Cervicovaginal fistula presenting during miscarriage.

Cervicovaginal fistula is a recognized complication of induced mid-trimester termination of pregnancy, but more recently it has also been recognized as representing a complication of prior cervical cerclage. We report the ultrasound findings of prolapse of the amniotic sac through a cervicovaginal fistula in a woman with prior cervical cerclage. A woman with cervical incompetence and prior failed McDonald cerclage presented for prophylactic Shirodkar cerclage. Before the procedure, transvaginal ultrasonography revealed a live intrauterine pregnancy at 14 weeks' gestation. Upon further ultrasound examination, the amniotic sac appeared to protrude through the posterior wall of the cervix into the vaginal vault. Pelvic examination verified prolapse of the amniotic sac through a cervicovaginal fistula. The patient underwent an uncomplicated dilatation and evacuation. Women with a history of cervical cerclage are at risk for the development of cervicovaginal fistula, the detection of which is important to prevent potential morbidity.

Cyclins, cyclin dependent kinases, and regulation of steroid receptor action.

Steroid receptors (SR), which are ligand activated transcription factors, and their coactivators are phosphoproteins whose activities are regulated by cell signaling pathways. Many of the identified phosphorylation sites in these proteins contain Ser/Thr-Pro motifs suggesting that they are substrates for cyclin dependent kinases and/or for mitogen activated protein kinases. An analysis of the roles of cyclins and their kinases in regulating receptor action has revealed that there are both stimulatory and inhibitory actions of cyclins, that some of the actions are independent of the partner kinases and that these activities are receptor specific. Consistent with this finding, the limited analyses of receptor activity as a function of cell cycle reveal distinct patterns of activation. SR often regulate cell proliferation. Thus, the cross-talk between cyclins and their kinases and the SR provides a means for integrating the actions of the SR with the cell cycle status of cells.

Isolation of Serpulina pilosicoli from rectal biopsy specimens showing evidence of intestinal spirochetosis.

Histologic evidence of intestinal spirochetosis (IS) was found in 22 of 41 (53.7%) rectal biopsy specimens from homosexual men attending a sexually transmitted diseases clinic. Serpulina pilosicoli was cultured from 11 of the IS-positive biopsy specimens (50%) and from 2 specimens (10.5%) in which spirochetes were not observed. The association between seeing spirochetes in biopsy specimens and isolating S. pilosicoli was statistically significant, clearly indicating that this spirochete is the agent of IS.

Paediatric enema syndrome in a rural African setting.

We have observed a distinct clinical syndrome amongst acutely unwell children frequently associated with the administration of a traditional medicine enema. We describe the clinicopathological features of this 'enema syndrome' based on retrospective case note review of 50 consecutive admissions to a South African rural district hospital. Admission was frequently prompted by sudden, marked clinical deterioration following enema administration (68% seen within 24 h). Respiratory distress with tachypnoea, abdominal distension, hypotonia and loss of consciousness occurred frequently. In-hospital mortality was 28% and was higher in those receiving herbal (43%) rather than chemical (21%) enemas. Hyperkalaemia, leucocytosis (> 15,000 mm3) and respiratory distress occurred more frequently in those who died. Diagnosis of an underlying illness was established in 78%. Whilst the majority of enemas are given without incident, children struggling with an underlying illness may be unable to tolerate rectally administered traditional medicines. Toxic chemical substances in frequent use may increase complication rates.

Helicobacter westmeadii sp. nov., a new species isolated from blood cultures of two AIDS patients.

A slowly growing anaerobic Helicobacter species was isolated from the blood cultures of two human immunodeficiency virus-positive patients admitted to Westmead Hospital, Westmead, Australia, with fevers. The morphology of the isolates was consistent with Helicobacter cinaedi or Helicobacter fennelliae. The results of culture growth conditions, biochemical tests, gas chromatography data, ribotyping, and 16S rDNA sequencing showed that these isolates represent a new Helicobacter species, for which the name Helicobacter westmeadii has been proposed.

Use of computerized information systems in U.S. health maintenance organizations and hospitals.

A comparison was made between the use of data processing in hospitals and Health Maintenance Organizations (HMOs). Findings indicate that the HMO and hospital data processing markets are currently quite distinct. As expected, the functions automated reflect the uses of the different care delivery systems. The hardware and software vendors to these markets are also different. A high percentage (50%) of HMOs are using software they developed in-house. In this respect, current HMO data processing is similar to the hospitals of a decade ago. The hospital market (for hardware and total systems) is highly concentrated. A few firms have a combined market share of over 50% and there are a large number of firms with very small shares. In the HMO market, there is a high concentration ratio for hardware but not for software or systems. HMOs and hospitals are almost uniformly satisfied with their hardware. Satisfaction with most applications is between 80 and 90% but there is a need, at least within HMOs, for improvements in support of the software supplied.

The regional educational impact of a Renal Stone Center.

This study evaluates the impact of the Renal Stone Center (RSC) at Yale University School of Medicine on the extent of the diagnostic search for urolithiasis risk factors at the Yale-New Haven Medical Center and four affiliated community hospitals. Using a multiple time series design and a Physician Performance Index (PPI) based on multiple normative practice criteria, the hospital and outpatient charts of 1,924 patients with a primary diagnosis of urolithiasis at the five hospitals were examined to determine whether there was a change over time that could be related to the RSC. There was no statistically significant improvement in the PPI at four of the five hospitals. At the fifth, there was a statistically significant improvement that possibly was related to factors other than the RSC. Routine blood, urine, and X-ray tests usually were performed well. However, the history of urolithiasis risk factors and the examination of 24-hour urines were generally done poorly or not at all, and this generalization held true (although modified somewhat) even when physician office records were examined as well.

The diagnostic evaluation of risk factors for urinary tract stones: an analysis of care patterns in five hospitals.

Medical records of hospitalized primary urolithiasis patients in five Connecticut hospitals were studied to determine the aggressiveness of the diagnostic search for metabolic and other renal stone risk factors. A total of 924 patients over three years were analyzed. Routine serum, urine, and X-ray tests were generally performed according to accepted criteria. However, medical histories were generally inadequate, and 24-hour urine studies for calcium and uric acid were performed on less than half of the patients for whom they were indicated. Neither the complexity of the stone problem nor the stone event number appeared to influence the intensity of the diagnostic search in any important way. Other deficiencies included the lack of followup of abnormal test findings and the lack of treatment of problems discovered. The diagnostic approach in each hospital was stable over time.