Wrong-site nerve blocks: 10 yr experience in a large multihospital health-care system.

INTRODUCTION: Although wrong-site surgery has garnered extensive scrutiny, the incidence of wrong-site blocks remains unknown. Our study thus sought to quantify the incidence of wrong-site blocks and examine some of their associated risk factors in our multihospital health-care system. METHODS: Using quality-improvement and billing data, we quantified the total number of blocks and wrong-site blocks occurring between July 1, 2002 and June 30, 2012 within the University of Pittsburgh Medical Center Health System. The incidence of wrong-site block was determined by block type, hospital, and type of service involved in performing the block. The incidence of wrong-site block was compared with that of wrong-site surgery. Fisher's exact tests were performed to determine associations between the incidence of wrong-site block and any of the aforementioned variables. A root-cause analysis was performed to determine the source of wrong-site blocks after the implementation of a timeout policy. RESULTS: Of the 85 915 patients receiving blocks, 70 441 received only unilateral blocks, yielding an overall incidence of wrong-site block of 1.28 (95% confidence interval 0.43-2.13) per 10 000 patients receiving unilateral blocks. The incidence of wrong-site block was highest with femoral blocks, and differed from the incidence of wrong-site surgery. All occurrences of wrong-site block after the implementation of the timeout policy involved policy violations. CONCLUSIONS: Our study provides the first incidence data on wrong-site block in a large patient population and can help hospitals to develop policies based on these data. It is yet to be determined whether active intervention can eliminate this adverse event.

The effect of residual neuromuscular blockade on the speed of reversal with sugammadex.

BACKGROUND: Sugammadex is a modified gamma cyclodextrin compound which encapsulates rocuronium resulting in rapid reversal of residual neuromuscular blockade. We performed a post hoc analysis of data from a multicenter study designed to mimic standard clinical practice which would test the hypothesis that the presence (versus the absence) of a twitch response to neuromuscular stimulation at the time of reversal drug administration would influence the speed and completeness of the reversal effect of sugammadex. METHODS: One-hundred-seventy-one consenting patients undergoing general anesthesia with a volatile-based anesthetic technique were enrolled in a multicenter observational study. All patients received rocuronium, 0.6 mg/kg i.v. for tracheal intubation and maintenance boluses of 0.15 mg/kg i.v. as needed during surgery. The degree of rocuronium-induced blockade was assessed during anesthesia using a TOF-Watch-SX acceleromyograph to record the train-of-four (TOF) responses on a laptop computer from induction of anesthesia until the TOF ratio returned to > or = 0.9 after completion of the surgical procedure. The patients received sugammadex, 4 mg/kg i.v., for reversal of neuromuscular blockade > 15 min after the last dose of rocuronium. Recovery data were compared in patients with either no (0) (n = 89) or > or = 1 twitch (n = 82) in response to TOF stimulation at the time of reversal drug administration. RESULTS: The patients without a twitch response were more likely to be female (60% vs 40%) and had a shorter time interval between the last bolus dose of rocuronium and the administration of the reversal drug (31+/-18 vs 45+/-23 min, P < 0.05). The time to achieve a TOF ratio of 0.9 was prolonged in the 0 twitch group compared with the > or = 1 twitch response group (173+/-162 vs 104+/-73 s, P < 0.05). Overall, 84% of the patients in the 0 twitch group recovered to a TOF of 0.9 in < or = 5 min compared to 91% of the patients in the group with > or = 1 twitch (P < 0.05). The times to achieve a TOF of 0.9 varied from 0.8 to 22.3 and 0.7 to 8.5 min in the 0 twitch and > or = 1 twitch groups, respectively. CONCLUSION: Reversal of rocuronium-induced neuromuscular blockade by sugammadex was influenced by the degree of residual blockade at the time the reversal drug was administered. Despite the wide variability, reversal of the TOF ratio to 0.9 occurred < or = 5 min in more than 80% of the patients regardless of the number of twitches at the time of reversal drug administration.

Genomic DNA sequence comparison between two inbred soybean cyst nematode biotypes facilitated by massively parallel 454 micro-bead sequencing.

Heterodera glycines, the soybean cyst nematode (SCN), is a damaging agricultural pest that could be effectively managed if critical phenotypes, such as virulence and host range could be understood. While SCN is amenable to genetic analysis, lack of DNA sequence data prevents the use of such methods to study this pathogen. Fortunately, new methods of DNA sequencing that produced large amounts of data and permit whole genome comparative analyses have become available. In this study, 400 million bases of genomic DNA sequence were collected from two inbred biotypes of SCN using 454 micro-bead DNA sequencing. Comparisons to a BAC, sequenced by Sanger sequencing, showed that the micro-bead sequences could identify low and high copy number regions within the BAC. Potential single nucleotide polymorphisms (SNPs) between the two SCN biotypes were identified by comparing the two sets of sequences. Selected resequencing revealed that up to 84% of the SNPs were correct. We conclude that the quality of the micro-bead sequence data was sufficient for de novo SNP identification and should be applicable to organisms with similar genome sizes and complexities. The SNPs identified will be an important starting point in associating phenotypes with specific regions of the SCN genome.

Dental surgery in pediatric patients with spina bifida and latex allergy.

Dental rehabilitation is a common outpatient pediatric surgical procedure. It requires the dentist to restore or extract the teeth of children with severe tooth decay or poor dental hygiene. Medical, physical, or emotional problems can make safe treatment in an outpatient setting impossible. These children require sedation or anesthesia for the dentist to gain access to their oral cavities. This article discusses caring for pediatric patients with spina bifida and latex allergy undergoing dental rehabilitation. Perioperative nurses must act as patient advocates in providing a latex-safe environment and also ensure quality care.

The genetics of phytochrome signalling in Arabidopsis.

The application of Arabidopsis genetics to research into the responses of plants to light has enabled rapid recent advances in this field. The plant photoreceptor phytochrome mediates well-defined responses that can be exploited to provide elegant and specific genetic screens. By this means, not only have mutants affecting the phytochromes themselves been isolated, but also mutants affecting the transduction of phytochrome signals. The genes involved in these processes have now begun to be characterized by using this genetic approach to isolate signal transduction components. Most of the components characterized so far are capable of being translocated to the cell nucleus, and they may help to define a new system of regulation of gene expression. This review summarises the ongoing contribution made by genetics to our understanding of light perception and signal transduction by the phytochrome system.

Haemodynamic effects of rocuronium bromide in adult cardiac surgical patients.

PURPOSE: To measure the haemodynamic effects of rocuronium in adults undergoing cardiac surgery with cardiopulmonary bypass (CPB). METHODS: Twenty patients undergoing elective cardiac surgical procedures with moderate hypothermic nonpulsatile bypass participated in this prospective, observational study. After anaesthetic induction, recovery from succinylcholine, and achievement of baseline haemodynamic stability, patients received 0.6 mg.kg-1 rocuronium as an initial rapid intravenous bolus. Maintenance dosing of 0.2 mg.kg-1 was continued for the remainder of the procedure. Haemodynamic measurements (heart rate, systemic arterial systolic, diastolic, and mean arterial pressure, pulmonary arterial systolic, diastolic, and mean pressure, pulmonary capillary wedge pressure, central venous pressure, and thermodilution cardiac output measurements) were obtained for the first five minutes after rocuronium administration, and subjects were observed for histamine-related symptoms. RESULTS: Central venous pressure decreased from baseline at two and five minutes after the rocuronium bolus, and mean pulmonary artery pressure decreased at five minutes. No changes were observed in heart rate, mean systemic arterial pressure, pulmonary capillary wedge pressure, cardiac index, stroke volume, systemic vascular resistance, or pulmonary vascular resistance, nor did any patient manifest any other histamine-related symptoms. CONCLUSION: The haemodynamic profile for a 0.6 mg.kg-1 bolus of rocuronium is acceptable for patients with cardiovascular disease.

Oral vaccine models: multiple delivery systems employing tetanus toxoid.

We have not yet directly examined the Th cell responses induced by using Salmonella/BRD 847 as a vector nor have we performed these experiments following immunization with microspheres. However, production of high serum levels of antigen-specific IgG1 may be indicative of a Th2-type response, whereas high serum levels of IgG2a may reflect a Th1-type response. An important issue in using various oral delivery systems is whether the system(s) employed affects the Th cell response to the same antigen. We therefore analyzed the serum antigen-specific IgG subclasses induced in each of the model systems we studied. Table 2 presents these results. Clearly, oral administration of soluble TT with CT as an adjuvant induced an IgG1 subclass, and encapsulation of TT within microspheres had no effect on this Th2-type response. On the other hand, oral immunization with live Salmonella expressing fragment C of tetanus toxin induced a strong IgG2a subclass response indicative of a Th1-type response. It should be noted that protection against a lethal TT challenge was afforded by elevated levels of both anti-TT IgG1 and IgG2a subclasses. We intend to examine the cytokine profiles in spleen CD4+ T cells from mice immunized with microspheres or Salmonella following in vitro antigen stimulation to confirm the T helper type responses suggested by the IgG subclass data. It will also be important to examine the cytokine patterns induced in Peyer's patch CD4+ T cells following immunization of C57BL/6 with Salmonella/BRD 847. Whereas analysis of the serum IgG subclass profile indicated a strong IgG2a response and thus a systemic Th1-type pattern, this vector also induced a good mucosal IgA response. If our current hypothesis concerning S-IgA production is correct, we would expect a predominant Th2-type profile in CD4+ T cells from Peyer's patch in these mice. Such a result would emphasize the bifurcation of T-cell responses in the systemic versus the mucosal immune environments. The data obtained to data suggest that adjuvants and various vehicle delivery systems may influence the induction of distinct T helper cell subsets to a specific antigen. The unique cytokine arrays produced by these T-cell subsets influence the immune responses in terms of systemic Ig subclasses produced, cell-mediated immune responses, and the production of mucosal S-IgA antibodies. Although additional studies are necessary, the manipulation of T-cell subsets employing adjuvants, antigen packaging, or perhaps even the addition of individual cytokines to various formulations holds significant promise for optimizing immune responses to orally administered vaccines.

High-grade immature teratoma of the testis in infancy.

Teratomas of the testis in infants are rare tumors which often display immature elements, disturbing in their histologic appearance. Although the presence of similar histologic features worsens prognosis in testicular teratomas in adults and in teratomas of infants and children presenting at other anatomic sites, the presence of immature elements in testicular teratomas of infancy does not appear to affect prognosis. Therefore, orchiectomy alone is adequate therapy for these neoplasms. The case of an 8-month-old infant with a teratoma of testis is presented.

Release of human serum albumin from poly(lactide-co-glycolide) microspheres.

Human serum albumin (HSA) was encapsulated in a 50:50 copolymer of DL-lactide/glycolide in the form of microspheres. These microspheres were used as a model formulation to study the feasibility of controlling the release of large proteins over a 20- to 30-day period. We show that HSA can be successfully incorporated into microspheres and released intact from these microspheres into various buffer systems at 37 degrees C. A continuous release of the protein could be achieved in physiological buffers at 37 degrees C over a 20- to 30-day period from microspheres with high protein loadings (11.6%). These results demonstrate the potential of poly(DL-lactide-co-glycolide) microspheres for continuous delivery of large proteins.

Controlled release of interleukin-2 from biodegradable microspheres.

We have evaluated the use of biodegradable poly(DL-lactide-co-glycolide) microspheres for the controlled release of interleukin-2 (IL-2) and its modified forms: succinyl IL-2 (SIL-2) and polyethylene glycol-modified IL-2 (PEG IL-2). We show that a microsphere formulation can be prepared from PEG IL-2 using HSA as an excipient which, after an initial burst, releases 2-3% PEG IL-2 per day in a bioactive form continuously over a 20- to 30-day period.