Complications of unintentional dural puncture during labour epidural analgesia: a 10-year retrospective observational study.

INTRODUCTION: Unintentional dural puncture (UDP) occurs in 0.5-1.5% of labour epidural analgesia cases. To date, little is known about evidence of UDP-related complications. This work aimed to assess the incidence of intrapartum and postpartum complications in parturients who experienced UDP. METHODS: This is a 10-year retrospective observational study on parturients admitted to our centre who presented UDP. Data collection gathered UDP-related complications during labour and postpartum. All women who displayed UDP received medical therapy and bed rest. An epidural blood patch (EBP) was not used in this population. Once asymptomatic, patients were discharged from the hospital. RESULTS: Out of 7718 neuraxial analgesia cases, 97 cases of UDP occurred (1.25%). During labour, complications appeared in a small percentage of analgesia procedures performed, including total spinal anaesthesia (1.0%), extended motor block (3%), hypotension (4.1%), abnormal foetal heart rate (2%), inadequate analgesia (14.4%), and general anaesthesia following neuraxial anaesthesia failure (33.3% of emergency caesarean sections). During the postpartum period, 53.6% of parturients exhibited a postdural puncture headache, 13.4% showed neurological symptoms, and 14.4% required neurological consultation and neuroimaging. No patient developed subdural hematoma or cerebral venous sinus thrombosis; one woman presented posterior reversible encephalopathy syndrome associated with eclampsia. Overall, 82.5% of women experienced an extension of hospital stay. CONCLUSION: Major complications occurred in a small percentage of patients during labour. However, since they represent high-risk maternal and neonatal health events, a dedicated anaesthesiologist and a trained obstetric team are essential. No major neurological complications were registered postpartum, and EBP was not performed. Nevertheless, all patients with UDP were carefully monitored and treated until complete recovery before discharge, leading to an extension of their hospitalization.

Management of posterior reversible syndrome in preeclamptic women.

Posterior reversible encephalopathy syndrome (PRES) is a neurological syndrome associated with a number of conditions including preeclampsia. It is characterized by seizures, alteration of consciousness, visual disturbances, and symmetric white matter abnormalities, typically in the posterior parietooccipital regions of the cerebral hemispheres, at computed tomography (CT) and magnetic resonance (MRI). We report three new cases of PRES in preeclamptic patients and describe the management of these patients. We present a brief review of other cases in the literature, with particular attention to the anesthetic management.

Evaluation of a computer-based intervention to enhance metabolic monitoring in psychiatry inpatients treated with second-generation antipsychotics.

WHAT IS KNOWN AND OBJECTIVE: Second-generation antipsychotics (SGAs) play an important role in the pharmacologic management of various psychiatric conditions. Use of these medications has been associated with metabolic complications. Adherence to guideline-recommended monitoring is suboptimal. We evaluated the effect of a computerized physician order entry (CPOE) pop-up alert designed to improve rates of laboratory metabolic monitoring of patients treated with SGAs on a University Hospital inpatient psychiatry unit. METHODS: A single-centre, retrospective chart review was performed in which patient demographics and SGA drug and laboratory data were extracted from the CPOE database. We assessed the number of orders for appropriate metabolic monitoring data for patients admitted within a 6-month period before or after the alert implementation. RESULTS AND DISCUSSION: Pre-alert (n = 171) and post-alert (n = 157) groups were similar with respect to age, length of stay, sex, race and comorbidities. Following alert implementation, significant increases in monitoring both random (92.4% vs. 100%) and fasting (46.8% vs. 70%) glucose levels as well as random (28.7% vs. 74.5%) and fasting (18.7% vs. 59.9%) lipid panels (all P ≤ 0.001) were observed. The number of patients with both a fasting glucose level and fasting lipid panel available for monitoring increased from 12.9% to 47.8% (P < 0.0001). Significantly more post-alert laboratory orders were submitted at the same time as the SGA drug order (P < 0.0001), suggesting that the alert itself had a direct influence on the ordering of metabolic monitoring labs. WHAT IS NEW AND CONCLUSIONS: Implementation and use of an electronic pop-up alert in an inpatient psychiatric unit significantly improved rates of ordering fasting blood glucose and lipid levels for inpatients treated with SGAs. Overall rates remain suboptimal, suggesting a need for additional strategies to further improve metabolic monitoring.

Duplex scanning of neck vessels: need for extending the consensus on indications.

We studied the percentage and distribution of appropriate indications for duplex scanning of neck vessels in an outpatient population. A total of 650 consecutive outpatients sent by their general practitioner (GP) or a specialist for duplex scanning of epi-aortic arterial vessels were studied. The aim was to verify the percentage of appropriate (APR) an inappropriate (INAPR) indications for the examination, according to the current literature. After analysis of indications as reported by GPs or specialists and a brief anamnestic examination, 77% of patients were found to have had one or more APR and 23% of patients had none. Analysis of severity of atheromasic lesions between the two groups showed that patients with APR had significantly ( p<0.001, chi-square test) more severe lesions than patients with INAPR. In more detail, no patient with INAPR had severe (>60%) stenosis while 6.4% of patients with APR had severe stenosis. Moreover, the percentage of normal examinations or intima-media thickness only was 32.5% in patients with INAPR but fell to 17.2% in patients with APR. In the entire group, women were more represented than men even after consideration of the natural prevalence of female gender in the local population. Among inappropriate indications for the examination, isolated dizziness or vertigo, syncope and tinnitus were the most frequent. Continuous medical education is needed to reduce inappropriate indications and thus to find solutions, although partial, to shorten the waiting lists that have become an urgent problem for the public health systems of several Western countries. However, this appears to be difficult challenge, as experiments conducted on this issue by other researchers only gave transient positive results.

Clinical correlative evaluation of an iterative method for reconstruction of brain SPECT images.

BACKGROUND: Brain SPECT and PET investigations have showed discrepancies in Alzheimer's disease (AD) when considering data deriving from deeply located structures, such as the mesial temporal lobe. These discrepancies could be due to a variety of factors, including substantial differences in gamma-cameras and underlying technology. Mesial temporal structures are deeply located within the brain and the commonly used Filtered Back-Projection (FBP) technique does not fully take into account either the physical parameters of gamma-cameras or geometry of collimators. In order to overcome these limitations, alternative reconstruction methods have been proposed, such as the iterative method of the Conjugate Gradients with modified matrix (CG). However, the clinical applications of these methods have so far been only anecdotal. The present study was planned to compare perfusional SPECT data as derived from the conventional FBP method and from the iterative CG method, which takes into account the geometrical and physical characteristics of the gamma-camera, by a correlative approach with neuropsychology. METHODS: Correlations were compared between perfusion of the hippocampal region, as achieved by both the FBP and the CG reconstruction methods, and a short-memory test (Selective Reminding Test, SRT), specifically addressing one of its function. A brain-dedicated camera (CERASPECT) was used for SPECT studies with 99mTc-hexamethylpropylene-amine-oxime in 23 consecutive patients (mean age: 74.2 +/- 6.5) with mild (Mini-Mental Status Examination score > or =15, mean 20.3 +/- 3), probable AD. Counts from a hippocampal region in each hemisphere were referred to the average thalamic counts. RESULTS: Hippocampal perfusion significantly correlated with the MMSE score with similar statistical significance (p < 0.01) between the two reconstruction methods. Correlation between hippocampal perfusion and the SRT score was better with the CG method (r = 0.50 for both hemispheres, p < 0.01) than with the FBP method (r = 0.37 and 0.43, respectively for the right and left hemisphere, p < 0.05 and p < 0.02). The bootstrap procedure showed that such correlation indexes were statistically different both in the right (p < 0.01) and in the left (p < 0.05) hemisphere. CONCLUSION: These results are interpreted as a better performance of the CG reconstruction method in correctly detecting counts from hippocampal ROI. By using the same gamma-camera or collimator, alternative methods for brain SPECT reconstruction may improve quality of data and then help SPECT diagnostic accuracy.

Aislamiento e identificación de hongos en alimentos procesados / Isolation and identification of fungi from processed foods

Se hizo un estudio micológico en alimentos procesados de consumo masivo (yogurt, mermelada, mortalidad y salchicha de pollo), aparentemente inalterados y dentro de su fecha de vencimiento, provenientes de diferentes supermercados de la ciudad de Maracaibo, Venezuela. Para el procesamiento de las muestras y el recuento de los hongos se usó la metodología indicada en las Normas COVENIN. Se aislaron las levaduras Cándida parapsilosis en los yogurt y C.diddensii en mermelada de una marca comercial. Los resultados obtenidos muestran un nivel de contaminación relativamente bajo (4.3 por ciento) en los alimentos analizados. El mayor aislamiento de levaduras se observó en el medio Rosa de Bengala Cloramfenicol Agar en comparación con el medio Extracto de Malta Agar, recomendado por las Normas

Receptor-coupled phosphoinositide hydrolysis in human retinal pigment epithelium.

Carbachol and histamine stimulated phosphoinositide (PPI) hydrolysis in cultured human retinal pigment epithelium (RPE), as reflected by an accumulation of 3H-inositol phosphates in the presence of 10 mM Li+. Carbachol increased PPI hydrolysis to greater than 600% of basal with an EC50 of 60 microM; stimulation was linear up to 60 min. This activation likely occurred via the M3 muscarinic cholinergic receptor based on the IC50 values for 4-diphenylacetoxy-N-methylpiperidine methiodide (0.47 nM), pirenzepine (280 nM), and 11-[[2-[(diethylamino)methyl]-1-piperidinyl]-acetyl]-5,11- dihydro-6H-pyrido[2,3-b][1,4]benzodiazepin-6-one (1.4 microM). Carbachol-mediated PPI hydrolysis was decreased by 80% in the absence of extracellular Ca2+. Histamine stimulated PPI turnover in a linear manner by 180% with an EC50 of 20 microM by the H1 histaminergic receptor. Serotonin, glutamate, norepinephrine, and dopamine were inactive. In human RPE, the resting cytoplasmic Ca2+ concentration, as determined by fura-2 fluorescence, was 138 +/- 24 nM. On the addition of carbachol, there was a 180% increase in peak intracellular Ca2+; addition of histamine increased intracellular Ca2+ by 187%. These results suggest receptor-mediated, inositol lipid hydrolysis is coupled to intracellular Ca2+ flux in human RPE.

Use of non-verbal construing and metaphor in psychotherapy.

This article begins by looking at the way we try to construe or make sense of the world in which we live. How in the very nature of such sense-making there is the potential for sowing the seeds of self-deception by trying to fit our (relatively simplified) bipolar constructs to a complex unitary universe. Non-verbal and verbal construing are compared. Verbal construing enables us to reach an even more sophisticated level of self-deception, via myths created by limiting metaphors--such as "man-the-machine." The institutions which we create and the people who are invested in them tend to solidify in-group myths, often with the help of metaphor. It is argued that personal, constructivist, and eclectic approaches to psychotherapy can be envisaged as enterprises to begin the process of demythologising clients in the safety of the therapeutic setting. In therapy, clients can experiment with empowering themselves in reconstruing the problem areas of their lives and actively testing out these new constructions against personal experience. Clients can also learn to explore the meaning behind symptoms, i.e., to give cognitive form to feeling with the help of their intuitive sensitivity.

Repression and somatization: a case history of hemodynamic activation.

A 52-year-old woman presented to the office about 2 and 1/2 years after the death of her husband from cancer. She had multiple hemodynamic and cardiovascular disorders such as hypertension, angina, tachycardia, dysmenorrhea, cardiac ectopics, and very cold hands and feet. The patient complained of tension and insomnia but refused to take any medications because of allergic responses to them. Hence, a relaxation and psychotherapeutic approach was adopted. Psychometric testing revealed extreme defensiveness (including repression). The patient had never mourned for her husband. Therapy helped her overcome her bereavement, tension, and insomnia. In addition, many of her physical manifestations subsided considerably during therapy.

Meditation, the unconscious, and psychosomatic disorders.

In this article, two basic meditation techniques are described--namely, concentration and mindfulness. The relationship between mindfulness and health is discussed in the context of findings linking repression to physical disorders. Parallels between meditation and psychoanalysis as methods for uncovering the unconscious, using both Freudian and Kellian constructs, are described. It is concluded that meditation, like free association, can be used to facilitate the emergence of unconscious (sub-verbal) material and allow for its integration at a higher (more cognitive) level of awareness.

Personality correlates of meditation practice frequency and dropout in an outpatient population.

A prospective study was conducted to determine personality trait correlates of regularity of meditation practice and dropout over a 2-year follow-up period in outpatients referred for relaxation therapy. Patients were supervised on a monthly basis and classified as regular vs. irregular practitioners or dropouts at 3, 6, 12, and 24 months after they began meditating on a daily basis. Short-term (3-month) compliance was related to low levels of pretest sensitization, introversion, suggestibility, and neuroticism. Long-term (6- to 24-month) compliance was related only to repression and extraversion. By the end of 2 years, roughly half (54%) of the patients had terminated meditation altogether.

Constructivist view of meditation.

Meditation experiences are viewed from a constructivist perspective. Concentrative and mindfulness approaches are compared. It is concluded that, although these meditative techniques differ (and often are used in conjunction), they both yield insight into how the mind processes experience at both the preverbal and verbal levels.

Comparative study of the effects of optic design on lens epithelium in vitro.

We performed two tissue culture experiments designed to compare the effects of various posterior chamber optics on lens epithelium. In the first experiment, we recorded, by phase contrast microphotography, the migration of rabbit lens epithelium exoplants placed adjacent to the optic of various posterior chamber lenses. In the second experiment, we used phase contrast microphotographs to document the effects of various posterior chamber optics when gently placed on a confluent layer of rabbit lens epithelium. From our in vitro studies, we conclude the following: There is inhibition of lens epithelial migration and even cytotoxic effects from direct contact with polymethylmethacrylate optics; glass optics have appreciably less effect on lens epithelium; polymethylmethacrylate optics with ridges (complete annulus or incomplete) do not inhibit lens epithelial migration as well as planoconvex lenses, and they do not have a cytotoxic effect except at the points of contact between the ridge and the supporting surface.

Lens epithelial inhibition by PMMA optic: implications for lens design.

It has been a clinical impression that posterior chamber lens implants in some way inhibit opacification of the posterior lens capsule after extracapsular cataract extraction. The mechanism of this inhibition is unclear; it may be related to mechanical contact or blockage of migration of lens epithelial cells, or possibly to the leeching of toxic factors from the lens itself. A better understanding of the exact mechanism of opacification inhibition may have important clinical implications for intraocular lens design. For example, some lens designs that facilitate Nd:YAG capsulotomy by physically separating the posterior chamber lens and the posterior capsule may result in less inhibition and in fact more opacification of posterior capsules. We performed in vitro tissue culture studies of the effect of the polymethylmethacrylate (PMMA) optic of a planoconvex intraocular lens on cultured rabbit lens epithelium. These studies demonstrated both inhibition of lens epithelial migration beneath the PMMA optic (plano side down) as well as metaplasia and necrosis of lens cells growing directly beneath the optic. The clinical implications of these studies for intraocular lens design are discussed.

Effects of expectancy on physiological responsivity in novice meditators.

Forty non-meditators were randomly assigned to 4 experimental cells devised to control for order and expectation effects. The subjects (all female) were continuously monitored on 7 physiological measures during both meditation and rest. Each subject was her own control in an 'abab' experimental paradigm comparing meditation to rest. The subjects, meditating for the first time, showed marginally lower psychophysiological arousal during the meditation than rest condition for systolic blood pressure, heart rate, skin conductance level and digital skin temperature. Deliberately fostering positive expectations of meditation was associated with lower physiological arousal in terms of diastolic and systolic blood pressure, heart rate and skin conductance level.

Biochemical indices associated with meditation practice: a literature review.

Research findings on biochemical responsivity to meditation are reviewed. Although there are some contradictory and inconclusive outcomes, there is nevertheless sufficient evidence of interest to warrant further investigation of this area. However, in the meantime, there is no compelling basis to conclude that meditation practice is associated with special state or trait effects at the biochemical level.