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Biomedical subjects

M P Dombrowski

Publications and source records attributed to M P Dombrowski.

At least 37 records · Page 2Linked to original sources
PubMed1998

The cost-effectiveness of routine type and screen admission testing for expected vaginal delivery.

OBJECTIVE: To evaluate the cost effectiveness of routine admission type and screen testing for expected vaginal delivery. METHODS: A retrospective review was conducted in patients transfused with blood during an admission that anticipated a vaginal delivery over a 3-year period, at Hutzel Hospital, in Detroit, Michigan. RESULTS: Of 16,291 patients admitted for an expectant vaginal delivery, 76 (.47%) (95% confidence interval [CI] .37%, .58%) required blood transfusion during the time of their admission. Medical records of these 76 patients were evaluated as to urgency and risk factors. Most of the blood transfusions were related to previously identified risk factors, including previous postpartum hemorrhage, multiple pregnancies, previous cesarean delivery, abruptio placentae, and admission anemia. Four patients received an urgent blood transfusion without a previously identifiable risk factor. We found an overall urgent blood transfusion rate without admission risk factors to be 2.5 per 10,000 vaginal deliveries (95% CI .9 per 10,000, 6.3 per 10,000) CONCLUSION: Routine admission type and screen testing for an expected normal vaginal delivery does not seem to enhance patient care and should be eliminated for patients without substantial risk factors. In the rare event that a patient without a previously identified risk factor required an urgent blood transfusion, O negative blood could be given in the interim pending formal type and cross match.

Blood Transfusion↗
PubMed1998

The development and implementation of normal vaginal delivery clinical pathways in a large multihospital health system.

The entire country has become more concerned with healthcare costs due to managed care, capitation risk-based contracts, and the near elimination of the cost-plus reimbursement system. Clinical pathways have become one way to reduce unnecessary resource consumption by reducing provider variance, improving clinical outcomes, and reducing cost. We present here our rationale and process for developing a common clinical pathway for normal vaginal delivery in a large and varied multihospital system. We also discuss how this new pathway is expected to improve quality of care and reduce costs.

Critical Pathways↗
PubMed1997

Telemedicine and fetal ultrasonography: assessment of technical performance and clinical feasibility.

OBJECTIVE: Our aim was to determine the performance and clinical feasibility of telesonography for the interpretation of fetal anatomic scans sent from a remote location compared with those obtained at a tertiary care prenatal ultrasonography center. STUDY DESIGN: Routine ultrasonographic studies from 35 patients were remotely interpreted. Evaluation included a blinded comparison of the sonographer's assessment of 38 fetal structures with that of the physician at the tertiary care center. Technical evaluation included system reliability and the number of digital telephone lines required for adequate real-time visualization. RESULTS: The mean gestational age at the time of the ultrasonography was 25.84 +/- 6.8 weeks (range 14 to 38). There was complete consistency of interpretation for 25 of 38 (66%) fetal structures. Thirteen structures had discrepancies in visualization, reflecting a difference in the adequacy of visualization, not the normalcy or identity of the structures. Three digital (integrated switching digital network, ISDN) telephone lines were required for real-time visualization. CONCLUSION: Our preliminary experience supports telesonography as a clinically useful tool for remote interpretation of fetal ultrasonographic examinations. Further studies are warranted for the continued evaluation of this emerging technology.

Female↗
PubMed1997

Precise gaussian distribution functions of maternal serum alpha-fetoprotein and free beta-subunit of human chorionic gonadotropin for trisomy 21 screening: improved accuracy for patient counseling.

OBJECTIVE: Gaussian equation curves are used to generate baseline curves against which a priori maternal age Down syndrome risks are adjusted to develop likelihood ratios for individual patients. We sought to evaluate the accuracy of these calculations, minimize the affects of outliers, and to make improvements. STUDY DESIGN: Gaussian distribution functions were used to investigate the best model for alpha-fetoprotein and free beta-human chorionic gonadotropin multiples of the median with use of nonlinear regressions. Parameters from distribution functions can be used to compute a more precise likelihood ratio for the decision logic for trisomy 21. A total of 58,297 normal cases and 348 cases of trisomy 21 were computed. RESULTS: Log normal distribution functions generated by nonlinear regression produced excellent but exaggerated goodness of fit R2 to the frequency distributions of the data. For normal cases values were as follows (in mean, SD, and R2, respectively): log alpha-fetoprotein -0.07199, 0.15681, and 0.9970; log beta-human chorionic gonadotropin -0.15203, 0.24284, and 0.9987. For trisomy 21 cases the values were (in mean, SD, and R2, respectively) for log alpha-fetoprotein -0.19303, 0.15802, and 0.9828 and for log beta-human chorionic gonadotropin 0.19996, 0.29760, and 0.9669. Distributions reconstructed with use of statistical means and SDs generated goodness of fit R2 from 0.585 to 0.914. Use of means and SDs derived from distribution functions increased the R2 to 0.855 and 0.999. The change in the model produces, at a 5% false-positive rate, a sensitivity of 57.18% (199/348). A 1 in 113 cutoff point risk is obtained and is tighter than the 1 in 251 without the distribution functions, as versus 1 in 270 by age calculations alone. CONCLUSIONS: Our data suggest that (1) normality of log transforms of alpha-fetoprotein and normality of log transforms of beta-human chorionic gonadotropin are reasonable models, (2) distribution functions can minimize the effect of outliers, which produces more realistic risk estimates, and (3) the effect of distribution functions versus standard mean and SDs cannot automatically be extrapolated to other parameters, which must be tested individually.

Chorionic Gonadotropin, beta Subunit, Human↗
PubMed1997

Pharmacologic therapy of asthma during pregnancy.

Asthma is a common, potentially serious medical complication during pregnancy. Optimal clinical and pharmacologic management is necessary to mitigate maternal and fetal complications. Mild asthma may be managed in most cases with inhaled beta 2-mimetics. Anti-inflammatory therapy is recommended for the treatment of moderate and severe asthma. Based on limited human experience, beclomethasone is currently the recommended inhaled corticosteroid during pregnancy. However, other inhaled corticosteroids may have advantages compared to beclomethasone because of reduced systemic absorption, which may adversely affect intrauterine growth. Based upon theoretic considerations, theophylline is now considered a secondary therapy, but data demonstrating the superiority of inhaled corticosteroids versus theophylline during pregnancy are lacking.

Adrenal Cortex Hormones↗
PubMed1997

Maternal thrombocytopenia. Predicting neonatal thrombocytopenia with cordocentesis.

OBJECTIVE: To evaluate the efficacy of cordocentesis for predicting fetal thrombocytopenia in the presence of maternal thrombocytopenia. STUDY DESIGN: We studied platelet counts obtained by cordocentesis from 42 consecutive immune thrombocytopenia purpura patients. Platelet counts were obtained on 36 neonates, and the statistical analysis included only these infants. Presence of maternal antiplatelet antibodies, interval from fetal sampling to delivery, neonatal platelet counts and outcome were evaluated. Thrombocytopenia was defined as a platelet count < or = 150,000/microL, with < or = 50,000 microL considered severe. RESULTS: No procedure-related complications occurred. A moderate correlation existed between fetal and neonatal platelet counts (r = .48, P = .003), unrelated to the interval between sampling and delivery. Eight of 36 fetuses had thrombocytopenia, and 4 were confirmed at delivery. Two neonates had thrombocytopenia at birth but not at cordocentesis. Two neonatal thrombocytopenia cases were severe. Neither was categorized as severe antenatally. The sensitivity, specificity, and positive and negative value for predicting severe neonatal thrombocytopenia were 0%, 100%, 0%, and 94%, respectively. Grade 1 intraventricular hemorrhages occurred in two neonates delivered at 35 weeks' with normal platelet counts. CONCLUSION: Cordocentesis was not reliable in predicting severe neonatal thrombocytopenia; however, the high negative predictive value was reassuring. The clinical utility of the technique and the population in which it should be used remain to be defined.

Adult↗
PubMed1996

Modified stylet technique for tenting of amniotic membranes.

A modified amniocentesis technique can reduce the failure rate in cases of tenting of the membranes. Failure to aspirate amniotic fluid (AF) because of amniotic membrane tenting may persist after advancement and rotation of the needle. In such cases, the membranes may be pierced by using a stylet that is longer than the length of the needle. With the needle in the middle of a suitable AF pocket, the stylet of the needle is replaced with a longer stylet. Under real-time ultrasonographic guidance, the tip of the stylet is then rapidly advanced 5-10 mm beyond the tip of the needle. During genetic amniocentesis, we have used the longer stylet technique to pierce tented membranes without complications in 21 of 22 cases.

Amniocentesis↗
PubMed1996

Cocaine and beta-adrenergic receptor function in pregnant myometrium.

OBJECTIVE: Our purpose was to evaluate the in vitro effect of cocaine on beta-adrenergic receptor function in pregnant human myometrium. STUDY DESIGN: Myometrium was obtained from 25 pregnant women at term who were undergoing cesarean section but who were not in labor. Membrane preparations were assayed for cyclic adenosine monophosphate production after exposure to isoproterenol, sodium fluoride, or forskolin in the presence and absence of either cocaine or benzoylecgonine, a major metabolite of cocaine. RESULTS: Cocaine inhibited isoproterenol-induced cyclic adenosine monophosphate production in concentrations as low as 10(-8) mol/L but had no effect on cyclic adenosine monophosphate production induced by sodium fluoride or forskolin. Benzoylecgonine (10(-4) mol/L) had no effect on isoproterenol-induced cyclic adenosine monophosphate production. CONCLUSION: Cocaine is a beta-adrenergic receptor antagonist in human myometrium at concentrations as low as 10(-8) mol/L. This acute effect of cocaine may result in increased uterine contractility with adrenergic stimulation, potentially leading to increased uterine activity associated with acute cocaine use.

Cocaine↗
PubMed1996

The economic cost of the medical-legal tort system.

OBJECTIVE: Our goal was to evaluate the financial expenditures of the medical-legal tort system on the single largest medical campus in the United States. STUDY DESIGN: The true financial expenditures directed to the medical-legal system were determined and related to the total revenue and expenses of the Detroit Medical Center. All costs were determined, including malpractice premiums, paid claims information, accrual expense information, and risk management administrative expenses for the fiscal years 1992, 1993, and 1994. RESULTS: The total medical-legal expenses for the years 1992, 1993, and 1994 were $73,732,000, $70,490,000, and $79,043,000, respectively. The claims paid to plaintiffs were 35.9%, 28.1%, and 28.1% for the same years. CONCLUSION: The medical-legal system process in the United States is very long and fraught with many inequities and inefficiencies. It was found that approximately 12% of the medical-legal expenditures of the Detroit Medical Center go to the individual alleged victim after defense and plaintiff attorney fees and costs and administrative costs. The failure of the American health care system could be in jeopardy if the nation's leaders do not reform the process to provide a more cost-effective system.

Legislation, Medical↗
PubMed1996

Lung maturity tests. Relation to source, clarity, gestational age and neonatal outcome.

OBJECTIVE: To determine whether gestational age is a significant determinant of neonatal outcome, irrespective of biochemical lung maturity. The effects of specimen source and clarity on the reliability of biochemical tests for predicting respiratory distress syndrome are also evaluated. STUDY DESIGN: Perinatal outcome was analyzed for 904 neonates undergoing amniotic fluid maturity studies within three days of delivery from 1991 to 1993. The relationships of gestational age and biochemical maturity to neonatal outcome were examined using multivariate analysis of covariance. Test reliability was evaluated using log-linear analysis of multiway frequency tables. RESULTS: Gestational age was a better predictor of neonatal outcome than biochemical lung maturity. Gestational age significantly correlated with every measure of outcome except intraventricular hemorrhage and jaundice. Test reliability was not significantly influenced by specimen source or clarity. CONCLUSION: Results obtained using contaminated amniotic fluid are reliable when the proper technique is used. Irrespective of biochemical maturity, neonatal outcome is significantly related to gestational age. Gestational age, and not just biochemical maturity, should be considered when timing delivery.

Amniotic Fluid↗
PubMed1996

Hyperemesis gravidarum. Effects on fetal outcome.

OBJECTIVE: To study perinatal outcomes in pregnancies complicated by hyperemesis gravidarum (HG) as compared to controls. STUDY DESIGN: Between 1984 and 1991, 138 patients were diagnosed with HG according to Fairweather's criteria. Subjects were stratified into groups of mild and severe HG according to the presence of at least one of the following criteria: ketonuria, increased blood urea nitrogen and hematocrit, and/or abnormal electrolytes. All patients without HG on whom records were available and who delivered during the study period were included as controls. Multiple gestations and stillbirths were excluded from the analysis. Student's t test and X2 were used for statistical analysis. RESULTS: Demographic data were not significantly different between the groups. Forty patients were diagnosed as having mild HG and 98 patients as having severe; 12,335 patients were defined as controls. Mean fetal birth weights were 3,110, 3,093, and 3,160 g in the mild, severe and control groups, respectively. The incidence of congenital anomalies was 2.5%, 2.0% and 1.6%, respectively. The incidence of prematurity was 17.5%, 11.2% and 10.7% in mild and severe HG and controls, respectively. None of the outcome variables for mild or severe HG were significantly different as compared to the controls. Differences in other neonatal outcomes, including frequency of five-minute Apgar score < 7 and neonatal intensive care unit admissions, were not significantly different between the three groups. CONCLUSION: In contrast to previous reports, this study demonstrated that fetuses of gravidas admitted for HG are not at increased risk of growth retardation, congenital anomalies or prematurity. No beneficial effect on pregnancy outcome was detected.

Adult↗
PubMed1995

Predictive value of fetal serum beta 2-microglobulin for neonatal renal function.

When fetal urinary-tract malformations (UTM) are discovered, management is based on the prediction of postnatal renal function, currently made by fetal urinary biochemistry and sonography. Serum beta 2-microglobulin has been used postnatally to estimate renal function and does not cross the placenta. We investigated the relation between fetal serum beta 2-microglobulin and renal function by comparing 64 unaffected fetuses and 15 fetuses with UTM. A beta 2-microglobulin above a 5.6 mg/L cut-off gave cross-validated sensitivity of 80.0%, specificity of 98.6%, a positive predictive value of 88.9%, and a negative predictive value of 97.1% for our cohort study.

Cohort Studies↗
PubMed1995

Computer-generated admission forms have greater accuracy.

We examined the accuracy of computer-generated admission forms to standardized handwritten admission forms for 40 patient records. There was a mean of 8.3 errors among handwritten forms but only 0.9 errors among computerized forms (p < 0.0001). Written forms had seven serious errors versus one for computerized forms (p < 0.05). We conclude that computerized admission forms have superior accuracy.

Admitting Department, Hospital↗
PubMed1995

Changes in health care delivery: a threat to academic obstetrics.

OBJECTIVE: Our purpose was to examine the effect of anticipated health care policy changes on delivery trends at leading academic obstetric institutions. STUDY DESIGN: The 51 centers in the United States with the most Society of Perinatal Obstetricians presentations in the past 2 years were surveyed regarding annual deliveries from 1990 to 1993 and reasons for any changes. Analysis of variance and chi 2 analysis were used as appropriate. RESULTS: Complete data were available from 43 hospitals representing 39 institutions. Their 1990 to 1993 delivery rates declined faster than United States delivery rates (12.3% vs 2.0%, p < 0.0001). The largest hospitals (> 6000 deliveries) had a decline of 18.2% compared with declines of 9.0% for medium and 0.9% for small hospitals (< 2500 deliveries). Regionally the greatest impact was seen in the West and the South, with 22% and 12% declines, respectively (p < 0.05). Reasons cited for the decline included competition from private or community physicians or hospitals (59%) and managed care (15%). CONCLUSION: As the national health care debate focuses on cost containment and coverage, we believe the potential effects of national policy on research and education should be considered. Continued selective reduction in deliveries at academic institutions can be expected to adversely affect research and education.

Delivery of Health Care↗
PubMed1995

The expert witness: real issues and suggestions.

Medical malpractice lawsuits generally require expert testimony. Defendants and plaintiffs deserve expert testimony that is exacting, accurate, and consistent. A study of four frequently testifying experts was undertaken with review of depositions, reports, and trial transcripts of those experts. Contradictions in claimed medical principles from one case to the next were found and examples were cited for each expert. The review suggested that expert testimony regarding the standard of care may be neither reliable nor accurate for the purposes of judging physician conduct is lawsuits. Presently, no peer review or sanction process has been implemented to ensure accuracy and reliability of expert testimony used in medical malpractice lawsuits. We recommend changes that would include independent court-appointed experts, central filing of opinion letters by experts with authoritative text citations, and a sanction process by courts and/or authorized boards for testimony that is deemed inaccurate, false, or contradictory to the standard of care.

Expert Testimony↗
PubMed1995

Combining humerus and femur length for improved ultrasonographic identification of pregnancies at increased risk for trisomy 21.

OBJECTIVE: Our purpose was to evaluate the value of the combination of femur and humerus length measurements in ultrasonographic screening for trisomy 21. STUDY DESIGN: Direct necropsy measurements were analyzed on 703 midgestational fetuses (641 normal, 62 with trisomy 21). The (leg+arm length)/foot length ratio was found to be significantly shortened for fetuses with trisomy 21. On the basis of necropsy data 576 midgestational pregnancies were evaluated ultrasonographically for (femur+humerus length)/foot length ratio to identify fetuses at increased risk for trisomy 21. RESULTS: An ultrasonographic (femur+humerus length)/foot length ratio < or = 1.75 gave a 15.3 odds ratio risk for trisomy 21 in our high-risk population and correctly identified 53% of fetuses with trisomy 21, with a false-positive rate of 7%. In addition, the use of this ratio eliminates the need for gestational age-corrected nomograms and complicated calculations in ultrasonographic screening. CONCLUSION: The (femur+humerus length)/foot length ratio may be an additional effective ultrasonographic marker for identification of fetuses at increased risk for trisomy 21.

Anthropometry↗