Biomedical subjects
Publications and source records attributed to D J Cooper.
Fatal severe rhabdomyolysis and anuric renal failure developed in a young man who had contracted hand, foot and mouth disease during an epidemic of this disease. Viral studies implicated coxsackievirus A16 as the infecting agent. This appears to be the first reported case of rhabdomyolysis that was associated with hand, foot and mouth disease and infection with coxsackievirus A16.
The authors describe two patients with traumatic cerebral edema and intracranial hypertension in whom the continued use of mannitol and furosemide resulted in a progressive lessening of the effect of these agents on the intracranial pressure (ICP) and caused prerenal failure. Intravenous administration of hypertonic saline (50 ml and 20 ml of a 5-mmol/ml saline solution over 10 minutes in Cases 1 and 2, respectively) produced a prolonged reduction in the ICP and improved renal function in both cases. It is suggested that if a reduction in ICP without diuresis is required in patients with traumatic cerebral edema, treatment with intravenous hypertonic saline should be considered.
In a patient with viral pneumonia, acute respiratory and renal failure and metabolic acidosis, a reduction in left ventricular stroke work was observed on the three occasions that 100 ml of 8.4% sodium bicarbonate was infused. Blood pressure and cardiac output decreased on two of the occasions. Since intravenous sodium bicarbonate may produce adverse cardiovascular effects, a right heart catheter should be inserted to monitor these effects when alkali therapy is administered to an acutely ill patient with metabolic acidosis.
Eight patients who inadvertently received theophylline by mouth and aminophylline by the intravenous route together were reviewed by the Clinical Pharmacology Service of the Royal Adelaide Hospital because their serum theophylline levels were in excess of the stated therapeutic range. Six of these patients were severely compromised by their high theophylline level, and two of them, who had advanced obstructive lung disease and respiratory failure, died shortly after the drug levels were detected. Oversights of this nature can arise during the early stages of a patient's hospital admission and when medical staff changes occur. All patients who receive aminophylline by the intravenous route must be kept under close surveillance to ensure that theophylline formulations are not given by mouth concurrently.
The integrity of the bladder neck was assessed in 98 continent women. Radiological and physiological evidence showed that half of these women had an incompetent bladder neck, but they were still continent. These data devalue the urodynamic finding of an incompetent bladder neck as an indication for surgery for incontinence and question the physiological importance of the internal sphincter.
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This prospective screening program of a large obstetric population was designed to determine the effectiveness of ultrasonic biometry to diagnose intrauterine growth retardation. The results of 3616 pregnancies were analyzed. All pregnancies were dated before the 24th week by ultrasonic measurements. The study compared the effectiveness of three ultrasonic growth parameters: biparietal diameter (BPD), head circumference, and abdominal circumference, to detect intrauterine growth retardation and to determine the optimal gestational age to perform the scan for this purpose. To maintain a high sensitivity required in a screening program, all ultrasonic measurements below the 25th percentile for gestational age were considered abnormal. The predictive value of a positive test in this situation ranged from 0.25 to 0.55, depending on the week of gestation in which the scan was performed. Accuracy of predictions improved greatly when the scans were performed within two weeks of delivery. Abdominal circumference measurements were more predictive of intrauterine growth retardation than either head circumference or BPD measurements or the combination of these parameters. In view of the sensitivity of the test and the prevalence of the disorder, it is concluded that 34 +/- 1 weeks of gestation is the optimal time to screen patients ultrasonically for intrauterine growth retardation.
We describe a patient with the unusual complication of massive upper gastrointestinal bleeding secondary to herpetic esophagitis, whose bleeding persisted despite a vigorous antireflux regimen but who responded dramatically to intravenous acyclovir. The patient is reported to underscore the importance of considering herpetic infection of the esophagus as a cause of severe gastrointestinal bleeding so that appropriate therapy may be instituted.
In a technician-oriented routine ultrasound program, the value of screening an entire obstetric population for predicting gestational age based on a single measurement was evaluated over selective scans performed on the basis of uncertain menstrual history. Consecutive pregnancies of 4527 women were scanned, and the results were analyzed. Gestational ages were determined by both menstrual history and ultrasonic crown-rump length or biparietal diameter (BPD) measurements. The estimated date of confinement based on ultrasound measurements was compared with menstrual history in its ability to predict the actual onset of spontaneous labor. Of patients with optimal menstrual history, 84.7% delivered within +/- two weeks of the date predicted. Only 69.7% delivered within +/- two weeks of the estimate date of confinement based on suspect menstrual history. Crown-rump length measurements were as predictive (84.6%) as optimal menstrual history. Biparietal diameter measurements done between 12 and 18 weeks' gestation were significantly more accurate in gestational predictions (89.4%) than those based on menstrual history (P less than .001). It is concluded that ultrasound cephalometry before 18 weeks is the single best dating parameter.
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Climacteric symptoms in 120 women were treated with a total of 469 hormone implants (oestradiol 50 mg and testosterone 100 mg) over a period of four years. All patients with a uterus were given an oral progestogen to prevent endometrial hyperplasia. There was a marked response to treatment, hot flushes being improved in all patients, depression in 99% and loss of libido in 92%. Patient acceptability of this type of treatment was good and there were few side effects or complications. After therapy, the serum oestradiol exceeded the serum oestrone but remained within normal limits. When climacteric symptoms returned and re-implantation occurred the serum levels of oestrone, oestradiol, luteinising hormone (LH), follicle stimulating hormone (FSH) and testosterone were within the normal range for the reproductive age. This indicates that the return of symptoms is due to a change in the hormone levels rather than absolute hypo- oestrogenism .
Carcinomas of the ileum and colon in patients with Crohn's disease are being reported with such increasing frequency as to raise the question of a surveillance program to find dysplasia or the carcinoma itself at the earliest possible time. Accordingly, we consider the overall risk with emphasis on specific manifestations of Crohn's disease which predispose to malignancy so that the surveillance might be given special direction. Two more cases of carcinoma in Crohn's disease are reported, one in association with a long-standing fistula, the other with synchronous, metachronous, and multifocal lesions, and both with dysplasia.
To assess the risks associated with the use of Kielland's forceps 2708 consecutive deliveries were studied prospectively and the neonatal outcome related to the mode of delivery. Of the 1191 primigravidas, 279 (23.4%) underwent instrumental delivery, of whom 65 (5.5%) were delivered with Kielland's forceps. There was no difference in early neonatal outcome (as judged by Apgar scores, intubations, and admission to the special care baby unit) between these babies and those delivered normally or by non-rotational forceps, but a higher proportion of the 127 (10.7%) delivered by emergency caesarean section were compromised. Of the 1517 multigravid patients, only 57 (3.8%) underwent instrumental delivery, 15 (1.0%) by Kielland's forceps. Among these babies, also, the outcome was no worse than for those delivered normally, but the babies delivered by caesarean section showed a greatly increased incidence of low Apgar scores, intubations, and admission to the special care baby unit. There were no stillbirths or neonatal deaths among babies delivered by Kielland's forceps, nor were there any cases of severe birth trauma or of obvious neonatal morbidity.
A detailed analysis of 2632 consecutive pregnancies in white, black and Asian women, who were delivered during the period 1978 to 1980, found significant differences between the three ethnic groups. Asian primiparae had the longest first and second stages of labour, with the highest incidence of prolonged latent phase (14%) and primary dysfunctional labour (30%). Black primiparae and multiparae had the highest incidence of secondary arrest in the first stage of labour (10% and 4% respectively) and of primary dysfunctional labour, with the greatest recourse to emergency caesarean section (13% and 4% respectively). The mean birthweight for singletons born between 37 and 42 weeks was 3.37 kg for white babies, 3.25 kg for black babies and 3.14 kg for Asian babies. There was no racial difference in perinatal mortality or morbidity in this survey.
From a study of 2000 consecutive labours the outcome of the 684 primigravid patients admitted in spontaneous labour has been examined according to their cervimetric progress during the first stage of labour. A partogram and labour stencil were used to identify dysfunctional labour which was treated with a standard protocol of augmentation by oxytocin. This policy achieved labours with a mean 'observed first stage' of 6.3 h and a caesarean section rate of 8.7%. There was one stillbirth due to multiple congenital abnormalities and no increase in perinatal morbidity. Our data show that the type of first stage cervimetric pattern is helpful in predicting the outcome of labour. A normal cervimetric pattern resulted in a vaginal delivery rate of 98.4%; primary dysfunctional labour, which could be improved by oxytocin, had a 93.8% incidence of vaginal delivery, but if there was no improvement in the rate of cervical dilatation when this was administered the vaginal delivery rate was only 22.7% . A prolonged latent phase was associated with a caesarean section rate of 16.7% and the incidence of neonatal intubation was nearly as high as that found in uncorrected primary dysfunctional labour. The neonatal asphyxia in secondary arrest was minimal with an overall caesarean section rate of 28.4%; there was no increased incidence of neonatal morbidity with this cervimetric type.
A prospective controlled study of 2000 patients to determine the incidence of postmaturity and the effect of a policy of non-induction of labour in prolonged pregnancy is reported. 'Certain postmaturity' was identified in 4% of the patients and was associated with an increased incidence of babies with Apgar scores of less than 5 at 1 min; induction of labour at 42 weeks gestation did not affect the neonatal outcome compared with that in patients allowed to go into spontaneous labour. Induction of labour in patients designated as 'certain postmature' and 'uncertain postmature' reduced the number of vaginal deliveries and increased the caesarean section rate from 9.6 to 26.7 and from 2.2 to 31.2% respectively. The failure to improve the perinatal outcome does not support or justify induction of labour for uncomplicated postmaturity.
The smoking habits of 2000 consecutive pregnant women have been analysed in relation to their race, social features and obstetric results. Only 60% of white patients were non-smokers compared with 80% of blacks and 90% of Asians, and whereas 20% of white patients smoked heavily only 3% of blacks or Asians did. Smokers booked later and were more frequently unsure of their dates, unemployed, unmarried and defaulters from the antenatal clinic. The incidence of antepartum haemorrhage was doubled amongst the heavy smoking multigravid patients in spite of a slightly decreased incidence of hypertensive disease. More non-smokers required induction of labour for raised blood pressure, and more smokers for fetal distress. The most significant differences between the smokers and non-smokers were the decrease in mean birth-weight associated with increased smoking (3.31 kg for non-smoking primigravidae compared with 3.14 kg for heavy smokers) and the threefold increased incidence of small-for-dates babies amongst the heavy smokers. There was no significant difference in the perinatal mortality.
From a study of 2000 consecutive labours, the outcome of 847 multigravid patients admitted in spontaneous labour was examined. Labour was classified according to the cervimetric pattern, and response to oxytocin given according to a strict protocol with the use of a nomogram and partogram. The mean 'observed first stage' was 3.4 h, and the caesarean section rate 1.4%. Normal labour occurred in 88.5%, with a vaginal delivery rate of 99.5% in this group. Stimulation was indicated in 98 patients (11.6%), augmentation improving the rate of progress in 86 (87.8%) of these, with vaginal delivery occurring in all but one. Successful accelerated labour was not associated with any increase in neonatal morbidity as judged by Apgar scores, intubation or transfer to the special care baby unit. Twelve patients did not have improvement following augmentation and seven were delivered by caesarean section, including one following a potentially preventable uterine rupture. The greatest neonatal morbidity was in the group with primary dysfunctional labour that did not improve with augmentation. It may be that this was related to the mode of delivery rather than augmentation, as there was no significant difference in neonatal condition between normal and abnormal labour if vaginal delivery occurred.