Biomedical subjects
Publications and source records attributed to R W Martin.
AFE, although rare, remains a significant cause of maternal mortality. Even with improvements in supportive care, the prognosis remains poor for mother and fetus. The guidelines presented may help the physician to recognize this condition when it occurs and give some direction for therapy.
OBJECTIVES: To determine if patients with multiple lower extremity fractures have worse outcomes than do patients with isolated femur fractures, and to determine if the Abbreviated Injury Scale (AIS) should distinguish between single and multiple lower extremity fractures. DESIGN: A retrospective study. MATERIALS AND METHODS: All blunt trauma patients at least 15 years of age treated at a level 1 trauma center from January 1990 through December 1993. Three groups of patients were selected. Group 1 included 50 patients whose only significant injury was a diaphyseal femur fracture. They had no other long bone fractures, minimal injuries to other body areas, and an Injury Severity Score (ISS) < or = 14. Group 2 was consisted of 29 patients with a femur fracture, at least one other diaphyseal lower extremity fracture, and also an ISS < or = 14. Group 3 consisted of 23 patients who had fracture patterns similar to those of group 2, but also had more severe nonextremity injuries (ISS > or = 15). Hospital morbidity and mortality rates were compared with t tests or chi-square analysis. Type 1 error probability was established at p < 0.05. MEASUREMENTS AND MAIN RESULTS: Compared with patients in group 1, patients in group 2 had an identical ISS (10.1 vs. 10.6, respectively), but had higher transfusion requirements (0.3 vs. 3.9 units), more days in the intensive care unit (ICU) (0.02 vs. 1.4), a higher incidence of adult respiratory distress syndrome (ARDS) (0 vs. 14%), longer hospital stays (6.0 vs. 14.8 days), greater disability at discharge (disability score 2.2 vs. 3.2), and a higher mortality rate (0 vs. 3.4%; p < 0.05 all variables). Patients in group 3 had worse outcomes than the other two groups: ISS = 30.1; transfusions = 11.9 units; ICU days = 9.1; ARDS incidence = 26%; hospital days = 29.9; disability score = 3.9; mortality = 26% (p < 0.05). CONCLUSIONS: Although AIS and ISS appropriately reflect the impact of extraskeletal injuries in patients with femur fractures, they do not adequately reflect the increased morbidity associated with multiple lower extremity fractures. The AIS-Extremity Score may need to be upgraded for multiple long bone fractures of the lower extremities.
We describe our response to the changing needs for dermatologic education and training at Cleveland medical centers affiliated with Case Western Reserve University School of Medicine (CWRU) located in Cleveland, Ohio. Our departmental plan for change is a multifaceted approach that alters the number of dermatology residents we train and also the way we interact with and educate our generalist colleagues. Like many other dermatologists, we have both idealistic and practical reasons for increasing our involvement in interdisciplinary education. One of our primary objectives is maximizing quality of care for dermatologic patients in our community. Traditionally, the majority of skin care in the United States has been provided by nondermatologists, and with the growth of managed care, this proportion is increasing. This has motivated us to increase our medical student teaching activities and to support the American Academy of Dermatology in its current efforts to develop a dermatology core curriculum for students. We should also be involved in the education of generalist physicians, since prior studies have suggested that their knowledge of dermatology needs improvement. Our goals should be both to improve the direct patient care skills of primary care physicians and to teach clinically appropriate referral thresholds. The American Academy of Dermatology has recently issued guidelines for the referral of dermatology patients in managed care settings to help ensure that our specialty has input into this process. In addition, teaching gatekeeper physicians to use appropriate referral criteria is important to many dermatologists in capitated managed care systems who often prefer limited as opposed to unrestricted access to their services.
OBJECTIVE: To determine if combining two commonly used methods or cervical ripening (intracervical prostaglandin E2 [Pge2] gel and Foley balloon catheter) would result in a higher number of successful inductions and fewer cesarean sections when compared to PGE2 gel alone. STUDY DESIGN: Seventy-eight patients with unfavorable cervixes eligible for induction of labor were prospectively randomized to receive either one dose (0.5 mg) of PGE2 gel followed by insertion of a 24-French Foley catheter (group 1, 41 patients) or two doses of 0.5 mg of intracervical gel (group 2, 37 patients). Outcome parameters included change in Bishop score, number of failed inductions, rate of cesarean section, rate of uterine hyperstimulation and postpartum infection. RESULTS: Patients in group 1 had a significant increase in posttreatment Bishop scores (7.26 +/- 2.0 SD vs. 4.82 +/- 1.8 P = .0001) and fewer failed inductions (0 vs. 6, P = .009) when compared to patients in group 2. Abdominal delivery rates, uterine hyperstimulation and infections complications were not different between the two groups. CONCLUSION: The combination of the Foley balloon and prostaglandin gel significantly improved the Bishop score and led to fewer failed inductions, although it did not increase the vaginal delivery rate.
Explore the source record for details and available documents.
Kaposi's sarcoma (KS) accounts for more than 15% of AIDS-related malignancies. The etiology of KS is unresolved but is postulated to be multifactorial, involving viruses and overexpression of cellular growth factors and/or oncogenes. Recently, herpesvirus-like sequences (KSHV) were identified with high prevalence in AIDS-KS (AKS), endemic KS, and in classic KS biopsies (CKS). To confirm the presence and the prevalence of the KSHV sequences, 18 CKS and 13 AKS samples were tested using polymerase chain reaction (PCR) analysis. To our knowledge this is the highest number of CKS samples that has ever been included in a single study, and it is also important that the biopsies were obtained from different institutions and geographical locations. KSHV sequences were detected in 100% of the AKS samples and 72% of the CKS biopsies using PCR analysis. The presence of the unique KSHV sequences was confirmed by direct sequencing of representative PCR products obtained from AKS and CKS samples. Reverse transcriptase (RT)-PCR experiments showed that the KSHV sequences were transcribed to mRNA in both AKS and CKS samples. Our results confirm that the putative new herpesvirus-like agent is associated with both AKS and CKS and may have an etiological role in the pathogenesis of this malignancy.
OBJECTIVE: Our purpose was to determine the incidence of adverse cardiovascular effects of terbutaline sulfate when administered as a continuous subcutaneous infusion in women with arrested preterm labor. STUDY DESIGN: Over a 6-year period records from 8709 women prescribed this therapy for preterm labor that had previously been arrested with other intravenous tocolytics were reviewed. These women were assessed daily for cardiovascular complaints and tolerance of the medication, while either in the hospital or at the home (by telephone). The main outcomes studied were the occurrence of pulmonary edema, sustained cardiac arrhythmias, chest pain, or myocardial ischemia. Any maternal death regardless of cause was also reviewed. RESULTS: Of the 8709 subjects, 47 (0.54%) had one or more cardiopulmonary problems. Pulmonary edema developed in 28 patients (0.32%) while receiving continuous subcutaneous infusion of terbutaline, 5 at home and 23 in the hospital. Of the total, 17 women were being treated concurrently with large amounts of intravenous fluids and one to three other tocolytic agents. In the 11 remaining subjects, 4 were diagnosed with pregnancy-induced hypertension and/or multiple gestation. Nineteen patients experienced other adverse cardiovascular effects, including electrocardiogram changes, irregular heart rate, chest pain, or shortness of breath. CONCLUSIONS: Continuous terbutaline infusion for women with stabilized preterm labor is associated with much fewer adverse effects than previous literature regarding intravenous beta-adrenergic agonist therapy would suggest.
We report the simultaneous measurement of esophageal wall layer thickness and intraluminal pressure in the sheep esophagus using a miniature suction device incorporating a high-frequency ultrasound transducer and a manometry system. Transnasal placement of the device into the distal esophagus of a conscious sheep allowed observation of 133 swallowing events during three trials, each lasting from 45 to 60 minutes. In a fourth trial, 11 sequential dry and 23 sequential wet swallows were compared. Maximum manometric pressure, esophageal wall layer thickness, and duration of contraction were measured. All swallowing events produced simultaneous increases in intraluminal pressure and esophageal wall thickness. Mean maximal pressures were lower for dry swallows (18 +/- 2.1 mm Hg) than wet swallows (22 +/- 3.0 mm Hg) (p < .01). Thickness of the inner (circular) muscle layer increased above baseline by 124% for dry swallows and 161% for wet swallows (p < .01). We conclude that thickening of the esophageal inner (circular) muscle layer may be important in the generation of intraluminal esophageal pressure in the sheep esophagus.
BACKGROUND: Graft-vs-host disease (GVHD) represents one of the major complications of allogeneic bone marrow transplantation (BMT) but is less common in autologous BMT. Following autologous BMT, chronic GVHD has been reported in only four patients, all of whom had a self-limited sclerodermoid form. Lichenoid chronic GVHD has not been previously reported in an autologous BMT patient. OBSERVATIONS: Mucosal and cutaneous lichenoid lesions and histologic findings compatible with chronic lichenoid GVHD developed in a patient 35 days after autologous BMT was performed. The onset of clinical lesions at 35 days after BMT is not incongruent with the diagnosis of chronic lichenoid GVHD (rather than a graft-vs-host reaction) and may have been augmented by cyclosporin A in a manner similar to animal model experiments. CONCLUSION: All forms of GVHD can and do occur following autologous BMT.
OBJECTIVE: Our purpose was to evaluate the impact of antepartum administration of corticosteroids on the course of the syndrome of hemolysis, elevated liver enzymes, and low platelets (HELLP) in pregnancies at 24 to 37 weeks' gestation. STUDY DESIGN: This prospective, randomized study was undertaken in 25 antepartum patients with atypical severe preeclampsia expressed as HELLP syndrome. Twelve pregnant women were randomized to receive double-dose dexamethasone (10 mg intravenously every 12 hours) until delivery, and 13 women were randomized to the control arm. Management and delivery decisions for all patients were based on a common protocol, with delivery undertaken for a deteriorating maternal or fetal condition. RESULTS: In the corticosteroid-treated group the maternal platelet count significantly increased (p = 0.006), whereas lactic dehydrogenase and alanine aminotransferase significantly decreased over time (p = 0.03 and p = 0.005) in comparison to the 13 women who did not receive corticosteroids. Maternal urinary output after entry into the study was significantly increased within hours after steroid administration versus the control group (p = 0.0006). The study entry-to-delivery interval (41 +/- 15 hours) was significantly longer in the group of steroid-treated women (p = 0.0068). CONCLUSIONS: Stabilization and significant improvement in the laboratory and clinical parameters associated with HELLP syndrome occurred in women who received high-dose antenatal corticosteroids, as measured by maternal platelet count, urinary output, lactic dehydrogenase, alanine aminotransferase, and postponement of delivery. We believe the findings of this investigation permit us to speculate that this therapeutic approach could enhance maternal-fetal care by postponing delivery of some previable fetuses, reduce the need for maternal transfusion of blood products, reduce neonatal morbidity or mortality from multiple systemic effects, and facilitate a safer transfer of the ill mother to a tertiary care site for optimal peripartal care.
To establish design parameters for a transesophageal ultrasonic probe to image the left ventricle (LV) in three dimensions, the geometrical relationship between the esophagus and the heart was studied in computed tomographic sections of ten humans. Points describing the esophageal centerpoint and the left-ventricular endocardium were digitized. Algorithms were developed to determine from any esophageal viewpoint the ranges of motion required to cover the LV with four modes of scanning; transverse oblique, longitudinal oblique, rotary and linear. Longitudinal oblique scanning was the only single-degree-of-freedom method that allowed complete imaging of the LV in all patients. However, for both conventional and three-dimensional LV imaging, the most promising probe design appears to be a rotary scanning probe with an added degree of freedom to tilt the axis of rotation +/- 29 degrees away from an axis perpendicular to the local esophageal axis.
RATIONALE AND OBJECTIVES: High-frequency ultrasound devices are often limited by a decreased depth of acoustic imaging caused by the increased attenuation of tissue at high frequencies. We investigated the role of adipose tissue in this phenomenon. METHODS: A substitution technique was used to calculate the ultrasonic attenuation (decibels per centimeter) of fresh samples of sheep rumen, omental fat, and back fat and swine back fat and various concentrations of bovine milk fat at 22 degrees C and 37 degrees C for frequencies of 15 and 20 MHz. RESULTS: The attenuation was significantly higher for sheep adipose tissue than for the intestinal wall, in descending order, omental fat, back fat, and rumen wall (P < 0.01). A correlation was found between bovine milk fat concentrations and attenuation at both frequencies (R2 > 0.9). The attenuation of adipose tissues decreased significantly with an increase in temperature (P < 0.01), whereas the attenuation of sheep rumen showed no significant change (P > 0.1). CONCLUSIONS: The ultrasonic attenuation of fat may contribute to limitations on the use of high-frequency ultrasound in clinical situations in which adipose tissue is present.
Explore the source record for details and available documents.
This study attempted to determine the best method of treatment for patients with recurrent preterm labor: administration of terbutaline via an automated, programmable, subcutaneous infusion pump or oral terbutaline. In this retrospective, controlled study, 32 patients diagnosed with recurrent preterm labor, as determined by persistent uterine contractions with cervical change, were treated with a programmable infusion pump adjusted to control uterine contraction frequency to < or = 4 contractions per hour. Patients in this group were matched for age, race, parity, gestational age and cervical dilation at diagnosis of recurrent preterm labor in subjects taking oral terbutaline. The patients receiving oral terbutaline were given an average of 6.5 mg every four to six hours to maintain uterine quiescence, while those in the pump group were given basal rates of terbutaline and in addition received four to six boluses per day (< 3 mg/d total dose) to achieve this outcome. Patients using the pump were more likely to reach term and less likely to fail tocolytic therapy than were those taking oral terbutaline. The terbutaline pump appeared to be more successful in prolonging pregnancies to term after the diagnosis of recurrent preterm labor than did oral terbutaline.
To assess the potential of a prototype transesophageal echocardiography probe for evaluating left-ventricular wall motion in three dimensions, we acquired images under anesthesia in 15 patients who had akinesia or dyskinesia and 8 patients who had normal function demonstrated on preoperative ventriculography. Short-axis, oblique transgastric scans were obtained in 16 of the patients and four-chamber, long-axis oblique scans were obtained in 12 patients, with five patients (22%) yielding good-quality scans of both types. Off-line, we outlined the endocardial borders manually and used the outlines to make computer-generated three-dimensional models of the endocardial surfaces, color-tiled according to regional ejection fraction. Compared with contrast ventriculograms, the regional ejection fraction histograms derived from these models showed 86% concordance for detecting dyssynergy. However, the concordance between the ventriculograms and the color-tiled models in localizing the dyssynergy was only 67% overall. Uncertainty in rotational alignment between the reconstructions and the ventriculograms appeared to contribute to misreading the location of dyssynergy. In addition, the apical region appeared to have been missed in 8 (50%) of the short-axis scans, whereas it was visualized in all long-axis scans. We conclude that three-dimensional analysis of the location, extent, and degree of left-ventricular dyssynergy is feasible from transesophageal echocardiograms and could have wide application in the study of regional ventricular function. However, improvements are necessary to enable the transducer to scan the cardiac apex more reliably from the short-axis viewpoint and to have a means for spatially orienting the images with respect to an external frame of reference.
OBJECTIVE: Our objective was to determine whether fetal fibronectin is a discriminator for preterm labor and early delivery in women who have intact membranes and uterine activity. STUDY DESIGN: In our prospective study 28 women between 24 and 34 weeks' gestation with regular, persistent uterine contractions (> 10/hr) and intact membranes were assessed for presence of fetal fibronectin. A Dacron swab was applied to the external os for 10 seconds. The cervix was < or = 1 cm, and all patients were diagnosed as having false labor. The assay was performed by using monoclonal antibody FDC-6 to bind fetal fibronectin. RESULTS: Of the 28 patients with false labor, 14 had a positive fetal fibronectin, and all had preterm labor (specificity and positive predictive value 100%). Of these, nine delivered preterm, yielding a specificity and positive predictive value of 72% and 64%, respectively. Among the 14 women with a negative fetal fibronectin, only four developed preterm labor (sensitivity 78%, negative predictive value 71%). One patient delivered preterm at 34 weeks (sensitivity 90% and negative predictive value 93%). CONCLUSIONS: A positive fetal fibronectin in women who have false labor indicates a significant risk for preterm labor and early delivery. A negative fetal fibronectin is a reassuring sign.
A technique is presented for three-dimensional (3-D) reconstruction of the left-ventricular endocardial surface from multiplanar transesophageal echocardiograms, using both commercial software and investigator written Fortran programs for Intel 80286 and 80386 microcomputers. The approach provides quantitative global and regional cardiac performance measures and allows viewing the endocardial surface, at end-diastole and end-systole, from chosen perspectives. Anatomical landmarks are incorporated to aid in orientation. For regional calculation, the surface is divided into equal angular elements with each conceptually connected to the left-ventricular end-diastole centroid, forming a pyramidal volume element. This angular division automatically normalizes for heart size. The fractional change of these elements over the cardiac cycle provides a regional ejection fraction measure which is color-coded on the reconstructed endocardial surface. Composite perspective views, regional ejection fraction histograms and calculations of global end-diastolic, end-systolic, and stroke volumes, are all performed by the method.
OBJECTIVE: Our purpose was to assess the frequency with which auscultation could be used as the primary mode of fetal assessment during labor in a busy labor and delivery suite by means of published criteria. STUDY DESIGN: During a 3-month period, 862 patients in labor with live fetuses between 24 and 43 weeks of gestation were available for auscultation in the prospective study. Auscultation was initiated during a contraction and extended for 30 seconds after uterine activity ceased. It was repeated every 15 minutes in the first stage and every 5 minutes in the second stage of labor. RESULTS: In 420 patients this modality was not begun because of inability of the nurses to meet 1:1 staffing requirements. In 19 patients auscultation was not performed because of obesity (12) or patient refusal (7). Of the 423 assessed by auscultation 392 were unable to complete monitoring caused by the frequency requirement (n = 212) or the recording criteria (n = 163). Of the 31 patients where auscultation was successfully completed, there was a 1:1 nurse ratio during the entire labor. CONCLUSIONS: Auscultation with stringent evaluation and recording frequency is not feasible under normal labor and delivery room conditions unless 1:1 nursing care is always available.