Apgar score and the risk of cause specific infant mortality: a population based cohort study of 1,029,207 livebirths

Background<p></p> The Apgar score has been used worldwide as an index of early neonatal condition for more than 60 years. With advances in health-care service provision, neonatal resuscitation, and infant care, its present relevance is unclear. The aim of the study was to establish the strength of the relation between Apgar score at 5 min and the risk of neonatal and infant mortality, subdivided by specific causes.<p></p> Methods<p></p> We linked routine discharge and mortality data for all births in Scotland, UK between 1992 and 2010. We restricted our analyses to singleton livebirths, in women aged over 10 years, with a gestational age at delivery between 22 and 44 weeks, and excluded deaths due to congenital anomalies or isoimmunisation. We calculated the relative risks (RRs) of neonatal and infant death of neonates with low (0–3) and intermediate (4–6) Apgar scores at 5 min referent to neonates with normal Apgar score (7–10) using binomial log-linear modelling with adjustment for confounders. Analyses were stratified by gestational age at birth because it was a significant effect modifier. Missing covariate data were imputed.<p></p> Findings<p></p> Complete data were available for 1 029 207 eligible livebirths. Across all gestational strata, low Apgar score at 5 min was associated with an increased risk of neonatal and infant death. However, the strength of the association (adjusted RR, 95% CI referent to Apgar 7–10) was strongest at term (p<0·0001). A low Apgar (0–3) was associated with an adjusted RR of 359·4 (95% CI 277·3–465·9) for early neonatal death, 30·5 (18·0–51·6) for late neonatal death, and 50·2 (42·8–59·0) for infant death. We noted similar associations of a lower magnitude for intermediate Apgar (4–6). The strongest associations were for deaths attributed to anoxia and low Apgar (0–3) for term infants (RR 961·7, 95% CI 681·3–1357·5) and preterm infants (141·7, 90·1–222·8). No association between Apgar score at 5 min and the risk of sudden infant death syndrome was noted at any gestational age (RR 0·6, 95% CI 0·1–4·6 at term; 1·2, 0·3–4·8 at preterm).<p></p> Interpretation<p></p> Low Apgar score at 5 min was strongly associated with the risk of neonatal and infant death. Our findings support its continued usefulness in contemporary practice

The mechanism and prevention of injury in soccer

The study was designed to provide an overview and a unique insight into the musculoskeletal demands of the professional footballer in Scotland. It can be concluded that preseason training, although non competitive, is a period of high risk and its contents must be re-examined. Emphasis should be placed on injury prevention, especially from overload and overuse injuries, to ensure peak performance and team stability. During season 1993-1994, 30 players (8.8%) required surgery and shared a total of 33 operations. Almost 1 in 10 players, therefore, required surgery during the season with all that entails. Not surprisingly, knee surgery was the commonest procedure, with 13 operations being performed on 11 players. Two players initially had arthroscopic examinations and subsequently required further reconstructive procedures. Surprisingly, the next most frequent operation was that of groin or hernia repair (6). Interestingly, 68% (23) of injuries requiring surgery during season 1993-1994 occurred during training, rather than as a result of a competitive match. This was confirmed when the mechanism of injury was assessed in detail, as 25 (75%) of injuries which required surgery were non contact. Of the 14 players requiring knee surgery, it is of concern that 6 (44.8%) of these players had previously required knee surgery, although there was no strong statistical evidence of an association (Fisher's exact test, p=0.094). Of the 342 players studied for the full season, 56 had reported previous knee surgery. Therefore, 19% of players who had previously had knee surgery required further surgery which would merit further research. There was also no strong evidence that the proportion of players requiring surgery differs for the different positions (Chi-squared=4.446, df=2, p=0.108). This study has provided a unique insight into the musculoskeletal demands of professional football. The mechanism and prevention of injury in soccer, has been studied in detail. This will provide a rational basis for future planning in the hope of optimising performance and minimising injury and its recurrence in soccer

Percutaneous Medial Collateral Ligament Repair and Posteromedial Corner Repair With Suture Tape Augmentation

The medial collateral ligament (MCL) is among the most commonly injured structures of the knee. Most cases are managed nonoperatively; however, grade III injuries and injuries associated with multiligament injuries to the knee are often managed surgically. MCL reconstruction procedures are the most widely used surgical option, but modern advancements have seen a renewed interest in ligamentous repair that avoids graft-site morbidity. In addition, augmentation of the repair protects the ligament during the healing phase and allows early mobilization. This article describes, with video illustration, percutaneous MCL repair and posteromedial corner repair with suture tape augmentation

Ultrasound-Guided Suture Tape Augmentation and Stabilization of the Medial Collateral Ligament

Management of medial collateral ligament (MCL) injuries usually consists of time and conservative management; however, patients are typically immobilized and need extensive time to return to sport. Although the MCL has been shown to have the ability to heal given time, surgical management is still sometimes needed to provide stability to the knee. Operative techniques vary in methodology, but are typically highly invasive and technically demanding. In the event of multiligamentous or severe injuries, reinforcing the MCL with an ultrahigh-strength, 2-mm-wide suture tape allows for early functional rehabilitation, permitting the native MCL tissue to heal and avoiding late reconstructions. This technical report details an ultrasound-guided technique for the percutaneous suture tape augmentation and stabilization of the MCL with or without repair. Ultrasound allows for anatomic percutaneous placement of the sockets, as opposed to landmark palpation guidance that has proven to be unreliable. This is a simple, quick procedure that provides instant stability to the MCL with or without operating on the ligament itself, allowing patients to return to activity faster with the reduced risk of reinjury due to less muscle atrophy and loss of function

Anterolateral Ligament Repair With Suture Tape Augmentation

Recent insights into the structure and function of the anterolateral ligament (ALL) of the knee has resulted in a recognition of its contribution in rotational control of the knee. Several ALL reconstruction techniques have been described in the literature. This article describes, with video illustration, a percutaneous repair technique using suture tape augmentation. A tendon graft is not needed. This technique allows early mobilization and encourages natural healing of the ligament by protecting the ligament during the healing phase as a secondary stabilizer

Posterolateral Corner Repair With Suture Tape Augmentation

The posterolateral corner (PLC) of the knee is the main restraint to varus forces of the knee as well as posterolateral rotation of the tibia relative to the femur. Primary PLC repairs have been associated with a high failure rate in past literature. However, with modern improved arthroscopic instrumentation and devices, there has been a renewed interest in repair of the ligaments around the knee. Internal bracing with suture tape augmentation encourages healing and allows early mobilization. This article describes, with video illustration, PLC repair with suture tape augmentation

Anterior Cruciate Ligament Repair Using Independent Suture Tape Reinforcement

Recently there has been renewed interest in primary repair of the anterior cruciate ligament (ACL). Repair of the acute proximal ruptured ACL can be achieved with the independent suture tape reinforcement ACL repair technique. The independent suture tape reinforcement technique reinforces the ligament as a secondary stabilizer, encouraging natural healing of the ligament by protecting it during the healing phase and supporting early mobilization. The purpose of this article is to describe, with video illustration, this ACL repair technique

Development and characterisation of a novel three-dimensional inter-kingdom wound biofilm model

Chronic diabetic foot ulcers are frequently colonised and infected by polymicrobial biofilms that ultimately prevent healing. This study aimed to create a novel in vitro inter-kingdom wound biofilm model on complex hydrogel-based cellulose substrata to test commonly used topical wound treatments. Inter-kingdom triadic biofilms composed of Candida albicans, Pseudomonas aeruginosa, and Staphylococcus aureus were shown to be quantitatively greater in this model compared to a simple substratum when assessed by conventional culture, metabolic dye and live dead qPCR. These biofilms were both structurally complex and compositionally dynamic in response to topical therapy, so when treated with either chlorhexidine or povidone iodine, principal component analysis revealed that the 3-D cellulose model was minimally impacted compared to the simple substratum model. This study highlights the importance of biofilm substratum and inclusion of relevant polymicrobial and inter-kingdom components, as these impact penetration and efficacy of topical antiseptics

Customised and Noncustomised Birth Weight Centiles and Prediction of Stillbirth and Infant Mortality and Morbidity: A Cohort Study of 979,912 Term Singleton Pregnancies in Scotland.

BACKGROUND: There is limited evidence to support the use of customised centile charts to identify those at risk of stillbirth and infant death at term. We sought to determine birth weight thresholds at which mortality and morbidity increased and the predictive ability of noncustomised (accounting for gestational age and sex) and partially customised centiles (additionally accounting for maternal height and parity) to identify fetuses at risk. METHODS: This is a population-based linkage study of 979,912 term singleton pregnancies in Scotland, United Kingdom, between 1992 and 2010. The main exposures were noncustomised and partially customised birth weight centiles. The primary outcomes were infant death, stillbirth, overall mortality (infant and stillbirth), Apgar score <7 at 5 min, and admission to the neonatal unit. Optimal thresholds that predicted outcomes for both non- and partially customised birth weight centiles were calculated. Prediction of mortality between non- and partially customised birth weight centiles was compared using area under the receiver operator characteristic curve (AUROC) and net reclassification index (NRI). FINDINGS: Birth weight ≤25th centile was associated with higher risk for all mortality and morbidity outcomes. For stillbirth, low Apgar score, and neonatal unit admission, risk also increased from the 85th centile. Similar patterns and magnitude of associations were observed for both non- and partially customised birth weight centiles. Partially customised birth weight centiles did not improve the discrimination of mortality (AUROC 0.61 [95%CI 0.60, 0.62]) compared with noncustomised birth weight centiles (AUROC 0.62 [95%CI 0.60, 0.63]) and slightly underperformed in reclassifying pregnancies to different risk categories for both fatal and non-fatal adverse outcomes (NRI -0.027 [95% CI -0.039, -0.016], p < 0.001). We were unable to fully customise centile charts because we lacked data on maternal weight and ethnicity. Additional analyses in an independent UK cohort (n = 10,515) suggested that lack of data on ethnicity in this population (in which national statistics show 98% are white British) and maternal weight would have misclassified ~15% of the large-for-gestation fetuses. CONCLUSIONS: At term, birth weight remains strongly associated with the risk of stillbirth and infant death and neonatal morbidity. Partial customisation does not improve prediction performance. Consideration of early term delivery or closer surveillance for those with a predicted birth weight ≤25th or ≥85th centile may reduce adverse outcomes. Replication of the analysis with fully customised centiles accounting for ethnicity is warranted.SI is funded by a UK Medical Research Council skills development fellowship (MR/N015177/1). DAL works in a Unit that receives funding from the University of Bristol and the UK Medical Research Council (MC_UU_12013/5); she is a National Institute of Health Research (NIHR) Senior Investigator (NF-SI-0611-10196). This work is also supported by the NIHR through the University of Bristol NIHR Biomedical Research Centre (BRC) and the University of Cambridge BRC. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript