Anthropometric measurements as predictors of cephalopelvic disproportion: Can the diagnostic accuracy be improved?

OBJECTIVE: We assessed the efficacy of maternal anthropometric measurements and clinical estimates of fetal weight in isolation and in combination as predictors of cephalopelvic disproportion (CPD). DESIGN: Prospective cohort study. SETTING: Tertiary care teaching hospital, two affiliated hospitals with facilities for conducting cesarean delivery and seven affiliated primary care facilities with no operation theaters. SAMPLE: Primigravidae over 37 weeks' gestation attending these facilities during a 20-month period with a singleton pregnancy in vertex presentation. METHODS: Several anthropometric measurements were taken in 249 primigravidae. Fetal weight was estimated. Differences in these measurements between the vaginal delivery and CPD groups were analyzed. The validity of these measurements in predicting CPD was analyzed by plotting receiver operating characteristic curves and by logistic regression analysis. MAIN OUTCOME MEASURE: Mode of delivery. RESULTS: Maternal height, foot size, inter-trochanteric diameter and bis-acromial diameter showed the highest positive predictive values for CPD. Combining some maternal measurements with estimates of fetal weight increased predictive values modestly, which are likely to be greater if the estimates of fetal weight are close to the actual birth weight. Based on multivariate analysis the risk factors for CPD in our population were foot length ≤23cm, inter-trochanteric diameter ≤30cm and estimated fetal weight ≥3 000g. CONCLUSIONS: Maternal anthropometric measurements can predict CPD to some extent. Combining maternal measurements with clinical estimates of fetal weight only enhances the predictive value to a relatively modest degree (positive predictive value 24%).

Cost-Effectiveness of Vitamin D Supplementation in Pregnant Woman and Young Children in Preventing Rickets: A Modeling Study.

Background: Literature on the cost of management of rickets and cost-effectiveness of vitamin D supplementation in preventing rickets is lacking. Methods: This study considered the cost-effectiveness of providing free vitamin D supplementation to pregnant women and children <4 years of age with varying degrees of skin pigmentation to prevent rickets in children. Estimates for the prevalence of rickets were calculated using all cases of rickets diagnosed in Central Manchester, UK and census data from the region. Cost of management of rickets were calculated using National Health Service, UK tariffs. The efficacy of vitamin D supplementation was based on a similar programme implemented in Birmingham. Quality of life was assessed using utility estimates derived from a systematic literature review. In this analysis the intervention was considered cost-effective if the incremental cost-effectiveness ratio (ICER) is below the National Institute for Health and Care Excellence, UK cost-effectiveness threshold of £20,000 per Quality-adjusted life year (QALY). Results: Fifty-seven patients (26 dark, 29 medium and 2 light skin tones) were managed for rickets and associated complications over 4-years. Rickets has an estimated annual incidence of 29·75 per 100,000 children <4 years of age. In the dark skin tone population vitamin D supplementation proved to be cost saving. In a medium skin tone population and light skin tone populations the ICER was £19,295 per QALY and £404,047 per QALY, respectively. Conclusion: Our study demonstrates that a vitamin D supplementation to prevent rickets is cost effective in dark and medium skin tone populations.

Prevalence and determinants of tobacco use in a highly literate rural community in southern India.

BACKGROUND: The adverse effects of tobacco use on the health of an individual are well known. It is essential to identify factors leading to tobacco use to plan strategies to limit its use. Education is known to influence the prevalence of tobacco use. We aimed to determine the prevalence and patterns of tobacco use in a rural community with a high literacy rate and to examine the socioeconomic and demographic correlates of tobacco consumption in the area. METHODS: A cross-sectional survey using personal interviews was carried out on 832 individuals > 15 years of age. The prevalence of current daily use of tobacco was used as the outcome measure. The main analytical methods used were chi-square test and multiple logistic regression analysis. RESULTS: The prevalence of tobacco use was 17.5%, being common among older persons, the lower socioeconomic group and those who were less educated. Tobacco was used predominantly in smokeless forms (chewing, snuff or both). The commonest reason cited for initiating tobacco use was to relieve toothache. CONCLUSIONS: Our findings in this rural community suggest that improvement in the educational and socioeconomic status may lead to a decline in the use of tobacco. Health education to improve dental hygiene may also help to reduce tobacco use in this community as it is predominantly used in the chewing form.

Healthcare resource utilization in the management of hypophosphatasia in three patients displaying a spectrum of manifestations.

BACKGROUND: Hypophosphatasia (HPP) is a rare, heterogeneous disease caused by low tissue-nonspecific alkaline phosphatase activity and associated with a range of signs and symptoms, including bone mineralization defects, respiratory problems, seizures, premature tooth loss, and fractures. Data from patients with HPP and their healthcare resource utilization are lacking. We evaluated healthcare utilization for 3 patients with differing severities of HPP. RESULTS: Patient 1 had perinatal HPP (received enzyme replacement therapy asfotase alfa under a compassionate use program), Patient 2 had infantile HPP, and Patient 3 had childhood HPP. Healthcare resources used in the National Health Service, England, were identified from coded activities in the hospital database and detailed medical records. These data showed that healthcare utilization was directly related to disease severity. Patient 1 had respiratory complications necessitating prolonged admission for ventilation from birth. Over 2.5 years, this patient was hospitalized 725 days, with visits from 16 specialists. Patient 2 had HPP-associated signs and symptoms starting in infancy, was treated for craniosynostosis, experienced multiple fractures, and required outpatient management for > 18 years. Patient 3 developed signs and symptoms of HPP in childhood and received outpatient and day case treatment for dental, orthopedic, and cardiovascular problems over 24 years. Healthcare utilization varied with severity and complexity of disease manifestations between these patients. CONCLUSIONS: With the recent approval of asfotase alfa for HPP, data from this analysis may help mobilize multidisciplinary healthcare resources for management of HPP by elucidating healthcare resource needs of patients who show a spectrum of clinical manifestations of HPP.

Attitudes Toward Euthanasia Among Doctors in a Tertiary Care Hospital in South India: A Cross Sectional study.

CONTEXT: Advances in expertise and equipment have enabled the medical profession to exercise more control over the processes of life and death, creating a number of moral and ethical dilemmas. People may live for extended periods with chronic painful or debilitating conditions that may be incurable. AIM: This study attempts to study the attitudes of doctors toward euthanasia and the possible factors responsible for these attitudes. SETTINGS AND DESIGN: A cross-sectional survey of 213 doctors working at a tertiary care hospital was conducted to determine their attitudes toward euthanasia. MATERIALS AND METHODS: A self-administered questionnaire was used to assess attitudes and personal perceptions about euthanasia. STATISTICAL ANALYSIS USED: The Chi square test was used to assess factors influencing attitudes toward euthanasia. RESULTS: A majority of the respondents (69.3%) supported the concept of euthanasia. Relief from unbearable pain and suffering was the most commonly (80.3%) cited reason for being willing to consider the option of euthanasia. Majority of those who were against euthanasia (66.2%) felt that the freedom to perform euthanasia could easily be misused. Disapproval of euthanasia was associated with religious affiliation (P<0.001) and speciality (P<0.001). CONCLUSIONS: A majority of the doctors in this study supported euthanasia for the relief of unbearable pain and suffering. Religion and speciality appear to be significant in determining attitudes toward euthanasia.