Analysis of outcome of pregnancy in type 1 diabetics treated with insulin pump or conventional insulin therapy.

We evaluated the outcome of pregnancies followed between 1990 and 2000 in 93 women with type 1 diabetes, treated with conventional intensive insulin therapy (n=68) or continuous subcutaneous insulin infusion (n=25). We evaluated metabolic control (fasting and 1-hour post-prandial plasma glucose and HbA1c levels), spontaneous or induced abortions, time and mode of delivery, maternal outcome (pregnancy-induced hypertension, preeclampsia, placental insufficiency, hydramnios, hypoglycemic coma, ketoacidosis) and fetal outcome (weight, hypoglycemia, hypocalcemia, hyperbilirubinemia, fetal distress, asphyxia, hyaline membrane disease, polycythemia, shoulder dystocia, malformations). Patients treated with insulin pump more frequently had background retinopathy and clinical neuropathy. No significant differences were observed between the two groups in metabolic control and maternal outcome. Glycemic control, non-optimal in the prepregnancy state, improved significantly during pregnancy, as shown by the progressive reduction in HbA1c levels. As regards fetal outcome, no differences were observed between the two groups in morbidity and especially in malformation rate. Patients with malformed babies did not have optimal metabolic control at conception. Thus, maternal and perinatal outcomes were comparable in patients treated with insulin pump and continuous subcutaneous insulin therapy, and depended on metabolic control. In patients in higher White's class and with more unstable glycemia, we achieved metabolic control and outcomes comparable with those of women of lower White's class and more stable glycemic values using the insulin pump. Our data suggest that insulin pump therapy is useful in problematic, complicated cases of women who want a baby.

Uterine first pass effect in postmenopausal women.

BACKGROUND: Vaginally administered drugs distribute preferentially to the uterus; counter-current transfer from the vaginal veins to the uterine artery probably plays a pivotal role. In each side, the ovarian and uterine arteries form arterial anastomoses and controversy exists regarding the origin of the arterial supply to the Fallopian tube and tubal part of the uterus, and consequently whether these tissues can be reached through vaginal administration. METHODS: A thermocatheter with four measurement points, each separated by 5 mm, was inserted under endoscopic control into the tubal corner of uterus in 10 conscious, menopausal women and the temperatures registered every 2 s. The vagina was then flushed for 15 min with 1.5 l of saline at room temperature, after which the probe position was re-assessed by the endoscope. RESULTS: The lowest measurement point (15 mm from the tip) cooled significantly more than the other points (P < 0.0001). At 15 min, mean temperature reduction at point 4 was significantly greater than at all other measurement points (P < 0.05) due to local transfer of cold from vaginal vein blood to the uterine arterial blood (but not the ovarian artery). CONCLUSIONS: The results support the theory that, at least in postmenopausal women, the uterine artery supplies most of the uterus while the corneal part of cavity (up to 5-10 mm from the ostium) receives the blood supply from the ovarian artery. This finding represents a rationale for vaginal administration of drugs when a local effect on the uterus (e.g. progestational or relaxation) in postmenopausal women is requested.

Absorption and preferential vagina-to-uterus distribution after vaginal administration of (99m)Tc-pertechnetate in postmenopausal women.

OBJECTIVE: To investigate in vivo and in humans the mechanisms and kinetics of vagina-to-uterus distribution. DESIGN: Controlled clinical study. SETTING: Volunteers in an academic research environment. PATIENT(S): Six postmenopausal women undergoing transabdominal hysterectomy were selected. INTERVENTION(S): Women received 0.2 mL of (99m)Tc-pertechnetate vaginally. In three patients the cervical canal was previously sealed by means of surgical glue. Six postmenopausal women who had received (99m)Tc-pertechnetate intravenously for a thyroid scintigraphy were considered as a control. MAIN OUTCOME MEASURE(S): Radioactivity was assessed every 30 minutes for 6 hours in the pelvis and in body regions where (99m)Tc-pertechnetate normally accumulates (thyroid, salivary glands, and stomach). RESULT(S): Uterine activity appeared after 60 minutes and peaked between 120 to 210 minutes. These same times were observed in the patients who had a sealed cervix. Thyroid uptake appeared after 180 minutes and peaked between 210 and 330 minutes. Uterine uptake did not occur in any of the intravenous patients; their thyroid uptake was rapid, appearing after 30 minutes. CONCLUSION(S): Preferential vagina-to-uterus distribution, at least in postmenopausal women, is not simply due an intracanalicular passage but is mediated by absorption of substances and probably by a countercurrent transfer mechanism.

Model of counter-current transfer from vagina to urethra in postmenopausal women.

BACKGROUND: Low-dose vaginal oestrogens are effective in treating post-menopausal urogenital atrophy without inducing endometrial proliferation. We aimed to assess whether this dichotomic effect could be the result of a preferential vagina-to-urethra transfer via a counter-current transfer of oestrogens from vagina to the arterial blood supplying the urethra. Due to the impossibility of obtaining blood samples from urethral arteries, and since the nature of counter-current exchange of substances is similar to the transfer of heat, we investigated cold transfer throughout the anterior vaginal wall to the vesical trigone and urethra. METHODS: Plastic tubes filled with cold saline were inserted into the vagina of 30 menopausal women. Temperatures were recorded at the vesical trigone and at three different urethral sites. Comparisons were performed 2 and 4.5 min after starting of cooling, and 4.5 min after removal of tubes. RESULTS: The urethra cooled significantly more than the bladder. Urethral cooling was not homogeneous; distal sites of the urethra cooled significantly more than proximal site and bladder despite a larger distance to the vaginal cooling device. CONCLUSIONS: Distribution of cold from the vagina to the urethra is not the result of simple diffusion and mechanisms of preferential distribution may exist from the vagina to the middle and low part of the urethra.

Preferential vascular-based transfer from vagina to the corpus but not to the tubal part of the uterus in postmenopausal women.

BACKGROUND: Vaginal administration of progesterone during infertility treatment has therapeutic advantages over oral administration. However, the reasons for this are poorly defined. To demonstrate a preferential vagina-to-uterus distribution of substances, we investigated cold distribution from vagina to the uterus and rectum. METHOD: In 10 postmenopausal women, thermoprobes were inserted into the uterine cavity and in the rectum at <9 cm or at >9 cm from the anus; temperatures were subsequently measured during 10 min flushing of vagina with cold saline. RESULTS: After 10 min, temperature decreased as follows: uterus, tubal angle: -0.22 +/- 0.07 degrees C, 10 (mean +/- SEM, n); uterus, middle cavity: -1.26 +/- 0.34 degrees C, 9; rectum, <9 cm insertion: -3.69 +/- 0.68 degrees C, 3; rectum, >9 cm insertion: -0.51 +/- 0.19 degrees C, 6. CONCLUSIONS: Despite obviously different distances to the vagina of the uterine and the low rectal probes (<9 cm) the temperature decrease occurred at the same time. Cold transfer from vagina to the uterus and rectum is probably not the result of simple diffusion but of a vascular counter-current transfer. Differential cooling of corpus and tubal angles suggests a different arterial supply; while uterine corpus is supplied from the uterine artery, the tubal angles seem to be mainly supplied from the ovarian artery via the tubal arcade.

Antepartum and early postpartum predictors of type 2 diabetes development in women with gestational diabetes mellitus.

OBJECTIVES: This study aimed at identifying ante-partum and early post-partum (one year) clinical and metabolic characteristics capable of predicting the future development of type 2 diabetes in pregnant women of Mediterranea area affected by gestational diabetes mellitus (GDM). MATERIAL AND METHODS: Seventy GDM patients were evaluated: mean age during pregnancy, plasma glucose levels under OGTT (100 gr. glucose), fasting, 1-h post-prandial plasma glucose levels, HbA(1c) at the third trimester, gestational week of GDM diagnosis, insulin therapy, and weight gain were all taken into consideration. Some maternal risk factors such as pre-pregnancy BMI, and maternal and fetal outcome of index pregnancy were also assessed. One year after delivery in the same patients, BMI, fasting and 1-h post-prandial plasma glucose, plasma glucose and insulinemia under OGTT (75 gr. glucose) were measured. We focused our attention on women who presented type 2 diabetes 5 years after pregnancy or IGT and those who, one year after pregnancy, were normal. RESULTS: Five years after pregnancy 49 women were normal, 5 had developed type 1 diabetes and were not considered, 6 had developed IGT, and 10 type 2 diabetes. Analysis of variables during pregnancy showed that those variables predicting type 2 diabetes were pre-pregnancy BMI, gestational week of diagnosis, need for insulin therapy, obesity, and plasma glucose at 60' OGTT. Analysis of variables evaluated one year after pregnancy showed that BMI, fasting and post-prandial plasma glucose, plasma glucose at each point of the OGTT, and plasma insulin at 30' OGTT were predictive of the development of type 2 diabetes. Furthermore, age, post-partum fasting plasma glucose, and plasma glucose under OGTT post-partum were predictive of the development of IGT. Our data show for the first time that, also in a Caucasian Mediterranean population, markers of the future development of diabetes do exist, as reported in literature. They also stress the importance of correct identification of GDM patients, in order to screen those at greater risk of developing diabetes, for whom it is imperative to set up prevention programs.

Assessing medication knowledge and practices of older adults.

An assessment instrument for home health nurses to use in assessing medication knowledge and practices of older adults was developed and tested on a convenience sample of 20 adults 65 and older admitted to a local home health agency. The tool was found usable by nurses, understood by patients, and had adequate test-retest reliability. The results emphasized the need for thorough medication assessments of all home health patients and provided a tool that home care nurses can use.

Preferential orienting to faces in newborns: a temporal-nasal asymmetry.

It has been proposed that newborns' preferential orienting to faces is primarily controlled by a subcortical mechanism. As an index of subcortical, extrageniculate mediation, the asymmetry between the temporal and nasal hemifields was exploited. In Experiment 1, under monocular viewing conditions, newborns were presented with a pattern that had 3 blobs in the appropriate locations for the eyes and the mouth or a pattern that had an inverted position of the blobs. Results showed that newborns preferentially oriented to the facelike pattern only when it was presented in the temporal hemifield. In Experiment 2, both patterns had the blobs in the inverted position. For one pattern the blobs were black, and for the other they were striped. Newborns preferentially oriented to the striped blobs in either hemifield. The results support the hypothesis that in newborns, preference for facelike patterns reflects the activity of a subcortical mechanism.

Outcome of fifty-five newborns of antiphospholipid antibody-positive mothers treated with calcium heparin during pregnancy.

OBJECTIVE: The outcome of 55 infants born to 53 antiphospholipid antibody (aPL)-positive mothers treated during pregnancy with calcium heparin is described. METHODS: The clinical state of the children was evaluated immediately after delivery by a clinical examination, and a neonatological check-up was performed no later than 24 hours after birth. Neonates with problems were transferred to the neonatal intensive care unit. After their discharge from hospital the clinical state of the babies was followed by means of interviews with the pediatricians and mothers for a period varying between 1.33 and 5.66 years (mean 2.51 +/- 0.92 SD). RESULTS: The newborns comprised 30 females and 25 males, including 2 sets of twins, delivered between the 25th and 40th weeks of gestation (mean 36.69 +/- 2.91 SD). They had a mean birth weight of 2.828 g +/- 706.50 SD (range 800-4.000) and a mean Apgar score at 5 minutes of 9.60 +/- 0.68 SD (range 7-10). Soon after delivery, 12 children (21.81%) were admitted to the neonatal intensive care unit for periods varying between 2 and 120 days (mean 30.33 +/- 33.40 SD), after which the clinical course was normal. All of these neonates suffered from complications exclusively due to prematurity. Malformations and signs of thrombosis or other aPL-related disorders were not observed in any of the newborns. During the follow-up, none of the diseases suffered by the 55 children differed from those of the normal pediatric population; in particular, aPL-related manifestations were never observed. CONCLUSION: These data indicate the absence of aPL-related problems in the offspring of aPL-positive mothers treated during pregnancy with calcium heparin.

The Neurobehavioral Assessment Scale as an instrument for early long-term prognosis and intervention in major disability in high-risk infants.

Evaluated the hypothesis that more effective prognosis is achieved by assessing the modifiability of infants' reactions than by evaluating the presence or absence of normal/abnormal reactions. To evaluate this hypothesis the Neurobehavioral Assessment Scale (NAS) was developed. The NAS assesses the extent to which infants can change their responses in functional contexts. The NAS was administered to 102 high-risk infants repeatedly over the first 16 months of life. Analysis confirmed that the modifiability of performance was predictive of outcome significantly earlier in development than scoring the same items in terms of their normalcy or abnormalcy.

The positive influence of animals: animal-assisted therapy in acute care.

Animal-assisted therapy is a therapeutic nursing intervention that brings animals together with persons with physical and/or emotional needs as a way of meeting those needs. It is based on the growing knowledge of benefits that animals provide to the sick, elderly, and isolated. A model for a responsible and outcome-oriented program in animal-assisted therapy in acute care settings is described in this article. Special areas include: types of therapy, specific treatment goals, patient and animal suitability, environmental considerations, and evaluation methods.

[Communication in the neonatal intensive therapy unit: the opinions of parents and of medical personnel compared]. / La comunicazione in terapia intensiva neonatale: opinioni dei genitori e del personale sanitario a confronto.

Within the framework of an European international project, the issue of parents-staff communication in Neonatal Intensive Care Units was explored. 5 Italian unit participated in the project. 80 mothers and 62 fathers of singleton, not malformed, very low birthweight babies were interviewed during the fourth week of their baby's life, while the views of the health personnel (60 doctors and 106 nurses) were collected through an anonymous, self-administered questionnaire. Most of the staff feels that parents should be informed completely about their baby's conditions and prognosis, while the actual practices about transmission of information are reported differently according to professional status: more nurses than doctors feel that the information is not as complete as it should be. Uncertainty of prognosis is the most commonly quoted reason for restricting the information. Parents, on the other hand, are generally satisfied about the information received, although some of them complain about the style of communication, and especially the need to ask repeatedly in order to be informed. These results show some of the gaps existing in communication both within the staff and with parents, and suggest possible ways of improvement.

[The preterm infant in the nursery?]. / Il pretermine al nido?

We evaluated 250 newborns, GA less than or equal to 37 weeks, admitted to the Nursery of the Pediatric Department of Padua, between 1.1.1990 and 31.7.1991. We considered particularly three groups of newborns with 35, 36 and 37 weeks gestation respectively. Other 80 fullterm newborns were included in the study as control group. The postnatal adaptation (table 1) is regular in 96.2% of the fullterm newborns, and in 62.9% of the 35 wks. Jaundice is the main cause of irregular postnatal adaptation in the preterm newborns (22.8% in the 35 wks group, and 16% of the control group). When we considered the feeding modalities (table 2), we found that only the 21.7% of the 36 wks group and the 11.4% of the 35 wks group were breast fed, against the 86.3% of the control group. The discharge from the Nursery was earlier (less than or equal to 4th day of life) in the term groups and later in the preterm, who often stay in the Nursery for a longer period because of their feeding, growth and postnatal adaptation problems. These results could be certainly improved introducing the rooming-in method, which at the moment is not fully applied in our Nursery.

[Modalities of adaptation to extrauterine environment of newborn infants during sleep]. / Modalità di adattamento all'ambiente extrauterino nel neonato in stato di sonno.

Three groups of healthy full term neonates, differing in delivery modalities (elective caesarean section, labor of greater than or less than 7 hours) were investigated during sleep to evaluate postnatal adaptation. Adaptation modalities were assessed by NBAS, using the cluster of the decrements. It was found that neonatal responses change during sleep in relation to delivery modalities and to type of stimuli applied.

[Psychological effects on medical students caused by earthquakes of 1985]. / Efectos psicológicos causados por los sismos de 1985 en estudiantes de medicina.

Eight months after the earthquakes of September 1985 in Mexico City, an analysis about the psychological symptoms, commonly associated with traumatic experiences was performed, among a population of 708 students, coursing the first year of Medical School. By means of a questionnaire, they reported the symptoms they had experienced before the earthquakes, during the following two weeks, and at the moment of the survey was still higher symptoms at the moment of the survey was still higher than before the earthquakes, so eight months appear to be an insufficient lapse for the complete remission of new cases. About 15.8 per cent of the studied population reported symptomatology that can be considered as having been triggered by the earthquakes. Another sector of the population (11%), previously symptomatic, reported remission after the earthquakes. The group of students directly affected by severe injuries for deaths of either family members, cohabiting persons, or of persons with whom strong affective ties prevailed, showed a greater tendency to present symptomatic states. Women represented the group most affected psychologically by the earthquakes.