Predictors of successful labor induction with oral or vaginal misoprostol.

OBJECTIVE: To identify independent predictors of successful labor induction with oral or vaginal misoprostol. METHODS: Women enrolled in four previous randomized trials involving oral or vaginal misoprostol for cervical ripening and labor induction were included in the present cohort study, with dosing of 25-50 microg every 4 to 6 h vaginally (n = 574) or 50 microg every 4 h orally (n = 207). Multiple logistic regression was performed to identify factors independently associated with successful labor induction -- defined as vaginal delivery within 12 h, vaginal delivery within 24 h and spontaneous vaginal delivery. Predictors of Cesarean birth and the need for only one dose of misoprostol were also identified. Variables included in the models were maternal age, weight, height, parity, gravidity, membrane status, route of misoprostol, gestational age, birth weight, and Bishop score and its individual components. RESULTS: Maternal age, height, weight, parity, birth weight, dilatation, effacement and cervical station were associated with vaginal delivery within 24 h of induction. Maternal age, height, weight, nulliparity, birth weight and route of misoprostol were associated with Cesarean birth, with oral misoprostol being associated with a lower rate of Cesarean birth. The need for only one dose of misoprostol was predicted by maternal height, weight, parity, gestational age, Bishop score and route of misoprostol. CONCLUSION: Characteristics of the woman (height, weight, parity), the fetus (birth weight) and some of the individual components of the Bishop score, were associated with successful labor induction, with oral misoprostol being associated with a lower rate of Cesarean birth.     

Indications for pulmonary artery flow-directed catheters

The pulmonary artery flow-directed catheter (Swan-Ganz catheter) has been in clinical use for 20 years. These devices are now used by 80% of UK intensive care units for the diagnosis and monitoring of a wide range of cardiorespiratory problems. The principal indications for the use of pulmonary artery catheters and the evidence supporting these indications are outlined in this article.     

Thymidine labeling index in breast tumors

The relationship between primary tumor proliferative activity and clinical and pathologic characteristics was analyzed in relation to menopausal status in 32 patients with malignant or benign breast disease. The thymidine labeling index (TLI) showed significantly higher median values in the cancer patients (3.48 per cent) than in the patients with benign diseases (1.02 per cent). TLI was not significantly affected by delayed incubation at room temperature for about 1 hour. In the breast cancer patients, TLI did not significantly correlate to tumor size, the presence of axillary lymph node metastasis or pathologic nuclear grading. The only significant difference was limited to the breast cancer patients without axillary lymph node metastasis in relation to menopausal status; the TLI in the premenopausal patients (5.10 per cent) was significantly higher (p<0.05) than that in the postmenopausal patients (2.28 per cent). These data thus suggest that among premenopausal patients without axillary lymph node metastasis, those with a high TLI could be potential candidates for adjuvant chemotherapy.     

Pelvic ring disruptions: effective classification system and treatment protocols

From January 1, 1985, to September 10, 1988, 210 consecutive patients with high-energy pelvic ring disruptions (exclusive of acetabular fractures) were admitted to a statewide referral center for adult multiple trauma. They were treated by one of four attending orthopaedic traumatologists per protocol as determined by their injury classification and hemodynamic status; the injury classification system was based on the vector of force involved and the quantification of disruption from that force, i.e., lateral compression, anteroposterior compression, vertical shear, and combined mechanical injury. Of the 210 patients, 162 had complete charts: 126 (78.0%) were admitted directly from the scene, 110 (67.9%) were injured in motor vehicle or motorcycle accidents, 25 (15.0%) were admitted in shock (blood pressure less than 90 mm Hg), the average Glasgow Coma Score was 13.2, and the average Injury Severity Score was 25.8. Treatment of the pelvic fracture included the following methods (alone or in combination): acute external fixation (45.0; 28.0%), open reduction/internal fixation (22; 13.5%), acute arterial embolization (11; 7.0%), and bedrest (68; 42.0%). Overall blood replacement averaged 5.9 units (lateral compression, 3.6 units; anteroposterior compression, 14.8 units; vertical shear, 9.2 units; combined mechanical, 8.5 units). Overall mortality was 8.6% (lateral compression, 7.0%; anteroposterior, 20.0%, vertical shear, 0%; combined mechanical, 18.0%). The cause of death was associated with the pelvic fracture in less than 50%; no patient with an isolated or vertical shear pelvic injury died. We conclude that the predictive value of our classification system (incorporating appreciation of the causative forces and resulting injury patterns) and our classification-based treatment protocols reduce the morbidity and mortality related to pelvic ring disruption.     

Nitric oxide treatment for fulminant pulmonary hypertension.

A 3 year old child with known pulmonary haemosiderosis suffered acute circulatory collapse secondary to raised pulmonary vascular resistance. Nitric oxide inhalation produced a profound improvement in circulatory parameters and gaseous exchange. Nitric oxide may have a therapeutic role in acute pulmonary hypertensive crisis.     

Inhibition of hepatic glucose production by SDZ 51641

The new oral hypoglycemic agent SDZ 51641 was evaluated in nondiabetic rats and a rat model of human non-insulin-dependent diabetes mellitus. Diabetes was induced with a single injection of 37.5 mg/kg streptozocin, and the rats exhibited hyperglycemia in the fed state with normal insulin levels. Treatment of nondiabetic animals with 100 mg/kg SDZ 51641 given orally significantly decreased serum glucose and ketone levels within 4 h without affecting insulin levels. Nonesterified fatty acids increased more than twofold during the same period. Its effect on ketone and fatty acid levels suggests that SDZ 51641 acts as an inhibitor of fatty acid oxidation. Diabetic rats treated with SDZ 51641 exhibited a significant acute hypoglycemic response, which was more pronounced after 3 days of treatment. The compound also significantly decreased serum cholesterol and triglyceride levels 27 and 53%, respectively. When endogenous hepatic glucose production was assessed in nondiabetic and diabetic animals via continuous infusion of [3-3H]glucose, we found that hepatic glucose production was elevated 43% in diabetic compared with control animals. When diabetic rats were treated with 100 mg/kg SDZ 51641, hepatic glucose production decreased to normal levels within 6 h. Hyperinsulinemic-euglycemic clamp studies indicated that SDZ 51641 had no effect on insulin-stimulated glucose utilization. Measurement of [1-14C]oleate oxidation in isolated hepatocytes demonstrated that SDZ 51641 inhibited long-chain fatty acid oxidation in a concentration-dependent manner. The compound was ineffective at inhibiting long-chain fatty acid oxidation in epitrochlearis or soleus muscles.(ABSTRACT TRUNCATED AT 250 WORDS)     

Comparison of Snellen letter and Vistech grating charts as refraction targets

Snellen letter and Vistech sine wave grating charts were used as refraction targets to determine differences in times required to accomplish subjective refractions, endpoint refractive values, and subject preferences. Thirty hyperopes and 30 myopes, divided into three age groups, were selected as subjects. Two examiners tested each subject using each chart. Both timed their subjective refractions and recorded their findings. After all data were recorded, each subject completed a questionnaire to determine chart preference. There were no clinically significant mean differences between the charts in terms of endpoint refractive data, but, on average, the Snellen chart was faster to use. Chart rating depended on the subject's refractive status with more myopes preferring the Snellen chart and more hyperopes rating the grating chart higher.     

Management of early-stage ovarian cancer.

Approximately 30% of patients with epithelial ovarian cancer present with localized or early-stage disease. Accuracy of staging is dependent on careful surgical staging. Subsets of patients with specific prognostic factors have now been identified who do not require additional therapy after proper primary surgical staging. Poor prognosis patients do require adjuvant therapy. Whole abdominal irradiation, intraperitoneal P32, and single agent and combination chemotherapy have been utilized. The optimal therapy or whether any therapy is truly effective remains unknown.     

Needs assessment for persons with severe mental illness: What services are needed for successful community living?

The development and implementation of effective community support systems are goals of many public mental health authorities who are attempting to shift the focus and dollars for mental health services from inpatient to community care. This article presents the results of a survey which asked 90 community mental health agency case managers to assess the community support and residential needs of over 1400 of their clients. Medication monitoring and therapy were rated high priority needs. Psychosocial treatment, day and vocational activities also ranked high. Survey responses regarding residential services indicated a need for more supported and supervised options.The study reported was a collaborative effort by county and agency staff.