In situ measurements of reef squid polarization patterns using two-dimensional polarization data mapped onto three-dimensional tessellated surfaces

Reef squids belong to a group reputed for polarization sensitivity, yet polarization patterns of reef squid have not been quantified in situ. To quantify polarization patterns from video polarimetric data, we developed a protocol to map two-dimensional polarization data onto squid-shaped three-dimensional tessellated surfaces. This protocol provided a robust data container used to investigate three-dimensional regions-of-interest, producing data lineouts derived from the squid's geometry. This protocol also extracted polarimeter and squid body orientations and the solar heading from polarization images. When averaged over the solar heading, the ventral midline gave a low degree of polarization (2.4 ± 5.3%), and the area between the ventral and flank midlines had higher values (9.0 ± 5.3%). These averaged data had a large discontinuity in the angle of polarization (AoP) at the mantle's ventral midline (64 ± 55°), with larger discontinuities measured on individual squid. Ray-tracing calculations demonstrated that the AoP pattern was not related to the squid's surface-normal geometry. However, the AoP followed virtual striation axes on the squid's surface oriented 24° to the squid's long axis, similar in angle (27°) to the striations of birefringent collagen fibres documented in other squid species' skin.

Clinical impact on treatment and prognosis of advanced cardiac imaging with echocardiography in the acute setting of a COVID-19 infection

Background and objectives

Despite myocardial injury being related to excess mortality in acute COVID-19 infection, its impact on imaging findings remains unclear. This study aimed to characterize transthoracic echocardiographic (TTE) findings in patients admitted with COVID-19 infections and its impact on management and prognosis.

Methods

A prospective observational cohort study was performed among 66 COVID-19 patients who were admitted to a tertiary center between March 1 and May 25, 2020 and underwent TTE. High-sensitivity troponin I (hs-cTnI) data, echocardiographic assessment of right and left ventricular (LV) functional parameters, strain, and myocardial work analysis were obtained.

Results

2025 patients were admitted with COVID-19 and in 200 a complete TTE study was performed. Due to poor image quality, only 66 studies were included in the final analysis. The median age was 62 years (IQR, 55–70) and 59.1% of patients were males. The most common comorbidity was hypertension (47%), followed by smoking history (30.3%), atrial fibrillation (9.1%), and chronic obstructive pulmonary disease (7.9%). More than half of the patients (39, 59%) were admitted to the ICU, and half of them (33, 50%) required invasive mechanical ventilation. TTE was mainly indicated because of concerns for systemic conditions (50%) and evaluation of hemodynamic assessment (30%). Thirty-six patients (54.5%) had an abnormal TTE result and 57% had elevated hs-cTnI levels. The most common cardiac abnormality was LV diastolic dysfunction in 33% of the patients, followed by right ventricular dysfunction (12%) and LV dysfunction (6%) (Figure 1). LV GLS was reduced in 48.5% of the cases. Myocardial work performance indices were all reduced in patients with an abnormal TTE (GWI 30%, GCW 30%, GWW 40%, and GWE 40%), although differences were not significant (P>0.2 for all parameters). Patients with an abnormal TTE were older and presented a higher cardiovascular risk profile. There were no significant differences in the levels of D-dimer, NTproBNP, and hs-cTnI between patients with and without diastolic dysfunction, RV, or LV dysfunction (P>0.3 for all parameters). Using Spearman rank correlation, there was an inverse relationship between hs-cTnI and LV strain and myocardial work analysis. TTE results impacted clinical management in 60 patients, mainly de-escalation of medical treatment (Figure 2). Abnormal TTE results did not impact in-hospital outcomes.

Conclusions

Severe echocardiographic abnormalities are uncommon in hospitalized patients with COVID-19 infections, presenting mostly with subclinical myocardial changes, such as diastolic dysfunction, reduced LV GLS, and myocardial work indices, both associated with high-sensitivity troponin I elevation. An echocardiographic study should be limited to rule out long-term ICU complications or to evaluate hemodynamic instability. Although TTE was a valuable tool for guiding management, it had no significant impact on prognosis.

Funding Acknowledgement

Type of funding sources: None. Figure 1. Findings on TTE studies.Figure 2. Changes in management.

Photodynamic inactivation of Lasiodiplodia theobromae: lighting the way towards an environmentally friendly phytosanitary treatment

The fungus Lasiodiplodia theobromae is one of the main causal agents of trunk canker and dieback of grapevine. The objective of this work was to evaluate the efficiency of photodynamic inactivation (PDI) of L. theobromae with synthetic and natural photosensitizers and irradiation with either sunlight or artificial photosynthetically active radiation. Although the growth of the mycelium could not be completely prevented with natural sunlight irradiation, phenothiazine dyes (methylene blue, MB; toluidine blue O, TBO), riboflavin and a cationic porphyrin (Tetra-Py⁺-Me) caused complete inhibition under continuous irradiation with artificial light. Free radicals were the main cytotoxic agents in the PDI with MB, indicating the predominance of the type I mechanism. PDI with MB or Tetra-Py⁺-Me may represent a promising approach for the sanitation of vine material in greenhouse nurseries, in order to reduce the risk of infection upon grafting.

Effects of milk feeding strategies on short- and long-term productivity of Holstein heifers

Research investigating the effects of feeding raw or pasteurized nonsaleable milk (NSM) on heifers' performance beyond the period of supplementation is limited. This study aimed to examine the effects of type of milk [NSM or milk replacer (MR)] and pasteurization of NSM on preweaning and first-lactation performance of heifers born with low (<36.3 kg) or normal birth weight (≥36.3 kg). Holstein heifers (n = 154) were sequentially assigned to 1 of 3 treatments: MR, pasteurized NSM, or raw NSM. Heifers assigned to raw NSM were fed raw colostrum, whereas heifers assigned to MR and pasteurized NSM were fed pasteurized colostrum. The low birth weight heifers were fed 1.4 L at each feeding until they reached 36.3 kg body weight, whereas normal birth weight heifers were fed 1.9 L at each feeding. A grain mix starter was offered throughout the study. Heifers were weaned ≥42 d old if consuming at least 0.9 kg/d of starter for 3 consecutive days. Data were analyzed with the MIXED procedure of SAS (SAS Institute Inc., Cary, NC), and the basic model included milk treatments, birth weight group, and treatment × birth weight group. The low birth weight heifers fed raw colostrum and NSM versus pasteurized colostrum and NSM had lower serum protein concentrations. Heifers fed MR versus NSM had or tended to have greater concentrations of hematocrit, red blood cells, and eosinophils but lesser concentrations of platelets, although some of those responses were temporary. Pasteurization tended to increase blood lymphocyte concentrations. Heifers with normal birth weight had greater concentrations of blood neutrophils, lymphocytes, and monocytes, compared with low birth weight heifers. For the first 42 d of life, low birth weight heifers fed pasteurized versus raw NSM had greater weight gain, grain intake, and feed efficiency and were weaned earlier (hazard ratio for weaning by 56 d: 2.90). These pasteurization effects for low birth weight heifers tended to be sustained through 24 wk of age, indicated by greater weight gain and hip height growth. In their first lactation, low birth weight heifers produced less mature-equivalent (MEq) protein and tended to produce less MEq milk and fat than normal birth weight heifers. However, the negative effects of low birth weight on MEq milk and fat yield was only evident in heifers fed raw NSM, whereas the performance of low birth weight heifers was similar to that of normal birth weight when fed MR or pasteurized NSM. These findings confirm that calf management practices influence future performance; in this case, failing to pasteurize milk and colostrum for low birth weight heifers had effects that remained apparent for more than 2 years.

A Phase I/II Clinical Trial to evaluate the efficacy of baricitinib to prevent respiratory insufficiency progression in onco-hematological patients affected with COVID19: A structured summary of a study protocol for a randomised controlled trial

OBJECTIVES

Baricitinib is supposed to have a double effect on SARS-CoV2 infection. Firstly, it reduces the inflammatory response through the inhibition of the Januse-Kinase signalling transducer and activator of transcription (JAK-STAT) pathway. Moreover, it reduces the receptor mediated viral endocytosis by AP2-associated protein kinase 1 (AAK1) inhibition. We propose the use of baricinitib to prevent the progression of the respiratory insufficiency in SARS-CoV2 pneumonia in onco-haematological patients. In this phase Ib/II study, the primary objective in the safety cohort is to describe the incidence of severe adverse events associated with baricitinib administration. The primary objective of the randomized phase (baricitinib cohort versus standard of care cohort) is to evaluate the number of patients who did not require mechanical oxygen support since start of therapy until day +14 or discharge (whichever it comes first). The secondary objectives of the study (only randomized phase of the study) are represented by the comparison between the two arms of the study in terms of mortality and toxicity at day+30. Moreover, a description of the immunological related changes between the two arms of the study will be reported.

TRIAL DESIGN

The trial is a phase I/II study with a safety run-in cohort (phase 1) followed by an open label phase II randomized controlled trial with an experimental arm compared to a standard of care arm.

PARTICIPANTS

The study will be performed at the Institut Català d'Oncologia, a tertiary level oncological referral center in the Catalonia region (Spain). The eligibility criteria are: patients > 18 years affected by oncological diseases; ECOG performance status < 2 (Karnofsky score > 60%); a laboratory confirmed infection with SARS-CoV-2 by means of real -time PCR; radiological signs of low respiratory tract disease; absence of organ dysfunction (a total bilirubin within normal institutional limits, AST/ALT≤2.5 X institutional upper limit of normal, alkaline phosphatase ≤2.5 X institutional upper limit of normal, coagulation within normal institutional limits, creatinine clearance >30 mL/min/1.73 m² for patients with creatinine levels above institutional normal); absence of HIV infection; no active or latent HBV or HCV infection. The exclusion criteria are: patients with oncological diseases who are not candidates to receive any active oncological treatment; hemodynamic instability at time of study enrollment; impossibility to receive oral medication; medical history of recent or active pulmonary embolism or deep venous thrombosis or patients at high-risk of suffering them (surgical intervention, immobilization); multi organ failure, rapid worsening of respiratory function with requirement of fraction of inspired oxygen (FiO₂) > 50% or high-flow nasal cannula before initiation of study treatment; uncontrolled intercurrent illness (ongoing or severe active infection, symptomatic congestive heart failure, unstable angina pectoris, cardiac arrhythmia, or psychiatric illness/social situations that would limit compliance with study requirements); allergy to one or more of study treatments; pregnant or breastfeeding women; positive pregnancy test in a pre-dose examination. Patients should have the ability to understand, and the willingness to sign, a written informed consent document; the willingness to accept randomization to any assigned treatment arm; and must agree not to enroll in another study of an investigational agent prior to completion of Day +28 of study. An electronic Case Report Form in the Research Electronic Data Capture (REDCap) platform will be used to collect the data of the trial. Removal from the study will apply in case of unacceptable adverse event(s), development of an intercurrent illness, condition or procedural complication, which could interfere with the patient's continued participation and voluntary patient withdrawal from study treatment (all patients are free to withdraw from participation in this study at any time, for any reasons, specified or unspecified, and without prejudice).

INTERVENTION AND COMPARATOR

Treatment will be administered on an inpatient basis. We will compare the experimental treatment with baricitinib plus the institutional standard of care compared with the standard of care alone. During the phase I, we will define the dose-limiting toxicity of baricitinib and the dose to be used in the phase 2 part of the study. The starting baricitinib dose will be an oral tablet 4 mg-once daily which can be reduced to 2 mg depending on the observed toxicity. The minimum duration of therapy will be 5 days and it can be extended to 7 days. The standard of care will include the following therapies. Antibiotics will be individualized based on clinical suspicion, including the management of febrile neutropenia. Prophylaxis of thromboembolic disease will be administered to all participants. Remdesivir administration will be considered only in patients with severe pneumonia (SatO₂ <94%) with less than 7 days of onset of symptoms and with supplemental oxygen requirements but not using high-flow nasal cannula, non-invasive or invasive mechanical ventilation or extracorporeal membrane oxygenation (ECMO). In the randomized phase, tocilizumab or interferon will not be allowed in the experimental arm. Tocilizumab can be used in patients in the standard of care arm at the discretion of the investigator. If it is prescribed it will be used according to the following criteria: patients who, according to his baseline clinical condition, would be an ICU tributary, interstitial pneumonia with severe respiratory failure, patients who are not on mechanical ventilation or ECMO and who are still progressing with corticoid treatment or if they are not candidates for corticosteroids. Mild ARDS (PAFI <300 mmHg) with radiological or blood gases deterioration that meets at least one of the following criteria: CRP >100mg/L D-Dimer >1,000μg/L LDH >400U/L Ferritin >700ng/ml Interleukin 6 ≥40ng/L. The use of tocilizumab is not recommended if there are AST/ALT values greater than 10 times the upper limit of normal, neutrophils <500 cells/mm3, sepsis due to other pathogens other than SARS-CoV-2, presence of comorbidity that can lead to a poor prognosis, complicated diverticulitis or intestinal perforation, ongoing skin infection. The dose will be that recommended by the Spanish Medicine Agency in patients ≥75Kg: 600mg dose whereas in patients <75kg: 400mg dose. Exceptionally, a second infusion can be assessed 12 hours after the first in those patients who experience a worsening of laboratory parameters after a first favourable response. The use of corticosteroids will be recommended in patients who have had symptoms for more than 7 days and who meet all the following criteria: need for oxygen support, non-invasive or invasive mechanical ventilation, acute respiratory failure or rapid deterioration of gas exchange, appearance or worsening of bilateral alveolar-interstitial infiltrates at the radiological level. In case of indication, it is recommended: dexamethasone 6mg/d p.o. or iv for 10 days or methylprednisolone 32mg/d orally or 30mg iv for 10 days or prednisone 40mg day p.o. for 10 days.

MAIN OUTCOMES

Phase 1 part: to describe the toxicity profile of baricitinib in COVID19 oncological patients during the 5-7 day treatment period and until day +14 or discharge (whichever it comes first). Phase 2 part: to describe the number of patients in the experimental arm that will not require mechanical oxygen support compared to the standard of care arm until day +14 or discharge (whichever it comes first).

RANDOMISATION

For the phase 2 of the study, the allocation ratio will be 1:1. Randomization process will be carried out electronically through the REDcap platform ( https://www.project-redcap.org/ ) BLINDING (MASKING): This is an open label study. No blinding will be performed.

NUMBERS TO BE RANDOMISED (SAMPLE SIZE)

The first part of the study (safety run-in cohort) will consist in the enrollment of 6 to 12 patients. In this population, we will test the toxicity of the experimental treatment. An incidence of severe adverse events grade 3-4 (graded by Common Terminology Criteria for Adverse Events v.5.0) inferior than 33% will be considered sufficient to follow with the next part of the study. The second part of the study we will perform an interim analysis of efficacy at first 64 assessed patients and a definitive one will analyze 128 assessed patients. Interim and definitive tests will be performed considering in both cases an alpha error of 0.05. We consider for the control arm this rate is expected to be 0.60 and for the experimental arm of 0.80. Considering this data, a superiority test to prove a difference of 0.20 with an overall alpha error of 0.10 and a beta error of 0.2 will be performed. Considering a 5% of dropout rate, it is expected that a total of 136 patients, 68 for each study arm, will be required to complete study accrual.

TRIAL STATUS

Version 5.0. 14^th October 2020 Recruitment started on the 16^th of December 2020. Expected end of recruitment is June 2021.

TRIAL REGISTRATION

AEMPs: 20-0356 EudraCT: 2020-001789-12, https://www.clinicaltrialsregister.eu/ctr-search/search (Not publically available as Phase I trial) Clinical trials: BARCOVID19, https://www.clinicaltrials.gov/ (In progress) FULL PROTOCOL: The full protocol is attached as an additional file, accessible from the Trials website (Additional file 1). In the interest in expediting dissemination of this material, the familiar formatting has been eliminated; this Letter serves as a summary of the key elements of the full protocol."

Pharmacological inhibition of syntenin PDZ2 domain impairs breast cancer cell activities and exosome loading with syndecan and EpCAM cargo

Exosomes support cell-to-cell communication in physiology and disease, including cancer. We currently lack tools, such as small chemicals, capable of modifying exosome composition and activity in a specific manner. Building on our previous understanding of how syntenin, and its PDZ partner syndecan (SDC), impact on exosome composition we optimized a small chemical compound targeting the PDZ2 domain of syntenin. In vitro , in tests on MCF-7 breast carcinoma cells, this compound is non-toxic and impairs cell proliferation, migration and primary sphere formation. It does not affect the size or the number of secreted particles, yet it decreases the amounts of exosomal syntenin, ALIX and SDC4 while leaving other exosomal markers unaffected. Interestingly, it also blocks the sorting of EpCAM, a bona fide target used for carcinoma exosome immunocapture. Our study highlights the first characterization of a small pharmacological inhibitor of the syntenin-exosomal pathway, of potential interest for exosome research and oncology.

Emergency biventricular assist device implantation in a patient with suspected COVID-19 disease

Severe coronavirus disease 2019 (COVID-19) is a multisystem inflammatory disorder and knowledge and experience with severe acute respiratory failure in infected patients has grown considerably since reports of the first few cases. Little is known about the effect of the severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) virus on the heart, and it has been suggested that fulminant cardiac failure, with or without respiratory failure, may occur several weeks following infection. A young man presented after a recent viral illness. He was in severe cardiogenic shock and was implanted with an emergency biventricular assist device, which also incorporated an extracorporeal membrane oxygenator. He stabilised soon after and, despite an intracerebral haemorrhage which resolved and bleeding into the trachea following percutaneous tracheostomy, he survived to explant and was successfully stepped down to a rehabilitation unit on postoperative day 50. He tested positive for SARS-CoV-2 antibodies when the test became available on postoperative day 33. We envisage there will be many more such presentations of acute COVID-19-associated cardiogenic shock and we recommend clinicians consider this diagnosis when presented with an acutely unwell patient with an unclear diagnosis following a viral illness. These patients should be discussed as early as possible with a transplant/mechanical circulatory support team.

Acute-phase protein α-1-acid glycoprotein is negatively associated with feed intake in postpartum dairy cows

α-1-Acid glycoprotein (AGP) is an acute-phase protein that may suppress dry matter intake (DMI), potentially by acting on the leptin receptor in the hypothalamus. Our objectives were to characterize plasma AGP concentration and associations with DMI during the transition period, and to determine the utility of AGP to identify or predict cows with low DMI. Plasma samples (n = 2,086) from 434 Holstein cows in 6 studies were analyzed on d -21, -13 ± 2, -3, 1, 3, 7 ± 1, 14 ± 1, and 21 ± 1 relative to parturition. A commercially available ELISA kit specific for bovine AGP was validated, and 2 internal controls were analyzed on each plate with interplate variation of 15.0 and 17.3%, respectively. Bivariate analysis was used to assess the relationship between AGP and DMI. For significant associations, treatment(study) was added to the model, and quadratic associations were included in the model if significant. Plasma AGP concentration (±SEM) increased from 213 ± 37.3 μg/mL on d -3 to 445 ± 60.0 μg/mL on d 14. On d 3, AGP was associated negatively with DMI in a quadratic manner for wk 1 and wk 2 and linearly for wk 3. Day 7 AGP was associated negatively with DMI in a quadratic manner for wk 2 and linearly for wk 3. Similarly, d 14 AGP was negatively associated with DMI for wk 3 and wk 4. As d 3 AGP concentration increased over the interquartile range, a calculated 1.4 (8.5%), 0.5 (2.7%), and 0.4 (1.9%) kg/d reduction in predicted DMI was detected during wk 1, 2, and 3, respectively. Using bivariate analysis, d 3 AGP explained 10% of the variation in DMI during wk 1. We explored the clinical utility of d 3 AGP to diagnose low DMI, defined as wk 1 DMI >1 standard deviation below the mean. Receiver operating characteristic analysis identified a threshold of 480.9 μg/mL, providing 76% specificity and 48% sensitivity (area under the curve = 0.60). Limited associations occurred between AGP and blood biomarkers; however, AGP was associated with plasma haptoglobin concentration postpartum and incidence of displaced abomasum, retained placenta, and metritis. These results demonstrate a negative association between plasma AGP concentration and DMI in early-postpartum dairy cows, although its diagnostic performance was marginal. Further investigation into whether AGP directly suppresses DMI in dairy cattle is warranted.

Factors that influence the response time in STEMI patients in Lisbon 2017

The success of the ST-segment elevation myocardial infarction (STEMI) approach is based on early diagnosis and on the institution of timely reperfusion therapy, with response times remaining variable. The objective of this study was to determine which factors influenced the response time to patients with STEMI until the treatment with coronary reperfusion from the prehospital service or the emergency room in three hospitals in the greater Lisbon area in 2017. An epidemiological, cross-sectional, retrospective, descriptive study with an analytical component was performed, with data from the National Institute of Medical Emergency (INEM) and clinical trials of patients. Patients who were not referred to these hospitals were excluded. Univariate statistical analysis was performed, as well as c2 tests, t-student and logistic regression model (r &lt; 0.05). The population included 95 patients, the majority being male (67.4%), and with a mean age of 63.8 years. 61.1% were hypertensive and the majority (87.4%) had no signs of previous heart failure. The mean door-to-balloon time was 159 minutes, with 57.4% showing time greater than 120 minutes. In patients in whom the INEM Coronary Greenway was activated, mean door-to-balloon time was 99 minutes. Diagnostic, symptom-admission and transport times showed a statistically significant association with the door-to-balloon time in the bivariate analysis. The times are fulfilled in the prehospital service, but in the hospital, services can be improved through the early accomplishment of electrocardiogram and the optimization of interhospital transport.

Key messages

Reducing ECG time and inter-hospital transport time improves STEMI response and outcome. Time is muscle is the main message for de concern of identifying influence factors of STEMI response time.

New perspectives on PPAR, VDR and FXRα as new actors in testicular pathophysiology

The incidence of reproductive disorders is constantly increasing and affects 15% of couples, with male's abnormalities diagnosed in almost half of the cases. The male gonads exert two major functions of the testis with the productions of gametes (exocrine function) and of sexual hormones (endocrine function). In the last decades, next to steroid receptors such as estrogen and androgen receptors, the involvement of other members of the nuclear receptor superfamily have been described such as Steroidogenic factor-1 (SF-1), Nerve growth factor IB (NGFIB), Liver-X-Receptorα (LXRα) and Dosage-sensitive sex reversal, adrenal hypoplasia critical region, on chromosome X, gene 1 (DAX-1). The purpose of this review is to highlight the emerging roles of some members of the nuclear receptor superfamily among which the vitamin-D Receptor (VDR), Peroxisome Proliferator-Activated Receptor (PPAR), Farnesoid-X-Receptor-α (FXRα). We discuss how these receptors could participate to explain male fertility disorders; and their potential to be use as biomarkers or therapeutic targets for management of fertility disorders.

The Educational Placement of Visually Impaired Children

The purpose of this study was to examine the educational placement of visually impaired children and related factors that might be helpful in the development of placement procedures for day school programs. The widespread acceptance of multiply handicapped children in day school programs appears to be affecting educational placement and related factors.

Health resource utilization of labor induction versus expectant management

BACKGROUND

Although induction of labor of low-risk nulliparous women at 39 weeks reduces the risk of cesarean delivery compared with expectant management, concern regarding more frequent use of labor induction remains, given that this intervention historically has been thought to incur greater resource utilization.

OBJECTIVE

The objective of the study was to determine whether planned elective labor induction at 39 weeks among low-risk nulliparous women, compared with expectant management, was associated with differences in health care resource utilization from the time of randomization through 8 weeks postpartum.

STUDY DESIGN

This is a planned secondary analysis of a multicenter randomized trial in which low-risk nulliparous women were assigned to induction of labor at 39 weeks or expectant management. We assessed resource utilization after randomization in 3 time periods: antepartum, delivery admission, and discharge through 8 weeks postpartum.

RESULTS

Of 6096 women with data available, those in the induction of labor group (n = 3059) were significantly less likely in the antepartum period after randomization to have at least 1 ambulatory visit for routine prenatal care (32.4% vs 68.4%), unanticipated care (0.5% vs 2.6%), or urgent care (16.2% vs 44.3%), or at least 1 antepartum hospitalization (0.8% vs 2.2%, P < .001 for all). They also had fewer tests (eg, sonograms, blood tests) and treatments (eg, antibiotics, intravenous hydration) prior to delivery. During the delivery admission, women in the induction of labor group spent a longer time in labor and delivery (median, 0.83 vs 0.57 days), but both women (P = .002) and their neonates (P < .001) had shorter postpartum stays. Women and neonates in both groups had similar frequencies of postpartum urgent care and hospital readmissions (P > .05 for all).

CONCLUSION

Women randomized to induction of labor had longer durations in labor and delivery but significantly fewer antepartum visits, tests, and treatments and shorter maternal and neonatal hospital durations after delivery. These results demonstrate that the health outcome advantages associated with induction of labor are gained without incurring uniformly greater health care resource use.