Continuous vs intermittent induction of labor with oxytocin in nulliparous patients: a randomized controlled trial

BACKGROUND

Oxytocin is considered the drug of choice for the induction of labor, although the optimal protocol and infusion duration remain to be determined.

OBJECTIVE

This study aimed to assess whether the duration of oxytocin infusion increases 24-hour delivery rates and affects the length of time-to-delivery and patient's experience.

STUDY DESIGN

A randomized controlled trial was performed at a single tertiary medical center, between January 1, 2020 and June 30, 2022. Nulliparous patients with a singleton pregnancy at a vertex presentation and a Bishop score ≥6 were randomly assigned to receive either continuous (16 hours, with a 4 hours pause in between infusions) or intermittent (8 hours, with a 4 hours pause in between infusions) oxytocin infusion, until delivery. In both groups, infusion was halted when signs of maternal or fetal compromise were observed. Randomization was conducted with a computer randomization sequence generation program. The primary outcome was delivery within 24 hours from the first oxytocin infusion and the secondary outcome included time-to-delivery, mode of delivery, and additional maternal and neonatal outcomes. Seventy-two patients per group were randomized to reach 80% statistical power with a 20% difference in the primary outcome according to previous studies.

RESULTS

A total of 153 patients were randomized, 72 to the continuous oxytocin infusion group and 81 to the intermittent infusion group. The total oxytocin infusion time was similar between the groups. Patients in the continuous arm were more likely to deliver within 24 hours from oxytocin initiation (79.73% vs 62.96%, P<.05), and had a shorter oxytocin-to-delivery time interval, compared with patients receiving intermittent treatment (9.3±3.7 hours vs 21±11.7 hours, P<.001). Furthermore, time from ruptured membranes to delivery was shorter (9.3±3.7 hours vs 21±11.7 hours; P<.0001) and chorioamnionitis was less frequent (9.46% vs 21%; P<.05) in the continuous compared with the intermittent arm. Cesarean delivery rate was 20% in both groups (P=.226). There was no difference in postpartum hemorrhage, or adverse neonatal outcomes between the groups. Patients receiving continuous oxytocin infusion were more satisfied with the birthing experience.

CONCLUSION

Continuous infusion of oxytocin for labor induction in nulliparous patients with a favorable cervix may be superior to intermittent oxytocin infusion, because it shortens time-to-delivery, decreases chorioamnionitis rate, and improves maternal satisfaction, without affecting adverse maternal or neonatal outcomes.

Hidradenitis Suppurativa Area and Severity Index Revised (HASI-R): psychometric property assessment

BACKGROUND

Validated, reliable, globally accepted outcome measurement instruments for hidradenitis suppurativa (HS) are needed. Current tools to measure the physical signs domain for HS rely on lesion counts, which are time-consuming and unreliable.

OBJECTIVES

To assess the reliability and validity of the Hidradenitis suppurativa Area and Severity Index Revised (HASI-R) tool, a novel method for assessing HS severity, incorporating signs of inflammation and body surface area involved.

METHODS

The measurement properties of the HASI-R tool were evaluated. The tool was created by combining the previously published HASI and Severity and Area Score for Hidradenitis instruments. Twenty raters evaluated 15 patients with HS in a hospital-based ambulatory dermatology clinic. The objectives of the study were to assess inter- and intra-rater reliability of the HASI-R and its components, as well as its construct and known-groups validity. Existing lesion count-based clinician-reported measures of HS and their components were also assessed. Raters were also asked their preferences regarding the various HS severity assessment tools.

RESULTS

The HASI-R had moderate inter-rater reliability [intra-class correlation coefficients (ICC) 0·60]. This was better than all other HS physical sign outcome measures evaluated, which had poor inter-rater reliability (ICC < 0·5). HASI-R had the highest intra-rater reliability (ICC 0·91). The HASI-R had good construct validity and demonstrated known-groups validity. The HASI-R was also the most preferred tool by all raters.

CONCLUSIONS

Results from the clinometric assessment of the HASI-R are encouraging, and support continued evaluation of this clinician-reported outcome measure.

Review article: The advent of capsule endoscopy--a not-so-futuristic approach to obscure gastrointestinal bleeding

Capsule endoscopy is a new, wireless, endoscopic examination of the small intestine. To date, two small clinical trials have been reported utilizing capsule endoscopy in patients with obscure gastrointestinal bleeding, and have shown its superiority to push enteroscopy in diagnosing the cause of blood loss. No outcome studies have been reported. This paper proposes a change in practice guidelines for obscure bleeding. It is our opinion that, in the future, with the advent of wireless capsule endoscopy, the evaluation of patients with obscure gastrointestinal bleeding will be very different from the practice of medicine today. We believe that capsule endoscopy will become the first-line method for the evaluation of patients with obscure bleeding, once upper endoscopy and colonoscopy have been shown to be negative. In patients with active bleeding, capsule endoscopy will confirm the small bowel as the site of bleeding, providing a location, or, if the study is negative for the small intestine, may indicate that the bleeding is either colonic or gastric in origin. In a patient with active bleeding within the small intestine, the capsule will guide further evaluation and therapy. A patient with a small bowel tumour detected by capsule endoscopy will proceed directly to laparoscopic surgery. If the site of bleeding is identified in the proximal small bowel and there is no mass, push enteroscopy will be used to re-identify the site and cauterize it. A distal small bowel site will require surgical intervention, coupled with intra-operative enteroscopy. Should the patient be too sick to undergo surgery, medical therapy utilizing hormonal agents will be considered. A colonic site will be evaluated by colonoscopy. In patients with a more occult or intermittent type of bleeding and in those whose upper endoscopies and colonoscopies are negative, capsule endoscopy will be used similarly to identify a bleeding lesion and thereby direct subsequent testing or treatment.

Evaluating health-related quality of life: cost comparison of computerized touch-screen technology and traditional paper systems

We estimated and compared the costs for three different methods of administering and evaluating the Short Form-36 as a routine part of clinical practice from the provider perspective. In an outpatient pain management practice, we assessed a computer touch-screen system with facsimile and scanning scoring methods. Equipment, supply, and labor costs needed to construct, maintain, and generate reports for each system were measured. The annual fixed, variable, and total costs/survey were calculated. Sensitivity analyses were performed varying the number of surveys administered/year. The facsimile method was the least costly, $9.62 and $5.88/survey, at annual questionnaire volumes of 250 and 1000, respectively. When the annual survey volume increased to 1250 (5 surveys/day), the costs of the facsimile ($5.63/survey) and computer touch-screen ($5.65/survey) methods were nearly equivalent per survey administration. At volumes of 1500 and above, the least costly method was the computer touch screen at $5.47/survey. The system implemented in a clinical practice is dependent not only on questionnaire volume but also on personnel availability, equipment access, required speed of results, and the acceptable level of data error.

The use of physician financial incentives and feedback to improve pediatric preventive care in Medicaid managed care

OBJECTIVE

Immunizations and other cost-effective preventive services remain underused by many children, especially those living in poverty. Given the effectiveness of provider-based tracking systems and the widespread use by managed care organizations of financial incentives to influence physician practice patterns, we designed and tested an intervention combining these strategies. We studied whether a system of semiannual assessment and feedback, coupled with financial incentives, could improve pediatric preventive care in a Medicaid health maintenance organization (HMO).

METHODOLOGY

We randomly assigned primary care sites serving children in a Medicaid HMO to one of three groups: a feedback group (where physicians received written feedback about compliance scores), a feedback and incentive group (where physicians received feedback and a financial bonus when compliance criteria were met), and a control group. We evaluated compliance with pediatric preventive care guidelines through semiannual chart audits during the years 1993 to 1995.

RESULTS

Compliance with pediatric preventive care improved dramatically in the study period. Repeated measures ANOVA demonstrated a significant increase in all three study groups throughout the time in total compliance scores (from 56%-73%), as well as scores for immunizations (from 62%-79%) and other preventive care (from 54%-71%). However, no significant differences were observed between either intervention group and the control group, nor were there any interaction (group-by-time) effects.

CONCLUSIONS

Feedback to physicians, with or without financial incentives, did not improve pediatric preventive care in this Medicaid HMO during a time of rapid, secular improvements in care. Possible explanations include the context and timing of the intervention, the magnitude of the financial incentives, and lack of physician awareness of the intervention.

Physician financial incentives and feedback: failure to increase cancer screening in Medicaid managed care

OBJECTIVES

A randomized controlled trial evaluated the impact of feedback and financial incentives on physician compliance with cancer screening guidelines for women 50 years of age and older in a Medicaid health maintenance organization (HMO).

METHODS

Half of 52 primary care sites received the intervention, which included written feedback and a financial bonus. Mammography, breast exam, colorectal screening, and Pap testing compliance rates were evaluated.

RESULTS

From 1993 to 1995, screening rates doubled overall (from 24% to 50%), with no significant differences between intervention and control group sites.

CONCLUSIONS

Financial incentives and feedback did not improve physician compliance with cancer screening guidelines in a Medicaid HMO.

Construction of a psb C deletion strain in Synechocystis 6803

Synechocystis 6803 is a cyanobacterium that carries out-oxygenic photosynthesis. We are interested in the introduction of mutations in the large extrinsic loop region of the CP43 protein of Photosystem II (PSII). CP43 appears to be required for the stable assembly of the PSII complex and also appears to play a role in photosynthetic oxygen evolution. Deletion of short segments of the large extrinsic loop results in mutants incapable of evolving oxygen. Alterations in psbC, the gene encoding CP43, are introduced into Synechocystis 6803 by transformation and homologous recombination. Specifically, plasmid constructs bearing the site-directed mutations are introduced into a deletion strain where the portion of the gene encoding the area of mutation has been deleted and replaced by a gene conferring antibiotic resistance. We have constructed a deletion strain of Synechocystis appropriate for the introduction of mutations in the large extrinsic loop of CP43 and have used it successfully to produce site-directed mutants.

Differences in mortality from coronary artery bypass graft surgery at five teaching hospitals

OBJECTIVE

To measure hospital- and surgeon-specific mortality rates for patients with coronary artery bypass graft (CABG) surgery and to examine possible reasons for any differences.

DESIGN

Cohort study using hospital discharge abstracts and itemized bills.

SETTING

Five major teaching hospitals in Philadelphia, Pa.

PATIENTS

Consecutive sample of all 4613 patients over a 30-month period.

MAIN OUTCOME MEASURE

In hospital mortality rates.

RESULTS

We observed differences in hospital mortality rates for patients who underwent coronary artery catheterization and CABG surgery during the same admission (diagnosis related group 106) but not for patients who underwent only CABG surgery during the admission (diagnosis related group 107). There were threefold differences in surgeon-specific mortality rates. The hospital mortality rates for coronary artery catheterization and CABG surgery during the same admission changed during the study and coincided with moves of surgeons among study hospitals. Our measures of illness severity did identify patients who were more likely to die, but differences in severity of illness did not explain differences in hospital- or surgeon-specific mortality rates. Patient mortality rates were not associated with the volume of procedures performed by individual surgeons. We found inconclusive evidence for an association with surgeons' clinical skills, and to a lesser extent, with the hospital's volume of procedures and the hospital's organization and staffing. A greater intensity of hospital services was not necessary for a lower mortality rate.

CONCLUSIONS

We conclude that studies of CABG mortality should examine mortality rates by diagnosis related group, collect data from more than 1 year, examine associations with surgeons' clinical skills, include information on hospital organization and staffing, and cautiously explore more efficient ways of providing care.