Cardiac arrest during cesarean section is very rare. Obstetrical teams have low exposure to these critical situations necessitating frequent rehearsal and knowledge of its differential diagnosis and ...treatment. A 40-year-old woman pregnant with triplets underwent cesarean sections because of vaginal bleeding due to a placenta previa at 35.2 weeks of gestation. Spinal anesthesia was performed. Asystole occurred during uterotomy. Immediate resuscitation and delivery of the neonates eventually resulted in good maternal and neonatal outcomes. The differential diagnosis is essential and should include obstetric and non-obstetric causes. We describe the consideration of Bezold Jarisch reflex and amniotic fluid embolism as most appropriate in this case.
Background Time to reperfusion in patients with ischemic stroke is strongly associated with functional outcome and may differ between hospitals and between patients within hospitals. Improvement in ...time to reperfusion can be guided by between-hospital and within-hospital comparisons and requires insight in specific targets for improvement. We aimed to quantify the variation in door-to-reperfusion time between and within Dutch intervention hospitals and to assess the contribution of different time intervals to this variation. Methods and Results We used data from the MR CLEAN (Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands) Registry. The door-to-reperfusion time was subdivided into time intervals, separately for direct patients (door-to-computed tomography, computed tomography-to-computed tomography angiography CTA, CTA-to-groin, and groin-to-reperfusion times) and for transferred patients (door-to-groin and groin-to-reperfusion times). We used linear mixed models to distinguish the variation in door-to-reperfusion time between hospitals and between patients. The proportional change in variance was used to estimate the amount of variance explained by each time interval. We included 2855 patients of 17 hospitals providing endovascular treatment. Of these patients, 44% arrived directly at an endovascular treatment hospital. The between-hospital variation in door-to-reperfusion time was 9%, and the within-hospital variation was 91%. The contribution of case-mix variables on the variation in door-to-reperfusion time was marginal (2%-7%). Of the between-hospital variation, CTA-to-groin time explained 83%, whereas groin-to-reperfusion time explained 15%. Within-hospital variation was mostly explained by CTA-to-groin time (33%) and groin-to-reperfusion time (42%). Similar results were found for transferred patients. Conclusions Door-to-reperfusion time varies between, but even more within, hospitals providing endovascular treatment for ischemic stroke. Quality of stroke care improvements should not only be guided by between-hospital comparisons, but also aim to reduce variation between patients within a hospital, and should specifically focus on CTA-to-groin time and groin-to-reperfusion time.
People living with HIV (PLWH) experience a higher cardiovascular disease (CVD) risk. Yet, traditional algorithms are often used to estimate CVD risk. We evaluated the performance of 4 commonly used ...algorithms.
The Netherlands.
We used data from 16,070 PLWH aged ≥18 years, who were in care between 2000 and 2016, had no pre-existing CVD, had initiated first combination antiretroviral therapy >1 year ago, and had available data on CD4 count, smoking status, cholesterol, and blood pressure. Predictive performance of 4 algorithms Data Collection on Adverse Effects of Anti-HIV Drugs Study (D:A:D); Systematic COronary Risk Evaluation adjusted for national data (SCORE-NL); Framingham CVD Risk Score (FRS); and American College of Cardiology and American Heart Association Pooled Cohort Equations (PCE) was evaluated using a Kaplan-Meier approach. Model discrimination was assessed using Harrell's C-statistic. Calibration was assessed using observed-versus-expected ratios, calibration plots, and Greenwood-Nam-D'Agostino goodness-of-fit tests.
All algorithms showed acceptable discrimination (Harrell's C-statistic 0.73-0.79). On a population level, D:A:D, SCORE-NL, and PCE slightly underestimated, whereas FRS slightly overestimated CVD risk (observed-versus-expected ratios 1.35, 1.38, 1.14, and 0.92, respectively). D:A:D, FRS, and PCE best fitted our data but still yielded a statistically significant lack of fit (Greenwood-Nam-D'Agostino χ ranged from 24.57 to 34.22, P < 0.05). Underestimation of CVD risk was particularly observed in low-predicted CVD risk groups.
All algorithms perform reasonably well in PLWH, with SCORE-NL performing poorest. Prediction algorithms are useful for clinical practice, but clinicians should be aware of their limitations (ie, lack of fit and slight underestimation of CVD risk in low-risk groups).
Interactions of influenza A virus (IAV) with sialic acid (SIA) receptors determine viral fitness and host tropism. Binding to mucus decoy receptors and receptors on epithelial host cells is ...determined by a receptor-binding hemagglutinin (HA), a receptor-destroying neuraminidase (NA) and a complex in vivo receptor-repertoire. The crucial but poorly understood dynamics of these multivalent virus-receptor interactions cannot be properly analyzed using equilibrium binding models and endpoint binding assays. In this study, the use of biolayer interferometric analysis revealed the virtually irreversible nature of IAV binding to surfaces coated with synthetic sialosides or engineered sialoglycoproteins in the absence of NA activity. In addition to HA, NA was shown to be able to contribute to the initial binding rate while catalytically active. Virus-receptor binding in turn contributed to receptor cleavage by NA. Multiple low-affinity HA-SIA interactions resulted in overall extremely high avidity but also permitted a dynamic binding mode, in which NA activity was driving rolling of virus particles over the receptor-surface. Virus dissociation only took place after receptor density of the complete receptor-surface was sufficiently decreased due to NA activity of rolling IAV particles. The results indicate that in vivo IAV particles, after landing on the mucus layer, reside continuously in a receptor-bound state while rolling through the mucus layer and over epithelial cell surfaces driven by the HA-NA-receptor balance. Quantitative BLI analysis enabled functional examination of this balance which governs this dynamic and motile interaction that is expected to be crucial for penetration of the mucus layer and subsequent infection of cells by IAV but likely also by other enveloped viruses carrying a receptor-destroying enzyme in addition to a receptor-binding protein.
Introduction
Identifying female-specific risk markers for cerebrovascular disease is becoming increasingly important. Both migraine and preeclampsia have been associated with higher incidence of ...brain white matter lesions (WML) and stroke. We assessed the association between WML and migraine among formerly (pre)eclamptic women.
Methods
A total of 118 women (76 formerly (pre)eclamptic and 42 control women) were screened for migraine and WML presence. Independent effects of migraine and (pre)eclampsia on WML were assessed.
Results
Migraine prevalence did not differ between the (pre)eclamptic (26/76; 34%); and control group (10/42; 24%), p = 0.17. Age-adjusted regression analysis failed to show a significant independent effect of migraine (OR 1.14; 95% CI 0.47–2.76; p = 0.77) on WML presence, and showed a non-significant effect of (pre)eclampsia (OR 2.30; 95% CI 0.90–5.83; p = 0.08).
Conclusion
Migraine prevalence was not found to be an independent risk factor for WML prevalence in formerly (pre)eclamptic women. Since this study had a small sample size, larger prospective studies are needed to examine female-specific risk factors for WML and its consequences.
Body residues are often better estimates of the amount of a chemical at the sites of toxic action in an organism than ambient soil concentrations, because bioavailability differences among soils are ...explicitly taken into account in considerations of body residues. Often, however, insufficient attention is paid to the rate and extent at which tissue concentrations respond to soil concentrations and soil characteristics. In this contribution the impact of soil characteristics on the environmental bioavailability of heavy metals for the oligochaete worm Eisenia andrei is reported. Uptake of As, Cd, Cr, Cu, Ni, Pb, and Zn in 20 Dutch field soils and in OECD artificial soil was quantified as a function of time. Internal metal concentrations varied less than the corresponding external levels. Metal uptake and elimination were both metal- and species-dependent. Worms typically attained steady-state concentrations rapidly for Cr, Cu, Ni, and Zn. Internal concentrations similar to those in the cultivation medium, linearly increasing body concentrations, or steady-state internal concentrations well above those in the cultivation medium were found for As, Cd, and Pb. Multivariate expressions were derived to describe uptake rate constants, steady-state concentrations, and bioaccumulation factors as a function of soil characteristics. Soil acidity is the most important solid-phase characteristic modulating the availability of As, Cd, and Pb. Although additional semimechanistic calculations yielded evidence of pore-water-related uptake of Cd and Pb modulated by competition between H+ and metal ions at the active sites of the membranes, the findings for Cr, Cu, Ni, and Zn point to additional influences, among which is probably regulation.
Aim The aim of this study was to analyse the feasibility and reliability of the tests used to determine muscle strength, sprint power, and aerobic capacity in athletes and non‐athletes with cerebral ...palsy (CP).
Methods Twenty individuals with spastic CP (four females, 16 males; age range 18–49y; Gross Motor Function Classification System level I, n=15; II, n=5; unilateral CP, n=10; bilateral CP, n=10; athletes, n=12; non‐athletes, n=8) participated in the study. Isometric and isokinetic knee flexor and extensor strength, sprint power, and aerobic capacity were determined, using, respectively an isokinetic dynamometer, a Wingate cycling test, and a graded maximal bicycle exercise test, on three occasions. Intraclass correlation coefficients (ICC), standard error of measurements, and smallest detectable differences (SDD) were calculated.
Results The feasibility of the isometric strength test, Wingate test, and graded exercise test was good; the isokinetic strength test was difficult to perform for five participants. The strength parameters showed moderate to good ICCs (isometric, 0.74–0.94; isokinetic, 0.88–0.93) but high SDDs (isometric, 25–45%; isokinetic, 30–45%). Sprint power (ICC 0.98; SDD 24%) and aerobic capacity (ICC 0.98–0.99; SDD 16–21%) showed good ICCs and moderate SDDs.
Interpretation All tests, except for the isokinetic strength test, seemed to be feasible for almost all participants. All tests are suitable for evaluating changes in a group; however, only large improvements (16–45%) can be detected when monitoring individual changes.
This article is commented on by Thorpe on pages 585‐586 of this issue
Pressure ulcers (PUs) are highly prevalent in people with spinal cord injury (SCI). Electrical stimulation (ES) activates muscles and might reduce risk factors. Our objectives were to study and ...compare the effects of two duty cycles during 3 h of ES-induced gluteal and hamstring activation on interface pressure distribution in sitting individuals with SCI and study the usability of a newly developed electrode garment (ES shorts). Ten individuals with SCI participated in this study, in which two ES protocols with different duty cycles (1:1 s vs 1:4 s on-off) were applied in counterbalanced order using a custom-made garment with built-in electrodes. Outcome variables included interface pressure of the ischial tuberosities (ITs) and pressure gradient. A questionnaire was used to determine usability of the ES shorts. In both protocols, ES caused a significant decrease in average IT pressure compared with rest (no ES); on average, 35% for protocol 1:4 and 13% for protocol 1:1. The ES on-off duty cycle of protocol 1:4 showed less muscle fatigue. In general, participants scored the usability of the ES shorts as satisfactory. In this study, the application of ES resulted in a significant decrease in IT pressure. The ES on-off duty cycle of 1:4 s is recommended because of the less fatiguing effect. ES of the hamstrings and gluteal muscles might be a promising method in preventing PUs, but further study is needed.
Prolonged high ischial tuberosities pressure (IT pressure), decreased regional blood flow (BF) and oxygenation (%SO2) are risk factors for developing pressure ulcers (PUs) in patients with spinal ...cord injury (SCI). Electrical stimulation (ES)-induced gluteal and hamstring muscle activation may improve pressure distribution by changing the shape of the buttocks while sitting and also increase BF and %SO2.
To compare acute effects of ES-induced gluteal and hamstring muscle activation with pressure relief movements (PRMs) on IT pressure, BF and %SO2.
Twelve men with SCI performed PRMs - push-ups, bending forward and leaning sideward - and received surface ES (87±19 mA) to the gluteal and hamstring muscles while sitting in their wheelchair. Ischial tuberosities pressure was measured using a pressure mapping system; (sub)cutaneous BF and %SO2 were measured using reflection spectroscopy and laser Doppler, respectively.
Compared with rest (156±26 mm Hg), IT pressure was significantly lower during all other conditions (push-ups 19±44; bending forward 56±33; leaning sideward 44±38; ES 67±45 mm Hg). For the whole group, all PRMs significantly augmented BF (+39 to -96%) and %SO2 (+6.0 to -7.9%-point), whereas ES-induced muscle activation did only for peak BF. In all, 63% of the participants showed an increased BF (average 52%) with ES.
PRMs acutely reduced IT pressure and improved oxygenation and BF in SCI. The currently used ES method cannot replace PRMs, but it may be used additionally. ES-induced muscle activation is not as effective for acute pressure relief, but the frequency of stimulation is much higher than the performance of PRMs and can therefore be more effective in the long term.
A randomized double-blind trial with a 7-valent pneumococcal conjugate vaccine was conducted in The Netherlands among 383 children, aged 1 to 7 years, with a history of recurrent acute otitis media. ...No effect of vaccination on the pneumococcal colonization rate was found. However, a shift in serotype distribution was clearly observed (R. Veenhoven et al., Lancet 361:2189-2195, 2003). We investigated the molecular epidemiology of 921 pneumococcal isolates retrieved from both the pneumococcal vaccine (PV) and control vaccine (CV) groups during the vaccination study. Within individuals a high turnover rate of pneumococcal restriction fragment end labeling genotypes, which was unaffected by vaccination, was observed. Comparison of the genetic structures before and after completion of the vaccination scheme revealed that, despite a shift in serotypes, there was clustering of 70% of the pneumococcal populations. The remaining isolates (30%) were equally observed in the PV and CV groups. In addition, the degree of genetic clustering was unaffected by vaccination. However, within the population genetic structure, nonvaccine serotype clusters with the serotypes 11, 15, and 23B became predominant over vaccine-type clusters after vaccination. Finally, overall pneumococcal resistance was low (14%), and, albeit not significant, a reduction in pneumococcal resistance as a result of pneumococcal vaccination was observed. Molecular surveillance of colonization in Dutch children shows no effect of pneumococcal conjugate vaccination on the degree of genetic clustering and the genetic structure of the pneumococcal population. However, within the genetic pneumococcal population structure, a clear shift toward nonvaccine serotype clusters was observed.
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