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The second stage of labor extends from complete cervical dilatation to delivery. During this stage, descent and rotation of the presenting part occur as the fetus passively negotiates its passage through the birth canal. Generally, descent begins during the deceleration phase of dilatation as the cervix is drawn upward around the fetal presenting part. The most common means of assessing the normality of the second stage of labor is to measure its duration, but progress can be more meaningfully gauged by measuring the change in fetal station as a function of time. Accurate clinical identification and evaluation of differences in patterns of fetal descent are necessary to assess second stage of labor progress and to make reasoned judgments about the need for intervention. Three distinct graphic abnormalities of the second stage of labor can be identified: protracted descent, arrest of descent, and failure of descent. All abnormalities have a strong association with cephalopelvic disproportion but may also occur in the presence of maternal obesity, uterine infection, excessive sedation, and fetal malpositions. Interpretation of the progress of fetal descent must be made in the context of other clinically discernable events and observations. These include fetal size, position, attitude, and degree of cranial molding and related evaluations of pelvic architecture and capacity to accommodate the fetus, uterine contractility, and fetal well-being. Oxytocin infusion can often resolve an arrest or failure of descent or a protracted descent caused by an inhibitory factor, such as a dense neuraxial block. It should be used only if thorough assessment of fetopelvic relationships reveals a low probability of cephalopelvic disproportion. The value of forced Valsalva pushing, fundal pressure, and routine episiotomy has been questioned. They should be used selectively and where indicated., (Copyright © 2022 Elsevier Inc. All rights reserved.)

The active phase of labor begins at various degrees of dilatation when the rate of dilatation transitions from the relatively flat slope of the latent phase to a more rapid slope. No diagnostic manifestations demarcate its onset, other than accelerating dilatation. It ends with apparent slowing of dilatation, a deceleration phase, which is usually short in duration and frequently undetected. Several aberrant labor patterns can be detected during the active phase, including protracted dilatation, arrest of dilatation, prolonged deceleration phase and failure of descent. Underlying factors may include cephalopelvic disproportion, excessive neuraxial block, poor uterine contractility, fetal malpositions, malpresentations, uterine infection, maternal obesity, advanced maternal age and previous cesarean delivery. When an active-phase disorder is identified, cesarean delivery is justifiable if there is compelling clinical evidence of disproportion. A prolonged deceleration disorder is strongly associated with disproportion and second stage abnormalities. Shoulder dystocia may occur if vaginal delivery eventuates. This review discusses several issues raised by the introduction of new clinical practice guidelines for labor management., (Copyright © 2022 Elsevier Inc. All rights reserved.)

The latent phase of labor extends from the initiation of labor to the onset of the active phase. Because neither margin is always precisely identifiable, the duration of the latent phase often can only be estimated. During this phase, the cervix undergoes a process of rapid remodeling, which may have begun gradually weeks before. As a consequence of extensive changes in its collagen and ground substance, the cervix softens, becomes thinner and dramatically more compliant, and may dilate modestly. All of these changes prepare the cervix for the more rapid dilatation that will occur during the active phase to follow. For the clinician, it is important to recognize that the latent phase may normally extend for many hours. The normal limit for the duration of the latent phase should be considered to be approximately 20 hours in a nullipara and 14 hours in a multipara. Factors that have been associated with a prolonged latent phase include deficient prelabor or intrapartum cervical remodeling, excessive maternal analgesia or anesthesia, maternal obesity, and chorioamnionitis. Approximately 10% of women with a prolonged latent phase are actually in false labor, and their contractions eventually abate spontaneously. The management of a prolonged latent phase involves either augmenting uterine activity with oxytocin or providing a sedative-induced period of maternal rest. Both are equally effective in advancing the labor to active phase dilatation. A very long latent phase may be a harbinger of other labor dysfunctions., (Copyright © 2022 Elsevier Inc. All rights reserved.)

There is no doubt that parturition can produce fetal and neonatal adversity, but the frequency with which this occurs is uncertain, particularly in modern healthcare settings. Moreover, there is a paucity of recent studies in this area. Substantial challenges impede epidemiologic study of the effect of parturition on offspring. Randomized trials would be ethically fraught. Therefore, large observational samples with detailed data concerning labor and delivery events are needed. Importantly, long-term follow-up of infants is necessary to reach reliable conclusions. Few such data sets exist, and it is difficult, expensive, and time-consuming to create and to study them. Reports of immediate newborn condition in relation to the antecedent labor are helpful, but this evidence is an imperfect predictor of long-term neurologic status. In this review, we endeavor to summarize existing information about the relationship between objectively defined abnormalities of labor progress and long-term disability in offspring. The only data available are from collected experiential information on outcomes stratified according to labor and delivery events. Most studies do not ensure against confounding by the many concurrent conditions that may affect outcome, or use inconsistent criteria to define abnormal labor. According to the best available evidence, dysfunctional labor patterns are potentially associated with poor outcomes for surviving infants. The question of whether these adverse effects can be mitigated by early diagnosis and expeditious management deserves to be answered, but cannot be at this time. In the absence of more conclusive results from well-designed studies, we can conclude that the best interests of offspring are served by adhering to evidence-based paradigms for the prompt identification and treatment of dysfunctional labor patterns., (Copyright © 2022 Elsevier Inc. All rights reserved.)

When the history of the COVID-19 pandemic is written, the failure of many states to live up to their human rights obligations should be a central narrative. The pandemic began with Wuhan officials in China suppressing information, silencing whistleblowers, and violating the freedom of expression and the right to health. Since then, COVID-19's effects have been profoundly unequal, both nationally and globally. These inequalities have emphatically highlighted how far countries are from meeting the supreme human rights command of non-discrimination, from achieving the highest attainable standard of health that is equally the right of all people everywhere, and from taking the human rights obligation of international assistance and cooperation seriously. We propose embedding human rights and equity within a transformed global health architecture as the necessary response to COVID-19's rights violations. This means vastly more funding from high-income countries to support low-income and middle-income countries in rights-based recoveries, plus implementing measures to ensure equitable distribution of COVID-19 medical technologies. We also emphasise structured approaches to funding and equitable distribution going forward, which includes embedding human rights into a new pandemic treaty. Above all, new legal instruments and mechanisms, from a right to health treaty to a fund for civil society right to health advocacy, are required so that the narratives of future health emergencies-and people's daily lives-are ones of equality and human rights., Competing Interests: Declaration of interests LOG is Director of the WHO Collaborating Center on National and Global Health Law, is a member of WHO's International Health Regulations Review Committee, and is a member of the Independent Panel for a Global Public Health Convention. WHO paid for LOG's travel for an International Health Regulations Review Committee meeting. All other authors declare no competing interests., (Copyright © 2023 Elsevier Ltd. All rights reserved.)

The ongoing debate about what models of cervical dilatation and fetal descent should guide clinical decision-making has sown uncertainty among obstetric practitioners. We previously argued that the adoption of recently published labor assessment guidelines promoted by the American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine may have been premature. Before accepting any new clinical approaches as the standard of care, their underlying hypotheses should be thoroughly tested to ensure they are at least equivalent (or, preferably, superior) to existing management paradigms. Some of the apparent urgency to subscribe to new clinical tactics has been fueled by legitimate concerns about the rise in the cesarean delivery rate over the past several decades. A major contributor to this change in practice patterns is that more cesarean deliveries are being done for diagnoses that fall under the rubric of dystocia than ever before. As a consequence, traditional labor curves-fundamental for assessing labor progress-and the practice paradigms associated with them have received intense scrutiny as a possible contributor to this delivery trend. Moreover, the recent proposal of new labor curves and accompanying management guidelines has, understandably, fed the appetite to correct a perceived problem. However, the cesarean delivery rate rose most rapidly during decades when there was no major change in traditional labor curves or in the guidelines for their interpretation. Also, during the years since the new guidelines were first published, there has been no major fall in cesarean delivery frequency. This raises the question of whether there was truly a fundamental flaw in the traditional labor management paradigms or whether their proper interpretation and use had been somehow forgotten, ignored, or corrupted. More important, existing studies have shown that application of the new guidelines often (but not always) results in a modest fall in the cesarean delivery rate, but that this change may be accompanied by significant increases in maternal and neonatal morbidity. These results strongly suggest more caution in the adoption of the American College of Obstetricians and Gynecologists / Society for Maternal-Fetal Medicine labor assessment recommendations. They are based on a hypothesis that has yet to undergo thorough evaluation of its risks and benefits., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Three candidates to be the next WHO Director-General remain: Tedros Adhanom Ghebreyesus, David Nabarro, and Sania Nishtar. The World Health Assembly's ultimate choice will lead an organisation facing daunting internal and external challenges, from its own funding shortfalls to antimicrobial resistance and immense health inequities. The new Director-General must transform WHO into a 21st century institution guided by the right to health. Topping the incoming Director-General's agenda will be a host of growing threats-risks to global health security, antimicrobial resistance, non-communicable diseases, and climate change-but also the transformative potential of the Sustainable Development Goals, including their universal health coverage target. Throughout, the next Director-General should emphasise equality, including through national health equity strategies and, more boldly still, advancing the Framework Convention on Global Health. Success in these areas will require a reinvigorated WHO, with sustainable financing, greater multisector engagement, enhanced accountability and transparency, and strengthened normative leadership. WHO must also evolve its governance to become far more welcoming of civil society and communities. To create the foundation for these transformative changes, the Director-General will need to focus first on gaining political support. This entails improving accountability and transparency to gain member state trust, and enabling meaningful civil society participation in WHO's governance and standing up for the right to health to gain civil society support. Ultimately, in the face of a global environment marked by heightened nationalism and xenophobia, member states must empower the next Director-General to enable WHO to be a bulwark for health and human rights, serving as an inspiring contra-example to today's destructive politics, demonstrating that the community of nations are indeed stronger together., (Copyright © 2017 Elsevier Ltd. All rights reserved.)

In a recent review we expressed concerns about new guidelines for the assessment and management of labor recommended jointly by the American Congress of Obstetricians and Gynecologists (ACOG) and the Society for Maternal-Fetal Medicine (SMFM). These guidelines are based heavily on a new concept of how cervical dilatation and fetal descent progress, derived from the work of Zhang et al. In their Viewpoint article they have addressed, but not allayed, the concerns we described in our review. We assert that the dilatation curve promulgated by Zhang et al cannot be reconciled with direct clinical observation. Even if they were correct, however, it still does not follow that the ACOG/SMFM guidelines should recommend replacing the coherent system of identifying and managing labor aberrations described by Friedman. That system is grounded in well-established clinical principles based on decades of use and the objectively documented association of some labor abnormalities with poor fetal and maternal outcomes. Recommendations for new clinical management protocols should require the demonstration of superior outcomes through extensive, preferably prospective, assessment. Using untested guidelines for the management of labor may adversely affect women and children. Even if those guidelines were to reduce the currently excessive cesarean delivery rate, the price of that benefit is likely to be a trade-off in harm to parturients and their offspring. The nature and degree of that harm needs to be documented before considering adoption of the guidelines., (Copyright © 2015 Elsevier Inc. All rights reserved.)

The Ebola virus disease outbreak in west Africa is pivotal for the worldwide health system. Just as the depth of the crisis ultimately spurred an unprecedented response, the failures of leadership suggest the need for innovative reforms. Such reforms would transform the existing worldwide health system architecture into a purposeful, organised system with an empowered, highly capable WHO at its apex and enduring, equitable national health systems at its foundation. It would be designed not only to provide security against epidemic threats, but also to meet everyday health needs, thus realising the right to health. This retrospective and prospective analysis offers a template for these reforms, responding to the profound harms posed by fragile national health systems, delays in the international response, deficient resource mobilisation, ill defined responsibilities, and insufficient coordination. The scope of the reforms should address failures in the Ebola response, and entrenched weaknesses that enabled the epidemic to reach its heights., (Copyright © 2015 Elsevier Ltd. All rights reserved.)

Recent guidelines issued jointly by the American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine for assessing labor progress differ substantially from those described initially by Friedman, which have guided clinical practice for decades. The guidelines are based on results obtained from new and untested methods of analyzing patterns of cervical dilatation and fetal descent. Before these new guidelines are adopted into clinical practice, the results obtained by these unconventional analytic approaches should be validated and shown to be superior, or at least equivalent, to currently accepted standards. The new guidelines indicate the patterns of labor originally described by Friedman are incorrect and, further, are inapplicable to modern obstetric practice. We contend that the original descriptions of normal and abnormal labor progress, which were based on direct clinical observations, accurately describe progress in dilatation and descent, and that the differences reported more recently are likely attributable to patient selection and the potential inaccuracy of very high-order polynomial curve-fitting methods. The clinical evaluation of labor is a process of serially estimating the likelihood of a safe vaginal delivery. Because many factors contribute to that likelihood, such as cranial molding, head position and attitude, and the bony architecture and capacity of the pelvis, graphic labor patterns should never be used in isolation. The new guidelines are based heavily on unvalidated notions of labor progress and ignore clinical parameters that should remain cornerstones of intrapartum decision-making., (Copyright © 2015. Published by Elsevier Inc.)

Establishing a reform agenda for the World Health Organization (WHO) requires understanding its role within the wider global health system and the purposes of that wider global health system. In this paper, the focus is on one particular purpose: achieving universal health coverage (UHC). The intention is to describe why achieving UHC requires something like a Framework Convention on Global Health (FCGH) that have been proposed elsewhere,(1) why WHO is in a unique position to usher in an FCGH, and what specific reforms would help enable WHO to assume this role., (Copyright © 2013 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved.)

Continuous growth of the end stage renal disease population treated by dialysis, outpaces deceased donor kidneys available, lengthens the waiting time for a deceased donor transplant. As estimated by the United States Department of Health & Human Services: '17 people die each day waiting for transplants that can't take place because of the shortage of donated organs.' Strategies to expand the donor pool--public relations campaigns and Drivers' license designation--have been mainly unsuccessful. Although illegal in most nations, and viewed as unethical by professional medical organizations, the voluntary sale of purchased donor kidneys now accounts for thousands of black market transplants. The case for legalizing kidney purchase hinges on the key premise that individuals are entitled to control of their body parts even to the point of inducing risk of life. One approach to expanding the pool of kidney donors is to legalize payment of a fair market price of about 40,000 dollars to donors. Establishing a federal agency to manage marketing and purchase of donor kidneys in collaboration with the United Network for Organ Sharing might be financially self-sustaining as reduction in costs of dialysis balances the expense of payment to donors.

Background: Impaired red blood cell deformability may play a key role in the pathogenesis of chronic vascular complications of diabetes mellitus and progression of renal failure. The present study was conducted to test whether impaired red blood cell deformability is indeed associated with development of diabetic nephropathy., Methods: We studied 57 adult type 2 diabetic patients divided into three groups according to serum creatinine concentration. Group I comprised 28 diabetic patients with normal renal function (serum creatinine concentration <1.5 mg/dL, mean 1.0 +/- 0.3 mg/dL). Group II comprised 10 diabetic patients with renal insufficiency (serum creatinine concentration ranging from 2 to 6 mg/dL, mean 3.9 +/- 1.54 mg/dL). Group III consisted of 19 diabetic subjects with end-stage renal disease (ESRD) on hemodialysis (serum creatinine concentration ranging from 7.7 to 14.6 mg/dL, mean 10.1 +/- 2.4 mg/dL). In addition, 11 (mean serum creatinine concentration 4.2 +/- 1.5 mg/dL) and 10 (mean serum creatinine concentration 11.5 +/- 3.6 mg/dL) nondiabetic individuals, matched renal function for the diabetic groups (group II and III, respectively) served as control. Red blood cell deformability, measured by filtration technique, is defined as the filtration rate of erythrocyte suspension through a micropore filter divided by the filtration rate of a physiologic buffer solution., Results: In the diabetic cohort, we found substantially impaired red blood cell deformability in those with normal renal function (group I). With further renal function loss, an increased impairment in red blood cell deformability was observed. Diabetic patients with renal insufficiency (group II) when compared to non-diabetic controls (renal insufficiency) had a significantly greater impairment in red blood cell deformability (P= 0.01). The nondiabetic cohort (renal insufficiency), on the other hand, manifested significant impairment in red blood cell deformability. Their degree of impairment was statistically higher than that in diabetic patients with normal renal function (P= 0.0005). Interestingly, there was a progressive increase in red blood cell deformability impairment, along with progression of renal insufficiency, and thus no significant difference in the degree of red blood cell deformability impairment was observed between diabetic and nondiabetic patients with ESRD (P= 0.52). There is significant correlation between serum creatinine and impairment in red blood cell deformability in both diabetic (group II plus III) (r= 0.43, P= 0.02) and nondiabetic (r= 0.62, P= 0.003) cohorts., Conclusion: In diabetic patients, early impairment in red blood cell deformability appears in patients with normal renal function, and progressive impairment in red blood cell deformability is associated with renal function loss in all patients regardless of the presence or absence of diabetes.

This article reviews reported evidence on the clinical aspects of chronic renal insufficiency, proffers the relative roles of nephrologist and nonnephroloist in the management of chronic renal insufficiency and highlights common errors in the management of patients with chronic renal insufficiency. A paradigm is proposed for management of individuals with progressive chronic renal insufficiency according to evidence of efficacy of options in intervention. Recognizing the interdependence of generalist/family physician and nephrologist, key issues surrounding the timing of referral for specialized renal care are examined. By preparing the patient for future uremia therapy well in advance of need, the stress of coping with a life-threatening crisis can be muted and selection of a specific modality (peritoneal dialysis, hemodialysis, renal transplantation) can be made with full thought, family support, and the time to effect the regimen. Common errors in handling patients with deteriorating renal function are examined with advice for their avoidance.

Renal disorders attributed to diabetes mellitus are increasingly recognized as the dominant feature of long-term management. Renal failure in diabetic patients is the most commonly recognized cause of irreversible uremia in the United States, Europe, and Japan. Treating hypertension and normalizing hyperglycemia slows the previously thought inexorable progress of renal insufficiency in diabetes. Once end-stage renal disease has developed, either dialytic therapy or a renal transplant affords life extension, often with excellent rehabilitation.

We studied skin biopsies from 14 patients after 6 months to 18 years on hemodialysis (HD) to discern any effect of duration of treatment on skin and dermal capillaries. Patients selected for biopsy were without evidence of other diseases known to affect vasculature such as diabetes mellitus. Pathological changes compared with duration of HD were: capillary wall thickening, endothelial proliferation and new capillary formation, lipid content, and epidermal atrophy. Severity of morphologic changes were graded from 0 to 4+ by a pathologist who had no knowledge of HD duration. The earliest change observed was reduplication of the capillary basement membrane. Narrowing of capillary lumina due to endothelial cell proliferation and new capillary formation were noted after five years of HD; lipid droplets were noted in capillaries by five years; and epidermal atrophy by 10 years. Progressive severity of each finding was associated with length of time on HD. Neither amyloid nor Ca++ deposits were observed in any specimens. By clinical observation, easy bruisability and increased skin fragility were worse the longer the patient was on HD. Capillary occlusion inducing tissue ischemia could be a cause of the atrophic skin changes noted. However, no patient manifested dermal necrosis. While pathogenesis of the capillary changes in uremic skin is unknown, the changes have been shown to stabilize following successful kidney transplantation.

In diabetes and ageing, glucose-derived advanced glycosylation endproducts (AGEs) cross-link proteins and cause vascular tissue damage. Elimination of circulating low-molecular weight AGE-modified molecules (LMW-AGEs) by the kidney is impaired in diabetic patients with end-stage renal disease, a group subject to accelerated atherosclerosis. We determined the effectiveness of current renal replacement treatments on elimination of serum LMW-AGEs in diabetic and non-diabetic patients with end-stage renal disease. Although diabetic patients receiving high-flux haemodialysis achieved 33% lower steady-state serum LMW-AGE than did those in conventional haemodialysis (p < 0.005), LMW-AGE concentrations remained 3.5-6 fold above normal, whether high-flux dialysis, conventional haemodialysis, or chronic ambulatory peritoneal dialysis were used. High-flux haemodialysis markedly reduced AGE during each treatment session (47.9% in the diabetic, p < 0.001 and 60.6% in the non-diabetic group, p < 0.001) but concentrations returned to pre-treatment range within 3 hours. In contrast, normal LMW-AGE concentrations were maintained in patients with functioning renal transplants. We found that LMW-AGEs with an apparent molecular weight of 2000-6000 circulate and retain strong inherent chemical reactivity--when exposed to collagen in vitro, up to 77% attached covalently to form AGE-collagen, and the AGE-crosslink inhibitor aminoguanidine completely inhibited this reaction. The results suggest that LMW-AGEs comprise a set of chemically-reactive molecules that are refractory to removal by current dialysis treatments. Through covalent reattachment onto vascular matrix or serum components, LMW-AGEs may exacerbate vascular pathology associated with end-stage renal disease.

A study was made of the relationship between electronic fetal heart monitoring and the Apgar score in 14,350 babies delivered between 1970 and 1975 at Beth Israel Hospital, Boston. Simple comparison of Apgar scores in monitored and unmonitored babies showed no difference at 5 minutes. When we controlled for gestational age and other potential confounders, a different pattern emerged. In a group of obviously high-risk pregnancies, monitored babies had a more favorable distribution of 5-minute Apgar scores (3.8% instead of 7.2% with a score below 6, P = 0.020). This group contained the 7.4% of all babies who were greater than or equal to 36 weeks of gestational age at highest risk (with problems such as hydramnios, multiple pregnancy, placental complication, or malpresentation). A similar trend for babies less than 36 weeks' gestational age with the same obstetric complications did not achieve statistical significance. There was no evidence for benefit in the other risk categories.

Developmental studies were done at 3 and 4 years of age in a series of 656 children and the results were correlated with the preceding labor pattern and the type of delivery. It was determined that there were significant adverse effects among offspring delivered by midforceps procedures or born following labors characterized by prolonged deceleration, secondary arrest of dilatation, or arrest of descent.

A survey of CAPD/CCPD patients with end-stage renal disease attributed to diabetes mellitus done by the USA NIH CAPD Registry obtained information from 499 patients. These data suggest that in diabetics with renal insufficiency, the time interval from age at diagnosis of diabetes to initiation of dialysis decreases as the age of diagnosis increases. Mean interval from the time of diabetes diagnosis to CAPD or CCPD initiation was 25 years for patients less than 20 years of age at diagnosis and 17 years for patients greater than or equal to 30 years of age. This trend is independent of the type of diabetes management and appeared to be independent of the type of diabetes. Patients were categorized on the basis of pre- and post-CAPD management of hyperglycemia. There were several associations noted between type of diabetes therapy and clinical findings: A higher proportion of legally blind patients had used insulin only (33%) compared with patients never using insulin (10%) and 78% of patients using insulin only were white compared with 49% among the never on insulin group. This latter result indicates that race influences the type of diabetes and/or progression of diabetes to renal insufficiency. Patients on insulin only reported parents and/or siblings with diabetes less often than did patients using insulin and oral agents, some insulin, or never any insulin to manage their diabetes. The authors also noted that peritonitis rates were not increased in those patients who added insulin to dialysis solutions.

The risk of developing contrast media-induced acute renal failure was studied in 49 randomly selected nonazotemic type 2 adult diabetic patients subjected to IVU. There were 19 men and 30 women in the group whose mean age was 62 +/- 10 years (range, 38 to 82 years). In preparation for IVU, patients were neither dehydrated nor given a laxative. The IVU was performed in the morning, using sodium diatrizoate and meglumine diatrizoate. Serum creatinine levels were measured pre-IVU and on days 1, 3, and 6 after the IVU. A total of three patients (6%) had an elevation of serum creatinine greater than 25% above the baseline by post-IVU day 3. One patient developed oliguria (less than 400 ml/24 hr) that lasted 2 days. Creatinine clearances of the three patients showing contrast media toxicity were 74, 60, and 105 ml/min pre-IVU. In each of the three patients, a return to pre-IVU serum creatinine concentration was noted within 2 weeks. It is concluded that the risk of acute renal failure post-IVU is small in hydrated nonazotemic type 2 diabetic patients.

Rats with hyperlipidemia associated with streptozotocin-induced diabetes or azotemia after subtotal nephrectomy were administered a diet containing 5% activated charcoal. Significant lowering of nonfasting serum cholesterol and triglyceride levels resulted. Charcoal-feeding also altered the abnormal high density lipoprotein electrophoresis pattern of diabetic rats toward normal.

A retrospective review was conducted of all pregnant women discharged undelivered during fiscal year 1985. If the current Medicare prospective payment plan were applied to these admissions, Diagnostic Related Group 383 (other antepartum diagnoses with medical complications) and Diagnostic Related Group 384 (other antepartum diagnoses without medical complications) would together generate a negative cash flow. Supplementation for capital costs and direct and indirect medical education costs would result in a positive cash flow; however, the supplementation is vulnerable to political and social forces that will tend to diminish or eliminate it.

Significant hypertriglyceridemia, the most common lipid abnormality in renal failure, first occurs when the creatinine clearance falls to 50 ml/min. The prevalence of hypertriglyceridemia continues to rise as creatinine clearance falls further with the highest rate developing at a creatinine clearance less than 10 ml/min. Hypertriglyceridemia is correlated with plasma glucagon levels but not growth hormone or insulin. Plasma cholesterol values remain normal in the face of deteriorating renal function and show no correlation with any of the hormones measured. Although all three hormones became elevated as renal function diminished, none were directly correlated with glomerular filtration rate. There was a distinct decrease in the prevalence of hyperlipidemia after 5 years of maintenance hemodialysis therapy. Plasma growth hormone and glucagon through an effect on plasma triglyceride and plasma insulin by effecting plasma cholesterol may play a role in this decline of hyperlipidemia with duration of hemodialysis.

We report the results of a study of 40 consecutive conditions seen in 38 ambulatory diabetics at a municipal hospital podiatry clinic and a university hospital nephrology clinic. The vast majority (92.5%) were preventable, had appropriate foot care procedures been followed. It is suggested that the lack of emphasis on prevention of foot pathology in diabetics by criteria for fee-for-service payment in medicine leads to excessive and unnecessary limb morbidity.

Prostaglandin E2 was administered orally for induction of labor in 100 normal term gravidas with two dosage regimens. The data derived were compared with comparable data from gravidas matched with study patients according to prelabor cervical preparation and other relevant obstetric and actuarial features. Analysis of patterns of cervical dilatation and station vs. time was carried out. A dose of 0.5 mg. hourly was found to be effective in inducing labor of good quality with minimal side effects, providing a better balance between efficacy and adverse reactions than the higher dosage level.

A matched control study was undertaken in which 156 children were examined between ages 23 and 62 months after births associated with spontaneous labor, oxytocin-induced labor, or prostaglandin E2 (PGE2)--induced labor. Physical development was not adversely affected by labor induction based on height and weight percentiles. The frequency of neurologic or developmental abnormalities not attributable to postdelivery events was the same overall in induced and spontaneous labors (19.2 per 1,000), but those abnormalities occurring after labor induction all followed use of oxytocin. None followed PGE2 despite case-selection criteria which specifically chose PGE2 cases from among those with documented adverse drug-related reactions.