Lung recruitment prevents collapse during laparoscopy in children: A randomised controlled trial

BACKGROUND Capnoperitoneum and anaesthesia impair lung aeration during laparoscopy in children. These changes can be detected and monitored at the bedside by lung ultrasound (LUS). OBJECTIVE The aim of our study was to assess the impact of general anaesthesia and capnoperitoneum on lung collapse and the potential preventive effect of lung recruitment manoeuvres, using LUS in children undergoing laparoscopy. DESIGN Randomised controlled study. SETTING Single-institution study, community hospital, Mar del Plata, Argentina. PATIENTS Forty-two children American Society of Anesthesiologists I–II aged 6 months to 7 years undergoing laparoscopy. INTERVENTIONS All patients were studied using LUS before, during and after capnoperitoneum. Children were allocated to a control group (C-group, n=21) receiving standard protective ventilation, or to a lung recruitment manoeuvre group (RM-group) (n=21), in which lung recruitment manoeuvres were performed after recording baseline LUS images before capnoperitoneum. Loss of aeration was scored by summing a progressive grading from 0 to 3 assigned to each of 12 lung areas, based on the detection of four main ultrasound patterns: normal aeration = 0, partial loss-mild = 1, partial loss-severe = 2, total loss-consolidation = 3. MAIN OUTCOME MEASURES Lung aeration score and atelectasis assessed by ultrasound. RESULTS Before capnoperitoneum and recruitment manoeuvres in the treated group the two groups presented similar ultrasound scores (5.95 ± 4.13 vs. 5.19 ± 3.33, P = 0.5). In the RM-group, lung aeration significantly improved both during (2.71 ± 2.47) and after capnoperitoneum (2.52 ± 2.86), compared with the C-group (6.71 ± 3.54, P 

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Ultrasound in Anesthesia, Critical Care, and Pain Management

No abstract available

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Interventional Spine and Pain Procedures in Patients on Antiplatelet and Anticoagulant Medications (Second Edition): Guidelines From the American Society of Regional Anesthesia and Pain Medicine, the European Society of Regional Anaesthesia and Pain Therapy, the American Academy of Pain Medicine, the International Neuromodulation Society, the North American Neuromodulation Society, and the World Institute of Pain

The American Society of Regional Anesthesia and Pain Medicine (ASRA) 2012 survey of meeting attendees showed that existing ASRA anticoagulation guidelines for regional anesthesia were insufficient for their needs. Those surveyed agreed that procedure-specific and patient-specific factors required separate guidelines for pain and spine procedures. In response, a guidelines committee was formed. After preliminary review of published complications reports and studies, the committee stratified interventional spine and pain procedures according to potential bleeding risk: low-, intermediate-, and high-risk procedures. The ASRA regional anesthesia anticoagulation guidelines were largely deemed appropriate for the low- and intermediate-risk categories, but the high-risk category required further investigation. The first guidelines specific to interventional spine and pain procedures were published in 2015. Recent reviews evaluating bleeding complications in patients undergoing specific interventional pain procedures, the development of new regional anesthesia and acute pain guidelines, and the development of new anticoagulants and antiplatelet medications necessitate complementary updated guidelines. The authors desired coordination with the authors of the recently updated regional and acute pain anticoagulation guidelines. The latest evidence was sought through extensive database search strategies and the recommendations were evidence based when available and pharmacology driven otherwise. We could not provide strength and grading of these recommendations because there are not enough well-designed large studies concerning interventional pain procedures to support such grading. Although the guidelines could not always be based on randomized studies or on large numbers of patients from pooled databases, it is hoped that they will provide sound recommendations and the evidentiary basis for such recommendations. This publication is intended as a living document to be updated periodically with consideration of new evidence. Accepted for publication September 1, 2017. Address correspondence to: Samer Narouze, MD, PhD, Center for Pain Medicine, Western Reserve Hospital, 1900 23rd St, Cuyahoga Falls, OH 44223 (e-mail: narouzs@hotmail.com). Brian D. Sites, MD, was acting Editor-in-Chief for this submission. S.N. is a paid member of an advisory board for Abbott Laboratories. D.P. receives research funding from Abbott Laboratories and Medtronic. He serves as a consultant to Abbott, Boston Scientific, Medtronic, Nevro, and Halyard. T.D. is a paid consultant for Axonics, Abbott, Bioness, Flowonix Medical, Jazz Pharmaceuticals, Nalu, SpineThera, Saluda Medical, Mainstay Medical, Vertos, Vertiflex. R.R. receives funding from Boston Scientific, Biodelivery Science Inc, and Jazz Pharma. In addition, R.R. receives ongoing research grants from Nektar, Biogen, Pfizer, SPR Therapeutics, Neuros, Mainstay, Saluda, Nevro, and Stimwave and also serves as chair of Data Safety Monitoring Boards and Clinical Events Committee of Mainstay and Saluda trials. He also serves as a speaker for AstraZeneca. M.A.H. serves on the Clinical Events Committee for a study funded by Saluda Medical Americas, Inc. and the Data Safety Monitoring Committee for a study funded by Mainstay Medical International PLC. He otherwise declares no potential conflicts of interest. The other authors declare no conflict of interest. S.N. and H.T.B. equally contributed to the manuscript. Copyright © 2017 by American Society of Regional Anesthesia and Pain Medicine.

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Sensory Assessment and Regression Rate of Bilateral Oblique Subcostal Transversus Abdominis Plane Block in Volunteers

Background and Objectives The analgesic effect and duration of a transversus abdominis plane (TAP) block remain controversial. Transversus abdominis plane blocks are effective for somatic/incisional pain but do not provide analgesia for visceral pain from intra-abdominal procedures. The purpose of this study was to assess the area and extent of cutaneous sensory blockade and the regression of dermatomal anesthesia after bilateral oblique subcostal TAP block. Methods This observational, prospective clinical study consisted of 12 healthy volunteers. All volunteers received a bilateral oblique subcostal TAP block under real-time ultrasound guidance with 20 mL of 0.375% ropivacaine. The anterior abdominal cutaneous area was divided into 3 parts (midabdomen, left-lateral abdomen, right-lateral abdomen) using 2 lines drawn in a parasagittal fashion 5 cm lateral to the midline. The area of cutaneous sensory blockade involving the anterior abdomen was assessed 30 minutes after institution of the block using a cold stimulus. This was followed by repeated measurements using a cold stimulus applied along parasagittal lines drawn 3 cm lateral to the midline at 0.5, 6, 10, 14, 18, 22, and 26 hours after blockade. Results The area of cutaneous sensory blockade of the abdomen was 332 (SD, 73) cm2; that of the midabdomen was 253 (SD, 29) cm2, which represented an average of 90% of the area of the midabdomen; and that of the lateral abdominal wall (combination of left-lateral abdomen and right-lateral abdomen) was 79 (SD, 62) cm2, which represented an average of 26% of total lateral abdominal area. Dermatomes T7–T12 of the midabdomen were successfully blocked in all volunteers after using the bilateral oblique subcostal technique. However, T6 and L1 were only variably blocked. The area of cutaneous sensory block of the anterior abdomen regressed over the ensuing 22 hours in the following manner: 90%, 87%, 73%, 50%, 22%, 3%, and 0% at 0.5, 6, 10, 14, 18, 22, and 26 hours, respectively. Conclusions Bilateral oblique subcostal TAP block produces a widespread cutaneous sensory blockade with a consistent dermatomal distribution in the midabdomen for a considerable effective duration. Accepted for publication July 17, 2017. Address correspondence to: Quanguang Wang, MD, Department of Anesthesiology, the First Affiliated Hospital of Wenzhou Medical University, Shangcai Village, South White Elephant Town, Wenzhou City, Zhejiang Province, China 325000 (e-mail: quanguangwang@sina.com). Y.C. and K.S. contributed equally to this work and should be considered co–first authors. The authors declare no conflict of interest. Y.C. helped design the study, prepare the manuscript, and collect and analyze data. K.S. helped design the study, prepare the manuscript, and analyze data. Y.X. helped analyze data and prepare the manuscript. X.Z. helped conduct the study. T.J.P. participated in manuscript preparation and critical manuscript review and approved the final manuscript. X.X. helped design the study, prepare the manuscript, and analyze data. Q.W. helped design the study, prepare the manuscript, and analyze data. Copyright © 2017 by American Society of Regional Anesthesia and Pain Medicine.

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Ethnic Differences Identified by Pain Sensitivity Questionnaire Correlate With Clinical Pain Responses

Background and Objectives The Pain Sensitivity Questionnaire, English version (PSQ-E), is predictive of pain-related responses to experimental stimuli. Ethnic differences have been noted in experimental measures of pain sensation using quantitative sensory testing. The present study sought to determine if the PSQ-E also identified similar ethnic differences. Methods Fifty-seven subjects who self-identified as African Americans (AAs) and who were scheduled to undergo a low-back interventional procedure completed the PSQ-E and other questionnaires. Their data were compared with an age-, sex-, and opioid usage–matched sample of 57 self-identified non-Hispanic white (NHW) subjects. Pain ratings on a visual analog scale (VAS) were obtained following 2 standardized injections of subcutaneous lidocaine (VAS1—infiltration in hand, VAS2—infiltration of procedural site). Correlations between PSQ-E scores, VAS measures, and other inventories were tested. Results The PSQ-E scores and clinical and experimental pain scores were all significantly elevated in AA compared with NHW patients (P

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Erector Spinae Plane Block for Surgery of the Posterior Thoracic Wall in a Pediatric Patient

Objective Historically, regional anesthesia for surgery on the posterior thoracic wall has been limited to neuraxial and paravertebral nerve blocks. The erector spinae plane (ESP) block is a novel technique that anesthetizes the dorsal rami of the spinal nerves innervating the posterior thoracic wall. We report the use of the ESP block for this clinical application in a pediatric patient. Case Report A healthy 3-year-old girl was scheduled for resection of a giant paraspinal lipoma extending over the T4–T7 dermatomes. She received a preoperative single-shot ESP block at the level of the T1 transverse process; this level was chosen to avoid the lipoma and cover the planned surgical incision over the T2–T8 dermatomes. Hemodynamic stability and excellent pain control perioperatively were obtained with minimal anesthetic requirements and no systemic analgesics apart from fentanyl administered for induction of anesthesia. Return to normal function (ambulation, feeding, and communication) was achieved within 2 hours after surgery. A pain score of 0 on the FLACC (Face, Legs, Activity, Cry, Consolability) scale was maintained until discharge from the hospital 4 hours after the surgery. First analgesic use was 18 hours after hospital discharge. No complications were reported. Conclusions The ESP block is an effective option for surgery on the posterior thoracic wall. The opioid- and anesthetic-sparing effects exhibited in this case facilitated rapid postoperative recovery and early discharge. Accepted for publication July 30, 2017. Address correspondence to: Maria Alejandra Hernandez, MD, Department of Anesthesia, Pereira Rossell Pediatric Hospital, Bulevar Gral, Artigas 1550, 11600 Montevideo, Uruguay (e-mail: Hernandez.malaquina.alejandra@gmail.com). This work should be attributed to the Department of Anesthesia. Dr Orlando Alassia Children's Hospital, Santa Fe, Argentina. The authors declare no conflict of interest. Copyright © 2017 by American Society of Regional Anesthesia and Pain Medicine.

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Local Application of Ultrasound Attenuates Neuropathic Allodynia and Proinflammatory Cytokines in Rats After Thoracotomy

Background and Objectives We aimed to investigate the effect of therapeutic ultrasound (TU) on pain sensitivity and the concentration inflammatory cytokines in a thoracotomy rat model. Methods Rats were distributed randomly into 4 groups: (1) sham operated, (2) thoracotomy and rib retraction (TRR), (3) TRR rats that received TU (TRR + TU-1), and (4) TRR rats that received TU with the ultrasound turned off (TRR + TU-0). Ultrasound was set at 1-MHz frequency (1.0-W/cm2 intensity and 100% duty cycle for 5 minutes), began on postoperative day (POD) 10, and then continued once per day, 5 days a week for 3 weeks. Results The TRR and TRR + TU-0 rats encountered tactile hypersensitivity from PODs 10 to 28. Mechanical withdrawal thresholds were increased (all P

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On-line preparatory information for children and their families undergoing dental extractions under general anesthesia: A phase III randomized controlled trial

Summary

Background

Family-centered interactive on-line games are increasingly popular in healthcare, but their effectiveness for preoperative preparation needs further research. www.scottga.org is the new on-line version of a proven nonweb-based game for children and parents/caregivers.

Aims

The aim of this study was to evaluate if www.scottga.org improved children's anxiety and families' satisfaction compared with controls.

Methods

In this phase III double-blind randomized controlled trial, children/parents/caregivers received (i) www.scottga.org, (ii) standard care, or (iii) a placebo hand-washing game. The intervention and placebo games were available online for home usage and provided again on the ward before surgery. All children were accompanied by parent/caregivers at induction and observed and scored using validated measures. Stratified randomization and generalized linear models were used. An intention-to-treat approach was adopted.

Results

Overall, 52/176 children had baseline "psychological disturbance." Children's anxiety increased preinduction, but there were no differences between groups (Facial Image Scale: video-standard OR = 1.08, P = .82, 95% CI [0.56, 2.1]; video-placebo OR = 0.9, P = .77 95% CI [0.46, 1.8]). There were no differences in induction behavior (visual analog scale: video mean = 3.5; standard care mean = 3.5; placebo mean = 3.7: video-standard OR = 2.0, P = .42, 95% CI [−0.6, 1.3]; video-placebo OR = 1.53, P = .65, 95% CI [−0.8, 1.1]) or induction anxiety (modified Yale Preoperative Anxiety Scale: video-standard OR 1.02, P = .97, 95% CI [0.61, 2.6]; video-placebo OR 1.38, P = .49, 95% CI [0.87, 3.81]). Families favored the intervention regarding the "child handling the visit better" (Treatment Evaluation Inventory: video-standard OR = 12; 95% CI 4.7-32; P < .001; video-placebo OR = 8.2; 95% CI 3-22; P < .001) and "improving the child's ability to cope" (Treatment Evaluation Inventory: video-standard OR = 21; 95% CI 8-56; P < .001 and video-placebo OR = 13; 95% CI 5-34; P < .001).

Conclusion

Families believed that a video-game preparation helped their child's perioperative anxiety, but there were no objective measures of behavioral improvement associated with this intervention.

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Characterization of the functional near-infrared spectroscopy response to nociception in a pediatric population

Summary

Background

Near-infrared spectroscopy can interrogate functional optical signal changes in regional brain oxygenation and blood volume to nociception analogous to functional magnetic resonance imaging.

Aims

This exploratory study aimed to characterize the near-infrared spectroscopy signals for oxy-, deoxy-, and total hemoglobin from the brain in response to nociceptive stimulation of varying intensity and duration, and after analgesic and neuromuscular paralytic in a pediatric population.

Methods

We enrolled children 6 months-21 years during propofol sedation before surgery. The near-infrared spectroscopy sensor was placed on the forehead and nociception was produced from an electrical current applied to the wrist. We determined the near-infrared spectroscopy signal response to increasing current intensity and duration, and after fentanyl, sevoflurane, and neuromuscular paralytic. Heart rate and arm movement during electrical stimulation was also recorded. The near-infrared spectroscopy signals for oxy-, deoxy-, and total hemoglobin were calculated as optical density*time (area under curve).

Results

During electrical stimulation, nociception was evident: tachycardia and arm withdrawal was observed that disappeared after fentanyl and sevoflurane, whereas after paralytic, tachycardia persisted while arm withdrawal disappeared. The near-infrared spectroscopy signals for oxy-, deoxy-, and total hemoglobin increased during stimulation and decreased after stimulation; the areas under the curves were greater for stimulations 30 mA vs 15 mA (13.9 [5.6-22.2], P = .0021; 5.6 [0.8-10.5], P = .0254, and 19.8 [10.5-29.1], P = .0002 for HbO₂, Hb, and Hb_T, respectively), 50 Hz vs 1 Hz (17.2 [5.8-28.6], P = .0046; 7.5 [0.7-14.3], P = .0314, and 21.9 [4.2-39.6], P = .0177 for HbO₂, Hb, and Hb_T, respectively) and 45 seconds vs 15 seconds (16.3 [3.4-29.2], P = .0188 and 22.0 [7.5-36.5], P = .0075 for HbO₂ and Hb_T, respectively); the areas under the curves were attenuated by analgesics but not by paralytic.

Conclusion

Near-infrared spectroscopy detected functional activation to nociception in a broad pediatric population. The near-infrared spectroscopy response appears to represent nociceptive processing because the signals increased with noxious stimulus intensity and duration, and were blocked by analgesics but not paralytics.

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Medial gastrocnemius muscle stiffness cannot explain the increased ankle joint range of motion following passive stretching in children with cerebral palsy

Abstract

Stretching is often used to increase/maintain joint range of motion (ROM) in children with cerebral palsy (CP) but the effectiveness of these interventions is limited. Therefore, this study aimed to determine the acute changes in muscle-tendon lengthening properties that contribute to increased ROM after a bout of stretching in children with CP. Eleven children with spastic CP (age:12.1(3)y, 5/6 hemiplegia/diplegia, 7/4 GMFCS level I/II) participated in this study. Each child received 3 sets of 5 × 20 s passive, manual static dorsiflexion stretches separated by 30 s rest, and 60 s rest between sets. Pre- and immediately post-stretching, ultrasound was used to measure medial gastrocnemius fascicle lengthening continuously over the full ROM and an individual common ROM pre- to post-stretching. Simultaneously, 3D motion of two marker clusters on the shank and the foot was captured to calculate ankle angle, and ankle joint torque was calculated from manually applied torques and forces on a 6DoF load cell. After stretching, ROM was increased (9.9° (12.0), P = 0.005). Over a ROM common to both pre and post measurements, there were no changes in fascicle lengthening or torque. The maximal ankle joint torque tolerated by the participants increased (2.9(2.4) Nm, P = 0.003) and at this highest passive torque maximal fascicle length was 2.8(2.4) mm greater (P = 0.009) when compared to before stretching. These results indicate that the stiffness of the muscle fascicles in children with CP remain unaltered by an acute bout of stretching.

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Cancer transcriptome profiling at the juncture of clinical translation

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Nuclear receptors in cancer — uncovering new and evolving roles through genomic analysis

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Technique: Single-cell transcriptomes in space

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Fine Mapping of QUICK ROOTING 1 and 2, Quantitative Trait Loci Increasing Root Length in Rice

The volume that the root system can occupy is associated with the efficiency of water and nutrient uptake from soil. Genetic improvement of root length, which is a limiting factor for root distribution, is necessary for increasing crop production. In this report, we describe identification of two QTLs for maximal root length, QUICK ROOTING 1 (QRO1) on chromosome 2 and QRO2 on chromosome 6 in cultivated rice (Oryza sativa L.). We measured the maximal root length in 26 lines carrying chromosome segments from the long-rooted upland rice cultivar Kinandang Patong in the genetic background of the short-rooted lowland cultivar IR64. Five lines had longer roots than IR64. By rough mapping of the target regions in BC₄F₂ populations, we detected putative QTLs for maximal root length on chromosomes 2, 6, and 8. To fine-map these QTLs, we used BC₄F₃ recombinant homozygous lines. QRO1 was mapped between markers RM5651 and RM6107, which delimit a 1.7-Mbp interval on chromosome 2, and QRO2 was mapped between markers RM20495 and RM3430-1, which delimit an 884-kbp interval on chromosome 6. Both QTLs may be promising gene resources for improving root system architecture in rice.

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Genetic Evidence for Roles of Yeast Mitotic Cyclins at Single-Stranded Gaps Created by DNA Replication

Paused/stalled replication forks are major threats to genome integrity; unraveling the complex pathways that contribute to fork stability/restart is crucial. Experimentally, fork stalling is induced by growth in presence of hydroxyurea (HU), which depletes the pool of deoxynucleoside triphosphates (dNTPs) and slows down replication progression in yeast. Here, I report an epistasis analysis, based on sensitivity to HU, between CLB2, the principal mitotic cyclin gene in S. cerevisiae, and genes involved in fork stability and recombination. clb2 cells are not sensitive to HU, but the strong synergistic effect of clb2 with most genes tested indicates, unexpectedly, that CLB2 plays an important role in DNA replication, in the stability and restart of stalled forks, in pathways dependent and independent of homologous recombination. Results indicate that CLB2 functions in parallel to SGS1 helicase-EXO1 exonuclease to allow proper Rad51 recombination, but also regulates a combined Sgs1-Exo1 activity in a Mec1- and a Rad53- checkpoint protein kinase dependent pathway. Data argue that Mec1 regulates Clb2 to prevent a deleterious Sgs1-Exo1 activity at paused/stalled forks, while Rad53 checkpoint activation regulates Clb2 to allow a necessary Sgs1-Exo1 activity at stalled/collapsed forks. Altogether, this study indicates that Clb2 regulates the activity of numerous nucleases at single-stranded gaps created by DNA replication. A model is proposed for the function and regulation of Clb2 at stalled forks. These data open new perspectives on the role of mitotic cyclins at the end of S phase.

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Neurophysiological correlates of word processing deficits in isolated reading and isolated spelling disorders

Publication date: Available online 24 December 2017
Source:Clinical Neurophysiology
Author(s): Sarolta Bakos, Karin Landerl, Jürgen Bartling, Gerd Schulte-Körne, Kristina Moll
ObjectiveIn consistent orthographies, isolated reading disorders (iRD) and isolated spelling disorders (iSD) are nearly as common as combined reading-spelling disorders (cRSD). However, the exact nature of the underlying word processing deficits in isolated versus combined literacy deficits are not well understood yet.MethodsWe applied a phonological lexical decision task (including words, pseudohomophones, legal and illegal pseudowords) during ERP recording to investigate the neurophysiological correlates of lexical and sublexical word-processing in children with iRD, iSD and cRSD compared to typically developing (TD) 9-year-olds.ResultsTD children showed enhanced early sensitivity (N170) for word material and for the violation of orthographic rules compared to the other groups. Lexical orthographic effects (higher LPC amplitude for words than for pseudohomophones) were the same in the TD and iRD groups, although processing took longer in children with iRD. In the iSD and cRSD groups, lexical orthographic effects were evident and stable over time only for correctly spelled words.ConclusionsOrthographic representations were intact in iRD children, but word processing took longer compared to TD. Children with spelling disorders had partly missing orthographic representations.SignificanceOur study is the first to specify the underlying neurophysiology of word processing deficits associated with isolated literacy deficits.



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Ser7 of RNAPII-CTD facilitates heterochromatin formation by linking ncRNA to RNAi [Genetics]

Some long noncoding RNAs (ncRNAs) transcribed by RNA polymerase II (RNAPII) are retained on chromatin, where they regulate RNAi and chromatin structure. The molecular basis of this retention remains unknown. We show that in fission yeast serine 7 (Ser7) of the C-terminal domain (CTD) of RNAPII is required for efficient...

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Effects of mutation and selection on plasticity of a promoter activity in Saccharomyces cerevisiae [Genetics]

Phenotypic plasticity is an evolvable property of biological systems that can arise from environment-specific regulation of gene expression. To better understand the evolutionary and molecular mechanisms that give rise to plasticity in gene expression, we quantified the effects of 235 single-nucleotide mutations in the Saccharomyces cerevisiae TDH3 promoter (PTDH3) on...

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Epigenetic control of pheromone MAPK signaling determines sexual fecundity in Candida albicans [Genetics]

Several pathogenic Candida species are capable of heritable and reversible switching between two epigenetic states, "white" and "opaque." In Candida albicans, white cells are essentially sterile, whereas opaque cells are mating-proficient. Here, we interrogate the mechanism by which the white-opaque switch regulates sexual fecundity and identify four genes in the...

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Prenatal and Postpartum Care Disparities in a Large Medicaid Program

Abstract

Objectives Pennsylvania's maternal mortality, infant mortality, and preterm birth rates rank 24th, 35th, and 25th in the country, and are higher among racial and ethnic minorities. Provision of prenatal and postpartum care represents one way to improve these outcomes. We assessed the extent of disparities in the provision and timeliness of prenatal and postpartum care for women enrolled in Pennsylvania Medicaid. Methods We performed a cross-sectional evaluation of representative samples of women who delivered live births from November 2011 to 2015. Our outcomes were three binary effectiveness-of-care measures: prenatal care timeliness, frequency of prenatal care, and postpartum care timeliness. Pennsylvania's Managed Care Organizations (MCOs) were required to submit these outcomes to the state after reviewing administrative and medical records through a standardized, validated sampling process. We assessed for differences in outcomes by race, ethnicity, region, year, and MCO using logistic regression. Results We analyzed data for 12,228 women who were 49% White, 31% Black/African American, 4% Asian, and 15% Hispanic/Latina. Compared to Black/African American women, white and Asian women had higher odds of prenatal and postpartum care. Hispanic/Latina women had higher frequency of prenatal care than non-Hispanic women. Pennsylvania's Southeast had lower prenatal care and Northwest had lower postpartum care than other regions. Prenatal care significantly decreased in 2014 and increased in 2015. We observed differences between MCOs, and as MCO performance diminished, racial disparities within each plan widened. We explored hypotheses for observed disparities in secondary analyses. Conclusions for Practice Our data demonstrate that interventions should address disparities by race, region, and MCO in equity-promoting measures.

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Genetic diagnosis of Down syndrome in an underserved community

It is a matter of course that in high-income countries, infants born with features suggestive of Down syndrome (DS) are offered genetic testing for confirmation of a clinical diagnosis. Benefits of a definitive diagnosis include an end to the diagnostic odyssey, informed prognosis, opportunities for caregiver support, inclusion to social support networks, and more meaningful genetic counseling. The healthcare experience for families of children born with DS in low- and middle-income nations is in stark contrast with such a level of care. Barriers to obtaining genetic diagnosis might include economic disparities, geographical isolation, and lack of access to health care professionals trained in genetic medicine. As part of a combined research and community outreach effort, we provided genetic testing for several patients with DS. These individuals and their families live on several resource-limited Caribbean islands and have either limited or virtually no access to medical genetics services. Within this group were three families with recurrent DS. Karyotype established that translocation events were not involved in the DS in any of these families. This information enabled genetic counseling to help family members understand their recurrent DS. A definitive diagnosis of DS is beneficial to families in resource-limited communities and may help to provide such families with genetic counseling, reassurance, and peace of mind.

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Postoperative mortality and morbidity following non-cardiac surgery in a healthy patient population

Abstract

Purpose

Perioperative mortality ranges from 0.4% to as high as nearly 12%. Currently, there are no large-scale studies looking specifically at the healthy surgical population alone. The primary objective of this study was to report 30-day mortality and morbidity in healthy patients and define any risk factors.

Methods

Using the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) dataset, all patients assigned an American Society of Anesthesiologists physical status (ASA PS) classification score of 1 or 2 were included. Further patients were excluded if they had a comorbidity or underwent a procedure not likely to classify them as ASA PS 1 or 2. Multivariable logistic regression was performed to identify predictors of the outcomes, in which odds ratios (OR) and 95% confidence intervals (95% CI) were reported.

Results

There were 687,552 healthy patients included in the final analysis. Following surgery, 0.7, 7.0, and 0.7 per 1000 persons experienced 30-day mortality, sepsis, and stroke or myocardial infarction, respectively. Healthy patients greater than 80 years of age had the highest odds for mortality (OR 17.7, 95% CI 12.4–25.1, p < 0.001). Case duration was associated with increased mortality, especially in cases greater than or equal to 6 h (OR 3.0, 95% CI 2.0–4.5, p < 0.001).

Conclusions

Thirty-day mortality and morbidity is, as expected, lower in the healthy surgical population. Age may be an indication to further risk stratify patients that are ASA PS 1 or 2 to better reflect perioperative risk.

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