Impact of a Policy to Deliver at 39 Weeks for the Indication of Class III Obesity.

OBJECTIVE: The aim of this study was to evaluate the effect of a policy to deliver at 39 weeks for class III obesity. METHODS: This was a retrospective cohort study of women with class III obesity delivering at ≥ 37 weeks before (May 2012 to April 2014) and after the policy (September 2014 to August 2016). The primary outcome was the cesarean rate. Secondary outcomes included maternal morbidities and a neonatal morbidity composite. Modified Poisson regression was used to adjust for demographic differences between groups. RESULTS: The study included a total of 1,210 patients, 580 before the policy and 630 after the policy. Before and after the policy, cesarean rates were similar (41.6% vs. 47.1%; risk ratio [RR]: 1.13 [95% CI: 1.00-1.29]; adjusted RR [aRR]: 1.03 [95% CI: 0.92-1.14]). In adjusted comparisons of women undergoing labor induction, parous women had lower cesarean rates (aRR: 0.62; 95% CI: 0.41-0.94) but nulliparous women had higher cesarean rates (aRR: 1.32; 95% CI: 1.04-1.68) after the policy (P for interaction = 0.01). Rates of chorioamnionitis, endometritis, and cesarean wound infection were not different between groups. Composite neonatal morbidity was not different between pre- and postpolicy groups. CONCLUSIONS: A policy of delivery at 39 weeks for class III obesity did not affect overall cesarean rate or rates of maternal or neonatal morbidity. Further investigation should evaluate subsets of women who may have a higher cesarean rate with this policy.

Incidencia de microorganismos en hemocultivos procesados en un hospital del estado Zulia y su resistencia a los agentes antimicrobianos / Incidence of Microorganisms in Blood Cultures Processed at a Hospital in the State of Zulia and Resistance to Antimicrobial Agents

Las infecciones del torrente sanguíneo causan una importante morbi-mortalidad en todo el mundo. Para conocer la incidencia de los principales microorganismos aislados de hemocultivos y su resistencia antimicrobiana en un hospital universitario, se revisaron los informes de 31.486 hemocultivos procesados desde enero de 2008 a diciembre de 2012. El porcentaje de hemocultivos positivos fue de 9,49%, el mayor número se obtuvo en las unidades de cuidados intensivos (36,22%). Se aislaron 3.054 microorganismos, 67,62% Gram positivos, 25,51% Gram negativos, 6,84% levaduras y 0,03% anaerobios estrictos. Los microorganismos predominantes fueron Staphylococcus coagulasa negativa, Staphylococcus aureus, Candida spp., Klebsiella pneumoniae, Enterococcus spp., Acinetobacter baumannii, Escherichia coli y Pseudomonas aeruginosa. Tanto S. aureus como las especies coagulasa negativa mostraron alta resistencia a oxacilina (72,0% y 88,9%, respectivamente) y sensibilidad a vancomicina. Un 26,4% de los enterococos (casi exclusivamente E. faecium) fueron resistentes a vancomicina. Acinetobacter baumannii y K. pneumoniae mostraron un alto porcentaje de resistencia a los antibióticos. En general, la mayoría de los microorganismos mostró un aumento progresivo de la resistencia a los antimicrobianos durante el quinquenio estudiado. Es necesario revisar y adecuar las políticas hospitalarias para el uso de antibióticos y reforzar las medidas de control del paciente infectado.

Bloodstream infections cause significant morbidity and mortality worldwide. To determine incidence of the main microorganisms isolated from blood cultures and their antimicrobial resistance in a university hospital, 31,486 blood culture reports processed from January, 2008, to December, 2012, were reviewed. The percentage of positive blood cultures was 9.49%; the highest number was obtained in intensive care units (36.22%). 3,054 microorganisms were isolated: 67.62% Gram positive, 25.51% Gram negative, 6.84% yeast and 0.03% strict anaerobes. The predominant organisms were coagulase-negative Staphylococcus, S. aureus, Candida spp., Klebsiella pneumoniae, Enterococcus spp., Acinetobacter baumannii, Escherichia coli and Pseudomonas aeruginosa. Both, S. aureus and the coagulase-negative species showed high resistance to oxacillin (72.0% and 88.9%, respectively) and sensitivity to vancomycin. A 26.4% of enterococci (E. faecium almost exclusively) were resistant to vancomycin. Acinetobacter baumannii and K. pneumoniae showed a high rate of resistance to the tested antibiotics. Overall, most of the microorganisms showed a progressive increase in antimicrobial resistance during the five years studied. It is necessary to review and adjust hospital policies for antibiotic use and strengthen control measures for the infected patient.

Limitations in the use of indices using glucose and insulin levels to predict insulin sensitivity: impact of race and gender and superiority of the indices derived from oral glucose tolerance test in African Americans.

OBJECTIVE To examine the utility of commonly used insulin sensitivity indices in nondiabetic European Americans (EAs) and African Americans (AAs). RESEARCH DESIGN AND METHODS Two-hundred forty nondiabetic participants were studied. Euglycemic-hyperinsulinemic clamp was the gold standard approach to assess glucose disposal rates (GDR) normalized by lean body mass. The homeostatic model assessment for insulin resistance (HOMA-IR) and the quantitative insulin sensitivity check index (QUICKI) were calculated from fasting plasma glucose and insulin (FIL). Oral glucose tolerance test (OGTT) was performed to determine Matsuda index, the simple index assessing insulin sensitivity (SI(is)OGTT), Avignon index, and Stomvoll index. Relationships among these indices with GDR were analyzed by multiple regression. RESULTS GDR values were similar in EA and AA subgroups; even so, AA exhibited higher FIL and were insulin-resistant compared with EA, as assessed by HOMA-IR, QUICKI, Matsuda index, SI(is)OGTT, Avignon index, and Stumvoll index. In the overall study population, GDR was significantly correlated with all studied insulin sensitivity indices (/r/ = 0.381-0.513); however, these indices were not superior to FIL in predicting GDR. Race and gender affected the strength of this relationship. In AA males, FIL and HOMA-IR were not correlated with GDR. In contrast, Matsuda index and SI(is)OGTT were significantly correlated with GDR in AA males, and Matsuda index was superior to HOMA-IR and QUICKI in AAs overall. CONCLUSIONS Insulin sensitivity indices based on glucose and insulin levels should be used cautiously as measures of peripheral insulin sensitivity when comparing mixed gender and mixed race populations. Matsuda index and SI(is)OGTT are reliable in studies that include AA males.