Cutaneous Adnexal Cylindroma of Breast: Epithelial Immunoreactivities for GATA-3, Mammaglobin, and E-Cadherin Do Not Equate to a Mammary Ductal Neoplasm.

Cylindromas are benign epithelial neoplasms derived from cutaneous eccrine adnexal structures. These tumors are most commonly encountered on the head, neck, and scalp of older women. In rare instances, solitary cylindromas may arise at other body sites. In the current case, a cylindroma of the skin of the breast was diagnosed by complete excision. Immunohistochemical studies confirmed the tumor cells to be immunoreactive with cytokeratin AE1/3, cytokeratin 5/6, cytokeratin 7, p63, and SOX10. The neoplastic cells were also noted to be immunoreactive with markers typically expected to be positive in ductal epithelium of the breast including GATA3, mammaglobin, and E-cadherin. The case emphasizes the importance of correlating clinical setting, imaging studies, patient history, and careful microscopic evaluation in arriving at an accurate diagnosis. This case also illustrates the point that not all "breast" tumors that are confirmed to be positive for GATA3, mammaglobin, and E-cadherin are derived from mammary ducts.

A somatodendritic distribution of Rab11 in rabbit brain neurons.

Comparisons of subcellular targeting in neurons and epithelial cells have led to suggestions that apical epithelial antigens localize to axons and nerve terminals. We have studied the distribution in brain of the small GTP-binding protein, Rab11, which is localized to apical vesicular populations in epithelial cells. Sections of rabbit brain were examined by immunohistochemistry using a monoclonal antibody against rabbit Rab11. Rab11 immunoreactivity was present exclusively in neurons. In all regions examined, including forebrain, cerebellum, thalamus and brainstem, Rab11 immunoreactivity was observed in cell bodies and dendrites. No staining was observed in hippocampal neurons. These results indicate that the distribution of Rab11 does not support previous suggestions that apical epithelial markers should localize to axons and synaptic endings.

The cost of maternal cocaine abuse: I. Perinatal cost.

Although the clinical impact of maternal cocaine abuse has been well documented in recent years, there have been no reports on the direct and indirect costs of such abuse. This study compares hospital charges of a cocaine-abusing population with those of a control group. Ninety-one mother-infant pairs testing positive for cocaine at delivery were compared with a screened drug-free control population matched for socioeconomic status, age, and parity. When compared with controls, cocaine-positive mothers were more likely to deliver prematurely (37 versus 2%) and to have low birth weight (2613 versus 3340 g) or growth-retarded infants (12 versus 0%) with Apgar scores less than 7 at 5 minutes (8 versus 1%), signs of cocaine exposure (63 versus 0%), neonatal intensive care use (30 versus 3%), and extensive hospitalization (11 versus 3 days). As expected, there was a substantial cost difference between the study and control groups. Hospital charges for the labor, delivery, and postpartum care of cocaine-positive mothers in the study group averaged $3608, whereas maternal control charges averaged $3147 (P less than .05). Neonatal charges from the cocaine-positive study group averaged $13,222, whereas control charges averaged only $1297 (P less than .03). Most of the statistically significant differences in perinatal cost between the cocaine-positive and control populations can be traced to the association between cocaine abuse and premature birth. This information should benefit institutions and organizations trying to assess cost-benefit aspects of programs for prevention and treatment of cocaine abuse during pregnancy.

An evaluation of the time of discovery of fetal malformations by an indication-based system for ordering obstetric ultrasound.

Circumstances of detection of 570 structural abnormalities in 364 fetuses were reviewed to determine whether referral for obstetric ultrasound according to specific indications resulted in late detection of abnormal fetuses and whether earlier detection might have changed pregnancy outcomes. A system of indication-based obstetric ultrasound discovered 124 abnormal fetuses (34%) at 22 weeks or less and 240 (66%) at 23 weeks or more. Most fetal abnormalities found at 23 weeks or more were probably detectable earlier, because the pattern of abnormalities discovered was reasonably similar in the two groups. Discovery of abnormal fetuses at 22 weeks or less was associated with a 67% termination rate and an 11% postnatal survival rate, whereas discovery at 23 weeks or more was associated with a 14% termination rate and a 51% postnatal survival rate. For fetal abnormalities not detected until 23 weeks or more, the indications that led to detection were present earlier in only 28%, and any indications were present earlier in only 44%. This study raises serious concern about the ability of the indication-based obstetric ultrasound system commonly used in the United States to detect fetal abnormalities before therapeutic options become limited. Evaluation of alternative systems for timing of obstetric ultrasound appears to be warranted.

Influence of gestational age and maternal height on fetal femur length calculations.

OBJECTIVE: To determine whether current methods of detecting Down syndrome based on fetal femur length calculations are influenced by gestational age or maternal height. METHODS: Four formulas were used to calculate expected femur length (FL) based on the fetal biparietal diameter (BPD) between 15 0/7 weeks' gestation and 19 6/7 weeks' gestation. For each gestational age, the BPD:FL ratio for women shorter than one standard deviation (SD) below the mean height was compared with the ratio for women taller than one SD above the mean height. A measured:expected FL ratio of 0.91 or less and a BPD:FL ratio greater than 1.5 SD above the mean was considered abnormal. RESULTS: The four formulas used to calculate measured:expected FL ratios were significantly more likely to be abnormal at 15--16 weeks' gestation, compared with 18-19 weeks' gestation (P <.05). Maternal height correlated with femur lengths at 18 and 19 weeks' gestation (P <.05) but not at earlier gestational ages. At 18 and 19 weeks' gestation, women shorter than one SD below the mean were twice as likely to have an abnormal BPD:FL ratio compared with women taller than one SD above the mean (relative risk 2.38; 95% confidence interval 1.21, 4.69). CONCLUSION: Early gestational age increases a woman's risk of having an abnormal measured:expected FL ratio, whereas short stature increases a woman's risk of having an abnormal BPD:FL ratio at later gestational ages. These findings indicate that risk assessment for fetal Down syndrome for such patients might be inaccurate. (Obstet Gynecol 2001;97:742-6.

Gastrointestinal disorders in pregnancy.

Gastrointestinal disorders constitute one of the most frequent complaints of pregnancy. An understanding of the mode of presentation and the incidence of the various gastrointestinal disorders will optimize care in obstetric patients. Disorders of the esophagus, stomach, duodenum, ilium, jejunum, colon, rectum, and appendix are individually discussed with reference to physiologic changes in pregnancy, infectious diseases, autoimmune disease, and ulcer formation.

The routine obstetric ultrasound examination.

Ultrasound is a readily available, noninvasive, and safe means of evaluating fetal health, determining gestational age, and assessing the intrauterine environment. It is an indispensable tool for the practice of obstetrics. The routine ultrasound examination is a beginning. It is a diagnostic test, yielding results that must be interpreted and integrated in a knowledgeable way. As is true for physical examination, the ultrasound study is most helpful when performed in a consistent and reproducible fashion, carefully documenting the pertinent positive and negative findings that are important in clinical decision making. The information gained from routine obstetric ultrasound may provide reassurance, guide therapy, or identify a pathologic condition that merits further investigation. It is always informative.

Emergency management of sudden puerperal fever.

The development of fever during the puerperium is a relatively common complication. Although the primary source of these fever usually stems from the genital tract, a thorough evaluation of the febrile puerperal patient for other sites of infection is necessary before initiating antibiotic therapy. Increased awareness of factors that predispose a patient to postpartum infection has significantly reduced maternal morbidity and mortality.

Ultrasound diagnosis of an obstructive cardiac rhabdomyoma with severe hydrops and hypoplastic lungs. A case report.

Cardiac rhabdomyomas of the fetus and neonate are benign cardiac muscle hamartomas with an incidence of 0.027% in pediatric autopsies. This is the third reported case of prenatally diagnosed cardiac rhabdomyoma, the second with severe hydrops and the only one associated with aortic valve hypoplasia and hypoplastic lungs.

Fetal malformations commonly detectable on obstetric ultrasound.

A review of 364 fetuses with a total of 570 malformations discovered on ultrasound throughout the Emanuel Hospital referral pattern from 1978 to 1987 was compared to a previous multicenter study of 50,282 children from 1959 to 1965 that found minor or major congenital malformations in 6.5% of children, for a rate of 8.8 malformations per 100 children. The comparison was made to determine which of the malformations reported in the earlier study were commonly detectable on obstetric ultrasound as performed throughout the referral area and to determine what the combined prevalence of those malformations was within the general population. For the comparison, the number of patients undergoing obstetric ultrasound throughout our referral area was estimated from the number of anencephalic fetuses found. The relative prevalences of all malformations in the two groups were then determined by extrapolation. The malformations commonly detectable on ultrasound according to that comparison were then assigned the prevalences obtained from the earlier clinical study. According to this analysis, 0.7-0.8% of fetuses have major malformations commonly detectable on ultrasound, for a rate of 1.2 malformations per 100 fetuses. That represents about 13% of all malformations and about 27% of major malformations. If cardiovascular abnormalities, cleft lip and clubfoot were usually detected, the rate of malformations considered commonly detectable would increase to 2.7 per 100 fetuses. That would represent about 31% of all malformations and about 63% of major ones.

Unexplained positive/elevated maternal serum alpha-fetoprotein associated with placenta increta. A case report.

Maternal serum alpha-fetoprotein (MSAFP) is a regularly utilized antenatal screening test for the identification of pregnancies at increased risk for a variety of genetic and nongenetic abnormalities. Complete mid-trimester evaluation of the patient with a positive screening test may fail to reveal an etiology for a positive MSAFP value. This case report concerns an unexplained positive/elevated MSAFP screening test for a patient found at delivery to have abnormal placentation.

Impact of prenatal care with reduced frequency of visits in a residency teaching program.

OBJECTIVE: To determine if decreasing the number of prenatal visits for routine obstetric patients affects pregnancy outcome. STUDY DESIGN: A historical control study was designed to include 734 deliveries from January 1 to December 31, 1991, in women who had prenatal care per American College of Obstetricians and Gynecologists Committee Opinion no. 79, January 1990, guidelines for uncomplicated obstetric care. A prospective study cohort of women with 711 deliveries from January 1 to December 31, 1994, underwent prenatal care with modified guidelines to include: first visit at 6-12 weeks to confirm dating and obtain initial laboratory data, second visit at 16-20 weeks to obtain maternal serum alpha-fetoprotein screening, third visit at 24-28 weeks for 28-week laboratory data, fourth visit at 32 weeks, fifth visit at 36 weeks, sixth visit at 38 weeks, seventh visit at 40 weeks and weekly thereafter. Pregnancy outcomes included estimated fetal weight, gestational age at delivery, preeclampsia, Apgar score at one and five minutes and delivery mode. Neonatal outcomes, including stillbirth rate, preterm delivery rate, intraventricular hemorrhage rate, bronchopulmonary dysplasia and neonatal mortality, were evaluated. RESULTS: There were no statistically significant differences in perinatal or neonatal outcomes with decreased prenatal visits from an average of 12 per pregnancy to 8. CONCLUSION: Prenatal visits can be decreased in a teaching hospital in women with uncomplicated pregnancies from the standard number, 12-14 visits, to an average of 7 or 8 per patient without adverse perinatal outcomes.

Urinary incontinence procedures performed at a military teaching hospital.

PURPOSE: This study provides follow-up of primary modified Pereyra needle urethropexy procedures performed with permanent suture by residents at a military teaching hospital. METHOD: Review of all resident-performed primary Pereyra urethropexy procedures performed at Keesler Medical Center (KMC) from December 1990 through April 1994. RESULTS: The results from 34 primary Pereyra needle urethropexy procedures, with 24 patients less than 2 years from surgery and mean follow-up of 19.5 months, demonstrated that 21/24 had improvement in their incontinence. This gives an 88% success rate at less than 2 years. We had 10 patients more than 2 years from surgery, with mean follow-up of 38 months, and 6/10 with continence. The overall success rate was 27/34 (79%). We noted that on preoperative evaluation, 5/7 failures were found to have urethral closing pressures of < 20 cm H2O (8-18). One of the late failures was found to have had no cystometrics performed and no demonstrable stress urinary incontinence. Her procedure was termed "prophylactic." Removing 6/7 failures for incomplete evaluation or use of less appropriate procedure, we find 27/28 patients (96%) with successful results. The presence of low urethral pressure (< 20 cm H2O) was a significant factor in the failures regardless of timing (< 2 years vs. > 2 years) (p < 0.04). There was no difference in parity, estrogen use, urgency component, age, socioeconomic status, associated operative procedures, postoperative infection, or complications noted between successful and unsuccessful Pereyra urethropexy as a primary method of genuine stress incontinence surgery. CONCLUSION: The primary Pereyra needle urethropexy had an overall success rate of 79% (27/34). Allowing for properly evaluated and treated patients, we find 96%(27/28) success. It appears that the primary modified Pereyra vaginal urethropexy with permanent suture is an easily taught and superior method of primary surgical treatment of stress urinary incontinence in a military training program.

Uncomplicated pregnancy: clinical pathway genesis based on the nursing process.

A prospective study of obstetrical patients from enrollment as outpatients until postpartum discharge was formulated at Madigan Army Medical Center. The control group included uncomplicated obstetrical patients from March 1 to August 31, 1994. The study group included uncomplicated obstetrical patients from March 1 to August 31, 1996. Patient satisfaction, identification of barriers to care, recognition of areas to improve quality of care, and cost-consequence analysis were studied. There were 1,042 control patients totaling 2,668 hospital days, with mean hospital stays of 2.56 days per patient (SD = 0.878). The study cohort comprised 1,050 patients with 1,965 hospital days, with a mean of 1.87 hospital days per patient (SD = 1.48). The study cohort demonstrated a statistically significant decrease (p < 0.05) in admission length of stay in the early discharge vaginal delivery gravidas, with cost savings from $3.2 million to $2.4 million. Using an interdisciplinary approach, we were able to elucidate the process necessary to identify critical nodes of patient care and satisfaction while providing significant cost savings.

Management of immune thrombocytopenia purpura at a military medical center.

OBJECTIVE: To investigate whether fetal platelets in immune thrombocytopenia purpura (ITP) may be predicted by antepartum assessment. METHODS: A prospective analysis was conducted of 28 pregnant women with ITP out of 8,056 deliveries. Of the 28 patients, 13 were evaluted by fetal scalp sampling and 11 were evaluated by percutaneous umbilical blood sampling (PUBS). RESULTS: The mean fetal and maternal platelet counts prior to delivery were 146,000 and 176,000, respectively. The mean fetal and maternal platelet counts after delivery were 245,000 and 149,000, respectively. Fetal cord platelet counts could not be predicted by maternal platelet count, the presence/absence of maternal direct/indirect anti-platelet antibodies, steroid therapy, or history of splenectomy. PUBS for fetal platelet assessment correlated well with fetal postdelivery counts. CONCLUSIONS: Patients with ITP rarely exhibit complications. No antepartum characteristic enhances reliable prediction of neonatal outcome. Method of delivery should be based on obstetric guidelines.

Focused obstetrical clinic for active duty junior enlisted service women: model for improved outcomes.

OBJECTIVE: To evaluate the utility of an interdisciplinary clinic in improving perinatal outcomes for all pregnant patients of junior enlisted rank (E4 and below) in response to previous reports that this group is at higher risk for adverse outcomes. METHODS: The study population included all junior enlisted active duty patients (E4 and below) delivering between January 1, 1993, and June 30, 1996. Outcomes for patients receiving care in a focused active duty obstetrical clinic were compared with outcomes in similar cohorts of senior active duty patients (E5 and above) and non-active duty pregnant patients. Evaluation was based on perinatal outcomes, including chorioamnionitis, postpartum hemorrhage, intrauterine growth retardation, cesarean delivery, preterm delivery rates (< 37 weeks), postterm delivery rates (> 41 weeks), postpartum days, mean gestational age at delivery, mean delivery weights, Apgar scores at 1 and 5 minutes, preeclampsia, and premature labor. Variables with potential to confound perinatal outcomes were also studied. Confounding variables included tobacco use, gestational diabetes, chronic hypertension, thyroid disease, history of substance abuse, and alcohol use. Power analysis accomplished before initiation of the study showed adequate sample size (> 240 patients in each group) to demonstrate statistically different rates of preterm delivery. Statistical analysis was done using the chi 2 test for categorical variables and Student's t test for continuous variables. RESULTS: There were no statistical differences between junior active duty patients, senior active duty patients, and non-active duty patients in preterm delivery and other outcome variables. CONCLUSION: The focused obstetrical clinic, conducted for junior enlisted soldiers by a senior nurse practitioner, appears to provide an intervention that ensures perinatal outcomes equal to those of both the non-active duty and the senior active duty population.

Perinatal hospice: a response to partial birth abortion for infants with congenital defects.

This article discusses decisions involving whether to terminate late-term pregnancies when fetal anomalies have been detected. Partial-birth abortion performed on fetuses with chromosomal abnormalities, while performed under the guise of reducing suffering, threatens the best interests of the mother and infant. An alternative for parents faced with the decision to terminate their pregnancy is perinatal hospice. Perinatal hospice recognizes the value of bringing these infants to term by treating them as beings conceived with a tangible future. This alternative is preferred because of post-termination psychological distress and because biblical teachings emphasize the dignity and worth of each fetus. Perinatal hospice supports parents through their grief when their infant dies and maximizes the opportunity for authentic mourning.