Clinical efficacy of intravenous followed by oral azithromycin monotherapy in hospitalized patients with community-acquired pneumonia. The Azithromycin Intravenous Clinical Trials Group.

The purpose of this study was to evaluate intravenous (i.v.) azithromycin followed by oral azithromycin as a monotherapeutic regimen for community-acquired pneumonia (CAP). Two trials of i.v. azithromycin used as initial monotherapy in hospitalized CAP patients are summarized. Clinical efficacy is reported from an open-label randomized trial of azithromycin compared to cefuroxime with or without erythromycin. Bacteriologic and clinical efficacy results are also presented from a noncomparative trial of i.v. azithromycin that was designed to give additional clinical experience with a larger number of pathogens. Azithromycin was administered to 414 patients: 202 and 212 in the comparative and noncomparative trials, respectively. The comparator regimen was used as treatment for 201 patients; 105 were treated with cefuroxime alone and 96 were given cefuroxime plus erythromycin. In the comparative trial, clinical outcome data were available for 268 evaluable patients with confirmed CAP at the 10- to 14-day visit, with 106 (77%) of the azithromycin patients cured or improved and 97 (74%) of the comparator patients cured or improved. Mean i.v. treatment duration and mean total treatment duration (i.v. and oral) for the clinically evaluable patients were significantly (P < 0.05) shorter for the azithromycin group (3.6 days for the i.v. group and 8.6 days for the i.v. and oral group) than for the evaluable patients given cefuroxime plus erythromycin (4.0 days for the i.v. group and 10.3 days for the i.v. and oral group). The present comparative study demonstrates that initial therapy with i.v. azithromycin for hospitalized patients with CAP is associated with fewer side effects and is equal in efficacy to a 1993 American Thoracic Society-suggested regimen of cefuroxime plus erythromycin when the erythromycin is deemed necessary by clinicians.

Preadmission nutrition screening: expanding hospital-based nutrition services by implementing earlier nutrition intervention.

The need to screen patients earlier than within the first 24 hours of hospital admission has resulted in the development of preadmission nutrition screening. At Providence Saint Joseph Medical Center (PSJMC), a 455-bed acute-care facility, this procedure has been used since 1994. The preadmission screening method was developed because of the use of critical pathways for patients in specific diagnosis-related groups. Critical pathways specified that registered dietitians must assess these patients within 24 hours of admission at PSJMC. However, at that time there was minimal data in the chart from which to assess the patient's nutritional status and the ability to interview the patient was often limited as a result of intubation or postoperative pain. Family members were not always available at the hospital to discuss a patient's preadmission nutritional status. To address this problem, we developed a system to call people at home before their admission to the hospital to obtain specific nutrition information. To analyze the effectiveness of the procedure, the Food and Nutrition Services Department developed a process to assess this method of screening and to improve the system. Patients were enrolled in a study over a 1-month period, demographics were identified for this sample population, and patient satisfaction was determined via an interview conducted by a dietetic technician after the patient was admitted. Most patients found this to be a very helpful process and an example is presented here on the role of preadmission nutrition screening in improving patient outcome. To better define the population of the case study presented, additional information was gathered on a second study group of patients screened before admission who were admitted for hip and knee surgery, one of the specific diagnosis-related groups with a critical pathway. Our findings indicate that preadmission nutrition screening has the potential to improve patient outcomes by increasing nutrient intake before their hospital admission, reducing hospitalization length, and enhancing patient satisfaction during their hospital stay.

A method of masking oxytocin infusion rates.

BACKGROUND: Controversy exists as to the optimum infusion rate of oxytocin during labor. A system is described to mask infusion rates, and this may help eliminate bias in the study of oxytocin infusion. METHOD: The hardware consists of a commercially available infusion pump that has the capability to receive and send computer messages and a laptop computer. The pump and a programmed computer are attached to a portable stand for bedside use. The display on the pump may be masked while the computer displays the level for any one of three actual rates. EXPERIENCE: Masked and unmasked simulations were performed without human subjects, followed by unmasked bedside testing in 45 patients. The simulation and bedside testing confirmed the system had the ability to maintain designated flow rates in all manner of increases, decreases, stoppages, and restarts. CONCLUSION: This system is a computer-controlled infusion pump with the ability to mask infusion rates. This may allow investigators to compare oxytocin infusion rates objectively in the induction and augmentation of labor.

Gestational diabetes mellitus: metabolic and blood glucose parameters in singleton versus twin pregnancies.

OBJECTIVES: This study compared the frequency, glucose tolerance test results, and parameters of blood glucose control in twin and singleton pregnancies associated with gestational diabetes mellitus and carbohydrate intolerance. STUDY DESIGN: Twin and singleton pregnancies associated with gestational diabetes mellitus and carbohydrate intolerance were compared as follows: frequency, maternal age, weight, 1-hour screen, glucose tolerance test results, posttreatment blood glucose values, insulin requirement, and insulin dose. Statistical analysis included the chi(2) and Student t tests. RESULTS: Gestational diabetes mellitus was increased in twins (7.7% vs 4.1%; P <.05). The maternal weight at first visit was significantly less, and the 3-hour glucose tolerance test value was significantly greater than that for singletons. The other parameters were not different. CONCLUSIONS: There is a significant increase in the incidence of gestational diabetes mellitus and disturbance of the 3-hour glucose tolerance test in twin pregnancies. However, insulin requirements were not different, suggesting a mild disturbance of carbohydrate tolerance that was effectively managed by the strategies used to achieve blood glucose control in singletons.

Chronic necrotizing pulmonary aspergillosis: approach to management.

OBJECTIVE: To describe our experience with 6 patients and to review the current literature to update the approach to the diagnosis and treatment of chronic necrotizing pulmonary aspergillosis. DESIGN: Patient reports and MEDLINE review of English-language literature published after 1980. RESULTS: Chronic necrotizing pulmonary aspergillosis (CNPA) is a subacute infection most commonly seen in patients with altered local defense from preexisting pulmonary disease or in patients with risk factors that alter systemic immune status. Delays in diagnosis are common. Although initial reports advocated intravenous amphotericin B, itraconazole has emerged as a better initial therapy because of its documented efficacy and minimal toxicity. The dose and duration of therapy should be based on clinical response. In patients who do not respond to medical therapy, pulmonary resection can be considered, but postoperative morbidity is high. Recurrent or relapsing infections occur; chronic maintenance therapy with itraconazole can be considered in patients with residual parenchymal scarring. A wide range of mortality rates has been reported for CNPA. Outcome is most likely influenced by severity of comorbid conditions, extent of underlying pulmonary disease, delays in diagnosis, and initiation of effective therapy.

Aspiration in a patient receiving enteral nutrition.

This case was selected to illustrate the advantages of an interdisciplinary team approach when the aspiration risks of enteral tube feeding are examined for patients with multisystem involvement. The case reviews a 79-year-old widowed woman with a cervical 6 to 7 spinal cord injury requiring mechanical ventilation and enteral feeding. The patient had multiple complications that prolonged her hospital course and required interdisciplinary involvement of medical, nutrition, nursing, respiratory, and speech pathology services. After an initial stay at another hospital, she was admitted to Providence Saint Joseph Medical Center (PSJMC) Acute Rehabilitation and Intensive Care Units. The patient was transferred home with PSJMC Home Health Services, and her case was part of a continuous quality improvement (CQI) project population group of ventilator-dependent patients. The purpose of the interdisciplinary CQI team was to enhance nutrition intervention, improve patient outcomes, and reduce costs. This teaching case has added to the body of information being evaluated by the CQI team on nutrition intervention of ventilator-dependent patients.

Enhanced enteral and parenteral nutrition practice and outcomes in an intensive care unit with a hospital-wide performance improvement process.

To improve patient outcomes at a 455-bed community health care facility, a performance improvement process was implemented for the delivery of enteral and parenteral nutrition in a 28-bed intensive care unit (ICU). In 1992, the study group consisted of all patients who were started on either enteral or parenteral nutrition while in the ICU during a 2-month period. These patients were followed up until discharge from the hospital or death to determine practice patterns and outcomes. Three actions were identified as opportunities to change practice and improve outcomes: increase use of the enteral route of alimentation compared with the parenteral route; start alimentation sooner, especially via the enteral route; and meet protein and energy needs of patients. Educational programs were developed targeting physician and nursing staff. Through an interdisciplinary approach, a nutrition support decision tree and patient outcome statement were developed. In 1994, evaluation of a group meeting the same criteria as the original group indicated that the goals for nutrition support practice improvement were met in all three areas identified. Providing a systematic approach to an interdisciplinary performance improvement process, as part of an organization-wide plan, enhanced nutrition support practice in a community hospital and resulted in quality improvement and cost savings.

Immediate delivery room repair of fetal abdominal wall defects.

Eighteen patients with a prenatal diagnosis of fetal abdominal wall defect were delivered by cesarean section and repaired either immediately (begun within 15 min, n = 9), or by the traditional (delayed) method (n = 9, average delay = 4.4 h). Neonates repaired immediately had comparable gestational ages and birthweight, however, subjectively had less edematous bowel with less fibrous peel. These fetuses were more likely to be closed primarily (7/9 vs. 4/9), spent less time on a ventilator (8.1 vs. 17.9 days), seemed to be fed sooner (7.6 vs. 17.9 days), and discharged home earlier (14.3 vs. 24.0 days). Our results suggest that for fetuses delivered by cesarean section, early defect repair may reduce bowel edema and fibrous peel formation thus facilitating primary closure, with earlier ventilator weaning, feeding and discharge home.

Acute iron intoxication in pregnancy: case report and review of the literature.

Limited reports exist regarding acute iron intoxication during pregnancy. The maternal and fetal effects of accidental or deliberate ingestion of large amounts of iron may be catastrophic. A case report of acute iron intoxication, management strategies, and a review of the literature are presented. The cornerstones of effective therapy are aggressive management with emesis induction or gastric lavage, bicarbonate instillation, vigorous intravenous hydration, and chelation therapy with deferoxamine.

Does the amniotic fluid index change over a short-term time interval?

The amniotic fluid index (AFI) is a rapid and simple technique that is commonly used to assess amniotic fluid volume. It is commonly used in conjunction with other tests of fetal well-being that extend over a variable time interval. The data on interobserver and intraobserver variability have not stated the interval between measurements, although it is likely that they have been repeated immediately. In this study an AFI was repeated after a short time interval to assess whether a significant difference exists, as this may be clinically relevant. In 91 patients, the AFI was performed at the beginning and end of an ultrasound scan for either growth and development, or for Doppler velocimetry. The interval between the two measurements was 30-45 min, and the respective results were as follows: mean 18.4 vs. 18.7; standard deviation 4.2 vs. 3.9; minimum value 10.1 vs. 11.0 and maximum value 35.0 vs. 30.0. There were no significant differences between the two measurements (p > 0.133; d.f. = 90) and the correlation coefficient was 0.874 (p < 0.0001). These results validate the reproducibility of the AFI over a 30-45 min interval, during which time most adjunctive tests are usually completed. Therefore, the timing of the AFI in relation to the other tests is not critical.

Eclampsia complicating a pregnancy with neurofibromatosis. A case report.

Neurofibromatosis occurs in approximately 1 in 3,000 births and is known to be associated with the development and/or worsening of hypertension in pregnancy. A woman was treated for eclampsia with neurofibromatosis and had a complicated course.

An evaluation of antenatal fetal acoustic stimulation.

Fetal heart rate reactivity was evaluated following acoustic stimulation testing (AST). The AST and NST (non-stress test) were compared with regards to certain adverse perinatal outcome criteria, and in a selected sample of cases, to other surveillance tests. These tests were the oxytocin challenge test (OCT) and biophysical profile (BPP). 479 tests were performed on 240 high-risk patients. The AST significantly increased fetal heart rate reactivity. With regards adverse perinatal outcome criteria, there was no significant difference between the AST and NST in relation to sensitivity, specificity or predictive values. In the 38 patients with both non-reactive NSTs and reactive ASTs, 5 (13.5%) had immediate follow-up surveillance tests (OCTs and/or BPPs) that were non-reassuring and necessitated delivery. In four of the five cases, there was evidence of potential fetal compromise. These preliminary observations suggest that the AST may have evoked reactivity in fetuses with early compromise, and raise concerns about replacing the NST with the AST as a primary screening test of fetal well-being.

Prenatal diagnosis of duplication cyst of the pylorus.

The first description of the antenatal appearance of a duplication cyst of the pylorus is presented. Prior to the infant's delivery, the possibility that this intra-abdominal cystic mass represented a choledochal cyst was also strongly considered. The antenatal detection of this cystic mass allowed close neonatal surveillance and timely surgical intervention prior to the onset of serious neonatal complications. The embryogenesis of duplication cysts of the gastrointestinal tract and bronchopulmonary foregut malformations is reviewed. The clinical utility of the prenatal diagnosis of such fetal gastrointestinal anomalies is also discussed.

Combined ultrasonography and amniocentesis for pregnant women with elevated serum alpha-fetoprotein. Revising the risk estimate.

A combination of ultrasound and amniocentesis for alpha-fetoprotein (AFP) and acetylcholinesterase (ACHE) identified 36 anomalous fetuses among 331 pregnant women evaluated at our center for "true" elevated maternal serum alpha-fetoprotein (MSAFP). In six cases the diagnosis of fetal anomalies was missed on initial ultrasonography. In addition, placental pathology was identified in 12 cases and adverse outcome (fetal demise, intrauterine growth retardation, severe oligohydramnios) in 15. When grouped by multiples of the median (MOM), a significant linear correlation was observed between increasing MSAFP and the rate of fetal anomalies or adverse outcome. The frequency of fetal anomalies increased from 0.93% when MSAFP was less than 3.0 MOM to 56% when MSAFP was greater than 7.5 MOM. No differences were observed in the frequency of placental pathology between the groups. A normal ultrasound study in these patients will decrease considerably, but not eliminate, the risk estimate for undetected fetal anomalies. From our 83% ultrasound sensitivity we calculate that with MSAFP greater than 3.0 MOM the risk of anomalies despite a reassuring scan is greater than 1% and clearly warrants offering amniocentesis for amniotic fluid AFP and ACHE. Between 2.5 and 3.0 MOM the risk is relatively low. Amniocentesis should be offered routinely to patients with MSAFP greater than 3.0 MOM and normal ultrasonography. In patients with MSAFP of 2.5-2.9 MOM and satisfactory ultrasonography the risk of amniocentesis may outweigh its benefits.

Conservative management of second-trimester post-amniocentesis fluid leakage.

During a 32-month period, 603 genetic amniocenteses were performed in our institution, and seven patients (1.2%) experienced fluid leakage within 24 hours of the procedure. All seven patients were hospitalized for strict bed rest and expectant management. Cessation of amniotic fluid leakage and reaccumulation of normal amniotic fluid occurred within 7 days in all cases. Six patients were delivered at term of appropriately grown infants without complication. One patient experienced an intrauterine death at 25 weeks' gestation (6 weeks after the occurrence of fluid leakage secondary to genetic amniocentesis). Although limited by the small number of patients, our experience suggests the following: 1) Appropriate respect for potential complications of genetic amniocentesis is still warranted; 2) expectant management of patients who experience membrane rupture after genetic amniocentesis may be associated with a good perinatal outcome; and 3) membrane rupture after genetic amniocentesis may represent a fundamentally different etiologic entity than spontaneous rupture of the membranes in the second trimester not associated with genetic amniocentesis.

Female sterilizations in the United States, 1987.

A study by the Association for Voluntary Surgical Contraception and the Centers for Disease Control estimated that 640,000 tubal sterilizations were performed in the United States during 1987. The majority of these were inpatient procedures (66 percent) performed in civilian or military hospitals. Hospitals were also the site for the largest share of the 215,000 outpatient procedures. Overall, 33 percent of sterilizations were laparoscopies: 10 percent of the inpatient sterilizations and 79 percent of outpatient procedures. The region with the largest number of sterilizations was the South, which also had the smallest proportion done on an outpatient basis.

Left upper lobe torsion following lower lobe resection. Early recognition of a rare complication.

Left upper lobe torsion occurred in a woman during the first 24 hours following left lower lobectomy for bronchogenic carcinoma resection. To our knowledge, this is the first report of left upper lobe torsion. When atypical chest pain or opacification of the remaining lung develops following resectional surgery, torsion of the remaining lung must be suspected. Prompt diagnosis and treatment may prevent the morbidity and mortality associated with pulmonary infarction from torsion.