Part 2. Antepartum and Intrapartum Care

The spread of human immunodeficiency virus (HIV) disease among childbearing women presents a unique nursing challenge in the delivery of specialized antepartum and intrapartum care. The nurse must be competent in the delivery of psychosocial and physical care to these women, as well as assume a pivotal role as a member of the multidisciplinary health-care team. Aspects of care, from the diagnosis of pregnancy through delivery of the neonate, that are unique to women with HIV disease are described.     

Neonatal hypotension: two years'experience in a neonatal intensive care nursery

ABSTRACT. Routine measurement of blood pressure in high risk neonates admitted to the intensive care nursery during a 2 year period resulted in detection of 18 infants with persistent hypotension requiring definitive treatment. The perinatal events in these babies were compared to those in a control group of infants. No single well defined factor responsible for neonatal hypotension could be found in the antenatal period or during labour. However 14 of the 18 babies were asphyxiated at the time of admission compared to 6 of 18 controls (p<0.02). Seventeen of 18 babies were preterm. Treatment consisted of maintenance of ventilation, oxygenation and acid-base status, volume expansion when indicated and inotropic agents. Nine of the 18 hypotensive babies died compared to 1 of 18 controls. Failure to respond within a few hours of commencement of treatment indicated poor prognosis.     

CORONAL CUFF: A PROBLEM SITE FOR BUCCAL MUCOSAL GRAFTS

PURPOSE: Urethral reconstruction of complex hypospadias or epispadias continues to present a significant challenge. Buccal mucosa as an onlay or tube graft is an excellent option when faced with paucity of penile skin. We identified the factors that lead to success or failure in these repairs. MATERIALS AND METHODS: During 6 years we placed 34 buccal mucosal grafts in 31 patients to repair complex hypospadias and epispadias. Penile skin was preferentially used for urethroplasty but a free buccal mucosal graft was used for reconstruction due to lack of adequate penile skin. The cases were complicated with an average of 5 previous unsuccessful repairs each in 16. Grafts ranged from 1.5 to 10 cm. and 10 patients required pieced grafts. We created 1 combination, 16 onlay and 17 full tube grafts. Buccal mucosa was used with a Thiersch-Duplay urethroplasty in 8 patients. RESULTS: Anastomotic stricture in 5 patients was proximal in 4. Fistula was a complication in 13 grafts that generally developed on the distal shaft, particularly at the coronal cuff. Of the 7 patients who underwent proximal Thiersch-Duplay urethroplasty with a distal buccal graft 6 had a coronal fistula. Fistula was more common with tube and pieced than with onlay grafts. CONCLUSIONS: Fistula is overwhelmingly the most common complication after buccal mucosal graft urethroplasty. Most fistulas develop at the coronal cuff, and we suspect that skin coverage and potential blood supply have not been good in that region. Anticipation of this problem during stage 1 of hypospadias repair would allow more advantageous distribution of the existing penile skin. Good distal skin coverage cannot be compromised in these complex cases.     

SELEGILINE IN THE TREATMENT OF BEHAVIOURAL DISTURBANCE IN ALZHEIMER'S DISEASE

Objective. The purpose of this study was to examine the behavioural and cognitive effects of selegiline in a group of moderately behaviourally disturbed AD patients. Design. This was a 14-week randomized double-blind placebo-controlled study of selegiline (10 mg) and placebo. Setting. An outpatient clinic in an urban-based tertiary referral centre in the USA. Patients. Twenty-five outpatients meeting NINCDS criteria for probable Alzheimer's disease with associated behavioural disturbance. Measures. The Brief Psychiatric Rating Scale (BPRS), the Dementia Mood Assessment Scale (DMAS) and the Alzheimer Disease Assessment Scale (Cognitive) (ADAS-COG). Results. In the primary analysis, improvement on the BPRS and DMAS scores with selegeline treatment did not reach statistical significance. A secondary analysis using a parallel design showed a significant benefit of drug treatment on BPRS scores with a trend towards improvement on the DMAS. Among the 10 subjects who could be tested, there was a significant improvement in cognitive function on the ADAS-COG with selegiline compared to placebo. Conclusions. Short-term selegiline treatment produced an improvement in behaviour and had a significant effect on cognition in a subset of testable patients. © 1997 by John Wiley & Sons, Ltd.     

AN IMMUNOHISTOCHEMICAL STUDY OF TAL-1 PROTEIN EXPRESSION IN LEUKAEMIAS AND LYMPHOMAS WITH A NOVEL MONOCLONAL ANTIBODY, 2TL 242

Fifty formalin fixed, paraffin-embedded cases of T-acute lymphoblastic leukaemia (T-ALL) from 12 bone marrow trephines and 38 lymph nodes were stained with a new monoclonal antibody, 2TL 242, raised against recombinant TAL1 protein. The antibody recognizes TAL-1 polypeptides of molecular weight 39 and 41 kD (full length). In addition, a variety of other leukaemias and lymphomas were also stained with 2TL 242. Twenty-four of the 50 cases of T-ALL showed nuclear positivity, ranging from 10 to 90 per cent of leukaemic cells. A positive staining reaction was nuclear and stippled in pattern. Nuclear staining was not seen in any other type of leukaemia or lymphoma. Five cases of follicular lymphoma showed diffuse cytoplasmic staining of variable intensity. Although some background staining is obtained with this antibody, positive nuclear staining is easily distinguishable. This monoclonal antibody has a potential role in primary diagnosis and in the detection of minimal residual disease in T-ALL.     

Insufflation vs intubation during esophagogastroduodenoscopy in children

Objectives: We compared adverse airway events during esophagogastroduodenoscopy (EGD) in children managed with insufflation vs intubation. Background: Optimum airway management during EGD in children remains undecided. Methods/materials: Following IRB approval and written informed parental consent, children between 1 and 12 years of age presenting for EGD were randomized to airway management with insufflation (Group I), intubation/awake extubation (Group A), or intubation/deep extubation (Group D). All subjects received a standardized anesthetic with sevoflurane in oxygen. Using uniform definitions, airway adverse events during and after EGD recovery were recorded. Categorical data were analysed with Chi‐square contingency tables or Fisher’s exact test as appropriate. Results: Analyzable data were available for 415 subjects (Group I: 209; Group A: 101; Group D: 105). Desaturation, laryngospasm, any airway adverse event, and multiple airway adverse events during EGD were significantly more common in subjects in Group I compared to those in Groups A and D. Complaints of sore throat, hoarseness, stridor, and/or dysphagia were more common in subjects in Groups A and D. Analysis of confounders suggested that younger age, obesity, and midazolam premedication were independent predictors of airway adverse events during EGD. Conclusions: Insufflation during EGD was associated with a higher incidence of airway adverse events, including desaturation and laryngospasm; intubation during EGD was associated with more frequent complaints related to sore throat. As our results show that insufflation during EGD offers no advantage in terms of operational efficiency and is associated with more airway adverse events, we recommend endotracheal intubation during EGD, especially in patients who are younger, obese, or have received midazolam premedication.     

Wrist actigraphic scoring for sleep laboratory patients: algorithm development

Wrist actigraphy is employed increasingly in sleep research and clinical sleep medicine. Critical evaluation of the performance of new actigraphs and software is needed. Actigraphic sleep–wake estimation was compared with polysomnographic (PSG) scoring as the standard in a clinical sleep laboratory. A convenience sample of 116 patients undergoing clinical sleep recordings volunteered to participate. Actiwatch‐L recordings were obtained from 98 participants, along with 18 recordings using the newer Spectrum model (Philips Electronics), but some of the actigraphic recordings could not be adequately aligned with the simultaneous PSGs. Of satisfactory alignments, 40 Actiwatch recordings were used as a training set to empirically develop a new Scripps Clinic algorithm for sleep–wake scoring. The Scripps Clinic algorithm was then prospectively evaluated in 39 Actiwatch recordings and 16 Spectrum recordings, producing epoch‐by‐epoch sleep–wake agreements of 85–87% and kappa statistics averaging 0.52 (indicating moderate agreement). Wake was underestimated by the scoring algorithm. The correlations of PSG versus actigraphic wake percentage estimates were r = 0.6690 for the Actiwatch and r = 0.2197 for the Spectrum. In general, using a different weighting of activity counts from previous and subsequent epochs, the Scripps Clinic algorithm discriminated sleep–wake more successfully than the manufacturer’s Actiware algorithms. Neither algorithm had fully satisfactory agreement with PSG. Further evaluations of algorithms for these actigraphs are needed, along with controlled comparisons of different actigraphic designs and software.