Magnesium Sulphate for Fetal Neuroprotection Magee, Laura, MD; Sawchuck, Diane, RN, PhD; Synnes, Anne, MD ...
Journal of obstetrics and gynaecology Canada,
05/2011, Letnik:
33, Številka:
5
Journal Article
Recenzirano
Abstract Objective To provide guidelines for the use of antenatal magnesium sulphate (MgSO4 ) for fetal neuroprotection of the preterm infant. Options Antenatal MgSO4 administration should be ...considered for fetal neuroprotection when women present at ≤ 31+6 weeks with imminent preterm birth, defined as a high likelihood of birth because of active labour with cervical dilatation ≥ 4 cm, with or without preterm pre-labour rupture of membranes, and/or planned preterm birth for fetal or maternal indications. There are no other known fetal neuroprotective agents. Outcomes The outcomes measured are the incidence of cerebral palsy (CP) and neonatal death. Evidence Published literature was retrieved through searches of PubMed or Medline, CINAHL, and the Cochrane Library in May 2010, using appropriate controlled vocabulary and key words (magnesium sulphate, cerebral palsy, preterm birth). Results were restricted to systematic reviews, randomized controlled trials, and relevant observational studies. There were no date or language restrictions. Searches were updated on a regular basis and incorporated in the guideline to August 2010. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology assessment-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies. Values The quality of evidence was rated using the criteria described in the Report of the Canadian Task Force on Preventive Health Care (Table 1). Benefits, harms, and costs: Antenatal magnesium sulphate for fetal neuroprotection reduces the risk of “death or CP” (RR 0.85; 95% CI 0.74 to 0.98; 4 trials, 4446 infants), “death or moderatesevere CP” (RR 0.85; 95% CI 0.73 to 0.99; 3 trials, 4250 infants), “any CP” (RR 0.71; 95% CI 0.55 to 0.91; 4, trials, 4446 infants), “moderate-to-severe CP” (RR 0.60; 95% CI 0.43 to 0.84; 3 trials, 4250 infants), and “substantial gross motor dysfunction” (inability to walk without assistance) (RR 0.60; 95% CI 0.43 to 0.83; 3 trials, 4287 women) at 2 years of age. Results were consistent between trials and across the meta-analyses. There is no anticipated significant increase in health care-related costs, because women eligible to receive antenatal MgSO4 will be judged to have imminent preterm birth. Validation Australian National Clinical Practice Guidelines were published in March 2010 by the Antenatal Magnesium Sulphate for Neuroprotection Guideline Development Panel. Antenatal MgSO4 was recommended for fetal neuroprotection in the same dosage as recommended in these guidelines. However, MgSO4 was recommended only at < 30 weeks’ gestation, based on 2 considerations. First, no one gestational age subgroup was considered to show a clear benefit. Second, in the face of uncertainty, the committee felt it was prudent to limit the impact of their clinical practice guidelines on resource allocation. Also in March 2010, the American College of Obstetricians and Gynecologists issued a Committee Opinion on MgSO4 for fetal neuroprotection. It stated that, “the available evidence suggests that magnesium sulphate given before anticipated early preterm birth reduces the risk of cerebral palsy in surviving infants.” No official opinion was given on a gestational age cut-off, but it was recommended that physicians develop specific guidelines around the issues of inclusion criteria, dosage, concurrent tocolysis, and monitoring in accordance with one of the larger trials. Sponsors Canadian Institutes of Health Research (CIHR).
Arrhythmogenic right ventricular cardiomyopathy/dysplasia (ARVC/D) is a genetic disease predominantly caused by desmosomal gene mutations that account for only ~50% of cases. Ryanodine receptor 2 ...(RYR2) gene mutations usually cause catecholaminergic polymorphic ventricular tachycardia but have been associated with a peculiar phenotype named ARVC2.
We aimed to determine the prevalence and phenotype associated with RYR2 mutations in a large ARVC/D population.
We analyzed the whole RYR2 coding sequence by Sanger sequencing in 64 ARVC/D probands without desmosomal gene mutations.
We have identified 6 rare missense variants: p.P1583S, p.A2213S, p.G2367R, p.Y2932H, p.V3219M, and p.L4670V. It corresponds to a 9% prevalence of rare RYR2 variants in the ARVC/D population (6 of 64 probands), which is significantly higher than the estimated frequency of rare RYR2 variants in controls (Fisher exact test, P = .03). Phenotypes associated with RYR2 variants were similar to desmosome-related ARVC/D, associating typical electrocardiographic abnormalities at rest, frequent monomorphic ventricular tachycardia, right ventricular dilatation, wall motion abnormalities, and fibrofatty replacement when histopathological examination was available.
In this first systematic screening of the whole coding region of the RYR2 gene in a large ARVC/D cohort without mutation in desmosomal genes, we show that putative RYR2 mutations are frequent (9% of ARVC/D probands) and are associated with a conventional phenotype of ARVC/D, which is in contrast with previous findings. The results support the role of the RYR2 gene in conventional ARVC/D.
To compare visual acuity, refraction, endothelial cell density (ECD), and complications after Descemet stripping automated endothelial keratoplasty (DSAEK) and ultrathin DSAEK (UT-DSAEK).
A ...multicenter, prospective, double-masked, randomized, controlled clinical trial.
From 66 patients with irreversible corneal endothelial dysfunction dues to Fuchs' dystrophy who enrolled from 4 tertiary medical centers in the Netherlands, 66 eyes were studied.
Participants were centrally randomized to undergo either UT-DSAEK or DSAEK, based on preoperative best spectacle-corrected visual acuity (BSCVA), recipient central corneal thickness, patient age, and recruitment center. Donor corneas were precut by a single cornea bank.
Participants underwent ophthalmic examinations preoperatively and 3, 6, and 12 months after the operation, including manifest refraction, BSCVA using an Early Treatment Diabetic Retinopathy Study chart, and endothelium imaging.
BSCVA 12 months postoperatively.
Preoperative BSCVA did not differ between patients undergoing DSAEK (0.35 logarithm of the minimum angle of resolution logMAR 95% confidence interval {CI} 0.27-0.43; n = 32) and UT-DSAEK (0.37 logMAR 95% CI 0.31-0.43; n = 34; P = 0.8). BSCVA was significantly better after UT-DSAEK compared with that after DSAEK at 3 months (0.17 logMAR 95% CI 0.13-0.21, n = 31 vs. 0.28 logMAR 95% CI 0.23-0.33, n = 31; P = 0.001), 6 months (0.14 logMAR 95% CI 0.10-0.18, n = 30 vs. 0.24 logMAR 95% CI 0.20-0.28, n = 30; P = 0.002), and 12 months (0.13 logMAR 95% CI 0.09-0.17, n = 33 vs. 0.20 logMAR 95% CI 0.15-0.25, n = 29; P = 0.03). Refraction, ECD loss (40% at 3 months; P < 0.001), donor loss (DSAEK n = 2 vs. UT-DSAEK n = 3 relative risk {RR} 1.4 {95% CI 0.24-7.5}; P = 0.7), and graft dislocation (DSAEK n = 5 vs. UT-DSAEK n = 5 RR 1.0 {95% CI 0.34-3.33}; P = 0.9) did not differ between UT-DSAEK and DSAEK. Donor thickness was significantly thinner for UT-DSAEK (101 μm 95% CI 93-110 μm; range 50-145 μm) than for DSAEK (209 μm 95% CI 196-222 μm; range 147-289 μm; P < 0.001).
This study indicates that compared with DSAEK, UT-DSAEK results in faster and better recovery of BSCVA with similar refractive outcomes, endothelial cell loss, and incidence of complications.
Despite achieving targets for low-density lipoprotein (LDL) cholesterol, blood pressure, and glycemia in accordance with current standards of care, patients with dyslipidemia remain at high residual ...risk of vascular events. Atherogenic dyslipidemia, characterized by elevated triglycerides and low levels of high-density lipoprotein (HDL) cholesterol, often with elevated apolipoprotein B and non-HDL cholesterol, is common in patients with established cardiovascular disease (CVD), type 2 diabetes mellitus, or metabolic syndrome and contributes to both macrovascular and microvascular residual risk. However, atherogenic dyslipidemia is largely underdiagnosed and undertreated in clinical practice. The Residual Risk Reduction Initiative (R3 i) was established to address this highly relevant clinical issue. The aims of this position paper are (1) to highlight evidence that atherogenic dyslipidemia is associated with residual macrovascular and microvascular risk in patients at high risk for CVD, despite current standards of care for dyslipidemia and diabetes; and (2) to recommend therapeutic intervention for reducing this residual vascular risk supported by evidence and expert consensus. Lifestyle modification with nutrition and exercise is an important, effective, and underutilized first step in reducing residual vascular risk. Therapeutic intervention aimed at achievement of all lipid targets is also often required. Combination lipid-modifying therapy, with the addition of niacin, a fibrate, or omega-3 fatty acids to statin therapy, increases the probability of achieving all lipid goals. Outcomes studies are in progress to evaluate whether these combination treatment strategies translate to a clinical benefit greater than that achieved with statins alone. The R3 i highlights the need to address with lifestyle and/or pharmacotherapy the high level of residual risk of CVD events and microvascular complications among patients with dyslipidemia receiving therapy for high levels of LDL cholesterol and for diabetes in accordance with current standards of care.
Abstract Context HIV infection has become a manageable chronic disease. There are few studies of pain and symptoms in the current treatment era. Objectives Our primary objective was to determine the ...prevalence of and risk factors for pain and physical and psychological symptoms in a population of ambulatory HIV patients. Methods We performed a cross-sectional study using the Brief Pain Inventory and the Memorial Symptom Assessment Scale-Short Form (MSAS). Results We evaluated 156 individuals with a median age of 47.5 years (range 21–71), median time since HIV diagnosis of 11 years (range <1 to 25), and median CD4+ cell count of 502 cells/mm3 (interquartile range IQR 308–683). Most (125, 80.6%) of the patients had an undetectable viral load. Seventy-six (48.7%) patients reported pain, of whom 39 (51.3%) had moderate to severe pain, and 43 (57.3%) had pain that caused moderate to severe interference with their lives. The median number of symptoms was eight (IQR 5–14.5) of 32 queried. In multivariable analyses, patients with psychiatric illness were 39.8% more likely to have pain ( P < 0.001). Psychiatric illness was associated with 0.7 and 1.2 point higher MSAS subscale scores, and IV drug use was associated with 0.4 and 0.5 higher subscale scores (out of four). Conclusion Pain and other physical and psychological symptoms were common among ambulatory HIV patients. Pain and symptoms were strongly associated with psychiatric illness and IV drug use. Future investigation should evaluate interventions that include psychiatric and substance abuse components for HIV patients with pain.
Background Numerous studies have examined the biomechanics of isolated variables in reverse total shoulder arthroplasty. This study directly compared the composite performance of two reverse total ...shoulder arthroplasty systems; each system was designed around either a medialized or a lateralized glenohumeral center of rotation. Methods Seven pairs of shoulders were tested on a biomechanical simulator. Center of rotation, position of the humerus, passive and active range of motion, and force to abduct the arm were quantified. Native arms were tested, implanted with a Tornier Aequalis or DJO Surgical Reverse Shoulder Prosthesis (RSP), and then retested. Differences from the native state were then documented. Results Both systems shifted the center of rotation medially and inferiorly relative to native. Medial shifts were greater in the Aequalis implant ( P < .037). All humeri shifted inferior compared with native but moved medially with the Aequalis ( P < .001). Peak passive abduction, internal rotation, and external rotation did not differ between systems ( P > .05). Both reverse total shoulder arthroplasty systems exhibited adduction deficits, but the RSP implant deficit was smaller ( P = .046 between implants). Both systems reduced forces to abduct the arm compared with native, although the Aequalis required more force to initiate motion from the resting position ( P = .022). Conclusion Given the differences in system designs and configurations, outcome variables were generally comparable. The RSP implant allowed slightly more adduction, had a more lateralized humeral position, and required less force to initiate elevation. These factors may play roles in limiting scapular notching, improving active external rotation by normalizing the residual rotator cuff length, and limiting excessive stress on the deltoid.
Cardiac toxicity remains an important side effect of anthracyclines. New drug formulations (eg, pegylated liposomal doxorubicin PL-DOX) seem to be a successful strategy for reducing it. Changes in ...cardiac function induced by early chemotherapy, however, are subtle and difficult to quantitate by conventional imaging methods. Doppler myocardial imaging-based velocity, strain, and strain rate measurements have been shown to sensitively quantify abnormalities in cardiac function in other settings.
We evaluated the feasibility and sensitivity of strain rate imaging compared with conventional echocardiography in detecting cardiac effects of PL-DOX therapy in elderly patients with cancer. In a pilot study, we examined 16 elderly women (age 69.8 +/- 3.1 years) with breast cancer receiving 6 cycles of PL-DOX. Conventional and Doppler myocardial imaging echocardiography were obtained at baseline and after 3 and 6 cycles of treatment. Segmental peak systolic longitudinal and radial velocity, strain, and strain rate were measured.
Left ventricular dimensions, ejection fraction, and systolic myocardial velocity did not change throughout the follow-up. In contrast, a significant reduction in longitudinal and radial strain and strain rate was found after 6 cycles (longitudinal strain -18.8% +/- 2.8% vs -22.7% +/- 2.8%, P < .001 vs baseline and P = .001 vs after 3 cycles; radial strain 32.3% +/- 8.1% vs 50.1% +/- 11.6%, P < .001 vs baseline). Changes in radial function appeared earlier and were more pronounced than in longitudinal direction.
In contrast with conventional echocardiography and myocardial velocity measurements, myocardial deformation parameters allowed detecting subtle changes in longitudinal and radial left ventricular function after 6 cycles of PL-DOX. We suggest that Doppler-based myocardial deformation imaging should be used for cardiac function monitoring during chemotherapy.
Transcatheter arterial chemoembolization (TACE) is an established treatment for unresectable liver cancer. This study was conducted to test the hypothesis that angiographic endpoints during TACE are ...measurable and reproducible by comparing subjective angiographic versus objective magnetic resonance (MR) endpoints of TACE.
The study included 12 consecutive patients who presented for TACE for surgically unresectable HCC or progressive hepatic metastases despite chemotherapy. All procedures were performed with a dedicated imaging system. Angiographic series before and after TACE were reviewed independently by three board-certified interventional radiologists. A subjective angiographic chemoembolization endpoint (SACE) classification scheme, modified from an established angiographic grading system in the cardiology literature, was designed to assist in reproducibly classifying angiographic endpoints. Reproducibility in SACE classification level was compared among operators, and MR imaging perfusion reduction was compared with SACE levels for each observer.
Twelve patients successfully underwent 15 separate TACE sessions. SACE levels ranged from I through IV. There was moderate agreement in SACE classification (kappa = 0.46 +/- 0.12). There was no correlation between SACE level and MR perfusion reduction (r = 0.16 for one operator and 0.02 for the other two).
Angiographic endpoints during TACE vary widely, have moderate reproducibility among operators, and do not correlate with functional MR imaging perfusion endpoints. Future research should aim to determine ideal angiographic and functional MR imaging endpoints for TACE according to outcome measures such as imaging response, pathologic response, and survival.
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