Anesthetic Complications in Pregnancy.

Anesthesia complications in the parturient can be divided into 2 categories: those related to airway manipulation and those related to neuraxial anesthesia. Physiologic changes of pregnancy can lead to challenging intubating conditions in a patient at risk of aspiration. Neuraxial techniques are used to provide analgesia for labor and anesthesia for surgical delivery. Therefore, complications associated with neuraxial techniques are often seen in this population. In the event of maternal cardiac arrest, modification to advanced cardiac life support algorithms must be made to accommodate the gravid uterus and to deliver the fetus if return of maternal circulation is not prompt.

Human and rodent pancreatic beta-cells express IL-4 receptors and IL-4 protects against beta-cell apoptosis by activation of the PI3K and JAK/STAT pathways.

Secretion of pro-inflammatory cytokines is associated with loss of pancreatic beta-cell viability and cell death. IL-4 (interleukin-4) has been reported to mediate a protective effect against the loss of pancreatic beta-cells, and IL-4 receptors have been found in rat pancreatic beta-cells at both the RNA and the protein level. The aim of the present study was to investigate IL-4 receptor expression in human islet cells and to examine the signalling pathways by which IL-4 exerts its effects using the rat beta-cell lines, BRIN-BD11 and INS-1E. By means of immunohistochemistry, it was demonstrated that IL-4 receptors are present on human islet cells. Using a flow cytometric method for evaluating cell death, it was confirmed that incubating beta-cells with IL-4 attenuated cell death induced by IL-1beta and interferon-gamma by approx. 65%. This effect was abrogated by the presence of the PI3K (phosphoinositide 3-kinase) inhibitor, wortmannin, suggesting that activation of the PI3K pathway is involved. In support of this, Western blotting revealed that incubation of cells with IL-4 resulted in increased phosphorylation of Akt (also called protein kinase B), a downstream target of PI3K. Increased tyrosine phosphorylation of STAT6 (signal transducer and activator of transcription 6) also occurred in response to IL-4 and a selective JAK3 (Janus kinase 3) inhibitor reduced the cytoprotective response. Both effects were prevented by overexpression of the tyrosine phosphatase, PTP-BL (protein tyrosine phosphatase-BL). We conclude that IL-4 receptors are functionally competent in pancreatic beta-cells and that they signal via PI3K and JAK/STAT pathways. These findings may have implications for future therapeutic strategies for the management of diabetes.

Invasive local recurrence increased after radiation therapy for ductal carcinoma in situ.

BACKGROUND: It is thought that equal numbers of invasive and noninvasive recurrences develop after conservative treatment for ductal carcinoma in situ. We analyzed our data to see if this was true. METHODS: A prospective database of 878 conservatively treated patients with ductal carcinoma in situ was analyzed. RESULTS: Among 551 excision patients, there were 88 recurrences. Thirty-five percent were invasive. Among 327 excision plus radiotherapy patients, there were 59 recurrences. Fifty-three percent were invasive. In an attempt to predict which patients develop invasive recurrences, prolonged time to recurrence was the only statistically significant factor. CONCLUSIONS: The median time to local recurrence for irradiated patients was more than twice as long when compared with nonirradiated patients, during which there is more time for local recurrence to progress to invasion. Irradiated patients had more breast scarring, making diagnosis by palpation and mammography harder. Irradiated patients develop invasive recurrences at a statistically higher rate than nonirradiated patients. Follow-up evaluation with magnetic resonance imaging should be considered.

Lymphatic mapping in patients with breast cancer and previous augmentation mammoplasty.

Sentinel lymph node biopsy (SLNB) is now an established method of axillary staging in patients with breast cancer. However, the augmented breast poses an interesting challenge to this procedure. We hypothesized that SLNB is feasible in patients with augmented breasts who subsequently develop breast cancer. A retrospective study was performed from 1995 to 2006. Ten patients with augmented breasts underwent breast conservation therapy with SLNB. Sentinel lymph nodes were identified in all 10 patients. Three patients had positive sentinel nodes. Two patients proceeded to axillary lymph node dissection (ALND), and one declined. The subsequent ALND were negative for metastatic cancer. Seven patients had negative sentinel nodes. One patient with a negative sentinel node underwent ALND with all nodes negative for metastasis. Two patients were lost to follow-up. Of the remaining eight patients, the mean duration of follow-up was 71 months. None of these patients had evidence of axillary recurrence or distant metastasis at time of last follow-up. SLNB is a feasible method of axillary node staging in patients who have undergone augmentation mammoplasty who subsequently develop breast cancer. Further studies are needed to better determine the accuracy of lymphatic mapping in this patient population.

Routine interval appendectomy in children is not indicated.

BACKGROUND: This study evaluates outcomes for children treated without interval appendectomy (IA) after successful nonoperative management of perforated appendicitis. METHODS: A retrospective study of pediatric patients with appendicitis was performed from 12 regional acute-care hospitals from 1992 to 2004 with mean length of follow-up of 7.5 years. Main outcomes were recurrent appendicitis and cumulative length of hospital stay. RESULTS: The study included 6439 patients, of which 6367 (99%) underwent initial appendectomy. Seventy-two (1%) patients were initially managed nonoperatively and 11 patients had IA. Of the remaining 61 patients without IA, 5 (8%) developed recurrent appendicitis. Age, sex, type of appendicitis, and abscess drainage had no influence on recurrent appendicitis. Cumulative length of hospital stay was 6.6 days in patients without IA, 8.5 days in patients with IA, and 9.6 days in patients with recurrent appendicitis. CONCLUSION: Recurrent appendicitis is rare in pediatric patients after successful nonoperative management of perforated appendicitis. Routine IA is not necessarily indicated for these children.

Routine interval appendectomy is not justified after initial nonoperative treatment of acute appendicitis.

BACKGROUND: The role of interval appendectomy (IA) after an episode of acute appendicitis is debated. HYPOTHESIS: Patients treated nonoperatively for acute appendicitis do not require routine IA. DESIGN: Retrospective cohort study using discharge abstract data. SETTING: Twelve regional Kaiser Permanente hospitals in Southern California. PATIENTS: A total of 32 938 patients were hospitalized with acute appendicitis. INTERVENTIONS: Appendectomy or nonoperative treatment with or without abscess drainage. MAIN OUTCOME MEASURES: Hospitalization for recurrent appendicitis or IA. RESULTS: The type of appendicitis was abscess in 7% of patients, peritonitis in 18%, and no peritonitis or abscess in 75%. Emergency appendectomy was performed in 31 926 (97%) patients. Nonoperative treatment was used initially in 1012 patients (3%). Of these, 148 (15%) had an IA and the remaining 864 (85%) did not. Thirty-nine patients (5%) recurred after a median follow-up of 4 years. Using Cox regression, sex had a slight influence on recurrent appendicitis (hazard ratio males vs females = 0.52, 95% CI, 0.27-0.99, P = .05). Age, Charlson comorbidity index, type of appendicitis, or percutaneous abscess drainage had no influence on recurrence. Median length of hospital stay was 4 days for the admission for recurrent appendicitis compared with 6 days for the IA admission (P = .006). CONCLUSIONS: Most patients with acute appendicitis undergo appendectomy initially. For those treated nonoperatively, the recurrence rate is low. Routine IA after initial successful nonoperative treatment is not justified and should be abandoned.

Involvement of the cGMP signalling pathway in the regulation of viability in insulin-secreting BRIN-BD11 cells.

We have evaluated the hypothesis that cGMP may serve as an intracellular messenger regulating the viability of pancreatic beta-cells. A direct activator of soluble guanylyl cyclase, YC-1, caused a time- and dose-dependent loss of viability in clonal BRIN-BD11 beta-cells. This was accompanied by a rise in cGMP and was antagonised by Rp-8-pCPT-cGMPS, a selective inhibitor of protein kinase G (PKG). Reverse transcription polymerase chain reaction analysis confirmed that BRIN-BD11 cells (and human islets) express all three known isoforms of PKG (PKG-Ialpha, -Ibeta and II). Cell death induced by YC-1 was not sensitive to cell-permeable caspase inhibitors and was not accompanied by oligonucleosomal DNA fragmentation. The response was, however, inhibited by actinomycin D, suggesting that a transcription-dependent pathway of programmed cell death is involved in the actions of cGMP.

Leukocytosis after posttraumatic splenectomy: a physiologic event or sign of sepsis?

HYPOTHESIS: Although elevations in white blood cell count (WBC) and platelet count (PC) after splenectomy for trauma constitute a physiologic event, certain WBC and PC patterns help differentiate patients with from those without sepsis. DESIGN: Medical record and trauma registry record retrospective review. SETTING: Academic level I trauma center. PATIENTS: From February 1997 through May 2001, 118 trauma patients underwent splenectomy. Sixty patients developed postoperative sepsis (pneumonia, abdominal infection, septicemia, or severe urinary tract infection) (septic group) and 58 did not (nonseptic group). MAIN OUTCOME MEASURES: White blood cell count, PC, and PC/WBC. RESULTS: After the fifth postoperative day, the WBC of patients with sepsis remained consistently greater than 15 x 10(3)/microL and the PC/WBC remained consistently less than 20. In patients without sepsis, these values remained less than 15 x 10(3)/microL and greater than 20, respectively. Stepwise regression analysis identified 3 independent predictors of sepsis: (1) day 5 PC/WBC less than 20, (2) Injury Severity Score greater than 16, and (3) day 5 WBC greater than 15 x 10(3)/microL. According to a statistical prediction model, the probability of sepsis when all 3 predictors were present was 97.4%; when all 3 were absent, it was 2.5%. CONCLUSIONS: At and after the fifth postoperative day, a WBC greater than 15 x 10(3)/microL and a PC/WBC less than 20 are highly associated with sepsis and should not be considered as part of the physiologic response to splenectomy. In view of the seriousness of postsplenectomy sepsis, these values may be used to increase vigilance and prompt early aggressive treatment.

Absence of gastroesophageal reflux disease in a majority of patients taking acid suppression medications after Nissen fundoplication.

Recent studies have shown that many patients use acid suppression medications after antireflux surgery. The aim of this study was to determine the frequency of gastroesophageal reflux disease in a cohort of surgically treated patients with postoperative symptoms and a high prevalence of acid suppression medication use. The study group consisted of 86 patients who had symptoms following Nissen fundoplication that were sufficient to merit evaluation with 24-hour distal esophageal pH monitoring. All completed a detailed symptom questionnaire. The mean postoperative follow-up period was 28 months (median 18 months). Thirty-seven patients (43%) were taking acid suppression medications after fundoplication. Only 23% (20 of 86) of all the patients and only 24% (9 of 37) of those taking acid suppression medications had abnormal esophageal acid exposure on the 24-hour pH study. Heartburn and regurgitation were the only symptoms that were significantly associated with an abnormal pH study. Endoscopic assessment of the fundoplication was the most significant factor associated with an abnormal pH study. Multivariable logistic regression analysis showed that patients with a disrupted, abnormally positioned fundoplication had a 52.6 times increased risk of abnormal esophageal acid exposure. Most patients who use acid suppression medications after antireflux surgery do not have abnormal esophageal acid exposure, and the use of these medications is thus often inappropriate. Because of the limited predictive power of symptoms, objective evidence of reflux disease should be obtained before prescribing acid suppression medication for patients who have undergone antireflux surgery.

Nonoperative management of blunt renal trauma: a prospective study.

Despite the abundance of literature on nonoperative management (NOM) of blunt trauma to the liver and spleen there is limited information on NOM of blunt renal injuries. In an effort to evaluate the role of NOM 37 consecutive unselected patients with renal injuries (grade 1, four; grade 2, 12; grade 3, 11; grade 4, six; and grade 5, four) were followed prospectively over 30 months (Match 1999 to September 2001). Patients without peritonitis or hemodynamic instability were managed nonoperatively regardless of the appearance of the kidney on CT scan. Six (16%) patients were operated on immediately but only two (5.4%) for the kidney (grades 3 and 5 respectively). Of the remaining 31 patients 26 (84%) were managed successfully without an operation (grade 1 or 2, 12; grades 3-5, 14). Five patients were taken to the operating room after a period of observation (3, 3.5, 9, 36, and 44 hours respectively) but only three for the kidney (grades 4 and 5). The overall failure rate was 16 per cent (5 of 31); the rate of failure specifically related to the renal injury was 9.6 per cent (three of 31). Compared with the patients with successful NOM the five patients with failed NOM were more severely injured (Injury Severity Score > or = 15 in 80% vs 27%, P = 0.04), required in the first 6 hours more fluids (4.17 +/- 1.72 vs 1.87 +/- 1.4 liters, P = 0.003) and blood transfusions (2.40 +/- 2 vs 0.42 +/- 1.17 units, P = 0.005), and more frequently had a positive trauma ultrasound (80% vs 11.5%, P = 0.005). We conclude that NOM is the prevailing method of treatment after blunt renal trauma. It is successful in the majority of patients without peritonitis or hemodynamic instability and should be considered regardless of the severity of renal injury. Predictors of failure may exist on the basis of injury severity, fluid and blood requirements, and abdominal ultrasonographic findings and need validation by a larger sample size.