Preventing Postoperative Nausea and Vomiting During an Ondansetron Shortage.

Postoperative nausea and vomiting (PONV) degrades patient experience and increases healthcare costs. Estimates of PONV range from 10% to 80%. The Apfel Simplified Score is an evidence-based instrument for determining individual risk of PONV. Scoring enables anesthesia providers to match antiemetic strategies with the calculated risk of PONV. Data were collected across 3 times. After the Apfel scoring system was automated into the electronic medical record, providers were more likely to increase PONV prophylaxis for patients at highest risk and reduce prophylaxis for patients at lowest risk. Rates of PONV remained similar at baseline (34.7%) and in the early postimplementation period (38.8%); a modest reduction was observed in the final period (26.5%). Intravenous ondansetron, the most common antiemetic at baseline, was not available in the early postimplementation period, which may partially explain the initial increase in PONV. While ondansetron was unavailable, providers began using 3 other antiemetics, a practice that persisted once intravenous ondansetron returned. The Apfel score is an evidence-based tool that providers can use to reduce the risk of PONV. This electronic tool and the reminder cards have been shared across the US Military Health System, fostering an organizational culture that values targeted prophylaxis for PONV.

Simulated insect defoliation on soybean: influence of row width.

An ongoing change in soybean production gaining popularity in the United States is a reduction in row spacing. Plant canopy closure is quicker and leaf area index is greater, thus yield is usually higher. Because yield response to insect defoliation is primarily a function of how defoliation causes changes in light interception, the possibility exists that the insect-injury-yield-loss relationship might differ among row widths. Soybean was grown in four states using similar methodologies. Insect defoliation was simulated by picking leaflets based on an insect defoliation model. Plant growth measurements were taken immediately following the end of defoliation. Numerous independent variables were measured or calculated, including percentage light interception, leaf area index, percentage defoliation, and leaf area per plot. Analyses of covariance were conducted on the resultant data to determine whether insect-injury-yield-loss relationships interact with row width. A significant interaction would indicate that the impact of the variables on yield was dependent on the row width, whereas a nonsignificant interaction would suggest that the relationship between the variables and yield is similar at all row widths. Few significant interactions were obtained, indicating that the impact of the variables on yield is similar across row widths. Because of the lack of significant interactions, the insect-injury-yield-loss relationships previously developed should be usable across varying row widths. Thus, treatment decisions based on light interception and leaf area indices, both considered more appropriated measures of insect injury, should be applicable for all row spacings.

Covert self-reinforcers, fear of consequences, and health behavior.

A sample of 125 U.S. college students reported how frequently they exercised vigorously; wore seat belts in automobiles; and avoided consumption of red meat and foods high in dietary cholesterol, saturated fat, and salt. They also reported their fears of long-term negative effects from the unhealthful alternatives and both the frequencies and intensities of 6 self-administered covert consequences: 3 positive for healthful behaviors and 3 negative for the unhealthful alternatives. Diet-related health behaviors were best predicated by a single scale composed of all 12 covert-consequence items. Factor analyses suggested the use of 2 scales for exercise and use of seat belts: 1 rating positive consequences and the other rating negative consequences. For both behaviors, only the positive-item scale predicted in multiple regression. Fear was correlated with all health behaviors except exercise, but it contributed independently only to red-meat avoidance.

Ultrasonographic characteristics of first-trimester gestations in recurrent spontaneous aborters.

OBJECTIVE: To compile, for the first time, serial ultrasonographic findings during the first trimester of pregnancy in women with a history of primary recurrent spontaneous abortion so as to define the dynamics of early normal and abnormal gestations in this category of gravidas. STUDY DESIGN: Transvaginal ultrasonograms were obtained weekly from 5 to 12 weeks' gestational age in 40 women, 10 each of four groups: recurrent spontaneous aborters and primiparas (controls), with both successful and failed gestations. RESULTS: Embryonic heart motion was detected in 40-50% of successful pregnancies during the fifth week of gestation and in the balance by the sixth week, while heart motion was detected in no more than 50% of pregnancies that later failed. Of the failed pregnancies, all were evident by the eighth week of gestation, including those with previously documented viability. The gestational sac size and crown-rump length were smaller than expected in both failed groups, with the sac size difference evident as early as week 5 and the crown-rump length difference apparent by week 7. CONCLUSION: Appropriate timing of the initial ultrasonogram in recurrent aborters (i.e., 8 weeks' gestational age) can identify, by means of heart motion and gestational sac features, all pregnancies that will ultimately fail.

Activation of complement in humans with a first-trimester pregnancy loss.

Serum complement (C') activity in recurrent spontaneous aborters and primiparous controls with successful and unsuccessful pregnancies was quantified so as to define the dynamics of C' activation in early pregnancy loss. C' hemolytic activity was shown to be stable throughout the first trimester of pregnancy and did not differ from preconception levels in all of the successful pregnancies of recurrent aborters and controls and in the majority of pregnancy losses. However, 30% of recurrent aborters and 20% of controls with a pregnancy loss demonstrated activation of C' by the alternate pathway as early as the 7th week with a progressive decline in C' activity until abortion was clinically completed. Circulating levels of C3 dropped from 1.34 to 0.53 mg/dl, and factor B levels declined from 0.34 to 0.14 mg/dl in these hypocomplementemic women. Pregnancy loss is therefore associated with C' activation in a subset of both recurrent and nonrecurrent aborters and this occurs largely before loss of fetal viability.

Isolated galactorrhea in sarcoidosis: a case report.

Neuroendocrine disorders are rare. A case of hypothalamopituitary sarcoidosis is presented in which hyperprolactinemia and galactorrhea occurred in isolation.

A retrospective look at tip location and complications of peripherally inserted central catheter lines.

In 1982, Southern Regional Medical Center in Riverdale, Ga, instituted a program for selected intravenous nurses to insert and manage peripherally inserted central catheters (PICCs). At present, approximately 125 to 150 PICCs are inserted annually by eight experienced IV nurses. In this retrospective study, the authors review medical record data on PICC insertions that occurred between January 1987 and December 1991. The optimal tip location is defined as the superior vena cava (SVC) and an anterior-posterior one-view chest x-ray is performed to confirm tip location. This study focuses on the initial location of the PICC and actions taken to correct the initial tip placement if not in the SVC. Medical records were reviewed for complications including mechanical phlebitis, infections, ruptured catheters, clotted catheters, or vein thromboses. The frequency of these complications, their prevention, and management are discussed.