Maternity Care and Liability: Pressing Problems,Substantive Solutions

BackgroundThis paper summarizes a new report presenting the best available research about the impact of the liability environment on maternity care, and policy options for improving this environment. Improved understanding of these matters can help to transcend polarized discourse and guide policy intervention.MethodsWe used a best available evidence approach and drew on more recent empirical legal studies and health services research about maternity care and liability when available, and considered other studies when unavailable.FindingsThe best available research does not support a series of widely held beliefs about maternity care and liability, including the economic impact of liability insurance premiums on maternity care clinicians, the existence of extensive defensive maternity care practice, and the impact of limiting the size of awards for non-economic damages in a malpractice lawsuit. In the practice of an average maternity caregiver, negligent injury of mothers and newborns seems to occur more frequently than any claim and far more frequently than a payout or trial. Many important gaps in knowledge relating to maternity care and liability remain. Some improvement strategies are likely to be more effective than others.ConclusionsEmpirical research does not support many widely held beliefs about maternity care and liability. The liability system does not currently serve well childbearing women and newborns, maternity care clinicians, or those who pay for maternity care. A number of promising strategies might lead to a higher functioning liability system, whereas others are unlikely to contribute to needed improvements.     

Daily flaxseed consumption improves glycemic control in obese men and women with pre-diabetes: a randomized study

The study hypothesis was that fasting glucose, insulin, fructosamine, C-reactive protein, and interleukin-6 decrease and adiponectin increases with daily flaxseed consumption in overweight or obese individuals with pre-diabetes. In this randomized, cross-over study overweight or obese men and postmenopausal women (n = 25) with pre-diabetes consumed 0, 13, or 26 g ground flaxseed for 12 weeks. Glucose, insulin, homeostatic model assessment (HOMA-IR), and normalized percent of α-linolenic fatty acid (ALA) were significantly different by treatment (multiple analysis of variance, P = .036, P = .013, P = .008, P = .024 respectively). Paired t tests showed glucose decreased on the 13 g intervention compared to the 0 g period [13g = −2.10 ± 1.66 mg/L (mean ± SEM), 0 g = 9.22 ± 4.44 mg/L, P = .036]. Insulin decreased on the 13 g intervention but not the 26 g (P = .021) and 0 g (P = .013) periods (13 g = −2.12 ± 1.00 mU/L, 26 g = 0.67 ± 0.84 mU/L, 0g = 1.20 ± 1.16 mU/L). HOMA-IR decreased on the 13 g period but not on the 26 g (P = .012) and 0 g (P = .008) periods (13g = −0.71 ± 0.31, 26g = 0.27 ± 0.24, 0g = 0.51 ± 0.35). The α-linolenic fatty acid decrease for the 0 g period was different than the 13 g (P = .024) and 26 g (P = .000) periods (13 g = 0.20 ± 0.04, 26g = 0.35 ± 0.07, 0g = −0.01 ± 0.07). Fructosamine, high sensitivity C-reactive protein, adiponectin, and high-sensitivity interleukin-6 had no significant differences. Flaxseed intake decreased glucose and insulin and improved insulin sensitivity as part of a habitual diet in overweight or obese individuals with pre-diabetes.     

A national study of the association between neighbourhood access to fast-food outlets and the diet and weight of local residents

Differential locational access to fast-food retailing between neighbourhoods of varying socioeconomic status has been suggested as a contextual explanation for the social distribution of diet-related mortality and morbidity. This New Zealand study examines whether neighbourhood access to fast-food outlets is associated with individual diet-related health outcomes. Travel distances to the closest fast-food outlet (multinational and locally operated) were calculated for all neighbourhoods and appended to a national health survey. Residents in neighbourhoods with the furthest access to a multinational fast-food outlet were more likely to eat the recommended intake of vegetables but also be overweight. There was no association with fruit consumption. Access to locally operated fast-food outlets was not associated with the consumption of the recommended fruit and vegetables or being overweight. Better neighbourhood access to fast-food retailing is unlikely to be a key contextual driver for inequalities in diet-related health outcomes in New Zealand.     

Apple Polyphenol Extracts Protect Against Aspirin‐induced Gastric Mucosal Damage in Rats

The protective role of two apple polyphenol extracts, Douglas‐FB (FB) and Douglas‐EF (EF), on gastric mucosal damage following aspirin ingestion was investigated in healthy rats. Polyphenol content of the apple extracts varied, with the EF extract having 20% w/w polyphenols and a high proportion of flavanols as epicatechin and procyanidin, whereas the FB extract comprised 12% w/w polyphenols, which were mostly flavonols as quercetin glycosides. Male Sprague–Dawley rats were allocated to control, FB and EF groups and fed the experimental diet during the 10‐day trial. Control treatment rats received 1 mL of deionised water, whereas apple polyphenol treatment group rats, FB and EF received a concentration of 10^?2 m polyphenols in 1 mL deionised water daily via oral gavage. At the end of 10‐day feeding period, rats were fasted overnight, and the following morning, aspirin (200 mg/kg) was given by oral gavage. Four hours after aspirin administration, the animals were euthanised, and samples taken for analysis. Both apple polyphenol extracts significantly reduced the ulcer area, ulcer lesion index and gastric injury score. The glutathione in gastric mucosa was increased significantly in rats given FB apple extract. Despite their different polyphenol compositions, FB and EF apple extracts assisted in protecting the gastric mucosa following acute aspirin administration in rats. Copyright © 2014 John Wiley & Sons, Ltd.     

Emotional and Behavioral Disorders in 1.5th Generation, 2nd Generation Immigrant Children,and Foreign Adoptees

Existing theories (e.g., acculturative stress theory) cannot adequately explain why mental disorders in immigrants are less prevalent than in non-immigrants. In this paper, the culture-gene co-evolutionary theory of mental disorders was utilized to generate a novel hypothesis that connection to heritage culture reduces the risk for mental disorders in immigrant children. Four groups of children aged 2–17 years were identified from the 2007 United States National Survey of Children’s Health: 1.5th generation immigrant children (n = 1378), 2nd generation immigrant children (n = 4194), foreign adoptees (n = 270), and non-immigrant children (n = 54,877). The 1.5th generation immigrant children’s connection to their heritage culture is stronger than or similar to the 2nd generation immigrants, while the foreign adoptees have little connection to their birth culture. Controlling for age, sex, family type and SES, the odds for having ADD/ADHD, Conduct Disorder, Anxiety Disorder, and Depression diagnosis were the lowest for the 1.5th generation immigrant children, followed by the 2nd generation immigrant children and the foreign adoptees. The foreign adoptees and non-adopted children were similar in the odds of having these disorders. Connection to heritage culture might be the underlying mechanism that explained recent immigrants’ lower rates of mental disorders.     

How does the Cox maze procedure compare? Cost-effectiveness analysis of alternative treatments of atrial fibrillation

Objectives: Data related to the cost effectiveness of surgical interventions and catheter ablation is sparse. This model-based analysis assessed the clinical and economic trade-offs involved in using catheter ablation or the Cox maze procedure in treating patients with atrial fibrillation.

Methods: A deterministic model was developed to project 1 year and lifetime health-related outcomes, costs, quality-adjusted life years (QALYs) and cost effectiveness of each treatment in patients with atrial fibrillation. Using previously unpublished Inova Heart and Vascular Institute (IHVI) data for patients undergoing either procedure, 1 year cost and clinical efficacy inputs were estimated. This data was supplemented with published literature and used to estimate costs, utilities, mortality and likelihood of patient improvement. Results were reported as cost-effectiveness ratios in $/QALY. Sensitivity analyses were conducted to assess the robustness of results.

Results: Patients initially treated with a Cox maze procedure were estimated to have higher costs than those treated with catheter ablation, both after 1 year and over the lifetime. However, patients undergoing the Cox maze procedure also had lower rates of 1 year mortality than catheter ablation patients (3.5% vs. 8.5%) and the highest rate of improvement following treatment, resulting in higher QALYs (12.4 vs. 10.2). Compared to catheter ablation, the lifetime incremental cost-effectiveness ratio for the Cox maze surgical procedure was $12,794 per QALY gained. Without quality adjustment, the ratio was $11,315. Results were most sensitive to the likelihood of improvement following each intervention and the cost of the initial procedure.

Conclusions: At a societal willingness to pay of $100,000/QALY, Cox maze procedure was found to both increase overall and quality-adjusted survival and constitute an effective use of resources in patients with atrial fibrillation.     

Metropolitan area income inequality and self-rated health--a multi-level study

We examined the association of income inequality measured at the metropolitan area (MA) and county levels with individual self-rated health. Individual-level data were drawn from 259,762 respondents to the March Current Population Survey in 1996 and 1998. Income inequality and average income were calculated from 1990 census data, the former using Gini coefficients. Multi-level logistic regression models were used. Controlling for sex, age, race, and individual-level household income, respondents living in high, medium-high, and medium-low income inequality MAs had odds ratios of fair/poor self-rated health of 1.20 (95% confidence interval 1.04-1.38), 1.07 (0.95-1.21), and 1.02 (0.91-1.15), respectively, compared to people living in the MAs with the lowest income inequality. However, we found only a small association of MA-level income inequality with fair/poor health when controlling further for average MA household income: odds ratios were 1.10 (0.95-1.28), 1.01 (0.89-1.14), and 1.00 (0.89-1.12), respectively. Likewise, we found only a small association of county-level income inequality with self-rated health although only 40.7% of the sample had an identified county on CPS data. Regarding the association of state-level income inequality with fair/poor health, we found the association to be considerably stronger among non-metropolitan (i.e. rural) compared to metropolitan residents.     

Factors influencing prescribing: an intern's perspective

OBJECTIVES: To examine the self-reported influences on intern prescribing practice. DESIGN: Qualitative interviews with a cross-sectional cohort. PARTICIPANTS AND SETTING: Ten interns practising in two urban teaching hospitals in New South Wales, Australia. RESULTS: The interns identified a number of factors that improve their confidence and perceived competence and allow them to extend their existing skills. These were approachable, available and up-to-date teachers (most often registrars and subspecialty nurses and pharmacists); timely, relevant and practical teaching (such as interactive bedside teaching); concise and widely accepted resources (such as prescribing pocket guides); and a constructive manner on the part of senior staff for dealing with prescribing errors. Interns also identified influences that are detrimental to confidence, conflict with their perceptions of appropriate prescribing and inhibit learning and skills acquisition. These were unapproachable, physically and mentally remote teachers (most often consultants); theoretical, inconsistent and irrelevant teaching (such as grand rounds or didactic education sessions); inconsistent and inaccessible resources; and a confrontational and accusatory way of dealing with prescribing errors. The added pressures of time, hospital hierarchies and the indirect influence of drug company promotion also impeded acquisition of good prescribing habits. CONCLUSIONS: At a critical time in skills development, interns encounter many forces that can potentially impact on prescribing practices in both positive and negative ways. Our data contribute to the understanding of the multifaceted learning environment of interns and may be useful in providing a foundation for prescriber education programmes tailored to the specific needs of junior doctors.     

Afatinib as First-line Treatment of Older Patients With EGFR Mutation-Positive Non-Small-Cell Lung Cancer: Subgroup Analyses of the LUX-Lung 3, LUX-Lung 6, and LUX-Lung 7 Trials

Background

Afatinib is approved in the US, Europe, and several other regions for first-line treatment for epidermal growth factor receptor mutation-positive (EGFRm⁺) non-small-cell lung cancer (NSCLC).