Diagnostic errors in the neonatal intensive care unit: State of the science and new directions

Diagnostic errors remain understudied in neonatology. The limited available evidence, however, suggests that diagnostic errors in the neonatal intensive care unit (NICU) result in significant and long-term consequences. In this narrative review, we discuss how the concept of diagnostic errors framed as missed opportunities can be applied to the non-linear nature of diagnosis in a critical care environment such as the NICU. We then explore how the etiology of an error in diagnosis can be related to both individual cognitive factors as well as organizational and systemic factors – all of which often contribute to the error. This multifactorial causation has limited the development of methodology to measure diagnostic errors as well as strategies to mitigate and prevent their adverse effects. We recommend research focused on the frequency and etiology of diagnostic error in the NICU as well as potential mitigation strategies to advance this important field in neonatal intensive care.     

Volume reduction of the uterus during and soon after hysterectomy

Gynecologists observe perceptible and variable reduction from uterine size in vivo to subsequent size in the pathology laboratory. To measure this decrease in uterine size, the thickness, breadth, and height of the corpus were measured four times: as soon as the abdomen had been opened, as soon as the uterine arteries had been ligated, as soon as the uterus was removed, and after 45 minutes in fixative. The cervical diameter and length were measured two times as soon as the uterus was removed and after 45 minutes in fixative. Reduction in volume varies from 20% to 64% in different specimens. Reduction in volume is greatest in women who have uterine hypertrophy and hypermenorrhea. It is least in postmenopausal women who have atrophic uteri.     

In vivo chemosensitivity testing in patients with gynecologic malignancies and nude mouse xenografts by monitoring cell kinetic parameters and DNA distribution patterns: a preliminary report

Using flow cytometry (FCM) and autoradiography we have evaluated changes in DNA-ploidy patterns as well as cell-cycle perturbations after chemotherapy in 12 patients with accessible tumors and 22 nude mice xenografts. Gynecologic malignancies growing as nude mouse xenografts serve as an experimental model to study the effect of chemotherapy at the cellular level. Excellent correlation was found between fine needle aspiration (FNA) and biopsy material for either FCM or autoradiography. It now appears possible to study the effects of chemotherapy in the patient as well as the animal model using serial FNAs as a microsampling technique.     

Role of glucose-regulated Protein 78 in embryonic development and neurological disorders

Glucose-regulated protein 78 (GRP78) is an important chaperone protein that is predominantly expressed in the endoplasmic reticulum. The multifunctional roles of GRP78 in protein folding, endoplasmic reticulum calcium binding, cytoprotection, and anti-apoptosis, as well as its function as a receptor on the cell surface, disclose its major involvement in physiological and numerous pathological conditions. Recent advances in mouse models targeting GRP78 allele have revealed the essential roles of GRP78 in development and neurological disorders, as well as accurate neural migration and neuroprotection. This review of correlation between GRP78 and embryogenesis and neurological disorders provides further directions for investigation, as well as potential therapeutics for clinical use.     

Clinical aspects of the administration of gestagen preparations (Volidan, Cyclofarlutal, Ovulen, Ciba AC-101 and Steridil)

203 women 19-40 years of age were administered the gestagen preparations Volidan, Cyclofarlutal, Ovulen, Ciba AC-101, and Stediril as a contraceptive. 49 other women were administered these preparations as therapeutic and/or diagnostic measures in different gynecological complications. Side effects such as spotting, acylic bleeding, nausea, headaches and breast swelling were more frequent with the high-dose preparations such as Volidan and Cyclofarlutal. Intolerance to the preparation and subsequent discontinuation occurred only in a small percentage of the users. All of the preparations achieved 100% effectiveness as contraceptives. It is noted that these preparations were used with some success in treating dysmenorrhea, menometrorrhagia because of hyperplasia of the endometrium, and in severe climacteric syndromes. It has also been used as a pregnancy test. Constant medical control of the administration of these preparations is necessary both when they are used as contraceptives and as therapeutic measures, particularly in the case of young women.     

Atypical antipsychotic (clozapine) self-poisoning in late pregnancy presenting with absent fetal heart rate variability without acidosis and delayed peristalsis in the newborn baby: A case report

A case of an attempted suicide with atypical antipsychotic (clozapine) in late pregnancy is reported. Toxic effects of clozapine in the mother as well as in the fetus and newborn were observed. It should be remembered as a rare cause of unexplained loss of consciousness in pregnant women, a cause of abnormalities on fetal cardiotocogram as well as a cause of delayed peristalsis in a newborn baby.     

Zyklusstörungen

Irregular menstrual bleeding is a common complaint during the reproductive years with increased frequency during adolescence and in the perimenopausal years. Symptoms are more frequent or infrequent cycles with amenorrhea as one extreme as well as aberrant duration and volume of blood loss most commonly presenting as menorrhagia or intermenstrual bleeding. The causes are mainly endocrinological or structural and when possible a causal therapy or symptomatic cycle regulation should be initiated. The mainstay of treatment is an individual approach considering the reproductive goals of the patient as well as other complaints and preferences with a focus on endometrial protection in general or therapeutic amenorrhea in acute situations.     

Twin delivery

The incidence of twin pregnancy has increased worldwide over the past 10 years largely as a consequence of the assisted reproductive technologies. Issues such as intrapartum monitoring and operative interventions, especially with regard to the second twin, provide a unique challenge in labour and delivery. Epidemiological data suggest that the term twin has a threefold higher mortality rate than the singleton. It is the authors' view that many aspects of twin delivery deserve as much import as those features of twin gestations such as pre-term birth and intrauterine growth restriction that, to date, have received much of the research and clinical interest in this area.Indications for elective Caesarean section are presented, incorporating new data derived from the delivery of the term singleton breech, and implications on the timing thereof are discussed.Vaginal delivery of both twins presenting by the vertex is recommended as safe as long as guidelines for the conduct of such delivery are followed. The recommended time interval between twins as well as the use of epidural, fetal monitoring and ultrasound in the delivery room are discussed.The second twin presenting as a non-vertex presents an urgent dilemma for accoucheurs. Data suggest that internal version and breech extractions are safer than external cephalic version provided that the appropriate techniques are applied. It is revealed, however, that the use of elective Caesarean section in this group of babies has not been subject to randomized controlled studies of sufficient power to determine the best method of delivery of the second twin - particularly in the low-birth-weight baby.     

Früherkennung des Mammakarzinoms

Primary prevention of breast cancer as well as for other malignancies is hardly accomplishable and still only finds limited acceptance in the population. Therefore, secondary prevention is so much more important. The diagnostic options used in early detection have made distinct progress. Therefore, diagnostics as well as treatment have been improved. Digital mammography is now the standard in clinical as well as in screening mammography. Moreover, it also offers further options, such as tomosynthesis and the use of CAD systems. Prospectively, these new options will influence the senological diagnostics in early detection. Regular general screening for women aged between 50 and 69 years old and intensified monitoring of women with a family history of breast cancer has recently been introduced in Germany. Results are expected at the end of the year. Available data suggest that implementation of a general mammography screening can reduce the mortality of breast cancer by about 25%.     

Comparison of 2 simple surgical methods: posterior colpoceliotomy versus laparoscopy--competition or synergism?

Celiocolpotomy and laparoscopy often have the same indications, such as oviduct sterilization or diagnostical inspection of the inner genital organs. In order to evaluate their significance in comparison, we examined the course of operation as well as postoperative development in 773 cases in our department in which either a celiocolpotomy (CCP n = 441) or laparoscopy (n = 332) had been performed. Both surgical methods were compared regarding indication, intra- and postoperative complications as well as surgical advantages an disadvantages. Concerning severe intraoperative complications and "failures" both methods appeared equivalent. The rate of--mostly bland--postoperative disturbances (urinary tract infection, rises of temperature) was higher in the CCP group. Regarding the results, it seems recommendable not to view both methods in competition, but to apply them synergistically: factors such as parity, obesity, prior operations, necessity to inspect the entire abdominal cavity as well as the probability and possibility to perform successfully under circumvention of laparotomy should be carefully valued in deciding which surgical method to chose.     

The amenorrhoea-galactorrhea syndrome: present diagnostic and therapeutic perspectives.

Recent progress in the field of radioimmunology, especially as regards prolactin (PRL) assay, as well as the use of new drugs have opened new perspectives for a better understanding of the "amenorrhoea-galactorrhea syndrome" both from the diagnostic and therapeutic points of view. This syndrome which formerly was considered infrequent, is now observed more and more often, perhaps as a result of the more widespread use of drugs such as phenothiazines, reserpine derivatives, alpha-methyldopa and tricyclic antidepressants, as well as owing to the large-scale use of estrogens and above all of estrogen-progestogen contraceptives. The problems of etiopathogenesis and management of the amenorrhea-galactorrhea syndrome are complicated by the fact that a variety of factors are responsible, as is shown also by the classical nosographic classification with the Forbes-Albright syndrome in the presence of a pituitary tumour, the Chiari-Frommel syndrome of amenorrhea-galactorrhea following pregnancy, and the Argonz-del Castillo-Ahumada syndrome in the absence of lither pregnancy or tumor.     

Sarcoma of the uterus: Factors influencing the results of treatment

The literature dealing with the results of treatment of sarcoma of the uterus is reviewed.A group of 43 cases of sarcoma of the uterus is analyzed from the standpoints of age, treatment, and factors which may influence the end-results.The incidence of sarcomatous degeneration in our series of myomas, as well as in cases collected from the literature, was 0.76 per cent.The total five-year salvage was 34.3 per cent.The five-year salvage in 20 operable cases was 50 per cent.Prognosis in sarcomatous degeneration of a myoma is three times more favorable than in primary sarcoma.The salvage in younger women is more than three times as great as in women who have passed the menopause.Small round cell and polymorphous tumors are more highly malignant than the spindle-celled type.Recurrences after operation were more than twice as frequent in a group of tumors presenting a large number of mitotic figures as in tumors with relatively lower counts. Conversely, the five-year salvage was almost four times as great in the low count groups as in the tumors showing more numerous mitoses. Although in final analysis the presence of mitoses indicates nothing more than rapid growth, these results seem to justify the conclusions that the estimated number of mitotic figures is a reliable gauge of the degree of malignancy and is of distinct value in prognosis.     

Incorporating sexual and reproductive health care in the medical curriculum in developing countries

Medical educators have a responsibility to train physicians and other health professionals in the core competencies needed to improve the sexual and reproductive health of their communities. Yet sexual and reproductive health care is significantly under-represented in the basic educational curriculum for medical and other health professionals, as well as in continuing medical education and professional development programmes for practising physicians and other health professionals. The Commonwealth Medical Association Trust is developing a model curriculum on sexual and reproductive health that can be integrated into undergraduate medical education and used with appropriate amendments for continuing medical education. This paper outlines topics for inclusion in the curriculum and three strategies for incorporating core components of sexual and reproductive health in the curriculum--by developing themes that can be integrated into the general curriculum in a multi-disciplinary fashion, adding free-standing modules as electives, and delegating cross-cutting issues such as gender issues and adolescent reproductive health to courses run by other departments. It argues for the use of problem-solving and case-based learning methodologies, as well as lectures, as the best way to teach health professionals how to provide information, counselling and support for sexual and reproductive health, as well as to cover the range of prevention and treatment needs of women and men seeking these services.     

Colposcopy—What Is It?

Colposcopy is a gynecologic diagnostic procedure permitting visualization of the cervix under bright light and magnification. It is used to assess changes in the surface patterns of lesions as well as changes in capillary networks. Colposcopy, in America, has recently experienced a rebirth, being used extensively in the evaluation of patients with abnormal cytologic smears. The value of colposcopy und treatment modulities which have emerged as a result of colposcopy, as well as the technique of the examination and implications for nursing, are discussed in this article.     

Previous stillbirth, late preterm, and early-term birth

Subsequent pregnancies are emotionally traumatic for families with previous stillbirths. Such pregnancies have a 2- to 10-fold increase in the risk for stillbirth as well as an increased probability of other adverse obstetrical outcomes. These medical risks as well as anxiety on the part of families and care providers contribute to an increase in late preterm and early-term birth. However, delivery before 39 weeks' gestation has not been proven to reduce the risk of recurrent stillbirth or adverse pregnancy outcomes in women with previous stillbirths. This work reviews data regarding the optimal timing of delivery in subsequent pregnancies after previous stillbirth, as well as for patients at risk from stillbirth in general. Management recommendations from current data are presented and knowledge gaps are highlighted.     

Pregnancy in young girls

More and increasingly young adolescents are sexually active and pay less or no attention to contraception. The pregnancy rate among adolescents has been definitely increasing in recent years and especially among the youngest. This entails a large proportion of medicosomatic and also psychosocial risks such as premature labour and delivery as well as social disadvantages. Moreover, abortions have greatly increased. e.g. by 20% in 2001. Among the causes besides earlier maturity we may assume inadequate sex education falling short of cognitive capacity and emotional needs as well as difficult social problems with deficiencies in tenderness requirements and poor prospects of vocational training and professional career 8 examples, case reports).The overall situation pre-programmes medium-term and long-term consequences such as deficient school education and training, financial dependence and excessive financial and emotional strain on mother and child. A considerable gap in this regard can be filled by medical health promotion in step with physical and mental development, as well as by primary and secondary prevention in respect of information deficits, within the framework of a sound relationship of trust and reliability between the physician and the (female) patient.     

Cord blood insulin level in relation to metabolic control of maternal diabetes, duration of pregnancy and neonatal birth weight

The aim of the study was to examine whether an association between cord blood insulin level (Ic) and maternal glycemic control, duration of pregnancy as well as neonatal birthweight exists. The study was performed in diabetic group consisted of 149 diabetic mothers (91 with GDM and 58 with IDDM) and 149 their babies as well as in the control group consisted of 100 healthy mothers and 100 their babies. Maternal glycemic control was indirectly assessment by using HbA1c and fructosamine levels estimated on the day of delivery. That was found a significant positive correlation between Ic and maternal HbA1c and fructosamine levels as well as between Ic and neonatal birthweight in the diabetic group. That was also found the significant negative correlation between Ic and duration of pregnancy in the diabetic group. We conclude that fetal hyperinsulinemia is a result of poor glycemic control during the last weeks of diabetic pregnancy. Furthermore the significant association exists between cord blood hyperinsulinemia and preterm delivery as well as higher birthweight of newborns born to diabetic mothers.     

Importance of angiogenesis in reproductive physiology

The cyclic angiogenesis that occurs uniquely within the female reproductive tract is critical for normal reproduction. Two families of endothelial cell-specific growth factors and their receptors have been identified in the ovary, uterus, and placenta: vascular endothelial growth factor/vascular permeability factor and the angiopoietins. These appear to have complementary actions on the vasculature and to be involved during intrauterine development as well as in the adult. Within the ovary, a complex cascade of events required for angiogenesis may play a role in follicular maturation and selection as well as in normal corpus luteum function. Aberrant expression of angiogenic factors plays a role in a wide variety of abnormalities in the ovary. In the uterus, angiogenesis is required for endometrial growth and remodeling. Peptide growth factors such as vascular endothelial growth factor may serve as local mediators of the effects of reproductive hormones on the endometrial vasculature. Disease states such as dysfunctional uterine bleeding, endometriosis, and endometrial hyperplasia or cancer may be associated with aberrant uterine angiogenesis.     

Changes in steroid receptors during histopathologic transformation of tissue in the human uterus

Estrogen (ER) and progesterone receptors (PR) were analyzed in the cytosol and nuclei prepared from specimens of human uterine tissue of patients with certain disorders identified as hyperplasia endometrii adenomatosa, myoma uteri per magnum, adenocarcinoma endometrii and adenocarcinoma corporis uteri. These investigations have revealed a different level of ER and PR in analyzed tissue specimens, as well as the existence of a relationship between changes in receptor levels and respective Kd. These changes suggest a correlation between steroid receptor levels and the type of tissue transformation. The functionality of the receptors was analyzed by the ultracentrifugation of non-activated and activated steroid-receptor complexes in sucrose density gradients, as well as by the investigation of their interaction with isolated nuclei. These results indicate that some changes in steroid receptor molecules can be detected when the tissue turns from normal to malignant transformation. On the basis of this investigation it could be proposed that the analysis of activated and non-activated steroid-receptor complexes by means of the methods used in this study can be applied as a useful clinical tool in the determination of the endocrine dependence of transformed tissues, as well as for the optimum dosing of individual treatment of patients with uterine and other tissue carcinoma.     

妊娠期溶血的管理

妊娠合并溶血可发生于原发性血液系统疾病,也可继发于妊娠期特发性疾病,需要产科医生尽早识别病因并全面评估母儿状况,给予合理的对症治疗、多学科管理以及发生严重并发症时的强化危重症管理。本文就妊娠期溶血的发病机制和临床表现,以及孕期常见溶血性疾病的监测及治疗进行讨论。