Long-term treatment with sildenafil in chronic thromboembolic pulmonary hypertension.

For chronic thromboembolic pulmonary hypertension not amenable to pulmonary endarterectomy, effective medical therapy is desired. In an open-label uncontrolled clinical trial, 104 patients (mean +/- sem age 62 +/- 11 yrs) with inoperable chronic thromboembolic pulmonary hypertension were treated with 50 mg sildenafil t.i.d. At baseline, patients had severe pulmonary hypertension (pulmonary vascular resistance 863 +/- 38 dyn.s.cm(-5)) and a 6-min walking distance of 310 +/- 11 m. Eight patients were in World Health Organization functional class II, 76 in class III and 20 in class IV. After 3 months' treatment, there was significant haemodynamic improvement, with reduction of pulmonary vascular resistance to 759 +/- 62 dyn.s.cm(-5). The 6-min walking distance increased significantly to 361 +/- 15 m after 3 months' treatment, and to 366 +/- 18 m after 12 months' treatment. A subset of 67 patients received a single dose of 50 mg sildenafil during initial right heart catheterisation. The acute haemodynamic effect of this was not predictive of long-term outcome. In this large series of patients with inoperable chronic thromboembolic pulmonary hypertension, open-label treatment with sildenafil led to significant long-term functional improvement. The acute effect of sildenafil may not predict the long-term outcome of therapy.     

Incidence of headache,nausea and vomiting following spinal anesthesia

A report of 500 cases of lumbar anesthesia is submitted with special reference to the incidence of postanesthetic headache, nausea, and vomiting in patients who are ambulatory within a short period after surgery.

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1. Postanesthetic headache occurred in 30.6 per cent of the cases; this is a much higher incidence than one finds in most published reports and may be explained upon the basis of the following considerations: cases reported in the literature are not selected cases, but those usually requiring seven to ten days of postoperative bed rest; the cases analyzed in the present study were largely those on whom anorectal operations had been performed, these patients requiring only a short period of recumbency.     

Grandmothers, Fathers, and Depressive Symptoms Are Associated with Food Insecurity among Low-Income First-Time African-American Mothers in North Carolina

African Americans experience household food insecurity, ie, the limited availability of nutritionally adequate and safe food, or ability to acquire acceptable foods in socially acceptable ways, at three times the rate of non-Hispanic whites. Thirty percent of all African-American children live in food-insecure households. The purpose of this study was to identify characteristics associated with household food insecurity among a high-risk postpartum population. Two-hundred six low-income, African-American mother−infant dyads were recruited through the Special Supplemental Nutrition Program for Women, Infants, and Children clinics. The six-item US Department of Agriculture food security scale was used to classify households as food secure, marginally food secure, or food insecure. Multinomial logistic regression was used to estimate the association between selected maternal/household characteristics and household food-security status. Fifty-three percent of households were food secure, 34% were marginally food secure, and 13% were food insecure. Maternal education less than college (relative risk ratio [RRR]=0.46; 95% confidence interval [CI]: 0.22 to 0.98) was inversely associated with marginal food security. Depressive symptoms (RRR=1.09; 95% CI: 1.02 to 1.16) and having the baby's father in the household (RRR=3.46; 95% CI: 1.22 to 9.82) were associated with household food insecurity, while having a grandmother in the household (RRR=0.15; 95% CI: 0.03 to 0.80) was inversely associated with experiencing household food insecurity. Findings from this study suggest that young, low-income, African-American families with only one child are particularly susceptible to experiencing household food insecurity. Intergenerational support and transfer of knowledge can be a key protective attribute among low-income African-American households.     

Elective laparoscopy for herald symptoms of mesenteric/internal hernia after laparoscopic Roux-en-Y gastric bypass

BackgroundMesenteric internal hernia (MIH) is the most common cause of small bowel obstruction (SBO) after laparoscopic Roux-en-Y gastric bypass. Because MIH is a potentially life-threatening complication, we hypothesized that elective repair of MIH before developing acute SBO could decrease morbidity in this population.MethodsThe records of 702 consecutive patients undergoing primary laparoscopic Roux-en-Y gastric bypass from January 2002 and August 2007 were retrospectively reviewed to determine the incidence and etiology of SBO. During the last 9 months of the study, we offered elective laparoscopy to any patient who presented to us with symptoms of intermittent SBO.ResultsOf the 702 patients, 27 (3.8%) developed acute SBO. Of these 27 patients, 15 (55%) had obstruction related to an MIH. Nearly all patients had a typical history of intermittent abdominal pain, nausea, and bloating before developing acute SBO. Elective laparoscopy was offered to 11 patients with symptoms of intermittent SBO. Two patients who refused subsequently underwent operations for acute SBO. MIH was found at elective laparoscopic exploration in all cases. Of the 9 patients undergoing elective surgery, 3 (33%) had small bowel volvulus.ConclusionSBO due to MIH after laparoscopic Roux-en-Y gastric bypass is typically preceded by symptoms of intermittent obstruction. Patients who have these herald symptoms should promptly be offered elective laparoscopic exploration. Elective repair of MIH can be performed safely and expeditiously.