Longitudinal changes of serum cytokines in patients with chronic low back pain and Modic changes.

OBJECTIVES: To explore serum cytokine levels over time in patients with chronic low back pain (cLBP) and Modic changes (MCs), difference in change between treatment groups in the Antibiotics in Modic Changes (AIM) study and associations between change in cytokines and low back pain. METHODS: Serum concentrations of 39 cytokines were measured at baseline and 1 year from 73 participants in the AIM study; 30 randomized to placebo, 43 to Amoxicillin. Low back pain intensity was measured by numeric rating scale. Change in cytokine levels over time were assessed by paired t-tests. Difference in change in cytokine levels between treatment groups and associations between changes in LBP and cytokine levels were assessed by linear regression models. Networks of cytokine changes in each treatment groups were explored by Pearson's correlations. RESULTS: Five cytokines changed from baseline to 1 year, (mean change, log transformed values with CI) C-X-C motif chemokine ligand (CXCL) 10 (IP-10) (0.11 (0.01-0.20)), CXCL13 (0.61 (0.00-0.12)), C-C motif chemokine ligand (CCL)26 (0.05 (0.01-0.1)), granulocyte macrophage-colony stimulating factor (GM-CSF) (-0.12 (-0.23 to 0.00)) and CXCL11 (0.12 (0.03-0.22)). Treatment group only influenced change in CCL21 (ß 0.07 (0.01-0.12)), and IL-6 (ß -0.17 (-0.30 to -0.03)). Change in CXCL13 (ß 2.43 (0.49-4.38)), CCL27 (ß 3.07 (0.46-5.69)), IL-8 (ß 1.83 (0.08-3.58)) and CCL19 (ß 3.10 (0.86-5.43)) were associated with change in LBP. The correlation networks of cytokine changes demonstrate small differences between treatment groups. CONCLUSIONS: Cytokine levels are relatively stable over time in our sample, with little difference between treatment groups. Some cytokines may be associated with LBP intensity. The differences between the correlation networks suggest that long-term Amoxicillin-treatment may have longstanding effects to be further explored.

Influence of ergonomic factors on peripheral neuropathy under HAV exposure.

BACKGROUND: Hand-arm vibration (HAV) is a risk factor for carpal tunnel syndrome (CTS) and ulnar neuropathy at the elbow (UNE). It is unclear how ergonomic factors influence the relationship between HAV exposure and CTS and UNE. AIMS: We aimed to assess the relationship between cumulative HAV exposure and CTS and UNE in workers exposed to HAV from two tools with different ergonomic profiles. METHODS: We performed nerve conduction studies (NCSs) of the sensory and motor median and ulnar nerves and recorded symptoms indicating CTS and UNE in workers exposed to HAV from impact wrenches or from rock drills. Exposure was measured as cumulative lifetime exposure. We used linear regression adjusted for age and body mass index to assess linear relationships. RESULTS: Sixty-five workers participated (33 rock drill and 32 impact wrench operators). We found inverse linear associations between cumulative HAV exposure and median nerve sensory conduction velocity in impact wrench operators and ulnar nerve motor conduction velocity in rock drill operators (beta of 0.63 and 0.75). Based on NCS findings and symptoms, seven impact wrench operators had CTS and one UNE, and four rock drill operators had CTS and six UNE. CONCLUSIONS: Our findings indicate that ergonomic factors influence the development of CTS and UNE under HAV exposure. The ergonomic profile seems to influence which type of neuropathy workers exposed to HAV will develop. Design of occupational exposure guidelines and future studies should be based on ergonomic profile and exposure characteristics for different tools and not merely HAV.

SARS-CoV-2 infection in pregnancy during the first wave of COVID-19 in the Netherlands: a prospective nationwide population-based cohort study (NethOSS).

OBJECTIVE: To describe characteristics, risk factors and maternal, obstetric and neonatal outcomes of pregnant women infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). DESIGN: Multi-centre prospective population-based cohort study. SETTING: Nationwide study in the Netherlands. POPULATION: Pregnant women with confirmed SARS-CoV-2 infection admitted to hospital or in home-isolation: 1 March 2020 to 31 August 2020. METHODS: Pregnant women with positive polymerase chain reaction or antibody tests were registered using the Netherlands Obstetrics Surveillance System (NethOSS). (Selective) testing occurred according to national guidelines. Data from the national birth registry (pregnant pre-coronavirus disease 2019 [COVID-19] cohort) and an age-matched cohort of COVID-19-positive women (National Institute for Public Health and the Environment; fertile age COVID-19 cohort) were used as reference. MAIN OUTCOME MEASURES: Incidence of SARS-CoV-2 infection in pregnant women. Maternal, obstetric and neonatal outcomes including hospital and intensive care admission. RESULTS: Of 376 registered pregnant women with confirmed SARS-CoV-2 infection, 20% (74/376) were admitted to hospital, of whom 84% (62/74) were due to SARS-CoV-2; 10% (6/62) were admitted to intensive care and 15% (9/62) to obstetric high-care units. Risk factors for admission were non-European country of origin (odds ratio [OR] 1.73, 95% CI 1.01-2.96) and being overweight/obese (OR 1.86, 95% CI 1.51-3.20). No maternal or perinatal deaths occurred. Caesarean section after labour-onset was increased (OR 1.58, 95% CI 1.09-2.28). Hospital and intensive care admission were higher compared with the fertile age COVID-19 cohort (OR 6.75, 95% CI 5.18-8.81 and OR 2.52, 95% CI 1.11-5.77, respectively). CONCLUSIONS: Non-European country of origin and being overweight/obese are risk factors for severe course of SARS-CoV-2 infection in pregnancy, risk of caesarean section and hospital and intensive care unit admission are increased. TWEETABLE ABSTRACT: Pregnant women with SARS-CoV-2 in the Netherlands show increased hospital/ICU admission and caesarean section.

Development and validation of a prediction model for incident hand osteoarthritis in the HUNT study.

OBJECTIVE: To develop and externally validate prediction models for incident hand osteoarthritis (OA) in a large population-based cohort of middle aged and older men and women. DESIGN: We included 17,153 men and 18,682 women from a population-based cohort, aged 35-70 years at baseline (1995-1997). Incident hand OA were obtained from diagnostic codes in the Norwegian National Patient Register (1995-2018). We studied whether a range of self-reported and clinically measured predictors could predict hand OA, using the Area Under the receiver-operating Curve (AUC) from logistic regression. External validation of an existing prediction model for male hand OA was tested on discrimination in a sample of men. Bootstrapping was used to avoid overfitting. RESULTS: The model for men showed modest discriminatory ability (AUC = 0.67, 95% CI 0.62-0.71). Adding a genetic risk score did not improve prediction. Similar discrimination was observed in the model for women (AUC = 0.62, 95% CI 0.59-0.64). Prediction was not improved by adding a genetic risk score or hormonal and reproductive factors. Applying external validation, similar results were observed among men in HUNT (The Nord-Trøndelag Health Study) as in the developmental sample (AUC = 0.62, 95% CI 0.57-0.65). CONCLUSION: We developed prediction models for incident hand OA in men and women. For women, the model included body mass index (BMI), heavy physical work, high physical activity and perceived poor health. The model showed moderate discrimination. For men, we have shown that a prediction model including BMI, education and information on sleep can predict incident hand OA in several populations with moderate discriminative ability.

The International Network of Obstetric Survey Systems study of uterine rupture: a descriptive multi-country population-based study.

OBJECTIVE: International comparison of complete uterine rupture. DESIGN: Descriptive multi-country population-based study. SETTING: International. POPULATION: International Network of Obstetric Survey Systems (INOSS). METHODS: We merged individual data, collected prospectively in nine population-based studies, of women with complete uterine rupture, defined as complete disruption of the uterine muscle and the uterine serosa, regardless of symptoms and rupture of fetal membranes. MAIN OUTCOME MEASURES: Prevalence of complete uterine rupture, regional variation and correlation with rates of caesarean section (CS) and trial of labour after CS (TOLAC). Severe maternal and perinatal morbidity and mortality. RESULTS: We identified 864 complete uterine ruptures in 2 625 017 deliveries. Overall prevalence was 3.3 (95% CI 3.1-3.5) per 10 000 deliveries, 22 (95% CI 21-24) in women with and 0.6 (95% CI 0.5-0.7) in women without previous CS. Prevalence in women with previous CS was negatively correlated with previous CS rate (ρ = -0.917) and positively correlated with TOLAC rate of the background population (ρ = 0.600). Uterine rupture resulted in peripartum hysterectomy in 87 of 864 women (10%, 95% CI 8-12%) and in a perinatal death in 116 of 874 infants (13.3%, 95% CI 11.2-15.7) whose mother had uterine rupture. Overall rate of neonatal asphyxia was 28% in neonates who survived. CONCLUSIONS: Higher prevalence of complete uterine ruptures per TOLAC was observed in countries with low previous CS and high TOLAC rates. Rates of hysterectomy and perinatal death are about 10% following complete uterine rupture, but in women undergoing TOLAC the rates are extremely low (only 2.2 and 3.2 per 10 000 TOLACs, respectively.) TWEETABLE ABSTRACT: Prevalence of complete uterine rupture is higher in countries with low previous CS and high TOLAC rates.

The causal role of smoking on the risk of headache. A Mendelian randomization analysis in the HUNT study.

BACKGROUND AND PURPOSE: Headache has been associated with various lifestyle and psychosocial factors, one of which is smoking. The aim of the present study was to investigate whether the association between smoking intensity and headache is likely to be causal. METHOD: A total of 58 316 participants from the Nord-Trøndelag Health (HUNT) study with information on headache status were genotyped for the rs1051730 C>T single-nucleotide polymorphism (SNP). The SNP was used as an instrument for smoking intensity in a Mendelian randomization analysis. The association between rs1051730 T alleles and headache was estimated by odds ratios with 95% confidence intervals. Additionally, the association between the SNP and migraine or non-migrainous headache versus no headache was investigated. All analyses were adjusted for age and sex. RESULTS: There was no strong evidence that the rs1051730 T allele was associated with headache in ever smokers (odds ratio 0.99, 95% confidence interval 0.95-1.02). Similarly, there was no association between the rs1051730 T allele and migraine or non-migrainous headache versus no headache. CONCLUSION: The findings from this study do not support that there is a strong causal relationship between smoking intensity and any type of headache. Larger Mendelian randomization studies are required to examine whether higher smoking quantity can lead to a moderate increase in the risk of headache subtypes.

Effects of spatial fMRI resolution on the classification of naturalistic movies.

Studies involving multivariate pattern analysis (MVPA) of BOLD fMRI data generally attribute the success of the information-theoretic approach to BOLD signal contrast on the fine spatial scale of millimeters facilitating the classification or decoding of perceptual stimuli. However, to date MVPA studies that have actually explored fMRI resolutions at less than 2 mm voxel size are rare and limited to small sets of unnatural stimuli (like visual gratings) as well as specific sub-regions of the brain, notably the primary somatosensory cortices. To investigate what spatial scale best supports high information extraction under more general conditions this study combined naturalistic movie stimuli with high-resolution fMRI at 7 T and linear discriminant analysis (LDA) of global and local BOLD signal patterns. Contrary to predictions, LDA and similar classifiers reached a maximum in classification accuracy (CA) at a smoothed resolution close to 3 mm, well above the 1.2 mm voxel size of the fMRI acquisition. Maximal CAs around 90% were contingent upon global fMRI signal patterns comprising 4 k-16 k of the most reactive voxels distributed sparsely throughout the occipital and ventro-temporal cortices. A Searchlight analysis of local fMRI patterns largely confirmed the global results, but also revealed a small subset of brain regions in early visual cortex showing limited increases in CA with higher resolution. Principal component analysis of the global and local fMRI signal patterns suggested that reproducible neuronal contributions were spatially auto-correlated and smooth, while other components of higher spatial frequency were likely related to physiological noise and responsible for the reduced CA at higher resolution. Systematic differences between experiments and subjects suggested that higher CA was significantly correlated with more consistent behavior revealed by eye tracking. Thus, the optimal resolution of fMRI data for MVPA was mainly limited by physiological noise of high spatial frequency as well as behavioral (in-)consistency.

Age of menarche is associated with knee joint replacement due to primary osteoarthritis (The HUNT Study and the Norwegian Arthroplasty Register).

OBJECTIVE: To investigate whether parity, age at menarche, menopausal status, age at menopause, use of oral contraceptives (OC) or use of hormone replacement therapy (HRT) were associated with total knee replacement (TKR) or total hip replacement (THR) due to primary osteoarthritis. METHOD: In a prospective cohort study of 30,289 women from the second and third surveys of the Nord-Trøndelag Health Study, data were linked to the Norwegian Arthroplasty Register (NAR) in order to identify TKR or THR due to primary osteoarthritis. Cox proportional hazards models were used to estimate the hazard ratios (HRs). RESULTS: We observed 430 TKRs and 675 THRs during a mean follow-up time of 8.3 years. Increasing age at menarche was inversely associated with the risk of TKR (P-trend < 0.001). Past users and users of systemic HRT were at higher risk of TKR compared to never users (HR 1.42 (95% confidence interval (CI) 1.06-1.90) and HR 1.40 (95% CI 1.03-1.90), respectively). No association was found between parity, age at menarche, menopausal status, age at menopause, oral contraceptive use or HRT use and THR. CONCLUSION: We found that increasing age at menarche reduced the risk of TKR. Past users and users of systemic HRT were at higher risk of TKR compared to never users. Parity did not increase the risk of THR or TKR.

The causal role of smoking on the risk of hip or knee replacement due to primary osteoarthritis: a Mendelian randomisation analysis of the HUNT study.

OBJECTIVE: Smoking has been associated with a reduced risk of hip and knee osteoarthritis (OA) and subsequent joint replacement. The aim of the present study was to assess whether the observed association is likely to be causal. METHOD: 55,745 participants of a population-based cohort were genotyped for the rs1051730 C > T single-nucleotide polymorphism (SNP), a proxy for smoking quantity among smokers. A Mendelian randomization analysis was performed using rs1051730 as an instrument to evaluate the causal role of smoking on the risk of hip or knee replacement (combined as total joint replacement (TJR)). Association between rs1051730 T alleles and TJR was estimated by hazard ratios (HRs) and 95% confidence intervals (CIs). All analyses were adjusted for age and sex. RESULTS: Smoking quantity (no. of cigarettes) was inversely associated with TJR (HR 0.97, 95% CI 0.97-0.98). In the Mendelian randomization analysis, rs1051730 T alleles were associated with reduced risk of TJR among current smokers (HR 0.84, 95% CI 0.76-0.98, per T allele), however we found no evidence of association among former (HR 0.97, 95% CI 0.88-1.07) and never smokers (HR 0.97, 95% CI 0.89-1.06). Neither adjusting for body mass index (BMI), cardiovascular disease (CVD) nor accounting for the competing risk of mortality substantially changed the results. CONCLUSION: This study suggests that smoking may be causally associated with the reduced risk of TJR. Our findings add support to the inverse association found in previous observational studies. More research is needed to further elucidate the underlying mechanisms of this causal association.

Caesarean section rates in subgroups of women and perinatal outcomes.

OBJECTIVES: To identify factors that are associated with a relatively low caesarean section (CS) rate by examining the CS rate in various subgroups in the Netherlands. DESIGN: Cross-sectional analysis. SETTINGS: the Netherlands. POPULATION: A total of 685 452 births in the Netherlands Perinatal Registry from 2007 to 2010. METHODS: A modified classification system for CS was used to categorise all women into ten groups. Labour management, mode of delivery, maternal and neonatal morbidity and mortality were assessed according to these ten groups. MAIN OUTCOME MEASURES: Caesarean section, labour induction, instrumental delivery, postpartum haemorrhage, perineal laceration, duration of second stage of labour, Apgar score, fetal and neonatal mortality. RESULTS: Total CS rate was 15.6%. Term, nulliparous and parous women with a singleton pregnancy of a fetus in cephalic position and spontaneous onset of labour had CS rates of 9.6 and 1.9% and instrumental birth rates of 19.4 and 2.4%, respectively; 17.3% of births were induced. Among women with a previous CS and term, singleton pregnancies with a fetus in cephalic presentation, 71% had trial of labour, of which 75% had a successful vaginal birth. Of women with multiple gestation, 43% had CS. Women with CS due to 'failure to progress' in the second stage of labour had a median duration of second-stage pushing of almost 2 hours in nulliparas and >90 minutes in parous women. CONCLUSIONS: Several obstetric practice patterns may have contributed to the relatively low overall CS rate in the Netherlands: a relatively low CS rate in term, singleton pregnancies of a fetus in cephalic position and spontaneous onset of labour, relatively low rate of labour induction, a high rate of a trial of labour after a previous CS, the use of vacuum and forceps, and a high proportion of women being taken care of by midwives. TWEETABLE ABSTRACT: The Netherlands has several practice patterns that may have contributed to its relatively low CS rate.

Effect of planned place of birth on obstetric interventions and maternal outcomes among low-risk women: a cohort study in the Netherlands.

BACKGROUND: The use of interventions in childbirth has increased the past decades. There is concern that some women might receive more interventions than they really need. For low-risk women, midwife-led birth settings may be of importance as a counterbalance towards the increasing rate of interventions. The effect of planned place of birth on interventions in the Netherlands is not yet clear. This study aims to give insight into differences in obstetric interventions and maternal outcomes for planned home versus planned hospital birth among women in midwife-led care. METHODS: Women from twenty practices across the Netherlands were included in 2009 and 2010. Of these, 3495 were low-risk and in midwife-led care at the onset of labour. Information about planned place of birth and outcomes, including instrumental birth (caesarean section, vacuum or forceps birth), labour augmentation, episiotomy, oxytocin in third stage, postpartum haemorrhage >1000 ml and perineal damage, came from the national midwife-led care perinatal database, and a postpartum questionnaire. RESULTS: Women who planned home birth more often had spontaneous birth (nulliparous women aOR 1.38, 95 % CI 1.08-1.76, parous women aOR 2.29, 95 % CI 1.21-4.36) and less often episiotomy (nulliparous women aOR 0.73, 0.58-0.91, parous women aOR 0.47, 0.33-0.68) and use of oxytocin in the third stage (nulliparous women aOR 0.58, 0.42-0.80, parous women aOR 0.47, 0.37-0.60) compared to women who planned hospital birth. Nulliparous women more often had anal sphincter damage (aOR 1.75, 1.01-3.03), but the difference was not statistically significant if women who had caesarean sections were excluded. Parous women less often had labour augmentation (aOR 0.55, 0.36-0.82) and more often an intact perineum (aOR 1.65, 1.34-2.03). There were no differences in rates of vacuum/forceps birth, unplanned caesarean section and postpartum haemorrhage >1000 ml. CONCLUSIONS: Women who planned home birth were more likely to give birth spontaneously and had fewer medical interventions.

Candidate-gene association study searching for genetic factors involved in migraine chronification.

INTRODUCTION: Chronic migraine (CM) is at the severe end of the clinical migraine spectrum, but its genetic background is unknown. Our study searched for evidence that genetic factors are involved in the chronification process. METHODS: We initially selected 144 single-nucleotide polymorphisms (SNPs) from 48 candidate genes, which we tested for association in two stages: The first stage encompassed 262 CM patients, the second investigated 226 patients with high-frequency migraine (HFM). Subsequently, SNPs with p values < 0.05 were forwarded to the replication stage containing 531 patients with CM or HFM. RESULTS: Eight SNPs were significantly associated with CM and HFM in the two-stage phase. None survived replication in the third stage. DISCUSSION: We present the first comprehensive genetic association study for migraine chronification. There were no significant findings. Future studies may benefit from larger, genome-wide data sets or should use other genetic approaches to identify genetic factors involved in migraine chronification.

Blood pressure as a risk factor for headache and migraine: a prospective population-based study.

BACKGROUND AND PURPOSE: During the past decade, several population-based studies have found an inverse association between blood pressure (BP) and headache. However, most of them have a cross-sectional design or lack a validated definition of a headache-free population at baseline. Therefore, additional population-based studies using a clearly defined headache-free population and a prospective design are warranted. METHODS: Data from two large epidemiological studies, the Nord-Trondelag Health Survey 1995-1997 (HUNT 2) and 2006-2008 (HUNT 3), were used to evaluate the association between BP (systolic, diastolic and pulse pressure) at baseline and headache (migraine and tension type headache) at follow-up. RESULTS: An inverse relationship was found between all three BP measures at baseline in HUNT 2 and any headache in HUNT 3, more evident for systolic BP [odds ratio (OR) 0.90 per 10 mmHg increase in systolic BP, 95% confidence interval (CI) 0.87-0.93, P < 0.001] and pulse pressure (OR 0.84 per 10 mmHg increase in pulse pressure, 95% CI 0.80-0.89, P < 0.001) than for diastolic BP (OR 0.92 per 10 mmHg increase in diastolic BP, 95% CI 0.87-1.00, P = 0.036). The most robust finding, evident for both sexes, was that increased pulse pressure was linked to decreased prevalence of both migraine and tension type headache. CONCLUSION: An inverse relationship between BP and subsequent development of headache was confirmed in this large-scale population-based cohort study. Nevertheless, further research is needed to investigate the underlying mechanisms explaining these findings.

The Neck Disability Index (NDI) and its correlation with quality of life and mental health measures among patients with single-level cervical disc disease scheduled for surgery.

BACKGROUND: The Neck Disability Index (NDI) is widely used as a self-rated disability score in patients with cervical radiculopathy. The purpose of this study was to evaluate whether the NDI score correlated with other assessments of quality of life and mental health in a specific group of patients with single-level cervical disc disease and corresponding radiculopathy. METHODS: One hundred thirty-six patients were included in a prospective, randomized controlled clinical multicenter study on one-level anterior cervical discectomy with arthroplasty (ACDA) versus one-level anterior cervical discectomy with fusion (ACDF). The preoperative data were obtained at hospital admission 1 to 3 days prior to surgery. The NDI score was used as the dependent variable and correlation as well as regression analyses were conducted to assess the relationship with the short form-36, EuroQol-5Dimension-3 level and Hospital Anxiety and Depression Scale. RESULTS: The mean age at inclusion was 44.1 years (SD ±7.0, range 26-59 years), of which 46.3 % were male. Mean NDI score was 48.6 (SD = 12.3, minimum 30 and maximum 88). Simple linear regression analysis demonstrated a significant correlation between NDI and the EuroQol-5Dimension-3 level [R = -0.64, 95 % confidence interval (CI) -30.1- -19.8, p < 0.001] and to a lesser extent between NDI and the short form-36 physical component summary [R = -0.49, 95 % CI (-1.10- -0.58), p < 0.001] and the short form-36 mental component summary [R = -0.25, 95 % CI (-0.47- -0-09), p = 0.004]. Regarding NDI and the Hospital Anxiety and Depression Scale, a significant correlation for depression was found [R = 0.26, 95 % CI (0.21-1.73), p = 0.01]. Multiple linear regression analysis showed a statistically significant and the strongest correlation between NDI and the independent variables in the following order: EuroQol-5Dimension-3 level [R = -0.64, 95 % CI (-23.5- -7.9), p <0.001], short form-36 physical component summary [R = -0.41, 95 % CI (-0.93- -0.23), p = 0.001] and short form-36 mental component summary [R = -0.36, 95 % CI (-0.53- -0.15), p = 0.001]. CONCLUSION: The results from the present study show that the NDI correlated significantly with a different quality of life and mental health measures among patients with single-level cervical disc disease and corresponding radiculopathy.

Eclampsia, a comparison within the International Network of Obstetric Survey Systems.

OBJECTIVE: To compare incidences, characteristics, management and outcome of eclampsia in the Netherlands and the UK. DESIGN: A comparative analysis of two population-based prospective cohort studies. SETTING: All hospitals with consultant-led maternity units. POPULATION: Women with eclampsia in the Netherlands (226) and the UK (264). METHODS: Comparison of individual level data from national studies in the Netherlands and the UK (LEMMoN 2004-06; UKOSS 2005/06). MAIN OUTCOME MEASURES: Incidence, maternal complications and differences in management strategies. RESULTS: Incidences of eclampsia differed significantly between both countries: the Netherlands 5.4/10,000 deliveries versus UK 2.7/10,000 (relative risk [RR] 1.94, 95% confidence intervals [95% CI] 1.6-2.4). The proportion of women with a preceding diagnosis of pre-eclampsia was comparable between both countries (the Netherlands 42%; UK 43%), as was the proportion who received magnesium sulphate prophylaxis. Women in the Netherlands had a significantly higher maximum diastolic blood pressure (111 mmHg versus 95 mmHg, P < 0.001); significantly fewer received anti-hypertensive medication (16% versus 71%; RR 0.2, 95% CI 0.1-0.3) and were treated less often with magnesium sulphate after their first fit (95% versus 99%; RR 0.96, 95% CI 0.92-0.99). Maternal death occurred in three cases in the Netherlands compared with zero in the UK. CONCLUSIONS: The incidence of eclampsia in the Netherlands was twice as high compared with the UK when using uniform definitions. Women with eclampsia in the Netherlands were not managed according to guidelines, particularly with respect to blood pressure management. Changes in management practice may reduce both incidence and poor outcomes.

Predicting the risks and recognizing the signs: a two-year prospective population-based study on pregnant women with uterine rupture in The Netherlands.

OBJECTIVE: To estimate the incidence of uterine rupture in the Netherlands and evaluate risk indicators prelabour and during labor of women with adverse maternal and/or perinatal outcome. METHODS: This is a population-based nationwide study using the Netherlands Obstetrics Surveillance System (NethOSS). We performed a two-year registration of pregnant women with uterine rupture. The first year of registration included both women with complete uterine rupture and women with incomplete (peritoneum intact) uterine rupture. The second year of registration included women with uterine rupture with adverse maternal and/or perinatal outcome. We collected maternal and obstetric characteristics, clinical signs, and symptoms during labor and CTG abnormalities. The main outcome measures were incidence of complete uterine rupture and uterine rupture with adverse outcome and adverse outcome defined as major obstetric hemorrhage, hysterectomy, embolization, perinatal asphyxia and/or (neonatal) intensive care unit admission. RESULTS: We registered 41 women with a complete uterine rupture (incidence: 2.5 per 10,000 births) and 35 women with uterine rupture with adverse outcome (incidence: 0.9 per 10,000 births). No adverse outcomes were found among women with incomplete uterine rupture. Risk indicators for adverse outcome included previous cesarean section, higher maternal age, gestational age <37 weeks, augmentation of labor, migration background from Sub-Saharan Africa or Asia. Compared to women with uterine rupture without adverse outcomes, women with adverse outcome more often expressed warning symptoms during labor such as abdominal pain (OR 3.34, 95%CI 1.26-8.90) and CTG abnormalities (OR 9.94, 95%CI 2.17-45.65). These symptoms were present most often 20 to 60 min prior to birth. CONCLUSION: Uterine rupture is a rare condition for which several risk indicators were identified. Maternal symptoms and CTG abnormalities are associated with adverse outcomes and time dependent. Further analysis could provide guidance to expedite delivery.

Body mass index and the risk of meningioma, glioma and schwannoma in a large prospective cohort study (The HUNT Study).

BACKGROUND: Obesity increases the risk for a number of solid malignant tumours. However, it is not clear whether body mass index (BMI) and height are associated with the risk of primary tumours of the central nervous system (CNS). METHODS: In a large population study (The Nord-Trøndelag Health Study (HUNT Study)) of 74 242 participants in Norway, weight and height were measured. During follow-up, incident CNS tumours were identified by individual linkage to the Norwegian Cancer Registry. Sex- and age-adjusted and multivariable Cox regression analyses were used to evaluate BMI and height in relation to the risk of meningioma, glioma and schwannoma. RESULTS: A total of 138 meningiomas, 148 gliomas and 39 schwannomas occurred during 23.5 years (median, range 0-25) of follow-up. In obese women (BMI ≥ 30 kg m(-2)), meningioma risk was 67% higher (hazard ratio (HR)=1.68, 95% confidence interval (CI): 0.97-2.92, P-trend=0.05) than in the reference group (BMI 20-24.9 kg m(-2)), whereas no association with obesity was observed in males. There was no association of BMI with glioma risk, but there was a negative association of overweight/obesity (BMI ≥ 25 kg m(-2)) with the risk of schwannoma (HR=0.48, 95% CI: 0.23-0.99). However, the schwannoma analysis was based on small numbers. Height was not associated with the risk for any tumour subgroup. CONCLUSION: These results suggest that BMI is positively associated with meningioma risk in women, and possibly, inversely associated with schwannoma risk.

The clinical benefit of blood transfusion: a hypothetical experiment based on a nationwide survey of severe maternal morbidity.

BACKGROUND: It is beyond doubt that blood transfusion services have added to the decline in maternal mortality in high-resource countries. To quantify the clinical benefit of red blood cell (RBC) transfusion in obstetric care, we performed a hypothetical experimental study using data from a prospective nationwide cohort of women giving birth in the Netherlands. STUDY DESIGN AND METHODS: Data were abstracted from a nationwide cohort study on severe maternal morbidity, including obstetric haemorrhage requiring 4 or more units of RBC, to obtain an observed and a hypothetical control group consisting of the same women. In the hypothetical control group, we simulated a situation where RBC transfusion was unavailable and estimated how many of these women would have died in that situation. A questionnaire survey asked experts in major (obstetric) haemorrhage to choose a critical minimal number of RBC transfusions at which a woman with obstetric haemorrhage would have died if RBC transfusion was not available. Maternal mortality rate per 100,000 maternities [maternal mortality ratios (MMR)] and relative risk were calculated for the observed and hypothetical group. RESULTS: The observed MMR was 13 per 100,000 maternities. According to 47 responding experts, the median number of RBC units without which a woman would have most probably died was nine, resulting in a hypothetical MMR of 87 per 100,000 maternities (relative risk 6·5; 95% confidence interval 4·2-10·0). CONCLUSIONS: It can be expected that unavailability of RBC transfusion in obstetric care increases the risk of maternal death 6.5-fold. Blood transfusion thus largely contributes to the decline of MMR and would also be an important pillar of improving quality of care in resource-poor settings.

Binational confidential enquiry of maternal deaths due to postpartum hemorrhage in France and the Netherlands: Lessons learned through the perspective of a different context of care.

OBJECTIVE: To learn lessons for maternity care by scrutinizing postpartum hemorrhage management (PPH) in cases of PPH-related maternal deaths in France and the Netherlands. METHODS: In this binational Confidential Enquiry into Maternal Deaths (CEMD), 14 PPH-related maternal deaths were reviewed by six experts from the French and Dutch national maternal death review committees regarding cause and preventability of death, clinical care and healthcare organization. Improvable care factors and lessons learned were identified. CEMD practices and PPH guidelines in France and the Netherlands were compared in the process. RESULTS: For France, new insights were primarily related to organization of healthcare, with lessons learned focusing on medical leadership and implementation of (surgical) checklists. For the Netherlands, insights were mainly related to clinical care, emphasizing hemostatic surgery earlier in the course of PPH and reducing the third stage of labor by prompter manual removal of the placenta. Experts recommended extending PPH guidelines with specific guidance for women refusing blood products and systematic evaluation of risk factors. The quality of CEMD was presumed to benefit from enhanced case finding, also through non-obstetric sources, and electronic reporting of maternal deaths to reduce the administrative burden. CONCLUSION: A binational CEMD revealed opportunities for improvement of care beyond lessons learned at the national level.