Comparing the outcomes of external oblique and transversus abdominus release using the AHSQC database.

PURPOSE: Myofascial release techniques at the time of complex hernia repair allow for tension-free closure of the midline fascia. Two common techniques are the open external oblique release (EOR) and the transversus abdominis release (TAR). Each technique has its reported advantages and disadvantages, but there have been few comparative studies. The purpose of this project was to compare the outcomes of these two myofascial release techniques. METHODS: The Americas Hernia Society Quality Collaborative (AHSQC) database was queried and produced a data set on 24 May 2018. All patients undergoing open incision hernia repair with an open EOR or TAR were evaluated, and outcomes were compared including hernia recurrence, quality of life, and 30-day wound-related complications. RESULTS: 3610 patients met the inclusion criteria of undergoing open incisional hernia repair (501 undergoing EOR and 3109 undergoing TAR). Seventy surgeons from 50 institutions contributed EOR patients, and 124 surgeons from 89 institutions contributed TAR patients with no differences between the two groups in surgeons' affiliation. Comparing open EOR and TAR showed no significant differences in hernia recurrence, quality of life, or 30-day surgical site infection rate. EOR had a significantly higher rate of surgical site occurrences compared with TAR (p < 0.05); however, this did not result in an increase in surgical site occurrences requiring procedural interventions. CONCLUSIONS: Equivalent outcomes were achieved using the EOR or TAR techniques in the open repair of incisional hernias. Both techniques offer consistently good outcomes and are important adjuncts in the repair of complex incisional hernias.

Further defining the risks confronting twins.

OBJECTIVE: We report the absolute and relative risks for neonatal and infant death, low and very low birth weight, and delivery at < 33 and < 35 weeks' gestation in twin pregnancy stratified by maternal race and age, as well as gender pair combinations of the twins. STUDY DESIGN: Data on 324,141 twin infants were obtained from the 1985 to 1988 U.S. Linked Birth/ Infant, Death Data Sets. In this observational cohort study, we analyzed the outcomes of 138,779 twin pregnancies of white and black women that ended with the delivery of two live-born infants. RESULTS: Rates for the aforementioned outcomes are increased for black infants, for male-male pairs compared with male-female pairs (with female-female pairs being intermediate), and for young mothers. For male-male twins born to young (< or = 22 years old) black women, relative risks range from 2.1 for both pair members being low birth weight (< 2500 gm) to 5.0 for both pair members dying in infancy, when male-female pairs born to older (> or = 28 years) white women served as the reference group. CONCLUSIONS: Although all twin pregnancies are at higher risk than singletons, risk is influenced by maternal race and age, as well as gender pair combination. These analyses provide useful information for counseling women pregnant with twins. Furthermore, they suggest that failure to consider variations in baseline risk may have seriously flawed studies evaluating prophylactic interventions in twin pregnancy.

How to find a wombmate: validation of an algorithm to identify twin pairs in Linked Birth/Infant Death Files.

Linked Birth/Infant Death Files available from the National Center for Health Statistics identify an infant as a twin, but do not identify twin pairs. An algorithm based on maternal, paternal, and infant characteristics has been used to identify twin pairs, but the validity of this algorithm has never been tested. The Missouri linked birth/infant death file from 1980 to 1990 identifies twin pairs by a sequence number. The authors tested the rate and accuracy with which the algorithm identified true pairs in the Missouri file and whether estimates of risk and possible risk factors calculated from pairs of twins identified by the algorithm agreed with these characteristics as calculated from known twin pairs. The algorithm identified 96% (8,273 of 8,620) of true pairs and one false pair. Despite incomplete pair identification, and even identification of a false pair, estimates from the subset identified by the algorithm generally agreed well with characteristics measured from all twin pairs. Nonetheless, incorporation of a multiple birth sequence number into Linked Birth/Infant Death Files would enhance their utility.

The risks confronting twins: a national perspective.

OBJECTIVES: Our objectives were twofold: (1) to report the relative risks and population-attributable risks of twins compared with singletons for several adverse pregnancy outcomes and (2) to describe the association between having been of low or very low birth weight and death in the neonatal, postneonatal, and infant periods for twins compared with singletons. STUDY DESIGN: We performed population-based analysis of all live births and infant deaths from 1985 to 1986 birth cohorts, as reported in the U.S. Linked Birth/Infant Death Data Sets. RESULTS: With singletons as the referent group, twins of all races had relative risk for very low birth weight, low birth weight, and neonatal, postneonatal, and infant death of 9.97, 8.61, 7.06, 2.75, and 5.43, respectively. Although twins make up only 2.09% of live births, the population-attributable risks of twins (the proportion of the population's adverse outcome associated with being a twin) for very low birth weight, low birth weight, and neonatal, postneonatal, and infant death was 15.8%, 13.7%, 11.2%, 3.4%, and 8.4%, respectively. CONCLUSIONS: These population-based data show that although twins are relatively infrequent they account for a disproportionately large share of adverse pregnancy outcomes. Given the relative ease with which twins can be identified early in the course of pregnancy, development and testing of interventions to postpone preterm delivery in twin pregnancy should become a national public health priority.

Prognostic implications of age at detection of air leak in very low birth weight infants requiring ventilatory support.

STUDY OBJECTIVE: To measure the association between the development of air leak (pneumothorax or pulmonary interstitial emphysema) during the first 27 postnatal days and neonatal death or chronic lung disease, as determined on day 28, among very low birth weight infants who required mechanical ventilation from the first day of life. DESIGN: Prospective, multicenter cohort study. PATIENTS: Two hundred sixty inborn, very low birth weight (501 to 1500 gm) infants given ventilatory support from the first day of life. RESULTS: The risk of an adverse outcome (death or chronic lung disease) changed with postnatal age at the time of diagnosis of the air leak. The association between air leak and an adverse outcome, as measured by gestational age-adjusted odds ratio (95% confidence interval), was 13.9 (1.7 to 114.6) for those in whom an air leak developed on day 0 or 1 (early), decreased to 1.7 (0.7 to 4.1) for those whose air leak developed on day 2 or 3 (intermediate), and increased to 16.6 (2.1 to 130.4) for those whose air leak developed on days 4 to 27 (late). The association with neonatal death showed even more striking fluctuations with postnatal age at occurrence of an air leak, ranging from an odds ratio of 40.3 (3.5 to 464.8) for the early group to 7.5 (2.3 to 25.0) for the intermediate group and 78.3 (6.9 to 889.5) for the late group. CONCLUSIONS: Air leak in newborn infants requiring mechanical ventilation is associated with increased risks of death or future morbidity, but the magnitude of these risks changes with postnatal age at the time of diagnosis of the air leak. Failure to consider the age at which the air leak is detected may miss changes in its prognostic implications and may partly explain inconsistent results in previous studies.

Improved neonatal survival following multiple doses of bovine surfactant in very premature neonates at risk for respiratory distress syndrome.

To determine whether multiple doses of bovine surfactant would improve neonatal mortality in very premature neonates, we conducted two multicenter controlled trials under identical protocols; the results were combined for analysis. Four hundred and thirty neonates born between 23 and 29 weeks gestation and weighing 600 to 1250 g at birth were assigned randomly at birth to receive either 100 mg of phospholipids/kg of Survanta, a modified bovine surfactant (n = 210), or a sham air placebo (n = 220) within 15 minutes of birth. Neonates who developed respiratory distress syndrome and required mechanical ventilation with at least 30% oxygen could be given up to three more doses in the first 48 hours after birth. Dosing was performed by investigators not involved in the clinical care of the neonates; nursery staff were kept blinded as to the treatment assignment. Cause of death was determined by a panel of three independent, board-certified neonatologists after blindly reviewing case report forms and autopsy reports. Fewer Survanta-treated neonates died of any cause (11.4% vs 18.8%, P = .031), died of respiratory distress syndrome (1.9% vs 15.6%, P less than .001), and either died or developed bronchopulmonary dysplasia due to respiratory distress syndrome (39.5% vs 49.1%, P = .044). The incidence of respiratory distress syndrome was also lower in Survanta-treated neonates (28.0% vs 56.9%, P less than .001), and the Survanta-treated neonates' oxygenation and ventilatory status were improved significantly at 72 hours. Survanta-treated neonates were also at lowered risk of developing pulmonary interstitial emphysema (23.3% vs 36.9%, P = .002) and other forms of pulmonary air leaks (9.6% vs 20.8%, P .002).(ABSTRACT TRUNCATED AT 250 WORDS)

Survival and ventilatory course of a regional cohort of very low birthweight (501-1500 gm) infants.

To minimize the selection bias inherent in reporting results gathered only in neonatal intensive care units, this study presents survival and respiratory course data on all 299 infants of birthweight 501 to 1500 gm liveborn to residents of the North Central Illinois Perinatal Region in 1985-1986. The survival rate was 86.8% (171 of 197) for infants between 1001 and 1500 gm, but only 35.3% (36 of 102) for infants weighing less than 1001 gm. In all, 207 infants (69.2%) survived. One hundred eighty-six infants (62.2%) required mechanical ventilation, and 122 (65.6%) ventilated infants survived. Seventy-five (40.3%) ventilated infants developed lung rupture and 54 (29%) developed chronic lung disease (CLD), as manifest by a supplemental oxygen requirement at 28 days of age. Lung rupture significantly predicted death in the first 7 days, the development of CLD, and fatal CLD. These data portray an accurate picture of the survival and ventilatory course of this group of babies because every member of the entire regional cohort is included.

Perinatal regionalization as measured by antenatal referral.

To assess the degree of perinatal regionalization, maternal and infant records were reviewed for all very low birth weight (501-1500 g) infants born in calendar years 1985-1986 to residents of the primarily rural North Central Perinatal Region of Illinois. Seventy-one percent of mothers who were expected to deliver in non-center hospitals could have realistically been referred to perinatal centers for delivery. Ninety-four percent of realistic antenatal referrals actually occurred. In Peoria, 79% of mothers expected to deliver very low birth weight infants at non-center hospitals could realistically have been referred to the center for delivery, and all such referrals actually occurred. Because a goal of regionalization is to deliver certain high-risk women in centers, the fact that 94% of rural and 100% of urban realistic antenatal referrals actually occurred suggests that the North Central Perinatal Region is well regionalized. Other centers should study the site of delivery of this or other well-defined regional cohorts of high-risk pregnancies to quantitate how well perinatal care is regionalized in their respective areas.

Perinatal market penetration rate. A tool to evaluate regional perinatal programs.

Very small babies born in tertiary centers fare better than outborn babies referred for tertiary care after birth. Viewing the 1001-1500 gm regional cohort of fetuses as a potential "market" for center delivery, and measuring a center's penetration into this market, quantitates how well a center draws to itself these small, high-risk fetuses for delivery. An Illinois center's annual penetration rate into its regional market for the years 1973-1983 is presented and significant increases are found. The penetration rates of nine Illinois perinatal centers are calculated and wide discrepancies are found. Defining a high-risk regional cohort as a market stresses a perinatal center's obligation to its region. The penetration rate into a defined market measures how well a center fulfills this obligation.

Changes in the pharmacology of warfarin during long-term administration in dogs.

Patients receiving an apparently appropriate maintenance dosage of oral anticoagulant may show unexpected changes in clotting status without readily identifiable cause. The object of this study was to determine whether a consistent change in the pharmacology of warfarin could account for the clinical observations during long-term dosing. Eleven healthy adult dogs received constant daily oral doses of warfarin for 4 weeks. Plasma warfarin concentration (W), measured by gas chromatography, and prothrombin time (PT), measured by the one-stage assay of Quick, were determined daily. W and PT decreased significantly (p less than 0.05) during the last 2 weeks of long-term treatment. No pharmacodynamic changes were observed after prolonged warfarin treatment, suggesting that the decreases in PT were due solely to the decreased W. The decrease in W was not due to an increased free warfarin fraction or to a reduction in W absorption from the gut. The reproducibility of these results was demonstrated in a second group of experiments done 1 month after the first set of studies. Over the entire group of dogs there was no consistent change in warfarin clearance during prolonged dosing. We conclude that during constant daily dosing, W and PT reach early peak values, after which they decrease to levels significantly below peak levels. These results suggest that clinical anticoagulation may require multiple dosage adjustments despite the early attainment of apparently therapeutic anticoagulant regulation with a fixed dosage schedule.

Bed rest in twin pregnancy: identification of a critical period and its cost implications.

Since twin pregnancies often result in poor perinatal outcomes, many physicians advise prolonged bed rest. Recommendations concerning the timing of bed rest conflict and are made with little assessment of costs. This review of twin pregnancies in the North Central Illinois perinatal region establishes that twins are most vulnerable if they are born between 27 and 34 weeks' gestation. If bed rest is to be imposed, it probably should be timed so as to influence this vulnerable period. Intervention (bed rest in the hospital from 27 to 34 weeks' gestation) would cost between $5,720 and $6,909 per twin pregnancy, whereas nonintervention (intensive care nursery charges for infants born before 34 weeks' completed gestation) would cost $1,689 per twin pregnancy. Before intervention can be universally advocated and costs of this magnitude incurred, a prospective controlled trial to determine the efficacy of bed rest in twin pregnancy is mandatory.