2 Minute Medicine Rewind January 17, 2022

Maternal and neonatal trauma following operative vaginal delivery

1. Maternal trauma rates following operative vaginal delivery were highest with forceps delivery, with more than 1 in 4 deliveries affected by maternal trauma and 1 in 105 infants affected by neonatal trauma. 

2. Maternal and neonatal trauma following vacuum deliveries occurred in 1 in 8 deliveries and 1 in 104 infants, respectively. 

3. Rates of maternal trauma following OVD varied substantially by region, but not by level of obstetric care or hospital volume.

Evidence Rating Level: 2 (Good)

Operative vaginal delivery (OVD) involves use of forceps or a vacuum extractor to assist during the second stage of labour and facilitate vaginal delivery. OVDs are alternatives to cesarean delivery, which can be challenging to perform and may result in significant maternal and neonatal morbidity and mortality. In multiple countries, including Canada, guidelines affirm the safety of OVD when performed by a trained healthcare professional. However, opportunities for training in OVD have declined and consequently, its current safety is unknown. Consequently, this cohort study quantified and described variation in incidence rates of maternal and neonatal trauma following OVD in Canada. All singleton, term (≥ 37 weeks), in-hospital deliveries to pregnant individuals without a previous cesarean delivery that resulted in a live birth or stillbirth, occurring between April 2013 and March 2019 across Canada, excluding Quebec, were included. Information on maternal characteristics and medical history, labour and delivery, and neonatal condition, diagnoses, and interventions was collected. The primary outcome measures were composite maternal trauma (including obstetric anal sphincter injury, cervical or high vaginal laceration, pelvic hematoma, obstetric injury to the pelvic organs, pelvic joints or ligaments, injury to the bladder or urethra, and other pelvic trauma) and composite neonatal trauma (including intracranial hemorrhage and laceration, skull fracture, severe injury to the central nervous system or the peripheral nervous system, fracture of the long bones, injury to the liver or spleen, seizures, and neonatal death). Of 1,326,191 deliveries, 38,500 (2.9%) were attempted forceps deliveries and 110,987 (8.4%) were attempted vacuum deliveries. The maternal and neonatal trauma rates following forceps delivery were 25.3% (95% CI 24.8%–25.7%) and 9.6 (95% CI 8.6–10.6) per 1000 live births, respectively. The maternal and neonatal trauma rates following vacuum delivery were 13.2% (95% CI 13.0%–13.4%) and 9.6 (95% CI 9.0–10.2) per 1000 live births, respectively. Rates of maternal trauma following OVD varied substantially by region, but not by level of obstetric care or hospital volume. These results demonstrate that rates of trauma following OVD in Canada are higher than previously reported and support a reassessment of OVD safety in Canada.

Exploring the causal role of intimate partner violence and abuse on depressive symptoms in young adults: A population-based cohort study 

1. Young adults experiencing intimate partner violence and abuse (IPVA) were more likely to have depressive symptoms than those not victimized.

2. This increased susceptibility to depression may be best explained by prior vulnerability, rather than a causal relationship between IPVA and depressive symptoms.  

Evidence Rating Level: 2 (Good)

In the United Kingdom, intimate partner violence and abuse (IPVA) is experienced by  approximately 30% of women and 24% of men between 18 and 21 years of age. Previous studies have shown an association between experience of IPVA and depression in young adults. It is unclear whether this is a causal relationship. Consequently, this prospective cohort study investigated the longitudinal relationship between IPVA at ages 18-21 and development of depressive symptoms several years later. A total of 2792 (N = 1764 women) participants were included. At age 21, participants were asked about IPVA using validated UK and European questionnaires. Depressive symptoms were captured at age 23 via Moods and Feelings Questionnaire scores. Of 1764 women and 1028 men, 482 (27%) and 210 (20%) reported that they experienced IPVA between 18-21 years of age, respectively. Women who experienced IPVA were found to have 26% higher depressive symptom scores, on average, compared with women who had not been victimized (ratio of geometric means 1.26, 95% CI 1.13 to 1.40). Among men, those who had experienced IPVA had 5% higher depressive symptom scores than those who had not (ratio of geometric means 1.05, 95% CI 0.92 to 1.21). For both women and men, there was no evidence that being exposed to IPVA affected change in depressive symptom scores over time. These results suggest that an increased vulnerability to depressive symptoms among young adults in a UK-based general population sample may be best explained by prior vulnerability, increasing risk of IPVA exposure and further bolstering depressive symptoms. 

Variety and quantity of dietary protein intake from different sources and risk of new-onset diabetes: A nationwide cohort study in China 

1. Consuming a greater variety of proteins from different food sources was associated with a significantly lower risk of new-onset diabetes.   

Evidence Rating Level: 2 (Good)

A healthy diet is critical for type 2 diabetes prevention and management. Previous research has suggested that amino acids/protein may have some effects on insulin release, thereby affecting glucose clearance. However, the relationship between different protein sources and new-onset diabetes has not yet been examined. This cohort study used data from the China Health and Nutrition Survey to investigate associations between protein intake from eight major food sources and development of diabetes. A total of 16,260 participants without diabetes at baseline were included. Dietary intake was measured by a household food inventory and three consecutive 24-hour dietary recalls. The number of protein sources consumed and their respective quantities were recorded. New-onset diabetes was defined as self-reported physician-diagnosed diabetes or either fasting glucose ≥ 7.0 mmol/L or glycated hemoglobin ≥ 6.5% during follow-up. During a median follow-up period of 9 years, a total of 1100 (6.8%) participants developed diabetes. Several distinct patterns between different protein sources and new-onset diabetes were found. Specifically, the associations between total protein, whole grain-derived, and poultry-derived proteins with new-onset diabetes were U-shaped, those between unprocessed or processed red meat-derived proteins with new-onset diabetes were J-shaped, those between fish-derived proteins with new-onset diabetes were reverse J-shaped, those between egg-derived and legume-derived proteins with new-onset diabetes were L-shaped, and finally, those between refined grain-derived proteins with new-onset diabetes were reverse L-shaped (all P values <0.001). Those who consumed a higher variety of protein sources were found to have a significantly lower risk of new-onset diabetes  (per score increment; HR, 0.69; 95%CI, 0.65–0.72). These findings further encourage consumption of a balanced diet from diverse food sources for the primary prevention of diabetes.   

Effectiveness of Fosfomycin for the treatment of multidrug-resistant Escherichia coli bacteremic urinary tract infections: A randomized clinical trial 

1. Fosfomycin did not demonstrate non-inferiority to comparators (ceftriaxone or meropenem) as targeted treatment of bacteremic urinary tract infections (bUTIs) caused by multidrug-resistant (MDR) Escherichia coli due to an increased rate of adverse event-related discontinuations.

2. Fosfomycin was found to be an effective treatment against bUTIs due to MDR E. coli and may be considered among select patients.  

Evidence Rating Level: 1 (Excellent)

Escherichia coli is a common human pathogen. As a result of liberal use of cephalosporins and fluoroquinolones against E. coli, multidrug-resistant (MDR) isolates have spread dramatically. Consequently, last-resort drugs, such as carbapenems, have become increasingly necessary for adequately treating infections, facilitating carbapenem-resistance. There is great medical need for finding alternatives for the treatment of MDR E. coli infections. Fosfomycin is active against a wide range of pathogens, including MDR Enterobacterales, but has been largely neglected as a therapeutic option. This randomized clinical trial explored whether Fosfomycin is non-inferior to ceftriaxone or meropenem in the targeted treatment of bacteremic urinary tract infections (bUTIs) due to MDR E. coli. A total of 161 participants with bUTIs due to MDR E. coli were recruited from 22 Spanish hospitals between June 2014 and December 2018. Participants were randomized to receive either intravenous Fosfomycin disodium at 4 g every 6 hours (N = 70) or a comparator (either ceftriaxone or meropenem; N = 73) and were followed for 60 days. The primary outcome was clinical and microbiological cure (CMC) 5 to 7 days after finalization of treatment. It was found that 48 of 70 participants (68.6%) treated with Fosfomycin and 57 of 73 participants (78.1%) treated with comparators reached CMC (risk difference, −9.4 percentage points; 1-sided 95% CI, −21.5 to ∞ percentage points; P = .10). An increased rate of adverse event-related discontinuations occurred with Fosfomycin versus comparators (6 discontinuations [8.5%] vs 0 discontinuations; P = .006). Although Fosfomycin did not demonstrate non-inferiority in the treatment of bUTI caused by MDR E. coli, it was found to be effective and may be considered among select patients. Some safety concerns were raised and warrant further investigation.   

Gender differences in the amount and type of student participation during in-person and virtual classes in academic medicine learning environments  

1. Women had a lower rate of asking and answering questions and were more likely to use differential language in large classes than men.

2. These disparities were attenuated in smaller, discussion-based and virtual classes. 

Evidence Rating Level: 2 (Good) 

Despite increased representation of women in medicine, disparities persist in how women and men assert and promote themselves in academic settings. This cohort study examined gender differences in amount and type of student participation during in-person and virtual classes in graduate-level academic medicine learning environments. Students in a graduate-level certificate program were observed during large, lecture-based classes and smaller, discussion-based classes held in-person for 2 weeks in July 2019 and virtually for 6 weeks from July to August 2020. The primary study outcome was number of questions asked. Secondary outcomes included number of questions answered and use of predefined deferential language when asking questions. During 2019 in-person classes, 156 students were observed, of which 94 (60%) were women and 147 (94%) were physicians. It was found that women had a lower rate of asking (IRR, 0.44 [95% CI, 0.36-0.55]) and answering (IRR, 0.28 [95% CI, 0.19-0.39]) in large, but not smaller, classes when compared with their male colleagues. During 2020 virtual classes, 138 students were observed, of which 84 (61%) were women and 130 (94%) were physicians. In large sessions, women were found to have a similar rate of asking questions but a lower rate of answering questions (IRR, 0.67 [95% CI, 0.57-0.80]) than men. In smaller sessions, women had a higher rate of asking questions (IRR, 1.86 [95% CI, 1.08-3.32]) and a similar rate of answering questions than men. Deferential language was used more frequently in questions asked by women than men in large classes (2019 in-person classes: RR, 1.48 [95% CI, 1.00-2.18]; and 2020 virtual classes: RR, 2.03 [95% CI, 1.49-2.76]) but not in small classes. These findings demonstrate that women assert themselves differently from men in academic settings, although these differences are attenuated in smaller classes. These differences have been associated with less positive evaluations and lower rates of promotion for women, suggesting that systems of evaluation may be biased toward characteristics more common in men.      

Image: PD

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