Outcomes,safety, and resource utilization in a collaborative care birth center program compared with traditional physician-based perinatal care

OBJECTIVE: We compared outcomes, safety, and resource utilization in a collaborative management birth center model of perinatal care versus traditional physician-based care. METHODS: We studied 2957 low-risk, low-income women: 1808 receiving collaborative care and 1149 receiving traditional care. RESULTS: Major antepartum (adjusted risk difference [RD] = -0.5%; 95% confidence interval [CI] = -2.5, 1.5), intrapartum (adjusted RD = 0.8%; 95% CI = -2.4, 4.0), and neonatal (adjusted RD = -1.8%; 95% CI = -3.8, 0.1) complications were similar, as were neonatal intensive care unit admissions (adjusted RD = -1.3%; 95% CI = -3.8, 1.1). Collaborative care had a greater number of normal spontaneous vaginal deliveries (adjusted RD = 14.9%; 95% CI = 11.5, 18.3) and less use of epidural anesthesia (adjusted RD = -35.7%; 95% CI = -39.5, -31.8). CONCLUSIONS: For low-risk women, both scenarios result in safe outcomes for mothers and babies. However, fewer operative deliveries and medical resources were used in collaborative care.     

Fascial dehiscence after trauma laparotomy: a sign of intra-abdominal sepsis

Fascial dehiscence (FD) after trauma laparotomy is associated with technical failure, wound sepsis, or intra-abdominal infection (IAI). The association of IAI with FD is inadequately evaluated. Knowing about its presence is essential to guide clinical diagnosis and management. Our objective was to identify the incidence and risk factors of IAI in patients with FD. We performed a medical record review of 55 trauma patients with FD. Patients with IAI were compared to patients without IAI and FD patients to all trauma laparotomy patients during the same period. Statistical significance was at P < 0.05. Thirty-nine (71%) FD patients had IAI, significantly higher than all trauma laparotomies (4.6%, P < 0.0001). Only 31 per cent of patients underwent laparotomy and drainage while 69 per cent received CT-guided percutaneous drainage followed by expectant management. Similarly, 33 per cent of the non-IAI group had operative management. No differences were found between the two groups in any of the examined factors. The majority of trauma patients with FD have IAI. No clinical or laboratory factors help identify FD patients likely to have IAI. Therefore, FD should be viewed as a sign of possible underlying IAI. Appropriate radiographic imaging or direct visualization of the entire abdominal cavity should be pursued before managing the dehisced fascia.     

Factitious oxygen desaturation after isosulfan blue injection

Profound pulse oximetery desaturations are observed following isosulfan blue dye injection during breast sentinel node biopsy. The objective of this study was to examine the effect isosulfan dye has on oxygenation status and the reliability of pulse oximetery in evaluating this parameter. After study design, institutional review board approval was obtained. A prospective 5-month study was performed between January and April 2002. Twenty-one women with invasive breast cancer were monitored during breast sentinel node biopsies. Twenty-two operative cases were analyzed by pulse oximetry and arterial catheterization to record oxygen saturation. Time intervals of analysis were 0, 5, 10, 20, 30, and 40 minutes following injection of isosulfan blue dye. Simultaneous pulse oximetry and arterial blood gas analysis allowed comparison of indirect oximetry oxygen saturation (SpO2) to actual arterial oxygen saturation (SaO2). SpO2 values were decreased from baseline values at 10, 20, and 30 minutes without decrease in SaO2 saturation (P < 0.001). The mean oximetry SpO2 desaturation was 5.6 per cent, with a range to 9 per cent. After injection with isosulfan blue dye, a significant SpO2 desaturation occurs. Clinicians must be aware of the factitious effect isosulfan blue dye has on SpO2 monitoring, to assess accurately the oxygenation status of the anesthetized patient.     

Portal vein thrombosis following splenectomy: identification of risk factors

Portal vein thrombosis (PVT) following splenectomy is a potentially life-threatening complication, and the true incidence of PVT in splenectomized patients is unknown. The objective of this study was to determine the incidence of symptomatic PVT after splenectomy. The hospital database was searched to identify cases of PVT associated with splenectomy from January 1990 to May 2002. Six hundred eighty-eight patients underwent splenectomy during this period, 321 of them for hematologic diseases. Eleven of the 688 patients had PVT associated with splenectomy, and the charts of these patients were reviewed. Six patients developed PVT after splenectomy. Five had hematologic diseases. Symptoms were abdominal pain (6), ileus (5), fever (3), or diarrhea (2). Diagnosis was confirmed by computed tomography (CT) (4), duplex ultrasonography (1), and magnetic resonance imaging (1). The indications for splenectomy included hemolytic anemia (3), thalassemia (1), and myelofibrosis (1). One patient had an incidental splenectomy during gastrectomy. There were four laparoscopic and two open splenectomies. The median interval between splenectomy and diagnosis of PVT was 40 days (range, 13-741). One patient died of pulmonary embolism. Five of six patients with postsplenectomy PVT had splenomegaly and hemolysis. We conclude that the risk of PVT is higher in patients with hematologic conditions associated with splenomegaly and hemolysis.     

Magnetization transfer contrast imaging in Niemann pick type C mouse liver

PURPOSE: To investigate livers of mice afflicted with Niemann Pick type C (NP-C) disease using magnetization transfer contrast (MTC) imaging and to test the hypothesis that the MT ratio reproducibly changes during disease progression. BACKGROUND: NP-C is a heritable defect of lipid metabolism that results in the accumulation of unesterified cholesterol and gangliosides in virtually all cells. Symptoms predominate in brain and liver, which have high endogenous rates of lipid turnover. It is fatal to children, usually early in the second decade of life. Previous work has shown that the efficiency of magnetization transfer (MT) can be affected by cholesterol and collagen in tissues. The MT ratio (MTR) was calculated and compared during growth and therapy of diseased and control mice. RESULTS: Significant differences in the MTR were observed between livers of diseased and control mice. These ratios were consistent with collagen deposition associated with fibrosis, and not the accumulation of unesterified cholesterol in this organ. CONCLUSION: These results indicate that MTC imaging may have clinical potential for monitoring progression and therapy in NP-C disease.