Therapy of chronic wounds with water-filtered infrared-A (wIRA)

The central portion of chronic wounds is often hypoxic and relatively hypothermic, representing a deficient energy supply of the tissue, which impedes wound healing or even makes it impossible. Water-filtered infrared-A (wIRA) is a special form of heat radiation with a high tissue penetration and a low thermal load to the skin surface. wIRA produces a therapeutically usable field of heat and increases temperature, oxygen partial pressure and perfusion of the tissue. These three factors are decisive for a sufficient tissue supply with energy and oxygen and consequently as well for wound healing, especially in chronic wounds, and infection defense. wIRA acts both by thermal and thermic as well as by non-thermal and non-thermic effects. wIRA can advance wound healing or improve an impaired wound healing process and can especially enable wound healing in non-healing chronic wounds. wIRA can considerably alleviate the pain and diminish wound exudation and inflammation and can show positive immunomodulatory effects.In a prospective, randomized, controlled study of 40 patients with chronic venous stasis ulcers of the lower legs irradiation with wIRA and visible light (VIS) accelerated the wound healing process (on average 18 vs. 42 days until complete wound closure, residual ulcer area after 42 days 0.4 cm² vs. 2.8 cm²) and led to a reduction of the required dose of pain medication in comparison to the control group of patients treated with the same standard care (wound cleansing, wound dressing with antibacterial gauze, and compression garment therapy) without the concomitant irradiation. Another prospective study of 10 patients with non-healing chronic venous stasis ulcers of the lower legs included extensive thermographic investigation. Therapy with wIRA(+VIS) resulted in a complete or almost complete wound healing in 7 patients and a marked reduction of the ulcer size in another 2 of the 10 patients, a clear reduction of pain and required dose of pain medication, and a normalization of the thermographic image. In a current prospective, randomized, controlled, blinded study patients with non-healing chronic venous stasis ulcers of the lower legs are treated with compression garment therapy, wound cleansing, wound dressings and 30 minutes irradiation five times per week over 9 weeks. A preliminary analysis of the first 23 patients of this study has shown in the group with wIRA(+VIS) compared to a control group with VIS an advanced wound healing, an improved granulation and in the later phase of treatment a decrease of the bacterial burden. Some case reports have demonstrated that wIRA can also be used for mixed arterial-venous ulcers or arterial ulcers, if irradiation intensity is chosen appropriately low and if irradiation is monitored carefully. wIRA can be used concerning decubital ulcers both in a preventive and in a therapeutic indication. wIRA can improve the resorption of topically applied substances also on wounds. An irradiation with VIS and wIRA presumably acts with endogenous protoporphyrin IX (or protoporphyrin IX of bacteria) virtually similar as a mild photodynamic therapy (endogenous PDT-like effect). This could lead to improved cell regeneration and wound healing and to antibacterial effects. In conclusion, these results indicate that wIRA generally should be considered for the treatment of chronic wounds.     

HIV-related services for persons with severe mental illness: Policy and practice in new hampshire community mental health

Rates of HIV and HIV risk behaviors are elevated among people with severe mental illnesses (SMI). Little is known about the extent to which community mental health (CMH) centers screen, refer, and educate their clients regarding HIV and sexually transmitted diseases (STDs). The authors surveyed CMH administrators and clinicians in New Hampshire regarding HIV/STD policy, practices, knowledge, and attitudes. HIV/STD service availability varied, and the amount of services provided was unrelated to the prevalence of HIV and AIDS in that region. Clinicians were knowledgeable about general HIV information but lacked specific knowledge about HIV related to persons with SMI. CMH staff had positive attitudes about helping clients with HIV issues. Administrators were interested in receiving training. Policy leadership, CMH practice guidelines, and training are warranted in light of the pressing public health implications of HIV/STDs among people with SMI.     

Fetus-placenta-newborn

OBJECTIVE: Our purpose was to determine whether third-trimester maternal serum α-fetoprotein predicts adverse perinatal outcome and whether use of both second- and third-trimester maternal serum α-fetoprotein enhances the positive predictive value for various abnormal outcomes.STUDY DESIGN: A cohort study with obstetric outcome assessed by chart analysis after delivery was performed at Regional Medical Center (Memphis, Tennessee), a hospital staffed by university-based physicians saving a large urban population with many indigent patients. A total of 650 women attending prenatal clincis in the above setting with a singleton pregnancy without a neural tube defect, contributing a maternal blood samples in both the second and third trimesters, and delivered in the above hospital participated. Various pregnancy outcomes were correlated with maternal serum α-fetoprotein levels in the second the third trimesters and in both.RESULTS: In the third trimester no significant associations were found between maternal serum α-fetoprotein elevations and pregnancy complications. In the second trimester elevation (≥2.0 multiples of the median) were, by contrast, significantly associated with preterm premature rupture of the membranes, preterm birth, and low birth weight. No association was found with certain other complications. When second-trimester data were grouped according to the types of complications occurring in individual women, only preterm premature rupture of the membrane proved statistically significant.CONCLUSIONS: Second-trimester but not third-trimester maternal serum α-fetoprotein is significantly elevated with preterm premature rupture of the membranes, preterm birth, and low birth weight; in this conhort study no association was found with preeclampsia, oligohydramnios, or polyhydramnios.     

Efficacy of outpatient induction with low-dose intravaginal prostaglandin E2: A randomized, double-blind, placebo-controlled trial

OBJECTIVE: Our purpose was to determine whether a protocol for outpatient induction is safe and effective for initiating labor.STUDY DESIGN: A randomized, double-blind, a placebo-controlled trial was performed with 100 low-risk patients having well-dated pregnancies. Women with a Bishop score ≤6 at 38 to 40 weeks' gestation were administered either 2 mg of intravaginal prostaglandin E₂ gel or placebo for 5 consecutive days as outpatients while undergoing fetal monitoring.RESULTS: The median interval from randomization to delivery was 4 days in the prostaglandin E₂ group (range 0 to 28 days) and versus 10 days in the placebo group (range 0 to 26 days, p = 0.002). Twenty-seven of 50 patients (54%) in the prostaglandin E₂ group were admitted for labor during the dosing interval compared with 10 placebo-treated patients (20%, p = 0.001). The mean gestational age at delivery was significantly reduced in the treatment group (39.9 ± 1.0 weeks vs 40.5 ± 0.99 weeks, p = 0.003) as was the incidence of postdates pregnancy (40% vs 66%, p = 0.016). Hyperstimulation was observed in one prostaglandin E₂-treated patient, but no intervention was required.CONCLUSIONS: Outpatient low-dose prostaglandin E₂ gel administration is effective for initiating labor in patients with an unfavorable cervix and appears safe if performed with adequate monitoring.     

Incisional bowel herniations after operative laparoscopy: A series of nineteen cases and review of the literature

Objectives: The objectives of this report were (1) to identify all cases of incisional bowel herniations noted after operative laparoscopy in 11 participating institutions and (2) to report the clinical details of such patients.Study Design: A retrospective case review was performed.Results: Nineteen cases of incisional bowel herniation were identified. The average age of the patients was 50.5 years. Initial laparoscopic procedures varied and included laparoscopically assisted vaginal hysterectomy (six Patients), laparoscopically assisted vaginal hysterectomy with lymphadenectomy (five patients), oophorectomy (two patients), adhesiolysis (two patients), myomectomy (two patients), lymphadenectomy alone (one patient), and ovarian cystectomy (one patient). The averge time to reoperation was 8.5 days.Conclusions: Incisional bowel herniation is a serious complication of operative laparoscopy. Herniations occur through ports ≥ 10 mm in size at both umbilical and extraumbilical sites. New techniques are needed to avoid this serious complication.     

Primary thrombocythemia in pregnancy: a report of two cases

We report two cases of primary thrombocythemia diagnosed during pregnancy. One patient developed transient visual field defects. She was treated with plateletpheresis at term and delivered of a normal child by cesarean section. The second patient was not treated. Intrauterine fetal death occurred at 36 weeks' gestation from multiple placental infarcts. In cases of primary thrombocythemia, we suggest close monitoring of both mother and fetus throughout pregnancy.     

Fetal foot length as a predictor of gestational age

Ultrasonographic measurement of fetal foot length is useful in the assessment of gestational age. Two hundred twenty-three postpartum and 224 ultrasonographic measurements were performed between 11 and 43 weeks' gestation; 207 postpartum and 160 ultrasonographic measurements met our requirements of secure dates and no physical anomaly or maternal disease. Mean foot length at each week of gestation compared favorably with Streeter's data, based on pathologic specimens, described in 1920. Comparison of curvilinear regression of foot length versus gestational age demonstrated a strong correlation with an R2 value of 0.981; 95% confidence intervals at each week compared favorably with both biparietal diameter and femur length data. Fetal foot length is a reliable parameter for use in the assessment of gestational age and is particularly useful when other parameters do not accurately predict gestational age, for example, hydrocephalus, anencephaly, short limb dysplasia.