Uterine Tonus Assessment by Midwives versus Patient self-assessment in the active management of the third stage of labor (UTAMP): study protocol for a randomized controlled trial.

BACKGROUND: Postpartum hemorrhage (PPH) is the leading cause of maternal mortality worldwide and accounts for one third of maternal deaths in low-income and middle-income countries. PPH can be prevented by active management of the third stage of labor (AMTSL), a series of steps recommended by the World Health Organization to be performed by skilled birth attendants (SBAs). Task shifting in the AMTSL step of uterotonic drugs administration to community health workers, traditional birth attendants and self-administration has been investigated as a strategy to increase access to quality obstetric care considering persistent SBA and facility-based delivery shortages. The aim of this study is to assess task shifting in the final step of AMTSL and compare uterine tonus assessment by a SBA to self-assessment. METHODS AND DESIGN: The study is an individual-level two-arm non-inferiority randomized controlled trial (RCT). A total of 800 women will be recruited in Korle Bu Teaching Hospital in Accra, Ghana. Adult women in labor at term with an expected vaginal delivery who received antenatal instructions for self-assessment of uterine tonus will be eligible for inclusion. Women with an increased risk for PPH will be excluded. Women will be randomized to uterine tone assessment by a skilled birth attendant (midwife) or uterine tone self-assessment (with the safety back-up of a midwife present in case of PPH or uterine atony). Postpartum blood loss will be measured through weighing of disposable mats. The main study endpoints are PPH (≥500 ml blood loss), severe PPH (≥1000 ml blood loss), mean blood loss, and routine maternal and neonatal outcomes. Participants and caregivers will not be blinded given the nature of the intervention. DISCUSSION: A reduction of PPH-related maternal mortality requires full implementation of AMTSL. Task shifting of uterine tone assessment may contribute to increased AMTSL implementation in (clinical) settings where SBAs capacity is constrained. TRIAL REGISTRATION: Clinicaltrials.gov: NCT02223806 , registration August 2014. PACTR: PACTR201402000736158 , registration July 2014. University of Ghana, Medical School Ethical and Protocol Review Committee: MS-Et/M.8-P4.1/2014-2015.

Quality assurance calibration of 125I rapid strand in a sterile environment.

PURPOSE: 125I seeds encased in stiffened absorbable suture material, commercially available from Amersham Healthcare as 125I Rapid Strand, are not readily calibrated because of the necessity of maintaining the sterility and integrity of the Rapid Strand. A method is proposed to verify the activity of 125I seeds in Rapid Strand in a sterile environment and to provide quality assurance of the resultant loading by autoradiographing loaded needles. METHODS AND MATERIALS: A sterilizable insert for a Standard Imaging HDR 1000 Plus well chamber was designed to accommodate Amersham's plastic spacing jig that holds the strand. The insert has a cylindrical lead sleeve allowing five of the 10 seeds in the jig to be exposed within the well chamber. A grooved tray for holding a batch of 30 needles was designed for autoradiographing the implant set. RESULTS: Position-dependent calibration factors for each of the seed wells in the jig were determined; then these individual factors were combined into a single chamber factor of 21.6 pA/mCi. Starting from the most distal spacing jig slot, relative position factors were 0.99, 1.00, 0.99, 0.93, 0.73, and 0.13 for the six positions which produced a nonnegligible signal. Anisotropy in the chamber factor was determined by rotating the well in 30 degrees increments about the seeds in the jig. The chamber factor showed only a 0.2% variation with rotational angle. Attenuation due to the Vicryl suture cladding material was 0.2% and was measured by stripping the Vicryl from the strand and remeasuring the chamber factor with the seeds in their original orientation. In the operating room, charge was collected from sterile Rapid Strands for a fixed time between 30 and 50 s and the measured ion chamber current was compared with the value predicted from Amersham's nominal activity. The average deviation between nominal and measured activity of 73 Rapid Strands tested was +0.5% +/- 2.2%. For single measurements, the maximum and minimum deviations observed were +4.8% and -3.7%, respectively. Autoradiographs taken of the entire implant set on an aluminum tray milled to hold the needles confirmed the actual seed loadings. CONCLUSIONS: The Rapid Strand calibration procedure described maintains the sterility and integrity of 125I Rapid Strands and verifies that the manufacturer's stated activity is accurate to within 5%.

Screening in special populations: a "case study" of recent Vietnamese immigrants.

PURPOSE: To determine how the medical and social profile of a particular special population, Vietnamese immigrants, should be used to tailor screening protocols that differ from those designed for the general population. PATIENTS AND METHODS: A consecutive series of Vietnamese immigrants living in the United States for less than 6 months were evaluated by interviewer-administered standardized questionnaire and medical record review. A total of 99 new Vietnamese immigrants (47 women and 52 men) aged 19 to 71 years presenting for primary care to two neighborhood health centers between October 1994 and June 1995 were identified. Data collected included smoking status, alcohol use (CAGE questionnaire), depression (Vietnamese Depression Scale [VDS]), PPD status, stool ova and parasites, hepatitis B and syphilis serologies. RESULTS: Overall, 32% were smokers and significantly more men than women smoked (54% vs. 9%) (P < .00001). Although 24% of patients used alcohol, none responded positively to any of the CAGE questions. Using the VDS, 17% (17 of 99) were depressed; age 40 and older was the only sociodemographic factor associated with depression (P < .00001). Ova or parasites were found in 51% (41 of 80), and 63% of those infected (26 of 41) required treatment for pathogenic infections. Seventy percent (66 of 94) tested positive on the tuberculin skin test (PPD), and antituberculous medication was recommended in 39% (37 of 94). Eighty-three percent (80 of 96) had been exposed to hepatitis B, and 14% (13 of 96) were chronic hepatitis B carriers. CONCLUSIONS: Caring for special populations provides an opportunity to institute appropriate unique screening tests not recommended for the general population. In the case of new Vietnamese immigrants, routine screening protocols should include the following: testing for tuberculosis by PPD, stool ova and parasite examinations, hepatitis B serologies, and assessment for depression and smoking status. The CAGE questionnaire may not be an effective instrument for detecting alcohol abuse in this particular population.

The electromyographic responses to dorsal rootlet stimulation during partial dorsal rhizotomy are inconsistent.

Concerns have arisen regarding the ability of physiologic techniques to select rootlets mediating spasticity in children undergoing partial dorsal rhizotomy (PDR) for the treatment of spastic gait from cerebral palsy. To determine whether these physiologic responses are reproducible, 60 rootlets in 6 patients were graded from 0 to 4+ according to the system first reported by Phillips and Park, and then retested and graded using a randomized, blinded paradigm. Two thirds of the rootlets had one or more grade difference between the two trials, and 25% had a grade change of 3 or more. Only 4 of 23 rootlets with a "normal' response (grade 0) on one test were also graded normal on the other test. Only 2 of 14 rootlets with a bilateral response (grade 4+) had a bilateral response on both trials. Statistical analysis demonstrated no correlation and poor agreement between trials. Regardless of whether responses are reflex in origin with technical or physiologic variability, or the consequence of stimulus spread to ventral roots, we found inconsistent responses with commonly used methods and the criteria most agreed upon. These findings suggest that currently used techniques are not reliable for rootlet "selection' and result only in a random partial rhizotomy.

Aberrant reinnervation of facial musculature in a subhuman primate: a correlative analysis of eyelid kinematics, muscle synkinesis, and motoneuron localization.

A macaque monkey with a preexisting facial nerve injury showed a synkinesis of perioral muscles with blinking and thus provided a serendipitous model for a multiphasic analysis of this common neurologic syndrome. The amplitude of the paretic eyelid in spontaneous and air-puff-induced blinks was about one-third that of the normal eyelid. Despite the blink hypometria, induced blink durations remained matched for the two lids. EMG confirmed co-contraction of the zygomaticus and orbicularis oculi muscles on the affected side during blinking, with silence of the zygomaticus on the normal side. Neuroanatomic investigation showed that, on the affected side, some zygomaticus motoneurons were in the somatotopically correct nuclear subdivisions but that the majority were in the dorsal subdivision, which normally innervates the orbicularis oculi. This study supports the contention that some orbicularis oculi motoneurons are incorrectly rerouted to supply the perioral musculature following recovery from a peripheral seventh-nerve injury. This same pattern of relative weakness in eyelid muscles and the stereotyped co-contraction of lid and perioral muscles with blinking occurs in humans, suggesting that aberrant reinnervation may be the mechanism for this clinical phenomenon.

Spinal deformity in Charcot-Marie-Tooth disease.

STUDY DESIGN: This retrospective study reviewed 100 children with clinically and electrodiagnostically proven Charcot-Marie-Tooth disease (CMTD). OBJECTIVE: To determine the incidence of spinal deformity in children with CMTD. SUMMARY OF BACKGROUND DATA: A 10% incidence of kyphoscoliosis has been reported. METHODS: All charts and electrodiagnostic studies were reviewed to confirm that CMTD diagnostic criteria were met. Existing radiographs on 89 children were available. Cobb angles were measured and deformity was defined as scoliosis > or = 10 degrees and kyphosis > 40 degrees. RESULTS: Thirty-seven of 89 CMTD children had spinal deformity. There was scoliosis in 20, kyphoscoliosis in 14, and kyphosis in 3. In children with radiographs taken at maturity, 50% had deformity. The most common scoliotic pattern was a thoracic curve with convexity in either direction. Spinal deformity is more likely in female and Type I patients. CONCLUSIONS: This study found an incidence of 37%-50% spinal deformity in children with CMTD, with female and Type I patients at greatest risk. However, the deformity rarely required treatment.

Hip abnormalities in children with Charcot-Marie-Tooth disease.

Hip dysplasia was recently observed in association with Charcot-Marie-Tooth disease (CMT). We retrospectively reviewed available radiographs of 74 of 100 children with clinically and electrodiagnostically proven CMT and noted six cases of hip dysplasia. Minor hip abnormalities, most commonly increased neck shaft angles, were noted in 21 other patients. Type I usually causes more weakness and had more hip dysplasia than type II. A female predominance was noted but may have resulted from sampling of more immature radiographs in males. Most dysplasia was asymptomatic and was detected only on screening radiographs.

Intraoperative electrophysiological monitoring in children.

Children, like adults, are at risk for neurological injury during a variety of surgical procedures. Intraoperative electrophysiological monitoring (IOM) provides information about the functional integrity of the nervous system during surgery. This information may determine the mechanism of injury and prevent damage by identifying nerves and detecting dysfunction at a reversible stage. Electrophysiological techniques may also help direct therapy by improving injury localization, detect the presence or absence of axonal integrity in peripheral nerve lesions, and identify rootlets with the greatest contribution to spasticity in patients undergoing selective dorsal rhizotomy (SDR). Electrophysiological techniques used are modified from those employed in the diagnostic laboratory. The first portion of this article reviews IOM experience at the Mayo Clinic in patients under 18 years of age from 1985 to 1991. The types of procedures monitored, the monitoring modalities used, technical problems unique to children, and neurological outcome are discussed. Subsequently presented are the application and techniques of electrophysiological monitoring during SDR as currently practiced at the University of Kentucky and other medical centers.

Carbamazepine-induced cardiac dysfunction. Characterization of two distinct clinical syndromes.

A patient with sinus bradycardia and atrioventricular block, induced by carbamazepine, prompted an extensive literature review of all previously reported cases. From the analysis of these cases, two distinct forms of carbamazepine-associated cardiac dysfunction emerged. One patient group developed sinus tachycardias in the setting of a massive carbamazepine overdose. The second group consisted almost exclusively of elderly women who developed potentially life-threatening bradyarrhythmias or atrioventricular conduction delay, associated with either therapeutic or modestly elevated carbamazepine serum levels. Because carbamazepine is widely used in the treatment of many neurologic and psychiatric conditions, the recognition of the latter syndrome has important implications for the use of this drug in elderly patients.

Congenital myopathy and cardiomyopathy with identical ultrastructural changes.

A 7-day-old girl with congenital hypotonia and unexplained episodes of bradycardia had a broad spectrum of similar skeletal muscle and myocardial degenerative ultrastructural abnormalities. Ultrastructural studies showed obliteration of cross striations, myofilament disorganization, streaming, smearing, clumping, and zigzag Z-band deformities. A decrease in glycogen, mitochondria, and T-tubular system occurred in the regions showing Z-band abnormalities of both skeletal muscle and myocardium. Concurrent structural cardiomyopathy should be considered in patients with congenital myopathies, particularly with unexplained cardiac conduction abnormalities or contractile insufficiency. Ultrastructural evaluation of skeletal and cardiac muscle may be necessary to define such disorders.

Creatine kinase and fibrillation potentials in patients with late sequelae of polio.

The incidence of an elevated creatine kinase (CK) in a group of polio patients with delayed weakness (15/29) did not differ from polio patients without delayed weakness (9/31) or others with amyotrophic lateral sclerosis (ALS; 10/21). Mean CK in polio patients without delayed weakness (151 IU/L) was lower than the CK in those with delayed weakness (270 IU/L) or ALS (224 IU/L) (P less than 0.05). An elevated CK in polio patients with delayed weakness did not correlate with new or residual weakness. These findings suggest that muscle overuse is either not important or inadequately measured by CK. Widely distributed fibrillations were associated with an elevated CK for all polio patients combined (P less than 0.01). Fibrillations occurred in more muscles of polio patients with delayed weakness (P less than 0.01) and implies that late denervation may play a role in the development of new weakness in some polio patients.

Neurophysiologic monitoring during surgery of peripheral and cranial nerves, and in selective dorsal rhizotomy.

Physiologic monitoring may warn of impending neural damage and intraoperative assessment may provide critical information used to direct the surgical procedure itself. Intraoperative techniques utilize methods modified from the diagnostic neurophysiologic laboratory. Simultaneous multimodality recording of different signal sources is of particular value for several types of procedures. Intraoperative studies must be tailored to each patient's clinical condition and to the specific surgical risks. Since studies have supported the benefits of intraoperative monitoring for peripheral nerve and cranial nerve surgery, monitoring is not likely to be subjected to the rigors of a randomized controlled study for these procedures.