Hypertriglyceridaemia in pregnancy: an unexpected diagnosis and its management

A woman in her 30s with gestational diabetes presented at 36 weeks’ gestation with reduced fetal movements and diminishing insulin requirements. In view of her gestation, she was induced and incidentally found to have profound hyponatraemia. Further biochemical investigations confirmed severe hypertriglyceridaemia and hypercholesterolaemia. This raises the possibility of secondary causes such as familial dysbetalipoproteinemia and polygenetic hypertriglyceridaemia. She was successfully managed by aggressive dietary modification. This involved a supervised fast followed by a fat-free diet. A fenofibrate was proposed but declined due to our patient’s wish to breastfeed. Management required considerable input from the multidisciplinary team. Treatment options to consider are aggressive dietary restriction of fat or the addition of a cholesterol-lowering medication, such as a fibrate. In refractory cases, a supervised fast may be required or, in cases where complications have arisen, apheresis. The patient and her baby made a good recovery with no long-lasting health implications.

Advantages of later motherhood

BACKGROUND

In high-income countries childbearing has been increasingly postponed since the 1970s and it is crucial to understand the consequences of this demographic shift. The literature has tended to characterize later motherhood as a significant health threat for children and parents.

OBJECTIVES

We contribute to this debate by reviewing recent evidence suggesting that an older maternal age can also have positive effects.

MATERIALS

Literature linking the age at parenthood with the sociodemographic characteristics of the parents, with macrolevel interactions, and with subjective well-being.

METHODS

Comprehensive review of the existing literature.

RESULTS

Recent studies show that there can also be advantages associated with later motherhood. First, whilst in past older mothers had low levels of education and large families, currently older mothers tend to have higher education and smaller families than their younger peers. Consequently, children born to older mothers in the past tended to have worse outcomes than children born to younger mothers, whilst the opposite is true in recent cohorts. Second, postponement of childbearing means that the child is born at a later date and in a later birth cohort, and may benefit from secular changes in the macroenvironment. Evidence shows that when the positive trends in the macroenvironment are strong they overweigh the negative effects of reproductive ageing. Third, existing studies show that happiness increases around and after childbirth among older mothers, whereas for younger mothers the effect does not exist or is short-lived.

CONCLUSION

There are important sociodemographic pathways associated with postponement of childbearing which might compensate or even more than compensate for the biological disadvantages associated with reproductive ageing.

Strategies to manage hepatitis C virus (HCV) infection disease burden - volume 2

The hepatitis C virus (HCV) epidemic was forecasted through 2030 for 15 countries, and the relative impact of two scenarios was considered: (i) increased treatment efficacy while holding the treated population constant and (ii) increased treatment efficacy and increased annual treated population. Increasing levels of diagnosis and treatment, in combination with improved treatment efficacy, were critical for achieving substantial reductions in disease burden. In most countries, the annual treated population had to increase several fold to achieve the largest reductions in HCV-related morbidity and mortality. This suggests that increased capacity for screening and treatment will be critical in many countries. Birth cohort screening is a helpful tool for maximizing resources. In most of the studied countries, the majority of patients were born between 1945 and 1985.

The present and future disease burden of hepatitis C virus (HCV) infections with today's treatment paradigm - volume 2

Morbidity and mortality attributable to chronic hepatitis C virus (HCV) infection are increasing in many countries as the infected population ages. Models were developed for 15 countries to quantify and characterize the viremic population, as well as estimate the number of new infections and HCV related deaths from 2013 to 2030. Expert consensus was used to determine current treatment levels and outcomes in each country. In most countries, viremic prevalence has already peaked. In every country studied, prevalence begins to decline before 2030, when current treatment levels were held constant. In contrast, cases of advanced liver disease and liver related deaths will continue to increase through 2030 in most countries. The current treatment paradigm is inadequate if large reductions in HCV related morbidity and mortality are to be achieved.

Historical epidemiology of hepatitis C virus (HCV) in select countries - volume 2

Chronic hepatitis C virus (HCV) infection is a leading cause of liver related morbidity and mortality. In many countries, there is a lack of comprehensive epidemiological data that are crucial in implementing disease control measures as new treatment options become available. Published literature, unpublished data and expert consensus were used to determine key parameters, including prevalence, viremia, genotype and the number of patients diagnosed and treated. In this study of 15 countries, viremic prevalence ranged from 0.13% in the Netherlands to 2.91% in Russia. The largest viremic populations were in India (8 666 000 cases) and Russia (4 162 000 cases). In most countries, males had a higher rate of infections, likely due to higher rates of injection drug use (IDU). Estimates characterizing the infected population are critical to focus screening and treatment efforts as new therapeutic options become available.

Polybrominated diphenyl ethers in sewage sludge and treated biosolids: effect factors and mass balance

Polybrominated diphenyl ether (PBDE) flame retardants have been consistently detected in sewage sludge and treated biosolids. Two hundred and eighty-eight samples including primary sludge (PS), waste biological sludge (WBS) and treated biosolids from fifteen wastewater treatment plants (WWTPs) in Canada were analyzed to investigate the factors affecting accumulation of PBDEs in sludge and biosolids. Factors examined included environmental/sewershed conditions and operational parameters of the WWTPs. PBDE concentrations in PS, WBS and treated biosolids were 230-82,000 ng/g, 530-8800 ng/g and 420-6000 ng/g, respectively; BDE-209,-99, and -47 were the predominant congeners. Concentrations were influenced by industrial input, leachate, and temperature. Several examinations including the measurement of BDE-202 indicated minimal debromination during wastewater treatment. Estimated solids-liquid distribution coefficients were moderately correlated to hydraulic retention time, solids loading rate, mixed liquor suspended solids, solids retention time, and removal of organic solids, indicating that PBDE partitioning to solids can be optimized by WWTPs' operational conditions. Solids treatment type strongly affected PBDE levels in biosolids: 1.5 times increase after solids digestion, therefore, digestion efficiency could be a potential factor for variability of PBDEs concentration. In contrast, alkaline treatment reduced PBDE concentrations in biosolids. Overall, mass balance approaches confirmed that PBDEs were removed from the liquid stream through partitioning to solids. Variability of PBDE levels in biosolids could result in different PBDEs burdens to agricultural land, and different exposure levels to soil organisms.

Parameters affecting the occurrence and removal of polybrominated diphenyl ethers in twenty Canadian wastewater treatment plants

This study determined PBDE levels in influent, primary effluent, and final effluent collected from diverse treatment processes including four aerated lagoons, two facultative lagoons, four primary treatments, eight secondary biological treatments and two advanced treatments. Parameters examined for correlation included seasonal temperature, community sizes, industrial inputs, and operational conditions. PBDE levels in influent were 21-1000 ng/L (median 190 ng/L). Higher concentrations in influent samples were found during summer, and in WWTPs which treated leachate and higher proportions of industrial wastewater vs. residential wastewater. Final effluent levels ranged between 3 and 270 ng/L (median 12 ng/L). Among all congeners, the sum of BDE-209, -47 and -99 accounted for 79 and 71% of total PBDEs in influent and final effluent, respectively, with BDE-209 having the highest proportion. Median removal efficiencies for all process types exceeded 90% except primary treatment at 70%. PBDE levels and removals were correlated to the levels and removals of conventional parameters that represent wastewater strength, such as chemical oxygen demand and total suspended solids. The role of the primary clarifier was significant (∼82% removal) and removal was associated with hydraulic retention time (HRT) and surface loading rate. Best removal of PBDEs was achieved at greater than 2000 mg/L mixed liquor suspended solids (MLSS), longer than 10 h of HRT, and 9 days of solids retention time.

Stress-related gene expression changes in rainbow trout hepatocytes exposed to various municipal wastewater treatment influents and effluents

The present study sought to examine the performance of six different wastewater treatment processes from 12 wastewater treatment plants using a toxicogenomic approach in rainbow trout hepatocytes. Freshly prepared rainbow trout hepatocytes were exposed to increasing concentrations of influent (untreated wastewaters) and effluent (C(18)) extracts for 48 h at 15 °C. A test battery of eight genes was selected to track changes in xenobiotic biotransformation, estrogenicity, heavy metal detoxification, and oxidative stress. The wastewaters were processed by six different treatment systems: facultative and aerated lagoons, activated sludge, biological aerated filter, biological nutrient removal, chemically assisted primary treated, and trickling filter/solids contact. Based on the chemical characteristics of the effluents, the treatment plants were generally effective in removing total suspended solids and chemical oxygen demand, but less so for ammonia and alkalinity. The 12 influents differed markedly with each other, which makes the comparison among treatment processes difficult. For the influents, both population size and flow rate influenced the increase in the following mRNA levels in exposed hepatocytes: metallothionein (MT), cytochrome P4503A4 (CYP3A4), and vitellogenin (VTG). Gene expression of glutathione S-transferase (GST) and the estrogen receptor (ER), were influenced only by population size in exposed cells to the influent extracts. The remaining genes-superoxide dismutase (SOD) and multidrug resistance transporter (MDR)-were not influenced by either population size or flow rate in exposed cells. It is noteworthy that the changes in MT, ER, and VTG in cells exposed to the effluents were significantly affected by the influents across the 12 cities examined. However, SOD, CYP1A1, CYP3A4, GST, and MDR gene expression were the least influenced by the incoming influents. The data also suggest that wastewater treatments involving biological or aeration processes had the best performance. We found that the effects of municipal effluents on gene expression depended on the population size, the initial properties of the incoming influent, and the wastewater treatment method applied. Considering that the long-term goals of wastewater treatment is to produce clean effluents for the aquatic biota and independent of the incoming influent, more research is needed in developing treatment processes to better protect aquatic life from anthropogenic contamination.

Distribution of antidepressant residues in wastewater and biosolids following different treatment processes by municipal wastewater treatment plants in Canada

The fate of 14 antidepressants along with their respective N-desmethyl metabolites and the anticonvulsive drug carbamazepine (CBZ) was studied in 5 different sewage treatment plants (STPs) across Canada. Using two validated LC-MS/MS analytical methods, the concentrations of the different compounds were determined in raw influent, final effluent and treated biosolids samples. Out of the 15 compounds investigated, 13 were positively detected in most 24-h composite raw influent samples. Analysis showed that venlafaxine (VEN), its metabolite O-desmethylvenlafaxine (DVEN), citalopram (CIT), and CBZ were detected at the highest concentrations in raw influent (up to 4.3 μg L(-1) for DVEN). Cumulated results showed strong evidence that primary treatment and trickling filter/solids contact has limited capacity to remove antidepressants from sewage, while activated sludge, biological aerated filter, and biological nutrient removal processes yielded moderate results (mean removal rates: 30%). The more recalcitrant compounds to be eliminated from secondary STPs were VEN, DVEN and CBZ with mean removal rates close to 12%. Parent compounds were removed to a greater degree than their metabolites. The highest mean concentrations in treated biosolids samples were found for CIT (1033 ng g(-1)), amitriptyline (768 ng g(-1)), and VEN (833 ng g(-1)). Experimental sorption coefficients (K(d)) were also determined. The lowest K(d) values were obtained with VEN, DVEN, and CBZ (67-490 L kg(-1)). Sorption of these compounds on solids was assumed negligible (log K(d) ≤ 2). However, important sorption on solids was observed for sertraline, desmethylsertraline, paroxetine and fluoxetine (log K(d) > 4).

Effect of bolus dose of remifentanil on haemodynamic response to tracheal intubation

A randomized placebo-controlled double-blinded study was conducted in 40 ASA 1 and 2 patients to determine the dose response of remifentanil in attenuating the haemodynamic response to tracheal intubation. Patients were allocated to one of four groups: placebo, remifentanil 1 microgram.kg-1, remifentanil 2 micrograms.kg-1 and remifentanil 4 micrograms.kg-1. A propofol target-controlled infusion was started at 4 micrograms.ml-1 and incrementally titrated to loss of verbal contact. Muscle relaxation was provided by cisatracurium. The study drug was given three minutes later over 30 seconds, and 90 seconds later the patient's trachea was intubated under direct laryngoscopy. Baseline noninvasive blood pressure and heart rate recordings were made prior to starting target-controlled infusion, then at one-minute intervals after loss of verbal contact for the duration of the study. Demographic data and target-controlled infusion rate at intubation was similar for the groups. Following intubation, heart rate increased by 15% in the placebo group, 10% in 1 microgram.kg-1 group, with no changes in 2 micrograms.kg-1 and 4 micrograms.kg-1 groups. Systolic blood pressure following intubation increased by 30% in the placebo group, 10% in the 1 microgram.kg-1 group and remained unchanged in the 2 micrograms.kg-1 and 4 micrograms.kg-1 groups. Remifentanil 1 microgram.kg-1 attenuated the rise in heart rate and systolic blood pressure. Remifentanil 2 micrograms.kg-1 blocked the haemodynamic response completely: no further benefit was shown from increasing the dose to 4 micrograms.kg-1.

Psychosocial costs of transferring indigenous women from their community for birth

OBJECTIVE

To describe the psychosocial effect of transferring Canadian Inuit women out of their communities for birth.

DESIGN

Semi-structured interviews.

SETTING

Two communities in the central Canadian arctic.

PARTICIPANTS

Postnatal women and their partners, Inuit community members.

MAIN FINDINGS

Women face many stressors as a result of being transferred from their community for the birth of their baby, not least of which is the lack of a partner and family support. Stressors were categorised as emotional, physical and economic, and women were given little choice or support for the place of birth and method of delivery.

KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

Midwives need to be aware of the psychosocial disruption and stress faced by women and their families as a result of being transferred from their community for birth. Maternal/child policies and care need to focus more on the psychosocial aspects of labour, such as family and professional support, and less on the physical aspects which cannot be adequately addressed without culturally sensitive care. Consumers must be involved in the development of maternity services.

Low-dose rocuronium improves conditions for tracheal intubation after induction of anaesthesia with propofol and alfentanil

We studied 60 adult patients to assess if low doses of rocuronium improved conditions for tracheal intubation during induction of anaesthesia with propofol 2.5 mg kg-1 and alfentanil 10 micrograms kg-1. In a double-blind, randomized design, patients were allocated to one of three groups: group P = saline; group R1 = rocuronium 0.1 mg kg-1; and group R3 = rocuronium 0.3 mg kg-1. Intubation conditions were judged as optimal, suboptimal or failure, based on the scoring of ease of jaw opening and laryngoscopy, position of the vocal cords and degree of straining after tracheal intubation. Intubation conditions were judged as optimal in one patient in group P, in six patients in group R1 and in 18 patients in group R3. Conditions were judged as a failure in seven patients in group P, in one patient in group R1 and in none in group R3. No laryngospasm or other complications were observed in any patient. The addition of low doses of rocuronium significantly improved intubation conditions (P < < 0.001). Ventilation was controlled during surgery, and in no patient was any problem encountered with antagonism of neuromuscular block with neostigmine. Injection of rocuronium 0.3 mg kg-1 (ED95) with propofol and alfentanil provided a high proportion of optimal intubation conditions.

Cricoid pressure applied after placement of the laryngeal mask prevents gastric insufflation but inhibits ventilation

We studied 50 patients, in a blind, crossover study, to assess if cricoid pressure applied after placement of the laryngeal mask prevented gastric insufflation without affecting ventilation. After induction of anaesthesia and neuromuscular block, a laryngeal mask was inserted and confirmed to be placed correctly. The lungs were ventilated with a maximum inflation pressure of 15 cm H2O. In the first 25 patients, expiratory volumes were measured with and without cricoid pressure (30 N). On both occasions, a free hand was placed under the patient's neck. In the next 25 patients, the effect of cricoid pressure on ventilation without support of the neck was also studied. The effect of cricoid pressure with support of the neck on gastric insufflation was then assessed using a stethoscope in all 50 patients, while the lungs were ventilated with a maximum inflation pressure of 30 cm H2O. At the end of the study, the position of the mask was re-assessed. Cricoid pressure significantly decreased mean expiratory volume (P << 0.001). This inhibitory effect was significantly greater when the pressure was applied without support of the neck (P << 0.001). Cricoid pressure significantly reduced the incidence of gastric insufflation (12 patients vs one patient; P << 0.001; 95% CI for difference 10.5-33.5%). In no patient was the mask dislodged after these procedures. Thus, although cricoid pressure applied after insertion of the laryngeal mask prevented gastric insufflation, it also decreased ventilation. The inhibitory effect of cricoid pressure on ventilation without support of the neck was greater than cricoid pressure with support of the neck.

Effects of magnesium sulphate on suxamethonium-induced complications during rapid-sequence induction of anaesthesia

Twenty patients were studied in a double-blind manner to investigate whether magnesium sulphate, when given during a rapid-sequence induction of anaesthesia, lessens the side effects caused by suxamethonium. Patients were randomly allocated to two groups; equal volumes of either magnesium sulphate (40 mg.kg-1) or saline were given during rapid-sequence induction of anaesthesia, after thiopentone but before the administration of suxamethonium (1.5 mg.kg-1). The changes in the serum potassium concentration, the degree of muscle fasciculations and the presence of postoperative myalgia were recorded. The mean serum potassium concentration increased by 0.08 mmol.l-1 in the magnesium group and by 0.1 mmol.l-1 in the control group at 2 min after injection of suxamethonium; in neither group was there a significant increase from baseline values. The systolic blood pressure and heart rate increased in both groups after tracheal intubation. The incidence of fasciculations was significantly lower in the magnesium group. Magnesium did not clinically prolong muscle relaxation. There was no difference between the groups in the incidence of myalgia after surgery (one patient in each group). Since no significant increase in the serum potassium concentration was demonstrated, no assessment could be made of the effect of magnesium sulphate on the serum potassium concentration after administration of suxamethonium.

Cricoid pressure impedes placement of the laryngeal mask airway

We have studied 22 patients to examine whether or not cricoid pressure affects ventilation of the lungs via the laryngeal mask and its correct positioning. In a randomized, crossover design, the laryngeal mask was inserted with or without cricoid pressure applied with a standardized force of 30 N using a cricoid yoke. A standardized pillow (6 cm in height) was placed under the patient's occiput, but the neck was not supported. Ventilation of the lungs via the laryngeal mask was adequate in all patients when no cricoid pressure was applied, but in only three of 22 patients when cricoid pressure was applied (P << 0.001; 95% confidence interval (CI) 0.72-1.0). The mask was positioned correctly in 18 patients when no pressure was applied, and in none after application of cricoid pressure (P << 0.001; 95% CI 0.66-0.98). We had planned to study, in an additional 20 patients, the effect of cricoid pressure without a pillow under the occiput; placement of the mask, however, was difficult even when cricoid pressure was not applied and there was a high incidence of bleeding from the oropharynx. We thus abandoned that part of the study after eight patients. In those eight patients, the success rate of ventilation via the laryngeal mask was lower when cricoid pressure was applied. We conclude that when sufficient force was applied, cricoid pressure, regardless of the method of application, did impede placement of the laryngeal mask.

Intra-ocular pressure changes in patients with glaucoma. Comparison between the laryngeal mask airway and tracheal tube

We performed a randomised prospective study in 20 patients with glaucoma to examine the effects of tracheal intubation and laryngeal mask insertion on intra-ocular pressure, mean arterial blood pressure and heart rate. After induction of anaesthesia with propofol, intra-ocular pressure decreased significantly below baseline values in both the laryngeal mask and tracheal tube groups. After insertion of the laryngeal mask, intra-ocular pressure remained significantly below baseline values in all patients. In contrast, tracheal intubation was associated with a significant increase in intra-ocular pressure to above baseline values in three out of eight patients. Insertion of the laryngeal mask had minimal effects on mean arterial blood pressure and heart rate, whereas tracheal intubation significantly increased both factors relative to pre-intubation values.

Analgesia after laparoscopic sterilisation. Effect of 2% lignocaine gel applied to Filshie clips

We performed a randomised controlled study in patients undergoing day case laparoscopic sterilisation to assess whether coating Filshie clips with 2% lignocaine gel prior to application to the Fallopian tubes would reduce postoperative pain. Sixty-two patients were studied, in 33 of whom the Filshie clips were coated in sterile 2% lignocaine gel. Pain scores in the lignocaine gel group were significantly lower than in the control group at 1 h after return to the ward, but no differences were found immediately on return to the ward, or at discharge or at 24 h. There were no significant differences between the two groups in postoperative analgesic requirements or in side effects.

Cricoid pressure impedes placement of the laryngeal mask airway and subsequent tracheal intubation through the mask

We have studied 40 patients to see if cricoid pressure affects the success rate of ventilation through, and the position of, the laryngeal mask and subsequent fiberscope-aided tracheal intubation. Adequate ventilation of the lungs was produced through the laryngeal mask in 19 of 20 patients in the control group, but in only 10 of 20 patients in the cricoid pressure group (P < 0.002). The laryngeal mask was positioned correctly in 16 patients in the control group, but in only two patients in the cricoid pressure group (P < 0.001). Tracheal intubation was accomplished in 19 patients in the control group, but in only three patients in the cricoid pressure group (P < 0.001). Release of cricoid pressure after placement of the laryngeal mask improved the view of the glottis, but tracheal intubation was still difficult because of laryngeal deviation. These results show that cricoid pressure impedes placement of the laryngeal mask and subsequent fiberscope-aided tracheal intubation.

Day case laparoscopy: a survey of postoperative pain and an assessment of the value of diclofenac

A randomised, controlled study was undertaken to assess the postoperative pain and side effects experienced by patients undergoing day case diagnostic laparoscopy and laparoscopic sterilisation, and to evaluate the effectiveness in these patients of peroperative diclofenac. Patients undergoing laparoscopic sterilisation had significantly higher pain scores at one hour postoperatively, and at discharge, than patients undergoing diagnostic laparoscopy (p less than 0.01) but there were no significant differences in pain scores 24 hours after discharge. The incidence of postoperative side effects following discharge from hospital was high, but there were no significant differences between the groups. Diclofenac had no significant effect in either group on the severity of postoperative pain, or the incidence of postoperative side effects.