Improved adherence to hip fracture standards reduces mortality after hip fractures

BACKGROUND

Hip fractures are increasing in incidence due to increasing life expectancy. Mortality continues to improve but it is important to explore which factors are responsible for driving improvements.

METHODS

A cohort of hip fracture patients predating SARS-CoV-2 was examined to determine the predictors of adherence to the six Irish Hip Fracture Standards (IHFS) and the impact of adherence on short (30 day) and long term (1 year) mortality. Our primary aim was assess the impact of a single HFS and cumulative number of HFS on mortality after hip fracture. Our secondary aim was to determine the impact of the HFS which are intrinsically linked to specialist Geriatric care.

RESULTS

Across 962 patients, over 5 years, the factors which were associated with adherence to HFS were female gender, increasing ASA grade and being nursed on an orthopaedic ward. Patients with increasing ASA were more likely to have met HFS 4-6 (Geriatrician review HFS4, bone health HFS5 & specialist falls assessment HFS6), less likely to have surgery within 48 h are more likely to develop a pressure ulcer. If the patient was not nursed on an orthopaedic ward all HFS were less likely to be met. At 30 days HFS 4-6 were associated with a statistically significant odds ratio (OR) of being alive, while at one year HFS 1 (admitted to an orthopaedic ward within 4 h), 5 and 6 were associated with a statistically significant OR of being alive. As increasing numbers of hip fracture standards were met patients were more likely to be alive at 30 days and one year.

CONCLUSION

This study has identified that improved adherence to hip fracture standards are associated with improved mortality at 30 days and one year.

Systemic juvenile idiopathic arthritis: The Great Ormond Street Hospital experience (2005-2021)

Systemic juvenile idiopathic arthritis (sJIA) is a complex, systemic inflammatory disorder driven by both innate and adaptive immunity. Improved understanding of sJIA pathophysiology has led to recent therapeutic advances including a growing evidence base for the earlier use of IL-1 or IL-6 blockade as first-line treatment. We conducted a retrospective case notes review of patients diagnosed with sJIA over a 16-year period (October 2005-October 2021) at Great Ormond Street Hospital for Children. We describe the clinical presentation, therapeutic interventions, complications, and remission rates at different timepoints over the disease course. We examined our data, which spanned a period of changing therapeutic landscape, to try and identify potential therapeutic signals in patients who received biologic treatment early in the disease course compared to those who did not. A total of 76-children (female n = 40, 53%) were diagnosed with sJIA, median age 4.5 years (range 0.6-14.1); 36% (27/76) presented with suspected or confirmed macrophage activation syndrome. A biologic disease-modifying anti-rheumatic drug (bDMARD) alone was commenced as first-line treatment in 28% (n = 21/76) of the cohort; however, at last review, 84% (n = 64/76) had received treatment with a bDMARD. Clinically inactive disease (CID) was achieved by 88% (n = 67/76) of the cohort at last review; however, only 32% (24/76) achieved treatment-free CID. At 1-year follow-up, CID was achieved in a significantly greater proportion of children who received treatment with a bDMARD within 3 months of diagnosis compared to those who did not (90% vs. 53%, p = 0.002). Based on an ever-increasing evidence base for the earlier use of bDMARD in sJIA and our experience of the largest UK single-centre case series described to date, we now propose a new therapeutic pathway for children diagnosed with sJIA in the UK based on early use of bDMARDs. Reappraisal of the current National Health Service commissioning pathway for sJIA is now urgently required.

Health resource utilization of labor induction versus expectant management

BACKGROUND

Although induction of labor of low-risk nulliparous women at 39 weeks reduces the risk of cesarean delivery compared with expectant management, concern regarding more frequent use of labor induction remains, given that this intervention historically has been thought to incur greater resource utilization.

OBJECTIVE

The objective of the study was to determine whether planned elective labor induction at 39 weeks among low-risk nulliparous women, compared with expectant management, was associated with differences in health care resource utilization from the time of randomization through 8 weeks postpartum.

STUDY DESIGN

This is a planned secondary analysis of a multicenter randomized trial in which low-risk nulliparous women were assigned to induction of labor at 39 weeks or expectant management. We assessed resource utilization after randomization in 3 time periods: antepartum, delivery admission, and discharge through 8 weeks postpartum.

RESULTS

Of 6096 women with data available, those in the induction of labor group (n = 3059) were significantly less likely in the antepartum period after randomization to have at least 1 ambulatory visit for routine prenatal care (32.4% vs 68.4%), unanticipated care (0.5% vs 2.6%), or urgent care (16.2% vs 44.3%), or at least 1 antepartum hospitalization (0.8% vs 2.2%, P < .001 for all). They also had fewer tests (eg, sonograms, blood tests) and treatments (eg, antibiotics, intravenous hydration) prior to delivery. During the delivery admission, women in the induction of labor group spent a longer time in labor and delivery (median, 0.83 vs 0.57 days), but both women (P = .002) and their neonates (P < .001) had shorter postpartum stays. Women and neonates in both groups had similar frequencies of postpartum urgent care and hospital readmissions (P > .05 for all).

CONCLUSION

Women randomized to induction of labor had longer durations in labor and delivery but significantly fewer antepartum visits, tests, and treatments and shorter maternal and neonatal hospital durations after delivery. These results demonstrate that the health outcome advantages associated with induction of labor are gained without incurring uniformly greater health care resource use.

Evaluation of Variability of Instruments Used in Pork Loin Quality Assessments

ObjectivesIt has been historically proven that when measuring instrumental color, the magnitude of the color value will differ between instruments types, (i.e., HunterLab and Minolta). However, it is not known whether variability of readings within machine differs between machine type when measuring instrumental color or pH. It is also not known if pH or color values from one machine can be used to predict values from a second machine. The objectives were to (1) evaluate the effect of machine on the variability of instrumental color and pH measurements of boneless pork loins and (2) determine if color or pH measurements from one machine type can be used to predict measurements from a second machine type.Materials and MethodsTwo different sets (n1 = 253 and n2 = 294, respectively) of loins from a commercial processing facility were measured for instrumental color analysis. Loins were evaluated on the ventral face at the approximate location of the 10th rib at 22 h postmortem. Instrumental color was measured using a Minolta CR-400 Chroma meter equipped with a D65 illuminant, 2° observer, 8mm aperture, and calibrated with a white tile specific to the machine, but the first set were measured with an open aperture while the second used a closed aperture. The HunterLab was equipped with a 10° observer, 25 mm port and calibrated with a black and white tile specific to the machine for both sets. Ultimate pH was measured on three additional sets of loins (n1 = 249, n2 = 170, and n3 = 285 for each group, respectively) using two separate pH meters. Color and pH data were analyzed using the MIXED procedure of SAS as a 1-way ANOVA with two levels (Minolta and Hunter for color, Meter A and Meter B for pH). Variances for each treatment were calculated using the means procedure and tested for homogeneity using the Levene’s test of the GLM procedure. Means and variances were considered different at P ≤ 0.05. Coefficients of determination (R2) were calculated using the REG procedure between Hunter and Minolta readings and between pH meters.ResultsRedness, Chroma and hue angle had greater variability (P < 0.01) when measured using the open aperture Minolta than HunterLab, while only chroma (P = 0.04) and hue angle (P < 0.01) had greater variability when using the closed aperture Minolta compared with the HunterLab. Variability of other traits did not differ between machines. For each set of loins, pH variability was greater for meter B than meter A. R2 values between the HunterLab and open aperture Minolta were 0.42 for lightness, 0.41 for redness, 0.27 for yellowness, 0.28 for saturation, and 0.18 for hue angle. R2 values between the HunterLab and closed aperture Minolta were 0.42 for lightness, 0.42 for redness, 0.33 for yellowness, 0.24 for saturation, and 0.04 for hue angle. Meter A was able to predict between 17–21% of variation in Meter B.ConclusionOverall, variability was generally not different between color machines, while pH meters had different variabilities between machines and on days of measurement. Neither color instruments nor pH meters were able to predict values from other instruments of different types well enough for practical use.

Artificial intelligence and amniotic fluid multiomics: prediction of perinatal outcome in asymptomatic women with short cervix

OBJECTIVE

To evaluate the application of artificial intelligence (AI), i.e. deep learning and other machine-learning techniques, to amniotic fluid (AF) metabolomics and proteomics, alone and in combination with sonographic, clinical and demographic factors, in the prediction of perinatal outcome in asymptomatic pregnant women with short cervical length (CL).

METHODS

AF samples, which had been obtained in the second trimester from asymptomatic women with short CL (< 15 mm) identified on transvaginal ultrasound, were analyzed. CL, funneling and the presence of AF 'sludge' were assessed in all cases close to the time of amniocentesis. A combination of liquid chromatography coupled with mass spectrometry and proton nuclear magnetic resonance spectroscopy-based metabolomics, as well as targeted proteomics analysis, including chemokines, cytokines and growth factors, was performed on the AF samples. To determine the robustness of the markers, we used six different machine-learning techniques, including deep learning, to predict preterm delivery < 34 weeks, latency period prior to delivery < 28 days after amniocentesis and requirement for admission to a neonatal intensive care unit (NICU). Omics biomarkers were evaluated alone and in combination with standard sonographic, clinical and demographic factors to predict outcome. Predictive accuracy was assessed using the area under the receiver-operating characteristics curve (AUC) with 95% CI, sensitivity and specificity.

RESULTS

Of the 32 patients included in the study, complete omics, demographic and clinical data and outcome information were available for 26. Of these, 11 (42.3%) patients delivered ≥ 34 weeks, while 15 (57.7%) delivered < 34 weeks. There was no statistically significant difference in CL between these two groups (mean ± SD, 11.2 ± 4.4 mm vs 8.9 ± 5.3 mm, P = 0.31). Using combined omics, demographic and clinical data, deep learning displayed good to excellent performance, with an AUC (95% CI) of 0.890 (0.810-0.970) for delivery < 34 weeks' gestation, 0.890 (0.790-0.990) for delivery < 28 days post-amniocentesis and 0.792 (0.689-0.894) for NICU admission. These values were higher overall than for the other five machine-learning methods, although each individual machine-learning technique yielded statistically significant prediction of the different perinatal outcomes.

CONCLUSIONS

This is the first study to report use of AI with AF proteomics and metabolomics and ultrasound assessment in pregnancy. Machine learning, particularly deep learning, achieved good to excellent prediction of perinatal outcome in asymptomatic pregnant women with short CL in the second trimester. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.

Experience of skin disease and relationships with healthcare providers: a qualitative study of Traveller women in Ireland

BACKGROUND

Significant health disparities exist between members of the Travelling community and those of the general population. Barriers to Traveller engagement with health services include the experience or perception of discrimination, and cultural and health literacy barriers. Experience of skin disease and interactions with healthcare providers has not been widely explored in this ethnic minority. The formation of positive relationships between the Travelling community and healthcare providers is important in the promotion of treatment adherence and improving health outcomes.

OBJECTIVES

To investigate Travellers' experience of skin disease and their relationships with healthcare providers.

METHODS

Focus groups were conducted with a purposive sample of female members of the Irish Travelling community with experience of skin health issues, between January 2018 and April 2018. Three focus groups were conducted at three separate locations with 10 participants in each group. Themes were identified from the focus group transcripts using an inductive thematic analysis framework.

RESULTS

Emergent themes surrounding relationships between Travellers and healthcare providers included health literacy, discrimination, information inconsistency, trust and communication. Factors that were valued in the creation of positive relationships included an appreciation of varying degrees of health literacy, the provision of sufficient information tailored to an individual's needs and a demonstration of cultural competence.

CONCLUSIONS

Dermatologists are well placed to provide practical, customized, treatment guidance and engage patients while integrating their culturally based beliefs.

Nitrergic relaxations and phenylephrine contractions are not compromised in isolated urethra in a rat model of diabetes

In vivo experiments in a diabetic rat model revealed compromised nitrergic urethral relaxations and increased sensitivity to adrenergic agonists. This study evaluated contractile and relaxation properties of urethral smooth muscle after streptozotocin (STZ)-induced diabetes, in vitro, with the aim of determining whether in vivo deficiencies are related to smooth muscle dysfunction. Urethral tissue was collected from adult female Sprague-Dawley rats naive, STZ-treated, vehicle-treated and sucrose-fed at 9-12 week post treatment. Strips from proximal, mid, and distal urethra were placed in tissue baths and stimulated using electric field stimulation (EFS) and pharmacological agents. nNOS staining was evaluated using immunohistochemistry. Phenylephrine (PE, 10μM) contracted all urethral strips with the highest amplitude in mid urethra, in all treatment groups. Likewise, EFS-induced relaxation amplitudes were larger and were observed more frequently in mid urethra. Relaxations were inhibited by the NOS inhibitor, L-NAME (1-100μM). Sodium nitroprusside (0.01-1μM), an NO donor, reversed PE-induced contractions. No statistical differences were observed between treatment groups with respect to any parameters. Qualitative immunohistochemistry showed no differences in the urethral nNOS innervation patterns across the treatment groups. In summary, nitrergic relaxations and adrenergic-induced contractions in the isolated diabetic rat urethra display similar properties to controls, suggesting no dysfunction on the nitrergic or alpha1 adrenergic receptor function in the smooth muscle. This further implies that compromised urethral relaxation and increased adrenergic agonist sensitivity observed in vivo in this model may be due to the disruption of neural signaling between the urethra and the spinal cord, or within the CNS.

Successful Treatment of Aplastic Variant of Hairy-cell Leukaemia with Deoxycoformycin

The case of a patient with the aplastic variant of hairy cell leukaemia, successfully treated with the drug Deoxycoformycin(Pentostatin), is presented. It is very important to be aware of this rare variant of a rare disease so that the right treatment can be offered.

Prefrontal space ratio: comparison between trisomy 21 and euploid fetuses in the second trimester

OBJECTIVE

To evaluate a novel ultrasound measurement, the prefrontal space ratio (PFSR), in second-trimester trisomy 21 and euploid fetuses.

METHODS

Stored three-dimensional volumes of fetal profiles from 26 trisomy 21 fetuses and 90 euploid fetuses at 15-25 weeks' gestation were examined. A line was drawn between the leading edge of the mandible and the maxilla (MM line) and extended in front of the forehead. The ratio of the distance between the leading edge of the skull and that of the skin (d(1)) to the distance between the skin and the point where the MM line was intercepted (d(2)) was calculated (d(2)/d(1)). The distributions of PFSR in trisomy 21 and euploid fetuses were compared, and the relationship with gestational age in each group was evaluated by Spearman's rank correlation coefficient (r(s) ).

RESULTS

The PFSR in trisomy 21 fetuses (mean, 0.36; range, 0-0.81) was significantly lower than in euploid fetuses (mean, 1.48; range, 0.85-2.95; P < 0.001 (Mann-Whitney U-test)). There was no significant association between PFSR and gestational age in either trisomy 21 (r(s) = 0.25; 95% CI, - 0.15 to 0.58) or euploid (r(s) = 0.06; 95% CI, - 0.15 to 0.27) fetuses.

CONCLUSION

The PFSR appears to be a highly sensitive and specific marker of trisomy 21 in the second trimester of pregnancy.

Endoscopic vs. laparoscopic gastrojejunostomy for duodenal obstruction: a randomized study in a porcine model

BACKGROUND AND STUDY AIMS

Open or laparoscopic gastrojejunostomy is an established treatment for malignant duodenal obstruction but may be associated with significant morbidity and mortality. The purpose of this study was to develop a model for an entirely endoscopic gastrojejunostomy to treat duodenal obstruction, and to compare this with the laparoscopic technique.

METHODS

During the first part of the study the endoscopic technique was developed and tested in porcine nonsurvival and survival experiments (n=12). During the second part of the study (n=10), endoscopic gastrojejunostomy for duodenal occlusion was compared with laparoscopic gastrojejunostomy in a survival randomized controlled trial (RCT). For both groups duodenal occlusion was achieved by the laparoscopic approach.

RESULTS

In the RCT, the median times for laparoscopic vs. endoscopic gastrojejunostomy were 70 minutes (interquartile range [IQR] 65-75) vs. 210 minutes (IQR 197-220; P=0.01). There was a trend toward increased anastomotic diameter at necropsy in the laparoscopic group (2 cm, IQR 2-3) compared to the endoscopic group (1.8 cm, IQR 1.6-1.8; P=0.06). One animal in the endoscopic group died secondarily to bowel ischemia from volvulus of the jejunal loop. One animal in the laparoscopic group was prematurely sacrificed due to extensive pulmonary congestion and edema. All anastomoses were intact and patent.

CONCLUSIONS

Purely endoscopic gastrojejunostomy using the developed technique and devices is feasible and can result in adequate relief of duodenal obstruction. Endoscopic anastomoses tend to be smaller than laparoscopic anastomoses, with the procedures being more time-consuming and associated with higher complication rates.

Quantitation of cell-associated borrelial DNA in the blood of Lyme disease patients with erythema migrans

Bloodstream invasion is an important event in the pathogenesis of the more serious manifestations of Lyme disease. The number of spirochetes in the blood of infected patients, however, has not been determined, and, therefore, it is unknown whether the number of spirochetes can be correlated with particular clinical or laboratory features. This study was designed to measure the level of Borrelia burgdorferi in the plasma of Lyme disease patients and correlate these levels with selected clinical and laboratory findings. Nested and quantitative polymerase chain reaction (qPCR) was employed to detect cell-associated flaB gene DNA in the plasma of untreated early Lyme disease patients with erythema migrans (EM). Twenty-nine (45.3%) of 64 patients had evidence of B. burgdorferi in their plasma by at least one of the PCR methods. For the 22 qPCR-positive patients, the mean number of flaB gene copies per mL of plasma was 4,660, with a range of 414 to 56,000. The number of flaB gene copies did not significantly correlate with any of the clinical, demographic, or laboratory variables assessed. For reasons discussed, we suggest caution in extrapolating an estimate of the number of viable Borrelia in plasma from the observed number of flaB copies.

A multicenter comparison study between the Endosafe PTS rapid-release testing system and traditional methods for detecting endotoxin in cell-therapy products

BACKGROUND

Rapid-release testing reduces the waiting period for administration of time-sensitive cell-therapy products. Current assay systems are labor intensive and time consuming. The Endosafe portable test system (PTS) is a chromogenic Limulus amebocyte lysate (LAL) portable endotoxin detection system that provides quantitative results in approximately 15 min. To evaluate Endosafe performance with cell-therapy products, side-by-side testing of traditional LAL systems and the Endosafe system was conducted at the Production Assistance for Cellular Therapies (PACT) facilities and the National Institutes of Health's Department of Transfusion Medicine, USA.

METHODS

Charles River Laboratories provided each center with a PTS reader and two commercially prepared lyophilized reference standard endotoxin (RSE) vials. All samples tested with the Endosafe system used 0.05-5.0 endotoxin unit/mL (EU/mL) sensitivity cartridges provided by Charles River. Each vial was reconstituted with LAL water and tested in triplicate using the Endosafe and in-house LAL methods. Subsequently, each center tested the endotoxin content of standard dilutions of cell-therapy products, thus creating paired test results for each sample. Additionally, fabricated endotoxin-positive samples containing varying concentrations of endotoxin were prepared and shipped to all centers to perform blinded testing.

RESULTS

Valid paired results, based on each center's LAL method and the Endosafe system criteria, were analyzed. Endotoxin detection between paired results was equivalent in most cases.

DISCUSSION

The Endosafe system provided reliable results with products typically produced in cell-therapy manufacturing facilities, and would be an appropriate test on which to base the release of time-sensitive cell-therapy products.

Multicenter study on in vitro characterization of dendritic cells

BACKGROUND

There is growing interest in the use of in vitro-expanded dendritic cells (DC) in cancer immunotherapy as cellular-based vaccines. However, the methods used for in vitro preparation vary widely between institutions. Therefore, a strong need exists for standardization, characterization and quality control (QC) of such vaccines. A first prospective multicenter pilot study was performed to investigate basic QC parameters of frozen/thawed DC. The study design was focused on comparison of test results for cell counts, immunophenotyping and cell viability.

METHODS

CD14+ monocytes were isolated from three healthy volunteers. The cells were expanded in vitro, matured and cryopreserved using a standardized protocol in one laboratory. The aliquots of cryopreserved DC and a panel of reagents were shipped to eight laboratories worldwide. The objective was to compare the results of non-functional QC assays between sites by testing identical DC vaccines and using a pre-defined test protocol.

RESULTS

Measurements of nucleated cell (NC) content of thawed DC vaccines with different types of hematology analyzers (HA) gave similar results for the majority of sites. Immunophenotyping using identical clones of monoclonal antibodies for the detection of surface antigens (i.e. CD1a, CD14, CD16, CD83, CD86 and HLA-DR) provided mostly comparable results between laboratories with an acceptable level of variation. In contrast, highly different results between study sites were generated for measuring the viability of thawed DC by flow cytometry using 7-amino-actinomycin D (7-AAD) dye exclusion.

DISCUSSION

In characterizing frozen/thawed DC vaccines, NC counts generated by HA yielded similar results between different laboratories. Furthermore, immunophenotyping of DC vaccines can be standardized between centers, i.e. by using identical reagents. Because of highly variable results between laboratories, 7-AAD viability testing of thawed DC needs to be studied further to identify potential causes for the observed variability.

Development and operation of a quality assurance system for deviations from standard operating procedures in a clinical cell therapy laboratory

BACKGROUND

Errors and accidents, or deviations from standard operating procedures, other policy, or regulations must be documented and reviewed, with corrective actions taken to assure quality performance in a cellular therapy laboratory. Though expectations and guidance for deviation management exist, a description of the framework for the development of such a program is lacking in the literature. Here we describe our deviation management program, which uses a Microsoft Access database and Microsoft Excel to analyze deviations and notable events, facilitating quality assurance (QA) functions and ongoing process improvement.

METHODS

Data is stored in a Microsoft Access database with an assignment to one of six deviation type categories. Deviation events are evaluated for potential impact on patient and product, and impact scores for each are determined using a 0- 4 grading scale. An immediate investigation occurs, and corrective actions are taken to prevent future similar events from taking place. Additionally, deviation data is collectively analyzed on a quarterly basis using Microsoft Excel, to identify recurring events or developing trends.

RESULTS

Between January 1, 2001 and December 31, 2001 over 2500 products were processed at our laboratory. During this time period, 335 deviations and notable events occurred, affecting 385 products and/or patients. Deviations within the 'technical error' category were most common (37%). Thirteen percent of deviations had a patient and/or a product impact score > or = 2, a score indicating, at a minimum, potentially affected patient outcome or moderate effect upon product quality.

DISCUSSION

Real-time analysis and quarterly review of deviations using our deviation management program allows for identification and correction of deviations. Monitoring of deviation trends allows for process improvement and overall successful functioning of the QA program in the cell therapy laboratory. Our deviation management program could serve as a model for other laboratories in need of such a program.

Osteomyelitis of the ischiopubic synchondrosis: imaging findings

Osteomyelitis of the ischiopubic synchondrosis in children is not rare and presents a diagnostic problem because of the diversity of presentation and the deceptive nature of symptoms. Radiological assessment is extremely difficult because of the variation in normal ossification on radiography and normal physiological uptake on radioisotope bone scan. We present two cases of osteomyelitis of the ischiopubic synchondrosis and describe findings on radiographs, isotope bone scan, computed tomography (CT) and magnetic resonance imaging (MRI). MRI changes have not been described in any of the case reports in the English literature. Aspiration and biopsy remain the gold standard for diagnosis. However, MRI appearances can significantly increase diagnostic confidence prior to intervention.

A randomized trial investigating an iron-rich natural mineral water as a prophylaxis against iron deficiency in pregnancy

Spatone Iron-Plus is a naturally occurring mineral water from Trefriw Wells Spa in Conwy County, North Wales, UK. It contains approximately 0.20 mg of iron per millilitre as ferrous sulphate and has been shown to provide iron in a highly bio-available form. A 24 ml sachet contains approximately 5 mg of iron. Iron deficiency is common in the obstetric population. However, compliance with traditional iron supplements is poor because of gastrointestinal side-effects. We designed a randomized, double-blind, placebo-controlled trial. A total of 102 low-risk antenatal patients, who were noncompliant with routinely prescribed ferrous sulphate tablets, were randomized to receive 48 ml of Spatone water or placebo. The study was conducted between 22 and 28 weeks gestation. Primary outcome measures were compliance, gastrointestinal side-effects and changes in ferritin levels during the trial period. Compliance in the intervention group was 57% compared with 67% in the control group, P = 0.22. Dyspepsia scores, as determined by a recognized and well-validated questionnaire, did not differ between the two groups. During the trial period, mean ferritin levels fell by 24% in the Spatone Iron-Plus group compared with a mean fall of 51% in ferritin levels among the control group, P = 0.016.

Nasal bone length throughout gestation: normal ranges based on 3537 fetal ultrasound measurements

OBJECTIVE

To establish normal ranges for nasal bone length measurements throughout gestation and to compare measurements in two subsets of patients of different race (African-American vs. Caucasian) to determine whether a different normal range should be used in these populations.

METHOD

Normal nasal bone length reference ranges were generated using prenatal measurements by a standardized technique in 3537 fetuses.

RESULTS

The nasal bone lengths were found to correlate positively with advancing gestation (R(2) = 0.77, second-order polynomial). No statistical difference was found between African-American and Caucasian subjects.

CONCLUSION

These reference ranges may prove to be useful in prenatal screening and diagnosis of syndromes known to be associated with nasal hypoplasia. Different normal ranges for African-American and Caucasian women are not required.

Techniques and materials for skin closure in caesarean section

BACKGROUND

Caesarean section is a common operation with no agreed standard on operative techniques and materials to use. The skin layer can be repaired by sub cuticular stitch immediately below the skin layer, an interrupted stitch or with skin staples. A great variety of materials and techniques are used for skin closure after caesarean section and there is a need to identify which provide the best outcomes for women.

OBJECTIVES

To compare the effects of skin closure techniques and materials on maternal outcomes and time taken to perform a caesarean section.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group trials register (August 2002).

SELECTION CRITERIA

All randomised comparisons of skin closure techniques in caesarean section.

DATA COLLECTION AND ANALYSIS

Three papers were identified from the search. Data were extracted independently by two reviewers. On further inspection two were not considered to be randomised controlled trials.

MAIN RESULTS

Only one small randomised controlled trial, involving 66 women, was included in the review. Frishman et al compared staples with absorbable sub-cuticular suture for closure following caesarean section. While operating time was significantly shorter when using staples, the use of absorbable sub cuticular suture resulted in less postoperative pain and yielded a better cosmetic result at the post-operative visit.

REVIEWER'S CONCLUSIONS

There is no conclusive evidence about how the skin should be closed after caesarean section. Questions regarding the best closure technique and material and the outcomes associated with each remain unanswered. The appearance and strength of the scar following caesarean section is important to women and the choice of technique and materials should be made by women in consultation with their obstetrician based on the limited information currently available.