Maternal and Perinatal Mortality Associated with Cesarean Section in Alberta (1955-1959)

A province-wide study of perinatal mortality was initiated in Alberta (population 1,283,000) in 1955. The period 1955-1959 covered 182,028 total births and 4219 perinatal deaths of which 260 were from 3813 Cesarean sections.The perinatal mortality rate in Cesarean-section births in rural hospitals (101.4 per thousand Cesarean births) was compared with that for urban hospitals (55.7 per thousand).Examination of the indications for primary Cesarean section in which a perinatal death occurred showed that hemorrhage accounted for 54 out of 85 of these deaths in rural hospitals, and 49 out of 110 similar urban deaths. Of 33 perinatal deaths associated with elective repeat sections, 17 were of premature babies.Eleven of the 85 maternal deaths during 1955-1959 were associated with Cesarean section, a maternal mortality rate of 28.8 per 10,000 Cesarean section births. Preventable factors were present in 8 of the 11 cases. Hemorrhage was the primary cause of death.     

TUBERCULOSIS ORGANISMS RESISTANT TO DRUGS—The Incidence and the Rate of Relapse Among Patients

In a study carried out under the sponsorship of the California Tuberculosis and Health Association, 15 institutions for tuberculous patients were sent a questionnaire to obtain information regarding drug resistance studies on positive sputums of new patients and data on the readmission rate to tuberculosis hospitals.The results of these studies showed that the problem of drug resistant tubercle bacilli is sizable and important. In this study it was larger than has been reported by other investigators. The average readmission rate for the tuberculosis institutions covered in this study was 19.2 per cent—but many of the patients left the hospitals against medical advice.     

Diagnosis of dystocia and management with cesarean section among primiparous women in Ottawa-Carleton.

We carried out a chart review study to determine the rate of diagnosis of dystocia (abnormal progress) and the use of cesarean section to treat dystocia among 3887 primiparous women who gave birth to a single baby in the vertex presentation at four hospitals in Ottawa-Carleton in 1984. Of the 3740 women who had some labour 1127 (30.1%) were given a diagnosis of dystocia. Cesarean section for dystocia was done during all phases of labour (41% of procedures in the latent phase, 38% in the active phase and 21% in the second stage). The cesarean section rate varied among the hospitals from 11.8% to 19.6%. A total of 75% of the cesarean sections were for dystocia, disproportion or failed induction. The findings suggest that cesarean section is being done for disproportion without a trial of labour beyond the latent phase and for dystocia in the absence of fetal distress. If these practices were modified the cesarean section rate could be reduced from 16% to about 8%, the rate found in some other centres and that observed in Canada in the early 1970s.     

Cesarean section in Iraqi Awassi ewes: A case study

We describe criteria for choosing Cesarean section to treat dystocia, and identify factors that appeared to influence the success of Cesarean section in Iraqi Awassi ewes under clinical condition. The study was conducted on 276 ewes presented for dystocia during the lambing seasons from 1985 to 1990. Out of 130 (47%) ewes assigned to undergo Cesarean section, 65 (50%) had ringwomb, while oversized fetus, emphysematous fetus, fetal monsters and hydroallantois accounted for 37 (28%), 16 (13%), 10 (7%) and 2 (1%) of the ewes, respectively. Primiparous and 2-year old ewes (54%) as well as ewes carrying singletons (53%) were assigned to surgery more frequently than multiparous ewes over 2 Y of age carrying twins. Ewes that delivered male lambs underwent surgery more frequently than those with female lambs (63 vs 37%). The maternal survival rate was 95% while after 86% of the surgeries the ewes had an uncomplicated recovery and conceived in the following estrus. Based on this case study, Cesarean section appears to be a safe and successful procedure for management of dystocia in Iraqi Awassi ewes.     

上海市产科和妇保医务人员对孕产妇产后抑郁和精神分裂症的识别情况调查

目的：了解现阶段上海市产科和妇保专业人员对孕产妇常见心理行为问题的识别率及处理方法。方法：共有332例上海市产科和妇保专业人员完成了《孕产妇常见心理行为问题案例分析》。该问卷包括2个案例,第一个为产后抑郁症,第二个为精神分裂症。每个案例后设置了同样的3个相关问题,分别为最可能的诊断、需要补充的资料和最合适的处理。结果：调查对象中91.0%能够正确识别产后抑郁症;多数受访者（81.9%）能够意识到信息不够,需要补充选项所列全部资料,10.8%的受访者只关心孕产期相关因素;18.1%的受访者选择转入精神科专科机构接受住院治疗。调查对象中仅13.9%能够正确识别精神分裂症,高达69.9%的受访者将其误判为产后抑郁症;78.3%认为需要补充选项所列全部资料;有24.7%的受访者认为目前最合适的处理方法是转入精神科专科机构接受住院治疗。医生比护士和助产士对孕产妇常见心理行为问题的识别能力高,二级医院的识别率比三级医院高。结论：上海市产科和妇保专业人员对产后抑郁症的识别率较高,但对精神分裂症的识别率还有待提高,且对孕产妇心理行为问题的处理方式不够恰当。职业类型（医生、护士或助产士）和单位级别为识别率的影响因素。     

Coronary artery bypass grafting in Canada: hospital mortality rates, 1992-1995

BACKGROUND: Rates of in-hospital death after coronary artery bypass grafting (CABG) have been studied in many regions of Canada as possible indicators of hospital-specific quality of care. This nationwide study examined observed and risk-adjusted death rates for 23 Canadian hospitals performing CABG. METHODS: Hospital discharge data were obtained from the Canadian Institute for Health Information and were used to identify all CABG procedures performed in Canadian hospitals in fiscal years 1992/93 through 1995/96. Cases from Quebec hospitals were not studied because hospitals in that province do not report to the institute. Observed death rates were evaluated, and a logistic regression model was used to calculate a risk-adjusted death rate for each hospital for the 4-year period studied. Changes over time in hospital-specific death rates were also examined. RESULTS: A total of 50,357 CABG cases were studied, with an overall death rate of 3.6%. Interhospital comparisons showed that average severity of illness varied considerably across hospitals. Despite risk adjustment accounting for this variable severity, there was considerable variation in adjusted death rates across the 23 hospitals, from 1.95% to 5.76% (p < 0.001 for difference across hospitals). For some hospitals, death rates decreased between 1992/93 and 1995/96, whereas for others the rates were stable or increased. INTERPRETATION: Risk-adjusted rates of in-hospital death after CABG vary widely across Canadian hospitals. There may be differences in quality of care across hospitals, and focused quality-improvement initiatives may be necessary in some institutions.     

CONTROL OF DIARRHEAL DISEASES IN CALIFORNIA STATE HOSPITALS FOR RETARDED CHILDREN

The three California state hospitals for mentally retarded persons have been having a severe problem with amebic and bacillary dysentery and with other infectious diseases of the gastrointestinal tract. At Sonoma, the oldest of these hospitals, this problem is known to have existed for many years. Improved medical and nursing staffing and the use of antibiotics and other effective drugs developed in recent years have greatly lowered morbidity and mortality rates in these institutions. However, in themselves these measures have not been effective in lowering the incidence of infection.Studies have demonstrated that mass treatment of cottage groups known to have a high incidence of amebic infection has resulted in control of this disease where such mass treatment was followed by adequate laboratory follow-up, with isolation and retreatment of treatment failures. Where mass treatment of such groups has been carried out without such laboratory followup, there was a rapid return to the previous high incidence of infection.Statistics show that these diseases are a serious threat to employees working in these institutions. Increasing attention is being paid to the potential threat to the surrounding communities and the state as a whole from the focus of infection present in these hospitals.     

Hepatitis B Prevention in Small Rural Hospitals

A retrospective study of 246 potential hepatitis B exposure incidents in 12 rural hospitals in Arizona over a two-year period revealed a rate of 6.3 incidents per 100 employees per year. Needle punctures accounted for 68% of the incidents; 17% were cuts from instruments or broken glassware. Although 51% occurred in nursing personnel, housekeepers accounted for a surprising 19.5% of the reports. Only 50% of the employees received any medical attention following incidents. None received hepatitis B immune globulin (HBIG); seven received immune globulin (IG). The mean cost to the hospitals for the 122 incidents where treatment was given was $64.50 per incident. In all, 10 hospitals had no written policy for hepatitis B prevention, 3 did not stock IG and 11 did not stock HBIG. There was little awareness of hepatitis B as a nosocomial problem within these institutions, perhaps because no reported cases of clinical hepatitis B occurred in employees of the 12 hospitals in the two years.     

The role of FNA in the initial management of thyroid lesions: 7-year experience in a district general hospital

Fine needle aspiration (FNA) cytology plays a major role in the diagnosis of the thyroid lesions in university hospitals and tertiary referral institutions. Our aim was to find out if this was possible in small district hospitals with limited resources. Over a 7-year period, from October 1994 to April 2002, 303 patients with thyroid swellings underwent FNA with an overall adequacy rate of 97.7%. FNAs were performed specifically by the pathologists, so that our inadequacy rate, 2.3% was far lower than 11-29% reported elsewhere. The FNA findings were compared with subsequent histology results in 67 cases. The diagnosis of benign and neoplastic lesions was predicted accurately by FNA in 93% and 94.7% of cases, respectively. The latter reached 100% if results of FNA in follicular neoplasms were excluded. Sensitivity and specificity were 85.6% and 97.6%, respectively, which is comparable with results from tertiary institutions. The commonest thyroid lesions in our hospital were nodular goitre (52.4%), followed by thyroiditis (17.6%) and neoplasia (13.9%). We conclude that, with the availability of appropriate personnel, FNA is feasible as the major modality in district general hospitals. FNA in follicular lesions remains challenging but could be overcome in part by recognizing the criteria to differentiate follicular variant of papillary carcinoma and other follicular proliferations. Aspiration, smearing, staining and interpretation should be left to pathologists or other well-trained personnel to ensure good quality and consistency.     

Where Do the Poorest Go to Seek Outpatient Care in Bangladesh: Hospitals Run by Government or Microfinance Institutions?

Introduction

Health programs implemented by microfinance institutions (MFIs) aim to benefit the poor, but whether these services reach the poorest remains uncertain. This study intended to investigate the socioeconomic distribution of patients in hospitals operated by microfinance institutions (i.e. MFI hospitals) in Bangladesh and compare the differences with public hospitals to determine if the programs were consistent with their pro-poor mandate.

Methods

In this cross-sectional study, we used the convenience sampling method to conduct an interviewer-assisted questionnaire survey among 347 female outpatients, with 170 in public hospitals and 177 in MFI hospitals. Independent variables were patient characteristics categorized into predisposing factors (age, education, marital status, family size), enabling factors (microcredit membership, household income) and need factors (self-rated health, perceived needs for care). We employed Generalized Estimating Equations (GEE) to evaluate how these factors contributed to MFI hospital use.

Results

Use of MFI hospitals was associated with microcredit membership over 5 years (OR=2.9, p<.01), moderately poor household (OR=4.09, p<.001), non-poor household (OR=7.34, p<.01) and need for preventive care (OR=3.4, p<.01), compared with public hospitals. Combining membership and income, we found microcredit members had a higher tendency towards utilization but membership effect pertained to the non- and moderately-poor. Compared with the group who were non-members and the poorest, microcredit members who were non-poor had the highest likelihood (OR=7.46, p<.001) to visit MFI hospitals, followed by members with moderate income (OR=6.91, p<.001) and then non-members in non-poor households (OR=4.48, p<.01). Those who were members but the poorest had a negative association (OR=0.42), though not significant. Despite a higher utilization of preventive services in MFI hospitals, expenditure there was significantly higher.

Conclusion

Inequity was more pronounced in MFI hospitals than public ones. MFI hospitals appeared to miss their target population. We suggest that MFIs reorganize health programs toward primary health care to make care equitable and universally accessible. This study holds practical implications for governments, development agencies and microfinance practitioners working at the grassroots level.     

Differences in Sepsis Treatment and Outcomes between Public and Private Hospitals in Brazil: A Multicenter Observational Study

Background

Previous studies showed higher sepsis mortality rates in Brazil compared to other developed or developing countries. Moreover, another trial demonstrated an increased mortality rate in public hospitals compared to private hospitals in Brazil. The reasons for these findings may include delayed recognition and inadequate treatment of sepsis in public facilities. We designed this study to evaluate the factors associated with mortality in septic patients admitted to intensive care units in a network of public and private institutions.

Materials and Methods

This study is a retrospective analysis of a prospective cohort of sepsis patients in 19 private and public institutions in Brazil. We analyzed data from the original database and collected additional data to assess compliance to the treatment guidelines and to determine the time from the onset of organ dysfunction and the sepsis diagnosis by the healthcare team.

Results

A total of 396 patients were analyzed. Patients in public hospitals were younger, had a greater number of dysfunctional organs at baseline and a lower chance to have sepsis diagnosed within two hours of the onset of organ dysfunction. Private hospitals had a better compliance to lactate and blood culture sampling and maintenance of glycemic control. The multivariate analysis showed that age, disease severity at baseline and being treated at a public hospital were independent risk factors for mortality. A delay in the sepsis diagnosis of longer than two hours was associated with mortality only in the public setting.

Conclusions

We confirmed a lower sepsis mortality rate in the private hospitals of this network. Being treated in a public hospital was an independent factor for mortality. Delayed recognition of sepsis was more frequent in public institutions and this might have been associated with a higher mortality. Improving sepsis recognition and early diagnosis may be important targets in public institutions.     

Cesarean Section Rates and Indications in Sub-Saharan Africa: A Multi-Country Study from Medecins sans Frontieres

Objectives

The World Health Organization considers Cesarean section rates of 5–15% to be the optimal range for targeted provision of this life saving intervention. However, access to safe Cesarean section in resource-limited settings is much lower, estimated at 1–2% reported in sub-Saharan Africa. This study reports Cesarean sections rates and indications in Democratic Republic of Congo, Burundi, and Sierra Leone, and describe the main parameters associated with maternal and early neonatal mortality.

Methods

Women undergoing Cesarean section from August 1 2010 to January 31 2011 were included in this prospective study. Logistic regression was used to model determinants of maternal and early neonatal mortality.

Results

1276 women underwent a Cesarean section, giving a frequency of 6.2% (range 4.1–16.8%). The most common indications were obstructed labor (399, 31%), poor presentation (233, 18%), previous Cesarean section (184, 14%), and fetal distress (128, 10%), uterine rupture (117, 9%) and antepartum hemorrhage (101, 8%). Parity >6 (adjusted odds ratio [aOR] = 8.6, P = 0.015), uterine rupture (aOR = 20.5; P = .010), antepartum hemorrhage (aOR = 13.1; P = .045), and pre-eclampsia/eclampsia (aOR = 42.9; P = .017) were associated with maternal death. Uterine rupture (aOR = 6.6, P<0.001), anterpartum hemorrhage (aOR = 3.6, P<0.001), and cord prolapse (aOR = 2.7, P = 0.017) were associated with early neonatal death.

Conclusions

This study demonstrates that target Cesarean section rates can be achieved in sub-Saharan Africa. Identifying the common indications for Cesarean section and associations with mortality can target improvements in antenatal services and emergency obstetric care.     

The teaching of the biology of ageing in France 1990-2005: DEA with the course of speciality of Master Seeks

In 1990, following an idea arising from an Inserm study section on aging, the Dipl?me d'études approfondies (DEA) de Biologie du vieillissement was created. Since then, more than 300 students have followed these courses which cover the cellular mechanisms of aging and associated diseases, from basic causes of aging to CNS and sensory organs aging, as well as nutritional aspects, sarcopenia and osteoporosis, vascular and neuroendocrine aging. More than 150 thesis have been defended and more than a quarter of students has been recruited on permanent positions in French universities and research institutions (10 %) and hospitals (16 %). Since its creation, one of the particularities of the DEA was the formal links between academia and industry since teaching takes place on private laboratory settings.     

Disappearance of differences in antibiotic resistance of Staphylococcus aureus strains isolated in hospitals and in general practice

There is general opinion that Staphylococcus aureus strains isolated in hospitals are more frequently resistant to antibiotics than community strains, however, the increasing resemblance between hospital and community strains has been recently reported. The aim of the study was to compare the antibiotic resistance and phage-type pattern of S. aureus strains isolated from patients treated either in hospitals or in general practice in northern part of Poland. The study was conducted on 771 S. aureus strains isolated from different specimens. Phage typing was performed according to the method of Blair and Williams. The drug susceptibility was determined by the disc-diffusion method. There were no significant differences in antibiotic resistance or phage-type pattern when hospital and community methicillin-sensitive S. aureus (MSSA) strains were compared. The most MSSA were resistant to penicillin (84.6% and 82.1% respectively) and doxycycline (49.3% and 50.4% respectively) whereas they were rarely resistant to other antibiotics. The predominance of phage group II was found in both hospitals (28.0%) and general practice (29.9%). Phage group III, usually associated with hospitals, occurred in small percentage (12.9% and 9.4% respectively) while to this group predominantly (76.6%) multiresistant methicillin resistant S. aureus (MRSA) isolated in hospitals belonged. These results suggest, that there is only slight difference in antibiotic resistance between hospital and community S. aureus strains. Antibiotic resistance pattern mainly results from frequency of appearance of MRSA, mostly occurring in hospitals.     

Variation in emergency department use of cervical spine radiography for alert,stable trauma patients

OBJECTIVE: To, assess the emergency department use of cervical spine radiography for alert, stable adult trauma patients in terms of utilization, yield for injury and variation in practices among hospitals and physicians. DESIGN: Retrospective survey of health records. SETTING: Emergency departments of 6 teaching and 2 community hospitals in Ontario and British Columbia. PATIENTS: Consecutive alert, stable adult trauma patients seen with potential cervical spine injury between July 1, 1994, and June 30, 1995. MAIN OUTCOME MEASURES: Total number of eligible patients, referral for cervical spine radiography (overall, by hospital and by physician), presence of cervical spine injury, patient characteristics and hospitals associated with use of radiography. RESULTS: Of 6855 eligible patients, cervical spine radiography was ordered for 3979 (58.0%). Only 60 (0.9%) patients were found to have an acute cervical spine injury (fracture, dislocation or ligamentous instability); 98.5% of the radiographic films were negative for any significant abnormality. The demographic and clinical characteristics of the patients were similar across the 8 hospitals, and no cervical spine injuries were missed. Significant variation was found among the 8 hospitals in the rate of ordering radiography (p < 0.0001), from a low of 37.0% to a high of 72.5%. After possible differences in case severity and patient characteristics at each hospital were controlled for, logistic regression analysis revealed that 6 of the hospitals were significantly associated with the use of radiography. At 7 hospitals, there was significant variation in the rate of ordering radiography among the attending emergency physicians (p < 0.05), from a low of 15.6% to a high of 91.5%. CONCLUSIONS: Despite considerable variation among institutions and individual physicians in the ordering of cervical spine radiography for alert, stable trauma patients with similar characteristics, no cervical spine injuries were missed. The number of radiographic films showing signs of abnormality was extremely low at all hospitals. The findings suggest that cervical spine radiography could be used more efficiently, possibly with the help of a clinical decision rule.     

Characteristics of Geriatric Patients in Mental Hospitals in the Province of Quebec

The results of a questionnaire completed by the superintendents of five of the six major mental hospitals in the Province of Quebec concerning patients aged 60 and over showed that this group made up one-fifth to two-fifths of the total populations. The proportion of the population that was over age 60 when admitted varied from just under one-third to almost three-quarters. The ratio of those who died or were discharged at age 60 or more to the total elderly population varied greatly among institutions.Between 67% and 91% of the elderly were capable of ambulation and self-care with minimal help, and from 13.5% to 53% were considered mentally capable of living in a private home or residential home.Diagnostic types varied, among hospitals, from 28% to 65% functional, 13% to 32% organic and 4% to 33% senile psychoses.Experience with preventive and treatment programs elsewhere is discussed.     

Contribution of general practitioner hospitals in England and Wales.

A survey of a one-in-seven sample of general practitioner hospitals in England and Wales, performed to determine the contribution they make to overall hospital work load and the attitudes of the general practitioners working in them, showed that 3% of acute hospital beds in England and Wales were in general practitioner hospitals, which provided initial hospital care for up to 20% of the population. Altogether 16% of general practitioners and 22% of consultants were on the staffs, and they coped with more than 13% of all casualties, 6% of operations, and 4% of x-ray examinations. Nearly a million casualties were treated at no cost to the National Health Service. Twenty new district general hospitals would be needed to cope with the work load currently dealt with by general practitioner hospitals. The results of this survey indicate that these smaller hospitals deal efficiently and cheaply with their work load, and that morale is high. General practitioner hospitals could have an important part to play in providing certain types of care, but there are no financial incentives to enable general practitioners to realise this potential fully.     

Maternal Clinical Diagnoses and Hospital Variation in the Risk of Cesarean Delivery: Analyses of a National US Hospital Discharge Database

Background

Cesarean delivery is the most common inpatient surgery in the United States, where 1.3 million cesarean sections occur annually, and rates vary widely by hospital. Identifying sources of variation in cesarean use is crucial to improving the consistency and quality of obstetric care. We used hospital discharge records to examine the extent to which variability in the likelihood of cesarean section across US hospitals was attributable to individual women''s clinical diagnoses.

Methods and Findings

Using data from the 2009 and 2010 Nationwide Inpatient Sample from the Healthcare Cost and Utilization Project—a 20% sample of US hospitals—we analyzed data for 1,475,457 births in 1,373 hospitals. We fitted multilevel logistic regression models (patients nested in hospitals). The outcome was cesarean (versus vaginal) delivery. Covariates included diagnosis of diabetes in pregnancy, hypertension in pregnancy, hemorrhage during pregnancy or placental complications, fetal distress, and fetal disproportion or obstructed labor; maternal age, race/ethnicity, and insurance status; and hospital size and location/teaching status.The cesarean section prevalence was 22.0% (95% confidence interval 22.0% to 22.1%) among women with no prior cesareans. In unadjusted models, the between-hospital variation in the individual risk of primary cesarean section was 0.14 (95% credible interval 0.12 to 0.15). The difference in the probability of having a cesarean delivery between hospitals was 25 percentage points. Hospital variability did not decrease after adjusting for patient diagnoses, socio-demographics, and hospital characteristics (0.16 [95% credible interval 0.14 to 0.18]). A limitation is that these data, while nationally representative, did not contain information on parity or gestational age.

Conclusions

Variability across hospitals in the individual risk of cesarean section is not decreased by accounting for differences in maternal diagnoses. These findings highlight the need for more comprehensive or linked data including parity and gestational age as well as examination of other factors—such as hospital policies, practices, and culture—in determining cesarean section use. Please see later in the article for the Editors'' Summary