Quantifying the incidence of clinically significant respiratory depression in women with and without obesity class III receiving neuraxial morphine for post-cesarean analgesia: a retrospective cohort study.

BACKGROUND: Obesity is a suspected risk factor for respiratory depression following neuraxial morphine for post-cesarean analgesia, however monitoring guidelines for obese obstetric patients are based on small, limited studies. We tested the hypothesis that clinically significant respiratory depression following neuraxial morphine occurs more commonly in women with body mass index (BMI) ≥40 kg/m2 compared with BMI <40 kg/m2. METHODS: We conducted a single-center, retrospective chart review (2006-2017) of obstetric patients with clinically significant respiratory depression following neuraxial morphine, defined as: (1) opioid antagonist administration; (2) rapid response team activation (initiated in April 2010); or (3) tracheal intubation due to a respiratory event. The incidence of respiratory depression was compared between women with BMI ≥40 kg/m2 and BMI <40 kg/m2. RESULTS: In total, 11 327 women received neuraxial morphine (n=1945 BMI ≥40 kg/m2; n=9382 BMI <40 kg/m2). Women with BMI ≥40 kg/m2 had higher rates of sleep apnea, hypertensive disorders, and magnesium administration. Sixteen cases of clinically significant respiratory depression occurred within seven days postpartum. The incidence did not significantly differ between groups (odds ratio 2.2, 95% CI 0.6 to 6.9, P=0.174). Neuraxial morphine was not deemed causative in any case, however women with BMI ≥40 kg/m2 had higher rates of tracheal intubation unrelated to neuraxial morphine (2/1945 vs. 0/9382, P=0.029). CONCLUSIONS: Respiratory depression in this population is rare. A larger sample (∼75 000) is required to determine whether the incidence is higher with BMI ≥40 kg/m2. Tracheal intubation was higher among the BMI ≥40 kg/m2 cohort, likely due to more comorbidities.

Laparoscopic repair of an incarcerated right indirect sliding inguinal hernia involving a retroperitoneal ileum.

INTRODUCTION: Laparoscopic techniques for the repair of inguinal hernias have become an increasingly popular alternative to open techniques. No clear consensus has emerged as to the best laparoscopic technique, but the body of evidence increasingly favors a total extraperitoneal (TEP) approach. RESULTS AND DISCUSSION: We report the case of an adult man with an incarcerated right indirect inguinal sliding hernia involving the first known instance of a retroperitoneal ileum, and the novel use of a laparoscopic combined TEP approach and transabdominal preperitoneal (TAPP) approach to repair his hernia without complications. The literature is reviewed and TEP and TAPP techniques for the treatment of inguinal hernias are discussed and compared. CONCLUSION: When faced with an unforeseen anomaly during herniorrhaphy in which improved abdominal visualization is necessary, a surgeon may convert from a TEP to a transabdominal laparoscopic approach safely and effectively.

The quantitative ADAM questionnaire: a new tool in quantifying the severity of hypogonadism.

Androgen deficiency is a pervasive problem in the older male population and is thought to be responsible for many symptoms once considered to be the result of normal aging. Numerous methods have been proposed to facilitate the detection of men at risk for androgen deficiency. In this article, we propose a novel screening tool, the quantitative Androgen Deficiency in the Aging Male (qADAM) questionnaire and report its successful use in quantifying the severity of androgen deficiency in a group of older men. Fifty-seven males scheduled to undergo radical prostatectomy for prostate cancer completed the qADAM as well as the Sexual Health Inventory for Men (SHIM) and the Expanded Prostate Cancer Index Composite hormonal/sexual (EPICh/EPICs) questionnaires. Thirty-four men also had serum testosterone levels measured for comparison. The qADAM showed statistically significant correlation to the SHIM (P=0.001), EPICh (P=0.016), EPICs (P= <0.001), and serum testosterone (P=0.046). The qADAM represents a viable alternative to existing questionnaires used to detect androgen deficiency and to assess response to treatment.

Computed tomography in urothelial tumors of renal pelvis and related filling defects.

Our study includes 12 patients. Of these, six had transitional cell carcinoma, three patients with stones and three patients with blood clots. With the use of computed tomography we were able to arrive at a reasonable staging and diagnosis of the filling defects. Computed tomography is not sufficiently sensitive to recognize microscopic invasion. Reactive fibrosis and postobstructive inflammatory changes can mimic tumor invasion on computed tomography, and in such cases staging will not be accurate.