[Comparative study on effect of Panax notoginseng and ticlid in treating early diabetic nephropathy]

OBJECTIVE

To explore the ameliorative effect and mechanism of Panax notoginseng (PNG) and ticlid in treating early diabetic nephropathy (DN).

METHODS

Fifty-eight patients were divided randomly into two groups, 28 patients of the ticlid group treated with ticlid 250 mg orally, once a day and 30 patients of the PNG group treated with PNG 8 ml in 250 ml of normal saline intravenous drip once a day. The therapeutic effect and relative indexes of the two groups were observed and compared.

RESULTS

After treatment, in both groups, the thromboxane B2 markedly reduced and was more prominent in the ticlid group (P < 0.05), while the 6-keto-prostaglandin F1 alpha increased obviously, so as to cause a significant lowering of T/K ratio, P < 0.01. Levels of urinary albumin, beta 2 microglobulin and blood alpha 1 microglobulin of both groups were lowered significantly, P < 0.01. A significant positive linear correlation was found in the ticlid group between urinary albumin and T/K ratio (r = 0.41, P < 0.01), as well as in blood alpha 1 microglobulin with T/K ratio (r = 0.34, P < 0.05), while it was not found in the PNG group.

CONCLUSION

Ticlid and PNG were beneficial to resume the balance of T/K and improve microcirculation, reduce whole blood viscosity and decrease urinary albumin so as to retard the progress of DN.

Persistence of antibodies in children after intradermal or intramuscular administration of preexposure primary and booster immunizations with purified Vero cell rabies vaccine

BACKGROUND

The use of intradermal (i.d.) injections of purified Vero cell rabies vaccine (PVRV) for preexposure prophylaxis has not been well-established. We studied the safety and immunogenicity of i.d. and intramuscular (i.m.) PVRV injections for primary and booster preexposure immunizations.

METHODS

One of two rabies preexposure PVRV regimens comprising three doses of either 0.1 ml i.d. or 0.5 ml i.m. administered during 28 days was assigned at random to 190 school children. One booster dose was given 1 year later either i.d. or i.m., according to their initial randomization group. Serologic results were available from 155 (82%) children at 1 year after primary immunization and 118 (62%) children at 2 years after booster.

RESULTS

Although children vaccinated i.d. had significantly lower rabies-neutralizing antibody titers after primary immunization as well as after booster than children vaccinated i.m. (P< 0.001 for all time points), there were no significant differences in the percentages of children with adequate titers (> or =0.15 IU/ml) between the i.d. and i.m. groups after both primary and booster immunizations. Mild local reactions were more frequent after i.d. vaccination. Mild or moderate systemic reactions were infrequent and similar after i.d. and i.m. vaccinations. Fever and headache were reported by < or =6%. The reactions after booster were not different from those of post-primary immunization.

CONCLUSIONS

Purified Vero cell rabies vaccine appears to be safe and immunogenic for primary and booster preexposure immunizations. An i.d. PVRV preexposure regimen should be useful especially for rabies-endemic countries with low per capita income.

[A computerized information system for gynecological patients]

OBJECTIVE

Clinical experiences in the fields of general gynecology, gynecological oncology and reproductive endocrinology had been accumulated over a long period of time. All of the recorded information was written on various kinds of sheets that could easily be damaged and lost with frequent reading. Statistical works were done manually. This is the situation may encountered by all of the hospitals in China, so a computerized information system for gynecological patients is eagerly needed.

METHODS

The program was designed on the basis of Foxpro 2.6 for Windows.

RESULTS

The interfaces were specially designed for every of 72 databases to be like the style of patient's records which can be easily operated with mouse pressing buttons. Some of the databases such as basal body temperature, metastasis of lymph nodes and classification of endometriosis were carefully designed. Because the program will be used in China, the interfaces were all in Chinese. A dictionary was used to simplify the importing of the data. When import, one can easily press the line with the appropriate meaning in the dictionary. A strong statistical function was attached to the program. With its friendly interface, statistical work can be done with ease. This system is capable of further development and fit into needs of various hospitals and departments.

CONCLUSION

This program is very useful for clinical doctors as well as scientific research personnel. With the help of this program, efficacy of our medical work can be raised, clinical experiences can be summarized in time and the clinical level can thus be improved.

Clinical safety of a polyvalent F(ab')2 equine antivenom in 223 African snake envenomations: a field trial in Cameroon. VAO (Venin Afrique de l'Ouest) Investigators

A large-scale clinical trials was conducted, according to World Health Organization Good Clinical Practice guidelines, in 7 centres in north Cameroon to determine the safety and efficacy of a polyvalent antivenom composed of purified F(ab')2. This study included 223 patients presenting clinically with obvious snake bite, predominantly due to Echis ocellatus (viper), the most abundant species in this savannah region. Clinical surveillance was maintained for 5 d in all patients and until the twenty-sixth day in 74% of cases. Two 10 mL ampoules of polyvalent F(ab')2 equine antivenom (Ipser Africa) were administered to each patient by intravenous infusion. If necessary, treatment was repeated 1 h after the end of the first infusion, and then with a frequency determined by the patient's clinical condition. Before initiation of antivenom treatment, the main clinical disorders observed on admission were oedema (93.7%) and haemorrhage (48.9%), with a clotting time longer than 30 min in 65.4% of patients. Clinical cure was obtained in 213 patients (96.8%). No amputation was necessary, and the case fatality rate was only 1.3%. On average, 4.6 (+/- 3.7) ampoules were administered per patient; 43% of subjects recovered after only a single infusion of 2 ampoules. Early adverse reactions, of varying degrees of severity, were observed in 6.3% of patients. A severe early reaction, anaphylactic shock, was observed in only one patient (0.4%). Serum sickness was observed in another patient. Polyvalent F(ab')2 equine antivenom given by repeated 20 mL intravenous infusions is a safe and effective treatment for envenomation caused by African vipers.

Cysteine-string proteins regulate exocytosis of insulin independent from transmembrane ion fluxes

Cysteine-string proteins (Csps) are vesicle proteins involved in exocytosis of synaptic vesicles in Drosophila and modulation of presynaptic calcium influx. As both the contribution of calcium channel regulation to the role of Csp in exocytosis and a function of Csp outside the nervous system are unknown, we studied its function in endocrine exocytosis from large dense core vesicles (LDCVs) using insulin-secreting pancreatic beta-cells. Csps were expressed in primary and derived beta-cell lines on insulin-containing LDCVs. Suppression of Csp expression reduced not only depolarisation induced insulin release but also exocytosis in permeabilised cells directly stimulated by Ca2+. Thus, Csp is a secretory granule protein and is required for endocrine exocytosis independent of the modulation of transmembrane calcium fluxes.

[Epidemiologic and genetic studies of canine hip dysplasia in a population of Labrador retrievers: a study over 25 years]

The occurrence of canine hip dysplasia (CHD) was analyzed in a colony of 738 Labrador Retrievers between 1972 and 1996. Of these dogs, 86.3% were radiographically examined for hip dysplasia. The overall prevalence of CHD was 31.3% during the study period of 25 years. Between 1972 and 1980, the prevalence of CHD was 57.9%. It decreased to 14.9% between 1991 and 1996. Univariate and multivariate logistic regression models were developed to identify the influence of potential risk factors for CHD such as age at examination, gender, color, year and season of birth, litter size, order of birth, birth weight, body weight and daily weight gain. Birth year and age at examination proved to be significant risk factors. No significant association was found between CHD and elbow dysplasia. Of the dogs diagnosed with CHD, 18% showed dysplastic changes only, without radiographic signs of secondary osteoarthritis (OA). The Norberg angle (NA) proved to be a significant risk factor for coxofemoral osteoarthritis with a moderate negative correlation between OA and NA. Finally, genetic effects were calculated in a mixed model. Heritability (h2) of CHD was estimated at 0.53 (SE = 0.17) for paternal half siblings. The proportion of the common environment of a litter to the total variance was estimated at C2 = 0.03.

Safety and efficacy of purified Vero cell rabies vaccine given intramuscularly and intradermally. (Results of a prospective randomized trial)

OBJECTIVES

To determine adverse reactions as a result of pre- and post-exposure rabies vaccination, using the conventional intramuscular, and reduced dose intradermal regimens and purified Vero cell rabies vaccine.

DESIGN

A prospective and randomized study of patients exposed to rabies and of subjects in need of pre-exposure rabies vaccination.

SETTING

A metropolitan rabies control center in a canine rabies endemic country.

PATIENTS

1198 subjects were recruited between May, 1994 and March, 1996. They were divided into four groups. Patients with suspected or proven rabies exposures were given the vaccine intramuscularly using the conventional regimen, or intradermally using the World Health Organization approved Thai Red Cross schedule. Human or equine rabies immune globulin was administered where indicated. Pre-exposure and post-exposure vaccine recipients were divided randomly into two groups each and given the vaccine either by the intramuscular or intradermal schedules.

MEASUREMENTS

All local and systemic adverse reactions were recorded and statistically analyzed.

RESULTS

Pruritus at injection sites was the only significant local reaction. It was more common in the intradermal groups. Low-grade fever, the only significant adverse systemic event, was more common in the intramuscular groups and was noted in 8% of all subjects. Eighty-four patients bitten by proven rabid animals were found to be alive and well 3 years later. Forty-four of these had received the intramuscular and 40 the intradermal postexposure regimens with human or equine immune globulin injected into wounds on the first day of treatment.

CONCLUSIONS

Purified Vero cell rabies vaccine is safe, carries a very low adverse reaction rate and is effective in preventing rabies in severely exposed subjects when used with human or equine rabies immune globulin.

[Interleukin 2 gene transfer on the proliferation and morphology of ovarian cancer cell line SKOV3]

OBJECTIVE

To study the effect of interleukin-2 (IL-2) gene transfer on the proliferation and morphology of ovarian cancer cell line SKOV3.

METHOD

IL-2 gene was introduced into ovarian cancer cell line SKOV3. The morphologic changes, mitosis, proliferation curve, 3H-uptaking and cell cycle were studied.

RESULTS

IL-2 cDNA, 490 bp, was transduced. IL-2 gene expression was detected. IL-2 activity was 30-318 U/10(6) cells/24hr. IL-2 gene modified cell is squamas like with smaller nucleus/cytoplasm ratio, larger cell area and more homogeneous. The ultrastructural study showed that the cytoplasma of IL-2 gene modified cells is markedly vacuolized and the chromatin is condensed. There was less mitosis found in SKOV3/IL-2 cells. SKOV3/IL-2 cell proliferate more slowly, the doubling time prolonged from 38.40 hr to 65.36 hr, 3H-uptaking decreased 52.3% of the parent cell. The cell cycle study showed that SKOV3/IL-2 cell was blocked to phase G1/G0.

CONCLUSIONS

The retrovirous vector can transduce Il-2 gene into ovarian cancer cell line SKOV3 effectly. IL-2 gene transfer can induce morphologic changes of SKOV3 cells, which may indicate the biologic behavior changes of the targets. IL-2 gene transfer can induce the proliferation inhibition of SKOV3 cells.

[The comparison of biological characteristics between tumor-infiltrating lymphocytes and tumor-associated lymphocytes in ascites of epithelial ovarian carcinoma]

OBJECTIVE

To compare biological charicteristics between tumor-infiltrating lymphocytes (TIL) and tumor-associated lymphocytes (TAL) in epithelial ovarian carcinomas.

METHODS

The surgical samples of four ovarian specimens and eight cancer ascites from epithelial ovarian carcinoma were collected, and ascites were divided into bloody and non-bloody groups. The cancer tissue was dissected to yield single cells suspensions. TIL and TAL were grown in coculture with autologous tumor cells and 500 U/ml recombinant interleukin-2 (rIL-2). Phenotype was studied using flow cytometry for a varity of human immunocompetent cell surface markers (CD3, CD4, CD8, CD25). Cytotoxicity was investigated using 4-hr 51Cr-release assays with primary ovarian carcinoma cell cultures and the CAOV3 cell line and the K562 cell line as target cells in cultured period.

RESULTS

(1) There was no significant difference in CD3, CD4, CD8 and CD25 expression among the three groups (P > 0.05). CD4 to CD8 (CD4/CD8) ratio was consistently more than 1 in cultured period. (2) In all three groups, Natural killer (NK) acitivity was high and no difference among them (P > 0.05). (3) In all twelve cases, TIL and TAL in the non-bloody ascites possess higher potential to lyse the autologous tumor target than TAL in the bloody ascites (P < 0.01) when effector cell to target cell (E:T) was 50 to 1 (50:1). Lytic activity was 30.2%-51.0% and 10.8%-15.8% respectively.

CONCLUSIONS

TIL and TAL in non-bloody ascites in epithelial ovarian cancer have the same biological characteristics.

[Application of coronal CT scan and three-dimensional reconstruction in rhinology]

To display the structure of the Ostiomeatal Complex (OMC) more clearly, and provide clearer and more living imaging for safe functional endoscopic sinus operation and thoroughly eliminating the focus of disease, coronal CT scanning and 3-dimensional reconstruction were performed in 168 sinusitis patients (290 sides) and 107 patients with sinusitis and nasal polyposis (175 sides). The CT findings were compared with endoscopic examination and normal people were taken as control. The found of coronal CT and endoscopic examination are consistent in recognizing mucosal thickening within nasal cavity and sinuses. Three-dimensional CT is more living than common coronal CT in displaying the uncinate process and turbinates. Our conclusion is that coronal CT scan processes high values for recognizing nasal sinus disease, anatomical variants, disease extent and adjacent structures of OMC. Three-dimensional reconstructed CT make the image of OMC more stereoscopic, audio-visual and living.

[Snake bite by European vipers. A multicenter study of tolerance to Viperfav, a new intravenous antivenom]

OBJECTIVES

To evaluate the tolerance and the effectiveness of i.v. Viperfav, a new antivenom containing F(ab')2 fragments of equine antibodies, for the treatment of European viper envenomed patients.

STUDY DESIGN

Open, multicentre field trial, associated with a cohort study.

PATIENTS

The study included 46 patients of either gender, nine aged less then 10 years, eight between 10 and 15 years, and 28 adults, who sustained a moderate or severe viper envenomation (Grade 2 or 3).

METHOD

At the inclusion, a single infusion of Viperfav was given. Depending on the clinical course, up to four additional infusions were to have been administered at 4-hour intervals. To evaluate tolerance, all symptoms were recorded. There were three effectiveness evaluation criterion (duration of hospitalisation, course of the severity grade, recovery (sequelae)) and one subjective criteria (value of the antivenom as ascertained by investigators).

RESULTS

In the 46 included patients, 79 infusions were administrated. Concerning tolerance, six mild symptoms were associated to the antivenom infusions. No severe reaction occurred. The mean duration of hospitalisation was 4 days 19 hours +/- 13 hours. A severity grade decrease by at least one point was observed in 35 patients, and all were discharged without sequelae. For the investigators the antivenom was inefficient in only two patients (grade 3 with tissue lesions).

CONCLUSIONS

In comparison with literature data (5 to 10% of severe reactions attributable to the antivenom), the tolerance of Viperfav can be considered as satisfactory. As all criteria were in favour of a positive benefit to risk ratio, the authors recommend the use of Viperfav i.v. for the grade 2 and 3 envenomations instead of the current less purified antivenom, which can only be administered by the intramuscular route.

Optimization of temperature distributions for regional hyperthermia based on a nonlinear heat transfer model

We describe an optimization process specially designed for regional hyperthermia of deep seated tumors in order to achieve desired steady-state temperature distributions. A nonlinear three-dimensional heat-transfer model based on temperature-dependent blood perfusion is applied to predict the temperature. Optimal heating is obtained by minimizing an integral object function which measures the distance between desired and model predicted temperatures. Sequential minima are calculated from successively improved constant-rate perfusion models employing a damped Newton method in an inner iteration. Numerical results for a Sigma 60 applicator are presented.

Ultrasonographic comparison of adhesions induced by two different methods of gastropexy in the dog

Ultrasonography was used to compare adhesions induced by two different methods of gastropexy in 16 dogs. An incisional gastropexy technique was used in eight dogs (group 1) and a 'modified' gastropexy technique in the remaining eight (group 2). The length and thickness of the gastropexy and the peristaltic activity of the stomach were measured ultrasonographically and compared between groups. Measurements for the two groups were taken in the early postoperative interval (two to four days), intermediate postoperative interval (eight to 20 days) and late postoperative interval (57 to 79 days). Both techniques were equally successful in forming permanent adhesions at two months postoperatively and there was no recurrence of gastric dilatation and volvulus. The length and thickness of the gastropexy were similar for both groups at two months postoperatively and there were no surgical complications with either technique. The modified gastropexy provides a technique that can easily be performed by a single surgeon, with no increased operative time or duration of anaesthesia, and with the formation of a permanent adhesion.

Prognostic significance of clinical grading of patients envenomed by Bothrops lanceolatus in Martinique. Members of the Research Group on Snake Bite in Martinique

The correlation between clinical grading of patients bitten by Bothrops lanceolatus and the subsequent development of their envenoming was examined. Severity of envenoming was graded using a 1-4 scale (minor to major). Patients were classified into 2 groups according to the time elapsed between bite and treatment with a specific purified equine F(ab')2 antivenom. The late/no treatment group (n = 33) was characterized by a systemic thrombotic complication rate of 14/33 (42.4%) leading to 4 deaths, which increased with the maximum severity assessed on the first day following the bite (P = 0.003). However, infarctions could develop in patients who presented initially with signs of moderate envenoming, normal blood clotting and low serum levels of venom antigens. No such complication of fatality occurred in the early (0.5-6 h) treatment group (n = 70). Multiple regression analysis showed that duration of stay in hospital in this group increased with the length of the snake (P = 0.017), venom antigenaemia (P = 0.016), initial grading (P < 0.001), and with the need for surgical debridement (n = 10/70, P < 0.001). Outcome was correlated with initial severity of envenoming. However, the only factor with a positive prognostic significance for the individual envenomed patient was the early infusion of specific antivenom, which led to 100% recovery in our series.

Synergistic effect of hydrochloric acid and bile acids on the pars esophageal mucosa of the porcine stomach

OBJECTIVES

To determine effects of finely ground diet and food deprivation on pH and bile acid concentration in the proximal portion of the porcine stomach and effects of bile acids and pH on the pars esophageal mucosa in vitro.

ANIMALS

Sixteen 15- to 30-kg pigs.

PROCEDURES

Gastric content samples obtained from pigs fed a finely ground pelleted or coarsely ground meal diet were assayed for gastric pH and bile acids. Stratified squamous epithelium was studied in an Ussing chamber, and histologically. Electrical conductance and transmucosal mannitol fluxes (as indices of tissue permeability) were determined at pH 4.0, 2.0, and 1.5 and in response to treatment with 0, 1, 2, or 3 mM taurodeoxycholate or glycocholate.

RESULTS

Pigs fed the finely ground feed had significantly (P = 0.01) lower proximal stomach pH than did pigs fed the coarse meal. Proximal stomach bile acids concentration was significantly (P = 0.04) higher in pigs fed the finely ground diet. The H+ and bile acids concentration increased with time after feeding. In vitro exposure of the stratified mucosa to high H+ (pH < 4.0) and bile salt concentration (> or = 1.0 mM) resulted in significant (P < 0.05) dose-dependent increase in tissue conductance and mannitol fluxes, whereas low pH or bile acids alone had little effect.

CONCLUSIONS

High H+ and bile acids concentration in the stomach of pigs fed finely ground diets or subjected to feed deprivation may contribute to ulceration of the pars esophageal tissue. Bile acids act synergistically and in dose-dependent manner, with low pH causing damage to the stratified squamous epithelium in vitro.

Ultrasonographic evaluation of adhesions induced by incisional gastropexy in 16 dogs

A study was undertaken to evaluate the use of ultrasonography to assess the gastropexy site for permanent adhesion in clinical cases. Two groups, each comprising eight dogs, were studied, all 16 cases undergoing decompression, anatomical repositioning of the stomach and an incisional gastropexy after gastric dilatation-volvulus (GDV). Group 1 was set up as a prospective group in which ultrasonographic examinations were performed three times (mean three, 12 and 67 days) after surgery to evaluate the gastropexy region. The gastropexy site was assessed ultrasonographically at only one stage (mean 449 days after surgery) in the group 2 dogs. Criteria used to assess the usefulness of the ultrasonographic evaluation included the ability to identify the gastropexy site, to obtain measurements of the length and thickness of the site and to assess the ultrasonographic appearance of the different gastric wall layers. The average number of peristaltic contractions and degree of gastric filling were also evaluated. The fixation between the stomach and the abdominal wall was easily detected in all 16 cases. Ultrasonography proved to be a simple and non-invasive technique to assess the permanency of the gastropexy. The incisional gastropexy was relatively easy to perform and induced permanent adhesions in all 16 dogs, without recurrence of GDV.

[Comparison of different surgical procedures for urinary stress incontinence]

OBJECTIVE

Comparison of different surgical procedures for urinary stress incontinence (USI).

METHODS

95 patients with and/or accompanying USI were treated operatively in a prospectively randomized manner.

RESULTS

The cure rate of colposuspension group 3 months after operation was 93% and was higher than 69% after Kelly operation (P < 0.05). But the cure rate 12 months after operation decreased to 74% and 58% respectively (P > 0.05). The percentage of abnormal sexual life was lower in the colposuspension group (4%) than that of those having Kelly operation (7%). The average days and times of intubation in the colposuspension group were more than in Kelly operation group (P < 0.05).

CONCLUSION

The cure rate of colposuspension 3 months was better than that of the Kelly operation. The cure rate at 1 year was similar in the two procedures. Transient urinary retention occurred more after in the colposuspension group.

Evaluation of the safety, immunogenicity, and pharmacokinetic profile of a new, highly purified, heat-treated equine rabies immunoglobulin, administered either alone or in association with a purified, Vero-cell rabies vaccine

A clinical evaluation of a new, purified, heat-treated equine rabies immunoglobulin (PHT-Erig), F(ab')2 preparation, was carried out in Thailand and in the Philippines-two countries where rabies is endemic. An initial prospective, randomised, controlled trial (Study 1), compared the safety and pharmacokinetics (serum concentrations of rabies antibodies) after administration either of PHT-Erig or of a commercially-available, equine rabies immune globulin (Erig PMC). A second trial (Study 2) simulated post-exposure rabies prophylaxis by using a reference cell culture vaccine, the purified Vero-cell rabies vaccine (PVRV), administered in association with either Erig PMC or PHT-Erig. In Study 1, 27 healthy, Thai adults received a 40 IU kg(-1) dose of either Erig PMC (n = 12) or PHT-Erig (n = 15) via the intramuscular (i.m.) route; half of the dose was injected into the deltoid area and the other half into the buttocks. Serum for rabies antibody determination and F(ab')2 concentration was collected at hours (H) 0, 6 and 12, and on day (D) 2, 3, 4, 6, 8, 10, 12 and 15. Both products were safe, with no serious adverse events, and in particular, no anaphylactic reactions or serum sickness was reported. A statistical comparison of the pharmacokinetic parameters did not demonstrate bioequivalence of the two products. Nonetheless, the relative bioavailability of 93% and the similar absorption rates suggest the pharmacokinetic profiles of Erig and PHT-Erig are similar. The antibody level in either group were low throughout the 15-day study period. The geometric mean titer (GMT) values ranged from group 0.027-0.117 IU ml(-1) in the Erig group and from 0.029 to 0.072 IU ml(-1) in the PHT-Erig. There was no significant difference between the evolution of GMT values for the two groups. In Study 2, 71 healthy volunteers received 40 IU kg(-1) via the intramuscular route of either Erig PMC (n = 36) or PHT-Erig (n = 35) on D0, in association with five doses of PVRV on D0, D3, D7, D14 and D28. The safety evaluation was performed during the 28-day follow-up and serum samples for anti-rabies antibody titration were collected on D0 (before injection) D3, D7, D14 and D28. No serious reactions were reported in either group. In particular, no immediate (anaphylactic type) or delayed (serum sickness) allergic reactions were observed. Over the 28-day follow-up period, GMT profiles of the two groups were statistically equivalent. On D14, 100% of the subjects had protective antibody titers (anti-rabies antibodies > or = 0.5 IU ml(-1), which is the WHO-recommended level of seroconversion), and Erig PMC and PHT-Erig were indistinguishable according to the clinical definition chosen. On D28, the GMT values were 33.2 IU ml(-1) (95% CI, 23.8-46.1 IU ml(-1)) in the Erig PMC/PVRV group and 31.4 IU ml(-1) (95% confidence interval, CI, 23.4-42.2 IU ml(-1)) in the PHT-Erig/PVRV group, showing evidence of adequate vaccine-induced antibody responses in both groups. The increased purity, the heat-treatment step introduced in the manufacturing process of PHT-Erig, and the good clinical results substantiate the use of this new generation, purified equine F(ab')2 preparation in the post-exposure prophylaxis of rabies.

The BirthPlace collaborative practice model: results from the San Diego Birth Center Study

Objective: The search for quality, cost-effective health care programs in the United States is now a major focus in the era of health care reform. New programs need to be evaluated as alternatives are developed in the health care system. The BirthPlace program provides comprehensive perinatal services with certified nurse-midwives and obstetricians working together in an integrated collaborative practice serving a primarily low-income population. Low-risk women are delivered by nurse-midwives in a freestanding birth center (The BirthPlace), which is one component of a larger integrated health network. All others are delivered by team obstetricians at the affiliated tertiary hospital. Wellness, preventive measures, early intervention, and family involvement are emphasized. The San Diego Birth Center Study is a 4-year research project funded by the U.S. Federal Agency for Health Care Policy and Research (#R01-HS07161) to evaluate this program. The National Birth Center Study (NEJM, 1989; 321(26): 1801-11) described the advantages and safety of freestanding birth centers. However, a prospective cohort study with a concurrent comparison group of comparable risk had not been conducted on a collaborative practice-freestanding birth center model to address questions of safety, cost, and patient satisfaction.Methods: The specific aims of this study are to compare this collaborative practice model to the traditional model of perinatal health care (physician providers and hospital delivery). A prospective cohort study comparing these two health care models was conducted with a final expected sample size of approximately 2,000 birth center and 1,350 traditional care subjects. Women were recruited from both the birth center and traditional care programs (private physicians offices and hospital based clinics) at the beginning of prenatal care and followed through the end of the perinatal period. Prenatal, intrapartum, postpartum and infant morbidity and mortality are being compared along with cost-effectiveness and acceptance of the model by patients. Data collection occurred primarily through medical record abstraction with the addition of two patient questionnaires. Comparability of the cohorts was established by using a validated methodology to determine medical/perinatal risk and birth center eligibility, which included assessment by two CNMs and an independent blind review by a perinatologist. The cost analysis uses a resource-utilization approach and new methodologies such as activity-based-costing to compare costs from both the perspective of the payor and the health care provider. Patient satisfaction was measured using a self-administered patient questionnaire.Results: Current preliminary results from approximately 38% of the final expected study sample are available. Crude and adjusted analysis have been conducted. Overall, the preliminary results suggest similar morbidity and mortality in the two groups. Fetal deaths are 0.75% in the index and 0.64% in the comparison group, with early neonatal deaths at 0.26% and 0.23%, respectively. The traditional care group showed adjusted rate differences of 5.83% more major maternal intrapartum complications and 9% more NICU admissions. While the birth center group showed adjusted rate differences of 5.5% more low birth weight and 0.95% more preterm birth. For other outcomes, the birth center group showed an adjusted rate difference of 22.34% more exclusive breastfeeding at discharge. Also, there was less utilization of cesarean section and assisted delivery in the birth center group as compared to the traditional care group. The adjusted rate difference for normal spontaneous vaginal deliveries in nulliparas was 10.23% more in the birth center group, with similar results in multiparas with and without history of cesarean (28.88% and 7.84%, respectively). Preliminary results also show that the average total cost for pregnancy-related services paid by California Medicaid was $4,550 for the birth center and $5,535 for the traditional care group. Final results based on the full study sample (full data available February 1998) details of payor costs such as provider, facility, NICU, and ancillary along with costs from the health care system perspective and patient satisfaction results will be presented.Conclusion: Current results suggest similar morbidity and mortality between the birth center program and traditional care groups, with less resource utilization translating to lower costs in the collaborative practice model. Results suggest that collaborative practice using a freestanding birth center as an adjunct to an integrated perinatal health care system may provide a quality, lower-cost alternative for the provision of perinatal services.