OBJECTIVE: To estimate the maternal morbidity associated with cesarean deliveries performed at term without labor compared with morbidity associated with induction of labor at term. METHODS: A 15- year population-base...OBJECTIVE: To estimate the maternal morbidity associated with cesarean deliveries performed at term without labor compared with morbidity associated with induction of labor at term. METHODS: A 15- year population-based cohort study (1988- 2002) using the Nova Scotia Atlee Perinatal Database compared maternal outcomes in nulliparous women delivering by cesarean delivery without labor and nulliparous women at term undergoing induction of labor for planned vaginal delivery with singleton, cephalic presentation. RESULTS: A total of 5,779 pregnancies satisfied inclusion and exclusion criteria, 879 of which were cesarean deliverieswithout labor. There were no maternal deaths. There was no difference in wound infection, puerperal febrile morbidity, blood transfusion or intraoperative trauma. After controlling for potential confounders, women undergoing cesarean delivery without labor were less likely to have complications of early postpartum hemorrhage (relative risk 0.61, 95% confidence interval 0.42- 0.88, number needed to treat 32) and composite maternal morbidity (relative risk 0.71, 95% confidence interval 0.52- 0.95, number needed to treat 34) compared with women undergoing induction of labor. Subgroup analyses of maternal outcomes after induction of labor in women by method of delivery were also performed and demonstrated additional risks of traumatic morbidity after induction of labor. The highest morbidity was found in the assisted vaginal delivery and cesarean delivery in labor groups. CONCLUSION: Early postpartum hemorrhage and composite maternal morbidity were decreased in cesarean delivery without labor compared with induction of labor. Hemorrhagic and traumatic morbidities with labor induction are increased after assisted vaginal delivery and cesarean delivery in labor compared with cesarean delivery without labor.展开更多
OBJECTIVE: To determine if the rates of pregnancy complications, preterm birth, small for gestational age, perinatal mortality, and serious neonatal morbidity are higher among mothers aged 35- 39 years or 40 years or ...OBJECTIVE: To determine if the rates of pregnancy complications, preterm birth, small for gestational age, perinatal mortality, and serious neonatal morbidity are higher among mothers aged 35- 39 years or 40 years or older, compared with mothers 20- 24 years. METHODS: We performed a population- based study of all women in Nova Scotia, Canada, who delivered a singleton fetus between 1988 and 2002 (N = 157,445). Family income of women who delivered between 1988 and 1995 was obtained through a confidential linkage with tax records (n = 76,300). The primary outcome was perinatal death (excluding congenital anomalies) or serious neonatal morbidity. Analysis was based on logistic models. RESULTS: Older women were more likely to be married, affluent, weigh 70 kg or more, attend prenatal classes, and have a bad obstetric history but less likely to be nulliparous and to smoke. They were more likely to have hypertension, diabetes mellitus, placental abruption, or placenta previa. Preterm birth and small- for- gestational age rates were also higher; compared with women aged 20- 24 years, adjusted rate ratios for preterm birth among women aged 35- 39 years and 40 years or older were 1.61 (95% confidence interval [CI] 1.42- 1.82; P < .001) and 1.80 (95% CI 1.37- 2.36; P < .001), respectively. Adjusted rate ratios for perinatal mortality/morbidity were 1.46 (95% CI 1.11- 1.92; P = .007) among women 35- 39 years and 1.95 (95% CI 1.13- 3.35; P = .02) among women 40 years or older. Perinatal mortality rates were low at all ages, especially in recent years. CONCLUSION: Older maternal age is associated with relatively higher risks of perinatal mortality/morbidity, although the absolute rate of such outcomes is low.展开更多
Background: After 1 to 4 years, seizure-free children with epilepsy are encou raged to stop daily antiepileptic drug (AED)-treatment. Approximately 70%are s uccessful. The authors examined how often intractable epilep...Background: After 1 to 4 years, seizure-free children with epilepsy are encou raged to stop daily antiepileptic drug (AED)-treatment. Approximately 70%are s uccessful. The authors examined how often intractable epilepsy follows discontin uation of AED treatment in a population-based cohort of children with epilepsy. Methods: The Nova Scotia population-based epilepsy cohort was used to identify children who discontinued AEDs but subsequently developed intractable epilepsy. All patients studied (ages 1 month to 16 years) developed epilepsy between 1977 and 1985, had epilepsies characterized by partialor convulsive seizures, and ha d at least 5 years of follow-up evaluation (n=367). Those with benign rolandic epilepsy were excluded. Intractability was defined as one or more seizure severy 3 months during the last year of follow-up review or until successful seizure surgery and failure of three or more AEDs at maximum tolerated doses. Results: O verall, 71%(260/367) of eligible children became free of seizure for 1 to 4 yea rs and discontinued AED treatment. Of this group, 70%remained seizure-free wit hout AED treatment, but 30%had recurrences.Only three children with recurrences later developed intractable epilepsy. Two then underwent a temporal lobectomy, one successful and one only partially successful (20-year follow-up periods). The third patient continued to have intractable epilepsy for 7 years after disco ntinuing AED treatment but eventually entered remission. Conclusion: Approximate ly 1%of children who became free of seizure and discontinued antiepileptic drug treatment had recurrent seizures that could not be controlled again with medica tion. The authors were unable to predict this outcome. It remains unclear whethe r a similar outcome would have occurred if antiepileptic drugs had not been disc ontinued.展开更多
Hurler syndrome is a lysosomal storage disease resulting in fatal cardiac or neurologic sequelae unless alpha-iduronid-ase production is reconstituted with hematopoietic stem cell transplantation. We report on a 4- ye...Hurler syndrome is a lysosomal storage disease resulting in fatal cardiac or neurologic sequelae unless alpha-iduronid-ase production is reconstituted with hematopoietic stem cell transplantation. We report on a 4- year, 6- month-old boy with mixed donor chimerism and low enzyme levels but a normal neurodevelopmental trajectory.展开更多
Background Anxiety and fear frequently causes an aversion to applying a face mask and increases difficulty during pediatric induction. There is at present little study of this problem. Therefore, the aim of this study...Background Anxiety and fear frequently causes an aversion to applying a face mask and increases difficulty during pediatric induction. There is at present little study of this problem. Therefore, the aim of this study was to investigate the effect of the combination of mask preconditioning and midazolam pretreatment on mask acceptance during pediatric induction and on postoperative mask fear. Methods One hundred and sixty children were randomly assigned into four groups： the mask preconditioning group （MaG）, the midazolam pretreatment group （MiG）, the mask/midazolam combination group （Ma/MiG）, and the saline group （SAG）. The Modified Yale Preoperative Anxiety Scale （m-YPAS） was employed to assess the anxiety in the operation room （OR）. A Mask Acceptance Score （MAS） was measured during inhalational induction and the incidence of mask fear （MAS 〈2） was evaluated postoperatively. Results The MaG and Ma/MiG groups had the highest mask acceptance scores but there were no differences between these two groups （P 〈0.05）. The average anxiety level of children entering the OR was much lower in the MaG and Ma/MiG groups than in the SaG group （P 〈0.05）. During induction, the anxiety level increased in the SaG and MaG groups but decreased in the MiG and Ma/MiG groups （P 〈0.05）. At the postoperative third day, the incidence of mask fears was as high as 23% in the SaG group, 15% in the MiG group, but only 2.5% in the MaG and Ma/MiG groups. Conclusions The single use of mask preconditioning has a better influence than midazolam for increasing mask acceptance during inhalational induction and reducing postoperative mask fear, reducing the anxiety level during induction, improving induction compliance and shortening the total mask time. A mask preconditioning and midazolam combination did not increase mask acceptance during inhalational induction, reduce mask fears postoperatively, improve induction compliance, nor shorten the total mask time. But it can better reduce the anxiety level during induction.展开更多
Tramadol is a potent analgesic.However,the analgesia efficacy of tramadol,particularly its minimum effective dose(MED),is not clear.The aim of this study is to find MED of tramadol for postoperative analgesia in infan...Tramadol is a potent analgesic.However,the analgesia efficacy of tramadol,particularly its minimum effective dose(MED),is not clear.The aim of this study is to find MED of tramadol for postoperative analgesia in infants.The continual reassessment method(CRM)was performed to find MED.Infants undergoing surgeries were included in the 3 phases of this series.In each phase,24 participants were allocated a different tramadol dose.Pain intensity was measured by face,legs,activity,cry,consolability(FLACC)measurement at 3-hour intervals.Tramadol was considered ineffective if the FLACC score was higher than 4 in 10 at anytime.In phase 1,seven dose levels were used within the range 0.1-0.4 mg·kg^(-1)·h^(-1).Phase 1 was insufficient to identify the MED,and we increased the dose to 0.4-0.8 mg·kg^(-1)·h^(-1) in phase 2.Phase 2 was insufficient to identify the MED.In phase 3,local anesthetic wound infiltration was introduced,and the tramadol dose levels tested were the same as in phase 1.The successful analgesia probability of tramadol 0.4 mg·kg^(-1)·h^(-1) was 82.1%(95%CI,0.742-0.925)in phase 1.In phase 2,it was 84.7%(95%CI,0.789-0.991)with the dose 0.8 mg·kg^(-1)·h^(-1).Phase 1 and phase 2 were insufficient to identify the MED.In phase 3,the successful analgesia probability for dose 0.35 mg·kg^(-1)·h^(-1) was 96.7%(95%CI,0.853-0.997).We have demonstrated that tramadol provides insufficient analgesia for surgeries considered to cause moderate-to-severe postoperative pain in infants if used as the sole analgesic,and that local anesthetic wound infiltration enhances the efficacy of tramadol.展开更多
文摘OBJECTIVE: To estimate the maternal morbidity associated with cesarean deliveries performed at term without labor compared with morbidity associated with induction of labor at term. METHODS: A 15- year population-based cohort study (1988- 2002) using the Nova Scotia Atlee Perinatal Database compared maternal outcomes in nulliparous women delivering by cesarean delivery without labor and nulliparous women at term undergoing induction of labor for planned vaginal delivery with singleton, cephalic presentation. RESULTS: A total of 5,779 pregnancies satisfied inclusion and exclusion criteria, 879 of which were cesarean deliverieswithout labor. There were no maternal deaths. There was no difference in wound infection, puerperal febrile morbidity, blood transfusion or intraoperative trauma. After controlling for potential confounders, women undergoing cesarean delivery without labor were less likely to have complications of early postpartum hemorrhage (relative risk 0.61, 95% confidence interval 0.42- 0.88, number needed to treat 32) and composite maternal morbidity (relative risk 0.71, 95% confidence interval 0.52- 0.95, number needed to treat 34) compared with women undergoing induction of labor. Subgroup analyses of maternal outcomes after induction of labor in women by method of delivery were also performed and demonstrated additional risks of traumatic morbidity after induction of labor. The highest morbidity was found in the assisted vaginal delivery and cesarean delivery in labor groups. CONCLUSION: Early postpartum hemorrhage and composite maternal morbidity were decreased in cesarean delivery without labor compared with induction of labor. Hemorrhagic and traumatic morbidities with labor induction are increased after assisted vaginal delivery and cesarean delivery in labor compared with cesarean delivery without labor.
文摘OBJECTIVE: To determine if the rates of pregnancy complications, preterm birth, small for gestational age, perinatal mortality, and serious neonatal morbidity are higher among mothers aged 35- 39 years or 40 years or older, compared with mothers 20- 24 years. METHODS: We performed a population- based study of all women in Nova Scotia, Canada, who delivered a singleton fetus between 1988 and 2002 (N = 157,445). Family income of women who delivered between 1988 and 1995 was obtained through a confidential linkage with tax records (n = 76,300). The primary outcome was perinatal death (excluding congenital anomalies) or serious neonatal morbidity. Analysis was based on logistic models. RESULTS: Older women were more likely to be married, affluent, weigh 70 kg or more, attend prenatal classes, and have a bad obstetric history but less likely to be nulliparous and to smoke. They were more likely to have hypertension, diabetes mellitus, placental abruption, or placenta previa. Preterm birth and small- for- gestational age rates were also higher; compared with women aged 20- 24 years, adjusted rate ratios for preterm birth among women aged 35- 39 years and 40 years or older were 1.61 (95% confidence interval [CI] 1.42- 1.82; P < .001) and 1.80 (95% CI 1.37- 2.36; P < .001), respectively. Adjusted rate ratios for perinatal mortality/morbidity were 1.46 (95% CI 1.11- 1.92; P = .007) among women 35- 39 years and 1.95 (95% CI 1.13- 3.35; P = .02) among women 40 years or older. Perinatal mortality rates were low at all ages, especially in recent years. CONCLUSION: Older maternal age is associated with relatively higher risks of perinatal mortality/morbidity, although the absolute rate of such outcomes is low.
文摘Background: After 1 to 4 years, seizure-free children with epilepsy are encou raged to stop daily antiepileptic drug (AED)-treatment. Approximately 70%are s uccessful. The authors examined how often intractable epilepsy follows discontin uation of AED treatment in a population-based cohort of children with epilepsy. Methods: The Nova Scotia population-based epilepsy cohort was used to identify children who discontinued AEDs but subsequently developed intractable epilepsy. All patients studied (ages 1 month to 16 years) developed epilepsy between 1977 and 1985, had epilepsies characterized by partialor convulsive seizures, and ha d at least 5 years of follow-up evaluation (n=367). Those with benign rolandic epilepsy were excluded. Intractability was defined as one or more seizure severy 3 months during the last year of follow-up review or until successful seizure surgery and failure of three or more AEDs at maximum tolerated doses. Results: O verall, 71%(260/367) of eligible children became free of seizure for 1 to 4 yea rs and discontinued AED treatment. Of this group, 70%remained seizure-free wit hout AED treatment, but 30%had recurrences.Only three children with recurrences later developed intractable epilepsy. Two then underwent a temporal lobectomy, one successful and one only partially successful (20-year follow-up periods). The third patient continued to have intractable epilepsy for 7 years after disco ntinuing AED treatment but eventually entered remission. Conclusion: Approximate ly 1%of children who became free of seizure and discontinued antiepileptic drug treatment had recurrent seizures that could not be controlled again with medica tion. The authors were unable to predict this outcome. It remains unclear whethe r a similar outcome would have occurred if antiepileptic drugs had not been disc ontinued.
文摘Hurler syndrome is a lysosomal storage disease resulting in fatal cardiac or neurologic sequelae unless alpha-iduronid-ase production is reconstituted with hematopoietic stem cell transplantation. We report on a 4- year, 6- month-old boy with mixed donor chimerism and low enzyme levels but a normal neurodevelopmental trajectory.
文摘Background Anxiety and fear frequently causes an aversion to applying a face mask and increases difficulty during pediatric induction. There is at present little study of this problem. Therefore, the aim of this study was to investigate the effect of the combination of mask preconditioning and midazolam pretreatment on mask acceptance during pediatric induction and on postoperative mask fear. Methods One hundred and sixty children were randomly assigned into four groups： the mask preconditioning group （MaG）, the midazolam pretreatment group （MiG）, the mask/midazolam combination group （Ma/MiG）, and the saline group （SAG）. The Modified Yale Preoperative Anxiety Scale （m-YPAS） was employed to assess the anxiety in the operation room （OR）. A Mask Acceptance Score （MAS） was measured during inhalational induction and the incidence of mask fear （MAS 〈2） was evaluated postoperatively. Results The MaG and Ma/MiG groups had the highest mask acceptance scores but there were no differences between these two groups （P 〈0.05）. The average anxiety level of children entering the OR was much lower in the MaG and Ma/MiG groups than in the SaG group （P 〈0.05）. During induction, the anxiety level increased in the SaG and MaG groups but decreased in the MiG and Ma/MiG groups （P 〈0.05）. At the postoperative third day, the incidence of mask fears was as high as 23% in the SaG group, 15% in the MiG group, but only 2.5% in the MaG and Ma/MiG groups. Conclusions The single use of mask preconditioning has a better influence than midazolam for increasing mask acceptance during inhalational induction and reducing postoperative mask fear, reducing the anxiety level during induction, improving induction compliance and shortening the total mask time. A mask preconditioning and midazolam combination did not increase mask acceptance during inhalational induction, reduce mask fears postoperatively, improve induction compliance, nor shorten the total mask time. But it can better reduce the anxiety level during induction.
文摘Tramadol is a potent analgesic.However,the analgesia efficacy of tramadol,particularly its minimum effective dose(MED),is not clear.The aim of this study is to find MED of tramadol for postoperative analgesia in infants.The continual reassessment method(CRM)was performed to find MED.Infants undergoing surgeries were included in the 3 phases of this series.In each phase,24 participants were allocated a different tramadol dose.Pain intensity was measured by face,legs,activity,cry,consolability(FLACC)measurement at 3-hour intervals.Tramadol was considered ineffective if the FLACC score was higher than 4 in 10 at anytime.In phase 1,seven dose levels were used within the range 0.1-0.4 mg·kg^(-1)·h^(-1).Phase 1 was insufficient to identify the MED,and we increased the dose to 0.4-0.8 mg·kg^(-1)·h^(-1) in phase 2.Phase 2 was insufficient to identify the MED.In phase 3,local anesthetic wound infiltration was introduced,and the tramadol dose levels tested were the same as in phase 1.The successful analgesia probability of tramadol 0.4 mg·kg^(-1)·h^(-1) was 82.1%(95%CI,0.742-0.925)in phase 1.In phase 2,it was 84.7%(95%CI,0.789-0.991)with the dose 0.8 mg·kg^(-1)·h^(-1).Phase 1 and phase 2 were insufficient to identify the MED.In phase 3,the successful analgesia probability for dose 0.35 mg·kg^(-1)·h^(-1) was 96.7%(95%CI,0.853-0.997).We have demonstrated that tramadol provides insufficient analgesia for surgeries considered to cause moderate-to-severe postoperative pain in infants if used as the sole analgesic,and that local anesthetic wound infiltration enhances the efficacy of tramadol.
