Variations in the use of caesarean section: a Comparison between France and Australia

Background

There has been a rise in obstetric intervention during labour and birth including rates of caesarean section around the world. The rates of caesarean section are lower in France (20%) than Australia (34%). Both countries have universal health care systems. Australia has a well-established program of obstetric benchmarking and national data collection for comparing maternal and perinatal outcomes taking into account maternity units and maternal characteristics. Although the optimal caesarean section rate is not known, variation in caesarean section rates raise questions about what is driving variation in practice and whether the right care is being delivered. The World Health Organisation has recently released non-clinical recommendations aiming to reduce unnecessary caesarean sections, including that births are classified by Robson classification for easier comparison.

Methods

We aim to compare rates of mode of birth in 2 tertiary hospitals- one in France and one in Australia using Robson classification. This project will investigate differences in patient casemix, and obstetric management that may lead to differences in outcome. In addition, we will try to explore differences in the health systems including clinical activity, induction rates, staffing (number, type (medical, nursing, midwifery)), and models of care.

Outcomes

Caesarean section is one of the most common operations performed in hospitals. Important variations of surgical rates raise question regarding whether access to this procedure is optimized. Determining current practice and outcomes of women in two different settings will provide important data to inform hospital practice and further research. In addition, this research may inform national guidelines about indications for caesarean section.

Clopidogrel, Turkey and a red herring?

The authors present the case of acute hepatitis E in a 61-year-old Edinburgh man who had returned from a holiday in Turkey 6 weeks previously. Diagnosis was ambiguous with his presentation initially attributed to a drug-induced liver injury.

Dissemination of brain emboli following captive bolt stunning of sheep: capacity for entry into the systemic arterial circulation

The epidemic of bovine spongiform encephalopathy in the United Kingdom and the recognition of a variant of Creutzfeldt-Jakob disease prompted revision of the guidelines for slaughter of cattle and sheep to prevent contamination of the edible parts of the carcass with central nervous system tissue. We previously showed that captive bolt gun stunning, which is routinely used for the slaughter of cattle and sheep, causes entry of fragments of central nervous system tissue into the jugular vein. To determine whether such tissue can traverse pulmonary capillaries to enter the systemic circulation, we introduced small volumes of brain tissue that had been disrupted by stunning with a captive bolt gun into the jugular vein of sheep sent for slaughter. We examined aortic blood samples by immunocytochemistry for neurofilament and S100 proteins and by enzyme-linked immunosorbent assay for glial fibrillary acidic protein and found fragments of neurofilament- and S100-immunopositive central nervous system tissue in samples from 2 of 11 sheep and elevated glial fibrillary acidic protein in 6 sheep. Our findings suggest that central nervous system tissue that is dislodged during routine captive bolt gun stunning and slaughter of sheep can enter the systemic arterial circulation and that, in some cases, this method of slaughter of an animal infected with bovine spongiform encephalopathy would be likely to contaminate edible parts of the carcass with infective material.

Anti-inflammatory effects of enteral diet components on Crohn's disease-affected tissues in vitro

BACKGROUND

The mechanism of action of elemental diet in Crohn's disease treatment, is unknown. Alteration of bacterial flora, low antigenicity, low fat content and improvement of nutritional status are postulated to play a role in the anti-inflammatory effect of elemental diet.

AIM

To determine whether elemental diet or its modifications has a direct anti-inflammatory effect on colonic tissue biopsies in vitro.

PATIENTS AND METHODS

Colonic or ileal biopsies from 39 patients with inflammatory bowel disease and control patients were incubated for 24 hours with enteral diets in which nitrogen sources were amino acids as in elemental diet, casein or whey. Tissues were incubated with elemental diet, casein or whey, at dilutions of 1:5, 1:10 or 1:20 in Waymouth's complete medium; a medium control was also included. Tissue viability was assessed by bromodeoxyuridine uptake. Interleukin-1beta, interleukin-1 receptor antagonist and interleukin-10 concentrations in supernatants were measured by immunoassay (enzyme-linked immunosorbent assay).

RESULTS

Incubation of tissues from Crohn's disease with elemental diet resulted in an increase in the ratio of interleukin-1 receptor antagonist/interleukin-1beta vs control statistically significant at 1:10 (89.6+/-17 vs 45.7+/-9. 1, p<0.05). Incubation of Crohn's tissue with casein resulted in a significant increase of interleukin-1 receptor antagonist/interleukin-1beta ratio at dilutions 1:20, 1:10 and 1:5 (101.8+/-22.0, p=0.05, 142.8+/-24.6, p<0.05; 109.7+/-25.0, p=0.05). In ulcerative colitis tissue and non-inflamed non-inflammatory bowel disease control tissue, no significant increase in interleukin 1 receptor antagonist/interleukin-1beta ratio was seen after incubation with elemental diet, casein and whey.

CONCLUSION

Elemental diet incubation increases anti-inflammatory:proinflammatory cytokine ratio in Crohn's disease and this anti-inflammatory effect is not specifically due to amino acid composition, as diets containing casein have similar anti-inflammatory effects.

Jugular venous emboli of brain tissue induced in sheep by the use of captive bolt guns

Emboli of central nervous tissue were detected in the jugular venous blood of two of 15 sheep stunned with a conventional cartridge-operated captive bolt gun and in two of 15 sheep stunned with a pneumatically activated gun. No emboli were detected in arterial blood from these sheep or in venous blood from sheep stunned electrically. Emboli from an animal with BSE could transmit the disease to people.

Methods for detection of haematogenous dissemination of brain tissue after stunning of cattle with captive bolt guns

Because of concern that the stunning of cattle with captive bolt guns (CBGs) could, if used on an animal with bovine spongiform encephalopathy (BSE), cause embolism of infective brain tissue and carcass contamination, the Ministry of Agriculture, Food and Fisheries commissioned research to assess the risk of haematogenous dissemination of CNS material after stunning. We have devised two methods to investigate this risk. The first involves the concentration of embolic tissue in buffy coat Cytoblocks that can be embedded for sectioning, microscopy and immunocytochemistry. The second method is an ELISA for the presynaptic protein, syntaxin 1B. The methods were validated by analysis of several bovine tissues, including blood samples deliberately contaminated with brain. We then studied jugular venous blood obtained before and after the stunning of 60 cattle with CBGs. Samples obtained, after stunning, from five of the cattle contained CNS tissue within the Cytoblocks and yielded positive syntaxin assays. Syntaxin was also detected in samples from one other animal that had been stunned with a pneumatically operated CBG. The described methods should allow an assessment of the risk of neuroembolism associated with different types of CBG and may also be useful in other contexts.

Dysphagia in oesophageal intramural pseudo-diverticulosis: fibrosis, dysmotility or web?

We describe two cases of oesophageal intramural pseudo-diverticulosis associated with a cervical oesophageal web presenting as intermittent dysphagia. In both cases, disruption of the web endoscopically resulted in lasting relief from symptoms. This observation, together with a review of the literature written during the past 39 years, suggests that oesophageal web formation may be under-reported in this condition and may be more important than either dysmotility or submucosal fibrosis and stricturing in the aetiology of the dysphagia seen in these patients. All patients with a radiological diagnosis of oesophageal intramural pseudo-diverticulosis should have an endoscopic examination which may be both diagnostic and potentially therapeutic.

Palliation of a malignant gastrocolic fistula by endoscopic human fibrin sealant injection

We report the case of a female patient with Hodgkin's disease resistant to therapy who developed a gastrocolic fistula as a consequence of her disease, leading to distressing faeculent vomiting. This was not considered to be amenable to surgical resection and her symptoms were successfully palliated endoscopically using injection of human fibrin sealant into the gastric and colonic aspect of the fistula tract. Both mechanical sealing and promotion of healing by human fibrin sealant are likely to be responsible for its efficacy.

Selective reduction of quisqualate (AMPA) receptors in Alzheimer cerebellum

Multiple sites involved in glutamatergic neurotransmission were examined in the cerebellar cortex of 6 patients with Alzheimer's disease and 6 age-matched control patients by using quantitative ligand-binding autoradiography. Quisqualate (AMPA) receptor binding was markedly reduced in the molecular layer of the cerebellum from patients with Alzheimer's disease (167 +/- 13 pmoles/gm) compared with control patients (280 +/- 13 pmoles/gm). In adjacent sections from the same patients and controls, there was preservation of kainate and N-methyl-D-aspartate receptor binding in the cerebellum from patients with Alzheimer's disease compared with control patients. Neuropathological examination of the cerebellar cortex revealed the presence of plaques and preservation of Purkinje cells in the patients with Alzheimer's disease.