Novel approaches facilitating neuraxial anesthesia placement in pregnant women with morbid obesity: case descriptions.

Clinical management of pregnant women with morbid obesity poses challenges in performing neuraxial anesthesia as well as positioning for cesarean delivery. Occupational injuries are also known to occur while caring for patients with morbid obesity. We describe two novel approaches to assist neuraxial anesthesia administration and positioning for cesarean delivery. With the assistance of the Institution's Safe Patient Handling and Mobility Team, a universal high-back sling can be placed to lift the patient into a sitting position before neuraxial anesthesia procedure. After placement of combined spinal epidural anesthesia, the ceiling lift is used to lift the patient into a seated position and then rotate to the appropriate location on the operating room table to facilitate supine positioning. The lifting system reduces shearing of the patient's posterior and compromising the epidural site. Team members also report reduced effort required when positioning patients from seated to supine on the operating room table. The second approach is the application of TraxiTM abdominal pannus retractor to retract fat folds encroaching on the epidural placement site in pregnant women with morbid obesity. This is particularly useful when the traditional taping of fat folds away from the site is inadequate. The pannus retractor results in a flatter surface facilitating epidural placement. We have introduced these two approaches into our clinical practice for pregnant women with morbid obesity requiring cesarean delivery under neuraxial anesthesia.

Fecal genotyping and contaminant analyses reveal variation in individual river otter exposure to localized persistent contaminants.

The present study investigated polyhalogenated aromatic hydrocarbon (PHAH) concentrations in feces of known river otters (Lontra canadensis) along the coast of southern Vancouver Island, British Columbia, Canada. Specifically, we combined microsatellite genotyping of DNA from feces for individual identification with fecal contaminant analyses to evaluate exposure of 23 wild otters to organochlorine pesticides (OCPs), polychlorinated biphenyls (PCBs), and polybrominated diphenylethers (PBDEs). Overall, feces collected from otters in urban/industrial Victoria Harbor had the greatest concentrations of nearly all compounds assessed. Fecal concentrations of OCPs and PBDEs were generally low throughout the region, whereas PCBs dominated in all locations. Re-sampling of known otters over space and time revealed that PCB exposure varied with movement and landscape use. Otters with the highest fecal PCB concentrations were those inhabiting the inner reaches of Victoria Harbor and adjacent Esquimalt Harbor, and those venturing into the harbor systems. Over 50% of samples collected from eight known otters in Victoria Harbor had total-PCB concentrations above the maximum allowable concentration as established for Eurasian otter (Lutra lutra) feces, with a geometric mean value (10.6 mg/kg lipid wt) that exceeded the reproductive toxicity threshold (9 mg/kg lipid wt). Those results are consistent with our findings from 1998 and 2004, and indicate that the harbors of southern Vancouver Island, particularly Victoria Harbor, are a chronic source of PCB exposure for otters. The present study further demonstrates the suitability of using otter feces as a noninvasive/destructive biomonitoring tool in contaminant studies, particularly when sampling of the same individuals at the local population-level is desired.

The Haitian connection.

Haiti is a land of overwhelming poverty, lacking in resources and struggling with underdeveloped health care. Social and health care problems contribute to produce a high infant mortality and infectious disease rate. Trauma care is mostly nonexistent although injury is common. Experiences encountered while working with the local population in Haiti are described.

Effects of manipulation of sodium balance on erythrocyte sodium transport.

The effects of changing sodium balance on blood pressure (BP) and erythrocyte sodium transport were investigated in normotensive first-degree relatives of hypertensive patients and control subjects randomised to receive low and high salt diets for two weeks, separated by a two week washout period. Changing from high to low salt intake produced a significant fall in standing diastolic pressure (DBP) in control subjects but not in the offspring of hypertensive patients. In both groups erythrocyte sodium efflux was not changed significantly by either manoeuvre, but the relatives had a significantly higher ouabain insensitive sodium efflux rate constant on both the low and the high salt diet compared to the controls (P less than 0.05). These results are not in keeping with the hypothesis which suggests the release of a humoral sodium pump inhibitor in response to sodium loading but lend support to the view that there is a disturbance of membrane permeability to sodium in subjects genetically prone to hypertension.

Effects of changes in sodium balance on leucocyte sodium transport: qualitative differences in normotensive offspring of hypertensives and matched controls.

To investigate the effects of changes in sodium balance on blood pressure and leucocyte sodium transport, normotensive first-degree relatives of hypertensive patients and control subjects were randomized to receive low- and high-salt diets for 2 weeks, separated by a wash-out period of 2 weeks. High-salt intake failed to alter blood pressure, whereas the low-salt diet produced significant falls in standing pressures in both groups. In the control subjects leucocyte sodium efflux was not changed by either manoeuvre, but in the relatives low-salt diet stimulated ouabain-insensitive sodium efflux rate constant. There was a significant qualitative difference in the pattern of response of total efflux rate constant to the two dietary periods between the two groups of subjects. These data are not compatible with the release of a humoral sodium pump inhibitor in response to sodium-induced volume expansion, and lend support to a disturbance of membrane permeability to sodium in subjects genetically prone to hypertension.

Dietary intake in thyrotoxicosis before and after adequate carbimazole therapy; the impact of dietary advice.

Dietary intake, including actual nutrient and energy intake, was assessed in 21 successive thyrotoxic patients before and after adequate carbimazole therapy. Group A (10 subjects) received regular formal dietary advice whereas Group B (11 subjects) did not. An age and sex matched control group, comprising 23 normal individuals, was also studied. The mean energy intake of all the thyrotoxic subjects was significantly greater than that of the normal control group (P less than 0.0025). There was a greater overall reduction in the energy intake of Group A as compared with Group B (P less than 0.01) and the former gained less weight, when expressed as a percentage of pretreatment weight. The mean final weight of all the thyrotoxic subjects exceeded the mean ideal weight for the group, reflecting a degree of true obesity at this stage. The simple measure of incorporating dietary advice into the treatment programme of thyrotoxic patients will usually result in some reduction of energy intake, and thus weight gain, en route to euthyroidism.