Omission of nitrous oxide from a propofol-based anesthetic does not affect the recovery of women undergoing outpatient gynecologic surgery

BACKGROUND: Although nitrous oxide (N2O) is used commonly during anesthesia, clinically relevant advantages-disadvantages of using this agent are not well established in the ambulatory setting. This study in women undergoing ambulatory gynecologic surgery compares outcomes in patients administered total intravenous anesthesia with propofol versus the propofol plus N2O. The primary outcome was the time to home readiness. Secondary outcomes included the incidence of postanesthetic adverse events. METHODS: Women presenting for elective ambulatory termination of pregnancy or gynecologic laparoscopy were induced with an intravenous sleep dose of propofol and fentanyl. After induction, subjects were randomly allocated to maintenance anesthesia with propofol alone or propofol plus 65% N2O. Patients were assessed by a blinded observer in the postanesthetic care unit at 20-min intervals to determine home readiness. Postoperative pain and nausea were measured with visual analog scales. Postoperative analgesics and antiemetics were recorded. The incidence of adverse events occurring after hospital discharge was assessed by a telephone interview 24 h postoperatively. RESULTS: A total of 740 patients received propofol alone, and 750 patients received propofol plus N2O. Mean home readiness times were not significantly different between treatment groups. There were no significant differences between groups in pain scores, nausea scores, analgesia administration, or antiemetic administration before discharge. There were no significant differences in the frequency of adverse events for 24 h after discharge from hospital. CONCLUSIONS: Omission of N2O from a propofol-based anesthetic for ambulatory gynecologic surgery does not affect time to home readiness or the incidence of postoperative adverse events up to 24 h after discharge from hospital. (Key words: Awareness; outpatient surgery; total intravenous anesthesia.)     

Phase I study of gefitinib plus celecoxib in recurrent or metastatic squamous cell carcinoma of the head and neck.

PURPOSE: Effective and tolerable palliative treatments are needed for patients with incurable squamous cell carcinoma of the head and neck (SCCHN). Single-agent targeted therapies have limited activity in this setting. The feasibility of adding celecoxib to gefitinib for the treatment of incurable SCCHN is unknown. PATIENTS AND METHODS: Nineteen patients with unresectable recurrent locoregional and/or distant metastatic SCCHN with progressive disease after at least one prior chemotherapy or chemoradiotherapy regimen were enrolled onto this single-institution phase I study. Three dose levels were explored: (1) celecoxib 200 mg twice daily plus gefitinib 250 mg daily; (2) celecoxib 400 mg twice daily plus gefitinib 250 mg daily; and (3) celecoxib 400 mg twice daily plus gefitinib 500 mg daily. RESULTS: No dose-limiting toxicities were encountered at any dose level. The most common toxicities were acneiform rash, diarrhea, hand reaction, dyspepsia, and anemia. Four of 18 patients assessable for response (22%; 95% CI, 2% to 42%) achieved a confirmed partial response. CONCLUSION: The combination of gefitinib 500 mg daily plus celecoxib 400 mg twice daily is well-tolerated. The encouraging responses seen in this early study suggest further evaluation of epidermal growth factor receptor and cyclooxygenase-2 inhibitors in SCCHN is warranted.     

Beyond homogenization discourse: Reconsidering the cultural consequences of globalized medical education

Introduction: Global medical education standards, largely designed in the West, have been promoted across national boundaries with limited regard for cultural differences. This review aims to identify discourses on cultural globalization in medical education literature from non-Western countries.

Methods: To explore the diversity of discourses related to globalization and culture in the field of medical education, the authors conducted a critical review of medical education research from non-Western countries published in Academic Medicine, Medical Education and Medical Teacher from 2006 to 2014. Key discourses about globalization and culture emerged from a preliminary analysis of this body of literature. A secondary analysis identified inductive sub-themes.

Results: Homogenization, polarization and hybridization emerged as key themes in the literature. These findings demonstrate the existence of discourses beyond Western-led homogenization and the co-existence of globalization discourses ranging from homogenization to syncretism to resistance.

Conclusions: This review calls attention to the existence of manifold discourses about globalization and culture in non-Western medical education contexts. In refocusing global medical education processes to avoid Western cultural imperialism, it will also be necessary to avoid the pitfalls of other globalization discourses. Moving beyond existing discourses, researchers and educators should work towards equitable, context-sensitive and locally-driven approaches to global medical education.     

Differential Effects of Dietary versus Exercise Intervention on Intrahepatic MAIT Cells and Histological Features of NAFLD

Background: Mucosal-associated invariant T (MAIT) cells promote inflammation in obesity and are implicated in the progression of non-alcoholic fatty liver disease (NAFLD). However, as the intrahepatic MAIT cell response to lifestyle intervention in NAFLD has not been investigated, this work aimed to examine circulating and intrahepatic MAIT cell populations in patients with NAFLD, after either 12 weeks of dietary intervention (DI) or aerobic exercise intervention (EI). Methods: Multicolour flow cytometry was used to immunophenotype circulating and intrahepatic MAIT cells and measure MAIT cell expression (median fluorescence intensity, MFI) of the activation marker CD69 and apoptotic marker CD95. Liver histology, clinical parameters, and MAIT cell populations were assessed at baseline (T0) and following completion (T1) of DI or EI. Results: Forty-five patients completed the study. DI participants showed decreased median (interquartile range) expression of the activation marker CD69 on circulating MAIT cells (T0: 104 (134) versus T1 27 (114) MFI; p = 0.0353) and improvements in histological steatosis grade post-intervention. EI participants showed increased expression of the apoptotic marker CD95, both in circulating (T0: 1549 (888) versus T1: 2563 (1371) MFI; p = 0.0043) and intrahepatic MAIT cells (T0: 2724 (862) versus T1: 3117 (1622) MFI; p = 0.0269). Moreover, the percentage of intrahepatic MAIT cells significantly decreased after EI (T0: 11.1 (14.4) versus T1: 5.3 (9.3)%; p = 0.0029), in conjunction with significant improvements in fibrosis stage and hepatocyte ballooning. Conclusions: These data demonstrate independent benefits from dietary and exercise intervention and suggest a role for intrahepatic MAIT cells in the observed histological improvements in NAFLD.     

Public Health Consequences of Terrorism on Maternal–Child Health in New York City and Madrid

Past research provides evidence for trajectories of health and wellness among individuals following disasters that follow specific pathways of resilience, resistance, recovery, or continued dysfunction. These individual responses are influenced by event type and pre-event capacities. This study was designed to utilize the trajectories of health model to determine if it translates to population health. We identified terrorist attacks that could potentially impact population health rather than only selected individuals within the areas of the attacks. We chose to examine a time series of population birth outcomes before and after the terrorist events of the New York City (NYC) World Trade Center (WTC) attacks of 2001 and the Madrid, Spain train bombings of 2004 to determine if the events affected maternal–child health of those cities and, if so, for how long. For percentages of low birth weight (LBW) and preterm births, we found no significant effects from the WTC attacks in NYC and transient but significant effects on rates of LBW and preterm births following the bombings in Madrid. We did find a significant positive and sustained effect on infant mortality rate in NYC following the WTC attacks but no similar effect in Madrid. There were no effects on any of the indicator variables in the comparison regions of New York state and the remainder of Spain. Thus, population maternal–health in New York and Madrid showed unique adverse effects after the terrorist attacks in those cities. Short-term effects on LBW and preterm birth rates in Madrid and long-term effects on infant mortality rates in NYC were found when quarterly data were analyzed from 1990 through 2008/2009. These findings raise questions about chronic changes in the population’s quality of life following catastrophic terrorist attacks. Public health should be monitored and interventions designed to address chronic stress, environmental, and socioeconomic threats beyond the acute aftermath of events.