Cesarean delivery or induction of labor in pre-labor twin gestations: a secondary analysis of the twin birth study.

BACKGROUND: In the Twin Birth Study, women at 320/7-386/7 weeks of gestation, in whom the first twin was in cephalic presentation, were randomized to planned vaginal delivery or cesarean section. The study found no significant differences in neonatal or maternal outcomes in the two planned mode of delivery groups. We aimed to compare neonatal and maternal outcomes of twin gestations without spontaneous onset of labor, who underwent induction of labor or pre-labor cesarean section as the intervention of induction may affect outcomes. METHODS: In this secondary analysis of the Twin Birth Study we compared those who had an induction of labor with those who had a pre-labor cesarean section. The primary outcome was a composite of fetal or neonatal death or serious neonatal morbidity. Secondary outcome was a composite of maternal morbidity and mortality. TRIAL REGISTRATION: NCT00187369. RESULTS: Of the 2804 women included in the Twin Birth Study, a total of 1347 (48%) women required a delivery before a spontaneous onset of labor occurred: 568 (42%) in the planned vaginal delivery arm and 779 (58%) in the planned cesarean arm. Induction of labor was attempted in 409 (30%), and 938 (70%) had a pre-labor cesarean section. The rate of intrapartum cesarean section in the induction of labor group was 41.3%. The rate of the primary outcome was comparable between the pre-labor cesarean section group and induction of labor group (1.65% vs. 1.97%; p = 0.61; OR 0.83; 95% CI 0.43-1.62). The maternal composite outcome was found to be lower with pre-labor cesarean section compared to induction of labor (7.25% vs. 11.25%; p = 0.01; OR 0.61; 95% CI 0.41-0.91). CONCLUSION: In women with twin gestation between 320/7-386/7 weeks of gestation, induction of labor and pre-labor cesarean section have similar neonatal outcomes. Pre-labor cesarean section is associated with favorable maternal outcomes which differs from the overall Twin Birth Study results. These data may be used to better counsel women with twin gestation who are faced with the decision of interventional delivery.

Low blood pressure in vegetarians: the possible role of potassium.

Ninety-eight confirmed adult vegetarians were examined against a matched group of nonvegetarians living in the same urban environment in order to evaluate the prevalence of arterial hypertension. The average blood pressure was 126/77 for the vegetarians and 147/88 for the control group (p less than 0.05). Significantly lower blood pressure was found in every decade of age. Only 2% of the vegetarians had hypertension (higher than 160/95) as compared to 26% hypertensives in the nonvegetarians. These differences in blood pressure were maintained also when individuals with the same "relative weight" were compared. Family history of hypertension was similar in both groups. Analysis of factors such as coffee drinking and smoking did not favor reduced blood pressure among the vegetarian group. Sodium and potassium intake were evaluated from their ratios to creatinine in a single urine sample. It was evident that both groups excreted the same amounts of sodium, while potassium excretion was significantly higher in the vegetarians. In view of the increasing evidence that potassium plays an important role in the regulation of blood pressure it is concluded that the protective antihypertensive factor in the vegetarian diet is the presence of high amounts of potassium.

From aviation to medicine: applying concepts of aviation safety to risk management in ambulatory care.

The development of a medical risk management programme based on the aviation safety approach and its implementation in a large ambulatory healthcare organisation is described. The following key safety principles were applied: (1). errors inevitably occur and usually derive from faulty system design, not from negligence; (2). accident prevention should be an ongoing process based on open and full reporting; (3). major accidents are only the "tip of the iceberg" of processes that indicate possibilities for organisational learning. Reporting physicians were granted immunity, which encouraged open reporting of errors. A telephone "hotline" served the medical staff for direct reporting and receipt of emotional support and medical guidance. Any adverse event which had learning potential was debriefed, while focusing on the human cause of error within a systemic context. Specific recommendations were formulated to rectify processes conducive to error when failures were identified. During the first 5 years of implementation, the aviation safety concept and tools were successfully adapted to ambulatory care, fostering a culture of greater concern for patient safety through risk management while providing support to the medical staff.

The prevention of amyloidosis in familial Mediterranean fever with colchicine.

Colchicine has been used since 1972 to prevent the acute attacks of familial Mediterranean fever. The present study shows that colchicine is also effective in the prevention of amyloidosis. If initiated in patients without evidence of renal disease there is no appearance of proteinuria and no progression to renal insufficiency over long follow-up periods. Moreover, it ameliorates the course of the disease in patients with amyloid nephropathy and normal renal function. It does not alter the course of the disease if initiated after renal function is even mildly impaired. These findings suggest that colchicine prevents the new deposition of amyloid.