Trial of labor after cesarean: Maternal and neonatal outcomes from the Consortium on Safe Labor.

BACKGROUND: The aim of our study is to describe maternal and neonatal morbidity and mortality in patients undergoing trial of labor after cesarean from the Consortium on Safe Labor. METHODS: This was a secondary analysis of the Consortium on Safe Labor database, a retrospective cohort study over a 7 year study period. Maternal and neonatal outcomes were evaluated based on desired delivery mode: planned elective repeat cesarean delivery or trial of labor after cesarean. RESULTS: Of 9858 patients in our analysis, our study population had 4400 patients (45%) who desired trial of labor after cesarean and 5458 patients (55%) who desired elective repeat cesarean delivery. Women who attempted trial of labor after cesarean compared to those who had an elective repeat cesarean delivery were more likely to have an obstetric hemorrhage (adjusted odds ratio 1.6; 95% CI 1.3 -2.0) and blood transfusion (adjusted odds ratio 2.3; 95% CI 1.6 -3.2). CONCLUSION: Maternal morbidity in women undergoing trial of labor after cesarean was predominantly hemorrhage-related.

Predicting risk of peripartum blood transfusion during vaginal and cesarean delivery: A risk prediction model.

OBJECTIVE: The objective of this study is to develop a model that will help predict the risk of blood transfusion using information available prior to delivery. STUDY DESIGN: The study is a secondary analysis of the Consortium on Safe Labor registry. Women who had a delivery from 2002 to 2008 were included. Pre-delivery variables that had significant associations with transfusion were included in a multivariable logistic regression model predicting transfusion. The prediction model was internally validated using randomly selected samples from the same population of women. RESULTS: Of 156,572 deliveries, 5,463 deliveries (3.5%) required transfusion. Women who had deliveries requiring transfusion were more likely to have a number of comorbidities such as preeclampsia (6.3% versus 4.1%, OR 1.21, 95% CI 1.08-1.36), placenta previa (1.8% versus 0.4%, OR 4.11, 95% CI 3.25-5.21) and anemia (10.6% versus 5.4%, OR 1.30, 95% CI 1.21-1.41). Transfusion was least likely to occur in university teaching hospitals compared to community hospitals. The c statistic was 0.71 (95% CI 0.70-0.72) in the derivation sample. The most salient predictors of transfusion included type of hospital, placenta previa, multiple gestations, diabetes mellitus, anemia, asthma, previous births, preeclampsia, type of insurance, age, gestational age, and vertex presentation. The model was well-calibrated and showed strong internal validation. CONCLUSION: The model identified independent risk factors that can help predict the risk of transfusion prior to delivery. If externally validated in another dataset, this model can assist health care professionals counsel patients and prepare facilities/resources to reduce maternal morbidity.

Umbilical hernia repair in pregnant patients: review of the American College of Surgeons National Surgical Quality Improvement Program.

BACKGROUND: Umbilical hernias present commonly during pregnancy secondary to increased intra-abdominal pressure. As a result, umbilical hernia incarceration or strangulation may affect pregnant females. The purpose of this study is to detail the operative management and 30-day outcomes of umbilical hernias in pregnant patients using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP). METHODS: All female patients undergoing umbilical hernia repair during pregnancy were identified within the ACS-NSQIP. Preoperative patient variables, intraoperative variables, and 30-day patient morbidity and mortality outcomes were investigated using a variety of statistical tests. RESULTS: A total of 126 pregnant patients underwent umbilical hernia repair from 2005 to 2014; 73 (58%) had incarceration or strangulation at the time of surgical intervention. The majority of patients (95%) underwent open umbilical hernia repair. Superficial surgical site infection was the most common morbidity in patients undergoing open umbilical hernia repair. CONCLUSIONS: Based on review of the ACS-NSQIP database, the incidence of umbilical hernia repair during pregnancy is very low; however, the majority of patients required repair for incarceration of strangulation. When symptoms develop, these hernias can be repaired with minimal 30-day morbidity to the mother. Additional studies are needed to determine the long-term recurrence rate of umbilical hernia repairs performed in pregnant patients and the effects of surgical intervention and approach on the fetus.

Comparison of Renal Complications between Endografts with Suprarenal and Infrarenal Fixation.

OBJECTIVES: Surgeons have multiple grafts options available for the endovascular treatment of abdominal aortic aneurysm (EVAR), and some hypothesize that suprarenal fixation endografts may result in higher rates of renal complications than infrarenal endografts. This study aimed to compare the outcomes of contemporary suprarenal and infrarenal endografts. METHODS: The Targeted Vascular Module of the National Surgical Quality Improvement Project was utilised to identify patients undergoing EVAR for infrarenal aneurysm from 2011 to 2013. Pre-operative and operative variables and 30 day outcomes were compared among suprarenal (Zenith and Endurant) and infrarenal fixation devices (Excluder). Renal complications included creatinine increase > 2 mg/dL or new dialysis, as defined by NSQIP. Multivariate regression was completed to account for patient demographics, comorbidities, and operative characteristics. RESULTS: A total of 3587 patients were evaluated including 2273 (63%) with suprarenal grafts and 1314 (37%) with infrarenal grafts. Patients with suprarenal grafts were less commonly white (84% vs. 88%, p < .01) and more commonly male (83% vs. 80%, p = .03). There were no differences in age or comorbidities. Renal complications (1.1% vs. 0.1%, p < .01) and length of stay more than 2 days (34% vs. 25%, p < .01) occurred more commonly after suprarenal fixation. After adjustment, suprarenal grafts had significantly higher rates of renal complications (OR, 12.0; 95% CI, 1.6-91) and length of stay more than 2 days (OR, 1.4; 95% CI, 1.2-1.7). CONCLUSION: Overall rates of renal complications following EVAR are low. Patients selected for suprarenal stent grafts are at increased risk of renal complications and prolonged length of stay, which may be due to selection bias, deployment techniques, or the presence of a bare stent overlying the renal arteries. Further studies are necessary to evaluate the mechanism and duration of renal dysfunction and important long-term outcomes of interest.

Dose-response of intrathecal morphine when administered with intravenous ketorolac for post-cesarean analgesia: a two-center, prospective, randomized, blinded trial.

BACKGROUND: The appropriate dose of intrathecal morphine for post-cesarean analgesia is unclear. With the inclusion of routine non-steroidal anti-inflammatory drugs, the required dose of morphine may be significantly less than the 200-300µg common a decade ago. We performed a two-center, prospective, randomized, blinded trial comparing three doses of intrathecal morphine, combined with routine intravenous ketorolac, in 144 healthy women undergoing elective cesarean delivery. METHODS: Patients received an intrathecal injection of hyperbaric bupivacaine 12mg, fentanyl 15µg and a randomized dose of 50, 100, or 150µg morphine in a volume of 2.2mL. Patients received intravenous ketorolac 30mg before leaving the operating room and 15mg intravenously every 6h for the duration of the study (24h). All received postoperative patient-controlled intravenous morphine. The primary endpoint was total intravenous morphine administered postoperatively over 24h, analyzed using mixed model regression. RESULTS: There were no differences between dose groups (or institutions) in intravenous morphine use over 24h. Visual analog scale scores for pain and nausea did not differ. Pruritus was greater in the 100 and 150µg groups than the 50µg group at 6h and 12h, but there was no difference between groups in nausea or pruritus treatments. Respiratory depression or significant sedation did not occur. CONCLUSION: The dose-response relationship of intrathecal morphine for multimodal post-cesarean analgesia suggests that 50µg produces analgesia similar to that produced by either 100µg or 150µg.

Association of serum electrolytes and smoking with salivary gland stone formation.

To further define potential factors that may contribute to stone formation in salivary glands (sialolithiasis), a retrospective chart review was performed of patients diagnosed with sialolithiasis between March 1, 1998 and February 29, 2012. Information on salivary gland stone number, location and size, medical history, medications, and serum electrolyte levels were collected. Associations between electrolyte levels and stone characteristics (such as stone number and size) were examined. Fifty-nine patients were identified; their median age was 58 years (range 25-89 years) and most were male (95%). Salivary stones were most commonly located in the submandibular glands (83%). Thirty-five patients (59%) had a smoking history, with 16 (27%) reported as current smokers. There was a significant association between current smoker status and stone size (mean largest stone size 12.4±8.8mm vs. 7.5±4.8mm in current smokers vs. non-smokers; P=0.03). Serum sodium levels (r=0.32, P=0.014) and serum potassium levels (r=0.31, P=0.017) showed significant positive correlations with stone size. While the aetiology of sialolithiasis remains unclear, smoking (which can contribute to reduced saliva flow) and higher serum sodium levels (which can reflect volume depletion) are associated with larger salivary stones.

Use of propofol as an induction agent in the acutely injured patient.

PURPOSE: Etomidate is a commonly used agent for rapid sequence induction (RSI) in trauma due to its limited hemodynamic effects. Given a recent nationwide shortage of etomidate, alternative induction agents may be required. Propofol is a frequent substitute; however, concern exists regarding its potential hypotensive effects. The study attempts to determine the hemodynamic effects of propofol and etomidate following RSI in trauma bay. METHODS: A retrospective study was performed on 76 consecutive trauma patients requiring RSI at a single academic medical center. Patients were stratified by age, gender, mechanism of injury, Injury Severity Score (ISS), and Glasgow Coma Scale (GCS). Pre-induction and post-induction hemodynamic parameters were evaluated, and a multivariate regression analysis was performed. RESULTS: The mean age was 42, ISS was 13, and GCS was 9.8. The mean dose of propofol was 127 ± 5 mg and the mean dose of etomidate was 21 ± 6 mg. Patients who received propofol were younger and had a lower ISS. The etomidate group had significantly increased post-induction systolic blood pressure but no difference in mean arterial pressure or heart rate when compared to pre-induction parameters. The propofol group had no significant changes in any post-induction parameter compared to pre-induction parameter. CONCLUSION: RSI with propofol did not result in hypotension in our patient population, suggesting that a reduced dose of propofol may represent a reasonable alternative to etomidate in hemodynamically stable trauma patient. Further research is warranted to assess the safety of propofol in the acutely injured patient.

Association study of SNAP25 and schizophrenia in Irish family and case-control samples.

SNAP25 occurs on chromosome 20p12.2, which has been linked to schizophrenia in some samples, and recently linked to latent classes of psychotic illness in our sample. SNAP25 is crucial to synaptic functioning, may be involved in axonal growth and dendritic sprouting, and its expression may be decreased in schizophrenia. We genotyped 18 haplotype-tagging SNPs in SNAP25 in a sample of 270 Irish high-density families. Single marker and haplotype analyses were performed in FBAT and PDT. We adjusted for multiple testing by computing q values. Association was followed up in an independent sample of 657 cases and 411 controls. We tested for allelic effects on the clinical phenotype by using the method of sequential addition and 5 factor-derived scores of the OPCRIT. Nine of 18 SNPs had P values <0.05 in either FBAT or PDT for one or more definitions of illness. Several two-marker haplotypes were also associated. Subjects inheriting the risk alleles of the most significantly associated two-marker haplotype were likely to have higher levels of hallucinations and delusions. The most significantly associated marker, rs6039820, was observed to perturb 12 transcription-factor binding sites in in silico analyses. An attempt to replicate association findings in the case-control sample resulted in no SNPs being significantly associated. We observed robust association in both single marker and haplotype-based analyses between SNAP25 and schizophrenia in an Irish family sample. Although we failed to replicate this in an independent sample, this gene should be further tested in other samples.

The structure of posttraumatic stress disorder symptoms in combat veterans: a confirmatory factor analysis of the impact of event scale.

There has been controversy over the most appropriate way to define symptom clusters for posttraumatic stress disorder (PTSD). We tested the factor structure of the Impact of Event Scale (IES) in a sample of 195 male combat veterans with chronic PTSD by using confirmatory factor analysis. The two-factor model including Intrusion (i.e., unwanted memories of the event) and Avoidance (i.e., attempts to avoid reminders and numbing of emotional responsiveness) deviated significantly from good fit. However, a four-factor model, including Intrusion and Effortful Avoidance subscales, as well as Sleep Disturbance and Emotional Numbing subscales, fit significantly better. Correlations with other PTSD measures are explored and implications for the conceptualization of PTSD are discussed.

Emotional processing in combat-related posttraumatic stress disorder: a comparison with traumatized and normal controls.

Emotional numbing (EN) symptoms are an important but poorly understood component of the response to trauma. To try to demonstrate EN, this laboratory study examined subjective and psychophysiological emotion responses to standardized visual stimuli in combat veterans with posttraumatic stress disorder (PTSD), combat veterans without PTSD, and nontraumatized controls. PTSD subjects showed no evidence of generalized reduction in subjective or psychophysiological emotion responses. In response to a subset of more evocative stimuli, PTSD subjects reported less experience of Positive Emotions, and more experience of Negative Emotions than controls. For controls, valence and arousal were uncorrelated, while they were negatively correlated for PTSD subjects. Verbal and nonverbal subjective emotion measures were positively correlated for all subject groups, but there was little correlation between subjective emotion measures and psychophysiological indices. Viewing time was positively correlated with Positive Emotions for PTSD subjects, and with Negative Emotions for combat controls.

Rorschach patterns of response in Vietnam veterans with posttraumatic stress disorder versus combat and normal controls.

To further evaluate Rorschach indicators of posttraumatic stress disorder (PTSD), test protocols of 16 combat veterans so diagnosed were compared with those of 9 combat controls and 12 noncombat subjects. Results replicated Rorschach abnormalities previously associated with this disorder, including signs of low stress tolerance, poor affect modulation, perceptual distortion, and interpersonal disengagement. However, only two indicators, EB (Erlebnistypus) and CC (combat-related content), differentiated PTSD subjects from controls (P < .05). Examination of negative findings revealed that all three groups similarly deviated from Exner nonpatient norms (Exner, 1993: The Rorschach, Vol 1. New York: John Wiley and Sons) on many Rorschach variables. Possible explanations for these findings are considered, and the need for control subjects in Rorschach investigation is underscored.

Psychophysiologic responses to the Rorschach in PTSD patients, noncombat and combat controls.

While psychophysiologic studies of posttraumatic stress disorder (PTSD) have investigated the effects of trauma-related stimuli on arousal, none have explored the development of intrusive imagery and affect states in the absence of such specific cues. The present study compares autonomic arousal during PTSD-related Rorschach responses in PTSD veterans vs. combat controls and noncombat controls. It was found that Rorshach responses containing traumatic content were found only in the PTSD group, and that these responses showed elevations in skin conductance (SC) and heart rate (HR). Our data also suggest that PTSD patients are more easily hyperaroused, especially under conditions of experienced stress and helplessness. Finally, combat control subjects exhibited lower baseline SC and HR than their counterparts, as well as decelerated HR during trauma- and stress-related Rorschach responses, suggesting a physiologic resilience in this group.

Clozapine fails to prevent the development of haloperidol-induced behavioral hypersensitivity in a cotreatment paradigm.

We have previously established that chronic cotreatments involving antimuscarinic agents and haloperidol attenuate the development of behavioral hypersensitivity without affecting dopamine receptor proliferation. The antipsychotic agent clozapine also has significant antimuscarinic activity and was coadministered with haloperidol in rats for 2 months to determine if it would similarly attenuate the development of hypersensitivity. Clozapine or chlorpromazine cotreatment, unlike thioridazine cotreatment, did not attenuate the development of haloperidol-induced behavioral hypersensitivity. Clozapine or thioridazine cotreatment also failed to prevent the development of haloperidol-induced D2 receptor proliferation, whereas chlorpromazine cotreatment enhanced D2 receptor proliferation relative to haloperidol-treated animals. Alterations in dopamine biochemistry in the striatum or nucleus accumbens could not explain this dissociation between behavioral hypersensitivity and dopamine receptor proliferation. It is therefore hypothesized that dopamine receptor proliferation is permissive for behavioral hypersensitivity and that factors in addition to alterations in dopamine function contribute to the expression of dopamine hypersensitivity states.

Dopaminergic alterations in cotreatments attenuating haloperidol-induced hypersensitivity.

Chronic treatment of the laboratory rat with haloperidol results in an increased stereotypic behavioral response to subsequent dopamine agonist challenge. This behavioral hypersensitivity (BH) is thought to reflect an increase in DA receptor number following chronic pharmacologic denervation. Using a cotreatment strategy, we demonstrate here that a variety of agents can attenuate or prevent the development of BH when administered chronically with haloperidol. Cotreatment with lithium and amantadine prevented the changes in DA biochemistry as well as the proliferation of DA receptors normally associated with chronic haloperidol treatment. Cotreatment with thioridazine or scopolamine did alter the changes in DA biochemistry normally associated with haloperidol treatment, but failed to attenuate the DA receptor proliferation. Taken together, these data suggest that mechanisms in addition to DA biochemical and receptor changes participate in the development and subsequent expression of BH. DA receptor proliferation must, therefore, be considered permissive to the development of BH.