The post-partum mid-upper arm circumference of adolescents is reduced by pregnancy in rural Nepal

The purpose of this study was to examine whether changes in the mid‐upper arm circumference (MUAC) in pregnancy and early post‐partum varied by maternal age. The MUAC of 3359 nulliparous pregnant women ≤25 years of age in rural Nepal was measured in early pregnancy and at 3 months post‐delivery of a live‐born infant. Regression was used to model the change in MUAC and prevalence of MUAC < 20 cm by maternal age, adjusted for confounders. A total of 5.2% of the pregnant women were under 16 years of age. The prevalence of MUAC measurements <20 cm was 11.3% in early pregnancy and did not differ by maternal age. The prevalence of low MUAC was 17.7% at post‐partum, but those <16 years of age had a significantly higher prevalence of low post‐partum MUAC [odds ratio: 2.47, 95% confidence interval (CI) 1.49, 4.10] compared with women 20–25 years of age, adjusted for maternal literacy, caste, meat consumption in early pregnancy and timing of measurements. All women reduced their MUAC from early pregnancy through post‐partum. The adjusted loss of the MUAC among those under 16 years of age was 0.97 cm (95% CI: ?1.33, ?0.60), compared with 0.40 cm (95% CI: ?0.70, ?0.10) among women 20–25 years of age. In an energy‐restricted environment, girls under 16 years contributed to a half centimetre more loss of MUAC than older women of the same parity. Such a loss of fat, muscle or both may put younger women and their breastfed offspring at greater risk of other adverse health and nutritional outcomes.     

Airway management in prone position with an intubating Laryngeal Mask Airway

The prone position impairs the ability for endotracheal intubation by direct laryngoscopy. We describe the airway management of a 25-year-old woman with an extensive open wound over her back and fractured pelvis. She was treated in the prone position and was scheduled for debridement of her wound with skin grafting during general anesthesia. Her trachea was successfully intubated on the first attempt using an intubating Laryngeal Mask Airway while she was in the prone position.     

Peri-operative outcomes for pancreatoduodenectomy in India: a multi-centric study

Background:

There have been an increasing number of reports world-wide relating improved outcomes after pancreatic resections to high volumes thereby supporting the idea of centralization of pancreatic resectional surgery. To date there has been no collective attempt from India at addressing this issue. This cohort study analysed peri-operative outcomes after pancreatoduodenectomy (PD) at seven major Indian centres.

Materials and Methods:

Between January 2005 and December 2007, retrospective data on PDs, including intra-operative and post-operative factors, were obtained from seven major centres for pancreatic surgery in India.

Results:

Between January 2005 and December 2007, a total of 718 PDs were performed in India at the seven centres. The median number of PDs performed per year was 34 (range 9–54). The median number of PDs per surgeon per year was 16 (range 7–38). Ninety-four per cent of surgeries were performed for suspected malignancy in the pancreatic head and periampullary region. The median mortality rate per centre was four (range 2–5%). Wound infections were the commonest complication with a median incidence per centre of 18% (range 9.3–32.2%), and the median post-operative duration of hospital stay was 16 days (range 4–100 days).

Conclusions:

This is the first multi-centric report of peri-operative outcomes of PD from India. The results from these specialist centers are very acceptable, and appear to support the thrust towards centralization.     

Medical student mentorship in a university setting as a strategy for a career in surgery

Gender balance in surgery is a respectable and necessary goal. At the University of Louisville (UL) School of Medicine, we have compared percentages of UL medical student applicants to general surgery or surgical subspecialty residency programs, surgical residents, and surgical faculty with the rest of the nation. Although UL has at times paralleled or exceeded the nation in many of these categories, there is room for improvement and the comparison data allow for strategic planning initiatives. To promote gender balance among future generations of surgeons at UL, we recently implemented a mentoring program that pairs medical students with residents and faculty in surgery. We plan to track the success over time and correct any shortcomings of this program. Virginia Commonwealth University's commitment to gender balance in surgery is exemplary. As part of a more comprehensive vision to create a mentorship program for female medical students at the UL School of Medicine, we have recently recruited female surgical residents and faculty, whom we hope will provide the type of inspiration and guidance that will increase the number of women from UL who decide to train in general surgery and the surgical specialties. To understand why women across the nation are not generally at numerical parity in these fields, it is important to consider the length and intensity of the surgical residency programs in the context of the other goals and objectives that a woman might have for her future. This article does not address this broad topic but provides a perspective of how a medical school can evaluate and perhaps intervene to mentor medical students more effectively about the satisfaction derived from a career in surgery. As part of this project, we have evaluated each step of the path through medical school and a surgical residency by comparing data for our students, residency programs, and faculty with national data.     

Changes in Murine Jejunal Morphology Evoked by the Bacterial Superantigen Staphylococcus aureus Enterotoxin B Are Mediated by CD4+ T Cells

Bacterial superantigens (SAgs) are potent T-cell stimuli that have been implicated in the pathophysiology of autoimmune and inflammatory disease. We used Staphylococcus aureus enterotoxin B (SEB) as a model SAg to assess the effects of SAg exposure on gut form and cellularity. BALB/c, SCID (lacking T cells) and T-cell-reconstituted SCID mice were treated with SEB (5 or 100 μg intraperitoneally), and segments of the mid-jejunum were removed 4, 12, or 48 h later and processed for histochemical or immunocytochemical analysis of gut morphology and major histocompatibility complex class II (MHC II) expression and the enumeration of CD3⁺ T cells and goblet cells. Control mice received saline only. SEB treatment of BALB/c mice caused a time- and dose-dependent enteropathy that was characterized by reduced villus height, increased crypt depth, and a significant increase in MHC II expression. An increase in the number of CD3⁺ T cells was observed 48 h after exposure to 100 μg of SEB. Enteric structural alterations were not apparent in SEB-treated SCID mice compared to saline-treated SCID mice. In contrast, SEB challenge of SCID mice reconstituted with a mixed lymphocyte population or purified murine CD4⁺ T cells resulted in enteric histopathological changes reminiscent of those observed in SEB-treated BALB/c mice. These findings implicate CD4⁺ T cells in this SEB-induced enteropathy. Our results show that SAg immune activation causes significant changes in jejunal villus-crypt architecture and cellularity that are likely to impact on normal physiological processes. We speculate that the elevated MHC II expression and increased number of T cells could allow for enhanced immune responsiveness to other SAgs or environmental antigens.Evidence from clinical observations, animal models of disease, and studies with cell lines indicate an intimate association between bacteria (and bacterial products) and the pathophysiology of enteric inflammatory and secretory disorders (28, 30). Moreover, significant tissue damage and abnormal physiology can be attributed to aberrant immune reactions, where T cells have been identified as a key cell type (5). A novel group of bacterial products have been identified that cross-link major histocompatibility complex class II (MHC II) molecules with a variable portion of the β chain (Vβ) of the T-cell receptor, binding beyond the antigen-specific site. These molecules do not require classical antigen-processing and presentation and can polyclonally stimulate up to 25% of T cells based on Vβ specificity, hence their designation as superantigens (SAgs) (8, 14). Skewed expression of T-cell receptor Vβ usage has been used to implicate SAgs in the pathogenesis of autoimmune and inflammatory disorders such as rheumatoid arthritis and diabetes (7, 27). More recently it has been postulated that SAgs could be involved in the initiation or exaggeration of inflammatory bowel disease in some patients (13, 29).Delineation of the physiological and pathophysiological effects, and mechanisms thereof, of exposure to SAgs has lagged behind the elucidation of the immunomodulatory properties of bacterial SAgs. The enterotoxins of the gram-positive Staphylococcus aureus are prototypic SAgs, and S. aureus enterotoxin B (SEB) has been used extensively as a model SAg to define the effects of these bacterial products on immune cells (14). Many elegant studies have shown that the murine immune response to SAgs is biphasic: an initial activation phase characterized by T-cell proliferation, cytokine production, and enhanced cytotoxic activity (10, 17, 25) is followed by a period of anergy and/or depletion of the appropriate Vβ-expressing T cells (32, 34). In beginning to define the enteric physiological consequences of exposure to bacterial SAgs, the objective of the present study was to assess the impact of SEB treatment on jejunal structure and cellularity in immunocompetent (BALB/c) and T-cell-deficient (severe combined immunodeficient [SCID]) mice. Our data demonstrate that SEB treatment of normal but not T-cell-deficient mice evokes a self-limiting enteropathy that is characterized by altered villus-crypt architecture, various degrees of histopathology, increased MHC II expression, and an increase in CD3⁺ T cells. We suggest that these changes will disrupt normal enteric physiological and homeostatic processes and have the potential to predispose the host to enhanced immune responsiveness to other antigens that gain access to the mucosa and/or submucosa.     

Risk of Depressive Symptoms Associated with Morbidity in Postpartum Women in Rural Bangladesh

Objectives Depression following pregnancy is common, but its extent and association with maternal morbidity in the first 6 months postpartum have not been well described in low resource settings such as rural Bangladesh. Methods We used data from a population-based, community trial of approximately 39,000 married rural Bangladeshi women aged 13–44 between 2001 and 2007 to examine the relation between women’s reported morbidity symptoms from childbirth to 3 months postpartum, and subsequent depressive symptoms assessed at 6 months postpartum. We calculated crude and adjusted risk ratios for depressive symptoms following women’s reports of reproductive, urinary, neurologic, nutrition and other illness measures constructed based on symptomatic reporting. Results In models adjusted for sociodemographic factors and co-morbidities, all postpartum illnesses were associated with an increased relative risk [RR, with 95% confidence intervals (CI) excluding 1] of depressive symptoms by 6 months postpartum. These morbidities included uterine prolapse (RR 1.20, 95% CI 1.04–1.39), urinary tract infection (RR 1.24, 95% CI 1.11–1.38), stress related incontinence (SRI) (RR 1.49, 95% 1.33–1.67), simultaneous SRI and continuously dripping urine (RR 1.60–2.96), headache [RR 1.20 (95% CI 1.12–1.28)], convulsions (RR 1.67, 95%CI 1.36–2.06), night blindness (RR 1.33, 95% CI 1.19–1.49), anemia (RR 1.38, 95% CI 1.31–1.46), pneumonia (RR 1.24, 95% CI 1.12–1.37), gastroenteritis (RR 1.24, 95% CI 1.17–1.31) and hepatobiliary disease (RR 2.10, 96% CI 1.69–2.60). Conclusions for Practice Illnesses during the first three postpartum months were risk factors for depressive symptoms, with the strongest associations noted for convulsions and hepatobiliary disease. Symptoms of depression may be of particular concern among women suffering from physical illnesses.Clinical trial registration: ClinicalTrials.gov NCT0019882.