Hospital Differences in Cesarean Deliveries in Massachusetts (US) 2004–2006: The Case against Case-Mix Artifact

Objective: We examined the extent to which differences in hospital-level cesarean delivery rates in Massachusetts were attributable to hospital-level, rather than maternal, characteristics. Methods: Birth certificate and maternal in-patient hospital discharge records for 2004–06 in Massachusetts were linked. The study population was nulliparous, term, singleton, and vertex births (NTSV) (n = 80,371) in 49 hospitals. Covariates included mother's age, race/ethnicity, education, infant birth weight, gestational age, labor induction (yes/no), hospital shift at time of birth, and preexisting health conditions. We estimated multilevel logistic regression models to assess the likelihood of a cesarean delivery. Results: Overall, among women with NTSV births, 26.5% births were cesarean, with a range of 14% to 38.3% across hospitals. In unadjusted models, the between-hospital variance was 0.103 (SE 0.022); adjusting for demographic, socioeconomic and preexisting medical conditions did not reduce any hospital-level variation 0.108 (SE 0.023). Conclusion: Even after adjusting for both socio-demographic and clinical factors, the chance of a cesarean delivery for NTSV pregnancies varied according to hospital, suggesting the importance of hospital practices and culture in determining a hospital's cesarean rate

“A Modest Proposal”: Universal Cesarean Section to Reduce Professional Liability Costs

ABSTRACT OBJECTIVE: To model the effect of universal cesarean delivery on professional liability costs. STUDY DESIGN: We examined all obstetric professional liability claims covered by a single insurer between January 1, 1990 and December 31, 2000. We reviewed each case to determine if an alternate route of delivery might reasonably have prevented the lawsuit. Costs were calculated by adding the cost of processing the claim, the legal defense, the settlement payments and/or the actuarially derived adjustments. Using a 20% cesarean rate as our baseline, we modeled the effect on liability costs of cesarean delivery in all patients. RESULTS: There were 205,241 births during the study period, and 91 lawsuits (incidence 4.4 per 10,000) were initiated with projected claims-costs totaling $53,731,903 ($590,460 per case). Among those 68 cases in which route of delivery may have affected outcome, we estimated $39,070,661 might have been saved if 63 cases had delivered by planned cesarean and$804,486 in claims-costs might have been saved if 5 patients had delivered vaginally rather than by cesarean. Finally, we identified 23 cases with costs of $10,638,797 in which the route of delivery would not have affected the outcome. With this model of universal cesarean section, the projected number of lawsuits decreases from 91 to 48 (a 53$14,661,242 ($305,442 per case); a potential savings of$39,070,661 (72.7%). CONCLUSIONS: In the current legal environment, a policy of 100% cesarean sections could hypothetically reduce professional liability costs by 73%. We do not propose such a policy because it would subject a majority of patients to medically unindicated surgery

Barriers to Follow-up for Women with a History of Gestational Diabetes

Women with gestational diabetes (GDM) are at increased risk for type 2 diabetes (T2DM), but many do not receive recommended follow-up. We sought to identify barriers to follow-up screening

Diabetes Screening Reminder for Women With Prior Gestational Diabetes: A Randomized Controlled Trial

To evaluate whether an electronic health record reminder improves rates of screening for type 2 diabetes (T2DM) in women with prior gestational diabetes (GDM)

Inflammation and glucose intolerance. A prospective study of gestational diabetes mellitus

WSTĘP. Podwyższony poziom leukocytów w surowicy krwi jest wskaźnikiem procesu zapalenia, który, jak wykazują badania prospektywne, wiąże się z rozwojem cukrzycy typu 2. Chociaż cukrzyca ciążowa oraz cukrzyca typu 2 mają dużo wspólnych mechanizmów patofizjologicznych, w niewielu pracach badano związek zapalenia z rozwojem cukrzycy ciążowej. MATERIAŁ I METODY. W badaniu oceniano w sposób prospektywny liczbę leukocytów w próbkach krwi pobranych podczas pierwszej rutynowej wizyty kontrolnej w grupie 2753 kobiet w ciąży &#8212; wieloródek z prawidłową wartością glikemii. U 98 (3,6%) z nich wystąpiła później cukrzyca ciążowa. Pacjentki podzielono na podgrupy w zależności od kwartyla liczby leukocytów i porównano wyniki przeprowadzanego w trzecim trymestrze przesiewowego testu tolerancji glukozy oraz częstość cukrzycy ciążowej wśród kobiet należących do poszczególnych kwartyli. Zastosowano test regresji logistycznej, aby obliczyć skorygowane względem jednego i wielu czynników względne ryzyko wystąpienia cukrzycy ciążowej w zależności od kwartyla leukocytozy. WYNIKI. U kobiet, u których doszło do rozwoju cukrzycy ciążowej, stężenie leukocytów w surowicy krwi było wyższe (10,5 &plusmn; 2,2 vs. 9,2 &plusmn; 2,2 × 103 komórek/ml; p < 0,01) niż u pacjentek, u których metabolizm węglowodanów pozostał prawidłowy. Wraz ze wzrostem kwartyla leukocytozy obserwowano liniowy wzrost glikemii po obciążeniu glukozą (p < 0,01), pola pod krzywą testu tolerancji glukozy (p < 0,01) oraz częstości cukrzycy ciążowej (kwartyl 1. &#8212; 1,1%; kwartyl 2. &#8212; 2,5%; kwartyl 3. &#8212; 4,2% i kwartyl 4. &#8212; 6,4%; p < 0,01). W analizie wieloczynnikowej, wraz ze wzrostem kwartyla leukocytozy, liniowy trend względnego ryzyka (RR, relative risk) rozwoju cukrzycy ciążowej pozostał statystycznie istotny [kwartyl 1. &#8212; referencyjny, kwartyl 2. &#8212; RR 2,3 (95% CI 0,9-5,7), kwartyl 3. &#8212; RR 3,3 (1,4&#8211;7,8), kwartyl 4. &#8212; RR 4,9 (2,1&#8211;11,2); p < 0,01]. WNIOSKI. Podwyższony poziom leukocytów we wczesnym okresie ciąży jest w sposób niezależny, liniowy związany z wynikami testów przesiewowych w kierunku cukrzycy ciążowej oraz ryzykiem wystąpienia tej choroby. Brak wyraźnej granicy w rozkładzie liczby leukocytów sprawia, że wskaźnik ten nie może mieć zastosowania klinicznego, chociaż dane sugerują, że proces zapalenia wiąże się z rozwojem cukrzycy ciążowej. Może to być kolejny mechanizm patofizjologiczny, łączący występowanie cukrzycy ciążowej z rozwojem w przyszłości cukrzycy typu 2.INTRODUCTION. Increased leukocyte count is a marker of inflammation that has been associated with the development of type 2 diabetes in prospective studies. Although gestational diabetes mellitus (GDM) and type 2 diabetes share certain pathophysiological mechanisms, few studies have examined inflammation and risk of GDM. MATERIAL AND METHODS. We prospectively examined routine leukocyte counts collected at the first prenatal visit in a cohort of 2,753 nulliparous euglycemic women, 98 (3.6%) of whom were later diagnosed with GDM. Subjects were divided into quartiles of leukocyte count, and the results of third-trimester glucose screening tests and the incidence of GDM among these quartiles were compared. Logistic regression was used to calculate univariate and multivariable-adjusted relative risks (RRs) of GDM according to leukocyte quartiles. RESULTS. Leukocyte counts were increased among women who subsequently developed GDM compared with those who remained free of GDM (10.5 &#177; &#177; 2.2 vs. 9.2 &#177; 2.2 × 103 cells/ml; P < 0.01). There was a linear increase in postloading mean glucose levels (P for trend < 0.01), the area under the glucose tolerance test curves (P for trend < 0.01), and the incidence of GDM (quartile 1, 1.1; quartile 2, 2.5; quartile 3, 4.2; and quartile 4, 6.4%; P for trend < 0.01) with increasing leukocyte quartiles. In the multivariable-adjusted analysis, the linear trend in the RR of GDM with increasing leukocyte quartiles remained statistically significant (quartile 1, reference; quartile 2, RR 2.3 [95% CI 0.9&#8211;5.7]; quartile 3, 3.3 [1.4&#8211;7.8]; quartile 4, 4.9 [2.1&#8211;11.2]; P for trend < 0.01). CONCLUSIONS. Increased leukocyte count early in pregnancy is independently and linearly associated with the results of GDM screening tests and the risk of GDM. Although overlap in the leukocyte count distributions precludes it from being a clinically useful biomarker, these data suggest that inflammation is associated with the development of GDM and may be another pathophysiological link between GDM and future type 2 diabetes

Understanding the Effects of Both CD14-Mediated Innate Immunity and Device/Tissue Mechanical Mismatch in the Neuroinflammatory Response to Intracortical Microelectrodes

Intracortical microelectrodes record neuronal activity of individual neurons within the brain, which can be used to bridge communication between the biological system and computer hardware for both research and rehabilitation purposes. However, long-term consistent neural recordings are difficult to achieve, in large part due to the neuroinflammatory tissue response to the microelectrodes. Prior studies have identified many factors that may contribute to the neuroinflammatory response to intracortical microelectrodes. Unfortunately, each proposed mechanism for the prolonged neuroinflammatory response has been investigated independently, while it is clear that mechanisms can overlap and be difficult to isolate. Therefore, we aimed to determine whether the dual targeting of the innate immune response by inhibiting innate immunity pathways associated with cluster of differentiation 14 (CD14), and the mechanical mismatch could improve the neuroinflammatory response to intracortical microelectrodes. A thiol-ene probe that softens on contact with the physiological environment was used to reduce mechanical mismatch. The thiol-ene probe was both softer and larger in size than the uncoated silicon control probe. Cd14-/- mice were used to completely inhibit contribution of CD14 to the neuroinflammatory response. Contrary to the initial hypothesis, dual targeting worsened the neuroinflammatory response to intracortical probes. Therefore, probe material and CD14 deficiency were independently assessed for their effect on inflammation and neuronal density by implanting each microelectrode type in both wild-type control and Cd14-/- mice. Histology results show that 2 weeks after implantation, targeting CD14 results in higher neuronal density and decreased glial scar around the probe, whereas the thiol-ene probe results in more microglia/macrophage activation and greater blood–brain barrier (BBB) disruption around the probe. Chronic histology demonstrate no differences in the inflammatory response at 16 weeks. Over acute time points, results also suggest immunomodulatory approaches such as targeting CD14 can be utilized to decrease inflammation to intracortical microelectrodes. The results obtained in the current study highlight the importance of not only probe material, but probe size, in regard to neuroinflammation

Machine learning classification of mesial temporal sclerosis in epilepsy patients

Background and purposeNovel approaches applying machine-learning methods to neuroimaging data seek to develop individualized measures that will aid in the diagnosis and treatment of brain-based disorders such as temporal lobe epilepsy (TLE). Using a large cohort of epilepsy patients with and without mesial temporal sclerosis (MTS), we sought to automatically classify MTS using measures of cortical morphology, and to further relate classification probabilities to measures of disease burden.Materials and methodsOur sample consisted of high-resolution T1 structural scans of 169 adults with epilepsy collected across five different 1.5T and four different 3T scanners at UCLA. We applied a multiple support vector machine recursive feature elimination algorithm to morphological measures generated from FreeSurfer's automated segmentation and parcellation in order to classify Epilepsy patients with MTS (n=85) from those without MTS (N=84).ResultsIn addition to hippocampal volume, we found that alterations in cortical thickness, surface area, volume and curvature in inferior frontal and anterior and inferior temporal regions contributed to a classification accuracy of up to 81% (p=1.3×10(-17)) in identifying MTS. We also found that MTS classification probabilities were associated with a longer duration of disease for epilepsy patients both with and without MTS.ConclusionsIn addition to implicating extra-hippocampal involvement of MTS, these findings shed further light on the pathogenesis of TLE and may ultimately assist in the development of automated tools that incorporate multiple neuroimaging measures to assist clinicians in detecting more subtle cases of TLE and MTS

Interhospital Transfer Before Thrombectomy Is Associated With Delayed Treatment and Worse Outcome in the STRATIS Registry (Systematic Evaluation of Patients Treated With Neurothrombectomy Devices for Acute Ischemic Stroke).

BACKGROUND: Endovascular treatment with mechanical thrombectomy (MT) is beneficial for patients with acute stroke suffering a large-vessel occlusion, although treatment efficacy is highly time-dependent. We hypothesized that interhospital transfer to endovascular-capable centers would result in treatment delays and worse clinical outcomes compared with direct presentation. METHODS: STRATIS (Systematic Evaluation of Patients Treated With Neurothrombectomy Devices for Acute Ischemic Stroke) was a prospective, multicenter, observational, single-arm study of real-world MT for acute stroke because of anterior-circulation large-vessel occlusion performed at 55 sites over 2 years, including 1000 patients with severe stroke and treated within 8 hours. Patients underwent MT with or without intravenous tissue plasminogen activator and were admitted to endovascular-capable centers via either interhospital transfer or direct presentation. The primary clinical outcome was functional independence (modified Rankin Score 0-2) at 90 days. We assessed (1) real-world time metrics of stroke care delivery, (2) outcome differences between direct and transfer patients undergoing MT, and (3) the potential impact of local hospital bypass. RESULTS: A total of 984 patients were analyzed. Median onset-to-revascularization time was 202.0 minutes for direct versus 311.5 minutes for transfer patients ( CONCLUSIONS: In this large, real-world study, interhospital transfer was associated with significant treatment delays and lower chance of good outcome. Strategies to facilitate more rapid identification of large-vessel occlusion and direct routing to endovascular-capable centers for patients with severe stroke may improve outcomes. CLINICAL TRIAL REGISTRATION: URL: https://www.clinicaltrials.gov. Unique identifier: NCT02239640