The effect of labour induction on the risk of caesarean delivery: using propensity scores to control confounding by indication.

OBJECTIVE: To use propensity score methods to control for confounding by indication in the association between labour induction and caesarean delivery. DESIGN: Cross-sectional analysis of administrative hospital discharge data supplemented by medical record information. SETTING: Fourteen US member hospitals of the National Perinatal Information Center. SAMPLE: A cohort of 166 559 singleton liveborn deliveries in the period 2007-2012. METHODS: We used propensity scores (PSs) to balance 83 covariates between induced and non-induced women, and compared estimates with traditional covariate adjustment. We estimated PSs for labour induction versus expectant management of pregnancy each week from 34 to 42 weeks of gestation. We estimated risk ratios (RRs) for the association between labour induction and primary caesarean delivery from models with no adjustment, traditional adjustment of five covariates, matched PS, and adjustment for continuous PS. MAIN OUTCOME MEASURE: Caesarean delivery in current or subsequent week of gestation. RESULTS: In crude models labour induction increased the risk of caesarean delivery in all weeks (RR 1.06-1.52), excepting 39 weeks of gestation (RR 0.89). After matching on PS, the analysis showed a significantly decreased risk of caesarean delivery with labour induction during weeks 35-39 (RR 0.77-0.92), and a significantly elevated risk at weeks 40 (RR 1.22) and 41 (RR 1.39). Traditional covariate and PS adjustment resulted in RRs between those from crude and PS-matched models. CONCLUSIONS: There is evidence of considerable confounding by indication in the association of labour induction and caesarean delivery, particularly for preterm deliveries. Using PS methods, we found a reduced risk of caesarean delivery with labour induction before 40 weeks of gestation, and an elevated risk for weeks 40-42. TWEETABLE ABSTRACT: With confounding adjustment, labour induction does not increase the risk of caesarean at 34-39 weeks of gestation.

Vitamin D deficiency in Tasmania: a whole of life perspective.

AIM: This study aims to describe the lifetime picture of vitamin D deficiency, as measured by serum 25(OH)D concentration, in Tasmania (latitude 43°S). METHODS: Five cross-sectional studies were used: a sample of primary schoolchildren (n = 201, aged 7-8 years), two samples of adolescents (sample 1: n = 374, aged 15-18 years; sample 2: n = 136, aged 16-19 years), a sample of young to middle-aged adults (n = 262, aged 19-59 years) and a sample of older adults (n = 1092, aged 50-80 years). RESULTS: In winter/spring, approximately two-thirds of the adolescents and adults (young, middle-aged and older) had 25(OH)D levels ≤50 nmol/L, and around 10% had 25(OH)D levels ≤25 nmol/L. The prevalence of vitamin D deficiency was much lower for primary schoolchildren (11.5% < 50 nmol/L, 0.5% ≤ 25 nmol/L). In summer/autumn, approximately one-third of the adolescents and adults had 25(OH)D levels ≤50 nmol/L, and very few had 25(OH)D levels ≤25 nmol/L. For the adolescents and adults, even among those who reported the highest category of sun exposure, approximately 45% had 25(OH)D levels ≤50 nmol/L in winter/spring. CONCLUSIONS: Vitamin D deficiency was uncommon among our sample of primary school children but increased substantially during the teenage years and seemed to remain high throughout the rest of life, suggesting that mild vitamin D deficiency is endemic in Tasmania apart from in the very young.

A cohort study of acute pancreatitis in relation to exenatide use.

AIM: Reports of acute pancreatitis associated with exenatide treatment prompted this study to estimate the association between acute pancreatitis and exenatide use relative to other antihyperglycaemic drugs. METHODS: This cohort study included patients without claims for prior pancreatic disease who initiated exenatide or other antihyperglycaemic drugs between June 2005 and December 2007. Acute pancreatitis was identified with diagnosis codes and confirmed through review of blinded medical records. Poisson regression models provided estimates of rate ratios (RRs) and 95% confidence intervals (CIs) comparing the rate of acute pancreatitis during periods of current (days supplied + 31 days), recent (current definition + 31 days) and past use (≥32 days beyond current definition) of exenatide relative to other antihyperglycaemic drugs, adjusted for propensity scores. A prespecified nested case-control analysis provided RR estimates adjusted for patient characteristics abstracted from medical records. RESULTS: Initiators of exenatide (N = 25719) had more baseline claims for obesity and concomitant diabetes drugs than comparators (N = 234536). There were 40 confirmed cases of acute pancreatitis in the exenatide cohort and 254 among other antihyperglycaemic drug initiators. Compared to other antihyperglycaemic drugs, the propensity score-adjusted RR for exenatide was 0.5 (95% CI 0.2-0.9) for current use, 1.1 (95% CI 0.4-3.2) for recent use and 2.8 (95% CI 1.6-4.7) for past use. The case-control analysis resulted in a RR of 0.2 for current use (95% CI 0.0-1.4) and 0.1 for recent use (95% CI 0.0-1.3), but an attenuated RR in the past use association (RR 1.1; 95% CI 0.1-11.0). CONCLUSIONS: Exenatide use was not associated with an increased risk of acute pancreatitis.

A pilot study of the reproducibility and validity of measuring knee subchondral bone density in the tibia.

OBJECTIVE: To describe the reproducibility and validity of six different measurement techniques for knee subchondral bone mineral density (sBMD). METHODS: A consecutive sample of 50 male and female participants from a population-based longitudinal study had sBMD assessed using dual energy X-ray absorptiometry scans. Anthropometric, knee pain, cartilage and bone measures by magnetic resonance imaging and radiographic osteoarthritis (OA) were assessed. The six methods were defined as: (1) the midpoint of one intercondylar spine, across the tibial surface and descending 10mm; from the midpoint of the two intercondylar spines (2) the top of the spine descending 20mm, (3) 10-20mm beneath the top of the spine; from the tibial surface descending, (4) 10mm, (5) 15 mm, and (6) 20mm. RESULTS: All six methods had excellent reproducibility (intra-class correlation coefficient 0.98-1.00). sBMD was higher in males (methods 2-4) and higher in those with medial tibial osteophytes (methods 1, 3 and 4). Medial tibial cartilage defects and overall cartilage defects correlated with sBMD (methods 3 and 4). Method 2, which includes the intercondylar spine, correlated with medial tibial bone size. Measuring sBMD using methods 3 and 4 produced the greatest number of associations with joint features of OA. CONCLUSIONS: These preliminary results need confirmation in larger longitudinal samples but suggest that sBMD can be accurately measured and plays a role in knee OA. Methods 3 and 4 had the best concurrent validity; however, method 2 adds additional information on tibial bone size, suggesting that two measures are necessary in clinical studies.

The Neutrons for Science Facility at SPIRAL-2.

The neutrons for science (NFS) facility is a component of SPIRAL-2, the new superconducting linear accelerator built at GANIL in Caen (France). The proton and deuteron beams delivered by the accelerator will allow producing intense neutron fields in the 100 keV-40 MeV energy range. Continuous and quasi-mono-kinetic energy spectra, respectively, will be available at NFS, produced by the interaction of a deuteron beam on a thick Be converter and by the 7Li(p,n) reaction on thin converter. The pulsed neutron beam, with a flux up to two orders of magnitude higher than those of other existing time-of-flight facilities, will open new opportunities of experiments in fundamental research as well as in nuclear data measurements. In addition to the neutron beam, irradiation stations for neutron-, proton- and deuteron-induced reactions will be available for cross-sections measurements and for the irradiation of electronic devices or biological cells. NFS, whose first experiment is foreseen in 2018, will be a very powerful tool for physics, fundamental research as well as applications like the transmutation of nuclear waste, design of future fission and fusion reactors, nuclear medicine or test and development of new detectors.

Antimicrobial resistance of Neisseria gonorrhoeae in Liberia.

The prevalence and molecular characteristics of penicillinase-producing Neisseria gonorrhoeae (PPNG) and tetracycline-resistant N. gonorrhoeae (TRNG) were determined in 10 clinics in Monrovia, Liberia, to assess the likely effectiveness of the current standard treatment with penicillin or tetracycline. One hundred gonococcal strains were isolated from 146 urethral swabs and 261 cervical swabs and screened for susceptibility to ceftriaxone, penicillin, spectinomycin and tetracycline by the disk diffusion method; 83% were resistant to penicillin and 63% to tetracycline. Twenty-one strains from 18 men and 3 women with uncomplicated gonorrhoea were subjected to more detailed characterization. These 21 strains belonged to 5 auxotype/serovar classes; 86% were PPNG/TRNG. Three PPNG harboured the 4.4 MDa penicillinase plasmid and 16 the 3.2 MDa plasmid. All TRNG harboured the 25.2 MDa plasmid and their MICs for tetracycline were > 32 mg/L. They gave a PCR product which, according to its restriction pattern, corresponded to the American type tetM gene. By the agar dilution method, all strains exhibited intermediate resistance to sulphamethoxazole-trimethoprim (19:1) (co-trimoxazole) with MICs of 8-32 mg/L. All strains were susceptible to spectinomycin and ciprofloxacin. The MICs for gentamicin were 4-8 mg/L. The use of effective and affordable antimicrobial chemotherapy with either 500 mg ciprofloxacin or a single dose of gentamicin is discussed, with consideration of molecular biological, pharmacological and public health aspects.

Evaluation of treatment modalities for septic arthritis with histological grading and analysis of levels of uronic acid, neutral protease, and interleukin-1.

We compared the effectiveness of antibiotics alone and in combination with arthroscopy, arthroscopy with debridement, arthrotomy, or needle aspiration for the treatment of septic arthritis. Each modality has its proponents, but, to our knowledge, no comparative studies have been conducted in animals. We used biochemical and histological analysis to compare these methods of treatment in an experimental model. The right hind knee of thirty goats was injected with 1 x 10(5) Staphylococcus aureus bacilli. The left hind knee was not inoculated and served as the normal control. Seventy-two hours after inoculation, a two-week course of treatment with intramuscular administration of cefuroxime sodium, either alone or in combination with another mode of treatment, was initiated in each of five groups. The cartilage was evaluated histologically with biochemical, enzymatic, and interleukin-1 analyses. Despite the early therapeutic intervention, on the average, there was a 25 per cent loss of uronic acid (t test, p < 0.001) and a 43 per cent increase in neutral protease activity (signed-rank test, p = 0.003) in the treatment groups. There were no significant intergroup differences with regard to the histochemical-histological rating or the levels of uronic acid, neutral protease, or interleukin-1.

Effect of the Medicare prospective payment system on the utilization of physical therapy.

The purpose of this study was to examine the effect of the Medicare prospective payment system on the utilization of physical therapy for patients served by Medicare. The total number of inpatient and outpatient physical therapy referrals and the percentage of physical therapy Medicare referrals from January 1981 through May 1985 for the 336 acute care beds in the county selected for this study were analyzed. The results indicated that acute care inpatient and outpatient physical therapy Medicare referrals have increased significantly since the implementation of the diagnostic related group system. The results indicate that physical therapy is being used increasingly to rehabilitate patients within the time and economic constraints established by the Medicare prospective payment system.

Bactericidal effect of 0.95-mW helium-neon and 5-mW indium-gallium-aluminum-phosphate laser irradiation at exposure times of 30, 60, and 120 seconds on photosensitized Staphylococcus aureus and Pseudomonas aeruginosa in vitro.

BACKGROUND AND PURPOSE: Studies have demonstrated a bactericidal effect of laser irradiation when lasers with power outputs of (6 mW are directed toward pathogenic or opportunistic bacteria previously treated with a photosensitizing agent. The purpose of this study was to determine the bactericidal capabilities of irradiation from lasers with power outputs of less than 6 mW on photosensitized microorganisms. METHODS: Two bacteria that commonly infect skin lesions, Staphylococcus aureus and Pseudomonas aeruginosa, were used. The 2 lasers used, the 0.95-mW helium -neon laser and the 5-mW indium-gallium-aluminum-phosphate laser, emit light at a wavelength close to the absorption maxima of the sensitizing agent chosen, toluidine blue O. This agent was used because of its proven effectiveness in sensitizing bacteria. For each bacterial strain, toluidine blue O was added to a 108 cells/mL solution until a 0.01% weight/volume ratio was obtained. These mixtures were spread on agar-coated petri dishes, which were then exposed to 1 of the 2 lasers for 30, 60, and 120 seconds. The cultures were then grown overnight and examined for one or more visible zones of inhibition. The areas surrounding the irradiated zone provided a control for the effects of toluidine blue O alone. To determine the effects of laser irradiation without prior toluidine blue O sensitization, separate plates were established using unsensitized bacteria. RESULTS: Although inconsistencies between plates were noted, both lasers produced at least one zone of inhibition in both bacterial species at all 3 time periods. The 5-mW laser, however, produced a greater number of these zones. CONCLUSION AND DISCUSSION: Laser-induced microbial killing of photosensitized organisms could have clinical applications in the treatment of infected skin lesions, pending in vivo studies.

Primary total hip arthroplasty in the older patient: optimizing the results.

Preoperative planning is the first step in adult reconstructive surgery of the hip. When executed properly, it provides a template of the procedure for the whole surgical team. Thorough planning also helps the team anticipate intraoperative problems and avert complications. It reduces surgical trial and error, thus reducing operative time. Planning shortens the learning curve for a new implant system, improves technical skills for performing THA, and ultimately can improve the clinical results.

Cleidocranial dysostosis and syringomyelia. Review of the literature and case report.

A 34-year-old woman with congenital cleidocranial dysostosis had scoliosis diagnosed at age 13. The scoliosis was treated during adolescence with spinal orthoses but continued to progress after skeletal maturation. She was diagnosed as having syringomyelia at age 34. The possibility of syringomyelia should be considered in patients with cleidocranial dysostosis, especially those with neurologic symptoms, scoliosis not responding to conservative therapy, or progressive scoliosis after skeletal maturation. Although only two previous patients have been reported in the literature, the condition undiagnosed could be a more common problem than generally supposed.

Micromotion measurements with hip center and modular neck length alterations.

Hip center relocation often is necessary because of acetabular deformity or in revision surgery. Superolateral relocation of the acetabular component increases the hip joint reaction forces and has been associated with early femoral implant loosening. In addition, relocation can necessitate the use of extended femoral neck lengths. The purpose of this study was to compare the initial stability (micromotion) of an anatomically placed femoral component with that of a superolaterally relocated component and with a component having an extended neck length. A six-degree of freedom device was constructed to measure three-dimensional micromotion at the proximal and distal regions of the femoral component. The instrumented femur was loaded using a unique loading device that included musculature necessary to simulate stairclimbing. Results showed that superolateral relocation of the hip center (25 mm) only moderately increased femoral component micromotion (13%). However, it was found that extending the neck length 12.5 mm produced a dramatic increase in micromotion (38%). Clinically this suggests that hip center lateralization and the use of long modular neck lengths should be avoided.

[Therapy of malignant hepatic tumors using percutaneous hot saline injections. Feasibility study and preliminary results]. / Terapia dei tumori epatici maligni mediante iniezione percutanea di soluzione fisiologica bollente. Studio di fattibilità e risultati preliminari.

PURPOSE: To investigate the feasibility and the results of percutaneous hot saline injection therapy (PSIT) of liver tumors. MATERIAL AND METHODS: Eight patients with hepatocellular carcinoma (11 nodules), 1 with cholangiocarcinoma and 1 with a metastasis from colon cancer underwent PSIT. The patients were selected according to variable criteria; thus, each patient was considered apart. A boiling saline solution was injected into the hepatic lesions through a needle like those commonly used for percutaneous ethanol injection (PEI). The results were assessed with US, CT, angiography, the measurement of tumor marker levels, the histopathologic examination of needle biopsy material, resected specimens, explanted liver material and follow-up. RESULTS: PSIT was more easily performed and altogether better accepted than PEI; in particular, pain immediately regressed upon infusion interruption. For this reason and for the atoxicity of the injected liquid, relatively large lesions could be treated with a greater volume per session and fewer sessions than with PEI. Treatment outcome was positive in all patients, except for the cholangiocarcinoma patient who required surgery. The only major complication was moderate peritoneal bleeding in a patient with severe coagulopathy. CONCLUSION: PSIT can be considered a useful tool for the local treatment of hepatic tumors. Its systematic use to treat hepatocellular carcinoma must be proceeded by further comparative studies with PEI.