Door to disposition times for obstetric triage visits: Is there a July phenomenon?

The July phenomenon refers to a change in patient outcomes within teaching hospitals with the arrival of new and inexperienced house staff at the start of the academic year (July to June). In our obstetric triage unit we retrospectively evaluated the door to disposition time (DTDT) for 1817 patients who presented across July, December and May of academic years 2009-2010 and 2010-2011. DTDT was examined for three visit levels: non-urgent, urgent and emergent. No significant differences in disposition time were found for emergent visits. For urgent visits the median DTDT significantly decreased from 171 min in July to 155 min in December and 135 min in May (p < 0.001). Similarly for non-urgent visits, the median DTDT was greater during July than May (179 min vs. 133 min; p < 0.05). Electronic medical records (EMRs) were implemented in November 2010. Following the introduction of EMR shorter DTDT was seen in December 2010 versus December 2009 (median, 171 min vs. 150 min; p < 0.05), respectively. Our findings suggest a 'July Phenomenon' of greater disposition intervals for urgent and non-urgent obstetric triage visits across the academic year. Additionally the use of EMRs may facilitate patient flow through the OB triage unit.

Phosphatase and Tensin Homolog Hamartoma Tumor Syndrome: A Case Report.

INTRODUCTION: Phosphatase and tensin homolog (PTEN) hamartoma tumor syndrome (PHTS) may manifest as one of four distinctive disorders: 1) Cowden syndrome; 2) Bannayan-Riley-Ruvalcaba syndrome; 3) Proteus syndrome; or 4) Proteus-like syndrome. Clinical features of PHTS commonly include multiple benign hamartomas of the skin and mucous membranes as well as macrocephaly. Despite the benign nature of the characteristic lesions, patients diagnosed with PHTS are at increased risk of certain cancers, most notably carcinomas of the breast, thyroid, and endometrium. CASE PRESENTATION: A 28-year-old African-American female presented with generalized gingival overgrowth that involved the palate, gingival margins, and retromolar areas. The dorsal tongue also exhibited a generalized tissue hyperplasia. Based on clinical presentation, biopsies were performed for histology and genetic testing. Although histology revealed non-specific fibroepithelial hyperplasia, genetic testing revealed a novel heterozygous mutation of the PTEN gene (c.158_164dupTAGTAAG), believed to result in premature termination of the protein. The patient did not exhibit macrocephaly or extraoral skin lesions and did not have any obvious cognitive deficit. CONCLUSIONS: This presentation of a Cowden syndrome-like scenario demonstrates that intraoral lesions may be the first symptom leading to a diagnosis of PHTS. Furthermore, the case shows that communication with and referral from the general dentist to specialists (e.g., oral pathologist, oral surgeon, or periodontist) can facilitate the establishment of a definitive diagnosis and allow for preventive screening and genetic counseling to aid in the treatment of secondary diseases, most notably associated cancers.

[Diagnostic role of different immunologic methods for laboratory diagnostics of legionellosis].

The aim of the study was a comparative analysis of diagnostic value of different laboratoty methods conducted on the basis of results of examination of patients during Legionnaires' disease outbreak in town Verkhnyaya Pyshma. Retrospective analysis of laboratory data from 74 patients with diagnosis of Legionnaires' disease was performed. Complex of laboratory methods was used (polymerase chain reaction (PCR), enzyme immunoassay (EIA), immunochromatography). In group of patients with Legionnaires' disease, the highest proportion of positive results (73%) was obtained by the EIA determining total specific antibodies in urine. Determination of antigen in urine by immunochromatographic express-test yielded 52% of positive results. PCR testing of blood specimens yielded positive results in 65% of samples but was low specific, due to that in 19% of patients from control group false-positive results were obtained. Testing of 3 autopsy samples showed that all specimens contained DNA of the causative agent. Performed analysis allowed to recommend complex use of immunochromatographic express-test of antigen detection and identification of total specific antibodies by EIA during mass people examination.

[Experience of information sharing between local healthcare management and regional Administration of Federal Service for Surveillance for Protection of Consumers Rights and Human Welfare in Sverdlovsk region during outbreak of Legionnaires' disease in town Verkhnyaya Pyshma in July-August 2007].

Issues of reliability, uniformity, and timeliness of reporting and sharing of information during outbreaks of infectious diseases are basic for establishment of tactics and strategy of organizational, antiepidemic, and clinical measures. Analysis of experience in sharing of information between medical care organization service and services ensuring sanitary-epidemiological welfare of population during outbreak of Legionnaires' disease in town Verkhnyaya Pyshma in July-August 2007 was performed in the article.

[Organization of medical care of patients with pneumonia caused by Legionella during outbreak in Sverdlovsk region].

Data on organization of medical care during outbreak of Legionnaires' disease in July-August, 2007 in town Verkhnyaya Pyshma in Sverdlovsk region are presented. Special feature of this outbreak was spreading of infection in boundaries of the town with total population of 70,600 people. Results of organizational work of health authorities in order to provide timely and adequate medical care for patients with Legionnaires' disease on both outpatient and inpatient levels of care, conduction of preventive measures in foci of infection, coordination of interaction between different medical organizations and services are summarized in the article.

Intrapartum management of nonvertex second-born twins: a critical analysis.

OBJECTIVE: Our purpose was to assess the impact of the mode of delivery--vaginal delivery versus cesarean section--on the perinatal outcomes of the second-born breech twins. STUDY DESIGN: This study was a retrospective analysis of second-born breech twins with a gestational age of > or =24 weeks at the onset of labor. The patients are divided into three groups: cesarean section without labor (group I), cesarean section after labor (group II), and vaginal breech delivery (group III). RESULTS: There were 141 patients: 40 in group I, 66 in group II, and 35 in group III. There was no birth injury or neonatal death. Group II had one fetus with grade II intraventricular hemorrhage. There was no significant difference among the groups with regard to gestational age, birth weight, hyaline membrane disease, Apgar scores at 1 and 5 minutes, and cord blood gas indices, except venous pH in infants with birth weights <1500 g. CONCLUSIONS: Vaginal delivery of breech second-born twins, with gestational ages of at least 24 weeks, especially those with birth weights of > or =1500 g, appears to be a safe alternative to cesarean section.

Idiopathic megarectum complicating pregnancy: report of a case.

Pregnancy often exacerbates constipation in young women with chronic constipation syndromes. The presence of the fetus presents a challenge in both the diagnosis and treatment of these syndromes. This study was conducted to report a rare case of idiopathic megarectum complicating a pregnancy. An aggressive polyethylene glycol (PEG) regimen allowed the patient to carry the child to term and to have a normal vaginal delivery. Successful proctocolectomy was performed with coloanal anastomosis 3 months postpartum. The patient has been free of constipation for 18 months without the need for cathartics or laxatives. All efforts to avoid operative intervention should be made in constipated patients during pregnancy. This principle holds true even in the setting of dilated large bowel. Idiopathic megarectum and the management of constipation in pregnancy are discussed.

Does preeclampsia influence fetal lung maturity?

OBJECTIVE: This retrospective study compared the fetal lung maturity biochemical profile of patients having preeclampsia with that of patients having preterm labor. STUDY DESIGN: Amniotic fluid was obtained by transabdominal amniocentesis in 90 patients, 59 patients with preterm labor (PTL) and 31 patients with preeclampsia (PRE). Pregnancies with fetal growth restriction were excluded. Fetal lung maturity was assessed by lecithin/sphingomyelin ratio (L/S) and by a fluorescence polarimetry assay (FLM). Mean values of L/S ratios and FLM were compared between the PTL and the PRE groups, each within two gestational age subgroups (27-32.9 weeks gestation and 33-36 weeks gestation). Student t-test, Chi-square test Fisher's exact test were used for statistical analysis. A p value < 0.05 was considered significant. RESULTS: During the gestational age interval of 33-36 weeks, the mean L/S ratios were significantly lower in pregnancies complicated by PRE than in those complicated by PTL (1.99 +/- 0.26 and 2.4 +/- 0.57, respectively; p = 0.01). Similarly, during this gestational age interval, the FLM values were also lower in PRE than in PTL, although the difference did not reach statistical significance. CONCLUSION: During the gestational age between 33 and 36 weeks of gestation, the biochemical profile of preeclamptic patients without IUGR has a significant lower L/S ratio compared to that of preterm patients.

Haplogroup-associated differences in neonatal death and incidence of low birth weight at elevation: a preliminary assessment.

OBJECTIVE: We sought to assess reproductive fitness differences between mitochondrial deoxyribonucleic acid haplogroups at high altitude. STUDY DESIGN: This study considers differences in outcomes of conception, birth weight, and neonatal mortality rates for 62 women classified according to haplogroups (B or non-B). RESULTS: The number of low-weight births (<2500 g) for the non-B group was significant (P =.019). Mothers in the non-B group reported more spontaneous abortions (P =.171) and stillbirths (P =.301). The difference in conceptions per woman between groups was significant (P =.036). However, no difference in infants alive at 1 month of age was evident. Neonatal death was significant (P =.017). The odds of an unsuccessful outcome among mothers in the B group was compared with mothers in the non-B group and was significant (P =.029). The chance of an adverse outcome, that is, fetal or infant death before 1 month, for mothers in the B group was between 11.1% and 88.7% lower than for mothers in the non-B group. CONCLUSIONS: The neonatal mortality rate for the non-B group was significantly elevated relative to the B group. The molecular basis for these observations is not clear.

Neonatal pulmonary hypoplasia and perinatal mortality in patients with midtrimester rupture of amniotic membranes--a critical analysis.

OBJECTIVE: We sought to critically assess the risk factors for neonatal pulmonary hypoplasia and perinatal death in patients with preterm rupture of the amniotic membranes from 15 to 28 weeks' gestation. STUDY DESIGN: This was a prospective cohort study. The study patients had preterm rupture of the amniotic membranes at 15 to 28 weeks' gestation and were without fetal anomalies, multiple gestation, and oligohydramnios before rupture of the membranes. The amniotic fluid volume index was determined at admission and weekly afterward until delivery. RESULTS: The incidence of pulmonary hypoplasia was 12.9% (21/163). The overall perinatal mortality rate was 54% (88/163). Logistic regression analysis revealed the following: (1) Gestational age at rupture of the membranes, the latency period, and either the initial or the average amniotic fluid index have significant influence on the development of pulmonary hypoplasia; (2) gestational age at rupture of the membranes and latency period are significant factors in predicting perinatal death. CONCLUSIONS: In this large population of patients with rupture of membranes at 15 to 28 weeks' gestation, gestational age at rupture of the membranes, latency period, and amniotic fluid index were important independent predictors of neonatal pulmonary hypoplasia. In addition, gestational age at rupture of the membranes and latency period were important independent determinants of perinatal death. Expectant management of patients with preterm rupture of the amniotic membranes during this gestational age interval was associated with improved perinatal survival, even though it may increase the risk of pulmonary hypoplasia.

Tocolysis with advanced cervical dilatation.

OBJECTIVE: To assess the feasibility and potential benefit of delaying delivery in women with advanced preterm labor. METHODS: Two hundred fifty-seven gravidas with intact membranes and preterm labor at cervical dilatations of at least 3 cm were studied. Women were excluded if they had premature rupture of membranes, gestational age less than 24 or more than 35.9 weeks, complete cervical dilatation, severe hemorrhage, chorioamnionitis, and triplets or higher-order gestations. Management consisted of tocolysis with intravenous magnesium sulfate as the primary agent, antenatal steroids, antibiotics, and amniocentesis. The primary endpoint was delay to delivery interval. Statistical analyses by cervical dilatation were performed using the Pearson chi2 test and a nonparametric test of trend. RESULTS: Eighty-one percent of pregnancies were referrals in utero from outlying hospitals. Delivery was delayed 24 hours or longer in 74% and beyond 48 hours in 60% of cases. Among 229 women who delivered at our center, 21% remained undelivered after 1 week. Evaluating delay as a function of cervical dilatation, trend analysis found a highly significant inverse relationship (P < .001). Among women dilated 5 cm, 46% delivered beyond 48 hours. Among those dilated 6 cm or more, 19% delivered beyond 48 hours. Mild pulmonary edema developed in five percent, and all responded promptly to medical interventions. Chorioamnionitis developed in eight percent. CONCLUSION: Delaying delivery 24-48 hours to allow antenatal steroid use or other interventions is possible in women with advanced preterm labor.

Serial changes in the biophysical profile in patients undergoing cervical ripening with a controlled release PGE2 vaginal pessary.

OBJECTIVE: The purpose of this study was to evaluate the effects of exogenous administration of PGE2 upon the components of the biophysical profile. METHODS: The study group included 17 nulliparas at > or = 38 weeks gestation, with a Bishop score of < or = 4, requiring induction of labor. A controlled release vaginal pessary containing 10 mg of PGE2, designed to release hormones at approximately 0.8 mg per hour in vitro, was used for 12 hours of cervical ripening. The BPP was performed by the same sonographer at three intervals: prior to pessary insertion, at 6 hours, and 12 hours. RESULTS: None of these patients had membrane rupture or went into spontaneous labor during the ripening process. All patients subsequently required amniotomy and oxytocin. The proportion of patients scoring 2 points for fetal breathing movements decreased from 59% at baseline to 0% at 12 hours, P < 0.0005, and the proportion of patients with fetal body movements decreased from 100% at baseline to 25% at 12 hours, P < 0.0005. However, the other components of the biophysical profile were not affected. The mean maternal plasma PGE2 metabolite concentrations were 235 pg/ml, 475 pg/ml, and 466 pg/ml at 0, 6 and 12 hours, respectively, P < 0.005. CONCLUSIONS: In term patients, vaginal administration of the PGE2 pessary was associated with improved Bishop score over 12 hours and significant increases in maternal plasma PGEM levels at 6 hours and 12 hours. These changes were inversely related to fetal breathing and body movements.

Impact of oligohydramnios on maternal and perinatal outcomes of spontaneous premature rupture of the membranes at 18-28 weeks.

OBJECTIVE: We compare the maternal and perinatal outcomes between 69 patients with oligohydramnios and 49 patients with adequate fluid at the time of initial evaluation for PROM. METHODS: One hundred and eighteen patients with spontaneous premature rupture of the membranes (PROM) at 18-28 weeks are included in the study. Inclusion criteria are singleton gestation, normal fetal anatomical survey and normal amniotic fluid prior to PROM, and absence of labor or abruption at the time of PROM. Oligohydramnios is defined as an amniotic fluid index (AFI) <5 cm of measurable pockets of amniotic fluid which are free of umbilical cord. Expectant management was carried during the 3-year period. The overall perinatal survival is 66%. Pulmonary hypoplasia is present in 18%, and skeletal deformities in 3% of all neonates. RESULTS: There is no significant difference between the two groups in the mean gestational ages at PROM (172+/-17 d vs. 171+/-14 d), latency periods (9+/-14 d vs. 8+/-13 d), incidences of chorioamnionitis (48 vs. 39%), endometritis (19 vs. 14%), neonatal sepsis (11 vs. 13%), or skeletal deformities (6 vs. 0%). Patients with oligohydraminos have significantly higher incidences of fetal heart rate decelerations (59 vs. 38%) and C-section (38 vs. 16%) (P < 0.05) than patients with adequate amniotic fluid. CONCLUSIONS: After adjusting for confounding variables, neonates with oligohydramnios are twice as likely to develop pulmonary hypoplasia (20 vs. 10%) and more likely to experience neonatal death (30 vs. 20%) when compared to those with adequate fluid, even though the difference is not statistically significant.

Role of fetal echocardiography in the management of isolated fetal heart block with ventricular rate <55 bpm.

Persistent bradycardia is an uncommon cardiac problem in fetuses but carries a high mortality in those with a ventricular rate <55 bpm. Fetal heart block is one of the most common causes of persistent fetal bradycardia (PFB). An optimal method for assessing and monitoring cardiovascular compensation in the setting of PFB due to heart block has not been fully established. We report the application of two-dimensional and Doppler echocardiography in close monitoring of cardiac function and hemodynamics in a third-trimester fetus with a ventricular rate <55 bpm due to heart block, which assisted in successful management of the pregnancy to term. Hemodynamic and cardiac adaptive changes in compromised fetuses, particularly due to heart block, are discussed.

Effects of serum from preeclamptic women on prostacyclin production by human endothelial cells.

There is growing evidence that proteinuric hypertension of pregnancy (preeclampsia) is associated with endothelial dysfunction. The aim of this study was to evaluate the effects of serum from preeclamptic patients on basal and agonist-stimulated prostacyclin production by human umbilical vein endothelial cells (HUVEC) in culture and to compare these to the effects of serum from normal pregnant and nonpregnant women. During a 24 h incubation of HUVEC with 20% of preeclampsia serum, baseline prostacyclin output was significantly (P < 0.01) increased over the control groups. However, this response was attenuated by extending the exposure to 72 h. Histamine, thrombin and the calcium ionophore, A23187, all acutely increased prostacyclin production, but the increase relative to baseline levels was greatest in HUVEC preincubated for 24 h in normal serum transiently promotes prostacyclin production in HUVEC derived from normal pregnancies, preeclampsia serum transiently promotes prostacyclin production in HUVEC derived from normal pregnancies, and 2) the relative increase in response to agonists is reduced by preeclampsia serum, compared to normal pregnancy sera.

The neonatal bisacromial diameter: a prenatal sonographic evaluation.

This study was designed to determine which fetal ultrasonographic parameter best correlates with the neonatal bisacromial diameter (BAD). The latter is defined as the distance between the two acromions of the scapulae. The study population included fifty-four uncomplicated singleton pregnant patients whose infants with birth weights of more than 3000 grams were delivered within a week of ultrasound examinations. Six fetal biometric parameters: circumferences of the chest, abdomen, head, arm, and thigh, and estimated fetal weight were obtained by ultrasonography and were compared with the BAD. The best predictor of the neonatal bisacromial diameter was the fetal chest circumference (r = 0.67, p = 0.003) followed by the arm circumference, (r = 0.59, p = 0.03). The fetal chest circumference correlates well with the neonatal shoulder girth as reflected by the neonatal bisacromial diameter.