Overcoming challenges in managing a high-risk pregnancy with placenta previa and newly diagnosed Bombay phenotype.

BACKGROUND: Bombay phenotype is rare and characterized by a lack of H antigen on the surface of red blood cells (RBCs) with naturally occurring anti-H antibodies. The presence of anti-H necessitates the exclusive use of Bombay phenotype RBCs for transfusion. We present a case of a pregnant woman with Bombay phenotype who required urgent cesarean section delivery due to high-risk placenta previa. CASE DESCRIPTION: A 36-year-old G1P0 woman of Indian origin presented at 36 weeks and 4 days gestation for management of a high-risk pregnancy with complete placenta previa. Bombay phenotype was unexpectedly identified on routine testing. Given the rarity of the blood, advanced gestation, and risk of post-partum hemorrhage associated with complete placenta previa and spontaneous labor, prompt strategic planning commenced for a successful delivery. Two frozen allogeneic Bombay phenotype RBCs were available as part of a concise transfusion plan. Intraoperative cell salvage was successfully employed and allogeneic transfusion was not required. CONCLUSION: Management of patients with rare blood types can be extremely challenging and guidance for those presenting later in pregnancy is scarce. Our patient's gestational age precluded the use of well-known effective strategies, including hemoglobin optimization, autologous and directed donation, and procurement of large quantities of rare blood. Rather, our approach utilized multidisciplinary expertise and strategic planning to yield a successful outcome.

The different clonal origins of metachronous and synchronous metastases.

BACKGROUND: Metastases are the leading cause of mortality in cancer patients. Linear and parallel are the two prominent models of metastatic progression. Metastases can be detected synchronously along with the primary tumor or metachronously, following treatment of localized disease. The aim of the study was to determine whether synchronous metastases (SM) and metachronous metastases (MM) differ only in lead-time or stem from different biological processes. MATERIALS AND METHODS: We retrospectively studied the chest CTs of 791 patients inflicted by eleven malignancy types that were treated in our institution in the years 2010-2020. Patient's population included 396 with SM and 395 with MM. The diameter of 15,427 lung metastases was measured. Clonal origin was deduced from the linear/parallel ratio (LPR)-a computerized analysis of metastases diameters. LPR of 1 suggests pure linear dissemination and - 1 pure parallel. RESULTS: Patients with MM were significantly older (average of 62.9 vs 60.7 years, p = 0.02), and higher percentage of them were males (58.7% vs 51.1%, p = 0.03). Median overall survival of patients with MM and SM was remarkably similar (23 months and 26 months respectively, p = 0.774) when calculated from the time of metastases diagnosis. Parallel dissemination (LPR ≤ 0) was found in 35.4% of patients with MM compared to only 19.8% of the patients with SM (p < 0.00001). CONCLUSION: Patients with SM and MM differ in demography and in clonal origin. Different therapeutic approaches may be considered in these two conditions.

Is it time for redefining oligometastatic disease? Analysis of lung metastases CT in ten tumor types.

BACKGROUND: Oligometastatic disease (OD) is usually defined arbitrarily as a condition in which there are ≤ 5 metastases. Given limited disease, it is expected that patients with OD should have better prognosis compared to other metastatic patients and that they can potentially benefit from metastasis-directed therapy (MDT). In this study, we attempted to redefine OD based upon objective evidence that fulfill these assumptions. METHODS: Chest CTSs of 773 patients with 15,947 lung metastases originating from ten malignancy types were evaluated. The number and largest diameter of each metastasis was recorded. Metastatic cluster was defined as a cluster of two or more metastases with diameter difference ≤ 1 mm. The prognostic power of seven statistical models on overall survival (OS) was analyzed. FINDINGS: Both the number of metastases and metastatic clusters had a highly significant impact on OS (p < 0.0001, p = 0.003 respectively). Patients with a single metastasis or a single cluster of metastases (regardless of metastases number), equaling 16.2% of all patients, had significantly better prognosis compared to other patients (p = 0.0002). If metastases diameter variability is ignored, as in the standard definition of OD, then patients with 2-5 and 6-10 metastases would have a similar prognosis. INTERPRETATION: Patients with a single cluster of metastases, theoretically originating from a single clone, have significantly better prognosis compared to patients with more than one cluster. Using this definition can potentially improve the results of MDT. The upper limit of metastases number should be determined by the technical capabilities of the MDT used.

Patterns of metastases progression- The linear parallel ratio.

BACKGROUND: Linear and parallel are the two leading models of metastatic progression. In this study we propose a simple way to differentiate between them. While the linear model predicts accumulation of genetic and epigenetic alterations within the primary tumor by founder cells before spreading as waves of metastases, the parallel model suggests preclinical distribution of less advanced disseminated tumor cells with independent selection and expansion at the ectopic sites. Due to identical clonal origin and time of dispatching, linear metastases are expected to have comparable diameters in any specific organ while parallel metastases are expected to appear in variable sizes. METHODS AND FINDINGS: Retrospective revision of chest CT of oncological patients with lung metastases was performed. Metastasis number and largest diameters were recorded. The sum number of metastases with a similar diameter (c) and those without (i) was counted and the linear/parallel ratio (LPR) was calculated for each patient using the formula (∑c-∑i)/(∑c+∑i). A LPR ratio of 1 implies pure linear progression pattern and -1 pure parallel. 12,887 metastases were measured in 503 patients with nine malignancy types. The median LPR of the entire group was 0.71 (IQR 0.14-0.93). In carcinomas of the pancreas, prostate, and thyroid the median LPR was 1. Median LPRs were 0.91, 0.65, 0.60, 0.58, 0.50 and 0.43 in renal cell carcinomas, melanomas, colorectal, breast, bladder, and sarcomas, respectively. CONCLUSIONS: Metastatic spread of thyroid, pancreas, and prostate tumors is almost exclusively by a linear route. The spread of kidney, melanoma, colorectal, breast, bladder and sarcoma is both linear and parallel with increasing dominance of the parallel route in this order. These findings can explain and predict the clinical and genomic features of these tumors and can potentially be used for evaluation of metastatic origin in the individual patient.

Retrograde Autologous Priming in Cardiac Surgery: Results From a Systematic Review and Meta-analysis.

BACKGROUND: Retrograde autologous priming (RAP) before cardiopulmonary bypass (CPB) may minimize allogeneic red cell transfusion. We conducted a systematic review of the literature to examine the impact of RAP on perioperative allogeneic red cell transfusions in cardiac surgical patients. METHODS: This study involved a systematic review and meta-analysis of randomized controlled trials (RCTs) and observational studies evaluating the use of RAP in cardiac surgery involving CPB. The primary outcome was intraoperative allogeneic red cell transfusion. Secondary outcomes included whole hospital allogeneic transfusions and adverse events such as acute kidney injury (AKI) and stroke. RESULTS: A total of 11 RCTs (n = 1337 patients) were included, comparing RAP patients (n = 674) to control (n = 663). In addition, 10 observational studies (n = 2327) were included, comparing RAP patients (n = 1257) to control (n = 1070). Overall, RAP was associated with a significantly reduced incidence of intraoperative red cell transfusion (n = 18 studies; odds ratio [OR] = 0.34; 95% confidence interval [CI], 0.22-0.55, P < .001) compared to controls. This effect was seen among RCTs (n = 10 studies; OR = 0.19; 95% CI, 0.08-0.45, P < .001) and observational studies (n = 8 studies; OR = 0.66; 95% CI, 0.50-0.87, P = .004) in isolation. RAP was also associated with a significantly reduced incidence of whole hospital red cell transfusion (n = 5 studies; OR = 0.28; 95% CI, 0.19-0.41, P < .001). Among the studies that reported AKI and stroke outcomes, there was no statistically significant increased odds of AKI or stroke in either RAP or control patients. CONCLUSIONS: Based on the pooled results of the available literature, RAP is associated with a significant reduction in intraoperative and whole hospital allogeneic red cell transfusion. Use of RAP may prevent hemodilution of cardiac surgical patients and thus, lessen transfusions. Additional high-quality prospective studies are necessary to determine the ideal priming volume necessary to confer the greatest benefit without incurring organ injury.

Effect of fractioning on antibacterial activity of n-butanol fraction from Enantia chlorantha stem bark methanol extract.

BACKGROUND: Enantia chlorantha is a plant belonging to Annonaceae Family. The Barks and leaves are used traditionally to treat infectious diseases. Earlier studies highlighted the antibacterial activity of stem barks methanol extract. This study is thus aimed at investigating the effect of fractionation on antibacterial activity of its n-butanol fraction. METHODS: The extract of E. chlorantha stem barks was obtained by maceration in methanol and then subjected to a liquid/liquid partition by successive depletion with solvents of increasing polarity. The n-butanol fraction was fractionated by adsorption chromatography on silica gel. A product was isolated from the dichloromethane/methanol (2%) fraction and the structure was determined on the basis of spectroscopic data; Proton Nuclear Magnetic Resonance (1H NMR), Carbon-13 Nuclear Magnetic Resonance (13C NMR), Heteronuclear Multiple Bond Correlation (HMBC), H-correlation spectroscopy (H-COSY), attached proton test (APT), heteronuclear multiple quantum coherence (HSQC). The antibacterial activity was evaluated by broth microdilution method against six reference strains and eight clinical bacterial strains. RESULTS: The n-butanol fraction was found to be active with MIC values ranging from 32 to 256 µg/mL. The FA sub-fraction was more efficient among the eight sub-fractions, the n-butanol fraction and comparable to Chloramphenicol used as reference antibiotic. The product obtained was elucidated as palmitin. The antibacterial activity of the latter was comparable to that of Chloramphenicol on one reference strain and 4 of the 6 clinical strains. CONCLUSION: The FA sub-fraction had better antibacterial activity than the n-butanol fraction and other sub-fractions, and possibly palmitin was the active substance responsible for the antibacterial activity of E. chlorantha.

Impact of Preoperative Erythropoietin on Allogeneic Blood Transfusions in Surgical Patients: Results From a Systematic Review and Meta-analysis.

BACKGROUND: Erythropoietic-stimulating agents such as erythropoietin have been used as part of patient blood management programs to reduce or even avoid the use of allogeneic blood transfusions. We review the literature to evaluate the effect of preoperative erythropoietin use on the risk of exposure to perioperative allogeneic blood transfusions. METHODS: The study involved a systematic review and meta-analysis of randomized controlled trials evaluating the use of preoperative erythropoietin. The primary outcome was the reported incidence of allogeneic red blood cell transfusions during inpatient hospitalizations. Secondary outcomes included phase-specific allogeneic red blood cell transfusions (ie, intraoperative, postoperative), intraoperative estimated blood loss, perioperative hemoglobin levels, length of stay, and thromboembolic events. RESULTS: A total of 32 randomized controlled trials (n = 4750 patients) were included, comparing preoperative erythropoietin (n = 2482 patients) to placebo (n = 2268 patients). Preoperative erythropoietin is associated with a significant decrease in incidence of allogeneic blood transfusions among all patients (n = 28 studies; risk ratio, 0.59; 95% CI, 0.47-0.73; P < .001) as well as patients undergoing cardiac (n = 9 studies; risk ratio, 0.55; 95% CI, 0.37-0.81; P = .003) and elective orthopedic (n = 5 studies; risk ratio, 0.36; 95% CI, 0.28-0.46; P < .001) surgery compared to placebo, respectively. Preoperative erythropoietin was also associated with fewer phase-specific red blood cell transfusions. There was no difference between groups in incidence of thromboembolic events (n = 28 studies; risk ratio, 1.02; 95% CI, 0.78-1.33; P = .68). CONCLUSIONS: Preoperative erythropoietin is associated with a significant reduction in perioperative allogeneic blood transfusions. This finding is also confirmed among the subset of patients undergoing cardiac and orthopedic surgery. Furthermore, our study demonstrates no significant increase in risk of thromboembolic complications with preoperative erythropoietin administration.

Effect of Fractioning on Antibacterial Activity of Enantia chlorantha Oliver (Annonaceae) Methanol Extract and Mode of Action.

Infectious diseases caused by bacteria constitute the main cause of morbidity and mortality throughout the world and mainly in developing countries. In this work, the influence of fractioning and the mode of action of stem barks methanol extract of Enantia chlorantha were investigated. The aim was to optimize the antibacterial activity of the methanol extract. The extract was prepared by maceration of barks powder in methanol. Fractioning was done using increasing solvents polarity. Standard phytochemical methods were used for phytochemical screening. Minimum Inhibitory Concentrations (MIC) and Minimum Bactericidal Concentration (MBC) of the methanol extract and fractions were determined using broth microdilution method. The studied mode of action of both methanol extract and n-butanol fraction included antibiofilm activity, H+-ATPase-mediated proton pumping assay, salt tolerance, and cells cycle. The methanol extract of E. chlorantha stem barks was found to be active on all the bacteria tested (32 ≤ MIC ≤ 512 µg/mL), its activity being significant (MIC < 100 µg/ml) out of 5 of the 28 clinical isolates used. Salmonella enterica serovar paratyphi A was the most sensitive (32 µg/mL). Compared to the extract and other fractions, the n-butanol fraction was found to be more active (32 ≤ MIC ≤ 256). Significant antibacterial activity of this fraction was observed out of 10 of the 28 bacterial isolates and 3 out of 7 bacterial strains. Lowest MIC values (32 µg/ml) of this fraction were obtained with Escherichia coli (136), Pseudomonas aeruginosa (CIP 76110), and Salmonella enterica serovar typhi 9. The methanol extract of E. chlorantha and its n-butanol fraction revealed several modes of action including the prolongation of the latency phase of the bacterial growth, the inhibition of the pump with protons H+ - ATPases bacterial, the loss of the salt tolerance of the Staphylococcus aureus, and inhibition of the formation of the bacterial biofilm. The present results showed that the n-butanol fraction of the methanol stem barks extract of E. chlorantha possess the essential antibacterial components and could best be used to fight against bacterial infections as compared to methanol extract.

Combination Intensity Modulated Proton Therapy and Passive Scatter Boost for Rapidly Progressing Nasal Cavity Squamous Cell Carcinoma.

Cancers of the nasal cavity and septum are associated with poor prognosis and are usually treated with surgery followed by post-operative radiotherapy with or without concurrent chemotherapy. Definitive radiotherapy is used in cases where the tumor is unresectable, patient is unfit for surgery, and/or the patient declines surgical intervention. Here, we present a case of a patient, who for non-medical reasons, opted to have non-surgical management of his rapidly progressing nasal cavity tumor. He was successfully treated with concurrent chemoradiotherapy utilizing a combination of intensity modulated proton therapy (IMPT) with passive scatter boost to reduce dose to the adjacent critical neural structures. Post-treatment clinical examination and imaging demonstrated complete clinical and metabolic response at the primary site and neck. This case highlights the use of IMPT and passive scatter boost in combination to achieve delivery of therapeutic dose to nasal cavity tumor and neck whilst limiting dose to numerous adjacent organs-at-risk.

Improving healthcare value through clinical community and supply chain collaboration.

BACKGROUND: We hypothesized that integrating supply chain with clinical communities would allow for clinician-led supply cost reduction and improved value in an academic health system. METHODS: Three clinical communities (spine, joint, blood management) and one clinical community-like physician led team of surgeon stakeholders partnered with the supply chain team on specific supply cost initiatives. The teams reviewed their specific utilization and cost data, and the physicians led consensus-building conversations over a series of team meetings to agree to standard supply utilization. RESULTS: The spine and joint clinical communities each agreed upon a vendor capping model that led to cost savings of $3 million dollars and $1.5 million dollars respectively. The blood management decreased blood product utilization and achieved $1.2 million dollars savings. $5.6 million dollars in savings was achieved by a clinical community-like group of surgeon stakeholders through standardization of sutures and endomechanicals. CONCLUSIONS: Physician led clinical teams empowered to lead change achieved substantial supply chain cost savings in an academic health system. The model of combining clinical communities with supply chain offers hope for an effective, practical, and scalable approach to improving value and engaging physicians in other academic health systems. IMPLICATIONS: This clinician led model could benefit both private and academic health systems engaging in value optimization efforts. LEVEL OF EVIDENCE: N/A.

Risk factors and prediction model for inpatient surgical site infection after major abdominal surgery.

BACKGROUND: Surgical site infections (SSIs) are a common source of postoperative morbidity and a marker of surgical quality. The ability to predict the incidence of SSIs is limited and most models have poor predictive value. We sought to identify risk factors associated with SSIs and develop a prediction model for SSIs after major abdominal surgery. METHODS: A total of 1744 patients undergoing pancreatic, hepatobiliary, and colorectal resections between January 1, 2010 and August 31, 2013 at Johns Hopkins Hospital were identified. Risk factors for any inpatient SSI (superficial and deep) were evaluated using multivariable logistic regression. RESULTS: Median patient age was 58 y (interquartile range 47, 68); surgical procedures included colorectal (59.0%), liver (26.2%), and pancreas (14.8%) resections. SSI occurred in 7.6% (n = 132) of patients. Factors associated with SSI included preoperative weight loss >4.5 kg (odds ratio [OR], 2.12; 95% confidence interval [CI], 1.06-4.25), emergency operations (OR, 2.05; 95% CI, 1.32-3.17), and colorectal resections (OR, 1.65; 95% CI, 1.13-2.43) (all P ≤ 0.003). Intraoperative and postoperative risk factors included estimated blood loss (EBL) >600 mL (OR, 2.23; 95% CI, 1.54-3.25), maximum respiratory rate (tachypnea) >20 breaths/min (OR, 1.74; 95% CI, 1.19-2.54), and perioperative transfusion (OR, 2.01; 95% CI, 1.33-3.04) (all P = 0.001). Intraoperative hypothermia, hyperthermia, bradycardia, tachycardia, hypotension, and hypertension were not associated with SSIs (all P > 0.05). After controlling competing risk factors, transfusion, EBL >600 mL, tachypnea, and colorectal resection were independently associated with SSIs (all P < 0.003). On the basis of the beta-coefficients in the multivariable model, an SSI scoring system was created by assigning 2 points for EBL >600 mL, 2 points for a colorectal resection, 3 points for tachypnea, and 3 points for a transfusion. The model showed good discriminatory ability to predict SSI (c-statistic = 0.7232; Akaike information criterion 875.37). CONCLUSIONS: A novel, simple 10-point SSI scoring system that incorporated perioperative risk factors such as blood transfusion, EBL, tachypnea, and the type of surgical procedure accurately stratifies patients according to SSI risk.

Anesthetic Management of Pheochromocytoma Resection in Adults with Single Ventricle Physiology.

Survival rates for patients with palliated congenital heart disease are increasing, and an increasing number of adults with cyanotic congenital heart disease (CCHD) might require surgical resection of pheochromocytoma-paraganglioma (PHEO-PGL). A recent study supports the idea that patients with a history of CCHD and current or historical cyanosis might be at increased risk for developing PHEO-PGL. We review the anesthetic management of two adults with single-ventricle physiology following Fontan palliation presenting for PHEO-PGL resection and review prior published case reports. We found the use of epidural analgesia to be safe and effective in the operative and postoperative management of our patients.

Infectious complications in transfused patients after radical cystectomy.

INTRODUCTION: Infectious complications are common after radical cystectomy (RC), and allogeneic blood transfusions may increase infection risk by an immunosuppressive effect. While it has been suggested that perioperative blood transfusion (PBT) may be associated with adverse oncologic outcomes after RC, no large analyses have assessed whether PBT increases the risk of perioperative infection after RC. MATERIALS AND METHODS: We used the Nationwide Inpatient Sample (1998 to 2011) to study the rate of PBT during RC for bladder cancer and identify infectious complications. We compared rates of infectious complications in patients who did and did not receive PBT and developed a multivariable model to assess the independent risk of infectious complication associated with PBT controlling for age, year of surgery, obesity, chronic kidney disease, comorbidity score, and type of urinary diversion. RESULTS: We identified 126,454 RCs performed during the study period. A total of 34,203 (27%) received a PBT. The use of PBT increased over the study period, from 18.4% in 1998 to 31.6% in 2011 (p < 0.0001). Patients who received a PBT had an increased risk of perioperative infectious complications [36.7% versus 27.7%, unadjusted OR (95% CI) = 1.51 (1.43-1.60), p < 0.0001]. After adjusting for potential confounders, PBT remained an independent predictor of infectious complications [adjusted OR (95% CI) = 1.46 (1.38-1.55), p < 0.0001]. CONCLUSIONS: This analysis provides strong observational evidence that PBT is associated with an increased risk of perioperative infectious complications, which may be secondary to transfusion-related immunomodulation. Urologists should aggressively pursue blood conservation strategies and adhere to evidence-based restrictive transfusion thresholds, particularly given the rising rate of PBT.

Robust optimization in intensity-modulated proton therapy to account for anatomy changes in lung cancer patients.

BACKGROUND AND PURPOSE: Robust optimization for IMPT takes setup and range uncertainties into account during plan optimization. However, anatomical changes were not prospectively included. The purpose of this study was to examine robustness and dose variation due to setup uncertainty and anatomical change in IMPT of lung cancer. MATERIAL AND METHODS: Plans were generated with multi-field optimization based on planning target volume (MFO-PTV) and worst-case robust optimization (MFO-RO) on simulation computed tomography scans (CT0) for nine patients. Robustness was evaluated on the CT0 by computing the standard deviation of DVH (SD-DVH). Dose variations calculated on weekly CTs were compared with SD-DVH. Equivalent uniform dose (EUD) change from the original plan on weekly dose was also calculated for both plans. RESULTS: SD-DVH and dose variation on weekly CTs were both significantly lower in the MFO-RO plans than in the MFO-PTV plans for targets, lungs, and the esophagus (p<0.05). When comparing EUD for ITV between weekly and planned dose distributions, three patients and 28% of repeated CTs for MFO-RO plans, and six patients and 44% of repeated CTs for MFO-PTV plans, respectively, showed an EUD change of >5%. CONCLUSIONS: RO in IMPT reduces the dose variation due to setup uncertainty and anatomy changes during treatment compared with PTV-based planning. However, dose variation could still be substantial; repeated imaging and adaptive planning as needed are highly recommended for IMPT of lung tumors.

Continuous cerebral blood flow autoregulation monitoring in patients undergoing liver transplantation.

BACKGROUND: Clinical monitoring of cerebral blood flow (CBF) autoregulation in patients undergoing liver transplantation may provide a means for optimizing blood pressure to reduce the risk of brain injury. The purpose of this pilot project is to test the feasibility of autoregulation monitoring with transcranial Doppler (TCD) and near-infrared spectroscopy (NIRS) in patients undergoing liver transplantation and to assess changes that may occur perioperatively. METHODS: We performed a prospective observational study in 9 consecutive patients undergoing orthotopic liver transplantation. Patients were monitored with TCD and NIRS. A continuous Pearson's correlation coefficient was calculated between mean arterial pressure (MAP) and CBF velocity and between MAP and NIRS data, rendering the variables mean velocity index (Mx) and cerebral oximetry index (COx), respectively. Both Mx and COx were averaged and compared during the dissection phase, anhepatic phase, first 30 min of reperfusion, and remaining reperfusion phase. Impaired autoregulation was defined as Mx ≥ 0.4. RESULTS: Autoregulation was impaired in one patient during all phases of surgery, in two patients during the anhepatic phase, and in one patient during reperfusion. Impaired autoregulation was associated with a MELD score >15 (p = 0.015) and postoperative seizures or stroke (p < 0.0001). Analysis of Mx categorized in 5 mmHg bins revealed that MAP at the lower limit of autoregulation (MAP when Mx increased to ≥ 0.4) ranged between 40 and 85 mmHg. Average Mx and average COx were significantly correlated (p = 0.0029). The relationship between COx and Mx remained when only patients with bilirubin >1.2 mg/dL were evaluated (p = 0.0419). There was no correlation between COx and baseline bilirubin (p = 0.2562) but MELD score and COx were correlated (p = 0.0458). Average COx was higher for patients with a MELD score >15 (p = 0.073) and for patients with a neurologic complication than for patients without neurologic complications (p = 0.0245). CONCLUSIONS: These results suggest that autoregulation is impaired in patients undergoing liver transplantation, even in the absence of acute, fulminant liver failure. Identification of patients at risk for neurologic complications after surgery may allow for prompt neuroprotective interventions, including directed pressure management.

Assessing the integrated pest management practices of southeastern US ornamental nursery operations.

BACKGROUND: The Southern Nursery Integrated Pest Management (SNIPM) working group surveyed ornamental nursery crop growers in the southeastern United States to determine their pest management practices. Respondents answered questions about monitoring practices for insects, diseases and weeds, prevention techniques, intervention decisions, concerns about IPM and educational opportunities. Survey respondents were categorized into three groups based on IPM knowledge and pest management practices adopted. RESULTS: The three groups differed in the use of standardized sampling plans for scouting pests, in monitoring techniques, e.g. sticky cards, phenology and growing degree days, in record-keeping, in the use of spot-spraying and in the number of samples sent to a diagnostic clinic for identification and management recommendation. CONCLUSIONS: Stronger emphasis is needed on deliberate scouting techniques and tools to monitor pest populations to provide earlier pest detection and greater flexibility of management options. Most respondents thought that IPM was effective and beneficial for both the environment and employees, but had concerns about the ability of natural enemies to control insect pests, and about the availability and effectiveness of alternatives to chemical controls. Research and field demonstration is needed for selecting appropriate natural enemies for augmentative biological control. Two groups utilized cooperative extension almost exclusively, which would be an avenue for educating those respondents.

Application of Vegard's law to mixed cation sodalites: a simple method for determining the stoichiometry.

Vegard's law describes the empirical relationship between the crystal lattice parameter of a mixture and its components. This relationship holds for some sodalites, in particular those containing mixtures of Li, K and Na as the charge balancing cations. By utilizing previously published lattice parameters for Li/Na and K/Na mixed cation chloride sodalites, linear curves were drawn allowing the composition of the mixed cation sodalites to be determined from their lattice parameters. Further, by mathematical addition of the curves for Li/Na and K/Na mixed cation chloride sodalites, a linear curve was developed and tested for the mixed tri-cation Li/Na/K chloride sodalites. This provides a simple way to monitor the composition of mixed cation sodalites and has an application in monitoring the composition of multi-phase materials where the sodalite phase cannot be easily separated for elemental analysis.

Decreased cardiac output in humans during laparoscopic antireflux surgery: direct measurements.

OBJECTIVE: In a porcine model, we demonstrated that laparoscopic Nissen fundoplication causes a significant drop in cardiac output (30%) because it exposes both the peritoneal cavity and the mediastinum to CO(2) under pressure. To determine if this occurs in humans, we examined cardiovascular physiology during laparoscopic Nissen fundoplication. Because of invasiveness required in this pilot trial, only six patients were studied. METHODS: The arterial blood pressure (via radial arterial catheter) and the pulmonary artery diastolic pressure and cardiac index (via pulmonary artery thermodilution catheter) were measured at seven points in time during each laparoscopic Nissen fundoplication. RESULTS: The systolic blood pressure decreased in all patients, and the cardiac index decreased in all but one patient. The exception was a patient with Huntington disease, in whom the cardiac output did not decrease. In four of the five patients, the cardiac output was lowest during hiatal dissection, and in the fifth, it was lowest after reverse Trendelenburg positioning. No significant change in the pulmonary artery diastolic pressure was noted. All patients received adequate intravenous fluid replacement (average, 58 +/- 16 mL/kg) to support blood pressure. In one patient, with a particularly large paraesophageal hernia, profound hypotension (40/25 mm Hg) developed during the mediastinal phase of the procedure, and this patient required alpha-adrenergic support followed by laparotomy to eliminate a surgical cause (none found). CONCLUSIONS: Although it is a tremendous advance for patients, laparoscopic Nissen fundoplication can be associated with a significant reduction in cardiac output and blood pressure. Surgeons and anesthesiologists must be alert to changes reflecting these decreases during procedures, which violate both the peritoneal cavity and the mediastinum. We propose careful hemodynamic monitoring during these procedures, especially in patients with coronary artery disease or significant left ventricular dysfunction.