Conservative management of preterm premature rupture of membranes beyond 32 weeks' gestation: is it worthwhile?

We aimed to investigate whether conservative management of preterm premature rupture of membranes (PPROM) at 32-34 weeks' gestation improves outcome. In this retrospective analysis of singleton pregnancies, the study group included patients with PPROM at 28-34 weeks' gestation and the control group included patients presented with spontaneous preterm delivery at 28-34 weeks' gestation. Both groups were subdivided according to gestational age - early (28-31 weeks' gestation) versus late (32-34 weeks' gestation). Adverse neonatal outcome included neonatal death, intraventricular haemorrhage grade 3/4, respiratory distress syndrome, periventricular leucomalacia and neonatal sepsis. The study and control groups included 94 and 86 women, respectively. The study group had a lower incidence of adverse neonatal outcome at the earlier weeks (28-31), compared with the control group at the same gestational age. In contrast, at 32-34 weeks' gestation no difference in the risk for adverse neonatal outcome was noticed. Additionally, within the study group, chorioamnionitis rate was significantly higher among those who delivered at 32-34 weeks' gestation (p < 0.01). No advantage for conservative management of PPROM was demonstrated beyond 31 weeks' gestation. Moreover, conservative management of PPROM at 32-34 weeks' gestation may expose both mother and neonate to infectious morbidity.

A comparison of paramedic didactic training hours and NREMT-P examination performance.

OBJECTIVE: The didactic hours required by paramedic training programs differ tremendously throughout the country. The authors hypothesized that a correlation exists between paramedic didactic training hours and pass/fail performance on the National Registry Examination. METHODS: The authors retrospectively examined the performance of every applicant for the National Registry Paramedic Examination in June 1996. Applicants were identified by their National Registry Identification Number. A database was established linking the applicants to whether they passed or failed the NREMT-P exam. The authors then searched through the National Registry's archives and pulled each applicant's original application papers. On each application is a space to indicate the number of didactic hours of training that the particular applicant underwent. This information was also included in the database. The numbers of didactic hours of training and pass/fail performance on the NREMT-P exam were compared by point biserial correlation. RESULTS: One thousand six hundred applicants applied for the National Registry Examination in June 1996. For the 1,553 applicants included in the study, the mean number of didactic training hours was 377.5, with a standard deviation of 167.0 and a range of 63 to 1,594. The correlation between paramedic didactic training hours and pass/fail performance on the National Registry Examination was rpb = 0.0493, p = 0.0522. CONCLUSION: There is no correlation between paramedic didactic training hours and pass/fail performance on the NREMT-P examination.

The efficacy of a standard training program for transillumination-guided endotracheal intubation.

OBJECTIVE: To evaluate the success rate, intubation time, and complication rate of transillumination-guided intubation following two hours of instruction in the use of the Trachlight (TL) device. METHODS: A prospective, randomized crossover laboratory trial was conducted at an emergency medical service training site with 30 nonpaid volunteer paramedic students, one month prior to their graduation. The students were instructed in the use of the TL in a standardized curriculum consisting of didactic, video, and demonstration sessions. Each student was required to successfully intubate a training manikin with the TL five times. Approximately three weeks later, the students were asked to intubate the manikin 20 times, alternating between direct laryngoscopy (DL) and TL. RESULTS: The success rates were 94% for DL and 63% for TL (p < 0.0001). The mean intubation times were 14.6 seconds for DL and 16.8 seconds for TL (p < 0.001). The incidences of trauma were 7.3% for DL and 1.4% for TL (p < 0.001). CONCLUSION: A two-hour training session, including five successful light-guided intubations using the TL, was inadequate for producing acceptable success rates during manikin intubations by paramedic students. While TL intubation intervals were shorter when successful, the 2.2-second difference was not clinically meaningful. The incidence of trauma in our manikin model during TL intubations was significantly lower than that with DL.

Crisis management can leave residual effects.

A healthcare organization that once suffered from poor financial performance may fail to correct recovery methods that can cause lingering legal and accounting problems. A crisis management style is prone to creating problems with an organization's debt structure, Medicare and Medicaid payment, tax issues, labor relations, licensing and accreditation, compliance with fraud and abuse rules, and accounting for charity care. After stabilizing a worrisome financial situation, a healthcare organization should conduct an internal audit to ensure that its legal and accounting practices remain above board.

Improved left ventricular function in myocardial infarction following intravenous thrombolytic therapy with acylated plasminogen activator.

Forty-six patients with acute myocardial infarction (MI) were treated within three hours of the onset of chest pain with an intravenous bolus (IV) of 30 units of anisolated plasminogen activator streptokinase complex (APSAC). Reperfusion was detected in 31 patients (67%) by clinical, electrocardiographic, and enzymatic criteria. The mean time elapsed between the onset of the chest pain to thrombolytic therapy was 114 +/- 53 minutes. Left ventricular ejection fraction (LVEF) was significantly better in patients with anterior and inferior myocardial infarction who had successful reperfusion, as compared with those who did not (48.8 +/- 13.0 vs 35.3 +/- 10.9, p less than 0.05 and 59.7 +/- 12.6 vs 47.9 +/- 15.3, p less than 0.05, respectively). The rate of reocclusion within three weeks was 22%. The overall one-year mortality was 4%. There were no serious adverse reactions following the thrombolytic treatment. Thus bolus IV injection of 30 units of APSAC is both safe and effective in preserving left ventricular function when given early in the course of acute myocardial infarction.

Psychological effects of breast-conserving cancer treatment and mastectomy.

Patients in the early stages of breast cancer were studied one year after treatment to ascertain the psychological effects of mastectomy and a breast-conserving alternative, lumpectomy plus radiation therapy. Patients who had had a mastectomy felt less attractive, less sexually desirable, and more ashamed of their breasts. They also experienced less enjoyment in their sexual relationships than they had before treatment. Patients who had radiation therapy experienced no changes in these areas. For these reasons, half of the mastectomy patients regretted not having chosen the breast-conserving alternative.

Psychological factors in the choice of treatment for breast cancer.

For several years women with an early diagnosis of breast cancer have been able to choose between two equally effective treatments: modified radical mastectomy and the breast-conserving treatment of lumpectomy plus radiation therapy. This study investigated the psychological factors that become involved when a woman chooses between treatments. Many more anticipatory concerns about body image, disfigurement, femininity, and the ability (or inability) to handle emotionally a mastectomy were expressed by lumpectomy/radiation therapy patients than by mastectomy patients. Those lumpectomy-radiation therapy patients who chose the treatment against medical advice were also found to be more concerned than the others about treatment effects on sexuality.

Working together separately: clarifying the relationship between college therapist and dean of students.

The authors, a college psychotherapist and dean of students, describe the relationship between these college personnel. They describe the dynamics of their interaction and the importance of communication and mutual understanding. They define counseling and therapy, discuss the issues of agency and confidentiality, suggest methods of referral and consultation, and emphasize the need for support and trust within a school community. Finally, they present case studies that illustrate the benefits of mutual trust, understanding, and respect.

Psychological aspects of primary radiation therapy for breast carcinoma.

Fifty-one patients who received primary radiation therapy as an alternative to radical mastectomy for the treatment of early breast cancer were studied in depth. They chose radiation therapy to avoid the disfigurement, difficulty with emotional adjustment, and adverse effects on their sexual lives they anticipated from mastectomy. Most of these women (median age 49) were leading active sexual lives in which their breasts play an important role. Their breasts also played an important role in enabling them to feel feminine, attractive, and sexually desirable. Forty-three percent of the patients who had had suicidal ideation because of feelings about breast cancer no longer were troubled by suicidal thoughts after learning about primary radiation therapy and the fact that they would not have to have a mastectomy. Recent reports that radiation therapy causes more psychic distress than other forms of cancer treatment appear to be incorrect in this particular population.

Bioadhesive and histotoxic properties of ethyl-2-cyanoacrylate.

Ethyl-2-cyanoacrylate was applied to the cortex of rabbits to evaluate its bioadhesive and histotoxic behavior. The animals were killed at 4 or 10 days. Half of the animals were pretreated with dexamethasone. Our results indicate that the application of ethyl-2-cyanoacrylate to brain tissue produced severe superficial cortical necrosis but not bioadhesion. Pretreatment with steroids did not provide a significant protective effect.