Use of femur length/abdominal circumference ratio in detecting the macrosomic fetus

The femur length/abdominal circumference ratio, expressed as FL/AC X 100, was determined in 156 fetuses and evaluated as a predictor of fetal macrosomia within one week prior to delivery. The normal range (mean +/- 2 SD) in the 105 normal-weight fetuses was 22.0 +/- 2, while the normal range in the 51 macrosomic fetuses was 20.5 +/- 2; these differences were highly significant (P = less than .0001). The predictive power of a positive ratio was 68%, with a sensitivity of 63%. This ratio was particularly useful in the subset (n = 9) of macrosomic fetuses whose mothers were diabetic, correctly identifying 89% of this group. Because it is age independent, this ratio should prove most helpful in identifying fetuses at risk for macrosomia in patients whose dates are not known, since it may become abnormal before the fetal weight falls above the 90th percentile at term (3,900 g). In patients whose dates are known, early fetal macrosomia is best predicted by evaluating the abdominal circumference against normal standards for age.     

Pediatricians' awareness of and attitudes about four clinical practice guidelines

BACKGROUND: The increasing complexity of medical care and a desire to increase quality and control costs have led to growing use of clinical practice guidelines (CPGs). It is unclear how helpful these guidelines are to the practitioners expected to use them. We surveyed pediatricians about their knowledge and impressions of four well-publicized CPGs: the American Academy of Pediatrics' "Practice Parameter for Hyperbilirubinemia in Newborns" (hyperbilirubinemia), "A Guideline for the Management of Febrile Infants" (fever), the Agency for Health Care Policy and Research's "Guideline for Otitis Media With Effusion" (otitis), and the US Preventive Services Task Force Guide to Clinical Preventive Services (preventive care). OBJECTIVES: 1) What percentage of practicing pediatricians are aware of these guidelines? 2) How helpful do they find them? 3) What are practitioners' perceived limitations of these guidelines? 4) Have these guidelines affected provider behavior? 5) Are there features of a provider's training or practice that are associated with changing practice as a result of guidelines? DESIGN: A national survey of 600 pediatricians selected at random from the American Medical Association master file. RESULTS: A total of 300 of 555 eligible participants (54%) returned surveys. Of the respondents, 66% were aware of the hyperbilirubinemia guideline, 64% of the fever guideline, 50% of the otitis guideline, but only 16% knew of the preventive care guidelines. Mean helpfulness scores (1 to 10 scale, where 1 = "not at all helpful" and 10 = "extremely helpful") ranged from 3.67 to 6.67 for the different guidelines. In terms of limitations, 15% to 33% of respondents reported that CPGs were "too cookbook," 6% to 19% reported that they were "too time-consuming," and 4% to 16% reported that they were "too cumbersome." Additional reported limitations were believing that a guideline left no room for personal experience and judgment, concern of increased liability risk, and poor parental acceptance of CPG recommendations. The proportions reporting change in management as a result of a CPG were 28% for the hyperbilirubinemia guideline, 36% for the fever guideline, 19% for the preventive care guidelines, and 28% for the otitis guideline. Mean helpfulness scores reported by nonuniversity-affiliated physicians were significantly higher than those reported by university-affiliated physicians. In a regression model of respondents aware of a particular guideline, more recent graduation from medical school and increased helpfulness scores were associated with guideline-related behavior change. CONCLUSION: In their present form, CPGs are not perceived as very helpful by most practitioners. More recent medical school graduates and nonuniversity-affiliated physicians are more likely to find them helpful and more likely to change their behavior because of them.     

Modulation of human cytotrophoblastic leptin secretion by interleukin-1alpha and 17beta-oestradiol and its effect on HCG secretion.

To investigate the role of leptin during pregnancy, we assessed leptin production by pure cultured human cytotrophoblastic cells (CTB), its regulation by cytokines and 17beta-oestradiol and its effects on human chorionic gonadotrophin (HCG) secretion. Purified CTB from first trimester placenta were incubated in duplicates in the presence or absence of cytokines or 17beta-oestradiol. Medium was harvested on day 2 and the culture stopped on day 4. Results were corrected for protein content of each individual well and expressed as percent of controls per day (mean +/- SEM). Basal CTB leptin production was 25.2 +/- 2.6 (ng/mg prot). In comparison with controls, leptin production was stimulated to 320 +/- 16% (P < 0.0001) and 195 +/- 3.2% (P < 0.0004) by 3 and 10 ng/ml of interleukin-1alpha respectively. 17beta-oestradiol 10(-6) to 10(-9) mol/l increased basal leptin production 5-9-fold, while 10(-5) mol/l had no such effect. Basal CTB HCG secretion was 5722 +/- 1055 (mIU/mg prot). There was a dose-dependent leptin-induced increase in HCG secretion (P = 0.0039) reaching a 5-fold increase with a leptin concentration of 1 microg/ml (P < 0.006). Gonadotrophin-releasing hormone (GnRH) 8.5 x 10(-8) mol/l significantly increased HCG secretion to 140 +/- 21% of controls (P = 0.031). Cetrorelix (0.1 microg/ml) inhibited leptin-induced HCG secretion (P = 0.0028).     

Role of decision aids in orthopaedic surgery

Medical treatment of patients inherently entails the risk of undesired complication or side effects. It is essential to inform the patient about the expected outcomes, but also the possible undesired outcomes. The patients preference and values regarding the potential outcomes should be involved in the decision making process. Even though many orthopaedic surgeons are positive towards shared decision-making, it is minimally introduced in the orthopaedic daily practice and decision-making is still mostly physician based. Decision aids are designed to support the physician and patient in the shared- decision-making process. By using decision aids, patients can learn more about their condition and treatment options in advance to the decision-making. This will reduce decisional conflict and improve participation and satisfaction.     

Multilobar electrocorticography monitoring during intracranial aneurysm surgery

Introduction  To detect a neuronal threshold of tolerance to ischemia, the usefulness of multilobar electrocorticography (mEcoG) during intracranial aneurysm surgery was compared to the scalp EEG and correlated with the postoperative neurological status and the radiological findings. Methods  Twenty-one patients harboring intracranial aneurysms were monitored by simultaneous scalp EEG and lobe-dependent mEcoG during surgical clipping. The patients were divided into group A (6 patients with no temporary clipping) and group B (15 patients with temporary clipping). Results  New focal modifications of the mEcoG signal with high frequency (HF)-β3 and delta waves were observed in none of the patients in group A and all of the patients in group B. These anomalies were followed by focal burst suppression pattern in eight cases (53%) in group B. These changes were detected in only two cases (9%) on the scalp EEG. New corticographic changes resolved in eight patients (53%) in group B. Among the seven patients in group B who had persistent focal burst pattern after clip removal, six (85%) presented with new neurological deficit or new hypodensity on CT. The Glasgow Outcome Scale was good (IV or V) in 85% of cases. Conclusion  mEcoG is more sensitive than scalp EEG. The appearance and persistence of the focal burst suppression pattern shown on mEcoG, was associated with a new neurological deficit or new hypodensity, whereas HF-β3 or delta waves per se were not associated with new changes. A better comprehension of these EEG anomalies could determine the duration of temporary clipping and consequently influence the surgical strategy.     

Neoadjuvant therapy for resectable pancreatic ductal adenocarcinoma: The need for patient-centered research

Pancreatic ductal adenocarcinoma is an aggressive cancer with high recurrence rates following surgical resection.While adjuvant chemotherapy improves survival,a significant proportion of patients are unable to initiate or complete all intended therapy following pancreatectomy due to postoperative complications or poor performance status.The administration of chemotherapy prior to surgical resection is an alternative strategy that ensures its early and near universal delivery as well as improves margin-negative resection rates and potentially improves long-term survival outcomes.Neoadjuvant therapy is increasingly being recommended to patients with pancreatic ductal adenocarcinoma,however,patient-centered research on its use is lacking.In this review,we highlight opportunities to focus research efforts in the domains of patient preferences,patient-reported outcomes,patient experience,and survivorship.Novel research in these areas may identify relevant barriers and facilitators to the use of neoadjuvant therapy thereby increasing its utilization,improve shareddecision making for patients and providers,and optimize the experience of those undergoing neoadjuvant therapy.