Risk factors and obstetric complications associated with macrosomia.

OBJECTIVE: Macrosomia is associated with adverse maternal outcomes. The objective of this study was to characterize the epidemiology of macrosomia and related maternal complications. METHOD: Live births (146,526) were identified between 1995 and 1999 in the Kaiser Permanente Medical Care Program's Northern California Region (KPMCP NCR) database. Bivariate and multivariate analyses were performed for risk factors and complications associated with macrosomia (birth weight >4500 g). RESULT: Male infant sex, multiparity, maternal age 30-40, white race, diabetes, and gestational age >41 weeks were associated with macrosomia (p<0.001). In bivariate and multivariate analyses, macrosomia was associated with higher rates of cesarean birth, chorioamnionitis, shoulder dystocia, fourth-degree perineal lacerations, postpartum hemorrhage, and prolonged hospital stay (p<0.01). CONCLUSION: Macrosomia was associated with adverse maternal outcomes in this cohort. More research is needed to determine how to prevent complications related to excessive birth weight.     

The hospital as an enterprise: management strategies

After introducing the context in which health systems exist in developing as well as in industrialized countries, the author describes the role that hospitals are expected to play as 'enterprises'. The rationale behind such a role is explored and the experience so far available discussed. Evidence from several developing countries suggests caution and tends to discourage radical and indiscriminate introduction of market‐oriented reforms, which international donors seem to be spearheading in Africa's health systems. It is likely, however, that a limited, gradual introduction of selected elements of these reforms (such as some aspects of contracting out, managerial decentralization, the split between purchasing and providing functions) may find its place and eventually have a positive impact on the performance of the health systems. But the 'mystique of markets' must not be allowed to deprive public hospitals of the sense of social utility and of the caring ethos which are essential requisites of a meaningful and effective public health system.     

Harvey Cushing's postoperative sketches of pediatric brain tumors

Harvey Cushing was a man of many talents. Not only was he a premier surgeon and scientist, but a prolific author and artist as well. In this paper, we present two postoperative sketches of pediatric brain tumors drawn by Dr. Cushing. These sketches are representative of drawings which accompany many of his operative notes at the Peter Bent Brigham Hospital. About 25% of Cushing's surgical sketches depict operations performed on children. The most commonly drawn childhood tumors were craniopharyngiomas and gliomas of the brain stem and cerebellum. These drawings reveal how Cushing maintained detailed records of his surgical experience. It is clearly evident from these records that Dr. Cushing gained substantial experience in the treatment of pediatric brain tumors.     

医疗器械包装设计浅谈

本文介绍了医疗器械之无菌包装系统的设计之关键要素和要求,介绍了目前流行的灭菌方式以及对无菌包装系统的要求和影响。本文最后还列举了常见的医疗器械包装系统。     

Intracerebral temperature monitoring in severely head injured patients

Summary In a series of 6 severely head injured patients, intraventricular as well as rectal, bladder and jugular vein temperature is recorded. The relationship between these temperatures in different conditions is evaluated. Intracerebral temperature is 0.5±0.2 °C (mean ± SD) higher than bladder temperature except in conditions such as brain death. It is concluded that rectal temperature is not representative and therefore not a good alternative to the measurement of brain temperature. More data on human intracerebral temperature are mandatory as well as prospective studies correlating intracerebral temperature with final outcome in head injury.     

甲基强的松龙冲击疗法治疗重型脱髓鞘脑病患者的护理

采用大剂量甲基强的松龙治疗脱髓鞘脑病患者１５例。在治疗过程中，积极预防应激性溃疡，加强呼吸道及人工冬眠护理。经５次治疗，１４例症状明显改善。     

Posterior segment eye-surgery in day care?

Day care is generally accepted in anterior segment eye-surgery. In the Rotterdam Eye Hospital this option was also considered for posterior segment surgery. We were interested in the opinion, of patients on this matter and therefore asked patients, who were admitted for posterior segment eye-surgery, to answer a questionnaire. The major question was: ‘If your physician had given his permission, do you think it would have been possible for you to go home on the evening after surgery?’. Other questions evaluated problems in organising assistance at home and transportation to the out-patient clinic as well as circumstances after the operation, such as pain, nausea, dizziness and anxiety. Eighty-one out of 87 patients responded: 56% answered ‘eyes’ and 44% ‘no’ to the major question. Relating the answer to the major question to medical data and to answers to the other questions, we found organizational problems at home and anxiety to have a statistical significant relation with a negative answer. Clinical factors like age, American Society of Anesthesiologists (ASA)-class, diabetes mellitus (including insulin-dependant), type of anesthesia, time of the day the surgery was finished, duration of surgery, pain, nausea or dizziness were not signficantly related. The number of patients involved in this study, however, is too small to draw conclusions on specific subgroups of patients.     

The therapeutic value of vasodilator prostaglandins in multiple organ failure associated with sepsis

There is considerable evidence from animal and human studies of sepsis and acute lung injury that prostacyclin and PGE₁ may have a beneficial effect on tissue perfusion with a reduction in the severity of tissue damage associated with these disorders. As yet, there are no good data from controlled clinical trials that these agents improve survival and it is not clear whether in the future such data will be forthcoming. Nevertheless, using various physiological end-points, both prostaglandins seem to be beneficial in sepsis and when used in combination with the whole process of Intensive Therapy, may contribute to the survival of some cases. Although the assessment of combinations of agents designed to inhibit mediator release might be more useful, it remains to be seen whether the relatively insensitive controlled clinical trial, with survival as its endpoint, is the appropriate tool for assessing efficacy in the ITU. Perhaps, the consensus approach has something to offer in this situation!     

Can a clinician predict the technical equipment a patient will need during intensive care unit treatment? An approach to standardize and redesign the intensive care unit workstation

The technical equipment of today's intensive care unit (ICU) workstation has been characterized by a gradual, incremental accumulation of individual devices, whose presence is dictated by patient needs. These devices usually present differently designed controls, operate under different alarm philosophies, and cannot communicate with each other. By contrast, ICU workstations could be equipped permanently and in a standardized manner with electronically linked modules if the attending physicians could reliably predict, at the time of admission, the patient's equipment needs. Over a period of 3 1/2 months, the doctors working in our 20-bed surgical ICU made 1,000 predictions concerning outcome, equipment need, duration of artificial ventilation, and duration of hospitalization for 300 recently admitted patients. The interviews were made within the first 24 hours after admission. The doctors being interviewed were usually (i.e., in over 90% of cases) unfamiliar with the patient. Information concerning the patient's general state of health, special pre-ICU events, and complications was offered to the interviewed clinician because this information represents standard admission data. It was found that the equipment need (represented by two different setups, high tech and low tech) could be predicted most reliably (96.4% correct predictions) compared with a prediction on outcome of ICU treatment (94.5%), on duration of artificial ventilation (75.4%), and on duration of stay (43.4%). There was no significant (p>0.05) difference in the reliability of predictions between residents and consultants. Factors influencing the postoperative equipment need varied with surgical specialty. The general state of health, as indicated by the ASA classification (p<0.001), and the specific intervention (all multiple-valve replacements needed the high-level equipment standard) appeared to be most important in cardiac surgery, while a state of septicemia was important in general surgery (p<0.001). Our findings suggest that ICU workstations may be standardized into at least two types.