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[Heart valve prosthesis, pregnancy and anticoagulant therapy].

The reproductive possibilities of cardiopathic patients with cardiac valvular prostheses have greatly improved in the past forty years. The correct management of this risk pregnancies remains a problem, however, especially as regards the chronic anticoagulant treatment to which these patients are subjected. The thirty years experience of a heart surgery-obstetric team is reported here. This included 14 pregnancies in women with aortic or mitral valvular prostheses. The problems relating to anticoagulant treatment in pregnancy and during labour are discussed.

Adult↗

[Anti-infective prophylactic measures in cesareans].

Septic complications remain important in obstetrical surgery due to the serious threat they pose to life and the sequelae which they may leave. The authors have therefore attempted to identify which of the anti-infectious prophylactic treatments used in cesareans were the most effective. This analysis was based on cases in their unit seen from 1984 to 1988 and on a review of the literature. Of the patients who underwent a cesarean (9.4 percent out of 7,855 deliveries), 2 percent were infected, with and incidence of 0.65 percent serious infections (0.4 percent septicemia). On the basis of the literature, the following risk factors were identified: 1st cesarean, cesarean during labor, rupture of the membranes, surgical problem, anemia, obesity and low socio-economic level. The local fundamental and systemic prophylactic measures taken were special antibiotic prophylaxis in the patients with a risk of infection only. The short protocol, with a single injection of penicillin A or a first generation cephalosporin, after clamping the umbilical was preferable and, according to all the studies, had the advantage of avoiding the selection of resistance.

Adult↗

[A study of referral pattern of group practice centers in Taiwan].

To investigate the referral patterns of group practice centers in Taiwan, 18 group practice centers were studied. These study sites were sampled in a stratified random method over four districts (eastern, northern, central, and southern) in Taiwan. The study period took place between July 1989 and June 1990. Prospective referral forms were applied in every study site during the 12-month period. A computer-assisted data base for referral contents was established to follow up referral cases. During the study period, 1,647 referrals were generated from 735,534 patient visits, for an overall referral rate of 0.22 percent of all office visits. According to the International Classification of Health Problems in Primary Care, 2nd edition, most of the problems that needed referral were signs, symptoms, ill-defined conditions, digestive system diseases, genitourinary system diseases, circulatory system diseases, neoplasms and musculoskeletal, connective tissue diseases. The top 6 consulting specialties were internal medicine, surgery, obstetrics & gynecology, orthopedics, urology and pediatrics. Periodic evaluation of the dynamic referral contents is a useful method to improve the quality of primary medical care.

Adolescent↗

[Comparative study of defibrotide and calcium heparin in the prevention of postoperative deep venous thrombosis. A randomized multicenter study].

The efficacy and tolerability of defibrotide (800 mg/i.v.) and calcium heparin (15,000 UI/s.c.) in the prophylaxis of post-surgical deep venous thrombosis (DVT) and pulmonary embolism (PE) were compared in a multicentre trial involving 60 Italian surgical institutions (general surgery, obstetrics and gynecology, urology). Total enrollment was 2,250 patients (defibrotide: 1.194; calcium heparin 1.056). According to the protocol, the clinical suspicion of DVT and/or PE led to in-depth diagnostic evaluations (DVT: Doppler ultrasound velocimetry; PE: chest X-rays; ECG, pulmonary scintigraphic scanning). The incidence of post-surgical DVT was similar in the two groups (defibrotide: 8 patients; calcium heparin: 10 patients). A trend towards a lower incidence of DVT in the defibrotide group no PE; calcium heparin: 4 cases (chi 2 = 4.530, p less than 0.05). The local and systemic tolerability of both treatment was excellent. This trial, carried out in routine surgical practice, establishes the profibrinolytic approach to DVT prophylaxis as a sound and effective alternative to the traditional interference with the coagulation cascade.

Analysis of Variance↗

Surgical approaches to pelvic infections in women.

Pelvic abscess is a complication of gynecologic disease or obstetric surgery. Tuboovarian complex is differentiated from abscesses because of the absence of a true abscess wall; treatment of a tuboovarian complex is conservative. The diagnosis of tuboovarian complex is made by history, pelvic examination and ultrasonography. Tuboovarian abscesses (TOAs) are sequelae of surgical procedures. Both conventional and novel surgical techniques can be used to manage them. Pelvic thrombophlebitis and ovarian vein thrombosis are late complications of pelvic infections that may be associated with significant morbidity and mortality.

Abscess↗

Delivery of anesthesia services throughout the world.

The application of the principles of basic sciences in anesthesiology not only has succeeded in allaying man's pain on Earth, but also within this decade has provided him with a controlled safe environment for successive journeys into outer space and to the moon and soon to planets beyond. These same principles have made possible his exploration of the ocean floors in artifical atmospheres and pressures and his escape, without breathing devices, from depths of 300 feet. The science of anesthesia has contributed immeasurably to the active treatment of paralytic poliomyelitis and to resuscitation. Furthermore, it has introduced needless jet injection for drug and vaccine therapy in epidemics and with increasing rapidity to diabetcs. This accumulating body of knowledge within the past 13 decades has contributed to the development of modern surgery, obstetrics, and dentistry, and provided techniques for the control of pain from metastatic cancer, from trauma, from arthritis, and during postoperative convalescence. The anesthesiologist shares with the surgeon and clinical pathologist the responsibility for the safe use of fluid and blood replacement therapy; and with the internist, psychiatrist, and general practitioner the proper sequential medication of analgesics, anesthetics, ataractics, cortisone, antihypertensive and antihistaminic agents, and prompt reversal of many undesirable depressions during emergence. A new concept is the reversal of many narcotic states with cyclic AMP. Major advances in anesthesia have been developed on every continent. The fact that there are at least 30 anesthetic techniques and 62 agents in worldwide use reemphasizes our present lack of an ideal single anesthetic agent and technique. Iti is encouraging to note that the science of anesthesiology has made more progress during the past three decades than in all of the previous century. The great preponderance of that progress has been largely confined to Canada, the United States, the British Commonwealth, Western Europe, and a few of the metropolitan areas in South America. Happily, the significant progress in the last decade has added monitors and other safeguards, understanding, tecyniques, agents, and pioneer investigators, in increasing proportions for a world that will double its population in the present half-century. Surely, there is no more important field toward the direction of world scientific effort for human betterment than in this broad area of universal agreement.

Altitude↗

[Willebrand's disease and pregnancy (author's transl)].

Autosomal dominant hemorrhagic disorder, Willebrand's disease causes hemorrhagic complications during post-partum period. Nevertheless our case-report as well as others's have shown that these complications only occur when there is no spontaneous biologic improvement and can be prevented by prophylactic treatment with cryoprecipitates or anti-hemophilic A fractions. This risk requires thus a regular watch of the biologic aspects during pregnancy and before the delivery date in order to decide of a possible treatment, which will be absolutely necessary in case of obstetrical surgery.

Adolescent↗

[Recommendations for the systemic perioperative prevention of infections in gynecology and obstetrics].

Antibiotic prophylaxis for gynecologic and obstetric surgery is reviewed. Numerous clinical studies conducted under controlled conditions have established and confirmed the beneficial effects of short term (preferentially single-dose) perioperative antibiotic prophylaxis for various procedures. Cephalosporins, particularly of the first generation, have been used extensively despite the fact that their antimicrobial spectrum does not include all pathogens recovered from postsurgical infections in gynecology. Perioperative antibiotic prophylaxis is effective in reducing the incidence of infection-related morbidity and mortality of vaginal hysterectomy, especially in premenopausal women. This protective effect is less pronounced for abdominal hysterectomy. The incidence of postoperative infections at a particular hospital should be used as guideline as to whether antibiotic prophylaxis will be beneficial or not for these patients. The same applies to C-sections, for which antibiotic prophylaxis should be administered to high risk patients only, such as secondary C-section or patients with severe underlying diseases. The optimal timing appears to be after cord clamping, which prevents transfer of the antibiotic to the newborn.

Anti-Bacterial Agents↗

[Need for effective collaboration between medical education and the health services].

The article reviews the health manpower training problems involved in the commitment of all countries to extend the coverage of their health services to the entire population by the year 2000. The author points out that the number of physicians in Latin America will double in seven or eight years, and doubts that they can all be absorbed by the labor market unless they are given a well-defined part to play in primary health care, which is the key to that goal. Necessary changes in medical practice--among them regionalization of the services--should, he feels, be accompanied by appropriate changes in the medical education process. Since the physician practicing at the primary care level stands at the point of entry to the regionalized health system, his training should be slanted toward dealing with the prevalent pathology, and particularly toward the care of the groups at highest risk: mothers and children. In addition, he will have to be ready to take the lead on a team consisting of the auxiliary staff and the members of the community itself. He admits that the breadth of the range of subjects studied in medical training today may have to be traded off for more intensive concentration on the basic fields of internal medicine, general surgery, obstetrics and pediatrics. Other essential changes include closer coordination between the medical school and the health services not only in the framing of policies and programs, but also in routine work; the provision of incentives to improve the geographic distribution of health personnel, and determining the contribution required of each discipline at the different training levels and in operating the services.

Community Health Services↗

[Ceftriaxone vs. cefazolin in obstetrical surgical prevention].

The cesarean section is associated with a high incidence of puerperal infections. The antibiotic prophylaxis in obstetric surgery may reduce infectious complications, nevertheless antibiotic prophylaxis only has proved to be effective in women with risk factors for the occurrence of infection. We made a comparative study of the prophylactic efficacy of the ceftriaxone a single dose versus cefazolin three doses, in women with risk factor for infection. There were enrolled 100 patients, 50 in each group. Six percent of the ceftriaxone group patients developed puerperal infections while 12% of the cefazolin group women developed this complication. The statistic analysis don't show difference between the groups. We consider the single dose prophylactic schema is better because its application is easier, administration is safety and reduces the risk of adverse reactions.

Adolescent↗

Prevalence of hepatitis C in health care workers investigated by 2nd generation enzyme-linked and line immunoassays.

The aim of this study was to evaluate the prevalence of antibodies to hepatitis C virus (anti-HCV) in health-care workers (HCW). Sera from 439 unselected HCW were assessed for anti-HCV by 2nd generation enzyme-linked immunoassay (ELISA) and anti-HBc by ELISA. Anti-HCV (+) sera were evaluated by line immunoassay (LIA) (LiaTeK, Organon). Anti-HCV proved positive by ELISA in 12 (2.73%) subjects, 6 of whom were reactive by LIA, one was indeterminate and 5 non reactive. The prevalence of anti-HCV confirmed by LIA was 1.59% (7 subjects). Positive anti-HCV results with an ELISA ratio greater than 3 were LIA reactive in 6/6 as compared with 5 LIA non reactive with an ELISA ratio less than 2, while in the indeterminate serum the ratio was 2.5. No differences in age, profession, seniority, history of hepatitis or transfusions were found between anti-HCV (+) and (-) subjects, but females predominate significantly. The areas of higher risk were hemodialysis, obstetrics, surgery and intensive care. Anti-HBc was (+) in 85.7% (6/7) of the anti-HCV (+) subjects. Follow-up of anti-HCV (+) subjects showed raised alaninoaminotransferase levels in 4 cases, while liver biopsies in 3 disclosed cirrhosis, chronic active hepatitis and chronic persistent hepatitis. The anti-HCV prevalence in HCW is low compared with other risk groups perhaps due to the peculiar epidemiological features of HCV. In low risk groups for HCV infection a positive ELISA result with a ratio lower than 3 should be confirmed by more specific tests.

Adult↗

Patient-centered computing: can it curb malpractice risk?

The threat of a medical malpractice suit represents a major cause of career dissatisfaction for American physicians. Patient-centered computing may improve physician-patient communications, thereby reducing liability risk. This review describes programs that have sought to enhance patient education and involvement pertaining to 5 major categories of malpractice lawsuits: Diagnosis, medications, obstetrics, surgery, and treatment errors.

Computer Systems↗

[Blood transfusions in Africa during the AIDS epidemic. Condition of localities and perspectives in the Ivory Coast].

HIV is transmitted essentially by the heterosexual route in Africa. As part of an international mobilization against the Aids epidemic, information, education and communication strategies should continue to reduce the frequency of the infection. In this paper, we underline the high risk of HIV infection from blood transfusion in Africa. Although few epidemiological data are available, we feel that this problem should be made a priority, and that blood transfusion in Africa can be made reasonably safe by rational use of limited resources. We first report how the Ivory Coast health ministry, with funding from the European Community, has organized blood transfusion services in the main urban areas. Despite routine screening tests, the risk of HIV transmission through blood products remains high because of the large number of infected donors who are antibody-negative. The accent must thus be placed on alternatives to blood transfusions, while the use of transfusions must be minimized, especially in pediatric and general medical wards. As malaria, undernutrition and obstetric surgery are leading causes of anemia, health programs should be aimed at controlling these factors with the ultimate goal of limiting the spread of HIV.

Adult↗

European consensus statement on the prevention of venous thromboembolism. European Consensus Conference, Windsor, U.K., November, 1991.

Since the Consensus Conference of the National Institute of Health in 1986, the developments in the field of prevention of venous thromboembolism were mainly characterized by a more specific and extended use of new prophylactic agents such as low molecular weight heparins as well as the perception that outpatients may be at risk for thromboembolic complications, too. Therefore, in November 1991, a European Consensus Conference on the prevention of thromboembolism was held in Windsor, UK, in order to analyse the risk constellation of various patient populations and to give recommendations for primary prophylaxis in general surgery, urology, neurosurgery, orthopaedic and trauma surgery, obstetrics and gynaecology and medical patients. In addition, the cost-effectiveness of the various methods was highlighted, and the question of secondary prevention addressed. The meeting was organized under the patronage of the European Economic Commission, and experts from 15 different countries were invited to participate. The conference was organized according to acknowledged guidelines of consensus conference organization, i.e. each expert had to formulate his provisional standpoint, the working documents were compiled by the organizer, and this file was sent to the delegates before the conference. During the first part of the meeting, the delegates presented their views in plenary sessions. Controversial points were discussed in working groups, and the results were discussed in plenary sessions. Consensus or lack of accord was documented and the open questions were formulated in order to be answered by future studies. The published statements and recommendations are based on different levels of evidence.(ABSTRACT TRUNCATED AT 250 WORDS)

Clinical Trials as Topic↗

[A rare complication of obstetric pathology: uretero-uterine fistula].

Accidental iatrogenic injuries of ureters and bladder in patients with abdominal and pelvic pathology are described as a possible lesion of a surgical or gynaecologic treatment. The ureteral lesion is less frequent in obstetric surgery, but the young age of the patients and the gravity of the consequences, impose a very serious problem for a early diagnosis with a conservative surgical treatment. On the contrary, this important injury, bears an important surgical management with possible functional damage of the reno-urinary tract. The Authors report the experience about the observation and treatment of a case of a young woman, 29 years old, who had a uretero-uterine fistula, after a cesarean section for the first pregnancy.

Adult↗

Trauma during pregnancy.

The appearance of a pregnant trauma patient is rare even in the busiest of trauma centers. Management of these cases can present difficult challenges. A successful outcome for both mother and child is dependent on an immediate team approach and response involving physician, nursing, and ancillary staff. The disciplines of emergency medicine, trauma surgery, obstetrics, and perinatology must be involved primarily in a timely and appropriate fashion. Other consultants required for the optimal treatment of injuries and pregnancy must also play a timely role. An aggressive rather than timid approach to resuscitation, diagnosis, and treatment of these patients must be taken. Knowledge of the normal physiologic changes occurring during pregnancy, special attention to prevention and early recognition of occult maternal hypoxia and hypovolemia, as well as a high index of suspicion for injuries to mother and fetus likely to occur during pregnancy should guide and temper management strategies. Care providers should resist emotional distractions and the urge to focus on the fetus before the mother is properly stabilized and evaluated. They should be cognizant of the fact that an apparently stable mother may be compensating at the expense of the fetus. Finally, the tenet of what benefits the mother will ultimately benefit the fetus should be adhered to. When these points are kept in mind, the potential for successful outcome and satisfying results is greatest for all parties involved.

Female↗

[Breast feeding, lactation disorders and inflammatory diseases of the female breast].

Approximately 98% of our female population are capable of breast-feeding. Optimal success in breast-feeding is achieved when the first suckling stimulus occurs no later than 2 h following delivery. Obstetrical surgery impairs breast-feeding. Lactation is considered to be optimal with 7 to 10 min of milk uptake and 7 to 10 min of suckling for galactopoesis and discontinuation. The individual pattern of suckling is critical for initiation and duration of lactation. Due to environmental contamination of the milk, a critical assessment of advantages and disadvantages of breast-feeding needs to be performed if it is considered for more than four months. Early diagnosis and immediate initiation of treatment of mastitis helps avoiding abscess formation with potential surgical sequelae. Medical--dopamine agonists--and physical therapy permit continuation of breast-feeding.

Breast Feeding↗

[Medical education at Universidad de los Andes, Santiago, Chile].

Universidad de los Andes School of Medicine started in 1991 with a new medical curriculum aimed at providing a medical education for its students, that is, it attempts to give, together with technical proficiency in medical matters, formation of character and a strong ethical attitude. The curriculum lasts for seven years: five of basic, pre-clinical and clinical theoretical and practical courses, followed by two years of internships in Internal Medicine, Surgery, Obstetrics and Pediatrics, plus a four month period of an elective internship. The courses have an integrated design, in which each matter is presented from multiple perspectives, e.g. in Internal Medicine together with the clinical aspects of disease, the pathophysiology and the pharmacology of the drugs used are presented. Also the Pathology of each disease is given in coordination in the Pathology course. General educational matters such as Anthropology, Psychology, Origin of Living Beings, Theology and Medical Ethics are interspersed in the curriculum. An important feature is the personal counselling system, in which each student may choose an academic counsellor and discuss with him (her) the subjects of his choosing. Clinical practice is given in a system that includes five hospitals and five private clinics that range from general medical practice to Psychiatry or Ophthalmology.

Chile↗