Proposed cutoff for fetal scalp blood lactate in intrapartum fetal surveillance based on neonatal outcomes: a large prospective observational study

OBJECTIVE

Determination of lactate in fetal scalp blood (FBS) during labour has been recognised since the 1970s. The internationally accepted cutoff of >4.8 mmol/l indicating fetal acidosis is exclusive for the point-of-care device (POC) LactatePro™, which is no longer in production. The aim of this study was to establish a new cutoff for scalp lactate based on neonatal outcomes with the use of the StatstripLactate^® /StatstripXpress^® Lactate system, the only POC designed for hospital use.

DESIGN

Observational study.

SETTING

January 2016 to March 2020 labouring women with indication for FBS were prospectively included from seven Swedish and one Australian delivery unit.

POPULATION

Inclusion criteria: singleton pregnancy, vertex presentation, ≥35⁺⁰  weeks of gestation.

METHOD

Based on the optimal correlation between FBS lactate and cord pH/lactate, only cases with ≤25 minutes from FBS to delivery were included in the final calculations.

MAIN OUTCOME MEASURES

Metabolic acidosis in cord blood defined as pH <7.05 plus BD_ecf >10 mmol/l and/or lactate >10 mmol/l.

RESULTS

A total of 3334 women were enrolled of whom 799 were delivered within 25 minutes. The areas under the receiver operating characteristics curves (AUC) and corresponding optimal cutoff values were as follows; metabolic acidosis AUC 0.87 (95% CI 0.77-0.97), cutoff 5.7 mmol/l; pH <7.0 AUC 0.83 (95% CI 0.68-0.97), cutoff 4.6 mmol/l; pH <7.05 plus BD_ecf ≥12 mmol/l AUC 0.97 (95% CI 0.92-1), cutoff 5.8 mmol/l; Apgar score <7 at 5 minutes AUC 0.74 (95% CI 0.63-0.86), cutoff 5.2 mmol/l; and pH <7.10 plus composite neonatal outcome AUC 0.76 (95% CI 0.67-0.85), cutoff 4.8 mmol/l.

CONCLUSION

A scalp lactate level <5.2 mmol/l using the StatstripLactate^® /StatstripXpress^® system will safely rule out fetal metabolic acidosis.

TWEETABLE ABSTRACT

Scalp blood lactate <5.2 mmol/l using the StatstripLactate^® /StatstripXpress system has an excellent ability to rule out fetal acidosis.

Factors Associated with Extraction following Root Canal Filling in Adults

Essentially, root fillings are performed to preserve natural teeth. Over time, however, some root-filled teeth will inevitably be extracted. The aim of this historical prospective cohort study in the adult Swedish population was to identify factors associated with extractions within 5 y of registration of a root filling. The cohort consisted of all those whose root fillings had been reported to the tax-funded Swedish Social Insurance Agency (SSIA) in 2009. Demographic data on the individuals registered with a root filling (sex, age, country of birth, disposable income, educational level, and marital status) were received from Statistics Sweden or the SSIA. Dental care setting, tooth type, and any registration of subsequent restorations within 6 mo were received from the SSIA. Multivariable regression analysis was used, and P < 0.05 was considered statistically significant. In total, 216,764 individuals had been registered with at least 1 root filling. Individuals (n = 824) without complete data were excluded from the analyses. After 5 y, 9.3% of the root-filled teeth had been registered as extracted. Logistic regression analysis found significant associations for all variables except country of birth, disposable income, and educational level. The highest odds ratios for extractions were associated with the type of restoration: teeth with no registration of any restoration and teeth with a direct restoration combined with a post were 3 times more likely to undergo extraction than teeth restored with an indirect restoration combined with a post and core. Overall, high odds ratios for extractions were associated with any type of composite restoration, including composite fillings and crowns combined with or without any post. In summary, after root filling in the Swedish adult population, several individual- and tooth-specific variables were associated with extraction. The reasons for the extractions remain to be studied further.

Is low-level HIV-1 viraemia associated with elevated levels of markers of immune activation, coagulation and cardiovascular disease?

OBJECTIVES

The clinical significance of low-level viraemia (LLV) during antiretroviral therapy (ART) is debated. We retrospectively investigated longitudinal levels of plasma markers associated with inflammation, altered coagulation and cardiovascular disease in Swedish HIV-positive adults in relation to LLV or permanent virological suppression during long-term ART.

METHODS

Plasma levels of C-reactive protein (CRP), D-dimer, vascular cell adhesion molecule 1 (VCAM-1), suppression of tumorigenicity 2 (ST2), growth differentiation factor 15 (GDF-15), soluble CD14 (sCD14), soluble CD163 (sCD163), interferon-γ-induced protein 10 (IP-10) and β-2-microglobulin were measured in 34 individuals with LLV (viral load 50-999 HIV-1 RNA copies/mL) and in matched controls with persistent virological suppression. Biomarker levels were analysed in samples obtained during episodes of LLV and follow-up samples obtained 1 year later (with similar timing for controls). All biomarkers were analysed using an independent sample t-test and analysis of covariance (ANCOVA) after logarithmic transformation. Log-rank analysis was applied for markers with concentration values out of range.

RESULTS

Compared with controls, patients with LLV had significantly higher levels of GDF-15 [geometric mean 3416 (95% confidence interval (CI) 804-14 516) pg/mL versus 2002 (95% CI 355-11 295) pg/mL in controls; P = 0.026] and D-dimer [mean 1114 (95% CI 125-9917) ng/mL versus 756 (95% CI 157-3626) ng/mL; P = 0.038] after adjustment for age, CD4 count nadir and type of ART. In the unadjusted t-test, only GDF-15 was significantly higher and in the log-rank test, both GDF-15 and D-dimer were significantly elevated. No significant differences were observed for the other biomarkers analysed.

CONCLUSIONS

Although levels of inflammation markers were similar in ART recipients with and without LLV, persons with LLV had significantly higher levels of GDF-15 and D-dimer. These findings suggest a potential link between LLV and cardiovascular outcomes.

Comparative analysis of general dental practitioners' fees and scheduled fees for root canal treatment and coronal restorations in the adult population of Sweden: a 5-year follow-up of data from the Swedish Dental Register

AIM

To investigate the fees charged by Swedish dentists for root fillings, coronal restorations and further dental interventions during a follow-up period of 5-6 years.

METHODOLOGY

A total of 248 299 root fillings were linked with the tooth, the patient and the provider and entered into the Swedish Social Insurance Agency register in 2009. The data register also recorded the subsidy-based (scheduled) fee and the fee actually charged for the root fillings. Fees charged for direct or indirect coronal restorations and additional interventions during the follow-up period were also recorded. One-way anova and t-test were used for statistical analysis.

RESULTS

The mean overall fee charged for a root filling was approximately 332 Euro and differed only marginally (13 Euro) from the scheduled fee. The total mean fee for preservation of a root filled tooth was 717 Euro, which included the root canal treatment, the coronal restoration and any additional interventions during the follow-up period. The fees for indirectly restored root filled teeth were significantly higher (1105 Euro) than for directly restored teeth (610 Euro), despite further additional treatment (P < 0.001). The mean fee for teeth which were subsequently extracted was higher (769 Euro) than for the retained teeth (711 Euro) (P < 0.001).

CONCLUSIONS

Fees charged by Swedish dentists for root canal treatment were in accordance with the scheduled fees. The overall mean fee was significantly higher for root filled teeth with indirect restorations than for teeth with direct coronal restorations. However, prospective clinical cost-effectiveness studies are needed to analyse the total costs.

Assessment of Cesarean hysterotomy scar in non-pregnant women: reliability of transvaginal sonography with and without contrast enhancement

OBJECTIVES

To determine intra- and interobserver reliability of evaluating the appearance and measurement of Cesarean hysterotomy scars using transvaginal ultrasound (TVS), with and without saline contrast sonohysterography (SCSH), in non-pregnant women.

METHODS

Fifty-six women with one previous Cesarean delivery were examined by TVS, with and without contrast enhancement, 6-9 months after the Cesarean delivery. Two observers, blinded to their own and each other's measurements, evaluated the appearance of the hysterotomy scar and measured the myometrial thickness adjacent to the scar or scar defect (MTS). If a scar defect was noted, the remaining myometrial thickness over the defect (RMT) was measured. A scar defect was defined as large if RMT was ≤ 2.2 mm on conventional TVS and ≤ 2.5 mm when SCSH was performed. Intra- and interobserver reliability of conventional TVS and SCSH were assessed.

RESULTS

Intraobserver reliability was good, with intraclass correlation coefficients (ICCs) of ≥ 0.97 for measurements of MTS and RMT on conventional TVS and SCSH. Interobserver ICCs for measurements obtained on SCSH were 0.85 (95% CI, 0.76-0.91) for MTS and 0.96 (95% CI, 0.93-0.98) for RMT, compared with 0.82 (95% CI, 0.72-0.89) for MTS and 0.87 (95% CI, 0.68-0.95) for RMT measured on conventional TVS. The kappa coefficient for measurements obtained on SCSH was 0.92, compared with 0.85 for conventional TVS. Intermethod ICC was 0.86 (95% CI, 0.78-0.92) for measurement of MTS and 0.89 (95% CI, 0.78-0.95) for measurement of RMT, with a kappa coefficient of 0.57.

CONCLUSIONS

Measurement of RMT using SCSH is a reliable method for assessing Cesarean hysterotomy scars in non-pregnant women and can be used in clinical practice. Copyright © 2015 ISUOG. Published by John Wiley & Sons Ltd.

Analysis of the perceived oral treatment need using Andersen's behavioural model

OBJECTIVES

The aim of this study was to investigate the influence of specific components of Andersen's behavioural model on adult individuals' perceived oral treatment need.

METHODS

A questionnaire was sent to a randomly selected sample of 9,690 individuals, 20 to 89 years old, living in Skåne, Sweden. The 58 questions, some with follow-up questions, were answered by 6,123 individuals; a 63% response rate. Selected for inclusion in the multivariate logistic regression analysis were those questions relating to Andersen's behavioural model, phase five. Responses to "How do you rate your oral treatment need today?" were used as a dependent variable. The 62 questions chosen as independent variables represented the components: individual characteristics, health behaviour and outcomes in the model.

RESULTS

Of the independent variables, 24 were significant at the p< or =0.05 level. Low educational level, previously unmet perceived oral TREATMENT need, frequent visiting pattern, perception of worse oral health than one's peers, an external locus of control, and to have received information from one's dental caregiver about a need for oral treatment were all highly significant (p<0.001) variables correlating with high self-perceived oral treatment need.

CONCLUSION

The Andersen behavioural model can be a useful theoretical tool for the study of perceived oral treatment need.

From children to young adults: cystic fibrosis and siblingship: a longitudinal study

AIM

To compare the results from our previous study in 1994/95 of children with cystic fibrosis (CF) at the age of 6-14 years and their healthy siblings with data from the same participants as young adults in regard to their self-esteem, life satisfaction and attitudes towards the CF siblingship situation.

METHODS

Thirty-seven sibling pairs participated. Three instruments were used: The 'As I see myself' self-evaluation questionnaire; the 'Ladder of life', assessing life satisfaction; and the 'Sibling Mirror', reflecting a person's feelings, when one's sibling or oneself has CF.

RESULTS

Contrary to 1994/95 study results, the female participants showed no signs of impaired self-esteem. Concerning life satisfaction, women in both groups and the men with CF have lower ratings than a healthy reference group. Individuals with CF look upon themselves today as independent, thoughtful and mature, but remember themselves as being active, spoiled or fussy. Healthy siblings consider themselves diplomatic, responsible, mature, important and loyal but remember themselves as angry, envious and neglected.

CONCLUSION

 The self-esteem of women in the sibling pairs (whether with CF or healthy sisters) has improved since their childhood. Overall, the results indicate that young adults with CF today are medically well controlled and psychosocially well adapted, albeit aware of their precarious future.

An algorithm including results of gray-scale and power Doppler ultrasound examination to predict endometrial malignancy in women with postmenopausal bleeding

OBJECTIVE

To determine if power Doppler ultrasound examination of the endometrium can contribute to a correct diagnosis of endometrial malignancy in women with postmenopausal bleeding and endometrium > or = 5 mm.

METHODS

Eighty-three women with postmenopausal bleeding and endometrium > or = 5 mm underwent gray-scale and power Doppler ultrasound examination using predetermined, standardized settings. Suspicion of endometrial malignancy at gray-scale ultrasound examination (endometrial morphology) was noted, and the color content of the endometrium at power Doppler examination was estimated subjectively (endometrial color score). Computer analysis of the most vascularized area of the endometrium was done off-line in a standardized manner. Stepwise multivariate logistic regression analysis was carried out to determine which subjective and objective ultrasound and power Doppler variables satisfied the criteria to be included in a model to calculate the probability of endometrial malignancy.

RESULTS

Endometrial thickness, vascularity index (vascularized area/endometrial area), and use of hormone replacement therapy (HRT) satisfied the criteria to be included in the model used to calculate the 'objective probability of endometrial malignancy'. Endometrial morphology, endometrial color score and HRT use satisfied the criteria to be included in the model to calculate the 'subjective probability of malignancy'. Endometrial thickness > or = 10.5 mm had a sensitivity with regard to endometrial cancer of 0.88 and a specificity of 0.61. At a fixed sensitivity of 0.88, the specificity of the 'objective probability of malignancy' (0.81) was superior to all other ultrasound and power Doppler variables (P = 0.001-0.02). The 'objective probability of malignancy' detected more malignancies at endometrium 5-15 mm than endometrial morphology (5/7 vs. 1/7, i.e. 0.71 vs. 0.14; P = 0.125) with a similar specificity (49/57 vs. 51/57, i.e. 0.86 vs. 0.89).

CONCLUSION

Power Doppler ultrasound can contribute to a correct diagnosis of endometrial malignancy, especially if the endometrium measures 5-15 mm. The use of regression models including power Doppler results to estimate the risk of endometrial cancer deserves further development.

Mortality of anxiety syndromes in a normal population. The Lundby Study

The mortality of anxiety syndromes between 1972 and 1992 was investigated in a prospective study of a normal population, the 1947 Lundby cohort. 121 persons with anxiety according to the Lundby definition (Anx), and 74 persons with panic disorder with/without agoraphobia (PD-Ag) according to the DSM-III-R, all of them developing their first episode between 1947 and 1972, were analyzed with regard to general mortality and special cause of death. Sex- and age-specific mortality rates for these groups were calculated and compared with the corresponding rates of the cohort's 1,877 remaining subjects without first episodes of Anx/PD-Ag. In contrast to the females, the annual rates of general mortality in males with Anx/PD-Ag were 1.9/2.2 times higher in the age group 65-84 years, compared with the rates of the non-Anx/PD-Ag groups. They also had an increase in death due to circulatory disorders, most pronounced in males with PD-Ag before the age of 65. There were no suicides in any of the Anx/PD-Ag groups during the observation period.

Corrected sagittal tomography of the temporomandibular joint. Influence of errors in film and patient positioning on linear and angular measurements

The aim of this study was to assess the variation in film and patient positioning in horizontally corrected sagittal tomography of the temporomandibular joint (TMJ). The influence of this variation on linear and angular measurements of some anatomic structures of the TMJ was also studied. There was no significant variation in film positioning in the tomograph, using a multi-film cassette. The variation in positioning the patient in the tomograph was significant when four dental assistants were asked to place the Frankfort plane parallel to the horizontal plane. The measurements with the film in a straight position were compared with the measurements with the film angulated, to simulate the mean variation in film and patient positioning. Linear and angular measurements of anatomic structures were performed in arthrotomograms of 58 joints, representing joints with superior disk position and joints with anterior disk position with and without reduction. There was a difference between the two measurements for four different distances and one angle independent of diagnosis. No differences could be found between patients belonging to the different diagnostic groups. The results indicate that variation in patient positioning influences linear and angular measurements of anatomic structures in TMJ arthrotomograms.

Ethnicity of Scandinavian populations from 1050-1500 A.D

In a skeletal material of five individuals from a non-christian cemetery in Middle Sweden (Vivallen) non-metric traits in skulls and mandibles were studied. Burial gifts and burial customs indicate Saamisch/Lappish origin of these individuals. Their affinities are explored here by comparing the traits with data on crania of Saamish populations from Northern Norway as well a with data of Nordic populations from Middle Sweden and Middle Norway. The Nordic populations from Sweden and Norway are dated to the Medieval period and the Saamish population is post-Medieval. The individuals of the Vivallen burial ground were found to exhibit Saamish as well as Nordic traits. These anthropological investigations together with odontological and palaeopathological studies constitute parts of the South-Saami project, in which also archaeologists from Sweden and Norway participate.

Clinical evaluation of the fetus and neonate. Relation between intra-partum cardiotocography, Apgar score, cord blood acid-base status and neonatal morbidity

The relation between intra-partum cardiotocography (CTG), cord blood acid-base status, Apgar score and neonatal morbidity was studied in 1228 consecutively live-born babies and in a subgroup of 200 babies (148 babies with a 1 min Apgar score < or = 8 and 52 randomly selected babies with a 1 min Apgar score > or = 9). The scores for the individual components of the 1 min Apgar score were strongly associated with each other, whereas the scores for the individual components of the 5 min Apgar score were less strongly associated. At 1 min the scores for muscle tone, reflex irritability and respiration but not the scores for heart rate and skin colour were associated with arterial and venous cord blood pH (low scores being associated with low pH). Out of the individual components of the Apgar score, heart rate and reflex irritability at 1 min were the best discriminators between "healthy or relatively healthy" and "severely ill" babies. Intrapartum CTG, total Apgar score and cord blood acid-base status were only weakly related. Venous cord blood pH was the best predictor of the 1 min Apgar score. Intra-partum CTG (silent pattern), 5 min Apgar score and venous cord blood pH were the best predictors of severe neonatal morbidity.

Premorbid personality traits and psychosomatic background factors in depression: the Lundby Study 1957-1972

The search for specific predepressive personality factors has a long tradition in psychiatry. Studies in which assessments were made prospectively, before the onset of a first-ever episode of the illness, are, however, rare. In the present report from the Lundby Study we have investigated premorbid, mainly personality-related background factors for first incidences of depressive disorder, diagnosed according to the Lundby criteria for 'Depression proper' and 'Depression plus other psychiatric symptoms'. The items found to be of a predictive value differed between the two diagnostic subgroups and also between men and women. The findings are discussed and compared with earlier predictor studies on depression.

Low birth weight and risk of high blood pressure in adulthood

Hospital birth records were sought for 104 men from a pool of male army conscripts with "normal" or "high" blood pressure when measured at 28 years of age. Of 77 men whose birth weight and date of the mother's last menstrual period before the pregnancy could be found, 25 had a resting diastolic blood pressure of greater than or equal to 90 mm Hg. In 11 of these compared with nine of the 52 men with normal diastolic pressures their birth weights in relation to gestational age had been below the mean and 1 SD of a comparable Swedish population. The risk of increased diastolic blood pressure in early adult life was significantly higher among men who had been growth retarded at birth than among those whose birth weight had been appropriate for gestational age (odds ratio 3.63; 95% confidence interval 1.14 to 12.57). Being born small for gestational age may be a predictor of raised blood pressure in early adult life.

Ambulatory 24 hour intraesophageal pH-monitoring in the diagnosis of gastroesophageal reflux disease

The results of ambulatory 24 hour oesophageal pH monitoring in 20 patients with established gastro-oesophageal reflux disease were compared with those of 20 healthy individuals with normal endoscopy. Cut off limits of pH 3, 4, and 5 were superior to pH 2 with respect to the discrimination of patients from normal subjects, and for the detection of pathological reflux. Using pH 4 as a cut off limit, the ambulant and recumbent periods of pH monitoring were more discriminatory than the postprandial period. Furthermore, it was possible to get complete separation between patients and normal subjects using several combinations of two reflux variables. Another group of 30 patients and 30 controls were investigated. Using percentage time at pH less than 4 as a single determinant of gastro-oesophageal reflux, the sensitivity and specificity were 87% and 97%, respectively, with 3.4% as upper limit for normality. Twenty four hour oesophageal pH monitoring in an ambulatory outpatient environment afforded clinically useful diagnostic accuracy in separating patients with gastro-oesophageal reflux disease from asymptomatic controls.

Relationships between growth at the sutures of the rabbit calvarium

The present study was designed to elucidate the relationships between growth increments at the cranial vault sutures in rabbits. Thirteen male New Zealand white rabbits were followed regularly from age 31 to 142 days using a roentgen stereophotogrammetric system. Spherical tantalum markers were implanted into the nasal, frontal, and parietal bones, and implant stability was checked at each stereo examination. Problems with instability were encountered only in the nasal bones. Registered growth rates conformed to our previous investigations. High correlations were observed between the following areas; the coronal suture to the frontonasal suture, the first principal component of the neurocranial suture group to the frontonasal suture, and the principal component of the craniofacial suture group to the coronal suture. Remaining relationships demonstrated dispersion to various extents. The findings indicate that there seems to exist a basic mutual dependence between neural and facial skeletal growth, as well as complex covariations between the various sutures of the rabbit calvarium.

Interdependence of pulse wave variables in the human fetal aorta

The problem of inferring the state of fetal circulation from diameter pulse waves in the descending aorta was studied with the aid of statistical methods in 12 fetuses in late uncomplicated gestation. By means of a phase-locked, echo-tracking ultrasound technique, aorta diameter-time waveforms and pulse propagation velocities were measured. In a factor analysis, three independent factors explained 75% of the total variance of variables in the waveforms. Relationships between some of the variables and biophysical events are suggested; they await confirmation from animal experiments, in order to develop a practical method for assessing fetal circulation.

Monitoring of zinc protoporphyrin levels in blood following occupational lead exposure

The value of measurements of zinc protoporphyrin in blood (ZPP) in the surveillance of workers occupationally exposed to lead has been studied. From a group of referents, consisting of 1,088 men and 511 women, it has been established that the normal mean ZPP is in the region of 25 micrograms/100 ml, and only rarely do values exceed 45 micrograms/100 ml. The higher ZPP values are frequently associated with low blood hemoglobin concentrations and appear to be manifestations of an iron-deficiency anemia. Women have higher ZPP values than men; smoking has no influence. Measurements of ZPP and blood lead concentration (PbB) have been made every other month for 2.5 years on a group of around 200 men and 40 women exposed to lead in a storage battery factory. The mean ZPP of the group throughout the period was 70.9 micrograms/100 ml blood, and a linear relation between log ZPP and PbB in the PbB range of 10-80 micrograms/100 ml has been established. ZPP thresholds in the control of excessive occupational lead exposure, and the economic advantage of ZPP measurements over PbB, are discussed.

The correlation between craniofacial and long bone growth: an experimental investigation in normal rabbits

The present study was undertaken to elucidate the relationships between craniofacial and long-bone growth. Nine male New Zealand white rabbits received spherical tantalum bone markers in the tibial epiphyses and in the nasal, frontal, and parietal bones. The animals were followed from 30 to 143 days of age. Growth changes were calculated with a roentgen stereometric system, and the results statistically evaluated. Except for the final interval when all variables varied at random, high correlations between tibial and frontonasal or coronal sutural growth were demonstrated; and the respective linear regression lines were homogeneously assembled. The relationship between the tibia and the sagittal suture displayed great variations between individual animals as well as between the suture's parts, although growth at the interfrontal suture was clearly correlated to tibial growth upon exclusion of the time factor. The first principal component of the three neurocranial sutures was calculated and seemed accurately correlated to long-bone growth. The present study concluded that growth at the frontonasal and coronal sutures normally seems to parallel general somatic development, while growth at the sagittal suture appears individually displaced in time. Nevertheless, when the principal component of the combination of the coronal suture and the neurocranial section of the sagittal suture was computed, this was highly correlated to body growth.

Predictors of alcoholism in the Lundby Study. III. Social risk factors for alcoholism

In 1957 all inhabitants (2,612) in a delimited geographical area, Lundby, were examined by a psychiatrist, and social factors were evaluated for each individual. During the following 15 years 58 men became alcoholics. Among the men who in 1957 were in the age group 0-14 years and belonged to a 'gang', the risk of becoming an alcoholic was 100-fold increased. 'Gang' was also an important factor in the age group 15-24 years. 'Crisis' was an important factor among those over 14, and 'disintegrated environment' in the age group 25-59 years. In the latter age group occupations such as 'entrepreneur', became important as a precipitating factor. 'Married' was the only protective factor found.