ajn@lww.com AJN June 2006 Vol. 106, No. 6 19

was found to support the follow-ing conclusions: that CDMRlessens the risk of maternal hem-orrhage, prolongs the length ofmaternal hospital stay, increasesthe neonate’s risk of life-threaten-ing respiratory distress, andincreases the risk of placentalabnormalities in subsequentpregnancies.

There was weak or no evi-dence to support any other con-clusions. The panel concludedthat “there is insufficient evi-dence to evaluate fully the benefits and risks of CDMR ascompared to PVD [planned vagi-nal delivery], and more researchis needed.” When pregnantwomen request cesarean deliverybut there is no medical reason toperform one, the report recom-mends that each case be consid-ered individually. The providershould address the mother’s spe-

cific concerns and the evidencethat does exist. It further recom-mended that providers who pre-fer not to perform cesareansections without medical indica-tions refer women who requestthem to another provider.

Deanne Williams, executivedirector of the American Collegeof Nurse-Midwives, expressedconcern that the panel did notgive more weight to the lack ofevidence that CDMR is safe. Shereported that many experts at theconference expressed concernthat if the panel didn’t say out-right not to perform electivecesarean sections, its positionmight be interpreted by somepregnant women and theirproviders as “it’s okay to do it.”At least one expert, who testifiedabout the direct and indirectsocietal costs, expressed concernthat the longer maternal hospital

According to the NationalInstitutes of Health (NIH),the cesarean delivery rate

in the United States steadilyincreased from 1996 to 2004,peaking in 2004 at 29% of alllive births—the highest rate on record. But does maternalpreference for a cesarean deliv-ery account for some of thatincrease? And does a “cesareandelivery performed at maternalrequest” (CDMR) improve orworsen maternal and infant outcomes?

The National Institute ofChild Health and HumanDevelopment, part of the NIH,held a state of the science confer-ence from March 27 throughMarch 29 to examine the avail-able evidence on CDMR. Priorto the conference, a panel ofexperts commissioned by theAgency for Healthcare Researchand Quality prepared a reportevaluating the evidence.

In addition to maternal prefer-ence, there are numerous reasonsfor performing a cesarean sec-tion, including medical emergen-cies, such as placenta previa, andrisk factors that can complicatevaginal deliveries, such as obesityor advanced maternal age.

According to the evidencereport, virtually no studies existon CDMR, and the expert panelfound that there have been nodirect comparisons of outcomesof CDMR with vaginal delivery.Only 54 studies of even moder-ate relevance to CDMR werefound. None had a strong levelof evidence on which to baseclinical decisions.

A moderate level of evidence

Cesarean Section on Demand Some fear that the lack of evidence will be interpreted as evidence of safety.

Scie

nce

Phot

o Lib

rary

/Tra

cey

Diom

iney

News Director: Maureen Shawn Kennedy, MA, RNE-mail: shawn.kennedy@wolterskluwer.com

20 AJN June 2006 Vol. 106, No. 6 http://www.nursingcenter.com

Early-Life Antibiotic Treatment and Childhood AsthmaIs there a link worth exploring?

stays and neonatal intensive careadmissions associated withCMDRs are forcing some tertiarycare centers to turn away thehigh-risk cases for which theywere designed.

The panel’s report cautions that“CDMR should not be performedprior to 39 weeks or without veri-fication of fetal lung maturity,” orin women who want several chil-dren, and urged that effective painmanagement be made available toall women regardless of mode ofdelivery. The report, including anaudio transcript from the confer-ence, is available at http://consensus.nih.gov/2006/2006CesareanSOS027html.htm.—Fran Mennick BSN, RN

Scie

nce

Phot

o Lib

rary

/Ian

Bod

dy

According to data from the Centers for DiseaseControl and Prevention,

asthma currently ranks as the sec-ond most common chronic illness inchildren. It has not gone unnoticedthat this coincides with an increaseduse of antibiotics in young children.To determine whether there is alink, Canadian researchers con-ducted a metaanalysis of studies

examining the association betweenthe number of courses of antibiotictherapy received in infancy and thelater development of asthma.

They included studies publishedfrom January 1966 to September2004 if the studies“explicitly definedantibiotic exposure as the receipt ofat least one prescription for anantibiotic in the first year of life, and included the development of physician-diagnosed childhoodasthma between the ages 1 and 18years as an outcome.” The eight stud-ies (out of more than 2,000 reviewed)that met these criteria involved a totalof more than 12,000 children and1,817 asthma cases. Four of theeight studies were prospective andfour were retrospective.

Pooling the findings from all eightstudies suggested an associationbetween antibiotic treatment duringthe first year of life and subsequentdiagnosis of asthma. When sub-group analysis was performed, how-ever, this association was significantin the retrospective but not in theprospective studies. Methodologic

limitations could account for thisdifference because most retrospec-tive studies used parent-reporteddata rather than medical records,thus raising concerns of recall bias.

Other limitations of the studiesinclude the relatively small samplesizes (the largest involved 4,178patients), varying analyticapproaches, and inconsistencyregarding which confounders wereadjusted for. Of particular concernwas the presence of asthma in somechildren before antibiotic prescrip-tions were given, which could haveresulted in more frequent diagnosisof upper respiratory tract infectionand more frequent antibiotic use.Only one retrospective studyinvolved high-risk children.

The investigators concluded thatthe findings from their metaanalysisshowed a positive associationbetween the use of antibiotics and alater diagnosis of asthma but call for“large-scale, prospective studies . . .to confirm this potential associa-tion.” —Gail M. Pfeifer, MA, RNMarra F et al. Chest 2006;129(3):610-8.

Widow Sues HCA for Insufficient RN StaffingA class-action suit alleges poor patient care.

On behalf of his client MildredSpires, Wichita, Kansas, attorney

Lawrence Williamson, Jr., filed suit infederal court on April 10 against theHospital Corporation of America (HCA),claiming that the HCA’s corporate philos-ophy of placing profits before patientshas resulted in unsafe nurse-staffing levelsand resulted in Spires’s husband’s deathand poor care for patients in all HCA-owned hospitals. They are seeking class-action status and ask for more than $12billion in damages to be paid to HCApatients. Ms. Spires’s husband, JosephSpires, died in April 2004 while apatient in the ICU at Wesley MedicalCenter in Wichita, a facility owned by

the HCA. The lawsuit charges that the“HCA has engaged in systematic under-staffing of registered nurses throughout allof its hospitals. This systematic practiceplaces patients at increased risks for vari-ous health ailments, including infections,bed sores and death.”

Cheryl Johnson, RN, president of the United American Nurses, AFL-CIO,commented, “A hospital that choosesunsafe RN staffing levels generates higherpatient costs and invites preventable med-ical errors, adverse patient outcomes anddeaths, and, inevitably, lawsuits.” To readthe complaint filed in court, see www.kansas.com/multimedia/kansas/archive/pdfs/041106spireshca.pdf.

ajn@lww.com AJN June 2006 Vol. 106, No. 6 21

infant grandson lived next doorand had received the oral vaccineshortly after the student arrived.The young woman developedfever and malaise, which pro-gressed to headache, neck andback pain, and leg weakness. Bythe time she was transported byair to a Phoenix hospital, she hadlower extremity weakness andrespiratory failure that requiredintubation. Cerebrospinal fluidshowed lymphocytic pleocytosisand an elevated protein level.Stool specimens sent to a CDClaboratory showed Sabin-strainpoliovirus types 2 and 3. Afterhospitalization and rehabilita-tion, the young woman wenthome. She still had weakness in

both legs 60 days after the onsetof illness.

A CDC panel of polio expertsconfirmed that this was a case ofimported VAPP with the onset ofillness occurring before entry intothe United States. It illustrates the danger of traveling withoutrecommended immunizations,and the CDC recommends vacci-nation for all travelers to coun-tries in which polio is endemic or polio outbreaks occur.Information on vaccinationrequirements for internationaltravelers is available at www.cdc.gov/travel/yb/index.htm.—Joanna E. Cain, BSN, RN

Landaverde M, et al. MMWR Morb MortalWkly Rep 2006;55(4):97-9.

Vaccine-associated para-lytic polio (VAPP) hasbeen uncommon in the

United States since 2000, whenuse of the live, attenuated oralpolio vaccine was discontinuedin favor of an inactivated poliovaccine. A recent report fromthe Centers for Disease Controland Prevention (CDC) describesthe first case of imported VAPPin an unvaccinated Americancollege student who wasexposed to live vaccine whiletraveling abroad.

The 22-year-old woman, whowas never immunized againstpolio because of a religiousexemption, was living with aCosta Rican family. The family’s

FROM THE NATIONAL INSTITUTE OF NURSING RESEARCH

While most patients who are terminally ill with cancerretain their will to live, some report a desire to has-

ten their dying. But little is known about the relationships ofthis desire to other variables, whether it changes over time,or whether caregiving by a spouse influences a patient’sattitude.

As part of a larger study on spouses of patients withcancer, researchers surveyed patients with late-stagecancer (virtually all white, two-thirds male, with a mean age of 63 years), measuring depression, attitudetoward “hastened death,” spiritual well-being, maritalsatisfaction, and symptom distress. Half of the patientshad lung cancer and 90% had received chemotherapy.Their spouse caregivers completed surveys on the num-ber of hours spent providing care and how this alteredother activities, including work schedules and socialrelationships. Almost 180 couples initially consented toparticipate, but attrition was high: the final sample con-sisted of 60 couples.

On average, the patients did not have high levels ofdesire to hasten death. Those experiencing higher levelsalso had higher levels of depression and symptom distressand lower levels of spiritual well-being; their caregivers

also reported higher levels of stress. Caregivers reportedspending almost 40 hours a week providing care, report-ing low-to-moderate degrees of stress from caregiving.

When the patients were surveyed again approxi-mately four months later, an increased desire for deathwas found to be associated with a higher level ofdepression, more hours required for caregiving, andgreater marital satisfaction. This last finding was a sur-prise, and the authors suggest that it may indicate adesire of the ailing patient to avoid burdening thespouse.

The authors caution that their findings of low levels ofdesire to hasten death are inconsistent with other studies,perhaps because of differences in the setting (ambula-tory versus institutional) and the degree of physical limi-tations of the patients. They also acknowledge thehomogeneity and small sample of this study as limita-tions. They do note however, that when planning inter-ventions for people with advanced cancer, health careproviders “should consider aspects of the marital and thecaregiving relationships that might lead a patient toexperience heightened distress at the end of life.”Ransom S, et al. Ann Behav Med 2006;31(1):63-9.

The Desire of Terminally Ill Patients to Hasten DyingDepression, symptom distress, and spouse caregivers are important.

Imported Vaccine-Associated Paralytic PoliomyelitisA previously unrecognized risk.

mammogram don’t have breastcancer. Women who are at aver-age risk for breast cancer wouldprobably prefer a less invasiveprocedure, but the evidenceshows that the less invasive pro-cedures currently available,including magnetic resonanceimaging, ultrasonography,positron emission tomographicscanning, and scintimammogra-phy, would miss between 38 and93 cancers out of 1,000 cases.

Maryann Napoli, of theCenter for Medical Consumers,agrees. “This report confirmslongstanding medical advice thatbiopsy is a woman’s best shot ataccuracy,” she says. “However, if

I had a nonpalpable breast cancerdiagnosed as a result of mam-mography, I would have a secondpathologist examine the biopsyresults because of the frequentconfusion over differentiatingbetween atypia hyperplasia andductal carcinoma in situ (DCIS).And DCIS, which now represents20% of all newly diagnosedbreast cancers, does not alwaysprogress to a life-threatening dis-ease. The key is distinguishing theones with lethal potential.”

The full report is available athttp://effectivehealthcare.ahrq.gov/synthesize/reports/final.cfm?Document=4&Topic=32. —Linda Epstein, BSN, RN

Many women age 40and older undergoannual mammo-

graphic screening for early breastcancer, but what is the next stepwhen the mammogram is abnor-mal? Should it be a needlebiopsy, or are less invasive testsjust as precise?

According to a recent reviewof the research by the Agency forHealthcare Research and Quality,after an abnormal mammogram,biopsy, either by needle samplingor surgical excision, is still themost accurate procedure for diagnosing breast cancer. Yet80% of women who undergo tissue biopsy after an abnormal

NewsCAPSNewsCAPS

Follow-up for Abnormal MammogramsThe AHRQ says only a biopsy can confirm malignancy.

22 AJN June 2006 Vol. 106, No. 6 http://www.nursingcenter.com

ÄWashington’s RNs get helpwith safe patient handling. OnMarch 8, Washington governorChristine Gregoire signed legisla-tion into law requiring health careinstitutions to create policies thatpromote safe handling and movingof patients, as well as safe patienthandling committees (with at least50% of their members involved in direct care), and to provideequipment and education for safelylifting patients. This legislation wasa top priority for the WashingtonState Nurses Association;Washington is only the fourth state to have such legislation (afterNew York, Ohio, and Texas).

ÄNew York RNs rally in Albany.On April 4, more than 1,200 RNsand nursing students participatedin the annual Lobby Day spon-sored by the New York StateNurses Association, right. Stateleaders, including Senate majority

leader Joseph Bruno, spoke to thegroup, assuring them of his sup-port for legislation on who can usethe title “nurse” and for increasingscholarship funds to prepare nurse

faculty. Along with Assemblyspeaker Sheldon Silver, heannounced a combined $1.5 mil-lion to fund the safe patient han-dling bill passed last year. t

Cou

rtesy

of N

ew Y

ork

Stat

e N

urse

s A

ssoc

iatio

n