RPA an advocate for excellence in nephrology in 1999.
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Clinical Competence↗
Biomedical subjects
D Singer
Publications and source records attributed to D Singer.
Anal sphincter integrity and function influences outcome in rectovaginal fistula repair.
PURPOSE: Traumatic sphincter disruption frequently is associated with a rectovaginal fistula, but the effect of a persistent sphincter defect on the outcome of rectovaginal fistula repair is poorly documented. We analyzed the outcome of rectovaginal fistula repairs based on preoperative sphincter status. PATIENTS AND METHODS: We identified 52 women who underwent 62 repairs of simple obstetrical rectovaginal fistulas between 1992 and 1995. Fourteen patients (27 percent) had preoperative endoanal ultrasound studies and 25 (48 percent) had anal manometry studies. Follow-up was by mailed questionnaire in 36 patients (69 percent) and by telephone interview in 12 (23 percent), for a total response rate of 92 percent. Median age was 30.5 (range, 18-70) years, and median follow-up was 15 (range, 0.5-123) months. Twenty-five patients (48 percent) complained of varying degrees of fecal incontinence before surgery. There were 27 endorectal advancement flaps and 35 sphincteroplasties (28 with and 8 without levatoroplasty). RESULTS: Success rates were 41 percent with endorectal advancement flaps and 80 percent with sphincteroplasties (96 percent success with and 33 percent without levatoroplasty; P = 0.0001). Endorectal advancement flap was successful in 50 percent of patients with normal sphincter function but in only 33 percent of patients with abnormal sphincter function (P = not significant). For sphincteroplasties, success rates were 73 vs. 84 percent for normal and abnormal sphincter function, respectively (P = not significant). Results were better after sphincteroplasties vs. endorectal advancement flaps in patients with sphincter defects identified by endoanal ultrasound (88 vs. 33 percent; P = not significant) and by manometry (86 vs. 33 percent; P = not significant). Poor results correlated with prior surgery in patients undergoing endorectal advancement flaps (45 percent vs. 25 percent; P = not significant) but not sphincteroplasties (80 vs. 75 percent; P = not significant). CONCLUSIONS: All patients with rectovaginal fistula should undergo preoperative evaluation for occult sphincter defects by endoanal ultrasound or anal manometry or both procedures. Local tissues are inadequate for endorectal advancement flap repairs in patients with sphincter defects and a history of previous repairs. Patients with clinical or anatomic sphincter defects should be treated by sphincteroplasty with levatoroplasty.
Adolescent↗
[Thermoregulation and anesthesia].
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Anesthesia↗
A study and comparative analysis of effective and ineffective leadership skills of physician and non-physician health care administrators.
This paper explores and compares, at both micro and macro levels, the leadership skills of effective and ineffective managers in a health care setting. In addition, it compares the leadership skills of physician and non-physician health care administrators at both levels. The results indicate that effective managers have significantly different leadership skill profiles than ineffective managers. Furthermore, effective managers have a more complete set of skills and are not as likely to rely on one type of skills as the ineffective managers. In addition, no substantial evidence was found to support prior assertions that physician administrators would be deficient in leadership skills.
Female↗
Reasons for first teen pregnancies predict the rate of subsequent teen conceptions.
OBJECTIVE: To identify reasons for inconsistent contraceptive use that antedate conception and continue to predispose participants in adolescent-oriented maternity programs to unsafe sexual practices after delivery. We hypothesized that teens who attributed their failure to use contraceptives before their first conception exclusively to concerns about their side effects and/or their own lack of motivation to prevent conception would report less consistent contraceptive use and more repeat conceptions than would teens who attributed their previous failure to use contraceptives to their lack of capacity to do so. METHOD: We conducted a 2-year, prospective, longitudinal study of contraceptive use and repeat conceptions in a racially/ethnically diverse population of poor 13- to 18-year-olds. The 198 study participants were enrolled consecutively during their first pregnancies from an adolescent-oriented maternity program. RESULTS: The majority (84%) of the teens attributed their failure to use contraceptives before their first pregnancy partially to a lack of capacity to do so. As hypothesized, these teen mothers were significantly more likely to use hormonal contraceptives (85% vs 62%), (particularly Norplant, 47% vs 19%) and less likely to conceive again (13% vs 41%). Most teens attributed their inconsistent contraceptive use during the postpartum study period to three factors: side effects, plans to abstain from sexual intercourse, and their lack of motivation to postpone additional childbearing. CONCLUSIONS: The reasons teen mothers give for not using contraceptives consistently before their first pregnancies predict the occurrence of subsequent conceptions during adolescence. Those who attribute their previous failure to use contraceptives consistently to side-effect concerns and their own lack of motivation to postpone childbearing are least likely to use hormonal contraceptives after delivery and most likely to conceive again. Our findings suggest that future research should focus on the development of more effective interventions for preventing repeat conceptions among adolescent mothers who had the capacity to prevent their first pregnancies.
Adolescent↗
The effect of monetary incentives and peer support groups on repeat adolescent pregnancies. A randomized trial of the Dollar-a-Day Program.
OBJECTIVES: To test the hypotheses that (1) a monetary incentive promotes peer-support group participation; and (2) peer-support group participation decreases repeat adolescent pregnancies. DESIGN: Two-year, prospective, randomized controlled trial. SETTING: Denver, Colo. PARTICIPANTS: A total of 286 primiparous girls younger than 18 years, whose infants were younger than 5 months. INTERVENTION: Participants were randomized to 4 interventions: monetary incentive and peer-support group, peer-support group only, monetary incentive only, or no intervention. MAIN OUTCOME MEASURES: Consistency of participation in planned intervention and repeat pregnancy. RESULTS: Participation in interventions was generally low. Hypothesis 1 was supported: 58% of those offered a monetary incentive participated in the peer-support groups, compared with 9% of those who were not offered the incentive. Hypothesis 2 was rejected: the peer-support group experience failed to prevent repeat pregnancies. The incidence of second pregnancies at 6 months (9%, 22/248), at 12 months (20%, 49/248), at 18 months (29%, 72/248), and at 24 months (39%, 97/248) following delivery did not vary significantly in relation to intervention strategy. Background sociodemographic characteristics significantly affected the timing of subsequent conceptions but not intervention participation. CONCLUSION: A monetary incentive draws adolescent mothers to sites where they can discuss the costs and benefits of contraception and conception with knowledgeable adults and supportive peers. These discussions do not prevent repeat pregnancies. Further studies are needed to determine if an intervention that produces substantive changes in the daily living environment will eliminate the sexual practices that are responsible for the high rate of repeat pregnancy in this population.
Adolescent↗
Airway humidification in mechanically ventilated neonates and infants: a comparative study of a heat and moisture exchanger vs. a heated humidifier using a new fast-response capacitive humidity sensor.
OBJECTIVE: To study the efficiency of a heated humidifier and a heat and moisture exchanger in mechanically ventilated neonates and infants. DESIGN: Prospective, controlled, clinical study. SETTING: University pediatric intensive care unit. PATIENTS: Forty neonates and infants who needed mechanical ventilation were enrolled in the study. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: A heat and moisture exchanger and active airway humidification were alternately used in the same patients to exclude interindividual differences in airway humidification. Airway humidity was measured by a new fast-response capacitive humidity sensor which measures airway humidity with an acquisition rate of 20 Hz throughout the respiratory cycle. The humidity sensor was placed at the endotracheal tube adapter. Measurements were done at the beginning and at the end of three consecutive sessions of passive, active, and again passive airway humidification, each session lasting 6 hrs. There was no significant difference between mean inspiratory airway humidity with the heated humidifier (33.8 +/- 2.9 mg/L) and with the heat and moisture exchanger (34.0 +/- 2.6 mg/L). Moreover, the mode of airway humidification did not significantly influence body temperature or PCO2. No serious side effects such as endotracheal tube occlusion were observed. CONCLUSIONS: Passive airway humidification by a heat and moisture exchanger is effective in mechanically ventilated neonates and infants over a 6-hr period. However, the performance and safety of a heat and moisture exchanger in prolonged mechanical ventilation remain to be proven.
Costs and Cost Analysis↗
[Pseudotumoral tuberculous choroiditis].
It is presented a case of a secondary tumoral retinal detachment that clinical examination and all paraclinical investigation go for a choroidal malignant melanoma. The anatomopathological examination of the enucleated eyeball has surprisingly put in evidence some choroidal consumptive lesions.
Adult↗
Pattern of prenatal care and infant immunization status in a comprehensive adolescent-oriented maternity program.
OBJECTIVE: To examine the relationship between patterns of prenatal care utilization and the subsequent pattern of preventive infant health care utilization among patients in a comprehensive, multidisciplinary, adolescent-oriented maternity program. METHODS: We hypothesized that the mothers of incompletely immunized 8-month-olds were less compliant with their own prenatal care appointments than were mothers of fully immunized 8-month-olds. We retrospectively reviewed the medical records of 150 consecutively delivered infants and their adolescent mothers. Data concerning the pattern of prenatal and postnatal use of preventive health care services and potentially confounding maternal characteristics were collected. RESULTS: Of the 150 infants aged 8 months, 22 (14.7%) were incompletely immunized. Mothers of completely and incompletely immunized infants did not differ in age, school enrollment status, or compliance with prenatal appointments. However, the latter group initiated prenatal care later, obtained fewer prenatal visits, returned later for postpartum care, and were more likely to be black and to report inadequate family support after delivery. Three of the 5 characteristics entered a logistic regression function that predicted the risk of incomplete immunizations at 8 months of age: third-trimester initiation of prenatal care (odds ratio, 4.05; 95% confidence interval, 1.19-13.7), inadequate family support (odds ratio, 3.42; 95% confidence interval, 1.17-10.0), and black race (odds ratio, 3.14; 95% confidence interval, 1.19-8.69). The total model chi 2 was 15.8 (P < .001). CONCLUSIONS: Among patients in a comprehensive adolescent-oriented maternity program, the timing of the first prenatal visit helps to identify infants who are at increased risk for incomplete primary immunization status. Our findings favor preferential allocation of scarce, costly outreach services to infants born to adolescent mothers who enter prenatal care during the third trimester.
Adolescent↗
Absence of negative attitudes toward childbearing among pregnant teenagers. A risk factor for a rapid repeat pregnancy?
OBJECTIVE: To test the hypothesis that adolescent mothers who conceive again during the first postpartum year express more positive attitudes toward childbearing while pregnant than do adolescent mothers who postpone further childbearing. METHOD: Prospective, cross-sectional, population-based survey. DESIGN: A racially diverse group of 200 consecutively enrolled, poor, pregnant 13- to 18-year-old patients in an adolescent-oriented maternity program were interviewed to determine why they had not used contraceptives prior to the index conception. The study participants were followed up prospectively for the first postpartum year. The data analysis included t tests, chi 2 tests, analysis of variance, and logistic regressions. RESULTS: The repeat pregnancy rate was 11.5% during the first postpartum year. As hypothesized, those who became pregnant again were more likely to have expressed positive attitudes toward childbearing during the index pregnancy (60.9% vs 39.6%; P = .05; odds ratio = 2.38; 95% confidence interval, 0.96-5.90). In addition, those who conceived again were more likely to have had a prior miscarriage, dropped out of school, abused illicit substances, moved away from home, and reported inadequate family support during the index pregnancy, and were less likely to plan to use levonorgestrel (Norplant) following delivery. The best model for predicting repeat pregnancy included education status, postpartum plans for Norplant use, and miscarriage history. Having a positive attitude toward childbearing during pregnancy was not included in the final model because it did not contribute to the model or affect any of the other parameters in the model. CONCLUSIONS: The sexually active teenaged mother who does not use contraception poses a perplexing diagnostic dilemma. The differential diagnosis is a long, complex one that includes ambivalent feelings about postponing future childbearing. This study demonstrates an indirect association between positive attitudes toward childbearing during pregnancy and repeat adolescent pregnancy. Our finding that this association operates through common linkages between maternal educational and contraceptive plans and both positive attitudes toward childbearing and repeat adolescent pregnancy suggests that interventions specifically targeting these underlying causes could reduce the unsafe sexual practices that persist among the participants in comprehensive adolescent-oriented maternity programs.
Adolescent↗
Microcalorimetric measurements carried out on isolated tumorous and nontumorous tissue samples from organs in the urogenital tract in comparison to histological and impulse-cytophotometric investigations.
In this comparative study, microcalorimetric measurements were carried out on a total of 96 tumorous and nontumorous tissue samples taken from organs of the urogenital tract using a thermal activity monitor (TAM). Changes in the heat emission of the tissue samples were measured at 1-min intervals and graphically displayed as a function of time. The aim of the study was to compare the microcalorimetric results with impulse-cytophotometric and histological findings and provide evidence for the metabolic activity of tumorous and nontumorous tissue. In order to obtain the variation in metabolic activity, the maxima (Pmax) of the curves were determined as a value of the maximum thermal power of a tissue sample, the mean values (P) were determined by the mean thermal power and the contour integrals (W) were defined by the behavior of the energy reserves and their mobilization. The first part of the study was carried out to investigate whether tumorous and nontumorous tissue samples differ in general according to their metabolic activity. We discovered, using the parameters described above, that in general tumorous tissue exhibited a higher metabolic activity than nontumorous tissue samples. For example, both W and P in tumorous prostate tissue samples were eightfold higher and the (Pmax) value was 8.4-fold higher than in normal tissue. Additional investigations on testicle and kidney tissues were performed to find a possible correlation between microcalorimetric results and histological grading. We found that an increasing malignancy correlated with a higher metabolic activity of the tissue. Based upon these results we were able to differentiate the various histological gradings of these tumorous tissues by microcalorimetric measurements. The results show it is possible to differentiate between normal and tumorous tissue samples by microcalorimetric measurement based on the distinctly higher metabolic activity of malignant tissue. Furthermore, microcalorimetry allows a differentiation and classification of tissue samples into their histological grading. With the help of microcalorimetry, it might be possible in future to detect and record the metabolic processes of isolated tissue structures and changes in these activities as a result of medical intervention such as cytostatic treatment.
Aged↗
Why pregnant adolescents say they did not use contraceptives prior to conception.
OBJECTIVE: In this study we attempted to learn why childbearing adolescents failed to use contraceptives prior to conception. We hypothesized that among adolescents who elect to bear their children, positive and/or ambivalent feelings about having a baby are the most frequently cited reasons for not having used contraceptives. STUDY DESIGN: This is a cross-sectional, clinic-based survey of a racially and ethnically diverse group of 200 consecutively enrolled, poor, pregnant, 13-18-year-old patients in an adolescent-oriented maternity program. The participants completed a self-administered questionnaire which elicited information about environmental and personal risk factors for inconsistent use of contraceptives and information about the reasons they had not used contraceptives consistently prior to conception. Student's t-tests, Chi-square, and logistic regression analyses were used. RESULTS: The most frequently cited reasons for not using contraceptives prior to conception were: "I didn't mind getting pregnant" (20%) and "I wanted to get pregnant" (17.5%), followed by "I was using birth control but it didn't work (broke)" (12%), "I thought there was something wrong with me and I couldn't get pregnant" (9%) and "I just didn't get around to it" (9%). Teenagers who cited positive and/or ambivalent attitudes toward childbearing as their primary reason for not using contraceptives at the time of conception did not differ from others with regard to age, Medicaid status, gravidity, parity, frequency of living with parents, partner's age, depressive symptoms, or perceived family support. They were, however, more likely to have known the father of the baby for more than 6 months at the time of conception [odds ratio (OR) 2.53; 95% confidence interval (CI) 1.22-5.26) and to have dropped out of school (OR) 2.15; 95% CI 1.10-4.26]. CONCLUSIONS: The study hypothesis was supported. The absence of negative attitudes toward having babies rather than negative attitudes toward contraceptives is the most commonly cited reason for nonuse of contraceptives among childbearing adolescents. The results of this study may enable health care and social service providers to design more effective programs for preventing first and subsequent adolescent pregnancies.
Adolescent↗
High energy phosphates and direct calorimetry as predictive parameters for metabolic recovery of the rat liver following ischemia.
BACKGROUND AND METHODS: Alteration of the hepatocellular function following ischemic damage may play a crucial role in the limited recovery after reperfusion. In spite of numerous efforts, finding a simple technique for predicting recovery of the liver after ischemic damage is still an unresolved problem. During ischemic storage of isolated rat livers at 25 degrees C tissue concentrations of high energy phosphates and lactate were determined photometrically and interstitial pH was measured by glass electrodes. In comparison, the metabolic rate was measured continuously by direct calorimetry. In a second series of experiments these results were compared with functional recovery after ischemia and reperfusion. Following ischemic storage at 25 degrees C for 60, 120 or 240 min, the isolated livers were reperfused for 30 min in a non-recirculating system with a constant flow rate. During reperfusion functional recovery, as assessed by oxygen consumption and bile flow, was determined. At the end of reperfusion tissue samples were taken for biochemical analysis of adenine nucleotides. Furthermore, morphologic integrity was determined by electron microscopy. RESULTS: Whereas the ATP concentration drops within 60 min of ischemia to 6.9% of the control value without further significant change, the continuously measured metabolic rate as assessed by direct calorimetry decreases in an exponential manner. Accordingly, a better correlation of hepatocellular secretory function and calorimetrically measured heat output (r2 = 0.85; P < 0.001) was observed than with high energy phosphates (r2 = 0.56; P < 0.001). CONCLUSIONS: These data suggest that if the metabolism of the ischemic rat liver falls below a critical level, recovery is incomplete or impossible. Therefore, assessment of the global metabolic rate by direct calorimetry seems not only to be a very good predictor of recovery after ischemic damage but also a good tool in the laboratory for studies concerning the sequelae of ischemic metabolism and for improvement of tissue protection.
Adenine Nucleotides↗
Enterococcal endocarditis after extracorporeal shock wave lithotripsy for nephrolithiasis.
We report a case of enterococcal endocarditis following extracorporeal shock wave lithotripsy (ESWL) for ureteral stone. Although endocarditis following ESWL is very rare, transient bacteraemia occurs during ESWL. This case is a reminder that enterococcal endocarditis may follow innovative genitourinary procedures without appropriate prophylaxis.
Endocarditis, Bacterial↗
Five years of experience with percutaneous cannula for establishing venous bypass access in orthotopic liver transplantation.
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Adult↗
[Hydroxyurea, erythrocyte volumes and hemoglobin F].
Hydroxyurea is used in the treatment of sickle cell anemia and beta-thalassemia major to increase the content of hemoglobin F (HbF) and presumably ameliorate clinical symptoms. Under therapy with hydroxyurea an increase of the mean corpuscular volume (MCV) of the erythrocytes can be observed. To evaluate a possible estimation of the content of HbF using the increase of MCV under treatment with hydroxyurea, we measured MCV and HbF during therapy with hydroxyurea. The median MCV before therapy was 87.8 fl (range 74.3-95.7) and under hydroxyurea 104.1 fl (81.0-139.5), and the median HbF 1.8% (0.1-5.4). Although both MCV and HbF increased under treatment with hydroxyurea, a linear correlation between these two parameters was not detectable. Therefore, MCV cannot replace the measurement of HbF.
Erythrocyte Indices↗
Ventricular expression and circulating levels of insulin-like growth factor I in heart transplant recipients.
1. Insulin-like growth factor I is a major mediator of growth-promoting activities. We studied the ventricular insulin-like growth factor I gene expression at mRNA and peptide levels in 24 heart transplant recipients (14 children and 10 adults), using 'slot blot' hybridization with insulin-like growth factor I cDNA probe and a specific radioimmunoassay. 2. Ventricular insulin-like growth factor I mRNA was detected in all the cardiac transplant children but was below the limit of detection in the cardiac transplant adults. Ventricular insulin-like growth factor I levels were significantly higher in the transplant children [174 +/- 15 (SEM; range 39-950) pg/mg soluble protein] than in transplant adults [39 +/- 2 (range 14-85) pg/mg soluble protein, P < 0.01, n = 14]. Circulating levels of insulin-like growth factor I in the cardiac transplant children [164 +/- 10 (range 105-192) ng/ml] and adults [176 +/- 15 (range 126-244) ng/ml] were within normal ranges for children and adults. 3. These results suggest that the human heart is a site for insulin-like growth factor I production and provide support for an autocrine role for insulin-like growth factor I in the ventricle, despite cardiac denervation.
Adolescent↗