Economic Evaluations Comparing a Trial of Labor with an Elective Repeat Cesarean Delivery: A Systematic Review.

BACKGROUND: For women who have had a previous low transverse cesarean delivery, the decision to undergo a trial of labor after cesarean (TOLAC) or an elective repeat cesarean delivery (ERCD) has important clinical and economic ramifications. OBJECTIVES: To evaluate the cost-effectiveness of the alternative choices of a TOLAC and an ERCD for women with low-risk, singleton gestation pregnancies. METHODS: We searched EMBASE, MEDLINE, CINAHL, Cochrane Library, EconLit, and the Cost-Effectiveness Analysis Registry with no language, publication, or date restrictions up until October 2015. Studies were included if they were primary research, compared a TOLAC with an ERCD, and provided information on the relative cost of the alternatives. Abstracts and partial economic evaluations were excluded. RESULTS: Of 310 studies initially reviewed, 7 studies were included in the systematic review. In the base-case analyses, 4 studies concluded that TOLAC was dominant over ERCD, 1 study found ERCD to be dominant, and 2 studies found that although TOLAC was more costly, it offered more benefits and was thus cost-effective from a population perspective when considering societal willingness to pay for better outcomes. In sensitivity analyses, cost-effectiveness was found to be dependent on a high likelihood of TOLAC success, low risk of uterine rupture, and low relative cost of TOLAC compared with ERCD. CONCLUSIONS: For women who are likely to have a successful vaginal delivery, routine ERCD may result in excess morbidity and cost from a population perspective.

Relationship between the nutritional status of breastfeeding Mayan mothers and their infants in Guatemala.

A case-control study was conducted to determine the association between maternal height and infant length-for-age, and to evaluate how this association is modified by either maternal or infant nutritional status. We hypothesised that maternal excess caloric intake [measured as body mass index (BMI)] would increase the association, while infant nutrition (measured in main meals consumed in addition to breastfeeding) will diminish the effect. Mother and infant pairs in Chimaltenango, Guatemala, were measured for anthropometric values and nutritional status, and mothers were interviewed to elicit nutritional and socio-economic information. Infant length was converted into z-scores based on the World Health Organization's (WHO) standards. Odds ratios (ORs), associated 95% confidence intervals (CIs) and the relative excess risk due to interaction (RERI) were calculated. Cases were infants below 2 z-scores of the WHO's length-for-age, while controls were infants within the -2 to 2 z-score range. Cases (n = 84) had an increased odds (OR: 3.00, 95% CI: 1.57-5.74) of being born to a stunted mother (below 145 cm) when compared with controls (n = 85). When adjusted for potential confounders, the OR decreased to 2.55 (95% CI: 1.30-5.02). Negative RERI values were produced for the joint exposure of maternal BMI ≥ 25 and maternal stuntedness (RERI: -0.96), as well as for the joint exposure of maternal stuntedness and infant nutrition (RERI: -2.27). Our results confirm that maternal stuntedness is a significant contributor to infant stuntedness; however, this association is modified negligibly by maternal nutritional status and significantly by infant nutritional status, each in a protective manner.

Symptomatic hypercalcemia in an infant secondary to excessive consumption of almond milk as a formula alternative.

A 4-month-old previously healthy female presented with persistent nonbloody, nonbilious emesis, decreased urine output, weight loss, fussiness, and lethargy. Serum levels of calcium were increased at 14.1 mg/dL, serum phosphate decreased at 1.6 mg/dL, and serum parathyroid hormone decreased at <4 pg/mL. The patient had been consuming unsweetened almond milk due to inability to find infant formula during a national infant formula shortage. Milk alternatives including almond milk are calorie-poor, low fat, low protein, and too high in free water and calcium to safely be the primary nutrition source for infants.

Evaluation of Intranasal Fentanyl and Midazolam Among Inpatient Pediatric Patients.

OBJECTIVES: The use of intranasal (IN) analgesics and sedatives has been studied among pediatrics patients in the emergency department and outpatient settings. However, less is known about their usage in inpatient settings. This study aims to evaluate the indications and safety profile for IN fentanyl and midazolam usage in pediatric patients admitted to a large tertiary care children's hospital. METHODS: This study is a retrospective chart review of admitted patients receiving IN fentanyl and/or midazolam over a 6-year period. Indications for medication use, medication dosages, patient characteristics, and any serious adverse drug reactions were recorded. Reported serious adverse outcomes include use of reversal agents as well as any documented respiratory depression, hypotension, or need for escalation of care. RESULTS: Of 156 patients included, 119 (76%) received IN midazolam alone, 20 (13%) patients received IN fentanyl alone, and 17 (11%) patients received both medications. The most common applications for IN medication administration were nasogastric tube placements (n = 62), peripheral intravenous line insertions (n = 30), peripherally-inserted central catheter placements (n = 23), and lumbar punctures (n = 16). No serious adverse events were reported. CONCLUSIONS: This study suggests that IN fentanyl and midazolam were administered to pediatric inpatients undergoing routine procedures without serious adverse drug reactions being reported. Although these findings are encouraging, more prospective studies are needed before wider implementation of IN fentanyl and midazolam administration in pediatric inpatients.

Moraxella catarrhalis Septic Arthritis Unveils Undiagnosed Systemic Lupus Erythematous in a Pediatric Patient.

Septic arthritis is uncommon in pediatric patients, who are less likely to have major risk factors such as underlying joint disease or prosthetic joints. It only rarely affects the elbow and is usually caused by Gram-positive cocci, with Staphylococcus aureus being the most common bacterial organism. We present the case of a 15-year-old previously healthy female who experienced new-onset monoarticular nontraumatic elbow pain and was found to have a synovial effusion growing from Moraxella catarrhalis. The atypical clinical presentation, coupled with the growth of an unusual organism, raised concern for an underlying immunocompromising or inflammatory joint disorder. Further laboratory workup ultimately revealed a diagnosis of systemic lupus erythematosus (SLE), which more commonly presents with arthralgias that are polyarticular, symmetric, and migratory. This case report should encourage clinicians to maintain a high degree of suspicion for underlying joint disease when septic arthritis presents atypically.

Friends Not Foes: Optimizing Collaboration with Subspecialists.

Pediatric orthopedic patients can be complex to manage. As orthopedists plan for possible surgical interventions, consultation with pediatric subspecialists will be necessary. This article discusses the considerations an orthopedist should make when deciding on the timing and the appropriateness of consultation-both preoperatively and perioperatively. Consultation before surgical intervention will especially be useful if the subspecialist will be collaborating in the management of the condition postoperatively (whether inpatient or outpatient). Clear and early consultation in both written and verbal format will facilitate quality and expedite the patient's care.