To determine the interrelationships during early pregnancy of complement-activation fragments Bb, C3a and sC5b-9, and angiogenesis-related factors placental growth factor (PiGF), soluble fms-like tyrosine kinase-1 (sFlt-1) and soluble endoglin (sEng), and their associations with pre-eclampsia.Prospective cohort study.Denver complement study (June 2005-June 2008).A total of 668 pregnant women with singleton gestations, recruited between 10 and 15 weeks of gestation.Using univariable and multivariable logistic regression analysis, concentrations of complement-activation fragments and angiogenesis-related factors were compared between 10 and 15 weeks of gestation in women who subsequently did or did not develop pre-eclampsia. Interrelationships between these variables were tested using the non-parametric Spearman rank correlation coefficient.Pre-eclampsia. The association of complement-activation fragments and angiogenesis-related factors with obesity was also examined.The mean (+/-SD) levels of complement Bb in early pregnancy among women who did and did not develop pre-eclampsia were 0.84 (+/-0.26) microg/ml and 0.69 (+/-0.2) microg/ml, respectively (P = 0.001). Concentrations of PiGF were significantly (P = 0.01) lower (31 +/- 12 pg/ml) in early pregnancy in the pre-eclamptic group of women, as compared with the normotensive group (39 +/- 32 pg/ml). The adjusted odds ratio (AOR) of Bb and PiGF were 2.1 (CI = 1.4-3.1, P < 0.0003) and 0.2 (CI = 0.07-0.7, P = 0.01), respectively. There was no significant difference in the levels of C3a, sC5b-9, sFlt-1 and sEng in early pregnancy among women who developed pre-eclampsia, compared with women who remained normotensive during pregnancy. Higher levels of Bb (P = 0.0001) and C3a (P = 0.03), and lower levels of sFlt-1 (P = 0.0002) and sEng (P = 0.0001) were found among women with obesity, compared with non-obese controls. No meaningful relationships were found between the complement-activation fragments and the angiogenesis-related factors.In this cohort during early pregnancy, increased concentrations of complement-activation factor Bb and lower concentrations of PiGF were associated with the development of pre-eclampsia later in pregnancy.
A feasibility study commissioned in May 1980 by Cork Corporation recommended a 2-lane immersed tube tunnel as the optimum crossing mode for the Downstream Crossing of the River Lee. In 1991 this was revised to a 4-lane immersed tube tunnel. Details are given of the environmental impact study carried out together with geotechnical, hydraulic and shipping studies. The contract strategy, which involved the choice of a Design and Construct contract, is discussed. The Employer's requirements are discussed including a) watertightness, b) tunnel cross section and c) tunnel operation. For the covering abstract see IRRD 895561.
We have previously shown that elevation of anticardiolipin antibodies (aCL) at the first prenatal visit is associated with increased fetal loss in normal pregnancy. The variation in aCL levels during normal pregnancy has not been established. To examine this question we measured IgG, IgM and IgA aCL levels five times during pregnancy at weeks 5-15, 16-25, 26-35, 36-37 and at delivery. Data were analyzed to determine: (a) the within and between subject variability of aCL during pregnancy; (2) the temporal trend of aCL; and (3) the relation of serial measures of aCL with maternal complications of pregnancy. We divided our cohort of 354 subjects into two groups. Group A included those subjects with consistently normal levels of aCL and group B those subjects with at least one elevated level of aCL. In group A the within subject variability was relatively low (28-34%). In group B we found wide fluctuations in aCL levels and a within subject variability of 88-91 %. Subjects in group B had no increase in maternal complications of pregnancy. The present data suggest that aCL may fluctuate significantly during normal pregnancy and there is little clinical value in measuring aCL on a serial basis during pregnancy.
This hardcover textbook has 768 pages and therefore is a desk reference. Electronic access is available through www.ExpertConsult.com, which increases its portability. The Web interface is not identical to a book; text can be printed on article (and to file). Diagrams can be saved as gif files. The copy I reviewed did not have upgraded premium content (unlike Miller’s Anesthesia,1 7th edition), which gives access to jpeg images for PowerPoint presentations. The quality of the article and color images is very high. I detected 1 typographical error; it was a footnoted surname on page 3. I counted 58 authors for 34 chapters, mainly from the United States. As Dr. Paul Barash writes in his foreword, the breadth of the book is remarkable for an “equipment” book. It would be pointless to compare this edition to the first edition, given the changes in anesthesia workstations and computing power in the interim. Amazon.com has a Kindle version, but I have not reviewed it. The authors’ preface makes a plea to the audience to “up their game” by becoming techno-educated. A reference to an editorial by Dr. Steven J. Barker correctly describes the anesthesiologists’ problem with too much reliance on technology, without understanding its basis, and sometimes, its limitations. As a “pseudo-techie,” there are things that I grasp readily and others that (I admit) escape me. As a teacher of clinical anesthesiology, I challenge residents daily to make the most of their equipment and to educate themselves in its operation. The book is divided into 7 parts, ranging from gases and ventilation to special equipment (except ultrasound, echocardiography, and rapid infusion systems), to safety and standards. The first 7 chapters cover the “expected stuff” and are well-illustrated. Two manufacturers are covered: GE Healthcare (Madison, WI) and Draeger Medical (Telford, PA). Although none of the Draeger Apollo workstations in our department is fitted with the optional common gas outlet, the text may err in stating that it lacks an accessible common gas outlet. A circa 1983 reference in chapter 4 regarding the desirability of an absorber bypass valve comes from a Canadian survey; not surprising to me, as a Canadian trainee of that period, but I doubt that modern anesthesiologists see the need for this feature. The chapter on anesthesia ventilators is complete enough but lacks much information about the Draeger “volume autoflow” mode, while covering the GE Healthcare version of pressure-control volume ventilation in some detail. Part II covers “System Monitors” and concentrates on gas monitoring and alarms. The discourse on “volumetric capnography” led me to a literature search, and I concluded that this is an up-and-coming field but not yet “state-of-the-art.” Strong clinical advice is found in the text regarding the most informative use of respiratory alarms. Chapter 10 emphasizes that capnography does not replace inspection, palpation, and auscultation and that precise PaCO2 measurement requires an arterial blood gas. This is a fact that I find I reiterate to trainees regularly. Pulse oximetry receives a chapter and as a standard monitor deserves full coverage. The suggestion that pulse oximetry can be a “fair-weather friend” is useful to remember (the sicker the patient, the higher the failure rate), and the section on motion artifact serves to emphasize that further studies are required to determine whether this technology improves performance in challenging scenarios. The section on plethysmographic variability opens the potential for future clinical uses; the reviewer missed any discussion on Philips “PERF INDEX.” Some indication of signal strength or quality may provide the end-user with trending information. The institutional decision to use either Masimo or Nellcor and connect the monitor (or module) to a Philips monitor essentially eliminates the “value” of this measurement, which anecdotally is used regularly by some clinicians. Masimo can provide a measure of pleth strength, while Nellcor technology appears to lack this ability. Another standard monitor is blood pressure (Chapter 12). In my opinion, Miller’s Anesthesia,1 7th edition, covers this topic better. The text under review categorically eliminates heparin from transducer flush solutions and mentions a continuous flush rate of 5 to 10 mL/h (actual flush rate is dependent on upstream pressure and downstream resistance and is usually quoted as 3–6 mL/h). The text mentions a “disposable damping device” in Figure 12–4 but without name, photograph, or sketch. The admonition to use the shortest connecting tubing is commonplace but often impractical in the operating room (e.g., cardiac surgery); I remain unimpressed with the effect of tubing length. I missed coverage of von Recklinghausen’s oscillotonometer in the history (fond memories of traineeship). Ensuing chapters are of good quality and cover electrocardiography, neuromuscular monitoring, and temperature. Chapters on airway equipment and pediatric anesthesia systems are adequate. Chapter 20 (Infection Prevention) provides nonintuitive and safe recommendations. As a result, I now change my disposable gloves much more frequently. Part V covers a range of topics from computers to informatics, from simulation to ergonomics. I particularly enjoyed the chapter on alarms, which addressed vigilance, fatigue, stress, substance abuse, and teams, among others. Part VI consists of 4 divergent chapters. Most appealing to me was the one on closed-circuit anesthesia, but I was converted in 1982. The chapter even explains liquid agent injection, a practice I learned in the 1980s as a resident and which I occasionally teach to selected trainees. Short chapters on challenging environments including the magnetic resonance imaging suite are found here. Part VII addresses safety and danger. “Hazards of the Anesthesia Delivery System,” if read carefully, will not fail to teach. The advice to perform a pre-use checkout “in the condition it will be used” is excellent and reminds the care provider to include the vaporizer, the nitric oxide injector, and any circuit additions when performing a pre-use workstation checkout. The chapter on electrical and fire safety is excellent. The chapter devoted to anesthesia machine pre-use checkout addresses an important matter and proceeds historically to explain how we got to where we are. The complexity of modern anesthesia workstations means that the end-user must use the automated checkout system and should have some understanding of what it is actually checking. At the top of the list of checkout list, however, must be a manual ventilation device and a source of oxygen, which this chapter includes with its minimum pre-anesthesia checklist. The development of local (departmental) checklists that meet the minimum (and exceed it, optimally) is sound advice. During my residency, my “go-to” books were Dorsch and Dorsch2 (and Scientific Foundations of Anaesthesia3). The former is now in its fifth edition (I only acquired my copy of the fourth edition 3 years ago, proving I am only a “pseudo-techie”). Anesthesia Equipment: Principles and Applications is only in its second edition and is a reference textbook both for the trainee and for the experienced. I recommend it for departmental libraries and for individuals.
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