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PubMed1985

Changes in obstetric practice in our time.

In the years since 1939 there has been a marked change in the nature and results of obstetric practice at the Royal Women's Hospital, Melbourne. The noteworthy changes have been a reduction in the number of maternal deaths (from 12.2 per 1,000 in the 1940's to 0.2 per 1,000 in the 1980's), especially those due to septic abortion, and an increase in the Caesarean section rate (from 2% to 14%). The increase in the operative delivery rate has been matched by a decrease in mortality in patients thus delivered, the maternal and perinatal mortality rates changing from 5.5 and 88.9 per 1,000 to 0 and 7.6 per 1,000 respectively in the case of forceps delivery and from 24.7 and 162.5 per 1,000 to 0.15 and 10.6 per 1,000 respectively in the case of Caesarean delivery.

Adult↗
PubMed1996

Causes of increasing mortality in a nursing home population.

OBJECTIVE: To examine the roles played by changes in case-mix, quality of care, and aggressiveness of care in explaining the 42% increase in mortality of the Medicaid nursing home population of Hennepin County, Minnesota, between 1984 and 1988. DESIGN: Retrospective chart review. SETTING: All nursing homes in Hennepin County, MN, that care for Medicaid patients. PATIENTS: A random sample of 1605 Medicaid nursing home residents from 1984 and 1988 stratified by year and by whether the resident died in that year. Sampling was disproportionate to allow approximately 400 individuals per stratum. A total of 1405 charts (87%) were reviewed; the remainder were either lost or destroyed. MAIN OUTCOME MEASURES: Measures included case-mix (Charlson index, functional status, implicit reviewer assigned severity [range 1-4]), aggressiveness of care (orders limiting care), quality of care (process of care for tracer conditions [range 1-5], falls), and resident death. RESULTS: Implicitly rated severity of illness worsened between 1984 and 1988 (2.77 vs 2.91; P = .009), but other measures of case-mix were unchanged. A greater percentage of residents had a DNR order in 1988 (12% in 1984 vs 37% in 1988; P < .001), and more received less aggressive care (31% vs 40%; P = .006). Overall process of care improved between 1984 and 1988 (2.88 vs 3.01; P < .05). With adjustment of the mortality rates and with logistic regression controlling for age and gender, changes in quality of care alone accounted for less than 5% of the mortality rate change between 1984 and 1988, case-mix alone accounted for 49%, and aggressiveness of care alone accounted for nearly 100%. CONCLUSIONS: The nursing home population became sicker between 1984 and 1988, but process of care improved. These changes had a modest effect on the mortality rate. The increase in less aggressive care between 1984 and 1988 accounts for nearly all of the increase in mortality.

Aged↗
PubMedDate not supplied

Autonomic reflexes in preterm infants.

Some autonomic nervous reflexes often tested in adult medicine have been studied in 21 preterm infants (25-37 gestational weeks). The aim was to develop such tests for preterm infants and see if there were any differences in babies with recurrent apnea and bradycardia and babies who had been exposed to sympathicolytic drugs before birth. To test sympathetic nervous activity the peripheral vascular resistance was measured before and during 45 degrees of head-up tilting. To test parasympathetic nervous activity the degree of bradycardia was measured in response to cold face test (application of an ice-cube on the fore-head) and laryngeal stimulation with saline. Finally the heart rate changes after a sudden noise (85 dB) were studied as an indicator of both sympathetic and vagal activity. The peripheral resistance was found to be relatively low in these preterm infants, particularly in some infants tested at the postnatal age of about two months. Heart rate and mean blood pressure did not change during tilting, while the peripheral resistance increased significantly mainly due to lowered limb blood flow. The median decrease of the heart rate during the cold face test was 20.0% and during laryngeal receptor stimulation 23.7%. The sudden noise usually caused a biphasic heart rate response. An autonomic nervous reflex score was calculated and found to be negative (parasympathetic) in infants with recurrent prolonged apnea and bradycardia and positive in infants with clinical signs of increased sympathetic nervous activity.

Apnea↗
PubMed1982

Relationship between fluorescein diacetate-stained hyphae and oxygen utilization, glucose utilization, and biomass of submerged fungal batch cultures.

The relationship between fungal activity and staining with fluorescein diacetate (FDA) was investigated by growing Penicillium citrinum and Rhizoctonia solani in submerged batch cultures at different initial glucose concentrations and aeration rates. A modified FDA staining method, similar to the Jones and Mollison technique (P. Jones and J. Mollison, J. Gen. Microbiol. 2:54-69, 1948), was developed to assess both total and FDA-stained hyphae. In previous studies, soil hyphae stained with FDA were considered viable. However, determination of a quantitative relationship between FDA staining and fungal activity is necessary before such an assumption can be made. Growth rates and the rate of change in the percentage of FDA-stained hyphae were significantly correlated. The regression equation calculated for the relationship was: growth rate (mg . ml-1 . h-1) = 0.34 + 1.1 (rate of change in the percentage of FDA-stained hyphae [. ml-1 . h-1]). Changes in activity as measured by O2 utilization, glucose utilization, and biomass correlated significantly with changes in the percentage of FDA-stained hyphae, although the relationships among these parameters were different for each fungal species. Fungal growth stage was also correlated with the percentage of FDA-stained hyphae. Staining was 10% or greater during fungal growth and less than 10% during the late growth, stationary, and death phases. Thus, the rate of change in the percentage of FDA-stained hyphae can be used to predict fungal activity rate changes for single fungal cultures and growth rates for mixed fungal cultures, and the growth stage can be assessed by the percentage of FDA-stained hyphae.

Aerobiosis↗
PubMed1996

Reduced heart rate variability after right-sided stroke.

BACKGROUND AND PURPOSE: Recently, asymmetries have been demonstrated in skin sudomotor and vasomotor function after unilateral cerebral lesions. The present study was performed to determine whether other bedside tests reflecting sympathetic and parasympathetic cardiovascular functions would reveal differences with respect to the side of cerebrovascular lesions. METHODS: Heart rate variability during deep breathing as well as blood pressure and heart rate changes during tilt and isometric handgrip was measured in a group of patients with a monofocal stroke and compared with similar data from age-matched patients with transient ischemic attack and healthy control subjects. RESULTS: Compared with left-sided stroke and with the control subjects, stroke location on the right side was associated with a reduced respiratory heart rate variability (P > .01), a reflex mainly under parasympathetic control. In contrast, reflexes mainly reflecting peripheral sympathetic function were equal for right- and left-sided lesions. CONCLUSIONS: Since an imbalance in cardiac autonomic innervation may be crucial for the generation of cardiac arrhythmias and since reduced heart rate variability has been associated with increased mortality, the findings suggest that the risk of sudden death may be correlated with lateralization and location of the brain infarct after stroke.

Analysis of Variance↗
PubMed1992

Dynamic analysis of cardiac R-R intervals in normal infants and in infants who subsequently succumbed to the sudden infant death syndrome.

Infants who subsequently succumb to the sudden infant death syndrome (SIDS) have higher heart rates and reduced heart rate variation compared with other infants. We examined dynamic changes in cardiac interbeat intervals to explore these differences in cardiac control. Recordings of electrocardiographic activity and respiratory movement were acquired from 13 SIDS victims before their deaths. Moment-to-moment changes in R-R intervals during quiet sleep, rapid eye movement sleep, and waking were compared with values of 13 matched control infants. For each sleep-waking state, every R-R interval was plotted against the previous interval (Poincaré plots), and each change in interbeat interval was plotted against the previous change. Dispersion of interbeat intervals at different heart rates was reduced in SIDS victims, resulting in Poincaré plots markedly different from those of controls. The dispersion, sampled at the 10th and 90th percentiles of heart rates, was reduced across all sleep-waking states in SIDS victims. At high heart rates, the difference between groups disappeared after correcting for basal rate; however, the reduced range at low heart rates was independent of basal rate. SIDS victims also showed smaller beat-to-beat changes in heart rate and fewer sustained runs of consistent heart rate changes during waking relative to controls. The differences in cardiac rate dynamics suggest altered autonomic control in infants who succumb to SIDS. We speculate that the autonomic disturbance may lead to cardiac instability or may indicate CNS alterations with the potential to affect other vital functions.

Autonomic Nervous System↗
PubMed2002

Delayed childbearing and its impact on population rate changes in lower birth weight, multiple birth, and preterm delivery.

OBJECTIVE: This study quantified the impact of delayed childbearing (maternal age greater-than-or-equal to 35 years) on population rate changes in low birth weight (LBW; < 2500 g), preterm delivery (< 37 weeks), multiple births, and small for gestational age (SGA; < 10th percentile) in Alberta, Canada, between 1990 (N = 42 930) and 1996 (N = 37 710). METHODS: Data were obtained from the provincial notification of a live or stillbirth. Analyses included relative risk estimates and chi(2) tests for trend. Potential confounding attributable to in vitro fertilization was investigated. RESULTS: The proportion of births to women greater-than-or-equal to 35 years of age was 8.4% in 1990 and 12.6% in 1996, a 51.2% increase. Among these women, LBW delivery increased 11%, and preterm delivery increased 14%. Delayed childbearing accounted for 78% of the change in LBW rate in the population and 36% of the change in preterm delivery rate in the population. Provincial multiple birth rates increased by 15% for twins and 14% for triplets. Delayed childbearing accounted for 15% of the twin increase and 69% of the triplet increase. When in vitro fertilization pregnancies were excluded, the change was 43% for preterm rates, 100% for LBW, 14% for twins, and 9% for triplets. Delayed childbearing did not contribute to changes in singleton SGA deliveries. CONCLUSIONS: The findings suggest that the recent increase in LBW and preterm delivery is partly related to the population phenomenon of delayed childbearing. Maternal age was not related to changes in SGA, suggesting that the age effect is through pregnancy complications that lead to preterm delivery and LBW. Prospective parents should be informed about the higher risk for neonatal morbidity associated with delayed childbearing. Health care providers should be aware of the impact of delayed childbearing on health care resources.

Adult↗
PubMed1991

Circadian variation of myocardial ischemia in patients with stable coronary artery disease.

The circadian variation of myocardial ischemia detected during 24-h ambulatory electrocardiographic monitoring (AEM) was analyzed in 123 patients with stable angina pectoris, positive exercise test, and angiographically proven coronary artery disease. A total of 437 ischemic episodes (ST-segment depression greater than or equal to 1 mm and duration greater than or equal to 1 min) were observed; 333 (76%) episodes remained asymptomatic, and only 104 (24%) episodes were accompanied by anginal pain. Ischemic episodes predominantly occurred during the morning hours, between 6 a.m. and noon, and another smaller peak was observed in the afternoon, between 4 and 5 p.m.; this diurnal pattern was influenced neither by the extent of coronary artery disease nor the degree of left ventricular dysfunction. The circadian variation was restricted to the 345 (78%) ischemic episodes preceded by increases in heart rate; the 92 (22%) episodes without prior heart rate changes occurred randomly throughout the day. The morning peak in ischemic episodes was not associated with less myocardial oxygen supply; in contrast, heart rate profile showed parallel increases during the morning and afternoon hours, indicating elevated myocardial demand during these periods. Ischemia-related ventricular arrhythmias were concentrated during the morning hours, but their overall prevalence was low--28 (6%) of 437 ischemic episodes. These findings may provide further insight into the pathomechanisms of acute clinical events in patients with coronary artery disease, since the circadian variation of myocardial ischemia is very similar to that observed for the onset of myocardial infarction and sudden cardiac death.

Adult↗
PubMed1997

Fertility levels and trends in the face of the AIDS epidemic in Uganda.

The paper uses data on ever-married women interviewed in 1992 and 1995 surveys in six districts of Uganda. Total fertility rates declined during the inter-survey period from 7.3 to 6.0. Women in households that experienced AIDS-related deaths had lower fertility levels than women in non-AIDS-affected households in both 1992 and 1995. This pattern was true of women at older ages, in polygamous unions, the widowed and separated, and among the highly educated and the uneducated.

Adolescent↗
PubMed1999

[Mechanism of spontaneous occurrence of tachycardia].

Tachycardias arise from an arrhythmogenic substrate and a trigger factor, an extrasystole, the two factors being under the influence of the autonomic nervous system. The study of the mechanisms of spontaneous initiation of arrhythmias must, therefore, take these three factors and their interactions into account. The frequency dependency of an arrhythmia and the sensitivity of the substrate to the adrenergic system varies with time in a given subject and from one patient to another according to the presence and type of cardiac disease. The mode of initiation of most ventricular tachycardias and the therapeutic consequences may be understood: in some forms of cardiac disease, such as arrhythmogenic right ventricular dysplasia, the increase in heart rate which usually precedes sustained ventricular arrhythmias is only perceptible in mild or recent forms, unlike the more chronic dysplasias. This suggests that the arrhythmogenic substrate becomes more sensitive to catecholamines with time, and therefore requires smaller changes in sympathetic tone in order to be expressed (adrenergic paradox). Heart rate changes accompany modifications of sinus variability. Holter monitoring has shown, and this has been confirmed by recordings obtained from patients with implanted automatic defibrillators, that global sinus variability decreases before the initiation of a ventricular arrhythmia. Studies of the dynamics of ventricular repolarisation should also confirm the changes of QT frequency-dependency. The analysis of the initiation of arrhythmias would only have an academic interest if this was limited to a purely descriptive exercise. It is one of the best means of understanding arrhythmias and their therapeutic implications. The development of computerised methods of analysis of Holter monitoring should lead to further progress in this field.

Cardiomegaly↗
PubMed1999

Congenital syphilis--United States, 1998.

Congenital syphilis (CS) occurs when the spirochete Treponema pallidum is transmitted from a pregnant woman with syphilis to her fetus. A multiorgan infection, CS may result in a neurologic or musculoskeletal handicap or death in the fetus when not properly treated. Trends in CS rates in women of childbearing age follow by approximately 1 year the rates of primary and secondary syphilis. The last national syphilis epidemic, which was followed by a CS epidemic, occurred during the late 1980s and early 1990s. The syphilis rate began to decline in 1991; the CS rate began to decline in 1992. To evaluate CS epidemiology since this decline, CDC analyzed 1998 CS notifiable disease data and assessed rate changes during 1992-1998. This report summarizes the results, which indicate that the CS rate declined 78.2% from 1992 to 1998, and that rates remained disproportionately high in the southeastern United States and among minority racial/ethnic populations.

Adolescent↗
PubMed1987

A new technique to determine the correlation between the QT interval and heart-rate for control and SIDS babies.

The ability of the autonomic nervous system to alter the QT interval in response to heart rate changes is essential to cardiovascular control. An accurate way to determine the relation between QT intervals and their corresponding RR intervals is described. A computer algorithm measures the RR intervals using digital filtering and cross-correlating the QRS sections of consecutive waveforms. The QT intervals is calculated by choosing a section of, the ECG that includes the T wave and cross-correlating it with all the consecutive T waves. At least 4000 pairs of QT-RR intervals are computed for each subject and a best fit correlation function determines the relations between the QT and RR intervals. This technique enables to establish a precise correlation between RR and QT in order to distinguish between control and SIDS babies.

Algorithms↗
PubMed1985

Biplot models applied to cancer mortality rates.

"A graphical method developed by Gabriel to display the rows and columns of a matrix is applied to tables of age- and period-specific cancer mortality rates. It is particularly useful when the pattern of age-specific rates changes with time. Trends in age-specific rates and changes in the age distribution are identified as projections. Three examples [from England and Wales] are given."

Age Distribution↗
PubMed1987

[Studies on the interrelation of fetal heart rate change, placental findings and fetal outcome].

The relation between antepartum fetal heart rate (FHR) non stress test (NST), maternal serum estriol, intrapartum FHR change, birth weight, placental findings and Apgar score were studied in 168 normal gestations and 36 high-risk pregnancies including 25 EPH-gestosis cases. The frequency of placental infarcts was higher in severe gestosis than in other high-risk pregnancies and normal gestation. Abnormal NST was more frequent in high-risk pregnancy than normal. Light for date (LFD) infants were more numerous in high-risk pregnancy than normal, and also frequent in the cases of placental infarcts. Particularly in high-risk pregnancy patients with abnormal NST and placental infarcts, 3 out of 5 showed LFD infants. Intrapartum fetal distress was more common in the cases of abnormal NST than normal. The five minute Apgar score was lower in the patients with abnormal NST and in the cases of placental infarcts than normal. The placental infarct ratio was higher in high-risk pregnancies with abnormal NST than normal. The maternal serum estriol level was not changed in cases of high-risk pregnancy, abnormal NST or placental infarcts when compared to normal gestation. The cases of succeeding fetal death, however, showed a low serum estriol level. In conclusion, antepartum abnormal NST suggests severe placental dysfunction caused by its infarcts and the prognosis is poor in patients with high-risk pregnancies, particularly EPH-gestosis. Coping with abnormal antepartum NST is regarded as important in fetal management.

Apgar Score↗
PubMed1996

[Increasing use of cesarean section, even in developing countries].

At Kaziba hospital in rural Zaire, the frequency of deliveries by Caesarean section rose from 6.2% in 1971 to 12% in 1992, and the fraction of repeated sections rose from 17% to 49%. During the same period, the overall maternal mortality decreased from 0.3% to 0.12%, and deaths connected with Caesarean section from 3.2% to 0.7%, but still the risk of dying remained 13 times higher for births by Caesarean section compared with vaginal deliveries. The frequency of vacuum deliveries was halved during the period, and mean birth weight decreased by about 100 g. Perinatal mortality remained at about 2%. Among 760 Caesarean sections performed in the years 1991 and 1992, 93% were emergency cases. Spinal anesthesia was used in 97%, and blood transfusion was given to 4% of the women. The main indications were mechanical (30%), previous Caesarean section (20%), foetal asphyxia (19%), and suspected uterine rupture (10%). Uterine rupture was verified in 37 cases (4.9%), of which 27 were Caesarean scar ruptures. 259 of the operations were performed by a nurse or a dentist. Operations carried out by persons other than physicians were complicated by wound infections at a higher rate (20.8%) than those carried out by experienced doctors (11.2%). In areas with a poorly developed health system, a high rate of Caesarean section represents a hazard to maternal health. The need for knowledge about alternative methods like vaginal extraction, symphyseotomy and active management of labour is underlined.

Cesarean Section↗
PubMed1996

Diagnosis and treatment of superficial bladder cancer: an update.

It is expected that approximately 50,500 new cases of bladder cancer will be diagnosed in 1995. In addition, approximately 10,000 people are expected to die of this disease during the year. An 11% increase in incidence observed from 1957 to 1987 was accompanied by a 19.4% decrease in the death rate in American males. This rate change may be attributable to stage migration to more localized disease as well as increased survival owing to improved treatment. Transurethral resection is standard first-line treatment for transitional cell carcinoma of the bladder. Intravesical therapy with cytotoxic agents or immunomodulators has become an important element in the management of patients with superficial bladder cancer at risk for disease recurrence and progression. Study results confirm the efficacy of both mitomycin and bacille Calmette-Guérin when administered intravesically. Comparative studies of these two agents are warranted to further clarify their respective roles in the prophylaxis of recurrences of superficial bladder cancer. Studies should enroll large numbers of patients, particularly those with high-grade lesions at significant risk of recurrence and progression. Current research involves evaluation methods of optimizing the efficacy of intravesical chemotherapy. High drug concentrations, hyperthermia, and combination modalities are a few new avenues being studied. In addition, new drugs like bropirimine, interferons, mycobacteria-associated antigens, and keyhole-limpet hemocyanin are being explored.

Adjuvants, Immunologic↗