A multicenter interdisciplinary survey of practices and opinions regarding oral intake during labor

INTRODUCTION

Different society guidelines diverge regarding oral intake in labor. Our goal was to assess practices and opinions in Israeli labor and delivery units, comparing different disciplines.

METHODS

An anonymous Google Forms survey was sent to anesthesiologists, obstetricians and midwives in all Israeli labor and delivery units.

RESULTS

Responses were collected from all 27 labor and delivery units contacted, with a total of 501 respondents comprising 161 anesthesiologists, 102 obstetricians and 238 midwives. Forty-eight per cent stated there were no institutional guidelines for oral intake. The most common oral intake permitted was light food (60%). Midwives were significantly more likely than anesthesiologists and obstetricians to consider that women who are both low risk for cesarean delivery (P <0.00001) and high risk for cesarean delivery (P=0.001) should eat. Epidural analgesia did not impact recommendations regarding oral intake. The most common reasons for restricting oral intake were obstetric. Sixty-two per cent identified aspiration as the main risk associated with eating during labor, but 19% of midwives compared with 4% of anesthesiologists and obstetricians stated there were no risks (P <0.00001). The annual delivery volume of the unit did not impact staff practices.

CONCLUSIONS

There was a discrepancy between opinions and practices across all disciplines. Permissive practices identified in this survey should be addressed to find the safe middle ground between restrictive and permissive policies for low- and high-risk women.

Efficacy of Tocilizumab in Patients Hospitalized with Covid-19

BACKGROUND

The efficacy of interleukin-6 receptor blockade in hospitalized patients with coronavirus disease 2019 (Covid-19) who are not receiving mechanical ventilation is unclear.

METHODS

We performed a randomized, double-blind, placebo-controlled trial involving patients with confirmed severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, hyperinflammatory states, and at least two of the following signs: fever (body temperature >38°C), pulmonary infiltrates, or the need for supplemental oxygen in order to maintain an oxygen saturation greater than 92%. Patients were randomly assigned in a 2:1 ratio to receive standard care plus a single dose of either tocilizumab (8 mg per kilogram of body weight) or placebo. The primary outcome was intubation or death, assessed in a time-to-event analysis. The secondary efficacy outcomes were clinical worsening and discontinuation of supplemental oxygen among patients who had been receiving it at baseline, both assessed in time-to-event analyses.

RESULTS

We enrolled 243 patients; 141 (58%) were men, and 102 (42%) were women. The median age was 59.8 years (range, 21.7 to 85.4), and 45% of the patients were Hispanic or Latino. The hazard ratio for intubation or death in the tocilizumab group as compared with the placebo group was 0.83 (95% confidence interval [CI], 0.38 to 1.81; P = 0.64), and the hazard ratio for disease worsening was 1.11 (95% CI, 0.59 to 2.10; P = 0.73). At 14 days, 18.0% of the patients in the tocilizumab group and 14.9% of the patients in the placebo group had had worsening of disease. The median time to discontinuation of supplemental oxygen was 5.0 days (95% CI, 3.8 to 7.6) in the tocilizumab group and 4.9 days (95% CI, 3.8 to 7.8) in the placebo group (P = 0.69). At 14 days, 24.6% of the patients in the tocilizumab group and 21.2% of the patients in the placebo group were still receiving supplemental oxygen. Patients who received tocilizumab had fewer serious infections than patients who received placebo.

CONCLUSIONS

Tocilizumab was not effective for preventing intubation or death in moderately ill hospitalized patients with Covid-19. Some benefit or harm cannot be ruled out, however, because the confidence intervals for efficacy comparisons were wide. (Funded by Genentech; ClinicalTrials.gov number, NCT04356937.).

A new digital classification schema to detect treatment variances and enable value-based payment reforms

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Background: Value based payment reforms which improve the outcome to cost ratio (paying for outcomes not for services) require detailed information on both elements. Although the digitalization of medicine via the EHR may facilitate data collection, the imprecise ICD9 and ICD10 schemas hinder analysis (eg: all breast cancers are ICD9 174.9). A more precise classification schema that accounts for biologic variances to allow analysis (and reduction) of treatment variances is needed. Methods: We have developed a digital classification (COTA Nodal Address) based on known clinically relevant prognostic variables. (eg: breast cancer variables include stage, tumor size, hormone status, her2 neu status, etc.). The digital classification also accounts for therapy status (neoadjuvant vs adjuvant, etc.) and line (1st or 2nd treatment, etc.). Results: Using breast cancer as an example, there are > 2975 unique CNA phenotypes that encompass prognostic and treatment status variables. However, in a series of 1204 patients in a community setting only 114 CNAs have been utilized, suggesting biologic disequilibrium. Two phenotypes accounted for the top 25% of cases, 6 for the top 50% and 16 for the top 75%. Early stage, small tumor, hormone receptor positive were most common. The CNA classification uncovered treatment variances among patients with similar phenotypes. In an ongoing episodes of care payment program, young breast cancer patients with early stage, good performance status, hormone positive, her2 neu negative, very small tumors (with similar extended attributes) received varying adjuvant treatment strategies (hormone alone 46% , non-anthracycline 35%, anthracycline chemotherapy 4%, observation 1%). Conclusions: Unlike ICD9/10 systems, a digital classification schema that precisely segregates cancers into unique cohorts based on complete biologic characteristics can rapidly identify behavioral variances at scale that drive differences in outcomes and costs. Using the breast cancer model, we have noted demographic disequilibrium in cancer presentations (potentially a factor of both biology and screening practices) and major variances in treatment strategies (with impact on outcomes/ costs).

Adenosine A1 receptors (A1Rs) play a critical role in osteoclast formation and function

Adenosine regulates a wide variety of physiological processes via interaction with one or more G-protein-coupled receptors (A(1)R, A(2A)R, A(2B)R, and A(3)R). Because A(1)R occupancy promotes fusion of human monocytes to form giant cells in vitro, we determined whether A(1)R occupancy similarly promotes osteoclast function and formation. Bone marrow cells (BMCs) were harvested from C57Bl/6 female mice or A(1)R-knockout mice and their wild-type (WT) littermates and differentiated into osteoclasts in the presence of colony stimulating factor-1 and receptor activator of NF-kappaB ligand in the presence or absence of the A(1)R antagonist 1,3-dipropyl-8-cyclopentyl xanthine (DPCPX). Osteoclast morphology was analyzed in tartrate-resistant acid phosphatase or F-actin-stained samples, and bone resorption was evaluated by toluidine blue staining of dentin. BMCs from A(1)R-knockout mice form fewer osteoclasts than BMCs from WT mice, and the A(1)R antagonist DPCPX inhibits osteoclast formation (IC(50)=1 nM), with altered morphology and reduced ability to resorb bone. A(1)R blockade increased ubiquitination and degradation of TRAF6 in RAW264.7 cells induced to differentiate into osteoclasts. These studies suggest a critical role for adenosine in bone homeostasis via interaction with adenosine A(1)R and further suggest that A(1)R may be a novel pharmacologic target to prevent the bone loss associated with inflammatory diseases and menopause.

Helicobacter pylori stimulates gastric epithelial cell MMP-1 secretion via CagA-dependent and -independent ERK activation

Because the mechanisms of Helicobacter pylori-induced gastric injury are incompletely understood, we examined the hypothesis that H. pylori induces matrix metalloproteinase-1 (MMP-1) secretion, with potential to disrupt gastric stroma. We further tested the role of CagA, an H. pylori virulence factor, in MMP-1 secretion. Co-incubation of AGS cells with Tx30a, an H. pylori strain lacking the cagA virulence gene, stimulated MMP-1 secretion, confirming cagA-independent secretion. Co-incubation with strain 147C (cagA(+)) resulted in CagA translocation into AGS cells and increased MMP-1 secretion relative to Tx30a. Transfection of cells with the recombinant 147C cagA gene also induced MMP-1 secretion, indicating that CagA can independently stimulate MMP-1 secretion. Co-incubation with strain 147A, containing a cagA gene that lacks an EPIYA tyrosine phosphorylation motif, as well as transfection with 147A cagA, yielded an MMP-1 secretion intermediate between no treatment and 147C, indicating that CagA tyrosine phosphorylation regulates cellular signaling in this model system. H. pylori induced activation of the MAP kinase ERK, with CagA-independent (early) and dependent (later) components. MEK inhibitors UO126 and PD98059 inhibited both CagA-independent and -dependent MMP-1 secretion, whereas p38 inhibition enhanced MMP-1 secretion and ERK activation, suggesting p38 negative regulation of MMP-1 and ERK. These data indicate H. pylori effects on host epithelial MMP-1 expression via ERK, with p38 playing a potential regulatory role.

Modulation of ultraviolet light-induced epidermal damage: beneficial effects of tocopherol

Oxygen free radicals have been shown to result from and mediate deleterious effects of ultraviolet radiation on the skin. The purpose of this study was to determine if topical DL-alpha-tocopherol (vitamin E) could reduce ultraviolet-induced damage to the epidermis. Twenty mice were treated with either ethanol or a 1:1 mixture of tocopherol and ethanol. Treatments consisted of once-daily 0.1-ml topical applications for 1 week, followed by irradiation with 0.30 mW/cm2 of ultraviolet B irradiation. A statistically significant decrease in Schiff base formation was noted between tocopherol-treated animals and their controls. Histologic study revealed a statistically significant increase in epidermal thickness in tocopherol-treated skin versus controls or vehicle alone. The thicker epidermis was accompanied by the presence of parakeratosis, implicating increased proliferation as the cause of the increasing thickness. The number of sunburn cells was decreased by tocopherol treatment. Tocopherol protection from ultraviolet irradiation may have been due to both direct protection from free radicals and indirect protection by means of increased epidermal thickness. The demonstration of beneficial effects of tocopherol administration suggests that further studies in clinically relevant models to define optimal dosage, frequency of administration, vehicle, and quantitation of the possible protective effects afforded to Langerhans cells may be useful.

Effects of dietary fish oil on renal insufficiency in rats with subtotal nephrectomy

We studied the effects of fish oil on the progression of renal insufficiency in rats with subtotal nephrectomy. Five weeks after a 1-2/3 nephrectomy, sixteen rats were fed two different diets which differed only in fat composition. Lipid in the control diet was primarily beef tallow; that of the experimental diet, menhaden oil. Fish oil-fed rats had significant increases in plasma creatinines, decreases in urinary PGE2 and accelerated death rates. An additional twelve rats underwent 1-1/3 nephrectomies, and the same dietary manipulations, followed by renal clearance, histologic and biochemical studies after 12 weeks on the diets. Fish oil-fed rats again did worse, with decreased glomerular filtration rates and filtration fractions, more proteinuria and more glomerular sclerosis. Glomeruli and slices of cortex, medulla and papillae from rats fed fish oil produced much less PGE2 and TXB2 than dietary controls. Fish oil-induced suppression of renal PGE2 may be deleterious in this model and may outweigh the beneficial effect derived from TXA2 suppression. In contrast to fish oil's potentially therapeutic role in cardiovascular and immune-mediated renal disease, this diet is detrimental in rat renoprival nephropathy. This illustrates the importance of examining the effects of fatty acid manipulation individually for each disease entity.

Measurement of effective renal plasma flow: a comparison of methods

We have compared two in vitro methods and three variations of kidney background (BG) subtraction within a gamma camera method (41 examinations, 31 patients) for determination of effective renal plasma flow (ERPF) using 131I orthoiodohippurate (OIH). Method I: plasma samples at 20 and 45 min after OIH injection, ERPF = dose X slope/intercept; Method II: 45-min plasma sample, ERPF = -51.1 + 8.21x + 0.019x2, x = dose/45-min plasma activity/I. Individual kidney and total ERPF were determined from gamma camera (GC) methods using renal uptake 1-2 min after injection. All methods were compared against Method I (previously validated against paraaminohippurate (PAH) clearances). Method II, which requires one blood sample is more accurate than GC methods. GC methods are insensitive to operator variability in placement of renal and BG regions of interest. They may be useful to follow changes in relative or total ERPF, but accurate depth correction of renal data is suggested. In vitro, blood sample-based methods are more accurate.

Attitudes toward women physicians in medical academia

To determine attitudes toward women physicians within medical academia, we administered a survey to a probability sample of male and female senior medical students, faculty, and top-level administrators in a randomized, stratified subset of ten medical schools. Of the 984 respondents (65% response rate), men were much less supportive overall than women of female leaders. While women strongly disagreed with the idea that women physicians who spend long hours at work neglect home and family, men were almost equally divided on this issue. Each group rated the "typical" faculty member as "strong, fair, and progressive," but male faculty also were characterized as "egotistical" while female faculty were rated more "sensitive and altruistic." Male students were least likely to support a search for a female dean, hiring more female faculty members, or accepting an incoming class in which the majority were women.

Indicine-N-oxide: the antitumor principle of Heliotropium indicum

Extracts of Heliotropium indicum Linn. (Boraginaceae) showed significant activity in several experimental tumor systems. The active principle is isolated and shown to be the N-oxide of the alkaloid, indicine, previously isolated from this plant. Supporting structural data and anti-tumor data are provided.