Airway management during the COVID-19 pandemic: macintosh laryngoscopy vs. video laryngoscopy.

OBJECTIVE: Our study aimed to compare video laryngoscopy (VL) vs. direct laryngoscopy (DL) for tracheal intubation in adult patients receiving general anesthesia for elective surgery during the COVID-19 pandemic. PATIENTS AND METHODS: The study included 150 patients 18-65 years old, ASA I-II (American Society of Anesthesiologists), and negative PCR tests before the operation was scheduled for elective surgery under general anesthesia. Patients were subdivided into two groups considering the intubation method: the video laryngoscopy group (Group VL, n=75) and the Macintosh laryngoscopy group (Group ML, n: 75). Demographic data, operation type, intubation comfort, and field of view, intubation times, complications were recorded. RESULTS: Both groups' demographic data, complications, and hemodynamic parameters were similar. In Group VL, Cormack-Lehane Scoring values were higher (p<0.001), the field of view was better (p<0.001), and the intubation was more comfortable (p<0.002). The duration for the vocal cord appearance was significantly shorter in the VL group than in the ML group (7.55±1.00 vs. 8.31±2.20 sec, p=0.008, respectively). The beginning of intubation to full ventilation of the lungs was significantly shorter in the VL group than the ML group (12.71±2.72 vs. 17.48±6.8, p<0.001, respectively). CONCLUSIONS: Using VL in endotracheal intubation may be more reliable in reducing intervention times and the risk of suspected transmission during the COVID-19 pandemic.

Tetanus in adults: results of the multicenter ID-IRI study.

Tetanus is an acute, severe infection caused by a neurotoxin secreting bacterium. Various prognostic factors affecting mortality in tetanus patients have been described in the literature. In this study, we aimed to analyze the factors affecting mortality in hospitalized tetanus patients in a large case series. This retrospective multicenter study pooled data of tetanus patients from 25 medical centers. The hospitals participating in this study were the collaborating centers of the Infectious Diseases International Research Initiative (ID-IRI). Only adult patients over the age of 15 years with tetanus were included. The diagnosis of tetanus was made by the clinicians at the participant centers. Izmir Bozyaka Education and Research Hospital's Review Board approved the study. Prognostic factors were analyzed by using the multivariate regression analysis method. In this study, 117 adult patients with tetanus were included. Of these, 79 (67.5%) patients survived and 38 (32.5%) patients died. Most of the deaths were observed in patients >60 years of age (60.5%). Generalized type of tetanus, presence of pain at the wound area, presence of generalized spasms, leukocytosis, high alanine aminotransferase (ALT) and C-reactive protein (CRP) values on admission, and the use of equine immunoglobulins in the treatment were found to be statistically associated with mortality (p < 0.05 for all). Here, we describe the prognostic factors for mortality in tetanus. Immunization seems to be the most critical point, considering the advanced age of our patients. A combination of laboratory and clinical parameters indicates mortality. Moreover, human immunoglobulins should be preferred over equine sera to increase survival.

The association between the regular use of preventive labour induction and improved term birth outcomes: findings of a systematic review and meta-analysis.

BACKGROUND: Despite a lack of high-quality evidence, the use of 'non-indicated' term labour induction is increasingly restricted throughout the world. OBJECTIVES: To assess published associations between the regular use of modelled risk-based 'non-indicated' term labour induction (hereinafter 'preventive induction') and rates of common adverse birth outcomes. SEARCH STRATEGY: MEDLINE and PUBMED databases were searched electronically. SELECTION CRITERIA: Studies were identified that compared term birth outcomes following either the current standard approach with its emphasis on the expectant management of intermediate-level risk or the regular use of preventive induction. DATA COLLECTION AND ANALYSIS: Four studies from four unique databases were identified. A meta-analysis was performed using STATA IC12. MAIN RESULTS: Pregnancies exposed to the regular use of preventive induction (n = 1153), as compared with pregnancies receiving the current standard approach (n = 1865), experienced a lower caesarean delivery rate (5.7% versus 14.4%; relative risk 0.39, 95% CI 0.31-0.50; I(2) P = 0.21), a lower neonatal intensive care unit admission rate (2.9% versus 6.5%; relative risk 0.45, 95% CI 0.31-0.65; I(2) P = 0.57), and a lower weighted adverse outcome index score (2.8 versus 6.1). CONCLUSIONS: The regular use of preventive induction, as compared with the current standard approach, was associated with a more favourable pattern of birth outcomes. Other recently published meta-analyses have also determined that certain types of 'non-indicated' labour induction are beneficial. Accordingly, the current broad restrictions on 'non-indicated' labour induction should be reconsidered. Adequately powered multi-site randomised clinical trials are needed to definitively study the risks and benefits of modelled risk-based 'non-indicated' (i.e. 'preventive') term labour induction.

Intrapartum fever, epidural analgesia and histologic chorioamnionitis.

OBJECTIVE: Our objective was to determine whether epidural analgesia and histologic chorioamnionitis were independent predictors of intrapartum fever. STUDY DESIGN: This secondary analysis, retrospective cohort study included term parturients with placental examination during 2005. Logistic regression used fever (⩾38 °C) as the dependent variable. Significance was defined as P⩽0.05. RESULT: There were 488 (76%) of 641 term parturients with placental examination and epidural. Independent predictors of intrapartum fever were epidural odds ratio (OR)=3.4, confidence interval (CI): 1.70, 6.81, histologic chorioamnionitis OR=3.18, 95% CI: 2.04, 4.95, birthweight OR=2.07, 95%CI: 1.38, 3.12, vaginal exams OR=1.15, 95% CI:1.06, 1.24, duration ruptured membranes OR=1.03, 95% CI: 1.01,1.05, parity⩾1 OR=0.44: 0.29, 0.66 and thick meconium OR=0.35: 95%CI: 0.24, 0.85. CONCLUSION: Epidural analgesia and histologic chorioamnionitis were independent predictors of intrapartum fever. Modification of labor management may reduce the incidence of intrapartum fever.

A review of thromboembolic complications in pregnancy.

Combined with the enlarging uterus compressing the venous system of the pelvis and the vessel trauma incurred in delivery, an increase in clotting factor production in pregnancy predisposes the gravid patient to the peril of thromboembolism. When a patient has an inherited thrombophilia and becomes pregnant, this combination of risk factors in the presence of pregnancy may be the tipping point, pushing the coagulation cascade into an activated state. All thrombophilias, deep vein thrombosis, and pulmonary embolism are factors associated with complications in pregnancy that may lead to catastrophic consequences. This review report on the most frequent thromboembolic complications in pregnancy.

Clinical and laboratory aspects of a trichinellosis outbreak in Izmir, Turkey.

Epidemiological, clinical and laboratory data were collected during an outbreak of trichinellosis, which occurred in Izmir, Turkey, between January and March 2004. The source of the infection was raw meatballs made with a mixture of uncooked beef and pork. Of 474 persons who were admitted at the Ataturk Training and Research Hospital during this period with a history of raw meatball consumption, the diagnosis of trichinellosis was confirmed for 154 (32.5%, 87 males and 67 females; mean age 31 years, range 6-67 years). Among persons with a confirmed diagnosis, 79% had myalgia, 77% weakness and malaise, 63% arthralgia, 40% jaw pain, 68% fever, 63% periorbital and/or facial oedema, 49% oedema at the trunk and limb, 42% abdominal pain, 40% nausea and vomiting, 28% diarrhoea, 23% subconjunctival haemorrhage, 25% macular or petechial rash, 4% subungual haemorrhage, 15% cardiac complaints and 0.2% neurological complaints. Nine patients (5.8%) were hospitalised due to severe myalgia (n = 2), high fever (n = 3), neurological manifestations (n = 1), thrombophlebitis (n = 2) and palmar erythema (n = 1). Eosinophilia was present in 88% of the confirmed cases at the admission. Elevated levels of serum creatine phosphokinase, lactic dehydrogenase and aspartate aminotransferase were detected in 72%, 70% and 16% of the confirmed cases, respectively. The seroconversion occurred in most of the infected people between the 4th and 6th weeks after the infection. All of the confirmed cases were treated with mebendazole. People with severe symptoms were treated also with prednisolone (60 mg/day for three days) and those with a moderately severe clinical pattern received a non-steroid anti-inflammatory drug (naproxen sodium, 550 mg/day). All confirmed cases recovered without any clinical sequela.

Fetal gender and sonographic assessment of crown-rump length: implications for multifetal pregnancy reduction.

OBJECTIVES: Fetal size is a common criterion for the selection of an individual fetus to be reduced during multifetal pregnancy reduction. We investigated whether a difference in crown-rump length (CRL) exists between male and female fetuses at 9-13 weeks' gestation. METHODS: A total of 883 singleton pregnancies was evaluated at the time of chorionic villus sampling. The mean gestational age at the time of intervention was 10.9 weeks. Pregnancies were dated by certain last menstrual period (LMP). Pregnancies with uncertain dating by LMP or with a sonographic difference of gestational age > 1 week compared with LMP were excluded, as were all cases with chromosomal abnormalities. CRL differences between male and female fetuses were compared using Student's t-test. RESULTS: A total of 417 female and 466 male fetuses fulfilled our study criteria. Their gestational ages ranged between 9.3 and 13.9 weeks. We found no significant difference in size between the male and female fetuses. CONCLUSION: Using the CRL to guide multifetal pregnancy reduction should not result in a clinically significant selection of either gender.

Continuous cervical epidural anesthesia in hand surgery.

Regional anesthesia, with its known benefits such as increased blood flow, reduced cost, and security, is a method of choice for hand surgery. Recently, the authors have switched from axillary block to continuous cervical epidural anesthesia, which has several advantages such as low cost, a pain-free postoperative period, better control of tourniquet pain, and the avoidance of a motor block so that early active motion is possible. Continuous cervical epidural anesthesia is a safe and reliable method, providing a sensory block with an infusion rate of 4 ml/hr ultracaine (articaine 2 percent), and a motor block when the dosage is increased to 8 ml/hr ultracaine (articaine 2 percent). Postoperatively, only 4 ml/hr ultracaine (articaine 2 percent) is sufficient to provide a sensory block. The method provides both good perfusion and a lower local anesthetic drug dosage than axillary block.

The degree of antenatal ventriculomegaly is related to pediatric neurological morbidity.

OBJECTIVE: Our hypothesis was that the degree of antenatally diagnosed cerebral ventriculomegaly is related to aneuploidy, perinatal mortality and long-term neurological morbidity. METHODS: Ninety-one cases of ventriculomegaly identified from 1 June 1994 to 1 July 1999 were examined for prenatal, intrapartum and neonatal complications. Pediatric follow-up was reviewed for infants with ventriculomegaly from birth up to as long as 4 years. Minor neurological morbidity was defined as a score of 70-80 on the clinical adaptive test/clinical linguistic and auditory milestone scale and included mild motor or language delay. Major morbidity included a score of < 70, evidence of cerebral palsy, or seizure disorder. The incidence of neurological complications was compared, on the basis of the degree of ventriculomegaly, with group 1 being > 10-15 mm and group 2 being > 15 mm. RESULTS: Twenty-seven cases (18 with neural tube defects and nine with holoprosencephaly) were excluded. Among the remaining 64 patients, 39 had a ventricular diameter of > 10-15 mm and comprised group 1. Five of the 39 cases (12.8%), all with other ultrasound anomalies, elected to terminate. The incidence of aneuploidy in group 1 was 14.2%. Among the 19 cases with isolated ventriculomegaly, 17 (89%) were normal and two (11%) had minor neurological morbidity. In group 1 there were two cases associated with cytomegalovirus (CMV) infection. Of the 25 cases in group 2, eight (32%), all with other ultrasound anomalies, elected to terminate. The incidence of aneuploidy in group 2 was 17.4%. For the nine cases with isolated ventriculomegaly of > 15 mm, one (11%) was normal (p < 0.001), five (56%) had minor neurological morbidity requiring a ventriculoperitoneal shunt (p = 0.035), and three (33%) had major neurological morbidity (p = 0.045) when compared to cases of isolated ventriculomegaly in group 1. There was one case of CMV infection in group 2. All perinatal deaths in both groups were associated with other anomalies. CONCLUSIONS: Amniocentesis to determine karyotype and the presence of CMV is warranted for all cases of ventriculomegaly of > 10 mm. The degree of antenatal ventriculomegaly is related to pediatric neurological morbidity and, when it is > 15 mm, it is associated with an increase in abnormal neurological development.

University hospital-based prenatal care decreases the rate of preterm delivery and costs, when compared to managed care.

OBJECTIVE: Our purpose was to compare the rate of recurrent preterm delivery and the combined costs of mother/infant care for patients with a history of preterm delivery cared for in an inner city hospital house staff (HS) clinic versus an inner city managed care organization (MCO). METHODS: A retrospective cohort study was conducted. The groups consisted of 96 patients with a history of preterm delivery who were cared for by the HS clinic and 164 patients cared for in a neighborhood MCO. All patients with a history of previous preterm delivery who delivered at the Johns Hopkins Hospital between 1 January 1994 and 31 December 1996 were included in the study. The groups were examined regarding source of prenatal care for the subsequent pregnancy (HS vs. MCO), baseline demographics, intensity of prenatal care, maternal and neonatal outcomes and total cost of the provision of care. RESULTS: There were no differences in baseline demographics between the groups. There was a higher rate of recurrent prematurity for patients cared for by the MCO (HS, 24% vs. MCO, 36%, p = 0.04). Mean total mother/infant costs were also higher in the MCO group ($13565) when compared to the HS group ($9082), (p = 0.02). CONCLUSION: While some MCOs may provide cost savings for some low-risk populations, our study demonstrates that this health-care delivery system resulted in greater total expenditures for patients with a history of preterm delivery.

Low 1-hour glucose screens and small for gestational age infants.

OBJECTIVE: To determine whether a 1-hour glucose screen done at 26 to 29 weeks' gestation that is below the fifth percentile is predictive of having a small for gestational age (SGA) infant. STUDY DESIGN: Pregnancies with 1-hour glucose screens were analyzed retrospectively. A total of 600 cases had values below the fifth percentile (< 71 mg/dl). A total of 6784 controls had values between the 25th and 75th percentiles. Infants were classified as being SGA if they had birth weights less than the 10th percentile adjusted for gestational age and infant gender. The Student's t-test, Fisher's exact test, and logistic regression were used for statistical analysis. RESULTS: The incidence of SGA infants differed significantly between cases and controls, 16.2% versus 12.0% (p = 0.0043). This association remained significant after adjustment for race (p = 0.02). CONCLUSION: A 1-hour glucose screen with a result that is less than the fifth percentile is an independent risk factor for having an SGA infant.

Bilateral ovarian stromal hyperplasia concealing a nonhilar, pure stromal-Leydig cell tumor. A case report.

BACKGROUND: Of ovarian stromal tumors containing Leydig cells, nonhilar, pure stromal-Leydig cell tumor is rare. CASE: An obese, diabetic, borderline hypertensive 41-year-old woman with a five-year history of oligomenorrhea and amenorrhea presented with complaints of masculinization. Physical examination revealed hirsutism and an enlarged clitoris. The only abnormal serum marker was elevated testosterone. At laparotomy both ovaries were enlarged and suspected to have bilateral stromal hyperthecosis. Histology revealed stromal hyperplasia along with a 1.5-cm, testosterone-producing pure stromal-Leydig cell tumor of the right ovary. CONCLUSION: Bilateral ovarian enlargement secondary to stromal hyperplasia in patients with masculinizing signs can conceal a small, unilateral pure stromal-Leydig cell tumor.

Helical CT amniography of congenital diaphragmatic hernia.

OBJECTIVE: Accurate prenatal diagnosis of congenital diaphragmatic hernia is important for perinatal planning and potential fetal surgery. We describe the application and usefulness of helical CT amniography in the evaluation of suspected congenital diaphragmatic hernia in three fetuses. CONCLUSION: Helical CT amniography is an efficient means for evaluation of congenital diaphragmatic hernia. Accurate diagnosis was made in all three patients.

Third-trimester rudimentary horn pregnancy. A case report.

BACKGROUND: Müllerian ducts fuse in the midline to form the uterus at about 10 weeks' gestation. Rudimentary horn pregnancies are unusual occurrences. CASE: A 34-year-old woman presented at 24 weeks' gestation for prenatal care. Rudimentary horn pregnancy was diagnosed. Shortly afterwards the patient developed an acute abdomen, followed by emergency delivery. Though the risks of complications were high, none occurred. CONCLUSION: The incidence of rudimentary horn pregnancy is 1/100,000-150,000. Surgery is the treatment of choice. The prognosis is poor.

Complete trisomy 9 in a term fetus: a case report.

Complete trisomy 9 was diagnosed in a 35-week fetus by amniocentesis. Several sonograms had revealed only a two-vessel cord and intrauterine growth restriction. No other abnormalities were noted. A stillborn infant was delivered at 37 weeks gestation after induction of labor.

Lack of prenatal care increases the rate of recurrent preterm delivery and health care costs when compared to university hospital-based prenatal care.

Objective: To compare perinatal outcomes and total health care costs for patients with a previous history of preterm delivery (PTD) cared for in an inner-city university hospital house staff (HS) clinic vs pregnant patients who have not received any prenatal care (NPC).Study Design: We conducted a retrospective review of pregnant women with a history of PTD delivered at our institution between January 1994 and December 1996. Inclusion criteria were a history of at least one previous PTD. Prenatal care was given in a comprehensive setting in a teaching hospital. Exclusion criteria were infants with major malformations and multiple gestations. Data were obtained on maternal demographics and history of prenatal visits.Results: The study groups consisted of 96 HS and 53 NPC patients. There were no differences in maternal demographics, however, the number of prior preterm births was greater in the NPC group (1.59 vs 1.23, P =.003). The incidence of recurrent PTD (<34 weeks) was greater in the NPC group (49% vs 13%, P = <.001). The mean gestational age at time of delivery was decreased in the NPC group (33 weeks vs 37.2 weeks, P = <.001). The length of NICU stay was greater in the NPC group (15.6 vs 3.1 days, P =.001). The mean birth weight was less in the NPC group (2172 g vs 2786 g, P = <.001). The mean total mother-infant costs were significantly less in the HS group ($7,127 vs $18,047, P =.003). Even HS patients with only one prenatal visit had a significantly lower incidence of PTD (16% vs 75%, P =.04).Conclusions: Inner-city patients with a history of PTD who received even minimal prenatal care in a university HS clinic had a significantly lower incidence of recurrent PTD than those who had no prenatal care. Prenatal care also lowers total health care costs in women with a history of PTD. The coordinated multidisciplinary aspect of care provided at academic centers may have a positive impact on the problem of PTD.