Local infiltration analgesia for total knee arthroplasty: should ketorolac be added?

BACKGROUND: Adequate postoperative analgesia with minimal side-effects is essential for early mobilization and recovery in patients undergoing total knee arthroplasty (TKA). High-volume local infiltration analgesia (LIA) with ropivacaine has been introduced, but effects of adjuvants are still debated. We tested the hypothesis that the addition of ketorolac to LIA significantly improves analgesia after TKA. METHODS: Sixty patients undergoing TKA were randomized to receive intraoperative LIA (ropivacaine 300 mg and epinephrine 0.5 mg) combined with either ketorolac 30 mg (ketorolac group) or saline (control group). After surgery, eight bolus doses of ropivacaine 100 mg combined with either ketorolac 15 mg (ketorolac group) or saline (control group) were administered every 6 h via an intra-articular catheter. The primary outcome was postoperative consumption of i.v. morphine patient-controlled analgesia (PCA). Secondary outcomes were time to first request of i.v. morphine PCA, pain intensity, side-effects, and readiness for hospital discharge. RESULTS: Consumption of i.v. morphine PCA was lower in the ketorolac group vs control group {0-6 h: 0 (0-0) vs 5 (0-10) mg, P<0.0001; 0-48 h: 10 (0-22.5) vs 48.75 (30-82.5) mg, P<0.0001 [median (inter-quartile range, IQR)]}. Time to first request of i.v. morphine PCA was longer in the ketorolac group vs the control group [490 (248-617) vs 223 (115-319) min, P=0.02, median (IQR)]. Early postoperative pain (<48 h) and readiness for hospital discharge were also significantly reduced in the ketorolac group. CONCLUSIONS: LIA with ketorolac results in reduced morphine consumption, reduced pain intensity, and earlier readiness for hospital discharge.

Detection of meticillin-resistant Staphylococcus aureus and carbapenemase-producing Enterobacteriaceae in Danish emergency departments - evaluation of national screening guidelines.

BACKGROUND: Multi-resistant bacteria (MRB) are an emerging problem. Early identification of patients colonized with MRB is mandatory to avoid in-hospital transmission and to target antibiotic treatment. Since most patients pass through specialized emergency departments (EDs), these departments are crucial in early identification. The Danish National Board of Health (DNBH) has developed exposure-based targeted screening tools to identify and isolate carriers of meticillin-resistant Staphylococcus aureus (MRSA) and carbapenemase-producing Enterobacteriaceae (CPE). AIM: To assess the national screening tools for detection of MRSA and CPE carriage in a cohort of acute patients. The objectives were to investigate: (i) if the colonized patients were detected; and (ii) if the colonized patients were isolated. METHODS: This was a multi-centre cross-sectional survey of adults visiting EDs. The patients answered the DNBH questions, and swabs were taken from the nose, throat and rectum. The collected samples were examined for MRSA and CPE. Screening performances were calculated. FINDINGS: Of the 5117 included patients, 16 were colonized with MRSA and four were colonized with CPE. The MRSA screening tool had sensitivity of 50% [95% confidence interval (CI) 25-75%] for carrier detection and 25% (95% CI 7-52%) for carrier isolation. The CPE screening tool had sensitivity of 25% (95% CI 1-81%) and none of the CPE carriers were isolated. CONCLUSION: The national screening tools were of limited use as the majority of MRSA and CPE carriers passed unidentified through the EDs, and many patients were isolated unnecessarily.

Three-dimensional structure in solution of acyl-coenzyme A binding protein from bovine liver.

The three-dimensional structure of acyl-coenzyme A binding protein as encoded by the recombinant gene in Escherichia coli has been determined using nuclear magnetic resonance (n.m.r.) spectroscopy. The structure consists of four alpha-helices A1 (residues 3 to 15), A2 (residues 20 to 36), A3 (residues 51 to 60), and A4 (residues 65 to 85). A1 and A4, and A2 and A3, run in parallel pairs. A2 runs anti-parallel to A1 and A4. The three-dimensional structure of the protein is reminiscent of a shallow bowl with a rim. The "rim" is characterized by many polar and charged groups, whereas the inside and outside surface is predominantly hydrophobic with patches of uncharged polar hydroxyl groups of threonyl, serinyl and tyrosyl residues. The inside bottom contains through two epsilon-amino groups of lysine residues (Lys13 and Lys32) suggesting that the binding site for the nucleotide part of the acyl-coenzyme A part of the ligand molecule is at the inside surface of the bowl. The structure determination was done on the basis of measurements of the intensities of nuclear Overhauser effects (NOEs) and coupling constants that were translated into interatom distance restraints for 833 atom pairs, and 87 dihedral angle restraints, of which 23 were in chiral centers. In all, 42 hydrogen bonds were identified by n.m.r. and provided an additional 84 distance restraints. A total of 20 structures were calculated and the structures can be aligned to a root-mean-square deviation of 0.5 A for the backbone atoms of the residues in the four helices. A region of six residues could not be defined by the restraints obtained by n.m.r. The program Pronto was used for the spectrum analysis in general, and especially for the assignment of the individual NOEs, the integration of the cross peaks, and the measurements of the coupling constants. The programs DIANA and X-PLOR have been used in the structure calculations and evaluations.

Accurate measurements of coupling constants from two-dimensional nuclear magnetic resonance spectra of proteins and determination of phi-angles.

A new and simple method to measure 3JHNH alpha coupling constants of proteins by adding and subtracting traces from corresponding two-dimensional nuclear Overhauser enhanced spectroscopy and two-dimensional correlated spectroscopy cross peaks after scaling is proposed. The optimal scaling for the addition and the subtraction of the two traces is obtained by minimizing an error function. The method was proven to give accurate and precise measurements of coupling constants when tested with a series of simulated spectra. The accuracy of the method was better than 0.1 Hz for all test cases including the limiting case of J = 2.0 Hz and line-width = 11.0 Hz. The accuracy of the method was better than 0.1 Hz for all test cases including The 3JHNH alpha coupling constants were measured in two-dimensional nuclear magnetic resonance spectra of the two proteins barley serine proteinase inhibitor (CI-2) and the bacterial ribonuclease (barnase) of Bacillus amyloliquefaciens. The experimentally measured coupling constants were used to calculate the constants in a Karplus equation to be: 3JHNH alpha = 6.7 cos2(phi-60) -1.3 cos(phi-60) +1.5. These constants are in good accordance with those obtained for basic pancreatic trypsin inhibitor (BPTI). In addition, special emphasis is given to the measurements of positive phi-angles, and to the contribution of molecular dynamics on the apparent coupling constants.

Determination of the rate constants k1 and k2 of the Linderström-Lang model for protein amide hydrogen exchange. A study of the individual amides in hen egg-white lysozyme.

The pH dependence of the amide/solvent hydrogen exchange of individual amide groups in hen egg-white lysozyme has been studied by nuclear magnetic resonance spectroscopy. Lysozyme has been used here as a model for a globular protein to re-examine the hypothesis for the amide/solvent hydrogen exchange reaction proposed by K. Linderstrøm-Lang and described in detail by Hvidt and Nielsen. The work has been focused on the most slowly exchanging amide at the temperature of 21 degrees C and in the pH range between 4 and 8. Exchange rates have been measured for 64 of the 126 amide protons and the pH dependence has been determined for 52 of these. The amides examined represent a sample that includes all the types of secondary structure and they are placed in the globular structure in a range of 3.2 A to 8.5 A from the closest water molecule on the surface. The measured exchange rates at pH 6 have been compared to these structural parameters and the results suggest that the rate constants are determined partly by the distance to the surface and partly by the type of secondary structure the amide is engaged in. Near the surface and in the very interior the distance to the surface seems to be rate-determining. Between the extremes the type of secondary structure is rate determining. The pH dependent exchange of the examined amides was shown to be in agreement with the Linderstrøm-Lang model. For each of the amides examined the rate constants for the opening and the closing reaction in the first reaction step of the Linderstrøm-Lang model has been calculated and compared to structural parameters.

Three-dimensional structure of the complex between acyl-coenzyme A binding protein and palmitoyl-coenzyme A.

Multidimensional 1H, 13C and 15N nuclear magnetic resonance spectroscopy has been used to study the complex between palmitoyl-coenzyme A and acyl-coenzyme A binding protein. The 1H and the 15N spectra of the holo-protein have been almost completely assigned and so has most of the 1H spectrum of the coenzyme A part of the protein-bound ligand. The palmitoyl part of the ligand has been uniformly labelled with 13C and the nuclear magnetic resonance signals of the carbon atoms and their protons have been assigned at the two ends of the hydrocarbon chain. A total of 1251 distance restraints from nuclear Overhauser effects and 131 dihedral angle restraints from three-bond coupling constants provided the basis for the structure calculation. A comparison of 20 structures calculated from these data to the average structure showed that they could be aligned with an atomic root-mean-square deviation of 1.3(+/- 0.2) A for all C, N, O, P and S atoms in protein and ligand. The apo-protein is a four-helix protein and this structure is maintained in the holo-protein. The four alpha-helices are Ac1 of residues 3 to 15, Ac2 from residue 20 to 36, Ac3 from 51 to 62, and Ac4 from 65 to 84. For the four alpha-helices of the peptide backbone of the holo-protein the root-mean-square deviation for the C, C alpha and N atoms was 0.42(+/- 0.08) A. The binding site for the palmitoyl-chain stretches between the N-terminal end of Ac3 where the carboxyl part binds, to the N-terminal of Ac3 where the omega-end of the palmitoyl part binds. The adenosine-3'-phosphate is bound near residues of each of the four helices in an arrangement where it can form salt bridges and/or hydrogen bonds to either backbone or side-chain atoms of Ala9, Tyr28, Lys32, Lys54 and Tyr73. The polar parts of the pantetheine and the pyrophosphate are structured in the bound ligand to form an interface with the solvent. Also the ligand forms a set of non-polar intramolecular interactions where the adenine, the pantetheine, and the palmitoyl-chain are associated, so overall the structure of the bound ligand seems to be organized to protect the lipophilic palmitoyl part from the polar solvent.

A nuclear magnetic resonance study of the hydrogen-exchange behaviour of lysozyme in crystals and solution.

Amide hydrogen/deuterium exchange behaviour has been studied for all of the peptide amides of hen lysozyme by means of two-dimensional n.m.r. spectroscopy. The amides have been grouped into four categories on the basis of their rates of exchange in solution at pH 4.2 and 7.5. The distribution of the amides into the different categories has been examined in the light of the crystallographic structural information, considering the type of secondary structure, the nature of hydrogen bonding and the distance from the protein surface. None of these features was found to determine uniquely the pattern of hydrogen exchange rates within the protein. The exchange behaviour of the individual amides could, however, in general be rationalized by a combination of these features. Hydrogen exchange was also monitored in both tetragonal and triclinic crystals of lysozyme, by allowing exchange to take place in the crystals prior to dissolution and recording of n.m.r. spectra under conditions where further exchange was minimized. This enabled direct comparison to be made of the exchange behaviour in the crystals and solution. A reduction in exchange rate was observed in the crystalline state relative to solution for a substantial number of amides and distinct differences between exchange in the different crystals could be observed. These differences between the solution and the different crystal states do not, however, correlate in a simple manner with proximity to intermolecular contacts in the crystals. However, the existence of these contacts, which are on the surface of the protein molecule, have a profound effect on the exchange of amides in the interior of the protein. The results indicate that the spectrum of fluctuations giving rise to hydrogen exchange may be significantly altered by the intermolecular interactions present within the crystalline state.

Structure in solution of a four-helix lipid binding protein.

Because of the low solubility of lipids in water, intercellular and intracellular pathways of lipid transfer are necessary, e.g., for membrane formation. The mechanism by which lipids in vivo are transported from their site of biogenesis (endoplasmatic reticulum and the chloroplasts) to their place of action is unknown. Several small plant proteins with the ability to mediate transfer of radiolabeled phospholipids in vitro from liposomal donor membranes to mitochondrial and chloroplast acceptor membranes have been isolated, and a protein with this ability, the nonspecific lipid transfer protein (nsLTP) isolated from barley seeds (bLTP), has been studied here. The structure and the protein lipid interactions of lipid transfer proteins are relevant for the understanding of their function, and here we present the three-dimensional structure in solution of bLTP as determined by NMR spectroscopy. The 1H NMR spectrum of the 91-residue protein was assigned for more than 97% of the protein 1H atoms, and the structure was calculated on the basis of 813 distance restraints from 1H-1H nuclear Overhauser effects, four disulfide bond restraints, from dihedral angle restraints for 66 phi-angles, 61 chi 1 angles, and 2 chi 2 angles, and from 31 sets of hydrogen bond restraints. The solution structure of bLTP consists of four well-defined alpha-helices A-D (A, Cys 3-Gly 19; B, Gly 25-Ala 38; C, Arg 44-Gly 57; D, Leu 63-Cys 73), separated by three short loops that are less well defined and concluded by a well defined C-terminal peptide segment with no observable regular secondary structure. For the 17 structures that are used to represent the solution structure of bLTP, the RMS deviation to an average structure is 0.63 A +/- 0.04 A for backbone atoms and 0.93 A +/- 0.06 A for all heavy atoms. The secondary structure elements and their locations in the sequence resemble those of nsLTP from two other plant species, wheat and maize, whose structures were previously determined (Gincel E et al, 1995, Eur J Biochem 226:413-422; Shin DH et al, 1995, Structure 3:189-199). In bLTP, the residues analogous to those in maize nsLTP that constitute the palmitate binding site are forming a similar hydrophobic cavity and a potential acyl group binding site. Analysis of the solution structure of bLTP and bLTP in complex with a ligand might provide information on the conformational changes in the protein upon ligand binding and subsequently provide information on the mode of ligand uptake and release. In this work, we hope to establish a foundation for further work of determining the solution structure of bLTP in complex with palmitoyl coenzyme A, which is a suitable ligand, and subsequently to outline the mode of ligand binding.

Analysis of the dynamics of rhizomucor miehei lipase at different temperatures.

The dynamics of Rhizomucor miehei lipase has been studied by molecular dynamics simulations at temperatures ranging from 200-500K. Simulations carried out in periodic boundary conditions and using explicit water molecules were performed for 400 ps at each temperature. Our results indicate that conformational changes and internal motions in the protein are significantly influenced by the temperature increase. With increasing temperature, the number of internal hydrogen bonds decreases, while surface accessibility, radius of gyration and the number of residues in random coil conformation increase. In the temperature range studied, the motions can be described in a low dimensional subspace, whose dimensionality decreases with increasing temperature. Approximately 80% of the total motion is described by the first (i) 80 eigenvectors at T=200K, (ii) 30 eigenvectors at T=300K and (iii) 10 eigenvectors at T=400K. At high temperature, the alpha-helix covering the active site in the native Rhizomucor miehei lipase, the helix at which end the active site is located, and in particular, the loop (Gly35-Lys50) show extensive flexibility.

[Risk of development of epileptic seizures in children with subclinical "epileptogenic" EEG abnormalities]. / Risiko for udvikling af epileptiske anfald hos børn med subkliniske "epileptogene" eeg-abnormiteter.

Sixty-six non-epileptic children with focal spikes in EEG and without cerebral palsy were followed for 16 to 35 years. The cumulative risk of developing one or more seizures was 33% when the first abnormal EEG was recorded, and increased to about 80% if abnormalities persisted three or more years. Focal spike activity was most persistent in children with retarded development or with organic brain diseases. We conclude that the presence of focal EEG spikes in children without epileptic seizures can be considered epileptogenic, especially if the abnormality is persistent and associated with clinical evidence of organic brain disorder.

[Quality assurance in antenatal, perinatal and neonatal care. A medical audit]. / Kvalitetssikring i svangreprofylaksen, fødselshjaelpen og nyfødthedsperioden. Medical audit.

Formalized quality assessment of prophylaxis, diagnosis, treatment, and care has recently been introduced in the Danish health service. A review is presented of quality assessment undertaken by the medical audit method and a model is described for quality assurance of prophylaxis, diagnosis, treatment and care during the ante-, peri and neonatal periods. The information is based partly on results from a medical audit project and also experience from work in a perinatal committee in the County of Copenhagen. The method of medical audit is reviewed, including here the specialists participating, the extent of the work and the material forming the basis for assessment of the quality. In addition, examples are quoted of criteria for satisfactory prophylaxis, diagnosis, treatment and care in the perinatal period and for how assessment by the specialists is carried out. A new classification of causes of death and review of the results of assessments of quality is presented. Finally, quality assessment as seen from the patients' point of view is discussed.

[Why do parents of small children visit casualty ward when their children suffer of acute illness?]. / Hvorfor opsøger børnefamilier skadestuen ved akut sygdom?

INTRODUCTION: People in big cities tend to use the casualty ward instead of their own doctor or the emergency service. This is both more expensive and an inappropriate use of the health care system in Denmark. We wanted to find out why parents used the casualty ward and to look for an alternative way of helping parents during minor acute illnesses in their children. MATERIAL AND METHOD: One hundred questionnaires were distributed in the paediatric ward of Rigshospitalet, Copenhagen, from 28.1.1999 to 9.4.1999 to parents who came to the casualty ward without a referral from a doctor. Only people who could speak Danish participated. RESULTS: Seventy-five percent had no referral from a doctor, the rest were verbally referred by a doctor. Twenty-five percent came to the casualty ward while their own doctor was on duty. Thirty-nine percent chose the casualty ward, because the staff had a special knowledge of children. Most parents wanted to have their children examined by a paediatrician. DISCUSSION: Parents need to be educated in the proper use of the health care system when their children are ill. Many use the casualty ward for convenience and to get expert knowledge about their children's illness, even when it is not necessary. We suggest that an experienced children's nurse should work with the emergency service, so as to keep children with minor, acute illness out of the casualty ward.

[The validity of the perinatal classification by the Health Department]. / Validiteten af Sundhedsstyrelsens perinatalklassifikation.

On the basis of 273 perinatal and neonatal deaths in three Danish counties in 1985 and 1986, the validity of the abbreviated classification of perinatal deaths by the National Board of Health which comprises six categories was assessed. The classification is relatively robust regarding incorrect classification of International Classification of Diseases (ICD) as 87% of the deaths were classified in the relevant categories. This may be because the classification is relatively rough but also because the classification, as regards ICD diagnoses, is based on information from the register of births.

[The quality of registration of causes of death in perinatal and neonatal deaths]. / Kvaliteten af dødsårsagsregistreringen ved peri- og neonatale dødsfald.

The quality of registration of the causes of death in 273 perinatal and neonatal deaths was assessed. The present authors classified the causes of death according to WHO classification of disease. The authors classification was compared with the Danish Health Department's original classification of deaths and a classification undertaken by one of the staff of the Danish Health Department, the coding of which was based exclusively on information from the original death certificates (death certificate classification). Agreement between the respective forms of classification was assessed by the observed agreement for positive diagnosis and the kappa coefficients calculated by the three-figure level in the ICD diagnosis for categories and between categories of causes of perinatal and neonatal death, respectively. The investigation revealed that the deaths were classified with great accuracy by coding by the staff member when the death certificates were correctly completed. Comparison between the "authors classification" and the "Danish Health Department's original classification" and the "death certificate classification", respectively revealed that the observed agreement for positive diagnoses were 52% and 50% and that the kappa coefficients were between 0.80-0.07 and 0.81-0.04, respectively, on comparison with the three-figure levels in the ICD diagnoses and 0.93-0.32 and 0.85 and 0.32 on comparing the categories in between. It is concluded that considerable improvement in registration of perinatal and neonatal deaths may be obtained if the Danish Health Departments states precisely what information is required on the death certificate in connection with perinatal and neonatal deaths. Correspondingly, local efforts should be made to complete death certificates more correctly.

[Classification of perinatal and neonatal deaths. Fetal, obstetrical and neonatal causes]. / Klassifikation af peri- og neonatale dødsfald. Føtale, obstetriske og neonatale årsager.

A new method of classification of causes of death which may be employed in connection with perinatal and neonatal deaths is presented. The classification of causes of death proposed by the authors identifies the factor which probably initiated the train of events leading to death. This classification includes nine main categories and illustrates foetal conditions, happenings in pregnancy, the course of delivery and also the neonatal period. Employment of classification is proposed in regional registration of perinatal and neonatal deaths and as an aid in the current assessment of the quality of antenatal, obstetric and neonatal care as these are employed in medical audits of the perinatal and neonatal deaths in many Danish counties.

[Ischemic cerebral apoplexy in children]. / Iskaemisk apoplexia cerebri hos børn.

During two years we identified eight children aged 1.5-10 years with cerebral ischaemic stroke. Prior to the stroke seven of eight children were in full health. Predisposing factors were endocarditis and trauma. Four children had prodomal symptoms prior to the infarction. All had acute hemiparesis on admission. Three of the children had fever, and five had varicellazoster infection three to 18 months prior to the stroke. Three children had convulsions. Seven of eight children had stenoses or occlusions of the middle cerebral or the basilar artery. Five children have persistent deficits and none have died. The children did not have coagulopathies, hypertension or arteriosclerosis. Echocardiography did not show patent foramen ovale. Early clinical and neuroradiological investigations are of importance in reaching the appropriate diagnosis.

[Teaching and counseling families with small children in an urban area about minor illnesses of childhood]. / Undervisning og rådgivning af småbørnsfamilier i et storbyområde om småbørns almindelige sygelighed.

INTRODUCTION: Parents' knowledge of and experience with illness in their children are often limited. They find it difficult to take the responsibility when their children are ill. They seek help immediately from the health care system, although the symptoms are mild. We wanted to discover whether teaching parents about minor illness in children and counselling over the telephone during acute illness would mean that parents sought help less often from the health care system, when their children became ill. This article deals with the teaching of the parents. MATERIAL AND METHODS: The project had an intervention group of 91 children aged 12-35 months and a control group of 400 children aged 9-33 months. The intervention group was instructed for two hours twice in the local day nursery and telephone counselling from a nurse trained in children's acute illnesses was made available from 4 pm to 11 pm on weekdays and from 10 am to 11 pm at weekends during the period 20th October 1998 to 1st May 1999. RESULTS: No visible change was seen in the use of the health care system in either group, but there was a small change in favour of the intervention group in the use of a general practitioner instead of calling the emergency medical service. Eighty per cent of the counselling dealt with common acute illnesses; 75% ended without referral. DISCUSSION: There was no visible difference in the use of the health care system in either group. Parents were happy with the offer of teaching and telephone counselling, but it should have been given when the infants started at the nursery. They felt their children were too old at the time the project started. We suggest a continuation of antenatal classes in the form of "parent preparation classes", where one subject could be minor acute illnesses in children.

[Cesarean section under epidural anesthesia. A questionnaire study]. / Kejsersnit i epidural anaestesi. En spørgeskemaundersøgelse.

Seventy-four women selected at random who had been subjected to Caesarean section replied to questions about their satisfaction with epidural anaesthesia at various stages during the intervention. General discomfort increased during the intervention and pain contributed most to this. 96% of the women would recommend the method to others.

[Preventive check-ups of pregnant women in Denmark. Common ailments in pregnancy]. / Forebyggende helbredsundersøgelser af gravide kvinder i Danmark. Almindelige helbredsgener i svangerskabet.

The study was conducted in order to describe the extent and content of advice on common ailments in pregnancy given by doctor or midwife during prenatal visits and to describe the frequency of ailments in the period before the visits. The design was a nationwide cross-sectional study based on questionnaires completed by pregnant women who had seen a general practitioner (GP), midwife or hospital doctor for prenatal care. Ailments and advice in connection with one specific visit were reported. The questionnaires were completed by 517 women after a prenatal visit to their GP (92% of eligible), by 514 women after a prenatal visit to the midwife (91% of eligible), and by 203 women after a prenatal visit to a doctor in the maternity department in pregnancy week 16-18 (84% of eligible). The results showed that nausea, pollakisuria, tiredness and heartburn had been present during the period before the visit in about half the women. Between a third and a fourth of the women had been discomforted by back pain, discharge or cramps. From 15 to 58 percent had been given advice, depending on the symptom. The advice was of many different kinds. To a large extent the women wanted to talk to the health professionals about the ailments, and most often they wanted to talk to a midwife about the ailments. We conclude that common ailments of pregnancy are frequent and they should be investigated more. Nearly all pregnant women want to talk about the subject during prenatal visits. The objectives of giving advice should be clearer, and clinical studies of the effectiveness of the advice are needed.

[Preventive health examinations of pregnant women in Denmark. Anamnestic practice and discussion of prenatal diagnosis in early pregnancy examinations in general practice, birth clinics and birthing centers]. / Forebyggende helbredsundersøgelser af gravide kvinder i Danmark. Anamnesepraksis og samtale om proenatal diagnostik ved tidlig undersøgelse i svangerskabet hos praktiserende loege, på fødestedet og hos jordemoder.

In Denmark, pregnant women are offered antenatal care in a nationwide programme. This programme is organized around health examinations in general practice, hospital outpatient departments and at midwives' centres. During winter 1986-1987, a nationwide investigation of antenatal care was carried out. A random sample of approximately 1/3 of the general practitioners, all of the midwives who had antenatal consultations and the medical staffs of 26 departments of obstetrics and gynaecology received a questionnaire about content of a definite antenatal examination. 62% of the general practitioners, 63% of the doctors at the place of delivery and 86% of the midwives replied. Among the pregnant women, 92% replied from general practice, 84% from hospital outpatient departments and 91% from midwives' centres. The interviews about date of delivery and genetic counselling at early visits in general practice, hospital outpatient departments and at midwives' centres were in agreement with the nationwide guidelines. Employment of routine ultrasound scanning was not associated with less detailed history taking by the doctors at hospital outpatient departments, where ultrasound scanning was employed only on special indications. It was concluded that there was a considerable overlap between the interview about the date of delivery and genetic counselling at early visits in general practice and in hospital outpatient departments and, to some extent, at the midwives' centres. The sharing of responsibility for care of pregnant women by three professional groups requires specification of the content of the consultation. Official guidelines should be more specific about this point.