Citations

Abstract Background: Occupational stress in resident physicians has profound implications for wellness, professionalism, and patient care. This observational pilot trial measured psychological and physiological stress biomarkers before, during, and after the start of anesthesia residency. Methods: Eighteen physician interns scheduled to begin anesthesia residency were recruited for evaluation at three time points: baseline (collected remotely before residency in June 2013); first-month visit 1 (July); and follow-up visit 2 (residency months 3 to 5, September–November). Validated scales were used to measure stress, anxiety, resilience, and wellness at all three time points. During visits 1 and 2, the authors measured resting heart-rate variability, responses to laboratory mental stress (hemodynamic, catecholamine, cortisol, and interleukin-6), and chronic stress indices (C-reactive protein, 24-h ambulatory heart rate and blood pressure, 24-h urinary cortisol and catecholamines, overnight heart-rate variability). Results: Thirteen interns agreed to participate (72% enrollment). There were seven men and six women, aged 27 to 33 yr. The mean ± SD of all study variables are reported. Conclusion: The novelty of this report is the prospective design in a defined cohort of residents newly exposed to the similar occupational stress of the operating environment. Because of the paucity of literature specific to the measures and stress conditions in this investigation, no data were available to generate a priori definition of primary outcomes and a data analytic plan. These findings will allow power analysis for future design of trials examining occupational stress and stress-reducing interventions. Given the importance of physician burnout in our country, the impact of chronic stress on resident wellness requires further study.

Several groups have reported cases of rectal cancer with carcinomatous involvement of the lumbosacral plexus and sciatic, obturator, pudendal, or spinal nerves. To our best knowledge, clear examples of perineural tumor spread in rectal carcinoma have not yet been described. We retrospectively reviewed clinical data and imaging studies of three patients with primary or recurrent rectal cancer involving the lumbosacral plexus. Imaging studies included MRI and 18FDG PET/CT scans in all (n = 3) patients, histological samples were available in two (n = 2). Imaging studies demonstrated distinct features of tumor spread from the organ to the plexus and beyond in all cases (n = 3), histological specimens demonstrated perineural involvement thus supporting our theory (n = 2). We present these three cases of perineural tumor spread in rectal cancer as a proof of concept. We hypothesize that not only our cases, but other similar reported cases can be explained anatomically by extension of the rectal cancer to the inferior hypogastric plexus with perineural tumor spread to the lumbosacral plexus using the pelvic and sacral splanchnic nerves as conduits. Once the tumor reaches the lumbosacral plexus, it can continue to spread proximally or distally. We believe that perineural spread of colon cancer represents an important, under‐recognized mechanism of recurrence to neighboring major nerves in the pelvis. Clin. Anat. 28:136–143, 2015. © 2014 Wiley Periodicals, Inc.

Abstract Life-threatening infections caused by Staphylococcus aureus, particularly the community-acquired methicillin-resistant strains of S. aureus, continue to pose serious problems. Greater virulence and increased pathogenicity of certain S. aureus strains are attributed to higher prevalence of exotoxins. Of these exotoxins, the superantigens (SAg) are likely most pathogenic because of their ability to rapidly and robustly activate the T cells even in extremely small quantities. Therefore, countering SAg-mediated T cell activation using T regulatory cells (Tregs) might be beneficial in diseases such as toxic shock syndrome (TSS). As the normal numbers of endogenous Tregs in a typical host are insufficient, we hypothesized that increasing the Treg numbers by administration of IL-2/anti–IL-2 Ab immune complexes (IL2C) or by adoptive transfer of ex vivo expanded Tregs might be more effective in countering SAg-mediated immune activation. HLA-DR3 transgenic mice that closely recapitulate human TSS were treated with IL2C to increase endogenous Tregs or received ex vivo expanded Tregs. Subsequently, they were challenged with SAg to induce TSS. Analyses of various parameters reflective of TSS (serum cytokine/chemokine levels, multiple organ pathology, and SAg-induced peripheral T cell expansion) indicated that increasing the Tregs failed to mitigate TSS. On the contrary, serum IFN-γ levels were increased in IL2C-treated mice. Exploration into the reasons behind the lack of protective effect of Tregs revealed IL-17 and IFN-γ–dependent loss of Tregs during TSS. In addition, significant upregulation of glucocorticoid-induced TNFR family-related receptor on conventional T cells during TSS could render them resistant to Treg-mediated suppression, contributing to failure of Treg-mediated immune regulation.

ProblemSeveral pregnancy complications have disparities based on the sex of the fetus. It is unknown whether the sex of the fetus differentially alters the maternal immune milieu, potentially contributing to the observed differences.Method of studyUsing maternal plasma collected during 38 uncomplicated pregnancies (19 males, 19 females), we compared levels of cytokines, sex hormones, and angiogenic factors throughout gestation and postpartum.ResultsMale fetal sex was associated with higher levels of proinflammatory cytokines (G‐CSF, IL‐12p70, IL‐21, and IL‐33) and angiogenic factors (PlGF and VEGF‐A) compared with female fetal sex at multiple timepoints. Female fetal sex was associated with higher levels of regulatory cytokines (IL‐5, IL‐9, IL‐17, and IL‐25). IL‐27 increased throughout pregnancy regardless of fetal sex. There was no fetal sex‐based difference in analyte concentrations at the postpartum measurement.ConclusionWomen carrying a male fetus exhibit a more proinflammatory/proangiogenic immune milieu than women carrying a female fetus.

Pulmonary hypertension (PH) has been found to have significant morbidity and mortality. The treatment of PH has advanced considerably with increasingly more effective and safer options. With an increasing effort to diagnose patients early, non-invasive techniques are often used to screen those patients likely to have PH. Computerized tomography (CT) chest scans are increasingly utilized in the evaluation of patients with exertional dyspnea, including those with suspected PH. The main role of the CT scan is to evaluate for any associated underlying diseases. There have been attempts to address the utility of CT to predict the presence of PH. This article reviews previously published investigations to summarize the relationship between pulmonary artery dimensions and PH to determine both the strength of the correlation and its discriminatory ability for use in clinical practice.

Objectives: Arthroscopy is being used more frequently as a treatment for intra-articular hip pathology due to femoroacetabular impingement (FAI). Prior to surgery, intra-articular anesthetic injection is commonly performed as a diagnostic test to localize the source of pain. Currently, there is a paucity of data correlating post-injection pain relief and functional outcomes after hip arthroscopy for FAI. The purpose of this study is to determine whether the amount of pain relief after preoperative intra-articular anesthetic injection predicts clinical and functional outcomes following hip arthroscopy with minimum one year follow-up. We hypothesize that increased pain relief (>50%) will correlate with better outcomes after surgery. Methods: The records of patients undergoing hip arthroscopy for FAI at our institution between April 2007 and April 2012 were reviewed. We identified patients who underwent pre-operative intra-articular anesthetic injection and subsequent hip arthroscopy. Inclusion criteria were: ultrasound or fluoroscopic guided intra-articular anesthetic injection performed at our institution, documented pre- and post-injection Numerical Rating Scale (NRS) pain scores, no prior ipsilateral hip surgery, and minimum 1 year follow-up. Pre-operative radiographs were reviewed and degree of osteoarthritis was determined using the Tonnis classification system. Outcomes were assessed with Modified Harris Hip Score (MHHS) and Hip Outcome Score (HOS). Univariate and multivariate models were performed to assess whether percent pain relief correlated with outcome scores. Results: 57 hips in 55 patients met our inclusion criteria and included 37 females (67%) and 18 males (33%) with a mean age of 42.6 ± 14.7 (range 15-68) years. 8 patients had Tonnis grade 0, 35 had Tonnis grade 1, and 14 had Tonnis grade 2. Mean pain relief after intra-articular injection was 74.4 ± 31.9 (range 0-100) percent. 13 patients (23%) had ≤50% pain relief while 44 (77%) had >50% pain relief. Outcome scores were obtained at a mean 25.5 (range 12- 60) months. Mean MHHS, HOS-ADL, and HOS-Sport scores were 82.1 ± 17.4 (range 42.9-100), 85.0 ± 16.6 (range 39.7-100), and 71.8 ± 28.1 (range 11.1-100) respectively. There was no correlation between percent pain relief and MHHS, HOS-ADL, or HOS-Sport scores. There was no significant difference in outcome scores between those with ≤50% and >50% pain relief. When adjusting for Tonnis grade there was no correlation between percent relief and any of the outcome scores measured. Conclusion: In patients undergoing hip arthroscopy for FAI, our data indicates that the amount of pain relief from intra-articular anesthetic injection does not correlate with minimum 1 year clinical and functional outcomes even when adjusting for Tonnis grade. Although pain relief did not predict outcomes in our study, we still believe it is a useful diagnostic tool to localize the source of pain in patients considering hip arthroscopy.