Routine Induction Research Articles

Earlier routine induction of labor-Consequences on mother and child morbidity.

A growing number of birth interventions had led to a concern for potential health consequences. This study investigates the consequences of earlier routine labor induction. It exploits a natural experiment caused by the introduction of new Danish obstetric guidelines in 2011. Consequently, routine labor induction was moved forward from 14 to 10-13days past the expected due date (EDD) and extended antenatal surveillance was introduced from 7days past the EDD. Using administrative data, I find that affected mothers on average had a 9-11 percentage points (32%-38%) higher risk of being induced the following years. Yet, mother and child short- and medium-term morbidity were largely unaffected.

Society of Family Planning Clinical Recommendation: Induction of fetal asystole before abortion Jointly developed with the Society for Maternal-Fetal Medicine

This document serves as a revision to the Society of Family Planning’s 2010 guidelines, integrating literature on new techniques and research and addressing the clinical, medical, and sociolegal questions surrounding the induction of fetal asystole. Insufficient evidence exists to recommend routine induction of fetal asystole before previable medication and procedural abortion. However, at periviable gestations and after fetal viability, inducing fetal asystole before abortion prevents the infrequent but serious occurrence of unanticipated expulsion of a fetus with cardiorespiratory activity (Best Practice). Defining viability is complicated as it represents a physiological continuum impacted by gestational duration along with multiple other individual clinical factors and circumstances; therefore, the exact gestational duration to offer fetal asystole will depend on the setting and clinical circumstances. If induction of fetal asystole before abortion is available, we recommend engaging in patient-centered counseling regarding the risks and benefits of induction of fetal asystole in the setting of each unique pregnancy scenario and the patient’s beliefs and priorities (Best Practice). We recommend that clinicians identify the optimal pharmacologic agent to administer for a given clinical scenario based on factors such as availability of each agent; the time frame in which fetal asystole needs to be established; and clinicians’ technical ability, preferences, and practice (Best Practice). Potassium chloride, lidocaine, and digoxin are all acceptable pharmaceutical agents to induce fetal asystole before abortion. To establish asystole rapidly, we suggest the use of potassium chloride (via intracardiac or intrafunic injection) or lidocaine (via intracardiac or intrafunic injection) (GRADE 2C), although intrathoracic administration of lidocaine may be acceptable. We recommend potassium chloride not be used if intracardiac or intrafunic location cannot be achieved to avoid the risk of accidental administration to the pregnant individual and because insufficient data support its efficacy via other intrafetal locations (GRADE 1C). When using digoxin, we recommend intrafetal administration (GRADE 1C), although intraamniotic administration may be acceptable depending on a clinician’s technical ability and setting. Because digoxin may take several hours to induce asystole, an alternative agent should be considered in settings where fetal asystole must be confirmed rapidly.

Airway Management of Intracranial Aneurysms Associated with Nasopharyngolaryngeal Hemangioma: A Case Report

Intracranial aneurysm is a very common disease, which is an abnormal bulge on the wall of intracranial artery. It is the first cause of subarachnoid hemorrhage. With the development of imaging, the disease is easily diagnosed. A 60-year-old man was diagnosed with anterior communicating artery aneurysm and underwent aneurysm clipping. During routine induction of anesthesia, a nasopharyngolaryngeal hemangioma was visualized under a video laryngoscope. This poses a serious challenge for tracheal intubation. With the assistance of a video laryngoscope and local anesthesia with lidocaine, a 6.5# reinforced endotracheal tube was inserted. Nasopharyngolaryngeal hemangioma is a congenital vascular anomaly characterized by proliferation of endothelial cells. The incidence of infantile and childhood hemangiomas is low, and most spontaneously resolve by the age of 4 to 6 years. Adult nasopharyngolaryngeal hemangioma are extremely rare and are residual lesions from infancy and childhood. Although nasopharyngolaryngeal hemangioma does not clearly affect the quality of life of patients, intracranial hemangioma has caused blurred vision and decreased vision. Therefore, surgery for intracranial aneurysm was necessary for this patient. This case emphasizes the management of unplanned difficult airway of pharyngeal hemangioma and the emergency plan for hemangioma rupture and bleeding. Provide guidance and risk management procedures for nasopharyngotracheal intubation.

The benefit of active management in true knot of the umbilical cord: a retrospective study

PurposeTo compare perinatal outcomes between active and routine management in true knot of the umbilical cord (TKUC).MethodsA retrospective study of singletons born beyond 22 6/7 weeks with TKUC. Active management included weekly fetal heart rate monitoring(FHRM) ≥ 30 weeks and labor induction at 36–37 weeks. Outcomes in active and routine management were compared, including composite asphyxia-related adverse outcome, fetal death, labor induction, Cesarean section (CS) or Instrumental delivery due to non-reassuring fetal heart rate (NRFHR), Apgar5 score < 7, cord Ph < 7, neonatal intensive care unit (NICU) admission and more.ResultsThe Active (n = 59) and Routine (n = 1091) Management groups demonstrated similar rates of composite asphyxia-related adverse outcome (16.9% vs 16.8%, p = 0.97). Active Management resulted in higher rates of labor induction < 37 weeks (22% vs 1.7%, p < 0.001), CS (37.3% vs 19.2%, p = 0.003) and NICU admissions (13.6% vs 3%, p < 0.001). Fetal death occurred exclusively in the Routine Management group (1.8% vs 0%, p = 0.6).ConclusionCompared with routine management, weekly FHRM and labor induction between 36 and 37 weeks in TKUC do not appear to reduce neonatal asphyxia. In its current form, active management is associated with higher rates of CS, induced prematurity and NICU admissions. Labor induction before 37 weeks should be avoided.

The Effect of Topical Benzydamine Hydrochloride and Cuff Pressure Monitorization on Postoperative Sore Throat Due to Intubation.

Postoperative sore throat (POST) is the most common discomfort after endotracheal intubation. Damage to the tracheal mucosa caused by inappropriate endotracheal tube (ETT) cuff pressure has been shown as the major factor. Monitoring the ETT cuff pressure at a certain value reduces this damage. Benzydamine hydrochloride (BH) has proven to be effective on sore throat and studies have shown that it is also effective on POST. In this study, the efficacy of BH and ETT cuff pressure monitoring on POST was evaluated. After ethics committee approval 210 patients in the ASA (American Society of Anesthesiologists) I-III risk group undergoing elective surgery were included in the study. Routine anesthesia monitoring, induction, and maintenance were provided. Patients were randomly divided into three groups. Thirty minutes before surgery, the posterior pharyngeal wall was sprayed with BHin group 1and distilled water in groups 2 and 3. Intraoperatively, the first and second groups were monitored to keep the ETT cuff pressure between 22 and 26 cmH2O, while no intervention was performed in the third group. The incidence and severity of postoperative dysphagia, hoarseness, and POST were questioned. There was no difference between demographic data, and gender was not associated with POST. There was a statistically significant difference between the first and second groups and the third group in terms of all three symptoms questioned (p<0.01). No difference was observed between the first and second groups. Side effect rates were similar. Smoking was not found to be associated with symptoms. The incidence and severity of POST, dysphagia, and hoarseness are reduced when the ETT cuff is inflated with a pressure of 22-26 cmH2O after intubation with a manometer and maintained at this pressure range throughout the operation. There was no beneficial effect of BH.

Effects of intraoperative Magnesium sulfate infusion on emergency agitation during general anesthesia in patients undergoing radical mastectomy: a randomized controlled study

BackgroundEmergency agitation is a common postoperative complication in patients under general anesthesia, which can lead to unpredictable damages such as shedding of drainage tube and bleeding from the wound. The purpose of the study is to investigate whether intraoperative infusion of Magnesium Sulfate reduces the incidence of emergency agitation (EA) in patients undergoing radical mastectomy, and to evaluate its safety and efficacy.MethodsA total of 70 patients were randomly assigned to two groups: the Magnesium group (M group) and the control group (C group). After a routine intravenous anesthetic induction, patients in the M group received a 30 mg/kg bolus of intravenous magnesium during the first hour and then a continuous infusion of 10 mg/kg ×h until the end of the surgery, patients in the C group received 0.9% saline at the same volume and rate. The sedation-agitation scale (SAS) and the visual analogue scale were used to assess agitation and pain, respectively.ResultsCompared to the C group, the M group reduced the incidence of EA significantly (odds ratio 0.26, 95% confidence interval 0.09–0.71, P = 0.009). The postoperative pain score of the magnesium sulfate group(0(0,1)) was lower than that of the control group(2(0,3)) at T0 (P = 0.011). Additionally, the M group required a lower dosage of remifentanil during surgery compared to the C group(300.4 ± 84 versus 559.3 ± 184 µg, respectively, P<0.001).Conclusionsthe intraoperative infusion of magnesium sulfate is a safe and effective method for reducing the incidence of emergency agitation in patients undergoing radical mastectomy.Trail registrationThe study was registered in Chictr.org with the identifier: ChiCTR2300070595 on 18/04/2023.

Comparison of lidocaine and its combination with ketamine for distal intravenous regional anesthesia (DIVRA) in bovines

The hoof diseases of cattle can be managed surgically under intravenous regional anesthesia (IVRA). For routine induction of IVRA, a tourniquet is placed circumferentially at the metacarpus/metatarsus. In the present study, hoof diseases of cattle were corrected using a modified IVRA technique. The cattle with hoof ailments were randomly divided into two groups and a tourniquet was placed just distal to the dew claws instead of at the metacarpus/metatarsus in order to decrease the dose of anesthetic. In group I lidocaine (2mg/kg) and in group II a mixture of lidocaine and ketamine (2mg/kg+1.5mg/kg) was injected into the axial digital vein to induce distal intravenous regional anesthesia (DIVRA). The heart rate, respiration rate, systolic and diastolic pressure were unaffected in both groups. Oxygen saturation was significantly (P&lt;0.05) lower between 5 and 60 minutes in group I and between 15and 40 minutes in group II animals. The sensory and motor block onset time was shorter, and the sensory and motor block recovery time was longer in group II animals as compared to group I animals. It was concluded that the DIVRA technique using lidocaine alone and lidocaine admixed with ketamine are suitable for hoof examination and surgery.

Projecting future prolapse outcomes with induction of labor at 39 weeks: a decision analysis.

In 2018, the ARRIVE trial (A Randomized Trial of Induction Versus Expectant Management) concluded that routine induction of labor (IOL) at 39 weeks gestation decreases cesarean delivery risk, with slightly lighter birthweight infants. We debated whether routine IOL would improve, worsen, or not change POP risk compared with expectant management (EM). We constructed a decision analysis model with a lifetime horizon where nulliparous women reaching 39 weeks underwent IOL or EM. Subsequent vaginal versus cesarean delivery varied based on prior deliveries for up to four births. Subsequent delivery prior to 39 weeks and distribution of gestational age, birthweight, and delivery mode between 24 and 39 weeks was modeled from national data. We modeled increased POP risk with increasing vaginal parity, forceps delivery, and weight of largest infant delivered vaginally, accounting for differential infant weights in each strategy. IOL and EM have similar population-wide POP risk (15.9% and 15.7% respectively). Among women with only spontaneous vaginal deliveries that reached 39 weeks or beyond, the prevalence of POP was 20% after one delivery and 29% after four deliveries, with no difference between groups. The cesarean rate was lower with IOL (27.8% versus 29.8%). Sensitivity analysis revealed no meaningful thresholds among the variables, supporting model robustness. While routine induction of labor at 39 weeks results in a meaningfully higher vaginal delivery rate, there was no increase in POP, possibly due to the protective effect of lower birthweight.

The Relationship of Occupational Health and Safety K3 to Employee Performance in the Workplace Systematic Review Prospective cohort study

Occupational health and safety K3 ensures that people are not injured or become sick due to hazards in the workplace. ensuring that preventing the risk of frequent industrial accidents and diseases that cause the loss of workers' lives and or affect employee performance. K3 is a science that focuses on ensuring safety in the workplace. Occupational safety and health (K3) is defined as the science and application of technology regarding the prevention of work accidents and occupational diseases. By providing OSH protection, it is expected that workers can work safely, healthily and productively. Research purposes. To find out health and safety K3 on employee performance in the workplace. Method. Descriptive with observational cohort. Prospective. Results. Knowing the level of occupational health and safety K3 on employee performance at work. Conclusion. Therefore, it can be concluded that in occupational health and safety risks of OSH to improve the safety of health workers, which includes various occupational risk factors in the workplace, provide refresher training and routine induction training on OSH and use personal protective equipment (PPE). To ensure safety and health in the sector prioritizing the health of workers.

Research Update: Healthy Birth Practice #1-Let Labor Begin on Its Own.

This article is an adaptation for print of Debby Amis's presentation at the 2022 Lamaze Virtual Conference. She discusses worldwide recommendations as to the optimal time for routine labor induction for low-risk pregnant persons, the recent research about the optimal time for routine labor induction, and recommendations to help the pregnant family make an informed decision about routine induction. This article includes an important new study not included in the Lamaze Virtual Conference that found an increase in perinatal deaths for low-risk pregnancies that were induced at 39 weeks as compared to low-risk pregnancies not induced at 39 weeks but were delivered no later than 42 weeks.

Impact of the "39-week rule" on adverse pregnancy outcomes: a statewide analysis.

The "39-week rule," adopted by the American College of Obstetricians and Gynecologists circa 2009, discouraged routine elective induction of labor in early-term gestations (37 weeks 0 days-38 weeks 6 days) to decrease the risk of adverse neonatal outcomes. However, little research exists regarding any unintended adverse pregnancy outcomes associated with this policy shift. This study aimed to quantify the difference in incidence of adverse pregnancy outcomes before and after the implementation of the 39-week rule. Deidentified data from all births in the state of South Carolina from 2000 to 2008 (before the 39-week rule) and from 2013 to 2017 (after statewide implementation and enforcement of the rule) were obtained from the South Carolina Revenue and Fiscal Affairs Office. Demographic data and International Classification of Diseases 9/10 codes were obtained for each birth. Our primary outcome was the incidence of any of the following adverse pregnancy outcomes: cesarean delivery, hypertensive disorders, chorioamnionitis, postpartum hemorrhage, high-degree lacerations, placental abruption, and intensive care unit admission. Propensity score analysis was used to control for age, body mass index, and race. After stratification by propensity score, the Cochran-Mantel-Haenszel test was used to compare the prerule and postrule groups. A total of 633,985 births were eligible for inclusion-412,632 from 2000 to 2008, and 221,353 from 2013 to 2017. There was a significant increase in the primary outcome in the postrule period (39.94% pre vs 42.76% post; P<.01). The incidence of all hypertensive disorders was significantly increased in the postrule period compared with the prerule period (7.75% pre vs 10.1% post; P<.01). The incidence of chorioamnionitis and cesarean delivery also increased in the postrule period (1.45% pre vs 1.92% post; P<.01; 29.6% pre vs 31.82% post; P<.01; respectively). There was a significant increase in the primary outcome following the implementation of the 39-week rule. Although the policy shift was driven by a desire to decrease adverse neonatal outcomes, aggregate benefit was not observed for pregnancy outcomes.

Fetal surveillance from 39 weeks’ gestation to reduce stillbirth in South Asian-born women

In July 2017, the State of Victoria's largest maternity service implemented a new clinical guideline to reduce the rates of stillbirth at term for South Asian women. This study aimed to evaluate the impact of offering fetal surveillance from 39 weeks to South Asian-born women on rates of stillbirth and neonatal and obstetrical interventions. This was a cohort study of all women receiving antenatal care at 3 large metropolitan university-affiliated teaching hospitals in Victoria, who gave birth in the term period between January 2016 and December 2020. Differences in rates of stillbirth, neonatal deaths, perinatal morbidities, and interventions after July 2017 were determined. Multigroup interrupted time-series analysis was used to assess changes in rates of stillbirth and induction of labor. A total of 3506 South Asian-born women gave birth before, and 8532 after the change in practice. There was a 64% reduction in term stillbirth (95% confidence interval, 87% to 2%; P=.047) after the change in practice from 2.3 per 1000 births to 0.8 per 1000 births. The rates of early neonatal death (3.1/1000 vs 1.3/1000; P=.03) and special care nursery admission (16.5% vs 11.1%; P<.001) also decreased. There were no significant differences in admission to the neonatal intensive care unit, 5-minute Apgar score <7, or birthweight, or differences in the trends of induction of labor per month. Fetal monitoring from 39 weeks may offer an alternative to routine earlier induction of labor to reduce the rates of stillbirth without causing an increase in neonatal morbidity and attenuating trends in obstetrical interventions.

Development and testing of a decision aid to achieve shared decision-making for routine labor induction.

This quality improvement project aimed to create a decision aid for labor induction in healthy pregnancies at or beyond 39 weeks that met the needs of pregnant people least likely to experience shared decision-making and to identify and test implementation strategies to support its use in prenatal care. We used quality improvement and qualitative methods to develop, test, and refine a patient decision aid. The decision aid was tested in three languages by providers across obstetrics, family medicine, and midwifery practices at a tertiary care hospital and two community health centers. Outcomes included patients' understanding of their choices, pros and cons of choices, and the decision being theirs or a shared one with their provider. Patient interview data indicated that shared decision-making on labor induction was achieved. Across three Plan-Do-Study-Act cycles, we interviewed a diverse group of 24 pregnant people: 20 were people of color, 16 were publicly insured, and 15 were born outside the United States. All but one (23/24) reported feeling the decision was theirs or a shared one with their provider. The majority could name induction choices they had along with pros and cons. Interviewees described the decision-making experience as empowering and positive. Nine medical providers tested the decision aid and gave feedback. Providers stated the tool helped improve the quality of their counseling and reduce bias. This project suggests that using an evidence-based and well-tested decision aid can help achieve shared decision-making on labor induction for a diverse group of pregnant people.

Comparison of double lumen tube insertion using the McGrath MAC versus direct laryngoscopy in adult patients with a limited glottis view: A prospective interventional study.

Passage of double-lumen tubes (DLT) can be challenging in patients with limited glottis view. This study aims to determine the usefulness of McGrath® MAC videolaryngoscope (VL) in cases with limited glottis view on direct laryngoscopy with Macintosh blade. After study approval and registration of trial, consent was sought from all adult patients planned for elective DLT insertion for lung isolation during the course of general anesthesia. Patients not consenting, less than 18 years, with anticipated difficult mask ventilation or need for rapid sequence induction were excluded. Following routine anesthetic induction, laryngoscopy was attempted by an experienced anesthesiologist using Macintosh scope. If the view obtained was Cormack and Lehane (CL) view IIB and above or the attempt at intubation using DLT failed despite a CL I/IIA view, the patient was included in the trial. The laryngoscope was removed and after ensuring adequate oxygenation and depth of anesthesia, intubation was attempted using McGrath® MAC VL. The percentage of glottis opening (POGO) score was noted for both the scopes. DLT insertion was attempted in 76 patients in the study period. Eight patients were included in the trial on account of limited glottis view/failure with Macintosh scope. Insertion of DLT with McGrath MAC was tried only in six patients, in two patients, the VL was not available for use. The mean (standard deviation) POGO score with Macintosh scope was 9 (±20), which significantly improved with the use of VL to 71 (±24), P = 0.01. McGrath MAC is helpful in inserting DLT in patients with limited glottis view with Macintosh scope.

A Psychological Resilience Briefing Intervention for Helicopter Emergency Medical Service Observers

ObjectiveHelicopter emergency medical services (HEMS) observers may be at risk of negative psychological effects associated with exposure to traumatic events during shifts. This article describes a quality improvement project for HEMS observers at Essex & Herts Air Ambulance. MethodsA psychological resilience briefing intervention (PRBi) was developed and delivered during induction training with 60 HEMS observers. The PRBi aimed to raise awareness of traumatic events that observers may experience and provided basic education on 5 domains, including likely forms of trauma exposure, possible psychological reactions, advice on coping strategies and supporting colleagues, and resources that they could use if required. The intervention was intended to bolster resilience and reduce posttraumatic stress disorder symptoms, and to encourage adaptive coping styles in observers. ResultsObservers learned from and valued the PRBi; statistically significant increases were observed in awareness of the 5 domains from pre- to post-delivery, and free-text responses cited a variety of benefits to the observers. There was no indication that the PRBi caused harm. ConclusionThe PRBi has now been included in the routine induction of observers at Essex & Herts Air Ambulance and has the potential to be repurposed for use in other settings, including medical schools.

P51 - Factors associated with spontaneous vaginal birth in nulliparous women at term: a systematic review

The aim of this systematic review was to identify the factors associated with spontaneous vaginal birth at term, in nulliparous, women with a singleton pregnancy. Exposures or interventions of interest included those related to safe and modifiable opportunities to attain a primary spontaneous vaginal birth, such as clinical practices, models of care and women’s own intentions and attributes. Nine databases were searched with dates extending from inception to 16 July 2021. Quantitative studies of all designs, published in English, of nulliparous women with a singleton pregnancy and cephalic presentation, who experienced a spontaneous vaginal birth (SVB) at term were included. Covidence was used to manage citation screening and full text review. Two reviewers undertook quality appraisal and RCTs with high risk of bias (ROB 2.0) and other designs (QATSDD) scoring ≤ 50% were excluded. Data was abstracted from 78 studies (31 RCTs, 33 cohort, 9 cross-sectional, 4 prevalence and 2 case control) and factors associated with SVB were categorised as maternal, clinical care and fetal to synthesise findings. There was established evidence to support interventions to address maternal BMI, birth intentions and fear of childbirth as well as childbirth education, breathing and exercise interventions in the antenatal period and midwifery models of care to increase SVB in nulliparas. Findings did not support routine induction to promote SVB, but the relationship between maternal pelvic anatomy and fetal positioning and strategies to optimise labour progression emerged as promising areas for further research. How women give birth the first time is important, and this review highlights key domains where evidence synthesis can guide improvements in care and direct future research.

Outcome of Spontaneous Vaginal Delivery and Elective Induction of Labour in Postdated Pregnancy

Background: Postdated pregnancies are associated with increased perinatal morbidity and mortality. The risk increases when pregnancy continues beyond 41 wks. So, the Induction of labor conducted at or beyond 41 wks could help prevent these complications. But there are certain risks associated with Induction of labor. Again, Induction success varies widely and depends on some modifiable and nonmodifiable factors. Objective: To assess the feto-maternal outcome and analyze the factors affecting the outcome of electively induced labour in postdated pregnancy with a low bishop score compared to spontaneous onset labour in a secondary level hospital. Materials and methods: Prospective analytical study involving 220 participants divided into induction (study) and spontaneous labour (control) groups. Data collected on socio-demographic data, characteristics of the study population, causes of failed Induction, maternal complications and neonatal outcomes. Results: Among electively induced postdated pregnancy (study group) vaginal delivery was 45.45% with caesarean section 54.54% compared to 80% and 20% respectively in the spontaneous labour (control group). Cervical dystocia was the commonest indication for caesarean section (P=0.001). Among maternal complications control group had significant perineal lacerations (P=0.016) and study group had a longer duration of hospital stay (P&lt;0.001). The neonatal outcome didn’t show significant difference. Conclusion: The present study showed routine Induction of labor in prolonged pregnancy may encourage higher caesarean section rate with prolonged hospital stay but judicious Induction even in poor bishop score is not associated with any major feto-maternal complication. Further multicentric study with a larger sample size is recommended. J Bangladesh Coll Phys Surg 2022; 40: 175-182

Restrictive Rather Than Routine Use Of Basiliximab For Heart Transplant Induction

Introduction The use of immunosuppression induction strategies greatly varies between heart transplant (HT) centers. Clinicians must weigh the risk of allograft rejection with infection and malignancies. Our center stopped routine induction with the Interleukin-2 receptor antagonist basiliximab in 2016 after findings of increased infection, malignancy, and a trend towards higher mortality. Hypothesis We aimed to assess the effect of our protocol change abandoning routine use of basiliximab on survival, allograft rejection, infection, and malignancy. Methods Retrospective single-center analysis of consecutive HT recipients from 2003 to 2015 and 2017-2019. In 2016 the induction protocol was changed, and the adjustment period was excluded. Furthermore, patients bridged to transplant with LVAD, re-transplantation and multi-organ transplants were not included. Results : A total of 398 patients were identified (mean age 55±11, 72% male) and grouped by induction with basiliximab or no induction. There were no clinically significant differences in baseline characteristics between the groups including age, panel reactive antibody % (PRA) and kidney function (Table). One-year mortality was significantly lower in the no-basiliximab group 1.9 vs 6.75% p 0.03 (Figure 1). Multivariate regression for basiliximab, PRA, age, gender, diabetes mellitus, creatinine did not identify independent risk factors for mortality. Significantly more patients in the no-basiliximab group had ≥ 1 rejection (≥ 2R ISHLT 2004) 68 vs 44% with significantly lower rejection free survival (p 0.0001) per log-rank test (Figure 2). There was no longer a significant difference in rates of bacterial and fungal infections as well as CMV-viremia and malignancies during the first-year post-transplant year. Conclusion Restrictive rather than routine use of basiliximab induction is no longer associated with increased infectious and early malignancy but remains associated with inferior survival despite lower incidence of early rejection and comparable immunological risk based on PRA. In the future improved individual immunologic risk profiling might be helpful to better risk stratify transplant candidates, who might benefit from induction. The use of immunosuppression induction strategies greatly varies between heart transplant (HT) centers. Clinicians must weigh the risk of allograft rejection with infection and malignancies. Our center stopped routine induction with the Interleukin-2 receptor antagonist basiliximab in 2016 after findings of increased infection, malignancy, and a trend towards higher mortality. We aimed to assess the effect of our protocol change abandoning routine use of basiliximab on survival, allograft rejection, infection, and malignancy. Retrospective single-center analysis of consecutive HT recipients from 2003 to 2015 and 2017-2019. In 2016 the induction protocol was changed, and the adjustment period was excluded. Furthermore, patients bridged to transplant with LVAD, re-transplantation and multi-organ transplants were not included. : A total of 398 patients were identified (mean age 55±11, 72% male) and grouped by induction with basiliximab or no induction. There were no clinically significant differences in baseline characteristics between the groups including age, panel reactive antibody % (PRA) and kidney function (Table). One-year mortality was significantly lower in the no-basiliximab group 1.9 vs 6.75% p 0.03 (Figure 1). Multivariate regression for basiliximab, PRA, age, gender, diabetes mellitus, creatinine did not identify independent risk factors for mortality. Significantly more patients in the no-basiliximab group had ≥ 1 rejection (≥ 2R ISHLT 2004) 68 vs 44% with significantly lower rejection free survival (p 0.0001) per log-rank test (Figure 2). There was no longer a significant difference in rates of bacterial and fungal infections as well as CMV-viremia and malignancies during the first-year post-transplant year. Restrictive rather than routine use of basiliximab induction is no longer associated with increased infectious and early malignancy but remains associated with inferior survival despite lower incidence of early rejection and comparable immunological risk based on PRA. In the future improved individual immunologic risk profiling might be helpful to better risk stratify transplant candidates, who might benefit from induction.

Maternal characteristics as indications for routine induction of labor: A nationwide retrospective cohort study.

BackgroundMaternal characteristics, such as parity and age, are increasingly considered indications for routine induction of labor of otherwise healthy women to prevent fetal and neonatal mortality. To fully balance the risks and benefits of induction of labor, we examined the association of additional relevant maternal characteristics and gestational age with fetal and neonatal mortality.MethodsWe conducted a nationwide retrospective cohort study among a healthy Dutch population consisting of all singleton pregnancies in midwife‐led care after 37 weeks of gestation in the period 2000‐2018. We examined the association of maternal ethnicity, age, parity, and socioeconomic status with fetal and neonatal mortality, stratified by gestational age. The association of single characteristics was examined using descriptive statistics, and univariable and multivariable logistics regression analyses. The associations of multiple characteristics were examined using inter‐categorical analyses and using interaction terms in the multivariable logistic regression analyses.ResultsThe results showed that ethnicity, age, parity, socioeconomic status, and gestational age did not act as single determinant of fetal and neonatal mortality. The probability of fetal and neonatal mortality differed among subgroups of women depending on which determinants were considered and the number of determinants included.ConclusionsDecision‐making about induction of labor to prevent fetal and neonatal mortality based on a single determinant may lead to overuse or underuse of IOL. A value‐based health care strategy, addressing social inequity, and investing in better screening and diagnostic methods that employ an individualized and multi‐determinant approach may be more effective at preventing fetal and neonatal mortality.

The impact of induction therapy on mortality and treated rejection in cardiac transplantation: A retrospective study

Evidence regarding the utility of routine induction therapy on outcomes is not clear. This study aims to evaluate whether induction therapy is associated with a reduced risk of treated rejection and improved overall survival. We retrospectively analyzed all adult patients (age ≥ 18 years) that are included in the UNOS database who underwent heart transplantation between 2000 and 2017. Patients with prior transplants and dual organ transplants were excluded. 34,361 patients were included in the final analysis. We assessed the impact of induction therapy with T cell depleting agents (TC-DA), IL2 receptor antagonists (IL2R antagonist) and compared that to no induction therapy using Cox regression models adjusted for propensity scores. The primary outcome measure was all-cause mortality, whereas treated rejection at one year was analyzed as a secondary outcome measure (available in 77% of patients). A total of 52% of the cohort did not receive any induction therapy. A total of 27% received IL2R antagonist and the rest received TC-DA. Median age of the recipients was 55 (IQR: 46-62) years. A total of 25% of the population were women and 39% were supported on left ventricular assist device therapy at the time of transplantation. Median follow-up was 4.2 (IQR: 1.1-8.5) years with 32% reported mortality. Multivariate analysis with propensity score adjustment showed that TC-DA induction did not have any effect on mortality (HR=0.98, 95% CI 0.93-1.03, p=0.48). However, IL2R antagonist was associated with a modestly increased risk of all-cause mortality compared to no induction (HR=1.06, 95% CI 1.01-1.11, p=0.02, respectively). A total of 25% of patients were found to have treated rejection at one year, TC-DA induction was associated with reduced odds of rejection at one year (OR=0.82, 95% CI 0.76-0.88, p < 0.001). However, induction with IL2R antagonist was not found to have a significant impact (OR=1.03, 95% CI 0.96-1.11, p = 0.36). Compared to no induction therapy, induction with TC-DA was associated with reduction in risk of treated rejection at 1 year with no effect on mortality and IL2R antagonist was associated with a small but statistically significant increase in mortality without any impact on risk of rejection.