Biomedical subjects
Publications and source records attributed to S Yeh.
In the past 2 years at our institution, 87 patients with hepatic metastasis from colorectal carcinoma have undergone surgical implantation of an arterial pump for the direct infusion of chemotherapeutic agents into the liver. We report six cases of cholangitis complicating the course of these patients.
External cephalic version performed in conjunction with tocolysis in the term breech presentation has been found to decrease the number of breech presentations at delivery and thus reduce the number of cesarean sections for breech presentation. However, information regarding the fetal heart rate (FHR) patterns associated with version is limited. In an attempt to broaden our understanding of the FHR changes that occur in association with version, the FHR tracings of 141 patients who had undergone version were analyzed. Approximately 39% of the fetuses exhibited changes in FHR characteristics during and/or after attempted version. These FHR changes were primarily manifested as bradycardias and/or decelerations. However, some of the fetuses (less than 5%) demonstrated a tachycardia or sine wave pattern. All of these FHR changes were transient and bore no apparent relationship to the subsequent outcome of the fetus. In addition to these FHR alterations, the incidence of diminished FHR variability (less than or equal to 5 bpm) was significantly higher after version than before version (p less than 0.01). The decline in FHR variability lasted 15 +/- 12 minutes. While this decline in variability appeared to be related to the success or failure of the version, the decreased variability observed after version was found to be unrelated to the tocolytic agent used and to the subsequent fetal outcome. In summary, alterations in FHR activity were frequent during the version process. All were transient and most responded to cessation of manipulation. Subsequent fetal outcome was apparently unrelated to the observed FHR alterations. Nonetheless, continuous fetal monitoring during and after the version is recommended.
In the United States over 90% of patients with a history of cesarean delivery in the prior pregnancy undergo repeat cesarean delivery in a subsequent pregnancy. The costs of the nearly universal approach to this issue are staggering and have been addressed by a recent National Institutes of Health consensus development conference. In 1979 at the Women's Hospital of Los Angeles County/University of Southern California Medical Center we initiated a policy of permitting a trial of spontaneous labor and vaginal delivery in selected patients with prior cesarean deliveries. Patients selected for a trial of labor (TOL) were those with a history of one prior uterine incision known to be low transverse. During 1980 there were 13,292 deliveries and 13,147 live births; 871 of these patients had a history of prior cesarean delivery. Of the 871 women, 308 (35%) were permitted a TOL. There were 240 vaginal deliveries, for a success rate of 78%. Twenty-two perinatal deaths occurred among the 871 patients, none directly attributable to the TOL. There were three ruptured uteri, one directly attributable to a TOL. Seven hysterectomies were performed in this group, none directly attributable to a TOL. This experience has encouraged us to expand the patient group offered a TOL after prior cesarean delivery under carefully controlled conditions.
Patients with previous cesarean births who delivered macrosomic infants (greater than or equal to 4,000 gm) during the study periods January 1 to December 31, 1980, and July 1, 1982, to June 30, 1983, were analyzed to determine the impact of fetal weight on a trial of labor (TOL). Of 140 women with macrosomic infants given a TOL, 94 (67%) delivered vaginally. The most common indication for cesarean delivery was cephalopelvic disproportion (CPD). The dehiscence rates were similar when patients who underwent a TOL were compared with those who did not. Factors associated with a successful TOL were a previous vaginal delivery after the original cesarean section, no oxytocin usage during the TOL and an indication for the previous cesarean section other than CPD. The risk associated with a TOL in a patient with a previous cesarean birth and a macrosomic infant appears to be no greater than that encountered in a similar group of patients without uterine scars.
In order to assess the current management of, and to develop a management scheme for, patients with postterm pregnancy and previous cesarean section (C/S), a retrospective analysis of 112 patients was done. All patients with postdates pregnancy and previous C/S were followed in a postdates clinic according to a previously published protocol. Thirty-four patients (30.4%) underwent elective repeat C/S, and 78 (69.6%) were permitted a trial of labor (TOL). Of these TOL patients, 57 (73.1%) delivered vaginally. Sixteen (42.2%) of 37 patients with a history of prior C/S for cephalopelvic disproportion delivered vaginally. Excluding 34 patients who underwent elective repeat C/S, the remaining 41 patients who had previous C/Ss for other indications delivered vaginally. This difference was statistically significant (p less than 0.001). Other factors--the number of previous vaginal deliveries, type of previous-C/S incision, the complications of the prior C/S and the interval since the previous C/S occurred--had no effect on vaginal delivery. There was no marked difference in perinatal morbidity between infants delivered vaginally and those delivered abdominally. The maternal morbidity, in terms of postpartum fever and requirement for transfusion, in patients with repeat C/S was significantly higher than that in women with vaginal deliveries. Postdates pregnancy was not associated with an increased risk of uterine rupture. On the basis of this experience we think that postterm pregnancy should not be considered a contraindication to a TOL.
Gallium nitrate is a new antineoplastic agent that has shown activity in a number of in vitro tumor systems. During a Phase I clinical trial, the pharmacokinetics of two methods of administration of gallium nitrate were studied: a seven-day continuous intravenous infusion, and a weekly rapid intravenous infusion. During the continuous infusion of 200 mg/M2 of gallium nitrate, plasma gallium concentrations of 0.9 +/- 0.2 microgram/ml in one patient, and 1.9 +/- 0.4 microgram/ml in a second were noted. Urine excretion of gallium approximated the daily administered dose by day 2-3. Overall, 68-107% of the total administered dose was recovered in the urine. Following a rapid intravenous infusion, a biphasic curve was generated. The T1/2 alpha ranged from 8.3-26 minutes; the T1/2 beta from 6.3-196 hours. From 69-91% of the administered dose was recovered in the urine. The effects of gallium nitrate on tissue localization and body retention of 67Ga are also presented.
To study quantitatively the effect of urinary bladder distention on labor and uterine activity, 68 patients requiring catheterization were studied. All patients were in the active phase of labor and had transcervical intrauterine pressure monitoring. Patients were studied in the same lateral position for 30 minutes before and after a catheterization interval, during which time uterine activity units were quantitated on line and changes were noted in cervical dilation and station and contraction frequency and tonus. Results were analyzed for the entire study group, for individual patients, and by urine volumes (10 to 550 ml) obtained at catheterization. Total uterine activity units increased in 43 patients and decreased in 25 after catheterization, but when compared with expected increases calculated from the slopes of the precatheterization interval in individual patients, there were 36 increases and 32 decreases. Individual slopes of uterine activity increased in 36 and decreased in 31 cases. There were no differences when the data were analyzed by urine volume, parity, or bith weight except possibly at large volumes. Changes in rates of cervical dilation and descent of the presenting part conform to the expected normal labor pattern. Within the limits of this study, emptying the urinary bladder has no effect on the course of labor or uterine activity based on the dynamic model of labor.
The clinical toxicology, clinical pharmacology, and therapeutic effects of bleomycin given by continuous intravenous infusion were studied in patients with far-advanced unresectable cancer. The toxicity of bleomycin given by that schedule was qualitatively and quantitatively the same as when it was given by daily intravenous "push"; mucocutaneous toxicity occurred regularly after 7-11 days of infusion. Careful monitoring of pulmonary function revealed minor changes in Total Lung Capacity and Pulmonary Diffusion Capacity in nearly all patients; however, overt pulmonary toxicity occurred in only six patients (5%). 111Indium-labeled bleomycin was used to follow blood levels of bleomycin; it correlated well with the levels determined by microbiologic assay and could be measured at levels lower than could be determined by bioassay. Useful therapeutic responses were seen in a variety of tumors; 30% patients with very far-advanced carcinoma of the cervix demonstrated CR or PR, an incidence higher than has been seen with other regimens. Sixty-nine percent of patients with disseminated germ cell neoplasms of the testis, refractory to bleomycin given by conventional dose schedules, have attained partial remission through the continuous infusion of bleomycin.
The clinical usage of intrapartum fetal monitoring has increased dramatically in the past few years. Understanding of the pathophysiologic significance of FHR patterns has been further elucidated, but quantitation and prediction on an individual basis at times present a practical clinical dilemma. Baseline FHR variability was evaluated in order to see if it provided additional commentary on fetal status. The presence of FHR variability appears to be a favorable commentary regarding both fetal and newborn status. A clinical method of apprasing FHR is presented and the significance of FHR variability suggested.
The Northwestern voice prosthesis for laryngectomees is described. The prosthesis contains no vibrator but activates vibration of the patient's pharyngeal or upper esophageal tissue by transporting air from the tracheostoma to a fistula in the upper neck, well away from major blood vessels. The prosthesis fits directly onto the laryngectomy tube and allows the patient to breathe, speak, and cough without any manual adjustments. The important advantage of this prosthesis is the fistula location. It can be placed at the time of original surgery and is also workable in patients who have had radiation and extensive radical surgery with total reconstruction of their gullet. The prosthesis can be used by primary total laryngectomees while learning esophageal speech or installed in those who are unable to use the electronic larynx or to learn esophageal speech. Four case studies are presented.
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Macrophage, fibroblast, and HeLa cell cultures have been infected with Toxoplasma gondii, and observations have been made on parasite entry and fate. A special procedure was devised for studying the entry of toxoplasmas by electron microscopy. Toxoplasmas were centrifuged onto the cells in the cold; fixation 1-3 min after warming yielded specimens showing numerous examples of parasites in the process of entering cells. The mechanism of entry into macrophages, fibroblasts, and HeLa cells was in all cases by phagocytosis. Micropseudopods were extended by the cells to envelop the attached parasites in a typical phagocytic vacuole. Apparently the toxoplasmas stimulated this response of HeLa cells and fibroblasts, cell types not usually phagocytic. No instance was seen of penetration of toxoplasmas through the cell membrane, or of parasites located free in the cytoplasm. Essentially all of the toxoplasmas that entered HeLa cells divided with a generation time of 9 hr; the parasites formed large rosettes situated in vacuoles, eventually leading to host cell rupture. Macrophages took in larger numbers of toxoplasmas than did HeLa cells, but approximately half of the parasites inside of macrophages degenerated within a few hours. The surviving toxoplasmas in macrophages divided every 8 hr, forming rosettes and eventually rupturing the cells.
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