Macrosomia Rates in Women with Diet-Controlled Gestational Diabetes: A Retrospective Study.

BACKGROUND: Current data on the rates of macrosomia in women with gestational diabetes mellitus (GDM) are heterogenous. No study has specifically examined macrosomia rates in women with diet-controlled gestational diabetes. AIMS: To compare the rates of macrosomia between mothers with diet-controlled GDM to mothers without diabetes mellitus. METHODS: A retrospective study in which all patients with diet-controlled GDM and singleton pregnancies in 2014 were considered for inclusion in the study. These cases were individually matched to mothers without GDM and without type 1 or 2 diabetes. Cases were matched to parity, age, and BMI. Controls were selected from the same year and as close as possible to the date of delivery of the case. Primary outcomes were macrosomia, defined by estimated fetal weight >90th centile and >95th centile (separately). RESULTS: The estimated adjusted odds ratio for the presence of maternal GDM in the presence of EFW > 90th percentile (adjusted for maternal age, BMI, gravidity, parity, baby gender, and EGA) was 0.63 (95% CI 0.30-1.3; P = 0.21). The estimated adjusted odds ratio for the association of maternal GDM and EFW > 95th percentile was 0.66 (95% CI 0.26-1.7; P = 0.38). CONCLUSIONS: Our findings suggest that macrosomia is not increased in women with diet-controlled GDM. The study registration number is AQA 16/01.

Waiting for definitive care: An analysis of elapsed time from decision to surgery or transfer in a rural centre.

OBJECTIVE: To examine the timing of operative management and interhospital transfer of emergency general surgical patients in a regional setting. DESIGN: Retrospective cohort study. SETTING: The surgical unit at a major rural referral centre for North-Eastern Victoria servicing a population of 90 000. PARTICIPANTS: General surgical patients (n = 649) admitted via the emergency department at Northeast Health Wangaratta between January 2011 and March 2013 undergoing operative management (n = 608) or transfer to a tertiary centre (n = 44). MAIN OUTCOME MEASURES: Timing of operative management, using appendicectomy as a benchmark operation, was measured as time from presentation to decision to operate, time from decision to surgery, percentage after-hours operating and length of stay (LOS). Time to interhospital transfer was calculated and reasons for delay were sought. RESULTS: Two hundred forty-six appendicectomies were performed. Median time from decision to operate to theatre was 3 hours (interquartile range (IQR) 2-8), and total LOS was 43 hours (IQR: 28-56). Two hundred seventy-two procedures (43%) were performed out-of-hours, including 48% of appendicectomies. Median time from decision making to transfer was 10.3 hours (IQR: 4.7-25). Transfer was less likely to be delayed in trauma patients when compared with urgent non-trauma patients (5.3 versus 10.6 hours; P = 0.04). CONCLUSION: Even in the absence of a strict four-hour rule program and a dedicated emergency surgical unit, main outcome measures appear to be comparatively efficient. However, the duration for transfer of patients is suboptimal because of the lack of established pathways for urgent non-trauma transfer from rural centres and bed availability in tertiary hospitals.

The arterial supply of the long head of biceps tendon: Anatomical study with implications for tendon rupture.

Zones of hypovascularity are thought to exist in several tendons of the shoulder, contributing to localized tendon weakness and subsequent rupture in clinical practice. Although these zones have been demonstrated in many frequently ruptured tendons, the existence of a similar area in the often ruptured long head of biceps (LHB) tendon is largely unknown. Twenty cadaveric upper limb specimens were dissected after injection with either a radio-opaque lead oxide/milk mixture or India ink, followed by histological sectioning of the tendons. The LHB tendon was consistently supplied via its osteotendinous and musculotendinous junctions by branches of the thoracoacromial and brachial arteries respectively. In two specimens, additional branches from the anterior circumflex humeral artery travelling in a mesotenon vascularized the midsection of tendon. These source arteries divided the LHB tendon into either two or three vascular territories, depending upon the presence of the mesotenon-derived vascular supply. A zone of hypovascularity was consistently found in the region of the LHB tendon most frequently prone to rupture. This zone covered an area 1.2-3 cm from the tendon origin, extending from midway through the glenohumeral joint to the proximal inter-tubercular groove. This hypovascular region occurred on the border of two adjacent vascular territories, where reduced caliber choke vessels provide limited arterial supply. While it is probable that the limited arterial supply contributes to the susceptibility of this area to rupture, similar to other tendons the true pathogenesis is likely to be a combination of both vascular and mechanical factors.

Anomalies of the flexor carpi ulnaris: clinical case report and cadaveric study.

Flexor carpi ulnaris (FCU) is an ever-present muscle of the anterior flexor compartment of the forearm. Variations of FCU are uncommon, with additional slips or heads of muscles described, and only one reported case of an accessory muscle. We describe a unique clinical case report in which an accessory FCU was identified and describe the findings of 5,000 cadaveric dissections of the forearm, performed as part of an ongoing institutional study of anatomical variations. An aberrant accessory forearm flexor muscle was identified incidentally at the wrist during surgery for an anterior interosseous to ulnar nerve transfer for management of ulnar nerve palsy. This muscle was seen running superficial to the ulnar nerve and radial to the FCU proper, arising from the common flexor origin and inserting at the triquetral carpal bone. This was therefore suitably acknowledged as an "accessory FCU". The anomaly was identified as bilateral using ultrasound imaging, and was found to be anomalously innervated by the median nerve with nerve conduction studies. A subsequent review of 5,000 cadaveric dissections of the forearm did not identify any such variations related to FCU, despite identifying a range of variations of the other forearm flexor musculature. While the scarcity of this anomaly is thus highlighted, consideration of an accessory FCU, and its aberrant innervation is important in a range of surgical approaches.