Reduced fetal movements and maternal medication - new pregnancy risk factors for neurodevelopmental disability in childhood.

A case-control study was undertaken of 471 children on the Nottingham Special Needs Register (SNR) who were born in one of the two maternity units in the city between 1987 and 1993 (inclusive). Controls were selected as the next infant born at the same hospital following each index case. The aim of the study was to identify risk factors on the Nottingham Obstetric Database for a baby subsequently appearing on the SNR. Disability was analysed by both ICD-9 coding and functional assessment. Factors which independently and significantly predicted a child's likelihood of being on the SNR were breech presentation (adjusted odds ratio (OR) = 4.0), congenital abnormality (OR=4.9), intrapartum fetal distress (OR=1.7), fetal growth restriction (OR=2.0), socioeconomic deprivation (OR=1.8), prematurity (OR=2.2), reduced fetal movements (OR=2.5) and medication in pregnancy (OR=10.4). To our knowledge the last two factors have not previously been reported as risk predictors for neurodevelopmental disability.

Genetic and environmental factors affecting bone mineral density in large families.

This study assessed whether relatives with low bone mineral density (BMD) could be identified in five large families using historical, biochemical, and genetic markers for osteoporosis. Fifty of 65 relatives had their bone density and bone turnover markers measured, together with an assessment of their risk factors for osteoporosis. Only 33% (5/15) of siblings, 50% (6/12) of children and 43% (10/23) of nephews and nieces had entirely normal BMD. There was no difference in life-style risk factors for osteoporosis, history of previous fractures or body mass index between normal subjects and those with osteopenia or osteoporosis. Osteopenic individuals had a significantly higher than normal osteocalcin value. Within families, there was no clear association between BMD and any of the genetic markers (vitamin D receptor gene polymorphisms, COL 1A1 and COL 1A2 polymorphisms of the collagen gene), either alone or in combination. The addition of genetic markers to the other risk factors for low BMD did not improve the prediction of BMD. In conclusion, we suggest that the presence of osteoporosis in a first degree relative should be one of the clinical indications for bone density measurement as the individuals at risk would not be picked up by other methods.

ACE for whom? Implications for clinical practice of post-infarct trials.

OBJECTIVE: To determine how many lives would be saved if patients were routinely treated with ACE inhibitors after myocardial infarction according to the criteria of four recent major clinical trials, and to estimate the costs and benefits of these approaches. DESIGN: Retrospective survey. SETTING: The Nottingham Health District. PATIENTS: Data from 7855 patients admitted between 1989 and 1990 were combined and the selection criteria of four major clinical trials (AIRE, SAVE, GISSI-3, and ISIS-4) were applied. RESULTS: Of the patients admitted in Nottingham with confirmed myocardial infarcts 39% were eligible for AIRE and 8% for SAVE. In patients with suspected myocardial infarction as defined by the major trials, 60% would have been eligible for GISSI-3 and 63% for ISIS-4. Treating appropriate patients in accordance with these trials would have saved 20 (AIRE), 3 (SAVE), 4 (GISSI-3) and 5 (ISIS-4) lives each year in Nottingham at a drug cost of 5400 pounds, 33 pounds 791, 2730 pounds, and 4116 pounds per life per year saved respectively. CONCLUSIONS: Short-term treatment with ACE inhibition appears to be cheaper but such an approach would save fewer lives. The AIRE study is the most applicable to current clinical practice but ACE inhibitors should be offered routinely to patients satisfying the criteria of any of the four major clinical trials.

Do women with acute myocardial infarction receive the same treatment as men?

OBJECTIVE: To determine whether women with acute myocardial infarction in the Nottingham health district receive the same therapeutic interventions as their male counterparts. DESIGN: Retrospective study. SETTING: University and City Hospitals, Nottingham. PATIENTS: All patients admitted with a suspected myocardial infarction during 1989 and 1990. MAIN OUTCOME MEASURES: Route and timing of admission to hospital, ward of admission, treatment, interventions in hospital, and mortality. RESULTS: Women with myocardial infarction took longer to arrive in hospital than men. They were less likely to be admitted to the coronary care unit and were therefore also less likely to receive thrombolytic treatment. They seemed to have more severe infarcts, with higher Killip classes, and had a slightly higher mortality during admission. They were less likely than men to receive secondary prophylaxis by being discharged taking beta blockers or aspirin. CONCLUSIONS: Survival chances both in hospital and after discharge in women with acute myocardial infarction are reduced because they do not have the same opportunity for therapeutic intervention as men.

Impact of hospital thrombolysis policy on out-of-hospital response to suspected myocardial infarction.

The treatment of acute myocardial infarction changed when several trials reported that thrombolytic agents given within a few hours of infarction improved outcome. We present data from the Nottingham Heart Attack Register comparing 1982-84, when thrombolysis was not available, and 1989-90, when it was hospital policy to give thrombolysis to all patients who arrived within 6 hours of the onset of symptoms, in the absence of a specific contraindication. The number of patients referred with symptoms suggestive of acute myocardial infarction increased by 75% from 1982 to 1990; a diagnosis of "possible infarction" was made in about half of all patients in 1982-84 and 23% in 1989-90. Our current thrombolytic policy has had little impact on patient and general practitioner (GP) behaviour. The GP was contacted by most patients. The median time between the onset of a patient's symptoms and admission to hospital when the GP was involved was 229 min in 1982-84 and 210 min in 1989-90; when he was not involved in arranging the admission median times to admission were 89 min and 75 min, respectively. By 6 hours from symptom onset, 60% of patients had been admitted; by 12 hours, about 70% were in hospital and by 24 hours, 80%. Of 7855 patients admitted with suspected acute myocardial infarction in 1989-90, 4465 were admitted within 6 hours of symptom onset. Of these, 736 (16%) patients received a thrombolytic drug. 389 (9%) patients had a specific, documented contraindication to thrombolysis. Although we estimate that the policy has saved about 8 lives per year, it is not surprising that there has been no improvement in overall case fatality after myocardial infarction.