Use of misoprostol for cervical ripening.

BACKGROUND: Misoprostol, the prostaglandin E1 analog, is increasingly used for cervical ripening and induction of labor. We evaluated our experience with misoprostol in an open-label setting. METHODS: Patients were selected for cervical ripening based on clinical profile. At 3 cm cervical dilation, misoprostol was discontinued and other means of labor augmentation were used. Over 13 months, 470 inductions of labor occurred, and 455 charts were available; 254 patients (56%) received misoprostol for cervical ripening, and 144 (32%) received dinoprostone (prostaglandin E2). RESULTS: With misoprostol, mean time from beginning of contractions until delivery was 7 hours, 30 minutes; vaginal birth occurred in 85% of cases, and spontaneous labor occurred in 38%. Hyperstimulation occurred in 4 cases (1.6%) and precipitate labor in 7 (3%). All infants were discharged in excellent condition; one had a 5-minute Apgar score <7, and 33 (13%) had meconium, none with aspiration. Twenty-three patients who had had a previous cesarean section received misoprostol and delivered vaginally. CONCLUSION: Misoprostol was found to be a safe and effective agent for cervical ripening as part of labor induction.

Compliance with post-hospitalization follow-up visits: rationing by inconvenience?

OBJECTIVES: Appointment-keeping after hospitalization is a poorly understood link between inpatient and outpatient care. We investigated how health care system and patient characteristics influence appointment-keeping after discharge from an acute care hospitalization. DESIGN: Prospective cohort study. SETTING: Urban public teaching hospital. SUBJECTS: All 372 consecutive eligible patients admitted over a 15 week period to medicine wards. METHODS AND MEASURES: We interviewed patients during hospitalization and after discharge, searched the hospital's electronic databases, and reviewed charts. We measured medication compliance, health care access and use, health status (SF-36), previous appointment compliance, and physician recommended follow-up appointments. Main outcome was appointment adherence after discharge. RESULTS: Patients were primarily African American (71%), uninsured (64%), female (53%), and had a mean age of 48 years; 64% of first appointments after discharge were kept. Adjusted odds ratios (95% confidence intervals) for appointment-keeping were 3.3 (1.7, 6.5) for receiving a written appointment at discharge, and 0.50 (0.27, 0.90) for previous difficulty with obtaining health care. Readmission rates were not associated with appointment adherence. CONCLUSION: Modifiable system, as well as patient, characteristics are associated with follow-up appointment-keeping. The practice of not giving patients written appointments at the time of discharge may constitute an implicit form of "rationing by inconvenience." Further studies should also evaluate potential associations between appointment-keeping and re-hospitalization.

Controversies in tocolytic therapy.

In general, tocolytic agents are effective in stopping uterine contractions and in temporarily delaying delivery. The benefit of stopping uterine contractions is dependent on the fetal status and gestational age. The rationale for stopping preterm labor is to improve neonatal outcome. At this time, the best way to improve neonatal outcome would be to assure delivery in a center capable of caring for a preterm infant and prescription of glucocorticoids to decrease the risk of respiratory distress syndrome and other neonatal complications. Intravenous tocolysis for premature labor has found a prominent place in the obstetrician's armamentarium. We recommend the use of magnesium sulfate as first-line therapy. When comparing maternal and fetal risks, side effects, and the safety profile, magnesium sulfate is superior to beta-mimetics; however, there are still significant problems with potential morbidity and mortality for both mother and fetus with any tocolytics. Adjunctive use of indomethacin with magnesium sulfate may be used through 32 weeks for up to 48 hours at a time. Most tocolytics are effective in stopping labor for 48-72 hours. None have been shown to decrease the rate of preterm delivery. Once the uterus is quiescent and intravenous tocolytics are stopped, prolonged use of tocolytics has not been shown to be effective in preventing preterm birth. Tocolytics have significant long-term side effects to the mother's cardiovascular system, carbohydrate metabolism, and the fetal cardiovascular system. Thus, the prolonged use of prophylactic tocolytics after cessation of intravenous medications is not recommended. Tocolytics may be an appropriate therapy during preterm labor vaginal bleeding, ruptured membranes, multiple gestation, or advanced cervical dilatation. In all situations, however, careful guidelines must be observed. These guidelines include: (1) maternal and fetal well-being must be established before tocolytic therapy; (2) causes of preterm labor should be evaluated and treated when possible; (3) the risk/benefit ratio for both the mother and fetus must be re-evaluated on an ongoing basis; (4) when tocolytics are given before pulmonary maturity, then antenatal corticosteroids also should be considered in every case; (5) long-term use of tocolytics is difficult to justify at this time; (6) the safest tocolytic should be used for the shortest amount of time possible. It is doubtful, because of the nature of tocolytics, that newer tocolytics will be developed that will eliminate the problems of preterm delivery. Preterm delivery is an end-stage symptom of a multifactorial disease. Preterm labor is one of the last symptoms in a cascade of biochemical events that lead to preterm delivery. The most appropriate way to end preterm delivery would be to prevent the causes that initiate the cascade that ends in preterm labor. Authors' Note: Literally hundreds of papers have been written in the last 30 years on tocoloysis. For the purposes of space, when studies are summarized in peer-reviewed articles, we have referenced the reviews instead of the individual studies.

Achievable benchmarks of care: the ABCs of benchmarking.

Benchmarking is generally considered to be an important tool for quality improvement. Traditional approaches to benchmarking have relied on subjective identification of 'leaders in the field'. We derive an objective, reproducible and attainable Achievable Benchmark of Care (ABC) by measuring and analysing performance on process-of-care indicators. Three characteristics of the ABC that we deem essential are: (1) benchmarks represent a measurable level of excellence; (2) benchmarks are demonstrably attainable; (3) benchmarks are derived from data in an objective, reproducible and predetermined fashion. From these characteristics it follows that (4) providers with high performance are selected to define a level of excellence in a predetermined fashion, but (5) providers with high performance on small numbers of cases do not influence unduly benchmark levels. We use the 'pared mean' to operationalize the ABC. Roughly, the pared mean summarizes the performance of top-ranked providers whereby at least 10% of the patient pool across all providers is included. Bayesian estimators for adjustment of performance of providers with small sample sizes are used to rank providers. Randomized controlled trials to assess the independent effect of the ABC in quality improvement projects are under way. We have developed a methodology objectively and reproducibly to derive a level of excellent, attainable performance, based on measured performance by a group of providers. The ABC can be applied to groups of providers in communities, to institutions and departments within them, or to individual practitioners.

Racial differences in the medical treatment of elderly Medicare patients with acute myocardial infarction.

OBJECTIVE: To compare the use of medications in African-American and Caucasian elderly Medicare patients hospitalized with acute myocardial infarction (AMI) in Alabama. DESIGN: Retrospective medical record review. SETTING: All acute care hospitals in Alabama. PATIENTS: All Medicare patients with a principal discharge diagnosis of AMI from June 1992 through February 1993. We excluded those patients less than 65 years of age and those of ethnicity other than African-American or Caucasian (N = 4,052). MEASUREMENTS: We first performed a crude analysis using all cases to compare by race the use of thrombolysis, beta-adrenergic blockade, and aspirin in the setting of AMI. In addition, we developed a multivariable model with receipt of therapy as the outcome and demographics, severity of illness, comorbidity, and algorithm-determined candidacy for therapy as covariates. The algorithms, developed as part of the Cooperative Cardiovascular Project, were designed to identify an "ideal" pool of candidates for each therapy. MAIN RESULTS: For all cases, 9.2% (95% confidence interval [CI] 6.8, 12.1) of African Americans received thrombolysis compared with 17.3% (95% CI 16.0, 18.6) of Caucasians. Approximately 16.4% of patients received beta-adrenergic blockade, and 45.1% received aspirin, both with no racial difference. By multivariate analysis, the adjusted odds ratio for African Americans receiving thrombolysis was 0.55 (95% CI 0.41, 0.76). The corresponding odds ratio was 1.25 (95% CI 0.99, 1.59) for beta-adrenergic blockade and 1.13 (95% CI 0.96, 1.37) for aspirin. African Americans presented later after the onset of chest pain, but the refusal rate of thrombolytic therapy did not differ. CONCLUSIONS: According to this analysis, Alabama physicians used beta-adrenergic blockade and aspirin equivalently in African Americans and Caucasians. African Americans received thrombolysis less often according to the crude analysis. The multivariable analysis suggests less use of thrombolytics, even after adjusting for several covariates including indication by clinical algorithm. However, the small number of African-American patients deemed ideal candidates for thrombolysis attenuates the precision of this finding.

Hospital responses to a data-driven statewide quality improvement project.

BACKGROUND: The overall success of any continuous quality improvement (CQI) project lies in the ability to measure changes resulting from the project and to show that changes have resulted n improved care. METHOD: A software tool was developed to categorize hospital responses and activities implemented by hospitals as a result of the Cooperative Cardiovascular Project CCP). Information was captured regarding the hospital's acceptance of data and the educational/interventional strategies implemented. Hospital size, number of acute myocardial infarction patients treated, indicator performances, and type of presentation given (on-site versus regional visit) was entered to allow analysis of factors affecting the response. RESULT: sixty-one of 107 hospitals responded to the peer review organization. Of those, 49% planned further educational activities and 75% planned to implement some form of CQI activity. Comparison of responses in relation to the type of presentation received suggested that on-site presentations are associated with higher response rates and more intense quality improvement efforts. This also could be attributed to other factors such as hospital size, teaching environment, or number of acute myocardial infarction patients treated. CONCLUSION: The system developed allowed us to collate hospital improvement efforts as a result of CCP. The system is limited in its ability to identify those activities taking place before CCP. Further development and refinement of the tool is warranted to document quality improvement efforts and determine best strategies for peer review organization intervention.

Risk factors associated with uterine rupture during trial of labor after cesarean delivery: a case-control study.

OBJECTIVE: The purpose of our study was to thoroughly investigate the risk factors of uterine rupture in patients undergoing trial of labor after cesarean section. STUDY DESIGN: We conducted a case-control study of 70 patients with prior cesarean delivery with uterine rupture during trial of labor between January 1983 and June 1990. The risk factors of uterine rupture were identified, and the estimates of the relative risks were reported. RESULTS: The risk of uterine rupture was increased in patients who had an excessive amount of oxytocin, who had experienced dysfunctional labor, and who had a history of two or more cesarean deliveries. Epidural anesthesia, macrosomia, history of successful vaginal delivery after cesarean section, unknown uterine scar, and history of cesarean delivery because of cephalopelvic disproportion were not associated with uterine rupture. CONCLUSIONS: We recommend that all patients with a history of cesarean delivery be observed closely for progression of labor. Recognition of an active-phase arrest disorder, despite adequate augmentation with oxytocin, requires operative delivery.

The use of a neural network for the ultrasonographic estimation of fetal weight in the macrosomic fetus.

The error associated with regression analysis methods for the ultrasonographic estimation of fetal weight in the suspected macrosomic fetus, approximately 10%, is clinically unacceptable. This study was undertaken to evaluate the applicability of an emerging technique, biologically simulated intelligence, to this problem. One hundred patients with suspected macrosomic fetuses underwent ultrasonographic measurements of biparietal diameter, head and abdominal circumference, femur length, abdominal subcutaneous tissue, and amniotic fluid index. The biologically simulated intelligence model included gestational age, fundal height, age, gravidity, and height. The model was then compared with results obtained from previously published formulas relying on the abdominal circumference and femur length. The biologically simulated intelligence yielded an average error of 4.7% from actual birth weight, statistically better (p = 0.001) than the results obtained from regression models.

Uterine rupture during trial of labor after previous cesarean section.

This study was undertaken to determine the incidence and associations of uterine rupture and dehiscence with an attempted vaginal birth after cesarean section. The charts from 137 patients who had uterine scar separation after a previous cesarean section from 1983 to 1989 were examined. Approximately 9.3% of the 119,395 women who were delivered in that interval had a prior cesarean section. Of those, 68.8% underwent a trial of labor with a 79.2% success rate. The uterine rupture rate in this latter group was 0.8%, while an additional 0.7% had a bloodless dehiscence. Bleeding and pain were unlikely findings with a uterine scar separation (3.4% and 7.6%, respectively). The most common manifestation of a scar separation was a prolonged fetal heart rate deceleration leading to operative intervention (70.3%). We conclude that, although the incidence of uterine rupture was low, the event is most often seen as an acute emergency. Prevention should be directed toward timely diagnosis and prompt management of labor dystocias. Staff and facilities for safe management of a uterine scar separation are a requisite for the conduct of a vaginal birth after previous cesarean section.

Cardiovascular responsivity in schizophrenics to videotaped social vignettes.

Heart rates, blood pressures, self-reported emotional level and anxiety of 15 schizophrenic outpatients indicated subjects discriminated among emotional levels in actors shown on videotape but their anxiety ratings did not change after viewing, and arousal after viewing highly emotional content was lower than at baseline.

Influence of norepinephrine administration upon pituitary hormone secretion in normal men.

This study has investigated the effects of 6.2, 12.5, 25, 50 and 100 ng/kg/min/60 min of NE infused to normal men. Blood samples were obtained every 10 min, before, during and after drug administration for 3 consecutive h. Plasma levels on NE, LH, FSH, PRL, and GH were measured in all samples. The administration of 12.5 ng/kg/min over 60 min of NE induced a significant increase (p less than 0.001) in plasma NE levels (n = 5) from a mean (+/- SE) baseline of 239 +/- 14 ng/L to 706 +/- 54 ng/L which peaked and plateaued at 40 min. The calculated area under the curve was 18562 +/- 3537 ng/L/h of NE and significantly higher (p less than 0.001) than during the h before the infusion (2358 +/- 780 ng/L/h). This increase in plasma NE correlated well with the rise in plasma LH which showed a steady increase from baseline of 7.4 +/- 1.3 mIU/ml to a significant (p less than 0.05) peak of 11 +/- 1.9 mIU/ml at the end of the infusion. Furthermore, analysis of the area under the curve revealed a greater (p less than 0.05) LH release during the NE infusion (180 +/- 18 mIU/ml/h) than before the infusion (92 +/- 17 mIU/ml/h). With the exception of the studies utilizing 12.5 ng/kg/min/60 min, all other doses of NE resulted in no significant and/or consistent changes in plasma concentration of LH, FSH, GH and PRL. Thus, the direct participation of NE in the control of LH secretion in humans seems to occur in a very narrow window.

Auditory sequence: confusion of patterns other than speech or music.

Accurate perception of temporal order is essential for many auditory tasks. Yet the temporal pattern of four successive sounds (for example, hisses, buzzes, and tones) could not be recognized even when the duration of each sound was considerably longer than either the average phoneme in normal discourse or the notes of melodies. Although each of the stimuli was perceived, their order remained frustratingly elusive.