Severe gastrointestinal bleeding after hematopoietic cell transplantation, 1987-1997: incidence, causes, and outcome.

OBJECTIVE: Severe GI bleeding after hematopoietic cell transplantation is commonly due to lesions that are unusual in nontransplant patients. The frequency of GI bleeding appears to have decreased over the last decade, but the reasons have not been readily apparent. We sought to determine the incidence of severe bleeding during two time periods, to describe the causes and outcomes of bleeding, and to analyze the reasons behind an apparent decline in severe bleeding over the decade covered. METHODS: During 1986-1987 and 1996-1997, we followed all patients with and without severe bleeding at our institution, a marrow transplant center. RESULTS: Over this decade, the incidence of severe bleeding declined from 50/467 (10.7%) to 15/635 (2.4%) (p < 0.0001). Overall mortality from intestinal bleeding declined from 3.6% to 0.9% (p = 0.002), but mortality in those with bleeding remained high (34% vs 40%). The onset (day 42 vs 47) and platelet counts (35,994 vs 37,600/microl) were similar, but the sites and causes of bleeding were different. During 1986-1987, 27/50 patients bled from multiple GI sites, viral and fungal ulcers, or graft-versus-host disease (GVHD). Over the decade, bleeding from GVHD had decreased 80% (p < 0.0001), and bleeding from viral (p < 0.0001) and fungal (p = 0.023) ulcers almost disappeared. CONCLUSIONS: The incidence of severe GI bleeding has declined significantly over the last decade because of prevention of viral and fungal infections and severe acute GVHD. However, severe bleeding after transplant remains a highly morbid event, particularly among patients with GVHD.

Pseudomembranous colitis: an update.

Clostridium difficile is the most common nosocomial infection of the gastrointestinal tract. Most cases are associated with antibiotic therapy that alters the fecal flora, allowing overgrowth of C difficile with production of its toxins. Diagnosis is made by detection of the organism or toxin in the stools. A variety of different tests can be used, but none is perfect. A stool culture can be positive in someone without diarrhea, ie, a carrier. While the cytotoxin is the gold standard, it is expensive, and there is a delay before results are available. Thus, many laboratories use the enzyme-linked immunoassay tests to detect toxin of C difficile because they are a more rapid screen. Depending on the specific test used, they can detect toxin A, toxin B or occasionally both. Sensitivity and specificity rates vary. First line therapy for C difficile disease should be metronidazole 250 mg qid for 10 days. Vancomycin should be reserved for severe cases where metronidazole has failed or where metronidazole cannot be tolerated or is contraindicated. Recurrent C difficile disease is a particularly vexing clinical problem. A variety of biotherapeutic approaches have been used. Retreatment with antibiotics is almost always necessary. In addition, the nonpathogenic yeast Saccharomyces boulardii has been showed to be of benefit as an adjunct in preventing further recurrences.

Anorectal pathology in AIDS.

Anorectal complaints are common in persons with AIDS and are being seen increasingly because advances in therapy for HIV, such as the new antiretroviral protease inhibitors, have resulted in longer life expectancy for those with HIV infection. In the past, many patients with HIV infection were seen at referral centers; now, however, primary care physicians as well as gastroenterologists and surgeons in the community are managing and caring for these patients. For this reason, it is important for clinicians to recognize the spectrum of anorectal disease in patients with AIDS, as well as its appropriate evaluation and management.

Limited utility of emergency department thoracotomy.

To assess the therapeutic role and cost effectiveness of resuscitative thoracotomy in an urban trauma center, a retrospective review of thoracotomies (n = 273) performed in a trauma unit between 1986 and 1992 was undertaken. A total of 252 thoracotomies were performed for penetrating injuries (92%), and 21 (8%) were performed for blunt trauma. Ten neurologically intact survivors (3.7%) were identified. Mechanisms of injury in survivors were stab wound (n = 6) and gunshot wound (n = 4). There were no neurologically intact survivors when resuscitative thoracotomy was done for blunt trauma. All survivors sustained penetrating truncal injuries; isolated thoracic injuries existed in six patients, while four patients presented with both thoracic and abdominal wounds. All survivors had signs of life either in the field or in the trauma unit. Of the 242 non-survivors who had sustained penetrating trauma, only 49 had signs of life either in the field or upon arrival at the trauma unit. In this group, survival was 17 per cent. Revised Trauma Scores, calculated in the trauma unit, failed to differentiate between survivors and nonsurvivors. In 1992, the average hospital charge for resuscitative thoracotomy was $3413 per patient. Total charges during the study period for resuscitative thoracotomy were approximately $932,000. This represents an expenditure of $93,000 per successful thoracotomy. If thoracotomy was limited to patients sustaining penetrating trauma who demonstrated signs of life, total charges would be approximately $201,367, representing an expenditure of $20,137 per successful thoracotomy.(ABSTRACT TRUNCATED AT 250 WORDS)

Value of preoperative bone and liver scans and alkaline phosphatase in the evaluation of breast cancer patients.

We reviewed the results of 133 bone scans and 63 liver scans (computed tomography, liver-spleen radionuclide scan, or ultrasonography) obtained for the preoperative evaluation of breast cancer patients. Information on the preoperative staging of breast cancer (TNM classification) was available in 131 of 133 patients. Bone scans had a low preoperative yield as only 4 of 133 patients (3%) had a positive bone scan that correlated with the results of plain films. Only 1 of 63 patients had a liver scan suggestive of possible metastasis. We also found that the alkaline phosphatase level was not a good predictor of bone or liver metastases in breast cancer patients. In 103 patients with normal bone scans, the majority (54%) had elevated alkaline phosphatase levels; conversely, 9 of 30 patients (30%) with abnormal scans had normal alkaline phosphatase levels. Furthermore, 51 of 63 patients (81%) with elevated alkaline phosphatase levels had normal liver scans. Approximately $74,000 was spent on these liver and bone scans.

Intrapartum Doppler velocimetry, amniotic fluid volume, and fetal heart rate as predictors of subsequent fetal distress. I. An initial report.

This study examines the usefulness of umbilical artery Doppler velocimetry, amniotic fluid volume assessment, and fetal heart rate data in the early intrapartum period as predictors of subsequent fetal distress. A total of 109 patients seen in the latent phase of labor in the labor and delivery area were studied. Both an abnormal initial fetal heart rate and an amniotic fluid index less than or equal to 5.0 cm were associated with a significant increase in the incidence of intrapartum fetal distress. Conversely, a systolic/diastolic ratio greater than 3.0 by Doppler ultrasonography was not associated with increased fetal morbidity. Overall, the sensitivities, specificities, and positive predictive values of the fetal heart rate tracing and the amniotic fluid volume assessment were comparable. Doppler systolic/diastolic ratios showed very poor sensitivity and positive predictive value. We conclude that the fetal heart rate tracing or the assessment of amniotic fluid volume in the early intrapartum period are reasonable predictors of subsequent fetal condition. The lack of patients with the absence of or reverse umbilical velocity preclude conclusions with regard to Doppler systolic/diastolic ratios for this purpose.

Maternal and fetal blood flow velocity waveforms in patients with preterm labor: relationship to outcome.

Elevated systolic/diastolic ratios obtained by umbilical and uterine velocimetry have been used to predict adverse pregnancy outcome. We performed pretherapy umbilical and uterine velocimetry by means of continuous-wave Doppler ultrasonography on 92 patients who came for treatment in preterm labor. Fourteen (15.2%) and 12 (13%) patients had elevated uterine (greater than 2.6) and umbilical (greater than 3.5) systolic/diastolic ratios, respectively, and 9 (9.8%) patients had both ratios elevated. Overall 17 (18.5%) patients had at least one abnormal systolic/diastolic ratio. Patients with abnormal Doppler waveforms had a significantly shorter gestation, infants with lower birth weights, and a higher incidence of adverse pregnancy outcome as determined by meconium, cesarean section for fetal distress, low 1- and 5-minute Apgar scores, and days in the neonatal intensive care unit, compared with patients with normal systolic/diastolic ratios. There was no significant difference in the ability of uterine, umbilical, or combined velocimetry to predict preterm birth or adverse pregnancy outcome. Doppler studies in preterm labor patients may help to identify patients at increased risk for preterm birth and poor pregnancy outcome. Further studies are warranted to assess its usefulness in the evaluation of these patients.

Placenta previa in twin gestations.

The incidence of placenta previa in twin gestations was compared to that found in singleton pregnancies over a ten-year period. During this period, eight placenta previas occurred in 1,464 twin pregnancies, for an incidence of 0.55%, which was significantly higher (P less than .05) than the incidence of 0.31% in singleton pregnancies (458 placenta previas in 148,197 singleton pregnancies). We conclude that a twin gestation confers an added risk of placenta previa.

Cerebral, umbilical, and uterine resistance using Doppler velocimetry in postterm pregnancy.

The purpose of this study is to assess alterations in vascular resistance as measured by Doppler ultrasound in the postterm fetus. Forty-five postterm patients (greater than or equal to 287 days gestation by "good" dates) underwent Doppler velocimetry and calculation of systolic to diastolic (S/D) ratios of the umbilical, internal carotid, and uterine artery waveforms within 7 days of delivery. Patients were divided into two groups. Group 1 consisted of 26 patients with normal antepartum fetal surveillance that included reactive nonstress test and an amniotic fluid index (using the four-quadrant technique) equal to or greater than 5 cm. Group 2 consisted of 19 patients with antepartum compromise on the antepartum fetal surveillance tests. There was significantly greater (p less than .05) morbidity in group 2 compared to group 1 as judged by cesarean section for fetal distress (47% vs 15%), meconium at delivery (53% vs 4%), and 5-minute Apgar score less than 7 (30% vs 4%). There were no significant differences in the umbilical and uterine artery S/D ratios in the two groups, although patients in group 2 had significantly lower cerebral S/D ratios (3.6 +/- .5) compared to group 1 (4.4 +/- 0.4) (p less than .05). The ratio of cerebral to placental (umbilical) resistance in group 2 was significantly lower (1.1 +/- .3) compared to group 1 (1.8 +/- .3) (p less than .05). There was a low incidence of abnormal umbilical (greater than 3) and uterine (greater than 2.6) S/D ratios in both groups.(ABSTRACT TRUNCATED AT 250 WORDS)

Placental vascular resistance using umbilical velocimetry in patients undergoing cesarean section for fetal distress.

Peak systolic (S) to lowest end-diastolic (D) ratios (S/D) of umbilical velocimetry have been used to assess downstream placental vascular resistance and predict adverse pregnancy outcome. The purpose of this study is to assess S/D ratios in patients undergoing cesarean section for clinical fetal distress. Fifty-six patients were identified who had umbilical velocimetry performed during antepartum fetal surveillance (nonstress testing and amniotic fluid index) within 7 days of undergoing cesarean section for fetal distress at Women's Hospital (Los Angeles, CA). The mean gestational age at delivery was 36.5 +/- 2.5 weeks. Thirty (53.6%) patients had elevated S/D ratios (greater than 3), 24 (42.9%) had abnormal amniotic fluid indices, and 20 (35.7%) had abnormal nonstress testing. Group 1 (N = 30) patients delivered small-for-gestational-age (SGA) fetuses and group 2 (N = 26) patients delivered appropriately grown (AGA) fetuses. In group 1, 24 (80%) patients had abnormal S/D ratios and 16 (53.3%) had abnormal amniotic fluid indices, compared to only 6 (23.1%) with abnormal S/D ratios and 8 (30.8%) with abnormal amniotic fluid indices in group 2 (p less than .05). In contrast, 14 (53.8%) of the 26 patients in group 2 had abnormal nonstress testing compared to only 6 (20%) of the 30 patients in group 1 (p less than .05). Eighteen (69.2%) of the 26 patients in group 2 were post-term pregnancies; 20 (66.7%) of the 30 patients in group 1 had chronic hypertension, pregnancy-induced hypertension, or superimposed preeclampsia.(ABSTRACT TRUNCATED AT 250 WORDS)

Fetal umbilical blood flow velocity waveforms using Doppler ultrasonography in patients with late decelerations.

The purpose of this study was to assess placental vascular resistance as measured by peak systolic to end-diastolic ratios (S/D) of the umbilical artery waveforms in patients with late decelerations. Fifty patients with persistent late decelerations and 50 gestational age-matched controls with reactive tracings underwent umbilical velocimetry with measurement of S/D ratios. The mean (+/- SD) S/D ratio in the late-deceleration group (4.32 +/- 1.1) was significantly higher than that of the control group (2.32 +/- 0.21) (P less than .01). Patients with late decelerations had a significantly higher incidence of adverse pregnancy outcome, as judged by the incidence of small for gestational age infants, meconium, cesarean section for fetal distress, low Apgar scores, and neonatal intensive care unit admissions, compared with the control group. However, there was no difference in the incidence of adverse pregnancy outcome in the late-deceleration group with normal S/D ratios compared with controls. The sensitivity, specificity, and positive and negative predictive values of S/D ratios in the late-deceleration group for predicting adverse pregnancy outcome were 85.7, 100, 100, and 89.6%, respectively. These data suggest that umbilical velocimetry might be able to discriminate late decelerations that constitute a false-positive test. Incorporation of umbilical velocimetry into antepartum and intrapartum fetal surveillance schemes may therefore be helpful.

A comparative study of fetal umbilical velocimetry with continuous- and pulsed-wave Doppler ultrasonography in high-risk pregnancies: relationship to outcome.

Systolic/diastolic ratios of umbilical velocimetry obtained with either continuous-wave or pulsed-wave Doppler ultrasonography have been used to assess downstream placental vascular resistance and fetal well-being. The purpose of this study is to compare the efficacy of systolic/diastolic ratios obtained by continuous-wave and pulsed-wave Doppler ultrasonography in the prediction of poor pregnancy outcome. Continuous-wave and pulsed-wave umbilical velocimetry was performed and systolic/diastolic ratios were measured in 200 high-risk pregnancies in the third trimester by use of Angioscan III and a General Electric RT 3600 scanner, respectively. A total of 165 study participants had normal systolic/diastolic ratios and 35 participants had elevated ratios (greater than 3.0) with both continuous-wave and pulsed-wave Doppler ultrasonography. Both methods identified 35 participants with abnormal ratios, and none of the women was misclassified by either method. The pulsed-wave and continuous-wave values for 35 participants with elevated ratios were 6.35 +/- 1.52 and 6.23 +/- 1.58, respectively; values for 165 participants with normal ratios were 1.95 +/- 0.40 and 1.96 +/- 0.41, respectively (not significantly different). Participants with elevated systolic/diastolic ratios within 7 days of delivery had significantly higher incidence of adverse pregnancy outcome as judged by small-for-gestational-age fetuses, presence of meconium at delivery, fetal distress in labor, cesarean sections and 5-minute Apgar scores less than 7. Fetuses with elevated ratios were delivered at an earlier gestational age (34 +/- 1.2 weeks), had lower birth weights (1422 +/- 151 gm), and spent more time in the neonatal intensive care unit (17.1 +/- 5.2 days), compared with fetuses with normal ratios (delivered at 38.5 weeks +/- 0.9 weeks, 3100 +/- 210 gm birth weights, and 2 +/- 0.2 days spent in neonatal intensive care units, respectively, p less than 0.05). We therefore conclude that continuous-wave and pulsed-wave Doppler ultrasonography produce similar results with regard to systolic/diastolic ratios in high-risk pregnancies, and either method appears to be a valuable adjunct in the surveillance of high-risk pregnancies.

Twice a cesarean, always a cesarean?

The cesarean delivery rate has quadrupled during the past two decades, resulting in considerable attention focused on alternatives to cesarean birth. One option, vaginal birth after one previous cesarean, has come to be recognized as an acceptable alternative to routine elective repeat cesarean delivery. The purpose of this report was to evaluate whether women with two previous cesareans can safely undergo a trial of labor. Between July 1, 1982 and June 30, 1986, data were collected prospectively on all women with previous cesareans. Those with a known classical incision or a medical or obstetric contraindication to a trial of labor were excluded from an attempted vaginal delivery. During this period, 67,784 patients were delivered, of whom 6250 (9.2%) had had a previous cesarean. Of the 6250 previous-cesarean patients, 1088 (17.4%) had had two previous cesareans; of these, 501 (46%) underwent a trial of labor and 346 (69%) delivered vaginally. Whereas the overall rate of uterine dehiscence was 3%, the rate in those women who attempted a vaginal delivery was 1.8%, versus 4.6% in those who did not. Overall, oxytocin was used in 284 (57%) and was associated with a dehiscence rate of 2.1%, versus 1.4% in the no-oxytocin group. Successful vaginal delivery was related significantly to the use of oxytocin and to a previous vaginal delivery. Trial of labor in patients with two previous cesareans appears to be a reasonable consideration.

Acute puerperal uterine inversion. New approaches to management.

A retrospective review identified 56 patients with uterine inversion, from July 1977 through June 1986, from weekly obstetric statistics, delivery records and computerized discharge diagnoses. All patients underwent delivery by house officers, midwives or medical students under supervision. An analysis of the data revealed that the risk factors were primiparity, a fundally implanted placenta and delivery of a macrosomic fetus. Also, patients who received oxytocin with or without MgSO4 were at higher risk of puerperal inversion. MgSO4 by itself did not appear to be a risk factor. A placenta attached at the time of inversion appeared to have a protective effect against the development of shock. The use of betamimetics or MgSO4 appeared to be an acceptable alternative to general anesthesia in relaxing the uterus and aiding in its repositioning. Those agents were more likely to be successful in acute cases than in subacute ones and in second-degree inversion than in third-degree.

Relationship of systolic/diastolic ratios from umbilical velocimetry to fetal heart rate.

We assessed the relationship between systolic/diastolic ratios as determined by umbilical velocimetry to fetal heart rate. Umbilical velocimetry was performed with continuous-wave Doppler ultrasound and systolic/diastolic ratios and fetal heart rate for the corresponding cardiac cycles were calculated in four groups of patients. Group 1 consisted of 30 patients undergoing antepartum fetal testing; systolic/diastolic ratios were found to be significantly lower (mean +/- SD, 2.0 +/- 0.15) during an evoked fetal heart rate acceleration with an artificial larynx than either before (2.4 +/- 0.14) or after the acceleration (2.35 +/- 0.10, p less than 0.01). In 20 patients with pyelonephritis (group 2), systolic/diastolic ratios were significantly lower during initial fetal tachycardia (1.6 +/- 0.21) as compared with those obtained after its resolution (2.1 +/- 0.12, p less than 0.08). In the 25 patients with chorioamnionitis in group 3, systolic/diastolic ratios were significantly higher during initial fetal tachycardia (1.4 +/- 0.21) than after its resolution (1.9 +/- 0.15, p less than 0.05). Twenty patients in labor (group 4) had 10 serial measurements at 1 to 2-hour intervals of systolic/diastolic ratio and FHR. Least-squares regression of each patient showed a negative slope that differed statistically from zero (p less than 0.05). There were no patients with elevated systolic/diastolic ratios greater than 3.0 in any group and all patients delivered fetuses appropriate for gestational age. These findings suggest an inverse relationship between systolic/diastolic ratio and fetal heart rate. Additionally, an alteration in fetal heart rate within the range studied does not itself produce abnormal ratios. Therefore normalization of the systolic/diastolic ratio for heart rate may be considered in clinical studies for statistical analysis and comparison but may have little practical or clinical relevance when the ratios are abnormal.

Antepartum improvement of abnormal umbilical artery velocimetry: does it occur?

Absence of end-diastolic velocity on umbilical artery velocimetry suggests extreme elevation of placental vascular resistance and is associated with adverse pregnancy outcome. This study was undertaken to assess whether antepartum improvement of abnormal umbilical artery waveforms occurs. Thirty-one fetuses identified with absence of end-diastolic velocity between July 1985 and December 1987 at Women's Hospital underwent sequential umbilical artery velocimetry at 1- to 3-day intervals. The presence of end-diastolic velocity on subsequent scans was considered an improvement in waveforms. The mean diagnosis-to-delivery interval (20.5 +/- 4 days), gestational age at delivery (32.5 +/- 1.2 weeks), and birth weight (1440 +/- 210 gm) were significantly higher in five fetuses that showed improvement in waveforms, compared with the 26 fetuses that did not show improvement in waveforms (9.5 +/- 3.5 days, 29.5 +/- 0.9 weeks, and 940 +/- 70 gm, respectively). Ten perinatal deaths occurred, for a perinatal mortality rate of 32.3%. There was significant perinatal morbidity in the overall group as judged by intrauterine growth retardation, meconium, 5-minute Apgar scores less than 7, and cesarean section for fetal distress. We conclude that although absence of end-diastolic velocity is associated with adverse pregnancy outcome, antepartum improvement in umbilical artery waveforms occurred in 15% of the fetuses studied and was associated with an improvement in perinatal outcome. Factors that influenced this improvement, though unclear, might be related to maternal bed rest or medication and require further investigation.

Fetal umbilical velocimetry using continuous-wave and pulsed-wave Doppler ultrasound in high-risk pregnancies: a comparison of systolic to diastolic ratios.

Systolic to diastolic (S/D) ratios of umbilical velocimetry using either continuous-wave or pulsed-wave Doppler ultrasound have been used to assess downstream placental resistance. The purpose of this study was to compare the S/D ratios obtained by both types of instrumentation to determine whether there are significant differences between measurement values. Umbilical velocimetry was performed on 200 high-risk pregnancies in the third trimester using the Angioscan III to obtain continuous-wave velocimetry and the General Electric RT3600 to obtain pulsed-wave velocimetry. Systolic to diastolic ratios were considered abnormally high if they were greater than 3. One hundred sixty-five patients had normal S/D ratios and 35 patients had elevated ratios on both continuous-wave and pulsed-wave ultrasound. There was no significant difference in the mean S/D ratios obtained by either method for the entire population (continuous-wave S/D 2.81 +/- 1.79, pulsed-wave S/D 2.71 +/- 1.83, R = 0.98), the normal group (continuous-wave S/D 1.96 +/- 0.41, pulsed-wave S/D 1.95 +/- 0.40, R = 0.91), and the abnormal group (continuous-wave S/D 6.23 +/- 1.58, pulsed-wave S/D 6.35 +/- 1.52, R = 0.94). Least-square regression was performed to model the relationships between pulsed wave and continuous wave, with both used as dependent variables. The slopes and intercept for the normal and abnormal groups were evaluated and were significantly different (P less than .01).(ABSTRACT TRUNCATED AT 250 WORDS)

Maternal and fetal blood flow velocity waveforms in patients with preterm labor: prediction of successful tocolysis.

Umbilical and uterine artery velocimetry was performed using continuous-wave Doppler ultrasound (Angioscan III) in 60 patients in preterm labor. Peak-systolic/end-diastolic ratios were calculated according to previously described techniques. All measurements were made before tocolytic therapy was begun: magnesium sulfate (n = 40) or ritodrine (n = 20). The mean gestational age was 33.1 +/- 1.5 weeks (range 29 to 36 weeks). Twelve (20%) patients had elevated (greater than 2.6) pretherapy uterine peak-systolic/end-diastolic ratios, 10 (16.7%) patients had elevated (greater than 3.5) pretherapy umbilical peak-systolic/end-diastolic ratios, and in eight (13.3%) patients both ratios were elevated. In seven (58.4%) of the 12 patients with elevated uterine peak-systolic/end-diastolic ratios, six (60%) of the 10 patients with elevated umbilical peak-systolic/end-diastolic ratios, and five (62.5%) of the eight patients with both ratios elevated tocolytics failed and the women were delivered within 48 hours, compared with seven (14.6%) of 48, eight (16%) of 50, and six (13.0%) of 46 with normal ratios, respectively (p less than 0.05). We conclude that patients in preterm labor with elevated pretherapy uterine and/or umbilical peak-systolic/end-diastolic ratios are more likely to fail tocolysis therapy and be delivered preterm than those with normal ratios. It may therefore be useful to include umbilical and uterine velocimetry in the initial evaluation of preterm labor.