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Cameron R Taylor, Jennifer E Dominguez, Ashraf S Habib Department of Anesthesiology, Division of Women’s Anesthesia, Duke University, Durham, NC 27710, USACorrespondence: Ashraf S HabibDepartment of Anesthesiology, Division of Women’s Anesthesia, Duke University, 2301 Erwin Road, Durham, NC 27710, USATel +1 919 668 2024Fax +1 919 681 4698Email ashraf.habib@duke.eduAbstract: Obesity is a significant global health problem. It results in a higher incidence of complications for pregnant women and their neonates. Cesarean deliveries are more common in obese parturients as well. The increased burden of comorbidities seen in this population, such as obstructive sleep apnea, necessitates antepartum anesthetic consultation. These patients pose unique challenges for the practicing anesthesiologist and may benefit from optimization prior to delivery. Complications from anesthesia and overall morbidity and mortality are higher in this population. Neuraxial anesthesia can be challenging to place in the obese parturient, but is the preferred anesthetic for cesarean delivery to avoid airway manipulation, minimize aspiration risk, prevent fetal exposure to volatile anesthetic, and decrease risk of post-partum hemorrhage from volatile anesthetic exposure. Monitoring and positioning of these patients for surgery may pose specific challenges. Functional labor epidural catheters can be topped up to provide conditions suitable for surgery. In the absence of a working epidural catheter, a combined spinal epidural anesthetic is often the technique of choice due to relative ease of placement versus a single shot spinal technique as well as the ability to extend the anesthetic through the epidural portion. For cesarean delivery with a vertical supraumbilical skin incision, a two-catheter technique may be beneficial. Concern for thromboembolism necessitates early mobilization and a multimodal analgesic regimen can help accomplish this. In addition, thromboprophylaxis is recommended in this population after delivery—especially cesarean delivery. These patients also need close monitoring in the post-partum period when they are at increased risk for several complications.Keywords: obesity, neuraxial anesthesia, labor analgesia, cesarean delivery

Background: Obstructive sleep apnea is associated with increased dementia risk, yet its role in postoperative neurocognitive disorders is unclear. Here, we studied whether the severity of untreated obstructive sleep apnea is associated with the severity of postoperative neurocognitive disorder., Methods: In this single-center prospective cohort study, older noncardiac surgery patients aged 60 years and above underwent preoperative home sleep apnea testing, and pre- and postoperative delirium assessments and cognitive testing. Sleep apnea severity was determined using the measured respiratory event index (REI). Global cognitive change from before to 6 weeks (and 1 year) after surgery was used to measure postoperative neurocognitive disorder severity. Postoperative changes in individual cognitive domain performance along with subjective cognitive complaints and/or deficits in instrumental activities of daily living were used to measure postoperative neurocognitive disorder incidence., Results: Of 96 subjects who completed home sleep apnea testing, 58 tested positive for sleep apnea. In univariable analyses, sleep apnea severity was not associated with increased postoperative neurocognitive disorder severity at 6 weeks (global cognitive change ; [95% confidence interval [CI], -0.02 to 0.03]; P = .79) or 1-year after surgery (; [95% CI, -0.02 to 0.03]; P = .70). Adjusting for age, sex, baseline cognition, and surgery duration, sleep apnea severity remained not associated with increased postoperative neurocognitive disorder severity at 6 weeks (; [95% CI, -0.02 to 0.04]; P = .40) or 1-year after surgery (; [95% CI, -0.02 to 0.04]; P = .55). In a multivariable analysis, sleep apnea severity was not associated with postoperative neurocognitive disorder (either mild or major) incidence at 6 weeks (odds ratio [OR] = 0.89, [95% CI, 0.59-1.14]; P = .45) or 1-year postoperatively (OR = 1.01, [95% CI, 0.81-1.24]; P = .90). Sleep apnea severity was also not associated with postoperative delirium in univariable analyses (delirium incidence OR = 0.88, [95% CI, 0.59-1.10]; P = .37; delirium severity ; [95% CI, -0.02 to 0.03]; P = .79) or in multivariable analyses (delirium incidence OR = 1.07, [95% CI, 0.81-1.38]; P = .74; delirium severity OR = 0.95, [95% CI, 0.81-1.10]; P = .48)., Conclusions: In this older noncardiac surgery cohort, untreated sleep apnea was not associated with increased incidence or severity of postoperative neurocognitive disorder or delirium., Competing Interests: Conflicts of Interest, Funding: Please see DISCLOSURES at the end of this article., (Copyright © 2024 International Anesthesia Research Society.)

The issue of obesity continues to reach new levels globally, affecting individuals across the age continuum. Obesity in pregnancy is associated with myriad comorbidities which may negatively impact the fetus, particularly dysfunctional labor and failure to progress ending in unplanned cesarean delivery. Neuraxial anesthesia represents the gold standard for cesarean delivery anesthesia and is increasingly beneficial for obese patients due to the risk of difficult airway. Obese parturients demonstrate higher rates of venous thromboembolism and wound infections and appropriate prophylaxis strategies to prevent these complications is imperative. While neuraxial anesthesia is the preferred technique for peripartum analgesia and cesarean delivery anesthesia, procedures can be technically challenging in patients with obesity, and may require more time, longer needles, increased experience, or ultrasound guidance. There is some concern for respiratory depression with the administration of neuraxial opioids in patients with obesity which has culminated in the development of post-operative monitoring guidelines., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024. Published by Elsevier Ltd.)

Background: Weeksella virosa pneumonia is an infection that has been described as a healthcare-associated infection. This is a rare gram-negative anaerobic bacterium associated with the use of mechanical ventilation for a long period of time and is more frequent in immunosuppressed patients. This is the first case reported in the state of Veracruz and the second in Mexico., Case Presentation: We present the case of a 64-year-old female from Veracruz, Mexico who developed an infectious process in the right pelvic limb after a transcatheter aortic valve replacement procedure and subsequently developed sudden cardiorespiratory arrest requiring mechanical ventilation, with subsequent imaging studies demonstrating a pneumonic process associated with a nosocomial infection., Discussion and Conclusions: We should take into consideration that this pathogen affects not only adults with multiple comorbidities but also children with renal, hepatic, or oncological pathologies, as well as immunocompromised patients, who should be considered high-risk populations for W. virosa infection., (© 2023. The Author(s).)

Rattus norvegicus and Rattus rattus are commensal pest rodents, considered reservoirs and vectors of zoonotic pathogens. In livestock farms, the wide use of antimicrobials and their release into the environment lead to high long-term residual concentrations, which may in turn lead to the occurrence of antimicrobial resistance (AMR). Farm environments serve as AMR sources, resulting in the transmission of antimicrobial-resistant bacteria and their AMR genes of livestock origin into wildlife. This study aimed to analyse the profile of enterobacteria carrying AMR determinants in rats captured in livestock farms to determine their potential vectors as for the spread of AMR. To this end, 56 rats (52 R. norvegicus and 4 R. rattus) were live-trapped on 11 farms (pig, dairy, poultry and mixed farms) located in central Argentina, from spring 2016 to autumn 2017. From 50 of the R. norvegicus individuals and three of the R. rattus individuals found in 10 of the farms, we isolated 53 Escherichia coli and five Salmonella strains. Susceptibility to antimicrobials, genotypic profiles, minimal inhibitory concentration of colistin and the presence of mcr-1 and genes encoding extended-spectrum β-lactamase (ESBL) were determined. Of the 58 isolates not susceptible to different antimicrobial classes, 28 of the E. coli strains and two of the Salmonella strains were defined as multi-drug resistant (MDR). S. Westhampton and S. Newport recovered were not susceptible to ampicillin or all the cephems tested. One of the E. coli obtained showed resistance to colistin and harboured the mcr-1 gene, demonstrated by PCR and conjugation. In two ESBL-producing Salmonella isolated from rats, CTX-M-2 genes were responsible for the observed resistance to third-generation cephalosporins. The MDR E. coli isolates showed several different resistance patterns (23), although some of them were the same in different individuals and different farms, with six resistance patterns, evidencing the dispersion of strains. These findings suggest that rats play a role in the dissemination of AMR determinants between animal, humans and environmental reservoirs., (© 2023 Wiley-VCH GmbH. Published by John Wiley & Sons Ltd.)

Introduction: Subspecialty training in obstetric anesthesiology is associated with improved patient outcomes and reduced anesthesia-related morbidity and mortality. Despite this, the demand for fellowship-trained obstetric anesthesiologists far exceeds the supply. This survey study aimed to evaluate the perceived value of obstetric anesthesiology subspecialty training on career trajectory, job satisfaction, quality of life, and job autonomy., Methods: After Institutional Review Board approval, we conducted a cross-sectional study of fellowship-trained obstetric anesthesiologists in the United States of America. In March and April 2022, program directors of obstetric anesthesiology fellowships distributed an electronic survey link containing 29 multiple-choice questions to their program alumni. Survey content included respondent demographic characteristics, practice models, career information, and perceived value of an obstetric anesthesiology fellowship., Results: We surveyed 217/502 (43%) fellowship-trained obstetric anesthesiologists with a response rate of 158/217 (73%). Most worked in urban, academic, and level IV perinatal health centers. The majority believed an obstetric anesthesiology fellowship was "extremely beneficial" (77%), enhanced quality of life (84%), improved the quality of patient care (99%), and was influential in helping obtain their first post-training job (86%). The perceived value of the fellowship included an enhanced career trajectory, a sense of purpose, improved job satisfaction, a sense of work community, lower burnout, involvement in maternal health initiatives, increased mentorship, and departmental leadership., Conclusion: In this survey study, fellowship-trained obstetric anesthesiologists perceived a positive impact of fellowship training on career trajectory, job protection and autonomy, quality of life, and job satisfaction. This information may be meaningful to trainees considering pursuing a fellowship and a career in obstetric anesthesiology., Competing Interests: Declaration of interests The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023 Elsevier Ltd. All rights reserved.)

Over the past two decades, diagnostic point-of-care ultrasound (POCUS) has emerged as a rapid and non-invasive bedside tool for addressing clinical inquiries related to gastric content. One emerging concern pertains to patients about to undergo sedation and/or endotracheal intubation: the elevated risk of aspiration from the patient's stomach contents. Aspiration of gastric contents into the lungs poses a serious and potentially life-threatening complication. This occurs more frequently when the stomach is considered "full" and can be affected by the techniques employed for airway management, making it potentially preventable. To mitigate the risk of peri-procedural aspiration, two distinct medical specialties (anesthesiology and critical care medicine) have independently developed techniques to utilize ultrasonography for identifying patients requiring "full stomach" precautions. Due to these separate specialties, the work of each group remains relatively unfamiliar outside its respective field. This article presents descriptions of both techniques for gastric ultrasound. Furthermore, it explains how these approaches can complement each other when one of them falls short. Regarding image acquisition, the article covers the following topics: indications and contraindications, selection of the appropriate probe, patient positioning, and troubleshooting. The article also delves into image interpretation, complete with example images. Additionally, it demonstrates how one of the two techniques can be employed to estimate gastric fluid volume. Lastly, the article briefly discusses medical decision-making based on the findings of this examination.

The Society of Anesthesia and Sleep Medicine and the Society for Obstetric Anesthesia and Perinatology tasked an expert group to review existing evidence and to generate recommendations on the screening, diagnosis, and treatment of patients with obstructive sleep apnea during pregnancy. These recommendations are based on a systematic review of the available scientific evidence and expert opinion when scientific evidence is lacking. This guideline may not be appropriate for all clinical situations and patients, and physicians must decide whether these recommendations are appropriate for their patients on an individual basis. We recognize that not all pregnant people may identify as women. However, data on non-cisgendered pregnant patients are lacking, and many published studies use gender-binary terms; therefore, depending on the study referenced, we may refer to pregnant individuals as women. This guideline may inform the creation of clinical protocols by individual institutions that consider the unique considerations of their patient populations and the available resources., Competing Interests: Financial Disclosure Jennifer E. Dominguez is a member of the Board of Directors of the Society for Anesthesia and Sleep Medicine. Ashraf S. Habib has grants funded by Haisco USA, Pacira Pharmaceuticals, and Heron Therapeutics. He has served on a data safety monitoring or advisory board for MDoloris, Heron Therapeutics, and Vertex Therapeutics, and is on the Board of Directors for the Society of Obstetric Anesthesia and Perinatology. Bilgay Izci-Balserak has received honoraria from the World Sleep Day Research Symposium and research equipment from Itamar Medical, Ltd. Ellen Lockhart is a consultant for AMN Healthcare. Judette M. Louis has received an honorarium from Hologic, is a member of the medical advisory board for the Preeclampsia Foundation, and is an unpaid member of the Board of Trustees of the March of Dimes. Louise M. O'Brien has received grant support from the NIH, Star Legacy Foundation, ResMed, the American Academy of Sleep Medicine, and the American Sleep Medicine Foundation. She has received research equipment from Itamar Medical Ltd, and Smart Human Dynamics, and serves on the board of the Star Legacy Foundation. Christine Won has received consulting fees from EBSCO Dynamed, Flo.com , and Jazz Pharmaceuticals and honoraria from the Canadian Anesthesiology Society, and is on the Board of Directors of the Society of Anesthesia and Sleep Medicine. Ghada Bourjeily has received grant support from NHLBI, NICHD, and NICCH, consulting fees from EBSCO, and research equipment from Dreem, and serves on the Sleep Network and Women and Pulmonary advisory groups for Chest. The other authors did not report any potential conflicts of interest., (Copyright © 2023 by the American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. All rights reserved.)

Background: Previous studies of obstructive sleep apnea (OSA) risk in gravidas with chronic hypertension (cHTN) did not control for obesity as a risk factor for OSA. We therefore performed this study to evaluate whether OSA is more prevalent among gravidas with cHTN compared to normotensive gravidas matched for body mass index (BMI) and gestational age (primary outcome). We also assessed whether OSA is more severe when comorbid with cHTN in pregnancy (secondary outcome)., Methods: This was a single-center, prospective cohort study. Adult gravidas at 10-20 weeks of gestation, with and without cHTN, were enrolled and BMI matched. All subjects answered OSA screening questionnaires and underwent a home sleep test when they were between 10 and 20 weeks of gestation. Pregnancy outcomes were followed for all subjects. We performed univariable and multivariable logistic regression to model the relationship between cHTN status and OSA., Results: A total of 100 pregnant subjects (50 with cHTN and 50 normotensive) completed a home sleep test of 2 hours or more. There were no differences in demographic variables between the 2 groups, except that gravidas with cHTN were significantly older than normotensive subjects (mean ± standard deviation [SD] 34 ± 4 vs 30 ± 6 years; P < .001). OSA was more prevalent (64% vs 38%; P = .009; odds ratio [95% confidence interval (CI)] 2.90 [1.30-6.65]; P = .01) and more severe in gravidas with cHTN (moderate or severe OSA 59% vs 21%; P = .009). After controlling for age, we found no overall association between cHTN on OSA risk (adjusted odds ratio [95% CI] 2.22 [0.92-5.40]; P = .076). However, among gravidas older than 25 years of age, cHTN was associated with higher odds of OSA (adjusted odds ratio [95% CI], 2.64 [1.06-6.71], P = .038)., Conclusions: cHTN and age are important risk factors for OSA in gravidas. Gravidas with cHTN should be screened for OSA in early pregnancy. Future studies may validate screening tools that include cHTN and age, and investigate the role of OSA therapy in blood pressure control., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2022 International Anesthesia Research Society.)

Obesity is a worldwide epidemic and is associated with an increased risk of hypertension, diabetes, and obstructive sleep apnea. Pregnant patients with obesity experience a higher risk of maternal and fetal complications. Anesthesia also poses higher risks for obese parturients and may be more technically challenging due to body habitus. Safe anesthesia practice for these patients must take into consideration the unique challenges associated with the combination of pregnancy and obesity., Competing Interests: Disclosure The authors have nothing to disclose., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Postpartum respiratory depression is a complex, multifactorial issue that encompasses a patient's baseline preexisting conditions, certain pregnancy-specific conditions or complications, as well as the iatrogenic element of various medications given in the peripartum period. In this review, we discuss many of these factors including obesity, sleep-disordered breathing, chronic lung disease, neuromuscular disorders, opioids, preeclampsia, peripartum cardiomyopathy, postpartum hemorrhage, amniotic fluid embolism, sepsis, acute respiratory distress syndrome (ARDS), and medications such as analgesics, sedatives, anesthetics, and magnesium. Current recommendations for screening, treatment, and prevention are also discussed., Competing Interests: Disclosure The authors have nothing to disclose., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Objectives: Dexamethasone has been shown to have analgesic properties in the general surgical population. However, the analgesic effects for women that undergo cesarean deliveries under spinal anesthesia remain unclear and may be related to the timing of dexamethasone administration. We hypothesized that intravenous dexamethasone administered before skin incision would significantly reduce postoperative opioid consumption at 24 h after cesarean delivery under spinal anesthesia with intrathecal morphine., Methods: Women undergoing elective cesarean deliveries under spinal anesthesia were randomly assigned to receive 8 mg of intravenous dexamethasone or placebo prior to skin incision. Both groups received a standardized spinal anesthetic and multimodal postoperative analgesic regime. The primary outcome was cumulative opioid consumption at 24 h. Secondary outcomes included cumulative opioid consumption at 48 h, time to first analgesic request, and pain scores at rest and on movement at 2, 24, and 48 h., Results: 47 patients were analyzed-23 subjects that received dexamethasone and 24 subjects that received placebo. There was no difference in the median (Q1, Q3) cumulative opioid consumption in the first 24 hours following cesarean delivery between the dexamethasone group {15 (7.5, 20.0) mg} and the placebo group {13.75 (2.5, 31.25) mg} ( P =0.740). There were no differences between the groups in cumulative opioid consumption at 48 h, time to first analgesic request, and pain scores., Conclusions: Intravenous dexamethasone 8 mg administered prior to skin incision did not reduce the opioid consumption of women that underwent cesarean deliveries under spinal anesthesia with intrathecal morphine and multimodal postoperative analgesic regimen., Competing Interests: The authors declare that they have no conflicts of interest., (Copyright © 2021 Jennifer E. Mehdiratta et al.)

Aims: The study was aimed to evaluate the antibacterial activity and efficacy of chestnut and quebracho wood extracts against Salmonella by in vitro assays and in vivo trials., Methods and Results: The extracts showed inhibitory activity against Salmonella determined by the minimum inhibitory concentration method as well as on the adhesion and invasion of S. Gallinarum (SG) and S. Enteritidis (SE) in Caco-2 cells. Also, transmission electron microscopy revealed that extract-treated Salmonella showed disruption of cell walls and membranes, damage of the cytoplasm and tannin-protein aggregations. In addition, efficacy of the extracts to control SG and SE was evaluated in experimental infection trials in laying hens and broilers respectively. SE excretion was significantly reduced on days 5 (P < 0·01) and 12 (P < 0·025) only in the quebracho group. In the fowl typhoid infection model, hens that received the chestnut extract showed a significantly reduced mortality (P < 0·05)., Conclusions: Our results evidence that these alternative natural products may be a useful tool to control Salmonella in poultry., Significance and Impact of the Study: Salmonella is a zoonotic pathogen usually associated with poultry production. This study provides information about the mechanism of antibacterial effects of chestnut and quebracho wood extracts to control Salmonella in poultry., (© 2020 The Society for Applied Microbiology.)

In the last 10 years, Salmonella Heidelberg has been extensively isolated from poultry in several countries. In this context, molecular characterization is essential to understand whether the strains have entered the farms from a single or several sources. Thus, the aim of this study was to determine the genetic relationship and antimicrobial susceptibility of S. Heidelberg strains isolated between 2011 and 2012 from broiler farms belonging to three integrated poultry companies located in Argentina. The genetic relatedness of the S. Heidelberg isolates was determined by pulsed-field gel electrophoresis (PFGE), and resistance to 21 antimicrobials was determined by the disc diffusion method. The isolates were assigned to four PFGE patterns. Most of the strains showed 100% similarity and belonged to the same integrated poultry company. This PFGE pattern was also prevalent in S. Heidelberg strains isolated from humans in several provinces of Argentina, which suggests an epidemiological association between human and poultry strains. All the isolates were classified as multidrug-resistant (MDR), and no clear relationship was observed between PFGE and resistance patterns. S. Heidelberg strains may circulate among farms from the same integrated company due to common sources of contamination. To guarantee the safety of the poultry product for the consumers, holistic approaches including surveillance of Salmonella throughout the production chain together with control measures are crucial., (© 2021 Wiley-VCH GmbH.)

Salmonella spp. causes digestive clinical signs in horses. Foals and hospitalized animals are more susceptible to the disease. Nowadays, the report of multidrug-resistant Salmonella spp. producer of extended-spectrum β-lactamases, is more frequent. The aim of this work was to study the clonal relationship and antimicrobial susceptibility profiles among Salmonella ser. Typhimurium isolates, obtained during a salmonellosis outbreak in an Argentinian equine hospital. Thus, in 2017, we studied the genotypic profiles and the susceptibility to antimicrobials of the strains isolated from three animals with diarrhea in an equine hospital of Argentina. The pulsotype identified by pulsed-field gel electrophoresis was the same among the isolates. Also, this pulsotype had been previously detected in human and porcine isolates, suggesting the circulation of the same strains in different species. Multidrug-resistant isolates with different β-lactam susceptibility profiles were identified and bla CTX-M-14 was detected for the first time from an isolate of equine-origin in Argentina. Salmonella ser. Typhimurium is an important pathogen in public and veterinary health, so our results emphasize the relevance of appropriate measures to prevent and control this disease. Furthermore, routine antibiotic susceptibility tests of local strains are needed to improve the empiric treatment of equine salmonellosis., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Patients who suffer an unintentional dural puncture have a high risk of developing a post-dural puncture headache. Other neurologic complications have been reported, but seizure is rarely seen. We present a case of a 21-year-old primigravida who experienced an unrecognized unintentional dural puncture that ultimately resulted in a tonic-clonic seizure from intracranial hypotension one week following the dural breach. Her trachea was intubated and she was transferred to the intensive care unit. Two epidural blood patches, performed by neuroradiologists, were needed before the patient experienced complete resolution of her headache. During the re-admission, she also experienced a pulmonary embolus which further lengthened her hospital stay., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

Objective: To evaluate the efficacy of wound infusion with ropivacaine plus ketorolac compared with placebo for post-cesarean delivery analgesia in women who received a multimodal analgesic regimen including intrathecal morphine., Methods: In a randomized double-blind study, women undergoing scheduled cesarean delivery under spinal or combined spinal epidural anesthesia were randomized to wound infusion with ropivacaine 0.2% plus ketorolac, or saline placebo using an elastometric pump for 48 hours. The primary outcome was pain score with movement at 24 hours after surgery (0-10 scale, 0=no pain and 10=worst possible pain). Secondary outcomes included pain scores at rest at 24 hours, pain scores at rest and with movement at 2 and 48 hours, opioid consumption, and time to first rescue analgesic. A sample size of 35 per group (n=70) was planned., Results: From November 8, 2016, to May 17, 2019, 247 women were screened, and 71 completed the study per protocol: 38 in the placebo group and 33 in the ropivacaine plus ketorolac group. Patient demographics and intraoperative characteristics were comparable between the groups. There was no significant difference between the groups in the primary outcome of pain score with movement at 24 hours (difference in median score 0, 95% CI -1 to 2, P=.94). There were also no significant differences between the placebo and ropivacaine plus ketorolac groups in pain scores at other time points, in total opioid consumption (difference in median consumption -12.5 mg, 95% CI -30 to 5, P=.11), or in time to rescue analgesics (median [interquartile range] 660 [9-1,496] vs 954 [244-1,710] minutes, hazard ratio 0.69, 95% CI 0.41 to 1.17, P=.16)., Conclusion: There was no benefit of wound infusion with ropivacaine and ketorolac in women who received intrathecal morphine and a multimodal analgesic regimen., Clinical Trial Registration: ClinicalTrials.gov, NCT02829944., Funding Source: The study was supported in part by Avanos Medical Inc.

In this study, we found mcr-1.1 and mcr-1.5 genes carried by IncI2 plasmids in a subset of Escherichia coli isolates recovered from commercial broiler farms in Argentina. The comparative analysis of the sequences of these plasmids with those described in human clinical isolates suggests that this replicon-type is one of the main mcr -disseminator sources in Argentina.

Background: Obesity is prevalent among pregnant women in the United States; obstructive sleep apnea is highly comorbid with obesity and is associated with adverse pregnancy outcomes. Screening for obstructive sleep apnea in pregnant women has remained a challenge because of a lack of validated screening tools., Objective: The purpose of this study was to evaluate established obstructive sleep apnea screening tools, a sleepiness scale, and individual component items in a cohort of pregnant women with extreme obesity in mid pregnancy with the use of objective testing to determine obstructive sleep apnea status and to describe the prevalence of obstructive sleep apnea among women with extreme obesity., Study Design: Adult pregnant subjects, between 24 and 35 weeks gestation, with a body mass index ≥40 kg/m 2 at the time of enrollment completed obstructive sleep apnea screening tools (Berlin Questionnaire, American Society of Anesthesiologists checklist, and STOP-BANG questionnaire) and the Epworth Sleepiness Scale; they also underwent physical examination of the neck, mouth, and airway. The published obstructive sleep apnea in pregnancy prediction score was calculated for each subject. Obstructive sleep apnea status for each subject was determined by the results of an overnight, unattended type III home sleep apnea test., Results: Twenty-four percent of pregnant women with extreme obesity had obstructive sleep apnea on home sleep apnea testing in mid pregnancy (Apnea-Hypopnea Index, ≥5 events per hour]. Established obstructive sleep apnea screening tools performed very poorly to screen for obstructive sleep apnea in this cohort. Age, body mass index, neck circumference, frequently witnessed apneas, and highly likely to fall asleep while driving were associated most strongly with obstructive sleep apnea status in this cohort., Conclusion: We found that 24% of pregnant women with body mass index ≥40 kg/m 2 between 24 and 35 weeks gestation have obstructive sleep apnea, defined as Apnea-Hypopnea Index ≥5 events per hour on an overnight type III home sleep apnea test. We found the Berlin Questionnaire, American Society of Anesthesiologists checklist, STOP-BANG, obstructive sleep apnea in pregnancy score by Facco et al, and the Epworth Sleepiness Scale were not useful screening tools for obstructive sleep apnea in a cohort of obese pregnant women. However, age, body mass index, neck circumference, frequently witnessed apneas, and likely to fall asleep while driving were associated with obstructive sleep apnea in this cohort. Further studies are needed to adjust the criteria and thresholds within the available screening tools to better predict obstructive sleep apnea in pregnant women with obesity., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Obesity is prevalent among pregnant women in the United States; 15-20% of obese pregnant women have obstructive sleep apnea. The prevalence of obstructive sleep apnea increases along with body mass index, age and in the presence of other co-morbidities. Untreated obstructive sleep apnea in women is associated with a range of cardiovascular, pulmonary and metabolic co-morbidities; recent studies suggest that women with obstructive sleep apnea in pregnancy may be at significantly greater risk of entering pregnancy with chronic hypertension and/or of developing hypertensive disorders of pregnancy: gestational hypertension; preeclampsia; or eclampsia. This has serious public health implications; hypertensive disorders of pregnancy are a major cause of maternal and neonatal morbidity and mortality and are associated with a greater lifetime risk for cardiovascular disease. The mechanisms that associated obstructive sleep apnea with hypertensive disorders of pregnancy have not been defined, but several pathways are scientifically plausible. In this review, we will present a comprehensive literature review of the following: the associations between obstructive sleep apnea and hypertensive disorders of pregnancy; the proposed mechanisms that may connect obstructive sleep apnea and hypertensive disorders of pregnancy; and the effectiveness of treatment at mitigating these adverse outcomes., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

Among obese pregnant women, 15%-20% have obstructive sleep apnea (OSA) and this prevalence increases along with body mass index and in the presence of other comorbidities. Prepregnancy obesity and pregnancy-related weight gain are certainly risk factors for sleep-disordered breathing in pregnancy, but certain physiologic changes of pregnancy may also increase a woman's risk of developing or worsening OSA. While it has been shown that untreated OSA in postmenopausal women is associated with a range of cardiovascular, pulmonary, and metabolic comorbidities, a body of literature is emerging that suggests OSA may also have serious implications for the health of mothers and fetuses during and after pregnancy. In this review, we discuss the following: pregnancy as a vulnerable period for the development or worsening of OSA; the associations between OSA and maternal and fetal outcomes; the current screening modalities for OSA in pregnancy; and current recommendations regarding peripartum management of OSA.

The use of antimicrobial growth promoters (AGPs) in sub-therapeutic doses for long periods promotes the selection of resistant microorganisms and the subsequent risk of spreading this resistance to the human population and the environment. Global concern about antimicrobial resistance development and transference of resistance genes from animal to human has been rising. The goal of our research was to evaluate the susceptibility pattern to different classes of antimicrobials of colistin-resistant Escherichia coli from poultry production systems that use AGPs, and characterize the resistance determinants associated to transferable platforms. E. coli strains ( n = 41) were obtained from fecal samples collected from typical Argentine commercial broiler farms and susceptibility for 23 antimicrobials, relevant for human or veterinary medicine, was determined. Isolates were tested by PCR for the presence of mcr-1 , extended spectrum β-lactamase encoding genes and plasmid-mediated quinolone resistance (PMQR) coding genes. Conjugation and susceptibility patterns of the transconjugant studies were performed. ERIC-PCR and REP-PCR analysis showed a high diversity of the isolates. Resistance to several antimicrobials was determined and all colistin-resistant isolates harbored the mcr-1 gene. CTX-M-2 cefotaximase was the main mechanism responsible for third generation cephalosporins resistance, and PMQR determinants were also identified. In addition, co-transference of the qnrB determinant on the mcr-1 -positive transconjugants was corroborated, which suggests that these resistance genes are likely to be located in the same plasmid. In this work a wide range of antimicrobial resistance mechanisms were identified in E. coli strains isolated from the environment of healthy chickens highlighting the risk of antimicrobial abuse/misuse in animals under intensive production systems and its consequences for public health.

The spectrum of sleep-disordered breathing (SDB) ranges from mild snoring to obstructive sleep apnea, the most severe form of SDB. Current recommendations are to treat these women with continuous positive airway pressure despite limited data. SDB in early and mid-pregnancy is associated with preeclampsia and gestational diabetes. Pregnant women with a diagnosis of obstructive sleep apnea at delivery were at significantly increased risk of having cardiomyopathy, congestive heart failure, pulmonary embolism, and in-hospital death. These effects were exacerbated in the presence of obesity. Postpartum, these women are at risk for respiratory suppression and should be monitored., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Purpose: Hypotension is common after spinal anesthesia for Cesarean delivery. It is associated with nausea, vomiting, and fetal acidosis. Previous research on phenylephrine excluded obese subjects. We compared the incidence of intraoperative nausea and vomiting (IONV) in obese patients who received a prophylactic phenylephrine infusion vs those who received bolus dosing for the treatment of spinal-induced hypotension., Methods: In this multicentre, double-blinded randomized controlled trial, 160 obese women undergoing elective Cesarean delivery under spinal anesthesia were randomized to receive a prophylactic phenylephrine infusion initiated at 50 μg·min -1 (and titrated according to a predefined algorithm) or 100 μg phenylephrine boluses to treat hypotension. Maternal systolic blood pressure was maintained within 20% of baseline. The primary study outcome was the incidence of IONV., Results: Intraoperative nausea and vomiting were significantly reduced in the infusion group compared to the bolus group (46% vs 75%, respectively; relative risk [RR], 0.61; 95% confidence interval [CI], 0.47 to 0.80; P < 0.001). This was associated with significantly reduced need for intraoperative rescue antiemetics (26% vs 42%, respectively; RR, 0.62; 95% CI, 0.40 to 0.97; P = 0.04), but no difference in the incidence of vomiting. Postoperative vomiting at two hours was reduced in the infusion group (11% vs 25%; RR, 0.44; 95% CI, 0.21 to 0.90; P = 0.02);however, there were no differences in the incidence or severity of postoperative nausea, need for rescue antiemetics at two hours and 24 hr, or the incidence of postoperative vomiting at 24 hr., Conclusion: In obese women undergoing Cesarean delivery with spinal anesthesia, prophylactic phenylephrine infusion was associated with less intraoperative nausea, less need for rescue antiemetics, and reduced early postoperative vomiting., Trial Registration: www.clinicaltrials.gov (NCT01481740). Registered 22 July 2011.

Background: Single-incision laparoscopic cholecystectomy has emerged as an alternative to conventional multiport laparoscopic cholecystectomy (LC). Technical difficulty, prolonged surgical times and increased complication rates have been reported in single-incision laparoscopic surgery. One of the concerns is lack of triangulation of instruments. The SPIDER ® surgical system is a single-incision laparoscopic device that utilizes flexible instruments with the purpose of achieving adequate triangulation. The purpose of this study is to compare the outcomes of SPIDER versus LC., Methods: A retrospective chart review of patients who underwent LC and SPIDER cholecystectomy by a single surgeon during a concurrent 44-month period at Baptist Health South Florida hospitals was performed focusing on demographics, indication for surgery, complications and incisional hernia rates. Exclusion criteria were concomitant surgery and hernia repair at the time of surgery., Results: A total of 612 patients underwent minimally invasive cholecystectomy: 279 cases for SPIDER cholecystectomy and 333 for multiport LC. Baseline differences in patient characteristics between the SPIDER and LC groups were statistically significant. The SPIDER group had younger and healthier patients (lower ASA classification scores) with predominant diagnosis of cholelithiasis (69 %) compared to the LC group which had more complex cases. Total complications rate for both SPIDER and LC were 0.4 % (n = 1) and 3 % (n = 10), respectively. Conversion to open cholecystectomy occurred in one patient from the LC group (0.3 %). Conversion rate from SPIDER to additional ports or LC was performed in 5 cases (1.8 %) with no conversions to open surgery. Hemoperitoneum was reported in 2 cases, one for each approach, requiring reoperation., Conclusion: Single-incision laparoscopic cholecystectomy with SPIDER is a safe and feasible technique with similar outcomes to multiport LC. However, statistical significant difference was reported in baseline characteristics of both groups. No incisional hernias were reported in this case series for either technique.

Background: With the growth of the discipline of laparoscopic surgery, technology has been further developed to facilitate the performance of minimally invasive hernia repair. Most of the published literature regarding robotic inguinal hernia repair has been performed by urologists who have dealt with this entity in a concomitant way during radical prostatectomies. General surgeons, who perform the vast majority of inguinal herniorrhaphies worldwide, have yet to describe the role of robotic inguinal hernia repair. Here, we describe our initial experience and create the foundation for future research questions regarding robotic inguinal hernia repair., Methods: A retrospective chart review was performed in 78 patients who underwent robotic transabdominal preperitoneal TAPP inguinal hernia repair with a prosthetic mesh using the da Vinci platform (Intuitive Surgical Inc). Data collected included patient demographics, past medical history, previous surgeries, details related to the surgical procedure, perioperative outcomes and complications., Results: A total of 123 hernias were repaired. Forty-five patients had bilateral robotic inguinal herniorrhaphies, and the mean age was 55.1 years (SD 15.1), with a mean BMI of 27.6 (SD 6.1). There were 71 male and 7 female patients. Surgical complications included hematoma in three patients (3.9 %), two seromas (2.6 %) and one superficial surgical site infection at a trocar site (1.3 %), which resolved with oral antibiotics. Chronic postoperative complications (>30 days post-surgery) included the persistence of hematomas in two patients (2.6 %). Same day discharge was achieved in 60 patients (76.9 %) with a mean length of stay of 8 h (SD 2.65). Neither mortality nor conversion to open surgery occurred., Conclusion: Our early experience has demonstrated that the robotic transabdominal preperitoneal (TAPP) inguinal hernia repair is a safe and versatile approach that allows the general surgeon to perform this procedure in more complex cases such as those involving incarcerated and/or recurrent hernias.

Abnormal placentation can be associated with significant blood loss and massive blood transfusions. Caring for parturients with abnormal placentation who refuse blood transfusion is very challenging. We present a 35-year-old, gravida 3, para 1, Jehovah's Witness at 35 weeks of gestation with placenta percreta, who underwent cesarean delivery and delayed hysterectomy. A multidisciplinary team developed a plan, including the use of perioperative erythropoietin and IV iron dextran, intraoperative acute normovolemic hemodilution, cell salvage, tranexamic acid, and uterine artery embolization. This strategy was successful in avoiding the need for allogeneic transfusion and ensuring an uneventful recovery after both surgical procedures.

Necrotic enteritis (NE) is an important concern in poultry industry since it causes economic losses, increased mortality, reduction of bird welfare, and contamination of chicken products for human consumption. For decades, the use of in-feed antimicrobial growth promoters (AGPs) has been the main strategy to control intestinal pathogens including Clostridium perfringens (CP), the causative agent of NE. However, the use of AGPs in animal diet has been linked to the emergence and transmission of antimicrobial resistance through food-borne microorganisms, which has led to the ban of AGPs in many countries. This scenario has challenged the poultry industry to search for safer alternative products in order to prevent NE. In this context, the utilization of natural plant extracts with antimicrobial properties appears as a promising and feasible tool to control NE in chicken. In this paper, we review the scientific studies analyzing the potential of plant extracts as alternative feed additives to reduce NE in poultry, with focus on two types of plant products that arise as promising candidates: tannins and essential oils. Some of these products showed antimicrobial activity against CP and coccidia in vitro and in vivo and are able to increase productive performance, emulating the bioactive properties of AGPs., Competing Interests: Some of the authors provide consulting services to companies related to poultry nutrition.

New technologies have been developed to make laparoscopic cholecystectomy less invasive through single incision laparoscopic surgery (SILS), however this approach has its own limitations. Single incision robotic surgery (SIRC) is designed to overcome them. The concerns that limit adoption of this technology are attributed increases in costs, prolonged learning curves and surgical times. Here, we provide a literature review as well as our own experience with SIRC, with the intent to clarify these important concerns., (© 2015 Wiley Periodicals, Inc.)

Inguinal hernias have been described throughout the history of medicine with many efforts to achieve the cure. Currently, with the advantages of minimally invasive surgery, new questions arise: what is going to be the best approach for inguinal hernia repair? Is there a real benefit with the robotic approach? Should minimally invasive hernia surgery be the standard of care? In this report we address these questions by describing our experience with robotic inguinal hernia repair., (© 2015 Wiley Periodicals, Inc.)

Tannins added in the diet are being used to improve nutrition and health in farm animals as an alternative to antibiotic growth promoters and to control enteric clostridial diseases. However, the capacity of Clostridium perfringens to develop resistance under the selective pressure of tannins is unknown. The purpose of this study was to determine if C. perfringens possess the ability to develop resistance against tannins in comparison with antimicrobial agents. Susceptibility for 7 AGPs (antimicrobial growth promoters), 9 therapeutic antimicrobials and 2 tannin based extracts was determined for 30 C. perfringens strains isolated from poultry and cattle. Two susceptible strains were selected and cultured in presence of sub-inhibitory concentrations of tannins and AGPs for resistant sub-populations selection. Tannin resistance of C. perfringens isolates from both animal species revealed no statistically significant differences in MICs (minimum inhibitory concentration). Poultry isolates showed higher MICs to several AGPs compared with cattle isolates. All isolates were susceptible to the therapeutic antimicrobials tested, but avian isolates showed a significantly lower susceptibility to these antimicrobials which was highly correlated with an increased resistance to bacitracin and others AGPs. In-vitro selection of resistant clones suggests that C. perfringens was unable to develop resistance against tannins at least compared to AGPs like bacitracin and avilamycin. Avian origin strains, which were previously exposed to antibiotics showed higher resistance, compared to cattle origin strains. These results suggest that the evolution of resistance against tannins in C. perfringens would be more difficult and slower than to the determined AGPs., (Copyright © 2015 Elsevier Ltd. All rights reserved.)

Parturients with super-morbid obesity, defined as body mass index greater than 50kg/m(2), represent a growing segment of patients who require anesthetic care for labor and delivery. Severe obesity and its comorbid conditions place the parturient and fetus at greater risk for pregnancy complications and cesarean delivery, as well as surgical and anesthetic complications. The surgical approach for cesarean delivery in these patients may require a supra-umbilical vertical midline incision due to a large pannus. The dense T4-level of spinal anesthesia can cause difficulties with ventilation for the obese patient during the procedure, which can be prolonged. Patients also may have respiratory complications in the postoperative period due to pain from the incision. We describe the anesthetic management of three parturients with body mass index ranging from 73 to 95kg/m(2) who had a cesarean delivery via a supra-umbilical vertical midline incision. Continuous lumbar spinal and low thoracic epidural catheters were placed in each patient for intraoperative anesthesia and postoperative analgesia, respectively. Continuous spinal catheters were dosed with incremental bupivacaine boluses to achieve surgical anesthesia. In one case, the patient required respiratory support with non-invasive positive pressure ventilation. Two cases were complicated by intraoperative hemorrhage. All patients had satisfactory postoperative analgesia with a thoracic epidural infusion. None suffered postoperative respiratory complications or postdural puncture headache. The use of a continuous lumbar spinal catheter and a low thoracic epidural provides several advantages in the anesthetic management of super-morbidly obese parturients for cesarean delivery., (Copyright © 2015 Elsevier Ltd. All rights reserved.)

Antibiotics have been included in the formulation of feed for livestock production for more than 40 years as a strategy to improve feed conversion rates and to reduce costs. The use of antimicrobials as growth-promoting factors (AGP) in sub-therapeutic doses for long periods is particularly favorable for the selection of antimicrobial resistant microorganisms. In the last years, global concern about development of antimicrobial resistance and transference of resistance genes from animal to human strains has been rising. Removal of AGP from animal diets involves tremendous pressure on the livestock and poultry farmers, one of the main consequences being a substantial increase in the incidence of infectious diseases with the associated increase in the use of antibiotics for therapy, and concomitantly, economic cost. Therefore, alternatives to AGP are urgently needed. The challenge is to implement new alternatives without affecting the production performances of livestock and avoiding the increase of antimicrobial resistant microorganisms. Plant extracts and purified derived substances are showing promising results for animal nutrition, either from their efficacy as well as from an economical point of view. Tannins are plant derived compounds that are being successfully used as additives in poultry feed to control diseases and to improve animal performance. Successful use of any of these extracts as feed additives must ensure a product of consistent quality in enough quantity to fulfill the actual requirements of the poultry industry. Chestnut (hydrolysable) and Quebracho (condensed) tannins are probably the most readily available commercial products that are covering those needs. The present report intends to analyze the available data supporting their use.

Respiratory depression can occur after neuraxial morphine administration. In the obstetric population, there are little data on respiratory depression after neuraxial morphine administration in women undergoing cesarean delivery. In this single-center, retrospective study in 5036 obstetric patients (mean body mass index = 34 kg/m) who underwent cesarean delivery and received neuraxial morphine, we did not identify any instances of respiratory depression requiring naloxone administration or rapid response team involvement. Therefore, the upper 95% confidence limit for respiratory depression in our study is 0.07% (1 event per 1429 cases).