Real-world impact of laparoscopic surgery for rectal cancer: a population-based analysis.

Background: Randomized trials have demonstrated equivalent oncologic outcomes and decreased morbidity in patients with rectal cancer who undergo laparoscopic surgery (lapsx) compared with open surgery (opensx). The objective of the present study was to compare short-term outcomes after lapsx and opensx in a real-world setting. Methods: A national discharge abstract database was used to identify all patients who underwent rectal cancer resection in Canada (excluding Quebec) from April 2004 through March 2015. Short-term outcomes examined included same-admission mortality and length of stay (los). Results: Of 28,455 patients, 82.4% underwent opensx, and 17.6%, lapsx. The use of lapsx increased to 34% in 2014 from 5.9% in 2004 (p < 0.0001). Same-admission mortality was lower among patients undergoing lapsx than among those undergoing opensx (1.08% and 1.95% respectively, p < 0.0001). On multivariable analysis, the odds of same-admission mortality with lapsx was 36% lower than that with opensx (odds ratio: 0.64; p = 0.003). Median los was shorter after lapsx than after opensx (5 days and 8 days respectively, p = 0.0001). The strong association of lapsx with shorter los was maintained on multivariable analysis controlling for patient, surgeon, and hospital factors. Conclusions: For patients with rectal cancer, shorter los and decreased same-admission mortality are associated with the use of lapsx compared with opensx.

Cost-utility analysis of proton pump inhibitors and other gastro-protective agents for prevention of gastrointestinal complications in elderly patients taking nonselective nonsteroidal anti-inflammatory agents.

BACKGROUND: The use of proton pump inhibitors (PPIs) among elderly patients using nonselective nonsteroidal anti-inflammatory drugs (nsNSAIDs) has increased; the price of PPIs is higher than that of majority of alternative treatment strategies. AIM: To evaluate the cost-effectiveness of nsNSAIDS + PPIs relative to alternative gastroprotective regimens in the prevention of GI complications among elderly patients (aged > or = 65 years). METHODS: An incremental cost-utility analysis, comparing PPIs with alternative gastroprotective regimens was conducted using a decision analytical model. Clinical outcomes, costs and utilities were derived from recently published studies. Probabilistic and deterministic sensitivity analyses were performed to test the robustness of the results to variation in model inputs and assumptions. RESULTS: The incremental cost-utility ratio (ICUR) of PPIs, relative to nsNSAID alone, was $206,315 per QALY gained or were more costly and less effective. Other co-prescribed treatment options had higher costs per QALY gained. In patients with a history of a complicated or uncomplicated ulcer, PPIs had ICURs of $24,277 and $40,876, respectively. CONCLUSIONS: Use of PPIs in all elderly patients taking nsNSAIDs is unlikely to represent an efficient use of finite healthcare resources. Co-prescribing PPIs, however, to elderly patients taking nsNSAIDs who have a history of complicated or uncomplicated ulcers appears to be economically attractive.

Baseline characteristics of patients enrolled in the Canadian Fabry Disease Initiative.

The Canadian Fabry Disease Initiative [CFDI] is a longitudinal study evaluating all Canadians diagnosed with Fabry disease [FD]. The study has 3 cohorts: Cohort 1A which includes 81 subjects who were on enzyme replacement therapy [ERT] prior to October 2006, Cohort 1B which has ongoing enrolment of subjects newly started on ERT who are randomized to agalsidase alfa or agalsidase beta, and Cohort 1C where subjects who do not meet nationally accepted Canadian criteria for ERT are followed to assess the natural history of disease complications. The study currently enrols 244 patients [95 males and 149 females] with a mean age of 41.9+/-14.5years. There is a high prevalence of the c.427G>C mutation. Cohort 1A contains 82 patients [59 males, 23 females] of whom 42% are known to have cardiac complications of FD and 38% renal complications. Cohort 1B at the time of writing contained 37 patients [15 males, 22 females] of whom the indications for ERT were cardiac in 55% and renal in 60%. Cohort 1C at the time of writing contained 125 patients [22 males, 103 females]. Enrolment is ongoing in both Cohorts 1B and 1C. When compared to subjects in the Fabry Outcome Survey and the Fabry Registry, subjects in the CFDI are less likely to be male reflecting less ascertainment bias. The CFDI is a robust national data set that will contribute to available data on the natural history of FD and on the comparative efficacy of the two commercially available ERT products.

Low levels of maternal serum PAPP-A in early pregnancy and the risk of adverse outcomes.

OBJECTIVES: To determine if low maternal serum level of pregnancy associated plasma protein A (PAPP-A) measured in early pregnancy can predict adverse pregnancy outcomes and to examine the gestational age (GA) sampling interval for these outcomes. METHODS: This was a nested case-control study from a prospective cohort of women recruited at <20 weeks of gestation in Halifax, NS. Cases (n=248) were defined as women who had a fetal loss or developed preeclampsia, severe pregnancy-induced hypertension (PIH), or small for gestational age infant (SGA). Controls (n=244) were frequency matched to cases by GA at the time of serum sampling (6 to <20 weeks GA). Participant information was obtained from questionnaires and medical chart reviews. RESULTS: Women with a low PAPP-A measure [0.4 MoM). However, performance as a screening test was poor [sensitivity=38.7%; specificity=81.6%; positive likelihood ratio (LR)=2.1; negative LR=0.75]. In the adjusted model, the 10- to 14-week GA period was the only time period where low PAPP-A was significantly associated with adverse outcomes. CONCLUSIONS: Women with a low PAPP-A early in their pregnancy have twice the risk of an adverse outcome, though PAPP-A as a one-time single marker test has limited value.

Rates of urinary tract injury from gynecologic surgery and the role of intraoperative cystoscopy.

OBJECTIVE: To estimate the rates of urinary tract injury after benign gynecologic surgery. To explore the role of routine intraoperative cystoscopy at benign gynecologic surgery. DATA SOURCES: We conducted a systematic MEDLINE search for urinary tract injuries at gynecologic surgery for the period from November 1998 to May 2004 and combined this with a previous systematic review performed in the same fashion for the period from January 1966 to October 1998. METHODS OF STUDY SELECTION: There were 47 studies that fit our inclusion criteria: 29 that did not use routine intraoperative cystoscopy, 17 that used routine intraoperative cystoscopy, and 1 that reported the frequency of urinary tract injury separately, with and without routine intraoperative cystoscopy. We determined the crude and fitted ureteric and bladder injury rates for each surgery type from the studies where routine intraoperative cystoscopy was not performed and then from the studies where routine intraoperative cystoscopy was performed. TABULATION, INTEGRATION, AND RESULTS: From studies without routine cystoscopy, combined ureter and bladder injury rates varied according to the complexity of the surgery, ranging from less than 1 injury per 1000 for subtotal hysterectomy with or without bilateral salpingo-oophorectomy to as many as 13 injuries per 1000 surgeries for laparoscopic hysterectomy with or without bilateral salpingo-oophorectomy and for other gynecologic and urogynecologic surgeries. Injury rates were higher when routine intraoperative cystoscopy was used, but the confidence intervals were wider. CONCLUSION: The reasons for higher injury detection rates when routine cystoscopy was performed are unclear. Further study is needed to identify the scenarios where routine cystoscopy is warranted after major gynecologic surgery.

Differences between perspectives of physicians and patients on anticoagulation in patients with atrial fibrillation: observational study.

OBJECTIVE: To determine and compare physicians' and patients' thresholds for how much reduction in risk of stroke is necessary and how much risk of excess bleeding is acceptable with antithrombotic treatment in people with atrial fibrillation. DESIGN: Prospective observational study. SETTING: Tertiary and peripheral referral centres in Nova Scotia, Canada. PARTICIPANTS: 63 physicians who were treating patients with atrial fibrillation and 61 patients at high risk for atrial fibrillation. MAIN OUTCOME MEASURES: Participants underwent a face to face interview with a probability trade-off tool. Thresholds were determined for the minimum reduction in risk of stroke necessary and the maximum increase in risk of excess bleeding acceptable for treatment with aspirin and warfarin in people with atrial fibrillation. RESULTS: The minimum number of strokes that needed to be prevented in 100 patients over two years for warfarin to be justified was significantly lower for patients than for physicians (1.8 (SD 1.9) v 2.5 (1.6), P=0.009), whereas for aspirin there was no difference between patients and physicians (1.3 (1.3) v 1.6 (1.5), P=0.29). The maximum number of excess bleeds acceptable in 100 patients over two years for use of warfarin and aspirin was significantly higher for patients than for physicians (warfarin 17.4 (7.1) v 10.3 (6.1); aspirin 14.7 (8.5) v 6.7 (6.2); P<0.001 for both comparisons). CONCLUSIONS: Patients at high risk for atrial fibrillation placed more value on the avoidance of stroke and less value on the avoidance of bleeding than did physicians who treat patients with atrial fibrillation. The views of the individual patient should be considered when decisions are being made about antithrombotic treatment for people with atrial fibrillation.

Performance of a commercial immunoassay for detection and differentiation of periodontal marker bacteria: analysis of immunochemical performance with clinical samples.

BACKGROUND: We employed a commercial immunoassay for simultaneous detection and differentiation of marker bacteria Actinobacillus actinomycetemcomitans, Porphyromonas gingivalis, and Prevotella intermedia and reassessed the immunochemical performance of the assay. METHODS: We compared the analytical performance of the immunoassay in our study of clinical samples from 249 periodontal patients in 2 private periodontal practices with the previously reported analytical performance of the same immunoassay. We also compared immunoassay measurements of the marker bacteria in clinical samples with values obtained in other studies by direct culture of the same organisms. RESULTS: The assay produced 3 times more high-end readings than reported previously. We also reassessed and revised previously published calibration curves for the immunoassay. The immunoassay provided measurements of the marker bacteria in clinical samples from our patients that were comparable to and consistent with measurements of the same bacteria by direct culture in other studies. CONCLUSIONS: We ascribe the increased sensitivity of the immunoassay in our study to: 1) a more standardized and vigorous sample dispersion that improves release of particulate and soluble antigens from dental plaque biofilm, and 2) better visualization of the reaction product of the enzyme-linked immunoassay. High-technology assays, such as diagnostic immunoassays, have a significant potential for future development in dental diagnosis, because they simplify detection and measurement of biologically important markers such as specific bacteria in clinical samples. Commercial assays also have an important potential for standardization of clinical measurements of biological markers.

Effects of smoking and treatment status on periodontal bacteria: evidence that smoking influences control of periodontal bacteria at the mucosal surface of the gingival crevice.

BACKGROUND: We examined whether smoking status could influence growth of potentially pathogenic bacteria in the periodontal environment of treated and untreated periodontal patients. METHODS: We have previously reported effects of treatment status on marker bacteria in our patients. We established a history of any smoking during 6 months prior to microbiological sampling (F-ME, 16 smokers out of 64; MHM, 70 smokers out of 185). We used a commercial immunoassay to quantitate Porphyromonas gingivalis, Prevotella intermedia, and Actinobacillus actinomycetemcomitans in paper point samples from periodontal sites. RESULTS: Logistic regression showed that in smokers, neither P. gingivalis nor A. actinomycetemcomitans was quantitatively increased, while P intermedia was somewhat increased. Multiple regression demonstrated that smoking disrupts the positive relationship between increasing probing depth and increasing bacterial growth that is found in non-smokers. In smokers, growth of marker bacteria at shallow sites (< or =5 mm) was significantly increased to the levels found at deeper sites (>5 mm) in both smokers and non-smokers. Supragingival plaque biofilm was identified as a reservoir for marker bacteria; smokers and nonsmokers had equal ranges of oral cleanliness. CONCLUSIONS: Smoking-associated periodontitis is not simply a reflection of oral cleanliness. Smoking extends a favorable habitat for bacteria such as P. gingivalis, P. intermedia, and A. actinomycetemcomitans to shallow sites (< or =5 mm). Molecular byproducts of smoking interfere with mechanisms that normally contain growth of damaging bacteria at the surface of the oral mucosa in gingival crevices. In this way, smoking can promote early development of periodontal lesions.

Physician characteristics in relation to cardiovascular drugs commonly prescribed for hypertension in Nova Scotia.

BACKGROUND: Cardiovascular drugs are the most frequently prescribed class of drugs in Canada. Among them, drugs used to treat hypertension are the single largest component. Variability in how these drugs are prescribed should be based on the specific characteristics of patients. However, some evidence shows that physician characteristics can also play a substantial role in prescribing trends. Such variation is also associated with varying beneficial and adverse patient outcomes. PURPOSE: To determine whether prescribing patterns of drugs used to treat hypertension in elderly patients in Nova Scotia varied by physician characteristics. METHODS: A retrospective, population-based descriptive study was done using the Nova Scotia Pharmacare program data for the fiscal year 1995/96. The unit of analysis was the individual physician. All drugs indicated in the management of hypertension were included for the analysis. RESULTS: Of 1466 physicians included in the analysis, 1004 were family physicians (FPs) and/or general practitioners (GPs), 155 were internal medicine specialists and 307 were other specialists. Fifty-eight per cent of 103,193 eligible senior citizens received at least one of the study medications. FPs and/or GPs prescribed 95.9% of all the study drugs. Internists prescribed proportionately fewer angiotensin-converting enzyme inhibitors, thiazides and other diuretics compared with the FPs and/or GPs but more beta-blockers and calcium channel blockers. A large proportion of the FPs and/or GPs (55.3%) prescribed less than 10% of the total day's supply of drugs, whereas a small proportion of FPs and/or GPs (16.3%) prescribed 52.6% of all the study drugs. There was no variation in the distribution of the types of antihypertensives prescribed based on physician age, sex or volume of prescribing. A slight variation in prescribing was seen with location of practice. CONCLUSIONS: Patterns of prescribing cardiovascular drugs used to treat hypertension were remarkably unaffected by physician characteristics. This finding counters other evidence in the literature that has raised concerns over prescribing patterns of certain types of physicians. Prescribing patterns may vary for other drug classes, but for this group of antihypertensives, little variability was found.

A comparative evaluation of waist circumference, waist-to-hip ratio and body mass index as indicators of cardiovascular risk factors. The Canadian Heart Health Surveys.

OBJECTIVE: To comparatively evaluate cut-off points of waist circumference, body mass index and waist to hip ratio with respect to their ability to predict other individual and multiple cardiovascular disease risk factors. DESIGN: Population-based, cross-sectional surveys. SUBJECTS: A total of 9913 men and women aged 18-74, selected using health insurance registries from five Canadian provinces. MEASUREMENTS: Anthropometric measures, other cardiovascular risk factors, receiver operating characteristic curves, sensitivity, specificity, positive and negative predictive values. RESULTS: : Waist circumference may be the best single indicator of other individual and multiple cardiovascular risk factors. Optimal cut-off points of all anthropometric measures are dependent on age, sex and the prevalence of the risk factor(s) being considered. For waist circumference, cut-off points of > or =90 cm in men and > or =80 cm in women may be most appropriate for prediction of individual and multiple risk factors in Caucasian populations. CONCLUSION: Health professionals should incorporate the use of waist circumference measurements in their routine clinical examination of adult patients.

Management of patients with suspected deep vein thrombosis in the emergency department: combining use of a clinical diagnosis model with D-dimer testing.

The management of patients presenting to hospital Emergency Departments with suspected deep vein thrombosis is problematic since urgent diagnostic imaging is at times unavailable. We evaluated the accuracy of a rapidly available D-dimer test and the potential of combining D-dimer testing with an explicit clinical model to improve the management of patients with suspected deep vein thrombosis. Two hundred and fourteen patients with suspected deep vein thrombosis presenting to the Emergency Departments of two tertiary care institutions were enrolled in this prospective cohort study. Patients were evaluated by an Emergency Physician who determined the pre-test probability for deep vein thrombosis to be either low, moderate, or high using an explicit clinical model. Patients were managed according to their pre-test probability category by specific algorithms that in all cases included venous ultrasound imaging within 24 h and a 90-day follow-up for the development of thromboembolic complications. Patients also underwent fingerstick SimpliRED(R) whole blood agglutination D-dimer testing; however, D-dimer results did not influence subsequent patient management. D-dimer had a sensitivity of 82.5% and a specificity of 84.9% for the diagnosis of deep vein thrombosis. The observed negative predictive value of D-dimer was 96.9% (95% CI, 93.0% to 99.1%) overall, and 100% (95% CI, 96.3% to 100%) in low probability patients, 94.1% (95% CI, 83.8% to 98.8%) in moderate probability patients, and 86.7% (95% CI, 59.4% to 98.3%) in high probability patients. SimpliRED(R) D-dimer has a high negative predictive value and may be useful in excluding the diagnosis in patients at low pre-test probability for deep vein thrombosis.

Intra and inter technologist variability in the quality assessment of respiratory tract specimens.

The majority of microbiology laboratories have implemented quality improvement procedures such as a Q scoring system to assess the nature of clinical specimens. Our study reviewed the sources and the amount of variation when Q scoring of lower respiratory secretions was performed. In total, 450 slides representing lower respiratory tract secretions were Q scored by three experienced technologists. Total agreement regarding the number of neutrophils, squamous epithelial cells and Q scores was 76%, 57% and 57% respectively. The major factor influencing Q score values was the enumeration of epithelial cells. From our findings, we expect that there is greater variability in Q scoring then is generally acknowledged and there is a substantial degree of subjectivity on part of individual technologists reading gram stains.

Thrombosis in the emergency department: use of a clinical diagnosis model to safely avoid the need for urgent radiological investigation.

CONTEXT: The management of patients presenting to hospital emergency departments with suspected deep vein thrombosis (DVT) is problematic because urgent diagnostic imaging capability is sometimes unavailable. Experienced physicians using clinical skills alone can classify patients with suspected DVT into low-, moderate-, and high-probability categories. OBJECTIVES: To determine the accuracy of an explicit clinical model for the diagnosis of DVT when applied by emergency department physicians and to assess the safety and feasibility of a management strategy based on the clinical pretest probability for patients presenting to the emergency department with suspected DVT outside of regular hospital staff work hours. METHODS: A prospective cohort study was performed in the emergency departments of 2 tertiary care institutions involving 344 patients with suspected DVT. Patient conditions were evaluated by an emergency department physician who determined the pretest probability for DVT to be low, moderate, or high using an explicit clinical model. Patients for whom DVT was considered a low pretest probability were discharged from the emergency department and returned the following day for venous compression ultrasound imaging of the affected leg. Patients for whom DVT was considered a moderate pre-test probability received a single, weight-adjusted dose of subcutaneous unfractionated heparin sodium (between 12 500 and 20 000 U), were discharged from the emergency department, and returned the next morning to undergo ultrasonography. Patients for whom DVT was considered a high pretest probability were admitted to the hospital, administered intravenous unfractionated heparin, and ultrasonography was arranged within 24 hours. Patients with positive ultrasonographic findings were diagnosed with DVT, except for those with low pretest probability for whom confirmatory venography was performed. Patients with DVT excluded in the initial evaluation period did not receive anticoagulant therapy. All patients were followed up for 90 days to monitor development of thromboembolic or bleeding complications. RESULTS: Twenty-four (49.0% [95% confidence interval (CI), 34.5%-63.6%]) of 49 patients in the high-probability category, 15 (14.3% [95% CI, 8.3%-22.4%]) of 105 in the moderate-, and 6 (3.2% [95% CI, 1.2%-6.7%]) of 190 in the low-probability category were confirmed to have DVT. Overall, 45 (13.1%) of 344 patients were confirmed to have DVT. No patient developed pulmonary embolism or major bleeding complications within 48 hours of initial evaluation in the emergency department. Of the 301 patients who had DVT excluded during the initial evaluation period, only 2 (0.7% [95% CI, 0.1%-2.3%]) developed venous thromboembolic complications (calf vein thromboses in both) in the 3-month follow-up period. CONCLUSIONS: Using an explicit clinical model, emergency department physicians can accurately classify patients with suspected DVT into high-, moderate-, and low-probability groups. A management plan based on probability for DVT that avoids the need for urgent diagnostic imaging is safe and feasible in the emergency department setting.

Diagnostic utility of specific microbiological markers for periodontal diseases.

Specific detection of marker organisms Porphyromonas gingivalis, Prevotella intermedia, and Actinobacillus actinomycetemcomitans with an immunoassay provided 2 types of useful information directly into private clinical practice: 1) persistence of P. gingivalis in patients undergoing regular treatment allowed rapid identification of pockets requiring further treatment without waiting for measurable progression of lesions and 2) presence of A. actinomycetemcomitans in adults at any stage of diagnosis or treatment identified patients who may prove to have difficult-to-manage periodontitis. We made these findings in 253 patients (234 in specialist periodontal practices [F-ME 55; MHM 179] and 19 in general dental practice [EWM]). The search for useful diagnostic markers overlaps only partly with the search for periodontal pathogens. The P. gingivalis marker and the A. actinomycetemcomitans marker identify 2 different patterns of infection that appear to reflect 2 different underlying problems. Demonstration of pocket-dependent infection with P. gingivalis in treated patients provides an outcome marker for sites not converting to marker-negative sites at detection levels of the immunoassay. This information facilitates selection of sites and patients requiring adjustment of treatment regimens. Detection of A. actinomycetemcomitans in adult patients is significantly associated with periodontitis characterized as refractory. Positive identification of A. actinomycetemcomitans with the immunoassay supports clinical decision-making by drawing attention to adult patients who require closer monitoring and intensive persistent treatment. Successful application of immunoassay detection of microbiological markers is based on continuous patient monitoring to support clinical decisions; it does not replace careful clinical judgment.

Periodontitis-associated marker bacteria in an urban North American patient population: application of a commercial immunoassay.

We used an immunoassay to demonstrate marker organisms (Porphyromonas gingivalis, Prevotella intermedia, and Actinobacillus actinomycetemcomitans) in 3 private practice populations (F-ME periodontist, 55 patients; MHM periodontist, 179 patients; and EWM general dentist, 19 patients). Occurrence of the marker organisms involves the whole oral environment, not just individual sites, as shown by close correlation between presence of the marker organisms in 2 independent sites/samples within a single mouth. Presence of the marker P. gingivalis (and P. intermedia) relates closely to periodontal pocketing while presence of A. actinomycetemcomitans does not have this pocket-associated characteristic. There was no significant relationship between presence of the marker organisms and the number of teeth in a mouth, and in the periodontal practice patients there was no significant effect of gender on occurrence of the marker organisms. A. actinomycetemcomitans and the other 2 markers were found over the entire age range (12 to 75) of our patients. Regular periodontal treatment reduced occurrence of all marker organisms and increased the frequency of marker-negative patients and sites. Occurrence of the marker organisms above immunoassay threshold levels appears to represent how receptive a patient is to each individual organism. Most patients appear receptive to the presence of P. intermedia whether treated or not. Significantly fewer patients who underwent regular treatment show the presence of P. gingivalis or A. actinomycetemcomitans when compared to untreated patients. Diagnostic application of microbial markers requires ongoing clinical assessment of patients and careful clinical judgment. 1391.

A simplified protocol for pessary management.

OBJECTIVE: To evaluate a simplified protocol for pessary management. METHODS: Women with symptomatic pelvic organ prolapse who opted for pessaries were enrolled in a prospective simplified protocol for pessary management. After the initial pessary fitting, they were seen at 2 weeks for reexamination and thereafter at 3- to 6-month intervals. RESULTS: One hundred ten women (mean age 65 years) were enrolled, and 81 (74%) of them were fitted successfully with a pessary. Life-table analysis showed that 66% of those who used a pessary for more than 1 month were still users after 12 months and 53% were still users after 36 months. The severity of pelvic prolapse did not predict the likelihood of pessary failure except in cases of complete vaginal eversion. Patients complaining of stress incontinence were less likely to have a successful pessary fitting and more likely to opt for surgery. Current hormone use and substantial perineal support do not predict greater likelihood of pessary fitting success. No serious complications from using the pessary were observed in the study sample. CONCLUSION: Stringent guidelines calling for frequent pelvic examinations during pessary use can be relaxed safely. Pessaries can be offered as a safe long-term option for the management of pelvic prolapse.

Relative importance of maternal constitutional factors and glucose intolerance of pregnancy in the development of newborn macrosomia.

The purpose of this case-control study was to determine the relative importance of various predictors of newborn macrosomia, with particular reference to maternal constitutional factors and glucose intolerance of pregnancy. Macrosomia was defined by both absolute birthweight > or = 4,000 g and birthweight > or = 90th centile for gestational age. One thousand mother/newborn pairs [209 macrosomic (cases) and 791 non-macrosomic newborns (controls)] were recruited. Mothers with pre-gestational diabetes mellitus were excluded. Data on pregnancy and pregnancy variables were collected by review of prenatal, labour, and delivery and newborn assessment records and interview with the mother. Predictors that entered the stepwise multiple regression model in order of significance were: previous history of macrosomia, increasing maternal weight, nonsmoking status, multiparity, male newborn gender, gestational age of 40-42 weeks, North American Aboriginal ethnicity, maternal birthweight > 4,000 g, maternal height and maternal age < 17 years. Glucose screen positive/100-g oral glucose tolerance test (GTT) negative status was a significant predictor for macrosomia as defined by birthweight greater than the 90th percentile for gestational age, but not for absolute birthweight over 4,000 g. It was the least significant of all the factors examined. Treated gestational diabetes was not a significant predictor. By multivariate analysis, maternal constitutional factors are more powerful predictors of newborn macrosomia than maternal mild glucose intolerance. Treatment of mothers with GDM may be masking the effect of more pronounced carbohydrate intolerance.

Relationship between plasma glucose levels in glucose-intolerant women and newborn macrosomia.

The purpose of this study was to examine the relationship between newborn macrosomia and plasma glucose profile in both a "glucose challenge test (GCT)-positive oral glucose tolerance test (OGTT)-negative" group (n = 113) and a gestational diabetes mellitus (GDM) group (n = 50). We examined 1) plasma glucose concentrations following a positive screen 50-g GCT (n = 163), 2) glucose concentrations following a 100-g OGTT (n = 163), and 3) the average fasting (AF) and 2-hour postprandial (APP) plasma glucose concentrations in the treated GDM group (n = 46). It was a case-control study with macrosomia vs. non-macrosomia in the ratio of 1:4. Macrosomia was analyzed by both birthweight > 4,000 g and gender-specific birthweight > 90th percentile for gestational age criteria. The GCT and the OGTT were performed between 26 and 30 weeks of pregnancy. The results demonstrated no significant impact of plasma glucose values from GCT, OGTT, AF, or APP on macrosomia in both "GCT-positive OGTT-negative" and GDM (treated) groups. Further, the screening and diagnostic plasma glucose concentrations were not related to macrosomia in both "GCT-positive OGTT-negative" and GDM groups. We found a difference of 0.6 mmol/liter in the maternal AF and APP glucose concentrations between mothers of macrosomic versus non-macrosomic newborns in the treated (diet or diet+insulin) GDM group. The clinical relevance of this difference remains to be explored. Our study provides a different methodological and analytic perspective in examining macrosomia versus non-macrosomia in the "GCT-positive OGTT-negative" and the GDM groups using univariate and multivariate analyses.

Endometrial biopsy in DUB.

OBJECTIVE: To determine the incidence of abnormal endometrial histology in women with dysfunctional uterine bleeding and to evaluate the predictive value of risk factors for endometrial cancer in women with dysfunctional uterine bleeding (DUB). STUDY DESIGN: We conducted a retrospective review of 310 women with DUB who underwent endometrial biopsy. The risk factors for abnormal endometrial histology included menstrual cycle irregularity, diabetes, nulliparity, hypertension, weight > or = 100 kg and age > or = 40 years. The incidence of endometrial abnormalities was determined, and the predictive value of combinations of risk factors was assessed using stepwise logistic regression. RESULTS: Twenty-one patients (6.7%) had abnormal endometrial biopsies. Menstrual cycle irregularity (P = .0001), age > or = 40 years (p = .022) and hypertension (P = .058) were independently significant risk factors for abnormal endometrial histology. The probability of abnormal endometrial histology in a premenopausal woman with DUB whose cycle was regular was < 1%. The presence of menstrual cycle irregularity increased the probability of abnormal endometrial histology to 14.3%. CONCLUSION: The patient who presents with DUB and a history of menstrual cycle irregularity warrants an endometrial biopsy, regardless of age. The current clinical emphasis on age (especially > or = 40 years) as justification for endometrial biopsy is unwarranted in patients with DUB. More careful selection of patients for endometrial biopsy will mean that fewer women are unnecessarily exposed to the discomfort and risk of complications associated with endometrial biopsy.

A simple model for predicting postoperative delirium in older patients undergoing elective orthopedic surgery.

OBJECTIVE: To determine the incidence, and severity of postoperative delirium (POD) in older patients undergoing elective orthopedic procedures and to identify potential preoperative risk factors. DESIGN: A prospectively studied cohort of elective orthopedic surgery patients. SETTING: A University teaching hospital. PATIENTS: Eighty patients who attended a preadmission clinic and, subsequently, underwent elective orthopedic surgery. All patients were aged 60 years or older, and all spoke English. MEASUREMENTS: Patients underwent preoperative medical, cognitive, and activities of daily living assessment with standardized instruments and were followed postoperatively with daily visits, telephone interviews with attending nurses using a modified confusion assessment model (CAM), and repeated cognitive testing. Suspected delirium was verified by direct physician assessment. RESULTS: The elective group had 14 (17.5%) cases of POD, of which six (7.5%) were severe. These incidences are low compared with those of nonelective surgery groups reported elsewhere in the literature. Stepwise multiple logistic regression identified two POD risk factors: clock-drawing scores < or = 6 (OR = 9.0, CI, 2.8 to 45.6) and male gender (OR = 5.6, CI 1.9 to 33.8). CONCLUSION: A simple model using clock-drawing scores and male gender for preoperative identification of elective patients at greatest risk for POD appears sensitive, predictive, and practical for the preadmission clinic setting, but it should be validated in a prospective trial.