Comparison of cesarean section rates between obstetricians preferring labor induction at early versus late gestational age.

OBJECTIVE: To compare the cesarean section (CS) rates of obstetricians with a preference of labor induction at early versus late gestational age. MATERIAL AND METHODS: Medical records of women who were low risk, nulliparous, singleton pregnancy, and >37 weeks and delivered their babies, were reviewed. Obstetricians, who preferred labor induction at<41 weeks, were allocated to the early induction group; and the other obstetricians were allocated to the late induction group. RESULTS: The late induction group had a higher percentage of labor induction at ≥41 weeks, compared with the early induction group (21% vs. 8%, p = 0.007). The late induction group had a lower CS rate (11.0% vs. 19.1%, p < 0.001). Multivariable Cox proportional hazard model revealed that the early induction group (hazard ratio [HR] = 2.14, p < 0.001), maternal age (HR = 1.04, p = 0.001), premature rupture of membranes (HR = 1.59, p = 0.006), and birth body weight (kg, HR = 2.13, p < 0.001) were independent predictors of CS. In women receiving labor induction (n = 312), birth body weight (kg, HR = 1.72, p = 0.04) was the sole predictor of CS; and there is a trend that the early induction group (HR = 1.54, p = 0.051) has a higher CS rate, compared with the late induction group. However, gestational age at labor induction was not a predictor of CS. CONCLUSION: In low-risk pregnancies, obstetricians preferring labor induction at early gestational age seem to be associated with a higher CS rate, compared with obstetricians preferring labor induction at late gestational age. Nonetheless, the above finding seems to be associated with physician's factor, instead of gestational age at labor induction.

Observational cohort study in older women with early breast cancer: Use of radiation therapy and impact on health-related quality of life and mortality.

BACKGROUND: Radiotherapy reduces in-breast recurrence risk in early breast cancer (EBC) in older women. This benefit may be small and should be balanced against treatment effect and holistic patient assessment. This study described treatment patterns according to fitness and impact on health-related quality-of-life (HRQoL). METHODS: A multicentre, observational study of EBC patients aged ≥ 70 years, undergoing breast-conserving surgery (BCS) or mastectomy, was undertaken. Associations between radiotherapy use, surgery, clinico-pathological parameters, fitness based on geriatric parameters and treatment centre were determined. HRQoL was measured using the European Organisation for the Research and Treatment of Cancer (EORTC) questionnaires. RESULTS: In 2013-2018 2811 women in 56 UK study centres underwent surgery with a median follow-up of 52 months. On multivariable analysis, age and tumour risk predicted radiotherapy use. Among healthier patients (based on geriatric assessments) with high-risk tumours, 534/613 (87.1%) having BCS and 185/341 (54.2%) having mastectomy received radiotherapy. In less fit individuals with low-risk tumours undergoing BCS, 149/207 (72.0%) received radiotherapy. Radiotherapy effects on HRQoL domains, including breast symptoms and fatigue were seen, resolving by 18 months. CONCLUSION: Radiotherapy use in EBC patients ≥ 70 years is affected by age and recurrence risk, whereas geriatric parameters have limited impact regardless of type of surgery. There was geographical variation in treatment, with some fit older women with high-risk tumours not receiving radiotherapy, and some older, low-risk, EBC patients receiving radiotherapy after BCS despite evidence of limited benefit. The impact on HRQoL is transient.

The effectiveness of acupressure in the management of depressive symptoms and in improving quality of life in older people living in the community: a randomised sham-controlled trial.

Objective: The primary aim of the current trial was to assess the clinical effectiveness of acupressure in the management of depression in elderly people compared to patients receiving sham acupressure or standard care alone.Methods: Randomized sham-controlled trial of acupressure, sham acupressure and standard care alone in older patients with depression living in the community. Patients with a score>/=8 in the Geriatric Depression Scale were recruited for this study. Intervention/sham treatments were provided four times/week for three months. Assessments related to depressive symptoms (primary outcome), well-being, resilience, spirituality and quality of life domains were carried out at baseline, end of the intervention and three-months after the intervention.Results: 118 patients were randomized to intervention (n = 40), sham (n = 40) or control arm (n = 38), with 84 patients providing final analysis data. Significant reduction in mean score of depressive symptoms was found in the acupressure group (from 10.6 (sd = 0.03) to 7.7 (sd = 0.07), p < 0.001 at end of intervention and 8.7 (sd = 0.8), p = 0.002 at follow-up) and the sham acupressure group (from 10.5 (sd = 0.3) to 8.4 (sd = 0.8), p = 0.005) at end of intervention and 8.4 (sd = 0.8), p = 0.006 at follow-up but not in the control group (from 10.8 to 9.9, p = 0.20). Resilience (p = 0.02) and spirituality (p = 0.02) were also improved in the intervention group at the end of intervention assessment but this change was not sustained at follow-up. Mind-body-spirit well-being and social functioning were improved both at the end of intervention and follow-up in the experimental as well as sham group. The sham group showed additional improvements in daily functioning and environmental quality of life.Conclusions: Although acupressure improved outcomes, a placebo effect was evident. Acupressure may be an effective approach to manage depression in elderly patients, but more evidence is needed in the future before it can be recommended for practice as well as more clear elucidation of any placebo effects.

Optimal Insertion Depth for Endotracheal Tubes in Extremely Low-Birth-Weight Infants.

OBJECTIVE: To determine the optimal endotracheal tube insertion depth in extremely low-birth-weight infants based on the association between endotracheal tube depth and gestational age, body weight, body length, and head and chest circumferences at birth. DESIGN: Retrospective chart review. SETTING: Neonatal ICU at a medical center. PATIENTS: Fifty-two hospitalized extremely low-birth-weight infants in our neonatal ICU. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Data regarding gestational age, body weight, body length (crown-heel length), head and chest circumferences, and final endotracheal tube depth were retrieved from the medical records of 52 newborn infants weighing less than or equal to 1,000 g at birth (boys, 29; girls, 23). The mean gestational age was 25.1 (range, 22-32) weeks, and the mean body weight was 724.5 (range, 400-1,000) g. Of the endotracheal tubes used, 3%, 87%, and 10% of endotracheal tubes were of size 2.0, 2.5, and 3.0, respectively. Linear regression analysis revealed a significant association between endotracheal tube depth and gestational age, body weight, body length, head, and chest circumferences (p < 0.001). Body weight had the highest coefficient of determination (r = 0.497), followed by body length (0.458), with all other variables having values of less than 0.4. CONCLUSIONS: In extremely low-birth-weight infants, a linear association exists between endotracheal tube insertion depth and gestational age, body weight, body length, chest, and head circumferences at birth. Although body weight is the most accurate method for predicting endotracheal tube insertion depth, body length is also appropriate and is more favorable than body weight in delivery room resuscitation. Although no substitute for radiologic confirmation exists, a tape measure that can convert body length to endotracheal tube depth may be helpful.

Noncardiac DiGeorge syndrome diagnosed with multiplex ligation-dependent probe amplification: A case report.

DiGeorge syndrome is not really a rare disease. A microdeletion of chromosome 22q11.2 is found in most patients. Sharing the same genetic cause, a wide spectrum of clinical manifestations such as conotruncal anomaly face syndrome, Cayler cardiofacial syndrome, and velocardiofacial syndrome have been reported. Classic characteristics are cardiac defects, abnormal facial features, thymic hypoplasia, cleft palate, and hypocalcemia. We report a 6-year-old female child presenting with generalized seizure resulting from hypocalcemia. She had no cardiac defects and no hypocalcemia episode in neonatal stage, and had been said to be normal before by her parents until the diagnosis was made. This highlights the importance of extracardiac manifestations in the diagnosis of DiGeorge syndrome, and many affected patients may be underestimated with minor facial dysmorphism. As health practitioners, it is our duty to identify the victims undermined in the population, and start thorough investigations and the following rehabilitation as soon as possible. Multiplex ligation-dependent probe amplification is a rapid, reliable, and economical alternative for the diagnosis of 22q11.2 deletion.

Parental smoking during pregnancy and its association with low birth weight, small for gestational age, and preterm birth offspring: a birth cohort study.

BACKGROUND: Intrauterine exposure to tobacco smoke has been discerned as an important risk factor for low birth weight (LBW), small for gestational age (SGA), and preterm birth infants. In this cohort study, we investigated the association of the amount of parental smoking during the different pregnancy stages with birth weight and the incidence of preterm delivery. METHODS: Our study population was acquired from the Taiwan Birth Cohort Study. Between June 2005 and July 2006, 21,248 postpartum women were interviewed 6 months after their deliveries by a structured questionnaire. The parents were divided into four groups according to the amount of smoking during preconception, the first trimester, and the second and third trimesters. The relationships of parental smoking with gestational age and birth weight during the different pregnancy stages were assessed using multivariate linear regression. Multiple logistic regression analyses were performed to estimate the odds ratios and 95% confidence intervals of preterm delivery, LBW, and SGA infants during the different parental smoking status and the different pregnancy stages. RESULTS: After adjusting for the physical and socioeconomic status of the parents and for paternal smoking during the same period, we found that maternal smoking decreased birth weight. Compared with the nonsmoking groups, all the maternal smoking groups had higher incidences of LBW, SGA, and preterm birth infants, especially when the mothers smoked >20 cigarettes/day. The association of paternal smoking with LBW, SGA, and preterm birth infants was insignificant. CONCLUSION: Maternal smoking is responsible for increased incidences of LBW and preterm delivery of babies, and therefore, smoking cessation/reduction should be advised to pregnant women to reduce morbidities in their neonates. Further studies are needed to clarify the correlation of fetal health with passive smoking, including exposure to environmental tobacco smoke and to other smokers in the family.

The interplay of host genetic factors and Epstein-Barr virus in the development of nasopharyngeal carcinoma / 癌症

The interplay between host cell genetics and Epstein-Barr virus (EBV) infection contributes to the development of nasopharyngeal carcinoma (NPC). Understanding the host genetic and epigenetic alterations and the influence of EBV on cell signaling and host gene regulation will aid in understanding the molecular pathogenesis of NPC and provide useful biomarkers and targets for diagnosis and therapy. In this review, we provide an update of the oncogenes and tumor suppressor genes associated with NPC, as well as genes associated with NPC risk including those involved in carcinogen detoxification and DNA repair. We also describe the importance of host genetics that govern the human leukocyte antigen (HLA) complex and immune responses, and we describe the impact of EBV infection on host cell signaling changes and epigenetic regulation of gene expression. High-power genomic sequencing approaches are needed to elucidate the genetic basis for inherited susceptibility to NPC and to identify the genes and pathways driving its molecular pathogenesis.

Design of superparamagnetic nanoparticles for magnetic particle imaging (MPI).

Magnetic particle imaging (MPI) is a promising medical imaging technique producing quantitative images of the distribution of tracer materials (superparamagnetic nanoparticles) without interference from the anatomical background of the imaging objects (either phantoms or lab animals). Theoretically, the MPI platform can image with relatively high temporal and spatial resolution and sensitivity. In practice, the quality of the MPI images hinges on both the applied magnetic field and the properties of the tracer nanoparticles. Langevin theory can model the performance of superparamagnetic nanoparticles and predict the crucial influence of nanoparticle core size on the MPI signal. In addition, the core size distribution, anisotropy of the magnetic core and surface modification of the superparamagnetic nanoparticles also determine the spatial resolution and sensitivity of the MPI images. As a result, through rational design of superparamagnetic nanoparticles, the performance of MPI could be effectively optimized. In this review, the performance of superparamagnetic nanoparticles in MPI is investigated. Rational synthesis and modification of superparamagnetic nanoparticles are discussed and summarized. The potential medical application areas for MPI, including cardiovascular system, oncology, stem cell tracking and immune related imaging are also analyzed and forecasted.

An infant with transient neonatal pustular melanosis presenting as pustules.

Transient neonatal pustular melanosis is mostly found in full-term black infants. It is a benign and self-limited disease, and the etiology is still unknown. We present a full-term female neonate with multiple vesiculopustular and pigmented macular lesions found immediately after her birth. A skin biopsy showed vesicles consisting of intracorneal and subcorneal aggregates of neutrophils, which is compatible with transient neonatal pustular melanosis. Although it is rare in Taiwan and Asian countries, transient neonatal pustular melanosis should always be considered when pustulosis is found in the neonatal period to prevent the use of unnecessary antibiotics. Dermatological consultation and histological confirmation are sometimes required for the final diagnosis.

Voice pitch characteristics of Cantonese and English produced by Cantonese-English bilingual children.

Two-minute spontaneous conversational speech of English and Cantonese was obtained from 86 Cantonese-English bilingual children. As a physical measurement of the rate of vocal fold vibration during speech production, fundamental frequency (F0) characteristics including the mean speaking F0, pitch sigma, minimum and maximum F0 values were measured from the medial 60-second portion of the speech samples by using Praat. F0 data measured from the English and Cantonese productions were statistically compared. Significant correlation was found for speaking F0, pitch sigma, and F0 range values between Cantonese and English. Results indicated that speaking F0 and F0 range values were significantly lower in Cantonese than in English. It is speculated that such difference is related to the tonal nature of Cantonese, although language proficiency may play a role in the discrepant F0 findings.

Hypernatremic dehydration due to concentrated infant formula: report of two cases.

Hypernatremic dehydration is a rare but serious clinical condition in newborns and small infants. It is usually caused by diarrhea, improperly prepared infant formula, decreased fluid intake, or exclusive breastfeeding. Symptoms are usually masked until neurological symptoms occur. We report two infants who presented with fever and hypernatremic dehydration caused by concentrating infant formula to alleviate symptoms of constipation, and careless formula preparation due to confusion over spoon sizes, respectively. In the first case, status epilepticus occurred during early treatment, despite close serum sodium monitoring, though the infant was asymptomatic and thriving 4 years after discharge, with no identified neurodevelopmental deficits. The course of treatment was smooth in the second case, and no neurological complications developed. The practice of concentrating infant formula to relieve symptoms of constipation, although temporarily effective, is hazardous to newborns or young infants and can cause hypernatremic dehydration. Spoon sizes supplied with commercial infant formulas (30 mL/spoonful or 60 mL/spoonful) should be unified to avoid mistakes during preparation, especially by inexperienced and teenage mothers.

Video-assisted thoracoscopic surgery in a 1-month-old infant with pleural empyema.

Pleural empyema is a frequent complication of bacterial pneumonia in childhood but is rare in neonates. Various modalities of treatment from intravenous antibiotics, chest tube drainage, intrapleural fibrinolytic agent installation, video-assisted thoracostomy to surgical decortication have been suggested to treat different stages of empyema in children, but management of progressive empyema in neonates is still at the stage of antimicrobial therapy and tube thoracostomy. Here, we report a 1-month-old infant with staphylococcal pneumonia complicated with multiloculated empyema who was successfully treated with video-assisted thoracoscopic surgery (VATS) after 4 days of chest tube drainage and parenteral antibiotics. The patient's condition improved rapidly after the operation and the antimicrobial therapy was continued for 3 weeks. He was asymptomatic and thriving at follow-up 1 year later. Chest radiography at 1 month was free of any lesion. This case suggests that VATS can be a safe and effective treatment for neonatal empyema.

Clinical manifestations and neurodevelopmental outcome following an event of accidental intramuscular injection of atracurium in newborns.

UNLABELLED: Pediatric populations are at risk for medication errors that may be associated with mortality and disability. The purpose of this study was to describe the clinical manifestations of seven newborns following an event of accidental intramuscular injection of atracurium and to assess the impact on neurodevelopmental outcome. This study enrolled seven newborns who were accidentally administered 10 mg of atracurium, equivalent to 2.6-3.3 mg/kg, in a local perinatal clinic. Accident reports and hospital records were reviewed to obtain the history and medical data for the event. The survivors were prospectively examined for their growth, health and neurodevelopment until 24 months of age. All newborns showed immediate apnea and cyanosis requiring resuscitation after atracurium injection and presented with respiratory failure and flaccid paralysis on arrival for emergency medical services. One newborn was asystolic despite resuscitation and died of multiple organ failure. Of the five survivors available for follow-up, all achieved favorable growth outcomes. However, four showed mild to significant delay in development; and two manifested mild hypomyelination of cerebral white matter on the brain magnetic resonance imaging. CONCLUSION: Newborns accidentally injected with high doses of atracurium are at risk of death and neurodevelopmental delay. The serious clinical manifestations, developmental delay and cerebral hypomyelination were most likely due to insufficient immediate respiratory assistance following atracurium injection.

Candidal arthritis after complete treatment of systemic candidiasis.

Over the last few decades, the incidence of invasive candidal infections in neonatal intensive care units has increased dramatically. Various complications, such as arthritis, endocarditis, meningitis, and endophthalmitis, have been reviewed. We present the case of a premature infant with systemic candidemia. Arthritis was discovered 6 months after completion of amphotericin B therapy, and was successfully treated with oral fluconazole for 6 weeks. We conclude that long-term follow-up is particularly important in patients with treated candidemia. To prevent complications, prolonged treatment with high-dose amphotericin B is suggested for systemic fungal infection, and oral fluconazole is an effective alternative for candidal arthritis.