Intrapartum management of multiple gestation

The intrapartum management of multiple gestation continues to challenge the obstetric profession. In general, attempted vaginal delivery is appropriate for vertex-vertex twins. The options of external version, breech delivery, and cesarean delivery are analyzed for vertex-nonvertex twins. Special considerations in the intrapartum management of multiple gestation include monoamniotic twins, conjoined twins, and triplet pregnancies.     

Ambulatory therapy of multiple myeloma with vincristine, adriamycin and dexamethasone

BACKGROUND AND OBJECTIVE: If multiple myeloma (MM) progresses in patients after chemotherapy with alkylating agents, the combination of vincristine, adriamycin and dexamethasone (VAD) can achieve a response in 40-70% of cases. Because of its low toxicity for haematopoetic stem-cells this form of chemotherapy is often undertaken before high-dose blood stem-cell transplantation. It was the objective of this study to examine effectiveness and complications of ambulant VAD treatment. PATIENTS AND METHODS: Within four years VAD chemotherapy was given to 62 ambulant MM patients, administered by microprocessor-regulated pumps via intravenously polyurethane catheters with a safety valve. Response to treatment, treatment-associated complications and infections were documented prospectively and analysed. RESULTS: VAD treatment achieved tumour reduction of more than 25% in 50 of 62 patients. This treatment had to be discontinued in two of 192 pump-infusions because of irreversible catheter occlusion. Eight patients were hospitalised because of infections and two for noninfectious complications. Severe infectious complications (> or = WHO grade III) occurred in 4% of treatment cycles. CONCLUSION: VAD chemotherapy can be performed with a low rate of infection in ambulant patients despite the need for prolonged intravenously infusion of the drugs. But to avoid complications by intravenously catheters, random prospective tests should first be done with oral alkylating agents.     

Intrapartum management of multiple gestations

The proper intrapartum management of multiple gestations continues to be debated in the obstetric community. Ultrasonography is key in this management, through its initial assessment of the fetuses in the labor and delivery suite, observations of the second twin after the first has delivered, and its role in external cephalic version. The proper route of delivery requires further investigation for each combination of twin presentations and estimated fetal weights. It is recommended that the nonvertex second twin that is greater than 24 weeks' gestational age and fewer than 1700 g estimated fetal weight should have an attempt made at ECV and, if unsuccessful, a cesarean section should be performed. In the nonvertex second twin weighing greater than 1700 g, ECV or assisted breech extraction is appropriate. It is believed that all triplet gestations should be delivered abdominally. The use of intravenous nitroglycerin for uterine relaxation in multiple gestations is still experimental but may prove to be useful in the abdominal delivery of the nonvertex fetus. Further research is required to elucidate the most critical issues associated with the labor and delivery management of multiple gestations.     

Obstetric management of high-order multiple pregnancies

High-order multiples are increasingly common as a result of assisted reproductive technologies and represent pregnancies at exceptional risk. This article discusses the antepartum management of high-order multiples, which has in general been highly individualized and poorly studied. Care for high-order multiples should include preterm birth prevention education, the frequent assessment of maternal symptoms and cervical status by a consistent provider, individualized modification of activity, attention to maternal nutrition, ultrasonography for the assessment of fetal anatomy and intra-uterine growth and anticipation of maternal complications. Interventions such as prophylactic cerclage, uterine activity monitoring, prophylactic tocolysis or hospitalization have not improved outcome when used routinely, and guidelines for selective use will be presented. Specialized care for high-order multiples should be directed at identifying congenital anomalies, maximizing fetal growth and preventing early preterm birth, the effect of which will be to improve perinatal outcome for these exceptional pregnancies.     

Ambulatory monitoring

Ambulatory monitoring has been hailed as the 'way forward' in urodynamic investigation. Its introduction has caused much excitement and there is no doubt that it detects more abnormalities than does conventional cystometry. It is, however, labour intensive and time consuming for both operator and patient, and requires commitment from both to be successful. No standards have been set as to how long a test ought to last, how many voids are required and how to interpret traces. To date the standard cystometric criteria of normality have been applied, but this would appear to be inappropriate. Several commercial companies have developed systems and are marketing them widely as an adjunct, or alternative, to conventional cystometry. It is recommended that before this technique is introduced into routine clinical practice it is fully evaluated, with standardization of terminology relating to its use.     

Ambulatory urodynamics

Ambulatory monitoring of lower and upper urinary tract continues to develop. The addition of electronic urine-loss measurements to indicate the exact time-related loss is an important new feature. In the near future, quantitative urine-loss measurements will become available. The additional possibility of plugging in a flowmeter completes the technique with respect to pressure-flow analysis. At present, however, ambulatory urodynamics is still confined to specialized urodynamic centers. Ambulatory urodynamic monitoring has shown that de-novo detrusor instability after a suspension operation is frequently missed as a preoperative diagnosis of detrusor overactivity. The first steps are being taken toward giving a quantitative analysis of detrusor activity during the filling phase. This justifies a more widespread use of this ambulatory monitoring.     

The surgical management of multiple lung metastases

From 1970 to June, 1976, 56 patients who had multiple metastatic tumors of the lung were treated by lung resection. Most of the bilateral lung lesions were removed through a median sternotomy so as to avoid staged bilateral thoracotomy. The surgical mortality was 1.8%. A total of 26 patients are alive at 7 to 69 months (estimated median survival, 20.7 months). Patients with tumor doubling time of less than 40 days had lower survival results (median, 9.5 months), compared to patients with tumor doubling time of more than 40 days (median not yet reached). The type of primary tumor, tumor-free interval, number of lesions removed, and presence of unilateral as opposed to bilateral lung metastases did not seem to affect the therapeutic results.     

Radiologic emergency management in multiple trauma cases

The management of multiple trauma patients has improved recently. Surgeons' education, preclinical rescue structures, initial clinical survey and therapeutic strategies, as well as diagnostic imaging, have progressed. Plain film imaging is increasingly being abandoned in favor of CT. Fast imaging techniques (spiral CT) have led to the inclusion of CT in the primary survey. To minimize the risk to the patient during prolonged diagnostic time, algorithms have to be defined concerning structures, emergency room equipment and quality. Basics, state of the art and suggestions concerning management of multiple trauma patients are presented and discussed from the radiologist's point of view.     

Bladder dysfunction and management in multiple sclerosis

Symptomatic bladder dysfunction occurs at some time in most patients with multiple sclerosis. The relapsing-remitting course and progressive loss of mobility associated with multiple sclerosis make management of urinary urgency and incontinence difficult. Urodynamic evaluation serves as a guideline for appropriate treatment. After accurate diagnosis of bladder dysfunction, a management program is developed with use of fluid schedules, voiding techniques, neuropharmacologic manipulation, intermittent catheterization, surgical treatment, and other adjunctive measures as indicated. The goals of treatment are to protect and preserve renal function, relieve symptomatic voiding dysfunction, and avoid subsequent urinary complications. A management program should be individualized, dynamic, and monitored with periodic, systematic urologic review to maintain these goals.     

Ambulatory laparoscopic fundoplication

BACKGROUND: Increasingly larger series of laparoscopic fundoplications (LF) are being reported. A well-documented advantage of the laparoscopic approach is shortened hospital stay. Most centers report typical lengths of stay (LOS) for LF of 2-3 days. Our success with LF with a LOS of 1 day led to an attempt at performing LF on an ambulatory basis. METHODS: Sixty-one consecutive patients with appropriate criteria for LF underwent surgery at our institution. Patients were counseled by the authors as to the usual postop course and progression of diet. All patients received preemptive analgesia (PEA) consisting of perioperative ketorolac and preincisional local infiltration with bupivicaine. Anesthetic management included induction with propofol, high-dose inhalational anesthetics, minimizing administration of parenteral narcotics, and avoidance of reversal of neuromuscular blockade. Immediate postop pain management included parenteral ketorolac and oral hydro- or oxycodone. All patients were given oral fluids and soft solids after transfer from the recovery room to the postoperative observation unit. Two patients were excluded from ambulatory consideration due to excessive driving distance from our hospital. Another two were hospitalized for observation after experiencing intraoperative technical problems. RESULTS: Of 57 patients in whom same-day discharge was attempted, there were three failures requiring overnight hospitalization: All were due to pain and nausea; one patient also suffered transient urinary retention. There were no adverse outcomes related to early discharge, and there were no readmissions. One patient returned to the emergency room after delayed development of urinary retention. Median time from conclusion of operation to discharge was less than 5 h. No patients expressed dissatisfaction with early discharge on follow-up interview. CONCLUSIONS: LF can be safely performed as an ambulatory procedure. Analgesic and anesthetic management should be tailored to minimize nausea and provide adequate pain control.     

Ambulatory opiate withdrawal

A 2.5-year-old boy presented with acute metabolic decompensation in whom 3-hydroxy-3-methyl-glutaryl-coenzyme A (HMG-CoA) lyase deficiency was diagnosed. Four days after metabolic decompensation, a stroke-like encephalopathy with tonic clonic convulsion of the left arm and leg and coma developed. Brain oedema and subsequent demarcation and atrophy were observed mainly within the supply areas of the right anterior and middle cerebral artery and to a lesser extent in various sites within the right hemisphere. Residual neurological deficits included spastic paresis of the left arm and leg. and left supranuclear facial palsy and aphasia, indicating bilateral diffuse brain affection. CONCLUSION: In the presented patient with HMG-CoA lyase deficiency, stroke-like encephalopathy occurred days after metabolic decompensation indicating ongoing (intracerebral) metabolic derangement. Monitoring of the intracerebral accumulation of toxic metabolites by magnetic resonance spectroscopy and of cerebral haemodynamics might be useful for a better understanding of the pathogenetic mechanisms of stroke-like encephalopathy and to identify patients at risk.     

Ambulatory lumbar myelography

Out-patient lumbar myelography was carried out on 74 consecutive patients, and adverse reactions were registered by the patients themselves. Twenty-four percent experienced moderate or severe headache; 62% experienced increasing back pain of a moderate or severe degree; 40% experienced increasing leg pain of a moderate or severe degree; 15% experienced nausea/general symptoms to a moderate or severe degree. Twenty-nine percent experienced the myelography as unpleasant in a moderate or severe degree. Fourty-seven percent had some kind of adverse reaction for > or = four days. Eleven patients (16%) were admitted to hospital because of severe adverse reactions, mostly headache, and nine of them were treated with a blood patch. Twenty-five percent were referred for operation for their back disease. Generally, out-patient lumbar myelography is well tolerated, but a large proportion of the patients experience temporary adverse reactions to a moderate or severe degree, perhaps in part because of immobilisation in connection with photographing procedures.     

Self-presentational persona: Simultaneous management of multiple impressions.

Most research on self-presentation has examined how people convey images of themselves on only 1 or 2 dimensions at a time. In everyday interactions, however, people often manage their impressions on several image-relevant dimensions simultaneously. By examining people's self-presentations to several targets across multiple dimensions, these 2 studies offer new insights into the nature of self-presentation and provide a novel paradigm for studying impression management. Results showed that most people rely on a relatively small number of basic self-presentational personas in which they convey particular profiles of impressions as a set and that these personas reflect both normative influences to project images that are appropriate to a particular target and distinctive influences by which people put an idiosyncratic spin on these normative images. Furthermore, although people's self-presentational profiles correlate moderately with their self-views, they tailor their public images to specific targets. The degree to which participants' self-presentations were normative and distinctive, as well as the extent to which they reflected their own self-views, were moderated by individual differences in agreeableness, self-esteem, authenticity, and Machiavellianism. (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

New therapeutic agents in the management of multiple sclerosis

THERAPEUTIC ADVANCES: Several effective therapies for multiple sclerosis capable of modifying the disease course in certain patients are now available in France. INTERFERONS: Interferon beta-1b and interferon beta-1a have been given specific marketing approval in France for ambulatory patients with active relapsing-remitting multiple sclerosis. Interferon beta-1b has been shown to have a beneficial effect in progressive multiple sclerosis. COPAXONE: This drug has a temporary authorization in France for ambulatory patients with relapsing-remitting multiple sclerosis who cannot tolerate interferon. PERSPECTIVES: Other promising therapeutic options (mitoxantrone, intravenous immunoglobulins, drug associations) are under evaluation.     

Ambulatory urodynamics of female soldiers

The purpose of this study was to assess the accuracy of ambulatory urodynamic monitoring compared with conventional urodynamic studies for the detection of exercise-induced urinary incontinence in the female soldier. Fifty active duty female soldiers with exercise-induced urinary incontinence and 10 asymptomatic control soldiers underwent conventional multichannel cystometry and then ambulatory monitoring during work or exercise. Ambulatory monitoring detected a greater number of abnormalities than conventional multichannel urodynamic studies in exercise-induced urinary incontinence. This greater sensitivity is valuable in formulating more effective treatment. Behavioral interventions were effective in treating exercise-induced urinary incontinence in this population. Test results normalized after behavioral intervention. It is neither cost-effective nor efficacious to require sophisticated urodynamic testing before instituting behavioral interventions.