Effects of kV, filtration, dose, and object size on soft tissue and iodine contrast in dedicated breast CT

PURPOSE

Clinical use of dedicated breast computed tomography (bCT) requires relatively short scan times necessitating systems with high frame rates. This in turn impacts the x-ray tube operating range. We characterize the effects of tube voltage, beam filtration, dose, and object size on contrast and noise properties related to soft tissue and iodine contrast agents as a way to optimize imaging protocols for soft tissue and iodine contrast at high frame rates.

METHODS

This study design uses the signal-difference-to-noise ratio (SDNR), noise-equivalent quanta (NEQ), and detectability (d´) as measures of imaging performance for a prototype breast CT scanner that utilizes a pulsed x-ray tube (with a 4 ms pulse width) at 43.5 fps acquisition rate. We assess a range of kV, filtration, breast phantom size, and mean glandular dose (MGD). Performance measures are estimated from images of adipose-equivalent breast phantoms machined to have a representative size and shape of small, medium, and large breasts. Water (glandular tissue equivalent) and iodine contrast (5 mg/ml) were used to fill two cylindrical wells in the phantoms.

RESULTS

Air kerma levels required for obtaining an MGD of 6 mGy ranged from 7.1 to 9.1 mGy and are reported across all kV, filtration, and breast phantom sizes. However, at 50 kV, the thick filters (0.3 mm of Cu or Gd) exceeded the maximum available mA of the x-ray generator, and hence, these conditions were excluded from subsequent analysis. There was a strong positive association between measurements of SDNR and d' (R²  > 0.97) within the range of parameters investigated in this work. A significant decrease in soft tissue SDNR was observed for increasing phantom size and increasing kV with a maximum SDNR at 50 kV with 0.2 mm Cu or 0.2 mm Gd filtration. For iodine contrast SDNR, a significant decrease was observed with increasing phantom size, but a decrease in SDNR for increasing kV was only observed for 70 kV (50 and 60 kV were not significantly different). Thicker Gd filtration (0.3 mm Gd) resulted in a significant increase in iodine SDNR and decrease in soft tissue SDNR but requires significantly more tube current to deliver the same MGD.

CONCLUSIONS

The choice of 60 kV with 0.2 mm Gd filtration provides a good trade-off for maximizing both soft tissue and iodine contrast. This scanning technique takes advantage of the ~50 keV Gd k-edge to produce contrast and can be achieved within operating range of the x-ray generator used in this work. Imaging at 60 kV allows for a greater range in dose delivered to the large breast sizes when uniform image quality is desired across all breast sizes. While imaging performance metrics (i.e., detectability index and SDNR) were shown to be strongly correlated, the methodologies presented in this work for the estimation of NEQ (and subsequently d') provides a meaningful description of the spatial resolution and noise characteristics of this prototype bCT system across a range of beam quality, dose, and object sizes.

A breast-specific, negligible-dose scatter correction technique for dedicated cone-beam breast CT: a physics-based approach to improve Hounsfield Unit accuracy

The purpose of this research was to develop a method to correct the cupping artifact caused from x-ray scattering and to achieve consistent Hounsfield Unit (HU) values of breast tissues for a dedicated breast CT (bCT) system. The use of a beam passing array (BPA) composed of parallel-holes has been previously proposed for scatter correction in various imaging applications. In this study, we first verified the efficacy and accuracy using BPA to measure the scatter signal on a cone-beam bCT system. A systematic scatter correction approach was then developed by modeling the scatter-to-primary ratio (SPR) in projection images acquired with and without BPA. To quantitatively evaluate the improved accuracy of HU values, different breast tissue-equivalent phantoms were scanned and radially averaged HU profiles through reconstructed planes were evaluated. The dependency of the correction method on object size and number of projections was studied. A simplified application of the proposed method on five clinical patient scans was performed to demonstrate efficacy. For the typical 10-18 cm breast diameters seen in the bCT application, the proposed method can effectively correct for the cupping artifact and reduce the variation of HU values of breast equivalent material from 150 to 40 HU. The measured HU values of 100% glandular tissue, 50/50 glandular/adipose tissue, and 100% adipose tissue were approximately 46, -35, and -94, respectively. It was found that only six BPA projections were necessary to accurately implement this method, and the additional dose requirement is less than 1% of the exam dose. The proposed method can effectively correct for the cupping artifact caused from x-ray scattering and retain consistent HU values of breast tissues.

PET characteristics of a dedicated breast PET/CT scanner prototype

A dedicated breast PET/CT system has been constructed at our institution, with the goal of having increased spatial resolution and sensitivity compared to whole-body systems. The purpose of this work is to describe the design and the performance characteristics of the PET component of this device. Average spatial resolution of a line source in warm background using maximum a posteriori (MAP) reconstruction was 2.5 mm, while the average spatial resolution of a phantom containing point sources using filtered back projection (FBP) was 3.27 mm. A sensitivity profile was computed with a point source translated across the axial field of view (FOV) and a peak sensitivity of 1.64% was measured at the center of the FOV. The average energy resolution determined on a per-crystal basis was 25%. The characteristic dead time for the front-end electronics and data acquisition (DAQ) was determined to be 145 ns and 3.6 micros, respectively. With no activity outside the FOV, a peak noise-equivalent count rate of 18.6 kcps was achieved at 318 microCi (11.766 MBq) in a cylindrical phantom of diameter 75 mm. After the effects of exposing PET detectors to x-ray flux were evaluated and ameliorated, a combined PET/CT scan was performed. The percentage standard deviations of uniformity along axial and transaxial directions were 3.7% and 2.8%, respectively. The impact of the increased reconstructed spatial resolution compared to typical whole-body PET scanners is currently being assessed in a clinical trial.

Singleton term breech deliveries in nulliparous and multiparous women: a 5-year experience at the University of Miami/Jackson Memorial Hospital

OBJECTIVE

The purpose of this retrospective study was to evaluate the feasibility of planned vaginal delivery, the maternal morbidity and mortality, and the short-term perinatal outcome in selected multiethnic women at term with singleton breech presentations.

STUDY DESIGN

Singleton breech deliveries were identified from the delivery database between January 1, 1989, and December 31, 1993. A retrospective chart review identified 310 nulliparous and 711 multiparous women at term (37-42 weeks) for a total of 1021. Parameters studied included the success rate of planned vaginal deliveries and the incidences of maternal morbidity, perinatal morbidity, and mortality as a whole stratified by parity and mode of delivery. The Student t test, chi(2) test, and Fisher exact test were used for statistical analysis.

RESULTS

Among 1021 women with singleton fetuses in a breech position at term, 191 were candidates for vaginal delivery, and 135 (70.7%) of these deliveries were successful. By parity, 12.3% of 310 nulliparous women and 21.5% of 711 multiparous women were candidates for vaginal delivery; 50% of the former and 75.8% of the latter underwent vaginal delivery. Maternal morbidity was more commonly associated with multiparity and cesarean delivery. Newborn intensive care admissions were equally distributed by parity, and significantly more were for vaginal than cesarean deliveries (17.4% vs 10.8%, P =.036). Premature rupture of the membranes complicated deliveries in 23.9% of the nulliparous women and only 6.5% of the multiparous women (P =.000).

CONCLUSION

In this multiethnic population 70.7% of candidates selected for attempted vaginal breech delivery at term were successful. The remaining 29.3% underwent cesarean delivery for labor disorders or nonreassuring fetal heart rate patterns.

A double-blind randomized trial of two dose regimens of misoprostol for cervical ripening and labor induction

OBJECTIVES

The objective of this study was to compare the efficacy and safety of two dosing regimens of misoprostol for cervical ripening and labor induction.

METHODS

Patients who fulfilled the study criteria were randomized to received misoprostol 25 microg or 50 microg intravaginally every 3 h for a total of eight doses for cervical ripening or until labor was established. Endpoints for successful cervical ripening was achievement of Bishop score of nine or greater, and for labor induction reaching the active phase of labor in the first 24 h. The rates of success, duration of first and second stages of labor, type of delivery, significant side effects, and neonatal outcome were measured and compared between the two study groups. Two hundred and fifty-one patients were randomized in two groups--126 received 50 microg and 125 received 25 microg misoprostol. Demographics of the two study groups were similar.

RESULTS

Patients in the 50 microg group had a shorter first stage (848 min vs. 1,122 min, P < 0.007), shorter induction-to-vaginal delivery interval (933 min vs. 1,194 min, P < 0.013), decreased incidence of oxytocin augmentation (53.9% vs. 68%, P < 0.015), and decreased total units of oxytocin (2,763 mU vs. 5,236 mU, P < 0.023), but there was a higher hyperstimulation rate (19% vs. 7.2%, P < 0.005).

CONCLUSIONS

Successful induction rate, delivery types, and fetal outcome were similar in both groups. Although the rate of vaginal delivery and neonatal outcome were similar in both groups, the 50 microg regimen had shorter first and second stages of labor, and a higher hyperstimulation rate that was easily manageable, allowing for flexibility in using the higher dose in low-risk pregnancies.

Prenatal care in cocaine-exposed pregnancies

OBJECTIVE

To examine the effect of prenatal care with and without drug rehabilitation on perinatal outcome in cocaine-using women.

METHODS

Cocaine-exposed pregnancies of 905 human immunodeficiency virus (HIV)-negative women were frequency matched (ratio 6:1) and compared with 150 nonusers. Cocaine subgroups consisted of 278 women who received prenatal care and drug rehabilitation ("comprehensive care"), 206 women who received prenatal care only, and 421 who received neither. Maternal and fetal complications, drug screening, and attendance were recorded. Pregnancy rates and HIV seroconversion were determined over the year following delivery.

RESULTS

The groups were similar in age, race, education and poverty level. Linear trends of increasing incidence of maternal complications were seen across the four groups. Comparing nonusers with cocaine users, the odds ratios, with 95% confidence intervals were: 28.0 (4.2, 103.2) for both anemia and weight under 100 lb; 2.4 (1.8, 5.0) for urinary tract infections; 15 (4.6, 36.1) for syphilis; and 11.2 (4.0, 35.8) for other sexually transmitted diseases. Perinatal outcome measures were similar for nonusers and "comprehensive care" groups but significantly worse for the other two groups. Four maternal deaths and two myocardial infarctions occurred with no care. Positive toxicology at delivery was 1.5 and 4.3 times more likely for the two groups without drug treatment, than for "comprehensive care." Congenital anomalies and HIV seroconversion increased in cocaine users. Repeat pregnancy was less likely and more often drug free with "comprehensive care."

CONCLUSION

"Comprehensive care" of the cocaine-using gravida increases the likelihood of carrying to term, having fewer complications, being drug free at delivery, and having fewer exposed repeat pregnancies.

Comparison of production of Staphylococcus intermedius exotoxin among clinically normal dogs, atopic dogs with recurrent pyoderma, and dogs with a single episode of pyoderma

OBJECTIVE

To determine whether exotoxin production by Staphylococcus intermedius is an important factor in recurrence of pyoderma in atopic dogs.

DESIGN

Prospective clinical study.

ANIMALS

30 client-owned dogs (10 clinically normal dogs, 10 atopic dogs with recurrent pyoderma, and 10 dogs with a single episode of pyoderma).

PROCEDURE

Specimens for bacterial culturing were obtained from a pustule or papule of affected dogs or from skin of clinically normal dogs. Staphylococcus intermedius was isolated and processed. Supernatants were analyzed for staphylococcal exotoxins. Types of lesions and severity of pruritus were assessed for each dog.

RESULTS

Exotoxins A and C were detected in S intermedius isolated from 1 clinically normal dog. In the atopic group, exotoxin C was isolated from 1 dog, exotoxins A and C were isolated from 1 dog, and exotoxin C and toxic shock syndrome toxin-1 were isolated from 1 dog. Exotoxins were isolated from 2 dogs with a single episode of pyoderma (exotoxin C, 1 dog; exotoxins A and C, 1 dog). Lesion types and severity of pruritus varied greatly among dogs with pyoderma and were not associated with detection of exotoxin or type of exotoxin.

CLINICAL IMPLICATIONS

Exotoxins were identified from few isolates of S intermedius, and we did not observe an association between type of lesions or severity of pruritus and detection of exotoxins. Production of exotoxin by S intermedius does not play a role in the recurrent nature of pyoderma in atopic dogs or on type of lesion or severity of pruritus associated with pyoderma.

Fetal tissue typing in anticipation of neonatal heart transplantation

BACKGROUND

Hypoplastic left heart syndrome is among the most common major congenital cardiac anomalies. Fetuses with this anomaly survive but require either reconstructive surgery or heart transplantation postnatally.

CASE

A woman whose fetus was diagnosed with hypoplastic left heart syndrome underwent funipuncture for fetal tissue typing. The fetus then was listed for heart transplantation. Once an ABO-compatible donor heart was procured, the fetus was delivered and immediately underwent transplantation.

CONCLUSION

In candidates for neonatal heart transplantation, fetal tissue typing allows the search for an ABO-compatible donor heart to begin earlier. This approach minimizes the morbidity associated with postnatal waiting and allows transplantation to take place while the neonate is less immunocompetent.

Comparison of conjunctival autografts, amniotic membrane grafts, and primary closure for pterygium excision

OBJECTIVE

The purpose of the study is to determine whether amniotic membrane can be used as an alternative to conjunctival autograft after pterygium excision.

DESIGN

A prospective study of amniotic membrane grafts (group A) and primary closure (group B) was compared retrospectively with conjunctival autografts (group C) in patients with pterygia.

PARTICIPANTS

Group A included 46 eyes with primary pterygia and 8 eyes with recurrent pterygia, group B had 20 eyes with primary pterygia, and group C consisted of 78 eyes with primary and 44 eyes with recurrent pterygia.

INTERVENTION

For the above three different surgeries, the amount of tissue removed was estimated from histopathologic analysis, and the result was evaluated by clinical examination.

MAIN OUTCOME MEASURES

Recurrence, survival analysis, and final appearance were compared.

RESULTS

In group A, the recurrence rate was 10.9%, 37.5%, and 14.8% for primary, recurrent, and all pterygia, respectively (mean follow-up, 11 months). These three rates were significantly higher than 2.6%, 9.1%, and 4.9% noted in group C (mean follow-up, 23 months) (P < 0.001, 0.018, and 0.01, respectively). However, the latter recurrence rate was significantly lower than 45% (mean follow-up, 5.2 months) in group B for primary pterygia (P < 0.001). The onset of recurrence was delayed significantly in group C as compared with that of groups A and B.

CONCLUSIONS

The relatively low recurrence rate for primary pterygia allows one to use amniotic membrane transplantation as an alternative first choice, especially for advanced cases with bilateral heads or those who might need glaucoma surgery later.

Patterns of cocaine binging: effect on pregnancy

OBJECTIVE

The purpose of this study was to determine how cocaine and crack binging affected perinatal complications.

STUDY DESIGN

Between Jan. 1 and Dec. 31, 1989, patterns of cocaine-crack binging and perinatal consequences in 905 pregnant women from multiethnic, multiracial, inner-city populations were studied. Binging cycles reflect the chaotic lifestyle of drug abuse and multiple obstetric at-risk cofactors as integral parts of binging and are more accurately defined than amount of drugs consumed.

RESULTS

Binging patterns in 905 pregnant women who use cocaine-crack as their primary drug were as follows: group 1, 78 women with "erratic" binging that is variable in intervals, duration, and amounts but who are very aggressive drug seekers; group 2, 67 women who binged daily; group 3, 760 women who binged in cycles at 3-, 5-, 7-, or > 7-day intervals. Binges ranged from 26.4 to 34.4 hours. Complications were proportional to the frequency of binging, (linear association p < 0.0007). The prematurity rate in group 1 was unexpectedly as high as that in group 2 (35.9% vs 34.3%). Acute problems (vaginal bleeding 21.8%, abruptio placentae 14.3%, stillbirths 20.5%) were most significant in group 1, while chronic problems (small-for-gestational-age infants 32.8%, systemic infections 31.3%, anemia 35.6%, and low maternal weight [< 100 pounds] 32.8%) were more significant in groups 2 and 3. Odds ratios show that prematurity, abruptio placentae, and vaginal bleeding were two to three times more likely to occur if test results for cocaine were positive at delivery. However, in group 1 the likelihood of abruptio placentae was unchanged whether toxicologic test results were positive (14.3%) or negative (14.0%), reflecting the role of cofactors in binging.

CONCLUSION

Erratic use of cocaine-crack results in perinatal complications that are as severe as those occurring with daily binging but the patterns differ. Cofactors play a significant role in outcomes.

Cocaine-related maternal death

Hemodynamic overload, cardiac ischemia, and arrhythmia are postulated to originate from "sex-cocaine" syndrome resulting in maternal and fetal death. High concentrations of cocaine and metabolites in maternal blood, urine, and nasal secretions confirmed recent ingestion. Changes in the maternal life-style may have contributed to the poor pregnancy outcome.

Perinatal implications of cocaine exposure

Obstetric outcome was reviewed for 139 women who volunteered information on cocaine abuse during pregnancy past 20 weeks. Information on the duration of use during pregnancy was not accurate enough for documentation. In previous pregnancies, only 44.6% of the infants were live born, with spontaneous or therapeutic abortions in 41.1% and stillbirths accounting for 3.6%. In the current pregnancies, 91 patients (66.1%) were nonwhite, and multiple-drug usage was found in 92%, with intravenous cocaine use in 44.6% and freebasing in 31.7% as the main routes of administration. Syphilis or another infection, no prenatal care and poor weight gain (less than or equal to 19 lb) in pregnancy was present in one-third of the patients, while 38% did not know their gestational age. Precipitate labor was found in 63.9% and meconium-stained amniotic fluid in 20.5%. The mean birth weight of the infants was significantly lower than that of the general hospital population; low birth weight (less than 2,500 g) occurred in 36.2%, small size for gestational age in 32.4%, neurologic problems in 30.9% and syphilis in 15.4% of the infants. Congenital abnormalities, in 17.4%, seemed to be multifactorial. The consistent pattern of poor outcome in both the previous and present pregnancies reflects the life-style peculiar to cocaine abusers. Prospective studies are in progress to identify the true incidence of cocaine usage and to outline the counseling of childbearing women against cocaine use during pregnancy, emphasizing prevention since cures are not available.

Evaluation of surgical staples in cesarean section

Experience with Lactomer absorbable surgical staples (Auto Suture Poly CS 57 disposable surgical stapler) in 62 cesarean sections was compared with an equal number of operations performed with standard techniques. The technique of application of the stapler evolved with experience. Countertraction to staplers with Allis' clamps prevented uterine V incisions. Operative time was longer for the stapled suture group for primary cesarean sections, but was unchanged for repeat procedures. Excellent hemostasis of the uterine incision was achieved even when varicose sinusoidal veins were present. Significant reductions of hemoglobin deficits from 2.16 to 1.31 gm/dl, postoperative anemia from 29% to 6.4%, and endometritis from 22.5% to 6.4% occurred respectively in nonstapled and stapled groups. A reduced hospital stay, shortened by 2.1 days, saved each patient +F42950. Blood loss estimates by surgeons or anesthetists were often at variance. Surgeons' acceptance of the procedure grew with experience. On the basis of these results, use of absorbable staples offers certain advantages in reducing blood loss, infection, and hospital stay in cesarean deliveries.

Effect of mode of delivery on incidence of respiratory distress syndrome

The effect of route of delivery on incidence of respiratory distress syndrome (RDS) has been controversial. While some investigators have reported no difference in RDS rates in infants born by cesarean section as compared to vaginal delivery, others have shown a significant increase in risk for RDS among infants born by cesarean section. Data from the 297 patients comprising the placebo group in the recently completed collaborative study of antenatal steroid therapy in the prevention of neonatal RDS, were analyzed to determine the effect of mode of delivery on RDS. The results indicate that infants born by cesarean section without labor have a higher risk for neonatal RDS than infants born vaginally or by cesarean section after a trial of labor.

Acute appendicitis during pregnancy. Diagnosis and management

Twelve patients underwent appendectomy during pregnancy or in the puerperium. The clinical presentation of acute appendicitis is altered during gestation, and diagnosis becomes increasingly difficult when close to term. Abdominal pain, nausea, and vomiting are important symptoms. Peritoneal signs occur in the right lower quadrant early in pregnancy, but the upper quadrant or entire right side are more common locations, as the appendix is displaced upward by the enlarging uterus. Delay in treatment is common because of uncertainty in making the diagnosis and hesitancy to proceed with surgery. In the group of six patients with perforation, there was one maternal death and a loss of three fetuses. There were no complications in the absence of perforation. Prompt diagnosis is the cornerstone of a good outcome, and early surgical intervention is indicated if acute appendicitis is suspected. Pregnancy is not a reason to delay surgery. We review the literature on this topic and present and analyze principles of management.

Lupus nephropathy and pregnancy

Early reports on SLE were too small in number to determine that pregnancy was contraindicated in patients with renal involvement. Later reports show that patients with lupus nephropathy can have successful pregnancies provided certain preconditions are established. Optimal preconditions include prepregnancy remission of at least 6 months, renal function with serum creatinine 1.5 mg/dl or less or creatinine clearance of 60 ml/min or more or proteinuria of 3 g/24 hr or less. Successful pregnancies have been recorded in some patients with more severe renal impairment. Renal function will remain unchanged in approximately 60% of pregnancies; and although deterioration may occur, it is only severe or permanent in less than 10%. In 26% of patients, mild to severe renal impairment was transient, with recovery to prepregnancy levels of renal function. Proteinuria with good creatinine clearance may not be dangerous. Hypertension or superimposed preeclampsia jeopardizes the outcome. Fetal outcome averaged approximately 70% (range, 41-77%) live births, 17.8% (range, 5.1-40%) spontaneous abortions, 19.7% (range, 3.0-38.5%) prematurity, and 8.2% SGA. Therapeutic abortion is not a modality of treatment of lupus nephropathy. Management of patients with lupus nephropathy is twofold and includes suppression of underlying lupus activity as well as the serial evaluation of chronic renal disease. In chronic lupus nephropathy with inactive SLE maternal and fetal outcome is the same as for pregnant patients with chronic renal disease of other causes. Strict fetal surveillance must be performed to decrease the stillbirth rate. The concomitant increase in prematurity demands the services of a tertiary care neonatal unit. Management necessitates the team approach of the obstetrician, nephrologist, rheumatologist, and neonatologist working in collaboration. The reports which contain large numbers of patients now allow better counseling of these patients who are contemplating pregnancy.

Association between ruptured membranes, tocolytic therapy, and respiratory distress syndrome

Two hundred ninety-seven patients from the placebo group of the National Institutes of Health Collaborative Study on Antenatal Steroid Therapy for prevention of respiratory distress syndrome were selected for analysis to investigate a possible association between premature rupture of the membranes, tocolytic therapy, and respiratory distress syndrome. Both premature rupture of the membranes and tocolytic therapy with isoxsuprine were individually associated with a lowered incidence of respiratory distress syndrome. However, when present together, their protective effect was not additive and resulted in a higher incidence of respiratory distress syndrome. It is suggested that the use of tocolytic therapy with beta-adrenergic agents be restricted to patients with intact membranes.

Maternal smoking and respiratory distress syndrome

Infants of 603 patients on whom information about smoking habits during pregnancy was available were studied for incidence respiratory distress syndrome. Among the 360 patients who did not smoke, the incidence of respiratory distress syndrome in the neonate was 15.1%, whereas among patients who smoked, the incidence was 9.1%. We speculate that smoking produces a condition of chronic stress in the fetus which brings about an acceleration of fetal pulmonary maturation.

Periarteritis nodosa and pregnancy

Pregnancy in patients with periarteritis resulted in maternal death in 7 of the 8 cases that have been reported. In the present case, periarteritis was in remission throughout the pregnancy; the patient was thus the second known maternal survivor. The infant also did well. It is suggested that pregnancy probably does not have as direct an effect on the course of the disorder as appears from the outcome of the previous cases. Extreme caution must prevail, especially as diagnosis is often difficult and experience so limited.

Blood glucose control during pregnancy

Pregnant diabetic women represent a unique category of patient in whom diabetic control is most desirable, since even minor degrees of hyperglycemia have adverse effects on the conceptus. In 18 insulin-dependent pregnant diabetic women (White Class B, N = 4; C, N = 5; D, N = 7; and R, N =2), we have utilized a therapeutic program consisting of intensive patient education, a multiple-component insulin regimen (two to four injections daily), careful dietary control, and meticulous balancing of food, activity, and insulin dosage, monitoring such balance with patient-determined blood glucose measurements four to seven times daily using the Dextrostix/Eyetone system. Our goals for blood glucose management have been to attain fasting levels of 60-90 mg/dl, preprandial levels less than 105 mg/dl, and postprandial levels less than 120 mg/dl, in the absence of significant hypoglycemia. We have been able to attain these goals for most of the period of monitoring in the majority of these patients, while in the others we have achieved marked improvement in diabetic control, although we did not consistently attain our goals. Despite this, there was not infrequent neonatal morbidity, including a 33% frequency of macrosomia, an 11% frequency of significant hypoglycemia, and a 22% frequency of congenital malformation. Nevertheless, all infants survived and are generally healthy, whereas only 38% of 21 previous pregnancies in these same women have eventuated in living offspring. Thus, although further refinement is clearly indicated, it appears that our approach has resulted in improved pregnancy outcome. Patient self-monitoring of blood glucose is a procedure that is relatively simple, practical, acceptable to patients, and facilitates the attainment of glycemic control.

Psychosexual attitudes in the female following sterilization

This study represents a three year follow-up, summarizing the psychosexual attitudes of 120 patients who were sterilized with tubal occlusion by one of three methods: culdoscopy, laparoscopy or postpartum laparotomy. The results indicate that most patients had a favorable impression of the procedure with little significant change in their sexual habits. Eight per cent of patients expressed regret at not being able to have more children. The frequency of coitus remained largely unchanged.