Severe hypertriglyceridemia is a rare condition in pregnancy. All the cases of severe gestational hypertriglyceridemia that have been reported previously in the literature were caused by genetic mutations or familial hypertriglyceridemia secondary to lipoprotein lipase deficiency or apolipoprotein C-II deficiency. We report the first case of severe, non-genetic, non-familial, pregnancy-induced hypertriglyceridemia. The genetic underlying causes were excluded by molecular genetic investigation. The reported case was managed solely by strict dietary control. Hypertriglyceridemia was diagnosed incidentally during pregnancy, in this case, while taking a blood sample to check her hemoglobin level. Acute pancreatitis, which is a relatively common life threatening complication of this condition, was avoided. This report reviews the subtypes of hyperlipidemia, clinical picture, antenatal management and its effect on pregnancy and vice versa. It is important that the clinician has a clear understanding of the normal lipid profile during pregnancy, the clinical picture, the potential complications, available treatment options of hypertriglyceridemia particularly during pregnancy. The timing and route of delivery should be individualized.
BackgroundIn human TKA studies, intraosseous regional administration (IORA) of prophylactic antibiotics achieves local tissue antibiotic concentrations 10 times greater than systemic administration. However, it is unclear if such high concentrations provide more effective prophylaxis.Questions/purposesWe asked: (1) What prophylaxis dosage and route (intravenous [IV] versus IORA of prophylactic antibiotics) produce less in vivo bacterial burden compared with no-antibiotic controls? (2) Compared with controls, what prophylaxis dosage and route yield fewer colony-forming units (CFUs) in euthanized animals in a model of TKA? (3) Is prophylactic IORA of antibiotics more effective than same-dose IV antibiotic administration in reducing CFUs?MethodsMice (six to nine per group) were block randomized to one of six prophylaxis regimens: control, systemic cefazolin (C100IV), IORA of cefazolin (C100IORA), systemic vancomycin (V110IV), low-dose systemic vancomycin (V25IV), and low-dose IORA of vancomycin (V25IORA). Surgery involved placement of an intraarticular knee prosthesis, followed by an inoculum of bioluminescent Staphylococcus aureus strain Xen36. Biophotonic imaging assessed in vivo bacterial loads, and after 4 days bacterial load was quantified using culture-based techniques. Comparisons were made for each prophylactic regimen to controls and between same-dose IV and IORA of prophylactic antibiotic regimens.ResultsMice treated with systemic high-dose vancomycin, IORA of vancomycin, or IORA of cefazolin had lower in vivo Staphylococcus aureus burdens (median area under curve, Control: 5.0 × 106; V110IV: 1.5 × 106, difference of medians 3.5 × 106, p = 0.003; V25IV: 1.94 × 106, difference 3.07 × 106, p = 0.49; V25IORA: 1.51 × 106, difference 3.5 × 106, p = 0.0011; C100IORA: 1.55 × 106, difference 3.46 × 106, p = 0.0016; C100IV: 2.35 × 106, difference 2.66 × 106, p = 0.23.) Similar findings were seen with culture-based techniques on recovered implants. IORA of prophylactic antibiotics was more effective than same-dose IV administration in reducing bacterial load on recovered implants (median CFUs < 7.0 × 100 vs 2.83 × 102, p = 0.0183).ConclusionsIORA of prophylactic cefazolin and vancomycin was more effective than the same dose of antibiotic given systemically. The effectiveness of vancomycin in particular was enhanced by IORA of prophylactic antibiotics despite using a lower dose.Clinical relevanceOur study supports previous studies of IORA of prophylactic antibiotics in humans and suggests this novel form of administration has the potential to enhance the effectiveness of prophylaxis in TKA. Because of concerns regarding antibiotic stewardship, IORA of prophylactic vancomycin may be more appropriately restricted to patients having TKA who are at greater risk of infection, and clinical trials are in progress.
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