Placenta percreta versus ectopic pregnancy.
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Diagnosis, Differential↗
Biomedical subjects
Deborah Levine
Publications and source records attributed to Deborah Levine.
Placental chorangiosis associated with markedly elevated maternal chorionic gonadotropin. A case report.
BACKGROUND: Chorangiosis is a rare abnormality of placental capillary proliferation, associated with hypoxia in utero. CASE: A 23-year-old primigravida with a total human chorionic gonadotropin (hCG) level of 644,139 IU/L was referred for evaluation. Obstetric ultrasound, pelvic magnetic resonance imaging, computed tomography of the head and chest, and karyotype of the fetus were normal. Complete chorioamniotic separation occurred after amniocentesis. Placental abruption occurred at 33 weeks' gestation, and an emergency cesarean section was performed. Placental histology revealed chorangiosis. The infant was discharged on day 18 of life and did well. Postpartum the hCG level returned to 0. CONCLUSION: Elevated total serum hCG can be associated with chorangiosis. This diagnosis should be considered in cases of elevated hCG when no other anomaly is identified. Patients with elevated hCG should be monitored for placental abruption, a known consequence of chorangiosis.
Abruptio Placentae↗
MR imaging of fetal central nervous system abnormalities.
Ultrasound is the screening modality of choice for fetal imaging. However, when additional information regarding fetal anatomy or pathology is needed, fast MR imaging is increasingly being used as a correlative imaging modality. Performances of high quality sonographic and MR examinations as well as interpretation by individuals familiar with prenatal diagnosis are important factors for optimal parental counseling. MR imaging frequently adds additional information regarding fetal central nervous system anomalies beyond that available with ultrasound. This information commonly changes patient counseling, and at times patient management.
Central Nervous System↗
Developing a collaborative community, academic, health department partnership for STD prevention: the Gonorrhea Community Action Project in Harlem.
Community interventions are rare in the field of sexually transmitted disease (STD) control and prevention. The goals of the Gonorrhea Community Action Project are to design and implement interventions for the reduction of gonorrhea in high-prevalence areas and to increase the appropriateness and effectiveness of STD care in the participating formative research and developing the interventions was the creation of a community-academic-health department collaborative partnership. Using a staged model, this article presents a case study of collaboration development in the community of Harlem, New York.
Community Health Centers↗
Case 46: encephalomalacia in surviving twin after death of monochorionic co-twin.
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Adult↗
MR imaging appearance of fetal cerebral ventricular morphology.
PURPOSE: To elucidate further the magnetic resonance (MR) imaging appearance of fetal cerebral ventricles by comparing ultrasonographic (US) and MR images. MATERIALS AND METHODS: A retrospective review of MR and US images was performed for 110 normal fetuses and 94 fetuses with central nervous system abnormalities to assess lateral ventricular morphology as having (a) a normal appearance, (b) mild, disproportionate dilatation of the occipital horns with overall preservation of ventricular morphology, (c) colpocephaly with or without normal orientation of the frontal horns, (d) abnormal orientation of the frontal horns without colpocephaly, (e) an angular appearance, (f) fused frontal horns, (g) global dilation, or (h) a distorted appearance. Ventricular morphology on US and MR images was compared and correlated with reference standard diagnoses. RESULTS: US and MR imaging classifications were concordant in 145 of 188 (77%) examinations. Mild disproportion of occipital horns with respect to frontal horns was seen only on MR images. This ventricular configuration was present in eight of 110 normal fetuses and in 10 of 16 fetuses with isolated mild ventriculomegaly (P <.001). An angular configuration of the lateral ventricles, which is seen in fetuses with neural tube defects (NTDs), was present on review of MR images in 11 fetuses and on US images in one fetus. The ventricles of fetuses with NTDs and angular ventricles (3-12 mm) were significantly smaller than those of fetuses with NTDs and global dilatation of the ventricles (13-25 mm; P <.05). CONCLUSION: Ventricular contours differ with differing diagnoses of central nervous system abnormalities.
Brain Mapping↗
Case 49: Beckwith-Wiedemann syndrome.
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Adult↗
Using a sonographic simulator to assess residents before overnight call.
OBJECTIVE: The purpose of our study was to evaluate the effectiveness of a sonographic simulator in evaluating residents before their taking overnight call. MATERIALS AND METHODS: A sonographic simulator was used to teach and evaluate two consecutive classes of first-year radiology residents. A test consisting of 10 cases was given to each resident. Tests were scored with respect to image quality, measurement accuracy, and interpretation of results. Constructive feedback for improvement and additional training before taking call were provided, as needed. Surveys were given before and after the study to evaluate perceived knowledge and skills. RESULTS: In the first year of the study, five of eight residents scanned appropriately, giving reasonable differential diagnoses, whereas three residents performed suboptimally and were given feedback, additional training, or both. The sonography curriculum was restructured based on initial resident performance. In the subsequent year, all eight residents performed satisfactorily on the test. Comparing the 2 years of the study, mean test scores increased from 3.5 to 4.0 (p > 0.05) for abdominal test questions and from 3.4 to 4.2 (p < 0.05) for early obstetric and gynecologic test questions. The residents' self-assessment of knowledge and scanning ability also significantly improved. CONCLUSION: Sonographic simulation allows objective assessment and identification of weaknesses. These weaknesses can then be addressed before taking call, with resultant improved resident education and the presumed benefit of improved patient care.
Abdomen↗
Barriers to providing osteoporosis care in skilled nursing facilities: perceptions of medical directors and directors of nursing.
OBJECTIVES: The objectives of this study were to identify the barriers to osteoporosis clinical practice guideline use perceived by Medical Directors (MED DIR) and Directors of Nursing (DON) in skilled nursing facilities; and to describe differences in the perceptions of MED DIRs and DONs. DESIGN: The authors conducted a cross-sectional national survey. PARTICIPANTS: This study consisted of a random national sample of MED DIRs (n = 1300) and DONs (n = 1300) belonging to the American Medical Directors Association or the National Association of Directors of Nursing Administration in Long-term Care. MEASUREMENTS: A 24-item survey using a five-point Likert scale was developed. The survey measured agreement to questions in four domains (provider factors, guideline characteristics, patient factors, environmental factors) and 10 content areas (problem acknowledgment, patient/family concern, patient/family compliance, testing availability, safety, reimbursement, regulatory oversight, staff knowledge/time/ability, belief in guidelines, and malpractice liability). Response distributions to each item were plotted and differences between MED DIRs and DONs were tested. RESULTS: Survey response rates were 40% for MED DIRs and 48% for DONs. Respondents strongly agreed that fractures are a problem in their facilities and that osteoporosis guidelines are useful and cost-beneficial (mean responses > or = 4.0). A large proportion of respondents (at least 40% of the sample) identified multiple patient comorbidities, reimbursement issues, length of stay, and regulatory oversight as barriers to providing osteoporosis care. Respondents did not believe that patient and family acceptance, testing availability, staff time, staff self-efficacy, or concerns about bisphosphonate safety were barriers to osteoporosis care. DONs were more likely than MED DIRs to believe that patients and families are concerned about fractures, whereas MED DIRs were more likely to endorse length of stay, staffing issues, and regulatory oversight as influencing treatment decisions. Years of practice and facility size, but not formal geriatrics training, significantly influenced responses. CONCLUSION: Perceived barriers to implementing osteoporosis guidelines differ between facilities and between MED DIRs and DONs. Identification of these barriers could facilitate quality improvement initiatives and improve the quality of osteoporosis care.
Aged↗
Barriers to providing osteoporosis care in skilled nursing facilities: perceptions of medical directors and directors of nursing.
OBJECTIVES: The objectives of this study were to identify the barriers to osteoporosis clinical practice guideline use perceived by Medical Directors (MED DIR) and Directors of Nursing (DON) in skilled nursing facilities; and to describe differences in the perceptions of MED DIRs and DONs. DESIGN: The authors conducted a cross-sectional national survey. PARTICIPANTS: This study consisted of a random national sample of MED DIRs (n=1300) and DONs (n=1300) belonging to the American Medical Directors Association or the National Association of Directors of Nursing Administration in Long-term Care. MEASUREMENTS: A 24-item survey using a five-point Likert scale was developed. The survey measured agreement to questions in four domains (provider factors, guideline characteristics, patient factors, environmental factors) and 10 content areas (problem acknowledgment, patient/family concern, patient/family compliance, testing availability, safety, reimbursement, regulatory oversight, staff knowledge/time/ability, belief in guidelines, and malpractice liability). Response distributions to each item were plotted and differences between MED DIRs and DONs were tested. RESULTS: Survey response rates were 40% for MED DIRs and 48% for DONs. Respondents strongly agreed that fractures are a problem in their facilities and that osteoporosis guidelines are useful and cost-beneficial (mean responses > or = 4.0). A large proportion of respondents (at least 40% of the sample) identified multiple patient comorbidities, reimbursement issues, length of stay, and regulatory oversight as barriers to providing osteoporosis care. Respondents did not believe that patient and family acceptance, testing availability, staff time, staff self-efficacy, or concerns about bisphosphonate safety were barriers to osteoporosis care. DONs were more likely than MED DIRs to believe that patients and families are concerned about fractures, whereas MED DIRs were more likely to endorse length of stay, staffing issues, and regulatory oversight as influencing treatment decisions. Years of practice and facility size, but not formal geriatrics training, significantly influenced responses. CONCLUSION: Perceived barriers to implementing osteoporosis guidelines differ between facilities and between MED DIRs and DONs. Identification of these barriers could facilitate quality improvement initiatives and improve the quality of osteoporosis care.
Attitude of Health Personnel↗
Intraabdominal fetal echogenic masses: a practical guide to diagnosis and management.
Intraabdominal calcifications and other echogenic masses are relatively common findings during fetal sonography. Many are associated with no additional risk for the fetus or neonate. They may arise from the liver, gallbladder, spleen, kidneys, adrenal glands, gastrointestinal tract, or peritoneal cavity. Detection of such lesions should prompt a detailed survey for additional findings and a review of the maternal history. In some cases, fetal karyotyping may be indicated. In most cases, the diagnosis, management, and outcome are determined according to a combination of specific ultrasound appearances and at least one additional maternal or fetal factor. In utero diagnosis can often be achieved with careful evaluation of the lesion echotexture, associated calcifications, additional findings, and evolution over time. In most cases, expectant management is sufficient, but some patients require transfer to a facility where early postnatal intervention is available. A systematic approach to the findings aids in differential diagnosis and management.
Abdominal Cavity↗
Appearance of an interhemispheric cyst associated with agenesis of the corpus callosum.
We describe a fetus with agenesis of the corpus callosum (ACC) and Dandy-Walker malformation that developed a frontal paramidline cyst late in gestation. The interval appearance of the cyst occurred in concert with increasing size of the lateral ventricles, which supports the hypothesis that cysts associated with ACC can develop with increasing intraventricular pressure. Recognition of the potential for a changing appearance of neurologic abnormalities is important to providing appropriate patient counseling.
Adult↗