4 similarly suppressed TLR responses in splenic DCs. IL-4 inhibition of IRGs and pro-inflammatory cytokine production upon TLR7 and TLR9 stimulation was STAT6-dependent, since DCs from STAT6-KO mice were resistant to the IL-4 suppression. Analysis of SOCS molecules (SOCS1, -2 and -3) showed that IL-4 induces SOCS1 and SOCS2 in a STAT6 dependent manner and suggest that IL-4 suppression could be mediated by SOCS molecules, in particular SOCS2. IL-4 also decreased the IFN response and increased permissiveness to viral infection of cDCs exposed to a HIV-based lentivirus. Our results indicate that IL-4 modulates and counteracts pro-inflammatory stimulation induced by TLR7 and TLR9 and it may negatively affect responses against viruses and intracellular parasites.

Significance of GATA-3 expression in outcomes of patients with breast cancer who received systemic chemotherapy and/or hormonal therapy and clinicopathologic features of GATA-3-positive tumors.

GATA-3 and estrogen receptor (ER) are involved in a positive cross-regulatory loop and are frequently coexpressed in breast cancers. GATA-3 expression was shown to be an independent predictor of overall and disease-free survival in some studies, whereas others showed no difference. However, the studies used different cutoff values for determining GATA-3 positivity and analyzed outcomes in patients who received systemic therapy together with those who did not. We investigated GATA-3 expression and correlated clinicopathologic findings and outcomes in 516 women who received systemic chemotherapy and/or hormonal therapy. Nuclear staining of 1% or greater was considered positive for GATA-3, ER and progesterone receptor (PR). Of 516 cases, 436 (84.5%) were GATA-3+. GATA-3+ tumors were more likely to be grade 1 or 2, ER+, PR+, non-triple-negative phenotypes (all P < .0001), and higher stage (P = .01). ER-/GATA-3+ tumors, compared with ER-/GATA-3- tumors, had worse breast cancer survival (BCS) (P = .02) and a trend for worse overall survival (OS) (P = .05) in univariate analysis. However, there was no difference in OS and BCS between patients who received chemotherapy and/or hormonal therapy among GATA-3-positive and GATA-3-negative groups. GATA-3+ tumors are correlated with lower grade, ER+, PR+, and non-triple-negative phenotypes. Although there was no difference in OS and BCS between GATA-3-positive and GATA-3-negative groups, there was an adverse effect of GATA-3 expression in the ER-negative subgroup of patients who received systemic therapy.

Correlation between HER2 determined by fluorescence in situ hybridization and reverse transcription-polymerase chain reaction of the oncotype DX test.

The human epidermal growth factor receptor 2 (HER2) gene is amplified and its protein product overexpressed in about 20% of invasive breast cancers. Despite more than a decade of efforts to standardize HER2 testing, controversy persists regarding the most optimal testing method. Recently, Oncotype DX reports have begun including HER2 results in addition to the previously reported Recurrence Score. We compared HER2 results obtained by fluorescence in situ hybridization (FISH) in our laboratories with HER2 results obtained by reverse transcription-polymerase chain reaction (RT-PCR) as documented in the Oncotype DX report. We then sought to identify potentially significant characteristics in the discrepant cases. We identified breast cancer patients with estrogen receptor-positive, lymph node-negative tumors who had Oncotype DX testing performed between September 2008 and March 2012. Patient and tumor characteristics including HER2 FISH and Oncotype DX test results were recorded. Image analysis was performed on cases with discrepancy between the HER2 FISH and Oncotype DX HER2 results to determine the relative proportion of invasive tumor. Eight of 194 (4.1%) cases showed discrepancy between HER2 FISH and Oncotype DX RT-PCR results. Although the overall percent agreement (96%) and percent negative agreement (100%) were high, percent positive agreement was only 50%. Three of 8 (38%) discrepant cases showed heterogeneous amplification by FISH. Seven of 8 (88%) discrepant cases had <50% invasive tumor in the Oncotype DX tissue block. Percent positive agreement between HER2 FISH and Oncotype DX RT-PCR is low. Multiple factors may contribute to this discrepancy including a suboptimal microdissection and possibly heterogeneous amplification of HER2 gene in some cases.

Myeloid dendritic cells from B6.NZM Sle1/Sle2/Sle3 lupus-prone mice express an IFN signature that precedes disease onset.

Patients with systemic lupus erythematosus show an overexpression of type I IFN-responsive genes that is referred to as "IFN signature." We found that B6.NZMSle1/Sle2/Sle3 (Sle1,2,3) lupus-prone mice also express an IFN signature compared with non-autoimmune C57BL/6 mice. In vitro, myeloid dendritic cells (mDCs) (GM-CSF bone marrow-derived dendritic cells; BMDCs) from Sle1,2,3 mice constitutively overexpressed IFN-responsive genes such as IFN-ß, Oas-3, Mx-1, ISG-15, and CXCL10 and members of the IFN signaling pathway STAT1, STAT2, and IRF7. The IFN signature was similar in Sle1,2,3 BMDCs from young, pre-autoimmune mice and from mice with high titers of autoantibodies, suggesting that the IFN signature in mDCs precedes disease onset and is independent from the autoantibodies. Sle1,2,3 BMDCs hyperresponded to stimulation with IFN-α and the TLR7 and TLR9 agonists R848 and CpGs. We propose that this hyperresponse is induced by the IFN signature and only partially contributes to the signature, as oligonucleotides inhibitory for TLR7 and TLR9 only partially suppressed the constitutive IFN signature, and pre-exposure to IFN-α induced the same hyperresponse in wild-type BMDCs as in Sle1,2,3 BMDCs. In vivo, mDCs and to a lesser extent T and B cells from young prediseased Sle1,2,3 mice also expressed the IFN signature, although they lacked the strength that BMDCs showed in vitro. Sle1,2,3 plasmacytoid DCs expressed the IFN signature in vitro but not in vivo, suggesting that mDCs may be more relevant before disease onset. We propose that Sle1,2,3 mice are useful tools to study the role of the IFN signature in lupus pathogenesis.

Concordance between tissue microarray and whole-section estrogen receptor expression and intratumoral heterogeneity.

Hormone receptor status determination for breast cancer is an important part of pathologists' daily sign outs and many retrospective and prospective studies. In this study, we compared the estrogen receptor (ER) expression tested on tissue microarray (TMA) sections to those tested on whole sections (WS) to find out concordance and frequency of intratumoral heterogeneity. Five and one-half percent of all tumors showed discrepancy in ER expression between TMA and WS. The rate of discrepancy was lower with increasing number of cores from individual cases. In 1.4% of cases, there was discrepancy in ER expression between cores in which >1 core was available on TMA section. We concluded that TMA can be used to determine ER status with good concordance to ER determination done on WS. Whenever the size of the tumor in the block allows it, more cores should be taken to construct TMAs.

The Rho pathway mediates transition to an alveolar type I cell phenotype during static stretch of alveolar type II cells.

Stretch is an essential mechanism for lung growth and development. Animal models in which fetal lungs have been chronically over or underdistended demonstrate a disrupted mix of type II and type I cells, with static overdistention typically promoting a type I cell phenotype. The Rho GTPase family, key regulators of cytoskeletal signaling, are known to mediate cellular differentiation in response to stretch in other organs. Using a well-described model of alveolar epithelial cell differentiation and a validated stretch device, we investigated the effects of supraphysiologic stretch on human fetal lung alveolar epithelial cell phenotype. Static stretch applied to epithelial cells suppressed type II cell markers (SP-B and Pepsinogen C, PGC), and induced type I cell markers (Caveolin-1, Claudin 7 and Plasminogen Activator Inhibitor-1, PAI-1) as predicted. Static stretch was also associated with Rho A activation. Furthermore, the Rho kinase inhibitor Y27632 decreased Rho A activation and blunted the stretch-induced changes in alveolar epithelial cell marker expression. Together these data provide further evidence that mechanical stimulation of the cytoskeleton and Rho activation are key upstream events in mechanotransduction-associated alveolar epithelial cell differentiation.

Diagnosis of metastatic pancreatic mesenchymal tumors by endoscopic ultrasound-guided fine-needle aspiration.

Involvement of the pancreas by metastatic sarcoma is rare, and can prove challenging to differentiate from sarcomatoid carcinomas which occur more commonly. The endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) technique has been successfully used for the diagnosis of pancreatic carcinomas whether primary or metastatic, and is now considered the most effective noninvasive method for the identification of pancreatic metastases. However, to date very few reports detail the diagnosis of mesenchymal neoplasms by EUS-FNA. Herein, we report a series of four patients who underwent EUS-FNA of the pancreas, where the diagnosis of metastatic sarcoma was made based on morphology and ancillary studies. The cases include metastases of leiomyosarcoma, liposarcoma, alveolar rhabdomyosarcoma, and solitary fibrous tumor. The history of a primary sarcoma of the chest wall, mediastinum, and respectively lower extremity was known for the first three of these patients while in the case of the solitary fibrous tumor a remote history of a paraspinal "hemangiopericytoma" was only elicited after the EUS-FNA diagnosis was made. We conclude that EUS-FNA is efficient and accurate in providing a diagnosis of sarcoma, even in patients without a known primary sarcoma, thus allowing institution of therapy without additional biopsies.

In vitro transdifferentiation of human fetal type II cells toward a type I-like cell.

For alveolar type I cells, phenotype plasticity and physiology other than gas exchange await further clarification due to in vitro study difficulties in isolating and maintaining type I cells in primary culture. Using an established in vitro model of human fetal type II cells, in which the type II phenotype is induced and maintained by adding hormones, we assessed for transdifferentiation in culture toward a type I-like cell with hormone removal for up to 144 h, followed by electron microscopy, permeability studies, and RNA and protein analysis. Hormone withdrawal resulted in diminished type II cell characteristics, including decreased microvilli, lamellar bodies, and type II cell marker RNA and protein. There was a simultaneous increase in type I characteristics, including increased epithelial cell barrier function indicative of a tight monolayer and increased type I cell marker RNA and protein. Our results indicate that hormone removal from cultured human fetal type II cells results in transdifferentiation toward a type I-like cell. This model will be useful for continued in vitro studies of human fetal alveolar epithelial cell differentiation and phenotype plasticity.

Primitive neuroectodermal tumor of the uterus: a case report and review of literature.

A case of primitive neuroectodermal tumor arising in the uterine corpus of a 43-year-old woman is presented. The tumor mass was 13.3 cm and extended to the uterine serosa, endocervical stroma, and left adnexa. Histologically, the tumor was composed of small blue cells with scant cytoplasm, indistinct cell borders, hyperchromatic round nuclei, and inconspicuous nucleoli focally forming pseudorosettes, suggestive of neuroectodermal origin. The tumor cells displayed strong immunoreactivity for CD99 and FLI1. Cytogenetic fluorescence in situ hybridization study revealed presence of an EWS-FLI1 fusion gene. To the best of our knowledge, this is the first case of primitive neuroectodermal tumor of the uterus with diagnosis confirmed by FLI1 immunohistochemical labeling and demonstration of t (11; 22) by fluorescence in situ hybridization.

Esophageal carcinoma with a rhabdoid phenotype: a case report of diagnosis by endoscopic ultrasound-guided fine-needle aspiration.

Malignant extra renal tumors with rhabdoid phenotype are aggressive neoplasms associated with a poor prognosis. These tumors have been reported in soft tissue and various organs including the gastrointestinal tract. We report one of such tumors arising in the esophagus and discuss the cytopathologic, immunohistochemical, and ultrastructural features. Endoscopic ultrasound-guided fine-needle aspiration (FNA) cytology revealed a highly cellular tumor, consisting of polygonal poorly cohesive cells with prominent eosinophilic paranuclear cytoplasmic inclusions. Immunohistochemical staining showed strong cytoplasmic positivity for vimentin and cytokeratin. Electron microscopy revealed presence of numerous intermediate filaments. To the best of our knowledge, this is the first example of carcinoma with rhabdoid phenotype of the esophagus diagnosed by FNA cytology.

A case report of anthracosilicotic spindle-cell pseudotumor of mediastinal lymph node: cytologic diagnosis by endoscopic ultrasound-guided fine-needle aspiration.

Pigmented spindle-cell tumors of the lymph nodes have a broad differential diagnosis, including both benign and malignant neoplasms. Here, we report a case of a pigmented spindle-cell lesion in a mediastinal lymph node mimicking a spindle-cell melanoma on fine-needle aspiration cytology. Smears showed atypical polygonal and spindle cells with bland nuclear features and abundant cytoplasmic anthracotic pigment. Immunohistochemistry was negative for melanoma markers, but showed positivity for histiocyte markers. Polarization microscopy revealed minute birefringent intracellular crystals consistent with silica. Electron microscopy was confirmatory and a diagnosis of anthracosilicotic spindle-cell pseudotumor was made. To the best of our knowledge, fine-needle aspiration cytology findings of this lesion have not been reported.

Lymphocytic colitis treated with proctocolectomy and ileal J-pouch-anal anastomosis: report of a case.

PURPOSE: We present a case of severe diarrhea caused by lymphocytic colitis and concurrent celiac sprue in a patient who did not respond to maximal medical therapy and required surgery. METHODS: The patient was initially treated with fecal diversion via an end ileostomy. Six months later, she underwent colectomy and one-stage ileal J-pouch-anal anastomosis. RESULTS: Notably, the characteristic microscopic changes of lymphocytic colitis were still present at the time of colectomy despite diversion. CONCLUSION: Colectomy with continent reconstruction is an option for treatment of patients with lymphocytic colitis refractory to medical therapy.