[COMPARATIVE STUDY OF THE TACTICS OF SURGICAL FIXATION WITH THE CLOSED INJURY OF THE CHEST: THE VIEW OF THE RESUSCITATOR, ECONOMIC ASPECTS].

The closed injury of chest with the breaks of edges is the vital problem of traumatology, anesthesiology and resuscitation For the change to conservative treatment with the aid of mechanical ventilation of lungs today come the methods of surgical fixation with the closed injury of chest. The conducted investigation showed the clinical and economic expediency of introducing the method of active surgical tactics.

[Fat embolism syndrome in skeletal trauma: particularities of the diagnosis, economic aspects and the role of non-invasive ventilation in intensive care].

The article deals with a multicenter study that demonstrates the possibility and feasibility of noninvasive ventilation in patients with skeletal trauma complicated wiith fat embolism syndrome. The authors found additional criteria for the severity of the condition of patients with trauma. Important criteria for the choose a type of ventilation (non-invasive and invasive) is the lack of consciousness, desynchronization of a patient with ventilator and the need for a specialized regimes or miorelaxation to synchronize with the respirator.

Do race and gender influence the use of invasive procedures?

OBJECTIVE: To assess the influence of race and gender influence on the use of invasive procedures in patients with acute myocardial infarction (AMI) in community hospitals. DESIGN: Prospective, observational. SETTING: Five mid-Michigan community hospitals. PATIENTS: All patients (838) identified with AMI between January 1994 and April 1995 in 1 of these hospitals. MEASUREMENTS AND MAIN RESULTS: After adjusting for age, hospital of admission, insurance type, severity of AMI, and comorbidity, using white men as the reference group, the rate of being offered cardiac catheterization (CC) was 0.88 (95% confidence interval [95% CI], 0.60 to 1.29) for white women; 0.79 (95% CI, 0.41 to 1.50) for black men; and 1.14 (95% CI, 0.53 to 2.45)for black women. Among patients who underwent CC, after also adjusting for coronary artery anatomy, the rate of being offered angioplasty, using white men as the reference group, was 1.22 (95% CI, 0.75 to 1.98) for white women; 0.61 (5% CI, 0.29 to 1.28, P =.192) for black men; and 0.40 (95% CI, 0.14 to 1.13) for black women The adjusted rate of being offered bypass surgery was 0.47 (95% CI, 0.24 to 0.89) for white women; 0.36 (95% CI, 0.12 to 1.06) for black men; and 0.37 (95% CI, 0.11 to 1.28)for black women. CONCLUSIONS: Our study shows that white women are less likely than white men to be offered bypass surgery after AMI. Although black men and women with AMI are less likely than white men to be offered percutaneous transluminal coronary angioplasty or coronary artery bypass grafting in both unadjusted and adjusted analyses, these findings did not reach statistical significance. Our study is limited in power due to the small number of blacks in the sample.

Rubella immunity in a cohort of pregnant women.

To assess the rubella immune status of a cohort of high-risk pregnant women visiting a Midwestern clinic, we retrospectively studied 50 random pregnancies per year from 1990 through 1996. Of 350 patients analyzed, 53 (15.1%) were not immune to rubella, and vaccination opportunities were missed.

Management of gestational diabetes by family physicians and obstetricians.

BACKGROUND: Studies suggest that there are differences between family physicians' (FPs) and obstetricians' (OBs) management of women with low-risk pregnancies. This study was conducted to examine outcomes in women with gestational diabetes mellitus (GDM) to see if similar patterns exist between those cared for by FPs and those cared for by OBs. METHODS: A retrospective chart review was undertaken and analyzed by prenatal care provider. Eight hundred thirteen women were identified as having a pregnancy complicated by GDM. Management outcome data of FPs and OBs were compared. RESULTS: Eighteen percent of patients were cared for by FPs. The percentage with a prior history of GDM did not differ between groups. Patient groups were similar demographically except that FPs cared for a significantly higher percentage of patients on public assistance (60% vs 38%, P < .001). Average prepregnancy weight and body mass index were equal, as were average weight gain, gestational week at entrance to care, and number of prenatal visits. Class instruction on diabetes was given to 83% of FP patients and 85% of OB patients. A greater percentage of OB patients were placed on insulin therapy (33% vs 24%, P < .05). Complications of pregnancy, labor, and delivery were equal, but a higher number of OB patients had a cesarean section (33% vs 11% for FPs). Despite the equal occurrence of preterm labor/delivery and low birthweight, OBs used tocolysis in significantly more women than did FPs (10.3% vs 4.7%, P < .03). Average birthweight of infants delivered by FPs and OBs (3259 g and 3356 g, respectively), macrosomia rate (12% and 13%, respectively), length of pregnancy, fetal complication rate, Apgar scores, and length of hospital stays were all equivalent. CONCLUSIONS: Although there are variations in the care of women whose pregnancy is complicated by gestational diabetes mellitus, there are no significant differences in neonatal outcome. There is, however, an overall lower rate of both cesarean section and tocolysis use among women cared for by FPs.

Variance cardiography for emergency department evaluation of chest pain patients.

OBJECTIVE: To determine the test performance of 24-lead variance cardiography (VC), an ECG technique that measures QRS morphologic variability, for ED evaluation of chest pain associated with coronary artery disease (CAD). METHODS: A prospective, single-blind study of VC was performed in a community teaching hospital ED. All chest pain patients (> 30 years of age) who, after initial emergency physician evaluation, were believed to have pain of potential cardiac etiology and were admitted to the hospital were eligible. Exclusion criteria included obvious noncardiac etiology for discomfort, bundle-branch block, atrial fibrillation, and incomplete subsequent cardiac evaluation. After initial evaluation and stabilization, VC was obtained. The numerical output of VC was a CAD index (CADI). Serum myoglobin and creatine kinase (CK)-MB levels were obtained at the time of presentation and after one, two, and six hours. Hospital records were reviewed to determine final diagnosis and in-hospital evaluation results. RESULTS: Fifty-two of 75 eligible patients had complete data. Final diagnoses were as follows: 27/52 (52%), noncardiac; 13/52 (25%), acute myocardial infarction (AMI); and 12/52 (23%), unstable angina due to CAD. Twenty-three percent (12/52) of the patients had CADIs < 75. Eleven of these were found to have noncardiac origins for their chest pain. The twelfth patient had a 12-lead ECG revealing AMI and had been given thrombolytic therapy with subsequent reperfusion prior to VC. Using a CADI < 75 as the cutoff for a negative study, VC alone had a negative predictive value of 92%, a sensitivity of 96%, a positive predictive value of 60%, and a specificity of 41%. CONCLUSION: A CADI < 75, in addition to clinical impression and initial ECG, may identify chest pain patients who do not have significant CAD. Further prospective assessment of VC is warranted.

Comparison of laparoscopic cholecystectomy versus elective open cholecystectomy.

Laparoscopic cholecystectomy has essentially replaced open cholecystectomy as the procedure of choice for gallbladder disease. This rapid shift to laparoscopic cholecystectomy, however, has resulted more from marketing forces than from prospective clinical trials. To evaluate the safety and efficacy of laparoscopic cholecystectomy, the first 486 laparoscopic cholecystectomies at two institutions were studied. These results were then compared to the results of the last 6 months of elective open cholecystectomy cases prior to the introduction of laparoscopic surgery. The age, sex, height, and weight were similar in both groups. The mean operative time was 78.8 +/- 1.8 min for laparoscopic cholecystectomy and 62.7 +/- 2.6 min for open cholecystectomy (p < 0.01). The mean time for tolerating a regular diet was 1.23 +/- 0.04 days in the laparoscopic group versus 2.44 +/- 0.07 days in the open group (p < 0.01). Laparoscopic cholecystectomy patients required only oral pain medications by a mean of 1.22 +/- 0.03 days postoperatively compared to 2.55 +/- 0.07 days postoperatively for those undergoing open cholecystectomy (p < 0.01). The mean length of hospitalization was 1.58 +/- 0.07 days for laparoscopic patients and 3.55 +/- 0.11 days for open patients (p < 0.01). Thirty-one patients undergoing laparoscopic cholecystectomy were converted to open cholecystectomy (6.4%). The most common reasons for conversion to open cholecystectomy were acute inflammation, adhesions, and bleeding. For the laparoscopic patients, the morbidity rate was 8.4% and the mortality rate 0.2% (1 death). In the open cholecystectomy group the morbidity rate was 8.0% and there were no deaths. The most troublesome complication in laparoscopic cholecystectomies continues to be bile leaks and bile duct injuries.(ABSTRACT TRUNCATED AT 250 WORDS)

The effects of nifedipine on pregnancy outcome and morphology of the placenta, uterus, and cervix during late pregnancy in the rat.

OBJECTIVE: Although the calcium antagonist nifedipine has been reported to suppress preterm labor, little is known of the effects of long-term nifedipine use in late pregnancy. In this study the effects of nifedipine on pregnancy outcome and the morphologic features of the reproductive tract in the late-pregnant rat were investigated. STUDY DESIGN: From days 14 to 21 of gestation pregnant rats were administered three or 30 times the maximum human dose of nifedipine reported to suppress preterm labor. Analysis was performed on day 21. RESULTS: Blood vessel dilatation, increased vascularization of the uterus and placenta, and trophoblast hypertrophy were seen in both nifedipine-treated groups. Placental weight was increased in the higher-dose group, but neither dose of nifedipine resulted in any change of fetal survival or malformations. Pup weight was not different from that of controls in the lower-dose group but was significantly reduced (p less than 0.001) with the higher dose. Histologic changes in uterine musculature and cervical collagen were consistent with the inhibitory effects of nifedipine on uterine contractions. CONCLUSION: The results suggest that, in addition to tocolysis, nifedipine can cause vascular dilatation in both the uterus and the placenta. The use of nifedipine within the normal dose range does not appear to adversely affect fetal outcome and may potentially improve fetal outcome in some disorders of pregnancy.

Demonstration of relaxin precursors in pregnant rat ovaries with antisera against bacterially expressed rat prorelaxin.

The existence of rat 18-kilodalton (kDa) prorelaxin, which has been postulated from the coding sequence of cloned cDNA and the results of cell-free translation studies, has been directly demonstrated in rat ovaries with antibodies against bacterially expressed rat prorelaxin. The peptide expressed in E. coli from a rat prorelaxin cDNA construct was comprised of the B- and A-chains of relaxin and a 105-amino acid connecting region. Immunoreactive bands of 18 and 16.5 kDa were shown in ovaries from day 20 pregnant rats. Partial amino acid sequence analysis of both peptides revealed that they had identical N-terminal sequences, corresponding to rat prorelaxin. Both 18- and 16.5-kDa bands were present only from midpregnancy until near term, when they declined sharply. These changes in the concentration of 18-kDa prorelaxin match changes in preprorelaxin mRNA levels, suggesting that relaxin synthesis is regulated at the transcriptional level and not by protein processing. Prorelaxin was transiently secreted by COS-1 cells transfected with preprorelaxin cDNA. Treatment of culture medium with trypsin resulted in the appearance of material corresponding in size to mature relaxin. Thus, correctly folded prorelaxin appears to be a suitable precursor for relaxin. The combined concentrations of 18- and 16.5-kDa peptides in ovaries on day 20 of pregnancy were considerably more than 30 times greater than that of relaxin, however, suggesting that prorelaxin might also be more than a precursor per se.

The use of bupivacaine in elective inguinal herniorrhaphy as a fast and safe technique for relief of postoperative pain.

The intraoperative use of local anesthetic agents to decrease postoperative pain has been used in many types of procedures. Most of these techniques involve needle injection of anesthetic and result in a low but troublesome incidence of complications. In this study, we evaluated the reliability, safety, and efficacy of a technique emphasizing bathing of tissues with anesthetic rather than needle injection for relieving postoperative pain. Thirty consecutive patients undergoing outpatient elective inguinal herniorrhaphy with general anesthetic were prospectively randomized into four treatment groups. Group 1 received 0.5 per cent bupivacaine plus epinephrine 1 to 200,000; group 2, 0.5 per cent bupivacaine; group 3, normal saline solution, and group 4, no treatment. At the end of the repair, one-third of the test solution (approximately 5 milliliters) was bathed along the spermatic cord throughout its length in the inguinal canal. The external oblique aponeurosis was closed superficial to the cord structures and another one-third of the solution was instilled into the wound. Just prior to the end of skin closure the remaining solution was instilled subcutaneously. No needles were used to instill the solutions and they were not suctioned or removed from the wound. Data collection consisted of an analog type of patient questionnaire allowing subjective assessment of postoperative pain at various time intervals during the first 20 hours postoperatively. Pain medication provided was propoxyphene, 100 milligrams and acetaminophen, 650 milligrams every three hours as needed. Total doses of pain medication for the study period and the time to first pain medication requirement were obtained. Results were analyzed using analysis of variance, and Wilcoxon ranked sums test. Patients in group 1 (0.5 per cent bupivacaine with epinephrine) exhibited significantly less pain than those in groups 3 (saline solution) and 4 (control) for more than 12 hours postoperatively. Patients in group 2 (0.5 per cent bupivacaine) likewise experienced less pain than those in groups 3 and 4 through seven hours. The patients receiving saline solution were not significantly different than those in the control group throughout. Objectively, groups 1 and 2 required fewer total doses of pain medication and waited longer before requesting oral pain medication postoperatively compared with those in the control group. No complications occurred that could be attributed to the technique. The results of this study indicate that the bathing of wounds with 0.5 per cent bupivacaine with or without epinephrine 1:200,000 is a safe and effective method of decreasing postoperative pain for several hours in patients undergoing elective inguinal herniorrhaphy.(ABSTRACT TRUNCATED AT 400 WORDS)

The role of estrogen and relaxin in the reproductive abnormalities of mice with Hertwig's anemia.

Mice homozygous for a mutant allele (an/an) causing a lifelong macrocytic anemia (Hertwig's anemia) also demonstrate an inability to deliver their offspring, despite normal ovulation, conception, implantation, and fetal development. We investigated the roles of estrogen and relaxin in the etiology of the reproductive defect in the Hertwig's anemia mice. Immunoreactive relaxin levels were undetectable in the nonpregnant controls, whereas levels in both timed-pregnant controls and timed-pregnant affected mice were significantly higher than in nonpregnant controls, but not significantly different from each other. Mean interpubic ligament length in the pregnant Hertwig's anemia mice was significantly greater than that in nonpregnant controls, but significantly less than that in the pregnant controls on Day 18 of pregnancy. Porcine relaxin was administered to nonpregnant affected and unaffected littermates and to nonpregnant controls. Whereas controls showed a significant response to porcine relaxin, neither the Hertwig's anemia mice nor their unaffected littermates responded to the porcine relaxin. Additional study was performed to determine estradiol effects in the affected and control animals utilizing detailed computerized morphometric analysis of uterine horns and cervices from immature, estradiol-injected controls and Hertwig's anemia mice. Results demonstrated a statistically significant trophic effect of estradiol upon uterine horn and cervical enlargement, as assessed by weight and volume, in controls. Only a slight, non-significant effect was seen in Hertwig's anemia mice. Additional histological effects of estradiol, including endometrial enfolding observed in controls, were not present in Hertwig's anemia mice. Lack of response to both estrogen and relaxin is responsible for the parturitional defect in Hertwig's anemia mice.

Laparoscopic tubal sterilization. The potential for thermal bowel injury.

One of the most severe complications of laparoscopic tubal sterilization is bowel burns, although they often go undetected at the time of laparoscopy. Controversy remains over whether these injuries are caused directly by operator error or indirectly from a hot oviduct's or instrument's inadvertently touching and burning the intestine. A study was performed to determine the potential for direct or indirect bowel burns using bipolar electrocoagulation in rabbits. The results indicate that neither a hot tube nor hot (recently used) forceps could cause injuries to the serosal surface of the intestine. That was true both of immediate injury and after one to five days of recovery. It was observed that the hot uterine tube caused significant bowel adhesions by five days after the procedure. Direct electrocoagulation of the bowel using 40 W for three seconds caused a minor, noticeable blanch on the bowel that was not detectable with gross or histologic means after one day of recovery. A direct bowel injury did result when 80 W was used for three seconds; the bowel became perforated after one day. These findings indicate that it is unlikely that one can produce a bowel burn indirectly from a hot uterine tube or instrument and that only a direct insult to the bowel appears to cause an injury. However, adhesions could be a complication of the procedure and should be considered.

Effects of early maturation on fetal growth.

While the association of young maternal age with low birthweight (LBW) is well known, the contribution of early menarche to this association has never been studied. We examined the effects of early menarche (less than or equal to 11 years) on LBW and its two major underlying causes: pre-term delivery and smallness-for-gestational-age (SGA). Results represent a narrow chronological age range, 17-18 years, of a larger geographically based cohort of 2789 pregnant adolescents. Adjusted odds ratios (AOR) indicated that early menarche was significantly associated with an increased risk of LBW which was specific to SGA. The attributable risk of SGA with early menarche exceeded 20%. Early age at menarche is also correlated with an earlier onset of sexual activity, pregnancy, and childbearing. Consequently, adolescents with early menarche are over-represented in a sample limited to young gravidae or a sample that contains a stratum of young gravidae. This may have previously obscured the effects or early menarche on foetal growth and attributed them to a more frequently measured characteristic, young maternal age. Thus, effects of secular change in age at menarche may not be wholly benign. Improvements in maternal fertility and nutritional status appear to be offset by intrauterine growth retardation in the offspring.

[The mechanism of skeletal musculature contraction induced by pulses of a high-intensity magnetic field]. / K mekhanizmu sokrashcheniia skeletnoi muskulatury, vyzvannogo impul'sami magnitnogo polia vysokoi intensivnosti.

Acute experiments on nembutal-anesthetized cats (50 mg/kg) were employed to investigate the effect of 1 T pulsating magnetic field (PMF) on neuromuscular system of the leg. Special techniques (tubocurarine administration, PMF exposure of the isolated nerve before and after cold blockade, immersion of the isolated nerve into the media with different surface area and electrical conductance) furnished evidence on muscular contractions resultant exclusively from stimulation of the motor fiber. The generation of the potential effect was recorded under the conditions of the nerve trunk contact with a conducting medium with surface area sufficient for appearance of the threshold potential difference in its periphery.

[A comprehensive laboratory evaluation of changes in the fibrinogen molecule in the diagnosis of acquired coagulopathy conditions]. / Kompleksnaia laboratornaia otsenka prevrashchenii molekuly fibrinogena v diagnostike priobretennykh koagulopaticheskikh sostoianii.

A scheme of physicochemical determination of fibrinogen and the major molecular derivatives in a single sample of plasma is suggested, available for the majority of clinical laboratories. Such determination gives valuable information for a clinician. Among other things, the level of rapidly thrombin clotted fibrinogen portion is determined, as is the content of high-molecular fibrin monomer complexes, not clotted with thrombin, and the level of fibrinogen and fibrin proteolytic degradation products. Clinical (in 42 patients with various conditions) and experimental (coagulopathy in amniotic fluid embolism) application of this scheme has confirmed its clinico-diagnostic value.

[Descending modulation of monosynaptic reflexes after traumatic injury of the cat spinal cord]. / Niskhodiashchaia moduliatsiia monosinapticheskikh refleksov posle travmaticheskogo povrezhdeniia spinnogo mozga u koshek.

Studies of the descending modulation of monosynaptic reflex responses have revealed that electrical stimulation of dorsolateral, ventrolateral and ventral funiculi in C2 facilitated and suppressed test responses of intact animals, but evoked only suppression of spinal reflexes after injury of the spinal cord. The obtained data have shown that descending pathways which transmit facilitatory influences are more vulnerable to injury of the spinal cord.

Eight weeks of streptozotocin-induced diabetes influences the effects of cold stress on immunoreactive beta-endorphin levels in female rats.

Cold stress produced a significant reduction in the concentration of immunoreactive beta-endorphin (IR-BE) in the anterior pituitary of diabetic female rats. IR-BE levels in the anterior pituitary of non-diabetic female rats were not affected by exposure to the cold. The effects of cold stress on IR-BE levels in the neurointermediate lobe of the pituitary and the hypothalamus were attenuated in diabetic as compared to control animals. These data suggest that in female rats, eight weeks of diabetes produced alterations in the neuroendocrine mechanisms which modulate IR-BE levels in the pituitary and hypothalamus in response to cold stress.

Weight gain during adolescent pregnancy. Associated maternal characteristics and effects on birth weight.

Prospective data from 696 adolescents who delivered at 37 weeks or more gestation were analyzed to determine factors associated with weight gain during pregnancy and effects of pregnancy gains on birth weight and other outcomes of pregnancy. Pregnancy weight gain was found to be associated with the following factors: mother's ethnicity, length of gestation, parity, and presence of pregnancy-related hypertension. Maternal weight gain during pregnancy markedly increased infant birth weight. The risk of a low birth-rate infant was greatly reduced (OR = 0.14; CL = 0.1-0.2), and the risk of a macrosomic infant was 13.1 times higher (OR = 13.1; CL = 8.9-19.2) in adolescents gaining 20 kg or more. There was no increased risk for Caesarean section, fetal/neonatal death, or neonatal intensive care unit admission based on maternal weight gain. No effect of prepregnant relative weight on maternal weight gain was detected. The effect of weight gain on birth weight was also independent of the maternal prepregnant relative weight.

Influence of young maternal age and parity on term and preterm low birthweight.

Data on 4496 singleton births to young women (19 years or less) are reported by maternal age and parity with birthweight and gestation cross-classified to yield rates of preterm and term low birthweight. After adjustment, the risk of preterm low birthweight was increased with very young maternity (15 years or less); preterm low birthweight and term low birthweight were each increased with young multiparity. These data suggest that the identification of factors associated with preterm birth and their incorporation into the prenatal care regimen may be important in improving pregnancy outcome in young women.

PIP: Of infants with low birthweights, there are 2 subheadings: those whose period in utero is abbreviated (preterm low birthweight) and those who developed slowly in the intrauterine (term low birthweight). Because low birthweight is distinguished into these separate subheadings, intervention should directly correlate to the specific cause of the low birthweight. This distinction was used in a study of 4496 singleton births to women 19 or younger. Maternal age and parity with birthweight and gestation was cross-classified to show the rates of preterm term low birthweight. The results of the study showed the very young women aged 15 or younger had an increased likelihood of preterm low birthweight and therefore, not unusually, showed an increase in low birthweight. The group of young women had a low birthweight number 8% greater than the 20-24 age group. Among the young multiparae, the preterm and term low birthweight rates increased. In young gravidae, background factors such as poverty or poor nutrition can adversely influence birthweight. While term low birthweight has declined in the United States, preterm birthweight has been unchanged. One possible theory is that intervention programs have been aimed at term birthweight rather than preterm. Therefore, research and study should be initiated on preterm low birthweight.