Journal of the New Zealand Medical Association, 08-September-2006, Vol 119 No 1241
Rates of caesarean delivery have risen from about 5% in developed countries in the early 1970s to more than 50% in some regions of the world in the late 1990s. There are many reasons for this other than pure obstetric indication. These include obstetricians’ defensive practice, changes in health systems, and patient demand. The question of pregnancy outcome vis-à-vis the increased surgical intervention arises. In this WHO sponsored study, data from 8 countries in Latin America—including Argentina, Brazil, Cuba, Ecuador, Mexico, Nicaragua, Paraguay, and Peru—has been collated. The researchers obtained data for 97,095 of 106,546 deliveries (91% coverage). The median rate of caesarean delivery was 33%, with the highest rates of caesarean delivery noted in private hospitals (51%).
The results—caesarean delivery was positively associated with postpartum antibiotic treatment and severe maternal morbidity and mortality, even after adjustment for risk factors. Furthermore, caesarean delivery was associated with an increase in fetal mortality rates and higher numbers of babies admitted to intensive care for 7 days or longer, even after adjustment for preterm delivery.
The message seems clear.
Much controversy has surrounded the use of β-agonists in patients with asthma ever since their introduction over 50 years ago. Regular β-agonist use is associated with tolerance of the drug’s effects and a worsening of disease control. Clearly, if regular β-agonists are suspect so must LABAs be regarded with suspicion. Hence a meta-analysis of LABA versus placebo trials. Pooled results from 19 trials with 33,826 participants found that long-acting β-agonists increased exacerbations requiring hospitalisation (odds ratio 2.6). The risk for asthma-related deaths was increased (odds ratio 3.5). However, the absolute increased risk of death was small—about one extra death for every 1000 patients using these drugs for a year.
And the conclusion? LABAs are powerful and complex and should be used with care. An accompanying editorial favours their use when all other strategies, including maximal doses of inhaled steroids, have failed.
Ann Intern Med 2006;144: 904–12 & 936–7
Surgery for carpal tunnel syndrome is one of the most often performed procedures. Apparently open carpal tunnel release may result in prolonged pain at the scar and proximal palm. Hence endoscopic procedures to release the carpal tunnel have been introduced with the presumed advantage of decreased postoperative pain and subsequently faster return of patients to work. Intuitively one would assume that this would be the case. A randomised trial of these two surgical techniques has been reported from Sweden. Yes, endoscopic surgery was associated with less postoperative pain than open surgery, but the small size of the benefit and similarity in other outcomes make its cost effectiveness uncertain. The median length of work absence after surgery was 28 days in both groups.
Otitis media (OM) is the most common illness for which children visit a medical practitioner, receive antibiotics, or undergo surgery in the United States. This is also likely to be true of New Zealand, we suspect.
Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis are isolated from approximately 25% of children with OM with a middle ear effusion, but polymerase chain reaction (PCR)-based methods have demonstrated sequence-specific DNA and RNA for these pathogens in nearly 80% of cases. Biofilms consist of aggregated bacteria, usually adherent to a surface, surrounded by an extracellular matrix, and have been implicated in several chronic bacterial infections. The question investigated in this report is whether chronic OM is biofilm related. Well it was in 92% of 50 cases studied.
This throws some light on why chronic OM is rather resistant to antibiotic treatment.
Cardiologists offer a lot of lifestyle advice—what are they like at taking it themselves? A group of cardiologists in the United States (US) posed a questionnaire to their colleagues on this topic. 471 answered the questions—the average age of the participants was 48.6 years; 7.1% were women. The average body mass index (BMI) was 25 kg/m2, and 8% were obese (BMI≥30 kg/m2); 1.3% were active smokers; 89% exercised ≥1 time/week; and 72% had ≥1 alcoholic drink/week. Red wine was the most frequently consumed alcoholic beverage. Associated cardiovascular risks included dyslipidaemia (28%), hypertension (14%), and diabetes mellitus (0.6%). Four percent had experienced coronary events.
Compared with matched cohorts from the US population, cardiologists reported lower rates of hypertension, dyslipidaemia, and diabetes mellitus, and the rates of smoking and obesity were 1/18 and 1/3 those of the US population, respectively. These data suggest that cardiologists as a group appear to have healthier lifestyles than the general adult US population. This is likely to translate into improved health and longevity among cardiologists.
As expected—a healthy lot. But the 471 were only 59% of the cohort. One can only speculate on the health profile of the other 41%.
Am J Cardiol 2006;97:1093–6
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