Maternal and Cord Serum Cytokine Changes with Continuous and Intermittent Labor Epidural Analgesia: A Randomized Study

Background. Maternal fever during labor epidural analgesia (LEA) may cause increased maternal and cord serum inflammatory cytokines. We report the effects of intermittent and continuous LEA on these cytokines. Methods. Ninety-two women were randomly assigned to continuous (CLEA) or intermittent (ILEA) groups, 46 in each. Maternal temperature was checked and blood drawn at epidural insertion (baseline) and four-hourly until 4 h postpartum (4 PP). Cord blood was drawn after placental delivery. Interleukin-1β (IL-1β), interleukin-6 (IL-6), interleukin-8 (IL-8), granulocyte macrophage-colony stimulating factor (GM-CSF), and tumor necrosis factor-α (TNF-α) were measured and analyzed according to group randomization, and then combined and reanalyzed as febrile (temperature ≥38°C) or afebrile groups. Results. Significant intragroup changes from baseline were noted in some groups. Data are pg/mL, median (Q1/Q3). IL-6 rose at all time points in all groups. CLEA: baseline: 18.5 (12.5/31.1), 4 h: 80.0 (46.3/110.8), 8 h: 171.9 (145.3/234.3), and 4 PP: 81 (55.7/137.4). ILEA: baseline: 15.7 (10.2/27.1), 4 h: 68.2 (33.3/95.0), 8 h: 125.0 (86.3/195.0), and 4 PP: 70.2 (54.8/103.6). Febrile group: baseline: 21.6 (13.8/40.9), 4 h: 83.9 (47.5/120.8), 8 h: 186.7 (149.6/349.9), and 4 PP: 105.8 (65.7/158.8). Afebrile group: baseline: 10.9 (2.1/17.4), 4 h: 38.2 (15.0/68.2), 8 h: 93.8 (57.1/135.7), and 4 PP: 52.9 (25.1/78). IL-8 rose at all time points in CLEA: baseline: 2.68 (0.0/4.3), 4 h: 3.7 (0.0/6.5), 8 h: 6.0 (3.3/9.6), 4 PP: 5.6 (0.8/8.0), and afebrile group baseline: 2.5 (0.0/4.7), 4 h: 3.3 (0.0/6.2), 8 h: 5.3 (1.9/9.8), and 4 PP: 4.7 (0.0/7.6). It fell at 4 PP in febrile group: baseline: 4.1 (0.0/6.4), 4 h: 3.8 (0.0/6.5), 8 h: 5.2 (2.5/8.0), and 4 PP: 2.9 (0.0/4.0). GM-CSF increased at 8 h and decreased at 4 PP in ILEA baseline: 2.73 (0.0/7.2), 4 h: 2.73 (0.0/7.9), 8 h: 3.9 (2.7/11.5), and 4 PP: 2.0 (0.0/7.2). It increased at 4 h and 8 h and decreased at 4 PP in febrile group: baseline: 2.6 (0.0/4.2), 4 h: 3.2 (2.1/7.0), 8 h: 4.0 (3.2/12.3), and 4 PP: 2.4 (1.7/12.6). There were no intergroup cytokine changes in maternal or cord serum in CLEA versus ILEA or febrile versus afebrile groups. Conclusions. Some cytokines, especially IL-6, rise physiologically during labor epidural analgesia

Mineral and Bone Disorders After Kidney Transplantation

The risk of mineral and bone disorders among patients with chronic kidney disease is substantially elevated, owing largely to alterations in calcium, phosphorus, vitamin D, parathyroid hormone, and fibroblast growth factor 23. The interwoven relationship among these minerals and hormones results in maladaptive responses that are differentially affected by the process of kidney transplantation. Interpretation of conventional labs, imaging, and other fracture risk assessment tools are not standardized in the post-transplant setting. Post-transplant bone disease is not uniformly improved and considerable variation exists in monitoring and treatment practices. A spectrum of abnormalities such as hypophosphatemia, hypercalcemia, hyperparathyroidism, osteomalacia, osteopenia, and osteoporosis are commonly encountered in the post-transplant period. Thus, reducing fracture risk and other bone-related complications requires recognition of these abnormalities along with the risk incurred by concomitant immunosuppression use. As kidney transplant recipients continue to age, the drivers of bone disease vary throughout the post-transplant period among persistent hyperparathyroidism, de novo hyperparathyroidism, and osteoporosis. The use of anti-resorptive therapies require understanding of different options and the clinical scenarios that warrant their use. With limited studies underscoring clinical events such as fractures, expert understanding of MBD physiology, and surrogate marker interpretation is needed to determine ideal and individualized therapy

Adaptive Feedback Techniques for Synchronized Multimedia Retrieval over Integrated Networks

Recent advances in networking, storage and computer technologies are stimulating the development of multimedia on-demand services providing services similar to those of a neighborhood videotape rental store over metropolitan area networks. In this paper, we develop inter-media synchronization techniques for multimedia on-demand retrieval over integrated networks in the absence of global clocks. In these techniques, multimedia servers use light-weight messages called feedback units transmitted by media display sites (such as audiophones and videophones, generically referred to as mediaphones) to detect asynchronies among those sites. We present strategies by which the multimedia server, based on its most recent estimate of how soon playback may go out of synchrony at each mediaphone, can adaptively control the feedback transmission rate from that mediaphone, so as to minimize the associated overheads without permitting the asynchrony to exceed tolerable limits. We propose vario..

Feedback Techniques for Intra-Media Continuity and Inter-Media Synchronization in Distributed Multimedia Systems

Future advances in networking and storage will make it feasible to build multimedia on-demand servers that provide services similar to those of a neighborhood videotape rental store over metropolitan area networks such as B-ISDN. Such multimedia servers can support real-time retrieval of multimedia objects by users onto their ISDN videophones and audiophones for playback. The design of techniques and protocols for providing continuous and synchronous access to multimedia services constitutes the subject matter of this paper. In future integrated networks, mediaphones that possess bare minimum capability to playback media but which lack the sophistication to run elaborate time synchronization protocols may be connected directly to the network. We present rate-based feedback strategies by which, during retrieval, a multimedia server uses light-weight messages called feedback units transmitted periodically by mediaphones, to accurately estimate the playback instants of media units. Using ..

Optimal Communication Architectures for Multimedia Conferencing in Distributed Systems

: Advances in computer and communication technologies have stimulated the integration of digital video and audio with computing, leading to the development of computer-assisted multimedia conferencing. We address the problem of media mixing which arises in teleconferencing applications. We compare the performance of monostage and multistage techniques for mixing. We analyze centralized and distributed architectures for their suitability to both monostage and multistage media mixing, and propose hierarchical architectures for significantly reducing bandwidth consumption. We present algorithms for designing hierarchies that optimize real-time end-to-end delays. We then propose a packet train protocol in which the routing nodes themselves of a network can be used as mixers and mixing can be integrated with routing. 1 Introduction Recent advances in communication technology have made large bandwidth networks pervasive. Coupled with the advances in computer technology, which have resulted..

Hierarchical Conferencing Architectures for Inter-Group Multimedia Collaboration

Advances in computer and communication technologies have stimulated the integration of digital video and audio with computing, leading to the development of various computer-assisted collaborations. In this paper, we propose a multi-level conferencing paradigm (called super conferences) for supporting collaborative interactions between geographically separated groups of users, with each group belonging to possibly a different organization. Hierarchical communication architectures are naturally suited for carrying out media transmission in super conferences. We study the performance of hierarchical communication architectures, and present algorithms for bounding end-to-end delays of real-time media traffic in them. We derive some interesting limits on the number of participants in a group and the number of groups within a super conference, so as not to violate bandwidth and delay requirements of multimedia. At the Multimedia Laboratory at the University of California, San Diego, we have..

Designing an On-Demand Multimedia Service

Future advances in networking coupled with rapid advances in storage technologies will make it feasible to build a multimedia on-demand server capable of providing services similar to those of a neighborhood videotape rental store on a metropolitan-area network. In this paper, we study various admission control policies that permit such a multimedia server to satisfy multiple subscribers simultaneously without violating any of their continuous media playback requirements. We propose a quality proportional policy that retrieves media blocks at a rate proportional on an average to the playback rates of media streams, but uses a staggered toggling technique by which successive numbers of media blocks retrieved are fine-tuned individually to admit and service an optimal number of subscribers simultaneously. This policy permits dynamic additions and deletions of requests in a transparent manner (i.e., without causing discontinuity in the retrieval of any of the existing requests). Performan..

Communication Architectures and Algorithms for Media Mixing in Multimedia Conferences

Advances in computer and communication technologies have stimulated the integration of digital video and audio with computing, leading to the development of computer-assisted multimedia conferencing. We address the problem of media mixing which arises in tele-conferencing applications such as tele-orchestra. We present a mixing algorithm which minimizes the difference between generation times of the media packets that are being mixed together in the absence of globally synchronized clocks, but in the presence of jitter in communication delays on packet switched networks. The algorithm is shown to be complete: given that there are no other message exchangesexcept media data between mixersandmediasources,there cannot be any other algorithm that succeeds when our algorithm fails. Mixing can be accomplished by several different communication architectures. In order to support applications such as tele-orchestra, which involve a large number of participants, we propose hierarchical mixing a..