Increased maternal serum human chorionic gonadotropin concentrations are an independent risk factor for SGA in dichorionic twin gestations.

OBJECTIVE: To determine maternal and neonatal complications among dichorionic and monochorionic twins with isolated midtrimester elevated maternal serum human chorionic gonadotropin (MShCG). MATERIAL AND METHODS: MShCG was determined in 247 women with dichorionic twins and 32 women with monochorionic twins between 16-18 weeks gestation. Among the dichorionic twins 219 patients had MShCG < 2.5 MoM, 14 between 2.5-3.0 MoM and 14 above 3.0 MoM. Of the patients with monochorionic twins 15 had MShCG < 2.5 MoM, nine between 2.5-3.0 MoM and 8 above 3.0 MoM. All patients had maternal serum alpha fetoprotein < 2.5 MoM. Karyotype was normal among all neonates. Statistical analysis was performed with SPSS package. RESULTS: Patients with monochorionic twins had higher rates of cesarean section when MShCG was > 3.0 MoM (100% vs. 44%; p = 0.03) and of preterm delivery when MShCG was > 2.5 MoM (87.5% vs. 46.7%; p = 0.04). A non significant higher rate of small for gestational age (SGA) neonates was found when MShCG was > 2.5 MoM among first twin (37.5% vs. 13.3%; p = 0.08). In contrast, patients with dichorionic twins had higher rates of SGA neonates and low 1 minute Apgar scores in the second twin when MShCG was > 2.5 MoM (23.1% vs. 10%; p = 0.04, 15.4% vs. 11.9%; p < 0.01). A multivariate logistic regression model with forward stepwise selection was performed with SGA as outcome variable. The model included the following variables: MShCG, hypertensive disorders, gestational age at delivery, chorionicity, twin order, cesarean section (CS) and preterm delivery. MShCG levels were the only significant factor predicting SGA among bichorionic twins (OR 1.76, 95% CI 1.2-2.5). CONCLUSIONS: (1) Increased concentrations of MShCG are an independent risk factor for SGA among dichorionic twins. (2) MShCG > 2.5 MoM are associated with adverse maternal outcome among monochorionic twins.     

Localization, detection and guided removal of soft tissue in the hands using sonography

Penetrating wounds and lacerations are frequent pathologies treated in the emergency room. The management of hand trauma represents a large part of the work in any surgical practice. Although X-rays are routinely taken, numerous foreign bodies remain undetected, and the wounds are just locally debrided and the lacerations sutured. Unfortunately, as not all foreign bodies are radio-opaque, the radiography results may appear normal, but the patient fails to recover. Patients complaining of persistent wound tenderness were sent for ultrasound investigations, and foreign bodies were detected. Had ultrasonography been carried out initially in the emergency room, the correct diagnosis would have been made, and the sonographic equipment could have helped to guide the physician in his attempt to remove the foreign body. Usually, in response to continued pain, an ultrasound investigation is ordered, and the pathology becomes apparent. A number of examples are briefly described in order to highlight the present inadequacies. It is suggested that hospital administrators consider the need to provide ultrasonographic services as an integral facility of the emergency room. Received: 20 December 1999     

Lack of effect of a low-fat, high-fruit, -vegetable, and -fiber diet on serum prostate-specific antigen of men without prostate cancer: results from a randomized trial.

PURPOSE: To determine whether a diet low in fat and high in fruits, vegetables, and fiber may be protective against prostate cancer by having an impact on serial levels of serum prostate-specific antigen (PSA). METHODS: Six hundred eighty-nine men were randomized to the intervention arm and 661 to the control arm. The intervention group received intensive counseling to consume a diet low in fat and high in fiber, fruits, and vegetables. The control group received a standard brochure on a healthy diet. PSA in serum was measured at baseline and annually thereafter for 4 years, and newly diagnosed prostate cancers were recorded. RESULTS: The individual PSA slope for each participant was calculated, and the distributions of slopes were compared between the two groups. There was no significant difference in distributions of the slopes (P =.99). The two groups were identical in the proportions of participants with elevated PSA at each time point. There was no difference in the PSA slopes between the two groups (P =.34) and in the frequencies of elevated PSA values for those with elevated PSA at baseline. Incidence of prostate cancer during the 4 years was similar in the two groups (19 and 22 in the control and intervention arms, respectively). CONCLUSION: Dietary intervention over a 4-year period with reduced fat and increased consumption of fruits, vegetables, and fiber has no impact on serum PSA levels in men. The study also offers no evidence that this dietary intervention over a 4-year period affects the incidence of prostate cancer during the 4 years.     

Sensorimotor control of knee stability. A review

Traditionally, the concept of joint stability considered the displacement (or subluxation) of two bones relative to each other as the measurement index, and attributed the preservation of such stability in its physiologic range to the various ligaments associated with the joint. Although the ligaments are indeed the major restraints of any joint, the significant contribution of the musculature toward joint stability had been grossly overlooked or neglected until the last 15 years. The value and importance of muscular activity in that role becomes immediately apparent if one performs even a superficial functional comparison of muscles and ligaments. Ligaments are passive viscoelastic structures, whereas muscles are dynamic viscoelastic organs. The viscoelastic effects of the ligaments are activated and applied strictly upon the geometric and kinematic configuration of the joint traversing through its range of motion according to fixed force-displacement relationships. The musculature, however, can apply passive viscoelastic effects to the joint when not active (passive tone) and variable dynamic viscoelastic effects when contracting under voluntary or reflexive control, and at any desirable point in the range of motion and in response to joint speed, external load, gravity, pain, and so forth, while executing the functional objective of the movement set by the individual. Preservation of joint stability cannot be ascribed to the ligaments alone, but should be considered as a synergistic function in which bones, joint capsules, ligaments, muscles, tendons, and sensory receptors and their spinal and cortical neural projects and connections function in harmony. The objective of this report is to first review the anatomy and physiology of the various mechanoreceptors and their neural pathways about the joint, and describe some of the current concepts of the reflex arcs elicited by such receptors, with special emphasis on biomechanical outcomes relative to stability. The role of the musculature in maintaining stability while controlling joint motion is then reviewed, with data obtained from experiments performed on humans and animals. Finally, some clinical findings from patients with anterior cruciate ligament deficiency using a brace that simulates the ligament-muscle functions is described.     

An increased risk for non allo-immunization related intrauterine fetal death in RhD-negative patients.

OBJECTIVE: To investigate immediate perinatal outcome of RhD-negative patients carrying RhD-positive fetuses who received antenatal Rh immunoglobulin for the prevention of RhD-mediated hemolytic disease of the fetus and newborn. METHODS: A retrospective population-based analysis was conducted comparing pregnancies of all RhD-negative women who received antenatal Rh immunoglobulin prophylaxis (anti-D), to RhD-positive parturients, during the years 1988-2003. All women were RhD-negative without evidence of RhD sensitization. Patients received anti-D during the 28-30th week of pregnancy, and an additional dosage within 72 hours following delivery after confirmation of the newborn's RhD status. RESULTS: Of 145,437 deliveries during the study period, 6.8% were of RhD-negative women (n = 9961). Perinatal mortality rate was significantly higher among the RhD-negative women who received antenatal prophylaxis rhesus immunoglobulin as compared with the controls (17/1000 vs. 12/1000, OR = 1.3, 95%CI 1.2-1.6; p < 0.001). This higher mortality rate was related to a higher rate of intrauterine fetal demise (IUFD) (10/1000 vs. 6/1000, OR = 1.5, 95%CI 1.2-1.9; p < 0.001). The association remained significant after controlling for RhD isoimmunization leading to hydrops fetalis, using the Mantel-Haenszel technique (weighted OR = 1.3; 95% CI 1.1-1.5; p = 0.001). The rate of RhD isoimmunization was 0.6% (n = 58). Using a multivariable analysis with IUFD as the outcome variable, controlling for known confounders for fetal demise, RhD-negative status was an independent risk factor for IUFD. CONCLUSION: RhD-negative women carrying RhD-positive newborns are at an increased risk for IUFD despite Rh immunoprophylaxis.     

HIS/BUI: A Conceptual Model for Bottom-Up Integration of Hospital Information Systems

Many successful applications of information systems have been introduced and implemented in hospitals. However, the integration of these applications into a cohesive hospital-wide information system has proved to be more complicated to develop and difficult to accomplish than expected. This paper introduces HIS/BUI, a framework for bottom-up integration of hospital information systems, and demonstrates its application through a real-life case scenario. The scope of the proposed framework is the integration of heterogeneous clinical, administrative, and financial information elements of a hospital into a unified system environment. Under the integrated architecture, all existing local applications are preserved and interconnected to an information hub that serves as a central medical and administrative data warehouse.     

Ideologies of mental healers: Evolving therapy orientations of novice psychotherapists

The first group initially scored high on the modes of change popularly considered the hallmark of psychoanalytic orientation. By the end of their rotation period resident's faith in these modes declined most significantly. ...The second group showed no preference for the presumptive hallmarks of the analytic orientation even at the beginning of their training.     

Vascular accidents in preretinal arterial loops

Three cases with preretinal arterial loops complicated by obstructive accidents of various intensities are reported. The range of the complication varied from arterial spasm to transient retinal hemorrhages and arterial branch occlusion with permanent field defect, followed by extensive recurrent vitreous hemorrhages. These results lend further support to the assumption that the spiral arterial loops have an inherent tendency to twist and produce occlusive episodes.