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Stem Cell and Regenerative Biology

Study Objective: Following robot assisted abdominal surgery, the pain can be moderate in severity. Neuraxial analgesia may decrease the activity of the detrusor muscle, reduce the incidence of bladder spasm and provide effective somatic and visceral analgesia. In this systematic review, we assessed the role of neuraxial analgesia in robot assisted abdominal surgery., Design: Systematic review., Settings: Robot assisted abdominal surgery., Patients: Adults., Interventions: Subsequent to a search of the electronic databases, observational studies and randomized controlled trials that assessed the effect of neuraxial analgesia instituted at induction of anesthesia or intraoperatively in adult and robot assisted abdominal surgery were considered for inclusion. The outcomes of observational studies as well as randomized controlled trials which were not subjected to meta-analysis were presented in descriptive terms. Meta-analysis was conducted if an outcome of interest was reported by two or more randomized controlled trials., Main Results: We included 19 and 11 studies that investigated spinal and epidural analgesia in adults, respectively. The coprimary outcomes were the pain score at rest at 24 h and the cumulative intravenous morphine consumption at 24 h. Spinal analgesia with long acting neuraxial opioid did not decrease the pain score at rest at 24 h although it reduced the cumulative intravenous morphine consumption at 24 h by a mean difference (95%CI) of 14.88 mg (-22.13--7.63; p < 0.0001, I 2  = 50%) with a low and moderate quality of evidence, respectively, on meta-analysis of randomized controlled trials. Spinal analgesia with long acting neuraxial opioid had a beneficial effect on analgesic indices till the second postoperative day and a positive influence on opioid consumption up to and including the 72 h time point. The majority of studies demonstrated the use of spinal analgesia with long acting neuraxial opioid to lead to no difference in the incidence of postoperative nausea and vomiting, and the occurrence of pruritus was found to be increased with spinal analgesia with long acting neuraxial opioid in recovery but not at later time points. No difference was revealed in the incidence of urinary retention. The evidence in regard to the quality of recovery-15 score at 24 h and hospital length of stay was not fully consistent, although most studies indicated no difference between spinal analgesia and control for these outcomes. Epidural analgesia in robot assisted abdominal surgery was shown to decrease the pain on movement at 12 h but it had not been studied with respect to its influence on the pain score at rest at 24 h or the cumulative intravenous morphine consumption at 24 h. It did not reduce the pain on movement at later time points and the evidence related to the hospital length of stay was inconsistent., Conclusions: Spinal analgesia with long acting neuraxial opioid had a favourable effect on analgesic indices and opioid consumption, and is recommended by the authors, but the evidence for spinal analgesia with short acting neuraxial opioid and epidural analgesia was limited., Competing Interests: Declaration of competing interest The authors declare that they do not have any conflicts of interest., (Copyright © 2023. Published by Elsevier Inc.)

Background: The COVID-19 pandemic has highlighted the importance of respiratory protective equipment for clinicians performing airway management., Aim: To evaluate the impact of powered air-purifying respirators, full-face air-purifying respirators and filtering facepieces on specially trained anaesthesiologists performing difficult airway procedures., Methods: All our COVID-19 intubation team members carried out various difficult intubation drills: unprotected, wearing a full-face respirator, a filtering facepiece or a powered respirator. Airway management times and wearer comfort were evaluated and analysed., Results: Total mean (SD) intubation times did not show significant differences between the control, the powered, the full-face respirator and the filtering facepiece groups: Airtraq 6.1 (4.4) vs. 5.4 (3.1) vs. 6.1 (5.6) vs. 7.7 (7.6) s; videolaryngoscopy 11.4 (9.0) vs. 7.7 (4.3) vs. 9.8 (8.4) vs. 12.7 (9.8) s; fibreoptic intubation 16.6 (7.8) vs.13.8 (6.7) vs. 13.6 (8.1) vs. 16.9 (9.2) s; and standard endotracheal intubation by direct laryngoscopy 8.1 (3.5) vs. 6.5 (5.6) vs. 6.2 (4.2) vs. 8.0 (4.4) s, respectively. Use of the Airtraq achieved the shortest intubation times. Anaesthesiologists rated temperature and vision significantly better in the powered respirator group., Conclusions: Advanced airway management remains unaffected by the respiratory protective equipment used if performed by a specially trained, designated team. We conclude that when advanced airway skills are performed by a designated, specially trained team, airway management times remain unaffected by the respiratory protective equipment used., Competing Interests: No competing interests declared., (© 2021 Elsevier Ltd. All rights reserved.)

Background & Aims: Death rates on liver transplant waiting lists range from 5%-25%. Herein, we report a unique experience with 50 anonymous individuals who volunteered to address this gap by offering to donate part of their liver to a recipient with whom they had no biological connection or prior relationship, so called anonymous live liver donation (A-LLD)., Methods: Candidates were screened to confirm excellent physical, mental, social, and financial health. Demographics and surgical outcomes were analyzed. Qualitative interviews after donation examined motivation and experiences. Validated self-reported questionnaires assessed personality traits and psychological impact., Results: A total of 50 A-LLD liver transplants were performed between 2005 and 2017. Most donors had a university education, a middle-class income, and a history of prior altruism. Half were women. Median age was 38.5 years (range 20-59). Thirty-three (70%) learned about this opportunity through public or social media. Saving a life, helping others, generativity, and reciprocity for past generosity were motivators. Social, financial, healthcare, and legal support in Canada were identified as facilitators. A-LLD identified most with the personality traits of agreeableness and conscientiousness. The median hospital stay was 6 days. One donor experienced a Dindo-Clavien Grade 3 complication that completely resolved. One-year recipient survival was 91% in 22 adults and 97% in 28 children. No A-LLD reported regretting their decision., Conclusions: This is the first and only report of the characteristics, motivations and facilitators of A-LLD in a large cohort. With rigorous protocols, outcomes are excellent. A-LLD has significant potential to reduce the gap between transplant organ demand and availability., Lay Summary: We report a unique experience with 50 living donors who volunteered to donate to a recipient with whom they had no biological connection or prior relationship (anonymous living donors). This report is the first to discuss motivations, strategies and facilitators that may mitigate physical, social and ethical risk factors in this patient population. With rigorous protocols, anonymous liver donation and recipient outcomes are excellent; with appropriate clinical expertise and system facilitators in place, our experience suggests that other centers may consider the procedure for its significant potential to reduce the gap between transplant organ demand and availability., (Copyright © 2019 European Association for the Study of the Liver. Published by Elsevier B.V. All rights reserved.)

Background: Stage 3 pancreatic ductal adenocarcinoma (PDAC) is defined by arterial involvement. This study objective was to evaluate outcomes for patients with stage 3 PDAC with potentially reconstructable arterial involvement, considered for neoadjuvant therapy (NAT) and pancreatic resection, and to compare outcomes following arterial (AR) and non-arterial resection (NAR)., Methods: This study included patients from 2009 to 2016 with biopsy-proven stage 3 PDAC who were offered NAT before surgical exploration. AR was performed if required to achieve R0 resection. Time to event outcomes were analysed from diagnosis date., Results: 87/89 patients (97.8%) received NAT (chemotherapy 41.6%, chemotherapy/radiotherapy 56.2%). 46/89 (51.7%) underwent exploration; 31 underwent resection (AR n = 20, NAR n = 11). AR patients had longer operative time (681 vs. 563 min, p = 0.006) and more blood loss (1600 vs. 575 mL, p = 0.0004), with no difference for blood transfusion, pancreatic fistula, length of stay, reoperation, or mortality. R0 rate was 30/31. Post-resection 90-day mortality was 3.2%. Median overall survival was statistically comparable between the AR and NAR groups (19.7 vs. 28.4 months, p = 0.41)., Conclusions: AR had comparable clinical and oncologic outcomes to NAR. Following careful selection and non-progression after NAT, major AR may cautiously be considered if required to obtain a negative resection margin., (Copyright © 2018. Published by Elsevier Ltd.)

Competing Interests: PG teaches on the Royal College of Anaesthetists 'Teaching and Training in the Workplace' and 'Anaesthetic Non-technical Skills' courses.

Background: The variability in risk tolerance in medicine is not well understood. Parallels are often drawn between aviation and anaesthesia. The aviation industry is perceived as culturally risk averse, and part of preflight checks involves a decision on whether the flight can operate. This is sometimes termed a go/no-go decision. This questionnaire study was undertaken to explore the equivalent go/no-go decision in anaesthesia. We presented anaesthetists with a range of situations in which additional risk might be expected and asked them to decide whether they would proceed with the case., Methods: An electronic questionnaire was distributed to anaesthetic colleagues of all grades in one National Health Service Trust. Eleven scenarios, all drawn from critical incident data, were presented. Participants were invited to consider whether they would proceed, how they would modify their anaesthetic technique, and to predict whether a colleague with similar experience would make the same decision. Textual responses were analysed qualitatively., Results: The scenario response rate was 28%. Consultants were significantly more likely to proceed than trainees. In no scenario was there absolute agreement over whether to proceed, even in scenarios where national guidelines would suggest a case should be cancelled. Thematic analysis suggested a wide variability in what anaesthetists consider acceptable or professional behaviour., Conclusions: It is clear that safety decisions cannot be made in isolation and that clinicians must consider operational requirements, such as throughput, when making a go/no-go decision. The level of variability in decision-making was surprising, particularly for scenarios that appeared to go against guidelines., (© The Author 2017. Published by Oxford University Press on behalf of the British Journal of Anaesthesia. All rights reserved. For Permissions, please email: journals.permissions@oup.com)

The increased prevalence of obesity worldwide threatens the pool of living liver donors. Although the negative effects of graft steatosis on liver donation and transplantation are well known, the impact of obesity in the absence of hepatic steatosis on outcome of living donor liver transplantation (LDLT) is unknown. Consequently, we compared the outcome of LDLT using donors with BMI <30 versus donors with BMI ≥30. Between April 2000 and May 2014, 105 patients received a right-lobe liver graft from donors with BMI ≥30, whereas 364 recipients were transplanted with grafts from donors with BMI <30. Liver steatosis >10% was excluded in all donors with BMI >30 by imaging and liver biopsies. None of the donors had any other comorbidity. Donors with BMI <30 versus ≥30 had similar postoperative complication rates (Dindo-Clavien ≥3b: 2% vs. 3%; p = 0.71) and lengths of hospital stay (6 vs. 6 days; p = 0.13). Recipient graft function, assessed by posttransplant peak serum bilirubin and international normalized ratio was identical. Furthermore, no difference was observed in recipient complication rates (Dindo-Clavien ≥3b: 25% vs. 20%; p = 0.3) or lengths of hospital stay between groups. We concluded that donors with BMI ≥30, in the absence of graft steatosis, are not contraindicated for LDLT., (© Copyright 2016 The American Society of Transplantation and the American Society of Transplant Surgeons.)

Liver transplantation (LT) is the treatment of choice for end-stage autoimmune liver diseases. However, the underlying disease may recur in the graft in some 20% of cases. The aim of this study is to determine whether LT using living donor grafts from first-degree relatives results in higher rates of recurrence than grafts from more distant/unrelated donors. Two hundred sixty-three patients, who underwent a first LT in the Toronto liver transplant program between January 2000 and March 2015 for autoimmune liver diseases, and had at least 6 months of post-LT follow-up, were included in this study. Of these, 72 (27%) received a graft from a first-degree living-related donor, 56 (21%) from a distant/unrelated living donor, and 135 (51%) from a deceased donor for primary sclerosing cholangitis (PSC) (n = 138, 52%), primary biliary cholangitis (PBC) (n = 69, 26%), autoimmune hepatitis (AIH) (n = 44, 17%), and overlap syndromes (n = 12, 5%). Recurrence occurred in 52 (20%) patients. Recurrence rates for each autoimmune liver disease were not significantly different after first-degree living-related, living-unrelated, or deceased-donor LT. Similarly, time to recurrence, recurrence-related graft failure, graft survival, and patient survival were not significantly different between groups. In conclusion, first-degree living-related donor LT for PSC, PBC, or AIH is not associated with an increased risk of disease recurrence., (© Copyright 2016 The American Society of Transplantation and the American Society of Transplant Surgeons.)

We report the outcome of live donor liver transplantation (LDLT) for patients suffering from acute liver failure (ALF). From 2006 to 2013, all patients with ALF who received a LDLT (n = 7) at our institution were compared to all ALF patients receiving a deceased donor liver transplantation (DDLT = 26). Groups were comparable regarding pretransplant ICU stay (DDLT: 1 [0-7] vs. LDLT: 1 days [0-10]; p = 0.38), mechanical ventilation support (DDLT: 69% vs. LDLT: 57%; p = 0.66), inotropic drug requirement (DDLT: 27% vs. LDLT: 43%; p = 0.64) and dialysis (DDLT: 2 vs. LDLT: 0 patients; p = 1). Median evaluation time for live donors was 24 h (18-72 h). LDLT versus DDLT had similar incidence of overall postoperative complications (31% vs. 43%; p = 0.66). No difference was detected between LDLT and DDLT patients regarding 1- (DDLT: 92% vs. LDLT: 86%), 3- (DDLT: 92% vs. LDLT: 86%), and 5- (DDLT: 92% vs. LDLT: 86%) year graft and patient survival (p = 0.63). No severe donor complication (Dindo-Clavien ≥3 b) occurred after live liver donation. ALF is a severe disease with high mortality on liver transplant waiting lists worldwide. Therefore, LDLT is an attractive option since live donor work-up can be expedited and liver transplantation can be performed within 24 h with excellent short- and long-term outcomes., (© Copyright 2015 The American Society of Transplantation and the American Society of Transplant Surgeons.)

Outcomes of living versus deceased donor liver transplantation in patients with chronic liver disease and hepatorenal syndrome (HRS) was compared using a matched pair study design. Thirty patients with HRS receiving a live donor liver transplantation (LDLT) and 90 HRS patients receiving a full graft deceased donor liver transplantation (DDLT) were compared. LDLT versus DDLT of patients with HRS was associated with decreased peak aspartate aminotransferase levels (339 ± 214 vs. 935 ± 1253 U/L; p = 0.0001), and similar 7-day bilirubin (8.42 ± 7.89 vs. 6.95 ± 7.13 mg/dL; p = 0.35), and international normalized ratio levels (1.93 ± 0.62 vs. 1.78 ± 0.78; p = 0.314). LDLT vs. DDLT had a decreased intensive care unit (2 [1-39] vs. 4 [0-93] days; p = 0.004), and hospital stay (17 [4-313] vs. 26 [0-126] days; p = 0.016) and a similar incidence of overall postoperative complications (20% vs. 27%; p = 0.62). No difference was detected between LDLT and DDLT patients regarding graft survival at 1 (80% vs. 82%), at 3 (69% vs. 76%) and 5 years (65% vs. 76%) (p = 0.63), as well as patient survival at 1 (83% vs. 82%), 3 (72% vs. 77%) and 5 years (72% vs. 77%) (p = 0.93). The incidence of chronic kidney disease post-LT (10% vs. 6%; p = 0.4) was similar between both groups. LDLT results in identical long-term outcome when compared with DDLT in patients with HRS., (© Copyright 2014 The American Society of Transplantation and the American Society of Transplant Surgeons.)

Background: A standardized definition of post-hepatectomy haemorrhage (PHH) has not yet been established., Methods: An international study group of hepatobiliary surgeons from high-volume centres was convened and a definition of PHH was developed together with a grading of severity considering the impact on patients' clinical management., Results: The definition of PHH varies strongly within the hepatic surgery literature. PHH is defined as a drop in haemoglobin level > 3 g/dl post-operatively compared with the post-operative baseline level and/or any post-operative transfusion of packed red blood cells (PRBC) for a falling haemoglobin and/or the need for radiological intervention (such as embolization) and/or re-laparotomy to stop bleeding. Evidence of intra-abdominal bleeding should be obtained by imaging or blood loss via the abdominal drains if present. Transfusion of up to two units of PRBC is considered as being Grade A PHH. Grade B PHH requires transfusion of more than two units of PRBC, whereas the need for invasive re-intervention such as embolization and/ or re-laparotomy defines Grade C PHH., Conclusion: The proposed definition and grading of severity of PHH enables valid comparisons of results from different studies. It is easily applicable in clinical routine and should be applied in future trials to standardize reporting of complications., (© 2011 International Hepato-Pancreato-Biliary Association.)

Donor safety is the paramount concern of living donor liver transplantation (LDLT). Although LDLT is employed worldwide, there is little data on rates and causes of 'no go' hepatectomies-patients brought to the operating room for possible donor hepatectomy whose procedure was aborted. We performed a single-center, retrospective review of all patients brought to the operating room for donor hepatectomy between October 2000 and November 2008. Of 257 right lobe donors, the donor operation was aborted in 12 cases (4.7%). The main reasons for stopping the operation were aberrant ductal or vascular anatomy (seven cases), unsuitable liver quality (three cases) or unexpected intraoperative events (two cases). Over the median period of follow-up of 23 months, there were no long-term complications of patients with aborted donor procedures. This report focuses exclusively on an important issue: the frequency and causes of no go decisions at a single large volume North American LDLT center. The rate of no go donor hepatectomies should be as low as possible without compromising donor safety--however, even with rigorous preoperative evaluation the rate of donor abortions will be significant. The default surgical position should always be to abort the donor operation if there is an unexpected finding that places the donor at increased risk.

Right lobe living donor liver transplantation is an effective treatment for selected individuals with end-stage liver disease. Although 1 year donor morbidity and mortality have been reported, little is known about outcomes beyond 1 year. Our objective was to analyze the outcomes of the first 202 consecutive donors performed at our center with a minimum follow-up of 12 months (range 12-96 months). All physical complications were prospectively recorded and categorized according to the modified Clavien classification system. Donors were seen by a dedicated family physician at 2 weeks, 1, 3 and 12 months postoperatively and yearly thereafter. The cohort included 108 males and 94 females (mean age 37.3 +/- 11.5 years). Donor survival was 100%. A total of 39.6% of donors experienced a medical complication during the first year after surgery (21 Grade 1, 27 Grade 2, 32 Grade 3). After 1 year, three donors experienced a medical complication (1 Grade 1, 1 Grade 2, 1 Grade 3). All donors returned to predonation employment or studies although four donors (2%) experienced a psychiatric complication. This prospective study suggests that living liver donation can be performed safely without any serious late medical complications and suggests that long-term follow-up may contribute to favorable donor outcomes.

Right lobe living donor liver transplantation (RLDLT) is not yet a fully accepted therapy for patients with end-stage liver failure in the Western hemisphere because of concerns about donor safety and inferior recipient outcomes. An outcome analysis from the time of listing for all adult patients who were listed for liver transplantation (LT) at our center was performed. From 2000 to 2006, 1091 patients were listed for LT. One hundred fifty-four patients (LRD; 14%) had suitable live donors and 153 (99%) underwent RLDLT. Of the remaining patients (DD/Waiting List; n = 937), 350 underwent deceased donor liver transplant (DDLT); 312 died or dropped off the waiting list; and 275 were still waiting at the time of this analysis. The LRD group had shorter mean waiting times (6.0 months vs. 9.8 months; p < 0.001). Although medical model for end-stage liver disease (MELD) scores were similar at the time of listing, MELD scores at LT were significantly higher in the DD/Waiting List group (15.4 vs. 19.5; p = 0.002). Patients in Group 1 had a survival advantage with RLDLT from the time of listing (1-year survival 90% vs. 80%; p < 0.001). To our knowledge, this is the first report to document a survival advantage at time of listing for RLDLT over DDLT.

Many centers are reluctant to use older donors (>44 years) for adult right-lobe living donor liver transplantation (RLDLT) due to concerns about possible increased morbidity in donors and poorer outcomes in recipients. Since 2000, 130 adult RLDLTs have been performed at our institution. Recipients were divided into those who received a right lobe graft from a donor 44 (n = 41, 32%; mean age 52). The two donor and recipient populations had similar demographic and operative profiles. With a median follow-up of 29 months, the severity and number of complications in older donors were similar to those in younger donors. No living donor died. Older donor allografts had initial allograft dysfunction compared to younger donors. Complication rates were similar among recipients in both groups but there was a higher bile duct stricture rate with older donor grafts (27% vs. 12%; p = 0.04). One-year recipient graft survival was 86% for older donors and 85% for younger donors (p = 0.95). Early experience with the use of selected older adults (>44 years) for RLDLT is encouraging, but may be associated with a higher rate of biliary complications in the recipient.

Biliary strictures remain the most challenging aspect of adult right lobe living donor liver transplantation (RLDLT). Between 04/2000 and 10/2005, 130 consecutive RLDLTs were performed in our center and followed prospectively. Median follow-up was 23 months (range 3-67) and 1-year graft and patient survival was 85% and 87%, respectively. Overall incidence of biliary leaks (n = 19) or strictures (n = 22) was 32% (41/128) in 33 patients (26%). A duct-to-duct (D-D) or Roux-en-Y (R-Y) anastomosis were performed equally (n = 64 each) with no difference in stricture rate (p = 0.31). The use of ductoplasty increased the number of grafts with a single duct for anastomosis and reduced the biliary complication rate compared to grafts >/=2 ducts (17% vs. 46%; p = 0.02). Independent risk factors for strictures included older donor age and previous history of a bile leak. All strictures were managed nonsurgically initially but four patients ultimately required conversion from D-D to R-Y. Ninety-six percent (123/128) of patients are currently free of any biliary complications. D-D anastomosis is safe after RLDLT and provides access for future endoscopic therapy in cases of leak or stricture. When presented with multiple bile ducts, ductoplasty should be considered to reduce the potential chance of stricture.

Drawn as a conclusion to the colloquium of Bordeaux (June 2003), on mother-child attachment, these reflections open up to new venues. Indeed, the author makes the assumption that attachment and detachment make up a fundamental couple with attachment and detachment, which leads to getting one's autonomy, discovering the world and expressing one's pulsions. The very tension inside this antagonistic and fundamental couple--between attachment and pulsions--would be the origin of all forms of language.

Objectives: 1) To characterize the presence of interleukin-1 alpha (IL-1 alpha), interleukin-1 beta (IL-1 beta), interleukin-6 (IL-6), and tumor necrosis factor-alpha (TNF-alpha) in the vagina during pregnancy and in labor; 2) to compare the vaginal levels of these inflammatory cytokines between laboring and nonlaboring patients; and 3) to compare the vaginal levels of these cytokines between women with and without bacterial vaginosis (BV)., Methods: Vaginal fluid was obtained by lavage from pregnant women with intact membranes at various gestational ages and during labor at term. These samples were analyzed for specific cytokine levels using standard enzyme-linked immunosorbent assay techniques. A Gram stain, wet mount, and pH were obtained from the vaginal fluid and were used to diagnose BV. The Mann-Whitney U test was used to evaluate the individual cytokine levels between groups, with P < .05 considered statistically significant., Results: There was a wide range of vaginal cytokine levels found in our pregnant population (N = 72). Vaginal levels of IL-1 beta (median 1070 versus 245.7 pg/mL) and IL-6 (9.0 versus 0 pg/mL) were found to be significantly elevated in laboring patients as compared with nonlaboring patients (P = .005 and P = .002, respectively). There were no significant differences in the levels of IL-1 alpha and TNF-alpha between the laboring and nonlaboring women. Interleukin-1 beta was also found to be significantly elevated in the group of patients with BV (3364 versus 245.7 pg/mL; P = .01), particularly those who were nonlaboring (P = .003). In each individual patient, there was a wide variation in the levels of the four different cytokines., Conclusions: Measurable levels of the inflammatory cytokines IL-1 alpha, IL-1 beta, IL-6, and TNF-alpha were present in the vagina during pregnancy and labor. Vaginal levels of IL-1 beta and IL-6 were found to be significantly elevated in laboring patients as compared with nonlaboring patients. Vaginal levels of IL-1 beta were also significantly elevated in nonlaboring patients with BV.

Objective: Our purpose was to determine whether maternal serum interleukin-6 concentrations are elevated in patients with preterm premature rupture of membranes and intrauterine infection., Study Design: By use of a sensitive enzyme-linked immunosorbent assay maternal serum interleukin-6 concentrations were measured in 110 samples from patients at 22 to 34 weeks gestation with the following conditions: nonlaboring, uninfected controls (n = 46), preterm premature rupture of membranes > 48 hours before delivery without infection (n = 27), preterm premature rupture of membranes 24 to 48 hours before delivery with subsequent clinical or histologic infection (n = 11), and preterm premature rupture of membranes < 24 hours before delivery with infection present by clinical or histologic criteria (n = 26). The Mann-Whitney U test was used for statistical analysis., Results: Compared with that of nonlaboring controls, serum interleukin-6 was significantly higher in patients with preterm premature rupture of membranes < 24 hours before delivery with evidence of infection (17.2 vs 1.6 pg/ml, p < 0.0001). Patients with preterm premature rupture of membranes 24 to 48 hours before delivery who had infection had significantly higher interleukin-6 concentrations than did nonlaboring controls (3.6 vs 1.6 pg/ml, p = 0.006). There was no significant difference in interleukin-6 concentrations in nonlaboring controls compared with patients with preterm premature rupture of membranes when serum was obtained > 48 hours before delivery (1.6 vs 1.6 pg/ml, p = 0.90). A serum interleukin-6 level > or = 8 pg/ml yielded a sensitivity of 81%, a specificity of 99%, a positive predictive value of 96%, and a negative predictive value of 95% for identifying intrauterine infection in patients with preterm premature rupture of membranes on the day of delivery., Conclusions: Maternal serum interleukin-6 concentrations are elevated in patients with preterm premature rupture of membranes with clinical or histologic chorioamnionitis.

Objective: To better understand the role of the antiinflammatory cytokine interleukin-10 in preterm labor and infection, we evaluated the amniotic fluid interleukin-10 concentrations through pregnancy, in term, and in preterm labor., Study Design: Amniotic fluid interleukin-10 levels were measured in 147 women throughout pregnancy including patients in the second trimester, patients at term with and without labor, and in patients in preterm labor with and without an intrauterine infection. We compared the amniotic fluid interleukin-10 concentrations among these five groups using the Mann-Whitney U test., Results: Amniotic fluid interleukin-10 was detected in 70% to 91% of patients in each of the five study groups. Higher concentrations were found at term compared with the second trimester (p < 0.001) and concentrations were significantly greater in patients with preterm labor and intrauterine infection compared with those patients in preterm labor without infection (p < 0.001), patients at term in labor (p < 0.001), or patients at term not in labor (p < 0.001). When the patients in preterm labor with infection were analyzed by gestational age, those patients at < 30 weeks had significantly higher amniotic fluid concentrations of interleukin-10 (p = 0.014)., Conclusions: Interleukin-10 was present in the amniotic fluid of the majority of pregnancies, with higher concentrations found at term compared with the second trimester. Intrauterine infection was associated with significantly increased concentrations, with even higher concentrations found in the very premature pregnancies. Interleukin-10 has a prominent yet undefined role in pregnancy and preterm labor complicated by intrauterine infection.

Objective: The purpose of this study was to evaluate the ability of a low amniotic fluid glucose level, as defined by previously published thresholds, to identify a subclinical intrauterine infection in women in preterm labor with intact membranes., Study Design: Amniotic fluid glucose levels, amniotic fluid cultures, and placental histologic characteristics were determined in women with preterm labor (n = 55) and in preterm controls (n = 58). These amniotic fluid glucose levels were compared between women with and without intrauterine infection using the Mann-Whitney U test. The sensitivity, specificity, and positive and negative predictive values for the identification of an intrauterine infection were determined with four different previously published amniotic fluid glucose threshold levels and the threshold from receiver-operator characteristic curve analysis of the study data., Results: The median amniotic fluid glucose level was significantly lower in patients with positive amniotic fluid cultures (intraamniotic infection group) but was not lower in the group of patients with only histologic chorioamnionitis (extra-amniotic infection group), compared with noninfected controls. The sensitivity of a low amniotic fluid glucose level to detect both types of intrauterine infection ranged from 41% to 55%, depending on the threshold used. The specificity of a low amniotic fluid glucose level to detect an intrauterine infection ranged from 94% to 100%, the positive predictive value ranged from 86% to 100%, and the negative predictive value ranged from 70% to 80% with the same thresholds., Conclusion: Low amniotic fluid glucose levels are a specific but not a sensitive marker for either intraamniotic or extra-amniotic intrauterine infections in patients with preterm labor.

Objectives: Our purpose was (1) to determine the frequency of intraamniotic and extraamniotic intrauterine infection in patients with premature labor and intact membranes and (2) to determine if intrauterine infection is associated with elevated amniotic fluid interleukin-6 levels., Study Design: Amniocentesis was performed on 57 patients in preterm labor and 201 controls at various gestational ages without labor and at term with labor. The amniotic fluid was evaluated with gram stain, cultures, and an enzyme-linked immunosorbent assay specific for interleukin-6. Placentas from study patients (n = 52) and term controls (n = 120) were analyzed., Results: The frequency of positive amniotic fluid cultures (intraamniotic intrauterine infection) was 10 of 57 (18%) in the preterm labor group and zero of 201 for controls. Histologic chorioamnionitis (extraamniotic intrauterine infection) was present in 21 of 24 (88%) of patients in preterm labor that failed tocolysis and 28 of 120 (23%) of term laboring controls. An amniotic fluid interleukin-6 level of > or = 600 pg/ml was 100% sensitive and 89% specific (positive predictive value 85%, negative predictive value 100%) for the identification of intrauterine infection., Conclusion: Interleukin-6 is a sensitive and specific marker for the identification of both intraamniotic and extraamniotic intrauterine infection in patients in preterm labor with intact membranes.

Objectives: Atosiban is a synthetic oxytocin antagonist that is currently undergoing dose-ranging clinical trials. To date, no data are available on the cardiovascular effects of combined oxytocin and vasopressin blockade during late pregnancy. Our aims were (1) to determine the effects of atosiban infusion on the maternal and fetal cardiovascular system and on uterine blood flow and (2) to determine the maternal pharmacokinetics and the rate of placental transfer of atosiban., Study Design: Five chronically catheterized pregnant sheep were treated with a 2-hour infusion of atosiban (300 micrograms.min-1) at 116 to 126 days' gestation. Maternal and fetal blood pressure and heart rate and uterine blood flow were measured before and during the infusion. Maternal and fetal arterial blood samples were obtained throughout the experiment for measurement of plasma atosiban levels and blood gas values., Results: No significant change in maternal cardiovascular parameters or uterine blood flow were observed. Similarly, no changes in fetal blood pressure and arterial blood gases were present during the infusion of the atosiban. Maternal plasma levels of atosiban reached a maximum of 585.2 +/- 82.2 (ng/ml mean +/- SD) at the end of the infusion and decreased biexponentially with a mean t1/2 alpha of 17 minutes and a mean t1/2 beta of 2.2 hours. Fetal plasma levels of atosiban were at or below the detection limit., Conclusion: Atosiban does not significantly affect maternal or fetal cardiovascular parameters when it is administered for 2 hours in late-pregnant sheep. Although significant levels were measured in maternal blood, negligible transfer to the fetus occurred.

Objective: The purpose of this study was to determine if cesarean delivery of the nonvertex second twin improved neonatal outcome., Study Design: We examined the maternal and neonatal records from 457 sets of twins delivered from 1985 to 1990. We compared 1- and 5-minute Apgar scores, umbilical artery and vein blood pH values, duration of neonatal hospitalization, the incidence and length of ventilation, intraventricular hemorrhage, birth trauma, and mortality rate between vertex and nonvertex second twins delivered either vaginally or by cesarean section., Results: The presentation and mode of delivery of the second twin was not associated with a significant difference in any of the outcome variables except for the 1-minute Apgar score, which was lower in the nonvertex group delivered vaginally., Conclusion: Our data do not support routine cesarean delivery for twins of any birth weight when the second twin is nonvertex.

Recurrence of hepatitis is a well-documented complication of hepatitis B liver disease, post-transplantation. It is well established also that the earliest hepatocellular change is the appearance of hepatitis B viral (HBV) markers and that the disease is rapidly progressive. In this article on 17 liver transplants in 16 HBV positive patients with long-term follow-ups (100-1234 days), the distinctive pathologic features of this disease are emphasized: the extreme viral load, the steatosis, and/or fibrosis. An attempt to quantitate the magnitude of the viral burden was made and the result was a staggering figure. In one patient, an estimated 10(18) HBV core particles were present in the liver. One of two patterns of progression were noted. In four patients in addition to the massive nuclear hepatitis B core antigen (HBcAg) and cytoplasmic hepatitis B surface antigen (HBsAg) positivity, superimposed hepatitic changes led to diffuse hepatic fibrosis (fibroviral hepatitis B); and in another six patients, extraordinary hepatocellular viral marker positivity and steatosis were the hallmarks (steatoviral hepatitis B). Steatosis is not usually considered a feature of HBV liver pathology. These results suggest that more than one type of posttransfusion recurrent hepatitis B liver disease exists pathologically.

To investigate the acute effect of sustained volume expansion in patients with chronic hepatic ascites, renal and hemodynamic studies were performed on six patients receiving the peritoneovenous shunt. Within 1 hr of shunt insertion, the cardiac output rose by 20% to 60% above the preoperative level and the renal blood flow by 70% to 300%. At the same time both the plasma renin activity and serum aldosterone levels fell to a mean of 34% of the preoperative levels. The urine output increased from fourfold to 38-fold, but the sodium excretion increased in only two of the six patients. The data show that the acute effect of sustained volume expansion is predominantly on water rather than on sodium excretion. This manoeuver acutely suppressed circulating renin and aldosterone levels; however, the blunted natriuretic response suggests that other factors are involved in the sodium retention in these patients.

Metabolic effects of increasing nitrogen intake during total parenteral nutrition (TPN) were studied in nine septic patients. The patients were given 5% dextrose (D5W) for 1 d. For the next 6 d they received total parenteral nutrition (TPN), at 1.35 times resting energy expenditure (REE), containing either 191 or 366 mg N/(kg.d) Non-protein calories were divided equally between glucose and lipid emulsion. Three patients were studied on both diets (n = 6 for each diet). On the high- but not the low-N diet were significant increases in protein oxidation, blood urea N, O2 consumption, and CO2 production. TPN normalized most plasma amino acid levels but intramuscular amino acids remained unchanged. Transient positive N balance occurred during days 1-3 on the high- but not the low-N intake; on days 5-6 N balance did not differ significantly from zero on either diet and the improvement (165 mg N/[kg.d]) was the same for both diets.