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Competing Interests: The authors have no conflicts of interest to report.

HIV-1 persists in a latent reservoir in resting CD4+ T cells despite antiretroviral therapy (ART). The reservoir decays slowly over the first 7 years of ART (t1/2 = 44 months). However, whether decay continues with long-term ART is unclear. Recent integration site studies indicate gradual selection against inducible, intact proviruses, raising speculation that decades of ART might allow treatment interruption without viral rebound. Therefore, we measured the reservoir in 42 people on long-term ART (mean 22 years) using a quantitative viral outgrowth assay. After 7 years of ART, there was no long-term decrease in the frequency of inducible, replication-competent proviruses but rather an increase with an estimated doubling time of 23 years. Another reservoir assay, the intact proviral DNA assay, confirmed that reservoir decay with t1/2 of 44 months did not continue with long-term ART. The lack of decay reflected proliferation of infected cells. Most inducible, replication-competent viruses (79.8%) had env sequences identical to those of other isolates from the same sample. Thus, although integration site analysis indicates changes in reservoir composition, the proliferation of CD4+ T cells counteracts decay, maintaining the frequency of inducible, replication-competent proviruses at roughly constant levels over the long term. These results reinforce the need for lifelong ART.

Background: The Accreditation Council for Graduate Medical Education establishes minimum case requirements for trainees. In the subspecialty of obstetric anesthesiology, requirements for fellow participation in nonobstetric antenatal procedures pose a particular challenge due to the physical location remote from labor and delivery and frequent last-minute scheduling., Objectives: In response to this challenge, we implemented an informatics-based notification system, with the aim of increasing fellow participation in nonobstetric antenatal surgeries., Methods: In December 2014 an automated email notification system to inform obstetric anesthesiology fellows of scheduled nonobstetric surgeries in pregnant patients was initiated. Cases were identified via daily automated query of the preoperative evaluation database looking for structured documentation of current pregnancy. Information on flagged cases including patient medical record number, operating room location, and date and time of procedure were communicated to fellows via automated email daily. Median fellow participation in nonobstetric antenatal procedures per quarter before and after implementation were compared using an exact Wilcoxon-Mann-Whitney test due to low baseline absolute counts. The fraction of antenatal cases representing nonobstetric procedures completed by fellows before and after implementation was compared using a Fisher's exact test., Results: The number of nonobstetric antenatal cases logged by fellows per quarter increased significantly following implementation, from median 0[0,1] to 3[1,6] cases/quarter ( p  = 0.007). Additionally, nonobstetric antenatal cases completed by fellows as a percentage of total antenatal cases completed increased from 14% in preimplementation years to 52% in postimplementation years ( p  < 0.001)., Conclusion: Through an automated email system to identify nonobstetric antenatal procedures in pregnant patients, we were able to increase the number of these cases completed by fellows during 3 years following implementation., Competing Interests: None declared., (Thieme. All rights reserved.)

Postdural puncture headache (PDPH) is a complication of dural puncture. An epidural blood patch (EBP) is the standard treatment; however, when EBP fails, alternative treatments and/or diagnoses must be considered. We present a case of orthostatic headache initially diagnosed as PDPH but likely due to spontaneous intracranial hypotension. It is imperative for anesthesiologists, as members of an interdisciplinary peripartum team, to be familiar with the evaluation and treatment of postpartum headache and recognize when further workup and consultation may be indicated.

Competing Interests: Conflict of Interest None.

Introduction: Postdural puncture headache due to accidental dural puncture is a consequence of excessive needle tip overshoot distance after entering the epidural space via a loss of resistance (LOR) technique. We are not aware of any quantitative comparison of the magnitude of needle tip overshoot (distance traveled by the needle tip beyond the point where LOR can be discerned) for the various LOR assessment techniques that are taught. Such a comparison may provide insight into contributing factors of accidental dural puncture and associated postdural puncture headache., Methods: A custom-built simulator was used to evaluate the following 3 LOR assessment techniques: incremental needle advancement, intermittent LOR assessment (II); continuous needle advancement, high-frequency intermittent LOR assessment (CI); and continuous needle advancement, continuous LOR assessment (CC)., Results: There were significant mean differences in maximum overshoot past a virtual LOR plane due to technique (F(2,124) = 79.31, P < 0.001) (Fig. 2). Specifically, maximum overshoot was greater with technique II [mean = 3.8 mm, 95% confidence interval (CI) = 3.4-4.3] versus either CC (mean = 1.9 mm, 95% CI = 1.5-1.8, P < 0.001) or CI (mean = 1.4 mm, 95% CI = 0.9-2.3, P < 0.001). Differences in maximum overshoot between CC and CI were not statistically different (P = 0.996). Maximum overshoot was greater at 4 cm (mean = 3.0 mm, 95% CI = 2.6-3.4) compared with 5 cm (mean = 2.3 mm, 95% CI = 2.0-2.5, P = 0.044), 6 cm (mean = 2.0 mm, 95% CI = 1.9-2.2, P = 0.054), 7 cm (mean = 1.9 mm, 95% CI = 1.7-2.1, P = 0.002), and 8 cm (mean = 1.8 mm, 95% CI = 1.6-2.1, P = 0.001). In addition, maximum overshoot at 5 cm was greater than that at 7 cm (P = 0.020) and 8 cm (P = 0.037). The other LOR depths were not statistically significantly different from each other. Depth did not have a significant interaction with technique (P = 0.517). Technique preference had neither a significant relationship to maximum overshoot (P = 0.588) nor a significant interaction with LOR assessment technique (P = 0.689)., Discussion: Technique II LOR assessment produced the greatest needle overshoot past the simulated LOR plane after obtaining LOR. This was consistent across all LOR depths. In this bench study, the II technique resulted in the deepest needle tip maximum overshoot. We are in the process of designing a clinical study to collect similar data in patients.

Nitrous oxide, long used during labor in Europe, is gaining popularity in the United States. It offers many beneficial attributes, with few drawbacks. Cost, safety, and side effect profiles are favorable. Analgesic effectiveness is highly variable, yet maternal satisfaction is often high among the women who choose to use it. Despite being less effective in treating labor pain than neuraxial analgesic modalities, nitrous oxide serves the needs and preferences of a subset of laboring parturients. Nitrous oxide should, therefore, be considered for inclusion in the repertoire of modalities used to alleviate pain and facilitate effective coping during labor., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background: Evidence on the analgesic effectiveness of nitrous oxide for labor pain is limited. Even fewer studies have looked at patient satisfaction. Although nitrous oxide appears less effective than neuraxial analgesia, it is unclear whether labor analgesic effectiveness is the most important factor in patient satisfaction. We sought to compare the relationship between analgesic effectiveness and patient satisfaction with analgesia in women who delivered vaginally using nitrous oxide, neuraxial analgesia (epidural or combined spinal-epidural [CSE]), or both (neuraxial after a trial of nitrous oxide)., Methods: A standardized survey was recorded on the first postpartum day for all women who received anesthetic care for labor and delivery. Data were queried for women who delivered vaginally with nitrous oxide and/or neuraxial labor analgesia over a 34-month period in 2011 to 2014. Parturients with complete data for analgesia quality and patient satisfaction were included. Analgesia and satisfaction scores were grouped into 8 to 10 high, 5 to 7 intermediate, and 0 to 4 low. These scores were compared with the use of ordinal logistic regression across 3 groups: nitrous oxide alone, epidural or CSE alone, or nitrous oxide followed by neuraxial (epidural or CSE) analgesia., Results: A total of 6507 women received anesthesia care and delivered vaginally. Complete data were available for 6242 (96%) women; 5261 (81%) chose neuraxial analgesia and 1246 (19%) chose nitrous oxide. Of the latter, 753 (60%) went on to deliver with nitrous oxide alone, and 493 (40%) switched to neuraxial analgesia. Most parturients who received neuraxial analgesia (>90%) reported high analgesic effectiveness. Those who used nitrous oxide alone experienced variable analgesic effectiveness, with only one-half reporting high effectiveness. Among all women who reported poor analgesia effectiveness (0-4; n = 257), those who received nitrous oxide alone were more likely to report high satisfaction (8-10) than women who received epidural analgesia alone (OR 2.5; 95% CI 1.4-4.5; P = .002). Women who reported moderate analgesia (5-7) and received nitrous oxide only were more likely to report high satisfaction compared with the other groups. Among women who reported a high level of analgesic effectiveness, satisfaction with anesthesia was high and not different among groups., Conclusions: Patients who received nitrous oxide alone were as likely to express satisfaction with anesthesia care as those who received neuraxial analgesia, even though they were less likely to report excellent analgesia. Although pain relief contributes to the satisfaction with labor analgesia care, our results suggest that analgesia is not the only contributor to maternal satisfaction.

The objective of this study was to evaluate the present conventional selection program of a swine nucleus farm and compare it with a new selection strategy employing genomic enhanced breeding value (GEBV) as the selection criteria. The ZPLAN+ software was employed to calculate and compare the genetic gain, total cost, return and profit of each selection strategy. The first strategy reflected the current conventional breeding program, which was a progeny test system (CS). The second strategy was a selection scheme based strictly on genomic information (GS1). The third scenario was the same as GS1, but the selection by GEBV was further supplemented by the performance test (GS2). The last scenario was a mixture of genomic information and progeny tests (GS3). The results showed that the accuracy of the selection index of young boars of GS1 was 26% higher than that of CS. On the other hand, both GS2 and GS3 gave 31% higher accuracy than CS for young boars. The annual monetary genetic gain of GS1, GS2 and GS3 was 10%, 12%, and 11% higher, respectively, than that of CS. As expected, the discounted costs of genomic selection strategies were higher than those of CS. The costs of GS1, GS2 and GS3 were 35%, 73%, and 89% higher than those of CS, respectively, assuming a genotyping cost of $120. As a result, the discounted profit per animal of GS1 and GS2 was 8% and 2% higher, respectively, than that of CS while GS3 was 6% lower. Comparison among genomic breeding scenarios revealed that GS1 was more profitable than GS2 and GS3. The genomic selection schemes, especially GS1 and GS2, were clearly superior to the conventional scheme in terms of monetary genetic gain and profit.

Data collected from 690 purebred Duroc pigs from 2009 to 2012 were used to estimate the heritability, and genetic and phenotypic correlations between production and meat quality traits. Variance components were obtained through the restricted maximum likelihood procedure using Wombat and SAS version 9.0. Animals were raised under the same management in five different breeding farms. The average daily gain, loin muscle area (LMA), backfat thickness (BF), and lean percent (LP) were measured as production traits. Meat quality traits included pH, cooking loss, lightness (L*), redness (a*), yellowness (b*), marbling score (MS), moisture content (MC), water holding capacity (WHC), and shear force. The results showed that the heritability estimates for meat quality traits varied largely from 0.19 to 0.79. Production traits were moderate to highly heritable from 0.41 to 0.73. Genotypically, the BF was positively correlated (p<0.05) with MC (0.786), WHC (0.904), and pH (0.328) but negatively correlated with shear force (-0.533). The results of genetic correlations indicated that selection for less BF could decrease pH, moisture content, and WHC and increase the shear force of meat. Additionally, a significant positive correlation was recorded between average daily gain and WHC, which indicates pork from faster-growing animals has higher WHC. Furthermore, selection for larger LMA and LP could increase MS and lightness color of meat. The meat quality and production traits could be improved simultaneously if desired. Hence, to avoid further deterioration of pork characteristics, appropriate selection of traits should be considered.

This study was conducted to estimate the genetic parameters for pork belly traits and muscles in Yorkshire pigs. Each pork belly was cut into nine parts perpendicular to the thoracic vertebrae (6th to 14th). Traits of belly muscles including the deep pectoral, latissimus dorsi, cutaneous trunci, rectus abdominis, external and internal abdominal oblique from 382 purebred pigs were recorded and analyzed using SAS Package (9.1) and Derivative-free restricted maximum likelihood methods. Heritability estimates for belly traits ranged from 0.27 to 0.49, while they were 0.12 to 0.66 for belly muscles. Moderate to high heritability estimates were noted in belly weight (0.33), belly length (0.28), and belly width (0.49). In belly muscles, the latissimus dorsi and deep pectoral, which are located only in the 6th to 9th vertebrae sections, were found to have heritability estimates ranging from 0.21 to 0.29 and 0.23 to 0.35, respectively. Strong heritability estimates were observed in the 7th to 13th sections of cutaneous trunci muscle ranging from 0.42 to 0.66. Genetic correlations of latissimus dorsi m. with belly length were positive (0.50), while cutaneous trunci m. with belly weight also revealed a positive relationship that ranged from 0.35 to 0.47. The estimated genetic parameters indicate that belly weight can be improved by genetic selection. Differences in the levels of heritability occurred among various parameters of Yorkshire pork belly, which should be considered when performing selection to improve pork belly quality. Moreover, these results can provide valuable information that can be used as the basis for further investigations to improve pork belly.

The Renal and Lung Living Donors Evaluation Study assesses outcomes of live lung (lobectomy) donors. This is a retrospective cohort study at University of Southern California (USC) and Washington University (WASHU) Medical Centers (1993–2006), using medical records to assess morbidity and national databases to ascertain postdonation survival and lung transplantation. Serious complications were defined as those that required significant treatment, were potentially life-threatening or led to prolonged hospitalization. The 369 live lung donors (287 USC, 82 WASHU) were predominantly white, non-Hispanic and male; 72% had a biological relationship to the recipient, and 30% were recipient parents. Serious complications occurred in 18% of donors; 2.2% underwent reoperation and 6.5% had an early rehospitalization. The two centers had significantly different incidences of serious complications (p < 0.001). No deaths occurred and no donors underwent lung transplantation during 4000+ person-years of follow-up (death: minimum 4, maximum 17 years; transplant: minimum 5, maximum 19). Live lung donation remains a potential option for recipients when using deceased donor lungs lacks feasibility. However, the use of two live donors for each recipient and the risk of morbidity associated with live lung donation do not justify this approach when deceased lung donors remain available. Center effects and long-term live donor outcomes require further evaluation.

Background and Aim. While aortic valve replacement for aortic stenosis can be performed safely in elderly patients, there is a need for hemodynamic and quality of life evaluation to determine the value of aortic valve replacement in older patients who may have age-related activity limitation. Materials and Methods. We conducted a prospective evaluation of patients who underwent aortic valve replacement for aortic stenosis with the Hancock II porcine bioprosthesis. All patients underwent transthoracic echocardiography (TTE) and completed the RAND 36-Item Health Survey (SF-36) preoperatively and six months postoperatively. Results. From 2004 to 2007, 33 patients were enrolled with an average age of 75.3 ± 5.3 years (24 men and 9 women). Preoperatively, 27/33 (82%) were New York Heart Association (NYHA) Functional Classification 3, and postoperatively 27/33 (82%) were NYHA Functional Classification 1. Patients had a mean predicted maximum V O2 (mL/kg/min) of 19.5 ± 4.3 and an actual max V O2 of 15.5 ± 3.9, which was 80% of the predicted V O2 . Patients were found to have significant improvements (P ≤ 0.01) in six of the nine SF-36 health parameters. Conclusions. In our sample of elderly patients with aortic stenosis, replacing the aortic valve with a Hancock II bioprosthesis resulted in improved hemodynamics and quality of life.

Background: Myxomatous mitral valve insufficiency is traditionally repaired by posterior leaflet quadrangular resection and reconstruction. A simplified repair technique without leaflet resection is described, and our initial experience is reviewed., Methods: Thirty-nine consecutive patients with significant mitral regurgitation underwent repair since January 2000 by placement of expanded polytetrafluoroethylene sutures between the leading (coapting) edge of the posterior leaflet and the corresponding papillary muscle. An annuloplasty ring was placed, and no leaflet tissue was resected. Patient medical records were obtained and retrospectively reviewed., Results: Twenty-five men and 14 women (median age, 61 years; range, 40-88 years) had their mitral valve repaired by a variety of surgical approaches, including robotic (18 patients), right thoracotomy (6 patients), and sternal (15 patients). Three patients have required valve replacement: 1 at the initial operation, 1 because of dehiscence of the annuloplasty ring, and 1 after subsequent rupture of a previously normal native chorda. At follow-up (median, 12 months), 92% (33/36) of the remaining patients had an intact mitral repair with no to mild regurgitation, 8.3% (3/36) of patients had moderate regurgitation, and 92% of all patients (36/39) were in New York Heart Association class I. There were no deaths., Conclusions: Myxomatous mitral regurgitation due to posterior leaflet insufficiency can be repaired without leaflet resection by placement of neochordae. This repair technique is effective and is readily accomplished by traditional and minimally invasive surgical approaches.

Background: The goal of the present study was to determine the intermediate-term survival and the independent predictors of survival and event-free survival for patients who undergo catheter balloon commissurotomy (CBC)., Methods and Results: CBC for the treatment of mitral stenosis was performed in 132 patients from 1986 through 1994. The use of CBC increased the mitral valve area (MVA) from 1.0 +/- 0.3 to 1.9 +/- 0.6 cm2 (P < .001). There were six early deaths (4.5%) up to 1 month after CBC ("hospital" deaths). In the past 4.5 years, there have been no hospital deaths. Four late deaths occurred after elective mitral valve replacement (MVR). Actuarial 7-year survival was 95 +/- 1%; when mortality after MVR is included, 7-year survival was 83 +/- 6%. Actuarial 1-, 3-, 5-, and 7-year event-free survival (survival without MVR or repeat CBC) was 80 +/- 4%, 77 +/- 4%, 65 +/- 6%, and 65 +/- 6%. On multivariate analysis, the only two independent predictors (both after CBC) of 7-year event-free survival were MVA of > or = 1.5 versus < 1.5 cm2 (75 +/- 7% versus 32 +/- 12%) and mean pulmonary artery wedge pressure of < or = 18 versus > 18 mm Hg (84 +/- 6% versus 38 +/- 11%) (P < .001 for both). Patients with MVA of > or = 1.5 cm2 (n = 96) could be further subdivided into high- and low-risk subgroups for 7-year event-free survival by two post-CBC variables: mean pulmonary artery wedge pressure of < or = 18 versus > 18 mm Hg (90 +/- 6% versus 48 +/- 14%) (P = .0002) and cardiac index of > or = 2.5 versus < 2.5 L.min-1.m-2 (82 +/- 8% versus 61 +/- 13%) (P = .004). Patients with post-CBC MVA of < 1.5 cm2 (n = 24) had no additional predictors of event-free survival. Of patients who did not undergo MVR or repeat CBC, 8% were in New York Heart Association functional class III and 92% were in class I or early class II at the last follow-up., Conclusions: The rates for intermediate-term survival and event-free survival after CBC are very encouraging. Most patients without events were asymptomatic or minimally symptomatic. Thus, in selected patients with mitral stenosis who require an interventional procedure, CBC is the procedure of choice at centers with physicians who have experience and skill in performing this procedure.

This paper analyses the importance of interpreting envy within the analytic situation. We proceed from the Kleinian definition of envy, that which stems from the subject, not from the frustrating characteristics of the object. Among the object's capabilities, that of tolerating what he has not is especially included (negative capacity). We maintain that on the attitude taken by the analyst when faced by negative transference--and by envy in particular--depend the different interpretive lines which will evolve. Owing to its confusional characteristics, envy is always subtly disguised and hardly ever appears in a straightforward manner. It is necessary, therefore, to assess carefully the 'frustration' which depends on envy and that which arises from the object. We consider it important to underline that to this specific complication a further one is added: if the analyst does not adequately interpret it, envy does not become apparent. Clinical material illustrates these points.