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Naylor AJ, Sessler DI, Maheshwari K, Khanna AK, Yang D, Mascha EJ, Suleiman I, Reville EM, Cote D, Hutcherson MT, Nguyen BM, Elsharkawy H, Kurz A. Arterial Catheters for Early Detection and Treatment of Hypotension During Major Noncardiac Surgery: A Randomized Trial. Anesth Analg 2020; 131:1540-1550. [PMID: 33079877 DOI: 10.1213/ane.0000000000004370] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Continuous blood pressure monitoring may facilitate early detection and prompt treatment of hypotension. We tested the hypothesis that area under the curve (AUC) mean arterial pressure (MAP) <65 mm Hg is reduced by continuous invasive arterial pressure monitoring. METHODS Adults having noncardiac surgery were randomly assigned to continuous invasive arterial pressure or intermittent oscillometric blood pressure monitoring. Arterial catheter pressures were recorded at 1-minute intervals; oscillometric pressures were typically recorded at 5-minute intervals. We estimated the arterial catheter effect on AUC-MAP <65 mm Hg using a multivariable proportional odds model adjusting for imbalanced baseline variables and duration of surgery. Pressures <65 mm Hg were categorized as 0, 1-17, 18-91, and >91 mm Hg × minutes of AUC-MAP <65 mm Hg (ie, no hypotension and 3 equally sized groups of increasing hypotension). RESULTS One hundred fifty-two patients were randomly assigned to arterial catheter use and 154 to oscillometric monitoring. For various clinical reasons, 143 patients received an arterial catheter, while 163 were monitored oscillometrically. There were a median [Q1, Q3] of 246 [187, 308] pressure measurements in patients with arterial catheters versus 55 (46, 75) measurements in patients monitored oscillometrically. In the primary intent-to-treat analysis, catheter-based monitoring increased detection of AUC-MAP <65 mm Hg, with an estimated proportional odds ratio (ie, odds of being in a worse hypotension category) of 1.78 (95% confidence interval [CI], 1.18-2.70; P = .006). The result was robust over an as-treated analysis and for sensitivity analyses with thresholds of 60 and 70 mm Hg. CONCLUSIONS Intraoperative blood pressure monitoring with arterial catheters detected nearly twice as much hypotension as oscillometric measurements.
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Affiliation(s)
| | | | | | - Ashish K Khanna
- From the Departments of Outcomes Research
- General Anesthesiology
| | - Dongsheng Yang
- From the Departments of Outcomes Research
- Quantitative Health Sciences, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio
| | - Edward J Mascha
- From the Departments of Outcomes Research
- Quantitative Health Sciences, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio
| | | | | | - Devan Cote
- From the Departments of Outcomes Research
| | | | | | | | - Andrea Kurz
- From the Departments of Outcomes Research
- General Anesthesiology
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Nicholson GP, Rao AJ, Naylor AJ, Waterman BR, O'Brien MC, Romeo AA, Cohen MS. Return to sporting activity after ulnar nerve transposition for isolated neuritis in competitive overhead athletes. J Shoulder Elbow Surg 2020; 29:1401-1405. [PMID: 32418855 DOI: 10.1016/j.jse.2020.02.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2019] [Revised: 01/28/2020] [Accepted: 02/02/2020] [Indexed: 02/01/2023]
Abstract
BACKGROUND Although ulnar neuritis can occur secondary to ulnar collateral ligament pathology, stress fractures, and traction apophysitis, isolated ulnar nerve dysfunction can lead to medial elbow pain. The purpose of this study was to evaluate the short-term outcomes of overhead athletes undergoing anterior ulnar nerve transposition for ulnar neuropathy. METHODS All overhead athletes who underwent isolated ulnar nerve transposition between 2009 and 2016 for refractory ulnar neuritis were identified. The primary outcome was return to sport, and secondary outcome measures included the Kerlan-Jobe Orthopaedic Clinic score; Mayo Elbow Performance Score; Quick Disabilities of the Arm, Shoulder and Hand score; Single Assessment Numeric Evaluation score; and visual analog scale score for pain. Complication and reoperation rates were recorded. RESULTS A total of 26 overhead athletes (21 male and 5 female athletes) underwent ulnar nerve transposition at an average age of 18.4 years (range, 11-25 years). Of the patients, 24 (92%) returned to their sporting activity at an average of 2.7 months postoperatively, including 16 (62%) at the previous level of play. The average visual analog scale pain score improved from 4.7 (±2.5) to 0.4 (±1.5) (P = .015). The average postoperative patient-reported outcome scores were as follows: Kerlan-Jobe Orthopaedic Clinic score, 80 (95% confidence interval [CI], 72.7-87.0); Single Assessment Numeric Evaluation score, 85 (95% CI, 75.4-94.7); Quick Disabilities of the Arm, Shoulder and Hand score, 5 (95% CI, 2.1-7.7); and Mayo Elbow Performance Score, 91 (95% CI, 86.8-96.0). CONCLUSION Cubital tunnel syndrome can cause medial elbow pain in overhead athletes in the presence of a normal ulnar collateral ligament. At mid-term follow-up, 92% of overhead athletes returned to sport after ulnar nerve transposition, with 62% resuming their previous level of performance.
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Affiliation(s)
- Gregory P Nicholson
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA.
| | - Allison J Rao
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Amanda J Naylor
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Brian R Waterman
- Department of Orthopaedic Surgery, Wake Forest Baptist Health, Winston-Salem, NC, USA
| | | | | | - Mark S Cohen
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA
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Otte RS, Naylor AJ, Blanchard KN, Cancienne JM, Chan W, Romeo AA, Garrigues GE, Nicholson GP. Salvage reverse total shoulder arthroplasty for failed anatomic total shoulder arthroplasty: a cohort analysis. J Shoulder Elbow Surg 2020; 29:S134-S138. [PMID: 32643607 DOI: 10.1016/j.jse.2020.04.013] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Revised: 03/29/2020] [Accepted: 04/01/2020] [Indexed: 02/01/2023]
Abstract
BACKGROUND Reverse total shoulder arthroplasty (RTSA) as a revision procedure for failed anatomic total shoulder arthroplasty (TSA) is increasing in incidence. The purpose of this study was to analyze the results of RTSA as a revision salvage procedure for failed TSA and identify factors that influenced those outcomes. METHODS All anatomic TSAs that were revised to RTSAs in adult patients, under the care of 2 senior surgeons at a single academic center from 2006 to 2018, were queried and reviewed. Cases in which hemiarthroplasty or RTSA was revised to RTSA were excluded. Electronic medical records and survey databases were reviewed for each subject. Demographic and surgical details were reviewed and analyzed with descriptive statistics. Preoperative and postoperative range of motion (ROM) including active forward elevation and active external rotation were evaluated. Patient-reported outcome surveys including the American Shoulder and Elbow Surgeons survey, Single Assessment Numeric Evaluation, and visual analog scale for pain were collected and analyzed. Improvement in ROM and outcome survey measures was assessed with 2-sample t tests. Complication and reoperation rates were analyzed with descriptive statistics. RESULTS A total of 75 patients (32 men and 43 women) were available for analysis at a mean of 22.3 months. The subjects were aged 60.3 ± 11.3 years at the time of TSA and 64.6 ± 9.7 years at the time of RTSA. The average period between TSA and RTSA was 4.3 years. The 3 most common indications for revision RTSA were painful arthroplasty (n = 62, 82.7%), rotator cuff failure (n = 56, 74.7%), and unstable arthroplasty (n = 25, 33.3%), but the majority of patients had multiple indications for surgery (n = 69, 92%). Significant improvements were found in all outcome measures from the time of failed TSA diagnosis to most recent follow-up after salvage RTSA with the exception of active external rotation: American Shoulder and Elbow Surgeons score, 39 ± 15 preoperatively vs. 62 ± 25 postoperatively; Single Assessment Numeric Evaluation, 27 ± 23 vs. 60 ± 30; visual analog scale pain score, 5 ± 2 vs. 3 ± 3; and active forward elevation, 79° ± 41° vs. 128° ± 33°. Major complications occurred in 21 patients (28.4%) after salvage RTSA, and 9 (12%) underwent reoperation. CONCLUSIONS RTSA for failed TSA can improve pain, function, and quality-of-life measures in patients with various TSA failure etiologies. However, postoperative ROM and patient-reported outcomes do not reach the values seen in the primary RTSA population.
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Affiliation(s)
| | - Amanda J Naylor
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA
| | | | | | - William Chan
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA
| | | | - Grant E Garrigues
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Gregory P Nicholson
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA.
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Cvetanovich GL, Naylor AJ, O'Brien MC, Waterman BR, Garcia GH, Nicholson GP. Anatomic total shoulder arthroplasty with an inlay glenoid component: clinical outcomes and return to activity. J Shoulder Elbow Surg 2020; 29:1188-1196. [PMID: 31899092 DOI: 10.1016/j.jse.2019.10.003] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Revised: 10/03/2019] [Accepted: 10/20/2019] [Indexed: 02/01/2023]
Abstract
BACKGROUND Biomechanical studies show that inlay glenoid components in total shoulder arthroplasty (TSA) can reduce edge loading and opposite-edge lift-off forces with humeral translation compared with onlay glenoids. However, clinical data for these implants are lacking. We report clinical outcomes and return to activities after anatomic TSA with an inlay glenoid component and a stemless ovoid humeral head in an active, young patient population. METHODS A retrospective review of TSA with an inlay glenoid component and an ovoid humeral head component was performed for 27 shoulders. Patients were evaluated with patient-reported outcome measures, range of motion, and radiographs. Return to occupational and sporting activity, complications, and reoperations were analyzed. RESULTS A total of 27 shoulders were available for minimum 2-year follow-up. Age averaged 52.1 years, and 92.6% of shoulders were in male patients. The preoperative Walch grade was A1 or A2 in 15 shoulders (55%), B1 in 8 (30%), and B2 in 4 (15%). Patients showed significant improvements in patient-reported outcome measures, active forward flexion, and external rotation (P < .001) with no reoperations. At an average of 3.7 months, the rate of return to work was 92.6%, with 76.0% of those patients returning to their preoperative occupational demand level. At an average of 9.1 months, 75% of patients who responded to our custom survey returned to sport, with 50% achieving the same level or a higher level of sporting activity. Annual postoperative radiographs revealed no inlay component loosening. CONCLUSION Anatomic TSA with an inlay glenoid coupled with a stemless ovoid humeral head in an active population resulted in improved clinical outcomes, no reoperations or radiographic loosening, and a high rate of return to activity at shorter-term follow-up.
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Affiliation(s)
- Gregory L Cvetanovich
- Department of Orthopaedic Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Amanda J Naylor
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA
| | | | - Brian R Waterman
- Department of Orthopaedic Surgery, Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | | | - Gregory P Nicholson
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA.
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Rao AJ, MacLean IS, Naylor AJ, Garrigues GE, Verma NN, Nicholson GP. Next-generation sequencing for diagnosis of infection: is more sensitive really better? J Shoulder Elbow Surg 2020; 29:20-26. [PMID: 31619355 DOI: 10.1016/j.jse.2019.07.039] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2019] [Revised: 07/23/2019] [Accepted: 07/28/2019] [Indexed: 02/01/2023]
Abstract
BACKGROUND The utility of next-generation sequencing (NGS) in differentiating between active infection and contaminant or baseline flora remains unclear. The purpose of this study is to compare NGS with culture-based methods in primary shoulder arthroplasty. METHODS A prospective series of primary shoulder arthroplasty patients with no history of infection or antibiotic use within 60 days of surgery was enrolled. All patients received standard perioperative antibiotics. After skin incision, a 10 × 3-mm sample of the medial skin edge was excised. A 2 × 2-cm synovial tissue biopsy was taken from the rotator interval after subscapularis takedown. Each sample set was halved and sent for NGS and standard cultures. RESULTS Samples from 25 patients were analyzed. Standard aerobic/anaerobic cultures were positive in 10 skin samples (40%, 95% confidence interval [CI] 20%-60%) and 3 deep tissue samples (12%, 90% CI 1%-23%]). NGS detected ≥1 bacterial species in 17 of the skin samples (68%, 95% CI 49%-87%) and 7 deep tissue samples (28%, 95% CI 9%-47%). There was a significant difference (P < .03) in the mean number of bacterial species detected with NGS between the positive standard culture (1.6 species) and the negative standard culture groups (5.7 species). CONCLUSION NGS identified bacteria at higher rates in skin and deep tissue samples than standard culture did in native, uninfected patients undergoing primary procedures. Further research is needed to determine which NGS results are clinically relevant and which are false positives before NGS can be reliably used in orthopedic cases.
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Affiliation(s)
- Allison J Rao
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Ian S MacLean
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Amanda J Naylor
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Grant E Garrigues
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Nikhil N Verma
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Gregory P Nicholson
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA.
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Ruetzler K, Lin P, You J, Schacham Y, Naylor AJ, Sessler DI, Saager L. The Association Between Timing of Routine Preoperative Blood Testing and a Composite of 30-Day Postoperative Morbidity and Mortality. Anesth Analg 2019; 127:897-903. [PMID: 29505442 DOI: 10.1213/ane.0000000000003300] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
BACKGROUND Laboratory testing is a common component of preanesthesia evaluation and is designed to identify medical abnormalities that might otherwise remain undetected. While blood testing might optimally be performed shortly before surgery, it is often done earlier for practical reasons. We tested the hypothesis that longer periods between preoperative laboratory testing and surgery are associated with increased odds of having a composite of 30-day morbidity and mortality. METHODS We obtained preoperative data from 2,320,920 patients in the American College of Surgeons National Surgical Quality Improvement Program who were treated between 2005 and 2012. Our analysis was restricted to relatively healthy patients with American Society of Anesthesiology physical status I-II who had elective surgery and normal blood test results (n = 235,010). The primary relationship of interest was the odds of 30-day morbidity and mortality as a function of delay between preoperative testing and surgery. A multivariable logistic regression model was used for the 10 pairwise comparisons among the 5 laboratory timing groups (laboratory blood tests within 1 week of surgery; 1-2 weeks; 2-4 weeks; 1-2 months; and 2-3 months) on 30-day morbidity, adjusting for any imbalanced baseline covariables and type of surgery. RESULTS A total of 4082 patients (1.74%) had at least one of the component morbidities or died within 30-days after surgery. The observed incidence (unadjusted) was 1.7% when the most recent laboratory blood tests measured within 1 week of surgery, 1.7% when it was within 1-2 weeks, 1.8% when it was within 2-4 weeks, 1.7% when it was between 1 and 2 months, and 2.0% for patients with most recent laboratory blood tests measured 2-3 months before surgery. None of the values within 2 months differed significantly: estimated odds ratios for patients within blood tested within 1 week were 1.00 (99.5% confidence interval, 0.89-1.12) as compared to 1-2 weeks, 0.88 (0.77-1.00) for 2-4 weeks, and 0.95 (0.79-1.14) for 1-2 months, respectively. The estimated odds ratio comparing 1-2 weeks to each of 2-4 weeks and 1-2 months were 0.88 (0.76-1.03) and 0.95 (0.78-1.16), respectively. Blood testing 2-3 months before surgery was associated with increased odds of outcome compared to patients whose most recent test was within 1 week (P = .002) and 1-2 weeks of the date of surgery. CONCLUSIONS In American Society of Anesthesiologists physical status I and II patients, risk of 30-day morbidity and mortality was not different with blood testing up to 2 months before surgery, suggesting that it is unnecessary to retest patients shortly before surgery.
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Affiliation(s)
- Kurt Ruetzler
- From the Departments of Outcomes Research.,General Anesthesiology, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio
| | - Peirong Lin
- Outcomes Research Consortium, Cleveland, Ohio.,Center for Anesthesia, Beijing Anzhen Hospital Capital Medical University, Beijing, China
| | - Jing You
- From the Departments of Outcomes Research.,Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio
| | | | | | | | - Leif Saager
- Outcomes Research Consortium, Cleveland, Ohio.,Department of Anesthesiology, University of Michigan, Ann Arbor, Michigan
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Babazade R, Saasouh W, Naylor AJ, Makarova N, Udeh CI, Turan A, Udeh BL. The cost-effectiveness of epidural, patient-controlled intravenous opioid analgesia, or transversus abdominis plane infiltration with liposomal bupivacaine for postoperative pain management. J Clin Anesth 2018; 53:56-63. [PMID: 30326379 DOI: 10.1016/j.jclinane.2018.10.003] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2018] [Revised: 09/29/2018] [Accepted: 10/07/2018] [Indexed: 12/27/2022]
Abstract
STUDY OBJECTIVE Intravenous patient-controlled opioid analgesia (IVPCA), epidural analgesia and transversus abdominis plane (TAP) infiltrations are frequently used postoperative pain management modalities. The aim of this study was to conduct a cost-effectiveness analysis comparing the use of epidural, IVPCA, and TAP infiltrations with liposomal bupivacaine for analgesia in the first 72 h postoperatively in patients undergoing major lower abdominal surgery. DESIGN Retrospective cost effectiveness analysis. SETTING Operating room. PATIENTS We obtained data on major lower-abdominal surgeries performed under general anesthesia on adult patients between January 2012 and July 2014. INTERVENTIONS A cost-effectiveness analysis was comparing the use of epidural, IVPCA, and TAP infiltrations with liposomal bupivacaine for analgesia in the first 72 h postoperatively. MEASUREMENTS A decision analytic model was used to estimate the health outcomes for patients undergoing major lower abdominal surgery. The primary outcome was time-weighted pain from 0 to 72 h after surgery, as measured by numerical rating scale pain scores. The analysis was conducted from the perspective of the hospital as the party responsible for most costs related to surgery. MAIN RESULTS From the base case analysis, IVPCA was the optimal strategy regarding cost and effect. TAP with LB, however, was only narrowly dominated, while epidural was clearly dominated. From the sensitivity analysis at willingness-to-pay (WTP) of $150, IV PCA and TAP infiltration were each the optimal strategy for approximately 50% of the iterations. At WTP of $10,000, epidural was only the optimal strategy in 10% of the iterations. CONCLUSIONS This is the first study in the literature to compare the cost-effectiveness of epidural, IVPCA, and TAP infiltrations with LB. Within reasonable WTP values, there is little differentiation in cost-effectiveness between IVPCA and TAP infiltration with LB. Epidural does not become a cost-effective strategy even at much higher WTP values.
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Affiliation(s)
- Rovnat Babazade
- Department of Anesthesiology, University of Texas Medical Branch, Galveston, TX, USA; Outcomes Research Consortium, Cleveland Clinic, OH, USA
| | - Wael Saasouh
- Department of Outcomes Research, Cleveland Clinic, Cleveland, OH, USA
| | - Amanda J Naylor
- Department of Outcomes Research, Cleveland Clinic, Cleveland, OH, USA
| | - Natalya Makarova
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH, USA
| | - Chiedozie I Udeh
- Department of Cardiothoracic Anesthesiology and the Center for Critical Care, Cleveland Clinic, Cleveland, OH, USA
| | - Alparslan Turan
- Department of Outcomes Research, Cleveland Clinic, Cleveland, OH, USA.
| | - Belinda L Udeh
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH, USA; Quality Institute, and Neurology Institute Center for Outcomes Research (NICORe), USA
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Hardy RS, Fenton C, Croft AP, Naylor AJ, Begum R, Desanti G, Buckley CD, Lavery G, Cooper MS, Raza K. 11 Beta-hydroxysteroid dehydrogenase type 1 regulates synovitis, joint destruction, and systemic bone loss in chronic polyarthritis. J Autoimmun 2018; 92:104-113. [PMID: 29891135 PMCID: PMC6066611 DOI: 10.1016/j.jaut.2018.05.010] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2018] [Revised: 05/25/2018] [Accepted: 05/29/2018] [Indexed: 01/15/2023]
Abstract
OBJECTIVE In rheumatoid arthritis, the enzyme 11 beta-hydroxysteroid dehydrogenase type 1 (11β-HSD1) is highly expressed at sites of inflammation, where it converts inactive glucocorticoids (GC) to their active counterparts. In conditions of GC excess it has been shown to be a critical regulator of muscle wasting and bone loss. Here we examine the contribution of 11β-HSD1 to the pathology of persistent chronic inflammatory disease. METHODS To determine the contribution of 11β-HSD1 to joint inflammation, destruction and systemic bone loss associated with persistent inflammatory arthritis, we generated mice with global and mesenchymal specific 11β-HSD1 deletions in the TNF-transgenic (TNF-tg) model of chronic polyarthritis. Disease severity was determined by clinical scoring. Histology was assessed in formalin fixed sections and fluorescence-activated cell sorting (FACS) analysis of synovial tissue was performed. Local and systemic bone loss were measured by micro computed tomography (micro-CT). Measures of inflammation and bone metabolism were assessed in serum and in tibia mRNA. RESULTS Global deletion of 11β-HSD1 drove an enhanced inflammatory phenotype, characterised by florid synovitis, joint destruction and systemic bone loss. This was associated with increased pannus invasion into subchondral bone, a marked polarisation towards pro-inflammatory M1 macrophages at sites of inflammation and increased osteoclast numbers. Targeted mesenchymal deletion of 11β-HSD1 failed to recapitulate this phenotype suggesting that 11β-HSD1 within leukocytes mediate its protective actions in vivo. CONCLUSIONS We demonstrate a fundamental role for 11β-HSD1 in the suppression of synovitis, joint destruction, and systemic bone loss. Whilst a role for 11β-HSD1 inhibitors has been proposed for metabolic complications in inflammatory diseases, our study suggests that this approach would greatly exacerbate disease severity.
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Affiliation(s)
- R S Hardy
- Institute of Inflammation and Ageing, ARUK Rheumatoid Arthritis Centre of Excellence, MRC ARUK Centre for Musculoskeletal Ageing, University of Birmingham, Birmingham, UK; Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK.
| | - C Fenton
- Institute of Inflammation and Ageing, ARUK Rheumatoid Arthritis Centre of Excellence, MRC ARUK Centre for Musculoskeletal Ageing, University of Birmingham, Birmingham, UK; Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
| | - A P Croft
- Institute of Inflammation and Ageing, ARUK Rheumatoid Arthritis Centre of Excellence, MRC ARUK Centre for Musculoskeletal Ageing, University of Birmingham, Birmingham, UK
| | - A J Naylor
- Institute of Inflammation and Ageing, ARUK Rheumatoid Arthritis Centre of Excellence, MRC ARUK Centre for Musculoskeletal Ageing, University of Birmingham, Birmingham, UK
| | - R Begum
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
| | - G Desanti
- Institute of Inflammation and Ageing, ARUK Rheumatoid Arthritis Centre of Excellence, MRC ARUK Centre for Musculoskeletal Ageing, University of Birmingham, Birmingham, UK
| | - C D Buckley
- Institute of Inflammation and Ageing, ARUK Rheumatoid Arthritis Centre of Excellence, MRC ARUK Centre for Musculoskeletal Ageing, University of Birmingham, Birmingham, UK
| | - G Lavery
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK; Centre for Endocrinology, Diabetes and Metabolism, UK
| | - M S Cooper
- ANZAC Research Institute, University of Sydney, Sydney, Australia
| | - K Raza
- Institute of Inflammation and Ageing, ARUK Rheumatoid Arthritis Centre of Excellence, MRC ARUK Centre for Musculoskeletal Ageing, University of Birmingham, Birmingham, UK; Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, UK
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Belcher AW, Khanna AK, Leung S, Naylor AJ, Hutcherson MT, Nguyen BM, Makarova N, Sessler DI, Devereaux P, Saager L. Long-Acting Patient-Controlled Opioids Are Not Associated With More Postoperative Hypoxemia Than Short-Acting Patient-Controlled Opioids After Noncardiac Surgery. Anesth Analg 2016; 123:1471-1479. [DOI: 10.1213/ane.0000000000001534] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
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Ross EA, Naylor AJ, O'Neil JD, Crowley T, Ridley ML, Crowe J, Smallie T, Tang TJ, Turner JD, Norling LV, Dominguez S, Perlman H, Verrills NM, Kollias G, Vitek MP, Filer A, Buckley CD, Dean JL, Clark AR. Treatment of inflammatory arthritis via targeting of tristetraprolin, a master regulator of pro-inflammatory gene expression. Ann Rheum Dis 2016; 76:612-619. [PMID: 27597652 PMCID: PMC5446007 DOI: 10.1136/annrheumdis-2016-209424] [Citation(s) in RCA: 51] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2016] [Revised: 08/10/2016] [Accepted: 08/11/2016] [Indexed: 02/07/2023]
Abstract
OBJECTIVES Tristetraprolin (TTP), a negative regulator of many pro-inflammatory genes, is strongly expressed in rheumatoid synovial cells. The mitogen-activated protein kinase (MAPK) p38 pathway mediates the inactivation of TTP via phosphorylation of two serine residues. We wished to test the hypothesis that these phosphorylations contribute to the development of inflammatory arthritis, and that, conversely, joint inflammation may be inhibited by promoting the dephosphorylation and activation of TTP. METHODS The expression of TTP and its relationship with MAPK p38 activity were examined in non-inflamed and rheumatoid arthritis (RA) synovial tissue. Experimental arthritis was induced in a genetically modified mouse strain, in which endogenous TTP cannot be phosphorylated and inactivated. In vitro and in vivo experiments were performed to test anti-inflammatory effects of compounds that activate the protein phosphatase 2A (PP2A) and promote dephosphorylation of TTP. RESULTS TTP expression was significantly higher in RA than non-inflamed synovium, detected in macrophages, vascular endothelial cells and some fibroblasts and co-localised with MAPK p38 activation. Substitution of TTP phosphorylation sites conferred dramatic protection against inflammatory arthritis in mice. Two distinct PP2A agonists also reduced inflammation and prevented bone erosion. In vitro anti-inflammatory effects of PP2A agonism were mediated by TTP activation. CONCLUSIONS The phosphorylation state of TTP is a critical determinant of inflammatory responses, and a tractable target for novel anti-inflammatory treatments.
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Affiliation(s)
- E A Ross
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - A J Naylor
- Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK
| | - J D O'Neil
- Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK
| | - T Crowley
- Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK
| | - M L Ridley
- Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK
| | - J Crowe
- Kennedy Institute of Rheumatology, University of Oxford, Oxford, UK
| | - T Smallie
- Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK
| | - T J Tang
- Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK
| | - J D Turner
- Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK
| | - L V Norling
- William Harvey Research Institute, QMUL, London, UK
| | - S Dominguez
- Division of Rheumatology, Northwestern University, Chicago, Illinois, USA
| | - H Perlman
- Division of Rheumatology, Northwestern University, Chicago, Illinois, USA
| | - N M Verrills
- School of Biomedical Sciences and Pharmacy, University of Newcastle, Callaghan, New South Wales, Australia
| | - G Kollias
- Division of Immunology, Biomedical Sciences Research Center 'Alexander Fleming', Vari, Greece
| | - M P Vitek
- Cognosci Inc., Research Triangle Park, North Carolina, USA
| | - A Filer
- Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK
| | - C D Buckley
- Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK
| | - J L Dean
- Kennedy Institute of Rheumatology, University of Oxford, Oxford, UK
| | - A R Clark
- Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK
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Turan A, Babazade R, Kurz A, Devereaux PJ, Zimmerman NM, Hutcherson MT, Naylor AJ, Ali Sakr Esa W, Parlow J, Gilron I, Honar H, Salmasi V, Sessler DI. Clonidine Does Not Reduce Pain or Opioid Consumption After Noncardiac Surgery. Anesth Analg 2016; 123:749-57. [DOI: 10.1213/ane.0000000000001356] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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12
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Babazade R, Sreenivasalu T, Jain P, Hutcherson MT, Naylor AJ, You J, Elsharkawy H, Wael ASE, Turan A. A nomogram for predicting the need for sciatic nerve block after total knee arthroplasty. J Anesth 2016; 30:864-72. [PMID: 27518727 DOI: 10.1007/s00540-016-2223-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2015] [Accepted: 07/20/2016] [Indexed: 10/21/2022]
Abstract
PURPOSE Sciatic nerve block (SNB) is commonly performed in combination with femoral nerve block (FNB) for postoperative analgesia following total knee arthroplasty (TKA). Despite the fact that 10-20 % of TKA patients require SNB for postoperative posterior knee pain, there are no existing studies that suggest a model to predict the need for SNB. The aim of our study was to develop a prediction tool to measure the likelihood of patients undergoing TKA surgery requiring a postoperative SNB. METHODS With institutional review board approval, we obtained data from the electronic medical record of patients who underwent TKA at the Cleveland Clinic. A multivariable logistic regression was used to estimate the probability of requiring a postoperative SNB. Clinicians selected potential predictors to create a model, and the potential nonlinear association between continuous predictors and SNB was assessed using the restricted cubic spline model. RESULTS In total 6279 TKA cases involving 2329 patients with complete datasets were used for building the prediction model, including 276 (12 %) patients who received a postoperative SNB and 2053 (88 %) patients who did not. The estimated C statistic of the prediction model was 0.64. The nomogram is used by first locating the patient position on each predictor variable scale, which has corresponding prognostic points. The cut-off of 11.6 % jointly maximizes the sensitivity and specificity. CONCLUSION This is the first study to be published on SNB prediction after TKA. Our nomogram may prove to be a useful tool for guiding physicians in terms of their decisions regarding SNB.
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Affiliation(s)
- Rovnat Babazade
- Department of Anesthesiology, University of Texas Medical Branch, Galveston, TX, USA.,Outcomes Research Consortium, Cleveland, OH, USA
| | - Thilak Sreenivasalu
- Outcomes Research Consortium, Cleveland, OH, USA.,Department of Anesthesiology, Saint Louis University Hospital, Saint Louis, MO, USA
| | - Pankaj Jain
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Matthew T Hutcherson
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Amanda J Naylor
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Jing You
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, USA.,Department of Quantitative Health Sciences,, Cleveland Clinic, Cleveland, OH, USA
| | - Hesham Elsharkawy
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, USA.,Anesthesiology, Cleveland Clinic, Lerner College of Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Ali Sakr Esa Wael
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, USA.,Anesthesiology, Cleveland Clinic, Lerner College of Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Alparslan Turan
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, USA.
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Desanti GE, Naylor AJ, Núñez LN, Saghir AN, Hardie DL, Watson SP, Buckley CD. A1.17 Podoplanin and its ligand CLEC-2 restrain synovial inflammation. Ann Rheum Dis 2016. [DOI: 10.1136/annrheumdis-2016-209124.17] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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14
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Sun Z, Sessler DI, Dalton JE, Devereaux PJ, Shahinyan A, Naylor AJ, Hutcherson MT, Finnegan PS, Tandon V, Darvish-Kazem S, Chugh S, Alzayer H, Kurz A. Postoperative Hypoxemia Is Common and Persistent: A Prospective Blinded Observational Study. Anesth Analg 2015; 121:709-715. [PMID: 26287299 DOI: 10.1213/ane.0000000000000836] [Citation(s) in RCA: 193] [Impact Index Per Article: 21.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND The incidence, severity, and duration of postoperative oxygen desaturation in the general surgical population are poorly characterized. We therefore used continuous pulse oximetry to quantify arterial oxygen saturation (SpO2) in a cross-section of patients having noncardiac surgery. METHODS Oxygen saturation, blinded to clinicians, was recorded at 1-minute intervals in patients >45 years old for up to 48 hours after noncardiac surgery in 1250 patients from Cleveland Clinic Main Campus and 250 patients from the Juravinski Hospital. We determined (1) the cumulative minutes of raw minute-by-minute values below various hypoxemic thresholds; and (2) the contiguous duration of kernel-smoothed (sliding window) values below various hypoxemic thresholds. Finally, we compared our blinded continuous values with saturations recorded during routine nursing care. RESULTS Eight hundred thirty-three patients had sufficient data for analyses. Twenty-one percent had ≥10 min/h with raw SpO2 values <90% averaged over the entire recording duration; 8% averaged ≥20 min/h <90%; and 8% averaged ≥5 min/h <85%. Prolonged hypoxemic episodes were common, with 37% of patients having at least 1 (smoothed) SpO2 <90% for an hour or more; 11% experienced at least 1 episode lasting ≥6 hours; and 3% had saturations <80% for at least 30 minutes. Clinical hypoxemia, according to nursing records, measured only in Cleveland Clinic patients (n = 594), occurred in 5% of the monitored patients. The nurses missed 90% of smoothed hypoxemic episodes in which saturation was <90% for at least one hour. CONCLUSIONS Hypoxemia was common and prolonged in hospitalized patients recovering from noncardiac surgery. The SpO2 values recorded in medical records seriously underestimated the severity of postoperative hypoxemia.
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Affiliation(s)
- Zhuo Sun
- From the *Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio; †Department of Medicine, The Population Health Research Institute, David Braley Cardiac, Vascular, and Stroke Research Institute, Hamilton, Ontario, Canada; ‡Department of Medicine, Juravinski Hospital of the Hamilton Health Sciences, Hamilton, Ontario, Canada; and §Adult Cardiology and ‖Department of Internal Medicine, McMaster University, Hamilton, Ontario, Canada
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Abstract
Inflammation is an unstable state; it either resolves or persists. Inflammatory reactions often have a propensity for specific anatomical sites. Why inflammation persists with specific tissue tropism remains obscure. Increasing evidence suggests that stromal cells which define tissue architecture are the key cells involved, and therefore make attractive therapeutic targets. Research on stromal cells in general and fibroblasts in particular has so far been hampered by a lack of fibroblast-specific cell markers. This review highlights our increasing understanding of the role of fibroblasts in inflammation, and suggests that these cells provide the cellular basis for site specific chronic inflammation.
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Affiliation(s)
- A J Naylor
- Rheumatology Research Group, Centre for Translational Inflammation Research, School of Immunity and Infection, College of Medical and Dental Sciences, University of Birmingham Research Laboratories, Queen Elizabeth Hospital, Birmingham, UK
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Abstract
(1) Selenium (Se) is an essential part of numerous selenoproteins, most of which are involved in the antioxidant system of the body. It is also required by poultry for the maintenance of optimal health and meat quality. This paper reports data from a study examining the effect of dietary source and concentration of selenium on broiler performance and meat quality. (2) Increased dietary selenium content markedly reduced feed conversion ratio (FCR) as a result of significantly lower feed intakes of birds while maintaining the same weight gains. (3) Selenium supplementation increased feathering, with organic selenium (selenised yeast) being superior to inorganic selenium (sodium selenite). (4) Birds receiving organic selenium in their diets had improved eviscerated weight, breast yield and reduced drip loss. (5) There were significant concentration x source interactions on yields of breasts and marylands (thigh plus drumstick), with elevated levels of organic selenium increasing the yields, whereas the opposite was true for the inorganic selenium.
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Affiliation(s)
- M Choct
- School of Rural Science and Agriculture, University of New England, Armidale, NSW, Australia.
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Abstract
The BFHI is a global UNICEF/WHO-sponsored effort to promote breastfeeding by ensuring that all women are provided with sound information regarding their infant feeding choices and that those who elect to breastfeed their infants are given physiologically sound, evidence-based advice and skilled assistance prenatally and as they begin nursing their infants during their postpartum hospital or birth center stay. The initiative is based on ten policy or procedure statements, The Ten Steps, which were jointly developed and published in 1989 by the sponsoring agencies in consultation with international experts. In 1990, the Ten Steps were accepted as the central theme of the Innocenti Declaration and, later that year, endorsed at the World Summit on Children. In 1992, UNICEF and WHO launched a major international campaign to encourage all hospitals with maternity services to accept the Ten Steps as basic maternity and newborn infant care policies and procedures. These Ten Steps were reviewed briefly in this article. Official designation as Baby Friendly requires a careful assessment completed by a trained external team to confirm that the institution is truly carrying out all Ten Steps and conforming to the International Code of Marketing of Breastmilk Substitutes. During the 8 years since the initiative began, more than 15,000 hospitals in 136 countries have been designated as Baby Friendly. Twenty-seven of these officially designated institutions are in the United States, where the campaign has been active only since 1996. The BFHI is considered one of the most successful international efforts ever performed to protect, promote, and support breastfeeding. Although it does not ensure that mothers will aspire to or achieve the widely accepted goal of approximately 6 months of exclusive breastfeeding, it helps mothers to initiate exclusive nursing, an essential step in the right direction.
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Affiliation(s)
- A J Naylor
- Wellstart International, San Diego, California, USA.
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Naylor AJ. WHO and industry partnership. Inconsistencies need to be resolved. BMJ 2000; 321:957-8; author reply 958-9. [PMID: 11030704] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/17/2023]
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Naylor AJ, Creer AE, Woodward-Lopez G, Dixon S. Lactation management education for physicians. Semin Perinatol 1994; 18:525-31. [PMID: 7701355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
All health professional groups support breastfeeding as the ideal way to nourish an infant, but numerous surveys have shown that, in general, even perinatal health professionals are not prepared to provide lactation management as part of routine care. Integration of lactation topics into current medical curriculum, whether traditional or problem-based, is the ideal and is possible. Faculty are encouraged to assess the current program for signs of "curriculosclerosis," a prevalent disease characterized by Abrahamson as "hardening of the categories," to look for ways to elasticize the relevant departments, and to integrate lactation management topics at the appropriate place in the larger educational plan. Faculty leadership is crucial. Remedial work, in terms of continuing education, will be necessary for perinatal health professionals until the curriculum model has been in place in preservice and postgraduate programs sufficiently long. Breastfeeding as a primary health care strategy, with its clear health and economic benefits, must be a part of any health care reform and, as such, will be a service expected to be provided by perinatal health professionals.
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Affiliation(s)
- A J Naylor
- Wellstart International, San Diego, CA 92103-2045
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Powers NG, Naylor AJ, Wester RA. Hospital policies: crucial to breastfeeding success. Semin Perinatol 1994; 18:517-24. [PMID: 7701354] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Affiliation(s)
- N G Powers
- Wellstart International, San Diego, CA 92103-2045
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Nyquist JG, Naylor AJ, Woodward-Lopez G, Dixon S. Use of performance-based assessment to evaluate the impact of a skill-oriented continuing education program. Acad Med 1994; 69:S51-S53. [PMID: 7916827 DOI: 10.1097/00001888-199410000-00040] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/22/2023]
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Naylor AJ, Wester RA, Powers NG, Slusser WM. Oral water intoxication. Am J Dis Child 1992; 146:893-4. [PMID: 1636644 DOI: 10.1001/archpedi.1992.02160200015002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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23
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Naylor AJ. Promoting successful breast-feeding. Pediatrics 1982; 70:825-6. [PMID: 7133836] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
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Weibert RT, Townsend RJ, Kaiser DG, Naylor AJ. Lack of ibuprofen secretion into human milk. Clin Pharm 1982; 1:457-8. [PMID: 7184678] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
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Naylor AJ. Allergy-epitomes of progress: immunologic benefits of breast feeding. West J Med 1982; 137:118. [PMID: 18749167 PMCID: PMC1274025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
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Bailey DN, Weibert RT, Naylor AJ, Shaw RF. A study of salicylate and caffeine excretion in the breast milk of two nursing mothers. J Anal Toxicol 1982; 6:64-8. [PMID: 7098450 DOI: 10.1093/jat/6.2.64] [Citation(s) in RCA: 37] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
Salicylate excretion was studied in the breast milk of a nursing mother (Patient A) taking chronic therapeutic doses of aspirin, and caffeine excretion was monitored in the breast milk of a nursing mother (Patient B) who was a heavy coffee drinker. Salicylate concentrations were maximal in serum at 2.25 hours (10.8 mg/dL) and in milk at 3.00 hours (1.0 mg/dL) following 975 mg of aspirin in Patient A. Caffeine concentrations peaked at 5.50 hours in serum (2.14 micrograms/mL) and at 2.00 hours in milk (1.15 micrograms/mL) during a period of steady coffee drinking by Patient B. Milk:serum concentration ratios ranged up to 0.08 for patient A and up to 0.63 for Patient B, demonstrating that relatively more caffeine than salicylate was excreted into milk. Sodium, potassium, pH, and percent solute remained essentially unchanged in milk samples from both patients throughout the study periods so that changes in the state of hydration of pH of the milk could not be implicated for the observed excretion patterns. More than 25 liters of milk at its peak drug concentration would have to be consumed by the infants of Patients A and B respectively to provide the salicylate content of one aspirin tablet or the caffeine content of an average cup of coffee.
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