Optogenetic manipulation of BMP signaling to drive chondrogenic differentiation of hPSCs

Optogenetics is a rapidly advancing technology combining photochemical, optical, and synthetic biology to control cellular behavior. Together, sensitive light-responsive optogenetic tools and human pluripotent stem cell differentiation models have the potential to fine-tune differentiation and unpick the processes by which cell specification and tissue patterning are controlled by morphogens. We used an optogenetic bone morphogenetic protein (BMP) signaling system (optoBMP) to drive chondrogenic differentiation of human embryonic stem cells (hESCs). We engineered light-sensitive hESCs through CRISPR-Cas9-mediated integration of the optoBMP system into the AAVS1 locus. The activation of optoBMP with blue light, in lieu of BMP growth factors, resulted in the activation of BMP signaling mechanisms and upregulation of a chondrogenic phenotype, with significant transcriptional differences compared to cells in the dark. Furthermore, cells differentiated with light could form chondrogenic pellets consisting of a hyaline-like cartilaginous matrix. Our findings indicate the applicability of optogenetics for understanding human development and tissue engineering.

Successful AV Fistula Creation does not Lead to Higher Catheter Use: The Experience by the Northwest Renal Network 16 Vascular access Quality Improvement Program. Four Years follow-up

Background

In 2002, the Center for Medicare and Medicaid Services (CMS) required all 18 Renal Networks to participate in a Vascular Access Quality Improvement Program (QIP). The Northwest Renal Network (NWRN 16) chose to increase arteriovenous fistula (AVF) use. NWRN 16 hypothesized that strategies which targeted the improvement of AVF rate and the reduction of catheter use were the same. In December 2001, 44.2% of hemodialysis (HD) patients in the NWRN 16 received HD using an AVF which met the Dialysis Outcome Quality Initiative (K/DOQI) 40% AVF guideline for prevalent patients. However, 43% of HD facilities (2869 patients) had less than 40% of AVF and higher HD catheter rates than the average Network catheter rates (25.0 vs. 20.3%). To address the needs of underperforming facilities, NWRN 16 provided education and tools for their vascular access decision makers to promote AVF creation and catheter reduction.

Methods

In 2002, NWRN 16 sponsored four regional workshops targeted at nephrologists, vascular surgeons, HD nurses, and interventional radiologists.

Results

Percentage of AVFs in use in invited facilities increased from 31.3% pre-intervention to 56.2% at 4 yrs: 78% increase (99% confidence interval: 77.8% to 81.5%). Percentage of catheters increased from 25% to 25.8%: 3.2% change over 4 yrs (99% confidence interval: 2.5% to 4%).

Conclusion

The success of Network 16's AVF interventions demonstrates the effectiveness of Network education promoting multidisciplinary teamwork, and innovative strategies to increase dramatically AVF use without substantial increase in catheter use.

Successful Multidisciplinary Interventions for Arterio-Venous Fistula Creation by the Pacific Northwest Renal Network 16 Vascular access Quality Improvement Program

Background

In December 2001, 44.2% of hemodialysis (HD) patients in the Northwest Renal Network (NWRN 16) received dialysis using an arteriovenous fistula (AVF). Substantial differences were noted in percentages of patients with AVF, ranging from 5% to 90% of the facility population, suggesting wide variation in physician practice patterns within the Network. To address the needs of facilities having <40% AVF, NWRN 16 provided education and tools for their vascular access decision-makers to promote AVF creation.

Methods

In 2002, the Network sponsored 4 regional workshops targeted to nephrologists, vascular surgeons, dialysis nurses, and interventional radiologists.

Results

46 facilities (43% of all Network facilities) had <40% AVF in use in December, 2001, dialyzing 2940 patients (Invited Units). Percent AVF in use in all the Invited Facilities increased from 31.3% pre-intervention to 39.8% at 1 year (p<0.001 vs pre) to 56.2% at four years: 79.8% increase in the prevalent AVF rate over a four-year period (95% confidence interval: 77.8% to 81.7%).

Conclusion

Low prevalent AVF rates in many NWRN 16 facilities may have resulted from differences in physician practice patterns. The success of Network 16 AVF Intervention demonstrates the effectiveness of Network education promoting multidisciplinary teamwork, innovative strategies to increase AVF rates among dialysis patients.

Development and performance of electronic acute kidney injury triggers to identify pediatric patients at risk for nephrotoxic medication-associated harm

BACKGROUND

Nephrotoxic medication-associated acute kidney injury (NTMx-AKI) is a costly clinical phenomenon and more common than previously recognized. Prior efforts to use technology to identify AKI have focused on detection after renal injury has occurred.

OBJECTIVES

Describe an approach and provide a technical framework for the creation of risk-stratifying AKI triggers and the development of an application to manage the AKI trigger data. Report the performance characteristics of those triggers and the refinement process and on the challenges of implementation.

METHODS

Initial manual trigger screening guided design of an automated electronic trigger report. A web-based application was designed to alleviate inefficiency and serve as a user interface and central workspace for the project. Performance of the NTMx exposure trigger reports from September 2011 to September 2013 were evaluated using sensitivity (SN), specificity (SP), positive and negative predictive values (PPV, NPV).

RESULTS

Automated reports were created to replace manual screening for NTMx-AKI. The initial performance of the NTMx exposure triggers for SN, SP, PPV, and NPV all were ≥0.78, and increased over the study, with all four measures reaching ≥0.95 consistently. A web-based application was implemented that simplifies data entry and couriering from the reports, expedites results viewing, and interfaces with an automated data visualization tool. Sociotechnical challenges were logged and reported.

CONCLUSION

We have built a risk-stratifying system based on electronic triggers that detects patients at-risk for NTMx-AKI before injury occurs. The performance of the NTMx-exposed reports has neared 100% through iterative optimization. The complexity of the trigger logic and clinical workflows surrounding NTMx-AKI led to a challenging implementation, but one that has been successful from technical, clinical, and quality improvement standpoints. This report summarizes the construction of a trigger-based application, the performance of the triggers, and the challenges uncovered during the design, build, and implementation of the system.

Can mobile technology improve response times of junior doctors to urgent out-of-hours calls? A prospective observational study

BACKGROUND

The Hospital at Night system has been widely adopted to manage Out-of-Hours workload. However, it has the potential to introduce delays and corruption of information. The introduction of newer technologies to replace landlines, pagers and paper may ameliorate these issues.

AIM

To establish if the introduction of a Hospital at Night system supported by a wireless taskflow system affected the escalation of high Early Warning Scores (EWSs) to medical attention, and the time taken to medical review.

DESIGN

Prospective 'pre and post' observational study in a teaching hospital in the UK.

METHODS

Review of observation charts and medical records, and data extraction from the electronic taskflow system.

RESULTS

The implementation of a technology-supported Hospital at Night system was associated with a significant decrease in time to documentation of initial review in those who were reviewed. However, there was no change in the proportion of those with a high EWS that were reviewed, and throughout the study a majority of patients with high EWSs were not reviewed in accordance with guidelines.

CONCLUSION

Introduction of a Hospital at Night system supported by mobile technology appeared to improve the transfer of information, but did not affect the nursing decision whether to escalate abnormal findings.

First Report of Cylindrocladiella parva as a Grapevine Pathogen in New Zealand

Isolates morphologically identified as Cylindrocladiella parva were isolated from characteristic black foot symptoms on a grapevine (Vitis vinifera) rooted on 101-14 rootstock from Central Otago in 2005 and 101-14 rootstocks from a nursery in the Auckland Region in 2007 and 2008. On potato dextrose agar, the isolates initially produced cottony, white mycelia that turned grayish cream or golden cream within 10 days, the initially tawny colony undersides becoming dark brown with age. Conidia (0 to 1 septate; 16.4 to 17.0 [16.7] × 2.3 to 2.6 [2.5] μm) and abundant chlamydospores were produced. To confirm identity of the isolates, genomic DNA was extracted and the ribosomal DNA (rDNA) and β-tubulin gene were amplified and sequenced (3,4). Sequences of the PCR products were compared with sequences in GenBank. The rDNA (535 bp) and β-tubulin (297 bp) sequences of the four isolates were 100 and 99% identical, respectively, to reported sequences of C. parva in GenBank (AY793454, grapevine isolate (4)/AY793455 for rDNA; AY793486/AY793488, grapevine isolate (4)/AY793489/HM034822 for β-tubulin). Although C. parva was previously isolated from grapevines in New Zealand (2) and rootstocks of mature grapevines, cuttings, and graft unions of grafted young grapevines in South Africa (4), its role as a pathogen of Vitis spp. has not been confirmed (2,4). However, it has been reported as a pathogen of Eucalyptus spp. (1) and was also isolated from Telopea speciosissima and Macadamia integrifolia in New Zealand (2,4). The C. parva isolates were tested as a mixed inoculum (four isolates) for pathogenicity on roots of 10 grapevine rootstock plants each of cvs. 101-14 and Schwarzmann (Sch). The rootstocks were grown in potting mix for 4 months, after which the root systems of all vines were wounded with an asparagus knife with a sharp, square tip, driven vertically down into the soil at four equidistant locations approximately 8 cm from the trunk. Each plant was inoculated with 50 ml of the mixed-isolate conidial suspension (10⁶/ml), or 50 ml water (controls), followed by 50 ml of water. After 7 months of growth, the plants were harvested. For C. parva-inoculated plants, internal blackening of the stem base tissue was observed. Isolations from surface-sterilized trunk bases recovered C. parva from four and nine plants of 101-14 and Sch, respectively, with C. parva infections in 25 and 48%, respectively, of the four wood pieces taken per plant. Plants inoculated with water had no blackening and no C. parva was isolated from their stem bases. Mean shoot dry weights of inoculated plants (17.9 and 15.0 g for 101-14 and Sch, respectively) were significantly lower (P = 0.035) than noninoculated controls (26.5 and 20.0 g for 101-14 and Sch, respectively). Mean root dry weights were reduced by C. parva inoculation, although not significantly (32.7 and 27.0 g for C. parva inoculated 101-14 and Sch, respectively, and 36.2 and 27.4 g for control 101-14 and Sch, respectively). To our knowledge, this is the first report of C. parva as a pathogen of grapevines (2,4) and suggests that along with Cylindrocarpon spp., C. parva is part of the pathogen complex responsible for black foot of grapevines. References: (1) P. W. Crous et al. Plant Pathol. 42:302, 1993. (2) P. D. Gadgil et al. Fungi on Trees and Shrubs in New Zealand. Fungal Diversity Press, Hong Kong, 2005. (3) N. L. Glass and G. C. Donaldson. Appl. Environ. Microbiol. 61:1323, 1995. (4) G. J. van Coller et al. Australas. Plant Pathol. 34:489, 2005.

Successful AV fistula creation does not lead to higher catheter use: the experience by the Northwest Renal Network 16 Vascular Access Quality Improvement Program. Four years follow-up

BACKGROUND

In 2002, the Center for Medicare and Medicaid Services (CMS) required all 18 Renal Networks to participate in a Vascular Access Quality Improvement Program (QIP). The Northwest Renal Network (NWRN 16) chose to increase arteriovenous fistula (AVF) use. NWRN 16 hypothesized that strategies which targeted the improvement of AVF rate and the reduction of catheter use were the same. In December 2001, 44.2% of hemodialysis (HD) patients in the NWRN 16 received HD using an AVF which met the Dialysis Outcome Quality Initiative (K/DOQI) 40% AVF guideline for prevalent patients. However, 43% of HD facilities (2869 patients) had less than 40% of AVF and higher HD catheter rates than the average Network catheter rates (25.0 vs. 20.3%). To address the needs of underperforming facilities, NWRN 16 provided education and tools for their vascular access decision makers to promote AVF creation and catheter reduction.

METHODS

In 2002, NWRN 16 sponsored four regional workshops targeted at nephrologists, vascular surgeons, HD nurses, and interventional radiologists.

RESULTS

Percentage of AVFs in use in invited facilities increased from 31.3% pre-intervention to 56.2% at 4 yrs: 78% increase (99% confidence interval: 77.8% to 81.5%). Percentage of catheters increased from 25% to 25.8%: 3.2% change over 4 yrs (99% confidence interval: 2.5% to 4%).

CONCLUSION

The success of Network 16's AVF interventions demonstrates the effectiveness of Network education promoting multidisciplinary teamwork, and innovative strategies to increase dramatically AVF use without substantial increase in catheter use.

Bilirubin as an antioxidant in micelles and lipid bilayers: its contribution to the total antioxidant capacity of human blood plasma

The antioxidant capacities, antioxidant activities, k(inh), and stoichiometric factors, n, of water-soluble derivatives of bilirubin (BR), BR-human serum albumin (BR-HSA), and BR-ditaurate disodium conjugate (BRC) were determined in aqueous/lipid dispersions of sodium dodecyl sulfate (SDS) micelles/methyl linoleate and in bilayers of dilinoleoylphosphatidylcholine (DLPC) during initiation by water-soluble azo-bis-amidinopropane dihydrochloride (ABAP). The inhibition rate constants for BRC and BR-HSA were similar in micelles (k(inh) approximately 1.3 x 10(4) M(-1) s(-1)), where n approximately 2, whereas the k(inh) for BR-HSA dropped by (1/2) in bilayers. The dimethyl ester of bilirubin (BRDE) gave a k(inh) only one-tenth that of the vitamin E analog, pentamethylhydroxychroman (PMHC) in SDS micelles/methyl linoleate when initiated by lipid-soluble azo-bis-2,4-dimethylvaleronitrile (DMVN). Biliverdin hydrochloride (BVHCl) was NOT an effective peroxyl radical-trapping agent in the micellar phase during initiation by ABAP or DMVN containing methyl linoleate but it inhibited oxygen uptake in the aqueous phase. Both BRC and BR-HSA extended the total radical antioxidant parameter (TRAP) of human blood plasma and their contribution to TRAP was in the range of 5-10% of the natural TRAP of blood plasma, depending on the BR content determined in the blood plasma.

Successful multidisciplinary interventions for arterio-venous fistula creation by the Pacific Northwest Renal Network 16 vascular access quality improvement program

BACKGROUND

In December 2001, 44.2% of hemodialysis (HD) patients in the Northwest Renal Network (NWRN 16) received dialysis using an arteriovenous fistula (AVF). Substantial differences were noted in percentages of patients with AVF, ranging from 5% to 90% of the facility population, suggesting wide variation in physician practice patterns within the Network. To address the needs of facilities having < 40% AVF, NWRN 16 provided education and tools for their vascular access decision-makers to promote AVF creation.

METHODS

In 2002, the Network sponsored 4 regional workshops targeted to nephrologists, vascular surgeons, dialysis nurses, and interventional radiologists.

RESULTS

46 facilities (43% of all Network facilities) had <40% AVF in use in December, 2001, dialyzing 2940 patients (Invited Units). Percent AVF in use in all the Invited Facilities increased from 31.3% pre-intervention to 39.8% at 1 year (p<0.001 vs pre) to 56.2% at four years: 79.8% increase in the prevalent AVF rate over a four-year period (95% confidence interval: 77.8% to 81.7%).

CONCLUSION

Low prevalent AVF rates in many NWRN 16 facilities may have resulted from differences in physician practice patterns. The success of Network 16 AVF Intervention demonstrates the effectiveness of Network education promoting multidisciplinary teamwork, innovative strategies to increase AVF rates among dialysis patients.

Hydraulic conductance and rootstock effects in grafted vines of kiwifruit

Whole-plant hydraulic conductance, shoot growth, and leaf photosynthetic properties were measured on kiwifruit vines with four clonal rootstocks to examine the relationship between plant hydraulic conductance and leaf stomatal conductance (gs) and to test the hypothesis that reduced hydraulic conductance can provide an explanation for reductions in plant vigour caused by rootstocks. The rootstocks were selected from four species of Actinidia and grafted with Actinidia chinensis var. chinensis 'Hort16A' (yellow kiwifruit) as the scion. Total leaf area of the scion on the least vigorous Actinidia rootstock, A. kolomikta, was 25% of the most vigorous, A. hemsleyana. Based on shoot growth and leaf area, the selections of A. kolomikta and A. polygama are low-vigour rootstocks, and A. macrosperma and A. hemsleyana are high-vigour rootstocks for A. chinensis. Whole-plant hydraulic conductance, the ratio of xylem sap flux to xylem water potential, was lower in the low-vigour rootstocks, reflecting their smaller size. However, leaf-area-specific conductance (Kl) and gs were both higher in the low-vigour rootstocks, the opposite of the expected pattern. Differences in Kl were found in the compartment from the roots to the scion stem, with no difference between rootstocks in the conductance of stems or leaves of the scion. There was no evidence that the graft union caused a significant reduction in hydraulic conductance of vines with low-vigour rootstocks. Leaf photosynthetic capacity did not vary between rootstocks, but photosynthesis and carbon isotope discrimination (Delta13C) under ambient conditions were higher in the low-vigour rootstocks because gs was higher. gs and Delta13C were positively correlated with Kl, although the mechanism for this relationship was not based on stomatal regulation of a similar xylem water potential because water potential varied between rootstocks. For Actinidia rootstocks, changes in Kl do not provide a direct explanation for changes in vigour of the scion. However, depending on the rootstock in question, changes in hydraulic conductance, biomass partitioning, and crown structure are involved in the response.

Dissociation of osmoregulation from plasma arginine vasopressin levels following thermal injury in childhood

Although the syndrome of inappropriate anti-diuretic hormone secretion has been recognised as a complication associated with burn and other trauma in adults, relatively little is known about its incidence in children. The objective of this study was to investigate whether it is a complication associated with burn injury in children. Plasma and urine levels of arginine vasopressin (anti-diuretic hormone), sodium and osmolality were measured in samples collected from 16 burn-injured children admitted to the burns unit of the regional children's hospital. No significant correlations were found between plasma vasopressin and plasma sodium or osmolality levels, but there were significant correlations between plasma vasopressin and urine osmolality, 36 (r=0.74, p=0. 009), 60 (r=0.92, p=0.000) and 84 h (r=0.84, p=0.001) after admission, respectively. There were also significant correlations between plasma sodium and plasma osmolality, 24 (r=0.7, p=0.005), 36 (r=0.57, p=0.04) and 84 h (r=0.84, p=0.004) after admission. The data suggest dissociation between the osmolar control of vasopressin secretion and vasopressin levels after burn injury in children, but do not support the incidence of inappropriate secretion of antidiuretic hormone.

Systemic hormonal, electrolyte, and substrate changes after non-thermal limb injury in children

Relatively little is known regarding the hormonal changes after injury in children. Adult protocols are often applied to children, although the latter often have different physiological responses to trauma. Twenty children with an angulated displaced fracture of the radius and/or ulna (injury severity score 9) were studied prospectively for changes in adrenaline, noradrenaline, cortisol, angiotensin II, arginine vasopressin, urea, electrolytes, and glucose. Two blood samples were taken: one an arrival at the accident and emergency department and one preoperatively several hours later. There were marked increases in adrenaline, noradrenaline, cortisol, and arginine vasopressin above the normal range. Five (25%) cases demonstrated greater early increases in adrenaline than those reported for adult injuries of similar severity. Early hypokalaemia in four cases had corrected towards normal within a few hours, without potassium supplementation.

The systemic stress response to thermal injury in children

OBJECTIVE

Thermal injury is extremely stressful, but data characterizing the endocrine stress response to this injury in children are sparse. The objective of this study was to measure the effects of thermal injury on the levels of stress hormones in children and to assess the temporal changes associated with them.

PATIENTS

Twenty-three children, 13 girls and 10 boys aged between 5 months and 12 years 3 months (mean, 2 years 11 months), with burns covering 10-61% of their body surface (mean, 20.5%) were studied during the first 5 days following injury.

MEASUREMENTS

The levels of arginine vasopressin, angiotensin II, cortisol, adrenaline, noradrenaline and dopamine were measured in sequential blood samples obtained from thermally injured children on admission and at specified time intervals during the 5 days of the investigation.

RESULTS

At admission the concentrations of all the hormones were high, and varied widely between individual patients. The geometric mean and 95% confidence intervals of admission hormone levels were as follows: arginine vasopressin 18.3 (8.3-40.7) pmol/l; angiotensin II 122.0 (56.0-266.2) pmol/l; cortisol 650.6 (473.0-895.0) nmol/l; dopamine 1.0 (0.1-8.0) nmol/l; adrenaline 6.4 (3.2-12.5) nmol/l and noradrenaline 2.3 (1.3-4.3) nmol/l. Although the concentrations of arginine vasopressin and cortisol returned to normal 24 to 36 h after admission, the levels of angiotensin II, adrenaline and dopamine fluctuated and remained higher than normal throughout the study (108 h).

CONCLUSIONS

Thermal injury results in the release of abnormally high levels of stress hormones in children. Although there are similarities between some of the data reported here and those reported in adults, higher levels of adrenaline and lower levels of noradrenaline than reported in adults suggest important differences too. These differences may need to be taken into account in the management of burn-injured children.

The bigger the burn, the greater the stress

Data characterizing the endocrine stress response to burn injury in children are sparse. We have measured the levels of the stress hormones arginine vasopressin, catecholamines-adrenaline, noradrenaline and dopamine-atrial natriuretic peptide and hormones of the renin-angiotensin-aldosterone system in admission blood samples taken from 35 children admitted to the burns unit of the regional children's hospital. Hormone levels were compared with the size of burn injury. With the exception of adrenaline, there were significant positive correlations between vasopressin (r = 0.707, p < 0.0001), plasma renin activity (r = 0.721, P < 0.0001), angiotensin II (r = 0.512, P = 0.002), aldosterone (r = 0.620, P < 0.0001), noradrenaline (r = 0.430, P = 0.0189), dopamine (r = 0.627, P = 0.0024) and percentage burn surface area, and a negative correlation between atrial natriuretic peptide (r = 0.548, P = 0.0008) and burn surface area. It is concluded that the hormones which react to stress are very sensitive to burn injury in children, and that the magnitude of their response is closely related to the size of the burn surface area.

Root resorption. 2: Internal root resorption

Internal root resorption is classically described as resulting from long standing chronic inflammation in the pulp. The resorption may be transient, where lacunae present within the canal walls, or progressive, where the odontoblasts are destroyed and no predentine can be laid down. The diagnosis of this process and its subsequent treatment is described in this series of eight patients with internal root resorption.

[Analysis of urinary infection in the 1st month after kidney transplantation. Value of short prophylaxis with norfloxacin]

Urinary tract infection is the most common complication in the first month after renal transplant, and it is associated with rejection and relapses. In addition, it is the leading cause of gram negative bacilli bacteremia. In a program of continuous epidemiological surveillance from March 1979 to October 1988, we evaluated the urinary tract infections in the first month after renal transplant, considering the following variables: duration of bladder catheterization, urologic complications, type of immunosuppression and preoperative and postoperative antibiotic prophylaxis. There were no differences between the development of urinary tract infections in relation with the duration of bladder catheterization (7 vs 4 days), the reduction of urologic complications (21 vs 6%), or with the introduction of cyclosporin to the conventional immunosuppressive regimen. However, when the group of 46 patients receiving postoperative antibiotic prophylaxis (norfloxacin 800 mg/day every 12 h during the time of vesical catheterization less than or equal to 4 days) was compared with the 147 without postoperative antibiotic prophylaxis, the rate of urinary tract infection in the first month was 8.7% vs 32.8%, respectively (p less than 0.01). Short-term prophylaxis with norfloxacin was a useful regimen, with good oral tolerance and a similar therapeutic efficacy as the sustained regimens reported in the literature.

Survey of general practitioners' opinions on the role of radiology in patients with low back pain

Ninety general practitioners responded to a questionnaire about the role of radiology in patients with low back pain. Their clinical indications for requesting radiographs were mostly in agreement with the opinions of radiologists, but nearly 80% requested investigations for their own or patients' reassurance. Understanding of the terms used by radiologists was good, although 25% thought that acute disc prolapse could be demonstrated on plain films. Previous training in radiology did not seem to influence knowledge. When general practitioners understood radiological terms they had clear therapeutic and specialist referral preferences. Poorly understood terms and those with which they were familiar but unclear about the implications for management were also identified.

A multicentre randomized trial comparing delivery with a silicone rubber cup and rigid metal vacuum extractor cups

A total of 258 women requiring assisted delivery where vacuum extraction was thought to be suitable were randomly allocated to delivery with a new silicone rubber cup or metal vacuum extractor cups. There was a tendency for the silicone rubber cup to effect delivery more quickly and to cause less scalp trauma, but to fail to effect delivery on more occasions than metal cups. However, none of these differences was statistically significant. There were no statistically significant differences in the rates of birth canal trauma, maternal blood loss, or neonatal jaundice. The silicone rubber cup produced a cosmetically more acceptable chignon than the metal cups. The introduction of vacuum extractors with silicone rubber cups into obstetric units should be encouraged.

Closed suction wound drainage and lower-segment caesarean section

In a randomized controlled study of wound suction drainage after transverse suprapubic incision for lower-segment caesarean section no significant advantages could be demonstrated for routine drainage in terms of wound infection, haematoma formation, duration of hospital stay or analgesic requirements.