Objective: To identify clinical markers available within the first 48 hours of admission that are associated with poor outcome in infective endocarditis. Designs: Retrospective cohort study. Setting: Teaching hospital. Patients: 208 of 220 patients with infective endocarditis. Methods: Consecutive patients with infective endocarditis presenting between 1981 and 1999 to a tertiary centre were studied. Clinical, echocardiographic, and haematological data recorded within 48 hours of admission were obtained. Data were analysed using logistic regression models. Main outcomes measures: Mortality at discharge and at six months. Results: Data were obtained for 93% of patients who were eligible for inclusion. 194 (93%) were positive for Duke criteria. Mean age was 52 (1.2) years, and 138 (66%) were men. 82 (39%) were transferred from other hospitals. 181 (87%) were blood culture positive, and 47 (23%) infections were Staphylococcus aureus. The infection was located on aortic (n = 85, 41%), mitral (n = 77, 37%), tricuspid (n = 18, 9%), and multiple valves (n = 20, 10%). 67 (32%) had prosthetic valve endocarditis. 48% of the cohort were managed with antibiotics alone. Mortality at discharge was 18% and at six months 27%. Duration of illness before admission, age, sex, valve infected, infecting organism, and left ventricular function were not predictors of adverse mortality. However, abnormal white cell count, serum albumin concentration, serum creatinine concentration, or cardiac rhythm, the presence of two major Duke criteria, or visible vegetation conferred a poor prognosis. Conclusions: Conventional prognostic factors in this study did not appear to predict outcome early during hospital admission. However, simple clinical indices, which are readily available, are reliable, cheap, and potentially powerful predictors of poor outcome.

The aim of this prospective screening study was to evaluate the implementation of an additional ultrasound examination, incorporating the measurement of fetal nuchal translucency thickness, at 10-13 weeks' gestation in two maternity units providing routine antenatal care. During the 1 year prior to the introduction of the first-trimester scan, the major indication for fetal karyotyping was maternal age > or = 35 years and only two out of the total of 11 cases of trisomy 21 were identified. In the first 5 months of the study, 70% of the women delivering in these hospitals attended for measurement of fetal nuchal translucency thickness and the measurement was obtained in all cases. This was achieved without an increase in the number of sonographers or ultrasound machines. The incidence of fetal nuchal translucency thickness > or = 2.5 mm was 3.6% (63 of 1763), and this group included three of the four fetuses with trisomy 21. The findings of this study demonstrate the feasibility of introducing scanning at 10-13 weeks' gestation and the measurement of fetal nuchal translucency thickness in routine maternity units. The sensitivity and specificity of this method of screening are at present being evaluated in a large multicenter study.

A national survey of anaesthetic and peri-operative management of category-1 caesarean section was sent to 245 consultant-led maternity units. There was a 70% response rate. The median (IQR [range]) general anaesthetic rate was 51% (29%-80% [6%-100%]), 12% (9%-16% [3%-93%]), 4% (2%-5% [<1%-18%]), for category-1 caesarean section, categories 1-3 (non-elective ⁄ emergency) and category-4 (elective) caesarean section, respectively. The main operating theatre for caesarean section is on the delivery suite in 151 (88%) units, and 112 (66%) units also have a second theatre in the same location. One hundred and thirty-nine (81%) use the standard urgency classification described in the NICE caesarean section guideline. However, only 72 (42%), 24 (14%), and 16 (9%) units comply with this guideline's recommended decision-delivery intervals for category-1 ( £ 30 min), category-2 ( £ 30 min) and category-3 ( £ 75 min) caesarean sections, respectively. Practice in the smaller units was similar to that in the larger units, although there was less availability of a dedicated anaesthetist, intra-uterine resuscitation guidelines and operating theatres on the delivery suite in the smaller units. A four-point classification of urgency of caesarean section was described by Lucas et al. [1], and was recommended for national use by the National Institute for Clinical Excellence (NICE) in 2004 [2]. 'Emergency' and 'elective' caesarean section equate to categories 1-3 and category 4 respectively. Category 1, the most urgent, is defined as 'immediate threat to life of woman or fetus'. The relative risk of maternal death for category-1 caesarean section was observed to be 15 times that of category-3 caesarean section, although it is not clear whether this is due to pre-existing maternal pathology, or the indication for caesarean section [3]. In emergency situations, there is a greater need for clear communication, teamwork and consistent practice. We wished to establish the organisational factors including staffing, anaesthetic practice and the existence of specific guidelines that may have an impact on management of category 1 caesarean sections in consultant-led obstetric units in the UK. MethodsA questionnaire was developed by the authors and reviewed by the Obstetric Anaesthetists' Association's Audit Subcommittee. The Subcommittee approved this as a national survey (number 63 -http://www.oaaanaes.ac.uk). Contact details for lead obstetric anaesthetists in 245 maternity units were provided and a questionnaire was sent by post (Appendix). The questionnaire asked about labour ward and operating Anaesthesia, 2010Anaesthesia, , 65, pages 362-368 doi:10.1111Anaesthesia, /j.1365Anaesthesia, -2044Anaesthesia, .2010 362Journal compilation Ó 2010 The Association of Anaesthetists of Great Britain and Ireland theatre organisation, staffing levels, the categorisation of urgency used for caesarean section in each unit, the choice of anaesthetic used according to urgency, and the existence of guidelines in each unit for anaesthesia, intraute...

SummaryFull clinical and laboratory details of 203 patients with postoperative jaundice were submitted to a panel of hepatologists. All patients whose jaundice may have had an identifiable cause were excluded, which left 76 patients with unexplained hepatitis following halothane anaesthesia (UHFH). Hepatitis in 95°o of these cases followed multiple exposure to halothane, with repeated exposure within four weeks in 551)O of cases. Twenty-nine patients were obese, 52 were aged 41-70, and 53 were women. Thirteen patients died in acute hepatic failure. Rapid onset of jaundice after anaesthesia, male sex, and obesity in either sex were poor prognostic signs. Of the clinical stigmata of hypersensitivity, only eosinophilia was impressive. The UHFH group had a much greater incidence of liver kidney microsomal (LKM) and thyroid antibodies and autoimmune complement fixation than those patients whose jaundice related to identifiable factors. Thirteen of the 19 patients with LKM antibodies also had thyroid antibodies. In six patients retested two to three years later LKM antibodies had disappeared, although thyroid antibodies persisted.Rapidly repeated exposure to halothane may cause hepatitis, but such a complication is probably rare. Possibly obese women with a tendency to organ-specific autoimmunity may be more at risk. Nevertheless, the comparative risks of rapidly repeated halothane or non-

The immunological implications of anaesthetic practice relate to the possibility that exposure to anaesthesia and surgery, by depressing a variety of both non-specific resistance mechanisms and specific immune responses, renders patients more liable to infections and the spread of malignancy in the period after operation. A review of the literature suggests that, although various anaesthetic agents themselves depress immune responses, the effects are shortlived and of minor importance when compared with the effects of the hormonal aspects of the stress response. A more aggressive approach to relief of pain and anxiety may be beneficial from the immunological point of view.