Increased Labyrinthine T1 Postgadolinium Signal Intensity Is Associated with the Degree of Ipsilateral Sensorineural Hearing Loss in Patients with Sporadic Vestibular Schwannoma.

BACKGROUND AND PURPOSE: Vestibular schwannomas are benign, generally slow-growing tumors, commonly presenting with hearing loss. Alterations in the labyrinthine signal are seen in patients with vestibular schwannoma; however, the association between imaging abnormalities and hearing function remains poorly defined. The purpose of this study was to determine whether labyrinthine signal intensity is associated with hearing in patients with sporadic vestibular schwannoma. MATERIALS AND METHODS: This was an institutional review board-approved retrospective review of patients from a prospectively maintained vestibular schwannoma registry imaged in 2003-2017. Signal-intensity ratios of the ipsilateral labyrinth were obtained using T1, T2-FLAIR, and postgadolinium T1 sequences. Signal-intensity ratios were compared with tumor volume and audiometric hearing threshold data including pure tone average, word recognition score, and American Academy of Otolaryngology-Head and Neck Surgery hearing class. RESULTS: One hundred ninety-five patients were analyzed. Ipsilateral labyrinthine signal intensity including postgadolinium T1 images was positively correlated with tumor volume (correlation coefficient = 0.17, P = .02). Among signal-intensity ratios, postgadolinium T1 was significantly positively associated with pure tone average (correlation coefficient = 0.28, P < .001) and negatively associated with the word recognition score (correlation coefficient = -0.21, P = .003). Overall, this result correlated with impaired American Academy of Otolaryngology-Head and Neck Surgery hearing class (P = .04). Multivariable analysis suggested persistent associations independent of tumor volume with pure tone average (correlation coefficient = 0.25, P < .001) and the word recognition score (correlation coefficient = -0.17, P = .02) but not hearing class (P = .14). No consistent significant associations were noted between noncontrast T1 and T2-FLAIR signal intensities and audiometric testing. CONCLUSIONS: Increased ipsilateral labyrinthine postgadolinium signal intensity is associated with hearing loss in patients with vestibular schwannoma.

Skin-Related complications of Klippel-Trenaunay Syndrome: a retrospective review of 410 patients.

BACKGROUND: Little is known about skin-related complications in Klippel-Trenaunay syndrome (KTS), a complex vascular anomaly defined by capillary malformation (CM), venous malformation (VM) ± lymphatic malformation (LM) and limb overgrowth. Reported skin-related complications of KTS include ulceration, vascular ectasias (blebs), bleeding and infection. OBJECTIVE: To determine the spectrum, prevalence and predictors of skin-related complications in KTS. METHODS: A retrospective review of 410 patients fulfilling KTS criteria was performed to assess for the presence of skin-related complications. RESULTS: Skin-related complications were present in 45% of patients. Most prevalent were CM-related complications including blebs, bleeding, thickening (25%), cellulitis (22%) and ulceration (21%). Features positively associated with skin-related complications were presence of LM (OR 17.17; P < 0.001), VM on the buttocks/perineum/genitalia (OR 1.92; P = 0.009), CM on the feet (OR 1.77; P = 0.039) and male sex (OR 1.63; P = 0.034). Features negatively associated with skin-related complications were CM on the trunk (OR 0.59; P = 0.029) and tissue hypertrophy of the hands (OR 0.27; P = 0.025). CONCLUSION: Skin-related complications affect nearly half of patients with KTS. Those with lymphatic involvement or malformation presence in the undergarment area or feet are most at risk.

Absorbable subcuticular staples versus suture for caesarean section closure: a randomised clinical trial.

OBJECTIVE: To compare outcomes of efficiency, safety, patient, and surgeon satisfaction between absorbable subcuticular staples and subcuticular suture for caesarean section skin closure. DESIGN: A prospective, randomised, non-blinded, parallel-group trial. SETTING: Mayo Clinic Family Birth Center in Rochester, MN, USA. POPULATION: At least 18 years old and 24 weeks' gestation, undergoing caesarean section. Exclusion criteria were body mass index >50, chorioamnionitis, intrauterine fetal death, and multifetal gestation. METHODS: Patients were stratified by prior caesarean section, body mass index, and surgeon level and randomised to absorbable subcuticular staples or subcuticular suture. Electronic medical records and surveys were used. MAIN OUTCOME MEASURES: Primary outcomes were total operating time, from incision start to close. Secondary outcomes included subcuticular skin closure time, patient and surgeon satisfaction, percutaneous injuries, pain (analgesic use), cosmesis, and wound complications. RESULTS: Of 220 randomised patients, 206 were included in the final analysis (103 per group). Baseline characteristics were similar. The primary outcome of total operative time was not significantly different between groups [54.0 (44.9-63.6) versus 58.0 (50.4-68.2) minutes, P = 0.053]. The subcuticular staple group had shorter subcuticular skin closure time [median 2.6 (1.8-4.0) versus 8.5 (6.2-10.5) minutes, P < 0.001]. There were no differences in analgesic use, wound complications, cosmesis or patient satisfaction. One needlestick injury occurred with suture. Surgeons were more likely to recommend (97% versus 85%, P = 0.004) and use (98% versus 82%, P < 0.001) absorbable subcuticular staples. CONCLUSION: For caesarean section skin closure, absorbable subcuticular staples did not result in significantly different total operative times compared with sutures. Analgesic use, wound complications, and cosmesis were comparable. Patient and surgeon satisfaction were high with both methods. TWEETABLE ABSTRACT: Absorbable subcuticular staples associated with a similar total operative time compared with suture.

Isolated Internal Auditory Canal Diverticula: A Normal Anatomic Variant Not Associated with Sensorineural Hearing Loss.

BACKGROUND AND PURPOSE: Bony internal auditory canal diverticula are relatively common, occurring in approximately 5% of temporal bone CTs. Internal auditory canal diverticula have historically been considered incidental; however, a recent publication reported that internal auditory canal diverticula are associated with sensorineural hearing loss. The objective of this study was to further characterize this potential association in a large cohort of patients. MATERIALS AND METHODS: A total of 1759 patients undergoing high-resolution temporal bone CT were collected during a 6-year interval, and audiometric data were obtained from those with internal auditory canal diverticula. To assess any association of isolated internal auditory canal diverticula with sensorineural hearing loss, we excluded from further analysis patients with concomitant otosclerosis and bilateral diverticula and those without audiometric data, leaving 22 index cases. Audiometric data for the ear with a diverticulum was compared with that in the contralateral ear, to serve as an internal control. RESULTS: Of 1759 patients, 82 (4.7%) had either unilateral (n = 33, 40%) or bilateral (n = 49, 60%) internal auditory canal diverticula. The co-incidence of otosclerosis and internal auditory canal diverticula was 34% (n = 28). There was no correlation between patient age and diverticulum size on either side. Among the index cases with isolated unilateral internal auditory canal diverticula and complete audiometric data, word recognition scores and the prevalence and severity of sensorineural hearing loss were not significantly different comparing the internal auditory canal diverticulum side to its contralateral control. CONCLUSIONS: This study did not find a statistically significant association between ears with internal auditory canal diverticula and worsening sensorineural hearing loss or word recognition. Internal auditory canal diverticula most likely represent a normal anatomic variant in ears without otosclerosis.

Henoch-Schönlein purpura and systemic disease in children: retrospective study of clinical findings, histopathology and direct immunofluorescence in 34 paediatric patients.

BACKGROUND: Henoch-Schönlein purpura (HSP), an IgA-mediated small vessel vasculitis, is the most common form of vasculitis in children. HSP is commonly associated with systemic involvement of the gastrointestinal tract, joints and kidneys. Renal involvement is the main cause of morbidity and mortality in HSP. OBJECTIVES: To characterize the clinical, histopathological and direct immunofluorescence (DIF) findings, and to correlate the findings with systemic disease in 34 children with HSP seen at our institution. METHODS: This was a retrospective review of paediatric patients with HSP and with available biopsy specimens seen at our institution between 1993 and 2013. RESULTS: Thirty-four paediatric patients were identified (mean age 10·7 years). Renal involvement was found in 17 (50%) patients, gastrointestinal tract involvement in 22 (65%) and joint involvement in 23 (68%). Renal involvement was significantly associated with papillary dermal oedema on histopathology (P < 0·01) and the presence of perivascular C3 on DIF (P = 0·01). The presence of lesions above the waist was significantly associated with gastrointestinal involvement (P = 0·03), as was the presence of clinically apparent oedema (P = 0·01). CONCLUSIONS: This study suggests that in children with HSP, microscopic dermal oedema and C3 on DIF may be predictive of renal involvement. Patients with clinically apparent oedema and lesions above the waist are more likely to have gastrointestinal involvement.

Histopathological findings in cutaneous small-vessel vasculitis associated with solid-organ malignancy.

BACKGROUND: Histopathological findings in biopsy specimens from patients with cutaneous small-vessel vasculitis (CSVV) secondary to solid-organ malignancy have not been previously reported. OBJECTIVES: We aimed to understand better the differences in histopathological findings between biopsy specimens from patients with CSVV associated with solid-organ malignancies and patients with CSVV secondary to other causes. METHODS: From a previously published group of patients with CSVV and solid-organ malignancy, we identified patients with available histopathology slides of biopsy specimens. We compared histopathological findings from these patients with those from 68 previously published patients with Henoch-Schönlein purpura not associated with solid-organ malignancy (60% male). RESULTS: We identified 15 patients (eight male, 53%) with available slides from biopsy specimens. The mean age of these patients with solid-organ malignancy-associated CSVV was 66·6 years, compared with 45·8 years in the Henoch-Schönlein purpura cases not associated with solid-organ malignancy (P < 0·001). Solid-organ malignancy-associated CSVV was less likely to demonstrate papillary dermal oedema (P = 0·04), papillary dermal inflammation (P < 0·001) and lymphocytes (P < 0·001), and more likely to have plasma cells (P = 0·02). Additionally, we detected nonsignificant differences in the presence of histiocytes (P = 0·05), intravascular thrombosis (P = 0·052) and microabscess formation (P = 0·06). CONCLUSIONS: CSVV associated with solid-organ malignancies tended to have deeper dermal involvement and a different cellular milieu from cases not associated with solid-organ malignancies. In addition, the patients with CSVV with solid-organ malignancies were significantly older than those without. Prospective studies with age-matched controls are needed to determine the clinical significance of the histopathological differences in solid-organ malignancy-associated CSVV.

[Undergraduate teaching in ophthalmology. Do standardized practical examinations make sense?]. / Studentische Lehre in der Augenheilkunde. Sind standardisierte praktische Prüfungen sinnvoll?

BACKGROUND: University teaching in ophthalmology has tended to focus on imparting knowledge rather than practical skills. The new skills laboratory at the University Medical Center in Göttingen enables practical skills to be taught. The focus is on basic skills that could help all physicians. The learning goals set are techniques considered basic in ophthalmology that can be mastered without requiring any physician to operate major equipment. METHODS: The design and results from four semesters of an ophthalmological objective structured clinical examination (OSCE) following students engaged in peer-teaching, as well as feedback from a student questionnaire are described. RESULTS: Practical skills can successfully be taught and mastered within 1 week and 68-100 % of all students achieved the maximum scores in the individual tests. The OSCE and peer- eaching were well received by the students. CONCLUSIONS: Practical skills and peer teaching fulfill student educational goals in ophthalmology and are well accepted by undergraduates.

Relationship between body mass index and the incidence of inguinal hernia repairs: a population-based study in Olmsted County, MN.

PURPOSE: The relationship between body mass index (BMI) and the risk of inguinal hernia development is unclear. To explore the relationship, we determined whether the incidence of inguinal hernia repairs (IHR) varied across patients with different BMI categories. STUDY DESIGN: A population-based incidence study was undertaken. We reviewed all IHR performed on adult residents of Olmsted County, MN from 2004 to 2008. Cases were ascertained through the Rochester Epidemiology Project, a records-linkage system with more than 97% population coverage. RESULTS: During the study period, a total of 1,168 IHR were performed on 879 men and 107 women. The median BMI of the cohort was 26.7 kg/m2 (range 14.9-58.1, interquartile range 23.9-28.9). Incidence rates varied significantly as a function of BMI (p<0.001). Rates were highest among men who were either normal weight or overweight (419.8 and 421.1 per 100,000 person-years for BMI<25 and BMI 25-29.9, respectively), and lowest for obese and morbidly obese men (273.5 and 99.4 per 100,000 person-years for BMI 30-34.9 and BMI C 35, respectively). Findings were similar across all age categories and in patients who had an IHR that was initial or recurrent, direct or indirect, and unilateral or bilateral. CONCLUSIONS: The incidence of IHR decreased as BMI increased. Obese and morbidly obese patients had a lower incidence of IHR than those who were normal weight or overweight. The causal mechanisms leading to such a relationship are unclear and warrant further study.

Trends in emergent inguinal hernia surgery in Olmsted County, MN: a population-based study.

BACKGROUND: Evidence suggests that watchful waiting of inguinal hernias (IH) is safe because the risk of acute strangulation requiring an emergent repair is low. However, population-based incidence rates are lacking, and it is unknown whether the incidence of emergent inguinal hernia repairs (IHR) has changed over time. STUDY DESIGN: A retrospective review of all IHR performed on adult residents of Olmsted County, Minnesota from 1989 to 2008 was performed using the Rochester epidemiology project, a record-linkage system that covers more than 97 % of the population (2010 US Census = 146,466). Incidence rates/100,000 person-years were calculated, and trends over time were evaluated using Poisson regression. RESULTS: A total of 4,026 IHR were performed on 3,599 patients; 136 repairs (3.8 %) were emergent. Of these, 19 patients (14 %) had bowel resection and three (2 %) died within 30 days of the repair. Rates/100,000 person-years yielded an overall incidence of 7.6 for emergent IHR and 200.0 for elective IHR. Emergent IHR rates increased with age. Overall emergent IHR rates declined from 18.2 to 12.4 in men and from 6.4 to 2.4 in women from 1989 to 2008 (p > 0.05). Older age, obesity, a high ASA risk score, a femoral and/or a recurrent hernia were more likely to be associated with an emergent IHR (all p ≤ 0.05). CONCLUSION: The incidence of emergent IHR is low. This risk has decreased over the past 20 years. However, patients who are either ≥70 years old, obese, with a high ASA score, or with a femoral or recurrent hernias are more likely to require an emergent IHR and could benefit from elective operative intervention if deemed adequate surgical candidates.

Contralateral metachronous inguinal hernias in adults: role for prophylaxis during the TEP repair.

PURPOSE: Contralateral exploration during laparoscopic totally extraperitoneal (TEP) inguinal herniorrhaphy allows for the repair of incidentally found hernias. Nonetheless, some patients with a negative contralateral exploration subsequently develop a symptomatic hernia on that side. We pondered the incidence of contralateral metachronous hernia development and whether prophylactic "repair" in these circumstances would be beneficial. METHODS: A retrospective analysis of patients who underwent laparoscopic TEP exploration at our institution was performed. Demographic, operative and follow-up information was obtained through medical record review, physical examination and telephone/mailed survey. RESULTS: From 1995 to 2009, a total of 1,479 inguinal herniorrhaphies on 976 patients were performed by a single staff surgeon. Bilateral exploration was completed in 923 (95%) of these patients, of whom bilateral repair was performed on 503 (55%). The study cohort comprises the 409 (42%) patients having a unilateral repair with a negative contralateral exploration and no previous contralateral hernia repair (n = 11). With a median follow-up of 5.9 years (range 0-14), 33 (8.1%) hernias developed on the previously "healthy" side, yielding incidence rates at 1, 5 and 10 years of 1.6, 5.9 and 11.8%, respectively. The median time to hernia development was 3.7 years (range 0.1-12.4). Of the 30 inguinal hernias that have been repaired, 25 (83%), 3 (10%) and 2 (7%) were of indirect, direct and pantaloon types, respectively. CONCLUSIONS: When considering prophylactic repair during TEP explorations, a yearly risk of 1.2% of developing a contralateral hernia after negative exploration needs to be balanced against the low but potential risk of groin pain following prophylactic repair.

[Subdental synchondrosis. Computed tomographic and histologic investigation on morphological aspects of fracture at the base of the dens in 36 human axis specimens]. / Die subdentale Synchondrose. Eine computertomographische und histologische Untersuchung zu morphologischen Aspekten der Densbasisfraktur an 36 humanen Axispräparaten.

BACKGROUND: During development of the axis, four different ossification centers are formed. The two cranial ossification centers are demarcated from the ossification center of the vertebral corpus by a subdental synchondrosis. During further development the subdental synchondrosis--which is thought to close spontaneously--might not close completely, which leads to the necessity for differentiating synchondrotic remnants from a fracture at the base of the dens (type II according to Anderson and D'Alonzo). RESULTS: To characterize the architecture of the axis with particular attention to the subdental synchondrosis, the axis was harvested from 36 age- and gender-matched patients covering the human aging process from adolescence to senescence. In all specimens bone mineral density (BMD) was measured by peripheral quantitative computed tomography (pQCT). Morphological analysis after undecalcified processing of all specimens revealed a persistency of the subdental synchondrosis in 87% of all patients. Histological characterization of the subdental synchondrosis showed a cartilaginous structure interspersed with focal mineralization. Furthermore, static histomorphometric analysis revealed that trabecular bone volume and cortical thickness were significantly reduced within the base of the axis as compared to the dens and the corpus, respectively. CONCLUSION: Taken together, these results provide evidence that the base of the axis is a structurally distinct region. Besides well-recognized biomechanical aspects, these results suggest that the structure of the base of the axis might contribute to the occurrence of fractures of the axis and offer an additional explanation for the observation of nonunion after type II dens fractures.

Oestrogen synthesis in the hippocampus: role in axon outgrowth.

Ovarian oestrogens have been postulated to be neuroprotective. It has also been shown that considerable amounts of oestrogens are synthesised in hippocampal neurones. In the present study, we focused on a potential role of hippocampus-derived oestradiol compared to gonad-derived oestradiol on axon outgrowth of hippocampal neurones. To address the role of hippocampus-derived oestradiol, we inhibited oestrogen synthesis by treatment of neonatal hippocampal cell cultures with letrozole, a specific aromatase inhibitor. As an alternative, we used siRNA against steroidogenic acute regulatory protein (StAR). Axon outgrowth and GAP-43 expression were significantly down-regulated in response to letrozole and in siRNA-StAR transfected cells. The effects after inhibition of oestrogen synthesis in response to letrozole and in siRNA-StAR transfected cells were reversed by oestrogen supplementation. No difference was found between ovariectomised animals, cycling animals at pro-oestrus and ovariectomised and subsequently oestradiol-treated animals. However, high pharmacological doses of oestradiol promoted axon outgrowth, which was possible to abolish by the oestrogen receptor antagonist ICI 182,780. Our results show that oestradiol-induced neurite outgrowth is very likely mediated by genomic oestrogen receptors and requires higher doses of oestradiol than physiological serum concentrations derived from the gonads.

Synaptic plasticity in the hippocampus: effects of estrogen from the gonads or hippocampus?

Different effects of estrogen on synaptic plasticity have [corrected] been reported. Here, we summarise effects of low, gonad-derived serum estrogen concentrations, of intermediate concentrations, provided by hippocampal cells, and of pharmacological doses of estrogen on synapses and spines and on the expression of synaptic proteins. No effects of low concentrations were found. To study the effects of hippocampus-derived estradiol, we inhibited hippocampal estrogen synthesis by treatment of hippocampal cell cultures with letrozole, an aromatase inhibitor. Alternatively, we used siRNA against Steroidogenic acute regulatory protein (StAR). Spines, synapses, and synaptic proteins were significantly down regulated in response to letrozole and in siRNA-StAR transfected cells. Application of high pharmacological doses of estradiol promoted only synaptophysin expression, a presynaptic protein, but did not increase the number of boutons. Our results point to an essential role of endogenous hippocampal estrogen in hippocampal synaptic plasticity rather than to a direct influence of estrogens derived from peripheral sources, such as the gonads.

Contralateral adrenal metastasis of renal cell carcinoma: treatment, outcome and a review.

OBJECTIVE: To report the surgical treatment of patients with renal cell carcinoma (RCC) metastatic to the contralateral adrenal gland and compare our experience with previous reports, as such metastases are found in 2.5% of patients with metastatic RCC at autopsy, and the role of resecting metastatic RCC at this site is not well defined. PATIENTS AND METHODS: We retrospectively identified 11 patients who had surgery for metastatic RCC to the contralateral adrenal gland between October 1978 and April 2001. The patients' medical records were reviewed for clinical, surgical and pathological features, and the patients' outcome. RESULTS: The mean (median, range) age of the patients at primary nephrectomy was 60.9 (64, 43-79) years; all had clear cell (conventional) RCC. Synchronous contralateral adrenal metastasis occurred in two patients. The mean (median, range) time to contralateral adrenal metastasis after primary nephrectomy for the remaining nine patients was 5.2 (6.1, 0.8-9.2) years. All patients were treated with adrenalectomy; there were no perioperative complications or mortality. Seven patients died from RCC at a mean (median, range) of 3.9 (3.7, 0.2-10) years after adrenalectomy for contralateral adrenal metastasis; one died from other causes at 3.4 years, one from an unknown cause at 1.7 years and two were still alive at the last follow-up. CONCLUSIONS: The surgical resection of contralateral adrenal metastasis from RCC is safe; although most patients died from RCC, survival may be prolonged in individual patients. Hence, in the era of cytoreductive surgery, the removal of solitary contralateral adrenal metastasis seems to be indicated.

A rare complication with TVT: vaginal protrusion of the tape.

The authors report a rare postoperative complication of TVT. A 38-year-old woman, suffering from genuine stress incontinence, presented 3 weeks after surgery with a 1 cm protrusion of the TVT across the median vaginal scar. A fastening point on the tape and covering it with the vaginal skin was unsuccessful. Three weeks later, we found a 5 mm protrusion of the tape. At this time we decided to resect the protruding fibers but without interrupting the tape. Regular clinical checks showed good local cicatrization, and 4 weeks later the vaginal epithelium covered the tape completely and the patient no longer suffered from genuine stress incontinence.

Mechanical methods for induction of labour.

BACKGROUND: Mechanical methods were the first methods developed to ripen the cervix or to induce labour. Devices which were used include various type of catheters and of laminaria tents, introduced into the cervical canal or into the extra-amniotic space. Mechanical methods were never completely abandoned, but were substituted by pharmacological methods during recent decades. Potential advantages of mechanical methods, compared with pharmacological methods, may include simplicity of preservation, lower cost and reduction of the side effects. However, special attention should be paid to contraindications (e.g. low-lying placenta), risk of infection and maternal discomfort when inserting these devices. This is one of a series of reviews of methods of cervical ripening and labour induction using standardised methodology. OBJECTIVES: To determine the effects of mechanical methods for third trimester cervical ripening or induction of labour in comparison with placebo/no treatment, prostaglandins (vaginal, intracervical, misoprostol) and oxytocin. SEARCH STRATEGY: The Cochrane Pregnancy and Childbirth Group Trials Register, the Cochrane Controlled Trials Register and bibliographies of relevant papers. Last searched April 2001. SELECTION CRITERIA: The criteria for inclusion were the following: (1) clinical trials comparing mechanical methods used for third trimester cervical ripening or labour induction with placebo/no treatment or other methods listed above it on a predefined list of labour induction methods; (2) random allocation to the treatment or control group; (3) adequate or unclear method for allocation concealment; (4) violations of allocated management not sufficient to materially affect conclusions; (5) clinically meaningful outcome measures reported; (6) data available for analysis according to the random allocation; (7) missing data insufficient to materially affect the conclusions. DATA COLLECTION AND ANALYSIS: A strategy has been developed to deal with the large volume and complexity of trial data relating to labour induction. This involved a two-stage method of data extraction. The initial data extraction was done centrally, and incorporated into a series of primary reviews arranged by methods of induction of labour, following a standardised methodology. The data will be extracted from the primary reviews into a series of secondary reviews, arranged by category of woman. MAIN RESULTS: In total, 58 studies were considered; 45 studies have been included and 13 were excluded. Studies generally included women with unfavourable cervix and intact membranes. Comparing mechanical methods with placebo/no treatment, only one study with 48 participants reported on vaginal delivery not achieved in 24 hours (69% with mechanical methods versus 77% with placebo/no treatment; relative risk (RR) 0.90; 95% confidence interval (CI): 0.64-1.26). Hyperstimulation with fetal heart rate changes was not reported. The risk of caesarean section, reported in six studies including 416 women, was similar between groups (34%; RR 1.00; 95% CI: 0.76-1.30). There were no reported cases of severe neonatal and maternal morbidity. Comparing mechanical methods with vaginal PGE2, only one trial (109 women) reported on vaginal delivery not achieved in 24 hours (73% versus 42%; relative risk (RR) 1.74; 95% CI: 1.21-2.49). Compared with intracervical PGE2, only one trial (100 women) reported on vaginal delivery not achieved in 24 hours (68% versus 40%; relative risk (RR) 1.70; 95% CI: 1.15-2.51). Compared with with misoprostol, the effectiveness of mechanical methods was similar (34% versus 30%; relative risk (RR) 1.15; 95% CI: 0.80-1.66). The use of mechanical method reduced the risk of hyperstimulation with fetal heart rate changes when compared with prostaglandins: vaginal PGE2 (0% versus 6%; RR 0.14; 95% CI: 0.04-0.53), intracervical PGE2 (0% versus 1%; RR 0.21; 95% CI: 0.04-1.20) and misoprostol (4% versus 9%; RR 0.41; 95% CI: 0.20-0.87). There was no difference in the risk of caesarean section between mechanical methods and prostaglandins. Serious neonatal (three cases) and maternal morbidity (one case) were infrequently reported. When compared with oxytocin, use of mechanical methods reduced the risk of caesarean section (4 trials; 198 women; 17% versus 32%; RR 0.55; 95% CI: 0.33-0.91). The likelihood of vaginal delivery in 24 hours and of hyperstimulation with fetal heart rate changes was not reported. There were no reported cases of serious maternal morbidity and severe neonatal morbidity was not reported. These results are similar whatever specific mechanical method was used, except with extra-amniotic infusion. When comparing extra-amniotic infusion with any prostaglandins, women were more likely to not achieve vaginal delivery within 24 hours (57% versus 42%; RR 1.33; 95% CI: 1.02-1.75), the risk of caesarean section was increased (31% versus 22%; RR 1.48; 95% CI: 1.14-1.90), without a reduction of the risk of hyperstimulation. REVIEWER'S CONCLUSIONS: There is insufficient evidence to evaluate the effectiveness, in terms of likelihood of vaginal delivery in 24 hours, of mechanical methods compared with placebo/no treatment or with prostaglandins. The risk of hyperstimulation was reduced when compared with prostaglandins (intracervical, intravaginal or misoprostol). Compared to oxytocin in women with unfavourable cervix, mechanical methods reduce the risk of caesarean section. There is no evidence to support the use of extra-amniotic infusion.

Incidence of venous thromboembolism in hospitalized patients vs community residents.

OBJECTIVE: To estimate the incidence rates of deep venous thrombosis (DVT) and pulmonary embolism (PE) in hospitalized patients and to compare these with incidence rates in community residents. PATIENTS AND METHODS: We performed a retrospective review of the complete medical records from a population-based inception cohort of patients who resided in Olmsted County, Minnesota, and had an incident DVT or PE from 1980 through 1990. RESULTS: From 1980 through 1990, 911 Olmsted County residents experienced their first lifetime event of definite, probable, or possible venous thromboembolism. Of these residents, 253 had been hospitalized for some reason other than a diagnosis of DVT or PE (in-hospital cases), and 658 were not hospitalized at onset of venous thromboembolism (community residents). The average annual age- and sex-adjusted incidence of in-hospital venous thromboembolism was 960.5 (95% confidence interval, 795.1-1125.9) per 10,000 person-years and was more than 100 times greater than the incidence among community residents at 7.1 (95% confidence interval, 6.5-7.6) per 10,000 person-years. The incidence of venous thromboembolism rose markedly with increasing age for both groups, with PE accounting for most of the age-related increase among in-hospital cases. Incidence rates in the 2 groups changed little over time despite a reduction in the average length of hospital stay between 1980 and 1990. CONCLUSIONS: Venous thromboembolism is a major national health problem, especially among elderly hospitalized patients. This finding emphasizes the need for accurate identification of hospitalized patients at risk for venous thromboembolism and a better understanding of the mechanisms involved so that safe and effective prophylaxis can be implemented.

Evaluation of nursing care after diagnostic coronary angiography.

BACKGROUND: Restricting inpatients who have undergone a cardiac catheterization to 6 hours of flat bed rest to reduce the potential for bleeding from the femoral arteriotomy site is based on tradition rather than on research and is associated with discomfort for the patients. OBJECTIVES: To (1) determine the prevalence of femoral arteriotomy complications after diagnostic coronary angiography among inpatients after implementation of a guideline that included reduced duration of bed rest, elimination of sandbags at the arteriotomy site, and 30 degrees elevation of the head of the bed; (2) compare complication rates in this study with rates in previous studies; and (3) determine patient- or practice-related characteristics associated with complications. METHODS: Records of 306 inpatients were reviewed retrospectively to determine the prevalence of femoral arteriotomy complications and the presence of patient- or practice-related characteristics potentially associated with complications. Associations between each characteristic and the presence of a complication were evaluated by using the Wilcoxon rank sum test for continuous data and the chi 2 or Fisher exact test for nominal data. RESULTS: Prevalences of complications were hematoma, 8.8%; bleeding, 4.5%; pseudoaneurysm, 1%; arteriovenous fistula, 0%; and thrombosis, 0%. No evidence indicated that the occurrence of a complication was related to any patient- or practice-related characteristic. Complication rates were comparable to those of previous studies. CONCLUSIONS: The findings support continuation of the current guideline for patients' care after diagnostic coronary angiography. However, further prospective studies with larger samples of inpatients are warranted.