[Prophylaxis of thromboembolic complications in obstetrics and gynaecology]. / Maladie thromboembolique périopératoire et obstétricale. Pathologie gynécologique et obstétricale.

Venous thromboembolism is a leading cause of maternal mortality in many countries, including France. Most enquiries have repeatedly demonstrated that many deaths could be avoided, suggesting the need to update and ensure a wider diffusion of recommendations. Although thromboembolism-induced maternal death plays a major role, the absolute incidence of events remains low, reducing the ability to perform well-designed research and the level of recommendations presented. Many personal or pregnancy-related factors have been identified as increasing the risk of thromboembolism in pregnant patients but few of them have been associated with a significantly increased risk. A history of thromboembolic event and some thrombophilic factors (including antithrombin deficiency and antiphospholipid syndrome) carry the greatest risk. Pregnancy itself, caesarean delivery and the postpartum period, although associated with an increased risk play a minor role when not combined with other risk factors. Prophylactic treatment relies mainly on low molecular weight heparins which safety is now well established in pregnant patients. Dose and duration of treatment should be adapted to the perceived level of risk. The occurrence of a thromboembolic event is also increased after gynaecological surgery but major and cancer surgery carry the greatest risk. Here also, low molecular weight heparins play a leading role, although non pharmacologic means are useful. Dose and duration should be dependent on the level of risk.

Fc gamma RII, but not erythropoietin or GM-CSF, mediates calcium mobilization in fetal hemopoietic blast cells.

A proportion of fetal liver hemopoietic blast cells express Fc gamma RII, and addition of the anti-Fc gamma RII monoclonal antibody CIKM5 induces a rise in calcium in these cells in suspension. Although these cells are thus capable of mobilizing intracellular calcium in response to surface receptor mediated events, neither granulocyte-macrophage colony-stimulating factor (GM-CSF) nor erythropoietin produced detectable changes in intracellular calcium ion concentration in these cells.

Environmental and workplace contamination in the semiconductor industry: implications for future health of the workforce and community.

The semiconductor industry has been an enormous worldwide growth industry. At the heart of computer and other electronic technological advances, the environment in and around these manufacturing facilities has not been scrutinized to fully detail the health effects to the workers and the community from such exposures. Hazard identification in this industry leads to the conclusion that there are many sources of potential exposure to chemicals including arsenic, solvents, photoactive polymers and other materials. As the size of the semiconductor work force expands, the potential for adverse health effects, ranging from transient irritant symptoms to reproductive effects and cancer, must be determined and control measures instituted. Risk assessments need to be effected for areas where these facilities conduct manufacturing. The predominance of women in the manufacturing areas requires evaluating the exposures to reproductive hazards and outcomes. Arsenic exposures must also be evaluated and minimized, especially for maintenance workers; evaluation for lung and skin cancers is also appropriate.

Impact of joint impairment on disability-specific domains at four years.

The objective of this study was to assess the longitudinal impact of joint impairment on overall disability and crossing domain-specific thresholds for physical activity, mobility, dexterity, instrumental activities of daily living (IADL), and activities of daily living (ADL) that are associated with use of long-term care. This 4-year longitudinal study observed 484 persons older than age 60. Logistic regression assessed the contribution of demographics, psychological mediators, lower- and upper-extremity joint impairment, and comorbidities to increased domain-specific self-reported disability above a threshold associated with use of long-term care. Lower-extremity joint impairment and age predicted crossing thresholds by year 4 in physical activity, mobility, IADL, and ADL disability that were associated with use of long-term care. Lower-extremity joint impairment is a strong risk factor for future disability that is associated with use of long-term care.

Joint impairment and hand function in the elderly.

OBJECTIVE: To test the contribution of joint impairment to observed hand function (grip strength and Williams Test) in the elderly, using a multivariate model. DESIGN: Cross-sectional observational data (baseline data from an ongoing longitudinal study). SUBJECTS: Five hundred forty-one persons over age 60, including continuing care retirement community (n = 222), homebound (n = 72), and ambulatory (n = 247) respondents. Mean age at assessment 76.7, (SD = 9.0). MEASUREMENT: Independent variables included sociodemographics, physician measures of upper joint impairment, an index of comorbidities derived from physical examination or chart abstract, self-assessed arthritis pain, depression, and anxiety. The dependent variables included grip strength and a modified Williams Test [Williams Test (M)]. MAIN RESULTS: The multiple regression explained 59% (Adjusted R2 = .59) of the variance in grip strength, with joint impairment accounting for a change in R2 of .07. Upper joint impairment and grip strength accounted for 3% and 5%, respectively, of the variance in the Williams Test (M) (total amount of explained variance = 45%). CONCLUSIONS: Demographics explain most of the variance in grip strength and performance on the Williams Test (M). Controlling for demographics, musculoskeletal disease represented by joint impairment is associated with diminished grip strength. Reduced grip strength is associated with poorer performance on the Williams Test (M).

Predictors of decline in manual performance in older adults.

OBJECTIVE: To determine factors that predict decline in manual performance using a multivariate model of determinants of functional limitation. DESIGN: Longitudinal observational study. SETTINGS: Ambulatory general medicine clinics, residences of homebound individuals, and a continuing care retirement community. PARTICIPANTS: Subjects were 485 persons more than 60 years of age and included continuing care retirement community (CCRC) residents (n = 215), chronically homebound older persons (n = 65), and ambulatory older adults (n = 205). Mean age at baseline was 78 years. MEASUREMENT: Independent variables included demographics, physician measures of upper-extremity joint impairment, comorbidities derived from physical examination and chart abstract, self-assessed arthritis pain, depression, and anxiety. The major dependent variable was 2-year decline in timed manual performance below a threshold associated with need for long-term care services. RESULTS: The proportion of subjects who exceed a Timed Manual Performance Test threshold of 350 seconds increased slowly from baseline through Year 4 for all age groups but rose rapidly from Year 4 to Year 6 for the oldest group (> 85 years at baseline). Using a discrete survival model, we found that age, education, grip strength, and psychological status predicted crossing the manual performance threshold within a 2-year period. CONCLUSIONS: The findings, coupled with earlier findings that upper extremity joint impairment predicted both grip strength and manual performance, suggest that joint impairment may be an important risk factor for future functional limitation. Since diminished hand function has been shown to predict dependency, development and testing of interventions to maintain or restore upper extremity joint function and reduce pain would appear to be a high research priority.

Joint impairment and ambulation in the elderly.

OBJECTIVE: To test the impact of joint impairment on ambulation in the elderly, using a multivariate model. DESIGN: Cross-sectional observational study (baseline data from an ongoing longitudinal study). SUBJECTS: Five hundred thirty-two persons over age 60, including continuing care retirement community (CCRC) (n = 222), homebound (n = 63), and ambulatory (n = 247) respondents. Mean age at assessment = 76.6 (SD = 6.6). MEASUREMENT: Independent variables included sociodemographics, physician measures of lower joint impairment, an index of cormorbidities derived from physical examination or chart abstract, self-assessed arthritis pain, depression, and anxiety. The dependent variable, ambulation, was measured as walk-rate, based on the time required to walk 50 feet. MAIN RESULTS: For the total sample, 61% of the subjects were impaired in more than one lower joint group, with almost 50% of the homebound impaired in more than three joint groups. Demographics (particularly age and education) explained much of the variance in walk-rate. After controlling for demographics and membership in the groups purposely sampled (CCRC, homebound, ambulatory), lower joint impairment accounted for an additional 7% of the variance in walk-rate. Total amount of variance explained by the model was 56% (Adjusted R2 = .56). A 3-point change in lower joint impairment score, equivalent to the maximum impairment score for a single joint group, is associated with a 4-second change in the mean time required to walk 50 feet. The knee and lower spine joints contributed most to the impact of the lower joint impairment measure. CONCLUSIONS: Among the elderly, age and education are strong predictors of performance on a walk-rate test. Independent of demographics and non-musculoskeletal conditions, joint impairment is associated with diminished walking ability in this population.

Binocular fusion and stereopsis associated with early surgery for monocular congenital cataracts.

Despite improved visual acuity results in infants undergoing early surgery for monocular congenital cataracts, virtually all reports indicate a lack of binocular vision and the presence of strabismus in these patients. We report herein the presence of motor fusion and stereopsis in patients who have undergone early surgery for monocular congenital cataracts. Of 13 patients with congenital cataracts who were operated on by age 9 weeks, five (38%) had essentially straight eyes and evidence of motor fusion with a minimum of 1 year of follow-up. Three (60%) of five patients demonstrated sensory fusion, two with Titmus testing and one with Randot Stereo Acuity (Stereo Optical Co Inc, Chicago, Ill) of 250 seconds of arc. We conclude that binocular fusion and stereo visual acuity are obtainable in patients with monocular congenital cataracts.

10-Diopter fixation test for amblyopia.

Fixation-preference testing has been useful in detecting amblyopia in children unable to give reliable visual acuities, except for children with small-angle tropias and those without manifest deviations. This study introduces a method of fixation testing that includes all children, regardless of the presence or size of the deviation. By placing a 10-diopter vertical prism over one eye, we induce a vertical deviation. Once the eyes are dissociated, fixation preference is evaluated and used to predict the presence of amblyopia. We prospectively studied fixation patterns in 98 children with either small-angle tropia or essentially straight eyes. All children with amblyopia of two lines or more showed abnormal fixation patterns, and those without amblyopia showed normal patterns. We were able to obtain fixation patterns on all children studied, including 13 infants less than 24 months of age. This test proved to be a reliable, objective method for detecting amblyopia in children with straight eyes or in children with microstrabismus of almost any age.

Reliability of fixation preference testing in diagnosing amblyopia.

We evaluated the sensitivity and specificity of standard fixation preference testing and the 10-prism diopter (PD) fixation test in 427 patients. Standard fixation preference testing showed good sensitivity and specificity for than 10 PD. Patients with small angle tropias, however, had a high false-positive rate, with 40% of nonamblyopic patients inappropriately responding with strong fixation preference. The 10-PD fixation test reduced this high false-positive rate and showed only 1.5% false-positive results. Unfortunately, this shift to equal fixation preference was also seen in some patients with amblyopia, as five of 19 patients with three or more lines difference alternated fixation with the 10-PD fixation test. Retesting disclosed that, although these children would briefly alternate to the amblyopic eye while viewing a stationary target, they would not hold fixation with the amblyopic eye through smooth pursuit. Our conclusion is that standard fixation preference testing can be used to diagnose moderate to severe amblyopia in patients with tropias greater than 10 PD. Patients with small angle deviations or straight eyes should be examined with the 10-PD fixation test, with the criterion for equal vision being the ability to hold fixation well with either eye through smooth pursuit.

High-grade stereo acuity after early surgery for congenital esotropia.

OBJECTIVE: To evaluate the effectiveness of very early surgery for establishing straight eyes and sensory fusion in patients with congenital esotropia. DESIGN: A review of consecutive patients with congenital esotropia who underwent surgery between 13 and 19 weeks of age. SETTING: A children's hospital with a teaching affiliation. PATIENTS: Seven patients who had surgery between 13 and 19 weeks of age. INTERVENTION: A bilateral medial rectus recession through a fornix incision with recessions ranging from 5.75 to 6.5 mm in infants younger than 6 months of age. MAIN OUTCOME MEASURES: Sensory fusion as measured by stereo acuity and Worth four-dot testing and motor alignment within 8 prism diopters. RESULTS: Five of the seven patients achieved essentially straight eyes with tropias of less than 8 prism diopters after one horizontal surgery. Five patients cooperated with sensory testing, and all showed stereo acuities that ranged from 400 to 40 seconds of arc. Three children had evidence of high-grade stereo acuity by showing stereopsis on random dot stereograms (Randot, Stereo Optical Co, Chicago, Ill) and by fusing the Worth four-dot test at distance and near range. Two of the patients with high-grade stereo acuity achieved a stereo acuity of 40 seconds of arc by Titmus testing; however, one had a late reduction of stereo acuity to 70 seconds of arc. CONCLUSION: Very early surgery can result in excellent motor alignment and high-grade stereo acuity in some patients with congenital esotropia.

Evaluation of the SprayGel adhesion barrier in the rat cecum abrasion and rabbit uterine horn adhesion models.

OBJECTIVE: To evaluate the efficacy of a new adhesion barrier in the prevention of postoperative adhesion formation. DESIGN: A double-blind controlled study of the efficacy of SprayGel in reducing postoperative adhesion formation in two animal models. SETTING: Animal care facility of a contract testing laboratory. ANIMAL(S): Sixteen Sprague-Dawley male rats were randomly allocated into two groups in the cecum abrasion model. Twenty New Zealand white female rabbits were randomly allocated into two groups in the uterine horn abrasion model. INTERVENTION(S): In the rat model, the cecum was abraded with gauze and the abdominal wall was abraded with a scalpel. Treated animals received SprayGel coating on injured surfaces; control animals received no treatment. In the rabbit model, uterine horns were abraded with a scalpel. Treated animals received SprayGel coating on injured surfaces; control animals received no treatment. MAIN OUTCOME MEASURE(S): Postoperative adhesion formation. RESULT(S): In the rat model, SprayGel was found to significantly reduce the incidence of adhesions, which formed in 7 of 8 control rats compared with 1 of 8 treated rats. In the rabbit model, SprayGel was found to significantly reduce both the extent and severity of adhesions. CONCLUSION(S): Application of SprayGel in two animal models reduced formation of postoperative adhesions. Further investigation in large animal and clinical settings is warranted.

Efficacy of bifocals in the treatment of accommodative esotropia.

We treated 84 patients with a partially refractive accommodative esotropia with bifocals. Twelve patients were able to fuse without bifocals at the end of therapy; in 19, the bifocal power could be reduced and further improvement can be expected in the future. Thirty-nine remained dependent on bifocals; and in 14, fusion had deteriorated in spite of therapy. Patients with a high AC/A ratio and those receiving supportive orthoptic treatment seemed to fare best with bifocals. In those with a low AC/A ratio, fusion tended to deteriorate because of a slowly increasing esodeviation at near fixation.

IL6 and acute phase plasma proteins in peritoneal fluid of women with endometriosis.

Several authors have documented signs of chronic inflammation in the pelvis of women with endometriosis. We investigated the possible involvement of interleukin 6 (IL6), an important regulator of inflammation and immunity, in minimal and mild endometriosis by measuring levels of IL6 and proteins (alpha 1-acid glycoprotein, alpha 1-antitrypsin, alpha 2-HS glycoprotein and albumin) the synthesis of which is regulated by IL6, in peritoneal fluid (PF) from infertile women with histologically confirmed endometriosis (stage I and II; n = 28) and from endometriosis-free fertile (n = 14) and infertile women (n = 13). Spontaneous and LPS-induced IL6 secretion by cultured PF macrophages from women with endometriosis (n = 12) and without endometriosis (n = 9) were also studied. No significant differences were observed in the concentrations of the four proteins studied. Immunoreactive IL6 was detected in all three groups, with no significant differences. In contrast, significantly higher levels of IL6 were released by both unstimulated (P = 0.01) and LPS-stimulated (P = 0.006) peritoneal macrophages from the women with endometriosis. We conclude that local IL6 synthesis by activated macrophages may play a role in the endometriosis process.

Impact of long-term home care on mortality, functional status, and unmet needs.

This article reports the outcomes of a four-year follow-up evaluation of the Five Hospital Program, a long-term home care program in Chicago. Outcomes assessed include the mortality, comprehensive functional status, and perceived unmet needs of its frail elderly clientele (mean age 81 years at entry). The evaluation utilized a pretest, multiple posttest design with a comparison group consisting of similarly elderly and impaired individuals receiving OAA Title III-C home-delivered meals. Consecutively accepted treatment (N = 157) and comparison group clients (N = 156) were interviewed using the OARS Multidimensional Functional Assessment Questionnaire at baseline, 9 months, and 48 months after acceptance to care. A multivariate analysis of mortality rates revealed no between-group differences attributable to treatment on this outcome. Major findings included significantly better cognitive functioning and reduced unmet needs in the treatment group at nine months. A longer-range, continued beneficial effect of treatment on cognitive status was also observed at 48 months. We conclude that long-term home care provided important benefits to clients at both 9 and 48 months, with no effect on mortality. However, we suggest that the four-year findings be interpreted with caution, since only a small percentage of clients (18 percent) were still alive and receiving active care in the community at that time.

Impact of long-term home care on hospital and nursing home use and cost.

This article reports the long-range impact of a long-term home care program in Chicago on hospital and nursing home use and on overall health care costs over four client-years of observation. The evaluation utilized a quasi-experimental design with a comparison group composed of clients who received home-delivered meals. The health services utilization experience of consecutively accepted treatment (N = 157) and comparison group (N = 156) subjects was monitored for 48 client-months following acceptance to care. Imputed costs were then assigned to each type of care measured. Findings include a significantly lower risk of permanent admission to sheltered and intermediate-level nursing home care in the treatment group but no difference in risk of permanent admission to skilled-level nursing home care. Despite savings in low-intensity nursing home days, preliminary findings indicate that total costs of care were 25 percent higher in the treatment group. However, these costs are accompanied by significant quality-of-life benefits in the treatment group (reported elsewhere).

Epidermal lipids and the natural history of hydrofluoric acid (HF) injury.

To explain several fortuitous observations, we hypothesized that there is a naturally occurring lipid 'barrier' to HF injury in guinea-pig skin and sought to characterize both the barrier and its role in the natural history of such injuries. Under anaesthesia, the dorsal trunk skin of groups of guinea-pigs was gently clipped of hair, washed with chloroform, soap and water, acetone or nothing (controls), and examined histologically for the presence of neutral lipid. Thereafter, in animal groups similarly washed, 1.5 in x 1.5 in (38 mm x 38 mm) areas were exposed to 40 per cent HF for up to 50 min and: (a) mean percentages of exposed areas with gross necrosis 5 days postinjury plotted on dose-response curves; or (b) less than 4 h after exposure to HF, intra-aortic India ink was injected and skin specimens examined to discern depth of ischaemia and necrosis. In contrast to controls, washing reduced neutral lipid in epidermis and significantly (at P < 0.001) increased susceptibility to injury by HF. With very rare (but interesting) exceptions, HF injury was found to be full thickness in depth with ischaemia and coagulative necrosis. In this study, development of guinea-pig skin necrosis due to HF was typically an 'all-or-nothing' 'barrier-penetration' phenomenon relating as much to the integrity of an epidermal lipid barrier as to the duration and intensity of noxious exposure.

Estimates and determinants of valid self-reports of musculoskeletal disease in the elderly.

This study examined the extent and nature of bias associated with self-reported versus standardized physician-examination/assessment-based accounts of musculoskeletal disease in a sample of 406 persons chosen to represent an aging and dependency continuum. Prevalence of musculoskeletal disease based on standardized physician examination/assessments was 97%. Using the standardized findings as the criterion, the self-report underestimated prevalence by 16%. Overall, the results indicated that self-reports of musculoskeletal conditions by the elderly capture the vast majority of persons with painful or functionally significant disease and are most valid for persons from ages 65 to 74 but do not reflect the presence of asymptomatic joint pathology. Standardized physician examinations/assessments would more accurately determine the presence of risk factors in epidemiological studies of musculoskeletal disability.

Visual outcome in high hypermetropia.

INTRODUCTION: We wished to determine whether final visual acuity is dependent on age at optical correction or presence of esotropia in children with bilateral high hypermetropia. METHODS: We reviewed the charts of all patients at Childrens Hospital Los Angeles Division of Ophthalmology with bilateral hypermetropia of greater than or equal to 5D who were able to provide objective visual acuity outcomes with Snellen letters or linear E. RESULTS: One hundred thirteen patients met entry criteria. The age at first optical correction ranged from 8 months to 141 months (average 45 months). Initial visual acuity (before optical correction) was obtainable in 82 patients. Initial visual acuity ranged from 20/20 to 20/200, with 57% of patients having acuity better than or equal to 20/40. Final visual acuity (after optical correction) ranged from 20/20 to 20/70, with 109 patients (96%) having acuity better than or equal to 20/40 and 104 patients (92%) having acuity better than or equal to 20/30. There was no relationship between final visual acuity and age that spectacles were first worn. Ninety-five patients (84%) had esotropia with or without glasses, and six of these (6%) had final visual acuity less than 20/30. Of the 18 patients with orthotropia, three (16%) had final visual acuity less than 20/30. The prevalence of ametropic amblyopia in patients with esotropia and orthotropia was not significantly different (p = 0.18). CONCLUSION: Visual acuity outcome in children with high hypermetropia is generally good regardless of age at initial optical correction or presence of strabismus. A significantly increased risk for ametropic amblyopia was not found in those patients with orthotropia.

Succinylcholine as a predictor in strabismus surgery.

Succinylcholine was injected intraoperatively in 20 patients with congenital esotropia, before and after the surgical procedure. Regression analysis was performed to investigate the relationship between the awake pre- and postoperative alignment and the drug-induced ocular positions, under anesthesia. The postoperative succinylcholine-induced ocular position was found to be a highly significant predictor of the one week postoperative alignment (r = 0.98, p less than 0.0001). Further investigation may lead to an ability to predict the postoperative alignment intraoperatively.