Aug 10, 2018

On schedule

The story

It’s never fun to think about pregnancy before your big Friday night date. But spoiled moods aside (and because anything can happen), here's the latest on how labor induction affects outcomes. 

The basics

Your nights on the OB ward taught you that babies do come from somewhere. And it turns out that somewhere is just a bit rosier after 39 weeks of gestation than after 41. About 60% of deliveries fall between the 39th and 40th week of gestation, but those that run late are subject to a rising rate of perinatal mortality. Enter labor induction: the technique makes sense as a tool to prevent late complications, though women tend not to trust it. There's little supporting evidence and parents generally prefer fewer interventions in the birth process.

The study

ARRIVE looked at 6,000 low-risk nulliparous women assigned to labor induction at 39 weeks vs. expectant management. The induction group had a 20% lower rate of the primary outcome – perinatal death or severe neonatal complications – that fell right on the border of prespecified trial criteria for significance. Induction did produce a significantly lower rate of C-sections (19% vs. 22%). Most eligible women declined to participate in the trial, which limited enrollment and made the study groups younger than the average US pregnancy population.

The takeaway

ARRIVE just missed significance due to a higher than expected rate of the primary outcome in both groups. The trial should, however, assure skeptics that induction of labor at 39 weeks is safe.

Say it on rounds

When your patient likes to skip a few appointments between visits

Best to get as much done as you can. Guidelines recommend confirming a diabetes diagnosis with repeat blood tests soon after the first positive result. An analysis of data from a large prospective cardiovascular study found that elevated fasting glucose (>126 mg / dL) and hemoglobin A1c (>6.5%) drawn from a single blood sample predicted a formal diagnosis of diabetes in a 5-year window with a specificity of 98%. While the single sample approach needs further validation before it's ready for prime time, it could soon be a boost for overbooked or low-resource clinics.

When you make sure to touch everything on the subway

When your baseline is hospital flora, you have nowhere to go but up. A study of the gut microbiome in 180 patients with cirrhosis linked patterns of fecal flora found on hospital admission to the development of decompensated cirrhosis, extra-hepatic organ failure, and even 30-day mortality. Specific bacterial groups were linked to good (Lachnospiraceae and Clostridia) and bad (Enterococcus and Strep) outcomes. Whether altering the microbiome in these patients can affect clinical endpoints remains to be seen.
Clin Gastro Hepatol

When the ED diagnosis doesn't quite fit

Women with heart attacks tend to present with atypical symptoms rather than crushing chest pain. An analysis of Florida records from 1991 – 2010 found that women with acute coronary syndrome were more likely to survive when treated by female physicians. Whether the female docs were able to better recognize or elicit ACS symptoms or were just more skillful than their male colleagues isn't clear, but on the whole 'gender concordance' reduced the probability of death by 5%.

Brush up

Acute viral encephalitis

Suspect viral encephalitis in patients with fever, confusion, or new seizures. The immunocompromised are especially vulnerable. Send patients for head imaging including MRI and arrange for lumbar puncture with a focus on cell count and CSF RT-PCR. Common culprits are HSV (50-75% of known cases), VZV, enteroviruses, or arboviruses like West Nile, though in up to 50% of cases cause remains unknown. Patients with suspected disease will often need aggressive supportive care including the ICU. 

What's the evidence

For empiric acyclovir in suspected viral encephalitis? IDSA guidelines give the med an A level recommendation, but evidence is sparse. A 2015 study of 87 patients with confirmed herpes simplex encephalitis found that 85% of patients had mild or absent cognitive impairment at 1 year after treatment with 2 - 3 weeks of intravenous acyclovir. Adding an additional 90 days of valacyclovir failed to improve outcomes.

What your single friends are talking about

There's enough online dating in your residency class that you don't need to see it on PubMed. But an evidence-based look at dating app choices shows that the average person aims for someone about 25% more desirable than themselves. The authors call this 'aspirational'.

The Scope App

Use search to find the article on the tip of your tongue
Get the app for free through our one-click sign-up referral programs for iOS and Android.

Spread the word

Share with friends, and help us make medicine more fun


Sign up at

Copyright © 2018 Scope Media, LLC. All rights reserved.