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.

Left Hepatic Lobectomy in the Living Donor-Comparison Between Open vs Laparoscopic Surgery

Laparoscopic hepatic surgery dramatically changed surgical practice in the last decades, improving outcomes in correctly selected patients. The reduction of postoperative pain, lower rate of complication, early return to work activities, and better esthetic result have been well described in several studies. The success of these procedures would inevitably clash in the more complex and delicate field of hepatectomy in the living donor. The 2nd International Consensus of the Conference on Laparoscopic Liver Surgery considers laparoscopic hepatectomy in the donor as an ideal procedure. The aim of this study is to compare the results between conventional and laparoscopic surgery; prospective data and retrospective analysis of 55 cases of live liver donor lobectomy were collected between January 2013 and June 2018. The mean age was 30.4 years in the video laparoscopic technique and 32.1 years in conventional surgery; the majority of donors were male in both groups. The mean time of ischemia was 70.2 minutes (range, 50-120 minutes) in laparoscopic surgery and 80.2 minutes (range, 50-165 minutes) in conventional surgery. The surgical time ranged from 270 to 800 minutes (mean, 452 minutes) in laparoscopic surgery and ranged from 300 to 600 minutes (mean, 424 minutes) in conventional surgery. The mean length of hospital stay was 2.2 days in laparoscopy and 3.97 days in conventional surgery. Laparoscopic left liver lobectomy in the living donor is safe and feasible. There was no significant difference in surgical time; however, the time of hospitalization was lower in patients submitted to laparoscopic technique.

Plasticity of Corynebacterium diphtheriae pathogenicity islands revealed by PCR

Despite the existence of a vaccine against diphtheria, this disease remains endemic and is reemerging in several regions due to many factors, including variations in genes coding for virulence factors. One common feature of virulence factors is their high concentration in pathogenicity islands (PAIs), very unstable regions acquired via horizontal gene transfer, which has lead to the emergence of various bacterial pathogens. The 13 putative PAIs in Corynebacterium diphtheriae NCTC 13129 and the reemergence of this disease point to the great variability in the PAIs of this species, which may reflect on bacterial life style and physiological versatility. We investigated the relationships between the large number of PAIs in C. diphtheriae and the possible implications of their plasticity in virulence. The GenoFrag software was used to design primers to analyze the genome plasticity of two pathogenicity islands of the reference strain (PiCds 3 and 8) in 11 different strains. We found that PiCd 3 was absent in only two strains, showing genes playing putative important roles in virulence and that only one strain harbored PiCd 8, due to its location in a putative "hotspot" for horizontal gene transfer events.

High seroprevalence of caseous lymphadenitis in Brazilian goat herds revealed by Corynebacterium pseudotuberculosis secreted proteins-based ELISA

We conducted a seroepidemiological survey to determine the prevalence of caseous lymphadenitis (CLA) in goat herds in Minas Gerais state, Brazil. Serum samples were collected from goats (n=676) from 108 rural properties in 2001, covering most of the sub-regions of this ca. 586,500 square kilometer state. Antibodies against Corynebacterium pseudotuberculosis secreted proteins were detected by an indirect enzyme-linked immunosorbent assay (ELISA). Most of the animals (78.9%) tested positive for CLA; 98% of flocks presented at least one seropositive animal. Goats managed under an extensive production system had a significantly higher seroprevalence of CLA than those in intensive and semi-intensive operations. The age distribution of the animals in the flocks affected the prevalence of this disease; however, goat breed did not. We found seropositivity against C. pseudotuberculosis to be highly prevalent in these Brazilian goat herds; consequently, appropriate management practices for the control of CLA should be implemented.

A description of genes of Corynebacterium pseudotuberculosis useful in diagnostics and vaccine applications

Corynebacterium pseudotuberculosis, a Gram-positive intracellular pathogen, is the etiological agent of caseous lymphadenitis or CLA. This bacterium infects goats and sheep and causes great economic losses worldwide annually, mainly for goat producers. Despite its importance, CLA is still poorly characterized. However, with advances in the genomic field, many C. pseudotuberculosis genes have already been characterized, mainly those related to virulence such as phospholipase D. Here, we examined the use of the several available genes of C. pseudotuberculosis and reviewed their applications in vaccine construction, more efficient diagnostics for CLA, and control of this disease, among other applications.

Mobilisation and bioavailability of arsenic around mesothermal gold deposits in a semiarid environment, Otago, New Zealand

Arsenopyrite (FeAsS) is the principal arsenic (As) mineral in mineralised mesothermal veins (typically 5,000 mg/kg As) in southeastern New Zealand. Groundwater in contact with arsenopyrite-bearing rocks has elevated As concentrations (up to 0.1 mg/l). The arsenopyrite decomposes slowly on oxidation in soils and historic mine workings in a cool semiarid climate. Dissolved As is predominantly As(III) in association with arsenopyrite, but this is rapidly oxidised over days to weeks to As(V) in the vadose zone. Oxidation is facilitated by particulate Fe and/or Mn oxyhydroxides, and by bacteria in surface waters. Evaporative concentration of dissolved As(V) in the vadose zone causes precipitation of scorodite (Fe(III)As(V)O4*2H2O). Adsorption of As(V) to Fe oxyhydroxides in soils and groundwater pathways lowers dissolved As concentrations. Soils over mineralised veins typically have <200 mg/kg As, as most As is removed in solution on geological time scales. Most plants on the mineralised rocks and soils do not take up As, although some inedible species can fix up to 18 mg/kg As. Hence, bioavailability of As(V) is low in this environment, despite the substantial As flux. Similar As mobility is seen in an active gold mine processing plant and tailings. Arsenopyrite dissolves more rapidly on agitation, and mine waters can have dissolved As >200 mg/l, predominantly as As(V). This dissolved As decreases in tailings waters to near 2 mg/l, mainly as As(III) when in contact with arsenopyrite. Weak oxidation of evaporatively dried tailings causes cementation with scorodite and iron oxyhydroxides, and scorodite precipitation exerts some control on dissolved As(V) concentrations. High dissolved As in mine waters is lowered by adsorption to iron oxyhydroxides, and waters discharged from the mine site have negligible dissolved As.

Temperature dependence of the topology of supported dimirystoyl-distearoyl phosphatidylcholine bilayers

Topology of fluid and gel domains in the supported bilayer two-component system formed from equimolar mixtures of dimyristoylphosphatidylcholine (DMPC) and distearoylphosphatidylcholine (DSPC) was determined by AFM, at various temperatures corresponding to the gel and the gel + fluid region of the phase diagram. The data show that, in the disconnected fluid part of the DMPC/DSPC gel-liquid crystal-phase-separation region, the size of fluid domains markedly exceeds that predicted from spectroscopic experiments or from Monte Carlo simulations. They provide a direct evidence for the transition from the disconnected fluid to the disconnected gel region of the phase diagram, again with gel-phase domains much larger than expected. Finally, images of the gel phase at different temperatures suggest that structural rearrangements of the phospholipids can disrupt the continuity of the supported bilayer.

[Sexual dysfunction with antidepressive agents. Effect of the change to amineptine in patients with sexual dysfunction secondary to SSRI]

Sexual dysfunction secondary to the use of antidepressants, especially clomipramine or SSRI's is an adverse effect that is often underestimated and according to earlier studies, this can affect approximately 60% of the patients. This presents as a decrease in libido, alterations in the ability to reach orgasm/ejaculation, and an erectile dysfunction or a decreased vaginal lubrication. This dysfunction appears to be related with the resulting increase in serotonin and with the stimulation of serotonin 5HT2 receptors.

OBJECTIVES

1) Evaluate the effect of amineptine, a drug with an increased dopamine transmission and scant serotonin transmission, on the sexual function of depressed patients who begin treatment, and 2) evaluate whether the change to amineptine improves the sexual function in patients who presented sexual dysfunction after beginning treatment with a SSRI.

MATERIAL AND METHODS

Prospective, observational, open and multicentric design. 111 patients with an average age of 41.3 years (36 men, 75 women) were distributed into three groups: Group 1 (n= 26): patients with depression (DSM IV) who begin de novo treatment with amineptine 200 mg/day. Group 2 (n= 47): depressed patients undergoing treatment with a SSRI who show a favorable response and who present sexual dysfunction secondary to a poorly tolerated treatment, so the treatment is changed to 200 mg/day of amineptine. Group 3 (n= 38): patients with the same characteristics as those of group 2, but whose treatment was changed to 20 mg/day of paroxetine. The <<Questionnaire for the Measure of Sexual Dysfunction Secondary to the use of Psychotropic Drugs>> (Montejo et al, 1996) was used together with the Hamilton Depression Scale, the IGC Scale, and an adverse events scale, over a 6 months follow up period during which visits took place at: baseline, month 1, month 2, month 3, and month 6.

RESULTS

In group 1, treated with amineptine from the beginning, of the 5 patients who showed a decrease in the libido at the beginning of the treatment, only one still presented this in the 6th month. The Hamilton Scale decreased from 23.12 (baseline) to 5.25 after 6 months. After substituting amineptine for SSRI's in patients with sexual dysfunction, the incidence of any type of sexual dysfunction decreased significantly from 100% (baseline) to 55.3% after 6 months. (P< 0.001). The incidence of delayed orgasm dropped to 15.8%, anorgasmia to 17.4%, and impotence dropped to 15.8% in this group, with the antidepressant effect that had already been achieved with the SSRI being maintained. However, in group 3 there was barely any improvement on the sexual function after changing to paroxetine (20 mg/day), with the baseline incidence being 100% and the incidence after 6 months being 89.7%. In this last group the antidepressant effect present at the baseline level, was maintained.

CONCLUSIONS

Amineptine was shown to be an effective antidepressant in the patients studied, and did not cause secondary sexual dysfunction, and even improved the dysfunction that was present in some patients. In those patients previously treated with SSRI's, amineptine is able to significantly improve the sexual dysfunction and yet maintain the efficacy of the antidepressive treatment used before these 6 months. On the other hand, Paroxetine did not improve the sexual dysfunction of the people in whom this drug substituted another SSRI, as this is an adverse effect common to the entire group of selective serotonin re-uptake inhibiting drugs. Amineptine showed a good safety and tolerance profile. Its most common side effect (anxiety/restlessness) disappeared 2 months after the beginning of the treatment.

Olfactory esthesioneuroma: a report of 40 cases

Olfactory esthesioneuroma is a rare malignant tumor arising in the olfactory epithelium. Forty cases observed at the Institut Gustave-Roussy from 1956 to 1987 are reported. This tumor usually grows slowly and is usually local, but it is important to be aware of the possibility of lymph node involvement (17%) and, particularly, of rapid development of distant metastases (25%), usually within 6 months. CT scan, and more recently, NMR have proved to be of value in choosing the surgical approach. In view of the usual point of departure, a combined neurosurgical and transfacial approach seems to be a satisfactory approach for obtaining oncological control of the lesion. The role of chemotherapy is discussed. The main prognostic factors seem to be the size of the lesion, the intracranial extension, and the lymph node involvement.

[Elective permanent exteriorization of cardiac pacemakers]

Three clinical cases are reported in which the authors decided for the permanent exteriorization of a cardiac pacemaker. The decision was based in that many previous surgical procedures had been performed and the possibilities of new approaches were exhausted or that the soft tissues were not in a satisfactory condition to support a new pacemaker. Considerations are made of the indications of this procedure, of the absence of previous reports in the literature, and the possibilities of long term follow-up morbidity. Emphasis is made in the necessity of thoroughly explaining the patients and their relatives of the risks involved, and not to overindicate the procedure if other possibilities have not been exhausted.