Recombinant human factor VIIa prevents hysterectomy in severe postpartum hemorrhage: single center study

Abstract Objective: To evaluate the effectiveness of human recombinant activated factor VII (rhFVIIa, NovoSeven) in avoiding hysterectomy postpartum in the management of severe postpartum hemorrhage (PPH). Methods: We performed a prospective cohort study at our university tertiary care center. Patients with severe post partum hemorrhage (blood loss >2000 mL) and failed medical and uterus-preserving surgical management, were treated with intravenous bolus administration of rhVIIa. Main outcome measures were cessation of bleeding, postpartum hysterectomy and thromboembolic events. Results: In 20/22 patients included, PPH was caused primarily by uterine atony, including 7 (32%) with additional lower genital tract lesion; in two women, it was due to pathologic placentation (placenta increta, 9%). One case of amniotic fluid embolism and one woman with uterine inversion were included. Recombinant hFVIIa was successful in stopping the PPH and in preventing a hysterectomy in 20/22 women (91%). The remaining two patients with persistent bleeding despite rhFVIIa treatment, who underwent postpartum hysterectomy, had placenta increta. No thromboembolic event was noticed. Conclusions: This study describes the largest single center series of rhFVIIa treatment for fertility preservation in severe postpartum hemorrhage published to date. Our data suggest that administration of rhFVIIa is effective in avoiding postpartum hysterectomy after conservative medical and surgical measures have failed. Although randomized studies are lacking, rhFVIIa should be considered as a second-line therapeutic option of life-threatening postpartal bleeding, in particular if preservation of fertility is warranted and hysterectomy is to be avoided.

The Hayman technique: a simple method to treat postpartum haemorrhage

Of the several uterine compression sutures described in more recent years to treat postpartum haemorrhage (PPH), the Hayman suture offers the potential advantages that can be applied faster and easier, avoiding the performance of a lower segment hysterotomy when PPH follows a vaginal delivery. Data on efficacy and safety are limited, and long-term follow-up information are lacking. We report our experience with the Hayman suture in 11 consecutive women with massive PPH. Of these, ten were successfully treated without further interventions. One woman ultimately required a hysterectomy. Postoperative course was uncomplicated in all the cases. The median follow-up time was 11 months (range 1-19). One woman conceived spontaneously 10 months after the procedure. Our results suggest that the Hayman suture is an effective and safe treatment for PPH.

Diagnosis and treatment of peripartum bleeding

Severe peripartum hemorrhage (PPH) contributes to maternal morbidity and mortality and is one of the most frequent emergencies in obstetrics, occurring at a prevalence of 0.5-5.0%. Detection of antepartum risk factors is essential in order to implement preventive measures. Proper training of obstetric staff and publication of recommendations and guidelines can effectively reduce the frequency of PPH and its resulting morbidity and mortality. Therefore, an interdisciplinary expert committee was formed, with members from Germany, Austria, and Switzerland, to summarize recent scientific findings. An up-to-date presentation of the importance of embolization and of the diagnosis of coagulopathy in PPH is provided. Furthermore, the committee recommends changes in the management of PPH including new surgical options and the off-label use of recombinant factor VIIa.

The paradox of adult respiratory distress syndrome in neonates

Six full-term newborn infants are described who suffered from severe adult respiratory distress syndrome (ARDS). The triggering event was intrauterine/perinatal asphyxia in five, and group B streptococcal (GBS) septicemia in three. All had severe respiratory distress/failure and were ventilated mechanically with high concentrations of inspired oxygen and positive end-expiratory pressure. Radiography of the chest showed dense bilateral consolidation with air bronchograms and reduced lung volume. Persistent pulmonary hypertension (PPH) was documented in all cases. The coincidence of ARDS and PPH rendered respiratory management extremely difficult. For this reason high-frequency ventilation was instituted in all patients in order to improve CO2 elimination and induce respiratory alkalosis. Acute complications of respiratory therapy were encountered in five patients (pneumothorax, pulmonary interstitial emphysema, pneumopericardium). Three infants died (irreversible septic shock, progressive severe hypoxemia, and sudden cardiac arrest) after 17, 80, and 175 h of life. Histologic examination of the lungs was possible in all fatal cases and revealed typical changes of acute to subacute stages of ARDS. Three infants survived, the mean time of mechanical respiratory support being 703 h. Two patients were still dependent on oxygen after 1 month of life, and all survivors had increased interstitial markings and increased lung volumes on their chest roentgenograms at this time.

Identification and analysis of novel mitotic inhibitors of the Caenorhabditis elegans Aurora B kinase

Proper execution of mitosis requires the accurate segregation of replicated DNA into each daughter cell. The highly conserved mitotic kinase AIR-2/Aurora B is a dynamic protein that interacts with subsets of cofactors and substrates to coordinate chromosome segregation and cytokinesis in Caenorhabdiris elegans. To identify components of the AIR-2 regulatory pathway, a genome-wide RNAi-based screen for suppressors of air-2 temperature-sensitive mutant lethality was conducted. Here, I present evidence that two classes of suppressors identified in this screen are bona fide regulators of the AIR-2 kinase. The strongest suppressor cdc-48.3, encodes an Afg2/Spaf-related Cdc48-like AAA+ ATPase that regulates AIR-2 kinase activity and stability during C. elegans embryogenesis. Loss of CDC-48.3 suppresses the lethality of air-2 mutant embryos, marked by the restoration of the dynamic behavior of AIR-2 and rescue of chromosome segregation and cytokinesis defects. Loss of CDC-48.3 leads to mitotic delays and abnormal accumulation of AIR-2 during late telophase/mitotic exit. In addition, AIR-2 kinase activity is significantly upregulated from metaphase through mitotic exit in CDC-48.3 depleted embryos. Inhibition of the AIR-2 kinase is dependent on (1) a direct physical interaction between CDC-48.3 and AIR-2, and (2) CDC-48.3 ATPase activity. Importantly, the increase in AIR-2 kinase activity does not correlate with the stabilization of AIR-2 in late mitosis. Hence, CDC-48.3 is a bi-functional inhibitor of AIR-2 that is likely to act via distinct mechanisms. The second class of suppressors consists of psy-2/smk-1 and pph-4.1, which encode two components of the conserved PP4 phosphatase complex that is essential for spindle assembly, chromosome segregation, and overall mitotic progression. AIR-2 and its substrates are likely to be targets of this complex since mitotic AIR-2 kinase activity is significantly increased during mitosis when either PSY-2/SMK-1 or PPH-4.l is depleted. Altogether, this study demonstrates that during the C. elegans embryonic cell cycle, regulators including the CDC-48.3 ATPase and PP4 phosphatase complex interact with and control the kinase activity, targeting behavior and protein stability of the Aurora B kinase to ensure accurate and timely progression of mitosis. ^

Los promotores en la metodología de intervención del programa Pro-Huerta Córdoba, Argentina

El Pro-Huerta (PPH) es un programa estatal nacional que aborda la seguridad alimentaria, dirigido a la población pobre. La zona Gran Córdoba comprende la ciudad de Córdoba y un amplio territorio que involucra los pueblos cercanos en un radio aproximado de unos 50 km de la capital, donde se trabaja con más de 120 promotores y 14.500 huerteros. Debido a que los promotores son los actores que los técnicos destacan como fundamentales en el funcionamiento del programa, las principales preguntas que este estudio se formula son: ¿quiénes son los actores que participan como promotores en el PPH de la provincia de Córdoba? y ¿cómo perciben los promotores los beneficios y limitaciones del componente de capacitación? La metodología utilizada combina procedimientos cuanti y cualitativos en el tratamiento de los datos. El universo de promotores fue clasificado contemplando las funciones que desempeñan en el programa y sus demandas de capacitación. Se observó una relación significativa entre el subtipo que cumple una función de promoción más integral y el subtipo que demanda capacitación en aspectos sociales. Asimismo es importante la relación entre el subtipo que limita su función sólo a convocar reuniones para repartir semillas con el que manifiesta una menor demanda de capacitación en general.

Misoprostol in addition to routine treatment of postpartum hemorrhage: A hospital-based randomized-controlled trial in Karachi, Pakistan

Background: Postpartum hemorrhage (PPH) remains a major killer of women worldwide. Standard uterotonic treatments used to control postpartum bleeding do not always work and are not always available. Misoprostol's potential as a treatment option for PPH is increasingly known, but its use remains ad hoc and available evidence does not support the safety or efficacy of one particular regimen. This study aimed to determine the adjunct benefit of misoprostol when combined with standard oxytocics for PPH treatment. Methods: A randomized controlled trial was conducted in four Karachi hospitals from December 2005 – April 2007 to assess the benefit of a 600 mcg dose of misoprostol given sublingually in addition to standard oxytocics for postpartum hemorrhage treatment. Consenting women had their blood loss measured after normal vaginal delivery and were enrolled in the study after losing more than 500 ml of blood. Women were randomly assigned to receive either 600 mcg sublingual misoprostol or matching placebo in addition to standard PPH treatment with injectable oxytocics. Both women and providers were blinded to the treatment assignment. Blood loss was collected until active bleeding stopped and for a minimum of one hour after PPH diagnosis. Total blood loss, hemoglobin measures, and treatment outcomes were recorded for all participants. Results: Due to a much lower rate of PPH than expected (1.2%), only sixty-one patients were diagnosed and treated for their PPH in this study, and we were therefore unable to measure statistical significance in any of the primary endpoints. The addition of 600 mcg sublingual misoprostol to standard PPH treatments does, however, suggest a trend in reduced postpartum blood loss, a smaller drop in postpartum hemoglobin, and need for fewer additional interventions. Women who bled less overall had a significantly smaller drop in hemoglobin and received fewer additional interventions. There were no hysterectomies or maternal deaths among study participants. The rate of transient shivering and fever was significantly higher among women receiving misoprostol Conclusion: A 600 mcg dose of misoprostol given sublingually shows promise as an adjunct treatment for PPH and its use should continue to be explored for its life-saving potential in the care of women experiencing PPH. Trial Registration: Clinical trials.gov, Registry No. NCT00116480

Chemical and isotope composition of rocks from the Omgon Range, Western Kamchatka coastal area

Hypabyssal rocks of the Omgon Range, Western Kamchatka that intrude Upper Albian-Lower Campanian deposits of the Eurasian continental margin belong to three coeval (62.5-63.0 Ma) associations: (1) ilmenite gabbro-dolerites, (2) titanomagnetite gabbro-dolerites and quartz microdiorites, and (3) porphyritic biotite granites and granite-aplites. Early Paleocene age of ilmenite gabbro-dolerites and biotite granites was confirmed by zircon and apatite fission-track dating. Ilmenite and titanomagnetite gabbro-dolerites were produced by multilevel fractional crystallization of basaltic melts with, respectively, moderate and high Fe-Ti contents and contamination of these melts with rhyolitic melts of different compositions. Moderate- and high-Fe-Ti basaltic melts were derived from mantle spinel peridotite variably depleted and metasomatized by slab-derived fluid prior to melting. The melts were generated at variable depths and different degrees of melting. Biotite granites and granite aplites were produced by combined fractional crystallization of a crustal rhyolitic melt and its contamination with terrigenous rocks of the Omgon Group. The rhyolitic melts were likely derived from metabasaltic rocks of suprasubduction nature. Early Paleocene hypabyssal rocks of the Omgon Range were demonstrated to have been formed in an extensional environment, which dominated in the margin of the Eurasian continent from Late Cretaceous throughout Early Paleocene. Extension in the Western Kamchatka segment preceded the origin of the Western Koryakian-Kamchatka (Kinkil') continental-margin volcanic belt in Eocene time. This research was conducted based on original geological, mineralogical, geochemical, and isotopic (Rb-Sr) data obtained by the authors.

Geological, geochemical and biogeochemical data on boundary zones of the Atlantic Ocean

Results of studies in two biogeochemically active zones of the Atlantic Ocean (the Benguela upwelling waters and the region influenced by the Congo River run-off) are reported in the book. A multidisciplinary approach included studies of the major elements of the ocean ecosystem: sea water, plankton, suspended matter, bottom sediments, interstitial waters, aerosols, as well as a wide complex of oceanographic studies carried out under a common program. Such an approach, as well as a use of new methodical solutions led to obtaining principally new information on different aspects of oceanology.

Poly(hydroxyether of phenolphthalein) and its blends with poly(ethylene oxid)

Poly(hydroxyether of phenolphthalein) (PPH) was synthesized through the polycondensation of phenolphthalein with epichlorohydrin. It was characterized by Fourier transform infrared (FTIR) spectroscopy, NMR spectroscopy, and differential scanning calorimetry (DSC). The miscibility of the blends of PPH with poly(ethylene oxide) (PEO) was established on the basis of the thermal analysis results. DSC showed that the PPH/PEO blends prepared via casting from N,N-dimethylformamide possessed single, composition-dependent glass-transition temperatures. Therefore, the blends were miscible in the amorphous state for all compositions. FTIR studies indicated that there were competitive hydrogen-bonding interactions with the addition of PEO to the system, which were involved with (OHO)-O-. . .=C

Iron catalysed assembly of an asymmetric mixed-ligand triple helicate

The 2-pyridinecarbaldehyde isonicotinoyl hydrazone (HPCIH) family of ligands are typically tridentate N,N,O chelators that exhibit very high in vitro activity in mobilizing intracellular Fe and are promising candidates for the treatment of Fe overload diseases. Complexation of ferrous perchlorate with HPCIH in MeCN solution gives the expected six-coordinate complex Fe-II(PCIH)(2). However, complexation of Fe-II with 2-pyridinecarbaldehyde picolinoyl hydrazone (HPCPH, an isomer of HPCIH) under the same conditions leads to spontaneous assembly of an unprecedented asymmetric, mixed-ligand dinuclear triple helical complex Fe-2(II)(PCPH)(2)(PPH), where PPH2- is the dianion of bis(picolinoyl) hydrazine. The X-ray crystal structure of this complex shows that each ligand binds simultaneously to both metal centres in a bidentate fashion. The dinuclear complex exhibits two well separated and totally reversible Fe-III/II redox couples as shown by cyclic voltammetry in MeCN solution.

Interrogation of a sonogashira cross-coupling of 8-bromoguanosine with phenylacetylene on amberlite:evidence for Pd/Cu ion binding and propagation of Pd/Cu nanoparticles

The reactivity of Amberlite (IRA-67) base "heterogeneous" resin in Sonogashira cross-coupling of 8-bromoguanosine 1 with phenylacetylene 3 to give 2 has been examined. Both 1 and 2 coordinate to Pd and Cu ions, which explains why at equivalent catalyst loadings, the homogeneous reaction employing triethylamine base is poor yielding. X-ray photo-electron spectroscopy (XPS) has been used to probe and quantify the active nitrogen base sites of the Amberlite resin, and postreaction Pd and Cu species. The Pd2Cl3(PPh)2 precatalyst and CuI cocatalyst degrade to give Amberlite-supported metal nanoparticles (average size ∼2.7 nm). The guanosine product 2 formed using the Amberlite Pd/Cu catalyst system is of higher purity than reactions using a homogeneous Pd precatalyst, a prerequisite for use in biological applications. Copyright © Taylor and Francis Group, LLC.

Stereoselective synthesis of vinyl germanes and silanes. Applications of tris(trimethyl)germanes and silanes in Pd-catalyzed cross -coupling reactions

Although group 14 organometallic compounds (Si, Sn) have been well developed as transmetallation reagents in cross-coupling reactions, the application of organogermanium compounds as cross-coupling reagents is still a relatively new area with few papers published. This study aimed to develop methods for the synthesis of new classes of vinyl germane and vinyl silane compounds, mainly Z and E tris(trimethylsilyl)germanes and silanes, which were then applied to Pd-catalyzed cross-couplings with aryl and alkenyl halides. The stereoselective radical-mediated desulfonylation of vinyl sulfones with tris(trimethyl)germanium or silane hydrides provided access to the synthesis of trans vinyl germanes or silanes. Alternatively hydrogermylation or hydrosilylation of terminal alkynes gave cis vinyl germanes or silanes. The application of these new classes of organometallic compounds in cross-coupling reactions with various aryl and alkenyl halides under aqueous [NaOH/H2O2/Pd(PPh 3)4] and anhydrous [KH/t-BuOOH/Pd(PPh 3)4] oxidative conditions were investigated. ^ It was found that the vinyl tris(trimethylsilyl)germanes successfully underwent Pd-catalyzed cross-couplings with aryl and alkenyl halides and aryl triflates under aqueous and anhydrous oxidative conditions. These procedures provided examples of "ligand-free" Pd-catalyzed coupling of organogermanes with aryl and alkenyl halides. Interestingly, couplings with fluorinated vinyl germanes appeared to occur more easily than with the corresponding (α-fluoro)vinyl stannanes and silanes since neither addition of an extra ligand nor activation with fluoride was necessary. The vinyl tris(trimethyl)silanes were found to be alternative substrates for the Hiyama reaction. The coupling of TTMS-silanes with various aryl, heteroaryl as well as alkenyl halides proceeded smoothly upon treatment with hydrogen peroxide in the presence of sodium hydroxide and fluoride ion. ^

Geochemical composition of sulfide and oxide minerals from ODP Sites 193-1188 and 193-1189, PACMANUS field

Ocean Drilling Program (ODP) Leg 193 recovered core from the active PACMANUS hydrothermal field (eastern Manus Basin, Papua New Guinea) that provided an excellent opportunity to study mineralization related to a seafloor hydrothermal system hosted by felsic volcanic rocks. The purpose of this work is to provide a data set of mineral chemistry of the sulfide-oxide mineralization and associated gold occurrence in samples drilled at Sites 1188 and 1189. PACMANUS consists of five active vent sites, namely Rogers Ruins, Roman Ruins, Satanic Mills, Tsukushi, and Snowcap. In this work two sites were studied: Snowcap and Roman Ruins. Snowcap is situated in a water depth of 1670 meters below sea level [mbsl], covers a knoll of dacite-rhyodacite lava, and is characterized by low-temperature diffuse venting. Roman Ruin lies in a water depth of 1693-1710 mbsl, is 150 m across, and contains numerous large, active and inactive, columnar chimneys. Sulfide mineralogy at the Roman Ruins site is dominated by pyrite with lesser amounts of chalcopyrite, sphalerite, pyrrhotite, marcasite, and galena. Sulfide minerals are relatively rare at Snow Cap. These are dominated by pyrite with minor chalcopyrite and sphalerite and traces of pyrrhotite. Native gold has been found in a single sample from Hole 1189B (Roman Ruins). Oxide minerals are represented by Ti magnetite, magnetite, ilmenite, hercynite (Fe spinel), and less abundant Al-Mg rich chromite (average = 10.6 wt% Al2O3 and 5.8 wt% MgO), Fe-Ti oxides, and a single occurrence of pyrophanite (Mn Ti O3). Oxide mineralization is more developed at Snowcap, whereas sulfide minerals are more extensive and show better development at Roman Ruins. The mineralogy was obtained mainly by a detailed optical microscopy study. Oxide mineral identifications were confirmed by X-ray diffraction, and mineral chemistry was determined by electron probe microanalyses.

Beyond maternal death: improving the quality of maternal care through national studies of ‘near-miss’ maternal morbidity

Knight M, Acosta C, Brocklehurst P, Cheshire A, Fitzpatrick K, Hinton L, Jokinen M, Kemp B, Kurinczuk JJ, Lewis G, Lindquist A, Locock L, Nair M, Patel N, Quigley M, Ridge D, Rivero-Arias O, Sellers S, Shah A on behalf of the UKNeS coapplicant group. Background Studies of maternal mortality have been shown to result in important improvements to women’s health. It is now recognised that in countries such as the UK, where maternal deaths are rare, the study of near-miss severe maternal morbidity provides additional information to aid disease prevention, treatment and service provision. Objectives To (1) estimate the incidence of specific near-miss morbidities; (2) assess the contribution of existing risk factors to incidence; (3) describe different interventions and their impact on outcomes and costs; (4) identify any groups in which outcomes differ; (5) investigate factors associated with maternal death; (6) compare an external confidential enquiry or a local review approach for investigating quality of care for affected women; and (7) assess the longer-term impacts. Methods Mixed quantitative and qualitative methods including primary national observational studies, database analyses, surveys and case studies overseen by a user advisory group. Setting Maternity units in all four countries of the UK. Participants Women with near-miss maternal morbidities, their partners and comparison women without severe morbidity. Main outcome measures The incidence, risk factors, management and outcomes of uterine rupture, placenta accreta, haemolysis, elevated liver enzymes and low platelets (HELLP) syndrome, severe sepsis, amniotic fluid embolism and pregnancy at advanced maternal age (≥ 48 years at completion of pregnancy); factors associated with progression from severe morbidity to death; associations between severe maternal morbidity and ethnicity and socioeconomic status; lessons for care identified by local and external review; economic evaluation of interventions for management of postpartum haemorrhage (PPH); women’s experiences of near-miss maternal morbidity; long-term outcomes; and models of maternity care commissioned through experience-led and standard approaches. Results Women and their partners reported long-term impacts of near-miss maternal morbidities on their physical and mental health. Older maternal age and caesarean delivery are associated with severe maternal morbidity in both current and future pregnancies. Antibiotic prescription for pregnant or postpartum women with suspected infection does not necessarily prevent progression to severe sepsis, which may be rapidly progressive. Delay in delivery, of up to 48 hours, may be safely undertaken in women with HELLP syndrome in whom there is no fetal compromise. Uterine compression sutures are a cost-effective second-line therapy for PPH. Medical comorbidities are associated with a fivefold increase in the odds of maternal death from direct pregnancy complications. External reviews identified more specific clinical messages for care than local reviews. Experience-led commissioning may be used as a way to commission maternity services. Limitations This programme used observational studies, some with limited sample size, and the possibility of uncontrolled confounding cannot be excluded. Conclusions Implementation of the findings of this research could prevent both future severe pregnancy complications as well as improving the outcome of pregnancy for women. One of the clearest findings relates to the population of women with other medical and mental health problems in pregnancy and their risk of severe morbidity. Further research into models of pre-pregnancy, pregnancy and postnatal care is clearly needed.