THE NATIONAL BIRTH CENTER STUDY Part II—Intrapartum and Immediate Postpartum and Neonatal Care

Part II of a three-part report of the National Birth Center Study describes care provided to 11,814 women and their newborns during and after labor and delivery until they were transferred or discharged from the birth centers. There were few low birth weight or preterm or postterm births, but more macrosomic babies than among all U.S. births during the same time period. Certified nurse-midwives provided most of the intrapartum care, which is described in the context of medically recommended standards and data that describe care provided to low-risk women giving birth in U.S. hospitals. Birth center care deviated from typical hospital care in several ways. Birth center clients were much less likely to receive central nervous system depressants, anesthesia, continuous electronic fetal monitoring, induction and/or augmentation of labor, intravenous infusions, amniotomies, or episiotomies, and they had relatively few vaginal examinations. They were more likely to eat solid food during labor and to take showers and/or baths Nulliparity was strongly associated with longer first stage labors and longer labor was associated with more frequent use of many kinds of interventions. Infant birth weight, mother's position during delivery, and forceps- or vacuum-assisted deliveries are examined in relation to episiotomies and lacerations and tears.     

How to use Chlamydia antibody testing in subfertility patients

Screening for tubal factor subfertility by means of Chlamydia antibody testing (CAT) was introduced into the initial work-up of subfertile couples several years ago. The results reported, however, are heterogeneous, and no uniformity exists in cut-off levels of titres, or in definitions of tubal factor subfertility. We performed a prospective cohort study to evaluate the implications of varying the definitions of tubal pathology and of modifying the cut-off levels on the clinical impact of CAT in predicting tubal factor subfertility. In 227 consecutive patients who attended our fertility clinic, the Chlamydia IgG antibody titre was determined and related to tuboperitoneal abnormalities at laparoscopy as a reference standard. According to received operating characteristic (ROC) curve analysis, a titre of 16 is the optimum cut-off level. Increasing the cut-off level improves specificity and positive likelihood ratio (LR+), at the expense of sensitivity and negative LR (LR-). Changing the definition of tubal factor subfertility from unspecified tuboperitoneal abnormalities into extensive adhesions and/or bilateral distal tubal occlusion improves LR+, LR- and kappa significantly. We conclude that CAT is more accurate in predicting severe distal tubal pathology than unspecified tuboperitoneal abnormalities. Although from a statistical point of view a titre of 16 is the optimum cut-off level, from a clinical point of view 32 or 64 may be preferable, depending on the aim of screening and the inception cohort.      

The anti-inflammatory and analgesic profile of 6,11-dihydrodibenzo-[b.e.]-thiepin-11-one-3-acetic acid (Tiopinac)

Tiopinac displayed marked anti-inflammatory activity when given p.o. in rat models of acute and chronic inflammation. It inhibited carrageenan-induced paw edema (40 x phenylbutazone), and cotton-pellet-induced granuloma (0.8 x indomethacin). In an 18-day test, tiopinac prevented the development of adjuvant-induced arthritis (10–15 x naproxen) and had similar activity versus pre-induced arthritis. Tiopinac exhibited antiphlogistic activity in adrenalectomized rats. It did not have corticosteroid activity. Depending upon the type of analgesic test used, the potency of tiopinac varied. When given p.o. it inhibited henylquinone-induced writhing in the mouse and rat (respectively 16 and 10 x aspirin). In contrast, tiopinac had 10 times the potency of indomethacin in increasing the pain threshold when yeast-inflamed paws were compressed. The pain threshold of the noninflamed paw was not increased. Tiopinac was highly active versus pain induced by flexing the adjuvant arthritic-inflamed paw (1000 x aspirin). It was inactive in the mouse hotplate test in which opiate-like agents are active. Tiopinac, p.o., lowered yeast-induced pyrexia (130 x aspirin). Tiopinac did not have significant cardiovascular or CNS activity. Whereas the ED₅₀ versus adjuvant arthritis in rats was 0.1 mg/kg/day p.o., rats tolerated up to 20 mg/kg/day p.o. in the 8-day cotton-pellet test. Lack of anorexia and emesis in dogs with up to 30 mg/kg p.o. and mild oral activity in producing gastric erosion in acute and subacute studies in rats suggests that tiopinac may have relatively little gastrointestinal irritating activity.A preliminary presentation of this study was delivered at the Federation of American Societies of Experimental Biology Meeting, Atlantic City, N.J., 1978 (Fed. Proc.37, 662 (1978).     

The basics of EDI (electronic data interchange): a pathway to the information highway

With EDI, patients such as Jane Russo can focus not on the time-consuming and often confusing business of benefit coordination, but on getting well. Similarly, the registration clerk's job is simplified thanks to a single electronic link that provides the information needed to perform his or her job accurately and efficiently. The health information management department can use EDI to maintain authority over the release of information and make the process of transferring patient information more expeditious. As EDI further evolves into the clinical arena, it will enhance care providers' access to longitudinal patient clinical records. In addition, the information highway will provide access to better information for quality assessment, outcomes management, and the development of clinical guidelines. With access to the information highway, healthcare providers, payers, and employers can take an evolutionary leap in their efforts toward coordinating truly patient-centered, high-quality care.     

Toremifene in the treatment of breast cancer

Although more widespread screening and routine adjuvant therapy has improved the outcome for breast cancer patients in recent years, there remains considerable scope for improving the efficacy, safety and tolerability of adjuvant therapy in the early stage disease and the treatment of advanced disease. Toremifene is a selective estrogen receptor modifier (SERM) that has been widely used for decades in hormone receptor positive breast cancer both in early and late stage disease. Its efficacy has been well established in nine prospective randomized phase III trials compared to tamoxifen involving more than 5500 patients, as well as in several large uncontrolled and non-randomized studies. Although most studies show therapeutic equivalence between the two SERMs, some show an advantage for toremifene. Several meta-analyses have also confirmed that the efficacy of toremifene is at least as good as that of tamoxifen. In terms of safety and tolerability toremifene is broadly similar to tamoxifen although there is some evidence that toremifene is less likely to cause uterine neoplasms, serious vascular events and it has a more positive effect on serum lipids than does tamoxifen. Toremifene is therefore effective and safe in the treatment of breast cancer. It provides not only a useful therapeutic alternative to tamoxifen, but may bring specific benefits.