Maternal, fetal, and placental conditions associated with medically indicated late preterm and early term delivery: a retrospective study.

OBJECTIVE: Our objectives were: (1) to examine the association between maternal, fetal, and placental phenotypes of preterm delivery and medically indicated early delivery of singletons during the late preterm and early term periods; and (2) to identify the specific maternal, fetal, and placental conditions associated with these early deliveries. DESIGN: Retrospective study. SETTING: City of London and Middlesex County, Ontario, Canada. SAMPLE: Singleton live deliveries, at 34-41 weeks of gestation to women in London and Middlesex. METHODS: We obtained data from a city-wide perinatal database (2002-2011; n = 25 699). We used multinomial logistic regression for multivariable analyses. MAIN OUTCOME MEASURE: The outcome was the occurrence of medically indicated late preterm (34-36 weeks of gestation) and early term (37-38 weeks of gestation) delivery, versus delivery at full term (39-41 weeks of gestation). RESULTS: After controlling for confounding factors, all phenotypes were associated with increased odds of medically indicated late preterm and early term delivery. Within the maternal phenotype, chronic maternal medical conditions were associated with increased odds of medically indicated early term delivery (e.g. for gastrointestinal disease, adjusted odds ratio, aOR 1.72, 95% CI 1.47-2.00; for anaemia, aOR 1.40, 95% CI 1.20-1.63), but not late preterm delivery. CONCLUSIONS: The aetiology of medically indicated early delivery close to full term is heterogeneous. Patterns of associations suggest slightly different conditions underlying the late preterm and early term phenotypes, with chronic maternal medical conditions being associated with early term delivery but not with late preterm delivery. These results have implications for the prevention of early delivery as well as the identification of high-risk groups among those born early. TWEETABLE ABSTRACT: The aetiology of medically indicated late preterm and early term delivery is heterogeneous.

Biological determinants of spontaneous late preterm and early term birth: a retrospective cohort study.

OBJECTIVE: Our aim was to examine the association between biological determinants of preterm birth (infection and inflammation, placental ischaemia and other hypoxia, diabetes mellitus, other) and spontaneous late preterm (34-36 weeks) and early term (37-38 weeks) birth. DESIGN: Retrospective cohort study. SETTING: City of London and Middlesex County, Canada. SAMPLE: Singleton live births, delivered at 34-41 weeks to London-Middlesex mothers following spontaneous labour. METHODS: Data were obtained from a city-wide perinatal database on births between 2002 and 2011 (n = 17,678). Multivariable analyses used multinomial logistic regression. MAIN OUTCOME MEASURE: The outcome of interest was the occurrence of late preterm (34-36 weeks) and early term (37-38 weeks) birth, compared with full term birth (39-41 weeks). RESULTS: After controlling for covariates, there were associations between infection and inflammation and late preterm birth (aOR = 2.07, 95% CI 1.65, 2.60); between placental ischaemia and other hypoxia and late preterm (aOR = 2.21, 95% CI 1.88, 2.61) and early term (aOR = 1.25, 95% CI 1.13, 1.39) birth; between diabetes mellitus and late preterm (aOR = 3.89, 95% CI 2.90, 5.21) and early term (aOR = 2.66, 95% CI 2.19, 3.23) birth; and between other biological determinants (polyhydramnios, oligohydramnios) and late preterm (aOR = 2.81, 95% CI 1.70, 4.64) and early term (aOR = 1.89, 95% CI 1.32, 2.70) birth. CONCLUSIONS: Our findings show that delivery following spontaneous labour even close to full term may be a result of pathological processes. Because these biological determinants of preterm birth contribute to an adverse intrauterine environment, they have important implications for fetal and neonatal health.

Thrombotic thrombocytopenic purpura/haemolytic uraemic syndrome: a new index predicting response to plasma exchange.

Despite the favourable response of thrombotic thrombocytopenic purpura/haemolytic uraemic syndrome (TTP/HUS) to plasma exchange, an early level of mortality persists. Non-response has been associated with a low frequency of exchange. The Rose index of TTP/HUS severity, occasionally used to predict the response of TTP/HUS to plasma exchange, remains unsatisfactory. The purpose of this study was to develop a new index predicting response of TTP/HUS to plasma exchange and to compare it with the Rose index. Retrospective analysis of 171 cases of TTP/HUS from 39 apheresis units across Canada between 1980 and 2001 was conducted. Logistic regression analysis was used to derive a model predicting 6-month mortality from presenting characteristics. The reduced model contained age >40 years, haemoglobin <9.0 g/dl and the presence of a fever at presentation. Gender, platelet count, creatinine and neurological signs were not part of the final model. This model predicted 13.4% of outcome variance. Predictive scores of 0, 2, 4 and 6 correlated with 6-month mortality rates of 12.5%, 14.0%, 31.3% and 61.5% respectively in our source population. This simple model may help identify those patients who would benefit from higher treatment intensity.

Comprehensive tobacco control policies and the smoking behaviour of Canadian adults.

OBJECTIVE: To examine the associations of cigarette prices, restrictions on public smoking, and health education with the odds of adult smoking and amount smoked daily. DESIGN: Multi-level analysis of adult (age 25+) smoking patterns in Canada's National Population Health Survey, after adding administrative data on prices, bylaws, and health education according to the survey respondent's place of residence. SETTING/SUBJECTS: Population based sample of Canadians age 25+ in households (n = 14 355). OUTCOME MEASURES: Smoking status, amount consumed daily. ANALYSIS: Logistic regression for smoking status, multiple regression for amount smoked, with controls for age, education, marital status; separate analyses for men and women. RESULTS: Cigarette prices were positively associated with the odds of being a non-smoker and negatively with amount smoked, for adults of both sexes. Per capita health education expenditures were positively associated with the odds of being a non-smoker and negatively with amount smoked--for men but not women. The restrictiveness of municipal bylaws limiting public smoking was positively associated with the odds of being a non-smoker and negatively with amount smoked--for women but not men. These results are independent of age, education, and marital status. CONCLUSIONS: To be effective, tobacco control must comprise a mix of strategies as men and women respond differently to health education and restrictions on public smoking; taxation, reflected in higher cigarette prices, is the only one of these measures related to smoking for both sexes. This model permits calculations of the level of increase in each measure that is required to reduce the prevalence of smoking by a specified amount.

A pilot trial of a cognitive treatment for children with developmental coordination disorder.

This pilot study compared a new treatment approach, the Cognitive Orientation to daily Occupational Performance (CO-OP) to the Contemporary Treatment Approach (CTA) to treating children with Developmental Coordination Disorder (DCD). CO-OP emphasises problem-solving strategies and guided discovery of child and task specific strategies. CTA encompasses a variety of approaches, such as neuromuscular, multi-sensory, and biomechanical, focusing on motor aspects of skill acquisition. Twenty children with a mean age of 9.05 years (S.D. = 1.23) participated in the study. All children had normal intelligence, scored below the 15th percentile on a standardised test of motor ability, and demonstrated motor difficulties significant enough to warrant referral for treatment. Pre- and post-measures included the Canadian Occupational Performance Measure (COPM), the Vineland Adaptive Behavior Scales (VABS), the Bruininks-Oseretsky Test of Motor Proficiency (BOTMP), the Developmental Test of Visual-Motor Integration-Revised (VMI), the motor items of the Self-Perception Profile for Children (SPPC), and the Performance Quality Rating Scale (PQRS). In both groups, treatment goals were child-chosen. Both treatments lead to improved COPM self-ratings of performance and satisfaction; however, improvements in the CO-OP group were greater than those in the CTA group. These results were paralleled by PQRS scores, and the Motor scores on the VABS, but not on the BOTMP measures. This outcome still needs replication as no control group was involved and because of the occurrence of pre-treatment differences between the CO-OP and CTA groups on relevant measures. Follow-up data indicated that children who received CO-OP tended to experience greater long-term maintenance of their motor goals and acquired strategies; follow-up parent-report rated CO-OP treatment as more useful than CTA treatment. Self-report, observer report, standardised assessment, and follow-up all demonstrated the effectiveness of the CO-OP approach, supporting the use of CO-OP and suggesting further investigation of this new cognitive intervention.

The search for subtypes of DCD: is cluster analysis the answer?

Studies using cluster analysis as a method to identify distinct subtypes of developmental coordination disorder (DCD) have been inconclusive leading some authors to conclude that the method of cluster analysis should be abandoned while others call for the validation of previously defined subtypes. The objective of the current study was to examine the use of cluster analysis as a method of searching for subtypes of DCD to gain a better understanding of how different samples and different measures influence the interpretation of results. The paper provides a detailed review of three commonly cited cluster analytical studies and then explores the possible reasons for the discrepant results by replicating the approach with a different clinical sample. The results highlight the impact of different measures on cluster structure and the importance of adoption of a common standard to facilitate interpretation across studies.

Hemodynamic comparison of second- and third-generation stented bioprostheses in aortic valve replacement.

BACKGROUND: The hemodynamic performance of aortic replacement prostheses is of extreme importance. There is renewed interest in hemodynamics because of the influence of prosthesis-patient mismatch on left ventricular mass regression and the potential influence on survival. METHODS: The hemodynamic performance of the second-generation Carpentier-Edwards supraannular porcine and pericardial (Perimount) bioprostheses and the third-generation Medtronic Mosaic porcine bioprosthesis were compared for mean gradient and effective orifice area index. The effective orifice area index of at least 0.85 cm2/M2 was considered as lack of prosthesis-patient mismatch. The study group included included 53 patients with Carpentier-Edwards supraannular porcine, 48 with pericardial, and 98 with Medtronic Mosaic porcine bioprostheses. RESULTS: The mean gradients were not different between the prostheses by prosthesis size. The Medtronic Mosaic was not provided in size 19. The mean gradients for the prostheses, except in the very large sizes, were all double-digit values. The effective orifice area index was not different between the prostheses but there was a trend toward prosthesis-patient mismatch in smaller size prostheses. CONCLUSIONS: There was no apparent hemodynamic advantage between porcine and pericardial bioprostheses in the aortic position.

Cognitive orientation to daily occupational performance (CO-OP): part III--the protocol in brief.

Parts I and II of this series introduced the Cognitive Orientation to daily Occupational Performance (CO-OP), a new approach to intervention that is based on the premise that cognition plays an important role in the acquisition of occupational skills and the development of occupational competency. Developed for use with children who have occupational performance deficits, CO-OP is an individualized, client-centred approach focused on strategy-based skill acquisition. This third paper in this series presents a brief description of the actual CO-OP protocol including its objectives, prerequisites and key features.

Treatment of children with Developmental Coordination Disorder: what is the evidence?

Children with Developmental Coordination Disorder (DCD) experience significant difficulty performing everyday tasks and management of these children is a great source of debate. Because little is understood about the etiology of the disorder, treatment design has been driven by competing theories of motor development and motor skill acquisition. Traditional approaches to treatment have been based on neuromaturational, hierarchical theories and, consequently, therapies have focused on remeditating underlying deficits with the expectation of subsequent improvement in motor performance. Contemporary approaches, drawn from human movement science, propose that treatment methods be based on the assumption that skill acquisition emerges from the interaction of the child, the task and the environment. This paper provides a review of the treatment literature over the past 15 years, highlighting the fact that little evidence exists to suggest any one approach is better than another. Given current demands for evidence-based practice, and evolving concepts in skill acquisition, a movement toward interventions that are based on functional outcomes is recommended.

Cognitive orientation to daily occupational performance (CO-OP): part II--the evidence.

CO-OP is a child-centred, cognitive based intervention, focused on enabling children to achieve their functional goals. It has been developed over the last nine years through a series of systematic studies that have specified the treatment protocol and evaluated its effect. Initially CO-OP was explored in two series of single case experimental studies. Subsequently, an informal follow-up study and a detailed analysis of the video-taped sessions of the approach were completed. Based on information from these studies, the approach was refined, key features elucidated and the protocol was specified. Next, a pilot randomized clinical trial was completed. The trial was conducted to determine how best to approach a full scale randomized clinical trial on the effectiveness of CO-OP, relative to the current therapeutic approach. Finally, a retrospective chart audit was carried out to examine the cumulative evidence on the effectiveness of CO-OP in improving the performance of children with DCD. This paper presents a detailed summary of these five studies and discusses the implications of the findings.

Clinical description of children with developmental coordination disorder.

Occupational therapists working within School Health Support Services are receiving increasing numbers of referrals, relative to past rates, for children who are experiencing motor problems and may have developmental coordination disorder. Based upon clinical experience, therapists indicate that these children are typically referred in the early school years and that most have handwriting difficulties; to date, however, there has been little empirical evidence to support these observations. In this paper, descriptive information is presented for 556 children who may be presumed to have developmental coordination disorder and who had been referred to school-based health services in two centres. Typical reasons for referral, co-morbidity information, and assessment practices are presented. Findings confirmed the presence of many occupational performance issues in this population, including handwriting difficulties, and challenge therapists to broaden the current scope of school health assessment and intervention practices.

Evidence for tumor-host cooperation in regulating MMP-2 expression in human colon cancer.

Matrix metalloproteinase 2 (MMP-2) facilitates tumor growth and metastasis in colon cancer. Although tumor cells may produce MMP-2, stromal cells, such as macrophages and fibroblasts, contribute significantly to MMP-2 synthesis in human tumors. We characterized four human colon cancer cell lines with differing biological behavior for MMP-2 expression. While the parent tumors from which the cell lines were derived all expressed MMP-2 mRNA, MMP-2 transcripts were detected in only one cell line, TF-17C, which is nontumorigenic in a nude mouse tumor model. TF-43C, which is tumorigenic and metastatic in the same tumor model, did not produce MMP-2, yet the tumors which arose from it after injection into nude mice did contain MMP-2 mRNA, suggesting a contribution from stromal cells. Co-culturing TF-43C with fibroblasts resulted in an increase in MMP-2 protein, whereas co-culturing with the nontumorigenic cell line TF-13Cm did not alter constitutive fibroblast MMP-2 secretion. Conditioned medium from TF-43C cells also stimulated fibroblast MMP-2 production. These data suggest that a soluble factor from TF-43C cells can stimulate fibroblast MMP-2 production and support the hypothesis that colon cancer cell interactions with stromal fibroblasts may be important determinants of tumor behavior in vivo.

An international collaborative study on the INR calibration of freeze-dried reference plasmas.

A study was carried out to calibrate potential European Reference Plasmas for prothrombin time (PT) standardization. The International Normalized Ratio (INR) values of three freeze-dried candidate plasmas (one pooled normal and two pools from anticoagulated patients) were determined in 20 laboratories using six thromboplastin reagents comprising three International Reference Thromboplastins (human, rabbit and bovine), two recombinant human reagents and one placental human reagent. Interlaboratory variability of INR estimation was low with geometric coefficients of variation (gcv) <10% except in one case. Significant differences in mean INR were found between the different thromboplastins with lowest INR values found with the bovine reagent. INR values from the International rabbit and human reagents differed by <6% and were combined to give proposed assigned INR values. Significant differences in INR estimates from four thromboplastins of human origin may indicate that single assigned INR values are not applicable for use with all thromboplastin reagents. Field trials to assess the validity of single assigned INR values in clinical practice are required.

The expression of acylphosphatase is associated with the metastatic phenotype in human colorectal tumors.

We have performed differential display comparing gene expression from cell lines derived from human colorectal tumors. The cell lines were selected for study based on their ability to form metastases following injection into athymic mice. One gene which was expressed exclusively by the metastatic lines was identified as human acylphosphatase (e.c. 3.6.1.7, acylphosphate phosphohydrolase). The expression of this gene was confirmed by RT-PCR using gene-specific primers. This gene product catalyzes the hydrolysis of phosphorylated intermediates of Na+/K(+)-ATPase and of Ca(2+)-ATPases of mammalian cells. Changes in the activity of the Na+/K(+)-ATPase pump, regulated by acylphosphatase, have been previously reported in chemically-induced colonic tumors. The differential expression of this gene in the human metastatic colorectal lines suggests it may be involved in the metastatic phenotype.

The cell-coded polypeptide U90 increased by herpes simplex virus type 2 infection induces Fos and DNA synthesis.

Lytic infection with herpes simplex virus type 2 (HSV-2) induces synthesis of a cell-coded protein of molecular mass 90 kDa, termed U90. U90, whose expression is specific in tumour cells is, in addition, excreted from he cell. To determine if the function of U90 could be advantageous for the virus the protein was purified from the medium of HSV-2 infected cells, shown to be similar to the internalized form and its effect on cell growth studied. Addition of U90 to quiescent fibroblast cells stimulated teh expression of Fos, the product of the cellular transcription factor c-fos and increased the incorporation of [3H]thymidine into DNA, factors which may facilitate HSV-2 replication. However, U90 might also induce abnormal cells such as those in precancerous lesions to proliferate.

Unilateral versus bilateral internal mammary revascularization. Survival and event-free performance.

BACKGROUND: The influence of unilateral (UL) and bilateral (BL) mammary artery revascularization, within age groups < or = 60 years and > 60 years, on patient survival, ischemic-related events, and interventional management was studied in 1142 patients who had coronary artery bypass graft surgery between 1984 and 1992. METHODS AND RESULTS: UL revascularization was performed in 765 (67%) and BL in 377 (33%) patients with supplemental vein grafts. The overall early and hospital mortality rate was 2.7%. For UL in the age group < or = 60 years, it was 1.1%; for BL < or = 60 years, 1.3% (P = NS); for UL > 60 years, 4.3%; and for BL > 60 years, 2.8% (P = NS). Twenty-five preoperative patient characteristics representing demographics, extent of disease, concomitant disease, ventricular dysfunction, previous surgery, and status did not differentiate the patient groups (P = NS). Patient survival at 5 years was not different: 94% for UL < or = 60 years, 95% for BL < or = 60 years, 91% for UL > 60 years, and 86% for BL > 60 years (P = NS). The freedom from ischemic-related events was not different at 5 years (P = NS). The freedom from recurrent angina was 78% for UL < or = 60 years, 88% for BL < or = 60 years, 82% for UL > 60 years, and 83% for BL > 60 years (P = NS). The myocardial infarction freedom was 98% for UL < or = 60 years, 96% for BL < or = 60 years, 99% for UL > 60 years, and 97% for BL > 60 years (P = NS). The freedom from sudden unexpected death and cardiac death did not differentiate the groups (P = NS). The freedom from angioplasty and reoperation did not differentiate the groups (P = NS). The freedom from all ischemic-related and interventional events was 76% for UL < or = 60 years, 84% for BL < or = 60 years, 81% for UL > 60 years, and 79% for BL > 60 years (P = NS). A trend exists for less angina pectoris in the bilateral population < or = 60 years, which reflects in the trend in the freedom from overall events. CONCLUSIONS: UL and BL mammary artery revascularizations have the same early mortality regardless of age but do not reveal any advantage for BL revascularization at 5 to 7 years.

Carpentier-Edwards supraannular porcine bioprosthesis: clinical performance to twelve years.

The Carpentier-Edwards supraannular porcine bioprosthesis, a second-generation biologic prosthesis, has had clinical performance assessment to 12 years. This bioprosthesis was used in 2,489 operations in 2,444 patients between 1982 and 1992, inclusive (mean age 64.1 years, age range 6 to 89 years). There were 1,335 aortic valve replacements (AVR), 938 mitral valve replacements (MVR), and 200 multiple valve replacements (MR). Concomitant procedures were performed in 1,017 cases (40.9%). The age group distribution was: 35 years or younger, 83 patients; 36 to 50 years, 245; 51 to 64 years, 728; 65 to 69 years, 458; and 70 years and older, 975. The total follow-up was 12,785 patient-years (mean, 5.1 years) and was 96% complete. The early mortality rate was 7.4% (185 patients), and the late mortality was 4.9%/patient year (623). Concomitant procedures influenced both early and late mortality (p < 0.05). The overall patient survival at 12 years was 44% +/- 3% (p < 0.05, AVR > MVR, MR). The freedom from thromboembolism was not different by valve position. The freedom from major thromboembolism at 12 years was 82% +/- 4% (p = not significant by valve position). The overall freedom from antithromboembolic hemorrhage was 96% +/- 1% at 12 years (p < 0.05, AVR > MVR > MR). The overall freedom from valve-related reoperation at 12 years was 58% +/- 5% (p < 0.05, AVR > MVR, MR), and from valve-related mortality 89% +/- 2% (p < 0.05, AVR > MVR > MR). The freedom from residual morbidity (permanent impairment) at 12 years was 87% +/- 4% (p = not significant by valve position).(ABSTRACT TRUNCATED AT 250 WORDS)

Structural deterioration in Carpentier-Edwards standard and supraannular porcine bioprostheses.

The Carpentier-Edwards standard (CE-S) porcine bioprosthesis was implanted in 1214 operations (1975 to 1985) and the Carpentier-Edwards supraannular (CE-SAV) bioprosthesis was implanted in 2,489 operations (1982 to 1992 inclusive). The early mortality was 7.6% and 7.4% for the CE-S and CE-SAV groups, respectively; the late mortality was 5.3% per patient-year and 4.9% per patient-year, respectively. The cumulative follow-up was 9,968 patient-years for the CE-S group and 12,784 patient-years for the CE-SAV group. Concomitant procedures were performed in 26.8% of the patients who received a CE-S and in 40.9% of those who received a CE-SAV (p < 0.05). The mean age of the patients receiving a CE-S was 57.3 years (range, 8 to 85 years) and was 64.1 years (range, 6 to 89 years) in those receiving a CE-SAV. The CE-S group consisted of 578 atrial valve replacements (AVRs), 512 mitral valve replacements (MVRs), and 115 multiple valve replacements (MRs). The CE-SAV group consisted of 1,335 AVRs, 938 MVRs, and 200 MRs. There was a total of 165 cases of structural valve deterioration (SDV) in the CE-SAV group (AVR, 35; MVR, 98; and MR, 32). The effect of trimming the aortic wall was also considered: 20 of the 931 trimmed prostheses used for MVRs and MRs and none of the 207 reduced-trimmed prostheses exhibited SVD. The cumulative follow-up was 5,422 years for the patients with trimmed prostheses and 470 for those with reduced-trimmed prostheses.(ABSTRACT TRUNCATED AT 250 WORDS)

A clinical trial of the process-oriented treatment approach for children with developmental co-ordination disorder.

The process-oriented treatment (POR chi) approach is a time-limited programme aimed at increasing the kinaesthetic performance of children with mild motor problems in order to improve their motor performance. The approach was compared with a traditional or general motor approach and with no treatment in a randomized clinical trial of 75 children with developmental co-ordination disorder. The children were assessed before and after treatment and after a six-week follow-up period. The results were mixed. The study provides evidence of the severity of so-called 'mild' motor problems of children referred to occupational therapy. The data suggest that these children do not improve spontaneously, and that their motor problems are very resistant to treatment. The data also suggest that an appropriate treatment strategy might be one that involves direct, repetitive training of a specific skill.