Surgery and Anesthesia in Patients with Pulmonary Hypertension.

Pulmonary hypertension is characterized by right ventricular impairment and a reduced ability to compensate for hemodynamic insults. Consequently, surgery can be challenging but is increasingly considered in view of available specific therapies and improved longer term survival. Optimal management requires a multidisciplinary patient-centered approach involving surgeons, anesthetists, pulmonary hypertension clinicians, and intensivists. The optimal pathway involves risk:benefit assessment for the proposed operation, optimization of pulmonary hypertension and any comorbidities, the appropriate anesthetic approach for the specific procedure and patient, and careful monitoring and management in the postoperative period. Where patients are carefully selected and meticulously managed, good outcomes can be achieved.

Prevalence of pre-eclampsia and adverse pregnancy outcomes in women with pre-existing cardiomyopathy: a multi-centre retrospective cohort study.

Pre-eclampsia is associated with postnatal cardiac dysfunction; however, the nature of this relationship remains uncertain. This multicentre retrospective cohort study aimed to determine the prevalence of pre-eclampsia in women with pre-existing cardiac dysfunction (left ventricular ejection fraction < 55%) and explore the relationship between pregnancy outcome and pre-pregnancy cardiac phenotype. In this cohort of 282 pregnancies, pre-eclampsia prevalence was not significantly increased (4.6% [95% C.I 2.2-7.0%] vs. population prevalence of 4.6% [95% C.I. 2.7-8.2], p = 0.99); 12/13 women had concurrent obstetric/medical risk factors for pre-eclampsia. The prevalence of preterm pre-eclampsia (< 37 weeks) and fetal growth restriction (FGR) was increased (1.8% vs. 0.7%, p = 0.03; 15.2% vs. 5.5%, p < 0.001, respectively). Neither systolic nor diastolic function correlated with pregnancy outcome. Antenatal ß blockers (n = 116) were associated with lower birthweight Z score (adjusted difference - 0.31 [95% C.I. - 0.61 to - 0.01], p = 0.04). To conclude, this study demonstrated a modest increase in preterm pre-eclampsia and significant increase in FGR in women with pre-existing cardiac dysfunction. Our results do not necessarily support a causal relationship between cardiac dysfunction and pre-eclampsia, especially given the population's background risk status. The mechanism underpinning the relationship between cardiac dysfunction and FGR merits further research but could be influenced by concomitant ß blocker use.

A case of acute post-laparoscopy bowel hypermotility and treatment with hyoscine butylbromide.

Post-laparoscopic pain is multi-factorial and many modes of perioperative analgesia have been proposed. We present the case of a patient who experienced severe abdominal pain following gynaecologic laparoscopy. Repeat laparoscopy revealed small bowel hypermotiliy which was successfully treated with intravenous (i.v.) hyoscine butylbromide. Neostigmine, a widely used muscle relaxant reversal agent, is known to increase small bowel motility. Intravenous hyoscine butylbromide is a rapid treatment of neostigmine-induced small bowel hypermotility post-laparoscopy.

Delayed discharges due to initiation of warfarin in atrial fibrillation: a prospective audit.

BACKGROUND: Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia. OBJECTIVE: The goal of this study was to determine whether initiation of warfarin treatment in patients with AF, while in thc hospital, is associated with an increased length of stay. METHODS: This was a prospective audit involving patients with AF newly started on warfarin while in the hospital. It was conducted in 3 acute medical wards (total, 96 beds) of a district general hospital. Patients were reviewed daily regarding the necessity of their hospital stay. Their stay was considered delayed if their original medical condition had resolved and their stay was attributed solely to initiation of warfarin to reach a therapeutic International Normalized Ratio (INR). The Barthel Index score was used to assess patients' activities of daily living. The medical teams treating these patients were unaware of the objective of the study. RESULTS: Over a 6-month period, 23 patients with AF (13 men, 10 women; mean [SD] age, 75.4 [9.2] years) were started on warfarin while in the hospital and thus comprised our study group. Of these 23 patients, 7 (30%) had delayed discharges that were solely attributed to initiation of warfarin. Total length of stay for all patients combined was 217 days; of these, 36 (17%) days were considered delayed discharges. Only 10 (43%) patients were discharged with their INR in the target range of 2 to 3. There was no significant difference between patients who had delayed discharges versus nondelayed discharges in terms of age, sex, number of comorbidities, number of medications, Barthel Index score, reason for admission, mean INR, number of patients achieving target INR on discharge, or main warfarin loading regimens. CONCLUSIONS: Initiation of warfarin in these patients with AF while in the hospital led to increased length of stay. A move toward starting anticoagulation in an outpatient setting could reduce length of hospital stay.

The impact of treatment for gynecological cancer on health-related quality of life (HRQoL): a systematic review.

Gynecologic cancers are major sources of mortality and morbidity. Although many review articles have reported on the impact of these diseases on health-related quality of life (HRQoL), none have reviewed the evidence in specific relation to the effect of treatment on HRQoL. Consequently, we systematically searched 4 electronic databases and hand-searched relevant reference lists and bibliographies to identify literature on this subject. Only 47 studies used a validated questionnaire to measure HRQoL. Although a meta-analysis was not possible, we found HRQoL rarely included as a treatment outcome, and when included assessment was often methodologically flawed. Seldom were pretreatment and posttreatment data collected or treatment regimes documented. Except for a few studies, analysis of HRQoL was conducted on small samples, excluding the cancer site and stage. Consequently, no definitive conclusions could be drawn and therefore we conclude with recommendations for the future reporting of HRQoL in gynecologic oncology studies.