Rocuronium-Induced Anaphylaxis in the Perioperative Period: A Clinical Review.

Rocuronium, a nondepolarizing neuromuscular blocking agent used for muscle relaxation especially during endotracheal intubation, can cause hypersensitivity reactions. This article provides an overview of anaphylactic reactions; risk factors; and the pathophysiology, presentation, diagnosis, treatment, and nursing implications associated with rocuronium-induced anaphylaxis. Life-threatening anaphylaxis can be immunoglobulin E-mediated or non-immunoglobulin E-mediated and usually occurs after the first dose. Anaphylaxis can present with hypotension and bronchospasm; cutaneal symptoms, such as erythema, may not be obvious. Diagnosis is initially presumptive and may require a transesophageal echocardiogram to rule out other causes of hypotension (eg, pulmonary embolus). Emergency treatment begins with epinephrine administration and fluid boluses; cardiac support devices may be needed. Definitive diagnosis requires early measurement of histamine and tryptase levels and skin testing after the patient recovers from the reaction. Perioperative nurses should be prepared to participate in emergency treatment of anaphylaxis and advocate for testing for a definitive diagnosis.

Perioperative Acute Myocardial Infarction and Ischemia After Noncardiac Surgery: Pathophysiology, Prevention, and Nursing Implications.

Perioperative acute myocardial infarction (AMI) after noncardiac surgery increases the mortality rate of patients who experience it. Depending on the definition of AMI used and the patient population studied, perioperative AMI occurs in 0.01% to 10% of patients. Most instances of perioperative AMI occur within the first two days after surgery, do not present with classic myocardial infarction symptoms, and are the result of myocardial oxygen supply versus oxygen demand mismatch. Older patients; those with preexisting cardiovascular conditions; those undergoing thoracic, upper abdominal, or major vascular procedures; and those who experience perioperative hemodynamic instability are at particular risk. This article provides a clinically based review of the pathophysiology, perioperative risks, treatment options, outcomes, and nursing implications of perioperative AMI and ischemia. It provides evidence to assist perioperative nurses with meeting the physiologic and safety needs of their patients and highlights the evolving scientific understanding and clinical guidelines to promote current practice.

Anesthesia Implications of Patient Use of Electronic Cigarettes.

Electronic cigarettes are essentially electronic nicotine delivery systems (ENDS). Use of ENDS has increased sharply in the United States in recent years, particularly among youth. We reviewed the literature on ENDS use, based on a PubMed search, with a focus on effects that could influence anesthetic and surgical outcomes. We also included a meta-analysis of articles published between 2016 and 2018 reporting injuries from exploding ENDS. These devices deliver nicotine, which is addictive and a cardiac stimulant. The nicotine in ENDS has been linked to increased risk of heart disease and myocardial infarction. Also, ENDS deliver vapors of solvents, flavorings, and other chemicals that can cause chronic and acute respiratory diseases. Furthermore, ENDS use may pose a cancer risk. However, ENDS are somewhat less dangerous than cigarettes and are used as smoking cessation devices. From the literature review, we identified 15 articles reporting injuries from ENDS fires and explosions to 93 patients. Most of these patients were young (mean age = 31.6 years) and male (91%). The most common injury sites were the thigh (62%) and hand (33%). Because the anesthetist will likely encounter increasing numbers of ENDS users in the future, it is important to identify these patients and to understand the risks of ENDS use.

Role of Alveolar-Arterial Gradient in Partial Pressure of Oxygen and PaO2/Fraction of Inspired Oxygen Ratio Measurements in Assessment of Pulmonary Dysfunction.

Assessment of pulmonary dysfunction is vital to anesthetists. Measurements including the gradient between the alveolar partial pressure of oxygen (PAo2) and the arterial partial pressure of oxygen (Pao2), called the PAo2 - Pao2 , and the ratio of the Pao2 to the fraction of inspired oxygen (FIo2) (Pao2/FIo2 ratio) are useful in determining the extent of acute lung injury. A literature review via MEDLINE using the terms PAo2 - Pao2 , Pao2/FIo2 ratio, and pulmonary dysfunction was performed to identify articles on the use of these measures in the perioperative period. Both measures have been found to predict clinical outcomes in most settings. We also developed a mathematical model to calculate values of the PAo2 - Pao2 and the Pao2/FIo2 ratio. In model results, as in clinical findings, both respond appropriately to reflect worsening pulmonary dysfunction when shunt or diffusion barrier (alveolar Po2 - pulmonary capillary partial pressure of oxygen) is increased. However, both are also sensitive to the FIo2. The increase in the Pao2/FIo2 ratio as the FIo2 increases is particularly problematic because it could disguise a deterioration in the patient's pulmonary status. The PAo2 - Pao2 and the Pao2/FIo2 ratio should be used with an understanding of their limitations.

The Impact of Maternal Obesity and Excessive Gestational Weight Gain on Maternal and Infant Outcomes in Maine: Analysis of Pregnancy Risk Assessment Monitoring System Results from 2000 to 2010.

The objective of this study is to understand the relationships between prepregnancy obesity and excessive gestational weight gain (GWG) and adverse maternal and fetal outcomes. Pregnancy risk assessment monitoring system (PRAMS) data from Maine for 2000-2010 were used to determine associations between demographic, socioeconomic, and health behavioral variables and maternal and infant outcomes. Multivariate logistic regression analysis was performed on the independent variables of age, race, smoking, previous live births, marital status, education, BMI, income, rurality, alcohol use, and GWG. Dependent variables included maternal hypertension, premature birth, birth weight, infant admission to the intensive care unit (ICU), and length of hospital stay of the infant. Excessive prepregnancy BMI and excessive GWG independently predicted maternal hypertension. A high prepregnancy BMI increased the risk of the infant being born prematurely, having a longer hospital stay, and having an excessive birth weight. Excessive GWG predicted a longer infant hospital stay and excessive birth weight. A low pregnancy BMI and a lower than recommended GWG were also associated with poor outcomes: prematurity, low birth weight, and an increased risk of the infant admitted to ICU. These findings support the importance of preconception care that promotes achievement of a healthy weight to enhance optimal reproductive outcomes.

Impact of rurality on maternal and infant health indicators and outcomes in Maine.

INTRODUCTION: Rural residents may face health challenges related to geographic barriers to care, physician shortages, poverty, lower educational attainment, and other demographic factors. In maternal and child health, these disparities may be evidenced by the health risks and behaviors of new mothers, the health of infants born to these mothers, and the care received by both mothers and infants. METHODS: To determine the impact of rurality on maternal and child health in Maine, USA, 11 years of data (2000-2010) for the state of Maine from the Pregnancy Risk Assessment Monitoring System (PRAMS) project were analyzed. PRAMS is a national public health surveillance system that uses questionnaires to survey women who had delivered live infants in the previous 2-4 months. Using a geographic information system, each questionnaire response was assigned a rurality tier (urban, suburban, large rural town, or isolated rural community) based on the rural-urban commuting area code of the town of residence of the mother. Results from the four rurality tiers were compared using the survey procedures in Statistical Analysis Software to adjust for the complex sampling strategy of the PRAMS dataset. Means (for continuous variables) and percentages (for categorical variables) were calculated for each rurality tier, along with 95% confidence intervals. Significant differences between rurality tiers were tested for using F-tests or χ2 tests. If significant differences between rurality tiers existed (p<0.05), specific tiers were judged to be different from each other if their 95% confidence intervals did not overlap. RESULTS: A total of 12 600 mothers responded to the PRAMS questionnaire during the study period. Compared to mothers from more urban areas, rural mothers were younger (10.5% of mothers from isolated rural areas were teenagers compared to 6.2% of mothers from urban areas), less well educated, less likely to be married, and more likely to live in lower income households (39.6% of isolated rural mothers had household incomes ≤US$20 000/year vs 28.8% of urban mothers). Rural mothers had higher pre-pregnancy body mass indexes (BMIs; average BMI 26.1 for isolated rural women vs 25.3 for urban women) and were more likely to smoke but less likely to drink alcohol (both before and during pregnancy). Compared to mothers from more urban areas, rural mothers were not sure they were pregnant until a later gestational age but received prenatal care just as early and were just as likely to receive prenatal care as early as they wished. There were no differences among rurality tiers in Caesarean section rates, rates of premature births (<37 weeks gestation), or rates of underweight births (<2500 g). However infants born to rural mothers were less likely to be breastfed (52.9% of isolated rural vs 60.9% of urban infants breast fed for ≥8 weeks). CONCLUSIONS: These results show that, while rural women face significant demographic and behavior challenges, their access to prenatal care, the care they receive while pregnant, and the outcomes of their pregnancies are similar to those of urban women. These results highlight areas where focused pre-pregnancy and prenatal education may improve maternal and child health in rural Maine.

11-year trends in pregnancy-related health indicators in Maine, 2000-2010.

The objective of this study is to understand health and demographic trends among mothers and infants in Maine relative to the goals of Healthy People 2020. Pregnancy risk assessment monitoring system (PRAMS) data from Maine for 2000-2010 were used to determine yearly values of pregnancy-related variables. Means (for continuous variables) and percentages (for categorical variables) were calculated using the survey procedures in SAS. Linear trend analysis was applied with study year as the independent variable. The slope and significance of the trend were then calculated. Over the study period, new mothers in Maine became better educated but the fraction of households with incomes <$20,000/year remained stagnant. Maternal prepregnancy BMI increased. Average pregnancy weight gain decreased but the number of women whose pregnancy weight gain was within the recommended range was unchanged. The rates of smoking and alcohol consumption (before and during pregnancy) increased. The Caesarean section rate rose and the fraction of infants born premature (<37 wks gestation) or underweight (<2500 gms) remained unchanged. The fraction of infants who were breast-fed increased. These results suggest that, despite some positive trends, Maine faces significant challenges in meeting Healthy People 2020 goals.

A cardiovascular disease risk factor screening program designed to reach rural residents of Maine, USA.

INTRODUCTION: Cardiovascular disease is the leading cause of death in many countries and a particular burden to rural communities. Hypertension and diabetes are risk factors for cardiovascular disease, but screening for them is suboptimal, particularly in rural settings. Thus screening programs targeting rural dwellers may be important. This article reports the findings of a blood pressure (BP) and blood glucose screening program conducted from a mobile van that visited community events including agricultural fairs across Maine, U.S.A. to bring screening to rural Mainers. The study objectives were to determine: (1) if the screening program was successful at reaching rural Mainers; (2) if rural screenees had a different risk of hypertension or diabetes compared with non-rural screenees; and (3) what characteristics of a community event predict that a screening conducted at that event will reach a high fraction of rural residents. METHODS: The van visited events from 2006-2009 conducting voluntary BP and blood glucose screenings. Results were analyzed by the rurality of the town of residence of the screenees, the rurality of location of the screening event, and the type of screening event (agricultural fair vs other). Systolic BP of 140 mmHg or greater or diastolic BP of 90 mmHg or greater was considered to be hypertension, and systolic BP of 120-139 mmHg or diastolic BP 80-89 mmHg as pre-hypertension. Blood glucose of 140-199 mg/dL was considered to be pre-diabetes and blood glucose of 200 mg/dL or greater as diabetes. Rurality was divided into urban, sub-urban, large rural town, and small rural town/ isolated rural based on Rural Urban Commuting Codes (RUCAs), assigned by zip code. Mean BP and blood glucose values were compared across residence rurality categories by ANOVA, the distribution of screening values into normal/ abnormal categories was compared across residence rurality categories by chi2 test, and the impact of type and rurality of location of screening event on the residence of screenees was assessed with analysis by regression with categorical variables. RESULTS: Over 4 years, 2451 Mainers from 254 towns were screened at 42 events located in 28 towns. Seventy-six percent of screenees lived in rural areas and screenees were more likely to live in rural areas compared with all Maine residents (p < 0.001). Rurality of residence impacted hypertension risk (p = 0.001) but not diabetes risk. Screenees from large rural towns had the highest mean systolic BPs and rural-dwellers had higher hypertension or pre-hypertension risk compared with urban/ sub-urban dwellers. Conducting screenings at agricultural fairs (p = 0.003) and in rural areas (p = 0.001) were independent predictors of attracting more rural screenees. CONCLUSIONS: Holding cardiovascular risk factor screenings in locations that are culturally appropriate and geographically convenient for an at-risk population are common approaches; however, their effectiveness is seldom tested. The results show that both the type of event at which the screening is conducted and the rurality of location of that event help attract rural screenees, and that it is possible for a screening program to reach a population significantly more rural than the population of the state and one that has an elevated hypertension risk.

Location of food stores near schools does not predict the weight status of Maine high school students.

OBJECTIVE: To examine the relationship between stores selling calorie-dense food near schools and student obesity risk, with the hypothesis that high availability predicts increased risk. METHODS: Mail surveys determined height, weight, and calorie-dense food consumption for 552 students at 11 Maine high schools. Driving distance from all food stores within 2 km (1.24 miles) of schools (or the closest store) was computed, and the impact of food store density and proximity to schools on student body mass index was determined by logistic regression. RESULTS: Ten schools had ≥ 1 store selling soda, and 8 schools had ≥1 fast-food restaurant within 1 km (0.62 miles). There were no significant relationships between the proximity or density of food stores around schools and student obesity risk. Students obtained sugar-sweetened beverages in many locations including at school. CONCLUSIONS AND IMPLICATIONS: Unhealthful food choices are ubiquitous. Consequently, stores selling these food items near schools have no significant affect on student obesity.

Impact of Maine's statewide nutrition policy on high school food environments.

INTRODUCTION: We assessed the effect on the food environments of public high schools of Maine's statewide nutrition policy (Chapter 51), which banned "foods of minimal nutritional value" (FMNV) in public high schools that participated in federally funded meal programs. We documented allowable exceptions to the policy and describe the school food environments. METHODS: We mailed surveys to 89 high school food-service directors to assess availability pre-Chapter 51 and post-Chapter 51 of soda, other sugar-sweetened beverages, and junk food. Frequency data were tabulated pre-Chapter 51 and post-Chapter 51, and Fisher exact test was used to assess significance in changes. We conducted food and beverage inventories at 11 high schools. RESULTS: The survey return rate was 61% (N = 54). Availability of soda in student vending significantly decreased pre-Chapter 51 versus post-Chapter 51 (P = .04). No significant changes were found for other sugar-sweetened beverages and junk food. Exceptions to Chapter 51 were permitted to staff (67%), to the public (86%), and in career and technical education programs (31%). Inventories in a subset of schools found no availability of soda for students, whereas other sugar-sweetened beverages and junk food were widely available in à la carte, vending machines, and school stores. Candy, considered a FMNV, was freely available. Soda advertisement on school grounds was common. CONCLUSION: Student vending choices improved after the implementation of Chapter 51; however, use of FMNV as the policy standard may be limiting, as availability of other sugar-sweetened beverages and junk food was pervasive. School environments were not necessarily supportive of the policy, as advertisement of soda was common and some FMNV were available. Furthermore, local exceptions to Chapter 51 likely reduced the overall effect of the policy.

Genome of the host-cell transforming parasite Theileria annulata compared with T. parva.

Theileria annulata and T. parva are closely related protozoan parasites that cause lymphoproliferative diseases of cattle. We sequenced the genome of T. annulata and compared it with that of T. parva to understand the mechanisms underlying transformation and tropism. Despite high conservation of gene sequences and synteny, the analysis reveals unequally expanded gene families and species-specific genes. We also identify divergent families of putative secreted polypeptides that may reduce immune recognition, candidate regulators of host-cell transformation, and a Theileria-specific protein domain [frequently associated in Theileria (FAINT)] present in a large number of secreted proteins.

Cardiac rehabilitation with nurse care management and telephonic interactions at a community hospital: program evaluation of participation and lipid outcomes.

Cardiac rehabilitation (CR) can help patients with heart disease control some risk factors, limit new coronary artery lesions, and decrease death rates. However, participation rates in CR are low. Using a descriptive design, we evaluated a modified CR program in which nurse care managers used telephonic communication with patients in their homes by comparing it to a traditional CR program in a hospital setting. Using multivariate analysis we compared the patient cohorts eligible for each of the programs, and program participants to the nonparticipants for each program. Compared to traditional CR, the modified CR program with nurse care management was associated with significantly improved participation rates (11% vs. 22%) and the apparent overcoming of several well-described barriers to CR participation (distance from the hospital and domestic isolation). Risk factor management, including testing of serum lipids and achieving goals for lipid reduction, for participants in both CR programs was superior to risk factor management for nonparticipants.

Comparative analysis of the genome sequences of Bordetella pertussis, Bordetella parapertussis and Bordetella bronchiseptica.

Bordetella pertussis, Bordetella parapertussis and Bordetella bronchiseptica are closely related Gram-negative beta-proteobacteria that colonize the respiratory tracts of mammals. B. pertussis is a strict human pathogen of recent evolutionary origin and is the primary etiologic agent of whooping cough. B. parapertussis can also cause whooping cough, and B. bronchiseptica causes chronic respiratory infections in a wide range of animals. We sequenced the genomes of B. bronchiseptica RB50 (5,338,400 bp; 5,007 predicted genes), B. parapertussis 12822 (4,773,551 bp; 4,404 genes) and B. pertussis Tohama I (4,086,186 bp; 3,816 genes). Our analysis indicates that B. parapertussis and B. pertussis are independent derivatives of B. bronchiseptica-like ancestors. During the evolution of these two host-restricted species there was large-scale gene loss and inactivation; host adaptation seems to be a consequence of loss, not gain, of function, and differences in virulence may be related to loss of regulatory or control functions.

Sequencing and analysis of the genome of the Whipple's disease bacterium Tropheryma whipplei.

BACKGROUND: Whipple's disease is a rare multisystem chronic infection, involving the intestinal tract as well as various other organs. The causative agent, Tropheryma whipplei, is a Gram-positive bacterium about which little is known. Our aim was to investigate the biology of this organism by generating and analysing the complete DNA sequence of its genome. METHODS: We isolated and propagated T whipplei strain TW08/27 from the cerebrospinal fluid of a patient diagnosed with Whipple's disease. We generated the complete sequence of the genome by the whole genome shotgun method, and analysed it with a combination of automatic and manual bioinformatic techniques. FINDINGS: Sequencing revealed a condensed 925938 bp genome with a lack of key biosynthetic pathways and a reduced capacity for energy metabolism. A family of large surface proteins was identified, some associated with large amounts of non-coding repetitive DNA, and an unexpected degree of sequence variation. INTERPRETATION: The genome reduction and lack of metabolic capabilities point to a host-restricted lifestyle for the organism. The sequence variation indicates both known and novel mechanisms for the elaboration and variation of surface structures, and suggests that immune evasion and host interaction play an important part in the lifestyle of this persistent bacterial pathogen.