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Biomedical subjects

M C Klein

Publications and source records attributed to M C Klein.

At least 37 records · Page 2Linked to original sources
PubMed1997

How can second-stage management prevent perineal trauma? Critical review.

OBJECTIVE: To learn which factors influencing perineal integrity were modifiable by physicians and pregnant women. DATA SOURCES: Medical, nursing, and midwifery literature was searched mainly for randomized controlled trials. STUDY SELECTION: We chose articles on perineal trauma pattern, sexual dysfunction or satisfaction, urinary incontinence, and pelvic floor function. We identified 80 papers and studied 16 in detail. SYNTHESIS: Five factors affected perineal integrity: episiotomy, third-trimester perineal massage, mother's position in second-stage labour, method of pushing, and administration of epidural analgesia. Episiotomy does not improve perineal outcomes when used routinely. Third-trimester perineal massage was discussed only in inadequate studies. Studies comparing position in birth chairs and recumbent versus upright positions were inadequate for making firm recommendations. Studies of methods of pushing and use of epidural analgesia were limited and uncontrolled; no recommendations were possible. CONCLUSION: Only limiting episiotomy can be strongly recommended. In the absence of strong data to the contrary, women should be encouraged to engage in perineal massage if they wish and to adopt the birth positions of their choice. Caretakers should be aware of the possibility of interfering with placental function when women hold their breath for a long time when pushing.

Delivery, Obstetric↗
PubMed1996

Controversies surrounding the administration of vitamin K to newborns: a review.

OBJECTIVE: To determine (1) the most effective method of administering vitamin K to infants to prevent hemorrhagic disease of the newborn (HDNB) and (2) the safest method, in light of preliminary evidence suggesting that intramuscular administration of vitamin K is associated with childhood cancer. DATA SOURCES: A MEDLINE search of articles published between Jan. 1, 1991, and Apr. 30, 1994, with the use of MeSH terms "hemorrhagic disease of the newborn", articles were limited to those involving human subjects, from birth to adolescence, and to articles from journals indexed through Index Medicus and written in English. References of all articles found through the initial search, the earliest of which was published in 1967, were also reviewed. STUDY SELECTION: Six controlled trials met the selection criteria: a minimum 4-week follow-up period, a minimum of 60 subjects and a comparison of oral and intramuscular administration or of regimens of single and multiple doses taken orally. All retrospective case reviews were evaluated. Because of its thoroughness, the authors selected a meta-analysis of almost all cases involving patients more than 7 days old published from 1967 to 1992. Only five studies that concerned safety were found, and all of these were reviewed. DATA EXTRACTION: In controlled trials, the risk of HDNB caused by vitamin K deficiency among infants receiving different regimens of vitamin K; in case studies, method of vitamin K administration and incidence of hemorrhagic disease; and in studies concerning safety, odds ratios and relative risks of childhood cancer following intramuscular administration of vitamin K. DATA SYNTHESIS: Vitamin K (1 mg, administered intramuscularly) is currently the most effective method of preventing HDNB. The previously reported relation between intramuscular administration of vitamin K and childhood cancer has not been substantiated. An oral regimen (three doses of 1 to 2 mg, the first given at the first feeding, the second at 2 to 4 weeks and the third at 8 weeks) may be an acceptable alternative but needs further testing in large clinical trials. CONCLUSION: There is no compelling evidence to alter the current practice of administering vitamin K intramuscularly to newborns.

Administration, Oral↗
PubMed1995

Physicians' beliefs and behaviour during a randomized controlled trial of episiotomy: consequences for women in their care.

OBJECTIVE: To evaluate whether physicians' beliefs concerning episiotomy are related to their use of procedures and to differential outcomes in childbirth. DESIGN: Post-hoc cohort analysis of physicians and patients involved in a randomized controlled trial of episiotomy. SETTING: Two tertiary care hospitals and one community hospital in Montreal. PARTICIPANTS: Of the 703 women at low risk of medical or obstetric problems enrolled in the trial we studied 447 women (226 primiparous and 221 multiparous) attended by 43 physicians. Subjects attended by residents or nurses were excluded. MAIN OUTCOME MEASURES PATIENTS: intact perineum v. perineal trauma, length of labour, procedures used (instrumental delivery, oxytocin augmentation of labour, cesarean section and episiotomy), position for birth, rate of and reasons for not assigning women to a study arm, postpartum perineal pain and satisfaction with the birth experience, physicians: beliefs concerning episiotomy. RESULTS: Women attended by physicians who viewed episiotomy very unfavorably were more likely than women attended by the other physicians to have an intact perineum (23% v. 11% to 13%, p < 0.05) and to experience less perineal trauma. The first stage of labour was 2.3 to 3.5 hours shorter for women attended by physicians who viewed episiotomy favourably than for women attended by physicians who viewed episiotomy very unfavorably (p < 0.05 to < 0.01), and the former physicians were more likely to use oxytocin augmentation of labour. Physicians who viewed episiotomy more favourably failed more often than those who viewed the procedure very unfavourably to assign patients to a study arm late in labour (odds ratio [OR] 1.88, p < 0.05), both overall and because they felt that "fetal distress" or cesarean section necessitated exclusion of the subject. They used the lithotomy position for birth more often (OR 3.94 to 4.55, p < 0.001), had difficulty limiting episiotomy in the restricted-use arm of the trial and diagnosed fetal distress and perineal inadequacy more often than the comparison groups. The patients of physicians who viewed episiotomy very favourably experienced more perineal pain (p < 0.01), and of those who viewed episiotomy favourably and very favourably experienced less satisfaction with the birth experience (p < 0.01) than the patients of physicians who viewed the procedure very unfavourably. CONCLUSIONS: Physicians with favourably views of episiotomy were more likely to use techniques to expedite labour, and their patients were more likely to have perineal trauma and to be less satisfied with the birth experience. This evidence that physician beliefs can influence patient outcomes has both clinical and research implications.

Adult↗
PubMed1995

Studying episiotomy: when beliefs conflict with science.

In 1984, we proposed to study the need for episiotomy in the first North American randomized controlled trial on this subject. Getting funded and published proved to be difficult since we were questioning not only established views on episiotomy but also conventional beliefs about birth. During the 10-year process from conceptualization to publishing, we were confronted with the paradigm of birth as a pathological state and episiotomy as of trivial consequence. Although many of the reviewers of our study found the topic to be of little importance and some disputed its scientific merit, others saw the study as both important and well conceived. The tension between these views and the place of episiotomy in a wider context of maternity care forms the subject of this paper.

Attitude of Health Personnel↗
PubMed1994

Relationship of episiotomy to perineal trauma and morbidity, sexual dysfunction, and pelvic floor relaxation.

OBJECTIVE: Our purpose was to compare consequences for women of receiving versus not receiving median episiotomy early and 3 months post partum on the outcomes perineal pain, urinary and pelvic floor functioning by electromyography, and sexual functioning and to analyze the relationship between episiotomy and third- and fourth-degree tears. STUDY DESIGN: A secondary cohort analysis was performed of participants within a randomized clinical trial, analyzed by type of perineal trauma and pain, pelvic floor, and sexual consequences of such trauma, while controlling for trial arm. The study was conducted in three university or community hospitals; 356 primiparous and 341 multiparous women were studied. RESULTS: Early and 3-month-postpartum perineal pain was least for women who gave birth with an intact perineum. Spontaneous perineal tears were less painful than episiotomy. Sexual functioning was best for women with an intact perineum or perineal tears. Postpartum urinary and pelvic floor symptoms were similar in all perineal groups. At 3 months post partum those delivered with an intact perineum had the strongest pelvic floor musculature, those with episiotomy the weakest. Among primiparous women third- and fourth-degree tears were associated with median episiotomy (46/47). After forceps births were removed and 21 other variables potentially associated within such tears were controlled for, episiotomy was strongly associated with third- and fourth-degree tears (odds ratio +22.08, 95% confidence interval 2.84 to 171.53). Physicians using episiotomy at high rates also used other procedures, including cesarean section, more frequently. CONCLUSION: Perineal and pelvic floor morbidity was greatest among women receiving median episiotomy versus those remaining intact or sustaining spontaneous perineal tears. Median episiotomy was causally related to third- and fourth-degree tears. Those using episiotomy at the highest rates were more likely use other interventions as well. Episiotomy use should be restricted to specified fetal-maternal indications.

Adolescent↗
PubMed1992

Does episiotomy prevent perineal trauma and pelvic floor relaxation?

OBJECTIVE: To compare the outcomes of the current practice of liberally or routinely employing episiotomy to prevent perineal tears and pelvic floor relaxation (control group) to a policy of restricting episiotomy use to specific fetal and maternal indications (experimental group). DESIGN: A randomized controlled trial (RCT). SETTING: Three university hospitals in Montreal. SUBJECTS: Seven hundred three low-risk women enrolled at 30 to 34 weeks of gestation were randomized late in labor to the designated trial arm, by parity, and followed up to 3 months postpartum. MAIN OUTCOME MEASURES: Antepartum and postpartum information on perineal trauma and pain, pelvic floor symptoms (urinary incontinence), and sexual activity was collected through the use of standard questionnaires; pelvic floor function was measured by electromyographic (EMG) perineometry. RESULTS: Restricting episiotomy use in primiparous women was associated with similar sutured perineal trauma to the liberal or routine approach. Multiparous women in the restricted episiotomy group more often gave birth with an intact perineum (31% compared with 19%, odds ratio (OR) = 1.85, 95% confidence interval (CI) = 1.09 to 3.16). All but one 3rd/4th-degree perineal tear was associated with median episiotomy (46 of 47 in primiparous women and 6 of 6 among multiparous women). No difference between trial groups was found in postpartum perineal pain, antepartum and 3-month postpartum EMG perineometry, and urinary and pelvic floor symptoms. CONCLUSIONS: We found no evidence that liberal or routine use of episiotomy prevents perineal trauma or pelvic floor relaxation. Virtually all severe perineal trauma was associated with median episiotomy. Restriction of episiotomy use among multiparous women resulted in significantly more intact perineums and less perineal suturing.

Adult↗
PubMed1985

Pressor and cardioaccelerator effects of gamma MSH and related peptides.

We have recently demonstrated that the hypertensinogenic and natriuretic actions of ACTHI-39 can be found in a non-steroidogenic fragment of ACTH, ACTH4-10. These effects of ACTH or ACTH4-10 may be due to their ability to act as weak agonists of gamma MSH. gamma MSH is found in the 16K N-terminus of pro-opiocortin, and contains a sequence analogous to ACTH4-10, gamma MSH3-9. We investigated the cardiovascular effects of gamma 2MSH, gamma MSH3-9, and sterically restricted analogs of ACTH4-10. The results indicate that gamma MSH3-9, had essentially the same activities as ACTH4-10. The addition of five other amino acid residues to gamma MSH3-9 (gamma 2MSH) resulted in significant enhancement of pressor and cardioaccelerator activity. Steric restriction of the ACTH4-10 sequence by the substitution of a D-Phe in place of an L-Phe residue in position #7, or cyclization of the peptide by a half-Cys4, half Cys10 intramolecular disulfide-bridge derivatization, resulted in increased cardiovascular activities. Based on these data, the cardiovascular actions of ACTH4-10, gamma MSH3-9, and gamma 2MSH are predicted to be due to the assumption of a reverse-turn three-dimensional structure. The additional residues in gamma 2MSH appear to specifically enhance the cardiovascular activities of gamma MSH3-9. The results suggest the existence of a new class of hypophyseal peptides with cardiovascular activities, which require the assumption of a defined three-dimensional structure.

Adrenocorticotropic Hormone↗
PubMed1985

Gamma-2MSH is natriuretic in the rat.

Previous reports suggest that peptides containing an amino acid sequence similar to that of ACTH-(4-10) increased Na excretion in the rat. gamma 2MSH contains such a sequence. An in vivo rat bioassay for natriuretic factors was employed to demonstrate the natriuretic action of gamma 2MSH. A significant natriuretic effect was observed, with a peak response 30-50 min following the bolus injections of 0.64, 6.4 or 64 pmol, but not with smaller or larger amounts of gamma 2MSH. A kaliuretic and diuretic action of gamma 2MSH was not consistently evident. gamma MSH may represent an endogenous compound involved in the physiological regulation of Na excretion.

Animals↗
PubMed1985

Natriuretic peptides derived from pro-opiocortin.

Natriuresis in response to hypertonicity, volume loads, or high sodium diets has been proposed to be mediated by the release of a humoral factor(s), and controlled by the central nervous system. We have determined that the natriuretic activity of ACTH or alpha MSH resides in a common sequence, ACTH(4-10)/alpha MSH(4-10). Steric restriction of this peptide by replacement of an L-Phe residue with a D-Phe produced a superagonist. Gamma-2 MSH is a peptide derived from the 16K N-terminus of pro-opiocortin, which contains an ACTH(4-10)-like sequence. The natriuretic effect of gamma-2 MSH was maximal between 0.64 pmole to 64 pmole. Doses greater than 128 pmole produced no significant effects on renal sodium excretion. The regulated release of gamma MSH peptides may contribute to CNS regulation of renal sodium excretion.

Adrenocorticotropic Hormone↗
PubMed1983

Studies on the mechanism of the cardiovascular action of central injections of histamine.

The role of the sympathetic nervous system in the mediation of cardiovascular function, following administration of histamine centrally was investigated. Intracerebroventricular (i.c.v.) injections of histamine into the lateral ventricle of conscious rats caused a dose-dependent increase in blood pressure as well as a dose-dependent fall in heart rate. The pressure and heart rate responses were both attenuated by pretreatment with chlorpheniramine. Peripheral blockade of autonomic ganglia with hexamethonium failed to block the centrally-mediated pressor response to histamine. Peripheral chemical sympathectomy with 6-hydroxydopamine also did not inhibit the pressor response to histamine. In this latter group of animals the pressor response to histamine was potentiated. It is concluded that in the conscious rat, increased in blood pressure resulting from central stimulation with histamine are not mediated solely through the activation of the sympathetic nervous system and are, at least in part, due to the release of a vasopressor substance.

Animals↗
PubMed1983

[Satisfaction of couples towards birth when using a birthing room or the traditional delivery room.].

Following a random distribution, two groups of couples, users of the B.R. (birth room) and users of the T. R. (traditional room) were compared in terms of each partner's feeling of satisfaction in relation to the giving birth process. Statistical analysis of the means of the B.R. and T.R. fathers, of the B.R. and T.R. mothers, three days after delivery and three months later, yields the following results : following birth, both fathers and mothers of the B.R. group indicate a higher feeling of satisfaction than the T.R. mothers and fathers in relation to the environment. Mothers of the B.R. and T.R. are equally satisfied in relation to the amount of time spent with their infant, whereas fathers of the B. R. are more satisfied than their spouses and more satisfied than the T.R. fathers. Three months later, the only difference to these above-mentioned results, is the higher degree of satisfaction of B.R. mothers over T.R. mothers in relation to the length of contact with their infant right after birth.

English Abstract↗
PubMed1981

Evidence for a role of endogenous histamine in central cardiovascular regulation: inhibition of histamine-N-methyltransferase by SKF 91488.

Studies were undertaken to determine whether changes in endogenous brain histamine levels would occur concomitant with centrally mediated cardiovascular responses. All experiments were performed on conscious rats since previous findings by others have indicated anesthesia alters cardiovascular responses. Rats were injected intracerebroventricularly (i.c.v.) with SKF 91488 (10-100 micrograms), a potent inhibitor of histamine-N-methyltransferase, while blood pressure and heart rate were recorded. In all animals, there was a dose-related increase in mean arterial blood pressure and a fall in mean heart rate after this treatment. These responses were very similar to the cardiovascular effects observed after i.c.v. injections of exogenous histamine (0.1-5.0 micrograms). Within 5 min after i.c.v. injection of SKF 91488, there was a statistically significant increase in hypothalamic histamine levels; within 15 min, histamine levels were significantly elevated in the cerebral cortex, hypothalamus and the remainder of the brain. In other experiments, cardiovascular responses after i.c.v. injection of histamine were potentiated by prior treatment with SKF 91488. It is concluded that brain histamine is involved in central cardiovascular regulation and that the hypothalamus may be a site of action. These results also imply a neurotransmitter role for histamine in the mammalian brain.

Animals↗
PubMed1977

Can perinatal regionalization be reconciled with family-centered maternal care?

Perinatal regionalization is necessary because of the enhanced quality of the outcome of high-risk pregnancies in hospitals that either have their own units or who use such centers regularly. Antenatal transfer of high-risk mothers is necessary but creates potential problems relating to separation from spouse and family. These can be minimized through closer working relationships between family physicians and perinatologists. The family physician has a responsibility to help the perinatal center increase its sensitivity to the needs of families that wish to be more involved in maternal care--even in a high-risk situation. Separation of the sick neonate from mother and family raises a set of similar but more severe problems that can also be modified by active involvement of the family physician with the perinatal team. Awareness of the interactional issues consequent to separation and attachment failures will help the family physician to anticipate and modify these unfortunate consequences of both the high-risk pregnancy itself and the neonate separated from the mother/family.

Counseling↗
PubMed1975

Non-treatment of screened children with intermediate blood lead levels.

An aggressive screening and follow-up program for children at risk for lead poisoning was conducted by a nurse practitioner in a small family practice unit. Subsequent venous blood lead determinations untreated cases show the natural fall in lead level over 12 to 18 months. Many of these children would have been chelated by others, yet individualized, specific, personalized care by a nurse practitioner permitted monitoring without treatment even in persistently leaded environments. No chelation therapy was necessary until the third summer, when coincident with a long, hot, dry season, the city's abatement system because nonfunctional. Non-treatment requires close follow-up, a relatively small population, and cooperation from the city.

Chelating Agents↗