Immunology update: hepatitis B virus immunization today.
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Adolescent↗
Biomedical subjects
S A Gall
Publications and source records attributed to S A Gall.
Female genital warts: global trends and treatments.
The increasing incidence of human papillomavirus (HPV) infection and HPV-associated conditions such as genital warts in women is a global concern. Genital warts are a clinical manifestation of HPV types 6 and 11, and are estimated to affect 1% of sexually active adults aged between 15 and 49. HPV infection is also strongly associated with cervical cancer, and is prevalent in as many as 99% of cases. The psychological stress of having genital warts is often greater than the morbidity of the disease, and therefore successful treatment is crucial. Current treatments are patient-applied and provider-administered therapies. Imiquimod 5% cream, a patient-applied therapy, is an efficacious treatment with tolerable side-effects and a low recurrence rate, and has the potential to be an effective strategy for the management of genital warts.
Adjuvants, Immunologic↗
Influenza and current guidelines for its control.
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Adolescent↗
Transmitting varicella to a gravida.
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Chickenpox↗
Epsilon-aminocaproic acid administration and stroke following coronary artery bypass graft surgery.
BACKGROUND: Epsilon-aminocaproic acid is routinely used to reduce bleeding during cardiac surgery. Anecdotal reports of thrombotic complications have led to speculation regarding this drug's safety. We investigated the association between epsilon-aminocaproic acid administration and postoperative stroke. METHODS: Six thousand two hundred ninety-eight patients undergoing isolated coronary artery bypass graft surgery between 1989 and 1995 were studied. Data was obtained from the Duke Cardiovascular Database as well as from an automated intraoperative anesthesia record keeper. Patients identified as having postoperative stroke were reviewed and confirmed by a board certified neurologist blinded to epsilon-aminocaproic acid administration. RESULTS: Postoperative stroke occurred in 97 patients (1.5%). Three thousand one hundred thirty-five (49.8%) patients received epsilon-aminocaproic acid. Increased age was associated with a higher incidence of postoperative stroke (p = 0.0001). In contrast, there was no significant difference (p = 0.7370) in the incidence of stroke between use of epsilon-aminocaproic acid (1.3%) and nonuse (1.7%). Multivariable logistic regression found no significant effect of epsilon-aminocaproic acid use on stroke after accounting for age, date of surgery, and history of diabetes. CONCLUSIONS: This series suggests that epsilon-aminocaproic acid administration does not increase the risk of postoperative stroke.
Adult↗
Weekly administration of prostaglandin E2 gel compared with expectant management in women with previous cesareans. Prepidil Gel Study Group.
OBJECTIVE: To compare the clinical effectiveness and safety of outpatient administration of intracervical prostaglandin (PG) E2 gel with expectant treatment for women desiring vaginal births after cesareans. METHODS: This was a randomized, multicenter investigation involving term pregnant women who each had one previous low-transverse cesarean and an unfavorable cervix (Bishop score no more than 6), and who was a candidate for vaginal delivery. They were assigned to receive 0.5 mg of PGE2, (Prepidil; Pharmacia-Upjohn, Kalamazoo, MI) intracervically at 39 weeks' gestation, repeated at weekly office visits for up to three doses, or expectant treatment. The main outcome variable was vaginal birth. RESULTS: Of 294 cases, 143 received gel and 151 were treated expectantly. No differences between groups were found for maternal age, race, or Bishop score. Compared with the expectant treatment group, the PGE2 gel group was not more likely to deliver sooner or vaginally (57% versus 55%, P = .68). The onset of labor, duration of labor among those delivering vaginally, and 1- and 5-minute Apgar scores were not different between groups. No uterine ruptures occurred, and adverse effects were equally likely in both groups. CONCLUSION: Although its safety was confirmed for outpatient use, weekly doses of intracervical PGE2 did not improve the likelihood of vaginal births after cesareans.
Adolescent↗
Transvaginal versus transperineal ultrasonography: a blinded comparison in the assessment of cervical length at midgestation.
OBJECTIVE: The study's objective was to determine the correlation and agreement between transperineal ultrasonography and transvaginal ultrasonography in the assessment of cervical length in gravid patients. STUDY DESIGN: After a pilot, unblinded series of transperineal and transvaginal cervical length measurements in 200 gravid patients, 206 study patients between 14 and 34 weeks' gestation with intact membranes and cervical dilatation of < or = 2 cm underwent transperineal and transvaginal cervical length assessment under a blinded, 2-sonographer protocol. The Pearson correlation coefficient, Lin concordance coefficient, and Bland-Altman plot were used. Acceptable concordance was defined as > 0.82, with an acceptable correlation of > 0.9 and an acceptable difference between the means of < 3 mm. The power of the study to detect this degree of concordance was estimated to be 95% at this sample size. RESULTS: Paired ultrasonographic measurements were obtained for all 206 study patients. Transperineal mean cervical length was 35 +/- 8.6 mm. Transvaginal mean cervical length was 35.9 +/- 8.8 mm. The Pearson correlation coefficient was 0.959, and the Lin concordance coefficient was 0.955, with a 95% confidence lower bound of 0.949. Close agreement between transperineal and transvaginal measurements was observed across the full range of cervical lengths (1-5 cm). The estimated difference between the paired means was 1 mm. The 95% tolerance interval for any given paired observation (Transperineal length - Transvaginal length) was -5.7 to +4 mm. CONCLUSIONS: Cervical length measured by transperineal ultrasonography demonstrates close correlation and agreement with transvaginal measurements. With sonographer experience and optimal technique, approximately 95% of transperineal cervical length observations can be expected to be within 5 mm of a given paired transvaginal measurement. Transperineal ultrasonography may be a preferred method of cervical length assessment for situations in which vaginal placement of instruments should be minimized.
Cervix Uteri↗
Ambulatory management of multiple gestation.
Ambulatory management of multiple gestation requires careful and continuing care by the obstetrician. The initial evaluation should include a comprehensive history, including use of fertility enhancing drugs and ART, family history, social history; a general physical examination, including a pelvic examination; laboratory evaluation, including complete blood cell count, dipstick urinalysis for protein and glucose, urine culture, blood type, Rh factor and irregular blood antibody determination, serology for rubella, syphilis, hepatitis B surface antigen and varicella (if there is no history). A Papanicolaou smear should be done at the time of the pelvic examination, as should evaluation for bacterial vaginosis. Ultrasound assessment of placentation should be done at 14 weeks' gestation, but vaginal or perineal ultrasound of cervical length should be done at the initial visit. Other testing procedures should include repeat ultrasound evaluation for fetal growth every 4 weeks in a dichorionic placentation and every 3 weeks if monochorionic placentation is present. Triple screen MSAFP at 16-18 weeks' gestation and blood sugar screening at 22-26 weeks should be performed. After the first trimester, the patient should schedule physician visits every 2 weeks or less. Routine medications should include one prenatal vitamin per day, additional folic acid supplementation of 1.0 mg per fetus, supplemental iron preparation, and additional calcium to equal 1500 mg/day. The use of low-dose aspirin to prevent preeclampsia in twin gestations has not been adequately studied. Continuing vigilance by the knowledgeable obstetrician should occur. Multiple gestations should not be cared for by non-physician providers or by family physicians. Referral to a maternal-fetal medicine unit is recommended.
Ambulatory Care↗
Clinical uses of intravenous immunoglobulin in pregnancy.
Intravenous immunoglobulin was licensed for use in the United States in 1981. Currently, there are only a few Food and Drug Administration-labeled indications for intravenous immunoglobulin, but up to 50 "off-label" uses are reported in the literature. The obstetric literature contains numerous reports on intravenous immunoglobulin therapy during pregnancy. This article reviews the properties, pharmacokinetics, mechanisms of action, and side effects of intravenous immunoglobulin, as well as the reported uses of intravenous immunoglobulin during pregnancy.
Antiphospholipid Syndrome↗
As originally published in 1989: Correlates of survival in patients with postinfarction ventricular septal defect. Updated in 1997.
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Female↗
Left ventricular adaptation to aortic regurgitation in conscious dogs.
OBJECTIVE: Cardiac failure as a result of valvular heart disease remains a major clinical problem that frequently leads to ventricular dysfunction, myocardial failure, and even death. The development of irreversible myocardial damage may be especially insidious in volume overload as a result of aortic or mitral regurgitation. METHODS AND RESULTS: Left ventricular wall volume, ventricular function, and myocardial performance were assessed in 10 chronically instrumented conscious dogs before and after creation of aortic regurgitation. Left ventricular wall volume was measured by serial echocardiography. Left ventricular function was assessed by total cardiac output, stroke work, the slope of the Frank-Starling relationship, and the slope of the end-systolic pressure-volume relationship. Myocardial performance was assessed by the slope of the myocardial power output versus end-diastolic strain relationship. End-diastolic wall stress and volume both increased acutely and remained elevated after creation of aortic regurgitation. Peak systolic wall stress increased initially (1 to 3 weeks) from 336 +/- 30 to 369 +/- 55 mm Hg but returned to control values as left ventricular wall volume increased from 78 +/- 13 to 88 +/- 16 ml after development of compensatory hypertrophy. Left ventricular systolic function remained constant or increased and was maintained initially by increased myocardial performance, which returned to baseline levels after the development of compensatory hypertrophy. CONCLUSIONS: Myocardial performance and ventricular function vary independently in aortic regurgitation. Measures of myocardial performance such as the myocardial power output versus end-diastolic strain relationship may be useful in clinical assessment of aortic regurgitation.
Animals↗
Persistence of penicillin G benzathine in pregnant group B streptococcus carriers.
OBJECTIVE: To determine if streptococcicidal levels of penicillin G benzathine can be detected in maternal serum 4 weeks after treatment with 4.8 million units. METHODS: Thirty-seven pregnant women with positive group B streptococcus vaginal or urine cultures were each given 4.8 million units of penicillin G benzathine. Maternal blood samples were collected after injection and at delivery. Serum penicillin levels were measured by high-pressure liquid chromatography. Follow-up cultures were done when possible. RESULTS: None of the patients had serum penicillin levels below 0.20 microgram/mL 30 days after treatment. Cord blood levels were approximately 50% lower than maternal levels. In all but three subjects, cord blood levels exceeded 0.06 microgram/mL, the minimal inhibitory concentration for group B streptococcus. The three exceptions were patients who delivered more than 100 days after treatment. Group B streptococcus cultures were negative at the time of delivery in 72% of cases. None of the patients with positive cultures were moderately or heavily colonized. CONCLUSION: In pregnant women, penicillin G benzathine levels are high enough to inhibit the growth of group B streptococcus for more than 4 weeks after injection with 4.8 million units. Further studies are needed to evaluate whether this regimen can prevent neonatal colonization and invasive group B streptococcus disease.
Adult↗
Umbilical cord blood interleukin-6 levels and neonatal morbidity.
OBJECTIVE: To study umbilical cord interleukin-6 levels and the occurrence of neonatal sepsis, congenital pneumonia, necrotizing enterocolitis, and grade II-IV intraventricular hemorrhage. METHODS: Umbilical cord blood was collected from 133 preterm newborns. The study population was divided according to the presence or absence of neonatal complications. Interleukin-6 levels and clinical characteristics were compared by univariate and multivariate analyses. RESULTS: Sixteen neonates had adverse outcomes, and 117 were unaffected. The median interleukin-6 level was significantly higher in affected than in unaffected infants (145 pg/mL versus 0 pg/mL, P = .002). Elevated interleukin-6 levels were associated independently with neonatal morbidity in multiple logistic regression modeling that included gestational age, birth weight, and antenatal steroid exposure. CONCLUSION: Umbilical cord blood interleukin-6 levels are elevated in neonates who subsequently develop sepsis, congenital pneumonia, necrotizing enterocolitis, or grade II-IV intraventricular hemorrhage.
Adult↗
Effects of valve replacement on ventricular mechanics in mitral regurgitation and aortic stenosis.
BACKGROUND: This study in humans assessed changes in left ventricular function early and late after correction of mitral regurgitation (MR) (n = 9) or aortic stenosis (AS) (n = 10). METHODS: Ventricular function was measured with radionuclide and micromanometer-derived pressure-volume loops during preload manipulation, thermodilution cardiac outputs, and echocardiograms. Late radionuclide and echocardiographic data were acquired at 24 hours and 20 months. RESULTS: Perioperative left ventricular performance (stroke work-end-diastolic volume relationship) did not change for patients with MR or AS. Significant changes in afterload occurred: ejection fraction (MR, 0.49 to 0.37; AS, 0.54 to 0.60; both, p = 0.013), mean left ventricular ejection pressure (MR, 73 to 91 mm Hg; AS, 138 to 93 mm Hg; both, p < 0.01), and end-systolic wall stress (MR, 26 to 42 x 10(3) dynes/cm2; AS, 37 to 22 x 10(3) dynes/cm2; both, p < 0.01). Ejection efficiency improved for MR patients (0.69 +/- 0.26 to 1.0 +/- 0.15; p < 0.05). The 20-month data showed improved New York Heart Association functional class, normal resting ejection fraction, and normal exercise response for both groups. CONCLUSIONS: Early after operation, a significant change in left ventricular load was seen with correction of MR and AS. Data obtained late after operation showed improvement consistent with ventricular remodeling.
Aged↗
Chlamydial cervicitis and urethritis: single dose treatment compared with doxycycline for seven days in community based practises.
STUDY GOAL: To compare the efficacy and safety of single 1 g oral azithromycin with doxycycline, 100 mg twice daily for seven days for treatment of uncomplicated urogenital chlamydial infection. STUDY DESIGN: Randomised, unblinded, comparative trial, involving 597 patients demonstrating clinical evidence of genital chlamydia and a positive non-culture assay for Chlamydia trachomatis. RESULTS: Among the azithromycin- and doxycycline-treated patients 61% and 60%, respectively, were asymptomatic within one week after the first dose. At two weeks, these figures increased to 86% and 83%, respectively. Bacteriological eradication, based on a negative assay, occurred in 338 (97%) of 347 azithromycin-treated patients and 161 (99%) of 163 doxycycline-treated patients. CONCLUSION: Treatment of uncomplicated chlamydial cervicitis and urethritis with single 1 g oral azithromycin is equivalent to standard therapy with doxycycline. Drug-related adverse events were approximately twice as common as previously reported for both drugs.
Adolescent↗
Management of microfistula following pulmonary resection.
The symptoms and signs of cough and changes in the air-fluid pattern on chest radiograph are critical as warning signs of bronchopleural fistula. Drainage of the pleural space is a critical first step for all patients to limit endobronchial contamination and prevent drowing. Once nutritional status is optimized and treatment for infection is established, suture reclosure of the bronchial stump with vascularized flap coverage is curative for the acutely presenting fistula, usually fewer than 2 weeks after surgery. Patients who present with bronchopleural fistula at times more remote from resection are unlikely to have direct reclosure of their fistula. These patients may have closure of their fistula by either an anterior, transpericardial approach, thoracotomy with muscle flap to fill the pleural space, or muscle flap coverage of the fistula with a limited thoracoplasty to obliterate the pleural space. Patients who cannot undergo operations of this magnitude may be treated with endoscopically placed tissue adhesives to seal the fistula. These various treatment options are successful in 75% to 100% of cases, and have been responsible for significantly reducing the morbidity and mortality from bronchopleural fistula.
Aged↗
Human papillomavirus infection and therapy with interferon.
The studies summarized have shown that therapy of condylomata acuminata with interferon is effective. The route of administration does not appear to influence the results; the intralesional, intramuscular, and subcutaneous routes were effective. Additional research is required to determine whether the natural interferon or recombinant product is superior. The appropriate administration schedule may also not have been attained.
Female↗
Oral terbutaline in the outpatient management of preterm labor.
OBJECTIVE: Our purpose was to prove our hypothesis that once preterm uterine contractions and/or labor is controlled with intravenous tocolysis, oral terbutaline, as a maintenance drug, does not prolong pregnancy. STUDY DESIGN: Before discharge, 184 patients between 24 and 35 completed weeks' gestation were prospectively randomized to continued bed rest either with or without oral terbutaline. Assignment was made with stratification into four groups: group 1, those patients with a Bishop score > or = 5 with oral terbutaline (n = 50); group 2, those with a Bishop score > or = 5 without oral terbutaline (n = 53); group 3, those with a Bishop score < 5 with oral terbutaline (n = 41); group 4, those with a Bishop score < 5 without oral terbutaline (n = 40). Oral terbutaline was discontinued at 37 completed weeks. RESULTS: No statistically significant differences were found in the number of readmissions, the number of unscheduled hospital visits, and the neonatal outcomes among the four groups. The gestational age at delivery and percent of deliveries at > or = 37 weeks were not significantly different when group 1 was compared with group 2 and group 3 was compared with group 4. CONCLUSION: Oral terbutaline maintenance does not improve pregnancy outcome in patients who have had initial successful intravenous tocolysis.
Administration, Oral↗