Non-medical Reasons Research Articles

Real-world safety and efficacy of CT-P13, an infliximab biosimilar, in Japanese rheumatoid arthritis patients naïve to or switched from biologics.

The aim of this post-marketing surveillance (PMS) study is to evaluate the real-world safety and efficacy of CT-P13, the first biosimilar of infliximab (IFX). Japanese patients with rheumatoid arthritis were prospectively registered from November 2014 and followed up for 1 year. Of 794 patients in the analysis set, 318 patients naïve to biological disease-modifying antirheumatic drugs (bDMARDs) showed an immediate decrease in Disease Activity Score in 28 joints with C-reactive protein (DAS28-CRP) and increased remission rate (DAS28-CRP < 2.6). In patients who switched from IFX to CT-P13 for non-medical reasons (n = 374), the low DAS28-CRP due to previous IFX treatment decreased further with continued CT-P13 therapy. As in naïve patients, patients who switched from other bDMARDs, mainly for medical reasons (n = 102), responded similarly to CT-P13. CT-P13 in this PMS and IFX in a previous PMS had similar adverse reaction profiles, although the incidence rate in naïve patients in this current PMS was lower due to earlier initiation of CT-P13 therapy. CT-P13 showed excellent effectiveness as first-line therapy, no clinical difficulties in switching from IFX, and clinical improvement in patients who failed other bDMARDs. CT-P13 could be a cost-effective alternative to IFX in the treatment of rheumatoid arthritis.

Comparison of the Effect and Complications of Sequential Bilateral Arthroplasty at Different Time Intervals and Simultaneous Bilateral Total Knee Arthroplasty: A Single-Centre Retrospective Cohort Study.

To the authors' knowledge, there is no current consensus regarding the optimal interprocedural interval for patients who have undergone bilateral total knee arthroplasty (BTKA). The purpose of this study is to evaluate complication rates and functional outcome in patients who have undergone BTKA (simultaneous or sequential at different time intervals), and to determine an optimal time frame for the second knee. Data from 315 patients who were able to tolerate simultaneous BTKA according to the anaesthesiologist's preoperative assessment between 2016 and 2020 were analysed retrospectively. According to the operative time interval, they were divided into simultaneous, ≤1-month sequential, 1- to 3-month sequential, and ≥3-month sequential BTKA groups. The primary outcomes were revision and readmission rates during the follow-up period, and the secondary outcomes were hospital length of stay (LOS), transfusion and postoperative complications. There was no difference in the implant survival or readmission rate between the groups (p>0.05). Multivariable linear regression showed that interprocedural interval and body mass index (BMI) affected LOS; the LOS of simultaneous BTKA was the shortest (p<0.05). BMI was associated with an increased LOS of 0.25days (95% CI 0.02-0.48, p=0.03). A modified Poisson regression model showed that the odds of blood transfusion were reduced in sequential BTKAs of any interval (p<0.05), and preoperative haemoglobin (Hb) was also a risk factor (RR 0.96, 95% CI 0.95-0.98, p<0.001). The interprocedural interval was not a risk factor for postoperative cardiovascular and cerebrovascular complications. For appropriate patients, simultaneous BTKA is beneficial. However, higher preoperative haemoglobin was required to mitigate the high blood transfusion rate associated with simultaneous surgeries. If suitable patients refuse simultaneous BTKA for other non-medical reasons, sequential BTKA with an interval greater than 1month is recommended.

Paracetamol: unconventional uses of a well-known drug.

To describe and map what is known about unconventional uses of paracetamol through a scoping review of published literature by adopting adopted a PRISMA systematic approach methodology. Four themes for unconventional uses of paracetamol emerged: (a) use of paracetamol in sleep (a-1) positive effect of paracetamol on sleep (n = 9) or (a-2) neutral or negative effect of paracetamol on sleep (n = 9); (b) use of paracetamol in sport (n = 13); (c) mixing paracetamol with drinks, waterpipe and illicit drugs (n = 5); and (d) miscellaneous uses (n = 4). Forty records were reviewed and charted. Available literature supports concern around the potential of harmful or non-medical use of paracetamol, especially among patients with a history of substance use, parents of young children or athletes. Paracetamol (acetaminophen) is one of the most popular and widely used drugs for the treatment of pain and fever. It is considered remarkably safe if used within instructions. However, there is growing evidence that paracetamol, is sometimes used outside approved indications or abused (i.e. used for non-medical reasons). This review highlights the need for enhanced pharmacovigilance and surveillance of non-medical paracetamol use and raising general public awareness of its potential dangers especially in higher than recommended doses.

Hospital staff at most psychiatric clinics in Stockholm experience that patients who self-harm have too long hospital stays, with ensuing detrimental effects

Background Previous research on patients who self-harm has indicated potential negative effects from long hospital stays. Yet, such care has been reported to occur regularly. We conducted this questionnaire study to investigate how hospital staff, who treat self-harming patients, experience the relation between lengths of stay and self-harm behaviour, and the motives for non-beneficial hospital stays. Methods The respondents of the questionnaire were nurses and mental health workers employed at public inpatient wards in Stockholm, treating patients who self-harm. The questionnaire contained questions with fixed answers and room for comments. A total of 304 questionnaires were distributed to 13 wards at five clinics, and the response rate was 63%. The data were analysed with descriptive statistics and qualitative descriptive content analysis. Results The results show that most staff experienced that more than a week’s stay either increased (57%) or had no effect (33%) on self-harm behaviour. Most respondents at most clinics considered the stays to be too long at their wards, and that the stays could be reduced. The respondents recognized several reasons for non-beneficial hospital stays, like fear of suicidal behaviour and doctors’ fear of complaints. Patients appearing as demanding or fragile were thought to be given more care than others. The respondents’ comments confirmed the majority’s experience of detrimental effects from longer hospital stays. Conclusions A majority of the health care staff experienced that patients who self-harm often receive too long hospital stays, with detrimental effects, and they had experienced several non-medical reasons for such care.

Litigation on Gender Confirmation Surgery and Hormonal Therapy among Trans Women Prisoners: Views from the U.S. Circuit Courts of Appeals

This article analyzes U.S. Circuit Courts of Appeals’ cases involving Title 42 U.S.C. §1983 actions filed by trans women inmates against corrections and/or medical officers for failure to provide hormone therapy and/or gender confirmation surgery (“GCS”) (N = 24). The courts varied in their decisions. The Ninth Circuit has been more progressive toward trans rights, holding that GCS can be medically necessary depending on the individualized needs of the transgender inmate because there is a medical consensus on the appropriateness of these treatments. The First and Fifth Circuits rejected requests for GCS because of the lack of medical consensus on the necessity of GCS. Both the Seventh and Eleventh Circuits held that failure to provide medically recommended care for a non-medical reason and unexplained delays in treatment can constitute deliberate indifference, violating the Eighth Amendment. Under Tenth Circuit precedent, prison officials are not deliberately indifferent for failing to provide hormone treatments.

Not the same, but is it the same? Cycling of biologic agents in rheumatoid arthritis. Experience in the Instituto Mexicano del Seguro Social

IntroductionAvailable data for biocomparable drugs are not enough to make clear decisions with respect to the potential consequences of a change for non-medical reasons in efficacy, security and inmunogenicity in patients. In the near future, options on biological treatments, biocomparable drugs, non biocomparable drugs and new chemical synthesis options will grow. Therefore, it is important to know how patients behave in persistence of treatment after a change for non- medical reasons, which already happens on a regular basis in social security institutions in Mexico. This information will help us to better understand the standard of treatment for patients with chronic immunomediated conditions. ObjectiveThe primary objective was to measure the impact of change for non-medical reasons in patients with rheumatoid arthritis (RA) treated with an innovative biological on persistence of treatment after changing to a biocomparable drug or a non-biocomparable drug, compared with those patients staying with the innovative biological. Study designThis is an observational study (non-interventionist) of paired cohorts, where an historic cohort obtained by review of clinical records of stable patients in which no modifications to treatment were made for at least six months is compared with two cohorts of patients whose treatments were switched to another treatment with the same therapeutic mechanism for-non-medical reasons (cycling). ResultsWe included 264 RA patients (ACR/EULAR, 2010); 132 were switched for non-medical reasons, and 132 were not switched. Two-hundred and thirty (87.1%) were female. Average age was 53.9 years, ranging from 16 to 84 years. Two-hundred and sixty-three patients were Latino (99.6%); one was Caucasian. Persistence of treatment 12 months after the change was 84.8% (85.8% in Enbrel/Infinitam, 78.9% for Remicade/Remsima). No statistical difference was found with respect to RA clinical activity measured by DAS28 12 months after the switch (P > .05). In the 134 switched patients, 20 discontinued the new treatment due to lack of efficacy of the new drug and were changed to a different drug with a different biologic target. Although no differences were found in the cohorts of switched patients with respect to DAS 28 after 12 months of use, we did find differences in the frequency of adverse events. Forty-two patients had an adverse event in the drug switch cohorts: 33 in the Enbrel-Infinitam group and 9 in the Remicade-Remsima group. ConclusionsThe persistence of treatment after switching from an innovative drug to a biocomparable or a non- biocomparable in RA patients did not show statistically significative differences in our cohorts, but we did find a higher number of adverse events when comparing those who were changed with those who continued on an innovative drug. Twenty patients in the switch groups had to receive a new drug with a different biological target due to lack of efficacy of the switched drug.

The limits of refusal: An ethical review of solid organ transplantation and vaccine hesitancy

Patients pursuing solid organ transplantation are encouraged to receive many vaccines on an accelerated timeline. Vaccination prior to transplantation offers the best chance of developing immunity and may expand the pool of donor organs that candidates can accept without needing posttransplant therapy. Furthermore, transplant recipients are at greater risk for acquiring vaccine-preventable illnesses or succumbing to severe sequelae of such illnesses. However, a rising rate of vaccine refusal has challenged transplant centers to address the phenomenon of vaccine hesitancy. Transplant centers may need to consider adopting a policy of denial of solid organ transplantation on the basis of vaccine refusal for non-medical reasons (i.e., philosophical or religious objections or personal beliefs that vaccines are unnecessary or unsafe). Arguments supporting such a policy are motivated by utility, stewardship, and beneficence. Arguments opposing such a policy emphasize justice and respect for persons, and seek to avoid worsening inequities or medical coercion. This paper examines these arguments and situates them within the special cases of pediatric transplantation, emergent transplantation, and living donation. Ultimately, a uniform national policy addressing vaccine refusal among transplant candidates is needed to resolve this ethical dilemma and establish a consistent, fair, and standard approach to vaccine refusal in transplantation.

Factors influencing treatment delays in a safety net hospital: teachable moments?

<h3>Objectives:</h3> Delays in diagnosis and treatment of ovarian cancer contribute to decreased overall survival. A post-hoc analysis of a GOG study demonstrated that initiation of chemotherapy more than 25 days after surgery adversely affected survival. Furthermore, previous studies have shown that socio-demographic factors also play a role in treatment delays. We sought to determine factors contributing to delays in treatment initiation and reasons for delay in chemotherapy administration in patients receiving primary treatment of epithelial ovarian cancer at our safety net hospital. <h3>Methods:</h3> All patients with epithelial ovarian cancer seen between 1/1/2009 and 12/1/2019 were identified. Only patients who had primary chemotherapy at our safety net hospital were included. Demographic variables included race, ethnicity, median household income (MHI), and age for patients undergoing both primary cytoreductive surgery (PCRS) and neoadjuvant chemotherapy (NACT). A delay in initiation of chemotherapy was defined as > 25 days post surgery (whether undergoing PCRS or interval cytoreduction after NACT). Time to treatment initiation (TTI) was defined as date of gynecologic oncology consult to surgery (for PCRS) or first cycle of chemotherapy (for NACT). Delays between cycles of chemotherapy were noted through chart review. Linear regression analyses were performed using demographic variables as predictors for treatment duration (with p value set at 0.05). <h3>Results:</h3> 101 patients were identified that met inclusion criteria. The median age in this cohort was 61 years (range 25-82). 18 (17.8%) were Black and 75 (74.3%) were Hispanic. 81 (80.2%) patients had a MHI less than $60,000. 63 (62.4%) patients underwent PCRS and 38 (37.6%) patients underwent NACT. 77.2% of patients did not initiate adjuvant chemotherapy until > 25 days post surgery. The median TTI in the PCRS group was 15 days; however, 53 (84.1%) patients undergoing PCRS received their first cycle of chemotherapy > 25 days post surgery. The median TTI in the NACT group was 19 days, and 25 (65.8%) patients who completed NACT received their first cycle of adjuvant chemotherapy > 25 days after surgery. Black patients undergoing PCRS experienced a 30 day longer TTI than White patients (p=0.013). TTI for patients undergoing PCRS and living in an area with a median household income < $30,000 was 42 days versus 14 days in patients living in an area with median household income >$60,000 (p=0.033). In patients greater than 65 years old undergoing NACT, the time from interval cytoreductive surgery to adjuvant chemotherapy start was longer: 27 days for patients age < 65 years versus 39 days for patients ≥65 years (p=0.005). There were 76 total delays in chemotherapy administration identified. 39 (60.9%) of these were due to medical reasons and 37 (48.6%) were due to non-medical reasons. Specifically, 5 (6.5%) were due to regimen intolerance; 11 (14.5%) were due to hospitalizations or surgeries; 15 (19.7%) were due to patient factors such as transportation; 22 (28.9%) were due to scheduling barriers; and 23 (30.1%) were due to lab abnormalities. <h3>Conclusions:</h3> Significant delays exist in initiation of treatment and completion of treatment in patients receiving first line therapy for epithelial ovarian cancer. Race, income, and age were predictors of delays in treatment. Both medical as well as non-medical factors precluded timely delivery of treatment. Future quality studies at our institution will investigate whether these changes decrease delays in cancer care.

Female Genital Mutilation: Knowledge and Skills of Health Professionals.

Background: Female genital mutilation (FGM) is any process that injures female genitals for non-medical reasons and is a violation of women’s human rights. An important number of women from countries where FGM is performed are arriving to Western countries. Health professionals are important for detecting cases of FGM. No surveys to assess knowledge, attitudes and practices on FGM among healthcare professionals has been conducted in Castilla la Mancha (Spain) until now. Methods: The main goal of the study is assessing knowledge, attitudes and perceptions of healthcare professionals in relation to FGM. A cross-sectional descriptive study was conducted based on self-administered online surveys to nurses, midwives, family doctors, pediatricians, obstetrics and gynecologists. Results: In total, 1168 professionals answered the surveys. Just 13.9% indicated that they had received training in FGM, however just 10.7% correctly identified the three types of FGM, 10.7% the countries where it is usually practiced, 33.9% knew the legislation in Spain and only 4.4% found a case of FGM during their professional practice. Regarding the knowledge about protocols, 8.64% of the sample indicated to know one of them. Conclusion: The present study demonstrate that it is necessary to improve the training and awareness of healthcare professionals related to FGM in Castilla la Mancha.

Social Freezing: Pressing Pause on Fertility.

Increasing numbers of women are undergoing oocyte or tissue cryopreservation for medical or social reasons to increase their chances of having genetic children. Social egg freezing (SEF) allows women to preserve their fertility in anticipation of age-related fertility decline and ineffective fertility treatments at older ages. The purpose of this study was to summarize recent findings focusing on the challenges of elective egg freezing. We performed a systematic literature review on social egg freezing published during the last ten years. From the systematically screened literature, we identified and analyzed five main topics of interest during the last decade: (a) different fertility preservation techniques, (b) safety of freezing, (c) usage rate of frozen oocytes, (d) ethical considerations, and (e) cost-effectiveness of SEF. Fertility can be preserved for non-medical reasons through oocyte, embryos, or ovarian tissue cryopreservation, with oocyte vitrification being a new and optimal approach. Elective oocyte cryopreservation is better accepted, supports social gender equality, and enhances women’s reproductive autonomy. Despite controversies, planned oocyte cryopreservation appears as a chosen strategy against age-related infertility and may allow women to feel that they are more socially, psychologically, and financially stable before motherhood.

Attitude towards female circumcision among women in Ethiopia

Female genital mutilation or cutting (FGM/C) is a global phenomenon mostly practiced in Africa, Asia, and the middle east. It involves the removal of the external female genitalia for non-medical reasons. The practice cuts across different ethnic and religious groups in Africa and is associated with several health complications. The following study assessed attitude towards the practice among Ethiopian women aged 15–49. Using the Ethiopia Demographic and Health Survey from 2016 as a data source, we analyzed a sample of 6984 women. We used the respectable femininity discourse to inform our variable selection. The main outcome variable assessed whether women supported or rejected the continuation of the practice. In the bivariate analysis, all the sociodemographic variables including women’s circumcision experience were strongly associated with the outcome variable. In the multiple logistic regression, only education, wealth, religion, and circumcision status were independently associated with women’s attitude towards FGM/C. For instance, compared to women with no education, women with at least a secondary education were more than 4 times (AOR 4.2, 95% CI 2.53–7.04, P-Value < 0.001) more likely to agree with the termination of the practice. Our findings suggest that changing attitudes towards FGM/C may require uplifting the social and economic status of women, working with those who have experienced FGM/C and collaborating with religious leaders.

Prevalence of subclinical bactibilia inapparently healthy shelter dogs.

To determine the prevalence of subclinical bactibilia in apparently healthy shelter dogs and characterise serum liver enzymes activities, hepatobiliary histopathology and bile cytology in apparently healthy dogs with and without bactibilia. Healthy, abandoned dogs euthanased for non-medical reasons were prospectively recruited for this cross-sectional study. Whole blood, collected immediately before euthanasia, was submitted for serum liver enzyme activity (alkaline phosphatase, alanine aminotransferase and gamma-glutamyl transferase) analyses. Bile, gall bladder and liver samples were collected aseptically from dogs within 25 minutes of euthanasia. Bile was submitted for bacterial culture and cytology in all dogs. Gall bladder and liver samples were submitted for histopathological examination in bactibilic dogs and nine randomly selected non-bactibilic dogs. Sixty-five healthy dogs were included in this study. Bactibilia was diagnosed in 10.8% (7/65) of dogs, with 9.2% (6/65) of dogs diagnosed on cytological examination and 4.6% (3/65) on culture. Elevated alanine aminotransferase activities were present in one bactibilic and five non-bactibilic dogs; and elevated gamma-glutamyl transferase activities in one bactibilic and two non-bactibilic dogs. No dogs had elevated alkaline phosphatase activities. Histopathological changes in bactibilic and non-bactibilic dogs included lymphoplasmocellular cholecystitis (7/7 and 9/9), gall bladder oedema (7/7 and 9/9), hepatic vacuolar degeneration (6/7 and 8/9), cholangitis (5/7 and 7/9), hepatic nodular hyperplasia (3/7 and 5/9) and hepatic cholestasis (2/7 and 4/9). This study confirms that subclinical bactibilia occurs in a small number of apparently healthy shelter dogs and that subclinical hepatobiliary histopathological abnormalities can occur in apparently healthy bactibilic and non-bactibilic dogs.

The perception of high school students in The Gambia towards the practice of female genital mutilation.

The World Health Organization defines female genital mutilation as all procedures involving partial or total removal of the external female genitalia for non-medical reasons [1]. Globally, it is estimated that more than 200 million girls and women alive today have undergone FGM [2]. In The Gambia, a study of 1157 women revealed that 58% of the participants had undergone FGM [3]. A similar study revealed that "78.8% of women aged 15 to 49 years had signs of having undergone female circumcision" [4]. The present study examined the perception of high school students regarding the practice of FGM and concluded that students' views remain unchanged in their support for the practice of FGM in The Gambia. In 2015, a survey of 152 high school students was conducted across the eight regions of The Gambia to examine student support of the practice of FGM. In every region, a high school was randomly selected, and the survey was administered to 25 students.

Refractory fibromyalgia.

In the medical literature, there are only a few references on refractory fibromyalgia and there is no consensus definition available on this concept. Some definitions of refractory fibromyalgia have been proposed based on the lack of response to a number of medications, and perhaps the most appropriate term is treatment-refractory fibromyalgia. To achieve the definition of treatment-refractory fibromyalgia, it is necessary to consider several previous steps, such as making sure the diagnosis has been made properly and a differential diagnosis with entities that can mimic fibromyalgia symptoms (including complete physical examination and laboratory test) has been made. The possibility that another factor that alters the response to treatment should be investigated, and in particular review all prescribed medication and search for some non-medical reasons that could mask the response to treatment (e.g., legal compensation). The definition of refractory fibromyalgia is complex and probably should include a lack of response to a specified number of drugs or to combination therapy with at least two non-pharmacological measures. In this article, it is not our purpose to present a formal definition, but to raise the possible bases for this purpose. We believe that it is a subject that must be discussed extensively before reaching a consensus definition. Key Points • There is no appropriate definition to classify fibromyalgia patients who do not respond to the usual pharmacological and non-pharmacological measures according to the national or international guidelines. • A consensus definition is required to classify these patients, which could help standardize future management strategies. In this article, we propose the bases on which refractory fibromyalgia could be defined.

Is Freezing the Future? Investigating Interest of Elective Oocyte Freezing Amongst Singaporean Women

A novel technological innovation called Elective Oocyte Freezing (EOF) has emerged as a solution for women who wish to preserve their fertility to delay childbearing for non-medical reasons. This technology has grown in popularity as women have undertaken a greater role in the workforce and faced the dilemma of balancing work and family. In spite of the rising trend of Singaporean women postponing childbearing to advance their careers, EOF is currently prohibited in Singapore. Many Singaporean individuals have declared this policy to be both outdated and a threat to women’s reproductive rights. However, prior to this survey, no research, to my knowledge, has analyzed Singaporean female professionals' interests in EOF, if made available. Through this quantitative, cross-sectional, 4-part survey, I conclude that if EOF was permitted, encouraged, and subsidised by the Singaporean government, Singaporean women possess a strong interest in freezing their eggs for social purposes This paper further demonstrates an existing positive relationship between 48 Singaporean female professionals’ interest in EOF prior to and following reading an information leaflet. Specifically, after being informed of the social benefits presented by EOF, participants were significantly more inclined to freeze their eggs if such practice was permitted in Singapore. This conclusion suggests that the Singaporean government should re-evaluate their position on EOF in order to facilitate childbearing dilemmas faced by the increasing number of women entering the country’s workforce each year. Additionally, as this policy is currently a subject of debate in Singapore, the implications of this research, revealing Singaporean female professionals’ interest in EOF, create a foundation for both future research and the possible evaluation of this policy. If this conclusion is corroborated with subsequent research, further evidence may substantiate my findings regarding the desires of Singaporean women and possibly result in a change of legislation.

How representative is a point-of-care randomized trial? Clinical outcomes of patients excluded from a point-of-care randomized controlled trial evaluating antibiotic duration for Gram-negative bacteraemia: a multicentre prospective observational cohort study

ObjectivesPatients included in randomized controlled trials (RCT) are poorly representative of the general population. We compared outcomes of patients excluded from the PIRATE trial, a point-of-care RCT evaluating antibiotic durations for Gram-negative bacteraemia, with those of enrolled patients. MethodsA prospective observational cohort study, ‘EPCO’ (Excluded Patients' Clinical Outcomes) included patients excluded from the PIRATE trial. As in PIRATE, whose patients were randomized to 7-day, 14-day, or C-reactive-protein (CRP)-guided antibiotic durations, EPCO's primary outcome was occurrence of clinical success at 30 days. We also compared baseline characteristics, outcome rates and treatment-effect estimates. ResultsIn all, 405 patients were included in EPCO and compared with the 503 PIRATE patients. Reasons for exclusion were mainly medical (317/405; 78%), the most frequent being complicated infection. Excluded patients had more co-morbidities (Charlson median 3 versus 1, p < 0.001). Bacteraemia was more often health-care-associated (26% versus 9%, p < 0.001). The 30-day success rate was significantly lower among EPCO patients (299/396; 76% versus 469/493; 95%, p < 0.001), but the success rate was not significantly different for those excluded for non-medical reasons (68/75; 91%, p 0.09). There was no significant difference in failure rates of EPCO patients according to their treatment duration (difference 7 days versus 14 days: p 0.75; 7 days versus CRP-correspondent: p 1.00; 14 days versus CRP-correspondent: p 1.00). ConclusionAlthough point-of-care-randomized trials are more inclusive and representative than traditional RCTs, they are still likely to select patients with lower failure risk. Shorter antibiotic durations were not associated with failure in either included or excluded patients, supporting the generalizability of the PIRATE trial's findings.

Induced abortion via telemedicine should become the norm: a commentary.

Women, girls, and vulnerable populations have been disproportionately impacted by the Covid-19 pandemic. Many countries have ill-advisedly deemed abortion 'non-essential'. [1] In response to the pandemic abortion for non-medical reasons was banned in six countries in Europe and suspended in another. [2] Early medical abortion (EMA) involves taking two drugs, mifepristone, followed 24-48 hours later by misoprostol.

Management of Vertical Sternal Fracture Nonunion in Elite-Level Athletes.

Background:Sternal fractures are rare, and they can be treated nonoperatively. Vertical sternal fractures have rarely been reported.Purpose:To describe the management and surgical treatment of a series of elite-level athletes who presented with symptomatic nonunions of a vertical sternal fracture.Study Design:Case series; Level of evidence, 4.Methods:Patients with an established symptomatic nonunion of a vertical sternal fracture, as diagnosed by computed tomography (CT) or magnetic resonance imaging (MRI), underwent open reduction and internal fixation using autologous bone graft and cannulated lag screws. The patients were assessed preoperatively and at the final follow-up using the Rockwood sternoclavicular joint (SCJ) score; Constant score; and shortened version of the Disabilities of the Arm, Shoulder and Hand (QuickDASH) scores. Bony union was confirmed on postoperative CT scan.Results:Five patients (4 men and 1 woman) were included; all were national- or international-level athletes (rugby, judo, show-jumping, and MotoGP). The mean age at surgery was 23.4 years (range, 19-27 years), the mean time from injury to referral was 13.6 months (range, 10-17 months), and the mean time from injury to surgery was 15.8 months (range, 11-20 months). The mean follow-up was 99.4 months (range, 25-168 months). There was a significant improvement after surgery in the mean Rockwood SCJ score (from 12.6 to 14.8 [P < .05]), Constant score (from 84 to 96.4 [P < .05]; 80% met the minimal clinically important difference [MCID] of 10.4 points), and QuickDASH (from 6.8 to 0.98 [P < .05]; 0% met the MCID of 15.9 points). Four of the patients were able to return to sport at their preinjury level, and 1 patient retired for nonmedical reasons. All of the fractures had united on the postoperative CT scan. There were no postoperative complications.Conclusion:Vertical fractures of the sternum are very rare and tend to behave clinically like an avulsion fracture injury to the capsuloligamentous structure of the inferior SCJ. The requirement of advanced imaging to diagnose this injury means that the actual incidence and natural history are not known. For high-demand athletes, early identification, surgical reduction, and fixation are likely to achieve the best outcome.

Intrapartum interventions and outcomes for women and children following induction of labour at term in uncomplicated pregnancies: a 16-year population-based linked data study

ObjectivesWe compared intrapartum interventions and outcomes for mothers, neonates and children up to 16 years, for induction of labour (IOL) versus spontaneous labour onset in uncomplicated term pregnancies with live...

Physical activity and sleep duration during pregnancy have interactive effects on caesarean delivery: a population-based cohort study in Tianjin, China

BackgroundThere were inconsistent findings in the literature regarding the associations of physical activity and sleep duration during pregnancy with caesarean delivery for different reasons. It was also unknown whether physical activity and sleep duration during pregnancy had interactive effects on the risks of different types of caesarean delivery. The study aimed to investigate the effects of physical activity, sleep duration and their interactions on the risk of caesarean delivery for medical reasons and non-medical reasons.MethodsFrom October 2010 to August 2012, a prospective population-based cohort of 13,015 pregnant women was established in six central urban districts of Tianjin, China. Pregnancy outcomes were retrieved from an electronic database and caesarean delivery was divided into caesarean delivery for medical reasons and caesarean delivery for non-medical reasons. Physical activity and sleep status were collected at 24–28 weeks of gestation using self-reported questionnaires. Logistic regression and additive interaction were used to examine physical activity, sleep duration and their interactive effects on risk of caesarean delivery.ResultsIn the cohort, 5692 (43.7%) and 2641 (20.3%) of women had caesarean delivery for medical reasons and non-medical reasons, respectively. Low physical activity increased the risk of caesarean delivery for medical reasons (adjusted OR: 1.13, 95%CI 1.04–1.23) but not caesarean delivery for non-medical reasons. Sleep duration < 7 h/day and poor sleep quality were not associated with caesarean delivery. Sleep duration ≥9 h/day increased the risk of caesarean delivery for medical reasons (1.12, 1.02–1.22) and caesarean delivery for non-medical reasons (1.16, 1.05–1.29). Co-presence of low physical activity and sleep duration ≥9 h/day increased risk of caesarean delivery (1.25, 1.12–1.41), and their additive interaction was statistically significant for caesarean delivery for medical reasons but not for caesarean delivery for non-medical reasons.ConclusionsLow physical activity and excessive sleep duration during pregnancy each increased the risk of caesarean delivery, and they had an interactive effect on the risk of caesarean delivery for medical reasons but not on the risk of caesarean delivery for non-medical reasons. Increasing physical activity and maintaining recommended sleep duration during pregnancy may have benefits for perinatal health.