Uterine exteriorisation at caesarean section: influence on maternal morbidity

OBJECTIVE: To compare the influence on caesarean section morbidity of uterine exteriorisation or in situ repair. DESIGN: Randomised controlled trial. SETTING: Princess Anne Maternity Unit of the Royal Bolton Hospital, UK. POPULATION: One hundred and ninety-four women undergoing delivery by caesarean section. METHODS: Two intra-operative readings of arterial pulse rate, mean arterial blood pressure, and arterial haemoglobin oxygen saturation were obtained. Pre-operative and day-3 haemoglobin concentrations were determined. Intra- and post-operative complications, puerperal pain scores, and febrile and infectious morbidity were assessed. A postal questionnaire was used to assess morbidity six weeks after delivery. MAIN OUTCOME MEASURES: Intra-operative changes in pulse rate, mean arterial blood pressure and oxygen saturation; peri-operative changes in haemoglobin concentration; incidence of intraoperative vomiting, pain, intra- and post-operative complications, and febrile and infectious morbidity; immediate and late puerperal pain scores; satisfaction with the operation. RESULTS: No clinically significant differences between uterine exteriorisation and in situ repair were found in pulse rate, mean arterial pressure, oxygen saturation and haemoglobin changes. Likewise, the incidence of vomiting and pain was similar. Vomiting occurred in 10% of all the women, and 57% of all pain complaints occurred at the initial skin incision. There was a trend towards higher immediate and late pain scores in the exteriorisation group, reaching statistical significance on day 3. Overall, pain scores averaged 6/10 on day 1 despite patient-controlled analgesia, and three-quarters of all women reported persisting pain on day 42. Intra- and post-operative complications, febrile and infectious morbidity, and duration of hospital stay were similar in both groups. CONCLUSIONS: We have demonstrated that uterine exteriorisation and in situ repair have similar effects on peri-operative caesarean section morbidity. Intra-operative pain reflected adequacy of anaesthesia, while vomiting reflected adequacy of pre-operative preparation of patients. Exteriorising the uterus at caesarean section is a valid option.     

Quinolone-resistant Neisseria gonorrhoeae: the beginning of the end? Report of quinolone-resistant isolates and surveillance in the southwestern United States, 1989 to 1997

BACKGROUND: Fluoroquinolones are one of the most widely used treatments for gonorrhoeae. Changes in the susceptibility of Neisseria gonorrhoeae to these agents may threaten their use. GOAL OF THIS STUDY: To report several resistant strains (>1 mcg/ml) isolated in the western United States and to evaluate the prevalence of strains with reduced susceptibility (ofloxacin 0.25 mcg/ml, ciprofloxacin 0.06 mcg/ml). STUDY DESIGN: The microbiology and epidemiology of three resistant strains were characterized and 12,761 other strains were evaluated for fluoroquinolone susceptibility as part of the Gonococcal Isolate Surveillance Project of the Centers for Disease Control and Prevention. RESULTS: Fluoroquinolone-resistant strains may appear sporadically. The prevalence of isolates with reduced susceptibility to fluoroquinolones remains low in the Southwest region of the United States. CONCLUSIONS: Continued active surveillance is needed to detect and control the spread of quinolone-resistant Neisseria gonorrhoeae.     

Superior vena cava syndrome: case report. A complication of permanent transvenous endocardial cardiac pacing requiring surgical correction

Superior vena cava syndrome developed in a patient in whom an endocardial transvenous pacemaker had been inserted five years previously. Venography demonstrated an obstructing lesion at the junction of the superior vena cava and right atrium. Balloon catheter dilatation failed to afford any relief from her progressive symptoms. Exploration of the area revealed a benign fibrotic lesion encircling the pacemaker lead within the right atrium. Excision of the lesion, removal of the lead, and patching the right atrium with pericardium resulted in rapid cure.     

Platinosomes produced in cultured cells by platinum coordination complexes

Cells in culture were exposed to cis-dichlorodiammineplatinum (II) and platinum-uracil blue. No platinum could be demonstrated in an intracellular location morphologically or by electron-probe x-ray analysis in the case of the former compound. However, platinum was readily demonstrated in phagosomes or phagolysosomes after exposure of cells to platinum-uracil blue.     

Cyclic changes of cervical mucus enzymes related to the time of ovulation II. Amino peptidase and esterase

Diconium bromide, 2-(3,4-dichloroanilino)-quinolizinium bromide, a potent antispasmodic in the lower bowel of the dog, was found in the present study to exert gastric acid-antisecretory and antiulcerogenic activities in the rat stomach. These effects were demonstrated by means of short- and long-term pyloric ligation, acetylsalicylic acid (ASA)-induced ulcerogenesis, and cold-and-restraint stress studies. A reduction of gastric acid concentration by the drug was probably responsible for the decrease in the degree of ulceration and hemorrhagic lesion formation. The drug's inhibition of stress hemorrhagic lesions may be related to an effect both on gastric HCl secretion and on the vasculature in the glabdular mucosa. The delay of gastric emptying by diclonium bromide results from its known antispasmodic or smooth-muscle depressant action. The toxicity of diclonium bromide, perorally, was low in rats and overt signs of drug effect were not evident until toxic doses were administered. It is concluded that diclonium bromide may represent a useful non-anticholinergic drug effective in treating both peptic ulcers and spasticity of the colon (irritable-colon syndrome) in man.     

Anesthesia-induced alteration of small vessel response to norepinephrine

To determine whether foreign medical graduates (FMGs) provide a disproportionate and increasing share of primary care in some rural areas, changes in physician distribution in a rural section of upstate New York over a 20-year period (1953-1973) were evaluated by country of medical education and type of practice. A contiguous urban area was examined for comparison. In 1953, FMGs accounted for a higher proportion of primary care physicians in rural areas (11%) than in urban practice (6%) (p less than 0.01). By 1973, this distribution had increased to 26% rural and 14% urban (p less than 0.001). During the two decades, the number of U.S. medical graduates in primary care declined by 15% in the rural areas but increased by 13% in the urban center. The number of primary care FMGs in this same period increased 88% in the rural area. With a 10% decline in (rural) FMGs trained in developed countries, this net increase in FMGs was accounted for by physicians from developing countries. Primary care physicians trained in the U.S. or in developed countries increased more in the urban center, while physicians from developing countries increased more in rural (53%) than urban (47%) practices. Finally, by 1973, rural primary care physicians were more likely than urban primary care physicians to be from developing countries (p less than 0.001).     

Short communication: A reproductive tract scoring system to manage fertility in lactating dairy cows

We developed a reproductive tract size and position score (SPS) system as a reproductive management tool to identify lactating dairy cows with decreased fertility. This system, relying solely on transrectal palpation, considers the size (cervical and uterine) and position of the reproductive tract relative to the pelvis. Cows undergoing pre-breeding exams were identified as having reproductive tracts that were small (SPS1), medium (SPS2), or large (SPS3). Cows designated SPS1 had small and compact uterine horns that rested within the pelvic cavity; SPS2 cows had reproductive tracts that were intermediate in cervical and uterine horn diameter, with longer uterine horns resting partially outside the pelvic cavity; and SPS3 cows had reproductive tracts that were larger and rested mostly outside the pelvic cavity. Cows that were SPS1 had a higher rate of pregnancy per artificial insemination (43.3 ± 3.7%) than cows that were SPS2 (36.9 ± 3.6%) or SPS3 (27.7 ± 4.3%). The percentage of cows with an SPS2 score differed in pregnancies per artificial insemination compared with SPS3 cows. The average days in milk was similar for SPS1, SPS2, and SPS3 cows (104.3 ± 3.5, 98.4 ± 3.4, and 94.7 ± 7.7, respectively). Ultrasound measurements of the uterine horn and cervical diameter, and length measurements of the uterine horns, cervix, and vagina confirmed differences among the SPS groups derived by transrectal palpation. The ease with which transrectal palpation can be used to determine the size and position of the reproductive tract attests to the relevance and usefulness of this scoring system to identify less fertile lactating dairy cows. The ability to do so with ease provides an opportunity to make economically relevant management decisions and maximize reproductive efficiency in a given herd.     

Oral manifestations of severe short-limb dwarfism resembling Grebe chondrodysplasia: report of a case

The oral and dental abnormalities associated with a distinct variety of severe short-limb dwarfism are described. The patient, a 9-year-old Arab boy, had delayed development and eruption of teeth, severe oligodontia of permanent dentition, hypodontia, microdontia, supplemental incisor, enamel hypoplasia of primary teeth, doubled and abnormal frenal attachments, bifid uvula, hypoplastic maxilla, and malocclusion. Clinical and radiographic examinations revealed asymmetric dysplasia and anaplasia of long bones, craniofacial dysmorphia, prominent forehead, budlike fingers and bulbous toes, dysplastic nails, severe hearing loss, and reduced joint mobility. These features resemble, in general, those characteristic of Grebe chondrodysplasia, an extremely rare ill-defined syndrome that is inherited as an autosomal-recessive disorder.     

Phenylselenenyl- and phenylthio-substituted pyrimidines as inhibitors of dihydrouracil dehydrogenase and uridine phosphorylase

Lithiation of 5-bromo-2,4-bis(benzyloxy)pyrimidine (3) with n-BuLi at -80 degrees C followed by the addition of diphenyl diselenide or diphenyl disulfide as an electrophile furnished the corresponding 5-(phenylhetera)-2,4-bis(benzyloxy)pyrimidine, which on exposure to trimethylsilyl iodide in CH2-Cl2 at room temperature yielded the 5-(phenylhetera)uracils in 70-75% yield. Similarly, the 6-(phenylhetera)uracils were prepared from 6-bromo-2,4-bis(benzyloxy)pyrimidine (10). 1-[(2-Hydroxyethoxy)methyl]-5-(phenylselenenyl)uracil (PSAU, 18) and 1-(ethoxymethyl)-5-(phenylselenenyl)uracil (17) were synthesized by the electrophilic addition of benzeneselenenyl chloride to the acyclic uracils under basic conditions. These compounds were evaluated for their ability to inhibit dihydrouracil dehydrogenase (DHUDase, E.C. 1.3.1.2), orotate phosphoribosyltransferase (OPRTase, E.C. 2.4.2.10), uridine phosphorylase (UrdPase, E.C. 2.4.2.3), and thymidine phosphorylase (dThdPase, E.C. 2.4.2.4). 5-(Phenylselenenyl)uracil (PSU, 6) and 5-(phenylthio)uracil (PTU, 7) inhibited DHUDase with apparent K(i) values of 4.8 and 5.4 microM, respectively. The corresponding 6-analogues, compounds 13 and 14, demonstrated inhibitory activity against OPRTase. PTU as well as PSU and its riboside, 2'-deoxyriboside, and acyclonucleosides were inhibitors of UrdPase, with PSAU (18) being the most potent with an apparent K(i) value of 3.8 microM. None of the compounds evaluated had any effect on dThdPase. Interestingly, most of the compounds showed modest selective anti-human-immunodeficiency-virus activity in acutely infected primary human lymphocytes.     

The sensitivity of transbronchial biopsy for the diagnosis of acute lung rejection

Transbronchial biopsy has become the procedure of choice for the diagnosis of acute lung rejection after transplantation, but the sensitivity of the technique in this setting remains unknown. In this study, 14 mongrel dogs underwent left lung transplantation, after which triple-drug immunosuppression was given for 5 days and then all immunosuppression was stopped. All animals had clear chest radiographs at this time. Transbronchial biopsy was performed in nine lung regions (two to six pieces of lung tissue were obtained per region, with a mean of 4.3 pieces per region) before the animals were killed 2 to 4 days later, at which time varying degrees of rejection had occurred. Rejection was graded histologically on a scale of 0 to 3 (0 = no rejection, 1 = mild rejection, 2 = moderate rejection, 3 = severe rejection) in each piece of lung tissue obtained at transbronchial biopsy. After the dogs were put to death, the true state of lung rejection was determined by histologic examination of the entire lung. We calculated the sensitivity of transbronchial biopsy with 95% confidence intervals. Five pieces of lung tissue were needed to yield a sensitivity of 92% (82%, 100%) to identify mild rejection in the entire lung with transbronchial biopsy. Three pieces of lung tissue were needed to yield a sensitivity of 92% (84%, 100%) to identify the presence of moderate to severe rejection in the entire lung (that is, rejection that requires pulse therapy) on transbronchial biopsy. These results indicate that three to five pieces of lung tissue that are suitable for diagnostic purposes obtained at transbronchial biopsy are adequate for the diagnosis of acute pulmonary rejection after lung transplantation.