Group B streptococcus colonization in pregnant diabetic women.

OBJECTIVE: To evaluate the influence of maternal diabetes on the risk of group B streptococcus colonization during pregnancy. METHODS: We prospectively analyzed data on 105 pregnant women with diabetes mellitus, both pregestational and gestational, and a control group of 300 pregnant women without carbohydrate intolerance. All had singleton gestations, negative tests for human immunodeficiency virus, and intact membranes at enrollment. Culture specimens for group B streptococcus were obtained from the lower vaginal walls and rectum. Two-tailed unpaired Student t test, Mann-Whitney U test, and chi 2 test were used as appropriate. Multiple logistic regression analyses were performed to evaluate the independent influence of maternal diabetes on the rate of group B streptococcus colonization. RESULTS: Compared to controls, diabetic women had a higher colonization rate (43.8 versus 22.7%, odds ratio [OR] 2.56, 95% confidence interval [CI] 1.6, 4.1). The prevalence of group B streptococcus colonization in pregestational diabetic women was 54.1% and in women with gestational diabetes it was 35.1% (P = .05). Among women with pregestational diabetes, the prevalence of group B streptococcus colonization was 59.1% in class B and 50.0% in class C to R (P = not significant). After we adjusted for maternal age, race, and obesity, diabetic women continued to be at increased risk of group B streptococcus colonization (OR 3.1, 95% CI 1.8, 5.2). CONCLUSION: Carbohydrate intolerance appears to be an independent risk factor for group B streptococcus colonization during pregnancy.

The effect of high dietary n-3 fatty acid supplementation on angiotensin II pressor response in human pregnancy.

OBJECTIVE: Our purpose was to evaluate the effects of n-3 fatty acid supplementation on vascular reactivity as measured by the angiotensin II sensitivity test. STUDY DESIGN: Ten subjects with uneventful pregnancies, who were free of any chronic medical illnesses, between 24 and 34 weeks' gestation participated. Each subject was provided with OMEGA-3 700 softgel capsules and instructed to take three tablets three times daily (approximately 3.6 gm of eicosapentaenoic acid). The angiotensin II sensitivity test was performed before and 28 days after supplementation. Compliance was assessed by analysis of computerized pill bottles. Statistical analyses of the data were performed with a paired t test for evenly distributed continuous data. A sample size of eight patients was required to detect a difference in effective pressor dose of > or = 10 ng/kg/min between the presupplement and postsupplement results, assuming an alpha of 0.05 and a beta of 0.20 (80% power). RESULTS: The effective pressor dose before treatment (13.6 +/- 6.3 ng/kg/min) (mean +/- SD) was significantly less (p = 0.001) than after supplementation (35.8 +/- 15.9 ng/kg/min). CONCLUSIONS: High-dose n-3 fatty acid supplementation resulted in an enhancement of the pregnancy-acquired refractoriness to angiotensin II.

Trial of labor in patients with a previous lower uterine vertical cesarean section.

OBJECTIVE: Our purpose was to determine the efficacy and safety of a trial of labor in patients previously delivered at least once by a lower uterine vertical cesarean section. STUDY DESIGN: A retrospective review was performed at a single tertiary perinatal center, The University of Florida Health Science Center, Jacksonville. The medical records of all patients with a previous low vertical cesarean section who underwent a trial of labor during a 72-month period from January 1988 until December 1993 were reviewed. The medical records of the next two patients who did not have a prior uterine incision admitted to labor and delivery after the index case served as the controls. The duration and outcome of labor, including mode of delivery, maternal and perinatal morbidity, and birth trauma were evaluated. RESULTS: Of 77 patients with a previous low vertical cesarean incision, 11 (14.3%) had a repeat operation compared with 14 of 154 patients (9.0%) in the no previous cesarean section group (not significant). No differences were noted in the incidences of operative vaginal deliveries or prolonged duration of the first or second stages of labor, or in the rate or maximum dose of oxytocin infusion between the two groups. One patient in the previous cesarean section group had uterine rupture. The incidence of umbilical artery pH < or = 7.20 was similar. No difference in the number of infants with 1- or 5-minute Apgar scores < or = 7 was noted. CONCLUSION: A trial of labor in women with previous low vertical cesarean sections results in an acceptable rate of vaginal delivery and appears safe for both mother and fetus.

Monitoring and assessing patient focused care performance.

This case study shares the experiences of converting a conventional financial and productivity performance system into one which measures, with greater detail, hospital operations undergoing changes in delivering patient care. An aggressive yet practical approach was used to meet management's main informational need for measuring the productivity and financial impacts of transitioning from a primary nursing care model (i.e., patient care being delivered exclusively by registered nurses) to a patient-focused care model while minimizing the impact of changing performance systems in the organization. Through this conversion, management can quickly detect and assess areas not complying with the patient-focused care model.

Labor induction in patients with previous cesarean section.

To determine the efficacy and safety of labor induction in patients previously delivered by at least one low transverse cesarean section, a retrospective review was done at a single tertiary perinatal center, the University of Florida Health Science Center, Jacksonville. All patients with a previous cesarean section who required labor induction from 1988 until the end of 1992 were identified. Duration and outcome of labor induction, including mode of delivery, maternal and perinatal morbidity, and birth trauma, were evaluated. Of 160 patients with a previous cesarean, 50 (31.3%) had a repeat operation compared to 18 (11.2%) in the no previous cesarean group (p = 0.001, odds ratio = 3.59; 95% confidence interval, 1.98, 6.49). Women in the cesarean group had a higher incidence of operative vaginal deliveries, prolonged duration of the first and second stages of labor, rate and maximum dose of oxytocin infusion. One patient in the previous cesarean group experienced uterine rupture. There was no difference in the rate of infants with low 5-minute Apgar scores or with cord pH values less than 7.20. Labor induction in women with previous low transverse cesarean sections results in an acceptable rate of vaginal delivery and appears safe for both mother and fetus.

A trial of labor complicated by uterine rupture following amnioinfusion.

Amnioinfusion has become accepted in the management of intrapartum cord compression, meconium-stained fluid, and oligohydramnios. Limited experience exists regarding amnioinfusion in patients undergoing a trial of labor after cesarean section and its potential complications. We report a case of trial of labor in which uterine rupture occurred following intrapartum amnioinfusion. This case demonstrates the need for careful attention to amnioinfusion volumes and administration in patients with a previous cesarean section.

Calcium supplementation in mild preeclampsia remote from term: a randomized double-blind clinical trial.

OBJECTIVE: To determine whether calcium supplementation prevents progression to severe disease in preterm nulliparous women with mild preeclampsia. METHODS: Seventy-five women hospitalized at 24-36 weeks' gestation because of mild preeclampsia were randomized to receive either 2 g/day of elemental calcium (36 women) or placebo (39). Both groups had similar demographic characteristics, initial blood pressure measurements, and amount of proteinuria. Diagnostic criteria and clinical management for severe preeclampsia were applied consistently. RESULTS: Eighteen of 36 calcium-treated subjects (50%, 95% confidence interval [CI] 33-67) developed severe preeclampsia, compared with 19 of 39 (48.7%, 95% CI 32-65) in the placebo group (relative risk 1.03, 95% CI 0.64-1.03; P = 1.00). Blood pressure values, gestational age at delivery, newborn weights, incidence of low Apgar scores, and umbilical arterial blood gases were similar for the two groups. CONCLUSION: Calcium supplementation does not prevent severe preeclampsia in preterm patients with mild disease.

Pyelonephritis in pregnancy: once-a-day ceftriaxone versus multiple doses of cefazolin. A randomized, double-blind trial.

OBJECTIVE: The purpose of this study was to compare the efficacy of a single daily dose of intravenous ceftriaxone with that of multiple-dose cefazolin in the treatment of acute pyelonephritis in pregnancy. STUDY DESIGN: This was a double-blind, randomized, clinical trial. Patients admitted to the hospital with the diagnosis of acute pyelonephritis in pregnancy were enrolled and randomized according to a computer-generated randomization schedule. The study group received a single daily 1 gm dose of ceftriaxone intravenously along with two additional doses of normal saline solution. The comparison group received three daily 2 gm doses of cefazolin intravenously. All infusions were given on an 8-hour schedule. Treatments were continued until the patient became afebrile. Each patient was discharged from the hospital on a regimen of appropriate oral antibiotics as directed by urine culture and sensitivities. At follow-up visits test-of-cure cultures were obtained. RESULTS: During the 2-year study period, 178 patients were randomized: 88 received cefazolin and 90 ceftriaxone. Patient demographics and presenting signs and symptoms were similar in both groups. No differences were noted between the groups regarding days of febrile morbidity, length of hospital stay, or treatment failures. CONCLUSIONS: Daily single-dose intravenous ceftriaxone is as effective as multiple-dose cefazolin in the treatment of patients with acute pyelonephritis during pregnancy.

Prevention of pregnancy-induced hypertension by calcium supplementation in angiotensin II-sensitive patients.

OBJECTIVE: To evaluate the efficacy of oral supplemental calcium in reducing the incidence of pregnancy-induced hypertension (gestational hypertension or preeclampsia) in angiotensin-sensitive nulliparas. METHODS: Sensitivity to intravenously infused angiotensin was determined at 24-28 weeks' gestation in 281 nulliparous women who had positive roll-over tests. Angiotensin-sensitive women were given 2 g/day of oral elemental calcium or placebo in a randomized, double-blind clinical trial. The tablets were dispensed by the hospital pharmacy in serially numbered computerized pill bottles so as to assess compliance. Repeat angiotensin sensitivity test was performed at 34-36 weeks' gestation. RESULTS: Sixty-three of 67 angiotensin-sensitive nulliparas were evaluable; 29 received calcium and 34 received placebo tablets. Four of 29 calcium-treated subjects (13.8%, 95% confidence interval [CI] 4-32%) developed preeclampsia, compared to 15 of 34 (44.1%, 95% CI 27-62%) in the placebo group (relative risk [RR] 0.37, 95% CI 0.15-0.92; P = .01). The incidence of any type of hypertension was nine of 29 (31%, 95% CI 15-51%) with calcium treatment, compared to 22 of 34 (64.7%, 95% CI 46-80%) with placebo (RR 0.46, 95% CI 0.25-0.86; P = .01). CONCLUSION: Calcium supplementation given in pregnancy to high-risk nulliparas reduces the incidence of pregnancy-induced hypertension.

Labor induction with the prostaglandin E1 methyl analogue misoprostol versus oxytocin: a randomized trial.

OBJECTIVE: To compare the safety and efficacy of intravaginal misoprostol versus intravenous (IV) oxytocin infusion for labor induction. METHODS: One hundred thirty patients were randomly assigned to one of two induction groups: 1) intravaginal misoprostol or 2) IV oxytocin by continuous infusion, with prior cervical ripening using prostaglandin (PG) E2 gel if necessary. RESULTS: Among 129 patients evaluated, 64 were allocated to the misoprostol group and 65 to the oxytocin group. Prostaglandin E2 gel was administered to 29 patients (45%) in the oxytocin group with unripe cervices. Uterine tachysystole occurred more frequently in patients in the misoprostol group (34.4%) than in the oxytocin group (13.8%) (P < .05). Nevertheless, no statistically significant differences were noted between the groups in intrapartum complications including uterine hyperstimulation syndrome, mode of delivery, and neonatal or maternal adverse outcomes. The interval from induction to vaginal delivery was significantly shorter in the misoprostol group (11 versus 18 hours; P = .004). In 74% of patients in the misoprostol group, only one intravaginal dose was required for successful labor induction. CONCLUSIONS: Intravaginal administration of misoprostol safely and effectively induces labor while minimizing the expense associated with IV oxytocin infusion. The higher frequency of uterine tachysystole associated with the use of misoprostol did not increase the risk of adverse intrapartum or perinatal outcomes. The use of PGE2 gel for cervical ripening contributed to the longer induction-to-vaginal delivery interval noted in the oxytocin group. Clinical trials appear warranted to detail misoprostol's optimal route, dose, and schedule for labor induction and its safety.

Auditory hallucinations, posttraumatic stress disorder, and ethnicity.

The occurrence of intrusive auditory perceptions has rarely been addressed in the study of posttraumatic stress disorder. This study examined the background of 59 individuals with combat-related posttraumatic stress disorder. Subjects with and without auditory hallucinations were compared on demographic military and symptom variables. The occurrence of hallucinations among veterans with posttraumatic stress disorder appears to be more frequent among subjects of Hispanic ethnicity. This may have been related to higher combat exposure or social stresses. The occurrence of hallucinations was unrelated to drug abuse and did not appear to be associated with any particular war.

Socioeconomic status, ethnicity, psychological distress, and readiness to utilize a mental health facility.

The effects of minority status versus ethnic culture on Mexican-Americans' underutilization of mental health services were reassessed through development and testing of an analytic path model that proposes a sequence of factors, including Mexican-American ethnicity, socioeconomic status, degree of social and institutional support, and depression, which culminate in a person's decision to utilize mental health facilities. The model also predicts that life stress will affect utilization through its influence on depression. Data from 783 subjects generally supported the model's predictions. A multifactorial approach to the causes of mental health problems and utilization behavior in the Mexican-American population is suggested.

Inflammatory bowel disease: overview and psychosomatics.

Ulcerative colitis and Crohn's disease are chronic inflammatory bowel disorders of unknown etiology and unpredictable course, usually causing diarrhea and/or abdominal pain and sometimes associated with fever, weight loss, or extraintestinal manifestations. Psychological factors may relate to the onset and course of disease and certainly have important implications for the treatment of these chronic diarrheal illnesses. We review the literature on psychosomatic aspects of inflammatory bowel disease and discuss current thinking regarding presentation and management.

Cytotoxic effects of neuroleptic drugs.

Agranulocytosis and the release of transaminase enzymes from liver cells are known consequences of neuroleptic drug use. These effects are most common with low potency neuroleptic drugs. It has been hypothesized that these effects are due to the direct toxic action of these drugs on blood and liver cells. The purpose of this study is to compare the cytotoxic effects of eight neuroleptic drugs in five different biological test systems. In all of the test systems, thioridazine, chlorpromazine, trifluoperazine, fluphenazine and thiothixene (group one drugs) were the most toxic drugs and molindone was the least toxic. Thioridazine was between 25 and 84 times more toxic than molindone. Loxapine was significantly more toxic than molindone, but less toxic than the group one drugs. Haloperidol was intermediate in toxicity between the group one drugs and loxapine. We conclude that the difference in cytotoxicity of the neuroleptic drugs observed in these experiments accounts in part for the increase in agranulocytosis and hepatotoxicity with thioridazine and chlorpromazine and for the lower incidence of these side effects with less toxic drugs. The possibility that tardive dyskinesia may be due to the cytotoxic effects of neuroleptic drugs is discussed and an experiment to test this hypothesis is suggested.

The community mental health center as a setting for a psychiatry junior clerkship.

The implementation of a psychiatric outpatient experience for a first class of junior medical students in a nonmedical model community mental health clinic is presented. The advantages and disadvantages of exposing students to a community-oriented, rather than a medical-center-oriented, treatment system are discussed in some detail. Differences between the two settings of particular import were the stress placed by the clinic upon team decision-making, diffuse responsibility for client care, a somewhat antimedical orientation, and treatment of clients whose complaints are more often "problems of living" rather than of psychiatric illness. It is felt that the positive aspects of such an exposure outweigh the negative ones and that by careful planning many of the potential drawbacks of such a setting for a psychiatric outpatient rotation can be successfully avoided.