Management of Secondary Poor Response to Botulinum Toxin in Cervical Dystonia: A Multicenter Audit.

BACKGROUND: Botulinum toxin A (BoNT-A) is an effective treatment for cervical dystonia. Nevertheless, up to 30% to 40% patients discontinue treatment, often because of poor response. The British Neurotoxin Network (BNN) recently published guidelines on the management of poor response to BoNT-A in cervical dystonia, but adherence to these guidelines has not yet been assessed. OBJECTIVES: To assess adherence to and usefulness of BNN guidelines in clinical practice. METHODS: We undertook a retrospective medical notes audit of adherence to the BNN guidelines in 3 United Kingdom tertiary neurosciences centers. RESULTS: Of 76 patients identified with poor response, 42 (55%) had a suboptimal response and, following BNN recommendations, 25 of them (60%) responded to adjustments in BoNT dose, muscle selection or injection technique. Of the remaining 34 (45%) patients with no BoNT response, 20 (59%) were tested for immune resistance, 8 (40%) of whom showed resistance. Fourteen (18%) of all patients were switched to BoNT-B, and 27 (36%) were referred for deep brain stimulation surgery. In those not immune to BoNT-A, clinical improvement was seen in 5 (41%) after adjusting their dose and injection technique. CONCLUSION: Our audit shows that optimizing BoNT dose or injection strategy largely led to improvements in those with suboptimal response and in those reporting no response without resistance. It would be helpful to standardize investigations of potential resistance in those with no therapeutic response.

Why even the threat of a twindemic isn't swaying the most vulnerable: Black women.

The fall season was accompanied by an urgent warning from the CDC of an impending "twindemic" of coronavirus disease 2019 and influenza. Despite the warnings, Black women are not lining up for vaccinations.

Elective delivery at less than 39 weeks.

PURPOSE OF REVIEW: The prevalence and impact of elective deliveries occurring prior to 39 weeks' gestation has been the focus of several important studies published in recent medical literature. Defined as scheduled deliveries in the absence of medical or obstetrical indications, concern has been raised that many of these procedures are not performed within the parameters of existing clinical guidelines. RECENT FINDINGS: The American College of Obstetricians and Gynecologists (ACOG) recommends that no elective delivery should be performed before the gestational age of 39 weeks; however, studies report rates of 28-35.8% of elective deliveries occurring before 39 weeks and reveal that they also contribute to increased rates of late-preterm births (34 0/7-36 6/7 weeks). These deliveries are associated with increased neonatal morbidity, neonatal intensive care unit admissions, and associated hospital costs compared to deliveries (37 0/7-38 6/7 weeks) occurring at 39-40 weeks. Prevention of early-term elective deliveries has not demonstrated an increased risk for stillbirth. The implementation of hospital quality improvement programs has successfully reduced the occurrence of elective early-term and late-preterm deliveries, as well as associated neonatal morbidity and mortality. SUMMARY: Improved compliance with ACOG recommendations and a reduction in elective deliveries before 39 weeks can be achieved through the use of quality improvement processes involving education, tracking of data, and strict enforcement of clinical practice policies.

Blueprint for action: steps toward a high-quality, high-value maternity care system.

Childbirth Connection hosted a 90th Anniversary national policy symposium, Transforming Maternity Care: A High Value Proposition, on April 3, 2009, in Washington, DC. Over 100 leaders from across the range of stakeholder perspectives were actively engaged in the symposium work to improve the quality and value of U.S. maternity care through broad system improvement. A multi-disciplinary symposium steering committee guided the strategy from its inception and contributed to every phase of the project. The "Blueprint for Action: Steps Toward a High Quality, High Value Maternity Care System", issued by the Transforming Maternity Care Symposium Steering Committee, answers the fundamental question, "Who needs to do what, to, for, and with whom to improve the quality of maternity care over the next five years?" Five stakeholder workgroups collaborated to propose actionable strategies in 11 critical focus areas for moving expeditiously toward the realization of the long term "2020 Vision for a High Quality, High Value Maternity Care System", also published in this issue. Following the symposium these workgroup reports and recommendations were synthesized into the current blueprint. For each critical focus area, the "Blueprint for Action" presents a brief problem statement, a set of system goals for improvement in that area, and major recommendations with proposed action steps to achieve them. This process created a clear sightline to action that if enacted could improve the structure, process, experiences of care, and outcomes of the maternity care system in ways that when anchored in the culture can indeed transform maternity care.

Surgeon General's Conference on the Prevention of Preterm Birth.

To address the serious and seemingly intractable problem of preterm birth, the Surgeon General's Conference on the Prevention of Preterm Birth convened many of the country's experts from the public and private sectors of research, public health, and health care delivery to discuss preventive strategies. The purpose of the conference was to increase awareness of preterm birth in the United States, review key findings and reports issued by experts in the field, and establish an agenda for activities in both the public and private sectors to mitigate the problem. The six work groups created focused on biomedical research, epidemiological research, psychosocial and behavioral factors in preterm birth, professional education and training, outreach and communication, and quality of care and health services. Several cross-cutting issues between the work groups were identified, and the conference concluded with the request to the Surgeon General to make the prevention of preterm birth a national public health priority. Reaching this goal through the implementation of the conference recommendations will require new resources to create broad-based research capacity, a vigorous national vital records system, multidisciplinary intervention programs, careful study of factors contributing to racial and ethnic disparities, reinvigorated health professional and consumer education programs, and access to high-quality preconception and perinatal healthcare for all Americans. Clinicians must be adequately informed to initiate activities to prevent this serious problem. Recommendations from this conference will inform Congress and create a national agenda to address the identification of the causes, risk factors, prevention, and treatment of preterm birth.

Prematurity--infant mortality: the scourge remains.

Preterm birth is a common, complex and serious disorder that disproportionately affects African-American families in the United States. In conjunction with low birthweight, prematurity has been the leading cause of neonatal death in African-American newborns for more than a decade and significantly characterizes the continuing racial and ethnic disparities seen in health outcomes today. During the past 20 years, preterm birth rates have increased from 9.5% in 1982 to a rate of 12.3% in 2003, an impressive 30% increase. While the chance of being born premature in 2003 was 1 in 8 for all US infants, the likelihood of being born premature was 1 in 6 for African-American infants. These factors, in addition to the associated economic cost of providing healthcare resources for vulnerable racial and ethnic populations that are expanding in numbers, has catapulted prematurity and its associated infant mortality to the forefront of public health. Our current challenge is to identify effective interventions through thoughtful social, clinical, and scientific research efforts and expand our approach to achieving improved pregnancy outcomes from a narrow focus on prenatal care to more broadly address the healthcare needs of women well before pregnancy occurs.