Cysteine-rich intestinal protein (CRIP): a new intestinal zinc transport protein.

Cysteine-rich intestinal protein (CRIP) is a newly identified peptide that occurs primarily in the intestine and binds zinc in the mucosa during absorption. High dietary zinc does not affect CRIP concentration, but it greatly increases metallothionein, which may compete with CRIP to decrease zinc absorption.


Women on the short end of the loaf: intrahousehold food allocation among members of poor Nepalese families.

Intensive and structure intrahousehold observations of the pattern of food allocation in poor rural Nepalese households indicate no difference in the distribution of nutrients between male and female children. In contrast, preferential food distribution patterns among adults show that women are less likely to achieve recommended levels of some nutrients than are men of the same age.


Iron overload in sub-Saharan Africa involves a genetic component.

A new study suggests that the iron overload observed in sub-Saharan Africans may be due to more than elevated iron intake. Genetic analysis indicates that a heritable, but unidentified, trait may account for a substantial portion of the variability in transferrin saturation seen in persons with iron overload. This defect may occur in over 30% of the population and appears to be distinct from the genetic factor controlling hemochromatosis in Caucasian populations.


Allergen avoidance in the treatment of dust-mite allergy and asthma.

House-dust-mite allergen is one of the primary causes of asthma. In many instances, asthma is an immunoglobulin gamma E mediated atopy (i.e., allergen-specific hypersensitivity) that leads to non-specific bronchial hyper-reactivity and subsequent symptom manifestations. These symptoms may range from an annoying cough to full-blown respiratory failure. Allergen-avoidance measures should be a primary mode of treatment for atopic asthmatics. This article focuses on the dust-mite allergen and its relationship to asthma. It details specific avoidance measures that should be implemented by the majority of asthmatics. Studies are cited that support the aggressive use of these measures to decrease allergen exposure, and to subsequently prevent or significantly reduce asthma symptoms. When health care providers have a better understanding of avoidance measures and the rationale underlying their use, these measures are more likely to be valued and given greater emphasis in education and treatment plans. Renewed emphasis on an immunomodulatory approach to asthma treatment may help to reverse the rise in asthma morbidity and mortality rates.


Assessing school readiness through the school-entry screening exam.

Although there exists no perfect screening tool that is predictive of a child's success in school, an office visit prior to school enrollment can detect potential problems. This visit should include a history and physical, and developmental assessment. The developmental assessment involves a sampling of a child's abilities in the areas of language, reasoning, gross and fine motor skills, and personal-social development. Providers must be alert to signs and symptoms indicating impediments to learning. Clinicians who are knowledgeable about trends in education regarding readiness testing, birth-date cutoffs and retention can serve as a valuable resource to parents. The clinician can also be a major contributor to the achievement of national education goals set forth by the Bush administration. Ten tools for assessing children are compared, and their appropriate use is discussed.


Frontier areas: opportunities for NPs' primary care services.

Demographers have recently designated frontier areas as distinct from other rural areas. Frontier counties are defined as those with less than six persons per square mile; as such, they constitute 45 percent of the U.S. land mass and include 2.2 million people. The health status among frontier residents is estimated to be lower than that of other rural or urban populations, and frontier health services, particularly primary care services, are scant. In this article, opportunities for nurse practitioners in frontier practice are explored, including specific suggestions for the development of new frontier NP practices.


The legal danger of written protocols and standards of practice.

Nurse practitioners have historically developed protocols and standards of practice to guide and improve the quality of their patient care. Written protocols and standards of practice can, however, create a potential malpractice problem. Lawyers who bring malpractice cases on behalf of patients will use the protocols and standards to measure the practitioner's care. The practice standards are often too high to be reasonably met by practitioners at all times and in all settings. As a result, the practitioner's care may breach those standards. Nurse practitioners should develop protocols that are based on a minimum safe level and not the maximum level aimed at ideal care. Standards and protocols should be updated and realistic. Once developed, protocols and standards must be followed precisely to limit potential liability.


Cardiovascular risk factors in Native American children.

Information concerning cardiovascular disease risk factors in Native American children is limited. In adult Native American populations, cardiovascular disease risk factors of non-insulin dependent diabetes mellitus, obesity, and cigarette smoking are prevalent, and recent reports indicate mortality caused by cardiovascular disease has dramatically increased. In a screening program at the Onondaga Nation School, six cardiovascular disease risk factors were evaluated. Of 95 school children, 55 representing 39 interrelated families, participated. Family histories were positive for diabetes mellitus in 72%, for cardiovascular disease in 54%, and for passive smoking in 90% of families. Physical examinations of the children revealed obesity (weight/height greater than 90th percentile) in 42% and hypertension (systolic or diastolic blood pressure/height greater than 95th percentile) in 22%. Fingerstick cholesterol levels (Reflotron system) were greater than 170 mg/dL in 25%. Overall, 85% of participants had three or more risk factors for cardiovascular disease. The study results indicate that Onondaga Native American children are at significant risk for cardiovascular disease; programs for identification and modification of cardiovascular disease risk factors are urgently needed.


The persistent vegetative state: an analysis of clinical correlates and costs.

A review was compiled of 23 patients in the persistent vegetative state; a condition that developed while the patients were in an acute care hospital. Before the onset of the persistent vegetative state, eight patients had had dementia, 11 were functionally dependent, and seven had neurologic disorders that gradually led to the persistent vegetative state. For patients in the persistent vegetative state, three types of mechanical support--respirators, nasogastric or gastrotomy tubes, and intravenous lines--were utilized. All three were necessary in 43% of patients, two types in 52%, and one type in 4%. All patients in the persistent vegetative state required at least one type of mechanical assistance. Their course was complicated in all cases by incontinence, and in the majority, by decubiti, pneumonia, and urinary tract infection. Only one patient improved enough to be able to say a few words. These patients required active medical care and invasive procedures that were costly but futile. The hospital bills obtained for 13 patients averaged $170,000, and the length of stay for all patients averaged 197 days, the equivalent to a total number of bed-days of 12.5 bed-years. The poor outcomes, requirements for mechanical support, and frequency of complications--especially when neurologic impairments were present before the onset of the persistent vegetative state--should be considered when evaluating the cost in hospital bills and bed occupancy.


Directions for nursing theory development in the 21st century.

The development of the discipline of nursing has gone through four stages: theorizing, developing a syntax, concept development, and philosophical debate. These stages helped in shaping the characteristics of the discipline as a human science, a practice science, a science with social goals to empower nurses to provide effective and quality care, and one in which gender differences and the need for understanding minorities are areas of primary concern. Further theoretical development in the discipline will be driven by population needs and will be characterized by reaching out to meet the integrative and interdisciplinary nature of these needs. Sources of theories of the future are practice, theory and research. It is anticipated that two models will evolve to guide the development of phenomenon-driven theories in the future and that third generation theorists will utilize these models.


The overview effect: the impact of space exploration on the evolution of nursing science.

The purpose of this article is to explore the overview effect, an experience evoked by space travel that has the capacity to transform all patterns of human existence and evolution toward greater potentials in human diversity and creativity. As nurses migrate with humanity into the solar system and beyond, they will experience the overview effect. The core components of the effect include changed perceptions of space, time, sound, and weight which have the potential to transform the evolution of nursing science. Nursing paradigms will encompass a view of humanity as integral with an infinite evolutionary universe. After generations of living in space in a diversity of new environments, the physical body will undergo radical changes, and the meaning of health will be transformed. The article concludes with a discussion on the parallels between Rogers' science of unitary human beings and the overview effect.


Nursing theory as a base for a computerized nursing information system.

This article illustrates how nursing theory can be used in a computerized nursing information system (CNIS). Before development of such a system can begin, data relationships must be specified so that: (a) the relationships are specific enough to support a computerized relational base and (b) the resultant information can support nursing science. Both goals were achieved through three interrelated processes: (a) validation of a practice model based on Orem's self-care deficit nursing theory, (b) classification of clinical data into theory-related categories, and (c) establishment of data relationships to yield meaningful information.


The Roy Adaptation Model and care of persons with Alzheimer's disease.

This article uses current nursing literature to examine the congruence of the care of patients with Alzheimer's disease (AD) with the Roy adaptation model. In relating concepts of the Roy model to the care of patients with Alzheimer's disease, it was found that ineffective coping responses can be used to describe disease-related disruptive behaviors. The degenerative disease process would result in the impairment of focal stimuli, such as memory and personality. Because focal stimuli are progressively impaired, the goal of nursing using the Roy model would be to promote adaptive responses through manipulation of the contextual stimuli, the patient's environment. Nursing literature describing positive patient outcomes following environmental interventions suggests that the Roy adaptation model could be very valuable in directing nursing research and devising nursing care strategies for patients with Alzheimer's disease.


Instrument development and the measurement of unitary constructs.

This article initiates needed dialogue on the development of instruments to measure unitary constructs. The concept of measurement is explored and current measurement in Rogerian research is considered in light of the issues raised in the discussion. The human field - environmental field relationship is presented as the clinical practice area serving as the basis for the development of a unitary instrument that purports to measure field pattern. The instrument entitled Mutual Exploration of the Healing Human Field - Environmental Field Relationship is offered as a beginning effort in constructing an instrument that measures a unitary phenomenon. Rogerian scholars are provided with the challenge to continue the debate regarding the whole field of measurement and the development of unitary tools.


Diet, nutrition and cancer in Japan.

A number of epidemiological and experimental studies have revealed that dietary habits and nutrition are one of the major risk factors for cancer. Dietary habits and nutrition are related to cancer in various ways and many factors are involved in the development of cancer. These include large intakes of salted foods and pickled vegetables, and too low intakes of fresh vegetables and fruits which are known to be major risk factors for stomach cancer. A large intake of green-yellow vegetables is known to be a protective factor against cancer of the stomach, lung and some other sites. In Japan the westernization of dietary habits and nutrition may have contributed to the changes in the mortality of several kinds of cancers which have been observed in Japan in recent years. Further improvements of dietary habits and nutrition intake are important and will be effective for primary prevention of cancer.


Nutritional factors and cellular immune responses.

Nutritional factors affect the immune response to infection and cancer in the elderly as well as young children. We studied the effects of lower and higher intake of food or nutrients on the immune cells of macrophage-lymphocytes series in the lung of rats. In rats of all ages taking voluntary exercise, a well balanced diet that contains adequate protein (20-40%) is crucial for maintenance of high levels of immune response. In addition, extra amounts of vitamins A and E activated the function of alveolar macrophages, which are probably stimulated by fat soluble vitamins coming into the lung via the lymphatic route from the intestine, and will be especially important in preventing pulmonary infection and cancer.


Nutrition for the young--its current problems.

The prevailing life style in Japan has been westernized and highly industrialised. This inevitably has bad effects on nutrition and the eating pattern of youth. These ill effects may be summarized as follows, 1) lack of daily physical activities, 2) an increasing number of working mothers, 3) irregular timing of food intake, 4) an increasing intake of energy in the form of fat, 5) increasing consumption of processed foods ready for eating, 6) lack of integrated management systems such as health education programs against atherogenic risk factors. These changes have resulted in increasing atherogenic risk factors among young people. It is necessary to study the present risk factors and their relation to prevailing life styles and to organize a follow-up system for surveillance of risk factors.


Achievement of school lunch system for the promotion of health of children in Japan.

In Japan, the modern school lunch system was improved after the establishment of the school lunch law in 1954, and now over 98% of boys and girls in primary schools and over 85% of junior high school pupils have lunch at their schools. In this report, the beneficial effect of this system is pointed out. This system contributes to an improvement of the physical condition of these children and it is very effective for improving the relationship between teachers and children. Knowledge concerning food, nutrition and food hygiene has also improved.


Nutritional factors for longevity in Okinawa--present and future.

Several factors, such as environment and heredity, are presumed to be related to longevity. Of these nutrition is believed to function as a regulatory factor. Okinawa prefecture is well known as the leading area for longevity in the world. We therefore examined present and past nutrition records together with the background of all the 88 centenarians (18 male, 70 female) who are living in Okinawa in 1991. Their leading occupation was agriculture, and they were in work until the 8th decade. They took rice or potato as carbohydrate with abundant vegetables and vegetable protein or fish protein. Although they did not take a rich diet it was well balanced, and was assumed to be related to longevity because of the decreased incidence of atherosclerosis; together with a good genetic background, suggested by the accumulation of longevity in their siblings.


Nutrition for the Japanese elderly.

The present paper examines the relationship of nutritional status to further life expectancy and health status in the Japanese elderly based on 3 epidemiological studies. 1. Nutrient intakes in 94 Japanese centenarians investigated between 1972 and 1973 showed a higher proportion of animal protein to total proteins than in contemporary average Japanese. 2. High intakes of milk and fats and oils had favorable effects on 10-year (1976-1986) survivorship in 422 urban residents aged 69-71. The survivors revealed a longitudinal increase in intakes of animal foods such as eggs, milk, fish and meat over the 10 years. 3. Nutrient intakes were compared, based on 24-hour dietary records, between a sample from Okinawa Prefecture where life expectancies at birth and 65 were the longest in Japan, and a sample from Akita Prefecture where the life expectancies were much shorter. Intakes of Ca, Fe, vitamins A, B1, B2, C, and the proportion of energy from proteins and fats were significantly higher in the former than in the latter. Intakes of carbohydrates and NaCl were lower.


Food policy for health in Japan.

In this half century, dietary habits in Japan have greatly changed and there is some confusion about what is healthy. In this report the causes of the confusion are analysed. To establish a healthy and normal dietary life, the recommendations for the public were considered from the various standpoints. There have been great changes in economic and social factors, and in supply and availability. Consumers rate convenience, diversity, good taste, healthiness, and "fashionableness" as important. To create a new food culture, the following three points would become the base; 1. It is necessary for each of us to have a sense of responsibility for our eating habits and our health. 2. We must cooperate with family and friends to work for the creation of an abundant and enjoyable dining table. 3. We have reached the stage in our dining culture where we must think not about what to eat, but how to eat, what conduct we should use when eating, and about our awareness of eating and what we are eating.


International cooperative study on the relationship between dietary factors and blood pressure: a preliminary report from the Cardiovascular Diseases and Alimentary Comparison (CARDIAC) Study. The CARDIAC Cooperative Study Research Group.

1. To investigate the epidemiological relationship of dietary factors to blood pressure (BP) and major cardiovascular diseases, we carried out the international cooperative Cardiovascular Diseases and Alimentary Comparison (CARDIAC) Study, which so far involves 48 centers in 20 countries as of August 1991. From each population, 100 men and 100 women aged 50-54 years were randomly selected for BP measurement, 24-h urine collection, blood tests, and medical interview. Various biological markers of diets from urine and blood were analyzed centrally in the Izumo CARDIAC center. 2. Cross center analysis using simple linear regression revealed strong significant correlations of body mass index (BMI) to systolic BP (SBP; p < 0.01) and diastolic BP (DBP; p < 0.001) in men. 24-h urinary sodium (Na) excretion in men also showed significant correlations with SBP (p < 0.05) and DBP p < 0.05) even after controlling for the effect of BMI (SBP; p < 0.05, DBP; p < 0.05). 3. Within center analysis using multiple linear regression implied that BMI and Na strongly adversely affect BP, whereas magnesium may have beneficial influence on BP. 4. Multicolinearities among 24h urinary sodium, calcium, and urea nitrogen were noted in men.


Trends in national nutritional survey of Japan.

The nutritional status of the Japanese has been measured and evaluated annually on a nationwide scale since the first National Nutrition Survey was carried out in 1946. Changes in dietary intake levels could thus be monitored systematically at a national level. According to the results observed, the whole 50 years of the postwar period can be divided into three stages in terms of dietary intakes and their postulated health outcome. Although it has certain limitations for the purpose of analysis the survey has performed a remarkable role in throwing light upon the general trends and current status of nutrition in Japanese populations and thereby enabling a successful nutritional policy to be established.


Nutritional improvement, cardiovascular diseases and longevity in Japan.

1. Nutritional conditions have improved remarkably for the past 40 years in Japan; major improvements are increases in protein intake (69.7 in 1955 to 79.2g/day per capita in '88), and fat intake (20.3 in '55 to 58.3 g/day per capita in '88), both of which are significantly related statistically to the gradual reduction of stroke mortality (r = -0.74, not significant; r = -0.78, p < 0.05) and to a remarkable extension of average life span (r = 0.91, p < 0.01; r = 0.98, p < 0.001) in the Japanese. 2. Average heights of 12-year old male and female children, correlating significantly with these nutritional improvements, are significantly positively correlated with average life spans (men and women respectively; r = 0.97, p < 0.001). 3. Thus, general nutritional improvements among the Japanese are regarded as the major contributory factor to the recent achievement of top-ranked position for longevity in the world.


Management of vertical root fracture in endodontically treated teeth.

Vertical root fracture is a common complication during and after endodontic treatment. The condition is often difficult to diagnose and treat. Management of the fracture usually represents a challenging dilemma that requires various techniques.


Survey of post procedures.

Methods used to restore endodontically treated teeth have changed over the last few years. The traditional standard of using a cast-gold post and core for all endodontically treated teeth has been questioned in the literature. The following is a report of a survey that the authors conducted to determine if there is a discrepancy between research and clinical practice.


Caveat preparator: maxillary second bicuspid root invaginations.

Seventy-five percent of maxillary second bicuspids have a single pulpal canal. The remainder present dual canals with one or two associated apical orifices and proximal root concavities. This latter phenomenon may well lead to root perforations when placing posts. The following case documents such an occurrence.


Recent changes in UK legislation and the licensing of radiopharmacies.

The implications of the recent loss of Crown Immunity to radiopharmacy in the NHS are reviewed. The options available are that the preparation of radiopharmaceuticals within a hospital will either be under the control of a pharmacist or be an activity licensed as 'Specials' manufacture. In the latter case the requirements for inspection by the Medicines Control Agency, the fees payable and the need for involvement of a pharmacist are reviewed. The requirements for the grant of a Specials Manufacturing Licence are presented in some detail. Reference is made to established and published sources of guidance, official and otherwise. Consideration is given to: staffing and personnel, open and closed procedures, environmental standards, handling of blood products, use of isolators, quality control and quality assurance, licensed and unlicensed materials, sterility testing, broth transfer tests, environmental monitoring and documentation.


Lacrimal scintigraphy in the diagnosis of epiphora.

The value of lacrimal scintigraphy in the assessment of nasolacrimal duct obstruction was determined by comparing the results with syringing in 67 patients (83 eyes). As expected, of 28 lacrimal drainage systems which were obstructed on syringing, 23 (82%) had abnormalities of tear drainage on scintigraphy. However, in 55 lacrimal drainage systems that were patent on syringing, 19 (35%) were normal, but in 36 (65%) abnormalities not apparent on syringing were detected on scintigraphy. Thus scintigraphy is a very useful technique in the assessment of nasolacrimal duct obstruction particularly in systems patent on syringing. Since the site of obstruction can be determined, lacrimal scintigraphy can facilitate the planning of the appropriate surgery.


Vertebral metastases and an equivocal bone scan: value of magnetic resonance imaging.

To assess the value of magnetic resonance imaging (MRI) in the investigation of patients with suspected but nonproven vertebral metastases 45 consecutive patients referred in a 6 month period with known primary malignancy and back pain in whom an isotope bone scan was reported as equivocal were studied. All patients had abnormal isotope uptake localized to the spine. Twelve patients were shown to have bony metastases on plain X-ray. In the remainder, where X-rays showed normal or benign appearance, MRI of the spine was offered. Twenty-four patients underwent MRI examination which showed vertebral metastases in 11 cases. Magnetic resonance imaging is shown to be a useful, noninvasive, complementary investigation for evaluation of patients known to have malignant disease and suspected of having vertebral metastases on bone scintigraphy.


A dual-isotope method for studying protein kinetics in pleural effusions in humans.

A method is described for studying protein kinetics in pleural effusions in humans. In 15 patients with pleural effusions from a variety of causes, protein inflow was monitored by measuring the rate of appearance in the effusion of the plasma protein transferrin, radiolabelled in vivo by intravenous injection of 113InmCl3. Protein outflow was measured from the rate of appearance in the blood of intrapleurally administered 125I-albumin. Compartmental analysis has been used to determine rate constants k(in) and kout for the movement of labelled proteins into and out of the effusion, respectively. The mean value of k(in) for 15 patients was 9.4 x 10(-4) h-1 (range 2.2-21.4). The mean value of kout in the same patients was 28 x 10(-4) h-1 (range 6-68). Using appropriate assumptions where necessary, the absolute transfer rates of albumin and transferrin were also estimated. For albumin, the mean rate of outflow was 66 mg h-1 (range 27-158), compared to mean estimated inflow of 133 mg h-1 (range 36-381). Protein inflow was highest in a case of metastatic ovarian carcinoma with pleural and peritoneal seedlings, indicating high vascular permeability. Protein outflow was very low in a case of mesothelioma, suggesting severely impaired lymphatic drainage. The technique may prove to be a useful tool for studying mechanisms resulting in the formation of malignant and nonmalignant pleural effusions, and may also be useful for studying the effects of putative therapeutic intervention.


67Ga uptake at sites of heterotopic calcification: a report of three cases.

Heterotopic calcification occurs commonly in spinal cord injured patients and following joint trauma or surgery. 99Tcm-methylene diphosphonate is useful in the detection of these lesions, many of which are subclinical. Three patients are presented with heterotopic calcification, one with severe hypoxic encephalopathy and two following major trauma. Intense 67Ga uptake within areas of heterotopic calcification was noted in all three patients. Two of the patients also underwent 99Tcm-methylene diphosphonate bone scanning and showed uptake of the bone agent corresponding to the areas of 67Ga uptake. In predisposed patients, heterotopic calcification should be considered in the differential diagnosis of a focal area of 67Ga uptake.


Hydroxamamide as a chelating moiety for the preparation of 99Tcm radiopharmaceuticals (I).

Hydroxamamides contain a nitrogen and an oxygen as donor atoms, and can be synthesized by the simple reaction of nitriles with hydroxylamine. Benzohydroxamamide (BHam) was investigated as a new ligand for 99Tcm. The yield of the 99Tcm-BHam complex was determined by thin-layer chromatography using cellulose strips. A high yield of the complex was obtained at room temperature over a wide pH range, even at BHam concentrations as low as 5 x 10(-7) M. Cellulose acetate electrophoresis indicated that the complex was uncharged. When the 99Tcm-BHam complex was injected into mice, it was cleared gradually from the blood by means of the hepatobiliary system with low urinary excretion. Uptake by the stomach and the spleen was low. These results demonstrate the high affinity of BHam for 99Tcm and the high stability of the 99Tcm-BHam complex. The hydroxamamide group may be a promising chelating moiety for designing new 99Tcm radiopharmaceuticals.


Visualization of myocardial infarction 6 h after injection of 111In-antimyosin antibodies using a blood pool subtraction technique.

111In-antimyosin antibodies are capable of visualizing myocardial infarction (MI). Because of slow blood clearance, images are usually recorded 24 or 48 h postinjection. In this pilot study, a blood pool subtraction technique, which makes it possible to visualize MI 6 h postinjection, is validated. Twenty-five patients with proven MI (16 anterior, 9 inferior) were imaged a few minutes, 6 and 24 h after an injection of 111 MBq 111In-labelled antimyosin antibodies. Three planar views are obtained each time. Using software which performs the geometric registration, the grey level normalization and the subtraction of images, the blood pool image (obtained a few minutes postinjection) is subtracted from the 6 h image. The resulting image is the blood pool corrected 6 h image. The 24 h images and the blood pool corrected 6 h images were interpreted blindly and the number of correct, incorrect and impossible MI localizations was counted. The number of correct localizations is 19/25 for the standard 24 h images and 22/25 for the blood pool corrected 6 h images. Then, with this blood pool subtraction method, it is possible to visualize MI 6 h postinjection. This has to be taken into account when discussing the role of antimyosin scintigraphy in the management of patients with MI.


Study of myocardial regional wall motion parameter's accuracy by software perfusion phantom.

Gated perfusion myocardial scintigraphy permits simultaneous evaluation of perfusion as well as regional contractile function of the left ventricle. Fourier analysis of regional myocardial spatial movement with respect to the myocardial geometric centre gives circular amplitude and phase profiles of ventricular contraction, in addition to regional maximum activity that represents an index of perfusion. To introduce such combined perfusion-contraction analysis the accuracy of the indices mentioned above should be evaluated for different doses of radioactivity typically administered to a patient. A mathematical software phantom, consisting of a half circularly profiled ring activity embedded in uniform background activity and noise generated by a Poisson-shaped random number generator, was constructed and used for this purpose. A 64 x 64 matrix and sequence of 16 frames per study was used. The maximum number of counts per pixel ranged from 10 to 100, simulating low count thallium and high count rate Tc-MIBI-gated studies. The relative standard error analysis (R.S.E.) with a 95.5% confidence level for a thallium type of 10 counts per pixel study exceeded 11%, while it reached acceptable values below 3% for studies with 60 and more counts per pixel. These results indicate that high count rate gated technetium-MIBI myocardial perfusion studies could also be used for reliable left ventricular regional wall motion evaluation.


99Tcm-HMPAO-labelled white blood cell scanning for the detection of carditis in the differentiation of rheumatic fever and inactive rheumatic heart disease in children.

Myocardial imaging with 99Tcm-hexamethylpropylene amineoxime (HMPAO)-labelled white blood cells (Tc-WBC) was used to detect carditis and differentiate rheumatic fever (RF) and inactive rheumatic heart disease (IRHD). Ten cases of RF and 15 cases of IRHD were studied, and the results revealed 60% (6/10) of the cases of RF with carditis, but none of the cases (0/15) of IRHD with carditis. There was significant difference (P less than 0.05, by Fisher's test) between RF and IRHD. In our preliminary conclusion, Tc-WBC heart scanning may be a noninvasive method for evaluating the existence of carditis in cases of RHD and in the differentiation of RF and IRHD.


Estimating the time of death in stillborn fetuses: II. Histologic evaluation of the placenta; a study of 71 stillborns.

To determine whether placental histologic examination is useful for predicting the approximate time of death in stillborn fetuses. Hematoxylin and eosin slides of 71 placentas of stillborns with accurately timed deaths were studied retrospectively. Fifty-one placentas (learning set) were used to develop proposed histologic criteria for the timing of fetal death, which were then tested in the remaining 20 placentas (test set). Among 15 histologic variables assessed in the learning set, three features appeared to correlate well with specific death-to-delivery intervals: 1) villous intravascular karyorrhexis (6 or more hours); 2) vascular lumen abnormalities of stem villi, including fibroblast "septation" and total luminal obliteration (multifocal, 2 or more days; extensive, 2 or more weeks); and 3) extensive fibrosis of terminal villi (2 or more weeks). When the placentas in the test set were evaluated using the three histologic criteria, 18 of 20 cases were classified correctly with respect to the approximate time of fetal death. Placental histologic examination seems to be useful for determining the approximate time of death in many stillborn fetuses.


Estimating the time of death in stillborn fetuses: III. External fetal examination; a study of 86 stillborns.

To determine how accurately the time of fetal death can be predicted from the extent of external maceration in a stillborn fetus. Autopsy photographs of 86 stillborns with well-timed deaths were studied retrospectively. Sixty randomly chosen fetuses (learning set) were assessed unblinded to develop proposed gross criteria for timing fetal death; 26 fetuses (test set) were then randomly and blindly assessed to test the accuracy of the proposed criteria. The two earliest changes in the learning cases were areas of desquamation measuring at least 1 cm in diameter and brown-red discoloration of the umbilical cord stump. Both changes occurred primarily in fetuses with death-to-delivery intervals of 6 or more hours. Other early changes included desquamation involving the face, abdomen, or back (12 or more hours); desquamation involving 5% or more of the body surface (18 or more hours); brown skin discoloration (24 or more hours); and a moderate or severe extent of desquamation (24 or more hours). The only late change that correlated with a specific duration of intrauterine retention was mummification (2 or more weeks). When the 26 test fetuses were randomly and blindly assessed using these gross criteria, 18 (69%) were classified correctly with respect to the approximate time of fetal death. External fetal examination is useful for estimating the time of death in many stillborns; this information may be helpful when a complete autopsy cannot be performed.


Fetal DNA in uterine vein blood.

To investigate whether the ratio of fetal cells in the maternal circulation differs before and after the blood passes through the maternal lung. We performed polymerase chain reaction-based Y-sequence analysis of DNA derived from antecubital vein blood obtained before and 2 hours after cesarean delivery, and from uterine vein blood obtained during cesarean of 14 women carrying male fetuses. Fetal DNA was detected in 17 tested specimens and, as estimated by comparison with parallel dilution series, the fetal-maternal DNA ratio was 1:10(5) to 1:10(6). However, there was no significant difference in the amount of Y-chromosomal DNA detectable between uterine vein blood and peripheral blood after polymerase chain reaction and Southern hybridization. In DNA derived from peripheral blood after delivery, the intensity of Y-specific fetal DNA sequences was also not significantly increased. Our results argue against the often-stated hypothesis of different ratios of fetal to maternal DNA in the uterine vein versus peripheral blood, and indicate that even delivery does not seem to increase the flow of fetal cells into the maternal circulation.


Effect of intra-amniotic administration of Exosurf in preterm rabbit fetuses.

Currently, treatment of respiratory distress syndrome (RDS) of the preterm newborn incorporates exogenous surfactant administration. Because fetuses make breathing motions, we proposed that intra-amniotic administration of an exogenous surfactant, Exosurf, to the preterm rabbit fetus results in uptake of Exosurf into the lungs and improves pulmonary mechanical properties compared with post-delivery treated and untreated litter mates. Ten preterm rabbit fetuses were used in a labeling study. A mixture of iron dextran and Exosurf was given in utero, and the minimum dose required to assure delivery of the mixture into the distal airways was 5 mL. In a lung function study, 30 rabbit pups received either 5 mL Exosurf in utero, 0.2 mL Exosurf post-delivery, or no treatment. Pressure-volume curves, opening pressures, and lung volumes at 50 cm H2O were compared among the three groups. Those rabbit pups receiving Exosurf either in utero or after delivery had significantly better pressure-volume relationships (P less than .001) and lower opening pressures (P less than .005) than the rabbit pups with no treatment. There were no differences between the animals treated intra-amniotically and post-delivery. Intrauterine administration of exogenous surfactant results in uptake of the surfactant solution into the lungs and alters the pulmonary characteristics of the preterm rabbit pup. Potential adverse effects of this means of surfactant administration must be evaluated further. Intrauterine surfactant delivery may provide an additional means of RDS prophylaxis in the antepartum period.


Seroprevalence and risk factors for hepatitis C virus antibody in pregnant women.

To better understand hepatitis C viropathies and seroprevalence by performing an epidemiologic analysis of pregnant women seropositive for antibody against hepatitis C. We studied 1013 consecutive obstetric patients at Parkland Memorial Hospital who gave informed consent for detailed interviews and serotesting. Sera were analyzed for antibody to the hepatitis C virus using both C100-3 and RIBA-4 assays. Neonatal assessment was carried out in the immediate postpartum period. Hepatitis C antibody was detected in 2.28% (N = 23) of the 1005 women in whom analysis was completed. Factors associated with seropositivity included intravenous (IV) drug use, sexually transmitted diseases, hepatitis B infection, maternal age greater than 22.5 years, increased parity (eg, greater than 2.1), history of transfusion, and three or more different lifetime sexual partners or a sexual partner who used IV drugs. Maternal and neonatal outcome was not different between hepatitis C antibody-positive and -negative groups. Epidemiologic data are consistent with sexual and parenteral modes of transmission. Women with hepatitis C antibody did not have excessive perinatal complications compared with antibody-negative women. A model protocol and cost analysis for screening pregnant women for hepatitis C infection are presented. However, routine screening for hepatitis C is not advocated.


Outcome of treated pregnancies in women with antiphospholipid syndrome: an update of the Utah experience.

To determine the outcome of treated pregnancies in women with well-characterized antiphospholipid syndrome. We reviewed 82 consecutive pregnancies in 54 women with antiphospholipid syndrome who were treated during pregnancy with the following: 1) prednisone and low-dose aspirin; 2) heparin and low-dose aspirin; 3) prednisone, heparin, and low-dose aspirin; or 4) other combinations of these medications or immunoglobulin. The overall neonatal survival rate was 73%, excluding spontaneous abortions, but treatment failures (fetal and neonatal deaths) occurred in all treatment groups. Patients with successful treated pregnancies had fewer previous fetal deaths than those with unsuccessful treated pregnancies. There were no significant differences in outcome among the four treatment groups. Preeclampsia and fetal distress occurred in half of all pregnancies, and fetal growth impairment occurred in nearly one-third. Preterm delivery due to maternal or fetal indications was required in 37% of the pregnancies. Four pregnancies were also complicated by postpartum thrombosis during treatment. Pregnancy in women with antiphospholipid syndrome appears to be improved by treatment, but fetal loss may occur despite treatment. Preeclampsia, fetal distress, fetal growth impairment, and premature delivery are common. Because of the clinically significant risk of thrombotic episodes, thrombosis prophylaxis should be considered in these patients.


Cost-benefit analysis of autologous blood donation in obstetrics.

To determine whether there are predictors of peripartum transfusion, other than placenta previa, that identify a population of pregnant women whose risk of transfusion is high enough to justify antepartum autologous blood donation. Using an established perinatal data base, we studied 14,267 consecutive term deliveries without placenta previa. Univariate and multivariate analyses were performed to assess ten predictors of peripartum transfusion that might reasonably be detected in the antepartum period. Costs were calculated for a hypothetical autologous blood donation program to prevent transfusion-related infection. Red-cell transfusion was used in 150 deliveries (1.1%). A total of 424 units was transfused (2.9 per 100 deliveries). Four risk factors were significantly (P less than .05) predictive of peripartum red-cell transfusion: preeclampsia (adjusted odds ratio 3.69), multiple gestation (2.82), elective cesarean (1.71), and nulliparity (1.51). Controlling for these, there was no association between transfusion and previous postpartum hemorrhage, previous cesarean with trial of labor, prior abortions, induction of labor, or ethnic group. A hypothetical antepartum blood donation program restricted to patients with three or more risk factors would cost $32,800-130,700 per case to prevent transfusion-related hepatitis and $26,000,000-78,000,000 per case to prevent human immunodeficiency virus infection. In obstetric patients without placenta previa, the need for peripartum red-cell transfusion cannot be predicted with sufficient accuracy to justify the costs of antepartum autologous blood donation.


The prediction of "controlled" uterine rupture by the use of intrauterine pressure catheters.

To determine whether uterine activity, assessed by either fluid-filled or solid pressure catheters, changes with uterine incision at cesarean delivery. Uterine activity was recorded continuously during low transverse cesarean delivery in ten parturients using fluid-filled pressure catheters and in ten women with solid pressure catheters. Visual analyses were performed of the last 30 minutes of uterine recording before uterine incision and of the period after incision; the analyses were then compared within and between the catheter groups for mean uterine tone and contraction amplitude, frequency, and duration. Oxytocin use, anesthesia method, mean gestational age, birth weight, length of labor, duration of monitoring, and uterine incision-to-delivery time were compared between the groups. All obstetric end points were similar in both catheter groups except for a higher mean birth weight in the solid-catheter group. The mean (+/- standard deviation) duration of post-incision monitoring was 4.7 +/- 0.94 minutes. After uterine incision, mean tone and contraction amplitude were unchanged, whereas mean contraction frequency and duration decreased significantly. Though intrauterine monitoring was brief, this model allows a unique view of "controlled" uterine rupture. Spontaneous uterine rupture may evolve more gradually; however, neither catheter type would be likely to aid its early recognition.


Effects of digital vaginal examinations on latency period in preterm premature rupture of membranes.

To compare the clinical outcome in patients with preterm premature rupture of membranes (PROM) who had a sterile speculum examination with those having a digital vaginal examination. We studied 271 singleton pregnancies complicated by preterm PROM from the Memorial Medical Center of Long Beach Perinatal Outreach program that met the criteria for expectant treatment from January 1986 to April 1990. Patients were not included in the study if they had multiple gestations, cerclage, advanced labor, or any indication for delivery on admission (eg, mature lung profile, chorioamnionitis). All subjects were maternal transports to our tertiary care facility and were managed similarly by our perinatal group. The women were questioned as to whether a digital vaginal examination had been performed before transport. Latency period and other obstetric characteristics were then compared. The latency period, defined as days from rupture of membranes until active intervention was initiated or labor began spontaneously, was also stratified by gestational age. One hundred twenty-seven subjects had a digital vaginal examination and 144 had a sterile speculum examination. A significantly (P less than .0001) shorter mean latency period (2.1 +/- 4.0 versus 11.3 +/- 13.4 days) was found in those who had a digital vaginal examination. In addition, a shorter latency period was noted for each gestational age. No difference in uterine activity or cervical dilatation and effacement was noted between the groups on admission. Digital vaginal examinations performed on patients whose pregnancies are complicated by preterm PROM appear to shorten significantly the latency period.


Five-year outcome of preterm and very low birth weight infants: a comparison between maternal and neonatal transport.

To determine the 5-year outcome of very low birth weight infants referred to tertiary perinatal centers. This study was part of a Dutch national collaborative survey of 1338 newborn infants younger than 32 weeks' gestation and/or with a birth weight of less than 1500 g born in 1983. Comparisons were made between maternal transport to university hospital perinatal centers versus delivery in local hospitals, and between neonatal transport to these centers versus treatment in local hospitals. For the 252 survivors meeting the entry criteria for this part of the study, adverse outcome at 5 years of age was evaluated by logistic regression analysis, including 26 perinatal risk factors as confounding variables. Outcome variables were disabilities and handicaps at 5 years as defined by the World Health Organization. There were no differences in handicaps and disabilities between infants born after maternal transport and those born in local hospitals. Handicaps and disabilities in neonates transported versus those treated in local hospitals were also not statistically different despite selection bias. The previously reported decrease in neonatal mortality risk after maternal transfer is not accompanied by an increased risk of adverse outcome for the survivors. In threatening very preterm delivery, maternal transport to a tertiary center is recommended.


Treatment-induced cyclic variations in serum lipids, lipoproteins, and apolipoproteins after 2 years of combined hormone replacement therapy: exaggerated cyclic variations in smokers.

To study the long-term effect of cigarette smoking on cyclic variations in serum lipids, lipoproteins, and apolipoproteins following combined hormone replacement therapy. One hundred eighteen healthy, early postmenopausal women were followed for 2 years in a randomized, placebo-controlled study. Four treatment groups received estradiol, either sequentially combined with levonorgestrel (75 micrograms), medroxyprogesterone acetate (10 mg), or desogestrel (150 micrograms), or continuously combined with cyproterone acetate (1 mg). Two groups received placebo. Serum lipids, lipoproteins, and apolipoproteins were measured at well-defined times. Information on smoking habits was elicited by questionnaire. We found statistically significant cyclic variations in apolipoprotein A1 in the levonorgestrel group (6.7%; 95% confidence interval [CI] 1.1-12.7%) and the desogestrel group (7.4%; 95% CI 2.9-12.1%). The cyclic variations in high-density lipoprotein (HDL) cholesterol were highly statistically significant in the levonorgestrel group (24.9%; 95% CI 10.2-39.2%). When women from sequential regimens were combined, further analysis showed that smokers had significantly larger cyclic variations in HDL cholesterol (P less than .01) and apolipoprotein A1 (P less than .05) than non-smokers. Sequentially combined hormone replacement therapy produces cyclic variations in HDL cholesterol and apolipoprotein A1 for at least 2 years. In addition, cigarette smoking is associated with an exaggeration of the cyclic effect of treatment on these indices.


Comparison of silastic rings and electrocoagulation for laparoscopic tubal ligation under local anesthesia.

To compare objectively the pain associated with tubal occlusion by Silastic rings versus electrocoagulation during laparoscopic tubal ligation under local anesthesia. Consecutive patients scheduled for laparoscopic tubal ligation under local anesthesia were randomized to Silastic rings (N = 50) or electrocoagulation (N = 52) as the method of tubal occlusion. Sterilization was performed under local anesthesia in a standard fashion. Bupivacaine 0.5% was used as the local anesthetic agent. Operative pain was measured based on intraoperative anesthesia requirements and a modified McGill pain questionnaire. This questionnaire was used to assess pain at 15 minutes, 1 hour, and 24 hours postoperatively. Demographics were similar for the two groups. Operative time was shorter in the Silastic-ring group (16.7 versus 21.8 minutes; P = .001), and this group also required less intraoperative anesthesia (P = .004). There were no statistical differences between the groups in self-reported pain intraoperatively or postoperatively. No patient in either group required antiemetics or pain medication in the recovery room. Silastic rings appear preferable to bipolar electrocoagulation for laparoscopic tubal sterilization under local anesthesia when long-acting local agents are used for tubal anesthesia.


Abdominal wound closure using a running, looped monofilament polybutester suture: comparison to Smead-Jones closure in historic controls.

To determine whether abdominal wound closure with a running, looped monofilament polybutester suture was as effective, inexpensive, and rapid as Smead-Jones closure using the same material. Between April 19, 1990 and August 29, 1991, 154 patients undergoing major gynecologic surgery had wound closure using a running, looped monofilament polybutester suture. Controls were 154 patients undergoing similar surgical procedures in the 15 months immediately preceding the study period (January 5, 1989 to April 18, 1990) whose wounds were closed with 0 polybutester using the Smead-Jones technique. All patients received prophylactic cephalosporin antibiotic therapy and external pneumatic leg compression perioperatively. The subcutaneous tissues were not sutured after fascial closure, and the skin was closed with stainless-steel staples. There was no difference between the groups when compared by mean weight, mean ponderal index, number of previous abdominal operations, operative blood loss, or the use of chemotherapy or radiotherapy in the pre- or postoperative period. Both groups had similar rates of complicating medical conditions including insulin-dependent and non-insulin-dependent diabetes mellitus, hypertension, obstructive pulmonary disease, atherosclerotic coronary disease, or peripheral vascular disease. The use of a running closure with looped monofilament polybutester suture in the study patients resulted in a reduction in operating time when compared with controls. The rates of superficial separation and wound infection were similar in both groups. In the study group, there was one minor fascial separation and one wound dehiscence, which occurred when the running suture was inadvertently snipped during debridement of a superficial infection. Running closure with looped polybutester is an acceptable, inexpensive, and expeditious method of abdominal wound closure.


Determinants of survival of surgically staged patients with endometrial carcinoma histologically confined to the uterus: implications for therapy.

To determine the factors that influence the survival of patients with endometrial carcinoma histologically confined to the uterus. Retrospective analysis was conducted of 262 surgically staged cases using multiple regression (Cox proportional hazards model). After excluding patients with clear-cell and serous tumors, which were adverse prognostic factors unrelated to any other variables, we found that survival was adversely affected by increasing stage, tumor grade and depth of myometrial invasion, cervical stromal and vascular space invasion by tumor, and increasing age. Tumor grade, myometrial invasion, and cervical involvement by tumor exerted their effects on survival as dichotomous rather than as ordinal variables. The greatest effect on survival was obtained by dichotomizing grade as grade 3 versus grade 1 or 2, myometrial invasion as invasion of more versus less than the inner third of the myometrium, and cervical spread as the presence versus absence of stromal invasion. The joint effect of the tumor-related prognostic factors was best expressed by constructing three risk groups consisting of patients with zero or one, two, and three or four risk factors. These risk groups were associated with 5-year survival rates of 97, 66, and 17%, respectively. After adjustment for risk factors, pelvic radiation did not affect survival significantly, although there was a trend toward improved survival of subjects with two risk factors who received pelvic radiation (70 versus 50% survival at 5 years). The number of tumor-related risk factors present is the best predictor of survival of patients with endometrial carcinoma confined to the uterus, and may provide the optimal basis for individualization of treatment.


Epidural analgesia in labor and fetal hyperthermia.

To assess the effect of epidural analgesia on fetal temperature in labor, contrasting intrauterine with oral thermometry. Fetal skin and maternal uterine wall temperatures were measured with an intrauterine probe in 57 laboring women at term. Maternal oral temperatures were measured in the normal way by birth attendants unaware that their measurements would be examined. Maximum recorded fetal, uterine, and oral temperatures were compared. Epidural analgesia resulted in a significant fetal temperature rise compared with other methods of analgesia. Duration of epidural analgesia correlated with the fetal temperature (R = 0.44, P = .012). Oral thermometry underestimated fetal temperature in 95% of the studies. We estimate that 5% of fetuses reached a core temperature in excess of 40C in this study, all in association with epidural analgesia. We suggest that antipyretic measures be considered after 5 hours of epidural analgesia in ambient temperatures above 24C.


Significance of cardiac activity on endovaginal ultrasound in very early embryos.

To evaluate the significance of cardiac activity on endovaginal ultrasound in embryos up to 10 mm in size. Ninety-six women with positive urinary pregnancy tests had vaginal probe ultrasound examinations at the first clinical visit. All had discernible embryos between 1-10 mm in greatest length. The presence or absence of discernible cardiac activity was recorded. None of the subjects had any antecedent bleeding. All were available for follow-up until delivery or completion of a failed pregnancy. Seventy-four women had cardiac activity present at the initial study and 22 did not. Eighty-one delivered healthy newborns and 15 had early pregnancy failure. All embryos that ultimately proved normal showed cardiac activity by the time they were 4 mm in size. However, absence of detectable cardiac activity in embryos of 3 mm or less was still associated with a 41% continuation rate. Cardiac activity is present in normal embryos before it can be detected on ultrasound. There are variations in the type and frequency of ultrasound equipment, maternal anatomical characteristics (obesity, coexisting fibroids, uterine version), and in the visual acuity of observers. Nevertheless, we conclude that in our hands, the absence of cardiac activity in embryos measuring 4 mm or more is reliably associated with embryonic death. In contrast, the lack of cardiac activity in embryos of 3 mm or less is nondiagnostic and may warrant follow-up study in 3-5 days.


Short-term fetal heart rate variation, decelerations, and umbilical flow velocity waveforms before labor.

To determine the value of computerized antepartum measurements of short-term fetal heart rate (FHR) variation and decelerations as a predictor of outcome, and to compare these with measurements of the umbilical artery flow velocity waveform. Data were collected from 3563 high-risk patients for measurements of FHR variables (15,702 records) and outcome (intrauterine death or metabolic acidemia on delivery). Detailed analyses were made on 89 patients with one or more records in which short-term FHR variation was 3 milliseconds or less. Umbilical artery flow velocity waveforms were measured concurrently on 2441 occasions in 991 patients. More than half of the patients with FHR variation of 3 milliseconds or less were identified before 31 weeks. When short-term FHR variation exceeded 3 milliseconds, there were no intrauterine deaths and only one instance of metabolic acidemia on cesarean delivery. When FHR variation fell below 2.6 milliseconds, 34% of the subjects had metabolic acidemia on cesarean or intrauterine death. The appearance or absence of decelerations was an unreliable guide to outcome. The correlation between FHR variation and the umbilical artery flow velocity waveform was low (r = 0.32). The population studied contained some patients without placental vascular disease or, in five with pre-eclampsia, without abnormal umbilical artery velocity waveforms but with grossly reduced FHR variation. Reduction in short-term FHR variation, as measured by computer, reliably predicts fetal outcome and is a more general measure of fetal well-being than are umbilical artery flow velocities.


Reappearance of end-diastolic velocities in the umbilical artery following maternal volume expansion: a preliminary study.

To determine the effects of maternal volume expansion on feto- and uteroplacental blood flow and neonatal outcome. Seven women with pregnancies characterized by absent end-diastolic velocity in the umbilical artery were treated with bed rest, antihypertensive medication, and volume expansion (expanded group) and compared with seven similar cases treated with bed rest and antihypertensive medication (unexpanded group). In the expanded group, end-diastolic flow reappeared temporarily in all cases after volume expansion. The pulsatility index in the umbilical artery decreased from 2.69 (95% confidence interval [CI] 2.1-3.2) to 2.15 (95% CI 1.74-2.56) 24 hours after maternal volume expansion (P less than .001). All cases in the unexpanded group continued to demonstrate absent end-diastolic velocity. There was no significant difference between the groups with regard to birth weight, which was 773 g (95% CI 521-1025) in the expanded group and 724 g (95% CI 429-1019) in the unexpanded group (P = .76). The gestational age at delivery was not significantly different between the groups: 203 days in the expanded group (95% CI 195-211) and 207 days in the unexpanded group (95% CI 189-225) (P = .71). The overall survival rate was significantly better in the expanded group: five of seven, versus one of seven in the unexpanded group (P less than .05). These preliminary data suggest that it is possible to improve feto- and uteroplacental perfusion with maternal volume expansion. The results point toward an improvement in neonatal outcome. Randomized trials are necessary to confirm our observations.


The significance of increasing umbilical artery systolic-diastolic ratios in third-trimester pregnancy.

To evaluate the clinical significance of a marked increase in the systolic-diastolic ratios (S/Ds) of the umbilical artery (UA) Doppler velocity waveforms of third-trimester fetuses. We evaluated 552 pregnancies at risk for placental insufficiency. Each patient had at least five successive weekly UA Doppler velocimetry studies between 32-42 weeks and a highest S/D within the normal range for gestational age. The S/D was considered markedly increased if it was at least 20% higher than the mean of four previous values. Clinical end points reviewed included mortality, fetal distress, 5-minute Apgar score below 7, metabolic acidosis, and neonatal intensive care unit (NICU) admissions for reasons other than prematurity. The S/Ds were normal in 478 patients and were markedly increased in 74. The two groups were similar in mean gestational age at testing and delivery and in the rates of fetal growth retardation and low 5-minute Apgar scores. The group without increased S/Ds had a higher mean birth weight and lower incidences of perinatal death, cesarean delivery for fetal distress, acidosis, and NICU admission. The overall sensitivity (43%), specificity (90%), positive predictive value (27%), and negative predictive value (95%) were similar to our previous experience in which we used a criterion of S/D above the 90th percentile. Marked increases in UA S/Ds, even if within an institutional "normal" range, may indicate a fetus at increased risk of compromise.


Clinical evaluation of the NBD-PC fluorescence polarization assay for prediction of fetal lung maturity.

1) To examine a fluorescence polarization (FP) assay with an independent set of data that contained more cases of respiratory distress syndrome (RDS) than a previous study, 2) to determine whether the same reference ranges are applicable to infants born to diabetic women, and 3) to evaluate whether adding the lecithin-sphingomyelin ratio (L/S) would substantially improve the prediction of RDS among women with an intermediate FP value (between 0.26-0.289). We identified 389 women who had FP analysis performed at the University of Washington Medical Center from February 1986 to October 1988 and who delivered within 3 days of amniocentesis. We reviewed the medical records of these women and their infants to extract information for our study. For FP values of 0.26 or greater, the sensitivity and specificity for prediction of RDS were 90.2 and 84.6%, respectively, compared with 100 and 82.0% in the previous study. For FP values of 0.29 or greater, the sensitivity and specificity were 62.8 and 94.2%, respectively (80.8 and 96.2% in the previous study). Among diabetics, an FP result below 0.26 was associated with the same low risk of RDS as among non-diabetics. Among the patients with FP between 0.26-0.289, the addition of L/S did not provide a clinically useful improvement in the prediction of fetal lung maturity. The NBD-PC FP assay can be used as the sole test of fetal lung maturity in most clinical circumstances.


Urethral diverticula: evaluation by urethral pressure profilometry, cystourethroscopy, and the voiding cystourethrogram.

To compare the value of urethral pressure profilometry with that of cystourethroscopy and the voiding cystourethrogram in the evaluation and management of urethral diverticula. Twelve women with signs or symptoms of a urethral diverticulum were referred. The initial evaluation included cystourethroscopy and a voiding cystourethrogram. All then underwent urethral pressure profilometry. Nine of 12 patients had urethral diverticula, two had Skene duct cysts, and one had genuine stress incontinence. Both cystourethroscopy and voiding cystourethrography demonstrated diverticula in all patients who had them. Excision was the preliminary surgical plan in these women. Urethral pressure profilometry demonstrated a pressure depression or biphasic curve in all nine cases with diverticula. Stress incontinence was noted in one of these nine women. A biphasic curve was also noted in one woman with a Skene duct cyst and in the one who had genuine stress incontinence only. According to preset criteria for profilometry, excision was the planned operative procedure for all. Cystourethroscopy and voiding cystourethrography were satisfactory techniques for diagnosing urethral diverticula and planning appropriate surgical treatment. The urethral pressure profile confirmed the presence of a diverticulum, but noted pressure depressions in cases other than diverticula. Profilometry did not change the surgical plan for treating diverticula, but allowed the planning of additional incontinence surgery in one patient.


Should women with familial ovarian cancer undergo prophylactic oophorectomy?

To estimate the lifetime probabilities of ovarian cancer in women from families with hereditary ovarian cancer syndromes and those with a family history of ovarian cancer, and to assess the needs for prevention and surveillance in such women. We searched for studies of familial ovarian cancer published since 1966 and used ovarian cancer incidence data from the Surveillance, Epidemiology, and End Results program of the National Cancer Institute. Pooled estimates of relative risk of ovarian cancer among women with a family history of ovarian cancer were derived using statistical methods based on fixed effects. Modified life-table methods were used to estimate the lifetime probability of ovarian cancer. The lifetime probability of ovarian cancer increases from about 1.6% in a 35-year-old woman without a family history of ovarian cancer to about 5% if she has one relative and 7% if she has two relatives with ovarian cancer. The lifetime probability may decrease to about 3-4% if she takes oral contraceptives for 5-9 years. Women from families with hereditary ovarian cancer syndromes may have as high as a 50% lifetime risk of ovarian cancer. The risk of ovarian cancer in women from families with hereditary ovarian cancer syndromes is sufficiently high to warrant prophylactic oophorectomy. Among women with one relative with ovarian cancer, the lifetime probability of ovarian cancer is not high enough to recommend oophorectomy. However, some women may choose oophorectomy depending on their attitudes concerning risk-taking, surgery, and hormone replacement. Oral contraceptives should be considered as preventive therapy to decrease the risk of ovarian cancer in women with a family history of ovarian cancer.


A quantitative assessment of oral contraceptive use and risk of ovarian cancer.

To provide a quantitative assessment of the association between oral contraceptive (OC) use and ovarian cancer using results from the published literature. We conducted a MEDLINE literature search for all epidemiologic studies of OC and ovarian cancer published in English between 1970-1991. The reference list for each article was reviewed to locate additional published articles. We included 20 studies in which a relative risk and either a standard error, confidence interval, or P value was reported, or sufficient data were presented to allow us to calculate these measures. We summarized the findings using weighted averages and regression analyses. We found a summary relative risk of 0.64 (95% confidence interval 0.57-0.73) associated with ever-use of OC, indicating a 36% reduction in ovarian cancer risk. The risk of ovarian cancer decreased with increasing duration of OC use; we noted a 10-12% decrease in risk with 1 year of use and approximately a 50% decrease after 5 years of use. The reduced risk was present among both nulliparous and parous women and it appeared to last for at least 10 years after cessation of use. Although most studies assessed the use of cessation of use. Although most studies assessed the use of OC formulations from the 1960s and 1970s, data from the Cancer and Steroid Hormone Study indicate that the decreased ovarian cancer risk may also be present with current lower-dose formulations. The protective effect of OC against ovarian cancer risk should be considered in a woman's decision to use OC.


The introduction of nitrous oxide analgesia into obstetrics.

Nitrous oxide analgesia was introduced into obstetrics by a young Polish-Russian physician who manufactured the gas himself, mixed it with oxygen, humidified the mixture with water vapor, and devised a mouthpiece for self-administration. After assessing the results on himself, he evaluated the effects on pain relief, maternal emotion, and maternal and fetal heart rates, as well as on the frequency, duration, and strength of uterine contractions in 25 parturients. He recognized that, in contrast to chloroform, nitrous oxide did not alter uterine activity. He concluded that the advantages of nitrous oxide administration far outweighed its disadvantages.


Clinicians who provide abortions: the thinning ranks.

Access to abortion services in the United States has become increasingly limited because of a decrease in rural hospital providers and a growing shortage of clinicians willing to offer this service. As of 1988, 83% of United States counties had no identified provider. The deficit in numbers of clinicians stems from the current imbalance between incentives and disincentives. The single most powerful incentive appears to be altruism. On the other hand, disincentives include poor pay, frequent harassment, low prestige, suboptimal working conditions, and tedium. In 1990 a symposium on abortion provision was held, sponsored by the National Abortion Federation and ACOG. Among the remedies suggested by the attendees were increasing the integration of abortion training into the mainstream of residency education, improving the pay and work environments for clinicians, and where feasible expanding the capacity of physician providers by using midlevel practitioners working under physician supervision.


Half-hitch knot for securing the end of continuous sutures.

Exploring means for tying a knot at the end of a continuous suture during laparoscopic surgery, it was found that formation of a single half-hitch over the last loop of the suture can secure the ending of the suture and protect against unraveling. This knot has been used successfully to complete running sutures in various endoscopic, gynecologic, and obstetric procedures.


Obstetric care and cesarean birth rates: a program to monitor quality of care.

To study the quality of obstetric care in relation to rising cesarean rates, a Task Force was formed in New York state by the Department of Health and ACOG District II. The Task Force also included the Organization of Obstetric, Gynecologic, and Neonatal Nurses and the Hospital Association of New York State. The goals were to enhance hospitals' in-house review processes, standardize terminology, and improve the quality of care. A premise of the program was that if quality of care improved, cesarean rates would fall. A Dictionary of Terms was developed to standardize clinical and diagnostic terminology. A two-tiered review process was instituted, using internal and external hospital reviews. A format for in-house review of obstetric care was developed and recommended to hospitals. External reviews were conducted at 24 hospitals during 1989-1990. Review teams, composed of obstetrician-gynecologists and obstetric nurses in active obstetric practice, assessed obstetric facilities, staffing, medical care, and the in-house review process. Contacts continued with the hospitals after site visits to follow up on implementation of recommendations. General recommendations to improve care, based on the overall program experience, were distributed to hospitals and physicians as part of educational efforts to improve quality of care. The state cesarean rate reversed. Statistics for 1989 and 1990 showed a stronger downward trend in reviewed hospitals than in non-reviewed hospitals. A survey of reviewed hospitals reported a positive response to the review process. A successful quality assurance program can be jointly developed by a state regulatory agency and a medical specialty society.


Smoking, pregnancy, and source of prenatal care: results from the Pregnancy Risk Assessment Monitoring System. The Pregnancy Risk Assessment Monitoring System Working Group.

To assess the impact of current smoking intervention efforts and to target future efforts by describing the relationships between maternal smoking, smoking cessation, and source of prenatal care. We used population-based data from 6319 mothers who delivered live-born infants during 1988 and 1989 in Maine, Michigan, Oklahoma, and West Virginia. The number of women sampled per state ranged from 1490-2659; state-specific response rates ranged from 66-84%. Analysis weights adjusted for selection probability and non-response. The prevalences of maternal smoking before, during, and after pregnancy among women receiving publicly funded prenatal care were 2.3-3.4 times the comparable prevalences among privately insured women receiving prenatal care from private providers. Although many smokers reduced or quit smoking during pregnancy, most resumed or increased their smoking to nearly pre-pregnancy levels by 3-6 months postpartum. Interventions should target the very high levels of smoking among the 27% of women receiving publicly funded prenatal care. However, from a population perspective, the greatest potential for reduction in smoking is among patients of private providers, who care for 61% of pre-pregnancy smokers.


Comparison of questionnaire screening and urine toxicology for detection of pregnancy complicated by substance use.

To compare the efficacy of structured questionnaire screening and prenatal urine toxicology for the detection of substance use by pregnant women, and to describe substance use patterns in a group of women presenting to a university-based obstetric clinic. All patients presenting to our obstetric clinic for their first prenatal visit were evaluated for evidence of current use of alcohol or any illicit substances. Nursing personnel administered an extensive questionnaire, which included detailed questions about past and current substance use patterns. Urine samples were examined by a commercial laboratory for alcohol and a number of illicit substances. Current users were defined as those who admitted use within the past 30 days or who had positive urine toxicology. Fifty-eight of 302 patients (19.2%) were identified as current users of alcohol or illicit substances. Only 17 of 41 women (41.5%) with toxicologic evidence of recent use admitted to current use. Only 17 of 34 (50.0%) admitting to current use had toxicology positive for any substance. Patients with a history of multiple past substance use were significantly more likely to have positive urine toxicology than those without such a history (26.1 versus 7.4%; P < .005). Among current users, multiple substance use (34.5%) and cigarette smoking (52%) were common. A screening combination of structured questionnaire and universal urine toxicology identifies more current users than either technique alone, and neither is clearly superior to the other. A history of multiple substance use may be an important indicator of current use.


Recurrence of gestational diabetes mellitus.

To assess the influence of several maternal and neonatal variables on the recurrence of gestational diabetes mellitus. A retrospective review was conducted on 90 of our patients whose index pregnancy was complicated by gestational diabetes mellitus and whose subsequent pregnancy was also managed at our institution. Forty-seven women (52%) had a recurrence of gestational diabetes mellitus in their subsequent pregnancy. These 47 women had an increased body mass index (BMI) (32.8 +/- 8.2 versus 28.9 +/- 7.2 kg/m2; P < .03) and more large for gestational age (LGA) neonates (38 versus 14%; P < .05) and more of them required insulin during their index pregnancy (38 versus 19%; P < .05) than did those who did not have a recurrence of gestational diabetes mellitus. Women who developed a recurrence of gestational diabetes mellitus also had higher fasting (P < .05), 1-hour, 2-hour, and total glucose tolerance test values (P < or = .01) during their index pregnancy. Women with a history of gestational diabetes mellitus who have a BMI greater than 35 kg/m2, whose previous newborn was LGA, and who required insulin during their previous pregnancy are at increased risk for recurrence of gestational diabetes mellitus.


Expectant management of preterm ruptured membranes: effects of antimicrobial therapy.

To determine whether the addition of broad-spectrum antimicrobial therapy to traditional expectant management improves pregnancy outcome in patients with premature rupture of membranes (PROM) remote from term. Patients with preterm PROM before 34 weeks' gestation who were not in labor and had no signs of infection or fetal distress were randomized to one of two study groups: 1) expectant management alone and 2) expectant management plus antimicrobial therapy. Women in the latter group received intravenous ampicillin, gentamicin, and clindamycin for 24 hours, followed by amoxicillin plus clavulanic acid orally for 7 days. Other than antibiotic use, management of the two groups was identical. Significantly more women (P < .01) treated with antibiotics (20 of 48, 42%) remained undelivered 7 days after admission compared with those managed expectantly without antibiotics (seven of 46, 15%). In addition, more neonates in the group managed with antibiotics were admitted to the routine nursery (nine of 48 versus two of 45; P = .03). However, there was no difference between the groups in the frequency of serious maternal or neonatal morbidity. The addition of broad-spectrum antimicrobial therapy to traditional expectant management of pregnancy complicated by preterm PROM may increase the number of gestations undelivered 7 days after admission. It may also decrease the proportion of infants admitted to special care nurseries. Whether these effects result in significant short- or long-term maternal or neonatal benefit remains to be determined.


Approximate entropy, a statistic of regularity, applied to fetal heart rate data before and during labor.

To determine whether approximate entropy (ApEn), a new statistic of regularity, when applied to fetal heart rate (FHR) data antepartum or in labor, would offer an advantage over standard statistics of variation in predicting outcome. A large data base of antepartum FHR records collected in clinical practice over 10 years was available. Two data sets in labor were stored on disk in small computers interfaced to fetal monitors on-line. Outcomes were assessed using blood gas values on delivery and Apgar scores. Antepartum, when the most favorable form of ApEn was used on 769 good-quality FHR records, the correlation with measurement of short-term variation was high. This was especially true when the fetal pulse interval variation fell below the normal range (less than 6 milliseconds short-term; r = 0.93) and in 20 other records with sinusoidal variation (r = 0.96). Approximate entropy varied with fetal sleep cycles and took longer to calculate than FHR variation. During the last hour of labor, in 319 records, there was no significant correlation between umbilical artery base deficit values on delivery and ApEn measurement. In 871 additional good-quality records of fetuses with normal outcome, the mean (+/- standard error [SE]) ApEn (0.95 +/- 0.005) was significantly greater than in 22 records (0.88 +/- 0.028) from fetuses with abnormal outcome (umbilical artery base deficit more than 12 mmol/L and Apgar score of 3 or less at 1 minute). However, consideration of the frequency distributions of these measurements showed that ApEn did not discriminate between normal and abnormal outcomes. The SD of fetal pulse intervals rose in labor whereas ApEn values fell, confirming that this new statistic of regularity differs from standard statistics of variation. Approximate entropy offered no advantage over measurement of short-term FHR variation antepartum, and neither measurement predicted outcome in labor.


Four-quadrant assessment of amniotic fluid volume: distribution's role in predicting fetal outcome.

The amniotic fluid (AF) index has been shown to be a useful tool in the area of antepartum surveillance. An intrapartum AF index less than or equal to 5.0 has been shown to have predictive value with respect to increased perinatal morbidity. This study was designed to determine whether the distribution of the AF within the AF index is related to perinatal outcome. Patients presenting for labor and delivery had an AF index determined and were divided into two groups. Patients with greater than 50% of their AF distributed in the upper quadrants were placed in the "upper-greater" group. The remaining patients were placed in the "lower-greater" group. The distribution data were compared with the following variables: meconium staining, 1- or 5-minute Apgar score of less than 7, persistent variable decelerations in the first stage of labor, late decelerations, neonatal intensive care unit admission, cesarean delivery for fetal distress, and umbilical arterial and venous pH less than 7.20. A total of 218 patients were evaluated, 125 in the upper-greater group and 93 in the lower-greater group. The upper-greater group had a greater incidence of meconium staining (32.8 versus 9.7%; P < .0001), 1-minute Apgar score of less than 7 (12.0 versus 2.2%; P < .007), variable decelerations (53.6 versus 19.4%; P < .00001), late decelerations (16.0 versus 0%; P < .0001), cesarean delivery for fetal distress (7.2 versus 0%; P < .008), umbilical arterial pH less than 7.20 (29.6 versus 8.9%; P < .0105), and umbilical venous pH less than 7.20 (8.9 versus 0%; P < .0398). These results were maintained regardless of the overall AF index. The distribution of the fluid within the AF index is predictive of perinatal outcome. In addition, the presence of a high negative predictive value for all of the perinatal indices studied enhances the value of this technique as a potential screening tool. Application of these results could provide additional guidelines in defining the intrapartum management and therapy of patients presenting for labor and delivery.


Cord-containing amniotic fluid pocket: a useful measurement in the management of oligohydramnios.

To test the hypothesis that among patients with a low amniotic fluid (AF) index, those who have a large cord-containing AF pocket will have a lower risk for adverse perinatal outcome than women with a small cord-containing pocket. Gravidas with an antepartum AF index no greater than 5 cm were studied prospectively. The vertical diameter of the single largest cord-containing pocket, which was excluded from the calculation of the AF index, was measured. Women with rupture of the membranes, multiple gestation, or fetal anomalies were excluded. Fifty-one women with gestational ages of 35-43 weeks were analyzed. Among 35 who had a cord-containing pocket of no more than 5 cm, eight (23%) had fetal distress necessitating operative delivery and eight neonates had cord arterial pH below 7.20. None of these complications occurred in the 16 women who had a cord-containing pocket above 5 cm (P < .05). The mean AF index (2.9 versus 2.8 cm) was not significantly different between the groups. Among women with a low AF index, a cord-containing pocket above 5 cm identifies a subgroup of women at lower perinatal risk compared with those with a smaller cord-containing pocket. The need for intervention may be reduced in women with a cord-containing pocket greater than 5 cm.


Sonographically detected hyperechoic fetal bowel: significance and implications for pregnancy management.

The clinical significance of sonographically detected hyperechoic fetal bowel has not been fully established. This report describes the natural history, pregnancy outcome, and associated features of 30 cases of prenatally diagnosed hyperechoic fetal bowel. Fetal bowel of similar or greater echogenicity than surrounding bone was considered hyperechoic. Fetuses so diagnosed were compared with matched controls and with our general obstetric population to determine the relative frequencies of cystic fibrosis, perinatal death, fetal growth retardation, and fetal trisomies. The incidence of hyperechoic fetal bowel during the study period was 0.2% (30 of 12,776 fetuses). Four of the 30 fetuses (13.3%) with hyperechoic bowel were found to have cystic fibrosis, as compared with one in 2200 (0.05%) in the general population. Hyperechoic fetal bowel was also associated with increased risks for perinatal death (16.7%, versus 3.8% in matched controls and 1.9% in the general obstetric population) and fetal growth retardation (23.3% versus 1.9% and 5%, respectively). One fetus with hyperechoic bowel had trisomy 18, an incidence of cytogenetic abnormalities of 3.3%. This was not significantly greater than observed in our general obstetric population (1.2%) (P > .25). The sonographic finding of hyperechoic fetal bowel is associated with an increased risk for cystic fibrosis, perinatal death, and growth retardation. The risk of fetal trisomy in cases of isolated hyperechoic bowel appears small. When detected, hyperechoic bowel should prompt a complete and careful fetal anatomical survey, consideration of parental carrier testing for cystic fibrosis, and serial sonographic assessment of fetal growth, with cytogenetic testing reserved for cases demonstrating other structural malformations.


Effects of methyldopa on umbilical and placental artery blood flow velocity waveforms.

To identify the effects of methyldopa on umbilical and placental artery Doppler velocity waveforms in mild preeclamptic and chronic hypertensive women with blood pressure below 160/110 mmHg. Twenty-two normotensive, 11 untreated mild preeclamptic, 14 treated mild preeclamptic, 29 untreated chronic hypertensive, and 14 treated chronic hypertensive women were studied. Methyldopa was begun if the blood pressure remained higher than 140/90 mmHg after 24 hours of hospitalization. The pulsatility index (PI) was measured on days 0 and 7. Blood pressure decreased significantly with methyldopa in chronic hypertensive women only (P < .05). The PI did not vary in the umbilical artery in the five groups, or in the placental artery in normotensive, untreated preeclamptic, and untreated chronic hypertensive women. The PI decreased significantly in treated preeclamptic and chronic hypertensive women (P < .05). Birth weight was similar in the hypertensive groups. Methyldopa decreases placental vascular resistance in mild preeclamptic and chronic hypertensive women.


Effects of induction of labor with prostaglandin E2 on fetal breathing and body movements: controlled, randomized, double-blind study.

To evaluate the effects of prostaglandin (PG) E2, given for induction of labor at term, on fetal breathing and body movements. Eighteen women with term pregnancies, mild gestational hypertension, intact membranes, and unripe cervices who were not in labor participated in this study. After a 60-minute baseline ultrasound examination of fetal chest and body movements, recorded on videotape, the patients were randomly assigned to either 3 mg intravaginal PGE2 tablets or controls (placebo intravaginal tablets). Following tablet insertion and a 3-hour observation time, a second 60-minute ultrasound recording of fetal movements was taped. The videotape recordings were interpreted according to the total amount of time occupied by fetal body movements and fetal breathing movements. There was a total of 2180 minutes of ultrasound tape recordings, with 136.2 minutes of fetal body movements (6.2%) and 207.8 minutes of fetal breathing movements (9.5%). Mean (+/- standard deviation) observation times per patient before and after tablet insertion were 60.3 +/- 1.2 and 56.4 +/- 1.2 minutes for the PGE2 group and 60.1 +/- 1.3 and 60.4 +/- 1.1 minutes for the control group. Three hours after PGE2 insertion, there were significant decreases in the percentage of time occupied by body movements (7.8 +/- 3.1 versus 3.4 +/- 2.0%; P < .003) and breathing movements (10.6 +/- 8.6 versus 3.9 +/- 2.3%; P < .007). Three hours after tablet insertion, there were statistically significant decreases in the percentage of time occupied by body movements (P < .025) and breathing movements (P < .01) between the control and study groups. Induction of labor with intravaginal PGE2 tablets inhibits fetal body and breathing movements. The effects could be due to direct action on the fetus or indirect effects of PGE2 (through uterine contraction and/or endogenous PG).


An assessment of the use of meconium alone as an indication for fetal blood sampling.

To assess the validity of meconium as an indication for fetal blood sampling. The study design was a prospective observational study in a teaching hospital. Fetal blood samples were taken from 401 women. One hundred sixty-five patients had meconium-stained amniotic fluid (77 of whom had no cardiotocographic abnormalities). In the remaining 236 patients, the indication for fetal blood sampling was cardiotocographic abnormalities without meconium. The main outcome measures were the values of pH and base excess obtained at fetal blood sampling, 1-minute Apgar scores, and umbilical artery pH values. Patients with meconium alone as an indication for fetal blood sampling had higher scalp sample pH values (P < .001) and 1-minute Apgar scores (P < .01) than laboring patients with both meconium and cardiotocographic abnormalities. The patients with meconium alone had higher scalp pH values than patients with cardiotocographic abnormalities but no meconium (P < .001). In only two patients with meconium alone was a fetal scalp pH less than 7.20 (both infants had good Apgar scores at delivery). However, when cardiotocographic abnormalities were present, the finding of meconium was significant, resulting in lower 1-minute Apgar scores (P < .01) despite a lack of difference in fetal blood sample pH values. In the absence of cardiotocographic abnormalities, meconium is not an indication for fetal blood sampling.


Transvaginal Doppler ultrasound assessment of intratumoral hemodynamic change before and during hypertensive intra-arterial chemotherapy for uterine cancer.

To evaluate blood flow in malignant uterine tumors during hypertensive intra-arterial chemotherapy. Hypertensive intra-arterial chemotherapy (angiotensin II, cisplatin 100 mg, doxorubicin 40 mg) was given to two women with cervical cancer (stage IVA) and seven with endometrial cancer (three stage IA, one stage IB, two stage II, and one stage III). The intratumoral blood flow velocity waveforms were imaged by transvaginal Doppler ultrasound before and during the chemotherapy in six patients. The mean peak systolic velocity during hypertensive intra-arterial chemotherapy (58.9 +/- 29.3 cm/second) was significantly higher than that before chemotherapy (16.0 +/- 6.3 cm/second) (P < .05). There was a significant difference between the end-diastolic velocity before (5.2 +/- 1.8 cm/second) and during chemotherapy (21.2 +/- 6.8 cm/second) (P < .05). The resistance index value during hypertensive intra-arterial chemotherapy (0.607 +/- 0.094) fell significantly from that before therapy (0.644 +/- 0.119) (P < .05). Blood flow velocity waveforms in normal myometrial tissue could be recorded in three cases; in all, the diastolic flow noted before hypertensive intra-arterial chemotherapy disappeared during chemotherapy. These results suggest that hypertensive intra-arterial chemotherapy induces a selective marked increase of blood flow in uterine cancer.


Percutaneous nephrostomy and ureteral stenting in gynecologic malignancies.

To identify the indications, complications, and efficacy of percutaneous nephrostomies and ureteral stents in women with gynecologic cancer. In a retrospective study, 40 women underwent urinary diversion with percutaneous nephrostomy and ureteral stents. Nine had ureteral stenosis on initial presentation, 18 had persistent or recurrent cancer, nine had no evidence of disease, and four had operative ureteral damage. Of the nine who were without disease, seven had a urinary conduit. Thirty-five patients had ureteral stenosis, which was bilateral in 24, and five had a ureteral fistula. Sixteen had a unilateral and 22 had bilateral percutaneous nephrostomies, with two cases having stents only. The most common complication was hematuria. Thirteen women were later hospitalized for pyelonephritis. Twenty-nine (72.5%) had ureteral stents, which were bilateral in 12. Renal function was abnormal in 26, but improved in 14 and returned to normal in six. Five fistulas were managed with ureteral stents alone and four were closed. The median time to death (N = 22) was 5.5 months, 12 months in primary cases versus 5.5 months in recurrent cases. Twelve of the remaining 18 were alive without evidence of disease at a median of 38 months, five were alive with disease at a median of 16 months, and one was lost to follow-up. These techniques are safe and often improve renal function. The procedures have different roles in women with primary and recurrent gynecologic cancer, in those without evidence of recurrent disease, and in those with urinary conduits.


Endometrial metaplasia associated with endometrial carcinoma.

To clarify the relationship of metaplasia to endometrial carcinoma. Between 1984-1990, 73 cases of stage I-II endometrial carcinoma treated initially by hysterectomy were reviewed histologically. The metaplasias were classified as squamous, syncytial papillary, ciliated-cell, eosinophilic, mucinous, clear-cell, or hobnail. We assessed the histologic type and grade of the carcinoma, depth of myometrial invasion, presence or absence of lymph-vascular space invasion, and presence or absence of lymph node metastases. Forty of 73 patients (55%) had one or more areas of metaplasia in the endometrium adjacent to the carcinoma. Ciliated-cell metaplasia (28 of 73; 38%) was the most common type encountered. Women with both endometrial carcinoma and metaplasia were significantly younger than those with carcinoma without metaplasia (P < .05). Compared with carcinomas without metaplasia, those with metaplasia were well differentiated (P < .01) and lacked myometrial invasion (P < .01) and pelvic lymph node metastases (P < .05). The presence of metaplasia was also significantly correlated with the presence of endometrial hyperplasia (P < .01). In endometrial carcinomas, the presence of endometrial metaplasia suggests a favorable prognosis.


Risk factors for ectopic pregnancy: an Italian case-control study.

To analyze risk factors for ectopic pregnancy in a population at low risk for the disease. Between September 1989 and February 1991 in Milan, we conducted a case-control study on 120 cases of ectopic pregnancy and 209 controls. The control subjects gave birth at term (more than 37 weeks' gestation) to healthy infants on randomly selected days at the same hospitals where the cases had been identified. The risk of ectopic gestation was about 40% higher in smokers than in controls, and the risk estimates increased with the number of cigarettes smoked per day (chi 2(1) trend 4.21, P = .04) and the duration of smoking (chi 2(1) trend 7.31, P < .01). However, smoking was not associated with the risk of ectopic pregnancy after adjustment for potential confounding factors (including history of pelvic inflammatory disease) in a multivariate analysis (relative risks [RRs] for ten or fewer and more than ten cigarettes per day versus no smoking were 0.8 and 1.1, respectively; chi 2(1) trend 0.10, P = not significant). Infertility problems or difficulty in conception were reported by 32% of the cases and 10% of the controls; the corresponding multivariate RR was 4.7 (95% confidence interval [CI] 2.3-9.5). A history of abdominal surgery was associated with about double the risk of ectopic pregnancy (multivariate RR 2.4, 95% CI 1.4-4.2). Similar estimates were found when the analysis was performed considering various types of surgery separately such as appendectomy, cesarean delivery, and other abdominal surgery. Finally, the risk of ectopic pregnancy was higher in women reporting a history of pelvic inflammatory disease (RR 2.7, 95% CI 0.9-8.7) and increased with the number of sexual partners (chi 2(1) trend 4.51, P = .03). Problems of infertility or difficulties in conception, history of pelvic inflammatory disease/salpingitis, and abdominal surgery are the main risk factors for ectopic pregnancy in this Italian study. Sexual habits also appear to have some independent effect.