A pilot study of intravenous ondansetron for hyperemesis gravidarum

OBJECTIVE

We attempted to determine whether the antiemetic ondansetron would be more effective than promethazine in treating hyperemesis gravidarum.

STUDY DESIGN

Patients with hyperemesis gravidarum who required hospital admission were randomized to receive either intravenous ondansetron (n = 15) or intravenous promethazine (n = 15) in a double-blind manner. Severity of disease was determined by electrolyte status, weight loss, ketonuria, and prior use of outpatient antiemetics. Outcome variables included degree of nausea, weight gain during treatment, days of hospitalization, and number of medication doses.

RESULTS

In this preliminary investigation ondansetron offered no advantage when compared with promethazine in the relief of nausea, weight gain, days of hospitalization (4.5 +/- 2.3 vs 4.5 +/- 1.5), and total doses of medication per hospitalization (2.1 +/- 1.2 vs 1.9 +/- 1.3).

CONCLUSION

This preliminary trial of ondansetron demonstrated no benefit over promethazine in patients hospitalized for hyperemesis gravidarum.

Amniotic fluid embolism

AFE, although rare, remains a significant cause of maternal mortality. Even with improvements in supportive care, the prognosis remains poor for mother and fetus. The guidelines presented may help the physician to recognize this condition when it occurs and give some direction for therapy.

Field Observations on the Common Striped Possum (Dactylopsila Trivirgata) in North Queensland

Habitat utilisation and foraging behaviour by the common striped possum (Dactylopsila trivirgata) was investigated by means of spotlighting and radio-tracking at Shiptons Flat, far north Queensland. Vine forest was the primary habitat of D. trivirgata; however, animals were also observed in open eucalypt (Eucalyptus tereticornis) woodland. Information collected on foraging behaviour suggests that D. trivirgata are generalist insectivores consuming some fruit and other foodstuffs, such as honey. Radio-tracking data were used to calculate the home-range areas of two subadult males. The home range of the smaller male (body weight 290 g) was 5.2 ha (by the 95% harmonic mean (HM) method) or 6.5 ha (by the minimum convex polygon (MCP) method), and that of the larger male (body weight 415 g) was 21.2 ha (95% HM) or 21.3 ha (MCP). Large trees with hollows, which are utilized for denning, appear to be an important feature of the habitat for this species. D. trivirgata exhibits a pronounced degree of sociality and may breed seasonally. Observations suggest that amethystine pythons (Morelia amethistina) may be major predators of D. trivirgata at Shiptons Flat.

Herpesvirus-like DNA sequences in classic Kaposi's sarcomas

Kaposi's sarcoma (KS) accounts for more than 15% of AIDS-related malignancies. The etiology of KS is unresolved but is postulated to be multifactorial, involving viruses and overexpression of cellular growth factors and/or oncogenes. Recently, herpesvirus-like sequences (KSHV) were identified with high prevalence in AIDS-KS (AKS), endemic KS, and in classic KS biopsies (CKS). To confirm the presence and the prevalence of the KSHV sequences, 18 CKS and 13 AKS samples were tested using polymerase chain reaction (PCR) analysis. To our knowledge this is the highest number of CKS samples that has ever been included in a single study, and it is also important that the biopsies were obtained from different institutions and geographical locations. KSHV sequences were detected in 100% of the AKS samples and 72% of the CKS biopsies using PCR analysis. The presence of the unique KSHV sequences was confirmed by direct sequencing of representative PCR products obtained from AKS and CKS samples. Reverse transcriptase (RT)-PCR experiments showed that the KSHV sequences were transcribed to mRNA in both AKS and CKS samples. Our results confirm that the putative new herpesvirus-like agent is associated with both AKS and CKS and may have an etiological role in the pathogenesis of this malignancy.

Incidence of adverse cardiopulmonary effects with low-dose continuous terbutaline infusion

OBJECTIVE

Our purpose was to determine the incidence of adverse cardiovascular effects of terbutaline sulfate when administered as a continuous subcutaneous infusion in women with arrested preterm labor.

STUDY DESIGN

Over a 6-year period records from 8709 women prescribed this therapy for preterm labor that had previously been arrested with other intravenous tocolytics were reviewed. These women were assessed daily for cardiovascular complaints and tolerance of the medication, while either in the hospital or at the home (by telephone). The main outcomes studied were the occurrence of pulmonary edema, sustained cardiac arrhythmias, chest pain, or myocardial ischemia. Any maternal death regardless of cause was also reviewed.

RESULTS

Of the 8709 subjects, 47 (0.54%) had one or more cardiopulmonary problems. Pulmonary edema developed in 28 patients (0.32%) while receiving continuous subcutaneous infusion of terbutaline, 5 at home and 23 in the hospital. Of the total, 17 women were being treated concurrently with large amounts of intravenous fluids and one to three other tocolytic agents. In the 11 remaining subjects, 4 were diagnosed with pregnancy-induced hypertension and/or multiple gestation. Nineteen patients experienced other adverse cardiovascular effects, including electrocardiogram changes, irregular heart rate, chest pain, or shortness of breath.

CONCLUSIONS

Continuous terbutaline infusion for women with stabilized preterm labor is associated with much fewer adverse effects than previous literature regarding intravenous beta-adrenergic agonist therapy would suggest.

Simultaneous M-mode echoesophagram and manometry in the sheep esophagus

We report the simultaneous measurement of esophageal wall layer thickness and intraluminal pressure in the sheep esophagus using a miniature suction device incorporating a high-frequency ultrasound transducer and a manometry system. Transnasal placement of the device into the distal esophagus of a conscious sheep allowed observation of 133 swallowing events during three trials, each lasting from 45 to 60 minutes. In a fourth trial, 11 sequential dry and 23 sequential wet swallows were compared. Maximum manometric pressure, esophageal wall layer thickness, and duration of contraction were measured. All swallowing events produced simultaneous increases in intraluminal pressure and esophageal wall thickness. Mean maximal pressures were lower for dry swallows (18 +/- 2.1 mm Hg) than wet swallows (22 +/- 3.0 mm Hg) (p < .01). Thickness of the inner (circular) muscle layer increased above baseline by 124% for dry swallows and 161% for wet swallows (p < .01). We conclude that thickening of the esophageal inner (circular) muscle layer may be important in the generation of intraluminal esophageal pressure in the sheep esophagus.

Lichenoid graft-vs-host disease in an autologous bone marrow transplant recipient

BACKGROUND

Graft-vs-host disease (GVHD) represents one of the major complications of allogeneic bone marrow transplantation (BMT) but is less common in autologous BMT. Following autologous BMT, chronic GVHD has been reported in only four patients, all of whom had a self-limited sclerodermoid form. Lichenoid chronic GVHD has not been previously reported in an autologous BMT patient.

OBSERVATIONS

Mucosal and cutaneous lichenoid lesions and histologic findings compatible with chronic lichenoid GVHD developed in a patient 35 days after autologous BMT was performed. The onset of clinical lesions at 35 days after BMT is not incongruent with the diagnosis of chronic lichenoid GVHD (rather than a graft-vs-host reaction) and may have been augmented by cyclosporin A in a manner similar to animal model experiments.

CONCLUSION

All forms of GVHD can and do occur following autologous BMT.

Hemorrhage associated with cesarean delivery: when is transfusion needed?

Our objective was to determine the incidence of blood administration after cesarean delivery and whether such transfusions are always beneficial. In this retrospective study 1610 women underwent cesarean delivery during a 2-year period and 127 of these patients had hemorrhage during or after operation. Of these subjects 103 received blood because of intraoperative hemorrhage, a reduction in the hematocrit of more than 10 points, or because the postoperative hematocrit was < 24%. These subjects were compared with the remaining women (n = 24) who met the same criteria for hemorrhage but did not receive transfusion. The maternal age, race, and parity were similar in both groups. The estimated blood loss (873 +/- 484 ml) and the preoperative hematocrit (33.4% +/- 6.4%) in the women who did not receive transfusion were not significantly different from those of patients who received packed red blood cells (854 +/- 576 ml and 30.0% +/- 5.4%, respectively). The postdelivery hematocrit was similar in both groups: 25.9% +/- 4.3% in the nontransfused group and 24.5% +/- 5.6% in the transfused group. Patients in the transfused group received a mean of 3.8 +/- 4.9 units of packed red blood cells, with a range of 1 to 40 units. The mean equilibrated (stable) hematocrit after transfusion was 28.4% +/- 5.4%, which was significantly greater than the mean equilibrated postoperative hematocrit of 22.7% +/- 4.6% in patients who did not receive transfusion (p < 0.0001). Nonetheless, the hospital stay, incidence of postoperative infection, and incidence of wound complications were similar in the two groups.(ABSTRACT TRUNCATED AT 250 WORDS)

Measurement of the ultrasonic attenuation of fat at high frequency

RATIONALE AND OBJECTIVES

High-frequency ultrasound devices are often limited by a decreased depth of acoustic imaging caused by the increased attenuation of tissue at high frequencies. We investigated the role of adipose tissue in this phenomenon.

METHODS

A substitution technique was used to calculate the ultrasonic attenuation (decibels per centimeter) of fresh samples of sheep rumen, omental fat, and back fat and swine back fat and various concentrations of bovine milk fat at 22 degrees C and 37 degrees C for frequencies of 15 and 20 MHz.

RESULTS

The attenuation was significantly higher for sheep adipose tissue than for the intestinal wall, in descending order, omental fat, back fat, and rumen wall (P < 0.01). A correlation was found between bovine milk fat concentrations and attenuation at both frequencies (R2 > 0.9). The attenuation of adipose tissues decreased significantly with an increase in temperature (P < 0.01), whereas the attenuation of sheep rumen showed no significant change (P > 0.1).

CONCLUSIONS

The ultrasonic attenuation of fat may contribute to limitations on the use of high-frequency ultrasound in clinical situations in which adipose tissue is present.

Antepartum corticosteroids: disease stabilization in patients with the syndrome of hemolysis, elevated liver enzymes, and low platelets (HELLP)

OBJECTIVE

Our purpose was to evaluate the impact of antepartum administration of corticosteroids on the course of the syndrome of hemolysis, elevated liver enzymes, and low platelets (HELLP) in pregnancies at 24 to 37 weeks' gestation.

STUDY DESIGN

This prospective, randomized study was undertaken in 25 antepartum patients with atypical severe preeclampsia expressed as HELLP syndrome. Twelve pregnant women were randomized to receive double-dose dexamethasone (10 mg intravenously every 12 hours) until delivery, and 13 women were randomized to the control arm. Management and delivery decisions for all patients were based on a common protocol, with delivery undertaken for a deteriorating maternal or fetal condition.

RESULTS

In the corticosteroid-treated group the maternal platelet count significantly increased (p = 0.006), whereas lactic dehydrogenase and alanine aminotransferase significantly decreased over time (p = 0.03 and p = 0.005) in comparison to the 13 women who did not receive corticosteroids. Maternal urinary output after entry into the study was significantly increased within hours after steroid administration versus the control group (p = 0.0006). The study entry-to-delivery interval (41 +/- 15 hours) was significantly longer in the group of steroid-treated women (p = 0.0068).

CONCLUSIONS

Stabilization and significant improvement in the laboratory and clinical parameters associated with HELLP syndrome occurred in women who received high-dose antenatal corticosteroids, as measured by maternal platelet count, urinary output, lactic dehydrogenase, alanine aminotransferase, and postponement of delivery. We believe the findings of this investigation permit us to speculate that this therapeutic approach could enhance maternal-fetal care by postponing delivery of some previable fetuses, reduce the need for maternal transfusion of blood products, reduce neonatal morbidity or mortality from multiple systemic effects, and facilitate a safer transfer of the ill mother to a tertiary care site for optimal peripartal care.

Tocolysis for recurrent preterm labor using a continuous subcutaneous infusion pump

This study attempted to determine the best method of treatment for patients with recurrent preterm labor: administration of terbutaline via an automated, programmable, subcutaneous infusion pump or oral terbutaline. In this retrospective, controlled study, 32 patients diagnosed with recurrent preterm labor, as determined by persistent uterine contractions with cervical change, were treated with a programmable infusion pump adjusted to control uterine contraction frequency to < or = 4 contractions per hour. Patients in this group were matched for age, race, parity, gestational age and cervical dilation at diagnosis of recurrent preterm labor in subjects taking oral terbutaline. The patients receiving oral terbutaline were given an average of 6.5 mg every four to six hours to maintain uterine quiescence, while those in the pump group were given basal rates of terbutaline and in addition received four to six boluses per day (< 3 mg/d total dose) to achieve this outcome. Patients using the pump were more likely to reach term and less likely to fail tocolytic therapy than were those taking oral terbutaline. The terbutaline pump appeared to be more successful in prolonging pregnancies to term after the diagnosis of recurrent preterm labor than did oral terbutaline.

The geometrical relationship between the human esophagus and left ventricle: implications for three-dimensional ultrasonic scanning

To establish design parameters for a transesophageal ultrasonic probe to image the left ventricle (LV) in three dimensions, the geometrical relationship between the esophagus and the heart was studied in computed tomographic sections of ten humans. Points describing the esophageal centerpoint and the left-ventricular endocardium were digitized. Algorithms were developed to determine from any esophageal viewpoint the ranges of motion required to cover the LV with four modes of scanning; transverse oblique, longitudinal oblique, rotary and linear. Longitudinal oblique scanning was the only single-degree-of-freedom method that allowed complete imaging of the LV in all patients. However, for both conventional and three-dimensional LV imaging, the most promising probe design appears to be a rotary scanning probe with an added degree of freedom to tilt the axis of rotation +/- 29 degrees away from an axis perpendicular to the local esophageal axis.

Obstetric challenges of massive obesity complicating pregnancy

This study examined the effects of massive maternal obesity on medical complications, mode of delivery, postpartum complications, and hospital confinement. In this retrospective case control study, women weighing > 300 pounds delivering from January 1, 1986, to November 1, 1991, were matched for age, race, parity, and height with lean parturient women (mean weight 160 +/- 21 pounds). Among massively obese women there was a greater incidence of chronic hypertension (p < 0.05) and diabetes (p < 0.05) than in the control group. Primary cesarean section was more frequent (p < 0.05), as was the postoperative complication of endometritis when obese patients were compared with lean women (p < 0.05). Cephalopelvic disproportion was the only indication for primary cesarean section, which occurred with greater frequency in the obese group. The postpartum hospital confinement was also significantly longer in the obese study group (p < 0.05). The gestation of a massively obese parturient woman is more frequently complicated by chronic hypertension and diabetes. Abdominal delivery for cephalopelvic disproportion is more likely, and this mode of birth is more often followed by endometritis, which results in longer hospital stays.

The interrelationship of eclampsia, HELLP syndrome, and prematurity: cofactors for significant maternal and perinatal risk

OBJECTIVE

To determine if there are differences between mothers and fetuses in eclamptic pregnancies with or without concurrent HELLP syndrome.

DESIGN

Retrospective review.

SETTING

A single tertiary perinatal centre, the University of Mississippi Medical Center.

SUBJECTS

All eclamptic pregnancies treated during a 141 month period from 1980 until the end of 1991.

METHODS

Pregnancies were grouped according to the presence or absence of HELLP syndrome subclassified as class 1 = platelet nadir < or = 50,000/microliters, class 2 = platelet nadir > 50,000 to < or = 100,000/microliters, and class 3 = platelet nadir > 100,000 to < or = 150,000/microliters.

RESULTS

Among 49,782 live births, there were 117 women with eclampsia prior to delivery (incidence 1:425), 62 of which had HELLP syndrome. The group with HELLP syndrome were delivered significantly earlier (32.1 vs 36.4 weeks), and had lower birthweights (1821 vs 2550 grams) and higher perinatal mortality (113 vs 18:100). They were also transfused more frequently (65% vs 35%), and suffered greater overall serious maternal morbidity and mortality.

CONCLUSION

Eclampsia is more likely to be associated with the HELLP syndrome at early gestations. Although eclamptic patients are already at risk, the presence of HELLP syndrome accentuates the risk for adverse maternal-perinatal outcome.

Headaches from chemical exposures

Headaches are a common complaint after work place or environmental exposures. A striking index case led to a literature review which uncovered only limited information. We then performed a retrospective descriptive study of 50 subjects referred to University Clinics with the complaint of headaches associated with chemical exposures at their work place. Our data suggest a different headache may exist depending on whether the chemical exposure is routine and limited versus accidental and extensive. Low level work place chemical exposures appear to cause headaches that abate soon after cessation of the exposure. A single accidental and extensive exposure may lead to patient complaints of a new headache syndrome that may last from several months to years. The characteristics associated with the onset of a new headache syndrome from accidental chemical exposures includes: 1) An acute large quantity of exposure. 2) A short latency of onset of the heralding headache. 3) A severe intensity and long duration of the heralding headache. 4) New recurring headaches that were not experienced before the acute exposure. We suggest a possible term for this high exposure syndrome i.e. Chemical Headache Exposure Syndrome (CHES).

Clinical estimate of birth-weight in labour: factors influencing its accuracy

Clinical assessments of birth-weight were made among 88 parturients at term, to determine what maternal and neonatal factors influence the accuracy of predicting neonatal weight. An estimate within +/- 10% of actual weight was considered accurate, while a prediction off by more than 10% was classified as inaccurate. Seventy-one per cent (63 of 88) of the estimates were considered accurate and 28% (25 of 88) inaccurate. Among these 2 groups of patients, univariate analysis did not identify maternal age, gravidity, parity, gestational age, maternal height, prepregnancy weight and maternal body mass index, maternal weight and maternal body mass index at the time of delivery, change in body mass index during pregnancy, intrapartum amniotic fluid index, newborn's weight, length, and ponderal index as being significant correlates of an accurate clinical estimate of the birth-weight. Over 2 years, as the provider gained experience in predicting the neonatal weight, the accuracy of the clinical estimate of birth-weight did not improve.

Fimbria damage and removal of adherent bacteria after exposure to acoustic energy

The physical effects of low-frequency acoustic energy on Actinomyces viscosus were studied with electron microscopy to explore both acoustically induced damage to fimbriae on the surface of these bacteria and acoustic removal of bacteria from saliva-treated hydroxyapatite disks. A bacterial suspension was exposed to acoustic energy from a laboratory acoustic generator (50 kPa, 200 Hz) and from a new electronic toothbrush, the Sonicare. The exposed bacteria were examined with electron microscopy after negative staining. A decrease in both the percentage of bacterial surface covered with fimbriae and the fimbria length was observed after acoustic exposure. To study the acoustic effects on adherent bacteria, A. viscosus bound to hydroxyapatite disks were exposed to acoustic energy and examined with scanning electron microscopy. Quantitative evaluation of the micrographs for the number of bacteria present after exposure revealed that acoustic energy removed both bacteria adherent to the hydroxyapatite surface and adherent to each other. The results support the concept that an electronic toothbrush employing low-frequency acoustic energy may help prevent and control periodontal diseases by altering bacterial adherence.

Blood loss at time of cesarean section by method of placental removal and exteriorization versus in situ repair of the uterine incision

The current study was undertaken to determine if blood loss at the time of cesarean section is affected by method of placental removal (spontaneous versus extracted) or uterine position for repair (in situ versus exteriorized). This prospective randomized study involved 100 women who were undergoing a cesarean section. The patients were placed into one of four groups--1, spontaneous placenta detachment, in situ uterine repair; 2, spontaneous placental detachment, exteriorized uterine repair; 3, manual placental removal, in situ uterine repair, and 4, manual placental removal, exteriorized uterine repair. Patients with spontaneous placental separation (groups 1 and 2) compared with manual removal (groups 3 and 4) revealed a significant decrease in blood loss (p < 0.001). Uterine position did not significantly affect blood loss in the spontaneous group (1 and 2; p = 0.971) or the manual placental removal groups (3 and 4; p = 0.061). The hematocrit values for all groups were similar preoperatively, but postoperatively, were significantly lower in the manual removal groups when compared with the spontaneous placental separation groups (p < 0.001). The method of placental removal and not the position of the uterus at the time of its repair has a significant role in blood loss during cesarean birth.

Benign Leydig cell tumor of the testis associated with human papillomavirus type 33 presenting with the sign of Leser-Trélat

We present a case of a benign testicular Leydig cell tumor and eruptive seborrheic keratosis associated with human papillomavirus type 33 infection. To our knowledge this is the first occurrence of a Leydig cell tumor in a patient with tuberous sclerosis and the second documented case of eruptive seborrheic keratoses (sign of Leser-Trélat) associated with a benign neoplasm.

Neonatal morbidity between 34 and 37 weeks' gestation

The objective of this study was to determine the risk of significant neonatal morbidity in women with preterm labor who deliver between 34 and 37 weeks' gestation. A total of 101 women between 34 and 37 weeks' gestation with documented preterm labor met inclusion and exclusion criteria; 90 gave informed consent and were randomly assigned to receive either intravenous magnesium tocolysis (treatment group) or conservative management with hydration, sedation, and observation (control group). Of the 90 women entering the study (45 in the treatment group and 45 in the control group), 2 discontinued tocolytic therapy because of gastrointestinal side effects. The gestational age on admission, cervical dilatation at diagnosis of preterm labor, interval to delivery, and birth weight were not significantly different between the treatment and control groups. There were no serious neonatal complications. In each group, three women had transient tachypnea and one had respiratory distress syndrome. We conclude that neonatal morbidity after delivery between 34 and 37 weeks' gestation is unchanged whether or not attempts to arrest labor are unsuccessful. The extra expense and maternal risk of tocolysis are not justified by beneficial results in the infant.