Neonatal outcome by planned mode of delivery in women with a body mass index of 35 or more: a retrospective cohort study.

OBJECTIVE: To compare neonatal outcomes of women with a body mass index (BMI) of ≥35 kg/m2 who underwent a trial of labour with those of women who underwent a planned primary caesarean section (CS). DESIGN: A retrospective cohort study of births between April 2012 and March 2014. SETTING: A provincial database: Better Outcomes Registry & Network (BORN) Ontario, Canada. POPULATION: A cohort of 8752 women with a BMI of ≥35 kg/m2 who had a singleton birth at 38-42 weeks of gestation. METHODS: Neonatal outcomes were compared between women who underwent a trial of labour (with either a successful vaginal birth or intrapartum CS) and those who underwent a planned CS. MAIN OUTCOME MEASURE: A composite of any of the following outcomes: intrapartum neonatal death, neonatal intensive care unit admission, 5-minute Apgar score of <7 or umbilical artery pH of <7.1. RESULTS: During the study period, 8433 (96.4%) women had a trial of labour and 319 (3.6%) had a planned CS. Intrapartum CS was performed in 1644 (19.5%) cases. There was no association between planned mode of delivery and the primary outcome (aOR 0.80, 95% CI 0.59-1.07). The primary outcome was lower among women who had a successful trial of labour (aOR 0.67, 95% CI 0.50-0.91) and was higher among women who had a failed trial of labour (aOR 1.74, 95% CI 1.21-2.48), compared with women who underwent a planned CS. CONCLUSIONS: In women with a BMI of ≥35 kg/m2 at a gestational age of 38-42 weeks, neonatal outcomes are comparable between planned vaginal delivery and planned CS, although a failed trial of labour is at risk of adverse neonatal outcome. TWEETABLE ABSTRACT: Neonatal outcomes are not affected by planned mode of delivery in women who are obese, with a BMI of ≥35 kg/m2 .

CARTR Plus: the creation of an ART registry in Canada.

STUDY QUESTION: What is the status of fertility treatment and birth outcomes documented over the first 6 years of the Canadian Assisted Reproductive Technologies Register (CARTR) Plus registry? SUMMARY ANSWER: The CARTR Plus registry is a robust database containing comprehensive Canadian fertility treatment data to assist with providing evidence-based rationale for clinical practice change. WHAT IS KNOWN ALREADY: The rate of infertility is increasing globally and having data on fertility treatment cycles and outcomes at a population level is important for accurately documenting and effecting changes in clinical practice. STUDY DESIGN SIZE DURATION: This is a descriptive manuscript of 183 739 fertility treatment cycles from 36 Canadian clinics over 6 years from the CARTR Plus registry. PARTICIPANTS/MATERIALS SETTING METHODS: Canadian ART treatment cycles from 2013 through 2018 were included. This manuscript described trends in type of fertility treatment cycles, pregnancy rates, multiple pregnancy rates, primary transfer rates and birth outcomes. MAIN RESULTS AND THE ROLE OF CHANCE: Over the 6 years of the CARTR Plus registry, the number of treatment cycles performed ranged from less than 200 to greater than 1000 per clinic. Patient age and the underlying cause of infertility were two of the most variable characteristics across clinics. Similar clinical pregnancy rates were found among IVF and frozen embryo transfer (FET) cycles with own oocytes (38.9 and 39.7% per embryo transfer cycle, respectively). Fertility treatment cycles that used donor oocytes had a higher clinical pregnancy rate among IVF cycles compared with FET cycles (54.9 and 39.8% per embryo transfer cycle, respectively). The multiple pregnancy rate was 7.4% per ongoing clinical pregnancy in 2018, which reflected a decreasing trend across the study period. Between 2013 and 2017, there were 31 811 pregnancies that had live births from all ART treatment cycles, which corresponded to a live birth rate of 21.4% per cycle start and 89.1% of these pregnancies were singleton live births. The low multiple pregnancy rate and high singleton birth rate are associated with the increase in single embryo transfers. LIMITATIONS REASONS FOR CAUTION: There is potential for misclassification of data, which is present in all administrative health databases. WIDER IMPLICATIONS OF THE FINDINGS: The CARTR Plus registry is a robust resource for ART data in Canada. It provides easily accessible aggregated data for Canadian fertility clinics, and it contains data that are internationally comparable. STUDY FUNDING/COMPETING INTERESTS: There was no funding provided for this study. The authors have no competing interests to declare.

The Canadian Assisted Reproductive Technologies Register (CARTR) Plus database: a validation study.

STUDY QUESTION: Are data accurately documented in the Canadian Assisted Reproductive Technologies Register (CARTR) Plus database? SUMMARY ANSWER: Measures of validity were strong for the majority of variables evaluated while those with moderate agreement were FSH levels, oocyte origin and elective single embryo transfer. WHAT IS KNOWN ALREADY: Health databases and registries are excellent sources of data. However, as these databases are typically not established for the primary purpose of performing research, they should be evaluated prior to utilization for research both to inform the study design and to determine the extent to which key study variables, such as patient characteristics or therapies provided, are accurately documented in the database. CARTR Plus is Canada's national register for collecting extensive information on IVF and corresponding pregnancy outcomes, and it has yet to be validated. STUDY DESIGN SIZE DURATION: This study evaluating the data translation CARTR Plus database examined IVF cycles performed in 2015 using data directly from patient charts. Six clinics across Canada were recruited to participate, using a purposive sampling strategy. Fixed random sampling was employed to select 146 patient cycles at each clinic, representing unique patients. Only a single treatment cycle record from a unique patient at each clinic was considered during chart selection. PARTICIPANTS/MATERIALS SETTING METHODS: Twenty-five data elements (patient characteristics, treatments and outcomes) were reabstracted from patient charts, which were declared the reference standard. Data were reabstracted by two independent auditors with relevant clinical knowledge after confirming inter-rater reliability. These data elements from the chart were then compared to those in CARTR Plus. To determine the validity of these variables, we calculated kappa coefficients, sensitivity, specificity, positive predictive value and negative predictive value with 95% CI for categorical variables and calculated median differences and intraclass correlation coefficients (ICC) for continuous variables. MAIN RESULTS AND THE ROLE OF CHANCE: Six clinics agreed to participate in this study representing five Canadian provinces. The mean age of patients was 35.5 years, which was similar between the two data sources, resulting in a near perfect level of agreement (ICC = 0.99; 95% CI: 0.99, 0.99). The agreement for FSH was moderate, ICC = 0.68 (95% CI: 0.64, 0.72). There was nearly perfect agreement for cycle type, kappa = 0.99 (95% CI: 0.98, 1.00). Over 90% of the cycles in the reabstracted charts used autologous oocytes; however, data on oocyte source were missing for 13% of cycles in CARTR Plus, resulting in a moderate degree of agreement, kappa = 0.45 (95% CI, 0.37, 0.52). Embryo transfer and number of embryos transferred had nearly perfect agreement, with kappa coefficients greater than 0.90, whereas that for elective single or double embryo transfer was much lower (kappa = 0.55; 95% CI: 0.49, 0.61). Agreement was nearly perfect for pregnancy type, and number of fetal sacs and fetal hearts on ultrasound, all with kappa coefficients greater than 0.90. LARGE-SCALE DATA: N/A. LIMITATIONS REASONS FOR CAUTION: CARTR Plus contains over 200 variables, of which only 25 were assessed in this study. This foundational validation work should be extended to other CARTR Plus database variables in future studies. WIDER IMPLICATIONS OF THE FINDINGS: This study provides the first assessment of the quality of the data translation process of the CARTR Plus database, and we found very high quality for the majority of the variables that were analyzed. We identified key data points that are either too often lacking or inconsistent with chart data, indicating that changes in the data entry process may be required. STUDY FUNDING/COMPETING INTERESTS: This study was funded by Canadian Institutes of Health Research (CIHR) (Grant Number FDN-148438) and by the Canadian Fertility and Andrology Society Research Seed Grant (Grant Number: N/A). The authors report no conflict of interest. TRIAL REGISTRATION NUMBER: Not applicable.

Antiviral medication use in a cohort of pregnant women during the 2009-2010 influenza pandemic.

Preventing influenza-like illness (ILI) during pregnancy with antiviral medication use (AVMU) can mitigate serious health risks to mother and foetus. We report on AVMU in pregnant women in Ontario, Canada, and describe characteristics of AVMU during the 2009-2010 H1N1 pandemic. Rates and risk estimates of AVMU were compared across multiple categories and stratified across ILI infection status. Increased AVMU was observed in women with influenza infections, active smokers, those vaccinated against influenza, and those with pre-existing co-morbidities. Decreased AVMU was observed in women with multiple gestations, and those in neighbourhoods of high immigrant concentrations. Our stratified analysis indicated that the observed patterns differed by ILI infection status. We demonstrated that once infected, women across multiple groups were equally likely to use antiviral medications. In this report we also propose possible clinical explanations for the observed differences in AVMU, which will be useful in planning prevention initiatives for future pandemics.

Evaluation of the impact of fetal fibronectin test implementation on hospital admissions for preterm labour in Ontario: a multiple baseline time-series design.

OBJECTIVE: To determine the impact of a health system-wide fetal fibronectin (fFN) testing programme on the rates of hospital admission for preterm labour (PTL). DESIGN: Multiple baseline time-series design. SETTING: Canadian province of Ontario. POPULATION: A retrospective population-based cohort of antepartum and delivered obstetrical admissions in all Ontario hospitals between 1 April 2002 and 31 March 2010. METHODS: International Classification of Diseases codes in a health system-wide hospital administrative database were used to identify the study population and define the outcome measure. An aggregate time series of monthly rates of hospital admissions for PTL was analysed using segmented regression models after aligning the fFN test implementation date for each institution. MAIN OUTCOME MEASURE: Rate of obstetrical hospital admission for PTL. RESULTS: Estimated rates of hospital admission for PTL following fFN implementation were lower than predicted had pre-implementation trends prevailed. The reduction in the rate was modest, but statistically significant, when estimated at 12 months following fFN implementation (-0.96 hospital admissions for PTL per 100 preterm births; 95% confidence interval [CI], -1.02 to -0.90, P = 0.04). The statistically significant reduction was sustained at 24 and 36 months following implementation. CONCLUSIONS: Using a robust quasi-experimental study design to overcome confounding as a result of underlying secular trends or concurrent interventions, we found evidence of a small but statistically significant reduction in the health system-level rate of hospital admissions for PTL following implementation of fFN testing in a large Canadian province.

Mars' south polar Ar enhancement: a tracer for south polar seasonal meridional mixing.

The gamma ray spectrometer on the Mars Odyssey spacecraft measured an enhancement of atmospheric argon over southern high latitudes during autumn followed by dissipation during winter and spring. Argon does not freeze at temperatures normal for southern winter (approximately 145 kelvin) and is left in the atmosphere, enriched relative to carbon dioxide (CO2), as the southern seasonal cap of CO2 frost accumulates. Calculations of seasonal transport of argon into and out of southern high latitudes point to meridional (north-south) mixing throughout southern winter and spring.

An automated computer system to support ultra high throughput SNP genotyping.

Celera Genomics has constructed an automated computer system to support ultra high-throughput SNP genotyping that satisfies the increasing demand that disease association studies are placing on current genotyping facilities. This system consists of the seamless integration of target SNP selection, automated oligo design, in silico assay quality validation, laboratory management of samples, reagents and plates, automated allele calling, optional manual review of autocalls, regular status reports, and linkage disequilibrium analysis. Celera has proven the system by generating over 2.5 million genotypes from more than 10,000 SNPs, and is approaching the target capacity of over 10,000 genotypes per machine per hour using limited human intervention with state of the art laboratory hardware.

Reducing the preterm birth rate: a population health strategy.

The rate of preterm birth has been increasing in Canada and the United States. Efforts to prevent preterm birth have been largely ineffective. A population health strategy that integrates disease prevention and health promotion is needed. In this article, the five categories of health determinants proposed by the Federal, Provincial and Territorial Advisory Committee on Population Health are used as a framework to discuss risk factors and propose policies and interventions to reduce the preterm birth rate.

Regulation of inflammation by collagen-binding integrins alpha1beta1 and alpha2beta1 in models of hypersensitivity and arthritis.

Adhesive interactions play an important role in inflammation by promoting leukocyte attachment and extravasation from the vasculature into the peripheral tissues. However, the importance of adhesion molecules within the extracellular matrix-rich environment of peripheral tissues, in which cells must migrate and be activated, has not been well explored. We investigated the role of the major collagen-binding integrins, alpha1beta1 and alpha2beta1, in several in vivo models of inflammation. mAb's against murine alpha1 and alpha2 were found to significantly inhibit effector phase inflammatory responses in animal models of delayed-type hypersensitivity (DTH), contact hypersensitivity (CHS), and arthritis. Mice that were alpha1-deficient also showed decreased inflammatory responses in the CHS and arthritis models when compared with wild-type mice. Decreased leukocyte infiltration and edema formation accompanied inhibition of antigen-specific models of inflammation, as nonspecific inflammation induced by croton oil was not inhibited. This study demonstrates the importance in vivo of alpha1beta1 and alpha2beta1, the collagen-binding integrins, in inflammatory diseases. The study also extends the role of integrins in inflammation beyond leukocyte attachment and extravasation at the vascular endothelial interface, revealing the extracellular matrix environment of peripheral tissues as a new point of intervention for adhesion-based therapies.

A data mining system for infection control surveillance.

Nosocomial infections and antimicrobial resistance are problems of enormous magnitude that impact the morbidity and mortality of hospitalized patients as well as their cost of care. The Data Mining Surveillance System (DMSS) uses novel data mining techniques to discover unsuspected, useful patterns of nosocomial infections and antimicrobial resistance from the analysis of hospital laboratory data. This report details a mature version of DMSS as well as an experiment in which DMSS was used to analyze all inpatient culture data, collected over 15 months at the University of Alabama at Birmingham Hospital.

Selective, tight-binding inhibitors of integrin alpha4beta1 that inhibit allergic airway responses.

Integrin alpha4beta1 mediates leukocyte recruitment, activation, mediator release, and apoptosis inhibition, and it plays a central role in inflammatory pathophysiology. High-affinity, selective inhibitors of alpha4beta1, based on the Leu-Asp-Val (LDV) sequence from the alternatively spliced connecting segment-1 (CS-1) peptide of cellular fibronectin, are described that employ a novel N-terminal peptide "cap" strategy. One inhibitor, BIO-1211, was approximately 10(6)-fold more potent than the starting peptide and exhibited tight-binding properties (koff = 1.4 x 10(-4) s-1, KD = 70 pM), a remarkable finding for a noncovalent, small-molecule inhibitor of a protein receptor. BIO-1211 was also 200-fold selective for the activated form of alpha4beta1, and it stimulated expression of ligand-induced epitopes on the integrin beta1 subunit, a property consistent with occupancy of the receptor's ligand-binding site. Pretreatment of allergic sheep with a 3-mg nebulized dose of BIO-1211 inhibited early and late airway responses following antigen challenge and prevented development of nonspecific airway hyperresponsiveness to carbachol. These results show that highly selective and potent small-molecule antagonists can be identified to integrins with primary specificity for peptide domains other than Arg-Gly-Asp (RGD); they confirm the generality of integrins as small molecule targets; and they validate alpha4beta1 as a therapeutic target for asthma.

Tension pneumocephalus: a case report and literature review.

Following a bifrontal craniotomy with frontal sinus involvement, a 64-year-old woman developed cerebrospinal fluid (CSF) rhinorrhoea. At a second operation the skull base dural defect was repaired from within the anterior cranial fossa. Ten days later, the patient developed signs and symptoms of raised intracranial pressure and mass effect. Following radiological investigation, the diagnosis of tension pneumocephalus was made and confirmed at the time of decompression. Within 24 h air had re-accumulated under pressure and concurrently an ongoing CSF leak, which until then had been subclinical, became apparent. Definitive repair of the fistula was performed via a frontal sinus approach and the patient made a total recovery. The relationship between CSF leak and delayed onset tension pneumocephalus is discussed, along with other significant issues regarding the diagnosis and management of this uncommon but dangerous condition. Copyright 1999 Harcourt Publishers Ltd.

Charting in record time.

Nurses working in intrapartum settings have many responsibilities to ensure a safe and satisfying birth experience for the families in their care. Paperwork, while essential, often takes time away from providing supportive care for laboring women and their families. In striking a balance between responsibilities and obligations, nurses must play an active role in designing a charting system that allows essential and important data to be recorded in the least amount of time.

Education of women about the prevention of preterm birth.

OBJECTIVES: To describe: 1) The education of pregnant women by health care professionals about the prevention of preterm birth; and 2) professionals' views about future initiatives. BACKGROUND: A population survey of health professionals was conducted in Eastern Ontario. The response rate was 73% (608/835). RESULTS: Education materials for women receiving prenatal care about the prevention of preterm birth were available from 10% (12/115) of family physicians, 40% (23/58) of obstetricians, 19% (57/306) of labour room nurses and 76% (94/124) of the prenatal teachers. Only one third of physicians routinely discussed the signs and symptoms of preterm labour prior to 20 weeks. Practitioners' future priorities were smoking cessation programs for pregnant women and increased attendance at early prenatal classes. CONCLUSIONS: Most women are not being educated by anyone in the health care team about the prevention of preterm birth. There is a need for multidisciplinary guidelines about the timing and type of information for women about risk reduction and the early identification and treatment of preterm labour.

Association rules and data mining in hospital infection control and public health surveillance.

OBJECTIVES: The authors consider the problem of identifying new, unexpected, and interesting patterns in hospital infection control and public health surveillance data and present a new data analysis process and system based on association rules to address this problem. DESIGN: The authors first illustrate the need for automated pattern discovery and data mining in hospital infection control and public health surveillance. Next, they define association rules, explain how those rules can be used in surveillance, and present a novel process and system--the Data Mining Surveillance System (DMSS)--that utilize association rules to identify new and interesting patterns in surveillance data. RESULTS: Experimental results were obtained using DMSS to analyze Pseudomonas aeruginosa infection control data collected over one year (1996) at University of Alabama at Birmingham Hospital. Experiments using one-, three-, and six-month time partitions yielded 34, 57, and 28 statistically significant events, respectively. Although not all statistically significant events are clinically significant, a subset of events generated in each analysis indicated potentially significant shifts in the occurrence of infection or antimicrobial resistance patterns of P. aeruginosa. CONCLUSION: The new process and system are efficient and effective in identifying new, unexpected, and interesting patterns in surveillance data. The clinical relevance and utility of this process await the results of prospective studies currently in progress.

Evaluation of a fetal monitoring education program.

OBJECTIVE: To evaluate the effectiveness of a fetal monitoring education program in increasing nurses' knowledge and clinical skills. DESIGN: Multicenter randomized control trial. SETTING: Twelve hospitals in eastern Ontario, Canada. PARTICIPANTS: One hundred nine volunteer registered nurses randomly assigned, within each hospital, to an experimental (n = 47) or control (n = 62) group. Ninety-six nurses (40 in the experimental group and 56 in the control group) completed the 6-month follow-up (88% retention). INTERVENTIONS: The experimental group participated in a 1-day fetal monitoring workshop and a review session 6 months later. MAIN OUTCOME MEASURES: Performance on a 45-item knowledge test and a 25-item skills checklist. The passing score was at least 75% correct on each test. RESULTS: The percentage of nurses in the experimental group passing both the knowledge and the clinical skills tests after the workshop was significantly higher (p < 0.01) than that of the nurses in the control group: 68.1% versus 6.5%, respectively. A large difference between the groups remained at the 6-month follow-up (experimental, 45%; control, 6.5%). The performance of the nurses in the experimental group improved to an 85% pass rate after they attended the 6-month review session. CONCLUSION: This comprehensive, research-based program is effective in increasing fetal monitoring knowledge and clinical skills.

Evidence for a basalt-free surface on Mercury and implications for internal heat.

Microwave and mid-infrared observations reveal that Mercury's surface contains less FeO + TiO2 and at least as much feldspar as the lunar highlands. The results are compatible with the high albedo (brightness) of Mercury's surface at visible wavelengths in suggesting a rock and soil composition that is devoid of basalt, the primary differentiate of terrestrial mantles. The occurrence of a basalt-free, highly differentiated crust is in accord with recent models of the planet's thermal evolution and suggests that Mercury has retained a hot interior as a result of a combination of inefficient mantle convection and minimal volcanic heat loss.