Patients Prefer Propofol to Midazolam Plus Fentanyl for Sedation for Colonoscopy: Results of a Single-Center Randomized Equivalence Trial.

BACKGROUND: Common sedation options for colonoscopy include propofol alone or a combination of midazolam and fentanyl. The former usually requires the presence of an anesthesia caregiver. The strategy that optimizes patient satisfaction has not yet been determined. OBJECTIVE: This study was designed to assess whether patient satisfaction at the time of colonoscopy is equivalent for propofol compared with midazolam and fentanyl. DESIGN: In this prospective, single-center, parallel group, single-blind, randomized, equivalence trial (NCT-01488045), 262 patients blinded to treatment received propofol (n = 126) or midazolam plus fentanyl (n = 136) at the time of colonoscopy. A patient satisfaction survey was administered in the recovery room and 1 to 5 days postprocedure. The endoscopist completed a survey immediately postprocedure. SETTINGS: This study was conducted at a tertiary academic hospital with a dedicated colon and rectal surgery division. PATIENTS: Patients over the age of 18 years who were undergoing elective colonoscopy were included in this study. MAIN OUTCOME MEASURES: The primary outcome was patient satisfaction with the colonoscopy. Secondary outcomes included physician and patient perception of patient pain, physician perception of patient tolerance of and difficulty of procedure, procedure duration, percentage of patients with cecal intubation, recovery time, and adverse events. RESULTS: Patient overall satisfaction scores in the recovery room after using the combination of midazolam and fentanyl (n = 136) during colonoscopy were not equivalent to patient satisfaction scores after using propofol (n = 126) alone (mean = 83.9 and 98.0 visual analog scale points) because the 90% CI (-18.5 to -9.6) for the mean treatment difference (-14.1) was completely outside the prespecified range of equivalence (±5 visual analog scale points). Patient pain as reported by the patient and as perceived by the physician and difficulty of the procedure were significantly worse for the midazolam/fentanyl group (n = 136) compared with the propofol group (n = 126). Time in the colonoscopy suite was significantly shorter for the propofol group, but the difference was small (4 minutes). There were no significant differences in percentage with cecal intubation, recovery time, or adverse events. LIMITATIONS: This is a single-institution, single-endoscopist study and is limited by the inability to perform blinding of the endoscopist. CONCLUSIONS: The use of propofol for conscious sedation during colonoscopy is associated with greater patient satisfaction and less pain when compared with midazolam/fentanyl, as perceived by the patient and endoscopist.

A comparison of laparoscopic and robotic colorectal surgery outcomes using the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database.

BACKGROUND: Until randomized trials mature, large database analyses assist in determining the role of robotics in colorectal surgery. ACS NSQIP database coding now allows differentiation between laparoscopic (LC) and robotic (RC) colorectal procedures. The purpose of this study was to compare LC and RC outcomes by analyzing the ACS NSQIP database. METHODS: The ACS NSQIP database was queried to identify patients who had undergone RC and LC during 2013. Demographic characteristics, intraoperative data, and postoperative outcomes were identified. Using propensity score matching, abdominal and pelvic colorectal operative and postoperative outcomes were analyzed. RESULTS: A total of 11,477 cases were identified. In the abdomen, 7790 LC and 299 RC cases were identified, and 2057 LC and 331 RC cases were identified in the pelvis. There were significant differences in operative time, conversion to an open procedure in the pelvis, and hospital length of stay. RC operative times were significantly longer in both abdominal and pelvic cases. Conversion rates in the pelvis were less for RC when compared to LC--10.0 and 13.7%, respectively (p = 0.01). Hospital length of stay was significantly shorter for RC abdominal cases than for LC abdominal cases (4.3 vs. 5.3 days, p < 0.001) and for RC pelvic cases when compared to LC pelvic cases (4.5 vs. 5.3 days, p < 0.001). There were no significant differences in surgical site infection (SSI), organ/space SSI, wound complications, anastomotic leak, sepsis/shock, or need for reoperation within 30 days. CONCLUSION: As the robotic platform continues to grow in colorectal surgery and as technical upgrades continue to advance, comparison of outcomes requires continuous reevaluation. This study demonstrated that robotic operations have longer operative times, decreased hospital length of stay, and decreased rates of conversion to open in the pelvis. These findings warrant continued evaluation of the role of minimally invasive technical upgrades in colorectal surgery.

Autologous Fat Grafting After Breast Reconstruction in Postmastectomy Patients: Complications, Biopsy Rates, and Locoregional Cancer Recurrence Rates.

BACKGROUND: Autologous fat grafting is widely used for refinements in postmastectomy breast reconstruction. However, there are few studies evaluating outcomes in this patient population. The purpose of this study was to assess outcomes of autologous fat grafting after breast reconstruction in postmastectomy patients. METHODS: We retrospectively reviewed the records of consecutive postmastectomy patients who underwent autologous fat grafting after breast reconstruction at a university center over a 5-year period. Patients with at least 6 months of follow-up were included. Medical records were reviewed for demographics, operative details, complications, incidence of palpable masses, and/or suspicious breast imaging findings requiring biopsy, and locoregional cancer recurrence. Descriptive statistics were generated. RESULTS: Between January 2008 and July 2013, 108 women and a total of 167 breast reconstructions underwent autologous fat grafting for revision of postmastectomy breast reconstruction. Their ages ranged from 22 to 71 years (mean, 48 years). Fat grafts were harvested, processed, and injected using the Coleman technique. The mean number of fat grafting procedures was 1.3 (range, 1-4) per breast. Follow-up ranged from 6 to 57 months (mean, 20.2 months). Fifty-three (31.7%) breasts underwent imaging after autologous fat grafting. Suspicious imaging findings requiring biopsy were discovered in 4 (2.4%) breasts, and clinically palpable lesions combined with suspicious imaging findings requiring biopsy were present in another 4 (2.4%) breasts. All 8 biopsies showed fat necrosis, scar, or oil cysts without evidence of malignancy. One (0.6%) local complication (a wound infection at the recipient site requiring oral antibiotics) after autologous fat grafting was reported. During the limited follow-up period, there were no locoregional cancer recurrences. CONCLUSIONS: Autologous fat grafting in conjunction with breast reconstruction resulted in a biopsy rate of 4.8%, and no cases of locoregional cancer recurrence were observed. Based on these preliminary findings, autologous fat grafting appears to be a relatively safe procedure for refinement of the reconstructed breast in postmastectomy patients.

Chlorhexidine with isopropyl alcohol versus iodine povacrylex with isopropyl alcohol and alcohol- versus nonalcohol-based skin preparations: the incidence of and readmissions for surgical site infections after colorectal operations.

BACKGROUND: Surgical site infections are a major cause of morbidity and mortality after colorectal operations. Preparation of the surgical site with antiseptic solutions is an essential part of wound infection prevention. To date, there is no universal consensus regarding which preparation is most efficacious. OBJECTIVE: This study compared 2.0% chlorhexidine with 70.0% isopropyl alcohol versus 0.7% iodine povacrylex with 74.0% isopropyl alcohol and alcohol-based versus nonalcohol-based skin preparations with regard to efficacy in preventing postoperative wound infections. DESIGN: This is a retrospective study from 2 prospectively collected statewide databases combined. A propensity score model was used to adjust for differences between the groups in patient demographics, characteristics, comorbidities, and laboratory values. SETTINGS: The multicenter data set used in this analysis represents a variety of academic and community hospitals within the state of Michigan from January 2010 through June 2012. PATIENTS: Patients over the age of 18 years who underwent clean-contaminated colorectal operations were included. MAIN OUTCOME MEASURES: The incidence of superficial surgical site infections, any surgical site infection, any wound complication, and readmission within 30 days for surgical site infection were measured. RESULTS: When 2.0% chlorhexidine with 70.0% isopropyl alcohol (n = 425) and 0.7% iodine povacrylex with 74.0% isopropyl alcohol (n = 115) were compared, a total of 540 colorectal cases met inclusion criteria. When alcohol-based (n = 610) and nonalcohol-based (n = 177) skin preparations were compared, a total of 787 colorectal cases met inclusion criteria. There was no significant difference in the propensity-adjusted odds for having any of the 4 outcomes of interest when comparing 2.0% chlorhexidine with 70.0% isopropyl alcohol to 0.7% iodine povacrylex with 74.0% isopropyl alcohol and when comparing alcohol-based with nonalcohol-based skin preparations. LIMITATIONS: This was a nonrandomized study performed retrospectively based on data collected within the state of Michigan. CONCLUSIONS: The use of 2.0% chlorhexidine with 70.0% isopropyl alcohol versus 0.7% iodine povacrylex with 74.0% isopropyl alcohol or alcohol-based versus nonalcohol-based skin preparations does not significantly influence the incidence of surgical site infections or readmission within 30 days for surgical site infection after clean-contaminated colorectal operations.

Nonsteroidal Anti-inflammatory Drugs: Do They Increase the Risk of Anastomotic Leaks Following Colorectal Operations?

BACKGROUND: Nonsteroidal anti-inflammatory drugs have become an important component of narcotic-sparing postoperative pain management protocols. However, conflicting evidence exists regarding the adverse association of nonsteroidal anti-inflammatory drug use with intestinal anastomotic healing in colorectal surgery. OBJECTIVE: This study compares patients receiving nonsteroidal anti-inflammatory drugs on postoperative day 1 with patients who did not receive nonsteroidal anti-inflammatory drugs with regard to the occurrence of anastomotic leaks. DESIGN: This is a retrospective study from a protocol-driven prospectively collected statewide database. A propensity score model was used to adjust for differences between the groups in patient demographics, characteristics, comorbidities, and laboratory values. SETTINGS: The multicenter data set used in this analysis represents a variety of academic and community hospitals within the state of Michigan from July 2012 through February 2014. PATIENTS: Nonpregnant patients over the age of 18 who underwent colon and rectal surgery with bowel anastomosis were selected. MAIN OUTCOME MEASURES: Occurrence of anastomotic leak, composite surgical site infection, sepsis, and death within 30 days of surgery were the primary outcomes measured. RESULTS: A total of 4360 patients met inclusion criteria, of which 1297 (29.7%) received nonsteroidal anti-inflammatory drugs and 3063 (70.3%) did not receive nonsteroidal anti-inflammatory drugs. There was no statistically significant difference between the 2 groups in the proportion of cases with anastomotic leak (OR, 1.33; CI, 0.86-2.05; p = 0.20), composite surgical site infection (OR, 1.26; CI, 0.96-1.66; p = 0.09), or death within 30 days (OR, 0.58; CI, 0.28-1.19; p = 0.14). There was a significantly greater risk of sepsis for patients given nonsteroidal anti-inflammatory drugs than for those patients not given nonsteroidal anti-inflammatory drugs (OR, 1.47; CI, 1.05-2.06; p = 0.03). LIMITATIONS: This is a nonrandomized study performed retrospectively, and it is based on data collected only within a subset of hospitals in the state of Michigan. CONCLUSIONS: No statistically significant increase in the proportion of patients with anastomotic leak was observed when prescribing nonsteroidal anti-inflammatory drugs for analgesia in the early postoperative period for patients undergoing elective colorectal surgery. Unexpectedly, there was an increased risk of sepsis that warrants further investigation (see video, Supplemental Digital Content 1, http://links.lww.com/DCR/A192, for a synopsis of this study).

Postoperative hyperglycemia and adverse outcomes in patients undergoing colorectal surgery: results from the Michigan surgical quality collaborative database.

PURPOSE: Our objective was to assess the relationship between high blood glucose levels (BG) in the early postoperative period and the incidence of surgical site infections (SSIs), sepsis, and death following colorectal operations. METHODS: The Michigan Surgical Quality Collaborative database was queried for colorectal operations from July 2012 to December 2013. Normoglycemic (BG < 180 mg/dL) and hyperglycemic (BG ≥ 180 mg/dL) groups were defined by using the highest BG within the first 72 h postoperatively. Outcomes of interest included the incidence of superficial, deep, and organ/space SSIs, sepsis, and death within 30 days. Initial unadjusted analysis was followed by propensity score matching and multiple logistic regression modeling after adjusting for significant predictors. Separate analyses were performed for previously diagnosed diabetic and non-diabetic patients. RESULTS: A total of 5145 cases met inclusion criteria, of which 1072 were diabetic. For diabetic patients, there was a marginally significant association between high BG and superficial SSI in the unadjusted analysis (OR = 1.75, p = 0.056), but not in the adjusted analysis (OR = 1.35, p = 0.39). There was no significant relationship between elevated BG and deep SSI, organ/space SSI, sepsis, or death among diabetic patients. For non-diabetic patients, there was a significant association between high BG and superficial SSI (OR = 1.53, p = 0.03), sepsis (OR = 1.61, p < 0.01), and death (OR = 2.26, p < 0.01), but not deep or organ/space SSI. CONCLUSIONS: Following colorectal operations, superficial SSI, sepsis, and death are associated with postoperative serum hyperglycemia in patients without diabetes, but not those with diabetes. Vigilant postoperative BG monitoring is critical for all patients undergoing colorectal surgery.

Dietary outcomes in a Spanish-language randomized controlled diabetes prevention trial with pregnant Latinas.

OBJECTIVES: We evaluated the effectiveness of a community-based healthy lifestyle intervention in improving dietary behaviors of pregnant Latinas from 2004 to 2006 in Detroit, Michigan. METHODS: The 11-week, culturally tailored, Spanish-language Healthy Mothers on the Move (MOMs) intervention offered home visits, group classes, related activities, and social support from trained community health workers (CHWs) and peers. Dietary behaviors were measured by food frequency questionnaire. Linear mixed models estimated pre- and post-intervention changes, within and between MOMs intervention and minimal intervention (MI) groups. RESULTS: MOMs (n = 139) and MI (n = 139) participants had similar baseline characteristics and dietary intake. Post-intervention, MOMs participants showed significant improvement in all dietary behaviors, except fruit and fiber consumption. Compared with MI participants, MOMs participants had significantly decreased consumption of added sugar (P = .05), total fat (P < .05), saturated fat (P < .01), percentage of daily calories from saturated fat (P < .001), solid fats and added sugars (P < .001), and had increased vegetable consumption (P < .001). Their increase in fiber consumption (P < .05) was significant relative to MI participants' decrease in fiber intake. CONCLUSIONS: We confirmed the hypothesis that a community-planned, CHW-led healthy lifestyle intervention could improve dietary behaviors of low-income Latina women during pregnancy.

Abdominal ultrasound versus hepato-imino diacetic acid scan in diagnosing acute cholecystitis--what is the real benefit?

BACKGROUND: Acute cholecystitis is one of the most common surgical problems, yet substantial debate remains over the utility of simple examination, abdominal ultrasound (AUS), or advanced imaging such as hepato-imino diacetic acid (HIDA) scan to support the diagnosis. MATERIALS AND METHODS: The preoperative diagnostic workup of patients who underwent cholecystectomy with histologically confirmed acute cholecystitis was reviewed to calculate the sensitivity of AUS, HIDA scan, or both. In addition, the sensitivity of the commonly described ultrasonographic findings was assessed. RESULTS: From 2010 through 2012, 406 patients among 9087 reviewed charts presented to the emergency department with acute upper abdominal pain and met inclusion criteria. 32.5% (N = 132) of patients underwent AUS only, 11.3% (N = 46) underwent HIDA scan only, and 56.2% (N = 228) had both studies performed for workup. 52.7% (N = 214) of patients had histopathologically confirmed acute cholecystitis. The sensitivities of AUS, HIDA, and AUS combined with HIDA for acute cholecystitis were 73.3% (95% confidence interval [CI] = 66.3%-79.5%), 91.7% (95% CI = 86.2%-95.5%), and 97.7% (95% CI = 93.4%-99.5%), respectively. Although of limited sensitivity, AUS findings of sonographic Murphy sign, gallbladder distension, and gallbladder wall thickening were associated with a diagnosis of acute cholecystitis. CONCLUSIONS: The sensitivity of AUS for diagnosing acute cholecystitis in patients with acute upper abdominal pain is limited. The addition of a HIDA scan in the diagnostic workup significantly improves sensitivity and can add valuable information in the appropriate clinical setting.

Classic Whipple versus pylorus-preserving pancreaticoduodenectomy in the ACS NSQIP.

BACKGROUND: The classic Whipple operation carries substantial risk of complications. A pylorus-preserving pancreaticoduodenectomy might confer the benefit of decreased perioperative morbidity, but existing data comparing both techniques are inconclusive. METHODS: Using a propensity score model to adjust for potentially confounding differences in patient characteristics, 30-d mortality, operative time, red blood cell transfusion requirements, major complications, and length of hospital stay were compared between both techniques in the American College of Surgeons' National Surgical Quality Improvement Program database. Separate analyses were carried out for underlying malignancy or benign disease, as defined by International Classification of Diseases, Ninth Revision codes. RESULTS: A total of 6988 pancreaticoduodenectomies from 2005 through 2010 were included. In 5424 patients (77.6%) with underlying malignancy, there were no significant differences for 30-d mortality (2.4% versus 2.8%, P = 0.33) and major organ system complications (all P > 0.10). Patients undergoing the classic Whipple operation had a significantly longer operative time (389 versus 366 min, P < 0.01), longer length of hospital stay (13.1 versus 12.0 days, P < 0.01), and higher red blood cell transfusion requirements (1.0 versus 0.8 units, P < 0.01). Results were similar for 1564 patients (22.4%) with underlying benign disease, except for a higher occurrence of postoperative pulmonary (P = 0.02) and renal (P = 0.05) complications in patients undergoing the classic Whipple operation. CONCLUSIONS: Short-term outcomes after classic and pylorus-preserving pancreaticoduodenectomy in this large, multicenter database are excellent, without significant differences in postoperative mortality and most major organ system complications. However, small advantages in resource and blood utilization may be accomplished with the pylorus-preserving technique.

Postoperative surgical site infections after ventral/incisional hernia repair: a comparison of open and laparoscopic outcomes.

BACKGROUND: The purpose of this study was to compare the incidence of postoperative surgical site infections (SSIs), operative times (OTs), and length of hospital stay (LOS) after open and laparoscopic ventral/incisional hernia repair (VIHR) using multicenter, prospectively collected data. METHODS: The incidence of postoperative SSIs, OTs, and LOS was determined for cases of VIHR in the American College of Surgeons' National Surgical Quality Improvement Program database in 2009 and 2010. Open and laparoscopic techniques were compared using a propensity score model to adjust for differences in patient demographics, characteristics, comorbidities, and laboratory values. RESULTS: A total of 26,766 cases met the inclusion criteria; 21,463 cases were open procedures (reducible, n = 15,520 [72 %]; incarcerated/strangulated, n = 5,943 [28 %]), and 5,303 cases were laparoscopic procedures (reducible, n = 3,883 [73 %]; incarcerated/strangulated, n = 1,420 [27 %]). Propensity score adjusted odds ratios (ORs) were significantly different between open and laparoscopic VIHR for reducible and incarcerated/strangulated hernias with regard to superficial SSI (OR 5.5, p < 0.01 and OR 3.1, p < 0.01, respectively), deep SSI (OR 6.9, p < 0.01, and OR 8.0, p < 0.01, respectively) and wound disruption (OR 4.6, p < 0.01 and OR 9.3, p = 0.03, respectively). The risk for organ/space SSI was significantly greater for open operations among reducible hernias (OR 1.9, p = 0.02), but there was no significant difference between the open and laparoscopic repair groups for incarcerated/strangulated hernias (OR 0.8, p = 0.41). The OT was significantly longer for laparoscopic procedures, both for reducible (98.5 vs. 84.9 min, p < 0.01) and incarcerated/strangulated hernias (96.4 vs. 81.2 min, p < 0.01). LOS (mean, 95 % confidence interval) was significantly longer for open repairs for both reducible (open = 2.79, 2.59-3.00; laparoscopic = 2.39, 2.20-2.60; p < 0.01) and incarcerated/strangulated (open = 2.64, 2.55-2.73; laparoscopic = 2.17, 2.02-2.33; p < 0.01) hernias. CONCLUSIONS: Laparoscopic VIHR for reducible and incarcerated/strangulated hernias is associated with shorter LOS and decreased risk for superficial SSI, deep SSI, and wound disruption, but longer OTs when compared to open repair.

Effect of the healthy MOMs lifestyle intervention on reducing depressive symptoms among pregnant Latinas.

Depression during the prenatal and postpartum periods is associated with poor maternal, perinatal and child outcomes. This study examines the effectiveness of a culturally and linguistically tailored, social support-based, healthy lifestyle intervention led by trained community health workers in reducing depressive symptoms among pregnant and early postpartum Latinas. A sample of 275 pregnant Latinas was randomized to the Healthy MOMs Healthy Lifestyle Intervention (MOMs) or the Healthy Pregnancy Education (control) group. More than one-third of participants were at risk for depression at baseline. MOMs participants were less likely than control group participants to be at risk for depression at follow-up. Between baseline and 6 weeks postpartum, MOMs participants experienced a significant decline in depressive symptoms; control participants experienced a marginally significant decline. For MOMs participants, most of this decline occurred during the pregnancy intervention period, a time when no change occurred for control participants. The change in depressive symptoms during this period was greater among MOMs than control participants ("intervention effect"). From baseline to postpartum, there was a significant intervention effect among non-English-speaking women only. These findings provide evidence that a community-planned, culturally tailored healthy lifestyle intervention led by community health workers can reduce depressive symptoms among pregnant, Spanish-speaking Latinas.

Intravenous fat emulsions reduction for patients with parenteral nutrition-associated liver disease.

OBJECTIVE: To test the hypothesis that implementation of a marked reduction in intravenous fat will result in reversal of parenteral nutrition-associated liver disease (PNALD) in infants. STUDY DESIGN: Prospective study of intravenous fat emulsion reduction in parenteral nutrition to 1 g/kg/d 2 times per week in neonates diagnosed with PNALD. Primary outcome measure was total bilirubin levels compared with gestational age, birth weight, and diagnosis-matched historical controls receiving 3 g/kg/d of intravenous lipids. RESULTS: Intravenous fat emulsion reduction resulted in a significant decline in total bilirubin levels compared with controls. Comparison of growth in the 2 groups was similar. Mild essential fatty acid deficiency was detected in 8 of 31 infants and was reversed with additional days of lipid infusion. No significant adverse events were noted. CONCLUSIONS: An association between intravenous lipid emulsion administration and the development of PNALD seems probable. Use of intravenous fat emulsion reduction is a potential approach to reverse PNALD in young infants. Frequent monitoring of essential fatty acid deficiency is needed with the use of this regimen.

Risk factors for anastomotic leakage after colectomy.

BACKGROUND: Anastomotic leakage is a morbid and potentially fatal complication of colorectal surgery. Determination of pre- and intraoperative risk factors may identify patients requiring increased postoperative surveillance for this major complication. OBJECTIVE: The purpose of this study was to identify risk factors associated with anastomotic leakage after colectomy with primary intra-abdominal anastomosis. DESIGN: The prospective, statewide multicenter Michigan Surgical Quality Collaborative database was analyzed. SETTING: This study was performed at academic and community medical centers in the state of Michigan. PATIENTS: Included were all cases of open and laparoscopic colectomy with primary intra-abdominal anastomosis from 2007 through 2010. MAIN OUTCOME MEASURES: Univariate analysis followed by a multivariate logistic regression model was used to determine the influence of patient factors and operative events with respect to the incidence of postoperative anastomotic leakage. RESULTS: Inclusion criteria were met by 4340 cases. Anastomotic leakage occurred in 85 (3.2%) of the 2626 (60.5%) open colectomies, and in 51 (3.0%) of the 1714 (39.5%) laparoscopic procedures, which was not significantly different (p = 0.63). Significant risk factors associated with anastomotic leakage based on the multivariate logistic regression model were fecal contamination with OR 2.51, 95% CI, 1.16 to 5.45, p = 0.02; and intraoperative blood loss of more than 100 mL and 300 mL, with OR 1.62, 95% CI, 1.10 to 2.40, p = 0.02; and OR 2.22, 95% CI, 1.32 to 3.76, p = 0.003. LIMITATIONS: The Michigan Surgical Quality Collaborative colectomy project excluded high-risk rectal resections and low pelvic anastomoses. Information about operative technique and intraoperative events is limited, and anastomotic leakage was determined through chart review. CONCLUSION: Fecal contamination and increased blood loss during colectomy should raise suspicion for potential postoperative anastomotic leakage.

Developmental programming: impact of excess prenatal testosterone on intrauterine fetal endocrine milieu and growth in sheep.

Prenatal testosterone excess in sheep leads to reproductive and metabolic disruptions that mimic those seen in women with polycystic ovary syndrome. Comparison of prenatal testosterone-treated sheep with prenatal dihydrotestosterone-treated sheep suggests facilitation of defects by androgenic as well as androgen-independent effects of testosterone. We hypothesized that the disruptive impact of prenatal testosterone on adult pathology may partially depend on its conversion to estrogen and consequent changes in maternal and fetal endocrine environments. Pregnant Suffolk sheep were administered either cottonseed oil (control) or testosterone propionate in cottonseed oil (100 mg, i.m. twice weekly), from Day 30 to Day 90 of gestation (term is ~147 d). Maternal (uterine) and fetal (umbilical) arterial samples were collected at Days 64-66, 87-90, and 139-140 (range; referred to as D65, D90, and D140, respectively) of gestation. Concentrations of gonadal and metabolic hormones, as well as differentiation factors, were measured using liquid chromatography/mass spectrometer, radioimmunoassay, or ELISA. Findings indicate that testosterone treatment produced maternal and fetal testosterone levels comparable to adult males and D65 control male fetuses, respectively. Testosterone treatment increased fetal estradiol and estrone levels during the treatment period in both sexes, supportive of placental aromatization of testosterone. These steroidal changes were followed by a reduction in maternal estradiol levels at term, a reduction in activin A availability, and induction of intrauterine growth restriction in D140 female fetuses. Overall, our findings provide the first direct evidence in support of the potential for both androgenic as well as estrogenic contribution in the development of adult reproductive and metabolic pathology in prenatal testosterone-treated sheep.

Survival outcomes of pediatric intestinal failure patients: analysis of factors contributing to improved survival over the past two decades.

BACKGROUND: Intestinal failure (IF) is associated with significant and life-threatening complications. Recent studies suggest that treatments for IF in the pediatric population are improving over time. Based on this, we examined whether pediatric IF survival rates have improved in our patient population over the past two decades, and secondarily examined which aspects of patient care contributed to changes in survival. METHODS: We conducted a retrospective chart review of all pediatric patients with IF at our children's hospital from 1990 through 2009. Cox regression analyses were used to determine change in survival rates over time (5-y cohorts), and we examined multiple covariates to determine their potential influence on survival rates over time. RESULTS: A significant improvement in survival of 171 children with IF was noted over the past two decades. Children with an onset of IF in the 1990-1994 cohort had significantly decreased survival compared with children in all subsequent cohorts (P = 0.011). The only intervention that was identified between this time period and future periods was the establishment of a comprehensive intestinal failure clinical care team. While the latter three cohorts were not significantly different, progressively increased survival was noted. Ability to wean off parenteral nutrition (PN) and small bowel length greater than 10% of the expected length were significantly associated with improved survival over this time period (P < 0.01). Other tested covariates, including the more recent use of ethanol lock therapy (to prevent catheter sepsis) and lipid reduction strategies (to treat PN-associated cholestasis) failed to show a significant impact on improved survival. CONCLUSIONS: Despite a striking improvement in survival of children with IF over the past two decades, the only identified intervention that significantly impacted survival was establishment of a comprehensive care team. These findings emphasize the need for multi-disciplinary efforts to care for such complex and challenging children.

Perineural dexmedetomidine added to ropivacaine causes a dose-dependent increase in the duration of thermal antinociception in sciatic nerve block in rat.

BACKGROUND: The current study was designed to test the hypothesis that dexmedetomidine added to ropivacaine would increase the duration of antinociception to a thermal stimulus in a dose-dependent fashion in a rat model of sciatic nerve blockade. METHODS: Fifty adult Sprague-Dawley rats (10 rats/group) received unilateral sciatic nerve blocks with 0.2 ml ropivacaine (0.5%) or 0.2 ml ropivacaine (0.5%) plus dexmedetomidine (2.7 microm [0.5 microg/kg], 11.7 microm [2 microg/kg], 34.1 microm [6 microg/kg], or 120.6 microm [20 microg/kg]) in a randomized, blinded fashion. Time to paw withdrawal latency to a thermal stimulus for both paws and an assessment of motor function were measured every 30 min after the nerve block until a return to baseline. RESULTS: Dexmedetomidine added to ropivacaine increased the duration of dense sensory blockade and time for return to normal sensory function in a dose-dependent fashion (P < 0.005). There was a significant time (P < 0.005), dose (P < 0.005), and time-by-dose effect (P < 0.005) on paw withdrawal latencies of the operative paws. There were no significant differences in paw withdrawal latencies of the control paws, indicating little systemic effect of the dexmedetomidine. The duration of motor blockade was also increased with dexmedetomidine. High-dose dexmedetomidine (120.6 mum) was not neurotoxic. CONCLUSION: This is the first study showing that dexmedetomidine added to ropivacaine increases the duration of sensory blockade in a dose-dependent fashion in rats. The findings are an essential first step encouraging future efficacy studies in humans.

Relationships among body mass index, parental perceptions, birthweight and parental weight after referral to a weight clinic.

OBJECTIVE: We sought to determine whether, in a specialty referral clinic, parental perceptions of their child's obesity were commensurate with the child's body mass index z score. Secondarily, we examined the impact of birth weight and parental body mass index on their child's body mass index z score and review results of an intake questionnaire. DESIGN: Cross-sectional study SETTING: University of Michigan from March 21, 2003 through June 30, 2004 PARTICIPANTS: Eighty-two children ages 1-20.2 years of age INTERVENTION: Body mass index z score for all participants was calculated. An intake questionnaire was completed by caregivers in which they were asked to describe their child as little overweight, overweight, very overweight or obese. OUTCOME MEASURES: Mean body mass index z score was compared to each parental descriptor. Regression analysis related body mass index z score to birthweight and parental body mass index. RESULTS: Body mass index z score was not related to parental descriptors. Maternal body mass index and child birthweight were predictors of the child's body mass index z score (r2=0.15, p<0.05; and r2=0.11, p<0.05, respectively). Both together produced a better model than either alone (r2=0.23, p<0.05). There was no relationship between paternal and child body mass index z score (p>0.05). CONCLUSIONS: There is a divergence between the parental perception of childhood obesity and the clinical definition that persists even in the context of an explicit referral. Given the significant impact of maternal weight on childhood overweight, education for prevention of overweight youth should encompass prenatal, early childhood and adolescent health maintenance.

Fetal programming: prenatal testosterone treatment leads to follicular persistence/luteal defects; partial restoration of ovarian function by cyclic progesterone treatment.

Prenatal testosterone (T) excess during midgestation leads to estrous cycle defects and polycystic ovaries in sheep. We hypothesized that follicular persistence causes polycystic ovaries and that cyclic progesterone (P) treatment would overcome follicular persistence and restore cyclicity. Twice-weekly blood samples for P measurements were taken from control (C; n = 16) and prenatally T-treated (T60; n = 14; 100 mg T, im, twice weekly from d 30-90 of gestation) Suffolk sheep starting before the onset of puberty and continuing through the second breeding season. A subset of C and T60 sheep were treated cyclically with a modified controlled internal drug-releasing device for 13-14 d every 17 d during the first anestrus (CP, 7; TP, 6). Transrectal ovarian ultrasonography was performed for 8 d in the first and 21 d in the second breeding season. Prenatal T excess reduced the number, but increased the duration of progestogenic cycles, reduced the proportion of ewes with normal cycles, increased the proportion of ewes with subluteal cycles, decreased the proportion of ewes with ovulatory cycles, induced the occurrence of persistent follicles, and reduced the number of corpora lutea in those that cycled. Cyclic P treatment in anestrus, which produced one third the P concentration seen during luteal phase of cycle, did not reduce the number of persistent follicles, but increased the number of progestogenic cycles while reducing their duration. These findings suggested that follicular persistence might contribute to the polycystic ovarian morphology. Cyclic P treatment was able to only partially restore follicular dynamics, but this may be related to the low replacement concentrations of P achieved.

The transmission of BANA-positive periodontal bacterial species from caregivers to children.

BACKGROUND: The purpose of the authors' study was to use the N-benzoyl-DL-arginine-2-naphthy-lamide (BANA) test (BANAMet LLC, Ann Arbor, Mich.) to obtain information regarding the prevalence of an enzyme unique to certain periodontal pathogens in plaque samples of children, as well as the potential transmission of these pathogens from caregivers to children. METHODS: The authors tested 218 subjects (3 to 10 years old) and 195 care-givers at four pediatric dentistry clinics in Taipei, Taiwan. RESULTS: Forty-four percent of the children had at least one plaque sample that tested positive and/or weakly positive. Positive results were more frequent in the mixed dentition, as well as in children with gingivitis (P < .001). A logistic regression model showed that if the BANA test results for the care-giver were positive, the odds of the child's also having positive test results were 55 times greater (P < .001; confidence interval [CI] = 14 to 224) than those for a child whose caregiver had negative BANA test results. Other predictors were the presence of a mixed dentition (P < .001; odds ratio [OR] = 11; CI = 3.5 to 33.5) and the children's papillary bleeding scores (P < .001, OR = 3.1, CI = 2.0 to 4.7). CONCLUSION: The BANA test results were positive for almost one-half of the children. A positive reaction was associated with gingivitis, a mixed dentition, a BANA-positive caregiver or a caregiver with a history of periodontal disease in the family. CLINICAL IMPLICATIONS: The authors propose an anaerobic periodontal infection risk model in which children with a mixed dentition who have gingivitis and a caregiver with a history of periodontal disease would undergo the BANA test.

Impact of the Nationwide Intravenous Selenium Product Shortage on the Development of Selenium Deficiency in Infants Dependent on Long-Term Parenteral Nutrition.

BACKGROUND: For patients dependent on parenteral nutrition (PN), selenium must be supplemented intravenously. A nationwide intravenous selenium shortage began in April 2011. The impact of this shortage on PN-dependent infants was evaluated by examining the provision of selenium, development of biochemical deficiency, and costs associated with the shortage. MATERIALS AND METHODS: This single-center, retrospective study included PN-dependent infants aged ≤1 year who weighed ≤30 kg, received PN for ≥1 month, and had ≥1 serum selenium measurement. The primary outcome was the incidence of biochemical selenium deficiency. Secondary outcomes included severity of biochemical deficiency, clinical manifestations, costs, and relationship between serum selenium levels and selenium dose. RESULTS: The average selenium dose decreased 2-fold during the shortage (2.1 ± 1.2 µg/kg/d; range, 0.2-4.6 µg/kg/d) versus the nonshortage period (3.8 ± 1 µg/kg/d; range, 2.4-6 µg/kg/d; P < .001). A linear relationship between serum selenium concentration and selenium dose was observed (r(2) = 0.42), with a dose of 6 µg/kg/d expected to result in normal serum levels in most cases. Similar proportions of patients developed biochemical deficiency in both groups: shortage period, 59.1%; nonshortage, 66.7%; P = .13. The severity of biochemical deficiency was similar between groups. A significant increase in incremental cost during the shortage was observed. CONCLUSION: This is the first study examining the impact of the intravenous selenium shortage on PN-dependent infants. Both groups exhibited similarly high incidences of biochemical selenium deficiency, suggesting higher empiric doses may benefit this population. However, ongoing shortages limit the ability to provide supplementation.