Incidence Of Adverse Outcomes Research Articles

Significance of oligohydramnios in preterm small‐for‐gestational‐age infants for outcome at 18 months of age

The aim of this study was to evaluate the association between oligohydramnios and other perinatal factors in preterm small-for-gestational-age (SGA) infants who had cerebral palsy at 18 months of age or who had died before this age. This retrospective study included 320 infants with birthweights<3rd percentile delivered between 22 and 33 complete weeks of gestation. We evaluated the incidence of CP at 18 months of age and of death before this age. The significant risk factors, including oligohydramnios, of CP or death of preterm SGA infants were evaluated by logistic regression analysis. The incidence of CP or death was 47/320 (14.7%), consisting of 24/320 (7.5%) cases of CP and 23/320 (7.2%) cases of death. Oligohydramnios (adjusted odds ratio, 2.18; 95% confidence interval, 1.07-4.45) and gestational age (adjusted odds ratio, 0.76; 95% confidence interval, 0.66-0.87) were independently correlated with outcome. The incidence of adverse outcomes was approximately 15% in preterm SGA infants. SGA infants born with oligohydramnios may be at increased risk for CP or death compared to those with normal amniotic volume.

Impact of gender difference on long-term outcomes of percutaneous coronary intervention for coronary artery disease in patients under statin treatment

The incidence of adverse outcomes after percutaneous coronary intervention (PCI) is higher in women than in men. Statins reduce the likelihood of cardiovascular events arising in patients with coronary artery disease (CAD), but the impact of gender difference on long-term outcomes of PCI for CAD under statin treatment has not been established. We prospectively enrolled 3,580 consecutive patients with CAD who were treated by PCI at our institution between 2000 and 2011. Among these, 2,009 (43.9%; male, n=1619; female, n=390) were under statin therapy at the time of PCI. We evaluated the incidence of major adverse cardiac events (MACE) including all-cause death and acute coronary syndrome (ACS). Age was significantly more advanced and the prevalences of hypertension and chronic kidney disease were higher among the female, than the male patients. Low-density lipoprotein cholesterol levels were significantly higher in women than in men (111.5±38.9 vs. 107.5±3 3.9mg/dL, p=0.04). During a median follow-up period of 6.3years, MACE that occurred in 336 (16.7%) patients included 206 (10.2%) with all-cause death and 154 (7.7%) with ACS. The cumulative rate of MACE tended to be higher in women than in men but the difference did not reach significance (19.7 vs. 16.0%; p=0.08, log-rank test). Multivariable Cox regression analysis showed that being female was not associated with MACE after adjusting for age (HR 1.22; 95% CI 0.94-1.57; p=0.13) and other variables (HR 1.14; 95% CI 0.86-1.49; p=0.35). Long-term clinical outcomes were comparable between male and female patients with coronary artery disease who were administered with statins and underwent PCI even though the baseline characteristics were worse among the females.

Adverse events associated with abacavir use in HIV-infected children and adolescents: a systematic review and meta-analysis

Concerns exist about the toxicity of drugs used in the implementation of large-scale antiretroviral programmes, and documentation of antiretroviral toxicity is essential. We did a systematic review and meta-analysis of adverse events among children and adolescents receiving regimens that contain abacavir, a widely used antiretroviral drug. We searched bibliographic databases and abstracts from relevant conferences from Jan 1, 2000, to March 1, 2015. All experimental and observational studies of HIV-infected patients aged 0-18 years who used abacavir, were eligible. Incidence of adverse outcomes in patients taking abacavir (number of new events in a period divided by population at risk at the beginning of the study) and relative risks (RR) compared with non-abacavir regimens were pooled with random effects models. Of 337 records and 21 conference abstracts identified, nine studies (eight full-text articles and one abstract) collected information about 2546 children, of whom 1769 (69%) were on abacavir regimens. Among children and adolescents taking abacavir, hypersensitivity reactions (eight studies) had a pooled incidence of 2·2% (95% CI 0·4-5·2); treatment switching or discontinuation (seven studies) pooled incidence was 10·9% (2·1-24·3); of grade 3-4 adverse events (six studies) pooled incidence was 9·9% (2·4-20·9); and adverse events other than hypersensitivity reaction (six studies) pooled incidence was 21·5% (2·8-48·4). Between-study inconsistency was significant for all outcomes (p<0·0001 for all inconsistencies). Incidence of death (four studies) was 3·3% (95% CI 1·5-5·6). In the three randomised clinical trials with comparative data, no increased risk of hypersensitivity reaction (pooled RR 1·08; 95% CI 0·19-6·15), grade 3 or 4 events (0·79 [0·44-1·42]), or death (1·72 [0·77-3·82]) was noted for abacavir relative to non-abacavir regimens. None of the reported deaths were related to abacavir. Abacavir-related toxicity occurs early after ART initiation and is manageable. Abacavir can be safely used for first-line or second-line antiretroviral regimens in children and adolescents, especially in sub-Saharan Africa were HLA B5701 genotype is rare. WHO.

Early Complications in Hip and Knee Arthroplasties in a Safety Net Hospital vs a University Center

BackgroundIndigent populations face unique challenges that may increase surgical risk and adversely affect the outcomes of hip and knee arthroplasties. This study examines whether there is a difference in early postoperative complications in patients treated in a safety net hospital and in a nearby university center. MethodsA retrospective review was undertaken of 533 consecutive hip and knee arthroplasties performed by a single experienced surgeon in a safety net hospital and in a university medical center from 2008 to 2012. Patients were followed for a minimum of 2 years. The primary outcomes evaluated were total complications, deep infections, and reoperations. Statistical comparison of the data from the 2 patient groups was carried out using Fisher exact test. ResultsDespite the lower percentage of index revision procedures in the safety net group (8% vs 20.5%; P = .0003), the incidence of adverse outcomes was higher in this group than in the university group: for total complications, 12.3% vs 4.9% (P = .003); for deep infections, 3.2% vs 0.6% (P = .025); and for reoperations, 7.5% vs 2.6% (P = .009). For primary procedures in particular, differences in the incidences of these outcomes were even more significant. ConclusionsIn this study, early complications were more frequent in patients who underwent hip and knee arthroplasties in a safety net hospital compared with those who underwent the same procedures in a nearby university center. Future prospective studies are warranted to determine which patient-related or care process-related factors should be optimized to improve arthroplasty outcomes in vulnerable, safety net populations.

Predicting Adverse Health Outcomes in Nursing Homes: A 9-Year Longitudinal Study and Development of the FRAIL-Minimum Data Set (MDS) Quick Screening Tool

ObjectivesTo examine the predictive validity of a quick frailty screening tool, the FRAIL-NH, for adverse health outcomes in nursing home residents, using variables from the Minimum Data Set (MDS). The screening items were compiled from the MDS for potential direct application in long-term care facilities using this health information system. DesignLongitudinal follow-up study of nursing home residents with annual clinical assessment using the MDS and mortality data between 2005 and 2013. SettingSix nursing homes operated by a nongovernmental organization in Hong Kong. ParticipantsParticipants included 2380 nursing home residents aged 65 years or older at study baseline. MeasurementsFrailty assessed using the FRAIL-NH model with items from the MDS. The model covers 8 areas: fatigue, resistance, ambulation, incontinence, polypharmacy, weight loss, nutritional approach, and help with dressing. Adverse health outcomes in subsequent years were measured: incident falls, worsening activities of daily living (ADL) function, hospitalization, and death. ResultsUsing a cutoff score of 5 on the FRAIL-NH, the prevalence of frailty was 58.5% in this nursing home sample. Frailty as identified using the FRAIL-NH predicts incident falls, worsening ADL function, hospitalization, and death (hazard ratios [HR] 2.00–3.73). This remained significant after adjusting for sociodemographic and other clinical characteristics. Each level of increase on the FRAIL-NH has strong distinguishing power on the incidence of adverse outcomes. Intermediate frailty status (score 1–4) also significantly predicts adverse health outcomes (HR 1.57–2.06). ConclusionThe FRAIL-NH is a quick screening tool that can be used to identify frail and prefrail nursing home residents at risk of adverse health outcomes. It can be applied using variables from the MDS, allowing direct adoption in long-term care facilities already using this health information system.

Predictive value of abnormal second-trimester maternal serum triple screening markers for adverse pregnancy outcomes

To investigate the predictive value of abnormal multiples of the median (MoM) of second trimester maternal serum triple screening (STMSTS) markers for adverse pregnancy outcomes. 16 000 singleton pregnancies at 15⁺⁰ to 20⁺⁵ weeks' gestation who underwent STMSTS between July 2010 and January 2013 in the First Hospital of Jilin University were recruited. Maternal serum AFP, free β-hCG (F-β-hCG) and unconjugated estriol (uE3) levels were measured using time- resolved fluoroimmunoassay, and then converted to MoM. LifeCycle 3.2 software was used to calculate risk, and a risk value greater than 1 in 270 or 1 in 350 was considered as high risk for trisomy 21 syndrome (Down syndrome, DS) and trisomy 18 syndrome (Edwards syndrome, ES), respectively. MoM of AFP more than 2.5 was considered high risk for open neural tube defect (ONTD). Amniocentesis and karyotyping, ultrasound screening were advised for high risk women. AFP, F-β-hCG higher than 2.0 MoM or uE3 lower than 0.5 MoM was considered as abnormal, respectively. The MoM of STMSTS marker between women with adverse pregnancy outcome and with normal outcome was compared. (1) The median MoM of AFP, F-β-hCG and uE3 was 0.91 MoM, 0.94 MoM and 1.05 MoM, respectively. Of the 16 000 pregnant women, there was no statistical difference in the median MoM of triple screening marker at different weeks of gestation (P > 0.05). The positive rate of DS, ES and ONTD in women ≤35 years old (n = 14 972) was 4.03% (603/14 972), 0.36% (54/14 972) and 0.29% (44/14 972) respectively. And in women>35 years old (n = 1 028), the positive rate was 24.51% (252/1 028), 1.95% (20/1 028) and 0.78% (8/1 028), respectively. There was a statistically significant difference of positive rate between the two groups (P < 0.05). (2) 9 cases of DS, 1 case of ES and 1 case of ONTD were found in the high risk group, and 2 cases of DS in the low risk group. The detection rate of DS, ES and ONTD was 9/11, 1/1 and 1/1 respectively; and the positive predictive value was 1.05% (9/855), 1.35% (1/74) and 1.92% (1/52), respectively. (3)The incidence of adverse outcome (group 1) was 1.49 % ( 239/16 000). 7 760 pregnant women in this study were healthy during pregnancy, so were their fetuses (group 2). There were significant differences in the age at delivery, body weight and markers' MoM of STMSTS between the two groups (P < 0.01). (4) In group 1, the rate of abnormal MoM of AFP or F-β-hCG was 7.95% (19/239) and 23.85% (57/239), and the abnormal rate of MoM of uE3 was 4.18% (10/239). The rate of two abnormal MoM of markers was 5.02% (12/239); the rate that all three MoM were abnormal was 0.84% (2/239). However, in group 2, the rate of two abnormal MoM of markers was 0.14 % ( 11/7 760); and the rate that all three MoM were abnormal was 0. There was a significant difference of abnormal MoM of maternal serum marker between the two groups (P < 0.01). There is a relationship between abnormal marker of STMSTS and adverse outcomes. STMSTS show a high value in the detection of DS, ES and ONTD.

Surgeon length of service and risk-adjusted outcomes: linked observational analysis of the UK National Adult Cardiac Surgery Audit Registry and General Medical Council Register.

To explore the relationship between in-hospital mortality following adult cardiac surgery and the time since primary clinical qualification for the responsible consultant cardiac surgeon (a proxy for experience). Retrospective analysis of prospectively collected national registry data over a 10-year period using mixed-effects multiple logistic regression modelling. Surgeon experience was defined as the time between the date of surgery and award of primary clinical qualification. UK National Health Service hospitals performing cardiac surgery between January 2003 and December 2012. All patients undergoing coronary artery bypass grafts and/or valve surgery under the care of a consultant cardiac surgeon. All-cause in-hospital mortality. A total of 292,973 operations performed by 273 consultant surgeons (with lengths of service from 11.2 to 42.0 years) were included. Crude mortality increased approximately linearly until 33 years service, before decreasing. After adjusting for case-mix and year of surgery, there remained a statistically significant (p=0.002) association between length of service and in-hospital mortality (odds ratio 1.013; 95% CI 1.005-1.021 for each year of 'experience'). Consultant cardiac surgeons take on increasingly complex surgery as they gain experience. With this progression, the incidence of adverse outcomes is expected to increase, as is demonstrated in this study. After adjusting for case-mix using the EuroSCORE, we observed an increased risk of mortality in patients operated on by longer serving surgeons. This finding may reflect under-adjustment for risk, unmeasured confounding or a real association. Further research into outcomes over the time course of surgeon's careers is required.

Coexistence of low vitamin D and high fibroblast growth factor-23 plasma levels predicts an adverse outcome in patients with coronary artery disease.

ObjectiveVitamin D and fibroblast growth factor-23 (FGF-23) are related with cardiovascular disorders. We have investigated the relationship of calcidiol (vitamin D metabolite) and FGF-23 plasma levels with the incidence of adverse outcomes in patients with coronary artery disease.MethodsProspective follow-up study of 704 outpatients, attending the departments of Cardiology of four hospitals in Spain, 6–12 months after an acute coronary event. Baseline calcidiol, FGF-23, parathormone, and phosphate plasma levels were assessed. The outcome was the development of acute ischemic events (any acute coronary syndrome, stroke, or transient ischemic attack), heart failure, or death. Cox regression adjusted for the main confounders was performed.ResultsCalcidiol levels showed a moderate-severe decrease in 57.3% of cases. Parathormone, FGF-23, and phosphate levels were increased in 30.0%, 11.5% and 0.9% of patients, respectively. Only 22.4% of patients had glomerular filtration rate<60 ml/min1.73 m2. After a mean follow-up was 2.15±0.99 years, 77 patients developed the outcome. Calcidiol (hazard ratio [HR] = 0.67; 95% confidence interval [CI] = 0.48–0.94; p = 0.021) and FGF-23 (HR = 1.13; 95% CI = 1.04–1.23; p = 0.005) plasma levels predicted independently the outcome. There was a significant interaction between calcidiol and FGF-23 levels (p = 0.025). When the population was divided according to FGF-23 levels, calcidiol still predicted the outcome independently in patients with FGF-23 levels higher than the median (HR = 0.50; 95% CI = 0.31–0.80; p = 0.003) but not in those with FGF-23 levels below this value (HR = 1.03; 95% CI = 0.62–1.71; p = 0.904).ConclusionsAbnormalities in mineral metabolism are frequent in patients with stable coronary artery disease. In this population, low calcidiol plasma levels predict an adverse prognosis in the presence of high FGF-23 levels.

Analysis of the newborns who transferred from other hospitals and occurrence of adverse outcomes from 2008 to 2011

Objective To analyze the characteristics of newborns in occurrence of adverse outcomes that transferred from other hospitals during the past four years, in order to improve the province′s perinatal survival quality and reduce mortality. Methods The clinical data of 255 cases in occurrence of adverse outcomes in transit during January 2008 to December 2011 were analyzed retrospectively.According chronologically 255 cases were divided into group A (124 cases, January 2008 to December 2009) and group B(131 cases, January 2010 to December 2011). We analyzed the basic data, perinatal factors and major diseases of the newborns, and compared the changes of related characteristics in different periods. Results Adverse outcomes in male patients were significantly higher than female patients (male∶female 3.05∶1, 192∶63); there were higher proportion of premature infants (73.3%, 187/255) and cesarean section (49%, 125/255). The major diseases were respiratory system diseases (71.4%, 182/255), followed by circulatory system diseases (40.4%, 103/255), and severe congenital abnormalities (26.3%, 67/255). Group B compared with group A: (1) the proportion of hospitalization time <24 hours increased(73/131 vs 50/124, P<0.05); (2) the proportion of more than two referrals increased(41/131 vs 23/124, P<0.05); (3) the proportion of very low birth weight infants (including extremely low birth weight) increased significantly(75/131 vs 43/124, P<0.05); (4) the proportion of respiratory system diseased(131/131 vs 124/124), asphyxia(9/131 vs 22/124) and hypoxic ischemic encephalopathy(6/131 vs 16/124) decreased significantly(P<0.05); (5) the proportion of circulation system diseased(60/131 vs 31/124) and congenital developmental abnormalities(51/131 vs 23/124) increased significantly(P<0.05); (6) the application of mechanical ventilation(115/131 vs 88/124) and pulmonary surfactant(85/131 vs 52/124) increased significantly(P<0.05); (7) the usage of blood products decreased significantly (39/131 vs 53/124, P<0.05); (8) giving up treatment due to economic reasons reduced significantly (22/131 vs 37/124, P<0.05). Conclusion For the grassroots medical institutions, the choice of transport time and referral hospital may affect the incidence of adverse outcomes; the high rate of cesarean section may increase the incidence of adverse outcomes; the treatment capacity of extremely low and very low birth weight infants may directly affect the incidence of adverse outcomes; the respiratory system diseases greatly impact on adverse outcomes, but the accompanied circulatory system diseases impact on adverse outcomes increased in recent years. Key words: Adverse outcomes; Emergency transport; Newborn

Relationship between nuchal translucency and adverse pregnant outcomes

Objective To discuss the relationship between pregnant outcomes and increased fetal nuchal translucency (NT),and to predict adverse outcomes of fetus with NT.Methods One thousand eight hundred and thirty-nine women who had their antenatal visits in the First Affiliated Hospital of Kunming Medical University from February 13,2009 to May 16,2010 were admitted into the study.Crown rump length (CRL) and NT of fetus were measured following the guideline of Fetal Medicine Foundation.Pregnant outcomes were followed-up.The cut-off points of high risk of adverse pregnant outcome were set as NT≥2.0 mm,2.5 mm,3.0 mm,3.5 mm or 4.5 mm.Receiver operating characteristics (ROC) curve was drawn at different cut-off points to estimate the value of NT to predict adverse pregnancy outcomes.Differences between sensitivity and false positive rate were analyzed by Chi-square test or Fisher's exact test.Results The adverse outcome rate in this population was 2.7％ (49/1839).The positive likelihood ratios of NT≥2.0 mm,2.5 mm,3.0 mm,3.5 mm and 4.5 mm for adverse outcomes were 1.6,3.4,12.4,51.0 and 92.0,respectively; and the incidences of adverse outcomes were 2.7％,1.0％,4.0％,17.0％ and 75.0％,which rose with the increase of NT.Area under ROC curve for adverse outcomes was 0.647 with 95％CI of 0.561-0.732.Conclusions NT increase is related to adverse pregnant outcomes.The predictive value of different NT for the incidence of adverse outcomes might provide evidence for clinical consultation.NT is applicable in predicting adverse outcomes. Key words: Nuchal translucency measurement; Uitrasonography, prenatal; Pregnacy outcome; ROC curve

Platelet reactivity in the early and late phases of acute coronary syndromes according to cytochrome P450 2C19 phenotypes

BackgroundIt remains unknown whether the time course of the antiplatelet effects of clopidogrel differs according to cytochrome P450 (CYP) 2C19 phenotype in Japanese patients with acute coronary syndromes (ACS). Methods and resultsPlatelet reactivity was serially assessed by VerifyNow-P2Y12 assay (Accumetrics, San Diego, CA, USA). Results were expressed as P2Y12-reaction-units (PRU) in 177 patients with ACS who underwent stent implantation and received aspirin plus a 300-mg loading dose of clopidogrel followed by 75mg/day. High on-clopidogrel treatment platelet reactivity (HTPR) was defined as PRU>235. On the basis of the CYP2C19*2 and *3 alleles, 46 patients (26.0%) were classified as extensive metabolizers (EM), 103 (58.2%) as intermediate metabolizers (IM), and 28 (15.8%) as poor metabolizers (PM). At <7 days, the PRU level (232±102 vs. 279±70, 308±67, p<0.001) and the incidence of HTPR (49% vs. 74%, 86%, p=0.001) was lower in EM than in IM and PM. At 14–28 days the effects of CYP2C19 polymorphisms on PRU levels increased in a stepwise fashion (168±99 vs. 213±77 vs. 278±69, p<0.001), and EM and IM had lower percentages of HTPR than PM (28%, 37% vs. 73%, p<0.001). There was no significant difference in the cumulative frequency of 12-month adverse cardiovascular events among 3 phenotypes (16.5%, 14.1%, 9.2%; p=0.67). ConclusionAbout three quarters of Japanese patients with ACS carried CYP2C19 variant alleles. The majority of IM and PM had increased platelet reactivity during the early phase of ACS. Although HTPR was frequently observed even 14–28 days after standard maintenance doses of clopidogrel in PM, the incidence of adverse outcomes did not differ, irrespective of CYP2C19 genotype.

Nalbuphine for the treatment of opioid-induced pruritus: a systematic review

Opioid-induced pruritus is a common side-effect in patients with acute pain associated with surgery or childbirth. There are several options available to treat opioid-induced pruritus, including nalbuphine. However, it is not known whether nalbuphine offers greater efficacy in treating pruritus without attenuation of analgesia and increase in the incidence of adverse outcomes. A systematic search of studies assessing treatment efficacy of nalbuphine was conducted through Medline, PubMed, Cochrane Library, CINAHL and ProQuest databases. The primary outcome was incidence reduction of pruritus, while the secondary outcomes included analgesia and adverse outcomes. Ten studies that met all inclusion criteria were identified, nine of which were randomized controlled trials and one case report. The incidence of pruritus was higher among patients receiving neuraxial opioids. Nalbuphine provided greater efficacy in treating opioid-induced pruritus when compared to placebo, control or other pharmacologic agents such as diphenhydramine, naloxone and propofol. There was no attenuation of analgesia or increased in sedation with low dose nalbuphine treatment. Further, nalbuphine was associated with incidence reduction of nausea or vomiting; and reversal of respiratory depression. Nalbuphine is superior in treating opioid-induced pruritus when compared to placebo, control, diphenhydramine, naloxone or propofol in patients receiving opioids for acute pain related to surgery or childbirth. Therefore, it is recommended that nalbuphine should be used as first line treatment of opioid-induced pruritus.

Induction and Airway Management for Pyloromyotomy

Study background: Infants with pyloric stenosis are considered having a full stomach; however, rapid sequence induction has not been the only method used to secure the airway. A retrospective chart review was performed to evaluate the differences in incidences of adverse outcomes (e.g., desaturation, aspiration, and failed the first attempt intubation) between various induction and airway management techniques. Methods: A retrospective chart review over a 10-year period was conducted at a University affiliated children’s hospital. Induction and airway management techniques were abstracted from medical charts, and the incidences of aspiration, desaturation, failed the first attempt intubation, and duration of hospitalization were also recorded. Results: One hundred patients received intravenous rapid sequence induction with succinylcholine (42.6%), 78 patients received IV induction with non-depolarizing muscle relaxant (33.1%), 18 patients received IV propofol only (7.7%), 35 received inhalation induction (14.9%), and 4 received awake intubation (1.7%). There was no incidence of aspiration (0%) for all inductions, while 27 (11.4%) infants that received intravenous induction experienced desaturation during induction. We found that patients that received awake intubation had longer postoperative stays as compared to patients that received rapid sequence induction (p=0.017) and inhalation induction (p=0.016). Conclusions: This retrospective chart review concluded that there were no differences in the incidence of aspiration, desaturation, and the rate of successful first attempt intubation between various types of induction techniques. Rapid sequence induction with succhinylcholine was the most popular induction technique to secure the airway of infants with pyloric stenosis undergoing pyloromyotomy.

The Use of Combined Spinal-Epidural Analgesia Utilizing Intrathecal Morphine for Labor Pain in a Community Hospital

Purpose: To assess the incidence of adverse outcomes in pre-selected laboring patients who received low dose intrathecal morphine as part of the regional technique for labor analgesia. Methods: Retrospective observational study of 205 laboring patients who delivered at a large community hospital between January 2007 and December 2010. All patients received Duramorph, 250 μg, and fentanyl, 25 μg intrathecally. The primary adverse outcome was delayed maternal respiratory depression. Secondary adverse outcomes included high pain scores, low Apgar scores, and postpartum hemorrhage. Results: No cases of respiratory depression requiring naloxone administration were reported during the study. No infants had Apgar scores 4. Conclusion: This study demonstrates that regional analgesia utilizing low doses of intrathecal morphine and fentanyl in selected laboring patients is safe and effective.

Balloon atrial septostomy performed “out-of-hours”: effects on the outcome

Balloon atrial septostomy is a common palliative procedure in neonates with cyanotic congenital heart disease with restricted interatrial blood flow. Despite its advantages, balloon atrial septostomy is not a risk-free procedure and can be associated with numerous complications. The objective of this study is to determine whether the performance of this procedure out-of-hours has a significant impact on the incidence of adverse outcome measures. A total of 106 neonates who underwent balloon atrial septostomy between 2004 and 2010 were studied retrospectively. In all, 64 infants had the procedure performed within routine hours (9 am to 6 pm), whereas 42 neonates underwent the procedure out-of-hours (6:01 pm to 8:59 am). Procedure-related complications occurred in 32 infants (30.2%), which included 12 out of 64 (18.8%) infants in the routine-hours group and 20 out of 42 (47.6%) in the out-of-hours group. During further follow-up after surgery and including both major and minor adverse events, seven more infants (10.9%) suffered complications after balloon atrial septostomy in the routine-hours group and four more infants (9.5%) suffered complications in the out-of-hours group. This totalled the complication rate in the routine-hours group to 19 infants (29.7%) and 24 infants (57.1%) in the out-of-hours group (p = 0.001). A higher overall mortality rate was also noted in the out-of-hours group. Balloon atrial septostomy performed out-of-hours produced higher complication rates as opposed to balloon atrial septostomy performed during routine hours. Only essential cases should be undertaken at night, and all other cases should be deferred to the daytime to limit unnecessary adverse complication.

Geriatric consultation service in emergency department: how does it work?

BackgroundHong Kong is having a significant prevalence of geriatric patients who usually require admission after presentation to the hospital through emergency departments. The geriatric consultation programme ‘We Care’ aims at...

Three-Times-Daily Subcutaneous Unfractionated Heparin and Neuraxial Anesthesia

Subcutaneous (SC) unfractionated heparin (UFH) administered 3 times daily (TID) is widely used for venous thromboembolism prophylaxis in the perioperative period. There are no data in the literature regarding the incidence of adverse outcomes with neuraxial analgesia in the setting of this regimen. In this retrospective review, we report the incidence of untoward events related to anticoagulation with SC UFH TID in patients with indwelling epidural catheters. We queried the electronic hospital databases to identify patients receiving thoracic epidural analgesia in conjunction with 5000 U UFH SC TID from July 2008 to October 2010. In this group, we identified the diagnoses of neuraxial hematoma, deep vein thrombosis, or pulmonary embolism and examined measured blood coagulation parameters. In addition, we determined the percentage of patients receiving concomitant therapy with ketorolac. We identified 928 patients who received thoracic epidural analgesia in conjunction with 5000 U UFH SC TID during this period. There were no cases of neuraxial bleeding. Seven patients had a diagnosed deep vein thrombosis or pulmonary embolism. Thirty-four percent (315/928) of patients received ketorolac. The measured activated thromboplastin time was more than 40 seconds (35 seconds being the upper limit of normal) in 115 patients (12%). Given the rare incidence of neuraxial hematoma, statements regarding the appropriateness of epidural analgesia in the setting of TID SC UFH cannot be made from this limited sample size. At present, information regarding epidural hematoma in the setting of a TID SC UFH dosing regimen does not exist in the literature. Our study represents an initial step in the accumulation of data needed to prove or disprove the safety of this practice.

A Population-Based Comparison of the Incidence of Adverse Outcomes After Simultaneous-Bilateral and Staged-Bilateral Total Knee Arthroplasty

A Population-Based Comparison of the Incidence of Adverse Outcomes After Simultaneous-Bilateral and Staged-Bilateral Total Knee Arthroplasty

664: Oxytocin use during trial of labot after cesarean section (TOLAC)-is it really that dangerous?

section (TOLAC)-is it really that dangerous? Shunit Armon, Aharon Tevet, Tehila Avitan, Hadar Rosen, Surina Grisaro-Granovsky, Arnon Samueloff Shaare Zedek Medical Center, Obstetrics and Gynecology, Jerusalem, Israel, Shaare Zedek Medical Center, Obstetrics and Gynecology, Jerusalem, Israel, Shaare Zedek MC, Affiliated to the Hebrew University Medical School, Obstetrics and Gynecology, Jerusalem, Israel OBJECTIVE: To evaluate the safety of oxytocin during TOLAC. STUDY DESIGN: Prospective historical cohort trial in a tertiary center, May 2005-May 2011. All women, with a history of a single low transverse cesarean section (LSTCS) attempting vaginal delivery were included. Multifetal gestation, noncephalic presentations, known fetal malformations and intrauterine death were excluded. A strict protocol was implemented for Oxytocin use during induction/augmentation of labor. The protocol allowed use of oxytocin at an initial dose of 0.5mU/min, with increments of 0.5mU/min at 20’ intervals. Continuous FHR monitoring was mandated. Oxytocin was withheld from grandmultiparas and women with uterine malformations. Statistical analysis:descriptive,t test, chi square, Pearson coefficient, Fishers exact test,logistic regression model. RESULTS: During the study period 73,881 deliveries were attended, 4806 met entry criteria and analyzed according to oxytocin use. Group 1-665(13.8%) women treated with oxytocin (mean duration of 267 min). Group 2-4141 (86.2%) women not treated with oxytocin. Groups were comparable for maternal age, gestational age and epidural anesthesia. The overall rate of uterine rupture (UR) was .3%, and did not differ between the groups (p .42) nor did the finding of scar dehiscence. Grandmultiparas did not have a higher UR rate (p .76). Duration of oxytocin use did not effect the rate of UR (P .09). Women in group 1 were more likely to be delivered by CS or Vaccum. The incidence of adverse outcomes mainly post partum hemorrhage (PPH) and febrile morbidity was higher in the oxytocin group, this could be explained by the higher CS rate and oxytocin use. There were no maternal deaths. Neonatal outcomes: there was no difference between the groups regarding NICU admission. Surprisingly, The incidence of 5 apgar score 7 was higher among neonates from the “no oxytocin” group, and did not change after adjustment for gestational age. One neonatal death was recorded (group 1). CONCLUSION: Use of oxytocin under a strict protocol does not pose an additional risk of uterine rupture during TOLAC.

Controlled or uncontrolled clinical and subclinical hypothyroidism in pregnant women and its effect on obstetrical and neonatal outcome

Objetive To investigate the obstetrical and neonatal outcomes of pregnant women with hypothyroidism or subclinical hypothyroidism.Methods One hundred and sixty-eight pregnant women with clinical or subclinical hypothyroidism during pregnancy,including 9 controlled hypothyroidism,29 uncontrolled hypothyroidism and 130 subclinical hypothyroidism,were enrolled in this study.The general clinical information,obstetrical complications and neonatal outcomes of these pregnant women were compared with that of 180 healthy pregnant women who delivered during the same period.Results Compared with control group,there were no significant differences in the levels of serum free triiodothyronine( FT3 ),free thyroxine ( FT4 ),thyrotropin-stimulating hormone (TSH) in the controlled hypothyroidism group in the third trimester [(3.68 ±1.11 ) pmol/L vs (3.19 ±0.33) pmol/L,(15.48 ±4.14) pmoL/L vs (13.95 ± 1.68) pmol/L,1.87 mU/L vs 1.76 mU/L,P ＞0.05].However,in the second and third trimester,the levels of FT3,FT4 in the uncontrolled hypothyroidism group were lower,while the levels of TSH were higher than in control group [(2.71 ±0.80) pmol/L vs (3.14 ± 0.34) pmoL/L,(10.94 ± 2.68) pmol/L vs (14.25 ±2.01) pmol/L,5.62 mU/L vs 2.28 mU/L,( 2.34 ± 0.70 ) pmol/L vs ( 3.19 ± 0.33 ) pmol/L,( 10.16 ± 1.65 ) pmol/L vs (13.95 ± 1.68) pmoL/L,7.13 mU/L vs 1.76 mU/L,t =2.754～9.15,P ＜0.01],the levels of TSH in the subclinical hypothyroidism were higher than in control group ( t =18.28,18.57,P ＜0.01 ).There was no adverse perinatal outcome of neonate happened in controlled hypothyroidism group.In contrast,the incidences of adverse perinatal outcomes and complications in the uncontrolled hypothyroidism group were higher than that in the control group ( 17.2％ vs 2.8％,37.9％ vs 5.6％,x2 =11.47,28.97,P ＜0.01 ).Compared with that of control group,the incidences of adverse obstetrical outcomes in pregnant women with subclinical hypothyroidism were increased (40.0％ vs 5.6％,x2 =52.97,P ＜ 0.01 ).Conclusions The rate of adverse obstetrical outcomes and complications is increased in women with clinical or subclinical hypothyroidism.But the incidence of adverse outcomes would decrease if hypothyroidism is controlled by treatment. Key words: Pregnancy complications/TH ; Hypothyroidism/CO/TH; Pregnancy outcome