Publications by authors named "Hannah Walter"

23 Publications

  • Page 1 of 1

The impact of the Auckland cellulitis pathway on length of hospital stay, mortality readmission rate, and antibiotic stewardship.

Clin Infect Dis 2021 Feb 26. Epub 2021 Feb 26.

Department of Infectious Diseases, Auckland District Health Board, Auckland, New Zealand.

Background: The Dundee classification of cellulitis severity, previously shown to predict disease outcomes, provides an opportunity to improve the management of patients with cellulitis.

Methods: We developed and implemented a pathway to guide the management of adults with cellulitis based on their Dundee severity class, and measured its effect on patient outcomes. We compared the outcomes in patients admitted to Auckland City Hospital (ACH) between July 2014 and July 2015 (the baseline cohort) with those in patients admitted between June 2017 and June 2018 (the intervention cohort).

Results: The median length of stay was shorter in the intervention cohort (0.7 days, IQR 0.1 to 3.0 days) than in the baseline cohort (1.8 days, IQR 0.1 to 4.4 days; P<0.001). The 30 day mortality rate declined from 1.8% (19/1092) in the baseline cohort to 0.7% (10/1362; P=0.02) in the intervention cohort. The 30 day cellulitis readmission rate increased from 6% in the baseline cohort to 11% (P<0.001) in the intervention cohort. Adherence to the ACH cellulitis antibiotic guideline improved from 38% to 48% (P<0.01) and was independently associated with reduced length of stay.

Conclusions: The implementation of the Auckland cellulitis pathway, readily generalizable to other settings, improved the outcomes in patients with cellulitis, and resulted in an annual saving of approximately 1,000 bed days.
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http://dx.doi.org/10.1093/cid/ciab181DOI Listing
February 2021

Testing a gamified Spider App to reduce spider fear and avoidance.

J Anxiety Disord 2021 Jan 25;77:102331. Epub 2020 Oct 25.

Justus-Liebig-University, Giessen, Germany. Electronic address:

Mobile applications are increasingly part of mental health programs and various apps have been developed for treating anxiety disorders. Typically, they aim to improve anxiety symptoms via established CBT techniques, such as exposure principles, which are considered extremely unpleasant for fearful individuals. We combined in a mobile application exposure principles with gamification elements (e.g. narrative background, level progression, points, and feedback). These elements should increase the motivation for confronting spider images and decrease the experienced distress. To evaluate the application, two groups of spider-fearful individuals played either the Spider App (experimental group) or a non-spider associated app (control group) twice a day for approximately 12 min for 7 days. After this week, participants of the experimental group showed less avoidance behavior of spiders (BAT), as well as lower anxiety of spiders (SPQ, FAS). Groups were not different in measures of depression or psychological distress. Interestingly, participants playing the Spider App reported higher anxiety, disgust and arousal ratings shortly after playing the app. However, anxiety, disgust, and arousal ratings decreased from day to day. We discuss our findings with respect to implications for the clinical practice.
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http://dx.doi.org/10.1016/j.janxdis.2020.102331DOI Listing
January 2021

Are You There? Genetic Variation Impacts Long-Distance Connections in Diabetes.

Trends Immunol 2020 04 10;41(4):269-271. Epub 2020 Mar 10.

Department of Microbiology, University of Alabama at Birmingham, Birmingham, AL, USA. Electronic address:

A new study by Fasolino et al. defines how genetic variation in a mouse model of type 1 diabetes mellitus (T1DM) affects long-distance genomic interactions. The research has widespread implications for understanding how genetic diversity impacts disease susceptibility, and raises important concepts about mechanisms that can be influenced by genetic diversity between individuals.
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http://dx.doi.org/10.1016/j.it.2020.02.006DOI Listing
April 2020

Sensitivity to changes in dynamic affordances for walking on land and at sea.

PLoS One 2019 17;14(10):e0221974. Epub 2019 Oct 17.

Affordance Perception-Action Laboratory, School of Kinesiology, University of Minnesota, Minneapolis, Minnesota, United States of America.

We investigated the perception of affordances for walking along a narrow path. We asked whether participants could perceive changes in affordances brought about by manipulation of properties of the body, or of the environment, without direct practice of the to-be-perceived affordance, and without external feedback about the accuracy of perception. In Experiment 1, participants made a series of 8 judgments of how far they could walk along a narrow path either, 1) without added weight, 2) while wearing a weighted vest, or 3) while wearing weights on their ankles. Before walking, mean judgments were lower when wearing weights than in the no-weight condition. In addition, in both weight conditions judgments changed across the series of 8 judgments, in the direction of greater accuracy. Control of the body in walking also can be influenced by motion of the ground surface, as commonly happens in vehicles. In Experiment 2, on a ship at sea, we evaluated the effects of walking with or without weight added to the body at the ankles. We again asked participants (experienced maritime crewmembers) to judge how far they could walk along a narrow path, with versus without ankle weights. As in Experiment 1, judgments made before walking mirrored the observed differences in walking performance. In addition, we again found evidence that judgment improved (without walking practice, or feedback) over the series of judgments. We conclude that participants were sensitive to (and spontaneously learned about) how affordances for walking were influenced by changes in the dynamics of body and the environment.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0221974PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6797110PMC
March 2020

The Role of Visual Feedback about Motion of the Ground on Postural Sway.

J Mot Behav 2020 17;52(3):352-359. Epub 2019 Jun 17.

School of Kinesiology, University of Minnesota, Minneapolis, MN, USA.

We asked whether body sway would be influenced by visual information about motion of the ground surface. On a ship at sea, standing participants performed a demanding visual search task or a simple visual inspection task. Display content was stationary relative to the ship or relative to the Earth. Participants faced the ship's bow or its port side. Performance on the visual search task was representative of terrestrial studies. Body sway was greater during viewing of the Earth Stationary displays than during viewing of the Ship Stationary displays. We discuss possible implications of these results for theoretical and applied issues.
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http://dx.doi.org/10.1080/00222895.2019.1627281DOI Listing
June 2019

Unstable coupling of body sway with imposed motion precedes visually induced motion sickness.

Hum Mov Sci 2019 Apr 12;64:389-397. Epub 2019 Mar 12.

School of Kinesiology, University of Minnesota, USA. Electronic address:

Motion sickness is preceded by differences in the quantitative kinematics of body sway between individuals who (later) become sick and those who do not. In existing research, this effect has been demonstrated only in measures of body sway, relative to the earth. However, body sway can become coupled with imposed oscillatory motion of the illuminated environment, and the nature of this coupling may differ between individuals who become sick and those who do not. We asked whether body sway would become coupled to complex oscillations of the illuminated environment, and whether individual differences in such coupling might be precursors of motion sickness. Standing participants (women) were exposed to complex oscillation of the illuminated environment. We examined the strength of coupling as a function of time during exposure. Following exposure, some participants reported motion sickness. The nature and temporal evolution of coupling differed between participants who later reported motion sickness and those who did not. Our results show that people can couple the complex dynamics of body sway with complex imposed motion, and that differences in the nature of this coupling are related to the risk of motion sickness.
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http://dx.doi.org/10.1016/j.humov.2019.03.006DOI Listing
April 2019

The Role of Palliative Care in Chronic Progressive Neurological Diseases-A Survey Amongst Neurologists in the Netherlands.

Front Neurol 2018 14;9:1157. Epub 2019 Jan 14.

Department of Neurology, Amsterdam University Medical Center, Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands.

Chronic progressive neurological diseases like high grade glioma (HGG), Parkinson's disease (PD), and multiple sclerosis (MS) are incurable, and associated with increasing disability including cognitive impairment, and reduced life expectancy. Patients with these diseases have complex care needs. Therefore, timely advance care planning (ACP) is required. Our aim was to investigate timing and content of discussions on treatment restrictions, i.e., to initiate, withhold, or withdraw treatment in patients with HGG, PD, and MS, from the neurologists' perspective. We performed a national online survey amongst consultants in neurology and residents in The Netherlands. The questionnaire focused on their daily practice concerning timing and content of discussions on treatment restrictions with patients suffering from HGG, PD or MS. We also inquired about education and training in discussing these issues. A total of 125 respondents [89 neurologists (71%), 62% male, with a median age of 44 years, and 36 residents (29%), 31% male with a median age of 29 years] responded. Initial discussions on treatment restrictions were said to take place during the first year after diagnosis in 28% of patients with HGG, and commonly no earlier than in the terminal phase in patients with PD and MS. In all conditions, significant cognitive decline was the most important trigger to advance discussions, followed by physical decline, and initiation of the terminal phase. Most discussed issues included ventilation, resuscitation, and admission to the intensive care unit. More than half of the consultants in neurology and residents felt that they needed (more) education and training in having discussions on treatment restrictions. In patients with HGG discussions on treatment restrictions are initiated earlier than in patients with PD or MS. However, in all three diseases these discussions usually take place when significant physical and cognitive decline has become apparent and commonly mark the initiation of end-of-life care. More than half of the responding consultants in neurology and residents feel the need for improvement of their skills in performing these discussions.
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http://dx.doi.org/10.3389/fneur.2018.01157DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6340288PMC
January 2019

Adaptive perception of changes in affordances for walking on a ship at sea.

Hum Mov Sci 2019 Apr 12;64:28-37. Epub 2019 Jan 12.

Affordance Perception-Action Laboratory, School of Kinesiology, University of Minnesota, USA. Electronic address:

Ocean waves cause oscillatory motion of ships. Oscillatory ship motion typically is greater in roll (i.e., the ship rolling from side to side) than in pitch (i.e., tipping from front to back). Affordances for walking on a ship at sea should be differentially influenced by ship motion in roll and pitch. When roll exceeds pitch, the maximum walkable distance within a defined path should be greater when walking along the ship's short, or athwart axis than when walking along its long, or fore-aft axis. When pitch exceeds roll, this relation should be reversed. We asked whether such changes in ship motion would be reflected in judgments of direction-specific affordances for walking. Participants (experienced maritime crewmembers) judged how far they could walk along a narrow path on the ship deck. On different days, sailing conditions were such that the relative magnitude of pitch and roll was reversed. Judgments of direction-specific affordances for walking mirrored these changes in ship motion. The accuracy of judgments was consistent across directions, and across changes in ship motion. We conclude that experienced maritime crewmembers were sensitive to dynamic variations in affordances for walking that were, themselves, a function of dynamic properties of the animal-environment system.
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http://dx.doi.org/10.1016/j.humov.2019.01.002DOI Listing
April 2019

Real-time visual feedback about postural activity increases postural instability and visually induced motion sickness.

Gait Posture 2018 09 8;65:251-255. Epub 2018 Aug 8.

School of Kinesiology, University of Minnesota, USA. Electronic address:

Background: Several studies have shown that the kinematics of standing body sway can be influenced by the provision of real time feedback about postural activity through visual displays.

Research Question: We asked whether real time visual feedback about the position of the body's center of pressure (COP) might affect body sway and the occurrence of visually induced motion sickness.

Methods: Standing participants (women) were exposed to complex visual oscillation in a moving room, a device that nearly filled the field of view. During exposure to complex visual oscillations, we provided real time feedback about displacements of the body's center of pressure through a visual display presented on a tablet computer.

Results: The incidence of motion sickness was greater than in a closely related study that did not provide real time feedback. We monitored the kinematics of the body's center of pressure before and during exposure to visual motion stimuli. Body sway differed between participants who reported motion sickness and those who did not. These differences existed before any participants experienced subjective symptoms of motion sickness.

Significance: Real time visual feedback about COP displacement did not reduce visually induced motion sickness, and may have increased it. We identified postural precursors of motion sickness that may have been exacerbated by the COP display. The results indicate that visual feedback about postural activity can destabilize postural control, leading to negative side effects. We suggest possible alternative types of visual displays that might help to stabilize posture, and reduce motion sickness.
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http://dx.doi.org/10.1016/j.gaitpost.2018.08.005DOI Listing
September 2018

Association of the Dundee severity classification with mortality, length of stay and readmission in adult inpatients with cellulitis.

J Antimicrob Chemother 2019 01;74(1):200-206

Department of Infectious Diseases, Auckland District Health Board, Auckland, New Zealand.

Background: The Dundee classification is a simple severity assessment tool that could optimize treatment decisions and clinical outcomes in adult patients with cellulitis; however, it has not been validated in a large cohort.

Objectives: To determine whether the Dundee classification reliably identified those patients with cellulitis who had a higher mortality, a longer length of hospital stay or an increased risk of readmission.

Methods: We performed a retrospective study of all adults with a primary discharge diagnosis of cellulitis admitted to Auckland City Hospital from August 2013 to June 2015. We classified patients by severity using the Dundee scoring system.

Results: The 30 day all-cause mortality in adult patients with a discharge diagnosis of cellulitis was 2% (29/1462) overall, and was 1% (10/806), 2% (6/271), 3% (10/353) and 9% (3/32) in Classes 1, 2, 3 and 4 of the Dundee classification, respectively (P = 0.01). Mortality was strongly associated with age >65 years (OR 9.37, 95% CI 3.00-41.23) and with heart failure (OR 6.16, 95% CI 2.73-14.23). There were significant associations between the Dundee classification and the incidence of bacteraemia, the length of hospital stay and the rate of readmission to hospital.

Conclusions: The Dundee classification is a simple, reliable tool that can be easily applied in clinical settings to predict risk of mortality in order to determine which patients can be managed in the community with oral or intravenous therapy, and which require inpatient care.
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http://dx.doi.org/10.1093/jac/dky400DOI Listing
January 2019

Impact of pulsed UV-B stress exposure on plant performance: How recovery periods stimulate secondary metabolism while reducing adaptive growth attenuation.

Plant Cell Environ 2019 03 13;42(3):801-814. Epub 2018 Aug 13.

Centre for Organismal Studies Heidelberg, Heidelberg University, Heidelberg, Germany.

Upon continuous stress exposure, plants display attenuated metabolic stress responses due to regulatory feedback loops. Here, we have tested the hypothesis that pulsed stress exposure with intervening recovery periods should affect these feedback loops, thereby causing increased accumulation of stress-induced metabolites. The response of Arabidopsis plantlets to continuous UV-B exposure (C ) was compared with that of pulsed UV-B exposure (P ). The differential responses to P versus C were monitored at the level of gene expression and metabolite accumulation, using wild type (WT) and different mutant lines. In comparison with C , P increased sinapyl and flavonol (S + F) content, whereas adaptive growth attenuation was reduced. Furthermore, in a myb4 mutant (AtMYB4, repressor-type R2R3-MYB transcription factor), the S + F content was increased only for C , but not beyond the level for P observed in WT. These observations and the ability of AtMYB4 to repress AtMYB12/AtMYB111-mediated activation of target gene promoters (pCHS and pFLS) indicate that the increase of S + F content after P observed in WT plants results from reduced feedback inhibition by AtMYB4. The results support the notion that stress-induced metabolic changes not necessarily cause a growth penalty. Furthermore, the observed P -induced increase in flavonol accumulation may stimulate reevaluation of commercial plant production practices.
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http://dx.doi.org/10.1111/pce.13409DOI Listing
March 2019

Postural time-to-contact as a precursor of visually induced motion sickness.

Exp Brain Res 2018 Jun 27;236(6):1631-1641. Epub 2018 Mar 27.

University of Minnesota, Minneapolis, USA.

The postural instability theory of motion sickness predicts that subjective symptoms of motion sickness will be preceded by unstable control of posture. In previous studies, this prediction has been confirmed with measures of the spatial magnitude and the temporal dynamics of postural activity. In the present study, we examine whether precursors of visually induced motion sickness might exist in postural time-to-contact, a measure of postural activity that is related to the risk of falling. Standing participants were exposed to oscillating visual motion stimuli in a standard laboratory protocol. Both before and during exposure to visual motion stimuli, we monitored the kinematics of the body's center of pressure. We predicted that postural activity would differ between participants who reported motion sickness and those who did not, and that these differences would exist before participants experienced subjective symptoms of motion sickness. During exposure to visual motion stimuli, the multifractality of sway differed between the Well and Sick groups. Postural time-to-contact differed between the Well and Sick groups during exposure to visual motion stimuli, but also before exposure to any motion stimuli. The results provide a qualitatively new type of support for the postural instability theory of motion sickness.
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http://dx.doi.org/10.1007/s00221-018-5246-yDOI Listing
June 2018

Living with otosclerosis: disease-specific health-related quality-of-life measurement in patients undergoing stapes surgery.

Eur Arch Otorhinolaryngol 2018 Jan 7;275(1):71-79. Epub 2017 Nov 7.

Department of Otorhinolaryngology, Head and Neck surgery, Technische Universität Dresden, Medizinische Fakultät Carl Gustav Carus, Fetscherstraße 74, 01307, Dresden, Saxony, Germany.

Introduction: Otosclerosis is associated with hearing disability, leading to communication deficits and social and psychological restrictions. The objective of our study was to analyze disease-specific health-related quality of life (HRQOL) after stapes surgery and compare the outcome of HRQOL with audiometric parameters. SUBJECTS AND METHODS: Our clinical case study was conducted at two tertiary referral centers. All the 37 patients who had undergone stapes surgery were analyzed clinically and by audiometric testing (pure tone and speech audiometry) in the pre- and postoperative settings. Disease-specific HRQOL was assessed by the validated Stapesplasty Outcome Test 25 (SPOT-25) pre- and postoperatively. The subjective hearing disability was evaluated by the hearing handicap inventory for adults (HHIA). The postinterventional benefit was measured by the Glasgow Benefit Inventory (GBI).

Results: Disease-specific HRQOL improved significantly after stapes surgery in all scales of the SPOT-25. Postoperatively, the total score and the subscore "hearing function" correlated well with the audiometric data. The subscores "tinnitus", "social restrictions", and "mental condition" did not show significant association with audiometric parameters. The comparison of pre- and postoperative HHIA offered a significant improvement in the hearing disability. The scores of the HHIA correlated very well with the audiometric data. The GBI showed a postoperative benefit for each individual patient.

Conclusion: Stapes surgery leads to a significant improvement in the hearing handicap and of disease-specific HRQOL. The audiometric parameters were shown as not being a sufficient indicator of social and mental well-being. HRQOL outcome measuring instruments should be used routinely in clinical practice to provide an individualized postoperative assessment.
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http://dx.doi.org/10.1007/s00405-017-4798-yDOI Listing
January 2018

Increasing potential for intense tropical and subtropical thunderstorms under global warming.

Proc Natl Acad Sci U S A 2017 10 16;114(44):11657-11662. Epub 2017 Oct 16.

Department of Atmospheric Sciences, Colorado State University, Fort Collins, CO 80523.

Intense thunderstorms produce rapid cloud updrafts and may be associated with a range of destructive weather events. An important ingredient in measures of the potential for intense thunderstorms is the convective available potential energy (CAPE). Climate models project increases in summertime mean CAPE in the tropics and subtropics in response to global warming, but the physical mechanisms responsible for such increases and the implications for future thunderstorm activity remain uncertain. Here, we show that high percentiles of the CAPE distribution (CAPE extremes) also increase robustly with warming across the tropics and subtropics in an ensemble of state-of-the-art climate models, implying strong increases in the frequency of occurrence of environments conducive to intense thunderstorms in future climate projections. The increase in CAPE extremes is consistent with a recently proposed theoretical model in which CAPE depends on the influence of convective entrainment on the tropospheric lapse rate, and we demonstrate the importance of this influence for simulated CAPE extremes using a climate model in which the convective entrainment rate is varied. We further show that the theoretical model is able to account for the climatological relationship between CAPE and a measure of lower-tropospheric humidity in simulations and in observations. Our results provide a physical basis on which to understand projected future increases in intense thunderstorm potential, and they suggest that an important mechanism that contributes to such increases may be present in Earth's atmosphere.
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http://dx.doi.org/10.1073/pnas.1707603114DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5676896PMC
October 2017

Dynamic perception of dynamic affordances: walking on a ship at sea.

Exp Brain Res 2017 02 27;235(2):517-524. Epub 2016 Oct 27.

School of Kinesiology, University of Minnesota, Minneapolis, MN, USA.

Motion of the surface of the sea (waves, and swell) causes oscillatory motion of ships at sea. Generally, ships are longer than they are wide. One consequence of this structural difference is that oscillatory ship motion typically will be greater in roll (i.e., the ship rolling from side to side) than in pitch (i.e., the bow and stern rising and falling). For persons on ships at sea, affordances for walking on the open deck should be differentially influenced by ship motion in roll and pitch. Specifically, the minimum width of a walkable path should be greater when walking along the ship's short, or athwart axis than when walking along its long, or fore-aft axis. On a ship at sea, we evaluated the effects of walking in different directions (fore-aft vs. athwart) on actual walking performance. We did this by laying out narrow paths on the deck and asking participants (experienced maritime crewmembers) to walk as far as they could while remaining within the lateral path boundaries. As predicted, participants walked farther along the athwart path than along the fore-aft path. Before actual walking, we evaluated participants' judgments of their walking ability in the fore-aft and athwart directions. These judgments mirrored the observed differences in walking performance, and the accuracy of judgments did not differ between the two directions. We conclude that experienced maritime crewmembers were sensitive to affordances for walking in which the relevant properties of the environment were exclusively dynamic.
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http://dx.doi.org/10.1007/s00221-016-4810-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5297405PMC
February 2017

A Lagrangian View of Moisture Dynamics During DYNAMO.

J Atmos Sci 2016 May 22;73(5):1967-1985. Epub 2016 Apr 22.

NASA Goddard Institute for Space Studies, Columbia University, New York, NY.

Column water vapor (CWV) is studied using data from the Dynamics of the Madden-Julian Oscillation (DYNAMO) field experiment. A distinctive moist mode in tropical CVW probability distributions motivates the work. The Lagrangian CWV tendency (LCT) leaves together the compensating tendencies from phase change and vertical advection, quantities which cannot be measured accurately by themselves, to emphasize their small residual, which governs evolution. The slope of LCT vs. CWV suggests that the combined effects of phase changes and vertical advection act as a robust positive feedback on CWV variations, while evaporation adds a broadscale positive tendency. Analyzed diabatic heating profiles become deeper and stronger as CWV increases. Stratiform heating is found to accompany Lagrangian drying at high CWV, but its association with deep convection makes the mean LCT positive at high CWV. Lower-tropospheric wind convergence is found in high-CVW airmasses, acting to shrink their area in time. When ECMWF heating profile indices and S-POL and TRMM radar data are binned jointly by CWV and LCT, bottom-heavy heating associated with shallow and congestus convection is found in columns transitioning through Lagrangian moistening into the humid, high-rainrate mode of the CWV distribution near 50-55mm, while non-raining columns and columns with widespread stratiform precipitation are preferentially associated with Lagrangian drying. Interpolated sounding-array data produce substantial errors in LCT budgets, because horizontal advection is inaccurate without satellite input to constrain horizontal gradients.
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http://dx.doi.org/10.1175/JAS-D-15-0243.1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7430520PMC
May 2016

Factors associated with maternal morbidity in the Term Breech Trial.

J Obstet Gynaecol Can 2007 Apr;29(4):324-330

Department of Obstetrics and Gynaecology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON.

Objective: In the Term Breech Trial, the risk of maternal morbidity in women who delivered after planning for a caesarean section (CS) was not significantly different from those who delivered after planning for a vaginal birth. We undertook secondary analyses to determine factors associated with maternal morbidity among 2078 women.

Methods: By using multiple logistic regression analyses, we determined the effect of prelabour CS, CS during early labour, CS during active labour, vaginal birth, and other factors on maternal morbidity. For 1536 women delivered after labour, we determined the effect of variables associated with labour on maternal morbidity.

Results: The risk of maternal morbidity was lowest following vaginal birth (odds ratio [OR] 1.0) and highest following CS during active labour (OR 3.33; 95% confidence intervals [CI] 1.75-6.33, P < 0.001). For those delivered after labour, a short active phase of the second stage of labour (< 30 minutes) was associated with the lowest risk of maternal morbidity (OR 0.25; 95% CI 0.11-0.57, P < 0.001).

Conclusion: For women with a singleton fetus in breech resentation at term, maternal morbidity is lowest following vaginal birth and highest following CS during active labour.
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http://dx.doi.org/10.1016/S1701-2163(16)32442-2DOI Listing
April 2007

The costs of planned cesarean versus planned vaginal birth in the Term Breech Trial.

CMAJ 2006 Apr;174(8):1109-13

Maternal, Infant and Reproductive Health Research Unit at the Centre for Research in Women's Health, University of Toronto, Toronto, Ont.

Background: The Term Breech Trial compared the safety of planned cesarean and planned vaginal birth for breech presentations at term. The combined outcome of perinatal or neonatal death and serious neonatal morbidity was found to be significantly lower among babies delivered by planned cesarean section. In this study we conducted a cost analysis of the 2 approaches to breech presentations at delivery.

Methods: We used a third-party-payer (i.e., Ministry of Health) perspective. We included all costs for physician services and all hospital-related costs incurred by both the mother and the infant. We collected health care utilization and outcomes for all study participants during the trial. We used only the utilization data from countries with low national rates of perinatal death (< or = 20/1000). Seven hospitals across Canada (4 teaching and 3 community centres) were selected for unit cost calculations.

Results: The estimated mean cost of a planned cesarean was significantly lower than that of a planned vaginal birth (7165 dollars v. 8042 dollars per mother and infant; mean difference -877 dollars, 95% credible interval -1286 dollars to -473 dollars). The estimated mean cost of a planned cesarean was lower than that of a planned vaginal birth for both women having a first birth (7255 dollars v. 8440 dollars) and women having had at least one prior birth (7071 dollars v. 7559 dollars). Although the treatment effect was largest in the subgroup of women having their first child, there was no statistically significant interaction between treatment and parity since the 95% credible intervals for difference in treatment effects between parity equalling zero and parity of one or greater all include zero.

Interpretation: Planned cesarean section was found to be less costly than planned vaginal birth for the singleton fetus in a breech presentation at term in the Term Breech Trial.
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http://dx.doi.org/10.1503/cmaj.050796DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1421479PMC
April 2006

Maternal outcomes at 2 years after planned cesarean section versus planned vaginal birth for breech presentation at term: the international randomized Term Breech Trial.

Am J Obstet Gynecol 2004 Sep;191(3):917-27

Department of Obstetrics and Gynaecology, Sunnybrook and Women's College Health Sciences Centre, University of Toronto, Ontario, Canada.

Objective: This study was undertaken to compare maternal outcomes at 2 years postpartum after planned cesarean section and planned vaginal birth for the singleton fetus in breech presentation at term.

Study Design: In selected centers in the Term Breech Trial, mothers completed a structured questionnaire at 2 or more years postpartum to determine their health in the previous 3 to 6 months.

Results: A total of 917 of 1159 (79.1%) mothers from 85 centers completed a follow-up questionnaire at 2 years postpartum. There were no differences between groups in breast feeding, relationship with child or partner, pain, subsequent pregnancy, incontinence, depression, urinary, menstrual or sexual problems, fatigue, or distressing memories of the birth experience. Planned cesarean section was associated with a higher risk of constipation (P = .02).

Conclusion: Maternal outcomes at 2 years postpartum are similar after planned cesarean section and planned vaginal birth for the singleton breech fetus at term.
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http://dx.doi.org/10.1016/j.ajog.2004.08.004DOI Listing
September 2004

Outcomes of children at 2 years after planned cesarean birth versus planned vaginal birth for breech presentation at term: the International Randomized Term Breech Trial.

Am J Obstet Gynecol 2004 Sep;191(3):864-71

Department of Pediatrics, Hospital for Sick Children, Toronto, Ontario, Canada.

Objective: The purpose of this study was to determine whether planned cesarean delivery for the singleton fetus in breech presentation at term reduces the risk of death or neurodevelopmental delay at 2 years of age.

Study Design: In selected centers in the Term Breech Trial, children were screened for abnormalities at > or =2 years of age with the Ages and Stages Questionnaire, followed by a neurodevelopmental assessment if the Ages and Stages Questionnaire score was abnormal.

Results: A total of 923 of 1159 children (79.6%) from 85 centers were followed to 2 years of age. The risk of death or neurodevelopmental delay was no different for the planned cesarean than for the planned vaginal birth groups (14 children [3.1%] vs 13 children [2.8%]; relative risk, 1.09; 95% CI, 0.52- 2.30; P = .85; risk difference, +0.3%; 95% CI, -1.9%, +2.4%).

Conclusion: Planned cesarean delivery is not associated with a reduction in risk of death or neurodevelopmental delay in children at 2 years of age.
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http://dx.doi.org/10.1016/j.ajog.2004.06.056DOI Listing
September 2004

Planned caesarean section decreases the risk of adverse perinatal outcome due to both labour and delivery complications in the Term Breech Trial.

BJOG 2004 Oct;111(10):1065-74

Maternal Infant and Reproductive Health Research Unit, Centre for Research in Women's Health, University of Toronto, Canada.

Objective: To determine if the decreased risk of adverse perinatal outcome, with a policy of planned caesarean, in the Term Breech Trial, was due to a reduction of problems of labour, problems of delivery or unrelated problems.

Design: Secondary analysis of data from the Term Breech Trial, a randomised controlled trial of planned caesarean versus planned vaginal birth for the singleton fetus in frank or complete breech presentation at term.

Setting: Women were recruited from 121 centres in 26 countries.

Population: Women who were enrolled in the Term Breech Trial.

Methods: Adverse perinatal outcome was classified as due to labour, due to delivery, due to neither labour nor delivery or unexplained by an experienced obstetrician who was masked to allocation group. The risk of an adverse outcome in each category was compared according to intention to treat and also by actual method of delivery.

Main Outcome Measures: Adverse perinatal outcome (excluding lethal congenital anomalies) that was due to labour, due to delivery, due to neither labour nor delivery or unexplained.

Results: Planned caesarean was associated with a lower risk of adverse outcome due to both labour (RR 0.14, 95% CI 0.04-0.45, P < 0.001) and delivery (RR 0.37, 95% CI 0.16-0.87, P= 0.03), compared with planned vaginal birth. Prelabour caesarean and caesarean during early labour were associated with the lowest risk and vaginal birth was associated with the highest risk of adverse outcome due to both labour (0%, 0.4% and 2.2%, respectively) and delivery (0.2%, 0% and 3.1%, respectively).

Conclusions: Planned caesarean decreases the risk of adverse perinatal outcome due to both problems of labour and problems of delivery for the singleton fetus in breech presentation at term, compared with planned vaginal birth.
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http://dx.doi.org/10.1111/j.1471-0528.2004.00266.xDOI Listing
October 2004

Factors associated with adverse perinatal outcome in the Term Breech Trial.

Am J Obstet Gynecol 2003 Sep;189(3):740-5

Department of Obstetrics and Gynecology, Sunnybrook and Women's College Health Sciences Centre.

Background: In the Term Breech Trial, the risk of adverse perinatal outcome was lower with planned cesarean section versus planned vaginal birth. We undertook secondary analyses to determine factors associated with adverse perinatal outcome.

Study Design: By using multiple logistic regression analyses, we determined the effect of prelabor cesarean section, cesarean section during early labor, cesarean section during active labor versus vaginal birth, and other factors, on adverse perinatal outcome. For 1384 fetuses delivered after labor, we determined the effect of variables associated with labor on adverse perinatal outcome.

Results: The risk of adverse perinatal outcome was lowest with prelabor cesarean section (odds ratio [OR]=0.13) and highest with vaginal birth. For those delivered after labor, labor augmentation (P=.007), birth weight less than 2.8 kg (P=.003), and longer time between pushing and delivery (P<.001) increased the risk, whereas the presence of an experienced clinician at delivery (P=.004) reduced the risk of adverse perinatal outcome.

Conclusion: Breech infants at term are best delivered by prelabor cesarean section.
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http://dx.doi.org/10.1067/s0002-9378(03)00822-6DOI Listing
September 2003

Outcomes at 3 months after planned cesarean vs planned vaginal delivery for breech presentation at term: the international randomized Term Breech Trial.

JAMA 2002 Apr;287(14):1822-31

Department of Obstetrics and Gynaecology, Sunnybrook and Women's College Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada.

Context: The Term Breech Trial found a significant reduction in adverse perinatal outcomes without an increased risk of immediate maternal morbidity with planned cesarean delivery compared with planned vaginal birth. No randomized controlled trial of planned cesarean delivery has measured benefits and risks of postpartum outcomes months after the birth.

Objective: To compare maternal outcomes of planned cesarean delivery and planned vaginal birth at 3 months post partum.

Design: Follow-up study to the Term Breech Trial, a randomized controlled trial conducted between January 9, 1997, and April 21, 2000.

Setting And Participants: A total of 1596 of 1940 women from 110 centers worldwide who had a singleton fetus in breech presentation at term responded to a follow-up questionnaire at 3 months post partum.

Main Outcome Measures: Breastfeeding; infant health; ease of caring for infant and adjusting to being a new mother; sexual relations and relationship with husband/partner; pain; urinary, flatal, and fecal incontinence; depression; and views regarding childbirth experience and study participation.

Results: Baseline information was similar for both the cesarean and vaginal delivery groups. Women in the planned cesarean delivery group were less likely to report urinary incontinence than those in the planned vaginal birth group (36/798 [4.5%] vs 58/797 [7.3%]; relative risk, 0.62; 95% confidence interval, 0.41-0.93). Incontinence of flatus was not different between groups but was less of a problem in the planned cesarean delivery group when it occurred (P =.006). There were no differences between groups in other outcomes.

Conclusions: Planned cesarean delivery for pregnancies with breech presentation at term may result in a lower risk of incontinence and is not associated with an increased risk of other problems for women at 3 months post partum, although the effect on longer-term outcomes is uncertain.
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http://dx.doi.org/10.1001/jama.287.14.1822DOI Listing
April 2002