Validity of sleep log compared with actigraphic sleep-wake state

OBJECTIVE: To evaluate the efficacy and complications of external cephalic version in term (37 or more weeks) gestation. STUDY DESIGN: A case series from February 1990 until December 1994 studied 160 patients with term singleton breech presentation. External cephalic version (ECV) with prophylactic tocolysis was the method used. RESULTS: ECV was successful in 67% of the cases (107/160) overall, in 56% of the nulliparous (57/102) and 86% of the multiparous women (50/58). About 90% of those with successful ECV (96/107) had a vaginal delivery with a vertex presentation of the fetus. Emergency Caesarean section due to fetal distress was not required during or immediately after the procedure. No perinatal mortality or babies with an Apgar score less than 7 at 5 min were observed. CONCLUSIONS: ECV in term pregnancy seems to be useful and it is safe both for the mother and the fetus. It should be performed at term, with close monitoring of the fetus, and in an environment able to provide an emergency Caesarean section.     

Factors associated with the use of flexible sigmoidoscopy as a screening test for the detection of colorectal carcinoma by primary care physicians

BACKGROUND: Despite current recommendations of flexible sigmoidoscopy as a screening test for the detection of colorectal carcinoma, relatively few asymptomatic patients undergo this procedure. To enhance the use of sigmoidoscopy, differences in the use of screening, as well as barriers to screening among specific physician groups, should be defined. METHODS: The authors surveyed 1762 practicing primary care physicians to determine their self-reported ability to perform sigmoidoscopy and perceived obstacles to either initiating or enhancing screening. RESULTS: A total of 884 physicians (50%) responded. Ninety percent of primary care physicians reported that they offered sigmoidoscopic screening to their patients, with 46% referring patients and 44% performing the procedure themselves. Physician characteristics were not associated with the overall use of sigmoidoscopy. In contrast, compared with physicians who referred patients for the procedure, physicians who performed sigmoidoscopy themselves were more often board certified, male, and graduated from medical school after 1970 (P < 0.001). In a multivariate analysis, these characteristics were also independently associated with the ability to perform sigmoidoscopy. The barrier to sigmoidoscopy cited most often was poor patient acceptance, whether or not the physician performed or referred patients for sigmoidoscopic screening. Other barriers cited were lack of training, lack of equipment, and time required, each of which was identified most often by physicians who did not screen at all. CONCLUSIONS: Most physicians surveyed reported using sigmoidoscopic screening to some degree in their practice, although many did not perform the procedure themselves. Population-based interventions to increase screening may benefit from targeting specific physician subgroups and attempting to improve patient acceptance of the procedure.     

The problem of Caesarean section (author's transl)

The Caesarean sections at the Universit?ts-Frauenklinik Innsbruck from January 1st, 1969 to December 31st, 1974 have been surveyed. Related to the total number of 12 579 deliveries 627 Caesarean sections have been performed. Two 3-year-intervals have been compared: 1969-1971 (group I) without and 1972-1974 (group II) with modern practices of prenatal supervision. There was a high significant increase of the section rate in group II (5,8% versus 4,1% which has been related to the increasing number of mainly fetal indications. The maternal morbidity didn't rise with the increasing section rate. A significant decrease in total infant mortality rate and mortality rate at vaginal deliveries has been found with the increasing incidence of Caesarean sections; whereas the number of depressed infants (Apgar score less than 7) was increased in group II. The reasons therefore have been discussed. The rise of the number of Caesarean sections in group II performed because of breech presentation (14,2% versus 6,2%) was correspondent with a statistically significant decrease in the mortality rate from 11,7 to 4,1%. A Caesarean section rate between 7% and 10% seems to be the limit at least in our hospital--the total infant mortality rate cannot be reduced by further increasing the section frequency: the infant mortality rate possibly could be lowered by a better and more wide spread prenatal care especially by taking more care for prematurity and by intensifying the perinatal period.     

The role of prostaglandins in the natriuresis of acutely salt-loaded rats

Mechanisms determining the natriuresis in ECV expansion are not yet completely known. The present study was therefore performed to investigate (1) the extent to which prostaglandins (PG) are involved in the natriuresis of ECV expansion and (2) by which mechanisms PG may affect renal Na absorption. In nonexpanded rats the prostaglandin synthetase inhibitor indomethacin (INDO) had no effect on renal function. In 16 Sprague-Dawley rats EVC expansion with isotonic saline corresponding to an increase in body weight of 10% was induced and maintained for 60 min. Ten animals received an oral dose of 10 mg/kg BW of INDO prior to ECV expansion. Six animals served as controls (C). Blood pressure (INDO: 132 +/- 4 (SE); C: 130 +/- 3 mm Hg), GFR (INDO: 12.5 +/- 1.0; C: 10.5 +/- 0.9 ml/min/kg BW), fractional K excretion (INDO: 32.1 +/- 2.6; C: 43.4 +/- 4.8%), CH2O and Na-k-ATPase activities in renal cortex, medulla and papilla did not significantly differ in either group. Significant differences were observed in urinary flow rate (INDO: 0.82 +/- 0.8; C: 1.82 +/- 0.23 ml/min/kg KG) and fractional Na absorption (INDO: 91.9 +/- 1.1; C: 81.7 +/- 1.2%). The results indicate that PG are involved in the natriuresis following acute expansion of the ECV and suggest that PG may inhibit the intrinsic tubular capacity for Na absorption in the rat.     

The influence of intrathecal fentanyl on the characteristics of subarachnoid block for caesarean section

Forty healthy parturients scheduled for elective Caesarean section were randomly allocated to receive either 0.3 ml 0.9% saline (control group, n = 20), or 15 micrograms (0.3 ml) fentanyl (treatment group, n = 20) added to 2.5 ml 0.5% hyperbaric bupivacaine given intrathecally in the sitting position. A sensory block to T4 was achieved after 6.5 min in those who received fentanyl compared to 8.0 min in the control group; this was not significantly different. The highest level of sensory block achieved in both groups was similar. Ephedrine was required earlier (p < 0.05) in those who received fentanyl but the total requirement of ephedrine intra-operatively was similar. Fentanyl significantly improved the quality of intra-operative surgical anaesthesia as none of the patients in the treatment group complained of discomfort compared with seven in the control group (p < 0.05). Similarly those in the treatment group had better comfort scores as evaluated by visual analogue score (p < 0.01). Regression of anaesthesia to T12 took longer (184 vs 156 min, p < 0.05) in those who received fentanyl but this did not affect the total requirement of morphine in the first 24 h after operation. There was no difference in the incidence of side effects in the mother and no adverse effects were detected in the baby. The results indicate that adding 15 micrograms fentanyl to hyperbaric bupivacaine for spinal anaesthesia markedly improves intra-operative anaesthesia for Caesarean section.     

Renal artery stenosis and accessory renal arteries: accuracy of detection and visualization with gadolinium-enhanced breath-hold MR angiography

Extracellular volume (ECV) of arms, trunk, and legs determined from segmental bioimpedance data in 11 healthy men (31.6 +/- 7 yr) obtained at the end of a 30-min equilibration phase in the supine body position was compared with ECV determined from whole body measurements (ECVWB). ECV was calculated from extracellular resistance (RECV) identified from the bioimpedance spectrum for a range of 10 frequencies. Whole body RECV (527.6 +/- 55.6 Omega) was equal to the sum of RECV in the arms, trunk, and legs (241.6 +/- 36. 3, 49.2 +/- 5.1, and 236.3 +/- 25.5 Omega, respectively). The sum of equilibrated ECV in arms (1.31 +/- 0.25 liters), trunk (10.08 +/- 1.65 liters), and legs (2.80 +/- 0.82 liters) was smaller than ECVWB (20.90 +/- 2.59 liters). In six subjects who changed from a standing to a supine body position, ECV decreased in arms (-2.59 +/- 2.51%, P = NS) and legs (-10.96 +/- 3.02%, P < 0.05) but increased in the trunk (+4.2 +/- 3.2%, P < 0.05). ECVWB also decreased (-4.98 +/- 1. 41%, P < 0.05). However, the sum of segmental extracellular volumes remained unchanged (-0.06 +/- 0.07%, P = NS). The sum of segmental ECVs is not sensitive to changes in body position, which otherwise interferes with the estimation of ECV in bioimpedance analysis when ECVWB is used.     

Can deliveries at risk be selected at smaller delivery units?

In order to explore the possibility of converting a delivery unit at a small hospital to a maternity home, we examined the medical records of those women who delivered by Caesarean section, forceps or vacuum extraction at Lofoten hospital during 1995. How many of these women might it have been necessary to transfer to an obstetrical department if Lofoten hospital had been a maternity home caring for low risk deliveries (primipara and multipara)? Out of a total of 271 deliveries (primiparas 98), 49 women delivered by Caesarean section (n = 35), forceps (n = 5) or vacuum extraction (n = 9). Using risk assessment, 22 women (45%) would have been selected for antenatal transfer, and 20 (41%) for intrapartum transport. For seven women no transfer would have been possible. These women would have delivered locally by vacuum extraction. Primipara versus multipara had a relative risk of 2.8 for Caesarean section or assisted vaginal delivery. It is estimated that 8-9% of the women would be selected prenatally for planned delivery at a hospital unit and that 7-8% would be transferred in labour if primiparas delivered at the maternity home. If primiparas were excluded, the proportions would be 41% and 1-2% respectively. In 1997 the delivery unit at Lofoten hospital was temporarily converted to a maternity home for a period of two years.     

The mechanism of activation of bovine prothrombin by an activator isolated from Echis carinatus venon and characterization of the new active intermediates

Bovine prothrombin was activated, in both the absence and presence of dissopropyphosphofluoridate (DEP) and benzamidine, by an activator which was highly purified from the venom of Echis carinatus (saw-scaled viper, ECV). The process of activation was monitored by sodium dodecysulfate (SDS)-polyacrylamide gel electrophoresis, and the reaction products were isolated and chemically characterized. In the absence of the inhibitors, prothrombin yielded two fragments with molecular weights of 28,000 and 57,000, of which the former was the N-terminal fragment of the zymogen and the latter was intermediate 1, consisting of a single polypeptide chain. Intermediate 1 was subsequently converted to an active intermediate, named intermediate ECV, without decrease of molecular weight. This new intermediate ECV, which showed little clotting activity but a strong alpha-N-tosyl-L-arginine methyl ester (TAME)-esterolytic activity and which bound with hirudin or antithrombin III, consisted of two polypeptide chains with molecular weights of 35,000 of 27,000 daltons. The former was indentified as the thrombin B chain with the N-terminal sequence Ile-Val-Glu-Gly and C-terminal serine, and the latter was a fragment with N-terminal Ser-Gly-Gly, linked to the thrombin A chain. On prolonged incubation, intermediate ECV autocaralytically yielded a fragment (inner fragment) of 14,000 daltons with N-terminal serine and the clotting enzyme alpha-thrombin [EC 3.4.21.5], which consists of A and B chains. In the presence of the inhibitors, intermediate ECV and the N-terminal fragment were accumulated in the activation mixture. On the other hand, when prothrombin was activated by the venom activator in the presence of hirudin, antithrombin III, or p-nitrophenyl p'-guanidinobenzoate, it did not yield any fragments but was converted to a derivative with two polypeptide chains having molecular weights of 51,000 and 34,000 daltons, of which the former consisted of N-terminal fragment, the inner fragment, and thrombin A chain, and the latter was thrombin B chain. This new prothrombin derivative, named prothrombin ECV, formed a high-molecular-weight complex, associating with antithrombin III. The complex was not dissociable even in the presence of SDS. Moreover, prothrombin ECV reacted with p-nitrophenyl p'-guanidinobenzoate. On the basis of the results described above, the mechanism of activaton of prothrombin by Echis carinatus venom activator can be summarized as follows: The venom activator first cleaves an Arg-Ile bond liniking thrombin A and B chains in the zymogen molecule, forming an active derivative, prothrombin ECV. This active derivative converts autocatalytically to intermediate ECV, liberating the N-terminal fragment, and active intermediate ECV generates alpha-thrombin, releasing the inner fragment. Thus, only a single peptide bond cleavage along the polypeptide chain of prothrombin is associated with activation by the venom activator...     

Antenatal HIV antibody testing in Australia

OBJECTIVE: To evaluate the role of voluntary antenatal testing in HIV surveillance and prevention by examining antenatal HIV antibody testing practice and policy in Australia. DESIGN: Cross-sectional study using a self-administered questionnaire. SUBJECTS AND SETTING: Specialist obstetricians and gynaecologists and general practitioners (GPs) affiliated with the Royal Australian College of Obstetricians and Gynaecologists and Australian public hospital antenatal clinics, August-November 1992. MAIN OUTCOME MEASURES: The percentage of public hospital antenatal clinics and specialist and GP obstetricians in Australia who tested pregnant women for HIV antibody as part of their antenatal care, and the proportion of pregnant women in Australia who had an antenatal HIV antibody test in the 1991-92 financial year. RESULTS: Questionnaires concerning antenatal HIV antibody testing were completed by 90% (993/1108) of specialists, 87% (2134/2461) of GPs and 93% (215/230) of public hospitals surveyed. Of the 706 specialists and 1503 GPs who reported that they were currently engaged in obstetric care, approximately 60% (430/706) and 935/1503, respectively) offered antenatal HIV testing either to all pregnant women or to selected groups at risk. There were significant differences in testing patterns between States and Territories. For the 95 public hospitals with antenatal clinics, 81% (77) offered the HIV antibody test to all or selected groups of pregnant women; these percentages did not differ significantly between States and Territories. It was estimated that 25% of pregnant women seen by specialists, 29% seen by GPs and 9% seen in public hospital clinics were tested for HIV antibody as part of their antenatal care in 1991-92. CONCLUSIONS: In Australia approximately one in five pregnant women were tested for HIV antibody as part of their antenatal care in 1991-92. Voluntary HIV testing in pregnancy may provide unrepresentative data for measuring the prevalence of HIV infection in pregnant women.     

Labor, method of delivery and maternofetal transmission of HIV

Within a prospective study of the course of HIV-infection in women, 80 HIV-infected women without AIDS were delivered of 80 children between 1985 and September 1992. The median of the age of gestation was 38 weeks. Until 1988 Caesarean section was chosen as mode of delivery (45 women). Later when the mode of delivery appeared to have no influence on the frequency of maternofetal HIV transmission, vaginal delivery was preferred (35 women). None of the infants was breastfed. Three infants --delivered vaginally--died within the first 6 months of life before their infection status could be determined. Seventy-seven children could be observed for 18 months or longer regularly every three months. 10 of the 77 children were found to be HIV- infected by serological, virological and clinical criteria. Taking into account the mode of delivery, of 32 children who were delivered vaginally or by emergency Caesarean section 8 were found to be HIV-infected. None of 26 children delivered by elective Caesarean section after an uneventful pregnancy is infected. In 19 women Caesarean section was performed within 2 hours after onset of labour or after episodes of preterm labour which required hospital admission for treatment. Two children of these women are infected. No differences of CD4+ cell counts and p24 antigenaemia could be determined between the mothers of the three groups. The risk of fetal HIV infection was increased by preterm labour (p < 0.01) and the mode of delivery (p < 0.01). A correlation between loss of CD4 cells in the mother and increased risk of infection for the child is seen in children born spontaneously or delivered by emergency Caesarean section (p < 0.001). No correlation was found between the length of labour at delivery, the time of the rupture of membranes before birth as well as of the parity and the risk of fetal infection in that group. These findings point to labour as an important factor which increases the risk of maternofetal transmission of HIV. The onset of labour is accompanied by dramatic immunological alterations as a sudden increase of chemotactics and inflammatory cytokines at the maternofetal interface. The accumulation and stimulation of maternal immune cells will--if these cells are carriers of HIV--result in production and release of infectious HIV. This virus may accumulate in the maternofetal interface or gain access to the amniotic cavity. Since amniotic fluid is swallowed by the fetus, the largest potential port of entry for HIV in the fetus are the fetal lungs and the gastrointestinal tract. For the prevention of maternofetal transmission of HIV delivery before onset of labour or alternatively the protection of the fetus during parturition by means of potent antiviral compounds can be considered.     

The perils of permanent punctal plugs

Satisfactory pain relief with postoperative extradural bupivacaine increases the amount of breast feeding after Caesarean section. To investigate the effect of extradural buprenorphine, we have evaluated the amount of breast feeding and the gain in infant weight for 11 days after Caesarean section in patients who received continuous extradural bupivacaine with or without buprenorphine. Extradural buprenorphine significantly decreased both measures although there was no significant difference in pain intensity. We suggest that extradural buprenorphine suppressed breast feeding after Caesarean section.     

Perceptions of women and men as entrepreneurs: Evidence for differential effects of attributional augmenting.

It was hypothesized that perceptions of women who become entrepreneurs are enhanced by attributional augmenting because they adopt this role despite major obstacles to doing so. In contrast, attributional augmenting was expected to operate to a lesser degree for men who become entrepreneurs because they presumably face weaker obstacles. Three studies offered support for these hypotheses; all of these investigations used between-subjects designs in which women and men shown in standard-format photos were described to different groups of raters as being either entrepreneurs or managers. As predicted, raters assigned significantly higher scores to women, but not to men, when they were described as entrepreneurs. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Cesarean section in a patient with cerebral ischemic pathology. Spinal anesthesia

The choice of anaesthesia for Caesarean sections, in patient with recent cerebral ischemic-hemorrhagic injuries, is a big problem. A case is reported of a woman submitted to Caesarean section in spinal anaesthesia who, in the first quarter, suffered an ischemic-hemorrhagic cerebral injury. Spinal anaesthesia was made by hyperbaric bupivacaine 0.5% at 10 mg dose + fentanyl 25 micrograms using 24G Sprotte needle. Spinal anaesthesia guarantees a good neuroendocrine protection to surgical aggression and a good hemodynamic stability. Hypotension prophylaxis by pre-filled is necessary and its treatment with ephedrine must be timely carried out. Risk of post-dural puncture headache, by atraumatic and very thin needles, is negligible. Spinal anaesthesia avoids general anaesthesia which may cause cardiovascular damages due to oro-tracheal intubation leading to possible cerebral damage. Induction-delivery time is more dangerous: the use of alogenate, oppioids, and/or some medicaments which may control the mother's adrenergic response, exhibit the newborn to risks.     

Value of spiro-ergometry and stress echocardiography on optimized programming of the upper frequency limit of dual chamber cardiac pacemakers]

OBJECTIVES: To assess the performance of selective opportunistic screening in a primary care group practice. DESIGN: Cross-sectional survey of coronary heart disease risk factors and retrospective chart audit of cholesterol testing. SETTING: Capitation-funded primary care group practice in Ontario, Canada. SUBJECTS: 7785 enrolled patients between the ages of 20 and 69 years. INTERVENTION: Protocol-based selective opportunistic screening program for hypercholesterolemia of 45 months duration. MAIN OUTCOME MEASURES: Targeting (proportion of screening tests that were appropriate), coverage (proportion of those meeting screening criteria who had a screening test performed), over-screening (proportion of those not meeting screening criteria who had a screening test performed), and screening ratio (likelihood that a screening test was performed on an individual who met screening criteria rather than one who failed to meet screening criteria). RESULTS: 64.7% of patients tested met the practice criteria for screening. 37.7% of patients who met the practice screening criteria were tested and 24.9% of those not meeting practice screening criteria had a cholesterol test performed. The screening ratio was 1.52. CONCLUSION: Our findings bring into question the effectiveness of opportunistic approaches to preventive care.     

Sequence analysis of genes encoding rodent homologues of the human tumor-rejection antigen SART-1

OBJECTIVE: To assess pregnant women's knowledge of, and attitudes towards, antenatal HIV testing, and its acceptability to them. SETTING: Antenatal clinic at Guy's Hospital, London, six community antenatal clinics and a midwifery group practice. POPULATION: Eight hundred and forty-three women attending the antenatal clinics. METHOD: The women received a leaflet explaining HIV testing, and completed a questionnaire before and after their booking appointment. This included an assessment of their knowledge of, and attitudes towards HIV testing, and its acceptability. RESULTS: Seven hundred and eighty-nine women (94%) completed questionnaires. Fifty-one percent (n = 405) were Caucasian, 25% (n = 195) African, 11% (n = 86) West Indian and 13% (n = 100) were from other ethnic groups. Fifty-eight percent received the HIV information leaflet, of whom 86% had read it. Knowledge relating to HIV was good, the median knowledge score being 6 out of a possible 8, but it was less in non-Caucasian women and those with lower educational qualifications. Knowledge was not related to uptake of testing. Thirty-five percent of women accepted the offer of an HIV test, rates being higher in hospital clinics (41%) than in the midwifery group practice (10%) and the community clinics (30%). Women more likely to accept the offer of an HIV test were non-Caucasian (P = 0.0443), those who had thought about the HIV test before this pregnancy (P = 0.0298) and those seeing one particular midwife (P = 0.0003). Most women (67%) thought that all pregnant women should be offered the HIV test and then make their own decision. Overall, 64% women did not change their original pre-discussion decision on testing for HIV. Thirty-six percent of women changed their decision from 'yes' to 'no' or 'don't know' after seeing the midwife. Women attending the community clinics (P = 0.003) and those who had been tested before (P = 0.0451) were more likely to change their decision. CONCLUSION: This study, in a multiethnic population, has shown that knowledge regarding HIV is good but does not increase the uptake of testing. Women prefer to be offered the HIV test and make their own choice regarding whether to accept it.     

Social comparison, task motivation, and the development of self-evaluative standards in children.

Investigated whether 30 1st graders and 27 4th graders were more interested in comparing with a similarly performing other than with others whose performances were superior or inferior to their own. Ss were given the opportunity to compare performances with a peer on each trial of an achievement task. Ss were given feedback that the peer's performance level was either consistently higher than, lower than, or roughly the same as their own. Ss who were offered comparison with a similarly performing peer (a) chose to compare more often, (b) persisted at the task for more trials, and (c) self-rewarded on a smaller proportion of the trials than did Ss offered comparison with a consistently superior or inferior peer. Those offered a superior peer did not differ from those offered an inferior peer on any of these measures. However, younger Ss compared more often with a similar other than did older ones. Results are discussed in the context of the role social comparison plays in children's establishment of standards for evaluating the goodness of their own performance. (19 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Postoperative hypocalcemia in patients who did or did not undergo parathyroid autotransplantation during thyroidectomy: a comparative study

BACKGROUND: Permanent hypoparathyroidism is a recognized complication of thyroidectomy. Apart from preservation of parathyroid glands in situ by meticulous dissection, parathyroid autotransplantation (PTHAT) has been performed increasingly to avoid permanent hypoparathyroidism. METHODS: From January 1995 to October 1997, PTHAT was performed routinely for devascularized or inadvertently removed glands in 98 (36%) of 271 patients undergoing thyroidectomy. Potential risk factors and the impact of PTHAT on postoperative hypocalcemia were studied. RESULTS: Postoperative hypocalcemia occurred in 40 patients (14.8%), whereas 5 patients (1.8%) had permanent hypocalcemia during a median follow-up of 9 months. The incidence of transient hypocalcemia (n = 35) was higher in patients who underwent PTHAT (21.4%) than in patients who did not undergo PTHAT (8.1%) (P < .01). Permanent hypocalcemia occurred only in patients who did not undergo PTHAT. None of the 21 patients who had postoperative hypocalemia after PTHAT had permanent hypoparathyroidism compared with 26% (5/19) of patients who did not undergo PTHAT (P = .018). When the resected thyroid gland was examined for parathyroid tissue, the incidence of positive identification was higher in patients who did not undergo PTHAT (13%) than in patients who did undergo PTHAT (4%) (P = .015). CONCLUSIONS: Patients with postoperative hypocalcemia after PTHAT have virtually no risk of having permanent hypoparathyroidism. A more careful examination of the resected thyroid tissue can help to identify inadvertently removed parathyroid glands for autotransplantation.