Allan G.W. McLeod

Septic shock of endotoxin type: Some observations based on the management of 50 patients

Abstract Septic shock of the endotoxin type remains of major importance because of persisting high mortality rates. Theories of pathogenesis remain mutually contradictory in many respects, and more basic work is required in this area. The treatment of this condition remains controversial. Fifty cases of septic shock in gynecologic and obstetric patients are reviewed. In 44 women the condition was associated with pregnancy. Septic abortion, chorioamnionitis, and pyelonephritis were the main sources of the infection. Methods of monitoring the patient in septic shock with special attention to blood pressure, central venous pressure, blood volume changes, and urinary output are discussed. Early surgical intervention and the proper use of vasopressors and corticosteroids in pharmacologic doses yielded good results in terms of patient survival. The mortality rate was 26 per cent in the first 6 years of the study and 5.3 per cent in the last 21 months. The over-all mortality rate was 18 per cent.

Septic shock in obstetrics and gynecology

Abstract 1.1. Thirty-five women in septic shock treated with metaraminol were studied. Their ages ranged from 17 to 65 years with the median age being 37 years. The most common cause of shock was septic abortion. 2.2. Twenty-three patients survived, but whereas 21 of 24 patients in moderate shock survived, only 3 of 11 patients in severe shock remained alive. This emphasizes the great need for early diagnosis as well as adequate treatment. 3.3. Metaraminol appears to be a useful agent in the management of septic shock. It has a relatively rapid onset and protracted action with minimal side effects. Patients who failed to respond to metaraminol were not improved when given other more potent vasopressor agents such as l-norepinephrine. 4.4. Corticosteroids were combined with vasopressor therapy in 18 patients and 16 of these responded satisfactorily. 5.5. Three patients maintained on metaraminol for over 48 hours, including one for 96 hours, recovered. Although vasopressors should be discontinued as soon as possible, these survivals suggest that perhaps the dangers of prolonged vasopressor therapy have been exaggerated. 6.6. In the patient with a septic incomplete abortion, the use of a suitable vasopressor is particularly useful to allow time for adequate evaluation of the patient, the institution of antibiotic therapy, and prompt evacuation of the uterus.

Prospective pricing system by diagnosis-related groups: comparison of federal diagnosis-related groups with high-risk obstetric care groups.

Of 468 diagnosis-related groups identified by the federal government for Medicaid reimbursement, 15 are related to obstetric hospital care. Each diagnosis-related group is considered a distinct group in which cases are homogeneous with respect to resource consumption. Because the diagnosis-related group system is based primarily on data from community and secondary care hospitals, it does not differentiate sufficiently among high-risk obstetric patients seen at tertiary care institutions, such as Floridas Regional Perinatal Intensive Care Centers. We developed an alternative scheme for diagnosis-related groups, called obstetric care groups, using the federal diagnosis-related groups as the model from which to depart. Data collected for 4192 women during a 2 1/2-year period indicate that obstetric care groups provide more homogeneous groups than diagnosis-related groups for our population of high-risk patients. The obstetric care groups differentiate between no complications, one complication, and two or more complications, while the diagnosis-related groups differentiate only between no complications and one or more complications. Also, complications for obstetric care groups are based on only 19 diagnoses that contribute significantly to resource consumption, while the list of possible complications exceeds 200 for diagnosis-related groups. Although the obstetric care group classification system is simpler than that for diagnosis-related groups, it results in a more accurate reimbursement of hospitalization charges for high-risk obstetric care.

Fatal amniotic fluid embolism in Dade County: An unusual incidence

Abstract Analysis of 6 maternal deaths due to amniotic fluid embolism revealed no satisfactory explanation for the increased incidence, but it did reinforce the need for more detailed study of each case, especially the hematologic changes in this condition to confirm the role of anticoagulant therapy as part of management. Improved mechanisms for notification and follow-up are urgently required in addition to accurate record keeping to facilitate study of all maternal deaths.

Retrospection and prospection.

Abstract It is with considerable pride, great appreciation, and some trepidation that I stand here to present this address. I cannot but recognize that you have elected me to a distinguished group of persons that contains names such as “Daddy” Ross, Bayard Carter, Frank Lock, Charles Collins, and many others who, each in his own way, has contributed much to our specialty and to this Association. Quite a tribute to a foreign medical graduate!

Multiple primary carcinoma of the uterus: Review of the literature and report of a case

Abstract 1. 1. The literature on multiple primary cancer with reference to the coexistent occurrence of squamous cell carcinoma of the cervix and adenocarcinoma of the endometrium is reviewed. 2. 2. A case of intraepithelial carcinoma of the cervix occurring simultaneously with adenocarcinoma of the endometrium is reported. 3. 3. Possible explanations for the paucity of reports is discussed and the possibility of these tumors being mutually antagonistic is considered. 4. 4. The necessity for diagnostic curettage in the investigation of postmenopausal bleeding, even in the presence of a negative Papanicolaou smear, is stressed. The value of multiple punch biopsies of the cervix, even in the absence of a visible lesion, is emphasized.