Predictors of maternal mortality and near-miss maternal morbidity.

OBJECTIVE: To identify risk factors for life-threatening maternal outcomes. STUDY DESIGN: Hospital charts were reviewed for cases of maternal mortality or near-miss and for controls overmatched 1:3. Significant risk factors were identified through simple and best subsets multiple logistic regression. RESULT: Eight cases of mortality and 69 near-miss cases were found. Significant risk factors with their odds ratios and 95% confidence intervals are: age 35 to 39 years (2.3, 1.2 to 4.4) and >39 years (5.1, 1.8 to 14.4); African-American race (7.4, 2.5 to 22.0) and Hispanic ethnicity (4.2, 1.3 to 13.2); chronic medical condition (2.7, 1.5 to 4.8); obesity (3.0, 1.7 to 5.3); prior cesarean (5.2, 2.8 to 9.8) and gravidity (1.2, 1.1 to 1.5 per pregnancy). In multivariable logistic regression, race remained significant while controlling for other significant factors and markers of socioeconomic status. CONCLUSION: Some risk factors can be modified through medical care, education or social support systems. Racial disparity in outcome is confirmed and is unexplained by traditional risk factors.

Analogues of the dioxolanes dexoxadrol and etoxadrol as potential phencyclidine-like agents. Synthesis and structure-activity relationships.

A series of dioxolane analogues based on dexoxadrol ((4S,6S)-2,2-diphenyl-4-(2-piperidyl)-1,3-dioxolane) and etoxadrol ((2S,4S,6S)-2-ethyl-2-phenyl-4-(2-piperidyl)-1,3-dioxolane) were prepared and tested for their ability to displace [3H]TCP (1-[1-(2-thienyl)cyclohexyl]piperidine) from PCP (1-(1-phenylcyclohexyl)piperidine) binding sites in rat brain tissue homogenates. Qualitative structure-activity relationships within this series were explored through modifications of the three major structural units of dexoxadrol, the piperidine, 1,3-dioxolane, and aromatic rings of the molecule. N-Alkyl derivatives of dexoxadrol were found to be inactive, as were those analogues where the dioxolane ring was modified. Phenyl-substituted etoxadrol analogues were compared to similarly substituted PCP analogues and distinct differences were found in their structure-activity relationships suggesting that the aromatic rings in these two drug classes interact differently with the PCP binding sites. The replacement of the phenyl ring in etoxadrol by either a 2- or 3-thienyl ring led to compounds with affinity comparable to etoxadrol, and the replacement of the ethyl moiety on etoxadrol's dioxolane ring with propyl (7) or isopropyl (8) led to compounds which were more potent than etoxadrol or PCP. The most potent compound was (2S,4S,6S)-2-ethyl- 2-(1-chlorophenyl)-4-(2-piperidyl)-1,3-dioxolane (11), where a chlorine moiety was placed in the ortho position in the aromatic ring of etoxadrol. Its potency was comparable with TCP in vitro.

Classification of anorectal malformations--initial approach, diagnostic tests, and colostomy.

The optimal surgical care of patients with imperforate anus begins with appropriate decision making in the critical newborn period. In most cases the decision to create a colostomy should be delayed until the infant is 18 to 24 hours old. Except in cases of a rectoperineal fistula, most neonates are best treated with a completely divided left-lower-quadrant colostomy between the descending and sigmoid colons. Female patients with cloacal anomalies must be recognized at birth so that all urgent urologic evaluations can be performed. Hydrocolpos and obstructive uropathy are common in these neonates and warrant urgent decompression of the urinary tract with a vaginostomy and/or vesicostomy as well as a colostomy. Renal ultrasonography and voiding cystourethrography are mandatory for all patients regardless of the height of the defect. It is critical to discover the important precursors to renal insufficiency including renal agenesis, renal dysplasia, and vesicoureteral reflux in the neonate. The presence of these anomalies mandates early consultation with a pediatric urologist because the morbidity and mortality of these lesions often exceed those of the imperforate anus. Spinal cord anomalies are common and can be found even in patients who have normal plain films and low defects. Spinal ultrasonography or magnetic resonance imaging should be performed in all neonates to rule out occult spinal pathology such as tethered cord or lipoma of the cord. Efficacious and cost-effective care of patients with imperforate anus begins with a carefully thought out plan in the neonate. Optimal execution of the evaluation and surgical treatment at this phase sets the stage for the best possible outcome later in life.

Health risk behavioral survey from 39 juvenile correctional facilities in the United States.

PURPOSE: The study surveyed adolescents in juvenile detention facilities to determine the incidence of health risk behaviors. METHODS: A modified version of the United States Centers for Disease Control Youth Risk Behavior Surveillance System was administered to 1801 minors at 39 facilities in the United States. RESULTS: Risky behavior begins early, the initiation plateauing at age 15 or 16 years. Girls and boys reported comparable rates of drinking, binge drinking, and illicit drug use. North American Natives and those individuals who designated themselves as being other than any of the offered choices for racial designation ("Other") began drinking at earlier ages, had more binge drinking, more illegal drug use, and the most fight-related behavior. By age 12 years 62% reported onset of sexual intercourse and by age 14 years 89% were sexually active. Fighting was reported by 69% of detainees. Fight-related injuries within the past year were reported by 25% of the respondents. Nearly 47% belonged to a gang. Drug/alcohol use, fighting, and gang membership were related. Suicide was considered by 22% of the detainees, planned by 20%, tried by 16%, 8% were injured because of a suicide attempt. Younger teens (White, N.A. Natives, and "Other") had the most frequent suicide ideation. Drug/alcohol use correlated with suicidal thoughts. Onset of sexual intercourse was at an average age of 12. Multiple partners and pregnancy, was highest among blacks and "Others". Blacks had the highest sexually transmitted disease (STD) rate. Less than half of all respondents used condoms at last intercourse. STDs were related to being female, being black, and having multiple sexual partners. Pregnancy was related to multiple sexual partners and violent behavior. CONCLUSION: Male and female detainees report a high incidence and early onset of risky behaviors. N.A. Natives and those of "other" races reported the highest incidence of risk behaviors.

Intestinal stoma complications in immunocompromised children.

BACKGROUND/PURPOSE: When performing an urgent gastrointestinal operation on an immunocompromised child, the pediatric surgeon may have to decide between performing an intestinal anastomosis (and risk leakage or sepsis) or creating an intestinal stoma. This study evaluates the postoperative course of those patients treated with intestinal stomas and the long-term survival rate of such patients. METHODS: A 13-year retrospective review of immunocompromised children with intestinal stomas was performed. Patients were assessed as to their diagnosis, indication for surgery, stoma type, postoperative complications (within 30 days of surgery), ostomy-related complications, and survival. RESULTS: 19 stomas (8 ileostomies and 11 colostomies) were created in 18 patients. Six children had immunodeficiency disorders; 12 were immunosuppressed from chemotherapy treatment for cancer. Indications for surgery included infectious complications (n = 8); neoplasm-induced bowel obstruction, perforation, or invasion (n = 10); and Hirschsprung's disease (n = 1). Postoperative complications occurred in 13 cases (68%); two warranted reoperation. Four of six patients with neutropenia had serious postoperative infectious complications. Stoma complications occurred in 6 cases (32%); 1 required revision. All 3 patients in whom bleeding developed from their stoma site were thrombocytopenic. Nine of 18 patients (50%) died, yet no patient died of complications attributable to their stomas. Of the surviving 9 children, 6 underwent stoma takedown at a mean of 19 months after creation; 1 has a permanent colostomy, and 2 currently are undergoing chemotherapy. CONCLUSION: Although immunocompromised children who require intestinal stomas frequently die of their underlying illnesses and their stomas often produce considerable morbidity, stoma creation does not jeopardize their chance of survival.

Neurogenic bladder in infants born with anorectal malformations: comparison with spinal and urologic status.

BACKGROUND/PURPOSE: Spinal dysraphism and neurovesical dysfunction (NVD) frequently are associated in children with anorectal malformations (ARM). This study compares the urodynamic data from a selected group of patients with the results of their spinal and urologic imaging studies. METHODS: Twenty-six children (20 with isolated imperforate anus and six with persistent cloacal malformations) were investigated. All patients were evaluated with leak point pressures (LPP), renal ultrasound scan, and voiding cystourethrography. Eight children had urodynamics performed before and after posterior sagittal anorectoplasty (PSARP). The spinal cord was assessed using ultrasonography or magnetic resonance imaging. Current urologic status was obtained to provide long-term follow-up. RESULTS: Twenty-one of 26 children demonstrated elevated LPPs above the established normal value of 40 cm H2O, and 15 of these children had normal spinal imaging study findings. Uroradiographic studies findings showed that 12 of 21 children with elevated LPPs had hydronephrosis or vesicoureteral reflux with seven of these patients having normal spinal cords. LPPs in the eight patients with pre- and postoperative studies were 74 +/- 14.7 cm H2O and 68 +/- 31.8 cm H2O (mean +/- SD), respectively. CONCLUSIONS: These urodynamic and radiographic data confirm that NVD (elevated LPP) is common in patients with anorectal malformations despite normal spinal cords. Bladder dysfunction does not appear to be a sequelae of a properly performed PSARP. Patients with ARM and any uroradiographic or clinical urologic abnormality should undergo urodynamic testing even though the spinal studies are normal.

Anaphylaxis during caesarean section in a patient with undiagnosed placenta accreta: it never rains but it pours!

Published guidelines exist for the management and investigation of suspected anaphylactic reactions associated with anaesthesia. We report a woman who had a life-threatening anaphylactic reaction during caesarean section under spinal anaesthesia, complicated by undiagnosed placenta accreta. We discuss the particular problems of the case and the practical difficulties of testing survivors of anaphylaxis: despite following the recommendations, we have been unable to identify the cause.

Product evaluation and the clinical nurse specialist: an opportunity for role development.

Product evaluation activity is an area ripe for clinical nurse specialist (CNS) participation and has a high potential for administrative support in a cost-conscious environment. This article describes how product evaluation has evolved in the hospital setting and the levels and scopes of product evaluation activity. A section is included on the relationship between nursing and the materiel management department, its main collaborator in product evaluation. The product evaluation process is described for those CNSs who are unfamiliar with this activity and would like to try this clinically related area to demonstrate cost effectiveness or as the basis for a nursing research project.

Avoidance of leakage and strictures when creating an invisible conduit for antegrade colonic enemas.

BACKGROUND: Antegrade enemas have been proven to minimize problems with stool control for many incontinent patients; however, foreign bodies are unsightly, and native tissues have been shown to leak or stricture. METHODS: Using a limited laparotomy incision, the appendix or a rolled cecal tube was sutured to the apex of the everted umbilical skin using a V-shaped incision. The skin then was inverted to hide the mucosa. The cecum was plicated around the base of the appendix or cecal tube and then tested by filling the cecum with saline to a pressure of 30 cm H2O. RESULTS: Twenty patients (aged 4.8 to 41 years) with fecal incontinence caused by imperforate anus (17 cases) and other causes underwent this procedure. Two patients had minor strictures that resolved with home dilatations, and one cecal tube necrosed, and the patient has refused reoperation. One patient had minor prolapse and underwent revision. None of the conduits leak. Two patients achieved continence and stopped cannulating their stomas. With adjustment and customization of each enema regimen, stool accidents are infrequent. Follow-up is 22 +/- 14 (mean +/- SD) months. CONCLUSION: A catheterizeable colocutaneous conduit has been developed that allows for an invisible, leak-proof, and relatively stricture-free means through which antegrade enemas can be given.

The sitting position for neurosurgery in children: a review of 16 years' experience.

BACKGROUND: Use of the sitting position for neurosurgery is controversial. The main concern is the risk of venous air embolus (VAE) and its sequelae. METHODS: The paediatric neurosurgeons at our institution routinely use the sitting position for posterior fossa and pineal surgery, and a retrospective audit of the incidence of VAE from 1982 to 1998 has been performed. RESULTS: Venous air embolism, defined as a fall in end-tidal carbon dioxide pressure >0.4 kPa, was detected in 38 of 407 operations (9.3%). A fall in systolic arterial pressure >10% accompanied the VAE in nine out of 43 episodes (20.9%); this represents 2% of all operations. All VAE episodes responded promptly to treatment and there was no perioperative morbidity or mortality directly attributed to it. CONCLUSIONS: This is the largest study of the incidence of VAE in children undergoing neurosurgery. Our results suggest that the sitting position can be used safely for neurosurgery in children.

Management of myocardial infarction: implications for current policy derived from the Nottingham Heart Attack Register.

OBJECTIVE: A register of patients with heart attacks in the Nottingham Health District has been maintained since 1973. Data from 1982 to 1984 inclusive, a period before trials of thrombolytic therapy started in Nottingham, were analysed to provide background information for the introduction of a policy of routine thrombolysis for appropriate patients. DESIGN: Data were collected prospectively on all patients transported to hospital in the Nottingham Health District with suspected myocardial infarction in the years 1982-84 and on patients treated at home during that time. SETTING: Two district general hospitals responsible for all emergency admissions in the health district. PATIENTS: 6712 patients admitted to hospital with suspected myocardial infarction and 1887 patients found dead on arrival at hospital. Approximately 1500 patients in whom a myocardial infarction was suspected were treated at home, but only 125 were identified who had a definite or probable infarction. RESULTS: Among the patients admitted within 24 hours of the onset of symptoms, the median delay from onset to hospital admission was 174 minutes; 25% of patients were admitted within 91 minutes. The only factor that seemed to affect the time taken was the patient's decision to call a general practitioner or an emergency ambulance. If a general practitioner referred the patient to hospital the median delay was 247 minutes, compared with 100 minutes when the patient summoned an ambulance. Ninety three per cent of all patients were transported by ambulance. The median time from the call for the ambulance to hospital arrival was 29 minutes. Once a patient was admitted to hospital, the time to admission and general practitioner involvement seemed relatively unimportant as predictors of outcome. Patients admitted more than nine hours after onset of symptoms with a diagnosis of definite or probable infarction had a poorer outcome than those admitted earlier (in-hospital mortality 22.4% v 13.1%). The fatality rates of those admitted to a coronary care unit or to an ordinary medical ward are similar. CONCLUSION: Although the introduction of thrombolytic therapy has brought with it an increased awareness of the need to minimise any delay in time to admission, it seems that in a predominantly urban area like Nottingham, patients with a suspected heart attack will continue to be admitted to hospital most quickly if an ambulance crew rather than a general practitioner is called. Because the ambulance crew was in contact with such patients for only a short time it seems unlikely that administration of a thrombolytic drug in the ambulance would be helpful.

Enantiomeric and diastereomeric dioxadrols: behavioral, biochemical and chemical determination of the configuration necessary for phencyclidine-like properties.

Dioxadrol exists in four isomeric forms. alpha-(+)-Dioxadrol (dexoxadrol) showed phencyclidine (PCP)-like activity in rhesus monkeys trained to discriminate s.c. administration of ketamine, but neither alpha-(-)-dioxadrol (levoxadrol) nor beta-(+/-)-dioxadrol showed such activity. In addition, response-contingent i.v. dexoxadrol maintained higher rates of responding than either levoxadrol or beta-dioxadrol in monkeys experienced with ketamine self-administration. The order of potency in displacing bound 1-[1-(2-thienyl)cyclohexyl]piperidine from binding sites in rat brain homogenates was dexoxadrol much greater than levoxadrol = beta-(+/-)-dioxadrol. Viewed in the context of previous studies with stereochemical probes of the PCP receptor, these results extend and confirm the supposition that dexoxadrol and levoxadrol are the stereochemical probes of choice in the study of effects mediated through PCP receptors. The absolute configuration of dexoxadrol was determined to be 4S, 6S by X-ray crystallography, thus defining the optimum chirality necessary for receptor binding and PCP-like activity in the dioxadrol series. Based on these and other considerations, receptor-active conformations of dexoxadrol and PCP are proposed.