Energy expenditure of genuine laughter

OBJECTIVE

To measure energy expenditure (EE) and heart rate (HR) during genuine laughter.

DESIGN

Experimental trial of viewing film clips in four cycles either intended to evoke laughter (humorous -10 min) or unlikely to elicit laughter (not humorous -5 min) under strictly controlled conditions of a whole-room indirect calorimeter equipped with audio recording system.

PARTICIPANTS

Forty five adult friend dyads in either same-sex male (n=7), same-sex female (n=21) and mix-sex male-female (n=17); age 18-34 years; body mass index 24.7+/-4.9 (range 17.9-41.1).

MEASUREMENTS

Energy expenditure in a whole-room indirect calorimeter, HR using Polar HR monitor. Laugh rate, duration and type from digitized audio data using a computerized system and synchronized with HR and EE results.

RESULTS

Laughter EE was 0.79+/-1.30 kJ/min (0.19+/-0.31 kcal/min) higher than resting EE (P<0.001, 95% confidence interval=0.75-0.88 kJ/min), ranging from -2.52 to 9.67 kJ/min (-0.60-2.31 kcal/min). Heart rate during laughter segments increased above resting by 2.1+/-3.8 beats/min, ranging from -7.6 to 26.8 beats/min. Laughter EE was correlated with HR (r (s)=0.250, P<0.01). Both laughter EE and HR were positively correlated with laughter duration (r (s)=0.282 and 0.337, both P<0.001) and rate (r(s)=0.256 and 0.298, both P<0.001).

CONCLUSION

Genuine voiced laughter causes a 10–20% increase in EE and HR above resting values, which means that 10–15 minutes of laughter per day could increase total EE by 10–40 kJ (2–10 kcal) [corrected].

The hemochromatosis C282Y allele: a risk factor for hepatic veno-occlusive disease after hematopoietic stem cell transplantation

Hepatic veno-occlusive disease (HVOD) is a serious complication of hematopoietic stem cell transplantation (HSCT). Since the liver is a major site of iron deposition in HFE-associated hemochromatosis, and iron has oxidative toxicity, we hypothesized that HFE genotype might influence the risk of HVOD after myeloablative HSCT. We determined HFE genotypes in 166 HSCT recipients who were evaluated prospectively for HVOD. We also tested whether a common variant of the rate-limiting urea cycle enzyme, carbamyl-phosphate synthetase (CPS), previously observed to protect against HVOD in this cohort, modified the effect of HFE genotype. Risk of HVOD was significantly higher in carriers of at least one C282Y allele (RR=3.7, 95% CI 1.2-12.1) and increased progressively with C282Y allelic dose (RR=1.7, 95% CI 0.4-6.8 in heterozygotes; RR=8.6, 95% CI 1.5-48.5 in homozygotes). The CPS A allele, which encodes a more efficient urea cycle enzyme, reduced the risk of HVOD associated with HFE C282Y. We conclude that HFE C282Y is a risk factor for HVOD and that CPS polymorphisms may counteract its adverse effects. Knowledge of these genotypes and monitoring of iron stores may facilitate risk-stratification and testing of strategies to prevent HVOD, such as iron chelation and pharmacologic support of the urea cycle.

A common beta1-adrenergic receptor polymorphism (Arg389Gly) affects blood pressure response to beta-blockade

BACKGROUND

A common polymorphism of the beta(1)-adrenergic receptor Arg389Gly markedly affects function in vitro, but little is known about its in vivo significance.

METHODS AND RESULTS

Resting and exercise hemodynamic responses were measured in subjects homozygous for Arg389 (n = 21) or Gly389 (n = 13) alleles before and 3 hours after administration of a beta-blocker, atenolol. Demographic characteristics and atenolol concentrations were similar in the two genotypic groups. Genotype had a marked effect on resting hemodynamic responses to atenolol, with Arg389-homozygous subjects having a larger decrease in resting systolic blood pressure (8.7 +/- 1.3 mm Hg versus 0.2 +/- 1.7 mm Hg, P < .001) and mean arterial blood pressure (7.2 +/- 1.0 mm Hg versus 2.0 +/- 1.7 mm Hg, P = .009). Attenuation of exercise-induced hemodynamic responses by atenolol was not affected by genotype.

CONCLUSIONS

There is reduced sensitivity of Gly389 homozygotes to a beta-adrenergic receptor antagonist, and this polymorphism may be an important determinant of variability in response to beta-blockade.

Surgical trial investigating nocturnal gastroesophageal reflux and sleep (STINGERS)

BACKGROUND

Nocturnal reflux is important in the pathogenesis of esophagitis. The relationship between reflux and sleep is poorly understood, although data support both paradigms of nocturnal reflux causing arousal and nocturnal arousal allowing reflux. Furthermore, the effect of fundoplication on sleep is unknown.

METHODS

Seven volunteers and 11 patients with gastroesophageal reflux disease (GERD) and nocturnal symptoms were studied with esophageal pH and polysomnography at baseline and at 8 to 10 weeks follow-up evaluation, with patients undergoing interval fundoplication. Gastrointestinal and sleep questionnaires were completed before each study.

RESULTS

Questionnaire data between the groups showed differences at baseline, which were eliminated by surgery. No objective differences in sleep were observed between the groups at baseline or at follow-up evaluation. However, the patient group significantly increased the fraction of the night spent in deeper sleep (49.6% vs 58.3%; p = 0.022). Reflux events were associated with arousals in sleep.

CONCLUSIONS

Fundoplication improves both subjective and objective sleep quality in patients with nocturnal GERD symptoms.

Maternal glycemic control and umbilical artery Doppler velocimetry

OBJECTIVE

To determine whether information from umbilical artery Doppler flow velocity waveforms significantly improves the prediction of adverse perinatal outcome, independently of maternal glycemic control, in pregnancies complicated by diabetes.

STUDY DESIGN

The medical records of 277 pregnant women with diabetes were reviewed. Glycemic control was determined by glycosylated hemoglobin concentration and umbilical artery Doppler velocimetry by using systolic/diastolic ratios (S:D), both obtained during the third trimester. Pregnancies with adverse perinatal outcome were compared to those with good outcome. Logistic regression analysis was used to adjust for glycemic control, and to test whether an elevated umbilical artery Doppler S:D ratio was independently associated with pregnancy outcome.

RESULTS

Adverse pregnancy outcome occurred in 51.6% of these pregnancies (143/277). The mean third-trimester glycosylated hemoglobin (7.7 +/- 1.9% vs. 6.7 +/- 1.3%, p < 0.001) and the umbilical artery S:D ratio were significantly higher (2.6 +/- 0.6 vs. 2.4 +/- 0.3, p < 0.001) in the pregnancies with adverse outcome. Logistic regression analysis showed that umbilical artery S:D ratio was an independent predictor of adverse perinatal outcome after adjusting for the third-trimester glycosylated hemoglobin level. Forty per cent of patients with normal Doppler findings (S:D ratio of < 3.0) and normal glycemic control values (glycosylated hemoglobin level of < 7.5%) had an adverse pregnancy outcome. Sixty-three per cent of patients with an abnormal result for one of these tests had an adverse pregnancy outcome. Ninety-six per cent of patients with both abnormal Doppler findings and abnormal glycemic control had an adverse pregnancy outcome.

CONCLUSION

Umbilical artery Doppler velocimetry improves the predictive value for adverse perinatal outcome, independently of glycemic control, in pregnancies complicated by diabetes. The combination of an abnormal umbilical artery S:D ratio and abnormal glycosylated hemoglobin was strongly associated with adverse pregnancy outcome.

The effect of common polymorphisms of the beta2-adrenergic receptor on agonist-mediated vascular desensitization

BACKGROUND

With continuous exposure to beta2-adrenergic agonists, vascular tissue becomes desensitized to agonist-mediated vasodilatation. We studied the effects of two common polymorphisms of the beta2-adrenergic receptor, one at codon 16 and one at codon 27, on agonist-mediated vasodilatation and desensitization in the vascular bed.

METHODS

We studied 26 healthy subjects who were selected to represent three genotypes: 7 were homozygous for the alleles encoding Arg16 and Gln27, 8 were homozygous for the alleles encoding Gly16 and Gln27, and 11 were homozygous for the alleles encoding Gly16 and Glu27. Vascular responses were assessed by measuring changes in the diameter of a dorsal hand vein. A dose-response curve of the effect of the beta2-adrenergic-receptor agonist isoproterenol was constructed (dose range, 4 to 480 ng per minute). Desensitization was then induced by a 2-hour continuous infusion of isoproterenol, and venodilatation was measured 30, 60, 90, and 120 minutes after the start of the infusion.

RESULTS

Subjects who were homozygous for Arg16 had almost complete desensitization; venodilatation in response to isoproterenol in this group decreased from a mean (+/-SE) of 44+/-11 percent to 8+/-4 percent (P=0.006). In contrast, subjects who were homozygous for Gly16 did not have significant desensitization, irrespective of the amino acid encoded by codon 27. Subjects who were homozygous for Glu27 had higher maximal venodilatation in response to isoproterenol than those who were homozygous for Gln27 (86+/-13 percent vs. 54+/-8 percent, P=0.03).

CONCLUSIONS

The Arg16 polymorphism of the beta2-adrenergic receptor is associated with enhanced agonist-mediated desensitization in the vasculature, and the Glu27 polymorphism is associated with increased agonist-mediated responsiveness. Therefore, polymorphisms of the beta2-adrenergic receptor are potentially important determinants of the vascular response to stress.

Laparoscopic management of adnexal masses

BACKGROUND AND OBJECTIVE

Although laparoscopic surgery for removal of adnexal masses is common, controversy exists about the safety and efficacy of this procedure for patients with malignancies. The aim of this study was to evaluate the effectiveness and safety of laparoscopic surgical treatment for patients with adnexal masses.

METHODS

This was a retrospective chart review of one surgeon's experience in managing patients diagnosed with adnexal masses at 2 urban referral teaching hospitals in New York City. We reviewed the charts for 100 consecutive patients who underwent operative laparoscopy for management of adnexal masses between March 4, 1996 and November 9, 1998. Conversion to laparotomy, malignancy rate, complications, length of stay, and blood loss were recorded for each patient.

RESULTS

Laparoscopic management was successfully completed for 81 of the 100 patients in this study; however, 19 required conversion to laparotomy. All 81 patients managed laparoscopically had a benign diagnosis, whereas 7 of the 19 patients who underwent laparotomy were diagnosed with malignancy. The median length of stay, estimated blood loss, and operating room time were significantly lower for those treated by laparoscopy alone compared with those converted to laparotomy (2 vs. 7 days; 100 vs. 500 ccs; 130 vs. 235 minutes, respectively; P < 0.05). Though few patients were in the laparotomy group, that data are presented for completeness. A total of 10 complications occurred, 4 in the group of patients managed laparoscopically (2 enterotomies, 1 pneumothorax, and 1 vaginal cuff cellulitis). Six complications occurred in those managed with laparotomy (2 enterotomies, 2 wound infections, 1 pneumonia, and 1 postoperative fever). The indications for conversion to laparotomy were: 7 malignancies (5 ovarian cancers and 2 uterine cancers), 7 dense adhesions, 2 small bowel enterotomies, 1 intraoperative bleeding, 1 secondary to a large uterus (880 grams), and 1 secondary to a large myoma (13 cm x 14.5 cm x 6 cm).

CONCLUSIONS

The laparoscopic approach is effective and safe for managing patients with adnexal masses of unknown pathology. Malignancies can be diagnosed accurately, converted to laparotomy, and staged appropriately. Adequate surgical skills along with timely use of frozen sections are required for successful operative management.

Optimal maternal weight gain during singleton pregnancy

The aim of this study was to determine optimal maternal weight gain in a singleton pregnancy and evaluate the current recommendations. We used a historical prospective design to evaluate the association between pregnancy weight gain and perinatal outcome. All singleton pregnancies without congenital anomalies delivered between 1987 and 1993 at a single institution in New York City were analyzed. After adjusting for the prepregnancy body mass index, we determined the weight gain associated with optimal perinatal outcome. During this 6-year study period, 20,971 pregnant women met the inclusion criteria. Among them, 1,975 (9.4%) had adverse perinatal outcome. Prepregnancy weight and weight gain during pregnancy were strongly associated with adverse outcome. For women of average size, optimal outcome was found in those who gained between 31 and 40 pounds. For women underweight prior to pregnancy, optimal outcome occurred in those who gained 36-40 pounds. For women who were overweight or obese, a gain of 26-30 pounds was associated with optimal outcome. Weight gain during pregnancy is strongly associated with perinatal outcome, independent of important confounding factors, and should be carefully monitored during pregnancy. A randomized controlled trial is required to determine if perinatal and maternal outcome can be improved by advising pregnant women to gain weight using these new ranges rather than the Institute of Medicine's recommendations.

Analysis of antepartum fetal heart rate tracing by physician and computer

OBJECTIVE

To compare the interpretation of fetal heart rate (FHR) tracings by three obstetricians with that of a computer analysis program.

METHODS

Our study population consisted of high-risk pregnant women referred as outpatients for antepartum FHR monitoring. A total of 121 FHR tracings, from a series of 54 consecutive women, were interpreted by three physicians and a computer program (Oxford Sonicaid System 8000, Oxford Sonicaid Ltd., Chichester, UK). The physicians used a modified FHR scoring system to interpret the tracings. Total scores were categorized as 0-4: abnormal, 5-7: questionable, and 8-10: normal. The computer program used overall variation, categorized as normal: longer than 30 ms, abnormal: shorter than 20 ms, and questionable: 20-30 ms.

RESULTS

Significant differences were found among the physicians and between the physicians and the computer analysis for the individual elements of FHR tracings. There was very good agreement between two physicians and the computer in the assessment of the FHR baseline. When physicians used a FHR scoring system to classify the tracings as normal, questionable, or abnormal, the agreement was poor (kappa values ranged from -0.037 to 0.28). The computerized analysis identified two FHR tracings as questionable but both were classified as normal by all three physicians.

CONCLUSIONS

The level of agreement in the interpretation of FHR tracings was poor among physicians and between physicians and the computer analysis. A FHR scoring system did not improve the level of agreement between physicians.

Comparison of visual and computerized interpretation of nonstress test results in a randomized controlled trial

OBJECTIVE

This study tested the null hypothesis that the number of fetal surveillance tests and perinatal outcomes would not differ statistically between pregnancies randomized to visual or computerized interpretation of antepartum nonstress test results.

STUDY DESIGN

A prospective, randomized controlled trial was conducted, which required a sample size of 404 patients. By using a random-number table with assignment codes concealed in opaque envelopes, half of the patients were randomized to computerized interpretation of nonstress test results and half to standard visual interpretation of nonstress test results. The amount of antepartum testing and the perinatal outcome were measured and compared between the groups. Logistic regression analysis was used to control for maternal risk factors while morbidity differences between the 2 groups were assessed.

RESULTS

The 2 randomized groups were similar at baseline, but the computerized interpretation group had significantly fewer biophysical profiles compared with the visual interpretation group (1.3 +/- 1.8 vs 1.9 +/- 2.1; P =.002). The patients in the computerized interpretation group spent less time per test than patients in the visual interpretation group (12 vs 20 minutes; P =.038). After the 5 pregnancies with congenital anomalies were excluded, the overall perinatal outcome was similar in the 2 groups. The computerized interpretation group, however, had a slightly lower proportion of infants who required >/=2 days of neonatal intensive care (7.4% vs 12.4%; P =.086; odds ratio, 0.56; 95% confidence interval, 0.29-1.09). The average number of neonatal intensive care days was also slightly lower in the computerized interpretation group (0.4 vs 0.9; P =.105). Neither of these variables was statistically significant.

CONCLUSIONS

Computerized interpretation of nonstress test results is associated with fewer additional fetal surveillance examinations, less time spent in testing, and a similar length of stay in the neonatal intensive care unit compared with standard visual interpretation.

Point-of-care and standard laboratory coagulation testing during cardiovascular surgery: balancing reliability and timeliness

OBJECTIVE

The use of point-of-care technology has increased faster than efforts to validate its effectiveness compared to standard laboratory testing modalities. To address this issue with a current point-of-care coagulation system (HEMOCHRON Jr, International Technidyne Corporation (ITC), Edison, NJ), we designed a study to test the hypothesis that data obtained from point-of-care coagulation equipment correlates with data obtained from standard laboratory coagulation equipment. One of the potential advantages gained using point-of-care testing is the ability to obtain more rapid results. To address this issue, turnaround time, defined as the elapsed time (in minutes) from when the sample was acquired from the patient until the investigators knew the results, was also determined.

METHODS

Following Human Investigation Committee approval and informed consent, a prospective study was conducted to compare results obtained from point-of-care coagulation equipment with those results obtained from standard laboratory coagulation equipment. The study was performed in three groups of patients undergoing cardiovascular surgery, each requiring different levels of anticoagulation.

RESULTS

Of the 83 patients who met the inclusion criteria, the correlation (combining data from groups 1-3) between results obtained from point-of-care and standard laboratory prothrombin time was r = 0.867, p < 0.001. The correlation (group 3) between point-of-care and standard laboratory international normalized ratio was r = 0.943, p < 0.001. The correlation (combining data from groups 1 & 2) between point-of-care and standard laboratory activated partial thromboplastin time was r = 0.825, p < 0.001. Median turnaround time for the standard laboratory was 90 minutes, with a mean turnaround time of 74 to 78 minutes, depending upon the group. In contrast, the median turnaround time for point-of-care testing was two minutes and 14 seconds.

CONCLUSIONS

The results from this study population reveal that data obtained from point-of-care prothrombin time, international normalized ratio and activated partial thromboplastin time results correlate with results obtained from standard laboratory coagulation testing. The value of obtaining reliable results in a timely fashion offers a potential advantage for point-of-care testing in dinical situations, such as in the operating room, where saving time may translate into financial savings.

Heparin management test versus activated coagulation time during cardiovascular surgery: correlation with anti-Xa activity

OBJECTIVE

To compare the abilities of the heparin management test (HMT) and the activated coagulation time (ACT) to provide a measurement of heparin effect in patients undergoing cardiac or peripheral vascular surgery. These measurements of heparin effect were also compared with measurements of heparin concentrations tested by anti-Xa activity. A secondary objective was to compare the performance of the noncitrated HMT with that of the citrated HMT.

DESIGN

A prospective study.

SETTING

A single-center study conducted in a university hospital.

PARTICIPANTS

After human investigation committee approval and informed consent were obtained, adult patients undergoing cardiac or peripheral vascular surgery were included in this study.

INTERVENTIONS

In both surgical groups, blood was sampled for ACT, HMT, and anti-Xa activity. Each HMT was performed on both noncitrated and citrated samples.

MEASUREMENTS AND MAIN RESULTS

As an indicator of heparin effect, the HMT had a strong correlation with the ACT (r = 0.899; p < 0.01). In addition, the HMT had a significantly stronger correlation with anti-Xa activity than the ACT (p < 0.01). The correlation obtained from the noncitrated samples was identical with that obtained from the citrated samples (r = 0.819; p < 0.001 for both groups).

CONCLUSION

The ability of the HMT and the ACT to measure heparin effect was similar. The HMT performed better than the ACT when using anti-Xa activity as a measure of heparin concentration. Noncitrated HMT results were similar to citrated HMT results, thus supporting the use of fresh whole blood for testing purposes.

Predicting and preventing pressure ulcers in adults with paralysis

A questionnaire mailed to all 2,295 members of the Eastern Paralyzed Veterans Association measured 45 potential risk factors for pressure ulcers. Logistic-regression analysis and Cox proportional-hazards analyses were used to identify the variables that were independently associated with pressure ulcers. The survey response rate was 42.2%. Among 15 risk factors from a previously published scale by the authors, 7 were independent predictors of pressure ulcer development: level of activity, level of mobility, complete spinal cord injury, urine incontinence or moisture, autonomic dysreflexia, pulmonary disease, and renal disease. In addition, 2 new variables added significant predictive value: being prone to infections that cause breathing problems and paralysis caused by trauma (as opposed to disease). Using these 9 risk factors, a new pressure ulcer risk assessment scale was designed specifically for persons with paralysis who are living in a community setting. It appears to be a more accurate method of predicting pressure ulcers than currently used risk assessment scales.

Doppler velocimetry discordancy of the uterine arteries in pregnancies complicated by diabetes

The aim of this study was to examine the association between uterine artery Doppler velocimetry discordance and perinatal outcome, specifically in pregnancies complicated by diabetes. We evaluated 265 women with singleton pregnancies complicated by diabetes who underwent Doppler ultrasonographic examinations of the right and left uterine arteries within 1 week before delivery. The absolute difference between the right and left uterine arteries was computed after measuring the uterine artery systolic-diastolic ratio. Adverse outcome was defined as still-birth, intrauterine growth restriction, delivery before 37 weeks' gestation, or cesarean delivery for fetal risk. The discordance between right and left uterine artery systolic-diastolic ratios ranged from 0 to 2.3, with a mean of 0.39 +/- 0.36 and a median of 0.30. The discordance was significantly larger in the 63 pregnancies with adverse outcome than in those with good outcome (0.48 versus 0.36, P = 0.018). Among the women with large uterine artery S/D ratio differences (> or = 0.60), a cesarean delivery for fetal risk was three times more likely (21.5% versus 7.5%, P = 0.002). In diabetic women with chronic hypertension (n = 36), the discordance was significantly larger than in the 201 normotensive women (0.54 versus 0.35, P = 0.001); yet for this subgroup uterine artery S/D ratio discordance was not predictive of adverse outcome. In conclusion, although considerable overlap in discordance exists between the good and adverse outcome groups, the uterine artery S/D ratio discordance added prognostic information on perinatal outcome for normotensive women with diabetes. The predictive value is independent of White's classification, third trimester glycemic control, sex of the infant, and umbilical artery Doppler waveform data.

Recurrence of initial pressure ulcer in persons with spinal cord injuries

Whether treated with surgery or by conservative, nonsurgical measures, pressure ulcers recur in 5% to 91% of spinal cord injured (SCI) patients. Factors other than the surgical technique used or the standard conservative management provided may be responsible. A retrospective study of 176 SCI patients with a history of one or more pressure ulcers was conducted at the Department of Veterans Affairs Medical Center at Castle Point, N.Y. Approximately 35% of patients who received either surgical or nonsurgical treatment had a recurrence. Patients who smoked and patients with diabetes or cardiovascular disease had higher recurrence rates.

Preoperative nutritional status and outcome of elective total hip replacement

Preoperative malnutrition increases the morbidity rate and length of hospitalization for various types of surgical patients. However, among patients who undergo elective total hip replacement, it is unclear how preoperative nutritional data can be used to detect a high risk subgroup. The purpose of this study was to identify preoperative nutritional factors that could be used to define a subgroup of patients who have undergone elective total hip replacement who are at high risk for poor post-operative outcome. Preoperative nutritional factors were evaluated in 89 consecutive patients who underwent elective total hip replacement. An inverse relationship was found between serum albumin and length of stay. Patients with an albumin level less than 3.9 were twice as likely to require prolonged hospitalization ( > 15 days) when compared with those in whom the albumin level was 3.9 or greater. Complications were related to the preoperative orthopaedic diagnosis of avascular necrosis of the hip. A subgroup of the patients undergoing elective total hip replacement who are at risk for prolonged recovery can be identified preoperatively by using a serum albumin level of less than 3.9 g/dL. The traditional normal range for albumin may be inappropriate for these patients.

Major risk factors for pressure ulcers in the spinal cord disabled: a literature review

Pressure ulcers remain a dominant health problem for persons with spinal cord injury despite abundant published research describing risk factors. Although information on these factors is plentiful, its usefulness to the spinal cord disabled is limited by three problems. First, the sheer volume is overwhelming; more than 200 risk factors for pressure ulcers have been described in the published literature. For most health care professionals, finding, no less reading and evaluating, the hundreds of articles published on this topic would be difficult. Second, most studies focused on elderly patients in nursing homes. Pressure ulcer risk factors for the spinal cord disabled are often different from those for the elderly; yet many findings from studies of the elderly provide valuable information. Third, inadequate sample sizes often hamper the usefulness of research on the spinal cord disabled. Drawing valid conclusions from these small studies, especially concerning potential risk factors is difficult. To address these three problems, we critically evaluated the medical, nursing, and nutritional research literature that pertained to risk factors for pressure ulcer development. The purpose of this paper is to provide a review of published reports on the principal risk factors for pressure ulcers in persons with spinal cord injuries.

Comparison of umbilical Doppler velocimetry, nonstress testing, and biophysical profile in pregnancies complicated by diabetes

The purpose of this study was to determine which test is best for predicting adverse outcomes in pregnancies complicated by diabetes: the nonstress test, biophysical profile, or umbilical artery velocimetry. We evaluated 207 singleton pregnancies complicated by diabetes within 1 week of delivery using the afore-mentioned pregnancy surveillance tests. Adverse pregnancy outcome was defined as delivery before 37 weeks of gestation or the occurrence of fetal growth restriction, hypocalcemia, hypoglycemia, hyperbilirubinemia, respiratory distress syndrome, or fetal risk requiring cesarean delivery. The prognostic value of each of the three tests was assessed, after controlling for the mothers' White classification and third trimester glycosylated hemoglobin value. Among the 207 pregnancies, 75 (36.2%) had an adverse outcome. In pregnancies in which the umbilical artery systolic to diastolic ratio was > or = 3.0, the relative risk of adverse outcome was 2.6 (95% confidence interval: 1.9-3.5, P < 0.001). For those with a biophysical profile < or = 6 the relative risk was 1.7 (95% confidence interval: 0.9-2.9, P = 0.109). Patients with a nonreactive nonstress test had a relative risk of 1.7 (95% confidence interval: 1.2-2.5, P = 0.009). Umbilical artery Doppler velocimetry was superior to either the nonstress test or the biophysical profile in identifying the subgroup of pregnancies complicated by diabetes that resulted in an adverse outcome.

A new pressure ulcer risk assessment scale for individuals with spinal cord injury

Each year, one-fourth of the 200,000 individuals with spinal cord injury in the United States develop pressure ulcers. No method currently exists, however, to accurately identify which of these individuals are at increased risk for development of pressure ulcers. We studied 219 spinal cord-injured patients, seen at a Veterans Affairs Medical Center, during a 6-yr period. Our goal was to develop a pressure ulcer risk assessment scale, specifically for persons with SCI. Each risk factor had to meet four criteria: (1) statistical association with pressure ulcer development; (2) biologically plausible mechanism; (3) literature support; (4) improved prediction. Among the 219 spinal cord-injured patients evaluated, 176 (80.4 percent) had a history of one or more pressure ulcers. Fifteen risk factors met the four criteria for inclusion into the risk assessment scale. They were as follows: restricted activity level, degree of immobility, complete spinal cord injury, urinary disease, impaired cognitive function, diabetes, cigarette smoking, residence in a nursing home or hospital, hypoalbuminemia, and anemia. Compared with the more general scales available, for quantifying the risk of pressure ulcer development, preliminary results suggest that this new scale is a significant improvement for the spinal cord-disabled.

Effect of gender on perinatal outcome in pregnancies complicated by diabetes

The aim of this study was to determine whether there is a gender-related difference in the morbidity and mortality of infants of diabetic mothers. We also wanted to identify risk factors associated with adverse pregnancy outcome, and create a perinatal morbidity index. We performed a retrospective review of 107 women whose pregnancies were singleton and complicated by diabetes. The subjects were divided according to the gender of the infant. The morbidity, mortality and confounding variables between the two groups were compared. Logistic regression analysis was used to identify the independent factors associated with an adverse pregnancy outcome. The male group (n = 62) had higher morbidity than the female group (n = 45). This was due to a higher incidence of hypoglycemia (relative risk = 3.9, 95% CI 1.2-12.5, p = 0.011) and need to stay in the neonatal intensive care unit 2 or more days (relative risk = 1.8, 95% CI 1.1-2.9, p = 0.015). There was one female stillbirth due to an episode of ketoacidosis in the mother. Male gender (relative risk = 1.8, 95% CI 1.2-2.7, p = 0.002) was one of three independent predictors of poor outcome. There is a male disadvantage in infants of diabetic mothers with regards to perinatal morbidity. Advanced White's classification, male gender, and third trimester mean glucose > or = 110 mg% identify the pregnancies at risk for diabetes-related morbidity.

Early predictors of sepsis in the motor-vehicle crash trauma victim

INTRODUCTION

Sepsis is a major cause of late morbidity and mortality in the victim of trauma. Currently, there is no method that is clinically practical and accurate for predicting the occurrence of sepsis in trauma victims.

METHODS

Data were collected on 3,759 motor-vehicle crash victims from 16 hospitals during a 4 1/2 year period. Retrospective analysis was done to examine the relationship of patient and injury factors known within the first 24 hours of admission on the development of sepsis.

RESULTS

Sepsis developed in 154 patients (4.1%) who had a mortality rate of 17.5%. Significant early predictors of sepsis included: 1) certain pre-existing conditions; 2) blood transfusion required; 3) seven or more injuries; 4) Glasgow Coma Scale score <10 and hypotension [corrected]; 5) major blood vessel injury; 6) head trauma; 7) internal injury of the chest or abdomen; 8) spinal-cord injury; and 9) certain fracture types.

CONCLUSIONS

These predictors might help target high-risk patients and, thus, promote earlier and more effective treatment for those patients.

Incidence of acute care complications in vertebral column fracture patients with and without spinal cord injury

STUDY DESIGN

This study retrospectively analyzed vertebral column fractures in trauma patients during a 2-year period. Data from a multicenter trauma registry were used.

OBJECTIVES

The purpose of this study was to ascertain and describe the initial in-hospital morbidity and mortality rates for patients with vertebral column fractures with and without spinal cord injury.

SUMMARY OF BACKGROUND DATA

Patients with vertebral fractures and associated spinal cord injuries experience more medical complications than those without spinal cord injuries. However, the precise incidence and relative risk of complications during acute care hospitalization for these two groups are not well documented.

METHODS

Vertebral column fractures in 419 adolescent and adult trauma patients hospitalized during a 2-year period were retrospectively analyzed using data from a multicenter trauma registry.

RESULTS

Of the 419 patients, 104 (24.8%) had an associated spinal cord injury. More than half of the spinal cord injury patients (52.9%) and 20.6% of those without spinal cord injury had one or more complications during their hospitalization. Complications resulted in an average of 33.1 extra hospital days, which extrapolates nationally into 1.5 million additional days annually. The four complications differing most significantly in incidence between the spinal cord injury group and the non-spinal cord injury group were: urinary tract infections (24.0% vs. 8.6%), respiratory (23.1% vs. 8.6%), cardiac (11.5% vs. 3.2%), and decubitus ulcer (7.7% vs. 1.0%). Pneumonia, although not statistically different, was high in both groups (13.5% vs. 7.3%).

CONCLUSIONS

The incidence of the 25 types of medical complications reported here provides specific and relevant information to assist health professionals in treating patients during their acute care. We estimate that complications during initial hospitalization add $1.5 billion annually to the cost of caring for patients with vertebral fractures in the United States.

The effects of non-thermal pulsed electromagnetic energy on wound healing of pressure ulcers in spinal cord-injured patients: a randomized, double-blind study

The objective of this randomized, double-blind study was to determine if non-thermal pulsed electromagnetic energy treatment significantly increases the healing rate of pressure ulcers in patients with spinal cord injuries. Subjects included volunteers admitted to a Veteran's Administration Hospital in New York over a 2 year period and consisted of 30 male spinal cord-injured patients, 20 with Stage II and 10 with Stage III pressure ulcers. Subjects were given non-thermal pulsed high-frequency electromagnetic energy treatment for 30 minutes twice daily for 12 weeks or until healed. The percentage of pressure ulcers healed was measured at one week. Of the 20 patients with Stage II pressure ulcers, the active group had a significantly increased rate of healing with a greater percentage of the ulcer healed at one week than the control group. After controlling for the baseline status of the pressure ulcer, active treatment was independently associated with a significantly shorter median time to complete healing of the ulcer. Stage III pressure ulcers healed faster in the treatment group but the sample size was limited. For spinal cord-injured men with Stage II pressure ulcers, active non-thermal pulsed electromagnetic energy treatment significantly improved healing.

Middle cerebral to umbilical artery Doppler ratio in post-date pregnancies

OBJECTIVE

To determine which antepartum test is the best predictor of post-date-related adverse outcome among the amniotic fluid index (AFI), nonstress test (NST), biophysical profile, or middle cerebral artery to umbilical artery Doppler ratio.

METHODS

Pregnant women of 41 or more weeks' gestation with singleton fetuses and vertex presentations underwent antepartum testing twice a week. Pulsed Doppler ultrasound was used to obtain the flow velocity waveforms from the umbilical and middle cerebral arteries. Adverse post-date-related outcome was defined as the occurrence of meconium aspiration syndrome, cesarean delivery for fetal distress, or fetal acidosis. The predictive values of an AFI equal to or less than 5 cm, a biophysical profile score equal to or greater than 6, a nonreactive NST, and a middle cerebral artery to umbilical artery ratio less than 1.05 in identifying adverse outcome were compared.

RESULTS

Forty-nine women met the inclusion criteria; ten (20.4%) had an adverse outcome. A middle cerebral artery to umbilical artery ratio of less than 1.05 was found to be the best predictor of adverse outcome, with a sensitivity of 80%, specificity of 95%, positive predictive value of 80%, and negative predictive value of 95%. The other three diagnostic tests had sensitivities equal to or less than 40%. The middle cerebral artery to umbilical artery ratio was also a better discriminator of adverse outcome than either the umbilical artery systolic-diastolic (S/D) ratio or the middle cerebral artery S/D ratio.

CONCLUSION

Although the sample size of our study was small, the results suggest that a middle cerebral artery to umbilical artery ratio of less than 1.05 is an accurate method of predicting post-date-related adverse outcome.

Laparoscopic cholecystectomy. The early experience of surgical attendings compared with that of residents trained by apprenticeship

During our first year of laparoscopic surgery, all cases were performed by attending surgeons; resident involvement was confined to camera work and occasionally to acting as first assistant. These residents were PGY3 or -4. During our second year, these same residents, who had learned the craft in the traditional apprenticeship method, on promotion to senior resident functioned as the primary surgeon in laparoscopic cholecystectomy cases, but under very close guidance by the credentialed attending. Ninety-two cases were attempted in the first year and 100 in the second. There were no differences in age, gender, or preoperative symptoms. More than half the patients had at least one co-morbidity in addition to their gallbladder disease. More women had laparoscopic cholecystectomy soon after pregnancy in the second year, but the percent of the patients with previous surgery declined from 21.4% to 5%. There was a threefold increase in the percent of cases performed in less than two hours and there was a significant reduction in hospital length of stay in the second year. Complication rates were similar in the first and second years. Training residents to do laparoscopic cholecystectomy can be done in a traditional residency program provided the attendings are adequately trained. However, the residents need a higher level of skill at this time than was necessary for open cholecystectomy and have to be further advanced in their training in order to perform this operation laparoscopically.

A study of pneumatic antishock garments in severely hypotensive trauma patients

The effectiveness of a pneumatic antishock garment (PASG) on severely hypotensive trauma patients (BP < or = 50 mm Hg) was studied using two data sets. The first included data from eight hospitals collected over 4 1/2 years; the second included 2 years of data from an additional eight hospitals. Data were collected by trained nurse abstractors whose interrater reliability was extremely high for AIS and ISS scoring. One hundred forty-two patients had blood pressures < 50 mm Hg. The PASG patients had a higher survival rate than non-PASG patients (Pr = 0.055). The PASG appeared to have the most effect on patients with abdominal injuries since no patient with such an injury survived unless a PASG was applied. Controlling for severity using the TRISS method, z scores indicated that the survival rate in the PASG group was significantly higher than expected whereas that in the non-PASG group was similar to that predicted; the same pattern was found when blunt injury and penetrating injury patients were analyzed separately. Improvement in survival among PASG patients occurred despite an average scene time that was 4.7 minutes longer than that for non-PASG patients. No improvement in survival among PASG versus non-PASG patients with blood pressures of 50-70 mm Hg or in those with blood pressures of 90 mm Hg or less was found. We conclude that the use of PASG in severely hypotensive patients (BP < or = 50) should be considered medically acceptable pending randomized controlled studies.

Association of skull base and facial fractures

A retrospective analysis of 268 trauma patients with facial fractures who received computed tomography of the head was undertaken to assess an association with skull base fractures. The incidence of skull base fracture was compared to facial fractures of various anatomic locations. Skull base fractures were significantly increased in orbital wall/rim fractures (36.0%, P = .0823). In contrast, skull base fractures related to orbital floor (27.3%, P = .6191) and maxillary/zygomatic (29.4%, P = .1148) fractures were not significantly greater and were infrequently seen with mandible (4.0%, P = .0454) and nasal (7.7%, P = .0345) fractures. The incidence of skull base fracture was directly associated with the number of facial fractures per patient; one facial fracture (21.0%), two facial fractures (30.4%), and three or more facial fractures (33.3%) (P < .05). The incidence of skull base fractures was related to the location of facial fractures and the number of facial fractures per patient. The results provide additional clinical information to facilitate the prompt detection and diagnoses of skull base fracture.

Comparison between TRISS and ASCOT methods in controlling for injury severity

ASCOT was developed by Champion et al. to address known limitations to TRISS. The present research attempted to validate ASCOT using an independent trauma registry. Data were collected by the Institute for Trauma and Emergency Care (ITEC), New York Medical College, between July 1, 1987 and June 30, 1989; 5685 trauma patients admitted to three level I trauma centers or five non-trauma center hospitals were included. Information was gathered by trained nurse-abstractors using all available prehospital and hospital records. ASCOT and TRISS were compared using sensitivity, disparity, misclassification rates, and the Hosmer-Lemeshow goodness-of-fit statistics. Disparity and sensitivity rates were relatively low for both indexes, particularly among blunt injury patients. Total numbers of patients misclassified by TRISS and by ASCOT were similar; most misclassifications were made by both TRISS and ASCOT and involved nonsurvivors. Each method had advantages in predicting the outcomes of particular subgroups of patients; ASCOT with regard to predicting outcomes among patients with head injuries and in correctly classifying blunt injured patients; TRISS in correctly classifying survivors. We conclude (1) the relatively small gain in predictive accuracy by ASCOT over TRISS is largely offset by its complexity and increased computer processing requirements; (2) Hosmer-Lemeshow tests indicate that neither index provides good statistical agreement between predicted and actual outcomes among either blunt or penetrating injury patients. Future models should include additional variables, stratify patients by several injury causes, and use decision rules to select variables and variable weights.

Survival after resection of carcinoma of the splenic flexure

Nine hundred ten patients undergoing colectomy for colon cancer were studied retrospectively. Seventy-four cancers (8 percent) were located at the splenic flexure. The stage at presentation was no different between splenic flexure cancers and colon carcinomas at other sites. Although splenic flexure cancers had twice the incidence of obstruction as did other colon cancers and obstruction in the overall series adversely affected survival, there was no difference in survival between splenic flexure cancer patients and patients with other colon cancers.

Limitations of the TRISS method for interhospital comparisons: a multihospital study

The value of the TRISS method for interhospital comparisons of trauma care was studied using data for 5,616 consecutive patients from three trauma centers and five community hospitals. Z-scores were used to compare mortality rates. Three limitations of the method were documented: 1) the lack of homogeneity within the patient subcategory of penetrating injuries, specifically between patients with gunshot versus stab wounds; 2) the inability of the TRISS method to predict the survival rate of patients suffering low falls; and 3) the inability of the TRISS method to account for multiple severe injuries to a single body part. Remedies to the first two of these limitations can be addressed within the present TRISS method. A remedy for the third requires a new method.

Central catheter-related infections: comparison of pulmonary artery catheters and triple lumen catheters for the delivery of hyperalimentation in a critical care setting

We prospectively studied the risk of catheter-related sepsis (CRS) in 75 critically ill patients who received total parenteral nutrition (TPN) through 158 pulmonary artery catheters (PACs) and 214 triple-lumen catheters (TLCs). We relied on semiquantitative cultures of the catheter tips, peripheral blood cultures in febrile patients and clinical response to catheter removal to diagnose catheter-related sepsis. The infection rate was 2.5% (4/158) of PACs and 6.5% (14/214) of TLCs (p = 0.124). Colonization rates were 29.1% for PACs and 32% for TLCs. PACs were left in place a significantly shorter length of time than TLCs, 3.1 vs 5.1 days (p less than 0.005). Guidewire exchanges and subclavian vein insertions were associated with a decreased rate of CRS when compared to new insertions and internal jugular vein insertions, respectively. We conclude that pulmonary artery catheters can be used safely for the delivery of hyperalimentation in critically ill patients with no increased risk for catheter-related sepsis compared to triple-lumen catheters. The use of the PAC in this manner allows for the use of a single central venous catheter for the delivery of hyperalimentation and hemodynamic monitoring.

Development of a computerized data base to evaluate pressure ulcers

A computerized data base for collecting information on patients with pressure ulcers was developed following a review of selected literature including Allman (1986), Bergstrom (1987), Barbenel (1977), Reichert (1986), Black (1987) and others. The data base was piloted, revised, and used for data collection on 103 patients admitted to two hospitals. Standardized data allowed for correlations of spinal cord injury (SCI) and location of pressure ulcers. Sacral ulcers were more prevalent with patients who had SCI at C4-T1 while ischial ulcers were more common with SCI at T11-L1. Some of the other correlations differ from prior research and warrant further investigation with a larger sample size from multiple institutions.