A Review of the Proceedings from the 2008 NICHD Workshop on Standardized Nomenclature for Cardiotocography: Update on Definitions, Interpretative Systems With Management Strategies, and Research Priorities in Relation to Intrapartum Electronic Fetal Monitoring

Despite evidence demonstrating no neonatal benefit, the medicolegal climate in the United States requires obstetricians to integrate continuous intrapartum surveillance into their care of the pregnant laboring patient. The intent of this article is to familiarize the reader with the most recent, standardized, quantitative nomenclature recommended to describe intrapartum CTG in order to reduce miscommunication among providers caring for the laboring patient, propagate consistent, evidence-based responses to CTG patterns, and systematize the terminology used by researchers investigating intrapartum CTG.Key words: Intrapartum cardiotocography, Electronic fetal monitoring, NICHD nomenclatureIn 2002, approximately 3.4 million fetuses (85% of approximately 4 million live births) in the United States were assessed with continuous cardiotocography (CTG), making it the most commonly performed obstetric procedure.¹ Although CTG, also known as electronic fetal monitoring, is widespread in developed nations, its ability to identify the fetus that may be becoming asphyxiated and therefore may benefit from intervention is limited, and has failed to lead to reduced rates of cerebral palsy and neurologic injury. There are no studies comparing CTG with an absence of intrapartum monitoring, but trials comparing CTG with intermittent auscultation show no reduction in the overall risk of perinatal death (relative risk [RR] 0.85; 95% confidence interval [95% CI], 0.59–1.23) or cerebral palsy (RR 1.74; 95% CI, 0.97–3.11).² What studies have demonstrated is that CTG versus intermittent auscultation leads to higher operative delivery rates by cesarean or assisted vaginal delivery (RR 1.66; 95% CI, 1.30–2.13 and RR 1.16; 95% CI, 1.01–1.32, respectively).²Despite compelling evidence demonstrating no neonatal benefit, the medicolegal climate in the United States requires obstetricians to integrate continuous intrapartum surveillance into their care of the pregnant laboring patient. Due to the setup of labor and delivery units and the team-oriented approach that exists in most facilities, nurses, residents, nurse midwives, and physicians may all be regularly involved in assessing the CTG. To communicate effectively in the event that an abnormal CTG exists and invoke an appropriate level of concern, standardized terminology is necessary.^3,4In 1997, the National Institutes of Child Health and Human Development (NICHD) sponsored a Research Planning Workshop that addressed this issue. The workshop’s express purpose was to develop “a standardized and rigorously, unambiguously described set of definitions that can be quantitated” for electronic fetal heart monitoring, with the ultimate goal of producing a common language that would facilitate further investigational research examining the predictive value of electronic fetal monitoring and management strategies to recognize and reduce intrapartum fetal compromise.⁵ The American College of Obstetricians and Gynecologists (ACOG); the Association of Women’s Health, Obstetric and Neonatal Nurses; the Royal College of Obstetricians and Gynaecologists; and the Society of Obstetricians and Gynaecologists of Canada not only endorsed the definitions, but recommended new interpretations, definitions, and particular intrapartum management actions for some situations.In April 2008, the NICHD, ACOG, and the Society for Maternal-Fetal Medicine (SMFM) jointly sponsored a workshop on CTG, or fetal heart rate (FHR) patterns. The goals of this workshop⁶ were (1) to review and update the definitions for CTG pattern categorization as compared with the prior workshop, (2) to assess existing classification systems for interpretation of particular CTG patterns and make new recommendations for a system to be employed in the United States, and (3) to make recommendations for research priorities as they relate to CTG. The intent of this article is to familiarize the reader with the resulting standardized, quantitative nomenclature that is recommended to describe intrapartum CTG to reduce miscommunication among providers caring for the laboring patient, as well as systematize the terminology used by researchers investigating intrapartum CTG. A new emphasis on interpretative systems and recommended management strategies, as set forth by the recent 2008 joint workshop, is also included and reviewed in detail.     

HPV testing as an adjunct to cytology in the follow up of women treated for cervical intraepithelial neoplasia

Objective  To evaluate human papillomavirus (HPV) testing in combination with cytology in the follow up of treated women.
Design  A prospective study.
Setting  Three UK centres: Manchester, Aberdeen and London.
Population or sample  Women treated for cervical intraepithelial neoplasia (CIN).
Methods  Women were recruited at 6 months of follow up, and cytology and HPV testing was carried out at 6 and 12 months. If either or both results were positive, colposcopy and if appropriate, a biopsy and retreatment was performed. At 24 months, cytology alone was performed.
Main outcome measures  Cytology and histology at 6, 12 and 24 months.
Results  Nine hundred and seventeen women were recruited at 6 months of follow up, with 778 (85%) and 707 (77.1%) being recruited at 12 and 24 months, respectively. At recruitment, 700 women had had high-grade CIN (grades 2 or 3) and 217 had CIN1. At 6 months, 14.6% were HPV positive and 10.7% had non-negative cytology. Of those with negative cytology, 9% were HPV positive. Of the 744 women who were cytology negative/HPV negative at baseline, 3 women with CIN2, 1 with CIN3, 1 with cancer and 1 with vaginal intraepithelial neoplasia (VAIN)1 were identified at 24 months. Nine of 10 cases of CIN3/cervical glandular intraepithelial neoplasia (CGIN) occurred in HPV-positive women. At 23 months, cancer was identified in a woman treated for CGIN with clear resection margins, who had been cytology negative/HPV negative at both 6 and 12 months.
Conclusions  Women who are cytology negative and HPV negative at 6 months after treatment for CIN can safely be returned to 3-year recall.     

THE BEHAVIOR OF POX VIRUSES IN THE RESPIRATORY TRACT : II. THE RESPONSE OF MICE TO THE NASAL INSTILLATION OF VARIOLA VIRUS

Variola virus was cultivated in embryonated eggs from smallpox crusts and maintained through 85 passages. Therein it produced foci of cellular proliferation and necrosis on the chorioallantoic membrane but did not affect the embryo. The virus from egg cultures was inactive in the skin of the rabbit on primary injection and in the testis both initially and on passage. In the monkey it provoked a cutaneous eruption of short duration after an incubation period of 5 days. On nasal instillation in the mouse the virus caused no symptoms and failed to survive on the mucous membrane of the upper air passages. Beginning with the 64th egg passage it was regularly recoverable from the lung, on subinoculation in eggs, through the 5th day and occasionally through the 7th day. Its presence in the lung was attended by progressive pathological changes.     

Factors associated with 5-year risk of hip fracture in postmenopausal women

Context  The 329 000 hip fractures that annually occur in the United States are associated with high morbidity, mortality, and cost. Identification of those at high risk is a step toward prevention. Objective  To develop an algorithm to predict the 5-year risk of hip fracture in postmenopausal women. Design, Setting, and Participants  A total of 93 676 women who participated in the observational component of the Women's Health Initiative (WHI), a multiethnic longitudinal study, were used to develop a predictive algorithm based on commonly available clinical features. Selected factors that predicted hip fracture were then validated by 68 132 women who participated in the clinical trial. The model was tested in a subset of 10 750 women who had undergone dual-energy x-ray absorptiometry (DXA) scans for bone mass density assessment. Main Outcome Measure  The prediction of centrally adjudicated hip fracture, measured by the area under the receiver operator characteristic (ROC) curves. Results  During a mean (SD) follow-up of 7.6 (1.7) years, 1132 hip fractures were identified among women participating in the observational study (annualized rate, 0.16%), whereas during a mean follow-up of 8.0 (1.7) years, 791 hip fractures occurred among women participating in the clinical trial (annualized rate, 0.14%). Eleven factors predicted hip fracture within 5 years: age, self-reported health, weight, height, race/ethnicity, self-reported physical activity, history of fracture after age 54 years, parental hip fracture, current smoking, current corticosteroid use, and treated diabetes. Receiver operating characteristic curves showed that the algorithm had an area under the curve of 80% (95% confidence interval [CI], 0.77%-0.82%) when tested in the cohort of different women who were in the clinical trial. A simplified point score was developed for the probability of hip fracture. Receiver operating characteristic curves comparing DXA-scan prediction based on a 10% subset of the cohort and the algorithm among those who participated the clinical trial were similar, with an area under the curve of 79% (95% CI, 73%-85%) vs 71% (95% CI, 66%-76%). Conclusion  This algorithm, based on 11 clinical factors, may be useful to predict the 5-year risk of hip fracture among postmenopausal women of various ethnic backgrounds. Further studies are needed to assess the clinical implication of the algorithm in general and specifically to identify treatment benefits.      

Early results of external iliac artery stenting combined with common femoral artery endarterectomy

PURPOSE: The endovascular approach to external iliac artery (EIA) disease extending into the common femoral artery (CFA) has been avoided because of problems with stent placement across the inguinal ligament. Surgical treatment for this disease distribution includes extensive endarterectomy or bypass procedures or both. We report our initial experience with a combined open and endovascular approach to these patients. METHODS: We performed a retrospective analysis of all patients who underwent intraoperative EIA stenting after CFA endarterectomy/patch angioplasty between 1997 and 2000. Stents were positioned to end at the proximal endarterectomy endpoint, without crossing the inguinal ligament. Technical success, hemodynamic success, and clinical success were determined according to Society of Vascular Surgery/International Society of Cardiovascular Surgery criteria. Life-table analysis was performed for patency. RESULTS: Thirty-four patients (mean age, 68 years; 23 male, 11 female) had combined endovascular and open treatment of iliofemoral occlusive disease. Indications were claudication in 41% and critical limb ischemia in 59%. Femoral reconstruction included endarterectomy with patch angioplasty in all patients. EIA stent deployment incorporated the stenotic iliac segment and the proximal endpoint of the endarterectomy in all patients. Four patients (12%) also needed common iliac angioplasty at the same time for proximal iliac disease, and 14 patients (41%) also needed distal revascularization for associated femoropopliteal or tibial disease. Technical success and hemodynamic success were achieved in 100% of patients. Clinical success was achieved in 97% of patients. The mean postoperative increase in ankle-brachial index in patients with inflow procedures only was 0.36 (range, 0.1 to 0.85). The overall complication rate was 15%. With a mean follow-up period of 13 months (range, 0.5 to 28 months), 1-year primary patency and primary-assisted patency rates were 84% and 97%, respectively. No perioperative mortality was seen. CONCLUSION: EIA stenting as an adjunct to CFA endarterectomy/patch angioplasty allows for more localized surgery than conventional bypass. This approach also allows a better interface between the stent and endarterectomy than staged preoperative stenting. Technical success and early patency rates are excellent.     

Small bowel transit and gastric emptying after biliodigestive anastomosis using the uncut jejunal loop

BACKGROUND: The Roux-en-Y loop is an effective procedure for biliodigestive drainage. However, up to 15% of patients suffer from postoperative cholangitis or blind loop syndrome. A new technique to prevent motility abnormalities has been developed. METHODS: Male Lewis rats were used to compare gastric emptying and transit in the small bowel after either a standard Roux-en-Y anastomosis or a new biliodigestive anastomosis technique which involves creating an "uncut" jejunal loop with luminal occlusion. Unoperated rats served as controls. (99)Technetium HIDA and (111)Indium-tagged amberlite were respectively used to investigate small bowel transit and gastric emptying. RESULTS: Histopathology showed distinctive abnormalities only in the liver of conventional Roux-en-Y animals. No recanalization of the obliterated gut lumen occurred in uncut Roux animals. Distribution of (99)Tc-HIDA and (111)In showed were similar in both groups. Gastric emptying is slowed in both groups. CONCLUSIONS: The uncut proximal jejunum loop is a good alternative to the conventional Roux-en-Y loop and showed preserved small bowel motility and adequate jejunal transit. Gastric emptying is slowed in both groups.