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Biomedical subjects

P Duff

Publications and source records attributed to P Duff.

At least 55 records · Page 3Linked to original sources
PubMed1993

Frequency of glove perforations and subsequent blood contact in association with selected obstetric surgical procedures.

OBJECTIVE: One purpose of this prospective investigation was to assess the frequency of glove perforations and subsequent blood contact associated with selected obstetric procedures. The second purpose was to assess the relative risk of perforation among different members of the surgical team and determine if time of day or urgency of the procedure affected the frequency of perforation. STUDY DESIGN: Over a 3-month period, obstetric personnel were asked to double glove for all surgical procedures. After surgery, they placed their gloves in plastic bags and noted the type of procedure, time of day, and position on the surgical team. They also indicated whether they were aware of a glove tear and, if so, whether blood or fluid was on their hands. Gloves were tested for injury by two methods: by inflating them with air and subsequently immersing them in water to detect air bubbles and by directly filling them with water to observe for leaks. RESULTS: A total of 540 glove sets (2160 individual gloves) were examined; 407 sets were from cesarean deliveries, 65 from puerperal tubal ligations, and 68 from vaginal deliveries. Sixty-seven of the sets (12.4%, 95% confidence interval 9.6% to 15.2%) had at least one hole; the total number of holes was 78. Sixty-six holes were in the outer glove only, and 7 were in the inner glove only. In five sets (0.9%, 95% confidence interval 0.5% to 1.3%) there were matching holes in the outer and inner gloves. In two of these cases (0.4%, 95% confidence interval 0.1% to 0.7%) the surgeons noted blood on their hands at the conclusion of the procedure. The difference in frequency of injury in outer versus inner gloves was highly significant (p < 0.005). Forty-six of the 78 holes (59%) were on the thumb or first two fingers of the nondominant hand. Only 2 (3%) of the glove tears were recognized by the surgeon. There was no difference in frequency of glove tears when cesarean sections were classified as urgent versus nonurgent. There also was no difference in frequency of glove tears in procedures performed at night compared with those during the daytime. Surgical nurses had 36% of all glove injuries and were more likely than physicians or medical students to sustain perforations (p < 0.005). Primary surgeons and first assistants were more likely than second assistants to sustain glove injuries (p < 0.05). For primary surgeons and first assistants, level of training did not significantly affect the frequency of glove perforations. CONCLUSIONS: Glove perforations occur in approximately 12% of obstetric surgical procedures. Surgical nurses are at greatest risk for perforation. Double gloving reduces the likelihood of penetrating injury to the inner glove and subsequent risk of blood contact.

Blood↗
PubMed1993

Rapid intrapartum detection of group B streptococcal colonization with an enzyme immunoassay.

OBJECTIVE: The purpose of this study was to determine the accuracy of a rapid immunoenzyme assay for detecting intrapartum colonization with group B streptococci. STUDY DESIGN: Three rayon-tipped swabs were used to collect specimens from the posterior vaginal wall of 424 preterm and term patients in labor. Three tests were performed on specimens obtained from the first 182 patients: semiquantitative culture on blood agar, culture in selective Todd-Hewitt broth, and ICON Strep B (Hybritech, San Diego) immunoconcentration assay. For the remaining 242 patients, the ICON test was performed only when the Todd-Hewitt broth culture was positive. RESULTS: The prevalence of positive cultures was 23%. For the first 182 patients, the immunoassay had a sensitivity of 11%, a specificity of 100%, a positive predictive value of 100%, and a negative predictive value of 78%. The overall sensitivity for all 424 patients was 9%. In eight women with heavy colonization, defined as an inoculum of > 10(5) cfu/ml the sensitivity of the assay was 100%. In the study population there were three cases of group B streptococcal sepsis in infants whose mothers were only lightly colonized. None of these cases of colonization were detected by the assay. CONCLUSION: The ICON immunoconcentration assay is very sensitive in identifying heavy group B streptococcal colonization of > 10(5) cfu/ml but quite insensitive in detecting lower levels of colonization. Thus it is not a suitable test for general screening.

Culture Media↗
PubMed1993

Viral hepatitis in pregnancy.

Hepatitis A is usually a benign, self-limited infection. A chronic carrier state does not exist, and perinatal transmission does not occur. Hepatitis B may cause chronic infection, and infants delivered to infected mothers are at considerable risk of developing neonatal hepatitis. Passive and active immunization with HBIG and HBV is highly effective in preventing perinatal transmission. Hepatitis D typically occurs as a coinfection or superinfection with hepatitis B. Patients infected with both viruses are at high risk for chronic liver disease. Perinatal transmission of hepatitis D can be prevented by the immunoprophylaxis used for hepatitis B. Non-A, non-B hepatitis occurs in two distinct forms: parenterally transmitted hepatitis C and enterically transmitted hepatitis E. Perinatal transmission of hepatitis C can occur, particularly in women who are concurrently infected with the human immunodeficiency virus. Neonatal immunoprophylaxis is not yet available. Hepatitis E may be associated with high maternal mortality rates in developing nations. However, a chronic carrier state does not exist, and perinatal transmission does not occur. Table 2 summarizes the most important features of each form of viral hepatitis.

Female↗
PubMed1993

Group B streptococcal infections during pregnancy.

Group B streptococcus, acquired intrapartum from the female genital tract, is the leading cause of neonatal sepsis. Intrapartum maternal antibiotic prophylaxis administered to colonized parturients is efficacious in reducing neonatal colonization and morbidity. However, the optimal method of identifying mother-infant pairs at risk remains controversial. Universal antenatal screening has been effective in identifying colonized women for subsequent intrapartum therapy in research protocols. However, the cost-effectiveness and efficacy of this management scheme, in a general population, has not been determined. The predictive value of antenatal cultures for identifying intrapartum group B streptococcus colonization varies inversely with the interval between culture and delivery with generally low predictive values for cultures performed more than 10 weeks before delivery. Rapid intrapartum screening with various methods has been investigated in a number of studies, while several methods are sensitive in identifying heavily colonized women, they remain insensitive in detecting light colonization.

Female↗
PubMed1993

Glove perforations and blood contact associated with manipulation of the fetal scalp electrode.

OBJECTIVE: To assess prospectively the frequency of glove injury associated with insertion of the fetal scalp electrode and subsequent examination of the cervix with the electrode in place. METHODS: Over a 7-month period, sterile gloves were collected after use for insertion of the fetal scalp electrode or cervical examination with the electrode in place. Attendants indicated their level of training, time, date and purpose of glove use, and cervical examination. They also noted whether they were aware of a glove perforation or observed blood, amniotic fluid, or genital tract secretions on their hand. Glove patency was assessed by filling the glove with water to 1.5-2.0 times its normal volume and observing for leaks. One hundred unused gloves were tested for patency and served as controls. RESULTS: Five hundred one gloves were evaluated, of which 13 (2.6%, 95% confidence interval [Cl] 1-4%) had perforations. Seven of 277 gloves (2.5%) used only for examinations had perforations, compared with six of 244 (2.5%) used only for insertion of the electrode. Two percent (95% CI 0-5%) of the unused control gloves had perforations. These observed differences were not statistically significant. Nineteen attendants (3.8%, 95% CI 2.1-5.5%) noted blood or genital tract secretions on their hand after insertion of the electrode (N = 4) or subsequent cervical examination (N = 15). Only one point of contract resulted from a glove perforation; the other 18 were on the wrist and apparently resulted from leakage of fluid around the open cuff of the glove. CONCLUSIONS: The risk of glove perforation during insertion of the fetal scalp electrode or subsequent cervical examination is low if proper technique is observed. Blood or fluid contact is more likely to result from leakage of fluid around the open cuff of the glove during a vaginal examination.

Amniotic Fluid↗
PubMed1993

Use of a DNA probe for the rapid detection of group B streptococci in obstetric patients.

OBJECTIVE: To determine the accuracy of a DNA probe as a rapid diagnostic test for detecting colonization of the female genital tract by group B streptococci during pregnancy. METHODS: Two rayon-tipped applicators were used to collect secretions from the posterior vaginal wall of 440 pregnant women. One of the applicators was inoculated into selective Todd-Hewitt broth and used as the reference standard for identification of group B streptococci. The other applicator was used for analysis with the DNA probe, preceded by either 2.5 hours of incubation for the initial 75 patients, or 3.5 hours' incubation for the remaining women. Following hybridization with an acridinium-labeled probe, chemiluminescence was measured with a luminometer. RESULTS: The prevalence of positive cultures was 20%. For the initial 75 patients whose cultures were amplified by incubation for 2.5 hours, the DNA probe had a sensitivity of 44%, specificity 94%, positive predictive value 79%, and negative predictive value 77%. For the cultures that were incubated for 3.5 hours, respective values were 71, 90, 61, and 94%. All vaginal specimens that had an average initial cell count of 1.5 x 10(3) cells/mL were accurately detected by the probe after 3.5 hours' growth amplification. False-positive results occurred primarily when the specimens were grossly contaminated with blood (26 of 39). The mean time required to perform the assay, including 3.5 hours of growth amplification, was 4.3 hours. CONCLUSIONS: The DNA probe demonstrated good overall sensitivity and gave no false-negative results when group B streptococci were present in concentrations of 1 x 10(4) cells/mL or greater. Sensitivity improved significantly with 3.5 hours' growth amplification as compared with 2.5 hours (P < .05), reflecting better identification of lightly colonized patients.

Carrier State↗
PubMed1993

Acute fatty liver of pregnancy in a patient with chronic active hepatitis and associated hepatocyte alpha 1-antitrypsin inclusions.

BACKGROUND: Acute fatty liver of pregnancy is a rare, potentially fatal condition that shares many of the signs and symptoms of severe preeclampsia. Early reports of this condition noted alarmingly high fetal and maternal mortality rates. However, recent reports have described more favorable outcomes due to prompt recognition and aggressive treatment. We here describe a patient with acute fatty liver of pregnancy superimposed on chronic active hepatitis. CASE: A 27-year-old woman, para 0-1-2-1, presented at 36 weeks' gestation with a 2-week history of malaise, nausea, emesis, diarrhea, and an 18-lb weight loss. The serum concentrations of transaminase enzymes, bilirubin, and alkaline phosphatase were increased, and a mild coagulopathy was present. The patient underwent repeat cesarean delivery and intraoperative needle biopsy of the liver. Histologic examination of the biopsy demonstrated the characteristic changes of acute fatty liver of pregnancy and chronic active hepatitis with associated alpha 1-antitrypsin hepatocyte inclusions. The serum alpha 1-antitrypsin level was mildly elevated and the phenotype was normal (PiMM), excluding alpha 1-antitrypsin deficiency. Viral and autoimmune etiologies for chronic hepatitis were excluded by laboratory studies. The woman experienced rapid resolution of symptoms and laboratory abnormalities in the immediate postoperative period. CONCLUSION: Acute fatty liver of pregnancy may occur in patients with underlying chronic liver disease. Prompt delivery is necessary to reduce the risk of fetal and maternal mortality.

Acute Disease↗
PubMed1992

Management of term patients with premature rupture of membranes and an unfavorable cervix.

The purpose of this prospective investigation was to evaluate a protocol for management of term patients with premature rupture of membranes (PROM) and a cervix unfavorable for induction of labor (Bishop score 4 or less). Patients initially were observed for 24 to 36 hours for the spontaneous onset of labor. If spontaneous contractions did not commence, labor was induced with oxytocin. Patients subsequently were divided into three groups: 44 who had spontaneous labor, 29 who had spontaneous labor but required oxytocin augmentation, and 39 women who had oxytocin induction. Patients who entered labor spontaneously had a significantly shorter mean latent period between rupture of membranes and onset of labor (16.0 versus 26.8 and 40.7 hours), shorter mean duration of labor (7.6 versus 12.1 and 13.1 hours), and shorter mean duration of rupture of membranes (23.6 versus 39.0 and 53.8 hours). These women also had a significant decrease in the frequency of chorioamnionitis (7 versus 14 and 33%), and their infants had fewer evaluations for sepsis (25.0 versus 34.5 and 53.8%). We conclude that term patients with PROM and an unfavorable cervix who require oxytocin augmentation or induction of labor are at increased risk for intrapartum and neonatal infection compared with those who progress through labor spontaneously.

Cervix Uteri↗
PubMed1992

Assessment of a rapid latex agglutination test for group B streptococcal colonization of the genital tract.

OBJECTIVE: The purpose of this study was to determine the reliability of a rapid enzyme extraction-latex agglutination test in detecting intrapartum colonization of the maternal genital tract by group B streptococci. METHODS: Swabs of vaginal secretions were obtained from 314 patients in labor with either ruptured or intact membranes. Four tests were performed on each specimen: 1) qualitative culture on blood agar, 2) semiquantitative culture on blood agar, 3) culture in selective Todd-Hewitt broth, and 4) latex agglutination preceded by enzyme extraction. RESULTS: The prevalence of positive cultures was 29%. When compared with culture in Todd-Hewitt broth, the latex agglutination test had a sensitivity of 30%, specificity 93%, positive predictive value 64%, and negative predictive value 76%. In patients with heavy colonization the test had a sensitivity of 76%, compared with 17% in patients with light growth (P less than .001). The lower limit of sensitivity of the test was 4 x 10(5) cfu/mL. The performance of the test was not affected by rupture of the membranes. CONCLUSION: Although the latex agglutination test is reasonably sensitive in detecting heavy colonization, low overall performance combined with technical difficulties in assessment of particle agglutination make the test unsuitable for general screening.

Evaluation Studies as Topic↗
PubMed1992

The aminoglycosides.

The three most commonly used aminoglycosides in obstetrics and gynecology are gentamicin, tobramycin, and amikacin. These drugs bind to subunits of the ribosome and inhibit bacterial protein synthesis. They are primarily active against aerobic gram-negative bacilli. Their principal adverse effects are nephrotoxicity, ototoxicity, and neuromuscular blockage. They may be administered intramuscularly or intravenously and usually are used in combination with other drugs for treatment of disorders such as pyelonephritis, chorioamnionitis, puerperal endometritis, and pelvic inflammatory disease.

Aminoglycosides↗
PubMed1992

The quinolone antibiotics.

The fluorinated quinolones are synthetic derivatives of nalidixic acid. They are well absorbed when administered orally and have an extended duration of action. They are of primary value in treating gonorrhea and complicated urinary tract infections in nonpregnant women.

4-Quinolones↗
PubMed1992

Assessment of rapid identification tests for genital carriage of group B streptococci.

OBJECTIVE: The purpose of this study was to assess the relative value of reported methods for rapid identification of group B streptococcal colonization of the female genital tract. DATA SOURCES: Trials of group B streptococcal identification techniques published in peer-reviewed journals were located using a computerized literature search and cited references from relevant articles or text chapters. METHODS OF STUDY SELECTION: Reports were included in the analysis if the methodology fulfilled the following criteria: 1) A reference culture method was used for comparison; 2) performance characteristics were presented or could be calculated; 3) the method could be performed in a standard laboratory on a 24-hour-a-day basis; and 4) results could be routinely available within 12 hours. DATA EXTRACTION AND SYNTHESIS: Performance characteristics such as sensitivity, specificity, and predictive values for the various methods were evaluated and compared. Factors such as colonization rates and methods for identifying carriers were included in the overall assessment of test performance. CONCLUSIONS: The overall sensitivity of current methods for the rapid detection of group B streptococcal colonization is low. However, some rapid antigen detection tests are highly sensitive in identifying heavily colonized patients, and therefore may be useful for selecting high-risk patients for intrapartum antibiotic prophylaxis.

Cervix Uteri↗
PubMed1992

The perinatal management of severe laryngeal stenosis.

BACKGROUND: Conditions that completely occlude the fetal larynx are rare. We describe the perinatal course of an infant with severe congenital subglottic stenosis, for whom the prenatal recognition of airway occlusion led to enhanced neonatal management. CASE: Serial ultrasound examinations from 23-37 weeks' gestation led to the diagnosis of upper airway obstruction in the fetus of a 29-year-old woman. Significant findings included fetal ascites, echogenic enlarged lungs, and a dilated fluid-filled trachea. The infant was delivered in a level III hospital with a neonatologist and anesthesiologist in attendance. The cord was not clamped until a tracheostomy was secured. CONCLUSION: Upper-airway obstruction can be diagnosed prenatally by the presence of secondary manifestations. Infant survival may depend on foreknowledge of the pathology and prompt, directed efforts at bypassing the airway obstruction.

Adult↗
PubMed1991

Progress in pathogenesis and management of clinical intraamniotic infection.

In the past decade, gratifying progress has been achieved in our understanding of clinical intraamniotic infection. With a usual incidence of 1% to 4%, clinical intraamniotic infection mainly develops as an ascending process after prolonged rupture of the membranes and labor, but other cases may be hematogenous in origin whereas still others complicate intrauterine procedures. The most common organisms isolated in amniotic fluid of cases of intraamniotic infections are anaerobes, genital mycoplasmas, group B streptococci, and Escherichia coli. The latter two are found most commonly in maternal or neonatal bacteremia complicating intraamniotic infection. Although the diagnosis remains largely a clinical one, laboratory tests have been suggested to confirm the diagnosis in women with symptoms. These include amniotic fluid Gram stain, gas-liquid chromatography, and leukocyte esterase measurement. Maternal treatment consists of antibiotic therapy and delivery. Studies to date have used a penicillin plus an aminoglycoside, with some authors advocating the addition of clindamycin after cesarean delivery. Other broad-spectrum regimens may be equally effective. Complications of clinical intraamniotic infections include an increase in cesarean section rate and in maternal and neonatal bacteremia. Poor neonatal outcomes in intraamniotic infection are more likely in the following cases: (1) when E. coli or group B streptococci are present in the amniotic fluid; (2) when the infant has a low birth weight; (3) when maternal antibiotic therapy is delayed until after delivery.

Amniotic Fluid↗
PubMed1991

Role of amniotic fluid cytogenetic analysis in the evaluation of recent fetal death.

Chromosome abnormalities may be present in approximately 10% of cases of fetal death. Because of cell maceration and autolysis, the likelihood of successful karyotype analysis of fetal tissue varies inversely with the time between fetal death and delivery. In an attempt to reduce the influence of these postmortem changes, we obtained amniotic fluid cells for cytogenetic studies from 12 fetuses as soon as possible after the diagnosis of fetal death was confirmed. We also obtained fetal tissue for cell culture in ten of the cases immediately following evacuation of the uterus. Cell culture was successful in 11 of 12 amniotic fluid specimens and in only one of ten fetal tissue specimens (p less than 0.001). Since the results of cytogenetic studies are of such importance in counseling patients regarding recurrence risk for fetal death, we recommend that amniotic fluid cells be obtained for karyotype analysis at the time of diagnosis of fetal death rather than awaiting delivery of a potentially macerated and autolyzed fetus.

Amniotic Fluid↗