The Use of Plant-Based Polysaccharide (PSP) Agents May Improve Early Outcomes Following Total Knee Arthroplasty-A Proof-of-Concept Study

Our study sought to investigate the effects of a topical plant-based polysaccharide (PSP) as an adjunctive hemostat to minimize blood loss and improve early clinical outcomes in patients undergoing primary TKA. In this multi-center and randomized proof-of-concept study, 61 patients undergoing TKA were randomly assigned to one of two groups: A) intraoperative utilization of PSP (n=31) or B) no intervention (n=30). The primary outcomes were blood loss and change in hemoglobin, measured preoperatively and 24 hours postoperatively. Other endpoints included postoperative complications, Knee Society Score (KSS), knee range of motion (ROM), and thigh circumference. There was no difference in postoperative change of hemoglobin or calculated blood loss between the PSP and control groups. The PSP group achieved elevated flexion at two weeks (100.1° vs. 86.6°, p<0.05) and better change in KSS from preop to 90 days (29.5 vs. 22.4, p<0.05) than the controls. Some early postoperative outcomes were improved, which suggests a potential benefit of using PSP in primary TKA. However, the clinical significance of these differences warrants further investigation in a larger randomized trial.

Arthritis Foundation/HSS Workshop on Hip Osteoarthritis, Part 4: Nonoperative Options, Machine Learning in Predicting Total Hip Arthroplasty, Robotics, and Phenotyping to Guide Precision Rehabilitation

Far more publications are available for osteoarthritis of the knee than of the hip. Recognizing this research gap, the Arthritis Foundation (AF), in partnership with the Hospital for Special Surgery (HSS), convened an in-person meeting of thought leaders to review the state of the science of and clinical approaches to hip osteoarthritis. This article summarizes the recommendations gleaned from presentations given in the "late-stage osteoarthritis" session of the 2023 Hip Osteoarthritis Clinical Studies Conference, which took place on February 17 and 18, 2023, in New York City. It covers conservative treatment, decision-making in end-stage hip osteoarthritis, advancements in robotics, and the role of phenotyping in precision rehabilitation post-total hip arthroplasty (THA).

Mid-Flexion Instability After Total Knee Arthroplasty: Diagnosis, Implant Design, and Outcomes

Mid-flexion instability (MFI) in total knee arthroplasty refers to a distinct clinical entity where the knee is stable at full extension and 90° of flexion, but unstable somewhere between these 2 points. The presentation of MFI is often vague, and studies defining objective clinical or intraoperative measurements are limited. In this review, we aim to properly define the condition, describe diagnostic criteria and risk factors contributing to MFI, review current implant design, and present outcomes of revision surgery performed for MFI. [Orthopedics. 2023;46(1):e13-e19.].

Polyethylene Components in Primary Total Knee Arthroplasty: A Comprehensive Overview of Fixed Bearing Design Options

The articular design of a polyethylene insert influences the kinematics and overall function of a total knee arthroplasty (TKA). Standard symmetric posterior-stabilized and cruciate-retaining polyethylene designs have a long track record of high patient satisfaction and longevity in TKA. However, the number and variety of polyethylene inserts and articulations have continued to evolve in an attempt to better replicate native knee kinematics or provide additional constraint. Ultracongruent polyethylene designs have been touted as increasing stability while maintaining the benefits of cruciate-retaining knees. Medial pivot and lateral/dual pivot polyethylene designs were introduced to mimic more normal knee kinematics with regard to femoral rollback. Further, with increasing recognition of knee instability as a cause for persistent symptoms and revision TKA, the utilization of midlevel constraint polyethylene inserts has been increasing, with multiple implant companies offering an insert design with increased constraint for use with a primary femoral component. In this rapidly evolving arena in with a myriad of options available, surgeons should be knowledgeable about the design concepts and their applicable uses for specific patient scenarios. Future research is needed to better understand whether a particular type or design of polyethylene insert and articulation leads to improved patient reported outcomes, improved replication of knee kinematics, and long-term durable implant survivorship.

Intraoperative Use of Betadine Irrigation is Associated With a 9-Fold Increased Likelihood of Penile Prosthesis Infection: Results From a Retrospective Case-Control Study

Introduction

Infection remains a persistent complication of penile prosthesis (PP) surgery. Despite popularity of Mulcahy’s PP washout protocol, Betadine has known tissue toxicity.

Aim

We evaluated PP infection rate based on the type of intraoperative irrigation used, ½ strength Betadine vs vancomycin/gentamicin.

Methods

We reviewed a prospective database of men undergoing primary, revision, and salvage PPs. No other changes to operative or perioperative techniques occurred after the change in irrigation solution. Univariate and logistic regression analyses were used to evaluate differences in infection rate with use of Betadine vs vancomycin/gentamicin irrigation. Potential confounders were reviewed.

Main Outcome Measure

The primary outcome was rate of PP infection before and after change of intraoperative irrigation.

Results

From 2014 to 2018, 217 patients underwent PP placement at our institution by a single surgeon; of whom, 21 (9.7%) experienced an infection (primary = 10 [7.1%], revision = 11 [17.19%], salvage = 0 [0%]). Overall, 152 (70%) received irrigation with Betadine and 65 (30%) with Vancomycin/Gentamicin. Univariate analysis demonstrated significantly increased infection rates with Betadine irrigation (odds ratio [OR]: 4.64, P = .006) and with revision surgery (OR: 2.68, P = .02). Significance of increased infection rate with Betadine was maintained (OR: 9.3; P = .025) after controlling for age, body mass index, Charlson comorbidity index, smoking, diabetes, primary vs revision/salvage, prior penile surgery, use of ectopic reservoir, and adjunctive glanulopexy.

Conclusions

Changing from intraoperative Betadine to vancomycin/gentamicin solution dramatically reduced infection rates among men undergoing PP placement in both primary and revision cases. We hypothesize that differences in infection rate may relate to the relative toxicity or non-sterile nature of Betadine.

Manka MG, Yang D, Andrews J, et al. Intraoperative Use of Betadine Irrigation is Associated With a 9-Fold Increased Likelihood of Penile Prosthesis Infection: Results From a Retrospective Case-Control Study. Sex Med 2020;8:422–427.

International validation of the European Organisation for Research and Treatment of Cancer QLQ-BRECON23 quality-of-life questionnaire for women undergoing breast reconstruction

Background

The aim was to carry out phase 4 international field-testing of the European Organisation for Research and Treatment of Cancer (EORTC) breast reconstruction (BRECON) module. The primary objective was finalization of its scale structure. Secondary objectives were evaluation of its reliability, validity, responsiveness, acceptability and interpretability in patients with breast cancer undergoing mastectomy and reconstruction.

Methods

The EORTC module development guidelines were followed. Patients were recruited from 28 centres in seven countries. A prospective cohort completed the QLQ-BRECON15 before mastectomy and the QLQ-BRECON24 at 4–8 months after reconstruction. The cross-sectional cohort completed the QLQ-BRECON24 at 1–5 years after reconstruction, and repeated this 2–8 weeks later (test–retest reliability). All participants completed debriefing questionnaires.

Results

A total of 438 patients were recruited, 234 in the prospective cohort and 204 in the cross-sectional cohort. A total of 414 reconstructions were immediate, with a comparable number of implants (176) and donor-site flaps (166). Control groups comprised patients who underwent two-stage implant procedures (72, 75 per cent) or delayed reconstruction (24, 25 per cent). Psychometric scale validity was supported by moderate to high item-own scale and item-total correlations (over 0·5). Questionnaire validity was confirmed by good scale-to-sample targeting, and computable scale scores exceeding 50 per cent, except nipple cosmesis (over 40 per cent). In known-group comparisons, QLQ-BRECON24 scales and items differentiated between patient groups defined by clinical criteria, such as type and timing of reconstruction, postmastectomy radiotherapy and surgical complications, with moderate effect sizes. Prospectively, sexuality and surgical side-effects scales showed significant responsiveness over time (P &lt; 0·001). Scale reliability was supported by high Cronbach's α coefficients (over 0·7) and test–retest (intraclass correlation more than 0·8). One item (finding a well fitting bra) was excluded based on high floor/ceiling effects, poor test–retest and weak correlations in factor analysis (below 0·3), thus generating the QLQ-BRECON23 questionnaire.

Conclusion

The QLQ-BRECON23 is an internationally validated tool to be used alongside the EORTC QLQ-C30 (cancer) and QLQ-BR23 (breast cancer) questionnaires for evaluating quality of life and satisfaction after breast reconstruction.

Rotational stability for intercarpal fixation is enhanced by a 4-tine staple

PURPOSE

To compare the torsional stability of 6 fixation techniques for intercarpal fixation including a 4-tine, in-line staple.

METHODS

We chose the scapholunate interval as the test site for rotational stability for various constructs. We used 42 pairs of embalmed scaphoids and lunates for the comparisons and created 6 construct groups. Fixation of the scapholunate gap was performed with a 3-mm screw, 2 1.1-mm (0.045-inch) K-wires spaced 2 mm apart, or 2 1.1-mm K-wires spaced 5 mm apart. One member of each pair was fixed with either a standard 2-tine peripherally placed staple or a customized 4-tine staple. Each scapholunate construct was tested in torsion to failure on a biaxial materials testing machine.

RESULTS

In all cases, the 4-tine staple significantly increased rotational stability. The 2-tine staple resulted in statistically insignificant increases in rotational stability. With central fixation alone, K-wires separated by 5 mm showed the greatest resistance to torsion, and the 3-mm screw showed the least.

CONCLUSIONS

Use of an in-line, 4-tine staple provided increased rotational stability and may result in enhanced healing of intercarpal ligamentous reconstructions and arthrodeses.

CLINICAL RELEVANCE

A 4-tine staple compared with a standard staple provided superior rotational stability for intercarpal fixation.

Factors influencing morbidity after surgical management of malignant thyroid disease

OBJECTIVES

We performed a retrospective study of cases from 2005 to 2010 at an academic tertiary care center to analyze the factors that influence morbidity in surgical management of thyroid malignancy.

METHODS

The rates of recurrent laryngeal nerve (RLN) injury and hypoparathyroidism (HPT) were analyzed in the entire cohort. The comparison groups were 1) primary surgery versus revision; 2) total thyroidectomy versus total thyroidectomy combined with neck node dissection; and 3) two groups defined by surgical technique according to the RLN approach: group 1, in which the RLN was identified inferiorly in the tracheoesophageal groove, and group 2, in which the RLN was identified near the cricothyroid joint point of entry.

RESULTS

We reviewed 308 patients who underwent surgery for thyroid cancer. Thirty-six (11.7%) had temporary HPT, and 8 (2.6%) had permanent HPT. Of a total of 586 RLNs at risk, 16 (2.7%) had temporary damage and 2 (0.3%) had permanent damage. The incidences of temporary RLN injury significantly differed between the primary-surgery and revision-surgery groups (2.5% versus 15.6%; p = 0.001), and also between the groups with total thyroidectomy and thyroidectomy with neck dissection (1.2% versus 7.8%; p = 0.027). The incidences of temporary HPT were significantly different between the groups with primary surgery and revision surgery (6.6% versus 31.3%; p = 0.001), between the groups with total thyroidectomy and total thyroidectomy with neck dissection (4.7% versus 15.6%; p = 0.009), and between group 1 and group 2 (surgical technique in terms of RLN approach; 8.2% versus 17.9%; p = 0.011). Permanent HPT and permanent RLN injury both occurred rarely in this cohort, with no significant differences among comparison groups.

CONCLUSIONS

Our study shows a higher incidence of temporary RLN injury and teniporary HPT in revision surgery cases and in total thyroidectomy with neck dissection. Temporary HPT was significantly more common when the RLN was identified near the cricothyroid joint.

Abstract 2409: Pharmacologic ascorbate inhibits pancreatic cancer cell EMT and sensitizes cancer cells to gemcitabine

Pharmacologic concentrations of ascorbate have been shown to act as a pro-oxidant anti-cancer agent. Our previous work has showed that pharmacologic ascorbate worked synergistically with gemcitabine in 8 pancreatic cancer cells lines, and in gemcitabine responsive and non-responsive mouse tumor models. This study aimed to investigate the mechanisms for this synergistic effect. In PANC-1 pancreatic cancer cells treated with 2.5 mM ascorbate, real time RT-PCR showed increased mRNA expression levels of E-cadherin, and decreased levels of Vimentin, indicating a reversal/inhibition of epithelial-mesenchymal transition (EMT). The inhibition of EMT was attribute to up-regulation of microRNAs mir429 and mir 200 family, which binds to to 3′ URTs of Zeb-1 and Zeb-2 mRNAs, thus inhibited Zeb-1/2 mRNA translation and accelerated their deadenylation and subsequent exonucleolytic digestion. Consistant with the mir429 and 200 increase, real-time RT-PCR showed decreased in Zeb-1. Since Zeb-1 is a repressor of E-cadherin, the inhibition in Zeb-1 resulted in the increased level of E-cadherin. Moreover, mRNAs for multiple MMPs were also found inhibited by ascorbate treatment, while collagen type IV and type II were largely increased. Relatively, mir21 was found decreased by ascorbate treatment. Mir21 is an oncomir that promotes cancer invasion. It inhibits TIMP-3 and up-regulate MMPs, and thus its inhibition is associated with repression of MMPs. At cellular level, immulofluorescence clearly showed an increase in E-cadherin and decrease in Vimentin expression, which confirmed the RT-PCR results in indicating EMT inhibition. As EMT is highly related to drug resistance, we co-treated PANC-1 cell with ascorbate and gemcitabine. PANC-1 cells exhibited a highly “EMTed” phenotype and were resistant to gemcitabine single-drug treatment. The combination treatment of ascorbate and gemcitabine dramatically increased cell death compared to gemcitabine alone. Using Chou-Talalay's constant ratio design, gemcitabine IC50 was decreased 3.5-fold, and gemcitabine IC90 was decreased 11.5-fold. In PANC-1 orthotopic mouse tumor model (n=3 for each group), live animal imaging showed predominant tumor growth and metastasis in saline-treated controls, but tumor regression in ascorbate (4 g/kg/day, i.p.) treated mice. At day 54, 2 of the 3 ascorbate-treated mice were tumor-free. Experiments are underway with larger groups of mice and with ascorbate/gemcitabine combination treatment to examine tumor growth and metastasis. Collectively, these data demonstrated that ascorbate at pharmacological doses inhibited pancreatic cancer growth. Inhibition in EMT by ascorbate resulted in a strong synergistic effect between ascorbate and gemcitabine. These results suggest a rational combination of high dose parenteral ascorbate and gemcitabine in treating pancreatic cancer, one of the most lethal cancers worldwide.

Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 103rd Annual Meeting of the American Association for Cancer Research; 2012 Mar 31-Apr 4; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2012;72(8 Suppl):Abstract nr 2409. doi:1538-7445.AM2012-2409

Pharmacologic ascorbate synergizes with gemcitabine in preclinical models of pancreatic cancer

Conventional treatment approaches have had little impact on the course of pancreatic cancer, which has the highest fatality rate among cancers. Gemcitabine, the primary therapeutic agent for pancreatic carcinoma, produces minimal survival benefit as a single agent. Therefore, numerous efforts have focused on gemcitabine combination treatments. Using a ratio design, this study established that combining pharmacologically achievable concentrations of ascorbate with gemcitabine resulted in a synergistic cytotoxic response in eight pancreatic tumor cell lines. Sensitization was evident regardless of inherent gemcitabine resistance and epithelial-mesenchymal phenotype. Our analysis suggested that the promiscuous oxidative actions of H(2)O(2) derived from pharmacologic ascorbate can culminate in synergism independent of the cancer cell's underlying phenotype and resistance to gemcitabine monotherapy. Gemcitabine-ascorbate combinations administered to mice bearing pancreatic tumor xenografts consistently enhanced inhibition of growth compared to gemcitabine alone, produced 50% growth inhibition in a tumor type not responsive to gemcitabine, and demonstrated a gemcitabine dose-sparing effect. These data support the testing of pharmacologic ascorbate in adjunctive treatments for cancers prone to high failure rates with conventional therapeutic regimens, such as pancreatic cancer.

Abstract C13: Ascorbate induces cytotoxicity in prostate cancer cells through an autophagy pathway

Ascorbate (Vitamin C) has been shown to act as a pro-oxidant agent under pharmacological concentrations, and thus can cause cancer cell death in vitro and inhibit tumor growth in animal models, through formation of H2O2. The cell death mechanisms induced by ascorbate need to be further elaborated.

The goal of our study was to determine whether ascorbate is cytotoxic to prostate cancer cells and if so, to determine the mechanism of ascorbate-induced cytotoxicity. We hypothesized that through generation of H2O2, pharmacological concentrations of ascorbate can deplete prostate cancer cell ATP and cause cell death through autophagy pathway. A panel of prostate cancer cell lines PC-3, LNCap, C4-2, LaPC4 and 22RV1 were incubated with millimolar range of ascorbate for two hours. Then ascorbate was washed out and cells were incubated in fresh media for 24 hrs before cell viability was assessed. Cell ATP levels were determined by HPLC. The results showed that 4 out of the 5 tested cell lines have IC50s &lt; 5 mM, while the most resistant cell line LaPC4 has IC50 at 12 mM. Addition of catalase - a H2O2 scavenger to the culture media, completely protected the cells from the death caused by ascorbate, confirming the death is mediated by H2O2. PC-3 cell ATP levels significantly decreased after 2 hrs of incubation with 5 mM ascorbate, and did not recover over the following 24 hrs. To determine if ascorbate induced autophagy, western blot of PC-3 cells for LC3 was performed. The results showed an increase of LC3-II form at 2 hrs of ascorbate treatment, indicating the processing of LC3 protein to its lipidated form. At 24 hrs the LC3-II bands were decreased, which may due to degradation of LC3 proteins at the autophagosomes. We also generated cells (PC3-LC3G) that express a fusion protein of LC-3 and GFP. The GFP-LC3 protein punctation were observed at 4 hrs of ascorbate treatment, indicating a translocation of LC3 to the autophagic membranes. These results suggest that ascorbate induces cytotoxicity in prostate cancer cells through depletion of cell ATP and induction of autophagy. To further confirm this pathway, an autophagy inhibitor 3-MA is under testing, the degradation of GFP-LC3 is also under analysis to determine whether ascorbate increases the autophagic flux. Also, to confirm the role of ATP drop in ascorbate-induced autophagy, 3-aminibenzamide (3AB) and 4-hydroxyquinazoline (4HQ) are being used to prevent the drop in ATP level.

Citation Information: Mol Cancer Ther 2009;8(12 Suppl):C13.

Why do women go along with this stuff?

Normal childbirth has become jeopardized by inexorably rising interventions around the world. In many countries and settings, cesarean surgery, labor induction, and epidural analgesia continue to increase beyond all precedent, and without convincing evidence that these actions result in improved outcomes (1,2). Use of electronic fetal monitoring is endemic, despite evidence of its ineffectiveness and consequences for most parturients (1,3); ultrasound examinations are too often done unnecessarily, redundantly, or for frivolous rather than indicated reasons (4); episiotomies are still routine in many settings despite clear evidence that this surgery results in more harm than good (5); and medical procedures, unphysiological positions, pubic shaving and enemas, intravenous lines, enforced fasting, drugs, and early mother-infant separation are used unnecessarily (1). Clinicians write and talk about the ideal of evidence-based obstetrics, but do not practice it consistently, if at all. Why do women go along with this stuff? In this Roundtable Discussion, Part 1, we asked some maternity care professionals and advocates to discuss this question.

Does previous infection protect against atopic eczema and recurrent wheeze in infancy?

BACKGROUND

Frequent infection in infancy and early childhood has been hypothesized to explain the low prevalence of asthma and other atopic disease among children in developing countries (the so-called 'hygiene hypothesis'), but the low prevalence in Eastern Europe remains unexplained.

OBJECTIVE

To test the hygiene hypothesis in the Republic of Belarus by examining the relationship between gastrointestinal (GI) and respiratory infection and two potentially atopic outcomes in the first 12 months of life: atopic eczema and recurrent wheeze. METHODS; We carried out two case-control studies nested within a large (n=17 046) randomized trial in Belarus, with cases defined as (1) first occurrence of atopic eczema (n=819) and (2) second episode of wheezing (n=112). Incidence density sampling was used to select four matched controls born within 1 month at the same hospital as the case. Exposure was defined as one or more episodes of GI or respiratory infection (examined separately) with onset >7 days before onset of the case's atopic outcome. Analyses controlled for family atopic history, duration of exclusive breastfeeding, sex, birth weight, maternal education, and (for recurrent wheeze) maternal smoking.

RESULTS

For atopic eczema, prior GI infection occurred in 7.4% of cases vs. 6.0% of controls [adjusted OR=1.27 (0.94-1.72)] and prior respiratory infection in 35.2% vs. 32.6% [adjusted OR=1.14 (95% CI=0.94-1.37)]. For recurrent wheeze, prior GI infection occurred in 9.8% of cases vs. 7.4% of controls [adjusted OR=1.30 (0.60-2.82)].

CONCLUSION

Our results do not support the hypothesis that infection protects against atopic eczema or recurrent wheezing in the first 12 months of life.

A report of women's birth experiences in Baku, Azerbaijan

The findings from a survey exploring women's perceptions of their care during pregnancy, birth and the postpartum period in Baku, Azerbaijan, initiated by the Ministry of Health and UNICEF, are reported here. In the former Soviet Union, on which the perinatal health care systems of Azerbaijan are based, care for women during the perinatal period was based on using available technology and on a physician-centred model of care. Women's perceptions of their care were infrequently if ever sought or heeded. As healthcare systems are being strengthened in these countries, there is an increasing interest in providing a woman-centered or family-centered approach to care as well as offering appropriate medical care birthing procedures. This study explores the progress made in Azerbaijan in implementing such changes since the introduction of a perinatal reform process a few years ago. Findings indicate some significant deviations from traditional maternity care practices in Baku since the breakdown of the Soviet Union. A more humanistic and evidence-based approach to care is being introduced. It is evident that maternity houses in Baku are also providing better support for infant feeding than many of their former Soviet Union counterparts indicating the effective implementation of the principles of breastfeeding encouraged through the WHO/UNICEF Baby Friendly Hospital Initiative program in that country.

Promotion of breastfeeding intervention trial (PROBIT): a cluster-randomized trial in the Republic of Belarus. Design, follow-up, and data validation

This paper summarizes the objectives, design, follow-up, and data validation of a cluster-randomized trial of a breastfeeding promotion intervention modeled on the WHO/UNICEF Baby-Friendly Hospital Initiative (BFHI). Thirty-four hospitals and their affiliated polyclinics in the Republic of Belarus were randomized to receive BFHI training of medical, midwifery, and nursing staffs (experimental group) or to continue their routine practices (control group). All breastfeeding mother-infant dyads were considered eligible for inclusion in the study if the infant was singleton, born at > or = 37 weeks gestation, weighed > or = 2500 grams at birth, and had a 5-minute Apgar score > or = 5, and neither mother nor infant had a medical condition for which breastfeeding was contraindicated. One experimental and one control site refused to accept their randomized allocation and dropped out of the trial. A total of 17,795 mothers were recruited at the 32 remaining sites, and their infants were followed up at 1, 2, 3, 6, 9, and 12 months of age. To our knowledge, this is the largest randomized trial ever undertaken in area of human milk and lactation. Monitoring visits of all experimental and control maternity hospitals and polyclinics were undertaken prior to recruitment and twice more during recruitment and follow-up to ensure compliance with the randomized allocation. Major study outcomes include the occurrence of > or = 1 episode of gastrointestinal infection, > or = 2 respiratory infections, and the duration of breastfeeding, and are analyzed according to randomized allocation ("intention to treat"). One of the 32 remaining study sites was dropped from the trial because of apparently falsified follow-up data, as suggested by an unrealistically low incidence of infection and unrealistically long duration of breastfeeding, and as confirmed by subsequent data audit of polyclinic charts and interviews with mothers of 64 randomly-selected study infants at the site. Smaller random audits at each of the remaining sites showed extremely high concordance between the PROBIT data forms and both the polyclinic charts and maternal interviews, with no evident difference in under- or over-reporting in experimental vs control sites. Of the 17,046 infants recruited from the 31 participating study sites, 16,491 (96.7%) completed the study and only 555 (3.3%) were lost to follow-up. PROBIT's results should help inform decision-making for clinicians, hospitals, industry, and governments concerning the support, protection, and promotion of breastfeeding.

WHO principles of perinatal care: the essential antenatal, perinatal, and postpartum care course

World Health Organization (WHO) recommendations and meta-analyses of controlled trials have concluded that inappropriate perinatal care and technology continue to be practiced widely throughout the world, despite the acceptance of evidence-based principles and care. The WHO Regional Office for Europe, in consultation with policy makers and reproductive health experts recently proposed ten "Principles of Perinatal Care," which have been endorsed by the reproductive health units of most member states. A comprehensive training program, based on the principles, is now being offered throughout the European region. This paper describes the development of the WHO principles and the WHO training course "Essential Antenatal, Perinatal and Postpartum Care." Together they provide an innovative model of evidence-based and psychosocially sensitive care for the future guidance of perinatal policy makers and caregivers worldwide.

Assessing effective care in normal labor: the Bologna score

The intention of the "Bologna score" is to quantify, both in an individual labor and in a wider population, the extent to which labors have been managed as if they are normal as opposed to complicated. In this way it may be possible to assess both attitudes and practices within a maternity service toward the effective care of normal labor. A scoring system for normal labor was proposed at the World Health Organization (Regional Office for Europe) Task Force Meeting on Monitoring and Evaluation of Perinatal Care, held in Bologna in January 2000. This paper describes conceptual development of the scale. Recommendations for future evaluation of the Bologna score's validity and potential include field testing globally, comparison with the Apgar score, and evaluation of the relative weight contributed by each of the five measures comprising the Bologna score.

Promotion of Breastfeeding Intervention Trial (PROBIT): a randomized trial in the Republic of Belarus

CONTEXT

Current evidence that breastfeeding is beneficial for infant and child health is based exclusively on observational studies. Potential sources of bias in such studies have led to doubts about the magnitude of these health benefits in industrialized countries.

OBJECTIVE

To assess the effects of breastfeeding promotion on breastfeeding duration and exclusivity and gastrointestinal and respiratory infection and atopic eczema among infants.

DESIGN

The Promotion of Breastfeeding Intervention Trial (PROBIT), a cluster-randomized trial conducted June 1996-December 1997 with a 1-year follow-up.

SETTING

Thirty-one maternity hospitals and polyclinics in the Republic of Belarus.

PARTICIPANTS

A total of 17 046 mother-infant pairs consisting of full-term singleton infants weighing at least 2500 g and their healthy mothers who intended to breastfeed, 16491 (96.7%) of which completed the entire 12 months of follow-up.

INTERVENTIONS

Sites were randomly assigned to receive an experimental intervention (n = 16) modeled on the Baby-Friendly Hospital Initiative of the World Health Organization and United Nations Children's Fund, which emphasizes health care worker assistance with initiating and maintaining breastfeeding and lactation and postnatal breastfeeding support, or a control intervention (n = 15) of continuing usual infant feeding practices and policies.

MAIN OUTCOME MEASURES

Duration of any breastfeeding, prevalence of predominant and exclusive breastfeeding at 3 and 6 months of life and occurrence of 1 or more episodes of gastrointestinal tract infection, 2 or more episodes of respiratory tract infection, and atopic eczema during the first 12 months of life, compared between the intervention and control groups.

RESULTS

Infants from the intervention sites were significantly more likely than control infants to be breastfed to any degree at 12 months (19.7% vs 11.4%; adjusted odds ratio [OR], 0.47; 95% confidence interval [CI], 0.32-0.69), were more likely to be exclusively breastfed at 3 months (43.3% vs 6.4%; P<.001) and at 6 months (7.9% vs 0.6%; P =.01), and had a significant reduction in the risk of 1 or more gastrointestinal tract infections (9.1% vs 13.2%; adjusted OR, 0.60; 95% CI, 0.40-0.91) and of atopic eczema (3.3% vs 6.3%; adjusted OR, 0.54; 95% CI, 0.31-0.95), but no significant reduction in respiratory tract infection (intervention group, 39.2%; control group, 39.4%; adjusted OR, 0.87; 95% CI, 0.59-1.28).

CONCLUSIONS

Our experimental intervention increased the duration and degree (exclusivity) of breastfeeding and decreased the risk of gastrointestinal tract infection and atopic eczema in the first year of life. These results provide a solid scientific underpinning for future interventions to promote breastfeeding.

432 Somali women's birth experiences in Canada after earlier female genital mutilation

BACKGROUND

Women with previous female genital mutilation (sometimes referred to as circumcision) are migrating, with increasing frequency, to countries where this practice is uncommon. Many health care professionals in these countries lack experience in assisting women with female genital mutilation during pregnancy and birth, and they are usually untrained in this aspect of care. Somali women who customarily practice the most extensive form of female mutilation, who were resident in Ontario and had recently given birth to a baby in Canada, were surveyed to explore their perceptions of perinatal care and their earlier genital mutilation experiences.

METHOD

Interviews of 432 Somali women with previous female genital mutilation, who had given birth to a baby in Canada in the past five years, were conducted at their homes by a Somali woman interviewer.

RESULTS

Findings suggested that women's needs are not always adequately met during their pregnancy and birth care. Women reported unhappiness with both clinical practice and quality of care.

CONCLUSIONS

Changes in clinical obstetric practice are necessary to incorporate women's perceptions and needs, to use fewer interventions, and to demonstrate greater sensitivity for cross-cultural practices and more respectful treatment than is currently available in the present system of care.

What women say about antenatal care in St Petersburg, Russian Federation

A capacity building program for professionals in maternal and child health care in St Petersburg, Russian Federation, commenced in 1994. The program was designed to provide 12 workshops in evidence-based antenatal and intrapartum care, as well as appropriate preparation of parents for pregnancy, birth and parenthood, for health care professionals in the city. As part of this program women's observations on the quality of their maternity care services during their transition to parenthood were explored. These reports reflect maternity care practices in the former Soviet Union.

Using the ALPHA form in practice to assess antenatal psychosocial health. Antenatal Psychosocial Health Assessment

BACKGROUND

The assessment of the psychosocial health of pregnant women and their families, although recommended, is not carried out by most practitioners. One reason is the lack of a practical and evidence-based tool. In response, a multidisciplinary group created the Antenatal Psychosocial Health Assessment (ALPHA) form. This article describes the development of this tool and experience with it in an initial field trial.

METHODS

A systematic literature review revealed 15 antenatal psychosocial risk factors associated with poor postpartum family outcomes of woman abuse, child abuse, postpartum depression, marital/couple dysfunction and increased physical illness. The ALPHA form, incorporating these risk factors, was developed and refined through several focus groups. It was then used by 5 obstetricians, 10 family physicians, 7 midwives and 4 antenatal clinic nurses in various urban, rural and culturally diverse locations across Ontario. After 3 months, these health care providers met in focus groups to discuss their experiences. A sample of pregnant women assessed using the ALPHA form were interviewed about their experience as well. Results were analysed according to qualitative methods.

RESULTS

The final version of the ALPHA form grouped the 15 risk factors into 4 categories--family factors, maternal factors, substance abuse and family violence--with suggested questions for each area of enquiry. The health care providers uniformly reported that the form helped them to uncover new and often surprising information, even when the women were well known to them. Incorporating the form into practice was usually accomplished after a period of familiarization. Most of the providers said the form was useful and would continue to use it if it became part of standard care. The pregnant women in the sample said they valued the enquiry and felt comfortable with the process, unless there were large cultural barriers.

INTERPRETATION

The ALPHA form appears to be an important tool in assessing psychosocial health in pregnancy and to be readily integrated into practice. More study is required to quantify the number of risks identified and resources used, to determine the form's reliability and validity and, ultimately, to assess the effect of its use on postpartum outcomes.

[Dietary intake of different forms of iron and other factors of anemia epidemiology in women of childbearing age in S. Petersburg]

Actual nutritional status and dietary intake of different iron forms of the women in Sankt-Peterburg were investigated. The concentration of blood hemoglobin was studied. Signs of deficiency of nutrition of the investigated women were not found both by analysis of foodstuffs and energy intake and by anthropometric estimation of nutritional status.

Women's experiences of birth in St. Petersburg, Russian Federation, following a maternal and child health intervention program

BACKGROUND

An educational program for professionals in maternal and child health care in St. Petersburg, Russian Federation, was conducted between 1994 and 1997.

METHODS

The program was designed to provide 12 workshops in evidence-based antenatal and intrapartum care, and appropriate preparation of parents for pregnancy, birth, and parenthood for health care professionals in the city.

RESULTS

Observations on the quality of maternity care service provided for women at the start and after the completion of the intervention program are reported. Significant changes occurred in maternity care practices during the period in which training programs were offered in St. Petersburg. In particular, more family centered care services were introduced, and breastfeeding practices improved. Significant reductions in maternal and perinatal mortality occurred.

CONCLUSIONS

Most maternity hospitals showed a reduction in the use of interventions in delivery over the period of study, although one or two showed tendencies to follow in their Western counterparts' footsteps, including the emergence of a high cesarean delivery rate. This is not yet a cause for concern, but is worth future monitoring by local authorities.

Psychosomatic obstetrics and gynecology in the next millennium: some thoughts and observations

While the importance of psychosocial and cultural issues inobstetric care has been increasingly acknowledged in recent decades there is still neglect and misunderstanding of what women want during pregnancy, birth and the postpartum period with regard to their care by health care providers. This paper highlights significant issues of concern which should be of value for caregivers, educators and health service planners as we move into the next millenium.

Reducing maternal mortality in St Petersburg

Following the entry of St Petersburg into Europe's Healthy Cities Project in 1991 it was decided that the highest priority should be given to reducing the city's maternal mortality ratio, then standing at approximately 70 deaths per 100,000 live births. Preventing deaths from unsafe, illegal abortion became the main focus of attention. The use of modern contraceptive methods was promoted, information was disseminated to improve the utilization of family planning services, special outreach services for teenagers were established, and providers were given opportunities for education and training. The maternal mortality ratio and the abortion rate have now declined and contraceptive use appears to be increasing. These achievements are attributable in large measure to the commitment of a broad spectrum of St Petersburg society as well as to outside support.

Childbirth in eastern Europe

Women's experiences of pregnancy and childbirth in the countries of central and eastern Europe are explored in this paper. A capacity building intervention programme in St Petersburg, Russia, which attempts to reform practices within the city, is described. The difficulties inherent in integrating differing cultural approaches to childbirth are highlighted.

What men say about pregnancy, birth and parenthood

Fathers' experiences during their transition to parenthood have been less well documented than those of mothers. This study explored the perceptions of three groups of fathers: fathers were asked to complete a questionnaire covering their experiences during their partner's pregnancy, during antenatal preparation programs or during birth. Fathers in all three groups were asked to respond to a follow-up questionnaire about parenthood. Their views are reported.

Companionship in labour: do the personality characteristics of labour supporters influence their effectiveness

Recent research has revealed beneficial post-partum, psychosocial effects on the mother following labour which was accompanied by supportive companions. Whether these effects are obtained as a result of having companionship during labour or because of specific personality characteristics of the companions provided is important and is explored in this paper. Although findings revealed few differences in adjustment between women who were supported by different companions, some variability in the postpartum state anxiety and depression scores were noted which suggest that selection of an appropriate supporter is an important aspect of such programmes.

Psychosomatic obstetrics in the countries of central and Eastern Europe

Womens' experiences of pregnancy and birth in the countries of Central and Eastern Europe are explored in this paper. Most of these countries are in transition from a totalitarian system of government to that of democracy. The implications of this re-orientation are many. Not least of all are the changes taking place in health care systems in general, as well as in maternal-child health care in particular. This paper reviews the current state of some perinatal care systems in these countries. It is not a research paper: it reflects observations and recommendations arising from humanitarian aid service in these countries and from available literature.

What women say about their birth experiences: a cross-cultural study

The reactions of 221 women to their place of delivery (state or private hospital), type of delivery (vaginal or Caesarean) and associated obstetrical interventions were explored by means of a structured interview conducted at 3 months postpartum. Women were randomly selected from the birth records of three cultural groups residing in the municiple area of Johannesburg, South Africa: White (n = 72), Indian (n = 79) and Mixed cultural origin (n = 78). The type of birth experienced by women differed in the cultural groups examined. While most women experienced positive emotional reactions to birth many also expressed a variety of negative reactions. The differences in care experienced by women in the present study reflect the impact of the two systems of care, private and state, that are available to women in South Africa.

Companionship in the perinatal period. A cross-cultural survey of women's experiences

Recent research indicates that the nature of the companionship available for women during their transition to parenthood is important for psychological adjustment. The specific nature of the best provider and form of support is not yet well defined. Cross-cultural differences in women's preferences for supportive companions in the perinatal period occur. The present study explores what companionship is currently offered and by whom, and women's reactions to this in three different cultural groups.

Postpartum depression and companionship in the clinical birth environment: a randomized, controlled study

OBJECTIVE

Postpartum depression is a common feature of childbearing and is the cause of considerable morbidity. We have explored the possibility that clinically oriented care during labor may contribute to its occurrence.

STUDY DESIGN

Of 189 nulliparous women laboring in a familiar community hospital, 92 were allocated by randomized, sealed envelopes to receive additional companionship from one of three volunteer labor companions recruited from the community.

RESULTS

The group receiving support attained higher self-esteem scores and lower postpartum depression and anxiety ratings 6 weeks after delivery.

CONCLUSION

In the clinical labor environment companionship modifies factors that contribute to the development of postnatal depression. We emphasize the importance of paying attention to the psychosocial environment in which labor takes place, to facilitate adaptation to parenthood.

Adherence to traditional Indian customs surrounding birth

Customs traditionally followed by Indian women during pregnancy, birth and early parenthood have been documented. An exploratory investigation of the extent to which some of these traditional beliefs, customs and practices are currently adhered to was undertaken by interviewing Indian mothers living in Johannesburg and its environs about 3 months after delivery. Results indicate that while some traditional customs are still adhered to by most Indian women, others are not so strictly followed. Since most customs relate to activities conducted at home rather than while in hospital for delivery, medical care would not be expected to influence their practice.

Annotation: care of children in hospital. The European Association for Children in Hospitals

The Charter for Children in Hospitals, drawn up by professional and women's groups from a number of European countries at the First Conference for the Care of Children in Hospital (Netherlands 1988) presents many fine guidelines for protecting the rights of children and their parents before, during and after hospitalization. The development of these guidelines, their current acceptance in Europe and the psychological principles underlying them, are outlined here.

Traditional Indian customs surrounding birth. A review

Since 1960, only a few studies have been made of traditional customs surrounding birth in Indian culture. Very few of these have described customs followed by Indians in South Africa. A review of these publications is presented here. Customs described include religious, social and psychological aspects of behaviour in relation to conception, pregnancy, birth and the early months of parenthood.

Social support in labor--a selective review

Support during labor has been offered by a variety of different people, including fathers, professional medical staff, trained labor coaches and monitrices, untrained lay supporters and family and friends. A comparison of the various findings shows that support given by trained or lay untrained female supporters, who are not necessarily known to the laboring woman, yields the most extensive, methodologically sound, and consistently positive effects on obstetric and psychosocial outcomes. Although trained labor coaches have been shown to exert a positive effect on outcome, the results of doula support are the most impressive when both methodology and outcome effects are considered. Studies of father support have yielded contradictory findings, although women do appear to value their presence in most studies. Family and friends have not been shown to influence outcomes. Support from professional medical staff is rare, but when given, has, in some cases, had a positive effect. These findings are important for the field, since the use of lay supporters constitutes a low-cost preventive intervention. The inclusion of lay supportive women is also consistent with traditional practices in most countries in the world.

Views of obstetricians and hysiotherapists on ante-natal preparation for childbirth

Obstetricians’ and physiotherapists' views of ante-natal childbirth preparation classes were examined by means of a postal questionnaire. Responses of 108 obstetricians and 57 physiotherapists revealed some marked differences in perceptions of childbirth classes offered by physiotherapists. In general physiotherapists' views were most favourable while obstetricians views were less so. Differences between physiotherapists’ and obstetricians’ views regarding the relevance of, and emphasis placed on, topics in childbirth preparation courses were also revealed. Data must, however, be viewed with caution due to the low response rate obtained.

Views of obstetricians and hysiotherapists on ante-natal preparation for childbirth

Obstetricians’ and physiotherapists' views of ante-natal childbirth preparation classes were examined by means of a postal questionnaire. Responses of 108 obstetricians and 57 physiotherapists revealed some marked differences in perceptions of childbirth classes offered by physiotherapists. In general physiotherapists' views were most favourable while obstetricians views were less so. Differences between physiotherapists’ and obstetricians’ views regarding the relevance of, and emphasis placed on, topics in childbirth preparation courses were also revealed. Data must, however, be viewed with caution due to the low response rate obtained.

Working while breast feeding among coloured women

The influence of a wide variety of factors on infants' feeding patterns has frequently been reported. Of growing interest is the role played by economic issues in determining the duration of breast feeding. The present study describes the attitudes toward, beliefs about, and practices in relation to working while breast feeding amongst 220 'Coloured' (of mixed ethnic origin) women. Breast feeding rates are initially high but drop rapidly about the time mothers return to work. Approximately two-thirds of the women studied returned to work in the post partum period. Most report that breast feeding and working are incompatible.