Epidural extension failure in obese women is comparable to that of non-obese women.

BACKGROUND: Management of labor epidurals in obese women is difficult and extension to surgical anesthesia is not always successful. Our previous retrospective pilot study found epidural extension was more likely to fail in obese women. This study used a prospective cohort to compare the failure rate of epidural extension in obese and non-obese women and to identify risk factors for extension failure. METHODS: One hundred obese participants (Group O, body mass index ≥ 40 kg/m2 ) were prospectively identified and allocated two sequential controls (Group C, body mass index ≤ 30 kg/m2 ). All subjects utilized epidural labor analgesia and subsequently required anesthesia for cesarean section. The primary outcome measure was failure of the labor epidural to be used as the primary anesthetic technique. Risk factors for extension failure were identified using Chi-squared and logistic regression. RESULTS: The odds ratio (OR) of extension failure was 1.69 in Group O (20% vs. 13%; 95% CI: 0.88-3.21, P = 0.11). Risk factors for failure in obese women included ineffective labor analgesia requiring anesthesiologist intervention, (OR 3.94, 95% CI: 1.16-13.45, P = 0.028) and BMI > 50 kg/m2 (OR 3.42, 95% CI: 1.07-10.96, P = 0.038). CONCLUSION: The failure rate of epidural extension did not differ significantly between the groups. Further research is needed to determine the influence of body mass index > 50 kg/m2 on epidural extension for cesarean section.

Disrupted salience network functional connectivity and white-matter microstructure in persons at risk for psychosis: findings from the LYRIKS study.

BACKGROUND: Salience network (SN) dysconnectivity has been hypothesized to contribute to schizophrenia. Nevertheless, little is known about the functional and structural dysconnectivity of SN in subjects at risk for psychosis. We hypothesized that SN functional and structural connectivity would be disrupted in subjects with At-Risk Mental State (ARMS) and would be associated with symptom severity and disease progression. METHOD: We examined 87 ARMS and 37 healthy participants using both resting-state functional magnetic resonance imaging and diffusion tensor imaging. Group differences in SN functional and structural connectivity were examined using a seed-based approach and tract-based spatial statistics. Subject-level functional connectivity measures and diffusion indices of disrupted regions were correlated with CAARMS scores and compared between ARMS with and without transition to psychosis. RESULTS: ARMS subjects exhibited reduced functional connectivity between the left ventral anterior insula and other SN regions. Reduced fractional anisotropy (FA) and axial diffusivity were also found along white-matter tracts in close proximity to regions of disrupted functional connectivity, including frontal-striatal-thalamic circuits and the cingulum. FA measures extracted from these disrupted white-matter regions correlated with individual symptom severity in the ARMS group. Furthermore, functional connectivity between the bilateral insula and FA at the forceps minor were further reduced in subjects who transitioned to psychosis after 2 years. CONCLUSIONS: Our findings support the insular dysconnectivity of the proximal SN hypothesis in the early stages of psychosis. Further developed, the combined structural and functional SN assays may inform the prognosis of persons at-risk for psychosis.

Assessing the impact of a nurse-delivered home dried blood spot service on uptake of testing for household contacts of hepatitis B-infected pregnant women across two London trusts.

Despite national guidance recommending testing and vaccination of household contacts of hepatitis B-infected pregnant women, provision and uptake of this is sub-optimal. The aim of this study was to evaluate the use of in-home dried blood spot (DBS) testing to increase testing and vaccination of household contacts of hepatitis B-infected pregnant women as an alternative approach to conventional primary-care follow-up. The study was conducted across two London maternity trusts (North Middlesex and Newham). All hepatitis B surface antigen-positive pregnant women identified through these trusts were eligible for inclusion. The intervention of in-home DBS testing for household contacts was introduced at North Middlesex Trust from November 2010 to December 2011. Data on testing and vaccination uptake from GP records across the two trusts were compared between baseline (2009) and intervention (2010-2011) periods. In-home DBS service increased testing uptake for all ages (P < 0·001) with the biggest impact seen in partners, where testing increased from 30·3% during the baseline period to 96·6% during the intervention period in North Middlesex Trust. Although impact on vaccine uptake was less marked, improvements were observed for adults. The provision of nurse-led home-based DBS may be useful in areas of high prevalence.

Influences of prenatal and postnatal maternal depression on amygdala volume and microstructure in young children.

Maternal depressive symptoms influence neurodevelopment in the offspring. Such effects may appear to be gender-dependent. The present study examined contributions of prenatal and postnatal maternal depressive symptoms to the volume and microstructure of the amygdala in 4.5-year-old boys and girls. Prenatal maternal depressive symptoms were measured using the Edinburgh Postnatal Depression Scale (EPDS) at 26 weeks of gestation. Postnatal maternal depression was assessed at 3 months using the EPDS and at 1, 2, 3 and 4.5 years using the Beck's Depression Inventory-II. Structural magnetic resonance imaging and diffusion tensor imaging were performed with 4.5-year-old children to extract the volume and fractional anisotropy (FA) values of the amygdala. Our results showed that greater prenatal maternal depressive symptoms were associated with larger right amygdala volume in girls, but not in boys. Increased postnatal maternal depressive symptoms were associated with higher right amygdala FA in the overall sample and girls, but not in boys. These results support the role of variation in right amygdala structure in transmission of maternal depression to the offspring, particularly to girls. The differential effects of prenatal and postnatal maternal depressive symptoms on the volume and FA of the right amygdala suggest the importance of the timing of exposure to maternal depressive symptoms in brain development of girls. This further underscores the need for intervention targeting both prenatal and postnatal maternal depression to girls in preventing adverse child outcomes.

Surgical complications of Tenckhoff catheters used in continuous ambulatory peritoneal dialysis.

INTRODUCTION: The objective of this study was to audit the early and late complications of open Tenckhoff catheter insertion under local anaesthesia in a single institution. METHODS: A review was carried out on 164 insertions in 139 patients over a three-year period. All patient records were retrospectively analysed until the time of transfer to haemodialysis, death, or to current time if alive and receiving continuous ambulatory peritoneal dialysis (CAPD). Patient characteristics, operative factors, early and late complications were recorded. RESULTS: Early complications were reported in 31 percent of catheter insertions, predominantly wound infections and catheter malfunctions. The factors that were significantly associated with early complications were diabetes mellitus, glomerulonephritis, ongoing sepsis, previous abdominal surgery and prolonged surgical time. Late complications were seen in 26 percent of catheter insertions, mainly CAPD peritonitis. Poor nutritional status had a significant negative impact on late complications. The overall median catheter survival time was 41.9 months (95 percent confidence interval, 25.8-58.0 months). In addition, no significant difference in catheter survival time was detected between those patients with and those without diabetes mellitus. CONCLUSION: Tenckhoff catheter insertion for CAPD is a procedure associated with significant surgical morbidity. Patients with diabetes mellitus, glomerulonephritis and ongoing sepsis are at greater risk of early complications, and hence, must have their conditions stabilised or treated before surgery. In addition, prolonged surgical time and patients with previous abdominal surgery are at increased risk. The rate of complications may be improved by early consideration of patients with poor tolerance of local anaesthetic surgery or with previous abdominal surgery for laparoscopic insertion under general anaesthesia. To prevent late complications dominated by CAPD peritonitis, patients' nutritional status and care of the catheter should both be optimised.

A comparison of the T-piece, Venturi T-piece and T-bag for emergence with the laryngeal mask.

We have compared the performance of a standard T-piece, a Venturi T-piece and a T-bag (T-piece with a small reservoir bag) for emergence with the laryngeal mask airway in 20 awake volunteers. FiO2, ETCO2 and FiCO2 were measured at oxygen flow rates of 2, 4 and 6 l.min-1 during three different breathing patterns: normal tidal volume, respiratory rate 12 .min-1; normal tidal volume, respiratory rate 20 .min-1; high tidal volume, respiratory rate 12 .min-1. The T-piece and T-bag delivered a higher overall average FiO2 than the Venturi T-piece (P < 0.00001). Compared with normal breathing, FiO2 was reduced at the higher respiratory rate and tidal volume with the T-piece and T-bag but was not reduced with the Venturi T-piece. FiO2 increased with increasing flow rates for all devices except the Venturi T-piece during normal breathing. ETCO2 was higher during normal breathing (4.4 +/- 0.8%) compared with higher respiratory rate (3.7 +/- 0.9%) and tidal volume (3.4 +/- 0.7%) for all devices. There were no differences in overall ETCO2 between devices. The FiCO2 was never higher than 0.2% in any subject. We conclude that the T-piece and T-bag are more effective oxygen enrichment devices than the Venturi T-piece. The T-bag provides a useful visual signal about depth and frequency of respiration.

Clearance of an obstructed endotracheal tube with an arterial embolectomy catheter with the patient in the prone position.

The obstruction of an endotracheal tube with the patient in the prone position creates major anaesthetic difficulties that may result in patient morbidity and mortality. We describe a case involving the clearing of a blocked endotracheal tube with an arterial embolectomy catheter and discuss the relevance to anaesthetic practice.