Noncardiac surgery in the patient with congenital heart disease.

The patient with congenital heart disease who presents for noncardiac surgery requires careful evaluation and planning to avoid adverse perioperative events. This chapter presents a physiological approach to the management of anesthesia for the most common congenital heart lesions. The various congenital heart defects are categorized into lesions resulting in: (1) left-to-right shunting; (2) right-to-left shunting; (3) complete mixing of pulmonary and systemic circulation; (4) complete separation of the pulmonary and systemic circulations; (5) increased myocardial work; and (6) mechanical obstruction of the airway.     

Hodgkin's disease in association with Down syndrome: a case report

The increased incidence of malignancies, especially acute leukemia, in Down syndrome has been clearly established. The association of Hodgkin's disease with Down syndrome has not been extensively documented, and only a few cases have been reported. We present here a case report of Hodgkin's disease in an 11-year-old female child with Down syndrome. The child presented with a stage IVB nodular sclerotic Hodgkin's disease and died of progressive disease. We also present a brief review of the mechanisms of development of malignancy in Down syndrome.     

A macro approach to the explanation of physician distribution in Canada

Physician distribution is influenced by complex factors. It is generally argued that the probability of physician increase will be greater in areas that have more to offer in the way of social and economic advantages, This study examines the effects of selected demographic, socioeconomic, and environmental factors (e.g., population size, percent university educated, and hospital bed/population ratio) on the spatial distribution of physicians, using data for "active" civilian physicians obtained from Health and Welfare Canada. The findings indicate that the variable "percentage university educated" is the most important factor influencing physician distribution, once demographic and environmental factors are controlled. The higher the educational level of the population, the higher the physician/population ratio and the higher the proportion of children under age 5, the lower the physician/population ratio. Findings provide evidence of a concentration of physicians in high-status areas. A pattern of larger relative dispersion was also observed for physician/population ratios across areas for suburban dwellers.     

Neonatal effects of anesthesia for caesarean section

Seventy eight parturient mothers undergoing elective caesarean section were studied with regard to the immediate neonatal outcome in those receiving general and spinal anesthesia. All mothers were of grade I anesthesia risk, were term and had singleton appropriate for gestational age fetuses. There was no difference in fetal acid base chemistry in the two groups. Babies delivered after general anesthesia appeared relatively depressed requiring more free flow oxygen and bag and mask ventilation, though one minute Apgar scores showed no significant difference in either group. Induction delivery intervals were longer in the spinal group but it was not associated with more morbidity. Uterine incision delivery intervals were very small in both groups and no meaningful conclusion could be drawn as regards effect on the newborn. A plea is made for more frequent use of spinal anesthesia considering its many postnatal advantages.     

Tubercular spondylodiscitis in elderly is a more severe disease: a report of 66 consecutive patients

Purpose

(1) To analyze peculiarities of presentation and prognosis of tubercular spondylodiscitis (TBS) in elderly. (2) To assess if associated co-morbidities and risks lead to poorer outcome (3) To observe if different management strategy needs to be implemented in them.

Methods

Retrospective analysis of 66 consecutive elderly TBS patients (>60 years) treated conservatively or surgically between January 2010 and July 2013 was performed. Details regarding clinical presentation (general health, ambulatory status, co-morbidities), neurological status, medical or surgical complications and outcome measurements [visual analog score, clinico-radiological evidence of healing and lumbar lordosis in lumbar (L) or lumbo-sacral (LS) or focal kyphosis in thoracic (T) or thoraco-lumbar (TL) disease] were analysed.

Results

Of 66 patients (mean age 67.9 years), 85% had at least one medical co-morbidity and only 45% were community ambulators. Mean delay in presentation was 132 days and lumbar disease was commonest. 35% had neuro-deficit. Most patients had stage 2 (38%) or 3 (42.4%) disease. 19 patients were conservatively managed, while others underwent surgery. Significant complications occurred in 23 patients, most common being liver dysfunction (9 patients). Five patients (8%) expired during treatment: three succumbed to multi-focal tubercular disease, while two expired secondary to medical illnesses. Mean loss of lordosis in conservatively treated (CG) L/LS disease was 8°, while lordosis was restored by 11.6° in operative group (OG). In T/TL disease, sagittal alignment correction by 12.6° was observed in OG as against 5.7° kyphotic collapse in CG patients. 92% patients were cured with no recurrences. The final VAS scores in operative and conservative groups were not significantly different (OG 1.4 ± 0.6, CG 1.9 ± 0.7).

Conclusion

TBS in elderly differed from that in younger by having a higher co-morbidities, later presentation, higher neuro-deficit, greater mortality and increased complications. Nevertheless, in those who survived, clinico-radiological outcomes of both conservative and surgical treatments were good.

     

Carbaryl‐induced ototoxicity in rat postnatal cochlear organotypic cultures

Carbaryl, a widely used carbamate‐based insecticide, is a potent anticholinesterase known to induce delayed neurotoxicity following chronic exposure. However, its potential toxic effects on the cochlea, the sensory organ for hearing that contains cholinergic efferent neurons and acetylcholine receptors on the hair cells (HC) and spiral ganglion neurons has heretofore not been evaluated. To assess ototoxic potential of carbaryl, cochlear organotypic cultures from postnatal day 3 rats were treated with doses of carbaryl ranging from 50 to 500 μM for 48 h up to 96 h. Carbaryl damaged both the sensory HC and spiral ganglion neurons in a dose‐ and duration‐dependent manner. HC and neuronal damage was observed at carbaryl concentrations as low as 50 μM after 96‐h treatment and 100 μM after 48‐h treatment. Hair cell was greatest in the high frequency basal region of the cochlea and progressively decreased towards the apex consistent with the majority of ototoxic drugs. In contrast, damage to the spiral ganglion neurons was of similar magnitude in the basal and apical regions of the cochlea. Carbaryl damage was characterized by soma shrinkage, nuclear condensation and fragmentation, and blebbing, morphological features of programmed cell death. Carbaryl upregulated the expression of executioner caspase‐3 in HC and spiral ganglion neurons indicating that cellular damage occurred primarily by caspase‐mediated apoptosis. These results suggest that chronic exposure to carbaryl and other carbamate anticholinesterases may be ototoxic. © 2016 Wiley Periodicals, Inc. Environ Toxicol 32: 956–969, 2017.