Physicians who induce labor for fetal macrosomia do not reduce cesarean delivery rates.

OBJECTIVE: To determine whether obstetricians with high rates of induction for the indication of fetal macrosomia had higher or lower cesarean section rates. STUDY DESIGN: Data were analyzed from 1432 deliveries with birthweights > 4000 g. Four physician populations were identified: a faculty service and three groups of private practitioners with induction rates 20% to 40%, 40% to 60% and > 60%. The average cesarean section rate was determined for each group as well as the percentage of each group's deliveries occurring before 39 weeks, at 39, at 40, and after 40 weeks. In addition, the relative risk of cesarean delivery was calculated for the entire study population. RESULTS: No correlation was found between the rate of induction of labor and the rate of cesarean section. Delivery of nulliparous and multiparous patients after 40 weeks carried an increased risk of cesarean section. Delivery of multiparous patients before 39 weeks did also. Obstetricians with induction rates > 40% significantly decreased the incidence of delivery after 40 weeks, which lowered their cesarean section rates, but no net lowering occurred because of increased rate of cesarean section < 39 weeks. CONCLUSION: A fetal weight of 4000 g or more is not an indication for induction of labor. For multiparous patients, induction at 38 weeks or before is associated with an increased rate of cesarean delivery.

The triad of substance abuse, violence, and depression are interrelated in pregnancy.

A study group of 271 registrants had their medical and social history taken by a nurse-interviewer and were requested to take the Substance Abuse Subtle Screening Inventory. If the nurse interviewer felt that the patient needed social service assessment, referral was made, and a social worker completed the the Social Service Review Questionnaire. The patients who were reported as positive for substance abuse did not respond differently from their negative counterparts for issues of demographics, pregnancy, social support, and career. They were highly likely to have had a history of severe depression and/or have been a victim of physical and/or sexual abuse. On the basis of these data we recommend that the prenatal patient who responds positively in her personal history regarding any of these three experiences should be carefully evaluated for problems related to the other two.

The substance abuse subtle screening inventory minimizes the need for toxicology screening of prenatal patients.

Multiple authors have reported attempts to effectively address the discovery of substance abuse in pregnancy using various mechanisms to encourage positive self-reports and urine toxicology to augment identification. In this study, we evaluated 1,251 patients with (a) self-report, (b) the Substance Abuse Subtle Screening Inventory (SASSI), and (c) urine toxicology screening to determine which modality or combination would yield the most cost-effective discovery. Combining the SASSI with the self-report was the most clinically effective and cost effective mode of discovery. This led to the development of a clinical protocol using the SASSI and self-report with limited use of urine toxicology for specific patient subgroups. Alcohol abuse, which is missed by toxicology and self-report, is detected by the SASSI.

Are obstetrical personnel required for intraoperative fetal monitoring during nonobstetric surgery?

OBJECTIVE: To determine if the scientific literature supports the practice of electronic monitoring of the fetal heart rate (FHR) during nonobstetric surgery. STUDY DESIGN: A search of the literature from 1966 to 1995 was performed using MEDLINE. RESULTS: No fetal hypoxic mortality or morbidity has been documented from nonobstetric surgery without occurrence of a maternal hypoxic complication regardless of the use of FHR monitoring or whether alterations of the FHR occurred. CONCLUSIONS: Fetal monitoring is an indirect assessment of maternal anesthetic and surgical management that is not as specific or effective as direct assessment of the maternal parameters to detect respiratory compromise. Current clinical evidence obtained does not substantiate the need for obstetric personnel to monitor FHR changes during surgical procedures because no change in fetal outcome has been documented.

Methotrexate pneumonitis after systemic treatment for ectopic pregnancy.

Pneumonitis is an infrequent complication of methotrexate therapy. Described is a case of pneumonitis after treatment of an ectopic pregnancy. A 20-year-old white woman, gravida 3, para 0, ectopic pregnancy 2, was treated for her third ectopic pregnancy with 88 mg (50 mg/m2) of intramuscular methotrexate. Four days later acute dyspnea, tachypnea, fever, patchy infiltrates on chest x-ray films, and a PO2 of 30 mm Hg developed. Respiratory distress resolved over 48 hours. Pneumonitis should be suspected in any patient treated with methotrexate who has unexplained dyspnea.

A study of resistive indices in the arcuate arteries of the kidney over the course of gestation.

OBJECTIVE: Our purpose was to assess whether there was a variation in the resistive index (RI) of the arcuate artery in the kidneys of patients with hydronephrosis in pregnancy. STUDY DESIGN: Forty-seven patients were studied to establish norms for the RI of the arcuate arteries in pregnancy, and these measurements were correlated with the development of hydronephrosis over the course of gestation. RESULTS AND CONCLUSIONS: The RIs were noted to remain unchanged from the nonpregnant state throughout gestation. They were also unchanged by the presence of the physiologic hydronephrosis of pregnancy.

The substance abuse subtle screening inventory is more cost effective and has better selectivity than urine toxicology for the detection of substance abuse in pregnancy.

OBJECTIVE: To compare the SASSI as a screen for substance abuse in pregnancy with the patient history and toxicology screening. STUDY DESIGN: On 560 patients the substance abuse history and urine toxicology was obtained at registration in the prenatal clinic. Each patient also completed the SASSI questionnaire. The SASSI was compared with each screen individually and the result of the SASSI and the patient's history were combined for comparison with the toxicology results. RESULTS: SASSI was found to be more selective as a screen for substance abuse than urine toxicology and it gave a profile of alcohol use which was absent on the toxicology screen. CONCLUSIONS: The SASSI is a more effective clinical tool for identifying substance abuse and more cost effective than toxicology screening.

Amiodarone versus bretylium for suppression of reperfusion arrhythmias in dogs.

Reperfusion arrhythmias are an important complication of interventions to limit infarct size. Recently, amiodarone has been shown to be rapidly effective in suppressing sustained, incessant ventricular tachycardia and ventricular fibrillation in this setting. This study evaluated the time course of arrhythmia suppression and comparative efficacy of amiodarone versus bretylium in a canine model of reperfusion arrhythmias. Of 23 dogs subjected to a Harris two-stage coronary artery ligation followed by release, 18 demonstrated clinically significant ventricular arrhythmias and received either intravenous amiodarone, 5 mg/kg (9 dogs), or intravenous bretylium, 5 mg/kg (9 dogs). Direct-current shocks for sustained ventricular tachycardia or ventricular fibrillation were administered as necessary. Amiodarone rapidly suppressed sustained ventricular tachycardia and ventricular fibrillation in this model with no dog in the amiodarone-treated group requiring cardioversion after completion of the 15-minute infusion versus 4 of 9 dogs in the bretylium-treated group (p less than 0.05). Amiodarone was more effective than bretylium in suppressing episodes of sustained ventricular tachycardia/ventricular fibrillation, episodes of nonsustained ventricular tachycardia, and premature ventricular complexes. The blood pressure and heart rate decreased more after amiodarone administration than after bretylium administration. We conclude that, in the canine reperfusion arrhythmia model, amiodarone is rapidly effective in suppressing ventricular arrhythmias and is more effective than bretylium.

Thoracoplasty: current application to the infected pleural space.

Thoracoplasty, once commonly used in the management of cavitary pulmonary disease, continues to find application in the obliteration of infected pleural spaces. This study reports a series of 13 patients receiving thoracoplasty between 1976 and 1989. Five patients had chronic apical empyema spaces without prior resection of lung tissue. Two of the empyemas were due to tuberculosis, two were due to atypical mycobacteria, and one was due to postpneumonic empyema. All patients had extensive destruction of upper lobe tissue. Eight patients had undergone prior pulmonary resection; 3 had persistent infected spaces in the early postoperative period, 3 had development of empyemas and bronchopleural fistulas late (5 to 19 years) after pulmonary resection, and 2 had postpneumonectomy empyema. All patients had rigid cavity walls preventing space obliteration by rib removal alone and required concomitant resection of the thickened pleura and intercostal muscle tissues. Bronchopleural fistulas were present in 11 patients and were closed with adjacent nonintercostal muscle. All patients survived and had successful obliteration of the infected spaces with acceptable physiological and cosmetic results. We conclude that thoracoplasty remains a useful procedure in the management of the infected pleural space in select patients.

Thoracic CT scanning in critically ill patients. Information obtained frequently alters management.

Conventional radiographic studies of the chest in the intensive care unit often fail to positively identify suspected intrathoracic pathology due to many patient- and equipment-related variables. Our experience has indicated that CT scanning of the chest improves diagnostic accuracy, precisely defines anatomic abnormalities, frequently affects treatment decisions, and has been performed safely in this fragile patient population. Examples of correctable lesions have included pneumothorax, empyema, lung abscess, mediastinal abscess and pleural effusion. Chest CT findings always occurred while the portable plane chest radiographs were nondiagnostic. CT-directed intervention often improved patient outcome.

Long-term survival after chemoradiotherapy for locally advanced squamous cell carcinoma of the esophagus.

Seven patients with locally far-advanced, inoperable, squamous cell cancer of the esophagus were given two cycles of concurrent radiation and chemotherapy. Each cycle consisted of 5-fluorouracil 1,000 mg/m2/day given as a continuous intravenous infusion over 96 hours, cisplatin 75 mg/m2 given as an intravenous bolus on day 1, and methotrexate 40 mg/m2 given as an intravenous bolus on days 8 and 15. Three thousand rads of radiation were given in 15 fractions between days 1 and 19. Six patients are evaluable for response. Symptomatic relief was obtained by all six and was complete in 4. Five patients achieved a complete response, and two remain alive and disease free. Five of the six evaluable patients survived for at least 12 months. Aggressive chemoradiotherapy may result in significant survival prolongation and symptomatic palliation in this poor-prognosis subset of patients with esophageal cancer.

Coverage of the open sternotomy wound with Biobrane dressing.

Massive edema accumulated after prolonged cardiopulmonary bypass for coronary grafting such that neither the sternum nor the presternal skin could be closed after insertion of a left ventricular assist device. To protect the mediastinum from infection, we applied Biobrane synthetic temporary wound dressing and placed a moist gauze dressing over it. When the dressing was removed 4 days later, the wound was pink, granulating, free from infection, and suitable for closure. Use of Biobrane biologic dressing should be considered when the mediastinum must remain exposed after median sternotomy.

Correlation between needle biopsy of lung tumors and histopathologic analysis of resected specimens.

Needle aspiration of a pulmonary mass may accurately delineate malignant from nonmalignant pulmonary lesions; however, needle aspiration may be unable to identify a specific cell type. Therefore, a retrospective review of patients undergoing needle aspiration of pulmonary masses was carried out for the years, 1979 through September 1984. A Lee needle was used, which produces a sample of tissue 1-mm in diameter suitable for histopathologic analysis as well as a cytologic specimen. A total of 87 needle biopsies were carried out, but only 46 patients later underwent resection. Five patients (6 percent) sustained a pneumothorax, and four required a chest tube. Minimal hemoptysis occurred in three patients (3 percent). Eight patients were subsequently found to have benign lesions, and there were 38 malignant tumors. Seven needle biopsies (18 percent; 7/38) were nondiagnostic and subsequently proved to be malignant. Thirty-one needle biopsies were diagnostic of malignant neoplasms (82 percent; 31/38). Twenty specimens showed the same cell type as the needle biopsy (65 percent 20/31). Eleven resected specimens disagreed with the cell type from the needle biopsy (35 percent; 11/31). In these 11 patients a change in management was indicated because of the delineation of a different cell type in only four (11 percent of all 38 patients with cancer). Mixed tumors and small cell carcinoma provide the area of most concern. Our conclusions are that needle biopsy accurately indicated a malignant neoplasm in 82 percent of the patients undergoing later resection and that the specimens from Lee needle biopsy accurately predicted the cell type in 65 percent of the specimens. The inaccurate histologic diagnosis was important clinically in only 11 percent of the patients. Overall, the needle biopsy of pulmonary lesions provided a correct decision on management in 87 percent of the cases in which biopsy provided diagnosis of a malignant neoplasm (31 patients).

Intra-aortic balloon counterpulsation via the ascending aorta.

Twenty-three patients have undergone intra-aortic balloon insertion via the ascending aorta; twenty-one in the operating room and two in the surgical intensive care unit. Direct insertion into the aorta within concentric purse-string sutures was utilized. Repeat exploration and balloon removal was accomplished safely with the added advantage of bypass graft inspection and revision where indicated. Only one patient suffered adverse sequelae from this technique, and thirteen patients are long-term survivors (one month-four years).

Mixed small cell and non-small cell lung cancer.

Seventeen (10 percent) of 176 patients with small-cell carcinoma of the lung seen at this hospital since 1976 proved to have mixed small-cell and non-small-cell tumors. The presence of a mixed lung cancer was established prior to chemotherapy or irradiation in nine patients. Eight were initially diagnosed as pure small-cell carcinoma but proved to have a mixed tumor at either surgery or autopsy. Of the 17 patients, eight received chemotherapy, and four had a partial response. Six of the 40 autopsies performed on patients with small-cell lung cancer demonstrated intrathoracic tumor which was histologically mixed. Extrathoracic metastases in these patients were heterogeneous and included pure small-cell, pure non-small-cell, and mixed histologic type. We conclude that mixed small-cell and non-small-cell lung cancers are relatively frequent and carry important prognostic and therapeutic implications. Clinical management of patients with small-cell lung cancer should therefore be flexible and tailored to the potential for histologic diversity. Mixed lung cancer in previously untreated patients suggests a common endodermal origin for small-cell and non-small-cell pulmonary tumors.

Readmission of patients to the surgical intensive care unit: patient profiles and possibilities for prevention.

Because experience is lacking regarding the profile of patients readmitted to a surgical ICU (SICU), we retrospectively reviewed total admissions, readmissions, patient profiles, and characteristics of illness requiring readmission to a multidisciplinary SICU. During a 1-yr period, the 721 recorded admissions included 68 readmissions for 57 patients (9.4% of the total). Eight patients had multiple readmissions. Seventy-five percent of the original admissions in these 57 patients occurred postoperatively, 9% were due to trauma, and 16% were caused by nonsurgical illness. Mortality for readmitted patients was 26%. Although 53 (78%) discharges were deemed appropriate, 62% of the patients manifested one or more of a retrospectively selected group of warning signs which might have alerted the responsible physician to alter the treatment plan. In half of these patients the reason for readmission was related to the warning sign. Readmission was related to the original disease in 65% of the incidents, while a new patient problem initiated readmission in 38%. The most common new problems were cardiopulmonary insufficiency and infection. All but one patient readmitted with pulmonary problems displayed retrospective evidence of clear warning signs before the original discharge. Recognition of SICU readmission patterns will allow more precise discharge planning: to delay discharge, to effect a lateral transfer, or to initiate a stepdown unit which may be able to help prevent costly and potentially lethal patient outcomes.

Utility of pneumonotomy in the treatment of cavitary lung disease.

Three patients were judged to be prohibitive operative risks despite the need for urgent drainage of cavitary pulmonary lesions. Cavernostomy was performed in each case, with a satisfactory long-term outcome in two patients. The third patient recovered from his pulmonary insult, but died much later, secondary to an unrelated illness. One patient had a purulent lung abscess due to aspiration, one had atypical tuberculosis resistant to all antibiotics, and the third patient experienced massive hemoptysis from a tuberculous cavity. Two-stage procedures were utilized in the first two patients, while urgent operation in the third patient was facilitated by adhesions from a previous thoracotomy and pleural infection. Care must be taken to minimize endobronchial and pleural contamination by meticulous attention to detail during the performance of percutaneous tube drainage. There are relatively few indications for percutaneous drainage of cavitary pulmonary lesions in this antibiotic era. However, certain clinical situations should prompt consideration for a pneumonotomy. These include a severely septic or debilitated patient who is unresponsive to medical management, the presence of resistant pathogens in a compromised host, and the presence of severe adhesive pleuritis which may prohibit an expeditious thoracotomy and resection for massive hemoptysis.