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Up to 2% of pregnant women develop a disease that requires nonobstetrical operative intervention during pregnancy. We discuss the issues unique to pregnant patients as they pertain to the presentation, diagnosis, and management of nonobstetric surgical disease, with an emphasis on 2 of the most common diseases that affect pregnant women: appendicitis and cholecystitis. Surgery has been demonstrated to be safe and effective during pregnancy, provided proper precautions are taken into account. It is the consensus of multiple professional committees and societies that no pregnant women should be delayed or denied a necessary surgery because of pregnancy.

OBJECTIVE The aim of this paper was to compare the severity of the initial neurological injury as well as the early changes in the American Spinal Injury Association (ASIA) motor score (AMS) between central cord syndrome (CCS) patients with and without an increased T2 signal intensity in their spinal cord. METHODS Patients with CCS were identified and stratified based on the presence of increased T2 signal intensity in their spinal cord. The severity of the initial neurological injury and the progression of the neurological injury over the 1st week were measured according to the patient's AMS. The effect of age, sex, congenital stenosis, surgery within 24 hours, and surgery in the initial hospitalization on the change in AMS was determined using an analysis of variance. RESULTS Patients with increased signal intensity had a more severe initial neurological injury (AMS 57.6 vs 75.3, respectively, p = 0.01). However, the change in AMS over the 1st week was less severe in patients with an increase in T2 signal intensity (−0.85 vs −4.3, p = 0.07). Analysis of variance did not find that age, sex, Injury Severity Score, congenital stenosis, surgery within 24 hours, or surgery during the initial hospitalization affected the change in AMS. CONCLUSIONS The neurological injury is different between patients with and without an increased T2 signal intensity. Patients with an increased T2 signal intensity are likely to have a more severe initial neurological deficit but will have relatively minimal early neurological deterioration. Comparatively, patients without an increase in the T2 signal intensity will likely have a less severe initial injury but can expect to have a slight decline in neurological function in the 1st week.

Out of the Straitjacket I see him, maybe not so clearly. He is in isolation, in a straitjacket. He’s just been committed, given a shot of haloperidol after he resisted going to the locked ward. He kicked, screamed, yelled, threatened…and now he cries.

To compare early changes in the ASIA Motor Score (AMS) between patients with central cord syndrome (CCS) from an acute fracture to patients without a fracture. Patients with CCS were identified and stratified based on the presence of a fracture. The AMS through the first week of the patients’ hospitalization was obtained. Initial injury severity as well as early neurologic recovery was measured using the AMS. Analysis of variance was performed to determine if age, gender, rectal tone at presentation, congenital stenosis, or surgery within 24 h significantly effected the change in AMS. A strong trend (p = 0.0504) towards a more severe initial neurologic injury in patients with a fracture (AMS 59.7) than in patients without a fracture (AMS 70.2) was identified. However, in the week after injury, patients with a fracture had an improvement in their neurologic function (ΔAMS +4.8) while patients without a fracture demonstrated neurologic decline (ΔAMS −5.9). The change in AMS between patients with and without a fracture was nearly significant (p = 0.06). Patients with central cord syndrome present with similar symptoms, but injuries with and without a fracture may be associated with a different early neurologic recovery. Patients with a fracture have a more severe injury at initial presentation, but tend to have neurologic improvement in the first week; conversely patients without a fracture have a less severe initial neurologic injury, but tend to have a slight decline in neurologic function over the first week.

Objective Our objective in this study was to extend diaphragmatic pacing therapy to include paraplegic patients with high cervical spinal cord injuries between C3 and C5. Introduction Diaphragmatic pacing has been used in patients experiencing ventilator-dependent respiratory failure due to spinal cord injury as a means to reduce or eliminate the need for mechanical ventilation. However, this technique relies on intact phrenic nerve function. Recently, phrenic nerve reconstruction with intercostal nerve grafting has expanded the indications for diaphragmatic pacing. Our study aimed to evaluate early outcomes and efficacy of intercostal nerve transfer in diaphragmatic pacing. Methods Four ventilator-dependent patients with high cervical spinal cord injuries were selected for this study. Each patient demonstrated absence of phrenic nerve function via external neck stimulation and laparoscopic diaphragm mapping. Each patient underwent intercostal to phrenic nerve grafting with implantation of a phrenic nerve pacer. The patients were followed, and ventilator dependence was reassessed at 1 year postoperatively. Results Our primary outcome was measured by the amount of time our patients tolerated off the ventilator per day. We found that all 4 patients have tolerated paced breathing independent of mechanical ventilation, with 1 patient achieving 24 hours of tracheostomy collar. Conclusions From this study, intercostal to phrenic nerve transfer seems to be a promising approach in reducing or eliminating ventilator support in patients with C3 to C5 high spinal cord injury.

Ventilator-dependent spinal cord-injured (SCI) patients require significant resources related to ventilator dependence. Diaphragm pacing (DP) has been shown to successfully replace mechanical ventilators for chronic ventilator-dependent tetraplegics. Early use of DP following SCI has not been described. Here, we report our multicenter review experience with the use of DP in the initial hospitalization after SCI.Under institutional review board approval for humanitarian use device, we retrospectively reviewed our multicenter nonrandomized interventional protocol of laparoscopic diaphragm motor point mapping with electrode implantation and subsequent diaphragm conditioning and ventilator weaning.Twenty-nine patients with an average age of 31 years (range, 17-65 years) with only two females were identified. Mechanism of injury included motor vehicle collision (7), diving (6), gunshot wounds (4), falls (4), athletic injuries (3), bicycle collision (2), heavy object falling on spine (2), and motorcycle collision (1). Elapsed time from injury to surgery was 40 days (range, 3-112 days). Seven (24%) of the 29 patients who were evaluated for the DP placement had nonstimulatable diaphragms from either phrenic nerve damage or infarction of the involved phrenic motor neurons and were not implanted. Of the stimulatable patients undergoing DP, 72% (16 of 22) were completely free of ventilator support in an average of 10.2 days. For the remaining six DP patients, two had delayed weans of 180 days, three had partial weans using DP at times during the day, and one patient successfully implanted went to a long-term acute care hospital and subsequently had life-prolonging measures withdrawn. Eight patients (36%) had complete recovery of respiration, and DP wires were removed.Early laparoscopic diaphragm mapping and DP implantation can successfully wean traumatic cervical SCI patients from ventilator support. Early laparoscopic mapping is also diagnostic in that a nonstimulatable diaphragm is a convincing evidence of an inability to wean from ventilator support, and long-term ventilator management can be immediately instituted.Therapeutic study, level V.

OBJECTIVE This study aims to develop a Respiratory Failure Risk Score (RFRS) with good predictability for elective abdominal and vascular patients to be used in the outpatient setting for risk stratification and to guide preoperative pulmonary optimization. SUMMARY BACKGROUND DATA Postoperative respiratory failure (RF), defined as ventilator dependency for more than 48 hours or unplanned reintubation within 30 days, is associated with increased mortality and hospital costs. Many tools have been previously described for risk stratification, but few target elective surgical candidates. METHODS Our training sample included patients undergoing inpatient, nonemergent general and vascular procedures sampled for the American College of Surgeon National Surgical Quality Improvement Program 2012 Participant Use File. Multivariable logistic regression identified independent preoperative risk factors associated with RF, used to derive a weighted RFRS. We then determined goodness-of-fit and optimal cutoff values through receiver operator characteristic analysis and Youden indices to evaluate internal and external validity with a retrospective institutional validation sample (2013 and 2014). RESULTS Multivariable analysis of 151,700 patients from the National Surgical Quality Improvement Program Participant Use File identified 12 variables independently associated with RF. The RFRS showed good external prediction in the validation sample with a c-statistic of 0.73 (95% confidence interval, 0.68-0.79). With the highest Youden index, 30 was determined to be the optimal cutoff value with a sensitivity 0.62 and specificity of 0.75. Additional cutoff values of 15 and 40 optimized sensitivity (>0.80) and specificity (>0.80), respectively. CONCLUSIONS In the preoperative setting, the RFRS can effectively stratify patients into low ( 39) to assist in patient counseling and guide application of perioperative pulmonary optimization measures.

Acute cervical spinal cord injury (cSCI) is associated with significant morbidity and mortality. Vertebral level and American Spinal Injury Association (ASIA) score influence both hospital course and ultimate outcome. While controlling for these variables, we describe the effect of age on cSCI-related pneumonia and mortality.All patients treated at our regional spinal cord injury center with an acute cSCI during a 5-year period (2005-2009) were reviewed retrospectively. Patient demographics, injury level, ASIA score, length of stay (LOS), radiologic, laboratory, and microbiology data were reviewed. Pneumonia was defined as an infiltrate on chest X-ray along with two of the following: leukocytosis, fever greater than 101°F, or positive bronchial alveolar lavage cultures; all occurring within the same 24-hour period.There were 244 cSCI during the study period. In-hospital mortality was significantly higher for those older than 75 years (40.5% vs. 4.0%, p0.0001). Pneumonia rates were not significantly different between age groups. In all age groups, high ASIA scores (A and B) were associated with increased pneumonia (61.9% vs. 17.4%, p0.0001) and mortality (16.7% vs. 3.5%, p = 0.002). Similarly, patients with higher cervical injury levels (C4 and above) had a higher incidence of pneumonia (39.5% vs. 25.9%, p0.05) and a trend toward higher mortality.Age was associated with an increase in mortality among patients with an acute cSCI. Injury level and ASIA score contributed significantly to overall pneumonia rate and mortality at all ages; however, pneumonia did not correlate directly with mortality in this population. Other factors play a role in the mortality associated with geriatric spinal cord-injured patients, including end-of-life decision making; these need to be investigated further in future studies.

This is a retrospective case series to evaluate clinical variables, complications and outcome of 50 patients who underwent anterior lumbar interbody fusion (ALIF) supplemented with posterior percutaneous pedicle screw fixation for degenerative conditions of the lumbar spine. Twenty-four patients underwent single-level fusion and 26 patients had a two-level fusion for a total of 76 levels fused. The mean lengths of the anterior and posterior (including repositioning) portions of the procedure were 131 and 102 min, respectively. The mean estimated blood loss for the entire procedure was 288 ml. The overall adverse event rate was 12%. The mean VAS score for leg pain, VAS score for back pain and mean ODI all improved postoperatively. This study found that ALIF using allograft bone and rhBMP-2 combined with percutaneous pedicle screw fixation had a high fusion rate and a low incidence of perioperative complications. Patient outcomes showed significant improvements in back and leg pain and physical functioning.

In their extensive writings, Hippocrates and Celsus counseled physicians to be knowledgeable in both the medical and surgical management of patient recovery.1 However, their words fell by the wayside because cutting of the body was forbidden by the Roman Catholic Church. Furthermore, the contemporaneous Arabic medical teachings emphasized tradition and authority over observation and personal experience. This created an ever-growing rift between the schools of surgical and pharmacologic medicine with both groups denying their involvement in the other domain. Surgeons had been plagued by postoperative complications including infection, malnutrition, and muscular wasting for centuries. Surgeons were forced to re-examine how diet and exercise affected outcomes before the advent of microbiology and advances in pharmacology. All of this changed when Ambroise Paré, a 16th century surgeon, revolutionized the medical world with his astute observations of postoperative diet and exercise.

We evaluated the incidence and risk factors for postoperative ileus (POI) after total joint arthroplasty in a consecutive group of patients between January 2004 and December 2005 using regional anesthesia and multimodal pain management protocols. Postoperative ileus developed in 31 (0.7%) of 4567 patients. Of these patients, 21 (67.7%) were men, and 10 (32.3%) were women, with a mean age of 68 years (range, 52-91 years). The ileus was treated successfully in 29 patients during the hospitalization. One patient died from this complication, and another one required sigmoid colon resection due to perforation. The risk factors for developing POI after joint arthroplasty were older age, male sex, hip arthroplasty, and prior history of abdominal surgery. The type and dose of narcotic medications, as administered using our current protocol, did not appear to influence the development of POI.

Contrasting traditional and common forms if ethics consultation with bioethics mediation. I describe the case of a "second opinion" consultation in the care of a patient with advanced cancer for whom treatment was futile. While the initial ethics consultation, performed by a colleague, let to a recommendation that some may deem ethical, the process failed to involve key stakeholders and failed to explore the underlying values and reasons for the opinions voiced by various stakeholders. The process of mediation ultimately led to creative solutions in which all stakeholders could reach consensus on a plan of care.

Despite advances in biomechanical engineering and safety devices, spinal cord injury (SCI) remains common in injured patients. Such injuries remain devastating events, often leaving patients with severe and life-changing disability. In acute and intensive care unit settings, the potential for neurologic compromise makes the rapid and accurate assessment, evaluation, and management of these patients of key importance in improving outcome.

The purpose of this endeavor is to compare the morbidity, mortality and costs of LVRS versus transplantation in severe emphysema. This was a retrospective review of severe emphysema patients who received LVRS (n = 70) from 1994-1999, or transplant (n = 87) from 1994-2004. Change in functional status was calculated by the change in modified BODE (mBODE) score. Financial data included physician, hospital and medication costs. Preoperatively, there was no significant difference between the transplant and LVRS groups (mean +/- SD) in age (57.7 +/- 5.7 vs. 59.1 +/- 8.3 years), BMI, Borg dyspnea score, 6-minute walk distance or mBODE (10.4 +/- 2.6 vs. 9.6 +/- 2.7, p = 0.4). Preoperatively, FEV1% (23.6 +/- 8.5 vs. 31.9 +/- 17.7, p = 0.008) was significantly lower in the transplant group. One year post-operatively, transplantation patients had a significantly greater improvement in mBODE (-5.7 vs. -2.0, p = 0.0004), FEV1% (43.4 vs. 2.2%, p = 0.0004) and Borg score (-3.0 vs. -1.4, p = 0.04). Transplantation patients had lower long-term survival compared to LVRS patients (p = 0.01). The only variable that affected survival was type of surgery favoring LVRS (hazard ratio 1.7, 95% confidence limits 1.05-2.77). During a mean follow-up of 2.4 +/- 2.5 years after transplant and 5.0 +/- 3.1 years after LVRS, transplantation mean total costs were greater ($381,732 vs. $140,637, p < 0.0001). Transplantation patients spent more time in the hospital (74.3 +/- 81.3 vs. 39.5 +/- 66.7 days, p = 0.009) and had more outpatient visits (29.9 +/- 28.8 vs. 12.3 +/- 12.6 visits, p < 0.0001). In patients who survive over 1 year, transplantation provides a higher level of functional status and a greater improvement in airflow obstruction, dyspnea, exercise tolerance, and mBODE score, but costs more and carries greater mortality.

Given the widening gap between the number of individuals on transplant waiting lists and the availability of donated organs, as well as the recent plateau in donations based on neurological criteria (i.e., brain death), there has been a growing interest in expanding donation after circulatory determination of death. While the prevalence of this form of organ donation continues to increase, many thorny ethical issues remain, often creating moral distress in both clinicians and families. In this article, we address one of these issues, namely, the challenges surrounding patient and surrogate informed consent for donation after circulatory determination of death. First we discuss several general concerns regarding consent related to this form of organ donation, and then we address additional issues that are unique to three different patient categories: adult patients with medical decision-making capacity or potential capacity, adult patients who lack capacity, and pediatric patients.

Ehyal Shweiki,1 Niels D Martin,2 Alec C Beekley,1 Jay S Jenoff,1 George J Koenig,1 Kris R Kaulback,1 Gary A Lindenbaum,1 Pankaj H Patel,1 Matthew M Rosen,1 Michael S Weinstein,1 Muhammad H Zubair,2 Murray J Cohen1 1Department of Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA; 2Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA Abstract: Medical resident education in the United States has been a matter of national priority for decades, exemplified initially through the Liaison Committee for Graduate Medical Education and then superseded by the Accreditation Council for Graduate Medical Education. A recent Special Report in the New England Journal of Medicine, however, has described resident educational programs to date as prescriptive, noting an absence of innovation in education. Current aims of contemporary medical resident education are thus being directed at ensuring quality in learning as well as in patient care. Achievement and work-motivation theories attempt to explain people's choice, performance, and persistence in tasks. Expectancy Theory as one such theory was reviewed in detail, appearing particularly applicable to surgical residency training. Correlations between Expectancy Theory as a work-motivation theory and residency education were explored. Understanding achievement and work-motivation theories affords an opportunity to gain insight into resident motivation in training. The application of Expectancy Theory in particular provides an innovative perspective into residency education. Afforded are opportunities to promote the development of programmatic methods facilitating surgical resident motivation in education. Keywords: learning, education, achievement

Retrospective case–control. To characterize changes in American Spinal Injury Association Motor Score (AMS) in patients treated with relative hypertension (HTN) (mean arterial pressure (MAP) > 85 mm Hg for 5 days) with and without preexisting HTN. A regional spinal cord injury (SCI) center in Pennsylvania, United States. All patients with an acute SCI who were treated with induced HTN (MAP goal above 85) in the intensive care unit (ICU) for at least 5 days were identified. Patients were stratified based on the presence of preexisting HTN, and the change in the AMS between admission and day 5 was determined. Predictors of outcome were identified using correlation analysis and multiple linear regression. Ninety-two patients met inclusion criteria of which 22 had a previous history of HTN. HTN was a predictor of poor early outcome. Patients with HTN had an average decline in their AMS of 7.6, compared with an average decrease of only 0.6 in the AMS of patients without HTN (P=0.04). HTN had no effect (P>0.05) on other in-hospital variables including length of stay, length of stay in the ICU, complications or mortality. Additionally, multiple linear regression analysis demonstrated that diabetes, coronary artery disease and pulmonary disease had no effect on the change in AMS. Chronic HTN is an independent risk factor for poor early neurologic recovery in patients treated with relative HTN for an acute SCI. This is independent of age and other comorbidities.

BACKGROUND End-of-life (EoL) decision making during critical illness and injury is important in facilitating compassionate care that is congruent with patient, family, and societal expectations. Herein, we evaluate factors that may effect and induce variability in practitioner EoL decision making, particularly years in practice, use of advance directives (ADs), and cost. METHODS An anonymous, online survey was offered to all active members of the Eastern Association for the Surgery of Trauma (n = 1,359) in June 2012. Demographic information and a series of questions dealing with common potentially influential factors were included. Responses were 5-point Likert scale based. RESULTS A total of 375 responses (27.6%) were received. Ninety-two percent of the respondents were physicians, 70% were male, and 77% were from Level 1 trauma centers. Of respondents, 65.8% rely on family to make EoL decisions most or all of the time, while 80.7% feel family members are rarely or only sometimes in appropriate emotional states to make such choices. A significant number of practitioners felt comfortable making decisions without family input at all, more so with experienced practitioners as compared with those in practice for less than 15 years (38.2% and 24.1% respectively, p < 0.01).Of the practitioners, 59.6% rely on ADs most or all of the time, only 61.1% agree or strongly agree that ADs are useful, and only 56.3% feel families follow their loved one's ADs most or all of the time. A patient's family support or ability to pay for aftercare was rarely or never considered important by 80.1% of the practitioners, despite 85.1% reporting that quality of life postillness/injury was important most or all of the time. CONCLUSION Practitioner comfort and motivation to influence EoL decision making varies with experience level. ADs are not uniformly perceived to be helpful, and costs are uncommonly considered. To improve EoL quality, these factors need to be considered. LEVEL OF EVIDENCE Care management study, level IV.

Geriatric patients constitute a substantial proportion of those utilizing critical care services in acute care hospital settings. This chapter reviews clinical indications for critical care services in this population. Specific treatments are reviewed in the context of overall care, including care at the end of life. Critical care medicine plays an important role in the management of elderly urologic patients with complex care requirements.

BACKGROUND In children, opioids are valuable both for their analgesic properties and for their salutary effect on emergence delirium. Although intraoperative administration of opioids is often cited as the cause of postoperative emesis, few data quantitating the magnitude of this effect exist. METHODS Patients undergoing inguinal surgery as outpatients were randomly assigned to one of two groups. One group received a single intravenous dose of morphine 0.1 mg/kg (morphine group), and the other (control) group had the identical anesthetic but instead received saline. Intravenous ketorolac was administered in response to verbal complaints of pain or a Children's Hospital of Eastern Ontario Pain Score greater than 9 on two successive evaluations performed at 5-min intervals. The authors compared the incidence of postoperative emesis and emergence, behavior, and pain scores between the two groups. RESULTS Patients in the morphine group (n = 48) were 5.6 +/- 2.8 yr old and weighed 20.8 +/- 7.8 kg, and those in the control group (n = 49) were 4.5 +/- 2.9 yr old and weighed 18.9 +/- 9.2 kg. More patients in the morphine group were cooperative and deeply asleep both on arrival and through the first 30 min of their stay in the postanesthesia care unit (PACU) (P < 0.05). Sixty-three percent of the children in the control group received ketorolac in the PACU compared with 20% of the morphine group (P < 0.01). The incidence of emesis for the 24 h after arrival in the PACU was 56% for those who received morphine compared with 25% in the control group (P < 0.01). CONCLUSIONS For children undergoing inguinal surgery, the administration of a single dose of intravenous morphine after the induction of anesthesia smooths emergence from anesthesia as assessed by improved cooperation and sedation in the PACU, decreases the need for postoperative analgesics, but increases the incidence of vomiting in the first 24 h after surgery.

Roadside pedestrian injuries represent a significant portion of trauma team activations, especially at urban trauma centers. Patient demographics and severity of injury vary greatly in this patient population. Herein, we hypothesize that injury patterns may be predictable, especially with respect to age.All patients with roadside pedestrian injuries evaluated at our urban, level one trauma center from January 2006 through December 2008 were retrospectively reviewed. Data were collected from the institutional trauma registry. Age was used as an independent variable and compared with injury type, substance abuse, discharge setting, and mortality.There were 226 roadside pedestrian injuries during the study period. Patients were divided into groups according to age, under 20 y, 21-40 y, 41-65 y, and over 65 y. Head injuries were more prevalent in patients over age 65, 30.4% versus 14.0% (P = 0.05). There was a trend for increasing alcohol use in the younger population. The likelihood of discharge to a rehab facility increased with age, 0%, 11.8%, 38.2%, 50.0%, respectively (P0.001). Mortality was significantly higher in patients older than 65 y, 15.2% versus 3.3% (P = 0.049).Roadside pedestrian injuries have predictable injury patterns based on age. Older patients are more likely to have a head injury, longer length of stay, need for a rehab stay, and have a higher mortality. Further studies are needed to correlate precise injuries with collision mechanism and evaluate specific risk factors in this high risk population.

Background: Femoral nerve palsy is not a common adverse effect of lumbar spinal surgery.Objective: To report 3 unique cases of femoral nerve neuropathy due to instrumentation and positioning during complex anterior and posterior spinal surgery.Methods: Case seriesResults: All 3 patients demonstrated femoral nerve neuropathy. The first patient presented postoperatively but after 6 months, the palsy resolved. Femoral nerve malfunctioning was documented in the second and third patients intraoperatively; however, with rapid patient repositioning and removal of offending instrumentation, postoperative palsy was avoided.Conclusions: Use of motor evoked potential monitoring of the femoral nerve during surgery is vital for the prevention of future neuropathies, an avoidable complication of spinal surgery.

Objectives Lumbar fusion has been widely used to treat unstable spinal disorders. Methods are evolving from open procedures to less invasive methods to avoid soft tissue trauma. Recently, a soft tissue sparing method to access the axial lumbosacral spine has been developed. It is crucial to determine structures potentially at risk for injury during this fusion technique. The anatomy of the presacral space and safety of the paracoccygeal approach were evaluated through cadaveric dissection and radiographic studies. The objective was to evaluate the safety of a paracoccygeal approach to the axial lumbosacral spine and determine structures that could potentially be injured. Methods The paracoccygeal approach was performed on two cadavers, followed by dissection. Distances from the midline trajectory of the approach to surrounding vascular structures were determined. Similar distances were also measured on computed tomography (CT) and magnetic resonance imaging (MRI) of 12 patients, as well as CT images of two additional patients. A "safe zone" was determined using the sagittal length of the presacral space and the distance between the most medial internal iliac vessel on the right and left, respectively. Results The coronal safe zone averaged 6.9 and 6.0 cm on MRI and CT, respectively. The mean distance from the anterior sacral margin to the rectum at the S3-S4 level was 1.2 and 1.3 cm on MRI and CT, respectively. Conclusion In this study, we defined the "coronal safe zone" within the presacral space. This "safe zone" may guide surgeons when utilizing the percutaneous paracoccygeal approach.

Introduction: Acute spinal cord injury (SCI) is often treated with induced hypertension to enhance spinal cord perfusion. The optimal mean arterial pressure (MAP) likely varies between patients. Arbitrary goals are often set, frequently requiring vasopressors to achieve, with no clear evidence supporting this practice. We hypothesize that increased MAP goals and episodes of relative hypotension do not affect hospital outcome. Materials and Methods: All cervical and thoracic SCI patients treated at a level one trauma and regional SCI center over at 2.5-year period were retrospectively reviewed. Lowest and average hourly MAP was recorded for the first 72 h of hospitalization, allowing for quantification of mean MAP and the total number of episodic relative hypotensive events. These data were further compared to daily American spinal injury association motor score (AMS), which was used to determine the severity of SCI and improvement/decline during hospitalization. Patient′s data were finally analyzed at theoretic MAP set points. Results: One hundred and five patients had complete data during the study period. At higher theoretic MAP set points (85 and 90), increased number of relative hypotensive episodes correlated with lower admission AMS (85 mmHg: 50 episodes, 22.0; P < 0.001) and the need for vasopressors (P < 0.03) but showed no statistical change in AMS by hospital discharge. The need for vasopressors correlated with the number of hypotensive episodes and inversely related to admission AMS at all theoretic MAP goal set points but was not correlated with the change in AMS during the hospitalization. Conclusions: The frequency of relative hypotension and the need for vasopressors are progressively related to more severe SCI, as denoted by lower admission AMS. However, episodes of hypotension and the need for vasopressors did not affect the change in AMS during the acute hospitalization, regardless of theoretic MAP goal set-point. Arbitrarily elevated MAP goals may not be efficacious.

Persistent low back pain developed in a 51-year-old woman after she had undergone abdominal sacrocolpopexy. Four months postoperatively, necrotizing myofascitis developed in her gluteal muscles. The infected mesh, which had eroded into the vagina, was removed. Cultures of the infected mesh and abscesses grew common vaginal flora, including Gardnerella vaginalis and Actinomyces.

There are quantitative deficiencies in the coagulation system for at least the first 6 mo of life. Clinical experience, however, does not indicate an increased risk of excessive bleeding during surgical procedures. Thrombelastography, a test providing a functional evaluation of coagulation, was used to assess the hemostatic system of pediatric patients under 2 yr of age. Thrombelastographic data were obtained from 237 healthy pediatric patients less than 2 yr of age undergoing elective noncardiac surgery. Five groups were distinguished: under 30 days, 1-3 mo, 3-6 mo, 6-12 mo, and 12-24 mo. Thrombelastography revealed no defects in coagulation when these groups were compared to each other or to adults, indicating a functionally intact hemostatic process even in neonates. Indeed, children less than 12 mo of age were found to initiate and develop clot faster than adults, with the coagulation process slowing to adult rates after 1 yr of age. In addition to defining functional integrity, our data represents a set of pediatric control thrombelastographic values that have not been previously reported and that may become important in understanding coagulation changes that accompany disease states and surgery in pediatric patients.

Introduction: Argatroban is a direct thrombin inhibitor indicated for prophylaxis or treatment of thrombosis in patients with heparin-induced thrombocytopenia. The recommended initial dose for argatroban is 2.0 mcg/kg/min for patients with normal hepatic function and 0.5 mcg/kg/min with moderate hep

The infectivity and distribution of Echinostoma trivolvis were studied in female ICR mice each infected with 25 metacercarial cysts. At 7 and 10 days post-exposure worm recoveries were 58.8 and 58.4%, respectively. Worm recovery declined to 38.2% by day 14, to 6.4% by day 21, and 0% by day 28. The distribution of the parasites demonstrated an anteriad shift over time. Comparative histopathological studies were carried out on E. trivolvis and Echinostoma caproni in the mouse. Compared to control and E. trivolvis -infected intestine, mouse intestine infected with E. caproni showed marked dilation and villous atrophy. E. trivolvis -infected intestine showed a nearly two-fold increase in goblet cells compared to control intestine, whereas the intestine of E. caproni -infected mice showed almost complete goblet cell loss. Additionally, there was a marked increase in collagen in the intestinal musculature of the mice infected with E. trivolvis compared to control and E. caproni -infected mice.