Self vs. other, child vs. adult. An experimental comparison of valuation perspectives for valuation of EQ-5D-Y-3L health states.

OBJECTIVES: EQ-5D-Y-3L health states are valued by adults taking the perspective of a 10-year-old child. Compared to valuation of adult EQ-5D instruments, this entails two changes to the perspective: (i) child health states are valued instead of adult health states and: (ii) health states are valued for someone else instead of for oneself. Although earlier work has shown that these combined changes yield different values for child and adult health states that are otherwise equal, it currently remains unclear why. Hence, we aimed to disentangle the effects of both changes. METHODS: A sample of 205 students (mean age: 19.48) was surveyed. Each respondent completed visual analogue scale (VAS) and time trade-off (TTO) tasks for five EQ-5D-Y-3L states, using four randomly ordered perspectives: (i) self-adult (themselves), (ii) other-adult (someone their age), (iii) self-child (themselves as a 10-year-old), (iv) other-child (a child of 10 years old). We compared how each perspective impacted outcomes, precision and quality of EQ-5D-Y-3L valuation. RESULTS: Overall, differences between perspectives were consistent, with their direction being dependent on the health states and respondents. For VAS, the effect on outcomes of valuation depended on severity, but variance was higher in valuation with child perspectives. For TTO, we observed that EQ-5D-Y-3L states valued on behalf of others (i.e., children or adults) received higher valuations, but lower variances. CONCLUSION: The use of a different perspective appears to yield systematic differences in EQ-5D-Y-3L valuation, with considerable heterogeneity between health states and respondents. This may explain mixed findings in earlier work.

Checklists and multidisciplinary team performance during simulated obstetric hemorrhage.

BACKGROUND: Checklists can optimize team performance during medical crises. However, there has been limited examination of checklist use during obstetric crises. In this simulation study we exposed multidisciplinary teams to checklist training to evaluate checklist use and team performance during a severe postpartum hemorrhage. METHODS: Fourteen multidisciplinary teams participated in a postpartum hemorrhage simulation occurring after vaginal delivery. Before participating, each team received checklist training. The primary study outcome was whether each team used the checklist during the simulation. Secondary outcomes were the times taken to activate our institution-specific massive transfusion protocol and commence red blood cell transfusion, and whether a designated checklist reader was used. RESULTS: The majority of teams (12/14 (86%)) used the checklist. Red blood cell transfusion was administered by all teams. The median [IQR] times taken to activate the massive transfusion protocol and transfuse red blood cells were 5min 14s [3:23-6:43] and 14min 40s [12:56-17:28], respectively. A designated checklist reader was used by 7/12 (58%) teams that used the checklist. Among teams that used a checklist with versus without a designated reader, we observed no differences in the times to activate the massive transfusion protocol or to commence red blood cell transfusion (P>0.05). CONCLUSIONS: Although checklist training was effective in promoting checklist use, multidisciplinary teams varied in their scope of checklist use during a postpartum hemorrhage simulation. Future studies are required to determine whether structured checklist training can result in more standardized checklist use during a postpartum hemorrhage.

Response times for emergency cesarean delivery: use of simulation drills to assess and improve obstetric team performance.

OBJECTIVE: We documented time to key milestones and determined reasons for transport-related delays during simulated emergency cesarean. STUDY DESIGN: Prospective, observational investigation of delivery of care processes by multidisciplinary teams of obstetric providers on the labor and delivery unit at Lucile Packard Children's Hospital, Stanford, CA, USA, during 14 simulated uterine rupture scenarios. The primary outcome measure was the total time from recognition of the emergency (time zero) to that of surgical incision. RESULT: The median (interquartile range) from time zero until incision was 9 min 27 s (8:55 to 10:27 min:s). CONCLUSION: In this series of emergency cesarean drills, our teams required approximately nine and a half minutes to move from the labor room to the nearby operating room (OR) and make the surgical incision. Multiple barriers to efficient transport were identified. This study demonstrates the utility of simulation to identify and correct institution-specific barriers that delay transport to the OR and initiation of emergency cesarean delivery.

Accidental intrathecal sufentanil overdose during combined spinal-epidural analgesia for labor.

A laboring woman was accidentally given 45 microg of sufentanil intrathecally in the course of combined spinal-epidural analgesia. She experienced intense pruritus and transient swallowing difficulty without respiratory depression, but still had incomplete pain relief, with delivery and episiotomy repair requiring additional analgesia. This case highlights the importance of adding local anesthetic to intrathecal opioids to facilitate effective analgesia during the second stage of labor. The contributory systems issues and multiple factors that allowed this error to occur are examined.

"Ultra-light" patient-controlled epidural analgesia during labor: effects of varying regimens on analgesia and physician workload.

BACKGROUND: Patient-controlled epidural analgesia (PCEA) offers many advantages over continuous epidural infusions for maintenance of labor analgesia. Some of these benefits may depend on the PCEA settings. This study evaluated several regimens for "ultra-light" (0.125%) PCEA with basal continuous infusion (CI) in labor with goals of minimizing physician interventions while providing good analgesia. METHODS: Two hundred and twenty ASA I-II women receiving epidural analgesia during active labor (cervical dilation <5 cm) were randomly assigned in a double-blind manner to four treatment groups (n=30 in each). Analgesia was maintained with a PCEA/CI pump using bupivacaine 0.0625% + sufentanil 0.35 microg/mL. PCEA settings were: group A: CI 10 mL/h, PCEA bolus 6 mL, 8-min lockout; group B: CI 10 mL/h, PCEA bolus 12 mL, 16-min lockout; group C: CI 15 mL/h, PCEA bolus 6 mL, 8-min lockout; group D: CI 15 mL/h, PCEA bolus 12 mL, 16-min lockout. RESULTS: In groups A, B, C and D, 76, 77, 75 and 85% of parturients respectively, required no physician rescue boluses. Pain scores were low and maternal satisfaction was high in all groups, with minimal differences among them. Spontaneous vaginal delivery occurred in 78% of patients overall, instrumental (forceps or vacuum) delivery in 10% and cesarean section in 12%. CONCLUSIONS: These ultra-light PCEA regimens provided excellent analgesia with minimal physician workload and a high spontaneous delivery rate. Use of moderate to high-volume, ultra-light PCEA/CI techniques should facilitate provision of labor analgesia in busy obstetric units.

Endovascular treatment of mycotic hepatic artery aneurysm in the hostile abdomen--a case report.

Mycotic hepatic artery aneurysms are rare. This report documents a case in which a mycotic hepatic artery aneurysm was associated with Crohn's disease, renal adenocarcinoma, and a urinary tract infection. Endovascular management of this mycotic hepatic artery aneurysm was successful in the setting of a hostile abdomen based on multiple previous operations, a stoma, and a scarred abdomen.

Mesoportal bypass: a unique operation for mesenteric hypertension.

A 47-year-old man was referred for evaluation and treatment of gastrointestinal variceal bleeding and possible transjugular intrahepatic portal-systemic shunting. Intrahepatic manometry disclosed a normal portal pressure, but selective mesenteric arteriography revealed occlusion of the superior mesenteric, splenic, and inferior mesenteric veins. Duodenal and gastric varices were noted, but no esophageal varices were seen. The portal vein was clearly patent. At surgery, a 2 cm mass was found at the superior mesenteric vein-splenic vein juncture, and subsequent pathologic examination confirmed the presence of suture material within dense fibrous tissue as the probable cause for this rare condition. The surgical procedure performed was a superior mesenteric vein-to-portal vein bypass, employing ringed expanded polytetrafluoroethylene. Graft patency and function have been confirmed postoperatively by means of both venous-phase mesenteric arteriography and duplex imaging. The surgical procedure was novel, in that it was possible to decompress the hypertensive mesenteric circulation from the distal superior mesenteric vein directly into the portal vein with a prosthetic bypass. The physiologic benefit of this operation is clear: the avoidance of the encephalopathic syndrome and the facilitation of hepatopetal blood flow.

Effect of cisapride, a new prokinetic agent, on esophageal motor function.

In this study, we assessed by a double-blinded, cross-over design the effect of intravenous and oral cisapride on esophageal motor activity during the late fed state in normal subjects. For the intravenous study, subjects were given placebo or 10 mg cisapride randomly, while in the oral study, they randomly received placebo or cisapride at 5, 10, or 20 mg. Cisapride given intravenously or orally caused a significant increase in resting LES pressure. The increase in LES pressure after oral administration was significant only after the 20 mg dose. Esophageal-body peristaltic amplitude, determined for all smooth-muscle sites, showed a modest but significant increase of approximately 10 mm Hg after intravenous cisapride, whereas no significant increase occurred after oral cisapride. Propagation time of peristalsis was unaffected by intravenous or oral cisapride. Side effects of treatment were minimal and at no time necessitated cessation of the study. We conclude that in healthy subjects during the late fed period, (1) cisapride at 10 mg intravenously or 20 mg orally increased resting LES pressure and (2) at 10 mg intravenously, but at no oral dose, cisapride increased peristaltic amplitude without affecting propagation time. The potentiating effect of cisapride on LES pressure suggests that cisapride could have an ancillary role in the therapy of gastroesophageal reflux disease.

Angioplasty-related iliac artery rupture: treatment by temporary balloon occlusion.

A case of nonsurgical treatment of common iliac artery rupture secondary to percutaneous transluminal angioplasty is reported.

Fetal intracranial teratoma: US diagnosis of three cases and a review of the literature.

We describe three cases of fetal intracranial teratoma diagnosed by ultrasound and review the literature. Sonographic features include cranial enlargement, gross distortion of normal cerebral architecture by a hyperechoic, multicystic mass, and polyhydramnios. Despite early diagnosis, the cesarean section rate is high and the overall prognosis is dismal.

Aarskog syndrome: full male and female expression associated with an X-autosome translocation.

We describe a male infant with the Aarskog syndrome and his equally prominently affected mother. The propositus and his mother have a balanced X-autosome translocation which originated in her. We postulate that the mother's translocation resulted in a presumed de novo point mutation for the Aarskog locus and that she has nonrandom inactivation of her structurally normal X. The full expression of the syndrome in the mother is compared to the partial expression in reported females. It is concluded that the Aarskog syndrome is an X-linked disorder and that the locus for the syndrome is at Xq13.

Transient immunologic effects of betamethasone in human pregnancy after suppression of preterm labor.

Maternal immune suppression is a potentially significant adverse effect when betamethasone is used to hasten lung maturation of the fetus at risk for preterm delivery. However, increased incidence of infection has not been observed consistently after betamethasone treatment of pregnant women. This study was designed to determine if the cellular immune response to steroids may be modified during pregnancy in a way that would diminish the infection risk associated with steroid treatment. The effect of betamethasone on immunocytes among patients with preterm labor or in nonpregnant subjects were determined following administration of 12 mg of betamethasone intramuscularly. We measured serially the circulating leukocytes, lymphocytes, T lymphocytes, and their subsets. Measurements were also made of localized leukocyte mobilization to serum-filled skin chambers covering experimental inflammatory sites. Patients in preterm labor had increased WBC counts prior to treatment with betamethasone but no additional leukocytosis was induced nor was mobilization of leukocytes to the skin chambers decreased. Lymphopenia and depression of T cells was more transient among pregnant patients compared to nonpregnant. Thus, the pregnant patients studied had diminished or more transient potentially adverse immunocyte responses to betamethasone as compared to nonpregnant subjects.

Use of a murine monoclonal antibody which binds to malignant keratinocytes to detect tumor cells in microscopically controlled surgery.

A new murine monoclonal antibody, termed VM-1, stains basal cell carcinoma cells and at least some squamous cell carcinoma cells. This antibody was used to visualize the tumor margins during microscopically controlled surgery using immunofluorescence (IF) and immunoperoxidase (IP) technics. Our experiments demonstrate that VM-1 is helpful in detecting small islands of tumor cells in the tissue at the margins of skin cancers. Thus, tissue staining with this antibody should improve the accuracy of microscopically controlled excision, and hopefully will decrease the rate of tumor recurrence after surgery.

Human monocyte chemotaxis: a quantitative in vivo technique.

This report describes a new quantitative technique for evaluating monocyte chemotaxis to a site of superficial epidermal abrasion. Micro-acrylic chambers containing 50% Zymosan activated autologous serum were separated from a 5-mm diameter epidermal abrasion by 2 Nucleopore filters which entrapped migrating monocytes but allowed free neutrophil migration. Monocytes were specifically identified by alpha napthyl acetate esterase activity. Monocytes accumulated within the filters by 4 hr and maximized at 16 and 20 hr. This technique is superior to previous skin chamber techniques in the high yield of monocytes and in specific histochemical identification of monocytes. In contrast to the Rebuck window, it does not generate attractants and has greater reproducibility. This technique will be useful in the study of diseases characterized by monocytic infiltrates, in contrasting the function of peripheral blood monocytes to those available in the skin, and in testing the effects of drugs, immunodeficiency and infection on monocyte function in vivo.