The association between fatty acid index and in vitro fertilization outcomes.

PURPOSE: Fatty acids have been shown to play an important role in oocyte competence and early implantation of the embryo. Our hypothesis-generating study sought to determine if individual fatty acids expressed as a percentage of total erythrocyte fatty acids are associated with embryo quality and other in vitro fertilization (IVF) outcomes. METHODS: This was a prospective cohort study at an academic fertility center. Sixty women undergoing their first IVF cycle were recruited. Serum measurements of 22 fatty acids were obtained. We calculated each fatty acid as a percentage of total fatty acids, defined as the index for that individual fatty acid. RESULTS: Omega-3 index had no correlation with IVF outcomes. A negative correlation was found between the trans fatty acid index, elaidic acid (EA), and IVF outcomes, including fertilization rate (r = - 0.261, p = 0.04), blastocyst conversion rate (r = - 0.41, p = 0.001), and number of usable blastocysts and embryos (r = - 0.411, p = 0.001). There was no correlation between EA index and number of oocytes retrieved, embryo grade, or clinical pregnancy. No consistent correlations were observed with the additional fatty acids analyzed. CONCLUSIONS: No correlation was observed between omega-3 index and IVF outcomes. Elevated erythrocyte EA index, the major trans fatty acid commonly consumed in hydrogenated oils, margarine, and fried foods, was negatively correlated with number of usable blastocysts and embryos, blastocyst conversion, and fertilization rate. Our findings suggest preliminary evidence that trans fat may be negatively associated with IVF outcomes.

Diagnostic Accuracy of Right Ventricular Dysfunction Markers in Normotensive Emergency Department Patients With Acute Pulmonary Embolism.

STUDY OBJECTIVE: We determine the diagnostic accuracy of goal-directed echocardiography, cardiac biomarkers, and computed tomography (CT) in early identification of severe right ventricular dysfunction in normotensive emergency department patients with pulmonary embolism compared with comprehensive echocardiography. METHODS: This was a prospective observational study of consecutive normotensive patients with confirmed pulmonary embolism. Investigators, blinded to clot burden and biomarkers, performed qualitative goal-directed echocardiography for right ventricular dysfunction: right ventricular enlargement (diameter greater than or equal to that of the left ventricle), severe right ventricular systolic dysfunction, and septal bowing. Brain natriuretic peptide and troponin cutoffs of greater than or equal to 90 pg/mL and greater than or equal to 0.07 ng/mL and CT right ventricular:left ventricular diameter ratio greater than or equal to 1.0 were also compared with comprehensive echocardiography. RESULTS: One hundred sixteen normotensive pulmonary embolism patients (111 confirmed by CT, 5 by ventilation-perfusion scan) were enrolled. Twenty-six of 116 patients (22%) had right ventricular dysfunction on comprehensive echocardiography. Goal-directed echocardiography had a sensitivity of 100% (95% confidence interval [CI] 87% to 100%), specificity of 99% (95% CI 94% to 100%), positive likelihood ratio (+LR) of 90.0 (95% CI 16.3 to 499.8), and negative likelihood ratio (-LR) of 0 (95% CI 0 to 0.13). Brain natriuretic peptide had a sensitivity of 88% (95% CI 70% to 98%), specificity of 68% (95% CI 57% to 78%), +LR of 2.8 (95% CI 2.0 to 3.9), and -LR of 0.17 (95% CI 0.06 to 0.43). Troponin had a sensitivity of 62% (95% CI 41% to 80%), specificity of 93% (95% CI 86% to 98%), +LR of 9.2 (95% CI 4.1 to 20.9), and -LR of 0.41 (95% CI 0.24 to 0.62). CT had a sensitivity of 91% (95% CI 72% to 99%), specificity of 79% (95% CI 69% to 87%), +LR of 4.3 (95% CI 2.8 to 6.7), and -LR of 0.11 (95% CI 0.03 to 0.34). CONCLUSION: Goal-directed echocardiography was highly accurate for early severe right ventricular dysfunction identification and pulmonary embolism risk-stratification. Brain natriuretic peptide was sensitive but less specific, whereas troponin had lower sensitivity but higher specificity. CT had good sensitivity and moderate specificity.

Early neurologic examination is not reliable for prognostication in post-cardiac arrest patients who undergo therapeutic hypothermia.

BACKGROUND: Recent advances in post-cardiac arrest (CA) care including therapeutic hypothermia (TH) have improved survival and favorable neurologic outcomes for survivors of CA. Survivors often present with deep coma and lack of brainstem reflexes, which are generally associated with adverse outcomes in many disease processes. Little is known regarding the role of initial emergency department (ED) neurological examination and its potential for prognostication. OBJECTIVES: The purpose of this study is to determine if components of a standardized neurologic examination are reliable prognosticators in patients recently resuscitated from CA. We hypothesize that lack of neurologic function does not reliably predict an adverse outcome and, therefore, should not be used to determine eligibility for TH. METHODS: A standardized neurologic examination was performed in the ED on a prospective, convenience cohort of post-CA patients presenting to a CA resuscitation center who would undergo a comprehensive postarrest care pathway that included TH. Data such as prior sedation or active neuromuscular blockade were documented to evaluate for the presence of possible confounders. Examination findings were then compared with hospital survival and neurologic outcome at discharge as defined by the cerebral performance category (CPC) score as documented in the institutional TH registry. RESULTS: Forty-nine subjects were enrolled, most of whom presented comatose with a Glasgow Coma Scale of 3 (n=41, 83.7%). Nineteen subjects (38.8%) had absence of all examination findings, of which 4 of 19 (21.1%) survived to hospital discharge. Of those with at least 1 positive examination finding, 13 of 30 subjects (43.3%) survived to hospital discharge. Subgroup analysis showed that 9 of the 19 patients with absence of brainstem reflexes did not have evidence of active neuromuscular blockade at the time of the examination; 2 of 9 (22.1%) survived to hospital discharge. Eight of these subjects in this group had not received any prior sedation; 1 of 8 (12.5%) survived to hospital discharge. Only 1 of the 17 subjects who survived was discharged with poor neurologic function with a CPC score=3, whereas all others who survived had good neurologic function, CPC score=1. CONCLUSION: In this cohort of patients treated in a comprehensive postarrest care pathway that included TH, absence of neurologic function on initial ED presentation was not reliable for prognostication. Given these findings, clinicians should refrain from using the initial ED neurological examination to guide the aggressiveness of care or in counseling of family members regarding anticipated outcome.

Interobserver and Intraobserver Agreement on Qualitative Assessments of Right Ventricular Dysfunction With Echocardiography in Patients With Pulmonary Embolism.

OBJECTIVES: To evaluate observer agreement using qualitative goal-directed echocardiographic criteria for right ventricular (RV) dysfunction prognostication in submassive pulmonary embolism (PE). METHODS: Two emergency physicians and 2 cardiologists independently reviewed 31 packets of goal-directed echocardiographic video clips consisting of at least 3 windows obtained by emergency physicians from normotensive patients with PE. Nine packets were repeated to assess for intraobserver agreement. Right ventricular dysfunction criteria on goal-directed echocardiography were as follows: RV enlargement was present, with a right-to-left ventricular basal diameter ratio of 1.0 or higher and blunting of the apex of the RV in 2 or more different windows; RV systolic dysfunction was present if the tricuspid annulus moved toward the apex 10 mm or less and there was RV free wall hypokinesis; and septal deviation was present with any flattening or deviation of the ventricular septum toward the left ventricle. RESULTS: Among the 4 participants, there was 83.9% agreement on the presence or absence of RV enlargement (κ = 0.84), 74.2% agreement on the presence or absence of RV systolic dysfunction (κ = 0.69), and 71.0% agreement on the presence or absence of septal deviation (κ = 0.59). Intraobserver agreement was 100% for each RV dysfunction variable for each observer (κ = 1.0). CONCLUSIONS: Agreement was substantial for both severe RV enlargement and RV systolic dysfunction and moderate for septal deviation. Right ventricular dysfunction assessment with qualitative goal-directed echocardiographic criteria is reproducible for PE risk stratification.

BCNU wafer placement with temozolomide (TMZ) in the immediate postoperative period after tumor resection followed by radiation therapy with TMZ in patients with newly diagnosed high grade glioma: final results of a prospective, multi-institutional, phase II trial.

Temozolomide (TMZ) and BCNU have demonstrated anti-glioma synergism in preclinical models. We report final data from a prospective, multi-institutional study of BCNU wafers and early TMZ followed by radiation therapy with TMZ in patients with newly diagnosed malignant glioma. 65 patients were consented in 4 institutions, and 46 patients (43 GBM, 3 AA) were eligible for analysis. After resection and BCNU wafer placement, TMZ began on day four postoperatively. Radiation and TMZ (RT/TMZ) were then administered, followed by monthly TMZ at 200 mg/m2 for the first 26 patients, which was reduced to 150 mg/m2 for the remaining 20 patients. Non-hematologic toxicities were minimal. Nine of 27 patients (33 %) who received 200 mg/m2 TMZ, but only 1 of 20 (5 %) who received 150 mg/m2, experienced grade 3/4 thrombocytopenia. Median progression free survival (PFS) and overall survival (OS) period was 8.5 and 18 months, respectively. The 1-year OS rate was 76 %, which is a significant improvement compared with the historical control 1-year OS rate of 59 % (p = 0.023). However, there was no difference in 1-year OS compared with standard RT/TMZ (p = 0.12) or BCNU wafer followed by RT/TMZ (p = 0.87) in post hoc analyses. Early post-operative TMZ can be safely administered with BCNU wafers following resection of malignant glioma at the 150 mg/m2 dose level. Although there was an OS benefit compared to historical control, there was no indication of benefit for BCNU wafers and early TMZ in addition to standard RT/TMZ or early TMZ in addition to regimens of BCNU wafers followed by RT/TMZ.

Increased Anesthesia Usage in a Large-Volume Endoscopy Unit: Patient Acuity Is Not the Main Predictor.

OBJECTIVES: The use of monitored anesthesia care (MAC) for colonoscopy sedation continues to increase. This study examined trends during a 9-year period in the use of MAC and explored which patient variables may have influenced these trends. METHODS: This was a retrospective review of all colonoscopies performed in our hospital-based endoscopy unit from 2003 through 2012. We determined whether MAC was used and if not, which quantitative doses of sedative agents were used. Several patient-related variables were evaluated for correlation. Data were analyzed (t test, χ(2), logistic regression) using SAS statistical software. RESULTS: Between January 2003 and October 2012, we identified 37,803 performed colonoscopies. The use of MAC increased significantly, from 0.38% in 2003 to 10.0% in 2012 (P < 0.0001). For cases in which conscious sedation was used, the mean doses of sedatives did not change significantly over time. Although there was an association between certain patient variables (female sex; higher American Society of Anesthesiologists class; diagnostic procedures; and pulmonary, psychiatric, renal or cerebrovascular diseases) and the use of MAC, the greatest predictor of MAC use was the year of the procedure. After adjusting for the patient variables that were examined, the odds of using MAC increased by approximately 1.5 times per year from 2003 through 2012. The adjusted odds of using MAC in 2012 were 35.8 times higher than in 2003. CONCLUSIONS: The use of MAC for colonoscopies performed in our endoscopy unit increased significantly from 2003 to 2012. Although increased MAC use was associated with some patient variables, it was most significantly associated with the year of the procedure. This suggests that there were other nonpatient-related factors influencing its use.

Production and expression of RANTES (CCL5) by human disc cells and modulation by IL-1-ß and TNF-α in 3D culture.

Chemokines act as important secondary inflammatory mediators which are released by cells in response to a variety of stimuli. Chemokines bind to cell surface receptors and act as second-order cytokines with specialized functions in inflammation. The role of RANTES (Regulated upon Activation, Normal T-cell Expressed, and Secreted) (also called CCL5 (chemokine (C-C motif) ligand 5)) has received little attention to date in disc tissue. Microarray analyses of lumbar disc annulus tissue revealed that RANTES expression was significantly upregulated in more degenerated Thompson grades IV and V discs compared to expression levels in grades I, II and III discs (p=0.032). Immunolocalization confirmed the presence of RANTES in the annulus and nucleus of the disc, and localized the RANTES receptors CCR1, CCR3 and CCR5 to cells in the disc. In vitro studies with IL-1-ß and TNF-α challenges, both proinflammatory cytokines resulted in elevated levels of RANTES in conditioned media (p<0.01); TNF-α exposure, however, produced significantly greater levels than did IL-1alpha (p<0.0001), suggesting a differential regulation by TNF-α. Local production of RANTES in vivo by annulus and nucleus cells, and in vitro induction of RANTES by proinflammatory cytokines suggest that disc cells are primary effector cells as well as target cells, and thus can mediate physiological immune-related processes during disc degeneration by both autocrine and paracrine signaling.

Vestibular deficits leading to disequilibrium and falls in ambulatory amyotrophic lateral sclerosis.

OBJECTIVE: To assess vestibular deficits in response to disequilibrium in ambulatory individuals with amyotrophic lateral sclerosis (ambALS). DESIGN: All participants completed standard protocols for the Sensory Organization Test (SOT) by computerized dynamic posturography. SETTING: Multidisciplinary amyotrophic lateral sclerosis clinic at an academic medical center. PARTICIPANTS: Study participants (N=34) consisted of ambALS (n=19) and healthy controls (HC) (n=15). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Equilibrium scores (ESs) obtained from averaged sway amplitude in condition 5 (ES5) and condition 6 (ES6) of the SOT. RESULTS: In conditions of altered somatosensory information with vision absent or vision sway-referenced, the mean ± SD scores for ambALS (ES5=51.4±22.5; ES6=50.8±22.1) were lower than those for HC (ES5=65.4±11.7, P≤.03; ES6=58.9±12.5, P>.05). Seven ambALS (37%) experienced a total of 19 falls during the sway-referenced support test conditions. There were no falls in the HC. CONCLUSIONS: Nearly 37% of ambALS with normal clinical balance testing have decreased ability to use the vestibular input and required increased reliance on visual input for postural orientation to sustain equilibrium. The mechanism of this alteration in sensory preference is not completely clear. Extrapyramidal involvement early in ALS may be indicated.

Spontaneous age-related cervical disc degeneration in the sand rat.

BACKGROUND: Disc space narrowing, osteophytes, and disc degeneration are common and increase with aging. Few animal models are appropriate for the study of spontaneous age-related cervical disc degeneration. QUESTIONS/PURPOSES: We used the sand rat, a member of the gerbil family with well-recognized age-related lumbar disc degeneration, to determine whether spontaneous cervical disc degeneration differed from lumbar degeneration when evaluated by (1) radiologic and (2) histologic measures. Animals 2 to 25 months of age were used in these analyses. METHODS: Cervical and lumbar discs of 99 sand rats were analyzed with radiology, and cervical discs of 67 sand rats were studied with histology. Lateral digital radiographs of cervical and lumbar spines were scored for presence or absence of wedging, disc space narrowing, osteophytes, end plate calcification, and irregular disc margins at C2-C3 through C6-C7 and T12-L1 through L7-S1. Percentages for presence were calculated and statistically analyzed for younger (range, 2-11.9 months old) versus older (range, 12.0-25 months old) animals. RESULTS: Cervical discs in younger animals exhibited a greater proportion of irregular margins compared with lumbar sites (94% versus 83%; p = 0.02; 95% CI for difference, 2.7, 19.0%). In older animals, cervical discs showed a greater proportion of osteophytes than did lumbar discs (7% versus 0%; p < 0.0001). The incidence of disc space narrowing was greater in cervical versus lumbar sites (99% versus 90%; p = 0.0008). Cervical spine sites which contained osteophytes morphologically showed irregular disc margins and revealed an extrusion of herniated disc material in the osteophytes. CONCLUSIONS: Radiologic and morphologic studies confirmed age-related disc degeneration in the cervical spine of the sand rat. CLINICAL RELEVANCE: Clinical cervical aging studies have shown that 14% of asymptomatic subjects younger than 40 years have abnormal MRI scans with an increase to 50% by 50 years old. We studied an economic rodent model for cervical age-related spontaneous disc.

Reliability of the timed 10-metre walk test during inpatient rehabilitation in ambulatory adults with traumatic brain injury.

OBJECTIVE: To determine the test-re-test reliability of the timed 10-metre walk test (10MWT) among adults with traumatic brain injury (TBI) enrolled in inpatient rehabilitation. DESIGN: Prospective reliability study using a correlational design. SETTING: Inpatient rehabilitation unit of a rehabilitation hospital. PARTICIPANTS: Twenty-three consecutive adults with acute TBI, mean age = 35.87, SD = 14.2 years (range = 18-64 years). This study tested 22 males and one female, who were 15.6 (SD = 9.1) days in inpatient rehabilitation at time of gait testing. METHOD: Repeated, timed 10-metre gait test within a 1-hour testing period with six trials at self-selected pace (SSP) and six trials at fastest pace (FP), recorded to the nearest 1/10 second with a hand-held stopwatch. RESULT: Gait speed measurements for SSP and FP were shown to have excellent test-re-test reliability (Intra Class Correlation coefficient = 0.964 and 0.961, respectively). CONCLUSIONS: These results add to the literature that the timed 10MWT is a reliable measure of gait velocity in adults with acute TBI for both FP and SSP.

Dietary intake and adherence to the 2010 Dietary Guidelines for Americans among individuals with chronic spinal cord injury: a pilot study.

OBJECTIVE: To investigate dietary intake and adherence to the 2010 Dietary Guidelines for Americans in individuals with chronic spinal cord injury (SCI) and able-bodied individuals. DESIGN: A pilot study of dietary intake among a sample of individuals with SCI >1 year ago from a single site compared with able-bodied individuals. PARTICIPANTS/METHODS: One hundred black or white adults aged 38-55 years old with SCI >1 year and 100 age-, sex-, and race-matched adults enrolled in the Coronary Artery Risk Development in Young Adults (CARDIA) study. Dietary intake was assessed by the CARDIA dietary history. Linear regression analysis was used to compare dietary intake between the subjects with SCI and those enrolled in the CARDIA study. Further, adherence to the 2010 Dietary Guidelines for dairy, fruits, and vegetables, and whole-grain foods was assessed. RESULTS: Compared with CARDIA participants, participants with SCI consumed fewer daily servings of dairy (2.10 vs. 5.0, P < 0.001), fruit (2.01 vs. 3.64, P = 0.002), and whole grain foods (1.20 vs. 2.44 P = 0.007). For each food group, fewer participants with SCI met the recommended servings compared with the CARDIA participants. Specifically, the participants with SCI and in CARDIA who met the guidelines were, respectively: dairy, 22% vs. 54% (P < 0.001), fruits and vegetables 39% vs. 70% (P = 0.001), and whole-grain foods 8% vs. 69.6% (P = 0.001). CONCLUSIONS: Compared with able-bodied individuals, SCI participants consumed fewer daily servings of fruit, dairy, and whole grain foods than proposed by the 2010 Dietary Guideline recommendations. Nutrition education for this population may be warranted.

Statistical grand rounds: a review of analysis and sample size calculation considerations for Wilcoxon tests.

When a study uses an ordinal outcome measure with unknown differences in the anchors and a small range such as 4 or 7, use of the Wilcoxon rank sum test or the Wilcoxon signed rank test may be most appropriate. However, because nonparametric methods are at best indirect functions of standard measures of location such as means or medians, the choice of the most appropriate summary measure can be difficult. The issues underlying use of these tests are discussed. The Wilcoxon-Mann-Whitney odds directly reflects the quantity that the rank sum procedure actually tests, and thus it can be a superior summary measure. Unlike the means and medians, its value will have a one-to-one correspondence with the Wilcoxon rank sum test result. The companion article appearing in this issue of Anesthesia & Analgesia ("Aromatherapy as Treatment for Postoperative Nausea: A Randomized Trial") illustrates these issues and provides an example of a situation for which the medians imply no difference between 2 groups, even though the groups are, in fact, quite different. The trial cited also provides an example of a single sample that has a median of zero, yet there is a substantial shift for much of the nonzero data, and the Wilcoxon signed rank test is quite significant. These examples highlight the potential discordance between medians and Wilcoxon test results. Along with the issues surrounding the choice of a summary measure, there are considerations for the computation of sample size and power, confidence intervals, and multiple comparison adjustment. In addition, despite the increased robustness of the Wilcoxon procedures relative to parametric tests, some circumstances in which the Wilcoxon tests may perform poorly are noted, along with alternative versions of the procedures that correct for such limitations.

Aromatherapy as treatment for postoperative nausea: a randomized trial.

BACKGROUND: Postoperative nausea (PON) is a common complication of anesthesia and surgery. Antiemetic medication for higher-risk patients may reduce but does not reliably prevent PON. We examined aromatherapy as a treatment for patients experiencing PON after ambulatory surgery. Our primary hypothesis was that in comparison with inhaling a placebo, PON will be reduced significantly by aromatherapy with (1) essential oil of ginger, (2) a blend of essential oils of ginger, spearmint, peppermint, and cardamom, or (3) isopropyl alcohol. Our secondary hypothesis was that the effectiveness of aromatherapy will depend upon the agent used. METHODS: A randomized trial of aromatherapy with patients who reported nausea in the postanesthesia care unit was conducted at one ambulatory surgical center. Eligibility criteria were adult, able to give consent, and no history of coagulation problems or allergy to the aromatherapy agents. Before surgery, demographic and risk factors were collected. Patients with a nausea level of 1 to 3 on a verbal descriptive scale (0-3) received a gauze pad saturated with a randomly chosen aromatherapy agent and were told to inhale deeply 3 times; nausea (0-3) was then measured again in 5 minutes. Prophylactic and postnausea antiemetics were given as ordered by physicians or as requested by the patient. RESULTS: A total of 1151 subjects were screened for inclusion; 303 subjects reporting nausea were enrolled (26.3%), and 301 meeting protocol were analyzed (26.2%). The change in nausea level was significant for the blend (P < 0.001) and ginger (P = 0.002) versus saline but not for alcohol (P < 0.76). The number of antiemetic medications requested after aromatherapy was also significantly reduced with ginger or blend aromatherapy versus saline (P = 0.002 and P < 0.001, respectively). CONCLUSION: The hypothesis that aromatherapy would be effective as a treatment for PON was supported. On the basis of our results, future research further evaluating aromatherapy is warranted. Aromatherapy is promising as an inexpensive, noninvasive treatment for PON that can be administered and controlled by patients as needed.

E-point septal separation compared to fractional shortening measurements of systolic function in emergency department patients: prospective randomized study.

OBJECTIVES: Rapid bedside assessment of left ventricular (LV) function can aid in the evaluation of the critically ill patient and guide clinical management. Our primary hypothesis was that mitral valve E-point septal separation measurements would correlate with contemporaneous fractional shortening measurements of LV systolic function when performed by emergency physicians. Our secondary hypothesis was that E-point septal separation as a continuous variable would predict fractional shortening using a linear regression model. METHODS: We studied a prospective convenience sample of patients undergoing a sequence of LV systolic function measurements during a 3-month period at a suburban academic emergency department with a census of 114,000 patients. The sample included adult emergency department patients who were determined by the treating emergency physician to have 1 or more clinical indications for bedside LV systolic function assessment. Investigators performed bedside M-mode cardiac sonographic measurements of fractional shortening and E-point septal separation using the parasternal long-axis window. The sequence of LV systolic function measurements was randomized. RESULTS: A total of 103 patients were enrolled. The Pearson correlation coefficient for E-point septal separation and fractional shortening measurements was -0.59 (P< .0001). Linear regression analysis performed for E-point septal separation with fractional shortening as the dependent variable yielded an R2 value of 0.35. CONCLUSIONS: E-point septal separation and fractional shortening measurements had a moderate negative correlation. E-point septal separation, when used as a continuous variable in a linear regression model, did not reliably predict fractional shortening.

Ultrasound measurements of the saphenous vein in the pediatric emergency department population with comparison to i.v. catheter size.

BACKGROUND: Saphenous vein cutdown is a rare venous access procedure. Ultrasound (US) can assist with many vascular access procedures. OBJECTIVES: Our objective was to identify the saphenous veins (SVs) using US in pediatric emergency department (ED) patients, and to determine if the SV size allows for potential cannulation by different standard-size intravenous (i.v.) catheters. METHODS: This study was a prospective, observational convenience sample of 60 pediatric patients at an urban, regional referral pediatric ED. Inclusion criteria were children ages 1 through 12 years categorized into four age groups: 1-<2, 2-4, 5-7, and 8-12 years, with informed consent and assent. Investigators performed US examination using a 10-MHz multi-frequency transducer to identify the SV on both legs and measure the SV in short-axis view. The US measurements were then used to calculate the SV areas. Diameters of typical pediatric gauge (G) catheters (24G, 22G, 20G, 18G) were used to calculate catheter areas. RESULTS: Sixty patients were enrolled, with five SVs unable to be measured in 4 patients (1 patient with both SVs). For the remaining 115 (96%) SVs available for further analysis, the median age was 4 years (interquartile range [IQR] 2) and median weight was 22.7 kg (IQR 14.5). Mean area (mm(2)) of the right SV was 2.85 ± 1.9 and for the left SV, 2.88 ± 1.8. For our study group, the compatibility rates of different size i.v. catheters to fit the measured SV areas were as follows: 24G = 100%, 22G = 100%, 20G = 97.3%, and 18G =86.1%. CONCLUSIONS: US can localize the SV in pediatric ED patients. US size of the SV in various pediatric age ranges suggests that the SV may be a potential US venous access site with multiple-size i.v. catheters up to 18G.

Evaluation of soft tissue attachments to a novel intra-abdominal prosthetic in a rabbit model.

BACKGROUND: Laparoscopic ventral hernia repair requires placement of an intraperitoneal prosthetic. Composite mesh types have been developed to address the shortcomings of standard meshes. The authors evaluated the host reaction to intraperitoneal placement of a novel composite material. MATERIALS AND METHODS: A comparison of an innovative polypropylene/polylactide composite mesh was made to parietex composite (PCO), Proceed, and DualMesh. Eighteen meshes per group were implanted on intact peritoneum in New Zealand white rabbits. The main outcome measures included the formation of visceral adhesions, adhesion tenacity, tensiometric measurements, and histological analysis. Evaluations of adhesions were made at 1, 4, and 16 weeks using a 2-mm minilaparoscopy. RESULTS: There were no significant differences in the mean adhesion scores between the composite mesh types at week 1 (P = .15) and week 16 (P = .06). At 4 weeks, PCO had significantly fewer adhesions when compared with the other 3 mesh types (P = .02). Adhesion tenacity was also equivalent within the group at 16 weeks (P = .06). Tensiometry and histological analysis revealed no statistically significant differences between the mesh types. CONCLUSIONS: Four different composite mesh types had equivalent intra-abdominal soft tissue attachments in a rabbit model after a 16-week implantation period. PCO demonstrated the lowest mean adhesion score of each mesh type. Each mesh exhibited equivalent stiffness and energy to failure after explantation. The 4 composite mesh types demonstrated the successful formation of a neoperitoneum and comparable host biocompatibility as evidenced by similar degrees of inflammation.

Risk factors of patients with and without postoperative nausea (PON).

This purpose of this analysis was to study risk factors of postoperative nausea (PON) and their strength. Data were obtained during the screening phase of a controlled clinical trial of aromatherapy for PON. In a sample of 1151 postsurgical subjects, 301 (26.2%) reported PON. Significant risk factors identified in the order of odds ratios for nausea were female gender, gastrointestinal surgery, use of volatile anesthesia gases, history of PON, history of motion sickness, and use of opioids after surgery. Although still over 1.0, the risk factors of length of surgery over 1 hour and gynecologic surgery had the lowest odds ratios. Likelihood of nausea increased significantly with the number of significant risk factors (P<.0001). Administration of preventive antiemetic medication also increased with the number of significant risk factors (P<.0001). Among 301 subjects reporting nausea, 49 (16.28%) received preventive medication. Despite prevention efforts, PON remains a substantial side effect for many surgical patients.

Adherence with the National Cholesterol Education Program guidelines in men with chronic spinal cord injury.

OBJECTIVE: Describe the management of dyslipidemia and adherence to the National Cholesterol Educational Program (NCEP) guidelines in men with Spinal Cord Injury (SCI). RESEARCH: Cross-sectional study of a consecutive sample of men with SCI presenting to a single site for coronary heart disease (CHD) risk assessment. PARTICIPANTS/METHODS: Men age 45 to 70 with traumatic SCI (ASIA A, B, and C) at least 10 years prior to participation in the study with no prior history of clinical CHD. Medical history, blood-pressure, and fasting lipid panel were used to calculate risk for CHD using NCEP guidelines and the Framingham Risk Score (FRS). Adherence to treatment recommendations and adequacy of control were assessed based on the NCEP guidelines. RESULTS: 38 men were assessed; 15/38 (39.5%, 95% CI: 24.0-56.6%) had dyslipidemia, defined as an LDL-C above their LDL-C treatment threshold (n=6) or being on treatment for dyslipidemia (n=9, for a 60% treatment rate (9/15, 95% CI: 32.3-83.7%)). Of the 9 individuals on treatment, 6 (66.7%) met their treatment goals (for a 40% overall control rate (6/15, 95% CI: 16.3-67.7%)). Dyslipidemia was well controlled in low risk individuals, but control was less common in higher risk individuals. CONCLUSIONS: Dyslipidemia is common in men age 45-70 with chronic SCI and no evidence of clinical cardiovascular disease. Rates of treatment and control of dyslipidemia in this population are far from optimal, especially among the intermediate- and high-risk groups.

Development and validation of a prognostic tool: Pulmonary embolism short-term clinical outcomes risk estimation (PE-SCORE).

OBJECTIVE: Develop and validate a prognostic model for clinical deterioration or death within days of pulmonary embolism (PE) diagnosis using point-of-care criteria. METHODS: We used prospective registry data from six emergency departments. The primary composite outcome was death or deterioration (respiratory failure, cardiac arrest, new dysrhythmia, sustained hypotension, and rescue reperfusion intervention) within 5 days. Candidate predictors included laboratory and imaging right ventricle (RV) assessments. The prognostic model was developed from 935 PE patients. Univariable analysis of 138 candidate variables was followed by penalized and standard logistic regression on 26 retained variables, and then tested with a validation database (N = 801). RESULTS: Logistic regression yielded a nine-variable model, then simplified to a nine-point tool (PE-SCORE): one point each for abnormal RV by echocardiography, abnormal RV by computed tomography, systolic blood pressure < 100 mmHg, dysrhythmia, suspected/confirmed systemic infection, syncope, medico-social admission reason, abnormal heart rate, and two points for creatinine greater than 2.0 mg/dL. In the development database, 22.4% had the primary outcome. Prognostic accuracy of logistic regression model versus PE-SCORE model: 0.83 (0.80, 0.86) vs. 0.78 (0.75, 0.82) using area under the curve (AUC) and 0.61 (0.57, 0.64) vs. 0.50 (0.39, 0.60) using precision-recall curve (AUCpr). In the validation database, 26.6% had the primary outcome. PE-SCORE had AUC 0.77 (0.73, 0.81) and AUCpr 0.63 (0.43, 0.81). As points increased, outcome proportions increased: a score of zero had 2% outcome, whereas scores of six and above had ≥ 69.6% outcomes. In the validation dataset, PE-SCORE zero had 8% outcome [no deaths], whereas all patients with PE-SCORE of six and above had the primary outcome. CONCLUSIONS: PE-SCORE model identifies PE patients at low- and high-risk for deterioration and may help guide decisions about early outpatient management versus need for hospital-based monitoring.