Validation of the 34-week gestation as definition of late onset preeclampsia: Testing different cutoffs from 30 to 37 weeks on a population-based cohort of 1700 preeclamptics.

INTRODUCTION: Early onset preeclampsia (EOP) and late onset preeclampsia (LOP) have been differentiated with a cut-point of ≤34 weeks. This classical definition has never been examined with respect to maternal characteristics by different gestational age cut-points. We examined maternal characteristics in a population-based cohort of 1736 preeclamptic deliveries at different gestational age cut-points from 30 to 37 weeks (CO30 to CO37). MATERIAL AND METHODS: Eighteen-year observational population-based historical cohort study (2001-2018). All consecutive births delivered at the Centre Hospitalier Universitaire Hospitalier Sud Reunion's maternity. Standardized epidemiological perinatal database. RESULTS: The incidence of EOP was lower in adolescents (1.8% vs 3.5%, odds ratio [OR] 0.50, P = .17). Conversely, the odds of LOP was increased for women over 35, beginning at C030 (OR 1.13, P = .02) and this effect (OR = 1.2) was still detectable at C037 (P = .06). Among primigravid women, the incidence of EOP was lower than LOP (OR ranging from 0.71 to 0.82 for different CO). Conversely, the incidence of LOP was higher (adjusted OR about 2.7 [CO30-CO34] with a rise to 3.3 at CO37 (P < .001). Women with EOP had a lower body mass index (BMI) as compared with LOP at CO34 and CO37. The adjusted OR (per 5 kg/m2 increment) declined from 1.06 to 1.03 from CO30 to C037 in EOP women. Conversely, for LOP, the adjusted odds ratio (aOR) increased from 1.04 to 1.06 from CO30 to CO37 (P < .001). Gestational diabetes mellitus was not associated with LOP at any cut-off (aOR 1.07, NS) but was protective against EOP from CO30 to CO34 (aOR 0.42, 0.61 and 0.73, respectively, P < .001). This protective effect disappeared at CO37. Chronic hypertension and history of preeclampsia were both EOP and LOP risks but with a much stronger effect for EOP (chronic hypertension: aOR 6.0-6.5, history of preeclampsia: aOR 12-17). CONCLUSIONS: The 34th week of gestation appears to provide a reasonable cut-point to differentiate between EOP and LOP. Additional research is needed to better describe the possible differences in the pathophysiology of these different phenotypes.

Diagnostic accuracy of fundal height and handheld ultrasound-measured abdominal circumference to screen for fetal growth abnormalities.

OBJECTIVE: We sought to compare fundal height and handheld ultrasound-measured fetal abdominal circumference (HHAC) for the prediction of fetal growth restriction (FGR) or large for gestational age. STUDY DESIGN: This was a diagnostic accuracy study in nonanomalous singleton pregnancies between 24 and 40 weeks' gestation. Patients underwent HHAC and fundal height measurement prior to formal growth ultrasound. FGR was defined as estimated fetal weight less than 10%, whereas large for gestational age was defined as estimated fetal weight greater than 90%. Sensitivity and specificity were calculated and compared using methods described elsewhere. RESULTS: There were 251 patients included in this study. HHAC had superior sensitivity and specificity for the detection of FGR (sensitivity, 100% vs 42.86%) and (specificity, 92.62% vs 85.24%). HHAC had higher specificity but lower sensitivity when screening for LGA (specificity, 85.66% vs 66.39%) and (sensitivity, 57.14% vs 71.43%). CONCLUSION: HHAC could prove to be a valuable screening tool in the detection of FGR. Further studies are needed in a larger population.

Estimating equations for cardiopulmonary exercise testing variables in Fontan patients: derivation and validation using a multicenter cross-sectional database.

Cardiopulmonary exercise testing (CPET) is a common method of evaluating patients with a Fontan circulation. Equations to calculate predicted CPET values are based on children with normal circulation. This study aims to create predictive equations for CPET variables solely based on patients with Fontan circulation. Patients who performed CPET in the multicenter Pediatric Heart Network Fontan Cross-Sectional Study were screened. Peak variable equations were calculated using patients who performed a maximal test (RER > 1.1) and anaerobic threshold (AT) variable equations on patients where AT was adequately calculated. Eighty percent of each cohort was randomly selected to derive the predictive equation and the remaining served as a validation cohort. Linear regression analysis was performed for each CPET variable within the derivation cohort. The resulting equations were applied to calculate predicted values in the validation cohort. Observed versus predicted variables were compared in the validation cohort using linear regression. 411 patients underwent CPET, 166 performed maximal exercise tests and 317 had adequately calculated AT. Predictive equations for peak CPET variables had good performance; peak VO2, R (2) = 0.61; maximum work, R (2) = 0.61; maximum O2 pulse, R (2) = 0.59. The equations for CPET variables at AT explained less of the variability; VO2 at AT, R (2) = 0.15; work at AT, R (2) = 0.39; O2 pulse at AT, R (2) = 0.34; VE/VCO2 at AT, R (2) = 0.18; VE/VO2 at AT, R (2) = 0.14. Only the models for VE/VCO2 and VE/VO2 at AT had significantly worse performance in validation cohort. Of the 8 equations for commonly measured CPET variables, six were able to be validated. The equations for peak variables were more robust in explaining variation in values than AT equations.

Effect of metabolic syndrome and its components on recurrence and survival in colon cancer patients.

BACKGROUND: Although epidemiologic studies suggest that metabolic syndrome (MetS) increases the risk of colorectal cancer, its effect on cancer mortality remains controversial. METHODS: The authors used the Surveillance, Epidemiology, and End Results (SEER)-Medicare linked database (1998-2006) to conduct a retrospective cohort study of 36,079 patients with colon cancer to determine the independent effect of MetS and its components on overall survival (OS) and recurrence-free rates (RFRs). Data on MetS and its components were ascertained from Medicare claims. OS and RFRs in patients with and without MetS and its components were compared using multivariate Cox models. RESULTS: MetS had no apparent effect on OS or RFR. Both elevated glucose/diabetes mellitus (DM) and elevated hypertension were associated with worse OS (adjusted hazard ratio [aHR], 1.17 [95% confidence interval, 1.13-1.21] and 1.08 [95% confidence interval, 1.03-1.12], respectively) and worse RFRs (aHR, 1.25 [95% confidence interval, 1.16-1.34] and 1.22 [95% confidence interval, 1.12-1.33], respectively). In contrast, dyslipidemia was associated with improved survival (aHR, 0.77; 95% confidence interval, 0.75-0.80) and reduced recurrence (aHR, 0.71; 95% confidence interval, 0.66-0.75). These effects were consistent for both men and women and were more pronounced in patients with early stage disease. CONCLUSIONS: MetS had no apparent effect on colon cancer outcomes, probably because of the combined adverse effects of elevated glucose/DM and hypertension and the protective effect of dyslipidemia in patients with nonmetastatic disease. The authors concluded that patients who have early stage colon cancer with elevated glucose/DM and/or hypertension may benefit from more intensive surveillance and/or broader use of adjuvant therapy and that trials to define the benefits of low-fat diets, insulin-lowering agents, and statins on recurrence/survival in patients with nonmetastatic colon cancer are warranted.

School readiness among children insured by Medicaid, South Carolina.

INTRODUCTION: The American Academy of Pediatrics recommends a schedule of age-specific well-child visits through age 21 years. For children insured by Medicaid, these visits are called Early and Periodic Screening, Diagnosis, and Treatment (EPSDT). These visits are designed to promote physical, emotional, and cognitive health. Six visits are recommended for the first year of life, 3 for the second year. We hypothesized that children with the recommended visits in the first 2 years of life would be more likely than others to be ready for school when they finish kindergarten. METHODS: We studied children insured by Medicaid in South Carolina, born during 2000 through 2002 (n = 21,998). Measures included the number of EPSDT visits in the first 2 years of life and an assessment of school readiness conducted at the end of kindergarten. We used logistic regression to examine the adjusted association between having the recommended visits and school readiness, controlling for characteristics of mothers, infants, prenatal care and delivery, and residence area. RESULTS: Children with the recommended visits had 23% higher adjusted odds of being ready for school than those with fewer visits. CONCLUSION: EPSDT may contribute to school readiness for children insured by Medicaid. Children having fewer than the recommended EPSDT visits may benefit from school readiness programs.

Comparison of maximum vasoactive inotropic score and low cardiac output syndrome as markers of early postoperative outcomes after neonatal cardiac surgery.

Low cardiac output syndrome (LCOS) and maximum vasoactive inotropic score (VIS) have been used as surrogate markers for early postoperative outcomes in pediatric cardiac surgery. The objective of this study was to determine the associations between LCOS and maximum VIS with clinical outcomes in neonatal cardiac surgery. This was a secondary retrospective analysis of a prospective randomized trial, and the setting was a pediatric cardiac intensive care unit in a tertiary care children's hospital. Neonates (n = 76) undergoing corrective or palliative cardiac operations requiring cardiopulmonary bypass were prospectively enrolled. LCOS was defined by a standardized clinical criteria. VIS values were calculated by a standard formula during the first 36 postoperative hours, and the maximum score was recorded. Postoperative outcomes included hospital mortality, duration of mechanical ventilation, intensive care unit (ICU) and hospital lengths of stay (LOS), as well as total hospital charges. At surgery, the median age was 7 days and weight was 3.2 kg. LCOS occurred in 32 of 76 (42%) subjects. Median maximum VIS was 15 (range 5-33). LCOS was not associated with duration of mechanical ventilation, ICU LOS, hospital LOS, and hospital charges. Greater VIS was moderately associated with a longer duration of mechanical ventilation (p = 0.001, r = 0.36), longer ICU LOS (p = 0.02, r = 0.27), and greater total hospital costs (p = 0.05, r = 0.22) but not hospital LOS (p = 0.52). LCOS was not associated with early postoperative outcomes. Maximum VIS has only modest correlation with duration of mechanical ventilation, ICU LOS, and total hospital charges.

The blurring boundaries between placental and maternal preeclampsia: a critical appraisal of 1800 consecutive preeclamptic cases.

OBJECTIVES: To present a comprehensive overview of different risk factors for early onset preeclampsia (<34 weeks gestation, EOP) vs. late onset (LOP). STUDY DESIGN: South-Reunion University's maternity (Reunion Island, Indian Ocean). 18.5 year-observational population-based cohort study (2001-2019). Epidemiological perinatal database with information on obstetrical and neonatal risk factors. All consecutive singleton pregnancies (>21 weeks) compared with all preeclamptic pregnancies delivered in the south of Reunion island. MAIN OUTCOME MEASURES: Comparing risk factors between EOP and LOP. RESULTS: Among 1814 singleton preeclamptic pregnancies (600 EOP and 1214 LOP), EOP women were older than LOP 29.5 vs. 28.6 years, p = .009, primigravidas (OR 0.78 [0.63-0.96], p = .02) were prone to LOP. History of preeclampsia (PE) (aOR 12.8 vs. 7.1), chronic hypertension (aOR 6.5 vs. 4.5) had much higher adjusted odds ratios for EOP than for LOP, p < .001. Specific to EOP: coagulopathies (aOR 2.95, p = .04), stimulated pregnancies (aOR 3.9, p = .02). Specific to LOP: renal diseases (aOR 2.0, p = .05) and protective effect for smoking (aOR 0.75, p = .008). EOP women were prone to have a lower BMI. CONCLUSION: "Placental preeclampsia" (defective placentation) being linked to early onset PE (<34 weeks gestation) while "maternal preeclampsia" (maternal cardiovascular predisposition) being typically manifesting as the late form of the disease LOP is not systematically verified. Future researches are needed to propose a more adapted paradigm.Highlights  Risk factors for different preeclampsia phenotypes (early/late); challenging proposed models.

Vitamin D deficiency and insufficiency is common during pregnancy.

The objective was to determine the incidence of vitamin D deficiency, insufficiency, and sufficiency in African-American, Hispanic, and Caucasian pregnant women. Blood samples were taken from 154 African-American, 194 Hispanic, and 146 Caucasian women at <14 weeks of gestation; 25 hydroxyvitamin D levels (25(OH)D) levels were measured by radioimmunoassay. The mean 25(OH)D levels in African-American, Hispanic, and Caucasian pregnant women were 15.5 ± 7.2 (standard deviation), 24.1 ± 8.7, 29.0 ± 8.5 ng/mL, respectively. Ninety-seven percent of African-Americans, 81% of Hispanics, and 67% of Caucasians were deficient (25(OH)D levels <20 ng/mL or <50 nmol/L) or insufficient (25(OH)D levels ≥ 20 ng/mL or <32 ng/mL or ≥ 50 nmol/L or <80 nmol/L). Of these pregnant women, 82% had vitamin D levels <32 ng/mL (<80 ng/mL). In logistic regression models, race was the most important risk factor for vitamin D deficiency or insufficiency. African-American women and Hispanic women were more likely to have vitamin D insufficiency and deficiency than Caucasian women. Furthermore, primigravid women were more at risk for vitamin D insufficiency. This study demonstrates widespread vitamin D deficiency and insufficiency in pregnant females living at a southern latitude. African-Americans are at greatest risk.

Ethnic differences in postmaturity syndrome in newborns. Reflections on different durations of gestation.

OBJECTIVE: To describe the prevalence, by weeks of gestation, of post-maturity signs in newborns by ethnic origins. STUDY DESIGN: Observational cohort study (2001-2018), of all consecutive singleton births delivered at Center Hospitalier Universitaire Hospitalier Sud Reunion's maternity (Reunion Island, French overseas department, Indian Ocean). The presence of clinical post-maturity signs was recorded by a week of gestation using Clifford's clinical post-maturity signs in newborns (desquamation, dry skin, wrinkling fingers and cracked skin). RESULTS: Of the 67,463 singleton births during the period, 58,503 newborns were from Reunion island, 5756 were of European origin (mainland France), and 4061 newborns from the archipelago of Comoros (North of Madagascar). Mean duration of gestation was 276 days in Caucasian women, 272 days in Comorian mothers and 273 days in Reunionese (p < .001). Post-maturity is defined by WHO as gestation greater than 293 days (41 weeks + 6 days). At 41 weeks (287 days) 12.1% of Caucasian babies presented post-maturity signs and 22.4% meconium-stained liquid versus respectively, 22.8 and 27.1% in Reunionese and 44 and 39.8% in Comorians (p < .001). CONCLUSION: Among African (Black) pregnancies, duration of gestation was approximately 7 days shorter than in Caucasian (White) pregnancies. In the Reunionese intermixed population and Comorians, the gestation was shorter by 3-4 days. Black newborns presented severe clinical post-maturity signs beginning around 40 weeks and 4-6 days, while it was 1 week later in white infants. Consequences of these differences, with respect to clinical outcomes, are discussed.

Increasing incidence of kidney stones in children evaluated in the emergency department.

OBJECTIVE: To test the hypothesis that there is an increase in the incidence of childhood nephrolithiasis in the state of South Carolina. STUDY DESIGN: We analyzed demographic data from a statewide database on incidence of kidney stones from emergency department data and financial charges. Data were compared with population data from the US Census to control for population growth. RESULTS: There was a significant increase in the incidence of kidney stones in children between 1996 and 2007. The greatest rate of increase was seen in adolescents, pre-adolescents, and Caucasian children. Infants, toddlers, and African-American children did not show significantly increased incidence in the period. Girls show a growing predominance in our population. The amount of money charged for care of children with kidney stones has gone up >4-fold in our state. CONCLUSION: The incidence of kidney stone disease has risen dramatically in the state of South Carolina since 1996. Further studies investigating potential contributing factors are needed to prevent this costly and painful condition.

An exploratory study of postpartum depression and vitamin d.

BACKGROUND: Low levels of serum 25-hydroxyvitamin D (25[OH]D), a reliable measurement of vitamin D, have been implicated in several mood disorders. To date, studies exploring the relationship between vitamin D and postpartum depression are absent from the literature. OBJECTIVES: To determine whether a relationship exists between symptoms associated with postpartum depression and vitamin D levels and to determine if serum 25(OH) D levels can predict the incidence of symptoms associated with postpartum depression. STUDY DESIGN: An exploratory, descriptive study using a convenience sample of 97 postpartum women attending seven monthly visits. Women provided serum 25(OH)D samples and completed the Edinburgh Postpartum Depression Scale (EPDS) at each visit. RESULTS: A significant relationship over time was found between low 25(OH)D levels and high EPDS scores, indicative of postpartum depression. CONCLUSIONS: Future rigorous studies investigating vitamin D and postpartum depression are warranted with larger sample sizes using confirmatory methods to diagnose postpartum depression.

Safety Aspects of a Randomized Clinical Trial of Maternal and Infant Vitamin D Supplementation by Feeding Type Through 7 Months Postpartum.

Background: The safety of higher dose vitamin D (vitD) supplementation in women who change from exclusive or full breastfeeding to combination feeding or who continue supplementation after cessation of breastfeeding is unknown. Objective: Compare vitD supplementation safety of 6,400 to 400 IU/day and 2,400 IU/day using specific laboratory parameters in postpartum women and their infants through 7 months postpartum by feeding type. Design: In this randomized controlled trial, mothers (exclusively breastfeeding or formula-feeding) were randomized at 4-6 weeks' postpartum to 400, 2,400, or 6,400 IU vitD3 (cholecalciferol)/day for 6 months. Breastfeeding infants in 400 IU group received oral 400 IU vitD3/day; infants in 2,400 and 6,400 IU groups received placebo. Maternal safety parameters (serum vitD, 25-hydroxy-vitamin D [25(OH)D; calcidiol], calcium, phosphorus, intact PTH; urinary calcium/creatinine ratios; and feeding type/changes) were measured monthly; infant parameters were measured at months 1, 4, and 7. Sufficiency was defined as 25(OH)D >50 nmol/L. Feeding type was defined as exclusive/full, combination, or formula-feeding. Data were analyzed using SAS 9.4. Results: Four hundred nineteen mother-infant pairs were randomized into the three treatment groups and followed: 346 breastfeeding and 73 formula-feeding pairs. A dose of 6400 IU/day safely and significantly increased maternal vitD and 25(OH)D from baseline in all mothers regardless of feeding type (p < 0.0001) and was superior to the 400 and 2,400 IU groups in achieving vitD sufficiency with no other differences in safety parameters by treatment or feeding type. Infants in the 2,400 IU group were more likely vitD-deficient than the other groups; otherwise, there were no infant safety parameter differences. Conclusions: While 6,400 IU/day was more effective than 400 or 2,400 IU/day in achieving maternal vitD sufficiency in all feeding groups, the groups did not differ on other safety parameters. Similarly, infant safety parameters did not differ by treatment group or feeding status. Clinical Trial Registration: FDA IND Number: 66,346; ClinicalTrials.gov Number: NCT00412074.

Why laparoscopic adhesiolysis should not be the victim of a single randomized clinical trial.

Randomized controlled trials may provide erroneous conclusions when the null hypothesis is not rejected because of insufficient analysis statistical power. The authors dispute the conclusion of a randomized controlled trial that compared chronic pain relief rates following laparoscopic adhesiolysis and diagnostic laparoscopy and recommended abandoning laparoscopic adhesiolysis. In the trial, the observed difference between pain rates (15%) was inferior to that expected (35%). On the basis of this result, we calculated the 90% confidence interval of the true difference, whose limits of -1% and 31% were found to fall outside the predetermined equivalency interval (-10% to 10%). The trial should therefore not have concluded that the 2 surgical procedures were equivalent. By doing so, it is likely that numerous surgeons have abandoned laparoscopic adhesiolysis on the basis of this statement. In any randomized trial, a calculation of statistical power is required each time that the null hypothesis cannot be rejected.

Increased BMI has a linear association with late-onset preeclampsia: A population-based study.

BACKGROUND: To investigate the ongoing controversy on the effect of BMI (body mass index) on EOP (early onset preeclampsia) vs LOP (late onset), especially focusing on diabetes and maternal booking/pre-pregnancy BMI as possible independent variables. METHODS: 18 year-observational cohort study (2001-2018). The study population consisted of all consecutive births delivered at the Centre Hospitalier Universitaire Hospitalier Sud Reunion's maternity (ap. 4,300 birth per year, only level 3 maternity in the south of Reunion Island, sole allowed to follow and deliver all preeclampsia cases of the area). History of pregnancies, deliveries and neonatal outcomes have been collected in standardized fashion into an epidemiological perinatal data base. RESULTS: Chronic hypertension and, history of preeclampsia in multigravidas, were the strongest risk factors for EOP. Primiparity, age over 35 years and BMI ≥ 35 kg/m² were rather associated with LOP. In a multivariate analysis with EOP or LOP as outcome variables compared with controls (normotensive), maternal age and pre-pregnancy BMI were independent risk factors for both EOP and LOP (p < 0.001). However, analyzing by increment of 5 (years of age, kg/m² for BMI) rising maternal ages and incidence of preeclampsia were strictly parallel for EOP and LOP, while increment of BMI was only associated with LOP. Controlling for maternal ages and booking/pre-pregnancy BMI, diabetes was not an independent risk factor neither for EOP or LOP. CONCLUSIONS: Metabolic factors, other than diabetes, associated with pre-pregnancy maternal corpulence are specifically associated with LOP. This may be a direction for future researches on the maternal preeclamptic syndrome. This may explain the discrepancy we are facing nowadays where high-income countries report 90% of their preeclampsia being LOP, while it is only 60-70% in medium-low income countries.

An evaluation of Echinacea angustifolia in experimental rhinovirus infections.

BACKGROUND: Echinacea has been widely used as an herbal remedy for the common cold, but efficacy studies have produced conflicting results, and there are a variety of echinacea products on the market with different phytochemical compositions. We evaluated the effect of chemically defined extracts from Echinacea angustifolia roots on rhinovirus infection. METHODS: Three preparations of echinacea, with distinct phytochemical profiles, were produced by extraction from E. angustifolia roots with supercritical carbon dioxide, 60 percent ethanol, or 20 percent ethanol. A total of 437 volunteers were randomly assigned to receive either prophylaxis (beginning seven days before the virus challenge) or treatment (beginning at the time of the challenge) either with one of these preparations or with placebo. The results for 399 volunteers who were challenged with rhinovirus type 39 and observed in a sequestered setting for five days were included in the data analysis. RESULTS: There were no statistically significant effects of the three echinacea extracts on rates of infection or severity of symptoms. Similarly, there were no significant effects of treatment on the volume of nasal secretions, on polymorphonuclear leukocyte or interleukin-8 concentrations in nasal-lavage specimens, or on quantitative-virus titer. CONCLUSIONS: The results of this study indicate that extracts of E. angustifolia root, either alone or in combination, do not have clinically significant effects on infection with a rhinovirus or on the clinical illness that results from it.

Surgeons' experience and interaction effect in randomized controlled trials regarding new surgical procedures.

The most reliable information on any type of medical intervention is provided through the results of randomized controlled trials (RCTs). However, RCTs comparing a new surgical technique with an older one may provide inaccurate conclusions when surgeons participating in the study have disparate experience with the new technique. In this case, the surgeon-to-surgeon variability may confound the outcome and lead to a significant interaction effect between surgeon and surgical technique. Subsequently the RCT design does not ensure the same outcome probability among patients assigned to the group undergoing the new technique. Overlooking the interaction effect may be responsible for inaccurate conclusions, which are usually unfavorable with regard to the new technique. We discuss how this interaction effect could be involved in conclusions provided by several RCTs that compared laparoscopic hysterectomy to vaginal hysterectomy. We demonstrate how this interaction may be revealed using a hypothetical RCT whose data was reasonably presumed on the basis of literature data.

Early-onset severe preeclampsia: induction of labor vs elective cesarean delivery and neonatal outcomes.

OBJECTIVE: The purpose of this study was to describe the success rate of and analyze differences in neonatal outcomes with labor induction, compared with elective cesarean delivery in women with early-onset severe preeclampsia. STUDY DESIGN: We conducted a cross-sectional study of women with severe preeclampsia who required delivery between 24 and 34 weeks of gestation. Bivariate and multivariable regression analyses were used to determine factors that were associated with assignment to, success of, and odds of neonatal outcomes after induction of labor. RESULTS: Fifty-seven and four-tenths percent of 491 women underwent induction of labor. Vaginal delivery occurred in 6.7%, 47.5%, and 68.8% of women who underwent labor induction between 24 and 28, 28 and 32, and 32 and 34 weeks of gestation, respectively. Induction of labor was not associated with an increase in neonatal morbidity or mortality rate after we controlled for gestational age and other confounders. CONCLUSION: Neonatal outcomes are not worsened by induction of labor in women with early-onset severe preeclampsia, although it is rarely successful at <28 weeks of gestation.

Evidence-based versus reported epilepsy management practices.

Evidence-based medicine practices are widely touted in medicine, although their adoption by busy practitioners is problematic and cumbersome. In this study, we examined published evidence underpinning 2 relevant clinical management questions in pediatric epilepsy: when to initiate an antiepileptic drug and when to prescribe the ketogenic diet. We surveyed practicing child neurologists who were attending their national meeting to determine whether their current practices aligned with the evidence. Clinical studies were evaluated using the Oxford Scale, which was adopted by the American Academy of Neurology. In addition, using a novel rating approach, we examined the impact on overall recommendations by scoring results from studies refuting a given practice. The data show that child neurologists' attitudes firmly adhere to evidence-based practice on when to initiate treatment with an antiepileptic drug, but not on when to prescribe the ketogenic diet. It seems clear that important differences in attitudes of practitioners toward different management strategies for epilepsy cannot be explained only by differences in the evidence. Safety and efficacy data suggest that the ketogenic diet should be more widely adopted as a management strategy in pediatric epilepsy.

Maternal body mass index at delivery and risk of caesarean due to dystocia in low risk pregnancies.

BACKGROUND: To investigate the association between maternal body mass index (BMI) at delivery and the risk of caesarean section due to dystocia during the first stage of labour in low risk pregnancies. METHODS: Historical cohort study that included 6,949 low risk women who delivered at the Medical University of South Carolina from 1994 to 2004, presenting a singleton birth at term, and a vaginal delivery attempt by spontaneous labour. Women presenting large for gestational age newborns were excluded. Adjusted odds ratios (ORs) for caesarean section due to dystocia and for caesarean section due to other reasons were estimated using a multinomial regression logistic model and compared using the Wald's test. RESULTS: Women with a BMI >=30 kg/m(2), of maternal age >=30 years and nulliparas had an increased rate of caesarean section delivery either due to dystocia or for other reasons. Newborn weight >=3,500 g, races other than Caucasian, age between 25 and 29 years, BMI between 25 and 29.9 kg/m(2), and fetal membranes rupture more than 24 h before the onset of the labour were associated with an increased rate of caesarean section due to dystocia only. On the contrary, newborn weight between 2,500 and 2,999 g was associated with a significant decrease in the rate of caesarean section due to dystocia. Newborn weight <3,000 g was associated with a risk for caesarean section due to other reasons. The population risk for caesarean section due to dystocia, attributable to BMI >=35 kg/m(2) in low risk pregnancies, was 13.3%. CONCLUSIONS: An increased maternal BMI was associated with the risk of caesarean section due to dystocia. This information should be made available to women who are overweight or obese at antenatal booking or at the first trimester visit.

Relationship between pre-pregnancy maternal BMI and optimal weight gain in singleton pregnancies.

BACKGROUND: There is a peculiar phenomenon: two separate individuals (mother and foetus) have a mutually interactive dependency concerning their respective weight. Very thin mothers have a higher risk of small for gestational age (SGA) infants, and rarely give birth to a large for gestational age (LGA) infant. While morbidly obese women often give birth to LGA infants, and rarely to SGA. Normal birthweight (AGA) infants (>10th and <90th centile of a neonatal population) typically have the lowest perinatal and long-term morbidity. The aim of the current study is (1) to determine the maternal body mass index (BMI) range associated with a balanced risk (10% SGA, 10% LGA), and (2) to investigate the interaction between maternal booking BMI, gestational weight gain (GWG) and neonatal birthweight centiles. METHODS: 16.5 year-observational cohort study (2001-2017). The study population consisted of all consecutive singleton term (37 weeks onward) live births delivered at University's maternity in Reunion island, French Overseas Department. FINDINGS: Of the 59,717 singleton term live births, we could define the booking BMI and the GWG in 52,092 parturients (87.2%). We had 2 major findings (1) Only women with a normal BMI achieve an equilibrium in the SGA/LGA risk (both 10%). We propose to call this crossing point the Maternal Fetal Corpulence Symbiosis (MFCS). (2) This MFCS shifts with increasing GWG. We tested the MFCS by 5 kg/m2 incremental BMI categories. The result is a linear law:opGWG (kg) = -1.2 ppBMI (Kg/m²) + 42 ± 2 kg. INTERPRETATION: IOM-2009 recommendations are adequate for normal and over-weighted women but not for thin and obese women: a thin woman (17 kg/m2) should gain 21.6 ± 2 kg (instead of 12.5-18). An obese 32 kg/m2 should gain 3.6 kg (instead of 5-9). Very obese 40 kg/m2 should lose 6 kg.