Factors Associated with the Choice of Delivery without Epidural Analgesia in Women at Low Risk in France

ABSTRACT: Background: Regional anesthesia is used for three‐fourths of the deliveries in France. Epidural analgesia during labor is supposed to be available to all women at low risk. The purpose of our study was to examine how the choice of delivery without an epidural varied in this context according to women’s characteristics, prenatal care, and type of maternity unit. Methods: The 2003 National Perinatal Survey in France collected data about a representative sample of births. We selected 8,233 women who were at low risk and therefore should have been able to choose whether or not to deliver without epidural analgesia. Women were interviewed in the maternity unit after delivery. The factors associated with women’s choice to deliver without epidural analgesia were studied with multivariable analyses. Results: Of the 2,720 women who gave birth without epidural analgesia, 37 percent reported that they had not wanted one; other reasons were labor occurring too quickly (43.9%), medical contraindication (3.3%), and unavailability of an anesthesiologist (2.8%). The reported decision to deliver without epidural analgesia was closely associated with high parity. It was also more frequent among women in an unfavorable social situation (not cohabiting, no or low‐qualified job) and among women who gave birth in nonuniversity public hospitals, in small‐ or medium‐sized maternity units, and in maternity units without an anesthesiologist always on site. Conclusions: Unfavorable social situation and organizational factors are associated with the reported choice to give birth without epidural analgesia. This finding suggests that women are not always in a position to make a real choice. It would be useful to improve the understanding of how pregnant women define their preferences and to know how these preferences change during pregnancy and labor. (BIRTH 35:3 September 2008)     

Prediction of persistence of combined evidence-based cardiovascular medications in patients with acute coronary syndrome after hospital discharge using neural networks

In the PREVENIR-5 study, artificial neural networks (NN) were applied to a large sample of patients with recent first acute coronary syndrome (ACS) to identify determinants of persistence of evidence-based cardiovascular medications (EBCM: antithrombotic + beta-blocker + statin + angiotensin converting enzyme inhibitor-ACEI and/or angiotensin-II receptor blocker-ARB). From October 2006 to April 2007, 1,811 general practitioners recruited 4,850 patients with a mean time of ACS occurrence of 24 months. Patient profile for EBCM persistence was determined using automatic rule generation from NN. The prediction accuracy of NN was compared with that of logistic regression (LR) using Area Under Receiver-Operating Characteristics-AUROC. At hospital discharge, EBCM was prescribed to 2,132 patients (44%). EBCM persistence rate, 24 months after ACS, was 86.7%. EBCM persistence profile combined overweight, hypercholesterolemia, no coronary artery bypass grafting and low educational level (Positive Predictive Value = 0.958). AUROC curves showed better predictive accuracy for NN compared to LR models.     

Place of the pathologist in the management of primary bone tumors (osteosarcoma and Ewing's family tumors after neoadjuvant treatment)

The survival of osteosarcoma and Ewing family tumours has been improved by the introduction of neoadjuvant chemotherapy. The response to preoperative chemotherapy is evaluated on the microscopic analysis of the surgical resection, by the percentage of tumour necrosis according to the Huvos and Rosen's grading. It remains the only reliable prognostic factor for patients and is used to guide the choice of post-operative chemotherapy. The macroscopic and microscopic management of the surgical resection (cf. supra) is essential and is the subject of a specific protocol. Several studies have been conducted to identify news factors able to predict the response to chemotherapy, the tumour aggressiveness and its ability to develop metastases. Inhibitors of mTOR and/or regulators of the balance RANKL/OPG are promising therapeutics. The study's expression of these new factors could be performed on the biopsy and will offer new therapeutic strategy.