Optimal management strategies for placenta accreta

Objective  To determine which interventions for managing placenta accreta were associated with reduced maternal morbidity.
Design  Retrospective cohort study.
Setting  Two tertiary care teaching hospitals in Utah.
Population  All identified cases of placenta accreta from 1996 to 2008.
Methods  Cases of placenta accreta were identified using standard ICD-9 codes for placenta accreta, placenta praevia, and caesarean hysterectomy. Medical records were then abstracted for maternal medical history, hospital course, and maternal and neonatal outcomes. Maternal and neonatal complications were compared according to antenatal suspicion of accreta, indications for delivery, preoperative preparation, attempts at placental removal before hysterectomy, and hypogastric artery ligation.
Main outcome measures  Early morbidity (prolonged maternal intensive care unit admission, large volume of blood transfusion, coagulopathy, ureteral injury, or early re-operation) and late morbidity (intra-abdominal infection, hospital re-admission, or need for delayed re-operation).
Results  Seventy-six cases of placenta accreta were identified. When accreta was suspected, scheduled caesarean hysterectomy without attempting placental removal was associated with a significantly reduced rate of early morbidity compared with cases in which placental removal was attempted (67 versus 36%, P = 0.038). Women with preoperative bilateral ureteric stents had a lower incidence of early morbidity compared with women without stents (18 versus 55%, P = 0.018). Hypogastric artery ligation did not reduce maternal morbidity.
Conclusions  Scheduled caesarean hysterectomy with preoperative ureteric stent placement and avoiding attempted placental removal are associated with reduced maternal morbidity in women with suspected placenta accreta.     

Nursing prioritization of the patient need for care: A tacit knowledge embedded in the clinical decision-making literature

Every day in clinical settings, nurses practise in complex and dynamic situations. Nurses work to achieve emergent order in these situations through nursing prioritization of the patient need for care. As direct research on nursing prioritization had not been reported, a study, using critical realism as method, was designed to discern the profession's embedded understanding from within the clinical decision-making literature. The research synthesizes a tacit knowledge on nursing prioritization of the patient need for care from key international literature (from 1966 to 2003). Nursing prioritization was discerned in both education and practice literatures; interrelationships between these and theoretical approaches were also identified. Nursing prioritization of the patient need for care was revealed both as a non-sequential decision-making process throughout unfolding patient situations and as an advanced skill of nursing practice. Increasing confidence with this skill is the hallmark of developing expertise.     

Chronic active plasmacytic gastritis associated with cytomegalovirus

Chronic active plasmacytic gastritis (CAPG) is characterized by the presence of chronic inflammatory cell infiltrates, mainly formed by plasma cells, involving the neck of gastric glands. This lesion, as well as Ménétrier disease, has been linked to cytomegalovirus (CMV). To test this association we evaluated the foveolar/glandular (F/G) index and the presence of CMV DNA (desoxirribonucleic acid) by means of polymerase chain reaction (PCR) in 12 cases of CAPG and 13 controls. Cases exhibiting CAPG included 2 with Ménétrier disease, 6 with foveolar hyperplasia, and 3 with normal foveolar/glandular (F/G) index. None showed either lymphocytic gastritis or CMV inclusions. Three CAPG cases were associated with gastric carcinoma. The F/G index was less than 1 in all controls. Eleven out of the 12 cases with CAPG showed amplification for CMV DNA while all controls were negative. Findings suggest a very close association, probably in progressive stages, between CMV infection, CAPG, foveolar hyperplasia (with or without Ménétrier disease) and gastric carcinoma. CAPG might be a histologic marker for CMV infection in the germinative zone of the neck of gastric glands. These findings resemble those of hepatitis B virus (HBV) infection, chronic hepatitis, cirrhosis, and hepatocellular carcinoma saga.