New guidelines for maternal and neonatal resuscitation

New evidence has prompted changes in our national cardiopulmonary resuscitation guidelines for both neonates and adult patients. The purpose of this article is to provide an overview of the changes recommended by the American Heart Association, Academy of American Pediatrics, and the American College of Obstetrics and Gynecology. In addition, a strategy for implementing these guidelines into practice is suggested.     

Health-enhancing physical activity,psychological needs satisfaction,and well-being: Is it how often,how long,or how much effort that matters?

The objective of this study was to examine the role of basic psychological need satisfaction as a potential mediator of the relationship between health-enhancing physical activity (HEPA) and well-being. Participants (N = 201) were young adults who recalled their HEPA behavior, experiences of psychological need satisfaction, and levels of well-being across multiple indicators using a cross-sectional design targeting the previous day. Results from path analysis demonstrated that effort put forth in HEPA activities, as opposed to frequency or duration of HEPA, predicted well-being. Further, psychological needs satisfaction mediated between 10% and 44% of the HEPA-Effort – well-being relationship. Overall, these findings lend credence to the notion that effortful investment is associated with well-being when engaged in HEPA, and that the satisfaction of basic psychological needs may act as a salient explanatory mechanism partially accounting for that relationship.     

Mutation and protein expression of p53 in acquired immunodeficiency syndrome-related lymphomas

p53 mutations are found in a variety of neoplasia. B-immunoblastic lymphoma (BIBL) is a rapidly progressive, aggressive lymphoma. As patients with acquired immunodeficiency syndrome (AIDS) live longer, BIBL is becoming an increasing problem. We asked three questions in our study. What is the frequency of p53 mutations in BIBL? Is it more frequent in patients with AIDS? Can immunohistochemical staining of lymph nodes for expression of p53 substitute for mutational analysis of p53 to detect lymphomas with mutated p53? Exons 5, 6, 7, 8 of the p53 gene (hot-spots for mutations) were amplified and examined for mutations by single-strand conformation polymorphism (SSCP) analysis. Altered migration was observed in 7 of 52 BIBL samples. Of these, 4 of 25 were from individuals infected with human immunodeficiency virus (HIV) and 3 of 27 were not infected with HIV. Direct sequencing of amplified material confirmed the presence of mutations in exons 5, 7, 8 of p53. A total of 26 BIBL as well as other lymphoma/leukemia samples, stained strongly by immunohistochemistry with three antibodies directed against human p53. Five of 6 BIBL samples with p53 mutations stained strongly for p53, but 20 lymphoma samples with no detectable p53 mutations also stained strongly for p53. Of note, however, 10 hyperplastic, nonmalignant lymph nodes from individuals either infected or not infected with HIV had negligible staining for p53 protein. In conclusion, p53 mutations occur in about 14% BIBL samples; the frequency of p53 mutations in BIBL in individuals with and without AIDS was similar. Positive p53 immunohistochemistry did not correlate with detectable p53 mutations in the same tissue, but positive immunohistochemical staining for p53 was only found in neoplastic lymph nodes. This latter finding provides a strong warning that p53 immunochemistry with available reagents cannot be used to determine which tumors have mutations of p53.     

Long-term follow-up of patients with tertiary hyperparathyroidism treated by resection of a single or double adenoma

OBJECTIVE: To determine whether patients with tertiary hyperparathyroidism due to single- or two-gland disease undergoing limited resection have similar long-term outcomes compared with patients with hyperplasia undergoing subtotal or total parathyroidectomy. SUMMARY BACKGROUND DATA: Tertiary hyperparathyroidism occurs in less than 2% of patients after renal transplantation. Approximately 30% of these cases are caused by one or two hyperfunctioning glands. Nevertheless, the standard operation for this disease has been subtotal or total parathyroidectomy with autotransplantation. METHODS: Seventy-one patients underwent surgery for tertiary hyperparathyroidism. At the time of surgery, 19 patients who had a single or double adenoma underwent limited resection of the enlarged glands only (adenoma group). The remaining 52 patients with three- or four-gland hyperplasia had subtotal or total parathyroidectomy with implantation (hyper group). Long-term cure rates between the two groups were compared. RESULTS: In the adenoma group, 7 patients had a single adenoma and 12 underwent resection of a double adenoma. In the hyper group, 49 patients had subtotal and 3 had total parathyroidectomies. After surgery, 70 of 71 patients (99%) were cured of their hypercalcemia. The incidence of postoperative transient hypocalcemia was significantly higher in the hyper group (27% vs. 5%). No patients in either group had permanent hypocalcemia requiring long-term supplementation. With up to 16 years of follow-up, there have been no recurrences in the adenoma group, whereas three patients (6%) in the hyper group have had recurrent or persistent hyperparathyroidism. CONCLUSIONS: Patients with tertiary hyperparathyroidism who underwent limited resection of a single or double adenoma only had equivalent long-term cure rates compared with patients undergoing more extensive resections. Therefore, the authors recommend in patients with tertiary hyperparathyroidism and enlargement of only one or two parathyroid glands that the resection be limited to these abnormal glands only.     

Postoperative narcotic requirement after microscopic lumbar discectomy is not affected by intraoperative ketorolac or bupivacaine

STUDY DESIGN: Prospective, randomized, double-blind study. OBJECTIVE: To assess the efficacy of ketorolac and bupivacaine in reducing postoperative pain after microsurgical lumbar discectomy. SUMMARY OF BACKGROUND DATA: Microsurgical lumbar discectomy often is performed as an ambulatory procedure. Pain, nausea, and urinary retention may delay discharge. It was hypothesized that intraoperative ketorolac or bupivacaine would reduce postoperative pain as measured by morphine demand. METHODS: After Institutional Review Board (IRB) approval and informed consent, 30 patients undergoing single-level microsurgical lumbar discectomy under general anesthesia randomly received either intravenous ketorolac, intramuscular bupivacaine, or placebo before wound closure. After surgery, all patients received intravenous, MSO4, patient-controlled analgesia. MSO4 demand was compared between groups at 30 minutes and at 1, 4, 8, 16, 20, and 24 hours after surgery by one-way ANOVA. Pre- and postoperative pain was assessed by using a standard scale and was correlated to postoperative MSO4 demand by Pearson correlation. Significance was assumed at P < 0.05. RESULTS: There were no group differences in age, gender, weight, disc level, preoperative pain, or preoperative use of pain medication. Neither ketorolac nor bupivacaine decreased pain or nausea scores, MSO4 demand, or time to void and ambulation. Preoperative pain was significantly correlated to postoperative narcotic demand (r = 0.46, P < 0.01). Preoperative narcotic or NSAID use was not correlated to either preoperative pain scores or postoperative MSO4 requirement. CONCLUSIONS: Neither ketorolac nor bupivacaine decreased the postoperative narcotic requirement in patients undergoing microsurgical lumbar discectomy. Postoperative narcotic requirements are increased in patients who are in severe pain before surgery, regardless of preoperative narcotic use.     

Obstructive nephropathy in the mouse: progressive fibrosis correlates with tubulointerstitial chemokine expression and accumulation of CC chemokine receptor 2- and 5-positive leukocytes

The infiltration of leukocytes plays a major role in mediating tubulointerstitial inflammation and fibrosis in chronic renal disease. CC chemokines participate in leukocyte migration and infiltration into inflamed renal tissue. Because CC chemokine-directed leukocyte migration is mediated by target cell expression of a group of CC chemokine receptors, this study examined the expression of CC chemokines and their receptors during initiation of tubulointerstitial fibrosis after unilateral ureteral obstruction in C57BL/6 mice. Obstructed kidneys developed hydronephrosis, tubular cell damage, interstitial inflammation, and fibrosis. From days 2 to 10, a progressive interstitial influx of F4/80+ macrophages and CD3+ lymphocytes occurred (macrophages, 4-fold; lymphocytes, 20-fold at day 10, compared with contralateral control kidneys). In parallel, the number of activated fibroblast-specific protein 1+ fibroblasts and interstitial collagen IV accumulation increased from days 2 to 10. The mRNA expression of CC chemokines (predominantly monocyte chemoattractant protein-1 [MCP-1]/CCL2, RANTES/CCL5) and their receptors CCR1, CCR2, CCR5 increased progressively from days 2 to 10. By in situ hybridization, a prominent interstitial mRNA expression of MCP-1 and RANTES and their receptors CCR2 and CCR5 localized to interstitial mononuclear cell infiltrates. MCP-1 and RANTES expression was also seen in tubular epithelial cells. Fluorescence-activated cell sorter analysis of single-cell suspensions from obstructed kidneys revealed a prominent expression of CCR2 and CCR5 by infiltrating macrophages, whereas most lymphocytes expressed CCR5 only. These data demonstrate an increased expression of MCP-1/CCL2 and RANTES/CCL5 at sites of tubulointerstitial damage and progressive fibrosis during unilateral ureteral obstruction that correlates with simultaneous accumulation of interstitial macrophages and T lymphocytes expressing the respective surface receptors CCR2 and CCR5. The chemokine receptor-mediated leukocyte influx into the tubulointerstitium could offer a new potential target for therapeutic intervention in progressive renal tubulointerstitial fibrosis.