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Abstract
PURPOSE OF REVIEW The present review examines how targeted approaches to care, based on individual variability in patient characteristics, could be applied in the perioperative setting. Such an approach would enhance individualized risk assessment and allow for targeted preventive and therapeutic decision-making in patients at increased risk for adverse perioperative events. RECENT FINDINGS Prior and current studies highlight valuable lessons on how future investigations attempting to link specific patient-related characteristics or treatment modalities with outcomes and adverse drug responses might be designed in the perioperative setting. SUMMARY Our review highlights the past, present, and future directions of perioperative precision medicine. Current evidence provides important lessons on how a specific patient and disease tailored approach can help perioperative physicians in delivering the most appropriate and safest perioperative care.
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Siddiqui M, Minhaj M, Mueller A, Tung A, Scavone B, Rana S, Shahul S. Increased Perinatal Morbidity and Mortality Among Asian American and Pacific Islander Women in the United States. Anesth Analg 2017; 124:879-886. [PMID: 28099290 DOI: 10.1213/ane.0000000000001778] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Asian American/Pacific Islanders (AAPIs) are the fastest-growing racial group in the United States. Despite a higher socioeconomic status, AAPI women experience higher rates of maternal morbidity and mortality. METHODS Using the National Inpatient Sample, we performed a retrospective cohort analysis of women who were hospitalized for delivery from 2002 to 2013. The primary outcome variable was inpatient mortality rate, and the presence of severe maternal morbidities was estimated using the Bateman Comorbidity Index, a validated tool for predicting obstetric morbidity. RESULTS AAPI women presenting for delivery between 2003 and 2012 were older, more likely to reside in a zip code in the top quartile of annual income, be privately insured than Caucasian women, and less likely to have a higher Bateman Comorbidity Index. However, AAPI women had a higher likelihood of postpartum hemorrhage (3.4% vs 2.7%, P < .001), uterine atony, severe perineal lacerations, and severe maternal morbidities. Procedures such as transfusion, hysterectomy, and mechanical ventilation were also more common in AAPI women. Furthermore, AAPI women had a higher mortality rate that persisted despite adjustment for an apparently higher income and comorbidities (odds ratio 1.72, 95% confidence interval: 1.14-2.59, P = .01). CONCLUSIONS Despite having a higher socioeconomic status, AAPI women had higher rates of maternal mortality during hospitalization for delivery. This increase persisted even after adjustment for factors known to affect peripartum outcomes. Further investigation is needed to better clarify the causes of racial differences in maternal morbidity and mortality.
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Affiliation(s)
- Maryam Siddiqui
- From the *Divisions of General Obstetrics & Gynecology and Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of Chicago, Chicago, Illinois; †Department of Anesthesia and Critical Care, University of Chicago, Chicago, Illinois; and ‡Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
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Konopka CK, Azzolin VF, Cadoná FC, Machado AK, Dornelles EB, Barbisan F, da Cruz IBM. Misoprostol modulates the gene expression prostaglandin E2 and oxidative stress markers in myometrial cells. Prostaglandins Other Lipid Mediat 2016; 126:38-45. [PMID: 27647508 DOI: 10.1016/j.prostaglandins.2016.09.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2016] [Revised: 09/03/2016] [Accepted: 09/15/2016] [Indexed: 10/21/2022]
Abstract
Misoprostol, prostaglandin E1 analogue, used for labour induction. However, one-third of patients who have labour induced with prostaglandins do not reach vaginal delivery. The differential expression of prostaglandin receptors in myometrial cells could account for this differential response. Since delivery physiology also involves modulation of oxidative metabolism that can be potentially affected by pharmacological drugs, in the present investigation the role of misoprostol on expression of prostaglandin receptors, and oxidative markers of myometrial cells was evaluated. Samples of myometrial tissues procured from women with spontaneous (SL) and nonspontaneous (NSL) labours were cultured in vitro and exposed to different concentrations of misoprostol. Gene expression was evaluated by qRT-PCR and oxidative biomarkers were evaluated by spectrophotometric and fluorometric analysis. Cells from SL women presented greater responsiveness to misoprostol, since an upregulation of genes related to increased muscle contraction was observed. Otherwise, cells from NSL women had low responsiveness to misoprostol exposure or even a suppressive effect on the expression of these genes. Oxidative biomarkers that previously have been related to labour physiology were affected by misoprostol treatment: lipoperoxidation and protein carbonylation (PC). However, a decrease in lipoperoxidation was observed only in SL cells treated with low concentrations of misoprostol, whereas a decrease of PC occurred in all samples treated with different misoprostol concentrations. The results suggest a pharmacogenetic effect of misoprostol in labour induction involving differential regulation of EP receptor genes, as well as some minor differential modulation of oxidative metabolism in myometrial cells.
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Affiliation(s)
- Cristine Kolling Konopka
- Graduating Program in Pharmacology, Center of Health Sciences, Federal University of Santa Maria, Av. Roraima 1000, Prédio 21, Zip code: 97105-900 Santa Maria-RS, Brazil; Department of Gynecology and Obstetrics, Center of Health Sciences, Federal University of Santa Maria, Av. Roraima 1000, Prédio 26, Zip code: 97105-900 Santa Maria, RS, Brazil.
| | - Verônica Farina Azzolin
- Graduating Program in Pharmacology, Center of Health Sciences, Federal University of Santa Maria, Av. Roraima 1000, Prédio 21, Zip code: 97105-900 Santa Maria-RS, Brazil.
| | - Francine Carla Cadoná
- Graduating Program in Toxicological Biochemistry, Center of Natural and Exact Sciences, Federal University of Santa Maria, Av. Roraima 1000, Prédio 18, Zip code: 97105-900 Santa Maria-RS, Brazil.
| | - Alencar Kolinski Machado
- Graduating Program in Pharmacology, Center of Health Sciences, Federal University of Santa Maria, Av. Roraima 1000, Prédio 21, Zip code: 97105-900 Santa Maria-RS, Brazil.
| | - Eduardo Bortoluzzi Dornelles
- Graduating Program in Toxicological Biochemistry, Center of Natural and Exact Sciences, Federal University of Santa Maria, Av. Roraima 1000, Prédio 18, Zip code: 97105-900 Santa Maria-RS, Brazil.
| | - Fernanda Barbisan
- Graduating Program in Pharmacology, Center of Health Sciences, Federal University of Santa Maria, Av. Roraima 1000, Prédio 21, Zip code: 97105-900 Santa Maria-RS, Brazil.
| | - Ivana Beatrice Mânica da Cruz
- Program in Pharmacology, Center of Health Sciences, Federal University of Santa Maria, Av. Roraima 1000, Prédio 21, Zip code: 97105-900 Santa Maria-RS, Brazil.
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Flood P, Dexter F, Ledolter J, Dutton RP. Large Heterogeneity in Mean Durations of Labor Analgesia Among Hospitals Reporting to the American Society of Anesthesiologists’ Anesthesia Quality Institute. Anesth Analg 2015; 121:1283-9. [DOI: 10.1213/ane.0000000000000897] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Miller R, Smiley R, Thom EA, Grobman WA, Iams JD, Mercer BM, Saade G, Tita AT, Reddy UM, Rouse DJ, Sorokin Y, Blackwell SC, Esplin MS, Tolosa JE, Caritis SN. The association of beta-2 adrenoceptor genotype with short-cervix mediated preterm birth: a case-control study. BJOG 2015; 122:1387-94. [PMID: 25600430 PMCID: PMC4508241 DOI: 10.1111/1471-0528.13243] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/31/2014] [Indexed: 12/19/2022]
Abstract
OBJECTIVE To determine whether β2 -adrenoceptor (β2 AR) genotype is associated with shortening of the cervix or with preterm birth (PTB) risk among women with a short cervix in the second trimester. DESIGN A case-control ancillary study to a multicentre randomised controlled trial. SETTING Fourteen participating centres of the Maternal-Fetal Medicine Units Network of the Eunice Kennedy Shriver National Institute of Child Health and Human Development. POPULATION Four hundred thirty-nine women, including 315 with short cervix and 124 with normal cervical length. METHODS Nulliparous women with cervical length <30 mm upon a 16-22-week transvaginal sonogram and controls frequency-matched for race/ethnicity with cervical lengths ≥40 mm were studied. β2 AR genotype was determined at positions encoding for amino acid residues 16 and 27. MAIN OUTCOME MEASURES Genotype distributions were compared between case and control groups. Within the short cervix group, pregnancy outcomes were compared by genotype, with a primary outcome of PTB <37 weeks. RESULTS Genotype data were available at position 16 for 433 women and at position 27 for 437. Using a recessive model testing for association between short cervix and genotype, and adjusted for ethnicity, there was no statistical difference between cases and controls for Arg16 homozygosity (OR 0.7, 95% CI 0.4-1.3) or Gln27 homozygosity (OR 0.9, 95% CI 0.3-2.7). Among cases, Arg16 homozygosity was not associated with protection from PTB or spontaneous PTB. Gln27 homozygosity was not associated with PTB risk, although sample size was limited. CONCLUSIONS β2 AR genotype does not seem to be associated with short cervical length or with PTB following the second-trimester identification of a short cervix. Influences on PTB associated with β2 AR genotype do not appear to involve a short cervix pathway.
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Affiliation(s)
- R Miller
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Columbia University College of Physicians and Surgeons, New York, NY, USA
| | - R Smiley
- Division of Obstetrical Anesthesiology, Department of Anesthesiology, Columbia University College of Physicians and Surgeons, New York, NY, USA
| | - E A Thom
- The George Washington University Biostatistics Center, Washington, DC, USA
| | - W A Grobman
- Departments of Obstetrics and Gynecology, Northwestern University, Chicago, IL, USA
| | - J D Iams
- The Ohio State University, Columbus, OH, USA
| | - B M Mercer
- Case Western Reserve University-MetroHealth Medical Center, Cleveland, OH, USA
| | - G Saade
- University of Texas Medical Branch, Galveston, TX, USA
| | - A T Tita
- University of Alabama at Birmingham, Birmingham, AL, USA
| | - U M Reddy
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD, USA
| | - D J Rouse
- Brown University, Providence, RI, USA
| | - Y Sorokin
- Wayne State University, Detroit, MI, USA
| | - S C Blackwell
- The University of Texas Health Science Center at Houston-Children's Memorial Hermann Hospital, Houston, TX, USA
| | - M S Esplin
- University of Utah Health Sciences Center, Salt Lake City, UT, USA
| | - J E Tolosa
- Oregon Health and Science University, Portland, OR, USA
| | - S N Caritis
- University of Pittsburgh, Pittsburgh, PA, USA
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Ahles A, Engelhardt S. Polymorphic Variants of Adrenoceptors: Pharmacology, Physiology, and Role in Disease. Pharmacol Rev 2014; 66:598-637. [DOI: 10.1124/pr.113.008219] [Citation(s) in RCA: 75] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
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Abstract
Studies on genetic contributions to labor analgesia have essentially evaluated the μ-opioid receptor gene (OPRM1), with some evidence that p.118A/G of OPRM1 influences the response to neuraxial opioids. As for labor progress, the β2-adrenergic receptor gene (ADRB2) is associated with preterm labor and delivery, and impacts the course of labor. Taken together though, there is no evidence that pharmacogenetic testing is needed or beneficial in the context of obstetric anesthesia; however, realizing the influence of genetic variants on specific phenotypes provides the rationale for a more cautious interpretation of clinical studies that attempt to find a dose-regimen that fits all.
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Affiliation(s)
- Ruth Landau
- Department of Anesthesiology and Pain Medicine, University of Washington Medical Center, 1959 NE Pacific Street, Seattle, WA 98195-6540, USA.
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2012 Gerard W. Ostheimer Lecture – What’s new in obstetric anesthesia? Int J Obstet Anesth 2012; 21:348-56. [DOI: 10.1016/j.ijoa.2012.08.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2012] [Accepted: 08/09/2012] [Indexed: 11/23/2022]
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Terkawi AS, Jackson WM, Thiet MP, Hansoti S, Tabassum R, Flood P. Oxytocin and catechol-O-methyltransferase receptor genotype predict the length of the first stage of labor. Am J Obstet Gynecol 2012; 207:184.e1-8. [PMID: 22939719 DOI: 10.1016/j.ajog.2012.06.079] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2012] [Revised: 05/13/2012] [Accepted: 06/28/2012] [Indexed: 11/16/2022]
Abstract
OBJECTIVE We aimed to identify genetic factors that influence the rate of the first stage of labor. STUDY DESIGN We prospectively enrolled 233 laboring nulliparous parturients. Demographic, clinical, and genetic data were collected. We evaluated the influence of population and individual variability using a nonlinear mixed effects model. RESULTS Parturients who were homozygous for "G" at oxytocin receptor gene rs53576 transitioned to active labor later and thus had slower labor. Catechol-O-methyltransferase rs4633 genotype TT was associated with slower latent phase labor. Labor induction with prostaglandin was associated with faster labor, and request for meperidine was associated with slower labor. Birthweight was related inversely to the rate of the active phase. CONCLUSION There are demographic, clinical, and genetic factors that influence an individual's rate of labor progress. This information could be used in automated form to improve the prediction of the length of the first stage of labor.
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Affiliation(s)
- Abdullah S Terkawi
- Department of Anesthesiology, King Farad Medical City, Riyadh, Saudi Arabia
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