Anesthetic Considerations for Cesarean Delivery in a Parturient With Severe Gitelman Syndrome.

Gitelman syndrome is an autosomal recessive inherited disorder that impairs the function of thiazide-sensitive sodium-chloride cotransporters in the distal convoluted tubule of the nephron. During labor and delivery, avoidance of sympathetic overactivity, meticulous hemodynamic monitoring, and expedited repletion of potassium and magnesium are required to avoid adverse outcomes. We present a parturient with severe Gitelman syndrome, requiring continuous electrolyte and fluid infusions, who underwent successful cesarean delivery. Potential severe morbidity was avoided with multidisciplinary planning and management.

Nitrous oxide analgesia for external cephalic version: A randomized controlled trial.

STUDY OBJECTIVE: Our study sought to determine whether or not nitrous oxide analgesia decreases pain compared to oxygen placebo during external cephalic version for breech presentation. Procedural success may be limited by pain and anxiety. Although neuraxial anesthesia has been studied extensively for these procedures, many centers lack resources for routine use. Nitrous oxide is noninvasive, has minimal side effects and requires limited facilities. We hypothesized that its analgesic properties would decrease pain compared to oxygen placebo during external cephalic version. DESIGN: Double-blinded randomized placebo-controlled trial. SETTING: Labor and delivery triage room. PATIENTS: Forty-eight patients, ≥18 years of age, 37-weeks' gestation or beyond, singleton pregnancy, breech presentation, and American Society of Anesthesiology physical status I-III, having an external cephalic version. INTERVENTIONS: Patients undergoing external cephalic version were randomized to receive self-administered 50% nitrous oxide/50% oxygen versus 100% oxygen placebo. MEASUREMENTS: The primary outcome measured was intra-procedural pain. Secondary outcomes were intra-procedural anxiety, patient satisfaction, and procedure difficulty. MAIN RESULTS: Forty-eight patients were enrolled; 23 received nitrous oxide and 25 received oxygen. No difference was noted in mean pain scores (nitrous oxide 5.5 ± 2.3, placebo 5.4 ± 2.7, [CI95% = -1.40, 1.51]; P = 0.943) or anxiety scores (nitrous oxide 1.6 ± 2.0, placebo 1.2 ± 1.8, [CI95% = -0.74, 1.45]; P = 0.515). Procedural difficulty (1-10 scale, 1 = very easy, 10 = extremely difficult) was not different between groups (nitrous oxide 6.1 ± 2.2, placebo 6.1 ± 3.2, [CI95% = -1.54, 1.66]; P = 0.944). There was a significant increase in the number of version attempts in the nitrous oxide group (nitrous oxide 3.9 ± 1.9, placebo 2.8 ± 1.4, [CI95% = 0.05, 2]; P = 0.046). Patient satisfaction was significantly lower in the nitrous oxide group (nitrous oxide 4.3 ± 4.0, placebo 6.9 ± 3.6, [CI95% = -4.93, -0.34]; P = 0.025). CONCLUSION: Despite the desirable properties of nitrous oxide, there was no analgesic benefit over oxygen for external cephalic version. Its routine use for these procedures was not supported.

Extracorporeal membrane oxygenation in pregnant and postpartum women: a ten-year case series.

Objective: tExtracorporeal membrane oxygenation (ECMO) is a life-saving therapy for severe, reversible cardiopulmonary failure, but data regarding its use in pregnancy and the postpartum period are limited. We sought to quantify survival of pregnant and postpartum women necessitating ECMO in a contemporary cohort at a single tertiary institution. Study Design: All women of reproductive age (14-44 years), who underwent ECMO at our institution between January 1, 2008, and December 31, 2017, were identified using a query of hospital encounters for ECMO-related CPT codes. We manually reviewed all charts of women of reproductive age; women who were pregnant or <6 weeks postpartum at the time of ECMO initiation were included. Clinical characteristics and maternal and fetal outcomes are described. Results: In this study, 54 women of reproductive age underwent ECMO for cardiopulmonary failure. Of those, 9 (17%) were pregnant or <6 weeks postpartum at the time of ECMO initiation: 4 antepartum, 1 intraoperative at the time of cesarean delivery, and 4 postpartum (including 2 in whom ECMO was initiated on postpartum day 0 or 1). Overall, maternal survival was 33%. The median maternal age was 24 years (range 19-39 years); most women were nonsmokers without underlying medical comorbidities. The most common indication for ECMO use in pregnant and postpartum women was acute respiratory distress syndrome, which was present in 7 cases (78%), including 5 cases that were due to infectious etiologies and 2 cases that were attributed to preeclampsia. The median number of days on ECMO was 6 (range 1-14). There were no cases of obstetric hemorrhage. Venovenous ECMO was utilized in all but 1 case, in which emergent attempted venoarterial ECMO was unsuccessful in resuscitating a postpartum patient with cardiac arrest and a massive pulmonary embolism. A total of 4 women were initiated on ECMO during pregnancy: their gestational ages at ECMO initiation were 21, 22, 29, and 30 weeks; maternal survival was 50%, and fetal mortality was 50%. A case of ECMO initiated during cesarean section at 29 weeks' gestation resulted in both maternal and fetal survival. Among 4 mothers with ECMO initiation after childbirth, none survived. Finally, we found a tendency toward survival in those patients for whom ECMO was initiated soon after mechanical ventilation, earlier in the disease process. In contrast, in this study, 23 of 45 women of reproductive age (51%) who were not pregnant but underwent ECMO survived. Conclusion: When ECMO was initiated during pregnancy or during childbirth, 60% of mothers and fetuses survived, supporting current use of ECMO as a salvage therapy in pregnant and intrapartum women. In this generally young and healthy population, ECMO has the potential to increase the survival rates of both mother and fetus and should be considered a salvage therapy for peripartum women with reversible forms of cardiorespiratory failure.

Do You Really Mean It? Assessing the Strength, Frequency, and Reliability of Applicant Commitment Statements During the Anesthesiology Residency Match.

BACKGROUND: Despite the critical nature of the residency interview process, few metrics have been shown to adequately predict applicant success in matching to a given program. While evaluating and ranking potential candidates, bias can occur when applicants make commitment statements to a program. Survey data show that pressure to demonstrate commitment leads applicants to express commitment to multiple institutions including telling >1 program that they will rank them #1. The primary purpose of this cross-sectional observational study is to evaluate the frequency of commitment statements from applicants to 5 anesthesiology departments during a single interview season, report how often each statement is associated with a successful match, and identify how frequently candidates incorrectly represented commitments to rank a program #1. METHODS: During the 2014 interview season, 5 participating anesthesiology programs collected written and verbal communications from applicants. Three residency program directors independently reviewed the statements to classify them into 1 of 3 categories; guaranteed commitment, high rank commitment, or strong interest. Each institution provided a deidentified rank list with associated commitment statements, biographical data, whether candidates were ranked-to-match, and if they successfully matched. RESULTS: Program directors consistently differentiated among strong interest, high rank, and guaranteed commitment statements with κ coefficients of 0.9 (95% CI, 0.8-0.9) or greater between any pair of reviewers. Overall, 35.8% of applicants (226/632) provided a statement demonstrating at least strong interest and 5.4% (34/632) gave guaranteed commitment statements. Guaranteed commitment statements resulted in a 95.7% match rate to that program in comparison to statements of high rank (25.6%), strong interest (14.6%), and those who provided no statement (5.9%). For those providing guaranteed commitment statements, it can be assumed that the 1 candidate (4.3%) who did not match incorrectly represented himself. Variables such as couples match, "R" positions, and not being ranked-to-match on both advanced and categorical rank lists were eliminated because they can result in a nonmatch despite truthfully ranking a program #1. CONCLUSIONS: Each level of commitment statement resulted in a progressively increased frequency of a successful match to the recipient program. Only 5.4% of applicants committed to rank a program #1, but these statements were very reliable. These data can help program directors interpret commitment statements and assist accurate evaluation of the interest of candidates throughout the match process.

The predictive value of pre-recruitment achievement on resident performance in anesthesiology.

STUDY OBJECTIVE: Selecting candidates for residency positions is challenging and there is little research on the correlation between commonly used selection criteria and subsequent performance in anesthesiology. This study examined the association between the selection measures and post-recruitment performance in residency. DESIGN: Retrospective review of archival data. SETTING: Anesthesiology residency program at a large academic anesthesiology department. SUBJECTS: Residents who were matched to the anesthesiology program over 9years (graduation classes of 2006 to 2014). INTERVENTIONS: None. MEASUREMENTS: The pre-recruitment achievements included a comprehensive list of measures obtained from residents' application portfolios in conjunction with interview performance. The post-recruitment examination outcomes consisted of the in-training examination (ITE) scores in the three clinical anesthesia (CA) years and first-attempt success on the written board certification examination administered by the American Board of Anesthesiology (ABA). Scholarly output during residency was measured by publication record. Clinical performance at the conclusion of residency was independently rated by three faculty members. Bivariate analysis and regression models were conducted to examine association between predictors and outcomes. MAIN RESULTS: High United States Medical Licensing Examination (USMLE) scores, class rank in medical school and interview performance were predictive of high examination scores in residency and good clinical performance. Class rank appeared to be the best predictor of scholarly publication and pursuing an academic career beyond residency. CONCLUSIONS: Comparative performance with classmates (i.e., class rank) in medical school appeared to be an effective predictor of overall performance in residency, which warrants more attention in future study. Although interview performance is subject to recruitment team members' interpretation, it is an important measure to include in recruitment decisions.

Emergence of Ixodes scapularis and Borrelia burgdorferi, the Lyme disease vector and agent, in Ohio.

Lyme disease, the most common vector-borne disease in the United States, is caused by a tick-borne infection with Borrelia burgdorferi. Currently, Ohio is considered by the Centers for Disease Control and Prevention (CDC) to be non-endemic for Lyme disease. The low incidence of Lyme disease in this state was largely attributed to the absence of the transmitting vector, Ixodes scapularis, commonly known as the blacklegged tick. However, a tick surveillance program established by Ohio Department of Health indicated that the number of I. scapularis in Ohio had increased sharply in recent years, from 0 - 5 ticks per year during 1983-2008 to 15 in 2009, 40 in 2010, and 184 in 2011. During the fall deer hunting season, examination of deer heads submitted to Ohio Department of Agriculture found 29 I. scapularis from 7 counties in 2010 and 1,830 from 25 counties in 2011. As of 2012, the tick had been found in 57 of the 88 counties of Ohio. In addition, all three active stages (larva, nymph, and adult) of I. scapularis were found in Tiverton Township of Coshocton County, demonstrating the presence of established tick populations at this central Ohio location. Of 530 nymphal or adult I. scapularis analyzed by quantitative polymerase chain reaction (qPCR), 32 (6.1%) tested positive for the B. burgdorferi flaB gene, ranging from 36 to 390,000 copies per tick. Antibodies to B. burgdorferi antigens were detected in 2 of 10 (20%) field-captured Peromyscus leucopus from Tiverton Township, and in 41 of 355 (11.5%) dogs residing in Ohio. Collectively, these data suggest that the enzootic life cycle of B. burgdorferi has become established in Ohio, which poses risk of Lyme disease to people and animals in the area.

Complaints associated with animal feeding facilities as reported to Ohio local health departments, 2006-2008.

Confined animal feeding facilities of all sizes have long been targeted as a source of human health and quality of life concerns. In order to describe and quantify these concerns in Ohio, a retrospective survey of local health departments was conducted focusing on reported complaints associated with animal feeding facilities. During 2006-2008, the most common complaints pertaining to any type of animal feeding facility were air quality and odor outside the home, followed by manure storage and application issues. The study described here showed that larger permitted livestock feeding facilities were not a major source of health and nuisance complaints associated with animal feeding facilities as reported to Ohio local health departments. Local health departments received few health complaints associated with any animal feeding facility. None were validated or confirmed by a physician in 2008.

Anesthetic management for cesarean delivery of a parturient with impetigo herpetiformis.

Impetigo herpetiformis (IH), or generalized pustular psoriasis of pregnancy, is an exceedingly rare, generalized pustular skin eruption occurring during pregnancy associated with hypovolemia, sepsis, hypocalcemia, and airway edema. Fetal outcomes are generally poor, and parturients with IH may present with emergent indications for cesarean delivery due to placental insufficiency. We present a case of IH in a 19-year-old G1P0 who underwent successful general anesthesia for cesarean delivery. Her case highlights the anesthetic implications for patients afflicted with this rare disease, including perioperative pain management, airway concerns, considerations for neuraxial anesthesia, and monitoring challenges.

Epidural anesthesia for repeat cesarean delivery in a parturient with Klippel-Feil syndrome.

A patient with Klippel-Feil syndrome, morbid obesity, and scoliosis required cesarean delivery. Her previous cesarean deliveries were performed under general anesthesia. She desired a regional technique. Following aspiration prophylaxis and placement of standard monitors, ultrasound was used to identify midline and L(2-3) interspace. Unintentional dural puncture occurred at 10 cm, with an inability to advance the catheter. On second attempt, an epidural catheter was placed easily. After negative test dose, 18 ml of 2% lidocaine with epinephrine was administered to the patient. A T4 level was achieved. The patient tolerated surgery well. Complete block resolution occurred at 4 hours with no neurologic sequelae.

Influence of oral rabies vaccine bait density on rabies seroprevalence in wild raccoons.

The effect of different oral rabies vaccine (ORV) bait densities (75, 150, and 300 baits/km(2)) on the seroprevalence of rabies virus neutralizing antibodies (RVNAs) in raccoons (Procyon lotor) was assessed at a 15% seroprevalence difference threshold in rural areas of northeast Ohio. Results (n=588 raccoons) indicated that seropositivity for RVNAs was associated with both bait density and bait campaign frequency. Associations were not detected for raccoon gender, age, or macro-habitat. The odds of being seropositive were greater for raccoons originating from 300 bait/km(2) treatment areas relative to those coming from the 75 bait/km(2) areas (odds ratio [OR]=4.4, probability [P]<0.001, 95% confidence interval [CI]=2.4-7.9), while accounting for cumulative ORV campaigns. No statistical advantage in seroprevalence was detected when comparing 150-75 baits/km(2). These results indicate that a relatively extreme bait density when evenly distributed may be necessary to obtain a significant increase in seroprevalence. Higher bait densities may be more appropriate and less costly to address focused outbreaks than labor intensive trap-vaccinate-release and local population reduction campaigns. Finally, dramatic increases in seroprevalence of RVNA were not observed in raccoons between sequential, semi-annual campaigns, yet cumulative ORV campaigns were associated with gradual increases in seroprevalence.

Pet rodents and fatal lymphocytic choriomeningitis in transplant patients.

In April 2005, 4 transplant recipients became ill after receiving organs infected with lymphocytic choriomeningitis virus (LCMV); 3 subsequently died. All organs came from a donor who had been exposed to a hamster infected with LCMV. The hamster was traced back through a Rhode Island pet store to a distribution center in Ohio, and more LCMV-infected hamsters were discovered in both. Rodents from the Ohio facility and its parent facility in Arkansas were tested for the same LCMV strain as the 1 involved in the transplant-associated deaths. Phylogenetic analysis of virus sequences linked the rodents from the Ohio facility to the Rhode Island pet store, the index hamster, and the transplant recipients. This report details the animal traceback and the supporting laboratory investigations.

Compendium of measures to control Chlamydophila psittaci (formerly Chlamydia psittaci) infection among humans (psittacosis) and pet birds, 2005.

Psittacosis, also known as parrot fever and ornithosis, is a bacterial infection of humans that can cause severe pneumonia and other serious health problems. It is caused by Chlamydophila psittaci, formerly known as Chlamydia psittaci. From 1988 through 2003, 935 human cases of psittacosis were reported to the CDC and most resulted from exposure to infected pet birds, usually cockatiels, parakeets, parrots, and macaws. In birds, C. psittaci infection is referred to as avian chlamydiosis. Infected birds shed the bacteria through feces and nasal discharges, and humans become infected from exposure to these materials. This compendium provides information about psittacosis and avian chlamydiosis to public health officials, physicians, veterinarians, the pet bird industry, and others concerned with controlling these diseases and protecting public health. The recommendations in this compendium provide standardized procedures for controlling avian chlamydiosis in birds, a vital step to protecting human health. This document will be reviewed and revised as necessary.

Differential sensitivity to central leptin and insulin in male and female rats.

The distribution of fat in the body differs between the male and female sexes and is associated with the relative secretion of the two "adiposity" hormones leptin and insulin. We now report that the brains of male and female rats are differentially sensitive to the catabolic actions of small doses of these two hormones. Leptin (1 or 3.5 microg/2 microl) or saline (2 microl) was administered into the third cerebral ventricle of age- and weight-matched male and female rats. Leptin significantly reduced food intake in female and male rats over 4 h; however, leptin reduced 24-h intake in female but not in male rats. When the same rats were administered insulin (1 or 4 mU/2 microl) or saline (2 microl), male but not female rats had a robust reduction in food intake over 24 h. Previous research demonstrates the melanocortins are a central mediator of the effects of both leptin and insulin. However, we found no sex differences in sensitivity to the melanocortin agonist MTII (0.01, 0.1, 0.3, and 1.0 nmol/2 microl). These results suggest that the sex differences in sensitivity to leptin and insulin at the doses that we injected occur upstream of the melanocortin receptors. Because insulin and leptin reflect different fat beds and are differentially distributed in the male and female sexes, the implication is that the male and female sexes regulate adiposity-relevant parameters differently.

Acute third ventricular administration of insulin decreases food intake in two paradigms.

The pancreatic hormone, insulin, has been hypothesized to be an important regulator of food intake. Consistent with this hypothesis is the finding that exogenous insulin, in doses that do not affect blood glucose, reliably suppresses food intake and body weight. However, previous experiments have utilized a long-term delivery paradigm, in which insulin is administered via osmotic minipump and changes in body weight and food intake are measured across days. In separate experiments, we report that acute central injections of insulin can reduce food intake. In Experiment 1, injection of insulin (8 mU) into the third cerebral ventricle reliably suppressed intake of pelleted rat chow beginning at onset of the rats' dark phase. In Experiment 2, central insulin reliably and dose dependently suppressed intake of a 1-h 15% sucrose meal in the middle of the light phase. These data suggest that insulin can reduce food intake in acute delivery paradigms and provide another means by which to assess the roles of other central systems in the mediation of insulin's effects on energy homeostasis.

Cost of distributing oral raccoon-variant rabies vaccine in Ohio: 1997-2000.

OBJECTIVE: Analysis of the cost of 8 distributions of oral rabies vaccine (ORV) with strains known to infect raccoons in Ohio between 1997 and 2000. DESIGN: Original study. PROCEDURE: Fishmeal bait containing ORV was distributed on foot, by vehicle, and by helicopter and fixed-wing aircraft. The cost of personnel, vehicles, and helicopter and aircraft use and other associated expenses were obtained from field records and interviews with personnel and agencies involved in the ORV program. RESULTS: Each bait distribution lasted approximately 1 week. Areas baited ranged from 1,701 km2 to 6,497 km2. Density varied for each distribution, with means of 79 baits/km2 for ground baiting and 93 baits/km2 for aerial baiting. Typically, 72 people participated in the ground portion of each distribution and 32 in the aerial portion. The cost of ground baiting (mean +/- SD, 19.24 dollars/km2 +/- 6.35 dollars/km2) was consistently less than that for air baiting (mean +/- SD, 24.71 dollars/km2 +/- 4.65 dollars/kml) for each distribution. The total cost of distribution varied from 30,568 dollars to 145,842 dollars (mean, 96,791 dollars), and bait cost varied from 150,714 dollars to 1,029,423 dollars (mean, 543,839 dollars). The total cost of ORV distributions ranged from 102 dollars/km2 to 261 dollars/km2 (mean, 153 dollars/km2). CONCLUSIONS: In the United States, rabies strains that infect raccoons have been responsible for the largest increase in rabies in animals in the past 3 decades. Use of ORV is a promising new tool that can be used to control rabies in raccoons. Documenting the estimated cost of implementing an ORV program may lead to more efficient use of resources to control and limit the spread of rabies. In addition, accurately measured distribution costs can be used to perform an economic cost-benefit analysis for an ORV program.