In search of effective education in burn and fire prevention.

Children younger than 14 years continue to be a high-risk group for burn-related and fire-related injuries. Burn and fire educators must find a way to reach these children that captures their imaginations. There may be no better way than games. Two burn and fire prevention games were developed. The games were distributed to 38 school districts encompassing a total of 164 elementary schools and reaching more than 1,035 youngsters in grades 1 through 4 in a two-county community. Before playing each game, the participants completed a multichoice pretest. A similar posttest was administered after gaming to determine mastery and retention of knowledge. In addition, classroom instructors were given an evaluation form to assess content, quality, and effectiveness. Pretest and posttest results indicated students gained and retained significant knowledge. Instructor evaluation recognized these games as entertaining and exciting, precipitating additional questions leading to further classroom discussion and learning.

Episiotomy repair: Vicryl versus Vicryl rapide.

Women suffer a significant degree of perineal morbidity in the postpartum period. For some, it can be significant and interfere with daily activities. Although there seems to be no doubt that polyglycolic acid derivatives are superior to non absorbable sutures with regard to wound healing, problems still occur with their use. In this study a relatively new product, Vicryl rapide, was compared with Vicryl.

Isolation and characterization of CRF-related diuretic hormones from the whitelined sphinx moth Hyles lineata.

We have isolated and characterized two diuretic hormones (DH), Hylli-DH41 and Hylli-DH30, from extracts of whole heads of the lepidopteran Hyles lineata. We monitored the isolation by measuring the ability of fractions to affect levels of cyclic AMP production by Malpighian tubules of Manduca sexta maintained in vitro. These DH are related to a family of vertebrate neuropeptides which includes sauvagine, corticotropin-releasing factor (CRF), and urotensin I. Both Hylli-DH41 (RMPSLSIDLPMSVLRQKLSLE KERKVQALRAAANRNFLNDI-NH2) and Hylli-DH30 (SFSVNPAVEILQHRYMEKVAQNNRNFLNRV-NH2) show extremely high similarity with two DH from the tobacco hornworm M. sexta. This is not surprising because both H. lineata and M. sexta are sphingid moths. The discovery of these DH provides a third example of two CRF-related DH occurring in one insect species.

Violent maternal deaths in North Carolina.

OBJECTIVE: To describe the frequency of domestic violence and substance abuse among a series of injury-related maternal deaths, determine awareness of the obstetric provider of domestic violence in those deaths by intimate partner homicide or depression in those deaths by suicide, and examine the relative risk of violent maternal death for unmarried status and non-white race. METHODS: A follow-up investigation was carried out for a case series of 41 injury-related maternal deaths identified from 1992 to 1994 in North Carolina. Death certificates, police records, newspapers, and records from medical examiners were used to ascertain mechanism and intent, history of alcohol or drug abuse, and, in cases of homicide, the relationship of the perpetrator to the victim. The obstetric provider was asked about his or her knowledge of domestic violence, depression, and drug or alcohol abuse relevant to the deceased victim. RESULTS: A total of 21 women (51.2%) were known to have or suspected of having been abused by either an intimate partner or an acquaintance. Of the 41 women, 11 (26.8%) were known to have abused drugs and/or alcohol. The obstetric provider was aware or suspicious of abuse in one third of homicides committed by an intimate partner. In three of the five suicide deaths, the obstetric provider was aware of depression. CONCLUSION: Domestic violence and drug and alcohol abuse were common in this series of injury-related maternal deaths. Domestic violence and depression were often unrecognized by the obstetric provider in these severe cases.

Early amniocentesis: effect of removing a reduced volume of amniotic fluid on pregnancy outcome.

In mid-trimester amniocentesis (MTA), 12-15 ml of amniotic fluid is aspirated for cytogenetic analysis. When a similar volume of amniotic fluid is removed by early amniocentesis (EA), it represents a significant proportion of the total amniotic fluid volume in the first trimester. The fluid depletion, which may persist for 7 to 10 days, is considered to impair development of fetal lungs and extremities and, possibly, contribute towards procedure-related congenital abnormalities and miscarriages. By only removing 7 ml of amniotic fluid, we have demonstrated a total miscarriage rate (3.8 per cent) comparable with previous large studies (Table V), a low incidence of respiratory difficulties at birth (2.7 per cent) and a low incidence of fixed flexion deformities (1.6 per cent), at the expense of a small increase in the incidence of culture failure (2.2 per cent).

Transplacental early amniocentesis and pregnancy outcome.

The effect on pregnancy outcome of transplacental needle insertion was studied in 401 consecutive women attending for early amniocentesis between 10 and 14 completed weeks of pregnancy. Transplacental early amniocentesis was associated with a significantly higher incidence (P < 0.001) of blood-stained amniotic fluid taps but a lower incidence (not significant; P > 0.05) of pregnancy loss and miscarriages. Women in the nontransplacental early amniocentesis group had a significantly higher (P < 0.01) incidence of late procedure-related antenatal complications, such as preterm rupture of membranes or preterm labour. Our study showed that transplacental early amniocentesis is a safe procedure; contrary to present recommendations, the study also showed that avoiding the placenta during early amniocentesis is an unnecessary practice.

A prospective study of insulin sensitivity and glucose metabolism in women using a continuous subdermal levonorgestrel implant system.

OBJECTIVE: Decreased insulin sensitivity and deterioration in oral glucose tolerance curves have been reported with oral contraceptive use, particularly with those containing levonorgestrel. However, the subdermal levonorgestrel systems release a lower dosage of steroid and avoid the first pass through the liver that occurs with oral administration. We hypothesized, therefore, that continuous subdermal levonorgestrel has no significant effect on insulin sensitivity and other indices of glucose metabolism. METHODS: Nine women desiring a subdermal hormonal contraceptive system were recruited for this longitudinal prospective study. Each subject underwent a 3-hour frequently sampled intravenous glucose tolerance test immediately before insertion and after 6 months of continuous use. Insulin sensitivity and glucose effectiveness were determined using a mathematical minimal modeling approach. Glucose clearance and fasting and peak levels of glucose and insulin were examined as well. The matched-pair data were analyzed using paired t tests. RESULTS: There was no significant change in insulin sensitivity, glucose effectiveness, glucose clearance, or fasting or peak insulin levels. Fasting glucose levels remained within a normal range. CONCLUSIONS: Subdermal levonorgestrel appears to have no significant effect on tissue insulin sensitivity or glucose metabolism after 6 months of continuous use.

Successful pregnancy in association with Zollinger-Ellison syndrome.

Persistent severe vomiting in pregnancy may be caused by underlying disease and should be investigated. A patient with intractable vomiting associated with abdominal pain and dental enamel erosion in two pregnancies had a gastrinoma. Symptoms were successfully controlled with omeprazole in a third pregnancy. All three babies were healthy.

Triploid partial molar pregnancy detected through maternal serum alpha-fetoprotein and HCG screening.

BACKGROUND: Screening for Down syndrome using maternal serum alpha-fetoprotein (MSAFP) and hCG, with or without unconjugated estriol (E3), has become standard practice in much of the United States. When both MSAFP and hCG are elevated, the possibility of a partial molar pregnancy with fetal neural tube or abdominal-wall defect should be added to the differential diagnosis, as illustrated by this case. CASE: A 22-year-old woman had elevated MSAFP and hCG levels on routine screening at 16 weeks' gestation. Ultrasound examination suggested a neural tube defect and a thickened placenta. Amniocentesis was performed. She very rapidly developed preeclampsia. Fluorescence in situ hybridization showed three distinct spots for the three probes tested. A triploid karyotype was confirmed with standard cytogenetic analysis. The fetus had an open neural tube defect, and placental pathology was consistent with a partial hydatidiform mole. CONCLUSIONS: A possible partial molar pregnancy with abdominal-wall or open neural tube defect should be added to the differential diagnosis for interpreting Down syndrome screens when both MSAFP and hCG are elevated. A presumptive diagnosis of triploidy using fluorescence in situ hybridization was important in the management of this pregnancy.

Myocardial infarction during pregnancy: management and outcome of two pregnancies.

OBJECTIVE: Each year in the United States approximately 500,000 women die from ischemic heart disease. However, there are < 100 reported cases of myocardial infarction occurring during pregnancy. The current management of these patients is empiric, with pulmonary artery catheterization during labor being frequently reported. STUDY DESIGN: In the past year we have managed and delivered two such patients, including the first reported case of myocardial infarction with a triplet gestation. RESULTS: Both patients had clinical and laboratory signs of myocardial infarction and underwent coronary angiography. They subsequently had preeclampsia and were prematurely delivered of viable fetuses. One patient had angina pectoris during labor and was successfully treated with sublingual nitroglycerin. Neither patient suffered reinfarction or heart failure. Invasive hemodynamic monitoring was not used, and the mode of delivery was determined solely on obstetric indications. CONCLUSION: In pregnant patients with myocardial infarction, invasive central monitoring is unnecessary in patients with good cardiac function and reserve and the mode of delivery should be based on obstetric indications.

Immature lecithin/sphingomyelin ratios and neonatal respiratory course.

OBJECTIVE: We hypothesized that the absolute value of an immature lecithin/sphingomyelin ratio, in addition to gestational age and birth weight, contributes significantly to predicting the clinical course of the neonate. The lecithin/sphingomyelin value may therefore enhance clinical decision-making regarding timing of delivery and use of tocolytics in high-risk pregnancies. STUDY DESIGN: One hundred four mother-baby pairs with delivery within 72 hours of an immature lecithin/sphingomyelin determination in the 3-year period immediately before the initiation of surfactant therapy in our hospital were retrospectively reviewed. Stepwise regression was performed for the independent variables of gestational age, birth weight, and lecithin/sphingomyelin values in a linear model to predict total days of respiratory support (oxygen, continuous positive airway pressure, or mechanical ventilation). RESULTS: In the patients without preterm premature rupture of membranes the lecithin/sphingomyelin value was the best predictor of duration of respiratory support (R2 = 0.2426, F = 12.4908, p = 0.011). After gestational age was controlled for, there was a significant inverse correlation between the lecithin/sphingomyelin value and days of respiratory support (F = 4.634, p = 0.031). In the patients with preterm premature rupture of membranes with vaginally collected fluid, however, lecithin/sphingomyelin values did not contribute significantly in predicting duration of respiratory support. Rupture-to-delivery interval and gestational age were the best predictors in this group. CONCLUSION: Although a mature lung profile is the ideal situation, preterm delivery may be indicated in pregnancies complicated by maternal disease or evidence of possible fetal compromise. We conclude that in patients without premature rupture of membranes the absolute value of the immature lecithin/sphingomyelin ratio is a better predictor than gestational age or birth weight of duration of respiratory support and should be considered in timing of delivery.

Tuboovarian pregnancy associated with elevated maternal serum alpha-fetoprotein. A case report.

Tuboovarian implantation is a rare form of pregnancy that is difficult to diagnose in early gestation. A patient with a tuboovarian pregnancy presented with abnormally elevated initial screening maternal serum alpha-fetoprotein (MSAFP). The elevated MSAFP and a pelvic mass of uncertain etiology on ultrasonography delayed the diagnosis until laparotomy was performed. Elevated MSAFP accompanied by oligohydramnios and a pelvic mass is a particularly suspect finding for a tuboovarian or other type of extrauterine implantation.

Phaeochromocytoma in pregnancy. Five cases and a review of the literature.

We report five patients with phaeochromocytoma associated with pregnancy and review the 42 other cases reported in the literature from 1980 to 1987. The overall maternal mortality was 17% and the fetal loss 26%; antenatal diagnosis of phaeochromocytoma reduced the maternal mortality to zero and the fetal loss to 15%, but was made in only 53% of the patients. Although phaeochromocytoma is rare, a high index of clinical suspicion must be maintained and all those at risk investigated if earlier diagnosis and improved outcome are to be achieved. Once the diagnosis is confirmed, alpha-blockade is essential and beta-blockade may be required. CT scan or magnetic resonance imaging may be used to localize the tumour during the antenatal period. In the first and second trimesters, tumour resection has a good fetal outcome; in later pregnancy, delivery by elective caesarean section followed by tumour resection is recommended.

Arginine vasopressin infusion stimulates adrenocorticotropic hormone and cortisol release in the ovine fetus.

Arginine vasopressin may play a role in the control of adrenocorticotropic hormone release during stress in the adult animal. Arginine vasopressin is also considered an important stress hormone in the fetus. The effect of arginine vasopressin infusion on adrenocorticotropic hormone release in the fetus was investigated in 14 chronically cannulated ovine fetuses with normal blood gas and pH values between 103 and 137 days' gestation. There was a significant increase in adrenocorticotropic hormone and cortisol levels during a 30-minute infusion of arginine vasopressin. Plasma renin activity was unchanged. The corticotropin-releasing activity of arginine vasopressin was not blocked by pretreatment with a V1-receptor antagonist and was not significantly different when the pressor response was attenuated by sodium nitroprusside infusion.

Human fetal breathing response to intravenous glucose is directly related to gestational age.

This prospective longitudinal study examined human fetal breathing activity over the second half of pregnancy both in the fasting state and after intravenous glucose administration. There was a linear relationship between gestational age and percent time spent breathing after glucose between 19 and 38 weeks' gestation. However, no such correlation could be demonstrated between gestational age and fetal breathing activity in the fasting state.