Perpetuating Myths, Fables, and Fairy Tales: A Half Century of Electronic Fetal Monitoring

Electronic fetal monitoring (EFM) entered clinical medical practice at the same time bioethics became reality. Bioethics changed the medical ethics landscape by replacing the traditional Hippocratic benign paternalism with patient autonomy, informed consent, beneficence, and nonmaleficence. But EFM use represents the polar opposite of bioethics' revered principles-it has been documented for half a century to be completely ineffectual, used without informed consent, and harmful to mothers and newborns alike. Despite EFM's ethical misuse, there has been no outcry from the bioethical world. Why? This article answers that question, discussing EFM's history and the reasons it was issued an ethics pass. And it explores the reason that even today mothers are still treated with blatant medical paternalism, deprived of autonomy and informed consent, and subjected to real medical risks under the guise that EFM is an essential safety device when in fact it is used almost solely to protect physicians and hospitals from cerebral palsy lawsuits.

Neonatal encephalopathy 2015: opportunity lost and words unspoken

The Task Force Study on Neonatal Encephalopathy Second Edition 2014 failed to address Electronic Fetal Monitoring (EFM) and its forty years of clinical futility, failed to condemn EFM's continued use against physicians in the world's courtrooms and ignored the ethical breaches EFM's use compels physicians to commit daily. This article considers why these critical points were overlooked and asks why the Task Force recommended continued EFM use for all women in labor while simultaneously acknowledging EFM's impotency. This paradox is explored among the background of trial lawyers' involvement in cerebral palsy and the failure of birth-related professional organizations to recognize that the Daubert doctrine may be used to exclude EFM junk science from the world's courtrooms.

Cerebral palsy litigation: change course or abandon ship

The cardinal driver of cerebral palsy litigation is electronic fetal monitoring, which has continued unabated for 40 years. Electronic fetal monitoring, however, is based on 19th-century childbirth myths, a virtually nonexistent scientific foundation, and has a false positive rate exceeding 99%. It has not affected the incidence of cerebral palsy. Electronic fetal monitoring has, however, increased the cesarian section rate, with the expected increase in mortality and morbidity risks to mothers and babies alike. This article explains why electronic fetal monitoring remains endorsed as efficacious in the worlds' labor rooms and courtrooms despite being such a feeble medical modality. It also reviews the reasons professional organizations have failed to condemn the use of electronic fetal monitoring in courtrooms. The failures of tort reform, special cerebral palsy courts, and damage limits to stem the escalating litigation are discussed. Finally, the authors propose using a currently available evidence rule-the Daubert doctrine that excludes "junk science" from the courtroom-as the beginning of the end to cerebral palsy litigation and electronic fetal monitoring's 40-year masquerade as science.

Chest radiography for active tuberculosis case finding in the homeless: a systematic review and meta-analysis

SETTING

In low-incidence regions, tuberculosis (TB) often affects vulnerable populations. Guidelines recommend active case finding (ACF) in homeless populations, but there is no consensus on a preferred screening method.

OBJECTIVE

We performed a systematic review and meta-analysis to evaluate the use of chest X-ray (CXR) screening in ACF for TB in homeless populations.

DESIGN

Articles were identified through EMBASE, Medline and the Cochrane Library. Studies using symptom screens, CXRs, sputum sweeps, tuberculin skin tests and/or interferon-gamma release assays to detect active TB in homeless populations were sought. Data were extracted using a standardised method by two reviewers and validated with an objective tool.

RESULTS

Sixteen studies addressing CXR screening of homeless populations for active TB in low-incidence regions were analysed. The pooled prevalence of active TB in the 16 study cohorts was 931 per 100 000 population screened (95%CI 565-1534) and 782/100 000 CXR performed (95%CI 566-1079). Six of seven longitudinal screening programs reported a reduction in regional TB incidence after implementation of the CXR-based ACF programme.

CONCLUSION

Our data suggest that CXR screening is a good tool for ACF in homeless populations in low-incidence regions.

Visual information processing from multiple displays

OBJECTIVE

In this study, we examined how effectively people can monitor new stimuli on a peripheral display while carrying out judgments on an adjacent central display.

BACKGROUND

Improved situation awareness is critical for improved operator performance in aviation and many other domains. Given the limited extent of foveal processing, acquiring additional information from peripheral vision offers high potential gains.

METHOD

Participants carried out a sequence of central perceptual judgments while simultaneously monitoring the periphery for new stimuli. Peripheral detection was measured as a function of central-judgment difficulty, the relative timing of the two tasks, and peripheral event rate.

RESULTS

Participants accurately detected and located peripheral targets, even at the highest eccentricity explored here (~30°). Peripheral detection was not reduced by increased central-task difficulty but was reduced when peripheral targets arrived later in the processing of central stimuli and when peripheral events were relatively rare.

CONCLUSION

Under favorable conditions-high-contrast stimuli and high event rate-people can successfully monitor peripheral displays for new events while carrying out an unrelated continuous task on an adjacent display.

APPLICATION

In many fields, such as aviation, existing displays were designed with low-contrast stimuli that provide little opportunity for peripheral vision. With appropriate redesign, operators might successfully monitor multiple displays over a large visual field. Designers need to be aware of nonvisual factors, such as low event rate and relative event timing, that can lead to failures to detect peripheral stimuli.

Treatment outcomes from community-based drug resistant tuberculosis treatment programs: a systematic review and meta-analysis

BACKGROUND

There is increasing evidence that community-based treatment of drug resistant tuberculosis (DRTB) is a feasible and cost-effective alternative to centralized, hospital-based care. Although several large programs have reported favourable outcomes from community-based treatment, to date there has been no systematic assessment of community-based DRTB treatment program outcomes. The objective of this study was to synthesize available evidence on treatment outcomes from community based multi-drug resistant (MDRTB) and extensively drug resistant tuberculosis (XDRTB) treatment programs.

METHODS

We performed a systematic review and meta-analysis of the published literature to examine treatment outcomes from community-based MDRTB and XDRTB treatment programs. Studies reporting outcomes from programs using community-based treatment strategies and reporting outcomes consistent with WHO guidelines were included for analysis. Treatment outcomes, including treatment success, default, failure, and death were pooled for analysis. Meta-regression was performed to examine for associations between treatment outcomes and program or patient factors.

RESULTS

Overall 10 studies reporting outcomes on 1288 DRTB patients were included for analysis. Of this population, 65% [95% CI 59-71%] of patients had a successful outcome, 15% [95% CI 12-19%] defaulted, 13% [95% CI 9-18%] died, and 6% [95% CI 3-11%] failed treatment for a total of 35% [95% CI 29-41%] with unsuccessful treatment outcome. Meta-regression failed to identify any factors associated with treatment success, including study year, age of participants, HIV prevalence, XDRTB prevalence, treatment regimen, directly observed therapy (DOT) location or DOT provider.

CONCLUSIONS

Outcomes of community-based MDRTB and XDRTB treatment outcomes appear similar to overall treatment outcomes published in three systematic reviews on MDRTB therapy. Work is needed to delineate program characteristics associated with improved treatment outcomes.

Tuberculosis in HIV-infected persons in British Columbia during the HAART era

OBJECTIVE

Prior to the introduction of highly active antiretroviral therapy (HAART), active tuberculosis (TB) was a major contributor to HIV-related morbidity and mortality in Canada and other low-incidence regions. We performed this study to examine TB incidence, clinical manifestations and screening uptake in HIV-infected TB patients during the era of HAART therapy.

METHODS

We performed a retrospective study on all HIV-infected TB patients in British Columbia over a 10-year period (2003-2012). Demographic and clinical characteristics were extracted along with screening and treatment outcomes. Trends in provincial TB incidence, HIV testing and HAART prevalence were also examined.

RESULTS

In total, 2,839 TB cases were identified in BC during this period, including 129 HIV-infected TB patients. Surprisingly, only 64 HIV-infected TB patients (50%) had a documented screening tuberculin skin test (TST) prior to TB diagnosis. Of the 39 HIV-infected TB patients with prior TST positivity, 38 (97.4%) had not completed a course of isoniazid preventive therapy. TB incidence decreased significantly in the HIV-infected population of BC over the study period, from 1.9 to 0.5 TB cases per 1,000 HIV-infected individuals (p<0.001).

CONCLUSION

The incidence of HIV-TB decreased significantly over the past decade despite suboptimal latent TB infection screening and prevention practices. This decrease in TB incidence is likely attributable to the increased uptake of HAART. Consideration should be given to intensifying prevention efforts to accelerate TB elimination in HIV-infected populations in low-incidence regions.

Neuroimaging of Ethiopian patients with epilepsy: a retrospective review

BACKGROUND

Epilepsy is arguably the most common neurological condition encountered by neurologists in Africa. Neuroimaging (CT and MRI) represents the most important recent contribution to the diagnosis, classification and management of the patient with epilepsy.

OBJECTIVE

To describe the role of neuroimaging in the evaluation of Ethiopian patients with epilepsy, by identifying intracranial pathology, and formulating syndromic and etiological diagnoses.

METHODS

We performed a retrospective review of neuroimaging in 181 patients with epilepsy presenting to a specialized referral hospital (Addis Ababa University Tikur Anbessa Teaching Hospital) and a private clinic (Yehuleshet Higher Clinic) in Addis Ababa, Ethiopia between September 2008 and August 2010. Each patient had an interictal EEG recording.

RESULTS

Neuroimaging demonstrated abnormal intracranial structural lesions in 65 of 181 or 35.9% of epileptic patients (31% with CT; 38% with MRI). Brain lesions were single in 28 (42.8%) and multiple in 23 (35.4%) patients. The lesions were lateralized in 35 patients (53.8%), with 23 (35.4%) on the left add 12 (18.5%) on the right. Twenty seven (41.5%) of these lesions originated in or involved the temporal or frontal lobes. Over one third of the lesions were lobar equally divided among temporal, frontal and parietal regions. The imaging findings demonstrated intracranial space occupying lesions (ICSOL) in 17 (9.4%) patients (with 64.7% brain tumors), cerebral infarctions in 15 (8.3%), cortical atrophy in 9 (5.0%), and gliosis in 7(3.9%). The interictal EEG recordings revealed epileptiform abnormalities in 60/181 patients (33.1%).

CONCLUSION

Neuroimaging detected intracranial pathology in more than one third of Ethiopian patients with epilepsy. A significant proportion of the cases demonstrated focal epileptiform discharges and non-epileptiform features with abnormal intracranial pathologies. Further prospective neuroimaging studies are recommended. Brain scan and EEG did help in the diagnosis, classification and treatment of epileptics.

Genomic analysis identifies targets of convergent positive selection in drug-resistant Mycobacterium tuberculosis

M. tuberculosis is evolving antibiotic resistance, threatening attempts at tuberculosis epidemic control. Mechanisms of resistance, including genetic changes favored by selection in resistant isolates, are incompletely understood. Using 116 newly sequenced and 7 previously sequenced M. tuberculosis whole genomes, we identified genome-wide signatures of positive selection specific to the 47 drug-resistant strains. By searching for convergent evolution--the independent fixation of mutations in the same nucleotide position or gene--we recovered 100% of a set of known resistance markers. We also found evidence of positive selection in an additional 39 genomic regions in resistant isolates. These regions encode components in cell wall biosynthesis, transcriptional regulation and DNA repair pathways. Mutations in these regions could directly confer resistance or compensate for fitness costs associated with resistance. Functional genetic analysis of mutations in one gene, ponA1, demonstrated an in vitro growth advantage in the presence of the drug rifampicin.

Mycobacterium tuberculosis mutation rate estimates from different lineages predict substantial differences in the emergence of drug-resistant tuberculosis

A critical question in tuberculosis control is why some strains of Mycobacterium tuberculosis are preferentially associated with multiple drug resistances. We demonstrate that M. tuberculosis strains from Lineage 2 (East Asian lineage and Beijing sublineage) acquire drug resistances in vitro more rapidly than M. tuberculosis strains from Lineage 4 (Euro-American lineage) and that this higher rate can be attributed to a higher mutation rate. Moreover, the in vitro mutation rate correlates well with the bacterial mutation rate in humans as determined by whole genome sequencing of clinical isolates. Finally, using a stochastic mathematical model, we demonstrate that the observed differences in mutation rate predict a substantially higher probability that patients infected with a drug susceptible Lineage 2 strain will harbor multidrug resistant bacteria at the time of diagnosis. These data suggest that interventions to prevent the emergence of drug resistant tuberculosis should target bacterial as well as treatment-related risk factors.

The expert witness in medical malpractice litigation: through the looking glass

Neurologists have professional, ethical, and social obligations to ensure that expert witness testimony is reliable, objective, and truthful. In the past, an absence of professional regulatory oversight combined with immunity from civil litigation allowed the partisan expert to flourish. This is no longer the case. The expert witness unquestionably faces an increasingly perilous liability climate, and must be cognizant of the legal rules and procedures. The authors provide guidelines with risk management strategies for the neurologist serving as an expert witness.

Syphilitic aortic aneurysm with spastic paraparesis: a novel presentation and review of the literature

Syphilitic aortic aneurismal erosion into the vertebral column with associated neurological dysfunction is extraordinarily rare, and the very few reported cases typically involve the descending aorta. We describe the novel presentation of a 55 year old man with a syphilitic aneurysm of the ascending aorta and arch causing spinal erosion with spastic paraparesis. Clinicians must remain cognizant that the resurgence of primary and secondary syphilis, exacerbated by the unrelenting HIV-AIDS epidemic, portends an increasing incidence of tertiary manifestations such as aortic aneurysm formation with its myriad complications including compressive myelopathy.

A randomised controlled trial of ribavirin in Crimean Congo haemorrhagic fever: ethical considerations

The randomised controlled trial (RCT) constitutes a quantitative, comparative, controlled study of a particular treatment, and provides invaluable evidence regarding its pharmacotherapeutic efficacy. These studies are generally predicated upon the ethical principle of clinical equipoise. However, this may be insufficient to justify withholding treatment from a control group while assessing drug therapy in a potentially fatal disease. Thus, the criteria for randomisation, informed consent methodology and timing, and consideration of treatment options in such a scenario remain the province of medical ethics. This paper addresses the need for an RCT of ribavirin in the treatment of Crimean Congo haemorrhagic fever, and highlights underlying ethical concerns in light of the current medical, virological and ethical literature.

Attentional limits in memory retrieval-revisited

Carrier and Pashler (1995) concluded-based on locus-of-slack dual-task methodology-that memory retrieval was subject to a central bottleneck. However, this conclusion conflicts with evidence from other lines of research suggesting that memory retrieval proceeds autonomously, in parallel with many other mental processes. In the present experiments we explored the possibility that Carrier and Pashler's conclusions were distorted by use of an experimental method unfavorable to parallel memory retrieval. New locus-of-slack experiments were performed that encouraged parallel memory retrieval strategies with instructions and feedback, along with the use of "preferred" stimulus-response modality mappings. Results from two psychological refractory period experiments showed that the effect of Task 2 recognition difficulty was consistently absorbed into cognitive slack, with both word and picture recognition. We conclude that the memory retrieval stage of recognition tasks can proceed in parallel with central operations of another task, at least under favorable conditions. Our new findings bring results from dual-task locus-of-slack methodology into agreement with other evidence that memory retrieval is not subject to severe, generic central resource limitations.

Septic elbow in the setting of neuropathic joint as the initial presentation of a cervical syrinx

Neuropathic arthropathy, or Charcot's joint, is a degenerative disorder resulting from abnormal sensory innervation that is associated with diabetes mellitus, tabes dorsalis, and syringomyelia. Patients may present with a painless instability of the affected joint, although a range of symptoms are seen. This article presents a case of a patient who presented with a swollen elbow, consistent with septic arthritis, and bilateral lower extremity weakness. Joint fluid cultures were positive for methicillin-resistant Staphylococcus aureus. Extensive joint destruction on radiographic imaging and a thorough neurologic examination revealing generalized weakness and upper motor neuron signs prompted magnetic resonance imaging (MRI) of the spine which revealed a cervical syrinx. Our patient was diagnosed with syringomyelia-associated neuropathic arthropathy that initially presented as a septic joint. In the setting of septic arthritis, substantial joint destruction (particularly in a patient with neurologic deficits) should prompt additional investigation, including MRI of the spine, for neurologic causes. Although surgery is generally not recommended for neuropathic arthropathy because of poor healing and high rates of complication, neuropathic arthropathy in the setting of a septic joint requires operative irrigation and debridement.

Whole-genome sequencing and social-network analysis of a tuberculosis outbreak

BACKGROUND

An outbreak of tuberculosis occurred over a 3-year period in a medium-size community in British Columbia, Canada. The results of mycobacterial interspersed repetitive unit-variable-number tandem-repeat (MIRU-VNTR) genotyping suggested the outbreak was clonal. Traditional contact tracing did not identify a source. We used whole-genome sequencing and social-network analysis in an effort to describe the outbreak dynamics at a higher resolution.

METHODS

We sequenced the complete genomes of 32 Mycobacterium tuberculosis outbreak isolates and 4 historical isolates (from the same region but sampled before the outbreak) with matching genotypes, using short-read sequencing. Epidemiologic and genomic data were overlaid on a social network constructed by means of interviews with patients to determine the origins and transmission dynamics of the outbreak.

RESULTS

Whole-genome data revealed two genetically distinct lineages of M. tuberculosis with identical MIRU-VNTR genotypes, suggesting two concomitant outbreaks. Integration of social-network and phylogenetic analyses revealed several transmission events, including those involving "superspreaders." Both lineages descended from a common ancestor and had been detected in the community before the outbreak, suggesting a social, rather than genetic, trigger. Further epidemiologic investigation revealed that the onset of the outbreak coincided with a recorded increase in crack cocaine use in the community.

CONCLUSIONS

Through integration of large-scale bacterial whole-genome sequencing and social-network analysis, we show that a socioenvironmental factor--most likely increased crack cocaine use--triggered the simultaneous expansion of two extant lineages of M. tuberculosis that was sustained by key members of a high-risk social network. Genotyping and contact tracing alone did not capture the true dynamics of the outbreak. (Funded by Genome British Columbia and others.).

Bilaterally symmetric cervical spondylotic amyotrophy: a novel presentation and review of the literature

BACKGROUND

Cervical spondylotic amyotrophy (CSA) is considered a syndrome of (1) unilateral upper extremity weakness and atrophy, (2) affecting either the proximal or distal musculature, (3) without sensory impairment or lower extremity dysfunction.

AIMS OF STUDY

The authors report a novel case of bilaterally symmetric CSA with blurring of the proximal-distal distinction, discuss the pathophysiology, and review the literature.

METHODS

A 45 year old man presented with a several year history of insidiously progressive bilaterally symmetric upper extremity weakness and wasting, profound in the proximal musculature and moderate to severe in the distal muscle groups.

RESULTS

Based on the clinical, neuroimaging and electrodiagnostic features, this patient harbors a more severe phenotype of the classical syndrome.

CONCLUSION

The authors propose expanding the generally accepted definition of CSA to include this bilaterally symmetric form of disease, thereby minimizing diagnostic error or delay. Additionally, based on this case and a review of the literature, adherence to the proximal-distal distinction should be avoided since it is commonly blurred. Accurate diagnosis is crucial since this presentation mimics the motor neuron disease variant Vulpian-Bernhardt syndrome. The importance of early diagnosis is underscored by reports of significant improvement with timely surgical decompression.