Pacific Medical Center Research Articles

Quantification of nursery length of stay by gestational age at delivery and plurality

DELIVERY AND PLURALITY FUNG LAM, DEBBIE RHEA, NIKI ISTWAN, GARY STANZIANO, ELLIOTT MAIN, California Pacific Medical Center, Ob/Gyn, San Francisco, California, Matria Healthcare, Clinical Research, Marietta, Georgia OBJECTIVE: To determine gestational age (GA) related neonatal outcomes and economic impact associated with prematurity. STUDY DESIGN: From a database we identified non-anomalous, live-born infants from singleton, twin, and triplet pregnancies with non-indicated delivery at 24-37 weeks. Records were examined for nursery utilization and length of stay. Neonatal deaths were excluded. Nursery charges were modeled: $500/day regular, $1200/day intermediate, and $2000/day for NICU. Higher-level nursery (HLN =NICU/ Intermediate) admission, nursery days and charges were compared by GA at delivery (GAD) in weeks and gestational type. RESULTS: Data from 26,264 singletons, 14,147 twins, and 3196 triplets representing 34,435 pregnancies were analyzed. Each additional infant significantly increased nursery stay and related charges for each successive GAD week between 27 and 37 (all P ! .05). Each additional week in utero resulted in substantially lower nursery days and charges for singletons (weeks 25-37), twins (weeks 27-37) and triplets (weeks 27-36) (all P ! .05). SMFM Abstracts S107

Forceps vs. vacuum: Which is associated with the greatest morbidity?

AARON B. CAUGHEY, PER SANDBERG, MARYA ZLATNIK, JULIAN T. PARER, MARIPAULE THIET, RUSSELL K. LAROS JR, University of California, San Francisco, Obstetrics, Gynecology and Reproductive Sciences, San Francisco, California, California Pacific Medical Center, Obstetrics and Gynecology, San Francisco, California OBJECTIVE: To compare perinatal outcomes between forceps and vacuum assisted deliveries. Our hypothesis was that the force vectors achieved in forceps delivery will lead to fewer shoulder dystocia, but greater perineal lacerations. STUDY DESIGN: This is a retrospective cohort study of 4120 term, cephalic, singleton, operative vaginal deliveries at a single institution. Outcomes examined included rates of shoulder dystocia, perineal and cervical lacerations, and neonatal trauma. Potential confounders including maternal age, birthweight, ethnicity, parity, gestational age, station at delivery, episiotomy, attending physician, anesthesia, and lengths of 1st and 2nd stages of labor were controlled for using multivariate logistic regression. RESULTS: In the study population, there were 2045 (49.6%) forceps and 2075 (50.4%) vacuum assisted deliveries. Of note, the rate of shoulder dystocia was higher among women undergoing vacuum assisted delivery (3.5% vs. 1.5%, P! .001). Other differences are reported in the table below. These differences in perinatal complication rate persisted when controlling for the confounders listed above with adjusted odds ratio for shoulder dystocia being 3.05 (95% CI 1.85– 5.04), and 3rd or 4th degree lacerations being 0.65 (95% CI 0.55–0.75) when comparing vacuum to forceps. CONCLUSION: Vacuum assisted vaginal birth is more often associated with shoulder dystocia and cephalohematoma. Forceps delivery is more often associated with 3rd and 4th degree perineal lacerations as well as cervical lacerations. These differences in complications rates should be considered among other factors when determining the optimal mode of delivery.

A descriptive analysis of an integrative medicine clinic.

To evaluate and describe an integrative medicine clinic including its patients; their presenting problems, medical objectives, treatment recommendations; whether recommendations were recalled and adhered to; and patients' self-reported health outcomes. A prospective cohort study of 160 new clinic patients were treated using a wide range of integrative medicine therapies. Patients were interviewed at intervals of 1, 3, and 6 months after their initial visit. The study was conducted at the Institute for Health and Healing clinic, at California Pacific Medical Center located in San Francisco, CA. The subjects were new clinic patients seeking care for a variety of symptoms and diagnoses. Patients presented with an average of 4.0 symptoms and 2.9 diagnoses; physicians recommended 9.5 "treatments" per patient. At 6-month follow-up, symptom intensity decreased from 6.5 to 4.2 (on a 10-point scale; p < 0.005); and 57% of the patients had made "substantial" progress or had completely achieved their health objectives (p < 0.005). The Short Form 12 (SF-12) measure of mental and physical functioning improved significantly from baseline to one month (p = 0.05; p = 0.001, respectively) and maintained this improvement at 3 (p = 0.01; p = 0.01) and 6 months (p = 0.001; p = .001). At 1-month follow-up, patients recalled 57% of the actionable statements from the physician without a prompt and they followed 55% of all recommendations well (90% or above). Over the follow-up period, patients increasingly attributed the reductions in symptoms (p = 0.01) and achieving their health objectives (p = 0.01) to the treatment plan. Self-reported measures of days ill and days missed at work/school did not differ significantly from the year before coming to the clinic. The results indicate that patients can recall and follow a complex treatment regimen. Subjective and objective measures of patients' health status improved after one month and this effect was sustained or improved further at 6 months follow-up. Further study is needed to determine whether patients' improvement was the result of the treatment regimen.

A Descriptive Analysis of an Integrative Medicine Clinic

Objective: To evaluate and describe an integrative medicine clinic including its patients; their presenting problems, medical objectives, treatment recommendations; whether recommendations were recalled and adhered to; and patients' self-reported health outcomes. Design: A prospective cohort study of 160 new clinic patients were treated using a wide range of integrative medicine therapies. Patients were interviewed at intervals of 1, 3, and 6 months after their initial visit. Setting: The study was conducted at the Institute for Health and Healing clinic, at California Pacific Medical Center located in San Francisco, CA. Subjects: The subjects were new clinic patients seeking care for a variety of symptoms and diagnoses. Intervention: Patients presented with an average of 4.0 symptoms and 2.9 diagnoses; physicians recommended 9.5 "treatments" per patient. Results: At 6-month follow-up, symptom intensity decreased from 6.5 to 4.2 (on a 10-point scale; p < 0.005); and 57% of the patients had made "substantial" progress or had completely achieved their health objectives (p < 0.005). The Short Form 12 (SF-12) measure of mental and physical functioning improved significantly from baseline to one month (p = 0.05; p = 0.001, respectively) and maintained this improvement at 3 (p = 0.01; p = 0.01) and 6 months (p = 0.001; p = .001). At 1-month follow-up, patients recalled 57% of the actionable statements from the physician without a prompt and they followed 55% of all recommendations well (90% or above). Over the follow-up period, patients increasingly attributed the reductions in symptoms (p = 0.01) and achieving their health objectives (p = 0.01) to the treatment plan. Self-reported measures of days ill and days missed at work/school did not differ significantly from the year before coming to the clinic. Conclusion: The results indicate that patients can recall and follow a complex treatment regimen. Subjective and objective measures of patients' health status improved after one month and this effect was sustained or improved further at 6 months follow-up. Further study is needed to determine whether patients' improvement was the result of the treatment regimen.

Detailed Neurovascular Anatomy of the Serratus Anterior Muscle: Implications for a Functional Muscle Flap with Multiple Independent Force Vectors

San Francisco, Calif. From the Buncke Clinic and the Division of Microsurgery, California Pacific Medical Center, Davies Campus. Received for publication August 27, 2003. Rudy Buntic, M.D. 45 Castro Street, Suite 140 North Tower, San Francisco, Calif. 94114, [email protected]

The thoratec IVAD: a new implantable ventricular assist device

THE THORATEC IVAD: A NEW IMPLANTABLE VENTRICULAR ASSIST DEVICE M.S. Slaughter, S.S.L. Tsui, A. El-Banayosy, R.L. Kormos, T.B. Icenogle, J.D. Hill, Surgery, Cardiothoracic Division, Advocate Christ Medical Center, Oak Lawn, IL; Surgery, Papworth Hospital, Cambridge, United Kingdom; Surgery, Heart Center NRW, Bad Oeynhausen, Germany; Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA; Surgery, Sacred Heart Medical Center, Spokane, WA; Surgery, California Pacific Medical Center, San Francisco, CA

Interview with John A. Astin, PhD

Dr. John A. Astin received his PhD in health psychology from the University of California, Irvine. He has been a research fellow in the Complementary and Alternative Medicine Program at the Stanford University School of Medicine and director of mind-body research at the Complementary Medicine Program, University of Maryland School of Medicine. In 2002, he joined California Pacific Medical Center in San Francisco as a research scientist. His research and clinical work has focused on several related areas: the use of mind-body therapies, particularly mindfulness meditation, to treat various health-related problems; psychosocial factors associated with use of complementary and alternative medical therapies; the psychological construct of control and its relationship to mental and physical health; and the role of spirituality in healthcare. His research has appeared in such journals as Archives of Internal Medicine, JAMA, and the Annals of Internal Medicine. He is coauthor (with Deane Shapiro) of the book, Control Therapy: An Integrated Approach to Psychotherapy, Health, and Healing. Along with his scholarly pursuits, Dr. Astin is an accomplished singer, songwriter, and recording artist and has produced five albums of original music that are distributed worldwide.

Purse-string mastectomy with immediate prosthetic reconstruction: an improved skin-sparing technique for small breasts.

San Francisco, Calif. From the Department of Plastic Surgery, California Pacific Medical Center. Received for publication September 19, 2001; revised January 13, 2003. Bryant A. Toth, M.D. 2100 Webster Suite 424 San Francisco, Calif. 94115 [email protected]

Unbound Bilirubin in a Term Newborn With Kernicterus

In premature newborns, bilirubin-induced changes in the auditory brainstem response (ABR) begin at unbound (nonalbumin-bound or “free”) bilirubin levels above .5 μg/dL,1 and kernicterus becomes likely at levels between ∼1 and 1.5 μg/dL (.017-.026 μmol/L).2,3 In term newborns, however, unbound bilirubin levels between .9 and 2 μg/dL, which would be associated kernicterus in premature newborns, produce only subtle, reversible changes in ABR wave latency and amplitude.4 Although the unbound bilirubin levels associated with kernicterus in term newborns are unknown, they clearly are greater than the levels associated with kernicterus in premature infants. This indicates that, as with the total bilirubin and total bilirubin/albumin ratio, the unbound bilirubin levels associated with kernicterus increase as birth weight and gestation increase.1,5 We have been using a Food & Drug Administration-approved method6 for measuring unbound bilirubin in jaundiced newborns as an adjunct to their clinical care since 1998. We use a weight-based unbound bilirubin reference value of 1.3 μg/dL/kg (the level of unbound bilirubin at which exchange transfusion should be considered) up to a maximum of 4 μg/dL to accommodate the need to increase the reference unbound bilirubin as birth weight increases and to incorporate the solubility limits of unbound bilirubin at ph 7.4 (∼4 μg/dL) into the reference criteria.1–5,7–9 We recently encountered a term, jaundiced newborn that developed acute shock and died, apparently from kernicterus. This report describes the infant’s clinical course and bilirubin-albumin binding data. This case provides insight into the levels of unbound bilirubin associated with kernicterus in term infants as well as the acute changes in distribution of the bilirubin load (miscible bilirubin pool) between the tissues and the vascular space following the onset of kernicterus. A 110-hour-old (4.5-day-old) Nigerian male newborn presented to … Reprint requests to (C.E.A.) Division of Neonatology, Department of Pediatrics, California Pacific Medical Center, 3850 California St, San Francisco, CA 94118. E-mail: ligand{at}centurytel.net

Single-Stage, Autologous Breast Restoration

Discussion by Bryant A. Toth, M.D., and Anna A. Kuang, M.D. Received for publication March 27, 2001. Bryant A. Toth, M.D. California Pacific Medical Center 2100 Webster Street, Suite 424 San Francisco, Calif. 94115[email protected]

Comparison of left atrial dimensions by transthoracic and transesophageal echocardiography Matthew Block, Lisa Hourigan, Wayne H. Bellows, John Reeves, III, Joseph L. Romson, Michael Tran, Darwin Pastor, Nelson Schiller, Jacqueline M. Leung. California Pacific Medical Center, San Francisco, CA, University of California, San Francisco, San Francisco, CA

Comparison of left atrial dimensions by transthoracic and transesophageal echocardiography Matthew Block, Lisa Hourigan, Wayne H. Bellows, John Reeves, III, Joseph L. Romson, Michael Tran, Darwin Pastor, Nelson Schiller, Jacqueline M. Leung. California Pacific Medical Center, San Francisco, CA, University of California, San Francisco, San Francisco, CA

EARLY ALLOGRAFT REJECTION IN CHILDREN AFTER LIVER TRANSPLANTATION IS ASSOCIATED WITH PERIPHERAL AND GRAFT EOSINOPHILIA

31 Acute allograft rejection in children after liver transplantation has still been a major problem in post transplant care despite improved immunosuppression. In adult patients marked elevation of peripheral eosinophils has been reported during acute rejection after solid organ transplantation. There have been no data reported about the role of eosinophils in children after liver transplantation. We have previously reported an increased expression of TH2-cytokines, especially interleukin-5, the major activator of eosinophils during allograft rejection. We therefore examined prospectively the number of peripheral eosinophils in 28 children after liver transplantation during the first 2-4 weeks post transplant in 1-2 days intervals (18 children transplanted between 1993 and 1994 at the California Pacific Medical Center and 10 children, transplanted between 1995 and 1998 at the University of Munich). The data were grouped according to clinical and histological observations in 4 groups: no rejection, early rejection, ongoing rejection, infection. All rejection episodes were proved by liver histology and results were correlated with the relative number of eosinophils within the periportal infiltrates during rejection. Early rejection was defined as 2 days prior to biopsy proven rejection. Results: 388 consecutive differential blood counts were analyzed during an average period of 21 days after transplant. (Table)TableAcute allograft rejection was associated with peripheral eosinophilia in 87%. Peripheral eosinophil numbers raised prior to GGT and bilirubin in 87% of rejection episodes. 22 of 24 liver biopsies with histological signs of allograft rejection showed a marked increase of eosinophils within the sites of inflammation. After treating rejection episodes with steroids eosinophil numbers decreased in all cases. In conclusion: Peripheral and intragraft eosinophilia might be a sensitive and specific additional marker for acute allograft rejection. Our results support the theory of an alternate pathway of liver allograft rejection including TH2-cytokines (IL-5) and eosinophils which might be not sufficiently suppressed by cyclosporine or tacrolimus.

My Year with Fuller Albright (1950–1951)

Clinical Professor of Medicine, University of California School of Medicine, San Francisco, California 94143. Consultant in Endocrinology, California Pacific Medical Center, San Francisco, California 94115.

APOPTOSIS AS A MECHANISM OF CELL DEATH IN LIVER ALLOGRAFT REJECTION (REPLY)

Our recent report that apoptotic cell death and DNA fragmentation are components of liver allograft rejection (1) is in complete agreement with the earlier report by Battersby et al.(2) that hepatocytes undergo apoptosis during porcine liver rejection. The purpose of our study (1) was to quantitate the morphological and biochemical changes associated with apoptosis in a well-described experimental model of orthotopic liver transplantation. Moreover, hepatocyte cell death was correlated with cytokine expression and histological and biochemical indicators of liver allograft rejection. We and others (3-6) have found that apoptosis can be inconspicuous on the light microscope level. The TUNEL technique is a tool that, when combined with morphological criteria, is helpful in discerning cells undergoing apoptosis. For example, the TUNEL technique, as used by Surh and Sprent (7), was instrumental in providing direct evidence of a longstanding assertion that the majority of newly produced thymocytes die in situ. Genetic and molecular advances have identified genes and biochemical processes involved in apoptosis(4). Further investigations into the regulatory mechanisms associated with apoptosis will facilitate an understanding of allograft rejection. Sheri M. Krams Olivia M. Martinez California Pacific Medical Center; Transplant Immunobiology Laboratory; San Francisco, California 94115

Significance of immune activation in recipients with autoimmune-mediated liver diseases in liver transplantation: [formula omitted] Transplantation Immunobiology Laboratory, California Pacific Medical Center, San Francisco, CA

Significance of immune activation in recipients with autoimmune-mediated liver diseases in liver transplantation: [formula omitted] Transplantation Immunobiology Laboratory, California Pacific Medical Center, San Francisco, CA

Application of a simple serology based genotyping assay in a prospective cohort of patients with chronic hepatitis C: [formula omitted] California Pacific Medical Center, San Franscio, CA; Section of Hepatobiliary Diseases 1, University of Florida, Gainesville, FL, and Murex Diagnostics 2, Kent, UK

We have examined retinol esterification in the established GRX cell line, representative of hepatic stellate cells, and in primary cultures of ex vivo purified murine hepatic stellate cells. The metabolism of [3H]retinol was compared in cells expressing the myofibroblast or the lipocyte phenotype, under the physiological retinol concentrations. Retinyl esters were the major metabolites, whose production was dependent upon both acyl-CoA:retinol acyltransferase (ARAT) and lecithin:retinol acyltransferase (LRAT). Lipocytes had a significantly higher esterification capacity than myofibroblasts. In order to distinguish the intrinsic enzyme activity from modulation of retinol uptake and CRBP-retinol content of the cytosol in the studied cells, we monitored enzyme kinetics in the purified microsomal fraction. We found that both LRAT and ARAT activities were induced during the conversion of myofibroblasts to lipocytes. LRAT induction was dependent upon retinoic acid, while that of ARAT was dependent upon the overall induction of the fat storing phenotype. The fatty acid composition of retinyl-esters suggested a preferential inclusion of exogenous fatty acids into retinyl esters. We conclude that both LRAT and ARAT participate in retinol esterification in hepatic stellate cells: LRAT’s activity correlates with the vitamin A status, while ARAT depends upon the availability of fatty acyl-CoA and the overall lipid metabolism in hepatic stellate cells.

Effects of cyclosporine and tacrolimus on activation of Kupffer cells in vitro: [formula omitted] Dept. of Transplantation, California Pacific Medical Center,San Francisco, ∗Kuzell Institute for Arthritis and Infectious Disease, San Francisco and ∗∗Dept. Of Transplantation, Stanford University, Palo Alto

Effects of cyclosporine and tacrolimus on activation of Kupffer cells in vitro: [formula omitted] Dept. of Transplantation, California Pacific Medical Center,San Francisco, ∗Kuzell Institute for Arthritis and Infectious Disease, San Francisco and ∗∗Dept. Of Transplantation, Stanford University, Palo Alto

A year free of Legionella: Results of intervention and education : K. Anderson, BA, MT (ASCP), CIC,∗ B. DeBaun, RN, BSN, CIC. California Pacific Medical Center (CPMC), San Francisco, CA

A year free of Legionella: Results of intervention and education : K. Anderson, BA, MT (ASCP), CIC,∗ B. DeBaun, RN, BSN, CIC. California Pacific Medical Center (CPMC), San Francisco, CA

Muscular Fatigue in Duchenne Dystrophy

The fatigability of the anterior tibial muscle in 11 boys with Duchenne muscular dystrophy (DMD) was compared to that of controls at the California Pacific Medical Center and the University of California, San Francisco.

HIV Disease and Managed Care

California Pacific Medical Center, San Francisco; Bioethics Consultation Group, Berkeley; and Kaiser Family Foundation, Menlo Park, California, U.S.A.