RESUMO
OBJECTIVES: Ultrasound-guided injections are used to treat common shoulder pathologies and have been shown to be more accurate and effective than traditional landmark-guided procedures. Currently, there exists no inexpensive shoulder model that accurately simulates the anatomical structures of the shoulder while also facilitating glenohumeral joint (GHJ) injection. Our model is an alternative to the traditional bedside training and provides a low-risk training environment. METHODS: We created this model from easily accessible materials. Polyvinyl chloride pipe was used to create the skeletal infrastructure pectoral girdle. A detergent pod was used to represent the GHJ space. Steaks were used to simulate the infraspinatus and deltoid muscles, with meat glue as a fascial layer between the two simulated muscles. Total cost of materials for the model was $19.71. RESULTS: Our model successfully replicates known anatomical features of the GHJ. Additionally, the model facilitates injection into a GHJ space, representing a GHJ injection. Our model was replicated to train medical student practitioners during five different educational sessions. The model was validated through comparison to standardized educational ultrasound training videos. It was further validated by ultrasound experts. CONCLUSIONS: The shoulder model we created is effective in simulating GHJ injections under ultrasound guidance. It simulates realistic muscle and bony landmarks both for ultrasound imaging and injection feel. Importantly, it is inexpensive and easy to replicate allowing more access to medical practitioners and students to be educated on the procedure.
Assuntos
Articulação do Ombro , Humanos , Articulação do Ombro/diagnóstico por imagem , Ombro , Ultrassonografia/métodos , Injeções Intra-Articulares , Ultrassonografia de IntervençãoRESUMO
The emergence of obstetric anesthesia in the second half of the nineteenth century was preceded by a transformation in the medical conceptualization of women's pain. In the eighteenth and early nineteenth centuries, physicians described pain in physiological terms as natural and unproblematic, but in the second half of the nineteenth century they adopted a newly emotional language that emphasized women's subjective experiences of suffering. Middle-class and elite white women shaped this transition by insisting that their physical and emotional anguish was extreme. Women's attitudes, combined with a growing perception that sensibility to pain was a marker of "civilization," pushed physicians to view suffering as real and problematic. As they began to depict pain relief as an urgent medical concern, physicians envisioned refined white women as the primary beneficiaries of their new technology; this perspective paved the way for the increasingly routine use of anesthesia for middle-class and elite white women.
Assuntos
Dor , Parto , Gravidez , Feminino , Humanos , Parto/psicologiaRESUMO
The objective of this study is to develop a simple, brief, self-report perinatal depression inventory that accurately measures severity in a number of populations. Our team developed 159 Likert-scale perinatal depression items using simple sentences with a fifth-grade reading level. Based on iterative cognitive interviewing (CI), an expert panel improved and winnowed the item pool based on pre-determined criteria. The resulting 67 items were administered to a sample of 628 pregnant and 251 postpartum women with different levels of depression at private and public sector obstetrics clinics, together with the Beck Depression Inventory (BDI-II), Edinburg Postpartum Depression Scale (EPDS), and the Patient Health Questionnaire (PHQ-9), as well as Module A of the Structured Clinical Interview for DSM-IV Diagnoses (SCID). Responses were evaluated using Item Response Theory (IRT). The Perinatal Depression Inventory (PDI)-14 items are highly informative regarding depression severity and function similarly and informatively across pregnant/postpartum, white/non-white, and private-clinic/public-clinic populations. PDI-14 scores correlate well with the PHQ-9, EPDS, and BDI-II, but the PDI-14 provides a more precise measure of severity using far fewer words. The PDI-14 is a brief depression assessment that excels at accurately measuring depression severity across a wide range of severity and perinatal populations.
Assuntos
Depressão Pós-Parto/diagnóstico , Depressão/diagnóstico , Transtorno Depressivo/diagnóstico , Programas de Rastreamento/instrumentação , Escalas de Graduação Psiquiátrica , Psicometria/estatística & dados numéricos , Adulto , Depressão/psicologia , Depressão Pós-Parto/psicologia , Transtorno Depressivo/psicologia , Feminino , Humanos , Programas de Rastreamento/métodos , Avaliação de Resultados em Cuidados de Saúde , Período Pós-Parto/psicologia , Gravidez , Reprodutibilidade dos Testes , Índice de Gravidade de Doença , Inquéritos e QuestionáriosRESUMO
OBJECTIVE: We sought to evaluate if the placental alpha-microglobulin (PAMG)-1 test vs the combined traditional diagnostic test (CTDT) of pooling, nitrazine, and ferning would be a cost-beneficial screening strategy in the setting of potential preterm premature rupture of membranes. STUDY DESIGN: A decision analysis model was used to estimate the economic impact of PAMG-1 test vs the CTDT on preterm delivery costs from a societal perspective. Our primary outcome was the annual net cost-benefit per person tested. Baseline probabilities and costs assumptions were derived from published literature. We conducted sensitivity analyses using both deterministic and probabilistic models. Cost estimates reflect 2013 US dollars. RESULTS: Annual net benefit from PAMG-1 was $20,014 per person tested, while CTDT had a net benefit of $15,757 per person tested. If the probability of rupture is <38%, PAMG-1 will be cost-beneficial with an annual net benefit of $16,000-37,000 per person tested, while CTDT will have an annual net benefit of $16,000-19,500 per person tested. If the probability of rupture is >38%, CTDT is more cost-beneficial. Monte Carlo simulations of 1 million trials selected PAMG-1 as the optimal strategy with a frequency of 89%, while CTDT was only selected as the optimal strategy with a frequency of 11%. Sensitivity analyses were robust. CONCLUSION: Our cost-benefit analysis provides the economic evidence for the adoption of PAMG-1 in diagnosing preterm premature rupture of membranes in uncertain presentations and when CTDT is equivocal at 34 to <37 weeks' gestation.
Assuntos
alfa-Globulinas/análise , Ruptura Prematura de Membranas Fetais/diagnóstico , Placenta/química , Análise Custo-Benefício , Árvores de Decisões , Técnicas de Diagnóstico Obstétrico e Ginecológico/economia , Feminino , Humanos , GravidezRESUMO
OBJECTIVE: Fetal growth restriction (FGR) is associated with an increased risk of adverse perinatal outcomes. The cerebroplacental ratio (CPR) represents the interaction of alterations in blood flow to the fetal brain and placenta. CPR has been utilized as a superior reflection of fetal hypoxia/acidemia and therefore a better predictor of fetal morbidity. We sought to determine the role of the CPR as an adjunctive tool to identify fetuses at increased risk of adverse perinatal outcomes in a study population of marijuana (MJ) exposed FGR fetuses. METHODS: This was a retrospective cohort study of high-risk singleton pregnancies over a 4-year period. Self-identified daily MJ users with FGR fetuses in the 3rd trimester were isolated. Fetal biometry, amniotic fluid indices, and CPRs were calculated. A CPR <1 was considered abnormal. FGR fetuses with normal and abnormal CPRs were then compared. RESULTS: 26/192 (13.5%) of MJ exposed fetuses were diagnosed with FGR in the 3rd trimester. 12/26 (46%) had an abnormal CPR and 14 had a normal CPR (mean CPR 0.60 vs 1.57, p = .0001). The mean EFW percentile was lower in the abnormal CPR group in comparison to the group with normal CPR (3.33 vs 7.64, p = .0001). Both groups showed evidence of brain sparing with an overall mean head circumference of 17.55 in comparison to a mean abdominal circumference of 5.63. A CPR <1 was associated with more severe FGR, oligohydramnios, and abnormal UA Doppler studies. CONCLUSIONS: Approximately half of the MJ exposed FGR fetuses had an abnormal CPR. In this subset of patients, >90% had severe FGR, a higher proportion had absence/reversal of end diastolic flow in the UA, and a higher proportion had oligohydramnios. This demonstrates that an abnormal CPR identifies a group of FGR fetuses at a greater risk of adverse perinatal outcomes.
Assuntos
Cannabis , Artéria Cerebral Média , Oligo-Hidrâmnio , Feminino , Humanos , Gravidez , Retardo do Crescimento Fetal/diagnóstico , Feto , Idade Gestacional , Artéria Cerebral Média/diagnóstico por imagem , Estudos Retrospectivos , Ultrassonografia Doppler , Ultrassonografia Pré-Natal , Artérias Umbilicais/diagnóstico por imagemRESUMO
Thrombophilias have been implicated in complications related to ischemic placental disease including recurrent pregnancy loss, intrauterine fetal demise, preeclampsia, fetal growth restriction, placental abruption, and preterm delivery. Maternal screening and treatment may lower the recurrence of these outcomes. Our objective was to estimate if antenatal screening for thrombophilias with the intention to offer treatment among women with a prior adverse pregnancy outcome (APO) is preferable to no screening. A decision-analytical model was constructed for pregnant women with prior APO, comparing screening for thrombophilia with intention to treat with no screening. Values obtained from previously published studies include probability of positive test: 0.3 (0.1 to 0.6); good outcome with treatment: 0.9 (0.3 to 0.99); no thrombophilia, good outcome: 0.75 (0.5 to 0.9); test negative, thrombophilia positive: 0.05 (0.01 to 0.1); test negative, thrombophilia positive, good outcome: 0.75 (0.5 to 0.9); thrombophilia/test negative, good outcome: 0.98 (0.5 to 0.99). Sensitivity analyses were run over a wide range of assumptions. Thrombophilia screening with intention to treat in women with prior APO associated with ischemic placental disease is the strategy of choice compared with no testing over a wide range of assumptions. Sensitivity analyses support this to be robust. Women with poor pregnancy history related to placental ischemic disease may benefit from thrombophilia screening and treatment in a subsequent pregnancy.
Assuntos
Técnicas de Apoio para a Decisão , Complicações Hematológicas na Gravidez/diagnóstico , Gravidez de Alto Risco , Diagnóstico Pré-Natal/métodos , Trombofilia/diagnóstico , Feminino , Humanos , Programas de Rastreamento , Gravidez , Complicações Hematológicas na Gravidez/prevenção & controle , Medição de RiscoRESUMO
OBJECTIVE: The recent legalization of marijuana has increased overall use, including in pregnancy. Studies have previously associated marijuana use with adverse fetal neurodevelopmental outcomes. We sought to compare fetal sonographic growth parameters and placental perfusion, as measured by umbilical artery Dopplers, in women using daily marijuana versus nonusers. METHODS: A retrospective cohort study capturing self - identified pregnant daily marijuana users with gestational aged matched controls was performed. We compared maternal demographics, fetal biometry, nuchal translucency, and umbilical artery Dopplers in marijuana users versus controls. Intrauterine growth restriction was defined as an estimated fetal weight <10th %. RESULTS: In 55 first trimester ultrasounds, there were no differences in crown rump lengths or nuchal translucencies between the groups. Likewise, in 195-second trimester ultrasounds, no differences were noted in biometry. Second trimester umbilical artery systolic to diastolic ratios were higher in marijuana users compared to nonusers (4.02 versus 3.92, p = .024). In the third trimester, 26 of 192 marijuana exposed fetuses were growth restricted compared to 6 of 192 controls (p = .002), and umbilical artery systolic to diastolic ratios were higher (3.52 versus 3.12, p = .0001). Four cases of absent and reversed end diastolic flow were observed in marijuana users, while no cases were observed in controls. CONCLUSIONS: Our data shows that daily marijuana use is associated with impaired fetal growth and increased placental vascular resistance. Marijuana consumption in pregnancy should be avoided until further studies delineate its exact potential for fetotoxicity.
Assuntos
Cannabis , Idoso , Cannabis/efeitos adversos , Feminino , Desenvolvimento Fetal , Retardo do Crescimento Fetal/induzido quimicamente , Retardo do Crescimento Fetal/diagnóstico por imagem , Humanos , Placenta/diagnóstico por imagem , Gravidez , Estudos Retrospectivos , Ultrassonografia Pré-Natal , Artérias Umbilicais/diagnóstico por imagem , Resistência VascularRESUMO
BACKGROUND: Preoperative transfusions are frequently given to prevent morbidity in nonpregnant patients with sickle cell disease. We describe a case of a life-threatening delayed hemolytic transfusion reaction with hyperhemolysis syndrome in pregnancy. CASE: A multigravida with sickle cell disease underwent prophylactic blood transfusion before repeat cesarean delivery. Her immediate postpartum course was uneventful, but on postoperative day number 6 she presented in grave condition with what was thought initially to be an infection versus crisis. Delayed hemolytic transfusion reaction with hyperhemolysis was ultimately diagnosed. CONCLUSION: In the gravida with sickle cell disease and known multiple red cell antibodies, blood transfusion may incur a higher risk for delayed transfusion reaction, hyperhemolysis syndrome, and possible death. Blood transfusion should be used cautiously in these patients.
Assuntos
Anemia Hemolítica/imunologia , Anemia Hemolítica/prevenção & controle , Anemia Falciforme/terapia , Complicações Hematológicas na Gravidez/terapia , Reação Transfusional , Anemia Falciforme/complicações , Incompatibilidade de Grupos Sanguíneos/etiologia , Recesariana , Feminino , Humanos , Período Pós-Parto , Gravidez , Resultado da Gravidez , Gravidez Múltipla , Cuidados Pré-Operatórios , Fatores de Risco , Fatores de TempoAssuntos
Aleitamento Materno , Manuais como Assunto , Comportamento Materno , Tocologia , Saúde da Mulher , Aleitamento Materno/etnologia , Aleitamento Materno/psicologia , História do Século XVIII , História do Século XIX , Humanos , Lactente , Cuidado do Lactente/história , Bem-Estar do Lactente/etnologia , Bem-Estar do Lactente/história , Recém-Nascido , Comportamento Materno/etnologia , Comportamento Materno/história , Comportamento Materno/fisiologia , Comportamento Materno/psicologia , Bem-Estar Materno/economia , Bem-Estar Materno/etnologia , Bem-Estar Materno/história , Bem-Estar Materno/psicologia , Tocologia/educação , Tocologia/história , Mães/educação , Mães/história , Mães/psicologia , Estados Unidos/etnologia , Saúde da Mulher/etnologia , Saúde da Mulher/históriaRESUMO
OBJECTIVE: Beginning in October 1995, and for several years thereafter, our institution used indomethacin as a first-line tocolytic drug. Our purpose is to compare the outcomes of very low birth weight infants who were exposed to antenatal indomethacin with those who were not exposed to this therapy. STUDY DESIGN: We used our center's component of the NICHD Neonatal Research Network's Generic Data Base which recorded the outcomes of all live born infants weighing less than 1500 g over a 5-year period. We abstracted data concerning neonatal morbidity (death, Grades III to IV intraventricular hemorrhage (IVH), necrotizing enterocolitis and patent ductus arteriosus), as well as other factors including gestational age, birth weight, antenatal corticosteroid treatment and maternal hypertension or pre-eclampsia. Univariate analysis was performed using Fisher's exact test. Multivariate analysis using logistic regression was performed to control for confounding factors. RESULTS: A total of 85 infants who were exposed to antenatal indomethacin were compared to 464 infants who were not exposed to the drug. In the univariate analysis, antenatal indomethacin exposure was not associated with a significant increase in the incidence of necrotizing enterocolitis or patent ductus arteriosus. The incidence of Grades III to IV IVH was 17.9% in those infants exposed to antenatal indomethacin compared to 7.1% in the nonexposed infants (p=0.008). The incidence of neonatal death in the exposed infants was 27.7 versus 16.4 in the nonexposed infants (p=0.02). After controlling for antenatal corticosteroids, maternal pre-eclampsia, gestational age and birth weight, antenatal indomethacin was significantly associated with an increased incidence of IVH, but not neonatal death. CONCLUSION: Antenatal indomethacin was associated with significantly higher rates of IVH. Additional studies assessing the potential risks of indomethacin tocolysis are needed before it is used as a first-line tocolytic therapy.
Assuntos
Causas de Morte , Indometacina/efeitos adversos , Doenças do Prematuro/induzido quimicamente , Doenças do Prematuro/mortalidade , Recém-Nascido de muito Baixo Peso , Efeitos Tardios da Exposição Pré-Natal , Estudos de Coortes , Cuidados Críticos , Permeabilidade do Canal Arterial/induzido quimicamente , Permeabilidade do Canal Arterial/mortalidade , Permeabilidade do Canal Arterial/fisiopatologia , Enterocolite Necrosante/induzido quimicamente , Enterocolite Necrosante/mortalidade , Enterocolite Necrosante/fisiopatologia , Feminino , Seguimentos , Humanos , Indometacina/uso terapêutico , Recém-Nascido , Doenças do Prematuro/fisiopatologia , Unidades de Terapia Intensiva Neonatal , Hemorragias Intracranianas/induzido quimicamente , Hemorragias Intracranianas/mortalidade , Hemorragias Intracranianas/fisiopatologia , Modelos Logísticos , Masculino , Gravidez , Probabilidade , Estudos Retrospectivos , Medição de Risco , Índice de Gravidade de Doença , Taxa de Sobrevida , Tocólise/efeitos adversosRESUMO
Arrhythmogenic right ventricular cardiomyopathy (ARVC) is a disorder that predominantly affects the right side of the heart and causes ventricular arrhythmias. In many patients the disease is familial. ARVC may account for as many as 5% of unexpected sudden deaths. We report a case of ARVC diagnosed at 21 weeks gestation treated with an implantable cardiac defibrillator. The remainder of her pregnancy was uneventful and the patient underwent induction of labor at 39 weeks gestation with a passive second stage forceps-assisted delivery resulting in delivery of a normal infant. In the gravida with cardiac arrhythmias, defibrillator placement may offer a safe, life-preserving treatment and should be considered.
Assuntos
Displasia Arritmogênica Ventricular Direita/diagnóstico , Complicações Cardiovasculares na Gravidez/diagnóstico , Adulto , Displasia Arritmogênica Ventricular Direita/terapia , Desfibriladores Implantáveis , Diagnóstico Diferencial , Feminino , Humanos , Recém-Nascido , Gravidez , Complicações Cardiovasculares na Gravidez/terapia , Segundo Trimestre da GravidezRESUMO
Congenital diaphragmatic hernia (CDH) occurs in 1 of every 2000 to 4000 births and accounts for 8% of all major congenital anomalies. Recurrence risk for a subsequent pregnancy is estimated at 2%. The mortality rate for CDH when diagnosed antenatally, varies with fetal age and with the presence or absence of hydramnios and degree of pulmonary hypoplasia. The prognosis has improved dramatically in recent years, primarily due to advances in neonatal and surgical interventions. Neonatal survival rates with an antenatal diagnosis now exceed 80% in some centers. Treatment for infants with CDH reflects other pediatric surgical problems in that a majority of the clinical research that shapes treatment is retrospective in nature. Because CDH is a relatively rare disease, using a compilation of cases, such as the CDH database provides, greatly aids our understanding of this disease process. Moreover, the application of a quality assessment scale provides the practitioner with a knowledge base to critically evaluate the published retrospective data.
Assuntos
Hérnia Diafragmática/terapia , Hérnias Diafragmáticas Congênitas , Betametasona/administração & dosagem , Oxigenação por Membrana Extracorpórea , Feminino , Glucocorticoides/administração & dosagem , Hérnia Diafragmática/diagnóstico , Humanos , Recém-Nascido , Masculino , Gravidez , Surfactantes Pulmonares/administração & dosagem , Ventilação Pulmonar , Sistema de Registros , Ultrassonografia Pré-NatalRESUMO
The ultrasound assessment of the cervix has contributed to the understanding of the pathways to preterm birth. Transvaginal ultrasound measurement of the cervix provides an objective and noninvasive tool for the evaluation of cervical status. Despite widespread use of this procedure, standardization of measurement indications, technique, and interval between examinations has not been achieved. The American College of Radiology has recently recommended that the cervix and lower uterine segment be imaged as part of every obstetric ultra-sound examination in the second trimester. These guidelines specifically suggest a search for a short cervix (less than 30 mm) or funneling. The expert panel on women's imaging further recommended evaluating the cervix sonographically on both the initial examination and all follow-up examinations for twin gestations. The American Institute of Ultrasound in Medicine guidelines indicate that evaluation of the uterus, including cervix, should be performed, but does not indicate specifically that the cervix should be measured. In contrast, the American College of Obstetricians and Gynecologists, although recognizing that cervical length assessment may be helpful in predicting the risk of preterm delivery (particularly from a negative predictive value), does not recommend routine use of cervical length measurement because of the lack of proved treatment or intervention methods. A review of the literature suggests that at the time of this writing the role of routine screening of low-risk women with cervical length assessment by ultrasound is not supported. In contrast, in women at risk for preterm delivery(eg, women with a prior history of preterm birth or women with multiple gestations) cervical length assessment may be useful for its negative predictive value. At present, however, there is no therapeutic intervention that has been proved to decrease the risk of preterm delivery in women with a documented cervix on ultrasound.
Assuntos
Trabalho de Parto Prematuro/prevenção & controle , Ultrassonografia Pré-Natal , Colo do Útero/anatomia & histologia , Colo do Útero/diagnóstico por imagem , Feminino , Humanos , Gravidez , Gravidez Múltipla , Fatores de Risco , Incompetência do Colo do Útero/diagnósticoRESUMO
Venous thromboembolic disease is a major cause of maternal morbidity and mortality. Virchow's triad of hypercoagulability, venous stasis, and vascular damage all occur during pregnancy. The risk of venous thromboembolism is five to six times higher during pregnancy and the puerperium. Risk factors include age greater than 35, antiphospholipid antibodies, inherited thrombophilias, operative delivery, increased parity, obesity, mechanical heart valves,and family history. Prophylactic and therapeutic anticoagulation is recommended for women at risk. Low molecular weight heparins are safe and effective in most cases.
Assuntos
Complicações Cardiovasculares na Gravidez/diagnóstico , Complicações Cardiovasculares na Gravidez/terapia , Trombofilia/diagnóstico , Trombofilia/terapia , Anticoagulantes/uso terapêutico , Feminino , Predisposição Genética para Doença , Humanos , Gravidez , Cuidado Pré-Natal , Trombofilia/genéticaRESUMO
Asthma is a chronic inflammatory disease of the airway system that is characterized by bronchoconstriction and bronchial hyperresponsiveness that are triggered by a host of stimuli. Asthma is the most common respiratory disease in pregnancy and affects approximately 4% of pregnant women. This article reviews asthma as a public health concern, the normal physiology of pregnancy,the pathophysiology of asthma in pregnancy, the effects of asthma on pregnancy and pregnancy on asthma, objective lung function testing, goals for the pregnant woman who has asthma, and treatment of chronic and acute episodes of asthma.
Assuntos
Asma/diagnóstico , Asma/terapia , Complicações na Gravidez/diagnóstico , Complicações na Gravidez/terapia , Antiasmáticos/uso terapêutico , Broncodilatadores/uso terapêutico , Feminino , Humanos , GravidezRESUMO
The available data unambiguously support the beneficial, short-term fetal effects of antenatal corticosteroids in women at risk for preterm delivery. There are still several incompletely addressed questions, including the use of corticosteroids in women with preterm premature rupture of membranes, the optimal corticosteroid preparation to be used, and the impact of repeated dosing. These issues are discussed in this review from the perspective of recent scientific evidence on the mechanisms responsible for positive short-term effects on survival and possible harmful long-term effects.
Assuntos
Corticosteroides/administração & dosagem , Corticosteroides/farmacologia , Ruptura Prematura de Membranas Fetais/complicações , Maturidade dos Órgãos Fetais/efeitos dos fármacos , Trabalho de Parto Prematuro/etiologia , Trabalho de Parto Prematuro/prevenção & controle , Betametasona/administração & dosagem , Betametasona/farmacologia , Conferências para Desenvolvimento de Consenso de NIH como Assunto , Dexametasona/administração & dosagem , Dexametasona/farmacologia , Feminino , Idade Gestacional , Humanos , Gravidez , Resultado da Gravidez , Estados UnidosRESUMO
BACKGROUND AND OBJECTIVES: The increasing use and acceptance of robotic platforms calls for the need to train not only established surgeons but also residents and fellow trainees within the context of the traditional residency and fellowship program. Our study aimed to clarify the current status of robotic training in gynecologic fellowship programs in the United States. METHODS: This was a Web-based survey of four gynecology fellowship programs in the United States from November 2010 to March 2011. Programs were selected based on their geographic areas. A questionnaire with 43 questions inquiring about robotic surgery performance and training was sent to the programs and either a fellow or the fellowship director was asked to complete. Participation was voluntary. RESULTS: We had 102 responders (18% respond rate) with an almost equal response rate from all four gynecologic fellowships, with a median response rate of 25% (range 21-29%). Minimally Invasive Surgery (MIS) and Gynecologic Oncology (Gyn Onc) fellowships had the highest rate of robotic training in their fellowship curriculum-95% and 83%, respectively. Simulator training was used as a training tool in 74% of Female Pelvic Medicine and Reconstructive Surgery (FPMRS); however, just 22% of Reproductive Endocrinology and Infertility fellowships had simulator training. Eighty-seven percent of Gyn Onc fellows graduate with >50 robotic cases, but this was 0% for Reproductive Endocrinology Infertility fellows. CONCLUSION: Our study showed that the use of a robotic system was built into fellowship curriculum of >80% of MIS and Gyn Onc fellowship programs that were entered in our study. Simulator training has been used widely in Ob&Gyn fellowship programs as part of their robotic training curriculum.
Assuntos
Currículo , Educação Médica/métodos , Ginecologia/educação , Internato e Residência , Robótica/educação , Especialidades Cirúrgicas/educação , Adulto , Feminino , Humanos , Masculino , Inquéritos e Questionários , Estados UnidosRESUMO
OBJECTIVE: Mother-to-child transmission of human immunodeficiency virus is the most common cause of pediatric human immunodeficiency virus in the United States; the Centers for Disease Control and Prevention recommendations endorse rapid human immunodeficiency virus testing for women with unknown viral status to quicken antiretroviral therapy. We compared the cost-effectiveness of Oraquick (Orasure Technologies, Bethlehem, Pa) rapid testing versus enzyme-linked immunosorbent assay testing for a low-risk population of Mexican American women who are in labor. STUDY DESIGN: Using decision analysis techniques, we tested 2 strategies: (1) testing with enzyme-linked immunosorbent assay that was confirmed by Western blot and (2) testing with Oraquick rapid testing that was confirmed by Western blot. All seropositive parturients received zidovudine treatment in labor. The baseline assumptions were the incidence of human immunodeficiency virus in Mexican American mothers (0.05%), mother-to-child transmission with no treatment (25%), with treatment in labor (10%), sensitivity of enzyme-linked immunosorbent assay (98%), positive predictive value of enzyme-linked immunosorbent assay (10%), sensitivity/specificity of Oraquick rapid testing (99%/100%), positive predictive value of Oraquick rapid testing (83%-100%), sensitivity/specificity of Western blot (97%/99%), costs (enzyme-linked immunosorbent assay [dollar 5], Oraquick rapid testing [dollar 15], Western blot [dollar 25], zidovudine treatment [dollar 76] for 12 hours labor, neonatal treatment [dollar 2.50], lifetime treatment of human immunodeficiency virus-affected child [dollar 194,250]). Sensitivity analyses were done over a wide range of assumptions that included the costs of tests, the sensitivity of Oraquick rapid testing, the positive predictive value of enzyme-linked immunosorbent assay and Oraquick rapid testing, and the costs of treatments. RESULTS: Oraquick rapid testing was the preferred strategy at dollar 98 spent per human immunodeficiency virus-negative child versus dollar 491 for enzyme-linked immunosorbent assay testing. Much of the cost of the enzyme-linked immunosorbent assay strategy was due to the treatment of women and infants with false-positive tests. Sensitivity analysis over test costs, test sensitivity, and other variables found the analysis results to be robust. Threshold analysis revealed that, if the cost remained < dollar 409.90, Oraquick rapid testing was the dominant test. CONCLUSION: In a low prevalence population, the universal use of Oraquick rapid testing is cost-effective because of the low rate of false-positive results, thus preventing the emotional and economic costs of unnecessary treatment for human immunodeficiency virus to the new mother and her family.
Assuntos
Ensaio de Imunoadsorção Enzimática/economia , Infecções por HIV/diagnóstico , Imunoensaio/métodos , Trabalho de Parto , Americanos Mexicanos , Complicações Infecciosas na Gravidez/diagnóstico , Fármacos Anti-HIV/uso terapêutico , Western Blotting , Técnicas de Apoio para a Decisão , Feminino , Humanos , Programas de Rastreamento/métodos , Sistemas Automatizados de Assistência Junto ao Leito , Gravidez , Sensibilidade e Especificidade , Texas , Zidovudina/uso terapêuticoRESUMO
OBJECTIVE: Vein of Galen aneurysmal malformations (VGAMs) are rare congenital malformations thought to develop during weeks 6 to 11 of fetal life. Although they represent less than 1% of all cerebral vascular malformations, they constitute up to 30% of all pediatric vascular malformations. Vein of Galen aneurysmal malformations cause high-output heart failure in the fetus and neonate secondary to the decreased resistance and high blood flow in the lesion. We describe 2 cases, 1 prenatal and 1 postnatal, in which unusual aortic Doppler flow patterns and substantial brachiocephalic vessel dilation contributed to the discovery of a VGAM. METHODS: Echocardiographic findings associated with VGAM malformations in 2 cases are described. RESULTS: Unusual Doppler flow patterns and substantial brachiocephalic vessel dilation were seen in both cases. Pseudocoarctation of the aorta was also noted in both cases. CONCLUSIONS: The echocardiographic findings in fetal and neonatal VGAM may include pseudocoarctation of the aorta. Abnormal fetal cardiac findings should raise the practitioner's suspicion for cerebral malformations and vice versa.
Assuntos
Coartação Aórtica/complicações , Coartação Aórtica/diagnóstico por imagem , Veias Cerebrais/anormalidades , Veias Cerebrais/diagnóstico por imagem , Ecocardiografia , Ultrassonografia Pré-Natal , Adulto , Tronco Braquiocefálico/diagnóstico por imagem , Feminino , Doenças Fetais/diagnóstico por imagem , Humanos , Ultrassonografia DopplerRESUMO
In December 2001, the American College of Obstetricians and Gynecologists revised their recommendations for breech delivery. These recommendations acknowledge that although a planned vaginal delivery may no longer be appropriate, there are instances in which vaginal breech delivery is inevitable. Moreover, there continues to be patients who for any number of reasons will choose vaginal over cesarean delivery when faced with a fetus in the breech presentation. We sought to review maternal and fetal outcomes in such circumstances when vaginal breech delivery occurs, and compare these outcomes to elective cesarean deliveries for breech presentation. We performed a retrospective review of all singleton breech deliveries at our county hospital from January 2002 through June 2003. We reviewed maternal age, ethnicity, gestational age, gravity, parity, birthweight, mode of delivery, Apgar scores, umbilical arterial blood gases, and maternal and infant complications of both cesarean deliveries and vaginal breech deliveries. Univariate and logistic regression statistical analyses were performed with NCSS software. We had a total of 150 term breech deliveries with gestational ages between 37 and 42 weeks. Of these, 41 were vaginal breech and 109 were cesarean deliveries. Greater than 95% of patients are of Hispanic origin. There were no statistically significant differences in maternal age, ethnicity, gravity, or gestational age. Mean birthweight was significantly lower and parity was significantly higher in the vaginal delivery group. There was also a higher proportion of patients who underwent labor induction/augmentation in the vaginal group. We found no differences in the outcomes of 5-minute Apgar scores, umbilical arterial blood gas values, neonatal intensive care unit admissions, deaths or maternal/fetal complications reported between the two groups. Mean umbilical arterial blood gas values were greater than 7.18 in both groups. Vaginal breech delivery cannot always be avoided. Moreover, at our county hospital several patients continue to choose vaginal breech delivery. Our data would suggest that vaginal breech delivery remains a viable option in selected patients.