Prospective diagnosis of 1,006 consecutive cases of congenital heart disease in the fetus.

OBJECTIVE: This report describes our experience with fetal congenital heart disease since 1980. BACKGROUND: Knowledge and expertise in the diagnosis, management and natural history of fetal congenital heart disease is increasingly demanded by both obstetricians and parents. The analysis of a large series should help the pediatric cardiologist to provide this service. METHODS: The notes of 1,006 patients, where a prospective diagnosis of fetal congenital heart disease was made, were reviewed. The reason for referral, the diagnosis made, the accuracy of diagnosis, the fetal karyotype and the outcome of the pregnancy were noted. The cases were grouped into malformation categories, and the spectrum of disease seen was compared with that found in infants. RESULTS: Most fetal cardiac anomalies are now suspected by the ultrasonographer during obstetric scanning. A different incidence of abnormalities is seen compared with that expected in infants. Chromosomal anomalies were more frequent in the fetus than in live births. The accuracy of diagnosis was good. The survival rate after diagnosis was poor because of frequent parental choice to interrupt pregnancy and the complexity of disease. CONCLUSIONS: A large experience with fetal congenital heart disease allows the spectrum of disease to be described with accuracy and compared with that in infancy. Knowledge of the natural history of heart malformations when they present in the fetus allows accurate counseling to be offered to the parents. If the trend in parental decisions found in this series continues, a smaller number of infants and children with complex cardiac lesions will present in postnatal life.

Abuse history and chronic pain in women: I. Prevalences of sexual abuse and physical abuse.

OBJECTIVE: To compare the prevalences of childhood and adult physical and sexual abuse in women with chronic pelvic pain to those in women with chronic nonpelvic pain (headache) and pain-free women. METHODS: Using a structured interview, we assessed the prevalence rates of both sexual abuse and physical abuse in 64 women with chronic pelvic pain, 42 women with chronic headache, and 46 pain-free women. Abuse histories were stratified by age at occurrence and severity. Demographic characteristics of the three groups were also assessed. RESULTS: Women with chronic pelvic pain were found to have a higher lifetime prevalence of sexual abuse, involving penetration or other contact with the unclothed genitals or anus (ie, major sexual abuse), than either comparison group. Further, more women in the chronic pelvic pain group had experienced major sexual abuse in both childhood and adulthood than women in the headache group, but there was no difference with the pain-free group. With respect to physical abuse, women in the chronic pelvic pain group had a higher lifetime prevalence than pain-free women, but not compared to those with chronic headache. In addition, more women with chronic pelvic pain reported physical abuse in both childhood and adulthood and both major sexual abuse and physical abuse at some time in their lives than did either comparison group. CONCLUSIONS: These results support a specific association between major sexual abuse and chronic pelvic pain and a more general association between physical abuse and chronic pain. Moreover, the global nature of the abuse histories of the women in the chronic pelvic pain group suggests that more rigorous studies of the relation between abuse history and chronic pelvic pain are needed.

Abuse history and chronic pain in women: II. A multivariate analysis of abuse and psychological morbidity.

OBJECTIVE: To assess the potential role of childhood and adulthood physical and sexual abuse and complaints of chronic pain in accounting for psychiatric symptomatology in adult women. METHODS: We assessed sexual abuse, physical abuse, depression, anxiety, and somatization in 64 women with chronic pelvic pain, 42 women with chronic headache, and 46 women without chronic pain complaints. Using multiple regression analyses, we tested a model comprising sociodemographic, chronic pain, childhood sexual abuse and physical abuse, and adulthood sexual abuse and physical abuse variables in the prediction of depression, anxiety and somatization. RESULTS: This model significantly predicted all three outcomes. However, childhood sexual abuse was not significant in the prediction of any of the outcome variables, whereas childhood physical abuse was significant in the prediction of all three. Further, the adulthood abuse variable set contributed significantly to the prediction of somatization, and the individual variable of adulthood sexual abuse was predictive of anxiety. CONCLUSIONS: The relation observed between childhood sexual abuse and the outcomes of depression, anxiety, and somatization in women may be a function of its association with other forms of abuse, particularly childhood physical abuse. Further investigation is clearly needed of the nature of the relations between the various categories of abuse and psychological morbidity.

Multidisciplinary approach to chronic pelvic pain.

Both diagnosis and management of CPP may be greatly facilitated by a multidisciplinary approach integrating specific medical interventions with cognitive-behavioral pain strategies and concurrent treatment of psychological morbidity. Available data suggest that measured outcomes, including pain severity, global health status, and somatization, associated with this approach are significantly better than those observed after isolated medical interventions. Because of the chronicity of many of the psychological and social variables predisposing to recurrent symptom formation, care must be continuous and longitudinal if recurrent adverse sequelae, including disability, inappropriate health care utilization, and depression, are to be prevented.

Workshop 8 (synthesis): challenges of expanding ecological sanitation into urban areas.

After seven papers discussing specific examples of ecological sanitation projects, the workshop considered the background, motivation and feasibility of this technology. It was agreed that ecological sanitation could help tackle water scarcity, health protection and, by recycling water and nutrients into agriculture, food scarcity. Dense cities are probably unsuitable for its implementation, but rural, town and peri-urban areas are promising. Key issues that remains are: the microbiological and chemical risks associated with the technology; the need for major information, education and support programmes; effective linking to reuse schemes; tailoring systems to meet local physical, socio-economic and cultural circumstances.

Use of Telephonetics RESULTS computer-facilitated telephone system with automatic results upload.

Our genitourinary medicine service implemented an automated telephone results system in 2010. This system is used in other services but few are able to upload negative results automatically from laboratory software. The use of this system reduced unanswered calls to a telephone results line and also the number of calls that had to be connected to clinical staff. Patients have better access to their results in a timely manner, as per the requirements of the recent Standards for the Management of Sexually Transmitted Infections document.

The effect of the local anaesthetic bupivacaine on the muscle spindle of rat.

The effects of a long-lasting local anaesthetic, bupivacaine, in combination with hyaluronidase, on the intrafusal muscle fibres of adult rat muscle spindles have been investigated by light and electron microscopy. Necrotic changes in the axial bundle are present within 4 h of the combined drug injection and are widespread by 2 days. The equatorial nucleation of the spindle is lost owing to the necrosis of the myonuclei. Satellite cells, however, appear to survive these changes, even where the underlying muscle fibres are grossly necrotic. Sensory nerve terminals undergo necrosis during this period and plate-type fusimotor nerve terminals withdraw from the degenerating muscle fibres. Macrophage infiltration and early regeneration of the axial bundle is apparent by the third day. Myoblasts first appear at the periphery of the affected muscle fibres, but decrease in number as regeneration proceeds. By the end of the third week, regeneration of the muscle component is complete and re-innervating fusimotor nerve terminals established. The encapsulated regions of the spindle remain abnormal, without recognizable bags or chains of nuclei, although the muscle fibres differ both in size and ultrastructure. Regenerating sensory axons make contacts with the intrafusal bundle that differ in their configuration and ultrastructure from normal terminals. The production of enucleated spindles is discussed in the light of the morphogenetic influences of the spindle nerve terminals, as well as the possible use of such a model in discovering the function of nuclear bags and nuclear chains.

Stages in the development of cat muscle spindles.

The structure of developing spindles has been examined in cat peroneal muscles by light and electron microscopy, beginning at the 34- to 38-day foetal stage. By this stage alpha motoneurons have formed end-plates on primary myotubes. Secondary extrafusal myotubes then develop beneath the basal lamina of primary myotubes, and are innervated by motor axons early in their assembly. First-series secondary myotubes separate from primary myotubes prior to the development of subsequent series. The assembly of extrafusal fibres is completed by birth. Intrafusal fibres assemble in a similar manner. At the 34- to 38-day foetal stage developing spindles consist of a single primary myotube containing a small accumulation of myonuclei beneath the terminals of the Ia afferent axon. Simple motor nerve terminals also innervate this myotube, which will ultimately become the bag2 fibre of the mature spindle. Secondary intrafusal myotubes then assemble beneath the basal lamina of the primary bag2 myotube, in the order presumptive bag1, long-chain, intermediate-chain and typical-chain fibres. Their assembly begins at the equator, beneath the sensory terminals, and spreads to the poles. The bag1 and long-chain myotubes separate from the bag2 in the spindle pole prior to the development of the other chain fibres. The assembly of intrafusal fibres is completed by birth. The periaxial space begins to develop in the first postnatal week. The development of tandem spindles containing b2c units is described. The role of sensory and motor innervation in the assembly and differentiation of mammalian intrafusal fibres is discussed.

The effects of temporary ischaemia on rat muscle spindles.

Soleus muscle of adult rat is revascularized 5-8 days after sectioning the supplying blood vessels. The temporary ischaemia thus produced results in the rapid concomitant degeneration of extra- and intrafusal muscle fibres along with their nerve terminals and supplying axons. The basal lamina of all muscle fibres usually remains intact throughout the degenerative phase. Necrotic sarcoplasm is removed by phagocytic cells. Satellite cells survive the temporary ischaemia and give rise to presumptive myoblasts which fill the basal-lamina tubes. These myoblasts fuse to form myotubes which, by the 14th day after devascularization, are maturing into muscle fibres in the absence of any innervation. Within the spindle, nuclear-bag fibres degenerate more rapidly than nuclear-chain fibres. Regeneration proceeds more rapidly within the basal-lamina tubes of the original bag fibres than within those of the chain fibres. Reinnervation of regenerating extra- and intrafusal fibres begins 21 days after devascularization and is completed some 7 days later, during which time further equatorial differentiation of some reinnervated intrafusal fibres may occur. Regenerated spindles vary considerably with respect to their innervation and equatorial nucleation. Most contain short, thin, additional muscle fibres as well as those that have regenerated within the basal-lamina tubes of the original fibres.

Outcome of intermittent tachyarrhythmias in the fetus.

Persistent fetal tachycardias are known to have an adverse effect on fetal outcome. The outcomes of intermittent fetal tachyarrhythmias over a 12-year period at a tertiary fetal cardiology center were studied. Main outcome criteria included control of arrhythmia and death during the prenatal or postnatal period. A total of 28 fetuses had an intermittent tachyarrhythmia: 4 had intermittent atrial flutter and 24 had supraventricular tachycardia. At the time of presentation 14 fetuses were hydropic, and in 5 of the 14 an arrhythmia had not been noted prior to referral. Of the 28 fetuses, 23 were treated by drug administration to the mother. Control of arrhythmia was achieved in 10 of 11 (91%) nonhydropic fetuses and 8 of 12 (67%) hydropic fetuses, with resolution of hydrops in four cases. In the overall group there was one intrauterine death, two neonatal deaths, and one infant death, all of which occurred in the hydropic group. The arrhythmia recurred postnatally in 11 of 23 (48%) fetuses. We conclude that intermittent tachyarrhythmias may have a deleterious effect on the fetus with a significant risk of death pre- or postnatally. The fetus with nonimmune hydrops should be evaluated for a cardiac cause. Maternal antiarrhythmic therapy is indicated for intermittent fetal tachyarrhythmias. There is a high risk of recurrence of the arrhythmia during infancy, particularly if hydrops was documented during the prenatal period or if Wolff-Parkinson-White syndrome is diagnosed. Fetal echocardiography is a useful tool for diagnosis and for monitoring the progress of the fetus.

Correlation between sexual abuse and somatization in women with somatic and nonsomatic chronic pelvic pain.

After a comprehensive clinical and psychological evaluation, 99 women with pelvic pain of at least 6 months' duration and normal findings at laparoscopy were divided into two groups, including 47 women with probable somatic causes of pain (group 1) and 52 women without identifiable somatic abnormality (group 2). Women without identifiable somatic abnormality (group 2) were younger, had higher mean somatization scores, and reported an earlier mean age at first intercourse, a higher number of total sexual partners, and a higher prevalence of sexual abuse before the age of 20. Within group 2 (nonsomatic pain) but not within group 1, mean somatization scores were significantly higher among women with a history of sexual abuse than among women with a negative history. When analyzed as risks for nonsomatic pelvic pain, the positive predictive value of both a history of sexual abuse and a high somatization score was 78% (relative risk compared with that of women with zero or one risk factor, 2.1; p less than 0.0001). These data suggest that the psychosocial profile of women with nonsomatic pelvic pain differs from that of women with somatic pelvic pain and that previous sexual abuse is a significant predisposing risk for somatization and non-somatic chronic pelvic pain.