Fever in labour and neonatal encephalopathy: a prospective cohort study

OBJECTIVE

To determine whether the reported association of maternal fever with neonatal encephalopathy is independent of other associated intrapartum risk factors.

DESIGN

Prospective cohort study.

SETTING

Dublin teaching hospital delivery ward.

POPULATION

4,915 low risk women in labour at 36-41 weeks of gestation.

METHODS

Using logistic regression with odds ratios and 95% confidence intervals, the incidence of neonatal encephalopathy and other neonatal outcomes of women who had an intrapartum fever >37.5 degrees C was compared with those who did not.

RESULTS

The cohort comprised 33% of all deliveries during the study period. Neonatal encephalopathy was diagnosed in 3.25/1,000 births. The incidence of intrapartum fever was 6.8%. Maternal fever was strongly associated with neonatal encephalopathy (crude OR 10.8, 95% CI 4.0-29.3). Univariate analysis showed maternal fever was associated with epidural analgesia, nulliparity, induction, longer labour, oxytocin administration, greater fetal birthweight and gestational age and instrumental vaginal delivery, but not with prolonged (>24hours) prelabour rupture of the membranes. The association of fever with neonatal encephalopathy persisted having adjusting for these covariates (adjusted OR 4.72, 95% CI 1.28-17.4).

CONCLUSIONS

The relationship between maternal intrapartum fever and neonatal encephalopathy is independent of other known intrapartum risk factors. This provides further evidence for the role of inflammatory processes in the aetiology of neonatal neurological morbidity.

Vital signs monitoring from home with open systems

This study investigates the applicability of a novel codification scheme based on two healthcare informatics standards (namely the VITAL (ENV 13734) and DICOM Sup. 30 Waveform Interchange) in addressing the robust interchange of waveform and medical data in remote healthcare applications. To further address system validation and clinical acceptance issues, pilots were set-up between home-monitoring stations and a hospital-based telemedicine consultation center. The pilots focused in assessing applicability, technical feasibility and performance of the proposed codification scheme based on the two standards. This paper presents the system and services requirements as studied for a home-care application, the design goals for the preservation of security stature, the practical issues of validation and the results of integrating these codification schemes into a commercial patient connected device.

An examination of methods for risk-adjustment of rehospitalization rates

This study examines three methods of conducting risk-adjustment to determine if the choice of method results in different conclusions about comparative mental health center performance. The three methods of risk-adjustment are stratification-weighting, logistic regression without interaction effects, and logistic regression with interaction effects. The dependent variable of interest is psychiatric rehospitalization within 14-60 days of discharge to a community mental health center. Subjects are adults discharged in fiscal year 1998 from inpatient psychiatric care to a designated community mental health center in Oklahoma. Using each method, we examine the mental health centers to determine whether their rehospitalization rates are significantly greater than, less than, or not different from, expected. Results show that, for some agencies, method of risk adjustment leads to different conclusions about center performance. Results are discussed with respect to identifying the preferred method of risk-adjustment, study limitations, and next steps in developing risk-adjustment technology and applications.

HCFA's new restrictions on the operation of hospital outpatient facilities

The Health Care Financing Administration has promulgated new regulations that substantially alter the manner in which it treats Outpatient Facilities. This Article (1) provides an overview of these new restrictions on the operation of Outpatient Facilities; (2) discusses potential unintended consequences associated with these restrictions; and (3) raises issues that providers must consider as they assess how to comply with these new restrictions.

Major complications after minimally invasive repair of pectus excavatum: case reports

BACKGROUND/PURPOSE

A recently introduced technique allows for minimally invasive repair of pectus excavatum deformity. Successful application of the procedure has been reported by several centers. The purpose of this report is to describe the occurrence of 3 major complications in 5 patients.

METHODS

These cases are taken from the combined experience of 3 surgeons at different institutions. Operative technique and postoperative management was not uniform.

RESULTS

The first complication was cardiac perforation requiring repair. This occurred in an 8-year-old boy who had hemorrhage immediately after transthoracic placement of the clamp. He required urgent sternotomy with right atrial, and right ventricle repair followed by tricuspid valve repair on cardiopulmonary bypass. The second complication is staphylococcal sepsis, bilateral empyema thoracis, and bacterial pericarditis. This 13-year-old boy required bilateral pleural debridement followed 2 days later by open debridement of his heart. The final complication is thoracic outlet syndrome. These patients, age 12, 14, and 15, experienced persistent parasthesias in one upper extremity. One case was further complicated by instability of the bar requiring removal. In the other 2 patients, the symptoms resolved within 4 weeks with the bar in place.

CONCLUSIONS

Minimally invasive pectus repair is a new surgical procedure. The spectrum and rate of complications is still emerging. Thorough and critical evaluation of the combined experience from many centers is essential to evaluate fully this novel approach to pectus repair.

Randomized comparison of cisplatin/vincristine/fluorouracil and cisplatin/continuous infusion doxorubicin for treatment of pediatric hepatoblastoma: A report from the Children's Cancer Group and the Pediatric Oncology Group

PURPOSE

Previous studies demonstrated that chemotherapy with either cisplatin, vincristine, and fluorouracil (regimen A) or cisplatin and continuous infusion doxorubicin (regimen B) improved survival in children with hepatoblastoma. The current trial is a randomized comparison of these two regimens.

PATIENTS AND METHODS

Patients (N = 182) were enrolled onto study between August 1989 and December 1992. After initial surgery, patients with stage I-unfavorable histology (UH; n = 43), stage II (n = 7), stage III (n = 83), and stage IV (n = 40) hepatoblastoma were randomized to receive regimen A (n = 92) or regimen B (n = 81). Patients with stage I-favorable histology (FH; n = 9) were treated with four cycles of doxorubicin alone.

RESULTS

There were no events among patients with stage I-FH disease. Five-year event-free survival (EFS) estimates were 57% (SD = 5%) and 69% (SD = 5%) for patients on regimens A and B, respectively (P =.09) with a relative risk of 1.54 (95% confidence interval, 0.93 to 2.5) for regimen A versus B. Toxicities were more frequent on regimen B. Patients with stage I-UH, stage II, stage III, or stage IV disease had 5-year EFS estimates of 91% (SD = 4%), 100%, 64% (SD = 5%), and 25% (SD = 7%), respectively. Outcome was similar for either regimen within disease stages. At postinduction surgery I, patients with stage III or IV disease who were found to be tumor-free had no events; those who had complete resections achieved a 5-year EFS of 83% (SD = 6%); other patients with stage III or IV disease had worse outcome.

CONCLUSION

Treatment outcome was not significantly different between regimen A and regimen B. Excellent outcome was achieved for patients with stage I-UH and stage II hepatoblastoma and for subsets of patients with stage III disease. New treatment strategies are needed for the majority of patients with advanced-stage hepatoblastoma.

Abdominal wall defects in infants with very low birth weight

Management strategies for infants with very low birth weight (VLBW) who have abdominal wall defects essentially are the same as for those in larger infants. The authors favor primary closure in infants with gastroschisis, and have achieved this goal in 91% of infants since 1985. Treatment of infants with omphalocele is based on the size of the defect and the presence of respiratory insufficiency or severe associated anomalies. Nonoperative treatment is used initially for infants with large defects or associated anomalies, with planned closure of the resultant ventral hernia when the infant weighs 20 pounds or is 1 year old. This technique helps avoid the complications associated with mechanical ventilation and with tight primary closure such as intestinal dysfunction and wound problems.

Responsibility attitudes and interpretations are characteristic of obsessive compulsive disorder

The cognitive-behavioural theory of Obsessive Compulsive Disorder (OCD) proposes that a key factor influencing obsessional behaviour is the way in which the intrusive cognitions are interpreted. The present paper reports an investigation of links between clinical symptoms (of anxiety, depression and obsessionality) and responsibility beliefs. These beliefs include not only measures of general responsibility attitudes (assumptions) but also more specific responsibility appraisals consequent on intrusive cognitions. The characteristics of two new questionnaires specifically designed to measure these beliefs were assessed in patients suffering from Obsessive Compulsive Disorder, in patients suffering from other anxiety disorders and in non-clinical controls. The scales measuring negative beliefs about responsibility were found to have good reliability and internal consistency. Comparisons between criterion groups indicate considerable specificity for both assumptions and appraisals with respect to OCD. There was also good evidence of specificity in the association between responsibility cognitions and obsessional symptoms across groups, and that this association was not a consequence of links with anxiety or depressive symptoms. Although the two measures were correlated, they each made unique contributions to the prediction of obsessional symptoms. Overall, the results are consistent with the hypothesis that responsibility beliefs are important in the experience of obsessional problems.

Emotional disclosure in school children

Recent research with adults by Pennebaker and his colleagues has found that emotional disclosure through writing about stressful events appears to have significant benefits in terms of psychological and physical health outcomes. This report describes a controlled trial of emotional disclosure, adapted for school children, with the major hypothesis that the repeated description of negative events will have beneficial effects on measures of mental health, attendance, and school performance. The sample consisted of children aged 8-13 years from four schools, a primary and a secondary school both from a suburban and an inner-city area. Children were randomly assigned to one of three conditions: writing about negative events, writing about nonemotional events, and a non-writing control group. Children in all groups were seen four times during a single week and were then followed up after 2 months with measures of health and school performance. The intervention was well received by both schools and children, and the scripts written by the emotional and nonemotional writing groups differed in content in the predicted ways. Contrary to expectation, there was little evidence of a specific effect of emotional disclosure, and several possible reasons for this are discussed. Nevertheless, there was a general reduction in symptom measures, indicating that children may have benefited from their involvement in the study. Although there are several possible explanations for our findings, they indicate that it is both feasible and potentially valuable to give children opportunities to engage in discussion about sources of stress and their reactions to them.

Autobiographical memory processes and the course of depression

The authors report a 6-month follow-up study of clinically depressed patients. At baseline, 2 indexes of autobiographical memory functioning were assessed: the presence of spontaneous intrusive memories of stressful life events and performance on the Autobiographical Memory Test (J. M. G. Williams & K. Broadbent, 1986), which measures overgeneral memory. The index of overgeneral memory was associated with greater levels of spontaneous intrusion of stressful memories. Overgeneral memory did not predict outcome, but depression at follow-up was predicted by the amount of intrusion and avoidance of stressful memories, even after controlling for initial severity of psychiatric symptoms.

The Thought Control Questionnaire--psychometric properties in a clinical sample, and relationships with PTSD and depression

BACKGROUND

Recent developments in research suggest that particular attempts to control thoughts may contribute to the problem of intrusion. An instrument capable of identifying strategies for dealing with unwanted intrusions in clinical populations may be used for differentiating between thought control strategies that may or may not be helpful.

METHODS

The Thought Control Questionnaire (TCQ) (Wells & Davies, 1994) developed and validated on a normal sample, was administered to a clinical sample in order to investigate the consistency of the original factor structure and its psychometric properties. The sensitivity of the scale to change associated with recovery was also examined. Relationships between individual differences in thought control strategies and psychiatric symptoms in patients with DSM-IV major depression, and PTSD with or without major depression were investigated.

RESULTS

The Scree Test suggested a six-factor solution which was rotated. This solution split the original distraction subscale into separate behavioural and cognitive distraction, otherwise the subscales were almost identical to those obtained in non-clinical subjects. As this split has been shown to be unreliable, further analyses in this study were based on the five-factor version of the TCQ obtained by Wells & Davies (1994). Predictors of recovery and of symptoms in PTSD and depression were explored.

CONCLUSIONS

Correlations between the TCQ subscales and other measures suggest that particular thought control strategies may be associated with the symptoms of PTSD and depression. The TCQ scales appear to be sensitive to changes associated with recovery. Significant differences emerged in thought control strategies between depressed and PTSD patients. Hierarchical regression analysis showed distraction, punishment and reappraisal control strategies predicted depression scores in depressed patients while use of distraction predicted intrusions in PTSD.

Autobiographical memory processes and the course of depression

The authors report a 6-month follow-up study of clinically depressed patients. At baseline, 2 indexes of autobiographical memory functioning were assessed: the presence of spontaneous intrusive memories of stressful life events and performance on the Autobiographical Memory Test (J. M. G. Williams & K. Broadbent, 1986), which measures overgeneral memory. The index of overgeneral memory was associated with greater levels of spontaneous intrusion of stressful memories. Overgeneral memory did not predict outcome, but depression at follow-up was predicted by the amount of intrusion and avoidance of stressful memories, even after controlling for initial severity of psychiatric symptoms.

Cell surface colligin/Hsp47 associates with tetraspanin protein CD9 in epidermoid carcinoma cell lines

Hsps expressed on the cell surface have been associated with tumor invasiveness and used as targets for molecular surveillance. The present study utilized four human oral squamous cell carcinoma cells lines, SCC-4, SCC-9, SCC-15, SCC-25, the murine epidermoid carcinoma cell line LL/2, and primary cultures of human gingival fibroblasts to assess the cell surface expression of colligin/Hsp47, a proposed marker for malignancy. Immunoprecipitation studies following protein crosslinking revealed that Hsp47 was associated with a number of membrane proteins including the tetraspanin CD9. Cytometric analyses were performed to determine the distribution of cell surface colligin/Hsp47 during the phases of the cell cycle. These studies showed that colligin/Hsp47 was not limited to any phase of the cell cycle in epidermoid carcinoma cells. Boyden chamber tumor invasion assays and colloidal gold migration assays utilizing a reconstituted basement membrane (Matrigel), collagen type I, and laminin-5 substrates revealed that cell lines expressing constitutive high levels of colligin/Hsp47 manifested the lowest invasion and migration indices. The incorporation of antibodies against Hsps into the migration and invasion assays, likewise, increased the invasion indices and the phagokinetic migration indices. These data indicate that colligin/Hsp47 is anchored to the cell membrane in a complex with CD9 where it moderates tumor cell invasion and motility possibly by acting as a serpin protein inhibitor or as a receptor for collagen.

In vitro evidence for the presence of hematopoietic stem cells in the adult human liver

Previous studies have identified novel lymphoid phenotypes in the adult human liver and provided evidence to suggest that lymphoid differentiation can occur locally in this organ. The aim of this study was to examine the adult human liver for the presence of hematopoietic stem cells that may provide the necessary precursor population for local hematopoietic and lymphoid differentiation. Hepatic mononuclear cells (HMNC) were extracted from normal adult liver biopsy specimens using a combination of mechanical disruption and enzymatic digestion. The stem cell marker CD34 was found on 0.81% to 2.35% of isolated HMNCs by flow cytometry. CD34(+) HMNCs were positively selected using magnetically labeled beads, and the enriched population was further examined for surface markers characteristically expressed by immature hematopoietic cells and early progenitors. CD45 was expressed by 49% (+/-23%) of CD34(+) HMNCs, indicating their hematopoietic origin. CD38, one of the first markers to be expressed by developing progenitor cells was found on 50% (+/-22%) of CD34(+) HMNCs indicating the presence of both pluripotent stem cells and committed precursors. The majority (90%) of CD34(+) HMNCs coexpressed the activation marker human leukocyte antigen DR, consistent with actively cycling cells. Functional maturation of these hepatic progenitors was shown by the detection of multilineage hematopoietic colony formation after tissue culture. Erythroid (BFU-E), granulocyte-monocyte (CFU-GM), and mixed colonies (CFU-GEMM) were detected after culture of unseparated HMNCs and the enriched CD34(+) HMNC population; 14.3 +/- 13.2 (mean +/- SD) BFU-E, 3.1 +/- 3.1 CFU-GM, and 0.4 +/- 0.9 CFU-GEMM per 1 x 10(5) unseparated HMNCs and 16.0 +/- 9.5 BFU-E and 1.7 +/- 0.9 CFU-GM were identified per 2.4 x 10(3) CD34(+) HMNCs plated. The detection of surface markers characteristic of immature hematopoietic cells and colony formation in tissue culture provides evidence for the presence of hematopoietic stem cells and early progenitor cells in the adult human liver. This would suggest that the adult human liver continues to contribute to hematopoiesis and may be an important site for the differentiation of lymphohematopoietic cells involved in disease states, such as autoimmune hepatitis and graft rejection after liver transplantation.

A randomized trial of cognitive therapy and imaginal exposure in the treatment of chronic posttraumatic stress disorder

A randomized trial was performed in which imaginal exposure (IE) and cognitive therapy (CT) were compared in the treatment of chronic posttraumatic stress disorder (PTSD). Patients who continued to meet PTSD caseness at the end of a 4-week symptom-monitoring baseline period (n = 72) were randomly allocated to either IE or CT. There was a significant improvement in all measures over treatment and at follow-up, although there were no significant differences between the 2 treatments at any assessment. A significantly greater number of patients who showed worsening over treatment received IE, although this effect was not found at follow-up. Patients who worsened showed a greater tendency to miss treatment sessions, rated therapy as less credible, and were rated as less motivated by the therapist. It was concluded that either exposure or a challenge to cognition can result in symptom reduction, although neither resulted in complete improvement.

Pediatric liver tumors

An infant or child who presents with a large intrahepatic mass will most likely have a malignant tumor. In children, benign tumors constitute only 30% of liver tumors and most are vascular in origin. Treatment of benign vascular tumors is conservative and seldom surgical. Hepatoblastoma is the most common malignant tumor followed by hepatocellular carcinoma. Treatment of malignant tumors is based on a combination of surgery and chemotherapy. Children with hepatic malignancies that can be resected have an excellent prognosis. Other rare benign and malignant tumors of the liver do occur and surgery plays a critical role in management.

Intrusive memories in depression and posttraumatic stress disorder

This study compared the stressors and consequent intrusive memories reported by matched samples of patients with posttraumatic stress disorder (PTSD) and major depression. Although intrusive memories were slightly more common among PTSD patients, both quantitative and qualitative measures revealed few differences between the groups. PTSD patients were more likely to have experienced personal illness or assault, and depressed patients family deaths and illness, and interpersonal events. Factor analysis of the associated emotions and memory characteristics suggested the existence of specific links between fear and reliving, and helplessness and out-of-body experiences. Possible inhibitory relationships between fear and sadness, and between guilt and anger, were also noted.