This article reviews available evidence regarding the transmission of cytomegalovirus (CMV) and concludes that sexual transmission--if it occurs at all--is medically and epidemiologically insignificant. The great majority of CMV infections, primary or recurrent, are completely asymptomatic and must be regarded as clinically inapparent entities. The virus does cause overt illness in some well-defined clinical situations, including heterophil-negative mononucleosis, after renal and cardiac transplants, in interstitial pneumonitis of early childhood, late neonatal sepsis, and congenital infection. Infections without concomitant disease, multiple sites of infection including oropharynx, urine, cervix, spermatic fluid, breast milk, and blood, and persistence of excretion over years have enabled CMV to parasitize human populations. Between .5% and 2.5% of the infant population is infected in utero, another 3-5% of live born infants become infected at delivery, in some areas of the world 90-100% of the population acquires the virus in early childhood by respiratory spread, and in the US and other developed countries 40-80% of the population is infected by puberty. By the 6th decade of life virtually the entire population is infected. Several lines of evidence suggest that sexual transmission is not important: the amply documented major role of alternative modes of transmission, the insignificant role of hygiene per se as a determinant of CMV prevalence in a population, the influence of hormonal status independent of sexual activity on active infection and presumably transmission, and the fact that CMV is not excreted from the human cervix beyond the age of 30. A possible exception to the general conclusion is the recent suggestion of clinical disease caused by sexually transmitted CMV in homosexual men, in which other factors however also appear to play a role.
In-utero transport has become an indispensible component of regionalized perinatal care. Successful implementation of a transport program, while requiring a high degree of professional and institutional cooperation, can produce enormous patient care dividends. Optimal survival at minimal cost is clearly possible in regionalized systems characterized by appropriate in-utero and infant transport. Given optimal circumstances, previously held contraindications to in-utero transport appear to decrease or disappear. Thus, in the context of a regionalized network, in-utero transport is the standard of care that should be offered to all infants at risk.
Abstract Downsizing and reengineering are facts of life in contemporary healthcare organizations. In most instances, these organizational changes are undertaken in an attempt to increase productivity or cut operational costs with results measured in these terms. Less often considered are potential detrimental effects on patient safety or strategies, which might be used to minimize these risks.
The role of fundal pressure during the second stage of labor is controversial and can result in clinical disagreements between nurses and physicians. Clearly the time for resolution of this issue is not when there is a physician request at the bedside in front of the patient. A prospectively agreed upon plan specifying how this request will be addressed is ideal. In order to develop this plan, risks, benefits, and alternative approaches to the use of fundal pressure should be reviewed by an interdisciplinary perinatal team. Much of the data about maternal-fetal injuries related to fundal pressure are not published for medical-legal reasons; however, anecdotal reports suggest that these risks exist. Unfortunately, it is therefore difficult to quantify with any degree of accuracy the exact number of maternal-fetal injuries that are directly related to use of fundal pressure to shorten an otherwise normal second stage of labor. However, there is enough evidence to suggest that if injury does occur when fundal pressure is used, there are significant medical-legal implications for the health care providers involved. This article will review what is currently known about fundal pressure including risks, benefits, and alternative approaches. In that context, suggestions will be offered for a safe approach to managing the second stage of labor.
Recent operations management papers model customers as solving multiarmed bandit problems, positing that consumers use a particular heuristic when choosing among suppliers. These papers then analyze the resulting competition among suppliers and mathematically characterize the equilibrium actions. There remains a question, however, as to whether the original customer models on which the analyses are built are reasonable representations of actual consumer choice. In this paper, we empirically investigate how well these choice rules match actual performance as people solve two-armed Bernoulli bandit problems. We find that some of the most analytically tractable models perform best in tests of model fit. We also find that the expected number of consecutive trials of a given supplier is increasing in its expected quality level, with increasing differences, a result consistent with the models' predictions as well as with loyalty effects described in the popular management literature.
The three main groups of deaths in early life- stillbirths, deaths in the first month, and deaths in the second to twelfth months-have characteristic distributions with respect to birth rank and maternal age.The risk of post-neonatal death is greatest for children of higher birth ranks and this has been especially evident among the later children of young mothers (Elderton, 1928; Gibson and McKeown, 1952; Baird, Thomson, and Duncan, 1953; Heady, Daly, and Morris, 1955).It seems likely that these effects have been pro- duced in two main ways.First, infections were brought into the household by older children; the birth rank effect was shown to be far greater for infective than non-infective deaths (Gibson and McKeown, 1952).Second, the increased effect of high birth rank when the mother was young suggests that the risk was influenced by factors especially associated with a very early start to child-bearing and with closely-spaced pregnancies, and that analysis in terms of rank and age together reflected a wide range of social circumstances which less directly but no less potently may have influenced the chances of survival.Since these demonstrations were presented infant mortality has fallen yet further.Much of the con- tinuing fall seems attributable to the prevention and treatment of serious infective illness and this accounts for the disproportionate fall in post-neonatal mortality compared with stillbirths and neonatal death rates.In a time of such rapid change, it is of interest to ask what has been happening to the association between high risks and certain birth rank/maternal age groups and to the separate inter- actions of the latter with changes in infective and in non-infective death rates.These questions are particularly relevant at the present time because
