Matthew Kim

Oral mucositis in patients undergoing bone marrow transplantation

Thirty patients who received bone marrow transplantation treatment from HLA identical sibling donors for immunologic and malignant diseases were studied. In essentially all of the patients oral changes developed during the first 30 days following transplant. Oral symptoms frequently constituted the major complaints of the patients during the follow-up period. The oral changes included mucositis, xerostomia, pain, and bleeding. Mucositis was more severe and of longer duration when associated with herpes simplex infections and when optimal oral hygiene was not maintained. Xerostomia which accompanies engraftment was an early sign of acute graft-versus-host disease. A nonbrushing method of oral hygiene was effective in reducing the severity and duration of mucositis. This technique offers a short-term alternative to brushing in pancytopenic patients who are susceptible to bleeding or trauma.

Methamphetamine use during pregnancy: maternal and neonatal implications.

OBJECTIVE: To report the demographic characteristics and clinical morbidity of methamphetamine-exposed pregnancies compared with control patients in a tertiary care, urban, academic medical center. METHODS: A single-site chart review from 2000 to 2006 was conducted. International Classification of Diseases, 9th Revision code 648.3x was used to identify potential study participants. Specific inclusion criteria required either a positive urine drug screen for methamphetamine use or by patient statement of methamphetamine use during pregnancy. Data from 276 identified patients were then compared with the 34,055 in the general obstetric population during the same period for various demographic factors and perinatal outcomes. RESULTS: Two hundred seventy-six patients responsible for 273 live births were identified between 2000 and 2006. Factors that were significantly associated with methamphetamine use were age younger than 20 years (9% methamphetamine compared with 16% control patients), non-Hispanic white ethnicity (55% compared with 71%), married (12% compared with 46%), preterm delivery (52% compared with 17%), low Apgar scores (6% compared with 1–2%), cesarean delivery (29% compared with 23%), and neonatal mortality (4% compared with 1%). Additionally, the maternal demographic characteristics suggested that these women were more likely to be unemployed, use other abusive substances, and have higher rates of domestic violence and adoption when compared with the control population. CONCLUSION: Methamphetamine use in pregnancy is complicated by more morbid maternal and neonatal outcomes when compared with the general obstetric population. Because the patients in this study were in a variety of ways demographically distinct, attempts to identify these patients early and intervene in an effort to improve pregnancy-related outcomes appears possible and warranted. LEVEL OF EVIDENCE: II

Effectiveness of hospital-based postpartum procedures on pertussis vaccination among postpartum women

OBJECTIVE Pertussis causes significant morbidity among adults, children, and especially infants. Since 2006, pertussis vaccination has been recommended for women after delivery. We conducted a prospective, controlled evaluation of in-hospital postpartum pertussis vaccination of birth mothers from October 2009 through July 2010 to evaluate the effectiveness of hospital-based procedures in increasing postpartum vaccination. STUDY DESIGN The intervention and comparison hospitals are private community facilities, each with 2000-6000 births/year. At the intervention hospital, physician opt-in orders for tetanus toxoid, reduced diphtheria toxoid and acellular pertussis vaccine (Tdap) before discharge were implemented in November 2009, followed by standing orders in February 2010. The comparison hospital maintained standard practice. Randomly selected hospital charts of women after delivery were reviewed for receipt of Tdap and demographic data. We evaluated postpartum Tdap vaccination rates and conducted multivariate analyses to evaluate characteristics that are associated with vaccination. We reviewed 1264 charts (658 intervention hospital; 606 comparison hospital) from women with completed deliveries. RESULTS Tdap postpartum vaccination was 0% at both hospitals at baseline. In the intervention hospital, the introduction of the opt-in order was followed by an increase in postpartum vaccination to 18%. The introduction of the standing order approach was followed by a further increase to 69% (P < .0001). No postpartum Tdap vaccinations were documented in the comparison hospital. Postpartum Tdap vaccination in the intervention hospital did not differ by demographic characteristics. CONCLUSION In-hospital ordering procedures substantially increased Tdap vaccination coverage in women after delivery. Opt-in orders increased coverage that increased substantially with standing orders.

First-trimester visualization of the fourth ventricle in fetuses with and without spina bifida.

The purpose of this study was to examine the efficacy of nonvisualization of the fourth ventricle for first‐trimester detection of spina bifida.

Teaching forceps: the impact of proactive faculty

OBJECTIVE The objective of the study was to evaluate the impact on resident forceps experience by a single proactive teacher. STUDY DESIGN A study was performed to assess the impact on delivery statistics and outcome following the assignment of a single attending to teach forceps to residents. A 2 year period immediately preceding and 2 years following the study was compared using χ(2) and Student t tests. RESULTS After appointment of the specific teaching attending, forceps deliveries increased by 59% (8% of all births), whereas vacuum procedures decreased to 3% of births (P < .0001) compared with the prior 2 years. The overall percentage of operative vaginal deliveries remained unchanged (11%). Cesarean section rates were unchanged during the study period at 27% of all births. Perineal laceration, 5 minute Apgar less than 7, and birth injuries were also not statistically different. There were fewer fetal pH events less than 7.1 in the teaching period (P = .003). CONCLUSION In the population studied, there was an association between increasing resident forceps use and a positive impact on birth outcomes from the designation of a full-time, experienced, and proactive faculty member to obstetrics teaching duty.

OC12.02: Spina bifida detection at 11–14 weeks: systematic analysis of technical factors associated with false‐positive and false‐negative image interpretation

Objectives: Screening at 11–14 weeks is changing from a simple NT measurement to a comprehensive first trimester anomaly scan. However, the detection of open neural tube defect (NTD) before 14 weeks is still a challenge, since lemon and banana signs, used in second trimester ultrasound, are rarely present. Aim of the study is to seek for simple first trimester signs to alert the examiner for the presence of NTD. Methods: The midsagittal view of the face used for NT and nasal bone measurements was analyzed in normal fetuses and fetuses with NTD. The region between the brain stem and occipital bone, includes the 4th ventricle (intracranial translucency = IT), the choroid plexus of the 4th ventricle and the future cisterna magna. Results: In normal fetuses between 11–14 weeks there is an increase in the anterior posterior diameters of posterior fossa structures. Fetuses with NTD detected prospectively and retrospectively showed however abnormal values due to the downward shifting of the brain stem. Conclusions: In the plane used for NT measurement the evaluation of the posterior part of the brain between the brain stem and the occipital bone appears to be the clue in suspecting NTD at the 11–14 weeks scan. Further prospective studies are needed to find the sensitivity of these observations during routine screening.

OC12.03: Visualization of the fourth ventricle in first trimester fetuses with a normal spine versus spina bifida

Objectives: Screening at 11–14 weeks is changing from a simple NT measurement to a comprehensive first trimester anomaly scan. However, the detection of open neural tube defect (NTD) before 14 weeks is still a challenge, since lemon and banana signs, used in second trimester ultrasound, are rarely present. Aim of the study is to seek for simple first trimester signs to alert the examiner for the presence of NTD. Methods: The midsagittal view of the face used for NT and nasal bone measurements was analyzed in normal fetuses and fetuses with NTD. The region between the brain stem and occipital bone, includes the 4th ventricle (intracranial translucency = IT), the choroid plexus of the 4th ventricle and the future cisterna magna. Results: In normal fetuses between 11–14 weeks there is an increase in the anterior posterior diameters of posterior fossa structures. Fetuses with NTD detected prospectively and retrospectively showed however abnormal values due to the downward shifting of the brain stem. Conclusions: In the plane used for NT measurement the evaluation of the posterior part of the brain between the brain stem and the occipital bone appears to be the clue in suspecting NTD at the 11–14 weeks scan. Further prospective studies are needed to find the sensitivity of these observations during routine screening.

Are open box gloves clean enough to perform vaginal examinations

the average of the past two years (16.5%). In May 2003, B. cepacia was detected in 17 (19.3%) of 88 patients (Figure 1); therefore we concluded that an outbreak had occurred. In the patients in whom B. cepacia was detected, however, subjective symptoms such as fever, an increase of discharge or objective symptoms such as increases in C-reactive protein or white blood cells were not detected. Environmental research was carried out to investigate the common source of infection. There were ten irrigators at outpatient and inpatient wards in our hospital. The benzalkonium chloride solution in all the irrigators was cultured. Next, undiluted solutions of benzalkonium chloride and the distilled water used for preparation were cultured. A total of nine environmental samples were collected. B. cepacia was cultured from all irrigators whereas Pseudomonas aeruginosa was not cultured from any. B. cepacia was also detected in the unopened 0.02% benzalkonium chloride liquid prepared in our hospital. In addition, B. cepacia was not grown from undiluted benzalkonium chloride and distilled water manufactured in our hospital. We stopped using irrigators immediately. When patients needed vagina disinfection, we used commercially available 0.25% inverted soap. Examining hands or vaginal speculi were moistened with saline when we performed pelvic or speculum examinations. By stopping use of the irrigators and using commercial 0.025% benzalkonium chloride, no more B. cepacia was found in patient specimens. We had used exclusive containers for the 0.02% benzalkonium chloride prepared in our hospital. We washed them with heat-disinfected distilled water after returning from each ward before filling, but we did not dry the containers each time. The benzalkonium chloride solution in all irrigators in each ward had been exchanged once a week. The exchange method was such that fresh solution was poured into the irrigator after discarding old solution and rinsing gently. Therefore, we suspect that the 0.02% benzalkonium chloride prepared in our hospital for pelvic examinations was the common source of B. cepacia infection. We considered that B. cepacia had colonised the container and increased within containers or irrigators, and that the patients vagina had been exposed to B. cepacia at the time of an internal examination. After use of irrigators had been stopped at each ward and commercial benzalkonium chloride had been adopted, B. cepacia was not seen. We use saline for internal examinations and there are no clinical problems without using irrigators. We should not overestimate the ability of a disinfectant to prevent nosocomial infection, and prohibition of any additional antiseptics should be mandatory. Moreover, as a prompt intervention measure against infection at the time of the outbreak was useful for preventing further cases, it seems that surveillance of vaginal culture results should be considered for early detection of an outbreak.

Obstetrical Healthcare Personnel's Attitudes and Perceptions on Maternal Vaccination with Tetanus-Diphtheria-Acellular Pertussis and Influenza

Objectives. To assess perceptions of obstetrical healthcare personnel (HCP) regarding routine delivery of Tdap and influenza vaccines to pregnant and postpartum women and identify perceived barriers to vaccination. Methods. Anonymous Web-based survey of obstetricians and nurses caring for pregnant and/or postpartum women. Results. We contacted 342 HCP and received 163 (48%) completed surveys (33/142 (23%) obstetricians, 130/200 (65%) nurses). Among obstetricians, 72% and 63% thought it was “beneficial” to immunize postpartum women against influenza and pertussis, respectively. Only 8% reported vaccinating >75% of pregnant women in their care against influenza. Similarly, <1% of obstetricians reported vaccinating against pertussis. Of all HCP surveyed, 92% and 58% were familiar with ACIP recommendations for influenza and pertussis, respectively. Reported perceived barriers included patient refusal to be vaccinated, reimbursement difficulties, and discomfort in providing vaccine education. Ninety-four percent of respondents agreed that standing orders would be helpful to ensure postpartum vaccination. Conclusions. HCP were less familiar with ACIP recommendations for Tdap compared to influenza vaccines. Substantial discrepancy existed between perceived benefit of vaccination and reported immunization practices. Most identified barriers could be addressed with provider training; however, other barriers require review and changes in systematic policies related to vaccine reimbursement.

Perimortem instrumental vaginal delivery

No abstract available