Biomedical subjects
Publications and source records attributed to P V Dilts.
A 49-year-old patient with breast cancer had a leiomyoma that rapidly enlarged shortly after she started therapy with tamoxifen. Exploratory laparotomy was necessary to confirm the diagnosis. The rapid growth may have resulted from the estrogen agonist properties of tamoxifen or alternatively by ovarian stimulation resulting in endogenous estrogen production.
The American Board of Obstetricians and Gynecologists recently issued a directive that education in breast disease be incorporated into all residency training programs. At the University of Michigan Medical Center, the Comprehensive Breast Care Center (BCC) provides the vehicle for the education and training of residents in the area of breast disease. The department of obstetrics and gynecology is fully integrated and participates actively in the care of patients in the BCC.
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Current problems leading to excessive stress in residency are presented and are compared with those of a generation ago. Solutions are proposed that can be summarized as follows: (1) commitment by the program director and chairman to resolving stress in residency and (2) flexibility by the American Board of Obstetrics and Gynecology and the Residency Review Committee. A general discussion is presented.
A formal curriculum for the teaching of bioethics was instituted within an obstetric and gynecologic residency program. The curriculum included an introductory lecture series, an ongoing series of case presentations, and occasional grand rounds on particular issues. An emphasis was placed on physician responsibilities within contemporary bioethical parameters. A summary of the first year of such an effort is presented.
Gentamicin is an aminoglycoside antibiotic frequently used in the treatment of mixed polymicrobial infections. Because patients with preeclampsia exhibit compromised renal function, decreased intravascular volume, and increased extravascular fluid, it was theorized gentamicin may be handled differently in normotensive versus preeclamptic patients. Eighteen patients with postpartum endometritis receiving gentamicin were divided into three treatment groups based on the presence and severity of preeclamptic symptoms. After the gentamicin steady state was achieved, serum samples were collected at 30, 150, and 450 minutes following completion of a timed 30-minute infusion. The mean half-life and gentamicin clearance in severe preeclamptic patients (3.15 hours and 91.5 ml/min) were significantly different from normotensive patients (2.38 hours and 135.9 ml/min) and mild preeclamptic patients (1.87 hours and 142 ml/min). No significant differences in volume of distribution were seen. A high correlation between elimination rate and distribution volume was noted in normotensive patients; however, a moderate correlation was seen in patients with preeclampsia. Therefore, alterations in renal function in patients with severe preeclampsia, and not changes in volume of distribution, may be the primary cause for delayed aminoglycoside elimination.
A brief survey was done in six major cities of parental complaints about family counseling offered at the time of the birth of a child with Down syndrome. Minimal parental expectations and counseling guidelines are discussed. The need for further parent-professional educational effort is emphasized.
Infants of 72 recently managed women with eclampsia before delivery were studied. Infants with gestational age of 36 weeks or less (56%) were analyzed separately from those infants of more than 36 weeks' gestation (44%). In addition, premature infants of eclamptic mothers were compared with 40 premature infants whose mothers did not have any medical complications. Intrauterine growth retardation was symmetrical in all seven infants whose mothers had eclampsia prior to 32 weeks. All neurological abnormalities were associated with abruptio placentae or intrauterine growth retardation. Among the preterm infants of eclamptic mothers and those of normotensive mothers, there was no significant difference in any commonly acquired laboratory data. Neonatal complications in premature infants of eclamptic mothers were frequent. However, neonatal complications of the low-birth weight infants were strikingly similar regardless of the presence of eclampsia. It is possible that most neonatal complications are consequence of prematurity, instead of a sole consequence of eclampsia. Observations from follow-up data (up to 4 years of age) suggest normal growth and development for infants of mothers with uncomplicated eclampsia.
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Although the recognition and treatment of preeclampsia theoretically should eliminate eclampsia, it has not disappeared and remains a substantial threat to maternal and fetal well-being. The therapy of choice for treatment and prevention of convulsions is magnesium sulfate (MgSO4 . 7H2O USP) and that for severe hypertension is intravenous hydralazine. Delivery of the fetus and placenta is recommended after the mother is stabilized from the effects of the convulsion(s). If the mother is to be transported before delivery, it is important that she receive an adequate dose of MgSO4.
A study of meperidine metabolism was undertaken in 21 normal parturients at term. Meperidine, 50 mg intravenously, was the sole analgesic agent used during the intrapartum period. Maternal and cord blood assessment for meperidine and normeperidine was done by gas chromatography-mass spectrophotometry. Most maternal sera showed a typical meperidine elimination curve. A secondary rise in maternal meperidine 30 to 180 minutes after injection was found in 4 patients. One patient showed a significant alteration in normeperidine appearance. These data add further validity to the hypothesis that the pregnant woman can metabolize meperidine by several pathways.
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It has been suggested that the decrease in blood pressure during sleep is greater in patients with chronic hypertension than in preeclamptic patients. The DINAMAP (device for indirect noninvasive automatic mean arterial pressure) monitor was used to determine the mean arterial, systolic, and diastolic blood pressure, at 15-minute intervals, and 24 hours. Three groups of 15 patients each were studied: mildly preeclamptic, chronically hypertensive, and normotensive patients in the third trimester. In addition, 2 patients with severe preeclampsia were studied. The automatic readings were compared with auscultated blood pressures. There was short-term variation in the systolic and diastolic blood pressure of 20 to 40 and 15 to 30 mmHg, respectively, with consecutive 15-minute recordings. A decrease in blood pressure during sleep was seen in all groups, except in the 2 patients with severe preeclampsia. This fall varied between 5 and 20 mmHg systolic and 5 and 18 mmHg diastolic. The auscultated blood pressure differed from the automatic blood pressure by 5 to 40 mmHg systolic and 5 to 35 mmHg diastolic. In the clinical management of patients, these findings are significant, as they demonstrate short-term variation in blood pressure and differences in the auscultated versus automatic blood pressure readings. Also, changes in blood pressure occur during sleep; this may be important with regard to the timing and dose of medication given to pregnant patients with chronic hypertension or preeclampsia.