Pathways between adverse childhood experiences and viral suppression among male HIV-infected adolescents in South Africa.

Fewer adolescents achieve viral suppression compared to adults. One impediment may be a history of adverse childhood experiences (ACEs). To better develop targets and timeframes for intervention, this study created more robust estimates of the impact of cumulative adversity on viral suppression, tested whether the association is sensitive to the timing of adversity, and simultaneously tested several potential mechanisms. We focus on males, who have lower viral suppression than females and who may contribute to disproportionate incidence among young women. We recruited 251 male perinatally HIV-infected adolescents aged 15-19 from HIV clinics in Soweto, South Africa. Adversity was captured using the Adverse Childhood Experience - International Questionnaire (ACE-IQ). Viral load was measured using blood samples; viral suppression was defined as <20 copies/mL. Indicators of medication adherence, depression, post-traumatic stress disorder (, and substance misuse were captured. A series of pathway analysis were performed. Our sample experienced a median of 7 lifetime and 4 past-year adversities. Less than half (44%) exhibited viral suppression. Adversity demonstrated a significant association with suppression; depression mediated the association. Primary prevention of adversity among children living with HIV is paramount, as is addressing the subsequent mental and behavioral health challenges that impede viral suppression among adolescents.

Factors affecting the decision to defer endotracheal extubation after surgery for congenital heart disease: a prospective observational study.

BACKGROUND: Fast-tracking and early endotracheal extubation have been described in patients undergoing surgery for congenital heart disease (CHD); however, criteria for patient selection have not been validated in a prospective manner. Our goal in this study was to prospectively identify factors associated with the decision to defer endotracheal extubation in the operating room (OR). METHODS: We performed a prospective observational study of 275 patients (median age 18 months) at the Mount Sinai Medical Center (MSMC), New York, New York, and 49 patients (median age 25 months) at the University of Tokyo Hospital (UTH), Tokyo, Japan, undergoing surgery for CHD requiring cardiopulmonary bypass. These patients were all eligible for fast-tracking, including extubation in the OR immediately after surgery, according to the respective inclusion/exclusion criteria applied at the 2 sites. RESULTS: Eighty-nine percent of patients at the MSMC, and 65% of patients at the UTH were extubated in the OR. At the MSMC, all patients without aortic cross-clamp, and patients with simple procedures (Risk Adjustment for Congenital Heart Surgery [RACHS] score 1) were extubated in the OR. Among the remaining MSMC patients, regression analysis showed that procedure complexity was still an independent predictor for not proceeding with planned extubation in the OR. Extubation was more likely to be deferred in the RACHS score 3 surgical risk patients compared with the RACHS score 2 group (P = 0.005, odds ratio 3.8 [CI: 1.5, 9.7]). Additionally, trisomy 21 (P = 0.0003, odds ratio 9.9 [CI: 2.9, 34.5]) and age (P = 0.0015) were significant independent predictors for deferring OR extubation. We tested our findings on the patients from the UTH by developing risk categories from the MSMC data that ranked eligible patients according to the chance of OR extubation. The risk categories proved to predict endotracheal extubation in the 49 patients who had undergone surgery at the UTH relative to their overall extubation rate, despite differences in anesthetic regimen and inclusion/exclusion criteria. CONCLUSIONS: Preoperatively known factors alone can predict the relative chances of deferring extubation after surgery for CHD. The early extubation strategies applied in the 2 centers were successful in the majority of cases.

Association of preanesthesia hypertension with adverse outcomes.

OBJECTIVE: To investigate the incidence of preanesthesia hypertension, case cancellation for hypertension, and association with postoperative outcomes. DESIGN: Retrospective descriptive, univariate, and multivariate analyses of electronic anesthesia and hospital records. SETTING: A large urban academic medical center. PARTICIPANTS: Adult elective surgical patients with preinduction blood pressure (BP) >140/90 mmHg during calendar years 2002 to 2008. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Preinduction hypertension was present in 21,126 of 209,985 (10%) patients, and the incidence of adverse outcomes (elevated troponin or in-hospital death) was 1.3% overall and 2.8% for the subset of patients with baseline systolic BP >200 mmHg. Independent predictors of adverse outcome included increased baseline systolic BP, intraoperative diastolic BP <85 mmHg, increased intraoperative heart rate, blood transfusion, and anesthetic technique, controlling for standard risk factors. A total of 69 hypertensive patients (0.3%) had surgery cancelled before the induction of anesthesia; 29 of these cancellations occurred among the 1,330 patients with baseline SBP >200 mmHg (2.2%). Among 42 "cancelled" patients who returned for surgery hours to years later, the average preinduction BP was 192/102 mmHg, and adverse cardiovascular outcomes occurred in 4.8%. CONCLUSIONS: The increasing severity of preinduction hypertension was an independent risk factor for postoperative myocardial injury/infarction or in-hospital death. Only a small percentage of cases with patients presenting with severe hypertension were cancelled, and the delay of surgery did not result in interval normalization of blood pressure.

Intraoperative carbon dioxide management and outcomes.

BACKGROUND AND OBJECTIVE: Intraoperative hyperventilation to induce hypocapnia has historically been common practice and has physiological effects that may be detrimental. In contrast, hypercapnia has effects that may be beneficial. As these effects may influence postoperative recovery, we investigated the association between variations in intraoperative carbon dioxide and length of hospital stay in patients who had elective colon resections and hysterectomies. METHODS: Data were extracted from electronic records for elective colon resections and hysterectomies done from 2002 to 2008. Patients were divided into four groups based on surgical procedure and use of laparoscopic technique. Parameters extracted for analysis included mean end-tidal carbon dioxide (EtCO2) during the surgical procedure as well as others previously purported to affect postoperative outcomes. In-hospital length of stay (LOS) was determined from administrative records and was used as the independent outcome variable. For each group, Poisson regression analysis was performed to find factors that were independently associated with the outcome. RESULTS: A total of 3421 case records in our database met inclusion criteria. Median EtCO2 was 31 mmHg. Median LOS was 7 and 5 days for open and laparoscopic colon resections, and 3 and 2 days for open and laparoscopic hysterectomies, respectively. Regression analysis revealed a statistically significant independent association between higher EtCO2 and reduced LOS for colon resection and open hysterectomy. CONCLUSION: There is a significant association between higher intraoperative EtCO2 and shorter LOS after colon resection and open hysterectomy. The common practice of inducing hypocapnia may be deleterious, and maintaining normocapnia or permitting hypercapnia may improve clinical outcomes.

Labor pain at the time of epidural analgesia and mode of delivery in nulliparous women presenting for an induction of labor.

OBJECTIVE: To assess whether the degree of labor pain at the initiation of neuraxial analgesia is associated with mode of delivery. METHODS: Nulliparous women who presented to the labor department for an induction of labor, who were between 37 and 41 weeks of gestation, and who requested labor epidural analgesia with a pain score of 0-3 (low pain) and a cervical dilatation less than 4 cm were assessed retrospectively. Maternal and neonatal outcome including mode of delivery and duration of labor were compared with a similar group of women with pain scores of 4-6 (moderate pain), and 7-10 (severe pain). Assessing whether there was an association between pain level at the time of epidural and operative delivery rates was analyzed using a chi test for trend and by logistic regression to include potentially relevant covariates. RESULTS: We found 185 nulliparous women with low pain and compared them with a randomly selected equal number of women in each of the other pain groups. There was no significant association between pain groups in terms of duration of the first or second stage of labor or mode of delivery. Women with low pain had an operative delivery rate (instrumental assisted vaginal delivery plus cesarean delivery) of 49%, compared with 45% and 45% in those with moderate and severe pain, respectively (P=.40). CONCLUSION: We did not find an association between the degree of labor pain at initiation of epidural analgesia and mode of delivery or duration of labor. LEVEL OF EVIDENCE: II.

Progression to colorectal neoplasia in ulcerative colitis: effect of mesalamine.

BACKGROUND & AIMS: Some studies have suggested that mesalamine can prevent the development of colorectal cancer in patients with ulcerative colitis (UC). The aim of this study was to compare rates of progression with advanced neoplasia in patient cohorts with UC taking low and high doses of mesalamine and to determine where in the process of neoplastic progression mesalamine might act. METHODS: Three cohorts of UC patients were identified from an institutional database: 311 patients with no dysplasia (NoD), 56 with indefinite dysplasia (IND), and 26 with flat low-grade dysplasia (fLGD). The impact of mesalamine exposure on the subsequent development of advanced neoplasia (high-grade dysplasia or colorectal cancer) was assessed using life-table methods. RESULTS: Seventeen of 311 patients with NoD progressed to advanced neoplasia (5-year rate, 1.1%). This rate was lower than the 5-year rate for the IND (9%; P = .02 vs NoD) and fLGD (45%; P < .001 vs NoD and P = .001 vs IND) cohorts. Among the NoD cohort, the hazard ratio for mesalamine users versus nonusers was 0.70 (95% confidence interval, 0.20-2.44), and for each 1 g/d increase in dose, the hazard ratio was 0.92 (95% confidence interval, 0.58-1.47). For patients with IND, no patients on greater than 2 g/d progressed versus 13.8% on low-dose mesalamine (P = .11). For fLGD, 62.5% on high dose progressed, versus 27.8% on low dose (P = .054). CONCLUSIONS: In long-standing UC, patients with fLGD have a higher rate of progression to advanced neoplasia than those with NoD or IND. However, at none of these stages of disease did mesalamine use show definitive chemopreventive activity.

Manual editing of automatically recorded data in an anesthesia information management system.

BACKGROUND: Anesthesia information management systems allow automatic recording of physiologic and anesthetic data. The authors investigated the prevalence of such data modification in an academic medical center. METHODS: The authors queried their anesthesia information management system database of anesthetics performed in 2006 and tabulated the counts of data points for automatically recorded physiologic and anesthetic parameters as well as the subset of those data that were manually invalidated by clinicians (both with and without alternate values manually appended). Patient, practitioner, data source, and timing characteristics of recorded values were also extracted to determine their associations with editing of various parameters in the anesthesia information management system record. RESULTS: A total of 29,491 cases were analyzed, 19% of which had one or more data points manually invalidated. Among 58 attending anesthesiologists, each invalidated data in a median of 7% of their cases when working as a sole practitioner. A minority of invalidated values were manually appended with alternate values. Pulse rate, blood pressure, and pulse oximetry were the most commonly invalidated parameters. Data invalidation usually resulted in a decrease in parameter variance. Factors independently associated with invalidation included extreme physiologic values, American Society of Anesthesiologists physical status classification, emergency status, timing (phase of the procedure/anesthetic), presence of an intraarterial catheter, resident or certified registered nurse anesthetist involvement, and procedure duration. CONCLUSIONS: Editing of physiologic data automatically recorded in an anesthesia information management system is a common practice and results in decreased variability of intraoperative data. Further investigation may clarify the reasons for and consequences of this behavior.

Local anesthetics and mode of delivery: bupivacaine versus ropivacaine versus levobupivacaine.

BACKGROUND: The influence of the labor epidural local anesthetic (LA) on mode of delivery has not been adequately studied. In this study, we sought to determine if there is a difference in mode of delivery among parturients who receive epidural bupivacaine, ropivacaine, or levobupivacaine. METHODS: Nulliparous women at term requesting labor analgesia with a cervical dilation <5 cm were randomized to receive epidural bupivacaine, ropivacaine, or levobupivacaine. Analgesia was initiated with a bolus of 15 mL of 0.0625% of the assigned LA with fentanyl 2 microg/mL. Analgesia was maintained with an infusion of the same solution at 10 mL/h. The primary endpoint was the operative delivery rate (instrumental assisted vaginal delivery plus cesarean delivery). RESULTS: Ninety-eight women received bupivacaine, 90 ropivacaine, and 34 levobupivacaine (before it was removed from the US market). There was no significant difference in the operative delivery rate (bupivacaine = 46%, ropivacaine = 39%, and levobupivacaine = 32%, P = 0.35) among groups. There was less motor block in the levobupivacaine group when compared with the ropivacaine and bupivacaine groups, P < 0.05. There was no significant difference in the duration of the first or second stage of labor, the total dose of LA received per hour of labor, or neonatal outcome among groups. CONCLUSIONS: Bupivacaine, ropivacaine, and levobupivacaine all confer adequate labor epidural analgesia, with no significant influence on mode of delivery, duration of labor, or neonatal outcome.

Changing patterns of postoperative nausea and vomiting prophylaxis drug use in an academic anesthesia practice.

STUDY OBJECTIVE: To characterize the evolution of postoperative nausea and vomiting (PONV) prophylactic drug use. DESIGN: Retrospective data extraction and analysis of electronic anesthesia records. SETTING: Anesthesia department of an urban academic medical center. MEASUREMENTS: 144,134 anesthetics given by 57 attending anesthesiologists were studied. Administered doses of droperidol, ondansetron, dexamethasone, and metoclopramide were tabulated for each year for each practitioner. MAIN RESULTS: Ondansetron use in the periods before and after the Food and Drug Administration (FDA) warning concerning droperidol was 8% and 35%, respectively. Use of PONV prophylaxis increased for all included patient and anesthetic factors. Among those who used droperidol before the revised FDA warning, 61% stopped using it altogether. Afterwards, 75% (27-100%) of droperidol use was in combination with another agent. CONCLUSIONS: We found a significant and sustained decrease in droperidol use after the FDA-mandated labeling revision. We also found a significant increase in ondansetron use--an increase that exceeded the amount needed to substitute for the decreased droperidol use. The changes may be related to multiple factors, including the FDA warning, a trend toward more PONV prophylaxis, and the increasing predominance of serotonin antagonists for this indication.

Using jugular bulb oxyhemoglobin saturation to guide onset of deep hypothermic circulatory arrest does not affect post-operative neuropsychological function.

OBJECTIVES: Deep hypothermic circulatory arrest (DHCA) is commonly used during thoracic aortic surgery, and is initiated only after a sufficient degree of cerebral hypothermia is induced. The criteria for initiating DHCA vary among institutions: most centers use temperature criteria, some use electroencephalography, and a minority use jugular bulb oxyhemoglobin saturation SjO(2) criteria. The purpose of this study was to determine whether the use of SjO(2) monitoring to guide the onset of DHCA was associated with better post-operative neuropsychological outcome. METHODS: Sixty-one thoracic aortic surgical patients underwent both pre- and post-operative neuropsychological testing. Patients were divided into three groups: (1) those with SjO(2)> or =95% at DHCA onset; (2) those with SjO(2)<95% at DHCA onset; and (3) those without SjO(2) monitoring. RESULTS: There were no statistically significant differences in the incidence of post-operative decline in neuropsychological function among the three groups of patients. Patients in whom SjO(2) data were used to guide onset of DHCA had lower esophageal and bladder temperatures at that time compared with patients without SjO(2) monitoring. CONCLUSIONS: Monitoring of SjO(2) had no apparent effect upon post-operative neuropsychological outcome, and there were no trends in our small patient cohort suggesting differences that our study was not adequately powered to detect. Use of SjO(2) monitoring was associated with more profound hypothermia prior to DHCA due to more prolonged cooling in attempts to bring the SjO(2) above the 95% threshold. Using our institutional cooling protocol, SjO(2) monitoring does not appear to increase neuroprotection in patients undergoing DHCA for thoracic aortic repairs.

Interleukin balance and early recovery from anesthesia in elderly surgical patients exposed to beta-adrenergic antagonism.

STUDY OBJECTIVE: To determine whether proinflammatory and antiinflammatory cytokines, as measured in blood specimens, would correlate with improved SF-36 physical composite scores observed in elderly surgical patients who were administered perioperative atenolol. DESIGN: Post hoc analysis of data from a randomized clinical study. SETTING: Department of Anesthesiology, Mount Sinai Medical School, New York. PATIENTS: 59 ASA physical status II, III, and IV patients > or =65 years of age, who were scheduled for major elective noncardiac surgery. INTERVENTIONS: Patients were randomized to one of three anesthetic regimens to receive 1) perioperative management without beta-adrenergic antagonism, 2) preoperative and postoperative administration of atenolol, or 3) intraoperative atenolol as a major component of the anesthetic regimen. MEASUREMENTS AND MAIN RESULTS: Blood samples were drawn perioperatively at seven different time points. Interleukin-1 beta, interleukin-6, interleukin-1ra, and interleukin-10 were measured using enzyme-linked immunosorbent assay (ELISA) kits. Also, recovery from anesthesia and physical/mental well-being (SF-36 questionnaire) were determined perioperatively. Compared with control patients, atenolol-treated patients experienced improved postoperative physical well-being, which paralleled the previously reported faster recovery from anesthesia and a decreased need for perioperative analgesics. Improved postoperative physical well-being of atenolol-treated patients was specifically caused by an ameliorated bodily pain score, a major component of the physical composite score of the SF-36 questionnaire. The cytokine response of these elderly surgical patients was similar to that of younger patients, and the perioperative profile of proinflammatory and antiinflammatory cytokines was not affected by atenolol. CONCLUSIONS: Perioperative administration of atenolol to elderly surgical patients markedly improves physical sense of well-being, which coincides with improved postoperative pain control and decreased analgesic requirements. This improvement experienced by patients receiving atenolol is not related to alterations in perioperative cytokine response.

Predictive model for postoperative delirium in cardiac surgical patients.

Delirium is a common complication following cardiac surgery, and the predictors of delirium remain unclear. The authors performed a prospective observational analysis to develop a predictive model for postoperative delirium using demographic and procedural parameters. A total of 112 adult postoperative cardiac surgical patients were evaluated twice daily for delirium using the Richmond Agitation-Sedation Scale (RASS) and Confusion Assessment Model for the ICU (CAM-ICU). The incidence of delirium was 34% (n = 38). Increased age (odds ratio [OR] = 2.5; 95% confidence interval [CI] = 1.6-3.9; P < .0001, per 10 years) and increased duration of surgery (OR = 1.3; 95% CI = 1.1-1.5; P = .0002, per 30 minutes) were independently associated with postoperative delirium. Gender, BMI, diabetes mellitus, preoperative ejection fraction, surgery type, length of cardiopulmonary bypass, intraoperative blood component administration, Acute Physiology and Chronic Health Evaluation II score, Sequential Organ Failure Assessment score, and Charlson Comorbidity Index, were not independently associated with postoperative delirium.

Extubation in the operating room after congenital heart surgery in children.

OBJECTIVE: Early extubation in the operating room after surgery for congenital heart disease has been described; however, postoperative mechanical ventilation in the intensive care unit remains common practice in many institutions. The goal of this study was to identify perioperative factors associated with not proceeding with planned operating room extubation. METHODS: We performed a retrospective chart review of 224 patients (aged 1 month to 18 years, median 20 months) undergoing surgery for congenital heart defects requiring cardiopulmonary bypass. Patients mechanically ventilated preoperatively were excluded. A stepwise logistic regression model was used to test for the independent influence of various perioperative factors on extubation in the operating room. RESULTS: Overall, 79% of patients were extubated in the operating room. Younger age and longer cardiopulmonary bypass time were the strongest predictors for not extubating. Each step down to a younger age group (<2, 2-4, 4-6, 6-12, >12 months) reduced the chance of extubation in the operating room by 56%. Cardiopulmonary bypass time for more than 150 minutes was associated with an 11.8-fold increased risk of not being extubated. Male gender and high inotrope requirement after cardiopulmonary bypass were also significantly associated with fewer children being extubated. CONCLUSION: Extubation in the operating room after surgery for congenital heart disease was successful in the majority of patients. The strongest independent risk factors for failure of this strategy included younger age and longer cardiopulmonary bypass time.

Histologic inflammation is a risk factor for progression to colorectal neoplasia in ulcerative colitis: a cohort study.

BACKGROUND & AIMS: Although inflammation is presumed to contribute to colonic neoplasia in ulcerative colitis (UC), few studies have directly examined this relationship. Our aim was to determine whether severity of microscopic inflammation over time is an independent risk factor for neoplastic progression in UC. METHODS: A cohort of patients with UC undergoing regular endoscopic surveillance for dysplasia was studied. Degree of inflammation at each biopsy site had been graded as part of routine clinical care using a highly reproducible histologic activity index. Progression to neoplasia was analyzed in proportional hazards models with inflammation summarized in 3 different ways and each included as a time-changing covariate: (1) mean inflammatory score (IS-mean), (2) binary inflammatory score (IS-bin), and (3) maximum inflammatory score (IS-max). Potential confounders were analyzed in univariate testing and, when significant, in a multivariable model. RESULTS: Of 418 patients who met inclusion criteria, 15 progressed to advanced neoplasia (high-grade dysplasia or colorectal cancer), and 65 progressed to any neoplasia (low-grade dysplasia, high-grade dysplasia, or colorectal cancer). Univariate analysis demonstrated significant relationships between histologic inflammation over time and progression to advanced neoplasia (hazard ration (HR), 3.0; 95% CI: 1.4-6.3 for IS-mean; HR, 3.4; 95% CI: 1.1-10.4 for IS-bin; and HR, 2.2; 95% CI: 1.2-4.2 for IS-max). This association was maintained in multivariable proportional hazards analysis. CONCLUSIONS: The severity of microscopic inflammation over time is an independent risk factor for developing advanced colorectal neoplasia among patients with long-standing UC.

Impact of donor age on survival and fibrosis progression in patients with hepatitis C undergoing liver transplantation using HCV+ allografts.

Studies have suggested that the use of hepatitis C virus (HCV)-positive (HCV+) donor allografts has no impact on survival. However, no studies have examined the effect that HCV+ donor histology has upon recipient and graft survival. We evaluated the clinical outcome and impact of histological features in HCV patients transplanted using HCV+ livers. We reviewed all patients transplanted for HCV at our institution from 1988 to 2004; 39 received HCV+ allografts and 580 received HCV-negative (HCV-) allografts. Survival curves compared graft and patient survival. Each HCV+ allograft was stringently matched to a control of HCV- graft recipients. No significant difference in survival was noted between recipients of HCV+ livers and controls. Patients receiving HCV+ allografts from older donors (age > or =50 yr) had higher rates of graft failure (hazard ratio, 2.74) and death rates (hazard ratio, 2.63) compared to HCV- allograft recipients receiving similarly-aged older donor livers. Matched case-control analysis revealed that recipients of HCV+ allografts had more severe fibrosis post-liver transplantation than recipients of HCV- livers (P = 0.008). More advanced fibrosis was observed in HCV+ grafts from older donors compared to HCV+ grafts from younger donors (P = 0.012). In conclusion, recipients of HCV+ grafts from older donors have higher rates of death and graft failure, and develop more extensive fibrosis than HCV- graft recipients from older donors. Recipients of HCV+ grafts, regardless of donor age, develop more advanced liver fibrosis than recipients of HCV- grafts.

Chemoprevention of colorectal neoplasia in ulcerative colitis: the effect of 6-mercaptopurine.

BACKGROUND & AIMS: Evidence suggests that mesalamine-based anti-inflammatory medicines may prevent colorectal cancer (CRC) in ulcerative colitis (UC). If mesalamine exerts its chemopreventive effect by its anti-inflammatory activity, then other medications that reduce colitis activity also should possess chemopreventive properties. Our aim was to determine the effect of the immunomodulators 6-mercaptopurine (6MP) and azathioprine (AZA) in preventing the development of dysplasia or CRC in UC. METHODS: Patients with UC who underwent a surveillance colonoscopy in 1996-1997 were identified from a gastrointestinal pathology database. A proportional hazards analysis assessing 6MP/AZA use as a time-changing covariate was performed to evaluate the effect of 6MP/AZA on: (1) progression to any neoplasia (low-grade dysplasia, high-grade dysplasia, or CRC), and (2) progression to advanced neoplasia (high-grade dysplasia or CRC). RESULTS: A total of 315 subjects met inclusion criteria and were followed for an average of 8 years from their first surveillance examination. There were no significant differences in rates of progression to advanced neoplasia or to any neoplasia between 6MP/AZA users and never-users by log-rank testing. The proportional hazards analysis resulted in hazard ratios of 1.06 (95% confidence interval, .59-1.93) and 1.30 (95% confidence interval, .45-3.75) when considering the effect of exposure to 6MP/AZA on progression to any or to advanced neoplasia, respectively. The results were unaffected by known potential confounders. CONCLUSIONS: In UC patients with no initial history of dysplasia, 6MP/AZA use appears to have little or no effect on the rate of neoplastic transformation in the colon. Importantly, the use of 6MP/AZA did not increase malignant transformation in UC.

Effect of labor epidural analgesia with and without fentanyl on infant breast-feeding: a prospective, randomized, double-blind study.

BACKGROUND: The influence of labor epidural fentanyl on the neonate is controversial. The purpose of this study was to determine whether epidural fentanyl has an impact on breast-feeding. METHODS: Women who previously breast-fed a child and who requested labor epidural analgesia were randomly assigned in a double-blinded manner to one of three groups: (1) no fentanyl group, (2) intermediate-dose fentanyl group (intent to administer between 1 and 150 microg epidural fentanyl), or (3) high-dose epidural fentanyl group (intent to administer > 150 microg epidural fentanyl). On postpartum day 1, the mother and a lactation consultant separately assessed whether the infant was experiencing difficulty breast-feeding, and a pediatrician assessed infant neurobehavior. All women were contacted 6 weeks postpartum to determine whether they were still breast-feeding. RESULTS: Sixty women were randomly assigned to receive no fentanyl, 59 were randomly assigned to receive an intermediate dose, and 58 were randomly assigned to receive high-dose fentanyl. On postpartum day 1, women who were randomly assigned to receive high-dose fentanyl reported difficulty breast-feeding (n = 12, 21%) more often than women who were randomly assigned to receive an intermediate fentanyl dose (n = 6, 10%), or no fentanyl (n = 6, 10%), although this did not reach statistical significance (P = 0.09). There was also no significant difference among groups in breast-feeding difficulty based on the lactation consultant's evaluation (40% difficulty in each group; P = 1.0). Neurobehavior scores were lowest in the infants of women who were randomly assigned to receive more than 150 microg fentanyl (P = 0.03). At 6 weeks postpartum, more women who were randomly assigned to high-dose epidural fentanyl were not breast-feeding (n = 10, 17%) than women who were randomly assigned to receive either an intermediate fentanyl dose (n = 3, 5%) or no fentanyl (n = 1, 2%) (P = 0.005). CONCLUSIONS: Among women who breast-fed previously, those who were randomly assigned to receive high-dose labor epidural fentanyl were more likely to have stopped breast-feeding 6 weeks postpartum than woman who were randomly assigned to receive less fentanyl or no fentanyl.

Predictors of hypotension after induction of general anesthesia.

Hypotension after induction of general anesthesia is a common event. In the current investigation, we sought to identify the predictors of clinically significant hypotension after the induction of general anesthesia. Computerized anesthesia records of 4096 patients undergoing general anesthesia were queried for arterial blood pressure (BP), demographic information, preoperative drug history, and anesthetic induction regimen. The median BP was determined preinduction and for 0-5 and 5-10 min postinduction of anesthesia. Hypotension was defined as either: mean arterial blood pressure (MAP) decrease of >40% and MAP <70 mm Hg or MAP <60 mm Hg. Overall, 9% of patients experienced severe hypotension 0-10 min postinduction of general anesthesia. Hypotension was more prevalent in the second half of the 0-10 min interval after anesthetic induction (P < 0.001). In 2406 patients with retrievable outcome data, prolonged postoperative stay and/or death was more common in patients with versus those without postinduction hypotension (13.3% and 8.6%, respectively, multivariate P < 0.02). Statistically significant multivariate predictors of hypotension 0-10 min after anesthetic induction included: ASA III-V, baseline MAP <70 mm Hg, age > or =50 yr, the use of propofol for induction of anesthesia, and increasing induction dosage of fentanyl. Smaller doses of propofol, etomidate, and thiopental were not associated with less hypotension. To avoid severe hypotension, alternatives to propofol anesthetic induction (e.g., etomidate) should be considered in patients older than 50 yr of age with ASA physical status > or =3. We conclude that it is advisable to avoid propofol induction in patients who present with baseline MAP <70 mm Hg.

Recurrent hepatitis C after retransplantation: factors affecting graft and patient outcome.

Retransplantation (re-LT) of patients with recurrent hepatitis C virus (HCV) carries significant morbidity and mortality, negatively impacting on an already scarce donor allograft pool. In this study, we investigated the outcome of allografts and patients after re-LT due to recurrent HCV. Between 1989 and 2002, 47 patients were retransplanted at our institution due to HCV-related graft failure. Clinical HCV recurrence after re-LT was diagnosed when patients had acute liver enzyme elevation correlated with histological recurrence. The independent influence of these variables on survival was tested using Cox regression model. Chi-squared tests were used to examine the influence of individual demographic and pre/perioperative variables on recurrence. Thirty-one (66%) patients died after re-LT (median 2.2 months). Donor age >60, clinical HCV recurrence, and graft failure due to cirrhosis were significant risk factors for mortality (risk ratios of 3.6, 3.3, and 2.4, respectively). Pre-LT MELD score was lower among survivors (22+/- 5 vs. 27+/- 8). Following re-LT, 38 patients had at least one biopsy due to acute liver dysfunction; 19 of them (50%) had recurrence within the first 3 months. High-dose solumedrol was correlated with early recurrence. No association was found between time of recurrence after the first LT and time of recurrence after re-LT. In conclusion, patients with cirrhosis due to recurrent HCV undergoing re-LT have an extremely high mortality rate; older allografts should be avoided in retransplanting these patients. The timing of clinical recurrence after initial liver transplantation is not predictive of the timing of recurrence after re-LT. Patients experiencing early graft failure due to accelerated forms of HCV should not be denied re-LT with the expectation that a similar disease course will occur after re-LT.

Histopathology and clinical correlates of end-stage hepatitis B cirrhosis: a possible mechanism to explain the response to antiviral therapy.

In chronic liver disease associated with histological necroinflammation, clinical severity is frequently greater in those with higher grades of activity. Conventional wisdom assumes that necroinflammation is mild or absent in patients with end-stage hepatitis B virus (HBV) cirrhosis due to the frequent presence of mildly elevated aminotransferase levels, the absence of hepatitis B e antigen (HBeAg), and low or undetectable HBV deoxyribonucleic acid (DNA) levels. However, a histopathologic analysis of such patients has not been undertaken. The aims of this study were 1) to assess severity and histological features of inflammation, 2) to correlate the severity of inflammation with biochemical and virologic parameters, and 3) to define the relationship between inflammation and clinical severity in explanted livers from patients undergoing liver transplantation for HBV cirrhosis. Characteristics of 34 consecutive patients undergoing liver transplantation for HBV cirrhosis were correlated with inflammation and immunohistological findings in the explanted livers. High-grade inflammation (grades 3 and 4) was found in many cases (47.1% interface hepatitis; 14.8% lobular inflammation; and 20.6% portal inflammation). The presence of positive cytoplasmic staining for hepatitis B core antigen (HBcAg) was associated with grade 3 or 4 interface hepatitis (P = .046) and lobular hepatitis (P = .005). There was no correlation between inflammatory activity and age, Asian ethnicity, aminotransferase levels, total bilirubin levels, HBeAg seropositivity, and detectable HBV DNA level. Patients with high-grade inflammation had greater degrees of hepatic decompensation. In conclusion, high-grade inflammation is common in end-stage HBV cirrhosis, but it is not readily detected by biochemical and virologic parameters. High-grade inflammation is associated with a greater degree of hepatic decompensation.