Trial of labor in patients with a previous cesarean section: does maternal age influence the outcome?

OBJECTIVE: This study was undertaken to evaluate the effect of maternal age on the rate of vaginal delivery and the rate of uterine rupture in patients undergoing a trial of labor (TOL) after a prior cesarean delivery. STUDY DESIGN: A cohort study of all women with a live singleton fetus undergoing a TOL after a previous low-transverse cesarean delivery was performed between 1988 and 2002 in a tertiary care center. Patients were divided into 3 groups according to maternal age: less than 30 years old, 30 to 34 years old, and 35 years or older. Women with no prior vaginal delivery and with at least 1 prior vaginal delivery were analyzed separately. The rate of vaginal delivery and the rate of symptomatic uterine rupture were calculated. Multivariate logistic regression analyses were performed to adjust for potential confounding variables. RESULTS: Of the 2493 patients who met the study criteria, there were 1750 women without a prior vaginal delivery (659, 721, and 370, respectively) and 743 women with a prior vaginal delivery (199, 327, and 217, respectively). The rate of uterine rupture was comparable between the groups (2.0%, 1.1%, 1.4%, P=.404 and 0%, 0.3%, 0.9%, P=.312). Successful vaginal delivery was inversely related to maternal age (71.9%, 70.7%, 65.1%, P=.063, and 91.5%, 91.1%, 82.9%, P=.005). After adjusting for confounding variables, maternal age equal to or greater than 35 years old was associated with a lower rate of successful vaginal delivery in patients without prior vaginal delivery (odds ratio [OR] 0.73, 95% CI: 0.56-0.94), and in patients with a prior vaginal delivery (OR: 0.47, 95% CI: 0.29-0.74). CONCLUSION: Patients who are 35 years or older are more prone to have a failed TOL after a prior cesarean delivery.     

Brain areas engaged during visual judgments by involuntary access to novel semantic information

Theories of visual recognition place different emphasis on the role of non-stimulus factors. Previously, we showed that arbitrary semantic associations influenced visual recognition of novel objects. Here, the neural substrate of this effect was investigated. During a visual task, novel objects associated with arbitrary semantic features produced more activation in frontal and parietal cortex than objects associated with names. Because the task required no semantic retrieval, access to semantics appears to be involuntary. The brain regions involved have been implicated in semantic processing, thus recently acquired semantics activate a similar network to semantics learned over a lifetime.     

Cardiac disease in children with primary glomerular disorders—role of focal segmental glomerulosclerosis

Anecdotal reports suggest a higher frequency of serious cardiac complications, particularly cardiomyopathy and congestive heart failure (CHF), in children with focal segmental glomerulosclerosis (FSGS). We report the occurrence of cardiac disease in children with FSGS compared with other glomerular causes of primary nephrotic syndrome (NS). A chart review was performed on all patients evaluated at the Schneider Childrens Hospital between 1985 and 2003 with a diagnosis of membranoproliferative glomerulonephritis (MPGN), membranous nephropathy (MN), focal global glomerulosclerosis (FGGS), and FSGS. Clinical and demographic data were compiled, specifically whether or not the patient had clinically evident cardiac disease. The blood pressure (BP) and hematocrit in patients with FSGS and chronic renal failure (CRF) (glomerular filtration rate <30 ml/min per 1.73 m²) in the 3 months prior to the development of cardiac complications were compared with the values in FSGS patients with CRF but no cardiac complications, and in patients with the other causes of primary NS in whom CRF developed. There were 48 patients with FSGS, 22 with MPGN, 19 with MN, and 4 with FGGS. Cardiac disease occurred in 6 children (mean age 11 years), all with FSGS. Four of these patients were black and 5 were female. CHF occurred in all patients, cardiomyopathy in 4, and left ventricular hypertrophy in 5 patients. There was no significant difference in the BP and the hematocrit levels between the 6 patients with both FSGS and cardiac disease, 3 patients with FSGS and CRF but no cardiac disease, and the 5 patients with the other glomerulopathies in whom CRF occurred (P>0.1). Our findings suggest that there is a clinical association between FSGS and cardiac disease in pediatric patients. We speculate that the immune mechanism responsible for the development of FSGS may also affect the heart.     

A clinical study assessing the tolerability and biological effects of infliximab, a TNF-alpha inhibitor, in patients with advanced cancer

BACKGROUND: Tumour necrosis factor-alpha (TNF-alpha) is an important regulator of the chronic inflammation contributing to tumour progression. Infliximab, an anti-TNF-alpha monoclonal antibody was investigated in this trial of patients with advanced cancer. The primary objectives were to determine the safety profile and biological response of infliximab in a cancer population. Clinical response was a secondary objective. PATIENTS AND METHODS: Forty-one patients received infliximab at 5 mg/kg (n = 21) or 10 mg/kg (n = 20) i.v. at 0 and 2 weeks and then every 4 weeks. Post-treatment samples were measured for changes in plasma and serum TNF-alpha, CCL2, IL-6 and C-reactive protein (CRP). RESULTS: Infliximab was well tolerated with no dose-limiting toxic effects. At both doses of infliximab, neutralisation of serum TNF-alpha was observed after 1 h while plasma CCL2, IL-6 and serum CRP were decreased 24 and 48 h following infliximab administration. Seven patients experienced disease stablisation (range 10-50+ weeks). There was no evidence of disease acceleration in any patient. CONCLUSIONS: Infliximab treatment was safe and well tolerated in patients with advanced cancer. There was evidence of biological activity with baseline TNF-alpha and CCL2 being correlated with infliximab response.     

Welfare reform and child care options for low-income families

For the changes under welfare reform to positively affect children, the gains that mothers make from employment must lead to improvements in children's daily settings at home, in child care, at school, or in the community. This article focuses on the role child care can play in promoting the development of, and life opportunities for, low-income children. Key observations include: Total federal and state funding for child care for welfare and working poor families has increased dramatically since welfare reform, from $2.8 billion in 1995 to $8.0 billion in 2000. The majority of welfare mothers tend to rely on informal child care arrangements when first participating in welfare-to-work programs, but as they move off welfare and into more stable jobs, they are more likely to choose a center or a family child care home. Although children from poor households stand to benefit the most from high-quality care, they are less likely to be enrolled in high-quality programs than are children from affluent families, partly due to uneven access to high-quality options in their neighborhoods. Less than one-quarter of all eligible families use child care subsidies, and usage varies widely across states and local areas reflecting various barriers to access and scarcity of quality center-based care. The authors conclude that to achieve welfare reform's ultimate goal of breaking the cycle of intergenerational poverty and dependence on government benefits, welfare-to-work programs should promote learning and development among children in welfare and working poor families by increasing access to high-quality child care in low-income neighborhoods.     

The impact of a single-layer or double-layer closure on uterine rupture

OBJECTIVE: Our purpose was to measure the impact of a single-layer or double-layer closure on uterine rupture at subsequent delivery. STUDY DESIGN: This is an observational cohort study of all women undergoing a trial of labor from 1988 to 2000 in a tertiary care center, after a single low transverse cesarean delivery. Factors most highly associated with uterine rupture were identified by using univariate regression analysis. Multivariate logistic regression analysis was used to adjust for selected confounding variables. RESULTS: Of the 2142 women who met the study criteria, 1980 (92.4%) had maternal records and original operative reports reviewed. After adjustments were made for confounding variables, the odds ratio for uterine rupture in women with a single-layer closure was 3.95 (95% CI, 1.35-11.49). CONCLUSION: A single-layer closure of the previous lower segment incision was the most influential factor and was associated with a 4-fold increase in the risk of uterine rupture compared with a double-layer closure.     

Regeneration of acutely and chronically injured descending respiratory pathways within post-traumatic nerve grafts

Central respiratory neurons, which are acutely axotomized by peripheral nerve grafts implanted at the level of the descending respiratory pathways within the C2 spinal cord, can regenerate their axons within the grafts and still transmit normal physiological messages [Decherchi et al., 1996. Exp. Neurol. 137, 1-14]. The present work investigated the extent to which mature central neurons, acutely or chronically axotomized by a spinal lesion, still maintain the potential to regenerate an axon following post-traumatic nerve grafting within supra-lesional spinal structures and remained functional. This study is an extension of earlier work employing the more chronic lesions, that investigated whether respiratory neurons chronically axotomized by a spinal cord injury can retain the ability to regenerate their axonal process within a post-traumatic peripheral nerve graft. Here implantation was performed into the supra-lesional ventrolateral part of the ipsilateral C2 spinal cord (at the level of the descending respiratory pathways) previously hemisected at the C3 level. In the present study, these post-traumatic peripheral nerve grafts were performed either acutely (group I, n=15, 2.5 h post-injury: acute conditions) or chronically (group II, n=17, 3 weeks; group III, n=6, 3 months: chronic conditions) after the injury.Electrophysiological recording of teased filaments (n=2362) within the post-traumatic peripheral nerve grafts revealed the presence of regenerated nerve fibers with spontaneous unitary impulse traffic (graft units, n=954) in all animals. These graft units were respiratory (n=247) and non-respiratory (n=707). Respiratory discharges originated from central respiratory neurons which remained functional with preserved afferent connections. Except for the group III, post-traumatic C2 peripheral nerve grafts of the groups I and II contained a significantly higher occurrence rate (13.2+/-2% and 11.6+/-1.9%) of respiratory units than C2 spinal peripheral nerve grafts (5.9+/-1.6%) realized without previous CNS injury.The main conclusion of our study is that for a prolonged period of 3 weeks following a spinal cord injury, central respiratory neurons have the potential to remain functional and to regenerate their axonal process within post-traumatic peripheral nerve grafts inserted rostrally to the spinal damage. This indicates that supra-lesional post-traumatic nerve grafts may constitute an efficient delayed strategy for inducing axonal regrowth of chronically axotomized adult central neurons. This suggests that surgical intervention which is not always possible immediately after a spinal cord injury may be satisfactorily carried out after an appropriate delay.