Time-to-delivery and delivery outcomes comparing three methods of labor induction in 7551 nulliparous women: a population-based cohort study.

OBJECTIVE: Determine time-to-delivery and mode-of-delivery in labor induction among women with unripe cervix. STUDY DESIGN: 7551 nulliparous women with singleton deliveries, ⩾37 weeks, Bishop Score ⩽6, induced with dinoprostone, misoprostol or transcervical single balloon catheter. Linear regression analysis was used to estimate mean time-to-delivery with ß-estimates and 95% confidence intervals with adjustments. Multivariable logistic regression analysis was used to calculate odds of cesarean delivery, instrumental vaginal delivery, maternal and neonatal outcomes. RESULTS: Adjusted mean time-to-delivery was 6.9 and 1.5 h shorter, respectively, when inducing labor with balloon catheter (mean 18.3 h, ß -6.9, 95% confidence intervals; -7.6 to -6.3) or misoprostol (mean 23.7 h, ß -1.5, 95% confidence intervals; -2.3 to -0.8) compared with dinoprostone (mean 25.2 h). There were no significant differences in adverse maternal or infant outcomes between induction methods. CONCLUSIONS: Balloon catheter is the most effective induction method with respect to time-to-delivery in nulliparous women at term compared with prostaglandin methods.

Atomic scale surface engineering of micro- to nano-sized pharmaceutical particles for drug delivery applications.

Atomic layer deposition on pharmaceutical particles for drug delivery applications is demonstrated using assisted fluidized bed dry powder processing. Complete and conformal layering is achieved on particle sizes from the lower micron to upper nanometer range under near ambient conditions. As few as 2-14 atomic alumina layers alter particle properties: dissolution, dispersibility and heat transfer.

Population-based reference curve for umbilical cord arterial pH in infants born at 28 to 42 weeks.

OBJECTIVE: The objective of the study was to examine normal variations of umbilical cord arterial pH by gestational age (GA). STUDY DESIGN: Population-based cohort study of 46 199 infants born from 2008 to 2014 in Stockholm, Sweden, with GA 28 to 42 weeks, Apgar score ⩾7 at 5 min, non-instrumental vaginal delivery, and birth weight for GA⩾3rd and ⩽97th percentile. Quantile regression was used to investigate the associations between GA and infant sex, and pH. RESULTS: The mean umbilical cord arterial pH (s.d.) was 7.29 (0.10), 7.27 (0.07), 7.25 (0.07) and 7.23 (0.07) among infants born at 28 to 31, 32 to 36, 37 to 41 and 42 weeks, respectively. Arterial pH decreased linearly with increasing GA, and female infants had higher pH than male infants (P<0.001). CONCLUSION: Umbilical cord arterial pH varied in a linear fashion by GA and was influenced by infant sex. The provided reference curve taking GA into account may yield a more accurate definition of acidosis at birth.

ViPAR: a software platform for the Virtual Pooling and Analysis of Research Data.

BACKGROUND: Research studies exploring the determinants of disease require sufficient statistical power to detect meaningful effects. Sample size is often increased through centralized pooling of disparately located datasets, though ethical, privacy and data ownership issues can often hamper this process. Methods that facilitate the sharing of research data that are sympathetic with these issues and which allow flexible and detailed statistical analyses are therefore in critical need. We have created a software platform for the Virtual Pooling and Analysis of Research data (ViPAR), which employs free and open source methods to provide researchers with a web-based platform to analyse datasets housed in disparate locations. METHODS: Database federation permits controlled access to remotely located datasets from a central location. The Secure Shell protocol allows data to be securely exchanged between devices over an insecure network. ViPAR combines these free technologies into a solution that facilitates 'virtual pooling' where data can be temporarily pooled into computer memory and made available for analysis without the need for permanent central storage. RESULTS: Within the ViPAR infrastructure, remote sites manage their own harmonized research dataset in a database hosted at their site, while a central server hosts the data federation component and a secure analysis portal. When an analysis is initiated, requested data are retrieved from each remote site and virtually pooled at the central site. The data are then analysed by statistical software and, on completion, results of the analysis are returned to the user and the virtually pooled data are removed from memory. CONCLUSIONS: ViPAR is a secure, flexible and powerful analysis platform built on open source technology that is currently in use by large international consortia, and is made publicly available at [http://bioinformatics.childhealthresearch.org.au/software/vipar/].

Prolonged second stage of labour, maternal infectious disease, urinary retention and other complications in the early postpartum period.

OBJECTIVE: To study the association between duration of second stage of labour and risks of maternal complications (infection, urinary retention, haematoma or ruptured sutures) in the early postpartum period. DESIGN: Population-based cohort study. SETTING AND SAMPLE: We included 72 593 mothers with singleton vaginal deliveries at ≥37 weeks of gestation in cephalic presentation, using the obstetric database from the Stockholm-Gotland region in Sweden, 2008-12. METHODS: Logistic regression analysis. Odds ratios (ORs) with 95% confidence intervals (95% CI) were calculated and adjustments were made for maternal age, body mass index, height, smoking, cohabitation, gestational age, labour induction, epidural analgesia and oxytocin augmentation. RESULTS: Rates of any complication varied by parity from 7.3% in parous women with previous caesarean section, 4.8% in primiparas and 1.7% in parous women with no previous caesarean section. Compared with a second stage <1 hour, the adjusted ORs for any complication (95% CI) in primiparas were for 1 to <2 hours 1.28 (1.11-1.47); 2 to <3 hours 1.54 (1.32-1.79), 3 to <4 hours 1.63 (1.38-1.93) and ≥4 hours 2.08 (1.74-2.49). The corresponding adjusted ORs for parous women without previous caesarean were 2.27 (1.78-2.90), 2.97 (2.09-4.22), 3.65 (2.25-5.94) and 3.16 (1.44-6.94), respectively. The adjusted ORs for women with previous caesarean were for 1 to <2 hours 1.62 (1.13-2.32); 2 to <3 hours 1.56 (1.00-2.43), 3 to <4 hours 2.42 (1.52-3.87), and ≥4 hours 2.31 (1.25-4.24). CONCLUSIONS: Risks of maternal complications in the postpartum period increase with duration of second stage of labour also after accounting for maternal, pregnancy and delivery characteristics. Special attention has to be given to parous women with previous caesarean deliveries.

Preventive care delivered within Public Dental Service after caries risk assessment of young adults.

OBJECTIVES: To study preventive care provided to young adults in relation to their estimated risk category over a 3-year period. METHODS: The amount and type of preventive treatment during 3 years was extracted from the digital dental records of 982 patients attending eight public dental clinics. The baseline caries risk assessment was carried out by the patient's regular team in four classes according to a predetermined model, and the team was responsible for all treatment decisions. Based on the variables 'oral health information', 'additional fluoride' and 'professional tooth cleaning', a cumulative score was constructed and dichotomized to 'basic prevention' and 'additional prevention'. RESULTS: More additional preventive care was provided to the patients in the 'low-risk' and 'some risk' categories than to those classified as 'high' or 'very high' risk (OR = 2.0, 95% CI 1.4-3.0; P < 0.05). Professional tooth cleaning and additional fluorides were most frequently employed in the 'low-risk' and 'some risk' categories, respectively. Around 15% of the patients in the high-risk categories did not receive additional preventive measures over the 3-year period. There was an insignificant tendency that patients with additional prevention developed less caries than those that received basic prevention in all risk categories except for the 'very high-risk' group. CONCLUSION: The caries risk assessment process was not accompanied by a corresponding targeted individual preventive care in a cohort of young adults attending public dental service. Further research is needed how to reach those with the greatest need of primary and secondary prevention.

Advances in inhaled technologies: understanding the therapeutic challenge, predicting clinical performance, and designing the optimal inhaled product.

Inhaled medicines are designed mainly to provide safe and efficacious treatment of respiratory diseases, offering the potential advantages of targeted drug delivery such as reduced onset time and increased therapeutic ratio. However, as a flipside of targeted drug delivery, drug levels in the relevant effect compartment cannot be easily assessed. In combination with technical challenges associated with aerosolizing and administering an inhaled medicine, this renders inhalation product development demanding in the regulatory aspect as well. Emerging technologies that could address some of these challenges include (i) mechanistic pharmacokinetic/pharmacodynamic (PK/PD) modeling, which in combination with experimental techniques such as positron emission tomography could provide information on local target engagement; (ii) patient-feedback features in combination with electronic monitoring, which may improve patient adherence as well as patient handling; and (iii) controlled-release formulations and nanotechnology-based formulations with high drug load, which may expand the scope of development of compounds and targets suitable for inhalation product development.

Clinical implementation of systematic medication reconciliation and review as part of the Lund Integrated Medicines Management model--impact on all-cause emergency department revisits.

WHAT IS KNOWN AND OBJECTIVE: Interventions involving medication reconciliation and review by clinical pharmacists can reduce drug-related problems and improve therapeutic outcomes. The objective of this study was to examine the impact of routine admission medication reconciliation and inpatient medication review on emergency department (ED) revisits after discharge. Secondary outcomes included the combined rate of post-discharge hospital revisits or death. METHODS: This prospective, controlled study included all patients hospitalized in three internal medicine wards in a university hospital, between 1 January 2006 and 31 May 2008. Medication reconciliation on admission and inpatient medication review, conducted by clinical pharmacists in a multiprofessional team, were implemented in these wards at different times during 2007 and 2008 (intervention periods). A discharge medication reconciliation was undertaken in all the study wards, during both control and intervention periods. Patients were included in the intervention group (n = 1216) if they attended a ward with medication reconciliation and review, whether they had received the intervention or not. Control patients (n = 2758) attended the wards before implementation of the intervention. RESULTS AND DISCUSSION: No impact of medication reconciliation and reviews on ED revisits [hazard ratio (HR), 0.95; 95% confidence interval (CI), 0.86-1.04]or event-free survival (HR, 0.96; 95% CI, 0.88-1.04) was demonstrated. In the intervention group, 594 patients (48.8%) visited the ED, compared with 1416 (51.3%) control patients. In total, 716 intervention (58.9%) and 1688 (61.2%) control patients experienced any event (ED visit, hospitalization or death). Because the time to a subsequent ED visit was longer for the control as well as the intervention groups in 2007 than in 2006 (P < 0.05), we re-examined this cohort of patients; the proportion of patients revisiting the ED was similar in both groups in 2007 (P = 0.608). WHAT IS NEW AND CONCLUSION: Routine implementation of medication reconciliation and reviews on admission and during the hospital stay did not appear to have any impact on ED revisits, re-hospitalizations or mortality over 6-month follow-up.

Caries risk profiles of 12-13-year-old children in Laos and Sweden.

PURPOSE: To analyse caries risk factors of 12-13-year-old children living in Laos, using the computer program Cariogram to illustrate the caries risk profile. In addition, to compare the results with a study performed in Sweden. MATERIALS AND METHODS: One hundred Laotian and 392 Swedish children were included. Interviews were performed to obtain information on diet intake and fluoride use. Saliva was analysed for mutans streptococci, lactobacilli and secretion rate/buffering capacity. Oral hygiene was assessed using the Silness and Löe criteria. Caries prevalence was recorded according to WHO. The data were entered into the Cariogram to determine each child's caries risk, expressed as 'the chance of avoiding caries'. The children were divided into five risk groups. RESULTS: Mean DMFT level of the Laotian children was 4.61 +/- 2.95 and 1.38 +/- 1.97 in the Swedish group. For the risk factors plaque amount, frequency of food intake, saliva secretion rate, buffering capacity and fluoride, the Laotian children had significantly less favourable values compared to the Swedes. Only 6% of Laotian children belonged to the Cariogram low risk group versus 40% of the Swedish children. The mean DMFT for the five Cariogram groups was (from low to high risk) 0.00, 3.00, 3.56, 5.66, 6.11 for the Lao children and 0.31, 1.39, 2.56, 3.03, 2.91 for the Swedish ones. The mean chance of avoiding caries was 37.3% for the Laotians and 69.2% for the Swedish children (p < 0.001). CONCLUSION: According to the 'opinion' of the Cariogram, the Laotian children demonstrated significantly higher caries risk than Swedish children.

Caries risk assessment as a predictor of metabolic control in young Type 1 diabetics.

AIMS: To investigate the relationship between caries risk and glucosylated haemoglobin and to evaluate the use of a computerized caries risk assessment program as a predictor of metabolic control in schoolchildren with Type 1 diabetes mellitus. METHODS: The material consisted of 64 young Type 1 diabetes mellitus patients (8-16 years) attending an outpatient paediatric clinic. Within 2 weeks after the onset of diabetes, a caries risk assessment was carried out with the aid of a computer-based program (Cariogram) and data on the level of metabolic control were collected from the medical records at the 3-year check-up. Caries increment was registered at recall clinical examinations. RESULTS: A statistically significant positive relationship between caries risk and metabolic control was found (r = 0.51; P < 0.01), with a sevenfold increased risk of impaired metabolic control after 3 years in those assessed with high caries risk at onset (OR 7.3; P < 0.01). When the Cariogram was used as a predictor for the metabolic state of the disease, the sensitivity and specificity was 75% and 71%, respectively. The negative predictive value was 91%. CONCLUSIONS: Our data suggested that a caries risk assessment at the diagnosis of diabetes mellitus in children may be a good indicator of overall health care that can provide useful prognostic information on the level of metabolic control after 3 years.

Evaluation of a computer program for caries risk assessment in schoolchildren.

The 'Cariogram' is an interactive PC program for caries risk evaluation. It takes into account the interactions between caries-related factors and expresses a graphic assessment of the risk. The aim of this study was to assess the caries risk in schoolchildren using the Cariogram and to evaluate the program by comparing the caries risk assessments with the actual change in DMF. A 2-year prospective study on 446 schoolchildren, 10-11 years old, was conducted. At baseline, data on general health, diet, oral hygiene and use of fluoride were obtained. Saliva analyses included mutans streptococci and lactobacilli counts, buffer capacity and secretion rate. DMFT and DMFS were calculated from records and bitewing radiographs. Scores were entered and caries risk was assessed. Re-examination for caries was done after 2 years. The children were divided into 5 groups according to the assessed caries risk at baseline. Where the Cariogram predicted a 0-20% (high risk), 21-40%, 41-60%, 61-80% and 81-100% (low risk) chance of avoiding new lesions, 8, 35, 42, 73 and 83%, respectively, had no new lesions 2 years later. Logistic regression analyses were carried out. When the Cariogram was included, only two factors, the Cariogram (p < 0.001) and the DMFS at baseline, i.e. past caries experience (p = 0.001), turned out to be significantly associated with caries increment. The Cariogram was the most powerful explanatory variable. When the Cariogram was excluded, lactobacillus count, mutans streptococci, diet intake frequency and DMFS at baseline were significantly associated with caries increment. The Cariogram predicted caries increment more accurately than any included single-factor model. How this finding can be translated into daily practice in the best and most practical way is a matter for future research.

Phenolic antioxidants in wood smoke.

Ten prominent dimethoxyphenols were determined in birchwood smoke from choked and open laboratory burning and in chimney smoke from a tiled stove. The structures of the methoxyphenols are similar to those of the well-known tocopherol and ubiquinol antioxidants. The 2,6-dimethoxyphenols characterising hardwood smoke are stronger antioxidants than the corresponding 2-methoxyphenols present mainly in softwood smoke. The antioxidant activity is highest for the 2,6-dimethoxyphenols with 4-alkenyl and 4-alkyl groups, which constitute 60-70% of the total amount of dimethoxyphenols. Phenolic antioxidants are scavengers of oxygen radicals and should be considered when health hazards of small-scale incomplete biomass burning are estimated.

[Continuing should be a part of the clinical reality. Courage is required to see both the strong and the weak sides of the professional situation]. / Fortbildning skall utgå från den kliniska verkligheten. Det krävs mod att se både de starka och de svaga sidoma i yrkessituationen.

Continuing professional development (CPD) is a joint responsibility of the individual physician and the employer. CPD should focus on identification and documentation of the learning needs of the individual, based on professional demands. Reflection, feedback and evaluation of the results are central elements of the process. Efficient learning demands active participation; modern information technology is now becoming more widely available.

Phenols and aromatic hydrocarbons in chimney emissions from traditional and modern residential wood burning.

The emissions from a traditional tiled stove consisted mainly of lignin-related methoxyphenols with antioxidant properties, and 1,6-anhydroglucose from cellulose degradation. A wood stove of presently introduced energy-efficient design for residential heating and hot-water supply was shown to emit small amounts of methoxyphenols and anhydrosugars from primary wood pyrolysis. Secondary harmful components like benzene and polycyclic aromatic hydrocarbons constituted a major portion of the organic emissions. It is concluded that differences in smoke composition are essential to consider in recommendations and rules for proper choices of wood burning devices.

Caffeine intake and the risk of first-trimester spontaneous abortion.

BACKGROUND: Some epidemiologic studies have suggested that the ingestion of caffeine increases the risk of spontaneous abortion, but the results have been inconsistent. METHODS: We performed a population-based, case-control study of early spontaneous abortion in Uppsala County, Sweden. The subjects were 562 women who had spontaneous abortion at 6 to 12 completed weeks of gestation (the case patients) and 953 women who did not have spontaneous abortion and were matched to the case patients according to the week of gestation (controls). Information on the ingestion of caffeine was obtained from in-person interviews. Plasma cotinine was measured as an indicator of cigarette smoking, and fetal karyotypes were determined from tissue samples. Multivariate analysis was used to estimate the relative risks associated with caffeine ingestion after adjustment for smoking and symptoms of pregnancy such as nausea, vomiting, and tiredness. RESULTS: Among nonsmokers, more spontaneous abortions occurred in women who ingested at least 100 mg of caffeine per day than in women who ingested less than 100 mg per day, with the increase in risk related to the amount ingested (100 to 299 mg per day: odds ratio, 1.3; 95 percent confidence interval, 0.9 to 1.8; 300 to 499 mg per day: odds ratio, 1.4; 95 percent confidence interval, 0.9 to 2.0; and 500 mg or more per day: odds ratio, 2.2; 95 percent confidence interval, 1.3 to 3.8). Among smokers, caffeine ingestion was not associated with an excess risk of spontaneous abortion. When the analyses were stratified according to the results of karyotyping, the ingestion of moderate or high levels of caffeine was found to be associated with an excess risk of spontaneous abortion when the fetus had a normal or unknown karyotype but not when the fetal karyotype was abnormal. CONCLUSIONS: The ingestion of caffeine may increase the risk of an early spontaneous abortion among non-smoking women carrying fetuses with normal karyotypes.

Methoxyphenols from burning of Scandinavian forest plant materials.

Semivolatile compounds in smoke from gram-scale incomplete burning of plant materials were assessed by gas chromatography and mass spectrometry. Gas syringe sampling was shown to be adequate by comparison with adsorbent sampling. Methoxyphenols as well as 1,6-anhydroglucose were released in amounts as large as 10 mg kg(-1) of dry biomass at 90% combustion efficiency. Wood, twigs, bark and needles from the conifers Norway spruce and Scots pine emitted 12 reported 2-methoxyphenols in similar proportions. Grass, heather and birchwood released the same 2-methoxyphenols but also the corresponding 2,6-dimethoxyphenols which are characteristic of angiosperms. The methoxyphenols are formed from lignin and differ in structure by the group in para position relative to the phenolic OH group. Prominent phenols were those with trans-1-propenyl and ethenyl groups in that position. Vanillin, 4-hydroxy-3-methoxybenzaldehyde, was a prominent carbonyl compound from the conifer materials.

Caries risk assessment: a comparison between the computer program 'Cariogram', dental hygienists and dentists.

UNLABELLED: The 'Cariogram', which is an interactive PC-program for caries risk evaluation, illustrates the interaction between caries related factors and expresses the caries risk graphically. It also demonstrates a weighted impact of the different etiological factors on the risk. The aim of this paper was to use the Cariogram program on a set of patients, and to compare the outcome of its risk evaluation with those made by dental hygienists and dentists. A questionnaire, containing the descriptions of five patients with detailed information on nine factors generally associated with caries, was given to the participants. They were asked to rank the patients according to their 'chance to avoid dental caries' during the coming year. The results were compared with the assessments obtained from the Cariogram. RESULTS: 73.5% of the dental hygienists and 78.5% of the dentists ranked the patients for caries risk either identically or with only one deviation when compared to the Cariogram. It was concluded that the 'opinion' of the Cariogram on caries risk was in agreement with that of the majority of the participants. In addition, the Cariogram program induced discussions about the relative impact of etiological factors of caries. It is envisaged that the Cariogram can serve as one further tool in the teaching of caries risk.

The influence of gestational age and smoking habits on the risk of subsequent preterm deliveries.

BACKGROUND: Previous preterm delivery and maternal smoking are associated with increased risks of preterm delivery. It is not known whether gestational age at the time of a preterm delivery is correlated with gestational age in successive preterm deliveries and whether changes in smoking habits influence the subsequent risk of preterm delivery. METHODS: We studied the associations among smoking habits, previous very preterm or moderately preterm delivery (before 32 weeks and at 32 to 36 weeks, respectively), and the risk of a subsequent very preterm or moderately preterm delivery in a population-based cohort of 243,858 women in Sweden between 1983 and 1993. The results were adjusted for covariates known to be associated with preterm delivery. RESULTS: The odds ratios for very or moderately preterm delivery in a subsequent pregnancy among women with a previous very preterm delivery, as compared with women who had a previous term delivery, were 12.4 (95 percent confidence interval, 9.1 to 17.0) and 7.1 (95 percent confidence interval, 6.0 to 8.4), respectively. Among women with a previous moderately preterm delivery, the corresponding odds ratios were 2.3 (95 percent confidence interval, 1.9 to 3.0) and 5.9 (95 percent confidence interval, 5.5 to 6.3), respectively. The odds ratios for a very preterm second delivery among the women who smoked 1 to 9 cigarettes per day and those who smoked 10 or more cigarettes per day, as compared with nonsmokers, were 1.4 (95 percent confidence interval, 1.1 to 1.7) and 1.6 (95 percent confidence interval, 1.3 to 2.0), respectively. The corresponding odds ratios for moderate preterm delivery were 1.3 (95% confidence interval, 1.2 to 1.4) and 1.5 (95 percent confidence interval, 1.4 to 1.6). The women who quit smoking between pregnancies were not at increased risk for very or moderately preterm delivery, whereas the women who started to smoke in the second pregnancy had the same risk as those who continued to smoke. CONCLUSIONS: The risk of a very preterm delivery in successive pregnancies is increased primarily among women with a previous very preterm delivery. Changes in smoking habits influence the risk of preterm delivery as well.

Gas chromatographic and mass spectrometric analysis of 36 lignin-related methoxyphenols from uncontrolled combustion of wood.

Eighteen 4-hydroxy-3-methoxyphenyl (guaiacyl) compounds in wood smoke from spruce, and 18 4-hydroxy-3,5-dimethoxyphenyl (syringyl) analogues in birchwood smoke were analysed. Smoke samples were taken by a gas syringe from wood burning under varying but more or less choked conditions in laboratory pot experiments. Retention index data for a methylsilicone column and basic mass spectral data are given for all compounds. Retention index in combination with molecular mass and structure-specific fragment ions greatly facilitates qualitative analysis. The syringyl and guaiacyl analogues differ by 240 units in retention index and the matching structure-specific ions in their mass spectra by 30 mass units. The identified methoxyphenols differ in the structure of the sidechain, which may be lacking, an alkyl group, an alkenyl group, a carbonyl-containing group or an alcoholic moiety. The proportions between these groups of compounds varied strongly with combustion conditions whereas the proportions of phenols within them were quite specific for each group. The phenols with reactive olefinic linkages in the sidechain were present in larger proportions than reported in other studies of methoxyphenols.