The use of neuroaxial blockades in obstetric practice for thrombocytopenia

Thrombocytopenia is the second most frequent hematological complication of pregnancy after anemia. Among all thrombocytopenia during pregnancy, the most common is gestational thrombocytopenia. Gestational thrombocytopenia is not accompanied by coagulation disorders, has a minimal risk of bleeding, for both a mother and her fetus. Nevertheless, according to modern concepts, thrombocytopenia is a contraindication for performing obstetric neuroaxial blockades only on the basis of quantitative count of platelets, without taking into account coagulation status. These contraindications are derived from the general surgery and traumatology practice due to the high risk of developing epidural hematoma, but do not take into account the features, including physiological hypercoagulation, of pregnant patients. Refusal of the patient to perform a neuroaxial blockade during delivery on the basis of only counting the number of platelets often leads to an unreasonable increase in the risk / benefit ratio for both the mother and the fetus. Analysis of the research results indicates a change in attitude towards this problem towards a more loyal approach, taking into account the assessment of the coagulative status of a particular patient

Возможности тромбоэластографии при оценке безопасности нейроаксиальных блокад при гестационной тромбоцитопении (клиническое исследование)

Gestational thrombocytopenia (GT) is the most common type of thrombocytopenia during pregnancy. Unlike other types of thrombocytopenia, it is not accompanied by dysfunction of the cellular component of hemostasis. Currently, a quantitative decrease in platelets in GT is a contraindication to neuraxial blockades (NAB), which significantly reduces the quality of care in childbirth.The aim of the study is to determine the possibility of safe use of neuraxial blockades in gestational thrombocytopenia. A retrospective prospective study involved 70 patients who were performed delivery, depending on obstetric indications, either conservatively or surgically. The patients were divided into two groups. The main group (group No. 1) included 35 patients with gestational thrombocytopenia. The comparison group (group No. 2) consisted of 35 patients with a platelet content above 150×109/l. A comparative intergroup analysis of indicators of a general blood test, coagulogram, thromboelastography with a test for functional fibrinogen before childbirth and 2 days after delivery. The change in platelet content and its effect on the coagulation status of patients during pregnancy were retrospectively analyzed. A comparative assessment of the volume of blood loss during childbirth and the early postpartum period and the risk of complications of neuraxial blockade in patients with and without gestational thrombocytopenia was carried out.It was found that during gestational thrombocytopenia in the perinatal period, there is no decrease in coagulation potential, assessed by the results of coagulography and thromboelastography at a platelet level above 49×109/l. The investigated indicators of hemostasis did not have significant intergroup differences during pregnancy and childbirth. In the group of patients with gestational thrombocytopenia, the volume of blood loss during labor and the postpartum period did not differ from the group without thrombocytopenia, regardless of the method of delivery. The median blood loss after vaginal delivery in group 1 was 225 ml, in group 2 – 250 ml, with abdominal delivery – 572 ml and 386 ml – respectively. In this study, no complications of neuraxial blockade were observed in any of the groups.The results obtained suggest that in patients with gestational thrombocytopenia, even with a significant decrease in platelet content, it is possible to perform neuraxial blockades during labor, taking into account the clinical picture and the absence of coagulation disorders confirmed by thromboelastography.ВВЕДЕНИЕ Гестационная тромбоцитопения (ГТ) является наиболее распространенным видом тромбоцитопении во время беременности. В отличие от других видов тромбоцитопении она не сопровождается нарушением функции клеточного звена гемостаза. В настоящее время количественное снижение тромбоцитов при ГТ является противопоказанием к проведению нейроаксиальных блокад (НАБ), что значительно снижает качество оказания помощи в родах.ЦЕЛЬ ИССЛЕДОВАНИЯ Определить возможности безопасного применения НАБ при ГТ.МАТЕРИАЛ И МЕТОДЫ В ретроспективно-проспективном исследовании приняли участие 70 пациенток, родоразрешенных в зависимости от акушерских показаний консервативным или оперативным путем. Пациентки были разделены на две группы. В основную группу (группа № 1) вошли 35 пациенток с ГТ. Группу сравнения (группа № 2) составили 35 пациенток с содержанием тромбоцитов в крови выше 150×109/л. Проведен сравнительный межгрупповой анализ показателей общего анализа крови, коагулограммы, тромбоэластографии с выполнением теста на функциональный фибриноген перед родами и через 2 дня после родоразрешения. Ретроспективно проанализированы изменение содержания тромбоцитов и его влияние на коагуляционный статус пациенток в течение беременности. Проведена сравнительная оценка объемов кровопотери в родах и раннем послеродовом периоде и риска развития осложнений НАБ у пациенток с ГТ и без нее. Выявлено, что при ГТ в перинатальном периоде не происходит снижения коагуляционного потенциала, оцениваемого по результатам коагулографии и тромбоэластографии при уровне тромбоцитов выше 49×109/л. Исследованные показатели гемостаза не имели значимых межгрупповых различий в течение беременности и родов. В группе пациенток с ГТ объем кровопотери в родах и послеродовом периоде не отличался от группы без тромбоцитопении независимо от метода родоразрешения. Медиана кровопотери после родов через естественные родовые пути в группе № 1 составила 225 мл, в группе № 2 — 250 мл, при абдоминальном родоразрешении — 572 мл и 386 мл соответственно. В проведенном исследовании не зафиксировано каких-либо осложнений НАБ ни в одной из групп.ЗАКЛЮЧЕНИЕ Полученные результаты позволяют предположить, что у пациенток с ГТ даже при значительном снижении содержания тромбоцитов возможно выполнение НАБ в родах с учетом клинической картины и отсутствия нарушений коагуляции, подтвержденных тромбоэластографией

Respiratory Health Effects of Exposure to Low-NOx Unflued Gas Heaters in the Classroom: A Double-Blind, Cluster-Randomized, Crossover Study

There are long-standing concerns about adverse effects of gas appliances on respiratory health. However, the potential adverse effect of low-NOx (nitrogen oxide) unflued gas heaters on children’s health has not been assessed. Our goal was to compare the respiratory health effects and air quality consequences of exposure to low-NOx unflued gas heaters with exposure to non–indoor-air-emitting flued gas heaters in school classrooms. We conducted a double-blind, cluster-randomized, crossover study in 400 primary school students attending 22 schools in New South Wales, Australia. Children measured their lung function and recorded symptoms and medication use twice daily. Nitrogen dioxide (NO₂) and formaldehyde concentrations were measured in classrooms using passive diffusion badges.NO₂ concentrations were, on average, 1.8 times higher [95% confidence interval (CI), 1.6–2.1] and formaldehyde concentrations were, on average, 9.4 ppb higher (95% CI, 5.7–13.1) during exposure to unflued gas versus flued gas heaters. Exposure to the unflued gas heaters was associated with increased cough reported in the evening [odds ratio (OR) = 1.16; 95% CI, 1.01–1.34] and wheeze reported in the morning (OR = 1.38; 95% CI, 1.04–1.83). The association with wheeze was greater in atopic subjects. There was no evidence of an adverse effect on lung function. We conclude that classroom exposure to low-NOx unflued gas heaters causes increased respiratory symptoms, particularly in atopic children, but is not associated with significant decrements in lung function. It is important to seek alternative sources of heating that do not have adverse effects on health

Mobile apps in the educational process

В статье рассматривается применение мобильных приложений в образовательном процессе. В способах представления учебного материала с помощью мобильного устройства рассмотрены плюсы и минусы. Представлена практика создания приложений реальных проектов в рамках разработанного курса для преподавателей.The article discusses the use of mobile applications in the educational process. How a teacher can present his material using a mobile device, the pros and cons are considered. The practice of developing applications for real projects within the framework of the developed course for teachers is presented

Comparative morphological characteristics of the uteroplacental area in abnormal placentation

The aim. To carry out a comparative morphological characteristic of the uteroplacental area with abnormal placentation – pl. accreta, pl. increta, pl. percreta. Materials and methods. The study included 47 patients with atypical placentation; the comparison group included 10 healthy pregnant women with uterine scar after a previous caesarean section. A histological study of uteroplacental area samples was performed with hematoxylin and eosin, methylene blue staining. An immunohistochemical study with primary antibodies to cytokeratin 7 (CK7), Hif2a, vascular endothelial growth factor, α-SMA was carried out. The differences between the compared values were considered to be statistically significant at p < 0.05. The results of the study. Pl. accreta was determined in 12 (25.5 %), pl. increta – in 30 (63.9 %), pl. percreta – in 5 (10.6 %) patients. In all patients of the main group, the decidua was completely or partially absent in the area of abnormal placentation or was replaced by an uneven layer of fetal fibrinoid. Cases when placental villi unevenly penetrated into the thickness of myometrium in the form of “tongues” or “coves” bordered by fetal fibrinoid and often located intermuscularly were defined as pl. increta (n = 26). Cases with the placental villi ingrowth to the serous membrane were considered as pl.  percreta (n  =  5). In cases with deep variants of  ingrowth (pl. increta and pl. percreta) (n = 31), the villi were visualized in the lumen of the vessels and the thinning of the lower uterine segment with the presence of stretched muscle bundles was revealed. Aseptic necrosis of  the myometrium was  found: in 2 (16.7 %) of 12 women with pl. accreta, in 26 (86.7 %) of 30 women with pl. increta and in 5 (100 %) women with pl. percreta. There were no areas of necrosis in the myometrium of the women of comparison group. Conclusion. The appearance and increase of myometrial necrosis zones in response to an increase in the depth of placental villus ingrowth were detected. Myometrial necrosis zones could be the cause of activation of angiogenic factors and an important stimulus for the development of abnormal vascularization in placenta accreta spectrum

Behavior and Impact of Zirconium in the Soil–Plant System: Plant Uptake and Phytotoxicity

Because of the large number of sites they pollute, toxic metals that contaminate terrestrial ecosystems are increasingly of environmental and sanitary concern (Uzu et al. 2010, 2011; Shahid et al. 2011a, b, 2012a). Among such metals is zirconium (Zr), which has the atomic number 40 and is a transition metal that resembles titanium in physical and chemical properties (Zaccone et al. 2008). Zr is widely used in many chemical industry processes and in nuclear reactors (Sandoval et al. 2011; Kamal et al. 2011), owing to its useful properties like hardness, corrosion-resistance and permeable to neutrons (Mushtaq 2012). Hence, the recent increased use of Zr by industry, and the occurrence of the Chernobyl and Fukashima catastrophe have enhanced environmental levels in soil and waters (Yirchenko and Agapkina 1993; Mosulishvili et al. 1994 ; Kruglov et al. 1996)

ПАЛЕОТЕКТОНИЧЕСКИЕ И ПАЛЕОГЕОГРАФИЧЕСКИЕ ОБСТАНОВКИ НАКОПЛЕНИЯ НИЖНЕРИФЕЙСКОЙ АЙСКОЙ СВИТЫ БАШКИРСКОГО ПОДНЯТИЯ (ЮЖНЫЙ УРАЛ) НА ОСНОВЕ ИЗУЧЕНИЯ ДЕТРИТОВЫХ ЦИРКОНОВ МЕТОДОМ «TERRANECHRONE®»

The TerraneChrone® (LA-ICP-MS) technique has been applied to carry out an integrated study of detrital zircons in sandstones sampled from the basal horizons of the stratotypical Riphean sequence in the Southern Urals, specifically the Navysh and Chudin suites of the Ai Formation of the Burzyan Group in the Bashkir Uplift. The concentrations of trace elements in the detrital zircons suggest that the role of oceanic or marginal-marine complexes among the primary sources of zircons was insignificant, and show a better agreement with the intra-continental rather than passive-margin origin of the Riphean basin, whose basal levels are composed by the Ai Formation. The U/Pb ages of zircons from samples K13-206 and M08-16-1 are generally similar: the Paleoproterozoic zircons predominate (the dominant peaks are actually coincident, 2063 and 2055 Ma), and only a few grains of the Archean age are present. Despite the similar U/Pb ages of the detrital zircons, these two samples considerably differ in their Hf isotopic features and the concentrations of trace elements, which means that the zircons in the studied sandstones are of different geodynamic origin. The characteristics of these zircons can be explained by a model showing the Ai Formation in the Navysh graben that is a rift structure and a predecessor of the Kama-Belaya aulacogene in the inner Volga-Ural region of the Paleoproterozoic supercontinent Columbia. At the initial stage of rifting, the granitoid complexes with a lower total silicic acidity, which composed the graben walls, had been eroded; as a result of erosion, coarse clastic rocks accumulated within the Navysh graben and formed the Navysh suite. A specific “carbonatitic” complex containing zircons (about 2.0, 2.5, 2.85 and 3.6 Ga) and the Palaeoarchean crustal material in the substrate of their parent rocks was also eroded. In the final stage of rifting, already at the initial stages of the development of the Kama-Belaya aulacogen (Chudin suite), the erosion products from the paleo-aquifers occupying vast areas began to be transported into the rift. The primary sources of clastics for the Chudin suite were both granitoids of the lower and normal silicic acidity. Besides, a specific “carbonatitic” complex containing juvenile zircons (about 2.05 Ga) was eroded. However, by that time, significant areas of the Archaean basement of the Volga-Ural region might have become hidden underneath a proto-cover and thus not eroded, so the Archean detritus in the Chudin suite is poorly represented in comparison with the Navysh suite, considering both the amounts and ages of detrital zircons. As of today, the Precambrian carbonatite rocks within both the Taratash complex (composing the basement of the Navysh graben) and the southeastern segment of the East-European Platform have not yet been described. The source of the “carbonatite” zircons remains unknown and can be discovered as more and more data on the basement rocks is accumulated. В статье представлены результаты комплексного изучения по методике «TerraneChrone®» (LA-ICP-MS) детритных цирконов, выделенных из песчаников, слагающих базальные горизонты (навышская и чудинская подсвиты айской свиты бурзянской серии Башкирского поднятия) стратотипического разреза рифея на Южном Урале. Зафиксированные в цирконах содержания элементов-примесей свидетельствуют о малой роли комплексов океанического или окраинно-морского генезиса среди первичных источников цирконов и лучше согласуются с внутриконтинентальным, а не окраинно-континентальным расположением рифейского бассейна, базальные уровни которого выполнены айской свитой. U/Pb возрастные характеристики изученных цирконов в обеих пробах в общем схожи: преобладают палеопротерозойские цирконы (доминирующие пики фактически совпали – 2063 и 2055 млн лет), а архей представлен только немногочисленными зернами. При схожести U/Pb возрастных параметров детритных цирконов по Hf-изотопным признакам этих цирконов и содержаниям в них элементов-примесей зафиксированы существенные различия между пробами, свидетельствующие о том, что источниками цирконов для изученных песчаников были различные по геодинамической природе комплексы. Особенности характеристик цирконов в изученных пробах могут быть объяснены в рамках модели формирования айской свиты в рифтовой структуре – Навышском грабене – предшественнике Камско-Бельского авлакогена во внутренней волго-уральской части палеопротерозойского суперконтинента Колумбия. На начальной стадии рифтогенеза в Навышском грабене накапливались грубообломочные породы (навышская подсвита), представляющие собой продукты размыва слагающих борта этого грабена гранитоидных комплексов пониженной валовой кремнекислотности. В размыв попал также комплекс, содержащий специфические «карбонатитовые» цирконы с возрастом около 2.0, 2.5, 2.85 и 3.6 млрд лет и с участием палеоархейского корового материала в субстрате материнских по отношению к ним пород. В завершающую стадию рифтогенеза, уже на начальных стадиях развития Камско-Бельского авлакогена (чудинская подсвита), в грабен стали попадать эрозионные продукты с палеоводосборов, занимающих более обширные площади, первичными источниками кластики для которых были гранитоиды как пониженной, так и нормальной кремнекислотности. В размыв попал также комплекс, содержащий специфические ювенильные «карбонатитовые» цирконы с возрастом около 2.05 млрд лет. Однако к этому времени значительные площади архейского фундамента Волго-Уралии, вероятно, были покрыты проточехлом и не дренировались, поэтому архейский детрит в навышской подсвите представлен скуднее по сравнению с чудинской подсвитой и по количеству, и по возрастным группам. До сих пор докембрийские карбонатитовые породы ни в тараташском комплексе, слагающем фундамент Навышского грабена, ни в юго-восточной части Восточно-Европейской платформы не описаны, и вопрос об источнике этих «карбонатитовых» цирконов остается открытым, но имеет перспективу быть решенным по мере накопления данных о фундаменте

Tuberous Sclerosis Complex-Associated Neuropsychiatric Disorders (TAND): New Findings on Age, Sex, and Genotype in Relation to Intellectual Phenotype

Background: Knowledge is increasing about TSC-Associated Neuropsychiatric Disorders (TAND), but little is known about the potentially confounding effects of intellectual ability (IA) on the rates of TAND across age, sex, and genotype. We evaluated TAND in (a) children vs. adults, (b) males vs. females, and (c) TSC1 vs. TSC2 mutations, after stratification for levels of IA, in a large, international cohort. Methods: Individuals of any age with a documented visit for TSC in the 12 months prior to enrolment were included. Frequency and percentages of baseline TAND manifestations were presented by categories of IA (no intellectual disability [ID, intelligence quotient (IQ)>70]; mild ID [IQ 50–70]; moderate-to-profound ID [IQ<50]). Chi-square tests were used to test associations between ID and TAND manifestations. The association between TAND and age (children vs. adults), sex (male vs. female), and genotype (TSC1 vs. TSC2) stratified by IA levels were examined using the Cochran–Mantel–Haenszel tests. Results: Eight hundred and ninety four of the 2,211 participants had formal IQ assessments. There was a significant association (P < 0.05) between levels of IA and the majority of TAND manifestations, except impulsivity (P = 0.12), overactivity (P = 0.26), mood swings (P = 0.08), hallucinations (P = 0.20), psychosis (P = 0.06), depressive disorder (P = 0.23), and anxiety disorder (P = 0.65). Once controlled for IA, children had higher rates of overactivity, but most behavioral difficulties were higher in adults. At the psychiatric level, attention deficit hyperactivity disorder (ADHD) was seen at higher rates in children while anxiety and depressive disorders were observed at higher rates in adults. Compared to females, males showed significantly higher rates of impulsivity and overactivity, as well as autism spectrum disorder (ASD) and ADHD. No significant age or sex differences were observed for academic difficulties or neuropsychological deficits. After controlling for IA no genotype-TAND associations were observed, except for higher rates of self-injury in individuals with TSC2 mutations. Conclusions: Findings suggest IA as risk marker for most TAND manifestations. We provide the first evidence of male preponderance of ASD and ADHD in individuals with TSC. The study also confirms the association between TSC2 and IA but, once controlling for IA, disproves the previously reported TSC2 association with ASD and with most other TAND manifestations

Tuberous Sclerosis Complex-Associated Neuropsychiatric Disorders (TAND): New Findings on Age, Sex, and Genotype in Relation to Intellectual Phenotype.

Background: Knowledge is increasing about TSC-Associated Neuropsychiatric Disorders (TAND), but little is known about the potentially confounding effects of intellectual ability (IA) on the rates of TAND across age, sex, and genotype. We evaluated TAND in (a) children vs. adults, (b) males vs. females, and (c) TSC1 vs. TSC2 mutations, after stratification for levels of IA, in a large, international cohort. Methods: Individuals of any age with a documented visit for TSC in the 12 months prior to enrolment were included. Frequency and percentages of baseline TAND manifestations were presented by categories of IA (no intellectual disability [ID, intelligence quotient (IQ)>70]; mild ID [IQ 50-70]; moderate-to-profound ID [IQ<50]). Chi-square tests were used to test associations between ID and TAND manifestations. The association between TAND and age (children vs. adults), sex (male vs. female), and genotype (TSC1 vs. TSC2) stratified by IA levels were examined using the Cochran-Mantel-Haenszel tests. Results: Eight hundred and ninety four of the 2,211 participants had formal IQ assessments. There was a significant association (P < 0.05) between levels of IA and the majority of TAND manifestations, except impulsivity (P = 0.12), overactivity (P = 0.26), mood swings (P = 0.08), hallucinations (P = 0.20), psychosis (P = 0.06), depressive disorder (P = 0.23), and anxiety disorder (P = 0.65). Once controlled for IA, children had higher rates of overactivity, but most behavioral difficulties were higher in adults. At the psychiatric level, attention deficit hyperactivity disorder (ADHD) was seen at higher rates in children while anxiety and depressive disorders were observed at higher rates in adults. Compared to females, males showed significantly higher rates of impulsivity and overactivity, as well as autism spectrum disorder (ASD) and ADHD. No significant age or sex differences were observed for academic difficulties or neuropsychological deficits. After controlling for IA no genotype-TAND associations were observed, except for higher rates of self-injury in individuals with TSC2 mutations. Conclusions: Findings suggest IA as risk marker for most TAND manifestations. We provide the first evidence of male preponderance of ASD and ADHD in individuals with TSC. The study also confirms the association between TSC2 and IA but, once controlling for IA, disproves the previously reported TSC2 association with ASD and with most other TAND manifestations

Renal angiomyolipoma in patients with tuberous sclerosis complex: findings from the TuberOus SClerosis registry to increase disease Awareness

BACKGROUND: Renal angiomyolipoma occurs at a high frequency in patients with tuberous sclerosis complex (TSC) and is associated with potentially life-threatening complications. Despite this frequency and severity, there are no large population-based cohort studies. Here we present baseline and follow-up data of the international TuberOus SClerosis registry to increase disease Awareness (TOSCA) with an aim to provide detailed clinical characteristics of renal angiomyolipoma among patients with TSC. METHODS: Patients of any age with a documented clinic visit for TSC within 12 months or who were newly diagnosed with TSC before participation in the registry were eligible. Data specific to renal angiomyolipoma included physical tumour characteristics (multiple, bilateral, lesion size and growing lesions), clinical signs and symptoms, and management. The effects of age, gender and genotype on the prevalence of renal angiomyolipoma were also evaluated. RESULTS: Renal angiomyolipoma was reported in 51.8% of patients at baseline, with higher frequency in female patients (57.8% versus 42.2%). The median age at diagnosis was 12 years. Prevalence of angiomyolipoma was higher in patients with TSC2 compared with TSC1 mutations (59.2% versus 33.3%, P 3 cm in 34.3% of patients. Most patients were asymptomatic (82%). Frequently reported angiomyolipoma-related symptoms included bleeding, pain, elevated blood pressure and impaired renal function. Embolization and mammalian target of rapamycin inhibitors were the two most common treatment modalities. CONCLUSIONS: The TOSCA registry highlights the burden of renal angiomyolipoma in patients with TSC and shows that renal manifestations are initially asymptomatic and are influenced by gender and genotype. Furthermore, the occurrence of significant problems from angiomyolipoma in a minority of younger patients suggests that surveillance should begin in infancy or at initial diagnosis