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Patrick Duff

Publications and source records attributed to Patrick Duff.

At least 19 recordsLinked to original sources
PubMed2006

Assessing the relationship between preterm delivery and various microorganisms recovered from the lower genital tract.

OBJECTIVE: To determine if the likelihood of preterm delivery is more dependent on the specific organisms present in the vagina than on the presence of bacterial vaginosis. METHODS: We evaluated the vaginal fluid of a prospective cohort of women at 23-32 weeks of gestation with signs and symptoms of preterm labor and intact membranes. Forward stepwise logistic regression models were used to evaluate the relationship between preterm delivery and the presence of anaerobic bacteria, Gardnerella, ureaplasmas and mycoplasmas, and sialidase. RESULTS: The cohort included 137 women, and complete delivery information was available for 134 of them. The rate of preterm delivery was 28% (37 of 134). Mycoplasma genitalium independently was associated with spontaneous preterm delivery (OR 3.48; 95% CI 1.41, 8.57). After controlling for this factor, none of the other variables were significantly prognostic for spontaneous preterm delivery (residual overall p = 0.19). CONCLUSION: The presence of Mycoplasma genitalium in the vagina of pregnant women is an independent risk factor for spontaneous preterm delivery.

Adult↗
PubMed2006

Dear graduate.

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Humans↗
PubMed2006

The interleukin-1 beta +3953 single nucleotide polymorphism: cervical protein concentration and preterm delivery risk.

PROBLEM: To determine the associations between preterm delivery <37 weeks (PTD), cervical fluid interleukin-1beta (IL-1beta) concentration, and its +3953 single nucleotide polymorphism (SNP). METHOD OF STUDY: Cervical fluid, peripheral blood, and cord blood samples were obtained from a cohort of women 23-32 weeks gestation with preterm labor symptoms and intact membranes. RESULTS: Increased cervical fluid concentrations of IL-1beta were associated with PTD (P = 0.017) and spontaneous PTD (P = 0.001). Maternal IL-1beta +3953 SNP genotype was associated neither with PTD (P = 0.43) nor with cervical fluid IL-1beta concentrations (P = 0.35). Neonatal IL-1beta +3953 SNP genotype was associated neither with PTD nor cervical IL-1beta concentrations. CONCLUSIONS: Cervical fluid concentrations of IL-1beta were elevated in symptomatic women destined to have a spontaneous PTD. The gene dosage of maternal IL-1beta +3953 allele 2 was associated neither with increased cervical fluid concentrations of IL-1beta nor with risk of PTD.

Adult↗
PubMed2005

Assessment of cervical antibody concentrations fails to enhance the value of cervical length as a predictor of preterm delivery.

OBJECTIVE: The purpose of this study was to determine if cervical fluid antibody concentrations can enhance the value of cervical length in predicting risk of preterm delivery. STUDY DESIGN: We obtained cervical fluid samples with preweighed cellulose wicks from a prospective cohort of women 23 to 32 weeks' gestation with signs and symptoms of preterm labor and intact membranes. Total immunoglobulin A and G (IgA and IgG) concentrations were determined by enzyme-linked immunosorbent assay. Bacterial vaginosis was diagnosed by Gram stain, and cervical length was measured with endovaginal ultrasound. RESULTS: For subjects with term (n = 77) and preterm (n = 24) deliveries, median IgA and IgG concentrations were 736 vs 643 microg/mL (P = .33) and 1528 vs 1769 microg/mL (P = .85). For subjects with normal flora (n = 71), intermediate flora (n = 14), and bacterial vaginosis (n = 16), median IgA and IgG concentrations were 717, 624, and 774 microg/mL (P = .90) and 1383, 1553, and 2731 microg/mL (P = .02). In a forward stepwise logistic regression model, cervical length was the only factor associated with preterm delivery (P < .001). CONCLUSION: Measuring the concentrations of IgA and IgG in cervical fluid does not enhance the value of cervical length in predicting risk of preterm delivery.

Adult↗
PubMed2005

The interleukin-6--174 single nucleotide polymorphism: cervical protein production and the risk of preterm delivery.

OBJECTIVE: The purpose of this study was to determine the associations between preterm delivery (PTD), cervical fluid interleukin-6 (IL-6) concentration, and the single nucleotide polymorphism at position -174 in the IL-6 gene. STUDY DESIGN: Cervical fluid samples were obtained from women 23 to 32 weeks' gestation with symptoms of preterm labor. Concentrations of IL-6 were determined by enzyme-linked immunosorbent assay (ELISA). IL-6 genotyping was performed using a polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) technique. RESULTS: One hundred thirty-seven women were enrolled, and complete information was available for 126. Cervical fluid IL-6 concentrations were not elevated in women destined to have a spontaneous PTD ( P = .86). IL-6 -174 genotype was not associated with PTD ( P = .62) or cervical fluid IL-6 concentration ( P = .36). Neonatal IL-6-174 genotype was not associated with PTD or IL-6 concentration. CONCLUSION: Cervical fluid concentrations of IL-6 were not elevated in symptomatic women destined to have a spontaneous PTD. The presence of maternal IL-6 -174C was not associated with cervical fluid concentration of IL-6 or risk of PTD.

Adult↗
PubMed2004

Misoprostol for uterine evacuation in patients with early pregnancy failures.

OBJECTIVE: The purpose of this study was to evaluate the effectiveness of misoprostol that is administered intravaginally for uterine evacuation in patients with early pregnancy failures. STUDY DESIGN: From March 2001 through March 2003, we treated 41 patients who had early pregnancy failures with vaginal misoprostol, 800 microg. A second course of misoprostol was administered if uterine evacuation did not occur in 24 hours. Patients who had no response to misoprostol underwent a surgical curettage. Our principal outcome measures were the percentage of patients who had successful evacuation of the products of conception and the frequency of adverse drug effects. RESULTS: Twenty-six patients had successful uterine evacuation with a single course of misoprostol; 6 patients required a second course. The overall success rate was 78% (95% CI, 63, 88). No patient experienced a serious adverse drug effect. CONCLUSION: Intravaginal misoprostol is a safe, effective alternative to surgical curettage for the treatment of early pregnancy failure.

Abortifacient Agents, Nonsteroidal↗
PubMed2004

Glyburide for the treatment of gestational diabetes.

OBJECTIVE: This study was undertaken to evaluate the effectiveness of glyburide in patients with gestational diabetes who failed diet therapy. METHODS: Patients who were beyond the first trimester and who failed to achieve satisfactory glucose control with diet therapy were treated with glyburide, at a starting dose of 2.5 mg daily. The dose was increased in increments to a maximum of 20 mg/day. The main treatment outcome was achievement of satisfactory glucose control, defined as a mean plasma fasting glucose 90 mg % or less and mean 1-hour postprandial plasma glucose determinations 135 mg % or less. Patients who failed to achieve satisfactory control were treated with twice-daily doses of insulin. RESULTS: During the period July 2001 through December 2002, we managed 197 patients with gestational diabetes. One-hundred twenty-four patients responded to diet alone; 73 were treated with glyburide. Of the 73 patients, 59 (81%, 95% CI 76.4-85.6) achieved satisfactory glucose control with glyburide; 44 women required 7.5 mg/day or less. Eleven of the 59 women (19%) had macrosomic infants. Eight patients (11%) experienced noticeable side effects related to glyburide; only 1 patient discontinued treatment. CONCLUSION: Approximately 80% of patients with gestational diabetes who fail to respond to diet therapy can be treated effectively with glyburide.

Adult↗
PubMed2004

Outcomes with premature rupture of membranes at 32 or 33 weeks when management is based on evaluation of fetal lung maturity.

OBJECTIVE: To assess outcomes of patients with premature rupture of membranes (PROM) at 32 or 33 weeks gestation. METHODS: This historical cohort study included all immune competent patients managed at our institution from October 1, 1999 to March 31, 2003 with singleton gestations and PROM at 32 or 33 weeks, and without clinical chorioamnionitis at presentation or antenatal diagnosis of a fetal anomaly. If amniotic fluid studies revealed pulmonary maturity, patients were intentionally delivered. Otherwise, they were expectantly managed until intentional delivery at 34 weeks, or labor, chorioamnionitis, or non -reassuring testing led to delivery sooner. RESULTS: For the groups with mature (n = 29) and immature or unobtainable (n = 60) fluid, respectively, rates of neonatal ICU admission (83% vs. 77%; p = 0.51), respiratory distress (41% vs. 45%; p = 0.75), mechanical ventilation (10% vs. 17%; p = 0.53), and proven neonatal infection (4% vs. 2%; p = 0.60) were similar, as were rates of other neonatal and maternal complications. The mature group had shorter mean maternal hospital stays (3.6 +/- 0.6 vs. 6.4 +/- 2.9 d; p < 0.001) and latency periods (30.2 +/- 19.3 vs. 83.8 +/- 68.7 h; p < 0.001). CONCLUSION: Compared to those managed expectantly due to immature or unavailable fetal lung studies, intentional delivery of patients with PROM at 32 or 33 weeks with mature fetal lung studies did not increase neonatal morbidity in our small cohort.

Adult↗
PubMed2004

Vaginal-perianal compared with vaginal-rectal cultures for identification of group B streptococci.

OBJECTIVE: To estimate whether the rates of recovery of group B streptococci from combined vaginal and perianal cultures and combined vaginal and rectal cultures are equivalent. METHODS: We performed a prospective cohort study of vaginal-perianal versus vaginal-rectal culture for group B streptococci. Two hundred pregnant women in the third trimester were enrolled. Three specimens were collected from each patient in the following order: lower third of the vagina, perianal skin, and rectum. Each specimen was cultured serially in selective broth media, then on sheep's blood agar. Suspicious colonies were confirmed by latex agglutination. Culture positivity rates from the combined sites of vagina and perianal skin were compared with vagina and rectum. Laboratory personnel were blinded to the collection site of each individual swab. RESULTS: Of the 200 subjects, 71 (36%) had a positive culture from at least 1 site. Vaginal culture was positive in 55 patients (28%), compared with 48 patients (24%) with positive perianal cultures and 50 patients (25%) with positive rectal cultures. Results of combined vaginal and perianal cultures were positive in 68 patients (34%); results of combined vaginal and rectal cultures were positive in 67 patients (34%) (P = 1.0). CONCLUSION: The group B streptococci detection rate from vaginal-perianal specimens is not significantly different from the detection rate from vaginal-rectal specimens. Therefore, pregnant women do not need to be subjected to the discomfort of collection of a rectal specimen. LEVEL OF EVIDENCE: II-2.

Adolescent↗
PubMed2004

Teaching and assessing professionalism in medicine.

Professionalism is the single most important of the clinical competencies. Lack of professional behavior, in turn, is the single most common cause for disciplinary action against third and fourth-year medical students, residents, fellows, and clinical practitioners. Desirable professional attributes include humility, honesty, responsibility, reliability, and accountability. The ability to preserve an appropriate balance between patient care responsibilities and personal commitments also is an important feature of professional behavior. Altruism, respectfulness, loyalty, compassion, sensitivity, and tactfulness are other desirable professional attributes. In addition, professionalism requires a heightened sense of intellectual curiosity, insight into personal strengths and weaknesses, maturity, and commitment to clinical excellence and self-directed learning. Professionalism can be taught and assessed through lectures, small-group seminars, role-playing exercises, directed reading, and one-on-one observation and counseling. However, the most effective way of teaching professionalism is for instructors to model appropriate behavior and to impose a consistent policy of zero tolerance for unprofessional behavior.

Attitude↗
PubMed2003

Single additional dose postpartum therapy for women with chorioamnionitis.

OBJECTIVE: To determine whether a short course of antibiotics provides adequate treatment for chorioamnionitis. METHODS: Women received intravenous ampicillin, 2 g every 6 hours, and gentamicin, 1.5 mg/kg every 8 hours, when clinical chorioamnionitis was diagnosed. After delivery, subjects were randomized to continue this regimen until afebrile and asymptomatic for 24 hours (control group) or to receive only the next scheduled dose of each drug (study group). If delivered via cesarean, patients received clindamycin, 900 mg intravenously, at umbilical cord clamping. The control group continued receiving clindamycin every 8 hours until antibiotics were discontinued. The primary outcome was treatment failure, defined as a single temperature after the first postpartum dose of antibiotics of 39.0C or more, or two temperatures 38.4C or more at least 4 hours apart. To detect a 150% increase in rate of treatment failures from 8% in the control group to 20% in the study group, 292 subjects were needed (alpha = .05; 1 - beta = .80). RESULTS: From December 26, 1999, to March 18, 2003, a total of 292 women were enrolled in the study. In the intent-to-treat analysis, treatment failure rate did not differ between the control (n = 141) and study (n = 151) groups (3.5% versus 4.6%; P = .639). CONCLUSION: If treated promptly intrapartum, one additional dose of a broad-spectrum combination of antibiotics is sufficient postpartum therapy for immune-competent women with chorioamnionitis.

Adult↗
PubMed2003

Is perioperative hypothermia a risk factor for post-Cesarean infection?

OBJECTIVE: To determine whether hypothermia during Cesarean delivery is a risk factor for postoperative infection. METHODS: An historical cohort investigation was conducted on all women delivered by Cesarean at our center during 2001. Initial recovery-room temperature, taken via the oral or axillary route, was used as a surrogate for intraoperative temperature. Adding 0.5 degrees C to axillary temperatures generated oral temperature equivalents. Women with chorioamnionitis were excluded, as were those with an initial recovery-room temperature that exceeded 37.9 degrees C or was recorded more than 20 minutes after the end of surgery. Prophylactic antibiotics (cefazolin, 1 g) were given during Cesarean delivery. RESULTS: A total of 42 women (7.6%) were diagnosed with postoperative infections. Infections included endometritis (n = 25), wound abscess (n = 7), wound cellulitis (n = 7) and urinary tract infection (UTI) (n = 4). No cases of septic pelvic thrombophlebitis or pelvic abscess occurred. One woman had both endometritis and a UTI. Mean temperatures were higher, rather than lower, for women who subsequently had postoperative infections compared with those who did not (36.4 +/- 0.8 degrees C vs. 35.9 +/- 0.7 degrees C; p < 0.001). Mean temperatures for the various postoperative infections were as follows: endometritis, 36.5 +/- 0.8 degrees C (p < 0.001 vs. uninfected group); wound abscess 36.0 +/- 0.8 degrees C (p = 0.63); wound cellulitis, 36.3 +/- 0.6 degrees C (p = 0.14); UTI, 36.7 +/- 0.9 degrees C (p = 0.04). CONCLUSIONS: Women who develop post-Cesarean infections have higher initial recovery-room temperatures than those who do not develop such infections. This suggests the presence of subclinical infection at the time of Cesarean. Evaluating whether intraoperative warming has any role during Cesarean delivery requires a randomized clinical trial.

Adult↗
PubMed2003

Intrapartum antibiotic prophylaxis and early-onset neonatal sepsis patterns.

OBJECTIVE: To compare the relative effects of intrapartum antibiotic prophylaxis regimens on patterns of early-onset neonatal sepsis. METHODS: We performed an historical cohort study of 17187 infants born at our center from September 1993 to February 2000. A risk-based strategy was employed prior to July 1996 and a screening-based strategy was utilized thereafter. Ampicillin was utilized prior to March 1995 and penicillin was used thereafter. RESULTS: There were 75 cases of neonatal sepsis, 34 (4. 10/1000) in the risk-based era and 41 (4.63/1000) in the screening-based era (p = 0.62). There were fewer ampicillin-resistant isolates during the risk-based than the screening-based era (32 versus 61%; p = 0.014). The only significant change in organism-specific sepsis rates was an increase in the rate of infection caused by coagulase-negative staphylococci in the screening-based era (0.36 versus 1.46/1000; p = 0.018), but 75% of infants infected with these organisms were not exposed to beta-lactam antibiotics within 72 h prior to delivery. For the risk- and screening-based eras, respectively, the rates of Gram-negative sepsis (1.21 versus 1.46/1000; p = 0.65) and the proportions of Gram-negative pathogens that were ampicillin-resistant (70 versus 77%; p = 1.0) were similar. The drug employed for prophylaxis did not appear to affect the pattern of sepsis cases. CONCLUSION: In our patient population, coagulase-negative staphylococci have become the most common cause of early-onset neonatal sepsis. The cause of this shift in pathogen prevalence is uncertain and seemingly unrelated to intrapartum antibiotic exposure.

Ampicillin↗
PubMed2002

Professionalism in medicine: an A-Z primer.

To be successful as physicians, we should adhere to a simple, time-honored code of conduct. We must commit ourselves to a lifetime of self-directed learning. We must strive to be thoughtful, kind, and sensitive. We must avoid arrogance, dogmatism, and negativism. We must be honest, moral, tolerant, trustworthy, and above all else, humble and compassionate. Consistent adherence to these traits will help us maintain the nobility and credibility of the medical profession.

Ethics, Medical↗
PubMed2002

Intrapartum antibiotic prophylaxis 1: relative effects of recommended antibiotics on gram-negative pathogens.

OBJECTIVE: To assess whether the antibiotic chosen for intrapartum antibiotic prophylaxis affects the subsequent exposure of the neonate to ampicillin-resistant gram-negative bacteria. METHODS: We performed a randomized clinical trial of ampicillin versus penicillin for intrapartum antibiotic prophylaxis. Genital tract cultures for Enterobacteriaceae were obtained at study entry and 8-36 hours postpartum. Organisms were isolated, identified, and tested for ampicillin susceptibility. RESULTS: The ampicillin (n = 175) and penicillin (n = 177) groups, respectively, did not differ in rates of ampicillin-resistant Escherichia coli at entry (25% versus 22%, P =.57) or postpartum (36% versus 38%, P =.64). Similarly, groups did not differ in rates of ampicillin-resistant Enterobacteriaceae at entry (38% versus 32%, P =.23) or postpartum (51% versus 55%, P =.46). However, postpartum culture rates of resistant Escherichia coli were higher than entry culture rates for both the ampicillin (36% versus 25%, P =.026) and penicillin (38% versus 22%, P <.001) groups. Postpartum culture rates of resistant Enterobacteriaceae were also higher than entry culture rates for both the ampicillin (51% versus 38%, P <.001) and penicillin (55% versus 32%, P <.001) groups. Results were similar when considering only women who received two or more doses and no additional antibiotics. CONCLUSION: Intrapartum antibiotic prophylaxis with either ampicillin or penicillin increases exposure of neonates to ampicillin-resistant Enterobacteriaceae.

Adolescent↗
PubMed2002

Intrapartum antibiotic prophylaxis 2: positive predictive value of antenatal group B streptococci cultures and antibiotic susceptibility of clinical isolates.

OBJECTIVE: To estimate the probability of positive intrapartum group B streptococcus cultures among women previously identified as carriers of this organism, and to estimate the susceptibility of group B streptococci to six commonly used antibiotics. METHODS: We performed a prospective cohort study of women identified as carriers of group B streptococci by current pregnancy genital tract (group 1) or urine cultures (group 2), or a positive culture in a prior pregnancy (group 3). Intrapartum culture specimens were obtained, and isolates were tested for susceptibility to six antibiotics using the agar disk diffusion technique. RESULTS: Intrapartum cultures were positive for 68% (62, 73), 61% (49, 72), and 48% (36, 60) of groups 1 (n = 249), 2 (n = 69), and 3 (n = 59), respectively. Cultures were positive in 67% (61, 73) of women in group 1 whose cultures were done 42 days or less before delivery (n = 218). The proportion of isolates (n = 239) susceptible to penicillin, ampicillin, cefazolin, and vancomycin was 100% (98, 100). The proportion susceptible to clindamycin and erythromycin was 91% (87, 94) and 79% (73, 84), respectively. CONCLUSION: The positive predictive value of antenatal group B streptococci cultures is lower than was previously reported. Clindamycin and erythromycin are not optimal agents for prophylaxis against early-onset neonatal group B streptococcal infection in patients who are allergic to penicillin.

Adolescent↗