Vasovagal Pre-Syncope Induced by Epidural Electrical Stimulation Test: A Rare Case Report in a 61-Year-Old Woman Undergoing Ventral Hernia Repair.

BACKGROUND Thoracic epidural analgesia is a commonly applied technique for perioperative pain management in major thoraco-abdominal surgery, but is complicated by high failure rates. The epidural electrical stimulation test (EEST) or "Tsui test" is a safe and effective method whereby low electrical current is used to confirm correct epidural catheter position and decrease the variability in analgesic effectiveness of the neuraxial technique. CASE REPORT We present the case of a 61-year-old woman with no prior cardiac or pulmonary comorbidities who was scheduled to undergo a ventral and parastomal hernia repair with component separation. The patient was offered a low thoracic epidural for perioperative analgesia. Technical aspects of the siting of the epidural catheter were uneventful and a confirmatory Tsui test was planned. At the initiation of electrical stimulation via the epidural catheter to confirm optimal catheter positioning, the patient experienced symptomatic bradycardia and hemodynamic instability that persisted despite terminating the electrical stimulation, and required pharmacologic intervention. CONCLUSIONS This report describes a rare case of vasovagal pre-syncope associated with the EEST or Tsui test. Although vasovagal reactions can be commonly associated with neuraxial procedures due to augmented venous return or severe emotional stress, we raise the possibility that through direct electrical stimulation in the epidural space, the EEST may have the potential to trigger such a physiologic response.

Chasing myocardial outcomes: perioperative myocardial infarction and cardiac troponin.

Perioperative myocardial infarction represents the most common cardiovascular complication following non-cardiac surgery, but frequently presents without the usual clinical signs and symptoms consistent with acute coronary syndrome. Given the silent nature of this event, a clinician's reliance on risk stratification tools and cardiac specific biomarkers to assist in the identification of at-risk individuals is heightened in the perioperative setting. Although cardiac troponin elevations following non-cardiac surgery have been consistently linked to increased mortality, uncertainty remains over how to clinically intervene to prevent harm. This decision is further complicated by the increasing sensitivity of the newest generation of cardiac biomarker immunoassays. In this narrative review, the growing body of evidence surrounding cardiac troponin elevations in the perioperative setting, how the evidence has been integrated into recent clinical practice guidelines, and its implications for the detection of perioperative myocardial infarction are discussed.

Relationship between potential opioid-related adverse effects and hospital length of stay in patients receiving opioids after orthopedic surgery.

STUDY OBJECTIVE: To determine whether there is an association between opioid-related adverse effects and postoperative hospital length of stay (p-LOS). DESIGN: Retrospective medical record review. SETTING: Large academic medical center. PATIENTS: Random sample of 402 patients (mean age 60.2 yrs, 50.3% female) who underwent orthopedic spine, hip, knee, or shoulder surgery during 2007 and received opioids during or after the procedure. MEASUREMENTS AND MAIN RESULTS: Potential opioid-related adverse effects were identified by using established criteria. Bivariate and multivariate analyses (generalized linear regression model, log transformed) were used to identify predictors of p-LOS. The model also estimated the effect of specific types of adverse effects and adverse-effect combinations on p-LOS. Mean ± SD p-LOS was 3.0 ± 2.1 days; median oral morphine equivalent postoperative dose was 60 mg/day. More than half of the patients (54.2%) experienced one or more adverse effects, 25.6% experienced two or more adverse effects, and 7.2% experienced three or more adverse effects. The composite of nausea and vomiting was experienced by 36.1% of study patients, and 12.6% had at least one emesis episode. Constipation and confusion were documented in 6.5% and 3.7% of patients, respectively. Constipation (p<0.0001), emesis (p<0.001), and confusion (p<0.01) were associated with increased p-LOS after adjusting for other significant variables. Patients with constipation had an adjusted 49% (95% confidence interval [CI] 25-77%) longer p-LOS (additional 1.4 days) compared with patients without constipation. Emesis and confusion significantly increased p-LOS by 25% (95% CI 10-42%) and 38% (95% CI 11-72%), respectively. Incremental increases in p-LOS for patients with two adverse effects (p=0.02), three adverse effects (p<0.001), and four adverse effects (p<0.001) versus patients with no adverse effects were 15%, 40%, and 82%, respectively. CONCLUSION: Constipation, emesis, and confusion were associated with increased p-LOS in patients receiving opioids after orthopedic surgery. In addition, there was a significant linear relationship between the number of adverse effects/patient and increased p-LOS, and the strength of the association increased as the number of adverse effects increased. Although the opioid dosages and adverse-effect rates were typical, these findings reinforce the need to balance pain management with risk of events.

58th annual meeting american society of human genetics, 2008.

The 2008 ASHG meeting, which took place from November 11 to 15, brought almost 6,500 attendees to Philadelphia to learn about the latest advances in human genetics and genomics research. This conference is considered the world's largest gathering of human genetics researchers, academicians, clinicians, genetic counselors, and nurses. This article reviews the 1,000 Genomes Project, Gaucher's disease, warfarin dosing, and Huntington's disease.

Comparative effectiveness: the employer perspective.

Biopharmaceuticals are rapidly emerging as a focal point of concern in benefit design. CE initiatives may prove their value, but controlling costs will be up to consumers.

Does allowing adolescents to smoke at home affect their consumption and dependence?

Negative parental attitudes towards smoking decrease adolescent smoking initiation but limited research explores the relationship between parental attitudes and degree of adolescent smoking among established smokers. The aim of this study was to examine the relationship between parental allowance of smoking in the home and adolescent smoking behavior and level of dependence. Interviews from 408 youths seeking assistance to quit smoking showed that adolescents who were allowed to smoke at home smoked more cigarettes per day and had higher scores on the Fagerström Test of Nicotine Dependence than those not allowed to smoke at home. Studies that additionally evaluate parental smoking status and the temporal relationship of parental allowance of smoking with changes in adolescent smoking behavior are warranted to clarify public health implications of parental smoking interdictions.